O&G #1 Flashcards
A 26-year-old multigravid woman is in spontaneous labour at 41 weeks. She
has no antenatal risk factors with normal ultrasound scans. On examination,
the head is 2/5th palpable per abdomen. She has a spontaneous
rupture of membranes at 3 cm with heavily blood-stained liquor. The
CTG shows significant abnormalities. The midwife performs a vaginal
examination and there is no cord protruding through the cervix which is
now 4 cm dilated. The mother feels no pain.
What is the most likely diagnosis?
A. Bloody show
B. Placental abruption
C. Placenta praevia
D. Uterine rupture
E. Vasa praevia
E – Vasa praevia
Vasa praevia is rare, occurring in only 1 in 3000 pregnancies. The umbilical cord
vessels travel away from the placenta in the membranes and overlie the internal
cervical os. The vessels can tear leading to rapid exsanguination of the fetal
circulation. The risk of vessels tearing is greatest when cervical dilation occurs
and at rupture of membranes. A severely abnormal cardiotocograph (CTG)
is seen with a small amount (,500 mL) of painless vaginal blood loss.
Because it is fetal blood that is lost in vasa praevia, fetal mortality is very high
(35–95%) while there is little risk to the mother. A Caesarean section must be
performed immediately and the neonate transfused. There is no specific
investigation for vasa praevia, so the diagnosis is clinical and only confirmed
when the placenta and membranes are examined after Caesarean section.
Vasa, plural of Latin vas ¼ vessel.
Which of the following conditions is an indication for routine delivery by
Caesarean section?
A. Hepatitis C virus
B. Maternal request
C. Preterm birth
D. Previous Caesarean section
E. Twin pregnancy with first twin breech and second twin cephalic
E – Twin pregnancy with first twin breech and second twin cephalic
A Caesarean section should be routinely offered to the following women:
† HIV with or without other concurrent infections
† Primary genital herpes in the third trimester (NB not a secondary attack)
† Placenta praevia major, i.e. grade 3 or 4
† Twin pregnancy where the first baby is breech
† Singleton breech at term but only after external cephalic version has been
offered and failed or contraindicated
These women should not routinely be offered a Caesarean section:
† Twin pregnancy where the first twin is cephalic
† Preterm birth
† Small for gestational age baby
† Hepatitis B virus without HIV
† Hepatitis C virus without HIV
† Recurrent genital herpes at term
Maternal request is not an indication for a Caesarean section and the obstetrician
must discuss in full why the woman wants to have a Caesarean and her
concerns about normal labour. She must also be informed about the risks and
benefits of Caesarean section compared with normal labour. Counselling can
be offered if the woman has a fear of childbirth. The obstetrician may refuse
to perform a section after a maternal request but is obligated to refer the
woman to another clinician for a second opinion.
A 25-year-old woman attends the GUM clinic complaining of increased
vaginal discharge which has an unpleasant odour. She says sexual intercourse
with her partner is uncomfortable. A swab is taken and sent to the
lab. On direct microscopy a flagellated protozoan is seen.
Which is the most likely pathogen?
A. Candida albicans
B. Chlamydia trachomatis
C. Gardnerella vaginalis
D. Neisseria gonorrhoeae
E. Trichomonas vaginalis
E – Trichomonas vaginalis
Trichomoniasis is a sexually transmitted infection caused by the flagellated
protozoan Trichomonas vaginalis, which invades superficial epithelial cells of
the vagina, urethra, glans penis, prostate and seminal vesicles. Affected
females present with an offensive frothy greeny-grey discharge, vulval soreness,
dyspareunia, dysuria, vaginitis and vulvitis, although some are asymptomatic.
On examination, the cervix may have a punctate erythematous (strawberry)
appearance. Males are mostly asymptomatic. Diagnosis is by direct microscopy
or culture of vaginal exudate. Treatment is with metronidazole.
Gonorrhoea is caused by the Gram-negative diplococcus Neisseria gonorrhoeae
infecting the mucosal surfaces of the genitourinary tract, rectum and
pharynx. The majority of females are asymptomatic (70%). Around 85–90%
of cases involve the cervix but only 10% of these cases have a significant increase
in vaginal discharge. Seventy percent of cases involve the urethra and again it is
generally asymptomatic although dysuria and urinary frequency may be seen.
The vagina is not infected. Complications include Bartholin’s abscess and gonococcal
salpingitis with irreversible tube damage. Infected males present with
dysuria, frequency and/or a mucopurulent discharge after 3 to 5 days,
coupled with urethritis and meatal oedema. Disseminated gonococcal infection
occurs in ,1% cases and causes pyrexia, a vasculitic rash and polyarthritis.
Culture sensitive antibiotics are used for treatment.
Chlamydia is caused by the oculogenital serovars D–K of Chlamydia trachomatis.
Infection tends to be asymptomatic, although there can be increased vaginal
discharge (30%), dysuria and urinary frequency. On examination, a ‘cobblestone’
appearance of the cervix may be noted. Ascending infection can cause
salpingitis and, if it enters the abdominal cavity, perihepatitis (Fitz-Hugh–Curtis
syndrome) which leads to right upper quadrant pain and tenderness. Chlamydia
is a major cause for infertility and increases the possibility of ectopic pregnancy. In
males, symptoms include mucopurulent discharge and dysuria (asymptomatic in
25%). Epididymo-orchitis is a complication. Diagnosis of chlamydia infection is by
urine antigen detection or vaginal swab culture. Treatment is with doxycycline.
A 57-year-old woman presents with a history of having to run to the toilet
and occasionally not getting there in time. She needs to wear pads every day
and this is negatively impacting on her life. She also complains of waking
up two or three times per night to pass urine. She has had two children
by normal delivery and has never had any surgery on her bladder. She
says she has been doing occasional pelvic floor exercises with little success.
Considering her diagnosis, what is the first-line treatment?
A. Bladder training
B. Botulinum toxin
C. Oxybutynin
D. Pelvic floor exercises with a trained physiotherapist
E. Tolteridone
A – Bladder training
Urinary incontinence affects 10–20% of the adult female population. It is a
social and hygienic problem. Incontinence occurs when the intravesical pressure
exceeds the urethral closure pressure.
This lady is suffering from an overactive bladder (OAB), also known as detrusor
instability, unstable bladder or hyperactive bladder. First-line treatment is
bladder training for 6 weeks.
OAB is the second most common type of urinary incontinence in females (after
genuine stress in continence). Other causes include retention with overflow,
fistula and congenital abnormalities. OAB is where an involuntary detrusor
contraction results in leakage of urine. It can occur in conjunction with
genuine stress incontinence. Women complain of frequency of micturition
and urgency, which they describe as an overwhelming desire to pass urine
with associated urge incontinence. This can also be associated with nocturnal
enuresis. It is important to establish how it affects her life, dependent on severity,
lifestyle and occupation, as this will impact on how aggressive the treatment
strategies will be.
You are looking at a CTG of a woman of 39 weeks gestation who has come to
the antenatal day unit as she has had reduced fetal movements. There is a
baseline rate of 170. There are four accelerations in a 20-minute section.
The variability is over 10 beats. There are no decelerations.
What could explain the features of this trace?
A. Maternal pyrexia
B. Normal trace
C. Pre-terminal trace
D. Sleep pattern of fetus
E. Thumb sucking of fetus
A – Maternal pyrexia
Cardiotocography (CTG) measures the fetal heart rate with uterine activity. It
can be used confidently after 32 weeks gestation to monitor the condition of
a fetus in correlation with the clinical situation. Prior to this gestation, the autonomic
nervous system is not sufficiently developed to produce the predictable
responses of the more mature fetus. A normal CTG is reassuring, but an
abnormal CTG is not always pathological.
Indications for CTG monitoring can be maternal (previous Caesarean section,
pre-eclampsia, diabetes, antepartum haemorrhage), fetal (intrauterine growth
restriction, prematurity, oligohydramnios, multiple pregnancy, breech) or intrapartum
(oxytocin use, epidural use, induction of labour). The CTG lead is placed
on the mother’s abdomen or attached vaginally to the fetal scalp.
The use of CTG does not appear to improve long-term neonatal outcome.
You are examining a woman in established labour with the midwife and she
asks you to tell her how you would describe the examination. The cervix is
fully dilated. Anteriorly you feel a diamond-shaped fontanelle and if you
follow a line posteriorly you can then feel a Y-shaped depression in the
skull bones.
How is the position best described?
A. Brow
B. Left occipitotransverse
C. Occipitoanterior
D. Occipitoposterior
E. Right occipitotransverse
Practice
D – Occipitoposterior
Vaginal examination often involves a speculum examination and a digital
examination, but in this case there is no need for a speculum as it is already
known that she is in established labour.
During labour, digital examinations are used to assess dilation of the cervix to
ensure adequate progression. This is described in centimetres of dilation and
how effaced the cervix is. The fetal head is also examined to assess its position
using fontanelles. Fontanelles are the soft spots on the baby’s head in
between the skull bones. They are covered with fibrous tissue and allow the
bones to overlap to allow the head to pass more easily through the birth
canal. The anterior fontanelle is a diamond-shaped structure formed at the
junction of the two frontal bones, which cover the forehead, and the two
parietal bones which cover the side of the head. This fontanelle will become
ossified by the child’s second birthday. The posterior fontanelle is Y-shape and
is made from the junction between the two parietal bones and the occipital
bone. This fontanelle will close during the first few months of life. The line felt
in the question was the sagittal suture which runs from the anterior to the
posterior fontanelle between the two parietal bones.
In which anatomical location does fertilization normally occur?
A. Ampulla of fallopian tube
B. Cervix
C. Fimbriae of fallopian tube
D. Infundibulum of fallopian tube
E. Uterus
A – Ampulla of fallopian tube
Fertilization is defined as the union of the ovum and the spermatozoon. The
ovum is normally released from the ovarian follicle every 28 days. The fimbrial
end of the fallopian tube lies close to the release spot so the ovum is taken up
into the fallopian tube. The lumen of the fallopian tube is lined by cilia and it
is the combination of the rhythmical movement of these cilia and the peristalsis
created by the muscles of the fallopian tube that moves the ovum along towards
the uterus. The ovum has a physiological pause of up to 38 hours when it
reaches the ampulla of the fallopian tube. It is this physiological pause that
means that fertilization normally happens in the ampulla. It also allows extra
time for the sperm and ovum to be in the ‘same place at the same time’ as
sexual intercourse happens at random in humans. The sperm can survive up
to 48 hours, so as long as sexual intercourse occurred within 2 days of ovulation,
fertilization is feasible. After the pause, and possible fertilization, the rhythmic
waves and peristalsis recommence and the ovum moves down into the uterus.
The lateral funnel-shaped end of the fallopian tube is called the infundibulum
which opens into the peritoneal cavity through the abdominal ostium. There
are many finger-like projections known as fimbriae at the end of the infundibulum
which spread over the medial surface of the ovary to waft the released ovum
into the fallopian tube. The ampulla is medial to the infundibulum and is the
longest and widest part: this is where fertilization occurs. The isthmus enters
the uterine horn and is thick-walled. The uterine portion travels through the
uterine wall to terminate in the uterine cavity at the uterine ostium.
A 21-year-old lady at 40 weeks þ 12 days is being induced. She has received
two doses of prostaglandins after examination revealed a low Bishop
score. She is experiencing mild contractions with good fetal movements.
Her CTG trace is reactive. She is fed up, tired and is becoming angry
with the midwives as she thought she would have delivered sooner.
On abdominal palpation there is cephalic presentation with two-fifths
palpable. On vaginal examination after the second dose of progesterone
she is 3 cm dilated with a partially effaced cervix.
What would be the next course of action?
A. Artificial rupture of membranes
B. Caesarean section
C. Further prostaglandin
D. Observation alone
E. Oxytocin
A – Artificial rupture of membranes
Induction of labour is offered if pregnancy continues past 40 weeks þ12 days.
The process involves vaginal prostaglandins with artificial rupture of membranes
(ARM) and use of oxytocin.
This lady has received two doses of vaginal prostaglandins (PGE2) to initiate
contractions and encourage cervical ripening. The tablets are 3 mg and are
given 6–8 hourly with a maximum dose of 6 mg/day. They have clearly
worked as she has progressed from a low Bishop score to a cervical dilation of
3 cm. If women are progressing well with strong contractions no other action
is needed, however if there is slow progress with minimal contractions (in this
case) an ARM can be performed and an oxytocin infusion is used to maintain
the contractions after membrane rupture. Further prostaglandins are contraindicated
due to the risk of hyperstimulation as she already feels some uterine activity.
An amnihook is used to pierce the membranes surrounding the baby. The
colour of the amniotic fluid should be recorded and any meconium or blood
should be noted and appropriate action should be taken if required. The fetal
heart should always be checked after an ARM. If there is a high head an ARM
may be performed in theatre due to the higher risk of a cord prolapse where
an immediate caesarean section may be needed.
Complications of induction and augmentation of labour include:
† Failure of induction – requiring operative delivery
† Uterine hyperstimulation (.7 contractions/15 minutes) – this can cause
maternal and fetal distress. An oxytocin infusion must be stopped and continuous
monitoring is needed. Tocolysis (suppression of contractions) can
be used but, if there is suspicion of fetal compromise, delivery is needed as
soon as possible.
† Nausea, vomiting, diarrhoea – systemic side-effects of prostaglandins
† Water intoxication – as oxytocin is infused with fluid
† Uterine rupture
Which measurement is the most reliable indicator of gestational age in the
first trimester?
A. Biophysical profile
B. Biparietal diameter
C. Crown–rump length
D. Femur length
E. Nuchal translucency
C – Crown–rump length
Ultrasound scanning is a means of monitoring pregnancy and to date is without
proven maternal or fetal risk. Scans can be performed abdominally or transvaginally.
The scan at 10–14 weeks is used to date the fetus by measuring crown–rump
length (CRL). The estimated delivery date (EDD) is calculated from the last menstrual
period (LMP) unless the ultrasound scan (USS) date differs by more than
one week. If there is a discrepancy of more than one week between the date
calculated from LMP and USS then it should be amended to be the EDD from
the CRL. The biparietal diameter or head circumference is used over 14 weeks
as the fetus becomes more flexed in shape so CRL is less accurate.
EDD can be calculated from the LMP however LMP may be not be accurately
recalled, there may be an irregular cycle and bleeding early in the pregnancy
may be mistaken as a period. The EDD is 40 weeks after the first day of the
LMP and not from the date of conception however this is only true if the
cycle is 28 days and regular. If the cycle is known to be shorter or longer then
days can be added or subtracted accordingly. The first date of a positive pregnancy
test can be useful as it will become positive on the day the next period
would have been due so when a positive pregnancy test is seen the gestation
must be at least 4 weeks.
Every woman should be offered an ultrasound scan early in pregnancy between
10–14 weeks. There are a number of reasons for this:
† To establish viability and ensure that either a molar pregnancy or missed
miscarriage has not occurred
† To detect multiple pregnancies and to determine chorionicity and amnionicity
(most reliably done in the first trimester)
† The nuchal translucency test is done between 11–14 weeks to assess risk
for Down’s syndrome
† Gross anatomical anomalies can be detected in the first trimester scan,
such as major anterior abdominal wall defects, cystic hygroma, anencephaly
and bladder outflow obstruction
A 32-year-old lady returns to the gynaecology clinic to find out the
results of her cervical screening test. You see her report says moderate
dyskaryosis.
What would be the next stage in her management?
A. Colposcopy
B. Recall in 6 months
C. Recall in 1 year
D. Recall in 3 years
E. Repeat the test today
A – Colposcopy
If a woman aged 25 to 49 years has a normal smear they are called back in
3 years. A woman may be recalled if there are inadequate cells for the study –
this would normally be in 6 months. If a diagnosis of mild dyskaryosis is made
a repeat is needed in 6 months as these cells often revert to normal without
any treatment. If on the repeat test at 6 months the cells still show mild dyskaryosis,
colposcopy will be required. A single diagnosis of moderate or severe
dyskaryosis indicates referral to colposcopy. Obviously a diagnosis of invasive
carcinoma would require immediate specialist referral. Immunocompromised
patients require annual screening
Which one of the following factors increases your risk of developing
ovarian cancer?
A. Early menopause
B. Late menarche
C. Multiparity
D. Nulliparity
E. Oral contraceptive pill
D – Nulliparity
Ovarian cancer is the most common gynaecological cancer in the UK and the
fifth most common cancer in the UK overall, and the incidence is rising. It is
seen mainly in the fifth, sixth and seventh decade. It has a poor 5-year survival
rate of only 25%. There is no premalignant phase so no screening test can be
developed.
Like all cancers there are numerous risk factors for its development. It may be
related to ovulation, due to the repair of the ovarian epithelium required following
each ovulation. This means the more you ovulate the more you increase your
risk of developing cancer of the ovary. Hence nulliparity, infertility, late menopause
and early menarche all increase your risk, whereas risk is lowered by the
contraceptive pill, breastfeeding and pregnancy. Pelvic surgery decreases the
risk (including hysterectomy, unilateral oophorectomy and sterilization) for
reasons that are not fully understood.
The risk of ovarian cancer is slightly increased with a positive family history and
this much more significant if there was early onset and more than one primary
relative affected. Around 5 to 10% of ovarian cancers have a direct genetic link
with the most significant being BRCA1 and BRCA2. Affected women have a lifetime
risk of up to 50% of developing ovarian cancer, hence close monitoring is
needed using CA125 and pelvic ultrasounds. Furthermore a prophylactic
bilateral oophorectomy may be considered by some once the family is complete.
Other cancers that are linked are breast, endometrial and colonic.
A 22-year-old woman attends the labour ward for induction of labour as she
is 40 weeks þ 12 days. She has had an uncomplicated pregnancy. She has no
pain in her abdomen and says that the baby is moving but less than normal.
A CTG is performed and the baseline is 135, variability is over 10, accelerations
are present and there are no decelerations. You examine her and
find a cephalic presentation and a long and closed cervix.
What would you like to do next?
A. Artificial rupture of membranes
B. Elective Caesarean section
C. Emergency Caesarean section
D. Oxytocin
E. Prostaglandin
Practice
E – Prostaglandin
Induction of labour (IOL) is used as there is increased risk of stillbirths with
increasing gestation over 37 weeks. The current data suggest the stillbirth rate is 1 per 3000 at 37 weeks, 3 per 3000 at 42 weeks and 6 per 3000 at 43 weeks.
About 20% women need IOL. If a woman declines IOL at 42 weeks they should
be offered twice-weekly cardiotocograph (CTG) and ultrasound scans to
measure maximum amniotic pool depth.
A stretch and sweep should be done prior to formal IOL. A finger is inserted into
the cervix and the membranes are stripped from the uterine wall with the aim of
inducing labour more naturally.
Prior to IOL the woman’s cervix should be assessed using the Bishop score. If the
Bishop score is very low, like this case, IOL involves vaginal prostaglandins (PGE2)
as either tablets or gels to initiate contractions and encourage cervical ripening.
The tablets are 3 mg and are given 6 to 8 hourly with a maximum dose of
6 mg. The CTG has to be reassuring for prostaglandins to be given and there
should be no pain or evidence of contractions otherwise you increase the risk
of uterine hyperstimulation.
If women are progressing well they can be left to labour; however, if there is slow
progress or the cervix is already dilated on initial examination an artificial rupture
of membranes can be performed along with an oxytocin infusion to maintain the
contractions. If there has been pre-labour rupture of membranes, the oxytocin
can be started regardless of the state of the cervix.
A 27-year-old woman is of 19 weeks gestation. She has a 3-day history of
flu-like symptoms with a macular rash over her body. Her doctor takes
serological testing. When he has the results he tells her that her baby is
at increased risk of sensorineural deafness, cataracts, congenital heart
disease, learning difficulties, hepatosplenomegaly and microcephaly.
What is the underlying causative agent?
A. Chickenpox
B. Cytomegalovirus
C. Listeria
D. Parvovirus
E. Rubella
E – Rubella
Rubella (German measles) is a viral infection spread by person-to-person
contact. It has an incubation period of 14 to 21 days. Rubella is rare nowadays
thanks to immunization (MMR vaccine), and the UK immunity is 97%. Women
develop a non-specific flu-like illness with a macular rash covering their trunk (20
to 50% infections are asymptomatic). Diagnosis is confirmed by serological antibody
testing. Rubella antibodies are checked at booking and postnatal vaccination
is offered to those with low titres. There is an 80% risk of infection to
the fetus if rubella develops in the first trimester, dropping to 25% at the end of the second trimester. Teratogenic effects are worse at earlier gestations, with
a 50% risk of abnormalities if the fetus is under 4 weeks, 25% at 5–8 weeks, 10%
at 9–12 weeks and 1% over 13 weeks. The characteristic abnormalities from
maternal rubella infection are sensorineural deafness, cataracts, congenital
heart disease, learning difficulties, hepatosplenomegaly, jaundice, microcephaly
and spontaneous miscarriage.
Rubella is also known as German measles as the first three reported cases were
described by German physicians who all thought the condition was a variant of
measles.
Listeria is a rare bacterial infection. The Gram-positive coccus, Listeria monocytogenes,
is found in soil, animal faeces, paˆte´ and unpasteurized dairy products
such as soft cheese. Pasteurized milk carries no risk. The incubation period is 3
to 70 days. The incidence and severity of infection is increased in pregnancy.
Symptoms include fever, headache, malaise, backache, abdominal pain, pharyngitis
or conjunctivitis. Diagnosis is by blood cultures or placental/neonatal
swabs. Treatment is with high dose penicillin. Listeria infection during
pregnancy can lead to miscarriage, stillbirth, preterm delivery and neonatal
listeriosis, which carries 50% mortality.
Parvovirus B19 infection is spread by respiratory droplets with an incubation
period of 18 days. It is often seen in outbreaks at schools and manifests in
children as erythema infectiosum – a ‘slapped cheek’ appearance. Erythema
infectiosum is also known as the fifth disease – so-called because it is the fifth
of the classical childhood skin rashes (the others being measles, chickenpox,
rubella, scarlet fever and roseola infantum). In adults, parvovirus infection
presents with fever, malaise and arthralgia. In women with parvovirus infection
fetal death is seen in 9%. The second trimester holds the highest risk of fetal
infection. The fetal sequelae are non-immune hydrops due to chronic haemolytic
anaemia and myocarditis. In utero blood transfusion of hydropic fetuses
may prevent demise. There are no long-term sequelae among survivors.
Parvovirus B19 is so-called since it was first discovered in well B19 (row B,
column 19) of a large series of Petri dishes.
The midwife is delivering a term baby. The head has been delivered.
Which movement should the midwife wait for before delivering the
shoulders?
A. Descent
B. Extension
C. External rotation
D. Flexion
E. Internal rotation
C – External rotation
Labour describes the expulsion of the fetus and the placenta by the uterus. There
are regular painful uterine contractions associated with dilation and effacement
of the cervix. A normal spontaneous labour should occur within 12 hours and is
divided into three stages.
The first stage is divided into a latent and active phase. In the latent phase there
is cervical effacement and dilation to 3 cm. The active phase is from 3 cm
dilation to 10 cm. The latent phase is a slow process and may take hours to
days, however the active phase is faster and should only take hours. The
second stage is from full dilation to delivery of the fetus. The passive phase of
the second stage is from full dilation until the woman feels an urge to push as
the head reaches the pelvic floor. The active phase of the second stage is
where the pressure on the pelvic floor generates an irresistible desire to push.
Which of the following hormones stimulate the growth of primary
follicles?
A. Activin
B. Follicle-stimulating hormone
C. Inhibin
D. Oestrogen
E. Progesterone
B – Follicle-stimulating hormone
Menstruation is controlled by the hypothalamic–pituitary–ovarian axis. There
are two phases: the follicular phase (days 1 to 14) and the luteal phase (days
15 to 28). During these phases there are changes in hormone levels, in endometrial
thickness and in cervical mucus.
Follicle-stimulating hormone (FSH) is a glycoprotein produced by the anterior
pituitary gland in response to gonadotrophin-releasing hormone (GnRH) from
the hypothalamus. The concentrations of FSH and luteinizing hormone (LH)
are allowed to rise during early follicular phase due to the low levels of oestrogen
and progesterone at the end of the previous cycle. The action of FSH along with
LH is to stimulate the growth of 6–12 primary follicles each month during the
follicular phase of the cycle (days 1 to 14). As the follicles mature there is a
rise in oestrogen due to increased production from the granulosa cells of the
developing follicles and this increase in oestrogen inhibits the release of FSH
and LH (negative feedback). This mechanism avoids hyperstimulation of the
ovary and the resultant maturation of multiple follicles. Thus only one of these
follicles will reach full maturation at the mid-follicular phase with the others
undergoing atresia.
As the oestrogen levels continue to rise throughout the follicular phase there is a
mild surge in FSH mid-cycle due to the very high levels of oestrogen (positive
feedback) but more importantly there is a concurrent surge in LH which initiates
ovulation. The gonadotrophins LH and FSH are low in the luteal phase and do
not rise again until degeneration of the corpus luteum with subsequent decrease
in steroid hormones (oestrogen and progesterone) at days 26 to 28 to repeat
the cycle.
FSH is low during childhood, increases with puberty to become cyclical
throughout a woman’s reproductive lifetime and is very high after menopause
as there are no follicles left to be released so there is no negative feedback
mechanism from oestrogen and progesterone.
The obstetric registrar is called to a 28-year-old primigravida who went into
spontaneous labour at 39 þ 5 weeks. She is now fully dilated after having an
epidural and oxytocin. She has been actively pushing for 2 hours and is
exhausted and tells you she cannot push any longer. On examination,
there is no head palpable abdominally, and an occipitoanterior position
is felt vaginally. The station is þ1 with a small caput and no moulding.
How should the baby be delivered?
A. Elective Caesarean section
B. Emergency Caesarean section
C. Kielland’s forceps
D. Manual rotation followed by Neville Barnes forceps
E. Neville Barnes forceps alone
E – Neville Barnes forceps alone
Delay in the second stage of labour, if birth is not imminent after 2 hours in
nulliparous women, or one hour in parous women, should be managed by a
trained obstetrician. Forceps are made of two interlocking blades which fit
around the baby’s head to guide it out. When correctly applied they should
lock together easily and not be forced. Neville Barnes forceps have both a
cephalic curve to fit the baby’s head and a pelvic curve which follows the
contours of the sacral hollow. These are used to aid delivery when rotation is
not required such as in this case.
A 31-year-old primigravid woman with a body mass index of 31 had a positive
glucose tolerance test at 28 weeks consistent with gestational diabetes
mellitus. Although she was advised to change her diet she did not do this
and her glucose control has been suboptimal. An ultrasound scan demonstrated
macrosomia.
Which emergency condition does this put her at a greater risk of?
A. Amniotic fluid embolisation
B. Disseminated intravascular coagulation
C. Shoulder dystocia
D. Uterine inversion
E. Uterine rupture
C – Shoulder dystocia
Shoulder dystocia describes impaction of the fetus’s anterior shoulder behind
the symphysis pubis after delivery of the head, impeding delivery of the rest
of the body.
This woman has gestational diabetes mellitus and is more likely to develop
macrosomia. Macrosomia – an abnormally large fetus – occurs in maternal diabetes
due to excessive production of fetal insulin and an increased deposition of
glycogen in the fetus. Macrosomia increases the risk of shoulder dystocia due to
the size of the shoulders. Other risk factors for shoulder dystocia include a past
history of dystocia, maternal obesity, prolonged first stage of labour, secondary
arrest .8 cm cervical dilation, mid-cavity arrest and forceps/ventouse delivery.
Consider shoulder dystocia if the head delivers slowly or with difficulty and
the neck does not appear, or if the chin retracts against the perineum (the
turtle sign).
Fetal morbidity and mortality occurs due to compression of the umbilical cord
between the fetal trunk and the maternal pelvis which rapidly leads to fetal
hypoxia and death. Nerve injury can also occur due to downward traction on
the head during attempts to deliver the baby (! Erb’s palsy or Klumpke’s
palsy). Fracture of the fetal humerus or clavicle may also occur but may be
necessary for delivery. Maternal complications include birth canal injuries,
femoral nerve injury from excessive hip flexion and increase in maternal
blood loss.
A 32-year-old woman complains of longstanding painful, heavy periods.
She has had two normal vaginal deliveries after difficulty conceiving with
both pregnancies. She suffers from significant pain on intercourse. On
further questioning she also states she has had occasional rectal bleeding
during her menstrual cycle throughout her life. Her past history includes
an appendicectomy aged 10. Pelvic examination reveals a fixed retroverted
uterus that is tender.
What is the most likely explanation for her pain?
A. Adhesions from surgery
B. Chronic pelvic inflammatory disease
C. Endometriosis
D. Fibroid degeneration
E. Ovarian cyst
C – Endometriosis
Endometriosis is the most likely diagnosis, with the typical symptoms of abdominal
pain, dyspareunia, secondary dysmenorrhoea and subfertility. Bimanual
palpation in this case has revealed a tender fixed uterus but there can also be uterosacral nodules, endometriomas, uterine or ovarian enlargement or adnexal
tenderness.
Endometriosis is where functioning endometrial tissue is seen outside the cavity
of the uterus. This tissue responds to the cyclical hormonal changes and bleeds
at the time of menstruation forming abdominal adhesions. The ovaries, uterosacral
ligaments or ovarian fossae are common sites of deposition of this
endometrial tissue. If there is deposition near the bowels, rectal bleeding can
be seen. It is most common in 25 to 35-year-olds. The aetiology is unclear
and likely to be multifactorial.
An ultrasound is useful to exclude other pathology but is not diagnostic of
endometriosis. It may pick up an endometrioma (blood filled ovarian cysts
often seen in endometriosis). Endometriomas are also known as chocolate
cysts due to their dark reddish brown appearance. Diagnosis can only be
made by clinical appearances on laparoscopy. Treatment choices must involve
the patient as it is dependent on age, fertility wishes and location and severity
of disease. Medical treatment includes analgesia, the combined oral contraceptive
pill, progestogens, gonadotrophin-releasing hormone analogues and
antiandrogens. Although useful for symptomatic relief many of these options
are not appropriate if the woman is trying to conceive. Surgical treatment is
used where fertility is required. Infertility is common even without visible tube
blockage. In vitro fertilization is commonly indicated.
Chronic pelvic inflammatory disease describes episodes of recurrent acute pelvic
infection which result in chronic inflammation of the pelvic organs with multiple
adhesions causing abdominal pain, dyspareunia and subfertility. Chronic pelvic
pain can be caused by adhesions from previous surgery however the significant
menstrual symptoms again point you away from this diagnosis. Treatment
options for this include adhesiolysis; however, this is not proven and is more
likely to be effective if there are large adhesions and if it is done laparoscopically.
There is still a significant risk of visceral damage and a chance of further
adhesions developing.
The pain from an ovarian cyst can be due to torsion, cyst rupture or bleeding
into a cyst. This would be unlikely to give menstrual and fertility problems.
Other causes of chronic pelvic pain can be functional pain, constipation or irritable
bowel syndrome.
A 43-year-old woman has conceived naturally for the first time despite two
failed IVF attempts. She is very concerned about Down’s syndrome and
would like a test performed as soon as possible that would give a firm
diagnosis. She is currently at 11 weeks gestation.
What test would be most appropriate?
A. Amniocentesis
B. Chorionic villus sampling
C. First trimester ultrasound scan
D. Nuchal translucency test
E. Serum triple test
B – Chorionic villus sampling
Chorionic villus sampling is a diagnostic test which means a definite diagnosis
can be given rather than a ‘risk’ of a condition being present. A biopsy of the
chorionic villus is taken either transabdominally or transcervically under ultrasound
guidance. Cells obtained are analysed and a result is ready in 48 hours.
The risk of miscarriage is around 1–2% and couples must be counselled
appropriately before undertaking a test like this due to its invasive nature. It is
performed at 11 to 14 weeks which means this woman could proceed with
this test after appropriate counselling. The early gestation means a decision
regarding termination of pregnancy can be made as early as possible before a pregnancy becomes easily visible under clothes. Chorionic villus sampling is not
performed before 9–11 weeks as fetal limb abnormalities can occur. There are
cases where inconclusive results can occur due to placental mosaicism; this
would mean that amniocentesis would have to be performed later. There can
be maternal contamination which would lead to false-negative results. Rhesus
D negative women must receive anti-D immunoglobulin.
Nuchal translucency is a screening tool for Down’s syndrome and other abnormalities.
It is used at 11–14 weeks. A measurement is made of the thickness of the
skin fold over the neck of the fetus. This information is combined with the
mother’s age and gestation of the pregnancy. This will not provide a definite
diagnosis. A first trimester ultrasound scan is used to establish viability and
confirm gestation during the first trimester. It detects defects in gross
anatomy and determines the chorionicity and amnionicity of multiple pregnancies.
It gives limited other information and on a routine scan no definitive
diagnosis of Down’s syndrome can be made.
A 26-year-old woman with a twin pregnancy has developed twin-to-twin
transfusion syndrome at 34 weeks gestation.
What type of twins is she likely to have?
A. Dizygotic dichorionic diamniotic
B. Dizygotic dichorionic monoamniotic
C. Dizygotic monochorionic monoamniotic
D. Monozygotic dichorionic diamniotic
E. Monozygotic monochorionic diamniotic
E – Monozygotic monochorionic diamniotic
The incidence of twins is 1 in 100, and triplets 1 in 1000. Predisposing factors are
increasing maternal age and parity, personal or family history, race and assisted
conception (20% of in vitro fertilization pregnancies are multiple). Multiple
pregnancies need closer monitoring as fetal and maternal mortality and morbidity
are greater. The mother has a greater risk of hyperemesis, miscarriage, hypertension
and pre-eclampsia, gestational diabetes, polyhydramnios (especially
with monozygotics), anaemia, antepartum and postpartum haemorrhages
and placenta praevia. The fetal risks include increased perinatal mortality,
increased congenital abnormality, preterm labour, placental insufficiency or
intrauterine growth restriction (especially in monozygotics), malpresentation,
twin–twin transfusion and vanishing twin syndrome.
Twin-to-twin transfusion is where, due to anastomosis of vessels in the single
placental mass of a monochorionic twin pregnancy, one twin gains at the
other’s expense. One twin becomes anaemic, hypovolaemic, oligohydramniotic
and growth-restricted while the other one develops polycythaemia, hypervolaemia,
polyuria and polyhydramnios. It occurs in varying degrees in up to 35% of
monochorionic twins and accounts for 15% of perinatal mortality. Ultrasound
scan is used to look at fetal wellbeing and to identify any abnormalities such
as liquor volume that may suggest twin-to-twin transfusion. Therapeutic amniocentesis
may be used to reduce the amniotic fluid pressure. Laser ablation of
placental vessels can be useful although there are risks of fetal demise or congenital
abnormalities. Vanishing twin syndrome is where a fetus in a multiplegestation
pregnancy dies in utero and is subsequently reabsorbed by the
mother (either partially or completely).
