RHCN Flashcards
what are the leading causes of maternal mortality worldwide
postpartum haemorrhage syntocinon etc can cause postpartum haemorrhage - pushing out uterus can’t contract afterwards as too tired
what is the most common cause of PPH (post party haemorrhage)
uterine atony (uterine failing to contract after delivery 4 T’s - causes of PPH: - tone - atony - trauma - tissue retained - thrombin clotting abnormalities
what is the leading cause of maternal mortality in the uk?
cardiac disease
what is the first line medication for an eclamptic seizure
first line: IV magnesium sulphate will prevent further seizure activity IV labetalol for managing HTN
risk factors for gestational diabetes
- PCOS (polycystic ovarian syndrome) - BAME ethnicities - older age - high BMI - previous big baby >4kg
what test do pregnant women need when high risk for gestational diabetes
GTT between 26 and 28 weeks gestational diabetes diagnosis: - fasting glucose > 5.6 - post sugar > 7.8 refer to gestational diabetes clinic
when choosing VBAC (virginal birth after Caesarean section) what is the risk of uterine rupture in spontaneous labour?
1/200 - best chance with spontaneous labour if induced with prostaglandin 1/50
a manoeuvre to aid delivery at shoulder dystocia
McRobert’s bed flat and knees up to chest
what is shoulder dystocia
anterior shoulder stuck behind pubic symphysis EMERGENCY delivery of head and then with the next push the baby should come out so if it doesn’t = shoulder dystocia
what injury is common with shoulder dystocia
brachial plexus injury
risk factors for shoulder dystocia
- macrosomia (big baby) - diabetes -maternal high BMI - previous shoulder dystocia
what is the upper limit of normal for the post-menopausal endometrium?
4mm
post manopausal bleeding investigations
- speculum and bimanual examination - transvaginal USS to look at endometrial thickening - normal <4mm if >4mm: - pipette endometrial biopsy/ hysteroscopy
a women presents with with postcoital bleeding and you see a mass on her cervix, what should you do
refer for urgent colposcopy
cervical smear
for people that are asymptotic screening checks for changes in cells
a 54yr old woman has USS, a complex ovarian cyst is seen, which blood test should be done
Ca125 - ovarian cancer USS
complex ovarian cyst in pre-menopausal woman which blood tests?
Ca125 AFP hCG CEA
what is recommended to all low risk women planning pregnancy and in the 1st trimester
folic acid 400mcg OD
who should get 500mcg folic acid during 1st trimester
high risk epilepsy previous fatal anomaly diabetes high BMI
what is the normal scan schedule in a low risk pregnancy
12 - dating scan - due date, screening offered here 20 weeks - anatomy scan
what is the scan schedule in a high risk pregnancy
12,20, 28, 36
how far away from the internal OS must the placenta be to allow vaginal birth
20mm
what is the UK gestational age viability
24 weeks
a 14yr old girl attends to ask for the pill, you deem her Fraser competent, what should you do
give her the pill, encourage her to discuss with her parents
what is the biggest risk factor for ectopic pregnancy + other risk factors
- tubal damage (ie from chlamydia) - endometriosis - previous surgery - conceiving while on the pill
a woman presents to the GP with shortness of breath 5 days post emergency CS, what should you do?
refer to hospital for investigation of PE commence LMWH if +ve
when is anti D prophylaxis required?
Rh -ve mother Rh +ve predicted fetus prophylaxis dose at 28 weeks then after delivery and at any desensitising events (eg bleed) Rh status checked at 16 weeks
what is a contraindication to fetal blood sampling
any maternal blood borne infection e.g.maternal HIV baby with predicted abnormal clotting mother been warfarinised (crosses placenta)
fatal blood sampling
look at pH of blood to see if baby is getting enough O2 to continue with labour need to be at least 3 cm dilated don’t do if under 36 weeks gestation
potential causes of polyhydramnios
too much fluid around baby - weeing too much or can’t wee it out - check for diabetes - check if they’ve had contact for acute CMV in pregnancy (cytomegalovirus) - foetal medicine to check for abnormalities
what is a normal FBS result?
pH > 7.25 if <7.20 - deliver within 30 mins 7.20 - 7.25: boarderline- repeat in 1hr
the different category Caesarean sections and how quickly they need to be carried out
cat 4: elective cat 3: no time limit but e.g.if they spontaneously rupture & so have to move elective CS forward cat 2: concern but not life threatening:<75mins cat 1: <30mins
what is the name for forceps
Keillands: rotational wrigleys: small Andersons and neville barnes: direct traction, straight delivery
a post menopausal woman has a multilocular ovarian cyst, her Ca125 is 100 what is the RMI (risk of malignancy index)?
RMI = Ca125 x ultrasound score x menopause status (RMI = Ca125 x U x M) ultrasound features: 1 point for: - multilocular cyst - solid areas - metasteses - ascites - bilateral lesions 0 points = U0 1 point = U1 2-5 points = U3 menopausal status: pre-menopausal = M1 post menopausal = M3 menopausal: woman with no period for 1yr or >50 with hysterectomy for this example: RMI = 100 x 1 x 3 = 300
which are the high risk strains of HPV
16 & 18
which surgical procedure should be performed for stage 1a endometrial cancer
1a: confined to the uterus total laparoscopic hysterectomy
how many sets of chromosomes are in a partial molar pregnancy
3 (69 total) two paternal + egg (3 sets)
molar/ partial molar pregnancy
abnormal pregnancy - molar and partial molar potential to cause malignancy - gestational trophoblastic disease
how many sets of chromosomes are in a molar pregnancy
2 (46) no maternal + 2 paternal
management for a partial/ molar pregnancy
evacuation of pregnancy and refer mother to specialist to get hCG to normalise
what is the most common site for an ectopic pregnancy
ampulla of the Fallopian tube (main length) - due to damage of cilia from things like chlamydia
what classifies as HTN in pregnancy?
two episodes >20mins apart > 140/90 beyond 20th week of pregnancy severe HTN: >160/100 without proteinuria: pregnancy induced HTN with proteinuria: pre-eclampsia
most common cause of post-menopausal bleeding
atrophic vaginitis endometrial atrophy
chocolate cyst diagnosis?
endometriosis
investigations and management for endometriosis
investigations: - pelvic examination - transvaginal USS if persistent/ pelvic signs - serum Ca125 - MRI for assessing other organ damage - diagnostic LAPAROSCOPY management: - first line= analgesia - NSAIDs & PARACETAMOL - COCP - IUS - mirena - excision or ablation - hysterectomy
endometriosis presentation
chronic pelvic pain - period related pain - deep pain during or after sexual intercourse - painful bowel movements - urinary symptoms
20yrs contraceptive advice UPSI four days ago most appropriate method of contraception
copper-containing intrauterine device acts as emergency contraception for up to 5 days after UPSI
movement of the fatal head from occipital-transverse to occipital-anterior position during labour. what is the most appropriate term for this
internal rotation the occiput leads and meets the pelvic floor first and rotates anteriorly 1/8th of the circle to come under the pubic symphysis. the anteroposterior diameter of the head now lies in the anteroposterior diameter of the pelvic outlet
newborn baby weight 3.8kg not moving left arm after difficult forceps delivery left arm is floppy, reflexes absent, hand in backward position. right arm moves normally which anatomical structure is most likely to have been damaged?
brachial plexus complete brachial plexus palsy: lies with arm held limp at side deep tendon reflexes in affected arm absent moro response is asymmetrical no active abduction of ipsilateral arm
48yrs regular periods till 45y now more frequent, bleeding twice a month and heavier. sweating, severe hot flushes, decreased libido single best management choice
take endometrial biopsy histological diagnosis in patients > 45yrs
descent of labour
due to forceful uterine contraction and retraction, rupture of membranes, complete cervical dilatation and maternal efforts
flexion of labour
flexion increased throughout labour. when head meets resistance of pelvic floor flexion is increased. this decreases the presenting diameter to a smaller diameter (9.5cm). the occiput becomes the leading part
mechanism of labour order
- flexion - internal rotation of head - crowning - extension of head - restitution
crowning in labour
- occiput slips beneath the subpubic arch - crowning occurs when the head no longer recedes back btwn contractions - widest transverse diameter (biparietal) is born
extension of head in labour
fatal head pivots around the pubic bone while the sinciput, face and chin sweep the perineum and head is born by the movement of extension
restitution in labour
the twist in the neck of the foetus that resulted from internal rotation is now corrected by a slight untwisting movement. the occiput moves 1/8th of a circle towards the side from which it started
antiphospholipid syndrome =
recurrent miscarriages + thrombocytopenia can be secondary to SLE
antiphospholipid syndrome ix
increased APTT antiphospholipid antibodies: anti-cardiolipin lupus anticoagulant antibodies
antiphospholipid mx in pregnancy
aspirin (after confirmation on urine testing) + LMWH (after seen on USS) during pregnancy for preventing arterial and venous thromboembolisms
why is warfarin teratogenic
crosses placenta
risk factors for endometrial cancer
obesity nulliparity early menarche late menopause unopposed oestrogen diabetes mellitus tamoxifen polycystic ovarian syndrome HNPCC
risks of COCP
heart attack stroke breast cancer cervical cancer
ix for polycystic ovarian syndrome
pelvic USS
check for impaired glucose tolerance
hyperinsulinaemia
high LH (high LH:FSH ratio)
endometriosis features
chronic pelvic pain dysmenorrhoea dyspeunia subfertility urinary symptoms and painful bowel movements
gold standard ix for endometriosis
laparoscopy
most common organism for pelvic inflammatory disease
chlamydia trachomatis
features of PID
lower abdo pain fever deep dyspareunia dysuria menstrual irregularities vaginal or cervical discharge cervical excitation
ix for PID
exclude ectopic pregnancy screen for chlamydia and gonorrhoea high vaginal swab
mx for PID
abx oral ofloxacin + oral metronidazole or IM ceftriaxone + oral doxy + oral metronidazole
complications of PID
perihepatitis (Fitz-Hugh Curtis syndrome) - RUQ pain infertility chronic pelvic pain ectopic pregnancy
risk factors for ovarian cancer
BRCA1 or BRCA2 mutations early menarche late menopause nulliparity
ix for ovarian cancer
CA125 USS diagnosis: laparotomy
bHCG >1,500
points towards ectopic pregnancy
risk factors for cervical cancer
HPV 16,18, 33 smoking HIV early first intercourse many sexual partners high parity lower socioeconomic status COCP
drugs to avoid during breast feeding
placenta accreta
attachment of placenta to the myometrium
as the placenta does not properly separate during labour there is a risk of post partum haemorrhage
risk factors:
previous caesarean section
placenta praevia
HPV screening
tested for HrHPV
- negative = return to normal recall
- positive = cytology
cytology abnormal = colposcopy
cytology normal = test repeated at 12 months
if repeat test -ve = return to normal recall
if repeat test hrHPV still +ve and cytology normal = further repeat in 12 months
if hrHPV -ve at 24months = return to normal recall
if hrHPV +ve at 24 months = colposcopy
if cytology sample inadequate = repeat within 3 months
if two consecutive inadequate samples = colposcopy
how often do you get the injectable contraceptive (depo provera)
every 12 weeks
contraindication of injectable contraceptives
breast cancer
< 40yrs
secondary ammenorrhoea
raised FSH, LH
infertility
hot flushes, night sweats
premature ovarian failure
- simialr to normal menopause symptoms but in earlier age
mode of action of contraceptive
which contraceptive can be relied upon immediately
copper coil
all others take 7 days to be relied upon
teenage girl
primary amenorrhoea
undescended testes causing groin swelling
breast development
diagnosis
androgen insensitivity syndrome
x-linked recessive
resistance to testosterone causing genotypically male children (46XY) to have a female phenotype
how long does the progesterone only pill take to become effective
after 2 days
if commenced on or before day 5 of cycle it provides immediate protection
missed pill >3hrs for POP
if > 3hrs late: take missed pill as soon as possible, continue with rest of pack, extra precautions for 48hrs
booking visit and bookking bloods when?
8-12 weeks (ideally <10)
anomaly scan time
18-20+6 weeks
first dose of anti-D prophylaxis to rhesus neg women
28 weeks
dating scan
10-13+6 week
10 weeks pregnant
vaginal bleeding
USS - snowstorm appearance, no fetus
B-hCG markedly elevated
hydatidiform mole
- happens when sperm fertilises empty egg so doubles its own DNA
- usually bleeding if first or early second trimester
- exaggerated symptoms of pregnancy
high hCG
pregnant
vaginal bleeding but haemodynamically stable
placenta praevia
= low lying placenta
usually picked up on 20wk abdo USS
do transvaginal USS to locate placenta
risk factors:
multiple pregnancies
previous caesarian
hydatidiform mole mx
urgent referral for evacuation of uterus
contraception to avoid pregnancy in next 12 months
risk of choriocarcinoma (cancer of uterus)
partial hydatidiform mole
normal haploid egg may be fertilised by two sperms or by one sperm with duplication of paternal chromosomes e.g. 69XXX or 69XXY
complete vs partial hydatidiform mole
complete: 46 2 paternal
partial: 69 XXX or XXY (2 paternal, 1 maternal)
fetal parts may be seen
down syndrome screening including nuchal scan
11-13+6 weeks (one week after dating scan)
early pregnancy ovarian cyst
usually physiological - corpus luteum - usually resolve from second trimester
first line mx for eclampsia
magnesium sulphate
- for preventing seizures in severe pre eclampsia and stopping them once developed
given once a decision to deliver has been made
should be continued 24hrs after last seizure or delivery
first line mx for magnesium sulphate induced respiratory depression
calcium gluconate
magnesium sulphate given for eclampsia
what weeks for antenal
first blood tests
urine culture to detect asymptomatic bacteriuria
booking visit
8-12 weeks
at how many weeks do you offer external cephalic version (to turn baby in to cephalic lie)
36 wks
pre-eclampsia presentation
after 20wks
pregnancy induced HTN
proteinuria (>0.3g/24hrs)
features of severe pre-eclampsia:
- HTN >170/110
proteiunuria ++/+++
headache
visual disturbance
papilloedema
RUQ/ epigastric pain
hyperreflexia
platelet count low
mx of pre-eclampsia
women at moderate/ high risk of pre-eclampsia = aspirin 75mg from 12 weeks until birth
treat BP >160/110 = oral labetalol
delivery of baby
risk factors for pre-eclampsia
36 wks pregnant
vaginal bleeding
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart absent/ distressed
placental abruption
maternal haemorrhage
vaginal bleeding but shock out of keeping with visible loss
anti D propylaxis dates
anti D given to rhesus negative women
28 weeks
34 weeks
baby born with:
blunted upper incisor teeth
keratitis
saber shins
saddle nose
deafness
congenital syphilis
baby born with
sensorineural deafness
congenital cataracts
patent ductus arteriosus
purpuric skin lesions
‘salt and pepper’ chorioretinitis
congenital rubella syndrome
classic triad of:
- cataract
- cardiac abnormalities - PDA
- deafness
purpuric skin lesions
‘salt and pepper’ chorioretinitis - on fundoscopy - grainy appearance
caused by togavirus
mx of rubella in pregnancy
Igm raised
should also be checked for parovirus B19
suspected cases discussed with local health protection unit
non-immune mothers should be offered MMR vaccination in post-natal period - should not be administered to women known to be pregnant or attempting to become pregnant
what type of contraceptive is nexplanon
implant
safest form of contraception for suspected/ personal hx of breast cancer or confirmed BRCA mutation
copper coil - category 1 on UKMEC
COCP is 3 - shouldnt be given
all others are 2
copper coil can also be given in current or past breast cancer but is the only one
UK Medical Eligibility Criteria for Contraceptive Use (UKMEC)
contraception should only be offered in primary care if it is considered category 1 or 2
routine recall for cervical smear
25-49: every 3yrs
50+: every 5yrs
tearing pelvic pain
vaginal bledding
haemodynamically unstable
ectopic pregnancy
USS shows no intra uterine pregnancy but bHCG is elevated
RUQ pain
fever
white vaginal discharge
pelvic pain and dyspareunia
pelvic inflammatory disease
RUQ pain –> Fitz Hugh Curtis syndrome - perihepatic inflammation occurs
usually mid cycle mild supra pubic pain
sharp onset
no systemic disturbance
Mittelschmerz
mid cycle pain due to small amount of fluid released during ovulation
inflammatory markers normal
FBC normal
USS - small quantity free fluid
usually subsides over 24-48hrs
sudden onset deep seated colicky abdo pain
vomiting and distress
vaginal examination - adnexial tenderness
ovarian torsion
- laparoscopy
mx for ectopic
laparoscopy or laparotomy if haemodynamically unstable
salphingectomy is usually performed
anti D should be given immediately in which scenarios
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
mx for the affected foetus from rhesus neg mother
transfusions and UV phototherapy
can result in hydrops fetalis
coombs test: direct vs indirect
Direct Coombs: Is a investigation used to look for autoimmune haemolytic anaemia
Indirect: Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.
pregnant woman in third trimester
pruritis in soles of hands and feet
deranged LFTs
obstetric cholestasis
pruritis
raised bilirubin
first line medical mx for obstetric cholestasis
ursodeoxycholic acid
increased risk of still birth - induction of labour at 37-38wks
at what stage do most people present with endometrial cancer - mx
most people present in stage 1
treated with hysterectomy + bilateral salpingo- oophorectomy
rupture of membranes followed by painless vaginal bleeding
fetal bradycardia
vasa praevia
classic triad
significant risk to fetus but no risk to mother
types of spontaneous abortion
threatened miscarriage: painless vaginal bleeding typically around 6-9 wks
missed (delayed) miscarriage: light vaginal bleeding and symptoms of pregnancy disappear
inevitable misscarriage: complete or incomplete
complete: all fetal and placental tissue expelled : little bleeding
incomplete: not all tissue expelled: heacy bleeing and crampy lower abdo pain
cardiotocography normal fetal heart rate
100-160
bradycardia: <100
tachycardia: > 160
decelerations in tocography
a single prolonged deceleration lasting 3 mins or more is abnormal
early decelerations: deceleration of heart rate which commences with contraction and returns to normal on completion of contraction
- head compression
late decelerations: lags behind onset of contraction
- fetal distress e.g. asphyxia or placental insufficiency
variable decelerations: independent of contractions
- cord compression
normal features of cardiotocography
100-160 beats/min heart rate
baseline variability of 5 or more beats/min
fetal heart rate accelerations
need for contraception after menopause
contraception after menopause:
>50: 12months after last period
<50: 24months after last period
why is the injectable contraceptive not advised in high BMI women
causes weight gain
contraceptive of choice for patient on epilepsy drug (carbamazepine)
copper coil - prefered (only one for lamotrigine)
progesterone injection
mirena intrauterine system
if taking others then they need to also use barrier protection - COCP and POP is UKMEC 3 so not recommended
down’s antenatal screening
nuchal translucency - thickened
+ bHCG - increased
+ pregnancy associated plasma protein A (PAPP-A) - decreased
can also assess for edwards and pataus - PAPP-A lower
taking COCP
post-coital bleeding
cervical smear negative
cervical ectropion
- elevated oestrogen levels leads to larger transformation zone on cervix –> post coital bleeding and vaginal discharge
breast lump after recent cessation from breast feeding
painless
no systemic symptoms
galactocele
can be differentiated from breast abscess with hx and ex so no further investigation necessary
- breast abscess more likely painful, fever
medical mx of ectopic pregnancy
methotrexate
for unruptured ectopic with no significant pain
expectant mx for ectopic pregnancy when?
if <35mm
unruptured
asymptomatic
no fetal heart beat
serum bHCG < 1000
visible fetal heart beat on ectopic pregnancy - mx
surgical mx
- salpingectomy (tubes removed) or salpingotomy (tubes preserved)
ix of choice for ectopic
cervical screening programme for HIV positive women
offered cytology at diagnosis
then offered cervical cytology annually
at increased risk of cervical cancer
first line mx for menorrhagia
requires contraception: intra-uterine system (mirena)
does not require contraception: tranexamic acid or NSAIDs (e.g mefenamic acid)
most common cause of early onset infection of baby in neonatal period
group B streptococcus
risk factors:
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
mx of GBS +ve mother during pregnancy
women with GBS detected in previous pregnancy:
- intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and then abx if still +ve
previous baby with early or late onset GBS disease: IAP
preterm labour regardless of GBS status: IAP
women with pyrexia during labour (>38) = IAP
IAP = benzylpenicillin
chickenpox exposure in pregnancy >20 wks (if not immune)
antivirals (acyclovir) of VZIG (varicella zoster immunoglobulins IM) given at days 7-14 post-exposure, not immediately
if theyre not sure if theyre immune (had it before): urgent bloods for varicella antibodies - if -ve then not immune
chicken pox exposure in pregnancy <20 weeks
varicella zoster immunoglobulin ASAP
effective up to 10 days post exposure
mx chickenpox in pregnancy
if presenting within 24hrs and >20 wks = oral acyclovir
if <20 weeks should be considered with caution
medical mx to shrink fibroid size
GnRH agonists
- short term shrinkage
eg before sugery
mx for large fibroids causing problems with fertility and woman wishes to conceive in future
myomectomy
bladder still palpable after urination
retention with urinary overflow incontinence
mx of PCOS symptoms
weight loss + smoking cessation - first line
contraception: COCP
hirsutism: COCP
infertility: clomifene or metformin
appropriate next step for postmenopausal women with ovarian cyst
referred to gynae for assessment regardless of nature or size - less likely physiological
next step of ovarian cyst in premenopausal women
if simple small (<5cm) cyst on USS: repeat USS in 8-12 wks and referral considered if it persists
stages of labour
stage 1: from the onset of true labour to when the cervix is fully dilated
latent phase: 0-3cm
active phase 3-10cm
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
false labour: in last 4 weeks of pregnancy. contractions in lower abdo, irregular, no cervical changes
