O&G Flashcards
What is the first-line management option for molar pregnancy?
Suction curettage
What is the most appropriate treatment option for a patient with CIN II who has completed their family?
Large loop excision of the transformation zone (LLETZ)
What investigation should be requested in pregnant women who have been exposed to Parvovirus B19?
Maternal IgM
How should a pregnancy be monitored if the patient develops parvovirus B19 infection?
Foetal ultrasound with Doppler of the middle cerebral artery fortnightly until delivery
Which scoring system is used to determine the likelihood that a patient has ovarian cancer and which factors does it take into account?
Risk of Malignancy Index
CA-125 + Menopause Status + Ultrasound Findings
Under what conditions can medical terminations of pregnancy be safely carried out at home?
If < 10 weeks’ gestation, the misoprostol can be taken at home 24-48 hours after having the mifepristone administered in a clinical setting
List the absolute contraindications for vaginal birth after C-section.
Previous classical C-section
Previous uterine rupture
Other absolute contraindications to vaginal birth (e.g. placenta praevia)
Which antihypertensive is most appropriate in the management of moderate gestational hypertension in a patient with severe asthma?
Nifedipine
What is the first-line treatment option for venous thromboembolism in pregnancy?
Low Molecular Weight Heparin (e.g. enoxaparin) until at least 6 weeks’ postnatally and for a minimum of 3 months.
Describe the classical presentation of an ectopic pregnancy.
Lower abdominal pain (usually the right or left iliac fossa)
Vaginal bleeding
If the ectopic ruptures, patients may also complain of shoulder tip pain and may present after collapsing.
Which diabetes medications are most appropriate to use during pregnancy?
Insulin and Metformin
Outline the criteria used to define hyperemesis gravidarum.
Severe dehydration
Weight loss (> 5% compared to pre-pregnant weight)
Electrolyte disturbance
Describe the clinical features of amniotic fluid embolism.
Chest pain
Sudden-onset dyspnoea
Seizures
Cardiac arrest
Massive postpartum haemorrhage
What are the two main causes of posterior vaginal wall prolapse?
Rectocele (low)
Enterocele (higher)
These can be distinguished with a DRE - a finger in the rectum will be seen to bulge into a rectocele but not into an enterocele
At what age does suspected menopause no longer require investigation?
Over the age of 45 years
List some pregnancy-related complications associated with hypothyroidism.
Miscarriage
Preterm delivery
Congenital hypothyroidism
Pre-eclampsia
The presence of which constituent of amniotic fluid would give rise to a positive ROM plus® test?
Insulin-like Growth Factor Binding Protein-1
What initial test is used to investigate foetal anaemia?
Doppler Ultrasound (assess blood flow through the foetal middle cerebral artery)
What is the likely cause of recurrent first trimester miscarriage in a patient with a normal pre-pregnancy transvasginal ultrasound scan?
Balanced Chromosomal Translocations
When should pregnant women be screened for anaemia?
At booking and at 28 weeks’ gestatio
What clinical features are classically associated with uterine fibroids?
Heavy menstrual bleeding
Subfertility
Symptoms begin at some point after menarche (i.e. periods are not heavy from the start)
What is the most important surveillance tool used to monitor a foetus that is small-for-gestational-age?
Umbilical Artery Doppler
What are the main clinical features of placental abruption?
Sudden-onset severe lower abdominal pain
Vaginal bleeding (though this could also be ‘concealed’)
Tender, woody uterus
Maternal haemodynamic instability
How does cord prolapse normally manifest?
Usually associated with an abnormal lie
Rupture of membranes is promptly followed by rapid foetal compromise (due to a constriction of umbilical blood flow)
How does shoulder dystocia tend to manifest?
Failure to progress in the second stage of labour
NOTE: more likely to occur in macrosomic babies
Which cause of puerperal sepsis is associated with the highest mortality?
Group A Streptococcus
What is the most important initial investigation to perform in a patient with suspected puerperal sepsis?
Blood Cultures
How is puerperal sepsis managed?
Sepsis 6
What Rhesus prophylaxis should be offered to a RhD positive mother who is having a sensitising event in their first pregnancy?
None - RhD prophylaxis is not required if the mother is RhD positive
For further information:
NICE guideline on routine anti-D prophylaxis: https://www.nice.org.uk/guidance/ta156/chapter/2-Clinical-need-and-practice
BCSH guideline for the use of anti-D immunoglobulin: https://onlinelibrary.wiley.com/doi/full/10.1111/tme.12091
What are the aims of the first ultrasound scan conducted during a pregnancy between 10 and 13+6 weeks’ gestation?
Detect multiple pregnancies
Assess gestational age based on crown-rump length
Measure nuchal translucency
What combination of results in the combined test would suggest that the foetus is at high risk of having Down syndrome?
Nuchal translucency > 6 mm
High hCG
Low PAPP-A
What should be offered to a patient who is identified as having a pregnancy that is at high risk of being affected by Down syndrome between 15 and 20 weeks’ gestation?
Amniocentesis
For further information:
RCOG green-top guideline on amniocentesis and chorionic villus sampling https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_8.pdf
What should be offered to a patient who is noted to have a symphysis fundal height that is lower than expected twice in a row?
Ultrasound Scan to Estimate Foetal Size
What testing should be offered to a pregnant patient who has had a previous pregnancy affected by gestational diabetes mellitus?
Oral glucose tolerance test at booking and at 24-28 weeks
What is the most common cause of secondary postpartum haemorrhage?
Endometritis
What is a category 1 C-section?
Highest priority C-section which is conducted because there is an immediate threat to the life of the woman or foetus
How should a mild microcytic anaemia identified in pregnancy be treated?
Oral Iron Supplementation
What feature of the history can help distinguish fibroids from endometriosis?
Fibroids may have a more acute history (i.e. not since menarche)
Endometriosis is more commonly associated with painful periods
What is a Bartholin’s cyst?
A swelling beside the vaginal introitus that is caused by blockage of the duct arising from Bartholin’s gland
It can become infected forming a Bartholin’s abscess which is exquisitely tender
What is uterine inversion?
Inversion and prolapse of the uterine fundus
It can cause significant haemodynamic instability and requires urgent correction
What measure can be taken to augment the contractions of a patient whose membranes have ruptured and is failing to progress in the second stage of labour?
Oxytocin Infusion
What are the main advantages of the levonorgestrel intrauterine system?
Effective immediately
Long-acting and reversible
Usually makes periods lighter and less painful
How does obstetric cholestasis manifest?
Obstructive pattern on liver function tests
Pruritus (mainly affecting the hands and feet)
Jaundice
What are the grounds of the abortion act?
GAP DECK BACK
Ground A: That the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated.
Ground B: That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman.
Ground C: That the pregnancy has not exceeded its 24th week and that continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.
Ground D: That the pregnancy has not exceeded its 24th week and that continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman.
Ground E: That there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Ground F: To save the life of the pregnant woman.
Ground G: To prevent grave permanent injury to the physical or mental health of the pregnant woman.
For further information:
Government website page on the abortion act and statistics https://www.gov.uk/government/statistics/abortion-statistics-for-england-and-wales-2020/abortion-statistics-england-and-wales-2020
How should uncomplicated lactational mastitis be managed?
Encourage continued breastfeeding from both breasts
Once identified, what is the first step in assessing a perineal tear?
Perform a digital rectal examination to assess involvement of the anal sphincter complex
What are the risks to the expecting mother of developing a urinary tract infection during pregnancy?
Increased risk of ascending infection resulting in pyelonephritis
How does neonatal herpes simplex manifest?
There are three main forms:
Skin, eyes and mouth (SEM) disease
Central nervous system disease
Disseminated diseases
What is the most common cause of early-onset sepsis?
Group B Streptococcus
Which combination of agents can be used to maximise the chances of fertilisation in a patient with polycystic ovarian syndrome and irregular, unpredictable periods?
Medroxyprogesterone acetate for 10 days (to induce a withdrawal bleed)
Start clomiphene on day 2 of the period and continue for 5 days
Measure serum progesterone on day 21 to check whether the patient has ovulated
This cycle can be repeated a maximum of 6 times
What cellular component does iodine bind to when used as a stain during colposcopy?
Glycogen
Abnormal cells lack glycogen so remain yellow whereas normal cells will turn dark brown
Define gestational hypertension.
Blood pressure (BP) ≥140/90 mmHg on two occasions (at least 4 hours apart) during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without the presence of proteinuria or other clinical features suggestive of pre-eclampsia.
What should be administered in patients with confirmed preterm labour without rupture of membranes?
Tocolytic (e.g. nifedipine)
Steroids (e.g. betamethasone)
Magnesium sulfate (may be considered in preterm labour for neuroprotection)
What options should be offered to patients with a background of mid-trimester pregnancy loss who are noted to have a short cervix (< 25 mm) at 16-24 weeks’ gestation?
Prophylactic Cervical Cerclage
Vaginal Progesterone
What is lichen planus?
Inflammatory skin condition that typically presents with the development of polygonal violaceous macules. It can affect the vulva and perianal region leading to discomfort, itching and dyspareunia.
The disease can also affect the oral mucosa and may be described as a ‘cobweb-like’ white markings known as Wikham striae.
How should a pregnant patient who is over 20 weeks’ gestation presenting within 24 hours of the onset of a chickenpox rash be treated?
Oral Aciclovir
What are the different types of third degree perineal tear?
3a: Less than 50% of external anal sphincter with internal anal sphincter intact
3b: More than 50% of external anal sphincter with internal anal sphincter intact
3c: Involving both the internal and external anal sphincter
Resources: RCOG
https://www.rcog.org.uk/en/patients/tears/tears-childbirth/
What is the first-line treatment option for gonorrhoea?
Ceftriaxone 500 mg IM STAT
Resources
BASHH
https://www.bashhguidelines.org/current-guidelines/urethritis-and-cervicitis/gonorrhoea-2018/
Notes
https://onedrive.live.com/redir?resid=C28D595D8C9DB2B6%21243&authkey=%21AF9HooYf1VVgiNM&page=View&wd=target%28Gynaecology.one%7Cd54dd729-2ce3-2a4a-996d-419214d1c9a4%2FGenitourinary%20Problems%7Cda1b2539-6435-f841-b4a1-7086f90bde75%2F%29
What are the main features of antiphospholipid syndrome?
Recurrent venous thromboembolism
Thrombocytopaenia
Recurrent miscarriage
Resources:
Osmosis: https://www.osmosis.org/learn/Antiphospholipid_syndrome
Which autoantibodies are associated with antiphospholipid syndrome?
Anticardiolipin Antibody
Lupus Anticoagulant
Anti-beta 2 Glycoprotein 1 Antibody
Resources:
Osmosis: https://www.osmosis.org/learn/Antiphospholipid_syndrome
What can be given to patients with antiphospholipid syndrome to reduce the risk of miscarriage?
Aspirin and Low Molecular Weight Heparin
Resources:
https://www.osmosis.org/learn/Antiphospholipid_syndrome
How does the levonorgestrel intrauterine system exert its contraceptive effects?
Thickens cervical mucus
Thins the endometrium
Creates a hostile environment for sperm
Prevents ovulation (only in some cases)
What is the most appropriate treatment option for a patient with a normal BMI who is struggling to conceive because of polycystic ovarian syndrome?
Clomiphene
What is the most appropriate surgical management option for a patient with painful periods due to endometriosis who is trying to conceive?
Laparoscopic Excision or Ablation with Adhesiolysis
How should a patient with a cervical smear that tests positive for high risk HPV with cytological evidence of mild dyskaryosis be managed?
Non-Urgent Referral for Colposcopy
What is the best treatment option for systemic menopausal symptoms in a post-menopausal patient with a uterus?
Continuous Combined HRT
What advice should be given to someone that is in week 2 of their patch cycle and has forgotten to change the patch for 3 days?
Change patch immediately and use barrier methods for next 7 days
Emergency contraception may be needed if the patient had unprotected sexual intercourse in the preceding 5 days
How should endometrial hyperplasia without atypia in a post-menopausal woman be managed?
Levonorgestrel Intrauterine System
What is the first-line treatment option for moderate premenstrual syndrome?
Combined oral contraceptive pill
What is the most appropriate surgical management option for a patient with painful periods due to endometriosis who is trying to conceive?
Laparoscopic Excision or Ablation with Adhesiolysis
How should a patient with a cervical smear that tests positive for high risk HPV with cytological evidence of mild dyskaryosis be managed?
Non-Urgent Referral for Colposcopy
What is the best treatment option for systemic menopausal symptoms in a post-menopausal patient with a uterus?
Continuous Combined HRT
What advice should be given to someone that is in week 2 of their patch cycle and has forgotten to change the patch for 3 days?
Change patch immediately and use barrier methods for next 7 days
Emergency contraception may be needed if the patient had unprotected sexual intercourse in the preceding 5 days
How should a Bartholin’s abscess be managed?
Broad-spectrum antibiotics
Marsupialisation or Balloon catheter insertion
How should endometrial hyperplasia without atypia in a post-menopausal woman be managed?
Levonorgestrel Intrauterine System
What is the first-line treatment option for moderate premenstrual syndrome?
Combined oral contraceptive pill
What is a suitable treatment option for urge incontinence in a frail, elderly patient who has failed to respond to bladder retraining?
Mirabegron (beta-3 agonist)
What happens to tidal volume in pregnancy?
Increases by 30-35%
What is the first-line treatment option for a symptomatic UTI in a pregnant patient in their second trimester?
7-day course of Nitrofurantoin
How should a first episode of genital herpes in the second trimester be managed?
Oral aciclovir from 36 weeks’ gestation until spontaneous vaginal delivery.
How should vasa praevia be managed?
Emergency C-section if diagnosed in early labour
If identified antenatally, should aim for elective C-section at around 34-36 weeks in asymptomatic women
List some common medications that are contraindicated in pregnancy?
Tetracycline antibiotics
Chloramphenicol
Sulphonamides
Ciprofloxacin
Lithium
Benzodiazepines
Aspirin
Carbimazole
Methotrexate
Cytotoxic drugs
Amiodarone
Codeine phosphate
Which combined test results are associated with a pregnancy being at high risk of Down syndrome?
High Nuchal Translucency, High β-hCG, Low PAPP-A
List some associated features of gestational trophoblastic disease.
Hyperemesis gravidarum
Hyperthyroidism
List some factors that deem a pregnancy high risk and, therefore, requires aspirin prophylaxis.
Previous pregnancy affected by hypertensive disease
Chronic kidney disease
Autoimmune diseases (e.g. SLE, antiphospholipid syndrome)
Diabetes mellitus
Chronic hypertension
Describe the presentation of lactational mastitis.
Breast pain, erythema and tenderness
Systemic symptoms (e.g. fever)
What examination finding is suggestive of umbilical cord prolapse?
The umbilical cord is palpated below the presenting part of the foetal head following rupture of membranes.
When is the anomaly scan offered?
18-20 weeks’ gestation
How should chickenpox in women who are over 20 weeks pregnant be treated?
Provided that they are presenting within 24 hours of the onset of symptoms, they should receive a course of aciclovir.
How long should patients who develop a VTE in pregnancy continue anticoagulant treatment for?
Until at least 6 weeks postpartum and for a minimum of 3 months in total.
What is cervical ectropion?
Natural cervical response to oestrogen where the cells of the endocervix appear on the ectocervix. They are fragile and more prone to bleeding following contact. It is more common in young women and women taking the COCP.
How do you define reduced foetal movements?
Maternal perception of reduced foetal movements based on their perception of the baby’s baseline pattern of movement
Which infections are screened for during antenatal screening?
HIV
Syphilis
Hepatitis B
Define complete miscarriage.
A form of miscarriage in which the patient has fully emptied their uterus of the products of conception.
It will present with vaginal bleeding and, upon assessment, the cervical os will be closed and a transvaginal ultrasound scan will reveal an empty uterus.
What viral load is required to consider vaginal delivery in a pregnant patient with HIV?
< 50 copies/mL at 36 weeks’ gestation
When should nulliparous women with a foetus in the breech position be offered external cephalic version?
36 weeks’ gestation
What is the investigation of choice for pregnant women presenting with features of PE and a DVT?
Compression duplex ultrasonography
Which antihypertensives are used in the treatment of hypertension in pregnancy?
1st Line: Labetalol
Alternative: Nifedipine, Methyldopa
How often should monochorionic diamniotic twin pregnancies undergo growth scans?
Monochorionic diamniotic twins should have appointments combined with growth scans every 2 weeks from 16 to 24 weeks, followed by scans at 28, 32 and 34 weeks’ gestation.
What is the first-line management option for stress incontinence?
Pelvic floor muscle training - 8 contractions, 3 times per day for 3 months
What are the diagnostic criteria for hyperemesis gravidarum?
> 5% pre-pregnancy weight loss
Electrolyte imbalance
Clinical evidence of dehydration
What is the first-line treatment option for vulvovaginal candidiasis in pregnancy?
Intravaginal antifungals (e.g. clotrimazole)
How does vulvovaginal candidiasis typically present?
Creamy, white vaginal discharge associated with vulvar itching and soreness
What is the definition of menopause?
Cessation of periods for 12 months in the absence of any other causes amenorrhoea (e.g. being underweight, using contraceptives).
Which complication of pelvic inflammatory disease is characterised by inflammation of the liver capsule?
Fitz-Hugh-Curtis Syndrome
How should lactational mastitis be managed?
Simple analgesia, encourage continued breastfeeding and, if the symptoms have not resolved after 12-24 hours of adequate milk expression, recommend a course of antibiotics (usually flucloxacillin).
In pregnant patients with a background of diabetes mellitus that is treated with insulin, how is their blood glucose concentration managed during labour?
Variable-rate insulin infusion
Which IM injection is administered during the latter stages of labour to facilitate the delivery of the placenta and membranes?
IM Oxytocin
How should placental abruption be managed?
Emergency C-section
Which IM injection is administered during the latter stages of labour to facilitate the delivery of the placenta and membranes?
IM Oxytocin
List some risk factors for placenta accreta.
Previous placenta accreta
Previous C-section
Maternal age
Previous endometrial curettage
What are the clinical features of a molar pregnancy?
Lower abdominal pain
Severe vomiting (hyperemesis gravidarum)
Vaginal bleeding
Large-for-dates uterus
List some contraindications for the ulipristal acetate morning after pill.
Severe asthma
Cervical cancer
Ovarian cancer
Uterine cancer
What is the first-line treatment option for endometrial hyperplasia without atypia?
Levonorgestrel intrauterine system (Mirena® coil)
What are the main subsections of the abortion act?
A: Continuation of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated.
B: Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman.
C: The pregnancy has not exceeded its 24th week and the continuation of the pregnancy would involve risk greater than if the pregnancy were termination, of injury to the physical or mental health of the pregnant woman.
D: The pregnancy has not exceeded its 24th week and the continuation of the pregnancy would involve injury to the physical or mental health of any existing child(ren) of the family of the pregnant woman.
E: There is substantial risk that, if the child were born, it would suffer from such physical or mental abnormalities as to be seriously disabled.
Which strains of HPV does the quadrivalent vaccine (Gardasil®) cover?
6, 11, 16 and 18
List some contraindications for taking a smear sample for cervical screening
Menstruation
< 12 weeks postnatal
< 12 weeks post TOP/miscarriage
Vaginal discharge or pelvic infection
How is cervical cancer that is stage IIB-IVA managed in the first instance?
Chemotherapy and Radiotherapy
What is a sentinel lymph node biopsy?
Removal of the first few lymph nodes into which the tumour directly drains
When can the COCP be restarted after childbirth in a patient who is breastfeeding?
6 weeks postpartum
After which major gynaecological/obstetric operation do patients no longer need to present to cervical cancer screening?
Total hysterectomy
Describe deinfibulation.
Cutting open the scar tissue at the entrance of the vagina. It is used as a surgical treatment option for type 3 female genital mutilation (infibulation).
What is the main treatment option for Asherman syndrome?
Hysteroscopy and adhesiolysis
Systemic oestrogens may be used as an adjunct
What is the first-line drug treatment for urge incontinence?
Anticholinergics (e.g. oxybutynin, tolterodine)
NOTE: oxybutynin should be avoided in frail, elderly patients as it can worsen cognitive impairment.
Outline the criteria for surgical management of an ectopic pregnancy.
Unable to return for follow-up
Significant pain
Ectopic > 35 mm
Foetal heart beat detected on ultrasound
Serum hCG > 5000 IU/L
Describe McRoberts Manoeuvre.
McRoberts manoeuvre is the first intervention trialled in shoulder dystocia. Asking the patient to lie on their back with their hips flexed and abducted allows for the widening of the pelvic outlet.
What are the features of an incomplete miscarriage?
Retained products of conception
Open cervical os
May require procedure to evacuate the uterus
Describe the presenting features of bacterial vaginosis.
Offensive vaginal discharge (commonly described as having a fishy odour)
Homogenous off-white discharge
How should a pregnant patient with a previous history of GBS sepsis in the newborn be managed?
Intrapartum benzylpenicillin
What is the first-line management option for heavy menstrual bleeding associated with fibroids?
Levonorgestrel Intrauterine System (Mirena coil)
What is Asherman syndrome?
Formation of fibrous bands and adhesions within the endometrial cavity resulting in subfertility.
What are the different types of female genital mutilation?
Type 1 – clitoridectomy (partial or total)
Type 2 – clitoridectomy (partial or total) + removal of labia minora +/- removal of labia majora
Type 3 – infibulation – narrowing of the vaginal opening either through stitching or by using the labia to form a seal
Type 4 – any other type of genital mutilation including piercing, stabbing, burning etc.
How does placental abruption tend to present?
Sudden-onset abdominal pain
Dark red vaginal bleeding
NOTE: some bleeds can be ‘concealed’
What is the gold-standard investigation for endometriosis?
Diagnostic Laparoscopy
Which infection is often implicated in the development of vulvar cancer?
Human papillomavirus
Which autoantibodies are associated with antiphospholipid syndrome?
Anticardiolipin antibodies
Lupus anticoagulant antibodies
Anti-β2 glycoprotein I
What triad of features is associated with Meig syndrome?
Benign ovarian tumour (usually a fibroma)
Ascites
Pleural effusions
How does endometrial cancer tend to present?
Post-menopausal bleeding
How does endometrial cancer tend to present?
Post-menopausal bleeding
What are the aims of the first ultrasound scan conducted during a pregnancy between 10 and 13+6 weeks’ gestation?
Detect multiple pregnancies
Assess gestational age based on crown-rump length
Measure nuchal translucency
For further information:
NICE guideline on antenatal care for uncomplicated pregnancies https://www.nice.org.uk/guidance/cg62/chapter/1-guidance
What combination of results in the combined test would suggest that the foetus is at high risk of having Down syndrome?
Nuchal translucency > 6 mm
High hCG
Low PAPP-A
What should be offered to a patient who is identified as having a pregnancy that is at high risk of being affected by Down syndrome between 15 and 20 weeks’ gestation?
Amniocentesis
What should be offered to a patient who is noted to have a symphysis fundal height that is lower than expected twice in a row?
Ultrasound Scan to Estimate Foetal Size
NOTE: an ultrasound scan should also be offered with a single symphysis fundal height measurement that is below the 10th centile
For further information:
RCOG green-top guideline on the investigation and management of the small-for-gestational-age fetus https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_31.pdf
What testing should be offered to a pregnant patient who has had a previous pregnancy affected by gestational diabetes mellitus?
Oral glucose tolerance test at booking and at 24-28 weeks
What is the most common cause of secondary postpartum haemorrhage?
Endometritis
For further information:
RCOG green-top guideline on the prevention and management of postpartum haemorrhage
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14178
What is a category 1 C-section?
Highest priority C-section which is conducted because there is an immediate threat to the life of the woman or foetus
For further information:
RCOG green-top guideline on assisted vaginal birth https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.16092
How should a mild microcytic anaemia identified in pregnancy be treated?
Oral Iron Supplementation
For further information:
RCOG green-top guideline on blood transfusion in Obstetrics https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-47.pdf
British society of haematology guideline on the management of iron deficiency in pregnancy https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.16221
What feature of the history can help distinguish fibroids from endometriosis?
Fibroids may have a more acute history (i.e. not since menarche)
Endometriosis is more commonly associated with painful periods
For further information:
NICE guideline on heavy menstrual bleeding https://www.nice.org.uk/guidance/ng88
What is the likely cause of recurrent first trimester miscarriage in a patient with a normal pre-pregnancy transvasginal ultrasound scan?
Balanced Chromosomal Translocations
When should pregnant women be screened for anaemia?
At booking and at 28 weeks’ gestation
For further information:
https://www.nice.org.uk/guidance/cg62/chapter/1-Guidance
What clinical features are classically associated with uterine fibroids?
Heavy menstrual bleeding
Subfertility
Symptoms begin at some point after menarche (i.e. periods are not heavy from the start)
For further information:
NICE guideline on Fertility problems: https://www.nice.org.uk/guidance/cg156/chapter/Recommendations
What is the most important surveillance tool used to monitor a foetus that is small-for-gestational-age?
Umbilical Artery Doppler
For further information:
RCOG green-top guideline on The investigation and management of the small-for-gestational-age fetus https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_31.pdf
What are the main clinical features of placental abruption?
Sudden-onset severe lower abdominal pain
Vaginal bleeding (though this could also be ‘concealed’)
Tender, woody uterus
Maternal haemodynamic instability
For further information:
RCOG green-top guideline on antepartum haemorrhage: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf
RCOG green-top guideline on vasa praevia: https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.15307
RCOG green-top guideline on placenta praevia and placenta accreta: https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.15306
How does cord prolapse normally manifest?
Usually associated with an abnormal lie
Rupture of membranes is promptly followed by rapid foetal compromise (due to a constriction of umbilical blood flow)
For further information:
RCOG green-top guideline on umbilical cord prolapse: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-50-umbilicalcordprolapse-2014.pdf
How does shoulder dystocia tend to manifest?
Failure to progress in the second stage of labour
NOTE: more likely to occur in macrosomic babies
For further information:
RCOG green-top guideline on shoulder dystocia: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf
Which cause of puerperal sepsis is associated with the highest mortality?
Group A Streptococcus
For further information:
RCOG green-top guideline on Bacterial sepsis following Pregnancy https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_64b.pdf
What is the most important initial investigation to perform in a patient with suspected puerperal sepsis?
Blood Cultures
For further information:
RCOG green-top guideline on Bacterial sepsis following Pregnancy https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_64b.pdf
How is puerperal sepsis managed?
Sepsis 6
For further information:
RCOG green-top guideline on Bacterial sepsis following Pregnancy https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_64b.pdf
What Rhesus prophylaxis should be offered to a RhD positive mother who is having a sensitising event in their first pregnancy?
None - RhD prophylaxis is not required if the mother is RhD positive
For further information:
● NICE guideline on routine anti-D prophylaxis: https://www.nice.org.uk/guidance/ta156/chapter/2-Clinical-need-and-practice
● BCSH guideline for the use of anti-D immunoglobulin:https://onlinelibrary.wiley.com/doi/full/10.1111/tme.12091
How should uncomplicated lactational mastitis be managed?
Encourage continued breastfeeding from both breasts
For further information:
● NICE CKS on Mastitis and breast abscess: https://cks.nice.org.uk/topics/mastitis-breast-abscess/diagnosis/
Once identified, what is the first step in assessing a perineal tear?
Perform a digital rectal examination to assess involvement of the anal sphincter complex
For further information
● RCOG green-top guideline on the management of third- and fourth-degree perineal tears https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf
What are the risks to the expecting mother of developing a urinary tract infection during pregnancy?
Increased risk of ascending infection resulting in pyelonephritis
How does neonatal herpes simplex manifest?
There are three main forms:
- Skin, eyes and mouth (SEM) disease
- Central nervous system disease
- Disseminated diseases
What is the most common cause of early-onset sepsis?
Group B Streptococcus
What is uterine inversion?
Inversion and prolapse of the uterine fundus
It can cause significant haemodynamic instability and requires urgent correction
What measure can be taken to augment the contractions of a patient whose membranes have ruptured and is failing to progress in the second stage of labour?
Oxytocin Infusion
What are the main advantages of the levonorgestrel intrauterine system?
Effective immediately
Long-acting and reversible
Usually makes periods lighter and less painful
How does obstetric cholestasis manifest?
Obstructive pattern on liver function tests
Pruritus (mainly affecting the hands and feet)
Jaundice
What are the grounds of the abortion act?
Ground A: That the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated.
Ground B: That the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman.
Ground C: That the pregnancy has not exceeded its 24th week and that continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.
Ground D: That the pregnancy has not exceeded its 24th week and that continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman.
Ground E: That there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
Ground F: To save the life of the pregnant woman.
Ground G: To prevent grave permanent injury to the physical or mental health of the pregnant woman.
For further information:
● Government website page on the abortion act and statistics https://www.gov.uk/government/statistics/abortion-statistics-for-england-and-wales-2020/abortion-statistics-england-and-wales-2020
Which two simple tests are done at all antenatal appointments as a screen for pre-eclampsia?
Blood Pressure
Urine Dipstick
What is HELLP syndrome?
Complication of pre-eclampsia that manifests with haemolysis, elevated liver enzymes and low platelets
If a patient is diagnosed with HIV in pregnancy, which additional viral infection is it particularly important to test for?
Hepatitis C Virus (co-infection with HIV and HCV is an indication for C-section)
Outline the rules followed when describing a patient’s gravidity and parity.
Gravidity: total number of times pregnant
Parity: total number of pregnancies birthed after 24 weeks’ gestation (including stillbirths)
What is the first step in the work up of a patient presenting with reduced foetal movements?
Foetal Heartbeat Auscultation
If heartbeat is absent → Ultrasound scan to confirm intrauterine death
If heartbeat is present → CTG to assess foetal wellbeing
List some risk factors for uterine rupture.
Previous C-section (most significant risk factor)
Previous uterine surgery (e.g. myomectomy)
Multiple pregnancy
Induction of labour
Use of agents that augment uterine contractions (e.g. syntocinon)
Outline how the day on which the zygote divides corresponds with the chorionicity of the developing pregnancy
Before Day 4: Dichorionic Diamniotic
Day 4 to 8: Monochorionic Diamniotic
Day 8 to 12: Monochorionic Monoamniotic
Day 13+: Conjoined Twins
What urine dipstick findings warrant referral for an OGTT in pregnancy?
One result that is 2+ for glucose
Two results that are 1+ for glucose
Which patients require screening for gestational diabetes in pregnancy?
Previous pregnancy affected by GDM → OGTT at 16-18 weeks’ gestation
BMI over 30, previous macrosomic baby, family history of GDM or type 2 diabetes mellitus, or specific ethnic background → OGTT at 24-48 weeks’ gestation
What is Kallmann syndrome?
Hypogonadotropic hypogonadism that results from the failure of development of the GnRH neurons within the hypothalamus
Low GnRH
Low LH and FSH
Low Oestrogen
Which medication can improve symptoms and increase the chances of conception in a patient with polycystic ovarian syndrome?
Metformin
In which areas of a hospital can epidurals be used to manage pain during labour?
Labour Ward
NOTE: it usually cannot be done in a birth centre
Which medications tend to be used to manage relatively mild pain during labour?
Paracetamol
Co-Dydramol
Pethidine
What are some benefits of forceps over the ventouse for assisted delivery?
More likely to be successful
Lower risk of intracranial haemorrhage
Lower risk of retinal haemorrhage
Which test can be used to rule out preterm labour?
Foetal Fibronectin
Which test can be used to rule out preterm labour?
Foetal Fibronectin
List some causes of oligohydramnios.
Placental Insufficiency
Foetal Renal Tract Anomalies
NSAID Use
Postdates Gestation
How should an oblique, transverse or unstable lie at term be managed?
Offer admission to monitor for onset of labour and rupture of membranes as there is a risk of cord prolapse
How should an oblique, transverse or unstable lie at term be managed?
Offer admission to monitor for onset of labour and rupture of membranes as there is a risk of cord prolapse
List which forms of miscarriage, termination of pregnancy and ectopic pregnancy require anti-D prophylaxis.
Surgical management of miscarriage
Surgical management of ectopic pregnancy
Surgical termination of pregnancy
What oral glucose tolerance test result is in keeping with a diagnosis of gestational diabetes mellitus?
Fasting plasma glucose >5.6 mmol/L
and/or
2-hour post-prandial glucose >7.8 mmol/L
How should asymptomatic bacteriuria in pregnancy be treated?
Nitrofurantoin, amoxicillin or cephalexin
Which antihypertensive should be used in a patient with pre-eclampsia who has a background of severe asthma?
Nifedipine
When can an intrauterine system or intrauterine device be inserted postpartum?
It can be inserted within 48 hours postpartum or after 4 weeks
What is the first step in the management of chickenpox exposure in a patient with an unclear previous history of chickenpox?
Check for presence of varicella zoster IgG
What are the indications for high dose (5 mg) folic acid supplementation during pregnancy?
Use of antiepileptic drugs
Previous pregnancy with spina bifida
Maternal/partner with spina bifida
Coeliac disease
Diabetes
Sickle cell disease, thalassaemia
BMI > 30 kg/m2
What is the first-line management option for vulvovaginal candidiasis?
Topical Clotrimazole (e.g. pessary)
NOTE: oral antifungals may be considered instead in older women as they are easier to administer
Describe the microscopic appearance of Neisseria gonorrhoeae.
Gram-negative diplococcus
What screening test is used for chlamydia and gonorrhoea?
Nucleic Acid Amplification Test (conducted on urine sample)
What is the first-line management option for chlamydia?
100 mg Doxycycline BD for 1 week
How does pelvic inflammatory disease tend to present?
Offensive vaginal discharge
Irregular menstrual bleeding
Lower abdominal pain
Which imaging modality is useful in assessing a suspected tubo-ovarian abscess?
Ultrasound Scan (many patients with pelvic inflammatory disease will not be able to tolerate a transvaginal ultrasound scan)
What is the first-line antibiotic treatment option for patients with pelvic inflammatory disease?
M Ceftriaxone STAT
Oral Doxycycline 14 Days
Oral Metronidazole 14 Days
Describe the appearance of Trichomonas vaginalis under a microscope.
Flagellated Unicellular Organism
Which type of swab is most likely to yield a positive result for Trichomonas vaginalis?
High Vaginal Swab
What is the first-line treatment option for trichomoniasis?
Metronidazole 2 g PO STAT
or
Metronidazole 400-500 mg PO BD for 5-7 days
or
Tinidazole 2 g PO STAT
Outline what happens at the booking appointment in early pregnancy.
Ideally done before 10 weeks’ gestation
Testing for HIV, hepatitis B and syphilis
Measure height and weight
Measure blood pressure
Advise starting multivitamin (containing folic acid)
Which rule is used to provide an estimated day of delivery based on the date of a patient’s last menstrual period?
Naegele rule
LMP + 9 months + 1 week
What preventative measures should be taken in patients with diabetes mellitus and hypertension who become pregnant?
Folic Acid 5 mg OD (reduce risk of neural tube defects)
Aspirin 75 mg OD until 12 weeks’ gestation (reduce risk of pre-eclampsia)
What are the indications for carrying out an OGTT at 26-28 weeks’ gestation?
BIG PE
BMI > 30 kg/m2
1st degree relative who has had gestational diabetes (GDM)
Gestational diabetes in the past
Previous pregnancy with birthweight >4.5kg
Ethnicity with high prevalence of diabetes e.g. South-Asian, Bl
How does obstetric cholestasis present?
Pruritus (often affecting the hands and feet)
Obstructive picture on liver function tests
NOTE: It is associated with an increased risk of stillbirth
How does vasa praevia tend to present?
Vaginal bleeding upon rupture of membranes
Rapid foetal compromise (mother’s observations may remain normal as blood is being lost from the foetal circulation)
Which scoring system is used to assess the severity of nausea and vomiting in pregnancy?
PUQE Score (based on duration of symptoms per day, number of times vomiting per day, number of times dry retching per day)
Which scoring tool is useful for assessing a patient with postnatal depression?
Edinburgh Postnatal Depression Scale
How does an amniotic fluid embolism present?
Sudden shortness of breath and hypoxia
Low blood pressure
Coagulopathy
What does active management of the third stage of labour entail?
10 IU IM syntocinon, early cord clamping and controlled cord traction
What are the main clinical features of pre-eclampsia?
High Blood Pressure
Proteinuria
Headache
Abdominal Discomfort
How is eclampsia prevented and treated?
IV Magnesium Sulphate
What are the two different phases of the first stage of labour?
First Stage: From the onset of regular painful contractions to 10 cm dilation of the cervix
Latent Phase: Up to cervical dilation of 3 cm
Active Phase: From 3 to 10 cm dilation of the cervix
Why should agents that increase the force of uterine contractions be avoided in patients who have had a previous C-section?
Increases the risk of needing another C-section and carries a risk of uterine rupture
What is the passive phase of the second stage of labour?
Full dilation of the cervix but without the maternal urge to push.
What diagnosis should always be considered in any pregnant patient presenting with acute-onset leg pain?
Deep Vein Thrombosis
Briefly outline the risks associated with CTPA and V/Q scans in a pregnant patient with a suspected PE.
V/Q Scan: increased risk of childhood cancer
CTPA: increased risk of maternal breast cancer
What is placenta accreta?
Attachment of the placental villi to the myometrium.
How should a 3rd degree perineal tear be managed?
Surgical repair in theatre under local or general anaesthetic
What is twin-to-twin transfusion syndrome?
A condition that occurs in monochorionic twins. It arises due to an imbalance in the sharing of blood between the two twins resulting in growth restriction in one twin and fluid overload in the other.
What framework is used to determine whether a child under the age of 16 years can accept medical treatments without needing parental input?
Gillick Competence
What is the main surgical management option for uterine fibroids?
Myomectomy
What are the contraindications for using the combined oral contraceptive pill?
SAILBOAT
· Smoking >15 cigarettes a day and >35 years old
· Aura: migraine with aura
· Immobility or recent surgery
· Liver disease
· Blood pressure >140/90mmHg
· Obesity: BMI ≥30
· Any oestrogen dependent tumour or unexplained PV bleed
· Thromboembolism or stroke history, cardiovascular disease, or family history of VTE under 45-years-old.
What is the most appropriate blood test to conduct to determine if a patient has ovulated?
Midluteal Progesterone (to be taken 7 days before the expected end of the cycle)
What is the gold-standard investigation for suspected endometriosis?
Diagnostic Laparoscopy
Describe the presenting symptoms of lichen sclerosus in a woman.
Itchy, pale and atrophic vulval skin
Dyspareunia
Bleeding
What are some red flag features that would warrant referral for further investigation of possible vulval cancer?
Unexplained vulval bleeding
Unexplained vulval lump
Ulceration
List some risk factors for cervical cancer.
HPV
SMoking
Long-term use of oral contraceptives
Multiple full-term pregnancies
How should a rectocele that has failed to respond to lifestyle changes and a shelf pessary be managed?
Surgical Repair
In a patient with suspected ovarian cancer, which prominent features would warrant immediate referral to gynaecology on the 2-week wait pathway?
Ascites
Abdominal or pelvic mass that is not known to be caused by fibroids
https://cks.nice.org.uk/topics/ovarian-cancer/management/managing-a-woman-with-suspected-ovarian-cancer/
What are the main clinical features of a molar pregnancy?
Vaginal bleeding
Large for dates uterus
Hyperemesis gravidarum
Hypertension
Features of hyperthyroidism
What is an inevitable miscarriage?
Patient is presenting whilst miscarrying
They will have some vaginal bleeding and abdominal pain (due to uterine contractions trying to expel the products of conception), and speculum examination will reveal an open cervical os
https://pathways.nice.org.uk/pathways/ectopic-pregnancy-and-miscarriage#content=view-node%3Anodes-using-ultrasound-scans-for-diagnosis
Outline the criteria for surgical management of an ectopic pregnancy.
There is significant pain, as in our case
· Visible foetal heartbeat
· Adnexal mass > 35 mm
· Serum β-HCG > 5000 iU/L
What is the first-line management option for a patient presenting with stress incontinence?
Pelvic Floor Muscle Training for at least 3 months
(1) https://pathways.nice.org.uk/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women#path=view%3A/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women/managing-stress-urinary-incontinence-in-women.xml&content=view-node%3Anodes-choice-of-procedure
(2) https://pathways.nice.org.uk/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women#path=view%3A/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women/managing-stress-urinary-incontinence-in-women.xml&content=view-node%3Anodes-when-to-offer-duloxetine
Overall NICE flowchart: https://pathways.nice.org.uk/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women#path=view%3A/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women/managing-stress-urinary-incontinence-in-women.xml&content=view-index
What is the first-line management option for urge incontinence?
Bladder Retraining
https://pathways.nice.org.uk/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women#path=view%3A/pathways/urinary-incontinence-and-pelvic-organ-prolapse-in-women/managing-overactive-bladder-in-women.xml&content=view-node%3Anodes-further-treatment-options
List some absolute contraindications for COCP use.
- Within 6 weeks’ postpartum
- Aged over 35 years and smoking over 15 cigarettes per day
- Hypertension (>160/100 mm Hg)
- Current or past history of VTE
- Ischaemic heart disease
- History of CVA
- Complicated valvular disease
- Migraine with aura
- Current breast cancer
- Diabetes with retinopathy/nephropathy/neuropathy
- Severe cirrhosis
- Liver tumour
(1) https://www.fsrh.org/documents/ukmec-2016/
Which surgical approach is likely to be used in the surgical termination of a pregnancy at 10 weeks’ gestation?
Vacuum Aspiration (over 14 weeks’ gestation, dilation and evacuation is preferred)
https://pathways.nice.org.uk/pathways/abortion-care#content=view-node%3Anodes-choice-and-timing-of-procedure
https://www.nice.org.uk/guidance/ng140/resources/abortion-before-14-weeks-choosing-between-medical-or-surgical-abortion-patient-decision-aid-pdf-6906582255
https://www.nice.org.uk/guidance/ng140/resources/abortion-from-14-weeks-up-to-24-weeks-choosing-between-medical-or-surgical-abortion-patient-decision-aid-pdf-6906582254
https://www.nhs.uk/conditions/abortion/what-happens/
(1)https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf
(2)https://bnf.nice.org.uk/drug/mifepristone.html
(3)https://bnf.nice.org.uk/drug/misoprostol.html#indicationsAndDoses
What surgical approach may be used to manage submucosal fibroids?
Transcervical Resection of the Fibroid
What is the gold standard diagnostic test for endometriosis?
Diagnostic Laparoscopy
(1) https://pathways.nice.org.uk/pathways/endometriosis#path=view%3A/pathways/endometriosis/diagnosing-and-assessing-endometriosis.xml&content=view-index
What is the gold-standard management option for endometrial hyperplasia with atypia in a post-menopausal patient?
Total Hysterectomy with Bilateral Salpingo-oophorectomy
Outline the criteria for diagnosing polycystic ovarian syndrome.
Polycystic ovarian syndrome is diagnosed if two of the three Rotterdam Criteria are met:
· Polycystic ovaries on TVUSS (either ≥12 follicles or increased ovarian volume of >10 cm3)
· Oligo-ovulation or anovulation
· Clinical and/or biochemical signs of hyperandrogenism
· Clinical: increased body hair, acne
· Biochemical: LH:FSH (>1:1), increased serum testosterone
What is the most effective form of emergency contraception?
Copper IUD
It can be inserted up to 5 days after unprotected sexual intercourse (UPSI) or expected ovulation date, whichever is earlier.
Outline the aspects of managing preterm prelabour rupture of membranes.
Regular monitoring
Steroids (to promote foetal lung maturation)
Magnesium sulphate for neuroprotection
Erythromycin (for 10 days) to reduce the risk of ascending infection
How does placenta praevia normally manifest?
It is usually identified at the 20-week scan
It may, however, present with painless vaginal bleeding
Later in pregnancy, the foetus may have a high, non-engaged head and breech or transverse lie is common
Once a patient is commenced on low molecular weight heparin for a DVT or PE in pregnancy, how long should it be continued for?
Remainder of pregnancy, AND at least 6 weeks postnatally AND at least 3 months in total
https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.pdf
What advice regarding the method of delivery and breastfeeding should be provided to pregnant women with HIV?
They can have a vaginal delivery provided that their viral load is less than 50 copies/mL at 36 weeks’ gestation
Patients should not breastfeed irrespective of their viral load
What is the first step in the management of varicella zoster virus exposure in pregnancy in a patient who is uncertain about whether they have had chickenpox in the past?
Check varicella zoster immunoglobulin levels
Administer varicella zoster immunoglobulin if there is no evidence of previous exposure
(1)https://www.rcog.org.uk/globalassets/documents/guidelines/gtg13.pdf
What is the mainstay of managing a cerebral venous sinus thrombosis?
IV heparin infusion followed by catheter-guided local thrombolysis
List some causes of symmetrical growth restriction.
Congenital/chromosomal abnormalities
Intrauterine infections
Environmental factors (maternal malnourishment)
List some indications for admitting a patient with hyperemesis gravidarum.
Continued nausea and vomiting and inability to keep down oral antiemetics
· Continued nausea and vomiting associated with ketonuria and/or weight loss (greater than 5% of body weight), despite oral antiemetics
· Confirmed or suspected comorbidity (such as urinary tract infection and inability to tolerate oral antibiotics).
(1) https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf
What is the gold-standard investigation for ectopic pregnancy?
Transvaginal Ultrasound Scan (TVUSS)
In what circumstance should insulin be started as the first-line management in a patient with gestational diabetes mellitus?
If the fasting blood glucose is over 7 mmol/L at the time of diagnosis
https://pathways.nice.org.uk/pathways/diabetes-in-pregnancy/diabetes-in-pregnancy-overview#content=view-node%3Anodes-blood-glucose-monitoring-and-control&path=view%3A/pathways/diabetes-in-pregnancy/gestational-diabetes-risk-assessment-testing-diagnosis-and-management.xml
How does acute fatty liver of pregnancy present?
Presents late in pregnancy (usually after 34 weeks’ gestation)
Abdominal discomfort and vomiting
Can progress rapidly and lead to all the complications of liver failure (e.g. coagulopathy, hypoglycaemia, fluid overload, encephalopathy)
What is the most appropriate hormone replacement therapy option for a perimenopausal patient with a uterus?
Cyclical Combined Hormone Replacement Therapy
Outline the diagnostic features of polycystic ovarian syndrome.
PCOS is diagnosed according to the Rotterdam criteria which requires 2 of the 3 following features:
- Ovulatory dysfunction (oligomenorrhoea or amenorrhoea)
- Hyperandrogenism
Clinical: hirsutism, acne
Biochemical: raised free testosterone or free androgen index - Polycystic ovaries on ultrasound scans (either ≥20 follicles per ovary or ovarian volume ≥10ml)
What are the main features of postnatal depression?
Core symptoms of depression (low mood, low energy, anhedonia)
Sleep disturbance
Changes in weight
Difficulty bonding with baby
Which antidepressants tend to be used in the treatment of postnatal depression?
Paroxetine and Fluoxetine
What is the first-line pharmacological agent used in the induction of labour?
Vaginal Prostaglandin (either a gel/tablet or a pessary)
What is stress incontinence?
Form of urinary incontinence caused by incompetence of the bladder outlet
It manifests with urine leakage whenever intra-abdominal pressure is increased (e.g. laughing, coughing)
What is the first investigation that is usually recommended in patients presenting with mixed incontinence?
Bladder Diary
What is the gold standard investigation for suspected urge incontinence?
Urodynamic Studies
Outline the different outcomes for cervical cancer screening.
Inadequate sample → Repeat within 3/12
If 2 consecutive inadequate samples → Colposcopy
HPV -ve → Return to normal recall
Exceptions: patients who are already being managed for CIN
HPV +ve → Cytology
Then:
Abnormal cytology → Colposcopy
‘Abnormal’ includes:
borderline changes in squamous or endocervical cells.
dyskaryosis
invasive squamous cell carcinoma.
glandular neoplasia
Normal cytology → Repeat test at 12 months
Then:
o HPV -ve → Return to normal recall
o HPV +ve & normal cytology → Repeat in 12 months
§ Then, if still HPV +ve on 2 further annual checks after initial test → Colposcopy
How are the different types of cervical intraepithelial neoplasia categorised?
CIN1: Bottom ⅓ of epithelium containing dysplastic cells
CIN2: Bottom ⅔ of epithelium containing dysplastic cells
CIN3: Entire thickness of epithelium containing dysplastic cells
At what age do women start being screened for cervical cancer and why?
25 years
In young patients, abnormal cellular changes are very likely to resolve spontaneously
Outline the different outcomes for cervical cancer screening.
Inadequate sample → Repeat within 3/12
If 2 consecutive inadequate samples → Colposcopy
HPV -ve → Return to normal recall
Exceptions: patients who are already being managed for CIN
HPV +ve → Cytology
Then:
Abnormal cytology → Colposcopy
‘Abnormal’ includes:
borderline changes in squamous or endocervical cells.
dyskaryosis
invasive squamous cell carcinoma.
glandular neoplasia
Normal cytology → Repeat test at 12 months
Then:
o HPV -ve → Return to normal recall
o HPV +ve & normal cytology → Repeat in 12 months
§ Then, if still hrHPV +ve → Colposcopy
What proportion of patients will have a successful vaginal birth after C-section if the current pregnancy is uncomplicated?
75%
Outline the absolute contraindications for vaginal birth after C-section.
The following are absolute contraindications to a VBAC:
Previous uterine rupture
Previous classical Caesarean section (midline scar)
3 or more C-sections: can consider VBAC but only with the input of an experienced obstetrician
VBAC is also contraindicated in situations where vaginal delivery would normally be contraindicated anyway, such as placenta praevia and cord prolapse.
What is the most common cause of UTIs in pregnancy?
Escherichia coli
Which sonographic sign is classically seen in patients with ovarian torsion?
Whirlpool Sign
What proportion of female patients experience urogenital atrophy after the menopause?
50%
What is an omphalocele?
Also known as an exomphalos, it is a congenital defect of the anterior abdominal wall through which abdominal contents can herniate. The herniated viscera are covered by a layer of peritoneum.
What test is used to diagnose chlamydia?
Nucleic Acid Amplification Test (NAAT) on endocervical swab sample or first-catch urine
What is the first-line management option for primary dysmenorrhoea?
Mefenamic Acid
How does the circulating level of antiepileptic drugs change in pregnancy?
They decrease due to increased renal and hepatic clearance of drugs and the increase in plasma volume
When should a low-lying placenta identified at the 20-week scan be re-scanned to check for any change?
32 weeks’ gestation
How should PPROM be managed once confirmed?
Admit for at least 48 hours (in the majority of cases, labour becomes established within 48 hours of PPROM).
In the absence of contraindications, expectant management should be offered until 37 weeks’ gestation with regular assessment.
What is the most common STI in the UK?
Chlamydia
Which form of emergency contraception is most appropriate for a patient that has ovulated by the time of presentation?
Copper Intrauterine Device
NOTE: levonorgestrel and ulipristal acetate work by delaying ovulation, so would be ineffective if the patient has likely already ovulated
What features of a history are suggestive of a diagnosis of primary dysmenorrhoea?
Painful periods that began within 12 months of menarche
Absence of other gynaecological symptoms (e.g. heavy menstrual bleeding)
Presence of non-gynaecological symptoms (e.g. nausea, fatigue, diarrhoea)
Which operation is the mainstay of managing stage 1 endometrial cancer?
Hysterectomy with Bilateral Salpingo-oophorectomy
Outline the Fraser guidelines.
- The young person understands
- The young person refuses to involve their parents
- The young person will begin/continue to have sex without contraception
- The young person’s physical or mental health will suffer without contraception
Prescribing contraception is in the young person’s best interests
Which cases of endometriosis are particularly important to refer to the endometriosis clinic?
Complicated endometriosis that involves the bladder, ureter or bowel
What is the best imaging modality for adenomyosis?
MRI
How should suspected female genital mutilation in a patient under the age of 18 years be managed?
Notify the police
How should a patient with a viral load of 400 copies/mL at 36 weeks’ gestation be managed?
Pre-labour C-section +/- intrapartum zidovudine
NOTE: If viral load is less than 50 copies/mL at 36 weeks’ gestation, spontaneous vaginal delivery could be considered.
How does ovarian torsion present?
Sudden-onset iliac fossa pain associated with nausea and vomiting
Usually occurs in people with an underlying ovarian mass (e.g. dermoid cyst)
Ultrasound is likely to reveal free fluid within the pelvis and ‘whirlpool’ sign is a classic finding.
What is the first-line option for inducing labour in a post-term pregnancy?
Membrane Sweep
Offered to nulliparous women from week 40 and multiparous women from week 41
What is the most common cause of UTIs in pregnancy?
Escherichia coli
What is the first step in the management of varicella zoster virus exposure in pregnancy in a patient who is uncertain about whether they have had chickenpox in the past?
Check varicella zoster immunoglobulin levels
Administer varicella zoster immunoglobulin if there is no evidence of previous exposure
(1)https://www.rcog.org.uk/globalassets/documents/guidelines/gtg13.pdf
Which scoring tool is useful for assessing a patient with postnatal depression?
Edinburgh Postnatal Depression Scale
How should a mild microcytic anaemia identified in pregnancy be treated?
Oral Iron Supplementation
For further information:
RCOG green-top guideline on blood transfusion in Obstetrics https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-47.pdf
British society of haematology guideline on the management of iron deficiency in pregnancy https://onlinelibrary.wile
How should a Bartholin’s abscess be managed?
Broad-spectrum antibiotics
Marsupialisation or Balloon catheter insertion
List the absolute contraindications for using the combined oral contraceptive pill.
Previous history of venous thrombosis, cerebrovascular accident, ischaemic heart disease, severe hypertension or migraine with aura
Active breast cancer
Active endometrial cancer
Active or chronic liver disease
Inherited thrombophilia
Pregnancy
Smokers > 35 years old, smoking > 15 cigarettes a day
BMI > 40
Diabetes with vascular complications
