Passmed 2 Flashcards
At what gestation do foetal movements occur
18-20
At what gest do you refer to foetal medicine unit if no foetal moevemnts are present
24 weeks
what are RF for hyperemesis
first pregnancy multiple pregnancies trophoblastic disease hyperthyroidism obesity Asian PMH/FH
what findings on uss are diagnostic of miscarrigae
crown-rump length greater than 7mm with no cardiac activity is diagnostic of a miscarriage
what are factors for continous CTG in labour
e following are present or arise during labour;
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour
what are the FRASER guidelines
- Person UNDERSTANDS advice
- Person CANNOT BE PERSUADED to inform parents
- Person likely to begin or continue having sex WITHOUT treatment
- Unless person does not receive contraception, mental and physical health is likely to suffer
- Person’s best interest requires them to receive contraceptive advice with / wihtout consent
What are MEC4 criteria for COCP
>35 and smoker (>15) migraine with aura PMH DVT/PE <45 yo PMH stroke /IHD Uncontrolled HTN Breast cancer Breast feeding AND <6week pp Recent surgery with prolonged immob
What are MEC3 for COCP
IMmobility >35 + smoker (<159 migrainwe, no aura FH DVT/PE <45 Controlled HTN
what med can you give to suppress lactation
cabergoline
explain classifications of third degree teara
3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact
When is lactational amenorrhoea effective as birth control
Only effective if:
- in the 6 months after birth
- FULL amenorrhoea
- fully/almost fully breastfeeding
how does haemochromatosis cause amenorrhoea
deposits iron in hypothalamus and ovaries
What is the diagnostic test for haemochromatosis
iron studies
When do you deliver dichorionic vs monochorionic
dichorionic: 37 weeks
monochorionic: 36 wks
How do you manage labour in a woman with infibulation (aka clasp circumcision)
ANTERIOR episiotomy during second stage of labour
How can you calculate delivery date based on woman’s LMP
Naegele’s rule:
LMP + 1 yr + 7 days - 3 months
When do you review a woman with expectant management of miscarriage
Discharge with review in 2 weeks
How do you safety net a woman managed with expectant mx of miscarriage
Return to early pregnancy unit if
- heavy bleeding /bleeding not lighter in 2 weeks
- sx infection (fever, discharge)
what women is expecant mx of miscarriage NOT appropriate in
- increased risk of haemorrhage (e.g. late first timerster, bleeding disorder)
- previous adverse/traumatic event in pregnancy (e.g. miscarriage, stillbirth, APH)
- Increased risk from effect of haemorrhage (e.g. cannot have blood transfusion)
- evidence of infection
what meds do you give. for. medical mx of miscarriagew
vaginal misoprostol
+ antiemetics + pain relief
What should a patient undergoing medical mx of miscarriage expect
nausea vomiting pain diarrhoea
vaginal bleeding
when should a woman take a pregnancy test after medical mx of miscarriage
3 weeks later
absolute contraindications for HRT
suspected pregnancy current breast cancer endometrial cancer active liver disease uncontrolled HTN known curent VTE thrombophilia
side effects of HRT
same as usual side effects of oestrogen and prog
what are two risks of HRT you should counsel pt on
- slightly increased risk of breast cancer (within 5 years of stopping use risk disappears)
- risk of VTE and stroke (very small, similar to OCP)
What conditions can you investigate with saline infusion sonography
Submucosal fibroids
Endometrial polyps
List the ix for fibroids
FBC - anaemia TVUSS - submucous, small intramural TAUSS - large intramural, subserosal Saline infusion sonographjy MRI Hysteroscopy
What are risk factors for ovarian cancer?
High oestrogen
- early menarche
- late menopause
- nullip
- tamoxifen
- obestiy
- cigarette smoking
What are protective factors for ovarian cancer
- COCP
- multip
- tubal lig
- salpingectomy, hysterectomy
What two genes are associated with ovarian cancer
BRCA
Lynch
What cancers does BRCA cause
Breast, ovarian, pancreatic
prostate in men
What cancers does Lynch cause
Ovarian, endometrial, colorectal
How do you manage pt with BRCA
COCP (reduced ovarian cancer by 50%)
As soon as family is complete: bilateral salpingo-oophorectomy
List all sx of ovarian cancer
- abdominal bloating, increased abdo girth
- early satiety
- pelvic pain
- change in bowel and bladder habit, urinary sx
- backache
- FLAWS
What two complications of ovarian cancer can you pick up on examination
Ascites
Pleural effusion
what kind of ovarian tumours produce sex hormones?
SEX CORD STROMAL TUMOURS:
- Granulosa cell tumours (inhibin)
. Sertoli leidig (androgens)
what symptoms occur with sex cord stromal tumours?
Manifestations of excess sex hormone production!! - irregular menstrual bleeding - postmenopausal bleeding - precocious puberty -
What investigation do you need to determine FIGO staging for endometrial cancer
MRI |!!
What percentage of endometrial hyperplasia SIMPLE prpgresses to cancer?
<5% progressed to cancer over 20 years
What percentage of endometrial hyperplasia complex progress to cancer
20% per annum
Explain ft of 1A cervical cancer and how it iis treated
MICROSCOPIC
remove surgically with clear margins
Explain how cervical cancer 1B-4 is treated
If localised: Wertheim’s hysterectomy (radical hysterectomy + bilat pelvic node resection)
If fertility sparing: radical trachelectomy (cervix + upper vagina + pelvic nodes)
If tumour is beyond cervix: radiotherapy
what is the presentation of lichen planus on the vagina
Pruritic, purple, polygonal papules
when is ovarian cyst rupture most likely to occur
during physical exercise e.g. a run, sexual intercourse
who do you offer OGTT in, and when
if risk factors are present: 24-28 weeks
if prior history of GDM: 16-18 weeks and repear at 24-28 weeks
when do you use TVUSS in pregnancy
early pregnancy <12 weeks
examining the cervix later in pregnancy
identifying lower edge of placenta
women with lots of adipose tissue
When do you use TAUSS in pregnancy
pregnancy >12 weeks
WHen can you use CRL for dating until 1
13+6
What can you use for dating from 14-20 weeks
FOETAL BIOMETRY (measurements on USS)
HC, BPD, FL
when can gestational age no longer be calculated by USS
> 20 weeks
what is the biggest risk with MCMA twins?
cord entanglement
How do you manage a mum with MCMA pregnacy
Admit from 28 weeks
CTG daily (for signs of cord compression
Deliver by CS 32-34 wks
when would you give mag sulph for neuroprotection if PTL
between 24 and 34 weeks if IN PRETERM LABOUR or having planned preterm birth within 24 hours
offer 23-30
consider 30-34
How do you manage HELLP syndrome
IV mg sulph
+ anti HTN therapy
NOT DEX
what BP must you aim for if HTN/PET in pregnancy
135/85
explain complications of PPROM
To foetus:
- prematurity > NEC, RDS et c
- infection > sepsis
- low fluid volume > lung hypoplasia, face and limb deformity
What is prom
Prelabour ROM
so rupture of membranes before the onset of labour at >37 weeks
How do you manage PROM
Monitor and wait 24 hours
Most women will go into labour spontaneously
if not, offer IOL
when does acute fatty liver of pregnancy typically occur
third trimester
what are fts of acute fatty liver of pregnancy
Jaundice
Abdominal pain (commonly in right upper quadrant)
Nausea and/or vomiting
Malais, Fatigue
Oliguria
Tachycardia, Fever
Disseminated Intravascular Coagulation
what is the main problem of AFLOP
metabolic acidosis (due to damaged hepatocytes) > foetal morbidity aand mortality
How do you manage AFLOP
delivery
What is outcome of quadruple test for Down’s
low AFP
low oestriol
high beta hCG
high inhibin A
what are sensitisation events for anti D
Antepartum haemorrhage
Placental abruption
Abdominal trauma
External cephalic version
Invasive uterine procedures such as amniocentesis and chorionic villus sampling
Rhesus positive blood transfusion to a rhesus negative woman
Intrauterine death, miscarriage or termination
Ectopic pregnancy
Delivery (normal, instrumental or Caesarean section)
What is the risk of having GBS again if positive in prior pregnancy? what should you do for these women?
Risk is 50%
Offer
- intrapartum prophylactic abx
- testing in late pregnancy
Who do you give intrapartum antibiotic prophylaxis to
- prior GBS baby
- incidental detection of GBS in current pregnancy
- GBS bacteriuria
- maternalpyrexia
- prolonged ROM >18 h
- Premature
How do you manage woman with high HIV viral load in delivery
Antiretroviral therapy (both antenatally and intrapartum)
IV zivodudine
Deliver by elective C section
How do you manage infant born to HIV positive mother
Immediate cord clamping
Bathe baby
Give zivodudine 4-6 weeks after birth
Advice to not breastfeed
What is testing of HIV like in baby born to HIV positive mother, so what should you do?
Neonates will test positive for HIV antibodies due to passive transfer from mother
So use PCR direct viral amplification - at birth, 3 weeks, 6 weeks, 6 months
Can a woman breastfeed if HIV positive? how is this affected by her viral load?
She CANNOT breastfeed REGARDLESS of viral load
unless in developing country, where baby would be at risk of starvation/death
How do you manage Hep B to prevent vertical transmission
GIve Hep B immunoglobulin immediately after birth
Give Hep B vaccine at birth, 1 momth, 6 months
what must you do in labour if CTG is suspicious
Repositionp mother IV fluids Reduce / stop oxytocin Correct any epidural related hypotension Continue CTG observation
What must you do in labour if CTG is pathological
IMMEDIATE VAGINAL EXAMINATION - eclude malpresentation or cord prolapse
- if fully diiated: instrumental delivery is possible
- if not fully dilated: FBS. If FBS abnormal: delivery immediately. If FBS normal, continue labour but repeat samples every 30-60 mins. if CTG abnormalities persist
What foetal pH indicates foetal compromise
pH <7.2
7.2 to 7.25 is borderline
what are the 3 indications for induction of labour
- Prolonged pregnancy max 41+5
- Prelabour ROM (if >37wks, induce in 24h; if <34wks, conservative)
- PET and other maternal HTN, OC, other deteriorating maternal illness
what are CONTRAindications for synctocinon during labour
- VBAC
- Intact membranes (risk of amniotic fluid embolus)
- Obstruction
what is vasa previa bleeding always preceded by
ROM
At what gestation do you reassess for placenta previa
32 weeks
and 36 weeks
