gynae and obs

Question 1

what happens to the ovaries during follicular phase and luteal phase?

Answer 1

Follicular
A number of follicles develop.
One follicle will become dominant around the mid-follicular phase

Luteal phase
Corpus luteum

Question 2

what happens to the endometrium during follicular phase and luteal phase?

Answer 2

Follicular phase
Proliferation of endometrium

Luteal phase
Endometrium changes to secretory lining under influence of progesterone

Question 3

what happens to LH and FSH during the follicular phase?

Answer 3

A rise in FSH results in the development of follicles which in turn secrete oestradiol
When the egg has matured; it secretes enough oestradiol to trigger the acute release of LH. This in turn leads to ovulation.
(LH surge leads to ovulation)

Question 4

what happens to progesterone and oestradiol during the luteal phase?

Answer 4

Progesterone secreted by corpus luteum rises through the luteal phase.
If fertilisation does not occur the corpus luteum will demise and progesterone levels fall
Oestradiol levels also rise again during the luteal phase

Question 5

what happens to cervical mucus during follicular phase?

Answer 5

Following menstruation the mucus is thick and forms a plug across the external os
Just prior to ovulation the mucus becomes clear, acellular, low viscosity. It also becomes ‘stretchy’ - a quality termed spinnbarkeit

Question 6

what happens to the cervical mucus during luteal phase?

Answer 6

Under the influence of progesterone it becomes thick, scant, and tacky

Question 7

what happens to basal body temperature during follicular phase?

Answer 7

Falls prior to ovulation due to the influence of oestradiol

Question 8

what happens to basal body temperature during luteal phase?

Answer 8

Rises following ovulation in response to higher progesterone levels

Question 9

what is primary amenorrhoea vs secondary?

Answer 9

Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer).

Question 10

what are the causes of primary amenorrhoea?

Answer 10

• Turner’s syndrome
• Testicular feminisation
• Congenital adrenal hyperplasia
• Congenital malformations of the genital tract

Question 11

what are the causes of secondary amenorrhoea?

Answer 11

• Hypothalamic amenorrhoea (e.g. Stress, excessive exercise)
• Polycystic ovarian syndrome (PCOS)
• Hyperprolactinaemia
• Premature ovarian failure
• Thyrotoxicosis (but hypothyroidism can also cause)

Question 12

what investigations are used for amenorrhoea?

Answer 12

• Exclude pregnancy with urinary or serum bHCG
• Gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest
an ovarian problem (e.g. Premature ovarian failure)
• Prolactin
• Androgen levels: raised levels may be seen in PCOS
• Oestradiol
• Thyroid function tests

Question 13

what happens to blood pressure in normal pregnancy?

Answer 13

in normal pregnancy:
• Blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
• After this time the blood pressure usually ↑ to pre-pregnancy levels by term

Question 14

what is hypertension in pregnancy defined as?

Answer 14

Hypertension in pregnancy in usually defined as:
• Systolic > 140 mmHg or diastolic > 90 mmHg
• Or an ↑ above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Question 15

what 3 groups should hypertensive pregnant ladies be divided into?

Answer 15

-Pre-existing hypertension
-Pregnancy-induced hypertension (PIH, gestational hypertension)
-Pre-eclampsia

Question 16

what is pre-existing hypertension?

Answer 16

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no edema
Occurs in 3-5% of pregnancies and is more common in older women

Question 17

what is pregnancy induced hypertension?

Answer 17

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no edema
Occurs in around 5-7% of pregnancies
Resolves following birth (typically after 1 month). Women with PIH are at ↑ risk of future pre-eclampsia or HTN later in life

Question 18

what is pre-eclampsia?

Answer 18

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Edema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies

is a condition seen after 20 weeks gestation characterized by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Edema used to be third element of the classic triad but is now often not included in the definition as it is not specifi

Question 19

what complications can pre-eclampsia lead to?

Answer 19

• Fetal: prematurity, intrauterine growth retardation
• Eclampsia
• Hemorrhage: placental abruption, intra-abdominal, intra-cerebral
• Cardiac failure
• Multi-organ failure

Question 20

long list of risk factors for pre-eclampsia: list a few

Answer 20

• > 40 years old
• Nulliparity (or new partner)
• Multiple pregnancy
• Body mass index > 30 kg/m^2
• Diabetes mellitus
• Pregnancy interval of more than 10 years
• Family history of pre-eclampsia
• Previous history of pre-eclampsia
• Pre-existing vascular disease such as hypertension or renal disease

Question 21

describe the management of pre-eclampsia

Answer 21

a woman at moderate or high risk of pre-eclampsia should take aspirin 75mg daily from 12 weeks gestation until the birth
consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold
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. The timing depends on the individual clinical scenario

Question 22

describe the management of eclampsia

Answer 22

Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
should be given once a decision to deliver has been made
in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Magnesium sulphate - monitor reflexes + respiratory rate
Fluid restrict to prevent overload

Question 23

what is HELLP?

Answer 23

HELLP is an abbreviation of the main findings:
• Hemolytic anemia
• Elevated Liver enzymes and
• Low Platelet count

Question 24

why is pregnancy a hypercoagulable state?

Answer 24

Pathophysiology
• ↑ in factors VII, VIII, X and fibrinogen
• ↓ in protein S
• Uterus presses on IVC causing venous stasis in legs

Question 25

what is the treatment for DVT/PE in pregnancy?

Answer 25

warfarin contraindicated
S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)

Question 26

Cholestasis of pregnancy:
-who is this seen in?
-who is this more commonly seen in?
-what is the most common symptom?
-what happens to ALT and ALP?

Answer 26

• Seen across maternal ages and in both nulliparous and primiparous women
• More common in women with a history of cholestasis associated with OCP use and those who
have a family history of cholestasis in pregnancy.
• Itching is the commonest symptom of cholestasis of pregnancy
• Severe jaundice is uncommon.
• Both ALT and Alk P are ↑.

Question 27

what is the management of cholestasis in pregnancy?
-what is the prognosis?

Answer 27

• Long-term maternal outcome is good, although the risk of gallstones is ↑.
• The condition rapidly resolves after delivery of the child.
• Prior to delivery, antihistamines, benzodiazepines and ursodeoxycholic acid may all have a role
to play in symptom relief

Question 28

what is peripartum cardiomyopathy?
-what is the cause?
-what are the symptoms?

Answer 28

Peripartum Cardiomyopathy: is a dilated cardiomyopathy of uncertain aetiology occurring in the last month of pregnancy or within 6 months after delivery. Symptoms are the same as those of cardiac failure in non-pregnant patients.

Question 29

what is included in the diagnosis of peripartum cardiomyopathy?

Answer 29

• Absence of any other cause for the cardiac failure
• Absence of heart disease before the last month of pregnancy
• Documented systolic dysfunction (echo)
• Biopsy is useless

Question 30

what is the treatment for peripartum cardiomyopathy?

Answer 30

• Same as for cardiac failure, although ACE inhibitors should be avoided
• Mainstay of medical treatment is digoxin and loop diuretics. If indicated nitrates and inotropic
support with dobutamine should be used.
• Heparin (during pregnancy) or Warfarin (postpartum) for the hypercoagulopathy (caused by
cardiomyopathy + peripartum)
• Salt or Na+ restriction

Question 31

what is the prognosis of peripartum cardiomyopathy?

Answer 31

Prognosis:
• 50% recover to normal
• Recurrence is high in further pregnancies
• If no recovery, heart transplantation is needed

Question 32

what are the features of PCOS?

Answer 32

• Subfertility and infertility
• Menstrual disturbances: oligomenorrhea and amenorrhoea
• Hirsuitism, acne (due to hyperandrogenism)
• Obesity
• Acanthosis nigricans (due to insulin resistance)

Question 33

what investigations are used in PCOS?

Answer 33

• Pelvic ultrasound
• FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a
‘classical’ feature but is no longer thought to be useful is diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
• Check for impaired glucose tolerance

Question 34

what is the treatment for hirsutism and acne in PCOS?

Answer 34

Hirsuitism and acne
• A COC pill may be used help manage hirsuitism. Possible options include a third generation
COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action.
Both of these types of COC may carry an ↑ risk of venous thromboembolism
• If doesn’t respond to COC then topical eflornithine may be tried
• Spironolactone, flutamide and finasteride may be used under specialist supervision

Question 35

what is the treatment for infertility in PCOS?

Answer 35

weight reduction if appropriate
the management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation
a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS
metformin is also used, either combined with clomifene or alone, particularly in patients who are obese
gonadotrophins

Question 36

how does clomifene work?

Answer 36

*work by occupying hypothalamic oestrogen receptors without activating them. This interferes with the binding of oestradiol and thus prevents negative feedback inhibition of FSH secretion

Question 37

what are the causative organisms in pelvic inflammatory disease?

Answer 37

• Chlamydia trachomatis - the most common cause
• Neisseria gonorrhoeae
• Mycoplasma genitalium
• Mycoplasma hominis

Question 38

what are the features of pelvis inflammatory disease?

Answer 38

• Lower abdominal pain
• Fever
• Deep dyspareunia
• Dysuria and menstrual irregularities may occur
• Vaginal or cervical discharge
• Cervical excitation

Question 39

what should be screened for in PID?

Answer 39

• Screen for Chlamydia and Gonorrhoea

Question 40

what is the management of PID?

Answer 40

• Due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
• Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
• RCOG guidelines suggest intrauterine contraceptive devices may be kept in in mild cases

Question 41

what are the complications found in PID?

Answer 41

Complications
• Infertility - the risk may be as high as 10-20% after a single episode
• Chronic pelvic pain
• Ectopic pregnancy

Question 42

what are familial risk factors for breast ca?

Answer 42

• Mother or sister diagnosed with breast cancer before the age of 40 years
• Close relatives from the same side of the family diagnosed with breast cancer at least one must
be a mother, sister or daughter
• 3 close relatives diagnosed with breast cancer at any age
• Father or brother diagnosed with breast cancer at any age
• Mother or sister with breast cancer in both breasts (the first cancer diagnosed before the age of
50 years)
• 1 close relative with ovarian cancer and one with breast cancer, diagnosed at any age at least
one must be a mother, sister or daughter.

Question 43

Long list of non-familial risk factors for Breat Ca - name a few

Answer 43

• Early NOT late menarche
• Late menopause
• Obesity
• Nulliparity
• Late pregnancy
• benign breast disease
• Oral contraceptives
• Hormone-replacement therapy
• Excess alcohol intake
• elevated insulin-like growth factor 1.

Question 44

is ovarian cancer common?
-what is the peak age of incidence?
-what is the prognosis?

Answer 44

Ovarian cancer is the fifth most common malignancy in ♀s. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin.

Question 45

what are the risk factors for ovarian ca?

Answer 45

Risk factors
• Family history: mutations of the BRCA1 or the BRCA2 gene
• Many ovulations: early menarche, late menopause, nulliparity

Question 46

does infertility treatment increase the risk of ovarian Ca?

Answer 46

It is traditionally taught that infertility treatment ↑ the risk of ovarian cancer, as it ↑ the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill ↓ the risk (fewer ovulations) as does having many pregnancies.

Question 47

what are the clinical features of ovarian ca?

Answer 47

Clinical features are notoriously vague
• Abdominal bloating
• Pelvic pain
• Urinary symptoms e.g. Urgency
• early satiety, bloating

Question 48

what is the diagnosis for ovarin ca?

Answer 48

Diagnosis is difficult and usually involves diagnostic laparotomy

Question 49

what are the risk factors for cervical ca?

Answer 49

Risk Factors: (Christiana is a poor lady who smoked cigarettes and became prostitute at a young age)
• Christians (male non-circumcision)
• Low socioeconomic status
• Smoking
• Multiple partners
• Commencement of sexual intercourse and/or pregnancy at young age
• Human papillomavirus (HPV), of course the 1st risk factor

Question 50

describe the cervical cancer screening programme?

Answer 50

Screening: Under the present UK Department of Health guidelines
• Women are sent their first invitation for routine screening at 25 years age.
• Then invited for screening every three years until the age of 49 years.
• From 50 to 64 years they are invited for screening every five years.
• Women who have had treatment for abnormal cells on the cervix may need to have a screening
test more often.
• After 65 years no need to have cervical screening unless they have had recent cervical changes,
or for some reason they have not had a screening test since the age of 50 years.

Question 51

what is the common finding in a cervical smear?

Answer 51

Common finding in cervical smear is Dyskaryosis or dysplasia refers to the precancerous change in cells. There are four types: borderline, mild, moderate and severe.
A smear result may also refer to CIN (cervical intraepithelial neoplasia); CIN1, CIN2, or CIN3 instead of mild, moderate or severe. This classification is not strictly accurate as CIN can only really be diagnosed with a biopsy.

Question 52

what happens:
-if smear shows mild change
-if two smears show mild change
-when is it safe to go back to routine screening?
-if smear show moderate or severe changes

Answer 52

• If the result shows mild cell changes or CIN1 → repeat smear in 6 months. Sometimes these slightly abnormal cells can go back to normal by themselves.
• If the next smear is abnormal, then referral is made for colposcopy.
• NHS guidelines: there should be 3 negative 6-monthly smears, before it is safe to go back to
routine screening.
• Women with smears showing moderate or severe precancerous changes will be referred for
colposcopy as they have a significant risk of proceeding to cervical cancer if left untreated.

Question 53

when is it unable to fly after pregnancy?

Answer 53

Pregnancy
• Most airlines do not allow travel after 36 weeks for a single pregnancy and after 32 weeks for a multiple pregnancy
• Most airlines require a certificate after 28 weeks confirming that the pregnancy is progressing normally