Day 15 OBGYN

Question 1

A 27-year-old female presents to her general practitioner complaining of vaginal itchiness and discharge. On examination, the doctor can observe an inflamed vulva and some white, thick vaginal discharge. The cervix looks normal and there is no pain on bimanual examination. A high vaginal swab shows a pH of 4.3.

She has a past medical history of asthma, well-controlled with salbutamol, and has no known allergies.

What is the most likely diagnosis?

What is the treatment?

Answer 1

White ‘curdy’ vaginal discharge with pH <4.5 is likely to be candidiasis

The correct treatment is oral itraconazole

Question 2

How would Trichomonas vaginalis present?

How is it treated?

Answer 2

Offensive, yellow-green discharge, and strawberry cervix.

It is treated using Oral metronidazole.

Question 3

How would Bacterial vaginosis present?

How is it treated?

Answer 3

Bacterial vaginosis presents with offensive thin, white-grey, ‘fishy’ discharge.

It is treated using Oral metronidazole.

Question 4

What do Trichomonas and Bacterial Vaginosis have in common?

(3)

Answer 4

raised pH

offensive discharge

treated with metronidazole

Question 5

How do BV and Trichmonas present differently?

(3)

Answer 5

Bacterial Vaginosis:

• Thin, white discharge
• “Clue” cells on microscopy

Trichomonas:

• Strawberry Cervix
• Frothy yellow/green discharge

Question 6

What are the risks of bacterial vaginosis in pregnancy?

(4)

Answer 6

results in an increased risk of preterm labour,

low birth weight and chorioamnionitis,

late miscarriage

Question 7

Why does bacterial vaginosis result in a raised pH

Answer 7

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

Question 8

What is oral itraconazole commonly used to treat?

Answer 8

vaginal candidiasis

Question 9

How is vaginal candidiasis treated?

(3)

Answer 9

• local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
• oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
• if pregnant then only local treatments

Question 10

What is Recurrent vaginal candidiasis?

What action should be taken?

(3)

Answer 10

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year

1. confirm the diagnosis of candidiasis
2. exclude differential diagnoses such as lichen sclerosus
3. consider the use of an induction-maintenance regime

Question 11

What can Topical clindamycin be used to treat?

Answer 11

used to treat bacterial vaginosis presenting with offensive thin, white-grey, ‘fishy’ discharge when oral therapy is contraindicated.

Question 12

What can Topical metronidazole be used to treat?

Answer 12

Topical metronidazole can be used to treat bacterial vaginosis presenting with offensive thin, white-grey, ‘fishy’ discharge when oral therapy is contraindicated.

Question 13

What are the clinical features of Vaginal candidiasis?

(4)

Answer 13

• ‘cottage cheese’, non-offensive discharge
• vulvitis: superficial dyspareunia, dysuria
• itch
• vulval erythema, fissuring, satellite lesions may be seen

Question 14

Your next patient in an antenatal clinic is a woman who is 30 weeks pregnant. Which of the finding during your examination would you be concerned with?

Answer 14

Fundal height growth of 2cm per week

Question 15

After 24 weeks what is the expected fundal height growth per week?

Answer 15

After 24 weeks you would only expect the fundal height to increase by 1cm a week.

Question 16

At how many weeks would you expect the fundus to be palpable

a) at the umbilicus
b) sternum

Answer 16

• You would expect the fundus to be palpable at the umbilicus from 20 weeks
• and at the xiphoid sternum from 36 weeks

Question 17

When is a breech position a problem?

(2)

Answer 17

Breech presentation is common before 34 weeks and only becomes a concern in women who go into preterm labour

Question 18

What are the three characteristics of asthma?

Answer 18

hypersensitivity

IgE mediated

Mucous secretion

Question 19

What are asthma triggers?

(5)

Answer 19

dust

pollen

exercise

cold

beta blockers

Question 20

When does the nuchal scan occur?

Answer 20

12 weeks

Question 21

Which week does the anomaly scan take place?

Answer 21

20 Weeks

Question 22

What is external cephalic version and when is it offered?

Answer 22

External cephalic version is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first

36 weeks

Question 23

What might U&Es be important in asthmatic patients?

Answer 23

Salbutamol decreases potassium concentration in the blood

Question 24

Which appointments occur at 28 and 34 weeks?

(2)

Answer 24

anti Rh prophylaxis injections

eclampsia screening

Question 25

Which of the following is the best way to detect ovulation?

Answer 25

Day 21 progesterone test is the most reliable test to confirm ovulation

> 30 nmol/l

Question 26

What is the luteal phase?

(2)

Answer 26

It occurs after the ovary releases an egg

it lasts 14 days

Question 27

Infertility: initial investigations

(2)

Answer 27

• semen analysis
• serum progesterone 7 days prior to the expected next period. For a typical 28 day cycle, this is done on day 21.
• Level*Interpretation< 16 nmol/lRepeat, if consistently low refer to specialist16 - 30 nmol/lRepeat> 30 nmol/lIndicates ovulation

Question 28

Treatment of acute asthma

(5)

Answer 28

Question 29

Why might you check a patient’s gonadatropins?

Answer 29

to measure the regularity of the menstrual cycle

Question 30

Which signs indicate ovulation?

Answer 30

The use of basal body temperature charts and cervical mucus thickness do not reliably predict ovulation and are not recommended.

Question 31

What is the definition of pre-eclampsia?

Answer 31

Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction

Question 32

What is the triad of pre-eclampsia?

Answer 32

• new-onset hypertension
• proteinuria
• oedema

Question 33

How is pre-eclampsia managed?

(3)

Answer 33

• women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
• oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
• delivery of the baby is the most important and definitive management step.

Question 34

What are the clinical features of severe pre-eclampsia?

(7)

Answer 34

Features of severe pre-eclampsia

• hypertension: typically > 160/110 mmHg and proteinuria as above
• proteinuria: dipstick ++/+++
• headache
• visual disturbance
• papilloedema
• RUQ/epigastric pain
• hyperreflexia
• platelet count < 100 * 10⁶/l, abnormal liver enzymes or HELLP syndrome

Question 35

Answer 35

Left occiput posterior

Question 36

A 26-year-old woman presents to rheumatology clinic asking for advice as she would like to start a family.

She and her partner both have rheumatoid arthritis, treated with weekly methotrexate. She was told when she started the medication that she would need advice regarding pregnancy.

What advice should you give?

Answer 36

The patient and her partner will both need to wait 6 months after stopping methotrexate before conceiving

Methotrexate: must be stopped at least 6 months before conception in both men and women

Question 37

What is the effect of methotrexate?

(3)

Answer 37

• Methotrexate is teratogenic because its inhibition of dihydrofolate reductase affects DNA synthesis.
• This particularly affects the rapidly dividing cells of the fetus, but there is also evidence that its effects on DNA synthesis can damage various semen parameters.
• Therefore both partners must stop methotrexate for 6 months before conceiving.

Question 38

A nurse informs you of a 28-year-old woman who is 24 weeks pregnant. He says that she has a blood pressure reading of 155/90 mmHg. Her previous blood pressure 2 days ago was 152/85 mmHg. She was previously healthy prior to becoming pregnant.

What is the first line management in this situation?

Answer 38

This woman has moderate gestational hypertension. According to the current guidelines, the first line treatment is Oral labetalol.

Question 39

A woman who is 14 weeks pregnant presents as she came into contact with a child who has chickenpox around 4 days ago. She is unsure if she had the condition herself as a child. Blood tests show the following:

Varicella IgMNegativeVaricella IgGNegative

What is the most appropriate management?

Answer 39

Chickenpox exposure in pregnancy <= 20 weeks - if not immune give VZIG

Question 40

What is FVS?

Answer 40

Fetal varicella syndrome (FVS)

• risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
• studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
• features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities

Question 41

How should chickenpox exposure be managed during pregnancy?

Answer 41

• if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
• if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible - RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
• if the pregnant 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 42

Ectopic pregnancy in which location is most associated with an increased risk of rupture?

Answer 42

isthmus

Question 43

A 32 year-old lady has a diagnosis of fibroids and has been trying for a baby for 18 months. She has been under investigation at the sub-fertility clinic and no abnormality has been found except for three uterine fibroids, for which she does not have any symptoms. Her partner has had sperm analysis which found no abnormality.

Which of the following treatments are most appropriate in this situation?

Answer 43

The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future

Question 44

What is the function of GnRH agonists?

Answer 44

GnRH agonists effectively turn off the ovaries, which causes the fibroids to shrink and therefore are easier to remove surgically.

Question 45

What is the function of Ulipristal acetate?

Answer 45

Ulipristal acetate is a selective progesterone receptor modulator. It is used pre-operatively for women with fibroids as it has been proven to shrink them, thus making surgery easier.

This medication affects fertility, thus is not suitable for women trying to get pregnant, unless (like GHRH agonists) it is used for a short period in combination with surgery.

Question 46

Which antenatal test results would be seen in Down’s syndrome?

Answer 46

Down’s syndrome is suggested by

• ↑ HCG,
• ↓ PAPP-A,
• thickened nuchal translucency

Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

Question 47

A 26-year-old woman, who is 12-weeks pregnant, attends routine clinic for her combined screening test. She is counselled on the implications of the test and consents. Her results are as follows, summarised:

B-HCGHighPAPP-ALowNuchal translucencyThickened

She is called to discuss the implications of these results, including the high probability of Down’s syndrome. Which two other syndromes would also present with similar findings during combined screening?

Answer 47

Down’s syndrome combined screening: trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

Question 48

A 64-year-old woman presents with a 1 month history of post-menopausal bleeding. Her only medication is aspirin 75 mg once daily. An ultrasound scan of the uterus shows an endometrial lining thickness of 4.1 mm. An endometrial pipelle biopsy is taken but is inconclusive. What is the next step?

Answer 48

Hysteroscopy with biopsy

Question 49

A 57-year-old nulliparous female is seen in the gynaecology outpatient department with a 2-month history of postmenopausal bleeding. She has a past medical history of type 2 diabetes mellitus. Her last menstrual period was 4 years ago.

Transvaginal ultrasound shows an endometrial thickness of 8mm and the results of a pipelle biopsy are reported as follows:

‘There is evidence of increased gland-to-stroma ratio, with some evidence of nuclear atypia’.

What is the most appropriate management option?

Answer 49

A total hysterectomy with bilateral salpingo-oophorectomy, in addition, is advisable for all postmenopausal women with atypical endometrial hyperplasia, due to the risk of malignant progression

Question 50

What is hyperemesis gravidarum and what increases the risk?

Answer 50

“morning sickness”

Smoking is associated with a decreased incidence of hyperemesis gravidarum

It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*.

Question 51

Management of morning sickness (4)

Answer 51

• antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
• ondansetron and metoclopramide may be used second-line
• ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
• admission may be needed for IV hydration

Question 52

Complications of morning sickness

(5)

Answer 52

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

Question 53

A 26-year-old primigravida woman presents for an ultrasound scan at 34 weeks gestation. It is discovered that her baby is in the breech position.

What is the most appropriate course of action?

Answer 53

External cephalic version is recommended if the foetus is breech at 36 weeks

Question 54

A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?

Answer 54

Menorrhagia - intrauterine system (Mirena) is first-line

Question 55

Which medication is known to causes folate deficiency?

Answer 55

Phenytoin

Folate deficiency associated with anti-epileptic medications is complex, however, it is believed that phenytoin induces intestinal pH changes affecting the enterohepatic circulation of folate.

Question 56

What is movicol and what is a known side effect?

Answer 56

Movicol is a laxative that is used for the relief of constipation.

Laxative use can occasionally be associated with vitamin D deficiency - this is mainly due to laxative abuse or excessive consumption.

Question 57

A 32-year-old woman attends your clinic as she is 8 weeks pregnant and wants a termination of pregnancy. After assessing her and counselling her about the options available to her, she decides she would like a medical termination of pregnancy.

Which medications would you use to facilitate this?

Answer 57

Medical abortions are undertaken using mifepristone followed by at least one episode of prostaglandins and are appropriate at any gestation

Question 58

What are the methods of termination of pregnancy and at which dates is each used?

Answer 58

• less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
• less than 13 weeks: surgical dilation and suction of uterine contents
• more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)

Question 59

A 40-year-old woman who has recently had a positive pregnancy test has come to visit her GP seeking advice for her pregnancy. She is 4 weeks pregnant and this is her first pregnancy. She states that she is anxious regarding the possibility of pre-eclampsia, as well as all the information she has seen online. A routine check is done and she appears well. The patient’s BMI is measured and calculated as 36 kg/m².

What is the correct advice to give to this patient with regards to medication or supplements she needs to take?

Answer 59

A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth

Question 60

A 33-year-old woman presents to her general practitioner for a routine antenatal visit. She is 22 weeks pregnant. It is her first pregnancy and it has been uncomplicated thus far. She does not have any significant past medical history and does not take any regular prescribed medications. She does not smoke cigarettes or drink alcohol.

Her blood pressure is 148/92 mmHg. This is confirmed on repeat assessment and was previously within normal limits in early pregnancy.

On examination, there is no oedema and her reflexes are normal.

Urinalysis is as follows:

ProteinnegativeBloodnegativeLeucocytesnegativeGlucosenegativeNitritesnegative

What is the most appropriate management?

Answer 60

Labetalol is first-line for pregnancy-induced hypertension

Question 61

A neonate is born at 38 weeks gestation via spontaneous vaginal delivery. The birth weight was 4.5kg. In the newborn postnatal check the attending doctor notes that there is adduction and internal rotation of the right arm. What is the most likely diagnosis?

Answer 61

Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’.

Question 62

Define foetal macrosomia

Answer 62

A baby is diagnosed with foetal macrosomia if they have a birth weight >4kg regardless of their gestational age.

Question 63

During a subfertility clinic you are asked to take a menstrual cycle history from a 30-year-old in order to establish on what day her mid-luteal progesterone level needs to be done. You clarify that the woman has a regular 35 day cycle.

On which day would you carry out mid-luteal progesterone level?

Answer 63

The correct answer here is on Day 28 - this is 7 days before the end of the lady’s regular cycle when progesterone levels should be tested.

An individual who has a normal 28-day cycle would be tested on Day 21.

Question 64

What counseling advice should be given to couples trying to conceive?

(4)

Answer 64

• folic acid
• aim for BMI 20-25
• advise regular sexual intercourse every 2 to 3 days
• smoking/drinking advice

Question 65

What are the risks/benefits of the combined oral contraceptive pill?

(2)

Answer 65

Cons

• increased risk of breast and cervical cancer
• increased risk of venous thromboembolic disease

Pros

• protective against ovarian and endometrial cancer
• usually makes periods regular, lighter and less painful

Question 66

In fertility clinic, when should progesterone levels be checked?

Answer 66

7 days before the end of the cycle

Question 67

You are a first-year doctor working in obstetrics and gynaecology. You are the first on the scene after an emergency call to midwife led delivery.

The delivery has not progressed for some time and midwife explains this is a case of shoulder dystocia. You decide to perform McRobert’s manoeuvre.

What position should the woman be in to achieve this?

Answer 67

Supine with both hips fully flexed and abducted

Question 68

What is McRobert’s manoeuvre?

When is it indicated?

Answer 68

The McRobert’s manoeuvre is a simple and effective intervention in shoulder dystocia.

The maneuver increases the mobility at the sacroiliac joints aiding rotation of the pelvis and allowing the release of the fetal shoulder. It is very important that additional help is called as the first step following recognition of shoulder dystocia.

Question 69

What are the risk factors for shoulder dystocia?

Answer 69

Key risk factors

• fetal macrosomia (hence association with maternal diabetes mellitus)
• high maternal body mass index
• diabetes mellitus
• prolonged labour

Question 70

A 76-year-old woman attends clinic complaining of ongoing urinary incontinence. It is worse when she laughs or coughs. On initial examination, she had a normal pelvic examination, urine dipstick and urine microscopy culture and sensitivities. Four months ago she started supervised pelvic floor exercises and although she noted a slight improvement in incontinence, she still feels her symptoms are affecting her quality of life. Referral for consideration of surgery was discussed but she would prefer medical management.

Which medication is most appropriate to manage her symptoms?

Answer 70

Duloxetine may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention

Question 71

What is Duloxetine used to treat?

Answer 71

Duloxetine may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention.

Question 72

What are antimuscarinics used to treat?

Answer 72

Antimuscarinics are used to manage patients with urge incontinence who do not respond to, or alongside, bladder training.

NICE recommend oxybutynin (immediate-release), tolterodine (immediate-release), or darifenacin (once daily preparation) first-line.

Question 73

A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky’s protuberance.

What is the most likely diagnosis?

Answer 73

Teratomas (dermoid cysts) are benign neoplasms derived from multiple germ cell layers.

Due to their germ cell origin a range of tissues can be produced within them including skin, hair, blood, fat, bone, nails, teeth, cartilage, and thyroid tissue.

Question 74

What is Rokitansky’s protuberance?

Answer 74

In gynecology, a Rokitansky nodule is a mass or lump in an ovarian teratomatous cyst.

Question 75

Risk of malignancy index (RMI) is calculated using which blood test?

Answer 75

serum CA-125

Question 76

A 42-year-old woman who is 12 weeks pregnant attends the antenatal clinic to discuss the results of her combined screening for Down’s syndrome.

Her obstetrician explains that tests are suggestive of a trisomy, but it is more likely trisomy 18 (Edward’s syndrome) or trisomy 13 (Patau syndrome) rather than trisomy 21 (Down’s syndrome).

What part of the combined test could differentiate these trisomies?

Answer 76

Down’s syndrome combined screening: trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

Question 77

How does nuchal translucency vary in all three trisomies?

Answer 77

Nuchal translucency is thickened to the same amount in all 3 of the trisomies

Question 78

A 17-year-old female comes to your GP clinic. She has recently travelled to Egypt to see her family, and now has come to visit as she is suffering with per vaginal bleeding and urinary incontinence.

She consents to examination with a chaperone present and you identify signs that suggest there have been recent trauma to the genitalia. You suspect this is a case of female genital mutilation.

What is the most appropriate course of action?

Answer 78

Female genital mutilation (FGM) is a criminal act. The GMC has now issued guidance that all cases of FGM must be reported to the police in under 18s.

Question 79

A 47-year-old patient has asked to discuss the result of her latest smear test. It demonstrated normal cytology and was negative for high-risk human papillomavirus (hrHPV). Her previous smear 12 months prior demonstrated normal cytology but was positive for hrHPV.

What should you advise the patient following her latest smear test result?

Answer 79

Cervical cancer screening: if 1st repeat smear at 12 months is now hrHPV -ve → return to routine recall

Question 80

You are called to review a woman in the maternity ward who is 3 days post-partum complaining of ongoing vaginal bleeding and passage of clots. You explain that lochia is normal in the post-partum period and can be expected to continue for some time.

After what period of time would continued lochia warrant further investigation with ultrasound?

Answer 80

An ultrasound is indicated if lochia persists beyond 6 weeks

Question 81

Define Puerperium

Answer 81

Puerperium is the period of approximately six weeks after childbirth during which time the woman’s reproductive organs return to normal. Lochia is a normal part of this process.

Question 82

A 45-year-old woman has come into your post-menopausal bleed clinic. When taking a history, you ask about her medical history and family history for things that may increase her risk of endometrial cancer.

Which condition is associated with an increased risk of endometrial cancer?

Answer 82

HNPCC/Lynch syndrome is a strong risk factor for endometrial cancer

Question 83

What are the key features of endometrial cancer?

(3)

Answer 83

• postmenopausal bleeding is the classic symptom
• premenopausal women may have a change intermenstrual bleeding
• pain and discharge are unusual features

Question 84

How are suspected endometrial cancers investigated?

(3)

Answer 84

• women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
• first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
• hysteroscopy with endometrial biopsy

Question 85

How is endometrial cancer managed?

(2)

Answer 85

• localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy
• progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Question 86

Which two factors are protective against endometrial cancer?

(2)

Answer 86

The combined oral contraceptive pill and smoking are protective

Question 87

A 72-year-old nulliparous female presents with post menopausal bleeding. She reports that her last cervical screening was 14 years ago. On examination she is found to be obese and hypertensive.

What is the most important diagnosis to rule out?

Answer 87

In a female with postmenopausal bleeding (PMB), the diagnosis is endometrial cancer until proven otherwise.

Question 88

What are the risk factors for endometrial cancer?

(9)

Answer 88

• obesity
• nulliparity
• early menarche
• late menopause
• unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
• diabetes mellitus
• tamoxifen
• polycystic ovarian syndrome
• hereditary non-polyposis colorectal carcinoma

Question 89

A 57-year-old lady presents to the postmenopausal bleed clinic with a 2 week history of light vaginal bleeding, and mild pain on intercourse. She is otherwise well. On vaginal examination she is tender and has slight dryness.

What should be done next in clinic?

Answer 89

Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS.

While this is most likely atrophic vaginitis, it still must be investigated to rule this out.

Once a TVUS is done, if it comes back normal then either discharge with cream or referral to HRT clinic would be the most appropriate, but TVUS must be done first. If it is abnormal (>4mm), then endometrial biopsy would be done.

Question 90

What are the features of Atrophic vaginitis?

(3)

Answer 90

• Atrophic vaginitis often occurs in women who are post-menopausal women.
• It presents with vaginal dryness, dyspareunia and occasional spotting.
• On examination, the vagina may appear pale and dry.

Question 91

What is the treatment for atrophic vaginitis?

Answer 91

Treatment is with vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.

Question 92

A 51-year-old female presents to a GP with hot flushes, irritability & a 7 month history of lighter periods. She has also noticed that they have become more irregular. The GP decides she is perimenopausal. Because she has not had a total abdominal hysterectomy, she is started on sequential combined HRT - Elleste duet tablets (estradiol + norethisterone). The GP discusses the risks.

Which of the following is most important to mention as a risk for the norethisterone (progesterone) component?

Answer 92

HRT: adding a progestogen increases the risk of breast cancer

Question 93

A 32-year-old female patient attends clinic. She is 33 weeks pregnant and so far has had no complications with the pregnancy. However, she is now worried as she feels that her baby’s usual kicking and moving has reduced over the past few days. She has not noticed any other symptoms of concern and otherwise feels well. She has no significant past medical history, nor family history. She has had two previous uncomplicated pregnancies.

Physical examination is unremarkable, and observations are stable and within normal parameters. A handheld Doppler scan is performed; no fetal heartbeat is detected.

What is the next step in management?

Answer 93

If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered

Question 94

A 31-year-old woman presents to her GP with progressively worsening menstrual pain that usually commences a few days before her period. She tried to take paracetamol and ibuprofen to alleviate the pain, but they are not effective in doing so. She also describes extreme discomfort when she has penetrative sex.

Digital vaginal examination reveals nodularity and marked tenderness in the posterior fornix of the cervix. Bimanual examination reveals a fixed, retroverted uterus.

What is the most likely diagnosis?

Which investigation is considered the gold standard?

Question 95

What are the clinical features of Endometriosis?

Answer 95

• chronic pelvic pain
• dysmenorrhoea - pain often starts days before bleeding
• deep dyspareunia
• subfertility
• non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
• on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Question 96

What is the gold standard investigation for endometriosis?

Answer 96

laparoscopy

Question 97

What are the management options for endometriosis?

(2)

Answer 97

• NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
• if analgesia does help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried

Question 98

You are a junior doctor working in a GP practice. A 13-year-old girl comes to see you requesting a prescription for the oral contraceptive pill. On further questioning, she tells you she has a sexual relationship with her 14-year-old boyfriend. She is refusing to speak to her parents about it and states that she will continue having sex even if she doesn’t get the pill and she understands the risks associated with this. She is otherwise well with no history of migraines and she has normal blood pressure. What do you do?

Answer 98

Give her a prescription for the contraceptive pill but encourage her to discuss this with a parent

Question 99

What are the “Fraser guidelines”?

(5)

Answer 99

‘You can provide contraceptive, abortion and STI advice and treatment, without parental knowledge or consent, to young people under 16 provided that:

• They understand all aspects of the advice and its implications
• You cannot persuade the young person to tell their parents or to allow you to tell them
• In relation to contraception and STIs, the young person is very likely to have sex with or without such treatment
• Their physical or mental health is likely to suffer unless they receive such advice or treatment, and
• It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent

Question 100

What dietary advice should be given during pregnancy?

Answer 100

• folic acid 400mcg should be given from before conception until 12 weeks to reduce the risk of neural tube defects. Certain women may require higher doses (women who take antiepileptics)
• iron supplementation should not be offered routinely
• vitamin A supplementation (intake above 700 micrograms) might be teratogenic. Liver is high in vitamin A so consumption should be avoided
• vitamin D: ‘women should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the supplement’. Particular care should be taken with higher risk women (i.e. those with darker skin or who cover their skin for cultural reasons)

Question 101

A 49-year-old patient presents with hot flushes and mood swings. She has no previous medical history or family history. She has been amenorrheic since her Mirena (levonorgestrel) coil was placed 2 years ago.

She would like to consider HRT with the least side effects.

Answer 101

Oestrogen patch

The patient requires combined HRT as she has a uterus, so requires progesterone for protection of the endometrial lining against estrogen. However, the patient has a Mirena coil in situ, which is the only form of contraception licensed to be used as the progesterone component in HRT. It is licensed for 4 years if used as HRT.

Therefore the patient only requires oestrogen preparation only.

Transdermal oestrogen such as patches and gels do not have an increased risk of deep vein thrombosis, compared to oral oestrogen preparations.

Question 102

A 55-year-old woman presents with mood swings and night sweats for the last few years which she has managed herself. She reports her last period was over 1 year ago but reports some vaginal bleeding a few days ago. She is not on any contraception.

Which HRT should she have?

Answer 102

HRT contraindicated33%

Undiagnosed vaginal bleeding is a contraindication. This woman has achieved her menopause as she has been amenorrheic for over 1 year, but per vaginal bleeding post menopause warrants further urgent investigation.

Question 103

A 48-year-old woman presents with perimenopausal symptoms. Apart from suffering from migraines with aura, she does not have any relevant medical history. She has a family history of deep vein thrombosis (DVT). The patient’s last menstrual periods are irregular, the last one being 3 months ago. She is not currently on any contraception.

Which HRT is best for her?

Answer 103

Topical cyclical combined HRT

• Migraine with aura is not a contraindication for HRT, unlike with the combined oral contraceptive pill, however, topical preparations are preferred rather than oral.
• This patient has a uterus, so combined oestrogen and progesterone treatment is required. The oestrogen replaces the oestrogen deficiency that occurs during menopause but also causes endometrial hyperplasia. Using progesterone with the oestrogen protects against this.
• As the patient has a family history of DVT, topical HRT is preferred here as there is no increased DVT risk compared to oral preparations.
• Menopause is defined as amenorrhea for >1 year, where a continuous regime can be used (oestrogen and progesterone daily).
• This patient has not yet achieved her menopause, so a cyclical regime should be used (oestrogen daily, but progesterone used for a few weeks in the cycle).

Question 104

Contraindications for menopausal HRT

(4)

Answer 104

• Current or past breast cancer
• Any oestrogen-sensitive cancer
• Undiagnosed vaginal bleeding
• Untreated endometrial hyperplasia

Question 105

A 52-year-old lady with a body mass index of 32kg/m² and type 2 diabetes mellitus comes to see you. She has had a Mirena coil (levonorgestrel-releasing intrauterine system) in place for the last 4 years and has been amenorrhoeic since 3 months post insertion. Over the last month, she has had a 3-day episode of vaginal bleeding and 2 episodes of post-coital bleeding.

What is the most appropriate next step in management?

Answer 105

The answer in this case is to refer the patient to the postmenopausal bleeding clinic for endometrial biopsy. Guidance from the Faculty of Sexual and Reproductive Health suggests that ‘endometrial biopsy should be considered in women aged 45 years using hormonal
contraception who present with persistent problematic bleeding or a change in bleeding pattern’.

Question 106

An 18-year-old female presents to the local sexual health clinic following unprotected sexual intercourse. The intercourse happened four days ago. She is not on any form of contraception. Her past medical history includes asthma, well-controlled with salbutamol. The patient would rather have an oral form of contraception as opposed to an invasive form.

What is the most appropriate management plan?

Answer 106

• The correct answer is to prescribe ulipristal. This patient is inquiring about emergency contraception for unprotected sexual intercourse that happened 96 hours ago. Ulipristal (a selective progesterone receptor modulator) can be prescribed up to 120 hours following the intercourse.
• Levonorgestrel must be taken within 72 hours of UPSI

Question 107

You are called to see a lady who has delivered her second child 2 hours ago. The baby was term, weighed 4.1kg, and was healthy. The labour was natural, lasted 6 hours, and she chose to have a physiological third stage. The nurse tells you she thinks she has lost approximately 800ml of blood, but her observations are stable and the bleeding appears to be slowing.

What is the most common cause of her blood loss?

Answer 107

Uterine atony

Question 108

Define post partum haemorrhage

Answer 108

Primary postpartum haemorrhage is defined as the loss of 500ml or more from the genital tract within 24 hours of the birth of a baby. This can be further defined as minor haemorrhage (500-1000ml) or major haemorrhage (>1000ml), and causes 6 deaths/million deliveries.

Question 109

What are the causes of primary post partum haemorrhage?

Answer 109

Causes can be grouped into the ‘four T’s’:

• tone
• tissue (retained placenta)
• trauma
• thrombin (coagulation abnormalities)

Question 110

You are reviewing a patient who is 35 weeks pregnant with her third child. Her second child had neonatal sepsis caused by Group B Streptococcus. She had an appointment with an obstetrician last week who has suggested that she should have antibiotics in labour to prevent this from happening again.

Which intravenous (IV) antibiotic should this lady receive?

Answer 110

Benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Question 111

Which infection is most likely to cause bacterial sepsis in premature newborns?

Answer 111

group b strep

Maternal intravenous antibiotics in labour are recommended for all women who have had a previous baby with early- or late-onset GBS disease.

The antibiotic of choice is IV benzylpenicillin.

Question 112

A 40-year-old woman presents on the fifth day after a normal delivery. Her husband has brought her in to accident and emergency, after he noticed an abrupt change in her behaviour. He describes her as confused and restless. On mental state examination she describes racing thoughts, low mood and suicidal ideation. Pressurised speech is also evident. What is the most likely diagnosis?

Answer 112

Puerperal psychosis is a condition characterised by an acute onset of a manic or psychotic episode shortly after childbirth. An abrupt change in mental state is a red flag for puerperal psychosis.

Question 113

Define Puerperal psychosis

Answer 113

Puerperal psychosis is a condition characterised by an acute onset of a manic or psychotic episode shortly after childbirth. An abrupt change in mental state is a red flag for puerperal psychosis.

Question 114

What is the mode of action of the Combined oral contraceptive pill

Answer 114

inhibits ovulation

Question 115

What is the mode of action of the Progestogen-only pill (excluding desogestrel)

Answer 115

Thickens cervical mucus

Question 116

What is the mode of action of the Desogestrel-only pill

Answer 116

Primary: Inhibits ovulation
Also: thickens cervical mucus

Question 117

What is the mode of action of the Injectable contraceptive (medroxyprogesterone acetate)

Answer 117

Primary: Inhibits ovulation
Also: thickens cervical mucus

Question 118

What is the mode of action of the Implantable contraceptive (etonogestrel)

Answer 118

Primary: Inhibits ovulation
Also: thickens cervical mucus

Question 119

What is the mode of action of the Intrauterine contraceptive device

Answer 119

Decreases sperm motility and survival

Question 120

What is the mode of action of the Intrauterine system (levonorgestrel)

Answer 120

• *Primary**: Prevents endometrial proliferation
• *Also**: Thickens cervical mucus

Question 121

What is the mechanism of Levonorgestrel emergency contraceptive?

Answer 121

inhibits ovulation

Question 122

What is the mechanism of Ulipristal emergency contraceptive?

Answer 122

inhibits ovulation

Question 123

A 53-year-old woman presents with urgency and frequency. Two weeks ago she consulted with a colleague as she felt ‘dry’ during intercourse. She has been treated for urinary tract infections on multiple occasions in the past but urine culture is always negative. Her only medication is continuous hormone replacement therapy.

A vaginal examination is performed which shows no evidence of vaginal atrophy and no masses are felt. An ultrasound is requested:

Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 5 cm complex ovarian cyst noted on left ovary. Right ovary and uterus normal

What is the most appropriate next step?

Answer 123

Any ovarian mass in a post-menopausal woman needs to be investigated.

Question 124

How are ovarian cysts managed?

Answer 124

Premenopausal women

• a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.

Postmenopausal women

• by definition physiological cysts are unlikely
• any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynecology for assessment

Question 125

A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test.

Which blood test is this?

Answer 125

Anti-Xa activity

Question 126

You review a 34-year-old woman who is 13 weeks pregnant. During her previous pregnancy she developed pre-eclampsia and had to have a caesarean section at 36 weeks gestation. Her blood pressure both following the last pregnancy and today is normal.

Which one of the following interventions should be offered to reduce the risk of developing pre-eclampsia again?

Answer 126

Low-dose aspirin

Question 127

A 25-year-old medical student has attended her GP practice for her first smear test. She is interested in the testing process and understands that the sample is initially tested for high risk strains of HPV. The student asks the practice nurse what will happen if the smear test is found to be positive in the laboratory.

If the smear test is found to be high risk HPV (hrHPV) positive, what test will be performed next?

Answer 127

If a cervical smear sample is hrHPV +ve then it is examined cytologically

Cervical smear samples are initially tested for high risk HPV (hrHPV). Cytology testing will only be performed if the sample is found to be hrHPV positive. If the sample is hrHPV negative, cytology testing is not required.

Question 128

A woman who is 34 weeks pregnant is admitted to the obstetric ward. She has been monitored for the past few weeks due to pregnancy-induced hypertension but has now developed proteinuria. Her blood pressure is 162/94 mmHg. Which drug is most appropriate to commence?

Answer 128

Labetalol is first-line for pregnancy-induced hypertension

Question 129

An 18-year-old female presents to her GP as she has missed one of her Microgynon 30 pills yesterday morning. She has taken Microgynon for the past 2 years and is currently 4 days into a packet of pills. She had sexual intercourse last night and is unsure what to do. She took yesterday’s pill and today’s pill this morning. What is the correct management?

Answer 129

If 1 pill is missed (at any time in the cycle)

• take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
• no additional contraceptive protection needed

Question 130

What would you advise a patient who has missed two oral contraceptives before UPSI?

Answer 130

• if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
• if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Question 131

A 38-year-old new mother is brought into the GP by her husband a month after giving birth. He is concerned about her current mood and states she has slept and ate very little since the baby was born.

What is the best next step?

Answer 131

Ask the mother to complete the ‘Edinburgh depression scale

Question 132

A 36-year-old woman has delivered her second child at 38 weeks gestation. She had a physiological third stage of labour without drugs. Five minutes after delivery she has a sudden gush of approximately 750 mL of blood. Her vital signs are stable. How should she be initially managed?

Answer 132

An atonic uterus is far the most likely cause of primary post-partum haemorrhage. Due to the degree of blood loss this woman should be advised to have Syntometrine or oxytocin to contract her uterus.

Question 133

A 29-year-old female patient has a telephone consultation with her GP, worried about an incident that occurred two days ago. She is currently 18 weeks pregnant, with no complications thus far. She works in a children’s nursery. Her boss called her today, informing her that one of the children she had cared for, two days prior, has since developed a chickenpox rash. The patient is worried about the impact that this exposure may have on her pregnancy. She feels well in herself and has no symptoms, nor rash. She is uncertain of whether or not she had chickenpox herself as a child.

What is the most appropriate management?

Answer 133

Given that the patient is asymptomatic, and uncertain about her immune status, antibodies should be checked and the result awaited, before taking action.

Giving varicella-zoster immunoglobulin (VZIG) now would be appropriate if she was certain that she has never had chickenpox herself.

Question 134

Risk factors for ovarian cancer

Answer 134

Risk factors

• family history: mutations of the BRCA1 or the BRCA2 gene
• many ovulations*: early menarche, late menopause, nulliparity

Question 135

A 22-year-old lady presents to the general practitioner for advice about her current contraception, microgynon 30. She went away for a few days this week and forgot to bring her pill packet resulting in her missing pills. The last pill she took was 76 hours ago, and she is unsure what to do now. The missed pills were from week 3 of her pack and she has not missed any other pills this month. She has had intercourse in the last week for which she did not use barrier contraception.

What advice should you give her?

Answer 135

Take 2 pills today, then finish the current pack, omit the pill-free interval and start the new pack immediately

Question 136

define Placental abruption

Answer 136

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Question 137

How is placental abruption managed?

Answer 137

Fetus alive and < 36 weeks

• fetal distress: immediate caesarean
• no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks

• fetal distress: immediate caesarean
• no fetal distress: deliver vaginally

Fetus dead

• induce vaginal delivery

Question 138

A 34-year-old woman attends a routine antenatal clinic at 16 weeks gestation.
She has no significant past medical history but suffers with occasional frontal headaches.

She is noted to have a blood pressure of 148/76mmHg.

Urinalysis reveals;

pH6.5Protein+1Nitrates0Leuc0Blood0

What is the most likely diagnosis?

Answer 138

chronic hypertension

Question 139

You review the blood results taken from a pregnant woman at her booking visit. In addition to the standard antenatal bloods she also had her rubella status checked as she didn’t have the MMR vaccine as a child. She is now 11 weeks pregnant and currently well.

Rubella IgGNOT detected

What is the most appropriate course of action?

Answer 139

Advise her of the risks and the need to keep away from anyone who has rubella

• MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

Question 140

When does the anomaly scan occur?

Answer 140

18 - 20+6 weeks

Question 141

When does nuchal screening take place?

Answer 141

11 - 13+6 weeks

Question 142

When does the booking visit take place?

Answer 142

8 - 12 weeks

Question 143

A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.

What is the most appropriate management for prophylaxis of Rhesus sensitisation?

Answer 143

One dose of Anti-D immunoglobulin followed by a Kleihauer test

Question 144

What is a Kleihauer test?

Answer 144

A Kleihauer test is a test for FMH which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.

Question 145

A 63-year-old nulliparous lady presents to her general practitioner with symptoms of abdominal bloating and diarrhoea. She has a family history of irritable bowel syndrome. On examination, the abdomen is soft and non-tender with a palpable pelvic mass. Which one of the following is the most suitable next step?

Answer 145

If suspicion of ovarian cancer but there is an abdominal or pelvic mass, CA125 and US test can be bypassed and the patient directly referred to gynaecology

Question 146

A 42-year-old female has just delivered her second and final child at 41 weeks gestation. She has currently been in the third stage of labour for 64 minutes. She has so far lost 2800ml of blood. Her previous baby was delivered by elective caesarean-section. Her only past medical history is pelvic inflammatory disease.

Due to her risk factors, an antenatal ultrasound was performed and confirmed the underlying diagnosis. Unfortunately, the results of this scan had not been seen by the delivery team until now.

What is the most definitive treatment of the underlying problem?

Answer 146

hysterectomy

Question 147

A 23-year-old woman presents because she is suffering from a low mood for around 1 week every month, just before her period begins. She states that she feels tearful and lacks motivation, these symptoms improve when her period starts. The symptoms bother her but are not impacting her work or personal life.

She has a 28-day regular cycle, does not have heavy or painful periods and denies any inter-menstrual bleeding. She is in a long term relationship and uses condoms for contraception. She does not want to conceive in the next few years.

What treatment should you offer for relief of her premenstrual symptoms?

Answer 147

Premenstrual syndrome: a new-generation combined oral contraceptive pill may be helpful

Question 148

A 23-year-old woman presents because she is suffering from a low mood for around 1 week every month, just before her period begins. She states that she feels tearful and lacks motivation, these symptoms improve when her period starts. The symptoms bother her but are not impacting her work or personal life.

She has a 28-day regular cycle, does not have heavy or painful periods and denies any inter-menstrual bleeding. She is in a long term relationship and uses condoms for contraception. She does not want to conceive in the next few years.

What treatment should you offer for relief of her premenstrual symptoms?

Answer 148

Premenstrual syndrome: a new-generation combined oral contraceptive pill may be helpfu