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Year 5 > Repro 4 > Flashcards

Repro 4 Flashcards

1
Q

Hyperemesis gravidarum

A
  • Severe form of nausea ad vomiting which occurs before 20 weeks of gestation
  • Tend to be between 8-12 weeks
  • Severe enough to need Hospital admission
  • Diagnosed through exclusion
  • May not respond to antiemetics and can vomit up to 10 times a day
  • Diagnosis: 5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
  • Use PUQE score
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2
Q

Hyperemesis gravidarum complications

A
  1. Inability to keep down fluids or solids leading to dehydration, electrolytes and nutrients
  2. Leading to weight loss (2-5 kg): malnutrition
  3. Dehydration: causing ketosis and VTE
  4. Electrolyte imbalance: hyponatraemia, kidney failure and hypoglycaemia
  5. Vitamin B deficiency (B6-polyneuropathy, Thiamine deficiency-Wernicke’s encephalopathy)
  6. Rarely liver failure, renal failure , fetal and maternal mortaliy. Can cause IUGR and premature birth
  7. Mallory-Weiss tears of oesophagus and haematemesis
  8. Wernicke’c encephalopathy , osmotic demylination syndrome-(pyramidal tract sighs, spastic quadriparasis, pseudobulbar palsy and impaired consciousness).
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3
Q

Hyperemesis gravidarum risk factors

A
  1. Higher levels of HCG
  2. Multiple pregnancies
  3. Molar pregnancies
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4
Q

Hyperemesis gravidarum investigations

A
  1. FBC and clotting
  2. U&E, Haematocrit, LFTs, Thyroid Function Tests if prolonged
  3. Urine for ketones, culture and sensitivity
  4. USS ? Multiple pregnancies, molar pregnancy
  5. Social aspects
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5
Q

Hyperemesis gravidarum principles of treatment

A
  1. Admit to hospital: ContinuedN+V with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics. OR comorbidity OR unable to keeps meds and liquids down
  2. Mild cases can be dealt in Pregnancy assessment unit. Refractory cases will need admission.
  3. Social and mental health Support.
  4. Conservative: ginger, acupressure on PC6
  5. Rarely parenteral feeding and steroids.
  6. Usually Termination of pregnancy is not required and multi-disciplinary care with involvement of Psychiatry, Gasroenterology ,dietetician and obstetric team will resolve the problem.
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6
Q

Medication for Hyperemesis gravidarum

A
  1. I/V fluid replacement -normal saline, hartman solution and electrolyte replacements. Daily monitor of U&e
  2. Anti-emetics: cyclizine or promethazine, then Onansetron and Metoclopramide. May need to be IV or IM
  3. Potassium chloride for Hypokalaemia
  4. Small frequent meals
  5. Antacids for epigastric discomfort
  6. Vitamin B supplements specially thiamine and folic acid to prevent wernicke’s encephalopathy
  7. TED stockings and LMWH due to increased VTE risk
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7
Q

Hyperemesis gravidarum; Wernicke’s encephalopathy

A

Wernicke’s encephalopathy can be precipitated by I/V dextrose solutions. Severe hyponatremia as well as rapid correction-osmotic demylation syndrome-central pontine mylinolysis

Features- diplopia, abnormal ocular movement, ataxia and confusion. Typical ocular signs are 6th nerve palsy, gaze palsy or nystagmus

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8
Q

Labour definition

A

painful, regular contractions stimulating progressive effacement and dilation of the cervix. A descent of the fetus through the pelvis, culminating in the spontaneous vaginal birth of the baby, followed by the expulsion of the placenta and membranes

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9
Q

How to monitor high risk pregnancies

A

High risk pregnancies are offered CTG monitoring off the heart rate from 4cm dilation. Its continuously monitored.

Investigations: US scan and blood tests

Monitor with CTG and Bishop score

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10
Q

Assessing a CTG

A
  • Contractions= How many in 10 minutes? Strength? Duration? (Aim for 4:10 if using synthetic oxytocin)
  • Baseline rate= Normal Baseline rate for full term pregnancy = 110-160bpm.
  • Variability= The amplitude of the beat-to-beat fluctuation of the fetal heart rate around the baseline. Should be 5-25bpm.
  • Acceleration= An increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds. The presence of accelerations is reassuring – they’re often associated with fetal movements. The absence of accelerations in an otherwise normal trace is an ambiguous finding.
  • Decelerations= A decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
  • Based on the features: Normal, Suspicious and Pathological.
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11
Q

Indications for the induction of labour

A
  • Prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery (>41 weeks gestation)
  • Prelabour premature rupture of the membranes, where labour does not start
  • Intrauterine foetal death, abnorml CTG
  • Diabetic mother > 38 weeks
  • Pre-eclampsia, cholestasis
  • Rhesus incompatibility
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12
Q

Bishops score

A
  • Components: Cervical position, Cervical consistency, Cervical effacement, Cervical dilation, Fetal station
  • 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
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13
Q

Methods for inducing labour

A
  • Membrane sweep
  • Vaginal prostaglandins (PGE2): preferred method for inducing labour. Either a tablet or pessary
  • Maternal oxytocin infusions
  • Amniotomy- breaking off waters
  • Cervical ripening balloon- passed through the endocervical canal and inflated to dilate the cervix. Alternative to prostaglandins (previous C-section, para >3)
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14
Q

Ongoing management for induction of labour

A
  • Most women give birth within 24 hours of induction if slow/no progress offer:
  • Further vaginal prostaglandins
  • Artificial rupture of membranesandoxytocin infusion
  • Cervical ripening balloon(CRB)
  • Elective caesarean section
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15
Q

Membrane sweep

A
  • Involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
  • 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
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16
Q

NICE guidelines for induction of labour and bishop score

A
  • If the Bishop score is <6: vaginal prostaglandins and oral misoprostol. Consider balloon catheter if high risk of hyperstimulation
  • If the Bishop score is >6: amniotomy and an IV oxytocin infusion
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17
Q

Complications of inducing labour- uterine hyperstimulation

A
  • 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, tocolysis with terbutaline
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18
Q

Failure to progress in the first stage of labour

A
  • Less than 2cm of cervical dilation in 4 hours
  • Slowing of progress in multiparous women
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19
Q

Failure to progress in the second stage of labour

A

when the active second stage (pushing) lasts over:

  • 3 hours in nulliparous women
  • 2 hour in multiparous women
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20
Q

Delay in the 3rd stage of labour

A
  • More than 30 minutes with active management
  • More than 60 minutes with physiological management
  • Active management= intramuscular oxytocin and controlled cord traction
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21
Q

Contraindications for induction of labour

A
  • Previous classical/vertical incision during caesarean section
  • Multiple lower uterine segment caesarean sections
  • Transmissible infections e.g. herpes simplex
  • Placenta praevia
  • Malpresentations
  • Severe foetal compromise
  • Cord prolapse
  • Vasa previa
22
Q

Lichen sclerosus features

A
  • Affects the anogenital area
  • Porcelin white patches on the skin which may progress to scarring, can be slightly raised
  • May be thinning or thickening of the skin, skin tightness, erosions, fissures
  • inguinal lymphadenopathy
  • may be associated with itching, irritation exacerbated by urination and sexual intercourse
  • May have bleeding over patches
  • Typically affects elderly females
23
Q

Lichen simplex and lichen planus

A

Lichen simplexis chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

Lichen planusis an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface calledWickham’s striae.

24
Q

Lichen sclerosus risk factors and complications

A
  • Is an autoimmune condition and is associated with other autoimmune conditions
  • Slightly increased risk of vulval cancer
25
Q

Lichen sclerosus treatment

A
  • Conservative: avoidance of soaps, tight clothing, rubbing or scratching
  • Watch and wait with close follow up
  • Topical corticosteroids: reduce inflammation and itch. Can use topical calcineurin inhibitors (Tacrolimus) in addition. Can give oral steroids if no response to topical
  • If post menopausal and scarring give topical oestrogen cream
  • Wide local excision (surgery) to remove the lesion: not common, only if severe adhesions and advanced scarring
  • Imiquimod cream
  • Laser ablation
26
Q

Lichen sclerosus investigations

A
  • Normally clinical diagnosis
  • Biopsy of the lesion: if needed to confirm
  • Sentinel node biopsy to demonstrate lymph node spread
  • Further imaging for staging (e.g. CT abdomen and pelvis)
27
Q

Menopause symptoms

A
  • Change in menstruating: change in length of menstrual cycle, dysfunctional uterine bleeding may occur
  • Vasomotor symptoms- hot flushes, night sweating
  • Urogenital: vaginal dryness and atrophy, urinary frequency, dyspareunia, reduced libido
  • Psychological: anxiety and depression, short term memory impairment
  • Longer term: osteoporosis, increased risk of ischaemic heart disease
28
Q

Menopause epidemiology

A

Average age is 51, when ovarian function stops. The permanent cessation of menstruation, due to a loss in follicular activity. Clinically diagnosed and is usually made in primary care, when the women has not had a period in 12 months.

29
Q

Menopause investigations

A
  • None if >40
  • If <40 tests for premature ovarian insufficiency i.e FSH. If <40 is premature menopause
  • Also test if 40-45 if menopausal symptoms or change in menstrual cycle
  • Would show: oestrogen and progesterone levels are low. LH and FSH are high
30
Q

Perimenopause and lifestyle treatment

A

Perimenopause: This period begins when symptoms of menopause start and continues until 12 months after the last menstrual period.

Lifestyle: regular exercise, weight loss, stress reduction and avoiding triggers (spicy food, caffeine, alcohol)

31
Q

Menopause: contraception use

A
  • 12 months after the last period in women >50
  • 24 months after the last period in women <50
  • Caution using COCP >40
32
Q

HRT contraindications

A
  • Current or past breast cancer
  • Any oestrogen sensitive cancer
  • Undiagnosed vaginal bleeding
  • Untreated endometrial hyperplasia
  • Current or previous VTE’s (unless on anticoagulant treatment)
  • Liver disease with abnormal LFT’s
33
Q

Types of HRT

A
  • Unopposed oestrogen increases risk of endometrial cancer. Therefore oral or transdermal combined HRT is given (contains progesterone as well).
  • Can give oestrogen only HRT if hysterectomy
  • Cyclical HRT for perimenopausal women still having periods. The progesterone can be added for the last 2 weeks or the months or the last 2 weeks every 3 months
  • Continuous HRT for postmenopausal women not having periods
34
Q

Risks and benefits of HRT

A
  • Venous thromboembolism, stroke, coronary heart disease, breast cancer, ovarian cancer
  • Oestrogen: breast tenderness, leg cramps, bloating, nausea and headaches, endometrial cancer
  • Progestogen: premenstrual syndrome-like symptoms, breast tenderness, backache, depression and pelvic pain.
  • Benefits are a reduction of symptoms
35
Q

Menopause: Management with non-HRT

A
  • Vasomotor symptoms: fluoxetine, citalopram or venlafaxine
  • Vaginal dryness: vaginal lubricant or moisturiser
  • Psychological help: self help groups, CBT, antidepressants
  • Urogenital symptoms: vaginal oestrogen even if they are taking HRT
36
Q

Menopause: stopping medication

A
  • Vasomotor symptoms: 2-5 years of HRT with regular attempts to stop
  • Vaginal oestrogen: long term
  • Important to gradually reduce HRT
37
Q

HRT is indicated for

A
  • the treatment of menopausal symptoms where the risk/benefit ratio is favourable
  • women with early menopause until the age of natural menopause (around 51 years), even if they are asymptomatic
  • women under 60 years who are at risk of an osteoporotic fracture in whom non-oestrogen treatments are unsuitable
38
Q

Miscarriage definition

A

expulsion of product of conception before 24 weeks of gestation (POG) which means before period of fetal viability

39
Q

Miscarriage risk factors

A
  1. Maternal age >35
  2. Trauma, exposure to chemical agents (tobacco, arsenic, pesticide)
  3. Endocrine disorders (diabetes, hypothyroidism, PCOS)
  4. Immunological disorders (SLE, antiphospholipid syndrome)
  5. Abnormalities in the uterus (uterine fibroid)
  6. Fetal/placental: infections (TORH), malaria, chromosomal abnormalities (triploidy, trisomies, sex chromosome monosomies)
40
Q

Types of miscarriage

A

Types of miscarriage: Threatened, Inevitable, Incomplete, Missed, Complete, Recurrent, Septic

Early miscarriage: <13 weeks

Late miscarriage: 13-24 weeks

41
Q

Threatened miscarriage

A
  1. Definition: painless vaginal bleeding that occurs anytime between implantation and 24 weeks gestation. Pregnancy has threatened to fail but has not done so yet
  2. Clinical features: bleeding (minimal, painless), associated with dull aching lower abdominal pain
  3. Examination: size of uterus corresponds to period of amenorrhea, closed cervical os
  4. U/S: well formed, rounded gestational sac with fetus within it
  5. Management: conservative
42
Q

Inevitable miscarriage

A
  1. Definition: painful vaginal bleeding from retro-placental site: POC is about to come out but has not yet passed. It can progress to complete/incomplete depending on whether or not all fetal and placental tissue has been expelled from the uterus
  2. Inevitable foetus will be lost
  3. Clinical features: vaginal bleeding (painful), associated with cramping pain at lower abdomen, loss of pregnancy symptoms (nausea)
  4. Examination: size of uterus corresponds to/less than pregnancy weeks, dilated cervical os
  5. US: foetus is intrauterine
  6. Management (consercative); hospitalisation if significant pain, bleeding, Analgesics for control of pain
43
Q

Incomplete miscarriage

A
  1. Definition: POC has been passed but not completely
  2. Clinical features: vaginal bleeding (heavy, passed out POC as fleshy masses), associated with colicky pain at lower abdomen. +/- signs of shock
  3. Examination: size of uterus is smaller than POG, open cervical Os.
  4. U/S: retained POC in the uterine cavity
  5. Management: resuscitate if bleeding is severe, do blood group and cross match, give analgesia for pain. Either medical or surgical management. Consider need for anti D
44
Q

Complete miscarriage

A
  1. Definition: all the POC has been completely passed
  2. Clinical features: history of pain and passage of product. Followed by absence of pain, minimal bleeding
  3. Examination: size of uterus is smaller than POG, closed cervical os.
  4. U/S: empty uterine cavity
  5. Management: U/S to look for empty of uterine cavity. Anti D if >11 weeks and blood group Rh negative and no abnormal antibodies. Miscarriage information leaflets, offer support and counselling.
45
Q

Missed miscarriage

A
  1. Definition: when the embryo/fetus is already dead but still remains in the uterine cavity for a period of time: without symptoms of miscarriage (early fetal demise)
  2. Clincal features: decreased pregnancy symptoms. Vaginal bleeding (absent/minimal)
  3. Examination: size of uterus is smaller than POG, closed cervical os.
  4. U/S: crumpled gestational sac: revealed fetal pole but no signs of activity (no heart size)
  5. Management: conservative wait for spontaneous expulsion. ERPOC (evacuation of products of conception), medical with Misoprostol.
46
Q

Investigations for miscarriage

A
  1. FBC
  2. Speculum exam
  3. Blood group and Rhesus status
  4. Threshold value and doubling time of Beta hCG
  5. Gestation sac, fetal pole, yolk sac
  6. Trans-abdominal or Trans-vaginal US
47
Q

Miscarriage treatment options

A
  1. Conservative:
  2. Medical: If missed miscarriage Mifepristone then 48 hours later misoprostol. If incomplete just misoprostol. Repeat pregnancy test 3 weeks later
  3. Go to hospital if bleeding doesnt stop 24 hours after giving Misoprostol
  4. Manual vacuum aspiration (MVA): must be <10 weeks gestation
  5. Surgical (ERPOC): for complications of evacuation of retained products of conception
  6. Surgical management when medical has failed or patient preference (past traumatic experience). If rhesus negative provide anti-D. Prostaglandins (misprostol) can be given before surgical management to soften the cervix
48
Q

Miscarriage: when to refer

A
  • Immediate admission to hospital: if signs of haemodynamic instability
  • Immediate admission to EPAU or out of hours gynaecology unit: suspicious of ectopic pregnancy
  • Referral to EPAU or out of hours gynae: symptoms of early pregnancy problems (cervical excitation) and >6 weeks pregnancy or any concerns about viability
49
Q

Conservative management for miscarriage

A
  • Allowing the products of conception to naturally expel. Wait 7-14 days for the miscarriage to complete spontaneously
  • Offered first line if <6 weeks unless increased risk of haemorrhage or previous traumatic pregnancy
  • Do urine pregnancy test 3 weeks after miscarriage is complete
  • If bleeding doesn’t start offer TV US
  • Patients can still recieve conservative management if >6 weeks pregnant but need to be assessed at EPAU
50
Q

Recurrent miscarriage and complications of miscarriage

A

Recurrent miscarriage: 3 or more consecutive spontaneous miscarriages (1% population)

Complications of miscarriage: Incomplete evacuation, post uterine bleeding, Ashermans syndrome, sepsis, psychological, Haemolytic disease of the newborn.

51
Q

Causes of recurrent miscarriage

A
  1. Unknown
  2. Chromosomal problems in parents 5%- mainly Balanced translocations.
  3. Endocrine (uncontrolled Diabetes mellitus, thyrotoxicosis, PCOS)
  4. Autoimmune conditions - anti phospholipid antibodies, lupus anticoagulant(also causes intra uterine fetal death, fetal growth restriction, severe Pre-eclampsia)
  5. Infection can cause late fetal death as well (TORCH)
  6. Thrombophilia: Factor V leiden
  7. Cervical incompetence (hx of termination of pregnancy, vigorous dilatation of cervix, hx of cone biopsy)
  8. Uterine abnormalities (septate or subseptate uterus), large uterine fibroid
52
Q

Investigations for recurrent miscarriage

A
  • Bloods: antiphospholipid antibodies, thrombophilia screen
  • Cytogenic analysis of products of conception: if abnormal karyotype
  • Pelvic US: for uterine abnormalities

Year 5 (24 decks)

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