Womens Health PTS Flashcards

Question

How do you medically treat menorrhagia?

Answer 1

Reassure Mirena coil – first line treatment if doesn’t want to get pregnant Anti-fibrinolytics – e.g. tranexamic acid taken during bleeding NSAIDS – e.g. mefanamic acid taken during bleeding COCP – triphasing (take back to back for 3 months, then break) Progestogens Norethisterone when they don’t want to bleed e.g. on holiday

Answer 2

Endometrial ablation – ONLY IF THEY HAVE COMPLETED THEIR FAMILY as it would lead to a very high risk pregnancy Uterine artery embolisation Hysterectomy – last resort

Answer 3

Painful periods +/- nausea and vomiting

Answer 4

Primary – unknown, no underlying physical cause Secondary – due to underlying cause: Endometriosis Adenomyosis Fibroids PID Cancer

Answer 5

Clinical assessment of the problem – full history and examination USS Endometrial biopsy Laparoscopy STI screen

Answer 6

NSAIDs – mefenamic acid given during menstruation Paracetamol COCP Smooth muscle anti-spasmodics – e.g. hyoscine butylbromide

Answer 7

NSAIDs – mefenamic acid Paracetamol Treat underlying cause – i.e. fibroids Mirena coil

Answer 8

Cervical cancer Other causes – polyps, cervical trauma, cervicitis, vaginitis, chlamidya

Answer 9

Endometrial cancer until proven otherwise Other causes – vaginitis, foreign bodies (e.g. pessaries), carcinoma of cervix or vulva, polyps, oestrogen withdrawal Ensure she is not confusing with rectal bleeding

Answer 10

Retrospective diagnosis After 12 months of amenorrhoea

Answer 11

Irregular periods Vasomotor symptoms – hot flushes, night sweats, impact on sleep, mood and QoL Mood swings Decreased sexual desire Joint aches and muscle pain Vaginal dryness Headache, dry skin Loss of energy

Answer 12

Before the age of 40

Answer 13

Osteoporosis - oestrogen inhibits osteoclasts and therefore once oestrogen levels drop, osteoclasts can become hyperactive Cardiovascular disease Dementia

Answer 14

Lifestyle advice – reduction of modifiable risk factors (smoking, heart disease, alcohol, diabetes) Hormonal treatments – HRT, vaginal oestrogen Non-hormonal – clonidine, alpha receptor agonist CBT

Answer 15

Benefits – relief of menopausal symptoms, bone mineral density protection, possibly prevents long term morbidity Risks – breast ca, VTE, CVD, stroke

Answer 16

Progesterone given alongside the oestrogen replacement Stops the oestrogen causing excessive proliferation of the endometrium by allowing shedding Not necessary if – they have had a hysterectomy, they have the Mirena coil

Answer 17

Oral HRT poses the highest risk Reduced by giving a transdermal patch instead Transdermal should always be offered to people with BMI > 30

Answer 18

Aim to manage and optimise RF before commencing on HRT – i.e. control hypertension, diabetes, cholesterol If someone has PREVIOUSLY HAD AN MI OR STROKE – they SHOULD NOT have HRT at all

Answer 19

Pessary Cream applied with applicator for local vaginal symptoms – bleeding, pain, UTI Patch Oral tablet

Answer 20

Patient choice Gastirc upset – malabsorption such as Crohn’s Increased risk of VTE

Answer 21

Skin irritation

Answer 22

COCP gives a SUPRAPHYSIOLOGICAL dose of oestrogen HRT only gives a physiological dose of oestrogen – what the body is used to

Answer 23

When periods stop < 40 years of age

Answer 24

Idiopathic Iatrogenic – chemotherapy (i.e. effect of childhood cancer treatment), radiotherapy, surgery

Answer 25

Infertility Amenorrhoea

Answer 26

Age < 40 years FSH > 25 in 2 samples > 4 weeks apart Plus 4 months of amenorrhoea

Answer 27

Oestrogen replacement – HRT, COCP. HRT encourage until they are at least 50 Androgen replacement – testosterone gel Fertility – donor egg

Answer 28

The loss of a pregnancy before 24 weeks’ gestation (after 24 weeks’ it would be classed as a still birth)

Answer 29

15-20% Usually in the first trimester

Answer 30

Maternal age ≥ 35 years Paternal age ≥ 40 years

Answer 31

Increased maternal age Smoking in pregnancy Alcohol Drugs High caffeine intake Obesity Infections and food poisoning Medicines such as ibuprofen Health conditions – thyroid, severe HTN Cervical incomptency

Answer 32

Heavy lifting Bumping tummy Having sex Air travel Being stressed

Answer 33

Unknown Chromosomal abnormalities Abnormal foetal development Maternal illness Infection Trauma Cervical weakness Chronic maternal disease (SLE)

Answer 34

The loss of ≥ 3 consecutive pregnancies before 24 weeks’ with the same biological father

Answer 35

Antiphospholipid syndrome Uterine abnormalities Thrombophilia e.g. Factor V Leiden, protein C or protein S deficiencies Parental chromosomal abnormality – unbalanced Robertsonian translocation Infection – bacterial vaginosis associated with 2nd trimester loss

Answer 36

Mild symptoms - i.e. mild abdominal pain and mild vaginal bleeding CERVICAL OS IS CLOSED

Answer 37

Severe abdominal pain Vaginal bleeding The cervical os is open If you can get a finger into the os = inevitable miscarriage

Answer 38

Incomplete miscarriage – most of the products have already been passed but the process may still be happening Missed miscarriage – foetus dies but remains in utero, os is closed, may be completely asymptomatic. Will be confirmed at USS Pregnancy of uncertain viability – small sac with no visible heart beat. Rescan in 10-14 days Complete – os closed, empty uterus

Answer 39

ABCDE approach to bleeding Expectant management (conservative) Inevitable and incomplete miscarriages – can be managed with misoprostol or surgical evacuation

Answer 40

Ectopic pregnancy Miscarriage Molar pregnancy

Answer 41

Implantation of a fertilised ovum outside the uterine cavity 97% occur in the fallopian tubes

Answer 42

Damage to tubes – PID, surgery Previous ectopic Endometriosis Copper coil IVF Smoking Past infection of the tubes or appendicitis

Answer 43

In exam Qs – LMP 8 weeks ago Vaginal bleeding Pain – generalised abdominal pain or confined to an iliac fossa Shoulder tip pain from haemoperitoneum

Answer 44

USS – intrauterine pregnancy? Foetal heartbeat? Serial HCG measurements Pelvic examination – CERVICAL EXCITATION /motion tenderness on speculum examination

Answer 45

ABCDE approach to bleeding Surgical options – salpingectomy is the best treatment option (but only do this if the other fallopian tube is viable), salpingotomy to remove the pregnancy if other tube not viable Medical management – methotrexate if BHCG is low

Answer 46

Vaginal bleeding Pain Uterus larger than it should be for the expected dates Very very high levels of BHCG Clinical hyperthyroidism Severe morning sickness

Answer 47

Removal by suction

Answer 48

Not an STI Creates patchy, white, thin skin around the vulval area Thought to be autoimmune Observe if doesn’t respond to treatment – can be pre-malignant Topical steroid cream or topic tacrolimus In children – 50% resolve by menarche

Answer 49

Cervical intra-epithelial neoplasia (CIN) Pre-invasive 60% regress to normal within 2 years Many develop into squamous carcinoma of the cervix

Answer 50

Refer to colposcopy If there is abnormal cytology or HPV +ve

Answer 51

Sexually active women aged 25-64 Every 3 years from 25-50 Every 5 years from 50-64

Answer 52

HPV infection Multiple partners Smoking Immune compromisation

Answer 53

HPV vaccination – offered to school girls at 12 years before they’re sexually active – no benefit if already exposed to HPV Colposcopy – used for further assessment of normal smear Large loop excision of the transformation zone

Answer 54

Squamous cell carcinoma

Answer 55

FIGO staging – 1/2/3/4

Answer 56

Confined to the cervix

Answer 57

Spread into the top part of the vagina

Answer 58

Spread into other nearby organs such as the ureter

Answer 59

Distant metastasis

Answer 60

HPV infection Early age intercourse (< 16 years) STIs Cigarette smoking – encourages persistence of HPV Previous CIN/abnormal smear Multiparity History of other genital tract neoplasia

Answer 61

HPV 16 and 18

Answer 62

Contain E6 and E7 oncoproteins E6 prevents p53 tumour suppressor gene working E7 attacks retinoblastoma tumour suppressor gene Leading to overstimulation of growth of the cells of the cervix

Answer 63

Often asymptomatic and picked up on smear Post coital bleeding Post-menopausal bleeding Watery vaginal discharge Features of advanced disease – heavy vaginal bleeding, ureteric obstruction, weight loss, bowel disturbance, vesico-vaginal fistula, pain

Answer 64

History – ask when their last cervical screening was and whether it was abnormal Physical examination – bimanual, speculum Punch biopsy for histology CT abdomen and pelvis –staging MRI pelvis – staging and identifying suspicious lymph nodes

Answer 65

Large loop excision of the transformation zone Knife cone biopsy +/- pelvic lymph nodes Simple hysterectomy Cervicetomy/ trachelectomy Radical hysterectomy (total abdominal hysterectomy) and pelvic lymph nodes Chemo/radiotherapy – if too large for surgery (impacts fertility)

Answer 66

Adenocarcinoma

Answer 67

Again staged with FIGO Stage 1 – confined to the endometrium and uterus Stage 2 – grown into the cervix Stage 3 – into the ovaries, vagina and surrounding lymph nodes Stage 4 – distant spread

Answer 68

Post-menopausal women

Answer 69

UNOPPOSED OESTROGEN - so anything that causes unopposed oestrogen Obesity Early menarche Late menopause Nulliparity PCOS Lynch syndrome HRT

Answer 70

OBESITY is the biggest risk - adipose tissue releases oestrogen – obesity is the reason for an increase in incidence of endometrial cancer Post-menopause – loss of progesterone so you have unopposed oestrogen

Answer 71

Parity (long time where there has been very high progesterone and low oestrogen during pregnancy) Combined OCP

Answer 72

Post-menopausal bleeding - anyone with PMB should be referred on 2 week wait In pre-menopausal women – heavy or irregular periods, PV discharge, pyrometra (infection of the uterus – 50% of ladies with pyrometra will have endometrial cancer)

Answer 73

Transvaginal USS Endometrial biopsy Hysteroscopy MRI

Answer 74

Surgery – total abdominal hysterectomy +/- lymph nodes Radiotherapy – adjuvant (brachytherapy/external beam) Progesterone therapy Good prognosis – 5 year survival for stage 1 disease 80%

Answer 75

Squamous cell In younger women – HPV In older women – lichen sclerosis

Answer 76

Vulval itching Vulval soreness Persistent ’lump’ Bleeding Pain on passing urine Past history of VIN (vulval intra-epithelial neoplasia) or lichen sclerosis

Answer 77

Epithelial cell tumours Some can be granulosa, germ cell (teratomas) or secondary i.e. associated with presence of upper GI cancers

Answer 78

Gene mutation – BCRA 1 and 2, HNPCC (Lynch syndrome) Ovulation – the more you have ovulated the higher your risk (early menarche, late menopause, never been pregnant, never taken the pill)

Answer 79

Nulliparity Early menarche and/or late menopause Family history – gene mutations

Answer 80

Pregnancy Breastfeeding COCP Tubal ligation (prevents ovulation)

Answer 81

Bloating/IBS like symptoms (esp. in someone with no history of IBS) Abdominal pain/discomfort Change in bowel habit Urinary frequency – due to pressure on bladder Bowel obstruction (late presentation) Asymptomatic until much later

Answer 82

Ca125 levels Transabdominal ultrasound scan Whether they are pre- or post-menopausal Combine the USS, menopausal status and Ca125 levels to determine the risk of malignancy index

Answer 83

Bilateral Multilocular Ascites Solid areas Metastasis One point scored for each of these findings

Answer 84

250 or above

Answer 85

Surgery – sometimes will also need bowel resections Chemo Biologics “holistic approach to management” – involved specialist cancer nurse, psychological therapy, social support etc.

Answer 86

Presence of endometrial tissue outside the uterus

Answer 87

Pouch of Douglas - rectal bleeding during period Lungs or pharynx – coughing up blood during period Nose – nosebleeds during period Umbilicus Points of previous scarring – e.g. at appendix scar – “lump near by scar that gets big and painful when I’m on my period” Endometrioma – bleeding into the ovaries during period

Answer 88

Sampson’s - Retrograde menstruation Meyer’s - Metaplasia of mesothelial cells Halban’s - Via the blood or lymphatic system

Answer 89

2 most common – PAIN AND SUB-FERTILITY Heavy bleeding Bleeding from other places during period – nosebleeds, haemoptysis, rectal bleeding, umbilicus

Answer 90

Cyclical pain due to endometrial tissue responding to menstrual cycle Worse 2-3 days before periods Gets better after period Deep dyspareunia Dysuria Pain on defecation (if there’s endometriosis in the pouch of douglas) IMPROVES during pregnancy (low oestrogen)

Answer 91

Areas of endometriosis release cytokines and harmful chemicals which can cause damage to various areas of the reproductive tract The damage can cause – reduced fallopian tube motility, scarring, bleeding, toxicity to the oocyte, adhesions and ovarian dysfunction

Answer 92

Adenomyosis – when the areas of endometrial tissue are localised to the myometrium

Answer 93

Laparoscopy

Answer 94

Abolish cyclicity Invoke glandular atrophy In addition to this – also provide pain relief (mefenamic acid, paracetemol)

Answer 95

COCP – triphasing method. Works well in young women who do not want to get pregnant GnRH agonists – “induces menopause” but reversible once the treatment is stopped. Works quicker than triphasing but they need HRT added

Answer 96

USE OF PROGESTERONE: Oral progestogens (mini pill) – stops the bleeding, but can cause PMS symptoms Depot Provera Mirena coil These all work well for ladies who do not want to get pregnant

Answer 97

Ablation – burning away of the endometriotic tissue Excision – cutting away of the endometriotic tissue

Answer 98

Oophorectomy – no ovaries = no oestrogen = no menstrual cycle = no endometriosis Hysterectomy The woman can also be given low dose HRT afterwards to improve menopausal symptoms

Answer 99

Excess endometrial tissue in the myometrium (muscle layer of the uterus) Unlike endometriosis (which is seen more commonly in younger ladies who haven’t had children), adenomyosis tends to happen in older women who have had lots of children So presents much later than endometriosis

Answer 100

Cyclic pain – gets worse when period starts Can last for 2 weeks after period stops (much longer than pain with endometriosis) Dysmenorrhoea Dyspareunia

Answer 101

Often hysterectomy – usually occur in women who have already completed their family

Answer 102

Benign smooth muscle tumours of the uterus, otherwise known as uterine leiomyomas Very common – 20% of women of reproductive age

Answer 103

Unknown But they are OESTROGEN DEPENDANT - so they shrink after the menopause Associated with mutation in the gene for fumarate hydratase

Answer 104

Increasing age (until menopause is reached) Afro-Caribbean women Family history Early puberty Obesity

Answer 105

Many asymptomatic and found incidentally Menorrhagia Dysmenorrhoea Fertility problems – submucosal fibroids may interfere with implantation Miscarriage – large or multiple tumours can compete for space Pain Mass Pressure symptoms – bladder frequency, varicose veins Bloating, constipation

Answer 106

Abdominal examination Bimanual pelvic examination Transvaginal ultrasound Transabdominal ultrasound Hysteroscopy

Answer 107

Bulky NON TENDER uterus

Answer 108

< 3 cm – IUS, tranexamic acid, NSAID (mefenamic acid) or COCP >3 cm – Trans-cervical resection of fibroids (TCRF), myomectomy, hysterectomy, uterine artery embolisation

Answer 109

Benign growths of the endometrium Some can be cancerous or precancerous

Answer 110

Being peri- or post-menopausal Hypertension Obesity Taxing tamoxifen (breast cancer therapy)

Answer 111

Irregular menstrual bleeding Menorrhagia Inter-menstrual bleeding Post-menopausal bleeding Infertility in younger ladies – competing with the foetus for space

Answer 112

Ultrasound – transvaginal and transabdominal Hysteroscopy Endometrial biopsy

Answer 113

Can be left alone – but monitor/biopsy if concered could be malignant or pre-malignant GnRH analogues (oestrogen sensitive) Polypectomy – can be done hysteroscopically Hysterectomy if symptoms severe

Answer 114

Functional cysts – enlarged persistent follicle or corpus luteum. Normal < 5cm, resolve after 2/3 cycles. Can cause pain and peritonitis if they bleed. COCP inhibits Mucinous cystadenomas – massive, unilateral, appear solid. Common in 30-40 years olds, 15% malignant – cause mucus ascites (pseudomyoxma peritonei) if rupture Serous cystadenomas – most common epithelial tumours, commonly bilateral, 30-50 year olds, 25% malignant Dermoid cyst - ’mature cystic teratoma’ – contain skin/hair/teeth. Most common cyst in < 30s. Bilateral 20-30%. Torsion most likely in dermoid cyst

Answer 115

Asymptomatic – may be incidental finding Chronic pain – dull ache, dyspareunia, cyclical pain, pressure effects Acute pain – unilateral - if bleeding, torsion or rupture Irregular vaginal bleeding Hormonal effects – e.g. sudden development of androgenic features Abdominal swelling or mass – ascites suggests malignancy or rupture mucinous cystademona

Answer 116

FBC Ca125 (if > 40 years) If < 40 years – check other tumour markers (AFP, CEA, HCG) Transvaginal USS Transabdominal USS Consider MRI for masses >7cm MRI and CT for staging malignancy

Answer 117

ABCDE and hospital admission if acute presentation Pre-menopausal women – preserve fertility and exclude malignancy. If no features of malignancy, leave alone. If cyst >5cm or symptomatic – laparoscopic ovarian cystectomy (avoid spilling cyst contents – can lead to chemical peritonitis if dermoid) Post-menopausal women – calculate risk of malignancy index, leave alone if <5cm, watch and wait. Remove if >5cm or symptomatic. Bilateral oopherectomy can be performed if moderate/high risk

Answer 118

Pregnancy Malformations Tumours Previous surgery

Answer 119

Acute unilateral abdominal pain (often during exercise) Radiates – back, thigh, pelvis Nausea and vomiting Fever – indicates necrotic ovary

Answer 120

Rule out ectopic – pregnancy test USS with colour Doppler = diagnostic gold standard

Answer 121

Laparoscopy Plus analgesia and fluid resuscitation

Answer 122

Acute abdominal pain (often during exercise) PV bleed N&V Circulatory collapse +/- weakness, syncope Fever/sepsis

Answer 123

Rule out ectopic – urinary HCG USS Laparoscopy = diagnostic gold standard

Answer 124

ABCDE assessment If stable – analgesia and supportive (fluids, painkillers) If unstable/bleeding – surgery – laparotomy may be necessary

Answer 125

A chronic infection of the upper genital tract

Answer 126

STI – 25% due to chlamydia and gonorrhoea Uterine instrumentation – hysteroscopy, insertion of IUCD, TOP Post-partum (retained tissue) Descend from other organs – appendicitis

Answer 127

Age < 25 History of STI New and multiple sexual partners

Answer 128

Barrier contraception Mirena COCP

Answer 129

Lower abdominal pain May be unilateral or bilateral May be constant or intermittent (but usually chronic in nature – i.e. lasting several months) Deep dyspareunia Vaginal discharge IMB PCB Dysmenorrhoea Fever

Answer 130

History Examination – vaginal bimanual examination and speculum examination Full STI screen – high and low vaginal swabs, endocervical swabs, urine sample TVS if abscess suspected FBC, CRP and blood cultures – if acutely unwell/septic

Answer 131

Cervical excitation (motion tenderness) on vaginal examination – BIG ONE FOR THE EXAMS Vaginal discharge Adnexal tenderness

Answer 132

Tubo-ovarian abscess Fitz-Hugh-Curtis syndrome – liver capsule inflammation Recurrent PID Ectopic pregnancy Subfertility from tubal blockage

Answer 133

Contact tracing Antibiotics – start before cultures come back (quicker treatment = reduced risk of complications) – ceftriaxone, doxycycline, metronidazole, azithromycin If very severe/very unwell – admit for ABX

Answer 134

Female – self-taken vulvo-vaginal swabs for gonorrhoea/chlamidya NAAT (nulceic acid amplification test), bloods for HIV and STIs Heterosexual male – first void urine, bloods MSM – first void urine (chlamidya and gonorrhoea), pharyngeal swab, rectal swab, bloods – STI, HIV, HEP B

Answer 135

Vulvovaginal swabs – Gonorrhoea and Chlamydia High vaginal swabs – BV, TV, candida Urethral swabs for men First void urine for men Dipstick urinalysis (looks for pus cells) Bloods Rectal and pharyngeal swabs and cultures for MSM

Answer 136

Vaginal discharge Vulval discomfort/soreness, itching or pain Superficial dysparuenia Deep dyspareunia Chronic pelvic pain Vulval lumps and ulcers Inter-menstrual bleeding Post-coital bleeding

Answer 137

Pain/burning during micturition Pain/discomfort in the urethra Urethral discharge Genital ulcers, sores or blisters Syphillis – primary shankra (can occur on the penis/glans) Genital lumps Rash on penis/genital area Testicular pain/swelling – e.g. orchiditis

Answer 138

Prevent re-infection of index patient Identify and treat asymptomatic infected individuals as a public health measure - i.e. preventing the disease from spreading further

Answer 139

Involuntary leakage of urine at a time which is not socially acceptable

Answer 140

20% of adult women

Answer 141

Overactive bladder (destrusor overactivity) – caused by involuntary bladder contractions Stress incontinence - caused by sphincter weakness Fistula – between urinary tract and vagina/bowel Neurological – nerve damage/MS Overflow incontinence – due to retention/prostate enlargement Functional Mixed incontinence

Answer 142

Age Increasing parity Obesity Smoking Previous surgery

Answer 143

Nerve damage from previous surgery Childbirth Diabetes – neuropathy may affect bladder control, polyuria and polydipsia as diabetes symptoms, renal impairment, nephropathy, reduced immunity and increased risk of infection Recurrent UTI – causing frequency

Answer 144

Urgency Urge incontinence Frequency Nocturia Noctural enuresis ‘Key in the door’ and ‘Hand wash’ can act as a trigger for bladder contractions in overactive bladder Intercourse

Answer 145

Involuntary leakage when: Cough Laugh Lifting Exercise Movement

Answer 146

HISTORY is the most important factor Bladder diary (frequency volume chart) – need to record when, how much and fluid intake

Answer 147

MSU – infections, nephritis, cancer, stones, diabetes, renal disease Residual urine measurement - in and out catheter, USS to measure how much urine left ePAQ questionnaire – asks about urinary, vaginal, bowel and sexul symptoms Urodynamics – measures the pressures in the abdomen and the bladder to figure out the detrusor pressure Cystogram – with contrast to view the bladder

Answer 148

Weight loss Smoking cessation Reduced caffeine intake Avoidance of straining and constipation

Answer 149

Bladder retraining Can also use pads to absorb any leaked urine – may be prefered to surgery

Answer 150

Pelvic floor exercises

Answer 151

ANTICHOLINERGICS: Oxybutinin Solifenacin Parasympathetic - pissing – decreasing the need to urinate MIRABEGRON: Beta-3-adrenergic receptor agonist (sympathetic – storage) Relaxes detrusor and increases bladder capacity BOTOX INJECTION – paralyses detrusor to stop it from being overactive

Answer 152

Dry mouth Blurred vision Drowsiness Constipation Tachycardia

Answer 153

Augmentation cystoplasty Indwelling catheters Bypass (urostomy)

Answer 154

60% is cured by physiotherapy and conservative measures - pelvic floor exercises, pads, pessaries, skin care, odor control Surgery – sling, suspension – supports the urethra to increase the urethral resistance

Answer 155

Cystocele – anterior wall of vagina and bladder – causes frequency and dysuria Rectocele – lower posterior wall or vagina and rectum – may beed to insert finger to vagina or press on perineum to aid defecation Enterocele – upper posterior wall of vagina and intestine Uterine prolapse – protrusion of the uterus fown the vagina Vault prolapse – if the woman has had a total hysterectomy

Answer 156

Cause – weakness of the ligaments and pelvic floor Risk factors - age, obesity, childbirth, previous surgery

Answer 157

”something coming down” – dragging sensation, feels as if something will fall out their vagina Pain Lump Discomfort Incontinence Sexual dysfunction Unable to go to the toilet – may complain of having to stick their fingers up to pass urine of faeces

Answer 158

Speculum examination – can see easily whether there’s something there

Answer 159

Conservative – reassure, pelvic floor exercises Pessary – ring, shelf, gelhorn Surgery if all else fails

Answer 160

Failure to conceive after 1 year or regular unprotected sex (2-3 times per week)

Answer 161

Unexplained – 25% Male factors – 30% Ovulatory disorders – 25% Tubal damage – 20% Uterine disorders – 10% In 40% - factors are due to both partners

Answer 162

Increasing age Extremes of weight

Answer 163

PCOS Pituitary tumours Sheehan’s syndrome Hyperprolactinaemia Premature ovarian failure Turner’s syndrome Hypothyroidism Previous chemo or radiotherapy

Answer 164

PID Sterilisation Asherman’s syndrome (adhesions) Fibroids Polyps Endometriosis Uterine malformation

Answer 165

See both partners together and write down everything you explain to avoid confusion Ovulatory tests – mid-luteal progesterone levels (day 21 in a 28 day cycle, day 28 in a 35 day cycle) Ovarian reserve testing – FSH, antral follicle count, antimullerian hormone Semen analysis – count, motility, morphology Other tests for the woman – prolactin levels, thyroid levels, free androgen levels, USS of uterus and tubes, karyotype

Answer 166

Use of anabolic steroids High prolactin Cystic fibrosis – even carriers can have absence of vas deferens History of undescended testes Childhood measles Working with a lot of heat – i.e. chefs

Answer 167

Semen analysis – sperm count, motility, morphology Imaging – vasogram, ultrasound, urology CF screen Karyotype

Answer 168

Recommend couples to keep trying for 1 year Inform about effect of age Preconception advice – intercourse 2-3x a week, folic acid, smear, rubella, stop smoking, BMI between 19-30, no alcohol or drugs, good control of existing medical conditions Refer to specialist after 1 more year or other criteria (covered next)

Answer 169

FEMALE: Age > 35 Menstrual disorder Previous abdominal/pelvic surgery PID MALE: Previous genital pathology or urogenital surgery Previous STI Systemic illness

Answer 170

Avoidance of extreme heat near the genitals Looser fitting underpants Stop smoking – smoking reduces fertility Moderate alcohol intake Avoid harmful chemicals in occupation Diet/supplements - folic acid Weight optimisation

Answer 171

Mild – intrauterine insemination Moderate – IVF Severe – Intracytoplasmic Sperm Injection (ICSI) If azoospermia – surgical sperm recovery or donor insemination Hormonal – bromocriptine if hyper-prolacintaemia, gonadotrophin replacement Ensure they are not taking anabolic steroids

Answer 172

Induction of ovulation Treat any tubal disease IVF If endometriosis – medical treatment doesn’t improve changes of pregnancy, they need surgical ablation or excision of the endometriotic areas

Answer 173

Ovulation induction Stimulated intrauterine insemination IVF ICSI Donor insemination Donor egg Donor embryo Host surrogacy (i.e. if the problem is with their uterus)

Answer 174

Multiple pregnancy Miscarriage Ectopic Ovarian hyper stimulation syndrome Bleeding and infection at egg collection

Answer 175

Age Cause of infertility Previous pregnancies – increases likelihood Duration of infertility Number of previous atempts Medical conditions Environmental factors

Answer 176

All procedures involving partial or total removal of female external genitalia or injury to female organs for non-medical reasons Involves damaging or removing normal, healthy female genital tissue and hence intereferes with function

Answer 177

Clitoridectomy – partial or total removal of the clitoris Excision – partial or total removal of the clitoris and labia minora +/- labia majora Infibulation - narrowing of the vaginal orifice by stiching the labia together All other harmful procedures to the female genitalia for non-medical purposes

Answer 178

Brings status and respect Preserves a girl’s virginity Part of being a woman Rite of passage Upholding family honor Cleanses and purifies the girl Fulfils a religious requirement Makes the girl acceptable for marriage Sense of belonging to the community

Answer 179

Blood borne viruses (no use of sterile equipments) Haemorrhage could occur Infection and sepsis

Answer 180

Illegal to perform FGM in England, Wales and northern Ireland Illegal to assist in the carrying out of FGM (including helping them book the flights, taking them to have it done or even knowing about it and not doing anything) If you see a child with FGM you need to phone the police

Answer 181

Sexual dysfunction with anorgasmia Chronic pain Keloid scar formation Dysmenorrhoea Haematocolpos - period blood backs up in the uterus as it cannot get released during the period Urinary outflow obstruction Recurrent UTI Difficulty conceiving – sexual intercourse can be very difficult PTSD

Answer 182

Fear of childbirth Increased likelihood of C-section, PPH, episiotomy, severe vaginal lacerations and fistula formation Extended hospital stay Difficulty in – performing vaginal examinations in pregnancy, applying fetal scalp electrodes and FBS Difficulty in catheterising the bladder Best to try and reverse infibulation before the woman falls pregnant

Answer 183

Report all cases of FGM in the medical notes (if adult) Call the police if child Ensure that families know FGM is illegal so they don’t keep doing it to their children

Answer 184

Synchronisation between maternal and blastocyst tissue Maternal adaptions to pregnnancy

Answer 185

HCG Progestins Oestrogens Human placental lactogen Prolactin Oxytocin

Answer 186

Secreted by – trophoblastic cells of the blastocyst Role – to signal the presence of the blastocyst to the mother Prevents the corpus luteum generating so it can persist until the placenta is formed

Answer 187

Initially come from the corpus luteum Then come from the placenta Prepares the endometrium and uterus for implanation by causing proliferation, vascularisation and differentiation of the endometrial stroma Facilitates myometrial quiescence (stops myometrium contracting too early)

Answer 188

Comes from the ovary initially (mother only) Then comes from the foetus too, later in pregnancy Role = promotes changes in CVS and alters carbohydrate metabolism Indicates foetal wellbeing (E3 - declines with foetal distress) E2 – facilitates progesterone by increasing endometrial progesterone receptors

Answer 189

Mobilises glucose from fat reserves Diabetogenic (raises blood glucose levels) – to help increase nutrient supply to the blastocyst Converts mammary glands into milk secreting tissue

Answer 190

Increased levels of prolactin allows milk production But ONLY when oestrogen and progesterone have declined post-partum Produced in the anterior pituitary

Answer 191

Facilitates uterine contractions during labour Milk ejection reflex post-partum PRODUCED in the hypothalamus, SECRETED by the posterior pituitary

Answer 192

Between day 20—24 WILL NOT implant outside this time frame

Answer 193

Placenta Decidua Myometrium Abdomen

Answer 194

Normal placenta – invades into decidua Placenta accreta – placenta invades into the superficial myometrium Placenta increta - invades into the deeper myometrium Placenta percreta – invades through myometrium, into nearby organs of the abdomen (bladder, bowel)

Answer 195

Poor placental separation (becomes difficult to deliver the placenta after the baby has been delivered. Retained products leads to increased risk of infection) Significant post-partum haemorrhage

Answer 196

HUMORAL – remains unchanged, plenty of circulating Th2 cells meaning mother can fight infections CELL MEDIATED – reduced during pregnancy. Progesterone down regulates the production of Th1 cells The dampening of Th1 production causes there to be a shift to increased Th2 production (Th2 bias)

Answer 197

Pre-eclampsia IUGR Miscarriage

Answer 198

IgG Role in rhesus disease/haemolytic disease of the newborn The primary immune deficiency hypogammaglobulinaemia can occur in babies who’s mother’s didn’t have high enough levels of IgG during pregnancy

Answer 199

If the MOTHER IS RH-VE AND THE FATHER IS RH+VE This is because 50-100% of their offspring will be Rh+ve also Not a problem if dad is also Rh-ve

Answer 200

During first pregnancy – sensitisation occurs Maternal immune reaction to the Rh+ve antigen of foetal RBC Produces IgM which doesn’t cross the placenta to affect this pregnancy However DOES produce memory cells – which means IgG can be produced in a subsquent pregnancy = CAN cross the placenta and CAN affect the baby

Answer 201

Causes RBC haemolysis Leading to severe foetal anaemia and possible death if no intervention

Answer 202

Anti-D prophylaxis Anti-D destroys anti-Rh+ve antibodies Given at 28 and 34 weeks and after birth Also given earlier in pregnancy if any sensitisation events occur

Answer 203

Post-prandial glucose peak is higher for longer to spare glucose for the foetus GLUCOSE IS THE MAIN SOURCE OF NUTRIENTS for the foetus

Answer 204

Macrosomic infant (>4kg birthweight) Which increases the risk of traumatic delivery (too big for the hole) and shoulder dystocia Still birth Congenital malformations – cleft palate most common At risk of neonatal hypoglycaemia (due to hyperinsulinaemia)

Answer 205

Ketoacidosis Pre-eclampsia Coronary heart disease Nephropathy (and all the other normal complications of diabetes)

Answer 206

OBESTIY Massively increases their risk of problems during pregnancy

Answer 207

B2 agonists – salbutamol and ritodrine CCB - nifedipine These are known as TOCOLYTIC DRUGS (stop labor) Used as a treatment for coming in in early labour – B2 agonists stop smooth muscle contraction (same way as they do in asthma) Causes MYOCYTES TO BECOME HYPERPOLARISED = which means they cannot depolarise = they cannot contract

Answer 208

Fetal fibronectin (fFN) High levels related to early labour If high level comes back – give IM steroids and keep a closer eye on the lady

Answer 209

Firstly – membrane sweep is done before medication to try and encourage labour to start on its own (promotes positive feedback of stretch 🡪 oxytocin release) Prostaglandin PGE2 – pessary or vaginal gel Oxytocin – the analogue given is syntocinon

Answer 210

Bishop score A score < 5 generally means induction will be needed A score > 9 indicates labour will likely be spontaneous

Answer 211

Oxytocin Ergometrine Combined form – syntometrine Helps the placenta be delivered after the baby comes out Then makes the uterus contract to stop bleeding

Answer 212

Cervical dilatation (remodelling) Myometrial contraction (pushing stage) Placental delivery

Answer 213

ATOSIBAN Was one of the first drugs used against premature labour Can inhibit premature myometrial contractions by blocking oxytocin (and oxytocin is why labour happens)

Answer 214

Spontaneous onset Low risk throughout Infant born spontaneously in the vertex position between 37 and 42 weeks of pregnancy At birth, mother and infant in good condition

Answer 215

2cm dilatation per 4 hours of active labour However there is no absolute time limit for labour and progress is assessed dynamically throughout

Answer 216

FIRST STAGE (preparation phase): Latent phase - painful, irregular contractions, cervical effacement and dilation to 4cm Active phase – >4cm, regular contractions, majority of dilatation happens in this phase SECOND STAGE (pushing stage): Passive stage – complete diltation but no pushing Active stage – maternal pushing until delivery THIRD STAGE – delivery of the placenta

Answer 217

Power Passenger Passage NB – can be a combination of all these factors. Maternal exhaustion also contributes in 2nd stage

Answer 218

MOST COMMON CAUSE of failure to progress Poor uterine contractions Common in primigravida ladies

Answer 219

Malpresentation Malposition of a large baby

Answer 220

Indadequate pelvis Cephalopelvic disproportion – big baby, small pelvis

Answer 221

Large baby Breach baby First time mother Previous delayed labour Premature rupture of membranes

Answer 222

Palpate abdomen for lie, head and contractions CTG Colour of amniotic fluid Vaginal examination

Answer 223

Offer amniotomy If membranes ruptured already – oxytocin infusion CTG FBS if concerns on CTG Consider LCSC if none of this helps

Answer 224

Allow to push - 2 hours if primip, 1 hour if multip If still no imminent delivery – obstetric review for instrumental delivery or LSCS

Answer 225

Foetal distress Foetal hypoxia 🡪 HIE Increased foetal morbidity and mortality

Answer 226

Bleeding Tears

Answer 227

FHR – monitors the wellbeing of the feotus Cervical dilatation Contractions per 10 minutes Drugs and IV fluids given Pulse and BP of the mother – ensures she is stable Urine

Answer 228

Nulliparous – 0.5cm/hour (1cm every 2 hours) Multiparous – 1cm/hour

Answer 229

Slow from the beginning (dysfunctional labour) Sudden slowing of labour (secondary arrest)

Answer 230

Action line indicates slow progression At the action line – ACTION needs to be taken Provides clear guidelines on when to intervene The point at which progression stops is useful in seeing where the problem is

Answer 231

When the foetus is not presenting by the vertex

Answer 232

When the presenting part of the foetus is not the head The foetus is in longitudinal lie with the buttocks or feet closest to the cervix

Answer 233

Extended breech Presenting part is the bottom

Answer 234

Idiopathic Uterine abnormalities – bicornate uterus, fibroids Prematurity (the baby hasn’t turned itself round yet) Placenta praevia Oligohydramnios Foetal abnormalities e.g. hydrocephalus

Answer 235

Try to diagnose antenatally with USS 30% present undiagnosed in labour – palpation via abdominal examination or feeling the breech vaginally Mother may complain of pain under the ribs

Answer 236

External cephalic version (ECV) – manoeuvring the baby to correct the breech This can be done at 37 weeks LCSC – if ECV is unsuccessful or contrainidcated

Answer 237

Placenta praevia Multiple pregnancies (except delivery of 2nd twin) APH in last 7 days Rupture membranes Growth restricted babies Abnormal CTG Mothers with uterine abnormalities or scars (e.g. previous LCSC) Foetal abnormality Pre-eclampsia or HTN (increased risk of abruption)

Answer 238

Occipito-anterior

Answer 239

The presenting part is in the right place but wrong position i.e. presenting occipito-posteriorly or occipito-transverse

Answer 240

Most can have normal delivery Some may need forceps Some may need LSCS

Answer 241

Admit to labour ward Artificial rupture of membranes CTG monitoring May need oxytocin drip to speed up the labour If this fails – may need LSCS

Answer 242

Size of baby Well-being of mother and baby Presentation of the baby How long labour has been going on for Maternal exhaustion Adequacy of pelvis

Answer 243

Determine presentation of the foetus as this will determine actions – if breech then no point giving oxytocin as will likely need LSCS CTG monitoring USS of foetus if unsure of lie If not breech – oxytocin and keep assessing If breech – external cephalic version or LSCS

Answer 244

Foetal distress Foetal maturity (i.e. late baby – ready to be born) Beware – aspiration of fresh meconium can cause severe pneumonitis

Answer 245

Relaxation techniques Massage Water births Getting in a comfortable position/posture Being in a comfortable setting/environment for their birth

Answer 246

Paracetamol and codeine useful in early stages of labour Entonox – gas and air Opiates - pethidine, morphine, diamorphine - can be IV or single shot IM Epidural

Answer 247

(gas and air – N2O and O2 mixed) Can cause nausea and vomiting

Answer 248

Foetal side effects – respiratory depression, diminishes breast seeking and feeding behaviour Materanl – euphoria, dysphoria (unease), nausea/vomiting, can prolong 1st and 2nd stage of labour, respiratory depression, pruritis

Answer 249

Maternal – increased length of 1st and 2nd stage of labour, need for more oxytocin, increased need for instrumental, loss of mobility, loss of bladder control, pyrexia Foetal – tachycardia, diminishes breast-feeding behaviour

Answer 250

L3 – L4 Can use USS to aid them and avoid damage of the spinal cord

Answer 251

Local anaesthetics – bupivacaine Opioids – fentanyl, diamorphine

Answer 252

Potential for damage to the spinal cord Hypotension and bradycardia Haematoma/abscess at injection site Anaphylaxis if allergic to the medicatoin Post dural puncture headache

Answer 253

Maternal request HTN/pre-eclampsia Cardiac disease Induced labour Multiple births Instrumental/operative delivery likely

Answer 254

Maternal refusal Local infection Allergy to local anesthetics

Answer 255

Regional block General anaesthetic

Answer 256

A process of identifying apparently individuals who may be at increased risk of a disease/condition

Answer 257

Disease has an acceptable test Disease is an “important” problem - i.e. affects large numbers of people Disease has a known latent phase Disease has a known progression/natural course Disease has a known treatment Agreed policy on who to treat

Answer 258

Does not guarantee protection against developing the condition (can only help reduce risk) False positives and negatives Not the same as a diagnosis – only looks for risk markers of the disease

Answer 259

The condition(s) being screened for When and how the test will be carried out How reliable the test is Different possible results and their meanings Options of the test is positive False positive and negative rates Detection rates

Answer 260

Down’s syndrome – trisomy 21 Edward’s syndrome – trisomy 18 Patau’s syndrome – trisomy 13

Answer 261

First trimester – combination of nuchal translucency + serum B HCG + Papp-A (combined test) – produces risk results for the trisomies Needs to be done before 13+6 weeks Second trimester – quadruple test give if late booker or nuchal translucency not obtained

Answer 262

Alpha fetoprotein Oestriol B-HCG

Answer 263

AFP BHCG Oestriol Inhibin A Done if after 15 weeks pregnancy

Answer 264

8 – 12 weeks

Answer 265

11 – 13+6 weeks

Answer 266

18 – 20+6 weeks

Answer 267

If the risk is 1 in 150 or worse

Answer 268

Diagnostic testing – can be done on the same day AMNIOCENTESIS OR CHORIONIC VILLUS SAMPLING

Answer 269

Early – assess gestational age Mid pregnancy scan – identify major abnormalities and conditions that may benefit from treatment before birth If any abnormalities detected - further scans may be offered

Answer 270

HIV Hepatitis B Syphillis

Answer 271

Sickle cell disease (and thallassamia) Congenital hypothyroidism Cystic fibrosis And 6 inborn errors of metabolism: Maple syrup urine disease Phenylketonuria Homocysteinuria 3 more that I will never remember

Answer 272

First = within 72 hours of birth Second = by GP at 6-8 weeks Screens for problems with: Hips – DDH Reflexes Eyes – absent red reflex, congenital cataracts Heart Mouth and palate Undescended testes/checks of the genitals

Answer 273

Can pick up foetal distress Can be on constantly to see any slight changes that need to be looked at

Answer 274

Does not improve still birth rates despite its use in high risk pregnancies Many women find the device uncomfortable to wear Ambulatory monitoring not possible Doesn’t give true beat to beat FHR monitoring

Answer 275

During labour for every women During high risk pregnancies

Answer 276

Baseline foetal heart rate (FHR) – resting HR FHR variability – variation in HR Number of accelerations – rise in baseline HR Number of decelerations - fall in baseline HR

Answer 277

Early – most likely due to uterine contractions Late – whilst the uterus is relaxing, sign of distress of the baby

Answer 278

Head compression due to uterine contraction

Answer 279

Uterine placental insufficiency /foetal distress

Answer 280

Cord compression

Answer 281

Baseline HR - 110-160bpm Variability - >5bpm Accelerations present No decelerations present

Answer 282

Define each parameter and whether it’s reassuring, non-reassuring or abnormal

Answer 283

40 mins Because the baby may be sleeping – but they never normally sleep for more than 40 mins

Answer 284

Via the baby’s scalp Gold standard of FHR monitoring – gives a true beat to beat FHR measurement

Answer 285

Invasive Can only be used during labour Can only be performed when membranes have ruptured and >2cm dilated Associated with scalp injury and perinatal infection

Answer 286

Abdominal foetal ECG True beat to beat recording Can be used ambulatory and at home Should only be used in HIGH RISK

Answer 287

>35 year and smoking < 15 cigarettes/day BMI > 35 kg/m2 Family history of thromboembolic disease in first degree relatives Controlled hypertension Immobility (e.g. wheelchair use) Known carrier of BRCA1/2 🡪 these are situations in which the risk outweigh the benefits of the pill, but are not absolutely contraindicated

Answer 288

>35 and smoking >15 a day Migraine with aura History of thromboembolic disease of thrombogenic mutatoin History of stroke of IHD Breast feeding < 6 weeks post-partum Uncontrolled HTN Current breast cancer Major surgery with prolonged immobilisation

Answer 289

HPV 6 and 11

Answer 290

Genital tract bleeding from 24 weeks’ gestation

Answer 291

Placental abruption Placenta praevia Vasa praevia (here the baby may bleed to death) Morbidly adherent placenta

Answer 292

Cervical polyps Cervicitis Carcinoma Vaginitis Vulval varicosities

Answer 293

When part of the placenta becomes detached from the uterus

Answer 294

Previous abruption Hypertension Multiple pregnancy Trauma Vascocontrictor drugs (cocaine and crack) Infection Thrombophilias Uterine abnormality Smoking Pre-eclampsia Increasing maternal age

Answer 295

Classically PAINFUL “Hidden bleeds” – bleeding may be localised to once placental area meaning that it can occur for a long time before presenting as vaginal bleeding - means that the mother may present in SHOCK with a relatively small amount of PV bleeding as the bleed is actually happening internally Posterior abruptions – backache

Answer 296

“Tender woody uterus” There will also be foetal distress (which you will not necessarily see in someone with placenta praevia – so can be another way to distinguish them)

Answer 297

Foetal death or anoxia leading to brain damage May prevent good contractions in labour Post partum haemorrhage Uterine hyper-contractility (>5 contractions/10 mins) Disseminated intravascular coagulation (DIC) Renal failure Sheehan’s syndrome (pituitary necrosis following PPH)

Answer 298

Admit to hospital - ABC IV fluids Oxygen ABO Rh compatible blood or O –ve blood If safe and term – delivery Mum comes first so if bleeding cannot be stopped, need to deliver the foetus even if it’s unlikely to survive

Answer 299

A low lying placenta – any part of the placenta has implanted into the lower segment of the uterus Major – fully covering the cervical os Minor – encroaching the lower segment but not fully covering the os

Answer 300

Digital PV examinations Penetrative intercourse SPECULUM EXAMINATION IS SAFE

Answer 301

Diagnosed antenatally on ultrasound scan - 20 week anomaly scan Can be re-checked closer to the time of delivery as can appear low lying at first but may change over the course of the pregnancy

Answer 302

PAINLESS Large amount of blood Which is very different to placental abruption which is painful with a smaller amount of blood

Answer 303

Previous c-section Previous termination of pregnancy – uterine evacuation Multiparity Multiple pregnancy Mother >40 years Assisted conception Manual removal of previous placenta Fibroids Endometriosis

Answer 304

Advise for which symptoms to look out for If minor - aim for normal delivery unless the placenta comes within 2cm of the os Major – elective C-section at 38-39 weeks

Answer 305

The major foetal vessels are presenting before the foetus These vessels are exposed meaning they are prone to rupture which can be potentially fatal for the foetus

Answer 306

ABC management of bleeding Delivery by caesarean (elective if detected antenatally, emergency if present with bleeding) Mortality 60%

Answer 307

MRI scan if degree of adherence uncertain Elective LSCS at 36-37 weeks’ Discuss possible interventions - caesarean hysterectomy, leaving the placenta in place

Answer 308

Haemorrhage Transfusion Caesarean hysterectomy ITU admission

Answer 309

Post-partum haemorrhage Premature labour/delivery DIC ITU admission ARDS Acute tubular necrosis Death (mother or foetus) Sheehan’s syndrome

Answer 310

The loss of >500ml in the first 24 hours after delivery

Answer 311

The 4 T’s: Tone – uterine atony Tissue – retained products (i.e. placenta) Trauma – i.e. a big tear in the genital tract Thrombin – clotting disorder

Answer 312

Uterine atony

Answer 313

Un-palpable uterus The uterus should normally be palpable in the period following giving birth but if it’s atonic it will not be palpable

Answer 314

Emptying bladder can help Rub the abdomen to help the uterus contract Bimanual compression of the uterine IV Syntocinon(combination of ergometrine and oxycotin to help the uterus contract) IM Carboprost Surgical options also available (B-lynch sutures, internal iliac artery ligation)

Answer 315

Excessive blood loss from the genital tract area after 24 hours – 12 weeks from delivery

Answer 316

Retained placental tissue

Answer 317

Antepartum haemorrhage (and any of the causes of) Previous PPH Previous retained placenta Maternal anaemia at onset of labour BMI > 35 Maternal age > 35 First baby Large baby Twins/triplets Operative delivery Fast labour and delivery

Answer 318

Medications to stop the bleeding – ergometrine, oxytocin, syntometrine (combination of ergo and oxy) - these cause the uterus to contract which should stop the bleeding IM Carboprost if this doesn’t work If mild/moderate – IV fluids, oxygen, blood products, try and find and prevent the source of bleeding If severe (>1500mls) – medical emergency – call 2222

Answer 319

Ligation of the internal iliac or uterine artery Uterine artery embolization Hysterectomy

Answer 320

Miscarriage Ectopic pregnancy

Answer 321

Pulmonary embolism High risk during the post-partum period

Answer 322

Thromboprophylaxis in labour and chilbirth 🡪 LMWH injection (i.e. deltaparin) and TEDS stockings

Answer 323

Previous VTE Family history Thrombophilia (acquired disorder) – beware antiphospholipid syndrome – recurrent miscarriages and tendency to clot BMI > 30 Smoking Age > 35 Pre-eclampsia C-section Immobility

Answer 324

Shortness of breath Chest pain Leg pain or swelling

Answer 325

DVT – ultrasound doppler PE – CTPA If suspicious – Well’s score and D-Dimer

Answer 326

Most importantly = prophylactic dose of LMWH given according to maternal weight Embolectomy Anti-coagulate afterwards

Answer 327

Flu – DO NOT UNDERESTIMATE FLU Pyelonephritis Chorioamnionitis Wound infection – i.e. C-section, episiotomy Pneumonia Pancreatitis Etc. – basically any infection GBS (group B strep)

Answer 328

Immunosuppressed – HIV, medication Obesity Diabetes Anaemia History of pelvic infection Amniocentesis and other invasive procedures Cervical stitch Prolonged ROM

Answer 329

Pyrexia or hypothermia Tachycardia Hypotension Oliguria Hypoxia Impaired consciousness

Answer 330

SEPSIS SIX – in the first hour Blood cultures IV fluids Monitor hourly urine output – catheterise Broad spectrum IV antibiotics ABG – lactate High flow oxygen

Answer 331

Give all pregnant ladies seasonal flu vaccine – flu must not be underestimated Sepsis 6 Give broad spec IV Abx BEFORE cultures come back – then alter when sensitivities come back if necessary Involve senior team and experts early

Answer 332

When the umbilical cord prolapses through the cervix when the membranes rupture

Answer 333

Exposure of the cord leads to vasospasm Can cause significant risk of foetal morbidity and mortality from hypoxia

Answer 334

Premature rupture of membranes Polyhydramnios Long umbilical cord Malpresentation Multiparity Mutliple pregnancy

Answer 335

Call 999 or emergency buzzer if in hospital Alleviate pressure on cord – put their feet up in the air (Trendelenberg position) Transfer to theatre to prepare for delivery

Answer 336

Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the foetal head Requires specific manoeuvers to facilitate delivery

Answer 337

Macrosomia (baby >4kg) Maternal diabetes - causes macrosomic babies Known small maternal pelvis/disproportion btween mother pelvis size and foetus size Post-maturity that required induction of labour Prolonged labour Instrumental delivery

Answer 338

MEDICAL EMERGENCY – so call for help/press emergency buzzer Either rotate the baby/use manouvers Or replace the head and deliver by LSCS

Answer 339

PPH Extensive vaginal tear Psychological impact to mother and partner

Answer 340

Hypoxia Fits CP Brachial plexus injury/Erb’s palsy Fractured clavical or humerus

Answer 341

Ensure optimum disease control – defer pregnancy until the condition is stable Effective contraception until ready to conceive Avoid use or teratogenic drugs (warfarin, valproate) Council mum on the risks of pregnancy with the condition MDT approach and regular check ups Agreed care plan with patient and other healthcare experts

Answer 342

Relative physiological anaemia due to increased blood volume Iron deficiency Folate deficiency

Answer 343

Low birthweight Preterm delivery

Answer 344

Iron and folate supplements

Answer 345

ALL of the normal asthma medications can be used in pregnancy (steroids, salbutamol, theophyllines etc.) As the baby grows it can press up on the lungs and make the asthma worse, but because all of these medications can be used during pregnancy it should be easy to optimise control (dose adjustment may be required) In asthma attack – prioritise mum

Answer 346

Cardiovascular disease In older women = ischaemic heart disease In younger women = congenital heart disease which is exacerbated by pregnancy e.g. coarctation of the aorta

Answer 347

FIXED OUTPUT HEART DISEASE: Aortic stenosis Coarctation Prosthetic valves (added issue of anti-coagulation) Cyanosed patients

Answer 348

Mitral regurgitation Aortic regurg ASD VSD

Answer 349

THEY CANNOT TAKE WARFARIN DURING PREGNANCY So take them off warfarin and get them on daltaparin instead – this is the ONLY LISCENSED ANTICOAGULANT IN PREGNANCY Also need to do a HASBLED score and predict their bleeding risk as they are at higher risk of antepartum and post-partum haemorrhage

Answer 350

Obstetric cholestasis (unique to pregnancy) Presents with itchy skin (mainly on hands and feet)

Answer 351

Ursodeoxycholic acid Piriton helps the itching Goes away after delivery – but increased risk during another pregnancy

Answer 352

HYPOthyroidism

Answer 353

Excessive vomiting So if someone presents with excessive vomiting check their thyroid levels

Answer 354

Propylthiourail – maternal liver failure (so more likely to use this one as treatment) Carbimazole – foetal abnormalities

Answer 355

Early foetal loss Congenital hypothyroidism – leading to neurodevelopmental delay

Answer 356

Carbohydrate intolerance first recognised during pregnancy

Answer 357

History of previous GDM FH of diabetes High BMI Persistent glycosuria on dipstick

Answer 358

Aim for HBA1c < 48 mmol/l Take 5mg folic acid Stop ACEi and statins Retinal screening Renal fucntion screening Establish GOOD diabetic control before pregnancy (and stay on contraception until good control is achieved) Good glycaemic control from conception improves the outcome of the pregnancy

Answer 359

DKA Hypoglycaemia (common) Progression of retinopathy and other microvascular complications Pre-eclampsia The usual micro and macrovascular complications of diabetes

Answer 360

Miscarriage Stillbirth Macrosomia Shoulder dystocia Foetal abnormality Neonatal hyperinsulinaemia 🡪 neonatal HYOPglycaemia (which can be dangerous) Respiratory distress Hypocalcaemia Polycythaemia

Answer 361

Type 1- insulin (dose adjustment as necessary for the normal changes to glucose metabolism during pregnancy) Type 2 – start with metformin but may need upgrading to insulin Gliclazide is contraindicated in pregnancy

Answer 362

Attempt to manage with diet first Start on medication if this is inadequate

Answer 363

Severe hypertension Deterioration in renal function/renal failure Pre-eclampsia Caesearian section

Answer 364

Premature delivery IUGR Stillbirth Foetal abnormalities due to maternal drug therapy

Answer 365

Pre-pregnancy risk assessment MDT care Close monitoring of renal function during pregnancy Regular BP and urine dip checks – if any proteinuria have a high index of suspicious for pre-eclampsia Regular foetal growth scans

Answer 366

Increase frequency of seizures Seizure could lead to falls which could cause trauma to the baby Sudden unexpected death in epilepsy – can happen in mothers who are breastfeeding and are therefore reluctant to take their anti-epileptic medications

Answer 367

Anti epileptic drugs are teratogenic VALPROATE – worst by far Neural tube defects, spina bifida Inheritence of epilepsy Risk of feotal hypoxia with maternal seizures

Answer 368

Preconception assessment – high dose folic acid Once pregnant – screen for abnormalities Control seizures Plan for delivery – pain relief, avoid prolonged labour

Answer 369

Hypertension diagnosed before pregnancy or 20th week of gestation

Answer 370

NEW HTN AFTER 20 WEEKS’ GESTATION Systolic BP >140 Diastolic BP >90

Answer 371

Hypertension and proteinuria during pregnancy (when the hypertension developed >20 weeks gestation)

Answer 372

Proteinuria, hypertension and generalised tonic-clonic seizures during pregnancy

Answer 373

Hypertension in pregnancy present before 20 weeks gestation Proteinuria develops after 20 weeks gestation

Answer 374

Smoking Young female First pregnancy Black people (2x increased risk) Multiple pregnancy Hypertension Diabetes Previous pre-eclamspia Family history

Answer 375

Inadequate arterial invasion of the placenta Meaning that less blood can get from mum to baby (the blood vessels are not as thick and dilated as they should be) So the body increases its blood pressure to try and get more blood through to the baby Which means that mother ends up with systemic HTN in order to get adequate nutrients to the baby

Answer 376

Proteinuria of pre-eclampsia leads to hypoalbuminaemia Leads to oedema Fluid loss into 3rd space = hypovolaemia Hypovolaemia = lack of perfusion to the vital organs (starts at kidneys and eventually effects the brain) Hypo-perfusion to the brain 🡪 seizures

Answer 377

Placenta ischaemia occurs due to inadequate invasion of spiral arteries Placenta then produces thromboplastins – which can lead to DIC You also get low platelets in pre-eclampsia

Answer 378

H – haemolysis E L– elevated liver enzymes (ALT and AST) L P – low platelets

Answer 379

Oliguria CNS – visual changes, headache, blind spots in vision, change in mental status Oedema – rings hard to get off, marks left in ankles by socks Epigastric or RUQ pain – hepatic swelling and inflammation, liver capsule stretches Rapid weight gain

Answer 380

Raised blood pressure ( >140/90) Proteinuria (+++ on dipstick if severe) Papilloedema RUQ tenderness Ankle clonus - NB brisk reflexes are normal during pregnancy but ankle clonus is not

Answer 381

BP Urine dip-stick Haemoglobin Platelets LFTs Protein:creatinine ratio Date pregnancy and assess foetal growth

Answer 382

Protein-creatinine ratio of OVER 30

Answer 383

Admit to hospital Only cure is to deliver the baby If not at term – give hydrazaline or labetelol to lower BP Give magnesium sulphate to prevent seizures Induction of labour if safe If pre-eclampsia very early onset then may need to terminate the pregnancy to save mum

Answer 384

Aspirin 75mg From 10 – 36 weeks’ gestation (the spiral arteries form around 12 weeks so aspirin is thought to help them develop properly)

Answer 385

High BMI Renal disease Known hypertension

Answer 386

An infant born before 37 weeks’ gestation

Answer 387

Below the 10th centile for their gestational age (so do need to consider their gestational age and then plot on the growth charts) Also known as small for gestational age (SGA)

Answer 388

Placental problems – pre-eclampsia, abruption Foetal factors – genetic abnormalities (trisomies, other syndromes such as Turner’s) Multiple pregnancy Maternal risk factors – smoking, age >40, cocaine use, BMI <20 Previous SGA baby Antepartum bleeding Low PAPP-A

Answer 389

Above the 90th centile for their gestational age

Answer 390

A baby born with a weight < 2.5 kg This measurement is regardless of their gestational age (although premature babies are more likely to have low birth weight)

Answer 391

A baby born weighing > 4kg Regardless of gestational age

Answer 392

Constitutionally large – familial (mum and dad would’ve been big babies too) Maternal diabetes Obesity

Answer 393

A baby which has not maintained its growth potential i.e. it drops below the centile line it was following Most common cause = placental issue (smoking, pre-eclampsia)

Answer 394

No apparent RF in 50% Antepartum haemorrhage (placenta praevia, abruption, etc.) Mulitple pregnancy – very unlikely to reach term with more than one baby in there Race Previous pre-term birth Genital infection or systemic infection Cervical weakness (can be treated with a cervical stitch)

Answer 395

Developmental delay Cerebral palsy Chronic lung disease Retinopathy of prematurity Necrotising enterocolitis

Answer 396

Neonatal steroids – given to mums expected to go into pre-term labour Artificial surfactant Ventilation Nutrition Antibiotics

Answer 397

Persistent uterine activity PLUS change in cervical dilatation and/or effacement

Answer 398

Measure cervical length with transvaginal USS Foetal fibronectin levels

Answer 399

Cervical stitch if length < 3cm IM or pessary progesterone can help reduce risk

Answer 400

Admit to hospital and contact consultant obstetrician and neonatologist Tocolytic drugs – salbutamol (this will delay it slightly but nothing can reverse labour once it has started) Corticosteroids – to protect the baby’s lungs

Answer 401

From delivery of the placenta to 6 weeks following birth

Answer 402

The period under which the woman and baby are still under midwife care For at least 10 days and for as long as the midwife feels necessary

Answer 403

The death of a women during or up to 6 weeks after her pregnancy Due to causes related to or aggrevated by the pregnancy

Answer 404

Mother dying as a result of obstetric complication (haemorrhage, PE)

Answer 405

Death resulting from pre-existing disease or disease that developed during the pregnancy, but not as a direct result from obstetric causes i.e. heart disease

Answer 406

3 T’s, white with sugar: Temperature (>38 or <36 *C) Tachycardia (>90bpm) Tachypnoea (>20 breaths per minute) White blood cell count (< 4 or >12) Sugar – blood glucose (> 7.7mmol in the absence of DM)

Answer 407

Any past medical history of a mental health problem Poor social networks/relationships Unemployed Poor living conditions/social isolation Family history of mental health problems History of abuse Carer for other adults or children

Answer 408

Low mood Loss of energy Anhedonia (loss of interest) Expressing feelings of guilt about not loving the baby Not wanting to hold/touch/feed the baby Loss of appetite Change in sex drive Social withdrawal

Answer 409

Polycythaemia – to try and compensate for the reduced oxygen supply from the mother, the baby develops more RBCs Blood redistribution – “head sparing effect” – blood is directed to the brain, heart and kidneys which means that their head and abdominal circumference may be bigger than their arms and legs and overall length

Answer 410

Neonatal jaundice Need to follow-up to prevent kernicterus

Answer 411

Hypogylcaemia – blood directed away from liver to brain and kidneys = glycogen stores not developed adequately Increased risk of NEC – blood supply to bowel reduced for head sparing Neonatal jaundice due to polycythaemia Hypothermia – no fat stores developed if growth restricted so cannot thermoregulate HIE/CP – if brain isn’t spared Respiratory problems - if kidneys don’t get enough perfusion, not enough urine is produced = less amniotic fluid = inadequate lung developement

Answer 412

Adequate blood flow from placenta Adequate maternal nutrient intake Foetal physiology – ability to metabolise and utilise nutrients from the mother – GLUCOSE is the most important Genetic factors

Answer 413

Growth scans every 2-3 weeks Umbilical artery doppler to see whether the baby is getting enough blood Offer corticosteroids for foetal lung maturity up to 35+6 weeks

Answer 414

Regular growth scans to assess progress Advise mother to have a low sugar diet Consider need for caesarean section delivery if the baby looks extremely large

Answer 415

Baby measured on USS Symphysial-fundal height measured Plot on the personalised growth chart for this lady – the baby may have dropped below its growth potential on the centile lines which could indicate growth restriction (or just < 10th centile if small for dates)

Answer 416

Is the baby moving? – lack of movements is very worrying Smoking/using cocaine Any previous SGA babies? Screen for signs of pre-eclampsia – urine, BP, headaches, ankle swelling? Has the lady had any infections during pregnancy? Has the lady had Down’s syndrome screening?

Answer 417

Estimated foetal weight on USS Symphysial fundal height measured Both plotted on personalised growth chart for this pregnancy - if >90th centile then large for dates

Answer 418

Blood glucose test for diabetes USS Ask about previous pregnancies – did this lady have a big baby before? Repeat ultrasound Vital signs Look at the amniotic fluid index

Answer 419

The loss of a pregnancy before 24 week’s gestation After this = would be a still birth

Answer 420

Maternal age >35 years Paternal age >40 years

Answer 421

Foetal chromosomal abnormalities that are incompatible with life Maternal illness – infections, pyrexia Trauma

Answer 422

The loss of ≥ 3 consecutive pregnancies Before 24 weeks’ gestation

Answer 423

50% unknown Chronic maternal disease – poorly controlled DM, SLE Anti-phospholipid syndrome Abnormality of the uterus making it unable to support foetal development Infection Parental chromosomal abnormality – balanced Robertsonian translocation Thrombophilia – factor V leiden deficiency, protein S an C deficiency

Answer 424

Lupus anticoagulant antibodies Anti-cardiolipin antibodies Phospholipid antibodies

Answer 425

Mild symptoms Cervical os closed 75% will settle

Answer 426

Severe symptoms Cervical os is open – if you can pass 1 finger through the cervical os then miscarriage is inevitable

Answer 427

Most of the products have already been passed But there are some retained products of conception

Answer 428

The foetus dies in utero without any symptoms of a miscarriage Picked up on USS – the foetus will appear on the scan to be dated before the actual date of the pregnancy E.g. 12 week scan finds a 9 week foetus with no heartbeat – missed miscarriage at 9 weeks

Answer 429

PV bleeding

Answer 430

SPECULUM EXAMINATION – most important examination as it allows you to see the cervical os Digital vaginal examination USS

Answer 431

Expectant management – let nature take its course and clear the foetus naturally Ergometrine – can help stop perfuse bleeding Medical management – mifepristone followed by misoprostol (bleeding may continue for ~3 weeks after) Surgical management – if there is unacceptable bleeding, pain or significant retained products seen on USS

Answer 432

Refer to specialist recurrent miscarriage clinic Test for anti-phospholipid antibodies Thrombophilia screening Pelvic USS to look at the structure of the uterus Karyotype foetal products after 3rd foetal loss – if chromosomal abnormality is found then karyotype the peripheral blood of the parents

Answer 433

Miscarriage Ectopic pregnancy

Answer 434

When a fertilised ovum implants outside the uterine cavity

Answer 435

In the ampulla of the fallopian tube

Answer 436

Previous ectopic pregnancy Pelvic inflammatory disease Damage to the tubes – i.e. from PID or surgery (adhesions etc.) Endometriosis Copper coil Progesterone only pill Smoking Tubal ligation

Answer 437

NB – ALWAYS consider ectopic in a sexually active woman with abdominal pain, bleeding, fainting, diarrhoea or vomiting Uncertain LMP and 6-8 weeks amenorrhoea Abdominal pain, classically unilateral Vaginal bleeding Diarrhoea and vomiting Dizziness and fainting Shoulder pain due to haemoperitoneum - irritates the diaphragm

Answer 438

Pregnancy test – urinary B-HCG Vaginal and speculum examination – cervical motion tenderness/cervical excitation Ultrasound scan FBC Group and save

Answer 439

Expectant management if HCG is falling, mild symptoms, no foetal heart activity on USS, woman is haemodynamically stable Medical management – methotrexate (teratogenic so ensure woman on effective contraception for 3 months afterwards) Surgical management – laparoscopy. If contralateral tube is healthy, then remove the whole tube that had the ectopic (salpingectomy). If Other tube unhealthy - salpingotomy (removal of the ectopic but leave the tube in place)

Answer 440

Conjunctivitis Stomatitis Diarrhoea Abdominal pain

Answer 441

Aka hydatidiform mole Uterus bigger than expected for gestation Hyperthyroidism Painless vaginal bleeding Excessive morning sickness High serum HCG (which causes hyperemesis gravidum and thyrotoxicosis)