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UM Press Flashcards

1
Q

Define antepartum hemorrhage.

A

It is defined as bleeding from the genital tract between the period of fetal viability to the onset of labour.

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2
Q

What are the causes of antepartum hemorrhage?

A
  1. Placenta previa
  2. Abruptio placentae
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3
Q

What are the types of bleeding in abruptio?

A
  1. Concealed
  2. Revealed
  3. Both
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4
Q

What are the 3 predisposing conditions for placenta previa?

A
  1. Multiparity
  2. Multiple pregnancy
  3. Previous C-section
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5
Q

What are the 4 predisposing conditions for abruptio placentae?

A
  1. Multiparity
  2. Hypertensive disorders
  3. Trauma to the maternal abdomen
  4. Sudden release of liquor in polyhydramnios (rare)
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6
Q

What are the abdomen features of a placenta previa?

A

Soft, non-tender, fetal parts easily palpable

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7
Q

What are the abdomen features of a abruptio placentae?

A

Tense and tender, “WOODY HARD”, fetal parts difficult to feel (Due to the tense abdomen)

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8
Q

What factors determine the subsequent management of the patient in placenta previae?

A
  1. The degree of bleeding and whether it begins to settle
  2. The maturity of the pregnancy
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9
Q

If fetus is preterm, and bleeding is under control in placenta previae, what regime should be carried out?

A

McCafee regime

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10
Q

What is included in McCafee regime?

A
  • Admission to the ward till delivery
  • Close observation for any further bleeding
  • Availability of at least 2 units of grouped and cross-matched blood at all times for the patient
  • Liberal use of C-section for delivery of the fetus as soon as fetal maturity is achieved
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11
Q

What are the conditions whereby vaginal delivery is allowed in a placenta previae case?

A
  1. Minor previa + no further episodes of per vaginal bleeding
  2. Minor previa that is ANTERIORLY placed
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12
Q

Why coagulopathy occurs in abruptio placentae?

A
  • In forming of the retroplacental clot, there is a consumption of the elements that promotes thrombosis in vessels, such as FIBRINOGEN, PLETELETS, and CLOTTING FACTORS.
  • Thus, it is sometimes called “CONSUMPTIVE COAGULOPATHY”
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13
Q

Why DIVC occurs in abruptio placentae?

A
  • Increase pressure within the uterus
  • Thromboplastins are released into the circulation from the retroplacental clot
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14
Q

How do you manage a case of abruptio placentae?

A
  • Immediate resuscitation and assessment of the coagulation status
  • Drip should be set up, blood grouped and cross-matched
  • DIVC screen should be sent
  • Continuous bladder drainage inserted to monitor the urinary output
  • US or doptone examination should be obtained to see if the fetus is dead or alive. If alive, CTG should be done to see if there is any fetal distress
  • Vaginal examination is done to assess how favorable the cervix is for an immediate delivery
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15
Q

If the fetus is dead in abruptio placentae, what is the next appropriate management?

A
  • Artificial rupture of the membrane must be performed -> Liquor release -> Syntocinon drip is set up to augment the labor
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16
Q

Define miscarriage

A

Miscarriage is the expulsion of the products of conception before the 24th week of pregnancy

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17
Q

What are the 3 most commonly seen miscarriages?

A
  1. Threatened miscarriage
  2. Incomplete miscarriage
  3. Missed miscarriage
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18
Q

How do one diagnose threatened miscarriage?

A

Vaginal examination
- Cervical os is closed
- The size of the uterus will correspond to the period of amenorrhoea

Ultrasound examination
- Well formed and rounded gestational sac with a viable fetus within it

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19
Q

What supplementation should be given for threatened miscarriage?

A
  • Folic acid supplements - promote development of the fetus
  • Progesterone supplements (orally or IM) - up to 12 weeks
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20
Q

What are the symptoms of incomplete miscarriage?

A
  • Bleeding is usually heavy
  • Colicky lower abdominal pain (caused by the uterus trying to expel the conceptus)
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21
Q

How do one diagnose a case of incomplete miscarriage?

A
  • Speculum examination -> cervical os is open
  • Bimanual examination -> uterus smaller than dates
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22
Q

What is the management for an incomplete miscarriage?

A
  • Resuscitation if bleeding is severe
  • Blood group and cross-matched
  • Ergometrine 0.5mg (IM) -> contract uterus and control bleeding
  • Once the patient is fit for anesthesia, evacuate the product of conception
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23
Q

How do you diagnose a missed miscarriage?

A
  • Uterus is smaller than the period of gestation
  • Vaginal examination, minimal bleeding and cervical os is closed
  • Bimanual examination shows uterus is smaller than period of gestation
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24
Q

What is the treatment for missed miscarriage?

A
  • Evacuation of the uterus of its product of conception
  • Best done by using SUCTION CANNULA
  • Cervical os will first need to be dilated
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25
Q

If a missed miscarriage occurs later in pregnancy (> 12 weeks), it may not be wised to evacuate the uterus surgically, due to increased risk of…?
1.
2.
3.

A
  • Incomplete evacuation
  • Perforation
  • Cervical incompetence

Instead, drug of choice is prostaglandin (e.g GAMEPROST)
If evacuation is incomplete, the remaining products of conception evacuated by a CURETTAGE

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26
Q

What are the causes of reduced weight gain?

A
  1. Intrauterine growth restriction
  2. Persistent nausea or vomiting
  3. Forced dieting
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27
Q

What are the causes of excessive weight gain?

A

Excessive fluid retention
- PIH
- Renal disease
- Poor dietary habits
- Polyhydramnios

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28
Q

How do we assess fetal movement?

A

Cardiff ‘count to ten’ kick chart
- Mother starts her counting at 9am
- Records the time it takes for the baby to move 10 times

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29
Q

What are the 2 most common measurements used to assess the growth of the fetus

A
  1. Bi-parietal diameter (BPD)
  2. Femur length (FL)

However, their sensitivity in assessing IUGR is limited as both the brain and fetal skeleton are spared in growth restriction

A more sensitive measurement is ABDOMINAL CIRCUMFERENCE

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30
Q

What are looked into when doing CTG?

A
  1. Baseline heart rate (120 - 160 bpm)
  2. Variability of heart rate (Normal variation is between 8 beats per minute)
    - A reactive tracing should be seen especially when there is fetal movement
  3. Presence or absence of decelerations, especially in relation to uterine contractions
    - Type 1 deceleration -> Head compression (2nd stage of labour)
    - Type 2 deceleration -> indicative of fetal distress
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31
Q

What is the principle behind Doppler Ultrasound?

A

It measures the blood velocity in the umbilical artery of the fetus
- The principle is blood velocity speeds up during systole and slows down during diastole
- The degree by which blood slows down during diastole would depend on the amount of resistance in the arterial bed in the placenta
- During normal fetal life, there is a gradual increase in diastolic blood velocity because the resistance downstream gradually decreases with advancing gestational age

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32
Q

What is measured next if the umbilical artery blood flow shows compromisation?

A

Middle cerebral artery blood flow

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33
Q

What factors affect the production of liquor?

A
  1. Placental size
  2. Placental function
  3. Fetal metabolism
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34
Q

What causes meconium stained liquor?

A
  • Sign of FETAL COMPROMISE
  • It is usually as a result of intestinal hurry or spontaneous dilatation of the anal sphincters
  • Both these reflexes are manifestation of some form of FETAL HYPOXIA
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35
Q

State the Indication for IOL

A

Fetal reasons
- IUGR
- PIH or Pre-eclampsia with evidence of growth restriction
- Post-datism or prolonged pregnancy (Placental function deteriorates after term)
- GDM
- Twin pregnancy at term
- Any history of unexplained antepartum hemorrhage
- Transverse, oblique or unstable lie of the fetus (Risk of cord prolapse)

Stabilizing induction is done here
1. ECV is first done to ensure fetus is in the longitudinal lie
2. Following ECV, syntocinon infusion is started and membranes are artificially ruptured

Maternal reasons
- Pre-eclampsia (risk of developing complications that may be life-threatening)
- Medical disorders
- IUD (risk of DIVC if pregnancy prolongs further)
- Fetal abnormality

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36
Q

What are the pre-requisites that must be fulfilled to subject the patient for IOL?

A
  • No evidence of cephalo-pelvic disproportion
  • Fetus must be able to withstand the stress of labour
  • Breech presentation (especially footling or flexed type)
  • Caution must be exercised when inducing patient with a previous scar on the uterus
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37
Q

What is the characteristic of a favourable cervix?

A
  • Soft
  • Anterior pointing
  • Effaced
  • Os dilated
  • Station of the presenting part is sufficiently low
    BISHOP SCORE >8

Once the cervix is favourable, artificial rupture of membrane is done and syntocinon infusion is started soon after

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38
Q

What are the 5 components of the modified Bishop score?

A
  • Cervical dilatation
  • Cervical length
  • Consistency
  • Station
  • Position (Pointing)
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39
Q

What to do if the cervix is unfavourable for the IOL?

A
  1. Do not proceed with IOL and go for C-section
  2. “Ripen” or “Prime” the cervix with hope of making it favourable
    - Most common method of ripenning the cervix is by inserting Prostaglandin (PROSTIN) pessary into the vagina or insert prostaglandin gel (PREPIDIL) into the cervical canal
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40
Q

What are the risk of IOL?

A
  • Failed induction
  • Prematurity
  • Sepsis
  • Hypertonicity of the uterus (Fetal asphyxia is a real risk)
  • Umbilical cord prolapse
  • Uterine rupture
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41
Q

Name 2 types of Caesarean section

A
  1. Classical
  2. Lower segment
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42
Q

Why is the lower segment more favourable for C-section?

A
  • Avascular
  • Does not take an active part in contraction and retraction during labour
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43
Q

What are the disadvantages of classical C-section?

A
  • More vascular -> Tends to bleed more than usual
  • Sutures tend to loosen and healing is poor due to rapid involution (during post-partum)
  • Risk of uterine scar rupture is high
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44
Q

What are the definite indications of doing a classical C-section?

A
  • Any reason for which the lower segment is not accessible
  • Impacted transverse lie of the fetus
  • Major placenta previa where the surgeon is inexperienced
  • Delivery of fetus before proceeding on to a radical hysterectomy for carcinoma of cervix
  • “Post mortem” C-section in which baby is delivered in anticipation of a mother that is going to die very soon
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45
Q

What are the common indications for emergency C-sections?

A
  • Fetal distress
  • Cephalo-pelvic disproportion
  • Umbilical cord prolapse
  • Abruptio placenta and when vaginal delivery is not imminent
  • Failed instrumental delivery
  • Failed IOL
  • Placenta previa
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46
Q

Why is elective C-section better than emergency C-section?

A
  1. The patient is forewarned and she is in the proper frame of mind to undergo the surgery
  2. Patient is well prepared pre-operatively
  3. The patient is fasted overnight and the risk of lung aspiration is reduced
  4. Blood is readily available
  5. Both obstetrician and anesthetist are at their best
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47
Q

What are the complications of C-section?

A
  1. Anesthetic complications
  2. Bleeding from the incision (Placenta previa)
  3. Injury to bladder or even ureter (Due to previous C-section and pelvic anatomy is distorted by adhesions)
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48
Q

Name the players of menstrual cycle.

A
  1. Hypothalamus
  2. Anterior pituitary gland
  3. Ovary
  4. Endometrium
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49
Q

State the respective roles of FSH and LH

A
  • FSH -> stimulates the development of follicles
  • LH -> Rupture of the dominant follicle at ovulation, releasing the ovum
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50
Q

What’s another term for dominant follicle?

A

Graafian follicle

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51
Q

State the 3 main purposes of estrogen during the follicular phase.

A
  • Causes both ENDOMETRIAL GLAND and STROMA to proliferate -> Increasing thickness of endometrium (proliferative phase)
  • Exerts a negative feedback on secretion of FSH from HYPOTHALAMUS and PITUITARY
  • Converts cervical mucus to a clear consistency (Makes cervical canal receptive to spermatozoa)
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52
Q

What happens at the day 14 of menstrual cycle?

A
  • There is a LH surge
  • In response to this, ovulation occurs within 30 - 40 hours
53
Q

What happens to the remaining follicle after the mature ovum is extruded?

A
  • Initially, they formed the CORPUS HAEMORRAGICUM
  • Under the continued influence of LH, the corpus luteum is formed
  • The corpus luteum secretes progesterone + some estrogen
  • This phase is termed the LUTEAL PHASE
54
Q

What is the lifespan of corpus luteum?

A

14 days

55
Q

Which part of the fallopian tube is the ovulated egg transported to?

A

AMPULLA of the oviduct

56
Q

What prevents poly-fertillization?

A

Zona Pellucida of the ovum

57
Q

When is it termed as decidua?

A

When there is sustained secretion of progesterone

58
Q

What will a single X phonotype result?

A
  1. Ovarian dysgenesis
  2. Underdevelopment (e.g Turner Syndrome)
59
Q

What is secreted in the presence of a testis?

A
  • Secretion of Mullerian inhibitory factor
  • This causes regression of Mullerian system (forerunner of female reproductive system) and will result in the absent of uterus and vagina
  • Also, androgen will be secreted. Androgens will virilise the cloaca -> Form male genitalia
60
Q

What approach should be done to rule out primary amenorrhea?

A
  1. Is she phenotypically a normal female?
  2. Does she have sexual infantilism?
  3. Is there evidence of virilism?
61
Q

If a female is phenotypically normal, what should one consider the problem to be?

A
  • Any development abnormality of the Mullerian system
  • The commonest would be TOTAL OR PARTIAL VAGINAL ATRESIA or IMPERFORATED HTMEN
62
Q

What is the treatment of complete vaginal atresia?

A
  • Creation of an artificial vagina
  • Vaginoplasty
    This should be done before marriage so that regular intercourse can keep the vagina patent
63
Q

If the patient is a phenotypically normal female that comes with amenorrhea + history of recurrent pelvic pain, what would you suspect?

A
  • One must suspect presence of a functioning uterus but with outlet obstruction from either a PARTIAL ATRESIA of the distal vagina or imperforated hymen
  • Physical examination -> reveal presence of a pelvic mass -> suggestive of HAEMATOCOLPOS or “blood in the vagina”
  • Diagnostic confirmation -> MRI
  • Last condition to considered is TESTICULAR FEMINIZING SYNDROME. Do karyotyping and this will reveal a 46XY genotype. Once diagnosis is confirmed, gonads must be removed especially if they are intra-abdominal (Due to high risk of malignancy DYSGERMINOMA). After surgery, start on hormonal replacement therapy
64
Q

What is the underlying cause of virilism?

A

Endogenous androgen production
2 conditions to consider:
- XY female in which the testis has become functional at puberty
- Adult onset congenital adrenal hyperplasia

65
Q

What normally causes secondary amenorrhea?

A

Endocrinological causes -> Pituitary or ovary involved

66
Q

What are the differentials for secondary amenorrhea?

A

Pituitary disorder
- Prolactinoma
- Galactorrhea syndrome
- Sheehan’s syndrome (pituitary necrosis)

Ovarian disorder
- Premature ovarian failure/premature menopause/resistant ovarian syndrome
- PCOS
- Ovarian tissue destruction
- Ovarian tumor

Uterine disorder

67
Q

What is the function of prolactin?

A

Prolactin, a hormone secreted by the anterior pituitary gland
- Suppress follicular development in the ovary -> indirectly causes amenorrhea
- Causes milk secretion from the breast

68
Q

How do we investigate and manage a case of prolactinoma?

A

Investigation:
- History
- Physical examination of the visual fields
- Presence of galactorrhea
- Raised prolactin level

Management:
- 1st line -> medical treatment
- Dopamine agonists (CABERGOLINE, QUINAGOLIDE)

69
Q

What is the typical history of Sheehan’s syndrome?

A
  • History of massive PPH
  • Amenorrhea persists after pregnancy
70
Q

Why is the pituitary gland in pregnancy susceptible to hypovolemic necrosis in Sheehan’s Syndrome?

A

This is because the pituitary gland has undergone compensatory hyperplasia or enlargement to cater for the physiological changes in pregnancy

71
Q

What is the clinical features of Sheehan’s syndrome post pregnancy?

A
  • Diabetes insipidus
  • Pan-hypopituitarism (such as hypothyroidism, atrophy of the genital tract, and loss of axillary and pubic hair)
72
Q

What is the serum hormonal profile of premature ovarian failure?

A
  • High FSH and LH levels
  • Low serum estradiol levels
73
Q

What is the management of PCOS?

A
  • Cyclical hormonal treatment
  • Cyproterone acetate -> as progesterone
74
Q

Give one example of androgen producing tumor.

A

Arrhenoblastoma
- Rare ovarian tumor that secretes male sex hormone

75
Q

How do you manage a case of intrauterine adhesions (synechiae)?

A
  • Break the adhesions through a hysteroscope
  • Place a IUD
  • Start on cyclical hormonal therapy
76
Q

What is the clinical approach to a patient presented with amenorrhea?

A
  • First, ensure she is not pregnant
  • If she has recently delivered, make sure she is not breastfeeding & ask for the history of PPH (exclude Sheehan’s syndrome)
  • Ask for any stress or going on a crash diet
  • Ask for a history of galactorrhea, recurrent headaches, and visual problems (exclude prolactinoma)
  • Ask for recent D&C (exclude Asherman syndrome)
  • Look for signs of PCOS
  • Do pelvic examination (exclude any pelvic tumours) If present, confirm by doing an US
  • Do serum levels of FSH, LH, estradiol, serum testosterone, prolactin and TFT
    1. If prolactin levels are high -> do MRI (exclude pituitary adenoma)
    2. If FSH and LH are high -> suspect menopause or premature ovarian failure
77
Q

Name some differentials for secondary dysmenorrhea.

A
  • Endometriosis
  • Uterine fibroids
  • Adenomyosis
  • PID
77
Q

How do manage a case of primary dysmenorrhea?

A
  • Symptomatic relief of the pain + some reassurance
  • Antagonize the prostaglandin action (e.g MEFENEMIC ACID) -> 3 times daily until pain recedes
  • Other drugs include: PARACETAMOL or COX2 NIHIBITORS (e.g ETORICOXIB)
  • If oral medication offers no relief, parenteral analgesics preferably NON-OPIATES (e.g TRAMADOL) can be used
78
Q

State the pathogenesis of endometriosis

A

Retrograde menstruation as advocated by Sampson
- Menstrual blood which contains endometrial gland and stroma, retrogrades and finds its way into the pelvis, through the Fallopian tube
- This occurs due to UTERINE CONTRACTIONS
- Once the endometrial gland and stroma enters the pelvis, it implants at the ovaries and peritoneum (e.g POUCH OF DOUGLAS, UTERO-SACRAL LIGAMENTS)
- “Menstrual blood” in the pelvis releases prostaglandin and other mediators such as interleukin -> PAIN

79
Q

State the staging system for endometriosis

A

Revised American Fertility Society
- Minimal or mild -> Only isolated foci with minimal adhesions (No distortions of pelvic anatomy)
- Moderate -> Adhesions are dense, more extensive and endometrioma may be present (but are <2cm)
- Severe -> Adhesions are dense, extensive, large endometrioma of >2cm, Pouch of Douglas is obliterated

80
Q

How to manage a case of endometriosis?

A
  • Stop recurrent bleeding -> Ovarian suppression
    1. Oral contraceptives or progestogens (Given continuously for 9 months)
    2. Danazol or Gestrinone (Potent androgenic and progestogenic agents) Given continuously for 5 months
    3. GHRH analogues (Monthly injections for 5-6 months) -> Suppress ovulation at pituitary level and induce amenorrhea
81
Q

When is surgery indicated for endometriotic patients?

A
  • Failed medical treatment
  • When disease is severe
  • Endometriomata are present
82
Q

What surgical treatment would you offer to a patient with endometriosis?

A

Depending on the age of the patient and the desire for future childbearing:
- For young women, CYSTECTOMY for endometriomata and removal of foci by CAUTERY
- For patient >45Y, TAHBSO

83
Q

How to manage a case of fibroid in short?

A
  1. For mild pain
    - Start on analgesics
    - Course of GnRH analogues -> results in amenorrhea -> relieves pain + shrinks the fibroids -> However, there is a chance of regrow once stopped
  2. Uterine artery embolization
    - Under radiological guidance, the uterine artery is canulated -> embolizing agent is injected -> Cut off the blood supply to the uterus
  3. High-intensity focus ultrasound (HIFU)
    - High intensity ultrasound wave causes destruction of the fibroids
  4. Surgery
    - If still wants more children, MYOMECTOMY (risk of bleeding during surgery -> may lead to a hysterectomy)
    - If patient has completed her family, hysterectomy + TAHBSO
84
Q

Which part of the uterus is adenomyosis involved in?

A

Myometrium of the uterus

85
Q

Why adenomyosis normally occurs in parous women?

A

It has been postulated that embolisation of endometrium occurs during labour

86
Q

How is the diagnosis of adenomyosis made?

A
  • The final diagnosis can only be made on HISTOPATHOLOGICAL EXAMINATION of the uterus after a hysterectomy
  • It will reveal the presence of endometrial glands and stroma interspersed within the myometrium
87
Q

What is PID?

A

It is an infection of the UTERUS, FALLOPIAN TUBE, ADJACENT PARAMETRIA and overlying pelvic peritoneum
- Commonest organs involved is the FALLOPIAN TUBE (a.k.a SALPINGITIS)
- Common organisms involved:
1. Chlamydia Trachomatis
2. Aerobes such as coliform, group B streptococci, H influenza
3. Anaerobes such as Bacteroides and gram negative bacilli (e.g E. COLI)

88
Q

What is the treatment for PID?

A
  • Analgesics for pain relief
  • A course of antibiotics
  • Final solution -> Pelvic clearance in the form of TAHBSO
89
Q

What is Mittleschmerz and how is it diagnosed?

A
  • It occurs in the middle of the cycle and is related to ovulation
  • Colicky in nature
  • Diagnosis is confirm by a therapeutic trial of oral contraceptives to inhibit ovulation ought to give relief
90
Q

How do we differentiate IBS from pelvic pain?

A

To make a diagnosis of IBS, the patient should have (Rome II criteria) at least 2 of the following:
- Relief of pain with defecation
- Change in frequency of stool
- Change in the form of the stool

91
Q

What are the factors preventing conception?

A
  • Male factor
  • Ovulatory factor
  • Tubal factor -> Tubal blockage or severe tubal adhesions
  • Endometriosis
92
Q

What should be checked on the first visit of the male visit to an infertility clinic?

A
  • Varicocele
  • Atrophy of the testis
  • Confirm the presence of the vas deferens
  • Look for any hypospadias
93
Q

What is a satisfactory seminal analysis?
1. Seminal plasma volume
2. Sperm concentration
3. Satisfactory motility pattern
4. Normal morphology

A
  • Seminal plasma volume of 2-5mL
  • Sperm concentration of >20million sperms per mL
  • Satisfactory motility pattern of >50% of sperms
  • Normal morphology in >50% of the sperms
  • Absence of pus cells -> Presence could indicate PROSTATITIS
94
Q

What should be ask to rule out ovulatory disorder in a case of infertility?

A
  • Any obesity, evidence of hirsutism, irregular and long menstrual cycles -> suggestive of PCOS
  • Any galactorrhea -> suggestive of hyperprolactinemia
95
Q

State the investigations done to rule out ovulatory disorder in a case of infertility and their relevant clinical diagnosis.

A
  • Very high FSH and LH -> Indicates early ovarian failure
  • Ratio of LH:FSH of >2:1 -> indicates PCOS
  • Raised serum prolactin level -> Do a CT/MRI -> TRO Prolactinoma
  • Low serum progesterone level -> indicates absent ovulation
96
Q

What is the typical appearance of polycystic ovaries?

A

Enlarged ovaries (about 4cm by 3cm) with pearly white capsules

97
Q

What test can be done to determine the patency of the Fallopian tube?

A
  • Dye injection through the cervix
  • X-ray hysterosalpingogram
98
Q

Define oligospermia and severe oligospermia

A
  • Oligospermia = sperm concentration <20 million
  • Severe oligospermia = sperm concentration <10 million
99
Q

What are the most common cause of obstructive azoospermia?

A
  • Fibrosis of the vas deferens due to GONORRHEA or TB
  • Congenital absence of the vas deferens (Rare)
100
Q

What are the most common cause of non-obstructive azoospermia?

A
  • Sequelae of mumps orchitis
  • Testis is hypoplastic on palpation
  • FSH is high -> indicates testicular damage and non-obstructive type
101
Q

What assisted conception can be done to aid in oligospermia patients?

A
  • In-vitro fertilization
  • Intra-cytoplasmic sperm injection (ICSI)
102
Q

What ovulation induction agents should be used in PCOS?

A
  • Clomiphene citrate (estrogen antagonist) -> encourages secretion of FSH
  • With rise in FSH, ovarian follicles are recruited with subsequent ovulation
  • The tablets are given from day 2 to day 6 of menstrual cycle
  • Treat this patient with metformin (insulin-enhancing agent) -> reduces insulin insensitivity -> helps in re-establishing regular menstrual cycles
  • If clomiphene citrate does not work -> gonadotrophins should be used (More potent ovulation induction agents)
  • Monitor patient closely due to a chance of hyperstimulation -> To avoid the risk of multiple pregnancy
  • Hyperstimulation syndrome is life threatening. In severe case, there is ASCITES, PLEURAL EFFUSION, SUSCEPTIBILITY TO FLUID and ELECTROLYTE IMBALANCE and VASCULAR THROMBOSIS
103
Q

What treatment is done for tubal factor in a case of infertility?

A
  • Salpingolysis
  • Alternative: ‘by-pass the problem’ -> subject the couple to IVF and embryo transfer
104
Q

Describe about the amniotic fluid based on the 3 trimesters.

A
  • 1st trimester, volume of liquor ranges from 60 - 100mL
  • By 20w, it increases to 500mL
  • Volume continues to increase and reaches a peak at 38w
  • Thereafter, there is a slight decline
  • Note that contents of amniotic fluid changes every 3 HOURS
105
Q

State the sources of amniotic fluid

A
  • Transudation from the fetal skin
  • Fetal voiding of urine
  • Fetal tracheal fluid
  • Transudation from the fetal aspect of the amnion and placenta
106
Q

What are the clinical signs of polyhydramnios?

A
  • Large abdomen with tense shinning skin
  • Flattening of umbilicus
  • Fullness of the flanks
  • Difficulty in feeling the fetal parts
  • Presence of fluid thrill
107
Q

Define polyhydramnios

A
  • Amniotic fluid index above the 95th centile for gestational age
  • AFI>20
108
Q

What are the commonly associated conditions for polyhydramnios?

A
  • Diabetes mellitus
    1. Related to fetal hyperglycemia -> POLYURIA
  • HYPERPLACENTOSIS -> Increase transudation process
  • Multiple pregnancy (especially in UNIOVULAR TYPE)
  • Fetal abnormalities
    1. CNS -> ANENCEPHALY & SPINA BIFIDA
    2. GIT -> ESOPHAGEAL & DUODENAL ATRESIA (Absence or ineffective fetal swallowing)
  • Hydrops fetalis (Related to large fetus and hyperplacentosis)
  • Chorioangioma of the placenta (RARE)
109
Q

State the complications of polyhydramnios.

A
  • Maternal discomfort
    May have supine hypotension due to compression of the IVC and aorta
  • Malpresentation
    If membrane rupture prematurely, there is a real risk of umbilical cord prolapse
  • Preterm labor
  • PPH
    Uterine distension predisposes to uterine atony
  • Abruptio placentae
  • PIH
110
Q

What is the management in a case of polyhydramnios?

A
  • Conservative approach
  • Indomethacin may be used -> Reduce amount of liquor (Must be used in cautious, due to risk of premature closure of the PDA in fetus)
  • If pre-term labor is a real risk, steroids should be given to reduce the incidence of respiratory distress syndrome in the baby
111
Q

Why is amniocenteses seldom done in polyhydramnios patients?

A
  • Fluid tends to re-accumulates within a couple of days
  • Risk of introducing infection or stimulating a preterm labour
112
Q

What is the management for the following condition?
1. Polyhydramnios
2. Malpresentation

A
  • Stabilizing induction should be done
  • Lie of fetus should be stabilized to longitudinal and with head at the brim
  • Membranes artificially ruptured and liquor slowly released
  • If DREW-SMYTHE CATHETER is available, it can be used to release the hind waters of the amniotic sac first
  • All this preferably be done in OT because emergency C-section can be done in the event of cord prolapse
113
Q

Define Oligohydramnios

A
  • AFI <5th centile for gestational age
  • Decrease the amount of liquor
114
Q

What are the cardinal signs of oligohydramnios?

A
  • Uterus is smaller than dates
  • Fetal parts easily felt
115
Q

What 2 conditions is oligohydramnios associated with?

A
  1. Failure to thrive of the fetus (Can be due to IUGR or post-maturity)
  2. Renal agenesis in the fetus
116
Q

Describe the 2 kind of IUGR.

A
  1. Placental insufficiency -> Later in pregnancy
    Common cause: Pre-eclampsia, Maternal infection
  2. Fetal abnormality

Therefore here, a US examination is very important
- Reduced AFI
- Altered head to abdominal circumference ratio
- Features of small or calcified placenta

117
Q

What is the relation between renal agenesis and oligohydramnios?

A
  • An US examination will reveal a very small amount of liquor and absence of fetal bladder or kidney
  • When delivered, baby will show symptoms of POTTER SYNDROME
    1. Low set ears
    2. Epicanthic folds
    3. Flattening of the nose
    4. Micrognathia

Baby is not compatible with extra-uterine life and should be terminated once the diagnosis is made

118
Q

What is the normal position in which the head delivers itself?

A
  • Well-flexed and occipito-anterior position
  • Presenting diameters: SUB-OCCIPITO-BREGMATIC (measuring about 9.5cm)
119
Q

Why is it that by 36weeks, the fetus is forced to stabilise?

A
  • Before 36 weeks, the fetus is still fairly mobile
  • By 36 weeks, it is forced to stabilize because the ratio of the amount of amniotic fluid to the size of the fetus decreases
120
Q

State 2 main reasons why most fetuses present at term with a longitudinal lie and cephalic presentation

A
  1. A wider mass of the fetal hind limbs together with the breech fits better into the broader and wider cavity of the fundal region of the uterus. Smaller head is more adapted to fit into the narrower lower pole
  2. The gravitational pull of the heavier head encourages the fetus to assume a cephalic presentation
121
Q

What are the predisposing condition of breech presentation?

A
  • Prematurity
  • Placenta previae
  • Fetal abnormality
  • Polyhydramnios
  • Intrauterine death
  • Pelvic masses
122
Q

State the 3 types of breech presentation

A
  • Extended or frank breech
  • Flexed breech
  • Footling breech
123
Q

What are the morbidities in an inexperienced hand during the delivery of the fetus in a breech presentation?

A
  • Fracture of the femur during delivery of the legs
  • Damage to the viscera if there is rough handling during the delivery of the abdomen
  • Shoulders may get ‘stuck’ at the pelvic brim if the clinician decides to pull down the abdomens and limbs in a hurry
  • Fracture of the humerus if a forced delivery of the shoulders
  • Intracranial hemorrhage may occur if the head is delivered uncontrolled and in a hurry (Therefore, it is best delivered by FORCEPS)
124
Q

What are the complications of an ECV?

A
  • Inducing pre-term labour
  • Abruptio placentae
  • Cord entanglement

ECV is now delayed till the 38 weeks of gestation
Chances of success in turning the fetus to cephalic is higher at 36 weeks
At 38 weeks, tocolytics can be given to relax the uterus

125
Q

What are the absolute contraindications to an ECV?

A
  • Previous scars on the uterus either due to C-section or myomectomy
  • Placenta previa
  • History of unexplained antepartum hemorrhage
  • Pre-eclampsia
  • Multiple pregnancy
126
Q

What are the relative contraindications to an ECV?

A
  • Rhesus isoimmunization -> Risk of causing feto-maternal blood exchange
  • Elderly primigravida -> Due to high chance of elective C-section even with cephalic presentation
  • IUGR -> Risk of further compromising the fetus
127
Q
A

OBG (4 decks)

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