Misc O&G (capsule, passmed, etc)

Question 1

What is the is the most common cause of early-onset severe infection in the neonatal period?

Answer 1

Group B Streptococcus (GBS)

Question 2

What are the risk factors for Group B Streptococcus (GBS)?

Answer 2

• prematurity
• prolonged rupture of the membranes
• previous sibling GBS infection
• maternal pyrexia e.g. secondary to chorioamnionitis

Question 3

Do the guidelines show that Group B Streptococcus (GBS) screening should be offered to all pregnant women?

Answer 3

• no
• maternal request is not an indication for screening

Question 4

What is the management of women who’ve had GBS detected in a previous pregnancy?

Answer 4

• women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%.
• They should be offered intrapartum antibiotic prophylaxis (IAP) OR
• testing in late pregnancy
• and then antibiotics if still positive

Question 5

When during the pregnancy are swabs for Group B Streptococcus indicated?

Answer 5

• if women are to have swabs for GBS this should be offered at:
  
  • 35-37 weeks or
  • 3-5 weeks prior to the anticipated delivery date

Question 6

When is intrapartum antibiotic prophylaxis (IAP) indicated?

Answer 6

• women who’ve had GBS detected in a previous pregnancy
• women with a previous baby with early- or late-onset GBS disease
• women in preterm labour regardless of their GBS status
• women with a pyrexia during labour (>38ºC)

Question 7

What is the antibiotic of choice for Group B Streptococcus (GBS) prophylaxis?

Answer 7

benzylpenicillinn

Question 8

What is the epidemiology of urinary incontinence?

Answer 8

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females.

Question 9

What are the RFs for urinary incontinence?

Answer 9

• advancing age
• previous pregnancy and childbirth
• high body mass index
• hysterectomy
• family history

Question 10

What is the classification of urinary incontience?

Answer 10

• overactive bladder (OAB)/urge incontinence: due to detrusor overactivity
• stress incontinence: leaking small amounts when coughing or laughing
• mixed incontinence: both urge and stress
• overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Question 11

What are the Ix for ?urinary incontinence?

Answer 11

• bladder diaries should be completed for a minimum of 3 days
• vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
• urine dipstick and culture
• urodynamic studies

Question 12

What is the Tx if urge incontinence is predominant?

Answer 12

• bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
• bladder stabilising drugs: antimuscarinics are first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
  
  • mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Question 13

What is the Tx if stress incontinence is predominant?

Answer 13

• pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
• surgical procedures: e.g. retropubic mid-urethral tape procedures
• duloxetine may be offered to women if they decline surgical procedures
  
  • a combined noradrenaline and serotonin reuptake inhibitor
  • mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Question 14

Name 2 antigen systems found on RBCs

Answer 14

• ABO system
• Rhesus system (D antigen)

Question 15

What % of mothers are Rhesus -tive?

Answer 15

15%

Question 16

What happens if a Rh -ve mother delivers a Rh +ve child?

Answer 16

• a leak of RBCs may occur during pregnancy or birth
• this causes anti-D IgG antibodies to form in mother
• in later pregnancies these can cross placenta and cause haemolysis in fetus
• this can also occur in the first pregnancy due to leaks

Question 17

How is haemolysis in a foetus due to anti D (Rh) antibodies, prevented?

Answer 17

• test for D antibodies in all Rh -ve mothers at booking
• NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
  
  • no difference between single dose at 28 weeks, or. double dose (also at 34 weeks)
• anti-D is prophylaxis - once sensitization has occurred it is irreversible
• if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present

Question 18

In which situtations should Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours)?

Answer 18

• delivery of a Rh +ve infant, whether live or stillborn
• any termination of pregnancy
• miscarriage if gestation is > 12 weeks
• ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
• external cephalic version
• antepartum haemorrhage
• amniocentesis, chorionic villus sampling, fetal blood sampling
• abdominal trauma

Question 19

Which tests must be performed on all babies born to Rh -tive mothers?

Answer 19

• cord blood taken at delivery for FBC, blood group & direct Coombs test
  
  • Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
  • Kleihauer test: add acid to maternal blood, fetal cells are resistant

Question 20

What are the signs that a foetus has been affected by Rh +tive antibodies?

Answer 20

• oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
• jaundice, anaemia, hepatosplenomegaly
• heart failure
• kernicterus

Question 21

What is the Tx for a foetus that has been affected by Rh +tive antibodies?

Answer 21

• transfusions
• UV phototherapy

Question 22

Describe chorioamnionitis

Answer 22

• affects <5% of all preegnancies
• potentially life-threatening to mother + foetus –> medical emergency
• Uusally result of an ascending bacterial infection of the amniotic fluid/membranes/placenta
• risk factor = preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens
• Tx. = Prompt delivery of the foetus (via C section if necessary) + IV ABx

Question 23

What is the action needed if a Traditional’ POP (Micronor, Noriday, Nogeston, Femulen) is taken less than 3 hours late?

Answer 23

no action needed, continue as normal

Question 24

What is the action needed if a Traditional’ POP (Micronor, Noriday, Nogeston, Femulen) is taken more than 3 hours late?

Answer 24

(i.e. more than 27 hours since the last pill was taken)

• take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
• continue with rest of pack
• extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 25

What is the action is needed if Cerazette (desogestrel) is taken less than 12 hours late?

Answer 25

no action needed, continue as normal

Question 26

What is the action needed if Cerazette (desogestrel) is taken more than 12 hours late?

Answer 26

(i.e. more than 36 hours since the last pill was taken)

• take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
• continue with rest of pack
• extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 27

What is the risk of exposure to chickenpox to a pregnant woman and her foetus?

Answer 27

• fetal varicella syndrome (affects both mother and foetus)
  
  • features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
  • risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
• 5 times greater risk of pneumonitis
• shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
• severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Question 28

What is the management of chickenpox exposure in pregnancy?

Answer 28

• if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
• if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) ASAP
• RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
• if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Question 29

What is the management of chickenpox in pregnancy?

Answer 29

• if a pregnant woman develops chickenpox in pregnancy then need specialist advice
• there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
• consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
• if the woman is < 20 weeks the aciclovir should be ‘considered with caution’

Question 30

What dose of folic acid is recommended to those trying to get pregnant/are pregnant?

Answer 30

recommended that all women who are planning to become pregnant should take a supplement of 400 micrograms of folic acid per day whilst trying to conceive and once pregnancy, they should continue taking this dose until the 12th week of pregnancy

Question 31

What dose of folic acid should be taken for those with a In cases where there has been a previous pregnancy affected by neural tube defects or if there is a family history (who are trying to get pregnant)?

Answer 31

dose should be increased to 5 milligrams

Question 32

What are some causes of folic acid deficiency?

Answer 32

Causes of folic acid deficiency:

• phenytoin
• methotrexate
• pregnancy
• alcohol excess

Question 33

What are the consquences of a folic acid deficiency?

Answer 33

• macrocytic, megaloblastic anaemia
• neural tube defects

Question 34

When are women considered high risk of folic acid deficiency?

Answer 34

women are considered higher risk:

• either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
• the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
• the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Question 35

Clinical findings thus far are indicative of which of the following?

• large bowel obstruction
• intra-abdominal ascites
• small bowel obstruction
• para-colic abscess
• small bowel ileus

Answer 35

intra-abdominal ascites

Question 36

Clinically this patient has ascites. Which initial investigations would you arrange?

Answer 36

• Rectal exam/sigmoidoscopy
• send blood for tumour markers
  
  • Blood should be sent for ovarian, pancreatic and colonic tumour markers.
• ascitic tap for cytology, protein content & culture and sensitivity
  
  • To indentify where to aspirate ask for an ultrasound guided mark for drainage or for a radiology – performed ultrasound guided aspiration
• chest radiograph (has breathlessness)
• US abdo and pelvis

Abdominal radiograph is not indicated there is no clinical evidence of bowel obstruction.

Question 37

Ascites may represent a transudate (protein content <30g/L) or an exudate (protein content >30g/L). Name some causes of exudative ascites

Answer 37

• Cardiac failure
• hypoalbuminaemia
• hepatic cirrhosis
• myxoedema
• renal failure

Question 38

The ascitic tap confirms adenocarcinoma cells in the aspirate and ultrasound demonstrates a 10cm complex solid/cystic mass in the pelvis with ascites, and a normal post-menopausal uterus. What is the most likely diagnosis?

Answer 38

Ovarian carcinoma

• In the context of ascites containing adenocarcinoma cells and a complex pelvic mass, ovarian carcinoma is most likely.
• Metastatic gastric, colonic and breast carcinoma could cause a similar appearance, although these ovarian metastases (Krukenberg tumour) tend to be solid.
• If there is clinical doubt GI endoscopy and mammography can be undertaken.
• Elevation of the ovarian tumour marker, CA-125, may also be supportive.
• Polycystic ovary syndrome, ovarian dermoid cyst, endometrioma, and ovarian fibroma are all benign conditions – ovarian fibromas can cause ascites (Meig’s syndrome).
• Most cervical carcinomas are squamous.

Question 39

What is a Krukenberg tumour?

Answer 39

• Metastatic gastric, colonic and breast carcinoma presenting in the ovary as metastases (Krukenberg tumour).
• The stomach followed by colon are the two most common primary tumours to result in ovarian metastases, pursued by the breast, lung, and contralateral ovary.
• Signet ring cells found in the ovary are indicative of a primary gastric tumour that has metastasised.
• These ovarian metastases tend to be solid.

Question 40

What is Meig’s syndrome?

Answer 40

Meigs syndrome is an uncommon presentation, where a benign ovarian tumor present along with ascites and pleural effusion.

• Meigs syndrome happens in 1% of all ovarian tumors.
• It is most commonly associated with ovarian fibroma.
• Ovarian fibromas are diagnosed in 2 to 5% of excised ovarian tumors.

Question 41

This patient is likely to have ovarian carcinoma and peritoneal metastatic disease. Which three actions would you take next?

• Arrange admission for ascitic drainage
• Arrange urgent referral to gynae
• Arrange laparoscopy for histology
• Arrange CT staging of abdo and pelvis
• Arrange barium enema to assess presence of serosal masses

Answer 41

• Arrange admission for ascitic drainage
• Arrange urgent referral to gynae
• Arrange CT staging of abdo and pelvis

In the absence of bowel symptoms formal large bowel investigation is not indicated in probable ovarian malignancy. Likewise laparoscopy is not required. Expert opinion is required in the management of ovarian cancer, and therefore referral to gynaecology is urgent. Drainage of ascites will help symptoms of dyspnoea and abdominal discomfort.

Question 42

Name some differentials

Answer 42

• UTI
• Acute pancreatitis
• Acute cholecystitis
• Duodenal ulcer

Question 43

Name some differentials

Answer 43

• UTI
• Acute pancreatitis
• Acute cholecystitis
• Duodenal ulcer

Question 44

Are pregnant women at increased risk of cholecystitis and cholelithiasis?

Answer 44

yes

(gall stones and biliary sludge seen in up to 30% of the pregnant women)

Question 45

What is a Urea breath test used to diagnose?

Answer 45

H Pylori infection

Question 46

Which investigations are required in the assessment of a ?Pulmonary thromboembolism in pregnancy

Answer 46

• CXR
  
  • useful first-line investigation to look for other causes of chest pain, such as: pneumothorax, lobar collapse and pneumonia
• Compression duplex doppler
  
  • Performing a bilateral lower-limb Doppler has been recommended as an investigation in patients with a normal CXR. This is because a diagnosis of DVT supports the diagnosis of chest pain being secondary to a PE, and thus potentially removes the need for further (potentially harmful) investigations.
• CTPA
  
  • CTPA (rather than V/Q scanning) is the investigation of choice in patients thought likely to have a PE, where the patient has an abnormal initial CXR
• V/Q scan
  
  • V/Q scanning and CTPA have a role in investigating patients with a normal CXR/ Doppler, in whom there is a high clinical suspicion of PE

D-Dimer testing should not be carried out to diagnose venous thromboembolic disease in pregnancy (either DVT or PE) as it is frequently elevated owing to physiological changes.

Question 47

Can D dimer tests be used in pregnancy?

Answer 47

D-Dimer testing should not be carried out to diagnose venous thromboembolic disease in pregnancy (either DVT or PE) as it is frequently elevated owing to physiological changes.

Question 48

What is the Tx for venous thromboembolic disease in pregnancy (either DVT or PE)?

Answer 48

LMWH (Clexane) BD, dose: 1mg/kg

(LMWHs do not cross the placenta)

• Warfarin should be avoided in pregnancy as it is teratogenic.
• Its long half-life makes it particularly unsuitable in the context of a patient who (at 34 weeks) could go into labour at any time

Question 49

How is anticoagulation with a) unfractionated heparin b) LMWH reversed?

Answer 49

1. anticoagulation with unfractionated heparin can be reversed by protamine sulphate
2. there is no way of reversing LMWH

Question 50

What is the long-term Mx of venous thromboembolic disease in pregnancy (either DVT or PE)?

Answer 50

• Graduated compression stockings can significantly reduce the risk of post-thrombotic syndrome (characterised by limb swelling/ pain).
• Anticoagulation should be continued for at least 6 weeks post-partum, given ongoing thrombosis risk factor of pregnancy. Total duration of treatment should be at least 3 months
• Thrombophilia screening should be carried out ideally after the patient has completed anticoagulation.

Question 51

After taking a detailed history, what is the most appropriate first line investigation for this woman?

• Abdo US
• Speculum exam
• Blood clotting studies
• Blood Hb
• TVUSS

Answer 51

TVUSS

• In a woman who is not actively bleeding, there is no indication to do a speculum or vaginal examination.*
• Speculum examination is only useful if she has very heavy bleeding, otherwise, ultrasound should be the first-line investigation.*

Question 52

A 22-year-old woman in her first pregnancy presents to the early pregnancy clinic with light vaginal bleeding for two days, her last period was 6 weeks ago.

The patient’s TV US is shown in figure 1. What is the most likely diagnosis?

• Ectopic pregnancy
• Incomplete miscarriage
• Inevitable miscarriage
• Missed miscarriage
• Threatened miscarriage

Answer 52

• There is a gestation sac but no evidence of a fetal pole.
• When the Mean Sac Diameter is > 25mm in diameter and/or the fetal pole is > 7 mm in length and the woman has been offered an interval scan 7 days later, you can make the clinical diagnosis of a missed miscarriage.
• A threatened miscarriage would show a viable intrauterine pregnancy.
• Women should be informed that the diagnosis of miscarriage using 1 ultrasound scan alone cannot be guaranteed to be 100% accurate and there is a small chance that the diagnosis may be incorrect particularly at very early gestational ages. (NICE guidance April 2019).

Question 53

A 22-year-old woman in her first pregnancy presents to the early pregnancy clinic with light vaginal bleeding for two days, her last period was 6 weeks ago.

Which three of the following are the treatment options for this woman now (on diagnosis of a missed miscarriage)?

• Conservative Mx and review in EPU in 2 weeks
• Medical Mx of miscarriage (mifepristone + misopristol)
• Surgical Mx with ERPC
• Surgical Mx with a laparascopy

Answer 53

• Conservative Mx and review in EPU in 2 weeks
• Medical Mx of miscarriage (mifepristone + misopristol)
• Surgical Mx with ERPC
• Surgical Mx with a laparascopy
• Any of these treatments are appropriate and we should be guided by the woman’s views.
• Assuming she has been appropriately counselled regarding the risks/benefits of all three options.
• It is difficult to favour one form of management of miscarriage over another.
• Although the success rates of conservative management and medical management are less than surgical management all operations carry inherent risk.
• Conservative management would offer her the lowest chance of success (where success is measured by the miscarriage completing itself), within a two week period, but would allow the least intervention.
• Surgery and medical management are equally efficacious but the former carries the risk of a surgical procedure.
• We must follow this woman up, and there is no indication to look for an extra uterine pregnancy.

Question 54

A 22-year-old woman in her first pregnancy presents to the early pregnancy clinic with light vaginal bleeding for two days, her last period was 6 weeks ago.

If this woman chooses to have an ERPC which of the following are the potential complications she needs to be counselled about? (Please select all that apply)

• bleeding
• cervical trauma
• infection
• retained products of conception
• repeat ERPC
• uterine perforation

Answer 54

All of the above

Question 55

A 25 year old woman has been delivered by ventouse 30 minutes earlier, following a prolonged labour. The placenta was delivered intact. The midwife reports heavy vaginal bleeding of around 700ml.

What is the most common cause of post-partum haemorrhage?

• uterine atony
• uterine rupture
• anaemia
• pre-eclampsia
• genital tract trauma

Answer 55

uterine atony

uterine atony (failure of the myometrium to contract down after delivery, creating the living ligature to control bleeding from the placental bed) accounts for in excess of 70% cases of PPH.

• Genital tract trauma is the next most common cause. Uterine rupture is a rare cause of PPH.
• Pre-eclampsia itself does not cause PPH, but coagulation disturbances in severe pre-eclampsia can lead to excessive bleeding after delivery.
• Anaemia is not a cause of PPH but women with low Hb can become haemodynamically unstable at lower blood loss volumes.

Question 56

Name some factors that increase the risk of PPH

Answer 56

• previous PPH
• previous C section
• prolonged labour
• increased foetal size
• intrapartum haemmorhage
• multiple pregnancy
• grand parity
• uterine fibroids

Question 57

What are the main causes of PPH?

Answer 57

The main causes of PPH are the four ‘T’s:

• TONE (uterine atony),
• TISSUE (retained placenta),
• TRAUMA (vaginal, cervical or uterine)
• THROMBIN (deranged clotting as a result of the bleeding).

Question 58

How can uterine atony be managed initially?

Answer 58

rubbing up a uterine contraction

Question 59

What is the primary management of this woman with a post partum haemorrhage?

Answer 59

Question 60

Name medications that can be used to cause uterine contractions

Answer 60

• ergometrine
• syntocinon
• syntometrin
• carboprost
• misopristol

Question 61

You are a GP in practice. A 24-year-old Afro-Caribbean pregnant woman attends your surgery at the request of the local midwife. She is 26 weeks into her first pregnancy. A urine dipstick has shown +++ glucose on routine testing.

She has glycosuria in pregnancy and therefore may have diabetes. What are the three most important symptoms that would, if present, support this diagnosis?

Answer 61

• polyuria
• dysuria (UTI)
• thirst

Question 62

You are a GP in practice. A 24-year-old Afro-Caribbean pregnant woman attends your surgery at the request of the local midwife. She is 26 weeks into her first pregnancy. A urine dipstick has shown +++ glucose on routine testing.

Which one of the following tests is NOT appropriate at this stage?

• Random plasma. glucose
• fasting plasma glucose
• insulin tolerance test
• urinary ketones
• HbA1C
• glucose tolerance test

Answer 62

insulin tolerance test

• Insulin tolerance tests are rarely undertaken and only once a diagnosis of diabetes has been made.
• Assessment of plasma glucose is essential.
• A fasting plasma glucose level of 5.6 or above and/or a 2 hour plasma glucose level of 7.8mmol/L or above are indicative of diabetes. Results of >6 to <7.8 are equivocal. If the plasma glucose is totally normal the woman may simply have glycosuria of pregnancy because of a lowered renal threshold for glucose. However, plasma glucose varies according to the time and quality of the last food ingestion, so further investigation is needed if the result is equivocal.
• Urine ketones are essential to rule out the possibility that the woman has newly presenting Type 1 diabetes and is very insulin deficient.
• If HbA1c is high, pre-existing diabetes is more likely than diabetes due to the relatively short duration of diabetes due to insulin resistance of late pregnancy.
• Pre-existing diabetes means the woman may have had high glucose concentrations in early pregnancy and this may have affected organogenesis, increasing the risk of fetal abnormality.

Question 63

You are a GP in practice. A 24-year-old Afro-Caribbean pregnant woman attends your surgery at the request of the local midwife. She is 26 weeks into her first pregnancy. A urine dipstick has shown +++ glucose on routine testing.

What would would be indicated if ketones were found in her urine dipstick?

Answer 63

MEDICAL EMERGENCY

Urine ketones are essential to rule out the possibility that the woman has newly presenting Type 1 diabetes and is very insulin deficient

Question 64

You are a GP in practice. A 24-year-old Afro-Caribbean pregnant woman attends your surgery at the request of the local midwife. She is 26 weeks into her first pregnancy. A urine dipstick has shown +++ glucose on routine testing.

How should this woman with GDM be treated? A fasting blood glucose of 8.5 mmol/L has been recorded

Answer 64

She requires insulin injections

• For women with gestational diabetes who have a fasting plasma glucose level of 7.0 mmol/litre or above at diagnosis, offer:
• immediate treatment with insulin, with or without metformin and diet and exercise changes.
• For women with gestational diabetes who have a fasting plasma glucose level below 7 mmol/ litre at diagnosis, offer a trial of diet and exercise changes.
• If blood glucose targets are not met with diet and exercise changes within 1 to 2 weeks, offer metformin.
• The patient will need to alter her diet to a calorie restricted specific diabetes diet. This involves re-designing the diet to minimise the rise in plasma glucose after eating – small frequent meals incorporating complex carbohydrates

Question 65

A 24-year-old lady presents to delivery suite at 29 weeks gestation in her first pregnancy with painful uterine contractions. The doctor performs an examination which shows the fetus to be cephalic and the cervix to be 3cm dilated with intact membranes. The fetal heart is normal. She is afebrile and the urine dipstick is negative.

What is the most likely diagnosis?

• Appendicitis
• Braxton-Hicks contractions
• Placental abruption
• UTI
• pre-term labour
• gastritis

Answer 65

Pre-term labour

The most likely diagnosis is preterm labour given that the painful uterine contractions are associated with cervical dilatation.

Braxton-Hicks contractions are painless and the cervix remains closed.

Question 66

A 24-year-old lady presents to delivery suite at 29 weeks gestation in her first pregnancy with painful uterine contractions. The doctor performs an examination which shows the fetus to be cephalic and the cervix to be 3cm dilated with intact membranes. The fetal heart is normal. She is afebrile and the urine dipstick is negative.

Which 3 investigations would be best to perform?

• US of foetus
• Abdo XR
• CTG
• CRP and FBC
• Transvaginal US for cervical length

Answer 66

• US of foetus
• CTG
• CRP and FBC
• A growth scan of the fetus will give an estimate of the fetal weight which is useful for the neonataologists to know.
• FBC and CRP will indicate if there is any subclinical infection causing the preterm labour.
• A CTG is useful to assess fetal wellbeing and to monitor uterine activity.
• A tranvaginal scan of cervical length may have helped to predict the likelihood of preterm labour if the cervix had been closed on examination. However in this woman the cervix is known to be dilated to 3cm and so a diagnosis of preterm labour has already been made.

Question 67

A 24-year-old lady presents to delivery suite at 29 weeks gestation in her first pregnancy with painful uterine contractions. The doctor performs an examination which shows the fetus to be cephalic and the cervix to be 3cm dilated with intact membranes. The fetal heart is normal. She is afebrile and the urine dipstick is negative.

What is the Mx for this lady in preterm labour?

Answer 67

Tocolysis and steroids

Question 68

Which one of the following agents is NOT a tocolytic?

• beta agonists
• Ca channel blockers
• alcohol
• oxytocin receptor antagonists
• beta blockers
• magnesium sulfate

Answer 68

• beta blockers

The two most common tocolytic drugs used in clinical practice in the UK are Nifedipine (Calcium channel blocker) and Atosiban (Oxytocin receptor antagonist).

Beta agonists are a good tocolytic but can cause significant maternal side effects so are no longer used routinely in delaying preterm labour. However you may see the short acting beta agonist terbutaline used to temporarily reduce contractions if the uterus is hyper-stimulating during labour or induction of labour.

Alcohol is a tocolytic but not used in clinical practice. Magnesium sulphate is used in the US as a tocolytic but not in the UK. It is used in the UK for fetal neuroprotection in suspected preterm labour before 30 weeks or for seizure prophylaxis/treatment in pre-eclampsia.

Question 69

A 28-year-old lady presents to you at 30 weeks gestation complaining of intense itching of her hands and soles of the feet over the last week. She is unable to sleep at night due to the symptoms.

On examination, there is no rash other than dermatitis artefacta due to scratching. Obstetric examination is normal.

Which four can be normal in pregnancy?

• pruritus
• spider naevi
• palmar erythema
• jaundice
• chloasma (melasma)

Answer 69

• pruritus
• spider naevi
• palmar erythema
• jaundice
• chloasma (melasma)
• It is important to remember certain stigmata of liver disease can be normal signs in pregnancy unrelated to liver to disease.
• These will disappear soon after delivery.
• Women with liver disease in pregnancy can commonly present with pruritus and jaundice, it is essential to investigate such women.
• Pruritis may be physiological in pregnancy but hepatic causes must be excluded first.

Question 70

A 28-year-old lady presents to you at 30 weeks gestation complaining of intense itching of her hands and soles of the feet over the last week. She is unable to sleep at night due to the symptoms.

On examination, there is no rash other than dermatitis artefacta due to scratching. Obstetric examination is normal.

What are your initial DDx?

Answer 70

• viral hepatitis
• extrahepatic obstruction from gallstones
• obstetric cholestasis
• autoimmune hepatitis
• acute fatty liver of pregnancy.
• drug-induced hepatitis

Question 71

Summarise obstetric cholestasis

Answer 71

• Obstetric Cholestasis (OC) or Intrahepatic cholestasis of pregnancy is a disease unique to pregnancy.
• It is a diagnosis of exclusion and must be differentiated from other causes of liver dysfunction in pregnancy as in the above list.
• It most commonly presents in the 3rd trimester with generalised itching, worst on palms and soles.
• It becomes more severe with advancing gestation and can be severe enough to prevent sleep.
• Associated insomnia and malaise are common.
• It is relieved within 48 hours following delivery.
• There may be anorexia, abdominal discomfort, pale stools, dark urine and steatorrhoea.
• Jaundice is not a common feature, but if present will remain until delivery.

Question 72

A 28-year-old lady presents to you at 30 weeks gestation complaining of intense itching of her hands and soles of the feet over the last week. She is unable to sleep at night due to the symptoms.

On examination, there is no rash other than dermatitis artefacta due to scratching. Obstetric examination is normal.

What investigations would be appropriate to consider?

Answer 72

• FBC
• U&Es
• LFTs
• clotting profile
• bile acids
• hepatitis serology
• autoimmune antibodies
• Liver USS

Question 73

What pattern is seen in the LFTs in obstetric cholestasis?

Answer 73

The usual pattern of abnormal liver function tests are:

1) A moderate rise in transaminases,
2) Increased serum total bile acid concentration,
3) ALP may be raised beyond normal pregnancy values,
4) Mild or no significant elevation of bilirubin.

Question 74

What is the cause of the extreme pruritus in obstetric cholestasis?

Answer 74

Bile acids are deposited in the skin and probably cause the extreme pruritus

Question 75

What happens to the PTT in obstetric cholestasis lasting a couple of weeks, and why?

Answer 75

If OC lasts several weeks –

• liver dysfunction can result in decreased Vit K reabsorption or decreased prothrombin production,
• prolonging the PTT.

Question 76

What happens to the ESR in pregnancy?

Answer 76

raised physiologically

Question 77

What are the RFs for obstetric cholestasis?

Answer 77

• previous OC
• asian origin
• genetic traits
• pruritus on the COCP

Question 78

What are the complications of obstetric cholestasis?

Answer 78

maternal:

• severe liver impairment
• PPH

foetal:

• foetal macrosomia
• foetal distress
• premature delivery
• intrauterine death

Question 79

What is the cause of the risk of PPH in obstetric cholestasis?

Answer 79

The most serious risk to maternal health is increased risk of primary PPH due to altered coagulation as a result of deficiency of Vitamin K (lack of intestinal bile)

Question 80

What is the 1st line investigation for ?PROM

Answer 80

sterile speculum examination

Question 80

What is the 1st line investigation for ?PROM? What are we looking for in this examination to confirm the diagnosis?

Answer 80

sterile speculum examination

→ to look for pooling of amniotic fluid in the posterior vaginal vault

Digital examination should be avoided due to the risk of introducing infection.

Question 81

What tests should be performed if amniotic fluid is not demonstrated on speculum examination in a patient with ?PROM

Answer 81

vaginal fluid tests for:

• PAMG-1,
• insulin‐like growth factor‐binding protein 1

Question 82

What is the Mx once PROM has been confirme/

Answer 82

• admission
• regular observations to ensure chorioamnionitis is not developing

Drugs:

• oral erythromycin should be given for 10 days
• antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome

Delivery plan:

• delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Question 83

A woman who is 8 weeks pregnant presents with abdominal pain and vaginal bleeding. On examination she is tender in the right iliac fossa and suprapubic region. Speculum examination shows an open cervical os. Ultrasound confirms an intrauterine pregnancy.

What is the most likely diagnosis?

Answer 83

(inevitable) Miscarriage90

Question 84

A woman who is 33 weeks pregnant presents with vaginal bleeding, which she describes as being like a period. She also has constant, lower abdominal pain. On assessment her blood pressure is 90/60 mmHg and pulse is 110/min

What is the most likely diagnosis?

Answer 84

Placental abruption84

Placental praevia would not usually present with abdominal pain.

Question 85

A woman who is 22 weeks pregnant presents with abdominal pain on the right side of her abdomen. On examination she has abdominal tenderness on the right side and urine dipstick is normal. White blood cells are raised at 18.5 * 10⁹/l

What is the most likely diagnosis?

Answer 85

Appendicitis

Ovarian torsion should be considered but would not normally be associated with such a leucocytosis.

Another differential diagnosis to consider is acute cholecystitis.