PassMed wrong answers Flashcards
What is postpartum thyroiditis? How is it managed?
The immune system attacks the thyroid within around 6 months of giving birth. This causes a temporary rise in thyroid hormone levels and symptoms of hyperthyroidism.
Three stages
1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function (but high recurrence rate in future pregnancies)
Thyroid peroxidase antibodies are found in 90% of patients
Management
1. Thyrotoxic phase:
Propranolol is typically used for symptom control.
Not usually treated with anti-thyroid drugs as the thyroid is not overactive. (Mild, temporary rise in thyroid hormones levels and function returns to normal after 12 months after childbirth so carbimazole not needed as a self-solving condition)
2. Hypothyroid phase
usually treated with thyroxine
What are the signs of a thyroid storm and how is it treated?
Thyroid storm is the complication of thyrotoxicosis.
Additional features to support a thyroid storm would include a fever >38.5ºC, confusion and agitation, nausea and vomiting, and hypertension.
Dexamethasone is given. This would be co-prescribed with thioamides, such as methimazole, IV fluids, and propranolol.
What is the first line treatment for hyperthyroidism during pregnancy?
Propylthiouracil
It is usually first-line during pregnancy because carbimazole has teratogenic properties.
How should reduced fetal movements be investigated?
If past 28 weeks gestation:
- Initially, handheld Doppler should be used to confirm fetal heartbeat.
- If no fetal heartbeat detectable, immediate ultrasound should be offered.
- If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
- If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.
If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.
If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
What might reduced fetal movements suggest?
Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.
What is the normal timeline of fetal movements?
The first onset of recognised fetal movements is known as quickening. This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau. Multiparous women will usually experience fetal movements sooner, from 16-18 weeks gestation. Towards the end of pregnancy, fetal movements should not reduce.
Expectant mothers will usually quickly recognise a pattern to these movements. The nature of the movements themselves can be very variable. There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.
What are the risk factors for reduced fetal movements?
Risk factors for reduced fetal movements
1. Posture: There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
2. Distraction:
Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
3. Placental position:
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
4. Medication: Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
5. Fetal position: Anterior fetal position means movements are less noticeable
6. Body habitus: Obese patients are less likely to feel prominent fetal movements
7. Amniotic fluid volume: Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
8. Fetal size: Up to 29% of women presenting with RFM have a SGA fetus
Which conditions are associated with raised or lowered alpha-fetoprotein levels?
AFP is a protein produced by the fetal liver and yolk sac. In a normal pregnancy, AFP levels in maternal blood start to rise early in gestation and peak at around 32 weeks.
Raised in neural tubes defects (meningocele and anencephaly), abdominal wall defects (omphalocele and gastroschisis) and multiple pregnancy
Decreased in Down’s syndrome
What are the UKMEC 3 conditions for avoiding the COCP?
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
What are the UKMEC 4 conditions for avoiding the COCP?
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
- history of stroke or ischaemic heart disease
- breast feeding < 6 weeks post-partum
- uncontrolled hypertension
- current breast cancer
- major surgery with prolonged immobilisation
- positive antiphospholipid antibodies (e.g. in SLE)
What are the two forms of hormonal emergency contraception and up to how long after UPSI can they be taken?
- Levonorgestrel
- acts both to stop ovulation and inhibit implantation
- should be taken as soon as possible - efficacy decreases with time
- must be taken within 72 hours of UPSI
- single dose of levonorgestrel 1.5mg
- the dose should be doubled for those with a BMI >26 or weight over 70kg
- 84% effective is used within 72 hours of UPSI
- Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 3 hours then the dose should be repeated
- can be used more than once in a menstrual cycle if clinically indicated
hormonal
- contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception - Ulipristal
- a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
- 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
concomitant use with levonorgestrel is not recommended
- Ulipristal may reduce the effectiveness of hormonal contraception.
- Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
- caution should be exercised in patients with severe asthma
- repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
- breastfeeding should be delayed for one week after taking ulipristal.
What are the criteria for using the copper coil as emergency contraception?
- must be inserted within 5 days of UPSI, or
- if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
- may inhibit fertilisation or implantation
- prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
- is 99% effective regardless of where it is used in the cycle
may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period
A copper coil is contraindicated in patients with an active STI or pelvic inflammatory disease. This would otherwise be the first-line option if the patient did not have a suspected STI.
What is normal weight loss after birth?
Weight loss of between 7-10% in the few days after birth is normal and most babies will return to their birth weight within the first 2 weeks of life
What are some potential ‘minor’ breastfeeding problems?
‘Minor’ breastfeeding problems
1. frequent feeding in a breastfed infant is not alone a sign of low milk supply
2. nipple pain: may be caused by a poor latch
3. blocked duct (‘milk bleb’): causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
4. nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby
How is mastitis due to breastfeeding managed?
Mastitis affects around 1 in 10 breastfeeding women. The BNF advises to treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days. Breastfeeding or expressing should continue during treatment.
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
How can raynaud’s disease of the nipple be treated?
In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.
Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
How is obstetric cholestasis managed?
- induction of labour at 37-38 weeks is common practice but may not be evidence based
- ursodeoxycholic acid - again widely used but evidence base not clear
- vitamin K supplementation
What are the contraindications to breastfeeding (/which drugs and conditions are contraindicated in breastfeeding)?
- antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- psychiatric drugs: lithium, benzodiazepines, clozapine
- aspirin
- carbimazole
- methotrexate
- sulfonylureas
- cytotoxic drugs
- amiodarone
- galactosaemia
- viral infections - this is controversial with respect to HIV in the developing world. This is because there is such an increased infant mortality and morbidity associated with bottle feeding that some doctors think the benefits outweigh the risk of HIV transmission
What is a typical quadruple test result that indicates Down’s syndrome?
↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A
People who receive an increased risk result from their screening test are offered non-invasive prenatal testing (NIPT), amniocentesis, or chorionic villous sampling to confirm the diagnosis.
When are Down’s syndrome tests undertaken?
the combined test is now standard
- these tests should be done between 11 - 13+6 weeks
- nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
- Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
- trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the hCG tends to lower
quadruple test
- if women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks
quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A
NIPT
analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
cffDNA derives from placental cells and is usually identical to fetal DNA
analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation
What should be monitored during treatment of eclampsia?
- urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
- respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
- treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
What are the UKMEC3 and 4 contraindications to the depo injection (medroxyprogesterone acetate)?
3 = past breast cancer
4 = current breast cancer
What are the 3 types of placenta accreta?
- accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
- increta: chorionic villi invade into the myometrium
- percreta: chorionic villi invade through the perimetrium
What are the missed pill rules if more than one is missed during the pill free interval or at the start of a cycle?
If you miss more than one pill during the pill-free interval or at the start of a cycle, then you are at risk of becoming pregnant. ‘the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row’. The use of emergency contraception is also recommended if there was an episode of unprotected sexual intercourse (UPSI) during the pill-free interval or week 1 of the cycle, as in this case. The additional recommendation would be to advise the patient to take the most recent missed pill and continue subsequent pills as normal.
What are the missed pill rules if one pill is missed at any time in the cycle?
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
What are the missed pill rules when 2 or more pills are missed for: week 1, week 2 and week 3?
- take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
- the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
- if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
- if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception
- if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
How are babies born to mothers with hepatitis B (chronic or acute) treated?
- all pregnant women are offered screening for hepatitis B
- babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy (hepatitis B surface antigen positive or high risk of HepB) should receive a complete course of vaccination (1 soon after birth, 2 at 1-2 months and 3 at 6 months) + hepatitis B immunoglobulin
- hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
What is the formal definition of pre-eclampsia?
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
-proteinuria
-other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
What is the function of folic acid?
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
What are the causes and consequences of folic acid deficiency?
Causes of folic acid deficiency:
-phenytoin
-methotrexate
-pregnancy
-alcohol excess
Consequences of folic acid deficiency:
-macrocytic, megaloblastic anaemia
-neural tube defects
How are neural tube defects prevented during pregnancy?
- all women should take 400mcg of folic acid until the 12th week of pregnancy
- women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
-women are considered higher risk if any of the following apply:
*either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
*the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
*the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
What are the risks to the mother and fetus in chicken pox exposure during pregnancy?
Risks to the mother
- 5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)
- risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
- studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
- features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Other risks to the fetus
- shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
- severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
How is maternal EXPOSURE to chickenpox managed?
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)
- if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
- if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
*RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure - if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 AFTER exposure
How is chickenpox in pregnancy managed?
- if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
- there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
- consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
- if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
When is metformin indicated in gestational diabetes?
If the fasting glucose is <7mmol/L
If diet and exercise have failed to control glucose levels after 1-2 weeks
When is OGTT offered ?
- 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
- women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Risk factors are: - 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 is insulin indicated in gestational diabetes?
- If glucose targets are not met with diet/exercise and metformin
-If at time of diagnosis the fasting glucose level is > = 7mmol/L - If fasting glucose is between 6-6.9nmol/L and there is evidence of complications such as macrosomia or hydramnios
Short-acting insulin is used
What is used in women who cannot tolerate metformin or need but decline insulin?
Glibemclamide
What are the glucose targets for self-monitoring of blood glucose in diabetes in pregnant women?
Fasting - 5.3nmol/L
1 hr after meals - 7.8nmol/L
2 hrs after meals - 6.4nmol/L
How is hypertension in pregnancy defined?
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
What are the appropriate treatments for hypertension in pregnancy?
Oral labetalol first line
Oral nifedipine (if asthmatic) and hydralazine
When is magnesium sulphate given in patients with pre-eclampsia?
- should be given once a decision to deliver has been made
- in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
- urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
- respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
- treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
How long does the progestogen-only-pill take to become effective?
48 hours
(unless commenced up to and including day 5 of the menstrual cycle, in which case the cover is immediate and when switching from COCP if continued directly from the end of a pill packet)
When is a POP missed and what are the rules?
- if < 3 hours* late: continue as normal
- if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
- diarrhoea and vomiting: continue taking POP but assume pills have been missed
(except for Cerazette (desogestrel) where a 12 hour period is allowed)
What is the gold standard investigation for endometriosis?
Laparoscopy
How is heavy menstrual bleeding managed?
- Does not require contraception
- either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
- if no improvement then try other drug whilst awaiting referral - Requires contraception, options include
- intrauterine system (Mirena) should be considered first-line
- combined oral contraceptive pill
- long-acting progestogens
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
How is placental abruption managed?
- Fetus alive and < 36 weeks
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation - Fetus alive and > 36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally - Fetus dead
induce vaginal delivery
What are the complications of placental abruption?
- Maternal
- shock
- DIC
- renal failure
- PPH - Fetal
- IUGR
- hypoxia
- death
How is obstetric cholestasis managed?
- induction of labour at 37-38 weeks is common practice but may not be evidence based
- ursodeoxycholic acid - again widely used but evidence base not clear
- vitamin K supplementation
How long is Mirena licensed for?
5 years
What is the mechanism of folic acid?
Folic acid is converted to tetrahydrofolate (THF)
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
What are the causes and consequences of folic acid?
Causes of folic acid deficiency:
- phenytoin
- methotrexate
- pregnancy
- alcohol excess
Consequences of folic acid deficiency:
- macrocytic, megaloblastic anaemia
- neural tube defects
What doses of folic acid are given to patient groups in pregnancy?
- all women should take 400mcg of folic acid until the 12th week of pregnancy
- women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
women are considered higher risk if any of the following apply:
- either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
- the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
- the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
What are the findings on quadruple test that may suggest Edward’s (Trisomy 18) syndrome?
LOW AFP
LOW oestriol
LOW beta-hCG
NORMAL inhibin A
What are the findings on quadruple test that may suggest neural tube defect?
Isolated HIGH AFP
Normal oestriol, hCG and inhibin A
When is induction of labour indicated?
- prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
- prelabour premature rupture of the membranes, where labour does not start
- maternal medical problems
*diabetic mother > 38 weeks
*pre-eclampsia
*obstetric cholestasis - intrauterine fetal death
What is the Bishop score?
The Bishop score is used to help assess whether induction of labour will be required. It has the following components:
- Cervical position
Posterior = 0
Intermediate = 1
Anterior =2 - Cervical consistency
Firm = 0
Intermediate = 1
Soft = 2 - Cervical effacement
0-30% = 0
40-50% = 1
60-70% = 2
80% = 3 - Cervical dilation
<1 cm = 0
1-2 cm = 1
3-4 cm = 2
>5 cm = 3 - Fetal station
-3 = 0
-2 = 1
-1, 0 = 2
+1,+2 = 3
Interpretation
*a score of < 5 indicates that labour is unlikely to start without induction
*a score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
What are the different methods of induction of labour?
- membrane sweep
- involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
- can be done by a midwife at the antenatal clinic. Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit
- membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction
- prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping - vaginal prostaglandin E2 (PGE2)
- also known as dinoprostone - oral prostaglandin E1
- also known as misoprostol - maternal oxytocin infusion
- amniotomy (‘breaking of waters’)
- cervical ripening balloon
*passed through the endocervical canal and gently inflated to dilate the cervix
Which induction methods should be used based on Bishop scores?
- if the Bishop score is ≤ 6
- vaginal prostaglandins or oral misoprostol
- mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
(Reassess cervix at 6 hours before considering oxytocin)
- if the Bishop score is > 6
- amniotomy and an intravenous oxytocin infusion
(do not use amniotomy alone, and oxytocin can increase pain felt from contractions so additional analgesia is recommended)
What is the main complication of induction of labour and how is it managed?
Uterine hyperstimulation
- the main complication of induction of labour
- refers to prolonged and frequent uterine contractions - sometimes called tachysystole
potential consequences:
*intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
*uterine rupture (rare)
management
- removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
- consider tocolysis
Which antibiotic is used for group B streptococcus prophylaxis intrapartum?
Benzylpenicillin
What are the risk factors for Group B streptococcus infection?
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS infection (women who’ve had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive)
- maternal pyrexia e.g. secondary to chorioamnionitis
What is the risk of GBS infection when GBS was detected in a previous pregnancy?
50%
These women should be offered testing in late pregnancy (35-37 weeks or 3-5 weeks before the anticipated delivery date)
When is intrapartum antibiotic prophylaxis for GBS indicated?
- All women with a previous baby with early or late onset GBS disease
- All women in preterm labour regardless of GBS status
- Women with pyrexia during labour
What are the criteria for expectant management of ectopic pregnancy?
Size <35mm
Unruptured
Asymptomatic
No fetal heartbeat
hCG < 1,000IU/L
Compatible if another intrauterine pregnancy
Monitor over 48 hours and if bhCG levels rise again or symptoms manifest then intervention is performed
What are the criteria for medical management of ectopic pregnancy?
Size <35mm
Unruptured
No significant pain
No fetal heartbeat
hCG < 1,500IU/L
Not suitable if another intrauterine pregnancy
Involved giving Methotrexate and can only be done if the patient is willing to attend follow-up
What are the criteria for surgical management of ectopic pregnancy?
Size >35mm
Can be ruptured
Pain
Visible fetal heartbeat
hCG < 5,000IU/L
Compatible with another intrauterine pregnancy
Surgical management can involve salpingectomy or salpingotomy
- Salpingectomy is first-line for women with no other risk factors for infertility
- Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage
*around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)
How is cervical cancer managed?
- Management of stage IA tumours
- Gold standard of treatment is hysterectomy +/- lymph node clearance
- Nodal clearance for A2 tumours
- For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
*Close follow-up of these patients is advised
- For A2 tumours, node evaluation must be performed
- Radical trachelectomy is also an option for A2 - Management of stage IB tumours
- For B1 tumours: radiotherapy with concurrent chemotherapy is advised
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent
- For B2 tumours: radical hysterectomy with pelvic lymph node dissection - Management of stage II and III tumours
- Radiation with concurrent chemotherapy
- See above for choice of chemotherapy and radiotherapy
- If hydronephrosis, nephrostomy should be considered - Management of stage IV tumours
- Radiation and/or chemotherapy is the treatment of choice
- Palliative chemotherapy may be best option for stage IVB
Management of recurrent disease
- Primary surgical treatment: offer chemoradiation or radiotherapy
- Primary radiation treatment: offer surgical therapy
How is cervical cancer staged?
FIGO Stage
IA - Confined to cervix, only visible by microscopy and less than 7 mm wide:
A1 = < 3 mm deep
A2 = 3-5 mm deep
IB - Confined to cervix, clinically visible or larger than 7 mm wide:
B1 = < 4 cm diameter
B2 = > 4 cm diameter
II - Extension of tumour beyond cervix but not to the pelvic wall
A = upper two thirds of vagina
B = parametrial involvement
III - Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall
NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III
IV - Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis
What are the complications of cervical cancer treatment?
Complications of surgery
- Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk)
- Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies
- Radical hysterectomy may result in a ureteral fistula
Complications of radiotherapy
- Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
- Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
How is vaginal candidiasis diagnosed?
Clinically
a high vaginal swab is NOT routinely indicated if the clinical features are consistent with candidiasis
How is pre-eclampsia INITIALLY managed?
- NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
- women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
How is suspected endometrial cancer investigated?
All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
- first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
- hysteroscopy with endometrial biopsy
How is amenorrhoea investigated?
- exclude pregnancy with urinary or serum bHCG
- full blood count, urea & electrolytes, coeliac screen, thyroid function tests
- gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure), raised if gonadal dysgenesis (e.g. Turner’s syndrome)
- prolactin
- androgen levels: raised levels may be seen in PCOS
- oestradiol
Which treatment should be used for vaginal candidiasis in pregnant women?
Clotrimazole pessary
Rather than Oral fluconazole as oral antifungals are contraindicated as they may be associated with congenital abnormalities.
What is the most common cause of PID?
Chlamydia trachomatis
What is the first line management for mastitis?
Continue breastfeeding
+ analgesia and warm compresses
When is axillary node clearance indicated in breast cancer?
Those with clinically palpable lymphadenopathy
Those with axillary node biopsies showing proven lymph node metastases
NOT indicated when biopsy shows isolated tumour cells or micrometastases (risks associated with surgery including lymphoedema and functional arm impairment outweigh the benefits of treatment)
Clinical features of endometriosis
chronic pelvic pain
secondary dysmenorrhoea: pain often starts days before bleeding
deep dyspareunia
subfertility
non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
How can uterine fibroids be treated to reduce the size before removal?
GnRH agonists
When is external cephalic version done?
From 36 weeks in nulliparous women
From 37 weeks in multiparous women
When is breast radiotherapy offered?
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
When is CTG monitoring indicated 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 - this was a new point added to the guidelines in 2014
Which are the SSRIs of choice in breastfeeding women?
Sertraline or paroxetine
How is infertility treated in PCOS?
Weight reduction
Clomifene
Metformin can also be used, particularly in patients who are obese
Gonadotrophins
Which medications are used for a medical abortion?
Mifepristone (anti-progestogen) followed by prostaglandins eg misoprostol 48 hours later to stimulate uterine contractions
Why should the COCP not be used in the first 21 days postpartum?
Due to increased VTE risk postpartum
What are the causes of increased nuchal translucency?
Down’s
Congenital heart defects
Abdominal wall defects
When is a woman considered post-menopausal?
Over 45 and not had a period in the last 12 months
How are perineal tears classified?
- first degree
- superficial damage with no muscle involvement
- do not require any repair - second degree
- injury to the perineal muscle, but not involving the anal sphincter
- require suturing on the ward by a suitably experienced midwife or clinician - third degree
- injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
require repair in theatre by a suitably trained clinician - fourth degree
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
require repair in theatre by a suitably trained clinician
What is the mechanism of action of metformin in PCOS?
Increases peripheral insulin sensitivity to reduce changes in the hypothalamic pituitary ovarian axis
How are reduced fetal movements investigated?
- If past 28 weeks gestation:
- Initially, handheld Doppler should be used to confirm fetal heartbeat.
- If no fetal heartbeat detectable, immediate ultrasound should be offered.
- If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
- If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement - If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.
- If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.
- If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
What is the screening tool for postnatal depression?
Edinburgh postnatal depression scale (EPDS) score of more than 13 suggests a ‘depressive illness of varying severity’
less, suggests their symptoms are less severe and more likely to be temporary.
How is stress incontinence managed?
- pelvic floor muscle training
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months - surgical procedures: e.g. retropubic mid-urethral tape procedures
- duloxetine may be offered to women if they decline surgical procedures
- a combined noradrenaline and serotonin reuptake inhibitor
- mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
What is the time frame for delivery in a CAT2 section?
Within 75 minutes
What should be done in the case of inadequate smear samples?
repeat the sample in 3 months
if two consecutive inadequate samples then → colposcopy
\What are the causes of delayed puberty based on stature?
Delayed puberty with short stature
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome
Delayed puberty with normal stature
- polycystic ovarian syndrome
- androgen insensitivity
- Kallman’s syndrome
- Klinefelter’s syndrome
What are the adverse effects of Tamoxifen?
Adverse effects
- menstrual disturbance: vaginal bleeding, amenorrhoea
- hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
- venous thromboembolism
- endometrial cancer
What are the side effects of aromatase inhibitors?
- osteoporosis: NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
- hot flushes
- arthralgia, myalgia
- insomnia
Which drug should women who are at risk of developing pre-eclampsia take?
Aspirin 75mg
Started from 12 weeks.
How is urge incontinence medically managed in frail older patients?
Oxybutynin/tolterodine/darifenacin should be avoided as they are antimuscarinics
Mirabegron (beta 3 agonist) can be used if there is concern about anticholinergic side effects
How is cervical intraepithelial neoplasia treated?
Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic. Alternative techniques include cryotherapy.
When a rhesus negative women given their first anti-D prophylaxis during pregnancy?
28 weeks
In ectopic pregnancy, which location is the most associated with an increased risk of rupture?
Isthmus
least able to expand to accommodate the growing embryo/fetus and is therefore most prone to rupture
How does Paget’s disease of the nipple differ from eczema of the nipple?
Paget’s disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
What can happen to fibroids during pregnancy?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
What are the indications for 1. Referral or 2. Consideration of referral to 2week wait for breast cancer?
Refer:
- aged 30 and over and have an unexplained breast lump with or without pain or
- aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Consider:
- with skin changes that suggest breast cancer or
- aged 30 and over with an unexplained lump in the axilla
when is non-urgent referral considered for breast lumps?
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.
Which fluids are given to women admitted with hyperemesis gravidarum?
0.9% saline with potassium:
Saline infusion is needed to replenish the lost intravascular volume. Adding potassium is essential as hypokalemia is common with hyperemesis gravidarum. It is worth knowing that women with hyperemesis gravidarum should have renal function and electrolytes, urine ketones and ultrasound (excluding multiple or molar pregnancies).
As thiamine deficiency is common in patients with hyperemesis gravidarum; fluids containing dextrose should not be given as dextrose increases the body’s need for thiamine which might precipitate Wernicke encephalopathy.
What are the risk factors for hyperemesis gravidarum?
- increased levels of beta-hCG
*multiple pregnancies
*trophoblastic disease - nulliparity
- obesity
- family or personal history of NVP
Smoking is associated with a decreased incidence of hyperemesis.
When is admission indicated in hyperemesis gravidarum?
- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
Also recommend having a lower threshold for admission to hospital if the woman has a co-existing condition (for example diabetes) that may be adversely affected by nausea and vomiting.
What is the triad needed to diagnose hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
How is hyperemesis gravidarum managed?
- simple measures
- rest and avoid triggers e.g. odours
- bland, plain food, particularly in the morning
- ginger
- P6 (wrist) acupressure - first-line medications CKS
- antihistamines: oral cyclizine or promethazine
- phenothiazines: oral prochlorperazine or chlorpromazine - second-line medications
- oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. The MHRA advise that if ondansetron is used then these risks should be discussed with the pregnant woman
- oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects eg tremor. It should therefore not be used for more than 5 days - admission may be needed for IV hydration
- normal saline with added potassium is used to rehydrate
What are the complications of hyperemesis gravidarum?
- acute kidney injury
- Wernicke’s encephalopathy
- oesophagitis, Mallory-Weiss tear
- venous thromboembolism
fetal outcome CKS
- studies generally show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms
- severe NVP resulting in multiple admissions and failure to ‘catch-up’ weight gain may be linked to a small increase in preterm birth and low birth weight
When is medical management indicated in mastitis?
- the BNF advises treating ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’
- the first-line antibiotic is oral flucloxacillin for 10-14 days
- reflects the fact that the most common organism causing infective mastitis is Staphylococcus aureus
- breastfeeding or expressing should continue during antibiotic treatment.
What is vulval intraepithelial neoplasia, what are the risk factors?
Vulval intraepithelial neoplasia (VIN) is a pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated. The average of an affected women is around 50 years
Risk factors
- human papilloma virus 16 & 18
- smoking
- herpes simplex virus 2
- lichen planus
Features
- itching, burning
- raised, well defined skin lesions
When are mastectomy or wide local excision indicated?
Wild local excision:
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- DCIS < 4cm
Mastectomy:
- Multifocal tumour
- Central tumour
- Large lesion in small breast
- DCIS > 4cm
When is radiotherapy used in breast cancer?
- Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
- For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
When is chemotherapy used in breast cancer?
Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
What is the sequence of management in PPH (after stabilising)?
- bimanual uterine compression to manually stimulate contraction
- intravenous oxytocin and/or ergometrine (no ergometrine in hx of hypertension)
- intramuscular carboprost (unless hx of asthma)
- intramyometrial carboprost
- rectal misoprostol
- surgical intervention such as balloon tamponade
*don’t give carboprost in history of asthma
What is the discharge like in mammary duct ectasia compared with intraductal papilloma?
Mammary duct ectasia:
- Dilatation breast ducts.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
Intraductal papilloma:
- Commoner in younger patients
- May cause blood stained discharge
- There is usually no palpable lump
When is lactational amenorrhoea considered reliable?
Lactational amenorrhoea is a reliable method of contraception if the following criteria are fulfilled:
- baby under 6 months;
- exclusively breastfeeding;
- amenorrhoea, and
- gaps between feeds do not exceed 4 hours in the day or 6 hours at night.
What are the risk factors for breech presentation?
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
What are the contraindications to external cephalic version?
- where caesarean delivery is required
- antepartum haemorrhage within the last 7 days
- abnormal cardiotocography
- major uterine anomaly
- ruptured membranes
- multiple pregnancy
When can you expect pregnancy test to become negative following a termination?
Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast
When should a smear take place if a woman is called while she is pregnant?
NICE guidelines suggest that a woman who has been called for routine screening wait until 12 weeks post-partum for her cervical smear.
If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.
What should be given to pregnant women at risk of developing pre-eclampsia?
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.
What needs to be monitored when giving magnesium sulphate treatment?
Monitor reflexes (toxicity is indicated by loss of deep tendon reflexes), respiratory rate, oxygen sats and urine output
(respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression)
How often is cervical screening done in women of varying ages?
25-49 = Every 3 years
50-64 = Every 5 years
What is the most common cause of cord prolapse? What are other risk factors?
Around 50% of cord prolapses occur at artificial rupture of the membranes.
Risk factors for cord prolapse include:
- prematurity
- multiparity
- polyhydramnios
- twin pregnancy
- cephalopelvic disproportion
- abnormal presentations e.g. Breech, transverse lie
When should women be given VTE prophylaxis in pregnancy?
A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.
A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin.
- Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal.
- If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include:
- Age > 35
- Body mass index > 30
- Parity > 3
- Smoker
- Gross varicose veins
- Current pre-eclampsia
- Immobility
- Family history of unprovoked VTE
- Low risk thrombophilia
- Multiple pregnancy
- IVF pregnancy
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
Which drug is used in the treatment/prophylaxis of VTE in pregnancy?
Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy.
Which antibiotic is used for group B streptococcus?
Benzylpenicillin
What are the side effects of using GnRH agonists for shrinking uterine fibroids?
GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
they act to overstimulate GnRH production resulting in exhaustion of the GnRH axis and reduced oestrogen and progesterone concentration. Because they decrease serum oestrogen they have an increased risk of resulting in loss of bone mineral density when used for a long period hence are only used for a short time. Other side effects include menopausal symptoms such as hot flashes and vaginal dryness.
When can hormonal contraception be used after ellaone?
5 days
Ulipristal may reduce the effectiveness of hormonal contraception.
When should ellaone be used with caution?
In patients with severe asthma
breastfeeding should be delayed for one week after taking ulipristal.
What causes an increased or decreased AFP?
Increased AFP
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
Decreased AFP
- Down’s syndrome
- Trisomy 18
- Maternal diabetes mellitus
- Maternal obesity
What are the risk factors for placental abruption?
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
What are the contraindications to expectant management of a miscarriage?
Some situations are better managed with medically or surgically. NICE list the following:
1. increased risk of haemorrhage
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
2. previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
3. evidence of infection
What 3 factors make up the risk malignancy index?
Risk malignancy index (RMI) prognosis in ovarian cancer is based on US findings, menopausal status and CA125 levels
What is a galactocele?
Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
Where is hCG secreted by?
Human chorionic gonadotrophin (HCG) is secreted by the syncytiotrophoblast into the maternal bloodstream, where is acts to maintain the production of progesterone by the corpus luteum in early pregnancy. It is later produced by the placental trophoblast.
HCG can be detected in the maternal blood as early as day 8 after conception.
What is periductal mastitis and how is it managed?
A non-lactational mastitis.
Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav
What is the Pearl index?
The Pearl Index is the most common technique used to describe the efficacy of a method of contraception. The Pearl Index describes the number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year.
Eg, Assuming the Pearl Index is 0.2 and the medication is adhered to perfectly, we would expect to see 0.2 pregnancies for every hundred women using the pill for one year - or 2 for every thousand.
When is axillary node dissection indicated during breast conserving surgery?
In patients with breast cancer undergoing breast conserving surgery with adjuvant radiotherapy if, at sentinel node biopsy, less than 3 involved nodes are found then no further management of the axilla is required
Otherwise, dissection is indicated
What are the Hb cut-offs for giving iron therapy in pregnant and postpartum women?
Normal = <115
First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L
Which is the only effective therapy to treat fibroids causing problems with fertility?
Myomectomy
What is duct ectasia and how is it managed?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. It typically presents with nipple retraction and occasionally nipple discharge or a peri-areolar lump.
Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
How is LMWH monitored?
Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE)
How is vaginal candidiasis treated?
options include local or oral treatment
NICE Clinical Knowledge Summaries recommends:
- oral fluconazole 150 mg as a single dose first-line
- clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
- If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
What are the potential complications of hormonal replacement therapy?
- increased risk of breast cancer
- increased by the addition of a progestogen
- the increased risk relates to the duration of use
- the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT - increased risk of endometrial cancer
- oestrogen by itself should not be given as HRT to women with a womb
- reduced by the addition of a progestogen but not eliminated completely
- the BNF states that the additional risk is eliminated if a progestogen is given continuously - increased risk of venous thromboembolism
- increased by the addition of a progestogen
- transdermal HRT does not appear to increase the risk of VTE
- NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal) - increased risk of stroke
- increased risk of ischaemic heart disease if taken more than 10 years after menopause
What is Meig’s syndrome?
The three features of Meig’s syndrome are:
- a benign ovarian tumour
- ascites
- pleural effusion
It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.
What is the definition of premature ovarian failure?
The onset of menopausal symptoms and elevated gonadotrophin levels (FSH > 25 IU/L on two occasions more than 4 weeks apart) before the age of 40 years
What are the high risk factors fir pre-eclampsia (presence of 1 merits aspirin 75mg from 12 weeks)?
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
What are the moderate risk factors for pre-eclampsia (presence of 2 merits aspirin 75mg from 12 weeks)?
- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- body mass index (BMI) of 35 kg/m² or more at first visit
- family history of pre-eclampsia
- multiple pregnancy
What bHCG level points towards an ectopic rather than miscarriage?
> 1,500
What are the types of endometrial hyperplasia and how should it be managed?
Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer
Types
- simple
- complex
- simple atypical
- complex atypical
Features
abnormal vaginal bleeding e.g. intermenstrual
Management
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypia: hysterectomy is usually advised in premenopausal women, and Hysterectomy with bilateral salpingo-oophorectomy is the recommended management for postmenopausal women due to increased risk of ovarian malignancy if bilateral salpingo-oophorectomy is not performed.
What is Mittelschmerz?
Mid cycle pain is very common and is due to the small amount of fluid released during ovulation
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.
Full blood count- usually normal
Ultrasound- may show small quantity of free fluid
What is the normal endometrial thickness at different stages of the menstrual cycle?
Normal endometrial thickness in premenopausal women:
- During menstruation: 2-4mm
- Early proliferative phase (day 6-14): 5-7mm
- Late proliferative: up to 11 mm
- Secretory phase: 7-16 mm
What are the diagnostic criteria for PCOS?
For a diagnosis of PCOS to be made, 2 out of 3 of the following must be present:
- Infrequent or no ovulation (usually manifested as infrequent or no menstruation).
- Clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne or elevated levels of total or free testosterone).
- Polycystic ovaries on ultrasound scan.
What is Sheehan’s syndrome?
Sheehan’s syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery. Diagnosis of Sheehan’s is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH
What investigations should be done in suspected PCOS?
pelvic ultrasound, FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)
What is alcohol advice during pregnancy?
Avoid alcohol throughout pregnancy.
According to the NICE guidelines, it is recommended that women who are pregnant or planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage. However, if they choose to drink, to minimise the risk to the baby, they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk. The safest approach is not drinking alcohol at all during pregnancy.
Why are withdrawal bleeds important in endometriosis?
In women with PCOS, intervals between menstruation of more than 3 months (or fewer than 4 per year) increase the risk of endometrial hyperplasia and carcinoma. Therefore inducing a withdrawal bleed every 3-4 months or preventing proliferation of the endometrium is recommended. This can be achieved with a cyclical oral progestogen (e.g. medroxyprogesterone) for at least 12 days a month, a combined oral contraceptive (COC), or levonorgestrel-releasing intrauterine system (LNG-IUS).
After what period of time would continued lochia warrant further investigation with ultrasound?
Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium. An ultrasound is indicated if lochia persists beyond 6 weeks
At what gestation is there risk of congenital rubella syndrome?
Risk
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks
How is rubella investigated and monitored in pregnancy?
Diagnosis
- suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
- IgM antibodies are raised in women recently exposed to the virus
- it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
Management
- suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
- since 2016, rubella immunity is no longer routinely checked at the booking visit
- if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
- non-immune mothers should be offered the MMR vaccination in the post-natal period
- MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
wot haz whirlpool sign?
Ovarian torison
What are the features of breast fibroadenomas and how are they managed?
- Develop from a whole lobule
- Mobile, firm, smooth breast lump - a ‘breast mouse’
- 12% of all breast masses
- Over a 2 year period up to 30% will get smaller
- No increase in risk of malignancy
- If >3cm surgical excision is usual
What are the risks of prematurity for baby?
- increased mortality depends on the gestation
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotizing enterocolitis
- chronic lung disease, hypothermia, feeding problems, infection, jaundice
- retinopathy of prematurity
*important cause of visual impairment in babies born before 32 weeks gestation
*the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization)
*screening is done in at-risk groups - hearing problems
What is paget’s disease of the breast?
intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
What is a duct papilloma?
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
What are the 3 types (with 5 overall subtypes) of benign ovarian cysts?
- Physiological cysts (functional cysts)
- Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
- Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts - Benign germ cell tumours
- Dermoid cyst
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours - Benign epithelial tumours - Arise from the ovarian surface epithelium
- Serous cystadenoma
the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)
bilateral in around 20%
- Mucinous cystadenoma
second most common benign epithelial tumour
they are typically large and may become massive
if ruptures may cause pseudomyxoma peritonei
What is fibroadenosis?
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
How are miscarriages managed?
- Expectant management
First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
If expectant management is unsuccessful then medical or surgical management may be offered
Some situations are better managed with medically or surgically. NICE list the following:
- increased risk of haemorrhage
- she is in the late first trimester
- if she has coagulopathies or is unable to have a blood transfusion
- previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
evidence of infection
- Medical management:
- Vaginal misoprostol
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines
Advise them to contact the doctor if the bleeding hasn’t started in 24 hours.
Should be given with antiemetics and pain relief - Surgical management
The two main options are vacuum aspiration (suction curettage) or surgical management in theatre
Vacuum aspiration is done under local anaesthetic as an outpatient
Surgical management is done in theatre under general anaesthetic.
What results of the quadruple test suggest edward’s or patau syndrome
Low AFP
Low Oestriol
Low hCG
Normal Inhibin A
What does a halo sign on a mammogram suggest?
A breast cyst
Who is breast cancer screening offered to and how often?
The NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.
How should urinary incontinence be initially investigated?
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture
- urodynamic studies
What should happen if a low-lying placenta is found at the 20 week scan?
If low-lying placenta at the 20-week scan:
- rescan at 32 weeks
- no need to limit activity or intercourse unless they bleed
- if still present at 32 weeks and grade I/II then scan every 2 weeks
- final ultrasound at 36-37 weeks to determine the method of delivery
elective caesarean section for grades III/IV between 37-38 weeks
- if grade I then a trial of vaginal delivery may be offered
- if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage
What are the surgical options for pelvic organ prolapse?
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy
Vault prolapse: Sacrocolpoplexy
Which bug is Group b streptococcus?
Streptococcus agalactiae
Which factors make candidiasis more likely?
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV
Which contraception can be used in patients assigned female at birth with a uterus that are taking testosterone therapy?
- Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects.
- Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy.
- Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation.
- Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.
Which non-hormonal medications can be used to manage menopausal symptoms?
- Vasomotor symptoms
fluoxetine, citalopram or venlafaxine - Vaginal dryness
vaginal lubricant or moisturiser - Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants - Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
What is puerperal pyrexia and how is it managed?
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes:
- endometritis: most common cause
- urinary tract infection
- wound infections (perineal tears + caesarean section)
- mastitis
- venous thromboembolism
Management
- if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
What does a ‘snowstorm’ sign on axillary lymph node ultrasound indicate?
The ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicates extracapsular breast implant rupture. It is due to leakage of the silicone, which then drains via the lymphatic system, giving the ‘snowstorm appearance’ both in the breast and the lymph nodes.
Where is the most common location of ectopic pregnancies?
The ampulla
What is fibronectin?
Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN
What type of inheritance is the BRCA1 mutation?
Autosomal dominant.
Majority of cases people are heterozygotes.
What is a snow-storm appearance of ultrasound scan?
A complete hydatidiform mole
(all genetic material comes from the father)
Features are:
- vaginal bleeding
- uterus size greater than expected for gestational age
-abnormally high serum hCG
- ultrasound: ‘snow storm’ appearance of mixed echogenicity
What are the risk factors for endometrial cancer?
- excess oestrogen
*nulliparity
*early menarche
*late menopause
*unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously - metabolic syndrome
*obesity
*diabetes mellitus
*polycystic ovarian syndrome - tamoxifen
- hereditary non-polyposis colorectal carcinoma
What are the 3 main categories of anovulation?
Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)
Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)
Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive
What are the forms of ovarian induction?
- Exercise and weight loss
Typically this is the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss
Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered - Letrozole
According to UptoDate, this is now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate
Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development
The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction
Side effects: fatigue (20%), dizziness (10%) - Clomiphene citrate
While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead
Mechanism of action: clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development
Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%) - Gonadotropin therapy
This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism
For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial
This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome
Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development
What is ovarian hyperstimulation syndrome?
- Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly
- In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including:
*Hypovolaemic shock
*Acute renal failure
*Venous or arterial thromboembolism
This is a rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction
Depending on the severity, the management includes:
- Fluid and electrolyte replacement
- Anti-coagulation therapy
- Abdominal ascitic paracentesis
- Pregnancy termination to prevent further hormonal imbalances
What is the wood screw’s manoeuvre for shoulder dystocia?
The Wood’s screw manoeuvre describes the action of putting a hand in the vagina and rotating the foetus 180 degrees in attempt to ‘dislodge’ the anterior shoulder from the symphysis pubis.
What is the Rubin’s manoeuvre for shoulder dystocia?
press on the posterior shoulder to allow the anterior shoulder extra room
Which layers are cut through during a lower segment C section?
- Skin
- Superficial fascia
- Deep fascia
- Anterior rectus sheath
- Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
- Transversalis fascia
- Extraperitoneal connective tissue
- Peritoneum
- Uterus
What are the 6 possible abnormalities on CTG and what are their causes?
- Baseline bradycardia
Heart rate < 100 /min
- Increased fetal vagal tone, maternal beta-blocker use - Baseline tachycardia
Heart rate > 160 /min
- Maternal pyrexia, chorioamnionitis, hypoxia, prematurity - Loss of baseline variability
< 5 beats / min
Prematurity, hypoxia - Early deceleration Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
- Usually an innocuous feature and indicates head compression - Late deceleration Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
- Indicates fetal distress e.g. asphyxia or placental insufficiency - Variable decelerations Independent of contractions
- May indicate cord compression
What are the causes of oligohydramnios?
In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
Causes
- premature rupture of membranes
- Potter sequence: bilateral renal agenesis + pulmonary hypoplasia
- intrauterine growth restriction
- post-term gestation
- pre-eclampsia
Which contraceptives can be used concurrently with antiepileptics?
There are a number of factors to consider for women with epilepsy:
- the effect of the contraceptive on the effectiveness of the anti-epileptic medication
- the effect of the anti-epileptic on the effectiveness of the contraceptive
- the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant
For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine:
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
For lamotrigine:
UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
If a COCP is chosen then it should contain a minimum of 30 µg of ethinylestradiol.
What is an amniotic fluid embolism?
This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.
- The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
- Symptoms include: chills, shivering, sweating, anxiety and coughing.
- Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
There may be a sudden collapse.
What are the rules for taking methotrexate during conception?
Methotrexate: must be stopped at least 6 months before conception in both men and women
What is the time until effectiveness if different contraceptives are not started on the first day of the period?
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Why is the depo not used in women over 50?
Effects on bone mineral density
What is the potential risk of ondansetron use in pregnancy?
Ondansetron during pregnancy is associated with a small increased risk of cleft palate/lip - the MHRA advise that these risks need to be discussed with the pregnant woman before use
What measures reduce vertical transmission of HIV from mother to baby?
- Factors which reduce vertical transmission (from 25-30% to 2%)
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding) - Screening
NICE guidelines recommend offering HIV screening to all pregnant women - Antiretroviral therapy
all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously - Mode of delivery
- vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
- a zidovudine infusion should be started four hours before beginning the caesarean section - Neonatal antiretroviral therapy:
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks. - Infant feeding
in the UK all women should be advised not to breast feed
How is placental abruption managed based on gestation and fetus?
Fetus alive and < 36 weeks
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Fetus dead
induce vaginal delivery
How is recurrent vaginal candidiasis managed?
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
- high vaginal swab for microscopy and culture
- consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
- induction: oral fluconazole every 3 days for 3 doses
- maintenance: oral fluconazole weekly for 6 months
What are the main considerations with hepatitis B and pregnancy?
- all pregnant women are offered screening for hepatitis B
- babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
(studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy) - there is little evidence to suggest caesarean section reduces vertical transmission rates
- hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
How should premature ovarian insufficiency be managed?
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes
What are the presentations of the two potential brachial plexus injuries from shoulder dystocia?
Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’.
Klumpke’s palsy occurs due to damage of the lower brachial plexus and commonly affects the nerves innervating the muscles of the hand.
How is endometriosis managed?
NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
if analgesia doesn’t help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried
If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include:
GnRH analogues - said to induce a ‘pseudomenopause’ due to the low oestrogen levels
drug therapy unfortunately does not seem to have a significant impact on fertility rates
surgery
this may be an option for women who have not responded to conventional medical treatment
for women who are trying to conceive, NICE recommend laparoscopic excision or ablation of endometriosis plus adhesiolysis as this has been shown to improve the chances of conception. Ovarian cystectomy (for endometriomas) is also recommended
