Women's health Flashcards
1
Q
What is the classic presentation of placenta previa?
A
Painless vaginal bleeding in the third trimester. Bright red. Often stops spontanously
2
Q
What is placenta praevia?
A
Abnormal placenta or covering of the cervical os
3
Q
What are the types of placenta praevia?
A
Complete and marginal
4
Q
What is the definition of complete placenta praevia?
A
Complete coverage of the cervical os by placenta
5
Q
What is the defintion of marginal placenta praevia?
A
Leading edge of placenta is less than 2 cm from internal os, but not fully covering
6
Q
What is the inherent risk of placenta praevia?
A
Haemorrhage
7
Q
What causes the bleeding in the third trimester due to placenta pravia?
A
Develpent of lower uterine segment in third trimester, placental attachment is thinned in preparation of labour
8
Q
What is the cause of placenta praevia?
A
Placental implantation is initiated by the embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the placenta having undergone atrophic changes could persist as a vasa previa.
9
Q
What are the risk factors of placenta praevia?
A
Advancing maternal age, infertility treatment, previous c-section, multiparity, multiple gestation, short interpregnancy interval, previous uterine surgery or injury, previous or recurrent abortions, previous placentapraevia, nonwhite ethnicity, low socioeconomic status, smoking, cocaine use
10
Q
What are the maternal complications of placenta praevia?
A
Haemorrhage, placental abruption, preterm delivery, post partum endometritis, mortality, septicemia, thrombophlebitis, need for hysterectomy
11
Q
What are the fetal complications of placenta praevia?
A
Congenital malformations, low birth weight, SIDS, intrauterine growth restriction, jaundice, neonatal respiratory distress, abnormal foetal presentation, foetal anemia and Rh isoimmunization,
12
Q
What should be aboided in patients with previous placenta praevia?
A
Decrease activity, avoid pelvic exam and intercourse maintain iron and folate,
13
Q
What can be seen in the examination ofa patient with placenta praevia?
A
Haemorrhage, hypotension, tachycardia, soft, nontender uterus, normal foetal heart tones
14
Q
What tests should be used to investigateplacenta pravia?
A
Rhcompatibility, fibrin split products, fibrinogen, PT aPTTT, FBC, blood type,
15
Q
What imaging tests should be used to investigate placenta praevia>
A
US, transvaginal,, transabdominal, transperineal, translabial, MRI to plan pregnancy
16
Q
How can haemorrhage be controlled during birth?
A
Oversewing the placental implantation site
Bilateral uterine artery ligation (O’Leary stitch)
Internal iliac artery ligation
Circular interrupted ligation around the lower uterine segment both above and below the transverse incision
Packing with gauze or tamponade with the Bakri balloon catheter
B-lynch stitch
Cesarean hysterectomy
17
Q
What is placental abruption?
A
Premature separation of placenta from uterus
18
Q
What does placental abruption usually present with?
A
Bleeding, uterine contractions, fetal distress, decreased foetal movement, abdominal or back pain, uterine tenderness, history of trauma, in second half of pregnancy
19
Q
What are the complications of a placental abruption?
A
Haemorrhage into the decidua basalis, haematoma formation, separation of placenta from uterine wall, disruption of foetal blood flow, retroplacental blood in the peritoneal cavity, myometrium rupture
20
Q
What is the classisification of placental abruption?
A
Class 0, 1, 2, 3
21
Q
What are the characteristics of a class 0 placental abruption?
A
Asymp, diagnosis made after birth looking at organised blood clot in the placenta
22
Q
What are the characteristics of a class 1 placental abruption?
A
No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress
23
Q
What are the characteristics of a class 1 placental abruption?
A
No vaginal bleeding to moderate vaginal bleeding
Moderate to severe uterine tenderness with possible tetanic contractions
Maternal tachycardia with orthostatic changes in BP and heart rate
Fetal distress
Hypofibrinogenemia (ie, 50-250 mg/dL)
24
Q
What are the characteristics of a class 1 placental abruption?
A
No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia (ie, < 150 mg/dL) Coagulopathy Fetal death
25
Name 10 risk factors of placental abruption
High maternal age, low maternal age, smoking, cocaine use, alcohol, short placenta, maternal hypertension, retroplacental bleeding, idiopathic, retroplacental fibromyoma, male baby, maternal trauma, sudden decompression of uterus, previous placental abrubtion, prolonged rupture of membranes, low socioeconomic status
26
What are the signs of suspected foetal compromise?
Prolonged fetal bradycardia, repetitive, late decelrations, absence of foetal heart sounds, decreased short-term variability
27
What lab tests should be used to investigate placental abruption?
FBC, Fibrinogen, PT, aPTT, renal function tests, blood and Rh types, kleihuaer betke test
28
Why should renal function tests be done in patients with haemorrhage?
The hypovolemic condition brought on by a significant abruption also affects renal function.
29
Why should coagulation studies be done on patients with bleeding?
Can have disseminated intravascular coagulation
30
What is the kleihauer-betke test?
Finding foetal RBCs in maternal circulation, used for rH incompatible mothers
31
What imaging studies should be done on a patient with placental abruption?
US, non stress test,
32
What is the initial managemnt of placental abruption?
Continuous foetal monitoring, IV access, fluid resus, type and cross match blood, transfusion if needed, correct coagulopathy if present, give Rh immune globulin if necescary, corticosteroids for prem baby
33
When i vaginal delivery used for placental abruption
If foetal death has occurred due to placental abruption
34
What are the four classifications of hypertension in pregnancy?
Chronic hypertension preeclampsia -eclampsia, preeclampsia + chronic hypertension, transient hypertension of pregnancy
35
What is preclampsia?
Disorder of widespread vascular endothelial malfunction and vasospasm defined by hypertension and proteinuria
36
When can preeclampsia occur?
20 weeks gestation to 6 weeks post partum
37
What is the definition of preeclampsia?
BP >=140 mmhg or >=90mmhg, in two occasions, 4 hours apart or bp >= 160/110
38
What are the rf for preeclampsia?
Nulliparity, age over 40, black, chronic hypertension, renal disease, DM, BMI, twin gestation, antiphospholipid syndrome, family history antiotensinogen gene
39
What are the signs and symptoms of preeclampsia?
Headache, visual disturbances, altered mental status, dyspnea, oedema, weakness, malaise, clonus, blindness, epigastric or ruq abdo pain
40
What is eclampsia?
Seizures in a women with no other cause other than preeclampsia
41
What lab tests can be used to diagnose preeclampsia?
FBC, LFTs, uric acid, urine dipstic, US, cardiotocography
42
What is the management of severe preeclampsia?
Birth
Primary management is to stabilise Bp and prevent eclampsia (with the use of mg sulfate and aim for the delivery of the baby), fluid restriction (to prevent pulmonary oedema)
43
What is the criteria for delivery in preeclampsia?
Signs of foetal distress, ruptured membranes, uncontrollable BP, oligohydramnios, severe uterine growth restriction, severe oligouria, pulmonary oedema, severe serum creatinine, placental abruption, eclampsia, abdo tenderness, headache, low platelet count
44
What is the relationship between thromboembolism and pregnancy?
Pregnancy increases the risk of thromboembolism 4-5 times
45
What are the two manifestations of venous thromboembolisms?
DVT and PE
46
What are the complications of venous thromboembolisms
Pulmonary hypertension, post thrombotic syndrome, venous insufficiency
47
What tests are done in thromboembolisms and pregnancy?
Doppler US
48
How are thromboemnbolisms managed in pregnancy?
Low molecular weight Heparin
49
How does pregnancy cause thromboembolism
Hypercoagulability
50
What factors are increased in pregnancy (clotting cascade factors)
I, II, VII, VIII, IX, X
51
What is the definition of gestational diabetes?
Glucose intolerance with onset or first recognition in pregnancy
52
What tests are used for diagnosing DM in pregnancy?
Glucose challenge test, OGTT
53
What antenatal testing must be done in the first trimester for gestational DM?
```
HbA1C
Blood urea nitrogen (BUN)
Serum creatinine
Thyroid-stimulating hormone
Free thyroxine levels
Spot urine protein-to-creatinine ratio
Capillary blood sugar levels
```
54
What antenatal testing must be done in the second trimester for gestational DM?
Spot urine protein-to-creatinine study in women with elevated value in first trimester
Repeat HbA1C
Capillary blood sugar levels
55
What antenatal imaging must be done for gestational DM?
First trimester - Ultrasonographic assessment for pregnancy dating and viability
Second trimester - Detailed anatomic ultrasonogram at 18-20 weeks and a fetal echocardiogram if the maternal glycohemoglobin value was elevated in the first trimester
Third trimester - Growth ultrasonogram to assess fetal size every 4-6 weeks from 26-36 weeks in women with overt preexisting diabetes; perform a growth ultrasonogram for fetal size at least once at 36-37 weeks for women with gestational diabetes mellitus
56
What is the management of gestational diabetes?
Diet, insulin, glyburide, metformin, prenatal obstertic management, management of neonate
57
What are the maternal complications of gestational diabetes?
Diabteic retinopathy, renal disease, hypertension
58
What are the foetal complications of gestational diabtes?
Miscarriage, birth defects, neural tube defects, cardiovascular defects, growthrestriction in t1D, obesity,high BW (marcrosomia), metabolic syndrome, SV rf, perinatal mortality, birth injury, resp problems,post natal hyperbilirubinaemia, resp problems, hypocalcemia
59
What are the rf for gestational diabetes?
Severe obesity, FH, PMH, glycosuria, polycystic ovarian syndrome
60
What is the rhesus factor?
RBC surface antigen
61
What is Rh incompatibility?
Women with Rh- blood is exposed to Rh+ blood and develops Rh antibodies
62
How can Rh incompatibility occur?
Exposure secondary to fetomaternal haemorrhage during pregnancy (Spontaneous or induced abortion, trauma, obstetric procedures, delivery), exposure duue to rh+blood transfusion
63
How long do Rh antibodies last once produced?
Forever
64
What can maternal Rh antibodies do to a fetus?
Haemolytic anaemia
65
Why are first borns usually not affected by Rh incompatibility?
Maternal Rh antibodies take a month to circulate after sensitization
66
What does sensitization refer to in rh incompatibility?
Exposure of Rh+ blood to Rh- mother that starts the production of Rh antibodies
67
What are the factors that affect the risk and severity of sensitization in Rh incompatibility?
Multiparity, volume of trnasplacental haemorrhage, extent of maternal immune response, concurrent presence of ABO incompatibility
68
What occurs in infants mildly affected by Rh incompatibility?
little to no anaemia, hyperbilirubinaemia
69
What occurs in infants moderately affected by Rh incompatibility?
Anaemia + hyperbilirubinaemia/jaundice
70
What occurs in infants severely affected by Rh incompatibility?
Kernicterus
71
What is kernicterus?
Neurological syndrome caused by deposition of bilirubin into CNS
72
What are the signs and symptoms of kernicterus?
Loss of moro reflex, posturing, poor feeding, inactivity, bulging fontanelles, high-pitched, shrill, cry, seizures
73
How long does kernicterus take to develop?
Several days after delivery
74
What are the complications of kernicterus?
Hypotonia, hearing loss, mental retardation
75
What is erythroblastosis fetalis?
Life threatening complication of Rh incompatibility in infants, characterised by hemolytic anemia and jaundice
76
What are the causes of Rh incompatibility (name 5)
Ectopic pregnancy placenta praevia, placental abruption, abdominal, pelvic trauma, lact of prenatal care, invasice obstetric procedures, spontaneous abortion, in utero feotal death
77
What tests are used to diagnose Rh incompatibility?
Rosette screening test, Kleihauer-Betke, determination of rh blood type
78
What are the postnatal tests done in Rh inncompatibility?
Examine cord blood for fetal blood type, Coomb test for antibiotic caused haemolytic anaemia, elevated serum bilirubin,
79
What is intrahepatic chlestasis of pregnancy?
Reversiblehormone influenced cholestasis developed in late pregnancy to genetically predisposed individuals
80
What is the pathophysiology of intrahepatic cholestasis o pregnancy>
Defect in excretion of bile salts > increased serum bile acids > deposited in skin > pruritus
81
What are the complications of intrahepatic cholestasis of pregnancy?
Pruritus, Sudden foetal death
82
What is usually done in intrahepatic cholestasis of pregnancy?
Induced birth
83
When is the preferred delivery time in intrahepatic cholestasis of pregnancy?
37 weeks
84
What is the typical presentation of intrahepatic cholestasis of pregnancy?
Pruritis, no rash, starts on sole of feet and palms progressint to trunk and face, worse at night. Steatorrhea, vit K deficiency, jaundice
85
What are the lab tests for intrahepatic cholestasis of pregnancy?
Serum bile acid, bilirubin, LFTs, cholic acid, chenodeoxycholic acid, transaminase, PT,PTT, INR
86
What medications are used to treat intrahepatic cholestasis of pregnancy?
Phenobarbitol, hydroxyzine, glutathione precursors, dexamethasone, cholestyramie, ursodeoxycholic acid, antihistamines
87
What is the defintion of breech presentation?
Foetus is in a longtitudinal lie withbuttocks or feet closest to cervix
88
Does increasing gestational age increase or decrease the incidence of breech presentation?
Decrease
89
What are the predisposing factors of breech presentation?
Prematurity, uterine malformation, fibroids, polyhydramnos, placenta previa, foetal abnormalties (CNS malformation, neck masses, aneuploidy), multiple gestations
90
What are the types of breech presentation?
Frank breech, comlete breech, footling
91
What is the definition of a frank breech?
Hips flexed, knees extended (pike position)
92
What is the defintion of a complete breech?
Hips and knees flexed (cannonball position)
93
What is the defintion of footling or incomplete breech presentation
One or both hips extended, foot presenting
94
What is the mort common type of breech?
Frank
| ly my dear, I don't give a damn
95
What are the types of vaginal breech delivery?
Spontaneous, assissted, total breech extraction
96
What is the most commpn type of vaginal breech delivery?
Assisted
97
What occurs in assisted breech delivery?
Infant spontanously delivers up till umbilicus, maneuvers are initiated to assit to deliver the rest of the baby
98
Whe is spontanous breech delivery used?
Preterm or nonviable deliveries
99
What occurs in total breech extraction?
Fetal feet are grasped, fetus is extracted
100
When is total breech extraction used?
For second twin
101
What are the complications of vaginal breech delivery?
Fetal head entrapment, nuchal arms, cervical spine injury, cord prolapse
102
What is the process for a vaginal breech delivery?
| 12 steps
Fetal membranes are left intact as long as possible, pinard maneuver to facilitate delivery of legs, no trction exerted on foetus til umbilicus is past the perinum, dry towl arounf infant;s hips to help traction, assistant applies transfundal pressure, once scapula is visible, rotate infant 90o and sweep ant. arm out of vagina by pressing on inner elbow, rotate babie 180o in reverse direction, get other arm out, rotate baby till back is anterior, fetal head should be maintained flexed, take baby out
103
WHat are the types of twins?
Monozygotic, dizygotic, [dichorionic, diamniotic], [monochorionic, diamniotic], [Monochorionic, monoamniotic]
104
What type of twins are dizygotic twins?
Dichorionic diamniotic
105
When must the egg split to create dichorionic, diamniotic monozygotic twins?
0-3 days aft fertilization
106
When must the egg split to create monochorionic, diamniotic monozygotic twins?
4-8 days aft fertilization
107
When must the egg split to create monochorionic, monoamniotic monozygotic twins?
8-12 days post fetilization
108
When must the egg split to create conjioned twins?
13 days aft. fertilization
109
What is the foetal complications of multifetal birth?
Prem, twin-twin transfusion sundrome, cerebral palsy, still birth, neonatal death
110
What is the maternal complications of multifetal birth?
Preterm labour, preterm premature rupture of membranes, PE, placental abruption, preeclampsia, postpartum haemorrhage
111
What is the most reliable test to detect multifoetal pregnancy?
Ultrasound
112
What is the definition of labour?
Physiological process during which fetus, membranes, umbilical cord and placenta are expelled from the uterus
113
How many stages of labour are there?
3
114
What does the first stage of labour begin and end with?
Regular uterine contractions and ends with complete cervical dilation at 10 cm
115
WHat is the first stage of labour devided into?
Latent and active phase
116
What occurs in the latent phase of the first stage of labour?
Mild, irregular uterine contractions that soften and chorten the cervix, contractions become more rhythmic and stronger
117
What occurs in the active phase of the first stage of labour?
starts with 3-4 cm of cervical dilation, characterized by rapid cervical dilation and decent of pr`esenting fetal part
118
What does the second stage of labour begin and end with?
Complete cervical dilation
| ends with delivery of fetus
119
What is considered prolonged labour in a nulliparous woman?
>3 hours w/ regional anaesthesia >2 hrs without anaesthesia
120
What is considered prolonged labour in a multiparous woman?
>2 hours w/ regional anaesthesia >1 hrs without anaesthesia
121
What does the third stage of labour begin and end with?
Delivery of fetus
| delivery of placenta and fetal membranes
122
What is considered prolonged for the third stage of labour?
>30 min
123
How can the third stage of labour be actively managed?
Oxytoxin, prostaglandins, ergot alkaloids, cord clamping, cutting, controlled traction of umbilical cord
124
What are the seven steps in the mechanism of labour?
```
Engagement
descent
flexion
internal rotation
extension
restitution and external rotation
expulsion
```
125
What management can be done in the first stage of labour?
Helping woman find a comfy position, periodic assessment of frequency and strength of contractions, changes in cervix and fetus station and position
Monitoring of HR
126
What management can be done in the second stage of labour?
Continuing observation, forceps, vacuum or c-section
Help mum find a comfy position
Episiotomy
Delivery maneuvers
127
What are the delivery maneouvers?
Head held in mid position till delivery, check fetus neck for wrapped umbilical cord, deliver ant. shoulder, help deliver post. shoulder, gentle traaction, cord cut, baby is stimulated then dried
128
What are the three signs that indicate that the placenta has seprated from the uterus?
Uterus contracts and rises, umbilical cord suddenly lengthens, gush of blood
129
What pain relief can be given to delivering mothers?
Meperidine, fentanyl, nalbuphine, butorphanol, morphine
130
What anaesthesia can be given to expectant mothers?
Epidural, spinal, combined
131
What is preterm labour?
Presence of uterine contractions of sufficient frequency and strength to effect progressive3 effacement and dilation of cervix prior to term gestation
132
What is the window of defintion of preterm labour?
20-27 weeks gestaation
133
What are the risks/causes of preterm labour?
Decidual haemorrhage, (abruption), uterine overdistention (multiple gestation, polyhydramnios), cervical incompetence (trauma, cone biopsy), uterine distortion, cervical inflammation, maternal inflammmation/fever, hormonal changes, uteroplacental insufficiency
134
what can cause uteroplacental inufficiency
Hypertension, insulin dependent diabetes, drug abuse, smoking, alcohol consumption
135
What can be done in a physical assessment for preterm labour?
Integrity of cervix with digital and speculum, cervical length (short cervical length is a warning sign)
136
What lab tests can be used for risk assessment of preterm labour/
```
Rapid plasma reagin test
Gonorrheal and chlamydial screening
Vaginal pH/wet smear/whiff test
Anticardiolipin antibody (eg, anticardiolipin immunoglobulin [Ig] G and IgM, anti-beta2 microglobulin)
Lupus anticoagulant antibody
Activated partial thromboplastin time
One-hour glucose challenge test
TORCH
```
137
What medications can be used to manage preterm labour (or reduce the risk)
Progesterone reduces the risk, tocolytic agents can reduce contractions (mg sulphate, indomethacin, nifedipine)
138
What is shoulder dystocia?
One or both shoulders become impacted against the bones of the maternal pelvis, as shown in the image below
139
Why does shoulder dystocia occur?
Either the shoulder dimensions are too large or maternal pelvis is to narrow to permit shoulder rotation to oblique pelvis
140
What are the direct antenatal RF of shoulder dystocia?
PH, fetal macrosomia, diabtes, impaired glucose tolerance,
141
What are the rf of moacrosomia?
Excessive weight gain during pregnancy, maternal obesity, asymmetric accelerated fetal growth postterm pregnancy, parity,
142
What are the intrapartum rf for shoulder dystopia?
Precipiuous second stage (<20min) operative vaginaldelivery, prolonged second stage
143
What are the contraindications for management in shoulder dystocia ( and why)
```
Fundal pressure (increases risk of permanant brachial plexus injury),
Strong lateral traction, head rotation beyond 90o
```
144
What fetal maneuvers can be used to treat shoulder dystocia>
Rubin, post-arm delivery, woods screw, cephalic replacement, shute forceps, cleidotomy
145
What maternal maneuvers can be used to treat shoulder dystocia?
McRoberts, ramp, lateral decubitis, all fours, suprapubic pressure, symphysiotomy
146
What are the complications of shoulder dystocia?
Postpartum haemorrhage, perineal laceration, neonatal claviacl fracture, fractured humurus, brachial plexus injury, neonatal hypoxic ischaemic encephalopathy, sudden fetal circulatory collapse
147
What is the definition of intrauterine growth restriction?
Conditions that cause the fetus to not achieve it's genetically determined potential size
148
What are the maternal causes of intrauterine growth restriction?
Chronic hypertension, pregnancy associated hypertension, cyanotic HD, diabetes, hemoglobinopathies, autoimmune disease, protein calorie malnutrition, smoking, substaance abuse, uterine malformations, thrombophilias, prolonged high altitude exposure
149
What are the placental or umbilical causes of intrauterine growth restriction?
Placental abnormalities, twin to twin ttransfusion syndromes, chronic abruption, placenta praevia, cord abnormalities, abnormal cord insertion, multiple gestations
150
What is the pathophysiology of intrauterine growth restrictions?
Gas exchange and nutrient delivery to fetus isn't suffiecient for it to thrive
151
What tests can be done to investigate intrauterine growth restriction?
Fetal karyotype, maternal serology for infectious processes, environmetal exposure history, US
152
What are the complications of IUGR?
C section, death, prematurity, compromise in labour, need for induced labour
153
What can cause increased mortality of fetuses in IUGR?
NEC, thrombocytopenia, temp instability, renal failure
154
How is IUGR screened for?
Fundal height from US
155
What is the definition of postterm pregnancy?
Extends after 42 weeks
156
WHat are the three management plans of postterm pregnancy?
Elective labour induction, expectant pregnancy management, antenatal testing
157
What are the fetal and neonatal risrks of postterm pregnancy?
SIDS, perinatal mortality, asphyzia, inttrauterne infection, meconium aspiration, neonatal acidaemia, low apgar scores, macrosomia, birth injury, prolonged labour, shoulder dystocia, cepahalopelvic disproportion, postmaturity
158
What are the maternal complications of postterm pregnancies?
Labor dystocia, perineal injury, c section, emotional impact, hamorrhage, enomyometritis
159
What is episiotomy?
Surgical incision of perineum performed to widen vaginal opening
160
What are the short-term benefits of episiotomy?
Ease of repair compared to spontaneous laceration, reduction of laceration, decreased postpartum pan
161
What are the long term benefits of episiotomy?
Prevents prolapse, sexual dysfunction, incontinence, asphyxiam cranial trauma, cerebral haemorrhage, shoulder dystoia
162
What are the complications of episiotomy?
Extension of severe perineal lacerations, dyspareunia, pelvic floor dysfunction
163
What are the indications for episiotomies?
difficult deliveries, delivery in nonreassuring fetal status, to avoid serious maternal laceration
164
What are the contraindications to episiotomy?
In vaginal delivery, need consent,, not in IBD and severe perineal malformations
165
What i the leading cause of maternal mortality?
Post-partum haemorrhage
166
What is the definition of postpartum haemorrhage?
Blood loss>500mL following vaginal delivery or >1000mL following c-section
167
What are the risk factors of postpartum haemorrhage?
Retained placenta, failure to progress during the second stage of labour, placenta accreta, lacerations, instrumental delivery, large for dates baby, hypertensive disorders, induction of labour, augmentation of labour with oxytocin, obesity, SNRIs
168
What are the causes of postpartum haemorrhage?
Tone, tissue, trauma, thrombosis
169
How can post partum haemorrhages be prevented?
Active management of the third stage of labour
170
What does the active management of labour entail?
Oxytocin upon delivery of baby
Early cord clamping anf cutting
gentle cord traction when uterus is well contracted
171
What are the presentation symptoms of postpartum haemorrhage?
Apart from MASSIVE BLOOD LOSS?
| Hypovolaemic shock: Palpitations, tachycardia, dizziness, weakness, sweating, pallor, oligouria, collapse, ar hunger
172
What tests postpartum haemorrhage?
FBC, baseline coag, crossmatch thould be reflected
173
How is postpartum haemorrhage managed?
Fluid resus, blood transfusion, correct coagulation problem, management of underlying cause
174
What is the most common cause of postpartum infection after a vaginal delivery?
Local spread of colonized bacteria
175
What is the most common infection in the postpartum period?
endometritis
176
WHat are the postpartum infections? 8
Post-surgical wound infections, perineal cellulitis, mastitis, resp. complications from anaesthesia, retained products of conception, endometritis, UTIs, pelvic phlebitis
177
When are wound infections more common?
After c-sections
178
What are the risk factors of endometritis?
C-section, prolonged rupture of membranes, prolonger use of foetal monitering, anemia, lower ses
179
Where are the sources of bacteria in endometritis?
Bowel, cervix, vagina, perineum
180
What bactueria are the most common cause of postpartum wound infection?
Staph and strep
181
What are the risk factors of UTIs and GTIs after birth?
Duration of labour, use of internal monitoring devices, number of vaginal exams
182
What are the most common pathogens of GTIs?
Polymicrobial:
| clostridium, E. coli, bacteroides
183
What is the most common cause of mastitis?
Bacteria spread from infant's mouth or throat during breastfeeding
184
What is the most common causative agent in mastitis?
Stap. A
185
What can mastitis cause?
thrombosis
186
What are the causitive organisms of UTIs?
Klebsiella, proteus, enterobacter
187
WHat are the general risk factors of postpartum infections?
History of c-section, premature rupture of membranes, frequent cervical exam, internal foetal monitoring, preexisting infection, diabetes, nutritional status, obesity
188
What are the complications of postpartum infections?
Scarring, infertility sepsis, septic shock death
189
What are the signs of endometritis?
Lower abdo tenderness, adnexal and parametrial tenderness, temp elevation, scanty, odourless lochia, foul-smelling lochia
190
What are the signs of a wound infection?
Erythema, oedema, tenderness out of proportion with postpartum pain, discharge from site
191
What are the signs of mastitis?
tender, engorged, erythematous breasts, usually unilateral
192
What are the signs of septic pelvic thrombophlepitis?
palpable pelvic veins, tachycardia out of proportion to fever
193
What investigations can be done in postpartum infections?
FBC, electrolytes, blood culture, urinalysis, cervical or uterine cultures, lactate, wound cultures, coag studies
194
What imaging studies can be done for pelvic problems?
Pelvic US, contrast enhanced CT or MRI
195
WHat percent of women experience mood disturbance after pregnancy?
85
196
What hormonal factors are risk factors for postpartum depression?
Abnormally sensitive to hormanal changes, may develop symptoms when treated with exogenous estrogen or progesterone
197
What are the psychological rf for post partum depression?
Inadequate social support, maritial discord/dissatisfaction, recent negative life events, partner violence, employment
198
What are the biological rf for postpartum depression?
FH, PMH, gestational diabetes
199
When d the symptoms of postpartum blues peak?
4th-5th day after birth
200
How are postpartum blues treted?
With support and reassurance
201
What are the presentations of postpartum depression?
Depressed mood, tearfullness, anhedonia, loss of appetite, fatigue, insomnia, suicidal thoughts, intense sadness, anxiety, despair
202
When does postpartum depression develop?
first 3 postpartum months
203
How is postpartum depression treated?
SSRIs, SNRIs, TCAs
204
What is the most severe form of postpartum psychiatric illness?
Postpartum psychosis
205
How is most at risk of postpartum psychosis?
PMH, history of bipolar disorder
206
When does postpartum psychosis usually onset?
within 2 weeks
207
What are the symptoms of postpartum psychosis?
Manic episode, restlessness, insomnia, irritability, rapidly shifting mood, disorganized behaviour, delusions, hallucinations
208
What happens with a diagnosis of post-partum psychosis?
Psychiatric emergency, inpatient treatment
209
What is the management of psotpartum psychosis?
Mood stabilizer (carbamazepine, lithium, valpoic acid) with antipsychotic and benzo
210
What is an important consideration in the medical managemtn of postpartum psychosis?
Most medications will be secreted into breast milk
211
What is the definition of c section?
Delivery of foetus through surcical incisions in abdominal wall and uterine wall
212
What are the maternal indications of c-section?
Repeat c-section, obstructive lesions in ential tract, pelvic abnormailities, cardiac conditions
213
What are the foetal indications of c-section delivery?
Infection, dystocia, breech presentation, foetal distress, congential malformation, infection, prolonged acidaemia,
214
When is c-section done to benefit both mom and foetus
Labour is contraindicated, placenta praevia, placenta accreta, cephalopelvic disproportion
215
What ar the contraindications of c-section?
Maternal stuatus may be compromised, if foetus has an abnormality that is non compatible with life
216
What is the preop management of c-section?
preop fasting of at least 2 hours from clear liquids, 8 hpurs from a meal, placement of IV line, infusion of IV fluids, foley catherer, external foetal monitor, preop antibiotc prohylaxis, evaluation by surgeon and anaesthesiologist
217
What lab testin is done befor c-section?
FBC, blood type and screen cross match, screening for HIv, hep B, syphylis, coag studies, US
218
What is the procedure of csection delivery? 6+1
1. Laprotomy
2. Hysterotomy
3. foetal delivery
5. Utrine repair
6. Closure
7. Contraception if requested
219
What is the post-op management of c-section?
Routine assessment, monitoring of vital signs, palpation of fundus, IV fluids, analgesia, ambulation, breastfeeding commences, discharge on day 2-4, refrain from sexual intercoarse
220
What are the complications of csection?
Increase in maternal mortality and morbidity, infection, thromboembolic problems, anaesthetic complications, surgical injury, uterine atony, delayed return of bowel function
221
What are the indications for forceps delivery?
Prolonged second stage of labour, suspicion of immediate or potential foetal compromise, shortening second stage of labour benefit of the mother
foetal malposition breech vaginal delivery
222
What are the prerequisites for forceps delivery?
Head must be engaged, cervix must be fully dilated, retracted, no disproportion between pelvic head and foetal head, membranes must be ruptured, patient must have adequate analgesia, adequate facilities,
223
What are the contraindications of forceps delivery?
Contradication to vaginal delivery inability to consent, cervis is not fully dilated, inability to determine the presentation anf foetal head position, inadequate pelvic size,, cephalopelvic disproportion, absence of analgesia, inadequate facilities and staff, insufficient experienced operator
224
How should the patient be prepared preop for forceps delivery?
Anaesthesia, lithotomy position
225
What is the definition of an etopic pregnancy
Embryo implants outside the uterine cavity
226
What are the risk factors of ectopic pregnancy
Low ses, age, pmh, fh, smoking, IUD
227
What is the clinical presentation of ectopic pregnancies?
scanty, dark Abnormal vaginal bleeding, lower abdo pain, collapse, syncope, shoulder tip pain, amenorrhea
228
What are the signs of an eectopic pregnacy?
Tachycardia, hypotension, collapse, abdominal and rebound tenderness, tender adnexum, cervical os is closed, uterus is smaller than expected
229
How are ectopic pregnancies investigated?
Pregnancy test, Transvaginal US, quantitative serum HCG, laproscopy
230
How is ectopic pregnancy managed?
Blood is cross matched, Anti D if needed, laproscopy, systemic single dose of methotrexate
231
What is polycystic ovarian disease?
Diagnosis of exclusion made by irregular periods, Hirsutism, raised serum testosterone or signs on ultrasound
232
What test is diagnostic for polycystic ovary?
Transvaginal US
233
Whaat can be seen in polycystic ovaries in a transvaginal US?
Mutliple, small (2mm-8mm) follicles in an enlarged ovary
234
WHat is tha pathophysiology of polycystic ovaries?
Disprdered (raised LH), peripheral insulin resistance w/ compensatory raised insulin leads to increased ovarian nd adrenal androgen production. This disrupts folliculogenesis, leading to excess small ovarian follicles and irregular or absent ovulation. Raised peripheral androgens cause hirsutism anf acne
235
Whatare the clinical features of a patient with polycystic ovarian syndrome?
Obese, acne, hirsutism, oligomenorrhea/ amennorrhea, miscarriage
236
What investigations can be done on a patient with polycystic ovaries
FSH (raised in ovarian failure) prolactic (prolactinoma), TSH, serum testosterone, transvaginal scan
237
What are the complications of polycystic ovarian syndrome?
T2D, gestational D, endometrial cancer
238
How is polycystic ovarian syndrome treated?
Diet advice, antiandrogens cyproterone acetate, spironolactone, metformin
239
What are fibroids?
Benign tumours of the myometrium
240
What are the types of fibroids?
Subserou polyp, subserous, intracavity polyp, intamural, mubmucosal, cervical
241
What are the possible causes of fibroid growth?
Oestrogen and progesterone
242
WHat are the clinial features of fibroids?
Menstrual problems: menorrhagia, intermenstrual loss, dysmenorrhea, increased urinary frequency, retention, hydronephrosis, reduced fertility, solic mass in pelvis or abdomen palpaple in exam
243
When do fibroids often stop growing?
Menopause
244
What can occur with fibroids an pregnancY?
Orem labour, malpresentation, transverse lie, obstructer labour, postpartum haemorrhage, red degenration
245
What are the complications of fibroids?
torsion of pedunculated fibroid, red degenration, hyaline/cystic degenration, calcification, leiomyosarcoma
246
What is the relationship between HRT and fibroids?
Continues fibroid growth aft menopause
247
How are fibroids investigated?
US, MRI, la[rpscp[y, hysteroscopy, HB concentration
248
How are fibroids treated?
Hysteroscopic surgery embolization
249
What is hyperemesis gravidarum?
When nausea and vomiting in early pregnancy are so severe the cause dehrdation, weight loss or electrolyte imbalance
250
How is hyperemesis gravidarum managed?
IV rehydration, antiemetics, thiamine, psychological support
251
What is the definition of endometriosis?
Presence and growth or endometrium-like tissue outside the uterus
252
Is endometriosis more or less common in nulliparous women?
More
253
Where can endometriosis occur?
Pelvis, uterosacral ligaments, on or behind ovaries, umbilicus, abdo. ound scars, vagina, bladder, rectum, lungs
254
What is an endometrioma and what does it look like?
Accumulted altered blood due to endometriosis that is dark brown and looks like a chocolate cyst Found in ovaries
255
What can endometriosis cause?
Inflammation, progressive fibrosis, adhesions, frozen pelvis
256
What is the possible cause of endometriosis?
Retrograde menstruation, metaplasia of coelomic cells
257
What are the symptoms of endometriosis?
Chronic cyclical pelvic pain, dysmeorrhe before menstruation, subfertility, deep dyspareunia, pain on passing stool during menses, ,emstrual pronlems
258
What are the symptoms of a ruptured chocolate cyst?
Acute pain
259
What do cyclical haematuria, rectal bleeding or umbilical bleeding suggest?
Severe endometriosis
260
What are the signs of endometriosis?
Tenderness, thickening behind uterus or in adnexa, retroverted and immobile uterus, retrovaginal node
261
How can endometriosis be investigated?
Laproscopy, transvaginal US, MRI, serum cncer antigen
262
What can be seen laproscopically that is indicative of endometriosis?
Active lesions- red vesicles or punctuate marks on peritoneum
Less active- White scars or brown spots
severe disease - extensive adhesions, endometriomata
263
How is endometriosis treated?
drugs to surpress ovarian activity, analgesia, progestogens, GnRH analogs, combined oral contraceptive, laser or bipolar diathermy
264
How do treatments for endometriosis work?
Either mimic pregnancy or mimic menopause
265
What is the link between endometriosis and fertility?
More severe the endometriosis, the greater the chance of subfertility
Escision of ovariam endometrioma cysts improves fertility
266
How are women with epilepsy counselled before becoming pregnant?
Seizure control with as few medications as possible at lowest dose, with folic acid supplementation
267
What does of folic acid is given to espectant mothers with epilepsy?
5mg/day
268
What epileptic medication must be avoided in pregnancy?
Sodium valproate
269
What is sodium valproate associated with in terms of pregnancy?
Higher rate of congenital abnormalities, lower intelligence in children
270
What seizure medication is best for expectant mothers?
Carbmezipine, iamotrigine
271
What is a molar pregnancy?
Trophoblastic tissue, which normally invades into endometrium, proliferates more aggressively than usual. HCG is usually secreted in excess
272
What is a hydatidiform mole?
Trophoblastic proliferation is localized and non-invasive
273
What are the types of hydatidiform moles?
Complete and partial
274
What is a complete mole?
Onr sperm fertilizes empty oocyte and undergoes mitosis. No foetal tissue, just a proliferation of swollen chorionic villi
275
WHat is a partial mole
Two sperms in one oocyte, with variable evidence of a foetus
276
What is a choriocarcinoma?
Matastasis from an invasive molar pregnancy
277
What are the risk factors for molar pregnancies?
Extrees of age, asians
278
What are the clinical fetues of molar pregnancies?
Heavy vaginal bleeding severe vomiting, large uterus, early pre-eclampsia, hyperthyroidism
279
How are molar pregnancies investigated?
US, Highe serum hCG, histology
280
What does an US of a molar pregnancy show?
Snowstorm
281
What are the complications of molar pregnancies?
Recurrence, malignant trophoblastic disease
282
hat is cervical ectropion?
When columnar epithelium of endocervix is visible as a red area around the os on the surfaceof the cervix
283
What causes cervical ectropion?
Eversion of the cervix
284
In whom are cervical ectropions common?
Pregnant, young, on the pill
285
What is the clinical presentation of cevical ectropion?
Asymp, postcoital bleeding, vaginal discharge
286
How are cervical ectropions treated?
Cryotherapy without anaesthetic
287
WHat must be done before a cervical ectropion is treated?
A smear and colposcopy
288
Why must a smear and colposcopy be done before a cervical ectropion is treated?
to exclude cervicalcancer
289
What are cervical polyps?
Benign tumours in the endocervical epithelium
290
WHo re cervical polyps most common in
age>40
291
What are the sizes of cervial polyps?
<1 cm
292
What ais the clinical presentation of cervical polyps?
intramenstrual bleeding or post coital bleeding
293
How are cervical polyps treated?
Avulsed without anaesthetic
294
What is pelvic inflammatory disease?
Salpingitis caused by an STI
295
What are the risk factors for pelvic inflammatory disease?
Multiple partners, not using barrier contraception
296
What is protective for pelvic inflammatory disease?
Combined oral contraceptive
297
What can cause an asymp STI to spread into the pelvis?
Spontaneous, uterine instrumentation, laproscopy, dye test, intrauterine devices, miscarriage, complications of child bearth, descending infection
298
What organisms can cause pelvic inflammatory disease?
Polymicrobial, chlamydia, gonococcus,
299
What are the symptoms of pelvic inflammatory disease?
Asyp, subfertility, mestrual problems, bilateral lower abdo pain, abnormal vaginal bleeding or discharge, fever, cervical excitation,
300
What are the signs of pelvic inflammatory isease>
tachycardia, high fever, lower abdo peritonism, bilateral adnexal tenderness, cervical excitation, pelvic mass (abscess)
301
WHat investigations can be done for pelvic inflammatory disease?
Endocervical swabs, blood culture, FBC, CRP, perlvic US, laproscopy, fimbral biopsy
302
What are the complications of pelvic inflammatory disease?
Abscess, pyoselpinx, tubal obstruction, subfertility, chronic pelvic infection, pelvic pain, ectopic pregnancy
303
What are the signs and symptoms of chronic pelvic inflammatory disease?
Chronic pelvic pain, dysmenorrhea, deep dyspareunia, heavy and irregular menses, chronic vaginal discharge, subfertility, abdominal and adnexal tenderness, fixed retroverted uterus
304
What can be seen in a transvaginal US in chroic pelvic inflammatory disease?
Fluid collections in fallopian tubes, surrounding adhesions
305
What is the best diagnostic tool for chronic pelvic inflammatory disease?
Laproscopy
306
How is chronic pelic inflammatory disease treated?
Anaelgesics and antibiotics
Adhesiolysis - cuts adhesions
Salpingectomy
307
What can cause chronic pelvic inflammatory disease?
Improper treatment o acute pelvic inflammatory disease
308
What are the causes of vaginal discharge?
Physiological, infection, trichomonas vaginitis, atrophic vaginitis, foreign body, malignancy
309
What cause physiological vaginal discharge?
Increases around pregnancy and ovulation and due to combined oral pill. exposure of columnar epithelium in cercival eversion can cause this
310
What are the most common vaginal infections?
Bacterial: candidiasis, chlamydia, gonorrhea, trichomonas vaginitis
311
What causes atrophic vaginitis,?
Oestrogen deficiency before menarche, lactatio, aft menopause
312
How is atrophic vaginitis treated?
Oestrogen cream, HRT,
313
What are the common foreign bodies that can cause vaginal discharge?
Swabs after childbirth, retained tampons
314
WHat does a non itchy, non offensive, clear vaginal discharge suggest?
Ectropion
315
How is cervical ectropion treated?
Cryotherapy
316
What does a non itchy, acidotic, fishy-smeling grey-whote vaginal dicharge suggest?
Bacterial vaginosis
317
What does an itchy, red, non-offensive white vaginal discharge suggest?
Candiasis
318
What does an itchy, grey-green, red, acidotic and offensive vaginal discharge suggest?
Trichomonas vaginitis
319
What does a variable-pH, offensive, red-brown vaginal discharge suggest?
Malignancy
320
How is bacterial vaginosis treated?
Antibiotics
321
How is trichomonas treated?
Antibiotics
322
How is vaginal candiasis treated?
Imidazoles
323
What dies a acidotic, red clear vaginal discharge suggest?
Atrophic vaginitis
324
What is the clinical presentation of the rupture of ovarian cysts?
Pain
325
What causes the pain in ovarian cyst rupture?
Torsion, haemorrhage
326
What are the side effects of ovulation induction?
Multiple pregnancy, breast and ovarian carcinoma, ovarian hyperstimulation syndrome
327
What increases the risk of multiple pregnancy in ovulation stimulation?
Clomifene or gonadotrophins
328
What is ovarian hyperstimulation syndrome?
Cloifene or gonadotrophins overstimulate the ovaries causing follicular enlargement
329
What can be seen in severe cases of ovarian hyperstimulation syndrome?
Hypovolaemia, ascites, thromboembolsim, PE, electrolyte imbalance
330
How is severe ovarian hyperstimulation treated?
Fluid resus, electrolyte monitoring, thrombolysis
331
How is ovarian hyperstimulation syndrome prevented?
Using lowest does of gonadotrophin, cancellation of HCG
332
How is ovulation induced?
Treatment of anovulation, lifestyle changes, gonadotrophin, climofene
333
What is the definition of asoospermia
No sperm
| Can be obstructive or non obstructive(testicular failure, fsh is high)
334
WHat is oligospermia?
<20 million/mL
335
What is severe oligospermia?
<5 illion/mL
336
Whattis asthenospermia?
No or little motility
337
What are the causes of abnormal/absent sperm relase?
Varioceole, idiopathuc, antisperm antiboies, drug exposure, infection, testicular abnormalities, obstruction, CF, congenital abnormailities, Kallmanns syndrome
338
How is male subfertility investigated?
Sperm analysis
339
How is oligospermia treated?
Intrauterine insemination
340
How is severe oligospermia treated?
IVF
341
How is azoopermia treated?
Investigation, karyotype, SPerm retriva and IVF
342
What general advice is given for male subfertility?
Reduce drug exposure, lifestyle changes
343
What drugs can cause male subfertility?
Alchohol, smoking, recreational, industrial solvents
344
What are the causes of anovulation?
Ovarian failure, PCOS, hypothalamic hypogonadism, thyroid dysfunction, hyperprolactinaemia
345
How is anaovulation investigated?
Mid-luteal progesterone, prolactin, fsh, Lh, testosterone, TSH levels, US,
346
What is urinary stress incontinence?
Involuntary loss of urine when bladder exceeds max urethral pressure in absenceof detruser muscle contraction
347
What are the causes of urinary stress incontinence?
Pregnancy, vaginal delivery, forceps, prolonged labour, obesity, age
348
What is the pathophysiology of stress urinary incontinence?
Bladder neck slips below pelvic floor cause support is weak
349
What are the symptoms of utodynamic stress incontinence?
Frequeny, urgency, psychological, affects QOL
350
What are the signs of urodynamic stress incontinence
Cystoeole or urethrocoele with coughing
351
What investigations can be done for urodynamic stress incontinence?
Urine dipstick, cystometry
352
What is the onservative management of urodynamic incontinence?
Pelvic floor exercises
353
What is the medical treatment of urinary stress incontinence?
Duloxetine, HRT, oestrogen supplimentation
354
WHat are the surgical treatments for urinary stress inontinence?
mid-urethral sling rpocedures
355
What is detrusor overactivity?
Involuntary detrusor contractions during filling phases that are either sponatneous or provoked
356
What is the pathophysiology of detrusor overactivity?
Detrusor contraction is usually interpreted by the body as urgency, and if it happens enough, bladder will release
357
What are the symptoms of detrusor overativity?
Urge incontinence, urgency, frequency, nocturia
358
How is detrusor overactivity managed?
Reduce caffeine and fluid intake, bladder training, antimuscuranics, intravignal oestrogen (if vaginal atrophy is present), botox or sacral nerve stiulation.
359
What are thr sims of antenatal care? 7
Detect and manage pre-existing maternal disorders that might afect pregnancy outcome
Prevent, or dectect and manage maternal and foetal compliacations of pregnancy
Detect congenital foetal problems if requested by the mother
Plan with the mother, the safest and most satisfacoty form of delivery
Educate about minor conditions of pregnancy and gove lifestyle advice
360
When is the first appointment of pregnancy made?
9-11 weeks of gestation
361
What is the purpose of the first appointment?
Screen for possible complcations, gestation of pregnancy is checked
362
What occurs in the 12 week scan?
Gestation is confirmed, viability is assessed, multiple pregnacy is diagnosed, screening for chromosomal abnormalities
363
Hos are chromosomal abnormailities screened for in the 12 week scan?
Nuchal translucency, beta-HCG, PAPPA
364
What blood tests are done during antenatal checks?
FBC, serum antibodies, blood glucose level, syphilis, HIV and heps B screening, rubella immunity, rhesus status, blood type and cross match
365
What other tests are done in antenatal appointments?
Urine dipstick, urine culture
366
When is the anomoly scan?
20 weeks
367
What are the antenatal visits?
16, 20, 25, 28, 34, 36, 38, 40, 41
368
What happens at the 16 week check?
Results for screening tests for chromosonal abnormalities and booking blood tests ahould be specifically reviewd. alternatively triple test
369
What happens at the 25 week check?
Nulliparous women, fundal height
370
What happens on the 28 and 34 week check?
Fundal height is measured, FBC and antibodies are checked. Glucose levels test, anti-D given to rhesus- women
371
What happens on the 31 week check?
Fundal height, blood tests from 28 weeks are reviewed
372
What happens on the 36, 38 and 40 week check?
Fundal height, foetal lie, presentation
373
What happens at the 41 week check?
Fundal height, foetal lie, presentation, membrane sweep i offered, indicuction of labour is offered
374
What are the minor conditions of pregnacy?
Itching, symphyis pubis dysfunction, abdo pain, heartburn, backache, constipation, ankle oedema, leg cramps, carpal tunnel, vaginits tiredness
375
What are the physiological changes in pregnancy?
Weight gain, genital tract, blod, cv system, lung changes, renal blood flow, glomerular filtration rates increase, reduced gut motility, delayed gastric emptying, constipation, thyroid enlargement
376
What are the changes seen in the genital tract in pregnacy?
Uterues weight increases, muscle atrophy, increased blood flow an contractilitym cervix siftens, effaces in third trimester
377
What are the changes in blood due to pregnancy?
Blood volume, red cell mass, WBC increase, HB decreases
378
What are the changes seen in the CV system due to pregnancy?
Increased CO, reduced PR, BP falls mid pregnancy
379
What are the changes seen in the lungs due to pregnancy?
Tidal volumee increases
380
What is the definition of miscarriage?
Fetus dies or delivers dead before 24 weeks
381
What is the definition of threatened miscarriage?
There is bleeding but the foetus is still alive, uterus is the expected size for dates and os is closed
382
What is the definition of inevitable miscarriage?
Bleeding is heavy, fetus may be alive, cervical os is open. Miscarriage is about to occur
383
What is the definition of incomplete miscarriage?
Some foetal parts have been passed, but Os is still open
384
What is the definition of complete miscarriage?
All foetal tissue has been passed, Bleeding has been diminished. Uterus is no longer enlarged. Os is closed
385
What is a septic miscarriage?
Contents of uterus are infected, causing endometritis. Vaginal loss is offensive, fever can be absent. Peritonism and abdo pain can occur
386
What is a missed miscarriage?
Fetuss has not developped, or has died in utero
387
What are the clinical features of a miscarriage?
Bleeding, Pain from uterine contractions, uterine size and state od os depending on type of miscarriage
388
How are possible miscarriages investigated?
Early PAU, history, exam, urine pregnancy, US, FBC, rhesus group
389
How are miscarriages managed?
Admission for ectopic pregnancies, resus or heavy bleeding Products of conception are removed by specum=lum and polyp forceps. Swabs, antiD
390
What are the complications of miscarriage?
Sepsis, blood loss
391
What is the definition of recurrent miscarriage?
Three or more miscarriages in suscession
392
What are the causes of recurrent miscarriages?
Antiphospholipid antibodies, Chromosomal defects, anatomical factors, infection, obesity, PCOS, higher maternal age
393
What is the most common vulval prblem?
Pruritis, soreness, burning, superficial dyspareunia
394
What are the benign disorders of the vulva?
Lichen simplex, lichen planus, lichen scerosus
395
What are the causes for pruritis vulvae?
Infections: candiasis, vulval warts, pubic lice, scabies
| dermatological issues, neoplasia
396
What us the classic presentation of lichen simplex?
Long history of pruritis and soreness, labia majora is thickened with hyper or hypo pigmentation
397
What is the classic presentation of lichen planus>
Irritation with flat, papular, purplish lesions in the anogenital area, can affect hair, nails and mucus membranes
398
What is the classic presentation of lichen scerosus?
Vulval epithelium is thin with loss og collagen. Associated with autoimmune stuff. pink white papules
399
What are vulval pain syndromes?
Spontaneous genralized vulval pain
400
When is vulval candiasis common?
Diabetics, pregnancy, antibiotic use, immunity is compromised
401
What can cause infections in the vulva?
Herpes simplex, vulval warts, syphylis, donovanosis, candidiasis
402
What can cause bartholin's gland cyst?
Blockage of bartholin's duct
403
What does the bartholin's gland do?
Secrete lubricant in anticipation of coitus
404
What can commonly cause infection of the bartholin's gland?
Staph or ecoli
405
What is the presentation of a bartholin's gland abscess?
Acutely painful, large, tender, red swelling/
406
What is introtial damage?
Overtightening, incorrect apposition at perineal repair or extensive scar tissue presenting with su[perficial dysparaunia. Commonly after child birth.
407
What are vaginal cysts?
Congenital cysts that arise in the vagina
408
What are the appearance of vaginal cysts?
Smooth white appearamce, sometimes can be as large as a golf ball
409
What is vaginal adenois?
When columnar epithelium is seen in the squamus cell epithelium of the vagina
410
What is associated with vaginal adenosis?
Pregnant moms with diethylstilboestrol, genital tract abnormalities
411
What is the risk with vaginal adenosis?
Can turn into malignancy?
412
What are the two types of vulval intraepitheliulial neoplasia?
Caused by HP
| Due to lichen simplex, causing lucjen sclerosis
413
What is the most common type of vulval carcinomas?
Squamous cell epithelium
414
What are thclinica features of vulval carcinoma?
Pruritis, bleeding, discharge, mass, can have late presentatio, ulcer or mass, enlarged inguinal lympnodes
415
Where is a vulval carcinoma most likely to present?
Labia majora or clitoris
416
What is a stage 1 vulval carcinoma?
Tumour <2 cm, no nodes involved
417
What is a stage 2 vulval carcinoma?
Tumour > 2cm, no nodes involved
418
What is a stage 3 vulval carcinoma?
Tumour has spread through to perineum, urethra, vagina or anus/ nodes on one side are affected
419
What is a stage 4 vulval carcinoma?
Tumour is in rectum, bladder, bone or distant metastasis, and/or nodes are invlved bilaterally
420
How is vulval carcinoma usually treated?
Wide ocal incision and groin lymphadectomy, preop, post op or palliative radiotherapy
421
What is the most common genital tract carcinoma?
Endometrial cancer
422
What is the mst common type of endometrial cancer?
Adenocarcinoma
423
What is the biggest risk for endometrialcancer?
High ratio of oestrogen to progesterone
424
What are the risk factors of endometrial cancers?
Exogenous eostrogen without progesterone, obesity, POCS, nulliparity, late menopause, ovarian granulosa cell tumours, tamoxifen, HTN and diabetes
425
What is the premalignant disease of endometrial carcinoma?
Endometrial hyperplassia with atypia
426
What are the clinical features of endometrial cancer?
Postmenopausal bleeding, irrguglar or intramenstual bleeding, cervical smear, atrophic vaginitis may co-exist
427
What are stage 1(a,b,c) endometrial carcinomas?
Lesions confined to the uterus
a) in endometrium only
b) deepest invasion <0.5 of endometrial thickness
c) deepest invasion >0.5 of myometrial thickness
428
What are stage 2 (a,b) endometrial cancers?
Lesions in cervix and uterus
a) in endocervical glands only
b) in cervical stroma
429
What are stage 3 (a,b,c) endometrical cancers
Tumour invades through the uterus
a) invades the serosa and or adnexa and positive cytopogy
b) vaginalmets
c) pelvic or para aortic mets
430
What are stage 4 (a,b) endometrical cancers
Further spread
a) in bowel and bladder
b) distant mets
431
How are endometrial carcinomas investigated?
transvaginal US, endometrual biopsy, staging after hysterectomy
432
How are endometrial carcinomas treated?
Hysterectomy and bilateral salpingectomy, peritoneal washing
Adjuvant treatment dependent on staging
Radio, chemo, progesterone
433
Where is recurrence of endometrial cancers most likely?
Within three years in vagina
434
What is the most common type of cervical carcinomas?
Squamous cell
435
What is the premalignant condition of cervical cencers?
Cervical intraepithelial neoplasia
436
What is the most common cause of cervical cancer?
HPV, immunosupression can increase spread
437
What are the clinical features of a cervical cancer?
Can be asymp, postcoital bleedinf, IMB, PMB, offensive vaginal discharge, uraemia, haematuria, rectal bleeding, pain, visible ulcer or mass
438
What are the characteristics of a stage 1 (ai, aii, bi, bii) cervical carcinomas?
Lsions confined to cervix,
ai) microinvasion <3mm from basement membrane, <7mm across, no lymp or vascular space involvement
aii) Invasion >3mm, <7mm across, <5mm deep
bi tumour sze <4cm
bii) invasion >4 cm
439
What are the characteristics of cervical carcinomas of stage 2 (a,b)?
Invasion into vaginna, but not on the pelvic side wall
a) invasion of upper 2/3 of vagina but not parametrium
b) invasion of parametrium
440
What are the characteristics of stage 3 cervical carcinomas?
Invasion of lower vaginal wall or pelvic wall, or causing ureteric obstruction
441
What are the characteristics of stage 4 cervical carcinomas?
Invasion of bladder or rectal mucosa, or beyond the true pelvis
442
How is cervical carcinoma investigated?
Biopsy of tumour, vaginal and rectal exam, colposcopu and MRI, FBC and Us and Es to check fitness for surgery
443
What are the indicatiors for poor prognosisin cervical carcinomas?
LN involvement advanced clinical stage, large primary tumour, early recurrence
444
What is the issue with ovarian cancer?
Silent nature of the carcinoma means that presentation tends to be late
445
What is the most likely type of ovarian carcinoma?
epithelial
446
What are the risk facotrs of epithelial cancers?
Number of ovulations: therefore, early menarchy, nulliparity, late menopause, lynch syndrome, braca genes
447
What are protective factors of ovarian cancers?
Pregnancy, the pill, breastfeeding
448
What are the clinical features of ovarian cancers?
tend to present in stage 3 or 4, with abdo distension, pain, abnormal bleeding, metastasisis symptoms, cachexia, abdo or pelvic mass, asites
449
What are the characteristics of a stage 1 (a,b,c) ovarian cancer?
Disease macroscopically confined to ovaries
a) one ovary is affected, capsule is intact
b? both ovaries are affeted capsule is intact
c) one/both ovaries affected, capsule is not intact, or malignant cells in abdo cavity
450
What are the characteristics of a stage 2 ovarrian carcinoma?
Disease is beyond the ovaries but confined to the pelvis
451
What are the characteristics of a stage 3 ovarian carcinoma?
Disease is beyond the pelvis but is confined to the abdomen
| omentum, small bowel and peritoneum are frequently involved
452
What are the characteristics of a stage 4 ovarian carcinoma?
Disease is beyonf the abdomen, like lungs or liver
453
How is ovarian carcinoma investigated?
US, tumour markers(ca 125- inflammation of pelvic peritoneum), Fbc, u and e, LFTs, car,
454
How is ovarian carcinoma treated?
laprotomy (abdo hysterectome + bilat. salpingectomy, and removal of omentum), chemo, radio
455
What is the pear index?
Measurement of the efficacy of contraception, risk of pregnancy per 100 woomen per year of using the given method
456
What contraception is used for adolescents typically?
Combined oral pill with condom to prevent STIs
457
What contraception is used for older women typically?
Oral contraceptive, IUDs, sterilization
458
What are the types of hormonal contraceptives?
Progesterone pill, combined pill, IUS, patch or ring
459
How does the combined pill?
Negative feedback on GnRH, inhibiting ovulation
460
How is the combined pill taken?
Taken every day for 3 weeks, then one week without, having a withdrawal bleed
461
How effective is the contraceptive pill?
0.2 PI
462
What are the contraindications of the combined pill?
Venous thrombosis, stroke, IHD, HTN, igraine with aura, active breast/endometrial cancer, Pregnancy, thrombophilia, smokers>35, more than 15/day, BMI>40, diabetes w/ vascular complications, active/chronic liver disease
Smokers, chronic inflammatory disease, renal impairment, diabetes, age>40, breastfeeding, high BMI
463
What are the side effects of progesterone?
Depression, PMS, bleeding, amenorrhea, acne, weight gain, reduced libido
464
WHat are the common side effects of oestrogen?
Nausea headaches increased mucus, fluid retention and weight gain, occasionally HTN, breast tenderness and fullness, bleeding
465
What are the complications of progesterone and oestrogen pills?
Venous thrombosis, MI, stroke, focal migraine, HTN, jaundice, liver, cervical amd brest cancer
466
How does the progesterone only pill work?
Makes cervical mucus hostile to sperm
467
What are the ide effects of progesterone pill?
Spotting, PMS, Mastalgia, weight gain, functional ovarian cysts
468
What does the implant contain?
Progestrone
469
Wheren are implants implanted?
Upper arm, subdermall, local anaesthetic
470
What is the efficacy of implants?
<1 PI
471
What are the side effect of the implant?
Irregular bleeding in the first year
472
Does the implant significanantly affect fertility?
No
473
What are the types of emergency contraception?
Morning after pill, IUD
474
What is the morning after pill
Single doese (1.5mg) of progesterone levonorgestre, within 24 hours ideally (72 hours) after unprotected intercoarse
475
What are the side effects of the morning after pill?
Vomitting, menstrual disturbances in the next cycle
476
When is the IUD used?
72 hours aft unprotected sex (up to 5 days aft expected day of ovulation
477
What are the types of barrier contraceptives?
Male condoms, female condoms, diaphragm, caps, spermicides
478
What are the types of IUD?
Copper containing hormone containing
479
How do copper IUDs work?
Copper ions are toxic to sperm, block implantation
480
How do hormone containing devices work
Release progesterone
481
What is the efficacy of IUDs?
0.5 PI
482
What are the complications of IUDs?
Expulsion of IUD, pain, carvical shock, perforation of uterine wall, heavier or more painful micturition, ectopic pregnancy
483
What are the contraindications of IUDs?
Endometrial or cervical cancer, undiagnosed vaginal bleeding, recent/active pelvic infecction, breast cancer, HIV, previous ectopic pregnancy, excessive menstrual loss, mutliple sex partners, young, nulliparous
484
How are women sterilized?
Tubes compressed with clips, prevents egg and sperm meeting
485
What is the efficacy of getting your tubes tied?
0.5 PI
486
What are the grounds for abortion after 24 weeks in England?
Continuation of pregnancy would lead to greater risk for woman.
Termination will prevent grave physical or mental harm to woman, Child would suffer from severe handicaps
487
What are the surgical methods of abortion>
Suction crettage, dilation and evacuation
488
When is surgical cutterage used?
7-13 weeks
489
When is dilation and evacuation used?
13 weeks
490
What are the medical methods of abortion?
Mifepristone plus prostaglandin
491
When is mifepristone used for abortion?
Less than 7 weeks, 7-9 weeks, 13-24 weeks aft 22 weeks for feticide
492
What are the complications of abortions
Haemorrhage, infection, uterine porforation, cervical trauma, failure
493
Wat is the definition of prolapse?
Descent if uterus and or vaginal walls within the vagina
494
The laxity f which ligaments contributes to prolapse?
transverse cervical and uteroscacral ligaments
495
The weakness of which muscles is contributing to prolapse?
Levator ani muscles
496
What are the types of prolapse?
Uterus, post vaginal wall, ant vaginal wall
497
What are the types of uterine prolapse?
1-3
498
What happpens in 1st degree prolapse?
Cervix is still in vagina
499
What happens in second degree uterine prolapse?
at introitus
500
What happens in 3rd degree uterine prolapse?
Entire uterus comes out of vagina
501
What are the types f ant. vaginal wall prolapses?
Cystocoele, urethrocoele
502
What is a cystocoele?
Prolapse of bladder forming a bulge in ant vaginal wall
503
What is a urethrocoele?
4 cm long urethra bulges in lower ant. wall
504
What are th types of post vaginal wall prolapses?
Rectocoele, enterocoele
505
What is an enterocoele?
Prolapse of pouch of douglas (peritoneal cavity) into post. vaginal wall, usually contains small bowe
506
What is a rectocoele?
Prolapse of rectum forming a bulge in the middle of post. wall
507
What are the causes of prolapse?
Weakened support of pelvic organs, increased strain on supports
508
What causes weakened support of pelvic organs?
Vaginal delivery, pudendal nerve damage, mechanica damage, prolonged delivery, instrumental delivery, poor suturing or perineal tears, bearing down before full dilation, oestrogen deficiency, iatrogenic (aft hysterectomy), genetics
509
What causes incresed strain on the supports?
Obesity, pelvic masses, chronic cough
510
What are the symptoms of rolapse?
Dragging sensation, lump,worse at the end of daay or when standing up, ulceration, bleeding, urinary frequency, incomplete bladder emptying, stress incontinence,difficulty defaecation
511
What does an examination of prolapse reveal?
Sims speculum to reveal prolapse
512
What investigations should be doen on a patient with prolapse?
Pelvic ultrasound, cystometry
513
How is prolapse managed?
Weight reduction, pessearies, surgical treatment
514
WHat are the types of pessaries?
Shelf, ring
515
What are the surgical treatments of prolapse?
Vaginal hysterectomy, sacrospinous colpopexy, tension free vaginal type, meshes
516
What are the types of ovarian tumour like conditions?
Endometriotic cyst - endometriosis in ovaries, chocolate cyst
Functional cysts
517
What are the types of ovarian cancer?
Epithelial tumour - cyst adenoma - clear = serous, murky = mucinous
Endometriod, clear cell carcinoma (from bladder) brenner tumour.
Germ cell - teratoma (younger ace group), dysgermimoma
Sex cord tumours - granulous a cell tumous, thecomas, fibromas
Secondary malignancy from breast and GI tract, krukenburg
518
What is adenomyosis?
Presence of endometrial gland tissue on myometrium, at least 2-3 mm below the endometrial surface
519
What are the causes of maternal collapse?
Sepsis
520
What are the rf of maternal sepsis?
Obesity, diabetes, anaemia, vaginal discharge, PMH, immunocompromised, prolonged spontaneous rupture of membranes
521
How is sepsis assessed in obstetrics?
Modified Early Obstetric Warning Score
522
How is maternal sepsis managed?
Broad spectrum antibiotics, fluids, IV immunoglobulins ( staph and strep), delivery of baby
523
What antibiotics can be used in pregnancy?
Co-amox, metronidazole, clindamycin, piperacillin-tazobactam, gentamicin.
524
What is an amniotic fluid embolism?
Adverse reaction when amniotic fluid enters circulatory system
525
When does an amniotic fluid embolism occur?
Birth, labour, vaginal or section, abortion, amniocentesis
526
What are the symptoms of amniotic fluid embolism?
Cardiac arret, rapid resp failure: fetal compromise, vomiting, nausea, seizures, anxiety, swearing, shivering, discolouration
Haemorrhage
Renal failure
527
How is amniotic fluid embolism investigated?
Obs, u and e, abg, ECG (lhf), ctg, PT, clotting
528
How is amniotic fluid embolisms managed?
O2 therapy, ventilation. Pulmonary artery catheter, drugs to control Bp. Blood transfusions,
529
What Is the treatment of cervicalIN!
Cutting diathermy under local anaesthetic
530
What is the most common type of cervical cancer?
Squamous cell
531
What is the most common cause of Cervical cancer?
HPV
532
Why does obesity increase the risk of endometrial cancer?
Oestrogens are fat based
533
What's the commonest cause of post menopausal bleeding?
Atrophic vaginitis
534
What are the types if ovulation disorders?
Hypothalamic pituitary failure, hypothalamic pituitary ovarian dysfunction, ovarian failure
535
How is hypothalamic pituitary failure?
Anorexics
| Advised to moderates exercise levels, increase BMI
536
How is ovarian failure treated?
Donated egg
537
How is ovarian reserve checked?
AMH (high indicates more)
| FSH (low indicates more)
