Quesmed Flashcards
1
Q
When does paget’s disease of the breast present?
A
In older women with an eczma like rash around the nipple and areola
May spread to rest of breast
2
Q
What are the features of padget’s disease of the breast?
A
Eczema-like rash on the skin of the nipple and areola. This is may be itchy, red, crusty and inflamed.
Nipple discharge which may be bloody.
Burning sensation, increased sensitivity or pain
Nipple changes such as nipple retraction or inverted
In some cases there may be a palpable breast lump
There may be a skin ulcer which does not heal
3
Q
What can infection mastitis lead to?
A
Accumulation of pus in an area of the breast which can lead to the development of a lactational breast absess
4
Q
What is the cause of a lactational breast absess?
A
The most common causative agent is staphylococcus aureus, which enters via a crack in the nipple skin or through a milk duct.
5
Q
What is the managemnet of a lactational breast absess?
A
Incision and drainage or needle aspiration (with or without diagnostic ultrasound)
6
Q
The combination of irregular, hard lump which is fixed to the deep tissue (likely her pectorialis major) is very suspicious for what?
A
Invasive breast cancer
7
Q
What is a fibroadenoma?
A
Benign breast lump commonly seen in young women. It typically presents as smooth, firm, highly mobile, painless mass in the breast which is slow growing. It may sometimes be called a “breast mouse” due to its highly mobile nature.
8
Q
Every patient who have a wide local excision should be offered what?
A
Adjuvant Rt
9
Q
Mechanism of action of tamoxifen?
A
Oestrogen receptor antagonist
10
Q
Where is tamoxifen metabolised?
A
pro-drug which is metabolised in the liver into active compounds (afimoxifene and endoxifen). T
11
Q
Main actions of tamoxifen?
A
Their main useful actions are as competitive antagonists at the oestrogen receptor. In oestrogen receptor positive tumours this acts to suppress activity or any residual tumour cells.
12
Q
What is cyclical mastalgia?
A
Cyclical mastalgia is breast tenderness which comes and goes with the monthly menstrual cycle.
13
Q
A 60 year old female presents to her general practice. She has noted a patch of dry, thickened and ‘flakey’ skin over her left nipple. She has not noticed any discharge from the nipple.
On examination the breasts are symmetrical, there is no nipple inversion, discharge, swelling or palpable lump. There are no other findings on examination.
Given the likely diagnosis what is the best option?
A
Refer for a two week wait breast clinic appointment
Suggests paget’s disease
14
Q
What is the first line mnagamet of uncomplicated mastitis?
A
continue breast feeding. This helps to stop the milk from building up in the breast. Static milk is prone to ascending infection via the milk ducts. Ensuring a proper latch is crucial as poor latching is a risk factor for mastit
15
Q
A 56 year old lady undergoes a mastectomy for a T3N0M0 breast cancer. Hormone receptor sensitivities return as oestrogen and progesterone receptor negative but HER2 positive. Which adjuvant therapy is she likely to benefit from?
A
Trastuzumab (otherwise known as Herceptin) is a monoclonal antibody against the extracellular domain of the HER2 receptor. It improves survival of patients with HER2 positive breast cancer.
16
Q
What patients as an adjuvant can tamoxifen be used
A
In patients who have oestrogen receptor positive breast cancer who are pre or peri-menopausal.
17
Q
A 70 year old female has undergone surgical treatment for an invasive, node negative non-metastatic breast cancer. The surgery was a success and post-operative adjuvant radiotherapy has also been completed. The patient has no other significant past medical history and has no allergies to any medications. The histology results for the tumour show that it is Her2 negative, Oestrogen receptor positive and Progesterone receptor negative.
Given what is known about the patient’s disease what is the best treatment to manage the patient?
A
Anastrozole
This aromatase inhibitor is used in post-menopausal patents with breast cancer that oestrogen receptor positive. This helps reduce the levels of oestrogen in post-menopausal women, who make the majority of their oestrogen via aromatisation.
18
Q
Trustuzamab (‘Herceptin’) side effects
A
Cardiac dysfunction – including heart failure
Teratogenicity
19
Q
Why is a mammogram difficult in pateitns under 40?
A
Denser breast tissue
20
Q
What is fat necrosis?
A
Fat necrosis is a benign pathology of the breast which is more common in obese patients.
21
Q
Possible complications of axillary node clearnace
A
Axillary node clearance related injury
Lymphoedema
Damage to brachial plexus cords or nerves
Axillary artery/vein injury
22
Q
What is a phyllodes tumour?
A
breast cancer originating from fibroepithelial tissue and can be difficult to distinguish from a benign fibroadenoma. They commonly present as a smooth, hard, mobile breast mass which can grow rapidly in size over a period of weeks or months
23
Q
What age group does phyllodes tumour usually present in?
A
Present in women in their 40s or 50s (in contrast to fibroadenomas, which tend to appear in younger women).
24
Q
Epidimology of fibrocytic disease?
A
Fibrocystic disease is the most common benign disease of the breast.
It occurs most commonly in the 20-50 year old age group.
It is caused by the cumulative effect of cyclical hormones such as oestrogen and progesterone (among many others) which leads to chronic changes in the breast including multiple small cysts and proliferative changes.§
25
Clinical features of fibrocystic disease?
Bilateral “lumpy” breasts – more commonly in upper outer quadrant
Breast pain
Symptoms which worsen with the menstrual cycle – normally peaking 1 week before menstruation
26
Management of fibrocystic disease?
Treatment is essentially supportive although there is some question as to whether oral contraceptives or hormone replacement therapy may work.
Most cases will resolve after menopause.
27
A 35 year old woman presents to the GP after noticing a breast lump in the shower 2 weeks ago. She is generally well, is not taking any regular medication and has no family history of breast cancer. She does not smoke or drink alcohol.
On examination, there is a small, solid 1cm mass in the right breast which is non-tender. There are no visible skin or nipple changes and the patient reports no discharge. No lymphadenopathy is felt on palpation of the axilla.
What is the most appropriate management in regards to referral to secondary care?
Urgent referral as the patient as over the age of 30 with an unexplained breast lump.
28
What are the clinical featrures of periductal mastitis?
The smoking history is a strong risk factor for periductal mastitis. The mammary duct fistula is a feature associated with periductal mastitis. This condition occurs when the ducts behind the nipple become infected.
29
Risk factors for breast carcinoma?
```
Increased hormone exposure; Early menarche or late menopause, Nulliparity or late first pregnancy, Oral contraceptives or Hormonal Replacement Therapy
Susceptibility gene mutations: Most commonly BRCA mutations (BRCA1/BRCA2)
Advancing age
Caucasian ethnicity
Obesity and lack of physical activity
Alcohol and tobacco use
Past history of breast cancer
Previous radiotherapy treatment
```
30
First line medication for mastitis?
Flucloaxcillin
31
First steps of management for shoulder dystocia?
Once shoulder dystocia has been recognised, management is as follows:
Immediately call for help - further midwifery assistance, senior obstetrician, paediatrician and anaesthetist may be required
Do not apply fundal pressure as this may lead to uterine rupture and discourage maternal pushing as this may exacerbate shoulder impaction
First line procedure is McRoberts manoeuvre
Hyperflexion and abduction of the mother's legs tightly to the abdomen
This may be accompanied with applied suprapubic pressure
Routine traction (as applied during normal delivery) in an axial direction should be applied to assess whether the shoulders have been released.
32
What should be done iif McRobert's manoeuvre fails?
All-fours position
Internal rotational manoeuvres:
Woods' screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest.
33
If both first and second line manoeuvres have failed, the following may be considered (but carry increased risk of morbidity and mortality and success rates are unknown):
Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section
34
Causes of polyhydramions?
Excess production can be due to increased foetal urination:
Maternal diabetes mellitus
Foetal renal disorders
Foetal anaemia
Twin-to-twin transfusion syndrome
Insufficient removal can be due to reduced foetal swallowing:
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
35
What is the defenition of acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is a rare condition which occurs in the third trimester of pregnancy.
The cause for this fatty liver is unclear but it is believed that it may be part of a spectrum of pregnancy conditions with HELLP syndrome and pre-eclampsia.
36
What are the clinical features of acute fatty liver of pregnancy?
```
Jaundice
Abdominal pain (commonly in right upper quadrant)
Disseminated Intravascular Coagulation
Nausea and/or vomiting
Malaise
Fatigue
Oliguria
Tachycardia
Fever
```
37
safest anti-epileptic medications to use during pregnancy.
Carbamazepine
| Iamotrigine
38
What is cabergoline?
Dopamine receptor agonist
| Inhibits prolactin production leading to suppression of lactation
39
What is frank breech?
Legs are fully extended up to the shoulders and the presenting part is the buttocks.
40
Certain circumstances call for addition or subtraction of points (Bishops score modifiers):
1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
41
The components of the bishop score can be remembered with the following mnemonic:
Pregnancy Can Enlarge Dainty Stomachs! (Position, Consistency, Effacement, Dilation, Station).
42
What can prostaglandin E2 PV do?
Encourage cervical ripening and increase the likelihood of a vaginal delivery
43
Management of hyperemesis gravidarum?
Fluid replacement therapy with normal saline
Potassium chloride as excessive vomiting usually causes hypokalaemia
Anti-emetic medications such as cyclizine (first line), metoclopramide or prochlorperazine. Ondansetron or domperidone may be used in severe cases.
Thiamine and folic acid to prevent development of Wernicke's encephalopathy
Antacids to relieve epigastric pain
Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration.
44
Selective screening for gestational diabetes is based on risk factors. Patients with any of the following risk factors can be offered an OGTT at 26-28 weeks gestation:
BMI above 30kg/m2.
Previous macrosomic baby (weighing 4.5kg or above).
Previous gestational diabetes.
First degree relative with diabetes.
Ethnic origin with a high prevalence of diabetes (South Asian, black Carribbean, Middle Eastern)
45
Antepartum haemorrhage is what?
Vaginal bleeding occurring between 24 weeks of pregnancy and birth.
46
What is the management of placental abruption?
Admit to hospital, obtain IV access and crossmatch blood, monitor fetus with cardiotocography and consider delivery
Antepartum haemorrhage may be concealed in some cases and thus she may be losing a lot of blood disproportionate to the visible blood loss.
47
What does milk ejection come from
Oxytocin
48
Where is oxytocin produced from?
Posterior pituitary gland
49
Side effects of progestrone
premenstrual syndrome-like symptoms, mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain
50
Where are follicle stimulating hormone (FSH) and luteinising hormone (LH) produced in males?
Anterior pituitary
51
What is human placental lactogen
has metabolic effects on the mother, including stimulating an increase in the plasma level of glucose, amino acids and free fatty acids. This ensures that there is a constant supply of energy substrates for the foetus to use.
52
Which hormone acts on the endometrium during the proliferative phase of the uterine cycle?
Oestrogen
53
Which of the following is a function of luteinising hormone (LH) in males?
LH acts on the Leydig cells in the testes to stimulate androgen production.
54
What nerve causes male erection?
The pelvic splanchnic nerve carries PARASYMPATHETIC fibres from S2-4, responsible for the male erection but not ejaculation. Remember, 'Point'.
55
What nerve causes ejaulation
Pudendal
56
What is shed during the menstrual phase of the uterine cycle?
The stratum functionalis of the endometrium
57
What is the cortical reaction
Reaction with prevents more than one sperm cell entering the same oocyte.
58
Which of the following is an action of oestrogen in the female reproductive cycle?
Promotes endometrial proliferation during the proliferative stage of the uterine cycle
59
What is the role of follicle stimulating hormone (FSH) in the male reproductive system?
FSH acts on Sertoli cells in the testes to stimulate spermatogenesis and to support spermiogenesi
60
action of luteinising hormone (LH) in females?
The LH surge induces ovulation.
Transforms the empty Graafian follicle into the corpus luteum after ovulation.
Stimulates the production of androgens by the theca cells, which then undergo FSH-stimulated aromatisation in the granulosa cells.
61
Which type of cell does follicle stimulating hormone (FSH) act on in males?
Sertoli cells
62
What happens to HR during pregnancy and why
Between week 6 and week 28 of gestation a woman’s cardiac output will increase by 30 to 50%. This is a necessary development to support a growing pregnancy; supplying the uterus and placenta with adequate blood and removing waste products from the fetal circulation.
63
What is prolactin secretion regulated by
Tonic dopamine secretion
64
Steps in spermatogenesis
Spermatogonia (diploid stem germ cells) lie on the basement membrane of the seminiferous tubules in the testes.
The stem cells multiply using the process of mitosis inside the testes. Half of the new cells from this go onto become the future sperm cells (type B spermatogonia), and the other half remain as stem cells so that there is a constant source of germ cells (A1 spermatogonia).
The spermatogonia that will undergo spermatogenesis cross the membrane into the sertoli cells. They become enlarged and are called primary sperm cells.
The primary sperm cells undergo meiosis which produces two secondary spermatocytes.
The secondary spermatocytes undergo a second division of meiosis which produces a total of four haploid spermatids.
The spermatids are released into the seminiferous tubules (a process called spermination).
The spermatids mature into spermatozoa in a process called spermiogenesis as they travel along the seminiferous tubule.
Once they reach the epididymus, the spermatids undergo the final stages of maturation. This can take up to a week.
65
A sustained erection, in the absence of physical and psychological stimuli, beyond 4 hours is called what
Priapism
66
A 31 year old woman delivered her first baby 4 weeks ago. After a good start with breastfeeding, the mother is now having difficulty producing milk. Which of the following may be implicated?
The mother is taking the OCCP
67
Which of the following best describes the acrosome reaction?
The release of hydrolytic enzymes from the head of the sperm which softens the zona pellucida to enable fertilisation to occur.
68
oestrogen-receptor-positive (ER +ve), early-stage breast cancer in postmenopausal women treatment
Aromatase inhibitors
anastrozole, exemestane and letrozole.
69
What does HCG do?
Produced by foetal trophoblast cells.
It is structurally similar to luteinising hormone (LH) so it is able to bind to LH receptors on the corpus luteum. This prevents the regression of the corpus luteum so that progesterone production continues for the first 8-10 weeks of pregnancy. After this, the placenta takes over the production of progesterone.
70
During pregnancy, oxytocin and oxytocin receptors in the myometrium are down-regulated to reduce myometrial excitability. Which hormone is responsible for this?
Progestrone
71
What triggers menstruation if fertilisation does not occur?
Degeneration of the corpus luteum leading to a fall in the level of progesterone
72
Which hormone in the combined oral contraceptive pill (COCP) is primarily responsible for preventing pregnancy?
Progestrone
73
Site of sperm maturation
Epididymis
74
Fluid that is released from the ducts of the seminal vesicles protects and supports the sperm. It has the following properties:
It is alkaline to neutralise the acidic environment of the male urethra and the female reproductive tract which would otherwise inactivate and harm the sperm cells.
It contains fructose, which the sperm use for ATP production.
It contains prostaglandins, which contributes to sperm mobility and may stimulate smooth muscle contraction within the female reproductive tract.
It contains clotting proteins, which help the semen to coagulate after ejaculation.
75
Which hormone acts on the endometrium during the secretory phase of the uterine cycle?
Progestrone
76
Criteria known as the UK Medical Eligibility Criteria (UKMEC) is used to guide decisions about when to start the COCP. There are four categories:
UKMEC1: a condition for which there is no restriction for the use of the COCP
UKMEC2: a condition where the advantages of using the COCP generally outweigh the theoretical or proven risks
UKMEC3: a condition where the theoretical or proven risks usually outweigh the advantages of using the COCP. The provision of a method requires excellent clinical judgment and referral to a specialist contraceptive provider. Not usually recommended unless other more appropriate methods are not available or not acceptable
UKMEC4: a condition which represents an unacceptable health risk if the COCP is used
77
UKMEC3 conditions include:
BMI more than 35
Family history of VTE
More than 35 years old and smoking, but less than 15 cigarettes per day
Immobility e.g. wheelchair use
Carrier of known gene mutations associated with breast cancer e.g. BRCA1/BRCA2
Controlled hypertension
Diabetes mellitus diagnosed more than 20 years ago but is not very severe
78
UKMEC4 conditions include:
Migraine with aura
More than 35 years old and smoking more than 15 cigarettes per day
History of VTE
History of stroke or heart disease
Breastfeeding less than 6 weeks post-partum
Uncontrolled hypertension
Major surgery with prolonged immobilisation
Severe diabetes mellitus diagnosed more than 20 years ago
79
What does an ovulation test measure
LH levels
80
Diagnosis of PCOS requires two out of the following:
infrequent or no periods, high levels of androgen hormones (such as testosterone) or the physical characteristics of androgen excess (such as hirsutism), and evidence of ovarian cysts on pelvic ultrasound. There is also an association with obesity and high levels of insulin and development of type II diabetes mellitus, which is why PCOS is often considered a metabolic syndrome. It is a common cause of fertility problems for females, as ovulation is impaired.
81
The ovarian ‘cysts’ described in the name PCOS are actually what
ovarian follicles which have arrested in their development, and can be seen around the periphery of the ovary on ultrasound. They are not the cause of the disease, and not all sufferers of PCOS actually have ‘polycystic ovaries’. The underlying aetiology of PCOS is as of yet unclear, although a combination of genetic and environmental factors has been implicated.
82
What is progestrone
released following ovulation. A blood test for the level of progesterone can be taken on day 21 of a regular menstrual cycle. A high progesterone level indicates that ovulation has occurred, whereas a low level indicates that the cycle was anovulatory.
83
What happens during the proliferative phase
Occurs from around day 6 to day 13.
Oestrogen secreted by growing ovarian follicles stimulates the repair of the endometrium. As the stratum basale remains, it is able to undergo mitosis to form a new stratum functionalis.
As the endometrium thickens, the endometrial glands become larger and more densely packed and the spiral arterioles coil and lengthen.
84
A 14 year old boy visits his GP because he is concerned that he hasn't had any growth of secondary sexual hair. What hormonal mechanism underpins this physiological change?
Activation of pulsatile GnRH secretion
85
Which of the following best describes the process of capacitation?
The physiological changes that spermatozoa undergo once in the female reproductive tract in order to gain the ability to penetrate and fertilise an oocyte.
86
What is the primary source of progesterone after 8-10 weeks of pregnancy?
The placenta
87
Approximately how long does spermatogenesis take?
74 days
88
If pregnancy does not occur, the corpus luteum will degenerate. What structure does this form?
Corpus albicans
89
Which of the following underpins the onset of menstrual bleeding in the normal cycle?
Following ovulation the corpus luteum maintains the lining of the womb. If the oocyte is not fertilised then the fall in lutenising hormone (LH) levels will result in the degeneration of the corpus luteum, and the womb lining will break down and be lost from the womb in vaginal bleeding.
90
Oestrogen is produced in the ovaries, and to a lesser degree, in the adrenal glands and adipose tissue. It is responsible for:
Development of the female reproductive structures.
Development of female secondary sexual characteristics. These include: distribution of adipose tissues in the breasts, abdomen, mons pubis and hips, pigmentation of the nipples, change in voice pitch, broadening of the pelvis, and changes to the pattern of hair growth on the body.
Increased protein anabolism (synergistic with growth hormone).
Maintenance of bone mineral density.
Reduction in cholesterol concentrations and increase in serum triglyceride concentrations.
During the ovarian cycle, oestrogen promotes endometrial proliferation, and triggers the LH surge which leads to ovulation. It also stimulates the muscles in the uterus to develop and contract, which helps to expel the dead tissue during menstruation.
91
Which type of cell does luteinising hormone (LH) act on in males?
Leydig cells
92
Management of PCOS
symptom control, including diet and exercise, and the use of medications such as metformin (an anti-diabetic drug) and the oral contraceptive pill to regulate bleeding and counteract the excess of androgens. Medication may also be used induce ovulation in women hoping to become pregnant.
93
A 21 year old female has been prescribed the combined oral contraceptive pill by her GP. Which of the following describes its effect on gonadotrophin releasing hormone (GnRH)?
Decreases the GnRH pulse frequency through negative feedback
94
What does the COOP contain
oestradiol (the most active of the oestrogens) plus a progestin (a progesterone analogue, such as Levonorgestrel, Desogestrel or Drospirenone). It is usually taken daily for 21 days, with a 7-day break before starting again. This allows a ‘break-through bleed’ or shedding of the endometrial lining, which will not occur if the pill is taken continuously. Monophasic formulations contain the same concentrations of hormones in each pill, whilst phasic formulations vary the concentrations to reflect a more natural cycle.
95
Hormonal methods of contraception often thicken the cervical mucus to prevent the passage of sperm into the uterus. Which hormone is responsible for this?
Progestrone
96
Once oestrogen production falls beyond a critical value what happens to LH and FSH
Less negative feedback so more FSH and LH
97
Where does oxytocin act
It acts via cell-surface G-protein coupled receptors to stimulate intracellular changes in myometrial cells, causing an increase in contractility.
98
Site of spermatogenesis
Seminiferous tubules
99
What happens during the menstral phase of the uterine cycle
Occurs from day 1 to around day 5. Declining levels of progesterone and oestrogen stimulate the release of prostaglandins that cause the uterine spiral arteries to constrict. As a result, the endometrial tissue becomes ischaemic. This causes cell death within the stratum functionalis of the endometrium and so it sloughs off.
Around 50-150 ml of blood, tissue fluid, mucus and epithelial cells are shed through the vagina
100
Once a spermatozoon reaches a secondary oocyte, it releases hydrolytic enzymes that break down the zona pellucida to enable it to reach the membrane of the oocyte for fertilisation. Which term describes this process?
The acrosome reaction
101
How many primordial follicles are stimulated each cycle
Multiple primordial follicles are stimulated each cycle to grow and develop, however usually only one follicle is allowed to reach full maturation and release its oocyte. In the case of dizygotic twins, two oocytes have been released during ovulation and fertilised by two sperm cells. This results in twins which are genetically equivalent to siblings, (and are sometimes called ‘fraternal twins’).
102
Correct order for spermatogenesis
Spermatogonia -> primary spermatocytes -> secondary spermatocytes -> spermatids -> sperm.
103
Does trnasmission of hep B and C occur through breast milk?
No
104
WHat is capacitation triggered by?
change in environment (especially exposure to heparin) once the sperm enters the female reproductive tract.
105
Which type of cell does follicle stimulating hormone (FSH) act on in females?
granulosa cells (which surround the oocytes in the ovaries) to stimulate the maturation of ovarian follicles. It also causes the granulosa cells to convert androgens to oestrogen by stimulating the production of the aromatase enzyme.
106
What does LH actr on in females
Theca cells
107
What does FSh act on in males
Sertoli cells
108
What does LH act on in males
Leydig cells
109
Where is gonadotropin-releasing hormone (GnRH) produced in females?
The hypothalamus
110
What stimulates follicular development
FSH
111
What prevents the corpus luteum from degenerating
human chorionic gonadotrophin
112
What does the LH surge do?
Trigger for ovulation to occur. The progesterone content of the combined oral contraceptive pill inhibits the release of LH from the anterior pituitary, and therefore, inhibits ovulation.
113
What thickens the cervical mucus
Progestrone
114
Whatr is the luteal phase
Occurs around day 14-28. After ovulation, the mature follicle collapses. There is minor bleeding, which clots to form the corpus haemorrhagicum.
Under the influence of LH, the empty follicle forms the corpus luteum. The corpus luteum secretes progesterone, and to a lesser extent, oestrogen, and inhibin.
115
Which hormone is produced by the corpus luteum during the luteal stage of the ovarian cycle?
Progestrone
116
Sertoli cells with continuous junctions line the seminiferous tubules in the testes to form the blood-testis barrier. Why is this necessary?
The haploid spermatids are genetically different from the host and so they express different surface antigens. This means that the host’s body would recognise them as foreign and launch an immune response against them. The blood-testis barrier is needed to separate these antigens from the systemic circulation.
117
Differentials for post coital bleeding
```
Cervical ectropion
Endocervical and cervical polyps
Cervical cancer
Sexually transmitted infections
Atrophic vaginitis
```
118
What is umbiliacal cord prolapse
occurs when the cord descends through the cervix prior to delivery of the foetus. This results in the cord becoming compressed, and placental blood flow to the foetus becomes compromised, manifesting as a foetal bradycardia and decelerations.
119
Risk factors for umbilical cord prolapse
multiparity, polyhydramnios, malpresentation and artificial rupture of membranes.
120
What is the Kleihauer test
used to quantify the dose of Rh-D antigen in maternal circulation. In significant sensitising events (events during which Rh-D antigen enters the maternal Rh-negative circulation), a Kleihauer test can guide the amount of anti-D IG needed to prevent maternal sensitisation
121
What is uterine hyperstimulation
Greater than 5 contractions occur in 10 minutes
122
First line tocolytic agent in pre term labour
Oral nifedipine
123
What is the mos common cause of PPH
Uterine atony
124
The screening results expected for trisomy 21 include what
low AFP, low oestriol, low PAPP-A, high human chorionic gonadotrophin beta-subunit (b-HCG), and thickened nuchal translucency
125
Complications of hyperemesis gravidarum
Gastrointestinal problems: Mallory-Weiss tears, malnutrition and anorexia
Dehydration relating to ketosis and venous thromboembolism
Metabolic disturbance such as hyponatraemia, Wernicke's encephalopathy, kidney failure, hypoglycaemia
Psychological sequelae such as depression, PTSD and resentment toward the pregnancy.
If the condition is very severe, the foetus may be affected due to maternal metabolic disturbance. Foetal complications include low birth weight, intrauterine growth restriction and premature labour.
126
What is hyperemesis gravidarum
severe vomiting with onset before 20 weeks of gestation.
It is severe enough to require admission to hospital and is a diagnosis of exclusion.
127
Features of obstetric cholestasis include:
Pruritis which is commonly worse on the hands and feet and can be severe in nature. It is not accompanied by a rash, but may have excoriation marks from itching.
Fatigue or malaise
Nausea and loss of appetite
Rarely there may be mild maternal jaundice (dark urine,pale stools)
Abdominal pain which is typically in the right upper quadrant
128
Treatment of obstetric choliestasis
Treatment is with chlorphenamine to reduce itch, vitamin K to reduce risk of haemorrhage and scheduling of early delivery to avoid prolonged risk of spontaneous intrauterine death.
129
When is external cephalic version offered
Is offered at 36 weeks for breech presentation (provided there is no absolute contraindication) for primiparous women. For multiparous women it is offered at 37 weeks.
130
How is External Cephalic Version performed?
ECV is a manual procedure where an experienced physician attempts to turn the baby using their hands on the abdomen. It generally has around a 50% success rate. ECV is usually carried out under ultrasound guidance. The mother is given analgesia, tocolytics and Anti-D immunoglobulin (if required) during the procedure. If ECV is unsuccessful and the baby is still breech presentation at term, the mother may choose to deliver vaginally or via Caesarean section.
There is a higher risk of complications with breech vaginal deliveries compared to cephalic births. There is also a greater risk of needing instrumentation or an emergency Caesarean section.
131
Absolute contraindications to External Cephalic Version
Caesarean section is already indicated for other reason
Ante-partum haemorrhage has occurred in the last 7 days
Non-reassuring cardiotocograph
Major uterine abnormality
Placental abruption or placenta praevia
Membranes have ruptured
Multiple pregnancy (but may be considered for delivery of the second twin)
132
In women over 50 reporting persistent abdominal symptoms a useful initial test is what
Serum CA-125
133
Medical management of endometriosis
The treatment for endometriosis depends on the symptoms, and the severity of these symptoms.
For managing pain, when only mild the use of simple analgesia such as paracetamol or NSAIDs may be all that is needed.
In cases where this is insufficient, creating an artificial menopause is used, with the use of medications such as
Combined oral contraceptive pill
Medroxyprogesterone acetate
Gonadotrophin-releasing hormone agonists
134
Management of PID
Treatment occurs in the outpatient setting, and involves ofloxacin + metronidazole
Analgesia may also be required, and the patient is reviewed in 4 weeks
All young sexually active women complaining of bilateral lower abdominal pain with adnexal tenderness are given empirical treatment for PID, due to the significant number of women that are not diagnosed.
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Surgical management of ectopic
Surgical management is recommended if the patient would be unable to attend follow-up or if the ectopic is advanced. An advanced ectopic is indicated if any of the following are present:
The patient is in a significant amount of pain
There is an adnexal mass of size ≥35mm
B-hCG levels are ≥5000IU/L
Ultrasound identifies a foetal heartbeat
Surgical management is often in the form of a salpingectomy where the Fallopian tube containing the ectopic is removed. In cases where the ectopic is in a woman with only one functioning Fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.
Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are done to exclude any trophoblastic tissue still within the Fallopian tube.
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Presentation of PCOS
Oligomenorrhoea
Subfertility
Acne
Hirsuitism
Obesity
Mood swings/depression/anxiety
Male pattern baldness
Acanthosis nigricans (secondary to insulin resistance)
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Pharmacological management of PCOS for women not planning pregnancy
Co-cyprindrol - Useful for reducing hirsutism and inducing regular menstruation.
Combined Oral Contraceptive Pill (COCP) - Used to reduce irregular bleeding and protects against endometrial cancer.
Metformin - Helps with menstrual regularity, hirsutism and acne.
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Pharmacological management of PCOS for women wishing to concieve
Clomiphene - Induces ovulation and improves conception rates.
Metformin - Can be used with/out clomiphene to increase the chances of a pregnancy.
Ovarian drilling - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary.
Gonadotrophins - Can induce ovulation if clomiphene and metformin have failed.
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Surgical management of endometriosis
Diathermy of lesions
Ovarian cystectomy (for endometriomas)
Adhesiolysis
Bilateral oophorectomy (sometimes with a hysterectomy)
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Contraindications to Vaginal birth after cessarian
classical (vertical) Caesarean scar, previous history of uterine rupture, and the usual contraindications to a vaginal delivery (such as major placenta praevia).
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Risk factors for shoulder dystocia
Maternal gestational diabetes
Macrosomia (birthweight >4kg)
Advanced maternal age
Maternal short stature or small pelvis
Maternal obesity
Post-dates pregnancy
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Investivation for cushings
Dexamethasone suppression test
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What is naegele's rule
Naegele's rule is used to calculate the EDD based on the first day of the woman's last menstrual period (LMP).
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How do you calculate naegele's rule
add one year and seven days to the first day of the LMP and subtract three months.
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Management of group B strep in pregnancy
Intra-partum antibiotic prophylaxis is the most effective method of preventing GBS infection in the newborn.
Antibiotics (commonly a penicillin) are given intravenously during labour and delivery if risk factors for GBS infection are present.
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Clinical features of placental abruption
Abdominal pain (often sudden and severe)
“Woody” hard uterus
Contractions
Vaginal bleeding (However in some cases haemorrhage may be confined to the uterus and thus concealed)
Reduced foetal movements and abnormal CTG
Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible
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Management of pregnant at 41 weeks
At 41 weeks, a membrane sweep should be offered to the mother. This procedure involves the midwife or doctor inserting a finger into the cervical opening and “sweeping” to separate the amniotic membranes from the cervix.
This separation causes release of prostaglandins which may stimulate spontaneous labour.
If membrane sweep is unsuccessful, an induction of labour is offered. Induction of labour involves the administration of prostaglandins to stimulate contractions.
If induction of labour is refused, expectant management involving regular foetal monitoring is required.
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What is atrophic vaginitis
inflammation of the vagina as a result of the mucosa becoming thinner and fragile. This is due to a fall in the level of oestrogen, hence is most common after menopause.
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Drug for managing eclamptic seqizure
Magnesium sulfate
150
What is a PPH
generally the loss of at least 500ml of blood within the first 24 hours of delivery.
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Risk factors for ectopic pregnancy
Pelvic inflammatory disease
Pelvic surgery
IUS/IUD
Assisted reproduction e.g. IVF
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What is a molar pregnancy
conception there is an imbalance in the number of chromosomes from the mother and father.
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Features of a complete mole
A complete mole is formed from 1 sperm and an empty egg with no genetic material.
The sperm then replicates to give a normal number of chromosomes; this is therefore diploid and all chromosomes are of paternal origin.
There is no foetal tissue present; just a proliferation of swollen chorionic villi.
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Features of a partial molar pregnancy
A partial mole is formed from 2 sperms and a normal egg.
Both paternal and maternal genetic material is present
There is variable evidence of foetal parts.
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Presentation of a molar pregnancy
Vaginal bleeding
Nausea
Hyperemesis gravidarum
Thyrotoxicosis (because hCG is closely related to TSH and can therefore activate it's receptors)
Uterus is larger than expected for gestational age. This enlargement is due to excessive growth of trophoblasts and retained blood.
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What does a bishop score of 5 or less suggest
Labour is unlikely without induction
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What is toxoplasmosis caused by
protozoan parasite Toxoplasma Gondii, commonly found in cat faeces, infected or meat or soil.
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Clinical featues of congenital toxoplasmosis
CNS problems such as cerebral palsy, epilepsy and hydrocephalus
learning disability
visual impairment
hearing loss
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What is taken to prevent spina bifida in babies
400 micrograms/day from 3 months prior to conception, until 12 weeks gestation
In women at higher risk (e.g. those with a child affected by a neural tube defect, or those on certain medications) are recommended a higher dose of 5mg/day
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Management of cord prolapse
The foetus should be delivered as rapidly as possible, e.g. via an instrumental delivery, or if the cervix is not fully dilated, caesarean section
While preparing for delivery, prevent further prolapse by adopting a 'knees-to-chest' position
Filling the bladder with 500ml warmed saline can aid in preventing further prolapse
Avoid exposure and handling of the cord, reduce cord into the vagina
Tocolytics e.g. terbutaline to stop uterine contractions
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What is placenta increta
The villi invade into but not through the myometrium
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First degree tear
Tear limited to the superficial perineal skin or vaginal mucosa only
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Second degree tear
Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)
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Third degree tear
3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact
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Fourth degree tear
Perineal skin, muscle, anal sphincter and anal mucosa are torn
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What is haemolutic disease of the newborn
Immune condition which develops after a rhesus negative mother becomes sensitised to the rhesus positive blood cells of her baby whilst in utero.
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What is premature ovarian insufficiency
Defined as menopause in a woman aged below 40 years.
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How is a diagnosis of premature ovarian insufficinecy done
Raised FSH levels indicate menopause. The levels should be repeated at least once to ensure the first result was not anomalous.
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Managment of premature ovarian insufficinecy
The patient should be treated with hormone replacement therapy (HRT) until at least the age of normal menopause (51), unless the risks of HRT treatment outweigh the benefits.
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What is the most appropriate investigation for diagnosing gestational diabetes for this patient?
A 2-hour oral glucose tolerance test as soon as possible following the booking visit
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What does betamethasone do?
A 2-hour oral glucose tolerance test as soon as possible following the booking visit
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What does erythromycin do?
used a antibiotic prophylaxis in preterm birth.
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What are tocolytics
drugs used during pregnancy which suppress contractions and thus labour.
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What is pregnancy induced hypertension
diagnosed when blood pressure is higher than 140/90mmHg in a pregnant woman who had normal blood pressure at booking, who is asymptomatic, and has no evidence of proteinuria.
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Who is cyclical combined HRT done for
for peri-menopausal women who are still having menstrual periods
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Who is cyclical continous HRT done for
for post-menopausal women who are not having menstrual periods
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Benefits of HRT
Relief of vasomotor symptoms
Relief of urogenital symptoms
Reduced risk of osteoporosis
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Risks of HRT
Increased risk of breast cancer
Increased risk of endometrial cancer if oestrogen given alone
Increased risk of venous thromboembolism
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What is a missed miscarriage
The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.
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What is found in HELLP syndrome
Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is managed via urgent delivery of the baby and supportive treatment of organ failure.
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Symptoms of HELLP
Headache
Nausea and/or vomiting
Epigastric pain
Right upper quadrant abdominal pain due to liver distention
Blurred vision
Peripheral oedema
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What is listeriosis
condition caused by the pathogen listeria monocytogenes
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How does placenta praevia present
The classical clinical presentation of placenta praevia is bright red vaginal bleeding which is painless. Placenta praevia should be suspected if there is vaginal bleeding which occurs after 24 weeks of pregnancy.
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Sensitisation events are those which carry a risk of foetal blood crossing the placenta into the material circulation and triggering formation of these antibodies. Sensitisation events include:
```
Antepartum haemorrhage
Significant abdominal trauma
Ectopic pregnancy
Miscarriage
Termination
Intrauterine death
External cephalic version
Invasive uterine procedures e.g. chorionic villus sampling or amniocentesis
Delivery of foetus (vaginal or by caesarean section)
```
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What is polymorphic eruption of pregnancy
PEP occurs most frequently in the third trimester and presents with itchy papules, typically first appearing on striae gravidarum, but may spread to the entire abdomen, thighs and buttocks. It may progress to a widespread eczematous rash with fluid-filled vesicles. PEP can be treated with emollients and and topical corticosteroids.
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When can IUDs be used after pregnancy
Can be inserted at the time of delivery, or up to 48 hours after uncomplicated vaginal delivery or caesarean section. After 48 hours, insertion should be postponed until 28 days after childbirth.
Copper intrauterine device (Cu-IUD)
Levonorgestrel-releasing intrauterine system (LNG-IUS)
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When can progestrone injection be used after pregnancy
Can be started at anytime
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When can progestrone implant be used after pregnancy
Anytime after delivery
189
When can POP be used after pregnancy
Anytime after delivery
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When can combined hormonal contraceptives be used after pregnancy
including pills, patches and vaginal rings - should not be started in the first three weeks postpartum. After this period, a risk assessment should be carried out for venous thromboembolism. COCP should not be prescribed to women with other risk factors for VTE within the first 6 weeks postpartum
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What is choriocarcinoma
rare tumour which is part of the spectrum of gestational trophoblastic disease. It arises when the fertilized ovum forms abnormal trophoblastic tissue instead of a foetus. Choriocarcinoma is the malignant form of the gestational trophoblastic disease. After evacuation of a hydatidiform mole, the levels of b-hCG are expected to fall and pregnancy should be avoided for 1 year. However, if they fail to drop, malignant choriocarcinoma should be suspected. Treatment involves specialist referral and methotrexate based chemotherapy is known to be effective.
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What is placenta accreta
Occurs when the placenta invades into the myometrium. It is more common in women with a previous history of caesarean section.
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What is Mittelschmerz
mid-cycle ovulatory pain and it is common. The pain is due to rupture of the Graafian (dominant) follicle, each month, which results in the release of an ovum into the fallopian tube. The pain can vary from being right-sided to left-sided depending on which ovary is ovulating that month. Duration of pain can vary from minutes up to a few days and it can be controlled using simple analgesics such as paracetamol and NSAIDs.
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What is congenital rubella syndrome
When a woman contracts rubella during her pregnancy, it can affect the developing foetus and cause Congenital Rubella Syndrome (CRS).
The risk of developing Congenital Rubella Syndrome is greatest in the first trimester.
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Clinical features of congenital rubella syndrome
Newborns with CRS commonly present with sensorineural deafness, cataracts or retinopathy and congenital heart disease.
Other features include:
Organ dysfunction
Microcephaly
Micrognathia
Haematological abnormalities
Low birth weight
Later children may have developmental delay and learning disability
Neonates also may develop a characteristic petechial rash described as a “blueberry muffin” rash.
This serious condition is now rare due to the success of the MMR (Measles, Mumps, Rubella) vaccine.
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What are the safest anti epileptics during pregnancy
Carbamazepine and lamotrigine are the safest anti-epileptic medications to use during pregnancy.
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What do prostaglandins do to the cervix
Prime it
| Allow it to become softer and shorter in preparation for labour
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When can a radical trachelectomy be done?
Can be done for slightly more advanced, yet still early-stage cancers when the aim is to spare fertility. This involves removal of the cervix, the upper vagina and pelvic lymph nodes.
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First line for hypertension in pregnancy when have asthma
Nifedipine
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What is vasa praevia
Vasa praevia is a condition seen in obstetrics where the foetal vessels run near to or across the internal cervical os.
The foetal vessels are likely to rupture in vasa praevia during rupture of membranes, as the vessels are unsupported by the umbilical cord or placental tissue. This can lead to foetal haemorrhage and foetal death.
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Clinical features of vasa praevia (classic triad)
Painless vaginal bleeding
Rupture of membranes
Foetal bradycardia (or resulting foetal death)
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NICE guidelines routinely recommend two supplements during pregnancy
Folic Acid 400 micrograms per day - shown to reduce the occurrence of neural tube defects (NTD). Recommended to all woman pre-pregnancy and up to 12 weeks gestation. A higher dose of 5mg per day is recommended to women at increased risk of NTD
Vitamin D 10 micrograms (400 units) per day - shown to be beneficial in foetal bone formation. Recommended for all pregnant women throughout pregnancy and breastfeeding
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What does the combined screening test measure
Nuchal translucency using ultrasound scan
PAPP-A hormone (level reduced in pregnancy affected with Down's syndrome)
Beta-hCG hormone (raised in pregnancy affected by Down's syndrome)
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When is the combined screening test done
Between 11-13 weeks
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What is the triple test
Beta-hCG
AFP (reduced in pregnancies affected by Down's syndrome)
uE3 (reduced in pregnancies affected by Down's syndrome)
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What is the quadruple test
triple test but with the addition of Inhibin-A levels (raised in pregnancies affected by Down's syndrome).
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What is an incomplete miscarrige
Abdominal pain and/or vaginal bleeding following a pregnancy loss where not all of the products of conception have been expelled from the uterus. On speculum examination, the cervical os may be open or closed, or there may be products seen within the os. On ultrasound, products of conception are seen persisting within the uterus.
Patients with incomplete miscarriage may be managed with 'watchful waiting', medical management with Misoprostol, or surgical management with dilatation and curettage
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What is a complete miscarriage
There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.
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Management of miscarriage
Miscarriage often cannot be prevented or stopped. Management therefore revolves around ensuring complete removal of foetal material.
It can be expectant, medical (misoprostol) or surgical. If managed surgically and the woman is rhesus negative they should receive anti-D prophylaxis.
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What is used to treat eclamptic seizures
Magnesium sulphate
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Why should a patient with severe pre-eclampsia have blood tests X3 per week
to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving haemolysis, elevated liver enzymes and low platelets.
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What is pre eclampsia
Placental condition affecting pregnant women commonly from around 20 weeks of gestation.
213
Clinical features of pre eclampsia
hypertension and proteinuria. Other signs include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia.
214
What is asherman's syndrome
characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea. In this case, the cyclical abdominal pain may be a sign that menstruation is occurring. Ultrasound examination is not particularly sensitive for making the diagnosis so an HSG or hysteroscopy might be needed for confirmation.
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What is adenomyosis
Condition where the lining of the uterus called the endometrium breaks through the myometrium and can cause menstrual cramps, menorrhagia, and abdominal pressure. In adenomyosis, the uterus will feel symmetrically enlarged, boggy, and tender to palpation.
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When does the uterus return to its non pregnat size
4 weeks post partum
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Risk factors for ectopic pregnancy
Pelvic inflammatory disease
Pelvic surgery
IUS/IUD
Assisted reproduction e.g. IVF
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Indications for elective caesarean section include:
Abnormal presentation e.g. breech or transverse.
Twin pregnancy if first twin is not cephalic.
Maternal HIV.
Primary genital herpes in third trimester.
Placenta praevia.
Anatomical reasons.
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What is ovarian hyperstimulation syndrome
complication of iatrogenic induction of ovulation.
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Presentation of ovarian hyperstimulation syndrome
The ovaries may enlarge to such an extent that they put pressure on the surrounding structures causing bloating and abdominal discomfort.
The vascular endothelial growth factor causes blood vessels to leak leading to the fluid retention in the form of:
Oedema
Pleural effusions
Ascites
Weight gain
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What are germ cell tumours
Originate from the germ cells in the embryonic gonad.
These tumours typically grow rapidly and spread predominantly via the lymphatic route.
Germ cell tumours most commonly arise in young women, which is atypical for most cases of ovarian cancer.
Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG).
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What is placental abruption
Occurs when the placental prematurely separates from the wall of the uterus. This can cause profuse bleeding as the uterine vessels are sheared.
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What should happen if someone on lithium gets pregnant and has unstable bipolar disorder
Should switch gradually to atypical antipsychiotic
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Management of hyperemesis gravardium
Fluid replacement therapy with normal saline
Potassium chloride as excessive vomiting usually causes hypokalaemia
Anti-emetic medications such as cyclizine (first line), metoclopramide or prochlorperazine. Ondansetron or domperidone may be used in severe cases.
Thiamine and folic acid to prevent development of Wernicke's encephalopathy
Antacids to relieve epigastric pain
Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration
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What does a whirpool sign indicate on doppler US
Ovarian torsion
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A 20 year old patient at 19 weeks gestation comes in for a routine visit. She undergoes urine dipstick analysis and the results indicate trace glucosuria. All other tests return as normal. IS THIS OK?
Glucosuria, especially in trace amounts, is a common finding during pregnancy as there is an increased glomerular filtration rate and a reduction in tubular reabsorption of filtered glucose.
227
Should asymptomatic bacteruria be treated in pregnancy?
recommended to treat asymptomatic bacteriuria with antibiotics e.g. Nitrofurantoin or Cefalexin as it has been shown to increase risk of spontaneous miscarriage and preterm labour.
228
How do b-Hcg LEVELS change in molar pregnancy
B-hCG levels are often much higher than would be expected in a normal pregnancy.
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How should the levels of levoythyroxine change when pregnancy is confirmed?
Increasing levothyroxine by 25 mcg as soon as pregnancy is confirmed despite a euthyroid state. This patient is currently euthyroid but because of her pregnancy, needs an increased dose of levothyroxine. The explanation for this is that in pregnancy there is a physiological increase in serum free thyroxine until the 12th week of pregnancy as the foetus is dependent on mother's circulating thyroxine until the 12th week of development when the foetal thyroid develops. Untreated hypothyroidism can lead to neurodevelopmental delay of the foetus. This surge is not seen in hypothyroid patients. Therefore, levothyroxine should be increased to mimic this surge.
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When should a membrane sweep be offered
All women should be offered a vaginal examination and membrane sweep at 40 weeks gestation. This is considered an adjunct to labour rather than an actual induction method. The cervix is assessed and if possible, a finger is passed into the cervical os to stretch it and separate the chorionic membranes from the cervix.
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Presentation of endometrial cancer
Post-menopausal bleeding
Bi-manual pelvic examination may be entirely normal as the gross uterus size may be unchanged.
Other causes of post-menopausal bleeding include vaginal atrophy, hormone replacement therapy, gynaecological polyps, and other gynaecological cancers.
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What is choriamnitis
infection of the membranes in the uterus. Typical symptoms are of a fever, abdominal pain, offensive vaginal discharge and evidence of preterm rupture of membranes. Typical signs are of maternal and foetal tachycardia, pyrexia and uterine tenderness.
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What is twin to twin transfusion syndrome caused by?
anastomoses of umbilical vessels between the two foetuses in the placenta of monochorionic twins.
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How to improve fertility in endometriosis
Surgery- Laparoscopic diathermy and adhesiolysis is a procedure that removes the endometrial deposits and adhesions from the pelvic cavity.
235
CMV features at birth
Low birth weight
Jaundice
Microcephaly
Seizures
Pneumonia
Petechial rash.
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CMV features in the first few years of life
Hearing loss
Visual impairment
Learning disability often become evident.
237
Statistically a couple stands an 80% chance of conceiving within 1 year if:
The woman is <40yo
They do not use contraception
They have regular intercourse
238
What is cervical ectropion
high levels of oestrogen trigger an enlargement of the cervix, causing eversion of the endocervical canal, which appears as a red ring.
239
What is placwenta percreta
The villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.
240
What is placenta increta
The villi invade into but not through the myometrium
241
A 32-year-old primagravida discovers from her booking blood tests that she has contracted hepatitis B. She is both HbsAg and HbeAg positive at the time of delivery.
Which of the following options represents the best management for the foetus?
This patient is positive for both Hbs and Hbe antigens, increasing the risk of vertical transmission at delivery. Using both HBV IgG and a vaccine reduces the risk of the foetus contracting HBV at birth to ~5%
242
Side effects of methotrexate
Cytopenia - Monitor full blood count and advise patients to report suspected infections and bruising.
Hepatotoxicity - Monitor liver function tests. Mild elevation is normal, but discontinue if they rise to more than 3x normal.
Renal impairment - Monitor renal function.
Pulmonary fibrosis - Take a baseline CXR. Advise patients to report any respiratory symptoms eg. dyspnoea/dry cough.
Teratogenicity - Advise patients to use contraception while taking methotrexate, and for 3 months after use.
243
WHat is cervical ectropion
happens when cells that line the inside of your cervix grow on the outside. These cells are redder and are more sensitive than the cells typically on the outside, which is why they may cause symptoms, like bleeding and discharge, for some women
244
Clinical features of vasa praevia
Painless vaginal bleeding
Rupture of membranes
Foetal bradycardia (or resulting foetal death)
245
What is lichen sclerosus
inflammatory skin condition which typically affects the genital and anal areas of the body. It is much more common in women than men.The sub-type vulvar lichen sclerosus is that which affects the inner vulva.
246
Signs of placental separation and imminent placental delivery:
Gush of blood
Lengthening of the umbilical cord
Ascension of the uterus in the abdomen
247
What is the role of Oxytocin given post-partum?
Prevention of PPH
248
What is uterine atony
The examination finding of a 'boggy' or non-contracted uterus suggests the uterus has failed to contract sufficiently to stem blood from from uterine vessels sheared during delivery.
249
Presentation of fibroids
Fibroids are often asymptomatic.
When symptoms occur, they usually involve menstrual dysfunction, in the form of menorrhagia and dysmenorrhoea.
If large enough, the fibroid may distort the uterine cavity to such extent they interfere with fertility.
If large, fibroids may be palpable on abdominal examination as a suprapubic mass. Pelvic examination may reveal an irregularly enlarged uterus.
250
Risk factors for endometrial cancer
Nulliparity
Obesity
Early menarche
Late menopause
Polycystic ovary syndrome
251
Featues of cervical cancer
Vaginal discharge
Bleeding (e.g. postcoital or with micturition or defaecation)
Vaginal discomfort
Urinary or bowel habit change
Suprapubic pain
Abnormal white/red patches on the cervix.
Pelvic bulkiness on PV examination
Mass felt on PR examination
252
First pharmacological line for pre eclampsia
Labetalol
253
When interpreting a CTG, look at four components;
aseline rate, variability, presence of accelerations and presence of decelerations. A normal foetal heart rate is 110-160bpm. There should be variability of between 5 and 25bpm. Accelerations should be present and there should not be decelerations in early labour.
254
What is primigravida
Women pregnant for first time
255
What is primiparous
describing a woman who has been pregnant and given birth once
256
What is oligohydramnios
presence of a lower than normal volume of amniotic fluid in the uterus.
257
Causes of oligohydramnios
Uteroplacental insufficiency leading tointrauterine growth restriction. This may be due to maternal disease such aschronic hypertension or pre-eclampsia, maternal smoking and placental abruption.
Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). Examples include renal agenesis, polycystic kidneys or urethral obstruction.
Premature rupture of membranes
Post-term gestation
Chromosomal anomalies
Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)
