Womens Health Flashcards
1
Q
Factors that increase your risk of a cystocele?
A
childbirth, age, obesity, chronic constipation and heavy lifting, chronic coughing, previous pelvic surgery
2
Q
Signs and symptoms for cystocele
A
Feeling that something has dropped out of your vagina
Leaking urine
Feeling of incomplete emptying of bladder.
3
Q
Treatment for cystocele
A
Vaginal pessary
Cystocele repair surgery
4
Q
Diagnostics for Cystocele?
A
Pelvic Exam
Urodynamics
Bladder Function tests
5
Q
What is a cystocele
A
Weakening of the wall between bladder and vagina. Causing bladder to drop/sag into vagina
6
Q
What are the weeks for the 3 trimesters?
A
1st - 1 to 12 (3M)
2nd - 13 to 27 (6/7M)
3rd - 28 to 41 (7-9M)
7
Q
How long before contraceptives becomes effective?
IUD, POP, COC
A
Instant: IUD
2 Days: POP
7 Days: COC, injection, IUS
If not taken on the first day period.
8
Q
What can reduce the effect of the contraceptive pill?
A
Liver enzymes inducing drugs
Vomiting within 2 hours of taking the COC pill
9
Q
What happens to BP during pregnancy?
A
BP falls in 1st trimester till 20-24 wks.
10
Q
When do urinalysis for pre-eclampsia what findings would you expect?
A
Proteinuria (>0.3g/300mg/ 24H)
11
Q
Define Pre-eclampsia
A
Pregnancy characterised by an onset of high bp and significant amount of protein in the urine.
12
Q
What is PID?
A
Pelvic Inflammatory Disease - Acute ascending polymicrobal infection of the female gynaecological tract.
13
Q
What pathogens are commons causes of PID?
A
Chlamydia trachomatis
Neisseria gonorrhoeae
14
Q
Clinical features of PID?
A
Lower abdominal pain Abnormal vaginal discharge Fever Nausea and vomiting Vaginal discharge w/foul odor Dysuria Lower back paid.
15
Q
Treatment for PID?
A
Antibiotics
Ceftriaxone(IM) + Doxycycline (Oral 2 weeks)
Sexual contact(s) treatment - STI evaluation + antibiotics
Consider IUD removal - If origin of infection. IV Hydration (If needed)
16
Q
Complications of PID?
A
Infertility (Increased risk with repeated episodes)
Ectopic pregnancy
Tubual damage - fallopian tube
17
Q
Risk factors for PID?
A
Prior STI infection - Gonorrhoea, chlamydia Young age onset of sexual activity. Unprotected sex w/multiple partners PMH of PID IUD use
18
Q
What is IUGR?
A
Intrauterine growth restriction -
When a baby in the womb (fetus) does not grow as expected. The baby is not as big as would be expected for the stage of the mother’s pregnancy (gestational age).
19
Q
Define Dysmenorrhoea?
A
Period Pains
painful cramping (in the lower abdomen) occurs shortly before or during menstruation,
20
Q
What are the types of dysmenorrhoea?
Treatment?
A
Primary - In young females in the absence of any identifiable underlying pelvic pathology. Caused by the production of uterine prostaglandins during menstruation, which causes uterine contractions and pain.
Secondary - Pain caused by underlying pelvic pathology - PID, IUD insertion, Fibroids, Endometriosis
Secondary causes must be excluded before primary diagnosis.
1st Line - Mefanamic Acid / Ibuprofen (NSAIDS)
2nd Line - COCP
21
Q
RF for dysmenorrhoea?
A
Early age at menarche,
Heavy menstrual flow,
Nulliparity (Haven’t given birth)
FH of dysmenorrhoea.
22
Q
What must always be considered in females of reproductive age for acute abdominal pain?
A
ECTOPIC PREGNACNY
Primary differential until proven otherwise.
23
Q
At what time is the greatest risk of an IUCD falling will being rejected?
A
Within 5 Days of fitting IUCD (20%)
24
Q
What is the Gold Standard investigation for endometriosis?
A
Laparoscopy
25
What are triple swabs?
Three swabs taken in vagina and cervix to look for signs of bacterial infection.
Endocervical charcoal swab - Gonorrhoea
High vag charcoal swab - Trichomonas Vaginalis (protozoa), Candida, BV, Group B strep
Endoservical NAAT swab - Chlamydia & Gonorrhoea
Nucleic acid amplification test (NAAT)
26
What levels of hCG indicate pregnancy?
>> 25 U/L
Takes 2 weeks for hCG levels to be high enough to be detected in your urine.
27
What Gravida?
The number of pregnancies a women has had regardless of the outcomes.
28
What is Parity?
The number of deliveries after 20 weeks gestation
29
What is the digit system to review a women's obstetric history?
G - Gravida (Total number of pregnancies)
T - Term births (Number delivered 37W+)
P - Preterm births (Number delivered <37W)
A - Abortion (Number of abortions, miscarriages, ectopic pregnancies <20W)
L - Living Children
+1,2,3 etc... = Still Births
30
Define Antepartum Haemorrhage (APH)?
Any vaginal bleeding from 24 weeks gestation until delivery.
2-5% of all pregnancies
31
Causes for APH?
Placental Abruption
Placenta Praevia
Rarer cases - uterine rupture, cervical lesions (polyps), Infection, Trauma, malignancy
32
Define early pregnancy loss
Pregnancy loss before 12 completed weeks.
33
How is bleeding in early pregnancy defined?
Bleeding that occurs within the first 24 weeks of gestation
34
Define Miscarriage?
Pregnancy loss under 24 weeks (20 Weeks WHO)
35
What is a crown rump length?
Length of the foetus from top of its head to the bottom of torso.
Most accurate estimation of gestational age in early pregnancy
36
What is HDN?
Haemorrhagic disease of the newborn - Bleeding disorder of newborn occurring after birth
3 Types - Early, Classic, Late
Early (within 24 hours of birth) - Due to drugs taken by the mum in pregnancy passing through the placenta and inhibiting vitamin K activity.
Classsic (D1-D7) - when babies don’t get enough vitamin K through breast milk.
Late (2-12Wks) - Babies not absorbing vitamin K because of liver disease or not getting enough vitamin K in their feeds.
37
Risk Factors for HDN?
Pre-term infant
Forcep delivery, C-section, Ventouse
Bruising during birth
Breathing issues/ Liver issues / poorly at birth
Mothers on - Epileptic meds, anticoagulants, TB mess
Breastfed babies (Formula has fortified vitamin K)
38
How is HDN prevented
Neonates are given IM Vit K once they have been born.
39
How would you be able to differentiate between the ABDOMINAL pain of uterine contractions and placental abruption.
Abruption - Continuous + Constant pain
| Contractions - Intermittent pattern
40
Normal amount of contractions during labour
3-4 every 10 mins
41
What causes abnormalities in uterine contractions?
Overdistension of uterus - Polyhydramnios/multiple gestation, Macrosomia
Functional/anatomical distortion of uterus - placenta praevia, fibroids, prolonged labour
Uterine relaxants - Nifedipine, magnesium sulphate, GTN, Terbutaline
Bladder distension - Prevents uterine contractions
Intra-amniotic infection - Chorioamnionitis (from prolonged rupture of membranes)
42
Define Macrosomia?
Newborn who's much larger than average
>8lbs13oz (>4kg)
BW Above 90th Centile
43
# Define Concealed pregnancy?
Possible involvement of which services?
Female through fear, ignorance or denial does not accept or is unaware of the pregnancy in an appropriate way.
Safeguarding Team, Social services, Psychiatric services
44
What is a still birth?
Fetal death at or after 24 weeks of pregnancy. baby born without signs of life.
1 every 200 births
45
Signs of life after birth?
```
Crying
Breathing
Active body movement
Heartbeat
Pulsation of the umbilical cord
```
46
How many weeks is considered late presentation to maternity services?
20 Weeks
47
What is precipitous labor?
Rapid labor followed by expulsion of fetes <3hrs
48
What are uterotonics?
Name some?
Pharmacological agents used to induce contraction/increase the tonicity of the uterus.
Synthetic oxytocin (Syntocin), Ergometrine (Syntometrine), carboprost (PGF2Alpha), Misoprostol (PGE1)
49
What is Misoprostol used for?
Induce Abortion / Treat PPH
50
What drugs are used for abortion?
Misoprostol + mifepristone
51
Risk factors for Primary PPH
```
Before Birth (9) ?
During Labours (7) ?
```
Before Birth
```
Previous PPH in a pregnancy
BMI > 35
Having had 4+ babies before
Multiple Gestation
South Asian ethnicity
Placenta Praevia
Placental abruption
Pre-eclampsia and/or high blood pressure
Anaemia
```
During Labour
```
Caesarean Section
Induction of Labour
Retained placenta
Episiotomy (a cut to help delivery)
Forceps or ventouse delivery
Labour >12 hours
Macrosomia
```
52
Define Placenta Abruption?
Separation of the placenta from the uterine resulting in maternal haemorrhage into the intervening space.
- Constant Abdo Pain + Vaginal bleeding
53
What 3 signs indicate the placenta is ready to deliver?
Lengthening of the umbilical cord
Gush of blood
Uterus becomes more globular
54
What are the 3 abnormal placenta implantations?
Placenta Accreta (79%) - Chorionic villi attaches to uterine myometrium
Placenta Increta (14%) - Chronic villi invades the uterine myometrium
Placenta Percreta (7%) - Chorionic villi invade the uterine myometrium and serosa and beyond into adjacent organs (e.g. bladder)
55
What's Salpingitis?
Most common causation?
Inflammation of the fallopian tubes.
Bacterial infection. (STIs- Gonorrhoea, Chylamdia)
56
1. Define Amenorrhea?
2. Define Dysmenorrhea?
3. Define Menorrhagia?
1. Absence of a period (Menstrual Cessation)
2. Painful periods (Painful Mensuration)
3. Heavy Menstrual bleeding (Increased frequency and volume of menstruation)
57
What is cervical motion tenderness?
Pain elicited when the uterine cervix is manipulated during pelvic examination.
Usually indicates inflammatory process in the pelvic organs or adjacent organs.
58
How much Folic acid should pregnant women or those trying to conceive take?
5mg Daily high risk
400mcg OD low risk
-To prevent neurological tubal defects .
-12 weeks
59
What are the risks of anti-epileptic medications in pregnancy?
Teratogenic potential
Anti-epileptic drugs are at a greater risk for low serum folate levels - Higher dose recommended
N.B - However the risk of malignancy outweigh risk of teratogenic fetus potential
60
What ranges is normal for fetal HR
100-160 bpm
61
Bradycardia FHR
| Tachycardia FHR
<100/min
| >160/min
62
What are the components of a CTG
Variability - Variation of fetal heart rate from one beat to the next. (5-25 bpm normal)
Accelerations - Increase in the baseline FHR >15 bpm for greater than 15 seconds.
Decelerations - Decrease in the baseline FHR >15 bpm for greater than 15 seconds.
Baseline rate - Avg HR of fetus within 10min window
63
Complications of premature labour/prematurity?
```
RDS , Chronic Lung disease
Intraventricular haemorrhage
Necrotising enterocolitis
Feeding problems
Infection
Hypothermia
Visual and hearing issues
Increased mortality risk
```
64
Management of Pre-Term Labour?
<34 weeks
Steroids
Erythromcyin (prevent NEC) = ONLY IF THE MEMBRANES ARE RUPTURED
Tocolytics prevent current pre-term labour
Mag Sulphate
65
Importance of steroid tx in pre-term labour management?
Helps to develop the foetal lungs to mature
66
Risk factors for gestational DM?
```
BMI >30
Previous Macrosomic baby
Prev GDM
Diabetes FH
Ethnic Minority origin
```
67
Diagnostic Criteria for GDM
Fasting glucose >5.6mmol/l
Post 2hr glucose >7.8 mol/l
Testing usually done 24-28 weeks (2nd Trimester)
68
Management for GDM?
1WK Referral to diabetes antenatal clinic
Lifestyle and diet modifications
Metformin (+Insulin - BM >7)
BM<7 Diet trial + exercise
Pre-Existing Diabetes
- Weight loss for high BMI
- Stopping oral hypoglycaemic agents apart from metformin (commence insulin)
- Tight glycemic control
- Treat retinopathy as can worsen
69
In postpartum women when the earlier you can considered contraception?
21 Days
70
Which stages are ovarian cancer surgically operated?
Stages 2-4
71
Management of Ovarian cancer?
Staging laparotomy which involves:
> Midline laparotomy
> Hysterectomy
> Bilateral salpingo-oophrectomy
> Omenectomy
> Lymph node sampling (para-aortic/pelvic nodes)
> Peritoneal washing (saline solution injected into peritoneal cavity and then removed for cytology)
Chemotherapy is recommended for everyone except low-grade stage Ia and Ib.
Stage III and IV cancers may additionally get neoadjuvant chemotherapy.
However, bear in mind how much of the above takes place is decided in an MDT. For instance, a palliative pathway may instead be considered for advanced stage IV ovarian cancers. Or for young women with early disease, the uterus and unaffected ovary may not be removed to preserve fertility.
72
What is reduced foetal movements?
<10 movements in 2 hours
73
First line investigation for foetal movements?
Doppler US
74
Causes of folic acid deficiency?
Phenytoin
Methotrexate
Alcohol excess
Pregnancy
75
Consequences of folic acid deficiency?
Macrocytic, megaloblastic anaemia
| Neural tube defects
76
'tense woody abdomen' on clinical examination.
Most likely differential?
Placental abruption
77
Define Placental abruption
Separation of normally sited placenta from the uterine wall
- Maternal haemorrhage into intervening space
78
Management of placental abruption
<36wks
- Fetal Distress: Immediate C-section
- No fetal distress:Close observation, steroids, no tocolysis
>36wks
- Fetal Distress: Immediate C-section
- No fetal distress: Deliver vaginally
Fetus dead
-Induce vaginal delivery
79
Complications of placental abruption on
Mum?
Baby?
Mum - Shock, Renal failure, PPH, DIC ]
| Baby - IUGR, Hypoxia, Death
80
What are the 3 types of miscarriage treatments?
Which option is first line?
Expectant management, Medical management, Surgical management
Expectant management
81
What treatment would you give for medical management of an ectopic pregnancy?
Oral Methotrexate
82
Explain expectant management for miscarriage?
Waiting for a spontaneous miscarriage
| 7-14 days.
83
Medical Management for miscarriage?
```
Medication to expedite the miscarriage
Vaginal misopristo(Prostaglandin)l + antiemetics and pain relief + Mifepristone (progesterone receptor antagonist)
Bleeding should occur within 24 hrs [Raise with doctor if delayed]
```
Mifepristone to end the pregnancy, misoprostol to let it out
84
Surgical Management for miscarriage?
Vacuum aspiration (Suction curettage) LA used
Evacuation of retained products of conception
Done under GA
85
What circumstances would medical or surgical management be preferred for miscarriage?
Increased haemorrhage risk
Late first trimester
Unable to have blood transfusion/coagulopthies
Evidence of active infection
Previous traumatic experience associated with pregnancy - miscarriage, stillbirth, APH
86
Define Hydramnios?
Too much amniotic fluid
87
Name some minor conditions of pregnancy
```
Itching
Heatburn
Thrush (Vaginitis)
Abdo pain
Constipation
Ankle swelling
Pelvic Girdle Pain
Carpal tunnel syndrome
Leg cramps
```
88
List the main antenatal appointments/scan
| [Hint: 10 Primary / 13 Total]
8-12 weeks - Booking visit + Bloods
10-14 weeks - Dating Scan, Multiple gestation check
11 - Downs screen [+Nuchal scan]
16 weeks
20 weeks - Structural anomaly scan / Placenta positioning
28 weeks - Rh blood group Tx (Anti-D) / Anaemia checks
34 weeks - Info on labour
36 weeks - ECV for breech presentations/ Vit K + breastfeeding info
38 weeks
41- Discuss labour plans/Induction of labour(Membrane sweeps)
[25 weeks - Pre-eclampsia check in nulliparous/ Bump (Symphysis-fundal height / USS Fetal Biometry ]
[32 weeks - Low lying placenta re-check ]
[40 weeks - Nulliparous Membrane sweep offering for non labour patients]
Usually 10 Appt Nulliparious / 7 Appts Multiparous
89
When does the uterus become palpable?
12 weeks
Fetal heart can be auscultated
90
Define Intrapartum?
Period from the onset of labor to the end of the third stage of labor.
91
Which conditions are screened for early in pregancy?
Between 8-12 weeks gestation.
Booking Bloods
```
Downs syndrome
Patau
Edwards syndrome
Sickle Cell, Thalassaemia
HIV, syphilis, Hep B
Rh Status
Red cell alloantibodies
Rubella immunity
```
92
Quadruple test - What is it?
Blood test
4 Protein measure - B-HCG, AFP (Alpha-fetoprotein), Oestriol, Plasma protein A (PAPP-A)
Only screens for downs
93
When can twins be confirmed?
12 week scan
94
What causes increased nuchal traslucency in fetus?
Down's
Congenital heart defects
Abdo wall defects
95
What type of infection is Rubella?
| Common infective pathogen?
Viral infection
| Togavirus
96
Define Polycystic ovary syndrome?
Hormonal disorder in which the ovaries produce an abnormal amount of androgens and symptoms of hyperandrogegism is displayed.
97
Clinical features of PCOS?
```
Acne
Hirsutism
Infertility
Oligomenorrhoea / Amenorrhoea
Scalp hair loss/Alopecia
```
98
Risk factors of PCOS?
```
Obesity
Low birth weight / High birth weight
Fetal androgen exposure
Early Menarche
FH PCOS
```
99
Associated conditions with PCOS?
```
Type 2 DM / Impaired glucose tolerance
Endometrial cancer / Ovarian cancer
Metabolic syndrome
NAFLD
Mood disorders
Obstructive sleep apnea
Arterial HTN
Subfertility
```
100
Tx for PCOS?
Reduction of hyperandrogegism and establish fertility plans
```
Improve fertility
Weight loss
Letrozole
Clomifene (Non-steroidal anti-oestrogen.Increases FSH)
+ Metformin
```
```
Not desiring fertility
Weight loss
OCP (Microgynon) - Ehinylestradiol
Metformin
Eflornithine cream (Hirsutism)
Spironolactone
Finesterde -5A Reductase inhibitor
GHRH Agonist -Leuprorelin + Microgynon
```
101
Diagnostic Investigations for PCOS?
Diagnosis of exclusion
- Pregnancy Test - Urine/B-HCG
- Serum 17-hydroxyprogesterone (Adult onset Adrenal hyperplasia)
- Hyperprolactinaemia/Prolactinoma (Serum Prolactin)
- Thyroid disease (TSH levels)
- Hypogonadotrophism
- Impaired glucose tolerance/Diabetes (OGTT)
- Dyslipidaemia (Cholesterol levels, LDLS, HDLs)
- Outlet obstruction (TVUS)
102
3 Criteria used for PCOS classification?
Rotterdam Criteria
1. Amenorrhoea/Oligomenorrhoea (Menstural irregularity)/Anovulation
2. Hyperandrogenism - Clinical/Biochemical signs
3. Polycystic ovaires (TVUS) - >12 / Increased ovarian volumes >10cm3
Diagnosis of exclusion
2/3 - Rotterdam crieteria
103
WHAT IS FTP IN PREGNANCY?
Failure to progress - Labor slows and delays delivery of the baby.
104
Define Slow labour
Failure of the cervix to dilate by 2 cm in 4 hours or a slowing of progress for multiparous women
105
What is slow progress in active labour call.
Primary dysfunctional labour
106
What's a partogram?
Record of labour - Notes key information about fetus and mum to monitor labour progress.
```
Obs -BP, HR, FHR, Temp
Time
Contractions
Drugs/Fluids
State of Membrane - Intact, Clear, Meconium stained
Urine analysis
```
107
What could Meconium present before 38 weeks gestation?
Listeriosis
| Bile secondary to bowel obstruction
108
Contraindications of epidural?
Patient refusal
Active maternal haemorrhage
Maternal septicaemia / Untreated febrile illness
Infection at or near needle insertion site
Maternal coagulopathy (inherited or acquired)
Severe Spinal abnormality
109
Side Effects of epidural?
Immediate
Hypotension
Urinary retention
Delayed
Localised Backache
Post dural headache
Leg weakness
110
Reason for Meconium stained liquor ?
Early maturation of foetus GI system.
| Possible signs of foetal distress
111
Define presentation?
The part of the foetus's body that leads the way out through the birth canal (Maternal pelvis)
112
Define Lie and position?
Lie - Relationship between long axis of fetus and mother (longitudinal, transverse or oblique)
Position - Position of the fetal head as it exits the birth canal. (Ocipito-anterior, posterior/transverse)
113
What is an episiotomy
An incision that widens the opening of the vagina to help with delivery
114
Define labour?
Onset of regular and painful contractions associated with cervical dilation and descent of the presenting part.
115
What monitoring should be done during labour?
[6 Points]
FHR monitoring - Every 15 minutes / Contious CTG
Contractions monitored - Every 30 min
Maternal obs - BP. Temp, Pulse rate
Vaginal examination - Every 4 hours to check of labour progression
Maternal urine- Checked for ketones and protein every 4 hours?
116
What is the symphysis-fundal height?
What is considered normal?
Measurement of distance between symphysis pubis and top of uterine fundus to assess fetal growth
Match the gestational age in weeks to within 2 cm. 24wks == 22-26cm
Usually begins between 26-28wks
117
What are the fundal height landmarks in weeks?
Pubic symphysis - 12 to 14 wks
Umbilicus - 20 to 22 wks
Xiphoid process of sternum - 36 to 40 weeks
118
What could a smaller or larger expected fundal height suggest?
```
Multiple pregnancy
Macrosomia
Polyhydramnios
Oligohydraminos
Slow fetal growth (IUGR)
```
119
Signs of true labour?
Shedding Mucus plug -seals the opening of the cervix
Rupture of membranes
Shortening and dilation of cervix
Regular painful uterine contractions (Shorter intervals)
120
What scoring criteria can be used to decide whether induction of labour is necessary?
Bishop Score
Cervical Position, consistency, effacement, dilation and fetal station
<5 Spontaneous Labour unlikely without induction
>9 Spontaneous Labour likely
121
Name the forms of emergency contraception?
Emergency hormonal contraception - Levonorgestrel (1.5mg) / Ulipristal (30mg)
[Within 72 hrs / 120]
IUD - Inserted within 5 days of incident
122
What are contraindications for emergency hormonal contraception?
Malabsorption diseases - Crohn's
Enzyme inducing drugs - Rifampicin
```
Ulipristal More C/I
Severe hepatic dysfunction
PPI drugs
Breastfeeding - Avoid for 7 days
Poorly controlled asthma - corticosteroids
```
123
Contraindications of Copper IUD?
Uterine fibroids
Suspected UTI / PID
-Tested for chlamydia and gonorrhoea prior to insertion
124
How long does an IUD last?
5-10 yrs
125
What age of is a women not legally considered to be able to consent to sexual activity?
Under 13 years of age.
Immediate safeguarding team referral
126
What risk is increased in a women following insertion of an IUD?
ECTOPIC PREGNANCY
Watch for late period >5days
Reduced bleeding + Severe Lower abdominal pain
127
Whats the main difference between and IUS and IUD?
IUS - Hormonal
| IUD - Non-hormonal
128
For Missed or Incomplete miscarriage what medical management would be given.
Misopristol ONLY
129
What is law around abortion?
Only be done before 24 weeks
Two registered medical practitioners must sign a legal document.
ONLY a registered medical practitioner can perform an abortion. IN AN NHS HOSPITAL / LICENSED PREMISES
130
Methods of abortions based on gestation age?
<9 Weeks: Mifepristone + Misopristol
<13 Weeks: Surgical dilation + Suction of uterine contents
>15 Weeks: Surgical dilation + Evacuation of uterine contents
131
If a patient vomits after taking the morning pill.
WHAT IS THE NEXT STEPS?
Within 3 hours
-Take another dose ASAP (Levonorgestrel / Ulipristal)
Vomiting - The contraception may not have been fully absorbed.
132
Names of hormonal contraceptives
```
Ella One (Ulipristal acetate)
Levonelle (Levonorgestrel)
```
133
Morning after pill in a woman with a BMI > 30 (Levernogestrel)
WHAT DO YOU DO ?
Double the dose
Double dose for those with a BMI >26 / weight over 70kg
134
Contraindications for COCP?
Smoking >15 cigarettes per day
| Migraine with aura
135
Unexplained vaginal bleeding contraindicates which types of contraceptions?
IUD & IUS
136
Contraindications for Injectable contraceptives?
Side effects of injectables?
Current breast cancer
```
S/E
Weight gain.
Irregular bleeding.
No quick reversal, pre-fertility level delayed.
Increased osteoporosis risk.
```
137
What type of contraceptive is the Mirena coil?
IUS
Levonorgestrel 20 mcg/24 hrs
138
Adverse effects for ICDs?
Periods heavier, longer and more painful - IUD
| Initial frequent uterine bleeding and spotting - IUS
139
1. What is the recommended treatment for a women who is at moderate/high risk of pre-eclampsia?
2. How long are women with pre-eclampsia at risk of seizures?
1. 75mg-150mg of aspirin daily from 12 weeks to delivery.
| 2. Up until day 5 postpartum [ Following this day they can be deemed 'safe']
140
Risk factors for neural tube defects?
Advice given?
```
Prev preg. w/ neural tube defect
FH history of neural tube defect on either parent side
Diabetes
Smoking
Obesity
Anti-epileptic medication
Sickle-cell disease
High AFP
```
5mg Folic acid from pre-conception till week 12 gestation
141
Women with hypothyroidism?
25mcg increase in medication (levothyroxine). Natural increase in T4 till week 12 is not present - Fetal thyroid development at risk
Testing Schedule
Repeated TFTs 2 weeks after the increase.
Each trimester levels checked.
2-6 post partum
Pre-conception/Early after pregnancy confirmation
Risks
- Developing gestational diabetes
- Placental abruption
142
Risk factors for miscarriage?
M - Multiple pregnancy/ Maternal disease(Autoimmune e.g. SLE)
I - Infection (Salmonella, Listeria, CMW, HSV, BV)
S - S(Cytotoxic drugs) - Poisons
C - Cervical incompetence (late miscarriage)
A - Anatomical anoaly (uterine septum)
R - Rise age of MUM
R - Radiation
I - implantation of placenta abnormal - (Placenta previa, IUD)
A - Abruption of placenta
G - Genetic abnormality in fetus
E - Endocrine (PCOS, DMT, Thyroid disease, Luteal insufficiency
143
Name some teratogenic drugs?
TERATOWA
```
T-Third Element (Lithium), Tetracylines
E-Epileptic drugs (Valproate, Phenytoin, Carbamazepine)
R-Retinoids (Vit A)
A-ACE-I
T-Thalidomide
O-Oral contraceptives
W-Wafarin
A-Alcohol
```
144
Define Enterocele?
Wall of the small intestines descends into the lower pelvic cavity and pushes into the upper vaginal wall.
145
Define Procidentia?
When uterus and cervix protrude from the introits, resulting in thickened vaginal mucous and ulceration.
146
What are the stages of the Pelvic Organ Prolapse Quantification?
Stage 0 - No prolapse demonstrated
Stage 1 - Cervix prolapses > 1cm above the hymen level
Stage 2 - Most distal prolapse is between 1cm above and 1cm below the level of the hymen
Stage 3 - Most distal portion of prolapse protrudes >1cm below the hymen but no >2cm than total vaginal length
(Not all of the vagina has prolapsed)
Stage 4 - Complete eversion of the vagina
147
Which Cells produce androgens?
Theca Cells
148
Define Molar Pregnancy?
| hydatidiform mole
Abnormal form of pregnancy in which a non-viable fertilised egg implants in the uterus and will fail to come to term. Characterised by the abnormal growth.
Very Rare - <1/700 pregnancies
Very high hCG levels
Nausea and EXCESSIVE VOMITING
Trophoblastic disease (Cystic components)
Snowstorm Pelvic US appearance (Intrauterine mass + Cystic components)
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What are the risks of pessaries?
Ulceration - Need to be changed every 6 months
150
Recently Diagnosed Chlamydia.
What is treatment?
Treatment for pregnant women?
(1) Doxycycline 100mg bd for seven days (contraindicated in pregnancy)
(2) Azithromycin 1g orally as a single dose, followed by 500mg OD for two days
Azithromycin 1g orally as a single dose.
151
First Line treatment for Allergic Rhinitis in pregnant women?
Loratadine
152
What Phase of the menstraul cycle does PMS occur?
Luteal phase
153
# Define Fibroids?
3 Main symptoms of Fibroids?
benign tumour of muscular and fibrous tissues (Usually myometrium in uterus)
Pain
Menorrhagia
Sub-Infertility
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What is Premature Ovarian Failure?
Early onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
Raised FSH, LH levels
Secondary Amenorrhoea
Infertility
Vasomotor symptoms - Hot flushes / Night Sweats
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What drug therapy can be used to treat Stress incontinence?
Duloxetine - Increases sphincter tone during the filling phase of urinary bladder function.
Drug therapy once - Pelvic floor exercises have been tried
156
HPV Infection
HPV - Infection which targets keratinocytes of the skin and mucous membranes.
6 & 11 - Non-carcinogenic [Causes genital warts]
16,18,33 - Carcinogenic high risk factor for cervical cancer
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IV antibiotic used for prophylaxis against GBS?
IV Benzylpenicillin / Clindamycin (if allergic)
Recommended in all women who have had a previous child with ear/late onset GBS diseases. (50% future child risk)
Women who develop pyrexia during labour >38deg
Women who are in pre-term labour
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What is considered a low birthweight infant
<2500g (2.5kg)
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Risk factors for GBS infection
Premeturity
PROM
Previous sibling GBS infection
Maternal pyrexia during labour
160
Risk factors of placenta abruption?
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Substance misuse -e.g. cocaine
Multiparity
Maternal trauma
Increasing maternal age
Proteinuric hypertension
```
161
Clinical features for Placenta abruption?
Constant Pain
Tender, tense uterus
Fetal heart - absent/distressed
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[FILLLLL]
Physiological Changes in pregnancy?
```
Systems
CVS
Resp
GU
GI
```
CVS
-Increased Blood Volume
[FILLLLL]
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DDX Post-Menopausal Bleeding
```
Vaginal atrophy
Cervical polyps
Endometrial polyps
Endometrial hyperplasia
Cervical ca
Endometrial ca
Ovarian ca
Vulval ca
Trauma
```
164
Define Menopause
Cessation of menstruation
- No menstrual periods for 12 consecutive months (no other biological or physiological cause)
- No longer able to get pregnant naturally
- 45 to 50
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What Anti-hypetensives should be used in pregnancy?
Labetalol (B-Blockers)
If C/I - CCB (Nifedipine) /
Methyldopa (alpha-antagonis) - C/I - In Depression
When women are considering getting pregnant they should seek changing anti-hypertensive drug classes to preferred ones.
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Fetal Malformations from ACE-I?
Renal agenesis
IUGR
Prematurity
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When is screening for Down's Syndrome carried out?
11+ 0 and 13+6 weals
Combined test - Blood Test + Ultrasound (Nuchal translucency)
Blood Test - PAPP-A + B-HCG
Down's (B-Hcg +++, PAPP-A - - - )
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What Quadruple Test?
When does it happen
What things does it check for?
Checks your chances of having a baby born with Down's syndrome.
15/16 weeks
aFP (Baby), Inhibin A (made by placenta), Unconjugated Oestriol (Placenta + baby liver), Total HCG (Placenta)
Low, Low, Raised, Raised - Associated with downs
ONLY CHECKS FOR DOWNS NOT EDWARDS/PATAU
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What further test does a high risk downs syndrome women need for diagnostic results?
Amniocentesis / Chorionic villous sampling (Karyotype of Fetus)
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What conditions do combined-test screen for?
Edwards (T18)
Patau (T13)
Downs (T21)
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Postnatally what BP Values would allowed cessation of Anti-hypertensive medication in
<130/180
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Risk Factors for Ectopic Pregnancy?
E - Previous Ectopic/ Endometriosis
C - Contraception (IUCD, POP)
T - Tubual surgery
O - Other surgery ( Appenicectomy, laparotomy)
P - PID
I - Infertility Treatment (IVF, etc ⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀⠀)
C - Unknown cause
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1. What day does FSH usually peak in the menstrual cycle ?
1. Day 3
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1. Pre-Eclampsia RF?
2. What tests are useful in monitoring pre-eclampsia in pregnancy?
3. Target BP range for women with Pre-Eclampsia?
4. What BP value requires admission
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1st Pregnancy
>40 YO
Pregnancy interval> 10 yrs
BMI >35
FH of Pre-eclampsia
Multiple pregnancies
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2. BP, Bloods, Urinalysis, Fetal growth scans, CTG
3. <150/100 / <140/90 - End organ damage
4. >160/110 [Severe]
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1. TREATMENT FOR ECLAMPSIA?
2. Why are reflexes monitored?
3. What should be avoided in 3rd labour phase
OBSTETRIC EMERGENCY
- URGENT ADMISSION
- IV MAGNESIUM SULPHATE (Vasodilation action), Loading dose then infusion (4g/5-15min ---> 1g/hr/24H)
- STRICT MONITORING OF (BP, HR, RR, URINE OUTPUT, REFLEXES, CTG
2. Magnesium toxicity
3. Ergometrine (IM/IV Syntocinion)
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What does liquor volume tell you?
Fetal kidney function
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Signs and symptoms of Pre-Eclampsia?
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Headache -Frontal
Visual disturbance (Flashing lights/blurring)
Oedema - Face, hands, feet
Epigastri/RUQ Pain
Nausea
Vomiitng
FGR / IUGR
```
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1. Define SGA?
| 2. Define IUGR ?
1. Estimated Fetal Weight (EFW) / abode circumference <10th centile
2. Failure of fetus to achieve its predetermined growth potential
(Growth falling across centiles/reduced growth velocity)
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# Define Eclampsia?
2. How would you check for organ dysfunction?
Occurrence of 1/more generalised convulsion and/or coma in the background of pre-eclampsia and absence of other other neurologic conditions
Seizure within Pregnancy / 10 days of delivery with at least two of:
Proteinuria
Thrombocytopenia
Raised AST/ALT
2.
FBC (low platelets, hb)
U+E (Raised urea, creatinine, rate)
LFTs (Raised ALT, AST)
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Complications of Pre-eclampsia?
1. Mother
2. Fetus
1. AKI, DIC, ARDS, Cerebrovascular haemorrhage, Future increased HTN risk, Death
2. SGA, IUGR, Placental abruption, Prematurity
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What separates gestational HTN from pre-eclampsia
Pre-eclampsia has proteinuria.
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When does gestational htn start to develop?
After 20 weeks - Transient/Chronic
Anything <20wks - Pre-exisiting HTN
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Most common cause of post menstrual bleeding?
Vaginal atrophy
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Causes of hyperprolactinaemia?
Investigations?
P - Pregnancy
I - Iatrogenic (OCP - containing oestrogen, Cushing syndrome, Dopamine antagonist -e.g Metoclopramide for N/V)
T - Tumours of the pituitary gland, Hypothyroidism
Pituitary MRI
Visual fields test
Bloods - TFT, Prolactin level, FSH and LH
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Treatment of prolactinoma causing Amenorrhoea?
MACRO (>10MM) OR MICRO (<10MM ) largest dimension
1. Dopamine Receptor Agonist (Bromocriptine/Cabergoline) - Tumour should shrinks + restoration axis
2. Surgery - If patient presents with visual defects or doesn't medical management doesn't work
50% reoccurrence rate w/surgery.
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Out of all contraceptive methods which is the most effective?
Progesterone implant
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Whats the earliest a women can get pregnant postpartum?
3 Weeks
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Define ectopic pregnancy?
Extrauterine pregnancy in which which the egg implants itself outside of the uterus and grows.
Non-viable pregnancy
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Symptoms of Macroprolactinoma?
GAIL PHD
G-alactorrhea
A-menorrhoea
I-mpotence (Men)
L-ethargy
P-ressure effects of tumour on head
H-air loss (Secondary sexual)
D-epression
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What are the expected cervical dilation for
A. Nulliparous
B. Multiparous
A. 1cm per hr
B. 1.5-2cm per hr
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What is defined as active phase of labour?
3cm to full cervical dilation (10cm)
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3 Stages of labour?
1. Initiation of regular contractions to full effacement and dilation of cervix to 10cm
Latent/Active Phase
2. Period from full dilation of the cervix to delivery of the feus
3. Delivery of the conception products (placenta, membranes) following fetal delivery.
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How often should CTG be monitored in second phase of labour?
Every 5 minutes or after every contraction.
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Term delivery?
37 - 42 weeks gestation
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Management for vaginal/Perineal tears?
1st - very small, no stitching, naturally heals (No muscle involvement)
[SKIN ONLY]
2nd - Skin, back of the vagina and perineum muscles torn - needs stitches
[Perineum]
3rd - Skin, back of vagina, muscles, partially/complete extension through anal sphincter -STITCHES
[ANAL Sphincter Complex Involvement]
4th - SAME AS 3RD + Extends into rectum breaching anal mucosa (Continuous opening from vagina and external sphincter)
STITCHES
[ASC + Anal Epithelium]
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What's a Laparoscopy?
Surgical procedure which examines the organs inside the abdomen.
Small incisions in the pelvis/abdomen
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What incision is common in C-Sections?
Pfannenstiel Incision (Bikini Line/Suprapubic) - incision made at the pubic hairline.
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Uses for Syntocinion?
Synthetic version of oxytocin (Stimulates contraction of uterus)
Used in 3rd Stage of labour -Active management
Induction of labour
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What is considered normal endometrial thickness?
<5mm (4-5)
>5 Abnormal - Possible RF for Ca
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What is considered protective for endometrial Ca?
combined oral contraceptive pill and smoking
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What is a hysteroscopy?
Inspection of the uterine cavity by endoscopy with access through the cervix.
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# Define recurrent miscarriage?
Causes?
3 or more consecutive spontaneous abortions.
Antiphospholipid syndrome (Autoimmune disorder)
Smoking
Parental chromosomal abnormalities
Uterine abnormalities (uterine septum)
Endocrine disorders - PCOS, (Poorly controlled DMT/Thyroid disorders)
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What is an adnexal mass?
Gynae Adenexa (Parts adjoining organ) - uterus, the ovaries, the Fallopian tubes, and the ligaments that hold the uterus in place
Growth that occurs in or near the uterus, ovaries, fallopian tubes, and the connecting tissues
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Risk factors for perineal tears?
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Shoulder Dystocia
Primigravida
Large Baby
Precipitant labour (Childbirth following a rapid labour)
Forceps delivery
```
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On a Nuchal scan:
1. What causes increased nuchal translucency?
2. What causes a hyperchogenic bowel?
1. Down's syndrome, Congenital heart defects, abdominal wall defects
2. Cystic fibrosis, Down's syndrome, CMV Infection
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VTE Risk factors in pregnancy?
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Age >35
BMI >30
Parity >3
Multiple gestation
Smoker
Current pre-eclampsia
FH VTE / PMH VTE
Immobility
IVF pregnancy
low risk thrombophiilia
```
4+ RF = Treatment with LMWH
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What precautions are taken for women with high VTE risk status?
LMWH (dalteparin) throughout 28wks until 6W postnatal (3+RF)
4> RF = Ongoing Dalteparin from 1st Trimerster
ON delivery admission
Ted stockings + Dalterparin
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Define threatened miscarriage?
Vaginal bleeding and an ongoing pregnancy (signs of fetal life)
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Define inevitable miscarriage?
Cervix begins to dilate
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Define incomplete miscarriage?
Passage of some, but not all of the products of conception.
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Define complete miscarriage?
All products of conception are expelled from the uterus
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Define missed miscarriage?
Fetus dies in utero but is not expelled
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Define an an anembryonic miscarriage?
Type of 'missed' miscarriage where embryonic development fails at a very early stage. Sac continues to develop but no fetal parts on ultrasound.
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Define septic miscarriage?
Complication of incomplete miscarriage in which an intrauterine infection occurs.
215
Percentages of live birth following a miscarriage?
For 1, 2, 3 miscarriages
1 - 85
2 -75
3 -60
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What are the complications of Rubella infection that's passed on from pregnancy to the child?
Triad:
Sensorineural hearing loss
CHD (PDA)
Congenital Glaucoma and cataracts
217
Dilutional Anaemia in pregnancy
CAUSE?
Normal MCV, Hb Low
Rise in in Plasma volume (50%) so RBCs are diluted out.
218
If a Pregnant women has Iron deficiency anemia what would the blood results show?
Microcytic anaemia - Low MCV, Low Hb
Treatment Iron Supplements - Ferrous Sulphate
219
Classic sign of poor latching?
Breast noise clicking when feeding
220
Signs of good latching?
```
Less visible areola
Wide open mouth
Rolled out lips
Chin touching the breast and free nose
Visible + audible swallowing sounds
```
221
Baby displays with white patches in the mouth after breastfeeding
What condition?
Management
Oral Thrush - Secondary to nipple thrush(fungal infection)
Topical Antifungal cream (Miconazole) - Nipples after every feed + Cream to infants mouth
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Signs of Nipple Thrush (Fungal infection)?
Sharp pain
Worsening pain after feeds
Bilateral erythema
223
Name the TORCH Pathogens that cause infection and severe congenital abnormalities?
Toxoplasmosis
Rubella
CMV
HSV
Carried through the bloodstream of mum to baby in the uterus .
224
Define Chorionamnionitis?
Infection of the membranes (Chorion, amnion) and/or amniotic fluid surrounding fetus
225
Investigations and Management for chorionamnionitis?>
```
Investigations
Clinical Signs + WCC (Increase)
Fever
ROM
Fluid leakage
Uterine tenderness
Elevated maternal HR >100bpm
Elevated FHR >160bmpm
Increased
```
Treatment
- Abx (Gentamicin, clindamycin, ampicillin)
- Induce delivery
- Afebrile status for 24hrs prior to discharge
226
Pregnant women presents with Herpes in the 1st/2nd Trimester
MANAGEMENT UNTIL BIRTH
Treat the primary infection with Acyclovir
PROPHYLATYIC ACICLOVIR DAILY FROM 36 WEEKS UNTIL EXPECTANT DELIVERY
227
PRIMARY HERPES INFECTION DURING LABOUR
ACTION?
Emergency C-Section + IV Aciclovir
228
Causes of Rhesus Incompatibility (Isoimmunisation) to fetus?
1 - Hepatosplenomegaly + Jaundice
2 - Kernicterus
3 - Hydrops fettles (gross oedema)
4 - Erythoblasts on peripheral blood smear, haemolytic anaemia + erythroblastosis fettles.
229
Most common causes of postcoital bleeding?
Cervical Abnormality - Cervical ectropion, polyps, infection, neoplasia
230
Cervical cancer red flags?
Postcoital/intermenstral bleeding, vaginal discharge in the ABSCENCE of infective symptoms
Non-specific pelvic pain & dyspareunia
231
Next steps if CERVICAL ABNORMALITY DETECTED on speculum exam?
Urgent Colposcopy referral - 2 weeks
Large cervical polyp/cervical ectropion - Gynae clinic referral from primary care.
NAD + Neg STI Swabs + Symptoms still persisting - 6 to 8 week colposcopy referral
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Cervical Smear Screening age + frequency?
Primary function of test?
25 to 49 - Repeated every 3 years
Cytological abnormalities - HPV infection, Maligancy, dyskaryosis (abnormal nucleus/cervical epithelial tissue)
233
What blood test is most specific for iron deficiency anaemia in pregnancy?
What points should FBC be taken to assess anaemia?
Ferritin <30ug/l
(<15ug/l -normal population)
Booking appt + 28 weeks
234
Treat for Anaemia during pregnancy?
Oral Iron supplementation + regular checks to see affect on anaemia.
(Any symptomatic normocytic/microcytic anaemia sufficient for treatment)
235
4 Classical symptoms of Endometriosis?
DIPS
Deep dyspareunia
Infertility
Pelvic Pain (cyclical)
Secondary dysmenorrhoea
236
Cellulitis Treatment?
Oral flucoxacillin / erythromycin (pen allergy)
237
What measures should be taken if a mother has had a previous GBS infection?
Intrapartam IV Abx
Prev GBS infection in pregnancy = Increase risk of 50% in next pregnancy
Swabs - (35 weeks+)
Prophylaxis Abx - Benzylpenicillin [Given women in preterm labour]
GBS+ve + Unaffected baby
IAP / Swab + IAP (If +ve)
Baby prev infective with GBS
IAP
238
What is vertical transmission?
Transmission of disease from parent to offspring.
| e.g HIV-1,
239
What treatment must occur in a neonate who's MUM HAS HEP B OR HAS BEEN INFECTED BY HEP B?
Hep B immunoglobulin + Complete course of vaccination
240
# Define puerperal pyrexia?
Causes?
Treatment?
Temp > 38ºC in the first 14 days following delivery
```
Endometritis
VTE
Mastitis
UTI
Wound infection (C-section + perineal tears)
```
IV Abx - Cindamycin and gentamicin until afebrile for greater than 24 hours
241
Define Oligohydramnios?
Reduced Amniotic fluid
AFI <5th Percentile/ <500ml (32-36 weeks)
```
Causes
PROM
Pre-eclampsia
IUGR
Fetal renal problems - renal agenesis (Missing kidney 1/2 at birth)
Post term gestations
```
242
Tocolytic example?
Suppressant of premature labour. Helps to prolong pregnancy.
MG Sulphate.
243
Contraindications for ECV?
Recent APH
Ruptured membranes
Uterine abnormalities
Previous C-section.
244
What should a Normal CTG look like?
Accelerations present,
Variability >5bpm,
No decelerations,
HR 110-160
Variability should be 5-25bpm
Decelerations are normal on contractions, but must resolve after.
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Management for shoulder dystocia?
HINT: HELPERR
1. Additional HELP called
2. Evaluate for EPISIOTOMY (+_/ Usually done after Leg to mcroberts)
3. Leg to MCROBERTS
4. SupraPUBIC PRESSURE
5. ENTER: rotational manoeuvres
6. REMOVE the POSTERIOR arm
7. ROLL pt to hands and knees (ALL FOURS)
HELPERR
246
What are the layers you go through when making incisions for a C-Section?
```
Anterior rectus sheath
Rectus abdominis
Transversals fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
```
247
What's the most common cause of cord-prolapse?
Artificial Amniotomy (ARM)
248
What hormone inhibits prolactin prolactin production?
Dopamine.
249
most common cause of infection after childbirth?
Endometritis.
Can lead to secondary PPH
250
What bloods results usually indicate DIC in pregnancy?
Elevated PT
Elevated aPTT
Low platelets
Low fibrinogens
251
Which oestrogen derivative increases the most during pregnancy?
A. Oestriol
B. Oestrogen
C. Oestrone
A - Oestriol
252
When can HCG be first detected in maternal blood?
What rate does HCG level increase by in first couple of weeks?
When do levels peak?
HCG can be detected in the maternal blood as early as day 8 after conception.
Doubles every 48hrs
Levels peak 8-10 wks
253
Explain what's involved in:
1. Direct Coombs Test ?
2. Indirect Coombs Test ? [1st trimester]
3. Kleinbauer Test? [ 2nd/3rd trimester]
Direct Coombs: Investigation used to look for autoimmune haemolytic anaemia,
Indirect: Test antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.
Kleihauer is used after a sensitising event to see if fetomaternal haemorrhage has occurred and volume of blood to help calculate Anti-D
254
Bishop Score Markers?
<4 Spontaneous labour less likely to occur
>8 Labour likely to occur
score ≤5: PGE2
score >5: amniotomy +- Oxytocin if labour doesn't begin
< 3 : IOL unlikely to be successful
<=5 : IOL with PV prostaglandin gel (should start labour or ripen cervix)
6-8 : AROM (amniotomy ± oxytocin infusion if labour does not begin)
>=9 : labour likely to occur spontaneously
255
What week can you attempt ECV in
1. Breech presentation?
2. Transverse presentation?
1. 36 Weeks
| 2. 32 weeks
256
Polyhydraminous volume criteria?
>2/3L of amniotic fluid
257
Which blood test can be used to indicate start of menopause?
FSH (Increases in level)
