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Gravidity?
no. of pregnancies (includes miscarriages, stillbirths)
Parity?
no. of pregnancies longer than 24 weeks
Menorrhagia
Heavy/long periods of bleeding
Dysmenorrhoea?
Painful periods
Amenorrhoea
Absence of period
Oligomenorrhoea
infrequent periods or >35days between
FIGO staging
0- in situ
1- confined to organ
2- surrounding tissue
3- distant nodes
4- mets
Placental praevia
the placenta is inserted partially or wholly in the lower uterine segment
Placental abruption
the placental lining separates from the uterus of the mother prior to delivery
Average rate of cervix dilation during labour
1cm per hour
Rheus disease
Mother and fetus (even if miscarriage or stillbirth) blood mix if mom Rh-ive and fetus +. Mother produces abs which could destroy current or future fetal Hbs.
Emergency contaceptives
Intrauterine copper coil up to 5 days
Tablets:
1- levonelle (progestonegen) up to 3 days
2- ellaOne (progesteron modulatior inhibitor) up to 5 days
CIs for the COCP pill?
Migrain with aura increases risk of ischaemic stroke so dont want the additional risk!
Types of miscarriage
Threatened
Incomplete
Complete
Missed/silent
Sx of miscarriage
ranges from pain and bleeding to asymptomatic (silent)
Silent miscarriage diagnosis and management
USS (crown rump length and mean sac diameter):
- CRL<7mm with no FH or MSD< 25 mm with no fetal pole -> repeat USS in 1-2 weeks
- CRL >7mm with no fetal heart or MSD >25 mm with no fetal pole -> second opinion or repeat in 1 week
Medical management of miscarriage
Misoprostol 800mcg
PRN: up to 4 doses of Misoprostol 400mcg every 3 hours
Repeat urine pregnancy test (UPT) in 3 weeks
Risk factors for ectopic pregnancy
PID
Previous ectopic
IUD/IUS
IVF
Progesterone only pill
Commonest site for ectopic pregnancy
majority in ampulla of fallopian tube
Pregnancy of unknown location investigation
up to 3 serial serum hCG every 48 hrs
In intra uterine pregnancy -> increases by 63% + levels > 1500
In a failing pregnancy -> decreases by 50%
If static -> ectopic
Medical management of ectopic pregnancy
methrotrexate
When can medically manage a patient with ectopic pregnancy
no significant pain / no ruptured ectopic
HCG<1500
<35 mm
Why shouldnt patients concieve after recieving methotrexate for ectopic pregnancy
depletes folate sources
should avoid for 3 months
2 types of molar pregnancy
pre malignant (complete or partial mole)
Malignant
Complete mole genetic constituition
Diploid, 46 paternal chromosomes
Partial mole genetic constituition
Triploid (1 set of paternal + 2 sets of maternal)
Management of molar pregnancy
Surgical evacuation
Methotrexate
follow up future pregnancies (could recurr)
Prevention of preterm labour
Cervical suture could be at:
- pre-pregnancy (if high risk)
- 2nd trimester
- following USS evidence
Diagnosing preterm labour
- Hx of regular painful contractions + cervical change
- USS
- If no cervical change, vaginal swabs
Vaginal swabs for Dx of preterm labour
- Actim partus (from cervical os)
- Quantitative Fetal Fibronectin (from high vaginal swab)
Preparing for preterm birth
Corticosteroids if <35 weeks
Magnesium sulphate if <30 weeks
Corticosteroid effects on preterm birth
lowers:
neonatal respiratory distress syndrome
neonatal intraventricular haemorrhage
death
Meds to try to stop preterm labour
Tocolysis with:
Nifedipine (Ca antagonist) or
Atosiban (oxytocin antagonist)
Tocolysis
stopping labour
when tocolysis contraindicated
when infection suspected eg SROM or bleeding
When are fetal movements first expected
18-20 weeks
Reliably reported by women at 24th week
How to identify reduced fetal movements
women over 24 weeks lie on their left side for 2hours should feel more than 10 discrete fetal movements
Assessment of fetal heart
< 28 weeks Doppler auscultation
> 28 weeks CTG
TORCH infections
Vertical transmission
Toxoplasmosis / Toxoplasma gondii
Others
Rubella
Cytomegalovirus
Herpes simplex virus-2 or neonatal herpes simplex
Others:
- Coxsackievirus
- Chickenpox (VZV)
- Chlamydia
- HIV
- Human T-lymphotropic virus
- Syphilis
- Zika fever
Small for gestational age (SGA) def?
Infant born less than 10th centile
Symmetrical causes of intraurterine growth restriction (IUGR)
Chromosmal
TORCH infections
Maternal smoking/alcohol/drugs
Maternal nutritional deficiency
Asymmetrical causes of intraurterine growth restriction (IUGR)
Utero-placental deficiency
Pre-eclampsia
Multiple gestation
Renal/cardiac disease
Pregnancy-associated plasma protein A (PAPP-A) significance?
Low level in first trimester ass with delivery of a SGA neonate
What counts as an early/late menupause?
40 early
52 late
Methods for Induction of labour
- Stretch and Sweep
- Prostoglandins (ripens cervix for amniotomy)
- Amniotomy
- Syntocinon infusion
- Mechanical cervical dilators
Risks ass with induction of labour
Increased instumental delivery
Hyperstimulation leading to uterine rupture
Prostoglandins used for induction
Propess (slow release over 24hrs)
Prostin PO/gel (over 6 hours)
Mechanical cervical dilator
cook cervical ripenning balloon
Bishop score
assesses start of labour
>9 spontaneous labour likely
<5 induction likely
Increased fetal HR on CTG
Sepsis
Reduced fetal HR on CTG
fetal distress
cord compression
Risk ass with amniotomy
cord prolapse
Whats a normal variabilty in fetal HR and what is indicative of
< 5bpm
normal CNS function
What are accelerations and deccelerations on CTG
a rise or fall of >15bpm over 15 secs
Accelerations a sign of
normal ANS function (and the fact that Tom isnt driving)
Decceleration a sign of
cord compression
Normal rate of contraction in labour
3-5 contractions per 10 mins
Length of fully dilated cervix
10 cm
Fetal blood sampling values
pH < 7.2 deliver
7.25 > pH > 7.2 borderline
pH > 7.25 healthy
pre eclampsia def
new HTN after 20 weeks with proteinuria
gestational HTN def
new HTN after 20 weeks without proteinuria
Pre-eclampsia RFs?
Changing of partner
FHs
Antiphospholipid syndrome
DM
High BMI
> 4yrs gaps between pregnancy
Anti hypertensives used for pre-eclampsia
Methyldopa
Nifedipine
Labetolol
Main SE of labetolol
intrauterine growth restriction
VTE prophylaxis used in pregnancy
LMW heparin
eg enoxaparin or dalteparin
Difficulty with LMW heparins in pregnancy
eGFR higher in pregnancy
Kidneys excrete them
higher doses required
Primary post partum haemorrhage def
blood loss from genital tract in 24 hours post birth
Secondary post partum haemorrhage def
blood loss from 24hrs post birth to 12 weeks post birth
Causes of post partum haemorrhage
4Ts:
Tone- uterus not contracting
Trauma- tear
Thrombin- DIC
Tissue- placenta missing
Manual methods of promoting uterine contraction for 3rd stage of labour
Uterine massage
Bimanual compression
Pharmacological methods of promoting uterine contraction for 3rd stage of labour
Syntometrine (2 IM injections)
Oxytocin (syntocinon infusion)
Misoprostol
Hemabate(PGF2α)
Management of continous post partum haemorrhage after manual and pharmacological management?
B lynch suture
Bakri balloon
Female genital mutilation types
III removal of clit, minor + suturing major
Different pelvic shapes
Gynecoid: Ideal shape,
Android: triangular inlet, and prominent ischial spines
Anthropoid: transverse diameter < anteroposterior diameter.
Platypelloid: Flat inlet + shortened anteroposterior diameter (Predispose to OT presentation)
Different types of presentation? which cant deliver?
OT
Vaginal tears
1 vaginal muscles torn
2 perineal muscles torn
3 anal sphincter torn
4 rectum torn
Pelvic nerves
Sciatic (L4 to S3)
Pudendal (S2 to S4)
Latent phase of labour
Cervix effacing and thinning
<4cm dilated
Painful irregular tightenings
First stage of labour
cervix effaced 4cm, fully dilated
Regular painful contractions
Second stage of labour
fully dilated cervix
Delicery of baby
Third stage of labour
delivery of placenta and membranes
Vasa praevia
cord vessels pass across the internal os
Could lead to blood loss from fetus
Different types of twins
Dichorionic diamniotic (DCDA)
Monochorionic: diamniotic (MCDA) or monoamniotic (MCMA)
Risk with MCMA twins?
cord entanglement
Twin to twin transfusion syndrome
Abnormal blood vessels
one becomes donor, one reciever
Donor is malnourished, reciever gets excess blood risk of heart failure
Could result in death of one or both
Twin to twin transfusion management
laser ablation of connecting vessels in utero
Types of malpresentation
Frank (extended)
Complete (flexed)
Footling
Kneeling
Options for management of breech presentation
- Eternal cephalic version ECV to manually change the lie
- Elective C section
- vaginal delivery with breech presentation
At which stage of pregnancy does nausea and vomiting occur most commonly
1st trimester
The severity of nausea and vomiting throughout pregnancy
starts at 4-7/40
peaks at 9/40
usually resolves by 20/40
Hyperemesis gravidarum def
N/V + triad of:
- 5% pre-pregnancy wt loss
- dehydration
- electrolyte imbalance
Rfs for hyperemesis gravidarum
Nulliparous
< 20 yo
High BMI
Multiple pregnancy
Molar pregnancy
Iron meds
Pathology of hyperemesis gravidarum
Higher levels of bHCG could be causing thyrotoxicosis similar sx
Gestational thyrotoxicosis path
bHCG similar structure to TSH
Stimulates T3/4 release
Suppresses natural TSH production
Sx and mx of gestional thyrotoxicosis
Clinically euthyroid
Normalises over course of pregnancy no mx
1st line antiemetics for pregnancy
Antihistamines : Cyclizine, Promethazine
Prochlorperazine
2nd line antiemetics for n/v during pregnancy
Metoclopromide
Ondasteron
SEs and CIs with metoclopromide during pregnancy
Maternal extrapyrimidal SEs: eg dyskinesia
Avoid in <18yo
SE of ondansteron in pregnancy
Slight association with cleft lip in 1st trimester
Maintenance fluid and electrolyte requirements in pregnancy
Same as normal
25-30 water mls/kg/day
1 mmols/kg/day K/Na/Cl
Analgesia during pregnancy
Paracetamol
Pethadine
Avoid NSAIDS
Abx to avoid in pregnancy
Trimethoprim (1st trimester)
Nitrofurantoin (3rd trimester, causes fetal haemolytic anaemia)
Meds in PEPSE
Raltagrivir and truvada
Obstetric cholestasis sx
itching of hands/feet
Risk associated with obstetric cholestasis
Preterm delivery
Meconium aspiration syndrome
Stillbirth
Management of obstetric cholestasis
ursodeoxycholic acid
antihistamin
aqeous cream + menthol
When does obstetric cholestasis present
3rd trimester
Dx of obstetric cholestasis
Itching + negative liver screening
Ix within liver screening
Hep A,B,C
EBV
CMV
autoimmune
USS
Placenta accreta
Placenta attatched to myometrium
Placenta percreta
placenta through uterus into other organs
How long after potential exposure should test for syphillis
up to 3 months
COCP side effect
blood clots
How long after potential exposure should test for gonnorrhoea/chlamydia
2 weeks
How long does sperm last in vagina
5 days
How to work out the ovulation day in cycle
14 days before the first day of bleeding
When is the optimum time for pregnancy
day 9 to 14
Progesterone side effect
reduced BMD
Risk of malignancy index (RMI) calculation
What RMI score is considered high?
>200
How does management change with RMI>200
high risk score
CT abdo/pelvis
Refer to senior gyno-oncologist
Classification of ovarian germ cell tumour
CA125 tumour marker§
Peritoneal inflammation: ovarian/ pancreatic etc
bHCG tumour marker
choriocarcinoma
AFP tumour marker
yolk sac tumour/immature teratoma
Contraception post partum if breastfeeding
- Natural: if meets all 3 criteria:
day and night breastfeeding & <6mo post partum & amenorrhoeic
- Progesterone only: anytime post partum
Which contraception not when breastfeeding
combined pills: start at 6 mo
(if not breastfeeding, start at 3rd week)
Puerperium
6 weeks after delivery
Maternal structural changes during puerperium
uterus from 1 kg to 100g (involution)
internal os closes by 3 days, external by 3 weeks
Lochia
endometrial slough, red and white cells passed through vagina
Day 1 -3 red (lochia ruba)
10- week 6 white (lochia alba)
Indications to episiotomy?
distressed baby
instrumental/breech delivery
protect premature head
prevent 3rd (not 4th) degree head
Pain relief in labour
- Breathing exercises
- Pethidine IM (not <2hrs of birth as depresses fetal resp)
- NO
- Pudendal block
- Spinal/epidural
Resus blood tests
Test mothers blood;
if negative, do Fetal DNA analysis (using mothers blood)
if both negative, dont do anything
If incompatible, give anti-D
Indications for an epidural during labour
OP position
instrumental/breech
pre-eclampsia
Problems with epidural in labour
postural hypotension
urinary retention
paralysis
Treatment of seizure (eclampsia)
4g magnesium sulfate
Diagnosis of gestational diabetes
OGTT
fasting above 5.6
2hrs above 7.8
Small for gestational age maternal causes
multiple pregnancy
malformation
infection
pre-eclampsia
What conditons are babies small for gestational age susceptible to in adult life
hypertension
coronary artery disease
autoimmune thyroid disease
non-insulin dependent DM
What complications are SGA babies susceptible post delivery
hypoxia
hypoglycaemia
temperature regulation problems
jaundice (hypoxic in utero, so Hb up)
Maternal history to ask in newborn infant physical examination (NIPE)
Pregnancy complications/delivery/USS
Babies position/lie at delivery
RFs for neonatal infection
FHx
Newborn history to ask in newborn infant physical examination (NIPE)
feeding pattern
urination
passing of meconium
What is shown
lichen simplex chronicus
hyperpigmented plaques
lichen simplex sx
itching/soreness of skin
Mx of lichen simplex
Steroid cream (betamethasone or clobetasol)
Coal tar cream/ointment for maintenance (anti-inflammatory)
vulvar lichen planus sx
very painful, burning sensation
white lacy pattern
What is shown
lichen sclerosis
hypopigmentation
what is lichen sclerosis
autoimmune condition, affecting vulva skin, of women of any age
Sx of lichen sclerosis
itchiing
Mx of lichen sclerosis
strong steroids
What is polyhydramnios
excess amniotic fluid
Maternal causes of polyhydramnios
gestational diabetes
TORCH
Fetal causes of polyhydramnios
problems with swalllowing : atresia/fistula
or
urinating
What is shown
- Caput succedaneum
- subcutaneous fluid collection due to trauma during delivery
Difference between caput succedaneum and cephalohaematoma
succ: oedama collection between skull and skin over the presenting part (crosses the suture line)
cephalohaematoma: blood collection between skull and its periosteum ( does not cross the suture line)
Why use misoprostol vs methotrexate for miscarriage?
Methotrexate destroys dividing cells so kills foetus
Miscarriage - foetus already dead but just want to ensure all tissue is removed
Misoprostol stimulates uterine contraction
COCP increases risk of which cancer
Cervical and breast
COCP protective against which cancers
endometrial
ovarian
HRT types
Cyclical
Continous
Cyclical HRT use
Only if peri-menupausal (LMP less than 1 year ago)
Continous HRT use
Post menupausal
or 1 year of cyclical HRT
PCOS dx criteria
2 out of 3:
Oligomenorrhoea or Anovulation
Biochemical changes
Polycystic ovaries or increased ovarian volume
Biochemical changes in PCOS
Sx: eg Hirsutism
Elevated levels of androgens (eg total or free testosterone)
High LH
Low FSH
