Clinical

Question 1

what is primary amenorrhoea ?

Answer 1

failure to start menstruating. it needs investigation in a 16-year old, or in a 14 year old who has no signs of puberty

Question 2

what is secondary amenorrhoea?

Answer 2

this is when periods stop for >6 months other than due to pregnancy. occurs after periods were previously occuring.

Question 3

what is oligomenorrhoea?

Answer 3

infrequent periods - common at the extremities of reproductive life when regular ovulation often does not occur

Question 4

what is menorrhagia?

Answer 4

excessive menstrual blood loss -

Question 5

what is dysmenorrhoea?

Answer 5

painful periods (+/- nausea or vomiting)

primary dysmenorrhoea - pain without organ pathology - often starting with anovulatory cycles after the menarche

secondary dysmenorrhoea - pain with associated with pathology e.g. adenomyosis, endometriosis, pelvic inflammatory disease

Question 6

what is intermenstrual bleeding?

Answer 6

vaginal bleeding (other than postcoital) at any time may follow after a mid-cycle fall in oestrogen production

Question 7

what is postcoital bleeding?

Answer 7

non-menstrual bleeding that occurs immediately after sexual intercourse

causes: cervical trauma, polyps; cervical, endometrial and vaginal carcinoma and vaginitis

Question 8

what is postmenopausal bleeding?

Answer 8

bleeding occuring >1yr after the last period.

Question 9

what is the main cause of postmenopausal bleeding?

Answer 9

endometrial carcinoma - always this unless proven otherwise

Question 10

what are the causes of inter menstrual bleeding?

Answer 10

pregnancy related

hormonal contraception

infection: chlamydia and PID

cervical ectropian, polyps and carcinoma

Question 11

what are other causes of postmenopausal bleeding?

Answer 11

oestrogen withdrawal

atrophic vaginitis

cervical polyps

cervical malignancy

endometrial polyps

Question 12

what are the causes of primary amenorrhoea?

Answer 12

1.Physiological causes:

Constitutional delay — no anatomical abnormality

Pregnancy

2.Genito-urinary malformations:

Imperforate hymen - cyclical pain

Transverse septum.

Absent vagina or uterus.

3.Endocrine disorders:

Hypothyroidism.
Hyperthyroidism.
Hyperprolactinaemia

Cushing’s syndrome.

Polycystic ovary syndrome (a rare cause of primary amenorrhoea).

Androgen insensitivity syndrome (rare, previously known as ‘testicular feminization’).

4.Causes of primary amenorrhoea in those with no secondary sexual characteristics (such as breast development) include:
Primary ovarian insufficiency (POI) due to:

Chromosomal irregularities (for example Turner’s syndrome [46XO] and gonadal agenesis [46XX or 46XY]).

5.Hypothalamic dysfunction due to:
Stress, excessive exercise, and/or weight loss

6. Chronic systemic illness (such as uncontrolled diabetes, severe renal and cardiac disorders, coeliac disease, cancer, and infections [for example tuberculosis]).
7. Causes of ambiguous genitalia:

5-alpha-reductase deficiency.
Androgen-secreting tumours.
Congenital adrenal hyperplasia.

Question 13

what are the causes of secondary amenorrhea

Answer 13

1.hypothalamic-pituitary ovarian causes: most common

mainly causes by stress, increase in exercise and weightloss

• The female athlete triad : low energy availability menstrual dysfunction, and low bone density e.g. athletes - 40% of female athletes have amenorrhoea
  2. physiological causes:

pregnancy

lactation

menopause

3. hyperprolactinaemia - 30% have galactorrhoea
4. severe systemic disease e.g. renal failure, thyroid disease, pituitary disease and haemochromatosis
5. Polycystic ovarian syndrome - common

Question 14

how do you diagnose amenorrhea?

Answer 14

Examine:

1. Measure height and body weight, and calculate body mass index (BMI) for weight-related causes of amenorrhoea
2. Turner’s syndrome features (short stature, web neck, shield chest with widely spaced nipples, wide carrying angle, and scoliosis).
3. Features of Cushing’s syndrome features (striae, buffalo hump, significant central obesity, easy bruising, hypertension, and proximal muscle weakness).
4. Hirsutism and acne (suggesting PCOS, especially in those with a high BMI).

testing

1. βhcg e.g. urinary - excludes pregnancy
2. FSH/LH - will be low in hypothalamic-pituitary causes but may be normal if weight loss or excessive exercise is the cause. will be raised
3. Prolactin - increased by stress, hypothyroidism,prolactinomas and drugs
4. Genetics - karotyping for turners
5. Thyroid function tests
6. tesosterone level - will be raised in androgen secreting tumor

Imaging:

MRI head for suspected pituitary tumour

Question 15

how do you manage amenorrhea?

Answer 15

1. manage the underlying cause
2. lifestyle changes - applies to secondary amenorrhea caused by weight loss, excessive exercise, stress, or chronic illness
3. contraception pills - as ovulation may occur at any time
4. assisted conception if she wants to be pregnant
5. manage risk for osteoporosis:

For women with premature ovarian failure (younger than 40 years of age), hypothalamic amenorrhoea, or hyperprolactinaemia (women with amenorrhoea associated with low oestrogen levels who are at increased risk of developing osteoporosis):

Treat the underlying cause, if possible.
Assess their fragility fracture risk.

Advise maintaining a healthy lifestyle to optimize bone health. This involves doing weight-bearing exercises, avoidance of smoking, eating a balanced diet, and maintenance of normal body weight.

Correct vitamin D deficiency, and ensure an adequate calcium intake.

Consider offering hormone replacement therapy (HRT) or the combined oral contraceptive (COC) pill (both off-label use) if amenorrhoea persists for more than 12 months.

Question 16

what is polycystic ovarian syndrome (PCOS)?

Answer 16

consists of:

hyperandrogenism

oligomenorrhoea

polycystic ovaries on Ultrasound

cause is unknown

Question 17

what is polycystic ovarian syndrome associated with?

Answer 17

obese

metabolic syndromes - hypertension, dyslipidaemia, insulin resistance, and visceral obesity

higher prevalence of T2DM and sleep apnoea

Question 18

how do you diagnose Polycystic ovarian syndrome?

Answer 18

Rotterdam criteria (2 out of 3 must be present) :

1. polycystic ovaries (12 or more follicles or ovarian volume >10cm3 on US)
2. oligo-ovulation or anovulation
3. clinical and/or biochemical signs of hyperandrogenism

same diagnosis as amenorrhea

imaging - pelvic ultrasound

oral glucose tolerance - for T2DM

fasting lipid panel

Question 19

how do patients with PCOS present?

Answer 19

oligomenotthea with or without hirsutism, acne and subfertility

Question 20

How do you manage PCOS?

Answer 20

Lifestyle management - weight loss and exercise are the mainstay of treatment and increase insulin sensitivity (metformin).

encourage smoking cessation

monitor + manage for - diabetes, hypertension,dyslipidaemia and sleep apnoea

fertility management:

clomifene citrate - induces ovulation

metformin as an alternative to clomifene- may improve menstrual disturbance and ovulatory function but does not have a significant on hirsutism or acne

use ovarian drilling if patient is not reacting to clomifene

gonadotrophins

IVF

hirsutism - treated cosmetically or with antiandrogen e.g. cyproterone

Question 21

what are the causes of menorrhagia

Answer 21

1. dysfunctional uterine bleeding (DUB) - heavy/ irregular bleeding without the absence of recognizable pelvic pathology - diagnosis of exclusion
2. IUCD
3. fibroids
4. endometriosis
5. adenomyosis
6. pelvic infection
7. polyps
8. hypothyroidism
9. coagulation disorders
10. increasing age
11. cooper coil
12. endometrial cancer

Question 22

what are the signs and symptoms of menorrhagia?

Answer 22

heavy prolonged vaginal bleeding

often worse at the extremes of reproductive life

dysmenorrhoea

symptoms of anaemia, pallor

enlarged uterus - suggests fibroids or adenomyosis

Question 23

how do you diagnose menorrhagia?

Answer 23

exclude pregnancy

PV exam

Bloods: FBC, TFT, LFT, coagulation screen

Imaging:

US first line

hysteroscopy and endometrial sampling

Question 24

how do you manage menorrhagia?

Answer 24

fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:

A LNG-IUS - first-line treatment e.g. mirena IUS

2. pharmacological treatment should be considered: non-hormonal

tranexamic acid

nonsteroidal anti-inflammatory drug

hormonal

combined hormonal contraception

cyclical oral progestogens

3. Secondary care treatment : pharmacological options not already tried, uterine artery embolization,

surgery

myomectomy

hysterectomy

second-generation endometrial ablation

Question 25

what is premenstrual syndrome (PMS)?

Answer 25

condition which manifests with distressing physical, behavioral and psycho social symptoms in the absence of organic or psychiatric disease, regularly occuring during the luteal phase of the menstrual cycle. significant improvement by the end of menstrual cycle

Question 26

what are the signs and symptoms of PMS?

Answer 26

mood swings irritability depression bloating breast tenderness headache reduced visuospatial ability increase in accidents

Question 27

how do you diagnose PMS?

Answer 27

physical examinatio indicated by the woman's age and routine gynaecological and medical recommendations patient record daily symptom diary for two or three cycles

Question 28

how do you manage PMS

Answer 28

``` 1. Offer lifestyle advice that includes: Regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates. Regular exercise. Regular sleep. Stress reduction. Smoking cessation (if applicable). Alcohol restriction (if applicable). ``` 2. if the predominant symptom is pain (for example headache or generalized aches and pains), prescribe a simple analgesic 3. For women with moderate PMS symptoms: Consider prescribing a new-generation combined oral contraceptive (COC) CBT 4. for women with severe PMS: Consider prescribing a selective serotonin reuptake inhibitor (SSRI)

Question 29

what is the menopause?

Answer 29

time of waning fertility leading up to the last period. it is a retrospective diagnosis having said to have 12 months after the last perioid average age is 52 yrs

Question 30

what is peri-menopause?

Answer 30

transition phase from pre to post menopausal and the time in which symptoms are experienced.

Question 31

what are the symptoms of menopause?

Answer 31

1. Hot flushes/night sweats (vasomotor symptoms) 2. Cognitive impairment and mood disorder 3. Urogenital symptoms (genitourinary syndrome of menopause) 4. Altered sexual function 5. Sleep disturbance 6. atropy of oestrogen- dependent tissues (genitalia, breasts) and skin 7. vaginal atrophy - atrophic vaginitis 8. osteoporosis 9. increased risk of cardiovascular and cerebrovascular disease

Question 32

how do you diagnose the menopause?

Answer 32

1. clinical | 2. investigation 2 consecutive: FSH level (more than 30 IU/L)

Question 33

how do you manage the menopause?

Answer 33

1. diet and exercise can relieve symptoms 2. Hormone replacement therapy (HRT) 3. vaginal dryness - oestrogen cream 4. menorrhagia responds to mirena coil

Question 34

what are the main routes of administration of Hormone replacement therapy?

Answer 34

1. oral 2. transdermal patch 3. injection 4. intra uterine (mirena) 5. intra vaginal (pessary ring)

Question 35

when do you prescribe oestrogen only HRT?

Answer 35

Oestrogen-only preparations are given to women without a uterus unopposed oestrogen is a risk factor for endometrial cancer

Question 36

when do you prescribe combined HRT?

Answer 36

combined oestrogen and progestogen preparations are given to women with an intact uterus routes - oral, patch, mirena coil

Question 37

what type of HRT do you prescribe for women who are having periods, or who are 12 months of a period? (perimenopausal)

Answer 37

Oestrogen and cyclical progestogen

Question 38

what type of HRT do you prescribe for postmenopausal woman ?

Answer 38

monthly or 3-monthly cyclical regimens, or a continuous combined regimen may be used.

Question 39

what are the adverse effects of HRT?

Answer 39

Oestrogen-related adverse effects: Fluid retention, bloating, breast tenderness or enlargement, nausea, headaches, leg cramps, dyspepsia, oestrogen-dependent cancer Progestogen-related adverse effects: Fluid retention, breast tenderness, headaches or migraine, mood swings, premenstrual syndrome-like symptoms, depression, acne vulgaris, lower abdominal pain, and back pain. Venous thromboembolism (VTE) Vaginal bleeding problems - common dementia endometrial cancer - risk only seeen in use of oestrogen only in women

Question 40

what are the benefits of HRT?

Answer 40

1. reduction of vasomotor symptoms 2. improvement in urogential symptoms and sexual 3. reduced risk of colorectal cancer 4. prevention and treatment of osteoporosis

Question 41

what is the latest date for a termination?

Answer 41

24 weeks unless for medical reasons

Question 42

what are the 2 main common grounds for termination of pregnancy?

Answer 42

``` • CLAUSE C – up to 23+6 weeks “the pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman” ``` ``` • CLAUSE E – no gestational limit “there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped” ```

Question 43

can a doctor refuse to carry out an abortion?

Answer 43

yes, HCPs the right to refuse to participate in abortion care however it Limits are: • Does not apply in emergency or life-threatening situations • Should not delay or prevent a patient’s access to care • Does not apply to ‘indirect’ tasks associated with abortion e.g. administrative, supervision of staff etc

Question 44

how do you carry out medical termination?

Answer 44

<9 weeks: vaginal misoprostol only - prostaglandin analogue advise them to contact doctor if bleeding hasn't started in 24 hrs

Question 45

what document certifies a termination and who signs it?

Answer 45

Certified on HSA1 form | (“Certificate A”) - 2 doctors sign

Question 46

what categories of medical termination are there?

Answer 46

early - <9weeks Late 9-13 weeks mid trimester/late 13-24

Question 47

how do you assess termination of pregnancy?

Answer 47

Clinical • Estimated by LMP +/- date of +ve UPT • Palpable uterus ( > 12 wks) ``` Ultrasound • Abdominal or transvaginal (< 6wks) • Frequently used for all pre-COVID • Now via risk assessment (~1/3) • Symptoms or risk factors for ectopic • Uncertainty about dates • Before STOP in some areas ```

Question 48

how is surgical method of termination of pregnancy is carried out?

Answer 48

Removal of pregnancy via surgical procedure (under anaesthesia) • Cervical priming via misoprostol or osmotic dilators < 14wks • Electric vacuum aspiration (GA) • Manual vacuum aspiration (up to 10wks; LA) > 14wks • Dilatation and evacuation

Question 49

what are the contraindications of abortions?

Answer 49

Haemorrhage +/- blood transfusion Failed/incomplete abortion Infection Uterine perforation (surgical risk only) ``` Cervical trauma (surgical risk only) ```

Question 50

where are endometriotic deposits normally found?

Answer 50

in the pelvis on the ovaries peritoneum uterosacral ligaments pouch of Douglas myometrium - this type of endometriosis is called adenomyosis

Question 51

what is subfertility?

Answer 51

Infertility is defined as the period of time people have been trying to conceive without success after which formal investigation is justified and possible treatment implemented. happens 1/7 couples

Question 52

what are the main causes for infertility?

Answer 52

1. Male factor (25%) 2. anovulation (21%) - may be caused by premature ovarian failure, turner syndrome, surgery or chemotherapy, CPOS, excessive weight loss or weight loss 3. tubal factor (15-20%) 4. unexplained (28%) 5. endometriosis (6-8%)

Question 53

what are the risk factors of infertility

Answer 53

smoking obesity occupational risks excessive alcohol consumption drug use. Female fertility declines with age; the effect of age on male fertility is less clear

Question 54

what investigations can be carried out primary care for infertility?

Answer 54

unable to conceive after 1 year of regular unprotected sexual intercourse men: chlamydia screening semen analysis - repeat in 3 months if abnormal plasma FH is raised in testicular failure karotype - exclude 47 xxy female: mid-luteal phase progesterone levels - in all women to confirm ovulation - day 21 progesterone >30nmol/L is indicative of ovulation serum gonadotrophins levels - only with women who have irregular cycles TFTS prolactin measurement chlamydia screening rubella immunity

Question 55

what imaging do you carry out for infertility

Answer 55

Transvaginal ultrasound Hysterosalpingogram (HSG) uses x-ray and contrast injected through a small cannula in the cervix laparoscopy and dye test - gold standard procedure for assessing tube patency but 2nd line to HSG or HYCOSY

Question 56

what are the causes of female infertility?

Answer 56

1. Ovulatory Group I ovulation disorders: also known as hypogonadotrophic hypogonadism) are caused by hypothalamic pituitary failure e.g. hypothalamic amenorrhea and hypogonadotrophic hypogonadism Group II ovulation disorders: dysfunctions of the hypothalamic-pituitary ovarian axis e.g. (PCOS) and hyperprolactinaemic amenorrhoea Group III ovulation disorders caused by ovarian failure hyperthyroidism and hypothyroidism Cushing's syndrome and congenital adrenal hyperplasia 2. Tubal, uterine, and cervical factors: STIs and PIDs Endometriosis Cervical mucus defect or dysfunction. Submucosal fibroids 3. Drugs Nonsteroidal anti-inflammatory drugs (NSAIDs) Spironolactone

Question 57

what are the causes of male infertility?

Answer 57

1. Primary spermatogenic failure ``` e.g. Anorchia (absence of testes). Testicular dysgenesis Trauma. Testicular torsion. Post-inflammatory forms varicocele tumours ``` 2. Genetic disorders: Klinefelter's syndrome with karyotype 47, XXY 3. Obstructive azoospermia (defined as the absence of both spermatozoa and spermatogenic cells in semen and post-ejaculate urine due to bilateral obstruction of the seminal ducts). e.g. Ejaculatory duct obstruction Vas deferens obstruction Epididymal obstruction 4. other: erectile dysfunction Sulfasalazine — can cause infertility and oligospermia Androgens and anabolic steroids

Question 58

what is the normal semen analysis?

Answer 58

semen volume - 1.4 ml total sperm number (million per ejaculate) - 39 sperm concentration (million per ml) -16 total motility - 42 progressive motility -30 vitality -54 sperm morphology - 4%

Question 59

what is azoospermia?

Answer 59

no sperm in ejaculate

Question 60

what asethenozoospermia?

Answer 60

% progressive motile sperm below reference limit

Question 61

what is oligozoospermia?

Answer 61

total number / concentration of sperm below reference limit

Question 62

What is teratozoospermia?

Answer 62

% morphologically normal sperm below reference limit

Question 63

what is oligoasthenozoospermia?

Answer 63

combination of: Asthenozoospermia (reduced sperm motility) and Oligozoospermia (low spermatozoon count)

Question 64

oligoteratozoospermia?

Answer 64

combination of teratozoospermia and azoospermia

Question 65

how do you manage subfertility?

Answer 65

1. ovulation induction A. clomifene citrate - 1st line 50-100-150 mg tab days 2-6 alternative is letrozole B. gonadotrophin injections - recombinant FSH can cause multiple pregnancy/ overstimulation C. laparoscopic ovarian drilling 2. surgical techniques Tubal microsurgery in women with mild tubal disease Surgical ablation, or resection of endometriosis plus laparoscopic adhesiolysis in women with endometriosis. men: Surgical correction of epididymal blockage in men with obstructive azoospermia IVF intrauterine insemination (IUI) intracytoplasmic sperm injections (ICSI)

Question 66

what is ovarian hyperstimulation syndrome?

Answer 66

complication of ovulation induction or superovulation. this is a systemic disease and vasoactive products are central to its pathophysiology

Question 67

what are the characteristics of ovaria hyperstimulation syndrome?

Answer 67

1. ovarian enlargement 2. fluid shift from intravascular to extravascular space 3. this leads to the accumulation of fluid in peritoneal and pleural spaces 4. intravascular volume depletion causes haemoconcentration are hypercoagulability

Question 68

what are the risk factors of ovarian hyperstimulation syndrome?

Answer 68

young age Low BMI polycystic ovaries previous OHSS

Question 69

what is the presentation of OHSS?

Answer 69

1. abdominal discomfort 2. nausea 3. vomiting 4. abdominal distention usually lasts 3-7 days after hcg administration or 12-17 days if pregnancy has ensured

Question 70

how do you manage OHSS?

Answer 70

mild - moderate: analgesia - avoid NSAIDs drink to thirst not to excess avoid strenuous activities and intercourse due to risk of ovarian torsion continue progesterone luteal support - avoid hCG severe: analgesia and antiemetics check FBCs, LFTs. U&E and albumin strict fluid balance check for ascites and thrombosis urinary catheter thromboprophylaxis with compression stockings and LMWH

Question 71

what is a prolapse?

Answer 71

occurs when the weakness of the supporting structures allows the pelvic organs to protrude within the vagina.

Question 72

what types of prolapses are there?

Answer 72

cystocele: anterior wall of the vagina and the bladder attached to it, bulge urethrocele: lower anterior wall is location of lump. v similar to cystocele Rectocele: lower posterior wall which is attached to rectum may bulge through weak levator ani. enterocele - bulges of the upper posterior vaginal wall may contain loops of intestine from the pouch of Douglas. uterine prolapse : protrusion of the uterus downwards into the vagina, taking with it the cervix and upper vagina.

Question 73

how do you grade prolapses?

Answer 73

1st degree - lowest part of the prolapse descends halfway down the vaginal axis to the introitus 2nd degree - lowest part of the prolapse extends to the level of the introitus and through the introitus on straining 3rd degree: lowest part of the prolapse extends through the introitus and outside the vagina. Procidentia: refers to 4th degree uterine prolapse - uterus lies outside the vagina

Question 74

what are the risk factors of prolapse?

Answer 74

1. congenital 2. prolonger labour 3. trauma from instrumental delivery 4. lack of postnatal pelvic floor exercise 5. obesity 6. chronic cough 7. constipation 8. smoking

Question 75

what are the symptoms of prolapse?

Answer 75

1. can be asymptomatic 2. dragging sensation 3. discomfort 4. sensation o heaviness or pulling in the vagina 4. feeling of a lump coming down 5. dyspareunia - painful intercourse 6. backache 7. urinary incontinence or retention

Question 76

what investigations do you carry out for prolapses?

Answer 76

1. Bimanual to exclude pelvic masses 2. Pelvic organ prolapse quantification system (POP-Q) patient straining - 6 specific sites are evaluated patient at rest - 3 sites measure each site in relation to the hymenal ring. if a site is above the hymen then give a negative number if a site is below the hymen then give a positive number 3. urodynamic studies if urinary continence 4. pelvic ultrasounds

Question 77

how do you manage prolapses?

Answer 77

1. conservative: avoid heavy lifting lose weight stop smoking vaginal oestrogens: only if symptomatic atrophic vaginitis Pessaries: useful for women unfit for surgeries. Relief symptoms whilst awaiting surgery further pregnancies planned or pregnant diagnostic test for prolapse 2. surgery: Cystocele/ uretrocele - anterior colporrhaphy Rectocele/ entereocele - posterior colporrhaphy uterine/ vaginal vault - sacrospinous ligament fixation or hysterectomy

Question 78

give example of contraception methods.

Answer 78

1. combined pill (hormonal method) 2. condoms (barrier method) 3. DMPA injection 4. patch (hormonal method) 5. contraceptive implant (hormonal method) 6. copper coil (intrauterine method) 7. diaphragm (barrier methods) 8. IUS (intrauterine method) 9. The ring (hormonal method) 10. mini pill (hormonal method) 11. surgical sterilisation (permanent method)

Question 79

what are the three types of mechanisms for contraception?

Answer 79

1. prevention of ovulation 2. prevention of fertilisation 3. prevention of implantation

Question 80

Give examples of Long acting reversible contraception (LARC)?

Answer 80

1. IUS 2. IUD either levo 3. Nexplanon

Question 81

What is the mechanism of LARC?

Answer 81

prevention of ovulation apart from hormone coil and traditional Progesterone only pill

Question 82

how long do LARCs provide contraceptive cover for?

Answer 82

12-14 weeks

Question 83

what are the contraindications for LARC?

Answer 83

1. Pregnancy 2. Breast cancer 3. severe cardiac disease 4. undiagnosed vaginal bleeding 5. submucosal fibroids 6. uterine malformation

Question 84

what are the side effects of LARC?

Answer 84

weight gain increased risk of osteoporosis risk factor for ectopic pregnancy delay in return of fertility irregular bleeding

Question 85

What is a VLARC?

Answer 85

very long acting resisting contraceptive

Question 86

give an example of a VLARC?

Answer 86

Copper coil - non hormonal IUD IUS: mirena coil Implant

Question 87

what is the mechanism of action for copper coil?

Answer 87

prevention of fertilisation

Question 88

how long does a copper coil stay in the uterus for?

Answer 88

5-10 years

Question 89

what are contraindications for copper coils?

Answer 89

peptic ulcer disease current pelvic infection abnormal uterine anatomy history or current endometrial or cervical cancer pregnancy - increased risk of ectopic pregnancy and second trimester miscarriage

Question 90

when should you insert a copper coil ?

Answer 90

first 7 days of period anytime if reasonably certain they are not pregnant up to 5 days UPSI for emergency contraception immediately after termination of pregnancy

Question 91

what are the side effects copper coil?

Answer 91

Side effects: heavy, prolonged periods problems with insertion: pain, increased risk of infection, uterine perforation, expulsion of device

Question 92

what type of mechanism of action does the IUS have?

Answer 92

prevention of implantation

Question 93

how long can a IUS be used for?

Answer 93

3- 5 years insertion

Question 94

what are the contraindications of IUS?

Answer 94

peptic ulcer disease current pelvic infection abnormal uterine anatomy history or current endometrial or cervical cancer pregnancy - increased risk of ectopic pregnancy and second trimester miscarriage not used as a method of emergency contraception

Question 95

when is an IUS suitable for insertion?

Answer 95

within first 7 days of period <48 hrs or >4 weeks post partum immediately after termination of pregnancy

Question 96

What is the mechanism of action for the implant?

Answer 96

inhibition of ovulation

Question 97

how long does the implant stay in the body for?

Answer 97

3 years - needs to be changed more regularly if obese

Question 98

when should you put an implant in?

Answer 98

1. within first 5 days of cycle 2. on or before day 21 post partum 3. up to 5 days post first or second trimester abortion 4. starting after last active pill taken

Question 99

when will condom cover be required for implants?

Answer 99

started an other time in the cycle used a s a quick start for emergency contraception switching from POP, mirena, IUD

Question 100

what are the side effects of Implants?

Answer 100

irregular bleeding, weight gain, acne problems with insertion: nerve damage and pain on insertion

Question 101

what do short acting combined hormonal contraception contain?

Answer 101

both oestrogen and progesterone

Question 102

what is the mechanism of action for short acting combined hormonal contraception?

Answer 102

inhibition of ovulation

Question 103

give examples of short acting combined hormonal contraception?

Answer 103

transdermal patch combined oral contraceptive pill short acting single hormonal contraception vaginal ring

Question 104

how does the transdermal patch last for?

Answer 104

single patch is applied for one week at a time for three weeks

Question 105

what are the problems for transdermal patch?

Answer 105

if the woman is obese it reduces efficacy breast pain, nausea and painful periods more common than with other combined preparations increased thrombotic risk

Question 106

How long does a vaginal ring last for?

Answer 106

21 days followed by a 7day ring free period

Question 107

How long do you need to take a combined oral contraceptive pill for?

Answer 107

pill taken for 21 consecutive days

Question 108

when do you start taking the contraceptive pill?

Answer 108

if taken on first 5 days of cycle - no cover required if taken after first 5 days of cycle - 7/7 condoms emergency contraception: immediately after levonelle, 5 days after ellaone

Question 109

what are the side effects of contraceptive pill?

Answer 109

vomiting - take again if this happens within 2 hours diarrhoea - take again if this happens within 24 hrs

Question 110

what happens if they miss taking a pill between 24<48 hrs?

Answer 110

take missed pill and continue with rest of pack as normal

Question 111

what happens if you miss 2 pills >48 hrs

Answer 111

week 1 - take most recent pill use 7/7 condom cover and consider emergency contraception week 2: take most recent pill, 7/7 condom cover week 3: take most recent pill, 7/7 condom cover and omit break

Question 112

what happens if you miss >2 pills?

Answer 112

emergency contraception if in first week continue with rest of the pack and omit break

Question 113

what are the benefits of combined pill?

Answer 113

improves acne improves pre menstrual symptoms protects against ovarian, endometrial and colorectal cancer

Question 114

what are the side effects of combined pill?

Answer 114

1. increased VTE 2. increased CVD and stroke risk 3. increased risk of breast and cervical cancer 4. increased BP 5. mood swings 6. nausea and vomiting 7. irregular bleeding

Question 115

what are the contraindications for combined pill?

Answer 115

1. migraine with aura- recurring headache that strikes after or at the same time as sensory disturbances called aura. 2. smoking >15 cigarettes if >35 yo 3. history of breast cancer 4. anti phospholipid syndrome

Question 116

what is a progesterone only pill?

Answer 116

pill which only contains progesterone e.g. etonogestrel or levenogestrel

Question 117

what is the mechanism of action for POP?

Answer 117

thickens cervical mucus

Question 118

how many times do you take POP?

Answer 118

take pill everyday at same time

Question 119

when do you prescribe POP?

Answer 119

to women who are usually contraindicated for combined one 1. breast feeding >35 and smoking

Question 120

what are the side effects of POP?

Answer 120

DUB Weight gain headaches

Question 121

where is incontinence in women maintained in the body?

Answer 121

urethra by the external sphincter and pelvic floor muscles

Question 122

what is incontinence?

Answer 122

involuntary leakage of urine which is divided into urge, stress and mixed urinary incontinence

Question 123

what is continuous urinary leakage most commonly associated with?

Answer 123

vesicovaginal fistula or congenital abnormality e.g. ectopic ureter

Question 124

what investigations do you carry out for incontinence?

Answer 124

Urinalysis Imaging - use US to exclude incomplete bladder emptying and define any pelvic mass . NOT routinely used however cystoscopy - used to visualise urethra bladder,mucosa, trione and ureteric orifices. Biopsies can be taken urodynamics - a combination of tests which lok at the ability of bladder to store and void urine. Uroflowmetry screens for voiding difficulties.

Question 125

What is stress urinary incontinence? (SUI)

Answer 125

involuntary leakage of urine on effort or exertion, or on sneezing or coughing mainly due to urethral sphincter weakness

Question 126

what is urge urinary incontinence?

Answer 126

is the involuntary leakage of urine with a strong desire to pass urine. commonly coexists with frequency and nocturia and forms overactive bladder syndrome

Question 127

What is mixed urinary incontinence?

Answer 127

is the combination of stress and urge incontinence and usually one symptom will predominate (treat that first)

Question 128

what is overflow incontinence?

Answer 128

usually due to injury or insult

Question 129

what is the main common type of incontinence in women?

Answer 129

stress urinary incontinence

Question 130

what is the pathophysiology of stress urinary incontinence?

Answer 130

when detrusor pressure exceeds the closing pressure of the urethra

Question 131

what investigations do you carry out for stress urinary incontinence?

Answer 131

Exclude UTI A frequency/ volume chart shows normal frequency and functional bladder capacity urodynamics when surgery is considereed check for detrusor overactivity check for voiding dysfunction - woman with poor flow rate is at risk fo long - term urinary retention

Question 132

what are the risk factors of SUI?

Answer 132

vaginal delivery oestrogen deficiency from menopause radiotherapy congenital weakness trauma from radical pelvic surgery

Question 133

how do you manage SUI?

Answer 133

Lifestyle advise - weight loss, smoking cessation, treatment of chronic cough Pelvic floor exercise (muscle training) for at least 3 months Surgery: Peri urethral injections of bulking agents if they reject surgery then - duloxetine tension- free vaginal tapes

Question 134

What is overactive bladder syndrome (OAB)?

Answer 134

chronic condition affecting women and implies underlying detrusor overactivity (DO)

Question 135

what are the causes of OAB?

Answer 135

incidence increases with age idiopathic - main cause rare caues: MS spina bifida secondary to pelvic or incontinence surgery

Question 136

what can provoke symptoms of OAB?

Answer 136

cold weather opening the front door coughing sneezing

Question 137

what are the symptoms of OAB?

Answer 137

stress incontinence symptoms

Question 138

how do you diagnose OAB?

Answer 138

detrusor overactivity - diagnosed via urodynamic testing exclude UTI frequency/ volume chart typically shows increased diurnal frequency and nocturia urodynamics shows involuntary detrusor contractions during filling - done when there is a doubt about diagnosis

Question 139

how do you manage OAB?

Answer 139

bladder retraining pharmacology: anticholinergics e.g. oxybutynin, solifenacin or mirabegron side effects include dry mouth, constipation and nausea intravaginal oestrogen cream can help in those with vaginal atrophy

Question 140

what are the causes of vulval lumps?

Answer 140

local varicose veins boils sebaceous cysts bartholins cyst or abscess uterine prolapse or polyp inguinal hernia varicocele carcinoma viral warts

Question 141

what are vulval warts?

Answer 141

genital warts caused by HPV spread via sexual contact incubation is weeks

Question 142

what body parts can be affected by vulval warts?

Answer 142

vulva perineum anus vagina cervix

Question 143

which HPV causes vulval warts?

Answer 143

HPV 6 and 11

Question 144

which HPV causes vulval and cervical intraepithelial neoplasia?

Answer 144

16,18 and 33

Question 145

what can vulval warts cause?

Answer 145

anal carcinoma

Question 146

how do you manage vulval warts?

Answer 146

warts can be destroyed via the following: cryotherapy trichloroacetic acid electrocautery only treat a few warts at a time to avoid toxicity self application: podophyllotoxin cream

Question 147

what type of cancers can HPV 6 and 11 may cause in offspring of affected mothers with vulval warts??

Answer 147

laryngeal or respiratory papilomas

Question 148

what is urethral caruncle?

Answer 148

This is a small red swelling at the urethral orifice.

Question 149

what is the main cause of urethral caruncle?

Answer 149

meatal prolapse

Question 150

when can urethral caruncle cause pain?

Answer 150

on micturition

Question 151

how do you manage urethral caruncle?

Answer 151

excision or diathermy

Question 152

what is a bartholin's cyst and abscess?

Answer 152

if the bartholin's duct and glands are blocked a painless cyst forms however if this becomes infected it can become extremely painful - basically cannot sit down a hot red labium is seen

Question 153

how do you manage bartholin's cyst and abscess?

Answer 153

abscess should be incised and permanent drainage ensured by marsupialisation

Question 154

what tests might you do for batholin's cyst and abscess?

Answer 154

exclude gonococcus

Question 155

what is vulvitis?

Answer 155

vulval inflammation may due to infections e.g. candida, herpes simplex, chemicals often associated with vaginal discharge

Question 156

what are the causes of vulval ulcers?

Answer 156

syphilis - main cause herpes simplex - common in young carcinoma chancroid TB Behcet syndrome crohns disease granuloma inguinale

Question 157

what is herpes simplex?

Answer 157

Herpes is an enveloped DNA virus.

Question 158

what types of herpes are there?

Answer 158

HSV 1 HSV 2

Question 159

which herpes causes genital infection?

Answer 159

both do HSV 2 more common though

Question 160

what is the primary infection of Herpes simplex?

Answer 160

usually the most severe starts with the prodrome (itching of affected skin) flu- like illness progresses to vulvitis pain and small vesicles on the vulva urinary retention may occur due to autonomic nerve dysfunction recurrent attacks are usually less severe and may be triggered by illness, stress, sexual intercourse and menstruation

Question 161

how do you manage herpes simplex?

Answer 161

strong analgesia lidocaine gel anti viral - aciclovir orally shorten symptoms. dont give topical cream

Question 162

what is the clinical presentation of carcinoma of the vulva?

Answer 162

lump : as an indurated ulcer which may not be noticed unless it causes pain and bleeding hence often presenting late

Question 163

how do you manage carcinoma of the vulva?

Answer 163

depends on size of tumor if <2cm wide and <1mm deep then lymph node excision is not needed if >1mm deep do triple incision surgery = wide radiotherapy may be used preoperatively to shrink tumours if sphincters are affected chemoradiation is used in people unsuitable for surgery to shrink large tumours preoperatively and for relapses

Question 164

what are the signs and symptoms of cervical cancers?

Answer 164

cervical smear showing invasion incidental finding on treatment of CIN postcoital and or postmenopausal bleeding watery vaginal discharge advance disease includes: heavy vaginal bleeding ureteric obstruction weight loss bowel disturbance vesicovaginal fistula pain

Question 165

what would you see when examining the cervix if there was cervical cancer?

Answer 165

colposcopy shows an irregular cervical surface abnormal vessels and dense uptake of acetic acid bimanual examination: the cervix feels roughened and hard and if disease is advanced there is loss of the fornices and the cervix is fixed speculum examination: shows an irregular mass that often will bleed on contact

Question 166

what investigations should you do for cervical cancer?

Answer 166

FBC , U&E LFTs Punch biopsy for histology large loop excision of the transformation zone (LLETZ) is contraindicated CT abdomen and pelvis for staging MRI pelvis helps with staging and identifying lymph nodes examination under anaesthetic helps staging

Question 167

what are the causes of cervical cancer?

Answer 167

HPV 16 and 18 are main causes

Question 168

what are the risk factors of cervical cancer?

Answer 168

HPV particularly 16 and 18 inadequate cervical screening 2. risk of HPV infection depends on: number of sexual partners age at first sexual intercourse no condom use 3. woman with HPV the following factors increase risk of progression to cervical cancer other STIs e.g. herpes simplex, chlamydia or gonococcal infections smoking high parity family history in a first degree relative oral contraceptive pill for longer than 5 years 4. immunosuppresed women

Question 169

how do you manage cervical cancer?

Answer 169

1.prevention NHS screening (offered 25 - 640 HPV vaccination - girls at 12-13 use of condoms 2. Management depends on stage: 1. CIN colposcopy biopsy and histological analysis moderate to severe abnormalities are found: excision or ablation 2. Stage IA1 (microinvasive disease) conservatively - no need for lymphadenectomy 3. Stage IA2 (early stage disease) tumour <4cm - radical hysterectomy with lymphadenectomy Tumour >4cm - chemoradiation 3. Stage IIB (locally advanced disease) chemoradiation 4. Stage IVB (metastatic disease) combination chemotherapy is the treatment of choice single agent therapy and palliative care also option

Question 170

what is cervical intraepithelial neoplasia (CIN)?

Answer 170

precursor lesion of invasive carcinoma diagnosis is made via biopsy

Question 171

what is a dyskaryosis

Answer 171

cytological term used to describe cervical smears the change of appearance in cells that cover the surface of the cervix high false positives and negatives so colposcopy is required

Question 172

what is colposcopy?

Answer 172

examination of the cervix via a colposcope two stains are used : iodine or acetic acid Iodine - abnormal areas don't change colour Acetic acid - abnormal areas turn white

Question 173

what do you do if there is high grade colposcopy?

Answer 173

suggests CIN II - III therefore intervene

Question 174

do colposcopy detect adenocarcinomas of the cervix?

Answer 174

nope

Question 175

define CIN I,II,III

Answer 175

CIN I - 1/3rd of the thickness of the cervical surface layer is affected. Regresses spontaneously in 60% of cases with no treatment CIN II- 2/3rds of the thickness of the surface layer is affected. progresses to cancer in 5% of cases CIN III - high grade dysplasia. full thickness of the surface layer is affected 20-30% of cases in CIN III progress to cervical cancer.

Question 176

how do you manage CIN?

Answer 176

LLETZ - large loop excision of the transformation zone occurs with colposcopy clinic local anaesthetic using loop diathermy - 90% cure rates in one treatment

Question 177

what is CGIN?

Answer 177

cervical glandular intraepithelial neoplasia it can coexist with CIN or be a sole finding difficult to manage as the endocervical epithelium extends into the cervical canal and therefore not completely visible at colposcopy associated with high risk HPV and higher skip lesions manage with cylindrical LLETZ ,cone biopsy or hysterectomy if she doesn't want kids

Question 178

what are the stages of cervical cancer?

Answer 178

stage I - tumours confined to cervix :1A microscopic 1B macroscopic Stage 2 - have extended locally to pper 2/3 of the vagina IIb to parametria Stage 3 - spread to lower 1/3 of vagina IIIa or pelvic wall stage 4 - spread to bladder or rectum 1

Question 179

how common are vaginal cancers?

Answer 179

extremely rare <1% of gynaecological malignancies

Question 180

what is the clinical presentation of vaginal cancers?

Answer 180

most are squamous in origin usually in older women commonest in the upper 1/3rd of vagina bleeding

Question 181

how do you manage vaginal cancers?

Answer 181

radiotherapy prognosis is poor

Question 182

what is the cause of endometrial cancer?

Answer 182

related to excessive exposure to oestrogen unopposed to progesterone

Question 183

what are the risk factors for endometrial cancer?

Answer 183

1. obesity 2. T2DM 3. hypertension 4. nulliparity 5. anovulatory cycles e.g. PCOS 6. early/late menopause 7. HNPCC (lynch II syndrome) gene 8. oestrogen only HRT 9. breast cancer 10. combined pill

Question 184

What is the clinical presentation of endometrial cancers?

Answer 184

1. older woman 2. post menopausal bleeding (PMB) 3. vaginal discharge 4. pyometra 5. Thrombocytosis 6. haematuria

Question 185

how do you diagnose Endometrial cancer?

Answer 185

1. PMB is early sign 2. visible haematuria and low haemoglobin levels 3. thrombocytosis 4. high blood glucose levels transvaginal ultrasonography (TVS) shows endometrial thickness >4mm then maybe suggestive Biopsy via outpatients or with hysteroscopy use CT for assessing distance metastases in those proven to have advanced local disease MRI - investigation of choice to stage pelvic disease

Question 186

what is the staging of endometrial cancer?

Answer 186

stage I - body of the uterus only II - body and cervix only III - beyond the uterus but not the pelvis IV - extends beyond the pelvis

Question 187

how do you manage endometrial cancer?

Answer 187

Surgical: total hysterectomy + bilateral salpingo-oophrectomy medical: external beam radiotherapy - used as palliative treatment in those who cant have surgery vaginal brachytherapy - is used to post op to reduce recurrence external beam radiotherapy oral progesterone chemotherapy all depends on stage stage 1 - surgery +/- radiotherapy stage 2 - surgery +/- radiotherapy stage 3 - maximal debulking surgery + lymph node dissection + radiotherapy stage 4 - maximal debulking surgery + palliative radio/chemotherapy

Question 188

what is the pathophysiology of benign ovarian tumours?

Answer 188

can be physiological due to follicular cysts or corpus luteal cysts epithelial tumours - serous and clear cell germ cell (mesoderm) tumours - mature teratoma, dermatoid cyst fibroma - meigs syndrome - ovarian fibroma + ascites +PE

Question 189

what would benign ovarian tumours be like on examination?

Answer 189

irregular looking ovaries may be normal if cyst is small or woman is obese abdominal examination: mass arising from the pelvis, tenderness, peritonism or ascites vaginal examination: vaginal discharge or bleeding, cervical excitation, adnexal mass, or tenderness nodular uterosacral ligaments and a fixed retroverted uterus ---- endometriosis ovarian torsion is uncommon : presents with severe lower abdominal pain and vomiting deep seated colicky abdominal pain fever may be in a minority whirlpool sign ( free fluid on US)

Question 190

what imaging do you do for benign ovarian tumours?

Answer 190

TVS - good at distinguishing benign from malignant mass transabdominal US for cyst extending out of pelvis MRI and CT used in staging

Question 191

how do you manage benign ovarian tumours?

Answer 191

same as ovarian cysts

Question 192

what is a ovarian functional cyst?

Answer 192

enlarged or persistent follicular or corpus luteum cysts usually resolve after 2-3 cycle can be painful if rupture

Question 193

what is an endometriomas

Answer 193

ovarian cysts filled with old blood also known as chocolate cyst

Question 194

what is a ovarian serous cystadenomas?

Answer 194

neoplasms which are commonest in women aged 30-40 30% become cancerous most common type of epithelial cell tumour

Question 195

what is a mucinous cystadenoma?

Answer 195

commonest large ovarian tumours filled with mucinous material remove appendix with suspected mucinous cystadenoma and send for histology ruptures may cause pseudomyxoma peritonei

Question 196

what is a fibroma?

Answer 196

these are small, solid, benign, fibrous tissue tumours associated with meigs syndrome: PE , often right sided + benign ovarian fibroma + ascites

Question 197

what is an ovarian teratoma?

Answer 197

tumour which arise from primitive germ cells contain well differentiated tissue ( hair, teeth) 20% are bilateral most common in young women

Question 198

what types of ovarian cancers are there?

Answer 198

epithelial - most common Non epithelial: germ cell tumours ovarian carcinosarcoma sex cord tumour stromal tumour small cell neuroendocrine squamous cell carcinoma

Question 199

where do secondary metastatic tumours in the ovary mostly come form?

Answer 199

endometrium breast GI tract

Question 200

what are the risk factors for ovarian cancer?

Answer 200

older women smoking obesity BRCA 1 and BRCA 2 gene family history of ovarian cancer family history of breast cancer nulliparity early menarche late menopause IVF HRT

Question 201

what are the signs and symptoms of ovarian cancer?

Answer 201

woman over 55 abdominal bloating feeling full and/or loss of appetite pelvic or abdominal pain increased urinary urgency weight loss malaise or fatigue change in bowel habit

Question 202

how do you diagnose ovarian cancer?

Answer 202

bloods Serum CA125 - raised ( greater than 35 IU/ml) . not specific though AFP, LDH and hCG too examination: Abdominal and pelvic examinations - may have ascites or a pelvic or abdominal mass ( make sure not uterine fibroids) Imaging: TVs or abdominal US first line staging: CT CAP Tissue sampling: Ascitic tap - for cytology staging surgery - laparotomy or laparoscopy for biopsy

Question 203

what are the stages of ovarian cancer?

Answer 203

Stage 1 limited to one or both ovaries stage 2 limited to pelvis Stage 3 limited to abdomen, including regional lymph node metastases Stage 4 - distant metastases outside abdominal cavity

Question 204

how do you manage ovarian cancer?

Answer 204

surgery: EARLY STAGES - OPEN HYSTERECTOMY, BSO ( bilateral salpingo oophorectomy and INFRACOLIC OMENTECTOMY LATE STAGES - RADICAL DEBULKING (Bring down disease burden to nil residual disease). if fertility required: early disease can keep uterus and other ovary may be left unilateral salpino-oophrectomy) chemo: recommended in everyone following surgery unless disease is low grade 1a - 1b platinum agents are best e.g. carboplatin with paclitaxel

Question 205

what type of epithelial ovarian cancers are there?

Answer 205

``` Serous Mucinous Endometrioid Clear cell Brenner Undifferentiated carcinoma ```

Question 206

what is endometriosis?

Answer 206

presence of endometriotic tissue outside the uterus hormone mediated endometriotic deposits are mainly found in the pelvis, on the ovaries, peritoneum, uterosacral ligaments and pouch of douglas

Question 207

what is the cause of endometriosis?

Answer 207

unknown three main theories: 1. retrograde menstruation 2. metaplasia of mesothelial cells 3. impaired immunity

Question 208

what are the signs and symptoms of endometriosis?

Answer 208

chronic pelvic pain period related pain (dysmenorrhoea) deep pain during or after sexual intercourse period related GI symptoms e.g. painful bowel movements period related urinary symptoms e.g. haematuria and pain passing urine subfertility can be asymptomatic

Question 209

how do you diagnose endometriosis?

Answer 209

Diagnostic: gold standard - laparoscopy with biopsy Examination: abdominal and pelvic exam - look for abdominal masses and reduced organ mobility and enlargement imaging: transvaginal ultrasound serum CA 125 may be raised can be normal though

Question 210

how do you manage endometriosis?

Answer 210

1.symptomatic relief: NSAIDs for pain 2. hormonal therapy : reduces endometriosis related pain. obvs dont give to women who want babies Combined pill POP Mirena coil COCP GnRH analogues 3. surgical management: laparoscopy with ablation or excision nodules should be excised rather than drained otherwise high recurrence hysterectomy is indicated ( adenomyosis or heavy menstrual bleeding that have not responded to other treatments) all visible endometriotic lesions should be excised at the time of hysterectomy. it is last resort

Question 211

what is an adenomyosis?

Answer 211

presence of endometrial tissue with the myometrium

Question 212

what are uterine fibroids?

Answer 212

most common benign tumour in women they are a mixture of smooth muscle cells and fibroblasts which form hard, round whorled tumours in the myometrium

Question 213

what are the risk factors of uterine fibroids?

Answer 213

mutation in the gene for fumarate hydratase increasing age early puberty obesity black ethnicity family history

Question 214

what is the clinical presentation of uterine fibroids?

Answer 214

mainly asymptomatic symptoms: heavy menstrual bleeding pelvic pain abdominal distention pelvic pressure urine frequency or incontinence subfertility

Question 215

how do you diagnose for uterine fibroids?

Answer 215

Pelvic examination: firm, enlarged and irregularly shaped non-tender uterus mass can be moved slightly from side to side large tumours- central irregular mass can be palpated on transabdominal examination imaging: ultrasound used to measure uterine length can also use hysteroscopy to measure to uterine length (>12 cm)

Question 216

how do you manage uterine fibroids?

Answer 216

if asymptomatic: no further investigation or management once diagnosed unless there is a rapid growth (suggests malignancy) symptomatic: GnRH analogues: e.g. goserelin - monthly 3-6 months before surgery used to shrink them. not long-term option Myomectomy - use different types depending on size and location. submucosal fibroids better removed hysteroscopically uterine artery embolization (UAE): don't give to women who want fertility

Question 217

what contraception do you give to women with fibroids?

Answer 217

without distortion of uterine cavity - all can be used with distortion of uterine cavity: barrier methods (condom) Combined hormonal contraception (Pill) POP female sterilisation - depends on location and size of the fibroid give HRT for women with no symptoms from fibroids

Question 218

what are the main sites of uterine fibroids?

Answer 218

intramural subserosal pedunculated submucosal

Question 219

What is pelvic inflammatory disease (PID)?

Answer 219

infection of the upper genital tract.

Question 220

what are the causes of PID?

Answer 220

STIs e.g. chlamydia trachomatis (main cause) Neisseria gonorrhoeae usually from ascending infection from the endocervix - caused by mycoplasma genitalium Uterine instrumentation e.g. due to termination of pregnancy or insertion of intrauterine device postpartum appendicitis anaerobes and endogenous bacteria e.g. haemophilus influenzae, gardnerella vaginalis

Question 221

what are the risk factors for PID?

Answer 221

young age (younger than 25) early age of losing virginity multiple sexual partners recent new partner

Question 222

what are the signs and symptoms of PID?

Answer 222

lower abdominal pain (usually bilateral can be uni) deep dyspareunia abnormal vaginal bleeding e.g. postcoital abnormal vaginal discharge as a result of associated cervicitis, endometritis or bacterial vaginosis examination: lower abdominal tenderness (bilateral usually) adnexal tenderness uterine tenderness speculum examination - abnormal cervical or vaginal mucopurulent discharge

Question 223

how do you diagnose PID?

Answer 223

1. High vaginal swab - to exclude other vaginal infections e.g. bacterial vaginosis and candidiasis 2. test for STIs chlamydia: vulvo- vaginal swab or endocervical swab FCU - sample can be collected if preferred Gonorrhoea: vulovovaginal swab or NAAT 3. ESR, C protein and leucocyte count imaging: US - helpful if an abscess is suspected but not helpful in uncomplicated PID MRI/ CT scanning of the pelvis can be helpful in differentiating PID from alternative diagnoses but not routinely used.

Question 224

how do you manage PID?

Answer 224

screen woman for infections trace sexual partners of the woman from the past 6 months 2. Drug treatment pain relief - ibuprofen or paracetamol 3. Antibiotics if gonococcal infection is low: ceftriaxone (as a single IM), oral doxycycline+ Oral metornidazole or oral ofloxacin (twice daily) + oral metronidazole (twice daily) if mycoplasma genitalium is positive: moxifloxacin if gonococcal risk is high: ceftriaxone (single IM dose), followed by oral doxycycline (twice daily) + oral metronidazole (twice daily) remember : ofloxacin and moxifloxacin or azithromycin are not recommended in women at high risk of gonococcal PID.

Question 225

what are the complications of PID?

Answer 225

1. Tubo-ovarian abscess 2. Fitz-hugh- curtis syndrome 3. recurrent PID 4. ectopic pregnancy 5. subfertility from tubal blockage

Question 226

what is an ectopic pregnancy?

Answer 226

fertilised ovum implants outside the uterine cavity

Question 227

what are the risk factors for ectopic pregnancies?

Answer 227

damage to the fallopian tube previous ectopic pregnancy history of infertility smoking endometriosis IVF maternal age over 35 POP and IUCD

Question 228

what are the main sites of ectopic pregnancies?

Answer 228

ampulla - most common site narrow inextensible isthmus ovary cervix caesarean section scar

Question 229

what are the main complications of ectopic pregnancies?

Answer 229

Tubal rupture - may lead to maternal death recurrent ectopic pregnancy grief, anxiety or depression

Question 230

what are the clinical features of ectopic pregnancy?

Answer 230

can have no signs or symptoms symptoms: abdominal/pelvic pain - pain increases 6-8 weeks into pregnancy in fallopian tubes. can vary in other places. amenorrhoea vaginal bleeding shoulder tip pain - referred pain signs: pelvic adnexal abdominal tenderness can have cervical motion tenderness abdominal distention shock

Question 231

how do you diagnose ectopic pregnancy?

Answer 231

1. confirm she's pregnant e.g. hCG via serum in bloods or urine. serum hCG may be used to determine subsequent management in women with pregnancy of unkown location (PUL) 2. vaginal and speculum examination - they do not rupture ectopic pregnancy gentle abdominal examination - do not palpate for pelvic mass as this can increase risk of rupture 3. Transvaginal US is gold standard tool for diagnosing ectopic surgery 4. transvaginal scans, serial hCG levels and laparoscopy can be used used to distinguish between normal intrauterine pregnancy, ectopic, miscarriage and a molar pregnancy 5. serum progesterone can be used to evaluate pregnancy visibility

Question 232

how do you manage ectopic pregnancy?

Answer 232

depends on numerous factors: 1. is she haemodynamically stable? - are her vital signs normal? 2. site of implantation of ectopic pregnancy 3. risk of tubal rupture 4. serum hcG level see if its doubling every 2 days which is typical in normal pregnancies. 5. woman needs to understand the diagnosis and risk of ectopic pregnancies Expectant management - expects to be resolved naturally. no active management required option for a few women: PUL, minimal or no symptoms and are clinically stable. hcG should ideally be falling <1500 check every 48hrs until confirmed fall, then weekly when <15 IU medical management: methotrexate - kills ectopic must have insignificant pain, unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat hCG level less than 1500 IU/L surgery: salpingectomy or salpingotomy - performed laparoscopically or by open surgery first line for women unable to return for follow up after methotrexate treatment or have the following: significant pain adnexal mass of 35 mm or larger fetal heartbeat visible on US scan serum of hCG level of 5000 IU/L or more

Question 233

what is a pregnancy of unknown location (PUL)?

Answer 233

there is no sign intrauterine or ectopic pregnancy or retained products of conception in the presence of a positive pregnancy test or serum hCG >5 IU

Question 234

what is a miscarriage?

Answer 234

the spontaneous loss of a pregnancy before 24 weeks of gestation early miscarriage - occurs before 13 weeks of gestation late miscarriage - occurs between 13 and 24 weeks of gestation

Question 235

what is a complete miscarriage?

Answer 235

when all products of conception have been expelled from the uterus and bleeding has stopped

Question 236

what is an incomplete miscarriage?

Answer 236

diagnosed non viable pregnancy in which bleeding has begun but pregnancy tissue remains in the uterus

Question 237

what is a missed miscarriage?

Answer 237

aka delayed or silent miscarriage diagnosed with a non viable pregnancy is identified on US without bleeding or pain

Question 238

what is a threatened miscarriage?

Answer 238

diagnosed when there is vaginal bleeding in the presence of a viable pregnancy in the first 24 weeks of gestation

Question 239

what is an inevitable miscarriage?

Answer 239

diagnosed non viable pregnancy in which bleeding has begun and the cervical OS is open, but pregnancy tissue remains in the uterus. The pregnancy will proceed to incomplete or complete miscarriage

Question 240

what are the causes of miscarriage?

Answer 240

chromosomal abnormalities - most common cause of first trimester defects in development of the placenta or embryo 2. recurrent miscarriages no cause of recurrent miscarriage can be determined in 1/2 of couples endocrine cause infective cause genetic abnormalities

Question 241

what are risk factors for miscarriages?

Answer 241

maternal age number of previous miscarriages occupational and environmental factors - heavy metals, pesiticide, high dose radiation lifestyle factors - stress, smoking and obesity

Question 242

what are the symptoms of miscarriages?

Answer 242

symptoms of pregnancy (amenorrhea, breast tenderness) and vaginal bleeding in first 24 weeks of pregnancy ( brownish discharge to bright red bleeding) can also get lower abdominal cramping pain or lower backache

Question 243

how do you diagnose miscarriage?

Answer 243

look for symptoms of ectopic pregnancy confirm pregnancy with a urine pregnancy test

Question 244

what reproductive signs suggest a patient might have turner's syndrome?

Answer 244

raised FSH/LH in primary amenorrhoea

Question 245

what is premature ovarian failure

Answer 245

transient or permanent loss of ovarian function before the age of 40 FSH raised characterised by menstrual disturbance e.g. amenorrhoea or oligomenorrhoea

Question 246

what pain relief can you give in labour?

Answer 246

Pharmacological 1. Entonox - 50% nitrous oxide, 50% air - used in early labour 2. Opiates: pethididne or diamorphine Mum SE: nausea and vomiting Foetal SE: drowsy, neonatal respiratory distress 3. Epidural It is the most effective form of analgesia disadvantages: slows second stage of labour , increases risk of operational vaginal delivery (not c section tho) must check BP and IV SE: causes hypotension for mum can lead to bradycardia for foetus mum can't lie flat either as this will increase aortocaval compression 4.Spinal it is anaethetic of choice for c sections SE: similar to epidural 5. Pudendal nerve block need to push sacrospinous ligament to inject pudendal nerve commonly used during operative vaginal delivery

Question 247

what is the puerperium?

Answer 247

period of recovery and repair following delivery typically lasts 6 weeks and is associated with return of tissues to pre pregnant state

Question 248

when is the risk of VTE highest during pregnancy?

Answer 248

puerperium

Question 249

what is the commonest cause of puerperal pyrexia

Answer 249

endometritis

Question 250

what is an operative vaginal delivery?

Answer 250

use of an instrument to aid delivery

Question 251

what are the indications for operative vaginal delivery?

Answer 251

Maternal: prolonged 2nd stage exhaustion medical avoidance of pushing e.g. severe cardiac disease Fetal: suspected fetal distress for the after-coming head in a breech delivery

Question 252

What is the safety criteria for operative vaginal delivery?

Answer 252

1. consent for procedure 2. 1/5th or less head palpable per abdomen 3. membranes have ruptured + fully dilated cervix 4. exact position of head is known and no maternal tissues are caught before applying instrument

Question 253

what type of forceps are there for operative vaginal delivery?

Answer 253

low cavity forceps- are used for 'lift out' deliveries when head is on the perineum Mid cavity non rotational forceps - have a long shank, cephalic and pelvic curves and must only be used when the sagittal suture lies in the AP diameter mid cavity rotational forceps - have a reduced pelvic curve

Question 254

what is a ventouse (vacuum extraction)?

Answer 254

suction devise to suck fetal scalp tissues into a ventouse cup. baby must be >34 weeks gestation and no maternal coagulopathy less successful than forceps kiwi omnicup - most common type of ventouse

Question 255

what are the complications of forceps?

Answer 255

1. perineal trauma 2. facial bruising 3. temporal facial nerve palsy

Question 256

what are the complications of ventouse?

Answer 256

higher failure rate | cone head - chignon

Question 257

when do you abandon operative vaginal delivery?

Answer 257

No descent with each subsequent pull delivery not imminent after 3 pulls when instrument is correctly applied proceeding to emergency LSCS

Question 258

what is a caesarean section (C section)?

Answer 258

delivery of a foetus through an incision in the abdominal wall and uterus

Question 259

what are the 4 main categories of c section

Answer 259

1: immediate threat to life of woman or baby 2: no immediate threat to life or baby 3: requires early delivery 4: delivery at a time that suits the woman and maternal services

Question 260

what are the indications for caesarean sections

Answer 260

1. repeat Cs 2. fetal compromise such as fetal bradycardia 3. failure to progress in labour 4. malpresentation 5. placenta praevia

Question 261

what types of caesarean sections are there?

Answer 261

Lower uterine segment incision: straight incision 3 cm above symphysis pubis with blunt dissection thereafter is recommended 2. Classical Cs- vertical incision on uterus with either transverse or vertical skin incision classical rarely used indications for classical: very premature fetus fetus lies transverse with ruptured membranes

Question 262

what are the complications of Cs?

Answer 262

intra operative: haemorrhage hysterectomy damage to surrounding organs such as bladder and bowel post -operative: VTE infection delayed recovery and longer stay in hospital

Question 263

What is pre labour rupture of membranes?

Answer 263

any situation in which there is a rupture of membranes before 37 weeks gestation

Question 264

what are the causes of pre labour rupture of membranes?

Answer 264

Lower genital tract infection

Question 265

how do you manage pre labour rupture of membranes?

Answer 265

sterile speculum exam performed (look for pooling of amniotic fluid ) but avoid digital exam if negative than do USS for oligohydroaminos if pre term steroids given antenatally active management: induce labour oral erythromycin for 10 days

Question 266

what would the failure to progress in first stage of labour be classed as?

Answer 266

longer than 3-8 hour to get to 4cm dilated

Question 267

what is primary arrest?

Answer 267

poor progress in active phase of stage 1 with this is being defined as <2cm dilation after 4 hrs

Question 268

what is secondary arrest?

Answer 268

poor progress of labour after reaching 7cm dilation

Question 269

what is failure in second stage classed as?

Answer 269

with epidural: primiparous - describing a woman who has been pregnant and given birth once (>3 hrs) multiparous - >2 hrs without epidural primiparous >2 hrs multiparous >1 hours

Question 270

what are the causes of failure to progress?

Answer 270

1. weak irregular contractions | 2. cephalo- pelvic disproportion - disproportion between the foetal head and maternal pelvis

Question 271

how do you manage failure to progress?

Answer 271

determine the reason for failure to progress management employed will depend on exact cause: 1.poor contractions examine every 2 hours offer artificial rupture of membranes, if spontaneous hasn't occurred - vaginal prostaglandins commence CTG and syntocinin infusion 2. malposition usually operative vaginal, depending on how far the baby has descended can't perform an operative vaginal if the head isn't at station yet

Question 272

what is fetal distress?

Answer 272

compromise of the fetus due to inadequate oxygen or nutrient supply. indicates fetal hypoxia

Question 273

what are the causes of fetal distress?

Answer 273

uteroplacental insufficiency

Question 274

what are the risk factors of fetal distress?

Answer 274

Stillbirth. Intrauterine growth restriction (IUGR). Oligohydramnios or polyhydramnios. Multiple pregnancy. Rhesus sensitisation. Hypertension. Obesity. Smoking. Diabetes and other chronic diseases. Pre-eclampsia or pregnancy-induced hypertension. Decreased fetal movements. Recurrent antepartum haemorrhage. Post-term pregnancy.

Question 275

what are the clinical features of fetal distress?

Answer 275

decreased fetal movements muconeum stained - thick, green and due to baby passing bowel movement CTG: shows the fetal heart rate response to fetal movement and to maternal contractions commence CTG if: maternal request meconium stained liquor abnormal heart rate on intermittent auscultation Augmentation of labour with syntocinin reduced foetal movements felt results on CTG which suggest fetal distress: bradycardia, loss of variability, late deceleration. (do foetal sampling)

Question 276

How do you manage fetal distress?

Answer 276

Sit mother up IV fluids stop syntoconin Take fetal blood sample can give terbutaline and plan for operative delivery Fetal blood sample- taken from scalp pH >7.25 is normal pH 7.-7.25 pH <7.25 - acidotic - immediate delivery required

Question 277

what is a cord prolapse?

Answer 277

hen an unborn baby's umbilical cord slips through the cervix and into the vagina after a mother's water breaks and before the baby descends into the birth canal. It is an emergency because cord compression and vasospasm from exposure of the cord causes foetal asphyxia

Question 278

what are the risk factors of cord prolapse?

Answer 278

prematurity polyhydraminos multiple pregnancies congenital abnormalities

Question 279

what are the clinical features of cord prolapse?

Answer 279

fetal distress following rupture of membranes pulsatile mass seen on vaginal examination cord descends ahead of the foetus if untouched will lead to foetal asphyxia (death)

Question 280

how do you manage cord prolapse?

Answer 280

cord prolapse is an obstetric emergency the presenting part of the fetus may be pushed back into the uterus to avoid compression if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm the patient is asked to go on 'all fours' until preparations for an immediate caesarian section the left lateral position is an alternative tocolytics may be used to reduce uterine contractions retrofilling the bladder with 500-700ml of saline may be helpful

Question 281

what is shoulder dystocia?

Answer 281

a delivery requiring additional obstetric manoeuvres as the shoulders get stuck and are unable to be delivered following delivery of the head

Question 282

what are the risk factors of the shoulder dystocia?

Answer 282

macrosomia - a newborn with an excessive birth weight postdate delivery increased maternal BMI poorly controlled diabetes assisted vaginal delivery

Question 283

how do you manage shoulder dystocia?

Answer 283

can die from asphyxia 1. HELP - get it 2. McRoberts position and manoeuvre (hyperflexed lithotomy) position: lie the bed flat and flex mother legs so that thighs are against the abdomen once in position delivery might occur on its own, but if not apply strong suprapubic pressure

Question 284

what are the complications of shoulder dystocia?

Answer 284

fetal asphyxiation and detah 3rd or 4th perineal tears post-partum haemorrhage brachial plexus injury: Erb Palsy (C5,6,7) arm is internally rotated with extension of the forearm and wrist with numbness down the lateral aspect of the arm Klumpkes palsy (C8-T1): loss of all function of the muscles of the hand, clawing of the fingers

Question 285

what is the pathophysiology amniotic fluid embolism?

Answer 285

usually occurs in the later stages of labour, has a high mortality rate unknown reasons, when amniotic fluid enters the maternal circulation it triggers: cardiopulmonary compromise severe disseminated intravascular coagulation

Question 286

what are the risk factors of amniotic fluid embolism?

Answer 286

multiple pregnancy maternal age >35 years Cs instrumental delivery eclampsia

Question 287

what are the clinical features of amniotic fluid embolism?

Answer 287

Dyspnoea chest pain hypotension fetal distress seizures reduced conscious level cardiac arrest feeling cold majority of women get Disseminated intravascular coagulation (DIC)

Question 288

how do you manage amniotic fluid embolism?

Answer 288

supportive care in ITU majority of women die if they get this. most happen in the first hour

Question 289

what are the clinical features of uterine rupture?

Answer 289

most common in VBAC (vaginal birth after cesarean) will be associated with loss of engagement, fetal distress and maternal shock

Question 290

how do you manage uterine rupture?

Answer 290

emergency laparotomy get the baby out asap!!!!

Question 291

what are the 4 classes of tears in labour?

Answer 291

1st degree - injury to perineal skin only 2nd degree - injury to perineal muscle and skin 3rd degree - injury to the perineal muscle, skin and anal sphincter 4th degree - injury to the perineal muscle, skin and anal sphincters and rectal mucosa

Question 292

how do you manage tears in labour?

Answer 292

analgesia: pudendal nerve block of no epidural 1-3 degree - stitch up 4th degree - requires repair under GA by a surgeon

Question 293

what are the complications of tears in labour?

Answer 293

Urinary incontinence pelvic organ prolapse fecal incontinence - if 3rd or 4th degree

Question 294

what is an episiotomy?

Answer 294

surgical postero-lateral incision through the skin and perineal muscles that is made from the vagina to the ischio-anal fossa

Question 295

why is an epiostomy carried out?

Answer 295

widen the birth canal reduce the risk of 3rd and 4th tears

Question 296

how do you manage episiostomy?

Answer 296

should be stitched up after delivery women should be given: laxative antibioitcs sufficient analgesia

Question 297

what is the normal term for pregnancy?

Answer 297

delivery from 37-42 +0 weeks

Question 298

what is classed as a post term pregnancy?

Answer 298

delivery after 42 completed weeks

Question 299

what is classed as pre term pregnancy?

Answer 299

moderate to late - 32-37 weeks very - 28-31 + 6 weeks extremely - before 28 weeks

Question 300

what are the risk factors of pre term labours?

Answer 300

IVF UGR acute illness: UTI, chest infection multiple pregnancies uterine abnormalities maternal disease: hypertension, diabetes

Question 301

what are the causes of pre term labour?

Answer 301

uterine infection cervical insufficiency preterm prelabour rupture of membranes

Question 302

how do you manage preterm labour?

Answer 302

1.assess risk of delivery: majority of women who present with threatened preterm labour do not delivery involves carrying out a fetal fibronectin test 2. if preterm prelabour rupture of membranes: cover with antibiotics (erythromycin) 3. deliberate delaying of delivery give nifedipine surgery - cervical closure with Mcdonald suture 4. preparing for delivery of premature baby continue fetal monitoring dexamethasone - 2 doses, 12 hours apart - helps to promote maturity of the lungs by stimulating surfactant production magnesium sulphate : given in established labour given to provide baby with neuroprotection give calcium gluconate for magnesium sulphate induced respiratory depression

Question 303

what is placental retention

Answer 303

a placenta which has not been completely passed within 30 minute of active management of 3rd stage within 60 minutes of active management of 3rd stage

Question 304

what are the causes of placental retention

Answer 304

pre term delivery induced labour maternal age >35 parity >5 placenta accreta: condition which the placenta embeds into the myometrium due to defective decidua basalis (bottom layer of placenta)

Question 305

how do you manage placental retention?

Answer 305

active management of 3rd stage: Injection of oxytocin and cord is clamped and cut between 1 and 5 minutes after the birth The placenta is pulled out by the midwife once it has separated from the wall of the uterus if this doesn't work: manual evacuation under anaesthesia - place mother lithotomy position managing placenta accreta: section +/- hysterectomy post-delivery contraception

Question 306

what are the definitions of post- partum haemorrhage?

Answer 306

defined as blood loss of > 500mls and may be primary or secondary primary occurs within 24 hrs secondary occurs within 24 hrs -12 weeks after delivery

Question 307

what are the risk factors for post-partum haemorrhage?

Answer 307

previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)

Question 308

what are the causes of post-partum haemorrhage?

Answer 308

4 T's Tone - uterine atony (uterus lacks tone so won't contract) - most common (90%) Trauma - perineal damage, rarely uterine rupture Tissue - retained placenta (placenta accreta) Thrombin - DIC (Disseminated intravascular coagulation) due to eclampsia, shock, amniotic fluid or abruption

Question 309

compare the different causes of PPH and the condition of the uterus and different clinical features.

Answer 309

main examples: Uterine atony (most common cause) - vaginal bleeding after the placenta has passed - soft uterus uterine rupture - severe abdominal pain, vaginal bleeding - painful uterus on palpation retained placenta - vaginal bleeding with incomplete passage of the placenta - soft or contracted uterus

Question 310

how do you manage PPH?

Answer 310

1.ABCDE: cross match - 4 litres including two peripheral cannulae, 14 gauge bimanual uterine massage IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms IM carboprost fluid resuscitation ( 3 litres) medical option fails: to control the bleeding then surgical options will need to be urgently considered intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Question 311

what blood tests can you carry out for fetal anomaly

Answer 311

Combined tests: main choice uses NT + free hCG + pregnancy associated plasma protein (PAPP-A) + woman's age achieves high detection rate for: Down's syndrome(Tri 21) - learning disabilities, characteristic appearance, cardiac abnormalities Edwards syndrome (Tri 18) - small chin, low set ears, rocker bottom feet Patau syndrome (Tri 13) - microcephaly, holoprosencephaly, exomphalos and cleft lip intergrated test: better than combined but too expensive uses NT+ PAPP-A in the 1st trim + quadruple test Quadruple test: blood test at 16 weeks using a dating scan plus alpha fetoprotein

Question 312

what would down's syndrome levels be with the following: hCG Inhibin A AFP PAPPA estriol

Answer 312

high: hCG, Inhibin A low: PAPPA AFP Estriol

Question 313

would twins have a high AFP levels or low levels?

Answer 313

High

Question 314

when is genetic testing offered?

Answer 314

family history of genetic condition downs screen comes back high risk

Question 315

name two types of invasive testing and reasons for their advantages.

Answer 315

1. Chorionic villus sampling US guided sampling of the placenta taken 10-13 weeks advantages: allows earliest diagnosis of chromosomal abnormality 2. Amniocentesis aspiration of fluid containing fetal cell from skin and gut 16 weeks onwards best for downs advantages: diagnose fetal infections such as CMV safer as miscarriage is lower

Question 316

what genetic tests can you carry out?

Answer 316

targeted gene - FISH whole genome - array CGH

Question 317

what are the two types of intra uterine growth restriction (IUGR)?

Answer 317

1. symmetrical - head and abdominal cirrcumference is small - suggest baby has grown less well than expected throughout pregnancy 2. asymmetrical - head circumference is normal but abdominal circumference is small. suggests reduction in has occurred in later pregnancy - due to placental insufficiency 2. asymmetrical -

Question 318

what is intra uterine growth reduction?

Answer 318

corrected birth weight is less than the 10th centile

Question 319

what are the clinical features of IUGR?

Answer 319

smaller than expected fundal height reduced fetal movements

Question 320

what are the causes of IUGR?

Answer 320

1.Maternal related lack of nutrition lifestyle: alcohol beta blockers 2.fetal related: multiple pregnancies congenital 3.Utero placental related pre eclampsia placental insufficiency

Question 321

what are the complications of IUGR?

Answer 321

still birth pre term labour

Question 322

how do you manage IUGR?

Answer 322

serial growth charts increase monitoring address modifiable risk factors

Question 323

what is large for date foetus?

Answer 323

symphysial fundal height > 2cm than expected for date

Question 324

what are the causes of large for date foetus?

Answer 324

diabetes polyhydramnios multiple pregnancies constitutionally large

Question 325

what types of twins are there based on zygosity.

Answer 325

dizygotic twins: 2 cells will be dichorionic and diamniotic (non identical twins) - 2 separate placentas, 2 separate amniotic sacs monozygotic twins: 1. diachronic diamniotic -2 separate placentas, 2 separate amniotic sacs 2. monochorionic diamniotic - most common - 1 placenta 2 sacs 3. monochorionic monoamniotic - 1 sac ,1 placenta (rarest)

Question 326

what is polyhydramnios?

Answer 326

excessive amount of amniotic fluid (>1500 ml, >8cm)

Question 327

what are the main causes of polyhydraminos?

Answer 327

twins diabetes hydrops fetalis

Question 328

what are the clinical features of polyhydraminos?

Answer 328

SOB abdominal discomfort feels like she is going to 'burst'

Question 329

what are the complication of polyhydraminos?

Answer 329

preterm labour cord prolapse premature rupture of membranes

Question 330

how do you manage polyhydraminos?

Answer 330

address and treat modifiable risk causes US to confirm diagnosis and asses fetal wellbeing increase monitoring throughout pregnancy

Question 331

what is oligohydraminos?

Answer 331

inadequate amount of amniotic fluid (<500 ml at 32-36 weeks)

Question 332

what are the causesoligohydraminos?

Answer 332

IUGR Renal ageneiss preclampsia

Question 333

how do you manage oligohydramnios?

Answer 333

address and treat modifiable risk causes US to confirm diagnosis and asses fetal wellbeing increase monitoring throughout pregnancy

Question 334

what is potters syndrome?

Answer 334

characteristic changes in foetuses due to oligohydramnios club feet pulmonary hypoplasia potters sequence - flat nose, recessed chin, low set ears

Question 335

what is rhesus haemolytic disease?

Answer 335

When a mother is Rh negative (no antigen expressed) and the baby is Rh positive (antign expressed) Rhesus antigen is an antigen on red blood cells IgM is produced first and DOESN'T cross the Placenta first pregnancy is not affected IgG will eventually be produced and DOES cross the placenta and will damage any future pregnancies by breaking down any fetal RBC will lead to: progressive anaemia cardiac failure hepato-splenomegaly fetal death

Question 336

how do you prevent rhesus haemolytic disease?

Answer 336

anti D at 28 and 34 weeks to negative mothers

Question 337

how do you diagnose rhesus haemolytic disease?

Answer 337

kleihauer: positive if fetal and maternal blood has mixed. also used to test if enough anti D has been given indirect coombs: tells you whether the mum is sensitised or not positive - sensitised negative - not Anti D cannot be used if mother is coombs positive anti D only given if: mother Rh negative Baby Rh positive mother is coombs negative

Question 338

how do you manage of fetus with rhesus haemolytic disease?

Answer 338

depend on the severity of disease and the gestation if still viable: fetal blood transfusion delivery if appropriate gestation assess well being via US

Question 339

what effect do teratogenic drugs have on babies?

Answer 339

1st trimester impacts foetal organ development 2nd and 3rd will affect growth and can cause intellectual/ behavioural abnormalities

Question 340

when can folic acid and multivitamins be taken in pregnancy?

Answer 340

3 months pre conception duration of first trimester

Question 341

Which vitamin will need supplementation during pregnancy?

Answer 341

D

Question 342

give examples of teratogenic drugs?

Answer 342

ACE I/ARB Androgens Lithium- cardiac abnormalities retinoid - used in abortion - causes ear cardiac and skeletal defects warfarin

Question 343

what drugs are safe in pregnancy?

Answer 343

Heparin methyldopa cyclizine paracetamolantacids nitrofurantoin

Question 344

what is hyperemesis gravidarum

Answer 344

the extreme form of 'nausea and vomiting of pregnancy' (NVP)

Question 345

what are the association of hyperemesis graviadum?

Answer 345

high hCG levels Increased placental mass First pregnancy History of hyperemesis gravidarum in a previous pregnancy multiple pregnancy (twins) H pylori infeciton - nausea and vomiting of pregnancy related

Question 346

when do you refer a patient with nausea and vomiting of pregnancy?

Answer 346

Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

Question 347

what is the triad of diagnosis for hyperemesis graviadum?

Answer 347

5% pre-pregnancy weight loss dehydration electrolyte imbalance

Question 348

what are the clinical features of hyperemesis gravidarum?

Answer 348

nausea vomiting loss of weight inability to tolerate food and drink

Question 349

how do you diagnose hyperemesis gravidarum?

Answer 349

Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP. FBC,ketones and UTI raised beta hCG triad: 5% pre-pregnancy weight loss dehydration electrolyte imbalance

Question 350

what are the consequences of hyperemesis gravidarum?

Answer 350

``` Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth ```

Question 351

how do you manage hyperemesis gravidarum?

Answer 351

antihistamines should be used first-line oral cyclizine or oral promethazine oral prochlorperazine is an alternative ondansetron and metoclopramide may be used second-line metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. if ondanestron is used then these risks should be discussed with the pregnant woman admission may be needed for IV hydration

Question 352

what happens to blood pressure in normal pregnancy?

Answer 352

BP falls in 1st half of pregnancy (up to 24 weeks) usually increases to pre-pregnancy levels by end

Question 353

what is the definition of hypertension in pregnancy?

Answer 353

140 mm Hg- systole 90 mm Hg - diastole

Question 354

what are the 3 categories of hypertension in pregnancy are there?

Answer 354

1. pre existing (chronic) - women who have a history of hypertension before or an elevated BP (>140/90) before 20 weeks gestation 2. Pregnancy induced hypertension (PIH) - hypertension in the second half of pregnancy 3. pre-eclampsia - hypertension in association with proteinuria ( >0.3g/24 hrs)

Question 355

compare the clinical features of the different types of hypertension associated with pregnancy?

Answer 355

chronic - no proteinuria no oedema, more common with older women. PIH - no proteinuria, no oedema. Resolves following birth (1 month roughly). they are at risk of developing pre eclampsia or hypertension later in life Pre eclampsia -Proteinuria, or renal insufficiency ( creatinine 90 micromol/litre), Liver involvement (elevated transaminases) , Neurological complications (eclampsia, altered mental status), Haematological complications ( thrombocytopenia) , Uteroplacental dysfunction (fetal growth restriction)

Question 356

how do you manage hypertension in pregnancy?

Answer 356

pre existing: stop ACE I/ ARB prior to conception Do not rush to start medication as BP which will naturally decrease in pregnancy Refer to specialist to increase antenatal care to optimise drug management and to monitor fetal wellbeing women who are high risk of pre eclampsia: Ensure that aspirin 75—150 mg daily is prescribed from 12 weeks' gestation until birth dip stick for proteinuria or urine protein/creatine ratio to rule out pre eclampsia Drug medication: Give anti hypertensives you can breast feed with all of these methyldopa labetolol Nifedipine SR Hydralazine avoid diuretics/ ACE inhibitors

Question 357

what would be classed as a hyperintensive emergency for pregnant women?

Answer 357

>160/110

Question 358

what is pre-eclampsia?

Answer 358

emergence of high BP during pregnancy that may be a precursor to developing eclampsia new onset blood pressure >140/90 mmHg after 20 weeks of pregnancy and 1 or more of the following: proteinuria other organ renal involvement - renal insufficiency ( creatinine 90 micromol/litre), Liver involvement (elevated transaminases) , Neurological complications (eclampsia, altered mental status), Haematological complications ( thrombocytopenia) , Uteroplacental dysfunction (fetal growth restriction)

Question 359

what are the risk factors of pre -clampsia?

Answer 359

high risk: previous severe or early onset pre eclampsia chronic hypertension or hypertension in previous pregnancy CKD diabetes mellitus SLE moderate risk: 1st pregnancy >40 year old BMI >35 Kg/m2 family history of pre-eclampsia

Question 360

what are the classically features of pre -eclampsia?

Answer 360

proteinuria oedema new onset hypertension features of severe pre-eclampsia: headache flashing lights HELLP: haemolysis , elevated LFT, Low platelets HELLP presents with: epigastric or RUQ pain N+V lethargy Eclampsia: tonic clonic seizures due to pre-eclampsia

Question 361

how do you diagnose Pre eclampsia?

Answer 361

hypertension >140/90 mm Hg and urine PCR >0.3 mg/dL proteinuria if absent proteinuria look for: Thrombocytopenia (platelets <100 x109/l) serum creatinine >88μmol/L elevated transaminases TESTS: dip stick and pcr for proteinuria BP - for hypertension Bloods: FBC ( anaemia and thrombocytopenia) , LFT and coagulation Fetal wellbeing: US (include umbilical artery dopplers)

Question 362

how do you manage pre-clampsia

Answer 362

emergency secondary care assessment for any woman in whom-pre eclampsia is suspected women with blood pressure >160/110 mmHg will be observed further management: oral labetalol first line give nifedipine if asthmatic

Question 363

what are the effects of pre eclampsia?

Answer 363

plasma volume decrease peripheral erisstance increase placental ischaemia

Question 364

what are the severe complications of pre- eclampsia?

Answer 364

eclampsia HELLP cerebral haemorrhage IUGR renal failure placental abruption

Question 365

what is post maturity (prolonged pregnancy)?

Answer 365

pregnancy exceeding 42 completed weeks

Question 366

what are the problems associated with postmaturity?

Answer 366

intrapartum deaths 4 times more common early neotnatal deaths 3 times more common increased rates of induction of labour placental insufficiency macrosomia fetal skull more ossified so less mouldable increased fetal distress in labour

Question 367

what are the reasons for home birth?

Answer 367

woman feels more relaxed at home fear of hospitals continuity with a named midwife

Question 368

is maternal mortality effected by home birth?

Answer 368

no stays same however perinatal mortality is slightly increased

Question 369

what types of diabetes do pregnant women get?

Answer 369

Gestational diabetes - 87% of cases Type 1 -7% of cases Type 2- 5% of cases

Question 370

what is gestational diabetes?

Answer 370

a condition characterized by an elevated level of glucose in the blood during pregnancy, typically resolving after the birth. diagnostic criteria fasting glucose >5.6 mmol/L or OGTT glucose >7.8 mmol/L

Question 371

what are the risk factors of gestational diabetes?

Answer 371

BMI of >30 Kg/M2 Previous macrosomic baby weighing 4.5 Kg or above previous gestational diabetes first degree- relatives with diabetes family origin with a high prevalence of diabetes (south asian and middle eastern)

Question 372

what is the management of gestational diabetes?

Answer 372

1. refer to joint diabetes and antenatal clinic within a week 2. teach women taught about self-monitoring of blood glucose 3. advise about diet 4. screening for gestational diabetes fasting glucose >5.6 mmol/L or OGTT glucose >7.8 mmol/L -diagnostic test of choice for gestational diabetes 5.if fasting glucose is <7 mmol/l then you can: trial and diet exercise if glucose target isn't reached after 1-2 weeks then give metformin 6. If fast glucose is >7mmol/l then: no exercise and diet give insulin straightaway 7. if fasting glucose is between 6-6.9 mmol/l there is evidence of macrosomia or hydraminos: offer insulin 8. give glibenclamide if they can't tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Question 373

what should pregnant women with previous gestational diabetes should be offered at 24-28 weeks?

Answer 373

OGTT -

Question 374

how do you manage pre-existing diabetes?

Answer 374

weight loss for women with BMI >27 stop oral hypoglycaemic agents - apart from metformin and commence insulin folic acid 5mg/day to 12 weeks gestation anomaly scan at 20 weeks include 4 chamber view of heart tight glycaemic control treat retinopathy

Question 375

what effect has hypothyroidism on pregnancy?

Answer 375

minimal effect on pregnancy however it is associated with: infertility oligomenrrhoea menorrhagia increased rate of miscarriage

Question 376

how do you manage hypothyroid?

Answer 376

dose of thyroxine may need to increase it (up to 50% as early as 4-6 weeks of pregnancy) thyroxine is safe in pregnancy and breastfeeding

Question 377

what effect has hyperthyroidism on pregnancy?

Answer 377

typically worst in first trimester and then improves in the second and third

Question 378

what are the impacts of hyperthyroidism if untreated?

Answer 378

Recurrent miscarriage preterm delivery IUGR

Question 379

how do you manage hyperthyroidism in pregnancy?

Answer 379

PTU (transient propylthiouracil) or carbimazole. PTU preferred PTU crosses placenta less and is used in newly diagnosed thyrotoxicosis in pregnancy

Question 380

how do you manage epilepsy in pregnancy?

Answer 380

preconcepton: 1. optimise treatment aim for seizure control on lowest dose - monotherapy 2. folic acid 5mg for >3 months prior to conception. keep giving until end of 1st trimester Risks of uncontrolled epilepsy outweigh risks of medication to the foetus: 1. aim for monotherapy 2. carbamazepine - often considered the least teratogenic of the older antiepileptics 3. Phenytoin - associated with cleft lip palate. take vitamin K last month of pregnancy 4. Iamotrigine - may need to increase dose in pregnancy 5. sodium valproate - only give if you have to. significant risk f neurodevelopment in children

Question 381

when are pregnant women screened for anaemia?

Answer 381

8-10 weeks 28 weeks

Question 382

when would you prescribe oral ferrous sulfate or ferrous fumarate in pregnant women for anaemia?

Answer 382

first trimester: <100g/L 2nd/3rd <105 g/L post partum <100 g/L

Question 383

when is a VTE at its highest risk in pregnant women?

Answer 383

puerperium period

Question 384

what are the risk factors for pregnant women in developing a VTE?

Answer 384

1. age 2. parity >3 3. c section 4. pre eclampsia 5. prolonged labour 6. OHS

Question 385

what are the clinical features of VTE in pregnant women?

Answer 385

DVT - leg swelling (left leg more likely), pain, redness, oedema, tenderness Pulmonary embolism (PE)- SOB, chest pain, haemoptysis, Raised JVP

Question 386

how do you diagnose VTE?

Answer 386

FBC U&E LFTs 2. DVT - doppler US 3. PE: 1st line: CXR and ECG 2nd: VQ, CTPA D-DIMER limited use in pregnancy as usually raised anyway

Question 387

how do you manage VTE in pregnancy?

Answer 387

warfarin contraindicated S/C LMWH preferred to IV heparin (less bleeding)

Question 388

when would cholestasis of pregnancy present?

Answer 388

3rd trimester

Question 389

what are the clinical features of Cholestasis in pregnancy?

Answer 389

intense itch- palms and soles biochem - raised bilirubin (jaundice)

Question 390

how do you manage cholestasis in pregnancy?

Answer 390

ureseodeoxycholic acid fo ritch regular check of LFT vitamin K pre and post birth to reduce change of haemorrhagic disease of new born induction of labour 37-38 weeks in

Question 391

which SSRI can you prescribe in pregnancy?

Answer 391

setraline remember aim for monotherapy at the lowest dose

Question 392

what is parovirus B19?

Answer 392

DNA virus spread by respiratory droplets with 4-20 day incubation

Question 393

what are the clinical features of parovirus?

Answer 393

child: slapped cheek rash maculopapular rash fever arthralgia parents: 50% of adults are asymptomatic. little consequence on mum if she has it unless she is immunocompromised

Question 394

how do you diagnose parovirus B19?

Answer 394

Parvovirus B19-specific immunoglobulin M (IgM)- (PCR) analysis IgG titres increase - antenatal booking blood samples. results: Positive for IgG and negative for IgM - women has past but not recent parovirus - immune Negative for both IgG and IgM, she is susceptible to infection. repeat blood test if negative again she hasn't been infected yet. Positive for IgM and negative for IgG, repeat a blood test immediately positive IgM suggest recent infection

Question 395

how do you manage parovirus B19 in pregnant women?

Answer 395

Serial fetal ultrasound scans and Doppler assessment to detect fetal anaemia, heart failure, and hydrops. If there is suspected fetal hydrops, options include: Parvovirus B19 viral DNA detection in amniotic fluid. Fetal blood sampling and intrauterine red blood cell transfusion, which may reduce the fetal mortality rate.

Question 396

what are the complication of parovirus B19 in foetuses?

Answer 396

cardiac failure fetal hydrops - severe swelling (oedema) 10% of foetus infected at <20 weeks die

Question 397

what is antepartum haemorrhage?

Answer 397

vaginal bleeding after 24 weeks prior to delivery of the fetus

Question 398

what are the causes of antepartum haemorrhage?

Answer 398

placental abruption placenta praevia vasa praevia lower genital tract causes: cervical polyps erosions and carcinoma vaginitis

Question 399

what history would you ask for with suspected APH?

Answer 399

1. gestation 2. bleeding When did it start? what were you doing when it started? colour of blood? how mych lost? how long did it last? any clots? has this happened in other pregnancies? 3. associated breaking of water, dizziness? abdominal pain, vomiting? urinary frequency? 4. current pregnancy? could you feel the baby move before bleed? any changes in fetal movements? how has the pregnancy been beside this? what antenatal appointments have you had? what did they say in the appointments? 5. past obstetric is this your first pregnancy? when and how did you deliver your last one? 6. general blood group? when was your last smear? lifestyle - smoking n.b. ask about domestic abuse as well

Question 400

how do you diagnose and investigate Antepartum haemorrhage?

Answer 400

Maternal: vital signs - look for shock pregnant abdomen exam speculum and then PV - only do PV when placenta praevia is ruled out (US) Fetal: assess for well being Doppler CTG investigations: FBC, coagulation, Kleihouer (blood test used to measure amount of fetal haemoglobin transferred from a fetus to a mother's bloodstream) imaging: Pelvic US either abdominal or transvaginal

Question 401

what is a placental abruption?

Answer 401

part of the placenta becomes detached the uterus outcome depends on the amount of blood loss and degree of separation

Question 402

what is placenta praevia?

Answer 402

when the placenta partially or completely implants in the lower segment of the uterus

Question 403

what types of placenta praevia are there?

Answer 403

minor: does not reach the internal os (opening of the uterus) major: either partially or completely covers the os

Question 404

what are the associated factors of placenta praevia?

Answer 404

multiparity multiple pregnancy embryos more likely to implant on a lower segment scar from previous caesarean section fibroids endometriosis

Question 405

what are the clinical features of placenta praevia?

Answer 405

shock in proportion to visible loss no pain uterus not tender lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large

Question 406

how do you diagnose placenta praevia?

Answer 406

often picked up on 20 weeks abdominal US Transvaginal US is superior to abdominal US however Repeat scan at 32 weeks if major praevia repeat scan at 36 weeks if minor

Question 407

how do you manage placenta praevia?

Answer 407

1.if low lying 20 week scan: Repeat scan at 32 weeks if major praevia repeat scan at 36 weeks if minor 2.final US: 36 -37 weeks to determine the method of delivery elective caesarean sections III/IV between 37-38 weeks if grade I then a trial of vaginal delivery may be offered known placenta praevia goes into labour prior to the elective CS than emergency should be performed due to risk of post-partum haemorrhage 3.Placenta praevia with bleeding admit ABC to stabilise the woman if not able to stabilise - emergency CS if in labour or term reached - emergency CS 4.Prognosis: death is now extremely rare

Question 408

what are the associated factors of placental abruption?

Answer 408

1. Proteinuric hypertension 2. cocaine 3. Multiparity 4. maternal trauma 5. increasing maternal age 6. pre eclampsia 7. DIC

Question 409

what are the clinical features placental abruption?

Answer 409

1. shock out of keeping with visible loss 2. pain constant 3. tender, tense uterus 4. normal lie and presentation 5. fetal heart: absent/distressed 6. coagulation problems

Question 410

how do you manage placental abruption?

Answer 410

Fetus alive and <36 weeks 1. fetal distress: immediate caesarean 2. no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetal alive >36 weeks 1. fetal distress: immediate caesarean 2. no fetal distress: deliver vaginally fetus dead: induce vaginal delivery

Question 411

what are the complications of placental abruption?

Answer 411

maternal: Shock DIC renal failure PPH Fetal: IUGR hypoxia death

Question 412

what is vasa previa?

Answer 412

when the fetal blood vessels develop within the membrane when the membranes rupture the fetal vessels will too resulting in catastrophic bleed and rapid onset of fetal distress and death

Question 413

what are the clinical features of vasa previa?

Answer 413

sudden painless vaginal bleeding following rupture of membranes

Question 414

how do you diagnose vasa previa?

Answer 414

diagnostic: Pelvic ultrasound CTG: fetal distress

Question 415

How do you manage Vasa previa?

Answer 415

if diagnosed pre labour: plan section before term if diagnosed ROM: emergency section

Question 416

what is a placenta accreta?

Answer 416

attachment of the placenta to the myometrium due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of PPH

Question 417

what 3 types of placenta accreta are there?

Answer 417

accreta: chorionic villi attach to myometrium inceta: chorionic villi invade into the myometrium percreta: chorionic villi invade through the perimetrium

Question 418

what is the main cause of early onset infection in neonates?

Answer 418

Group B streptococcus - benzylpenicillin is antibiotic of choice

Question 419

how do you manage reduced fetal heartbeat by gestation?

Answer 419

past 28 weeks handheld Doppler is first step if no heart beat detected ultrasound should be offered immediately if heartbeat detected then use CTG to monitor it for the next 20 minutes between 24 and 28 weeks gestation a handheld Doppler should be used to confirm presence of fetal heartbeat. If below 24 weeks gestation fetal movements have previously been felt, a handheld Doppler should be used. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit

Question 420

what immunoglobulins would be raised in a mother recently infected with rubella?

Answer 420

IgM

Question 421

what is chicken pox caused by?

Answer 421

varicella-zoster virus

Question 422

what is the risk of chicken pox to mothers?

Answer 422

greater risk of pneumonitis

Question 423

what is the risk of chicken pox to foetus?

Answer 423

can develop Foetal varicella syndrome (FVS) risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation features of FVS include: skin scarring eye defects (microphthalmia) limb hypoplasia microcephaly learning disabilities

Question 424

what is the management of chicken pox exposure in pregnancy?

Answer 424

1. mum should be urgently checked for varicella antibodies - if she is unsure if she has been exposed before 2. if woman <20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible 3. if woman> 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Question 425

how do you manage chicken pox in pregnancy?

Answer 425

if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash if the woman is < 20 weeks the aciclovir should be 'considered with caution'

Question 426

what is Twin to twin transfusion syndrome (TTTS)

Answer 426

two fetuses share a single placenta, meaning that blood can flow between the twins. In TTTS, one fetus, the 'donor' receives a lesser share of the placenta's blood flow than the other twin, the 'recipient donor - become anaemic recipient - fluid overloaded severe cases can be fatal to one or both

Question 427

when do you scan for TTTS in twins?

Answer 427

thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition.

Question 428

what do you scan for after 24 weeks in twins?

Answer 428

fetal growth restriction.

Question 429

Which additional measure can aid the effectiveness of McRoberts manoeuvre?

Answer 429

suprapubic pressure.

Question 430

what are the clinical features of baby blues?

Answer 430

Mothers are characteristically anxious, tearful and irritable

Question 431

what are the clinical features of postpartum depression?

Answer 431

depression seen in other circumstances

Question 432

what are the clinical features?

Answer 432

severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Question 433

what would a bishop score <5 mean?

Answer 433

labour is unlikely to start without induction

Question 434

what would a bishop score >8 mean?

Answer 434

'favourable' - a high chance of spontaneous labour, or response to interventions made to induce labour

Question 435

how do you induce labour?

Answer 435

vaginal prostaglandin E2 (PGE2) - main choice Amniotomy with an amnio hook is only appropriate if the cervix is favourable for this intervention (it is ripe and slightly dilated) can give oxytocin along with it.

Question 436

what is a molar pregnancy (Hydatidiform mole)?

Answer 436

pre-cancerous form of gestational trophoblastic disease. non viable pregnancies. clinical features: vaginal bleeding in early pregnancy and a uterus which is large for dates. Ultrasound: appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as 'snow-storm' appearance). bloods: High beta hCG, low TSH, high thyroxine

Question 437

when does the uterus extend to the umbilicus?

Answer 437

20 weeks

Question 438

what are the indications for antibiotics in problems with breastfeeding? ii. what would be firstline?

Answer 438

infected nipple fissure symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk culture positive ii. flucloxacillin for 10-14 days or erythromycin or clarithromycin if penicillin allergic.

Question 439

what is Post partum Haemorrhage (PPH)?

Answer 439

defined as blood loss of > 500mls after giving birth

Question 440

what is the most common cause of PPH?

Answer 440

uterine atony

Question 441

how do you manage PPH?

Answer 441

ABC including two peripheral cannulae, 14 gauge IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms IM carboprost surgery: intrauterine balloon tamponade

Question 442

what are the clinical features of vulval carcinoma?

Answer 442

lump or ulcer on the labia majora inguinal lymphadenopathy may be associated with itching, irritation

Question 443

what is the most effective form of emergency contraception?

Answer 443

copper intra-uterine is 99% effective regardless of where it is used in the cycle criteria: inserted within 5 days of UPSI, or if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date

Question 444

how do you manage antiphospholipid syndrome in pregnancy?

Answer 444

aspirin + LMWH

Question 445

what are the clinical features of hydatidiform mole?

Answer 445

vaginal bleeding uterus greater than expected for gestational age abnormally high serum hCG snow storm appearance of mixed echogenicity

Question 446

what is vesicovaginal fistula associated with?

Answer 446

continuous dribbling incontinence after prolonged labour patient from an area with limited obstetric services.

Question 447

what is sheehan's syndrome?

Answer 447

post partum hypopituitarism reduction in function of pituitary gland due to hypovolaemic shock features: hypothyroidism problems with milk production amenhorrhea

Question 448

what is RMI index based on?

Answer 448

CA 125 menopausal status US findings

Question 449

Which of the following changes would you expect to see in a healthy pregnant patient as compared to before pregnancy? Increased serum haemoglobin Increased serum platelets Increased serum creatinine Decreased serum urea Decreased urine protein

Answer 449

decreased serum urea Normal laboratory findings in pregnancy: Reduced urea, reduced creatinine, increased urinary protein loss

Question 450

During a lower segment Caesarian section, what are the layers in between the skin and the fetus?

Answer 450

``` Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus ```

Question 451

what are causes of nipple discharge?

Answer 451

1. physiological 2. Galactorrhoea - commonest cause may be response to emotional events 3. hyperprolactinaemia - commonest type of pituitary tumour 4. mammary duct ectasia - commonest cause in menopausal women 5. carcinoma - often blood stained. palpable lump 6. intraductal papilloma - commoner in younger patients. no palpable lump

Question 452

what can mastitis develop into?

Answer 452

a breast abscess

Question 453

how do you manage mastitis?

Answer 453

flucloxacillin for 10-14 days. Breastfeeding or expressing should continue during treatment.

Question 454

how do you manage breast abscess?

Answer 454

incision and drainage.

Question 455

compare galactocele to breast abscess?

Answer 455

galactocele is usually painless, with no local or systemic signs of infection.