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Women's Health Flashcards

1
Q

Disorders of the Puerperium

What is puerperium?

A

The time from the delivery of the placenta to six weeks following the birth

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2
Q

Disorders of the puerperium

What are the 3 features of puerperium?

A
  • Return to pre-pregnant state
  • Initiation/suppression of lactation
  • Transition to parenthood
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3
Q

Disorders of the puerperium

What endocrinological changes are seen in the puerperium?

A

Profound decrease in serum levels of placental hormones:
* human placental lactogen, HCG, oestrogen and progesterone

Increased prolactin

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4
Q

Disorders of the puerperium

What happens to the uterus and genital tract during puerperium?

A

Involution of the uterus and genital tract
* Muscle: ischaemia, autolysis and phagocytosis
* Decidua: shed as lochia (rubra, serosa and alba)

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5
Q

Disorders of the puerperium

What happens to the breasts during puerperium?

A

Establishment of lactation - colostrum initially at birth
Lactation suppression takes 7-10 days

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6
Q

Disorders of the puerperium

What hormones are involved in lactogenesis and what do they do?

A

Prolactin: milk production
Oxytocin: milk ejection reflex

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7
Q

Disorders of the puerperium

What are the functions and features of prolactin?

A
  • Suppresses ovulation
  • Secreted by anterior pituitary gland and goes to the breast, lactocytes then produce milk
  • More is secreted at night
  • Levels peak after the feed to produce milk for the next feed
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8
Q

Disorders of the puerperium

What are the functions and features of oxytocin?

A
  • Produced by postrior pituitary gland –> breast –> myoepithelial cells contract and expel milk
  • Helped by sight, sound and smell of baby
  • Becomes conditioned over time
  • Hindered by anxiety, stress, pain and doubt
  • Works before and during the feed to make the milk flow
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9
Q

Disorders of puerperium

What are the 3 types of risks to infant feeding?

A

Risks of not breastfeeding
Risks of artificial feeding
Risks of not being at the breast

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10
Q

Disorders of the puerperium

What is lactoferrin?

A
  • Multifunctional protein in milk
  • 7x higher in colostrum than later milk
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11
Q

Disorder of the puerperium

What are the functions of lactoferrin?

A
  • Regulates iron absorption in intestines and delivery of iron to the cells
  • Protection against bacterial infection, some viruses and fungi
  • Involved in regulation of bone marrow function
  • Boosts immune system
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12
Q

Disorders of the puerperium

What are some examples of mild-moderate postnatal problems?

A

Infection
Post-partum haemorrhage
Fatigue
Anaemia
Backache
Breast engorgement/mastitis
Urinary stress incontinence
Hemorrhoids/constipation
The ‘blues’

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13
Q

Disorders of the puerperium

What are some examples of major postnatal problems?

A

Sepsis
Severe PPH
Pre-eclampsia/eclampsia
Thrombosis
Uterine prolapse
Incontinence
Post dural puncture headache
Breast abscess
Depression/psychosis

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14
Q

Disorders of the puerperium

What are the differences between sepsis, severe sepsis and septic shock?

A

Sepsis = infection + systemic manifestations of infection

Severe sepsis = sepsis + sepsis-induced organ dysfunction or tissue hypoperfusion

Septic shock = the persistence of hypoperfusion despite adequate fluid replacement therapy

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15
Q

Disorders of the puerperium

What are the risk factors for maternal sepsis?

A
  • Obesity
  • Diabetes
  • Anaemia
  • Amniocentesis/invasive procedures
  • Prolonged SROM
  • Vaginal trauma/CS
  • Ethnicity BME
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16
Q

Disorders of the puerperium

What are the most common causes of maternal sepsis?

A
  • Endometriosis
  • Skin and soft tissue infection
  • Mastitis
  • UTI
  • Pneumonia
  • Gastroenteritis
  • Pharyngitis
  • Infection related to epidural/spinal
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17
Q

Disorders of the puerperium?

What investigations should be performed for maternal sepsis?

A

3Ts, white with sugar
Temperature: <36 or >38C
Tachycardia: HR >90bpm
Tachypnoea: RR >20 bpm
WCC >12 or <4 x 10^9/L
Hyperglycaemia >7.7mmol

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18
Q

Disorders of the puerperium

What is the SEPSIS 6?

A

Blood cultures
Urine output
Fluid resuscitation
Antibiotics
Lactate
Oxygen

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19
Q

Disorders of the puerperium

What is a post partum haemorrhage and how is it classified?

A

Primary PPH: >500ml estimated blood loss after birth of the baby

Secondary PPH: abnormal or excessive bleeding from the birth canal between 24hrs and 12 weeks postnatally

Minor PPH: <1500mls and no signs of shock
Major PPH: >1500mls and signs of shock or continuing to bleed

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20
Q

Disorders of the puerperium

What are the causes of secondary PPH?

A
  • Endometriosis
  • Retained products of conception
  • Subinvolution of the placental implantation site
  • Pseudoaneurysms
  • Arteriovenous malformations
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21
Q

Disorders of the puerperium

What investigations should be performed for a PPH?

A

ABCDE
Assess blood loss
Assess haemodynamic status
Bacteriological testing (HVS and endocervical swab)
Pelvic ultrasound

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22
Q

Disorders of the puerperium

What are the high risk factors for venous thromboembolism?

A

Any previous VTE
Anyone requiring antenatal LMWH
High risk thrombophilia
Low risk thrombophilia and family history

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23
Q

Disorders of the puerperium

What is the prophylaxis of high risk VTE?

A

6 or more weeks of postnatal LMWH

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24
Q

Disorders of the puerperium

What are the moderate risk factors for VTE?

A

C-section
BMI >/= 40
Readmission or prolonged admission (>/= 3 days) during puerperium
Any surgical procedure except the immediate repair of the perineum
Medical comorbidities

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25
Q

Disorders of the puerperium

What is the prophylaxis of moderate risk VTE?

A

10 or more days postnatal LMWH

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26
Q

Disorders of the puerperium

What are the symptoms of post-dural puncture headache?

A

Headahce worse on sitting or standing, starts 1-7 days after spinal/epidural
Neck stiffness
Photophobia

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27
Q

Disorders of the puerperium

How is post-dural puncture headache managed?

A

Lying flat, simple analgesia, manage fluids and caffeine, epidural blood patch

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28
Q

Disorders of the puerperium

What is postnatal urinary retention?

A

The abrupt onset of aching or painless ability to completely micturate, requiring urinary cathetirisation, over 12 hrs after giving birth
OR
not to void spontaneously within 6hrs of vaginal delivery

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29
Q

Disorders of the puerperium

What are the risk factors for postnatal urinary retention?

A

Epidural analgesia
Prolonged second stage of labour
Forceps or ventouse delivery
Extensive perineal lacerations
Poor labour bladder care

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30
Q

Disorders of the puerperium

How is postnatal urinary retention managed?

A

Aims to:
* maintain bladder function
* minimise risk of damage to urethra/bladder
* provide appropriate management strategies for women who have problems with bladder emptying
* prevent long term problems with bladder emptying

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31
Q

Disorders of the puerperium

What are baby blues?

A

A period of feeling emotional and tearful around 3-10 days after giving birth, it normally only lasts a few days

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32
Q

Disorders of the puerperium

Whata are the 3 red flags for mental health disorders in the puerperium?

A
  1. Recent significant change in mental state or emergence of new symptoms
  2. New thoughts or acts of violent self-harm
  3. New and persistent expressions of incompetency as a mother or estrangement from the infant
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33
Q

Disorders of the puerperium

How does postnatal depression present?

A
  • 10% of new mothers
  • Depressed
  • Irritable
  • Tired
  • Sleepless
  • Appetite changes
  • Negative thoughts
  • Anxiety
  • Affects bonding
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34
Q

Disorders of the puerperium

How does postpartum psychosis present?

A
  • 1-2 in 1000 mothers affected
  • Depression
  • Mania (feeling elated or excited)
  • Rapid mood changes
  • Feeling confused or disorientated
  • Feeling restless
  • Being unable to sleep
  • Being unable to concentrate
  • Experiencing psychotic symptoms e.g., delusions, hallucinations
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35
Q

Disorders of the puerperium

What are the risk factors for postnatal post-traumatic stress disorder?

A
  • Perceived lack of care
  • Poor communication
  • Perceived unsafe care
  • Perceived focus on outcome over experience of the mother
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36
Q

Disorders of the puerperium

How does postnatal PTSD present?

A
  • Anger
  • Low mood
  • Self-blame
  • Suicidal ideation
  • Isolation
  • Dissociation
  • Intrusive and distressing flashbacks
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37
Q

Disorders of the puerperium

What are the consequences of postnatal PTSD?

A

Women may delay or avoid future pregnancies.

Request C-sections to avoid vaginal delivery.

Avoidance of intimate physical relationships.

Impact on breastfeeding.

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38
Q

Disorders of the puerperium

What is the definition of maternal death?

A

The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its managemnet, but not from accidental or incidental causes.

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39
Q

Disorders of the puerperium

What are some causes of maternal deaths?

A
  • Suicide
  • Infection
  • Obstetric haemorrhage
  • Hypertensive disorders e.g., pre-eclampsia/eclampsia
  • Non-obstetric complications
  • Obstetric complications
40
Q

Gynaecological malignancy

How does cancer metastasise?

A

Loss of adhesion, invasion, angiogenesis

41
Q

Gynaecological malignancy

What is apoptosis?

A

Normal, programmed cell death
It maintains cell population and prevents malignant transformation

42
Q

Gynaecological malignancy

What are tumour-suppressor genes?

A

Act as braking signals during the G1 phase of the cell cycle, to stop or slow the cycle before S phase

Mutations = uncontrolled growth

43
Q

Gynaecological malignancy

What are two examples of tumour-suppressor genes?

A

p53 - transcription factor, regulates cell devision and cell death
Rb - alters activity of transcription factors and controls cell division

44
Q

Gynaecological malignancy

What do oncogenes do?

A

Stimulate development of cancer.
In normal cells, they contribute to the development of cancer by instructing cells to make proteins that stimulate excessive cell growth and division.

45
Q

Gynaecological malignancy

What is the most common gynaecological cancer in the UK?

A

Endometrial

46
Q

Gynaecological malignancy

What are the risk factors of endometrial cancer?

A

Unopposed oestrogen
* obesity
* type 2 diabetes
* nulliparity
* late menopause
* ovarian tumours (granulosa)
* oestrogen only HRT
* pelvic irradiation
* tamoxifen
* PCOS
* Lynch syndrome

47
Q

Gynaecological malignancy

What is the most common presenting complaint in women with endometrial cancer?

A

Post-menopausal bleeding

48
Q

Gynaecological cancer

What investigations are performed for endometrial cancer?

A

Transvaginal ultrasound
Endometrial biopsy
Hysteroscopy

49
Q

Gynaecological malignancy

What is the management of endometrial cancer?

A

Surgery: hysterectomy +/- pelvic nodes
Radiotherapy: adjuvant
Progesterone therapy

50
Q

Gynaecological malignancy

What are the risk factors for cervical cancer?

A
  • High risk HPV
  • Missed vaccination
  • Early age intercourse
  • Multiple sexual partners
  • STDs
  • Previous CIN
  • Immunosuppression
  • Oral contraceptive pill
  • Cigarette smoking - more persistent HPV
51
Q

Gynaecological malignancy

What organisms are associated with cervical cancer?

A

HPV 16 and 18 most commonly

52
Q

Gynaecological mallignancy

What is the management of cervical cancer?

A

Stage 1 - LLETZ or hysterectomy depending on size
Stages 2+ - radiotherapy, chemotherapy, palliative care

53
Q

Gynaecological malignancy

What conditions are associated with an increased risk of vulval cancer?

A

High risk HPV and lichen sclerosis

54
Q

Gynaecological malignancy

How does vulval cancer present?

A
  • Vulval itching
  • Vulval soreness
  • Persistent lump
  • Bleeding
  • Pain on passing urine
  • Past history of VIN or lichen sclerosis
55
Q

Gynaecological malignancy

How does ovarian cancer present?

A
  • asymptomatic
  • bloating/IBS like symptoms
  • abdominal pain/discomfort
  • change in bowel habit
  • urinary frequency
  • bowel obstruction
  • 75-79 years old most common
56
Q

Gynaecological malignancy

What are the risk factors associated with ovarian cancer?

A

Ovulation: menarche, menopause, parity, breast feeding, oral contraceptive pill, hysterectomy, ovulation induction
Genetic: BRCA 1/2 and Lynch syndrome

57
Q

Gynaecological malignancy

What investigations should be performed for ovarian cancer?

A

CA125
Ultrasound

58
Q

Gynaecological malignancies

What is the management of ovarian cancer?

A

Surgery and chemotherapy

59
Q

Maternal conditions

What is pre-eclampsia and how does it present?

A

Hypertension (>140/90) and proteinuria
* Asymptomatic
* Headahce
* Malaise
* Vomiting
* Epigastric/right upper quadrant pain
* Visual disturbance
* Flashing lights
* Leg swelling
* Hyperreflexia

60
Q

Maternal conditions

What is eclampsia characterised by?

A

Tonic-clonis seizures

61
Q

Maternal conditions

What are the maternal complications of pre-eclampsia?

A

Renal failure
Liver failure
Cerebral haemorrhage
HELLP syndrome
Papilloedema
Pulmonary oedema
Placental abruption
Disseminated intravascular coagulation
Eclampsia
Death

62
Q

Maternal conditions

What is HELLP syndrome?

A

Haemolysis (low Hb)
Elevated Liver enzymes
Low Platelets

63
Q

Materanl conditions

What are the foetal complications of pre-eclampsia?

A

Intrauterine growth restriction
Intrauterine death
Iatrogenic preterm delivery

64
Q

Maternal conditions

How is pre-eclampsia managed?

A

Labetalol
Steroids for lung maturity
Induction of labour and avoid ergometrine
May need C-section

65
Q

Maternal conditions

How does obstetric cholestasis present?

A

Pruritis and jaundice

66
Q

Maternal conditions

What investigations should be performed for obstetric cholestasis?

A

Weekly monitoring
* LFTs
* serum bile acids
* liver screen
* liver USS (normal)

67
Q

Maternal conditions

How is maternal cholestasis managed?

A

Topical emollients
Antihistamines
Ursodeoxycholic acid
Vitamin K
Foetal monitoring
IOL at 37 weeks

68
Q

Maternal conditions

What are the foetal complications of obstetric cholestasis?

A
  • Increased risk of pre-term labour
  • Intrauterine death
  • Iatrogenic prematurity
  • Meconium stained liquor
69
Q

Maternal conditions

What are the maternal complications of obstetric cholestasis?

A
  • Vitamin K deficiency
  • Increased risk of PPH
  • Increased risk in future pregnancies
70
Q

Maternal conditions

What are the foetal complications of maternal diabetes?

A

Increased risk of:
* congenital anomalies
* perinatal mortality
* macrosomia
* shoulder dystocia
* polyhydramnios

71
Q

Maternal conditions

What are the maternal complications of diabetes?

A

Diabetic nephropathy and retinopathy may deteriorate
Increased risk of miscarriage, pre-eclampsia and operative delivery

72
Q

Maternal conditions

What is the management of maternal diabetes?

A

Increased insulin requirement
Oral hypoglycaemics avoided
Strict glycaemic control
IOL at 38-39 weeks

73
Q

Maternal conditions

What are the foetal complications of epilepsy in pregnancy?

A

Some anti-epileptics are teratogenic
Increased risk of neural tube defects, orofacial clefts and heart defects

74
Q

Maternal conditions

What is the management of epilepsy in pregnancy?

A

Folic acid 5mg - reduces neural tube defects
Adjust medication
Vitamin K from 36 weeks due to risk of haemorrhagic disease of the newborn

75
Q

Foetal conditions

What genetic abnormality causes Down’s syndrome?

A

Trisomy 21

76
Q

Foetal conditions

What screening tests are available for Down’s syndrome in pregnancy?

A

The combined test
Quadruple test

77
Q

Foetal conditions

When is the combined test for Down’s syndrome performed?

A

Between 11-13+6 weeks

78
Q

Foetal conditions

What tests are included in the combined test for Down’s syndrome and what results are suggestive of the condition?

A

Nuchal translucency = thickened
Serum B-hCG = raised
Pregnancy-associated plasma protein A (PAPP-A) = reduced

79
Q

Foetal conditions

When is quadruple test performed for Down’s syndrome?

A

In women booking late, between 15-20 weeks

80
Q

Foetal conditions

What tests are included in the quadruple test for Down’s syndrome and what results are suggestive of this condition?

A

Alpha-fetoprotein = reduced
Unconjugated oestriol = reduced
Human chorionic gonadotrophin = raised
Inhibin A = raised

81
Q

Foetal conditions

What is the pathophysiology of rhesus disease?

A

Rhesus -ve mothers with a rhesus +ve foetus

Blood mixes (may be during delivery, placental abruption, invasive procedures, miscarriage etc) and maternal IgM antibodies are produced to the Rh antigen but do not cross the placenta.

In future pregnancies, IgG is produced which crosses placenta and causes haemolytic disease of the foetus.

82
Q

Foetal conditions

What are the foetal complications of rhesus disease?

A

Haemolytic disease, intrauterine growth restriction, hydrops fetalis, death

83
Q

Foetal conditions

How is rhesus disease prevented?

A

Give anti-D IgG to all rhesus -ve mothers

84
Q

Foetal conditions

What are the risk factors for intrauterine growth restriction?

A
  • poor nutrition
  • smoking
  • alcohol
  • drug abuse
  • maternal disease
  • in-utero infection
  • placental insufficiency
85
Q

Obstetric complications

What are the causes of antepartum haemorrhage?

A

Placental abruption
Placenta praevia
Vasa praevia
Miscarriage
Ectopic pregnancy
Cervical/vaginal mass

86
Q

Obstetric complications

What is placenta praevia?

A

A placenta that is partially or wholly covering the lower uterine segment/the cervix

87
Q

Obstetric complications

How does placenta praevia present?

A

May be asymptomatic
Associated with painless PV bleeding

88
Q

Obstetric complications

How is placenta praevia diagnosed?

A

Uusally on the 20 week anomaly scan
Another scan in third trimester as placenta may move away from the lower segment

89
Q

Obstetric complications

What is the management of placenta praevia?

90
Q

Obstetric complications

What is placental abruption?

A

Premature separation of the placenta from the uterine wall

91
Q

Obstetric complications

What are the risk factors for placental abruption?

A
  • Trauma
  • Following rupture of membranes
  • Multiple pregnancy
  • Polyhydramnios
  • Pre-eclapmsia
  • Smokers
92
Q

Obstetric complications

How does placental abruption present?

A

Painful PV bleeding, may present as abdominal pain without foetal/meternal compromise
‘Woody’ hard uterus

93
Q

Obstetric complications

What are the risk factors for preterm labour?

A
  • Acute illness
  • Low BMI
  • Multiple pregnancy
  • Polyhydramnios
  • Preterm rupture of membranes
  • Previous cervical surgery
  • Smoking
  • Previous preterm delivery
  • Uterine abnormalities
94
Q

Obstetric complications

What are the indications for induction of labour?

A

Postmaturity
Pre-labour rupture of membranes
Suspected IUGR
Obstetric cholestasis
Gestational diabetes
Pre-eclamptic toxaemia
Intrauterine death
Maternal request

95
Q

Obstetric complications

What is used for induction of labour?

A

Membrane sweep, artificial rupture of membranes, cervical balloon
Medical: vaginal prostaglandins, oxytocin infusion

Phase 3a (10 decks)

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