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Finals > Women’s health > Flashcards

Women’s health Flashcards

1
Q

Long term Complications of hysterectomy with anterioposterior repair

A

Enterocoele and vaginal vault prolapse

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2
Q

3 criteria for diagnosis of post partum thyroiditis

A

Within 12 months of giving birth
Clinical manifestations of hypothyroidism
Thyroid function tests

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3
Q

PCOS diagnosis

A

2/3 of:
1 infrequent or no ovulation
Clinical or biochemical signs of hyperandrogenism or elevated free or total testosterone
Polycystic ovaries on USS or increased ovary volume

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4
Q

Causes of spontaneous miscarriage in first trimester

A 
Antiphospholipid syndrome
Uterine abn eg septum
Endocrine - thyroid, diabetes badly controlled, pcoS
Parental chromosomal abnormalities
Smoking
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5
Q

Immediate medications in premature early stage labour

A

Tocolytics and steroids

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6
Q

Risks of prematurity

A 
Chronic lung disease
Retinopathy 
Intraventricular haemorrhage
Jaundice
Respiratory distress syndrome
NEC
Hypothermia
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7
Q

Indications for continuous combined HRT

A

LMP over 1y ago
Or 2y iif under 40
Cyclic for 1y

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8
Q

HRt if hysterectomy

A

Continuous oestrogen

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9
Q

Features of endometriosis and diagnosis

A 
Chronic pelvic pain
Deep dysparaunia
Dysmenorrhea 
Sub fertility 
Urine sx and painful bowel movements
Exam - tender nodularity in post fornix, reduced organ motility, endometriosis lesions
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10
Q

Manage endometriosis

A

NSAIDs
COCP, progestogens
GnRH analogues to induce pseudo menopause due to low oestrogen
Laparoscopic/laser removal of cysts for fertility

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11
Q

What to do if missed POP

A

Under 3h - take and continue as normal

Over 3h - take as soon as possible but use condkms until pills used for 48h as normal

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12
Q

In what situations does POP provide immediate protection

A

Start on Up to day 5 of cycle

Start after day 21 exactly from COCP

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13
Q

What antibiotic to be cautious with for POP

A

Rifampicin

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14
Q

drug for magnesium sulphate-caused respiratory depression

A

Calcium gluconate

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15
Q

Drug for benzo OD

A

Flumazenil

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16
Q

How do the main contraceptives work (primary action)

A

COCP - inhibit ovulation
POP (not desorgestrel) - thicken cervical mucus
Desorgestrel pill, prog inject or implant - inhibit ovulation
Copper device - inhibit implantation

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17
Q

Sign that hyperemesis requires hospital admission

A

Ketonuria, weight loss, oral antiemetics not controlling sx

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18
Q

Most common causes of PPH

A

1) uterine stony (80-90%)

Coagulopathy, retained placenta, trauma

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19
Q

Risk factors for PPH

A 
Maternal age
Pre-eclampsia
Polyhydramnios
Macrosomia
Placenta praevia/accreta
Previous PPH
Prolonged labour
Emergency c section
B2 adrenergic receptor agonist for tocolysis
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20
Q

Manage PPH

A

Syntocin (oxytocin) IV or ergometrine
IM carboprost
Surgical - balloon tamponade, ligation of uterine or int iliac arteric

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21
Q

Muscarinic antagonists for incontinence

A

Tolterodine, oxybutynin

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22
Q

What is lochia and how long does it last

A

Blood mucus and uterine tissue up to 4-6w post partum

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23
Q

What is rokitansky protuberance

A

Where dermis, bone and teeth come from in mature teratoma

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24
Q

Types of functional ovarian cysts

A

Follicular - non rupture of dominant follicle

Corpus luteum cyst - blood or fluid, with intraperitoneal bleeding

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25
Q

Epidemiology of benign dermoid cyst/teratoma of ovary

A

Most common benign ovarian tumour in under 30s, commonest at 30y,
Bilateral in 10-20%

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26
Q

Types of benign epithelial tumours

A

Serous cystadenoma most common

Mucinous cystadenoma - large, causes pseudomyxoma peritonei if rupture

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27
Q

3 categories of benign ovarian cyst

A

Physiological/functional
Epithelial
Germ cell/dermoid

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28
Q

2 manoeuvres for shoulder dystocia

A

Woodscrew - put hand in vagina and turn baby 180

McRoberts - hyperflex legs and apply suprapubic pressure

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29
Q

Medical management for ectopic pregnancy, adv and disadv

A

IM methotrexate - must attend follow up - bHCG on day 4 and 7, repeat if fallen <15%
+: can go home, avoid surgery
-: diarrhoea and abdo pain; hepatitis, renal impairment, myelosuppression, teratogenic (contraception for 3m)

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30
Q

Surgical management for ectopic pregnancy and adv and disadv

A

Salpingectomy or salpingotomy
+ = definitive, high success rate
- = damage to adjacent structures eg ureters, GA risk, DVT/PE, infertility, infection

+ anti-D prophylaxis if >12w or known rh-ve

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31
Q

Indications for surgical management ectopic

A 
>35mm
Intrauterine pregnancy as well
Visible foetal heart beat
Serum bhCG high
Can be ruptured
Severe pain
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32
Q

Indications for medical management of ectopic

A 
<3.5cm and no heartbeat
Asymptomatic or mild
No haemoperitoneum on TVUS
BhCG not high 
Not suitable if intrauterine pregnancy as well
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33
Q

Expectant management for ectopic and its indications

A

<30mm
Asymotomaic, no foetal heart beat, hCG low and getting lower
Compatible with intrauterine pregnancy
Monitor every 48h until confirmed fall then weekly

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34
Q

Risk factors for cord prolapse

A 
Artificial rupture of membranes 
Multi parity
Prematurity
Polyhydramnios
Twins
Breech or transverse
Placenta praevia
Long cord
High foetal station
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35
Q

Hyperemesis severity scoring system

A

Pregnancy Unique Quantificatoin of Emesis score

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36
Q

Steroid used in lung maturation

A

Dexamethasone

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37
Q

Suppression of lactation medication

A

Cabergoline - dopamine receptor agonist

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38
Q

Sx of abruption

A 
Continuous Pain
Woody firm uterus/spasm
Shock disproportionate to blood loss visible
Foetus hard to feel
Heart hard to auscultate
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39
Q

Features of Sheehan syndrome

A

Agalactorrhoea
Amenorrhoea
Hypothyroid sx
Hypoadrenalism sx

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40
Q

What are molar pregnancies and features including on USS

A

Imbalance of chromosomes - non viable
Causes early bleeding and large uterus for dates
Hyperemesis gravidRum and thyrotoxicosis from excessive hCG (mimics TSH) “from abnormal trophoblastic tissue
Solid collection of echos with anenchoic spaces -bunch of grapes

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41
Q

3 disorders of gestational trophoblastic disease

A

Complete hydatiform mole - sperm duplicates it’s own DNA so all 46 chromosomes of parental origin
Partial hydatiform mole - 2 sperms or 1 sperm that duplicates, so 69XXX or 69XXY, maternal and paternal
ChoriocArcinoma

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42
Q

When to stop COCP before surgery and what to do instead

A

4w before, use progestogen only instead

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43
Q

Cause of macrocytic anaemia in pregnancy

A

Folate deficiency

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44
Q

Causes of folic acid deficiency

A

Pregnancy
Alcohol
Phenytoin
Methotrexate

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45
Q

When should folic acid be taken in pregnancy and what are indications for the higher dose?

A 
Up to 12w
History of neural tube defects - personal or family
Antiepileptics
Diabetes, coeliac, thalassaemia 
Obese
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46
Q

Initial management of labour not starting a 41w

A

Membrane sweep

Vaginal prostaglandin gel

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47
Q

When to give anti-d to rhesus negative mother

A 
Not yet sensitised, family history
Rhesus positive baby born
Miscarriage over 12w
Termination
Amniocentesis, chorionic villus sampling 
Antepartum haemorrjage
External cephalic version
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48
Q

Features of foetus affected by rhesus disease

A

Oedematous (albumin not produced due to over production of RBC from liver), hydrops fetalis
Jaundice, anaemia, hepatosplenomegaly
Heart failure
Kernicterus

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49
Q

Surgical management of tubal ectopic

A

Salpingectomy

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50
Q

Indications for induction of labour

A

Diabetic >38w
Rhesus incompatibility
Over 12d after estimated DD
PPROM without labour

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51
Q

Methods of induction

A

Membrane sweep
Intravaginal prostaglandins
Break waters
Oxytocin

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52
Q

Who can authorise and perform abortion?

A

2 registered medical professionals sign, registered medical practitioner in NHS hospital or licensed premise perform

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53
Q

Method for termination at different ages

A

<9w = mifepristone (anti-progesterone) then prostaglandins after 48h to stimulate uterine contractions
<13w - surgical dilation and suction of uterine contents
>15w - surgical dilation and evacuation or late medical abortion (mini labour)

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54
Q

4 Requirements of abortion act

A

Not exceeded 24tth week and continuance is more risk than termination
Needed to prevent permanent injury to health of woman
Risk life of woman
Risk of child having severe handicap

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55
Q

How much does hCG decrease after termination

A

Half every 2 days, can stay positive for 4w

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56
Q

Features of vasa praevia

A

Foetal vessels inserted into membranes

Painless vaginal bleeding, foetal bradycardia, membrane rupture

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57
Q

Risk factors for placenta praevia

A

Multiparity
Multiple pregnancy
Lower segment scar from previous c section

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58
Q

Grades of placenta praevia

A

1 - lower segment but not internal os
2 - reaches os but doesn’t cover
3 - covers os but not when dilated
4 - completely coversf os

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59
Q

How much fundal height growth

A

2cm a week until 24w then 1cm a week

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60
Q

What does IUD and IUS do to periods

A

IUD - Heavier, longer, more painful

IUS - initial frequent bleeding and spotting for 6m then light/amenorrhoea

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61
Q

Requirements for instrumental delivery

A 
FORCEPS:
Fully dilated cervix and second stage+
OA position preferable and location of head known
Ruptured membranes
Cephalic presentation
Engaged presenting part  (at or below ischial spines and not palpable abdominally)
Pain relief
Sphincter (bladdeR) empty
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62
Q

Indications for forceps

A

Foetal distress
Maternal exhaustion
Not progressing in 2nd stage
Contnrol head if breech

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63
Q

Smears for women with hiv

A

Annual cytology

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64
Q

Biggest risk of TOP

A

10% Infection

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65
Q

antiepileptics safest in pregnancy

A

Lamotrigine, carbamazepine, levtiricitam

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66
Q

Definition of PPH

A

500ml loss from genital tract within 24h of birth

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67
Q

Cause of secondary PPH

A

Retained placental tissue or endometritis

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68
Q

Which contraceptive causes the biggest delay in fertility returning

A

Depot provera IM injectable every 12w - for up to a year

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69
Q

Condition that includes benign ovarian tumour and the triad

A

Meig’s syndrome: Benign fibroma ovarian tumour, Pleural effusion, ascites

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70
Q

What makes pregnancy induced hypertension pre eclampsia?

A

Proteinuria

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71
Q

Complications of PPROM for mum and baby

A

Mum - chorioamnionitis

Baby - premature, infection, pulmonary hypoplasia

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72
Q

Abx for PPROM

A

Erythromycin 10d PO

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73
Q

Test for complications of rhesus incompatability and when

A

Kleihauer test for foetomaternal haemorrhage to detect foetal cells in maternal circulation and volume to calculate additional anti - d ig needed
Any sensitising event after 20w

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74
Q

Most common cardiac abnormality in pregnant women

A

Mitral stenosis

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75
Q

Sudden onset chest pain in 3rd trimester and high bp

A

Aortic dissection, can block right coronary artery and cause MI

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76
Q

Treat aortic dissection in pregnancy

A

<28w = repair
28-32 depends on foetal condition
>32w = c section then repair

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77
Q

Anticoagulation for PE in pregnancy

A

LMWH throughout and 4-6w after birth

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78
Q

Treat vaginal vault prolapse

A

Sacrocolpoplexy - suspends vaginal apex to sacral promontory by uterosacral ligaments

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79
Q

Features of chorioamnionitis

A

Infection ascending into amniotic fluid, membranes or placenta. Uterine tenderness and foul smelling discharge, baseline foetal tachycardia

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80
Q

Contraceptives time until effective

A

Instant IUD
2 days POP
7 days COCP, injection, implant, IUS

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81
Q

When can pre eclampsia be diagnosed and how to prevent if high risk

A

From 20w

Aspirin 75mg OD from 12w

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82
Q

High risk for pre eclampsia

A

Hypertensive in previous pregnancy
CKD
AI - SLE, antiphospholipid
DM1 or 2

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83
Q

What infections are screened for in pregnancy

A 
HIV
Syphilis
Rubella
Asymptomatic bacteriuria
Hep b
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84
Q

4 most common causes of premature ovarian failure

A

Idiopathic
Chemo
AI
Radiation

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85
Q

4 ADRs of depo provera

A

Weight gain
Infertility for 1y
Osteoporosis
Irregular bleeding

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86
Q

Proven contraceptive to cause weight gain

A

Depo provera

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87
Q

First line antihypertensive if asthma and prenant

A

Nifedipine

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88
Q

CVS changes in pregnancy

A

SV 30% HR 15% CO 40%

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89
Q

Resp changes in pregnancy

A

pulmonary ventilation 40%, tidal volume to 700ml, o2 requirements increase by 20% so pCO2 can decrease
Bmr up to 15%

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90
Q

When is twin transfusion syndrome diagnosed

A

US 16-24

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91
Q

Medication prior to surgery for fibroid removal

A

GnRH agonist to shrink and reduce post op blood loss

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92
Q

Why is footling presentation dangerous

A

Risk of cord prolapse

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93
Q

5 causes of oligohydramnios

A 
Renal problems
Premature rupture of membranes
iugr
Post term gestation
Pre eclampsia
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94
Q

What is a galactocoele

A

Benign collection of milk from blocked lactiferous duct

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95
Q

Treat GBS identified early in pregnancy

A

intrapartum Iv benzylpenicillin to reduce neonatal transmission

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96
Q

RF for ectopic

A 
Previous ectopic 
Tube damage - PID, surgery
Endometriosis
IUCD, POP, IVF
Smoking
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97
Q

Symptoms and signs of ectopic and why bleed

A

Bleed as sub-optimal BHCG means endometrial lining isn’t maintained and starts to shed

Amenorrhoea, pain (unilateral), bleeding
Diarrhoea, loose stools, vomiting
Shoulder tip pain from diaphragmatic irritation from haemoperitoneum

Signs: collapse
Cervical excitation +- adnexal tenderness
Peritonism

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98
Q

Most common sites for ectopic

A

Tubal - ampulla = 1

2 = isthmus (narrow, inextensible, presents early and higher risk of rupture )

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99
Q

Inv ectopic pregnancy

A 
FBC, G&amp;S (6u)
Serum progesterone
BHCG
TVUS
Laparoscopy if unknown location
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100
Q

Definition of pregnancy of unknown location and causes

A

Pos pregnancy test or bHCG >5 but no signs f intrauterine or ectopic pregnancy or retained products of conception

Eaarly intrauterine pregnancy
Complete miscarriage
Ectopic
Failing PUL which wil resolve on its own

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101
Q

Inv pregnancy of unknown location

A

Based on symptoms
Pain and haemoperitoneum = laparoscopy
Well - repeat 48h later scan, prog and bHCG and follow up - prog will fall (failed pregnancy), HCG will increase a lot (pregnancy) or plateau (ectopic?)

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102
Q

How much does HCG normally increase

A

> 66% in 48h in early pregnancy

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103
Q

What is a miscarriage

A

expulsion of pregnancy whe its incapable of independent survival - all losses <24w

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104
Q

Cervical os open, bleeding/pain

A

Inevitable miscarriage

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105
Q

Cervical os closed, mild pain

A

Threatened miscarriage

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106
Q

Findings of incomplete miscarriage and management

A

Some retained POC, sliding sign, endometrial thickening
Os open

Expectant
Ergometrine IM or surgery if bleeding/pain profuse

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107
Q

bleeding and smal for dates uterus with closed os and specific findings

A

Missed miscarriage - foetus died in utero
Pain, bleeding, asymptomatic, cervix closed, small uterus
Foetal pole >7m with no hr
Gestational sac >25mm with no foetal pole or yolk sac

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108
Q

Manage missed miscarriage

A

Mifepristone - antiprogestogen - -sheds lining and removes supply to POC
Mifoprostol 24-48h later - prostaglandin analogue - ripens cervix and causes expulsion by myometrial conctractions
Can bleed for 3w

Or suction - manual under LA <13w or under GA
- if patient chooses of bleeding after 2w ++

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109
Q

What is septic misscarriaghe

A

complete or incomplete, os open or closed

Inf

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110
Q

complete miscarriage signs

A

No endometrial thickening, no RPOC, os closed

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111
Q

RF for mischarriage

A 
Previous miscarriage
Age
Foetal chromosome abnormalities 
Maternal uterine abnormalities or cervical weakness
Infection or illness eg SLE
Ssmoking 
Obestiy 
Antiphospholipid syndrome
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112
Q

Sx of miscarriage

A

Bleeding , clots, POC
Suprapubic cramping pain
Dizzy, SOB

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113
Q

Manage antiphospholipid syndrome in pregnancy ad risks other than. Miscarriage

A

Aspirin 75mg from day of pos pregnancy test
Pre eclampsia
Severe growth restriction
PReterm birth

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114
Q

causes of recurrent miscarriage

A

Endocrine - thyroid, DM - badly controlled
Uterine abnormality
Infection - bv in 2nd trimester
Parental chromosome abnormality
Antiphospholipid syndrome - 1st trimester
Thrombophilia

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115
Q

Test for antiphospholipid syndrome

A

2 tests 12 weeks apart - test all women

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116
Q

What to do before TOP

A 
Counselling
USS screen to  confirm gestation and no other viable foetus
Metronidazole and Azithromycin
STI screen
Anti-D if neg
Discuss contraception
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117
Q

Methods of TOP

A

Medical - mifepristone and misoprostol + nsaid

Surgical + misoprostol to dilate cervix. Vacuum 7-14w, dilatation and evacuation 13-24w

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118
Q

RF for heavy bleeding - 3

A

1) age - menarche, pre menopause
2) obesity
3) c section - adenomyosis

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119
Q

Wha is heavy bleeding

A

Interfering with qol
>80
Fatigue, sob

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120
Q

Findings on exam for heavy bleeding

A

Mass - smooth/irregular
Vaginal tumour
Cervix - polyp, tumour, inflammation
Tender/excitation - adenomyosis, endometriosis

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121
Q

Causes of heavy bleeding

A

1 = DUB - no other abn, vessel contraction abn
Med problem - SLE, hypothyroid, liver disease, cancer
FIGO classification : PALM-COEIN
Polyp - endom, cervical. Intermenstrual or postcoital, no pain
Adenomyosis - dyuria , bulky tender uterus
Leiomyoma - mass, heavy bleed, shrink after meno
Malignancy or hyperplasia - vaginal, endometrial or cervical
Coagulopathy - vwf, anticoagulants, thrombocytopoenia, leukaemia
Ovarian - pcos
Endometriosis
Iatrogenic - contraception, IUCD
Not known - dub

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122
Q

Investaigiaons for heavy bleeding

A

Pregnancy
FBC, clotting and vwf, hormones (PCOS), TFT
Smear, swabs
TVUS if mass, pharm failed, risk factors
Endometrial pipelle biopsy if >45yo and persistent
Hysteroscopy and biopsy if pathological or inconclusive US

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123
Q

MAnage heavy bleeding and ADRs - medical

A

1 - levonorgestrel releasing IUS: shrinks fibroid, thins endom, 5yy, contraceptive
- ADR - progesterone ADRs, 6m of irregular bleeding

2 - antiifibrinoltics inhibit tPA so less plasminogen activation and less fibrinolysis - clot stabilissied

  • tranexamic acid CI VTE, ADR tinnitus, rash, nausea
  • mefanamic acid (also NSAID) CI ulcer, ADR GI, headache
  • COCP - decrease gonadotrophins

3 - progesterone - norethisterone (short term), depo or implant

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124
Q

Surgical management of heavy bleeding

A

1 - endometrial thermal ablation - but can burn through to bladder and can regrow
2 - hysterectomy
3 - myomectomy or uterine artery emoblisation if >3cm fibroid and want to stay fertile

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125
Q

Signs and symptoms of fibroids other than heavy bleedin

A

Asymmetrical enlarged uterus
Lower abdo pain
Dysuria

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126
Q

Sx of adenomyosis other than bleedin

A

Symmetrically enlarged boggy uterus
Chronic pain
Dysuria
Older women

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127
Q

Sx of PID other than bleedin

A

Tender on exam
Discharge
Fever
New onset

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128
Q

Polyps sx as well as bleeding

A

Not usually painful
Intermenstrual
Post coital if cervical

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129
Q

Gold standard investigation for endometriosis

A

Diagnostic/explorative laparoscopy

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130
Q

7 RF for endometrial cancer

A 
Too much oestrogen:
- nulliparity
- early menarche
- late menopause
- pcos
Obesity 
Family history of breast ovarian or colon cancer
Diabetes
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131
Q

Cancer most linked to endometrial

A

Colon - HNPCC

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132
Q

Why are BMI and PCOS risk factors for endometrial cancer

A

Obese - increased peripheral aromatisation of androgens to oestrogens. 2x risk >25, 3x risk >30
PCOS - loner anovulation so less progesterone to counteract oestrogen

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133
Q

Staging of endometrial cancer

A 
FIGO staging:
1 - uterine body
2 - uterine body and cervix
3 - outside uterus but in pelvis 
4 - local/regional spread of tumour (bowel, bladder etc)
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134
Q

Inv endometrial cancer

A

TVUS for thickness >4mm
Biopsy with hysteroscopy (visualise) or as outpatient bedside
CT/MRI for staging

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135
Q

Surgery for endometrial cancer

A

TAHBSO
RT as adjuvant to prevent recurrence or external beam to control bleeding if unfit for surgery
High dose progesterone for bleeding in palliation

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136
Q

4 types of fibroid

A

Subserosal (visceral)
Intramural
Submucosal (under endometrium)
Pedunculated

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137
Q

RF for fibroid

A

Age
Afrocaribbean
FHx
Oestrogen - pregnancy and COCP

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138
Q

Presentation of fibroids - 4

A

Menorrhagia - heavy and pronged, not intermenstrual
Pain - from pedunculated torsion or red degeneration (thrombus)
Mass effect - pressure on bladder
Infertility - distort cavity nd prevent implantation

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139
Q

Manage fibroids

A

None if symptoms not too bad
Med
- GnRH analogue or ullipristal acetate (selective progesterone receptor modulator) for 3-6m before surgery to shrink and induce amenorrhoea. Ullipristal acetate needs regular LFTs and FBCs
Surg
- uterine artery embolisation (v painful post op, can cause infected necrotic uterus)
- myomectomy (hysteroscopy or laparotomy) - best for future pregnancy but will need c section if uterus breached
- hystorectomy

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140
Q

Fibroids in pregnancy

A

Red degeneration:
2nd trimester - grow, can get thrombus of vessels, causing venous engorgement and inflammation = abdo pain, vomiting, low grade fever and localised tenderness
Will resolve in 4-7d with rest and analgesia

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141
Q

Fibroid after menopause

A

Most regress

Can become sarcoma = pain, malaise, bleeding, grow

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142
Q

Causes of intermenstrual bleeding

A

Cervical polyp, cancer of ectropion

Trauma or abrasion - post coital

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143
Q

Causes of post menopause bleedin

A

endometrial - polyp, cancer, hyperplasia
Cervical - polyp, cancer
Vulval cancer

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144
Q

What is endometriosis nd adenomyosis

A

Endo - endometrial tissue outside uterus

Adeno - endometrial tissue in myometrium

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145
Q

3 causes of endometriosis

A

Retrograde menstruation - adherence, invasion and growth
Impaired immunity
Metalasia of mesothelium cells

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146
Q

Inv endometriosis

A

TVUS for ovarian cysts
MRI if bowel symptoms to map extent
Diag - laparoscopy with biopsy - deep infiltrating lesions, do 3m after stopping hormones

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147
Q

Cells in cervix

A

Endocervix canal = mucous columnar epithelium
Vaginal cervix = squamous epithelium
Junction = transitional zone = predisposed to malig

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148
Q

What is ectropion and treatment

A

Extension of mucous columnar endocervix epithelium into ectocervix - prone to bleed, infection, mucous
Extends under hormones - puberty, pregnancy, COCP
No treatment necessary but can treat by removing hormonal contraception or diathermy

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149
Q

Manage cervical polyps

A

Post coital bleeding/discharge
If young, avulsed
Older - TVUS +- hysteroscopy to exclude interuterne polyp

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150
Q

Caus of cervicitis

A

Follicular or mucopurulent

Chlamydia, gonococci or herpes

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151
Q

What is CIN and different stages and management

A

Dyskaryosis of cervical tissue - pre-invasive
CIN1 - lower 1/3
- most will regress spontaneously
CIN2 <2/3
CIN3 >2/3
- less likely to regress, more likely to progress to invasive squamous cell cancer and quickly in younger women

Smear : CIN2-3:
Inflammatory - repeat in 6m, do swab, colposcopy if 3x abnormal
Borderline dyskaryosis = HPV test. If pos = 6 monthly colposcopy, LLETZ if persistent
If neg = 3y screening

If mod or severe dyskaryosis = colposcopy + LLETZ, then smear and HPV test in 6m. Pos = colp again

Suspected invasion or abnormal glandular cells (adenocarcinoma of cervix) = urgent colposcopy

Colposcopy = visualise transformation zone, give acetic acid which is taken up by neoplastic cells = white = abnormal, then do punch biopsy. Also look for microinvaion - vascular abnormalities

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152
Q

Inv CIN in pregnancy

A

Colp but no LLETZ

- definitive treatment 12w postpartum

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153
Q

Complications of Lletz

A

Haemorrhage
Infection
Vasovagal, anxiety
Cervical stenosis

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154
Q

What is related to CIN but not cancer

A

Cervical glandular intraepithelial neoplasia
Also HPV risk
Less visible, has skip lesions
LLETZ or cone biopsy or hysterectomy

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155
Q

Different HPVs vaccinated against

A

6 and 11 = anogenial warts

16 and 18 = cancer

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156
Q

cervical cancer bimanual exam - 4

A

rough and hard cervix
Loss of fornices and fixed cervix
Irregular mass on speculum may bleed on contact

157
Q

Inv cervical cancer and staging

A 
FBC UE LFT
Punch biopsy for histology - LLETZ will bleed heavily
CT abdo pelvis for staging
MRI pelvis for staging and nodes
(EUA - cystoscopy, hysteroscopy, PV/PR)

Stage 1 - cervix, 1a microscopic 1b macroscopic
2 - upper 2/3 vagina, 2b - parametria
3 - a = lower 1/3 vagina, b = pelvic wall
4 - rectum or bladder
4b distant organs

158
Q

Treat cervical cancer and ADRs

A

1a - Local excision or hysterectomy
>2b = combined crt
4b - palliative radio for bleeding

Hysterectomy ADR - bleeding, infection, VTE, ureteric fistula, bladder dysfunction, lymphodedma
RT - bowel and bladder dysfunction - tenesmus, bleeding, ulceration, strictures

159
Q

Rf for cervical cancer

A 
HPV16 and 18
STD
High parity 
Long term COCP
Non-barrier contraception 
Smoking
160
Q

CIs to cervical screening

A

Not had sex
Pregnancy or <12w post partum
Hysterectomy
Previous radio to cervix

161
Q

% of CIN that will progress to cervical cancer

A

20-30%

162
Q

Cancers linked to HPV

A

Cervical
Anal
Head and neck

163
Q

When is cervical cancer diagnosed

A

Half <47yo

Peak in 20-30 and 70s

164
Q

Sx of cervical cancer

A 
Abn bleeding- PCB, IMB, postmenopause
Vaginal discharge
Dysparunia
Dysuria, pelvic pain 
Weight loss
165
Q

Causes of dysmenorrhea and treatment

A

Primary - crampy, back/groin, worse in first 2 days, with anovulaory cycles and excess prostaglandins causing uterine contractions. Give NSAID/paracetamol. If pain with ovulation = COCP
Secondary - later - adeomyosis, PID, fibroid, endometriosis - constant pain, deep dysparaunia. Treat cause, mirena coil. (IUCD usually makes dysmenorrhea worse)

166
Q

Causes of PMB

A

Atrophic vaginitis
Carcinoma of cervix/vulva
Endometrial or cervical polyps
Oestrogen withdrawal - HRT or ovarian tumour

167
Q

Causes of amenorrhoea

A

Primary - structural or genetic - Turner’s, hormonal (androgen insensitivity) - look for SSC, consider tests for secondary

Secondary -
HPO - stress, exercise, weight loss
Hyperprolactinaemia - Sheehan’s
Ovarian - PCOS, ovarian insufficiency (prem menopause)
Uterus - pregnancy, Asherman’s, post-pill

168
Q

Manage HPO cause of amenorrhoea

A

Stress management
Medroxyproesterone acetate challenge = endometrium is shed in 10d - confirms, unless severe and shut down
LH, FSH, oestrogen low
Clomifene will stimulate ovary release but will need GnRH for fertility if severe

169
Q

Inv amenorrhoea

A

BHCG - pregnancy
Prolactin - high in stress, hypothyroid, prolactinoma, drugs
LH, FSH - low if HPO
TFT
Testosterone - androgen secreting tumour or late onset CAH

170
Q

Sx of PMS

A

Psych - irritability, depression, mood swings
Phys - bloating, breast tenderness, headache

Improve significantly after period
- do diary

171
Q

Treat PMS

A

Exercise, stress, weight loss, smoking
1 - CBT, combined contraception, SSRI
2 - oestradiol patch and progestogen, high dose SSRI
3 - GnRH analogue and HRT but sx will return when ovarian activity returns, and risk of bone thinning >6m
4 - TAHBSO

172
Q

What is found on high vagina (4) and endocervical swab (2)

A

Endocervical - chlamydia tracomatis, neisseria gonorrhoea

High vaginal - candidiasis, trichomonas vaginalis, GBS, gardnerella vaginalis

173
Q

Chlamydia treatment

A

Doxycline 7d or azithromycin stat

Erythromycin if pregnant - stop neonatal conjunctivitis

174
Q

Gonorrhoea treatment

A

Ceftriaxone IM and azithromycin - both stat

Test cure with culture 72h post abx

175
Q

Bacterial vaginalis and trichomonas treatment

A

PO metronidazole stat or clindamycin PV gel 7d

176
Q

Candidiasis treatment

A

Intravaginal clotrimazole or oral fluconazole

177
Q

RF for candida and what is the candida and inv

A

Candida albicans
Pregnancy, COCP, immunodeficiency, steroids, antibiotic, diabetes
Inv - micro for spores and culture

178
Q

Sx of trichomonas vaginalis

A

Vaginitis
Bubbly thin fish smelling discharge
Strawberry cervix
Wet film - motile flagelettes, or culture

179
Q

Sx of BV and complications

A

10% have it, mostly asymptomatic
Fishy odour, rarely itching
Altered overgrowth - Gardenrella and mycoplasma
Clue cells on wet film

Pregnancy - preterm labour, intraamniotic inf, HIV susceptibility, post TOP sepsis

180
Q

Chlamydia sx, inv and complications

A

70% asymptomatic
Dysuria, discharge, IMB/PCB

Diag with vulvovaaginal or endocervical NAAT

Complications - PID, Fitz-Hugh Curtis syndrome (perihepatitis), tubal infertility, ectopic pregnancy, Reiter’s syndrome

In pregnancy - PPROM and prem delivery, neonatal conjunctivitis and pneumonia

181
Q

Gonorrhoea - gram stain, sx, complications

A

Gr neg diplococcus

Asymptomatic, loser abdo pain, vaginal discharge, IMB
Complictions - PID, Bartholin’s abscess, tubular infertility and ectopic pregnancy
Disseminated - fever, pustular rash, polyarthralgia, septic arthritis

NAAT - vulvovaginal, endocervical, urethra, rectal and pharyngeal swabs
Then culture for sensitivity
Treat with stat ceftriaxone and azithromycin. ?Abx resistance

Pregnancy - risk of PROM and delivery, chorioamnionitis, neonatal conjunctivitis

182
Q

Vulval warts cause, complication and treatent

A

HPV6 and 11
Can be penile, vulval, perineal, vagina, cervical, anal
Increase in pregnancy and immunosuppression
- risk of laryngeal or respiratory papilloma to offspring

Treat with cryotherapy in clinic or podophyllotoxin cream for 4-6w if vulval/anal (CI pregancy and only a few at once)

183
Q

Herpes sx and treatment

A

Flu-like, itching, vulvitis, pain and small vesicles on vulva
Urinary retention from autonomic nerve dysfunction
Relapse when stress, illness, sex, mensturation
Men might be asymptomatic for years

Treat with analgesia and lidocaine gel, and oral acyclovir for 5d or year of suppressant if recurrent

184
Q

Syphilis sx

A

Treponema pallidum - spirochaete

Primary - chancre where lesion was that infection entered through - very infective
Secondary 6w-6m later
- rash on face, trunk, hands and feet
- malaise, lymphadenopathy, fever
- tonsillitis
- glomerulonephritis, optic neuritis, uveitis, hepatitis
Tertiary >2y - granulomas in skin, bones, joints
Quaternary - aortic aneurysm, tabes dorsalis (ataxia, numb, Charcot)

Inv - T pallidum assay
Treat - penicillin

185
Q

What is vulvovaginitis and treatment

A

Desquamative inflammatory vaginitis with shiny erythematous patches and petechiae
May be due to NSAID or statin - stop for 2w
Intraavaginal clindamycin cream

186
Q

What is causing white vulval patches with skin thickening

A

Leukoplakia. Itchy and biopsy as may be pre malignant

Treat with topical steroids and phototherapy

187
Q

Very itchy red erosions on vulva

A

Lichen sclerosis - AI, elastic tissue turns to collagen.
May be bullae and ulceration
Vulva will eventually turn to white, flat and shiny.
May be premalignant - biopsy
Clobetasol cream

188
Q

What is VIN and treatment

A

HPV link
White patches with surrounding inflammation
Surveillance
Remove if irritating but will often reoccur
Treat with imiquimod - stimulates macrophages and monocytes

189
Q

Hot swollen red labia

A

Bartholin cyst, under labia minora, secretes thin lubricating fluid
Blocked = red hot swollen and painful
Treat - incise, may need permanent drainage. Check for gonorrhoea

190
Q

Cells in vulval cancer, presentation and treatment

A

Mostly squamous
Also melanoma, basal cell, carcinoma of Bartholin gland
Sx - induration ulcer, not noticed until bleeding and painful - late
Generally >70yo

If <2cm wide and 1mm deep, excise
If larger = wide local excision and ipsilateral groin node
Adjcanat RT to shrink if risk of damaging sphincter
CRT if unsuitablefor surgery

191
Q

What is endometrititis

A

Infection of endometrium, when invaded by TOP, IUCD, childbirth, surgery, miscarriage
Lower abdo pain and uterine tenderness on bimanual palpation
Foul discharge
Can spread to tubes

High vaginal swabs and blood culture if septic
Abx, remove IUCD if not working

192
Q

Normal endometrial thickness and when to do hysteroscopy

A

<5mm post menopause
- >4 = hysteroscopy
11mm in proliferative phase, 7-16 in late cycle
- >20 = hysteroscopy

193
Q

Vaginal tumours - what kind and RF and treatment

A

Mostly secondary from cervix, uterine, vulva
Primary are mostly squamous
Generally upper 1/3 vagina
Related to CIN, radiation, chronic inflammation from pressure
Treat with radiotherapy, poor prognosis

194
Q

Benign ovarian cyst sx

A

Asymptomatic
Dull ache, dysparaunia, cyclic pain, mass effect
Irregular bleeding
Hormone effect - androgenic
Abdo swelling, ascites = malignant
Severe pain and bleeding if torsion - impaired blood supply - oedematous - raised WCC and CRP
Cyst rupture = haemorrhic shock

Exam: adnexal mass, discharge, bleeding, cervical excitation, ascites, peritonism

195
Q

Inv benign ovarian tuumour

A

CA125
BHCG, AFP
CA19-9, CEA, LDH

TVUS - malignant = multiloculated, solid area, ascites, mets, ascites
MRI if >7cm

196
Q

Treat benign ovarian tumour

A

Unstable = laparoscopy. Stable = TVUS

Pre-meno: <5cm and no sx = no treatment, rescan in 6w.
>5cm or sx: laparoscopic ovarian cystectomy, don’t spill contents

Post-meno: calculate risk of malignancy with TVUS, CA125 and US features every 4m for 1y then discharge if no change

Mod risk = bilateral oopherectomy

197
Q

Types of ovarian tumours

A

Functional cyst - enlarged or persistent follicular or corpus luteum cyst. Very common, may rupture at ovulation or bleed

Endometrioma - chocolate cyst

Serous cystadenoma - papillary growths, may appear solid. May be bilateral or malignant

Mucinous cystadenoma - very large, multilocular, most common, filled in mucinous material. May rupture and cause pseudomyxoma peritonei (thick jelly like deposits in abdo - bad prognosis)

Fibroma - small solid benign fibrous tissue. Meig’s syndrome = (right sided) pleural effusion and benign ovarian fibroma and ascites

Teratoma - from primitive germ cells. Benign and mature = dermoid cyst. Well differentiated eg hair. In young women

198
Q

Score for ovarian cancer

A

Risk of Malignancy Index:
Ca125 x US findings (0-2) x menopausal (3 = post)
US: multiloculaed, solid, mets, ascites, bilateral

199
Q

Ovarian cancer type and RF and protective factors

A

Mostly epithelial

RF:
Early menarche late menopause
Nulliparity
HNPCC (Lynch 2)
BRCA1 or 2

Protective: pregnancy, breastfeeding, COCP, tubal ligation

Borderline ovarian tumour = epithelial and not benign, in younger women, general pre-meno and confined to ovary with difficult with histological diagnosis. Better prognosis than carcinoma and only need oopherectomy

200
Q

Screening for ovarian cancer

A

If gene mutation - yearly TVUS and CA125

If BRCA+ offer BSO

201
Q

Sx and inv for ovarian cancer

A

Bloating, fatigue, non spec abdo pain, bowel/bladder sx, weight loss, vagina bleeding

Inv - CA125, CA19-9 = mucinous
If <40 = AFP, BHCG, LDH
TVUS
CXR for pleural effusion 
CT abdo pelvis for peritoneal, liver, omental, para-aortic nodes 
MRI for benign/malignant
Ascites/pleural effusion cytology
202
Q

Staging for ovarian cancer and treatment

A 
FIGO:
1 - ovary 
- 1c if capsule breached, on ovarian surface, or ruptured
2 - pelvis
3 - abdo and nodes
4 - distant

Full staging involves laparotomy, hysterectomy, BSO, omentectomy, nodes etc

Can leave uterus and other ovary if want to stay fertile
Neoadjuvant chemo for 2-4

203
Q

Causes of PID - 4

A 
Infection  of upper genital tract
STI
Uterine instrumentation - hysteroscopy, IUCD insertion, TOP
Post-partum 
Descending inf eg appendicitis

Chlamydia and gonorrhoea, or anaerobes and endogenous bact

204
Q

RF and protective factors for Pid

A

RF: <25, STI hx, new/multiple partner
Protective: barrier contraception, IUS, COCP

205
Q

Sx of PID

A

Lower abdo, bi/unilateral pain, constant or intermittent
Deep dysparaunia, dysmenorrhea
Discharge
IMB, PCB

Fever
Afebrile if mild or chronic

Cervical excitation on exam, +- adnexal tenderness

206
Q

Inv PID

A

FBC, WBC, CRP, cultures
Swab - chlamydia and gonorrhoea and mc&s

TVS if tubo-ovarian abscess

207
Q

Complications of PID - 5

Chronic PID

A 
Tubo-ovarian abscess
Fitz-Hugh Curtis syndrome - perihepatic adhesions and liver capsule inflammation 
Subfertility 
Ectopic pregnancy 
Recurrent PID

Chronic - fibrosis and adhesions, pyosalpinx, hydrosalpinx. Chronic pain, dysparauunia, dysmenorrhoea, menorrhagia
Tube masses, tenderness, fixed retroverted uterus
Laparoscopy = infection vs endometriosis
Pain difficult to control and abx not helpful

208
Q

Manage PID

A

Ceftriaxone, doxycycline, metronidazole
Check for improvement in 72h
Inpatient if severe, sepsis or fail to respond to abx

209
Q

Causes of chronic pelvic pain and management

A

Analgesia, gabapentin (pain clinic), hormonal
Treat depression

> 6m, intermittent or constant lower abdo pain not associated exclusively with menstruation, sex or pregnancy

Non-gynae: IBS, constipation, neuropathic (surgery), fibromyalgia

Endometriosis, adenomyosis, adhesions

  • COCP may help if cyclical pain
  • GnRH course can predict success of hysterectomy

Mitelschmerz - mid-cycle menstrual pain in teenagers and older women around time of ovulation

Pelvic congestion: lax pelvic veins seen on laparoscopy get worse when standing or premenstrually.
- Deep post-coital ache
- Exam - most tender over ovaries, blue vagina and cervix from congestion
- Look for deep leg varicosities
Treat: ovarian suppression, relaxation techniques, migraine remedies.
Severe - bilateral ovarian vein ligation, radiological embolisation, hysterectomy with salpingo-oopherectomy

210
Q

Causes of polycystic ovaries and RF/assoc conditions with main cause

A

Cushing’s
Late onset adrenal hyperplasia
PCOS
- obesity, diabetes 2, metabolic syndrome (dyslipidaemia, htn, insulin resistance, visceral obesity), cvs risk, OSA, acanthosis nigricans from hyperinsulinaemia

211
Q

Diagnosis of PCOS

A

Rotterdam criteria - 2/3 of:

  1. Hyperandrogenism - clinical or biochemical sx
  2. Polycystic ovaries on US - >=12 follicles of >10cm^3 volume
  3. Oligomenorrheoa - oligo/anovulation

Exclude other causes of irreg cycles - hyperprolactinaemia, thyroid, CAH, androgen secreting tumour, Cushing’s
If hyperandrogenergic and testosterone >5, check 17-hydroxyprogesterone to exclude androgen secreting tumour

212
Q

Manage PCOS and long term consequences

A

Weight loss and exercise improve insulin sensitivity
Smoking cessation
Treat dyslipidaemia, hypertension, DM2

Metformin - increases insulin sensitivity in short term, reduces disturbance of menstrual and ovulatory function. Doesn’t cause weight loss
Clomifene - induces ovulation. Risk of multiple pregnancies, ovarian hypersensitivity (esp if assisted contraception) - monitor response on US for first cycle, ovarian cancer
Ovarian drilling needle point diathermy - reduces hormonal production. Risk of future preterm, large babies, gestational diabetes, pre-eclampsia

COCP to increase progesterone and decrease risk of endometrial cancer from unopposed oestrogen

Induce regular withdrawal bleed with norethisterone (/3m) if not on COCP to reduce risk of endometrial cancer

Treat hirsuitism with cyproterone anti-androgen cream

Long term = endometrial cancer, gestational and type 2 diabetes, CVS disease. NO increased risk of ovarian or breast cancer

213
Q

What is ovarian hyperstimulation syndrome and RFs and sx and prevention

A

Vasoactive mediator production including VEGF, systemic disease
In young, PCOS, low BMI, previous OHSS

Sx:
- ovarian enlargement
- shift of fluid from intra to extracellular spaces:
— haemoconcentration and hypercoagulability
— fluid in pleural and peritoneal spaces

Presents with abdo discomfort and nausea, vomiting, distension
3-7d after HCG, 12-17d after pregnancy ensues
Prevent with lowest level of gonadotrophs, may need to cancel next cycle

214
Q

Manage OHSS

A

Mild and moderate - bloating, mild/mod pain, ascites on US, ovary 8-12cm:

  • Analgesia - paracetamol (avoid NSAIDs as encourage shift from intra to extracellular space and renal impairment)
  • Avoid strenuous exercise - risk of torsion
  • Continue progesterone luteal support and avoid HCG
  • See fertility team every 2-3d

Severe - clinical ascites, haematocrit >45%, hypoproteinaemia, oliguria, ovary >12cm:

  • Admit, daily FBC/UE/LFT/albumin
  • Analgesia and anti-emetics
  • VTE - stockings and LMWH
  • Measure ascites, weight, legs (thrombus)
  • Paracentesis for sx relief +- albumin replacement
  • Careful fluid management and catheter

Critical - tense ascites, oligo/anuria, haematocrit >55%, WCC raised, VTE, ARDS:

  • ITU
  • Drain symptomatic pleural effusion
  • VTE
  • Fluid balance, caution of hyponatraemia
215
Q

RF for uterine prolapse

A

Intra-abdo pressure - obese, chronic cough, constipation

Trauma from instrumental births, prolonged labour, poor perineal repair/exercises

216
Q

5 types of prolapse

A

Uterine - protrusion of uterus into vagina, with upper vagina and cervix
Cystocoele - anterior wall of vagina and attached bladder bulge. May have residual urine = frequency, dysuria +- urethra (cystourethrocoele)
Rectocoele - lower posterior wall attached to rectum pushes through weak levator ani. Patient needs to put finger in vagina or push on perineum to defacate
Enterocoele - bulges of the upper posterior vaginal wall may contain loops of intestine from pouch of Douglas
Vaginal vault prolapse if had hysterectomy

217
Q

Grading of prolapse

A

1st degree - to level of introitus
2nd - through introitus on straining
3rd - through introitus and outside vagina
4th = procidentia = uterus outside of vagina

218
Q

Symptoms of prolapse and exam

A

Something coming down, dysparaunia, dragging sensation, back ache
Cystocoele - dysuria, frequency, incomplete emptying, urinary retention if urethra kinked
Rectocoele - constipation, difficulty with defecating

Exam - bimanual for pelvic mass
Left lateral to look at anterior and posterior walls, for atrophy and descent
No obvious prolapse = strain or stand
Urodynamic studies if incontinent

219
Q

Management of prolapse

A

Conservative - weight loss, stop smoking, pelvic floor exercises
Ring pessary + oestrogen cream for erosion: between posterior fornix of vagina and posterior symphysis pubis, change /6m, interferes with sex
Surgery if severe, pessary failed, or sexually active:
- debulking and support (may narrow cervix)
- hysterectomy

220
Q

Symptoms of menopause - 4

A

12m since period, average 52yo

  1. Vasomotor - flushing, sweats, palpitations
  2. Atrophy of oestrogen dependent tissues - breasts, vaginal dryness, dysparaunia, bleeding, incontinence, prolapse
  3. Menstrual irregularities - anovulatory cycles
  4. Osteoporosis
221
Q

Basic steps in menopause management - 5

A 
Ensure not hypothyroid or psychological
Encourage exercise and diet
Topical oestrogen for dryness
Mirena IUS for menorrhagia
Contraception for 1y if >50, 2y if <50
222
Q

Types of HRT

A

No uterus = progesterone only
Uterus and <12m since period - continuous oestrogen and cyclic progesterone (withdrawal bleed)
Uterus and >12m since period - continuous combined

Oestrogen and progesterone = oral or transdermal (gel, patch)
Oestrogen - SC or topical vaginally
Progesterone - IUS

223
Q

Side effects of HRT

A

Progesterone = mood swings, depression, acne, backache

Bloating, fluid retention, breast tenderness, nausea, headache, dyspepsia

224
Q

CI to HRT

A 
Undiagnosed PV bleed
Previous PE or phlebitis
Raised LFTs
Pregnancy or breast feeding
Oestrogen dependent cancer
225
Q

Annual check for someone on HRT - 4

A

BP - stop and investigate if >160
Breasts
Weight
Abnormal bleeding

226
Q

Alternatives to HRT - 3

A

Topical oestrogen or lubricant for vaginal dryness
SSRI (clomifene) for vasomotor sx
Calcium, vit d, bisphosphonates, SERM for osteoporosis

227
Q

Benefits of HRT - 4

A

Reduced fracture risk - must be life long
Reduced colon cancer by 1/3
Reduced vasomotor sx - start at 4w, peak at 3m, stay on for 1y to minimise recurrence
Reduced urogenital sx - takes months for effects, use long term

228
Q

Risks of HRT - 4

A

Endometrial cancer from unopposed oestrogen
Breast cancer - increases for each year on, back to baseline after 5y off. Esp with combined continuous. Increase of 3/1000 if started at 50yo for 5y
VTE - esp if oral and older
Gall stones?

229
Q

5 general advice when starting HRT

A 
Exercise, diet, local > systemic
Minimum dose minimum time
Breasts - awareness, screening, report changes — be aware of family history 
Benefits and risks
Start close to menopause
230
Q

Risks of HRT - 4

A

Endometrial cancer from unopposed oestrogen
Breast cancer - increases for each year on, back to baseline after 5y off. Esp with combined continuous. Increase of 3/1000 if started at 50yo for 5y
VTE - esp if oral and older
Gall stones?

231
Q

5 general advice when starting HRT

A 
Exercise, diet, local > systemic
Minimum dose minimum time
Breasts - awareness, screening, report changes — be aware of family history 
Benefits and risks
Start close to menopause
232
Q

Features of Fraser guidelines - 4

A

<16yo
Cannot be persuaded to tell parents
Will begin or continue to have sex with or without contraception
Failure to give contraception will result in physical or mental health suffering
Best interests of the child are to give contraception and not tell parents

233
Q

CI to IUD

A 
Pregnant, or <4w post-partum
STI or pelvic infection 
Wilson’s disease 
Copper allergy
Undiagnosed abn uterine bleed
Distorted cavity  
Heavy painful periods
Trophoblastic disease or gynaecological malignancy
Caution if coagulopathy
234
Q

Problems with IUD - 4

A
  1. May be expelled - esp if uterine distorted (fibroid) or nulliparity
  2. Risk of PID up to 21d after insertion
  3. Menorrhagia and dysmenorrhoea
  4. Risk of ectopic pregnancy if becomes pregnant
235
Q

CI to IUD

A

Pregnant, or <4w post-partum
STI or PID
Wilson’s disease
Undiagnosed PV bleed

236
Q

Insertion of IUD and removal

A

STI screen or give azithromycin 1g stat dose afterwards
Mild analgesia before
Warning of faint - vagal tone. Legs up and head down. Have atropine and AED if epilepsy
Warn of mild cramping
Check for strings after periods
Most expulsions in 1st 3m - follow up after 1st period

Removal - other contraception for 7d before

237
Q

What to do if lost threads on IUD

A

Extra contraception and pregnancy test
US to locate
X-ray if can’t

238
Q

Infection with IUD?

A

Treat with coil in place
If removed - don’t replace for 3m
If actinomyces, send strings for culture

239
Q

Pregnancy with IUD?

A

Remove to reduce risk of miscarriage and miscarriage with infection

240
Q

IUS levonorgestrel effect, advantages, uses

A

Mirena = levonorgestrel
Local - prevent implantation - endometrial atrophy

Lighter periods, may be amenorrhoea
Good for endometriosis, adenomyosis, endometrial hyperplasia
Can use in breastfeeding, obesity, CVD, hepatic enzyme-inducing drugs

May have spotting/heavy bleed for 3-6m after insertion
Can’t be used for emergency contraception

Ectopic and PID less of a risk than IUD

241
Q

How do progesterone only contraceptives work

A

Inhibit implantation
Thicken cervical mucus
May inhibit ovulation

Also reduce pelvic infection and can be used when oestrogen cannot

242
Q

CIs to progesterone only contraception

A

New sx of migraine with aura, IHD, stroke
Breast cancer <5y ago
Trophoblastic disease
Liver disease - cirrhosis, tumour, hepatitis
SLE with antiphospholipid antibodies
Undiagnosed PV bleeding

243
Q

Progesterone only pill - time windows and ADRs

A

Desonorgestrel has 12h window, others have 3h window
Immediate effect if day 1-5, otherwise use barrier for 2d
Start >3w postpartum
Efficacy affected by hepatic enzyme inducing drugs
ADR - acne, mood swings, depression, menstrual irregularities higher failure rate ad ectopic pregnancy rate, functional ovarian cysts

244
Q

Depot progesterone - indication and 4 ADRs

A

/12w or /8w
Start during first 5 days of cycle
Not for adolescents
Can use up to 50yo if no other rf for osteoporosis

ADR:
Menstrual irregularities, then amenorrhoea for some 
?osteoporosis
Weight gain
Delay in fertility after starting again
245
Q

Implant progesterone

A

Change /3y, earlier if obese

Immediate effect if day 1-5, otherwise use barrier for 7d

246
Q

Initial management for emergency contraception appointment

A 
LMP, normal cycle
Number of hours since unprotected sex
CIs to COCP in future
BP
STI/HIV screen
Discuss future contraception 
- COCP from day 1 of next cycle, or explain extra cover if going to start immediately (7d) 
- Follow up in 3-6w if IUD now
247
Q

Types of emergency contraception and requirments

A

IUD <5d since intercourse, or <5d since ovulation.

  • Toxic effect to inhibit implantation.
  • STI screen or 1g stat azithromycin.
  • No interaction with hepatic enzyme inducing drugs
Ullipristal acetate (progesterone receptor modulator) <5d, inhibits/delays ovulation 
- caution in asthma, liver disease, don’t breastfeed for 36h after

Levonorgestrel <3d, inhibits ovulation

  • suitable if focal migraine and past VTE
  • higher dose if enzyme inducer taken in last 28d
  • use contraception until next period
248
Q

Combined contraception types and CIs

A

COCP - 21d then 7d off for withdrawal bleed. If many progesterone SEs, use desorgestrel
Patch - change on day 8 and 15, remove on day 22
Ring - remove on day 22

Venous disease - avoid if VTE or hx, or sclerosing treatment to treat varicose veins.
 Caution in 1 of:
- smoker >15d (>35d = avoid)
- >35yo
- BMI>30 (>35 avoid) 
- 1st degree rel <45yo
- immobile 
- superficial thrombophlebitis

Arterial disease - avoid if valvular or congenital heart disease with complications, or CVD eg stroke, IHD, TIA, peripheral vascular disease, hypertensive retinopathy.
Caution in 1 of:
- smoker >15d (>35d = avoid)
- >35yo
- 1st degree rel <45yo
- diabetes, hypertension >140/90 (avoid if >160/95)
- migraine (with aura = avoid)

CI:

  • Liver disease - hepatitis, cirrhosis, gall bladders disease
  • Breast cancer <5 years ago
  • Pregnancy complications- pruritis, choolesasis
  • Hepatic enzyme inducing drugs eg rifampicin
  • migraine with aura
  • smoke >35/d
  • BP >160/95
  • BMI >35
249
Q

Features of migraine with aura - 6

A

Slow evolution of sx over several minutes
10-30m aura resolves in 1h
Visual - bilateral homonmous hemianopia, scotoma
Sensory disturbance
Speech - dysphasia, dysarthria
Motor

250
Q

Short term SEs of COCP

A

Oestrogens - bloating, breast tenderness, nausea, weight gain, discharge
Progestogenic - headache, mood swings, decreased libido, acne
Headaches
Breakthrough bleeding for up to 6m

251
Q

Risks and benefits of COCP - 4 of each

A 
Risks:
VTE
Breast and cervical cancer
Mood changes
Ischaemic stoke
Benefits:
Reduced ovarian, endometrial and bowel cancer 
Dysmenorrhoea and menorrhagia
Menopause sx
Improvement in acne
252
Q

Starting COCP, what to do if missed one

A

If after day 5, barrier for 7d
Start 21d postpartum, 14d post surgery
Don’t take if breastfeeding (take POP)

Missed one - 7d condoms, start new pack with no break if at end of pack

253
Q

Warnings to stop taking pill

A 
Breathless, chest pain, calf swelling
Prolonged headache or vision loss, dysphasia, motor/sensoriloss
Severe stomach pain
Hepatitis, jaundice, hepatomegaly
SBP >160
4w before major surgery
254
Q

Why does COCP make VTE more likely

A

Increase resistance to activated protein c

Thrombosis risk increases if antithrombin, protein c/s, factor 5 Leiden deficiency

255
Q

When to take emergency contraception with COCP or POP

A

COCP if 2+ pills missed in first 7 days, and had sex in those days or in pill free week

POP if 1+ missed and sex in 2 days since

256
Q

Female vs male sterilisation

A

Female - GA, laparoscopic tube ligation

  • ADR = heavy bleeding
  • pregnancy test before
  • remove IUCD after next period as may have fertilised ovum
  • 1:200 failure

Male - LA, vasectomy (vas def ligated and excised)

  • ADR = bruising, haematoma, chronic testicular pain
  • takes 3m for sperm stores to be used up - can test ejaculates to be neg at 8 and 12w post op before stopping other contraception
  • failure 1:2000
257
Q

Questions to ask in sterilisation - 6

A 
Other methods 
Consent of both partners
Who 
Irreversible
Failure
Side effects
258
Q

HPO in menstruation

A

Hypothalamus has pulsatile release of GnRH which stimulates ant pituitary to release gonadotrophs LH and FSH
These stimulate ovary to release oestrogen and progesterone which have negative feedback on hypothalamus and pituitary

259
Q

Process of menstruation

A

Day 1 = first day of menstruation. FSH levels high for 4 days, stimulating primary follicle to develop. This then make oestrogen which stimulates glandular proliferative endometrium and cervical mucus receptive to sperm (clear and stringy) and controls release of LH and FSH
By 14 days before end of cycle, oestrogen high enough to stimulate LH surge which stimulates ovulation. Primary follicle then becomes corpus luteum which secretes progesterone, preparing endometrium for implantation - convoluted glands in excretory phase, and makes mucus viscid hostile to sperm
If it doesn’t get fertilised in 14d, corpus luteum breaks down and hormone levels drop, stimulating spiral arteries in lining to constrict and shed lining
If it is fertilised = high levels of chorionic gonadotropin and embroil embeds in decidua

260
Q

How to delay ovulation

A

Norethisterone from 3d before bleeding due until to acceptable level
Or 2 packets of COCP with no break

261
Q

Normal menarche

A

From 10yo, average 12.7. Breast buds - pubic hair - axillary hair - menses
14yo with no SSC
16yo with no menses

262
Q

When to investigate subfertility

A

> =1y of regular sex (84% conceive within 1y, 92% in 2)
Earlier if woman >=35yo, a/oligomenorrhoea, previous PID, previous cancer treatment to either partner or undescended testes

263
Q

Causes of subfertility in order - 5

A 
[UMATE]
Unexplained 
Male factor
Anovulation
Tubal
Endometriosis
264
Q

History and exam for subfertility

A 
Women:
- menstrual
- pain, sti
- surgery
Men:
- undescended testes
- mumps
- ed
Both:
- smoking
- alcohol
- children

Exam:

  • BMI - reduced fertility and cannot get trt
  • evidence of endocrine eg pcos
  • evidence of pelvic pathology eg endometriosis or fibroids
  • cervical smear if due, STI screen
265
Q

Investigate subfertility - primary and secondary care

A

Primary care:

  • baseline hormone profile - FSH and LH at start of cycle
  • progesterone surge 7d before menses (midluteal)
  • TSH, prolactin, testosterone
  • rubella
  • chlamydia
  • semen analysis - lifestyle changes and vit c supplements then reanalyse in 3m

Secondary care:
- TVUS for adnexal mass, submucosal fibroid, endometrial polyp, PCOS
- laparoscopy and dye test for tubal patency
- hysterosalpingogram with contrast and x-ray or sonogram with TVUS - dye into cervix for uterine and tubal abn
— chlamydia screen first and stat azithromycin

266
Q

Lifestyle modification for subfertility management

A

Alcohol, smoking

Sex 2-3x/w, not timed

267
Q

Management of subfertility in woman

A

Clomifene citrate - antioestrogen, increases FSH by negative feedback to pituitary
SE: ?multiple pregnancy, ovarian hyperstimulation - monitor with US, SE - labile mood, flushing
- 6-12 cycles (?ovarian cancer link)

Laparoscopic ovarian drilling for PCOS reduces LH and restores feedback mechanisms

Gonadotrophins if clomifene resistant or low oestrogen wth normal FSH

Metformin may stimulate ovulation in PCOS

Surgery: tubal catetherisation of hysteroscopic cannulation, but high rates of ectopic.
Treat endometriosis, adhesions (adhesiolysis)

268
Q

Indications and good prognosis signs for IVF

A

IVF if:

  • tubal disease
  • male factor
  • clomifene failure and anovulation
  • > 2y of unexplained, or old

Prognosis good if:

  • AMH not too low
  • smoking, BMI
  • age, duration of trying

Screen for HIV, HepB and C
Ovaries stimulated, ova collected, fertilised and 1 embryo put in 3-5d later
Luteal support with progestogens
Pregnancy test 2w later

269
Q

Hormone production in men

A

In seminiferous tubules. Undifferentiated diploid germ cells (spermatogonia) multiple and become haploid spermatozoa - takes 74d
LH - leydig cells - testosterone
Testosterone and FSH - sertolli cells - substances for metabolic support of germ cells and spermatogenesis

270
Q

Spermatozoa anatomy and how much

Normal semen analysis

A

Motile tail, head with haploid chromosome, covered with acrosome granule with enzymes for fertilisation
Seminal fluid = 90% of ejaculate volume, alkaline to buffer vaginal acidity

  1. Volume >1.5ml
  2. Concentration 15 x 10^6/ml
  3. Progressive motility 32%
  4. Motility 40%
  5. Normal forms = 4%
271
Q

Male causes of subfertility - 4 categories

A

Semen abnormality - testicular cancer, drugs (alcohol), varicocoele
Azoospermia:
- pretesticular - hypogonadotrophic hypogonadism, kalman’s syndrome, anabolic steriods
- non obstructive - cryptorchidism, kleinefelters, chemo
- obstructive - vasectomy, chlamydia, gonorrhoea
Immunological - idiopathic, infective
Coital dysfunction:
- ED (b blockers, antidepressants)
- phimosis, hypospadias, disability
- ejactulatory failure (MS)

272
Q

Examination, tests and treatment for subfertilty in men

A

Exam: SSC, gynaecomastia, testicular volume (15-35ml = normal), rectal exam for prostatitis

Inv:

  • Plasma FSH in testicular failure
  • Testosterone and LH if suspect androgen deficiency
  • Karyotype if suspect 47XXY
  • CF screen for absent vas def

Treat:

  • vitamins and lifestyle changes then check again in 3m
  • intracytoplasmic sperm injection - sperm from epididymis or testes
273
Q

Where is uterus felt at 16w, 20-24w and 36w and growth rate

A 
16w = halfway between pubic symphysis and umbilicus
20-24w = umbilicus
36w = ribs
16-26w = SFH = weeks 
26-36cm = SFH +-2
>36w = SFH +-3
274
Q

Reasons for discrepancy between fundal height and dates - 6

A 
Inaccurate menstural history 
Fibroid or adnexal mass
Multiple pregnancy
Polyhydramnios
Hydatiform mole
Maternal size
275
Q

What to note on abdo inspection for pregnancy

A

Size, asymmetry
Foetal movements

Linea nigra
Striae gravidarum - purple new, silver old
C section or lap scars

276
Q

Abdo palpation in pregnancy and when difficult

A
  1. Palpate size if <20w, measure SFH from 20w
  2. Number of foetuses
  3. Foetal lie - longitudinal, oblique, transverse
    - presentation = occipitoposterior, occipitoanterior or occipitotransverse
  4. Presentation - cephalic, breach
  5. Head engagement - /5 with Pawlik’s grip between lower pole of uterus

Watch patient’s face for pain

Difficult if: polyhydramnios, maternal size, tense abdo muscles

277
Q

When and where to listen for foetal heart

A

Doppler US on anterior shoulder of foetus

From 12w

278
Q

When are foetal movements felt and inv if stop

A

From 18-20w, increase until 32w
Reduced >28w = CTG
- if RF for IUGR, still birth or still reduced movements= US for growth, liquor volume and umbilical artery Doppler

279
Q

Effect of hormones in pregnancy on woman

A

Progesterone reduce smooth muscle excitability, relaxing gut, ureters and uterus. Also raises temperature
Oestrogen increases breast and nipple growth and fluid retention
Thyroid growth from colloid production
Prolactin increases throughout pregnancy

280
Q

Genital changes in pregnant woman

A

Discharge is more towards end of pregnancy
Uterus hypertrophies until 20w then stretches
Cervix may develop ectropion

281
Q

Blood result changes in pregnancy

A

Plasma volume increases
Red cell volume increases - dilution anaemia
WCC, platelets, ESR, cholesterol, fibrinogen raised
Albumin, urea and creatinine fall

282
Q

CVS changes in pregnancy

A

CO increases from increase in SV and HR
Peripheral resistance falls from hormonal changes
Aorta-caval compression can reduce CO
BP (diastolic) decreases in 2nd trimester then back to normal by 3rd
Varicose veins
Vasodilation and hypotension = renin and angiotensin release for BP regulation

283
Q

Resp, GI, renal and skin changes in pregnancy

A

SOB, ventilation increases, maternal pCO2 lower to allow removal of foetal CO2
GI reduced motility so constipation and delayed emptying, and lower oesophageal sphincter relaxes = heart burn
GFR increases early and mass puts pressure on bladder = increased frequency
Skin pigmentation - linea nigra, spider naevi, palmar erythema, striae

284
Q

Pregnancy testing

A

From 9 days after conception

BHCG

285
Q

What should be checked antenatal booking visit

A

12w
Obestetric hx and fhx of twins, DM, BP, foetal abnormality
PMH
Mental health
VTE risk
Gestational diabetes risk and 75g OGTT:
- screen at 16+28w if previous GDM
- screen at 28w if BMI >30, first degree relative diabetic, previous baby >4.5kg, family origin from high diabetes prevalence
Risk of haemoglobinopathy, viruses, cardiac disease
Support, substance abuse, vitamins
Folic acid - from 4w before pregnancy until 13w. Give higher dose if AED, HIV, obesity, history of NTD

Examine:
Heart, lungs, BP, weight, abdo, ?cervical smear

Inv:
Hb, blood group, antibody screen
Syphilis, HbsAg, HIV
MSU
Consider Mantoux and CXR if TB endemic
Offer screening for chr/structural abnormalities

Advice: smoking, alcohol, diet, vitamins, antenatal classes, seatbelts, benefits, dentist

286
Q

When to have antenatal visits and what for

A

10-12w booking
Later - discuss screening results and treat anaemia or UTI
Each appointment = BP, proteinuria, fundal height
Visits at: 12, 16, 25, 28, 31, 34, 36, 38, 40, 41 (primip)
28 - Hb and Rh autoantibodies and Anti-D if needed
34 - labour and birth plan, pain relief
36 - breastfeeding, neonatal vit k and postnatal care, postnatal depression
40 - discuss post dates pregnancy management
41 - membrane sweep, offer induction by 42w

287
Q

When to test Rh and when to give anti-D

A

Test at booking visit
Give to everyone if TOP or miscarriage before this (12w), or if Rh-ve before procedures eg ECV, uterine procedures, intra uterine death. Bigger dose after 20w
If haemorrhage, test for concentration of foetal RBC in blood with Kleinhauer test, to see how much is needed
After birth, give to Rh-ve mum if cannot determine baby blood group within 72h

288
Q

Antenatal scans and what’s done at each

A 
11-14:
Dating
- 1st trimester, use crown rump length
- after 14w, biparietal best (until 34w) 
- head circumference
- then abdo circumference, femur length
If first present in 3rd trimester, do 2 scans 2w apart to estimate gestation
Umbilical artery Doppler if SGA

At 11-14w: nuchal translucency and combined test (fold measurement and blood test). NT = exclude miscarriage, heart failure, dates pregnancy.

18-22w: anomalies - cardiac, renal, neural tube
- skull shape and interior, spine, abdo, heart, arms and legs, face and lips
- fatal abnormalities are bilateral renal agenesis, some cardiac, some trisomy 18/13
Echo if high risk of cardiac abn eg hx, suspected abnormality, drugs, monochorionic twins

Invasive testing if combined test = high risk (<1:150):
CVS from 10w
Amniocentesis from 15w

Extras:
Early <11w if pain, hyperemesis, bleeding - exclude molar or twins
Uterine artery Doppler at 23w if high risk pre-eclampsia
If placenta over cervical os, rescan at 32w for placenta praevia

289
Q

Trisomy tests

A

11-14w: Combined test

  • NT
  • PAPP-A
  • hCG
  • maternal age

15-20w: Quadruple test

  • dating scan
  • AFP
  • unconjugated oestradiol
  • inhibit-A
  • bhCG
  • maternal age

Integrated:

  • NT
  • PAPP-A
  • quadruple test

AFP = released from liver. Increased in abnormalities - exomphalos, nephrosis, open neural tube defect, Turner’s syndrome

PAPP-A = released by placenta. Low = pre-eclampsia, IUGR, trisomy 18/21

Chorionic villus sampling - 10-13w. Karyotyping in 2d, full analysis in 3.

  • CI = dichorionic twins
  • ADR = BBV, miscarriage

Amniocentesis - >16w. Can detect CMV. Less risk of miscarriage than CVS

Cell free foetal DNA - non-invasive prenatal testing, cells from 1st trimester. For specific purposes eg Rh-ve.
- fewer cells available if dichorionic, obese, <10w

290
Q

RF for hyperemesis gravidarum

A

Molar pregnancy
Multiple pregnancy
Previous hyperemesis gravidarum

291
Q

Presentation of hyperemesis gravidarum and tests

A 
Dehydration, hypovolaemia, hypotension 
Cannot eat, malnutrition, polyneuritis
Hyponatraemia
Hyperthyroid
Mallory-Weiss tear, liver, renal failure

Urine dip for ketones and UTI (MSU)
FBC - raised haematocrit
U&E - hypokalaemia, hyponatraemia
Abn transaminases and low albumin

US for multiple pregancy and mole

292
Q

treat HG

A

Oral antiemetic - cyclizine, metaclopramide PO/IV/IM
Admit and rehydration if not better - NaCl and K
Prednisolone if intractable
Thiamine and folic acid to prevent Wernicke’s encephalopathy
Enoxiparin and stockings if VTE risk

293
Q

Risks of hypertension in pregnancy and what might be causing it

A

Pre-eclampsia
IUGR
Placental abruption

Exclude: Conn’s, Cushing’ s, coarctation of aorta, renal artery stenosis, renal disease, phaeochromocytoma

294
Q

Manage chronic high bp throughout pregancy

A

Prenatal: change ACEi/ARB to labetalol or methyldopa

Antenatal: keep bp <150/90 (140 if end organ damage), keeping diastolic >80. >160/110 = admit

  • aspirin 75mg OD from day of conception to birth
  • US /4w from 28w for growth restriction, amniotic fluid volume, umbilical artery Doppler. Abn activity = CTG

Intrapartum: monitor /h if <159/109, continuously if >160/100

  • operative delivery if intractable
  • no ergometrine as will cause severe htn

Postpartum: day 1, 2, 3-5 and 2w. Change methyldopa (postnatal depression). Likely to fall then increase by day 5

295
Q

Manage pregnancy induced htn

A

Usually 2nd half, >140/90, no proteinuria or signs of preeclampsia
Increased risk of pre-eclampsia
Mild 140/90-149/99 = monitor bp and urine (PCR) weekly. US/4w
150/100-159/109 = labetolol and monitor twice a week
>160/110 = admit, monitor bp 4x/d, urine daily, FBC/UE/LFT/bilirubin at presentation and weekly

Deliver at 37w
Continue antihypertensives during labour and monitor hourly or continuously if >160/110

296
Q

What is pre-eclampsia, what can it cause

A

Htn and proteinuria
Failure of trophoblastic invasion of spiral arteries so stay vasoactive - BP increases to compensate.
Also affects renal, liver and coagulation
After 20w, resolves 6w after birth

Causes:

  • fatal - cerebral haemrrrhage, multi-organ failure, ARDS, iatrogenic prematurity
  • liver involvement = DIC
  • micro-aneurysms if >180/140 = DIC
  • renal failure
  • HELLP with placental infarcts
  • eclampsia
  • sudden oedema
  • iugr
  • increased peripheral resistance, decreased plasma volume
297
Q

Risk factors for pre-eclampsia

A

High:

  • previous severe or early onset pre-eclampsia, chronic htn/htn of pregnancy
  • CKD, DM
  • AI (SLE-antiphospholipid)

Mod:

  • fhx of pre-eclampsia
  • multiple pregnancy
  • 1st preg >40yo or >10y gap
  • BMI >=30
  • low PAPP-A

If 1 high or 2 mod, give aspirin from 12w

298
Q

Presentation of pre-eclampsia and inv

A 
Asymptomatic
Headache, flashing lights, swollen hands/face
RUQ/epigastric pain
Nausea, vomiting 
Fits

Exam:
RUQ tenderness
Clonus, brisk reflexes
IUGR, abruption, still birth

Inv:
PCR of urine
Thrombocytopoenia, increased clotting time
Transaminases raised
Urate and creatinine high
Anaemia if haemolysis - and raised LDH
Oligohydramnios, foetal growth restriction, notching of uterine arteries, abn umbilical arteries on Doppler

299
Q

Manage pre-eclampsia

A

Mild - BP/4h, FBC/UE/LFT 2x/w, growth scans every 2w

Moderate - same but bloods 3x/w, CTG 2x/d

Severe (>160/110 or sx or evidence of end organ damage) - contact obstetrics, anaesthetics, midwife.

  • nifedipine PO - IV labetolol - magnesium sulphate prophylaxis
  • catheter, maintain fluid balance
  • steroids
  • deliver if >34w
  • if <34w, deliver within 48h under senior advice
300
Q

What is eclampsia and management

A

Pre-eclampsia and tonic clonic seizure. Pre, intra or post-partum

IV magnesium sulphate - 4g IV / 5-10mins then 1g/h for 24h, and future 2g boluses in seizures
- monitor for low rr, loss of reflexes or urine output - may need Calcium Gluconate if toxic effects
Catheterise, fluid restrict (unless haemorrhage)
Diazepam for repeated seizures
Monitor foetal hr with CTG
Deliver once stable - c section for speed
- oxytocin for 3rd stage

301
Q

What is HELLP syndrome

A

Haemolysis
Elevated liver enzymes (first to present)
Low platelets
= RUQ pain, nv, dark urine
No regional anaesthesia if platelets <80. Transfuse if <50 annd need surgery

302
Q

RF for preterm labour

A 
Previous preterm birth 
Multiple pregnancy
Uterine abnormalities
Medial conditions
Previous cervical surgery eg LLETZ
Pre-eclampsia
IUGR
303
Q

Preterm rupture of membranes management

A

Admit for 48h, 80% will deliver
If don’t, discharge, the weekly follow up with FBC and CRP
Report change in discharge (offensive smell) or reduced movements
Avoid sex
Give steroids and erythromycin
Induction of labour >34w

Deliver immediately if evidence of chorioamnionitis - temp, high vaginal swab, MSU, tender uterus, maternal or foetal tachycardia
Or bleeding, foetal compromise or active labour

304
Q

Manage preterm labour

A

50% contractions will stop spontaneously
Treat cause eg glomerulonephritis
Can use nifedipine tocolytic but minimal evidence

FBC, CRP, MSU, HVS
Speculum for PROM. If not ruptured, assess dilation. Take foetal fibronectin (predictive of preterm labour. Shouldn’t’ be in discharge from 22-36w)

Give abx IV if in labour

305
Q

Contraindications for tocolytics and advantages

A

Nifedipine. Reduces RDS and ITU admission

CI: chorioamnionitis, foetal death, condition requirement immediate delivery
- relative = pre eclampsia, praevia, abrupation, cervix >4cm

306
Q

When to give steroids to pregnant mother - 4 - and what monitoring

A
  • Risk of delivery <35w, or <36w if iugr
  • ?35-36w if pre-eclampsia so expedited delivery
  • ?20-24w
  • <39w if elective c section

2nd dose if 1st <26w and new indication arises
Monitor glucose if diabetic mother

307
Q

Delivery of premature babies

A

<28w - deliver at 26 degrees, don’t dry, put into plastic bag, place under heat, don’t cut cord for 3m, hold 20cm below introitus to increase haematocrit and reduces oxygen requirements and IVH but increases phototherapy need

308
Q

Definition of onset of labour

A

Contractions become regular and cervical effacement and dilatation become progressive
1 - onset of contractions
2 - cervical effacement and dilatation
3 - rupture of membranes
4 - descent of presenting part through birth canal

309
Q

Stages of labour

A

First - latent = irregular painful contractions, cervix effacing and dilates up to 4cm. Established = regular contractions from 4-10cm (0.5cm/h).
Takes 8-18h for primip, 5-12h for nullip
Monitor:
- foetal hr /15m
- contractions /30m - should be 3-4/10m, 1m each
- pulse /h
- assess dilatation and position of head /4h
- urine for ketones/protein /4h
- bp and temp /4h

Second

  • passive (if epidural, to reduce chance of instrumental delivery). Complete dilatation but no pushing.
  • active - pushing with abdo muscles and Valhalla manoeuvre. Use oxytocin if plateau. Should deliver within 3h of active phase starting
  • contractions /30m
  • pulse and bp /h
  • temp /4h

Third - placental delivery (1h), uterus contracts to <24w. Signs = lengthening of cord, rush of blood, uterus rises.
Can give ergometrine and oxytocin (syntometrin) once ant shoulder delivered - decreases PPH, need for transfusion and postnatal anaemia
- can cause MI, dont use in htn, pre eclampsia, liver or renal disease
- SE nv, headache

310
Q

Sequence of passage of baby

A
  1. Engage and decent in occipitotransverse
  2. Internal rotation to occipitoanterior at level of ischial spines
  3. Crowning - extend head, extending peritoneum until delivered
  4. Realign head with spine
  5. External rotation of shoulders
  6. Anterior shoulder
  7. Posterior shoulder
311
Q

When to induce labour

A

Uteroplacental insufficiency, iugr, oligo/anhydramnios, intrauterine foetal death
Htn/pre-eclampsia, diabetes, rhesus disease, abruption
Prolonged prenancy, PROM >37w
Bishops score 4-5

312
Q

What is in Bishops score and what is it for

A

Check before and durin induction. = cervix: Position, consistency, effacement, dilation, station
>9 likely to begin spontaneously
>7 can artificial rupture membranes
<5 will need induction
<4 induction unlikely to be useful. If notripened = long labour, foetal distress, c section

313
Q

CI to induction

A 
Placenta praevia
Vasa praevia
transverse
Cord prolapse
Previous classical section 
Active primary genital herpes

Relative CI: breech,2previous sections, triplets

314
Q

Methods of induction of labour

A

Membrane sweep - separate decidua from chorionic membrane to encourage pg release and start labour. Can titrate until 4 contractions /10m

Pg gel or tablet or pessary to constrict sm and ripen cervix. Monitor on CTG before and for 30m after. SE- nv, bronchospasm, maternal pyrexia

Amniotic hook - artificial rupture of membranes and encourage pg release and labour onset. Only once cervix ripened. Can give with oxytocin to increase strength and frequency

Oxytocin - increase cervical pg, titrate up . Continuous CTG

315
Q

Complications of induction

A 
Failure
Uterine hyperstimulation - can counteract with tocolytics terbutaline
Cord prolapse
Infection 
Pain
Rupture uterus
Increased rate of intervention
316
Q

When to monitor foetus during labour and 2 types

A

Monitoring I uncomplicated pregnancy: intermittent auscultation - for 60s
/15m in 1st stage and /5m in 2nd stage

CTG or foetal electrode scalp monitoring

317
Q

Indications for CTG

Features of CTG and causes of each

A

Records hr and uterine activity
Foetal: iugr, prem, oligohydramnios, twins, breech
Maternal: pre-eclampsia, diabetes, antiparticle haemorrhage, previous csection
Intrapartum: bleeding, oxytocin, econium staining, epidural

Baseline rate = FHR mean.
<110 = hypoxia
>160 = foetal distress, maternal tachycardia

Baseline variability excluding accelerations and decelerations - 5-25
<5 = hypoxia, CNS/cardiac malformations, drugs (GA, methydopa), severe prematurity

Accelerations = 15bpm for 15s +
Decelerations = 15bpm for 15s +
- variable
- early decelerations = peak coincides with peak of contraction
- late = peak 15s after peak of contraction = acidosis

318
Q

Indications for foetal scalp electrode monitoring

A

When membranes ruptured, cervix 2-3cm dilated and other monitoring unsatisfactory

319
Q

Signs of foetal distress

A

Cannot calculate baseline heart rate
Hr <110 (hypoxia) or >160 (Distressor maternal pyrexia)
Variability <5bpm (cardiac/CNS malformation, extreme prem, hypoxia, drugs (GA, methydopa)
Late decelerations (>15bpm >15s after contraction peak) -acidosis

320
Q

Who should be treated with VTE prophylaxis in pregnancy and how long for?

A

Give LMWH
High risk - 1 of: unprovoked or oestrogen-proved VTE, thrombophilia (factor 5 Leiden, protein c/s def), antithrombin 3 deficiency
Moderate risk - consider if 1 of: thrombophilia but no VTE, single provoked VTE, medical comorbidities (CVS or resp disease, SLE, sickle cell, nephrotic), PWID
If 3 of: obese, BMI >35, smoker, immobile, multiple parity, multiple pregnancy, pre-eclampsia, varicose veins

Intrapartum: instrumental, PPH or transfusion

Give for 7d after c section or 6w after vaginal delivery
Start asap, as long as >4h since epidural and no more PPH

321
Q

Inv PE/DVT in pregnancy and treat

A

PE - ABG, ECG, CXR - if normal = duplex us of deep veins, if DVT assume PE. If normal = VQ mismatch
DVT - duplex US - if normal, give LMWH and repeat in a week

Massive PE = PCI, thrombolysis, embolectomy, UFH, aim for INR1.5-2.5
LMWH for 6m and 6w postpartum, including throughout next preg and 6w postpartum

Stop LMWH during labour. Don’t give regional anaesthesia for 12h post prophylactic dose and 24h post therapeutic dose
Don’t give LMWH until 4h after epidural catheter removed
Don’t remove catheter until 12h after dose

322
Q

Risks of measles in pregnancy and management

A

Risk of preterm delivery and foetal loss

Treat with immunoglobulin if rash appears 6d before or after delivery, to prevent subacute sclerosing panencephalitis

323
Q

MMR vaccine and pregnancy

A

AVoid pregnancy for >4w after MMR as live vaccine

324
Q

Rubella complications in pregnancy

A

Worse <16w gestation:

  • miscarriage and stillbirth
  • sensorineural loss, cataracts
  • cardiac lesions
  • jaundice, hepatosplenomegaly
  • purpura, thrombocytopoenia
  • cerebral palsy, microcephaly

Take antibody levels 10d apart and check for antibody 4-5w from date of contact

325
Q

CMV sx and complications in pregnancy

A

Maternal: mild, rash, lymphadenopathy, raised temperature
Foetal outcome worse if presents with sx at birth
Early:
- IUGR, microcephaly
- thrombocytopoenia, jaundice, hepatosplenomegaly
Late:
- motor and cognitive impairment
- sensorineural loss

326
Q

How to avoid toxoplasmosis

A

Avoid raw meat
Wear gloves if gardening or cat urine
Avoid sheep during lambing

327
Q

Compicatiotns of parvovirus in pregancy

A

Maternal haemolysis if not immune

Foetal suppressed erythropoiesis and cardiotoxicitty - cardiac failure and hydrops fatalis

328
Q

Intrauterine syphilis sx and treatment

A

Neonatal - rhinitis, rash, jaundice, nephrosis, keratitis

Give benzylpenicillin to mum and baby

329
Q

Listeria complications in pregnacny

A

Recurrent foetal loss
Premature labour
Stillbirth
Resp distress from pneumonia, conjunctivitis

330
Q

Hep b transmission and results in pregnancy

Screening and

A

Very high level transmitted, mostly at birth but some transplacental
Screen all mothers, Give immunoglobulin and vaccinate babies of carriers and infected mothers at birth
Check immunisation status at 12-15m old. Protected if anti-HBs present and HBsAg neg
Will cause chronic infection, hepatocellular cancer and cirrhosis

331
Q

hep e in pregnancy

A

Maternal fulminant hepatic failure after delivery and coma, massive PPH annd death
30-50% of babies infected
No vaccine yet

332
Q

Manage hep c in pregnancy

A

Elective c section only if HIV and not on HAART as well

Check for HCV RNA at 2-3m and again at 12m. Refer if positive

333
Q

Herpes simplex in pregnancy

A

Secondary inf recurrence not normally problem as maternal antibodies
If develop primary (first ever) genital herpes during pregnancy, refer to GUM to screen for other inf to ensure primary inf

3rd trimester = oral acyclovir and encourage CS if within 6w of delivery date

If labour and active lesions, give maternal IVI and newborn high dose acyclovir, and do baby PCR at birth
Avoid foetal blood sampling, scalp electrode and instrumental delivery

If baby infected, presents at 5-21d with vesicles/pustular rash on red base on traumatised area +- periocular/conjunctival

Can cause blindness, epilepsy, reduced IQ, jaundice, RDS, DIC, death

334
Q

Manage varicella zoster in pregnancy

A

Oral acyclovir to mum, varicella immune Ig at birth to baby and monitor for 28d, give azyclovir if chicken pox

335
Q

Causes of ophthalmia neonatorum

A

Chlamydia, herpes, staph, strep, pneumonococci, E. coli

336
Q

Treat chlamydia and gonorroehoa in newbord

A

Chlamydia - erythromycin

Gonorrhoea - cefotaxime and chloramphenicol eye drops, and benzylpenicillin

337
Q

Risks of GBS

Who to treat for GBS and what is it

A

Severe early onset infection - pneumonia, meningitis, septicaemia - 20% death
Treat if:
- pos high vaginal swab or urine at any point in pregnancy
- previous baby with GBS - 50% of infection this time, have prophylactic abx or test later on then have abx
- intrapartum fever
- <37w
- prolonged rupture of membranes for >18h

Give benzylpenicillin IV

338
Q

What is GBS and diagnoses

A

Strep agalactiae
Common bowel/vagina commensal
Swab loser vaginal annd perianal

339
Q

HIV risks in pregna

A

Transmission during labour or breast feeding
Spontaneous abortion
Postpartum endometritis

340
Q

Factors that increase risk of HIV complications in pregnancy

A 
Primary infection during pregnancy
Low CD4
HIV core antigens
Other STDs
Chorioamnionitis
Rupture of membranes
Premature
Invasive procedures
Vaginal delivery
341
Q

Management of HIV in pregnancy

A

Screen at 12w and 28w
HAART, or ART if advanced, and start after 1st trimester
Elective CS - can have vaginal delivery if CD4 is high and viral load low
Discourage breast feeding
Consider confidentiality, housing, other children testing

342
Q

TORCH screen

A 
Toxoplasma
Rubella
CMV
Herpes, HIV
Syphilis
[ToRCHHS]
343
Q

Pain relief in labour

A

Non-pharm: breathing, partner, water, TENS (short)

Pharm:
NO
- CI = pneumothorax
- SI = NV, fainting
Narcotic - pethidine and cyclizine
- SI to mum = drowsy, nv
- SI to baby = temporary resp distress, drowsy
Pudendal nerve block - L2-4 - lidocaine
Lidocaine for repairing perineum

Regional:
Spinal 2h CS. No sensorimotor function
- ADR: profound hypotension
Epidural anywhere: 25-30m onset, large amount of fluid but leave in cannula so can increase /30m. Sensation loss but function maintained. Monitor BP/5m for 20m
- SE: failure to place, patchy, hypotension, accidentally puncture dura, headache if puncture dura

344
Q

What layers does spinal and epidural go through

A

Spinal - through dura into subdural space = CSF

Epidural - just through lig flavum into epidural space

345
Q

Indications for episiotomy and where

Repair and ADR

A

Foetal distress
Complicated labour - shoulder dystocia, instrumental
Perineum scarred from poor previous repair or FGM

Mediolateral

Repair: lidocaine, suture vaginal wall, perineal muscle then perineum wall
- check in rectum for no sutures

Risks: pain, infection, prolapse

346
Q

Instrumental delivery - when, general risks and requirements

A

If:

  • malposition of foetus
  • maternal tiring
  • abnormal CTG

Risks:

  • genital tract trauma
  • infection or haemorrhage

Requirements:

  • adequate analgesia
  • engagement 0/5 or 1/5
  • head at or past ischial spines
  • fullly dilated cervix
347
Q

Ventouse indications and ADR

A 
>34w
Requires mother effort and contractions
Can rotate baby
Better for mother
Less successful that forceps

ADR: scalp oedema, cephalohaematoma (between periosteum and skull)

348
Q

Forcesps indications and ADR

A 
<34w
Bladder must be empty
Mum unable to push
Face forward
Baby has bleeding disorder 
Slow down head delivery with breech

ADR:

  • bruising
  • nerve palsy
  • skull depression or fracture
  • genital damage
349
Q

Indications for cs

A

Breech or malpresentation
Multiple pregnancy
Foetal compromise - abn CTG, umbilical artery Doppler or scalp sample
Transmissible infection incl herpes
Maternal request
Previous 3/4th degree tear, previous shoulder dysocia
Maternal diabetes, maternal conditions

350
Q

Categories of CS

A

1 - immediate threat to life, within 30m
2 - some foetal/maternal compromise but not immediately life threatening, within 75m
3 - needs early delivery but no compromise
4 - elective

351
Q

Types of CS

A

Lower uterine incision and blunt dissection - horizontal line above pubic symphysis
Classical - vertical line above umbilicus. If 1) very premature, 2) transverse with membrane rupture, 3) fibroids

352
Q

VBAC advantages, risks, indications for better outcome and CI

A 
3/4 women can have VBAC
Less time in hospital
Early skin to skin
Reduced foetal distress
No operative complications
Risks:
May need instruments
Uterine rupture - 1:200
1/4 will need emergency CS - worse outcomes than elective CS, but 1/5 general pop need emergency CS anyway 
More likely to need transfusion 
May tear

Better outcome if:
Previous labour
BMI<30
<41w and spontaneous labour

CI:
3+ CS
Previous uterine rupture
Classical CS
Other indications for CS
353
Q

Causes of PROM -5

A 
Unknown
Infection 
Polyhydramnios
Malpresentation
Multiple prenancy
354
Q

Sx of PROM

A 
Gush of fluid
Look for evidence of fluid on speculum
Nitrazine test:  swab fluid - amniotic pH 7.1-7.3 instead of vaginal 4.5-6
Fibronectin and AFP
Temp, pulse, BP
CTG
355
Q

Signs of chorioamnionitis in PROM and complications of PROM

A 
Foetus or maternal tachy
Raised temp
Raised CRP or leukocytes
Pyrexia
Irritable/tender uterus

Risks:

  • maternal endometritis postpartum or intra-amniotic infection
  • need for cs
  • premature
356
Q

Degrees of tear in labour and management

A

First - perineum skin only. Heals without stitches in a few days, can sting on urination
Second - includes perineum muscle and may extend into vagina. Will need stitches, heal in a few weeks
Third - extends to anal sphincter. Needs repair with anaesthesia, may cause faecal incontinence and painful sex
Fourth - extends to rectal mucosa, likely to need more specialised repair. Cause faecal incontinence and painful sex

Management:
Ice, warm water, sit on cushion
Laxatives, numbing spray
Tell doctor if persisting, severe or getting worse

357
Q

Diagnosis of transverse lie

A 
Wide abdomen
Low fundus
Foetal pole not felt in pelvis
Hr more inferior 
Foetal head palpable to one side
DO NOT do vaginal exam until excluded praevia
358
Q

Causes of transverse/breech lie and complications and management

A 
Premature
Multiparity 
Praevia
Uterine abnormalities - fibroid
Foetal abnormality - hypotonia, hydrocephalus

Cord prolapse = spontaneous rupture of membranes
Prematurity
Birth trauma - soft tissue injury, IVH

ECV if membranes intact, not advancing labour and no foetal distress - at 37w
- give medication to relax uterus then turn
- anti-D
- 50% effective, may return
- ADR: pain, abruption, PROM
- CI: antipartum haemorrhage, pelvic mass, praevia
Transverse may turn in uterine contractions in labour
Elective CS

359
Q

Cause of face/brow presentation and management

A

Neck tumour or anencephaly
Face: face can turn oedematous on delivery
Can try to turn with forceps
Likely to need CS

Brow: membranes rupture early, high risk of cord prolapse. Too wide for canal = CS

360
Q

Retained placenta - causes and management

A

Delayed 3rd stage - >30m to deliver

  1. Placenta adherens - myometrium doesn’t contract behind it
  2. Trapped placenta - trapped behind closed cervix
  3. Partial accretion - still embedded

If had rush of blood and lengthening of cord, rub uterus up and pull and twist cord
IV oxytocin if bleeding
May need surgical removal

Risks: infection, PPH

361
Q

2 types of shoulder dystocia and risk factors

A

Anterior - against pubic symphysis = most
Posterior - against sacral promontory

RF:
Pre-partum:
- Macrosomia >4.5kg
- DM = macrosomia 
- BMI >30
- previous shoulder dystocia
- induced
Intrapartum
- prolonged 1st or 2nd stage
- secondary arrest
- oxytocin
- instrumental vaginal delivery
362
Q

Features of shoulder dystocia and dangers

A

Failure of restitution - stays occipito-anterior
Head/chin stuck
‘Turtle neck’ - withdraws

Baby - death, hypoxic injury, brachial plexus injury, humerus/clavicle fracture
Mum - 3/4th degree tears

363
Q

Manage shoulder dystocia

A
  1. Help
  2. Stop pushing
  3. ?episiotomy

McRobert’s procedure with suprapubic pressure
Posterior arm or internal rotation to oblique

Postpartum:
Manage 3rd stage to minimise PPH
Paediatrics review for fractures, nerve injury or hypoxia
Check PR for tear
Physio review for pelvic floor weakness, nerve injury, MSK pain

364
Q

Causes of primary postpartum haemorrhage and management and prevention

A

500-1000ml - minor
>1000 - major
In 1st 24h since birth
Prevent: oxytocin IM if vaginal, IV if cs

Tone - RF: multiple pregancy, polyhydramnios, previous pregnancies, previous PPH, praevia, abruption, >35BMI, Asian, >40yo, prolonged labour

  • bimanual massage (ant adnexa and abdoment) to increase uterine contraction
  • oxytocin IV, syntometrine IM, ergometrine IV/IM, misoprostol PR, carboprost
  • EUA, balloon tamponade, Lynch suture around uterus, uterine or int iliac artery ligation, hysterectomy

Trauma - RF: instrumental delivery, epidisiotomy
- repair

Tissue - retained placenta = uterus can’t contract

  • RF = age, parity, uterine surgery, premature, induction
  • examine placenta after birth
  • manual removal, oxytocin

Thrombin

  • thrombophilia, vwf, ITP, DIC
  • vasc - pre-eclampsia, hypertension

2222 massive haemorrhage
Rhneg O blood
RBC, FFP, hartmann’s

365
Q

Causes of secondary postpartum haemorrhage

A

24h-6w after birth
1) retained placenta - high uterus
— placenta adherens - myometrium not contracted behind
— partial accreta - still attached
— trapped placenta behind cervical os
2) endometritis - give ampicillin, metronidazole (and gentamicin if septic)
- foul selling lochia, rigor, fever, tender uterus
3) thromboplastic
4) abnormal involution of placenta - inadequate closure and slough of spiral arteries

Sx - spotting, bleeding
Inv - FBC, UE, CRP, coag, G&S, culture, US pelvis

Treat - oxytocin, ergometrine, surgery

366
Q

5 causes of APH and inv

A

FBC, UE, LFT, CRP, coag, G&S, cross match 6u, TVUS, CTG - sinusoidal = maternofoetal haemorrhage

  • mild bleed - admit, do inv, high risk serial scans then CS at 37-38w
  • big bleed - raise legs, fluids, blood transfusion, CS, maintain UO

Placenta praevia - placenta in lower segment of uterus, covering os
- major or minor
- normally diagnosed at 20w scan. Scan again at 32w if major, 36w if minor
— can vaginal deliver if mild or >2cm from os, otherwise CS
- DO NOT do vaginal exam
- soft and non tender uterus, painless bleed, can be heavy
- assoc with smoking, iugr, polyhydramnios, maternal age, fibroids, D&C
- if foetal head engaged = not praevia

Placenta abruption - placenta partially/completely separates from uterus before labour

  • painful, woody uterus, with contractions
  • foetal hr absent or distressed, normal lie
  • concealed or revealed, shock out of keeping with visible blood
  • DIC from thromboplastin release
  • assoc with pre-eclampsia and htn
  • CS if signs of distress

Vasa praevia - foetal vessels near/over os and can rupture
Genital tract trauma
Infection

367
Q

Types of placenta

A

Accreta: abnormal adherence of placenta to uterus, also increta = myometrium, percreta = serosa

Membranacea - thin placenta all round baby

Succenturia - one lobe separate

Velematous - umbilical vessels in membrane before placental insertion

Vasa praevia

368
Q

Causes of preterm labour and drug management

A 
Infection
Ischaemia eg abruption
Cervical incompetence
Multiple pregnancy or polyhydramnios 
Iatrogenic eg for IUGR

Check foetal lie, presentation and hr

Abx if infection
Steroids - 2 IM inj 12h apart
Consider tocolytics for a few days: oxytocin receptor antagonist or nifedipine

369
Q

RF for uterine rupture, sx and management

A

RF:

  • previous CS, esp classical, or uterine surgery (endometritis, neonatal death, transfusion, rupture more likely with VBAC)
  • obstructed labour in multiparity esp with oxytocin
  • breech
  • internal version
  • high use of forceps
  • polyhydramnios

Sx:

  • loads or minimal blood - shock - tachycardia, abdo very/mild pain
  • cessation of contractions
  • loss of presenting part in pelvis
  • foetal distress

Manage: O2, blood transfusion, CS and investigation, may need hysterectomy if cervix or vagina involved
Cefuroxime and metronidazole

370
Q

Risks of prolonged pregnancy and management

A

Mum
- instrumental delivery, genital tract trauma
- PPH
- obstructed
Baby
- meconium aspiration
- macrosomia - shoulder dystocia, birth injury, prolonged labour
- placental insufficiency = acidosis, encephalopathy, seizures
- IUGR
- stillbirth

Manage: membrane sweep at 41w, IOL at 42w

371
Q

Sx of obstetric cholestasis, risks and management

A 
3rd trimester
Pruritis esp at night and on trunk and limbs
Anorexia, malaise
Epigastric discomfort
Dark urine and steatthoroea

Inv: LFT 2-3x raised, bile acids, clotting screen, viral serology and AI screen, US

Risks: still birth, meconium aspiration, prem, vit K def for mum

Manage:

  • water soluble vit K
  • topical emollients
  • ursodeoxycholic acid
  • deliver at 37w if very high bile acids as increased risk of still birth
372
Q

Differentials of 1st seizure in pregnancy

A 
Vascular abn
Eclampsia
Encephalitis, meningitis 
SOL
Electrolyte disturbance
Epilepsy
373
Q

Risks of AED in pregnancy

A

All: teratogenicity, neonatal withdrawal, baby vit K def, behavioural/developmental difficulty

Phenytoin: cardiac and cleft lip/palate defect

Carbamazepine: also neutral tube defects

Valproate: also GUM defect (hypospadias)

374
Q

Manage epilepsy in pregnancy

A

If already pregnant, no point changing drug as already had teratogenic effect

Before pregnancy: lamotrigine, minimal dose, folic acid 5mg OD 12w before pregnancy
Vit K 4w before birth

Advice: no bathing or sleep deprivation, once born don’t stand and hold baby
Detailed foetal anomaly scan, consider echo, AFP

Intrapartum: vaginal delivery, benzos, neonatal vit K, breastfeeding

375
Q

Manage diabetes in pregnancy and risks

A

Stop all drugs except metformin, start insulin
Lose weight if BMI>27
Tight glycaemic control - HBA1c <6.1%
Monitor retinopathy as can worsen
Folic acid from before conceptiotn to 12w
Detailed anomaly scan at 20w

Intrapartum: insulin sliding scale for 24h after giving steroids, and during birth
Insulin - will need to double in pregnancy
Stop insulin at birth if not previously on it

Risk: infection, macrosomia, CS, hypoglycaemia unawareness, pre-eclampsia, malformation, IUGR, neonatal reflex hypoglycaemia

376
Q

Gestational diabetes RF and management

A

OGTT >=7.8 or fasting >=5.6mmol/l - check at 24-28w

RF:
Previous GDM or baby >4.5kg
BMI >30
1st degree relative diabetes
Family origin

Diet and exercise (30m/d) for 2w then metformin, then insulin
4w scans from 28w
BM 4x/d
Aim for 7.8 1h, 6.4 2h, 5.3 fasting
Check BM 6w postpartum, 50% will go on to develop DM2 - advice

377
Q

Complications of Grave’s in pregnancy and treatment

A

Foetal thyrotoxicosis - foetal tachycardia, prem delivery

Carbimazole
Propylthiouracil - less crosses placenta and into breast milk
Partial thyroidectomy in 2nd trimester
Check neonatal TFT

378
Q

Postnatal depression sx, RF and managemen

A

Anxiety, tiredness, irritability, lack of bonding
2-3m, resolve by 6-12m

RF: previous psych illness, sleep deprivation, stress including around birth
Edinburgh postnatal depression score

Treat: CBT, SSRI, ECT/admission

379
Q

Puerperual psychosis RF , sx and treatment

A

10-14d after birth
Sx - mania, depression, confusion, paranoia, hallucinations, delusions
RF: previous psych illness, primip
Treat: lithium, hospitalisation, ECT

380
Q

Gestational trophoblastic disease, types, sx and treatment

A

1) Hydatiform mole - unfertilised ovum implants into uterus and forms mass, benign
2) Choriocarinoma - trophoblastic cells tumour, can be complete (no foetal tissue) or partial (some foetal tissue but usually not viable). Can develop when mole doesn’t regress after surgery

Sx - sign features of pregnancy early, from v v high bHCG = vomiting, uterus large for dates
USS = bunch of grapes echogenic

Treat - surgery to remove, and ensure bHCG levels falling in following weeks - fortnightly, then monthly urine for HCG to see if reactivation to choriocarcinoma
Choriocarcinoma = chemotherapy

381
Q

Rf for multiple preganncy

A

Age
Family history of dichorionic twins
Ethnicity
IVF/assisted reproduction

382
Q

Complications during pregnancy of multiple pregnancy and manage during and at labour

A 
Polyhydramnios
1 sac = entanglement
1 placenta = twin to twin transfusion 
Worse hyperemesis
Gestational diabetes
Pre-eclampsia 
Placena praevia/accreta as bigger placenta
APH
PPH

Foetus: asphyxia (esp second twin), premature, malformation
Labour: malpresentation, vasa praevia, abruption, cord prolapse, cord entanglement, PPH

Plan to deliver at 37w for dichorionic, 36 for monochorionic and 35 for triplets. Most go into spontaneous labour before this
At delivery, have IV access, anaesthetist and 1 paediatrician for each baby

See on scan at 11-14w, scan monthly from 20w, every 2w if monochorionic
FBC monthly
Discordant growth >25% = refer to tertiary centre
Weekly visits from 30w
Tell mother what to do if spontaneous labour
Aspirin from 12w if other indications for pre-eclampsia

383
Q

RF for cord prolapse, sx and management

A

2nd twin, footling, transverse or unstable lie
Not engaged head
Premature, polyhydramnios

Sx: may see cord, or foetal brady/late deceleration

Manage: if before membrane rupture, CS immediately
Deliver with CS or forceps if fully dilated
Don’t touch cord as will spasm
Get help
1. Keep presenting part away from compressing cord - push head during contraction
2. Knees to chest to keep head lower than pelvis
3. Saline into bladder
4. Tocolysis

After birth, check cord pH and bicarb to exclude hypoxic injury

384
Q

Severely oedematous baby, 8 RFs and management

A 
Hydrops fetalis - oedematous with stiff oedematous lungs
RF:  
- pre-eclampsia
- diabetes
- infection - toxoplasmosis, syphilis, parvovirus
- thalassaemia
- isoimmunisaton
- anaemia = CCF = oedema
- twin to twin transfusion 
- hypoproteinaemia

At birth: get help and take cord blood for:

  • hb, mcv, blood group, Coombs
  • bilirubin, protein, LFT
  • infection screen
  • high pressure ventilation
  • vit K
  • correct anaemia
  • drain pleural effusion and ascites if impairing breathing
  • furosemide if CCF
  • fluid restriction
  • monitor glucose and treat
385
Q

Cause of hydrops fetalis in rhesus disease

A 
Anaemia = CCF = oedema
Anaemia = hypoproteinaemia = oedema
386
Q

Causes of oligohydramnios

A

<500ml at 32-36w

Renal abnormalities - agenesis, cystic dysplasia
Reduced flow to kidneys - chronic hypoxia causes blood to divert to other organs
- IUGR
- Placental insufficiency
Post-term
PROM

RF:
Foetal:
- chromosomal or congenital
- IUGR, post-term, foetal demise

Maternal:

  • pre eclampsia
  • diabetes
  • hypertension
  • hypoxia
  • dehydration

Placental:

  • twin-twin transfusion
  • abruption

Drugs - ACEi, indomethacin

387
Q

Diagnosing and manage oligohydramnios

A

Discrepancy in SFH measurements, foetus easily palpated
US - also check for placenta, IUGR and Doppler umbilical arteries
Speculum and nitrazine for ROM
Maternal causes including SLE

Pre-term: expectant management. Amniotic transfusion. If uropathy, can do vesico-amniotic shunt
At term: deliver, continuous hr monitoring during labour

Complications:

  • pulmonary hypoplasia
  • amniotic band syndrome
  • foetal compromise
  • infection if ROM
388
Q

Causes of polyhydramnios

A 
Reduced swallowing - oesophageal atresia
Increased urine output - anaemia causing increased CO, twin-twin transfusion receiver produces a lot of urine
Other defects - neural tube, CVS, renal
Chromosomal 
Hydrops fatalis
Maternal:  diabetes, multiple pregnancy
389
Q

Diagnose polyhydramnios and treat and complications

A

Rule out other causes eg choriocarcinoma or multiple pregnancy
Present: large for dates, SOB, PROM, cord prolapse
Measure on scan - amniotic fluid index
Check for renal/GI abnormalities
Maternal screen for infections, diabetes, antibodies (?hydrops), chromosomes

Expectant if mild, or deliver if foetal compromise
Aspirate amniotic fluid
Indomethecin to reduce perfusion to foetal kidneys

Independent factor for low birth weight and death
Cord prolapse, PROM, premature, malpresentation, PPH
Maternal UTI as increased pressure on bladder

Finals (13 decks)

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