PACES Obs&Gynae Flashcards
What Additional Blood Tests Should a pregnant women testing positive for HIV Have?
- Varicella Zoster
- Hep C
- Measles
- Toxoplasmosis
- She should be screened for genital infections (at booking an again at 28 weeks)
Postnatal management of
a baby born to an HIV+ mother?
All neonates should be treated with anti-retroviral therapy within 4 hours of birth. –> Zidovudine monotherapy for 2-4 weeks
Those at high risk of HIV infection should be treated with HAART. (Highly active anti retroviral therapy)
Infants should be tested for HIV DNA and RNA at 1 day, 6 weeks and 12 weeks of age.
A confirmatory HIV antibody test is performed at 18 months of age.
Which babies should have PCP prophylaxis?
Prophylaxis against PCP is recommended only for neonates at high risk of HIV infection.
What is contraindicated intrapartum in HIV+ mothers?
Foetal blood sampling
Mode of delivery for HIV+ mothers
Women should have elective C section at 38 weeks to prevent ROM
Exception: Vaginal delivery can be considered in women taking HAART with a VL<50 copies at 36 weeks
BUT avoid ARM, invasive foetal monitoring (scalp electrode) or instrumental delivery
Breastfeeding advice in HIV+ women
Not to Breastfeed
(breastfeeding if the viral load is low is only recommended in low resources countries therefore not the UK)
Can women HIV+ have ECV
Yes if the viral load is <50 copies/mL
Follow up of HIV+ women during pregnancy
They will be seen every 2 weeks at the joint HIV and obstetric clinic
Viral load will be monitored every 2-4 weeks + 36 weeks + post delivery
Post natal management of babies at high risk of transmission of HIV
Triple ART (zidovudine, lamivudine and nevirapine) for 4 weeks
Anti retroviral treatment in pregnancy
All HIV+ women should be offered it regardless of whether they were previously taking it
Vaccinations offered to HIV+ mothers in pregnancy
All pregnant women are offered the whooping cough vaccine. Flu vaccine and COVID vaccine
You will also be recommended to have vaccinations for hepatitis B (if you are not immune) and pneumococcus, and the flu vaccine (in the autumn/ winter months).
Is anti-retroviral treatment safe in pregnancy?
Anti-retroviral drugs are generally safe but they can sometimes have side effects, including stomach and digestive problems, diabetes, rashes, extreme tiredness, high temperature and breathlessness.
Anti-retroviral treatment itself does not appear to be harmful for babies. Not taking the medication is much more likely to be harmful for your baby, because the risk of passing HIV on to your baby will be much higher.
What is hysteroscopic sterilisation?
Insert expanding springs into the tubal ostia via a hysteroscope
This induces fibrosis over 3 months
Additional contraception should be used during this time
How is female sterilisation performed at laparoscopy?
Occlude Fallopian tubes with Filshie clips
What advice should be given to women who have had a laparoscopic sterilisation?
Additional contraception should be used until the first period after the procedure
Which organism causes thrush
Candida albicans
What are some causes of dysmenorrhoea?
Endometriosis
Adenomyosis
PID
Fibroids
List some causes of PV bleeding
Cancer (endometrial, cervical, ovarian)
Fibroids
Endometriosis
Bloody show
PID
Period
Cervical ectropion
List some types of endometrial cancer
Endometrioid:
- Mucinous adenocarcinoma
- Serous adenocarcinoma
Non-endometrioid:
- Clear cell carcinoma
List some risk factors for endometrial cancer
Obesity
Nulliparity
Early menarche and late menopause
Unopposed oestrogen therapy
Diabetes mellitus
Tamoxifen
PCOS
HNPCC
How is endometrial cancer treated?
Localised disease: total abdominal hysterectomy with bilateral salpingo-oophorectomy
High risk patients may receive post-operative radiotherapy
Progesterone therapy is sometimes used in frail elderly patients who are unfit for surgery
What might you do to high risk patient with endometrial cancer?
High risk patients may receive post-operative radiotherapy
Alternative treatment to surgery for frail patients with endometrial cancer
Progesterone therapy (Mirena Coil for at least 6 months) is sometimes used in frail elderly patients who are unfit for surgery
How frequently are women offered cervical cancer screening?
Every 3 years: 25-49
Every 5 years: 50-64
What are some risk factors for ectopic pregnancy?
Maternal age
Previous ectopic pregnancy
Pelvic or abdominal surgery
PID
Termination of pregnancy
Smoking
Endometriosis
Copper IUD
What are the types of gestational trophoblastic disease?
Complete and partial mole
Invasive mole
Choriocarcinom
What must you always do with cases of FGM?
Document in the hospital notes
If < 18 years, refer to police and social services
Explore whether other children are at risk
Core features of PTSD (ICD-10)
TRIAD = HYPERAROUSAL, AVOIDANCE, RE-EXPERIENCING
- An event of exceptionally threatening nature that is likely to cause pervasive distress in almost anyone
- Symptoms start within 6 months
- Avoidance of circumstances
- Intrusive recollection/memories of the event
- Difficulty remembering some of the event
6.Increased psychological/autonomic sensitivity: hypervigilant, difficulty concentrating, outbursts of anger, poor concentration, difficulty sleeping, startle response
Charities for FGM
- Daughters of Eve
- NSPCC FGM Helpline
- Foundation for Women’s Health Research and Development (FORWARD)
Why is FGM undertaken?
- To signal that a girl has now become a woman.
- To protect a girl’s virginity /to prove she has not had sex before marriage.
- To decrease a womans’ sexual desire.
- To prepare a girl for marriage. Once FGM has been performed a girl is seen as ready for marriage.
- To follow a religious requirement (although there is no evidence to suggest that FGM is required by any religion).
Where is FGM most prevalent?
Mali
Somalia
Sudan
Egypt
Ethiopia
What is the legal situation of FGM in UK?
Mandatory legal DUTY to inform police about suspected FGM in under 18s
What is the legal situation of underage marriage in UK?
It is now an offence to cause a child under the age of 18 to enter a marriage in any circumstances, without the need to prove that a form of coercion was used.
This includes non-legally binding ‘traditional’ ceremonies which would still be viewed as marriages by the parties and their families.
When should an OGTT be performed in women with a high risk of GDM?
24-28 weeks
If previous history of GDM, this should be done at 16-18 weeks and a repeat at 24-28 weeks
Why should an ultrasound scan be performed at the time of diagnosis of GDM?(3)
Exclude congenital anomaly
Assess foetal growth
Assess liquor volume
Who should review a woman with a new diagnosis of GDM and when should this happen?
Joint diabetes and antenatal clinic within 1 week of diagnosis
What is gestational trophoblastic disease?
Spectrum of tumours and tumour-like conditions characterised by proliferation of pregnancy-associated trophoblastic tissue
What are the risks associated with intrauterine contraceptive devices?
Uterine perforation (2 in 1000)
Ectopic pregnancy (relative not absolute) ( and only for IUD)
Infection (in first 20 days)
Expulsion (risk is 1 in 20)
Abnormal bleeding (IUS: initial frequent bleeding and spotting followed by intermittent light menses; IUD: heavier, longer and more painful)
State some risks of HRT
VTE& stroke (but can be avoided if given as a patch or gel)
Coronary heart disease if over 60
Breast and ovarian cancer
What are the main benefits of HRT?
- Improved vasomotor symptoms
- Reduced risk of osteoporosis
- Improved genital tract symptoms
List some absolute contraindications for HRT (6)
Pregnancy
Breast cancer
Endometrial cancer
Uncontrolled HTN
Current VTE
Thrombophilia
What is the most common gynaecological cancer in women?
Endometrial
Which cancers occurring in females have national screening programmes?
Breast
Cervical
List some non-hormonal treatments for menopause.
- Alpha agonists (clonidine)
- Beta-blockers (propranolol)
- SSRIs (fluoxetine) Symptomatic: lubricants, osteoporosis treatments
List some causes of subfertility.
PCOS
Idiopathic
Male factor
Surgery/chemotherapy
Adhesions
Endometriosis
Blocked Fallopian tubes
List some causes of premature ovarian insufficiency. (5)
- Chromosomal abnormalities (e.g. Turner’s syndrome, fragile X)
- Autoimmune disease (e.g. hypothyroidism, Addison’s, myasthenia gravis)
- Enzyme deficiencies (e.g. galactosaemia, 17a-hydroxylase deficiency)
- Chemotherapy or radiotherapy
- Infections (e.g. TB, mumps, malaria, varicella)
Causes of secondary amenorrhoea
Hypogonadotrophic hypogonadism (e.g. Sheehan’s syndrome)
PCOS
Asherman’s syndrome
Low BMI
Cervical stenosis
Physiological: lactational, pregnancy
Aetiology of secondary amenorrhoea
Usually due to HPO axis dysfunction:
S → {{c1::Stress}}
T → {{c2::Tumour (Pituitary)}}
O → {{c3::Over-exercise and weight loss == Hypothalamic Hypogonadism}}
P → {{c4::Psychiatric: anorexia nervosa}}
Other causes
T → {{c5::Thyrotoxicosis}}
A → {{c6::Asherman’s syndrome: adhesions}}
M → {{c7::Menopause (early)}}
P → {{c8::PCOS}}
O → {{c9::Ovarian tumour}}
N → {{c10::Neonatal → post-pregnancy and breast-feeding}}
What is the definition of a miscarriage?
Pregnancy that ends spontaneously before 24 weeks gestation
List some causes of recurrent miscarriage.
Antiphospholipid syndrome
Cervical abnormalities
Foetal chromosomal abnormalities
Uterine malformations
Thrombophilia
Most common site of the fallopian tube for ectopic pregnancies
The ampullary portion of the tube, where over 80% of ectopic pregnancies occur
The site where an ectopic pregnancy is more likely to burst?
Isthmus
List some common side-effects of sex hormones.
Progestogenic – depression, PMS, bleeding, acne, weight gain
Oestrogenic – headache, nausea, breast tenderness
Can you describe some methods of male and female sterilisation?
Female – Filshie clips, transcervical sterilisation involving hysteroscopic placement of micro-inserts, hysterectomy
Male – vasectomy
Risk factors for vaginal prolapse
Obesity
Chronic cough
Chronic constipation
Post-menopausal
Connective tissue disorders
Which complex of muscles makes up the bulk of the perineum
Levator ani
Which muscles make up the levator ani?
Puborectalis
Pubococcygeus
Iliococcygeus
What are the four categories of uterine prolapse?
Stage 1: cervix is in the upper half of the vagina
Stage 2: cervix is at the introitus
Stage 3: cervix protrudes out of the introitus
Stage 4: procidentia – uterus is outside the vagina
Treated conservatively with pelvic floor exercises, wt loss, less constipation and avoiding heavy lifting.
MEdically with oestrogen cream and pessary
Surgically depending on the prolapse.
Which blood test would you do if you suspected anti-phospholipid syndrome?
Lupus anticoagulant
Anticardiolipin antibodies
Diagnosis requires 2 positive results at least 12 weeks apart
How can a miscarriage be managed medically?
Vaginal misoprostol
Analgesia and anti-emetic
What is a uterine fibroid?
Leiomyoma – benign tumour arising from the smooth muscle
What is a dangerous complication of fibroids in pregnancy?
Red degeneration
What are the three types of fibroid?
-Submucous
Intramural
Subserosal
What agent may be used to reduce the size of the fibroid in preparation for surgery?
Injectable GnRH agonist
–> not sure if they do this anymore
What is the difference between a complete and partial mole?
Complete: empty egg is fertilised by 2 sperm or 1 sperm that duplicates. Produces a mass of cells with no foetus
Partial: normal ovum gets fertilised by 2 sperm. An abnormal foetus starts to form but it cannot survive of develop into a baby
What can be given to ripen the cervix before suction and curettage?
Prostaglandins
What is the incidence of molar pregnancy?
1 in 600
–> it’s 590 if you want to be exact
What are the different types of FGM?
Type 1: clitoroidectomy
Type 2: clitoroidectomy with partial or total removal of the labia minora with or without removal of the labia majora
Type 3: infibulation (stitching to narrow the vagina)
Type 4: any other non-medical procedures to the external genitalia (e.g. piercings, cauterisation)
What are some complications of pelvic inflammatory disease?
Infertility
Ectopic pregnancy
Chronic pelvic pain
Sepsis
Fitz-Hugh-Curtis syndrome
What is the difference between a high vaginal swab and an endocervical swab?
Endocervical – chlamydia and gonorrhoea
High vaginal – anaerobes (e.g. BV)
What are the high risk types of HPV?
16 and 18
Name an HPV vaccine and the types of HPV covered by it.
Gardasil – 6, 11, 16 and 18
What are some causes of antepartum haemorrhage?
Placental abruption
Placenta praevia
Placenta accreta
Vasa praevia
Cervical ectropion
Trauma
What are some risk factors for placental abruption
Previous placental abruption
Smoking
C-sections
Cocaine use
Pre-eclampsia
Investigations for suspected placenta abruption
- Observations
- Pregnant Abdomen Examination
- CTG
- Ultrasound
- Speculum
- Kleihauer Test: can be performed to determine the extent of fetomaternal mixing of the blood so that a sufficient dose of anti-D can be given
- FBC, coagulation screen and 4 units of blood cross-matched
What are the steps in the management of a patient with hyperemesis gravidarum?
1st line: antihistamines (promethazine or cyclizine)
2nd line: ondansetron or metoclopramide
Alternative: P6 acupressure, ginger
If severely dehydration: admit for IV rehydration, thiamine supplementation and thromboprophylaxis
What triad of features defines hyperemesis gravidarum?
More than 5% pre-pregnancy weight loss
Electrolyte imbalance
Dehydration
Which treatment option can be used if the patient fails to respond to several anti-emetics
Steroids
How long does normal morning sickness tend to last?
It gets better by around 14 weeks
If the symptoms of HG persist into the second and third trimesters, are there any additional aspects of management that you might offer?
Serial scans to monitor foetal growth
How can preterm premature rupture of membranes be prevented in high-risk women?
Prophylactic vaginal progesterone
Cervical cerclage
If pooling of amniotic fluid is not observed on examination of a woman with suspected PPROM, which other test could be conducted?
IGF binding protein-1 test or placental alpha-microglobulin-1 test
Which organisms are typically implicated in chorioamnionitis?
GBS
E. coli
How would a patient with PPROM but no signs of infection be managed?
Monitor for signs of infection
Offer oral erythromycin 250 mg QDS for a maximum of 10 days or until the patient is in established labour
Do NOT use tocolysis (increases risk of infection)
Decision to deliver depends on balance of risk of prematurity and risk of maternal/foetal infection if delivery is delayed
How can women at high-risk of pre-eclampsia be managed during pregnancy?
75 mg OD aspirin from 12 weeks until birth
Indications: diabetes mellitus, autoimmune disease, hypertensive disease during previous pregnancy, chronic hypertension, chronic kidney disease
List some risk factors for pre-eclampsia.
First pregnancy
Multiple pregnancy
History of PET
Age > 40 yrs
BMI >35
> 10 year pregnancy interval
Gestational diabetes is defined as
Fasting plasma glucose > 5.6 mmol/L
2-hour OGTT > 7.8 mmol/L
risks of gestational diabetes and why it needs to be controlled
Foetal: macrosomia, polyhydramnios, neonatal hypoglycaemia, shoulder dystocia, congenital defects, miscarriage, later risk of T2DM and obesity
Maternal: traumatic delivery due to macrosomia, increased risk of T2DM, increased future risk of gestational diabetes (50%), pre-eclampsia
What is the target level of plasma glucose in a patient with GD?
Fasting plasma glucose < 5.3 mmol/L
2-hour post-meal < 6.4 mmol/L
How should sexual contacts of someone with PID be treated?
Single dose azithromycin 1 g
Which antibiotic regimen is recommended for PID?
- Intramuscular ceftriaxone 250 mg immediately
+oral doxycycline 100 mg twice a day for 14 days
+ metronidazole 400 mg twice a day for 14 days.
What is the treatment of PMS?
Mild -> Lifestyle such as sleep better or exercise more and stop smoking. Smaller more meals with complex carbohydrates
Moderate -> COCP
Severe -> SSRIs
