GOSH

Question 1

Which antihypertensives are not used in pregnancy and why?

Answer 1

ACE inh, ARBs, thiazide or thiazide-like diuretics due to an increased risk of congenital abnormalities

Question 2

When should you avoid giving Labetalol in pregnancy?

Answer 2

If they are asthmatic or diabetic

Question 3

What is eclampsia?

Answer 3

It is defined as the occurrence ofone or more convulsions in a pre-eclamptic womanin the absence of any other neurological or metabolic causes.

Question 4

What makes up the triad of pre-eclampsia?

Answer 4

hypertension
proteinuria
oedema
(post 20 weeks gestation)

Question 5

What is a common complication of C sections and what is the presentation?

Answer 5

Endometritis is common following a C section and refers to the inflammation of the endometrial lining. It is usually as a result of an infection and presents with vaginal bleeding

Question 6

When do NICE guidelines say that you can insert an intrauterine system after delivery?

Answer 6

either within 48 hours of delivery or 4 weeks postpartum because there is a higher risk of uterine perforation

Question 7

Which method of contraception can be started any time after delivery?

Answer 7

progesterone-only pill

Question 8

How long after delivery can all forms of contraception be considered?

Answer 8

after six weeks postpartum

Question 9

What are some contraindicators of the COCP?

Answer 9

smoking, age over 35, <6 weeks postpartum

Question 10

Which routine prophylaxis is given to all women undergoing a total abdominal hysteroscopy?

Answer 10

Co-amoxiclav IV intraoperatively

Question 11

What is the most likely cause of primary infertility in the following patient: a 32 y.o. woman has a regular menstrual cycle but describes severe dysmenorrhoea and deep dyspareunia. She has no other medical or surgical history of note. O/E she has a fixed retroverted uterus. Her 35 y.o. male partner has no medical history of note.

Answer 11

Given her age (25-35 years) and the fixed retroverted uterus, the most likely diagnosis is endometriosis.

Question 12

What is oesophageal atresia?

Answer 12

a birth defect in which part of a baby’s oesophagus doe snot develop properly. This results in an impairment of swallowing by the fetus leading to polyhydramnios

Question 13

Which meds can and can not be used as pain relief in breast feeding?

Answer 13

can: paracetamol and ibuprofen, and codeine and other opiates can be used sparingly as 3rd line meds
cannot: aspirin (risk of infant developing Reye’s disease)

Question 14

When does premenstrual syndrome occur?

Answer 14

in the late luteal phase

Question 15

a 24 y.o. woman in a stable relationship presents in the clinic with a 1 year history of lower abdo pain, deep dyspareunia, secondary dysmenorrhoea and an inability to conceive. What is the most likely diagnosis?

Answer 15

Endometriosis: clinical features are lower abdo pain, deep dyspareunia, subfertility and secondary dysmenorrhoea. The mention of a stable relationship implies that PID should not be your first choice of answer

Question 16

a 49 y.o. woman noticed an increase in her abdominal girth, alongside other symptoms of constipation and weight loss. What is the most liekly diagnosis?

Answer 16

the patient is of premenopausal age and has noticed a swelling of abdo circumference, together with weight loss and constipation. One has to think malignant, potentially already advanced, ovarian tumour

Question 17

When is oral glucose tolerance test offered?

Answer 17

test at 24-28 weeks

Question 18

When should women have a routine smear test after pregnancy?

Answer 18

When women are pregnant, if they are due for a routine smear test, the screening is deferred until at least 3 months post-delivery

Question 19

Why are elective C sections typically planned for >39 weeks gestation?

Answer 19

reduces the risk of respiratory distress in newborn

Question 20

Which medication is typically administered intra-operatively to aid delivery of the placenta?

Answer 20

Oxytocin 5iu is given IV by the anaesthetist to aid delivery of the placenta by controlled cord traction by the surgeon

Question 21

Which of the following structures is NOT incised during a routine C section: Camper’s fascia, external oblique muscle, rectus abdominus, anterior rectus sheath?

Answer 21

external oblique

Question 22

Which of the following would be classed as a late complication of a C section: bladder trauma, VTE, fetal laceration, placenta praevia?

Answer 22

Placenta praevia
Fetal laceration and bladder trauma can happen intraoperatively so are immediate complications. VTE is classed as an intermediate complication

Question 23

What is Sheehan’s syndrome?

Answer 23

Hypopituitarism secondary to pituitary infarction due to haemorrhagic shock in labour and the peripartum period. The anterior pituitary is usually affected as blood supply to it is from the low-pressure hypophyseal portal system, whereas the posterior pituitary has its own direct arterial supply and is typically unaffected.

Question 24

A 45 y.o. hypertensive multiparous woman who smokes 25 cigarettes per day presents to the ED with a convulsion. She is currently 12 weeks pregnant. She has never had a convulsion before. What is the most likely cause?

Answer 24

Cerebral infarction - age, hypertension and heavy cigarette smoking, combined with her pregnancy, make an atherosclerotic cause for convulsion very likely

Question 25

What is the treatment of choice for hypertension in the setting of pre-eclampsia/eclampsia?

Answer 25

hydralazine or labetalol infusion

Question 26

A 33 y.o. woman who is exclusively breastfeeding presents 4 months postpartum with burning pains and itching of the nipples. She has occasional sharp pains behind the areolae and reports that symptoms are worse after feeding. O/E both nipples appear erythematous and inflamed, with small fissures. On further questioning, she reports no history of atopy. She also tells you that last night, she noticed some white patches in her infant’s mouth that she tried to wipe off but were stuck on the mucosa. What is the most likely diagnosis?

Answer 26

Nipple thrush

Question 27

What. is the treatment of nipple thrush?

Answer 27

give the mother topical miconazole after feeds for 2 weeks and the baby with oral miconazole gel. This is licensed for infants of 4 months of age and above

Question 28

A 29 y.o. woman with epilepsy, associated with generalised tonic-clonic seizures presents with her partner to her routine Epilepsy Clinic appointment. She is currently on the combined oral contraceptive pill, but she wishes to start trying for a baby. She is currently taking sodium valproate and has been seizure-free all year. What is the most appropriate antiepileptic medication for this patient to take during the pre-conception period and pregnancy?

Answer 28

Stop sodium valproate and commence lamotrigine

Question 29

A 25 y.o. man presents to his GP complaining of painful, swollen lymph nodes around his groin. He had recently visited friends in the Caribbean and tells you that he had unprotected sex with 2 local women. A couple of weeks before the painful lymph nodes began, he noticed a small, painless ulcer on his penis. O/E he noticed a very large, painful, inguinal lymph nodes. A lymph node biopsy shows stellate lymph node abscess. PCR is positive for Chlamydia. WHat is the most likely diagnosis?

Answer 29

lymphogranuloma venereum - an endemic form of Chlamydia infection, present in several areas of the world, including the Caribbean, It begins with a painless ulcer, which is followed a few weeks later by severe painful inguinal lymphadenopathy.

Question 30

A 57 y.o. woman is referred to Gynae as she has been suffering from unexplained abdo bloating and pain for several months. She has no other symptoms and exam is normal, asides from her obesity. She recently began experiencing menopausal symptoms, and started on HRT. She had a right sided salpingo oopherectomy for polycystic ovaries when she was 23 y.o. and has never had children. Which cancer is this woman most likely to be at risk of having?

Answer 30

Classic symptoms of endometrial cancer: unexplained abdo pain and bloating. RF: history of PCOS, and being nulliparous and menopause past age 52; other: obesity, endometrial hyperplasia, diabetes, tamoxifen and unopposed oestrogen

Question 31

which medication should be given to woman with 10 weeks gestation who is experiencing nausea and vomiting?

Answer 31

cyclizine is first line

Question 32

Sarah is a 28 y.o. woman who attended for cervical screening 1 week ago. She is well with no past medical history. Her result is positive for high-risk human papillomavirus (hrHPV). Cervical cytology has returned as inadequate. What is the most appropriate next step?

Answer 32

If smear inadequate then repeat within 3 months.

Question 33

A 72 y.o. 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 33

endometrial adenocarcinoma

Question 34

A 33 y.o. woman presents to the GP as she has not had a period for 6 months. She has also noticed that she is sweating more at night and has started to have occasional hot flush, although she thinks this may just be due to the weather. She does not want children and has only com today to check there is no sinister cause for her lack of periods. She has no past medical history and no family history.
Blood tests show high FSH and low oestradiol. What is the most appropriate management?

Answer 34

Combined hormone replacement therapy (or hormone replacement therapy) should be offered to women until the age of 51 for premature ovarian insufficiency

Question 35

A 28-year-old woman presents with cyclical pelvic pain that is worse around her periods. The pain starts 2 days before the period and lasts until several days after. She has associated dyspareunia and has had some painful bowel movements. Paracetamol and ibuprofen previously helped, however, they no longer do.
An examination reveals generalised tenderness, a fixed and retroverted uterus and uterosacral ligament nodules. Her BMI is 29 kg/m². She would like to start a family next year but does not mind taking contraceptives if she is able to stop and conceive then.
What is the next best step in her management?

Answer 35

offer combined oral contraceptive pill
if analgesia doesn’t help endometriosis then the combined oral contraceptive pill or a progestogen should be tried

Question 36

When should a repeat semen sample be done if it is abnormal?

Answer 36

If a semen sample is abnormal, a repeat test should be arranged ideally 3 months later

Question 37

A 48-year-old woman visits her general practitioner with a 6-week history of unbearable hot flushes and vaginal dryness. She suspects that she is going through menopause. Her past medical history includes hypothyroidism and psoriasis. She takes regular levothyroxine and has the Mirena intrauterine system in situ.
What is the most appropriate additional treatment to initiate for this patient?

Answer 37

Estradiol
The Mirena intrauterine system is licensed for use as the progesterone component of HRT for 4 years

Question 38

A 39-year-old female with a history of chronic pelvic pain is diagnosed with endometriosis. Which one of the following is not a recognised treatment for this condition?
Dilation and curettage
Gonadotrophin-releasing hormone analogue
Combined oral contraceptive pill
Medroxyprogesterone acetate
Intrauterine system (mirena)

Answer 38

Dilation and curettage has no role in the management of endometriosis

Question 39

A well 35-year-old female attends the GP practice with her partner as she is struggling to become pregnant. They have been trying for a year with regular sexual intercourse. What is the most appropriate first line investigation?

Answer 39

A Day 21 progesterone
This is a non-invasive test and can tell you whether the patient is actually ovulating

Question 40

A couple presents to their GP asking for advice about fertility. They have been having unprotected sexual intercourse 3 times a week for 1 year.

The GP suggests semen analysis and measuring serum progesterone levels.

When is the most appropriate time to measure serum progesterone levels?

Answer 40

To confirm ovulation, take the serum progesterone level 7 days prior to the expected next period
A level >30 nmol/l indicates ovulation so other causes of infertility should be considered

Question 41

A 42-year-old Nigerian woman presents with a 3 month history of menorrhagia and pelvic pain. On examination there is a palpable, firm, non-tender abdominal mass arising from the pelvis. Pelvic ultrasound confirms the presence of a large uterine fibroid. A decision is taken to perform a hysterectomy. Which medication would be most appropriate in preparation for her surgery?

Answer 41

For patients with uterine fibroids, GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment

Question 42

A 72-year-old woman with ovarian cancer is seen in the gynaecological oncology clinic. There, the consultant talks through her pre-surgical prognosis, based on her risk malignancy index (RMI). What are the three components of the RMI?

Answer 42

Risk malignancy index (RMI) prognosis in ovarian cancer is based on US findings, menopausal status and CA125 levels

Question 43

An 18-year-old girl attended her routine appointment at the hospital. At age 1, she had surgery to remove bilateral abdominal masses, which her parents noticed.

At 14, she had not had her first menstruation, and Tanner’s staging was 1. She was started on medical treatment, and during her recent follow-up, her Tanner staging was assessed as stage 2.

Given the likely diagnosis, what is the genotype?

Answer 43

46XY
Primary amenorrhoea, little or no axillary and pubic hair, elevated testosterone → androgen insensitivity syndrome
The condition presented is androgen insensitivity syndrome; the child is genotypically male but presents as female phenotypically. This is due to a mutation in the gene encoding the androgen receptor causing resistance to testosterone. The abdominal masses removed were undescended testes. The absence of menstruation is contributed by the lack of development of internal female genitalia due to the anti-Mullerian hormone produced by the testes. She was started on estrogen hormone replacement to help with physical female characteristics development, which subsequently led to breast development described as Tanner stage 2.

Question 44

A 28-year-old woman who is 11 weeks pregnant is referred to the early pregnancy assessment unit with a one day history of abdominal pain and vaginal bleeding. A trans-vaginal ultrasound scan confirms a failed intra-uterine pregnancy. The patient is currently afebrile and haemodynamically stable, but has a past medical history of Von Willebrand disease.

What is the most appropriate initial management of this patients miscarriage?

Answer 44

vaginal misoprostol
vaginal misoprostol is most appropriate as the patients past medical history of coagulopathy (Von Willebrand disease) is a contra-indication to expectant management, but not medical management.

Question 45

A 29-year-old woman visits her GP. She is currently 10 weeks pregnant. After discussion with her partner, she has decided to have the pregnancy terminated. The GP makes the appropriate referral and the termination is conducted.

Two weeks later, she phones the GP, sounding concerned. She has performed a urine pregnancy test and it is still showing as positive.

For what maximum period following termination is this considered normal?

Answer 45

Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast

Question 46

A 75-year-old woman presents with urinary incontinence. She describes a sudden and very intense need to pass urine which is often followed by incontinence. She has a past medical history of Alzheimer’s disease and closed-angle glaucoma.

What is the preferred treatment?

Answer 46

Anticholinergics for urge incontinence are associated with confusion in elderly people - mirabegron is a preferable alternative

Question 47

Polycystic ovarian syndrome (PCOS) increases the long-term risk of which cancerous conditions?

Answer 47

endometrial cancer

Question 48

A 34-year-old woman has oligomenorrhoea with only 1-2 menstrual periods a year. She also has mild acne and hirsutism. Her pelvic ultrasound scan confirms the appearance of polycystic ovaries, with normal endometrial thickness. She is sexually active and is not using any regular contraception, but does not wish to get pregnant for another 3 years. Her body mass index (BMI) is 37 kg/m2. Her HbA1c is normal.
Treatment?

Answer 48

Levonorgestrel-releasing intrauterine system

Question 49

A 34-year-old woman has oligomenorrhoea with only 1-2 menstrual periods a year. She also has mild acne and hirsutism. Her pelvic ultrasound scan confirms the appearance of polycystic ovaries, with normal endometrial thickness. She is sexually active and is not using any regular contraception, but does not wish to get pregnant for another 3 years. Her body mass index (BMI) is 37 kg/m2. Her HbA1c is normal.
Treatment?

Answer 49

Levonorgestrel-releasing intrauterine system

Question 50

A 35-year-old woman has irregular periods, acne and hirsutism. She has also been trying to conceive with her partner for 6 months but has been unsuccessful. A pelvic ultrasound scan has confirmed the presence of polycystic ovaries. She has tried losing weight and her current BMI is 28 kg/m2. Her HbA1c is normal
Management?

Answer 50

Referral to fertility services
As this woman has a known cause of infertility in the form of PCOS, she should be referred immediately to fertility services for consideration of further treatment. NICE recommends that these women be offered clomifene citrate or metformin, or a combination of the two, as first-line treatment. If this proves unsuccessful, laparoscopic ovarian drilling or gonadotrophins may be considered.