Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 5 Specialities > O&G > Flashcards

O&G Flashcards

1
Q

Snowstorm appearance in USS

A

Molar pregnancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Woman w painless PV bleeding, what ix should you never do first?

A

Vaginal exam should NOT be done until USS done (exclude placenta praevia)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

State the anatomy/structures of the types of placenta below.

a) Placenta Accreta
b) Placenta Increta
c) Placenta Percreta
d) Placenta Praevia

A

a) Invades into endometrium, not myometrium
b) Invades into myometrium through endometrium
c) Through the uterus, i.e. into abdomen, through myometrium
d) Covering the os (contraindication to vaginal birth)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

O/E wooden uterus and bleeding, pt is in pain and a known smoker

Likely diagnosis?

A

Placental abruption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

RFs of placental abruption

A 
Pre-eclapmsia
HTN
Abdo trauma
Cocaine
Smoking
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the role of AMH in reproductive tract formation?

A

AMH drives degeneration of Mullerian duct (goes onto form uterus, cervix and upper vagina)

Lack of AMH leads to degeneration of Wolffian duct (goes onto form epididymis, vas deferens, seminal ducts)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

15 yo presents as mum worried she has never had a period, normal breast and pubic hair development

Likely diagnosis?

A

aka Mayer-Rokitansky-Kuster-Hauser syndrome

Failure of lower Mullerian duct to develop

Also have associated w renal defects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

13 yo presents w severe acute pelvic pain, has not had their first period, pain is worsening monthly for the last 3 months

Likely diagnosis?

A

Imperforate hymen .

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Which organ structures would be affected if the metanephros was impaired?

A

Renal tract

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Indomethacin vs prostaglandins for patent ductus arteriosum in fetus

A

Indomethacin (NSAID) used to CLOSE it

Prostaglandins used to keep it OPEN
- multiple cardiac defects, can be useful to have patent to maintain circulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are these structures formed from in the fetus?

a) Median umbilical ligament
b) Ligamentum arteriosum
c) Ligamentum teres of liver
d) Fossa ovalis
d) Ligamentum venosum
e) Medial umbilical ligament

A

a) Allantois duct (mediaN)
b) Ductus arteriosum
c) Umbilical vein
d) Foramen ovale
e) Ductus venosus
f) Umbilical artery (mediaL)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the karyotype of the following molar pregnancies?

a) Partial
b) Complete

A

a) Triploid: 69XXX, 69 XXY, 69 XYY

b) Majority are 46XX due to subsequent mitosis of the fertilising sperm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the 7 layers we go through in a C-section?

A
  1. Skin
  2. Fat
  3. Rectus sheath
  4. Rectus
  5. Parietal peritoneum
  6. Visceral peritoneum
  7. Uterus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the ideal types of incisions for a C-section

A

Transverse
- lower post-op pain, and increased cosmesis

Joel Cohen
- reduced op time and

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the ideal types of incisions for a C-section

A

Transverse
- lower post-op pain, and increased cosmesis

Joel Cohen
- reduced op time and reduced post-op infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Which arteries do we need to avoid damaging when inserting a laparoscopic port?

A

Superior and inferior epigastric arteries (anastomose at umbilicus)

Supplies anterior abdo wall and part of diaphragm - lead to severe bleed and bruising

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Where is Palmer’s point and why do we use it?

A

3cm below costal margin on the left midclavicular line

Visceral-parietal adhesions rarely found here

Use indicated to insert first laparoscopic port when pt has multiple prior abdo surgery or is obese

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the borders of the pelvic inlet?

A

Sacral promontory
Arcuate line (ilium)
Pubic symphysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the borders of the pelvic outlet?

A

Pubic arch
Ischial tuberosity
Tip of coccyx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the average diameters of pelvic inlet/outlet?

A

Average width: 11cm

Average top-to-bottom: 13cm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is pudendal nerve block used for?

A

LA for quick pain relief prior to instrumental delivery

Pudendal nerve supplies clitoris, perineum, and anus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the use of the ischial spines?

A

Landmark for pudendal blocks

- Bony prmenines at 4 and 8 o’clock at about finger-length into the cagina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is the use of the ischial spines?

A

Landmark for pudendal blocks

- Bony prmenines at 4 and 8 o’clock at about finger-length into the cagina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

When may episiotomies be performed?

A

NEVER prophylatically

During second stage of labour to avoid tearing damage

  • usually isntrumental delivery
  • under pudendal block
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Where can tearing damage occur during labour?

A

Anal sphincter (incontinence)

Perineal body (reduce postpartum pelvic floor dysfunction)

Reduce blood loss (muscles well supported)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is cut through during an episiotomy?

A

Perineal skin
Bulbospongiosus
Deep transverse perineal muscle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is the levator ani made up of?

A

Group of muscles:

  • Puborectalis
  • Pubococcygeus
  • Iliococcygeus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Describe the types of prolapse below:

a) Cystocele
b) Rectocele
c) Uterine prolapse
d) Vaginal vault

A

a) Herniation of bladder
b) Herniation of rectum
c) Herniation of uterus
d) Herniation of vaginal canal, typically post-hysterectomy

All herniate through the levator hiatus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

How can we quantify how bad prolapse sx are?

A

POP-Q

  • quantify and describe degree of prolapse
  • help determine mx plan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What do we want to avoid cutting in an episiotomy?

A

AVOID

  • Bartholin’s glands
  • Perineal body
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What do the levator ani muscles do?

A

Support urethra, vagina, and rectal canal

Support fetal head during delivery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What complications can occur if the levator ani muscles are damaged?

A

Urinary stress incontinence
Anal incontinence
Pelvic floor prolapse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What are the main hormones involved in the menstrual cycle?

A

LH
- androgen production and ovulation

FSH
- oestrogen production and recruitment of follicles

Estradiol
- preparation of endometrium for implantation and secondary sex characteristics

Progesterone
- maintenance of pregnancy and inhibits lactation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What do LH and FSH act on to make which hormones?

A

LH stimulates androgen secretion from ovarian thecal cells

FSH stimulates oestrogen secretion from ovarian granulosa cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Define menopause

A

Last period 12 months ago

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

4 Ts of PPH

A

Tissue (retained placenta)
Tone (atony of uterus)
Tears/trauma
Thrombin (coagulopathy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Primary postpartum haemorrhage definition

A

Minor
- Loss of >500ml blood <24hr of delivery

Major
- Loss of >1000ml blood <24hr delivery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Secondary postpartum haemorrhage definition

A

Abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Causes and RFs of PPH due to atony

A

Overdistension of uterus
- polyhydramnios, multiple gestation, macrosomia

Intra-amniotic infection
- fever, prolonged rupture of membranes

Functional/anatomic distortion of uterus
- rapid labour, prolonged labour, fibroids, placenta praevia, uterine abnormalities

Uterine relaxants (Mg and nifdeipine)
- terbutaline, halogenated anaesthetics, glyceryl trinitrate

Bladder distention
- may prevent uterine contraction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Causes of PPH due to tissue

A 
Retained placenta (cotyledone or succenturiate lobe)
- likely w placenta accreta

Retained blood clots

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Causes and risk factors of PPH due to thrombin

A

Pre-existing state
- haemophilia A, ITP, VWd, hx of previous PPH

Acquired in pregnancy
- gestational thrombocytopenic, pre-eclampsia

Disseminated intravascular coagulation

Therapeutic anticoagulation
- hx of thromboembolic disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Causes and risk factors of PPH due to trauma

A

Lacerations of cervix, vagina or perineum
- precipitous delivery, operative delivery

Extensions, lacerations at C-section
- malposition, deep engagement

Uterine rupture
- previous uterine surgery

Uterine inversion
- high parity w excessive cord traction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Green top guideline measures for minor PPH and no clinical shock

A

Intravenous access (one 14-gauge cannula)

Urgent venepuncture (20 ml) for:
– group and screen
– full blood count
– coagulation screen, including fibrinogen

Pulse, respiratory rate and blood pressure recording every 15 minutes

Commence warmed crystalloid infusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Green top guideline measures for major PPH or continuing to bleed or clinical shock

A

ABCDE

Position patient flat and keep them warm

Transfuse blood as soon as possible, if clinically required

Until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmed isotonic crystalloid

(Further fluid resuscitation can continue with additional isotonic crystalloid or colloid)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Monitoring and ix in major PPH and ongoing haemorrhage or clinical shock

A

Immediate venepuncture

  • cross-match
  • FBC
  • coagulation screen
  • renal and LFT for baseline

Monitor obs

Foley catheter to monitor urine output

Two peripheral cannulae 14 gauge

Consider ART, ICU, escalating if abnormal MEOWS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

How is uterine atony managed if this is the cause of PPH?

A
  1. Palpate uterine fundus and rub it to stimulate contractions
  2. Ensure bladder empty with Foley catheter

Next steps…

  1. Oxytocin 5 iu by slow IV
  2. Ergometrine 0.5mg slow IV or IM injection
  3. Oxytocin infusion

Further surgical steps…

  1. Uterine balloon tamponade
  2. Hysterectomy final resort
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What is a contraindication to ergometrine use?

A

Hypertension therefore pre-eclampsia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

How should secondary PPH be managed?

A

Assessment of vaginal microbiology (high vaginal and endocervical swabs)

Start abx therapy if endometritis is suspected

Pelvic US to exclude retained placenta

Surgical evacuation of retained placental tissue if needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

A

Ectopic pregnancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

A

Hydatidiform mole

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed

A

Placental abruption

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal

A

Placental praevia

*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

A

Vasa praevia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination

A

Pelvic inflammatory disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination

A

Ovarian torsion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Chronic pelvic pain
Dysmenorrhoea - pain often starts days before bleeding
Deep dyspareunia
Subfertility

A

Endometriosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain
Large cysts may cause abdominal swelling or pressure effects on the bladder

A

Ovarian cyst

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Seen in older women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency

A

Urogenital prolapse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

What would the following on a CTG suggest?

a) baseline bradycardia
b) baseline tachycardia
c) loss of baseline variability
d) early deceleration
e) late deceleration
f) variable decelerations

A

a) increased fetal vagal tone, maternal beta-blocker use
b) maternal pyrexia, chorioamnionitis, hypoxia, prematurity
c) prematurity, hypoxia
d) usually innocuous feature and indicates head compression
e) indicates fetal distress, e.g. asphyxia or placental insufficiency
f) may indicate cord compression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

What gives you +1 in the Bishops score?

A

Intermediate cervical position and consistency (firm-soft)
40-50% cervical effacement
1-2cm cervical dilation
-2 fetal station

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What gives you +2 in the Bishops score?

A 
Anterior cervical position
Soft cervical consistency
60-70% cervical effacement
3-4cm cervical dilation
-1, 0 fetal station
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

What gives you +3 in the Bishops score?

A

80% cervical effacement
>5 cm cervical dilation
+1, +2 fetal station

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

High risk factors for pre-eclampsia

A

Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease, such as systemic lupus Erythematosus or antiphospholipid syndrome
Type 1 or type 2 diabetes
Chronic hypertension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Moderate risk factors for pre-eclampsia

A 
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m² or more at booking
Family history of pre-eclampsia
Multiple pregnancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Define pre-eclampsia

A

Onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:

  • proteinuria
  • other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Maternal complications of pre-eclampsia

A 
Eclampsia 
Cerebrovascular accident
Haemolysis, HELLP
Disseminated intravascular coagulation (DIC)
Liver failure
Renal failure
Pulmonary oedema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Ix for pre-eclampsia

A

Confirm diagnosis
- MSU, urine protein measurement (PCR or 24h collection)

Monitor

  • Watch BP, serial FBC, uric acid, U&Es, LFTs, clotting screen, platelets, creatinine
  • fetal surveillance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Preventative tx for pre-eclampsia (incl when it is done)

A

Women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Mx of pre-eclampsia during pregnancy

A

Definitive tx is give birth

Antenatal
- Labetalol, nifedipine, methyldopa - antihypertensives

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Features of severe pre-eclampsia

A 
Hypertension: typically > 160/110 mmHg and proteinuria as above
Proteinuria: dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

Mx of eclampsia

A

IV magnesium sulfate

  • prevent and treat seizures
  • continue for 24hrs after last seizures/delivery

**Respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

Questions you must ask in a gynae hx

A

Menstrual
- LMP, cycle, heavy, IMB, PMB, PCB

Sex
- active, painful, contraception, STI scren

Smear
- last one done, any abnormal

Urinary
- frequency, incontinence, lump/heavy

Obs hx
- ever been pregnant, detail

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Pharmacological tx for menorrhagia

A

1st line
- Mirena (IUS) if doesn’t want to get pregnant

2nd line

  • Tranexamic acid (1st line wants fertility)
  • NSAIDs; mefenamic acid (1st line wants fertility)
  • COCP

3rd line

  • Progestogens (high oral dose/IM Depo-Provera)
  • GnRH analogues
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

When is an endometrial biopsy indicated?

A

Endometrial thickness
- >10mm in premenopausal
- >4mm in postmenopausal
Age > 40
Menorrhagia with IMB
Prior to endometrial ablation/diathermy to collect tissue for pathology lab
If abnormal uterine bleeding results in acute admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Causes of postcoital bleeding

A

Cervical Ca
Cervical ectropion
Cervical polyps
Cervicitis, vaginitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Surgical tx for menorrhagia

A

Hysteroscopic surgery: resection or ablation
Hysterectomy
Myomectomy/embolisation if fibroids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Ix for menorrhagia

A

FBC
Pelvic USS
Endometrial biopsy +/- hysteroscopy if IMB/thickened or irregular endometrium/age > 40 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

Structural causes of menorrhagia

A 
PALM
Polyps
Adenomyosis
Leiomyomas
- submucosal
- other
Malignancy and hyperplasia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Pt presents with thick white vaginal discharge, non-offensive order, vulval itch, superficial dyspareunia, dysuria

What is dx and what signs and microscopy would you expect?

A

Vulvovaginal candidiasis/thrush

Signs:

  • vulval erythema
  • oedema
  • fissuring
  • satellite lesions

Microscopy:
- yeasts and pseudohyphae

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Pt presents with thin vaginal discharge, offensive and fishy odour, no discomfort or itch noted

What is dx and what signs and microscopy would you expect?

A

Bacterial vaginosis

Signs:

  • discharge coating vagina and vestibule
  • no inflammation of vulva

Microscopy:
- “clue” cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Pt presents with profuse yellow discharge, offensive odour, vulval itch, dysuria, lower abdominal pain, and dyspareunia

What is dx and what signs would you expect?

A

Trichomoniasis

Signs:

  • vulvitis and vaginitis
  • ‘strawberry’ cervix
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

Three most common causes of vaginal discharge in reproductive years

A

Thrush
Bacterial vaginosis
Trichomoniasis vaginalis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

Potential complications of ERPC

A

Evacuation of retained products of conception

  • bleeding
  • cervical trauma
  • infection
  • retained products of conception
  • repeat ERPC needed
  • uterine perforation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

Which five drugs can be used to cause uterine contractions?

A 
Syntocinon
Syntometrine
Ergometrine
Carboprost (hemabate)
Misoprostol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

Non-structural causes of menorrhagia

A 
COEIN
Coagulopathy
Ovulatory dysfunction
Endometrial (1o disorder of mechanisms regulating local endometrial haemostasis) 
Iatrogenic
Not yet specified
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

How is pre-eclampsia classified based on timing of manifestations?

A

Early: < 34 weeks
Late: > 34 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

How is urinary protein assessed in pregnancy?

A

Bedside dipstick
- +/++ = need to quantify

Protein: creatinine ratio (PCR)
- >30mg/nmol = confirmed significant proteinuria

24h urine collection
- >0.3g/24h = confirmed significant proteinuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

What would you see in HELLP syndrome?

A

H (haemolysis)
- dark urine, raised lactic dehydrogenase (LH), anaemia

EL (elevated liver enzymes)
- epigastric pain, liver failure, abnormal clotting

LP (low platelets)
- normally self-limiting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

What would you see in HELLP syndrome?

A

H (haemolysis)
- dark urine, raised lactic dehydrogenase (LH), anaemia

EL (elevated liver enzymes)
- epigastric pain, liver failure, abnormal clotting

LP (low platelets)
- normally self-limiting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

Fetal complications of pre-eclampsia

A

Intrauterine growth restriction (IUGR)
Preterm birth
Placental abruption
Hypoxia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

Criteria for admission in suspected/confirmed pre-eclampsia

A

Symptomatic
Proteinuria with PCR >30, or >0,3/24h on 24-h collection
Severe hypertension: >/= 160/110mmHg
Growth restriction with abnormal umbilical artery Doppler
Abnormal CTG
Abnormal sFit-1/PIGF assay

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

What preventative tx can be given if at increased risk for pre-eclampsia?

A

Aspiring 75mg from <16 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

What preventative tx can be given if at increased risk for pre-eclampsia?

A

Aspiring 75mg from <16 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

Fetal complications of GDM

A

Macrosomia
Congenital abnormalities
Preterm labour
Birth trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

Maternal complications of GDM

A 
Hypertension, pre-eclampsia 
Retinopathy
DKA
Nephropathy, UTIs
C-section, instrumental delivery wound, endometrial infection
Increased insulin requirements
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

Risk factors for GDM

A 
Previous hx of GDM 
Previous fetus >4.5kg
Previous unexplained stillbirth
First-degree relative with diabetes
BMI > 30
Racial origin 
Polyhydramnios
Persistent glycosuria
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

What is initial GDM treatment?

A

Initial treatment if fasting between 5.6-7:
Give glucometer
Advise re diet and exercise
Check HbA1c to identify pre-existing diabetes
Review in 2 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

What is initial GDM treatment?

A

Give glucometer
Advise re diet and exercise
Check HbA1c to identify pre-existing diabetes
Review in 2 weeks unless fasting > 7 => commence insulin
After 2 weeks if > 5.3 before meals or > 7.8 1-h after meals => commence metformin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

When would you commence metformin in GDM?

A

If 2 weeks after advise re diet and exercise and blood glucose monitoring but have the following readings:

Glucose before meals > 5.3
Glucose 1-h after meals > 7.8

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

How is antiphospholipid syndrome diagnosed?

A

+1 clinical criteria

  • vascular thrombosis
  • 1+ death of fetus > 10 weeks
  • pre-eclampsia or IUGR needing delivery < 34 weeks
  • 3+ fetal losses < 10 weeks, otherwise unexplained

WITH lab criteria

  • lupus anticoagulant
  • high ACAs or anti-B2-glycoprotein I antibody (measured twice >3 months apart)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

How is antiphospholipid syndrome diagnosed?

A

+1 clinical criteria

  • vascular thrombosis
  • 1+ death of fetus > 10 weeks
  • pre-eclampsia or IUGR needing delivery < 34 weeks
  • 3+ fetal losses < 10 weeks, otherwise unexplained

WITH lab criteria

  • lupus anticoagulant
  • high ACAs or anti-B2-glycoprotein I antibody (measured twice >3 months apart)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

Major risk factors for VTE

A

Any previous VTE (unless single post surgery)
High-risk thrombophilia
Low-risk thrombophilia with FHx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

Intermediate risk factors for VTE

A

BMI > 40
Readmission or prolonged admission (>/= 3 days)
Surgical procedure (except perineal repair)
Major medical comorbidity
C-section in labour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

When would you give LMWH in pregnancy?

A

If 4+ risk factors, prophylactic LMWH throughout pregnancy and 6 weeks postnatal

If 3 risk factors, prophylactic LMWH from 28 weeks gestation and 6 weeks postnatal

If 2 risk factors, consider prophylactic LMWH for 10 days postnatally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

When would you give LMWH in pregnancy?

A

If 4+ risk factors, prophylactic LMWH throughout pregnancy and 6 weeks postnatal

If 3 risk factors, prophylactic LMWH from 28 weeks gestation and 6 weeks postnatal

If 2 risk factors, consider prophylactic LMWH for 10 days postnatally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

How is the fetus managed in if mother has diabetes background?

A

Cardiac scan, growth scans at 32 and 36 weeks
Induction at 37-39 weeks; C-section if > 4-4.5kg
Beware neonatal hypoglycaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

What postnatal follow-up is required for GDM?

A

Fasting blood glucose at 6 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

Complications of sickle cell disease in pregnancy

A

Maternal
- crises, thrombosis, pre-eclampsia

Fetal
- IUGR increased perinatal mortality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

Complications of sickle cell disease in pregnancy

A

Maternal
- crises, thrombosis, pre-eclampsia

Fetal
- IUGR increased perinatal mortality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

Pt presents with pruritus without a rash and elevated liver enzymes

How would you manage?

A

Cholestasis

  • ursodeoxycholic acid (UDCA)
  • increased risk of stillbirth, discuss induction from 38 weeks
  • monitor LFTs, give vit K late pregnancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

Types of fibroids and where they are found

A

Subserous polyp
- pedunculated out of outer layer of uterus into pelvic/abdominal cavity

Subserous
- outer layer of uterus

Intracavity polyp
- pedunculated into uterine cavity

Intramural
- middle layer of uterus

Submucosal
- endometrium/inner layer of uterus, can grow into uterine cavity

Cervical (self-explanatory m8)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
112
Q

Sx of fibroids

A 
None (50%)
Menorrhagia (30%)
Erratic/bleeding (IMB) 
Pressure effects 
Subfertility
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
113
Q

Complications of fibroids

A 
Torsion of pedunculated fibroid
Degenerations
- red (pregnancy), hyaline/cystic, calcification (PMB and asx)
Malignanct
- leiomyosarcoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
114
Q

What is adenomyosis?

A

Endometrial tissue in myometrium causing moderate enlargement
May be asx, commonly have painful, regular, heavy periods
O/E uterus mildly enlarged and tender

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
115
Q

Risk factors for endometrial carcinoma

A

Endogenous E2 excess
- PCOS, obesity, nulliparity, early menarche, late menopause

Exogenous E2
- unopposed E2 therapy, tamoxifen therapy

Misc
- diabetes, Lynch type II syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
116
Q

Spread and staging for endometrial carcinoma

A

Stage 1, 90% 5YSR

  • A = < 1/2 of myometrial invasion
  • B = > 1/2 of myometrial invasion

Stage 2, 75% 5YSR
- as above but also cervical stromal invasion, NOT in uterus

Stage 3 (invades uterus), 60% 5YSR

  • A => invades serosa/adnexae
  • B => vaginal and/or parametrial involvement
  • Ci => pelvic node involvement
  • Cii => para-aortic involvement

Stage 4 (further spread), 25% 5YSR

  • A => in bowel or bladder
  • B => distant mets
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
117
Q

Most common type of endometrial cancer

A

Adenocarcinomas

  • type 1 less aggressive, E2 dependant
  • type 2 more aggressive, not E2 dependant
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
118
Q

What are potentially rhesus sensitising events?

A

Termination of pregnancy
Evacuation of retained products of conception after miscarriage
Ectopic pregnancy
Vaginal bleeding < 12 weeks, or > 12 weeks if heavy
External cephalic version
Invasive uterine procedure (amniocentesis, CVS)
Intrauterine death
Delivery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
119
Q

How do we prevent rhesus disease antenatally?

A

Booking and 28 weeks
- check women for antibodies

If rhesus-negative with unknown baby Rh status/Rh+
- give anti-D 1500IU at 28 weeks, after any rhesus sensitising event, and after delivery if neonate Rh+

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
120
Q

What can rhesus disease lead to in pregnancy?

A

Haemolysis causes anaemia
Hydrops and fetal death if severe
Neonatal jaundice and/or anaemia if less severe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
121
Q

Prevention methods of cervical cancer

A

HPV vaccination
Prevention of CIN: sexual and barrier contraceptive education
Identification and treatment of CIN: cervical smear programmes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
122
Q

Spread and staging for cervical carcinoma

A

Stage 1
- lesions confined to the cervix

Stage 2
- invasion into vagina but not the pelvic side wall

Stage 3
- invasion of lower vagina or pelvic wall, or causing ureteric obstruction

Stage 4
- invasion of bladder or rectal mucosa, or beyond the true pelvis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
123
Q

Stages of cervical carcinoma and their treatment

A

1ai
- cone biopsy or simple hysterectomy

1aii-1bi
- laparoscopic lymphadenectomy and radical trachelectomy

1bii-2a
- radical hysterectomy (if lymph node -ve) or chemo-radiotherapy

2b+/lymph node +ve
- chemo-radiotherapy alone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
124
Q

Indications for chemo-radiotherapy for cervical carcinoma

A

Lymph nodes +ve on MRI or after lymphadenectomy

If lymph node -ve as alternative to hysterectomy

Surgical resection margins not clear

Palliation for bone pain or haemorrhage (radiotherapy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
125
Q

Most common type of cervical cancer

A

90% squamous

Can also get adenocarcinomas

126
Q

Which HPV strains do we vaccinate against?

A

Gardasil 9: 6, 11, 16, 18, 31, 33, 45, 52 and 58

Cervical cancer

  • 16 and 18 (>80% case)
  • 31, 33, 45, 52, 58 (another 15% of cases)

Genital warts
- 6 and 11 (around 90% cases)

127
Q

Common ovarian masses

A

Premenopausal

  • follicular/lutein cysts
  • dermoid cysts
  • endometriomas
  • benign epithelial tumour

Postmenopausal

  • benign epithelial tumour
  • malignancy
128
Q

Most common type of ovarian malignancy

A

Epithelial carcinoma, 90% cases

If < 30 yo - germ cell tumour

129
Q

Possible signs and sx of ovarian cancer

A

Pain (unusual)
Abdominal distension or mass palpated by pt
Urinary urgency and/or frequency
Vaginal bleeding

130
Q

What features are suggestive of a malignant ovarian mass?

A 
Rapid growth (> 5cm) 
Ascites
Advanced age
Bilateral masses
Solid/separate nature on USS
Increased vascularity
131
Q

Describe the overall stages of ovarian cancer

A

Stage 1

  • disease macroscopically confined to ovaries
  • a = one ovary, b = both ovaries, c = +ve peritoneal washings/ruptured capsule

Stage 2
- disease extending to pelvis, i.e. fallopian tubes, uterus

Stage 3
- Abdominal disease and/or affected lymph nodes

Stage 4
- Disease beyond abdomen, e.g. lungs or liver parenchyma

132
Q

How does ovarian cancer typically spread?

A

Via transcoelomic spread

- directly within the pelvis and abdomen

133
Q

Name epithelial ovarian tumours

A 
Serous cystadenomas (b/m)
Mucinous cystadenomas (b/m)
Endometrioid carcinoma (m)
Clear cell carcinoma (m)
Brenner tumour (b)
134
Q

Name germ cell ovarian tumours

A 
Dermoid cysts (b)
Solid teratoma (m)
Dysgerminoma (m)
135
Q

Name sex cord ovarian tumours

A

Granulosa cell tumours (b/m)
Thecomas (b)
Fibromas (b)

136
Q

Risk factors for ovarian cancer

A

FHx
Nulliparity
Early menarche, late menopause

137
Q

Tx for ovarian cancer

A

Surgery

  • total abdominal hysterectomy,
  • bilateral salpingo-oophorectomy
  • omentectomy
  • lymph node biopsy/removal

Debulk all advanced tumours

Consider laparoscopy + oophorectomy alone for young women looking to preserve fertility with close monitoring

Neoadjuvant chemotherapy

138
Q

Causes of pruritus vulvae

A

Infection

  • candidiasis
  • vaginal warts
  • pubic lice, scabies

Dermatological disease
- i.e. eczema, psoriasis, lichen simplex, contact dermatitis

Neoplasia

  • carcinoma
  • premalignant disease (vulval intraepithelial neoplasia)
139
Q

Which pathogens result in a Bartholin’s gland cyst abscess?

A

Staphylococcus or E. coli

140
Q

How are Bartholin’s gland cyst abscesses treated?

A

Incision and drainage, and marsupialization (incision sutured open to reduce risk of re-formation)

141
Q

Most common type of vulval malignancy

A

Squamous cell carcinoma (95% cases)

142
Q

What is vulval malignancy associated with?

A 
Lichen sclerosis
Immunosuppression
Vulvar intraepithelial neoplasia
Oncogenic HPVs
Paget's disease of the vulva 
Age > 60 years old
143
Q

What is the lymph drainage of the vulva?

A

Inguinal -> femoral -> pelvic

144
Q

Symptoms of PID

A 
Pelvic pain (can be unilateral), constant or intermittent
Deep dyspareunia
Vaginal discharge
Irregular menses/intermenstrual or postcoital bleeding
145
Q

Signs of PID

A

Cervical motion pain (cervical excitation)
Adnexal discomfort (commonly bilateral but may be unilateral)
Fever (unusual in chronic infection)

146
Q

Complications of PID

A 
Pelvic abscess 
Chronic PID 
Subfertility
Chronic pelvic pain
Ectopic pregnancy
147
Q

Candidiasis features

A

Itch, cottage cheese discharge +/- vulvitis

148
Q

Bacterial vaginosis features

A

Malodour, worse w intercourse, not usually associated w vulvovaginitis

149
Q

Trichomoniasis features

A

Vulvovaginitis/cherry red cervix

50% asx

150
Q

Gonorrhoea vaginal discharge features

A

Rare cause of discharge but pts with gonorrhoea commonly have BV (30%)

151
Q

Chlamydia vaginal discharge features

A

Rare cause of discharge, occasional mucopurulent cervicitis

152
Q

Primary vaginal HSV vaginal discharge features

A

Frank, vulvovaginitis with cervicitis and genital/cervical ulceration

153
Q

Foreign body vaginal discharge features

A

Anaerobic/malodorous, will resolve with removal, abx not usually required

154
Q

What is atrophic vaginitis due to?

A

Due to E2 deficiency and common during lactation/after the menopause

155
Q

Causes of prolapse

A 
Vaginal delivery and pregnancy
Congenital collagen deficiency 
Menopause 
Chronic elevated abdominal pressure (cough, obesity)
Pelvic surgery or masses
156
Q

Types of female genital prolapses

A

Anterior wall

  • cystocele
  • urethrocele

Apical
- Uterus, cervix, upper vagina; vaginal vault if previous hysterectomy

Posterior wall
- rectocoele, enterocoele (pouch of Douglas)

157
Q

Sx of prolapse

A

Often asx
Dragging sensation
Vaginal lump
Urinary frequency, incontinence (anterior wall)
Occasional difficulty in defecating (posterior wall)

158
Q

Mx for prolapses

A

General

  • lose weight
  • treat chest problems including smoking

Pessaries

  • ring or shelf, if frail
  • change 6-9 monthly

Surgery

  • hysteropexy, vaginal hysterectomy
  • anterior/posterior repair
  • sacrospinous fixation or sacrocolpopexy
159
Q

Surgical tx for uterine prolapse

A

Hysteropexy, vaginal hysterectomy

160
Q

Surgical tx for cystocoele

A

Anterior wall repair

161
Q

Surgical tx for rectocoele

A

Posterior wall repair

162
Q

Surgical tx for vault prolapse

A

Sacrospinous fixation, sacrocolpopexy

163
Q

Define preterm delivery

A

Delivery > 24 weeks and < 37 weeks

164
Q

Causes of preterm delivery

A 
Subclinical infection
Cervical incompetence
Multiple pregnancy
Antepartum haemorrhage
Diabetes
Polyhydramnios
Fetal compromise
Uterine abnormalities 
Idiopathic 
Iatrogenic
165
Q

Features of preterm delivery

A 
Abdominal pain
Antepartum haemorrhage
Ruptured membranes
Sepsis
If cervical incompetence - silent sx
166
Q

Methods to prevent preterm delivery

A

Abx if BV, UTI, STI
Vaginal cervical suture if cervix shortens on US
Elective suture if repeated preterm deliveries/miscarriages
Progesterone pessaries if cervix shortens
Fetal reduction, amnioreduction

167
Q

Mx of preterm delivery

A 
Steroids if  < 34 weeks, tocolysis for max. 24 h
Magnesium if 23-32 weeks 
Abx if in confirmed labour only 
C section if indicated
Inform neonatologists 
Transfer to NICU
168
Q

Complication of preterm delivery

A

Neonatal morbidity (50% of all cerebral palsy result of preterm delivery) and mortality

169
Q

Ix if suspected PPROM

A

Lie and presentation checked
Speculum examination to see if pooling of fluid in posterior fornix
Digital examination AVOIDED to reduce risk of infection

170
Q

Complications of twin pregnancies

A

Maternal
- pre-eclampsia, anaemia, GDM, operative delivery

All twins
- increased morbidity and mortality due to miscarriage, preterm labour, placental insufficiency/IUGR, antepartum and postpartum haemorrhage, malpresentations

MC twins
- congenital abnormalities, twin-twin transfusion, IUGR

171
Q

Types of twins

A

DC (70% cases)

  • dichorionic
  • either monozygotic or dizygotic; do not share placenta or sac

MCDA (30% cases)

  • monochorionic diamniotic
  • monozygotic twins that share placenta but not amniotic sac

MCMA (1% cases)

  • monochorionic monoamniotic
  • monozygotic twins that share placenta and amniotic sac
172
Q

Mx of multiple pregnancy

A

Early diagnosis, identify chorionicity
Consultant care
Iron + folic acid supplements
Anomaly scan, increased surveillance for pre-eclampsia, diabetes, anaemia
Serial US at 28, 32 and 36 weeks
Increased surveillance if MC twins
Delivery at 37 if DC, 36 if MC
Labour continuous CTG
C-section if first twin not cephalic
Otherwise after 1st twin delivered, check lie of 2nd - ECV if indicated
Ventouse or breech extraction if fetal distress

173
Q

What extra surveillance is required for MC twins?

A

USS fortnightly from 12 weeks for TTTS and IUGR

174
Q

What is TTTS?

A

Twin-twin transfusion syndrome

  • unequal blood distributed between MC twins
  • treated with laser ablation (50% both twins survive, 80% one twin survives)
175
Q

Diagnosis of TTTS

A

Discordant liquor volumes
Recipient twin larger - polyhydramnios, fluid overload, heart failure
Donor twin smaller - stuck with oligohydrmanios

176
Q

Complications of TTTS

A

Late miscarriage and severe preterm delivery
In utero death
Neurological damage

177
Q

Risk factors for placental abruption

A

A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

178
Q

Describe the gradings of perineal tears

A

First-degree tear: Injury to perineal skin and/or vaginal mucosa.

Second-degree tear: Injury to perineum involving perineal muscles but not involving the anal sphincter.

Third-degree tear: Injury to perineum involving the anal sphincter complex:

  • Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
  • Grade 3b tear: More than 50% of EAS thickness torn.
  • Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.

Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa.

179
Q

What should the post operative plan for any obstetric anal sphincter repair include?

A

Antibiotics alongside adequate analgesia.

Laxatives are required to reduce the risk of constipation and the need for straining.

A dedicated physiotherapy appointment should be made to guide pelvic floor exercises, as well as a gynaecology outpatient appointment to check for symptoms of incontinence.

The GP sees all patients after delivery at their 6 week check, however the GP alone should not be expected to manage the recovery after a 3rd or 4th degree tear

180
Q

What are the categories of C-sections?

A
  1. immediate threat to the life of the woman or fetus
  2. maternal or fetal compromise which is not immediately life-threatening
  3. no maternal or fetal compromise but needs early delivery
  4. delivery timed to suit woman or staff.
181
Q

What are normal urinary sx?

A

Daytime voiding: 4-7 voids per day

Nocturnal enuresis: only single void per night (after 70)

182
Q

Urodynamic stress incontinence vs stress incontinence

A

Urodynamic stress incontinence (USI)
- disorder diagnosed only after cytometry of which stress incontinence is major sx

Stress incontinence
- description of a symptom ‘I leak when I cough’ but may be result of overactive bladder or overflow incontinence

183
Q

Causes of urgency and frequency

A 
UTI
Bladder pathology
Pelvic mass compressing the bladder
Overactive bladder
Urodynamic stress incontinence
184
Q

Stress incontinence mx

A

Conservative

  • lose weight if obese
  • stop smoking
  • reduce excessive fluid intake
  • pelvic floor muscle training

Medical
- duloxetine (if does not want surgery)

Surgical

  • Burch colposuspension
  • injectable periurethral bulking agents
  • mid-urethral sling procedures (tension-free vaginal tape)
185
Q

Urge incontinence/overactive bladder mx

A

Conservative

  • lose weight if obese
  • stop smoking
  • reduce excessive fluid intake
  • bladder training

Medical

  • anticholinergics/antimuscarinics (oxybutynin, tolterodine, solefinacin)
  • sympathomimetics (mirabegron)
  • botulinum toxin A

Other

  • neuromodulation and sacral nerve stimulation
  • surgery if severe (clam augmentation ileocystoplasty)
186
Q

Define spontaneous miscarriage

A

Fetus dies or delivers dead before 24 weeks of pregnancy

187
Q

Types of miscarriages

A 
Threatened
Inevitable
Incomplete
Complete
Septic
Missed
188
Q

Bleeding, fetus still alive, uterus expected size from dates, and cervical os closed

Which miscarriage is this?

A

Threatened

- only 25% go onto miscarry

189
Q

Heavy bleeding, fetus could be alive, cervical os open

Which miscarriage is this?

A

Inevitable

- miscarriage about to occur

190
Q

Some fetal parts passed, os usually open

Which miscarriage is this?

A

Incomplete

191
Q

All fetal tissue has passed, bleeding diminished, uterus no longer enlarged, cervical os closed

Which miscarriage is this?

A

Complete

192
Q

Endometritis, vaginal loss is offensive, uterus is tender,

Which miscarriage is this?

A

Septic

  • contents of uterus infected
  • if pelvic infection, abdo pain and peritonism occurs
193
Q

Uterus smaller than expected date, cervical os closed, fetus is undeveloped/dead

Which miscarriage is this?

A

Missed

194
Q

Miscarriage expectant mx

A

If woman willing and no signs of infection

  • success within 2-6 weeks in > 80% cases
  • large intact sac associated w lower success rates

Risks: heavy bleeding, need for surgical evacuation, infection

195
Q

Miscarriage medical mx

A

Vaginal or oral prostaglandin = misoprostol

Urine pregnancy test repeated 3 weeks later to exclude ectopic or molar pregnancy

Risks: heavy bleeding, need for surgical evacuation infection

196
Q

Miscarriage surgical mx

A

Surgical management of miscarriage (SMM)

  • under GA using vacuum aspiration
  • tissue examined histologically to exclude molar pregnany

Risks: Asherman’s syndrome, uterus perforation

197
Q

Ix for recurrent miscarriage

A

Antiphospholipid antibody screen (repeat at 6 weeks if +ve)
Karyotyping of fetal miscarriage tissue
Thryoid function
Pelvic USS (and MRI or hysterosalpingogram if abnormal)

198
Q

Grounds for termination of pregnancy in England, Scotland and Wales

A
  1. Continuing pregnancy would be risk to life of pregnant woman greater than if pregnancy was terminated
  2. Termination necessary to prevent grave permanent injury to physical or mental health of pregnant woman
  3. Pregnancy has not exceeded 24th week and risk to pregnant woman physical and mental health > if continues with pregnancy
  4. Pregnancy has not exceeded 24th week and risk to any existing children of pregnant woman physical or mental health > if continues with pregnancy
  5. Substantial risk if child born it would suffer from severe physical or mental abnormalities
199
Q

Surgical methods of TOP

A

Surgical curettage
- between 7 and 12-14 weeks

Dilatation and evacuation (D&E)

  • above 14 weeks
  • cervix prepared with preop vaginal misoprostol and abx prophylaxis given
200
Q

Medical methods of TOP

A

Antiprogesterone MIFEPRISTONE then prostaglandin MISOPROSTOL 36-48 hours later
- most effective method < 7 weeks and 13-14 weeks

201
Q

Complications of TOP

A 
Haemorrhage
Infection
Uterine perforation
Cervical trauma
Failure of procedure
Multiple surgical abortions -> increased risk of preterm delivery
202
Q

Mx of sx suspected ectopic pregnancy

A 
NBM 
FBC and cross-match blood
Pregnancy test
USS
Laparoscopy or consider medical mx if criteria met
IV access
203
Q

Criteria for expectant mx of an ectopic pregnancy

A 
Size < 35 mm
Unruptured
Asx
No fetal heartbeat
hCG < 1000 IU/L
Compatible if another intrauterine pregnancy
204
Q

Criteria for medical mx of an ectopic pregnancy

A 
Size < 35 mm 
Unruptured
No significant pain
No fetal heartbeat
hCG < 1500 IU/L
Not suitable if intrauterine pregnancy
205
Q

Criteria for surgical mx of an ectopic pregnancy

A 
Size > 35 mm
Can be ruptured
Pain 
Visible fetal heartbeat
hCG > 5000 IU/L
Compatible with another intrauterine pregnancy
206
Q

Tx options for ectopic pregnancy

A

Expectant

  • criteria met, hCG < 1000 IU/L
  • close monitoring over 48 hours
  • if hCG levels rise or sx manifest, next step in mx

Medical

  • METHOTREXATE
  • criteria met, hCG < 1500 IU/L
  • only done if pt willing to attend follow up (
  • serial hCG taken to confirm all trophoblastic tissue gone

Surgical

  • salpingectomy or salpingotomy
  • criteria met, hCG > 5000 IU/L
207
Q

What is hyperemesis gravidarum?

A

Nausea and vomiting in early pregnancy so severe it causes:

  1. dehydration
  2. wt loss
  3. electrolyte disturbance

Subsidies by 14 weeks usually

208
Q

Pt who is 8 weeks pregnant comes in with vaginal bleeding and severe vomiting

O/E uterus is large, cervical os is closed

USS shows ‘snowstorm’ appearance

How would you manage this pt?

A

Trophoblastic disease suspected

  • hCG will be high
  • needs histology to confirm diagnosis

Tissue removed by suction curettage (ERPC) and serial hCG taken to ensure all tissue removed

Pregnancy must be avoided until completion of surveillance period

209
Q

Risk factors for spontaneous miscarriage

A 
Increasing maternal age
>50% chromosomal abnormalities 
Antiphospholipid syndrome
Uterine abnormalities
Parental chromosome abnormalities
210
Q

When would you give anti-D for miscarriage mx?

A

Anti-D if rhesus -ve when:

  1. miscarriage occurs from 12 weeks’ gestation
  2. treated medically or surgically at any gestation
211
Q

Risk factors for ectopic pregnancy

A 
Tubal damage (PID, surgery)
Previous ectopic
Endometriosis
IUCD
POP
IVF
212
Q

Where do ectopic pregnancies occur in the reproductive tract?

A

95% in fallopian tube

  • most in ampulla
  • more dangerous if isthmus

Can occur in ovary, cervix, peritoneum

213
Q

Maternal infection suitable for screening

A

Syphilis
Hep B
Rubella
Can also consider: Chlamydia, BV, beta-haemolytic streptococcus

214
Q

Teratogenic maternal infections

A 
Cytomegalovirus
Rubella
Toxoplasmosis 
Syphilis 
Herpes zoster
215
Q

Methods to prevent vertical transmission of HIV

A

Maternal antiretroviral therapy
Elective caesarean section
Avoidance of breastfeeding
Neonatal antiretroviral therapy

216
Q

Prevention of vertical transmission of group B streptococcus

A

Treat with IV penicillin intrapartum if:

  • previous hx
  • intrapartum fever > 38oC
  • current preterm labour
  • rupture of membranes > 18hrs

Can screen with vaginal and rectal swab at 35-37 weeks to treat same as above if +ve

217
Q

Why should consumption of pates, soft cheese, and prepacked meals be avoided during pregnancy?

A

Risk of Listeria monocytogenes infection

  • gram +ve bacillus causing non-specific febrile illness
  • can be fatal infection for fetus
  • prevention is to avoid high-risk foods in pregnancy
218
Q

Consequences of HIV infection to fetus

A

Prematurity
IUGR
Stillbirth

219
Q

What requires continuous CTG monitoring if any of the following are present or arise during labour?

A

Suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
Severe hypertension 160/110 mmHg or above
oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops in labour

220
Q

Which fibroids do you do an open myomectomy for?

A

Very large and/or numerous subserosal or intramural fibroids

221
Q

Which fibroids do you do a hysteroscopic myomectomy for?

A

Submucous fibroids in the uterine cavity

222
Q

Which fibroids do you do a laparoscopic myomectomy for?

A

Small number of subserous fibroids

223
Q

Circumstances that allow more room for fetus to turn

A 
Polyhydramnios
High parity (lax uterus)
224
Q

Conditions that prevent fetus from turning

A

Fetal abnormalities
Uterine abnormalities (fibroids)
Twin pregnancies

225
Q

Conditions that prevent engagement of fetus

A

Placenta praevia
Pelvic tumours
Uterine deformities (fibroids)

226
Q

Mx of breech presentation

A

37 weeks ECV offered (anti-D if rhesus -ve)
Elective C section at 39 weeks
Planned vaginal breech birth

227
Q

Contraindications to ECV

A 
If fetus compromised 
Vaginal delivery contraindicated (placenta praevia)
Multiple pregnancy
Rupture of membranes 
Recent antepartum haemorrhage
228
Q

Which vaginal breech births are more risky?

A

Fetus > 3.8 kg
Evidence of fetal compromise
Extended head or footling legs

229
Q

What are the breech presentations?

A

Extended (70%)
- bum first, thighs against chest and feet up by ears

Flexed (15%)
- bum first, feet next to bottom, thighs against chest and knees bent

Footling (15%)
- one or both baby’s feet below its bottom

230
Q

What manoeuvres are used for vaginal breech delivery?

A

Delivery of bottom = hands off approach

Delivery of legs & lower body = Pinard’s manoeuvre if extended, spontaneous if flexed

Delivery of shoulders = Loveset’s manouvre to rotate due to allow for winging of scapulae

Delivery of head = Maueiceau-Smellie-Veit manouvere where baby rested on forearm and head pulled downwards

231
Q

Risk factors for shoulder dystocia

A

Macromia
GDM
Previous shoulder dystocia
Obesity

232
Q

Complications of shoulder dystocia

A

Maternal

  • perineal tears
  • psychological trauma

Fetal

  • brain hypoxia
  • Erb’s palsy (upper brachial plexus injury)
233
Q

Mx of shoulder dystocia

A

Senior and neonatal help called
McRoberts’ (legs hyperextended onto abdomen)
Suprapubic pressure
Episiotomy if it will make internal rotation easier
Wood’s screw (place pressure behind posterior shoulder to rotate it)
Symphysiotomy/cleidotomy (last resort)
Zavanelli (replace head for C section - irreversible fetal damage by this point + last last resort)

234
Q

How is a cord prolapse diagnosed?

A

At vaginal examination, usually after identification of fetal distress

235
Q

Risk factors for cord prolapse

A 
Preterm labour
Breech presentation
Polyhydramnios 
Abnormal lie
Multiple pregnancy
Artificial amniotomy
236
Q

Cord prolapse mx

A

Mother goes onto all fours
Presenting part pushed up by examining finger
CAT 1 C Section

237
Q

Classification of placenta praevia

A

Marginal
- placenta in lower segment, not over os

Major
- placenta completely or partially covering os

238
Q

Causes of antepartum haemorrhage

A

Common

  • undetermined origin
  • placental abruption
  • placenta praevia

Rarer

  • incidental genital tract pathology
  • uterine rupture
  • vasa praevia
239
Q

Presentation of placenta praevia

A

Incidental finding on USS
Vaginal bleeding
Abnormal lie, breech presentation

240
Q

Placental abruption vs placenta praevia

A

Abruption

  • shock inconsistent with external loss
  • severe pain
  • bleeding could be absent, often dark
  • tender, hard uterus
  • fetus normal, could be distressed or dead
  • normal USS, placenta not low

Praevia

  • shock consistent with external loss
  • no pain or tenderness
  • red and often profuse blood, often small APHs
  • fetus lie often abnormal/lie, HR normal
  • placenta low
241
Q

Major risk factors for placental abruption

A 
IUGR 
Pre-eclampsia 
Pre-existing HTN 
Maternal smoking, cocaine use
Previous abruption
242
Q

Features of major placental abruption

A 
Maternal collapse
Coagulopathy 
Fetal distress or demise 
Woody hard uterus 
Poor urine output or renal failure 
N.B degree of vagina loss often unhelpful
243
Q

Clinical features of placental abruption

A 
Pallor
Hypotension
Tender, hard uterus
Fetal distress or absent heart sounds
Tachycardia
Abdominal pain 
Vaginal bleeding
244
Q

Mx of major placental abruption

A

Call for senior help, including senior midwife, obstetric SHO or reg, alert the consultant

Call the anaesthetic SHO or reg

Call the on-call haemoatlogist

Alert blood transfusion lab and call porters for delivery of blood

Initial A-E management with focus on circulation
Establish two large bore cannulae and take FBC, coagulation screen, U&Es, cross match (4 units)

Position lady into left lateral tilt and keep warm

Replace fluid loss with warmed crystalloid Hartmann’s solution

Transfuse blood asap +/- blood products

Assess fetus health with CTG and prep theatres for CAT 1 C section for delivery

245
Q

Factors associated with placenta praevia

A

Large placenta
Scarred uterus
High parity/age
Multiple pregnancy

246
Q

Complications of placenta praevia

A

Haemorrhage
Preterm, C section
Risk of placenta accreta if previous LSCS

247
Q

Complications of placental abruption

A

Fetal death
Massive haemorrhage causing DIC
Renal failure
Maternal death

248
Q

Ddx of endometriosis

A

Adenomyosis
Chronic PID
Chronic pelvic pain
IBS

249
Q

Endometriosis tx

A

Medical

  • analgesia
  • COCP
  • Progesterones
  • GnRH +/- HRT
  • IUS

Surgical

  • Laparoscopic laser ablation/diathermy/scissors +/- adhesiolysis
  • Hysterectomy and bilateral salpingo-oophorectomy (BSO)
250
Q

Peritoneal inflammation causing fibrosis, adhesions, and chocolate cysts

A

Endometriosis

251
Q

Why do we routinely palpate the pregnant abdomen?

A

< 24 weeks
- check dates, assess if twins

> 24 weeks
- assess well-being by assessing size and liquor

> 36 weeks
- check lie, presentation and engagement

252
Q

What do you examine on the pregnant abdomen?

A

Inspect
- size, scars, fetal movements

Palpate

  • symphysis-fundal height and plot on serial measurement chart
  • > 24 weeks assess lie and presentation, liquor volume, engagement of presenting part

Listen
- fetal heart over anterior shoulder using doppler

253
Q

Clinical features of PCOS

A 
Subfertility 
Oligomenorrhoea/amenorrhea
Hirsutism and/or acne
Obesity 
Miscarriage
254
Q

Ix for PCOS

A

TVUSS
FSH, LH, AMH, testosterone, prolactin, TSH work up
Fasting lipids and glucose to screen for diabetes and hypercholesterolaemia complications

255
Q

How many bleeds per year are required to provide a protective factor from endometrial Ca?

A

3-4/year (doesn’t matter if spontaneous or induced)

256
Q

Common causes of anovulation

A 
PCOS
Hypothalamic hypogonadism
- anorexia, stress, exercise, idiopathic
Hyperprolactinaemia 
Thyroid disease
Premature ovarian insufficiency
257
Q

First-line ovulation induction drug in PCOS

A

Clomifene

- anti-oestrogen thus increasing release of FH and LSH via negative feedback loop

258
Q

Risks of ovulation induction

A

Multiple pregnancy
Ovarian hyperstimulation syndrome
Ovarian and breast Ca (not the largest risk, conflicting evidence)

259
Q

Reasons why sperm may not meet the egg for fertilisation

A 
Tubal damage
- Infection (PID)
- Endometriosis
- Surgery/adhesions
Cervical problems
Sexual problems
260
Q

Indications for assisted conception

A 
When all other methods have failed
Unexplained subfertility 
Male factor subfertility => ICSI
Tubal blockage 
Endometriosis 
Genetic disorders
261
Q

Overview of stages in IVF

A

Multiple follicular development
Ovulation and egg collection
Fertilisation and culture
Embryo transfer

262
Q

Complications of assisted conception

A

Superovulation
- multiple pregnancy, OHSS

Egg collection
- intraperitoneal haemorrhage, pelvic infection

Pregnancy complications
- higher rates of ectopic pregnancy, chromosomal & gene abnormalities seen

263
Q

Common side effects of progestogenic contraception

A 
Depression
Premenstrual tension-like symptoms
Bleeding: amenorrhoea 
Acne
Breast discomfort 
Weight gain 
Reduced libido
264
Q

Common side effects of oestrogenic contraception

A 
Nausea
Headaches
Increased mucus
Fluid retention and weight gain 
Occasionally hypertension 
Breast tenderness and fullness
Bleeding
265
Q

Advice if woman forgets to take 1 pill of the COCP

A

If 1 pill is missed (at any time in the cycle)

  • take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
  • no additional contraceptive protection needed
266
Q

Advice if woman forgets to take 2 pills of the COCP in a row

A

If 2 or more pills missed

  • take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
  • the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
Week 1 (day 1-7): EMERGENCY CONTRACEPTION if UPSI in pill-free interval/week 1
Week 2 (day 8-14): NO NEED for emergency contraception if taken all okay prior
Week 3 (day 15-21): finish pills in pack and OMIT PILL-FREE INTERVAL
267
Q

How long before surgery should you stop the COCP?

A

4 weeks

268
Q

Counselling points re COCP

A

Major complications and benefits
Stop smoking
See doctor if signs of major complications, i.e. DVT
Remind about poor absorption when taken with abx and if vomiting
What to do about missed pills
Stress important of follow-up and blood pressure measurement

269
Q

Major complications of COCP

A 
Cerebrovascular accident
Focal migraine 
Hypertension
Breast carcinoma 
Cervical carcinoma 
Deep vein thrombosis and pulmonary embolism
270
Q

Absolute CIs to COCP

A 
Hx of VTE
Hx of CVA, IHD, severe HTN
Migraine with aura 
Active breast/cervical Ca
Inherited thrombophilia 
Pregnancy
Smokers > 35 and smoking > 15 cigs/day
BMI > 40 
Diabetes with vascular complications
Active/chronic liver disease
271
Q

Relative CIs to COCP

A 
Smokers
Chronic inflammatory disease
Renal impairment, diabetes
Age > 40 
BMI 35-40 
Breastfeeding up to 6 months postpartum
272
Q

3 hour POPs

A

Micronor, Noriday, Nogeston, Femulen

273
Q

12 hour POP

A

Cerazette (desogestrel)

274
Q

Absolute CIs to IUD

A 
Endometrial/cervical Ca
Undiagnosed vaginal bleeding
Active/recent pelvic infection
Current breast Ca (for progesterone IUS)
Pregnancy
275
Q

Relative CIs to IUD

A 
Previous ectopic pregnancy
Excessive menstrual loss (unless progesterone IUS)
Multiple sexual partners
Young/nulliparous 
Immunocompromised, including HIV+
276
Q

Counselling points to consider before IUD insertion

A 
Major risks
Inform her doctor if experiences
- IMB
- pelvic pain
- vaginal discharge
- thinks she may be pregnant
Check for strings after each period
277
Q

Labour stages

A

1st
= Initiation of painful contractions to full cervical dilatation

2nd
= Full cervical dilatation to delivery of fetus

3rd
= Delivery of fetus to delivery of placenta

278
Q

Movements of fetal head during labour

A
  1. Engagement in occipito-transverse position for head to pass through pelvic inlet
  2. Descent and flexion into mid-cavity, measured by descent relative to ischial spines (station)
  3. Rotation 90o to occipito-anterior position for head to pass through pelvic outlet
  4. Descent
  5. Extension and delivery
  6. Restitution and delivery of shoulders thanks to head rotating 90o (external rotation)
279
Q

General mx of first stage labour

A

Maternal
- obs, position, fluid, analgesia

Fetal
- intermittent auscultation/CTG, resus +/- fetal blood sample if abnormal HR, LSCS if fetal distress

Labour
- vaginal exam, augmentation if required, LSCS if dilatation not imminent by 12 hours

280
Q

General mx of second stage labour

A

Maternal
- obs, position, fluid, analgesia

Fetal
- intermittent asucultation/CTG

Labour
- oxytocin, push when mum has desire/head visible, instrumental delivery if not delivered after 1 hour of pushing or prerequisites met

281
Q

Slow labour is…

A

… progress slower than 0.5cm/h after 4cm (latent phase)

282
Q

Prolonged labour is…

A

… > 12 h duration after latent phase

283
Q

Features of occiptio-posterior position baby

A

Slow labour
Back pain
Early desire to push

284
Q

Common indications for induction

A 
Prolonged pregnacy
Suspected growth restriction
Prelabour term rupture of membranes
Pre-eclampsia
Medical disease: hypertension and diabetes
285
Q

Causes of PMB

A 
Endometrial Ca
Endometrial hyperplasia
Cervical Ca
Atrophic vaginitis
Cervicitis
Ovarian Ca
Cervical polyps
286
Q

HRT impact on cancer risks

A

Increased risk

  • breast if combined
  • endometrial if E2 only

Decreased risk
- potentially colon

287
Q

Long term complications of hysterecomy

A

Prolapse
Genuine stress incontinence
Premature menopause
Pain and psychosexual problems

288
Q

When are scans done antenatally?

A

11-13+6
= scan to date and identify twins

18-20+6
= routine anomaly scan

Serial USS later if

  • polyhydramnios
  • breech
  • suspected IUGR
289
Q

Routine booking ix

A 
Urine culture
FBC
Antibody screen
Serological test for syphilis
Rubella IgG
HIV and Hep B 
USS
Screen for chromosomal abnormalities
Haemoglobin electrophoresis
290
Q

Physiological blood changes seen in pregnancy

A

Blood volume increases 50%

Red cell mass increases

Haemoglobin decreases due to dilution

White blood cell count increases

291
Q

Physiological CVS changes seen in pregnancy

A

Cardiac output 40% increase
Peripheral resistance 50% reduction
BP small mid-pregnancy fall

292
Q

Physiological lung changes seen in pregnancy

A

Tidal volume 40% increase

RR no change

293
Q

USS findings for Down’s syndrome

A 
Thickened nuchal syndrome
Some structural abnormalities 
Absent or shortened nasal bone
Tricuspid regurgitation
Severe fetal growth restriction
294
Q

Antenatal blood test findings for Down’s syndrome

A

1st trimester

  • low PAPP-A
  • high B-hCG
  • low AFP

2nd trimester

  • high B-hCG
  • low AFP
  • low E2
  • high inhibin
295
Q

Mx of polyhydramnios

A

Detailed USS screening
Exclude gestational diabetes

Consider reducing liquor if severe

  • amnioreduction
  • NSAIDs to reduce fetal urine output

Delivery
- vaginal unless persistent unstable lie or other obstetric indication

296
Q

Major risk factors for SGA

A 
Previous hx of SGA or stillbirth
Heavy smoking
Cocaine usage
Heavy daily exercise
Maternal illness, i.e. diabetes
Parental SGA
297
Q

Non-rotational forceps

A

Simpson’s

Neville-Barnes

298
Q

Rotational forceps

A

Kielland’s

299
Q

Indications for instrumental delivery

A

Prolonged active second stage
Maternal exhaustion
Fetal distress in second stage to expedite delivery

300
Q

Prerequisites for instrumental delivery

A 
Head not palpable abdominally
Head at/below ischial spines on vaginal examination
Cervix fully dilated
Position of head known
Adequate analgesia
Valid indication for delivery
Bladder empty
301
Q

Forceps vs ventouse

A

Ventouse causes:

  • higher failure rate
  • more fetal trauma
  • no difference in Agpar scores
  • less maternal trauma
302
Q

Indications for C section

A

Emergency

  • failure to progress in labour
  • fetal distress

Elective

  • previous C section
  • breech presentation
303
Q

Complications of instrumental delivery

A

Maternal
- lacerations, haemorrhages, third-degree tears

Fetal
- lacerations, bruising, facial nerve injury, hypoxia if prolonged delivery

304
Q

What is the puerperium?

A

6-week period post-delivery where body returns to its pre-pregnant state

305
Q

Advantages of breastfeeding

A 
Protection against infection in neonate
Bonding
Protection against cancers (mother)
Cannot give too much (no overfeeding) 
Cost saving lol
306
Q

Define stillbirth

A

Fetus born dead at 24+ weeks

307
Q

Define neonatal death

A

Neonate dies < 28 days after delivery (early is < 7 days)

308
Q

Polymorphic eruptions of pregnancy

A

Pruritic condition associated with the last trimester
Lesions often first appear in abdominal striae
Periumbilical area is often spared
Management depends on severity: emollients, mild Potency topical steroids and oral steroids may be used

309
Q

Chemo for ovarian Ca

A

Carboplatin
- not cisplatin as more nephrotoxic not a vibe
Paclitaxel
- peripheral neuropathy, neutropenia, myaliga so also give
STEROIDS

310
Q

Bevacizumab indication

A

3rd line ovarian Ca tx

  • surgery done
  • chemo done
  • bitch still struggling

Year 5 Specialities (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions