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What is anaemia defined as? "<b><i>Anaemia</i></b><span style=""color: rgb(76,
76, 76); background-color: rgb(255, 255, 255);""> is defined as a low
concentration of </span><b><i>haemoglobin</i></b><span style=""color: rgb(76,
76, 76); background-color: rgb(255, 255, 255);""> in the blood. This is the
result of an underlying disease and is not a disease itself.</span>"
When are women screened for anaemia? <div>Women are routinely screened for
anaemia twice during pregnancy:</div><ul><li>Booking clinic</li><li>28 weeks
gestation</li></ul><br>
How does naturally anaemia occur in pregnancy? <div>During pregnancy,
the <b><i>plasma volume</i></b> increases. This results in a reduction in
the <b><i>haemoglobin concentration</i></b>. The blood is diluted due to the
higher plasma volume.</div><div>It is important to optimise the treatment of
anaemia during pregnancy so that the woman has reasonable reserves, in case there
is significant blood loss during delivery.</div>
How does anaemia in pregnancy present? <div>Often anaemia in pregnancy is
asymptomatic. Women may have:</div><ul><li>Shortness of
breath</li><li>Fatigue</li><li>Dizziness</li><li>Pallor</li></ul><br>
What is the normal haemoglobin concentration at booking?
<table><tbody><tr><td><div>> 110
g/l</div></td></tr><tr><td></td></tr></tbody></table><br>
What is the normal range of haemoglobin at 28 weeks gestation? >105g/L
What is the normal range of haemoglobin post partum? >100g/L
What is the cause of low MCV anaemia? <ul><li>Low MCV may
indicate <b><i>iron deficiency</i></b></li></ul><br>
What is the cause of normal MCV anaemia? <ul><li>Normal MCV may indicate
a <b><i>physiological anaemia</i></b> due to the increased plasma volume
of pregnancy</li></ul><br>
What is the caused of raised MCV anaemia? <ul><li>Raised MCV may
indicate <b><i>B12</i></b> or <b><i>folate
deficiency</i></b></li></ul><br>
What are the type haemoglobinopathies that women are offered screening for at the
booking clinic? <div>Women are offered <b><i>haemoglobinopathy
screening</i></b> at the booking clinic
for <b><i>thalassaemia</i></b> (all women) and <b><i>sickle cell
disease</i></b> (women at higher risk). Both are causes of significant anaemia
in pregnancy.</div><br>
What are the different ways you manage anaemia in pregnancy?
<div><b>Iron</b></div><div>Women with anaemia in pregnancy are started on
iron replacement (e.g. ferrous sulphate 200mg three times daily). When women are
not anaemic, but have a low ferritin (indicating low iron stores), they may be
started on supplementary iron.</div><div> </div><div><b>B12</b></div><div>The
increased plasma volume and B12 requirements often result in a low B12 in
pregnancy. Women with low B12 should be tested for <b><i>pernicious
anaemia</i></b> (checking for <b><i>intrinsic factor
antibodies</i></b>).</div><div><br></div><div>Advice should be sought from a
haematologist regarding further investigations and treatment of low B12 in
pregnancy. Treatment options for low B12
are:</div><ul><li>Intramuscular <b><i>hydroxocobalamin</i></b> injections
</li><li>Oral <b><i>cyanocobalamin</i></b> tablets</li></
ul><div> </div><div><b>Folate</b></div><div>All women should already be taking
folic acid 400mcg per day. Women with folate deficiency are started on folic acid
5mg daily.</div><div> </div><div><b>Thalassaemia and Sickle Cell
Anaemia</b></div><div>Women with a haemoglobinopathy will be managed jointly with a
specialist haematologist. They require high dose folic acid (5mg), close monitoring
and transfusions when required.</div><br>
What is atrophic vaginitis? "<span style=""color: rgb(76, 76, 76); background-
color: rgb(255, 255, 255);"">Atrophic vaginitis refers
,to </span><b><i>dryness</i></b><span style=""color: rgb(76, 76, 76);
background-color: rgb(255, 255,
255);""> and </span><b><i>atrophy</i></b><span style=""color: rgb(76, 76,
76); background-color: rgb(255, 255, 255);""> of the vaginal mucosa related to
a lack of </span><b><i>oestrogen</i></b><span style=""color: rgb(76, 76, 76);
background-color: rgb(255, 255, 255);"">. Atrophic vaginitis can also be referred
to as </span><b><i>genitourinary syndrome of menopause</i></b><span
style=""color: rgb(76, 76, 76); background-color: rgb(255, 255, 255);"">. It occurs
in women entering the menopause. </span>"
Describe the pathophysiology of atrophic vaginitis.
<div>The <b><i>epithelial lining</i></b> of the vagina and urinary
tract responds to oestrogen by becoming thicker, more elastic and producing
secretions. As women enter the menopause, oestrogen levels fall, resulting in the
mucosa becoming <b><i>thinner</i></b>, <b><i>less
elastic</i></b> and more <b><i>dry</i></b>. The tissue is more prone
to <b><i>inflammation</i></b>. There are also changes in
the <b><i>vaginal pH</i></b> and <b><i>microbial
flora</i></b> that can contribute to localised
infections. </div><div>Oestrogen also helps maintain
healthy <b><i>connective tissue</i></b> around the pelvic organs, and a
lack of oestrogen can contribute to <b><i>pelvic organ
prolapse</i></b> and <b><i>stress incontinence</i></b>. </div>
How does atrophic vaginitis present? <div>Atrophic vaginitis presents in
postmenopausal women with symptoms
of:</div><ul><li>Itching</li><li>Dryness</li><li>Dyspareunia (discomfort or pain
during sex)</li><li>Bleeding due to localised inflammation</li></ul><div>You should
also consider atrophic vaginitis in older women presenting
with <b><i>recurrent urinary tract infections, stress
incontinence</i></b> or <b><i>pelvic organ prolapse</i></b>. Treatment
with topical oestrogen where appropriate may improve the symptoms of these
conditions. </div><div><br></div><div>It is worth asking about symptoms of
vaginal dryness and discomfort, as women will often be reluctant to bring it up
during a consultation. It is straightforward to treat and can make a big difference
to their quality of life. </div><br>
What do you see on examination of the labia and vagina for atrophic vaginitis?
<div>Examination of the labia and vagina will demonstrate:</div><ul><li>Pale
mucosa</li><li>Thin skin</li><li>Reduced skin folds</li><li>Erythema and
inflammation</li><li>Dryness</li><li>Sparse pubic hair</li></ul><br>
How do you manage atrophic vaginitis? <div>Vaginal lubricants can help symptoms
of dryness. Examples
include <b><i>Sylk</i></b>, <b><i>Replens</i></b> and <b><i>YES
</i></b>.</div><div><br></div><div>Topical oestrogen can make a big difference in
symptoms. Options include:</div><ul><li><b><i>Estriol cream</i></b>, applied using
an applicator (syringe) at bedtime</li><li><b><i>Estriol pessaries</i></b>,
inserted at bedtime</li><li><b><i>Estradiol
tablets</i></b> (<b><i>Vagifem</i></b>), once daily</li><li><b><i>Estradiol
ring</i></b> (<b><i>Estring</i></b>), replaced every three
months</li></ul><div>Topical oestrogen shares
many <b><i>contraindications</i></b> with <b><i>systemic
HRT</i></b>, such as <b><i>breast cancer,
angina</i></b> and <b><i>venous thromboembolism</i></b>. It is unclear
whether long term use of topical oestrogen increases the risk of endometrial
hyperplasia and endometrial cancer. Women should be monitored at least annually,
with a view of stopping treatment whenever possible.</div><br>
What is bacterial vaginosis? <div>Bacterial vaginosis (<b><i>BV</i></b>) refers to
an overgrowth of bacteria in the vagina, specifically <b><i>anaerobic
bacteria</i></b>. It is not a sexually transmitted infection. It is caused by
a <b><i>loss</i></b> of
the <b><i>lactobacilli</i></b> “friendly bacteria” in the vagina.
,Bacterial vaginosis can increase the risk of women developing sexually transmitted
infections.</div><br>
Describe the role of lactobacili in the vaginal flora.
"<b><i>Lactobacilli</i></b><span style=""color: rgb(76, 76, 76); background-
color: rgb(255, 255, 255);""> are the main component of the healthy
vaginal </span><b><i>bacterial flora</i></b><span style=""color: rgb(76, 76,
76); background-color: rgb(255, 255, 255);"">. These bacteria
produce </span><b><i>lactic acid</i></b><span style=""color: rgb(76, 76, 76);
background-color: rgb(255, 255, 255);""> that keeps
the </span><b><i>vaginal pH</i></b><span style=""color: rgb(76, 76, 76);
background-color: rgb(255, 255, 255);""> low (under 4.5). The acidic
environment prevents other bacteria from overgrowing. When there are reduced
numbers of lactobacilli in the vagina, the </span><b><i>pH rises</i></b><span
style=""color: rgb(76, 76, 76); background-color: rgb(255, 255, 255);"">. This
more </span><b><i>alkaline</i></b><span style=""color: rgb(76, 76, 76);
background-color: rgb(255, 255, 255);""> environment
enables </span><b><i>anaerobic bacteria</i></b><span style=""color: rgb(76,
76, 76); background-color: rgb(255, 255, 255);""> to multiply.</span>"
What anaerobic bacteria are associated with bacterial vaginosis? <div>Examples of
anaerobic bacteria associated with bacterial vaginosis
are:</div><ul><li><b><i>Gardnerella vaginalis</i></b> (most
common)</li><li><b><i>Mycoplasma
hominis</i></b></li><li><b><i>Prevotella</i></b> species</li></ul>
How does bacterial vaginosis present? <div>The standard presenting feature of
bacterial vaginosis is a <b><i>fishy-smelling</i></b> watery grey or
white vaginal discharge. Half of women with BV are
asymptomatic.</div><div><br></div><div>Itching, irritation and pain are not
typically associated with BV and suggest an alternative cause or co-occurring
infection.</div><div><br></div><div>A <b><i>speculum
examination</i></b> can be performed to confirm the typical discharge,
complete a high vaginal swab and exclude other causes of symptoms. Examination is
not always required where the symptoms are typical, and the women is low risk of
sexually transmitted infections.</div>
What is the management for bacterial vaginosis? "<div>Asymptomatic BV does not
usually require treatment. Additionally, it may resolve without
treatment.</div><div><span style=""font-weight: bold;""><br></span></div><div><span
style=""font-weight: bold;"">Metronidazole</span> is the antibiotic of choice
for treating bacterial vaginosis. Metronidazole specifically targets anaerobic
bacteria. This is given <b><i>orally</i></b>, or by <b><i>vaginal
gel</i></b>. <b><i>Clindamycin</i></b> is an alternative but less optimal
antibiotic choice.</div><div><br></div><div>Always assess the risk of additional
pelvic infections, with swabs
for <b><i>chlamydia</i></b> and <b><i>gonorrhoea</i></b> where
appropriate.</div><div><br></div><div>Provide advice and information about measures
that can reduce the risk of further episodes of bacterial vaginosis, such as
avoiding vaginal irrigation or cleaning with soaps that may disrupt the natural
flora.</div>"
What do you advise patients when prescribing metronidazole?"<div><span
style=""color: rgb(0, 128, 0);""><b><i>Whenever prescribing metronidazole advise
patients to avoid alcohol for the duration of treatment. This is a crucial
association you should remember, and something examiners will look out for when you
are explaining the treatment to a patient. Alcohol and metronidazole can cause a
“disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe
symptoms of shock and angioedema.</i></b></span></div><br>"
What are the complications of bacterial vaginosis in non-pregnant women?
<div>Bacterial vaginosis can increase the risk of
catching <b><i>sexually transmitted infections</i></b>,
including <b><i>chlamydia</i></b>,<b><i> gonorrhoea </i></
b>and <b><i>HIV</i></b>.</div><br>
, What are the complications of bacterial vaginosis in pregnant women? <div>It is
also associated with several complications in pregnant
women:</div><ul><li>Miscarriage</li><li>Preterm delivery</li><li>Premature rupture
of membranes</li><li>Chorioamnionitis</li><li>Low birth weight</li><li>Postpartum
endometritis</li></ul>
How much blood is the fetus receiving in the uterus? 500ml a minute
What are the four reasons why the mother’s body need to adapt to pregnancy? "1. To
support the fetus in the womb:
<br>Volume ( space)
<br>Oxygen
<br>Nutrition
<br>Waste removal
<br><br>2. To protect the fetus:
<br>Immune regulation
<br>Drugs
<br>Toxins
<br><br>3. To protect the mother from harm during delivery:
Adaptations in pregnancy
<br><br>4. To prepare the mother for delivery: Adaptations in
pregnancy"
How can shortness of breath be normal in pregnancy? "Many women complain of
shortness-of-breath (SOB) during pregnancy:As the abdomen
grows, the diaphragm elevates 4cm and the ribs are pushed up and out. This creates
a decreased expiratory reserve volume , and although this is physiologically
balanced out
by an increased tidal volume this still gives the sensation of being SOB. Normally
good
explanation and reassurance is all that is needed."
Why should you be concerned regarding shortness of breath in pregnancy?
pulmonary embolism
What changes occur in the lungs during pregnancy that can be seen on a chest X-ray?
"1. There may be an increase in the amont of vascular soft tissues visible.
<br><br>2. Small pleural effusions may be visible, especially soon after delivery
of the baby"
How do the results of a lung function change change during pregnancy? "<img
src=""Screenshot 2022-12-05 at 20.02.19.png"">"
What causes the changes in the lung function tests in pregnancy? "thought to be a
result of
increased progesterone levels."
What causes the fluid accumulation in pregnancy? there's a drop in albumin at
the end of pregnancy as they need to hold a little more fluid making them
oedematous
What part of the respiratory system is most effected in pregnancy? tidal volume
by 40%
How do blood gases change in pregnancy? "<img src=""Screenshot 2022-12-05 at
20.03.27.png"">"
Why does the mother go into a state of compensated respiratory alkalosis in
pregnancy? "Substances move from an area of high concentration to an area of low
concentration. <br><br>CO2
falls in the mother is so that CO2
is drawn out of the
fetal blood into the mothers, where it can be breathed out in the lungs.
<br><br>You would have thought that the opposite would apply
and that there would be an equally large rise in the oxygen levels in the maternal
blood, however this is not necessary as the haemoglobin in the fetus (fetal
haemoglobin) has a
higher oxygen carrying capacity than adult haemoglobin.
<br><br>Remember because the bicarbonate levels also decrease,
pregnancy gives a state of COMPENSATED RESPIRATORY
