Pastest Flashcards
When is hyperemesis worst?
Between 8 and 12 weeks, although it can persist
What is the triad of symptoms required to diagnose hyperemesis gravidarum?
1) Loss of 5% pre-pregnancy weight
2) dehydration
3) electrolyte imbalance (ketones often present)
Management of hyperemesis
1) Anti-histamine e.g. promethiazine
2) anti-emetic such as ondansetron/ metoclopramide
3) Admission
What level is a ‘raised’ CA125?
> 35 IU/ml
ovarian cancer + endometriosis, menstruation, ovarian cyst etc
Lamotrigine is a good in pregnancy
Remember that trimethoprim is CI in the first trimester as it is a folate antagonist
How does acute fatty liver of pregnancy present?
Abdo pain Jaundice Mild pyrexia Raised LFT Steatosis on imaging Presents after 30 weeks
Supportive management - beware clotting
How does cholestasis of pregnancy present?
Pruritis - hands and soles in second half of pregnancy
Manage with ursodeoxycolic acid
What drug are women at high risk of pre-eclampsia advised to take?
Aspiring from week 12 to birth
What is the target HbA1c for women planning a pregnancy?
<48 mmol/ mol
remember metformin and insulin are ok
How is the contraceptive patch taken?
Water patch for 1 week, then change x 3
For week 4 wear no patch
Managment of a lady who is pregnant and has been exposed to a child with chickenpox. She has never had chickenpox
Refer for varicella zoster immunoglobulin
Only effective if given up to 10 days post-exposure
What is the commonest complication of surgical TOP?
Infection - the risk is up to 10%
Prophylaxis is given e.g. metronidazole before and azithromycin after
Other complications such as haemorrhage, retained products, failure and cervical damage occur less often
Management of pregnant lady who has had a previous VTE
High risk for VTE in pregnancy
Needs LMWH antenatally for the duration of pregnancy and 6 weeks post-partum
If a patch change is delayed for >48 hours what should you advice?
Barrier contraception for next 7 days
What is first line for painful periods?
NSAIDs such as ibuprofen or mefenamic acid
What is the first line management of shoulder dystopia?
McRobert manoeuvre
Get mum to flex and abduct hips maximally to maximise pelvic outlet
A pregnant lady is invited for her smear. All previous smears have been normal. What should be advised?
Reschedule smear for at least 12 weeks post-partum
Management of a breech presentation
If < 36 weeks, many will turn spontaneously
Breech at 36 weeks = external cephalon version (turn it round)
Unsuccessful = planned section (preferred) or vaginal birth
What is the management of thrush in pregnancy?
Clotrimazole pregnancy
Oral fluconazole is CI in pregnancy
Define HT in pregnancy?
Systolic >140 or diastolic >90
OR
Increase of >30 systolic or 15 diastolic from booking
What is the normal fetal HR?
100-160 bpm
Loss of baseline variability and late deceleration are bad signs
Management of a pregnant lady with +ve GBS swab?
IV benzylpencillin during labour
There is no advantage in treating before labour
(same for women with previous group B strep in pregnancy)
What is the commonest ovarian cyst?
Follicular cyst (due to non-rupture of dominant follicle or non-atresia of non-dominant)
What is the commonest benign epithelial tumour?
Serous cystadenoma
The forceps mnemonic can be used to remember the requirements for an instrumental delivery
F = fully dilated O = OA position R = ruptured membranes C = cepheid Presentation E = engaged presenting part P = pain relief S = sphincter (bladder) empty
What is gold standard investigation for endometriosis?
Laparoscopy
Membrane rupture + vaginal bleeding + fetal bradycardia
Most likely placenta/ vasa praevia
What is the main complication of monochorionic twins?
The risk of twin to twin transfusion syndrome - one is overloaded, one is anaemia
After treatment for CIN II, patients should have repeat colposcopy in 6 months
After treatment for CIN II, patients should have repeat colposcopy in 6 months
First line management in patients with stress incontinence?
Pelvic floor exercise
Atony is the major risk factor for PPH. How is it managed?
ABCDE
Uterine massage is first line
Then pharmacological e.g. Syntocinon or IV ergometrine
Pre-eclampsia and gestational DM can only occur after 20 weeks gestation
Prior to that, HT is longstanding
Which screening tool is used to identify post-natal depression?
Edinburgh screening tool
How does metformin work in PCOS?
It increases the peripheral insulin sensitivity
Who should be prescribed cyclical combined HRT?
Women with a uterus and menopausal symptoms who had their LMP <1 year ago
Who should be prescribed continuous HRT?
Women with a uterus who have been on cyclical for 1 year or if it has been >1 year since LMP
What are the components of the Bisphops score?
Cervcical dilatation Position Consistency Effacement Fetal station
A score <5/6 = labour unlikely to start spontaneously
A score > 9 = spontaneous labour likely
If the cord is palpable vaginally in labour what should you do?
Call the obstetrics reg
Elevate the presenting part or push the presenting part back in (if it is out) to avoid compression
What is the most common identifiable cause of postcoital bleeding?
Cervical ectropion
What is the smear test policy in HIV +ve patients?
Attended for smear every year (rather than the 3 years) which is typical
What is a high voiding pressure and low peak flow rate suggestive of?
Bladder outlet obstruction
Presents with straining, poor flow and incomplete bladder emptying
What is a tocolytic? Give an example
Drugs which delay onset of labour in lady who beings labour prematurely
E.g. Terbutaline or nifidepine
What are the fetal and maternal risks of PROM?
Fetal = prematurity, infection, pulmonary hyperplasia Maternal = chorioamnionitis
Admit and give steroids (if beyond 24 weeks) and antibiotics (erythromycin)
What is the commonest cause of early onset severe infection in a newborn?
Group B strep
What is Sheehan’s syndrome?
A complication of a severe PPH - the pituitary undergoes ischaemia —> presents as hypopituitarism
Which serotypes of HPV are most associated with cervical cancer?
16, 18 and 33
Placenta praevia occurs when the placenta is attached to the lower part of the uterus. It presents with painless PV bleeding. What are the RF?
Previous placenta praevia
Previous LSCS
Multiple pregnancies
Remember the lie is often unusual due to the placenta location
What is the fetal fibronectin test?
A test to assess if a lady is in premature labour
If not the fetal fibronectin will be -ve
It is kind of like a glue which is in the membranes
What are the 4 classifications of perineal tear?
1 = superficial only 2 = involves the perineal muscles but not anal sphincters 3 = perineal muscle and anal sphincter involved 4 = perineal muscles, anal sphincter and rectal mucosa involved
What is the cut off age to be able to consent for sex?
Regardless of competency, no child under 13 can consent - it is a child protection issue
What is the difference between tranexamic acid and mefenamic acid?
Tranexamic = plasminogen activator which acts as an anti-fibrinolytic to reduce heavy flow
Mefenamic acid = an NSAID
Uterine fibroids are sensitive to oestrogen so can grow in pregnancy. If they outgrow their blood supply, red degeneration can occur. How does this present?
Abdo pain
Fever
Vomiting
Usually resolves ok with rest and analgesia
Breast feeding and <6 weeks post-partum is a UKMEC 4 for using OCP
Migraine with no aura, BMI >35 and FH of VTE in 1st degree relative aged <45 is UKMEC 3
What medication could be given to relieve symptoms of fibroids prior to surgery?
GnRH agonists e.g. buserelin or goserelin
Women under the age of 50 require contraception at least 2 years after their LMP
For those >50, they need contraception for at 1 year after their LMP
Beta HCG is very similar in structure to LH, FSH and TSH.
Women with a molar pregnancy often have high thyroxine (as stimulated by bHCG) and low TSH (-ve feedback)
Action in a 16 y/o child with FGM?
Inform medical team and police ASAP
What is the normal endometrial thickness in a post-menopausal lady?
<4mm
Diagnostic criteria for PCOS?
At least 2/3 of:
1) Infrequent or absent periods
2) Evidence of androgen excess
3) Polycytic ovaries
Vaginal discharge after being treated for UTI?
Most commonly fungal infection due to recent antibiotics
Define perpetual pyrexia
A temperature >38 in the first 14 days following delivery
Most common causes are endometriosis, UTI, wound infection and VTE
If endometritis is suspected, she should be sent to hospital for IV fluids
Nexplanon is effective immediately with no need for condoms if fitted…
Within the first 5 days of you cycle
It is safe for mothers with Hep B to breastfeed. What is the risk of transmission for a Hep B +ve mum?
20%
If they gave the Hep B e antigen this increases to 90%
How do you describe head position of the presenting part?
1) Remember the symphysis pubis is anterior and the coccyx is posterior
2) talk in terms of the occipital bone (single bit at the back)
Features of combined test for DS?
AT 10 - 13+ 6 weeks
Nuchal thickness + BHCG + PAPPA
BHCG = high in DS PAPPA = low in DS
Features of quadruple assessment in DS
Done between 14 and 20 weeks
BHCG and inhibin = high
AFP and oestrodiol = low
Other than DS, what other causes of increased nuchal thickness are there?
CHD
CDH
Lady with sudden onset SOB and collapse after rupture of membrane?
Think amniotic fluid embolism
Rokitansky protuberance?
Dermoid cyst
Smear frequency for ladies aged 50 or over?
From 50-64 = every 5 years!
Briefly talk about the staging of ovarian cancer
Stage 1 = confined to ovary
Stage 2 = outisde ovary but within pelvis
Stage 3= outside ovary but within abdomen
Stage 4 = distant mets
75% of women with endometrial cancer present with stage 1 disease
Treatment is usually a TAHBL
Remember that although chorioamnionitis is more common with ruptured membranes, it can happen without - especially with mycoplasma genital infection
Septic miscarriages make people really unwell with crampy pain and heavy, prolonged bleeding
What is the early point that a lady would need emergency contraception post-partum?
21 days
Ovulation can begin at 28 days and sperm can survive for 7 days
What if first line for anovulatory infertility from PCOS? What is the major risk?
Clomifene - it is an oestrogen blocker which increase LH/ FSH release due to lack of negative feedback
6 month treatment - it increases multiple pregnancy risk to 11%
First line treatment for endometriosis in a lady who does not want to conceive?
COCP
Endometriosis is worsened by oestrogen, COCP blocks ovulation -> symptoms improve
A family history of a mother who developed pre-eclampsia =
Moderate risk —> take aspirin
How long after insertion will the IUD and IUS become effective?
IUD = immediately (whenever inserted) IUS = 7 days (if inserted out with first 5 days)
What normally happens to blood pressure in pregnancy?
Falls in the first half of pregnancy then rises to pre-pregnancy level before term
Advice for a patient on the COP having elective surgery?
Stop pill 4 weeks before and start 2 weeks after
The POP primarily inhibits ovulation, but also thickens cervical mucus
The IUD inhibits fertilisation as is toxic to egg and sperm
What clinical features suggest IUGR?
SFH < expected
Reduced liquor
Reduced movement
When is fetal movement normally felt?
From about 18 to 20 weeks
How is fetal growth monitored?
By measuring head and abdominal circumference and plotting on graph
Define loss of baseline variability of CTG?
Baseline fetal heart rate varying by <5beats/ minute
What 3 Doppler measurements are done to assess fetal wellbeing?
1) Umbilical flow (2 arteries, 1 vein)
2) Middle cerebral artery (increased flow is a bad sign)
3) Ductus venosus
3 risk factors for placental abruption?
Maternal trauma
Multiparity
Increased maternal age
What is the primary mode of action of the implant?
Inhibits ovulation
also COC and injection
Rules for POP and antibiotics?
No need for extra precautions
What is the most common side effect of the IUS?
Irregular bleeding for the first 6 months
List some indications for anti-d prophylaxis?
1) PV bleeding in pregnancy/ trauma
2) Miscarriage after 12 weeks
3) Ectopic pregnancy managed surgically
4) External cephalic version
5) TOP
6) Amniocentesis
What is the Kleihauer test?
A test of fetomaternal haemorrhage e.g. how many baby cells are in the mum
Should be performed after any sensitising event after 20 weeks gestation
What is the most common type of ovarian cancer?
Serous carcinoma (a type of epithelial cancer which accounts for 70-80% of all cancer)
The primary treatment for stage 2,3 and 4 is surgical excision of the tumour (with or without chemo)
Lady with hyperemesis gravidarum, diplopia and ataxia?
She has developed Wernicke’s encephalopathy due to thiamine (vit B1) deficiency
Define premature ovarian failure
The onset of menopausal symptoms + elevated gonadotropin before the age of 40
Which is the only form of contraception that has no restriction for use in migraine with aura?
IUD
Why are perimenopausal women given cyclincal HRT?
It produces predictable withdrawl bleeds - continuous causes very unpredictable bleeding
OCP + surgery rules?
Stop 4 weeks before
Can switch to POP if desired
Only restart OCP after mobilisation
HIV and pregnancy?
All women should be on ART
Elective section will reduce risk of transmission
If in UK avoid breastfeeding
What is the pneumonic for looking at a CTG?
Dr = Define risk
C = Contractions - should have 5 in 10 min in established labour
BRA = Baseline rate - 110-160
V = variability - 5 -25 beats/ min
A = Acceleration - a rise of 15 bpm lasting for 15 seconds or more
D = deceleration - a decrease of 15 bpm lasting for 15 seconds of more
O = overall impression
Indications for a category 1 (urgent c section)
Bradycardia
Single prolonged deceleration with baseline below 100 bpm for > 3min
Action if late deceleration and no other abnormality on CTG?
Fetal blood sampling to look for hypoxia and acidosis - pH >7.2 is normal
Methotrexate is teratogenic and must be stopped in both men and women at least 3 months before conception
Methotrexate is teratogenic and must be stopped in both men and women at least 3 months before conception
Oxybutynin should be stopped in frail, elderly women at risk of falls
It causes constipation, dizziness and drowsiness and is a falls risk
How would you explain cervical ectropion to a patient?
- the cells normally inside your cervix have moved to the outside.
- they are a bit fragile so can bleed very easily
- nothing to worry about, very common in women, especially if they are on the pill
CBT is first line for women with PND who do not have a history of severe depression
If there is a history of severe depression or CBT is unacceptable/ ineffective then try SSRI
Which drug should be given prior to surgery for uterine fibroids?
GnRH agonists such as leuroplide which reduce the size of the fibroid pre-surgery
This makes surgery easier and helps to reduce bleeding
VTE prophylaxis in a lady with 2 previous DVT who gets pregnant
Will need LMWH starting ASAP and continued until 6 weeks post-natal
Teenage girl with sudden onset lower abdominal pain. US shows free fluid and ‘whirlpool sign’
Ovarian torsion
In PCOS and infertility, clomifene is better than metformin at inducing ovulation and getting pregnancy BUT
It is associated with a greatly increased risk of multiple pregnancy
What is the criteria for methotrexate therapy to manage an ectopic?
- Small <35mm
- unruptured with no heart beat
- bHCG <1500
- no pain
In a well positioned, well flexed baby what is the smallest skull diameter?
Suboccipitobregmatic diameter = 9.5cm
- 5 = fetal head at ischial spines
0 = at level of ischial spines = engagement
COCP inhibits ovulation
POP inhibits implantation
OHSS results from the release of vasoactive mediators from the hyperstimulated ovaries. What symptoms does it cause?
Symptoms result from fluid shift from intravascular compartment to 3rd space:
Effusions - pleural, pericardial and Ascites
Liver or kidney dysfunction
Haemoconcentration —> increased risk of thrombosis and coagulopathy
Known complication are AKI, ARDS, VTE and ovarian torsion
Young women with PCOS are at greatest risk
Which medical treatment is available for ladies with stress incontinence who have not controlled treatment with pelvic floor exercises?
Duloxetine (SNRI)
In what circumstances should a Sim’s speculum be used to perform a vaginal examination?
To assess for a uterovaginal prolapse
The patient should be examined on her left lateral position
OCP raises risk of Breast and Cervical cancer
Decreases risk of ovarian and endometrial cancer
Which form of contraception is associated with a long delay in return to natural fertility?
Depo-provera
Can take up to 12 months to return
What is the commonest side effect of the POP?
Eratic bleeding
up to 40% will be affected
