Mixed TOGS

Question 1

Presentation of leaking abdominal aneurysm in pregnancy?

Answer 1

Unexplained collapse preceded by severe acute abdo/back pain, typically intercapsular

Question 2

Who is more at risk of abdominal aneurysm?

Answer 2

Marfan’s

Question 3

What is murphy’s sign and what does it indicate?

Answer 3

Tenderness increased on inspiration while palpating RUQ
Acute cholecystitis

Question 4

Typical presentation of pancreatitis?

Answer 4

Upper abdominal pain eased by leaning forward
Often history of biliary colic/cholecystitis

Question 5

Types of non-epithelial ovarian cancer

Answer 5

Malignant ovarian germ cell tumours - dysgerminoma, embryonal, immature teratoma, choriocarcinoma, yolk sac tumour

Sex cord-stromal tumours - thecoma, granuloa cell, sertoli-leydig

Question 6

Most common germ cell tumour?

Answer 6

Dysgerminoma

Question 7

Features of dysgerminoma?

Answer 7

20-30s
Fish flesh cut surface
Haemorrhage and necrosis common
SOlid, round, lobulated
90% 5 year survival
LDH used to monitor disease

Question 8

Tumour markers in immature teratoma?

Answer 8

AFP, LDH, DHEA can be raised

Question 9

Features of endodermal sinus tumour/YS tumour?

Answer 9

Elevated AFP
Malignant
Radioresistant
Unilateral
Large, solid, lobulated
Schiller-Duvall bodies (glomerulois tufts)

Question 10

Pathognomomic feature of granulosa cell tumour?

Answer 10

Call-exner bodies
Isosexual precococious puberty in 50%

Question 11

Features of immature teratoma?

Answer 11

Malignant
Elements from all 3 germ cell layers
May coexist with mature teratoma

Question 12

Features of mature teratoma?

Answer 12

95% benign, rarely undergo malignant transformation
Cystic masses with focal solid areas - rokitansky’s protuberance
hair, sebum, teeth

Question 13

Features of choriocarcinoma (non-gestational type)

Answer 13

Very rare
Isosexual precocity
High hCG
Large haemorrhagic masses
Derived from syncytiotrophoblas and cytotrophoblast

Question 14

Which NEOCs may have raised testosterone?

Answer 14

granulosa cell, sertoli-leydig

Question 15

Which NEOCS have raised hCG?

Answer 15

choriocarcinoma, embryonal

Question 16

Yolk sac tumour will have raised…

Answer 16

AFP, LDH

Question 17

In which NEOC can you have raised AMH?

Answer 17

granulosa cell tumour
(inhibin also raised)

Question 18

How are NEOCs managed?

Answer 18

Surgery and chemotherapy
Unilateral salpingo-oophorectomy if fertility preservation required

Question 19

Which medications should be stopped prior to conception in women with IBD?

Answer 19

Mycophenolate mofetil and methotrexate

Question 20

Drugs used for UC that are safe in pregnancy?

Answer 20

Sulfasalazine
Metronidazole short courses
Steroids

Question 21

Sulfasalazine MoA?

Answer 21

interferes with folate synthesis by inhibiting dihydrofolate reductase
Therefore need to give high dose folic acid

Question 22

Risks to fetus with sulfasalazine use?

Answer 22

Bloody diarrhoea in infant, avoid >3g/day due to fetal nephrotoxicity, theoretical risk kernicterus in newborn

Question 23

What are the key challenges with use of biologics in IBD in pregnancy?

Answer 23

Minimal data
Infliximab crosses placenta at high rates in 3rd trimester which can cause immunosuppression in newborns for 6 months. Therefore often discontinued at 32w

Question 24

Considerations for labour in IBD?

Answer 24

Avoid episiotomy as can trigger perinanal disease

Question 25

Definition of very advance maternal age?

Answer 25

>45 years at time of delivery

Question 26

Main risks of pregnancy in women with very advanced maternal age?

Answer 26

Caesarean section delivery 50% Hypertension/ PET - especially in egg donation conception GDM Fetal growth restriction Pre-term delivery Placenta praevia Higher risk of admission to ICU

Question 27

If Na 125-130 in labour- what should you do?

Answer 27

Fluid restrict to 80ml/h Repeat Na in 4 hours Inform obs team/NNU

Question 28

If Na <125 in labour - what should you do?

Answer 28

Fluid restrict to 30ml/h Stop oxytocin Repeat Na in 2 hours MDT involvement

Question 29

If after initial measures Na <125 and worsening/symptomatic, what should you do?

Answer 29

CCU involvement Consider 2.7% saline 200ml in 30mins Consider furosemide 20mg IV if fluid overload

Question 30

Post-natally, at what Na level should you fluid restrict/stop oxytocin?

Answer 30

<125 Restrict to 30ml/h MDT involvement

Question 31

Signs/symptoms of hyponatraemia

Answer 31

headache, nausea, no appetite, apathy disorientation, agitation, seizures, coma, respiratory arrest, pulmonary oedema

Question 32

Most common vulval malignancy?

Answer 32

vulval squamous cell carcinoma

Question 33

What are the 2 main precursors to vulval squamous cell carcinoma?

Answer 33

HPV dependent - vulval high grade squamous intraepithelial lesion (vHSIL) >10% 10year risk ca HPV independent - differentiated type vulval intraepithelial lesion (dVIN) >50% 10 year risk ca

Question 34

Which HPV types are high risk for vulval ca?

Answer 34

HPV 16 and HPV 33

Question 35

Main risk factors for HPV independent vulval ca?

Answer 35

lichen sclerosus and age

Question 36

How to biopsy suspected VIN

Answer 36

Incisional punch biopsy 4mm width, 5mm depth Ensure biopsy is mapped

Question 37

Management of VIN

Answer 37

Surgical - local excision if small/defined OR vulvectomy if extensive disease Medical management - imiquimod 5% cream

Question 38

MoA imiquimod?

Answer 38

Immunomodulator - agonism of toll-like receptors 7+8

Question 39

Risk of recurrence after treament of VIN?

Answer 39

26%

Question 40

Features of usual type (HPV dependent) VIN?

Answer 40

basaloid, warty, multifocal 35-55 years old RFs: HPV, smoking, immunodeficiency

Question 41

Features of differentiated VIN?

Answer 41

Unifocal Post-menopausal

Question 42

Lichen sclerosis is associated with what other immune conditions?

Answer 42

Thyroid disease T1DM

Question 43

What is extra mammary paget's?

Answer 43

Rare vulval lesion in 60-80yo Associated with adenocarcinoma e.g. breast or GO Strawberries and cream appearance - erythematous and scaly patches Paget cells seen on biopsy High recurrence - excision is treatment

Question 44

Nodes affected in vulval cancer?

Answer 44

Inguino-femoral nodes

Question 45

Incision type to remove vulval cancer?

Answer 45

Triple incision with primary closure

Question 46

Appearance of squamous vulval ca?

Answer 46

Warty, rolled edges

Question 47

Treatment for vulvodynia?

Answer 47

gabapentin amitriptyline