Women's Health Flashcards
1
Q
Parity
A
The number of times a woman has delivered potentially viable pregnancies (>24 weeks)
2
Q
What does the b mean in:
Para a + b
A
b = the number of pregnancies that have miscarried or been terminated
3
Q
Gravidity
A
no. of times a woman has been pregnant
4
Q
Nulliparous
A
delivered no live / potentially live babies (n.b. may have had a TOP or miscarriage)
–> e.g. para 0 + 2
5
Q
Multiparous
A
delivered live / potentially live (>24 weeks) babies
6
Q
Primapara
A
pregnant for the 1st time
7
Q
What tablets should every woman trying to conceive take and when?
A
400 micrograms FOLIC ACID (before + 12 weeks after conception)
8
Q
Which anti-epileptic is safer than sodium valporate?
A
Lamotrigine
9
Q
What ages have increased risk of obstetric and medical complications in pregnany
A
Below 17 and over 35
10
Q
Timeline of normal pregnancy
A
<12 weeks – 1st visit 11-13 weeks – Scan >14 weeks – CXR if TB risk 18-20 weeks – Scan 36 weeks – Check lie and presentation 37 weeks – Head engaged
11
Q
Define polyhydramnios
A
Liquor volume increased
Deepest liquor pool >10cm is generally considered abnormal
12
Q
Clinical features of polyhydramnios
A
Maternal discomfort
Large for dates
Abnormal lie
Malpresentation
13
Q
Complications of polyhydramnios
A
Preterm labour
Maternal discomfort
Abnormal lie
Malpresentation
14
Q
How to manage polyhydramnios?
A
If >34 weeks and severe, amnioreduction, or use of NSAIDs to reduce fetal UO
If <34 weeks consider steroids
15
Q
Aetiology of polyhydramnios?
A
Idiopathic
Maternal disorders (e.g. DM)
Twins (e.g. TTTS)
Foetal anomaly (e.g. impaired swallow)
16
Q
When are the trimesters?
A
1st = 0-12 weeks 2nd = 13-27 weeks 3rd = 28-40 weeks
17
Q
Difference between screening and a diagnostic test
A
Screening test is available for all women and gives a measure of the risk of a foetus being affected by a particular disorder, a ‘higher risk’ pt can then be offered a diagnostic test
18
Q
What are the routine booking investigations?
A
Urine culture FBC Antibody screen Serological tests for syphilis Rubella IgG Offer HIV and Hep B USS Screening for chromosomal abnormalities Haemoglobin electrophoresis
19
Q
What day does embryo implant
A
Day 9
20
Q
What day is heartbeat detectable
A
Day 22
21
Q
Combined test
A
NT, bhCG, PAPP-a
(both blood and USS)
11 - 13 +6
22
Q
Quadrudple
A
alpha-feto protein
hCG
Oestriol
(inhibin a)
At 15-20 weeks if >13 weeks booking
23
Q
What would combined test show for Down’s syndrome?
A
NT and bhCG raised
PAPP-a low
24
Q
What duct gives rise to some of the female reproductive organs?
A
Paramesonephric/Mullerian ducts
25
What duct gives rise to male reproductive organs?
Mesonephric/Wolfian duct
26
How many structures make up the umbilical cord?
3:
- 2 umbillical arteries
- 1 umbilical vein
(central vein and artery spiralling round)
27
What happens in passive part of 2nd stage of labour?
Contractions make baby come out (no urge to push at this point)
28
What drug can you use to stop PPH
Oxytocin (most of it is due to uterine atonia)
29
4 Ts that cause PPH
Tone - approx. 70%
Trauma - lacerations, hematomas, inversion or rupture
Tissue (retained tissue or invasive placenta)
Thrombin - coagulopathies
30
What maternal conditions necessitate CTG
```
Gest HTN
GDM
Obstetric cholestasis (uterus presses on CBD -->
Pre-eclampsia
Temperature of 38 degrees C or above
Suspected chorioamnionitis
Suspected sepsis
Presence of significant meconium
new PV bleeding in labour
```
31
What fetal conditions necessitate CTG
**
32
If blood when membranes rupture
Vasa Previa
33
Twins: morula cleavage at days 1-3
Dichorionic / diamniotic
34
Twins : morula cleavage at days 4-8
monochorionic / diamniotic
35
Twins: cleavage days 8-13
monochorionic / monoamniotic
36
Twins: cleavage days 13-15
conjoined twins
37
Methods of induction of labour
- membrane sweep
- intravag prostaglandin E2 (misoprostol)
- amniotomy + oxytocin
38
what drug for normal delivery?
oxytocin (syntocinon - 10 units IM)
39
Treatment for antiphospholipid syndrom
LMWH and aspirin
40
When is the maternal blood test and what does it test for?
0-10 weeks
- Sickle cell anaemia
- thalassaemia
41
When is routine congenital anomaly screen, and what does it test for?
Detailed US scan at 18-20 w
- Neural tube defects
- Major heart defects
- Renal agenesis
- Skeletal / CNS abnormality
42
When can Chorionic Villous Sampling take place? and what is it?
11-13 weeks gestation
| Placental biopsy of foetal cells
43
When can amniocentesis occur?
15-20 weeks
| amniotic biopsy of foetal cells
44
Presentation of down's syndrome
Intellectural disability
Stunted growth
Dysmorphia
45
CFs Patau's syndrome
Polydactyly
Cleft lip/palate
VSD, PDA
Global developmental delay
46
What is Edward's syndrome associated with?
IUGR
| Polyhydramnios
47
CFs edwards syndrome
Similar to Patau's but without Polydactyly
| Also: prominent occiput, kidney malformation, developmental delay
48
CFs Turner's syndrome
Short stature, shield chest, low set ears, webbed neck, wide spaced nipples
49
Turner's syndrome associations
```
Amenorrhoea
Delayed puberty
Sterility
Coarctation of the aorta
Bicuspid aortic valve
Obesity
Horseshoe kidney
Thyroid disorder
```
50
Rx Turner's syndrome
Growth hormone
Oestrogen replacement (COCP)
Fertility
51
What are the TORCH infections?
```
Toxoplasmosis,
Other (syphilis, varicella-zoster, parvovirus B19),
Rubella,
Cytomegalovirus (CMV)
Herpes infections,
```
(some of the most common associated with congenital abnormalities)
52
What is cervical ectopy/ectropian?
Inner lining of cervical canal (columnar ep) come out into part of the cervix that can be seen on sepculum
53
Px cervical ectropian?
Post-coital bleed
| Discharge
54
What is cervical ectropian associaed with?
Hormonal changes:
- pregnancy
- cocp etc.
55
What is tamoxifen and what is its role in the breast, and endometrium?
A selective oestrogen receptor modulator
- Antagonises receptors in the breast
- Agnoises them in the endometrium --> hyperplasia
56
When do you give anti-D to non-sensitised Rh- mums?
at 28 and 34 weeks
57
What are some potentially sensitising events in pregnancy?
- ectopic
- evacuation of RPOC and molar
- vaginal bleeding <12wks (only if heavy, painful or persistent)
- VB > 12 weeks
- CVS & amniocentesis
- APH
- Abdo trauma
- external cephalic version
- post-delivery (if baby is +ve)
58
When does ovulation occur?
36hrs after the LH surge
~ day 13
LH = let her ovulate!
59
When do progesterone levels peak?
mid-luteal phase
~day 21 (7 days before end of cycle)
60
Average age of menopause, and when is premature?
51
before 40
61
Define menopause
Permanent cessation of menstruation.
12 consecutive months of amennorhoea.
Loss of folicular activity.
(or onset of symptoms if hysterectomy)
62
Peri-menopause
/ climacteric
Time between first features of menopause and 12 months after last period
63
Vasomotor (early) symptoms menopause
Hot flushes
| Night sweats
64
Urogenital (mid) symptoms of menopause
Vaginal atrophy + dryness
| Urinary frequency
65
Ix menopause
FSH - day 5
Anti-mullerian hormone
Others: TFT, DEXA
66
Longer term complications of menopause
Osteoporosis
| Increased risk of CV disease and dementia
67
Mx menopause lifestyle
regular exercise, weight loss, reduce stress, good sleep hygiene
68
Contraindications HRT
- current or past breast cancer
- any oestrogen-sensitive cancer
- undiagnosed Vaginal bleeding
- untreated endometrial hyperplasia
69
What type of HRT if have uterus?
Oral or transdermal combined HRT
| reduces risk of endometrial hyperplasia / carcinoma
70
Contraception and menopause
For:
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
71
How long do symptoms of menopause last for?
2-5yrs
72
Risks of treatment with HRT
Oral: VTE, Stroke
Combined: Coronary HD, breast cancer
All HRT: ovarian cancer
73
Mx menopause non-HRT
Vasomotor symptoms: fluoexetine
Vaginal dryness: lube / moisturiser
74
Define menorrhagia
Excessive menstrual blood loss that interferes with the woman's psysical, emotional, social and material QoL
75
Causes menorrhagia
- Dysfunctional uterine bleeding
- Local: polyps, carcinoma, fibroids, adenomyosis
- Systemic: DM, hypothy, obesity, coagulopathy e.g. VWD
- Iatrogenic: IUD (copper coil, IUS is actually used to treat!), anticoagulants
76
What must you exclude in woman over 45 with mennorhagia?
Endometrial carcinoma
77
Ix Mennorhagia
Examination
FBC
If clinically indicated: TVUSS or endometrial biopsy
78
Mx Menorrhagia if does not require contraeption
Antifibrinolytic =Tranexamic
OR mefenamic acid - an NSAID (particularly if there is dysmennorhea as well)
(take during menstruation only)
If fails --> surgery...
79
Mx Menorrhagia if requires contraception
1. Intrauterine system (Mirena)
2. COCP
3. Long-acting progesterones
NSAIDs also useful for dysmenorrhoea
80
Define secondary amenorrhoea & causes
Periods stop for 6 months or more
- PREGNANCY
- hypothalamic amenorrhoea: stress, excessive exercise
- PCOS
- hyperprolactinaemia
- premature ovarian failure
- Thyrotoxicosis, hypothy sheehan's, asherman's
81
Define primary amenorrhoea & causes
Failure to start menses by age 16
- Turners, testicular feminisation, CAH, congenital malformations
82
Ix amennhorhoea
- Urinary / serum bHCG
- Gonadotropins:
- low levels -> hypothalamic cause
- high levels --> ovarian problem
- Prolactin
- Androgen levels (raised in PCOS)
- Oestradiol
- TFTs
83
what is it and Features primary dysmenorrhoea
No underlying pelvic pathology, appears 1-2yrs after menarche
- Pain starts just before or within a few hrs of period starting
- Supra pubic cramping pains, may --> down back or down thigh
84
Mx primary dysmenorrhoea
1. NSAIDs e.g. mefenamic acid or ibuprofen
2. COCP
Also: local application of heat, transcutaneous electrical nerve stimulation
85
What is secondary dysmenorrhoea and its features?
Develops many years afte menarche, result from underlying pathology
Pain starts 2-3 days before onset of period
86
Causes of secondary dysmenorrhoea
- Endometriosis
- Adenomyosis
- PID
- Intrauterine device (Cu coil, NOTE mirena may be Rx)
- Fibroids
87
Ix secondary dysmenorrhoea
1. Examination
2. Swabs if STI risk
Refer to gynae
- pelvic USS, laparoscopy
88
Causes: irregular menstruation and IMB
1. Anovulatory cycles
2. Non-malignant pelvic pathology:
- fibroids, uterine / cervical polyps, adenomyosis, ovarian cysts, PID
3. Malignant: ovarian, endo, C
89
Ix IMB
- FBC: assess effect of blood loss
- TFT / clotting
- FSH/ LH
- cervial smear
- USS uterine cavity if >35yrs
90
Mx IMB
1. IUS or COCP
2. Progesterones, HRT
Others as for menorrhagia
91
Causes of post-coital bleeding
1. Cervical carcinoma - must be ruled out
2. Cervical ectropian
3. Cervical polyps
92
Define uterine fibroids
Benign smooth muscle tumours of the uterus
93
Uterine fibroids risk factors
Afro-carribean
Near menopause
PHMx of early pubery
FH
94
Protective factors fibroids
Late puberty, parous, COCP
| risk increases from puberty to menopause
95
Features uterine fibroids
- asymptomatic
- menorrhagia
- lower abdo pain: cramping often during menstruation
- urinary e.g. freq with large fibroids
- subfertility
96
Dx uterine fibroids
TVUSS
| also, pelvic exam, FBC (Hb may be low if heavy bleeding
97
Mx uterine fibroids
1. IUS (Mirena) - levonorgestrel-releasing
2. Tranexamic acid, COCP
3. GnRH agonists
4. Surgery e.g. myomectomy
5. Uterine artery emolisation
98
Complications of fibroid
Red degeneration - haemorrhage into tumor
Commonly occurs during pregnancy
(ALso malpresentation, transverse lie, premature, or obstructed labout
99
RFs endometrial cancer
Endogenous oestrogen excess:
- PCOS
- Late menopause / early menarche
- Obestity
- Nulliparity
Exogenous oestrogen:
- Tamoxifen
- Unopposed oestrogen (reduce this by giving prog too in HRT)
ALSO: T2DM, HNPCC
100
Features endometrial cancer
- PMB
- Change in intermenstrual bleeding for pre-menopausal women
- Pain and discharge (unsual)
101
Ix endometrial cancer
TVUSS (normal endo thickness, of <4mm, has high NPV)
| Hysteroscopy with endometrial biopsy
102
Most common type of endometrial cancer
Adenocarcinoma of columnar endometrial gland cells
103
Mx Endometrial cancer
Localised disease: total abdo hysterectomy + bilateral salpingo-oophorectomy
High risk disease: post-operative RT
104
Protective factor endometrial cancer
COCP
105
Definition adenomyosis
Presence of endometrial tissue within the myometriu
106
RF adenomyosis
multiparous women
| toward end of reproductive years
107
Features adenomyosis
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
108
Mx adenomyosis
IUS (mirena progesterone)
COCP
GnRH trial
Hyterectomy
109
CFs intrauterine polyps
Menorrhagia
IMB
Sometimes prolapse
110
Dx intrauterine polyps
USS
| Hysteroscopy
111
Mx intrauterine polyps
Resection with cutting diathermy
112
What causes congenital vaginal abnormalities?
Differing degrees of failure of fusion of mullerian duct
113
Mx cervical ectropian
Stop OCP
Cryotherapy or diathermy
Smear / colcoscopy to exclude carcinoma
114
Screening protocol CIN?
All females from age 25
- Rpt every 3 yrs until age 49
- From age 50-64: every 5yrs
115
How is cervical cancer screen performed? And why better than pap?
Liquid-based cytology (LBC)
| increase sensitivity and specificity, fewer inadequate samples
116
CIN grading
CIN I: atypical cells in lower third of epithelium
CIN II: in lower 2/3rds
CIN III: carcinoma in situ, occupy fully thickness
- 1/3rd progress to cervical cancer in 3yrs
117
Mx CIN
Large loop excision of the transformation zone (LLETZ)
118
2 types of cervical cancer
Squamous cell cancer (80%)
| Adenocarcinoma (20 - worse prog)
119
Features Cervical cancer
- detected during routine screening
- abnormal vaginal bleeding: psotcoital, IMB or PMB
- Offensive vaginal discharge
120
RFs cervical cancer
```
HPV (16,18,33)
smoking
HIV
early first intercourse, many sexual partners
high parity
lower SE status
COCP
```
121
Ix cercival cancer
Colposcopy to biopsy tumor
122
Triad of PCOS
1. Polycystic ovaries on USS
2. Irregular periods (>35 days apart - oligo/amenorrhoea)
3. Hirtusim: clinical or biochemical (acne, excess body hair, raised testosterone levels)
ALSO: fertility problems, obesity
123
What do affected PCOS patients have raised in blood and what does it lea d to?
Insulin and LH
Leads to lots of free floating androgen
124
Dx PCOS
2 of the triad
125
Ix PCOS
Pelvic ultrasound scan (multiple cysts)
Bloods: FSH, LH, prolactin, testosterone
GTT
126
Mx PCOS
Genral: wt reduction, COC
Hirtusim + acne: COC e.g. co-cyprindiol (dianete)
Infertility: wt reduction, Clomifene, metformin, Gonadotropins (ovarian induction)
127
Name 3 ovarian cysts
1. Mucinous cystadenomas
2. Teratoma (dermoid cyst) - teeth!!
3. Chocolate cyst (from endometriosis)
128
Symptoms ovarian cyst
1. Ache/pain in lower abdo / back
2. Dyspareunia
3. Large cysts: pressure (bladder frequency, veins-oedema/varicosity), abdo distension
129
Ix ovarian cysts
- USS
Things to rule out:
1. CA125 blood test to rule out cancer
2. Pregnancy
3. Urinalysis for urinary symptoms
130
RFs ovarian cancer
FH: mutations of the BRCA1 or the BRCA2 gene
HNPCC
Many ovulations
131
CFs ovarian cancer
Notoriously vague
- abdo distension + bloating
- abdo + pelvic pain
- urinary symptoms e.g. urgency
- early satiety
- diarrhoea
132
Ix ovarian cancer
CA125 initially
If raised --> urgent USS of abdo and pelvis (or if abdo/pelvic mass/ascites)
133
Dx ovarian cancer
Diagnostic laparotomy
134
Mx ovarian cancer
Combo of surgery and platinum-based chemo
135
Prominent feature Lichen sclerosus
Itch
136
Mx Lichen sclerosus
Topical steroids and emolients
137
FU lichen sclerosus
Increased risk of vulval cancer (5% transform into it, biopsy is a good shout!)
138
What are 90% of ovarian cancer? and 5yr survival rate
epithelial tumors
35-45%
139
What is most common type of vulval carcinoma?
Squamous cell carinoma
140
RFs vulval carcinoma
```
>65
HPV
VIN
immunosupression
lichen slerosus
```
141
Features vulval carcinoma
lump / ulcer on labia majora
| itching / irritation
142
what is a urogenital prolapse?
descent of one of the pelvic organs --> protrusion on the vaginal walls
143
Types of prolapse (give 4)
- Cystocele
- Cystourethrocele
- Rectocele
- Uterine prolapse
144
RFs prolapse (give 4)
Increasing age
multiparity, vaginal delivery
obesity
spina bifida
145
CFs prolapse
- Sensation of pressure, heaviness, 'bearing-down'
| - Urinary symptoms: incontinence, frequency, urgency
146
Mx prolapse
Conservative: wt loss, pelvic floor muscle exercises
Ring pessary
Surgery
147
Surgical options prolapse
- Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- Uterine prolapse: hysterectomy, sacrohysteropexy
- Rectocele: posterior colporrhaphy
148
CFs thrush
Cottage-cheese discharge
Irritation
Itching
149
Mx thrush
Clotrimazole
pessary, cream or capsule
150
CFs bacterial vaginosis
Grey-white discharge
| Fishy odour
151
Causative organism thrush
Candida Albicans
152
Causative organism Bacterial Vaginosis
Gardnerella Vaginalis
153
Mx bacteria vaginosis
Metronidazole (PO)
or
Clindamycin (topical)
- both are Abx
154
Causative organism chlamydia
Chlamydia trachmoatis
155
CFs chlamydia
asympt
discharge, urethritis, irregular bleeding
156
Rx chlamydia
Azithromycin - single dose
157
Causative organism Gonorrhoea
Neisseria gonorrhoea
158
CFs Gonorrhoea
Asympt
Urethritis, vaginal discharge, bartholinitis + cervicitis
159
Rx Gonorrhoea
IM ceftriaxone
160
Causative agent genital warts
HPV
161
Rx genital warts
Imiquimod cream
162
Causative agent genital herpes
HSV type 2 mostly
163
CFs genital herpes
Many small, painful vesicles and ulcers
swollen local lymph nodes, systemic symptoms, dysuria
164
Dx genital herpes
viral swabs
165
Rx genital herpes
Aciclovir
166
Causative organism syphilis and Rx
Treponema Pallidum
Rx: IM penicillin
167
CFs Trichomoniasis
Offensive green-grey discharge
Vulval irritation
Superficial dysparenuina
Strawberry lesions on cevix
168
Rx Trichomoniasis
Metronidazole
169
Causative organisms PID
Chlamydia Trachomatis
| Neisseria Gonorrhoeae
170
CFs PID
```
lower abdo pain
fever
deep dysparenia
dysuria + menstrual irregularities
vaginal or cervical discharge
cervical excitation
```
171
Ix PID
Endocervical swabs for chalmydia and gonorrhoea
172
Rx PID
IM ceftriaxone + doxycycline + metronidazole
If febrile --> admission for IV Abx
173
What can non-treatment or inadequate treatment of PID lead to?
Chronic PID
- dense pelvic adhesions
- fallopian tube obstruction
174
Method of TOP if less than 9 weeks
Mifepristone (an anti-progestogen)
+
Prostaglandins 48hrs later (to stimulate uterine contractins)
175
Method of TOP if between 9 and 13 weeks
Surgical dilation and suction of uterine contents
176
What are the ovarian cyst accidents?
Rupture of cyst contents
Haemorrhage into cyst
Torsion of the pedicle --> infarction of ovary
177
Mx ovarian cyst pedicle torsion
Urgent surgery + detorsion if the ovary is to be saved
178
Suspicious symptoms in breast history
1. painless lump
2. skin distortion
3. bloody discharge
4. recent onset nipple inversion
5. axillary lymphadenopathy
6. ulceration
7. pagets disease of the nipple
8. peau d'orange
179
What is the most common type of breast cancer?
Preinvasive: Invasive ductal carinoma in situ
Invasice: ductal, lobular
180
Breat cancer RFs
```
BRCA genes - 40% lifetime risk of breast / ovarian cancer
FHx
Nulliparity, 1st pregnancy >30yrs
Many ovulations
HRT, COCP
Not breastfeeding
Obesity
```
181
National screening for breast Ca
Triennial: 47 - 73 yrs
Annually if FHx between 40&50yrs
182
Triple assessment breast cancer
1. Clinical Ex
2. Imaging ( M or USS)
3. Needle biopsy
183
Grading in breast cancer
1. well differentiated with a low mitotic rate
---> 3. (the opposite)
184
Relevant Receptors in breast cancer
Oestrogen receptor = better prognosis. Rx: anti-oestrogens
Human epidermal growth factor (HER2) = poor prognosis. Rx: herceptin
185
Indications for mastectomy in breast cancer
```
Large tumor
Multifocal
CI to RT v.strong
Failed conservation surgery
Prophylactic in gene carriers
```
186
Indications for lumpectomy in breast cancer
Pt choice
Unifocal tumor
Suitable for RT (must have as an adjunct)
187
Difference between axillary node clearance and sential node biopsy breast Ca
ANC: standard if AND. ANC has many complications
SNB: check if there is spread to 1st node & do clearance if it has. Far less complications than ANC
188
TMN staging breast cancer
1-4
T --> primary tumor (in situ --> increasing size)
N --> nodes
M --> mets (stage 1: Br, 2: ax nodes, 3: locally adv, 4: mets)
189
Hormonal Rx breast Cancer
Pre-men: Tamoxifen (selective oestrogen receptor modulator)
Post-men: aromative inhibitors, prevent oestogen productio
190
Features of fibroadenoma
<30yrs
'Breast mice' as discrete, non-tender, firm, highly mobile lumps
No increased risk of brast Ca
If >3cm, excision is usual
191
Features of a breast cyst
Smooth discrete lump
| Small increased risk of breast Ca
192
Features of a benign breast cyst
1. Fluid not blood-stained
2. No residual lump
3. Same cyst doesn't continually refil
193
What are the trisomies more common with?
Advancing maternal age
194
Risk of miscarriage in amniocentesis?
1%
195
What causes toxoplasmosis
```
Toxoplasma gondi (a protozoan parasite)
rom cat faeces, soil, meat
```
196
Rx toxoplasmosis
Spiramycin ASAP
197
What does listeria cause in pregnancy and how can it be avoided?
Fetal distress, respiratory distress, convulsions
Avoid soft cheeses if pregnant
198
List 3 maternal physiological adaptations to pregnancy
1. Wt gain 1-15kg
2. Blood: vol increases by 50%
3. Lungs: tidal volume: 40% increase!
199
Whats aorto-caval compression?
Compresion of IVC in supine position, decreasing venous return, and hence decreases CO by 40%.
Put woman in left lateral position to relieve pressure.
Maintain at least 15% of left lateral tilt
200
List 3 minor conditions of pregnancy
1. Itching (watch out for intrahepatic cholestasis of pregnancy)
2. Pelvic girdle pain (Mx: PT, analgesics)
3. Heart burn (rule out Pre-E, as can present with epigastric pain)
4. Varicose veins
201
What is intrahepatic cholestasis of pregnancy due to?
How is it Ix?
The cholestatic effects of oestrogen
Associated with stillbirth
Serum bile salts
202
Complication of intrahepatic cholestasis of pregnancy and how to prevent?
Maternal and fetal haemorrhage
Give vit K
203
Classification of hypertensive disorders in pregnancy
PREGNANCY INDUCED HYPERTENSION
>140/90 after 20 weeks
Can be due to pre-eclampsia or gestational HTN
PRE-EXISTING HYPERTENSION
BP >140/90 before 20 weeks, or those on anti-hypertensive medication
- may be primary or secondary (e.g. to renal disease)
204
What antihypertensives can you use for women with mild-moderate hypertension in pregnancy?
Labetalol
| Nifedipine
205
What happens to BP in normal pregnancy?
Falls in first trimester, and continues to fall until ~20 weeks
Then, it usually increases to pre-pregnancy levels by term
206
Define pre-eclampsia
A multi-system disease of pregnancy seen after 20 weeks gestation and characterised by HTN (BP 140/90) with proteinuria
207
Pathology pre-eclampsia
Incomplete trophoblastic invasion
Endothelial cell damage + vasospasm which can affect the fetus and almost all maternal organs.
Of placental origin and only cure is delivery
208
What does pre-eclampsia predispose to?
```
Fetal: prematurity, IUGR
Eclampsia
Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
Cardiac failure
Multi-organ failure
```
209
RFs pre-eclampsia
```
POHx hypertensive disease
CKD
AI disease
T1 or T2 DM
Nuliparity
Older age
High BMI
FHx
TWINS
```
210
Features of severe pre-eclampsia
```
HTN (typc >170/110) and proteinuria
Proteinuria dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epi pain
Hyperreflexia
HELLP
```
211
What is visual disturbance in pre-eclampsia as a result of?
Reduced blood flow to retina
212
Mx pre-eclampsia
1. Labetalol if BP 150/110
2. Steroids if: mod/severe @ <34wks
3. Delivery if: mild @ 37wks, mod/severe at 34-36, or maternal complications at any gestation
213
What Mx if eclampsia?
Magnesium sulphate
214
Screening of pre-eclampsia
Observation of high-risk pregnancies
| Uterine artery doppler to pick up decreased flow
215
Prevention pre-eclampsia
Aspirin 75mg /day from <16wks if high risk pregnancy
216
Why does glucose tolerance decrease in pregnancy?
1. altered carbohydrate metabolism
| 2. antagonistic effects of progesterone & cortisol
217
Define gestational DM
Carb intolerance which is Dx in pregnancy and may/may not resolve after pregnancy
218
RFs gestational diabetes
BMI > 30
Previous macrosomic baba
POHx GDM
FHx DM
219
Screening for GDM
If previously had GDM, OGTT right after booking, and at 24-28 wks if first is normal
If have any other RFs, OGTT at 24-28wk
220
Fetal complications GDM
Congen abnormalities
Pre-term labour
Macrosomnia (--> increase UO and polyhydramnios)
Higher abdo:head as lots of extra glucose in liver
Birth trauma
Fetal distress
221
Maternal complications GDM
```
increased insulin requirements
hypogly
infections
prre-eclampsia
operative delivery
```
222
Diagnositc thresholds
Fasting glucose is >= 5.6
Or
2hr is >= 7.8
223
Mx GDM
1. Education: diet & exercise trial
2. +Metformin
3. +Insulin
224
Mx pre-existing DM (in pregnancy)
1. wt loss
2. stop oral hypoglycaemic agents, apart from metformin, and start insulin
3. folic acid pre-c --> 12wk
4. aspirin 75mg from 12wks --> birth
5. detailed anomaly scan at 20wks
6. tight glycaemic control reduces complication rates
7. treat retinopathy as can worsen during pregnancy
225
What 2 oral hypoglycaemic drugs are definitely contra-indicated in pregnancy?
Gliclazide
| Liraglutide
226
Define preterm delivery
between 24 and 37 weeks
227
Give 4 Causes of preterm delivery
Subclniical infection
Cervical 'intompetence'
TWINS
Polyhydramnios
228
Prediction of preterm delivery
PMHx
| Transvaginal sonography of cervical length
229
Prevention of preterm delivery
Abx if infection
Cervical suture
Progesterone pessaries
230
CFs preterm delivery
Abdo pain
APH
Rupture of membranes
Fever
231
Ix preterm deivery
CTG and USS
TVS of cervical length
Fetal fibronectin assay
High vaginal swabs
Maternal CRP
232
Mx preterm delivery
Steroids (if <34 weeks)
| Abx if in confirmed labour only
233
How long do steroids take to promote pulmonary maturity? and how can this be helped
24hrs
| Delay delivery by tocolysis (atosiban = an oxytocin receptor antagonist)
234
APH define
Bleeding from genital tract after 24 weeks of pregnancy, prior to delivery of the fetus
235
What happens in placenta praevia?
Placenta is implanted in the lower segment of the uterus
- can have marginal and major types. (major over/partly covers the os)
236
complications placenta praevia?
1. obstructs engagement of head --> c-sec
2. Haemorrhage: preterm/c delivery
3. Risk of placenta accreta if prev lower segmet c-section --> placenta may implant so deep placenta can't separate
237
What must you exclude before you do a VE on a woman bleeding vaginally? and how to exclude it?
Placenta praevia
TVUSS
238
Ix placenta praevia (in addition to TVUSS)
FBC + crossmatch
239
Definition of placental abruption
Separation of all/part of placenta before delivery, after 24weeks
240
RFs placental abruption
```
IUGR
pre-eclampsia
AI disease
smoking
prev abruption
```
241
Complications placental abruption
fetal death
massive haemorrhage caused by DIC
renal failure
maternal death
242
Distinguishing between placenta praevia and placental abruption
PP:
1. shock in proportion to visible loss
2. no pain
3. uterus not tender
4. lie and presentation may be abnormal
5. fetal heart usually normal
6. coagulation problems rare
7. small bleeds before large
PA:
1. shock out of keeping with visible loss
2. tender, tense, woody uterus
3. normal lie and presentation
4. fetal heart: absent / distressed
5. coagulation problems
6. beware pre-eclampsia, DIC, anuria
243
Mx placental abruption
Admit = if severe, IV fluids given (w steroids if <34)
FD present: c-sec
FD absent and >37w: induce labour w amniotomy
244
Key features of vasa praevia
Painless, moderate vaginal bleeding at amniotomy or SROM
| - Accompanied by severe FD
245
What happens in vasa praevia
Fetal blood vessels run in the membranes in front of presenting part. Cord is Attached to membranes not placenta. When they rupture, vessel may too --> massive fetal bleeding
246
Mx vasa praevia?
C-sec
its often not fast enough to save the fetus
247
If low lying placenta at 16-20 week scan
- rescan at 34 weeks
- no need to limit activity or intercourse unless they bleed
if still present at 34 weeks and grade I/II then scan every 2 weeks
- if high presenting part or abnormal lie at 37 weeks then Caesarean section should be performed
248
Mx placenta praevia with bleeding
- admit
- treat shock
- cross match blood
- final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery
249
What does lie mean in pregnancy
relationship of fetus to long axis of uterus e.g. longitudinal
250
What does presentation mean in pregnancy?
Part of the fetus that occupies the lower segment of the uterus/pelvis.
if neither cephalic or brech it is oblique or transverse
251
Cause abnormal lie
```
Uterine malformations e.g. fibroids
Polyhydramnios / high parity (lax uterus)
Oligohyd
Placenta praevia
Fetal abnormality
Prematurity
```
252
What is breehc presentation and what are the types?
Presentation of the buttocks
- extended
- flexed
- footlin
253
Complications breech
increased perinatal mort and morb
254
Mx breech presentation
if <36 wks: will turn spontaneously
at 36/37 weeks: external cephalic version
If ECV no work: c-section or vaginal delivery
255
Mx transverse / obliqye lie if >37wks
Admit, USS to find cause
| If not stabilised by 41 weeks --> elective c-sec
256
RFs multiple pregnancy
older, IVF, genetics
257
Complications mutliple preg
Maternal: pre-e, anaemia, GDM, operative delivery
Twins: morb and mort, preterm labour, IUGR, APH, malpresentation
258
Pathology TTTS
unequal blood distribution in shared placenta --> disconcordant blood volumes, liqour + often growth
259
Mx twins
- rest
- ultrasound for diagnosis + monthly checks
- additional iron + folate
- more antenatal care (e.g. weekly > 30 weeks)
- precautions at labour (e.g. 2 obstetricians present)
- 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
260
Mx TTTS
US surveillance from 12 wks, laser therapy if TTTS diagnosed
261
Define labour
The onset of regular and painful contractions associated with cervical dilation and descent of the presenting part
262
Signs of labour
- Regular and painful uterine contractions
- A show (shedding of mucous plug)
- Rupture of the membranes (not always)
- Shortening and dilation of the cervix
263
Stages of labour
1: from the onset of labour to fill dilatation of the cervix
2: full cervical dilatation to delivery of fetus
3. delivery of fetus to delivery of placenta
264
What are the mechanical factors of labour?
1. The powers = the degree of force expelling the uterus
2. The passage = the dimensions of the pelvis and resistance of the soft tissue
3. The passenger = the diameters of the fetal head
265
What does station mean and how can it be measured?
The level of descent of the head on VE
Measured in reference to the Ischial spines (-2cm, 0 , + 2)
266
What does attitude refer to in labour?
Degree of flexion of the fetal head on the neck
267
What does position refer to inlabour?
The degree of rotation of the head on the neck
Usually delivered in OA position (occipito-anterior)
268
What is the occiput?
The posterior fontanelle, lies on back of top of head
269
What are the 3 elements in the passenger?
The position, the attitude and the size of head
270
Movements of the head in labour
```
Engagement in OT
Descent and flexion
Rotation 90 degrees to OA (so face is facing sacrum)
Descent + perineum distends
Extension to deliver
Resitution + delivery of shoulders
```
271
What contractions are felt throughout 3rd trimester?
Contractions of uterine smooth muscle --> Braxton Hicks contractions
272
What do prostaglandins do in labour? (2 things)
1. decrease cervical resistance
2. increase oxytocin release from posterior pituitary
(aid stimulation of contractions that arise from one of the pacemakers situated in each cornu of the uterus)
273
Diagnosis of labour
When painful regualr contractions --> effacement then dilatation of the cervix
274
What constitutes the 1st stage of labour?
- Dx of labour --> 10cm cervical dilation
| - Rupture of membranes
275
What are the 2 phases in the 1st stage of labour
LATENT PHASE: <3cm
| ACTIVE PHASE: 3-10cm
276
What constitutes the second stage of labour?
From full dilation --> delivery
277
What are the 2 phases of the 2nd stage of labour?
PASSIVE: full dilation --> head reaches pelvic floor. rotation and flexion commonly completed
ACTIVE: pushing, woman gets in most comfortable position and bears down
278
What constitutes the 3rd stage of labour?
What is given?
Delivery of fetus --> delivery of placenta
Oxytoxin IM to help uterus contract once the shoulder are delivered
279
Degrees of tear in perineal trauma
1st: minor damage to fourchette
2nd: involve perineal muscle
3rd involve anal sphincter
4th: involve anal mucosa
280
Why is it important for women to be relaxed in labour?
Fear + anxiety --> adrenaline secretion --> decreased contractions
281
What is used to record progress in dilatation of cervix in labour ?
Partogram
assessed on VE and plotted against time
alert and action lines
282
What is augmentation and how can it be done?
The artificial strengthening of contractions in established labour
ARM or amniotomy
283
Induction
The artificial initiation of labour
284
Whats in bishops score
```
Cervical postion
Cervical consistency
Cervical effacement
Cervical dilation
Fetal station
```
<5 --> labour unlikely to start w/o induction
> 9 --> will most likely commence spontaneously
285
Indications induction of labour
```
Prolonged preg
Spontaneous PROM at term
Diabetic mother >38wks
Pre-eclampsia
Rhesus incompatibility
Social reasons + inutero death
```
286
Common causes of failure to progress in labour (think 3 ps!)
(common in nuliparous women)
the powers: inefficient uterine action**
the passage: cephalo-pelvic disproportion
the passenger: fetal size, disorder of rotation or flexion
287
Causes of fetal damage/injury
1. Fetal hypoxia (distress)
2. Infection/inlammation (e.g. GBS)
3. Meconium inspiration
4. Trauma
5. Fetal blood loss: Vasa praevia
288
Define fetal distress and what test indicates it?
An acute situation, such as Hypoxia that may result in fetal damage or death if not reversed or the fetus delivered urgently
pH <7.2 in fetal scalp capillary blood
OR : omonious FHR abnormalities
289
What is meconium?
The bowel contents of the fetus that stains amniotic fluid
Rare in preterm fetuses, common after 41 weeks
290
Why is meconium an indication for caution?
1. fetuses may aspirate it --> meconium aspiration syndrome
| 2. hypoxia is more likely
291
Monitoring methods for fetal distress
- Intermittent auscultation (IA) of FHR w hand-held Doppler
- Inspection for meconium
- CTG
- Fetal blood sample
292
Normal features of CTG
rate 110-160
accelerations
variability >5bpm
293
Mx if fetal blood sample abnormal?
Delivery by quickest route:
If 1st stage: c-sec
If 2nd and criteria met: instrumental
294
Mx slow to progress labour
1. Amniotomy + oxytocin
2. If fail in 1st stage: c-sec
3. If in 2nd stage: >1hr pushing, instrumental delivery if criteria met
295
Define sfd
Weight of fetus < the 10th centile for its gestation
| used for whole population
296
IUGR
Fetuses that have failed to reach their own 'growth potentia', when compared to genetic determinants, and are compromised
(most IUGR babies are SFD, but a proportion appear not to be)
297
Define fetal compromise
a chronic situation, when the conditions for the normal growth and neurological development are not optimal
298
Cause SFD + IUGR
Physiological determinants of size: race, parity, fetal gender, maternal size
Pathological: maternal illness (relan/pre-ec), twins, chromosomal abnormalities, infection, smoking
299
CFs SDF + IUGR
low symphysis-findal height
| features of pre-eclmapsia
300
Mx SFD
monitor growth
301
Mx IUGR
From 36 wks = deliver
34-36 = regular umbilical artery doppler, daily CTG, consider delivery
<34 wks = give steroids, then as for 34-36wks
302
Complications IUGR
NEC
| CP
303
Aims of fetal surveillance (3)
1. Identify the high-risk pregnancy
2. monitor the fetus for growth + well-being
3. Intervene at an appropriate time (In-utero compromise vs. intervention & prematurity)
304
What is the significance of maternal PAPP-A ?
A placental hormone
Reduced in 1st trimester with chromosomal abnormalities (Downs)
Also high risk for IUGR, placental abruption and --> stillbirth
305
Whats the significance of doppler umbilical artery wave forms in fetal surveillance?
Evidence of high resistance circulation i.e. reduced flow in fetal diastole compared to systole suggests placental dysfunction
Benefits: helps identify which small fetuses are actually growth restricted + therefore compromised
306
What are the 3 elements of screening for high risk pregnancies?
1. maternal, past obstetric and pregnancy history for RFs
2. uterine artery doppler (e.g. at 12 or 23 weeks)
3. maternal blood tests e.g. PAPP-A
Integration of the 3 = best!
307
What does cardiotocography do?
Records pressure changes in the uterus using internal or external pressure transducers
308
What is the DR C BRAVADO mneumonic?
Useful for assessing a CTG
```
Dr: define risk
C: contractions per 10 mins
BR: baseline rate
V: variability
A: accelerations
D: decelerations
O: overall
```
309
Describe baseline bradycardia on CTG and causes?
HR < 100/min (or <110?)
Increased fetal vagal tone
Maternal beta blocker use
310
Define baseline tachycardia on CTG and causes
HR > 160/min
Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity
311
Define loss of baseline variability on CTG and causess
< 5 beats / min
Prematurity
Hypoxia
312
Define early deceleration on CTG and causes
Synchronous with a contraction as a normal response to head compression
313
Define late deceleration on CTG and causes
Persist after the contraction is completed and suggest fetal hypoxia
314
Define variable deceleration on CTG and causes
Independent of contractions (vary in timing)
May indicate cord compression, which can ultimately --> hypoxia
315
Mx fetal distress
1. place woman in left lateral position (avoid aortocaval campression)
2. O2 +IV fluid
3. stop any oxytocin, and contractions can be stopped with a b2 agonist
4. VE to check for cord prolapse or v. rapid progress
5. FBS performed: if <7.2 deliver asap
316
Non-medical pain relief in labour
birth attendant + partner
maintain mobility
TENS
water
317
List 5 medical pain reliefs in labour
1. etonox (n2O+O2 - SEs: nausea, hypervent)
2. opiates (SEs: sedation, confusion, resp depression in the newborn- reverse with naloxone)
3. epidural
4. spinal athaesthesia
5. pudendal nerve block
318
What is epidural anaethesia and its advantages?
Injection of local anaesthetic into epidural space
Best pain relief, prevents premature pushing
319
Disadvantages epidural anaesthesia
```
Increased supervision
Maternal fever
Reduced mobility
Increased intrumental delivery rate
Hypotension
Urinary retention
```
320
Complications epidual anaethesia
Spinal tap
321
CI epidural
sepsis
active neuro disease
hypovolaemia
322
Complications induction of labour
LCSC
Other interventions
Longer labour
PPH
323
What it the vaginal delivery rate if attempted after previous c-section?
60-80%
324
CIs Vaginal delivery after C-section
Vertical uterine scar
325
Define preterm prelabour rupture of membranes
Before 37wks, and before the onset of labour
326
Complications PPROM
fetal: prematurity ,infection, pulm hypoplasia
maternal: chorioamnionitis
327
Ix PPROM
sterile speculum examnation
328
Mx PPROM
Oral erythromycin for 10 days
antenatal corticosteroids
consider delivery at 34 weeks
329
Indications instrumental delivery
Prolonged 2nd stage
| Fetal distress in 2nd stage, when pushing contraindicated
330
Prerequisites intrumental del
```
full dilated
position known
head deeply engaged
analgesia
empty bladder
```
331
complications instrumental del
lacerations, haemorrhage,
| fetal facial nerve injury
332
Common indications c-sec
- elective
- emergency
Elective: breech-presetation, prev LSCS, placenta praevia
Emergency: failure to advance, fetal distress
333
Complications C-sec
Haemorrhage
Sepsis
Thromboembolism
Anaesthetic
334
Define PPH
Blood loss of >500mls
```
Primary = in first 24hrs
Secondary = 24hrs --> 12wks
```
335
RFs PPH
```
c-sec
forceps
prlonged labour
APH
Prev Hx
```
336
Causes of PPH
Uterine atony
Retained placental parts
Vagnal, uterine, or cervical lacerations
337
Mx PPH
- ? bimanual uterine compression ; suture cervical / vag tears
- ABC (resus w IV fluids + blood if neccessary)
- IV oxytocin
- IM prostaglandin F2a
338
What is secondary PPH due to?
Retained placental tissue
| OR endometritis
339
CFs endometritis
(much more common afte c-sec)
Fever, abdo pain, offensive discharge, tachy
340
Ix endometritis
cultures
FBC (increased WCC)
MSU
HVS
341
Mx endometritis
clindamycin + gentamicin in hospital
342
Puerperium
the 6 week period following delivery, when body returns to its pregnant state
343
Puerperal pyrexia
A temp of >38degrees in the first 14 days following delivery
344
Causes puerperal pyrexia
```
Endometritis
UTI
would infections
mastitis
VTE
```
345
Define spontaneous miscarriage
Expulsion or death of fetus before 24weeks
| many types
346
Define threatened miscarriage
- Painless V bleeding before 24 weeks
- cervical os is closed, uterus size is as expected from dates
- fetus is alive
347
Define inevitable miscarriage
- Heavy bleeding with clots and pain
| - Cervical os is open
348
Incomplete miscarriage
- not all POC have been expelled
- pain and vaginal bleeding
- os is open
349
Complete miscarriage
- all POC have been passed
- uterus no longer enlarged
- os closed
350
Missed (delayed) miscarriage
- a gestational sac which contains a dead fetus before 20 weeks w/o the symptoms of expulsion
- light vaginal bleeding and symptoms of pregnancy disappear
- uterus is smaller than expected
- os is closed
351
Define recurrent miscarriage
3 more more miscarriages occur in succession
352
Causes recurrent miscarriage
```
Antiphospholipid syndrome
Endocrine: poorly controlled DM, thyroid disorders, PCOS
Uterine abnormality e.g. uterine septum
Parental chromosomal abnormalities
Cmoking
Infection
```
353
Ix recurrent miscarriage
Antiphospholipid screen
Karyotping of both parents
Pelvis USS
354
What scale to screen for PND?
Edinburgh Postnatal Depression Scale
355
What is the 'baby-blues'?
typically 3-7 days following birth
anxious, tearful and irritable
356
Rx baby blues
Reassurance and support
| Health visitor plays a key role
357
CFs and onset PND
Start within a month and typically peak at 3 months
Sx: tiredness, guilt, feelings of worthlessness
358
Rx PND
1. Reassurance + support
2. CBT
3. SSRI (sertraline or paroetine
359
CFs Puerperal psychosis
Severe mood swings (similar to bipolar)
| Disordered perception e.g. auditory hallucinations
360
Rx Puerperal psychosis
Psych admission
Major tranquilisers
20% recurrence risk following future pregnancues
361
Triad to diagnose hyperemesis gravidarm
and what is it otherwise?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Nausea and vomiting of preg (NVP
362
RFs hyperemesis gravidarmum
+ 1 seemingly protective factor
```
multiple pregnancies
trophoblastic disease (molar preg)
hyperthyroidism
nulliparity
obesity
```
*smoking ? protetive
363
Mx hyperemesis gravidarum
- Exclude UTI or molar preg
- Antihistamine e.g. promethazine
- Antiemetics: cyclizine
- steroids in severe cases
Admission may be needed for IV hydration
**psychological support is essential
364
Complications hyperemesis gravidarum
- Wernicke's encephalopathy
- Mallory-Weiss tear
- Central pontine necrosis
- Fetal: small for gestational age, pre-term birth
365
Define ectopic pregnancy
Implantation of a fertilized ovum outside the uterus
366
RFs ectopic pregnancy
Anything slowing the ovum's passage to the uterus
- damage to tubes (salpingitis, surgery)
- prev ectopic
- endometriosis
- IUCD
- IVF
(also submucosal fibroids, PID< chlamydia)
367
Location of ectopics
95% fallopian tube
- which can --> tubal tupture + intraperitoneal bleeding
368
Incidence and recurrence rate ectopic
1%
| 10%
369
CFs ectopic
| acute and subacute
4-10 weeks of amenorrhoea
1. ACUTE: collapse with abdo pain + bleeding, shock
2. SUBACUTE: abdo pain, scanty dark blood PV
370
Ex findings ectopic
- lower abdo tenderness, cervical excitation, adnexal tenderness
DO NOT examine for an adnexal mass --> risk of rupture
371
Ix ectopic
Pregnancy test
Transvaginal USS
hCG
Laparoscopy to confirm + treat unless Dx certain and medical Mx proposed
372
What does Mx ectopic depend on?
Depends on clincial scenario e.g. size, rupture, pain, fetal heartbeat
373
Surgical Mx ectopic
To stop/prevent bleeding
1. Salpingectomy
2. Salpinotomy
374
Medical Mx ectopic
1. Methotrexate
- a DMARD that stops growth of rapidly dividing cells
- can only be given if patient agrees to attend FU
375
Expectant Mx ectopic
Close monitoring over 48hrs
| If B-hCG levels rise again, or symptoms manifest --> intervention
376
What is tubal absorption in an ectopic?
where the blood and embryo may be shed or converted into a tubal mole and absorbed
377
What happens in gestational trophoblastic disease? and what is secreted in excess
Trophoblastic tissue proliferates more aggressively than normal
hCG
378
What is a hydatiform mole in comparison to a invasive one?
Proliferation that is localised and non-invasive
Invasive has characteristics of malignant tissue, but is only local within the uterus
379
What is a complete hydatidiform mole? + what happens to form it?
Benign tumor of trophoblastic material
When an empty egg is fertilized by a single sperm that then duplicates its own DNA - hence all the 46 chromosomes are of paternal origin
No fetal tissue - just a prolif of swollen chorionic villi
380
CFs complete hydatidiform mole
- (painless) V bleeding in early preg
- very high hCG
- Uterus large for dates
- Exaggerated symptoms of preg e.g. hyperemesis
- HTN and hyperthyroidism may be seen (hCG can mimic TSH)
381
Mx complete hydatidiform mole
Urgent referrla to specialist centre - ERPC
Contraception to avoid pregnancy in next 12 months
382
What do 2-3% of complete hydatiform moles go on to develop?
Choriocarcinoma
383
What is a partial hydatiform mole?
A normal haploid egg fertilised by 2 sperms, or by one sperm with duplication of the paternal chromosomes
DNA is both maternal and paternal in origin
Usually triploid e.g. 69 XXX or 69 XXY
Fetal parts may be seen
384
What is a choriocarcinoma
metastasis of an invasive mole
385
USS gestational trophoblastic disease
Small bunch of grapes
| 'snow-storm' appearance
386
Confirmation Dx GTD
Histologically
387
Causative organism mastitis
Staphlycoccus aureus
388
Pathology mastitis
Milk statis due to overproduction or insufficient removal
| - can be infectious or non-infectious
389
CFs mastitis
Breat pain (usually uilateral)
Erythematous, warm + tender area
? fever + flu-like symptoms
390
Mx mastitis
Treat if:
- systemically unwell
- nipple fissure present
- if symptoms dont improve after 12-24hrs of effective milk removal
- if culture indicates infection
Abx: flucloxacillin for 10-14 days
- breast feeding / expression should continue during this
391
What can mastitis develpo into if untreated?
Breast abcess
392
DDx mastitis
Inflammatory breast cancer
393
Define rhesus disease
maternal antibody response against fetal red blood cell antigen entering her circulation: passage of antibodies into fetus --> haemolysis
394
Tx Rhesus disease
Transfuse if fetus anaemic
Deliver if >36weeks
Also, UV phototherapy
395
Implications for fetus in rhesus disease
Oedematous (Hydrops fetalis)
| Jaundice, anaemia, hepatosplenomegaly, HF, kernicterus
396
Define subfertility
Failure to conceive after a year
Primary: never conceived
Sec: previosly conceived
397
Causes of subfertility
1. Annovulation: e.g. PCOS & other causes of amenorrhoea
2. Male factor: 25% e.g. idiopathic, varicocoele
3. No fert: Tubal factor e.g. endometriosis, infection, surgery
4. unexplained (30%)
398
Ix subfertility
After 1 yr of attempting to conceive
- Semen analysis
- Mid-luteral phase progesterone (7 days before end of cycle)
(also: HyCoSy to detect tubal factor, and FSH/LH/prolactin/TSH/progesterone to detec cause of annovulation)
399
Key counselling points sub/in-fertility
- Folic acid
- Aim for BMI 20-25
- regular intercourse every 2-3 days
- smoking / driving advice
400
Rx infertility
Lifestyle + folic
Treat cause
IVF if unexplained
401
Common causes of male infertility
1. unknown
2. drug exposure (incl canabis, chemo)
3. Varicocele
402
What is varicocele
Abnormal enlargement of the testicular veins (pampiniform plexus)
403
CFs varicocele
Left side
Bag of worms
Subfertility
Dull ache
(but surgery has little effect on subsequent fertility)
