O&G

Question 1

Who should be offered a GTT (NICE)

Answer 1

BMI above 30 kg/m2
 Previous macrosomic baby weighing 4.5 kg or above
 Previous gestational diabetes
 Family history of diabetes (first-degree relative with diabetes)
 Minority ethnic family origin with a high prevalence of diabetes
 Glycosuria: 2+ on one occasion or 1+ on 2 occasions

Question 2

What GTT involves

Answer 2

 Mother fasted overnight
 Pre-test (fasted) blood glucose
 75g glucose drink administered
 Blood glucose checked 1 and 2 hours after

Question 3

Effects of GDM

Answer 3

Fetus:
 Fetal macrosomia
 Polyhydraminos
 Neonatal hypoglycaemia
 Neonatal respiratory distress syndrome
 Increased still birth rate
Maternal:
 Increased risk of traumatic delivery (shoulder dystocia)
 Increased c-section risk
 Increased risk of GDM in subsequent pregnancies
 50% increased risk of developing T2DM within 15 years

Question 4

Management of GDM?

Answer 4

 Offer women a review in the joint diabetes and antenatal clinic within 1 week of diagnosis
 Educate women how to monitor blood glucose levels and that they are to keep a diary of results:
o Fasting: 5.3 mmol/L
o 1 hour post meal: 7.8 mmol/L
o 2 hours post meal : 6.4 mmol/L
o Only aim for these results if it is not causing problematic
hypoglycaemia and ensure that women are aware of the dangers
and symptoms of hypoglycaemia  Diet and exercise advice (offer to all):
o Eat healthily and replace high GI foods with low GI foods
o Refer all women to a dietician
o Regular exercise e.g. 30 min walk post meal
o Offer a one week trial of diet and exercise to those with fasting
glucose <7mmol/L. If blood targets are not met introduce
medication

Question 5

HRT follow-up?

Answer 5

3 months of treatment

Question 6

HRT counselling

Answer 6

• Explain that unscheduled vaginal bleeding is a common side effect of HRT within first 3 months of treatment and should be reported at 3-month review appointment
• Complementary therapies: explain that efficacy and safety of these are unknown
• Stop HRT immediately if:
   Sudden severe chest pain (even if not radiating to left arm).
   Sudden breathlessness or cough with blood-stained sputum.
   Unexplained swelling or severe pain in calf of one leg.
   Severe abdominal pain.
   Serious neurological effects, including unusually severe, prolonged headach.
   Hepatitis, jaundice, or liver enlargement.
   Blood pressure above systolic 160 mmHg or diastolic 95 mmHg.
   Prolonged immobility after surgery or leg injury.
   Detection of a risk factor which contraindicates treatment
  o Stress the importance of regular breast self-examination and attending breast and cervical screening.

Question 7

In the counselling candidate should mention:*

Answer 7

1. Sleep hygiene
2. Alcohol and caffeine reduction, stopping smoking
3. Regular exercise.
   Fan at night, loose clothing
   Follow up:
   o At 3 months to assess efficacy and tolerability
   o Annually thereafter unless there are clinical indications for an earlier review
   (such as treatment ineffectiveness, side effects or adverse events).

Question 8

Menopause risks and benefits?

Answer 8

Risks: breast cancer, ovarian cancer. Some irregular bleeding to start with, nausea. Very small risk of CVD.
Benefits - protects bone, symptom control, reduces the risk of colorectal cancer by 1/3

Question 9

Ix for neonatal jaundice

Answer 9

Bloods:
o FBC: anaemia and WCC for infection
o LFTs
o Bilirubin: both conjugated and unconjugated
o Baby’s blood group
o Serum T4 and TSH
o Blood film: looking for spherocytes etc
o Screen for inherited disorders: pyruvate kinase levels, UDP glucoronyl
transferase, alpha 1 antirypsin, plasma galactose
 Urine dipstick (to exclude infection)

Question 10

Complications of biliary atresia?

Answer 10

May need full liver transplant
Kernicterus

Question 11

Follow up Kawasaki disease

Answer 11

Follow up
 Echo at 6 weeks to confirm absence of aneurysm
 Close follow-up with repeat echocardiograms required to rule out
complication of aneurysms

Question 12

Differentials for leukaemia?

Answer 12

Aplastic anaemia, EBV, hepatitis, neuroblastoma

Question 13

Follow-up after meningitis?

Answer 13

Hearing tests as can cause deafness

Question 14

Risk factors of OC?

Answer 14

 Personal history
South American, Indian
 Family history
Multiple pregnancy
Older age

Question 15

Urge incontinence cause?

Answer 15

Due to destrusor overactivity

Question 16

Clomiphene risks?

Answer 16

Multiple pregnancy,

Question 17

2nd line after clomiphene?

Answer 17

GnRH

Question 18

Histuism treatment?

Answer 18

COCP (Dianette)
Cyproterone acetate

Question 19

Follow-up care of PID?

Answer 19

Review in 72 hours and at 2-4 weeks

Question 20

Large for dates

Answer 20

Differential Diagnosis for large for dates
 Constitutionally large for dates (LFD). 

 Polyhydramnios. 

o The increased discomfort, irritable uterus and shortness of breath suggest polyhydramnios. 

o Amniotic fluid is produced almost exclusively from the fetal urine from the second trimester onwards. Polyhydramnios is given to an excess of amniotic fluid, AFI > 95th centile for gestation on ultrasound estimation.
o Causes of polyhydramnios:
 Maternal
 Diabetes -
 Placental
 Chorioangioma
 Arterio-venous fistula
 Foetal
 Multiple gestation
 Mono-chorionic – twin-twin transfusion syndrome
 Idiopathic
 Oesophageal atresia, Duodenal atresia, Neuromuscular
fetal condition and anencephaly – prevent swallowing of
the amniotic fluid
 Renal complications
 The previous dating and second-trimester USSs have excluded multiple pregnancy and fetal anomaly which might be associated with polyhydramnios (e.g. duodenal atresia). 

 Wrong dates.
 Multiple pregnancy. 

 Macrosomia (e.g. secondary to diabetes). 

 Hydrops. 


Question 21

Investigations for polyhydramnios

Answer 21

 Glucose tolerance test of the mother
 USS
1. Confirm LFD (BPD, abdominal circumference); 

2. Measure liquor volume; 

3. Exclude multiple pregnancy; 

4. Exclude fetal anomaly that may have been missed on earlier scans
5. Identify evidence of hydrops (e.g. fetal oedema/effusions and/or ascites). 

 Rhesus status and antibodies – hydrops

Question 22

Risks of polhydramnios?

Answer 22

Pre-term labour, PPROM, cord prolapse, unstable lie, PPH, malpresentation

Question 23

Differential diagnosis of PCB

Answer 23

Differential diagnosis of PCB
Uterine:
 Neoplasia
 Hyperplasia  Polyps
 Fibroids
Cervical:
 Ectropion
 Endocervical polyp
 Complication of COCP
 Chlamydia or other STI
 Cervical malignancy
Vaginal:
 Trauma
 Atrophy
 STI Urogenital:
 Haemorrhoids

Question 24

Investigations for PCB?

Answer 24

 Full STI screen:
o Endocervical swab for chlamydia
o Endocervical swab for gonorrhoea
o High vaginal swab for trichomonas and candida (not an STI but could
cause vaginitis and thus PCB)
 Take a smear to exclude CIN/ malignancy although this is highly unlikely
considering her age
 Always investigate PCB to exclude significant pathology

Question 25

Three treatment options for cervical ectropion?

Answer 25

o Stop COCP and switch to another contraceptive o Cold coagulation of the cervix
o Diathermy ablation of the ectocervix

Question 26

Confirming PPROM

Answer 26

 Nitrazine testing: Allows for the detection of amniotic fluid which alkaline compared
to vaginal secretions which are acidic. Elevated pH turns nitrazine stick black.
 Ultrasound: Amniotic fluid volume directly correlates to the latency period in
PPROM
 Amniocentesis: Sample amniotic fluid can be sent for Gram stain and MC&S to
establish the cause of the intrauterine infection

Question 27

Treatment of PPROM?

Answer 27

Senior help, ABC assessment
High vaginal swabs, CTG continuous, erythromycin. Needs IOL.
In pregnant women with diagnosed PPROM, delivery should be considered at 34 weeks of gestation. Where expectant management is considered beyond this gestation, women should be informed of the increased risk of chorioamnionitis and the decreased risk of respiratory problems in the neonate.

Question 28

Testing amniotic fluid in PPROM?

Answer 28

Insulin-like-growth factor binding protein 1 or placenta alpha microglobumin-1 (PAMG-1)

Question 29

Premature labour risk factors?

Answer 29

Young maternal age, chorioamniotis, polyhydramnios, sepsis, illegal drug use, pre-eclampsia, previous preterm delivery

Question 30

Treatment of premature labour?

Answer 30

Management
 Continuous fetal monitoring
 Maternal steroids:
o Betamethasone IM – ideally two doses between 12-24 hours apart
Tocolytics:
o Aim to prolong labour for 24 hours to:
 Allow steroids to be effective
 Transfer of mother to unit with NICU facilities
o Choice agents:
 Atosiban (oxytocin antagonist)  Ritodrine (beta agonist)
 Nifedipine
 GTN

Question 31

Assessing prolapse?

Answer 31

POP-Q score

Question 32

Causes of prolapse?

Answer 32

Vaginal delivery and pregnancy
Congenital factors, menopause, iatrogenic

Question 33

Ix for prolapse?

Answer 33

Observations, BMI, abdo exam, speculum and bimanual, pelvic USS,

Question 34

Prolapse treatment

Answer 34

Conservative
Weight control.
Stop smoking.
Pelvic floor exercises.
Vaginal pessaries (e.g. ring or shelf) may be used to provide symptom relief if the patient is unfit for operation, or wishes to avoid, surgery. Pessaries are more likely to be helpful in women with a prominent suprapubic arch and strong perineal body for support; otherwise the pessary is easily expelled. Pessaries are generally replaced every 4–6 months.
Medical
Vaginal oestrogen cream or HRT.
Surgical options

Question 35

Prolapse surgeries

Answer 35

Sacrohysteropexy, Manchester repair, vaginal hysterectomy with sacrospinous fixation,

Question 36

Causes of reduced fetal movements

Answer 36

Prolonged periods of fetal sleep without any compromise.
Fetal compromise.
Fetal death.
Fetal movement decreases with advancing gestational age, oligohydramnios, smoking, betamethasone therapy.

Question 37

Management of stress induced amenorrhoea

Answer 37

 Encouraging the woman to eat a more normal diet and to avoid exercising
is the ideal management
 Anorexia is a chronic disease that is often refractory to treatment.
 Explanation that her periods will return if she increases her BMI may
possibly encourage her to put on weight. 

 The combined oral contraceptive pill should be prescribed in the
meantime, which will prevent osteoporosis and bring on periods, albeit pharmacologically induced. 

JWH, JM, AJS, VA
155
 Referral to a specialist eating disorders unit is vital in addressing the long-term problem for this woman.
 Commonly, eating disorders arise out of childhood difficulties and family or group therapy should be considered. 

 If the investigations suggest renal or hepatic impairment then inpatient management is likely to be necessary. 


Question 38

SGA investigations?

Answer 38

BP, urinanalysis, CTG, USS, doppler
Regular check ups, USS and dopplers during pregnancy (every 2-4 weeks) and may have to deliver early

Question 39

N.B: The symptom of bleeding between the pill-free interval in a woman taking the combined oral contraceptive pill is known as breakthrough bleeding. History should include:

Answer 39

 Has she been missing any pills? 

 Has she taken any other medication, which might interefere with the COCP (e.g.

 antibiotics, enzyme inducers)? 

 Has she had any intercurrent illnesses causing diarrhoea or vomiting? 

 Has she ever had any sexually transmitted infections, or been investigated for
this? 

 How many sexual partners has she had in the last 3 months? 

 Has she recently changed the COCP that she uses?

Question 40

IMB differentials?

Answer 40

1. COCP related
   o Poor compliance
   o Infection causing poor pill absorption o Drug interactions
   o Inadequate oestrogen component
   o Pregnancy
2. Unrelated to COCP
   o STI: chlamydia, gonorrhea and trichomonas o Non –STI: Candida
   o Cervical: Ectropion or polyp
   o Bleeding disorder

Question 41

IMB ix?

Answer 41

Obs, abdo, vaginal and speculum exam, high vaginal and endocervical swabs, pregnancy test, USS if required

Question 42

STI Advice?

Answer 42

 Avoid intercourse, including oral and rectal, before treatment of partners is completed.
 Use condoms when treatment is complete, as this is the only contraception that protects against ST)’s.
 A follow up interview within 2-4 weeks
 Retesting if any doubt about complete treatment. Test of cure should be
performed a minimum of 5 weeks after initiation of treatment
 If change of partner, retesting between 3-12 months

Question 43

Management of stress incontinence

Answer 43

Conservative:
 Lifestyle
 Control exacerbating symptoms:
o Reduce weight
o Stop smoking to relieve chronic cough
o Alter diet and consider laxatives to avoid constipation
 Pelvis floor exercises: properly taught PFE can improve symptoms or cure
in up to 85% of women. 1st line for 3 months. 8 contractions, at least 3 times a day.
Medical:
 Duloxetine: SNRI drug. Common s/e is nausea
Surgical:
 Transvaginal or transobturator tape
 Colposuspension
 Periurethral bulking injection in refractory cases or unsuitable for
surgery.

Question 44

Questions for TOP?

Answer 44

Patient’s feeling about pregnancy, her partner, future life plans, LMP,
Long acting contraception, safeguarding, STI screen
Arrangement for follow-up, support groups etc.

Question 45

Surgical methods of abortion

Answer 45

Surgical methods
 Perform chest examination to see if they are up to general anaesthesia
 0-14 weeks of gestation
o Vacuum aspiration with suction cup and blunt forceps
 Either electric or manual vacuum aspiration
 Dilate the cervix
 Vacuum aspiration under 7 weeks of gestation should be
performed with appropriate safeguards to ensure complete
abortion
 After 14 weeks of gestation
o Dilatation and evacuation under general anaesthetic
 Cervical preparation for surgical abortions
o Should be considered in all cases
o Misoprostol vaginally or sublingually prior to surgery
o Prevents cervical trauma and haemorrhage leading to future
cervical incompetency
 Pain relief for surgical abortion
o NSAIDS

Question 46

Follow up after abortion?

Answer 46

After
 Follow-up
o 2 weeks after the procedure to check:  Abortion is complete
 Exclude an ongoing pregnancy
 Check for possible pelvic infection
 Assess the woman􏰁s emotional state
 Advice on contraception and sexual health
 Medical

o Anti-D to RhD-negative women  Contraception
o OCP, IUCD
o All hormonal methods should be started on the day of the abortion. o Female sterilisation is usually performed 6-8 weeks after an
abortion, as it has a higher failure rate when undertaken at the time of surgical abortion.

Question 47

RISKS OF C-SECTION:

Answer 47

Surgical e.g. haemorrhage, infection, long recovery, thromboembolic disease
 Anaesthetic
 Increased risk of IRDS (infant respiratory distress syndrome)

Question 48

VBAC where is birth?

Answer 48

Labour ward
Continuous CTG

Question 49

Disadvantages of VBAC?

Answer 49

E C-section, sar rupture

Question 50

VTE/PE Ix?

Answer 50

Observations, examination
ECG, ABG, CXR
Doppler USS, thrombophilia screen, anti-cardiolipin antibodies