Repro 9 Flashcards
1
Q
Amenorrhoea: karyotyping
A
- 46- XY: androgen insensitivity (TSF syndrome)
- 46- XX: Mullerian agenesis
2
Q
Management of amenorrhoea
A
- Infertility-Restoration of ovulatory function
- Estrogen deficiency -If possible HRT and prevention of osteoporosis and atherosclerosis
- Endometrial hyperplasia- Progesteron for prevention of endometrial hyperplasia in patients with normal estradiol levels
- Vaginal reconstruction in vaginal agenesis
- Gonadal tumors-If there is Y chromozome gonadectomy following puberty
3
Q
Most common causes of amenorrhoea
A
- Polycystic ovary syndrome
- Hypothalmic amenorrhoea
- Hyerprolactinaemia amenorrhoea
- Ovarian failure
4
Q
The powers
A
contractions start in the fundus and spread downwards through the myometrium. Regular, strong contractions are essential to enable progress in labour
5
Q
The 3 stages of labour
A
- First stage: onset of labour to full dilation of the cervix
- Second stage: full dilation to delivery of baby
- Third stage: delivery of baby to delivery of placenta and membranes
6
Q
First stage of labour
A
- Latent phase: painful contractions often irregular. Cervical changes (softening/effacement). Dilation up to 4cms
- Active stage: regular painful contractions and progressive cervical dilation up to 10cm
- On average- 12 hours if primigravida and 7 ½ hours multiparous
7
Q
Progress in labour
A
- Varies between individuals
- Effacement (thinning)
- Dilatation (opening)
- Descent (progress through the birth canal)
- Progress assessed by vaginal examination
- Cervix moves from posterior to anterior
Normal progress in 1st stage: 2cm in four hours
8
Q
Descent
A
- Defined relative to the ischial spine
- 0 station= top of head at the spines
- +2 station= 2cm below the ischial spine
9
Q
Fetal monitoring in low risk labour
A
- Intermittent auscultation using Doppler or Pinards stethoscope
- For one minute
- Following a contraction
- Every 15 minutes in the first stage
- Every 5 minutes in the second stage
10
Q
Labour analgesia
A
- Non-pharmacological: supportive birth partner, TENS, Birthing pool, Acupuncture
- Pharmacological: oral analgesia, Entonox, Opiate + anti-emetic, epidural
11
Q
Second stage of labour
A
- Passive: from full dilation, allows spontaneous descent of presenting part, may have some involuntary urge to push, may see some anal dilation
- Active second stage: mother is encouraged to actively push, fetal head descends- perineum stretches. Head is delivered and the body with the next contraction.
12
Q
Mechanism of delivery
A
- Descent thro the pelvis
- Flexion of the head: (chin to chest)
- Internal rotation: transverse diameter to AP
- Crowning of the head
- Extension: face sweeps the perineum
- Restitution: Head rotates to align with shoulders
- Internal rotation of the shoulders
- Expulsion: Shoulders delivered in AP diameter
13
Q
Moulding and caput succadaneum
A
Moulding: overlapping of the fetal skull bones at the suture line. Occurs during labour as the fetus descends through the pelvis
Caput succedaneum: temporary swelling of the soft parts of the head due to compression by the muscles of the cervix.
14
Q
What happens at birth
A
- Baby is delivered onto the mothers abdomen
- Delayed cord clamping allows blood to flow from the placenta to the baby
- Clamp cord approx. 2cm away from the babys abdomen
- Baby placed in direct contact with mother’s skin and dried with pre-warmed towels. Initial assessment of baby’s condition.
- Early mother baby contact to be encouraged.
- Assess for perineal trauma and manage as appropriate.
15
Q
The third stage of labour
A
- Can be active or physiological
- Physiological: can take up to an hour. Watch for signs of placental separation. Uterus well contracted at the level of the umbilicus. A sudden gush of blood, lengthening of cord
- Monitor for signs of excessive bleeding- increased risk of PPH
16
Q
The third stage of labour- active management
A
- IM injection of oxytocin (uteronic drug) following birth
- Observe for signs of separation
- Controlled cord traction
- Guard the uterus
17
Q
Ascending cholangitis definition and causes
A
Definition: severe acute infection and inflammation of the biliary tree often due to obstruction in the common bile duct
Causes: Biliary calculi (stones), benign biliary stricture, Malignancy
18
Q
Ascending cholangitis: charcots triad and Reynolds pentad
A
Charcot’s triad: RUQ pain, fever, jaundice
Reynold’s pentad
- RUQ pain, fever, jaundice, hypotension, mental confusion
- In severe cases of ascending cholangitis
19
Q
Ascending cholangitis Inx
A
- Bloods: LFT, FBC, CRP
- 1st line: US which will show bile duct dilation
- 2nd line: CT, MRCP, ERCP
20
Q
Ascending cholangitis Mx
A
- Resus with IV fluids and Abx
- Biliary drainage via ERCP, percutaneous drainage or surgical drainage
- Management of underlying cause; i.e. cholecystectomy if gallstones
21
Q
Summary of ascending cholangitis
A
- Pain: RUQ steady and severe
- Symptoms: jaundice, fever N+V
- Cause: Biliary obstruction
- Complications: sepsis, organ dysfunction
22
Q
Cholecystitis features
A
- Pain: RUQ steady, severe
- Symptoms: maybe jaundice and fever. N+V
- Murphy’s sign: present
- Cause: gallbladder inflammation
- Complications: Empyema, gangrene
23
Q
Biliary colic features
A
- Pain: Epigastric or RQ, colicky intermittent
- NO jaundice or fever
- Cause: gallstone in cystic duct
24
Q
Cholecystitis definition
A
inflammation of the gallbladder, can be either acute or chronic. Chronic has less symptoms and occurs for longer. Normally caused by cholelithiasis or gallstones. Either calculous or acalculous based on presence or not of gallstones
25
Cholecystitis causes
predominantly by obstruction of the cystic duct by gallstones. Can cause infection in the gallbladder due to E.coli, Klebdiella, Enterococcus.
26
Cholecystitis symptoms
- Right upper quadrant/epigastric pain, which can radiate to the right shoulder tip if the diaphragm is irritated
- Fever
- Nausea and vomiting
- Right upper quadrant tenderness
- Positive Murphy's sign
- If associated biliary obstruction: may have jaundice, dark urine and pale stool
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Cholecystitis Inx
- Ultrasound: can show gallstones, gallbladder wall thickening
- Bloods: FBC, U&E, CRP and LFT
- CT abdo-pelvis
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Cholecystitis Mx
- Acalculous cholecystitis: prompt surgery
- Acute calculous: bowel rest, fasting and IV fluids if mild. Abx and cholecystectomy
- Chronic: elective cholecystectomy
29
Complications of laparoscopic cholecystectomy
- Haemorrhage
- Post cholecystectomy syndrome: colicky abdo pain, diarrhoea, vague abdo pain and jaundice. Treat with anti-spasmadics for pain and nausea
- Bile duct injury
- Pneumoperitoneum
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Cholecystitis complications
- Empyema
- Gangrenous cholecystitis
- Perforation
- Abscess formation
- Bile duct obstruction
31
Gallstones definition and risk factors
Definition: solid deposits often of cholesterol or bilirubin which form in the gallbladder
Risk factors: (4 F’s), fat, forty, female, fertile (pregnancy), diabetes, COCP, rapid weight change and family history
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Types of gallstone
1. Pigment (<10%) Associated with haemolysis, stasis and infection.
2. Cholesterol (90%) Associated with female sex, increasing age and obesity.
3. Mixed
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Gallstone related problems 1
- Biliary colic: Colicky right upper quadrant pain, worse after eating, no fever, negative Murphy's sign.
- Acute cholecystitis: Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated), fever, nausea and vomiting, right upper quadrant tenderness, positive Murphy's sign.
- Ascending cholangitis: Right upper quadrant pain, fever, jaundice, hypotension, and confusion if sepsis is severe.
34
Gallstone related problems 2
- Mirizzi's syndrome: Chronic right upper quadrant pain, intermittent jaundice due to extrinsic compression of the common hepatic duct by an impacted stone in the cystic duct or gallbladder neck.
- Chronic cholecystitis: Flatulent dyspepsia, vague abdominal pain, nausea, bloating, symptoms worsening after a fatty meal, occasional colicky pain.
- Gallstone ileus: Signs of small bowel obstruction due to gallstone migration.
- Cholangiocarcinoma: Abdominal pain, jaundice, anorexia, weight loss, possible right upper quadrant mass.
35
Ix for gallstones
- Bloods: LFT, CRP
- US: first line
- Other scans: CT, MRCP, ERCP
36
Management of gallstones and complications
- Resus: IV fluids and Abx
- Biliary drainage: Via ERCP, percutaneous or surgical
- Surgery; cholecystectomy
37
Acute mesenteric ischaemia definitions
life threatening surgical emergency due to the abrupt onset of blood flow restriction (hypoperfusion) to a portion of the small intestine. Either occlusive or non-occlusive primarily affecting the superior mesenteric artery. Rare but very deadly, tends to affect >60.
38
Acute mesenteric ischaemia signs and symptoms
- Sudden severe abdominal pain and guarding, often out of proportion to the physical examination
- Nausea and vomiting
- Signs of shock, such as hypotension, tachycardia, altered mental status
- Metabolic acidosis on arterial blood gas (ABG) analysis
- Rectal bleeding can occasionally be seen in advanced ischemia
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Acute mesenteric ischaemia management
- Resus: fluid management and correction of metabolic abnormalities
- Anticoagulation: IV heparin
- Surgical intervention: Including embolectomy, arterial bypass, or bowel resection if necrosis is present
- Non surgical: intra-arterial vasodilators or thrombolytic therapy
- Supportive: analgesia, antibiotics and nutritional support
41
Risk factors for kidney stones
- dehydration
- hypercalciuria, hyperparathyroidism, hypercalcaemia
- Urate stones: gout, ileostomy
- Drugs: loop diuretics, steroids
- renal tubular acidosis
- medullary sponge kidney, polycystic kidney disease
- beryllium or cadmium exposure
- Male 50-60
42
Types of kidney stones
- Calcium oxolate: risk factors are Hypercalciuria. Stones are radio-opaque
- Cystine: multiple stones may form, relatively radiodense
- Uric acid: risk factor is excess purine and malignancy. Radiolucent
- Calcium phosphate: risk factors are renal tubular acidosis. Radio-opaque stones
- Struvite: associated with chronic infection. Slightly radio-opaque
43
Clinical features of kidney stones
- loin pain: typically severe, intermittent 'colic' pain. The patient often is restless/moving around
- nausea and vomiting is common
- haematuria
- dysuria
- secondary infection may cause fever
44
Inx for kidney stones
- Bedside: urine dipstick and culture
- Bloods: FBC, U&E, CRP, calcium, urate, clotting
- Inx: CT KUB first line
45
Stag horn calculi
Stag-horn calculi involve the renal pelvis and extend into at least 2 calyces. They develop in alkaline urine and are composed of struvite (ammonium magnesium phosphate, triple phosphate). Ureaplasma urealyticum and Proteus infections predispose to their formation
46
Management of renal colic
- Renal colic: NSAID (diclofenic) or IV paracetamol
- Alpha blockers: if <10mm
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49
Renal stones Mx
- watchful waiting if < 5mm (tend to pass spontaneously)
- 5-10mm shockwave lithotripsy
- 10-20 mm shockwave lithotripsy OR ureteroscopy
- > 20 mm percutaneous nephrolithotomy
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