Reproductive health general Flashcards
How would placenta praevia vs placental abruption present itself
Placenta praevia
- painless
- bright red blood
Placental abruption
- abdominal pain
- dark red blood
- heavy PV flow
- A classical feature is a hard or “woody” uterus which is tender on palpation.
A newborn on the postnatal ward develops respiratory distress a day after birth. The delivery was an uncomplicated vaginal birth. On examination she is pyrexial, tachycardic and has laboured breathing. She also appears floppy and lethargic, but there are no dysmorphic features. The mother is distressed and confesses to eating copious amounts of Camembert cheese during the pregnancy due to cravings. Which is the most likely causative organism?
listeria monocytogenes
You see a 24 year old primigravida woman who has attended the maternity ward at 39+2 weeks gestation in early labour. The woman is well and this is an uncomplicated pregnancy. The midwife performs a routine cardiotocography (CTG) over 30 minutes.
Which of the following is a normal interpretation of a CTG in the first stage of labour?
Baseline rate: 125bpm. Variability: 15bpm. Accelerations: present. Decelerations: absent
When interpreting a CTG, look at four components; baseline rate, variability, presence of accelerations and presence of decelerations. A normal foetal heart rate is 110-160bpm. There should be variability of between 5 and 25bpm. Accelerations should be present and there should not be decelerations in early labour
You are a foundation doctor on labour ward and have just assisted with an urgent Caesarean section. A medical student asks you to explain the categorisation of Caesarean sections.
Which of the following is correct regarding category 1 Caesarean sections?
Occur due to foetal compromise
- foetal scalp sampling <7.2
- should be done within 30 min
- cord prolapse is an indication
Which of the following is the correct sequence of layers that will be dissected through to gain access to the foetus during caesarean section?
Skin - subcutaneous fat - rectus sheath - rectus abdominus muscle - peritoneum - uterine myometrium - amniotic sac
A 28 year old 39 weeks pregnant lady is due to have an induction of labour. A pelvic examination is performed and a Bishop score of 5 is calculated.
What is the most appropriate first-line in inducing labour?
Prostaglandin pessary
The bishop score is used to predict whether spontaneous labour will occur or induction of labour will be required. A score of 5 or less suggests labour is unlikely to occur without induction. First-line measure is using a prostaglandin pessary, which causes cervical ripening and labour induction
The Bishop score
is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):
Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)
A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.
A 23-year-old woman has just found out that she has an incomplete miscarriage at 8 weeks’ gestation. After careful counselling, she decides to have medical management to complete the miscarriage. Which of the following is involved in medical management?
Misoprostol
Misoprostol is a synthetic prostaglandin that encourages the expulsion of the products of conception.
what is mifepristone
Mifepristone is an progesterone-receptor antagonist. This is used in the termination of pregnancy to end the pregnancy. Misoprostol is then used to expel the pregnancy. In a miscarriage, only misoprostol is needed.
The most commonly used medication for infertility in women with PCOS is clomifene
clomifene
A 56-year-old woman presents at the GP with spotting. She had her last menstrual period 6 years ago. Bimanual vaginal exam is normal. Which of the following is the most appropriate investigation?
Transvaginal ultrasound (TVS)
According to NICE guidance, any woman over 55 with postmenopausal bleeding (defined as unexplained vaginal bleeding 12 months after the last menstrual period) should be referred under a 2-week wait pathway for endometrial cancer. The first-line investigation for endometrial cancer is a TVS to assess endometrial thickness.
placenta increta vs increta vs percreta
- Placenta accreta occurs where adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle.
- Placenta increta occurs where the villi invade into but not through the myometrium
- Placenta percreta occurs when the villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.
A 32-year-old primagravida discovers from her booking blood tests that she has contracted hepatitis B. She is both HbsAg and HbeAg positive at the time of delivery.
Which of the following options represents the best management for the foetus?
HBV IgG and HBV vaccination within 24 hours of delivery
This patient is positive for both Hbs and Hbe antigens, increasing the risk of vertical transmission at delivery. Using both HBV IgG and a vaccine reduces the risk of the foetus contracting HBV at birth to ~5%
A 32-year-old primagravida discovers from her booking blood tests that she has contracted hepatitis B. She is both HbsAg and HbeAg positive at the time of delivery.
Which of the following options represents the best management for the foetus?
HBV IgG and HBV vaccination within 24 hours of delivery
This patient is positive for both Hbs and Hbe antigens, increasing the risk of vertical transmission at delivery. Using both HBV IgG and a vaccine reduces the risk of the foetus contracting HBV at birth to ~5%
A 39 year old para 2 woman had a normal vaginal delivery 30 minutes ago of a healthy baby in the midwife-led delivery suite. She delivered the placenta five minutes later. She now has heavy vaginal bleeding, is not feeling well, and her midwife is concerned.
On examination, her pulse is 110pm, blood pressure is 90/65, and she looks pale and sweaty. Her abdomen is tender and fundal palpation reveals a spongy feeling uterus. Vaginal bleeding is ongoing.
What is the most likely cause of this patient’s post partum haemorrhage?
Uterine atony
The examination finding of a ‘boggy’ or non-contracted uterus suggests the uterus has failed to contract sufficiently to stem blood from from uterine vessels sheared during delivery.
This lady appears hypovolaemic (evidenced by the tachycardia and hypotension) and requires urgent resuscitation, uterine massage and probably uterotonic drugs to encourage uterine contraction
Which of the following defines a major primary post-partum haemorrhage?
Blood loss >1000 ml within 24 hours of delivery
Post-partum haemorrhage (PPH) is defined as any bleeding from the genital tract following recent delivery. It can be divided into primary and secondary and major and minor.
- Major PPH is when blood loss is of >1000 mls within 24 hours of delivery.
- The most common cause is uterine atony.
- This is an obstetric emergency and needs prompt resuscitation and treatment often with the use of IV oxytocin and bimanual uterine compression to encourage uterine contraction
A newborn check is carried out on an infant who was delivered vaginally 24 hours ago at 37 weeks gestation. There were no complications during the pregnancy. On examination there is bilateral loss of the red reflexes, purpuric skin lesions covering the torso and a continuous “machine-like” murmur heard on cardiac auscultation. An immediate automated otoacoustic emission test is requested which returns an abnormal result. What is the likely diagnosis?
congenital rubella syndrome
A 40-year-old woman is admitted at 38 weeks gestation because she is persistently hypertensive. You are called by the patient’s partner because she is having a ‘fit’. When you arrive she is having a tonic-clonic seizure. Once her airway is stabilised, what is the most appropriate next step in management?
Intravenous magnesium sulfate
This patient is likely having an eclamptic seizure. The drug of choice for managing this is magnesium sulfate. It both controls the current episode and prevents further seizures
A 20 year old woman at 38+5 weeks gestation attends the maternity unit in labour. She is having regular contractions every 6 minutes, lasting 30-60 seconds.
The midwife performs a vaginal examination to assess the progress of labour.
She finds the cervix anterior, approximately 1cm in length and of a soft consistency. The cervix is 1cm dilated and she can feel the foetal head 1cm above the ischial spines.
What is this woman’s Bishop’s score?
Therefore this woman’s score is as follows:
Position of the cervix = anterior = 2
Length of the cervix = 1cm = 2
Consistency of the cervix = soft = 2
Dilatation of the cervix = 1
Station of the presenting part (distance in cm in relation to the ischial spines) = 1
A 28 year old G2P2 presents to the antenatal clinic at 24 weeks gestation. She is inquiring about the safety of having a vaginal birth after having had a previous caesarean section.
Which of the following is an absolute contraindication for vaginal birth after caesarean (VBAC)?
Classic caesarean section scar (vertical)
Classic caesarean section scar is an absolute contraindication to VBAC due to a high risk of uterine rupture, which is an obstetric emergency carrying a significant maternal and foetal mortality and morbidity
A 24 year old gentleman visits the GUM clinic.
Upon genital examination, he has a painless lesion on his penis. There is also evidence of a swollen and painful inguinal ligament.
What is the most likely causative organism for this condition?
Chlamydia Trachomatis
The presentation in this instance is Lymphogranuloma Venereum (LGV). This is a tropical disease, rare in the UK. It classically presents with a non indurated lesion on his penis, and due to lymphatic destruction, it can cause a swollen inguinal ligament. This is known as the Groove sign, with a groove visible above and below the inguinal ligament. LGV is caused by Chlamydia, specifically serovars L1/L2/L3
NOT
Herpes Simplex Virus
This would be appropriate in Herpes infection, which would present with multiple painful lesions in the genital area
A 47 year old HIV positive man presents to A & E with a non-productive cough and shortness of breath.
He notes that he has become more breathless recently as he walks.
Which of the following is the most likely causative organism?
The classic sign of PCP is a lowering of oxygen saturations on exercise. This would manifest as newfound breathlessness in patients recently infected
A 67 year old homeless man presents to the Emergency Depratment after a sudden onset weakness of his right arm and leg. He is currently alert but unable to recall the events leading up to his admission. Neurological examination also reveals a positive Romberg’s sign, bilateral hyporeflexia of his lower limbs and upgoing plantars. He has reduced vibration and joint position sensation of both lower limbs. Cardiovascular examination reveals an early diastolic murmur loudest over the upper right sternal edge. He has multiple hyperpigmented lesions on his shins with central necrosis.
Which of the following investigations is most likely to confirm the underlying diagnosis?
Enzyme immunosorbent assay (EIA)
This is the initial screening tool used for syphilis. This patient has features of tertiary syphilis, as seen from his neurological signs (stroke, sensory ataxia, proprioceptive loss, mixed upper and lower motor neuron signs), cardiac signs (aortic regurgitation), cutaneous granulomas and dementia
A 67 year old homeless man presents to the Emergency Depratment after a sudden onset weakness of his right arm and leg. He is currently alert but unable to recall the events leading up to his admission. Neurological examination also reveals a positive Romberg’s sign, bilateral hyporeflexia of his lower limbs and upgoing plantars. He has reduced vibration and joint position sensation of both lower limbs. Cardiovascular examination reveals an early diastolic murmur loudest over the upper right sternal edge. He has multiple hyperpigmented lesions on his shins with central necrosis.
Which of the following investigations is most likely to confirm the underlying diagnosis?
Enzyme immunosorbent assay (EIA)
This is the initial screening tool used for syphilis. This patient has features of tertiary syphilis, as seen from his neurological signs (stroke, sensory ataxia, proprioceptive loss, mixed upper and lower motor neuron signs), cardiac signs (aortic regurgitation), cutaneous granulomas and dementia
Appropriate contraception for a women 3 weeks postpartum
POP
- COCP contraindicated in women breastfeeding and <6 weeks after birth
- IUS/IUD must be inserted within 48 hours of birth or after 4 weeks
at what thickness of endometrial tissue should the patient be investigated for endometrial cancer
> 5mm
A 28 year old woman attends A&E with breathlessness, abdominal pain and vomiting. She has been undergoing fertility treatment privately, and 5 days ago had an egg retrieval procedure which yielded 22 eggs and was uncomplicated.
Her observations are as follows:
- Pulse 80
- Blood pressure 90/70
- Respiratory rate 20
- SpO2 97% on air
- Temperature 36.7
- On examination, her abdomen is distended and tense but not peritonitic. Her chest is clear with reduced breath sounds at both bases.
- Urinary HCG is negative.
What is the most likely diagnosis?
Ovarian hyperstimulation syndrome
OHSS is a known side effect of fertility treatments, which is characterised by an increase in ovarian size and shifting of fluid which can result in ascites and pleural effusions.
Treatment is largely supportive, with fluid replacement as appropriate, and drainage of ascites/pleural effusions if required.
OHSS is a hypercoagulable state, so it is important to ensure these patients receive appropriate thromboprophylaxis
Uterine hyperstimulation
is a serious complication of labour induction. It is defined as as single contractions lasting 2 minutes or more, or five or more contractions in a 10 minute period.
A 29-year-old woman with gestational diabetes is in the second stage of an uncomplicated labour. The head has delivered but the midwife cannot see the anterior shoulder, and the head retracts in between contractions.
What is the next step in the management of her delivery?
Attempt McRobert’s manoeuvre
This patient’s labour has been complicated by shoulder dystocia, which is likely related to her gestational diabetes. The first line management of shoulder dystocia (after calling for help) is to attempt McRobert’s manoeuvre. If performed correctly, this has a 90% success rate in delivering the baby vaginally.
