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MRCOG part 1 > CLINICAL MANAGEMENT > Flashcards

CLINICAL MANAGEMENT Flashcards

1
Q

How many pregnancies get shoulder dystocia

How many get erb’s palsy?

How many have lasting neurological damage?

A

0.65%

2-16%

<10%

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2
Q

How does the COCP work? Describe the effects on LH/FSH/SHBG/ovarian and adrenal androgens

A

suppresses LH AND FSH

Suppresses ovarian androgen secretion because LH is low

INCREASES SHBG release from liver which reduces circulating androgens

Suppresses adrenal androgens

Prevents conversion of testosterone to dihydrotestosterone which therefore cannot bind to androgen receptors

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3
Q

Which are the paraneoplastic bits of SCLC

A

SIADH

cushing’s

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4
Q

Which are the paraneoplastic bits of squamous cell lung cancer

A

hypercalaemia

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5
Q

Paraneoplastic - polycythemia - which cancer?

A

renal (EPO)
hepatocellular (alcoholics)

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6
Q

Which is better for images in hysteroscopy - saline or CO2

A

saline

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7
Q

What type of hysteroscope is used for outpatients?

A

2.7mm minihysteroscope

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8
Q

Analgesia for hysteroscopy?

A

NSAIDs 1 hour before.

NO OPIATES routinely

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9
Q

Which drug classes cause raised prolactin?

A

Opiates
Oestrogens
Antipsychotics
SSRI
H2 antagonists

ASHOO - if you sneeze you will get a raised prolactin

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10
Q

How does mifepristone work?

A

It is an anti-progestogen. It competes for progesterone receptors

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11
Q

What are the risk factors for bladder cancer?

A

SMOKING IS BIGGEST - 4x higher

SPOF

smoking
painter
obesity
family history

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12
Q

Treatment of chlamydia in pregnancy

A

erythromycin QDS 500mg 7/7

OR BD 500mg 14/7

amoxicillin 500mg TDS

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13
Q

Obstetric cholestasis:
How common in UK?
How common is itch?
Investigation?
Management?
Can cause?

A

0.7%

23%

LFTs - repeat weekly and 10 days postnatally

Tx - ursodeoxycholic acid

meconium, early delivery, neonatal distress, PPH
MEN-P

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14
Q

key to how methotrexate works

A

look for word folate!

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15
Q

What is this?

How many pregnancies get the this?

What is it due to?

What else can it cause?

A

3/4 pregnancies

melanocyte stimulating hormone from the placenta

melasma - darkening patches on the face

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16
Q

Stages of syphilis

A
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17
Q

Suture technique for OASIS repair of: anal mucosa, EAS, IAS

A

AM - PG3

EAS - end-to-end (ALL THE E’s) PDS or PG2

IAS - interrupted (ALL THE I’s) or mattress - inside your house PDS or PG2

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18
Q

What is PIGF and how is it interpreted

A

Placental growth factor.

If it is low in high risk pregnancies it indicates that preterm birth is imminent and there is a higher risk of pre-eclampsia and still birth

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19
Q

Management of hypertnesion in pregnancy.

Who is admitted?

What is moderate and what is severe and how are each managed?

What is the target BP?

What needs to be monitored?

A
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20
Q

Management of pre-eclampsia in pregnancy.

Who is admitted?

Who gets treated?

What is moderate and what is severe and how are each managed?

What is the target BP?

What needs to be monitored?

A

First column is moderate - BP <149/<109

Second column is severe >160/>110

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21
Q

What would prompt admission in pre-eclampsia

A

Renal - creatinine rise of >90
oedema - signs of pulmonary oedema
Liver - rise in ALT of >70 or twice upper limit
E - eclampsia - signs of this impending
Sustained BP >160
Fetal compromise
Platelets - fall <150

ROLES of Fetal Protection

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22
Q

Choice of antihypertensive for pregnant women

A

1st - labetalol
2nd - nifedipine
3rd - methyldopa

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23
Q

How do define pre-eclampsia

A

Hypertension - systolic>140 OR >90 diastolic

PLUS ONE OF

Renal - creatinine >90

Urine - protein:creatinine >30 mg/mmol or albumin:creatinine >8mg/mmol or 2+ protein in urine

B - blood. platelets <150, haemolysis

L - ALT >40

N - neuro - eclampsia, blindness, stroke

BURN - Like pre-eclampsia

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24
Q

What are 3 types of emergency contraception?

What is the drug content?

When can it be used?

Which is the most effective?

A

Levenorgestrel
- progesterone
- can be used up to 72h after intercourse
- give dose again if they vomit within 2 hours
- prevents ovulation/fertilisation

Ulipristal (ellaOne)
- progesterone receptor modulator
- up to 5 days
- give again if vomit in 3 hours
- works by inhibiting ovulation

IUD - copper coil
- most effective
- - can be given up to 120 hours after SI

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25
Q

Most common type of fibroid degeneration in prenant/non-prenant women?

A

PREGNANT = RED (pregnant women see red)

NON-PREGNANT = hyaline

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26
Q

What to do if a women who is hypertensive has +1 protein in urine on a stick

A

Organise protein:creatinine ratio OR albumin:creatining ratio

NOT 24h URINE ROUTINELY

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27
Q

What are the risks of complications in hysteroscopy: diagnostic vs therapeutic?

Risk of uterine perforation?

A

Risk of uterine perforation:
Diagnostic - 0.1%
Therapeutic - 0.8%

overall risk of serious complication for diagnostic = 0.2%

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28
Q

What is the key process causing cervical ripening

A

degredation of type 1 collagen

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29
Q

Describe the cervical Ca screening programme

Describe the pathway for the results following screening

A

25-49 = every 3 years
49-65 = every 5 years

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30
Q

When are women treated for CIN called back?

A

6 months

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31
Q

Are secondary sexual characteristics present in:

androgen resistance
turners

A

AR = YES

Turner’s = NO

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32
Q

Which vitamin deficiency leads to wernicke’s encephalopathy

A

B1

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33
Q

When is amniocentesis performed?

When is CVS performed?

What is it and what is CVS?

A

Amnio - No earlier than 15 weeks

Chorio - 11-13+6 weeks

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34
Q

COCP with lamotrigine?
Is this ok?

A

NO

COCP - specifically the oestrogen - can reduce lamotrigine levels and increase seizure risk

lamotrigine is NOT an enzyme inducer

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35
Q

Most common cause of abnormal vaginal discharge in women of childbearing age?

A

BV

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36
Q

Incidence of OASIS in primip/multip/overall?

A

PRIM = 6.1%

MULTI = 1.7%

OVERALL = 2.9%

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37
Q

What percentage of cervical cancers are due to HPV?

A

Almost 100%!

70% due to HPV 16/18

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38
Q

Most common age group for chlamydia?

A

20-24

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39
Q

What is the most common cause of sepsis in the pueperum?

What is the management?

What is the mortality rate of severe sepsis, septic shock?

A

Endometritis

Tazocin within 1 hour + sepsis 6

20-40%, 60%

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40
Q

Are unilateral ureter injuries noticed more intra-op or post-op ?

A

post-op = 70%

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41
Q

Describe the 3 groups of ovulation disorders

What are the management options for each?

A
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42
Q

What is the difference in vascular/bowel injury risk for hassan (open) vs varess (closed) techniques for insertion of the first trochar?

A

No real difference

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43
Q

Risk factors for acute fatty liver of pregnancy?

Mortality rate?

A

Who gets it? Those who MOP up the Munchies

Multiple pregnancy
Obesity
Primigravida

Male fetus

Fetal/maternal mortality 20%

prevalence = 1/10,000

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44
Q

How common is ecoptic pregnancy?
Where are most of the pregnancies?

A

1/100 roughly

mortality 2/1000

Tubal = 93-95%
Next most common is interstitial

WITHIN TUBE:
= 70% ampulla
then isthmus, then fimbrial, then corneal

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45
Q

Thrush in pregnancy.

Most common organism?

How many pregnancy women vs non-pregnant women are colonised with this?

Treatment?

A

Candida albicans (90%)

20% non-preg, 40% preg

Topical imidazole used in pregnancy

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46
Q

At what gestation does the amniotic fluid peak volume level?

A

35 weeks

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47
Q

Describe the RMI
What is the value which determines referral to the MDT as likely malignancy?

A

Scoring system for ovarian masses. Looks at 3 things:

  1. USS appearance
  2. Menopausal status
  3. Ca125 value

USS appearance looks at 5 things:
1. ascites
2. multilocular cyst
3. intrabdominal metastases
4. Solid areas
5. Bilateral lesions

As per RCOG - RMI of >200 highly sus of ovarian ca

48
Q

Chlamydia.

Investigation

Management

How many people contract it if they have had sex with an asymptomatic partner

A

NAAT

Treatment = 7/7 metronidazole

65% contract after sex with asymptomatic

49
Q

Contraindications for POP MEC3

A

IHD
Neuro - Stroke
Breast Ca - past or cleared 5 years ago
Aura in migraine
Liver - Cirrhosis or tumour or hepatitis
GTD

A - BLING

50
Q

Which antibiotics are given to women undergoing a surgical abortion?

What about a medical abortion?

A

100mg doxycycline BD 7 days

NONE FOR MEDICAL

51
Q

Prelabour rupture of membranes.

When should induction be offered?

How many women will labour after prom in 24h?

What is the risk of serious neonatal infection with PROM vs normal?

A

Induction offered 24h after if still no labour if >37 weeks. If <37 weeks do not offer induction

60% will start to labour within 24h

Risk is 1% compared to 0.5% in no-PROM

52
Q

Describe the endometrial Ca staging.

A
53
Q

Group B strep.

When do you treat during pregnancy?

What happens during delivery?

A

You treat if they have bacteruria and symptoms. You do not treat during pregnancy if asymptomatic

If vaginal delivery patient needs intrapartum antibiotics

54
Q

TSH aim for 1st, 2nd and 3rd trimester

A

TSH <2.5 = 1st
TSH <3 = 2nd, 3rd

55
Q

Molar pregnancy.

How many pregnancies?

Symptoms?

What are the types?

USS appearances?

Treatment?

How many can cause hyperthyroidism?

How many cases of choriocarcinoma occur after molar pregnancy?

A

Complete = empty egg fertilised by 2 sperm. USS = snow storm appearance - reticular shadows, bunch of grapes - villous distension
Incomplete = egg fertilised by 2 sperm

1/1000 are molar

Symptoms: hyperemesis, vaginal bleeding, large for dates

Management = methotrexate

3% can have hyperthyroidism. Caused by excessive hcg

70% of chorio occur after molar

56
Q

Oxytocin.

Where does it come from?

What receptors does it act on?
What is required for it to act on receptors?

Half life?

A

Made in hypothalamus but stored and released by posterior pituitary

G-coupled protein receptors
Requires Mg and cholesterol

5 minute half life

56
Q

Syphilis
Causative organism?
Symptoms?
Treatment?

A

Treponema pallidum

1 (<90 days) = chancre, lymphadenopathy
2 (<10 weeks) = hands and feet rash, wart lesions
latent = asymptomatic
tertiary (>3 years) = neurosyphilis, gumma, cardiovascular syphilis

Treatment: benzylpenicillin IM single dose (if primary or secondary). Alternatives: cef or doxy

56
Q

Ergometrine.
What is it?
Receptors?
Half life?
Contraindications?

A

Ergot alkaloid

Stimulates 5HT2, dopamine receptors
30-120 minute half life

Cant use in PET/hypertension

57
Q

How many babies are exclusively breast fed at birth vs 3 months

A

70%

20%

57
Q

Benefits of breast feeding for baby?
For mum?

A

Baby: increased immunity because of IgA in colostrum
Decreased rates of SIDS, childhood leukaemia, obesity, diabetes and cardiovascular disease

Mum: decreased rates of breast cancer, ovarian cancer, osteoporosis, CVD

57
Q

According to greentop guidelines: what level of blood loss (without shock) can we continue ‘basic measures’ - IV access, monitoring, bloods

A

Up to 1000ml without shock

58
Q

As per the PPH infusion/transfusion protocol, what are the triggers for platelets, cryo, FFP

A

Plt <75 and ongoing need for haemostasis

Cryo - fibrinogen <2 and ongoing need for haemostasis

FFP - transfused 4 units RBC and ongoing need for haemostasis OR PT/APTT ratio raised and ongoing need for haemostasis

59
Q

Half life of ergometrine

A

30-120 minutes

60
Q

How many cases of endometrial hyperplasia WITHOUT atypia turn into EC within 20 years

A

<5%

61
Q

How many deliveries have a PPH in the UK

A

13.8%

62
Q

What is the follow-up for endometrial hyperplasia WITHOUT atypia

A

Hysteroscopy and biopsy every 6 months until 2x negative biopsies

63
Q

What is the management of endometrial hyperplasia WITHOUT atypia

A

IUD first line

If they dont want this then oral progesterone.

After this if all fails can do hysterectomy.
Ablation NOT recommended

64
Q

What is the management of endometrial hyperplasia WITH atypia

A

Hysterectomy. As in 10 years 25-30% turn into cancer

65
Q

PROM

How many patients will go into labour within 24h?
What is the risk of a serious neonatal infection?
When should induction be recommended?

A

60% will go into spont labour

1% risk serious neonatal infection

If >34 weeks and been ruptured for 24h

66
Q

What causes endometrial hyperplasia

A

Unopposed oestrogen

Nulliparity
Early menarche/late menopause
Tamoxifen (acts like oestrogen in uterus and bone, blocks oestrogen in breast)
PCOS
Obesity (adipose tissue secrete oestrogen)

67
Q

How many patients with recurrent miscarriages have APLS

A

15%

68
Q

Which clotting factors reduce during pregnancy, and which rise?

A

REDUCE = 11 and 13

RISE = everything else (including fibrinogen)

69
Q

When taking EllaOne (ulipristal) - when should you advice patient re-takes the medication if she vomits?

What about levonorgestrel

A

if vomited within 3 hours

Levo - if vomits within 2 hours

Dont levo it longer than 2 hours to take it again, and if you vomit after 3 hours you only need EllaOne

70
Q

How many cases of choriocarcinoma occur after TOP, molar pregnancy or normal pregnancy

A

TOP - 20%

Molar - 70%

Normal - 10%

71
Q

What is the male infertility rate in cycstic fibrosis

A

98%

72
Q

Which hormone stimultes milk ejection?

Which hormone stimulates lactogenesis?

A

Ejection - oxytocin

Lactogenesis - prolactin

73
Q

What is karyotype for really tall male with azoospermia and infertility from this

A

Kleinfelters - XXY

74
Q

Which cancers are acanthosis nigricans associated with

A

Mostly GI - stomach is more likely accounts for 90%

75
Q
A
76
Q

What is used to treat type 1 WHO classification causes of infertility

How do they work?

A

This is hypothalamic pituitary disorders
- anorexia, stress

Treatment
- gain weight
- cure stress
- pulsation GNRH

Pulsation GNRH: (PREGNANCY)
- GNRH needs to be released in a pulsation fashion because this mimics how it is released naturally:
- maintains sensitivity of the pituitary GNRH receptors

Continuous GNRH (CANCER)
- GNRH receptors on the pituitary decrease in sensitivity as exposure is continuous
- therefore reduces LH and FSH and sex hormones
- used to treat sex hormone sensitive cancers eg prostate

77
Q

Which nerves are involved in Erbs palsy

A

C5/6

78
Q

Which nerve roots are involved in erbs palsy

A

C5/6

79
Q

How common are mole pregnancies

A

1 in 1000

80
Q

How many cases of chorio carcinoma occur after molar pregnancy, TOP, normal pregnancy

A

Molar - 70%
TOP - 20%
normal - 10%

81
Q

What causes hyperthyroidism in early pregnancy

A

HCG causes increased release of t3/t4

Only happens in about 3% of cases of molar pregnancies

82
Q

When is the luteo-placental phase

A

6-8 weeks

When placenta takes over production of progesterone and oestrogen

83
Q

How many positive HPV swabs to trigger colp

A

On third

In between this is a 1 year recall

84
Q

What percentage of smears have:
Normal
Mild dyskaryosis
Mod dyskaryosis
Severe dyskaryosis

A

Normal - 94%
Mild - 2.5%
Mod - 0.5%
Severe 0.7%

85
Q

How common is hyperthyroidism in pregnancy

Treatment?

A

2:1,000

Propylthiouracil - crosses placenta less readily than carbimazole

86
Q

What causes OAB?
Describe the treatment for OAB (urge incontinence)

A

Causes:
- neurological (Parkinson’s/dementia)
- physiological (detrusor overactivity, too little water - concentrated urine irritates bladder, too much water - increased volume and increased contraction, inflammation eg from chronic or recurrent UTI)
- anatomical (BPH - incomplete emptying —> increased contraction)
- lifestyle ( diet - caffeine/spicy, fat - pressure on the bladder)

OAB Management:
- bladder training
- topical oestrogen for atrophic vaginitis
- desmopressin for noctoria

AFTER THIS: antimuscarinic anticholinergics - reduce contraction of detrusor
- oxybutinin
- darifenacin
- tolterodine

2nd line - mirabegron

87
Q

Does lamotrigine interact with POP?

A

NO but it does interact with COCP - oestrogen reduces the seizure threshold.

88
Q

What is the mechanism of action of:
Quinolones

A

Quinolones - DNA gyrase inhibitor
Trimethoprim - dihydrofolate reductase inhibitor
Nitrofurantoin - damaged DNA
Tetracyclines - binds to 30S ribosomes
Macrolides - peptidyltransferase inhibitor
Cephalosporins - betalactam inhibit
Penicillin - betalactam inhibit

The QUEEN GRAZES on TWO FIGS and NOT DATES because THEY ROT if MICE PICK CONSTANTLY BEFORE PIGS BITE

89
Q

How long does it take for the uterus to go back to normal size after birth

A

4-6 weeks

90
Q

How long do after pains continue for following birth

A

2-3 days

91
Q

How long does lochia flow continue for

A

3-6 weeks

92
Q

How long does cervical constriction take following delivery

A

7 days

93
Q
A
94
Q
A
95
Q

Risk of unsuccessful VBAC

A

Average 25%

96
Q

Risk of readmission following CS
Risk of prolonged Abdo pain following CS
Risk of infection following CS

Uncommon:
Bladder injury
Ureteric injury
Death
VTE

A

Common risks:
5%
9%
6%

Uncommon risks:
1 in 1000
3 in 10,000
1 in 12,000
4-16 in 10,000

97
Q

RCOG guidelines for sepsis:
How much crystalloid?
If not responding to fluids what to do? What are target BPs if not responding?
If lactate over __ what do you want for central venous pressure?

A

20ml/kg initially
If not responding - vasopressors and aim MAP >65

Septic shock: hypotension and not responding to fluids
If not responding to fluids and lactate over 4 aim for CVP to be 8mmhg
Aim central venous sats to be 70%

98
Q

What are the classes of thrombophillias?

Give examples of type 1

A

Type 1 - deficient in anticoagulation factors (typically congenital)
Type 2 - too much clotting factor

Type 1 - protein C deficiency, protein S deficiency, antithrombin deficiency

Type 2 - factor V leiden, prothrombin g20210A

99
Q

Bacterial Vaginosis:

Which pathogen is typically associated with BV

What is the pathogenesis

Criteria ?

A

Gardnerella vaginalis

Overgrowth of anaerobic bacteria making vagina alkali

Amsel/nugent criteria

100
Q

What is the histology for lichen sclerosis?

What is the histology for VIN?

Histology for lichen planus?

Histology for lichen simplex?

A

Lichen sclerosis - epidermal thinning, degeneration of basal layer

Macroscopic - small introitus, loss of architecture

VIN - Atypical nuclei, loss of differentiation of surface layer , increased mitosis

Macroscopic - lumpy - white or pigmented

Lichen planus - violet plaques with white lace over the top (wickham’s striae), can have eroded layers in genital and buccal areas

Lichen simplex - lichenification (whitening), epithelial thickening, increased mitosis in basal and prikle layers
Macroscopic - erosions and excoriation

101
Q

Management of simple ovarian cysts according to size?

A

<5cm - no follow-up (premenopausal)

5-7cm - annual follow-up with USS

> 7cm - surgery or further evaluation with MRI

NO CA125 if patient premenopausal and SIMPLE CYST

102
Q

TRICHOMONAS
- Causative organism?
- Symptoms?
- How many asymptomatic?
- Investigation?
- Treatment?

A

Trichomonas vaginalis

Vaginal discharge (green frothy), abdo pain, dysparenunia, dysuria, itching, strawberry cervix 2%

50% asymptomatic (WOMEN)

Investigation - wet smear microscopy or PCR

Tx - 7/7 metronidazole

103
Q

USS features scoring points in RMI

A

multilocular cyst
Solid areas
Ascites
Intra-abdominal mets

104
Q

What is most common bug causing pueperal sepsis

A

Group A Strep

105
Q

Definition of latent phase vs first stage

A

Latent - contractions and dilation up to 4cm

First stage - from 4cm to fully

106
Q

Define delay in the third stage with:
- Active
- Physiological

A

Active >30 minutes
Physiological >1 hour

107
Q

FIBROIDS

What are the hormonal management options?

What are the surgical management options?

A

IUS - ?risk of expulsion depending on location

GNRH analongues
- limited to 6 months as risk of osteoporosis
- given with back up tibolone (small dose oestrogen to reduce SEs)

Surgical:
- UAE (some evidence can affect ovarian function). Need MRI and hysteroscopy prior to this

108
Q

What are the relative contraindications for uterine artery embolisation?

A

Submucosal or pedunculated fibroids (location means does not work as well)

Postmenopausal women

109
Q

With HMB, when is the hormonal coil most appropriate

A

Fibroids <3cm, adenomyosis, ovulatory cause, endometriosis

110
Q

What are the outcomes of EA?

What are the criteria?

A

3rd of women are amenorrhoeic

90% are satisfied with results

Needs to have cavity normal size <10cm length
Normal pathology
Completed her family
Fibroids not larger than 3cm in size

111
Q

Endometrial hyperplasia

Risk of progression to cancer?

Tx?

A

WITHOUT:
- 5% risk in 20 years
- Mirena
- Norethisterone 15mg/day
- 6 month endomtrial biopsu
- Minimum 2 negative prior to d/c

WITH:
- 12% risk in 9 years
- 43% risk of concomitant carcinoma - missed on biopsy
- HYSTERECTOMY

112
Q

How do you manage VWB as cause of HMB

A

Ideally COC - increases fibrinogen and other factors

Can also use mirena or EA if family complete

MRCOG part 1 (16 decks)

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