Repro Misc Flashcards
What level does ART in HIV aim to keep CD4+ count at?
> 350
WHO advice on the duration of breastfeeding and transition off of it?
Exclusively breastfeed for 6 months
Then a combination of foods and breastfeeding up until 2 years of age
Post partum haemorrhage after placental delivery, exam reveals a hard, contracted uterus?
Likely perineal trauma
Hard contracted uterus normal - rules out atonic uterus
Woman suddenly collapses after delivering placenta and is in a state of shock, fundus is difficult to elicit on abdo exam?
Uterine inversion
Woman collapses suddenly before she was due to be discharged 5 days after delivery by c-section?
PE likely - always suspect in unexplained collapse after surgery or in peurperium
Woman has constant abdo pain then collapses whilst in labour. Foetal bradycardia on CTG. This is 2nd pregnancy, previous child delivered by C-section?
Uterine rupture
How is induction of labour performed?
If Bishops <6 - vaginal PGE2 then reassess 6hr later
Then if Bishops still <7 another vaginal PGE2 and reassess 6hr later
If this fails then artificial ROM and syntocinon
When is artificial ROM most commonly performed?
When a woman is in active labour but her waters have not broken
When is a membrane sweep performed?
To try and kick-start active labour at 40 and 41 weeks in nulliparous, and 41 weeks if multiparous
3 enzymes that HIV contains?
Reverse transcriptase
Protease
Integrase
How does HIV establish persistence?
By constantly mutating through a process called antigenic variation
What happens once HIV infects a cell?
It is a retrovirus, therefore, carries 2 copies of RNA. Once a cell is infected, the RNA is transcribed into DNA and is integrated into the host cell genome
Diagnosis of gestational diabetes?
Fasting glucose 5.6 or more; OR
2-hour OGTT 7.8 or more
Management of gestational diabetes?
If fasting glucose <7 then lifestyle advice and reassess in 2 weeks. If still 5.6-7 then metformin
If fasting glucose >7 at diagnosis then start insulin immediately
What clinical finding is typical of pneumocystis jirovicii?
Exercise desaturation
What is a progesterone challenge test?
Give medroxyprogesterone acetate for 5 days and it should stimulate a withdrawal bleed
Proves normal functioning endometrium and intact outflow tract
17 y/o girl with developed secondary sex characteristics has primary amenorrhoea. All endocrine tests are normal, but she fails a progesterone challenge test?
Absent uterus
Woman due for elective ankle surgery in 4 weeks on COCP where she will be immobilised for a minimum of 10 days after?
Stop the pill 4 weeks before surgery and restart 2 weeks after - switching to POP would be a suitable alternative
UKMEC 4 - major surgery with prolonged immobilisation - does not apply to minor surgical procedures or laparoscopic procedures
First line investigations for a couple presenting with infertility for 1 year?
Female - day 21 progesterone
Male - semen analysis
Is previous ectopic pregnancy a contraindication for contraception?
No, copper coil only increases the risk of it occurring
A couple are infertile for 1 year and testing reveals the woman has endometriosis. What is the management?
Continue trying to conceive naturally for another year.
The guidance for patients with mild male factor infertility, mild endometriosis or unexplained infertility –> try conceiving naturally for 2 years before offering IVF/ICSI
What 5 female factors for infertility warrant early referral to infertility clinic (i.e. before 1 year)?
>35y/o Amenorrhoea Previous pelvic surgery Previous STI Abnormal genital exam
What 5 male factors for infertility warrant early referral to infertility clinic (i.e. before 12 months)?
Previous surgery on genitalia Previous STI Varicocele Significant systemic illness Abnormal genital exam
Is emergency contraception affected by BMI?
If BMI>26, a double dose of Levonelle is required
EllaOne and Cu IUD are fine
Which contraceptive is associated with weight gain?
Depo-Provera (2-3kg in the first year)
Which cancer would have the greatest PERCENTAGE reduction if it was possible to remove the effect of obesity?
Oesophagus
Is there increased contractility of the heart during pregnancy?
Yes - to allow greater CO
Is uterine fibroids a cause of large for dates pregnancy?
Yes
What does the vas deferens develop from embryologically?
Mesonephric duct
What does the fornix of the vagina develop from embryologically?
Paramesonephric duct
Is IVF a cause of IUGR?
Yes
Is maternal anaemia a cause of IUGR?
No
Is maternal BMI <18 a cause of IUGR?
Yes
When can nuchal thickness be tested in screening for Down Syndrome?
11-14 weeks
When is the uterine fundus normally palpable in a singleton pregnancy?
12 weeks
A woman in labour suite requires forceps delivery. 4 options for analgesia?
Epidural
Spinal anaesthesia
Pudendal nerve block
Perinial block
When can the sex of the foetus be determined by USS?
18 weeks
How is pain from female repro tract carried to CNS?
Bladder, uterus, ovary, adnexae (endocervix?) - all the bits touching the peritoneum basically –> T11-L2 via visceral afferents
Below this but above levator ani –> S2-S4 via parasympathetic fibres (referred to back of legs/buttocks)
Below levator ani –> S2-S4 via somatic sensory (localised pain in perineum)
83 y/o lady is having falls. She takes Oxybutynin for urge incontinence. What can this be replaced by?
Mirabegron (beta3 agonist therefore no anticholinergic SE)
For women experiencing hot flushes in menopause, apart from HRT what can be offered?
Fluoxetine - can be used for vasomotor symptoms of menopause
citalopram and venlafaxine also licensed for this
How are medical deliveries of miscarriages carried out?
Vaginal misoprostol alone
no need for PO mifepristone
At booking appointment woman reveals Hx of 2 previous DVT’s, management?
LMWH starting immediately, until 6 weeks post-partum
Is aminophylline CI during breast feeding?
No
Is amiodarone CI during breastfeeding?
Yes
Most common cause of infection in a newborn <7 days old?
group B strep
Most common cause of haemorrhage in a newborn?
Prolonged ventouse delivery
Can mothers with HepB breastfeed?
Yes
Difference in presentation between acute fatty liver of pregnancy and cholestasis of pregnancy?
Cholestasis - pruritis, nausea, lethargy, jaundice, obstructive pattern LFT’s
AFLP - non-specific e.g. malaise fatigue, nausea
Which infections are screened for at booking appt?
HIV
HepB
Rubella
Syphilis
What placental abnormality is higher with assisted conception?
Placenta praevia
Management of suspected PE in pregnancy?
Confirm DVT by doppler USS, if present give LMWH before CTPA/VQ-scan
What can be given to suppress lactation if wishing to cease breastfeeding?
Cabergoline (dopamine agonist)
If a 52y/o woman who still has a uterus opts for oestrogen-only HRT, what else can be given?
Mirena IUS for 4 years
What is a normal symphyseal fundal height?
Within +2/-2 of the gestational age
Woman presents at 9 weeks gestation with vaginal bleeding. US confirms viable intrauterine pregnancy, however high vaginal swab isolates Group B strep, management?
Intrapartum IV Benzylpenicillin (or Clindamycin)
It is likely group B strep is her natural flora so treating with Erythromycin will not reduce the chance of colonisation at birth.
Where do ectopic pregnancies most commonly occur?
Where are they most likely to cause rupture?
Most commonly in Ampulla
Rupture in Isthmus
A pregnant woman has an episode of urinary incontinence. 3 weeks later, at 37 weeks gestation, she appears with fever, tachycardia and feeling generally unwell. Foetal tachycardia also present. Likely cause?
Chorioamnionitis
Likely that ‘incontinence’ was rupture of membranes
What triad of signs should make you consider chorioamnionitis?
Maternal fever
Maternal tachycardia
Foetal tachycardia
Hx of premature ROM
Woman presents with menorrhagia. What are the full management steps starting with investigations?
Start with FBC.
If structural/histological abnormality suggested, refer for TVUS
If no contraception required, prescribe Tranexamic acid or Mefanamic acid (if there’s pain)
If contraception required, offer Mirena 1st line, or COCP/POP 2nd line
33 y/o woman presents with sudden onset LIF pain that has been getting worse for 5 hours. It started just after sexual intercourse. Lower abdo tender on exam, no guarding, bimanual exam unremarkable. USS shows free fluid in pelvic cavity. Urine hCG test negative?
Ruptured ovarian cyst
How to differentiate ovarian torsion from ruptured ovarian cyst?
Cyst:
Sudden onset unilateral pain
Preceded by intercourse/strenuous activity
Abdo exam tender but no guarding/peritonism
Bimanual exam may be uncomfortable but generally unremarkable
Torsion: Quick onset unilateral pain Assoc w nausea and vomiting May be guarding on exam Bimanual exam - tender adnexal mass USS shoes enlarged, oedematous ovary with impaired blood flow
How to differentiate fibroids and adenomyosis by bimanual exam?
Both have Hx of abdo pain and menorrhagia:
Fibroids - uterus feels bulky
Adenomyosis - uterus feels boggy
Man and woman both taking methotrexate for rheumatological problems, wish to get pregnant. What is the management?
BOTH man + woman must stop methotrexate for 3 months before trying to conceive
Couple having fertility problems, semen analysis normal, TVUS of woman reveals 3 submucosal fibroids - management?
Myomectomy
What is 2nd line to Labetalol for pregnancy-induced hypertension/pre-eclampsia if asthmatic?
Nifedipine
How can USS be used to predict risk of pre-eclampsia?
At 20 weeks, USS may show bilateral maternal uterine artery doppler waveform abnormalities - high risk of developing pre-eclampsia
Woman is 6 days post-natal with uncomplicated pregnancy and no PMHx. She isn’t sleeping and yesterday seemed confused. Today she is full of ideas about activities for the coming day. She is very confident about caring for her baby and reports being extremely happy. Diagnosis?
Puerperal psychosis
Which of the following is NOT part of foetal alcohol syndrome spectrum:
- Dysplastic kidneys
- Ventricular septal defect
- Micrognathia and smooth philtrum
- Anencephaly
- Microcephaly
Anencephaly
Where does fluid in the foetal lung come from?
It is mostly produced in the foetal lungs
What % oxygen should be used initially in newborn resuscitation?
Ratio of compressions:breaths?
21-30%
3:1
For a preterm infant, what should be taken into account when measuring growth& development?
For how long?
Corrected gestational age
Until 12 months
What normal finding can some newborns have on their trunk?
Dry, cracked skin
Is short time between pregnancies a risk factor for developing pelvic girdle pain in pregnancy?
No
What is first line management for pre-menstrual syndrome?
If this doesn’t work what medication can be offered?
Lifestyle - diet, exercise, sleep hygiene, reduce stress
Meds - if not planning pregnancy COCP, if planning pregnancy SSRI
Complementary therapy may work e.g. Vit B6 (pyroxidine supplements) may work
Woman presents 20 weeks gestation in her 2nd pregnancy with lower backache, fever and vaginal loss of a cloudy white, viscous substance. Temp 38.2C, HR 98, suprapubic tenderness on palpation. Os slightly open with fluid draining. Diagnosis?
Chorioamnionitis
Which hormonal medication is assoc w development of endometrial hyperplasia?
Tamoxifen
What cells secrete hCG?
How long after fertilisation can it be detected in maternal bloodstream?
Syncytiotrophoblasts
8 days
Which screening tool can be used to screen for post-natal depression?
Edinburgh Scale
Investigation for placenta praevia?
TVUS
A 42 y/o woman has been in stage 3 labour for 64 mins and lost 2800ml of blood. She has 1 previous child who was delivered by C-section. PMHx = PID. An antenatal USS clocked a problem, which was not picked up by the delivery team. What is the underlying problem, and what is the management?
Placenta accreta
Emergency hysterectomy
Investigation for post-menopausal bleeding?
1st - TVUS
If endometrial wall thickened –> hysterescopy + biposy
In LCSC, after skin and superficial + deep fascia, what are the the layers you must go through to reach uterus?
Anterior rectus sheath Rectus abdominis muscle Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
How long can lochia persist for?
What Ix is warranted if it persists for longer?
6 weeks
TVUS
A 24y/o lady with T1DM is 25+3 weeks pregnant. She has thin, watery discharge from her vagina. Speculum exam normal. Foetal fibronectin level 300 (+ve). Management?
Admit
2 doses of Dexamethasone 12 hours apart
Monitor blood glucose carefully and adjust insulin pump accordingly - steroids can cause hyperglycaemia
(foetal fibronectin is a protein released from gestational sac - high levels gives a high chance of premature labour)
How can the COCP mask PCOS?
By causing normal periods (may even be heavy) and decreasing acne, hirsutism etc.
Weight gain will still be present, and once stopping the pill patients will become oligo-/a-amenorrhoeic
A 30 y/o woman presents 10 weeks gestation with 2 episodes of foul-smelling red discharge PV. There is assoc lower back pain, temp 39, BP 85/65. Cervical os is open and US confirms products of conception in uterus. What is going on?
Inevitable miscarriage which has become septic
–> surgical management pronto
Management of miscarriage?
Usually expectant
If risk of haemorrhage, maternal request or evidence of infection then intervention warranted
- If septic, surgical removal required
- If no increased risk, vaginal misoprostol can be used to augment excretion
Management of post-natal depression assuming good support network, no suicide risk etc and no Hx of depression?
1st - CBT
2nd - SSRI or TCA
A 43 y/o woman is 27 weeks gestation and is having regular, weak contractions. Her cervix is 3cm dilated and membranes are intact. Management?
Admit
Give tocolytics + steroids
Common complications after hysterectomy with antero-posterior repair? (1 acute, 2 chronic)
Acute - urinary retention
Chronic - enterocele and vaginal vault prolapse
Which lymph nodes would malignancy from these locations spread to:
- Ovary
- Uterus
- Cervix
Ovary - para-aortic
Uterus - para-aortic
Cervix - internal iliac
Woman in 3rd trimester has lower back pain worse at night, why does this happen?
Pelvic muscles and ligaments start to relax in preparation for labour
When are foetal movements usually first felt?
Around 20 weeks if primigravida
16-18 weeks if multiparous
When should nipples enlarge and darken during pregnancy?
Nipples enlarge in first few weeks due to high circulating oestrogen and human placental lactogen
They darken at 12 weeks due to high circulating melanocyte stimulating hormone
1st and 2nd line analgesia in pregnancy?
1st - paracetamol
2nd - low dose codeine
How long after chancre does it take for secondary syphilis to present?
2-8 weeks
Presentation of lymphogranuloma venerum abscess?
Initially painles groin ulcer
Then a couple of weeks later painful inguinal lymphadenopathy
If left untreated, can develop into large perianal or vulval abscess
Rx: doxcycline or erythromycin
If a pregnant woman is exposed to chicken pox and is not immune, within how long should she receive varicella Ig?
10 days
Best treatment for Bartholin’s Cyst abscess?
Marsupialisation process
Cut open the abscess and suture the edges to leave it open so it can drain freely
What is the first line investigation in any elderly lady presenting with urinary incontinence?
Why?
Urinalysis
To ensure there is no underlying UTI/diabetes causing or precipitating the incontinence
In an uncomplicated pregnancy, if baby not born at 40 weeks, when should IOL be offered?
Between 41-42 weeks to decrease risk of complications assoc w prolonged pregnancy
How long after TOP can pregnancy test still be positive for?
4 weeks
After this indicates potential incomplete abortion or persistent trophoblast
What to give as prophylaxis for group B strep?
Erythromycin
OR
If temp >38C then Benzylpenicillin
Who is offered HepB screening?
When should babies receive HepB vaccine?
What is given and when?
Can it be passed via breastfeeding?
Everyone
If high risk, e.g. mother chronically infected, IVDU, has acute HepB during pregnancy etc
HepB Ig + vaccine within 12 hours of birth, then vaccine again at 1-2 and 6 months
No (HIV can though)
What is McRobert’s position?
Supine with both hips fully flexed and abducted (increases space in SI joint)
PCOS increases the long-term risk of which disease?
Endometrial carcinoma
Is Hx of PID a CI for IUD?
If it was <3 months ago yes
