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SAQs Knowledge Flashcards

1
Q

Presentation of ovarian torsion

A
  • Acute onset
  • Unimproving pain
  • May cause inflammatory response and raised CRP
  • Leukocytes within normal range
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2
Q

What can transabdominal USS often not visualise?

A

Appendix

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3
Q

5 VTE facts about HRT

A
  1. Risk of VTE is highest in the 1st year
  2. Thrombophilia screening is not routine (may be indicated with family hx)
  3. No evidence of continued VTE risk on stopping HRT
  4. Cannot take oral HRT with a VTE risk
  5. Stop HRT immediately if VTE develops
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4
Q

What are the safest blood transfusion products to offer?

A
  1. Fully cross-matched blood (takes 45 mins to mix patient and donor blood products to test for haemolytic reaction)
  2. Group specific blood (takes 15 mins to test the patient’s blood group and select compatible blood)
  3. O negative blood (only used in emergencies, no tests are completed against recipient blood)

If the patient is haemodynamically stable, use fully cross-matched blood

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5
Q

What are the risks of developing ovarian cancer at each RMI value?

A
  • <50 3%
  • 50-250 20%
  • > 250 75%
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6
Q

What are the concerning features of ovarian cyst on ultrasound?

A
  • Bilateral
  • Multiloculated
  • Solid components
  • Ascites
  • Metastases
  • > 5cm
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7
Q

What is the management for simple ovarian cysts <5cm?

A

Conservative (NSAIDs)

FU: TVUSS and CA125 every 4 months for one year

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8
Q

What are the most important differentials to exclude with PMB?

A
  1. Endometrial cancer
  2. Ovarian cancer (much less likely)
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9
Q

What investigation should be offered before HRT?

A

TVUSS to ensure endometrial thickness is <4mm

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10
Q

What is the main function of progesterone?

A

Enhances endometrial reciptivity, once there’s a successful implantation BHCG is produced to maintain corpus luteum function

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11
Q

What blood test should not be carried out for HMB?

A

Female hormone testing

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12
Q

When is USS offered for HMB?

A
  • Uterus is palpable abdominally
  • Hx or examination suggests mass
  • Examination is difficult or inconclusive eg. obesity
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13
Q

What are the treatments for HMB?

A
  1. Levonogestrel IUS

If IUS is declined or contraindicated
2. Txa &/or NSAIDs
3. COCP/ cyclical oral progesterone

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14
Q

When is IUS contraindicated?

A
  • Active infection
  • Active pregnancy
  • Fibroids >3cm
  • Fibroids distorting uterine cavity
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15
Q

What is the management for PMS?

A

All women
- Conservative

Moderate
- COCP (Yasmin best evidence base, cyclical or continous, better evidence for continuous)

Severe
- Referral for CBT
- SSRI trail for 3 months (can be continuous or just during luteal phase)

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16
Q

What is severe PMS?

A

Withdrawal from social and professional activities and prevents normal functioning

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17
Q

Which patients are oestrogen alone HRT used for?

A

Post hysterectomy OR in-situ LNG-IUS

Ellesete Solo

BMI >30 give as a transdermal patch (increased VTE risk with oral)

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18
Q

What is combined oestrogen and progesterone HRT brand name?

A

Ellesete Duet

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19
Q

When is cyclical Ellesete Duet prescribed?

A

Peri-menopausal women

Monthly
- Oestrogen every day of the month + progesterone for last 14 days

Three monthly
- Oestrogen every day for 3 months + progesterone for last 14 days

Withdrawal bleeds when taking progesterone

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20
Q

When is continuous Ellesete Duet taken?

A

Post-menopausal women
- Oestrogen and progesterone daily

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21
Q

What are the routes of HRT?

A
  • Oral (low VTE risk)
  • Transdermal (high VTE risk)
  • Vaginal creams/ gels (if predominantly vaginal sx)
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22
Q

What are the side effects of oestrogenic HRT?

A
  • Breast tenderness
  • Nausea
  • Headaches
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23
Q

What are the side effects of progestogenic HRT?

A
  • Fluid retention
  • Mood swings
  • Depression
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24
Q

What are the risks of HRT?

A
  • Breast cancer
  • Cardiovascular disease
  • VTE
  • Ovarian cancer
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25
Q

What are the contraindications for hormonal HRT?

A
  • Pregnancy
  • Current or present breast cancer
  • Endometrial cancer
  • Uncontrolled hypertension
  • Current VTE
  • Current thrombophilia
  • Undiagnosed vaginal bleeding
  • Severe liver disease
  • Untreated endometrial hyperplasia
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26
Q

Which component of HRT is most effective at reducing hot flushes?

A

Oestrogen

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27
Q

What is done if a woman has breakthrough bleeding within the first 6 months of combined continuous HRT?

A

Pelvic USS and biopsy

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28
Q

What are the non-hormonal treatments of menopause?

A
  • Alpha agonists (clonidine)
  • Beta-blockers (propranolol)
  • SSRIs (vasomotor symptoms)
  • Symptomatic: lubricants, osteoporosis treatments etc
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29
Q

What is the managment pathway for endometriosis?

A
  1. Analgesia (NO opiates, can worsen co-existing IBS)
  2. COCP
  3. Progestogens (if COCP contraindicated)
  4. GnRH agonists
  5. Surgical tx (fertility sparing: laparoscopy, non-sparing: hypsterectomy & oophorectomy, may not necessarily cure symptoms or disease)
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30
Q

What is the function of COCP in endometriosis?

A

Symptomatic relief

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31
Q

How is COCP taken for endometriosis?

A

Most effective: tricycle packets (3 packets back to back)

Can be taken for 21 days with 7 day pill-free interval

Can also be taken without a break to induce amenorrhea

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32
Q

What is the function of progestogens in endometriosis?

A

Induce amenorrhea

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33
Q

Progestogen options for endometriosis?

A
  • Depot medroxyprogesterone acetate
  • Levonogestrel IUS
  • POP
  • Implant (nexplanon)
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34
Q

What is the function of GnRH agonists in endometriosis?

A

Effective at relieving the severity and syptoms of endometriosis

  • Usually administered as slow-release depot formulations (lasting 1 month)
  • Can be taken as intranasal sprays (daily)
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35
Q

Why should GnRH agonists not be used for more than 6 months?

A

Risk of osteoporosis

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36
Q

What is the preferred management for endometriosis if fertility is a priority?

A

Laparoscopic excision or ablation of endometriosis plus adhesiolysis

3 months of GnRH prior to surgery for deep endometriosis involving the bowel, bladder or ureter

Risk of recurrence 30% so start medical therapy immediately after surgery

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37
Q

When is referral to specialist endometriosis service indicated?

A

Suspected/ confirmed endometriosis involving bladder, bowel or ureter

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38
Q

When is follow up indicated for endometriosis?

A
  • Deep endometriosis involving bowel, bladder or ureter
  • 1 or more endometrioma >3cm
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39
Q

Pathological features of CTG

A

BRA
- <100bpm or >180bpm

V
- <5bpm >50mins
- >25bpm >25mins

A
- Absent (uncertain significance)

D
- Repetitive variable decelerations with concerning characteristics >30 mins
- Repetitive late decelerations >30 mins
- Single prolonged deceleration >3 mins
- Acute bradycardia (3 mins = call for help, 6 mins = move to theatre, if persists beyond 9 minutes, expedite delivery, deliver by 15 mins)

O
- Pathological = 1 pathological feature or >= 2 non-reassuring features

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40
Q

What is the managment of suspicious and pathological CTGs?

A

Suspicious
- Involve senior midwife/ obstetrician
- Conservative management: mobilise patient/ left lateral position, maternal obs, fluids, hold oxytocin

Pathological
- Involve senior midwife and obstetrician
- Conservative management

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41
Q

When is ARM avoided?

A

If presenting part is mobile or high OR if cord is felt below presenting part on vaginal examination

42
Q

Management of cord prolapse

A
  • Call for senior help, CTG, theatre for immediate delivery
  • Elevate presenting part (manual or fill bladder with 500ml saline)
  • Reposition mother: all fours, knee-to-chest, left lateral position head down
  • Consider tocolytics when preparing for c-section if there are still foetal heart abnormalities
  • ASAP DELIVERY QUICKEST ROUTE (eg. if dilated and vaginal is quickest, expedite vaginal delivery)
43
Q

What are the absolute contraindications for epidural?

A
  • Patient refusal
  • Allergies to anaesthesia
  • Systemic infection
  • Skin infection over site
  • Bleeding disorders
  • Platelets <80 000/ml
  • Uncontrolled hypotension
44
Q

Which position can woman be put in to increase venous return?

A

Left lateral tilt

45
Q

What are the risk factors for LMWH prophylaxis?

A
  • Age >35
  • BMI >30
  • Family hx DVT
  • Smoker
  • Immobile
  • Mild thrombophilia
  • P>3
  • Gross varicose veins
  • PET
  • Multiple pregnancy
  • IVF pregnancy (high levels of oestrogen = procoagulatory)

> =4 commence on LMWH immediately until 6 weeks post partum

3 commence on LMWH from 28 weeks to 6 weeks post partum

2 commence on LMWH for 10 days post partum

46
Q

When are DVT risk assessments taken for pregnant women?

A
  • Early pregnancy
  • When they’re admitted to hospital for any reason
  • Intra or post partum
47
Q

LMWH with DVT in pregnancy

A

Commence LMWH immediately until 6 weeks post partum, or they’ve had 3 months of treatment

(Whichever is longer)

48
Q

What is the foetal surveillance for parvovirus B19 in pregnancy?

A

Fortnightly monitoring with Doppler USS of Middle Cerebral Artery (monitors for anaemia)

49
Q

What is an elevated Ca125?

A

> 35IU/ml

50
Q

What is the risk of malignancy index?

A

RMI = Ca125 x M x U

M= pre or post menopausal (1 or 3 pts)
U= USS features, 0=0, 1=1, >1=3

51
Q

What are the USS features for RMI?

A
  • Multiloculated cysts
  • Bilateral cysts
  • Solid components
  • Mets
  • Ascites
52
Q

What HbA1c would cause a doctor to advise against pregnancy?

A

> = 86mmol/mol (10%)

53
Q

What is the criteria for hyperemesis gravidarum?

A
  • Significant dehydration
  • Weight loss >5% pre-pregnancy body weight
  • Electrolyte disturbance
54
Q

What is the score to assess hyperemesis gravidarum?

A

Pregnancy-Unique Quantification of Emesis score

55
Q

What are the foetal risks of pregnancy in hypothyroidism?

A
  • Miscarriage
  • Preterm delivery
  • Intellectual impairment in the neonate
56
Q

How often are thyroid levels checked for hypothyroidism in pregnancy?

A

Every 2-4 weeks

Thyroxine requirements may increase in the first trimester due to increased oestrogen binding to thyroid binding globulin

57
Q

What are the increased maternal risks with hypothyroidism in pregnancy?

A

Pre-eclampsia, especially with antithyroid antibodies

58
Q

What is the ROM plus test and what is it used for?

A

Tests for: insulin-like growth factor binding protein 1 and alpha-macroglobulin 1

Used when PPROM is suspected but there is no pooling of liquor in the posterior vaginal space

59
Q

What is an early miscarriage?

A

Losing a pregnancy within 12 weeks

60
Q

What is the most common cause of early miscarriages?

A

Genetic/ chromosomal abnormalities eg. balanced chromosomal translocations

After the first miscarriage, products of conception sent to the lab for cytogenic analysis. If balanced chromosomal translocation found, karyotype performed on both parents

61
Q

When do miscarriages occur in anti-phospholipid syndrome?

A

After the first trimester (>14 weeks)

62
Q

Which antibodies are present in anti-phospholipid syndrome?

A

Anti-cardiolipin and lupus anticoagulant antibodies

63
Q

What reduces the risk of miscarriage in anti-phosopholipid syndrome?

A

Aspirin and LMWH (low dose)

64
Q

When do miscarriages occur with cervical weakness?

A

After 20 weeks

65
Q

Which types of fibroids are most likely to cause miscarriages?

A

Submucosal fibroids

If pregnancy occurs, miscarriage most likely to occur in the 2nd trimester

66
Q

When is screening for anaemia performed in pregnancy?

A

Booking and 28 weeks

67
Q

When are neural tube defects screened for?

A
  • Booking
  • Anomaly scan
68
Q

What is the combined screening test?

A

11-13+6 (offer to all pregnant women)
- Nuchal translucency (>6mm DS)
- hCG (high DS)
- PAPP-A (low DS)

69
Q

What is the quadruple test?

A

14+2-20 (those who’ve missed the combined test)
- hCG
- Inihibin A
- AFP
- Unconjucated oestriol (uE3)

70
Q

When is the quadruple test offered?

A
  • Late presentation
  • Nuchal translucency can’t be obtained
  • CRL >84mm and head circumference between 101-172mm during USS
71
Q

What is the most important surveillance tool for monitoring SGA?

A

Umbilical artery Doppler

Can predict foetal acidaemia which enables prompt delivery of the baby with avoid IU death and end organ damage

72
Q

What is the biophysical profile?

A
  • Breathing movements
  • Gross body movements
  • CTG
  • Amniotic fluid volumes

Each variable graded as 2 (normal) or 0 (abnormal)

73
Q

When should SFH be monitored?

A

Every antenatal appointment from 24 weeks

74
Q

What is an antepartum haemorrhage?

A

Bleeding after 24 weeks

75
Q

What are the doppler USS findings that would predict foetal anaemia?

A

Elevated peak systolic velocity through the middle cerebral artery

76
Q

What is the timeline for puerperal sepsis?

A

Occurs within 6 weeks of childbirth

77
Q

How does peurperal sepsis present?

A

Commonly with severe abdominal pain that’s not responsive to pain relief in the post partum period

+ tachycardia, tachypnea, +- hypotension

78
Q

What is the most common pathogen indicated in peurperal sepsis?

A

Group A strep (strep pyogenes)

79
Q

What is the anti-D prophylaxis for a Rh-ve woman <20 weeks with a sensitising event?

A

250 IU anti-D IgG wtihin 72 hours

80
Q

What is the anti-D prophylaxis for a Rh-ve woman >20 weeks with a sensitising event?

A

500 IU anti-D within 72 hours and a Kleinhauer test

81
Q

What does Kleinhauer test measure?

A

Degree of fetomaternal haemorrhage, significant may warrant more doses of anti-D

82
Q

What is routinely offered to all Rh -ve women?

A

1500IU anti-D IgG at 28 weeks

Either one dose at 28 weeks or 2 doses at 28 and 34 weeks

83
Q

What is the protocol for RhD negative women once babies are born?

A

Cord blood taken and tested for FBC, blood group and indirect Coomb’s test

If baby RhD+ve, mother offered 500IU anti-D IgG within 72 hours and a Kleinhauer test performed

84
Q

What is the aim of the booking USS?

A
  • Detect multiple pregnancies
  • Determine gestational age (based on CRL, if >84mm head circumference used instead)
  • Measure nuchal translucency
85
Q

When is CRL no longer useful to estimate gestational age?

A
  • Beyond 13+6 weeks
  • > 84mm

In these cases other variables eg:
- Femur length
- Abdominal circumference

Used

86
Q

When is CVS offered?

A

Between 11-13+6 weeks (transabdominal or transcervical approach)

87
Q

When is amniocentesis offered?

A

15-20 weeks

88
Q

What is the most common cause of secondary PPH?

A

Endometritis (occurring between 24 hrs to 12 weeks of birth)

89
Q

What is the most common cause of primary PPH?

A

Uterine atony (occuring within 24 hours of birth)

90
Q

How is endometritis investigated?

A

High vaginal swabs and treated with abx

91
Q

What are the typical sx of uterine rupture?

A
  • Abdo pain
  • Vaginal bleeding
  • Change in the pattern of contractions
  • Haemodynamic instability (mother)
  • Non-reassuring foetal heart rate tract (usually bradycardia)
92
Q

What is the time requirement for category 3 c-sections?

A

Within 24 hours

93
Q

When is vaginal delivery appropriate in patients with uterine rupture?

A

When delivery is imminent

94
Q

What are the requirements for foreceps delivery?

A

Cervix fully dilated and effaced and baby’s head is engaged (aligned with ischial spines)

95
Q

When is ventouse not used?

A

When giving birth <36 weeks (baby’s head is too soft), absolute contraindication <32 weeks

Higher rate of failure in general than foreceps

Aim to deliver within 3 pulls

Discontinue with 2 pop offs, seek support for less experienced opperaters with 1 pop off

96
Q

When is mediolateral episiotomy performed?

A

Discussed as part of preparation for assisted birth

  • Cut should be 60 defrees initiated when the head is distending the perineum
97
Q

What abx prophylaxis is given following assisted vaginal birth?

A

Single prophylactic dose of IV amoxicillin and clavulanic acid

98
Q

When is a trial assisted birth attempted?

A

Higher risk of failure

Non-rotational low-pelvic and lift out assisted vaginal births have low probability of failure

99
Q

What are the thresholds for anaemia in pregnancy?

A

1st trimester: <110g/l
2nd trimester: <105g/l
3rd trimester: <100g/l

Women <100g/l at delivery under consultant led care

100
Q

What is the most common cause of anaemia in pregnancy?

A

Iron deficiency

101
Q

When should FBC be taken in multiple pregnancies?

A
  • Booking
  • 20-24 weeks
  • 28 weeks
102
Q

What is the management of IDA in pregnancy?

A
  • Oral iron
  • If that fails IV irone or blood transfusions

O&G (11 decks)

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