GYNECOLOGY

Question 1

Menstrual physiology:

Answer 1

Question 2

Answer 2

Question 3

amenorrea dx algo

Answer 3

Question 4

Answer 4

BREAST + UTERUS +

Question 5

BREAST + UTERUS -

Differentiate because pubic and axilary hair are absent

Answer 5

Question 6

breast - uterus +

Answer 6

A) Gonadal Dysgenesis (Turner syndrome) 45,X0 (missing x on 23 par)
Short stature ,ovarian insufficiency
Instead of developing ovaries they have streak gonads.
**Fsh levels elevated because of ** no feedback inhibition from estrogen to the pituitary.
Treatment: Estrogen and progesterone replacement.

B)Hypothalamic –Pituitary Failure :Kallman Syndrome: Inability of Hypothalamus to produce Gnrh and also anosmia because the defect is close to olfactory area.
FSH levels are low
Treatment: Estrogen and progesterone replacement for secondary sexual characteristics. *(also known as hypothalamic hypogonadism, familial hypogonadism with anosmia, or hypogonadotropic hypogonadism)

kallman = inherited condition, meaning it ispassed on from parents to their children. Mothers can passon the gene to their daughters and sons, but fathers can usually only pass it onto their daughters. The condition is five times more common in boys (one boy in every 10,000) than in girls.

Question 7

Answer 7

Question 8

Secondary amenorrhea:

3 main causes:

Answer 8

Question 9

Secondary amenorreah managment ?

Answer 9

1.First Step is to rule out Pregnancy through **Beta Hcg **.

Next step:??

2.Thyrotropin TSH:Hypothyroidism can lead to amenorrhea by elevating TRH that in turns elevates prolactin.Treatment:Thyroid replacement
3.Prolactin Level:Elevated prolactin level leads to amenorrhea through Gnrh.
- Medications:Anti psychotics and anti depressants have anti dopamine effect.
- Tumor: Pituitary Tumor and idiopathic.
- Hint:Dopamineand prolactin are inversely related

4 .** Progesterone Challenge** Test: PCT:
Administer a single dose of I/M progesterone or 7 days of oral medroxy-progesterone acetate.(MPA)

-Positive PCT: Withdrawl bleeding is diagnostic of anovulation.
-Negative PCT:reasons may be inadequate Estrogen or outflow tract obstruction.

5. Estrogen-Progesterone Challenge test: EPCT: **
- 21 days of oral estrogen followed by 7 days of MPA> Positive EPCT:
- Withdrawal bleed positive means inadequate estrogen.
- Etiology ?
- FSH?
- ●Low** FSH = CNS Pathology
- ●High FSH = Ovarian Failure .There can be two causes of Premature Ovarian failure:
- 1. X Chromosome Mosaicism:Premature ovarian failure (POF, OMIM 311360) is defined as the cessation of ovarian function before the age of 40, associated with elevated gonadotropins serum levels **(FSH ≥ 40 UI/l) **and affects at least 1%–3% of women of reproductive age,X chromosome can have multiple kind of defects during ageing in these people like deletions,tranlocations etc…

2.Savage Syndrome:
-1.Ovaries have follicles are present but don’t response to GNRH impulses
-2.Resistant ovary syndrome isone of the disease lead to ovarian failure and secondary amenorrhea. Diagnosis of this disease is based on having a normal 46, XX karyotype, normal secondary sexual characteristics, elevated follicle-stimulating and luteinizing hormone, and normal anti-Müllerian hormone.
————
Negative EPCT:
Absence of withdrawl bleeding
Cause could be outflow tract obstruction
-Asherman Syndrome: Result of extensive Curettage and infection induces Adhesions.
Next Step? Hysterosalpingogram.
Treatment:Hysterscopic adhenolysis followed by estrogen stimulation an inflatable stent is then placed to prevent readhesions**

Question 9

HEAVY MENSTRUAL BLEEDING

AND

DYSMENO

Answer 9

Question 10

HMB causes:

• most common sigle cause is DYSFUNCTIONAL UTERINE BLEEDING ( DUB)
• 2 types :

HMB causes:

Answer 10

Question 11

DUB investigations

Answer 11

Question 12

uterine causes:

HMB causes:

Answer 12

Question 13

systemic causes:

HMB causes:

Answer 13

Question 14

HMB TREATMENT :

Answer 14

1. non hormonal (nsaids or tranexamic acid)
2. hormonal (levonnogestrel mirena)

Question 15

emergency menorrhagia

Answer 15

Question 16

Uterine fibroids (leiomyoma):

Answer 16

Fibroids are benign tumours of smooth muscle of the myometrium. They are classified according to their location: subserosal, intramural, subendometrial or intra-uterine. They are oestrogen-dependent and shrink with the onset of menopause.

CLINICAL FEATURES:
Lifetime incidence of 60–70% in Caucasian women
Only 1 in 800 develop malignancy
Usually asymptomatic
SYMPTOMS:
Often asymptomatic if small
Menorrhagia
Dysmenorrhoea
Pelvic discomfort ±pain (pressure) including dyspareunia
Bladder dysfunction
Pain with torsion of pedunculatedfibroid
Pain with ‘red degeneration’—only in pregnancy (pain, fever, local tenderness)
Infertility (acts like IUCD if submucosal)
Calcification

MANAGEMENT:
Medical management the same as for DUB :
-Levonorgestrel IUD has now largely taken over as the Preferred option for reduction of bleeding.
-GnRH analogues—especially if >42 years can shrink fibroids (maximum 6 months)—use only immediately pre-operative

●Surgical options:
–myomectomy (remove fibroids only, esp. child-bearing years)
–hysteroscopic resection/endometrial ablation
–hysterectomy
●Other option: uterine embolisation

Question 17

Premenstrual Syndrome:

Answer 17

Premenstrual syndrome (PMS) is defined as a disorder of non-specific somatic, psychological or behavioral symptoms occurring during the late luteal phase of the menstrual cycle.The symptoms of PMS decrease in severity just before and during menstruation. Premenstrual Syndrome:
The most common psychological symptoms are depression and irritability, while headache, bloating and breast tenderness are the most common physical symptoms.

CLASSIFICATION:
It is convenient to classify PMS in terms of severity of symptoms.

●Mild:symptoms signal onset of menstruation. No medical advice sought or needed.
●Moderate:symptoms annoying but insufficient to interfere with function at home or work. Medical advice sought in about one-third.
●Severe:symptoms are such that functions at work or home are disrupted. Medical advice is usually sought. This disruptive form is labelled **PMDD **

Diagnosis:
Thorough history—including diet, exercise habits, psychosocial background, emotional influences and family history
Menstrual calendar—for 3 months, showing timing of the three main symptoms

Physical examination to exclude gynecological, endocrine or other systemic disease; and also include:–breast examination (if breast tenderness)–cervical screening test

Investigations (to exclude other causes):
●–thyroid function tests
●–full blood count
●–electrolytes and creatinine
●–FSH and oestradiol—if perimenopause suspected
●–serum androgens—if oligomenorrhoea present

**MANAGEMENT **
**Explanation, reassurance and insight
**Cognitive-based therapy , which has been shown to have a positive effect in several RCTs,is very Helpful.
●Keeping a diary
●Advise the patient to keep a daily diary of all her symptoms and when they occur over a 2–3 month period. This information should help her to plan around her symptoms: for example, avoid too many social events and demanding business appointments at the time when PMS symptoms are worst.

Dietary advice
1:Advise the patient to eat regularly and sensibly; eat small, frequent meals and aim for ideal weight.Increase amount of low-GI complex carbohydrates, leafy green vegetables and legumes.
Decrease or avoid: refined sugar, salt, alcohol, caffeine (tea, coffee, chocolate), tobacco, red meat and excessive fluid intake during premenstrual phase.
Decrease total protein to 1 g/kg/day; decrease fats.

Exercise
Recommend a program of regular exercise such as swimming, aerobics, jogging or tennis. Such exercise has been proven to decrease depression, anxiety and fluid retention premenstrually
Relaxation
Advise patients to plan activities that they find relaxing and enjoyable at the appropriate time. Consider stress reduction therapy, including meditation, yoga, relaxation techniques and appropriate counselling.Appropriate dress:loosedressing
●Medication:

●Pharmaceutical agents that have been used with success in some patients and little or no relief in others include diuretics (e.g. spironolactone), vitamins and minerals (e.g. pyridoxine and evening primrose oil), simple anti-inflammatories (e.g. aspirin, mefenamic acid) and hormonal preparations such as the **OCP. A combination of agents may have to be used.
SUPPLEMENTS:Women often enquire about the use of vitamins, minerals and herbal remedies for PMS. The evidence base for symptom relief so far is as follows:
pyridoxine/vitamin B6 up to 100 mg daily (evidence limited, beware nerve damage to hands/feet with higher doses)elemental calcium, 1200 mg to 1500 mg daily (two randomisedcontrolled trials have shown significant benefit)elemental magnesium** up to 400 mg daily (minimal evidence)evening primrose oil 500 mg daily (no benefit over placebo)Agnuscastus(Premular®) is an extract of the berries from the chaste tree (several small randomisedcontrolled trials have indicated some benefit over placebo)

ORAL CONTRACEPTION:It is appropriate to use a COC-containing ethinyloestradiol and drospirenone since a meta-analysis of drospirenone, which is a progestogenderivative of spironolactone, concluded that it was effective in reducing the severe symptoms of PMDD.
Moderate to severe PMDD:fluoxetine20 mg (o) or sertraline50 mg (o) daily in morning for 14 days before anticipated onset of menstruation and through to the first full day of menses of each cycle

Question 18

Atrophic vaginitis:

Answer 18

In the absence of oestrogen stimulation, the vaginal and vulval tissues begin to shrink and become thin and dry in old age in post menopausal women. This renders the vagina more susceptible to bacterial attack because of the loss of vaginal acidity. Rarely, a severe attack can occur with a very haemorrhagicvagina and heavy discharge:
●yellowish, non-offensive discharge
●tenderness and dyspareunia
●spotting or bleeding with coitus
●the vagina may be reddened with superficial haemorrhagicareas

TX
Oestrogen cream or pessary(e.g. Ovestin, Vagifem) daily at bedtime for 2–3 weeks, then once or twice weekly
●or
●zinc and castor oil soothing cream
●Note:perform a careful speculum examination.

Question 19

Answer 19

Question 20

VULVOVAGINAL CANDIDIASIS:
clinic

Answer 20

• Usually in the presence of estrogen.
• CLINICAL
• ●Intense vaginal and vulval pruritus
  -●Vulval soreness
  ●Vulval fissures
  ●Vulvo vaginal erythema(brick red)
  ●Vaginal excoriation and oedema
  ●White, curd-like discharge
  ●Superficial dyspareunia
  ●Dysuria

Question 21

VULVOVAGINAL CANDIDIASIS:
factors predisponing

Answer 21

ENDOGENOUS
●Diabetes mellitus●Pregnancy●Immune deficiency, e.g. HIV

EXOGENOUS
●Oral contraceptives (but cessation of the OCP does not usually improve candidiasis)
●MHT or topical oestrogen
●Antibiotics
●Corticosteroid therapy
●Immunosuppressants
●Orogenital/anogenitalintercourse
●IUCD
●Tight-fitting jeans
●Nylon underwear
●Wet bathing suit

Question 22

vaginal candidiasis
tx ?
chronic vulvovaginal candidiasis tx?

Answer 22

Question 23

resistan infection, candida
tx

Answer 23

Question 24

Trichomonas vaginalis: clinic tx

Answer 24

Flagellated protozoan Transmitted via sexual intercourse. In Australia, trichomonasis more common in older women and women from regional and remote areas, especially **Aboriginal and Torres Strait Islander ------------------- **Profuse, thin discharge (grey to yellow–green in colour) ** ●**Small bubbles **may be seen in 20–30% ●**Vulval itch** ●**Malodorous** discharge ●Dyspareunia ●Diffuse erythemaof cervix and vaginal walls ●**Characteristic punctate appearance on cervix** . TX Oral Metronidazole 2 g as a single dose (preferable) or 400 mg bdfor 5 days (if relapse) ●or ●tinidazole 2 g as a single dose **" Sexual PARTNERS must be treated simultaneously " ●No sexual contact is advised for 7 days after treatment for patient and partner**

Question 25

Bacterial vaginosis:

Answer 25

mixed flora (referredtoaspolymicrobialclinicalsyndrome) consisting of Gardnerella vaginalis, other anaerobes suchas Atopobium vaginae ,Mobiluncus species and Mycoplasma hominis. **This accounts for the alkalinity of the vaginal pH.** - ●A white or grey, homogenous discharge ●Malodorous ●No obvious vulvitisor vaginitis ●Liberates an amine-like, fishy odouron admixture of 10% KOH (the amine whiff test) ●Clue cells on wet preparation ●±Dyspareunia and dysuria ●±Pruritus (uncommon) ## Footnote METRONIDAZOLE OR CLINDAMICINA

Question 26

Lichen Planus: clinic dx tx ## Footnote Lichen planus (LP) is a chronic, inflammatory, puriticskin disorder, typically found on the limbs (especially flexor surfaces), mucous membranes (often in the mouth) and genitals –including inside the vagina

Answer 26

Question 27

Lichen sclerosis:lichen sclerosus et atrophicus

Answer 27

Complications: if untreated: ●Vulvalatrophy and labial (even clitoral hood) fusion, introitalstenosis ●Lifetime risk of SCC 2–6%

Question 28

Uterovaginal prolapse: 4 of - uterine prolapse are: -

Answer 28

Treatment:Medical:Kegelexercises,Pessaries,Estrogen replacement. Surgical:anteriorand posterior vaginal wall repair or colporapphy For uterine prolapse:Sacrohysteropexy

Question 29

cervix types: factor risk

Answer 29

-fourth most common cause of cancer - The most common is squamous cell carcinoma (SCC) 80% of cases. Adenocarcinoma is less common and more difficult to diagnose because it starts higher in the cervix. - Cervical cancer almost exclusively occurs in women who have been sexually active, due to exposure to human papillomavirus(HPV). Other risk **factors include smoking, use of combined oral contraception >5 years, immunosuppressionand exposure to diethylstilboestrol in utero.** - HPV 16 and 18 -

Question 30

cervix Who should be screened?

Answer 30

Women are invited to commence cervical screening at 25 years (or two years after first sexual intercourse, whichever is later). ●Both HPV-vaccinated and non-vaccinated women should be screened. ●An exit test can be performed at age 70–74 years. ●Women aged 75 years or older may request screening. ●Screening applies only to asymptomatic women. Women with postcoitalor persistent intermenstrual bleeding require a **co-test (both HPV test and diagnostic LBC), and referral for an appropriate investigatio**n to exclude malignancy should be considered.10 ●For women who experienced first sexual activity at a young age (<14 years) and who had not received the HPV vaccine before sexual debut, a single HPV test between 20 and 24 years of age could be considered on an individual basis

Question 31

cervix special groups hysterectomy pregnancy postmeno inmunodeficient DES

Answer 31

Question 32

CIN comparison of nomeclature

Answer 32

Question 33

Algorithm for management of low-grade squamous

Answer 33

Question 34

INFERTILITY female factors ovulation disorders: Tubal disease: uterine and cervical anormalites:

Answer 34

Question 35

INFERTILITY male factors

Answer 35

Question 36

physical examination nad investigation man infertility:

Answer 36

Question 37

physical examination woman infertility: and investigations first ovulation status:

Answer 37

Question 38

fertility awareness: chance of fertilization is best during:

Answer 38

Question 39

Answer 39

endometriosis

Question 40

endometriosis symptoms:

Answer 40

Question 41

dx endometriosis most acurate test

Answer 41

laparoscopy and biopsy

Question 42

endometriosis tx

Answer 42

ocp nsaid

Question 43

Answer 43

first line investigation basal body temperature and cervical mucus dairy semen analisis serum progesterona transvaginal us rubella inmune status

Question 44

male infertility investigation most important endocrine test?

Answer 44

Question 45

female investigation in infertilty

Answer 45

Question 46

infertility tx options

Answer 46

Question 47

Answer 47

Poor nutrition and weight ovulation disorders

Question 48

DX CRITERIA (ROTTERDAM) ## Footnote LH - TECA- ANDROGENOS + PROGESTERONA FSH - GRANULOSA - ESTROGENOS

Answer 48

EXCLUDE OTHERS: Hipotiroidismo hiperprolactinemia = GnRH DOWN = fsh y lh down

Question 49

PCOS SYMPTOMS

Answer 49

Question 50

PCOS investigations

Answer 50

riesgo cancer endometrial

Question 51

managment PCOS

Answer 51

Question 52

Answer 52

Question 53

Premature Ovarian Failure Clinical Features: Investigations Investigations

Answer 53

Question 54

Answer 54

Question 55

tanner staging

Answer 55

Question 56

Answer 56

Question 57

Klienfelter’s Syndrome –XXY:

Answer 57

Question 58

Answer 58

Question 59

Answer 59

Question 60

Answer 60

Question 61

Answer 61

next step would be pelvic examination if she is a virgin (or US trasnvaginal)

Question 62

Answer 62

imperforate hymen

Question 63

Answer 63

hyperprolactinemia

Question 64

Answer 64

STOP METROTEXATE BUT CONTINUE HYDROXICLOROQUINE

Question 65

Answer 65

ULTRASOUND * remember the best is **hysterosalpingogram**

Question 66

BREAST

Answer 66

TRIPLE TEST :

Question 67

INVESTIGATION X RAY MAMMOGRAPHY ## Footnote **MOST EFFECTIVE TOOL FOR BREAST CANCER** SCREENING 50 YEARS -

Answer 67

BREAST ULTRASOUND

Question 68

**Breast imaging** for palpable lumps According to age:

Answer 68

<35 35-50 50>

Question 69

NEEDLE ASPIRATION AND BIOPSY TECHNIQUES

Answer 69

Question 70

Fibrocystic Disease: clinical features:

Answer 70

- fluctuate with periods! - pain tender and swelling reassure that is no cancer

Question 71

FIBROADENOMA

Answer 71

REASSURANCE

Question 72

breast cyst

Answer 72

Question 73

Localized Nodularity:

Answer 73

Lactation Cysts

Question 74

Phyllodes Tumor

Answer 74

Question 75

FAT NECROSIS ## Footnote Breast

Answer 75

Most accurate test : biopsy reassurance and triple test

Question 76

Duct Papillomas: ## Footnote breast

Answer 76

Question 77

mammary duct ectasia:

Answer 77

Question 78

Red Flag Pointers for Breast Lumps

Answer 78

*Hard and irregular lump *Skin dimpling and puckering *Skin oedema (‘peau d’orange’) *Nipple discharge *Nipple distortion *Nipple eczema *Postmenopausal women

Question 79

Diagnosis of Breast Cancer dx:

Answer 79

Question 80

TX BREAST CANCER

Answer 80

Question 81

Adjuvant Therapy for breast cancer:

Answer 81

Question 82

screening for breast cancer RISK 1SLIGHTLY 2 MODERATE 3 HIGH

Answer 82

Question 83

Lymphoedema of arm

Answer 83

Question 84

Ductal Carcinoma in Situ risks: tx:

Answer 84

Question 85

Paget disease of the nipple:

Answer 85

Question 86

Lumps that require investigations and referral:

Answer 86

Question 87

# [](http://)[](http://) MASTALGIA

Answer 87

CYCLICAL AND NON CYCLICAL

Question 88

TX MASTALGIA

Answer 88

Question 89

Mastitis carcinomatosa

Answer 89

Question 90

# [](http://)[](http://)[](http://)[](http://) TIETZE SYNDROM

Answer 90

Question 91

breast abcess:

Answer 91

Question 92

Breast Infections MASTITIS CLINICAL candida symptoms? tx?

Answer 92

If systemic symptoms develop: ***Antibiotics**:resolution without progression to an abscess will usually be prevented by antibiotics: *(di/(flu)cloxacillin 500 mg (o) 6 hourly for 10 days or (if hypersensitive to penicillin), cephalexin 500 mg (o) 6 hourly for 10 days) *If severe cellulitis di/(flu)cloxacillin 2 g (IV) 6 hourly *Therapeutic ultrasound (2 W/cm 2 for 6 minutes) daily for 2–3 days *Ibuprofen or paracetamol for pain .*For** Candida albicans** infection:(fluconazole 200–400 mg (o) daily for 2–4 weeks, second line—nystatin 500 000 U (o) tds

Question 93

Answer 93

Question 94

Answer 94

Question 95

Answer 95

Question 96

Answer 96

Question 97

Answer 97

Question 98

OSTEOPOROSIS definition common sites of fracture:

Answer 98

It is also defined by bone mineral density (BMD) as a T score of ≤–2.5.

Question 99

gold standard of osteoporosis: t score and z scorea

Answer 99

Question 100

Risk factors for minimal-trauma fracture. age when to review fracture risk? men and women

Answer 100

fall women menopause age

Question 101

osteoporosis identifyng risk : average: high:

Answer 101

**average** risk: clinical assement for risk factors **increase** risk: DXA **high risk: ** DXA (every 2 years)

Question 102

prevention of osteoporosis: ## Footnote fracture orevention

Answer 102

Question 103

Calcium and osteoporosis dosis vitamin D

Answer 103

1300 mg osteoporosis 1300 mg women > 50 years < 1000 mg 1300 mg men > 70 years < 1000 mg **calcium carbonate** first line **calcium citrato (if proton pump inhibitor)** * * * remeber to consider the possibility of. a secondary cause

Question 104

Management of osteoporosis following minimal-trauma fracture:

Answer 104

Question 105

Management of osteoporosis in the absence of fracture:

Answer 105

Question 106

Choice of drug therapy for osteoporosis summary

Answer 106

Question 107

Bisphosphonates regimens:

Answer 107

inhibiting osteoclasts

Question 108

Zoledronic acid adverse effects:

Answer 108

Question 109

Duration of bisphosphonate therapy

Answer 109

Bisphosphonates are retained in the skeleton after treatment withdrawal. The beneficial effects on BMD persist for several years after stopping alendronate and zoledronic acid. ●In contrast, BMD decreases within one year of stopping risedronate. ●Long-term bisphosphonate therapy has been linked to an **increased risk of skeletal adverse effects such as osteonecrosis of the jaw and atypical fracture of the femur, although the absolute risk remains low**. Limiting the duration of bisphosphonate therapy may reduce the incidence of these effects. ●**Riserdonateis slightly safer option in patients with gastrointestinal irritation**

Question 110

**denosumab**

Answer 110

**reducing osteoclast formation and differentiation and increasing osteoclast apoptosis.** Can cause **HYPOCALCEMIA **CHECK VITAMINA D CALCIO SERUM CREATININE CLEAREANCE

Question 111

Teriparatide

Answer 111

Therapy must be started by a specialist, and the patient must have a T-score of –3 or less, and at least two minimal-trauma fractures, including a fracture after at least one year of antiresorptive therapy. - Teriparatide is also indicated to be used if the patient has a fracture while on therapy with osteoporosis - The maximum lifetime duration of teriparatide is 24 months. - DO NOT USE IN:

Question 112

Romosozumab

Answer 112

serious cardiovascular adverse events and is therefore not recommended for use in patients that have had a myocardial infarction or stroke within the previous year - Romosozumab'suse is limited by strict eligibility criteria for PBS subsidy—●therapy must be started by a specialist, the patient must have a T-score of –3 or less and they must have experienced at least one symptomatic new fracture after at least 12 months of therapy with an antiresorptive drug.

Question 113

ESTROGEN THERAPY OSTEOPOROSIS

Answer 113

Question 114

how to monitor patients with osteoporosis:

Answer 114

BMD

Question 115

Skeletal adverse effects of drugs used for osteoporosis:

Answer 115

Question 116

Glucocorticoid-induced osteoporosis

Answer 116

**The extent of bone loss is related to the dose and the duration of glucocorticoid therapy. **A prednis(ol)one dose of at least 7.5 mg per day, or an equivalent dose of another glucocorticoid is associated with the greatest risk.**

Question 117

Answer 117

Question 118

effectiveness of contraceptive methods.

Answer 118

Question 119

Classification of contraceptive methods

Answer 119

Contraceptive methods can be classified by their mechanism of action (hormonal versus non hormonal) or duration of action (long acting versus shorter acting). ** Long-acting reversible contraception(LARCs)** ➢intrauterine contraceptive devices (IUDs)—levonorgestrel-releasing and copper intrauterine IUDs ➢etonogestrelcontraceptive implant **Shorter-acting hormonal contraception **➢depot medroxyprogesterone injection ➢combined hormonal contraception—combined oral contraceptives (COCs) and the contraceptive➢vaginal ring ➢progestogen-only contraceptive pills

Question 120

Hormonal contraception

Answer 120

Question 121

Progestogen-only contraception : uses:

Answer 121

women who are **breastfeeding** or have a contraindication to taking **oestrogen** Progestogen-only contraception is **contraindicated** in women with active **breast cancer within the past 5 years (MEC 4)**, but has relatively few other contraindications.

Question 122

Etonogestrel implant (Implanon NXT)

Answer 122

3 years inhibits ovulation **IRREGULAR BLEEDING MOST COMMON EFFECT**

Question 123

Depot medroxyprogesterone acetate: dosis: return of fertility? adverse effect? age?

Answer 123

**(amenorrhoea rate 50–70% by 12 months), weight gain (average 2–6%), breast tenderness, mood changes and a delay in return of fertility (mean time 8 months).** Long-term use is associated with **accelerated bone loss. ** For this reason it is not recommended as a first-line contraceptive for women less than 18 and more than 45 years.

Question 124

Progestogen-only contraceptive pill:

Answer 124

The POP (mini-pill) is most commonly prescribed for **breastfeeding** women for whom an oestrogen contraceptive was previously not recommended. **POP is safe from 4 weeks after delivery** evonorgestrel 30 mcg/day ●norethisterone 350 mcg/day

Question 125

uterine contraceptive devices absolute contraindications:

Answer 125

including young and nulliparous women All IUDs prevent pregnancy by inhibiting sperm migration and ovum transport and preventing implantation The levonorgestrel IUD also causes endometrial suppression and cervical mucus thickening and may prevent ovulation. - copper IUDs: 99.5% perfect and typical use - **Absolute contraindications** -active PID, -undiagnosed abnormal genital tract bleeding -current or past history of breast cancer for those considering levonorgestrel IUD (MEC 4)

Question 126

uterine contraceptive devices Side effects and complications of IUD use:

Answer 126

**Pregnancy/ectopic pregnancy** - Early removal of the IUD is essential - IF pregnancy occurs there is an increased risk of abortion and intra-uterine sepsis during the second trimester. - **risk is low **compared to non users **Pelvic inflammatory disease** - small increased risk of PID in the first 20 days post-insertion **Extrusion, perforation of uterus and translocation** - Factors that increase risk of perforation include breastfeeding, first 6 months postpartum and previous caesarean section. - translocation of the IUD outside the uterus is proved by X-ray and pelvic ultrasound, referral for removal is mandatory - woman should attend for a follow-up visit between 3–6 weeks after insertion specifically to exclude infection, perforation or expulsion

Question 127

Combined hormonal contraception (CHC) dose: ## Footnote Combined hormonal contraceptives contain an oestrogen and progestogen, and their main mode of action is inhibition of hypothalamic and pituitary function leading to anovulation

Answer 127

Efficacy is 99.5%with perfect use, 93% with typical use. - COCs in Australia contain ethinyloestradiol(EE), oestradiol valerate (EV), oestradiol (E2) or mestranol and one of a range of progestogens. - **EE is the most commonly used oestrogen. The active oestrogen in the newer E2 and EV pills is structurally identical to the E2 produced by the ovaries. ** - use a dose of 35 mcg EE or less. - Formulations containing 50 mcg EE are no longer recommended because there is no known additional benefit from their use and they are associated with an **increased risk of VTE. ** ●Women starting on a 20 mcg EE pill are likely to have fewer hormonally related side effects such as headaches or mood swings, but have a higher chance of discontinuation due to breakthrough bleeding. - which progesterone ? image

Question 128

combined oral contraceptive formulations in AUSTRALIA

Answer 128

Question 129

Starting the pill: which COC to use?

Answer 129

past menstrual and medical history of the woman should be documented and contraindications excluded: **30 mcg or 35 mcg ethinyloestradiol (EE) with levonorgestrel or norethisterone (e.g. Nordette, Microgynon 30, Monofeme, LevlenED, Brevinor).** *Education and counselling are very important for the woman starting the pill. Suitable patient education should be given. - YOUNGS: **Contraception (excluding sterilisation) can be provided without parental consent to adolescents assessed as being able to consent to their own medical treatment. ●Clinicians should be aware of mandatory reporting requirements in their jurisdiction for young people assessed as being at risk of harm (non consensual sexual activity, significant age gap or power differential between the young person and the sexual partner**)

Question 130

first-line option in adolescence contraception?

Answer 130

**Long-acting reversible contraception (LARC) (the etonogestrel implant and intrauterine contraceptive devices [IUDs]) is the first-line option in adolescence**

Question 131

Postpartum contraception

Answer 131

<6 weeks = progesterona >6 weeks: estrogenos - The etonogestrelimplant can be inserted any time postpartum, including immediately before leaving hospital and during breastfeeding. - A levonorgestrel-releasing or copper intrauterine contraceptive device (IUD) can be inserted immediately postpartum (within 48 hours), (>considerar por especialista en otro tiempo) - 4> semanas es safe DIU , (riks of perforation because of breastfeeding) - Depot medroxyprogesterone injection is safe to use immediately postpartum and during breastfeeding. It can be a useful option for those awaiting IUD insertion after delivery. ●Progestogen-only pills (POPs) are commonly prescribed for individuals who are breastfeeding because they do not increase the risk of VTE (unlike combined hormonal contraception). ●The POP can be started immediately after delivery. - COP or vaginal ring = 6> semanas

Question 132

Thromboembolic risk: Migrane with aura: migrane without aura: smokers: developmental disability: >35 years: liver enzyme inducing drugs:

Answer 132

All **combined** hormonal contraceptives (combined oral contraceptives [COCs] or the contraceptive vaginal ring) increase the relative risk of venous thromboembolism (VTE). -**Depot medroxyprogesterone** is not associated with a clinically significant risk of VTE. Despite a small increase in VTE risk if started in the first week postpartum, it is considered safe to use immediately postpartum. ●Other **progestogen-only contraceptives** are not associated with an increased risk of VTE . **Migrane with aura:** Progestogen-only methods of contraception are safe to use for individuals with a current or past history of migraine with aura. **migrane without aura: **Progestogen-only methods better than COPs **smokers**: contraindicated in individuals 35 years or older who smoke 15 or more cigarettes per day; **developmental disability:** assessed for their capacity to consent to treatment **>35 years:** *CHC use is safe for healthy non-smoking women until 50 years (MEC 2 for women over 40). *CHC is not recommended if a woman is over 35 years and has cardiovascular risk factors, including obesity, smoking, diabetes and hypertension (MEC 3/4 **liver enzyme inducing drugs:** DMPA and IUDs antibiotics that interfere (The only exceptions are liver enzyme-inducing rifabutin and rifampicin.) Other liver enzyme-inducing drugs include many of the older anti-epileptics (e.g. phenytoin, carbamazepine), St John’s wort and protease inhibitors. **For women who still request the use of COC, an extended or tricycling regime of a higher dose pill (e.g. containing at least 50 mcg EE) may be effective.**

Question 133

ABSOLUTE AND RELATIVE CONTRAINDICATIONS OF COPS

Answer 133

Question 134

Serious side effects of CHCs

Question 135

MOST COMMON SIDE EFFECTS OF COC

Question 136

Important advice for the patient

Answer 136

Important advice for the patient:If a woman vomits within 2 hours of taking an active pill, she should take an additional active pill A missed pill is defined as one that is taken more than 24 hours late (>48 hours since last pill was taken). <24 Horas tomar dos

Question 137

Emergency contraception

Answer 137

**>70kg or bmi >26 DOUBLE DOSE**

Question 138

vaginal ring

Question 139

delaying a period

Answer 139

Question 140

Lactational amenorrhoea method (LAM) conditions

Answer 140

Question 141

menopause premature ovarian failure: early menopause

Answer 141

Question 142

menopause symptoms and tx

Answer 142

The classic vasomotor symptom of menopause is the hot flush. A hot flush lasts 1–2 minutes, begins in the chest and then spreads up over the face and body. There may be associated redness, sweats which can be drenching, panic attacks, palpitations and faintnes. - HT is the most effective method for relieving distressing symptoms such as hot flushes, urogenital symptoms, sleeplessness and joint symptoms. - strogen + progesterone = has UTERUS (hyperplasia and there is a 5–10 times increased risk of endometrial cancer if only estrogen.) - tibolone - no uterus estrogenos transdermal (less VTE risk) testosteron - for libido - perimenopausal -(12 m) - ** progesterone must be cyclical ** after it trasnfer to continuous - Women who are prescribed MHT should be reviewed at least annually -**first line therapy non hormonal lubricant in DRYNESS** THEN TOPIC OESTROGEN VAGINAL

Question 143

PRECONCEPTION CARE folic acid dosis: folic acid for women with risk:

Answer 143

Question 144

supplementation preconception care

Answer 144

Question 145

preconception restrictions:

Answer 145

Question 146

pregnancy confirmation: physical:

Answer 146

Question 147

pregnancy differential: complications:

Answer 147

Question 148

HORMONAL CHANGES

Answer 148

Question 149

Cardiovascular System Changes

Answer 149

Question 150

Hematologic Changes

Answer 150

Question 151

respiratory system changes renal changes inmune changes gastrointestinal

Answer 151

increase estogen -> cholesterol secretion increase progesterone -> decreased bile acid secretion and muscle relaxation RISK **CHOLELITHIASIS**

Question 152

Answer 152

Question 153

ANTENATAL CARE TIMING VISITS:

Answer 153

Question 154

routine ANTENATAL SCREENING

Answer 154

Question 155

ROUTINE LAB/DX STUDIES

Answer 155

RUBELLA TSH <3 CM FUNDUS ERROR REFER!

Question 156

TIME OF MAJOR PRENATAL TESTS* important ## Footnote if the cDNA reveals high risk -> CVS = **RISK 1-100 MISCARRIAGE**

Answer 156

Question 157

SCREENING TESTS again summary pregnancy

Answer 157

Question 158

dx test pregnancy

Answer 158

Question 159

vaccinations recomended in pregnancy 3

Answer 159

Question 160

glucose challenge in pregnant when ?

Answer 160

Question 161

Answer 161

Question 162

Answer 162

Question 163

Answer 163

Question 164

Answer 164

Question 165

Answer 165

Question 166

Answer 166

Question 167

Answer 167

Question 168

Vaginal bleeding in early pregnancy: 1-Trimester

Answer 168

1. MISCARRIAGE 2. ECTOPIC PREGNANCY 3. MOLAR (rare) **20-40% pregnant women will BLEED 1 TRIMESTER** <6 semanas - hcg se eleva 66% cada 48 horas (sino ectopico) - hCG > 1500 IU/L PEDIR TRASNV US *** 6-8 SEMANAS - usar US - repetir en una semana >8 semanas: - normal US is reassuring **REST IS NOT NECESSARY FOR THREATHNED MISCARRIAGE** ANTI D - **ONLY IN COMPLETE MISCARRIAGE**

Question 169

vaginal bleeding 1 trimester investigations:

Answer 169

1. US TV 2. hCG ( <50% 48 = no viable or ectopic) 3. maternal blood group and antibody (determine Rhd inmunoglobuline)

Question 170

Answer 170

Question 171

shoulder tip pain sign suspect:

Answer 171

Of the option, however, shoulder tip pain is the most important sign demanding urgent action. This sign is notcommon but if present in suspected EP, **demands urgent surgical action** because indicates** free blood in the peritoneum and peritoneal irritation**. The mechanism such pain is produced is thought to be irritation of the diaphragm and the phrenic nerve by the free blood in the peritoneal cavity. Then pain can radiate to the shouldertip especially on the right side

Question 172

Answer 172

Question 173

risk factors for ectopic pregnancy?

Answer 173

Question 174

ectopic pregnancy most commonly location?

Answer 174

Question 175

vaginal examination in ectopic pregnancy ?

Answer 175

Question 176

->Ectopic Pregnancy differentials tx

Answer 176

- METROTEXATE - ALL RH (D) **NEGATIVES = ANTI D INMUNOGLOBULIN**

Question 177

INEVITABLE, INCOMPLETE, COMPLETE MISCARRIAGE

Answer 177

- **inevitable** - uterine bleeding, dilatation, contractions. - complete - incomplete tx HOSPITAL analgesic heavy bleeding (ergotamine) vaginal examination and forceps removal - residual gestational tissue US removal surgically by sponge forceps or medically misoprostol

Question 178

ecotpic pregnancy diagnosis?

Answer 178

- b-hCG - <5 not pregnant + -> US TV - 1000 = fetal heart beat - no result in US => serial B hcg - **SNOWSTORM = MOLAR**

Question 179

Answer 179

Question 180

DEFINITIONS OF MISCARRIAGE

Answer 180

as recommended that a fetus be considered potentially viable when the gestation periodhas reached 22 weeks or more, or when the fetus weighs 500 g or more. ABORTION TERM USED FOR DELIBERATELY TERMINATED

Question 181

Answer 181

Question 182

Answer 182

Question 183

DEFINITIONS IN MISCARRIAGE

Answer 183

Question 184

THREATNED MISCARRIAGE

Answer 184

- UTERINE BLEEDING (WITH OT WITHOUT PAIN) - CERVIX CLOSED - US - IF subchorionic hematoma preganncy monitered closely - NO BED REST

Question 185

recurrent miscarriage antiphospholipid syndrome dx and tx: also cervical incompetence (do cerckage)

Answer 185

3 or more sucessive miscarriages . lupus anticoagulant anticardiolipina anti b2 glicoprotein tx aspirin and unfractioned heparin

Question 186

# ``` ```

Answer 186

Question 187

Answer 187

Question 188

# ``` ``` law on abortion in NSW

Answer 188

Question 189

abortion

Answer 189

Question 190

epilepsy in pregnancy:

Answer 190

- no seizure in 6 months

Question 191

complications epilepsy on pregnancy

Answer 191

**Effect of pregnancy on epilepsy** *In most women seizures do not increase during pregnancy *1-2% incidence of seizures during labour and in 24 hours post delivery **Effect of epilepsy on pregnancy Maternal** *Vaginal bleeding, abruptio placentae, PET, preterm labour Fetal ***Neural tube defects,** I UG R, heart and skeletal defects, prematurity. **Newborn** *Hemorrhagic disease of newborn****

Question 192

care and investigations epilepsy pregnancy:

Answer 192

**Antenatal Care** *High risk pregnancy clinic-MDT with neurologist* Continue antiepileptic medication *Screening for spina bifida: *by nuchal translucency scan for anencephaly, maternal alpha fetoprotein at 16-20 weeks, **detailed U/S at 20 weeks which is most predictive for neural tube defects** MCQ######### *Monitor anticonvulsant levels once in each trimester ***Oral Vitamin K **2omg/day during last 1 month of pregnancy. **Intrapartum and Postnatal care** *Vaginal delivery at tertiary hospital*I/M 1mg vitamin K to newborn*Breastfeeding is not contraindicated despite the drugs crossing into the breast milk.

Question 193

DVT pregnancy when is most risk? tx?

Answer 193

**The prevalence of VTE is equally distributed throughout pregnancy, but the day by day risk is greatest in the immediate puerperium. 6 weeks** The major risk factors include caesarean section, obesity, prolonged immobility, preeclampsia, current infection, previous VTE and familial thrombophilia.**The preferred treatment of VTE during pregnancy is low molecular weight heparin (LMWH).** Compared withunfractionated heparin, as LMWH does not cross the placenta, there is a reduced risk of bleeding and no thrombocytopenia. Incidence 1% Symptoms: Pain, swelling in the leg usually unilateral and **on left leg (80%) **with redness, warmth. **Complication** *pulmonary embolism **Investigation of choice** **Compression Doppler US** -If U/S **negative** =clinical suspicion low, anticoagulation discontinued - If clinical suspicion **high** = repeat doppler U/S, venography or magnetic resonant direct thrombus imaging.

Question 194

PE in pregnancy best initial investigation TX-

Answer 194

UNFRACTIONED HEPARINE FOR MASIVE LMWH FOR PROPHYLAXIS

Question 195

TX DVT PREGNANCY OVER VIEW: above the knee distal DVT

Answer 195

LMWH anticoagulant of choice warfarina contraindicated during pregnancy warfarine first chhoice in **breastfeeeding** - Delivery *Planned delivery preferably *Discontinue therapeutic LMWH 24 hours prior and give prophylactic LMWH until 12 hours prior induction or c-section *If spontaneous delivery : - Stop LMWH and send blood for cross match, group and hold. ***If high risk of bleeding, unfractionated heparin **is preferred and is has shorter half life and can be completely reversed with **protamine sulphate** ***Unfractionated heparin also indicated in RENAL FAILURE.** **Care during subsequent pregnancy:** *Screen for thrombophilia *LMWH from 14 weeks to 4 to 6 week post partum *Compression stocking and avoid immobilization

Question 196

Gestational diabetes values: DM vs GDM

Answer 196

(oh) * fasting glucose >5.1 mmol * (1h)* post 75 gr 1 hour > 10 * * 2 hour> 8.5 ## Footnote all pregnant women should be screened at 24-28 weeks with 75 gr

Question 197

unfractioned heparine indicated in pregnancy: antidote:

Answer 197

- renal failure - massive PTE with cardiovascular compromise - high risk of bleeding (placenta previa)

Question 198

risk factors for GDM: ## Footnote gestational diabetes

Answer 198

Question 199

uncertain values gdm

Answer 199

FASTING PLASMA GLUCOSE <5 mmol/L = normal **5.1-5.9 mmol/L** :uncertain. considere lifestyle. OGTT = 16-18 weeks **6.6.0-6.9 mml/L**: lifestly advice. OGTT = 16-18 weeks. consider SMBG RANDOM PLASMA GLUCOSE 9-11mmol/L : signficance unknown. further investigation - fasting or HbA1c. GLYCATED HAEMOGLOBIN (HbA1c) - 5,9-6,4 = reasonable predicting a dx of GDM . Lifestyle. consider SMBG ## Footnote remember - > OGTT: 1. Fasting(eight hours) 2. 75 g glucose administered orally 3. Blood is collected from a fasting venous sample and two-hour post-glucose challenge venous sample

Question 200

managment of diabetes screening and diagnosing type 2 diabetes

Answer 200

Question 201

dx criteria type 2 diabetes adults symptomatic - asymptomatic

Answer 201

Question 202

GESTATIONAL DIABETES RECOMENDATIONS

Answer 202

Question 203

GESTATIONAL DIABETES MANAGEMENT

Answer 203

Question 204

GESTATIONAL DIABETES follow up: exams: - 40% risk of subsequent GDM in pregnancy

Answer 204

Question 205

GESTATIONAL DIABETES COMPLICATIONS MATERNAL FETAL

Answer 205

Question 206

GESTATIONAL DAIBETES DURING PREGNANCY DURING LABOUR FOLLOW UP?

Answer 206

Question 207

Answer 207

Question 208

Answer 208

Question 209

Answer 209

Question 210

PROM Premature Rupture of membranes: risk factors symptoms **complications? ** ## Footnote **premature rupture of membranes (PROM)** occurs when a patient at ≥ 37 weeks of gestation presents with rupture of membranes (ROM) prior to the start of uterine contractions **PPROM**:preterm premature rupture of membranes (PPROM) describes PROM that occurs < 37 weeks of gestation

Answer 210

Question 211

Chorioamnionitis ## Footnote investigations

Answer 211

## Footnote To prevent chorioamnionitis, it is recommended that all women with PROM more than 18 hours be started on parenteral antibiotic.

Question 212

Management of PPROM:

Answer 212

## Footnote **Chorioamnionitis is an absolute contraindication to tocolysis** AB - **Chorioamnionitis is a feared feature of PROM of over 18 hours.

Question 213

memorize this PPROM

Answer 213

Fifty percent of women with PROM women will be in labor in12 hours, 86 % within 24 hours, and 94 % will be established in labor within 48-95 hours. 6% will not establish in labor within 96 hours of PROM. **Chorioamnionitis is a feared feature of PROM of over 18 hours.** The most important risk factors for development of chorioamnionitis include: * Increasing numbers of digital vaginal examinations* Longer duration of active labor* Meconium staining of the amniotic fluid ## Footnote To prevent chorioamnionitis, it is recommended that all women with PROM more than 18 hours be started on parenteral antibiotic.

Question 214

Answer 214

Question 215

Answer 215

Question 216

PRETERM LABOUR criteria

Answer 216

The diagnosis of preterm labour must be made carefully **The criteria or diagnosis are: ** * The gestational period is less than 36 completed weeks. * Uterine contractions, preferably recorded on a tocograph, occur every 5–10 minutes, last or at least 30 seconds and persist or at least 60 minutes. * The cervix is >2.5 cm dilated and >75% effaced. ## Footnote Using these criteria, two-thirds of women presenting with presumed preterm labour will not be in labour. They need reassurance, not drug treatment

Question 217

PRETERM LABOUR causes : investigations:

Answer 217

Question 218

PRETERM LABOUR Fibronectintest

Answer 218

Fetal fibronectin (FFN) is an extracellular matrix glycoprotein localized at the maternal-fetal interface of the amniotic membranes, between chorion and decidua, where it is concentrated in this area between decidua and trophoblast. In normal conditions, FFN is found at very low levels in cervicovaginal secretions. Levels greater than or equal to 50 ng/mL at or after 22 weeks have been associated with an increased risk of spontaneous preterm birth. **In fact, FFN is one of the best predictors of preterm birth.** **Indications** **-Symptomatic women with threatened preterm labour: ** o Between 22+0 and 36+0 weeks gestation and o Intact membranes and o Cervical dilatation less than or equal to 3 cm **-OR Asymptomatic women, greater than 22 weeks gestation, with a history of**: o Cervical surgery/trauma or o PTB in previous pregnancy or o Late miscarriage in previous pregnancy. **Contraindications of FFN** * Cervical dilatation more than 3 cm * Ruptured membranes *Cervical cerclage in situ * Presence of soaps, gels, lubricants or disinfectants **Relative contraindications*** Visual evidence of moderate or gross bleeding * Within 24 hours of vaginal intercourse * A negative fFNresult of less than 10 ng/mL is still valid: o If a woman reports having intercourse in the previous 24 hours o In the presence of moderate or gross vaginal bleeding

Question 219

Preterm Labour Management

Answer 219

Question 220

Preterm Labour Management guidelines

Answer 220

Question 221

Answer 221

Question 222

Answer 222

Question 223

Answer 223

Question 224

Abnormal foetal presentations:

Answer 224

Question 225

TRANSVERSE LIE Abnormal foetal presentations:

Answer 225

Question 226

BREECH PRESENTATIONS

Answer 226

Question 227

breech presentation management occipito posterior? face presentation?

Answer 227

Question 228

Answer 228

Question 229

Answer 229

Question 230

Answer 230

Question 231

Answer 231

Question 232

shoulder dystocia read basic

Answer 232

Question 233

shoulder dystocia management

Answer 233

Question 234

CORD PROLAPSE

Answer 234

Question 235

Answer 235

Question 236

Answer 236

Question 237

OBSTRUCTED LABOUR

Answer 237

Question 238

Answer 238

Question 239

Induction of labour –bishop score

Answer 239

Question 240

Induction of labour –bishop score GUIDELINES

Answer 240

Question 241

Substance of abuse in pregnancy medications teratogenos

Answer 241

## Footnote weeks 1-3 of gestation ●“ all-or-none" effects ●weeks ●3-8 of gestation embryonic period most susceptible time period due to organogenesis ●week 8 of gestation until birth growth and function of organs are affected

Question 242

Substance of abuse in pregnancy Heavy alcohol

Answer 242

Heavy alcohol consumption in pregnancy (>120 g, or 12 standard drinks a day) is associated with: * 1-IUGR * 2-Developmental delay and neurological complications in the baby * 3 -Fetal alcohol syndrome (facial characteristics: low-set ears, elongated midface, small head and upturned nose, skeletal and cardiac malformations). The incidence of FAS is multifactorial and compounded by smoking and other drug abuse, poor diet and social deprivation. *A consumption of seven standard drinks in a week and no more than two in any 1 day spread over at least 2 hours does not appear to have any damaging effects on the fetus or mother. Nevertheless, a pregnant woman should be advised to limit her consumption of alcohol especially during the first trimester, as there is concern about the long-term effects on the neurodevelopment of the child, particularly with numerical problem solving and reading proficiency, which is dose dependent*

Question 243

Substance of abuse in pregnancy Heroin

Answer 243

Question 244

Substance of abuse in pregnancy cocaine

Answer 244

Question 245

Substance of abuse in pregnancy Amphetamines

Answer 245

Question 246

Substance of abuse in pregnancy Cannabis

Answer 246

Question 247

Answer 247

Question 248

Answer 248

Question 249

Answer 249

Question 250

Answer 250

Question 251

Answer 251

Question 252

CTG interpretation

Answer 252

CTG variabilidad

Question 253

CTG interpretation acelerations

Answer 253

Question 254

CTG interpretation decelerations types

Answer 254

Question 255

CTG interpretation Overall impression reassuring non reasuring abnormal:

Answer 255

Question 256

Answer 256

Question 257

Answer 257

Question 258

Answer 258

Question 259

JAUNDICE DURING PREGNANCY causes 3 : ## Footnote Systemic disease in pregnancy

Answer 259

Jaundice in pregnancy can be caused by ●viral hepatitis, ●intrahepatic cholestasis of pregnancy, ●choledocholithiases, ●HELLP syndrome. Causes associated with **pregnancy** Severe hyperemesis gravidarum : **●HELLP ●Acute fatty liver of pregnancy ●Intrahepatic cholestasis of pregnancy** Causes not associatedwithpregnancy * Viral hepatitis * Gallstone disease * Autoimmune hepatitis * Hemolyticjaundice * Drug induced

Question 260

JAUNDICE DURING PREGNANCY **ACUTE FATTY LIVER OF PREGNANCY** ## Footnote Systemic disease in pregnancy

Answer 260

Question 261

Cholestasis of pregnancy ## Footnote Systemic disease in pregnancy

Answer 261

Question 262

HELLP syndrome ## Footnote Systemic disease in pregnancy

Answer 262

Question 263

THROMBOCYTOPENIA ## Footnote Systemic disease in pregnancy

Answer 263

Question 264

Answer 264

Question 265

Answer 265

Question 266

pulmonary embolism pregnancy daigram

Answer 266

Question 267

Answer 267

Question 268

Answer 268

Question 269

Appendicitis

Answer 269

Question 270

POSTPARTUM PSYCHIATRIC PROBLEMS overview

Answer 270

Question 271

INFECTIOUS DISEASES MEASELS clinical features:

Answer 271

**measles complication most common = OTITIS MEDIA**

Question 272

INFECTIOUS DISEASES MEASELS prevention:

Answer 272

**measles complication most common = OTITIS MEDIA**

Question 273

Answer 273

Question 274

Answer 274

Question 275

Answer 275

Question 276

Answer 276

Question 277

Answer 277

Question 278

Answer 278

## Footnote NOTE -Interpretation of CMV lgM results in pregnancy requires specialist opinion. Fetal diagnosis is best achieved by a combination of fetal ultrasound, amniocentesis+/-fetal serology; however, the definite diagnosis of fetal infection is by amniocentesis and PCR or the amniotic fluid for CMV. It should be born in mind that positive results do not predict any degree of fetal damage. Since this woman is 16 weeks pregnant, amniocentesis for definite diagnosis is the most appropriate option. Amniocentesis is perfomedin the rather small window of 15-18 (up to 20) weeks. However, repeating the test in 2-4 weeks was the most appropraiteoption if it was an option.

Question 279

round ligament pain pregnancy

Answer 279

Question 280

food to avoid during pregnancy

Answer 280

Question 281

HEPTATITIS B SCREENING

Answer 281

HEPTATITIS B ANTENATAL MANAGEMENT

Question 282

HEPTATITIS B MAGAMENET POTENTIAL EXPOSURE DURING PREGNANCY

Answer 282

HEPTATITIS B NEONATAL MAGAMENET

Question 283

HEPATITIS C ANTENATAL DIAGNOSIS

Answer 283

HEPATITIS C ANTENATAL MANAGEMENT

Question 284

HEPATITIS C MANAGEMENT AND FOLLOW UP

Answer 284

Question 285

DIAGNOSIS OF HIV INFECTION IN PREGNANT WOMEN

Answer 285

STRATEGTY TO MINIMISE HIV INFECTION IN PREGNANT WOMEN

Question 286

MANAGEMENT OF INFANT RISK HIV

Answer 286

Question 287

ANTI D PROPHYLAXIS

Answer 287

Question 288

ANTI D PROPHYLAXIS POSTPARTUM

Answer 288

Question 289

Answer 289

Question 290

HEMOLYTIC DISEASE OF NEW BORN

Answer 290

Question 291

Answer 291

Question 292

Answer 292

blood trasnfusion

Question 293

Answer 293

a

Question 294

GESTATIONAL THROPHOBLASTIC DISEASE

Answer 294

HYPERMESIS VAGINAL BLEEDING UTERUS LARGER THAN EXPECTED

Question 295

Answer 295

Question 296

HYPERTENSIVE DISEASE

Answer 296

Question 297

MANAGEMENT HYPERTENSION PREGNANCY SUMMARY

Answer 297

Question 298

preeclampsia:

Answer 298

Question 299

preeclampsia RISK FACTORS:

Answer 299

Question 300

ECLAMPSIA

Answer 300

Question 301

PREECLAMPSIA ANTIHYPERTENSIVE MEDS TIME O F BIRTH:

Answer 301

Question 302

Answer 302

Question 303

Answer 303

Question 304

Answer 304

Question 305

hemorrage antepartum > 20 weeks ## Footnote Inmediate actions just read

Answer 305

Question 306

PLACENTAE PREVIA DX SYMPTOMS INVESTIGATIONS? Important ? ## Footnote hemorrage antepartum > 20 weeks

Answer 306

Question 307

PLACENTAE PREVIA TX risk factors memory ! mcq

Answer 307

Question 308

PLANCETAE ACRETA, INCRETA, PERCRETA

Answer 308

Question 309

VASA PREVIA

Answer 309

Question 310

Abruptio placentae

Answer 310

Question 311

UTERINE RUPTURE

Answer 311

Question 312

BLEEDING>20 WEEKS ANTEPARTUM BLEEDING SUMMARY UTERINE RUPTURE ABRUPTO PLACENTAE PLACENTAE PREVIA VASA PREVIA

Answer 312

Question 313

Answer 313

Question 314

Answer 314

Question 315

Answer 315

Question 316

Answer 316

Question 317

Answer 317

ADHESIONS

Question 318

Answer 318

Question 319

Answer 319

Question 320

Answer 320

Question 321

Answer 321

Question 322

Cervical cancer screening

Answer 322

2 years after first sexual intercourse or 25–75 years. HPV test + cell cytology Negative Result: Every five years. Unsatisfactory: repeat 6-12 weeks Positive NON 16-18: Repeat in 12 month. Again positive: Colposcopy. Positive 16-18: Colposcopy. Low grade: Repeat in 12 month. Again positive: Colposcopy. High grade: Colposcopy

Question 323

Breast cancer: Risk factors

Answer 323

Risk factors: - **Individuals with age of onset of cancer less than 50 years** - Individuals with ovarian cancer *Increasing age is a major risk factor. *Personal history of atypical hyperplasia or lobular carcinoma in situ. *Strong family history of the disease or mutation in a breast cancer predisposition gene. *Previous radiotherapy. *High bone mass or obesity. -Jewish ancestry - Breast cancer in a male relative

Question 324

Breast cancer: Screening Low risk

Answer 324

Low risk: Family member diagnosed at 50 years or over. Screening: mammograms every two years for women aged 50–74 years

Question 325

Breast cancer: Screening Moderate risk

Answer 325

Moderate risk: One 1st degree diagnosed before 50 years or Two 1st degree in the same family side at any age or Two 2nd degree in the same family side diagnosed before 50 years. Screening: Annual mammogram for women age 40 years

Question 326

Breast cancer: Screening High risk

Answer 326

High risk: Member of the family in prescence of BRCA 1-2. or Two 1st or 2nd degree on the same family side diagnosed with BC or ovarian Ca PLUS: *Additional relatives with BC or OC. *BC diagnosed before 40 years. *Bilateral BC. *Breast & Ovarian Ca in the same woman. *BC in a male relative. *Ashkenazi jewish ancestry. or One 1st or 2nd degree with BC < 45 PLUS One 1st or 2nd degree with sarcoma < 45 Screening: Annual mammogram for women age 40 years Referral to a cancer clinic for risk assessment, possible genetic testing and management plan.

Question 327

List of all enzyme inducers

Answer 327

- Phenobarbital - Primidone - Phenytoin - Carbamazepine - Oxcarbazepine - Topiramate -ST John's Wort

Question 328

Non-enzyme inducing anti epileptics

Answer 328

- lamotrigine - Levetiracetam NOTE: Increase dose in case of OCP as they increase metabolism

Question 329

When does ovulation occur?

Answer 329

14th day (midcycle) - LH surge - next 24 h (12-36)

Question 330

Ovulation **occurring** investigation

Answer 330

plasma oestradiol peaks - ovulation to occur in 36-48 hrs Cervical mucus alteration immediately before ovulation -more abundant/maximal - clear and slippery NOTE: These are less accurate ways to predict ovulation

Question 331

Investigation of choice to predict ovulation has **occurred**

Answer 331

Serum progesterone surge at day 21 (luteal phase) - level > 20nmol/L

Question 332

Ovulation pain is also known as

Answer 332

Mittelschmerz syndrome

Question 333

Ovulation inducing drugs

Answer 333

Clomiphene

Question 334

Primary Dysmenorrhoea

Answer 334

- Pain occurs before menses - Initial treatments NSAID's - Trial of OCP's for 2 months upon px request

Question 335

Secondary dysmenorrhoea

Answer 335

- Treat underlying problem DRAFT

Question 336

Difference between biphasic and triphasic contraceptive pills

Answer 336

**biphasic:** same amount of oestrogen but level of progestin is increased halfway through **triphasic:** 3 different doses of oestrogen and progesterone every week for 3 weeks along with sugar pills

Question 337

COCP doses

Answer 337

- **low dose:** 20mcg of oestrogen. - **regular dose:** 30-35mcg oestrogen. - **high dose:** 50mcg of oestrogen.

Question 338

High dose COCP indications

Answer 338

* Break through bleeding on low dose pills. * When low dose pill fails. * Concomitant use of enzyme inducing drugs * Control of menorrhagia.

Question 339

Approach to PMS

Answer 339

1st line: Conservative treatment for 3 menstrual cycles (yoga) 2nd line: COCP, SSRI 3rd: GNRH antagonists due tenderness (danazol) careful because this drug can induce menopause, main complaint of fluid retention spironolactone, main complaint of dysmenorrhoea (mefenamic acid) BEST method: endometrial ablation, hysterectomy? DRAFT

Question 340

OCP absolute contraindications

Answer 340

* Pregnancy. * < 6 weeks post-partum. * Thromboembolic disease. * CVA. * CAD like known IHD * Migraine with aura. * Age >35 years and smoking > 15 cigarettes per day. * Oestrogen dependent tumours. * Active liver disease. * Polycythaemia. * Undiagnosed vaginal bleeding.

Question 341

OCP relative contraindications

Answer 341

* Age > 35-45 * BMI > 35 * Smoker >15 cigarettes per day * Breast feeding * HT ( >160/ 100) * DM * Hyperlipidaemia. * Depression * SLE * 4 weeks before and 2weeks after surgery

Question 342

Monthly COCP contents

Answer 342

28 pill pack: * 21 hormonal pills and *7 sugar pills.

Question 343

COCP administration

Answer 343

* Start on 1st day of menstrual period, continue till 21 days and then 7 sugar pills. * Take pill on the same time every day, 1pill /day. * On starting sugar pills, the lady gets periods. * Protection starts from 1st day of using pills if taken from the 1st day of periods. * Or if at any other time of the cycle, alternate methods of contraception should be used for 7 days and pregnancy needs to be ruled out. NOTE: a 24/4 pill pack is also available.

Question 344

COCP advantages

Answer 344

* Decreased menorrhagia, dysmenorrhea and pre-menstrual syndrome. (Periods become shorter, lighter and regular). * Decreased iron deficiency anaemia. * Decreased incidence of functional ovarian cysts, PID, acne, thyroid disorders

Question 345

OCP's increase the risk of which cancer/s

Answer 345

if used more than 5 years: - cervical - breast NOTE: conflicting data, use with caution

Question 346

OCP decreased risk of which cancer/s

Answer 346

- Ovarian cancer 30-50% - Colorectal cancer 15-20% - Endometrial cancer >30%

Question 347

OCP's and ovarian cancer

Answer 347

OCP's have no relation to developing ovarian cancer. Some sources have even labelled it as a protective factor

Question 348

COCPs mild side effects

Answer 348

* **Break through bleeding** * Nausea * Vomiting * Bloating

Question 349

COCPs breakthrough bleeding management

Answer 349

* Usually settles in 3-4 months. If not, check compliance * Change from low dose to regular dose * Change progesterone to 2nd or 3rd generation if already on regular dose OR * Another contraceptive or vaginal ring

Question 350

COCPs major side effects

Question 351

Irregular bleeding while on OCP risks

Answer 351

– Smoking – Chronic malabsorption syndrome – Severe nausea, vomiting and diarrhoea. – Hepatic enzyme-inducing drugs (anti-epileptics, anti-tuberculosis and drugs used to treat HIV.) NOTE: Modafinil is a drug used in patients with a history of narcolepsy can also interfere with contraceptive pills efficacy due to enhanced liver metabolism

Question 352

OCP's and diarrhoea

Answer 352

Severe diarrhoea & vomiting decrease the effectiveness of OCP's - take an extra pill add barrier method in addition

Question 353

Missed pills on OCP > 48 h

Answer 353

-1st week (1-7) emergency contraception, finish the pack as regular after - 2nd week (8-14): No need for emergency contraception, finish the pack - 3rd week (15-21): Next pack of pills should be started without a break (pill-free period omitted) NOTE: > 7 pills missed, start new fresh pack (exclude pregnancy)

Question 354

Px with hypertension on OCP

Answer 354

Change to POP

Question 355

OCP and Otosclerosis

Answer 355

- Systemic hormones from OCP can exacerbate otosclerosis - Prescribe IUD instead

Question 356

Px with DVT on OCP

Answer 356

- If px has family history but DOESN'T have DVT herself: POP - if px has history of DVT: POP - prescribe barrier methods DRAFT

Question 357

Contraindications to POP

Answer 357

Current VTE **Rifampicin** (absolute contraindication) CYP3A4 inducers malabsorption syndromes ovarian cysts previous sex steroid-dependent cancers (breast cancer) undiagnosed vaginal bleeding previous ectopic pregnancy severe active liver disease successfully treated Breast Cancer > 5 years

Question 358

Absolute contraindication for progesterone implant (Implanon)

Answer 358

Breast cancer

Question 359

Contraception of choice in breastfeeding women

Answer 359

POP for around 6 months, changing to OCP

Question 360

POP's in surgery

Answer 360

can be given but be on lookout for VTE

Question 361

Progesterone increases the risk of

Answer 361

DVT

Question 362

Px on epileptics wanting contraception

Answer 362

- Give IUD (Mirena) - IF patient is seizure free for 2 years we can reduce the dose of anti-epileptics and give high dose OCP - If patient not seizure free then only high dose OCP NOTE: anti-epileptics are enzyme inducers and reduce OCP efficacy by 40-50%

Question 363

Postinor-2

Answer 363

Progesterone only emergency contraceptive - 2 tablets at the same time associated with less adverse effects (Virilisation) DRAFT

Question 364

Best emergency contraception until 5 days

Answer 364

1st Ulipristal 2nd Copper IUD

Question 365

IUD best time for insertion

Answer 365

During the first 7 days of your menstrual cycle, which starts with the first day of bleeding

Question 366

1st line treatment for Dysfunctional uterine bleeding

Answer 366

Mild: NSAID's & **Tranexamic acid** Moderate: COCP or POP Severe: IV fluids, tranexamic acid, high dose norethisterone

Question 367

HPV vaccination

Answer 367

administered in high school

Question 368

Uterine prolapse

Answer 368

weakening of the uterosacral ligament

Question 369

risk factors for the development of urinary incontinence

Answer 369

- Obesity (stress) – Prenatal urinary incontinence (detrusor) – Constipation (stress) – Instrumental delivery -Third and fourth-degree tears -Baby with a birth weight of more than 4.0 kg (detrusor)

Question 370

Post menopause is defined as

Answer 370

permanent end of menstruation and fertility, defined as occurring **12 months after the last menstrual period**

Question 371

Most likely cause of post-menopausal bleeding

Answer 371

vaginitis due to oestrogen deficiency

Question 372

Age of onset for ovarian cancer

Answer 372

50

Question 373

HPV can cause what type of cancers

Answer 373

– Cancer of cervix. – Cancer of oro-pharyngeal cavity. – Squamous cell carcinoma of anus, penis and vagina. – Cancer of the uterus

Question 374

Cervical cancer risk factors

Answer 374

-All women who are or ever have been sexually active. -Early age at first sexual intercourse. - after 35 - prolonged use of OCP ( > 5 years) - immunosuppression - multiparity (>5) - persistent HPV infection -Multiple sexual partners. -Genital warts virus infection. -Cigarette smoking

Question 375

genital warts HPV

Answer 375

6-11

Question 376

Conservative methods to manage urinary incontinence

Answer 376

-Lose weight by 5% or more -Reduce caffeine intake -Modify fluid intake-according to hydration status. -Pelvic floor muscle training -Treat constipation to avoid straining. -Treatment of respiratory conditions leading to a chronic cough

Question 377

Investigation of choice for the diagnosis of endometriosis

Answer 377

Diagnostic laparoscopy with histopathology

Question 378

What criteria of women that do not need cervical screening?

Answer 378

Women who have never engaged in sexual intercourse

Question 379

Mastalgia causes

Answer 379

- cyclical mastalgia (most common) - pregnancy - caffeine - breast cancer < 10% mastitis carcinomatosa (red and hot breast during lactation)

Question 380

Oral contraceptive pills increase the incidence of which cancer

Answer 380

cervical cancer

Question 381

most common type of cervical cancer

Answer 381

- Squamous cell carcinoma 80% - adenocarcinoma

Question 382

Stein- Leventhal syndrome is also known as

Answer 382

PCOS

Question 383

Ovarian cyst: premenopausal cyst less than 5cm and asymptomatic

Answer 383

reassure

Question 384

Ovarian cyst: premenopausal cyst 5-7cm and asymptomatic

Answer 384

Repeat US in 3-4months and monitor to see if the cyst grows

Question 385

Ovarian cyst: premenopausal cyst >7cm and symptomatic

Answer 385

high risk of torsion Refer to gynaecologist

Question 386

Ovarian cyst: Post menopausal Simple unilateral, unilocular ovarian cysts of <5 cm and low risk of malignancy (normal Ca125)

Answer 386

managed conservatively conservatively as the RMI would be zero and 50% of these will resolve spontaneously in 3 months.

Question 387

Ovarian cyst: Post menopausal

Answer 387

Cysts of 2–5 cm should be rescanned in 3–4 months. Women with a moderate-to-high risk RMI should be referred to a referred to a gynaecologist or gynaecological oncologist for consideration of surgical management.

Question 388

Menopause hot flushes due to oestrogen

Answer 388

SSRI

Question 389

Menopause hot flushes

Answer 389

Cyclical oestrogen and progesterone HRT (oestrogen only in hysterectomy)

Question 390

progestogen-only conditions

Answer 390

1-Hypertension 2-Superficial thrombophlebitis 3-History of thromboembolism 4-Biliary tract disease 5-Thyroid disease 6-Epilepsy 7-Diabetes without vascular disease

Question 391

Premature menopause

Answer 391

- < 40 years - oocytes produce less oestrogen and progesterone, both LH and FSH start to rise - Menstrual irregularity and vaginal atrophy - **increased FSH level is diagnostic**

Question 392

Ovarian cancer risk factors

Answer 392

– A family history of either ovarian or breast cancer. – Personal history of breast cancer due to BRACA genes. – Early menarche. – Late menopause. – Nulliparity. – Increasing age - obesity

Question 393

sexually active malodorous gray vaginal

Answer 393

Gardenerella vaginalis

Question 394

Endometrial cancer risk factor

Answer 394

– History of chronic anovulation – Exposure to unopposed oestrogen – Polycystic ovary syndrome (PCOS) associated with chronic anovulation – Exposure to tamoxifen – Strong family history of endometrial or colon cancer (Lynch syndrome) – Nulliparity – Obesity – Endometrial thickness more than 8mm in premenopausal woman

Question 395

Lynch syndrome

Answer 395

MLH1 + MSH2 mutation - 40% endometrial cancer - 10% ovarian cancer Strong family history of endometrial or colon cancer (<50 years) - 3 family members - generational - (<50 years)

Question 396

Tumour with hair and teeth upon presentation

Answer 396

mature cystic teratoma (dermoid tumor)

Question 397

Presentation of PID

Answer 397

lower abdominal pain that is gradual in onset and bilateral Fever, vaginal discharge, dysuria, and occasionally abnormal vaginal bleeding PID can lead to tubal scarring diagnostic criteria include **uterine, adnexal, or cervical motion tenderness**

Question 398

Risk factors of familial breast-ovarian syndrome

Answer 398

1.Two first-degree or second-degree relatives on one side of the family with ovarian or breast cancer. 2.Individuals with age of onset of cancer less than 50 years. 3.Individuals with bilateral or multifocal breast cancer. 4.Individuals with ovarian cancer. 5.Breast cancer in a male relative. 6.Jewish ancestry

Question 399

Breast cancer age cut off

Answer 399

50

Question 400

Colon cancer age cut off

Answer 400

55

Question 401

Prostatic cancer age cut off

Answer 401

65

Question 402

hyperprolactinemia anovulation and should be treated with

Answer 402

bromocriptine

Question 403

Minimum time for a couple for infertility before starting treatment

Answer 403

1 year

Question 404

gynaecology referral cases

Answer 404

– Unexplained pelvic pain. – Pelvic mass which is tender on bi-manual vaginal examination. – Primary infertility of greater than a year. – Patient with suspected diagnosis of endometriosis unresponsive to initial treatment

Question 405

Painless mass

Answer 405

- rule out malignancy - biopsy

Question 406

Indications to use progestogen-only pills

Answer 406

1-Age 45 years or more 2-Smokers aged 45 years or more 3-Contraindications to oestrogen 4-Diabetes Mellitus 5-A migraine (combined oral contraceptive pills have absolute contraindication) 6-Well-controlled hypertension 7-Lactation 8-Chloasma (large brown patches on skin)

Question 407

Contraindications to use progestogen-only pills

Answer 407

- pregnancy - undiagnosed genital tract bleeding - concomitant use of enzyme-inducing drugs

Question 408

Features of dysfunctional uterine bleeding

Question 409

Post menopausal treatment for endometriosis

Answer 409

Danazol

Question 410

Medical treatment for endometriosis

Answer 410

- OCP - continuous progestins - danazol - GnRH analogues

Question 411

Premenstrual dysmorphic disorder

Answer 411

Mimics PMS but displays more severe symptoms that get in the way of the patients ability to function and feeling overwhelmed/ out of control, frequent tearfulness (abdominal bloating, headaches, reduced libido, reduced concentration and anger management issues)

Question 412

Contraindication to oral administration of oestrogen

Answer 412

DVT (liver metabolism is a contraindication)

Question 413

Features of trichomoniasis

Answer 413

- increased frothy, yellowish, fouls smelling vaginal discharge - dyspareunia and dysuria. - genital area is usually red and sore

Question 414

Treatment of trichomoniasis

Answer 414

Metronidazole 2 g

Question 415

severe symptoms of premenstrual dysmorphic disorder treatment

Answer 415

Clomipramine and danazol

Question 416

significant intrauterine adhesions symptoms

Answer 416

-Infertility. -Menstrual irregularities (amenorrhea). -Cyclic pelvic pain. -Recurrent pregnancy loss. The gold standard is diagnostic hysteroscopy.

Question 417

Pituitary necrosis + hx of postpartum haemorrhage + lactation failure+ signs of early menopause

Answer 417

Sheehan’s Syndrome

Question 418

Diagnostic method for Sheehan's syndrome

Answer 418

MRI

Question 419

diagnosis of bacterial vaginosis

Answer 419

– Thin, white, fishy, offensive and grey homogeneous discharge. – Vaginal fluid pH more than 4.5. – **Clue cells visualised on a wet preparation of a vaginal swab or Gram-stained smear.** – Fishy odour when adding alkali (potassium hydroxide 10%) to discharge. - Gardenerella vaginalis - Relapse rate is more than 50% in 3 months time

Question 420

Treatment of bacterial vaginosis

Answer 420

Metronidazole Clindamycin (if pregnant)

Question 421

premature ovarian failure investigation of choice

Answer 421

FSH & LH levels are high and oestradiol levels are low LOW (<1) LH/FSH ratio

Question 422

Tanner stages

Answer 422

I: - 0–15 years - None II: - Commencement of puberty -8–15 - Pubic hair first, along with breast budding (pubes flow, boobs grow) III: - Increase in hair and pigmentation

Question 423

Menorrhagia features

Answer 423

- menstrual periods lasting over 7 days and/or involving blood loss greater than 80mL Ovulatory: - Abnormal blood loss at **regular** intervals - uterine issue (**leiomyoma, endometriosis, adenomyosis, polyps**) Anovulatory: - **irregular** and unpredictable - Hormonal issue (PCOS, hypothyroidism, hyperprolactinemia, Cushing syndrome)

Question 424

Menorrhagia Investigation

Answer 424

- Exclude pregnancy **first** Ovulatory: - Transvaginal US (abdominal if adolescent px) Anovulatory: - FBE if anaemia present - Serum TSH, prolactin, LH (look for signs of hyperthyroidism to consider this)

Question 425

Atrophic vaginitis features

Answer 425

- Atrophic changes 5 years after menopause - oestrogen deficiency - brown vaginal discharge - itching, burning, dryness and irritation - dyspareunia - can lead to bacterial vaginosis with vaginal discharge - increased risk of UTI - thinning of bladder and urethral linings leading to chronic dysuria

Question 426

Atrophic vaginitis management

Answer 426

- Topical Oestrogen

Question 427

Atrophic vaginitis contraindication

Answer 427

- Breast cancer (can give SSRI for mood changes)

Question 428

Atrophic vaginitis ddx

Answer 428

- Candidiasis (topical antifungal) - Lichen Sclerosis (very potent topical corticosteroids)

Question 429

Postcoital bleeding in post-menopausal woman investigation

Answer 429

Co-test of HPV and LBC (Rule out cervical cancer)

Question 430

Most common causes of intrauterine bleeding

Answer 430

- STI (chlamydia cervicitis) - cervical ectropion - cervical polyp (30-40 years)

Question 431

Primary amenorrhoea

Answer 431

- Turner syndrome (ovarian dysgenesis) (pubes grow normally) 43% - Mullerian agenesis 15% Imperforated hymen (cyclic abdominal pain, abdominal mass)

Question 432

Most common cause of non-menopausal hot flushes

Answer 432

- Hyperthyroidism - Hypertension

Question 433

Primary ovarian insufficiency

Answer 433

- ovarian failure before 40 years of age - amenorrhoea = or > 4 months - **High FSH > 40U/L** and **LOW oestradiol** - oestrogen deficiency symptoms - increased gonadotropin levels - LOW LH/FSH ratio (<1)

Question 434

Primary ovarian insufficiency management

Answer 434

Desire to conceive: HRT until menopausal age (51 yo) Contraception: COCP - calcium and Vitamin D supplementation

Question 435

Emergency contraception window

Answer 435

5 days post coitus

Question 436

Cervical cancer during pregnancy

Answer 436

Same outline as regular screening BUT if there's evidence of invasive carcinoma, termination is recommended but dependant on px's choice

Question 437

CIN grading

Answer 437

I: low grade (lower 1/3) II/III: high grade (entire thickness of the epithelium)

Question 438

Cervical motion tenderness indicates

Answer 438

PID or Ectopic pregnancy

Question 439

Pelvic inflammatory disease (PID) dx

Answer 439

- Risk of STD - Lower abdominal pain - **cervical motion **, uterine, adnexal tenderness

Question 440

Pelvic inflammatory disease (PID) investigation

Answer 440

- Cervical swabs for culture

Question 441

Pelvic inflammatory disease (PID) management

Answer 441

- empirical antibiotics

Question 442

Ovarian teratoma features

Answer 442

- occurs in ages 20-30 years - diameter <10cm usually, can exceed 15cm (super rare) - made of different cells (hair, teeth, sebum, eyes, bone etc) - adnexal location

Question 443

Endometriosis common sites

Answer 443

- ovaries - posterior cul-de-sac - broad ligament - uterosacral ligament - rectosigmoid colon - bladder - distal ureter

Question 444

Green vaginal discharge

Answer 444

Chlamydia trachomatous -trachomonous vaginalis (frothy yellow- green)

Question 445

Drospirenone and ethinylestradiol

Answer 445

- less fluid retention - less weight gain

Question 446

Dilation & curettage complications

Answer 446

intrauterine adhesions (90%) - infertility - amenorrhoea - cyclic pelvic pain - recurrent miscarriages

Question 447

intrauterine adhesions investigation

Answer 447

transvaginal US (initial) Hysteroscopy (gold standard)

Question 448

Post menopausal HRT protocol (MHT)

Answer 448

**Cyclical or sequential therapy** Continuous estrogen + cyclic progestogen Continuous estrogen for 28 days and then progesterone is added during the last 14 days. Indication: **Peri menopausal women and during 1st year of menopause**. Will get cyclical bleeds. **Continuous combined therapy** Continuous estrogen+ continuous progestogen Indication: **after 1 year of menopause**. Spotting and breakthrough bleeding is common in the first 3-4 months of therapy. **Estrogen alone therapy** In women who had hysterectomy

Question 449

MHT CONTRAINDICATIONS

Answer 449

 Age 60 years or older  Previous DVT  Previous MI, Uncontrolled HT  Stroke, Previous TIA  Breast cancer  Endometrial cancer  Undiagnosed vaginal bleeding  Significant liver disease  Porphyria/ SLE

Question 450

MHT increase the Risk of:

Answer 450

Not to be given after 60 years due to the risk of VTE and stroke  Invasive breast cancer (increased with longer duration of combined MHT and persists up to 10 years after MHT is stopped. Risks greater for continuous combined than with cyclical MHT)  Stroke (usually above 60 years)  DVT  Gallbladder disease  Coronary heart disease (usually above 60 years)

Question 451

MHT Side Effects

Answer 451

 Breakthrough bleed- settles in 8 to 12 weeks  In cyclical if not settled within 2 to 3 months, increase duration of progestogen  In continuous combined, increase progestogen dose, change type or route or change to tibolone  Review in 2 to 3 months. If still present investigate  Nausea- change to transdermal therapy  Breast tenderness- reduce oestrogen or progestogen  Initiating therapy with low dose will minimise these side effects

Question 452

MHT FOLLOW UP

Answer 452

 Review in 6 to 8 weeks and then at 6 months and then every 6 – 12 months with general health check, breast check  Mammogram every 2 years  DEXA where indicated  Vaginal bleed after 6 months of therapy needs further investigations  Most guidelines recommend using MHT for 4 to 5 years

Question 453

Hormonal Alternative to continuous combined MHT (>1y of menopause)

Answer 453

1. **Tibolone**  Synthetic steroid with oestrogenic and progestogenic activity and weak androgenic activity  **Less effective than MHT**  Improves bone mineral density and decreases risk of vertebral and non vertebral fractures  Does not increase breast density but **increases risk of breast cancer recurrence**  Increases risk of stroke after 60 years of age  **No increased risk of DVT** 2. **Conjugated oestrogens + bazedoxifene**  Less effective than MHT  Increases hip and spine bone density

Question 454

Non hormonal Alternatives to MHT

Answer 454

 SSRI like citalopram, escitalopram, paroxetine  SNRI- venlafaxine, desvenlafaxine Both of above alleviates vasomotor symptoms but to a lesser degree than MHT  Gabapentin-equally effective as low dose estrogen for vasomotor symptoms.  Pregabalin  Clonidine- mildly effective

Question 455

PCOS features

Answer 455

1. Clinical or biochemical hyperandrogenism -hirsutism - acne - deep voice - acanthosis nigricans 2. Menstrual dysfunction - irregularity - lack of ovulation 3. Polycystic ovaries on US

Question 456

PCOS Rotterdam Criteria

Answer 456

Question 457

PCOS hormonal changes

Answer 457

- increased serum free testosterone - Serum FSH low/normal - LH elevated - FSH/LH ratio 2:1/3:1 perhaps

Question 458

PCOS biochemical hyperandrogenism

Answer 458

Question 459

Bartholin abscess features

Answer 459

- base of labia minora - Neisseria gonorrhoea/ Chlamydia trachomatis asymptomatic <3cm: no treatment/warm compress symptomatic: - < 3cm Incision & drainage - >3cm word catheter - marsupialisation if after 1-2 failed then word catheter - gland excision if marsupialisation fails

Question 460

Endometrial cancer/hyperplasia risk factors

Answer 460

-unopposed oestrogen therapy 2-10% - increasing age 50-70 years 1-4% - obesity 2-4% - chronic anovulation (PCOS) 3% - late menopause >55 25 - Nulliparity 2% - Diabetes 2%

Question 461

Smoking protective factor

Answer 461

uterine leiomyomas ulcerative colitis Parkinson's

Question 462

Uterine fibroids/leiomyoma risk factors

Question 463

Features of Turner syndrome

Answer 463

- Short stature - Webbed neck - Puffy hands and feet - Coartaction of the aorta - cardiac abnormalities - high- arched palate - **absent secondary sexual characteristics** during puberty - B/L streak ovaries - horse shoe kidney - obstructed Uteropelvic junction

Question 464

Bacterial vaginosis management

Answer 464

1st line: oral metronidazole 7 days (400mg twice daily) 2nd line: vaginal clindamycin (1g at night) NOTE: for pregnancy: Clindamycin 300mg orally for 7 days initially or metronidazole 400mg orally 7 days

Question 465

High grade squamous intraepithelial lesion (HSIL)

Answer 465

1. Colposcopy & cervical cytology in 4-6 months 2. cervical cytology and human papilloma virus typing at 12 months after treatment annually until tested negative BOTH tests for 2 consecutive occasions 3. Returned to standard 5 yearly screening

Question 466

Most common cause of chronic pelvic pain in developed countries

Answer 466

Endometriosis

Question 467

Most common symptom of endometriosis

Answer 467

dysmenorrhoea

Question 468

premenopausal management of ovarian cysts

Answer 468

- Asymptomatic women with simple ovarian cyst <5 cm on ultrasound = no follow-up, cysts will resolve within 3 menstrual cycles - Simple cysts of 5–7 cm, a repeat ultrasound should be obtained - cysts of >7 cm surgical intervention should be considered. If surgery is required, a laparoscopic cystectomy is the operation of choice, as aspiration can cause recurrence.

Question 469

Lactation amenorrhoea

Answer 469

1st 6 months after delivery - baby fully breastfed - woman remains amenorrhoeic

Question 470

Endometrial cancer types

Answer 470

- simple - complex - cystic glandular (most common in perimenopausal women) -atypical simple - atypical complex

Question 471

Endometrial cancer features

Answer 471

- bleeding between periods - heavy and/or prolonged periods - vaginal discharge - abdominal pain

Question 472

Treatment of infertility

Answer 472

- < 35 years but BMI > 25, lifestyle modifications for 1st 6 months - >35 years BMI 30-32 metformin (with or without clomiphene citrate) - >32 BMI combined metformin with clomiphene citrate - Metformin & clomiphene citrate unsuccessful, then gonadotropins - if PCOS present, laparoscopy with ovarian surgery - IVF

Question 473

HRT and mammography

Answer 473

- continue HRT (no need to reduce dose or stop) and commence mammography screening as per guidelines

Question 474

HRT and breast cancer

Answer 474

- after 5 years risk of breast cancer increases - No breast cancer risk up to 7 years if HRT oestrogen alone (hysterectomy) - review medications annually - breast cancer screening per normal as other women

Question 475

HRT & PE/DVT/ stroke

Answer 475

increased incidence - oestrogen only not enough evidence

Question 476

HRT reduced incidence

Answer 476

- Osteoporosis/fractures - colon cancer

Question 477

Osteoporosis treatment

Answer 477

- Alendronate, risedronate and zoledronic acid: first-line therapy in **postmenopausal osteoporosis ** and prevent vertebral, Non-vertebral and hip fractures. - bisphosphonates: primary prevention of fractures in px who never had minimal trauma fracture, secondary prevention of **fractures** - Strontium ranelate: primary prevention of osteoporosis in women - bisphosphonates and raloxifene: secondary prevention of fractures in women who have had minimal trauma fractures

Question 478

Osteoporosis treatment not going to plan, what to do

Answer 478

- BMD T-score of =<-3 - > 1 symptomatic new fracture after at least 12-months of continuous therapy - > 2 minimal trauma fractures despite being on sufficient doses of bisphosphonates. switch to **teriparatide** for 18 months

Question 479

Stress incontinence management

Answer 479

Pelvic floor exercises (Kiegel)

Question 480

Urge incontinence management

Answer 480

Bladder training

Question 481

Urinary incontinence with cystocele management

Answer 481

Anterior colporrhaphy

Question 482

shoulder tip main mainly refers to

Answer 482

ectopic pregnancy

Question 483

unilateral dull pain that can become diffuse smooth adnexal mass with or without peritoneal signs

Answer 483

ovarian cyst

Question 484

ascites + pleural effusion + ovarian tumour

Answer 484

Meig's syndrome - Ovarian fibroma - spindle shaped cells

Question 485

Presence of Signet cells on histology

Answer 485

Krukenberg tumour

Question 486

Turner syndrome is also known as

Answer 486

- Gonadal dysgenesis - Ovarian dysgenesis

Question 487

Endometriosis diagnostic time period

Answer 487

Due to the variability in this condition, there is a diagnostic delay around 8-10 years

Question 488

Post coital bleeding ddx

Answer 488

Rule out malignancy first 1-Cervical erosion 2-Cervical polyp 3-Presence of IUCD 4-Cervical cancer 5-Intra-uterine cancer

Question 489

Ectopic pregnancy high risk factors

Answer 489

Previous ectopic pregnancy Previous tubal surgery Tubal pathology Past & current use of IUD IVF

Question 490

Mirena contraindications

Answer 490

– History of breast, cervical or uterine cancer. – History of liver disease. - Septic abortion – Uterine abnormalities, such as fibroids, that interfere with the placement or retention of Mirena. – Current pelvic infection or have a history of a pelvic inflammatory disease (PID). – Unexplained vaginal bleeding. -Being at high risk of a sexually transmitted disease

Question 491

Endometrial ablation contraindications

Answer 491

– Pregnancy. – Suspected genital tract infection. – The desire to preserve fertility. – Post-menopausal women.

Question 492

Post-menopausal endometrial thickness

Answer 492

Suspect endometrial malignancy - endometrial thickness of 4mm or more with vaginal bleeding mandates endometrial biopsy

Question 493

Ovarian cancer diagnostic approach

Answer 493

CA-125 test along with transvaginal ultrasound

Question 494

Features of endometritis

Answer 494

- Lower abdominal pain and uterine tenderness (first 24 to 72 hours) - Purulent lochia - chills, headache - malaise - anorexia

Question 495

endometritis management

Answer 495

- augmentin - triple test

Question 496

Preoperative staging for endometriosis

Answer 496

MRI - visualising soft tissues as well as all pelvic compartments at one time as opposed to US

Question 497

Asymptomatic bacteriuria treatment indication

Answer 497

- Pregnancy - elective urological procedures (TURP)

Question 498

Right lower quadrant (RLQ) pain ddx

Answer 498

Gynae -ectopic pregnancy - tubo-ovarian abscess - ruptured corpus luteum ovarian cyst - ovarian torsion GI -appendicitis -inflammatory bowel disease - diverticulitis - hernia

Question 499

Features of threatened abortion

Answer 499

- closed cervical os - absent history of passing foetal tissue

Question 500

Features of inevitable abortion

Answer 500

- open cervical os - bulging of membranes of the os

Question 501

Features of complete abortion

Answer 501

- closed cervical os - passing of foetal tissue

Question 502

Features of septic abortion

Answer 502

- uterine infection during any time - vaginal bleeding -cramping pain - fever - purulent cervical discharge

Question 503

Features of missed abortion

Answer 503

- Closed cervical os - No spotting or bleeding (no foetal tissue passed) - Ultrasound scans diagnosis of a non-viable IUP (empty sac)

Question 504

HPV 6 & 11 indicate

Answer 504

benign condyloma (genital warts)

Question 505

features of Sertoli-Leydig tumour

Answer 505

- high androgen production (seborrhoea, acne, menstrual irregularity, hirsutism, breast atrophy, alopecia, deepening of the voice, and clitoromegaly)

Question 506

Features of Kruckenberg tumour

Answer 506

- Bilateral solid mass on the ovary -Metastasis from other organs (stomach, intestine)

Question 507

evidence of glial tissue and immature cerebellar and cortical tissue

Answer 507

Immature teratoma

Question 508

Testosterone cream uses

Answer 508

- Lichen sclerosis - vaginal dryness - vulvar atrophy - post menopause

Question 509

Prader-Willi syndrome

Answer 509

deletion of chromosome 15 (70%) after the newborn period: - hypotonia - hypogonadism - hyperphagia - hypomentia - obesity

Question 510

Infertility Treatment for premature ovarian failure/ menopause

Answer 510

IVF only

Question 511

Premature menopause dx

Answer 511

occurs spontaneously before 40 years. - frequent follicular development - infrequent ovulation

Question 512

HPV can cause what type of cancers

Answer 512

– Cervical cancer. – Cancer of oro-pharyngeal cavity. – Squamous cell carcinoma of anus, penis and vagina. – Cancer of the uterus.

Question 513

common cause of gynaecological cancer deaths

Answer 513

Ovarian cancer

Question 514

Most common type of ovarian cancer

Answer 514

Epithelial ovarian cancer (90%)

Question 515

Treatment of Lichen- sclerosis

Answer 515

Potent topical steroids

Question 516

Lichen- Sclerosis dx

Answer 516

- pre-pubertal and peri-menopausal women TRIAD: genital itching, soreness and white wrinkled plaques in the genital area -Dx: biopsy

Question 517

Specific Indications for cone biopsy

Answer 517

1. Fail to visualize Transformation zone in pt with HSIL on her Cervical smear ref 2. Suspecting early invasive Cx cancer on cytology, biopsy or colposcopic assessment 3. Suspecting glandular abnormalities on cytology or biopsy

Question 518

chlamydial urethritis treatment

Answer 518

Azithromycin 1 g oral

Question 519

Post menopausal + endometrial thickness 4mm or above + vaginal bleeding

Answer 519

Suspect Endometrial cancer and refer to gynaec for endometrial biospy

Question 520

GBS treatment

Answer 520

The following women should be treated for GBS during labour: All women with a history of a GBS-related disease – these women should be given intrapartum antibiotics in all their subsequent pregnancies regardless of the swab culture results All women with a GBS positive swab or urine culture result in the current pregnancy Premature rupture of membranes for more than 18 hours, or when the time is unknown Maternal pre- or intra-partum fever of 38°C Women with unknown status of GBS colonization

Question 521

most important Endocrine test in assessing male infertility

Answer 521

FSH : more than 2time the normal indictaed irreversible testicular failure

Question 522

Aromatase inhibitors cause

Answer 522

- increased osteoporosis - cardiac abnormalities

Question 523

Cushing syndrome symptoms in women

Answer 523

- anxiety - tremulousness - weight gain - severe fatigue - menstrual irregularities -hypertension - hyperglycaemia - Pinkish stria on buttocks, thighs, breast - Skin becomes thin and bruises easily - check serum cortisol level

Question 524

Contraceptives used in the treatment of acne

Answer 524

- Cyproterone acetate - Desogestrel - Drospirenone - Gestodene