Round up Lecture Flashcards
What are the risk factors for an ectopic pregnancy?
Smoking, IUD, IVF, increased maternal age, laproscopic sterilisation, previous ectopic, assisted pregnancy, previous tubal surgery.
Before carrying out an internal exam, what is crucial to know and can be found in the patients hand held notes?
The position of the placenta. If it is low-lying there is risk that an internal exam may exacerbate bleeding.
What is a common presentation for an ectopic pregnancy?
Unilateral IF pain
When should you perform a serial HCG blood test?
After ultrasound has confirmed a pregnancy of unknown location (PUL)
Which HCG levels suggest an ectopic pregnancy?
A rise of less than 66% every 48 hours suggests ectopic between 6-10 weeks.
What three things could a PUL be?
Ectopic, miscarriage or early uterine pregnancy
What are the 5 types of miscarriage and what do they mean?
A threatened miscarriage, inevitable miscarriage, incomplete, complete and missed (septic??)
What is a threatened miscarriage and what percentage will go on to miscarry?
PV bleeding before 24 weeks, normal size for dates and the os is closed. 25% will go on to miscarry.
What is an inevitable miscarriage?
Bleeding is usually heavier. Although the fetus may still be alive, the cervical os is open and miscarriage is about to occur.
What is an incomplete miscarriage?
Some fetal parts have been passed but the os is usually open.
What is a complete miscarriage?
All fetal tissue has been passed. Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.
What is a septic miscarriage?
The contents of the uterus are infected, causing endometritis. Vaginal loss is offensive and the uterus is tender. A fever can be absent. If pelvic infection occurs there is abdominal pain and peritonism.
What is a missed miscarriage?
The fetus has not developed or died in utero, but this is not recognised until bleeding has occurred or noticed on USS. The uterus is smaller than expected from the dates and the os is closed.
What is the management of miscarriages?
Medical & Surgical, (can be both) & expectant
What can products of conception in the cervical os cause?
Pain, bleeding & vasovagal shock. They are removed using polyp forceps.
If bleeding occurs after 12 weeks gestation or the uterus is instrumented what should be given?
Anti-D should be given to women who are rhesus negative and experience this. This reduces the risk of iso-immuniazation leading to possible rhesus disease in future pregnancies.
What percentage of women will miscarry, who have feral heart activity at 8 weeks.
10%
What is expectant management or miscarriage?
This can be continued for as long as the woman is willing and there are no signs of infection.
What is the medical management of a miscarriage and what are the success rates?
Prostaglandin (Misoprostal PGE1 analog). It is taken oral, sublingual or vaginally. It is sometimes preceded by the anti progesterone mifepristone. It is successful in 80% of women with INCOMPLETE miscarriages and 40-90% od women with a MISSED miscarriage. sc
When is misoprostal indicated?
When the uterine size is less than or equal to 12 weeks LMP. It facilitates uterine evacuation.
When should misoprostal be used with surgery?
In nullparous women
What is the surgical management of a miscarriage and when is this suitable? What is the success rate and why is tissue examined histologically?
Evacuation of retained products of conception (ERPC) under anaesthetic using vacuum aspiration. It is suitable when the woman prefers it, there is heavy bleeding, or signs of infection.
Success rates are >95% for both incomplete and missed miscarriage.
Tissue is examined to exclude molar pregnancy
What condition can surgical management of miscarriage cause?
Ashermans syndrome
Do long-term conception rates differ between the management options?
No
When should further investigation regarding miscarriage be carried out?
Because they are so common (1 in 5 pregnancies) then investigation should be reserved for women who have had 3 miscarriages.
What are the three therapies for ectopic pregnancies?
Salpingectomy, salpingotomy & Methotrexate.
When is medical management for miscarriage not suitable?
If there is free fluid in the abdomen (i.e. following a rupture) then surgical management is required.
Who is eligible for medical management of ectopic?
If there is no bleeding, the product is less than 3cm and the HCG is less than 5000 with no feral heart beat.
If a womans had a previous ectopic, when should she be seen in the EPU?
6 weeks
What is an antepartum haemorrhage?
Bleeding from the genital tract after 24 weeks gestation?
What are the common causes of APH?
Undetermined origin, placental abruption or placenta praevia.
What are the uncommon causes of APH?
Incidental genital tract pathology (cervical carcinoma), uterine rupture, vasa praevia and placenta previa.
What is vase praevia?
This occurs when a foetal blood vessel runs in the membranes in front of the presenting part. They are rare but they typically occur when the umbilical cord is attached to the membranes rather than the placenta.
When the membranes rupture, the vessel may too causing a large foetal bleed.
How common is vasa praevia?
Occurs in 1 in 5000 pregnancies. Also can be detected on USS but seldom are.
What is the typical presentation of vasa praevia?
Painless, moderate vaginal bleeding at amniotomy or spontaneous ROM, which is accompanied by severe foetal distress.
What is a threatened miscarriage?
PVB less than 24 weeks
How do you confirm the diagnosis of pre-eclampsia?
Protein: Creatinine ratio on a single urine sample can be used. A level of 30mg/nmol is significant. Equivalent to 0.3g/24h.
How do you monitor maternal complications in pre-eclampsia?
Blood tests show elevation of uric acid (although poor predictor of complications). Haemoglobin is often high as a result of haemoconcentration. A rapid fall in platelets due to platelet aggregation on damaged endothelium indicates impending HELLP or DIC. LFTs are initially normal but a rise suggests impending liver damage or HELLP. LDH levels rise with liver disease and haemolysis.
How are foetal complications monitored in pre-eclampsia?
An USS helps estimate weight and is used to assess feral growth and liqua volume. (before 36 weeks principal problem is IUGR). An umbilical artery doppler is carried out and a CTG( from 26 weeks on).
In foetuses who are in intrauterine distress, what is shown on the umbilical artery doppler?
There can be a reduction in end diastolic flow, absent end diastolic flow or reversed end diastolic flow (the blood is returned back to the fetus, not placenta in end diastole.)
What are the symptoms of pre-eclampsia?
Headache, visual disturbances, vomiting, drowsiness, epigastric pain/tenderness and oedema( ASK ABOUT THIS IN HISTORY)
What are the signs of pre-eclampsia?
Clonus (hyper-reflexia is seen in pre-eclampsia), oedema, high BP, and low symphysis fundal height.
What is HELLP syndrome?
Haemolysis (dark urine, raised LDH, anaemia), elevated liver enzymes (epigastric pain, liver failure, abnormal clotting), low platelets,
What percent of pre-eclampsia occurs post partum?
40%
What is the criteria for admission of pre-eclampsia?
proteinuria (2+) or >0.3g/24h collection. Diastolic blood pressure >(or equal to)170/110 and suspected foetal compromise.
How do you manage high blood pressure in pre-eclampsia?
Antihypertensives are given if the blood pressure reaches 170/110. Methyl-dopa is best for maintenance but causes drowsiness. Oral nifedipine is used for initial control, with intravenous labetalol as second line for sever hypertension.
What is the blood pressure aim with treatment in pre-eclampsia?
140/90
What drug is used in both the treatment and prevention of pre-eclampsia?
Magnesium sulfate, IV dose followed by an IV infusion.
What should also be given when treating pre-eclampsia if the gestation is < 34 weeks.
12mg of dextamethosone (in leeds) 2 infusions 24 hours apart or dexta in other trusts
When is labetolol use contraindicated?
In asthmatics
Who do calcium channels work better in?
Black women
When is IOL performed in women with pre-eclampsia?
At 37 weeks gestation in women with PIH and pre-eclampsia.
When can instrumental delivery only be carried out?
At 10cm dilatation.
What is uterine blood flow?
500ml/min
In someone with PV bleeding, what can you find out from their notes that will help you?
Rhesus status, location of placenta
How many hours after a sensitizing event can you still administer anti-D?
Up to 72 hours after.
Which antibody can cross the placenta?
IgG
What questions will you ask someone with a PV bleed in pregnancy?
Amount, pain, post-coital?, contractions, foetal movements, last smear.
What does an abrupt uterus feel like?
Hard & woody
Who is most in danger with a placent praevia?
The mother, the foetuses blood supply is yet to be compromised. Important to know location of placenta before speculum.
Who is a vasa praevia most dangerous for?
The foetus, must be careful when doing an amniotomy.
What are the types of abruption?
External abruption (pt will present with PV bleed), relatively concealed abruption and concealed abruption.
What is a serious of a concealed abruption?
DIC, a lot of clotting factors are consumed behind the placenta.
What is the most common cause of post-menopausal bleeding?
Atrophic vaginitis
What are the risk factors for endometrial cancer?
Unopposed oestrogen exposure, tamoxifen, obesity (conversion of androgens to oestrogens), nulliparity, PCOS, early menarche, late menopause
Why does PCOS cause endometrial cancer?
Essentially a state of unopposed oestrogen exposure
What are the investigations for endometrial carcinoma?
Hysteroscopy, assess endometrial thickness, endometrial biopsy (pipelle in clinic?) Chest x-ray to exclude pulmonary spread.
What is the correct term for an infection of the uterus after birth?
Puerperal fever caused by endometritis
Which bacteria is likely to be the cause of puerperal fever?
Group A strep
What is the typical bleeding pattern for a post partum bleed?
Heavy, then light then heavy again. Foul smell
What symptoms would a woman with a PPH have?
Headache, fever, malaise. Don’t forget breasts- mastitis
How do you treat a group A strep infection?
IV ceforexime, with oral switch to ?
Why should you do a speculum exam on a post partum patient with endometritis?
To check that the cervical os is closed. If it is open there may be retained products
What is a common presentation of a PPH?
lower abdominal pain with heavy PV bleeding.
If co-amoxoclav is given to treat post partum endometritis, what is given if the patient is penicillin allergic?
Clindamycin
Why do you not do a bimanual when you suspect theres been a ROM?
Risk of chorioamnionitis
How can you elicit pain with symphysis pubic dysfunction (SPD) in clinic?
A straight leg raise elicits a lot of pain in the patient. It is also exacerbated by movement.
When is tocolysis contraindicated?
Bleeding and infection (chorioamnioitis), you don’t want to delay birth
