Women's Health Flashcards
When should you take folic acid during pregnancy and why?
Before pregnancy ideally - up until 12 weeks pregnant
You cannot get enough of it through diet during pregnancy
Helps prevent risk of neural tube defects - e.g spina bifida, cleft palate
What is the normal dose of folic acid mothers should take when pregnant?
400micrograms daily
When would you take a higher dose of 5mg folic acid?
If you have a previous baby with neural tube defect
If you or your partner have a neural tube defect
If you are taking an antiepileptic medications
If you have diabetes, obesity or Crohn’s disease
When is the booking appointment and what is done there?
8-10 weeks pregnant
Full history taken and risk is assessed
When is the dating scan and what is done there?
12 weeks
Scan is able to date the pregnancy (give a due date)
Measurements are taken from the nuchal fold for downs test
When does anomaly screening happen and what is involved?
12 weeks
Test for Down’s syndrome
Triple test: nuchal translucency measurement (from sca) PAPP-A and beta HCG
If the screening for Down’s syndrome is deemed high risk then how can it be diagnosed?
Amniocentesis - 2% risk of miscarriage
Chorionic villus sampling - 1% risk of miscarriage
NIPT (non invasive prenatal blood test) - this is not on NHS currently but carries less risk of miscarriage
When does the anomaly scan happen?
18-20 weeks
When would a mother be offered the OGTT at 26 weeks?
If she is at risk for developing GDM: BMI >30 Ethnic origins - black African, Indian Family history of diabetes PCOS Previous macrosomia Previous GDM
What is a normal OGTT?
<5.1 fasting
<7.8 2 hour after glucose drink
When is anti D given?
To all Rhesus negative mothers
At 28 weeks (prophylactic dose)
At 34 weeks
48 hours after delivery
What is the role of oestrogen during pregnancy?
It increases the amount of oxytocin receptors within the uterus to prepare the body for delivery
It helps develop the breast tissue for feeding
What is the role of progesterone during pregnancy?
Acts as a smooth muscle relaxant
Maintains the uterus lining
Causes enlargement of the breast lobules - for milk to be secreted into
When does beta HCG peak during pregnancy?
At 8 weeks
What blood tests are offered prior to pregnancy?
FBC - check for anaemia
G&S - check blood group (looking for rhesus anti D)
Virus screen - Hep B, syphilis, HIV
When is the quadruple test used and what is it?
Testing for Down’s syndrome
If you are too late for the combined test (between 14-20 weeks)
Blood test - AFP, inhibin A, Oestriol, Beta HCG
What is the normal changes to BP during pregnancy?
BP normally drops
This is due to a drop in vascular resistance
What are the haematological changes during pregnancy?
Increase in plasma volume by 40%
Increase in RBC volume by 25%
This can lead to anaemia as there is a greater increase in plasma volume compared to the increase in RBC volume
Why do you get peripheral odema in pregnancy?
Due to an increase in plasma volume
Why is pregnancy known as a hypercoagubility state?
Due to an increase in clotting factors during pregnancy
This happens to prevent losing too much blood during labour and birth
However it increases the risk of blood clots during pregnancy
Which factors would make a women high risk during pregnancy?
Advanced maternal age >40 Low maternal age <20 Certain medical conditions Previous surgery IVF treatment Previous Caesarean section Previous problems in pregnancy - hypertension, grown restriction, GDM, fetal abnormalities
How is the symphysis fundal height measured?
Why is it measured?
Get women to empty bladder first - this can add 2-3cm to measurement
Measure from highest point of fundus to symphysis pubis
Plot on growth chart
What is good pre-pregnancy counselling?
Reduce BMI <30 Optimise any health conditions Take folic acid and vitamin D Exercise as normal Check for MMR Vaccine
What is the pre-pregnancy planning for women with diabetes?
Take 5mg folic acid OD
Switched to metformin or insulin (safe in pregnancy)
Aim for HbA1c <48
Screening for retinopathy and nephropathy (if not had in 6 months)
Check U&Es
When would a diabetic women be advised against pregnancy?
If HbA1c >86
What are the glucose targets for diabetic mothers during pregnancy?
Fasting <5.3
1 hour post meal <7.8
What extra care should be given to patients with diabetes during pregnancy?
Aspirin 75mg OD - started before 12 weeks (this reduces risk of pre-eclampsia)
Regular monitoring of glucose levels
Regular contact with midwife (Every 2 weeks)
Retinal and renal assessment at 1st appointment
Serial Scans every 4 weeks from 28 weeks (in uncomplicated diabetes)
What are the risks of diabetes on pregnancy?
Miscarriage PET Renal dysfunction Infection Congenital malformations Still Birth
Why does GDM occur during pregnancy?
Hormone production in pregnancy stimualtes the production of glucose (to ensure energy levels are high in pregnancy)
Hormones in pregnancy can also instigate insulin resistance - so glucose is unable to be taken up by cells (to ensure glucose is readily available for the baby)
However if this happens to excess then there is too much circulating glucose (GDM)
What is fetal macrosomia?
Why is it more common in diabetes or GDM?
Enlargement of the fetus >4.5kg
High glucose levels in fetus drives production of insulin. Insulin stimulates fat storage and organ growth
What is polyhydramnios and when is it more common?
Excess liquor around baby - occurs more in macrosomic babies
What is shoulder dystocia?
Where shoulders get stuck after head is delivered
More common in macrosomia babies
How is the timing of delivery planned for diabetic or GDM patients?
Offer women delivery between 37-40 weeks by LSCS or IOL
Offer women on insulin delivery by 38 weeks
Women with GDM delivery should be no later than 40+6
Women with macrosomia (>4.5kg) should have elective LSCS due to concerns regarding shoulder dystocia
Why should diabetic mothers breastfeed within 30 mins of labour?
When should fetal blood glucose be checked after birth?
Risk of fetal hypoglycaemia
Check fetal blood glucose every 2-4 hours after birth
When will women with GDM return to normal?
Straight away
All glucose reducing agents should be stopped immediately after delivery
Are women who have GDM more at risk of developing type II diabetes?
Yes
They should have a fasting glucose test 6-12 weeks after birth
How is diabetes controlled during pregnancy?
1st line - diet
2nd line - metformin
3rd line - insulin
What is the optimal timing of LSCS delivery in non diabetic patients and why?
> 39 weeks
Before this the fetus lungs are not fully developed
They are more at risk of acute respiratory distress syndrome (ADRS)
Why are steroids given to mothers who have early induction of labour?
For fetal lung maturity
What might be the affect of giving steroids to diabetic mothers?
How is this monitored
Can lead to hyperglycaemia - occurs 24-48 hours from administration
Slide and scale monitor for this period of time
What is the difference between pregnancy induced hypertension and PET?
Pregnancy induced hypertension - hypertension after 20 weeks without proteinuria
PET - hypertension after 20 weeks with proteinuria
How is PET diagnosed?
BP >140/90 on 2 occasions 4 hours apart
Proteinuria >300mg/24 hours or >30mg/mmol on PCR
What are the symptoms of PET?
Severe headache (due to oedema on brain)
Visual changes (Blurred vision / spots before eyes)
Oedema (Swelling in hands and face)
Epigastric pain
Vomiting
Hyperreflexia - this is more a specific sign
What is the pathophysiology of pre-eclampsia ?
It is a placental disease
An abnormal placenta leads to poor placental perfusion
This causes the placenta to release factors
These factors activate the vascular endothelium and cause dysfunction
This leads to hypertension
What is HELLP?
A severe form of pre-eclampsia whose features include:
Haemolysis
Elevated Liver enzymes
Low Platelets
How is pre-eclampsia managed?
Asprin 75mg - given from 12 weeks to anyone at risk
BP medications - labetalol, nifedipine and methyl dopa
Fluid restriction - to reduce pulmonary odema
Magnesium sulphate - seizure prevention
What are the risk factors for PET?
Nullparity (or first birth from different dad) Age >40 Pregnancy interval >10 years Family or personal history of PET Multiple pregnancies BMI >35 Vascular or kidney disease Smoking
When is labetalol contraindicated in pregnancy?
If the patient has asthma
When is FBC checked during pregnancy routinely?
Why?
Booking appt (8 weeks) 28 weeks
Look for anaemia
What is gestational thrombocytopenia?
Low platelet count in pregnancy
Up to pregnant women get this
There is no increase in bleeding risk unless platelets fall below 100
What is small for gestational age (SGA)?
Difference between SGA and FGR
When the fetus is born with a birth weight below the 10th centile. These babies will have a small growth curve throughout the pregnancy
Not all babies with SGA have FGR - 50-70% of babies are constitutionally small
What is FGR?
Fetal growth restriction
Failure of fetus to reach pre determined growth
These babies will start off with a normal growth curve and then plateau off
What is the difference between symmetrical FGR and asymmetrical FGR?
Symmetrical - where head and abdomen are equally small
(due to insult early in pregnancy - cogenital abnormalites, intrauterine infections, substance abuse)
Asymmetrical - where blood is directed to head/brain and heart, and abdominal fat stores are reduced (due to late insult in pregnancy - maternal smoking, hypertension)
What are the major risk factors for FGR?
Smoking (>11 a day) Maternal age >40 Diseases - renal, hypertension, diabetes Heavy PV bleeding Low PAPP-A Cocaine use Paternal or maternal SGA Antiphospholipid syndrome
What are the minor risk factors for FGR?
IVF pregnancy Nulloiparity BMI <20 or >25 Smoking (1-10 a day) Previous PET
Which patients are unsuitable for fundal growth height monitoring?
How do you assess these patients?
Patients with fibroids
BMI >35
Serial scans from 28 weeks to check for FGR
What would you do if you suspected FGR from the growth chart?
Arrange an USS scan
Get an estimated fetal weight (EFW)
Check liquor volume - if below expected this may indicate FGR
Umbilical artery Doppler - check blood flow to the placenta
How is FGR managed?
If in early pregnancy - check for cogenital abnormlaites, give steroids and monitor
If in late pregnancy - give steroids and consider delivery
What is the APGAR scoring?
This is a test performed on the baby at 1 and 5 minutes after birth: A - appearance (are they blue or pink) P - pulse (pulse should be over 100) G - grimace (are they crying) A - activity (are they moving) R - respiration (is the baby breathing)
What is a normal APGAR score?
Over 7
When is aspirin given in pregnancy?
If diabetic
If at risk of developing PET
What are the thresholds for anaemia in pregnancy?
<110 in 1st trimester
<105 in 2nd trimester
<100 in 3rd trimester
How is iron deficiency anaemia managed in pregnancy?
Dietary information given
Ferrous sulphate iron replacement is given
What pharmacological agents can be used in the management of post-partum haemorrhage?
Syntocinon Syntometrine Ergometrine Misoprostol Carboprost Transexamic acid
What is the definition of PPH?
Loss of 500mL or more within 24 hours of birth
Minor - 500-1000
Major >1000
Severe >2000
What is the management of PPH?
Bloods - G&S, FBC, Coagulation screen
Obs - pulse, resp rate, BP every 15 mins
Fluids - warmed crystalloid infusion
Blood transfusion - for major PPH
What are the different causes for heavy menstrual bleeding?
Normal - some women can just have heavy bleeding
Fibroids
Endometrial polyps
Endometriosis
PCOS
Endometrial cancer (especially if >45 years old)
What non gynaolocigcal causes do you have to rule out in a patient with heavy menstrual bleeding?
Haemophilia
Von villebrands disease
New medication: anticoagulants
What are the management options for heavy menstrual periods? (Where there is no underlying pathology)
Contraception - mirena coil, or POP (progesterone supresses mensturation)
NSAIDS - reduce prostaglandin (which is linked to heavy periods)
Mefanamic acid (NSAID)
Endometrial ablation
Hysterectomy
Tranexamic acid - to prevent excessive blood loss
What are Fibroids?
What is the pathophysiology?
Non cancerous growths that develop in the uterus
They are thought to grow in the presence of oestrogen - will tend to shrink after menopause
How are fibroids managed?
Can be left alone if not causing symptoms
Myomectomy - surgery to remove
Uterine artery embolisation - shrinks fibroids
Hysterectomy
What are the symptoms you might get with fibroids?
Heavy periods Sensation of pelvic mass - described as pressure in pelvis Abdominal pain Lower back pain Urinary frequency Constipation Pain during sex
What is the most common type of fibroid?
Intramural
Develops inside of the muscle wall in the womb
What are GNRHs and how do they work?
Gonadotropin releasing hormone analogues given to help treat symptoms caused by fibroids
Given by injection - act on the pituitary gland to stop production of oestrogen
Can stop menstrual cycle - but are not a form of contraception
When would GNRHs be used for fibroids?
If a women is just before menopause and is still getting symptoms from the fibroids
Given before surgery to shrink fibroids
What are the side effects of taking GNRHs
They stop oestrogen production - so can bring on menopause like symptoms
Also cause risk of osteoporosis (due to lack of oestrogen)
What are the different types of medication given to shrink fibroids?
GnRHas
Ulipristal acetate
What are the red flag symptoms in regard to PV bleeding?
Age >45 Intermenstural bleeding Postcoital bleeding Post menopausal bleeding Abnormal examination findings e.g,pelvic mass or cervix lesion Treatment failure after 3 months
What are the main risks of a mirena coil?
Ovarian cysts Acne Mood changes Breast soreness Weight gain (not proven) Risk of expulsion of coil into the myometrium Risk of perforation Risk of infection
What is the difference between an early and late miscarriage?
Early - before 12 weeks gestation
Late - between 12-24 weeks gestation
Why might a women have a miscarriage?
They are common - 15% of recognised pregnancies result in miscarriage
Chromosomal abnormalities (50%) - problems with early replication
Fetal malformations
Placental abnormalities
What are the risk factors for having a miscarriage?
Multiple pregnancies Advanced maternal/paternal age Lifestyle: Smoking, alcohol, high BMI, stress Previous TOP Previous miscarriage IVF Chronic illnesses - thyroid, diabetes, PCOS Uterine malformations - fibroids, polyps Medications - e.g, teratogens
What are the 2 separate things seen on USS that indicate a miscarriage?
Embryo >7mm with NO fetal heart action
Gestational sac diameter >25mm wth no yolk sac or embryo
If an embryo is less than 7mm on USS and with no fetal heart heart beat what does this mean?
Could mean that the baby is still too small to hear heart beat
Could mean a miscarriage - have to watch and wait
What is a threatened miscarriage?
Anyone who is less than 24 weeks pregnant that presents with vaginal bleeding
What is an inevitable miscarriage?
Where the cervix is open on examination - therefore the miscarriage is about to be imminently passed in the next few hours
What is a complete miscarriage?
Where all the pregnancy tissue is passed from the uterus
What is an incomplete miscarriage?
Where some of the pregnancy tissue remains in the uterus
What is a delayed miscarriage?
Where the pregnancy has stopped growing, or the fetus has died but there has been no signs of bleeding
So when a miscarriage has happened without anyone noticing
How would you manage someone that had come in with a suspected miscarriage?
Vital signs - check for hypovolamia
Exam - abdominal exam to rule out ectopic
Bloods - FBC, G&S, serum HCG
USS - to look for signs of miscarriage
Swab - if there are signs of infections, must rule out a septic miscarriage
What are the 3 main management options if someone has a miscarriage?
Expectant management - wait for products to bleed out
Medical management - give misoprostol to stimulate miscarriage
Surgical management - surgically remove pregnancy from womb
Why might you advise against expectant management of miscarriage?
Can vary from days to weeks before miscarriage happens - degree of uncertainty
Can have severe bleeding - risk of anaemia
Seeing the pregnancy pass at home alone may be distressing
What is misoprostol?
Prostaglandin used to start uterine contraction and the passing of pregnancy tissue
What are the risks with surgical management of miscarriage?
Infection
Uterine perforation
GA risk
How can an ectopic pregnancy present?
Abdominal pain
Shoulder tip pain - due to peritoneal diaphragmatic irritation from blood
Rectal pain or diarrhoea - due to blood irritation
Vaginal bleeding - may or may not have this
What are the differentials to consider for ectopic pregnancy?
Miscarriage
Corpus luteum cyst
Appendicitis
What is the management of suspected ectopic pregnancy?
Obvs - looking for hypovolemic shock
Examination - abdo may be tender, cervical excitation
Large bore cannula
Bloods - FBC, G&S, betaHCG
USS - may show ectopic pregnancy (if not then this does not exclude it)
How does betaHCG levels differ in normal pregnancy, failing pregnancy and ectopic pregnancy?
Normal - increases by >63% every 48 hours
Failing - will fall sometimes
Ectopic - unpredictable (can behave normally or like falling, or do something different)
At what level of betaHCG would you expect to see an intrauterine pregnancy on USS?
Once betaHCG reaches 1000
What are the 3 types of management for ectopic pregnancies?
Surgical
Medical
Conservative (expectant)
When would you perform surgical management of ectopic pregnancy?
When patient is haemodynamically unstable
When betaHCG is >5000
When USS mass is >3.5cm
What happens during surgical management of ectopic pregnancy?
Laparoscopic salphingectomy
The Fallopian tube with ectopic in is removed
What is the most common site for ectopic pregnancy?
Fallopian tube
What is the medical management of ectopic pregnancy?
How does it work?
Intramuscular (IM) Methotrexate
Works by preventing proliferation of pregnancy tissue
When would you give medical management for ectopic pregnancy?
If patient is pain free
If beta HCG <5000 (<3000 more ideal)
What do you need to counsel to a patient before giving methotrexate for treating ectopic pregnancy?
May not work - may need a 2nd dose if betaHCG isn’t falling
Can be painful
Can effect liver - so LFTs must be monitored
Must avoid getting pregnant for 3 months after - due to teratogenic properties of methotrexate
Must avoid alcohol and NSAIDs for 3 months after - due to effect on liver
When would conservative management for ectopic pregnancy be offered?
If the patient has no symptoms
If betaHCG <1500
If mass on USS is <3.5cm
If a women has one ectopic pregnancy what does she need to be counselled about regarding future pregnancies?
10% risk of recurrence - this is because it is normally due to damage to Fallopian tube which will either still be there, or have similar damage in other tube
She will be offered an USS at 7 weeks to confirm pregnancy is intrauterine
What are the risk factors for an ectopic pregnancy?
Anything that causes damage to the Fallopian tubes: PID Smoking - effects mucus clearance Tubal surgery IVF IUD POP - as this reduces cilia movements
What is a molar pregnancy?
A pregnancy which develops as a result of imbalance in the amount of genetic material when the embryo first develops
What is molar pregnancy a risk factor for?
Cancer
It is a precancerous form - can progress to gestational trophoblastic neoplasia (GTD)
What are the two types of molar pregnancies?
Complete mole
Partial molar
What is a complete molar pregnancy?
Where a single sperm goes into empty ovum and then sperm divides in two
OR
Where two sperm go into an empty ovum
What is a partial molar pregnancy?
Where 2 sperm enter a normal ovum - you get 69 chromosomes
What % of molar pregnancies need chemotherapy?
Complete molar - 15% need chemo
Partial molar - 0.5% need chemo
What is the management of a molar pregnancy?
USS - to confirm Bloods - FBC, G&S, LFTs (may need methotrexate), beta HCG IV fluids - stabalise Medical management - methotrexate Surgical evacuation if needed
How would you counsel someone who has had a molar pregnancy?
Not to get pregnant for 6 months after
Will need follow up in specialist centre
What is the pathophysiology of hyperemesis gravidarum?
Production of betaHCG during pregnancy
BetaHCG causes nausea and vomiting
Why can you get hyperthyroidism during the first trimester of pregnancy?
Why is it self limiting?
BetaHCG acts like TSH
Binds to receptors causing production of T4
This leads to hyperthyroidism
Beta HCG peaks at 12 weeks so hyperthyroidism should level off when beta HCG decreases
What are the risk factors for hyperemesis gravidarum?
Multiple pregnancies
Molar pregnancies
What investigations should be done and why when someone presents with vomiting during pregnancy?
FBC - look for infection G&S - sepsis? U&Es - look for electrolyte imbalances TFTs - hyperthyroidism assocaited with hyperemesis Beta HCG - diagnostic for hyperemesis Calcium phosphate Amylase - rule out pancreatitis as cause LFTs - exclude gallstones, hepatitis Urine dip - look for ketones
How the severity of hyperemesis gravidarum assessed?
PUQE score
Pregnancy unique quantification of emesis
How is hyperemesis gravidarum managed?
If mild, If ketones <2 or PUQE score <13:
Oral antiemetics, ginger
If ketones >2
Admit for rehydration - cannula IV fluids and antiemetics (cyclizine)
IV potassium - to correct electrolyte imbalances
Thiamine supplementation - should be given to all women admitted with prolonged vomiting to prevent wernickes encephalopathy
VTE prophylaxis - LMWH
Steroid replacement - if other treatment has failed
Paranatel nutrition - if all else fails
What are the differentials for abnormal discharge?
Bacterial vaginosis
Candida (thrush)
STIs - chlamydia, gonorrhoea, trichomonas, herpes
Cervical ca
When are the routine smear tests for women carried out?
Aged 25-49 every 3 years
Aged 50-64 every 5 years
What happens at a smear test?
Use a fine brush that goes into the cervix and is rotated several times to ‘scrape’ the cells off the cervix
What does dyskaryosis mean?
This means abnormal nucleus
It is based on how abnormal the cells on the cervix look during a smear
Dependant on the degree of dyskaryosis present at a smear test, what happens?
Borderline or mild dyskaryosis - HPV tested (if HPV positive then referred to colposcopy)
Moderate or severe dyskaryosis - refer to colposcopy
What are the different stains used in colposcopy and why?
Acetic acid (white) - used to stain cells with higher ribosomal activity white. Cancer cells will turn white
Iodine stain (brown) - stains cytoplasm brown. Cancer cells lack cytoplasm so won’t turn brown
What is CIN?
Cervical Intraepithelial Neoplasia
This is areas on the cervix which have dysplasia (abnormal growth). CIN Refers to precancerous areas on the cervix
Acetic acid stains these areas white during colposcopy
These areas are diagnosed through biopsy and histology
What are the different stages of CIN?
CIN1 - 1/3rd of cervix is affected
CIN2 - 2/3rds of cervix is affected
CIN3 - 3/3rds of cervix is affected
At what levels of CIN will the cervix be treated?
CIN2 and CIN3 have a higher risk of developing into cancer
These are treated
CIN1 cells usually spontaneous return to normal by themselves - this is due to the natural immune response
How are abnormal cervical cells managed?
LLETZ (large loop excision of transformation zone)
Removal of the transformation zone under local anaesthetic
After LLETZ, what is the follow up?
Histology for HPV positive - smear in 6 months
Histology for HPV negative - smear in 3 years as normal
What are the other management options for abnormal cervical cells apart from LLETZ?
Cryotherapy - freezing affected area of cervic
Laser treatment - to destroy abnormal cells
Cold coag - using heat to destroy and remove cells
Is colposcopy safe in pregnancy?
Yes it is safe to exclude disease
However biopsy should be avoided unless malignancy is suspected
What counsel should you give to a patient after colposcopy?
Wear a sanitary pad - for bleeding
Dark fluid may be seen on pad - this is the stain used
Might get some spotting and discharge for 3 days
Avoid sex, tampons and swimming for 2 days
Risk of infection
If treatment carried out - then blood stained discharge present for 2-4 weeks
How does candida present?
Itching and soreness around entrance to vagina
Vaginal discharge - odourless, thick and white
Painful intercourse
Stinging sensation when peeing
What is the most common cause for altered vaginal discharge?
Bacterial vaginosis
How does bacterial vaginosis present?
Greyish/white discharge Thin watery discharge Strong malodour (fishy smell)
How is bacterial vaginosis treated?
Antibiotics
Usually metronidazole and clidamycin
What are the causes for bacterial vaginosis?
Caused by a change of natural balance of bacteria in vagina
Being sexually active - it is not an STI but can be triggered by sex
Change of sexual partner
If you have an intrauterine device
How is thrush managed
Oral antifungals (imidazole and triazole) Topical antifungals - clotrimazole (this is found in canesten as the pessary)
Steroid cream - to reduce itching
What are the 4 STIs you want to rule out in someone presenting with altered vaginal discharge?
Chlamydia
Gonorrhoea
Trichomonas
Herpes simplex
What investigations should be done for someone presenting with abnormal discharge?
Endocervical swab - looking for chlamydia and gonorrhoea
Vaginal pH - >4.5 suggests BV or trichomonas
Bloods - for HIV and syphilis
Consider High vaginal swab - helps aid diagnosis of bacterial vaginosis, candidas, trichomonas
Who should you carry out a HIV test on?
Any new patient in high risk area
Anyone at risk - patients with other STIs, MSM, sex workers, from country of high prevalence, IVDUs, any sexual partner at risk
Anyone with clinical indicator infection - e.g, pneumonia, TB, lymphoma, meningitis
Anyone who asks for it
How would you counsel a patient prior to having a HIV test?
The test - blood test
Explain it is a routine blood test
Explain benefits of testing - earlier diagnosis better prognosis, effective treatments are now available
Explain window period (4 weeks 95%, 3 months 99% antibody production)
Insurance issues - if negative, then insurers don’t need to know they had test. If positive - must declare (like all medical conditions)
How would they like results - check contact details
What are the causes for abnormal vaginal discharge?
Infective - BV and candida
Non infective - cervical ectopy, polyps, foreign bodes
STIs - chlamydia, gonorrhoea, trichomonas
What is the normal pH of the vagina?
3.5-4.5
In which infections would the vaginal PH be altered?
Bacterial vaginosis
Trichomonas
Ph >4.5
What would blood in vaginal discharge make you think of?
Possible malignancy (cervical)
What laboratory tests are performed on a high vaginal swab?
Microscopy, sensitivity and culture
What proportion of CIN1 progress to invasive cervical cancer?
1%
What proportion of CIN3 progress to invasive cervical cancer?
12%
What are the stepwise hormone changes during Parturition?
ACTH release - from fetus anterior pituitary (due to stress)
Cortisol release - from fetal adrenal glands
Hormone alteration in placenta - cortisol causes a decrease in oestrogen and progesterone from placenta, and in turn increases prostaglandin production
Prostaglandin action - causes uterine contraction and cervical stretching
Cervix stimulation - stretching of cervix stimulates sensory nerves
Oxytocin production - sensory nerves stimulate oxytocin production from mothers hypothalamus
Oxytocin release - from posterior pituitary gland
Oxytocin action - causes further uterine contraction and and further prostaglandin stimulation
When is a full term baby delivered?
Between 37-42 weeks
What are the 3 stages of labour?
Effacement (cervical dilation)
Fetal expulsion
Placental delivery
What are the two stages of the first stage of labour?
Latent - up until cervix is 4cm dilated
Established - 4cm-10cm dilated
What 3 things must be present to diagnose labour?
Effacement of the cervix (thinning)
Dilation of cervix >4cm
Regular painful contractions
What are the 4 different places a women can give birth?
Home
Free standing midwifery led unit (birth centre)
Alongside standing midwifery led unit (birth centre in hospital)
Obstetric unit (consultant led delivery suite)
Which patients can have a home birth?
Low risk patients
What should you counsel a mother on regarding home birth?
If first baby - 50% rate of transfer to hospital (usually due to pain relief)
If 2nd or 3rd baby - transfer rate is 1 in 12
Pain relief - usually entanox (NO) (epidural not available)
Need a phone line and mobile signal (? If live rurally)
If you go over by 12 days then will need induction in hospital
Contact on call midwife when go into labour (not always your midwife, it is part of a team)
Midwifes are able to do stitches if you need them to
What do you need to counsel a women on if she is wanting to have birth in midwifery led centre (birth centre)?
1st baby transfer rates to hospital - 40%
2nd baby transfer rates to hospital - 10%
If unit is separate from hospital, then might not be able to have epidural
CTG not always available - normally just use fetal Doppler
How many cm an hour would you be expected to dilate in labour?
Primigravid - 0.5cm an hour
Multipgravid - 1cm an hour
What is meconium
Green fluid from the babies bowls
If light green then not concerning
If it is thick and then this can suggest fetal distress
When would you do a fetal blood sample and how?
If the baby seems in distress from a CTG
Any delivery is not imminent
Put in speculum and nick the top of babies scalp to get blood sample
Blood sample will tell you gas composition and pH
At what pH levels would you be concerned on a fetal blood sample?
Normal pH >7.25
Between 7.2-7.25 - check again in 30 mins
If pH <7.2 - immediate delivery is needed, either from Caesarean section or instrumental delivery
Once a women is fully dilated, what do you do?
Allow 1 hour for passive descent
After 1 hour commence pushing
After 2 hours if no baby then help is needed
What are the two options for the 3rd stage of labour?
Physiological - wait for placenta to pass naturally (this can take up to an hour)
Active - use drugs to pass placenta (Takes 5 minutes)
What happens in the active 3rd stage of labour?
Hormones given IM to mother - usually synometrin (combination of syntocinon and ergometrine)
Cord lengthens out - it is then clamped and cut
Midwife then pulls on the cord, to pull the placenta through the vagina
What hormones are given in the active 3rd stage of labour and why?
Syntometrin (syntocinon and ergometrine)
Ergomentrine - fast acting causes uterine contractions
Syntocinon (artificial oxytocin) - maintains uterine contractions
Why can’t you give ergometrine to a women with raised BP?
As this can make it even higher
When would you offer induction of labour?
If it is a high risk baby and you want to get it out
If uncomplicated baby but between 41 and 42 weeks and not gone into spontaneous labour
If a women has had rupture of membranes at term
What drug is usually given for induction of labour
Vaginal prostin (prostaglandin)
When is a membrane sweep offered?
What is it?
At 41 weeks
A vaginal examination which stimulates the neck of the womb to trigger labour. It may take 24-48 hours to get into labour
What are the signs of labour
Start with irregular contractions, they will become more often, lasting longer and stronger (can take up to 24 hours for this to happen)
Backache
Spontaneous rupture o membranes - leak of amniotic fluid
What are the 3Ps that can slow the process of labour down?
Powers - how strong and effective the contractions are
Passages - shape and size of pelvis (also placenta praevia)
Passenger - size of baby and which way it is lying
What different options are available for pain relief in labour (non pharmaceutical and pharmaceutical)?
Warm bath TENS machine - transcutaneous electrical nerve stimulation Breathing exercises Massage Entanox (gas and air) Epidurals
What would you counsel a women who wants a VBAC (vaginal birth after Caesarean section)
75% of women have successful VBAC
1 in 4 women will still need emergency c section during labour
You are encouraged to give birth in hospital because of this
When to advice against it - more than 2 previous c sections, complicated uterine scars, high BMI, older mother
Absolute contraindications - classical c section scar, or uterine rupture
Explain the process of labour
Explain anatomy of pelvis
Explain anatomy of fetal skull
Explain station (+ once below ischial spines)
Definition of labour (3 things)
Stages of labour
Mechanism of labour (engagement, flexion, rotation etc)
3rd stage of labour
What is the mechanism of labour?
Engagement, descent and flexion
Internal rotation - so baby is facing occipitoanterior
Extension - of head out of the pelvis
External rotation and resitution - baby roatates back to transverse and lines up the shoulders
Delivery of shoulders - anterior (downward traction) followed by posterior
What are the causes of Intrapartum Haemorrhage?
Uterine rupture
Vasa previa
What is vasa previa?
Condition where the fetal blood vessels cross or run near the opening of the uterus
These vessels are at risk of rupture when the membranes rupture
What do ketones in urine mean during pregnancy?
Ketones mean that fat is being broken down instead of carbohydrates
Ketones suggest that mother and baby are not getting enough fuel (can be due to diet, or severe nausea and vomiting)
May suggest fetal distress
May be linked to gestational diabetes if BMs increased
What is shoulder dystocia?
Where the baby’s head has been born but one of the shoulders becomes stuck behind the mothers pubic bone
If this happens usually additional movements are need to release the baby’s shoulder
What is primary and secondary and PPH?
Primary - >500mL blood loss within 24 hours of delivery
Secondary - any significant blood loss between 24 hours and 12 weeks of delivery
What is the difference between minor and major PPH?
Minor: 500-1000mL
Major: >1000mL
What are the 4 Ts of PPH?
Tone
Trauma
Tissue
Thrombin
What is the most common cause of PPH?
Uterine Atony
Where the uterine fails to contract after birth, so the placental arteries don’t clamp, and excessive bleeding occurs
How is PPH caused by uterine atony treated?
Fundal massage - causes smooth muscle in uterine wall to contract and harden
Uterine contracting meds given -Ergometrine, syntocinon infusion, misoprostol, carboprost
Tranexamic acid - to stop the bleeding
Breast feeding - this stimulates secretion of oxytocin
Catheter - empty bladder (which might be compressing on uterus)
What can causes of Trauma leading to PPH?
Incision fro c section
Tearing of perineum
Damage to perinium from medical instruments
What are the Tissue Causes of PPH?
Retained placenta
Placenta accreta - placenta invades myometrium so doesn’t easily separate
Placenta previa
What is the general management of PPH?
A-E assessment General Obs - BP, HR, RR, Cap refill 2 large bore canulas - one in each arm Bloods - FBC, G&S, clotting, U&Es, LFTs (clotting Factors) Fluids - give warm cystalloid fluids Transfusion - O- blood given
What are the different degrees of perineal tears?
1st degree - injury to perineal skin and vaginal epithelium
2nd degree - injury to fascia and muscles (not anal sphincter muscles)
3rd degree - injury to anal sphincter complex (3A <50% external) (3B >50% external) (3C external and internal)
4th degree - involves perineal fascia, muscles, both anal sphincters and epithelium
What are the risk factors for PPH?
Physiological 3rd stage of labour Pre-eclampsia High BMI Prolonged labour Multiple pregnancies Placenta previa
What is the main cause of Thrombin in PPH?
Coagulopathy
E.g, due to pre-eclampsia
What are the time periods for the 4 common STIs before they are picked up on testing?
Chlamydia - 2 weeks
Gonorrhoea - 2 weeks
HIV - 1 month
Shyphilis - 3 months
What is placenta previa?
Where the placenta is low lying and covers either partially or fully the cervical os
How is placenta previa diagnosed?
Transvaginal USS
How far must the placenta be from the cervical os for the mother to have a vaginal delivery?
2cm
For women who have placenta previa on USS at their anomaly scan, what counsel would you give?
Reach with vaginal USS at 32 weeks
11% of women will still have placenta previa at this time (so majority of the time the placenta moves up)
If placenta previa is present at 32 weeks - 90% of women will still have low for delivery
C section is advised
What are the differentials for abdominal pain in the 3rd trimester of pregnancy?
Pre-term labour Placental abruption Uterine rupture Appendicitis Ovarian torsion UTI
What is the fetal fibronectin test?
A test to check protein levels of fetal fibronectin - this is a protein which can suggest pre term labour (positive predictive value of 46-80%)
After 35 weeks it begins to break down
So if detected between 22-35 weeks it is an indicator of preterm birth risk
When would you do a fetal fibronectin test?
If a women is 30-35 weeks pregnant and you want to know if she is in preterm labour (e.g, presents with abdo pain)
And transvaginal USS is not available or acceptable
If >50 this suggests pre term labour
What is placental abruption?
Separation of placenta from the uterine wall
What are the symptoms for placenta abruption?
Abdominal pain PV bleeding (not always present as can be inside) Uterine tenderness (woody hardiness)
What is the management for placenta abruption ?
Expectant management
Induction of delivery - if there is any sign of maternal or fetal compromise
What is the main risk factor for uterine rupture?
Previous Caesarean section
When trying vaginal birth after C section risk of uterine rupture is 7 in 1000
What are the signs of uterine rupture?
Abdominal pain
Hypovolemic shock
Uterine contractions may stop
Where does the pain location differ for appendicitis in the different trimesters of pregnancy?
This is because the appendix moves during pregnancy
1st trimester - lower right quadrant
2nd trimester - umbilical level
3rd trimester - diffuse pain or upper right quadrant
How would you interpret a CTG?
DR - define risk
C - contractions (how many in 10 mins)
Bra - baseline HR of fetus (normal is 110-160)
V - variability (is it >5bpm)
A - accelerations (increase in HR of >15bpm for >15 seconds)
D - decelerations (decrease in HR of >15bpm for >15 seconds)
O - overall impression (reassuring or non reassuring)
What are the different types of decelerations?
Early decelerations - in time with uterine contractions (suggests pull on the cord)
Variable decelerations - rapid fall in HR with variable recovery (caused by umbilical cord compression during labour)
Late decelerations - begin at peak of uterine contractions and recover after contractions end (suggests insufficient blood flow to placenta)
Prolonged decelerations - >3 minutes. This is non reassuring
What might a sinosoidal pattern suggest on an CTG?
Severe fetal hypoxia
Fetal thumb sucking
What are the differentials for PV bleeding in the 3rd trimester?
Cervical ectropians - more common during pregnancy
Candidas infection
Cervical dilation - bleeding can occur at the start of normal labour
Placental abruption
Placenta praevia
Vas praevia
How would you manage a women who presents with 3rd trimester bleeding?
A+E assessment Check obs BP, HR, cap refill, make sure they are haemodynamically stable Abdominal exam PV exam - bimanual and speculum Bloods - FBC, G&S, clotting screen CTG - check on baby USS - check on baby growth
What treatment would you give to a pregnant women who had a VTE risk?
LMWH - this does not cross the placenta so cannot harm baby
Why would you stop LMWH treatment before labour?
Risk of bleeding
Need to stop at least 24 hours before epidural
How would you assess VTE risk in a pregnant women admitted to hospital
Check level of mobility - all patients with reduced mobility should be considered for further risk assessment
Check thrombis risk - using risk factors e.g, wells score
Check bleeding risk
Balance thrombosis risk against bleeding risk
What is the kleihauer test and when would you do it?
Used to measure the amount of fetal haemoglobin transferred from a fetus to a mothers blood stream
If there is a risk of bleeding during pregnancy and the women is rhesus -
If this klihauer test is positive then you need to give anti-D
What are tocolytics?
Medications used to supress premature labour
When would nifidepine be given as a tocolytic?
If the women is between 24 - 37 weeks and who is in suspected preterm labour but with intact membranes
What is P-PROM?
Preterm Premature rupture of membranes
How would you manage P-PROM?
Offer oral erythromycin until women is in established labour
Blood tests to check for intrauterine infection
When would operative vaginal delivery be offered?
If there is fetal compromise
If there is failure to progress
If the head is no more than 1/5th palpable abdominally (do not attempt if the baby’s head is more than 2/5ths palpable in abdomen)
What is the timeframe for inadequate process to progress in labour?
Lack of progress for <2 hours - nulliparous women
Lack of progress for <1 hours - multiparous women
What are the two main operational vaginal deliveries?
Forceps Vacuum extraction (Venthouse delivery)
What are the different types of forceps?
Outlet forceps (wridleys) - used when skull is visible without separating labia Low/mid cavity forceps (Neville Barnes/simpsons) - used when fetal head is 1/5th palpable and 2+ station Rotational forceps (kiellands) - use to rotate back to normal position
When would you abandon operative vaginal delivery?
When there is no evidence of progressive decent with moderate traction during each contraction
Where delivery is not imminent following 3 contractions of a correctly applied instrument by an experienced operator
How do you work out which position the baby is in from feeling the head PV?
Use finger to find sagittal suture - run finger around in circle
If you can feel 3 sutures - this is posterior fontanelle
If you can feed 4 sutures - this is the anterior fontanelle
What would significant moulding suggest?
Cephalopelvic disproportion
Consider Caesarean section
What should the duration be for the 2nd stage of labour?
In nulliparous women - no more than 2 hours (or 3 hours with epidural)
In multiparous women - no more than 1 hours (or 2 hours with epidural)
When would you suspect delay in the 2nd stage of labour?
What would you do?
Nulliparous women - suspect delay if progress inadequate after 1 hour (offer amniotomy if membranes in tact). Diagnose delay if not happened in 2 hours and undertake operative vaginal delivery
Multiparous women - suspect delay if progress inadequate after 30 mins (offer aminotomy if membranes in tact). Diagnose delay if not happened in 1 hour and undertake operative vaginal delivery
In which women is operative vaginal delivery more common?
Primiparous women
Women in supine and lithotomy positions
Women who have epidural anaesthesia
When should vacuum extraction not be performed?
If the baby is less than 36 weeks
If there is significant caput or moulding
How is Ovulation controlled?
GnRH - released by hypothalamus
GnRH acts on anterior pituitary gland to release FSH and LH
FSH acts on the ovaries causing follicle development
LH stimulates androgen production, androgens are then aromatised to make oestrogen
Oestrogen normally inhibits LH/FSH release, however a peak of oestrogen production causes release of LH/FSH (negative to positive feedback)
Surge of LH is responsible for Ovulation
How can you tell if a women is ovulating?
Regular cycles usually suggest ovulation
Mid luteal progesterone measurement - this can confirm whether women is ovulating
FSH/LH - these can be measured to see if women is ovulating
What are the stages of the menstrual cycle?
Menses stage - where lining breaks down
Proliferative stage - oestrogen repairs endotherlium
Ovulation - egg is released
Luteal stage - progesterone is high in preparation for fertilisation, the uterine wall grows
What is AMH?
Anti mullerian hormone
Produced by ovary - indicator of ovarian reserve
What would the hormone levels be in a women if she had a hypothalamus or pituitary problem resulting in Ovulation dysfunction?
Low FSH
Low LH
Low oestrogen
What would the hormone levels be in a women if she had PCOS?
FSH normal
LH raised
Oestrogen normal
What is the main ovarian cause for Ovulation dysfunction?
Polycystic ovarian disease (PCOS)
What would the hormone levels be if a women had premature ovarian failure?
FSH high
LH high
Oestrogen low
What are the fertility rates in the UK?
80% of couples will get pregnant in 1 year if:
- the women is <40
- they have regular unprotected sexual intercourse
What are the risk factors for infertility?
Increased female age
Uterine abnormalities - firboids, polyps
Lifestyle factors - obesity, alcohol, smoking, drugs
Men who wear tight body wear - due to increased scrotal temp
Men who use body building drugs
What investigations would you carry out on a women with infertility?
Ovarian reserve testing - AMH
Progesterone testing in luteal phase - especially in irregular cycles
FSH and LH - offered to women with irregular cycles
Rubella testing - offered to all women with infertility problems
STI screening - especially chlamydia
In a women presenting with oligomenorhoea or amenorrhea what other tests would you want to do?
Thyroid function tests
What additional imaging tests can be done to assess infertility in a women?
Hysterosalpingography - X ray to look at Fallopian tubes, dye is inserted which travels up the tubes
Hysterocontrastsonosalpingogram (HyCoSy) - USS to look at Fallopian tubes, uterus and endometrium
What are the normal ranges for semen analysis?
Semen volume >1.5mL PH >7.2 Sperm concentration >15 million per mL Sperm number >39 million per ejaculate Total motility >40% motile, or >32% with progressive motility Vitality >58% Morphology >4%
What would you do if a semen analysis is abnormal?
Repeat analysis in 3 months (this allows sperm cycle formation to be completed)
If there is gross spermatozoa deficiency then repeat test done asap
What are the main causes for infertility?
Male factor
Ovulation problems
Tubal problems
What are the risk factors for tubal damage?
STIs - chlamydia and gonorrhoea Pelvic inflammatory disease Endometriosis Previous abdominal surgery Caesarean sections
How is tubal patency assessed?
No risk factors - Hysterosalpingography (HSG) X ray and dye
Risk factors - laparoscopy
What is the best chance for conception if a women has a tubal factor?
IVF
What is endometriosis?
Where the lining of the womb grows in other places such as the Fallopian tubes or ovaries
What are the theories of pathophysiology of endometriosis?
Retrograde flow - lining travels up during menstruation
Vascular and lymphatic dissemination - endometrial cells travel through vascular and lymph
Coelomic metaplasia - stem cells in peritoneal cavity develop into endometrial tissue
What are the symptoms of endometriosis?
Pelvic pain (worse on period) Dysmenorrhea (period pain) - stops from doing normal activity Dyspareunia (painful intercourse) Pain urinating or passing stools Infertility Heavy periods
How is endometriosis managed?
Analgesia
Contraception - causes atrophy of endometrial tissue, can also control heavy periods
Surgery - ablation of visible endometrial tissue OR hysterectomy bilateral salpingo-oopherectomy
What are the symptoms of PCOS?
Irregular periods (or no periods (amenorrhea) Hirtisum - increase facial or body hair Obesity Oily skin/acne Reduced fertility
Why do people with PCOS get the symptoms they do?
Related to hormone levels
Excess testosterone - related to excess hair and acne
Insulin resistance - which can lead to weight gain, heavy periods, fertility problems and high testosterone
How do you diagnose PCOS?
Need to have 2 of the following:
- Irregular or no periods
- Androgen excess sign e.g, increase hair or acne
- USS showing Polycystic ovaries (>10mm in size)
What is the LH/FSH ratio in PCOS?
LH is higher
LH/FSH ratio can be as high as 3:1
What is the management of PCOS?
Oral contraceptive pill - given to control periods and supress androgen production
Weight loss advice
What treatments can be given to help fertility in patients who have PCOS?
Metformin
Clomiphene - helps to induce ovulation
Ovarian drilling - this helps encourage ovulation
What are the different types of ovulation disorders?
Group I - problem with hypothalamus or anterior pituitary gland release of hormones
Group II - PCOS
Group III - ovarian failure
How are group I ovulation disorders treated?
Lifestyle adjustments- increase BMI to >20, decrease exercise
GnRH - offer women positive administration if hypothalamus not working
What are the different assisted conception methods available?
Intrauterine Insemination
In vitro fertilisation (IVF)
Intracytoplasmic sperm injection - used alongside IVF
What is intrauterine insemination
Sperm are surgically extracted from testis
Better quality sperm are filtered out
These sperm are then injected into the womb - so they don’t have far to swim
What happens in IVF?
Ovarian stimulation and egg collection surgically
Sperm collection surgically
Mixing of eggs and sperm in vitro
Embryo development 2-6 days in vitro
Several good quality embryos are selected and cyropreserved
Strongest embryo is implanted
How long does IVF take?
4-6 weeks
What is the criteria for women undergoing IVF on the NHS?
Must be under 40
Must have 2 years regular unprotected intercourse
Must be between 40-42
Must have 2 years regular unprotected intercourse
Must have never tried IVF before
Must have no evidence of low ovarian reserve
Additional criteria:
- No children from either parent
- healthy weight
- non smoking
How many cycles of IVF are women offered on the NHS?
Under 40: 3 cycles
40-42: 1 cycle
What are the risks involved in IVF?
Ovarian hyperstimulation syndrome (OHSS) - reaction to fertility drugs
Multiple pregnancies
Ectopic pregnancy
Possible birth defects
What is intracytoplasmic sperm injection
This is used alongside IVF
It is where a single sperm is injected into an egg - this maximises the change of fertilisation as it bypasses any potential problems the sperm will have getting in the egg
Who is recommended to have intracytoplasmic sperm injection
If the male has a very low sperm count
If the male has low quality sperm
If the couple had previous IVF which didn’t work
What are the risk factors for ovarian cancer?
Age >0 Family history of breast or ovarian cancer Obesity Nullparity Subfertility HRT Endometriosis
What are the red flag symptoms for ovarian cancer?
Feeling bloated (abdominal distention) Swollen tummy Pelvic discomfort Early satiety (feeling full early) Loss of appetite Increased urgency/frequency
What should you do if a women >50 presents with IBS like symptoms?
Investigate for ovarian cancer
What are the primary investigations for ovarian cancer that are carried out in primary care?
CA125 - if >35 then suspicious
USS of abdomen and pelvis
What are the 2ww referral guidelines for ovarian cancer?
Ascites and/or pelvic mass felt on examination (that is obviously not fibroids)
If USS is concerning for ovarian malignancy
If RMI >250
What points would score abnormal for ovarian cancer on USS?
Multinodular cysts Solid areas Metastases Ascites Bilateral lesions
What is the RMI?
Risk of malignancy index (U x M x CA125)
U - USS score (1 for 1 point, 3 for 2-5 points)
M - menopausal (1 for pre menopausal, 3 for post menopausal)
CA125 score
What is the management for ovarian cancer?
Surgery
Can have chemo before (neoadjuvant) to shrink
Can have chemo after(adjuvan)
What is the staging of ovarian cancer?
Stage 1 - in ovary or ovaries
Stage 2 - in one or both ovaries and elsewhere in pelvis
Stage 3 - in one or both ovaries and has spread to lymph nodes
Stage 4 - distant mets
What are the diffferent types of chemotherapy used in ovarian cancer?
Carboplatin - platinum based chemotherapy
Paclitaxal
What is the most common type of ovarian cancer?
High grade serous carcinoma
When is follow up arranged after treatment for ovarian cancer?
1st year - every 3 months
2nd year - every 4 months
Why is CA125 not used routinely for follow up for ovarian cancer?
As there is no evidence that detection for recurrence improves overall survival
What % of high grade serous carcinoma is BCRA related?
15%
What are PARP inhibitors?
Drugs used to treat high grade ovarian cancers
They inhibit the enzyme poly ADP ribose polymerase (PARP)
This is an enzyme involved in DNA repair - and is the only mechanism for repair in cancer cells
Name a commonly used PARP inhibitor
Niraparib
Why is ovarian cancer becoming a chronic disease?
Because of the high rates of relapse
Most cases are not curable
Has to be managed cytotoxically every so often
When would BRCA gene testing be offered to a women with ovarian cancer?
If she had high grade serous carcinoma
How should a women with post menopausal bleeding be investigated?
2ww referral to gynaecological cancer
Trans vaginal USS
Hysteroscopy and endometrial biopsy (if endometrial thickness >4 on USS)
What would the management be of a mother who had a previous baby with group B streptococcus infection?
Give her Intrapartum antibiotics
What screening tool should be used to screen for postnatal depression?
Edinburgh Scale
Which SSRIs can be used in women with postnatal depression?
Sertraline
Paroxetine
When can contraception be started postpartum and what types?
Combined pill - contraindicated in women who are breast feeding and <6 weeks postpartum
Mirena and IUD - can be used from 4 weeks post partum
POP - can be started on 21 days post partum
Implant - can be started on 21 days post partum
No contraception is needed before day 21
What are the 3 forms of emergency contraception available and when can they be used?
Levonorgestrel - used with 72 hours
Ulipristal acetate (Ella One) - used with 120 hours
IUD - used with 5 days (this is the most effective)
How is intrahepatic cholestasis of pregnancy managed?
Emollients - reduce itching
Ursodeoxycholic acid - reduce itching and improve LFTS
Induction of labour at 37 weeks - to reduce risk of stillbirth
How does fibroid degeneration present in pregnancy and why?
Low grade fever
Pain
Vomiting
Fibroids grow during pregnancy due to oestrogen, if they outgrow their blood supply then undergo degeneration
How would you counsel a women who had a breech presentation during pregnancy?
If <36 weeks - most fetuses will turn spontaneously
If breech at 36 weeks - offer external cephalic version (ECV), which has a success rate of around 60% (this is done at 37 weeks in multiparous women)
If baby is still breech after this than plan for C section
What are the absolute contraindications to ECV?
Where caesarean delivery is required Antepartum haemorrhage within the last 7 days Abnormal CTG Ruptured membranes Multiple pregnancy
What happens during an external cephalic version (ECV)
Doctor applies pressure on pelvis to gently turn the baby from breech to a sideways presentation
USS is done prior to check breech position
CTG is done to monitor baby throughout
Rh-D negative are offered anti D after procedure
What is the lactational amenorrhoea method (LAM) for contraception?
It is the contraceptive effect post partum
It is 98% effective providing the women is full breast feeding (no supplementary feeds), she is amenorrhoeic and is <6 months post partum
What are the contraindications for receiving HRT?
Current, past or suspected breast cancer
Undiagnosed vaginal bleeding
Untreated endometrial hypoplasia
Previous VTE - unless women is on anticoagulant medication
Untreated hypertension
What are the risks of HRT?
Slight increase of breast cancer and endometrial cancer
Increase risk of blood clots - DVT and PE
Small increased risk of heart disease and strokes
What are the symptoms of menopause?
Hot flushes Night sweats Headaches Irritability Anxiety Low mood Vaginal atrophy (vaginal dryness)
What age is early menopause defined?
Menopause below the age of 40 years
What would you advice in regards to HRT women who go through early menopause?
Take HRT until the natural age of menopause (Around 51)
What are the two hormone options in regards to HRT?
Combined HRT
Oestrogen only HRT
Which women are okay to take oestrogen only HRT?
Women without a womb (who have had a hysterectomy)
Why is combined HRT advised for women with a uterus?
As unopposed oestrogen can cause endometrial proliferation
What are the 2 different HRT treatment routines?
Cyclical HRT - to be given for women still having periods but with menopausal symptoms
Continuous combined HRT - for post menopausal women
What are the 2 types of cyclical HRT and when would you give them?
Monthly HRT (for women having regular periods) - take oestrogen every day and progesterone alongside it for last 14 days of menstrual cycle
3 monthly HRT (for women having irregular periods) - take oestrogen everyday and progesterone for around 14 days every 3 months
When is a women said to be post menopausal?
If she has not had a period for at least 1 year
What are the different forms HRT comes in?
Tablets - can have oestrogen only or combined
Skin patches - can have oestrogen or combined (these are to be replaced every few days)
Implants - oestrogen only
IUS - progesterone only
Vaginal oestrogen - to help with vaginal dryness
How is urge incontinence managed?
Bladder retraining - for 6 weeks
Muscarinic antagonist - e.g, oxybutynin, tolterodine, solifenacin
Use mirabegron (beta 3 agonist) - if there is concern about anti-cholinergic side effects in frail elderly patients
How is stress incontinence managed?
Pelvic floor muscle training
Surgical procedures - e.g, retropubic mid-urethral tape procedures
How should incontinence be investigated in women?
Bladder diaries
Vaginal examination - to exclude prolapse for a cause
Urine dipstick and culture
Urodynamic studies
