Crash course 2 Flashcards
The following is an indication for the use of a vaginal pessary to manage genital prolapse:
A. The patient is post-menopausal
B. The patient prefers surgical management
C. The patient is medically fit for surgery
D. The patient is on the waiting list for surgery
E. Major degrees of prolapse with lax introitus
D. Vaginal pessaries can be used as definitive management or as a temporary measure by patients on an elective waiting list for surgery. They can remain in situ for up to 6 months before they need to be changed.
A patient has been diagnosed with genital prolapse. She has weakness in the levatorani muscles which has caused a bulge in the mid-posterior vaginal wall. This is called: A. Cystocele B. Procidentia C. Vault descent D. Uterine descent E. Rectocele
E. None of the other options indicate deficiency in the posterior vaginal wall. Management will depend on the severity and impact on the patient’s quality of life, as well as patient’s choice. Sometimes reassurance and a good explanation of this benign condition is all that is required.
A patient has prolapse of the upper anterior wall of the vagina, attached to bladder by fascia. This is called: A. Cystocele B. Cystourethrocoele C. Vault descent D. Enterocoele E. Uterine descent
A. Patients will often present with urinary symptoms in association with the prolapse. These can include voiding difficulty and recurrent UTIs.
An 18-year-old woman seeks emergency contraception after unprotected sexual intercourse 72 hours ago. She has had two surgical terminations of pregnancy, following condom failure. Which is the most suitable method to offer?
A. Le v o n e lle
B. Intrauterine contraceptive device (IUCD)
C. Ulipristal acetate
D. Implanon
E. Combined oral contraception
B. The IUCD is the ideal form of emergency contraception here, as it not only prevents a third unplanned pregnancy, but also can remain in situ as an effective contraception for a further 5 years. It can be inserted up to 120 hours (5 days) after the earliest episode of unprotected sexual intercourse.
A 21-year-old student is requesting a reliable long- acting non-hormonal contraceptive. She has never been pregnant and is in a stable relationship. What is the most suitable option for her? A. Condoms B. Progesterone only pill C. Diaphragm D. Copper IUCD E. Progestogen implant (Implanon)
D. This is the best option for a woman in stable relationship who specifically wants to avoid hormonal contraception. Trained practitioners are required to insert the coil. Since she has never been pregnant, a narrow cervical canal may impede the smooth transit of the copper coil into the uterus causing some discomfort and requiring local anaesthetic.
A 42-year-old woman is requesting sterilization. She has completed her family, does not want to use an IUCD and her husband has refused to have a vasectomy. What is the lifetime failure rate of sterilization? A. 1:20 000 B. 1:20 C. 1:200 D. 1: 2000 E. 1 : 2
C. Interestingly this is the same risk quoted when counselling women who want to use Levonorgestrel (Mirena). IUS which avoids surgery altogether and has the added advantage of being reversible and making menstrual periods lighter.
Which of these risk factors is an absolute contraindication to combined oral contraceptive pill? A. Family history of thrombosis B. Hypertension C. Migraine D. Varicose veins E. Pregnancy
E. It is vitally important that a detailed history and pregnancy test is taken prior to commencing any contraception.
Which of the following most accurately confirms molar pregnancy?
A. Ultrasound findings
B. Histology
C. Speculum findings
D. History of hyperemesis
E. Enlarged uterus, greater than gestation dates
B. Molar pregnancy is a histological diagnosis.
Which of the following can result in an on-going, viable pregnancy? A. Ectopic pregnancy B. Molar pregnancy C. Delayed miscarriage D. Incomplete miscarriage E. Threatened miscarriage
E. PV bleeding in early pregnancy with a closed cervix (threatened miscarriage) is managed conservatively. Cause is not known – there is some suggestion that undiagnosed marginal placental bleeds are responsible.
Which of the following investigations for recurrent miscarriage is best diagnosed by careful history taking?
A. Karyotyping of both partners and retained
products of conception
B. Pelvic ultrasound to inspect uterine cavity and
ovaries
C. High vaginal swab for bacterial vaginosis
D. Cervical weakness
E. Antiphospholipid antibodies
D. History of late miscarriages, previous (repeat) cervical surgery are risk factors for cervical weakness. If there is a high clinical suspicion of cervical weakness patients can have serial cervical length measurements in pregnancy.
Which of the following is NOT a recognized aetiological factor of ectopic pregnancy? A. Pelvic inflammatory disease B. Tubal surgery C. Combined oral contraceptive pill D. In-vitro fertilization E. IUCD (‘coil’) in situ
C. The progesterone-only pill is a recognized aetiological factor of ectopic pregnancy, not combined oral contraceptive pill.
In order to perform a routine hysteroscopy the following are essential:
A. An ultrasound
B. A light source
C. Distilled water to distend the uterine cavity
D. General anaesthesia
E. A catheterized bladder
B. A light source is essential to view the inside of the uterine cavity. Not all patients need to have an ultrasound before undergoing hysteroscopy. The media used to distend the uterine cavity include normalsalineorglycine.Distilledwaterisnotnormally used. Outpatient hysteroscopy under local an- aesthesia is possible. There is no need to catheterize – it does not facilitate insertion of telescope.
In order to perform a routine diagnostic laparoscopy the following are essential:
A. Normal saline to distend the peritoneal cavity
B. Indwelling catheter
C. Verress needle
D. Pregnancy test
E. Diathermy
D. A pregnancy test must be performed prior to undertaking a laparoscopy or hysteroscopy. CO2, rather than saline, is inserted into the peritoneal cavity to avoid injury to organs and facilitate view. The bladder must be emptied to avoid injury to the bladder, but an indwelling catheter is not indicated. Direct insertion of the trocar is possible by dissection under direct vision. A diathermy is not usually required for diagnostic laparoscopy.
In order to perform a transvaginal ultrasound scan the following are essential: A. A full bladder B. Bowel preparation C. Ultrasound gel D. A sedated patient E. A light source
C. Ultrasound gel to allow transmission of sound waves. A full bladder is only required for transabdominal ultrasound. Bowel preparation is not a usual requirement and the procedure does not usually cause discomfort. As ultrasound relies on sound waves and not light, a light source is not required.
The following can be diagnosed during a routine hysteroscopy: A. Endometrial polyp B. Endometriosis C. Polycystic ovaries D. Meig’s syndrome E. Subserous fibroids
A. Endometrial polyps can be diagnosed during a routine hysteroscopy. These have a typical polypoid appearance. By definition, endometriosis is aberrant uterine tissue lying outside of the uterine cavity and, therefore, will not be seen on hysteroscopy. Polycystic ovaries and the peritoneal fluid/ pleural effusions and benign ovarian tumours of Meigs’ syndrome cannot be seen via hysteroscopy. Sub- mucous fibroids can be diagnosed via hysteroscopy, but subserous fibroids cannot.
The following should be performed in the assessment of all patients with abnormal vaginal bleeding: A. Eliciting a menstrual history B. Coagulation studies C. High vaginal swab D. Thyroid function tests E. Abdominal X-ray
A. A menstrual history is essential in a patient with abnormal bleeding. Coagulation studies should only be performed if a clotting disorder is suspected. Although useful in investigating intermenstrual and post-coital bleeding, a high vaginal swab is not clinically indicated in menorrhagia. Thyroid function tests are not an essential part of the routine work up for the investigation of abnormal periods unless other symptoms suggest a thyroid disorder. An abdominal X-ray is not usually required for investigation of abnormal genital tract bleeding. Caution should be exercised if one is ordered as the patient could be pregnant.
A 55-year-old woman presents with a 3-day mild vaginal bleed. Her last menstrual period was at the age of 52 years. The following would be appropriate with regards to differential diagnosis and subsequent management:
A. The most likely cause is atrophic vaginitis so no
further action is required
B. An ultrasound scan would be appropriate
C. A hysteroscopy should be performed
D. A full blood count should be taken
E. A normal pipelle excludes endometrial
carcinoma
B. An ultrasound scan is the standard investigation for postmenopausal bleeding for endometrial thickness. Action is always required for postmenopausal bleeding. Hysteroscopy should only be performed if clinically indicated or if ultrasound reveals pathology. A full blood count is only indicated in a symptomatic patient or heavy bleeding. A pipelle sample of the endometrium is reassuring, but does not absolutely exclude malignancy.
Which of these are the possible symptoms caused by a 3 cm submucosal fibroid: A. Hirsu t ism B. Subfertility C. Detrusor instability D. Deep vein thrombosis E. Dysmenorrhoea
B. A 3 cm submucosal fibroid may be the cause of due interference with implantation mechanism. Fibroids are not associated with hirsutism. They may press on the bladder leading to urinary frequency or stress incontinence, not detrusor instability. Subserous or large submucosal fibroids may cause deep vein thrombosis. Fibroids may cause menorrhagia, but are not associated with dysmenorrhoea.
What are the commonly associated complications of fibroids in pregnancy: A. Diabetes B. Chorioamnionitis C. Malpresentation D. Intrauterine growth restriction E. Pre-eclampsia
C. Malpresentation can be due to obstruction by fibroid in the lower segment/ cervix. There is no association between fibroids and pre-eclampsia. Both fibroids and pregnancy may cause urinary frequency, but there is no association between fibroids and chorioamnionitis. Intrauterine growth restriction and pre-eclampsia are not recognized complications of fibroids.
Which of these are common sites for endometriotic deposits: A. Pouch of Douglas B. Fallopian tube C. Femur D. Scars E. Lungs
A. The Pouch of Douglas is a common site common sites for endometriotic deposits. Fallopian tubes, femur, scars, lungs are all rare.
What are the possible medical treatments of endometriosis: A. Ovarian drilling B. Combined oral contraceptive pill C. Corticosteroids D. Tranexamic acid E. Metronidazole
B. The combined oral contraceptive pill provides ovulation suppression plus continuous progestogenic activity. Ovarian drilling is a surgical intervention used to treat polycystic syndrome. Corticosteroids have no known benefits for endometriosis. Tranexamic acid is used to treat menorrhagia. There are no known benefits for antibiotics in treating endometriosis.
A 45-year-old woman presents with pruritus vulvae. The following are suggestive of an infective cause:
A. Progressively worsening symptoms over 6 months
B. Menorrhagia
C. A thick creamy white discharge
D. Red plaques in the vulval area
E. Fused labia
C. A thick creamy white discharge supports a diagnosis of infection, possibly candida. An acute onset, rather than progressively worsening symptoms over 6 months suggests infection. There is no association between menorrhagia and pruritus vulvae. Red plaques in the vulval areas suggest psoriasis or eczema. Fused labia suggest lichen sclerosis.
The following are important in the management of a woman with pruritus vulvae:
A. Administering antibiotics
B. A speculum examination of the cervix and smear test
C. All women should be seen in colposcopy clinic
D. Excision of the area of the discomfort
E. An abdominal X-ray
B. CIN is often associated with VIN. Antibiotics should only be prescribed where infection is found. Women should be referred to colposcopy only where clinically indicated. Surgical intervention is not common practice. Abdominal X-ray is not a usual part of the routine work-up for pruritus vulvae.
The following are possible methods of investigation of vulval disease: A. CRP B. Biopsy of vulva C. Ultrasound scan D. Hysteroscopy E. Endocervical swabs
B. Biopsy of vulva for histological diagnosis. CRP does not identify a cause, but provides a marker for infective causes only. Ultrasound is not commonly used to investigate vulval disease; CT and MRI are more sensitive when considering vulval malignancy. Hysteroscopy alone does not identify vulval pathology, but an examination under anaesthetic may. Endocervical swabs will exclude endocervical infection only.
The following are correct about lichen sclerosis:
A. The vulval skin always appears white
B. Skin biopsy shows thinning of the epidermis
C. A biopsy is not necessary as the diagnosis is usually obvious
D. Surgical excision is first-line treatment
E. A short course of antibiotic treatment is usually required
B. The epidermis is usually thin and hyalinized. Lichen sclerosis can appear as white or reddish plaques. A skin biopsy is mandatory to exclude malignant change. 50% of symptoms of pruritus vulvae can recur following surgical excision. A long course of steroids is often required.
