MR CS Flashcards
A 22 year old patient attends clinic. She reports unprotected sexual intercourse 48 hours earlier. She is not using any form of contraception. Following discussion you prescribe Ulipristal 30mg as a stat dose. What should you advise regarding vomiting?
With Ulipristal a repeat dose is indicated if vomiting occurs within 3 hours. With Levonorgestrel a repeat dose is indicated if vomiting occurs within 2 hours.
Levenogestrel (Levonelle®)
Synthetic progesterone 1.5mg single dose as soon as possible after sexual intercourse, licensed up to 72 hours after SI. If vomiting within 2 hours repeat dose can be given
Ulipristal (EllaOne®)
Selective progesterone receptor modulator 30mg single dose Effective up to 5 days after sexual intercourse If vomiting within 3 hours repeat dose can be given Individual studies suggest that ulipristal is as effective as levonorgestrel for EC. Pooled data suggest superior to Levenogestrel.
Copper Intra-uterine Device (IUD)
More effective than Levenogestrel Can be inserted up to 120 hours after SI
NOTE
If a patient is taking enzyme inducing drugs (e.g. Phenytoin) then the effectiveness of Levenogestrel, and possibly Ulipristal, is reduced. In these circumstances a copper IUD should be offered or a single 3.0g dose of Levenogestrel used.
A patient is attending for medical abortion. She is 15 weeks gestation. She has no known drug allergies. Which of the following is the most appropriate regarding antibiotic prophylaxis?
If the patient has a negative Chlamydia screen then a stat dose of metronidazole monotherapy is appropriate. You do not know this patients Chlamydia status and therefore dual therapy with metronidazole + doxycycline or azithromycin is appropriate.
The RCOG syllabus advises that you should be familiar with the pharmacology of drugs used for medical termination of pregnancy.
In practice this means you should be familiar with
- Drugs used for abortion itself (Mifepristone and Misoprostol)
- Drugs required depending on Rhesus status
- Antibiotic provision.
Details for these are given below
1.Medication regimes for medical abortion
Medical abortion regimens using 200 mg oral mifepristone and misoprostol are effective and appropriate at any gestation. The misprostol dose varies depending on the gestation asper the table below
Gestation Mifepristone dose Misoprostol dose & timing after Mifepristone
49 days Mifepristone 200 mg orallly 24-48 hours later by 400 mcg oral misoprostol
50 to 63 Mifepristone 200 mg orallly 24-48 hours later by 400 mcg oral misoprostol
+ 2nd dose 400 mcg vaginal or oral misoprostal if no abortion within 4 hrs of 1st dose
63 days Mifepristone 200 mg orallly 24-48 hours later by misoprostol 800 micrograms
(vaginal, buccal or sublingual)
9 to 13 weeks Mifepristone 200 mg orallly 36-48 hours later by misoprostol 800 micrograms vaginally
Up to 4 further doses of misoprostol 400 mcg (PO or PV) at 3 hourly intervals
13-24 weeks Mifepristone 200 mg orallly 36-48 hours later by misoprostol 800 micrograms vaginally
400 micrograms misoprostal (PO or PV) 3 hourly intervals up to 4 doses.
If abortion has not occurred mifepristone can then be repeated three hours after the last misoprostol followed by misoprostol 12 hours after that
2.Rhesus Status
Rhesus Anti-D IgG should be given, by injection into the deltoid muscle, to all non-sensitised RhD negative women within 72 hours following abortion, whether by surgical or medical methods.
3.Infection Prophylaxis
The following regimes are suggested:
Azithromycin 1g PO on the day of abortion, plus metronidazole 1g PR or 800 mg PO prior to or at the time of abortion Doxycycline100mg PO BD 7days starting on day of abortion, plus metronidazole 1 g PR or 800 mg PO prior to or at the time of the abortion Metronidazole 1g PR or 800mg PO prior to or at the time of abortion for women who have tested negative for C. trachomatis infection
A couple present to the fertility clinic after failing to conceive despite trying for 2.5 years. The semen analysis shows azoospermia.You perform a full examination of the male partner which reveals Height 190cm, BMI 20.0, small testes and scant pubic hair. What is the likely diagnosis?
If you are asked in the exam about males with azoospermia the most likely diagnosis will be Klinefelter’s syndrome. Klinefelter’s is fairly common affecting around 1 in 500-1000 boys. It is due to trisomy of sex chromosomes with those affected having XXY karyotype.
For other causes of azoospermia such as cystic fibrosis, acquired azoospermia secondary to orchitis or vasectomy, idiopathic (obesity) the question history will be highly suggestive.
Also note at least some of the typical features of Klinefelters syndrome will be in the question stem:
Tall and thin
Reduced facial & pubic hair
Atrophy of testes
Low libido
Gynaecomastia
Late puberty
Sometimes mild learning disability though most are of normal intelligence
A fibroid is a type of
A fibroid is a benign smooth muscle tumour or Leiomyoma. As such it is something of a misnomer.
Leiomyosarcoma and Angioleiomyoma are malignant tumours of smooth muscle under the WHO sort tissue tumour classification
Rhabdomyoma is a skeletal muscle tumour
Myofibroma is seen in fibromatosis
Risk Factors
Black Ethnicity
Obesity
Early Puberty
Increasing age (from puberty until menopause)
Protective Factors
Pregnancy
Increasing number of pregnancies
Note Hormonal contraception has not been proven to have an effect on fibroid prevalence though evidence is conflicting
An 18 year old patient comes to see you following her recent diagnosis of Polycystic Ovarian syndrome. Her BMI is 25.0 and her BP is 122/80. She is a non-smoker and there is no personal or family history of VTE or migraine. She would like to start the pill for her facial hair. What is the most appropriate option?
Although waxing is a legitimate treatment option PCOS does not preclude the use of the COCP.
Topical eflorithine is first line treatment for facial hirsutism but shouldn’t be given to women under 19 years of age (or pregnant or breastfeeding women).
Co-Cyprindiol (Dianette) is licensed for use for hirsutism. It should be stopped 3 to 4 months after resolution of hirsutism. NICE advises consider switching to Yasmin (unlicensed use) if relapse occurs when Dianette is stopped. Note patients should be counselled about increased VTE risk with Dianette and Yasmin compared to other COCPs.
Microgynon isn’t licensed of for use in treating hirsutism.
COCP
COCP Safety
The UKMEC criteria can be useful for assessing the safety of use of the combined oral contraceptive (COCP or CHC) for an individual. The UKMEC criteria classify risks from 1-4 as summarised below:
UKMEC Definition of category
UKMEC 1 A condition for which there is no restriction for the use of the method
UKMEC 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks
UKMEC 3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
UKMEC 4 A condition which represents an unacceptable health risk if the method is used
In practice this usually translates to patients who have conditions that fall into UKMEC 1 and 2 categories being safe to prescribe to whereas those with UKMEC 3 or 4 conditions would be deemed unsafe to prescribe to. There are obviously caveats where it may be deemed appropriate for a patient with a UKMEC 3 condition to use the COCP and those with multiple UKMEC 2 conditions being deemed unsuitable.
COCP UKMEC 4 conditions:
<6 weeks postpartum (breastfeeding) <3 weeks postpartum (not breastfeeding) + other risk factor VTE Age ≥ 35 and smoking ≥15 cigarettes/day Systolic BP ≥160mmHg Diastolic BP ≥100mmHg Vascular disease Ischaemic heart disease Stroke History VTE VTE currently being treated with antioagulants Major surgery with prolonged immobilisation Known thrombogenic mutations eg factor V Leiden Complicated valvular heart disease eg history SBE, tetralogy of Fallot, aortic stenosis. Cardiomyopathy with impaired cardiac function Atrial fibrillation Migraine with Aura Current breast cancer Severe (decompensated) liver cirrhosis Benign hepatocellular adenoma Hepatocellular carcinoma Positive antiphospholipid antibodies
What does NICE advise pregnant diabetic women should keep their HBA1C below?
6.1% is the old target from NICE guideline 63. This guidance was replaced by NICE guideline 3 in February 2015.
The current recommendation is to keep HBA1C below 6.5% or 48mmol/mol
NICE updated its guidance on management of diabetes in pregnancy in 2015. The current guidelines advise the following regarding management including new HBA1C targets:
Advise women with diabetes who are planning to become pregnant to aim to keep their HbA1c level below 48 mmol/mol (6.5%), if this is achievable without causing problematic hypoglycaemia. Reassure women that any reduction in HbA1c level towards the target of 48 mmol/mol (6.5%) is likely to reduce the risk of congenital malformations in the baby. Strongly advise women with diabetes whose HbA1c level is above 86 mmol/mol (10%) not to get pregnant because of the associated risks
A 28 year old women has undergone emergency hysterectomy due to obstetric haemorrhage during her 3rd pregnancy. The previous pregnancies were both term C-section deliveries. Examination of the uterus shows the placenta had invaded the myometrium but not the serosa. What condition is this?
Regarding abnormal placental invasion there are 3 forms (sometimes discussed together under the term Accreta):
Accreta: chorionic villi attached to myometrium rather than decidua basalis Increta: chorionic villi invade into the myometrium. Percreta: chorionic villi invade through the myometrium
Accreta is the most common form accounting for around 76% of cases, Increta is 2nd most common with 17% of cases and Percreta 7% of cases.
Previous C-section is a risk factor with the risk rising with each c-section. Risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries, respectively.
Placenta praevia is also a risk factor. Additional reported risk factors for placenta accreta include maternal age and multiparity, other prior uterine surgery, prior uterine curettage, uterine irradiation,endometrial ablation, Asherman syndrome, uterine leiomyomata, uterine anomalies, hypertensive disorders of pregnancy, and smoking.
You are asked to speak to a patient following a recent cervical smear. Microscopy has revealed trichomoniasis infection. The patient has had no symptoms. What percentage of trichomoniasis infections are asymptomatic?
The RCOG quotes up to 50% of women as being asymptomatic and as they set the exam its best to use their figures. BASHH advise 10-50% are asymptomatic.
Note the RCOG and BASHH both state up to 70% of women will have vaginal discharge. Its worth bearing this in mind if you are asked about what % of women have vaginal discharge and you are aware 50% are asymptomatic as the numbers don’t quite add up!
You are asked to speak to a patient following a recent cervical smear. Microscopy has revealed trichomoniasis infection. The patient has had no symptoms. What percentage of trichomoniasis infections are asymptomatic?
Trichomoniasis Key Points
Trichomoniasis Vaginalis causative organism Flagellate protazoan Sexually transmitted Up to 50% of women have no symptoms Vaginal discharge is most common symptom (up to 70%). Classic discharge described as frothy and yellow-green (occurs in 20% of infected women) but can be variable. Other symptoms are vulvovaginal soreness and itching, offensive odour, lower abdo pain, dysuria and dyspareunia Clinical findings typically vulval inflammation. Rarely strawberry cervix (cervicitis - 2% of cases) Diagnosis wet smear microscopy or culture/PCR Metronidazole 400 to 500 mg twice a day for 5 to 7 days (dose and course length depending on patient group) is 1st line treatment for men and women (including those who are breastfeeding or pregnant)
Which hormone is responsible for contraction of myoepithelial cells in lactation?
Lactation
Oxytocin stimulates the milk ejection reflex (let-down) in response to suckling. Galactopoiesis is maintained via the action of Prolactin. Alveolar gland proliferation and differentiation occurs under the actions of Oestragens, Progesterone, HPL and prolactin. Prolactin stimulates Lactogenesis when not inhibited
A patients MSU comes back showing heavy growth of E.Coli that is resistant to trimethoprim, amoxicillin and nitrofurantoin. You decide to prescribe a course of Cefalexin. What is the mechanism of action of Cefalexin?
Cephalosporins, like penicillins, are active via Beta-Lactams which inhibit peptidoglycan cross-links in bacterial cell walls.
Note Beta Lactamase enzymes are produced by bacteria resistant to Beta-Lactam antibiotics
MOA of each abx class
- Penicillin
- Cephalosporin
- Macrolides
- Quinolone
- Tetracycline
- Nitrofurantoin
Antibiotics
Antibiotic Class
Mode of Action
Examples of Drugs
- Penicillin-
Beta-Lactam inhibit peptidoglycan cross-links in bacterial cell wall
Amoxicillin, Phenoxymethylpenicillin, Flucloxacillin - Cephalosporins
Beta-Lactam inhibit peptidoglycan cross-links in bacterial cell wall
Cefalexin,Ceftriaxone,Cefuroxime - Macrolides Peptidyltransferase Inhibitor Erythromycin, Clarithromycin, Azithromycin
- Quinolones DNA Gyrase Inhibitor
Ciprofloxacin, Levofloxacin, Moxifloxacin - Tetracyclines
Bind to 30S subunit of microbial ribosomes blocking attachment of aminoacyl-tRNA to the A site on the ribosome
Lymecycline, Oxytetracyline, Doxycycline
6.Nitrofurantoin
Damages bacterial DNA via multiple reactive intermediaries Nitrofurantoin
- Trimethoprim Dihydrofolate Reductase Inhibitor Trimethoprim
When consenting someone for laparoscopy you discuss the risk of vascular injury. The incidence of vascular injury during laparoscopy according to the BSGE guidelines is?
Major vessel injury is the most important potential complication when undertaking laparoscopy. It’s incidence is 0.2/1000.
Bowel Injury is more common at 0.4/1000
Laparascopy
Guideline advice:
Women must be informed of the risks and potential complications associated with laparoscopy. This should include discussion of the risks of the entry technique used: specifically, injury to the bowel, urinary tract and major blood vessels, and later complications associated with the entry ports: specifically, hernia formation
Risk of Complications
Overall risk of 'serous complications' is 2/1000 Risk of bowel injury 0.4/1000 Risk of vascular injury 0.2/1000 Risk of death is 5 in 100,000
When consenting a patient for abdominal hysterectomy (for a benign condition) what would you advise regarding the risk?
Ans” injury to ureter/bladder~ 1%
According to the RCOG consent advice for abdominal hysterectomy for benign conditions. The following risks are quoted:
Overall Risk serious complication 4% Haemorrhage requiring blood transfusion 2.3% Bladder and/or ureter injury and/or long-term disturbance of bladder function 0.7% Return to theatre (e.g. because of bleeding/wound dehiscence etc) 0.7% VTE 0.4% Pelvic abscess/infection: 0.2% Bowel injury: 0.04% (4 in 10 000) Risk of death within 6 weeks, 0.03%
When deciding on entry method for laparoscopy a patients build is important. Which of the following entry methods is inappropriately matched to the patient?
In patients with normal BMI there is no preferential entry method. The Varess technique is not appropriate for morbidly obese or very thin patients for the reasons set out below:
Morbid Obesity (BMI>40): Hasson technique or entry at Palmers point Reason: difficult penetration with Varess needle
Very Thin Patients:
Hasson technique or insertion at Palmers point
Reason: higher risk of vascular injury
