Selected Notes obgyn 3 Flashcards
What is stress incontinence?
Leaking small amounts when coughing/laughing
What is mixed incontinence?
Both urge and stress
What is overflow incontinence?
Due to bladder outlet obstruction<br></br>E.g. from prostate enlargement
When is cystometry not recommended?
In patients with clear histories and a clear cause of incontinence
When is a cystogram suggested as an investigation for urinary incontinence?
When a fistula is suspected
When should you be cautious in prescribing anticholinergics for urge incontinence?
In the elderly due to risk of falls
When is a vaginal vault prolapse most common?<br></br>
After a hysterectomy
What is the surgical management for a uterine prolapse?
Hystrectomy, sacrohysteropexy
What is the surgical management of a rectocele?
Posterior colporrhaphy
When can’t LNG-IUS(levornegstrel intrauterine device) be used for treating uterine fibroids?
If there is distortion of the uterine cavity
What treatment/management should be used to shrink/remove fibroids?
GnRH agonists-> short term treatment to reduce size of fibroids<br></br>Surgical-> myomectomty, ablation, uterine artery embolisation, hysterectomy
Why can’t GnRH agonists be used long term to treat fibroids?
Side effects such as menopausal symptoms (hot flushes, vaignal dryness) and loss of bone mineral density
Where do submucosal fibroids grow?
Just below the lining of the uterus (endometrium)
What is Meig’s syndrome?
Triad of:<br></br><ul><li>Ovarian fibroma(benign ovarian tumour)</li><li>Pleural effusion</li><li>Ascites</li></ul><div>Typically occurs in older women-> remove tumour and other issues resolve</div>
What should be considered in a patient presenting with recurrent ovarian cysts?
PCOS<br></br>Can’t be diagnosed just off cysts, needs 2 of:<br></br><ul><li>Anovulation</li><li>Hyperandrogenism</li><li>Polycystic ovaries on US</li></ul>
What is the commonest type of ovarian cyst?
Follicular cysts
Whatg are the tumour markers for a germ cell tumour?
<ul><li><b><i>Lactate dehydrogenase</i></b> (<b><i>LDH</i></b>)</li><li><b><i>Alpha-fetoprotein</i></b> (<b><i>α-FP</i></b>)</li><li><b><i>Human chorionic gonadotropin</i></b> (<b><i>HCG</i></b>)</li></ul>
<div> </div>
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What is taken into account with the risk of malignancy index for ovariance tumours?
<ul><li>Menopausal status</li><li>Ultrasound findings</li><li>CA125 level</li></ul>
What is ovarian torsion?
Ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply
When can ovarian torsion happen in normal ovaries in girls before menarche
When girls have longer infundibulopelvic ligaments that can twist more easily
What might be present upon examination of a patient with ovarian torsion?
Localised tenderness<br></br>Palpable mass in the pelvis-may be absent
What parts of the body does lichen sclerosus typically affect?
Gential and anal regions of the body
What is the most common type of cervical cancer?
Squamous cell carcinoma
What is the second most common type of cervical cancer?
Adeoncarcinoma
What is the most common casue of cervical cancer?
HPV-typically type 16 and 18
What is meant by dysplasia?
Premalignant changes
What is the grading system for the level of dysplasia in the cervix?
Cervical intraepithelial neoplasia(CIN)
What is the first thing smear tests looking for cervical cancer are tested for?
High risk HPV<br></br>If HPV is negative, cells aren’t examined further, returned to normalm screening programme
What might be seen in cervical cancer screening in women with the coil/IUD?
Actinomyces-like organisms-no treatment required unless symptomatic
What is pelvic exenteration?
Operation that involved removing ost or all of the pelvic organs including vagina cervix, uterus, fallopian tubes, ovaries bladder and rectum<br></br>Last resort for cervical cancer<br></br>Significant implications
What monoclonal antibody can be used to treat cervical cancer?
Bevacizumab(avastin) used in combination with other chemo to treat metastatic/recurrent cervical cancer
Which strains does the HPV vaccine Gardasil protect against?
Strains 6,11,16,18,31,33,45,52,58
What might you find on bimanual pelvic examination in a patient with endometrial cancer
Enlarged uterus(may be normal)<br></br>
What is the most common type of endometrial cancer?
Adenocarcinoma
What stimulates the growth of endometrial cancer cells?
Oestrogen
Why is obesity a risk factor for endometrial cancer?
Adipose tissue is a source of oestrogen
Why does ovarian cancer typically carry a poor prognosis?
Uusally diangosed late
What is the peak age of incidence of ovarian cancer?
60years
What is the most common type of ovarian cancer?
Epithelial origin-serous carcinomas
What is recognised as the site of origin of many ovarian cancers?
Distal end of the fallopian tubes
Where do epithelial ovarian cancers originate from?
Epithelium which lines the fimbria of the fallopian tubes or ovaries
Where do epithelial ovarian tumours typically spread to first?
<ul><li>Peritoneal cavity->m particularly bladder, paracolic gutters and diaphragm</li></ul>
Where do germ cell ovarian tumours typically originate from?
Germ cells in the embryonic gonad
Where do ovarian sex cord stromal tumours arise from?
Connective tissue
Which is more aggressive: sex cord stromal ovarian tumours or ovarian epithelial tumours?
Epithelial
Which genes are associated with developing ovarian cancer?
BRCA1&2
Why does late stage ovarian cancer cause ascites
Vascular growth factors causing increased vessel permeability
When should CA125 not be used?
For screening for ovarian cancer in asymptomatic women
What is the most common type of vulval cancer?
Squamous cell carcinoma
Which skin cancers can affect the vulva?
<ul><li>Squamous cell carcinoma-most common</li><li>Basal cell carcinoma</li><li>Melanomas</li></ul>
What proportion of patients with lichen sclerosus get vulval cancer?
About 5%
What is vulval intraepithelial neoplasia?
<span>Premalignant condition affecting the </span><b><i>squamous epithelium</i></b><span> of the skin that can precede vulval cancer</span>
What type of VIN is associated with HPV infection and younger women?
High grade squamous intraepithelial lesion
Which type of VIN is associated with lichen sclerosus?
Differentiated VIN
What might be seen on a pelvic exam of a patient with endometriosis?
<ul><li><span>Tender, nodular masses may be palpable on ovaries or ligaments surrounding the uterus</span></li><li><span>Reduced organ mobility</span></li><li><span>Visible vaginal endometriotic lesions </span></li></ul>
When do symptoms of adenomyosis tend to resolve?
After menopause
What might be found on examination of a patient with adenomyosis?
Enlarged and tender uterus<br></br>Feels more soft than a uterus containing fibroids
When is atrophic vaginitis most common?
After menopause
What is the difference between early and late miscarriages?
<ul><li>Early-most common: <13 weeks</li><li>Late: 13-24 weeks</li></ul>
What is the definitive way a miscarriage can be diagnosed?
Transvaginal US: fetal cardiac activity (from 5.5 weeks gestation)<br></br>Also fetal crown rump length(>7mm) and mean sac diameter<br></br><ul><li>>25mm-failed pregnancy</li><li><25mm: repeat scan in 10-14 days</li></ul>
What surgery would be performed in a miscarriage?
<12 weeks: manual vacuum aspiration<br></br>>12 weeks: evacuation of retained products of conception(ERPC)
What risks are associated with conservative management of msicarriage?
<ul><li>Allowing it to pass naturally</li><li>Risks: infection, heamorrhage</li></ul>
What risks are associated with surgical management of a miscarriage?
<ul><li>Infection</li><li>Uterine perforation</li><li>Haemorrhage</li></ul>
What would be seen on a transvaginal US in a threatened pregnancy?
<ul><li>Viable pregnancy</li></ul>
What would be seen on a transvaginal ultrasound of a patient with an inevitable miscarriage?
<ul><li>Internal cervical os open</li><li>Fetus viable or non-viable</li></ul>
What might be seen on a transvaginal US in a patient with a missed/delayed miscarriage?
<ul><li>No fetal heart pulsation where crown rump >7mm</li></ul>
What might be seen on an ultrasound of a patient who has had a complete miscarriage?
<ul><li>No POC in uterus</li><li>Endometrium <15mm diameter</li><li>Previous pregnancy proof</li></ul>
What might be found on examination of a patient with an ectopic pregnancy?
<ul><li>Bimanual exam: Cervical tenderness-Chandelier sign</li><li>Hameodynamic instability of ectopic ruptures, signs of peritonitis</li><li>Vaginal exam: Pouch of Douglas</li></ul>
When is IM methotrexate likely to be used as treatment for an ectopic pregnancy
Patients with:<br></br><ul><li>Well controlled pain</li><li>B-HCG<1500iU</li><li>Unruptured and no visible heartbeat</li></ul>
What is the most common site for an ectopic pregnancy to occur?
<ul><li>Ampullary portion of fallopian tube</li></ul>
What is oligohydramnios?
Lower levels of amniotic fluid within the uterus
What results in low levels of amniotic fluid
<ul><li>Anything that decreases urine production, blocks urine outputs, or ruptures membranes</li></ul>
What is polyhydramnios?
<ul><li>Presence of too much amniotic fluid in the uterus</li></ul>
What is the first stage of labour?
<ul><li>Period that starts with regular uterine contractions and ends when cervix is fully dilated to 10cm</li></ul>
Which hormones are primarily indicated in the first stage of labour?
<ul><li>Prostaglandins and oxytocin</li></ul>
What is the second stage of labour?
<ul><li>Period from complete cervical dilation to delivery of the foetus</li></ul>
What is the third stage of labout?
<ul><li>Period beginning at the delivery of the foetus and ending with delivery of placenta and foetal membranes</li></ul>
What is pre-term labour?
<ul><li>Onset of regular uterine contractions and cervical changes occuring before 37 weeks gestation</li></ul>
What is preterm birth?
<ul><li>Delivery of baby >20wks but <37wks</li></ul>
What is the premature rupture of membranes?
<ul><li>Rupture of membranes at least one hour before onset of contractions</li></ul>
What is prolonged premature rupture of membranes?
<ul><li>Rupture of membranes >24 hours before onset of labour</li></ul>
What is pre-term premature rupture of the membranes?
<ul><li>Early rupture of the membranes <37 weeks gestation</li></ul>
What is menopause?
<ul><li>Permanent cessation of menstruation characterised by at lease 12 months of amenorrhoea in otherwise health women who aren't using contraception</li></ul>
What is the underlying cause of menopause?
<ul><li>Ovarian failure resulting in oestrogen deficiency</li></ul>
What is perimenopause?
<ul><li>Period when symptoms of menopause begin, continues until 12 months after last menstrual period</li></ul>
What is the difference between premature ovarian insufficiency and menopause?
<ul><li>Premature ovarian insufficiency: <40 years</li></ul>
When should oestrogen only HRT be used vs oestrogen and progesterone?
<ul><li>Oestrogen only: for women with a hysterectomy</li><li>Otherwise use combined</li></ul>
What medication can be used as a non hormonal treatment for menopause
<ul><li>Clonidine</li><li>alpha 2 adrenergic receptor agonist</li></ul>
What is the normal duration of a menstrual cycle?
<ul><li>21-35 days</li></ul>
Which axis controls the menstrual cycle?
<ul><li>Hypothalamic-pituitary-gonadal axis</li></ul>
What is the role of FSH in menstruation?
<ul><li>Binds to granulosa cells to stimulate follicle growth, permit the conversion of androgens(from theca cells) to oestrogens and stimulate inhibin secretion</li></ul>
What is the role of LH in menstruation?
<ul><li>Acts on theca cells to stimulate production and secretion of androgens</li></ul>
What is the corpus luteum?
<ul><li>Tissue in the ovary that forms at the site of a ruptured follicle following ovulation. </li><li>Produces oestrogens, progesteron and inhibin to maintain conditions ofr fertilisation and implantation</li></ul>
What produces HCG?
<ul><li>synctiotrophoblast of embryo</li></ul>
When does menses occur?
<ul><li>Start of new menstrual cycle</li><li>Occurs in absence of fertilisation when corpus luteum has broken down and internal lining of uterus is shed</li></ul>
What is PCOS?
<ul><li>Condition characterised by hyperandrogenism, ovulation disorders and polycystic ovarian morphology</li></ul>
What might be seen on imaging in a patient with PCOS?
<ul><li>Transvag/Transabdo US</li><li>Increased ovarian volume and multiple cysts</li></ul>
What might be found on blood tests of patients with PCOS
<ul><li>increase in LH:FSH ratio</li><li>prolactin normal or mildly raised</li><li>testosterone normal or mildly raised</li><li>sex hormone-binding globulin normal/low</li></ul>
What is the most common cause of Asherman’s syndrome?
<ul><li>Post pregnancy related dilatation and curettgae procedure e.g. retianed products of conception</li></ul>
What is the prognosis of Asherman’s syndrome like?
<ul><li>Recurrence of adhesions post treatment is common</li></ul>
When do congenital malformations of the female genital tract typically present?
<ul><li>Often not until or after puberty</li></ul>
What is ovotesticular disorder of sex development?
<ul><li>'True hermaphroditism'</li><li>Presence of both ovarian and testicula tissue in single patient</li><li>Many menstruate and some can become pregnant</li><li>Treatment: remove contradictory organs and reconstruct external genitalia corresponding to sex of rearing-can wait until person can decide gender</li></ul>
What symptoms might someone with endometrial polyps present with?
<ul><li>Asx</li><li>Abnormal uterine bleeding: menorrhagia, intermenstrual bleeding</li><li>Postmenopausal bleeding</li><li>Infertility or recurrent pregnancy loss</li></ul>
What is pelvic inflammatory disease(PID)?
<ul><li>Infeciton/inflammation of the pelvic organs including uterus, fallopian tubes, ovaries and peritoneum, usually due to ascending infection form endocervix from vagina</li></ul>
What is urolithiasis?
<ul><li>Urinary tract stones-> solid concretions or crystal aggregations formed in urinary system from substances present in urine</li></ul>
What is the circular body of the breast?
<ul><li>Large and most prominent part of the breast</li></ul>
What is the axillary tail of the breast?
<ul><li>Inferior lateral edge or pec major towards axillary fossa</li><li>Nipple at centre surrounded by areola</li></ul>
Where do veins in the breast drain into?
<ul><li>Axillary and internal throacic veins</li></ul>
Where does the skin of the breast drain into?
<ul><li>Axillay, inferior deep cervical and infraclavicular nodes</li></ul>
Where does the nipple and areola of the breast drain into?
<ul><li>Drains to subareolar lymphatic plexus</li></ul>
Which hormones regulate the production and secretion of milk from the breast?
<ul><li>Prolactin </li><li>Oxytocin</li></ul>
Where do fibroadenomas originate from?
<ul><li>Originate from lobules</li></ul>
Where does breast cancer most commonly metastasise to?
<ul><li>Bones</li><li>Liver</li><li>Lungs</li><li>Brain</li></ul>
What is the most common subtype of breast cancer?
<ul><li>Invasive ductal carcinoma</li></ul>
What is the difference between invasive and pre-invasive breast cancer?
<ul><li>Invassive: penetrated through the basement membrane</li></ul>
What screening is in place for breast cancer?
<ul><li>Mammogram every 3 years for women aged 50-70yrs</li></ul>
What is the criteria for a 2 week wait referral for breast cancer?
<ul><li>Unexplained breast lump in a woman >30yrs</li><li>>50 yrs with unilateral nipple changes: dicharge, retraction etc</li></ul>
<div><br></br></div>
<div>Consider if:</div>
<div><ul><li>Skin changes suggestive of breast cancer</li><li>>30yrs with a lump in axilla</li></ul></div>
What mammogram features might be seen in a patient with pre-invasive breast cancer?
<ul><li>Unifocal/widespread microcalcifications</li></ul>
What mammogram features might be seen in a patient with invasive breast cancer?
<ul><li>Irregular spiculated mass</li><li>Clustered microcalcifications</li><li>Linear branching calcifications</li></ul>
What surgical techniques might be used for a patient with breast cancer?
<ul><li>Tumour excision</li><li>Mastectomy</li><li>Breast reconstruction</li><li>Sentinel node biopsies durng surgeryy/axillary node clearance if invasive</li></ul>
When is radiotherapy used for breast cancer treatment?
<ul><li>Recommended after a wide local excision</li><li>Or after a mastectomy for those with >4 positive axillary nodes</li></ul>
When might chemotherapy be used for breast cancer treatment?
<ul><li>Downstage a primary lesion or after surgery depending on stage of tumour, e.g. if axillary node disease</li></ul>
Why is anastrazole used for post-menopausal women?
<ul><li>It's an aromatose inhibitor</li><li>Sromatisation accounts for majority of oestrogen production in post menopausal women</li></ul>
When is hormonal therapy offered to women?
<ul><li>If tumours are positive for hormone receptors</li><li>HER2 over expressing hormone receptor negative patients</li></ul>
What is Paget’s disease of the nipple?
<ul><li>Rare condition characterised by the presence of cancer cells in the nipple</li><li>Often underlying DCIS/invasive breast cancer</li></ul>
What is the role of oxytocin in labour?
<ul><li>Surge in levels at onset of labour will contract the uterus</li></ul>
What is the role of prolactin in pregnancy
<ul><li>Starts the process of milk production in the mammary glands</li></ul>
What is the role of oestrogen in labour
<ul><li>Surges at onset of labour to inhibit progesterone to prepare the smooth muscles for labour</li></ul>
What is the role of prostaglandins in labour
<ul><li>Aid with cervical ripening</li></ul>
What is the role of beta endorphins in labour?
<ul><li>Natural pain relief</li></ul>
What is the role of adrenaline in labour?
<ul><li>Released when birth is imminent to give the woman energy for birth</li></ul>
What is meant by dilation in pregnancy and how is this measured?
<ul><li>Diameter of opening of the cervix</li><li>Measured in cm through vaginal exam</li></ul>
What is the most common pelvis type in females?
<ul><li>Gynaecoid</li></ul>
<div><img></img><br></br></div>
When does ‘descent’ stage of labour happen?
<ul><li>Can be from 37 weeks gestation onwards</li><li>Might not happen until established labour</li></ul>
What pain managment techniques might be used in labour
Non invasive: <br></br><ul><li>Water immersion</li><li>Massage</li><li>TENS machine</li></ul><div><br></br></div><ul><li>Entonox(gas and air)</li><li>Paracetemol</li><li>Codeine</li></ul><div><br></br></div><div><ul><li>Diamorphine</li><li>Pethidine</li><li>Remifentanyl</li></ul></div>
Whata re the disadvantages of using entotox?
<ul><li>Can cause nausea/light headedness</li><li>Effect wears off quickly</li></ul>
What is the ventouse?
<ul><li>Instrument that attaches a cup to a fetal head via a vacuum</li></ul>
What stage of labour should the decision for an operative vaginal delivery be based on?
<ul><li>2nd stage of labour</li></ul>
What is the combined test?
<ul><li>Assesses chance of fetus having Down's, Edward's or Patau's using maternal and fetal measurements</li></ul>
When is the combined test done?
<ul><li>11-14 weeks-anomaly screen</li></ul>
What things are measured in the combined test?
Maternal:<br></br><ul><li>Age</li><li>Free B-HCG(high: downs, low: edwards.pataus)</li><li>Pregnancy associated plasma protein A-PAPP-A(low in all 3)</li></ul><div>Fetus via US:</div><div><ul><li>Nuchal translucency(high-Down’s)</li><li>Crown Rump length</li></ul></div>
What is nuchal translucency?
<ul><li>Measure via US the thickness of the nuchal pad at the nape of the fetal neck</li></ul>
What is the quadruple test?
<ul><li>Screens for Down's syndreom</li></ul>
When is the quadruple test offered?
<ul><li>14-20 weeks</li></ul>
What weeks are in 1st trimester?
<ul><li>1-13</li></ul>
What weeks are in 2nd trimester?
<ul><li>14-27</li></ul>
What weeks are in 3rd trimester?
<ul><li>28-40</li></ul>
What things are check in the quadruple test?
<ul><li>Alpha fetoprotein(AFP)</li><li>hCG or free bhCG</li><li>Inhibin A</li><li>Unconjugated oestriol(uE3)</li></ul>
Which is more accurate-the combined test or the quadruple test?
<ul><li>Combined</li><li>Quadruple has a lower detection rate and higher screen positive rate</li></ul>
What is the cut off for combined/quadruple screening test?
1/150<br></br><ul><li>Low: <1/150</li><li>High: >=1/150</li></ul>
What options are available for women who have been deemed higher risk of Down’s syndrome?
<ul><li>No further testing</li><li>Non-invasive prenatal testing(NIPT)</li><li>Prenatal diagnostic testing</li></ul>
What is non-invasive prenatal testing(NIPT)?
<ul><li>Assess placental cell-free fetal DNA found in maternal blood and combines with mother's probability of a trisomy to provide a likelihood ratio</li><li>Screening test only-positive result needs to be confirmede through invasive testing</li></ul>
When is the anomaly scan offered?
<ul><li>18-20+6 weeks</li></ul>
What is mastitis?
<ul><li>Inflammation of the breast tissue with/without infectoin associated with lactation</li></ul>
What is puerperal mastitis?
<ul><li>Mastitis associated with lactation in postpartum women</li></ul>
What organism is implicated in infective mastitis?
<ul><li>S.aureus<br></br></li></ul>
What organism most commonly causes bacterial vaginosis?
<ul><li>Mc gardnerella vaginalis</li><li>Often polymicrobial</li></ul>
What is the treaatment for bacterial vaginosis?
<ul><li>Oral/vaginal gel: metronidazole or clindamycin</li><li>Avoid douching, shampoos etc, recurrence is common</li></ul>
What is vulvovaginal candidiasis?
<ul><li>'Yeast infection/thrush'</li><li>Fungal infection of lower reproductive tract</li></ul>
What should be done if treatement for vulvovaginal candidiasis fails?
<ul><li>Consider further ix</li><li>Assess risk factors-> diabetes control etc</li><li>Medication concordance</li><li>Specialist referral</li></ul>
Why is<b> </b>vulvovaginal candidiasis more common in pregnancy?
<ul><li>Oestrogen-> increased glycogen production-> promotes candida growth</li></ul>
What organism causes chlamydia?
<ul><li>Chlamydia trachomatis</li><li>Obligate intracellular gram negative organism</li></ul>
When would test of cure be done for chlamydia treatment?
<ul><li>Pregnant women</li><li>Poor complicance</li><li>Rectal infection</li><li>Persistent symptoms</li></ul>
What is the incubation period of gonorrhoea
<ul><li>2-5 days</li></ul>
What might be seen on microscopy in a patient with v
<ul><li>Gram negative diplococci</li><li>Polymorphonucelar leukocytes</li></ul>
Which HPV strains are associated with cancer?
<ul><li>HPV 16/18-cervical cancer</li></ul>
What is the best treatment for genital warts in pregnancy?
<ul><li>Physical ablation</li></ul>
What should be monitored in patients with HIV?
<ul><li>CD4 count</li><li>HIV viral load</li><li>FBC</li><li>U&Es</li><li>Urinalysis</li><li>AST, ALT, bilirubin</li></ul>
What is PEP?
<ul><li>Post exposure prophylaxis</li><li>Given within 72 hours, lasts for 1 month</li></ul>
What medications are used in PEP?
<ul><li>Truvada(1 tablet daily) + raltegravir(1 tablet BD)</li></ul>
What would be seen on transvagianl US in a threatened miscarriage?
<ul><li>Viable pregnancy</li></ul>
What is the treatment for a threatened miscarriage?
<ul><li>Reassurance</li><li>If heavy: admit and observe</li><li>If >12 weeks + rhesus negative: Anti D</li></ul>
What is the role of misoprostol in miscarriage management?
<ul><li>Vaginal misoprostol-> stimulate cervical ripening and myometrial contractions</li></ul>
What should be done if the cause of polyhydramnios is idiopathic?
<ul><li>Baby's 1st feed needs to be examined</li><li>NG tube to check for fistula/atresia</li></ul>
Why is there a higher risk of postpartum haemorrhage in patient with polyhydramnios?
<ul><li>Uterus has to contract more to achieve haemostasis</li></ul>
What is the difference between post-term pregnancy and post dates pregnancy?
<ul><li>Post term: past 42 weeks</li><li>Post dates: pregnancy past estimated delivery date(EDD) or due date(40 weeks gestation)</li></ul>
What should be considered as a differential for prolonged pregnancy?
<ul><li>Consider inaccurate dating</li><li>Incidence of this has decreased now due to 11-14 week scans</li></ul>
What is the main complication of a prolonged pregnancy?
<ul><li>Stillbirth</li></ul>
What is placenta praevia?
<ul><li>Placenta lying over the cervical os</li></ul>
<div><img></img><br></br></div>
Why is it important to identify placenta praevia early?
<ul><li>Important cause of antepartum haemorrhage-> vaginal bleeding from 24 weeks gestation</li></ul>
What is placental abruption?
<ul><li>Part of all of the placenta separates from the uterus prematurely</li><li><img></img><br></br></li></ul>
<div><img></img><br></br></div>
What might be found on exam of a patient with placental abruption?
<ul><li>'woody' uterus</li><li>Tense all the time and painful on palpation</li></ul>
What is meant by ‘breech’ presentation?
<ul><li>Baby present bottom down</li></ul>
When is a vaginal breech brith contraindicated?
<ul><li>Footling breech due to risk of head trapping</li></ul>
What is the difference between ‘lie’, ‘presentation’ and ‘position’ with regards to fetal position?
<ul><li>Fetal lie: relationship between long axis of fetus and mother</li><li>Presentation: fetal part that first enter the mother's pelvis</li><li>Position: fetal head position as it enters the birth canal</li></ul>
What is pre-eclampsia?
<ul><li>Placental condition affecting wmen from 20 weeks gestation characterised by hypertension and proteinuria</li></ul>
What is the criteria for pre-eclampsia?
Criteria:<br></br><ol><li>Htn(>140/90) on 2 occasions at least 4 hours apart</li><li>Significant proteinuria >300mg protein in 24 hr sample or >30mg/mmol urinary protein: creatinine ratio</li><li>Women >20 wks gestation</li></ol>
What should be given for magnesium sulfate toxicity
<ul><li>Calcium gluconate</li></ul>
What is the target MAP in a patient on treatment for eclampsia?
<ul><li><120mmHg</li></ul>
What is t<span>richomoniasis?</span>
<ul><li>STI caused by flagellated protozoan parasite: trichomonas vaginalis</li><li>Primarily infects the urogenital tract</li></ul>
What kind of organism is trichomonas vaginalis?
<ul><li>Highly motile, flagellates protozoan parasite</li></ul>
What is the incubation period of t<span>richomoniasis</span>
<ul><li>7 days</li></ul>
What is l<span>ymphogranuloma venereum?</span>
<ul><li>STI caused by L1, L2 or L3 serovars of chlamydia trachomatis</li></ul>
What is the treatment for bacterial balanitis?
<ul><li>Oral flucloxacillin</li><li>Clarrithromycin in penicillin allergy</li></ul>
What is syphilis?
<ul><li>STI caused by the spircohete bacterium treponema pallidum</li></ul>
What is the incubation period of syphilis?
<ul><li>9-90 days</li></ul>
What tests can be used to diagnose syphilis?
<ul><li>Dark field microscopy: shouldn't be used for oral lesions</li><li>PCR: oral lesions</li><li>Serological testing-main-used for screening, diagnosis confirmation and treatment monitoring</li><li>Serology usually done using a combination of treponemal and non-treponemal tests</li></ul>
What is the treatment for breast cysts?
<ul><li>If large/painful: might need draining</li><li>Usually no treatment</li></ul>
What is mammaary duct ectasia?
<ul><li>Dilatation of the large breast ducts</li></ul>
When is mammary duct ectasia most common?
<ul><li>Most common around the menopause</li></ul>
What might mammography look like in a patient with mammary duct ectasia?
<ul><li>Potentially similar to cancer</li></ul>
When does HELLP syndorme usually manifest?
<ul><li>3rd trimester</li></ul>
What is the main risk of a cord prolapse?
<ul><li>Acute risk ro umbilical blood supply to infant</li></ul>
What is vasa praevia?
<ul><li>Fetal vessels unprotected by umbilical cord or placental tissue run dangerously close to or across the internal cervical os</li></ul>
<div><img></img><br></br></div>
What od fetal vessels lack the protection of?
<ul><li>Wharton's jelly</li></ul>
What is velamentous insertion?
<ul><li>Umbilical cord inserts into the chorioamniotic membranes instead of centrally into placental mass</li></ul>
What is puerperal psychosis?
<ul><li>Severe psych disorder that typicallly develops within the first 2 weeks following childbirth</li></ul>
What is the main risk of peurperal psychosis
<ul><li>Self harm/suicide</li><li>Harm to baby</li></ul>
What is postpartum depression?
<ul><li>Significant mood disorder that can develop any time up to one year after the birth of a baby</li></ul>
Which antidepressants are safe for use in breastfeeding?
<ul><li>SSRIs: sertraline and paroxetine</li></ul>
What needs to be balanced when deciding delivery time in a patient with PPROM?
<ul><li>Increased risk of maternal chorioamnionitis</li><li>Decreased risk of respiratory distress syndrome</li></ul>
What is postpartum haemorrhage?
<ul><li>Loss of >=500ml blood within the first 24 hours of a vaginal delivery</li></ul>
What is the difference between primary and secondary postpartum haemorrhage?
<ul><li>Primary: within 24 hours</li><li>Secondary: 24hours-12 weeks</li></ul>
What usually causes secondary postpartum haemorrhage?
<ul><li>Retained placental tissue or endometritis</li></ul>
What is the Kleihauer test?
<ul><li>Determines proportion of fetal RBCs present-used in rhesus negative pregnancies</li></ul>
What tests are used in rhesus negative pregnancies?
<ul><li>All babies born to rheesus negative mother will have cord blood taken for FBC, blood group and direct Coombs test</li><li>Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby</li><li>Kelihauer test: add acid to maternal lood, fetal cells are resistant</li></ul>
What is the current law surrounding abortion in the UK?
<ul><li>1967 abortion act</li><li>Abortion up to 24 weeks in most cases</li></ul>
What kind of medication is mifepristone and how does it work?
<ul><li>Progesterone antagonist</li><li>Blocks progesterone reqquired for continuation of pregnancy</li></ul>
What kind of medication is misoprostol and how does it work?
<ul><li>Prostaglandin analogue</li><li>Stimulates uterine myometrium contractions resulting in expulsion of uterine contentss</li></ul>
Where can medical termination of pregnancy occur?
<ul><li>Early: 0-9 weeks:: at home</li><li>9-24weeks: clinic</li></ul>
What might be required for later pregnancies undergoing medical termination of pregnancies?
<ul><li>>=22 wweeks</li><li>Feticide(intracardiac KCl injection)-stops fetal heart before abortion</li></ul>
What options are there for surgical termination of pregnancy?
<ul><li>Suction termination</li><li>Dilatation and evacuation/curettage('D&C')</li></ul>
<ul><li>Cervical priming with misoprostol +/- mifepristone</li><li>Women generally offered local anaesthesia alone, conscious sedation with local anaethetics, deep sedation or general anaesthetic</li></ul>
<div></div>
When are women considered high risk for developing neural tube defects?
<ul><li>Either partner has a neural tube defect, previous pregnancy affected by NTD, or fhx</li><li>Women is taking antieepileptic drugs, has coeliac disease, diabetes or thalassaemia trait</li><li>Woman is obese: BMI>=30kg/m2</li></ul>
What screening is done for gestational diabetes?
<ul><li>Oral glucose tolerance test: OGTT</li><li>If previous gestational diabetes: OGTT asap after booking and at 24-28 weeks if first test normal</li><li>Any other risk factors: OFTT at 24-28 weeks</li></ul>
Whata re the features of pre-existing hypertension in pregnancy?
<ul><li>History of htn before pregnancy or elevated BP before 20 weeks gestation</li><li>No proteinuria or oedema</li><li>Mc in older women</li><li>3-5% of pregnancies</li></ul>
What organism causes Group B strep infection?
<ul><li>Bacterium streptococcus agalactiae</li></ul>
What is obesity during pregnancy defined as?
BMI>30kg/m2 at first booking visit
What is the main consequence of cephalopelvic disproportion?
<ul><li>Obstructed labour-? dystocia etc</li></ul>
What is the most common cause of cephalopelvic disproportion?
<ul><li>Contracted pelvis with an average sized infant</li></ul>
What is prolonged labour?
<ul><li>AKA dystocia</li><li>Slow cervical dilation and/or descent of fetus, typically beyond expected time frame of 20 hrs for primigravida and 14 hrs for multigravida women</li></ul>
What is obstetric cholestasis?
<ul><li>AKA intra-hepatic cholestasis of pregnancy</li><li>Impaired bile flow-> accumulation of bile acids, typically manifests after 24 weeks</li></ul>
What is the main risk assoociated with obstetric cholestasis?
<ul><li>Risk of spontaneous intrauterine death</li></ul>
What is shoulder dystocia?
<ul><li>Type of obstructed labour where following delivery of fetal head the anterior shoulder becomes impacted behind maternal pubic symphysis</li><li>Complication of vaginal cephalic delivery</li></ul>
What is the McRoberts manoeuvre?
<ul><li>Hyperflexion and abduction of mother's legs tightly into abdoment</li><li>Applied suprapubic pressure</li><li>Routine traction in axial direction to assess if shoulders have been delivered</li></ul>
What is symphysiotomy?
<ul><li>Division of maternal symphysial ligament</li></ul>
What is the Zavanelli manoeuvre?
<ul><li>Replacement of head into canal and subsequent delivery via C section</li></ul>
What monitoring should be done following the delivery of a baby with shoulder dystocia?
<ul><li>Mother: examined for PPH, severe perineal tears and genital tract trauma</li><li>Baby: examined by neonatologist for injury including brachial plexus injury, hypoxic brain injury, humeral/clavicle fractures</li></ul>
Why are pregnant women predisposed to anaemia?
<ul><li>During pregnancy: both plasma volume and RBC mass increase</li><li>Plasma volume increases disproportionately -> haemodilution effect</li></ul>
What screening is done for anaemia in pregnancy?
<ul><li>All screened at booking and at 28 weeks</li><li>Mutiple pregnancy: extra screenign at 20-28 weeks</li></ul>
What is treatment for micro/normo-cytic anaemia in pregnancy?
<ul><li>Mc: iron deficiency anaemia</li><li>Trial of oral iron(100-200mg)-repeat FBC after 2 weeks of treatment</li><li>Parental iron infusion considered if poor complicance or evidence of malabsorption</li></ul>
What is the treatment for beta thalassaemia in pregnancy>
<ul><li>Folate supplementation and blood transfusions as required</li><li>Aim for Hb of 80g/L during pregnancy and 100g/L at delivery</li></ul>
What is the treatment for sickle cell disease in pregnancy?
<ul><li>Folate supplementation and irone supplementation if lab evidence of iron deficiency</li></ul>
What is the incubation period and infectivity period of rubella?
<ul><li>Incubation period: 14-21 days</li><li>Infectious from 7 days before symptoms appear to 4 days after onset of rash</li></ul>
What signs/sympotms might newborn with congenital rubella syndrome have?
<ul><li>Sensorineural deafness</li><li>Cataracts or retinopathy</li><li>Congenital heart disease</li></ul>
<div>Also:</div>
<div><ul><li>Organ dysfunction</li><li>Microcephaly</li><li>Micrognathia</li><li>Haematological abnormalities</li><li>Low birth weight</li><li>Developmental delay and learning disability later in life</li><li>Characteristic petechial rash described as a 'blueberry muffin' rash</li><li>Cerebral palsy</li><li>'Salt and pepper' chorioretinitis</li></ul></div>
Why is it important to check parvovirus B19 serology in patients who might have congenital rubella syndrome?
<ul><li>Difficult to distinguish rubella from parvovirus B19 clinically</li><li>Parvovirus B19-30% risk of transplacental infection with a 5-10% risk of fetal loss</li></ul>
When should MMR vaccines not be givenn?
<ul><li>Women known to be pregnant or attempting to be pregnancy</li></ul>
When is an amniotic fluid embolism most likely to occur?
<ul><li>During or shortly after labour</li></ul>
When is hyperemesis gravidarum most common?
<ul><li>Between 8-12 weeks</li></ul>
When should hospital admission be considered in patients with hyperemesis gravidarum?
<ul><li>Continued n+v and unable to keep down liquids/oral antiemetics</li><li>Continueed n+v +ketonuria +/- weight loss despite treatment of oral antiemetics</li><li>Confirmed/suspected comorbidity(e.g. unable to tolerate abx for UTI)</li></ul>
What risks are associated with metoclopramide use in pregnancy?
<ul><li>Can cause extrapyramidal side effects: don't use for >5 days</li></ul>
When does acute fatty liver of pregnancy most commonly develop?
<ul><li>Sx almost always ddevelop in 3rd trimester</li></ul>
When might liver transplantation be considered for acute fatty liver of pregnancy
<ul><li>Heaptic rupture</li><li>Acute liver failure </li><li>Post birth</li></ul>
What thromboprophylaxis might be used in pregnancy?
<ul><li>LMWH</li></ul>
What VTE prophylaxis might be used in pregnancy?
<ul><li>LMWH</li></ul>
What is obstructed labour?
<ul><li>Failure of fetus to descend through the birth canal due to a barrier blocking its descent despite strong uterine contractions</li><li>Usually occurs at pelvic brim</li></ul>
What is ovarian hyperstimulation syndrome?
<ul><li>Complication arising from iatrogenic induction of ovulation, characterised by an exaggerated response to hormonal therapies used in procedures like IVF</li></ul>
What is the risk to the mother of exposure to VZV in pregnancy?
<ul><li>5 times greater risk of pneumonitis</li></ul>
What is placental insufficiency?
<ul><li>Oxygen and nutrients aren't sufficiently transferred to the fetus via the placenta during pregnancy</li></ul>
When should a VTE assessment be completed in a pregnant woman?
<ul><li>At booking and on any subsequent hospital admission</li></ul>
What treatments/prophylaxis for VTE should be avoided in pregnancy?
<ul><li>DOACs</li><li>Warfarin</li></ul>
What kind of twin is more at risk of complications and needs to be monitored more closely?
<ul><li>Monozygotic</li></ul>
Why is the rate of dizygotic twins increasing?
<ul><li>Infertility treatment</li></ul>
What is twin-to-twin transfusion syndrome?
<ul><li>Severe condition that can occur in 10-15% of twins sharing a placenta(monochorionic twins)</li></ul>
What signs and symptoms might be exhibited in twin-to-twin transfusion syndrome
<ul><li>Heart failure in both twins</li><li>Fetal hydrops</li><li>Donor twin: high output cardiac failure: severe anaemia</li><li>Recipient twin: fluid overload due to excess blood volume</li></ul>
What is the most common puerperal infection and why?
<ul><li>Endometritis</li><li>Lining of uterus undergoes trauma and tears during the birthing process</li></ul>
Whata re the most common causes of puerperal infection?
<ul><li>S.pyogenes</li><li>S.auureus</li><li>E.coli</li></ul>
What is primary amenorrhoea?
<ul><li>Never had a period</li><li>13+ no primary sex development</li><li>15+ no secondary sex development</li></ul>
What is seconday amenorrhoea?
<ul><li>6 montjs without a period in normal cucle</li></ul>
Whhat is an imperforated hymen?
<ul><li>Hymen blocks the passage of the vagina preventing menstrual blood and discharge</li></ul>
What is Sheehan’s syndrome?
<ul><li>Postpartum hypopituitarism causing necrosis of pituitary secondary to hypovolaemic shock</li></ul>
When is serum progesterone measured?
<ul><li>7 days before the end of the menstrual cycle(usually day 21)</li></ul>
What medications might be used for treating fertility?
<ul><li>Clomiphene</li><li>FSH and LH injections</li><li>GnRH or DA agonists</li></ul>
What surgical options are there for treating infertility?
<ul><li>Assisted reproductive technology including IVF or intracytoplasmic sperm injection</li><li>Treat underlying cause: e.g. fibroids, endo etc</li></ul>
Which location of an ectopic pregnancy would increase the risk of rupture?
<ul><li>Isthmus</li></ul>
