Women's Flashcards

1
Q

describe the hormonal changes in pregnancy

A

↑ acth = ↑ cortisol + aldosterone
↑ prolactin
↑ T3/4
↑ progesterone - to maintain pregnancy
↑oestrogen - produced by placenta

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2
Q

describe the resproductive system changes in pregnancy

A

uterus increase in size = hypertrophy/hyperplasia
cervical discharge
hypertrophy of vaginal muscles + vaginal discharge

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3
Q

describe the CVS changes in pregnancy

A

↑ blood volume
↑ plasma volume
↑ cardiac output/stroke volume/heart rate
↓ peripheral vasc resistance
↓ blood pressure in early/mid pregnancy
varicose veins
peripheral vasodilation = flushing/hot sweats

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4
Q

describe the respiratory changes in pregnancy

A

increase tidal volume
increase resp rate

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5
Q

describe the renal changes in pregnancy

A

↑ renal blood flow
↑ GFR
↑ aldosterone = ↑ Na/water retention
↑ protein excretion
LESS urea + creatinine
dilatation of ureters and collecting system = hydonephrosis

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6
Q

describe the haematological changes in pregnancy

A

↑ RBC
↑ iron/folate/B12/calcium requirements
↑ WBC
↑ ESR/d dimer
↑ ALP (secreted by placenta)

↓haemoglobin concentration
↓ clotting factors/fibrinogen
↓ haemocrit
↓ platelets
↓ albumin (loss thru kidneys)

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7
Q

describe the skin and hair changes in pregnancy

A

increase pigmentation due to ↑ melanocyte stimulating hormone = linea nigra and melasma
striae gravidarum
pruitus
spider naevi
palmar erythema
postpartum hair loss

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8
Q

describe the GI changes in pregnancy

A

delayed gastric emptying
cardiac sphincter relaxation (= heart burn)
reduced secretion of CCK from GB
increased risk of gallstones
dyspepsia
slower gut transit time
small bowel = increase nutrient uptake
large bowel = increased water absorption = constipation risk

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9
Q

what is an ovarian cyst and what is the main type

A

fluid filled sac
functional = common in premenopausal + fluctuate with hormones
= follicular cyst most common but not harmful
= corpus luteum cyst can cause pain/discomfort/delayed menstruation

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10
Q

describe 5 other types of ovarian cysts

A
  1. serous cystadenoma = benign
  2. mucinous cystadenoma = benign but can become huge
  3. endometrioma = endometriosis lumps of tissue = pain/disrupt ovulation
  4. dermoid cyst/germ cell tumour = benign, associated with torsion
  5. sex cord-stromal tumours = rare, can be malignant
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11
Q

what features suggest ovarian cyst malignancy

A

abdo bloating
reduced appetite
weight loss
urinary symptoms
pain
ascites/lymphadenopathy

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12
Q

describe the investigations and management for a simple/small ovarian cyst

A

blood test
USS
CT or MRI if unable to see on USS
laparoscopy and fine needle aspirate
premenopausal + simple cyst <5cm on USS = no further
rule out pregnancy + CA125 tumour marker

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13
Q

what is the tumour marker for ovarian cancer and what does a raised marker indicate

A

CA125
raised = not specific:
endometriosis
fibroids
adenomyosis
pelvic infection
liver disease
pregnancy

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14
Q

what is the risk of malignancy index

A

RMI = risk of malignant ovarian mass:
1. menopausal status
2. USS findings
3. CA125 level

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15
Q

describe the management for a larger ovarian cyst

A

5-7cm - refer to gynae and yearly USS
>7cm - MRI or surgical evaluation = laparoscopy/ovarian cystectoomy/oopherctomy

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16
Q

what are the complications of an ovarian cyst

A

= ACUTE ONSET PAIN
torsion
haemorrhage into the cyst
rupture = bleeding into peritoneum

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17
Q

what is Meig’s syndrome

A

triad:
1. ovarian fibroma (mass)
2. pleural effusion
3. ascites
= older women
= remove tumour to resolve effusion/ascites

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18
Q

what is early miscarriage vs late miscarriage

A

spontaneous termination of pregnancy
early = before 12 weeks
late = 12-24 weeks gestation

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19
Q

what is a missed miscarriage

A

fetus no longer alive but no symptoms

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20
Q

what is a threatened miscarriage

A

vaginal bleeding with closed cervix and alive foetus

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21
Q

what is an inevitable miscarriage

A

vaginal bleeding and open cervix (finger into internal os)

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22
Q

what is an incomplete miscarriage vs complete miscarriage

A

incomplete = retained products of conception remain in uterus = may need medical/surgical management for miscarriage
complete = full miscarriage, no products left in uterus

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23
Q

what is an anembryonic pregnancy

A

gestational sac present but no embryo

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24
Q

how is a miscarriage diagnosed

A

transvaginal USS
1. mean gestational sac diameter (should be >25mm before pole)
2. fetal pole and crown-rump length (should be >7mm before heartbeat)
3. fetal heartbeat = pregnancy considered viable

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25
how is a miscarriage <6 weeks gestation managed
expectantly = allow natural course repeat urine test 7-10 days
26
how is a miscarriage >6 weeks gestation managed
early pregnancy assessment unit = USS 1. expectant 2. medical = misoprostol = prostaglandin analogue 3. surgical = manual/electric vacuum aspiration
27
describe the medical management of miscarriage
misoprostol = prostaglandin analogue softens cervix and stimualtes contracions vaginal suppository/oral dose SE of bleeding/nausea/vomiting/diarrhoea
28
what is the most common site of ectopic pregnancy
fallopian tubes
29
what are the risk factors for ectopic pregnancy
previous ectopic previous PID previous surgery to fallopian tube coils older age smoking
30
how does ectopic pregnancy present
6-8 weeks missed period constant LIF/RIF pain vaginal bleeding lower abdo/pelvic pain cervical motion tenderness
31
describe the findings on transvaginal USS of ectopic pregnancy
gestational sac in fallopian tube mass moving separately to ovary empty uterus fluid in uterus
32
describe a pregnancy of unknown location
positive test but no evidence on USS = monitor hCG: should rise by >63% in 48hrs = normal pregnancy rise <63% = ectopic fall >50% = miscarriage
33
describe the management for ectopic pregnancy
1. expectant - monitor 2. medical = methotrexate 3. surgical =laproscopic salpingectomy 1st line laparoscopic salpingotomy may be used if increased risk of infertility = remove ectopic but fallopian tube remains
34
what is hyperemesis gravidarum
excessive vomiting with dehydration and ketosis thought that higher hCG = more vomiting/nausea start 4-7 weeks worst 10-12 weeks resolve 16-20
35
what is the diagnostic criteria for hyperemesis gravidarum
more than 5% weight loss dehydration electrolyte imbalance
36
describe the antiemetics used in pregnancy
1. prochlorperazine (stemetil) 2. cyclizine 3. ondansetron 4. metoclopramide (ranitidine or omeprazole if bad reflux)
37
how is moderate/severe hyperemesis gravidarum managed
= unable to tolerate oral = ketones present on dipstick 1. admit to hospital 2. IV/IM antiemetics 3. IV fluids 4. monitor U&E 5. thiamine supplements 6. thromboprophylaxis
38
what is menopause
retrospective diagnosis after no periods for 12 months = end of menstruation average age 51 years
39
what is perimenopause
period leading up to menopause irregular periods mood swings hot flushes urogenital atrophy women >45 years
40
describe the physiology of menopause
lack of ovarian follicular function = oestrogen and progesterone LOW = LH/FSH are HIGH due to absence of negative feedback
41
describe the symptoms of perimenopause
hot flushes emotional instability PMS symptoms irregular periods heavier/lighter perods vaginal dryness/atrophy reduced libido
42
what risks are associated with perimenopause
CVS/stroke osteoporosis pelvic organ prolapse urinary incontinence
43
why is the progesterone depot injection unsuitable for women over 45 years old and when else is it CONTRAINDICATED
SE = weight gain and reduced mineral bone density contraindicated in current breast cancer
44
describe the benefits of HRT
relief of menopause symptoms bone mineral density protection possible prevent long term morbidity
45
describe the risks of HRT
breast cancer VTE - oral HRT increases risk CVS disease - fine if started under 60y/o or monitored well stroke - oral HRT increases risk
46
how should HRT be given in women with intact uterus
need progestogen to be given with oestrogen to protect endometrium from over-proliferating = neoplasm risk (oestrogen effect)
47
what is the difference between sequential and continuous combined form of HRT
oestrogen everyday sequential = progesterone 12-14 days every 4 weeks = bleeding continuous combined = progesterone every day = no bleeding
48
what is Tibolone
synthetic form of continuous combined HRT taken daily
49
how is HRT given in those without a uterus/ with a MIRENA in situ
mirena = already supplies progesterone = no progesterone needed in combination with oestrogen
50
when is transdermal HRT given
malabsoprtion syndromes need for steady absorption (epilepsy) medical conditions older women increased risk of VTE
51
what is premature ovarian insufficiency POI
menopause <40 y/o = hypergonadotrophic hypogonadism = under-activity in gonads = lack of negative feedback on pituitary gland = excess of gonadotrophins = ↑ FSH/LH = low oestradiol
52
what are the causes of POI
idiopathic (50%) iatrogenic - chemo/radio/surgery autoimmune - associated coeliac, T1DM, adrenal insufficiency genetic infections - mumps/TB/CMV
53
how does POI present and how is it diagnosed
irregular/lack of menstrual periods hot flushes night sweats vaginal dryness diagnosis = symptoms + <40 y/o + persistently raised FSH
54
what conditions are women with POI at risk of
CVS disease stroke osteoporosis cognitive impairment dementia parkinsons
55
how is POI managed
HRT until 51 y/o traditional hrt OR combined OCP * can still be fertile so contraception is needed*
56
describe some non hormonal treatments for menopause
CBT SSRI antidepressants antiepileptics
57
what are some contraindications for HRT
breast cancer current or past known or suspected oestrogen-dependent cancer undiagnosed vaginal bleeding VTE previous or current acute liver disease pregnancy thrombophilic disorder
58
what is the puerperium and what are the features
delivery of placenta to 6 weeks following birth = return to prepregnant state = intitiation/suppression lactation = trasnition to parenthood
59
describe the prolactin response with breast feeding
baby suckles prolatin secreted by ant. pit. goes to breasts lactocytes produce milk suppresses ovulation more at night
60
describe the oxytocin reflex in breastfeeding
baby suckles oxytocin secreted by post. pit. goes to breasts myoepithelial cells contract to expel milk helped by senses of baby happens before and after feed
61
what is lactoferrin and what does it do
functional protein in breast milk high colostrum earlier regulates Fe absorpt protects against bacteria/viruses/funghi helps regulate bone marrow function boost immune system
62
what are the signs of sepsis in a new mother
3 Ts with sugar Temp <36 or >38 Tachycardia >90bpm Tachypnoea >20 Hyperglycaemia >7.7mmol WBC >12 or <4(x10^9)
63
what is adenomyosis and who is it more common in
endometrial tissue inside myometrium = muscle layer of uterus 10% of women premenopausal women but older than endometriosis previous uterine surgery
64
how does adenomyosis present
dysmenorrhoea menorrhoea dyspareunia (pain in intercourse) fertility/pregnancy complications examination = enlarged and tender uterus
65
how is adenomyosis diagnosed
transvaginal USS = 1st line MRI/transabdo USS = alternate GOLD STD = histological exam after hysterectomy but not always possible
66
how is adenomyosis managed
depends on sympt/age/pregnancy plans same Tx as for menorrhagia specialist options = GnRH to induce menopause or endometrial ablation or hysterectomy
67
what are some complications of adenomyosis
infertility miscarriage preterm birth/rupture of membranes small for gestational age postpartum haemorrhage
68
describe the different types of fibroids
intramural = within myometrium subserosal = just below outer layer uterus = can fill abdo cavity submucosal = below lining of uterus pedunculated = on a stallk
69
a pregnant woman with history of fibroids presents with severe abdo pain and low grade fever - likely diagnosis?
red degeneration of fibroids
70
what is pelvic congestion syndrome
incompetence of pelvic vein valves typical after pregnancy occurs in 1 in 5 with varicose veins
71
what are the features of pelvic congestion syndrome
constant dull ache lower abdomen worse after standing/prolonged standing or after intercourse can cause interstitial cystitis
72
what is salpingitis, oophoritis and parametritis
salpingitis = inflammation of fallopian tubes oophoritis = inflammation of ovaries parametritis = inflammation of the parametrium (connective tissue around uterus)
73
what is a vault prolapse
hysterectomy = no uterus top of vagina descends into vagina
74
what is a rectocele
defect of post. wall of vagina = rectum prolapse into vagina = causes constipation and urinary retention = can use fingers to temporarily fix
75
what is a cystocele
ant. vagina wall defect = bladder prolapse backwards into vagina urethra prolapse also possible = urethrocele
76
what are some risk factors for pelvic organ prolapse
multiple vaginal deliveries prolonged/traumatic delivery advanced age an post menopause obesity chronic resp disease causing coughing chronic constipation causing straining
77
describe the pregnancy trimesters
1st = conception to 12 weeks 2nd = 13-26 weeks 3rd = 27 weeks until birth
78
what is an USS used to assess in pregnancy
assess growth liquor volume umbilical artery doppler = if abnormal then placenta is insufficient
79
what mneumonic is used for CTG interpretation
CTG = cardiotocography Dr = define risk C = contractions Bra = baseline rate V = variability A = accelerations D = decelerations (early/variable/late) O = overall assessment
80
when is CTG used, when is it suspicious and when is it pathological
high risk pregnancies in hospital suspicious = 1 non-reassuring feature pathological = 2+ non reassuring feature or 1+ abnormal feature
81
what is the gold standard for fetal heart monitoring
fetal scalp ECG
82
when is the dating scan and what happens at it
10-13+6 weeks gestational age calculated from crown rump length multiple pregnancies identified
83
when is the anomaly scan
18-20+6 weeks USS to identify anomalies e.g. heart conditions
84
what occurs at the routine antenatal appointments
symphysis-findal height measured from 24 weeks + fetal presentation from 36+ wks urine dip for protein for pre-eclampsia BP for pre-eclampsia urine for microscopy = asymptomatic bacteruria
85
what vaccines are offered to pregnant women
pertussis form 16 wks influenza when available live vaccines avoided
86
how does low lying placenta present and how is it diagnosed
antepartum bleeding painless bleed USS
87
what is intrauterine growth restriction
baby's growth slows or ceases when in the uterus part of wider group of small for gestational age fetusus (SGA) applies to neonates born with features of malnutrition and IN UTERO growth restriction IRRESPECTIVE of birth weight percentile
88
what signs indicate IUGR
reduced amniotic fluid abnormal doppler studies reduced foetal movements abnormal CTGs
89
how are low risk women monitored for IUGR
symphysis fundal height at every antenatal appt after 24 wks plotted on a graph SFH <10th centile = need serial growth scans with umbilical artery doppler
90
how are high risk women for SGA monitored
USS measuring: estimated fetal weight + abdominal circumference = growth velocity umbilical arterial pulsatility index amniotic fluid volume
91
what is chorioamnionitis
infection of chorioamniotic membranes and amniotic fluid = leading cause of maternal sepsis and can cause DEATH occurs later in pregnancy/during labour
92
what constitutes a primary/secondary/minor/major PPH
primary = >500mls blood loss after birth of baby secondary = >24hrs to 2 weeks after birth minor = <1500mls lost and no shock major = 1500ml + continuing to bleed OR shock
93
describe the management of post partum haemorrhage (8 steps)
1. resus ABCDE 2. lie flat, warm and calm 3. 2 large bore cannulas 4. bloods for FBC/U&E/clotting 5. cross match 4 units 6. warmed IV fluid and blood resus as needed 7. oxygen regardless of sats 8. fresh frozen plasma if clotting abnormalities/after 4 units
94
what is a secondary postpartum haemorrhage
bleeding occurs 24hrs to 12 week postpartum likely due to retained products of conception or infection USS/endocervical swab for infection treat by surgery or antibiotics for infection
95
what is a postdural puncture headache and how does it present
accidental dural puncture during epidural leakage of CFS and reduced pressure in fluid around brain headache worse on sitting/standing 1-7 days after epidural neck stiffness/photosensitivity
96
how is postdural puncture headache treated
lying flat analgesia epidural blood patch
97
what is the leading cause of maternal death up to 6 weeks after pregnancy in the UK
VTE
98
what is the leading cause of direct deaths 6wk- 1 year after end of pregnancy
maternal suicide
99
when is the risk of VTE highest
postpartum
100
name some of the VTE risk factors
smoking parity over 3/multiple pregnancy age over 35 bmi under 30 reduced mobility preeclampsia varicose veins family history thrombophilia IVF pregnancy
101
when should VTE prophylaxis be started
28 weeks if 3 RFs first trimester if 4+ RFs continues until 6 wk postnatal temporarily STOPPED in labour
102
what prophylaxis is given for VTE
LWMH = enoxaparin = dalteparin = tinzaparin
103
name 2 forms of mechanical VTE prophylaxis
intermittent pneumatic compression anti-embolic compression socks
104
how does VTE present
UNILATERAL calf leg swelling dilated veins tender calf oedema colour changes >3cm between calf diameter = significant
105
how does a PE present
SoB cough +/- blood pleuritic chest pain hypoxia tachypnoe/tachycardia
106
how is VTE diagnosed
doppler USS suspected PE = CXR and ECG CTPA = definitive diagnosis (higher risk mother) VQ scan also can be used (higher risk foetus)
107
what is NOT used for investigation of VTE in pregnancy
D dimer
108
what are the Tx options for PE in pregnancy
unfractionated heparin thrombolysis surgical embolectomy
109
what is baby blues and when does it present
>50% women affected within 1st week post natal mood swings low mood anxiety irritable tearful = usually resolve within 2 weeks
110
what is postnatal depression and when does it present
1 in 10 women peak 3 months postnatal 1. low mood 2. anhedonia (lack of pleasure in activities) 3. low energy sympt for 2 weeks before diagnosis can be made
111
how is postnatal depression treated
mild = behavioural/therapy moderate - antidepressants and CBT severe = specialist psychiatry
112
what screening tool is used for postnatal depression
edinburgh postnatal depression scale 10 questions 30 points >10 = suggests diagnosis
113
what is puerperal psychosis and when/how does it present
rare but severe 2-3 weeks postnatal - delusions - hallucinations - depression - mania - confusion
114
how is puerperal psychosis treated
urgent assessment and input from specialist services 1. admit to mother and baby unit 2. CBT 3. antidepressants/antipsychotics/mood stabilisers 4. electroconvulsive therapy
115
how are pregnant women with existing mental health concerns managed
referred to perinatal mental health services for specialist input continue on medications plan for delivery neonates monitored for neonatal abstinence syndrome
116
what is the difference between stress incontinence and urge incontinence
stress incontinence = weak pelvic floor and sphincter muscles urge incontinence = overactivity of detrusor muscle
117
what is overflow incontinence
chronic urinary retention due to obstruction to the outflow of urine = overflow of urine = incontinence without urge to pass urine can occur with neurological conditions (MS, diabetic neuropathy, spinal cord injury) more common in men
118
what are the risk factors for urinary incontinence
increased age post menopause increase BMI previous pregnancies/vaginal deliveries pelvic organ prolapse pelvic floor surgery neuro conditions (MS) cognitive impairment/dementia
119
describe the physiology of detrusor contraction
parasympathetic S2,3,4 nerves from brain => ACh to muscarinic M3, M3 receptors => detrusor contraction
120
what is an obstetric fistula
hole develops in birth canal due to childbirth can be between vagina and rectum/ureter/bladder result in incontinence of urine or faeces rare in developed world urinary catheter/stent can be useful treatment surgery may be needed to close fistula/repair tissue
121
what advice should you give when prescribing metronidazole
NO ALCOHOL can cause disulfiram-like reaction: nausea/vomiting/flushing rare = shock + angioedema
122
what is trichomonas vaginalis and what does it increase the risk of
protozoan with flagella increase risk: - contracting HIV - BV - cervical cancer - PID - pregnancy complications
123
what is the typical discharge associated with trichomonas vaginalis
frothy yellow-green (maybe fishy)
124
what is the typical examination findings of trichomonas vaginalis
strawberry cervix (colpitis) = inflammation = tiny haemorrhages vaginal pH above 4.5
125
where should swabs be taken for trichomonas vaginalis
from the posterior fornix of vagina
126
describe the different strains of herpes virus and what they are associated with
HSV-1 : = cold sores = contracted in childhood = cause genital herpes by oral sex HSV-2: = genital herpes = STI spread
127
describe the presentation of herpes
initial episode more severe, recurrent = milder ulcers/blisters neuropathic pain = tingling/burning flu-like sympts dysuria inguinal lymphadenopathy
128
how is herpes diagnosed and managed
clinically based on history and exam viral PCR swab refer to GUM Tx = acyclovir topical lidocaine paracetamol vaseline
129
what is the concern with herpes in pregnancy
risk of neonatal herpes simplex infection = high morbidity and mortality pregnant woman antibodies should cross placenta and give baby passive immunity acyclovir still given in pregnancy asympt women can have vaginal delivery sympt women should have C section
130
what is lymphogranuloma venerum (LGV)
condition affects lymphoid tissue around site of chlamydia infection most common MSM primary stage = painless ulcer secondary stage = lyphadenitis swelling/pain tertiary stage = inflammation of the retum and anus (proctitis)
131
what is proctocolitis and how does it present
inflammation of rectum and colon anal pain change in bowel habit tenesmus discharge
132
how is LGV treated
doxycycline 100mg twice daily for 21 days = 1st line
133
describe the natural course of HIV
1. acute primary infection = transient immunosuppression = low then high CD4 2. asymptomatic phase = progressive loss of CD4 = poor immunity 3. early symptomatic phase = manifestation of clinical features
134
how is AIDS defined (late stage HIV)
CD4 <200 immune deficiency symptoms and opportunistic infections normally 5-10 years to reach AIDS
135
how is HIV transmitted
1. unprotected vaginal/anal/oral sex 2. mother to child = vertical 3. mucous membranes = blood/bodily fluids
136
name 6 examples of AIDS defining illnesses
kaposi's sarcoma pneumocystisis jirovecci pneumonia (PCP) CMV candidiasis lymphoma TB
137
who should be tested for HIV and when
all persons admitted to hospital with infectious disease all high risks persons test initially then repeat 3 months later as antibodies take 3 months to build up
138
what are the HIV infection markers
CD4 count RNA = viral load
139
how is HIV treated and what are the treatment aims
antiretroviral therapy (ART) for all people - different regimes depending on person aims: achieve normal CD4 count and undetectable viral load treat individual infections
140
what is the prophylactic for PCP
co-trimoxazole (septrin)
141
what monitoring do female patients with HIV need
yearly cervical smears increased risk HPV and cervical cancer
142
how should women with HIV give birth
normal vaginal if viral load <50 CS if viral load >50 IV zidovudine if high or unknown viral load
143
what prophylaxis is given to babies of HIV+ mothers
low risk = zidovudine for 4 weeks high risk = zidovudine + lamivudine + nevirapine for 4 weeks
144
what should new mothers with HIV NOT do
breastfeed
145
what is post menopausal bleeding until proven otherise
endometrial cancer
146
what is endometrial hyperplasia
precancerous condition = thickening of endometrium <5% progress to cancer hyperplasia +/- atypia treat with IUS or continuous oral progestogens
147
what HPV strains are responsible for the majority of cervical cancers
type 16 type 18
148
how does HPV promote the development of cancer
inhibits tumour suppressor genes p53 and pRb
149
describe the management of smear results (PHE guidelines)
inadequate sample = repeat after at least 3 months HPV negative = continue routine screening HPV positive with normal cytology = repeat HPV test 12 months HPV positive with abnormal cytology = refer for colposcopy
150
what is a colposcopy
insert speculum and magnify the cervix can apply stains to differentiate abnormal areas e.g. acetic acid pr schillers iodine test
151
what is a large loop excision of the transformation zone LLETZ
loop biopsy can be performed during a colposcopy = removes abnormal epithelium and cauterises the wound
152
what is a cone biopsy and what is it used for
treatment for cervical intraepithelial neoplasia (CIN) under GA = cone shaped piece of cervix removed = sample sent to histology risk of bleeding/infection/pain/scars
153
what is vulval intraepithelial neoplasia
premalignant proliferation of squamous epithelium of vulva high grade = associated with HPV + young women 35-50 differentiated = associated lichen sclerosis age 50-60 Tx: W&W wide local excision imiquimod cream laser ablation
154
describe the initial investigations for infertility
BMI chlamydia screening semen analysis female hormonal testing rubella immunity in mum
155
describe the female hormone testing for infertility
serum LH/FSH on day 2-5 of cycle serum progesterone on day 21 anti-mullarian hormone TFT prolactin when sypts = galactorrhea or amenorrhoea
156
what is the most accurate indicator of ovarian reserve
antimullarian hormone
157
what is a hysterosalpingogram (HSG)
scan used to assess shape of uterus and fallopian tube patency also has therapeutic effect = increase rate of conception contrast and XR risk of infection with procedure = prophylactic Abx screening for STI needed before scan
158
what is a laparoscopy and dye test
dye injected into uterus = can see entering fallopian tubes can assess for endometriosis/adhesions and treat
159
describe the management of anovulation
1. weight loss 2. clomifene/letrozole = stimulate ovulation 3. gonadotrophins 4. ovarian drilling = for PCOS 5. metformin for insulin insenstitivity and obesity in PCOS
160
what is clomifene and how does it work
ani-oestrogen given on day 2-6 stops neg feedback of oestrogen = greater GnRH and FSH/LH
161
how is infertility treated when it is a tubal problem
tubal cannulation during HSG laparoscopy to remove adhesions/endometriosis IVF
162
how are sperm fertility problems managed
surgical sperm retrieval = directly from epididymis surgical correction of obstuctrion intra-uterine insemination intracytoplasmic sperm injection ICSI donor insemination
163
what are dermoid cysts/germ cell tumours
benign ovarian tumours can contain hair/skin/teeth/bone can cause raised alpha FP and hCG
164
what is a krukenberg tumour
metastasis in the ovary usually from GI tract 'signet-ring' appearance on histology
165
when are women screened for anaemia in pregnancy
booking clinic 28 weeks screening for haemoglobinopathies, sickle cell and thalassaemia also occur
166
what are the normal ranges of Hb in pregnancy
booking = >110 28 weeks = >105 post partum = >100
167
how does the MCV indicate the cause of anaemia
low MCV = iron deficiency normal MCV = physiological anaemia (pregnancy) raised MCV = B12/folate deficiency
168
how is anaemia in pregnancy treated
1. iron replacement 200mg 3x daily ferrous sulfate 2. low ferritin = iron supplement test for pernicious anaemia = IM hydroxocobalamin or oral cyanocobalamin 3. ALL women to take 400mcg folic acid every day + 5mg folic acid if deficient 4. thalassaemia = specialist Mx
169
why is iron deficient anaemia bad in pregnancy
associated with preterm birth and low birthweight
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which asthma meds can be used in pregnancy
all of them
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what is the leading cause of maternal death in the UK
cardiac disease ischaemic or congenital
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what are some high risk cardiac issues in pregnancy
aortic stenosis coarctation of aorta prostetic valves cyanosed mum
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what are the lower risk cardiac issues in pregnancy
mitral/aortic incompetence ASD VSD
174
describe hyperthyroidism in pregnancy
uncommon often resolves after 1st trimester risk of thyroid crisis with caridac failure risk of foetal thyrotoxicosis can treat with antithyroid drugs (carbimazole)
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describe hypothyroidism in pregnancy
common if untreated = early foetal loss and impaired neuro development aim for adequate replacement with thyroxine in 1st trimester especially
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what screening is needed in pregnant women with pre-existing diabetes
retinopathy screening after booking + at 28 weeks
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what is recommended for pregnant women with pre-existing diabetes
planned delivery at 37-38+6 weeks sliding scale insulin during labour in T1DM
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what are the foetal complications for babies with diabetic mothers
neonatal hypoglycaemia jaundice polycytheamia congenital heart disease cardiomyopathy
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what medications should be stopped in pregnancy
(AST) ACEi/ARBs Statins Thiazide and thiazide-like diuretics
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what are the complications of gestational diabetes for the mother
DKA hypoglycaemia (common) progression of retiopathy pre-eclampsia premature labour
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what are the complications of gestational diabetes for the baby
miscarriage stillbirth macrosomia = shoulder dystocia fetal abnormality neonatal hypoglycaemia
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what is the effect of chronic renal disease on pregnancy
severe HTN deterioration renal function growth restriction abnormalities due to drug therapy pre-eclampsia C section premature delivery stillbirth
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which medications for HTN are suitable for use in pregnancies
labetalol (other BB not suitable) CCBs (nifedipine) alpha blockers (doxazosin)
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how are pregnant women with epilepsy managed
5mg folic acid reduce neural tube defects AVOID sodium valproate = neural tube defects AVOID phenytoin = cleft lip/palate CAN USE levetiracem/lamotrigine/carbamazepine
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how is a pregnant woman with rheumatoid arthritis managed
AVOID methotrexate = teratogenic 1st choice = hydroxychloroquine sulfasalazine is safe corticosteroids can be used in flare ups
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how are pregnant women monitored for UTIs
urine dip and urine sample for asymptomatic bacteriuria at booking and routinely at appointments
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what are the causes of UTI in pregnant women and how are they managed
e.coli most common klebsiella pneumoniae 7 days of Abx - nitrofurantoin (NOT in 3rd trim) - amoxycilin (after sensitivities) - cefalexin AVOID trimethoprim in 1st trimester (and most of pregnancy)
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what is chronic hypertension vs pregnancy induced HTN/gestational HTN
chronic = exist before 20 weeks gestation and longstanding pregnancy induced =occuring after 20 weeks WITHOUT proteinuria
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what is PlGF testing
test for placental growth factor in pre-eclampsia = LOW can be used to rule out pre-eclampsia
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what is used to treat eclampsia
IV magnesium sulfate
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how is pre-eclampsia treated after delivery
1. enalapril 2. nifedipine/amlodipine (1st line black/caribbean) 3. labetalol or atenolol
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what is HELLP syndrome
Haemolysis Elavated Liver enymes Low Plateletes = complication of preeclampsa = exacerbation of sympts = definitive Tx is delivery of child
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what are the foetal indications to deliver in preeclampsia
severe foetal growth restriction nonreassuring foetal test results oligohydramnios
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what are the maternal indications to deliver in preeclampsia
over 38 weeks plt <100,000 deterioration liver and renal function suspected placenta abruption persistent symptoms
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name 3 causes of antepartum haemorrhage
1. placenta praevia 2. placental abruption 3. vasa praevia
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describe the breast imaging pathway for symptomatic women
under 35: 1. clinical exam 2. targeted USS over 35: 1. clinical exam 2. bilateral mammogram AND targeted USS
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what is mammography used for
1st choice imaging >40 screening asymptomatic characterise symptomatic abnormalities follow up and surveillance detect breast cancer 90%
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what are the benefits and limitations of breast MRI
high sensitivity for invasive breast carcinoma does NOT use ionising radiation limited availability expensive limited biopsy facilities
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what are the risk factors for breast cancer
radiotherapy <35 y/o BRCA1 BRCA2 HRT Li Fraumeni syndrome moderate/high alcohol consumption not breast feeding nuliparous
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when was nhs breast screening introduced and how many lives a year does it save
1988 1400 lives a year
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how are high risk women screened for breast cancer
= use MRI further Ix = USS and biopsy
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describe the genetics of breast cancer
BRCA1 = chromosome 17 = 60% BC + 40% ovarian cancer BRCA2 = chromosome 13 = 40% BC + 15% ovarian cancer
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where can breast cancer metastasise to
Lungs Liver Bones Brain
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what is a ductal carcinoma in situ DCIS
(pre)cancerous epithelial cells of breast duct localised 1 area mammogram Dx potential to spread locally 30% become invasive good prognosis if fully excised + adjuvant treatment
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what is a lobular carcinoma in situ LCIS (lobular neoplasia)
precancerous condition in premenopausal women asymptomatic and undetectable in mammogram incidental Dx on biopsy 30% increase risk of invasive cancer managed with close monitoring (6 monthly)
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what is invasive breast cancer NST
no specific type NST originate in cells from breast ducts 80% of invasive breast cancers Dx on mammogram
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what are invasive lobular carcinomas ILC
10% of invasive breast cancer originate in cells from lobules not always visible on mammogram
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what is inflammatory breast cancer
1-3% present similar to abcess/mastitis swollen/warm/red/tender + PEU D'ORANGE no response to Abx = consider inflamm breast cancer worse prognosis
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what is paget's disease of the nipple
eczema of nipple/areolar red scaly rash = breast cancer of nipple may represent DCIS/invasive BC requires biopsy/staging/treatment
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name the conditions screened for at antenatal clinic
sickle cell and thalassaemia infectious diseases Down's/Edwards/Patau's foetal anomaly scan diabetic eye screening
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what is alpha thalassaemia
depletion of alpha chains no. faulty genes related to severity african/asian population alpha thalassaemia major = fatal (hydrops fatalis)
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what is beta thalassaemia
depletion of beta chains no. fautly genes NOT related to severity mediterranean/middle east/africa/asia require lifelong transfusion therapy/chelation therapy to Tx iron overload
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when are pregnant women screened for sickle cell
8-10 weeks prenatal diagnosis (of baby?) by 12+6 can be offered termination
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what infectious diseases are women screened for
HIV Hep B syphillis reoffered at 20 weeks to anyone who declines
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what are the complications of syphilis in pregnancy
miscarriage pre-term labour stillbirth congenital syphilis
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describe the testing for fetal anomaly
downs (T21) edwards (T18) Patau's (T13) offered to ALL women combined test = 11+2 - 14+1 weeks quadruple testing = 14+2 - 20 weeks low chance = receive letter higher chance = screening and offer of prenatal diagnosis DOCUMENT RESULTS/OUTCOMES
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what is edward's syndrome
T18 incidence ^ with maternal age 80% female survival rates beyond 1 year = 10% severe learning difficulties + extremely serious physical disabilities most = stillborn
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what is patau's syndrome
T13 incidence ^ with maternal age most stillborn/die shortly after birth associated with multiple severe foetal abnormalities : congenital heart defects holoprosencephaly face/abdo/urogenital malformations
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what is the purpose of the early pregnancy scan
confirm viability singleton or multiple estimate gestational age detect major structural abnormalities component of screening for trisomy
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when are ultrasounds performed in pregnancy
early = 10-14 weeks structural abnormalities = 18+0 - 20+6
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what is the triple assessment for breast cancer
1. clinical score 2. imaging score 3. biopsy score
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describe the stages of labour
LATENT: 0-4cm irregular contractions cervix begins effacement 2-3 days ACTIVE: stronger contractions 1st = 4-10cm 2nd = 10cm - head delivery 3rd = head delivery to placenta delivery
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describe the mechanism of labour
DESCENT FLEXION = fetus head flexes INTERNAL ROTATION = fetus head pushed onto pelvic floor = with each contraction small rotations to 90 degrees EXTENSION = fetus extends head during birth RESTITUTION/EXTERNAL ROTATION = fetus head turn to align with shoulders BODY DELIVERY
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what gynae complaints may FGM present as
dysparareunia sexual dysfunction/anorgasmia chronic pain keloid scar dysmenorrhoea (including haematocolpos) urinary obstruction/recurrent UTI PTSD
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what obstetric complains may FGM present as
fear of childbirth increased risk of CS/PPH/episiotomy/vaginal lacerations difficulty performing VE in labour difficulty in catheterisation in labour
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what is precocious puberty in boys and girls
girls = before 8 boys = before 9
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when is an oral glucose tolerance test performed
in women with risk factors (BMI/ethnicity/family history/obstetric history) 24-28 weeks
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when does the fetus have rights
in termination - after 24 weeks is person with rights mum has a right to refuse emergency CS and fetus has no rights there
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define abnormal uterine bleeding
any menstrual bleeding from uterus that is abnormal in volume/regularity/timing or is non-menstrual
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what are the causes of heavy menstrual bleeding
uterine fibroids uterine polyps adenomysosis endometriosis (rarely presents this way) 40-60% have no clear pathology on investigation
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what are uterine polyps
common benign localised growths of endometrium fibrous covered by columnar epithelium disordered cycles of apoptosis and regrowth = polyp malignancy is RARE
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describe the investigation of menorrhagia
1. FBC 2. TVUSS 3. endometrial biopsy if >45 + IMB + unresponsive to Tx 4. hysteroscopy if abnormal/concerning Ix
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what is post menopausal bleeding
bleeding that occurs after 1 year of amenorrhoea in a woman NOT receiving HRT
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name the causes of post menopausal bleeding
vaginal atrophy (most common) use of HRT endometrial hyperplasia endometrial cancer endometrial polyps cervical/ovarian cancer
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what is endometrial hyperplasia, how is it classified and what are the risk factors
abnormal proliferation of the endometrium atypical = premalignant condition without atypia = low risk of carcinoma risk factors = anything causing increased oestrogen
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how does endometrial hyperplasia present
abnormal vaginal bleeding: intermenstrual irregular menorrhagia post-menopausal +/- discharge
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how is endometrial hyperplasia investigated
endometrial biopsy = definitive diagnosis hysteroscopy and biopsy TVUS = can be used to distinguish between normal proliferation and hyperproliferation + indicate need for biopsy
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how is endometrial hyperplasia managed
without atypia: reassurance (cancer risk) address RFs WW progestogen treatment follow up and monitoring atypical: (30-40% progress to carcinoma) hysterectomy +/- salpingo-oophrectomy
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what is dysfunctional uterine bleeding
menorrhagia with no underlying cause diagnosis when other causes excluded use contraceptives to treat hysterectomy/endometrial ablation in severe cases
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how does ovarian torsion present
sudden onset severe unilateral pelvic pain pain constant and progressively worse nausea + vomiting localised tenderness palpable mass (not always)
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how is ovarian torsion investigated and managed
pelvic USS - TV ideal = whirlpool sign = free fluid in pelvis and oedema of ovary laparoscopic surgery = definitive diagnosis + detorsion and removal of ovary
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describe the complications of ovarian torsion
lead to loss of ovary necrotic = infected = abcess = sepsis = rupture = peritonitis = adhesions
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name some treatments for PMS
COCP containing dispirenone continuous use of the pill GnRH analogues to induce menopausal state + HRT hysterectomy + bilaterla oophorectomy + HRT danazole + tamoxifen for breast pain spirinolactone for oedema in PMS
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name the causes of hypogonadotrophic hypogonadism
= low LH low FSH low oestrogen hypopituitarism damage to hypothalamus/pituitary (surgery/radiation) chronic condition (IBD/cystic fibrosis) excessive diet or exercising or stress constitutional delay = temporary/no underlying pathology endocrine disorders (hypothyroid/cushings) kallman syndrome
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name the causes of hypergonadotrophic hypogonadism
high LH/FSH but low oestrogen previous damage to gonads = torsion/cancer/infections congenital absence of ovaries turners syndrome X0
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what is ashermans syndrome
adhesions in uterus following damage/surgery can distort pelvic organs and bind walls together/endocervix shut secondary amenorrhoea lighter periods dysmenorrhoea
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how is ashermans syndrome diagnosed and managed
hysteroscopy = gold standard hysterosalpingography = contrast injected and XR sonohysterography = uterus filled with fluid and USS MRI scan dissection of adhesions = treatment
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name some causes of oligomenorrhoea
pcos contraceptives/HRT perimenopause thyroid disease/diabetes eating disorders/excessive exercise medications = anti-psychotics or anti-epileptics
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when would anti D be given to mothers
to Rh -ve mothers: - abdo trauma - miscarriage after 12 wks - bleeding - 28 wks pregnant - after birth if baby is +ve
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what is a bishop score and what factors are included
= assessment of how likely a woman will go into labour - dilation of cervix - effacement of cervix (how thin) - consistency of cervix (soft/firm) - position of cervix - foetal station (how far up birth canal)
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what is tested for in a TORCH screening and when is it routinely performed
Toxoplasmosis Other (parvovirus) Rubella Cytomegalovirus Hepatitis routinely at 28 wks in all pregnancies
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name some indications for induction of labour
prolonged gestation 40-42+ wks PROM >37 (unless <37 then depending on baby and mother health, <34 = delay) maternal health - HTN/preeclampsia/DM etc foetal growth restriction intrauterine foetal death
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what are the contraindications for induction of labour/vaginal delivery
ABSOLUTE: cephalic disproportion major placenta praevia vasa praevia cord prolapse transverse lie acute primary genital herpes previous classical C section RELATIVE: breech triplet + 2+ low transverse C section
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what is the role of prostaglandins in labour
ripen cervix contraction of SM of uterus
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describe the 2 types of premature rupture of membranes
1. PROM = rupture at least 1hr prior to onset of labour >37 weeks occurs in 10-15% pregnancies minimal risk to mother and baby 2. Preterm PROM = rupture of membranes <37 weeks 2% pregnancies higher risk complications associated with 40% preterm deliveries
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what is the kleihauer test
checks how much foetal blood has passed to mother during sensitising event used after any sensitising event >20wks check to see if further doses anti-D needed
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how is preterm labour prevented
1. vaginal progesterone = decreases activity of myometrium and prevent cervix remodelling for delivery offered 16-24wks <25mm cervical length 2. cervical cerclage = stitch in cervix to support and keep closed removed when in labour given to 16-24wks <25mm and previous preterm can be given as rescue stitch
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what is preterm labour with intact membranes
painful regular contractions and cervical dilatation without rupture of amniotic sac requires speculum to assess dilatation requires management of preterm labour
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describe the management of preterm labour
- CTG - tocolysis with nifedipine (CCB suppresses labour) - maternal corticosteroids for foetal lungs - IV magnesium sulfate <34wks to protect fetal brain (CP) - delayed cord clamping/cord milking = increase baby blood volume/Hb at birth
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what is given to babies born <34 weeks
magnesium sulfate bolus then infusion for up to 24hrs following birth prevent cerebral palsy
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what needs to be monitored if mother is given IV MgSo4
magnesium toxicity at least 4 hrly - reduced RR - reduced BP - absent reflexes
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what is foetal hydrops
occurs in fetal parvovirus B19 infection parvovirus causes replication of erythoid progenitor cells in liver and BM = severe anaemia = high output cardiac failure = increased hepatic erythropoiesis = portal HTN and hypoproteinaemia = ascites
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how is foetal hydrops diagnosed and managed
diagnosis on USS: ascites subcutaneous oedema pleural effusion pericardial effusion scalp oedema polyhydroamnios treatment limited + high fetal mortality
264
describe the features of congenital rubella syndrome
congenital deafness congenital cataracts congenital heart disease (PDA and pulmonary stenosis) learning disability risk is higher earlier in pregnancy
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describe the management of rubella in pregnancy
<12 weeks = termination of pregnancy 12-20 weeks = prenatal diagnosis required, if fetal rubella confirmed = termination of pregnancy of USS surveillance of defects >20 weeks no action required
266
what is congenital cytomegalovirus
occurs due to CMV infection in mother spread by infected saliva/urine of asymptomatic children features: - fetal growth restriction - microcephaly - hearing loss - vision loss - learning disability - seizures
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what is congenital toxoplasmosis
toxoplasma gondii parasite spread by cat faeces risk is higher later in pregnancy TRIAD: 1. intracranial calcification 2. hydrocephalus 3. chorioentinitis (inflammation choroid and retina of eye)
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describe the complications of parvovirus in pregnancy
miscarriage/foetal death severe foetal anaemia hydrops fetalis maternal pre-eclampsia-like sydrome
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describe maternal pre-eclampsia-like syndrome
aka mirror syndrome rare complication of hydrops fetalis 1. hydrops fetalis 2. placental oedema 3. oedema in mother - HTN - proteinuria
270
describe the risk factors of GBS infection of the neonate
GBS in previous baby prematurity <37 weeks rupture of membranes >24hrs before delivery pyrexia during labour positive GBS in mother mother diagnosed with GBS UTI in pregnancy **give benpen
271
what are the indications for an instrumental delivery
failure to progress fetal distress maternal exhaustion control of the head in various fetal positions epidural = increased risk instrumental
272
what are the risks for the mother of an instrumental delivery
PPH episiotomy perineal tears injury to anal sphincter bladder/bowel incontinence nerve injury (obturator/femoral)
273
what are the risk to the baby of an instrumental delivery
cephalohaematoma with ventous facial nerve palsy with forceps serious: - subgaleal haemorrhage - intracranial haemorrhage - skull fracture - spinal cord injury
274
which type of twin pregnancy is most successful
diamniotic dichorionic
275
how does each type of twin present on USS
dichorionic diamniotic = membrane between + lamda/twin peak sign monochorionic diamniotic = membrane between + T sign monochorionic monoamniotic = no membrane separating
276
when do foetal movements begin to be felt
16-24 weeks generally after 20 weeks
277
what is the average birth weight of a healthy baby
3-4kg 6-8lbs
278
describe the difference between miscarriage and stillbirth
early miscarriage = <12 weeks late miscarriage = 12-24wks stillbirth = birth of a dead foetus after 24 weeks
279
describe the types malpresentation
most common = breech complete = hips and knees flexed frank = flexed at hips, extended at knees (most common) footling = one or both legs extended at hip, foot is presenting part oblique lie = head in iliac fossa transverse lie = lie across abdomen unstable lie = changes day to day
280
what is the best foetal position for vaginal delivery
occipito-anterior
281
which position is most associated with umbilical cord prolapse
footling breech
282
describe the usual position of the head at engagement
occipitotransverse
283
describe the important diameters in brow and face presentation
brow presentation = mentovertical face presentation = submentobregmatic
284
describe the management of breech birth
1. external cephalic version = manipulate foetus into cephalic pres. BUT contraindications 2. C section 3. vaginal delivery but requires highly skilled practitioners
285
how might breech presentation present
meconium stained liquor = foetal distress due to breech
286
what are the risk factors associated with obesity in pregnancy
gestational diabetes pre-eclampsia gestational HTN sleep apnoea macrosomia birth defects miscarriage preterm birth stillbirth
287
what are some risk factors for congenital anomalies
genetic factors socioeconomic factors (lack of access to healthcare) environmental factors (chemicals/medications) infections (rubella/syphillis) maternal nutrition (folic acid)
288
what are the most common congenital anomalies
heart defects neural tube defects downs syndrome
289
abortion is legal up until
24 weeks 1990 human fertilisation and embryology act
290
what are the legal requirements for an abortion
2 registered medical practitioners must agree carried out by registered practitioner in an NHS hospital/clinic
291
describe a medical abortion
mifepristone (anti-progestogen) = halt pregnancy/relax cervix misoprostol (prostaglandin analogue) = softens cervix/stimulate contractions rhesus negative = require antiD fetus will be expelled
292
describe a surgical abortion
under local/local+sedation/general give misoprostol/mifepristone before cervical dilation with suction (up to 14weeks) or forceps (14-24 weeks)
293
what is a hydatiform mole
= molar pregnancy = growing mass of tissue in uterus that will not develop into a baby complete hydatidiform mole = empty egg fertilised partial = 2 sperm 1 egg higher levels of hCG vaginal bleeding early in pregnancy diagnosed through USS and hCG need to be removed through tube into uterus and suction small risk of developing gestational trophoblastic neoplasia continual monitoring of hCG afterwards
294
what causes gonorrhoea and how does it present
gram negative diplococcus bacteria infecting mucous membranes of columnar epithelium can affect urethra/rectum/conjunctivwa/pharynx = STI females (90% sympt) vs males (50%): odourless purulent discharge dysuria pelvic pain/testicular pain
295
how is gonorrhoea diagnosed
nucleic acid amplification test NAAT to detect rna/dna of gonorrhoea charcoal endocervical/vulvovaginal/urethral/1st catch urine/rectal/pharyngeal swabs standard charcoal endocervical swab for microscopy/culture/sensitivities
296
how is gonorrhoea managed
high levels of antibiotic resistance single dose IM ceftriaxone 1g OR oral ciprofloxacin 500mg is sensitivities known need follow up test abstain from sex 7 days treat other STIs **consider safeguarding**
297
name some complications of gonorrhoea
PID chronic pelvic pain infertility epididymo-orchiditis conjunctivities neonatal gonococcal conjunctivitis during birth
298
what is a disseminated gonoccocal infection
= complication of gonorrhoea = bacteria spread to skin and joints various non-specific skin lesions polyarthralgia migratory polyarthritis tenosynovitis systemic symptoms
299
what is the danger of chicken pox in pregnancy
if immune = no problems not immune = given VZ Igs chickenpox <28 weeks = developmental problems chickenpox around delivery = dangerous neonatal infection = VZ Igs + aciclovir
300
what constitutes proteinuria
urine protein = Cr >30mg/mmol urine albumin = Cr >8mg/mmol
301
what is a strong indicator of rupture of membranes and where is it found
insulin-like growth factor protein binding 1 is found in amniotic fluid if present in vagina = strong indicator of RoM
302
what are the causes of PPH
Tone = most common Trauma Tissue - clots/retained products Thrombin - bleeding