womens health Flashcards

Question

endometrial cancer - type of cancer - investigations - treatment

Answer 1

adenocarcinoma (glandular cells) Transvaginal ultrasound Endometrial biopsy Hysteroscopy (camera) Surgery - hysterectomy +/- pelvic lymph nodes Radiotherapy adjuvant to surgery Progesterone therapy (hormone treatment) - if unable to be operated on

Answer 2

High risk, persistent HPV infection - Missed vaccination - Immunosuppression- body less able to clear high risk HPV - Early age intercourse, multiple sexual partners - Smoking cigarettes - body less able to clear high risk HPV - Pill - STDs

Answer 3

squamous Vaccination programme in young girls Screening with HPV testing Surgery - hysterectomy for stage 1 Stage 2+ Radiotherapy Chemotherapy palliative care inc pain relief

Answer 4

squamous High risk HPV Lichen sclerosis Past history of VIN or Lichen Sclerosis Surgical excision Radiotherapy Chemotherapy

Answer 5

Often asymptomatic Bloating, IBS-like abdominal pain/ discomfort Change in bowel habit Urinary frequency Bowel obstruction - abdominal distention 'pelvic heaviness'

Answer 6

Vulval itching Vulval soreness Persistent ‘lump’ Bleeding Pain on passing urine

Answer 7

Post menopausal women normally present more times you’ve ovulated, the greater the risks - Early first period - Late menopause - No parity - No ovulation suppressing contraception

Answer 8

epithelial surgery and chemotherapy ultrasound Calculate risk of malignancy index poor due to late presentation

Answer 9

Offered to all - 8-10 weeks ideally inc testing biological parents in adoption situations Positive result → counselling and prenatal diagnosis. Offered termination of the baby or can wait till newborn screening Family origin questionnaire - origins of biological parents, assists the lab interpret the results recessive pre natal

Answer 10

Recommended to all in early pregnancy (Early aids prevention of transmission mum to baby) Reoffered by 20w if initially declines Assessment, treatment and vaccination plans if positive, as per guidance HIV, Hep B, syphilis prenatal

Answer 11

- treponema pallidium - Can be transmitted at any stage of pregnancy - May results in miscarriage, pre-term labour, still birth and congenital syphilis

Answer 12

Can result in acute or chronic HBV infection for the baby (Dependant on when transmitted, and viral mode of mum)

Answer 13

Offered to all between 11+2 to 14+1 weeks Combined test for T21, T18, T13 (first trimester) - Nuchal translucency ultrasound scan - increased level of fluid behind neck - Crown rump length - Maternal age - Able to assess risk for each baby if twins (identical will be equal chance though) - part of fetal anomaly scan Quadruple test (second trimester) - (used if NT fails x2, or if too late for this) - Blood test - Alpha FetoProtein, total Beta HCG, Oestriol & Inhibin A - For downs only - Less accurate for fraternal twins If + - Can wait, do nothing - Non invasive prenatal testing (private) -----Examines fragments of fetal DNA in maternal blood for all trisomies and baby sex -----Not diagnostic but highly accurate -Invasive prenatal testing - CVS or amniocentesis

Answer 14

Trisomy of chromosome 21 Learning disability, facial features, good quality of life Increased incidence of physical health conditions such as epilepsy, leukaemia, thyroid and heart conditions, hearing and vision loss

Answer 15

Trisomy of chromosome 18 Low survival rates Severe learning disability and serious physical problems eg heart/ respiratory/ renal / intestinal defects

Answer 16

Trisomy of chromosome 13 Low survival rates Severe physical abnormalities - congenital heart defects, urogenital, Holoprosencephaly (brain doesn't divide into 2 halves), microcephaly, neural tube defects, deafness, severe learning disability

Answer 17

Offer minimum 2 ultrasounds 10-14 w - Confirm viability - Singleton vs multiple pregnancy - Estimate gestational age - This forms part of the trisomy screening - crown rump length and nuchal translucency 18-20+6 w - Detect major structural abnormalities. Identify if any require treatment before birth and to create delivery plans including post natal treatment. Provide information and option to terminate

Answer 18

For mum if diabetic before pregnancy Tested at least twice prenatal

Answer 19

72h and 6-8w Looking for congenital defects / concerns including eyes (cataracts), heart, hips (dysplasia) and testes (Descension). Prompt referral if required

Answer 20

Breech presentation pre or at birth First degree family history of hip problems in early life If your twin had breech birth

Answer 21

hearing aid fitted soon after birth (80 days on average) to aid development. referral to specialist . All: automated otoacoustic emission (AOAE) test Small device placed in ear that emits clicking noise and ear response is measured by screening equipment Some babies also need a second test, the automated auditory brainstem response (AABR) test 3 sensors on baby’s head and headphones play baby clicking noise

Answer 22

Offered and recommended Parents can decline them individually or all Day 5 Screens for 9 conditions - Sickle cell disease (SCD) - Cystic fibrosis (CF) - Congenital hypothyroidism (CHT) and 6 inherited metabolic disorders (IMDs) - Phenylketonuria (PKU) - Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) - Maple syrup urine disease (MSUD) - Isovaleric acidaemia (IVA) - Glutaric aciduria type 1 (GA1) - Homocystinuria (HCU)

Answer 23

= patches of endometrial tissue outside of the endometrial cavity Chronic Pain - Cyclical endometrial patches respond like the endometrium does during periods ie bleeds - Dysmenorrhea - Dyspareunia - pain during or post sex - May also have pain during sex, bowel movements, heavy periods Infertility young and nulliparous oestrogen dependant TVS (transvaginal ultrasound) Gold standard = diagnostic laparoscopy bloods/CT help but not enough alone

Answer 24

conservative - laxatives - NSAIDs - tranexamic acid (Abolish cyclicity ) - Oral contraceptive pill ---- Cheap ---- Effective ---- Minimal side effects - GnRH antagonists ---- Long duration ---- HRT may be necessary (Glandular atrophy) - Oral prostagens - Depot provera (form of progesterone) - Mirena (hormonal IUD intrauterine device - coil) - releases progesterone Surgery - Ablation - Excision - Oopherectomy (bye bye fertility) - Pelvic clearance (bye bye fertility)

Answer 25

ectopic Endometrial tissue within the myometrium - Thickened wall of uterus Often old and multiparous oestrogen dependant pain! -similar symptoms and management to endometriosis Localised = adenomyoma Diffuse = adenomyosis

Answer 26

leiomyoma Benign myometrium uterine tumours Smooth muscle tumours Variable size and number well circumscribed Prevalence: 30% of women above 30. more common in A-C Oestrogen dependant - Risk factors dependant on contraception, pregnancies, menopause, HRT etc Symptoms - Depend on location and size -often asymptomatic - Pain in pelvis - Heavy periods - Anaemia - Infertility - Miscarriage - urgency, frequency, retention Myomectomy = removes fibroids . good for fertility preservation NSAIDS, tranexamic acid Coil, COCP Hysterectomy

Answer 27

common Bleeding Infertility Fibrous tissue covered in columnar epithelium

Answer 28

death of mother within 42 days of birth irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Answer 29

Abrupt onset of aching Inability to urinate Urgent catheterization i think Epidural analgesia Prolonged second stage of labour Forceps or ventouse delivery Extensive perineal lacerations Poor labour bladder care

Answer 30

post partum haemorrhage after 24h from birth. primary = before 24h Causes -Endometritis - Retained products of conception (RPOC) - Subinvolution of the placental implantation site - Pseudoaneurysms - Arteriovenous malformations Investigations - Assess blood loss - Assess haemodynamic status - Bacteriological testing (HVS and endocervical swab) - Possibly Pelvic ultrasound

Answer 31

‘Minor’ - Infection - Postpartum haemorrhage (PPH) - Fatigue - Anaemia - Backache - Breast engorgement / mastitis - Urinary stress incontinence - Hemorrhoids/Constipation - The ‘blues’ ‘Major’ - Sepsis - Severe PPH - Pre-Eclampsia/eclampsia - Thrombosis - Uterine prolapse - Incontinence (urinary or faecal) - Post dural puncture headache - Breast abscess - Depression / psychosis / PTSD

Answer 32

Accidental dural puncture → CSF leakage so reduced pressure around brain Symptoms - Headache -worse on sitting or standing -Starts 1-7 days after spinal/epidural sited - Neck stiffness - Dislike of bright lights Treatment - Lying flat! - Simple analgesia - Fluids and caffeine - Epidural blood patch - seals hole in dura to stop leak so blood injected near the site

Answer 33

If high risk, give prophylactic LMW heparin for 6w - Previous VTE - Antenatal LMW heparin - High risk thrombophilia - Low risk thrombophilia + family history If medium risk, give prophylactic LMW heparin for 10 days - C section - BMI above 40 (Severely obese) - Long admission/ readmission - Any surgery other than perineum repair - Cancer - IBD - SLE - T1DM - IVDU - Nephrotic syndrome - Sickle cell 2 or more from - Obese (30+BMI) - 35y+ - Parity 3+ - Smoker - VTE Fx - Elective cesarean - Gross varicose veins - Pre-eclampsia - Systemic infection - Immobility - Prolonged pregnancy - Stillbirth - PPH - Preterm delivery

Answer 34

Headaches accompanied by one or more of the following symptoms within first 72hrs after birth: Visual disturbances, Nausea or vomiting

Answer 35

Sudden and profuse blood loss or persistent increased blood loss Faintness, dizziness or palpitations/tachycardia post partum haemorrhage mild= less than 1500mls blood loss (estimated) severe = more than 1500mls and continuing OR in shock

Answer 36

Infection plus systemic manifestations - low BP, high HR (90+), high glucose(7.7+), high RR(20+), high or low WBC, temperature above 38 or below 36, low O2 saturation,… leading to organ hypoperfusion and dysfunction Action = sepsis 6 BUFALO in 1st hour - Bloods cultures (and standard bloods) - Urine output - catheter to measure hourly - Fluid Resuscitation eg saline - Antibiotics - broad spectrum initially - Lactate, Hb, glucose - Oxygen given - to get over 94% - PLUS: - Consider delivery - Evacuation of Retained Products of Conception (ERPC) - VTE prophylaxis

Answer 37

3-10 days after birth Emotional and tearful Short lasting

Answer 38

Lactogenesis Prolactin – milk production - When baby sucks, nipple sensors cause the anterior pituitary to secrete more prolactin, stocking up for the next feed Oxytocin aka Milk ejection reflex (MER) - When baby sucks, nipple sensors cause the posterior pituitary to secrete oxytocin causing the myoepithelial cells to contract so that milk is released from the breasts

Answer 39

initial secretion from breasts after birth, form of milk? Colostrum = rich in proteins, vitamin A, sodium chloride, growth factors, antimicrobials, antibodies but contains lower amounts of carbohydrates, lipids, and potassium than mature milk. Higher amounts of lactoferrin - Regulates iron absorption in intestines and delivery of iron to the cells - Protection against bacterial infection, some viruses and fungi -- antimicrobial - Involved in regulation of bone marrow function - Boosts immune system

Answer 40

- Profound decrease in serum levels of placental hormones (human placental lactogen, hcg, oestrogen and progesterone) to pre pregnant levels - Increase of prolactin - Muscle returns to normal thickness (decreases) - ischaemia, autolysis and phagocytosis - Decidua is shed as lochia: rubra(Red) , serosa (pink) and alba (white) -- secretions - Uterus descends inferiorly - Endometrium regenerates

Answer 41

from the delivery of the placenta, to 6w after the birth

Answer 42

dont know what this means but 7-10 days

Answer 43

>80ml per cycle

Answer 44

Difficulty emptying bladder/ bowels - may need to lean forward or only certain times of day Heavy feeling ask about this with heavy menstrual bleeding

Answer 45

Self- questionnaire on NHS website Vaginal examination not always indicated Bloods- FBC - For anaemia symptoms Transvaginal ultrasound - For pressure symptoms Diagnostic hysteroscopy - For persistent bleeding between periods - For significant risk factors - POS, unopposed oestrogen, obesity, cancer history etc

Answer 46

PALM COEIN Polyps Adenomyosis Leiomyoma Malignancy - hyperplasia Coagulopathy Ovulatory dysfunction -- PCOS -- Perimenopausal Endometrial disorders Iatrogenic -- Hormonal therapies Not yet classified -- Chronic endometriosis -- AV malformations Diagnosis then becomes HMB-C if that is the cause identified

Answer 47

1st line = Mirena coil (LNG-IUS) Progesterone delivered locally Effective , might take a while to work, long term in there (5 years) But need to check for risk of STI / unprotected sex Risks PID No lag of fertility on removal Small risk of perforation

Answer 48

1st line = Mirena coil (LNG-IUS) ____?? to reduce size of fibroids Tranexamic acid -- Reduce bleed -- Not contraceptive NSAID -- Reduce bleed -- Not contraceptive Combined pill Oral progesterones - mydroxy…. -- Not contraceptive -- Reduce bleeding -- No affect on infertility Progesterone contraceptive Implant

Answer 49

Myomectomy = removal of fibroids - For big or troublesome fibroids - Keyhole / open surgery - Maintains fertility - Major surgery which carries risk - bleeding, infections, adhesions. Return of fibroids is not protected against. Polypectomy Endometrial ablation - Causes infertility - Devascularized - Minimally invasive - Maybe some pain/bleeding - Best surgical treatment for no fibroids Uterine artery embolization - Block blood supply to shrink fibroids Hysterectomy - Total / subtotal (leaves cervix behind) - Should be considered if other management options have failed - Causes infertility - contraception not needed - Periods stop permanently and no more treatment required - Major irreversible surgery - infection, urine issues - Possible removal of ovaries - menopause symptoms, but may have this even if ovaries are left. Oestrogen has an impact on many other things. History of ovarian cancer may influence decision

Answer 50

non - cyclical (but can have cyclical elements, but not purely) 6 months + In pelvis / lower abdomen Not occurring exclusively with periods / sex / pregnancy

Answer 51

Endometriosis Adenomyosis Leiomyoma (fibroids) Pelvic congestion syndrome Pelvic inflammatory infection (PID) Pelvic organ prolapse IBS Diverticular disease Interstitial cystitis Degenerative joint disease Somatization Nerve entrapmen

Answer 52

normal history (socrates) plus... MOSSCC Menstrual - Regularity, length, heaviness, change over time Obstetric Sexual - partners, type of sex, deep dyspareunia, contraception, STIs Surgical - Abdominal surgery → adhesion Cytology - cervical smear history Contraception Urinary, bowel symptoms, MSK, bleeding along with pain

Answer 53

General demeanor Vital signs Abdominal examination – distension, masses, tenderness, guarding, rebound Vaginal speculum + bimanual examination

Answer 54

Urinalysis + MSU Pregnancy test FBC, CRP, TFT, LFTs HVS (high-vaginal swab) - charcoal + ECS (endocervical swab) - green TVS (transvaginal USS) for adnexal masses MRI may be useful in adenomyosis Diagnostic laparoscopy

Answer 55

Typically post-pregnancy Constant dull ache - Worse standing/ prolonged activity/ prior to periods/ during or post intercourse Varicose veins-y Problems with blood return TVS MRI venogram Pain relief Pressure stockings - return blood Vascular surgery

Answer 56

Infection of the upper genital tract (cervix, uterus, fallopian tubes) Most commonly due to STI (chlamydia, gonorrhea). So risk factors - young, sexual partners, no protection Rarely due to descending infection (e.g. appendicitis) Bilateral lower abdominal pain, could be chronic Deep dyspareunia Abnormal vaginal bleeding (postcoital, intermenstrual or menorrhagia) Vaginal or cervical discharge that is purulent Tender abdomen Fever Bloods HSV and endocervical swabs Diagnostic laparoscopy Contact tracing Ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily for 14 days Antibiotics

Answer 57

Partial or total remove of female external genitalia, or injury to the female organs for non-medical reasons. 1 - clitoridectomy Partial or total removal of the clitoris 2 - excision Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora 3 - infibulation Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora/majora, with or without excision of the clitoris 4- other All other harmful procedures for non-medical purposes, involving pricking, piercing, incising, scraping and cauterisation

Answer 58

illegal to perform or assist compulsory to record and report FGM . police informed if under 18 (including piercing)

Answer 59

Acute - not seen as FGM not done in UK Haemotoma Excessive bleeding Later Dyspareunia Sexual dysfunction - anorgasmia Chronic pain Keloid scar Dysmennorrhea --- Hematocolpos - menstrual blood unable to exit so builds up Urinary outflow obstruction, recurrent UTI PTSD Difficulty getting pregnant

Answer 60

Fear of childbirth Increased amounts of - Cesarean - Postpartum haemorrhage - Episiotomy - cut to allow baby out - Severe vaginal lacerations - Fistula formation - Longer hospital stay Difficulty - Examining vagina - Applying fetal scalp electrodes - Performing fetal blood sampling - Catheterising the bladder

Answer 61

Reversal of infibulation is best preconceptionally. Can be done intra-partum, as the baby is crowning. Defibulation : - Assess extent of scar - Incise fused labia (using diathermy), extending to clitoral region - Raw edges sutured

Answer 62

Onset between 12-13y (11-14.5) Preceded by secondary sexual characteristics and peak height velocity Initial cycles pain free and long gaps between. No ovulation Bleeds duration 3-7 days Interval 21-45 days Thelarche (breast) → pubarche (genital hair) → menarche (periods)

Answer 63

Amenorrhea Oligomenorrhea Precocious puberty Delayed puberty Menstrual disorders - Irregular - Heavy - Dysmenorrhea - PMT(PMS)

Answer 64

Primary - never had period - no period by the age of 16 with the Presence of secondary sexual characteristics --- Hypothalamic --- Hypopituitary --- Ovarian tumours --- Anatomical - No period by 13 in the absence of secondary sexual characteristics --- Underlying chromosomal abnormalities Secondary - had a period but now none for at least 6 months - cessation - Excessive exercise - Weight loss , anorexia - Polycystic ovaries (PCOS)

Answer 65

Menses more than 35 days apart

Answer 66

Puberty before 8 in girls or 9 in boys Physical or hormonal signs Types - Central --- Gonadotropin-dependant --- HPG axis matures. Due to high amplitude secretion pulses GnRH by hypothalamus --- Can occur due to trauma, tumours and hydrocephalus - Pseudopuberty --- Gonadotropin-independent --- Can occur due to adrenal or ovarian tumours

Answer 67

Runs in families Investigations - FBC, CRP, ESR, U/E, LFT, bone profile, TSH and T4 - exclude malnutrition, anaemia, liver disease, iron deficiency, bowel disease, hypothyroidism

Answer 68

often combined pill (rule out migraines and DVT FH)

Answer 69

All people with a cervix aged 25-64 If 65+ and one of your three last smears was abnormal Screening for HPV 16 and 18 are high risk for cervical cancer Aim is to find pre-cancerous change

Answer 70

No evidence of high risk HPV - Rescreen in 3 years if 25-49 - Rescreen in 5 years if 50-64 Yes evidence of high risk HPV - High risk HPV and normal cells → repeat in 1 year - High risk HPV and abnormal cells → refer for colposcopy - High risk HPV and normal cells, 2 years running → refer for colposcopy

Answer 71

if evidence of High risk HPV and precancerous cervical cancer... Direct magnification of cervix Acetic acid sprayed on -- Coagulates and clears mucus -- Triggers reversible precipitation of nuclear proteins. shows mitotic activity Abnormal cells (dividing more than normal, reduced repair) go white iodine stains glycogen in squamous cells - if not taken up, cells are abnormal/ not repairing as well ‘See and treat’

Answer 72

not able to conceive in 1 year, having sex 2 times a week

Answer 73

LMP = 1st day of last period Menstrual cycle = interval between 1st day of last period and 1st day of next

Answer 74

menstrual day 1-5 proliferative 6-15 secretory 16-28 follicular -1-14 luteal 15-28 ovulation 14

Answer 75

DAY 21 corpus luteum produces progesterone

Answer 76

Low oestrogen , low progesterone → stimulate GnRH pulses (hypothalamus) GnRH → acts on hypothalamus to secrete LH and FSH FSH and LH → ovarian follicles enlargen and produce oestrogen , so oestrogen rises

Answer 77

when low - inhibits LH/ FSH when high - stimulates LH lots (and FSH a bit) causing spike mid cycle. this LH causes ovulation

Answer 78

ovulation. the folicle the egg came from becomes corpus luteum --> progesterone

Answer 79

the follicle the egg was released from in ovulation stimulated by LH surge, which was stimulated by rising oestrogen (GnRH stimulated by low prog/oes) this secretes oestrogen

Answer 80

Egg fertilised : - Corpus luteum → beta HCG → acts like LH and keeps corpus luteum going - Corpus luteum persists for 6 months - Placenta takes over role 3 months in Egg not fertilized: - Progesterone peaks day 21 - Lowers LH, which is needed to fuel corpus luteum, so it breaks down (negative feedback) - Lack of corpus luteum means progesterone and oestrogen levels drop, causing period

Answer 81

mostly due to chromosomal abnormalities

Answer 82

Most couples will get pregnant in 1st year. Half of remaining will conceive in second year Give advice about age - if ready, go go go Pre-conception advice - Folic acid --- 3 months prior - first 3 months of pregnancy --- 0.4mg (5mg if high risk) --- to prevent neural tube defect - Stop smoking for both - Stop alcohol for women - Weight loss/ gain --- More maternal risk if overweight --- Less fertilty if overweight --- BMI over 35 not treated for fertility issues ---BMI 30-35 need to self-fund - Up to date cervical smears - 2-3 x week sex - Medication review --- No ACEi --- No recreational drugs --- No valporate - Rubella advice- most vaccinated, booster shot available

Answer 83

Criteria for early referral (6months of trying) 35y+ Known or suspected problem Above causes Abnormal examination normally referral after 1 year i believe

Answer 84

Ovulation - At day 21, should be peak progesterone - <16 - not ovulating, >30 - def ovulating. In between is maybe: so try next month or do series in case of long/irregular cycle Ovarian reserve - This is used to gauge response to fertility treatment, rather than predicting natural conception chances. 1. High FSH - brain needs more to stimulate eggs so high FSH (8.9+) , there is low ovarian reserve. <4 = high ovarian reserve. 2. Antral follicle count (AFC) - scan looking for follicles. 4 = low, 16 = high 3. Anti Mullerian hormone (AMH) - <5.4 = low, >25 = high, but this is age dependant tubal patency - Low risk of having issues (no STI problems, no surgeries): --- HSG (hysterosalpingogram) - dye scan --- HyCoSy - High risk --- Laparoscopy and dye --- Screened for STI first- so as not to flush bugs higher Smears up to date Pelvic swabs for STIs Hormone profile - FSH - Progesterone - TFT - Prolactin

Answer 85

Semen quality - Count should be >15million sperm / ml - Motility should be > 40% (how many are going forwards rather than backwards or wiggling) - Morphology should be >4% (head and tail and look normal) - Total should be >39 million - Repeat if abnormal after a month (time for spermatogenesis) if not normal - Ask about illness, drug use, steroids - Clinical examination - secondary sexual characteristics and testicular size If <5mill sperm/mil - Endocrine - FSH, LH, testosterone, prolactin - Karyotype eg klinefelters - Cystic fibrosis maybe: Testicular biopsy (azoospermia)- cryopreservation Imaging - vasogram, ultrasound, urology

Answer 86

Mild → Intrauterine insemination (IUI) = Ejaculate into sample, then sample injected into womb Moderate → IVF = Fertilise egg with lots of sperm in dish, then implant embryo Severe → Intracytoplasmic sperm injection (ICSI) = Single sperm injected into a single egg separately. Implant embryo If no sperm → - Surgical sperm recovery - Donor insemination - IUI or IVF (ICSI not needed as sperm good quality) - Reverse vasectomy - Hormonal treatment ---- hypogonadotropic hypogonadism → gonadotropins given ---- Hyperprolactinemia → suppress Conservative measures - Occupation --- Balls too near bodies for too long → heat eg truck drivers, cyclists - Looser boxers (not definitely a cause but no harm trying) - Stop smoking and drinking - Folic acid, antioxidants - Weight

Answer 87

Low FSH/LH causing anovulation Cause: - Weight loss - Stress - Extreme exercise Treatment - Normalise weight - FSH and LH - GnRH pump

Answer 88

Normal FSH Cause = PCOS Need 2 of 3: - Seen on scan - more than 12 on an ovary, or high volume - Oligomenorrhea / amenorrhea / anovulation - Raised androgens - clinical or biochemical Treatment - Normalise weight - Ovulation induction - clomiphene or tamoxifen - Metformin (adjuvant)

Answer 89

Cause = menopause High FSH Treatment- Donor egg

Answer 90

Ovulation induction, (helps ovulation) first line infertility treatment

Answer 91

- remove patches surgically. more effective than medicine. could connect tube around damaged area (amastamosis) - undo adhesions surgically

Answer 92

<40 - 3 cycles 40-42 - 1 cycle Treat after 2 years or 12 months insemination or if old mum Multiple pregnancies (main risk) ectopic pregnancy Miscarriage Possible fetal abnormalities Ovarian hyperstimulation syndrome Egg collection could cause - trauma, infection, bleeding Ovarian cancer

Answer 93

analgesia - no pain anaesthesi - no sensation

Answer 94

Intermittent intense periods of pain Seconds-minutes Continues for many hours 1st stage - uterine contractions, cervical dilation 2nd stage - descent of baby’s head, stretching of vagina and perineum Pain moves therefore

Answer 95

Gas and air - Oral analgesia - paracetamol, codeine Parenteral opioids ‘ single shot’ IV opioids administered with patient button Regional techniques ---> Spinal / epidural / combined spinal epidural (CSE)

Answer 96

entonox 50% N20 nitrous oxide, 50% 02 Rapid onset Low risk Self-limiting Green- house gas

Answer 97

Morphine, diamorphine Sedation, respiratory distress, n/v Could cross placenta - make baby sleepy too

Answer 98

Fentanyl, alfentanil, remifentanil Rapid onset, rapid offset

Answer 99

Spinal / epidural / combined spinal epidural (CSE) Spinal - into CSF - One off injection - Feel pop/ give when going through dura - Better anaesthetic block - Shorter lasting- 2h Epidural - into epidural space (superficial to the dura) - Long lasting . patient can top up Spinal cord terminates at L2 so perform at L3/4 L3/4 is where tuffier's line is : join two iliac crests What is injected in? - Local anaesthetic --- Bupivacaine - Opioids --- Fentanyl --- Diamorphine Why? - Maternal pain - Cardiac condition - valve regurgitation - Multiple births - instrumental/ operative delivery likely Why not? - Mum doesnt want - Local infection - Allergy - Coagulopathy - Hypovolemia - Systemic infection - Abnormal anatomy Complications - CSF leak - Headache - allergy/ anaphylaxis - Hyoptension - Bradycardia - Haematoma

Answer 100

Preconception assessment - Optimise disease control - Defer pregnancy until condition is stable - Effective contraception until ready to conceive Medication review (start / stop) Advise on risks Effect of pregnancy on preexisting conditions - Some worsen eg mitral stenosis - Some improve eg rheumatoid arthritis Effect on preexisting conditions on baby and pregnancy - Risks of complications eg HTN → pre-eclampsia - Drugs may cause abnormalities on baby Plan delivery - Safest mode - Antenatal care

Answer 101

- iron def (micro), then folate def (macro) -- due to increased number of rbc - low birth weight, prematurity - supplements

Answer 102

Risk of exacerbation of asthma is high if poorly controlled at time of conception Risk of fetal growth restriction due to inadequate placental perfusion Risk of premature delivery if mum deteriorates all asthma medication can continue to be used safely

Answer 103

Low risk - ASD - VSD - aortic/ mitral incompetence High risk - Aortic stenosis - Aortic coarctation - Prosthetic valves Should see specialist - echo Alter medication to be safe for baby Monitor fetal growth larget cause of maternal death

Answer 104

Itching, no rash Raised ALT/AST Resolves after but likely to reoccur in further pregnancies Treatment= Symptomatic - Antihistamines - Ursodeoxycholic acid Risk still birth / prematurity Common More so scandinavia, chile

Answer 105

Thyroid crisis with cardiac failure = maternal risk Thyrotoxicosis through to baby - transfer of antibodies through placenta review medication - some not appropriate

Answer 106

May cause early fetal loss / impaired neurodevelopment Needs to be treated early - thyroxine

Answer 107

Retinal screening Renal function Folic acid higher dose - 5mg Prevention of complications = glycaemic control risks to mum - diabetic ketoacidosis - preeclampsia - retinopathy progression - hypoglycaemia risks to baby - shoulder dystocia (Related to macrosomia) - macrosomia - miscarrigae, still birth - fetal abnormality - prematurity - respiratory distress - neonatal hypoglycaemia, hypocalcaemia, polycythaemia

Answer 108

to mum - HTN - superimposed pre-eclampsia - renal disease worsens to baby - intrauterine growth restriction - prematurity - still birth - fetal abnormalities more likely to get ascending infections due to dilated urinary tract

Answer 109

Risk due to medication (anticonvulsants) mainly, but also the condition for mum: - more seizures - SUDEP - sudden unexpected death in epilepsy - mainly for medication non compliance for baby: - epilepsy inheritance - fetal abnormalities - fetal hypoxia during seizures Pre-pregnancy assessment, Monitoring to check for fetal growth - Medications may need to be changed - sodium valproate and other anticonvulsants are teratogenic - neural tube defects, ASD, cleft palate, autism, learning difficulties, polydactyly - High dose folic acid 5mg - Plan delivery- avoid prolonged labour - Control seizures - Screen for abnormalities - Postpartum support

Answer 110

Risk factors - BMI - Age - Operative delivery DVT prophylaxis if high risk DVT found - LMW heparin Warfarin teratogenic

Answer 111

Plasma volume increases (1-2L) - Sodium and potassium retention (Rather than just one!) - Increase in natriuretic factors (get rid of salt) - Increase in anti natriuretic factors (retain salt) - this outweighs Osmolality - Reduction in osmolality, reduction in concentration of dissolved particles - But no diuresis (trying to get rid of the water) - so the osmolality threshold must be reset in pregnancy - Reduced threshold of thirst - drink at lower osmolalities - Less oncotic pressure - less serum albumin

Answer 112

Increase in size - dilation (+20%) - Loss of muscle tone (due to progesterone) Compression of ureters (esp in R kidney) - Fluid backing up in kidney - Hydronephrosis - Urine stasis - increased risk of UTI Increase in blood flow to kidneys (+50%) Increase in GFR Increase in creatinine clearance → reduced serum creatinine Glucosuria and aminoaciduria- not reabsorbed as much as salt

Answer 113

Increase in HR : from 5th week until term Increase in stroke volume Increase in cardiac output Early : - Reduced BP (both diastolic and systolic) - Reduced peripheral resistance Late: - Increased BP (both diastolic and systolic) Early phase - peripheral vasodilation Dilution anaemia - Big increase in red blood cells. But plasma increases even more. So concentration (of rbc and haemoglobin) is reduced - Increase in demand for more rbc Small increase in white blood cells Blood become hypercoagulable → risk of thromboembolism (up to 6 months postpartum) - Increase in fibrinogen levels - So ESR increased - Increase in clotting factors- 7, 9, 10 - Increase in plasminogen activator inhibitor

Answer 114

Heart goes up and left, Apex goes more lateral, more horizontal So this means ECG changes occur - Inverted T wave in lead 3 - Prominent Q wave in lead 3 and aVF - QRS axis changes - left deviation Altered heart sounds

Answer 115

Increase in pulmonary blood flow Increase in atria and ventricle size and ventricular muscle size

Answer 116

Maternal oxygen consumption increases Mechanic - Greater thoracic volume --- Diaphragmatic elevation (+4cm) --- Subcostal angle increases - ribs more splayed - Reduced thoracic compliance - Better flow in and out - tracheo - bronchial smooth muscle relaxation (progesterone) - Increase in tidal volume (so other volumes reduce) - Reduce in overall lung volume Biochemical - Tidal volume increase → reduced CO2 partial pressure - blowing off CO2 (due to progesterone making central CO2 chemoreceptors more sensitive) --- Because fetal CO2 needs to diffuse to mum so mums should be lower to allow that steeper gradient allowing more rapid CO2 loss --- Risk of respiratory alkalosis - but kidney excretes excess bicarbonate HCO3- maintaining pH balance --- Lower HCO3- in blood - a state of compensated respiratory alkalosis - PO2 oxygen concentration vs %Hb saturation curve --- Maternal: shift to the right - allowing oxygen to be released to the fetus at lower levels - Bohr effect (due to increased DPG affinity in rbc) --- Fetus: shifts to the left - favour O2 uptake - double Bohr effect (due to low DPG affinity)

Answer 117

Delayed gastric emptying Cardiac sphincter relaxation → risk of heartburn Anesthetic risk - aspiration pneumonitis

Answer 118

Reduced CCK secretion → Less inhibition of acid synthesis, lower pH in tummy → makes dyspepsia worse Reduced gallbladder motility → risk of gallstones Obstetric cholestasis

Answer 119

Reduced gut transit time → More nutrient uptake in small bowel and more water uptake in large bowel Risk of constipation

Answer 120

Hyperemesis gravidarum - chronic pregnancy vomiting Ptyalism - sialorrhea gravidarum Sensation of excess salvation Altered appetite - Cravings - Pica - ingestion of non-nutritive substances (Eg mud, batteries, soap, coal, paper)

Answer 121

Weight gain (mean 12.5kg) Glucose - Principle nutrient for fetus - Hyperlipidaemia and glucosuria for mum - No limit of glucose transport from mum to baby- high levels of glucose will go to baby and this can be harmful including baby growing too big and cleft palate Insulin - More insulin in response to glucose - Decreased insulin sensitivity - more insulin resistance - Risks gestational diabetes which is dangerous for mum and baby

Answer 122

Mass increases - smooth muscle hyperplasia and hypertrophy - Potential to compress aorta and inferior vena cava - aortocaval compression syndrome - lying lateral helps to take off the pressure Uterine natural killer cells - Control fetal evasion, immune protection Spiral arteries remodelled - endovascular invasion - Dilation→ wild bore, low resistance → greater supply of maternal blood If this fails you are more likely to have - Premature delivery - Preeclampsia - Recurrent miscariage - Fetal growth restriction - Placental abruption

Answer 123

Increased softness Increased vascularity Blue-tinge (caused by oestrogen) - Chadwicks sign - Pooled blood Increased volume Fat deposition around gland tissue Increased serum prolactin

Answer 124

Primigradivity Black Young female Pre-existing renal diseasef HTN Collagen vascular disease Multifetal pregnancies

Answer 125

New HTN after 20w Systolic >140 Diastolic>90 No /little proteinuria 25% develop pre-eclampsia

Answer 126

New HTN after 20w - Systolic >140 - Diastolic>90 Yes proteinuria ≥ 0.3g protein /24hr ≥ +2 on urine dip specimen And possible the following - Severe headache - Visual disturbances e.g. blurring/flashing lights - Papilloedema - Clonus - Liver tenderness - Abnormal liver enzymes - Platelet count falls to < 100 x 109/litre Spiral arteries don't dilate → inadequate blood delivery to placenta → baby growth is not correct

Answer 127

features of preeclampsia plus generalised tonic-clonic seizures

Answer 128

Early - <34 week Worse prognosis Late >34 weeks

Answer 129

Symptoms - Most asymptomatic - Visual disturbance - Headache - Weight gain - Epigastric pain - Oedema Signs - Hyperreflexia - Clonus

Answer 130

Haemoglobin, platelets Serum uric acid Liver function tests If 1+ protein by clean catch dip stick Timed collection for protein and creatinine Accurate dating and assessment of fetal growth

Answer 131

- Not much can be done - Restricted fluid - 80mls if severe - Delivery baby cures - good for mum, but may not be good for baby - Hospitalization for assessment - IV MgSO4 (anticonvulsant) if hyperreflexia - Antihypertensive - stabilise BP ---Labetalol --- Nifedipine - monitor baby, bloods, urine output, coagulation

Answer 132

Maternal - Gestational age 38 wks - Platelet count < 100,000 cells/mm3 - Progressive deterioration in liver and renal function - Suspected abruptio placentae - Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting Fetal - Severe fetal growth restriction - Nonreassuring fetal testing results - Oligohydramnios Deliver vaginally if poss Induce labour Epidural Hydralazine or labetalol are pretreatments to reduce hypertension during delivery.

Answer 133

high BP prior to pregnancy Before 20w, if BP not assessed before pregnancy Not resolved post-partum

Answer 134

Prematurity =Born before 37w term = 37-42 w Low birth weight = born less than 2.5kg May be related or appropriate for their gestational age VLBW <1500g ELBW <1000

Answer 135

- developmental delay - visual impairment - chronic lung disease - cerebral palsy

Answer 136

50% have none Non recurrent - Antepartum haemorrhage and vaginal bleeding - Multiple pregnancy (eg twin) Recurrent - Race - Previous preterm birth - Genital infection --- Increased prostaglandins → premature delivery --- BV --- UTI --- Appendicitis --- Pylonephritis Cervical weakness

Answer 137

primary - Smoking cessation - STD prevention - Prevent multiple pregnancy - fewer embryos transferred with IVF - Advice on physical / sexual activity Secondary - Identify those at higher risk and follow up - TV ultrasound ---- Cervical length - shorter with funner in uterus above it - Qualitative fetal fibronectin test - ---Extracellular matrix protein -- May indicate attachment (to decidua (uterus lining)) disruption - Examination - Exclude infection - Treatments --- Progesterone IM/ pessary --- Cervical cerclage (Treatment for cervical shortness) Tertiary - Drugs to stop contractions - tocolysis - Steroids to improve fetal lung maturity

Answer 138

Any part of placenta that implants onto lower segment Major = reaching/ covering os Minor = not Diagnosis Anomaly scan 20w Repeat TV scans - minor at 36w, major at 32w

Answer 139

If placenta <20mm from os → c section 38-39w

Answer 140

ABCDE Examination - general, abdominal, vaginal Fetal monitoring Steroids if <34w

Answer 141

placenta envades through myometrium accreta --> increta -->percreta Pick up on scan Arrange caesarian (CS) at 36-37w Discuss possible outcomes with parents Discussion of hysterectomy at same time, or leave it but risk infection Interventional radiology and ureter management Arrange blood to be available as may be needed Make a critical care bed available

Answer 142

Vessels over cervical os, unprotected by placental tissue or umbilical cord. may rupture Major risk to baby, not mum Early delivery

Answer 143

Premature separation of placenta from uterine wall Can be concealed/revealed effect Fetal distress→ maternal shock Large → resuscitation of mum Management Consider premature delivery Blood transfusion May need to go to intensive care

Answer 144

(4 T’S) Tissue retention Surgery to remove remaining placenta Tone : uterus not contracted Trauma - tear → repair Thrombin - blood clotting abnormality, so check clotting

Answer 145

Big baby Nulliparity and grand multiparity Multiple pregnancy Precipitate or prolonged labour Maternal pyrexia Operative delivery Shoulder dystocia Previous PPH

Answer 146

Obesity Diabetes Impaired immunity/ immunosuppressant medication Anaemia Vaginal discharge History of pelvic infection History of group B Strep infection Amniocentesis and other invasive procedures Cervical cerclage Prolonged spontaneous rupture of membranes Group A Strep infection in close contacts / family members

Answer 147

Seizure in a woman with preeclampsia Assume seizure in pregnancy is eclampsia until proven otherwise IV MgSO4 4mgs over 5 mins Treat HTN (labetalol, nifedipine) Delivery Stabilise mum first Deliver if bradycardia

Answer 148

Vasospasm Baby isn't getting any blood so risks fetal morbidity Risk factors - Membrane rupture - Polyhydramnios (i.e. a large volume of amniotic fluid) - Long cords - Fetal malpresentation - breech, tummy down - Multiparity - Multiple pregnancy Management - Get mum on knees to take pressure off , feet higher than head - Alleviate pressure on cord - with hand - Go to theatre - Monitor baby

Answer 149

= Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the fetal head Head comes out but not rest of body Risky for mum and baby Complications Mum - postpartum hemorrhage - Vaginal tear - Psychological impact on mum Baby - Hypoxia - Cerebral palsy - Fits - Injury to brachial plexus (due to maneuvers done) --- Often resolves --- Physio review needed Risk factors - Macrosomia - big baby (related to diabetes) - Maternal diabetes - Previous shoulder dystocia - Disproportion between mother and fetus - Postmaturity and induction of labour - Maternal obesity - Prolonged 1st or 2nd stage of labour - Instrumental delivery Management - HELPER H – Call for help (emergency buzzer) E – Evaluate for episiotomy L – Legs in McRoberts Hold legs bent towards mums chest P – Suprapubic pressure Decompress anterior shoulder to pass under pubis E – Enter pelvis R – Rotational manoeuvres Press on anterior shoulder or posterior arm moved (R – Replace head and deliver by LSCS -Zavanelli) Rare --- Risks skull fracture --- Difficult

Answer 150

Hormonal - One off high progesterone pill - Inhibits ovulation - Decreases viability - Kills sperm - May stop implantation Pros - Widely available - One off Cons - Feels sick - STI not protected - No long term pregnancy protection Non hormonal contraception - Copper coil - Needs professional fitting Pros - Most effective - Can be used after 72 h - Long term contraception as well Cons - Risk of PID - Painful insertion

Answer 151

Pros - More effective than female - Minor operation - Permanent Cons - Not reversible (not NHS) Complications: - Infection - Chronic scrotal pain - Sperm antibodies - Sperm granulomas

Answer 152

Wait til period to flush out eggs then all good Pros: Highly effective Permanent No hormones Cons : Surgery Anaesthetic bladder/ bowel injury Not reversible (on nhs, hard privately, and risk ectopic pregnancies)

Answer 153

Progesterone coil Mirena Endometrial atrophy and may suppress ovulation Pros - Long term - Effective - May help with menstrual symptoms Cons - Need STI screen negative - Risk PID - Risk ectopic pregnancy - Fitting may be painful - Esp if not pregnant before

Answer 154

Copper Coi Non hormonal Makes a foreign body reaction - preventing implantation and sperm transport Pros - Effective - Long term - Non hormonal - Emergency contraception - effective immediately Cons - Menstrual symptoms- spotting - Risk of PID - Risk of ectopic preg - Risk of perforation at time of insertion - sti screen negative before insertion

Answer 155

Plastic releases progesterone slowly Pros - Most effective contraceptive - Immediately reversible after taken out - 3 years lasting - Can help menstrual stuff - No oestrogen effects Cons - Minor surgery for in and out - Infection - Occasionally uncomfortable

Answer 156

High dose progesterone injected and slowly released Depo provera IM sayana pres SC= Self administered Pros - Reversible - Effective - Can help with symptoms menstrually - Far apart - 12/13weeks Cons - Menstrual symptoms - Delay of fertility after stopping - Weight gain - Lowers bone mineral density in younger age group

Answer 157

If breastfeeding fully day and night, protected for 6 months If hand pumped / bleed/ period restarts - no longer effective Not recommended - should have other contraception in place

Answer 158

Pros If used well, very effective Cons Hard to use well Need few cycles to get data Not good if irregular cycles Includes periods of abstinence

Answer 159

Pros Sti protection Can be inserted any point before intercourse (not during male erection) Cons Fitted by staff (one time) Spermicide can be messy Can be dislodged Must remain in between 6-30h post intercourse

Answer 160

Thickens cervical mucus, maintains thin womb lining, decreases tubal motility, can stop ovulation Taken continuously 2 types (3h window vs 12h) Pros - Prevents oestrogen side effects (breast tender, headaches) - Can be used with oestrogen contraindications (migraine, smoker, BP) - Can be used in morbidly obese Cons - Shorter window to take - Less effective than COCP - Increased risk of ectopic pregnancy - decreased tubal motility - Ovarian cysts may develop

Answer 161

Flexible soft vaginal ring . Emits low oestrogen dose Insert for 3w, then 1w break then new one Pros Works well despite diar/vom Ease PMS and bleeding Cons Side effects - headaches, vaginal discharge, breast tenderness - but normally temporary

Answer 162

Oestrogen and progesterone suppresses LH surge so prevents oestrogen Thins womb and makes cervical mucus harder for sperm to penetrate Can do 3w on, 1w off, or back to back until break through bleed Pros - Reversible -Can help acne - Can help periods lighten / less painful - Protective against ovarian ad endometrial cancer - 12h window Cons - Drugs interactions - No STI protection - Possible increase risk of breast and cervical cancer - Increase risk of clot - Reduced efficacy if taken late / post vomit

Answer 163

staging system based on history contraindications 1- no restriction to using 2- advantages of contraception outweigh disadvantages 3- disadvantages generally outweigh advantages Only sexual practitioner can green light 4- def no no

Answer 164

- menstrual symptoms - parity (coil more sore) - previous success with contracpetion - smoking (no OCP) - migraine (no OCP) - medication review - liver problems - age (injectables not good for younger age group) - breastfeeding (no OCP) - clot history (no OCP)

Answer 165

Must have sufficient maturity and intelligence to understand Must persuade them to talk to their parents or allow doctor to You think they will have sex regardless You think their mental health will suffer if you do not The advice/ treatment is in their best interest to give advice/ contraception to under 16s (over 13s - 13 cant coonsent - safeguarding) gillicks applies to under 16 medical and surgical treatment but does not include contraception, terminations or sexual health

Answer 166

Loss length : 2-8 days (mean 5 days) Cycle: 21-35 (28) Loss volume: 60-80mls

Answer 167

Heavy Menstrual Bleeding HMB that occurs at expected intervals of the menstrual cycle

Answer 168

Menstrual blood loss that is subjectively considered to be excessive by the woman and interferes with her physical, emotional, social and material quality of life

Answer 169

Uterine bleeding that occurs between clearly defined cyclic and predictable menses

Answer 170

Any menstrual bleeding from the uterus that is either abnormal in volume (excessive duration and heavy), regularity, timing (delayed or frequent) or is non-menstrual (PCB, IMB, PMB)

Answer 171

Coagulopathy Ovulatory Endometrial dysfunction Uterine fibroids aka leiomyomas Uterine polyps Adenomyosis Endometriosis

Answer 172

Gynecological malignancy presents as intermenstrual bleeding (IMB), post menopausal bleeding (PMB) or postcoital bleeding (PCB) rather than HMB

Answer 173

FBC +/ haematinics Coagulation TFT TVS Hysteroscopy - possible endometrial biopsy Indicated if aged >45yrs and - IMB - Unresponsive to treatment - New onset/change in menstrual pattern Consider at any age if: - Persistent IMB or irregular bleeding - Infrequent heavy bleeding who are obese or have PCOS - Women taking Tamoxifen - Treatment for HMB has been unsuccessful - New onset/change in menstrual pattern

Answer 174

LNG IUS - mirena progesterone coil Antifibrinolytics (Tranexamic acid) NSAIDs (Mefenamic acid) Prostagens COCP POP Danazol (steroid) Reassurance (primary care)

Answer 175

(secondary care) Endometrial ablations Hysterectomy Uterine artery ablation Myomectomy - resection of fibroids

Answer 176

Indications Heavy menstrual loss Not expecting amenorrhoea Normal endometrium Uterus less than 12 weeks size Completed family Contraindications Malignancy Acute PID Desire for future pregnancy Excessive cavity length

Answer 177

Miscarriage Ectopic pregnancy Hyperemesis Gravidarum Molar pregnancies - GTD (gestational trophoblastic disease)

Answer 178

20% of pregnancies Threatened = Any pregnancies with vaginal bleeding, with or without or abdominal pain (But 60% will remain viable ) Inevitable = The cervical os is open enough to admit one finger - body ready to (and will) expel embryo. bleeding happens Delayed (aka missed/ silent)=Diagnosed with ultrasound scan (TV) -Gestational sac but no foetus within - maybe fetal pole but no fetal heart rate. foetus has died or not developed. often no bleeding, may be picked up Complete = all pregnancy tissue has exited from uterus Incomplete = Some of the matter has been expelled from the uterus, some has remained Management - Expectant = Wait and see. preg test after 3w, if positive, come back, if negative, all finished ---- (less so with missed, as it hasnt happened yet) - Medical --- Usually complete within 24h if less than 12w, otherwise few more days --- Antiprogesterone then prostaglandin (misoprostol) --- pregnancy test after 3w as before - Surgical --- Products of conception removed by suction, under anaesthetic --- Small risk of uterine perforation, infection, womb scarring, failure, --- pregnancy test after 3w as before

Answer 179

The serum bhCG levels in a woman with a healthy, viable pregnancy during the first few weeks, can be expected to double in 36 to 48 hours.

Answer 180

1% of pregnancies Site - Most common = fallopian tube (90%) --- Fimbrial (12%) --- Ampullary (50%) --- Isthmus (20%) --- Cornual/ interstitial (10%) - junction of fallopian tube and uterus - Ovary - Abdomen (a baby was born after growing in the liver!) - Cervix Presentation Intermittent → persistent pain, normally low down on one side Vaginal bleeding Nausea Full, off food Pain pooing/weeing Investigations - An ectopic pregnancy must be considered a possibility when an empty uterus is found on ultrasound scan in a patient with a positive pregnancy test. Even with low beta HCG levels - Slowly rising or static beta HCG levels Management - Rarely treated expectantly (watch and wait), not recommended (very very rare to deliver alive, and risky to leave -- rupture!) - Medical --- Methotrexate (chemo). And monitoring - Surgical --- Fallopian tube removal --- or removal of ectopic pregnancy from the tube- Risk of incomplete removal so medical given too

Answer 181

a sharp, sudden and intense pain in your tummy feeling very dizzy or fainting feeling sick looking very pale

Answer 182

pregnancy test

Answer 183

Presentation - severe Vomiting → dehydration +Ketosis - Severe weight loss can cause but more rarely More common in high levels of betaHCG (twins, molar pregnancies) Treatment - Regular small meals - IV fluids - Vitamin supplements - Dalteparin to prevent clots - Antiemetics

Answer 184

Molar pregnancies - GTD (gestational trophoblastic disease) aka hydatidiform moles Partial molar - Some fetal tissue, some molar tissue - Triploid = 2 sperm fertilise Ovum that contains genetic material Complete molar - No fetal tissue, all molar tissue - Diploid =2 sperm fertilise ovum without any genetic material (empty ovum) (no maternal component) - chance of turning into carcinoma more common in Asian pregnancies diagnosis: characterized by presence of large fluid filled bubbles “snowstorm” on TV ultrasound scan Beta HCG levels extremely high Treatment - Empty uterus surgically preferred (less chance of material remaining) - Methotrexate (chemo) offered if beta HCG does not fall satisfactorily (10%) - persistent trophoblastic disease

Answer 185

Classified as high or low risk at beginning of pregnancy. Continuous risk assessment throughout in case it changes. still birth avoidance High risk - Come to antenatal clinic appointments, extra scans, different monitoring - Maternal factors : Geriatric, young, smoking, alcohol, drugs, safeguarding, BMI - Previous pregnancy complications eg PPH, pre-eclampsia - Current pregnancy complications eg Pre-eclampsia - Medical condition - inc diabetes, kidney problems, HTN, epilepsy Low risk - Care provided in community - midwife

Answer 186

Ultrasound 1. Growth - Head and abdominal circumference and Femur length → estimated body weight - Look for intrauterine growth restriction (higher risk of stillbirth) - Asymmetrical 70% --- Normal head size, small body and limbs --- Smoking, preeclampsia - Symmetrical 30% --- Both head and body small --- Infection, downs 2. umbilical cords - blood flow to baby -- dopplers 3. Fluid around baby - liquor volume, fetal urine indicates kidneys are working

Answer 187

Intermittent auscultation - For low risk pregnancies!! - Pinard stethoscope - Hand-held doppler device - 1st stage (4cm-9cm)- at least 1 min after a contraction, every 15 mins - 2nd stage (fully dilated)- at least 1 min after a contraction, every 5 mins Pros - Non invasive - Non expensive - Can be used in home setting Cons - Not super sensitive - Not able to monitor long term - Affected by maternal movement and heart rate continuous monitoring - For high risk pregnancies!! - Cardiotocography (CTG) Pros - Long term monitoring - Identifies hypoxic babies Cons - Can't move around as much - Hospital based - More expensive - No improvement in outcomes in low-risk pregnancies

Answer 188

very rare Abdominal - True beat-to-beat fetal HR Scalp - Invasive - on baby’s scalp - Gold standard - Risks scalp injury and perinatal infection

Answer 189

Speculum into vagina Then little tube does blood prick Measures pH

Answer 190

Cessation of menopause - 12 months ammenorhea for diagnosis Average 51y Perimenopause =Period leading up to menopause

Answer 191

hysterectomy

Answer 192

SHORT Hot flushes - impact sleep Menstrual irregularities Mood swings, irritability Loss of memory, poor concentration Loss of confidence Lack of energy Headaches Dry and itchy skin Joint pains MEDIUM Urogenital atrophy - recurrent UTIs, postmenopausal bleeding, dysparenuria, urinary incontience LONG Osteoporosis (no oestrogen) CVD - increased prevalence with early menopause Dementia - increased prevalence with early menopause

Answer 193

Lifestyle advice CBT Pharmacological Hormonal - HRT - Vaginal oestrogen Non-hormonal - Clonidine (alpha adrenergic receptor agonist) - SSRI (fluoxetine, paroxetine, citalopram, sertraline) - SNRI (venlafaxine) - Antiepileptics (gabapentin)

Answer 194

Oral / transdermal TD for : - GI issues eg crohns - VTE/ stroke risk eg HTN - epilepsy/ migraine require steady absorption - Patients choice Pros - Protects bone mineral density - Menopause symptoms relief Cons - Breast cancer (Esp if HRT is oestrogen and progesterone) ... Contraindication if they get diagnosed or have history - VTE ... Only really for oral HRT, not transdermal - CVD...Only if 60y+ ... so Be careful starting in over 60s - Stroke ... Only really for oral HRT, not transdermal - Risk irregular bleeding

Answer 195

premature ovarian insufficiency POI Menopause <40 Causes - Idiopathic (most) - Chromosome abnormalities - Autoimmune disease - Enzyme deficiency - Surgery - Chemo - Radiotherapy Diagnosis FSH samples 4 w apart 4 months of amenorhea

Answer 196

Still need contraception Fertile for 2y if menopause <50 y Fertile for 1y if menopause >50y

Answer 197

BRCA1, BRCA2 gene (family history of breast cancer) Radiotherapy below 35yrs (eg Hodgkin's lymphoma) HRT Nulliparous Not breastfeeding Moderate- high alcohol consumption Li fraunemi syndrome (genetic)- predisposed to lots of cancers OCP obesity, exercise Early menarche, late menopause Dense breast tissue

Answer 198

increased incidence but reduced mortality

Answer 199

50-70 invited (47-73 in trial now), every 3 years <50 breast tissue is denser (rather than fatty) so not likely to find anything if high risk woman (BRCA1/2) - then you will be offered younger, but due to breast density, MRI with contrast is used instead - From 30y, MRI - From 40y MRI and mammograms MRI also for breast implant patients

Answer 200

M1 Normal M2 Benign M3 Indeterminate M4 Probably malignant M5 Almost certainly malignant

Answer 201

Mass Microcalcification Parenchymal distortion/ deformity - breast tissue pulled in by cancer cells Asymmetrical density Large axillary lymph nodes Clinical recall -if patient has a lump Technical recall - unclear results

Answer 202

US, biopsy, further mammograms

Answer 203

BRCA1 - female breast cancer, ovarian cancer BRCA2- female and male breast cancer, ovarian, prostate and pancreatic cancer

Answer 204

Most appear normal Skin tethering Nipple discharge including bleeding Palpable lump - Most common painless. Pain is rare - Irregular - Hard - Fixed Nipple inversion Locally advanced disease- coming through skin Metastatic presentation

Answer 205

- clinical - imaging - biopsy each graded 1-5

Answer 206

Lumpectomy (/breast conservation/wide excision) + Radiotherapy (always given as adjuvant ) - Small tumour <25% or 25-50 - No previous radiotherapy - Chemotherapy beforehand is possible Mastectomy - Large tumour - Multiple cancers in same breast, esp if different quadrants - May have reconstruction following this Axilla surgery 1. Full axillary clearance - All glands removed - For axillary disease - Palpable or imaged node - Can risk lymphoedema in arm - can be permanent and unpleasant 2. Sentinel node biopsy - Remove 1-4 nodes that are most likely to have cancer (dye scan) - For no axillary disease after stuff is removed -- pathology and staging -Then look to see if they need to clear more or not or do radiotherapy etc gene analysis?

Answer 207

Chemo - Only for high risk of disease - Young, Advanced disease, aggressive, oncotypes Endocrine - Tamoxifen inhibits oestrogen receptor on breast cells --- Poorly tolerated- menopause-like SE --- For premenopausal mainly - Aromatase inhibitor - stop post-menopausal women producing oestrogen by converting from androgens, does not affect ovary oestrogen (only for oldies) Radiotherapy --- For lumpectomy always --- For aggressive disease post-mastectomy sometimes ---Can change breast shape and texture Bisphosphonates - For high risk cancer, post menopausal women - Reduce rate of bone metastases Trastuzumab - Alongside chemo - For Her 2 - Small risk of cardiac failure Reconstructive surgery

Answer 208

Hard Fixed Painless Irregular Skin tethering Nodal swelling Older age

Answer 209

Benign breast change Fibroadenoma Cyst Sebaceous cyst Papilloma Fat necrosis/haematoma Mastitis/abscess Cancer Sarcoma, lymphoma, metastases Implant related: (migration, capsule formation, rupture, edge or crease)

Answer 210

25-30y Smooth, mobile, non tender, 1-3cm Leave unless it is growing

Answer 211

35-55y 1mm-20cm May be multiples May feel cystic or hard and irregular If symptomatic - aspirate Will cease at menopause (unless on HRT)

Answer 212

Tender, painful, rubbery nodularity Cyclical variation Any age, usually young Reassure, no tx Benign breast change / aka fibrocystic change

Answer 213

Breast sepsis Red, tender, swollen, painful, flu-like symptoms May be lactational may go on to abscess Treatment = antibiotics, aspiration <50y Can look like inflammatory breast cancer - refer if antibiotics dont settle

Answer 214

(Blood) nipple discharge (needs imaging just in case) Removed generally Risk factor for breast cancer

Answer 215

Low risk at start and throughout pregnancy Spontaneous onset of labour- No induction of labour No spinal or epidural or general anaesthetic Baby born in vertex position No forceps, ventouse, C- section or episiotomy (perineum cut) Born between 37-42w ('term') After birth, mum and baby in good condition

Answer 216

Latent stage - Contractions (ir/regular) - Mucoid plug (“show”) is lost - Cervix begins to dilate :0-4cm - Length 3-4days, long in first pregnancy First stage - Stronger contractions - Cervix dilates up to 10cm - 0.5cm/hour is acceptable in primiparus Second stage - From full dilation up to birth Third stage - After birth up to placenta expulsion (Fourth stage) - Early postnatal period - skin to skin → increased oxytocin production in mum and baby --- Regulates baby's heart rate and breathing --- Contracts mums uterus --- bonding

Answer 217

Prostaglandins - cervical ripening Oxytocin - surges at start of labour - causes uterus contractions (Triggered by baby's head pressing on bottom of uterus - positive feedback, so occiput anterior most stimulation as engages most receptors in this area due to angle) Oestrogen - surges at start of labour - inhibits progesterone to prepare labour smooth muscle Beta endorphins- natural pain relief Adrenaline - released when birth is imminent - energy for labour (but can reduce oxytocin and slow contractions due to fight/flight) Prolactin - to begin milk production in mammary glands

Answer 218

Cephalic = head down (most) Breech = head up (most - C section) Transverse lie = baby is horizontal (all C section)

Answer 219

Starts in fundus (pacemaker) Shortens muscle fibres Contractions increase in power as labour progresses Fetus forced downwards - more pressure on cervix

Answer 220

cervical ripening Cervix shortens shrinks in thickness from 4cm to very thin Cervix is closed by mucus plug

Answer 221

prontal, temporal, parietal

Answer 222

Descent - Fetus descends into pelvis from 37w to labour - Encouraged by abdominal strength and longer, more powerful contractions Flexion - Due to contractions - Occiput comes into contact with pelvic floor - Fetal neck flexes - so circumference of head reduces, allowing easier passage Internal rotation - Due to contractions - 90 degree turn Extension - Fetal occiput slip under suprapubic arch and neck extends once beyond this - Head out of mum now, usually facing mums back Restitution / External rotation - Foetus aligns its head with its shoulders to face L/R Delivery of body - Gentle axial traction assists shoulder delivery

Answer 223

SROM = spontaneous rupture of membranes Before or during labour ARM = artificial rupture of membranes Induce labour rupture of sac (amnion) that holds amniotic fluid (liquor)

Answer 224

at least 1 min after delivery Beneficial for pre-term especially Gives time for baby to transition More cells and other stuff given - better for growth and development

Answer 225

IM oxytocic drug then Examine - to check all complete

Answer 226

medical treatment for miscarriage - vaginal pill to encourage body to expel products (then 3w later a preg test to check it has worked)

Answer 227

could be haemorrhage from placental attachment site (could be emergency blood loss)

Answer 228

earliest stool of unborn baby meconium in liquor - baby can inhale this MAS meconium aspiration syndrome - airway obstruction - surfactant dysfunction - inflammation - respiratory distress - oedema - pulmonary vaso and bronchoconstriction

Answer 229

to prevent pre-eclampsia development if high risk , from 12 w on

Answer 230

aspiring for prevention (if high risk) if def have it - monitoring, blood pressure control

Answer 231

higher risk of - gestational DM - gestationall HTN - pre-eclampsia surgery more complicated - more adipose tissue - infections, slower healing - hernias more likely - if very time pressured, c section will take longer to get to baby

Answer 232

post-natal psychosis (not post-natal depression)

Answer 233

HIV, even if undetectable, higher risk of stillbirth group strep B can go to baby, so infection needs to be tested and treated

Answer 234

purpose of folic acid = prevention of neural tube defect indications - either parent has neural tube defect or previous pregnancy with neural tube defect - mum has coeliac or another malabsorption state - mum has DM - mum has sickle cell - mum on anti-epileptic meds - mum BMI 30+ contraindications - allergy/sensitivity - persistant hyperemesis - cancer - folate dependant tumours - untreated B12 deficiency

Answer 235

tight muscles --> pain, stinging, itching dilators physio CBT (vaginismus - psychological element)

Answer 236

first line = mirena coil contraceptive pill GnRH, HRT, oestrogen patch CBT hyster/oophrectomy

Answer 237

swab - chlamidya, gonorrhea blood - HIV, syphillis hep B/C hep C - drug use hep B - MSM, certain countries..

Answer 238

1 (once a year, oral mainly) 2 (4x a year, oral or genital) microbiology distinguishes aciclovir - continuous suppression - episodic treatment - take when bump occurs

Answer 239

after it stops pulsating- few mins (previously done straight away)

Answer 240

synometrin = oxytocin and ergometrine this induces placenta expulsion through contractions - the muscle tightenings clamp blood vessels shut

Answer 241

controlled cord traction pressure on lower belly to straighten lower uterus and pull down on cord firmly but gently to deliver the placenta

Answer 242

good = 3 in 10mins hyperstimulated = 5+

Answer 243

nose to lips primi - effacement then dilation prev multiparous - same time

Answer 244

= mucus plug lost (due to dilation) it protects the uterus from ascending infection not in itself a sign of labour, but usually in latent stage

Answer 245

lie = baby's axis (longitudinal, transverse, oblique) attitude = flexion of baby's neck (flexion better - smaller circumference) position = where a position on baby's body relates to birth canal (LOP, LOA..) presentation = body part presenting itself first through the birth canal station = how far descended fetal head is (-2 to +2 with 0 at iliac spines)

Answer 246

face= face bregma = anterior fontanelle (quadrilateral) at top of skull occiput = back/base sinciput = between bregma and face, front top part of skull vertex = between two fontanelles - back top part of skull posterior fontanelle (triangle) - seperater occiput and vertex

Answer 247

widest circumference of head through

Answer 248

110-160 more if pre-term, less if post

Answer 249

Menopause at 51ish, final period,12 months with no bleed = certainty, less responsive to LH/FSH → oes and prog falls Menopause symptoms - stress incontinence, brittle hair/nails, erratic bleeding Investigations - 2 readings from different points of cycle (2 or 6w later - should drop if no pathology) - LH/FSH/oes/prog. FH is key one - should rise (no inhibition of GnRH, trying to get the sex hormones to go big) Treatments - HRT (oestrogen + progesterone), SSRI, Topical oestrogens for reduced libido/ vaginal dryness, symptoms control eg lube, bladder training Unopposed oestrogen only fine if hysterectomy (endometrial cancer risk)

Answer 250

<45 early menopause, <30 = premature ovarian insufficiency FH Oophorectomy chemo/radiotherapy ?pituitary tumour

Answer 251

endometrial/ ovarian cancer, trauma, polyps, endometrial hyperplasia (HRT), endometrial atrophy, atrophic vaginitis (both due to lower oestrogen)

Answer 252

endometrial cancer

Answer 253

cervical cancer (bleeds when hit)

Answer 254

only before 24w fingers may go through cervix and disrupt baby/ placenta/ amniotic fluid

Answer 255

from 14w ish

Answer 256

- age - smoking, alcohol - how long trying together/ marriage status, how often trying - current relationship and previous relationship - miscarriage, stillbirth, ectopic, muller, live children, TOP - FH of fertility issues - cancer and treatment - PMH/PSH - esp gential/ pelvic/ thyroid/ pituitary/ STI

Answer 257

prev child (m/f, inc previous relationship, inc adopted) previous sterilsation (m/f, even if reversed) 42y (f) smoking (m/f) BMI 30+ (f)

Answer 258

- previous assisted conception - menstrual (regulatity, heaviness, contracpetion, menarche..) - endocrine history (PCOS, thyroid, weight, hyperprolactinaemia) -BMI - bleeding in/post coital (endometriosis reduces fertility- if in tubes/ ovaries/ painful as reduces sex freq) - menopause

Answer 259

sterilisations (not 100% effective) - m +f depo provera injections - can cause fertility issues for 12m afterwards

Answer 260

cystic fibrosis (vas deferens not present) - ask about chest symptoms ejaculation/ erection/ penetration issues

Answer 261

- vaginal USS - semen analysis (density and mobility) - STI screen - hormone levels (LH, FSH, TFT, oes, prog, prolactin) - tubal patency (dye injected -hysterosalpingo (Scan) VS laproscopy/dye (look)) - karyotyping

Answer 262

cystic fibrosis (vas deferens not present) - ask about chest symptoms ejaculation/ erection/ penetration issues

Answer 263

increase in nucleus size / ratio to cytoplasm chromosomal clumping more nuclei hyperchromatin

Answer 264

squamous (stratified) down to vagina columnar (single cell) in entrance way - cervix . as it is single celled, you can see the vessels below

Answer 265

endometriosis

Answer 266

endometriosis on ovary

Answer 267

endometriosis. symptoms complete picture. chocolate cyst/ laproscopy for diagnosis. certain diagnosis not needed for treatment though

Answer 268

treats pre eclampsia and eclampsia slows contractions in labour (maybe done to give more time)

Answer 269

ask immediately in post birth assessment to aid family planning no oestrogen for a bit - clots

Answer 270

antiprogesterone PO (corpus luteum dies) 48h prostaglandin PV (contraction, dilation, miscarriage 2w later - do pregnancy test

Answer 271

in first 24h = bad 1-21d fine (fetal hb --> adult hb) increased production - hemolytic disease --- haemolytic anemia e.g SLE --- haematoma --- rhesus incompatibility --- congential infection e.g. rubella, CMV, herpes, syphillis, toxoplasmosis - polycythaemia - ventricular haemorrhage decreased clearance - prematurity - metabolism errors e.g. gilberts - hypothyroid/ hypopituitary

Answer 272

look tan (not yellow) billirubin monitored (transcutaneous, blood test)

Answer 273

observe for sepsis - sleepy - poor feeding - floppy - altered behaviour - altered HR/RR/BP/temp phototherapy (UV box) IV immunoglob exchange tranfusion via belly button (rarer)

Answer 274

birth trauma (not an issue) polycythaemia (could be due to delayed chord clamping)

Answer 275

group b strep PROM >24h preterm mum or infant on antibiotics twin intubation