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3a > Women's Health > Flashcards

Women's Health Flashcards

1
Q

Give 5 groups at high risk of developing pre-eclampsia:

A
  1. HTN, eclampsia or pre-eclampsia during previous pregnancies
  2. pre-existing CKD
  3. Autoimmune disease e.g. SLE or antiphospholipid syndrome
  4. Type 1 or 2 DM
  5. Chronic HTN
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2
Q

How does blood pressure vary throughout a normal pregnancy?

A

BP falls during the first trimester (particular diastolic)

Continues to fall until 20-24 weeks

BP then increases to pre pregnancy levels by term

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3
Q

How do you define pre-eclampsia?

A

Systolic BP >140
Diastolic BP >90
AND any of:
- proteinuria
- organ dysfunction (raised creatinine, elevated liver anzymes etc)
- placental dysfunctional (fetal growth restriction)

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4
Q

How do you categorise HTN in pregnancy? (3 groups)

A
  1. Pre-existing HTN = a Hx of HTN before pregnancy or elevated BP >140/90 before 20 weeks gestation
  2. Pregnancy related HTN = HTN after 20 weeks (occurs in 5-7% of pregnancies)
  3. Pre-eclampsia = pregnancy induced HTN in association with proteinuria of >0.3g in 24 hours
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5
Q

How is ‘moderate HTN’ defined in pregnancy?

A

150-159/100-109 mmHg

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6
Q

How do you manage moderate HTN in pregnancy?

A

Aim for BP equal to or less than 135/8

Once or twice weekly BP monitoring

Once or twice weekly urine dip

Weekly bloods (FBC, liver enzymes, U&Es)

PGIF testing once

Start Labetalol if remains high

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7
Q

How is ‘mild HTN’ defined in pregnancy?

A

140-149/90-99 mmHg

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8
Q

How do you manage mild HTN in pregnancy?

A
  1. Monitor BP at least 4 times a day

2. Twice weekly bloods - FBC, U&Es, creatinine, LFTs

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9
Q

How is ‘severe HTN’ defined in pregnancy?

A

≥160/110mmHG

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10
Q

How do you manage severe HTN in pregnancy?

A
  1. Monitor BP more than 4 times a day
  2. Start labetalol, aiming to keep systolic BP <150 and diastolic between 80-100
  3. Blood tests three times per week
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11
Q

What is the normal dose of folic acid required when trying to conceive and during pregnancy?

A

400 micrograms OD to be taken before conception and until week 12 of pregnancy

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12
Q

What dose of folic acid should someone on an antiepileptic drug take whilst they are trying to conceive?

A

5mg OD to be taken before conception and until week 12 of pregnancy

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13
Q

Give 6 long term complications of PCOS:

A
  1. Endometrial cancer
  2. Subfertility
  3. Diabetes
  4. Stroke/TIA
  5. Obstructive sleep apnoea
  6. Coronary artery disease
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14
Q

What is the most common cause of post-partum haemorrhage?

A

90% of cases are due to uterine atony

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15
Q

How do you initially manage PPH? (3)

A

ABCDE
Mechanical tx: rub uterus, catheterise
Medical tx: oxytocin, ergometrine, carboprost
Surgical tx

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16
Q

What is placenta praevia?

A

Placenta lying wholly or partially in the lower uterine segment

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17
Q

3 factors associated with placenta praevia:

A
  1. Multiparity
  2. Multiple pregnancy
  3. Previous c-section
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18
Q

When is placenta praevia normally identified? How is it diagnosed?

A

On routine 20 week abdo USS

Transvaginal USS is recommended to confirm diagnosis

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19
Q

Grading of placenta praevia I to IV:

A

I - placenta reaches lower segment but not the internal os

II - placenta reaches internal os but doesn’t cover it

III - placenta covers the internal os before dilation but not when dilated

IV (‘major’) - placenta completely covers the internal os

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20
Q

At what gestation should external cephalic version be recommended if a baby is breech?

A

36 weeks

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21
Q

What is primary dysmenorhoea?

A

Painful periods with no underlying pelvic pathology

Affects up to 50% of menstruating women

Excessive endometrial prostaglandin production is thought to be partially responsible

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22
Q

How do you manage primary dysmenhorrhoea?

A
  1. NSAIDS: mefenamic acid, ibuprofen

2. Second line: combined oral contraceptive

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23
Q

What is pelvic inflammatory disease?

A

Infection of the upper female genital tract including the uterus, fallopian tubes and ovaries

A common complication of STIs

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24
Q

3 risk factors for PID:

A
  1. Risk factors for acquiring an STI
  2. IUCD inserted in prev. 20 days
  3. Termination of pregnancy
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25
Q

5 signs/symptoms of PID:

A
  1. BIL lower abdominal pain
  2. Deep dyspareunia
  3. Abnormal vaginal bleeding (post-coital, intermenstrual, menhorrhagia)
  4. Mucopurulent cervical discharge and cervicitis on exam
  5. Cervical motion tenderness
  6. Adnexal tenderness
  7. +/- fever
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26
Q

When should someone with PID be admitted to hospital for treatment? (7)

A
  1. Diagnostic uncertainty
  2. Severe symptoms
  3. Failure of tx
  4. Pregnancy
  5. Tubo-ovarian abscess
  6. Deteriorating condition
  7. Immunodeficiency
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27
Q

Treatment of PID in primary care:

A

IM ceftriaxone 1g single dose AND doxycycline PO 100mg BD for 14 days AND metronidazole 400mg BD PO for 14 days

OR

IM ceftriaxone 1g single dose AND azithromycin 1g/week for 2 weeks

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28
Q

4 possible complications of PID (in a woman who is not currently pregnant):

A
  1. Infertility
  2. Ectopic pregnancy
  3. Chronic pelvic pain
  4. Perihepatitis
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29
Q

Complications of PID during pregnancy: (3)

A
  1. Preterm delivery
  2. Maternal and fetal morbidity
  3. Transmission of STI to neonate
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30
Q

3 risk factors for recurrent UTI:

A
  1. Use of spermicide
  2. Frequent sexual intercourse
  3. New sexual partner
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31
Q

Tx of UTI:

A

Trimethoprim 200mgBD for 3 days

Or

Nitrofurantoin 100mg modified release BD for 3 days

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32
Q

What prophylactic treatment can a patient experiencing recurrent cystitis associated with sex be given?

A

Low dose trimethoprim 100mg within two hours of sex

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33
Q

What prophylactic treatment can a patient experiencing recurrent cystitis NOT associated with sex be given?

A

Low dose trimethoprim for 6 months

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34
Q

7 risk factors for ectopic pregnancy:

A
  1. IVF
  2. Hx of pelvic infection/PID
  3. Adhesions from infection
  4. Inflammation from endometriosis
  5. Previous tubal surgery
  6. IUCDs
  7. Progesterone only contraceptive methods
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35
Q

Most common symptoms of ectopic pregnancy: (4)

A
  1. Abdominal pain
  2. Pelvic pain
  3. Amenorrhoea or missed period
  4. Vaginal bleeding
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36
Q

When should you offer surgical management of an ectopic pregnancy?

A

Those with any of the following:

  1. Significant pain
  2. Adnexal mass >35mm
  3. Fetal heartbeat visible on scan
  4. Serum hCG>5000 IU/L

NB: all those who have surgery need anti-D prohphylaxis

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37
Q

How do you medically manage an ectopic pregnancy?

A

Single dose of methotrexate

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38
Q

4 risk factors for ovarian cysts:

A
  1. Obesity
  2. Tamoxifen therapy
  3. Early menarche
  4. Infertility
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39
Q

How might torsion, infarction or rupture/haemorrhage of an ovarian cyst present?

A

Severe pain
Torsion may be intermittent with intermittent episodes of severe pain
Rupture of a large cyst may cause peritonitis and shock

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40
Q

4 investigations necessary when diagnosing an ovarian cyst:

A
  1. Pregnancy test
  2. FBC
  3. USS
  4. Cancer antigen 125 if post-menopausal
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41
Q

How do you manage ovarian cysts?

A

Small cysts tend to resolve within three menstrual cycles

Cysts 50-70mm in diameter should have yearly follow-up monitoring

Surgical removal if persistent and larger than 5-10cm or if haemorrhagic

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42
Q

Definition of an early miscarriage:

A

<12 weeks gestation

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43
Q

Definition of a late miscarriage:

A

13 to 24 weeks gestation

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44
Q

Risk factors for miscarriage: (5)

A
  1. advancing age
  2. smoking
  3. excess alcohol
  4. low pre-pregnancy BMI
  5. paternal age >45

and more..

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45
Q

How might a miscarriage present?

A

Vaginal bleeding and pain worse than the patient’s usual period pain

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46
Q

Name 5 causes of chronic pelvic pain:

A
  1. chronic PID
  2. endometriosis
  3. fibroids
  4. IBS or IBD
  5. PCOS
  6. Chronic interstitial cystitis
  7. adhesions
  8. adenomyosis
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47
Q

What does the combined test measure? When is it done?

A
  1. Nuchal translucency
  2. Serum B-HCG
  3. Pregnancy associated plasma protein A (PAPP-A)

Done at 10-14 weeks

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48
Q

What might the results of a combined test at 10-14 weeks show if the baby is likely to have Down’s syndrome?

A

Raised B-HCG
Low PAPP-A
Thickened nuchal translucency

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49
Q

What might the results of a combined test at 10-14 weeks show if the baby is likely to have Edwards or Patau syndrome?

A

Similar results to Down’s (raised HCG, low PAPP-A, thickened nucal translucency) but PAPP-A tends to be lower

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50
Q

Management of PCOS: (4)

A
  1. Weight loss
  2. COC pill
  3. Metformin
  4. Orlistat
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51
Q

Diagnostic criteria for PCOS: (3)

A

Rotterdam criteria

Two of the three following are diagnostic, assuming other causes have been excluded:

  1. Polycystic overies (12 or more peripheral follicles or increased ovarian volume >10cm3)
  2. Oligo-ovulaion or anovulation
  3. Clinical/biochemical signs of hyperandrogenism
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52
Q

8 symptoms of PCOS:

A
  1. Oligomenorrhoea (<9 periods/year)
  2. Infertility/subfertility
  3. Hirsutism
  4. Alopecia
  5. Obesity or difficulty losing weight
  6. Psychological symptoms (mood swings, depression, anxiety, poor self-esteem)
  7. Sleep apnoea
  8. Acne
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53
Q

What is Acanthosis nigricans? what can it be a sign of?

A

dry, dark patches of skin that usually appear in the armpits, neck or groin

PCOS

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54
Q

PCOS investigations and results: (4)

A
  1. Testosterone: normal/raised
  2. SHBG: normal/low
  3. LH: elevated with LH:FSH ratio increased
  4. UUS: characteristic ovaries
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55
Q

What is the most appropriate action following a cervical smear with the results:
HPV positive
cytology normal

A

Repeat smear in 1 year

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56
Q

What is the most appropriate action following a cervical smear with the results:
HPV negative
Cytology normal

A

No further analysis needed, attend next routine screening in 3 years time (if 25-49) or 5 years time (if 50-64)

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57
Q

What is the most appropriate action following a cervical smear with the results:
HPV positive
Abnormal cytology

A

Refer to colposcopy with 2 week wait or 18 week wait depending on severity

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58
Q

How does HRT affect your risk of endometrial and breast cancer?

A

Unopposed oestrogen HRT:

  • Increased risk of endometrial cancer
  • Increased risk of breast cancer (but less of an increase than combined HRT)

Combined oestrogen and progesterone HRT:

  • Decreased risk of endometrial cancer in patients with a uterus
  • Increased risk of breast cancer
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59
Q

4 common symptoms of endometriosis:

A
  1. Dysmenorrhoea
  2. Dyspareunia
  3. Cyclical or chronic pelvic pain
  4. Subfertility
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60
Q

Diagnostic criteria for gestational diabetes:

A

Fasting plasma glucose level of 5.6 mmol/L or above

OR

Two-hour plasma glucose levle of 7.8 mmol/L or above

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61
Q

Risk factors for gestational diabetes: (5)

A
  1. increasing age
  2. smoking
  3. high BMI before pregnancy
  4. short interval between pregnancies
  5. family hx

& more

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62
Q

Who should be screened for gestational diabetes? (5)

A

Women with the following risk factors:

  1. BMI >30
  2. Previous GDM
  3. Previous macrosomic baby >4.5kg
  4. First degree relative with GDM
  5. Family origin with high prevalence of DM (south asian, black caribbean, middle eastern)
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63
Q

How is GDM managed?

A

First line: exercise and diet changes (if fasting glucose is below 7 at diagnosis)

Second line: metformin

Third line: Add insulin

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64
Q

How does a diagnosis of GDM affect advice about labour?

A

Women with GDM should give birth no later than 40+6 weeks, offer elective birth or induction if they haven’t given birth by this time

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65
Q

At what point in the menstrual cycle should a copper coil be inserted?

A

At any point - it can also be fitted immediately after a 1st or 2nd trimester abortion and from 4 weeks post partum

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66
Q

What is endometriosis?

A

A condition where there is ectopic endometrial tissue outside the uterus

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67
Q

What is a ‘cholocate cyst’?

A

An endometrioma (lump of endometrial tissue) in the ovaries

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68
Q

What is adenomyosis?

A

Endometrial tissue within the myometrium (muscular layer) of the uterus

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69
Q

What is retrograde menstruation?

A

The theory that during menstruation the endometrial lining flows backwards through the Fallopian tubes and out into the pelvis and peritoneum - resulting in endometriosis

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70
Q

5 signs/symptoms of endometriosis:

A
  1. Cyclical chronic pelvic pain
  2. Dysmenorrhoea
  3. Deep dysparenia
  4. Subfertility
  5. Pain on passing stool
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71
Q

3 signs on examination of endometriosis:

A
  1. Endometrial tissue visible in the vagina on speculum exam
  2. A fixed cervix on bimanual examination
  3. Tenderness in the vagina, cervix and adnexa
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72
Q

What is the gold standard diagnostic test for endometriosis?

A

Biopsy of lesions during laproscopic surgery

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73
Q

Management of endometriosis: (3)

A
  1. Analgesia - NSAIDs
  2. Hormonal management - coc, pop etc.
  3. Laproscopic surgery to excise or ablate endometrial tissue (this will also help improve fertility as well as pain etc.)
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74
Q

What are fibroids?

A

Benign tumours of the smooth muscle of the uterus

AKA uterine leiomyomas

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75
Q

What hormone are fibroids sensitive to?

A

Oestrogen

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76
Q

4 types of fibroid:

A
  1. Intramural - within the myometrium, distort the shape of the uterus as they grow
  2. Subserosal - just below the outer serosal layer, can become very large and fill the abdo cavity
  3. Submucosal - just below the endometrium
  4. Pedunculated - on a stalk
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77
Q

7 symptoms of fibroids:

A

Often asymptomatic but may present with:

  1. Heavy menstrual bleeding
  2. Prolonged menstruation (>7 days)
  3. Abdo pain, worse during menstruation
  4. Bloating/feeling full
  5. Urinary/bowel symptoms due to pelvic pressure
  6. Deep dyspareunia
  7. Reduced fertility
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78
Q

3 possible investigations used for diagnosing fibroids:

A
  1. Hyteroscopy for submucosal fibroids presenting with heavy bleeding
  2. Pelvic USS for larger fibroids
  3. MRI scan before surgery to establish size, blood supply, shape
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79
Q

Non-surgical treatment of menorrhagia secondary to small fibroid (<3cm):

A
  1. Mirena coil
  2. NSAIDs e.g. mefenamic acid
  3. Hormonal contraception e.g. coc
  4. Tranexamic acid
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80
Q

Surgical options for smaller fibroids with heavy menstrual bleeding:

A
  1. Endometrial ablation
  2. Resection of submucosal fibroids during hysteroscopy
  3. Hysterectomy
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81
Q

What type of drugs are goserelin and leuprorelin? What can they be used for?

A

GnRH agonists, used to reduce the size of fibroids before surgery

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82
Q

4 complications of fibroids:

A
  1. Reduced fertility
  2. Bladder & bowel complications (constipation, UTIs)
  3. Red degeneration of fibroid
  4. Torsion of fibroid
  5. Malignant change of fibroid to a leiomyosarcoma
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83
Q

What is red degeneration of fibroids?

A

Ischaemia, infarction and necrosis of a fibroid due to disrupted blood supply

More common in larger fibroids (>5cm) and during the 2nd and 3rd trimesters of pregnancy

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84
Q

How does red degeneration of a fibroid present? (4)

A
  1. Severe abdo pain
  2. Low grade fever
  3. Tachycardia
  4. Vomiting
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85
Q

How do you manage red degeneration?

A

Supportive tx: rest, fluids, analgesia

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86
Q

3 complications of gestational diabetes:

A
  1. Large for dates fetus
  2. Macrosomia causing sholder dystocia at birth
  3. Mum has a higher risk of DM2 after pregnancy
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87
Q

Any pregnant woman with risk factors for gestational diabetes should be screened at 24-29 weeks, what are these risk factors? (5)

A
  1. Previous gestational diabetes
  2. Previous macrosomic baby (≥4.5kg)
  3. BMI >30
  4. Ethnic origin (black Carribean, middle eastern, south asian)
  5. Family hx of diabetes (first degree relative)
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88
Q

What is the screening test of choice for gestational diabetes?

A

oral glucose tolerance test (OGTT)

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89
Q

3 signs that suggest gesational diabetes:

A
  1. large for dates fetus
  2. polyhydramnios
  3. glucose on urine dipstick
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90
Q

What are the cut off values for gestational diabetes?

A

OGTT results of:
fasting glucose >5.6 mmol/L

2 hours after >7.8mmol/L

NB: remember 5-6-7-8

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91
Q

How is the OGTT conducted for screening for gestational diabetes?

A

In the morning, take two readings:

  1. Fasted
  2. Two hours after drinking a 75g glucose drink
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92
Q

In a woman with gestational diabetes and a fasting glucose of less than 7 mmol/L, what should the first line management be?

A

Trial of diet and exercise for 1-2 weeks

Followed by metformin and then insulin if necessary

All women with GD also need four weekly USS to monitor fetal growth and amniotic fluid from 28 to 36 weeks

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93
Q

In a woman with gestational diabetes and a fasting glucose of more than 7 mmol/L, what should the first line management be?

A

Start insulin +/- metformin

All women with GD also need four weekly USS to monitor fetal growth and amniotic fluid from 28 to 36 weeks

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94
Q

In a woman with gestational diabetes and a fasting glucose of more than 6 mmol/L with macrsomia (or other complications) what should the first line treatment be?

A

Insulin +/- metformin

All women with GD also need four weekly USS to monitor fetal growth and amniotic fluid from 28 to 36 weeks

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95
Q

A woman with gestational diabetes can’t tolerate metformin - what drug might you give her instead?

A

Glibenclamide (a sulfonylurea)

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96
Q

What dose of folic acid should a woman with pre-existing diabetes take whilst trying to get pregnant?

A

5mg from preconception until 12 weeks gestation

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97
Q

At what gestation should retinopathy screening take place in a pregnant woman with pre-existing diabetes?

A

28 weeks

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98
Q

How does delivery differ for women with pre-existing versus gestational diabetes?

A

Pre-existing: advised to have a planned delivery between 37 and 38+6 weeks

Gestational: can give birth up to 40+6

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99
Q

Babies of mothers with diabetes are at risk of: (5)

A
  1. Neonatal hypoglycaemia
  2. Polycythaemia (raised Hb)
  3. Jaundice
  4. Congenital heart disease
  5. Cardiomyopathy
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100
Q

How soon after delivery can a woman with gestational diabetes stop her medications?

A

Straight after birth BUT they must continue measuring their sugars for at least 6 weeks after

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101
Q

Babies of mothers with gestational diabetes are at risk of neonatal hypoglycaemia, how do you manage this risk?

A

Regular blood glucose checks

Frequent feeds

If blood sugar dips below 2mmol/L may need IV dextrose and NG feeding

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102
Q

What are the blood sugar targets for gestational diabetes:

  • fasting
  • 1 hour post meal
  • 2 hours post meal
A

Fasting: 5.3
1 hour post-meal: 7.8
2 hours post-meal: 6.4

Avoiding levels of 4mmol/L or below

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103
Q

What type of insulin is used in pregnancy? Why?

A

Short acting insulin is used.

Long acting insulin is associated with adverse birth outcomes and can lead to maternal hypoglycaemia.

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104
Q

What does high elvels of fetal fibronectin (fFN) indicate?

A

fFN is a protein that is released from the gestational sac, high levels are associated with early labour

Depending on the level you can calculate the probability of labour within one week, two weeks etc.

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105
Q

How should you manage blood sugar levels during labour in a woman with pre-existing type 1 DM?

A

Sliding-scale insulin regime: dextrose and insulin infusion is titrated to blood sugar levels according to local protocol

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106
Q

How might a woman with pre-existing DM2 be asked to change her diabetes medication during pregnancy?

A

Stop all oral hypoglycaemic agents except for metformin

Commence of insulin

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107
Q

Which oral hypoglycemics are safe to use when breastfeeding?

A

Metformin is safe

Do NOT use sulfonylureas e.g. gliclazide (theoretical risk of neonatal hypoglycaemia)

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108
Q

What is pre-eclampsia?

A

New high blood pressure after 20 weeks gestation where the spiral arteries have formed abnormally leading to high vascular resistance in the vessels

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109
Q

Triad of pre-eclampsia:

A
  1. HTN
  2. Proteinuria
  3. Oedema
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110
Q

What is eclampsia?

A

When seizures occur as a result of pre-eclampsia

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111
Q

7 symptoms of pre-eclampsia:

A
  1. headache
  2. visual disturbance or blurriness
  3. N&V
  4. upper abdo or epigastric pain (due to liver swelling)
  5. oedema
  6. reduced urine output
  7. brisk reflexes
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112
Q

NICE guidlines (2019) for diagnosing pre-eclampsia:

A 
Systolic BP >140
Diastolic BP>90
Plus any of:
- proteinuria 
- organ dysfunction
- placental dysfunction
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113
Q

3 ways of checking proteinuria in pre-eclampsia:

A
  1. Urine dipstick 1+ or above
  2. protein:creatinine ratio 30mg/mmol or above
  3. albumin:creatinine 8mg or above
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114
Q

What is placental growth factor (PlGF)? What is it used as an indicator of in pregnancy?

A

A protein released by the placenta that functions to stimulate the development of new blood vessels

In pre-eclampsia PlGF levels are low, NICE recommends checking levels between 20 and 35 weeks to rule out pre-eclampsia

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115
Q

How is pre-eclampsia prevented from developing in pregnancy?

A

Aspirin (75-150mg OD) is given from 12 weeks gestation to women with:

  • A single high risk factor
  • Two or more moderate risk factors

All pregnant women are routinely monitored at every antenatal appt:

  • BP
  • Symptoms
  • Urine dipstick
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116
Q

Once gestational HTN without proteinuria is identified, how do you manage the risk of pre-eclampsia?

A
  1. Treat HTN with aim of BP below 135/85
  2. Urine dipstick at least weekly
  3. Monitor bloods weekly
  4. Monitor fetal growth
  5. PlGF testing on one occaison
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117
Q

At what BP should you admit a woman with gestational HTN (without proteinuria)?

A

above 160/110

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118
Q

Name two scoring systems used to determine whether to admit a woman with pre-eclampsia:

A

fullPIERS

PREP-S

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119
Q

How do you monitor pre-eclampsia if the woman is not going to be admitted?

A
  1. BP monitored at least every 48 hours

2. USS of fetus, amniotic fluid and dopplers weekly

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120
Q

What antihypertensive is used first line in pre-eclampsia?

What is used 2nd and 3rd line?

A

1st: Labetolol
2nd: Nifedipine
3rd: Methyldopa

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121
Q

What steps might be taken during labour to support a woman with pre-eclampsia? (3)

A
  1. IV hydralazine as antihypertensive in critical care due to severe pre-eclampsia or eclampsia
  2. IV magnesium sulphate during labour and for 24hrs after to prevent seizures
  3. Fluid restriction during labour in severe pre-eclampsia and eclampsia
  4. Monitor BP closely after birth, should return to normal once placenta is removed
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122
Q

BP should return to normal after labour in women with pre-eclampsia - what anti-HTN medications might be used after delivery?

A
  1. Enalapril first line
  2. Nifedipine or amlodipine first line in black African or Carribean patients
  3. Labetolol or atenolol third line
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123
Q

What is HELLP syndrome?

A

A combination of features that occur as a complication of pre-eclampsia and eclampsia:

Haemolysis
Elevated Liver enzymes
Low Platelets

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124
Q

9 Risk factors for pre-eclampsia:

A 
Moderate Risk:
- Age 40 or above
- Nulliparity
- Pregnancy interval of more than 10 years 
- Family hx of pre-eclampsia
- multiple pregnancy
- BMI more than or equal to 35
High Risk:
- Prev hx of pre-eclampsia
- Pre-existing HTN or other vascular disease
- Pre-existing renal disease/CKD
- diabetes
- autoimmune disease (SLE, antiphospholipid syndrome)
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125
Q

At what gestations are women routinely screened for anaemia during pregnancy? (2)

A
  1. Booking clinic

2. 28 weeks gestation

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126
Q

Anaemia is often asymptomatic in pregnancy - but what symptoms could you potentially see? (4)

A
  1. SOB
  2. Fatigue
  3. Dizziness
  4. Pallor
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127
Q

Normal ranges for Hb during at:

  • Booking clinic
  • 28 weeks gestation
  • Post partum
A

Booking clinic: >110 g/L
28 weeks: >105 g/L
Post partum: >100g/L

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128
Q

What might cause a normal MCV anaemia in pregnancy?

A

May indicate a physiological anaemia due to increased plasma volume during pregnancy

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129
Q

What might cause a low MCV anaemia in pregnancy?

A

Iron deficiency

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130
Q

What might cause a raised MCV anaemia in pregnancy?

A

B12 or folate deficiency

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131
Q

When during pregnancy are women screened for sickle cell and thalassaemia? Why?

A

At the booking clinic, because both are significant causes of anaemia during pregnancy

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132
Q

How do you manage low B12 levels in pregnant women? (2)

A
  1. Test for pernicious anaemia (by checking intrinsic factor antibodies)
  2. Refer to haematology for possible treatment with:
    - IM hydroxycobalamin injections
    - Oral cyanobalamin tablets
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133
Q

What is obstetric cholestasis?

A

A common complication of pregnancy

AKA intrahepatic cholestasis of pregnancy

Comprises of reduced outflow of bile acids from the liver

Resolves after delivery

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134
Q

When does obstetric cholestasis typically develop?

A

Later in pregnancy (i.e. after 28 weeks) as a result of increased oestrogen and progesterone levels

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135
Q

How does obstetric cholestasis present? (5)

A

Main symptom: - Itching of palms of hands and soles of feet

Other symptoms:

  • Fatigue
  • Dark urine
  • Pale, greasy stools
  • Jaundice

NB: There is NO rash associated, if you see a rash think about an alternative diagnosis e.g. polymorphic eruption of pregnancy

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136
Q

Investigations required and results seen in obstetric cholestasis:

A
  1. LFTS: abnormal, mainly AST, ALT and GGT

2. Bile acids: raised

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137
Q

How do liver anzymes change during normal pregnancy?

A

ALP rises because the placenta produces ALP

A rise in ALP without other abnormal LFT results is usually not pathological

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138
Q

How do you treat obstetric cholestasis?

A
  1. Ursodeoxycholic acid - improves LFTs, bile acids and symptoms
  2. Emolients for itching
  3. Antihistamines can help sleeping
  4. Water soluble vitamin K if prothrombin time is deranged
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139
Q

How should you monitor a woman with obstetric cholestasis?

A
  1. Weekly LFTS
  2. LFTs 10 days after delivery
  3. Consider planned delivery at 37 weeks

NB: risk of stillbirth

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140
Q

What is the most prevalent and active version of oestrogen?

A

17-beta oestradiol

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141
Q

Oestrogen acts on tissues with oestrogen receptors to promote female secondary sexual characteristics. This includes stimulating…(4)

A
  1. Breast tissue development
  2. Growth and development of female sex organs at puberty (vulva, vagina, uterus)
  3. Blood vessel development in the uterus
  4. Development of the endometrium
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142
Q

Where is progesterone produced in pregnancy?

A

Initially produced by the corpus luteum after ovulation

Mainly produced by the placenta from 10 weeks gestation onwards

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143
Q

3 actions of progesterone:

A
  1. Thicken and maintains the endometrium
  2. Thickens cervical mucus
  3. Increases body temp
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144
Q

Summarise what happens in the ovaries during the pre-ovulatory phase of menstruation (AKA follicular phase): (7 steps)

A
  1. FSH and LH trigger follicle development
  2. Follicles release oestrogen
  3. Oestrogen causes a drop in FSH and LH
  4. Follicles die EXCEPT for the dominant follicle
  5. Dominant follicle secretes lots of oestrogen
  6. Peak in oestrogen triggers secretion of LOTS of FSH and LH (black magic)
  7. High FSH and LH causes rupture and release of oocyte from dominant follicle = OVULATION
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145
Q

What happens in the cervix during the pre-ovulatory phase of menstruation (AKA menstrual and proliferative phases)?

A
  1. Days 0 to 5 = bleeding, shedding of the old endometrium
  2. Day 5 onwards, high oestrogen causes:
    - Proliferation of endometrium
    - Spiral arteries grow
    - Mucus consistency changes
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146
Q

What happens in the post-ovulatory phase (luteal phase) in the ovaries?

A
  1. Remnants of the old follicle becomes the corpus luteum
  2. Corpus luteum secretes LOTS of progesterone, some inhibin and some oestrogen
  3. Inhibin and prgesterone suppress release of FSH and LH
  4. Oestrogen continues to decline
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147
Q

What happens in the cervix during the post-ovulatory phase?

A
  1. High progesterone levels promote growth of the spiral arteries and secretion of mucus
  2. Eventually once the window for fertilisation closes oestrogen and progesterone fall very low
  3. This causes:
    - Mucus to thicken
    - Corpus luteum degenerates
    - Spiral arteries degenerate
    - Endometrium prepares for shedding
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148
Q

What does ‘para’ mean?

A

Number of time a woman has given birth after 24 weeks gestation regardless of outcome

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149
Q

What does multiparous mean?

A

A patient who has given birth after 24 weeks two or more times

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150
Q

What does gravida mean?

A

Total number of pregnancies

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151
Q

How long is the first trimester?

A

Start of pregnancy to 12 weeks

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152
Q

How long is the second trimester?

A

13 weeks to 26 weeks

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153
Q

how long is the third trimester?

A

27 weeks till birth

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154
Q

At what gestation do fetal movements start?

A

20 weeks

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155
Q

When does the booking clinic occur? What does it involve?

A

Before 10 weeks, baseline assessment and plan the pregnancy

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156
Q

When is the dating scan done?

A

Between 10 and 13+6 weeks gestation

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157
Q

How is gestational age calculated?

A

From the crown rump length (CRL), measured at the dating scan between 10 and 13+6 weeks

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158
Q

At what gestation is the first antenatal appointment?

A

16 weeks

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159
Q

When is the anomly scan?

A

Between 18 and 20+6 weeks gestation

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160
Q

At how many weeks gestations are all the antenatal appointments?

A

10 appointments:

16, 25, 28, 31, 34, 36, 38, 40, 41, 42

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161
Q

What is the order of all the key appoinments during pregnancy?

A 
Booking clinic (<10)
Dating Scan (10-13+6)
First antenatal appt (16)
Anomaly scan (18-20+6)
All other antenatal appts (25, 28, 31, 34, 36, 38, 40, 41, 42)
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162
Q

Give 5 things that might be done at a routine antenatal appointment:

A
  1. Symphysis-fundal height measurement from 24 weeks onwards
  2. Fetal presentation assessment from 36 weeks onwards
  3. Urine dipstick for protein
  4. BP
  5. Urine MC&S
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163
Q

What two vaccines are offered to all pregnant women?

A
  1. Whooping cough (pertussis) from 16 weeks
  2. Influenza in autumn/winter

NB: Avoid live vaccines e.g. MMR

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164
Q

What is the normal course of symptoms of nausea during pregnancy?

A

N&V begins at 4-7 weeks

At its worst at 10-12 weeks

Resolves by 16-20 weeks

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165
Q

What is thought to cause nausea in pregnancy?

A

hCG produced by the placenta

higher levels = worse symptoms

therefore, high levels of hCG in molar and multiple pregnancies leads to worse N&V

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166
Q

Risk factors for severe N&V during pregnancy: (4)

A
  1. Multiple pregnancy
  2. Molar pregnancy
  3. Overweight/obese
  4. First pregnancy
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167
Q

3 criteria for diagnosing hypermesis gravidarum:

A
  1. More than 5% weight loss compared with before pregnancy
  2. Dehydration
  3. Electrolyte imbalance
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168
Q

What scoring system is used to assess vomiting in pregnancy?

A

Pregnancy-Uniwue Quantification of Emesis (PUQE)

Scoring:
<7 mild
7-12 moderate
>12 severe

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169
Q

Give 4 antiemetics used in pregnancy in order of preference and known safety

A
  1. Prochlorperazine (stemetil)
  2. Cyclizine
  3. Ondansetron
  4. Metoclopramide
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170
Q

Two drugs used to treat acid reflux in pregnancy:

A

Ranitidine

Omeprazole

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171
Q

When should you consider admission to hospital with hypermesis gravidarum? (4)

A
  1. Unable to tolerate oral anti-emetics or keep down any fluids
  2. More than 5% weight loss compared with pre-pregnancy
  3. Ketones in urine on dipstick
  4. Other medical conditions that need treating that required admisstion
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172
Q

Management of hyperemesis gravidarum in hospital:

A
  1. IV or IM anti-emetics
  2. IV fluids
  3. Daily U&Es
  4. Thiamine supplementation
  5. TED stocking and LMWH whilst admitted
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173
Q

What medication can be given to shrink fibroids?

A

GnRH agonists for short-term reduction in fibroid size e.g. triptorelin

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174
Q

What is shoulder dystocia?

A

An obstetric emergency in which the anterior shoulder of the baby becomes stuck behind the pubic symphysis after the head has been delivered

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175
Q

What is the turtle neck sign seen in labour?

A

Occurs in shoulder dystocia

The head is delivered but then retracts back into the vagina

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176
Q

What is failure of restitution?

A

Where the head remains facing downwards (OA) and does not turn sidewards as expected after delviery of the head

Occurs in shoulder dystocia

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177
Q

Give 6 possible ways to manage shoulder dystocia:

A
  1. Episiotomy
  2. Mcroberts manoeuvre
  3. Pressure to the anterior shoulder by pressing on the suprapubic region of the abdomen
  4. Rubins manoeuvre
  5. Wood screw’s manouvre
  6. Zavanelli manoeuver
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178
Q

What is zananelli’s manoever and when is it used?

A

Used in shoulder dystocia

Involves pushing the baby’s headback into the vagina so it can be delivered by emergency c-section

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179
Q

What are rubin and wood’s screw manoeuvres? When are they used?

A

Involves reaching into the vagina with two hands to manipulate the baby’s shoulder and help delivery during shoulder dystocia

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180
Q

What is McRobert’s Manouevre? When is it used?

A

The mum brings her knees to her abdomen providing a pelvic tilt that lifts the pubic symphysis out of the way if the baby is experiencing shoulder dystocia

= supine with both hips fully flexed and abducted

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181
Q

4 key complications of should dystocia:

A
  1. Fetal hypoxia
  2. Brachial plexus injury and Erb’s palsy
  3. Perineal tears
  4. Postpartum haemorrhage
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182
Q

What causes Erb’s palsy?

A

Damage to the upper brachial plexus most commonly due to shoulder dystocia

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183
Q

How does Erb’s palsy present?

A

With the waiter’s tip sign: adduction and internal rotation of the arm, pronation of the forarm

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184
Q

Give 8 indications for elective c-section:

A
  1. previous c-section
  2. symptomatic after prev significant perineal tear
  3. placenta praevia
  4. vasa praevia
  5. breech presentation
  6. multiple pregnancy
  7. uncontrolled HIV
  8. cervical cancer
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185
Q

At what gestation are elective c-sections performed and under what kind of anaesthetic?

A

after 39 weeks, spinal

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186
Q

What are the four categories for c-sections?

A

1: threat to life of mum or baby, must deliver in 30 mins of decision
2: urgent but no threat to life, deliver in 75 mins
3: delivery required but mum and baby are stable
4: elective

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187
Q

Layers of the abdomen dissected during c-section: (7)

A
  1. skin
  2. subcutaneous tissue
  3. Rectus sheath
  4. rectus abdominis muscles
  5. peritoneum
  6. vesicouterine peritoneum
  7. uterus
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188
Q

4 medications given previous to c-section to reduce risk of complications:

A
  1. PPI or H2 receptor antagonists (risk of aspiration pneumonia due to reflux when lying flat)
  2. Prophylactic antibiotics
  3. Oxytocin (reduces risk of PPH)
  4. VTE with LMWH
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189
Q

4 risks to future pregnancies increased by having a c-section:

A
  1. repeat c-section
  2. uterine rupture
  3. placenta praevia
  4. still birth
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190
Q

3 contraindications to vaginal birth after c-section (VBAC):

A
  1. Prev. uterine rupture
  2. Vertical (classical) scar
  3. Other usual contraindications to vaginal delivery e.g. placental praevia
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191
Q

VTE prophylaxis following c-section involves 3 things:

A
  1. Early mobilisation
  2. TED stockings or flowtrons
  3. LMWH e.g. enoxaparin
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192
Q

6 risk factors for perineal tears:

A
  1. First birth
  2. Large baby (>4kg)
  3. Shoulder dystocia
  4. Asian ethnicity
  5. OP position
  6. Instrumental delivery
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193
Q

First degree perineal tear:

A

Injury limited to the frenulum of the labia minora and superficial skin

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194
Q

Second degree perineal tear:

A

Includes the perineal muscles but does not affect the anal sphincter

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195
Q

Third degree perineal tear:

A

Includes the anal sphincter but does not affect the rectal mucosa

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196
Q

Fourth degree perineal tear:

A

Includes the rectal muscosa

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197
Q

How are third degree tears sub-categorised?

A

3A - less than 50% of external anal sphincter affected

3B - more than 50% of external anal sphincter affected

3C - external and internal anal sphincter affected

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198
Q

How do you manage perineal tears surgically?

A

First degree are unlikely to require sutures

Larger than a first degree tear will require sutures but this may not need to be done in theatre

Third and fourth degree tears likley need reparing in theatre

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199
Q

Aside from suturing, how are perineal tears managed? (5)

A
  1. Broad spectrum abx
  2. Laxatives
  3. Physiotherapy
  4. Follow up minotring
  5. Offer elective c-section for subsequent pregnancies if 3rd or 4th degree tear
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200
Q

How can perineal tears be avoided?

A

Perineal massage can be done from 34 weeks onwards to prepare and stretch the tissue before delivery

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201
Q

What is the most significant risk factor for cord prolapse?

A

Abnormal lie after 37 weeks gestation

This allows space for the cord to prolapse below the presenting part, whereas in cephalic presentation the head descends into the pelvis leaving no room for the cord to descend

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202
Q

What is cord prolapse?

A

When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after the rupture of the membranes

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203
Q

Why is cord prolapse an emergency?

A

The cord is at high risk of being compressed by the presenting part of the baby, resulting in fetal hypoxia

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204
Q

How is cord prolapse diagnosed?

A
  1. Signs of fetal distress on CTG
  2. Vaginal exam
  3. Speculum exam
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205
Q

How do you manage a prolapsed cord?

A

Emergency c-section:

  • Mum in left lateral position or on all fours (this position uses gravity to draw the presenting part of the baby away from the pelvis and reduce compression of the cord)
  • Push presenting part of baby upwards to prevent cord compression or fill bladder to same effect
  • Give tocolytic medication e.g. terbutaline to minimise contractions whilst waiting for delivery
  • Keep the cord warm and wet
  • Handle the cord minimally (causes vasospasm)
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206
Q

More than half of all cord prolapses occur in women who have had what procedure?

A

Artificial rupture of membranes

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207
Q

3 things that reduce the risk of cord prolapse:

A
  1. cephalic position
  2. nulliparity
  3. prolonged pregnancy
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208
Q

At what gestation is induction offered?

A

Between 41 and 42 weeks

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209
Q

Other than at 41-42 weeks, why else might induction be offered? (6)

A

Due to:

  1. Prelabour rupture of membranes
  2. Fetal growth restriction
  3. Pre-eclampsia
  4. Obstetric cholestasis
  5. Diabetes
  6. Intrauterine fetal death
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210
Q

What scoring system is used to decide whether to induce labour?

A

Bishop score

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211
Q

What five things are assessed in the bishop score?

A
  1. fetal station
  2. cervical position
  3. cervical dilatation
  4. cervical effacement
  5. cervical consistency
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212
Q

What does a Bishop score of 8 or more indicate?

A

Predicts a successful induction of labour

A score below this suggests cervical ripening may be required to prepare the cervix

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213
Q

How is labour induced when intrauterine fetal death has occurred?

A

Oral mifepristone and misoprostol

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214
Q

4 options for induction of labour and why you would choose each one:

A
  1. Membrane sweep - used from 40 weeks, in antenatal clinic, should produce onset of labour within 48hrs
  2. Vaginal prostaglandin E2 pessary - done in a hospital setting
  3. Cervical ripening balloon - used when vaginal prostaglandins are not preferred e.g. in women with prev c-section or multiparous women
  4. Artificial rupture of membranes with an oxytocin infusion - used if vaginal prostaglandins are contraindicated or haven’t produced enough progress yet
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215
Q

Four options for if induction of labour causes slow or no progress:

A
  1. Further vaginal prostaglandins
  2. Artificial rupture of membranes and oxytocin infusion
  3. Cervical ripening balloon (CRB)
  4. Elective caesarean section
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216
Q

What is uterine hyperstimulation? What causes it?

A

Induction of labour with vaginal prostaglandins can cause uterine hyperstimulation.

Uterus contractions are prolonged and frequent, causing fetal distress and possible uterine rupture

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217
Q

Criteria for uterine hyperstimulation:

A

Individual contractions lasting more than two minutes

or

More than five contractions every 10 mins

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218
Q

How do you manage uterine hyperstimulation?

A
  1. Remove vaginal prostaglandins/stop oxytocin

2. Tocolysis with terbutaline

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219
Q

What antibiotic is given after an instrumental delivery?

A

Single dose of co-amoxiclav to reduce the risk of maternal infection

220
Q

3 key indications for instrumental delivery:

A
  1. failure to progress
  2. fetal distress
  3. maternal exhaustion
221
Q

What type of analgesia during labour can increase the risk of requiring instrumental delivery?

A

Epidural

222
Q

5 increased risks to the mum as a result of instrumental delivery:

A
  1. PPH
  2. Episiotomy
  3. Perineal tears/anal sphincter injury
  4. Incontinence of bowel/bladder
  5. Nerve injury (obturator or femoral)
223
Q

6 increased risks to the baby as a result of an instrumental delivery:

A
  1. Cephalohaematoma with ventouse
  2. Facial nerve palsy with forceps
  3. Subgaleal haemorrhage (most dangerous)
  4. Intracranial haemorrhage
  5. Skull fracture
  6. Spinal cord injury
224
Q

7 requirements for an instrumental delivery: (FORCEPS)

A 
F - fully dilated cervix
O - OA or OP position
R - ruptured membranes
C - cephalic position
E - engaged presenting part 
P - pain relief
S - sphincter, bladder empty and catheterised
225
Q

What is placenta praevia?

A

Where the placenta is attached to the lower portion of the uterus, lower than the presenting part of the fetus

226
Q

3 key causes of antepartum haemorrhage:

A
  1. Placenta praevia
  2. Placental abruption
  3. Vasa praevia
227
Q

3 causes of spotting or minor bleeding in pregnancy:

A
  1. Cervical ectropion
  2. Infection
  3. Vaginal abrasions from intercourse or procedures
228
Q

5 risks increased by placenta praevia:

A
  1. Antepartum haemorrhage
  2. Emergency c-section
  3. Maternal anaemia & transfusions
  4. Preterm birth and low birth weight
  5. Still birth
229
Q

What is the difference between a ‘low lying placenta’ and placenta praevia?

A

Low lying placenta: placenta within 20mm of the internal cervical os

Placenta praevia: placenta OVER the internal cervical os

230
Q

At what gestation is placenta praevia checked for?

A

20 week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia

231
Q

How do you manage placenta praevia? (3)

A
  1. Repeat transvaginal USS at 32 and 36 weeks
  2. Corticosteroids between 34 to 35+6 weeks
  3. Planned c-section between 36 to 37 weeks (may require USS and vertical incision)
232
Q

Grades of placenta praevia:

A

I - low lying placenta
II - placenta reaches but doesn’t cover internal os
III - placenta partially covers internal os
IV - palcenta completely covers internal os

233
Q

Grades of placenta praevia:

A

I - low lying placenta
II - placenta reaches but doesn’t cover internal os
III - placenta partially covers internal os
IV - palcenta completely covers internal os

234
Q

What is placental abruption?

A

When the placenta separates from the wall of the uterus during pregnancy

235
Q

5 key features of the presentation of placental abruption:

A
  1. “Woody” abdomen on palpation (suggests large haemorrhage)
  2. Sudden onset severe abdominal pain that is continuous
  3. Vaginal bleeding
  4. Shock (hypotension & tachycardia)
  5. CTG abnormalities (fetal distress)
236
Q

5 key features of the presentation of placental abruption:

A
  1. “Woody” abdomen on palpation (suggests large haemorrhage)
  2. Sudden onset severe abdominal pain that is continuous
  3. Vaginal bleeding
  4. Shock (hypotension & tachycardia)
  5. CTG abnormalities (fetal distress)
237
Q

What is a concealed abruption?

A

Where the cervical os remains closed so that any bleeding remains within the uterine cavity

238
Q

What is a concealed abruption?

A

Where the cervical os remains closed so that any bleeding remains within the uterine cavity

239
Q

What is the difference between a primary and secondary PPH?

A

Primary: bleeding within 24 hours of birth

Secondary: bleeding from 24 hours to 12 weeks after birth

240
Q

What volume of blood loss is classified as a PPH in vaginal and c-section deliveries?

A

Vaginal: 500ml

C-section: 1000ml

241
Q

4 causes of PPH:

A
  1. Tone - uterine atony
  2. Trauma - perineal tear
  3. Tissue - retained palcenta
  4. Thrombin - bleeding disorder
242
Q

4 ways of reducing the risk and consequences of PPH:

A
  1. Treat anaemia during antenatal period
  2. Give birth with an empthy bladder (full bladder reduces uterine contractions)
  3. Active management of 3rd stage (IM oxytocin)
  4. IV traneamic acid
243
Q

Mechanical treatment to stop bleeding in PHH: (2)

A
  1. Rubbing the uterus through the abdomento stimulate contraction
  2. Catheterisation to empty the bladder (full bladder prevents uterus contractions)
244
Q

Medical treatments to stop bleeding in PPH: (4)

A
  1. Oxytocin (slow injection then continuous infusion)
  2. Ergometrine (IV or IM)
  3. Carboprost (IV or IM)
  4. Misoprostol (sublingual)
  5. Tranexamic acid (IV)
245
Q

What is ergometrine? When is it contraindicated?

A

Used in PPH to stop bleeding, it stimulates smooth muscle contraction

Contraindicated in HTN/eclampsia

246
Q

What is carboprost? When should it be used with caution?

A

A prostaglandin analogue that stimulates uterine contraction

Used for PPH

Caution in asthma

247
Q

What is misoprostol?

A

A prostaglandin analogue, stimulates uterine contraction

248
Q

How is an infusion of oxytocin given?

A

IV infusion of 40 units in 500mls

249
Q

How is an infusion of oxytocin given?

A

IV infusion of 40 units in 500mls

250
Q

4 surgical interventions in PPH:

A
  1. Intrauterine balloon tamponade
  2. B lynch suture
  3. Uterine artery ligation
  4. Hysterectomy
251
Q

Investigations used in secondary PPH:

A
  1. USS for retained products of conception

2. Endocervical swabs and high vaginal swabs for infection

252
Q

Investigations used in secondary PPH:

A
  1. USS for retained products of conception

2. Endocervical swabs and high vaginal swabs for infection

253
Q

4 features of congenital rubella syndrome:

A
  1. deafness
  2. cataracts
  3. heart disease (PDA and pulmonary stenosis)
  4. learning disability
254
Q

3 serious complication of chickenpox during pregnancy:

A
  1. Maternal complications: varicella pneumonitis, hepatitis, encephalitis
  2. Fetal varicella syndrome
  3. Severe neonatal varicella infection
255
Q

A woman who has not previously had chicken pox is exposed to the virus during pregnancy, what should happen next?

A
  1. Immunity testing for VZV IgG levels, if positive no further action needed
  2. If they are not immune and yet to develop chicken pox, treat with IV varicella immunoglobulins within ten days of exposure
  3. If chicken pox rash has already started, treat with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation
256
Q

5 features of congenital varicella syndrome:

A
  1. fetal growth restriction
  2. microencephaly, hydrocephalus & learning disability
  3. scars, significant skin changes in specific dermatomes
  4. limb hypoplasia
  5. cataracts and inflammation in the eye
257
Q

How is listeria typically transmitted?

A

Unpasteurised dairy products, processes meats, contaminated foods

Pregnant women are told to avoid high risk foods (e.g. blue cheese) and practice good food hygiene.

258
Q

How is CMV typically transmitted?

A

In the saliva or urine of asymptomatic children

259
Q

6 features of congenital CMV:

A
  1. fetal growth restriction
  2. microencephaly
  3. hearing loss
  4. vision loss
  5. learning disability
  6. seizures
260
Q

What maternal infection can cause hydrops fetalis? What is hydrops fetalis?

A

Parvovirus B19 infection of the erythroid progenitor cells in the bone marrow and liver causes fetal anaemia and heart failure

261
Q

What maternal infection can cause hydrops fetalis? What is hydrops fetalis?

A

Parvovirus B19 infection of the erythroid progenitor cells in the bone marrow and liver

262
Q

Triad of mirror syndrome:

A
  1. Hydrops fetalis
  2. Placental oedema
  3. Maternal oedema
263
Q

Triad of mirror syndrome:

A
  1. Hydrops fetalis
  2. Placental oedema
  3. Maternal oedema
264
Q

How do you manage Parvovirus B19 infection in pregnant women?

A
  1. Supportive

2. Monitor fetus for complications and malformations

265
Q

How do you manage Parvovirus B19 infection in pregnant women?

A
  1. Supportive

2. Monitor fetus for complications and malformations

266
Q

Who should be offered intrapartum antibiotic prophylaxis (IAP) for group B strep?

A
  1. Pregnant women with GBS on vaginal swab
  2. Pregnant women with GBS bacteruria
  3. Women with a previous baby with GBS disease
267
Q

Routine antenatal screening is completed for what infections during pregnancy? At what gestation?

A

Before 16 weeks:

  1. Hep B surface antigen
  2. Syphilis
  3. HIV antibody
  4. Urine culture to treat any asymptomatic UTI
268
Q

When is multiple pregnancy usually diagnosed? What else is checked at this point?

A

At the booking USS. Also determines:

  • gestational age
  • number of placentas
  • number of amniotic sacs
  • risk of Down’s
269
Q

What is the T sign on UUS?

A

Where the membrane between twins abruptly meets the chorion, giving a T appearance

Indicates a monochorionic pregnancy (single placenta)

270
Q

What is the T sign on UUS?

A

Where the membrane between twins abruptly meets the chorion, giving a T appearance

Indicates a monochorionic pregnancy (single placenta)

271
Q

What is twin-twin transfusion syndrome?

A

Occurs when the fetuses share a placenta

One fetus (recipient) may receive the majority of the blood from the placenta whilst the other (donor) is starved

In severe cases laser treatment will be used to destroy the connection between the two blood supplies

272
Q

Features of the ‘donor’ twin in twin-twin transfusion syndrome:

A
  1. Growth restriction
  2. Anaemia
  3. Oligohydraminios
273
Q

Features of the ‘receipient’ twin in twin-twin syndrome:

A
  1. Fluid overloaded
  2. Heart failure
  3. Polyhydramnios
274
Q

What is twin anaemia polycythaemia sequence?

A

A less severe vesion of twin-twin syndrome in which one twin becomes anaemic and the other develops raised Hb (polycythaemia)

275
Q

How are monoamniotic and diamniotic twins delivered?

A

Mono: elective c-section, 32 to 33+6 weeks

Di: vaginal delivery is possible if the first baby is cephalic, c-section may be required for second baby

276
Q

How are monoamniotic and diamniotic twins delivered?

A

Mono: elective c-section, 32 to 33+6 weeks

Di:

277
Q

At what age on average do women experience menopause?

A

51 years

278
Q

What is perimenopause?

A

The time around menopause where women may experience:

  • vasomotor symptoms
  • irregular periods

Typically in women >45 years

279
Q

Summarize the physiology of menopause:

A

FSH stimulates the further development of secondary follicles

Secondary follicles grow, and surrounding granulosa cells secrete increasing amounts of oestrogn

In menopause, the development of ovarian follicles begins to decline.

This causes a reduction in the amount of oestrogen produced.

As oestrogen falls, there is an absence of negative feedback on the pituitary gland, so LH and FSH increases

Lack of follicular development means ovulation doesn’t occur, resulting in irregular menstrual cycles

Low oestrogen means the endometrium doesn’t develop and menstruation stops. Perimenopausal symptoms also occur.

280
Q

Summarize the physiology of menopause:

A

FSH stimulates the further development of secondary follicles

Secondary follicles grow, and surrounding granulosa cells secrete increasing amounts of oestrogn

In menopause, the development of ovarian follicles begins to decline.

This causes a reduction in the amount of oestrogen produced.

As oestrogen falls, there is an absence of negative feedback on the pituitary gland, so LH and FSH increases

Lack of follicular development means ovulation doesn’t occur, resulting in irregular menstrual cycles

Low oestrogen means the endometrium doesn’t develop and menstruation stops. Perimenopausal symptoms also occur.

281
Q

Give 8 symptoms of perimenopause caused by a lack of oestrogen:

A
  1. Hot flushes
  2. Emotional lability or low mood
  3. Premenstrual syndrome
  4. Irregular periods
  5. Joint pains
  6. Heavier or lighter periods
  7. Vaginal dryness and atrophy
  8. Reduced libido
282
Q

Give 4 conditions that a lack of oestrogen increases the risk of during menopause:

A
  1. CVS disease and stroke
  2. Osteoporosis
  3. Pelvic organ prolapse
  4. Urinary incontinence
283
Q

How do you diagnose perimenopause and menopause?

A

Clinical diagnosis with no investigations.

FSH blood test may be used in women under 40 or in women aged 40-45 whose symptoms change with their cycle

284
Q

How long to peri/menopausal women need to use effective contraception for?

A

Two years after their last menstrual period in women under 50

One year after their last menstrual period in women over 50

285
Q

Two key side effects of the progesterone only depot injection:

A
  1. Weight gain

2. Reduced bone mineral density (therefore not appropriate for menopausal women)

286
Q

Give 4 benefits of HRT:

A
  1. Reduce vasomotor, mood and urogenital symptoms
  2. Reduced risk of osteoporosis
  3. Reduced risk of CVS disease
  4. Reduced risk of colorectal cancer
287
Q

Give 5 risks increased by HRT:

A
  1. VTE (particularly with oral HRT, those at high risk of VTE should have transdermal patch)
  2. Ischaemic stroke
  3. Breast cancer (highest risk in women who have extreme BMI, late menopause, early menarche, nulliparity etc.)
  4. Endometrial cancer (substantial increase with oestrogen-only HRT)
  5. Ovarian cancer (conflicting evidence)
288
Q

Give 5 risks increased by HRT:

A
  1. VTE (particularly with oral HRT, those at high risk of VTE should have transdermal patch)
  2. Ischaemic stroke
  3. Breast cancer (highest risk in women who have extreme BMI, late menopause, early menarche, nulliparity etc.)
  4. Endometrial cancer (substantial increase with oestrogen-only HRT)
  5. Ovarian cancer (conflicting evidence)
289
Q

Investigations for starting HRT are not usually necessary, except for in these circumstances: (4)

A
  1. Sudden change in menstrual pattern/worrying bleeding
  2. Personal or family hx of VTE
  3. High risk of breast cancer
  4. High risk of arterial disease
290
Q

What is tibolone?

A

A selective oestrogen receptor modulator (SERM)

Alternative/addition to HRT

291
Q

Side-effects of oestrogen and progesterone in HRT:

A

Oestrogen:

  • breast tenderness
  • leg cramps
  • nausea
  • headaches

Progesterone:

  • premenstrual-like symptomes
  • breast tenderness
  • backache
  • depression
  • pelvic pain

Breakthrough blleding is also common in the first 3-6 months

292
Q

Side-effects of oestrogen and progesterone in HRT:

A

Oestrogen:

  • breast tenderness
  • leg cramps
  • nausea
  • headaches

Progesterone:

  • premenstrual-like symptomes
  • breast tenderness
  • backache
  • depression
  • pelvic pain

Breakthrough blleding is also common in the first 3-6 months

293
Q

Why is cyclical HRT preferred rather than continuous HRT in perimenopausal women?

A

Cyclical HRT produces predictable withdrawal blelds whereas continous regimens often cause unpredictable bleeding

294
Q

Why is cyclical HRT preferred rather than continuous HRT in perimenopausal women?

A

Cyclical HRT produces predictable withdrawal blelds whereas continous regimens often cause unpredictable bleeding

295
Q

At what age are children vaccinated against HPV? Which strains are they vaccinated against?

A

12 to 13 years

Type 6, 11, 16 and 18 strains

296
Q

At what age are children vaccinated against HPV? Which strains are they vaccinated against?

A

12 to 13 years

Type 16 and 18 strains

297
Q

Which strains of HPV are most commonly responsible for cervical cancers?

A

Type 16 and 18

298
Q

How does HPV infection cause cervical cancer?

A

HPV produces two proteins (E6 and E7) that inhibit the P53 and pRb tumour suppressor genes

299
Q

Risk factors for cervical cancer (divided into three groups, 10 in total):

A

Increased risk of catching HPV:

  • Early sexual activity
  • Increased n of sexual partners
  • Sexual partners who have had more partners
  • Not using condoms

Late detection of precancerous or cancerous changes:
- Non-engagement with screening

Other:
- smoking
- HIV
- COC pill
- increased n of full-term pregnancies
- family hx
exposure to diethylbestrol during fetal development (prev. used to prevent miscarriages before 1971)
300
Q

4 symptoms to indicate cervical cancer as a differential:

A
  1. Abnormal vaginal bleeding
  2. Vaginal discharge
  3. Pelvic pain
  4. Dyspareunia
301
Q

Features of an abnormal cervix on examination that suggest possible cervical cancer: (4)

A
  1. Ulceration
  2. Inflammation
  3. Bleeding
  4. Visible tumour
302
Q

What is the Cervical Intraepithelial Neoplasia grading system?

A

Used to classify colposcopy results:

CIN I - mild dysplasia, affects 1/3rd of thickness of epithelial layer, likely to return to normal wthout tx

CIN II - moderate, afecting 2/3rds, likely to progress to cancer if untreated

CIN III - severe dysplasia, very likely to progress

303
Q

What is the Cervical Intraepithelial Neoplasia grading system?

A

Used to classify colposcopy results:

CIN I - mild dysplasia, affects 1/3rd of thickness of epithelial layer, likely to return to normal wthout tx
CIN II -

304
Q

What is dyskaryosis?

A

Pre-cancerous cell changes found in a smear test

uses liquid based cytology

305
Q

How is a smear test done?

A

Involves a speculum examination and collection of cells by a qualified practioner.

Samples are initially tested for high risk HPV.

If negative for high risk HPV no further testing is done.

If positive, the cells are examined for dyskaryosis.

306
Q

How frequently are people screened for cervical cancer?

A

Anyone with a cervix is screened:

  • Every three years at ages 25-49
  • Every 5 years at ages 50-64
307
Q

Who might have additional screening for cervical cancer?

A
  1. Women with HIV (screened annually)
  2. Women over 65 can request one if they haven’t had one since age 50
  3. Women with previous CIN
  4. Certain immunocompromised individuals
308
Q

How soon after pregnancy can you have your routine smear?

A

Must wait until 12 weeks post-partum

309
Q

Other than cell changes, what else might be discovered on a smear? (2)

A
  1. Infections e.g. BV, thrush, thrichomoniasis

2. Actinomyces-like organisms in women with IUDs (no tx needed unless symptomatic)

310
Q

International Federation of Gynae and Obs (FIGO) staging system for cervical cancer:

A

Stage 1: confined to cervix
Stage 2: invades uterus or upper 2/3rds vagina
Stage 3: invades pelvic wall or lower 1/3rd vagina
Stage 4: invades bladder, rectum or beyond pelvis

311
Q

Give X types of treatment that might be used to manage cervical cancer:

A
  1. Cone biopsy
  2. Radical hysterectomy & removal of local lymph nodes
  3. Chemotherapy
  4. Radiotherapy
  5. Pelvic exenteration (removal of almost all pelvic organs)
  6. Bevacizumab (avastin) monoclonal antibody (used in metastatic or recurrent cancer)
312
Q

Give 6 types of treatment that might be used to manage cervical cancer:

A
  1. Cone biopsy
  2. Radical hysterectomy & removal of local lymph nodes
  3. Chemotherapy
  4. Radiotherapy
  5. Pelvic exenteration (removal of almost all pelvic organs)
  6. Bevacizumab (avastin) monoclonal antibody (used in metastatic or recurrent cancer)
313
Q

Which strains of HPV cause genital warts?

A

6 and 11

314
Q

Patients with positive HPV are called back for smears sooner than the routine programme. What happens in the following scenarios?

  1. Initial smear shows positive HPV but negative cytology
  2. Test repeated at 12 months shows positive HPV but negative cytology
  3. Test repeated at 12 months shows negative HPV
  4. Second repeat test at 24 months is still HPV positive
A
  1. Recall in 12 months for a repeat smear
  2. Recall in 12 months for another repeat smear
  3. Return to routine programme
  4. Refer for colposcopy
315
Q

What is the most common type of endometrial cancer?

A

Adenocarcinoma (80%)

316
Q

Endometrial cancer is dependent on which hormone?

A

Oestrogen (stimulates the growth of endometrial cancer cells)

317
Q

Two types of endometrial hyperplasia:

A
  1. Hyperplasia without atypia

2. Atypical hyperplasia

318
Q

Endometrial hyperplasia is precancerous thickening of the endometrium. What % go on to be cancerous? How is it treated in this precancerous stage?

A

Less than 5%

Progestogens e.g. Mirena coil or continuous pop e.g. levonorgestrel

319
Q

Risk of endometrial cancer is increased by unopposed exposure to oestrogen. Give 8 situations in which exposure to unopposed oestrogen is increased:

A
  1. Increasing age
  2. Late menopause
  3. Early menarche
  4. Oestrogen only HRT
  5. No or fewer pregnancies
  6. Obesity
  7. PCOS
  8. Tamoxifen
320
Q

Why does PCOS carry an increased risk of endometrial cancer?

A

Lack of ovulation in PCOS increases exposure to unopposed oestrogen. Without ovulation, the corpus luteum never forms, and it is the corpus luteum that is responsible for producing lots of progesterone.

321
Q

Why is obesity a key risk factor for endometrial cancer?

A

Adipose tissue is a source of oestrogen. It contains aromatase, an enzyme that converts androgens to oestrogen.

322
Q

Why does tamoxifen increase the risk of endometrial cancer?

A

tamoxifen has an anti-oestrogenic affect on breast tissue (helping to treat breast cancer) BUT an oestrogenic affect on the endometrium

323
Q

Other than unopposed oestrogen exposure, give two additional risk factors for endometrial cancer:

A
  1. Type 2 DM

2. Hereditary nonpolyposis cancer or Lynch syndrome

324
Q

4 protective factors against endometrial cancer:

A
  1. COC pill
  2. Mirena coil
  3. Increased pregnancies
  4. Smoking (anti-oestrogenic)
325
Q

How does endometrial cancer present?

A

Most important symptom = POSTMENOPAUSAL BLEEDING

Other symptoms/signs:

  • post coital bleeding
  • intermenstrual bleeding
  • unusually heavy menstrual bleeding
  • abnormal vaginal discharge
  • haematuria
  • anaemia
  • raised platelet count
326
Q

3 important investigations for endometrial cancer:

A
  1. Transvaginal USS for endometrial thickness
  2. Pipelle biopsy (can be done in outpatient clinic)
  3. Hysteroscopy with endometrial biopsy
327
Q

What qualifies as a normal endometrial thickness when completing a transvaginal USS to investigate possible endometrial cancer?

A

Normal endometrial thickness is less than 4mm post menopause

328
Q

How are stage 1 and 2 endometrial cancers managed?

A

Total abdominal hysterectomy with bilateral salpingo-oopherctomy (TAH and BSO)

329
Q

Which is the most common type of ovarian cancer?

A

Epithelial cell tumours

330
Q

Four types of ovarian cancer:

A
  1. Epithelial cell tumours (most common)
  2. Dermoid cysts/germ cell tumours (AKA teratomas)
  3. Sex cord-stromal tumours
  4. Metastasis from cancer elsewhere
331
Q

Complications/features of germ cell ovarian tumours: (3)

A
  1. Ovarian torsion
  2. Raised alpha-fetoprotein
  3. Raised hCG
332
Q

What is a Krukenberg tumour? What cells are characteristically seen on histology?

A

A metastasis in the ovary from a GI cancer

Have characteristic “signet-ring” cells on histology

333
Q

6 risk factors for ovarian cancer:

A
  1. Age (peaks at 60)
  2. BRCA1 and BRCA2
  3. Increased n of ovulations (early-onset menarche, late menopause, no pregnancies)
  4. Obesity
  5. Smoking
  6. Recurrent used of clomifene
334
Q

3 protective factors against ovarian cancer:

A

Anything that stops or reduces the number of lifetime ovulations:

  1. COC pill
  2. Breastfeeding
  3. Pregnancy
335
Q

How does ovarian cancer present?

A

Non-specific symptoms, e.g.:

  1. Abdo bloating
  2. Early satiety
  3. Loss of appetite
  4. Pelvic pain
  5. Weight loss
  6. Referred hip or groin pain due to mass pressing on obturator nerve
336
Q

What three things indicate the need for an urgent two week wait referral for possible ovarian cancer when completing a physical examination?

A
  1. Ascites
  2. Pelvic mass (unless clearly due to fibroids)
  3. Abdominal mass
337
Q

Initial primary care investigations for suspected ovarian cancer: (3)

A
  1. CA125 blood test
  2. Pelvic USS
  3. Risk of malignancy index
338
Q

What scoring system is used to estimate the risk of an ovarian mass being malignant?

A

Risk of malignancy index (RMI):

  1. Menopausal status
  2. USS findings
  3. CA125 level
339
Q

What level of CA125 is significant when investifgating possible ovarian cancer?

A

> 35 IU/mL

340
Q

What further investigations might be done in secondary care when diagnosing ovarian cancer?

A
  1. CT scan
  2. Histology
  3. Paracentesis (ascites tap)
  4. Tumour markers for possible germ cell tumour: alpha-FP, hCG
341
Q

CA125 is not very specific, other than an ovarian mass, what can cause raised CA125? (6)

A
  1. endometriosis
  2. fibroids
  3. adenomyosis
  4. pelvic inflammation
  5. liver disease
  6. pregnancy
342
Q

FIGO staging of ovarian cancer:

A

1: confined to ovary
2: confined to pelvis
3: confined to abdomen
4: spread past abdomen

343
Q

What is the most common type of vulval cancer?

A

Squamous cell carcinomas (90%)

344
Q

4 risk factors for vulval cancer:

A
  1. advanced age (>75)
  2. immunosuppresion
  3. HPV infection
  4. Lichen sclerosus
345
Q

What is vulval intraepithelial neoplasia?

A

A pre-malignant condition affecting the squamous epithelium of the skin that can precede vuval cancer

346
Q

How is vulval intraepitherlial neoplasia diagnosed? What are the 4 tx options?

A

Biopsy

Treatment options:

  1. watch and wait
  2. wide local excision
  3. Imiquimod cream
  4. laser ablation
347
Q

Vulval cancer most commonly affcets the labia majora, what does it look like?

A
  1. irregular mass
  2. fungating lesion
  3. ulceration
  4. bleeding
348
Q

Define primary amenhorrea:

A

Not starting menstruation:

  • By 13 years when there is no other evidence of pubertal development
  • By 15 years when there are other signs of development (e.g. breast buds)
349
Q

When does puberty normally start in girls and boys?

A

Girls: 8 to 14 years
Boys: 9 to 15 years

350
Q

How long does puberty take?

A

4 years

351
Q

What features develop first in puberty for girls?

A

Breast buds, then pubic hair, then menstrual periods about two years after the start of puberty

352
Q

What is hypogonadotropic hypogonadism?

A

A deficiency of LH and FSH

353
Q

What is hypergonadotropic hypogonadism?

A

A lack of RESPONSE to LH and FSH by the gonads

354
Q

5 possible causes of hypogonadotropic hypogonadism:

A
  1. Hypopituitarism
  2. Damage to hypothalamus or pituitary e.g. radiotherapy, surgery
  3. Significant chronic conditions that delay puberty e.g. cf, IBD
  4. Excessive exercise/dieting
  5. Endo disorders e.g. hypothyroid, cushinsg’s
  6. Kallman’s syndrome
355
Q

What causes hypergonadotropic hypogonadism?

A

Abnormal functioning of the gonads, this could be due to:

  1. Damange to the gonads e.g torsion, cancer, mumps
  2. Congenital absence of ovaries
  3. Turner’s syndrome (XO)
356
Q

What is Kallman’s syndrome?

A

A genetic condition that causes hypogonadotrophic hypogonadism with a failure to start puberty

Associated with reduced or absent sense of smell

357
Q

What causes congenital adrenal hyperplasia?

A
  1. A faulty gene prevents the adrenal cortex from producing cortisol/corticosteroids (commonly due to a deficiency in 21-hydroxylase)
  2. Low levels of corticosteroids are detected in the blood by the brain, the brain signals to the adrenal cortex to work harder (increases ACTH)
  3. The cortex under goes hypertrophy but STILL can’t produce cortisol
  4. Instead the cortex produces excess androgens

= Low corticosteroids, High androgens

358
Q

How might a girl with a milder case of congenital adrenal hyperplasia present in late childhood/puberty?

A
  1. tall for age
  2. facial hair
  3. absent periods
  4. deep voice
  5. early puberty
359
Q

Structural pathology can cause primary amennohrea, what symptom might be associated with this?

A

Cyclical abdominal pain as menses build up but cannot escape through the vagina

360
Q

5 types of structural pathology that can cause primary amenhorrea:

A
  1. Imperforate hymen
  2. transverse vaginal septae
  3. absent uterus
  4. FGM
  5. vaginal agenesis
361
Q

When do you need to investigate primary amenhorrea?

A

When there is NO evidence of pubertal change in a girl aged 13.

OR

When there is SOME evidence but NO progression after 2 years.

362
Q

Initial investigations used in primary amenhorrea:

A
  1. Bloods: FBC, ferritin, U&E, Anti-TTG and anti-EMA
  2. Hormonal blood tests: FSH, LH, TFTs, insulin-like growth factor (screen for GH deficiency), prolactin, testosterone
  3. Genetic testing with mircoarray (turner’s)
  4. Imaging:
    - XR wrist to assess bone age and dx constitutional delay
    - pelvic USS
    - MRI brain
363
Q

How do you treat hypogonadotrophic hypogonadism?

A

Pulsatile GnRH

364
Q

What is secondary amenorrhoea?

A

No menstruation for more than three months after previous regular menstruation

365
Q

When should you investigate secondary amenorrhea?

A

No menstruation for more than three to six months following regular menstruation

OR

Previous infrequent or irregular periods and no periods for six to twelve months

366
Q

Causes of secondary amenhorrea: (8)

A
  1. Pregnancy
  2. Menopause and premature ovarian failure
  3. Hormonal contraception
  4. PCOS
  5. Hypothalamic or pituitary pathology
  6. Uterine pathology e,g. Asherman’s
  7. Thyroid pathology
  8. Hyperprolactinaemia
367
Q

Two pituitary causes of secondary amennorhea:

A
  1. Pituitary tumours e.g. prolactinoma

2. Pituitary failure e.g. trauma, radiotherapy, surgery

368
Q

Why/how does prolactinaemia cause secondary amenorrhea

A

High levels of prolactin act on the hypothalamus preventing the release of GnRH

Without GnRH there is no release of FSH and LH

369
Q

What is the most common cause of hyperprolactinaemia?

A

Pituitary adenoma that secretes prolactin

370
Q

What drug might be given to treat hyperprolactinaemia?

A

dopamine agonists e.g. bromocriptine or cabergoline

371
Q

When does premenstrual syndrome (PMS) typically occur? When should it end?

A

During the luteal phase of the menstrual cycle

Symptoms should resolve once menstruation begins

372
Q

How do you diagnose PMS?

A

Keep a symptom diary and look for cyclical symptoms

A specialist might administer GnRH analogues to halt the menstrual cycle to see if symptoms resolve

373
Q

Primary care management options for PMS:

A
  1. Lifestyle changes
  2. COC pill
  3. SSRI
  4. CBT
374
Q

What medication can be given to treat physical symptoms of PMS such as breast swelling?

A

spironolactone

375
Q

If a mother does NOT plan to breast feed, can she restart her combined oral contraceptive pill? If so, when?

A

Yes, after 21 days due to increased VTE risk

376
Q

Definition of a threatened miscarriage:

A

Vaginal bleeding with a CLOSED cervix and a fetus that is ALIVE

377
Q

Definition of an inevitable miscarriage:

A

Vaginal bleeding with an OPEN cervix

378
Q

Definition of an incomplete miscarriage:

A

Retained products of conception in the uterus after miscarriage

379
Q

Complete miscarriage:

A

A full miscarriage has occured with no products of conception left behind in the uterus

380
Q

Definition of an anembryonic pregnancy:

A

A gestational sac is present but contains no embryo

381
Q

At what crown-rump length do you expect a fetal heart beat to be present?

A

7mm or more

382
Q

Three features assessed in early pregnancy on transvaginal USS to determine viability of a pregnancy:

A
  1. Mean gestational sac diameter
  2. Fetal pole and crown-rump length
  3. Fetal heart beat

(develops sequentially)

383
Q

In a transvaginal USS of an early pregnancy the sonography finds a crown-rump length of <7mm and no fetal heartbeat - what should be done next?

A

Repeat the scan after at least one week to ensure a heartbeat develops

384
Q

In an early pregnancy, the sonographer finds a crown-rump legnth of >7mm but no fetal heart beat, what should happen next?

A

The scan should be repeated after one week before confirmed a non-viable pregnancy

385
Q

At what gestational sac diameter is a fetal pole expected?

A

25mm or more

386
Q

How do you manage a miscarriage at less than 6 weeks gestation?

A

Expectant management: await miscarriage with no investigations or treatments (as long as there are no complications, risk factors or pain)

Repeat urine pregnancy test in 7-10 days

387
Q

Medical management of a miscarriage: (1)

A

Misoprostol (vaginal or oral) to expediate process

388
Q

4 key side effects of giving misoprostol in miscarriage:

A
  1. heavier bleeding
  2. pain
  3. vomiting
  4. diarrhoea
389
Q

Surgical management of miscarriage: (2)

A
  1. Manual vacuum aspiration under local anaesthetic
  2. Electric vacuum aspiration under general

NB: Also given misoprostol to soften cervix and anti-rhesus D if rhesus negative

390
Q

Management of an incomplete miscarriage:

A

Removal of retained products medically (misoprostol) or surgically (evacuation)

391
Q

What is the latest gestational age that abortion is legal at? What law defines this?

A

24 weeks according to the 1990 human fertilisation and embryology act

392
Q

In what circumstances can an abortion at any time during the pregnancy? (3)

A
  1. continuing the pregnancy is likely to risk the life of the woman
  2. terminating the pregnancy will prevent ‘grave permenant injury’ to the physical or mental health of the mother
  3. there is ‘substantial risk’ that the child would suffer physical or mental abnormalities making them seriously handicapped
393
Q

Legal requirments for an abortion: (3)

A
  1. Two registered medical practioners must sign agreeing that an abortion is indicated
  2. Must be carried out by a registerd medical professional
  3. Must take place in an NHS or approved premise
394
Q

What does a medical abortion involve? (2)

A
  1. Mifepristone (anti-progesterone)
  2. Misoprostol one to two days after mifepristone

Anti-D prophylaxis if woman is rhesus negative and of 10 weeks or above

395
Q

What does a surgical abortion involve? (3)

A
  1. Medications for cervical priming: misoprostol, mifepristone, osmotic dilators
  2. Cervical dilatation and suction of contents (up to 14 weeks)
  3. OR: cervical dilatation and evacuation using forceps between 14 and 24 weeks

NB: anti-D prophylaxis if rhesus neg

396
Q

3 common signs of ectopic pregnancy:

A
  1. pelvic tenderness
  2. adnexal tenderness
  3. abdominal tenderness

Beta-hCG >1,500

397
Q

Risk factors for ectopic pregnancy:

A
  1. previous ectopic pregnancy
  2. previous PID
  3. previous surgery to fallopian tubes
  4. older age
  5. smoking
  6. IVF treatment
398
Q

5 classic features of ectopic pregnancy:

A
  1. missed period
  2. constant lower abdo pain in right or left iliac fossa
  3. vaginal bleeding
  4. lower abdo or pelvic tenderness
  5. cervical motion tenderness

NB: also worth asking about shoulder tip pain (peritonitis) and dizziness/syncope (blood loss)

399
Q

What is the ‘blob sign’ seen on transvaginal USS? (AKA bagel sign or tubal ring sign)

A

A mass seen in the Fallopian tube containing an empty gestational sac. Indicates an ectopic pregnancy.

400
Q

How do you diagnose an ectopic pregnancy?

A

Transvaginal USS

401
Q

What is a pregnancy of unknown location?

A

When a woman has a positive pregnancy test but no evidence of pregnancy on USS

402
Q

How do you manage a pregnancy of unknown location?

A

Maintain high suspiscion of ectopic pregnancy and track serum hCG over time

403
Q

What do the following changes in hCG levels indicate?

  1. Rise of more than 63% after 48 hours
  2. Rise of less than 63% after 48 hours
  3. Fall of more than 50%
A
  1. Intrauterine pregnancy
  2. Ectopic pregnancy
  3. Miscarriage
404
Q

How should hCG levels change from baseline in to 48 hours later in a normal intrauterine pregnancy?

A

Should rise by more than 63%

405
Q

When a pregnancy is visible on USS, what level should hCG be at?

A

above 1500 IU/L

406
Q

Criteria for medical management of an ectopic pregnancy: (2)

A

hCG level less than 5000 IU/L

Confirmed absence of intrauterine pregnancy on USS

<35mm in size

407
Q

What is used to medically manage an ectopic pregnancy?

A

Methotrexate given by IM injection

408
Q

What are the common side effects of methotrexate following medical management of ectopic pregnancy? What advise is crucial to give after treatment?

A

Common SEs:

  • vaginal bleeding
  • N&V
  • abdo pain
  • stomatitis

Do NOT get pregnant for 3 months

409
Q

Indications for surgical management of an ectopic pregnancy:

A
  1. Pain
  2. Adnexal mass >35mm
  3. Visible heartbeat
  4. hCG levels >5000 IU/L
410
Q

Surgical options for management of ectopic pregnancy:

A

1st line: laproscopic salpinectomy

2nd line: laproscopic salpingotomy

411
Q

85% will conceive when having regular unprotected sex for what period of time?

A

within 1 year

412
Q

When should investigation and referral for infertility be initiated?

A

After a couple has been trying to conceive without success for 12 months

This can be reduced to 6 months if the woman is older than 35

413
Q

Lifestyle advise given to couples trying to get pregnant:

A
  1. 400mg folic acid daily for the woman
  2. healthy BMI
  3. avoid excessive alcohol and smoking
  4. reduce stress
  5. aim for sex every 2 to 3 days
  6. don’t time sex with menstrual cycle (too stressful)
414
Q

Primary care investigations for infertility: (5)

A
  1. BMI
  2. chlamydia screening
  3. semen analysis
  4. female hormone testing (LH, FSH, progesterone, TFTs, prolactin, anti-mullerian)
  5. rubella immunity in mother
415
Q

Why and when is anti-mullerian hormone measured when investigating infertility?

A

Can be measured at any time during the cycle

Is the most accurate marker of ovarian reserve

High levels = good ovarian reserve

416
Q

What might high FSH levels indicate in a woman being investigated for infertility?

A

Poor ovarian reserve

417
Q

What might high LH levels indicate in a woman being investigated for infertility?

A

PCOS

418
Q

Infertility investigations completed in secondary care: (3)

A
  1. USS pelvis
  2. Hysterosalpingogram - looks at patency of fallopian tubes
  3. Laproscopy and dye test to look for adhesions and endometriosis
419
Q

What medication is given to stimulate ovulation in women with fertility issues?

A

Clomifene

420
Q

What are some alternatives to clomifene?

A

Letrozole

Gonadotropins

421
Q

Other than giving clomifene, how might a woman with anovulation be managed? (3)

A
  1. Weight loss advice for patients with PCOS
  2. Ovarian drilling for PCOS
  3. Metformin for obesity, PCOS etc.
422
Q

If a tubal factor is found to be the cause of infertility, what is the mangement? (3)

A
  1. Tubal cannulation during hysterosalpingogram
  2. Laproscopy to remove adhesions or endometriosis
  3. IVF
423
Q

5 management options for infertility caused by sperm problems:

A
  1. Surgical retrieval of sperm
  2. Surgical correction of obstruction of vas deferens
  3. intra-uterine insemination
  4. intracytoplasmic sperm injection
  5. donor insemination
424
Q

What is vasa praevia?

A

In normal circumstance the umbilical cord containing the fetal vessels inserts directly into the placenta.

In vasa praevia the fetal vessels are exposed, outside the protection of the umbilical cord or placenta. Instead the travel through the chorioamniotic membranes and across the internal cervical os.

425
Q

What is wharton’s jelly?

A

A layer of soft connective tissue that surrounds the blood vessels in the umbilical cord, offering protection

426
Q

Risk factors for vasa praevia: (3)

A
  1. low lying placenta
  2. IVF pregnancy
  3. multiple pregnancy
427
Q

Management of vasa praevia: (2)

A
  1. Planned c-section for 34 to 36 weeks

2. Corticosteroids from 32 weeks to mature fetal lungs

428
Q

What is the first stage of labour?

A

From the onset of true contractions until the cervix is 10cm dilated

429
Q

What is the second stage of labour?

A

From 10cm cervical dilatation until the delivery of the baby

430
Q

What is the third stage of labour?

A

From delivery of the baby until delivery of the placenta

431
Q

Three phases of the first stage of labour:

A
  1. Latent phase - 0 to 3cm dilation, 0.5cm progress/hour, irregular contractions
  2. Active phase - 3 to 7cm dilation, 1cm progress/hour, regular contractions
  3. Transition phase - 7 to 10cm dilation, progress 1cm/hour, strong regular contractions
432
Q

Define prolonged rupture of membranes (PROM):

A

Amniotic sac ruptures more than 18 hours before delivery

433
Q

Define preterm prelabour rupture of membranes (P-PROM):

A

Amniotic sac ruptures before the onset of labour and before 37 weeks gestation

434
Q

Define prematurity:

A

Birth before 37 weeks gestation

435
Q

WHO classification of prematurity: extreme, very, moderate to late preterm

A

Extreme preterm: under 28 weeks
Very preterm: 28 to 32 weeks
Moderate to late preterm: 32-37

436
Q

2 methods of preventing preterm labour and when/who you can offer them to:

A
  1. Vaginal progesterone:
    - Women with a cervical length <25mm on TVUSS, between 16 and 24 weeks
  2. Cervical cerclage:
    - Women with a cervical length <25mm on TVUSS between 16 and 24 weeks who have had previous premature birth or cervical trauma (e.g. colposcopy)
437
Q

What is “rescue” cervical cerclage and when is it used?

A

A stitch in the cervix to support it and keep it closed.

Offered between 16 and 27+6 weeks gestation when there is cervical dilatation without rupture of membranes, prevent progression and premature delivery.

438
Q

Rupture of membranes is normally obvious on vaginal examination - if you are unsure, what tests can you do to confirm their rupture?

A
  1. Insulin-like growth factor-binding protein-1 (IGFB-1) - a protein that is present in high concentrations in amniotic fluid
  2. Placental alpha-microglobin-1 (PAMG-1) similar to IGFB-1
439
Q

How do you manage preterm prelabour rupture of membranes? (2)

A
  1. Erythromycin 250mg QDS for 10 days oruntil labour is established
  2. Induction of labour from 34 weeks
440
Q

How do you diagnose preterm labour with intact membranes?

A

<30 weeks gestation: clinical assessment of cervical dilation

> 30 weeks: TVUSS to assess cervical length, less than 15mm = likely preterm labour

441
Q

What does measuring fetal fibronectin establish?

A

Used to determine if pre-term labour is occuring

Fetal fibronectin is the ‘glue’ between the chorion and the uterus, found in the vagina during labour

<50ng/ml = preterm labour is UNLIKELY

442
Q

5 possible steps to improve outcomes in preterm labour:

A
  1. Fetal monitoring (CTG)
  2. Tocolysis with nifedipine
  3. Maternal corticosteroids
  4. IV magnesium sulfate
  5. Delayed cord clamping or cord milking
443
Q

Why is nifedipine given in preterm labour? At what gestation can it be used?

A

Nifedipine is a tocolytic drug i.e. it stops uterine contractions

It can be used between 24 and 33+6 weeks to delay delivery and buy time for futher fetal development

444
Q

If the tocolytic nifedipine is contraindicated, what alternative can you use?

A

Atosiban - an oxcytocin receptor agonist

445
Q

At what gestation can you use maternal corticosteroids to support fetal lung maturation?

A

Less than 36 weeks gestation

e.g. two doses of IM betamethasone 24 hours apart

446
Q

Why do you give IV magnesium sulfate in preterm labour? At what gestation is this done?

A

Helps protect fetal brain, reducing the risk of cerebral palsy.

Given within 24 horus of delivery of preterm babies less than 34 weeks gestation, by bolus and IV infusions for up to 24 hours.

447
Q

What complication must you monitor for closely when given magnesium sulfate? How does this present?

A

Magnesium toxicity:

  • Absent reflexes
  • Reduced BP
  • Reduced resp rate
448
Q

Why does delayed cord clamping improve outcomes in premature babies?

A

Can increase the circulating blood volume

449
Q

CTG: what is the baseline rate?

A

the baseline fetal heart rate

450
Q

CTG: what is variability?

A

how the fetal heart varies up and down from the baseline

451
Q

CTG: what are accelerations?

A

periods where the fetal heart rate spike

452
Q

CTG: what are decelerations?

A

periods where the fetal heart rate drops

453
Q

CTG: what is an abnormal baseline rate?

A

Below 100 or above 180

454
Q

CTG: what is abnormal variability?

A

Less than 5 for over 50 minutes

OR

More than 25 for over 25 minutes

455
Q

CTG: what are early decelerations?

A

Gradual dips and recoveries in heart rate that correspond with uterine contractions

They are NORMAL and not pathological

456
Q

CTG: what are late decelerations?

A

Gradual falls in heart rate that start AFTER the uterine contraction has already begun

They indicate possible fetal HYPOXIA

457
Q

CTG: what are variable decelerations?

A

Abrupt decelerations that may be unrelated to uterine contractions

Often indicate intermittent COMPRESSION of the umbilical cord causing fetal HYPOXIA

458
Q

CTG: what are prolonged decelerations?

A

Decelerations lasting 2 to 10 minutes indicating compression of the cord

459
Q

4 categories for CTG:

A
  1. normal
  2. suspicious
  3. pathological
  4. need for urgent intervention
460
Q

If a CTG reading is causing concern, what steps might be taken to further investigate the situation?

A
  1. Fetal scalp stimulation - to stimulate an acceleration as a reassuring sign
  2. Fetal scalp blood sampling - to test for fetal acidosis
  3. Further assessment for possible causes e.g. maternal hypotension, cord prolapse
  4. ESCALATE to senior
461
Q

The rule of 3’s for fetal bradycardia:

A

3 minutes - call for help
6 minutes - move to theatre
9 minutes - prepare for delivery
12 minutes - delivery the baby by 15 minutes

462
Q

What is sinusoidal CTG?

A

A rare pattern similar to a sine wave with an amplitude of 5-15 bpm that indicates severe fetal anaemia

463
Q

4 uses of IV oxytocin:

A
  1. induction of labour
  2. progression of labour
  3. improve strength and freq of uterine contractions
  4. prevent or treat PPH
464
Q

What is syntometrine? When/why is it used?

A

A combination drug containing oxytocin and egometrine. Used to prevent or treat PPH.

465
Q

When/why is ergometrine used?

A

Used in the third stage of labour to assist the delivery of the placenta and reduce postpartum bleeding.

Stimulates smooth muscle in the uterus and blood vessels.

466
Q

4 side effects of ergometrine:

A
  1. HTN
  2. Diarrhoea
  3. Vomiting
  4. Angina
467
Q

Contraindications for ergometrine:

A

HTN and pre-eclampsia!

468
Q

Which prostglandin is used to induce labour? What forms does it come it?

A

Dinoprostone - prostaglandin E2

Pessaries, tablets or gel

469
Q

What is prostaglandin E2 used for?

A

Inducing labour

470
Q

Mechanism of action of misoprostol:

A

Prostaglandin analogue

471
Q

What is terbutaline? What is it used for?

A

A tocolytic beta-2agonist, used to treat uterine hyperstimulation

472
Q

What is carboprost? WHat is it used for?

A

A synthetic prostaglandin analogue. Given via deep IM injection to treat PPH when ergometrine and oxytocin have failed.

473
Q

What is the earliest test you can do for down’s syndrome?

A

the combined test at 11 to 14 weeks gestation

474
Q

What does the combined test involve?

A
  1. USS: measures nuchal translucency

2. Maternal bloods: beta-hCG and pregnancy associated plasma protein A (PAPPA)

475
Q

What is nuchal translucency? What value is significant?

A

The thickness of the back of the neck of the fetus

> 6mm = likely Down’s syndrome

476
Q

In the combined test, what maternal blood results would indicate a greater risk of Down’s syndrome?

A

High beta-hCG

Low PAPPA

477
Q

After the combined test, what screening tests can be offered to assess the risk of Down’s syndrome? When can they be done?

A

The triple and quadruple tests at 14 to 20 weeks

478
Q

What do the triple and quadruple tests involve?

A

Triple:

  • beta-hCG
  • alpha-fetoprotein
  • serum oestriol

Quadtruple:

  • as above
  • AND inhibin A
479
Q

What results from the quadruple test would indicate a HIGH risk of Down’s?

A

Beta-hCG: high
AFP: low
Serum oestriol: low
Inhibin-A: High

480
Q

When are women offered antenatal testing for Down’s syndrome beyond the routine screening tests?

A

If the screening tests provide a risk score of greater than 1 in 150

481
Q

Methods of antenatal testing for Down’s syndrome:

A
  1. Chorionic villus sampling - USS guided biopdy of placental tissue, done before 15 weeks
  2. Amniocentesis - aspiration of amniotic fluid
  3. Non-invasive prenatal testing (NIPT) blood test
482
Q

How should a woman’s treatment for hypothyroidism be altered when she is pregnant?

A

Increase levothyroxine dose usually by at least 25-50 mcg

483
Q

Give three blood pressure medications that MUST be stopped in pregnancy:

A

ACEi
ARBs
Thiazide and thiazide-like diuretics

484
Q

Give three blood pressure medications that are SAFE to use in pregnancy:

A

Labetalol
CCBs
Alpha blockers e.g. doxazosin

485
Q

Name two anti-epileptic drugs avoided in pregnancy and why:

A
  1. Sodium valproate - neural tube degects and developmental delay
  2. Phenytoin - cleft lip and palate
486
Q

Name three anti-epilepsy drugs that are safer to use in pregnancy:

A

Levetiracetam
Lamotrigine
Carbamazepine

487
Q

What advise should a woman with rheumatoid arthritis be given before trying to get pregnant?

A
  1. Aim for three months of well controlled RA before getting pregnant
  2. RA symptoms may improve during pregnancy but worsen after delivery
  3. Some medications will have to be stopped e.g. methotrexate
488
Q

2 medications considered safe to use to treat rheumatoid arthritis in pregnant women:

A

Hydroxychloroquine

Sulfasalazine

489
Q

How do you treat a UTI in pregnancy?

A

7 days of an abx:

  • Nitro (avoid in 3rd trimester)
  • Amoxicillin (only if sensitivities known)
  • Cefalexin
490
Q

Why is nitrofurantoin avoided in the third trimester?

A

Risk of neonatal haemolysis

491
Q

Why is trimethoprim avoided in the first trimester?

A

Works as a folate antagonist, and known to cause congenital malformations e.g. spina bifida

492
Q

When is anti-D given to rhesus negative women?

A 
Routinely at:
- 28 weeks
- Birth
Also within 72 hours of any potential sensitisation event:
- Antepartum haemorrhage
- Amniocentesis
- Abdominal trauma
493
Q

What is the Kleihauer test?

A

A test to check how much fetal blood has passed into the mother’s blood during a sensitisation event.

Used after any sensitisation event past 20 weeks gestation to assess whether further anti-D is required.

494
Q

3 possible reasons for failure to progress in labour:

A
  1. Power - contractions not frequent or strong enough
  2. Passage - pelvis inadequate, fracture, fibroids etc.
  3. Passenger - position or presentation unsuitable, baby too big etc.
495
Q

When is external cephalic version done?

A

At 37 weeks to attempt to turn the baby to a cephalic position

50% success rate

496
Q

External cephalic version process:

A
  1. Give mum a tocolytic
  2. Both hands are pushed on the abdomen to disengage the baby from the pelvis and then push into correct position (under USS guidance)
  3. CTG straight after
  4. Anti-D given if mum rhesus -
497
Q

How do you manage a simple ovarian cyst in premenopausal women?

A

Less than 5cm: almost always resolve within three cycles, do not require follow up scan

5 to 7cm: require routine gynae and yearly USS

More than 7cm: consider MRI or surgical evaluation

498
Q

What is Meig’s syndrome?

A

A triad of:

  1. ovarian fibroma
  2. pleural effusion
  3. ascites

Typically in older women, requires removal of tumour

499
Q

What is urge incontinence?

A

Overactivity of the detrusor muscles.

Sudden urge to pass urine, unable to make it to the bathroom

500
Q

What is stress incontinence?

A

Weakness of the pelvic floor sphincter muscles allowing urine to leak at times of increased pressure on the bladder e.g. coughing, laughing

501
Q

What is mixed incontinence?

A

A combination of stress and urge incontinence

502
Q

What is overflow incontinence?

A

chronic urinary retention due to obstruction of outflow, results in incontinence without the urge to pass urine

503
Q

4 causes of overflow urinary incontinence:

A
  1. anticholinergic medications
  2. fibroids
  3. pelvic tumours
  4. neuro conditions e.g. MS, dibaetic nephropathy, spinal cord injuries
504
Q

4 modifiable lifestyle factors for urinary incontinence:

A
  1. caffeine
  2. alcohol
  3. medications
  4. BMI
505
Q

What is the modified oxford grading system of urinary incontinence?

A

used to assess strength of pelvic muscle contractions on bimanual examination (‘squeeze my fingers’)

0=no contraction
5=strong contraction

506
Q

How is urinary incontinence investigated? (4)

A
  1. bladder diary
  2. urine dipstick
  3. post-void residual bladder volume scan
  4. urodynamic tests
507
Q

Management of stress urinary incontinence:

A
  1. Lifestyle modifications
  2. Pelvic floor exercises
  3. Surgery
  4. Duloextine
508
Q

Management of urge urinary incontinence:

A
  1. bladder retraining
  2. anticholinergic medication e.g. oxybutynin
  3. Mirabegron (contraindicated in uncontrolled HTN)
  4. Invasive procedures e.g. botox injection
509
Q

What causes pelvic organ prolapses?

A

Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

510
Q

What is a uterine prolapse?

A

Where the uterus descends into the vagina

511
Q

What is a vault prolapse?

A

Occurs in women who have had a hysterectomy. The top of the vagina descends into the vagina.

512
Q

What is a rectocele?

A

A defect in the posterior vaginal wall allowing the rectum to prolapse forwards into the vagina.

513
Q

How does rectocele present? (3)

A
  1. constipation
  2. urinary retention
  3. palpable lump in the vagina
514
Q

What is a cystocele?

A

A defect in the anterior vaginal wall allowing the bladder to prolapse backwards into the vagina

515
Q

Risk factors for pelvic organ prolapse:

A
  1. multiple vaginal deliveries
  2. instrumental/prolonged/traumatic delivery
  3. advanced age
  4. obesity
  5. chronic coughing
  6. chronic straining (constipation)
516
Q

Management of pelvic organ prolapse:

A
  1. Conservative: physio, weight loss, tx of related symptoms, vaginal oestrogen cream
  2. Pessary to support pelvic organs: ring, shelf, cube, donut, hodge
  3. Surgery
517
Q

1st line medical tx for infertility in women with PCOS:

A

Letrozole

518
Q

When does the booking visit take place and what does it involve?

A 
Ideally before 10 weeks:
- General info on diet, folic acid etc
- BP
- Urine dipstick
- BMI
- FBC
- Rhesus status
- Red cell alloantibodies
- Haemoglobinopathies
INFECTIONS: 
- Hep B
- Syphilis
- HIV
- Urine culture
519
Q

How many antenatal visits are recommended in a first pregnancy if uncomplicated?

A

10

520
Q

How many antenatal visits are recommended in subsequent pregnancies if uncomplicated?

A

7

521
Q

When is the anomaly scan done? What does it involve?

A

18 to 20+6

Looks for 11 rare conditions

522
Q

What are the 11 rare conditions looked for on the anamoly scan?

A 
Anencephaly
Open spina bifida
Cleft lip
Diaphragmatic hernia
Gastroschisis
Exomphalos
Serious cardia abnormalities
Bilateral renal agenesis
Lethal skeletal dysplasia
Edward's syndrome
Patau's syndrome
523
Q

At what gestation are anaemia and atypical red cell alloantibodies checked for?

A

booking visit (8-12 weeks) and 28 weeks

524
Q

5 causes of oligohydramnios:

A
  1. Pre-eclampsia (hypoperfusion of placenta)
  2. fetal renal problems
  3. intrauterine growth restriction
  4. post-term gestation
  5. PROM
525
Q

What are postnatal blues?

A 
Occur in 50% of women
Evident by day 3, peaks at day 5, subsides within 10 days
Px:
- tearful
- irritable
- anxiety about baby
- poor concentraion
526
Q

How is postnatal depression different from postnatal blue?

A

Postnatal depression can last months and is less common

527
Q

What are puerperal psychoses?

A

Post-labour psychosis, incidence of 1 in1000 deliveries

Symptoms develop within first 2 weeks

Manic depression/schizophrenia with high suicide drive

528
Q

Following termination of pregnancy, how long might a pregnancy test remain positive for?

A

Up to four weeks

529
Q

5 indications for continuous CTG monitoring during labour:

A
  1. Suspected sepsis/temp >38
  2. Severe HTN, 160/110
  3. Oxytocin use
  4. Significant meconium
  5. Fresh vaginal bleeding that develops during labour
530
Q

What medication can be used to suppress lactation when ceasing breastfeeding?

A

Cabergoline

531
Q

What is a Rokintansky proturbance?

A

A histopathological sign seen in teratomas

532
Q

Presentation of a molar pregnancy: (4)

A
  1. Vaginal bleeding after amenorrhoea
  2. Hyperemesis gravidarum
  3. Passing of grape like vesicles
  4. Hyperthyroidism
  5. anaemia
  6. abnormal uterine enlargement
  7. resp distress
  8. pre-eclampsia
533
Q

What will imaging of a complete molar pregnancy look like?

A
  • Absent gestational sac

- Complex echogenic intrauterine mass with cystic space = snow storm appearance

534
Q

How do you manage complete and partial molar pregnancy?

A

Complete - surgical evacuation

Partial - medical termination

535
Q

What causes complete molar pregnancies?

A

An empty oocyte lacking maternal genes is fertilised.
All of the genetic material comes from the father.
There is no fetal tissue.

536
Q

What causes a partial molar pregnancy?

A

Two sperm fertilise the ovum at the ame time leading to three sets of chromosomes

537
Q

risk factors for molar pregnancy:

A
  1. maternal age <16 or >45
  2. multiple pregnancies
  3. previous molar pregnancy
  4. menarche over age of 12, hx of oral contracpetive, light menstruation
  5. asian women
  6. blood group A
  7. low protein, low folic acid, low carotene diet
538
Q

What is asherman’s syndrome?

A

Intrauterine adhesions, can be caused by dilation and curettage

539
Q

What is sheehan’s syndrome?

A

Hypopituitarism caused by ischaemic necrosis due to blood loss and hypovolaemic shock

540
Q

Features of sheehan’s syndrome:

A
  1. agalactorrhoea
  2. amenhorrhea
  3. hypothyroidism
  4. hypoadrenalism
541
Q

Proteinuria definitions:

A

Urine protein:creatinine ratio >30mg/mmol

Urine albumin:creatininge ratio >8mg/mmol

542
Q

Surgical treatment for fibroids >3cm:

A

Options include:

  1. uterine artery embolisation
  2. myomectomy
  3. hysterectomy
543
Q

What medication might be given to shrink a fibroid prior to surgery?

A

Goserelin or Leuprorelin (GnRH agonists)

544
Q

What are the IOTA “M” criteria?

A

Criteria that indicate a likely malignant ovarian cyst found on USS:

  1. Irregular, solid tumour
  2. Ascites
  3. At least 4 papillary structures
  4. Ireggular multilocular solid tumour with largest diameter >100mm
  5. Very strong blood flow

A woman with any of the “M” criteria should be referred to oncology.

545
Q

What are the IOTA “B” criteria?

A

Criteria that indicate a likely benign ovarian cysts:

  1. unilocular cyst
  2. smooth multilocular tumour <10cm
  3. presence of solid components <7mm in diameter
  4. presence of acoustic shadows
  5. no detectable doppler signal

Must have at least one of these features and no “m” criteria to be confidently considered benign

546
Q

Risk factors for placental abruption:

A 
proteinuric hypertension
    cocaine use
    multiparity
    maternal trauma
    increasing maternal age
547
Q

How should you treat group B strep if discovered prior to labour?

A

intrapartum intravenous benzylpenicillin is required to reduce neonatal transmission. An alternative would be clindamycin

3a (8 decks)

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