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*Phase 3a Julia > Women's Health > Flashcards

Women's Health Flashcards

1
Q

Parity

A

The number of times a woman has delivered potentially viable pregnancies (>24 weeks)

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2
Q

What does the b mean in:

Para a + b

A

b = the number of pregnancies that have miscarried or been terminated

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3
Q

Gravidity

A

no. of times a woman has been pregnant

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4
Q

Nulliparous

A

delivered no live / potentially live babies (n.b. may have had a TOP or miscarriage)

–> e.g. para 0 + 2

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5
Q

Multiparous

A

delivered live / potentially live (>24 weeks) babies

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6
Q

Primapara

A

pregnant for the 1st time

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7
Q

What tablets should every woman trying to conceive take and when?

A

400 micrograms FOLIC ACID (before + 12 weeks after conception)

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8
Q

Which anti-epileptic is safer than sodium valporate?

A

Lamotrigine

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9
Q

What ages have increased risk of obstetric and medical complications in pregnany

A

Below 17 and over 35

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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
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11
Q

Define polyhydramnios

A

Liquor volume increased

Deepest liquor pool >10cm is generally considered abnormal

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12
Q

Clinical features of polyhydramnios

A

Maternal discomfort
Large for dates
Abnormal lie
Malpresentation

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13
Q

Complications of polyhydramnios

A

Preterm labour
Maternal discomfort
Abnormal lie
Malpresentation

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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

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15
Q

Aetiology of polyhydramnios?

A

Idiopathic
Maternal disorders (e.g. DM)
Twins (e.g. TTTS)
Foetal anomaly (e.g. impaired swallow)

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16
Q

When are the trimesters?

A 
1st = 0-12 weeks
2nd = 13-27 weeks
3rd = 28-40 weeks
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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

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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
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19
Q

What day does embryo implant

A

Day 9

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20
Q

What day is heartbeat detectable

A

Day 22

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21
Q

Combined test

A

NT, bhCG, PAPP-a
(both blood and USS)

11 - 13 +6

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22
Q

Quadrudple

A

alpha-feto protein
hCG
Oestriol

(inhibin a)

At 15-20 weeks if >13 weeks booking

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23
Q

What would combined test show for Down’s syndrome?

A

NT and bhCG raised

PAPP-a low

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24
Q

What duct gives rise to some of the female reproductive organs?

A

Paramesonephric/Mullerian ducts

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25
Q

What duct gives rise to male reproductive organs?

A

Mesonephric/Wolfian duct

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26
Q

How many structures make up the umbilical cord?

A

3:

  • 2 umbillical arteries
  • 1 umbilical vein

(central vein and artery spiralling round)

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27
Q

What happens in passive part of 2nd stage of labour?

A

Contractions make baby come out (no urge to push at this point)

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28
Q

What drug can you use to stop PPH

A

Oxytocin (most of it is due to uterine atonia)

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29
Q

4 Ts that cause PPH

A

Tone - approx. 70%
Trauma - lacerations, hematomas, inversion or rupture
Tissue (retained tissue or invasive placenta)
Thrombin - coagulopathies

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30
Q

What maternal conditions necessitate CTG

A 
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
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31
Q

What fetal conditions necessitate CTG

A

**

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32
Q

If blood when membranes rupture

A

Vasa Previa

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33
Q

Twins: morula cleavage at days 1-3

A

Dichorionic / diamniotic

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34
Q

Twins : morula cleavage at days 4-8

A

monochorionic / diamniotic

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35
Q

Twins: cleavage days 8-13

A

monochorionic / monoamniotic

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36
Q

Twins: cleavage days 13-15

A

conjoined twins

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37
Q

Methods of induction of labour

A
  • membrane sweep
  • intravag prostaglandin E2 (misoprostol)
  • amniotomy + oxytocin
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38
Q

what drug for normal delivery?

A

oxytocin (syntocinon - 10 units IM)

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39
Q

Treatment for antiphospholipid syndrom

A

LMWH and aspirin

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40
Q

When is the maternal blood test and what does it test for?

A

0-10 weeks

  • Sickle cell anaemia
  • thalassaemia
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41
Q

When is routine congenital anomaly screen, and what does it test for?

A

Detailed US scan at 18-20 w

  • Neural tube defects
  • Major heart defects
  • Renal agenesis
  • Skeletal / CNS abnormality
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42
Q

When can Chorionic Villous Sampling take place? and what is it?

A

11-13 weeks gestation

Placental biopsy of foetal cells

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43
Q

When can amniocentesis occur?

A

15-20 weeks

amniotic biopsy of foetal cells

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44
Q

Presentation of down’s syndrome

A

Intellectural disability
Stunted growth
Dysmorphia

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45
Q

CFs Patau’s syndrome

A

Polydactyly
Cleft lip/palate
VSD, PDA
Global developmental delay

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46
Q

What is Edward’s syndrome associated with?

A

IUGR

Polyhydramnios

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47
Q

CFs edwards syndrome

A

Similar to Patau’s but without Polydactyly

Also: prominent occiput, kidney malformation, developmental delay

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48
Q

CFs Turner’s syndrome

A

Short stature, shield chest, low set ears, webbed neck, wide spaced nipples

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49
Q

Turner’s syndrome associations

A 
Amenorrhoea
Delayed puberty
Sterility
Coarctation of the aorta
Bicuspid aortic valve
Obesity
Horseshoe kidney
Thyroid disorder
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50
Q

Rx Turner’s syndrome

A

Growth hormone
Oestrogen replacement (COCP)
Fertility

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51
Q

What are the TORCH infections?

A 
Toxoplasmosis, 
Other (syphilis, varicella-zoster, parvovirus B19), 
Rubella, 
Cytomegalovirus (CMV)
Herpes infections,

(some of the most common associated with congenital abnormalities)

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52
Q

What is cervical ectopy/ectropian?

A

Inner lining of cervical canal (columnar ep) come out into part of the cervix that can be seen on sepculum

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53
Q

Px cervical ectropian?

A

Post-coital bleed

Discharge

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54
Q

What is cervical ectropian associaed with?

A

Hormonal changes:

  • pregnancy
  • cocp etc.
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55
Q

What is tamoxifen and what is its role in the breast, and endometrium?

A

A selective oestrogen receptor modulator

  • Antagonises receptors in the breast
  • Agnoises them in the endometrium –> hyperplasia
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56
Q

When do you give anti-D to non-sensitised Rh- mums?

A

at 28 and 34 weeks

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57
Q

What are some potentially sensitising events in pregnancy?

A
  • 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)
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58
Q

When does ovulation occur?

A

36hrs after the LH surge
~ day 13

LH = let her ovulate!

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59
Q

When do progesterone levels peak?

A

mid-luteal phase

~day 21 (7 days before end of cycle)

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60
Q

Average age of menopause, and when is premature?

A

51

before 40

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61
Q

Define menopause

A

Permanent cessation of menstruation.
12 consecutive months of amennorhoea.
Loss of folicular activity.

(or onset of symptoms if hysterectomy)

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62
Q

Peri-menopause

/ climacteric

A

Time between first features of menopause and 12 months after last period

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63
Q

Vasomotor (early) symptoms menopause

A

Hot flushes

Night sweats

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64
Q

Urogenital (mid) symptoms of menopause

A

Vaginal atrophy + dryness

Urinary frequency

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65
Q

Ix menopause

A

FSH - day 5
Anti-mullerian hormone

Others: TFT, DEXA

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66
Q

Longer term complications of menopause

A

Osteoporosis

Increased risk of CV disease and dementia

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67
Q

Mx menopause lifestyle

A

regular exercise, weight loss, reduce stress, good sleep hygiene

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68
Q

Contraindications HRT

A
  • current or past breast cancer
  • any oestrogen-sensitive cancer
  • undiagnosed Vaginal bleeding
  • untreated endometrial hyperplasia
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69
Q

What type of HRT if have uterus?

A

Oral or transdermal combined HRT

reduces risk of endometrial hyperplasia / carcinoma

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70
Q

Contraception and menopause

A

For:
12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

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71
Q

How long do symptoms of menopause last for?

A

2-5yrs

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72
Q

Risks of treatment with HRT

A

Oral: VTE, Stroke

Combined: Coronary HD, breast cancer

All HRT: ovarian cancer

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73
Q

Mx menopause non-HRT

A

Vasomotor symptoms: fluoexetine

Vaginal dryness: lube / moisturiser

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74
Q

Define menorrhagia

A

Excessive menstrual blood loss that interferes with the woman’s psysical, emotional, social and material QoL

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75
Q

Causes menorrhagia

A
  • 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
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76
Q

What must you exclude in woman over 45 with mennorhagia?

A

Endometrial carcinoma

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77
Q

Ix Mennorhagia

A

Examination
FBC
If clinically indicated: TVUSS or endometrial biopsy

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78
Q

Mx Menorrhagia if does not require contraeption

A

Antifibrinolytic =Tranexamic

OR mefenamic acid - an NSAID (particularly if there is dysmennorhea as well)

(take during menstruation only)

If fails –> surgery…

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79
Q

Mx Menorrhagia if requires contraception

A
  1. Intrauterine system (Mirena)
  2. COCP
  3. Long-acting progesterones

NSAIDs also useful for dysmenorrhoea

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80
Q

Define secondary amenorrhoea & causes

A

Periods stop for 6 months or more

  • PREGNANCY
  • hypothalamic amenorrhoea: stress, excessive exercise
  • PCOS
  • hyperprolactinaemia
  • premature ovarian failure
  • Thyrotoxicosis, hypothy sheehan’s, asherman’s
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81
Q

Define primary amenorrhoea & causes

A

Failure to start menses by age 16

  • Turners, testicular feminisation, CAH, congenital malformations
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82
Q

Ix amennhorhoea

A
  • Urinary / serum bHCG
  • Gonadotropins:
    • low levels -> hypothalamic cause
    • high levels –> ovarian problem
  • Prolactin
  • Androgen levels (raised in PCOS)
  • Oestradiol
  • TFTs
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83
Q

what is it and Features primary dysmenorrhoea

A

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
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84
Q

Mx primary dysmenorrhoea

A
  1. NSAIDs e.g. mefenamic acid or ibuprofen
  2. COCP

Also: local application of heat, transcutaneous electrical nerve stimulation

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85
Q

What is secondary dysmenorrhoea and its features?

A

Develops many years afte menarche, result from underlying pathology

Pain starts 2-3 days before onset of period

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86
Q

Causes of secondary dysmenorrhoea

A
  • Endometriosis
  • Adenomyosis
  • PID
  • Intrauterine device (Cu coil, NOTE mirena may be Rx)
  • Fibroids
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87
Q

Ix secondary dysmenorrhoea

A
  1. Examination
  2. Swabs if STI risk

Refer to gynae
- pelvic USS, laparoscopy

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88
Q

Causes: irregular menstruation and IMB

A
  1. Anovulatory cycles
  2. Non-malignant pelvic pathology:
    - fibroids, uterine / cervical polyps, adenomyosis, ovarian cysts, PID
  3. Malignant: ovarian, endo, C
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89
Q

Ix IMB

A
  • FBC: assess effect of blood loss
  • TFT / clotting
  • FSH/ LH
  • cervial smear
  • USS uterine cavity if >35yrs
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90
Q

Mx IMB

A
  1. IUS or COCP
  2. Progesterones, HRT
    Others as for menorrhagia
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91
Q

Causes of post-coital bleeding

A
  1. Cervical carcinoma - must be ruled out
  2. Cervical ectropian
  3. Cervical polyps
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92
Q

Define uterine fibroids

A

Benign smooth muscle tumours of the uterus

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93
Q

Uterine fibroids risk factors

A

Afro-carribean
Near menopause
PHMx of early pubery
FH

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94
Q

Protective factors fibroids

A

Late puberty, parous, COCP

risk increases from puberty to menopause

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95
Q

Features uterine fibroids

A
  • asymptomatic
  • menorrhagia
  • lower abdo pain: cramping often during menstruation
  • urinary e.g. freq with large fibroids
  • subfertility
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96
Q

Dx uterine fibroids

A

TVUSS

also, pelvic exam, FBC (Hb may be low if heavy bleeding

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97
Q

Mx uterine fibroids

A
  1. IUS (Mirena) - levonorgestrel-releasing
  2. Tranexamic acid, COCP
  3. GnRH agonists
  4. Surgery e.g. myomectomy
  5. Uterine artery emolisation
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98
Q

Complications of fibroid

A

Red degeneration - haemorrhage into tumor
Commonly occurs during pregnancy

(ALso malpresentation, transverse lie, premature, or obstructed labout

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99
Q

RFs endometrial cancer

A

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

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100
Q

Features endometrial cancer

A
  • PMB
  • Change in intermenstrual bleeding for pre-menopausal women
  • Pain and discharge (unsual)
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101
Q

Ix endometrial cancer

A

TVUSS (normal endo thickness, of <4mm, has high NPV)

Hysteroscopy with endometrial biopsy

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102
Q

Most common type of endometrial cancer

A

Adenocarcinoma of columnar endometrial gland cells

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103
Q

Mx Endometrial cancer

A

Localised disease: total abdo hysterectomy + bilateral salpingo-oophorectomy

High risk disease: post-operative RT

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104
Q

Protective factor endometrial cancer

A

COCP

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105
Q

Definition adenomyosis

A

Presence of endometrial tissue within the myometriu

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106
Q

RF adenomyosis

A

multiparous women

toward end of reproductive years

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107
Q

Features adenomyosis

A

Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus

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108
Q

Mx adenomyosis

A

IUS (mirena progesterone)
COCP
GnRH trial
Hyterectomy

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109
Q

CFs intrauterine polyps

A

Menorrhagia
IMB
Sometimes prolapse

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110
Q

Dx intrauterine polyps

A

USS

Hysteroscopy

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111
Q

Mx intrauterine polyps

A

Resection with cutting diathermy

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112
Q

What causes congenital vaginal abnormalities?

A

Differing degrees of failure of fusion of mullerian duct

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113
Q

Mx cervical ectropian

A

Stop OCP
Cryotherapy or diathermy
Smear / colcoscopy to exclude carcinoma

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114
Q

Screening protocol CIN?

A

All females from age 25

  • Rpt every 3 yrs until age 49
  • From age 50-64: every 5yrs
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115
Q

How is cervical cancer screen performed? And why better than pap?

A

Liquid-based cytology (LBC)

increase sensitivity and specificity, fewer inadequate samples

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116
Q

CIN grading

A

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

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117
Q

Mx CIN

A

Large loop excision of the transformation zone (LLETZ)

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118
Q

2 types of cervical cancer

A

Squamous cell cancer (80%)

Adenocarcinoma (20 - worse prog)

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119
Q

Features Cervical cancer

A
  • detected during routine screening
  • abnormal vaginal bleeding: psotcoital, IMB or PMB
  • Offensive vaginal discharge
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120
Q

RFs cervical cancer

A 
HPV (16,18,33)
smoking
HIV
early first intercourse, many sexual partners
high parity
lower SE status
COCP
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121
Q

Ix cercival cancer

A

Colposcopy to biopsy tumor

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122
Q

Triad of PCOS

A
  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

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123
Q

What do affected PCOS patients have raised in blood and what does it lea d to?

A

Insulin and LH

Leads to lots of free floating androgen

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124
Q

Dx PCOS

A

2 of the triad

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125
Q

Ix PCOS

A

Pelvic ultrasound scan (multiple cysts)

Bloods: FSH, LH, prolactin, testosterone

GTT

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126
Q

Mx PCOS

A

Genral: wt reduction, COC

Hirtusim + acne: COC e.g. co-cyprindiol (dianete)

Infertility: wt reduction, Clomifene, metformin, Gonadotropins (ovarian induction)

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127
Q

Name 3 ovarian cysts

A
  1. Mucinous cystadenomas
  2. Teratoma (dermoid cyst) - teeth!!
  3. Chocolate cyst (from endometriosis)
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128
Q

Symptoms ovarian cyst

A
  1. Ache/pain in lower abdo / back
  2. Dyspareunia
  3. Large cysts: pressure (bladder frequency, veins-oedema/varicosity), abdo distension
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129
Q

Ix ovarian cysts

A
  • USS

Things to rule out:

  1. CA125 blood test to rule out cancer
  2. Pregnancy
  3. Urinalysis for urinary symptoms
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130
Q

RFs ovarian cancer

A

FH: mutations of the BRCA1 or the BRCA2 gene

HNPCC

Many ovulations

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131
Q

CFs ovarian cancer

A

Notoriously vague

  • abdo distension + bloating
  • abdo + pelvic pain
  • urinary symptoms e.g. urgency
  • early satiety
  • diarrhoea
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132
Q

Ix ovarian cancer

A

CA125 initially

If raised –> urgent USS of abdo and pelvis (or if abdo/pelvic mass/ascites)

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133
Q

Dx ovarian cancer

A

Diagnostic laparotomy

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134
Q

Mx ovarian cancer

A

Combo of surgery and platinum-based chemo

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135
Q

Prominent feature Lichen sclerosus

A

Itch

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136
Q

Mx Lichen sclerosus

A

Topical steroids and emolients

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137
Q

FU lichen sclerosus

A

Increased risk of vulval cancer (5% transform into it, biopsy is a good shout!)

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138
Q

What are 90% of ovarian cancer? and 5yr survival rate

A

epithelial tumors

35-45%

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139
Q

What is most common type of vulval carcinoma?

A

Squamous cell carinoma

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140
Q

RFs vulval carcinoma

A 
>65
HPV
VIN
immunosupression
lichen slerosus
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141
Q

Features vulval carcinoma

A

lump / ulcer on labia majora

itching / irritation

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142
Q

what is a urogenital prolapse?

A

descent of one of the pelvic organs –> protrusion on the vaginal walls

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143
Q

Types of prolapse (give 4)

A
  • Cystocele
  • Cystourethrocele
  • Rectocele
  • Uterine prolapse
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144
Q

RFs prolapse (give 4)

A

Increasing age
multiparity, vaginal delivery
obesity
spina bifida

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145
Q

CFs prolapse

A
  • Sensation of pressure, heaviness, ‘bearing-down’

- Urinary symptoms: incontinence, frequency, urgency

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146
Q

Mx prolapse

A

Conservative: wt loss, pelvic floor muscle exercises

Ring pessary

Surgery

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147
Q

Surgical options prolapse

A
  • Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
  • Uterine prolapse: hysterectomy, sacrohysteropexy
  • Rectocele: posterior colporrhaphy
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148
Q

CFs thrush

A

Cottage-cheese discharge
Irritation
Itching

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149
Q

Mx thrush

A

Clotrimazole

pessary, cream or capsule

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150
Q

CFs bacterial vaginosis

A

Grey-white discharge

Fishy odour

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151
Q

Causative organism thrush

A

Candida Albicans

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152
Q

Causative organism Bacterial Vaginosis

A

Gardnerella Vaginalis

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153
Q

Mx bacteria vaginosis

A

Metronidazole (PO)

or

Clindamycin (topical)

  • both are Abx
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154
Q

Causative organism chlamydia

A

Chlamydia trachmoatis

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155
Q

CFs chlamydia

A

asympt

discharge, urethritis, irregular bleeding

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156
Q

Rx chlamydia

A

Azithromycin - single dose

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157
Q

Causative organism Gonorrhoea

A

Neisseria gonorrhoea

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158
Q

CFs Gonorrhoea

A

Asympt

Urethritis, vaginal discharge, bartholinitis + cervicitis

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159
Q

Rx Gonorrhoea

A

IM ceftriaxone

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160
Q

Causative agent genital warts

A

HPV

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161
Q

Rx genital warts

A

Imiquimod cream

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162
Q

Causative agent genital herpes

A

HSV type 2 mostly

163
Q

CFs genital herpes

A

Many small, painful vesicles and ulcers

swollen local lymph nodes, systemic symptoms, dysuria

164
Q

Dx genital herpes

A

viral swabs

165
Q

Rx genital herpes

A

Aciclovir

166
Q

Causative organism syphilis and Rx

A

Treponema Pallidum

Rx: IM penicillin

167
Q

CFs Trichomoniasis

A

Offensive green-grey discharge
Vulval irritation
Superficial dysparenuina
Strawberry lesions on cevix

168
Q

Rx Trichomoniasis

A

Metronidazole

169
Q

Causative organisms PID

A

Chlamydia Trachomatis

Neisseria Gonorrhoeae

170
Q

CFs PID

A 
lower abdo pain
fever
deep dysparenia
dysuria + menstrual irregularities
vaginal or cervical discharge
cervical excitation
171
Q

Ix PID

A

Endocervical swabs for chalmydia and gonorrhoea

172
Q

Rx PID

A

IM ceftriaxone + doxycycline + metronidazole

If febrile –> admission for IV Abx

173
Q

What can non-treatment or inadequate treatment of PID lead to?

A

Chronic PID

  • dense pelvic adhesions
  • fallopian tube obstruction
174
Q

Method of TOP if less than 9 weeks

A

Mifepristone (an anti-progestogen)
+
Prostaglandins 48hrs later (to stimulate uterine contractins)

175
Q

Method of TOP if between 9 and 13 weeks

A

Surgical dilation and suction of uterine contents

176
Q

What are the ovarian cyst accidents?

A

Rupture of cyst contents
Haemorrhage into cyst
Torsion of the pedicle –> infarction of ovary

177
Q

Mx ovarian cyst pedicle torsion

A

Urgent surgery + detorsion if the ovary is to be saved

178
Q

Suspicious symptoms in breast history

A
  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
Q

What is the most common type of breast cancer?

A

Preinvasive: Invasive ductal carinoma in situ

Invasice: ductal, lobular

180
Q

Breat cancer RFs

A 
BRCA genes - 40% lifetime risk of breast / ovarian cancer
FHx
Nulliparity, 1st pregnancy >30yrs
Many ovulations
HRT, COCP
Not breastfeeding
Obesity
181
Q

National screening for breast Ca

A

Triennial: 47 - 73 yrs

Annually if FHx between 40&50yrs

182
Q

Triple assessment breast cancer

A
  1. Clinical Ex
  2. Imaging ( M or USS)
  3. Needle biopsy
183
Q

Grading in breast cancer

A
  1. well differentiated with a low mitotic rate

—> 3. (the opposite)

184
Q

Relevant Receptors in breast cancer

A

Oestrogen receptor = better prognosis. Rx: anti-oestrogens

Human epidermal growth factor (HER2) = poor prognosis. Rx: herceptin

185
Q

Indications for mastectomy in breast cancer

A 
Large tumor
Multifocal
CI to RT v.strong
Failed conservation surgery
Prophylactic in gene carriers
186
Q

Indications for lumpectomy in breast cancer

A

Pt choice
Unifocal tumor
Suitable for RT (must have as an adjunct)

187
Q

Difference between axillary node clearance and sential node biopsy breast Ca

A

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
Q

TMN staging breast cancer

A

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
Q

Hormonal Rx breast Cancer

A

Pre-men: Tamoxifen (selective oestrogen receptor modulator)

Post-men: aromative inhibitors, prevent oestogen productio

190
Q

Features of fibroadenoma

A

<30yrs
‘Breast mice’ as discrete, non-tender, firm, highly mobile lumps

No increased risk of brast Ca
If >3cm, excision is usual

191
Q

Features of a breast cyst

A

Smooth discrete lump

Small increased risk of breast Ca

192
Q

Features of a benign breast cyst

A
  1. Fluid not blood-stained
  2. No residual lump
  3. Same cyst doesn’t continually refil
193
Q

What are the trisomies more common with?

A

Advancing maternal age

194
Q

Risk of miscarriage in amniocentesis?

A

1%

195
Q

What causes toxoplasmosis

A 
Toxoplasma gondi (a protozoan parasite)
rom cat faeces, soil, meat
196
Q

Rx toxoplasmosis

A

Spiramycin ASAP

197
Q

What does listeria cause in pregnancy and how can it be avoided?

A

Fetal distress, respiratory distress, convulsions

Avoid soft cheeses if pregnant

198
Q

List 3 maternal physiological adaptations to pregnancy

A
  1. Wt gain 1-15kg
  2. Blood: vol increases by 50%
  3. Lungs: tidal volume: 40% increase!
199
Q

Whats aorto-caval compression?

A

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
Q

List 3 minor conditions of pregnancy

A
  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
Q

What is intrahepatic cholestasis of pregnancy due to?

How is it Ix?

A

The cholestatic effects of oestrogen

Associated with stillbirth

Serum bile salts

202
Q

Complication of intrahepatic cholestasis of pregnancy and how to prevent?

A

Maternal and fetal haemorrhage

Give vit K

203
Q

Classification of hypertensive disorders in pregnancy

A

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
Q

What antihypertensives can you use for women with mild-moderate hypertension in pregnancy?

A

Labetalol

Nifedipine

205
Q

What happens to BP in normal pregnancy?

A

Falls in first trimester, and continues to fall until ~20 weeks

Then, it usually increases to pre-pregnancy levels by term

206
Q

Define pre-eclampsia

A

A multi-system disease of pregnancy seen after 20 weeks gestation and characterised by HTN (BP 140/90) with proteinuria

207
Q

Pathology pre-eclampsia

A

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
Q

What does pre-eclampsia predispose to?

A 
Fetal: prematurity, IUGR
Eclampsia
Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
Cardiac failure
Multi-organ failure
209
Q

RFs pre-eclampsia

A 
POHx hypertensive disease
CKD
AI disease
T1 or T2 DM
Nuliparity
Older age
High BMI
FHx
TWINS
210
Q

Features of severe pre-eclampsia

A 
HTN (typc >170/110) and proteinuria
Proteinuria dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epi pain
Hyperreflexia
HELLP
211
Q

What is visual disturbance in pre-eclampsia as a result of?

A

Reduced blood flow to retina

212
Q

Mx pre-eclampsia

A
  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
Q

What Mx if eclampsia?

A

Magnesium sulphate

214
Q

Screening of pre-eclampsia

A

Observation of high-risk pregnancies

Uterine artery doppler to pick up decreased flow

215
Q

Prevention pre-eclampsia

A

Aspirin 75mg /day from <16wks if high risk pregnancy

216
Q

Why does glucose tolerance decrease in pregnancy?

A
  1. altered carbohydrate metabolism

2. antagonistic effects of progesterone & cortisol

217
Q

Define gestational DM

A

Carb intolerance which is Dx in pregnancy and may/may not resolve after pregnancy

218
Q

RFs gestational diabetes

A

BMI > 30
Previous macrosomic baba
POHx GDM
FHx DM

219
Q

Screening for GDM

A

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
Q

Fetal complications GDM

A

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
Q

Maternal complications GDM

A 
increased insulin requirements
hypogly
infections
prre-eclampsia
operative delivery
222
Q

Diagnositc thresholds

A

Fasting glucose is >= 5.6
Or
2hr is >= 7.8

223
Q

Mx GDM

A
  1. Education: diet & exercise trial
  2. +Metformin
  3. +Insulin
224
Q

Mx pre-existing DM (in pregnancy)

A
  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
Q

What 2 oral hypoglycaemic drugs are definitely contra-indicated in pregnancy?

A

Gliclazide

Liraglutide

226
Q

Define preterm delivery

A

between 24 and 37 weeks

227
Q

Give 4 Causes of preterm delivery

A

Subclniical infection
Cervical ‘intompetence’
TWINS
Polyhydramnios

228
Q

Prediction of preterm delivery

A

PMHx

Transvaginal sonography of cervical length

229
Q

Prevention of preterm delivery

A

Abx if infection
Cervical suture
Progesterone pessaries

230
Q

CFs preterm delivery

A

Abdo pain
APH
Rupture of membranes
Fever

231
Q

Ix preterm deivery

A

CTG and USS

TVS of cervical length
Fetal fibronectin assay

High vaginal swabs
Maternal CRP

232
Q

Mx preterm delivery

A

Steroids (if <34 weeks)

Abx if in confirmed labour only

233
Q

How long do steroids take to promote pulmonary maturity? and how can this be helped

A

24hrs

Delay delivery by tocolysis (atosiban = an oxytocin receptor antagonist)

234
Q

APH define

A

Bleeding from genital tract after 24 weeks of pregnancy, prior to delivery of the fetus

235
Q

What happens in placenta praevia?

A

Placenta is implanted in the lower segment of the uterus

  • can have marginal and major types. (major over/partly covers the os)
236
Q

complications placenta praevia?

A
  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
Q

What must you exclude before you do a VE on a woman bleeding vaginally? and how to exclude it?

A

Placenta praevia

TVUSS

238
Q

Ix placenta praevia (in addition to TVUSS)

A

FBC + crossmatch

239
Q

Definition of placental abruption

A

Separation of all/part of placenta before delivery, after 24weeks

240
Q

RFs placental abruption

A 
IUGR
pre-eclampsia
AI disease
smoking
prev abruption
241
Q

Complications placental abruption

A

fetal death
massive haemorrhage caused by DIC
renal failure
maternal death

242
Q

Distinguishing between placenta praevia and placental abruption

A

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
Q

Mx placental abruption

A

Admit = if severe, IV fluids given (w steroids if <34)
FD present: c-sec
FD absent and >37w: induce labour w amniotomy

244
Q

Key features of vasa praevia

A

Painless, moderate vaginal bleeding at amniotomy or SROM

- Accompanied by severe FD

245
Q

What happens in vasa praevia

A

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
Q

Mx vasa praevia?

A

C-sec

its often not fast enough to save the fetus

247
Q

If low lying placenta at 16-20 week scan

A
  • 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
Q

Mx placenta praevia with bleeding

A
  • 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
Q

What does lie mean in pregnancy

A

relationship of fetus to long axis of uterus e.g. longitudinal

250
Q

What does presentation mean in pregnancy?

A

Part of the fetus that occupies the lower segment of the uterus/pelvis.
if neither cephalic or brech it is oblique or transverse

251
Q

Cause abnormal lie

A 
Uterine malformations e.g. fibroids
Polyhydramnios / high parity (lax uterus)
Oligohyd
Placenta praevia
Fetal abnormality
Prematurity
252
Q

What is breehc presentation and what are the types?

A

Presentation of the buttocks

  • extended
  • flexed
  • footlin
253
Q

Complications breech

A

increased perinatal mort and morb

254
Q

Mx breech presentation

A

if <36 wks: will turn spontaneously
at 36/37 weeks: external cephalic version
If ECV no work: c-section or vaginal delivery

255
Q

Mx transverse / obliqye lie if >37wks

A

Admit, USS to find cause

If not stabilised by 41 weeks –> elective c-sec

256
Q

RFs multiple pregnancy

A

older, IVF, genetics

257
Q

Complications mutliple preg

A

Maternal: pre-e, anaemia, GDM, operative delivery

Twins: morb and mort, preterm labour, IUGR, APH, malpresentation

258
Q

Pathology TTTS

A

unequal blood distribution in shared placenta –> disconcordant blood volumes, liqour + often growth

259
Q

Mx twins

A
  • 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
Q

Mx TTTS

A

US surveillance from 12 wks, laser therapy if TTTS diagnosed

261
Q

Define labour

A

The onset of regular and painful contractions associated with cervical dilation and descent of the presenting part

262
Q

Signs of labour

A
  • Regular and painful uterine contractions
  • A show (shedding of mucous plug)
  • Rupture of the membranes (not always)
  • Shortening and dilation of the cervix
263
Q

Stages of labour

A

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
Q

What are the mechanical factors of labour?

A
  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
Q

What does station mean and how can it be measured?

A

The level of descent of the head on VE

Measured in reference to the Ischial spines (-2cm, 0 , + 2)

266
Q

What does attitude refer to in labour?

A

Degree of flexion of the fetal head on the neck

267
Q

What does position refer to inlabour?

A

The degree of rotation of the head on the neck

Usually delivered in OA position (occipito-anterior)

268
Q

What is the occiput?

A

The posterior fontanelle, lies on back of top of head

269
Q

What are the 3 elements in the passenger?

A

The position, the attitude and the size of head

270
Q

Movements of the head in labour

A 
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
Q

What contractions are felt throughout 3rd trimester?

A

Contractions of uterine smooth muscle –> Braxton Hicks contractions

272
Q

What do prostaglandins do in labour? (2 things)

A
  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
Q

Diagnosis of labour

A

When painful regualr contractions –> effacement then dilatation of the cervix

274
Q

What constitutes the 1st stage of labour?

A
  • Dx of labour –> 10cm cervical dilation

- Rupture of membranes

275
Q

What are the 2 phases in the 1st stage of labour

A

LATENT PHASE: <3cm

ACTIVE PHASE: 3-10cm

276
Q

What constitutes the second stage of labour?

A

From full dilation –> delivery

277
Q

What are the 2 phases of the 2nd stage of labour?

A

PASSIVE: full dilation –> head reaches pelvic floor. rotation and flexion commonly completed
ACTIVE: pushing, woman gets in most comfortable position and bears down

278
Q

What constitutes the 3rd stage of labour?

What is given?

A

Delivery of fetus –> delivery of placenta

Oxytoxin IM to help uterus contract once the shoulder are delivered

279
Q

Degrees of tear in perineal trauma

A

1st: minor damage to fourchette
2nd: involve perineal muscle
3rd involve anal sphincter
4th: involve anal mucosa

280
Q

Why is it important for women to be relaxed in labour?

A

Fear + anxiety –> adrenaline secretion –> decreased contractions

281
Q

What is used to record progress in dilatation of cervix in labour ?

A

Partogram
assessed on VE and plotted against time
alert and action lines

282
Q

What is augmentation and how can it be done?

A

The artificial strengthening of contractions in established labour

ARM or amniotomy

283
Q

Induction

A

The artificial initiation of labour

284
Q

Whats in bishops score

A 
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
Q

Indications induction of labour

A 
Prolonged preg
Spontaneous PROM at term
Diabetic mother >38wks
Pre-eclampsia
Rhesus incompatibility
Social reasons + inutero death
286
Q

Common causes of failure to progress in labour (think 3 ps!)

A

(common in nuliparous women)

the powers: inefficient uterine action**

the passage: cephalo-pelvic disproportion

the passenger: fetal size, disorder of rotation or flexion

287
Q

Causes of fetal damage/injury

A
  1. Fetal hypoxia (distress)
  2. Infection/inlammation (e.g. GBS)
  3. Meconium inspiration
  4. Trauma
  5. Fetal blood loss: Vasa praevia
288
Q

Define fetal distress and what test indicates it?

A

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
Q

What is meconium?

A

The bowel contents of the fetus that stains amniotic fluid

Rare in preterm fetuses, common after 41 weeks

290
Q

Why is meconium an indication for caution?

A
  1. fetuses may aspirate it –> meconium aspiration syndrome

2. hypoxia is more likely

291
Q

Monitoring methods for fetal distress

A
  • Intermittent auscultation (IA) of FHR w hand-held Doppler
  • Inspection for meconium
  • CTG
  • Fetal blood sample
292
Q

Normal features of CTG

A

rate 110-160
accelerations
variability >5bpm

293
Q

Mx if fetal blood sample abnormal?

A

Delivery by quickest route:

If 1st stage: c-sec
If 2nd and criteria met: instrumental

294
Q

Mx slow to progress labour

A
  1. Amniotomy + oxytocin
  2. If fail in 1st stage: c-sec
  3. If in 2nd stage: >1hr pushing, instrumental delivery if criteria met
295
Q

Define sfd

A

Weight of fetus < the 10th centile for its gestation

used for whole population

296
Q

IUGR

A

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
Q

Define fetal compromise

A

a chronic situation, when the conditions for the normal growth and neurological development are not optimal

298
Q

Cause SFD + IUGR

A

Physiological determinants of size: race, parity, fetal gender, maternal size

Pathological: maternal illness (relan/pre-ec), twins, chromosomal abnormalities, infection, smoking

299
Q

CFs SDF + IUGR

A

low symphysis-findal height

features of pre-eclmapsia

300
Q

Mx SFD

A

monitor growth

301
Q

Mx IUGR

A

From 36 wks = deliver
34-36 = regular umbilical artery doppler, daily CTG, consider delivery
<34 wks = give steroids, then as for 34-36wks

302
Q

Complications IUGR

A

NEC

CP

303
Q

Aims of fetal surveillance (3)

A
  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
Q

What is the significance of maternal PAPP-A ?

A

A placental hormone
Reduced in 1st trimester with chromosomal abnormalities (Downs)

Also high risk for IUGR, placental abruption and –> stillbirth

305
Q

Whats the significance of doppler umbilical artery wave forms in fetal surveillance?

A

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
Q

What are the 3 elements of screening for high risk pregnancies?

A
  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
Q

What does cardiotocography do?

A

Records pressure changes in the uterus using internal or external pressure transducers

308
Q

What is the DR C BRAVADO mneumonic?

A

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
Q

Describe baseline bradycardia on CTG and causes?

A

HR < 100/min (or <110?)

Increased fetal vagal tone
Maternal beta blocker use

310
Q

Define baseline tachycardia on CTG and causes

A

HR > 160/min

Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity

311
Q

Define loss of baseline variability on CTG and causess

A

< 5 beats / min

Prematurity
Hypoxia

312
Q

Define early deceleration on CTG and causes

A

Synchronous with a contraction as a normal response to head compression

313
Q

Define late deceleration on CTG and causes

A

Persist after the contraction is completed and suggest fetal hypoxia

314
Q

Define variable deceleration on CTG and causes

A

Independent of contractions (vary in timing)

May indicate cord compression, which can ultimately –> hypoxia

315
Q

Mx fetal distress

A
  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
Q

Non-medical pain relief in labour

A

birth attendant + partner
maintain mobility
TENS
water

317
Q

List 5 medical pain reliefs in labour

A
  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
Q

What is epidural anaethesia and its advantages?

A

Injection of local anaesthetic into epidural space

Best pain relief, prevents premature pushing

319
Q

Disadvantages epidural anaesthesia

A 
Increased supervision
Maternal fever
Reduced mobility
Increased intrumental delivery rate
Hypotension
Urinary retention
320
Q

Complications epidual anaethesia

A

Spinal tap

321
Q

CI epidural

A

sepsis
active neuro disease
hypovolaemia

322
Q

Complications induction of labour

A

LCSC
Other interventions
Longer labour
PPH

323
Q

What it the vaginal delivery rate if attempted after previous c-section?

A

60-80%

324
Q

CIs Vaginal delivery after C-section

A

Vertical uterine scar

325
Q

Define preterm prelabour rupture of membranes

A

Before 37wks, and before the onset of labour

326
Q

Complications PPROM

A

fetal: prematurity ,infection, pulm hypoplasia
maternal: chorioamnionitis

327
Q

Ix PPROM

A

sterile speculum examnation

328
Q

Mx PPROM

A

Oral erythromycin for 10 days
antenatal corticosteroids
consider delivery at 34 weeks

329
Q

Indications instrumental delivery

A

Prolonged 2nd stage

Fetal distress in 2nd stage, when pushing contraindicated

330
Q

Prerequisites intrumental del

A 
full dilated
position known
head deeply engaged
analgesia
empty bladder
331
Q

complications instrumental del

A

lacerations, haemorrhage,

fetal facial nerve injury

332
Q

Common indications c-sec

  • elective
  • emergency
A

Elective: breech-presetation, prev LSCS, placenta praevia

Emergency: failure to advance, fetal distress

333
Q

Complications C-sec

A

Haemorrhage
Sepsis
Thromboembolism
Anaesthetic

334
Q

Define PPH

A

Blood loss of >500mls

Primary = in first 24hrs
Secondary = 24hrs --> 12wks
335
Q

RFs PPH

A 
c-sec
forceps
prlonged labour
APH
Prev Hx
336
Q

Causes of PPH

A

Uterine atony
Retained placental parts
Vagnal, uterine, or cervical lacerations

337
Q

Mx PPH

A
  • ? bimanual uterine compression ; suture cervical / vag tears
  • ABC (resus w IV fluids + blood if neccessary)
  • IV oxytocin
  • IM prostaglandin F2a
338
Q

What is secondary PPH due to?

A

Retained placental tissue

OR endometritis

339
Q

CFs endometritis

A

(much more common afte c-sec)

Fever, abdo pain, offensive discharge, tachy

340
Q

Ix endometritis

A

cultures
FBC (increased WCC)
MSU
HVS

341
Q

Mx endometritis

A

clindamycin + gentamicin in hospital

342
Q

Puerperium

A

the 6 week period following delivery, when body returns to its pregnant state

343
Q

Puerperal pyrexia

A

A temp of >38degrees in the first 14 days following delivery

344
Q

Causes puerperal pyrexia

A 
Endometritis
UTI
would infections 
mastitis
VTE
345
Q

Define spontaneous miscarriage

A

Expulsion or death of fetus before 24weeks

many types

346
Q

Define threatened miscarriage

A
  • Painless V bleeding before 24 weeks
  • cervical os is closed, uterus size is as expected from dates
  • fetus is alive
347
Q

Define inevitable miscarriage

A
  • Heavy bleeding with clots and pain

- Cervical os is open

348
Q

Incomplete miscarriage

A
  • not all POC have been expelled
  • pain and vaginal bleeding
  • os is open
349
Q

Complete miscarriage

A
  • all POC have been passed
  • uterus no longer enlarged
  • os closed
350
Q

Missed (delayed) miscarriage

A
  • 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
Q

Define recurrent miscarriage

A

3 more more miscarriages occur in succession

352
Q

Causes recurrent miscarriage

A 
Antiphospholipid syndrome
Endocrine: poorly controlled DM, thyroid disorders, PCOS
Uterine abnormality e.g. uterine septum
Parental chromosomal abnormalities
Cmoking
Infection
353
Q

Ix recurrent miscarriage

A

Antiphospholipid screen
Karyotping of both parents
Pelvis USS

354
Q

What scale to screen for PND?

A

Edinburgh Postnatal Depression Scale

355
Q

What is the ‘baby-blues’?

A

typically 3-7 days following birth

anxious, tearful and irritable

356
Q

Rx baby blues

A

Reassurance and support

Health visitor plays a key role

357
Q

CFs and onset PND

A

Start within a month and typically peak at 3 months

Sx: tiredness, guilt, feelings of worthlessness

358
Q

Rx PND

A
  1. Reassurance + support
  2. CBT
  3. SSRI (sertraline or paroetine
359
Q

CFs Puerperal psychosis

A

Severe mood swings (similar to bipolar)

Disordered perception e.g. auditory hallucinations

360
Q

Rx Puerperal psychosis

A

Psych admission
Major tranquilisers

20% recurrence risk following future pregnancues

361
Q

Triad to diagnose hyperemesis gravidarm

and what is it otherwise?

A
  • 5% pre-pregnancy weight loss
  • dehydration
  • electrolyte imbalance

Nausea and vomiting of preg (NVP

362
Q

RFs hyperemesis gravidarmum

+ 1 seemingly protective factor

A 
multiple pregnancies
trophoblastic disease (molar preg)
hyperthyroidism
nulliparity
obesity

*smoking ? protetive

363
Q

Mx hyperemesis gravidarum

A
  • 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
Q

Complications hyperemesis gravidarum

A
  • Wernicke’s encephalopathy
  • Mallory-Weiss tear
  • Central pontine necrosis
  • Fetal: small for gestational age, pre-term birth
365
Q

Define ectopic pregnancy

A

Implantation of a fertilized ovum outside the uterus

366
Q

RFs ectopic pregnancy

A

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
Q

Location of ectopics

A

95% fallopian tube

  • which can –> tubal tupture + intraperitoneal bleeding
368
Q

Incidence and recurrence rate ectopic

A

1%

10%

369
Q

CFs ectopic

acute and subacute

A

4-10 weeks of amenorrhoea

  1. ACUTE: collapse with abdo pain + bleeding, shock
  2. SUBACUTE: abdo pain, scanty dark blood PV
370
Q

Ex findings ectopic

A
  • lower abdo tenderness, cervical excitation, adnexal tenderness

DO NOT examine for an adnexal mass –> risk of rupture

371
Q

Ix ectopic

A

Pregnancy test
Transvaginal USS
hCG

Laparoscopy to confirm + treat unless Dx certain and medical Mx proposed

372
Q

What does Mx ectopic depend on?

A

Depends on clincial scenario e.g. size, rupture, pain, fetal heartbeat

373
Q

Surgical Mx ectopic

A

To stop/prevent bleeding

  1. Salpingectomy
  2. Salpinotomy
374
Q

Medical Mx ectopic

A
  1. Methotrexate
    - a DMARD that stops growth of rapidly dividing cells
    - can only be given if patient agrees to attend FU
375
Q

Expectant Mx ectopic

A

Close monitoring over 48hrs

If B-hCG levels rise again, or symptoms manifest –> intervention

376
Q

What is tubal absorption in an ectopic?

A

where the blood and embryo may be shed or converted into a tubal mole and absorbed

377
Q

What happens in gestational trophoblastic disease? and what is secreted in excess

A

Trophoblastic tissue proliferates more aggressively than normal

hCG

378
Q

What is a hydatiform mole in comparison to a invasive one?

A

Proliferation that is localised and non-invasive

Invasive has characteristics of malignant tissue, but is only local within the uterus

379
Q

What is a complete hydatidiform mole? + what happens to form it?

A

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
Q

CFs complete hydatidiform mole

A
  • (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
Q

Mx complete hydatidiform mole

A

Urgent referrla to specialist centre - ERPC

Contraception to avoid pregnancy in next 12 months

382
Q

What do 2-3% of complete hydatiform moles go on to develop?

A

Choriocarcinoma

383
Q

What is a partial hydatiform mole?

A

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
Q

What is a choriocarcinoma

A

metastasis of an invasive mole

385
Q

USS gestational trophoblastic disease

A

Small bunch of grapes

‘snow-storm’ appearance

386
Q

Confirmation Dx GTD

A

Histologically

387
Q

Causative organism mastitis

A

Staphlycoccus aureus

388
Q

Pathology mastitis

A

Milk statis due to overproduction or insufficient removal

- can be infectious or non-infectious

389
Q

CFs mastitis

A

Breat pain (usually uilateral)
Erythematous, warm + tender area
? fever + flu-like symptoms

390
Q

Mx mastitis

A

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
Q

What can mastitis develpo into if untreated?

A

Breast abcess

392
Q

DDx mastitis

A

Inflammatory breast cancer

393
Q

Define rhesus disease

A

maternal antibody response against fetal red blood cell antigen entering her circulation: passage of antibodies into fetus –> haemolysis

394
Q

Tx Rhesus disease

A

Transfuse if fetus anaemic
Deliver if >36weeks

Also, UV phototherapy

395
Q

Implications for fetus in rhesus disease

A

Oedematous (Hydrops fetalis)

Jaundice, anaemia, hepatosplenomegaly, HF, kernicterus

396
Q

Define subfertility

A

Failure to conceive after a year

Primary: never conceived
Sec: previosly conceived

397
Q

Causes of subfertility

A
  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
Q

Ix subfertility

A

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
Q

Key counselling points sub/in-fertility

A
  • Folic acid
  • Aim for BMI 20-25
  • regular intercourse every 2-3 days
  • smoking / driving advice
400
Q

Rx infertility

A

Lifestyle + folic
Treat cause
IVF if unexplained

401
Q

Common causes of male infertility

A
  1. unknown
  2. drug exposure (incl canabis, chemo)
  3. Varicocele
402
Q

What is varicocele

A

Abnormal enlargement of the testicular veins (pampiniform plexus)

403
Q

CFs varicocele

A

Left side
Bag of worms
Subfertility
Dull ache

(but surgery has little effect on subsequent fertility)

*Phase 3a Julia (8 decks)

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