Adam Sullivan O&G Flashcards
Differential diagnosis for pain in early pregnancy
Ectopic
Miscarriage
OHSS
Differential for cycle independent pain
PID
Mass
Annual of prevalence of chronic pelvic pain in women 15-73
38/1000
Definition of primary amenorrhoea
Lack of menstruation by 16 in the presence of secondary sexual characteristics; by 14 in the absence of secondary characteristics.
Staging of OHSS
Mild - pain/bloating
Moderate - Mild + N+V + USS ascites
Severe - Clinical ascites, haematocrit >45%, hypoproteinaemia
Critical - VTE/ARDS/anuria/tense ascites
You are asked to see a 32 year old woman in the antenatal clinic after her routine dating scan. She is in her first pregnancy and her last menstrual period was 12 weeks ago. She felt very sick when she first got pregnant but more recently these symptoms have subsided. The ultrasonographer shows you the scan report which documents an intrauterine gestation sac measuring 30mm in diameter. A small fetal pole is seen measuring 10mm but no fetal heart was present. The patient does not report any vaginal bleeding.
A. Ovarian torsion B. Heterotopic pregnancy C. Threatened miscarriage D. Inevitable miscarriage E. Delayed miscarriage F. Appendicitis G. Ectopic pregnancy H. Haemorrhagic corpus luteum I. Pelvic inflammatory disease J. Complete miscarriage
Delayed miscarriage
A 28 year old woman presents to the GP surgery with her baby, who is three weeks old. The delivery was by emergency caesarean section for failure to progress in labour. She was discharged on day three after the delivery. She had minimal bleeding for the first two weeks, but over the last few days, bleeding has increased. She is now passing clots vaginally and is feeling unwell. On palpation, the abdomen is tender suprapubically. Her temperature is 38ºC.
A. Endometritis B. Urinary tract infection C. Wound haematoma D. Pulmonary embolism E. Deep venous thromboembolism F. Urinary retention G. Incisional hernia H. Retained products of conception I. Wound infection J. Atelectasis
Endometritis
You are called to see a 35 year old woman who is in labour. She was last examined 4 hours ago when the cervix was 6cm dilated. The cardiotogograph indicates a fetal heart rate of 70bpm for the last 10 minutes. There is meconium staining of the liquor. You perform a vaginal examination which shows the cervix to be 8cm dilated.
A. Continue CTG and review later B. Perform fetal blood sample C. Increase syntocinon infusion D. Admit to antenatal ward for observation E. Start syntocinon infusion F. Cardiotocograph G. Complete partogram H. Perform caesarean section I. Speculum examination
Perform caesarean section
A 38 year old woman is being induced at 41+5 weeks’ gestation in her first pregnancy. She has had an uneventful pregnancy so far. She has been given 2 doses of prostaglandin by the midwives on the antenatal ward and had an amniotomy (artificial rupture of membranes) 4 hours ago. She is not contracting. The cardiotocograph is reassuring.
A. Continue CTG and review later B. Perform fetal blood sample C. Increase syntocinon infusion D. Admit to antenatal ward for observation E. Start syntocinon infusion F. Cardiotocograph G. Complete partogram H. Perform caesarean section I. Speculum examination
Start syntocin infusion
At 10pm you are called to see a 25 year old woman who is in labour at 41 weeks’ gestation. At 6pm cervical assessment showed a dilatation of 6cm. The cardiotocograph shows the fetal heart rate to have a baseline of 150bpm, with reduced variability for 1 hour. There are also variable decelerations present for the last hour. Vaginal examination reveals the cervix to be 9cm dilated and the head is at the level of the ischial spines. The liquor is clear.
A. Continue CTG and review later B. Perform fetal blood sample C. Increase syntocinon infusion D. Admit to antenatal ward for observation E. Start syntocinon infusion F. Cardiotocograph G. Complete partogram H. Perform caesarean section I. Speculum examination
Perform fetal blood sample.
A 33 year old nulliparous lady has a cervical smear performed in accordance with the NHS Cervical Screening Programme and it is reported as inadequate. Her previous cervical smears have always been normal and she has no gynaecological complaints. She uses the combined oral contraceptive pill for contraception. The correct management for this patient is.
- She should be referred for colposcopy where she should be seen within 8 weeks
- She should be advised to discontinue the combined oral contraceptive pill and have the smear repeated in 4 weeks time
- She should be referred for colposcopy where she should be seen within 2 weeks
- The smear should be repeated and she should be referred for colposcopy if 3 consecutive smears are reported as inadequate
- The smear should be repeated and she should be referred for colposcopy if 2 consecutive smears are reported as inadequate
The smear should be repeated and she should be referred for colposcopy if 2 consecutive smears are reported as inadequate
A 24 year old primagravida has HIV antibody testing as part of her antenatal booking investigations at 15 weeks gestation. The test is positive. Which of the following statements regarding mother to child transmission of HIV is NOT true.
- Exclusive formula feeding reduces transmission by half
- All women, irrespective of their plasma viral load, should be advised to take antiretroviral therapy in pregnancy in order to reduce the risk of transmission
- Without intervention transmission occurs in approximately 60% of cases
- All neonates born to HIV-infected women should be given antiretroviral therapy to reduce the risk of transmission
- Transmission most commonly occurs at the time of delivery
Without intervention transmission occurs in approximately 60% of cases
The number of weeks at which induction should be considered if maternal diabetic control has not been optimal.
A. 8 B. 40 C. 2 D. 36 E. 7 F. 38 G. 6 H. 3 I. 1 J. 34
38
For tight control a woman’s % HbA1c should be below this number.
A. 8 B. 40 C. 2 D. 36 E. 7 F. 38 G. 6 H. 3 I. 1 J. 34
7
A 26 year old primigravida is admitted to the delivery suite in spontaneous labour at term. She has no obstetric risk factors and undergoes epidural anaesthesia at 5cm dilatation. Full dilatation is confirmed at 21.30, where the baby is shown to be in the OP position, at ischial spines, with minimal caput/moulding. According to the RCOG guidelines, at what time may an assisted delivery be offered for delay in second stage?
a) at any time
b) 2230
c) 2330
d) 0030
e) 0130
0030.
This lady is nulliparous and one hour passive second stage should be recommended due to her epidural anaesthesia.
Delivery should then be expected within 2 hours of active 2nd stage.
Which of the following is an absolute contraindication to external cephalic version?
a) fetal abnormalities
b) maternal hypotension
c) oligohydramnios
d) 1 previous C-section
e) Transverse lie
C - oligohydramnios
Think of a vacuum-packed foetus. Lack of amniotic fluid means ECV won’t work.
A,B & D are relative contraindications.
E is an indication.
Which is false in relation to medical terminology relating to miscarriage?
a) A complete miscarriage should have a closed cervix clinically and an empty uterus on USS.
b) A missed miscarriage should have a closed cervix with evidence of a fetal pole on USS and women may have slightly symptoms of pain/bleeding.
c) A threatened miscarriage should have a closed cervix and evidence of an intrauterine gestational sac on USS.
d) An incomplete miscarriage should have evidence of tissue/sac on USS with a possibly open cervix clinically.
e) An inevitable miscarriage should have a closed cervix clinically with evidence of an intrauterine gestation sac on USS.
E
An inevitable miscarriage will have an open cervical os.
Which is true regarding antepartum haemorrhage?
a) All women with APH should be admitted
b) Refers to bleeding from or into the genital tract from conception until the delivery of the baby
c) Steroids should be administered at
D
a - All women with APH heavier than spotting and women with ongoing bleeding should be admitted.
b - from 24/40 until delivery
c)
Which of the following regarding hCG if true?
a) It is detectable in maternal bloodstream at 3 days after fertilisation.
b) It is maintained by progesterone.
c) It is maintained by the corpus lute
d) It is secreted by syncytiotrophoblasts
e) It is secreted by the corpus luteum
D
hCG is secreted by the syncytiotrophoblast into the maternal bloodstream, where it acts to maintain the production of progesterone by the corpus lute in early pregnancy.
hCG can be detected in the maternal bloodstream as early as day 8 after conception.
Which of the following is true in relation to placenta praevia?
a) Can be diagnosed from 12/40 gestation.
b) Describes when the chorionic villi are seen at the interface with the myometrium
c) Describes when the chorionic villi invade the full thickness of the uterine wall
d) Describes when the placental cord overlies the cervical opening
e) Describes when the leading part of the placenta is within 5cm of the cervical os.
E
a - Lower segment develops at 28/40 and so before this point it is not possible to diagnose praevia as it describes a condition relating to the position of the placenta within the lower segment
b - placenta accreta
c - placenta percreta
d - vasa praevia
In relation to Termination of Pregnancy
a) Late TOP are usually performed surgically
b) It is more likely to have retained products following a surgical TOP than a medical TOP
c) Mifepristone is used in both medical and surgical TOPs
d) Misoprostol is used in both medical and surgical TOPs.
e) Potential complications of medical TOPS include future cervical incompetence.
D
a - Surgical TOPs from 7-13.6/40
b - mTOP > sTOP for risk of incomplete evacuation
c - Mifepristone is an anti-progesterogenic steroid that ripens the cervix. Used in mTOPs only.
e - Cervical incompetence is a complication of sTOPs not mTOPs.
Which of the following make up the standard bloods taken at a woman’s first booking visit for pregnancy.
a) autoAbs, CMV, Hbopathies, Hepatitis, HIV, Rubella, syphilis, VZV
b) autoAbs, CMV, EBV, FBC, Hepatitis, HIV, Rubella, syphilis, VZV
c) autoAbs, FBC, Hbopathies, Hepatitis, HIV, Rubella, syphilis,
d) CMV, FBC, Hbopathies, Hepatitis, HIV, Rubella, VZV
e) FBC, Hepatitis, HIV, Rubella, syphilis,
C
VZV not included
CMV not included: although potentially fatal to the foetus there is no available treatment so no point screening.
Which of the following if false in relation to GDM?
a) Even if initial screening is negative, the OGTT should be done at 34/40 if there are concerns.
b) First line management is with diet and exercise alone.
c) Management aims include normoglycemia and avoidance of ketosis.
d) Risk factors include BMI >30, a previous baby weighing >4.5kg, and a 1st degree relative with DM.
e) The WHO recommend universal screening at 26-28 weeks.
E.
The WHO does not advocate universal screening but selective screening based on risk.
Post partum, patient treatment is stopped and glucose checked prior to discharge to ensure a return to normal and a 6 week follow up OGTT is organised.
NB. GDM has a 50% risk of developed T2DM within 25y
A 43 year old woman is admitted acutely at 33/40. She describes heavy PV blood loss and lower abdominal pains for the last 2 hours. The placenta is not low lying and she is RhD positive. Examination reveals a firm tender abdomen with palpable contractions 3-4:10, a moderate amount of active bleeding through the (closed) cervical os, and no evidence of UGI tract bleeding. CTG monitoring reveals a sinusoidal foetal heart rate pattern for 30 minutes, with no accelerations. What is the most appropriate management.
a) Induction of labour with prostaglandin pessary
b) Steroid administation - 2 does 24 hours apart
c) Steroid administration - 2 does 24 hours apart with tocolytic cover
d) Tocolysis
e) Urgent delivery by C-section.
E
This women has had a significant APH, likely due to placental abruption.
A sinusoidal CTG pattern is associated with severe foetal anaemia and therefore indicative of severe foetal compromise.
Urgent delivery is indicated for foetal wellbeing, with induction of labour being far long a process to undertake with the suspicion of foetal compromise.
Prior to delivery a singly dose of beclamethasone may give some benefit to foetal respiratory function,however the indication is too urgent to allow a full course to be given.
Tocolysis is contraindicated in the presence of APH.
Recommended induction of labour protocols do not include:
a) Amniotomy alone
b) Amniotomy and oxytocin
c) Oxytocin alone
d) Prostaglandins
e) 2 prostaglandin doses 6hr apart
A
ARM alone is not recommended for induction of labour. It can be used later in labour to help progression.
ARM + oxytocin has been shown to decrease the interval between induction and delivery.
Oxytocin should be started at a low dose and increased to induce optimal contractions.
Prostaglandins should be used in conjunction with CTG to confirm foetal wellbeing and detect hyper stimulation. IF no effect noted at 6hrs on VE, another dose may be administered.
The 4 common causes of PPH include all except:
a) Tears
b) Thrombosis
c) Tissue
d) Tone
e) Underlying haemostasis defects.
B
4 common causes of PPH as 4 Ts
Tone - uterine atony where it fails to contract post-partum.
Trauma - include tears from vaginal delivery
Tissue - retained products.
Thrombin - underlying coagulation defects or acquired defects (drugs).
Which of the following is true with reference to PCOS?
a) An elevated LH:FSH ratio is needed for diagnosis.
b) It is related to type I DM
c) It can be diagnosed using the Rotterdam criteria
d) It is responsible for 50% of all cases of anovulatory sub fertility
e) USS evidence of polycystic ovaries is seen in 10% of women.
C
Rotterdram criteria requires the presence of 2 of the following in the absence of other disorders:
- irregular/absent ovulations (>42 day cycles)
- clinical/biochemical signs of hyperandrogenism
- polycystic ovaries on pelvic USS: >12 antral follicles on 1 ovary.
- Ovarian volume >10mls.
a - an elevated LH:FSH ratio is often seen but not needed for diagnosis.
b - related to T2DM
d - responsible for 80% of all cases of anovulatory sub fertility
e - USS evidence is seen in 20-30% of women.
Concerning cervical disorders, which of the following statements is true?
a) The most common histological subtype of cervical cancer is adenocarcinoma, which is derived from columnar epithelial cells.
b) The most common histological subtype of cervical cancer is adenocarcinoma, which is derived from squamous epithelial cells.
c) Smear tests are used to detect cervical intraepithelial neoplasia
d) All HPV subtypes cause cervical cancer
e) CIN has a characteristic white appearance when stained with 5% acetic acid (vinegar)
E
Acetic acid is used to visualise areas of CIN at colposcopy.
The most common histological subtype of cervical cancer is squamous cell carcinoma, which is derived from squamous epithelial cells.
Smear test are used to detect dyskariosis which is the cytological finding. CIN is a histological finding and therefore requires biopsy to look at the cellular architecture. CIN is grade I-III depending on what proportion of the epithelium is affected.
Of >40 genital mucosal HPV subtypes identified, approx 15 are known to be oncogenic.
Which of the following is not an ABSOLUTE contraindication to the combined OCP?
a) History of VTE in a 1st degree relative.
b) Smoker >35 yrs old and
a.
Absolute contraindication of COCP with regards to VTE are:
- Hx of DVT/PE, not on anticoagulation therapy and higher risk of recurrence
- Hx of oestrogen-associated DVT/PE
- Pregnancy-associated DVT/PE
- Idiopathic DVT/PE
- Known thrombophilia, including antiphospholipid syndrome
- active cancer (incl. within 6/12 of remission)
- active PE/DVT
Diagnostic criteria for anti-phospholipid syndrome
1 clinical feature • ≥3 miscarriages • mid-trimester fetal loss • severe early-onset preeclampsia, IUGR or abruption • A/V thrombosis
AND haematological feature
• 2 positive anticardiolipin Ab or lupus anticoagulant at least 6/52 apart.
Management of endometriosis
• Surgical
o Laparoscopic ablation or excision of endometriotic deposits
o Incision and drainage of cysts (‘chocolate cysts’)
• Medical
o COCP, GnRH analogues and IUS can limit endometriosis but ineffective vs endometriomas
A 42 year old woman and a 51 year old man have conceived their first child together with a gestation of 11 weeks. They are very concerned about the possibility of Down’s syndrome. They would like a test that would give them the definitive diagnosis as to whether their baby has Down’s syndrome, as they may consider terminating the pregnancy if an abnormality is found.
A amniocentesis B CTG C CVS D FBS E fetal echo F fetal ECG G fetal tissue sampling H 1st trimester USS I Nuchal translucency test J 2nd trimester USS K Serum 'triple test' L Uterine artery Doppler USS
.
A 42 year old woman and a 51 year old man have conceived their first child together with a gestation of 11 weeks. They are very concerned about the possibility of Down’s syndrome. They would like a test that would give them the definitive diagnosis as to whether their baby has Down’s syndrome, as they may consider terminating the pregnancy if an abnormality is found.
A amniocentesis B CTG C CVS D FBS E fetal echo F fetal ECG G fetal tissue sampling H 1st trimester USS I Nuchal translucency test J 2nd trimester USS K Serum 'triple test' L Uterine artery Doppler USS
Chorionic villus sampling.
CVS is a diagnostic test: it will give a definite answer rather than the ‘risk’ of a condition being present. A chorionic villus (placental) biopsy is taken either transabdominally or transcervically under US guidance, and the cells analysed.
It is performed between 11 and 14 weeks (which is why it is appropriate for the couple in this question) and therefore a decision regarding possible termination can be made as early as possible before a pregnancy becomes easily visible ‘under the clothes’. It is not performed before 9-11 weeks, as there is a risk of foetal limb abnormalities.
The risk of miscarriage is around 2%. Results of CVS are ready in 48 hours. In a few cases, inconclusive results occur due to placental mosaicism; this would mean that amniocentesis would have to be performed later. There is also a possibility of maternal contamination, which would lead to false negative. Rhesus D-negative women must receive anti-D when undergoing CVS.
A 25 year old woman would like a non-invasive initial assessment for Down’s syndrome and spina bifida. She is 16 weeks gestation.
A amniocentesis B CTG C CVS D FBS E fetal echo F fetal ECG G fetal tissue sampling H 1st trimester USS I Nuchal translucency test J 2nd trimester USS K Serum 'triple test' L Uterine artery Doppler USS
.
A 25 year old woman would like a non-invasive initial assessment for Down’s syndrome and spina bifida. She is 16 weeks gestation.
A amniocentesis B CTG C CVS D FBS E fetal echo F fetal ECG G fetal tissue sampling H 1st trimester USS I Nuchal translucency test J 2nd trimester USS K Serum 'triple test' L Uterine artery Doppler USS
Serum ‘triple test’
The triple test screens for Down’s syndrome, and spina bifida. A number of serum markers are used in combination with the age of the mother and confirmed gestation of the pregnancy to give a ‘risk’ of Down’s syndrome. The serum markers used are AFP, oestriol and BhCG, hence ‘triple’. Triple testing is available from 14-20 weeks (optimal being 15-16) with results being ready in 2 weeks. A high BhCG, low AFP and low estriol are associated with Down’s syndrome.
The false positive rate is around 5%. Increasing maternal age is the strongest risk factoring the incidence of Down’s. A ‘risk’ of the foetus having Down’s syndrome is presented to the parents with a counsellor present so that the appropriate course of action can be taken. A ‘positive’ result is said to be anything about a risk of 1 in 250. In these cases, amniocentesis or CVS is offered.
An incidental finding of raised AFP alone is associated with a break in the foetal skin, often indicating neural tube defects such as spina bifida and anencephaly. As there is a large overlap with the normal and abnormal levels of AFP, further testing (imaging) is needed to confirm a diagnosis of spina bifida.
On CTG tracing, a dip in the foetal heart rate of 20 bpm is seen. It starts at the same time as contractions and recovers to normal by the end of contraction.
A accelerations B Baseline tachycardia C early decelerations D late decelerations E normal baseline fetal heart rate F normal variability G pseudosinusoidal pattern H reduced variability I sinusoidal pattern J sustained tachycardia K variable decelerations
Early decelerations.
On CTG tracing, a dip in the foetal heart rate of 20 bpm is seen. It starts at the same time as contractions and recovers to normal by the end of contraction.
A accelerations B Baseline tachycardia C early decelerations D late decelerations E normal baseline fetal heart rate F normal variability G pseudosinusoidal pattern H reduced variability I sinusoidal pattern J sustained tachycardia K variable decelerations
Early decelerations.
This pattern is often seen in cord compression, particularly in oligohydramnios.
A accelerations B Baseline tachycardia C early decelerations D late decelerations E normal baseline fetal heart rate F normal variability G pseudosinusoidal pattern H reduced variability I sinusoidal pattern J sustained tachycardia K variable decelerations
Variable decelerations
On CTG tracing, a dip in the foetal heart rate of 20 bpm is seen. It starts at the same time as contractions and recovers to normal by the end of contraction.
A accelerations B Baseline tachycardia C early decelerations D late decelerations E normal baseline fetal heart rate F normal variability G pseudosinusoidal pattern H reduced variability I sinusoidal pattern J sustained tachycardia K variable decelerations
Early decelerations.
These occur with contractions and return to normal by the end of contraction. They are probably physiological and are thought to reflect increased vagal tone when foetal intracranial pressure increases during a contraction. They are uniform in depth, length and shape.
This pattern is often seen in cord compression, particularly in oligohydramnios.
A accelerations B Baseline tachycardia C early decelerations D late decelerations E normal baseline fetal heart rate F normal variability G pseudosinusoidal pattern H reduced variability I sinusoidal pattern J sustained tachycardia K variable decelerations
Variable decelerations
These vary in timing and shape in relation to uterine contraction. They suggest cord compression, especially in oligohydramnios. ‘Shouldering’ is a sign that the foetus is coping well with the compression: this is when there is a small acceleration before and after the decelerations. These may resolve if the mother’s position is changed.
