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3rd year medicine > repro > Flashcards

repro Flashcards

1
Q

CPR on pregnant woman?

A

keep woman supine with let uterine displacement

30 compressions (100-120 bpm) - depth 5-6cm

2 breaths: 30 compressions

if no response to CPR in 4 mins = C-section!!

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2
Q

Shockable rhythms process?

A

defib adrenaline 1mg after 3rd shock - then every 4 mins

amiodarone 300mg after 3rd shock

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3
Q

non-shockable rhythm process?

A

adrenaline every 3-5 mins

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4
Q

drugs for VF/VT? opiate overdose? magnesium toxicity? local anaesthetic toxicity?

A

VF/VT = 300mg amiodarone

opiate = naloxone

Mg = calcium gluconate

LA = intralipid

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5
Q

anaphylaxis ABCDE?

A

remove allergen

high flow oxygen

IM adrenaline 500mcg every 5 mins and IV crystalloid bolus

chlorohreniramine

20mg IV hydrocortisone

200mg IV salbutamol neb

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6
Q

Diabetic emergencies?

A

Hypo

* STOP INSULIIN

* glucose <4mmol/l = 50ml of 10% dextrose IV/1mg glucagon IM/glucogel

DKA

* insulin

* fluids - saline

NOTE - CAN BE NORMOGLYCAEMIC IN PREGNANCY

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7
Q

amniotic fluid embolism presentation? Tx?

A

not predictable or preventable acute presentation

* profound foetal distress

* sudden respiratory distress

* seizure

* DIC

Tx = ITU - supportive

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8
Q

PE s/s preg + postnatal?

A

symptoms

* dyspnoea

* pain

* cough

* haemoptysis

* collapse

signs

* temp >37

* raised JVP

* enlarged liver

* parasternal heave

* fixed splitting of 2nd heart sound

* cyanosis

* tachycardia

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9
Q

Dx PE preg/postnatal? Tx?

A

ECG - tachy, RVH (rarely S1Q3T3)

CXR - pleural effusion, raised hemi, wedge collapse

ABG - hypoxia + normal CO2

ECHO - rule out dissection and tamponade

CTPA!!

Tx = thrombolysis!!

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10
Q

stroke Ax pregnancy?

A

PRE-ECLAMPSIA!!!

thrombosis

amniotic fluid embolism

haemorrhagic infarct - infection, cocaine, vasculitis

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11
Q

cord prolapse risk factors

Tx

A

breech

preterm labour

2nd twin

AROM

Tx = tocolysis + all 4’s/immediate delivery

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12
Q

shoulder dystocia risk factors? Signs?

A

obesity

diabetes

macrosomia

prolonged 1st + 2nd stage

instrumental delivery

Signs = turtle sign!

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13
Q

Complications shoulder dystocia? Tx?

A

Comps

* stillbirth

* hypoxic brain injury

* brachial plexus injury - Erb’s palsy

* fractures

* PPH

Tx = HELPERR

* Help

* Episiotomy

* Legs (McRoberts manouvre)

* Pressure (suprapubic)

* Enter (rotational pringle-can manouvre)

* Remove posterior arm

* Roll patient onto her hands and knees

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14
Q

admission to mother + baby unit when?

A

rapidly changing mental state

suicidal ideation

significant estrangement from infant

guilt or hopelessness

beliefs of inadequacy as mother

psychosis

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15
Q

bipolar in pregnancy?

A

50% relapse rate if untreated

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16
Q

baby blues? Tx?

A

50% women

tearful, irritable, anxiety, poor sleep + confusion

3-10 days

Tx = self-limiting! support + reassurance

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17
Q

puerpueral psychosis? risk factors?

A

presents within 2 weeks of delivery

* sleep disturbance

* confusion + irrational ideas

* develops into mania, delusions, hallucinations

Risk factors

* bipolar

* previous puerperal psychosis (50%)

* 1st degree relative with history of bipolar

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18
Q

Tx puerperal psychosis? Main complication?

A

EMERGENCY - needs admission to mother baby unit

Tx

* antidepressants

* antipsychotics

* mood stabilisers

* ECT

25% go on to develop bipolar disorder

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19
Q

postnatal depression symptoms? onset? Tx?

A

tearful, irritable, anxiety, anhedonia, poor sleep, weight loss - can present with concerns regarding baby and parenting skills

onset = 2-6 weeks postnatally (later than puerpural psychosis and baby blues), lasts weeks to months

Tx = CBT, antidepressants, if very severe consider admission

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20
Q

complication postnatal depression?

A

70% lifetime risk of depression

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21
Q

bipolar tx pregnancy?

A

lamitrogine safest in pregnancy?

* valproate gives neural tube defects

* carbamezapine can cause cardiac defects, neural tube defects

* lithium can cause ebstein’s anomaly + heart defects

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22
Q

should bipolar treatment be stopped in pregnancy?

breastfeeding?

A

no - 50% relapse without Tx

lithium is contraindicated in breastfeeding

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23
Q

shizophrenia Tx pregnancy?

A

antipsychotics are safe in pregnancy

clozapine contraindicated in breastfeeding!!! - life threatening

avoid anticholingerics in pregnancy!!

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24
Q

risk to foetus if mother is bipolar?

schizophrenic

A

bipolar = 1 in 7

schizophrenia = 10%

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25
Q

depression Tx in pregnancy?

A

sertraline first line (pulmonary hypertension is main complication)

venlafaxine = hypertension

paroxetine = cadiac abnormalities

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26
Q

depression meds breastfeeding?

A

sertraline 1st line

TCAs are ok too

avoid citalopram + fluoxetine (high levels in breast milk)

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27
Q

alcoholism in pregnancy consequences

A

miscarriage

foetal alcohol syndrome (facial deformities, lower IQ, epilepsy)

maternal Wernicke’s encephalopathy

maternal korsakoff syndrome (permanent)

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28
Q

consequences of drug use (cocaine, ecstasy) in pregnancy

A

death

teratogenic - microcephaly, heart defects

pre-eclampsia

placental abruption

IUGR + preterm labour

miscarriage

withdrawal

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29
Q

nicotine in pregnancy?

A

miscarriage

placental abruption

IUGR

stillbirth

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30
Q

antenatal care for substance abuse

A

methadone program

child protection + social work

breastfeeding contraindicated if alcohol >8, HIV, cocaine

labour plan regarding analgesia

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31
Q

paroxetine in pregnancy?

A

generally avoided - less safe than other SSRIs (heart defects)

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32
Q

complication of antipsychotics in pregnancy?

A

they are safe but 2nd gen (olazapine, quetiapine etc) carry risk of gestational diabetes

however, olanzapine and quetiapine have best evidence base

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33
Q

recommendations mood stabilisers in pregnancy?

A

lamotrigine in pregnancy! (antipsychotics like quetiapine also safe)

valproate and carbamazepine avoided at all costs

lithium - avoid if possible (Ebstein’s anomaly) but consider reintroduction immediately post-partum if not breastfeeding

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34
Q

anxiety Tx pregnancy?

A

SSRIs first line

avoid benozdiazepines - cleft lip, neonatal withdrawal (floppy baby)

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35
Q

final recommendations for Tx of mental illness in pregnancy

A
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36
Q
A

baby blues

reassure patient + breast exam

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37
Q
A

rate of recurrence = 50% (untreated)

psychiatry, midwife

strong advise to start meds antenatally (mood stabilisers + antipsychotics)

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38
Q

bimanual pelvic exam

A

one hand on cervix, one hand on abdomen

if mass felt in centre = uterine

fel tlaterally = ovarian

if mass moves in line with cervix = uterine

if mass does not move = adnexae

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39
Q

ovarian cancer Tx?

A

radiotherapy is NOT USED!!!

tx = chemo + debulking surgery

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40
Q

ovarian cancer makers

CEA: Ca125 ratio?

A

Ca125, AFP, HCG, LDH

if Ca125>CEA = primary ovarian tumour

if CEA>Ca125 = GI origin

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41
Q

struma ovarii

A

thyroid tissue in ovary - hyperthyroidism

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42
Q

RMI score

A
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43
Q

Meig’s syndrome

A

triad = benign ovarian tumour + ascites + pleural effusion

resolves after resection of the tumour

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44
Q

clinical feature of ovarian torsion?

A

pain does not settle with analgesia

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45
Q

smear test timing

A

begins at 25 years

if negative HPV = next test in 5 years (from ages 25-65)

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46
Q

smoking cervical cancer?

A

nicotine is a co-carcinogen (helps HPV thrive in body)

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47
Q

definitions of bleeding in pregnancy

A

bleeding in early pregnancy <24 weeks

bleeding in late pregnancy (antepartum haemorrhage) >24 weeks

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48
Q

hormones produced by placenta

A

HPL + HCG

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49
Q

antepartum haemorrhage (APH)?

commonest causes?

A

APH = >24 weeks gestation and before second stage of labour (PPH)

placental abruption

placenta praevia

uterine rupture

vasa praevia

local causes: ectoprion, polyp, infection, carcinoma

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50
Q

quantifying APH

A

pretty sure this should say 500

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51
Q

placental abruption?

pathology?

A

seperation of placenta too early = bleeding (may be concealed)

blood escapes into amniotic sac OR myometrium (concealed)

interrupts placental circulation causing hypoxia

can result in couvelaire uterus (bruised uterus that doesnt contrast much due to bleeding in myometrium)

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52
Q

placental abruption risk factors?

A

70% occur in low risk pregnancies

pre-eclampsia/HTN

trauma

smoking, cocaine, amphetamines

thrombophillia (APS)

diabetes

renal disease

polyhydramnios, multiple pregnancy

PRROM

abnromal placenta + previous abruption

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53
Q

symptoms PA?

A

severe continuous abdominal pain (labour is intermitent)

* continuous backache with posterior placenta

bleeding (may be concealed)

preterm labour - PPROM

may simply present with maternal collapse

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54
Q

signs PA

A

unwell distressed patient, bleeding may be concealed

uterus tender, woody hard, cannot feel foetal parts

foetal HR = bradycardia/absent

CTG shows irritable uterus (10 contractions/10 mins)

CTG also shows maternal tachycardia, loss of variability, decellerations

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55
Q

PA management?

A

resuscitate mother

* 2 large bore IV

* bloods - FBC, clotting, LFT U+E, Xmatch, Kleinhauer if resus negative

* Fluids (careful with PET - fluid overload)

* catheter (empty bladder?)

uregent delivery by C/S

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56
Q

complications placental abruption

A

maternal = hypovolaemic shock, anaemia, PPH (25%), renal failure, infection, thromboembolism

foetal = IUD, hypoxia, prematurity

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57
Q

PA recurrence

A

10% recurrence - cant really prevent

stop smoking, drug use

APS - LMWH + LDA

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58
Q

placenta praevia?

A

Placenta praevia = when the placenta lies directly over the internal os

Low-lying placenta = placental edge is <20mm from internal os on TVUS

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59
Q

placenta praevia complication?

risk factors

A

placenta praveia = 20% APH

risk factors = previous C/S, previous abortion, multiparity, assisted conception, smoking, endometritis, fibroid

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60
Q

placenta praevia screening

A

foetal anomaly scan

rescan at 32 + 36 weeks (TVUS)

MRI if placenta accreta suspected

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61
Q

placenta praevia symptoms

signs?

A

painless bleeding >24 weeks

foetal movements present

signs

* uterus soft, non-tender (unlike aburption)

* presenting part high due to placental mass in lower uterus

* may be transvserse, breech

* CTG normal

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62
Q

what must be avoided in placenta praevia

A

digital exam !!

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63
Q

Dx placenta praevia?

A

check anomaly scan

confirm by TVUS

MRI to exclude placenta accreta

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64
Q

placenta praevia Tx?

A

resus mother - large bore IV + assess baby

steroids <36 weeks

MgSO4 <32 weeks

anti-D if rhesus neg

MgSO4 for neuro protection

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65
Q

placenta praevia Tx - not bleeding?

A

advise patient to attend immeditely if bleeding including spotting or contractions/pain

no sex

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66
Q

placenta praevia delivery?

A

consider from 34-36 weeks if bleeding

if uncomplicated, consider delivery between 36-37 weeks

(give steroids)

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67
Q

placenta praevia delivery style

A

C/S if placenta covers os or <2cm from os

vaginal delivery if placenta >2cm from os and no malpresentation

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68
Q

placenta accreta?

risk factors

complictions

A

placenta abnormally adherent to uterine wall

risk factors = placenta praevia + C/S

complications = severe bleeding, PPH, death

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69
Q

placenta accreta classification

A

increta = invading myometrium

percreta = penetrating uterus to bladder

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70
Q

mnagement placenta accreta

A

expect to lose >3L of blood

prophylactic iliac artery balloon

hysterectomy

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71
Q

uterine rupture?

risk factors

A

full thickness opening of uterus (including serosa)

* if serosa is intact = dehiscence

risk factors = previous C/S or uterine surgery (e.g. myomectomy), multiparity, IOL (prostaglandins, syntocinon), obstructed labour

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72
Q

symptoms uterine rupture?

signs?

A

severe abdominal pain

shoulder-tip pain

maternal collapse

PV bleeding

signs = loss of contractions, acute abdomen, peritonism, foetal distress/IUD

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73
Q

Tx uterine rupture

A

urgent resus + surgery

2 large bore IV access

FBC, clotting, Xmatch, LFT U+E, Kleinhauer

IV fluids

anti-D if rhesus neg

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74
Q

vasa praevia?

Dx?

S/s?

A

unprotected foetal vessels travel below presenting part over internal cervical os

Dx = TVUS

S/s = sudden dark red bleeding and foetal bradycardia/death

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75
Q

types vasa praevia?

risk factors?

A

type 1 = vessel connected to velamentous umbilical cord

type 2 = connected to accessory lobe

risk factors = bi-lobed or accessory placenta, low-lying placenta, multiple pregnancy, IVF (1 in 300)

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76
Q

Tx vasa praevia?

A

steroids <36 weeks

deliver C/S by 36 weeks

APH from vasa praevia = emergency C/S

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77
Q

PPH?

types?

A

blood loss >500ml after birth of baby

primary = within 24 hours of delivery

secondary = after 24 hours (can be up to 6 weeks later)

minor = 500-1000ml (without shock)

major = >1000ml (or signs of shock)

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78
Q

Ax PPH?

A

4T’s = uterine atony (70%), trauma, tissue, thrombin

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79
Q

risk factors PPH

A

anaemia, previous CS, placenta praevia/accreta, previous PPH, multiple pregnancy, polyhydramnios, obesity, macrosomia

intrapartum risk factors = prolonged labour, C/S, retained placenta, active management of third stage (syntocinon/syntometrine)

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80
Q

PPH Tx?

A

ABCDE

oxygen

2 large bore IV

FBC, Xmatch, LFT U +E, clotting (fibrinogen)

if DIC/coagulopathy = FFP, cryoprecipitate, platelets

stop the bleeding

* uterine massage

* 5 units IV syntocinon stat

* empty bladder

* Bakri or Rusch balloon

if still bleeding = ergometrine (not in HTN), carboprost, misoprostol, tranexamic acid

if STILL bleeding = surgery

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81
Q

secondary PPH?

main causes?

A

>24 hours

RPOC + infection

(exclude RPOC with USS)

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82
Q

thing to remember APH?

A

Kleihauer, anti-D and steroids

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83
Q

common viral infections in pregnancy?

A

rubella, measles, mumps, influenzae, chicken pox, CMV

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84
Q

Rubella?

S/s?

Maternal infection?

A

viral infection transmitted by direct contact/droplet

s/s = fever, rash, lymphadenopathy, poluarthritis

maternal infection can cause miscarriage, stillbirth, birth defects (CRS)

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85
Q

congenital rubella syndrome?

A

triad = cataract + cardiac abnormalities (PDA) + deafness

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86
Q

outcome of maternal rubella infection?

Management

A

dependent on gestation - worse early on

Tx

* blood IgM within 10 days of exposure

* IgG can be detected after natural infection or vaccination

* if patient not immune consider TOP

* supportive Tx = rest, fluids, paracetamol, avoid contact with other pregnant women

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87
Q

measles?

S/s?

maternal infection?

Tx

A

caused by paramyxovirus = highly contagious!!

S/s = fever, white spots in mouth (koplik’s spots), runny nose, cough, red eyes, rash

usually non teratogenic but can cause IUGT, microcephaly, miscarriage, preterm birth

Tx = supportive

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88
Q

chicken pox?

S/s?

Tx?

A

varicella zoster - spread via droplet

s/s = fever, malaise, vesicular rash

Tx

* check VZV immunity

* offer VZ immunoglobulin within 10 days of exposure

* if >10 days = aciclovir?

* aciclovir also given if >20 weeks gestation

* avoid other pregnant women

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89
Q

severe chicken pox?

Tx?

A

severe infection = hepatitis, encephalitis, pneumonia

Tx - hospitalisation + IV aciclovir

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90
Q

foetal varicella syndrome?

A

occurs form 7-28 weeks gestation:

hypoplasia of limbs

IUGR

cataracts

microcephaly

cutaenous scarring

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91
Q

commonest congenital infection?

significance?

complications?

A

CMV

leading non-genetic cause for sensorineural deafness

comps = miscarriage, stillbirth, IUGR, microcephaly, thrombocytopenia, mental retardation, deafness

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92
Q

maternal infection CMV?

A

unlike rubella, chance of congenital infection increases later on in pregnancy

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93
Q

Dx CMV?

Tx CMV pregnancy?

A

Dx = amniocentesis + guage how symptomatic foetus is via MRI foetal brain

valacyclovir

immunoglobulin

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94
Q

parvovirus?

maternal infection?

complications?

A

slapped check syndrome/fifth disease

maternal infection is self limited

foetal complications = mainly affects erythroid precursors

* aplastic anaemia, congenital heart failure, hydrops foetalis + foetal death

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95
Q

Dx + Tx parvovirus in pregnancy?

A

Dx = virus specific IgM

Tx = self-limiting

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96
Q

mumps?

Symptoms?

A

RNA virus - no ill effects on pregnancy or foetus

symptoms = fever, headache, no rash, swollen salivary glands

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97
Q

MMR vaccine pregnancy?

A

live vaccine so contraindicated

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98
Q

influenza pregnancy

prophylaxis?

Tx?

A

if infection super virulent = can cause miscarriage + preterm labour

vaccine safe during pregnancy + breastfeeding

Tx = antivirals

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99
Q

zika virus?

complications?

prophylaxis?

A

mosquito bite

comps = microcephaly, brain defects, deafness + blindness, epilepsy, developmental delay

no vaccine so only way to avoid is to not travel to Zika affected area

if returning from Zika affected area do not try to coneive for 6 months

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100
Q

HSV in pregnancy?

A

if genital lesions near time of delivery = C/S

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101
Q

HIV pregnancy

comps?

Tx?

A

routinely screened for alongside syphillis + hep B

comps = IUGR, miscarriage (maternal mortility and morbidity not increased)

management

* screen for CMV, TB and toxoplasmosis

* HAART treatment

* prophylactic antibiotics

* elective C/S reduced risk of transmission by 50% (zidovudine infusion commenced 4 hours prior to CS)

* DO NOT BREASTFEED

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102
Q

HIV delivery?

A

C/S recommended

however if viral load <50 copies/ml (on HAART), vaginal delivery can be considered

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103
Q

toxoplasmosis pregnancy?

complications

treatment

A

toxoplasmosis = from raw/undercooked meat or cat faeces

comps = hydrocephalus, chorioretinitis, cerebral calcifications, microcephaly, mental retardation

Tx = self-limiting

acute toxoplasmosis in pregnancy = spiramycin

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104
Q

listerosis?

symptoms?

complications pregnancy?

Tx?

A

listeria monocytogenes = eating infected food

symptoms = headache, diarrhoea, abdominal pain, nausea

complications = neonatal death, neonatal sepsis, preterm labour, stillbirth

Tx = amoxicillin + gentamicin

(co-trimoxazole if allergic)

co-trimox also known as trimethorpim-sulfamethoxazole

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105
Q

prevention listeriosis in pregnancy?

A

avoid unpasturised milk, soft cheese, refrigerated smoked seafood (salmon etc)

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106
Q

group B strep pregnancy Tx?

if chorioamnionitis?

A

IV penicillin

chorioamnionitis = broast spectrum antibiotics

* gentamicin + metronidazole

* s/s = tender abdomen, foul-smelling discharge

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107
Q

puerperium?

physiological changes

A

from end of 3rd stage of labour to 6 weeks postpartum

uterus contracts immediately after delivery, not palpable after 10 days

cervical os closed by 10 days

lochia - blood stained for up to 14 days (rubra), then yellow then white (sera, alba)

menstruation resumes at 6 weeks if not breastfeeding

cardio = CO and PV return to normal in a week, oedema up to 6 weeks, BP normal within 6 weeks

GFR decreases to normal over 3 months

blood = U+E’s return to normal, Hb and HCT rise again, WCC falls, platelet and clotting factors fall but hypercoagulable state can persist for up to 6 weeks

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108
Q

perineal tears

A

1st degree = skin

2nd degree = skin and muscle

(can both be repaired by midwife, as can episiotomy)

3a = <50% external anal sphincter

3b = >50%

3c = involves internal anal spincter

4th degree = involves anal or rectal mucosa

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109
Q

VTE post-partum?

prophylaxis?

A

hypercoagulable state

low risk = hyration + mobilisation

mod risk = 10 days prophylactic LMWH

high risk = 6 weeks prophylactic LMWH

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110
Q

endometritis risk factors?

Ax?

Tx?

A

risk factors = prologed labour, prolonged ROM, forceps delivery, RPOC, C/S

Ax = GBS!!!, staph, E.coli, anaerobes

Tx = broad spectrum antibiotics (co-amox/clinamycin if allergic + matronidazole + gentamicin)

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111
Q

seocndary PPH Ax?

Tx?

A

endometritis (infection) + RPOC

Tx = antibiotics, evacuation of RPOC

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112
Q

urinary retention women tx?

A

catheterise - treat underlying cause

trial without catheter after 48 hours

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113
Q

vesico-vaginal fistula?

A

caused by prolonged obstructed labour

(common in 3rd world countries)

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114
Q

puerpeural psychosis recurrence?

A

60% recurrence

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115
Q

mastitis?

Tx

A

staph infection - presents with fever and breast tenderness

Tx = continue breastfeeding + antibiotics

(may progress to breast abscess req surgical drainage)

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116
Q

Contraception methods

A

barrier methods

oral hormonal = POP, COCP

injectable progestogen

LARC = nexplanon, IUD (copper or Mirena IUS)

sterilisation

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117
Q

likely diagnosis?

A

endometritis

could also be wound infection, UTI, chest infection, thrombophlebitis, mastitis/breast abscess, viral infection

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118
Q

SOB after delivery?

A

PE until proven otherwise

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119
Q

suspected PE Tx?

A

LMWH until VQ scan/CTPA result

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120
Q

inhaled meconium?

A

black streaky lungs

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121
Q

foetal shunts?

how does foetal circulation work

A

ductus venosus

formaen ovale

ductus arteriosus

oxygenated blood in IVC in foetus

deoxygenated blood in umbillical arteries

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122
Q

foetal preparation for birth

A

surfactant production (type 2 pneumocytes)

accumulation of glycogen - liver, muscle, heart

accumulation of brown fat - between scapulae and internal organs

swallow amniotic fluid + inhale it = helps lungs grow (severe oligohydramnios can result in hypoplastic lungs)

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123
Q

how is amniotic fluid in lungs absorbed?

A

vaginal delivery squeezes lungs

baby absorbs rest by crying

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124
Q

foetal cardiovascular changes following birth?

failure of this process?

A

pulmonary resistance drops

systemic vascualr resistance increases

ducts/shunts close (DA becomes ligamentum arteriosus, DV becomes ligamentum teres)

patent foramen ovale

persistent ductus arteriosus

persistent pulmonary hypertension of the newborn

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125
Q

persistent pulmonary hypertension of the newborn?

Dx?

Tx?

A

shunts remain (PFO + DA)

Dx

branches that supply right upper limb are always preductal so Dx = pre and post-ductal saturations

right hand will have more oxygenation than left leg

Tx = oxygen, nitric oxide (vasodilation of pulomary arteries so lowers pulmonary resistance), inotropes to aid CO

if all this fails = ECMO

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126
Q

transient tachypnoea of the newborn?

s/s?

tx?

A

seen in big healthy babies born by C section

no vaginal “squeeze” so take longer to absorb amniotic fluid

s/s = tachypnoea, grunting

self-limiting but screen for infection

127
Q

thermoregulation newborn?

A

main source of heat production is non-shivering thermogenesis (cannot physiclly shiver as a baby)

breakdown of brown fat

need hats, skin to skin contact, blanket, clothes

128
Q

Ax hypoglycaemia newborn?

A

unwell

premature (low glycogen stores)

maternal diabetes

hyperinsulinism

129
Q

physiological jaundice of newborn?

A

unconjugated bilirubin (breakdown of foetal Hb)

130
Q

Common STIs

A
131
Q

describe blood film

likely diagnosis - this is from urethral disharge swab

A

gram negative coccus

neisseria gonorrhoea

(can’t be chlamydia because chlamydia does not gram stain - use NAAT instead)

132
Q

PCR testing for gonorrhoea and chlamydia?

A

NAATS

133
Q
A

more sensitive test

134
Q

Tx gonorrhoea?

A

ceftriaxone

if allergic to penicillin = ??

135
Q

gram appearance?

likely diagnosis given history is: vaginal discharge, intense itch, vulva red and inflammed, thick white discharge

A

gram +ve cocci

candida!! - large gram +ve round

136
Q

Tx vaginal candida albicans?

A

1st line = topical clotrimazole

2nd line = oral fluconazole

137
Q

non-albicans candida?

A

less likely to respond to fluconazole

138
Q

Tx trichomonas vaginalis?

important to remember?

A

metronidazole

with metronidazole, not not drink alcohol (2 days before and 2 dys after) - disulfiram reaction

treat partners too - as very difficult to diagnose

139
Q

Dx HSV-2 genital lesions?

Tx?

A

PCR from de-roofed vesicle

Tx = aciclovir

140
Q

differentials?

Tx?

A

DDx painless lesion = syphillis + LGV

Tx syphillis = IM benzylpenicillin (if allergic = doxycycline or azithromycin)

141
Q

syphillis Dx?

Test of treatment effectiveness?

A

RPR (rapid plasma reagin) used to test response to treatment - want it to decrease

142
Q

transabdominal ultrasound req?

advantags vs disadvatages?

A

bladder must be full

advantages = safe, readily available, no radiation

disadvantages = difficult in obese patients + gaseous distension

143
Q
A

..

144
Q

which vessel is ovary next to?

A

external iliac

145
Q

TVUS req?

therefore if need to do TAUS and TVUS

A

TVUS needs empty bladder

so do TAUS first, let patient urinate then do TVUS

146
Q
A

..

147
Q

acute abdomen Ix?

A

1st line = USS

2nd line = CT

148
Q

hysterosalpingography (HSG)?

A

x-ray real time imaging

for assessment of tubal patency in pateints with infertility

149
Q

endometrial cancer Dx?

A

TVUS!

MRI to assess degree of myometrial invasion

CT to look for datnt metastases

150
Q

TORCH screen?

A

toxoplasmosis, rubella, CMV, herpes simplex, HIV

151
Q

first line test for analysing foetal chromosomes

what does it do?

A

foetal chromosome microarray

has higher resolution but only detects chromosomal imbalance (insertions/deletions)

technique for balanced translocations = karyotype

152
Q
A

answer = A

women with PET can have severe foetal grwoth restriction

153
Q

differential diagnosis vulval itch

A
154
Q

lichen sclerosis?

Ax?

Epidemiology?

Symptoms?

A

inflammatory, scarring dermatosis of ano-genital skin

Ax = unknown

Epidemiology = women>men, pre-pubescent children + post-menopausal women, associated with other autoimmune diseases

symptoms = itch, pain, dyspareunia, constipation (esp children)

155
Q

lichen sclerosis O/E?

A

white papules + plaques - figure of 8 pattern

ecchymosis, erosions + fissures

156
Q

DDx lichen sclerosis?

S/s?

Associated with?

A

lichen planus

however will affect mucosal membranes (mouth), nails, hair

S/s lichen planus = itch, pain, dyspareunia, discharge

associated with vitiligo, pemphigoid, morphoea

157
Q

complication lichen sclerosis?

Tx?

A

SCC - esp in smokers

Tx = good genital skin care + super potent topical steroid (dermovate)

158
Q

Dx?

tx?

A

genitourinary syndrome of the memopause

* pallor of vestibule

* urethral caruncle

* loss of vaginal rugae

* inside vagina = pallor with petechial haemorrhages

tx = vaginal oestrogen

159
Q

vulval pain DDx

A
160
Q

vulvodynia?

tx?

A

burning vulval pain occuring in absence of visible findings

Tx

* localised provoked pain = lidocine ointment, physio

* unprovoked pain = tricyclics, gabepentin/pregabalin

* psychosexual interventions

161
Q

FGM types

A
162
Q

must report FGM?

A

100% - offense for failing to proect a girl at risk of FGM

163
Q

Tx FGM?

A

type 3 = de-infibulation

164
Q

painful genital lesion DDx?

A
165
Q

history = painful lesion

Dx?

A

vulval epithelial neoplasia

HPV-related, VIN similar to CIN

s/s = itchy/painful

166
Q

pregnnancy trimesters?

A

1st trimester = week 1 to week 12

2nd = week 13 to week 26

3rd = week 27 to end of pregnancy

167
Q

types of ovarian cyst?

A

Follicular e.g. polycystic ovaries

Luteal (corpus luteum)

Endometriod (2* to endometriosis)

Epithelial

Mesothelial

168
Q

commonest type of ovarian cyst?

Ax?

Tx?

A

follicular cyst - thin walled, lined by granulosa cells

form when ovulation doesn’t occur e.g. PCOS

Tx = usually resolve over a few months

169
Q

endometriosis?

S/s?

Sites?

A

endometrial glands and stroma found outside uterine body

(in myometrium called andenomyosis)

Pain, pelvic inflammation, infertility

sites = ovary “chocolate cyst”, pouch of douglas, cervix, bladder, bowel etc

170
Q

ovarian enodmetriosis macroscopic? Microscopic?

complications?

A

macroscopic = peritoneal spots, fibrous adhesions, chocolate cysts

microscopic = endometrial glands and stroma

complicatons = pain, cyst formation, adhesions, infertility, ectopic pregnancy, malignancy (endometrioid carcinoma)

171
Q
A

endometriosis - endometrial spots

172
Q
A

chocolate cyst endometriosis

173
Q

types of ovarian tumour

A

Epithelial (most common)

Germ cell

Sex chord/stromal

Metastatic

174
Q

epithelial ovarian tumours?

A

Serous (most common)

Mucinous

Endometrioid

Clear cell

Brenner

175
Q

serous ovarian carcinoma types?

how are serous carcinoma of ovary and uterus linked?

A

High grade:

precursor = serous tubal intraepithelial carcinoma (STIC)

Low grade:

Precursor = serous borderline tumour

serous carcinoma of uterus + ovary both have TP53 mutation

176
Q

classification ovarian tumour?

A

Benign = no cytological abnormalities, no stromal invasion

Borderline = cytological abnormalities, no stromal invasion

Malignant = stromal invasion

177
Q

endometrioid and clear cell carcinoma of ovary associations?

A

associated with endometriosis of the ovary + lynch syndrome

178
Q

brenner tumour of the ovary?

A

transitional epithelium in the ovary

usually benign!

179
Q

germ cell tumours in the ovary?

A

teratoma

immature teratoma

dysgerminoma (most common malignant germ cell tumour)

yolk sac tumour

choriocarcinoma

180
Q

most common malignant germ cell tumour ovary?

histological appearance?

A

dysgerminoma (equivalent to seminoma in testes)

large primitive germ cells surrounded by lymphocytes

181
Q

most common benign germ cell tumour?

rare variant?

A

teratoma (dermoid cyst)

contain sebum, hair, skin, GI, thyroid tissue etc

immature teratoma (embryonic tissues) is very rare

182
Q

sex chord/stromal ovarian tumours?

A

fibroma/thecoma (benign) - can produce oestrogen causing uterine bleeding

granulosa cell tumour (malignant) - also produce ostreogen

sertoli-leydig tumours - produce androgens

183
Q

commonest origins of ovarian metastatic tumours?

when to suspect?

A

Stomach

Colon

Breast

Pancreas

suspect when tumours are bilteral and small

184
Q

FIGO staging ovarian cancer

A

1A = tumour in 1 ovary

1B = both ovaries

1C = burst through ovary

2A = uterus/fallopian tube

2B = pelvic organs like bowel/bladder

3A = lymph nodes (para-aortic) or microscopic peritoneal extrapelvic involvement

3B = macroscopic peritoneal metastasis <2cm

3C = macroscopic peritoneal metastasis >2cm

4 = distant metastasis

185
Q

pathology of fallopian tubes?

A

Inflammation - salpingitis due to infection

Cysts and tumours

Serous tubal intraepithelial carcinoma

Endometriosis

Ectopic pregnancy

186
Q

ectopic pregnancy?

commonest site?

complication?

when to suspect

A

ectopic pregnancy = implantation of conceptus outside endometrial cavity

commonest site = ampulla of fallopian tube

major complication = can rupture and cause haemorrhage (hypovolaemic shock)

suspect in any female of reproductive age with amenorrhoea and acute hypotension + acute abdomen

187
Q

Ax cervical cancer?

risk factors

presentation?

A

HPV 16 + 18

risk factors = smoking, early intercourse, “high risk” male, OCP, multiple partners

presentation

* at screening

* post-coital bleeding/IMB/PMB

* acute renal failure

188
Q

staging cervical cancer

A

1a - microscopic

1b - visible lesion

2a - vaginal involvement

2b - parametrial involvement

3 - lower vagina or pelvic sidewall

4 - bladder/rectum or metastases

189
Q

Tx cervical cancer

A

surgery - LLETZ (fertiliy sparing), Wertheim (radical hysterectomy)

radiotherapy

chemotherapy - cisplatin, barboplatin/paclitaxol

190
Q

Ax endometrial cancer?

S/s?

Tx?

A

obesity, oestrogens (HRT/Tamoxifen), Lynch syndrome HNPCC

s/s = post-menopausal bleeding

Tx = TAH-BSO

191
Q

side effects chemo?

A

Fatigue

Hair loss

Anaemia

bleeding/bruising

Nausea + vomiting

192
Q

neoadjuvant vs adjuvant chemo

A

Neoadjuvant = before main treatment to reduce the size of a tumor

Adjuvant = after main treatment to destroy remaining cancer cells

193
Q

symtpoms ovarian cancer

A

bloating

early satiety/loss of appetite

pelvic/abdominal pain

increased urinary frequency/urgency

194
Q

red flag ovarian cancer?

A

new onset IBS >50 y/o

195
Q

Dx ovarian cancer?

A

bloods - ca125

if ca125 >35 IU/ml = USS of abdomen + pelvis

196
Q

large for dates?

Ax?

A

symphyseal-fundal height >2cm for gestational age

Ax

* Wrong dates

* Foetal macrosomia

* Polyhydramnios

* Diabetes

* Multiple pregnancy

197
Q

foetal macrosomia?

risks?

A

USS EFW >90th centile (>4.5kg), abdominal circumference >97th centile

risks = obsructed labour, shoulder dystocia (esp diabetes), PPH

198
Q

Tx macrosomia?

A

exclude diabetes

in absence of any other conditions, induction of labour should NOT be carried out simply because of macrosomia

discuss C/S?

199
Q

Dx?

criteria?

Ax?

A

polyhydramnios = excess amniotic fluid

criteria: AFI >25cm, deepest pool >8cm

Ax

* diabetes

* GI atresia/cardiac/tumours

* monochorionic twin pregnancy

* hydrops foetalis

* viral infection (erythrovirus B19, toxo, CMV)

200
Q

symptoms polyhydramnios?

signs?

Dx?

Ix?

Tx?

A

symptoms = abdominal discomfort, PROM, preterm labour, cord prolapse

signs = LFD, malpresentation, tense shiny abdomen, inability to feel foetal parts

Dx = AFI >25cm, deppest pool >8cm

Ix = OGTT, serology (toxo, CMV, parvovirus), US foetal survery (GI tract, heart)

Tx = IOL by 40 weeks

201
Q

complications polyhydramnios?

A

malpresentation

preterm labour + PROM

cord prolapse

PPH

202
Q

risk factors multiple pregnancy?

A

Assisted conception - clomid, IVF (UK limits to 2 embryos)

Race - African

FHx

Increased maternal age

Increased parity

Tall women > short women

203
Q

types of multiple pregnancy?

A

monozygotic (splitting of 1 egg), dizygotic (fetilisation of 2 ova by 2 sperm)

chorionicity = 1 or 2 placentas

dizygous = always DCDA

monozygous = MCMA, MCDA, DCDA, conjoined

204
Q

determining chorionicity?

why is this important?

A

USS lambda sign - strongly suggests dichorionic

important to determine as MCMA at very high risk of complications

205
Q

symptoms multiple pregnancy?

signs?

A

symptoms = excessive sickness/hyperemesis gravidarum

signs = high AFP, large for dates, multiple foetal poles, USS confirmation at 12 weeks

206
Q

multiple pregnancy complications?

A

Higher perinatal mortality (6 x higher than singleton)

Foetal = congenital abnormalities (e.g. acardiac twin), IUD + IUGR (single/both), preterm birth, cerebral palsy, twin to twin transfusion (oligohydramnios + polyhydramnios)

Mother = hyperemesis gravidarum, anaemia, pre-eclampsia, antepartum haemorrhage (placental abruption), placenta praevia, preterm labour, cesarean section

207
Q

Tx multiple pregnancy?

A

USS (every 2 weeks MC, 4 weeks DC)

500mcg folic acid

delivery = C/S for triplets or MCMA

208
Q

complications monochorionic twins?

A

Single foetal death

Selective growth restriction (SGR)

Twin-to-twin transfusion syndrome (TTTS)

Twin anaemia-polycythaemia sequence (TAPS)

Absent EDV (AEDV) or revered (REDV)

209
Q

if one foetus dies, risk to twin?

A

Death (15%)

Neurological abnormality (26%)

(so need MRI foetal brain 4 weeks post death of co-twin)

210
Q

TTTS?

complications?

Dx?

Tx?

A

artery-vein anastomosis (donor twin perfuses recipient twin)

compication = 90% mortality with no treatment

Dx = oligohydramnios-polyhydramnios (oly-poly)

Tx

* <26 weeks = laser ablation (can cause TAPS)

* >26 weeks = amnioreduction septostomy

delivery before 36 weeks

211
Q

delivery of twins?

delivery method?

risk?

A

MCMA = C/S by 34 weeks

MCDA = by 36 weeks

DCDA = by 38 weeks

MCMA = cesarean section

for others, vaginal delivery can be considered

* continuous foetal monitoring

* syntocinon after twin 1 (prevents haemorrhage)

* intertwin delivery time <30 mins

remember risk of PPH

212
Q

complications diabetes in pregnancy (T1, T2 + GD)?

A

Congenital abnormalities

Miscarriage + Intrauterine death

Worsening diabetic complications e.g. retinopathy, nephropathy

Pre-eclampsia

Polyhydramnios

Macrosomia

Shoulder dystocia!!

Neonatal hypoglycemia

213
Q

pre-pregnancy counselling type 1 + 2 diabetes

A

aim for HbA1c <48 mmol

stop embryopathic medication = ACE-I, statins, sulphonylureas

folic acid 5mg (3 months before conception to 12 weeks gestation)

214
Q

Tx gestational diabetes?

A

metofrmin + insulin

folic acid 5mg (3 months before conception –> 12 weeks preg)

low dose aspirin from 12 weeks (PET)

regular eye checks for retinopathy

growth scans 4 weeks from 28 weeks

counsel about shoulder dystocia

deliver at 38 weeks (earlier if complications)

215
Q

risk factors gestational diabetes

A

Previous GDM

Obesity BMI >30

FH: 1st degree relative

Ethnicity: South Asia (India/Pakistan/Bangladesh), Middle Eastern, Black Caribbean

Previous big baby or current big baby

Polyhydramnios

216
Q

diabetogenic hormones in pregnancy?

A

human placental lactogen (HPL) + cortisol

217
Q

previous GDM recurrence risk?

A

50% recurrence risk

218
Q

screening GDM?

Dx?

A

risk factors at boking

OGTT 24-28 weeks

fasting >5.6

2 hour > 7.8

219
Q

how often check blood glucose in gestational diabetes?

normal values?

A

Check BG minimum 4 times a day (premeals)

1 hour post-meal + once before bed

3.5-5.5 mmol/l premeals

1 hour post-meal = <7.8 mmol/l

220
Q

timing of delivery GDM + pregestational DM?

mode of delivery?

A

pregestational = 38 weeks

GDM = generally 38 weeks

C-section if EFW >4.5kg

221
Q

GDM risk of developing T2DM?

follow-up?

A

70%

fasting blood sugar 6-8 weeks postnatally

222
Q

small for gestational age?

foetal growth restriction?

A

SGA = birth weight <10th centile (<2.5kg)

AC + EFW <10th centile

FGR = failure to achieve genetic growth potential

* AC/EFW <3rd centile or <10 centile with evidence of placental dysfunction (abnormal uterine artery doppler)

223
Q

Ax small for gestational age?

A

placental = infarcts, abruption, pre-eclampsia!! (common)

foetal infection = rubella, CMV, toxo (can caus epolyhydramnios so LFD but SGA?)

congenital abnormalities (renal agenesis)

chromosomal abnormalities (Downs syndrome)

maternal lifestyle = smoking, alcohol, drugs

224
Q

complications SGA and FGR?

A

IUD/stillbirth

hypoxia + effects of chronic apsphyxia (neurodevelopment)

hypoglycaemia

hypothermia

polcytheamia

hyperbilirubinemia

Iatrogenic preterm birth (39 weeks)

225
Q

single measurement <10th centile?

A

SGA = referral for serial growth scans

226
Q

major risk factors SGA?

A

>40 y/o

smoking

cocaine

daily vigorous exercise

previous SGA

APS

low PAPP-A

BMI >35 or <20

large fibroids

227
Q

whats this?

A

uterine artery notching

major risk factor for FGR and pre-eclampsia

228
Q

management SGA?

A

serial growth scans

150mg aspirin from 12 weeks for women at risk of PET

229
Q

mod vs major risk factors SGA

A
230
Q

Ix SGA?

A

Consider offering genetic testing (Downs)

Consider offering infection screening (rubella, CMV, toxo)

Use of umbilical artery doppler (PET)

231
Q

advanced doppler studies SGA?

A

middle cerebral artery + ductus venosus

MCA = change to low resistance vessel suggests foetus diverting blood flow to head

DV = abnormalitie suggest foetal acidaemia

232
Q

delivery SGA?

A

39 weeks even if everything else is normal (unlike macrosomia)

FGR (i.e. below <3rd centile) = 37 weeks

if doppler normal = IOL vaginal delivery

if abnormal = C-section

233
Q

what is folic acid?

deficiency in pregnancy?

recommended dose?

A

vitamin B9

deficiency = spina bifida, heart/limb defects, anaemia

dose = 400mg for most women

234
Q

when do you give high dose folic acid 500mg?

A

previous pregnancy with spina bifida

woman/partner has spina bifida

AEDs

coeliac disease

diabetes

BMI >30

sickle-cell or thalassaemia

folic acid deficiency

235
Q

vitamin D pregnant women?

higher dose?

A

daily dose of 10mg

higher dose in:

darker skin

BMI >30

diet low in vitamin D-rich foods (eggs, meat, cereal)

autumn/winter

236
Q

importance of vit D in pregnancy?

A

deficiency can cause:

maternal = osteomalacia, pre-eclampsia, gestational diabetes

foetal = SGA, neonatal hypocalcaemia, asthma, rickets

237
Q

listeriosis complications pregnancy?

reducing risk?

A

complications = miscarriage, stillbirth, preterm labour

avoid unpasturised milk, soft cheese (camembert, brie, blue), paté, undercooked food, deli meat

238
Q

reducing risk of toxoplasmosis in pregnancy?

A

wash all fruit and veg, including ready-prepared salads

avoid undercooked meat

wash hands thoroughy after handling soil

avoid contact with cat faeces

239
Q

pregnancy complications iron deficiency?

A

tiredness

SOB

preterm labour

stillbirth

IUGR/SGA

placental abruption

PPH

neurodevelopmental delay

240
Q

iron rich foods?

A

red meat (beef, lamb, pork)

pulses (beans, peas + lentils)

fresh leafy greens (cabbage, spinach, parsley)

prunes, raisins, figs

fish (no more than 4 cans/week)

nuts

241
Q

Dx + Tx iron defieincy pregnancy

important to remember with Tx?

A

Dx = FBC at booking + 28 weeks

Tx = diet, iron tablets (take with vitamin C)

caffiene and tea reduce absorption of iron tablets

242
Q

foods to avoid in pregnancy?

A

soft cheeses

undercooked meat

tuna

raw eggs

patè

liver (high vitamin A neurotoxic to foetus)

fish oil supplements

243
Q

risks low BMI in pregnancy?

A

low BMI = <18.5

IUGR + low birthweight

preterm labour

244
Q

maternal and foetal risks obesity?

A

Obseity = BMI >30

maternal = miscarriage, gestational diabetes, pre-eclampsia, PE, labour/shoulder dystocia, PPH

foetal = IUD/stillbirth, macrosomia, foetal anomalies

245
Q

Tx obesity in pregnancy

A

folic acid 500mg til 12 weeks

LDA from 12 weeks til delivery (PET)

vitamin D 10mg

OGTT 28 weeks

USS growth from 28 weeks

postpartum = fragmin (PE)

246
Q

initiation of labour?

A

change in oestrogen/progesterone ratio

progesterone keeps uterus settled

oestrogen makes uterus contract + promotes prostagaldnin production

oxytocin initiates and sustains contractions (also promotes porstaglandin release)

247
Q

Bishop score?

A

position, consistency, effacement, dilation + station in pelvis

determines whether ssafe to induce labour

248
Q

stages of labour?

A

1st stage

* latent phase = 3-4cm

* active stage = 4-10cm

2nd stage = delivery of baby

3rd stage = delivery of placenta

249
Q

prolonged 2nd stage?

Tx?

A

nulliparous = 2 hours (3 hours with epidural)

multiparous = 1 hour (2 hours with epidural)

Tx = episiotomy, instrumental delivery, C/S

250
Q

duration of 3rd stage of labour?

A

approx 10 mins but can last up to 30 mins

after 1 hour must be removed under GA

251
Q

Braxton Hicks?

A

false labour

can start from 6 weeks gestation

irregular, do not increase in frequency or intensity (relatively painless)

252
Q

frequency of contractions?

duration?

A

normal = 3-4 in 10 mins

10-15 seconds long, max 45 seconds (builds up)

253
Q

types of female pelvis?

A

gynaecoid = most suitable shape

anthropoid = pelvis inlet has larger OA diameter than transverse

android pelvis = triangular or heart-shaped

254
Q

analgesia options birth?

A

paracetamol/co-codamol

entonox

diamorphine

epidural

spinal anaesethetic

remifentanyl

pudenal nerve block

255
Q

7 cardinal movements of foetus during labour?

A

1 - engagement (3/5ths in pelvis, 2/5ths felt abdominally)

2 - descent

3 - flexion

4 - internal rotation

5 - crowning and extension

6 - external rotation

7 - expulsion (anterior shoulder first)

256
Q

vaginal examinations normal labour?

A

approx every 4 hours

257
Q

delayed cord clamping?

A

once pulsations have stopped or up to 3 minutes after expulsion

258
Q

active management of 3rd stage?

A

syntometrine (only given in 3rd stage)

or oxytocin (if hypertension i.e. ergometrine CI)

+ controlled cord traction

259
Q

normal blood loss labour?

A

normal = <500mls

PPH = >500mls

significant PPH = >1000mls

260
Q

lactation initiation?

A

decrease in oestrogen + progesterone

increase in prolactin

oxytocin triggers lactation via nipple stimulation

261
Q

observations during labour?

A

30 mins - 60 mins = contractions

Hourly pulse

4 hourly temp and BP - pre-eclampsia or sepsis

Frequency of passed urine

Vaginal examination 4 hourly

262
Q

foetal monitoring labour?

A

intermittent = 1 min after contraction every 15 mins in 1st stage, 5 mins in 2nd stage

continous = CTG

263
Q

delay first stage labour?

A

<2cm in 4 hours

264
Q

PPH Tx

A

empty bladder

uterine massage

uterotonic drugs

IV fluids

265
Q

HCG produced by?

Function?

A

placenta

signals corpus luteum to keep producing progesterone

266
Q

placenta function?

A

oxygen transport (umbilical vein) + CO2 removal

nutrient + waste transport

hormone secretion

267
Q

hormone changes in pregnancy?

importance?

A

HCG increases (doubles every 48 hours in first few weeks)

* ectopic (static or slow rising)

* failing pregnancy (falling)

* ongoing viable pregnancy (doubling)

HPL = acts like a grwoth hormone, decreases insulin sensitivty in mother

progesterone + oestrogen increase as pregnancy progresses

268
Q

side effects HCG?

high levels?

complication?

A

side effects = nausea + vomiting

high levels = multiple or molar pregnancy

can cause hyperthryroidism (HCG same effect as TSH)

269
Q

physiological changes pregnancy

A

CO increases (HR increases)

BP drops (lowest point in 2nd trimester)

anaemia as RBC and PV increases (Hb diluted)

resp rate increases

GFR increases

hypercoagulable state due to increased fibrinogen and clotting factors

270
Q

anaemia in pregnancy values?

A

1st trimester Hb <110g/L

2nd + 3rd trimester Hb <105g/L

271
Q

2 metabolic phases pregnancy?

A

1st - 20th week = anabolic phase

Small demands of foetus

lipogenesis, growth of breats, uterus, weight gain

21-40th week (esp. Last trimester) = catabolic phase

High metabolic demands of foetus

Accelerated starvation of mother (insulin resistance + lypolysis)

272
Q

what hormone stimulates milk production?

A

prolactin

273
Q

Naegele’s rule?

A

due date = LMP + 9 months + 7 days

274
Q

what is done at every antenatal appointment?

A

BP

urinalysis (UTI, asymptomatic bacteruria, PET, diabetes)

macrosomia/IUGR

275
Q

if placenta low lying at anomaly scan when is it re-checked?

A

32 weeks

276
Q

trisomy screening for which conditions?

process?

A

Down’s syndrome T21, edwards syndrome T18, Patau’s syndrome T13

1st trimester = NT combined with HGC + PAPP-A

if high risk = NITP

if NITP positive = CVS/amniocentesis

277
Q

2nd trimester screening for trisomy?

i.e. if missed 1st trimester screening

A

AFP

HCG

unconjugated oestradiol (UE3)

inhibin A (high)

(everything down in Downs except those that are HI (HCG and inhibin A)

278
Q

what is NIPT?

why is it useful?

A

Cell free foetal DNA (cffDNA) - also known as non-invasive prenatal testing (NIPT)

Improved accuracy means fewer women will have to have invasive diagnostic test (CVS/amniocentesis) when their baby does not have downs syndrome

(predictive value >90%)

279
Q

diagnostic tests trisomy?

A

Amniocentesis

performed after 15 weeks

Carries miscarriage rate of 1%

Chorionic villus sampling (riskier procedure)

performed after 11-12 weeks

Carries miscarriage rate of <2%

280
Q

high risk vs moderate risk pre-eclampsia Tx?

A

high risk = HTN previous pregnancy, CKD, SLE or APS, T1/T2DM, chronic HTN

150mg aspirin from 12 weeks

mod risk = first pregnancy, >40 y/o, pregnancy intrval >10 years, BMI >35, FH pre-eclampsia, multiple pregnancy

75mg aspirin from 12 weeks

281
Q

conditions screened for at booking?

20 weeks?

28 weeks?

A

haemoglobinopathies (thalassemia, HbS), hep B, HIV, syphillis, rhesus state, anaemia, trisomy screening offered

20 weeks = anomaly scan

28 weeks = rhesus, OGTT, anaemia

282
Q

chest pain pregnancy?

A

All women with chest pain should have ECG

283
Q

palpitations pregnancy?

A

physiological = common, occur at rest/lying down

ectopic beats = common, relived by exercise

sinus tachy = part of normal pregnancy

SVT = usually predates pregnancy

hyperthyroidism

phaemchromocytoma = headache, sweating, hypertension (24 hour catecholamines)

284
Q

breathlessness pregnancy?

A

very common in 3rd trimester

improves with exertion (different from anaemia)

285
Q

asthma in pregnancy?

A

continue treatment as normal

inhaled B2-agonists do not ipair uterine activity or delay onset of labour

286
Q

where do most DVTs arise in pregancy?

A

90% in left leg

287
Q

when to give LMWH in pregnancy?

A

previous VTE

thrombophillia (APS)

co-morbidities: cancer, heart failure, SLE, IBD, CKD, T1DM, sickle cell, OHSS

288
Q

LMWH examples?

A

enoxaparin, daletparin (fragmin), tinzaparin

289
Q

symptoms + signs DVT?

Dx?

A

swelling (oedema)

leg pain

tenderness

increased leg temp

elevated white cell count

Dx = duplex ultrasound

if iliac vein thrombosis suspected (whole leg swollen + back pain) = MRI venography

290
Q

symptoms PE

signs?

Dx?

A

symptoms = dyspnoea, pleuritic chest pain, collapse, haemoptysis

signs = raised JVP

Dx = CTPA

291
Q

why are LMWHs used in pregnancy?

A

warfarin is teratogenic!!!!!

292
Q

are anticoagulants contraindicated in breastfeeding?

A

both herparin and warfarin are safe in breastfeeding

recommence warfarin 5th post-natal day (remember CI in pregnancy)

293
Q

CTD drugs that are safe in pregnancy?

contraindicated?

A

safe = steroids, azathioprine, sulphasalazine, hydroxychloroquine, aspirin, biologics

unsafe = NSAIDs, cyclophosphamide, methotrexate, chlorambucil, gold, penicillamine, leflunamide

294
Q

APS s/s?

Dx?

clinical Dx?

A

s/s: thrombosis, recurrent early pregnancy loss, late preganancy loss (preceded by FGR), placental abruption, severe early onset pre-eclampsia, severe FGR

Dx = anticardiolipid (aCL) + lupus anticoagulant (LA)

(must be 2 x 6 weeks apart - LA and aCL can be transiently raised in infection)

clinical Dx

>3 miscarriages <10 weeks old

>1 foetal loss >10 weeks (morphologically normal foetus)

>1 preterm birth due to PET

295
Q

Tx APS pregnancy?

A

LDA + LMWH

296
Q

epilepsy Tx pregnancy?

A

All women with epilepsy (WWE) should take 5mg/day folic acid

Lowest effective dose of most appropriate AED should be used (AVOID sodium valproate)

if seizure = benzodiazepines (lorazepam)

297
Q

Tx seizures in pregnancy?

A

if no history of epilepsy = MgSO4

if history of epilepsy = IV lorazepam

298
Q

enzyme inducing AEDs

A
299
Q

preterm birth?

post-term?

A

preterm = <37 weeks

post-term = >42 weeks

300
Q

commonest type of breech?

most dangerous?

other types?

A

commonest = Frank breech

most dangerous = footling

other types = complete breech, transverse (shoulder/arm), face + brow presentations

301
Q

complications epidural?

A

Hypotension

Dural puncture - CI IN COAGULOPATHY

Headache

High block e.g. higher than T11/T12 (can be associated with breathing problems)

Atonic bladder (40%)

302
Q

complications obstructed labour?

A

Sepsis

Uterine rupture (more common in 2nd/3rd pregnancy or previous Cesarean section)

Obstructed AKI

PPH

Fistula formation

Foetal asphyxia

303
Q

signs of labour obstruction?

A

Moulding (bones of baby’s head)

Caput (oedema in the scalp)

Anuria

Haematuria

Vulval oedema

304
Q

partogram used for?

what does it monitor

A

partogram = assess progression of labour

monitors: foetal heart, amniotic fluid, cervical dilation, descent, contractions, obstruction (moulding), meternal observations

305
Q

risk factors foetal hypoxia?

A

small foetus

pre/post dates

antepartum haemorrhage

HTN/PET

diabetes

meconium

epidural

VBAC

PROM >24 hrs

sepsis

IOL

306
Q

causes of foetal hypoxia?

A

acute = uterine hyperstimulation, cord prolapse, uterine rupture, abruption, regional anesthesia, vasa praevia

chronic = pre-eclampsia (placental insufficiency)

307
Q

CTG interpretation

A

DR C BRAVADO

determine

risk

contractions

baseline

R

ate

variability

accelerations

decelerations

overall impression

308
Q
A

Low risk

Heartrate normal

Baseline rate = 120

Accelerations present

Approx 3 contractions 10 minutes

Normal

309
Q
A

High risk pregnancy

At least 4 contractions in 10 mins

Baseline rate high - 170

No accelerations

Variability reduced

Late decelerations - beyond peak of contraction

310
Q

management abnormal CTG?

A

Change maternal position (all 4s)

IV fluids

Stop syntocinon

Scalp stimulation

Consider tocolysis - terbutaline 250 micrograms s/c

Consider foetal blood sampling (FBS - acidosis)

Operative delivery (category 1 delivery)

311
Q

foetal blood sampling interpretation?

A
312
Q

indications for operative delivery?

A

failure to progress (stage 2 >2 hours)

foetal distress

severe PET

umbilical cord prolapse stage 2

breech

313
Q

causes of maternal collapse?

A

head = eclampsia, epilepsy, CVA

heart = MI, arrythmias, peripartum cardiomyopathy (orthopnoea)

hypoxia = asthma, PE, anaphylaxis

haemorrhage = abruption, uterine rupture, trauma, uterine inversion

whole body = hypoglycaemia, amniotic fluid embolism, sepsis

314
Q

reversible causes of cardiac arrest?

+ pregnancy

A

4 H’s and 4T’s (reversible causes of cardiac arrest)

4H’s = hypoxia, hypovolaemia, hypo/hypermetabolic , hypothermia

4T’s = thrombo-embolism, tamponade, toxins, tension pneumothorax

And in pregnancy, 2 C’s

Eclampsia

Intracerebral bleed

3rd year medicine (13 decks)

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