O&G Flashcards
What is the most common cause of vaginal candidiasis?
Candida albicans
What are the risk factors for vaginal candidiasis?
Diabetes mellitus,
Antibiotics, steroids
Pregnancy
Immunosuppression: HIV
What is the first line management for vaginal candidasis?
Single dose oral fuconazole 150 mg
OR clotrimazole 500 mg intravaginal pessary is first line is contraindicated
What is the first line management for endometriosis if analgesia is ineffective?
Combined oral contraceptive pill or progestogens
What is the gold standard investigation for diagnosing endometriosis?
Laparoscopy
What is the fasting glucose diagnosis threshold for gestational diabetes mellitus?
> 5.6 mmol/L
How long does the progestogen-only pill take to become effective?
48 hours
What muscarinic antagonist is prescribed to manage urgency incontinence, despite bladder retraining?
Oxybutynin, tolterodine
What is the endocrine complication associated with severe PPH?
Sheehan’s syndrome
Which dose of folic acid should be prescribed in women who are on antiepileptics and are attempting to conceive?
5 mg folic acid
Which drug is prescribed to manage infertility in PCOS?
Clomifene
When is folic acid advised in pregnancy?
From conception to the 12th week
What threshold of fasting blood glucose indicates insulin administration?
> 7 mmol/L
When are OGTT investigations performed for screening gestational diabetes in a patient with a previous GDM?
Immediately, and at 24-28 weeks.
When is breast feeding an absolute contraindication to COCP use (UKMEC 4)?
<6w post partum
What should be administered to a rhesus-negative mother undergoing surgical removal of an ectopic pregnancy?
Anti-D immunoglobulin
At what stage should a serum progesterone level be measured for assessing ovulation?
7 days prior to the expected next period
First line investigation for pregnancy exposure to varicella zoster (with uncertain background)?
IgG VZ antibodies (<100 = high risk)
Define Asherman’s syndrome
Intrauterine adhesions/scar tissue resulting in dysfunctional endometrium - typically followers dilation and curettage.
Which thromboprophylaxis should be prescribed in high risk pregnant women?
Low molecular weight heparin
What is the management for positive group B strep in pregnancy?
Intrapartum IV benzylpenicillin
First line SSRI in postpartum depression
Sertraline (not fluoxetine)
What is the management for breech position at 36w?
External cephalic version
What is the first line non-hormonal management for menorrhagia?
Tranexamic acid
What is the management for Premenstrual dysphoric disorder?
Sertraline
What is the second line management for stress incontinence after a trial of pelvic floor muscle training (3 months)?
Duloxetine
Tamoxifen increases which type of cancer?
Endometrial cancer - behaves as an oestrogen receptor agonist on endometrial cells.
When is an anomaly scan performed?
18 - 20+6 weeks
What drug is prescribed to ripen the cervix during induction of labour (Bishop Score <7)?
Vaginal prostaglandin
What is the complication of cholestastic disease of pregnancy?
Stillbirth
What are the risk factors for cord prolapse?
- Rupture of membranes – high outward flow of amniotic fluid Carries the umbilical cord.
- Preterm gestational age
- Second twin
- Low birth weight
- Low lying placentation (placental praevia).
- Pelvic deformities
- Uterine malformations
- Multiparity
- Polyhydramnios
- Long umbilical cord
What is the largest risk factor for cord prolapse?
- Rupture of membranes
What is cord prolapse?
Overt prolapse – Cord slips ahead of the foetal presenting part and prolapses into cervical canal, vagina or beyond – Obstetric emergency – vulnerable to complete occlusion (compression of all three vessels), or partial occlusion (compression of umbilical vein) or vasospasm of the umbilical artery.
What obstetric interventions can result in a cord prolapse?
Obstetric interventions account for ~50% of cord prolapse: Iatrogenic rupture of membranes, cervical ripening with a balloon catheter, induction of labour, amnioinfusion, manual rotation of the foetal head.
What foetal presentation is associated with cord prolapse?
Severe prolonged foetal bradycardia
Moderate to severe variable decelerations
Risk of foetal hypoxia
What is the antepartum diagnosis of cord prolapse?
Ultrasound - demonstrates that the umbilical cord is interposed between the presenting part of the foetus and the internal cervical os.
+ Colour flow Doppler studies
What is the emergency management option for cord prolapse?
Emergency caesarean section
- Keep cord warm and wet – minimal handing (handling causes vasospasm) – urinary catheter.
In cord compression, what position is recommended for the mother?
Left lateral position
Knee-chest position
What is the knee-chest position for the management of cord prolapse?
Using gravity to draw the foetus away from the pelvis to reduce cord compression.
What is the main cause of atrophic vaginitis?
Menopause
What is the main presenting features associated with atrophic vaginitis?
- Vulvovaginal dryness
- Decreased vaginal lubrication during sexual activity.
- Dyspareunia – vulvar or vaginal pain
- Vaginal bleeding e.g., postcoital, labial fissures
- Decreased arousal, orgasm, or sexual desire
- Vulvovaginal burning, irritation or itching.
- Levator spasm
- Vaginal discharge (leukorrhea or yellow and malodorous)
- Urinary tract symptoms (e.g., urinary frequency, urinary urgency, dysuria, urethral discomfort, haematuria, recent UTIs).
- Urethral prolapse.
What are the examination features associated with atrophic vaginitis?
- Labia minora resorption of fusion
- Tissue fragility
- Loss of hymenal remnants
- Prominence of urethral meatus
- Loss of vaginal rugae, vulvovaginal pallor/erythema/decreased elasticity and abnormal discharge.
What is the 1st line treatment for atrophic vaginitis?
Non-hormonal vaginal moisturisers and lubricants
What is the 2nd line treatment option for atrophic vaginitis?
Vaginal oestrogen therapy
What is the normal microbiome of the vagina?
Lactobacillus
What does Lactobacillus produce?
Hydrogen peroxide and lactic acid
Which bacteria is implicated in the pathogenesis of bacterial vaginosis?
Gardnerella vaginalis
What type of bacteria is Gardnerella vaginalis?
Anaerobic gram-negative rod
What are the risk factors associated with BV?
- Sexually active + concurrent STIs
- Use of douches, deodorant, and vaginal washes
- Menstruation and semen – associated with alkaline vaginal pH.
- Copper intrauterine devices
- Smoking.
What happens to the vaginal pH in BV?
> 4.5
What are the protective factors associated with BV?
use of hormonal contraception
consistent condom use
Circumcised partner
What is the classical presentation of BV?
- Vaginal discharge
o Off-white, thin, and homogenous discharge coating the walls of the vagina and vestibule.
o Malodorous – ‘fishy smell’ (noticeable post-coital and during menses).
No itching or soreness.
What are the four investigations for diagnosing BV?
Vaginal swab
pH test - >4.5
Positive white-amine test
Sample for gram-staining and microscopy
What microscopy findings are observed in bacterial vaginosis?
Clue cells on saline wet mount
stippled vaginal epithelial cells >20%
Which criteria is commonly used to diagnose BV?
Amsel’s criteria
What are the four parameters of Amsel’s criteria?
- Homogenous, thin, grayish-white discharge coating the vaginal walls.
- Vaginal pH >4.5
- Positive whiff-amine test
- Clue cells on saline wet mount
Only need 3 out of the 4
What is the 1st line ABx for BV?
Oral metronidazole 400 mg BD for 5-7 days.
If oral metronidazole is not tolerated in BV, what is the alternative option?
Intravaginal metronidazole 0.75% gel OD for 5 days or intravaginal clindamycin OD for 7 days.
What are the complications associated with BV during pregnancy?
Late miscarriage, preterm birth, PROM and postpartum endometritis.
What is the cause of Trichomonas Vaginalis?
Protozoan trichomonas vaginlias
What are the risk factors of Trichomonas Vaginalis?
Sexually active women <25 years (>1 partner in the last 12 months + history of STI)
What clinical presentation differentiates between TV and BV?
Vulval itching and soreness
What type of vaginal discharge is seen in Trichomonas Vaginalis?
Frothy and yellow-green malodorous discharge
What is the clinical presentation of Trichomonas Vaginalis?
Asymptomatic in ~50% of women
* Vaginal discharge
o Frothy, and yellow-green, malodours discharge (in 10-30% of affected women).
* Vulval itching and soreness.
* Dysuria
* Offensive odour
* Lower abdominal pain
* Vaginal pH >4.5
* Dyspareunia
On examination of the vulva and cervix, what characteristic features are seen?
Strawberry Cervix
A strawberry cervix is associated with what pathology?
Trichomonas Vaginalis
If Trichomonas Vaginalis is suspected what is the management referral?
Refer to the GUM clinic for confirmed diagnosis
What type of swab is recommended for Trichomonas Vaginalis?
High vaginal swab from the posterior fornix
+ STI tests for chlamydia, gonorrhoea, HIV and syphillis
What is the diagnostic test for Trichomonas Vaginalis?
Microscopy of a wet mount slide - revealing motile trophozoites
What is the first-line antibiotic for the management of Trichomonas Vaginalis?
Metronidazole 400-500 mg BD for 5-7 days OR single 2 g dose of metronidazole.
Is a STAT dose prescribed in Trichomonas Vaginalis during pregnancy?
No, offer 5-7 400 mg prescription of metronidazole
What advice is given to women with Trichomonas Vaginalis?
Sexual abstinence for at least 1 week and for partners to complete treatment + contact tracing.
What are perinatal complications associated with Trichomonas Vaginalis?
Preterm delivery
Low birthweight infant
What type of bacteria is chlamydia?
An obligate intracellular gram-negative bacterium
What is uncomplicated Chlamydia ?
Has not ascended to the upper genital tract
What does ascending Chlamydia cause?
Pelvic inflammatory disease
Which is the most common infected anatomic site for Chlamydia ?
Cervix
What is the clinical presentation associated with Chlamydia ?
Cervix is the most commonly infected anatomic site:
* Cervicitis
* Dysuria-pyruria syndrome due to urethritis
* Cervical discharge
- Cloudy or yellow discharge
- Mucopurulent
* Friable cervix
- Cervix bleeds easily with friction from a polyester swab.
* Abnormal vaginal bleeding
- Postcoital or intermenstrual bleeding.
* Vaginal discharge (increased)
* Dyspareunia
* Abdominal tenderness and pelvic pain.
What are the symptoms of lymphogranuloma venereum?
Tenesmus
Anorectal discharge
Diarrhoea
Altered bowel habit
What is the first-line investigation for Chlamydia?
Vulvovaginal or endocervical swab or first-catch urine
NAAT positive
What is the antibiotic of choice for the management of Chlamydia ?
Doxycycline
What is the starting dose for doxycycline for Chlamydia ?
100 mg BD for 7 days
Which ABx for Chlamydia is contraindicated in pregnancy?
Doxycycline
Direct microscopy in Chlamydia reveals what?
Neutrophils - in non-gonococcal urethritis
What Abx is recommended in pregnant women with Chlamydia ?
Azithromycin 1 g single dose or 500 mg OD for 2 days
oR
Erythromycin 500 mg QDS for 7 days or amoxicillin
What is the second line ABx for Chlamydia ?
Azithromycin
When is the test of cure performed for Chlamydia ?
5 weeks (and avoid sexual intercourse until treatment has completed)
How far back should contact tracing go for Chlamydia ?
6 months
What are the complications associated with Chlamydia ?
Pelvic inflammatory disease
Endometritis
Increased incidence of ectopic pregnancy
Infertility
Reactive arthritis
Fitz-Hugh Curtis Syndrome (perihepatitis)
When does annual screening for Chlamydia begin in sexually active women?
<25 years of age
What type of bacteria is Gonorrhoea?
Gram-negative intracellular coccus
What are the risk factors for Gonorrhoea ?
Age 15-24 years, black ancestry, current or history of STI, multiple sexual partners, inconsistent condom use, MSM.
What are the presenting features of cervicitis in Gonorrhoea?
o ~70% are asymptomatic.
o Vaginal pruritus
o Mucopurulent discharge
o Examination – cervix is friable.
What are the clinical features associated with Gonorrhoea?
- Cervicitis
o ~70% are asymptomatic.
o Vaginal pruritus
o Mucopurulent discharge
o Examination – cervix is friable. - Urethritis
- Lower abdominal pain (~25%)
- Dyspareunia – Ascending infection Pelvic inflammatory disease.
- Dysuria
What does a bimanual examination assess for?
Perform bimanual examination for cervical motion tenderness, uterine tenderness, and adnexal tenderness.
What is the first-line investigation for suspected Gonorrhoea ?
Vulvovaginal swab for nucleic acid amplification testing (NAAT)
What is the antibiotic of choice for antimicrobial susceptible Gonorrhoea ?
Ciprofloxacin 500 mg Oral - Stat
What is the first -line antibiotic for the management of Gonorrhoea ?
Ceftriaxone 1g single dose IM
When is a test of cure performed in Gonorrhoea ?
1 week follow-up (avoid sex for 7 days and initiate contact tracing)
What are the complications associated with Gonorrhoea infections in women?
Pelvic inflammatory disease - chronic pelvic pain, tubal infertility, or ectopic pregnancy
Fitz-Hugh Curtis Syndrome
Disseminated - septic arthritis, polyarthralgia, tenosynovitis, petechial skin lesions and meningitis
What are the pregnancy complications of Gonorrhoea ?
- Pregnancy complications:
o Spontaneous abortion
o Premature labour
o Premature rupture of foetal membranes
o Perinatal mortality
o Gonococcal conjunctivitis in the newborn (vertical transmission).
Define Pelvic Inflammatory Disease
PID -Infection of the upper genital tract in sexually active young women, ascending from the vagina and endocervix.
What are the two most common pathogens implicated in the pathology of pelvic inflammatory disease?
Neisseria gonorrhoeae and chlamydia trachomatis (most common)
What are the risk factors associated with predisposing PID?
Sexual activity, African ancestry, multiple partners, history of current or previous STI, 15 to 25 years, previous PID, inconsistent barrier contraception, vaginal douching, IUCD 4-6 week insertion.
What is the clinical presentation of pelvic inflammatory diseae?
- Lower abdominal pain
o Cardinal presenting symptom – bilateral <2 weeks duration. - Mucopurulent cervical or vaginal discharge
- Fever
- Deep dyspareunia
- Secondary dysmenorrhoea
- Intermenstrual, postcoital or heavy menstrual bleeding – secondary to associated cervicitis and endometritis.
- RUQ pain/right shoulder pain due to perihepatitis (Fitz-Hughs Curtis Syndrome)
o Inflammation of the liver capsule and peritoneal surfaces of the anterior RUQ. - Nausea and vomiting - ~50% + fever.
What is the clinical presentation of Fitz-Hugh Curtis Syndrome?
RUQ pain/right shoulder pain due to perihepatitis
What are the diagnostic criteria for pelvic inflammatory disease on bimanual examination (/3)?
- Uterine tenderness
- Cervical motion tenderness
- Adnexal tenderness - a sensitive marker for endometritis
What are the first-line investigations for pelvic inflammatory disease?
Perform a urine pregnancy test to exclude ectopic pregnancy
Triple Swabs (high vaginal swabs x2 + endocervical) - NAAT testing
On a wet mount vaginal smear, what is revealed in PID?
Pus cells
What imaging modality is used to detect for tubo-ovarian abscess secondary to PID?
TVUSS
What are the three criterions for admission in patient with PID?
- Pregnant or ectopic pregnancy is suspected.
- Adnexal mass, tubo-ovarian abscess, or pelvic peritonitis
- Pyrexia (>38C, or suspected sepsis/systemically unwell).
What are the three outpatient antibiotics prescribed to patients with PID?
- Ceftriaxone 1 g - Single IM dose
- Oral doxycycline 100 mg BD for 14 days
- Oral metronidazole 400 mg BD for 14 days
What is the advice pertaining to IUD/Copper coils in patients with PID?
For moderate symptoms - remain in situ
Severe -Removed
What is the alternative antibiotic regimen for pelvic inflammatory disease?
- Oral ofloxacin 400 bd
- Oral metronidazole 400 mg BD for 14 days
When should patients with PID be followed-up post ABx management?
Within 72 hours
What is the antibiotic regiment for a patient with PID and is pyrexic or oral Tx has failed?
IV cefoxitin and doxycycline (offer post-IV ceftriaxone)
OR
2nd line: IV clindamycin and gentamicin
Why are patients followed-up 72 hours after PID antibiotic therapy?
To assess for compliance with ABx and adjust regimen if necessary
if no improvement - admit for IV antibiotics
When should a follow-up be arranged to ensure for resolution of PID?
2-4 weeks
What is the antibiotic prescribed to a partner within 6 months of disease onset in contact tracing?
Doxycycline for 7 days
What are the complications associated with PID?
- Ectopic pregnancy – Absolute risk – 1%.
- Pelvic peritonitis and sepsis
- Tubo-ovarian abscess – Fever, systemic illness, and severe pelvic pain Increased risk of rupture.
- Perihepatitis – Pleuritic RUQ pain, and right shoulder pain.
- Tubal factor infertility - caused by scarring and adhesions.
What is Cervical intraepithelial neoplasia (CIN)?
A pre-malignant condition referring to dysplastic change to the squamous epithelium of the ectocervix
What type of cells lines the ectocervix?
squamous epithelium.
What type of cells line the endocervix?
glandular epithelium (columnar)
What does Cervical intraepithelial neoplasia (CIN) stage 1 refer to?
A low-grade lesion - atypical cellular changes in the lower 1/3 of the epithelium
What does Cervical intraepithelial neoplasia (CIN) stage 2 refer to?
High-grade lesion - moderately atypical cellular changes confined to the basal 2/3rd of the epithelium (moderate dysplasia)
What does Cervical intraepithelial neoplasia (CIN) stage 3 refer to?
- CIN3 – Severe dysplasia – Carcinoma in situ – Atypical cell extend throughout the full thickness of the epithelium with minimal differentiation and maturation on the surface – Extending to upper 1/3 of epithelium Risk of stage Ia1 FIGO.
What are the four main dysplastic epithelial changes observed in CIN?
Dysplastic epithelial changes:
1. Increased nuclear to cytoplasmic ratio
2. Abnormal nuclear shape – poikilocytosis
3. Increased nuclear size, and nuclear density
4. Decreased cytoplasm.
Which HPV is carcinogenic for CIN?
HPV 16 and 18
What are the risk factors associated with CIN?
Human papillomavirus (HPV) is the major cause of cervical precancer and cancer.
* Environmental risk factors: Cigarette smoking, multiple sexual partners, early age of first intercourse, HIV.
* Peak age 25-29yo; cancer peak age 45-50yo.
When is the national vaccination for HPV adminstered?
For girls and boys aged 12-13 years old.
What HPV subtypes are vaccinated against?
HPV subtypes 6, 11, 16 and 18
When does cervical screening begin?
Age - 25 years
How frequent is cervical cancer screening for 25 to 49 year olds?
Every 3 years
How frequent is cervical cancer screening for 50-65 year olds?
Every 5 years
How frequent should you screen a patient for cervical cancer with a positive HPV/HIV status?
Every year
If there is an inadequate cervical smear, when should the next one be?
In 3 months
How many inadequate cervical smears warrants a colposcopy?
3
When should a cervical smear be conduced postpartum?
3 months post partum
For borderline/mild dyskaryosis on cervical smear, what is the next-step investigation?
HPV testing - followed by colposcopy if positive
For Moderate to severe dyskaryosis/CN II/III, what is the next step investigation?
Urgent colposcopy
What does dyskaryosis refer to?
Abnormal nuclei
What is the first line management for CIN I?
Repeat smear in 12 months
What is the first line surgical intervention for CIN?
Large loop excision of the transformation zone (LLETZ)
What is Large loop excision of the transformation zone (LLETZ)?
Removal of abnormal cells using a thin wire loop, heated by an electric current, under LA
What are the side effects associated with Large loop excision of the transformation zone (LLETZ)?
Cervical stenosis
Cervical incontinence
Pyometra
Smear follow-up difficulties
Bleeding for 3-5 days
No sex for 4 weeks
What obstetric risks are associated with Large loop excision of the transformation zone (LLETZ)?
Mid-trimester miscarriage
What is a cone biopsy?
Used less frequently and under a GA – Performed if a large area of tissue needs to be removed + Increased risk of preterm birth.
What obstetric risk is associated with a cone biopsy?
Preterm delivery
When should a follow-up test of cure be performed following an LLETZ?
6 months - with smear and HPV testing
If negative - routine recall
If positive - repeat colposcopy
If hysterectomy for CIN , what type of smear is performed at 6m and 18m?
Vault smear
Where does cervical cancer originate from (anatomy)?
Transformation zone
What are the risk factors for cervical cancer?
- Risk factors: HPV-related, oral contraceptive use, intrauterine device, cigarette smoking and low socioeconomic status.
Which HPV subtypes predispose patients to developing cervical cancer?
HPV types 16 and 18
What is the median age of diagnosis for cervical cancer?
50 years
What is the most common histological type of cervical cancer?
Squamous cell carcinoma (80%)
Adenocarcinoma (20%)
What is the clinical presentation of cervical cancer?
- Abnormal vaginal bleeding
- Postcoital bleeding
- Postmenopausal bleeding and not taking HRT.
o Increased in heaviness, duration of bleeding, or irregular bleeding if taking HRT. - Pelvic or back pain
- Dyspareunia
- Cervical mass/+bleeding on vaginal examination.
What is the first line step for a patient with suspected cervical cancer (cervical mass on examination)?
Urgent 2ww referral for colposcopy (all women with pm bleeding)
What urgent investigations are performed for cervical cancer?
Urgent colposcopy and MRI
What are the diagnostic changes observed in cervical cancer?
Abnormal vascularity
White change with acetic acid
Visible exophytic lesions
What change is observed with acetic acid in cervical cancer?
White change
What staging system is used to classify cervical cancer?
FIGO
What is FIGO stage I for cervical cancer?
Carcinoma is confined to the cervix
What is FIGO stage II for cervical cancer?
Carcinoma invades beyond the uterus, but NOT into the lower third vagina
What is FIGO stage III for cervical cancer?
Carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or causes hydronephrosis or non-functioning kidney and/or para-aortic lymph nodes.
What is FIGO stage 4 for cervical cancer?
Carcinoma has extended beyond the true pelvis or biopsy-proven involvement of the mucosa of the bladder or rectum to distant organs.
What is the management for StageIA1 (micro invasive disease) cervical cancer?
Loop electrosurgical excision and conization.
If a woman does not want to preserve fertility, what is the management for cervical IA1?
Simple hysterectomy
What stage IA2-IB2 (early) disease, what is the first-line surgical approach (<4 cm)?
Radical hysterectomy (resection of the cervix, uterus, parametria, and cuff of upper vagina) AND bilateral salpingectomy (if fertility-sparing surgery is appropriate in low-risk disease)
Consider Wertheim’s for bilateral oophorectomy with bilateral pelvic lymphadenopathy
For stage IA2-IB2 tumours measuring >4 cm, what is the first-line management for cervical cancer?
Consider adjuvant chemotherapy or radiotherapy
For <4cm cervical tumours desiring fertility, what is the first line surgical management (Stage IA2-IB2)?
Radica trachelectomy
What are the surgical risks associated with radical trachelectomy?
o Bladder dysfunction (atony) -Common
o Sexual dysfunction
o Lymphoedema
May require intermittent self-catheterisation
What is the first-line management for IB3-IVA locally advanced disesae?
Chemoradiation - external beam radiotherapy
Intracavity radiotherapy
What is the preferred chemotherapy drug for cervical cancer?
Cisplatin
What are the risks associated with radiotherapy?
o Lethargy, fatigue
o Skin erythema
o Urgency
o Dyspareunia/vaginal stenosis
o Infertility
o Dysuria
o Diarrhoea/Malabsorption
o Incontinence.
Cystitis like symptoms
Malabsorption and mucous diarrrhoea
Radiotherapy induced menopause
What is type 1 endometrial cancer?
(SEM)
Secretory
Endometrioid
Mucinous carcinoma
What type of cancers is type 1 endometrial cancer?
Oestrogen-driven, affecting young patients and is low-grade
What are the two most common mutations implicated in endometrial cancer?
PTEN and P13KCA
What are the 2 main subtypes of type II endometrial cancer?
SC
Uterine papillary serous carcinoma
Clear cel carcinoma
What is the main mutation associated with serous carcinoma?
p53
What classification system is used for endometrial cancer?
FIGO
What is the most common histological subtype of endometrial cancer?
Adenocarcinoma
What is the peak incidence of endometrial cancer?
60-70 years
What is the main aetiology driving the development of endometrial cancer?
Long-term exposure to increased unopposed oestrogen
What are the risk factors of endometrial cancer?
Chronic anovulation
Obesity
Lynch Syndrome
Early menarche, late menopause
Tamoxifen
TD2M, PCOS
What are the protective factors of endometrial cancer?
Oestrogen-progestin or Progestin-only contraceptives (protective against oestrogen-driven carcinomas (Grades 1-2)).
Which clinical feature warrants further referral for suspected endometrial cancer?
Abnormal uterine bleeding
Post-menopausal bleeding warrants what?
2ww referral to gynaecologist
What are the clinical features of endometrial cancer?
- Abnormal uterine bleeding (75-90% of cases).
o Post-menopausal bleeding (Urgent 2w referral to gynaecologist)
o Intermenstrual bleeding (Frequent, heavy, or prolonged >7 days).
On examination (bimanual), what is observed in endometrial cancer?
Uterine mass, fixed uterus, or adnexal mass indicating extra-uterine disease – as detected by a bimanual examination.
* Associated with bulky uterus.
What is the first line investigation for suspected endometrial cancer?
Pelvic transvaginal ultrasound
What is normal endometrial thickness
<4 mm
What level of endometrial thickness is highly sensitive for endometrial cancer?
> 5 mm
What is the definitive diagnostic investigation for confirming endometrial cancer?
Outpatient hysteroscopy
with endometrial biopsy
What is the management for stage 1 endometrial cancer?
Total abdominal hysterectomy and bilateral salpingo-oophorectomy and peritoneal washings.
What is the surgical management for stage 2+ endometrial cancer?
- Radical hysterectomy (including cervix)
- Radiotherapy adjunct.
What hormonal therapy is available for young women desiring for conception with endometrial cancer?
High dose oral and intrauterine progestins (LNG-IUS)
What are the common sites of endometriosis?
Pelvis, on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas.
What is the definition of endometriosis?
Endometriosis is characterised by the growth of endometrium-like tissue outside the uterus.
What are the risk factors associated with endometriosis?
Early menarche, late menopause, delayed childbearing, nulliparity, FHx, white ethnicity, high BMI, vaginal outflow obstruction, smoking, and autoimmune disease (Oestrogen driven).
What are the protective factors of endometriosis?
Fruit/veg; multiparity, Omega 3, prolonged lactation/breastfeeding.
Which ovarian cancer is associated with endometriosis?
Clear cell ovarian carcinoma
What is Sampson’s theory?
Retrograde menstruation and implantation may be the cause.
What is the coleomic metaplasia of multipotent cells?
Endometriosis originates from the metaplasia of multipotent cells present in the mesothelial lining of the visceral and abdominal peritoneum.
What are the three types of endometriosis?
- Endometrioma (ovarian cysts)
- Superficial peritoneal lesions (located on the pelvic organ or peritoneum)
- Deep infiltrative endometriosis.
What is the clinical presentation of endometriosis?
- Chronic pelvic pain
o Minimum of 6 months of cyclical or continuous pain. - Period-related pain (dysmenorrhoea)
o Affecting daily activities and QoL. - Deep pain during or after sexual intercourse (dyspareunia) – due to adhesions present in fixed uterus.
- Period-related or cyclical gastrointestinal symptoms – painful bowel movements.
- Period-related or cyclical urinary symptoms – blood in urine or dysuria.
- Infertility
- Fatigue
- Associated with depression and anxiety.
N.B: No menorrhagia – differentiates this from fibroids.
On examination, what are the characteristic features associated with endometriosis?
Pelvic mass, reduced organ mobility, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions
A fixed retroverted uterus in endometriosis is suggestive of what?
Ectopic tissue on uterosacral ligament
What is the first-line investigation for suspected endometriosis?
TVUSS
What is the diagnostic investigation for endometriosis?
Laparoscopic visualisation of the pelvis.
Red vesicles or punctuate marks on the peritoneum in endometriosis is indicative of what?
Active lesions
What is the first line pain relief management for endometriosis?
Short trial of paracetamol or NSAIDs (3 months)
What adjunctive medication to pain killers can be prescribed as first-line non-hormonal medication in endometriosis?
Tranexamic acid
What is the first-line hormonal management for endometriosis?
Combined oral contraceptive pill, or progestogen (depot-provera or Mirena coil)
How long should hormonal treatment should be prescribed as a first line trial?
3 months
How does the COCP work in the management of endometriosis?
- COCP provides cycle control and contraception whilst alleviating symptoms of endometriosis.
- Continue until pregnancy required.
- Progesterone – used to induce amenorrhea in those where COCP is contraindicated
What is the preferred surgical intervention for mild endometriosis?
Laparoscopic ablation
What is the radical surgical option for endometriosis?
- Hysterectomy with BSO
For patients with endometriosis desiring conception, what is the surgical management?
Laparoscopic ablation + endometrioma cystectomy
What is the pre-operative management prescribed to patients undergoing surgery for endometriosis?
GnRH analogues (e.g., leuprorelin)
What side effects are associated with using GnRh analogues?
pseudo-menopause
Menopause-like side effects: hot flushes, night sweats
What co-existing conditions are associated with endometriosis?
IBS and constipation in up to 80%
What are the complications associated with endometriosis?
Subfertility
Recurrence
Adhesions
Ovarian failure post-operatively
Predisposition to autoimmune disease + mental health issues
Increased risk of miscarriage, ectopic pregnancy, and placenta praevia
Name the two layers of endometrial hyperplasia?
Functional - glands and stroma
Basal - regenerates the functional layer after each menstrual cycle
What are the risk factors of endometrial hyperplasia?
Prolonged exposure to oestrogen
In which phase during the menstrual cycle is associated with oestrogen stimulating growth of endometrial glands?
Proliferative phase
Which ratio is raised in endometrial hyperplasia?
High gland: stroma ratio
What are the risk factors for endometrial hyperplasia?
Obesity
Granulosa cel tumours
PCOS
Early menarche
Late menopause
Nulliparity
Drugs - oestrogen-only hormone replacement therapy , tamoxifen
Mutations - PTEN, lynch syndrome and HNPCC
Why does obesity cause endometrial hyperplasia?
Adipose tissue converts androgens to oestrogen
Why do granulosa-cell tumours increase the risk of endometrial hyperplasia?
Oestrogen secreting tumours
Why do cystic follicles increase the risk of endometrial hyperplasia?
Secretes oestrogen
Chronic anovulation and no progesterone-secreting luteal bodies
Which breast cancer drug increases the risk of endometrial hyperplasia (and why?)
Tamoxifen
- Blocks oestrogen receptors + stimulates oestrogen receptors.
What is the presentation of endometrial hyperplasia?
- Menorrhagia – heavy or prolonged menstrual bleeding
- Metrorrhagia
- Amenorrhea
What is the first line of investigation for suspected endometrial hyperplasia?
Transvaginal ultrasound
What is the threshold for prompting 2nd line investigations for endometrial hyperplasia?
> 4 mm
What is the gold-standard investigation for endometrial hyperplasia?
Outpatient hysteroscopy with a pipelle biopsy
What is simple endometrial hyperplasia?
Normal stroma : gland ratio
What is complex hyperplasia?
Increased gland : stroma ratio (large and hyperchromatic nucleus)
Associated with nuclear atypia
What is the risk of developing endometrial cancer in patients with hyperplasia with nuclear atypia?
30%
What is the management for EH without atypia (simple)?
Reversal of risk factors:
1. Weight loss
2. Correcting PCOS
3. Progesterone medications
4. Hysterectomy – surgical removal of uterus
Endometrial surveillance every week 6 monthseverse risk factors.
Treatment option: Oral progesterone
How frequent should endometrial surveillance be in a patient with EH without atypia?
Every 6 months
2 negative biopsies - discharge
What is the first line medical management for EH without atypia?
Oral progesterone - continuous
What is the fertility non-sparing treatment option for EH with atypia?
Total hysterectomy + BSO if post-menopausal
What is the fertility-sparing treatment option for EH with atypia?
2nd line: Oral progestogens, routine surveillance with biopsies
How many consecutive negative biopsies are required for discharge in a patient with EH?
2
Define a uterine fibroid
A benign smooth muscle tumour of the uterus - leiomyoma - monoclonal proliferation of smooth muscle cells and fibroblasts
What are the risk factors associated with fibroids?
- Afro-Caribbean Ethnicity – affects females during pregnancy and pre-menopausal women (oestrogen exposure).
- Nulliparity
- Breastfeeding
- Late menopause and early menarche
-Hypertension - Hereditary leiomyomatosis and renal papillary cell carcinoma syndrome (Reed’s Syndrome)
- Oestrogen and progesterone – Fibroids upregulate ER receptors and produce aromatase activity– mitogenic effect.
o Oestrogen – IGF-1, EGFR, TGF-B1
o Progesterone – EGF, TGF-B1/3
What are the protective factors associated with uterine fibroids?
Smoking
Multiparity
COCP
What are the four types of fibroids?
Subserosal
Intramural
Submucosal fibroid
Pedunculated fibroids
Where do subserosal fibroids develop?
Develop in the wall of the uterus.
Where do intramural fibroids develop?
From myometrial cells at the perimetrium | can detach from uterus.
Where do submucosal fibroids develop?
From myometrial cells below the endometrium.
What are pedunculated fibroids?
Can grow into the cavity of the uterus.
What is red-generation in regards to fibroids?
Coagulative necrosis in pregnancy , cystic change
What is the presentation of fibroids?
- Abnormal uterine bleeding – iron deficiency anaemia
o Heavy menstrual bleeding - Abdominal pain – pressure on pelvic organs.
o Pelvic pain, pressure, discomfort, abdominal discomfort, bloating, back pain - Bowel and bladder compressive symptoms
o Urinary symptoms – frequency, urgency, urinary incontinence, or retention, UTIs.
o Bowel symptoms – Bloating, constipation, and/or painful defecation. - Infertility and increased risk of miscarriage.
o Associated with submucosal and intramural fibroids. - Pregnancy – Foetal malpresentation, preterm labour and postpartum haemorrhage.
On bimanual examination, what are the positive findings associated with fibroids?
Firm, enlarged, and irregularly shaped non-tender uterus
What is the first line investigation for fibroids?
Transvaginal ultrasound - to assess size and location
What are the differential diagnoses for fibroids?
Ovarian cancer, endometrial cancer (not associated with pelvic mass), endometrial polyps, adenomyosis, endometriosis, ectopic pregnancy or urinary retention.
For fibroids <3 cm in size, what is the first line management?
IUS - Mirena coil
For fibroids >3 cm, what is the first-line medical management?
1 - Hormonal - COCP or cyclical oral progestogens
OR
1 - (Non-contraceptive - fertility required)
- Transexamic acid and mefenamic aicid
What medication is used to manage pain associated with fibroids?
Mefenamic acid / NSADIs
Mefenamic is contraindicated in what disorder?
IBD
What class of drug is Transexamic acid ?
Antifibrinolytic - 1 TDS
What is the fertility sparing surgical option for the management of fibroids?
Myomectomy
Transexamic acid is contraindicated in what?
Renal impairment, thrombotic disease
What is the non-fertility-sparing definitive surgical option for fibroid treatment?
Hysterectomy
If surgery is not tolerated or unsuitable, what alternative approach is indicated for the management of fibroids?
Uterine artery embolisation
How does uterine artery embolisation work?
Catheter reduces blood flow to fibroids – atrophy.
What class of drug is ulipristal?
Selective progesterone receptor modulator
What medication is prescribed pre-operatively to shrink fibroids?
GnRH analogues
What are the side effects associated with the use of GnRH analogues?
Chemical menopause - Hot flushes, sweating, vaginal dryness, osteoporosis
What are the four criteria indicating specialist referral in fibroids?
- An uncertain diagnosis
- Severe heavy menstrual bleeding or compressive symptoms
- Confirmed fibroids measuring >3 cm or suspected submucosal fibroids.
- Suspected fertility or obstetric issues.
Describe the pathophysiology of cervical ectropion
Migration of endocervix columnar cells from the transformation zone to the ectocervix
What type of cells line the endocervix?
Columnar cells
What histopathological change occurs in cervical ectropion?
Metaplastic change of squamous to columnar cells
What are the symptoms of cervical ectropion?
Intermenstrual bleeding, post-coital bleeding, and increased discharge (most common identifiable cause of post-coital bleeding).
What are the risk factors associated with cervical ectropion?
Linked to oestrogen - pregnancy and COCP
What is the management of cervical ectropion?
Reassurance, cauterisation, cryotherapy.
Definition of cervical polyps
Overgrowth of endocervical columnar epithelium - benig and solitary
What is the diagnostic investigation for endometrial polyps?
1st line = TVUSS
Gold-standard - outpatient hysteroscopy and saline - infusion sonography
What is the surgical management for symptomatic endometrial polyps?
Polypectomy
What is the latin name of anogenital warts?
Condylomata acuminate
What is the common site of anogenital warts?
Vaginal introitus
What HPV subtypes are indicated in the development of anogenital warts?
HPV subtypes 6 and 11
What are the high risk HVP subtypes?
16 and 18
What is the presentation of genital warts?
- Pain
- Arises if the lesions become friable or are irritated due to local trauma.
- Urinary symptoms – Terminal haematuria or abnormal stream of urine – can indicate lesions in the distal urethra and meatus.
- Bleeding – Due to local trauma (e.g., underwear).
- Warts – Pedunculated/or pigmented.
o Appearance – Cauliflower growths of varying size, small popular, keratotic, flat papules/plaques.
Flesh-coloured, whitish, hyperpigmented, or erythematous.
<10 mm in diameter – can coalesce in large plaques.
What is the characteristic appearance of genital warts?
Cauliflower growths
What is the management for genital warts?
Referral to sexual health specialist
What is the first line management for genital warts (non-keratainised)?
Topical podophyllotoxin
What is the first line of management for keratinisied external genital and perianal warts?
Imiquimod
What is the surgical management for keratinisied genital warts?
Ablative methods (cryotherapy, excisions, and electrocautery)
What is type 1 FGM?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
What is type II FGM?
Partial or total removal of the clitoris and the labia minora (with or without excision of the labia majora)
What is type III FGM?
Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora with or without the clitoris (Infibulation).
What is type IV FGM?
Type IV: Other harmful procedures – pricking, piercing, incising, scraping and cauterisation.
What clinical features are associated with FGM?
Presentation:
* Constant pain,
* Dyspareunia
* Bleeding, cysts, abscesses
* Incontinence
* Depression, flashbacks, self-harm.
What is the management for FGM?
Deinfibulation
* Offered to those unable to have sex, pass urine or pregnant women at risk during delivery.
* Analgesia to avoid flashbacks.
What is the management for a patient <18 years presenting with FGM?
Report to the police and social services
What is the management for a patient >18 years presenting with FGM?
No obligatory duty to report Offer Deinfibulation.
What are the complications associated with FGM?
Repeated infections Infertility, life threatening complications during labour, childbirth.
What is the diagnosis of the following presentation :
Distressing emotional and physical symptoms during the luteal phase of the menstrual cycle (in the absence of disease).
* Only occurs in the presence of ovulatory menstrual cycles – not prior to puberty, during pregnancy or menopause.
Premenstrual Syndrome
What are the clinical features associated with PMS?
- Mood swings
- Anergia
- Breast tenderness
- Anxiety
- Changes in appetite
- Headache
- Disturbed sleep
- Poor concentration
- Bloating
What is the first line investigation for suspected PMS?
Symptom diary - minimum over 2 cycles
What is the first line management for moderate PMS?
COCP - yasmin - paracetamol or NSAIDs
consider CBT
What is severe PMS?
Premenstrual dysphoric disorder (Withdrawal from activities, prevent normal functioning)
What is the first line management for severe PMS?
Sertraline
What are the three classifications of ovarian tumours?
- Epithelial surface derived tumours
- Germ cell tumours
- Sex-cord stromal tissues
What are the risk factors associated with ovarian tumours?
Increased ovulation - nulliparity, early menarche, and late menopause
Which genes are implicated in increasing the risk of ovarian tumours?
BRCA1/2, MSH2, MLH1
What genetic syndrome is associated with increasing ovarian tumour development?
Lynch Syndrome
Which mutations are associated with Lynch syndrome?
MSH2 and MLH1
Which type of ovarian tumour is the most common?
Epithelial
Which type of ovarian tumour is most common in postmenopausal women?
Epithelial ovarian tumour
What are the most common epithelial tumours?
Serous cystadenoma
Mucinous cystadenoma
What are malignant serous epithelial ovarian tumours associated with on histology?
Psammoma body
Definition of Psammoma body?
Plaques with calcium and cellular deposits
What are mucinous cystadenomas?
Associated with mucous filled cysts (ovarian epithelial tumour)
What complication are malignant mucinous epithelial ovarian tumours associated with?
pseudomyxoma peritonei.
What is pseudomyxoma peritonei?
Mucinous material collecting within the peritoneal cavity
Name the four types of epithelial ovarian tumours?
- Serous cystadenoma
- Mucinous cystadenoma
- Endometrioid
- Transitional cell
Name the characteristic cysts associated with endometrioid tumours?
Chocolate cysts
What are Brenner tumours?
Transitional ovarian tumours - coffee bean nuclei
What histological finding (nuclei) is found in Brenner tumours?
Coffee Bean Nuclei
What is the presentation of ovarian tumours?
- Abdominal distension
- Bloating
- Abdominal/pelvic pain
- Ascites
- Abdominal mass
- Bowel obstruction
- Dyspareunia
- Sister-Mary Joseph Nodule – Metastasise to the umbilicus.
What are the common benign ovarian tumours associated in women <30 years of age?
Teratoma
What are common types of germ cell ovarian tumours?
Teratoma (dermoid cyst)
Dysgerminoma
Yolk sac tumour
Choriocarcinoma
Which type of ovarian tumour is associated with thyroid tissue?
Struma-Ovarri Tumour - causes hyperthyroidism
(Associated with mature cystic teratoma)
What is the most common germ cell tumour associated in children?
Yolk Sac tumour
What types of bodies are associated with yolk ovarian tumours?
Schiller–Duval Bodies
What are Schiller–Duval Bodies?
Rings of cells around a central blood vessel.
What cell do choriocarcinoma derive from?
Syncytiotrophoblast cells
What do choriocarcinoma secrete?
Beta-hcg
Which type of germ-cell ovarian cancer is most malignant?
Dysgerminoma
what are the four common sex-cord stromal ovarian cancers?
- Fibroma - no endocrine function
- Thecoma - Oestrogen
- Granulosa cell tumour - Oestrogen
- Sertoli-Leydig cell tumour - androgens variable
Which cell does LH stimulate?
Theca cells
What do theca cells produce?
Androgens
What effect does FSH have?
Oestradiol production via stimulating aromatase activity
Call-Exner bodies are associated with which type of Sex-cord stromal ovarian cancer?
Granulosa-theca cell cancer
What are the hallmark features associated with granulosa-theca cell cancer?
Granulosa-theca cell – Most common malignant stromal tumour
* Oestradiol overproduction
o Uterine bleeding
o Breast tenderness
o Early puberty
Fluid pockets -Call-Exner bodies
What is Meigs syndrome?
Tumour causing transudative fluid accumulation - pleural effusion and ascites.
What histological finding is associated with Sertoli-Leydig cells?
Reinke Crystals - Pink crystals
What first-line tumour marker should be performed in a patient with suspected ovarian cancer?
Serum CA-125
What is the diagnostic threshold for serum CA-125 in ovarian cancer?
> 35 IU/L
What is the next-step investigation following a raised CA-125 in suspected ovarian cancer?
Refer to 2WW for ovarian cancer - urgent TVUSS and pelvic/abdominal US scan
What factors can cause an falsely raised CA-125?
Pregnancy, endometriosis, and alcoholic liver disease, heart failure
Which risk index is used to determine the risk associated with ovarian tumours?
Risk of Malignancy Index (RMI)
What are the three parameters included in the RMI?
- Menopausal status
- USS features – Ultrasound abdomen and pelvis
- CA125
A threshold RMI score of what is considered high-risk for ovarian cancer?
> 250 IU/L
What type of neoadjuvant chemotherapy is administered in ovarian cancer?
Platinum-based compounds with paciltaxel
What are the common platinum-based chemotherapy compounds implicated in the management of ovarian cancer?
Carboplatin
What are the three chemotherapy and immunotherapy agents indicated in the management of ovarian cancer?
Carboplatin
Paciltaxel
Bevacizumab
What is the mechanism of action of carboplatin in the management of ovarian cancer?
Cross-linkage of DNA leading to cell cycle arrest
How does Paclitaxel work in the management of ovarian cancer?
Microtubular damage resulting in cell division inhibition
What are the side effects associated with the use of Paclitaxel in ovarian cancer?
Loss of body hair
What medication is given to reduce hypersensitivity reactions and side effects associated with Paclitaxel?
Steroids
What is the definitive surgical approach for ovarian cancer?
Laparotomy (TAH + BSO omentectomy + extra debulking)
Define ovarian torsion:
Ovarian torsion – refers to complete or partial rotation of the ovary on its ligamentous supports Common gynaecological emergencies.
Which ligament suspends the ovary?
Suspensory ligament
Which ovarian ligaments are implicated in the pathogenesis of ovarian tumours (name 2)?
Utero-ovarian ligament
infundibulopelvic ligament
Which ovary (right or left) is most likely affected by ovarian torsion?
Right due to longer utero-ovarian ligament
What is adnexal torsion?
Fallopian tube + ovarian twisting
What are the risk factors for ovarian torsion?
Ovarian cysts, tumours
Long ovarian ligaments
Pregnancy
Tubal ligation
What is the presentation/clinical features of ovarian torsion?
- Pelvic pain (acute onset)
o Diffuse and localised/ipsilateral
o Colicky, stabbing and cramping (1–3-day history). - Abdominal tenderness (right illiac fossa)
- Nausea + vomiting
- Ovarian mass
- Fever
What first-line investigation should be performed in a patient presenting with features of ovarian torsion?
Urine hCG test to exclude for pregnancy
What is the first line diagnostic investigation for a patient with suspected ovarian torsion?
Ultrasound with Doppler
What sign is demonstrated by an ultrasound with Doppler in ovarian torsion?
Whirlpool sign
What is the diagnostic test for confirming ovarian torsion?
Diagnostic laparoscopy + perform detorsion
What is the therapeutic management to alleviate ovarian torsion?
laparoscopic detorsion
What is the management of ovarian torsion with a viable adnexa without pathology?
- Oophoropexy – fix the ovary to the pelvic sidewall or round ligament (Limit range of motion).
a. Indicated: Contralateral ovary is absent or repeated torsion.
Management of ovarian torsion for a viable adnexa with pathology?
Perform a cystectomy if ovarian torsion is a result of a simple or dermoid cyst
Perform oophorectomy in postmenopausal women
Perform salpingectomy if the fallopian tube is adherent to the ovary or the patient has completed childbearing.
What is the surgical management indicated for a patient with a non-viable adnexa in ovarian torsion?
- Oophorectomy or salpingectomy
What are the four types of urinary incontinence?
- Stress
- Urge
- Mixed
- Overflow
What is stress incontinence?
Leakage on effort or exertion e.g., sneezing or coughing.
What is urgency incontinence?
a. Involuntary leakage accompanied by a sudden desire to pass urine which is difficult to defer – Part of overactive bladder syndrome.
What is an overactive bladder?
Urinary urgency associated with increased frequency + nocturia.
c. Associated with involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle – OVERACTIVITY.
What is mixed urinary incontinence?
a. Both stress and urgency incontinence – involuntary leakage is associated with both urgency and physical stress (exertion, effort, sneezing, or coughing).
What are the causes of urgency urinary incontinence?
Idiopathic | Parkinson’s disease, MS or pelvic injury.
What is overflow urinary incontinence?
a. Detrusor underactivity or bladder outlet obstruction - Urine leakage.
What medications are associated with causing overflow urinary incontinence?
ACEi, antidepressants, antihistamines, antimuscarinic, AP, beta-adrenergic agonists, opioids, sedatives.
What are the risk factors associated with urinary incontinence?
- Older age (50-70 years)
- Obesity – Pressure on pelvic tissue and stretching/weakening of muscles and nerves.
- Constipation – weaken pelvic floor muscles.
- Pregnancy and vaginal delivery – Weakened pelvic floor muscles and connective tissue + damage to pudenal and pelvic nerve.
- Deficiency in supporting tissue – Hysterectomy, prolapse, lack of oestrogen at the menopause (oestrogen maintains urethral seal).
- FHx, smoking (chronic cough), drugs (ACEi)
What is the first line set of investigations indicated in a patient presenting with urinary incontinence?
- Urine dipstick to exclude UTI + DM
- Bladder diary (min 3 days)
- Speculum examination to exclude pelvic organ prolapse
What is the minimum time period for a bladder diary?
3 days
What testing is indicated in a patient presenting with mixed urinary incontinence?
Urodynamic studies (assessment of 3 pressures)
Which type of exercises is used to assess the contraction of the pelvic floor?
Kegel exercise
During the pelvic examination what manoeuvre should be performed to assess for fluid eakage?
Ask patient to cough (Valsalva) during exam to check for fluid leakage.
What grading system is used to assess for urinary incontinence?
Oxford Grading System
What postpartum complication is associated with incontinence?
Vesicovaginal fistula
What is the first line management indicated for stress urinary incontinence?
3-month trial of supervised pelvic floor muscle training
What lifestyle advice is provided to patients with stress urinary incontinence?
Lifestyle advice on: Caffeine intake, fluid intake, weight loss (<30 BMI), smoking cessation.
What is the second line management for stress urinary incontinence (medical)?
Duloxetine
What is the first line management for urgency incontinence?
Bladder training for 6 weeks
What is the second line of management following bladder training for urgency incontinence?
Oxybutynin
What class of drug is oxybutynin?
Antimuscarinic
What are the adverse effects associated with oxybutynin ?
Dry mouth and constipation
What is the referral criteria for patients presenting with overflow urinary incontinence?
- Aged >45 years AND
- Unexplained visible haematuria without UTI.
- Or >60 with unexplained non-visible haematuria + dysuria + raised WCC.
What is the definition of menorrhagia (mL)?
> 80 mL of blood and duration of more than 7 days
What are the common causes of Menorrhagia ?
o Uterine fibroids, endometrial polyps
o Ovarian, cervical, or endometrial cancer.
o Endometriosis and adenomyosis.
o PCOS
o Pelvic inflammatory disease
o Systemic disorders: Coagulation disorder, hypothyroidism, T2DM, hyperprolactinaemia.
What is the first line blood test indicated for investigating Menorrhagia ?
FBC - assess for IDA
+ Pregnancy test
Test for coagulation disorders
What IX (imaging) for Menorrhagia ?
TVUSS
What are the two cancer referral criteria for Menorrhagia ?
Pelvic mass + unexplained bleeding or weight loss
Women aged >55 years with postmenopausal bleeding
What is the first line management for Menorrhagia (with no identified pathology, + fibroids <3 cm)?
Levonorgestrel intrauterine system (LNG-IUS)
What is the non-hormonal management for menorrhagia?
Tranexamic acid 1g TDS or NSAID | Mefenamic acid 500 mg TDS.
What are the three lines of hormonal management options for menorrhagia?
1st line - IUS
2nd line: COCP
3rd line - Long-acting progestogens e.g., depo-provera
Which emergency contraception is administered within the first 72 hours of UPSI?
Levonorgestrel
Mechanism of action for Levonorgestrel?
Inhibits ovulation and implantation
What singe dose is prescribed for Levonorgestrel as emergency contraception?
1.5 mg
What dose is prescribed for Levonorgestrel indicated for UPSI (BMI >26)?
Double dose
When can Ulipristal be prescribed?
Within 5 days (120 hours) of unprotected sexual intercourse
What is the mechanism of action for Ulipristal ?
Selective progesterone receptor modulator (EllaOne) - inhibits ovulation
What dose of Ulipristal is prescribed as emergency contraception?
30 mg oral dose
What is the contraindication for Ulipristal as emeregency contraception?
Asthma
What is the preferred emergency contraception?
Intrauterine Device - copper coil
When must the IUD be inserted to be an effective mode of emergency contraception?
Within 5 days or up to day 19.
When must a pregnancy test be performed following emergency contraception?
3 weeks after UPSI
What is the mode of action of the Copper IUD as emergency contraception?
Prevents implantation of fertilized ovum, toxic to sperm and eggs.
What is the most common type of vulval cancer?
Squamous cell carcinomas
What are the risk factors for vulval cancer?
o Advanced age (>75 years)
o Immunosuppression
o HPV infection (Type 16)
o Lichen sclerosus.
~5% with lichen sclerosus develop vulval cancer.
What is the premalignant condition prior to the development of vulval cancer?
Vulval Intraepithelial Neoplasia
A high-grade squamous intra-epithelial lesion (VIN) is associated with what?
HPV infection
What is the diagnostic investigation to confirm Vulval Intraepithelial Neoplasia?
Biopsy (+ sentinel node biopsy)
What is the management for VIN?
Watch-and-wait; wide local excision, imiquimod cream, laser ablation
Which anatomical site is commonly affected by vulval cancer?
Labia majora
For suspected vulval cancer, what is the confirmatory diganostic test?
Biopsy + sentinel lymph node biopsy
CT
What is the first line surgical management for vulval cancer?
Vulvectomy + bilateral inguinal lymphadenopathy
For stage 1a vulval cancer what is the surgical management?
Wide local excision
What is the surgical management for stage >1a vulval cancer?
Radical vulvectomy
What is the definition of adenomyosis?
The presence of endometrial tissue inside the myometrium - more common in later reproductive years
What is the presentation of Adenomyosis?
- Dysmenorrhoea (Painful periods)
- Menorrhagia
- Dyspareunia
What are the examination findings for adenomyosis?
An enlarged, boggy and tender uterus
What is the first line of investigation for suspected adenomyosis?
Transvaginal ultrasound
On ultrasound what distinct appearance is demonstrated?
‘Venetian blind appearance’* Heterogenous myometrium:
o Streaky shadowing
o Asymmetric myometrial thickness
o Myometrial cysts
What is the gold-standard investigation for confirming adenomyosis?
Outpatient hysteroscopy with histological examination (biopsy)
What is the first line of medical management for a patient with adenomyosis?
Tranexamic acid - reduce bleeding
Mefenamic acid - reduce pain
For when contraception is desired, what is the first line medical management for adenomyosis?
Mirena coil
COCP
Cyclical oral progestogens
What is the definitive management for adenomyosis?
- Hysterectomy - causes infertility
What is the fertility-sparing surgical management for adenomyosis?
Uterine artery embolisation
What is the time period for infertility to be defined as, in a woman <35 years of age?
12 months of unsusccesful conception despite active sexual intercourse
What is the most common cause of infertility in a woman?
Ovulation and tubal problems - 40%
Idiopathic - 20 %
Uterine problems - 10 %
(Male factor infertility (sperm motility) - 30%)
What is the lifestyle advice indicated for a patient presenting with infertility?
- Folate supplementation – 400 mcg Daily
- Healthy BMI
- Smoking cessation and alcohol discontinuation
- Reduce stress.
- Regular intercourse 2-3 days (avoid timing intercourse).
Why is timed intercourse not recommended in the management for infertility?
Timed intercourse – coincide with ovulation – can lead to stress and pressure.
What does a raised FSH indicate in a patient presenting with infertility?
Poor ovarian reserve - consider AMH
Which is an accurate marker of ovarian reserve and is released by granulosa cells?
Anti-Mullerian Hormone
Which is the recommended investigation performed in a patient presenting with infertility?
Serum progesterone on day 21 (7 days before the end of the cycle)
A raised LH in a female presenting with infertility suggests what diagnosis?
Polycystic ovarian syndrome
What are the two outpatient diagnostic investigations for a patient with infertility?
- Hysterosalpingogram
. * Laparoscopy and Dye Test
How does a Hysterosalpingogram work in the diagnosis of infertility?
Patency of the fallopian tubes
o Tubal cannulation under X-ray guidance – to increase tubal patency (Contrast guided).
Reveals tubal obstruction if there is discontinuous dye flow.
What dye is used in a
Laparoscopy and Dye Test?
Methylene blue - injected into the uterus to assess for tubal obstruction
Which anti-oestrogen drug is prescribed to support fertility?
o Clomifine
What drug class is prescribed to stimulate ovulation in clomifene-resistant patients?
Gonadotrophins
Define Asherman’s syndrome
Asherman syndrome is characterised as intrauterine adhesions/synechiae occurring when scar tissue forms inside the uterus/cervix.
Which surgical procedure is implicated in perpetuating Asherman’s syndrome?
Dilation and curettage for ToP or incomplete miscarriage or for retained products of conception
What are the three main aetiological causes for Asherman’s?
- Post-operative (Dilation and curettage).
- Pelvic infection (Endometritis)
- Myomectomy
What is the presentation of Asherman’s Syndrome?
- Secondary amenorrhoea (Menstrual flow is obstructed due to adhesions near or within the cervix)
- Significantly lighter periods
- Dysmenorrhoea
What is the gold-standard investigation for Asherman’s syndrome?
Hysteroscopy
What is the management Asherman’s syndrome?
Hysteroscopy - Dissection of the adhesions
What are the complications associated with Asherman’s syndrome?
- Repetitive pregnancy loss/abortions.
- Infertility
- Abnormal placentation
What is the common position of a Bartholin’s cyst (Clock face)?
4 and 8 o clock
What is a Bartholin’s gland?
Bartholin’s glands reside on either side of the posterior part of the vaginal introitus – pea-sized and non-palpable.
* Produce mucous and support vaginal lubrication.
Definition of a Bartholin’s cyst?
Unilateral, asymptomatic blockage of the Bartholin gland (2-4 cm in diameter); filled with non-purulent fluid that contains staphylococcus, streptococcus, and E. coli.
What are the risk factors for Bartholin’s cyst?
- Nulliparous
- Previous Bartholin’s cyst
- Sexually active (STIs)
What is the presentation of Bartholin’s Cyst?
- Tenderness with activities – waking, sitting, standing or sexual intercourse.
- Vaginal bleeding/discharge or STIs
- Unilateral labial swelling is often asymptomatic/painless.
- Infected – Abscess with cardinal signs of infection, fever, dyspareunia.
What are the three symptoms associated with a Bartholin’s abscess?
Hot
Tender
Purulent
What is the conservative approach for a Bartholin’s cyst?
Good hygiene, analgesia and warm compress
Spontaneous drainage - Sitz baths and analgesia
What is the definitive management for a Bartholin’s cyst?
Words Catheter
What is the management for a Bartholin’s abscess?
Incision and drainage
Marsupialisation
What is the characteristic appearance of lichen sclerosus?
Patches of shiny ‘porcelain-white’ skin affecting the labia, perineum and perianal area.
What are the autoimmune risk factors for lichen sclerosus?
T1DM, alopecia, hypothyroid, and vitiligo
What is the presentation of lichen slcerosus?
- 45-60 years complaining of vulval itching and skin changes.
- Itching
- Soreness
- Skin tightness
- Painful sex (superficial dyspareunia)
- Erosions
- Fissures
- Dysuria
What is the Koebner phenomenon in Lichen Sclerosus?
Refers to when symptoms are worsened by friction to the skin.
What is the topical management for lichen sclerosus?
High potency steroids (Clobetasol propionate) for 3 months
What is the 2nd line management for lichen sclerosus?
Topical calcineurin inhibitors and imiquimod
What is the complication associated with lichen sclerosus?
Vulval squamous cell carcinoma
What is an imperforate hymen?
- An imperforate hymen = does not spontaneously rupture during neonatal development (presents with obstructive symptoms of the female genital and urinary tract).
The Wolffian duct forms what?
Vas deferens in men
What is the presentation of an imperforate hymen?
Patients remain asymptomatic until menarche.
* Cyclic abdominal pain – menstrual blood that expands the vaginal canal and uterus with resultant hematometra.
- Cramping pain
* Amenorrhoea
On examination what feature is observed in an imperforate hymen?
Haematocolpos
What is a Haematocolpos ?
Haematocolpos – accumulation of menstrual blood in the vaginal or uterine cavities Pelvic mass identified on physical exam (blue, bulging perineal mass).
What is the definitive management for an imperforate hymen?
- Hymenectomy using cruciate or annular incisions.
- Hymenectomy using electrocautery.
- Carbon dioxide laser treatment
What is the main complication associated with an uncorrected imperforate hymen?
Endometriosis as a result of retrograde menstruation
What are the two types of physiological ovarian cysts?
Follicular
Luteal
What is the most common type of ovarian cyst in postmenopausal women?
Graafian follicle cyst
What is a follicular cyst?
Failure to rupture during ovulation - follicular cysts form due to inadequate LH surge or excessive FSH simulation
Which cells line follicular cysts?
Granulosa cells
How long do corpus luteal cysts last?
14 days
What hormone do corpus luteal cysts secrete?
Progesterone
When do corpus luteal cysts typically occur?
In the first trimester of pregnancy
Corpus luteal cysts are lined by what type of cells?
Luteal cells
Which type of cyst is formed as a result of overstimulation in elevated Hcg levels?
Theca luteal cysts
What are the complications associated with follicular and corpus luteal cysts?
Transformation into a haemorrhagic cyst
What complication is associated with mucinous cystadenoma cysts?
Pseudomyxoma peritonei
Struma ovarri tumours are associated with which type of cyst?
Dermoid cysts - mature cystic teratomas
What term describes multiple white shiny masses that protrude out of dermoid cysts?
Rokitansky protuberances
What is the presentation of an ovarian cyst rupture?
Lower abdominal pain - sudden acute - nausea + vomiting
What is the first line investigation for a patient presenting with a neoplastic ovarian cyst?
Serum CA-125 to exclude for malignancy
Beta-hCG to exclude for pregnancy
What is the management for an asymptomatic <10 mm ovarian cyst?
Serial monitoring with TVUSS - spontaneous resolution
What are the indications for surgical cyst removal?
Ovarian torson
Adnexal mass
Acute abdominal pain
Suspected malignancy i
What is a cystocele?
Bladder prolapse – herniation and descent of the bladder through the anterior wall of the vagina.
What risk factors are associated with cystocele?
- Risk factors:
- Obesity – BMI >25
- Increasing age
- Parity
- Increased intra-abdominal pressure.
- Pelvic surgery
- Instrumental, prolonged or traumatic delivery
- Chronic respiratory disease-causing coughing
- Chronic constipation causing straining
What is the presentation of a cystocele?
- Vaginal pressure – bulging sensation
- Urinary symptoms
- Stress incontinence, frequency, and urgency associated with an overactive bladder.
- Sexual dysfunction
- Dyspareunia
- Urinary incontinence during intercourse, obstruction, and dryness.
What questionnaire is used to assess for pelvic prolapse related symptoms?
Pelvic floor impact questionnaire (PFIQ)
What position is recommended for examining cystocele?
dorsal lithotomy position and diagnosed using the POPQ
What staging scale is used to assess for cystocele?
POPQ
Which speculum is used to assess for cystocele?
Sims speculum
What is the conservative approach for managing cysotcele?
Vaginal pessaries
Kegel exercises for stage 1-2 prolapse
What is the surgical management for cystocele?
Anterior colporrhapy - anterior repair
OR
Sacral colpopexy
What is the definitive surgical management for a uterine prolapse?
Hysterectomy, sacrohysteropexy
In what women does a vault prolapse occurs in?
Occurs in women that have had a hysterectomy and no longer have a uterus
What is a rectocele?
Posterior vaginal wall defect – allowing the rectum to prolapse into the vagina – associated with constipation.
Can cause faecal loading
What is the surgical management of a rectocele?
Posterior colporrhaphy
Which criteria is used for the diagnosis of PCOS?
Rotterdam criteria
What are the three parameters included in the Rotterdam Criteria?
- Hyperandrogenism (clinical or biological)
- Polycystic ovaries
- Irregular menstrual periods
What are the associated morbidities associated with PCOS?
- Infertility
- Metabolic syndrome
- Obesity
- Impaired glucose tolerance
- Type 2 diabetes
- Cardiovascular risk
- OSA
- Non-alcoholic fatty liver disease
What is the main risk associated with PCOS?
Endometrial cancer
Why is insulin resistance implicated in the pathophysiology of PCOS?
Sensitises the ovary to LH - premature lutenisaition of Granulosa cells - and increased LH.
- Androgen excess - recruitment of primordial follicles into growth pool
- LH decreases SHBG
-Decrease in FSH and ovarian dysregulation
How is ovarian androgen production increased in PCOS?
Insulin -> Increased LH –> Increased androgen production
What happens to Sex-hormone binding globulin in PCOS?
Decreases - increases bioavailability of testosterone
What happens to FSH in PCOS?
Reduces aromatase activity within granulosa cells
What is the presentation of PCOS?
- Hyperandrogenism
- Acne
- Female pattern hair loss
- Hirsutism
- Menstrual irregularities:
- Oligomenorrhoea, amenorrhoea and infertility
What are the indirect clinical signs of insulin resistance associated with PCOS?
Obesity, and acanthosis nigricans.
Which ultrasound sign is observed in PCOS?
Pearl necklace sign
What is the diagnostic threshold for US ovarian follicles?
> 20 in one ovary
What is the free-androgen index?
100 x total testosterone/SHBG value
What are the signs of virilisation?
deep voice, reduced breast size, increased muscle bulk and clitoral hypertrophy
Is virilisation observed in PCOS (and what else in)?
No.
Seen in: congenital adrenal hyperplasia, Cushing’s syndrome or an androgen-secreting tumour
What testosterone level is associated with virilisation?
> 5 nmol/L
What is the first line clinical management for PCOS?
COCP
What is the off-label clinical drug prescribed as part of the management of PCOS?
Metformin
What lifestyle and dietary modification advice is prescribed to adults with PCOS?
Offer lifestyle and dietary modification advice – weight management to reduce complications.
* Weight loss (Consider orlistat in women with BMI >30)
* Low glycaemic index, calorie-controlled diet
* Exercise
* Smoking cessation
* Statins when QRISK >10%
What drug is prescribed to induce a withdrawal bleed for prolonged amenorrhoea?
Cyclical progestogen (medroxyprogesterone 10 mg daily for 14 days)
What type of drug is clomifene?
Anti-oestrogen (prescribe for up to 6 months)
What class of drug is letrozole?
Aromatase inhibitor
What is the risk associated with the use of gonadotrophins in PCOS?
Ovarian hyperstimulation syndrome
What is the surgical option indicated in the management of PCOS?
Laparoscopic ovarian drilling
What is the range for impaired fasting glucose?
6.1 to 6.9 mmol/L
What is the range for impaired glucose tolerance?
7.8 to 11.1 mmol/L
Why is there an increased risk of endometrial cancer in PCOS?
The corpus luteum releases progesterone after ovulation. In PCOS, there is anovulation, therefore inadequate progesterone.
Define cord prolapse
Overt prolapse – Cord slips ahead of the foetal presenting part and prolapses into the cervical canal, vagina or beyond – Obstetric emergency – vulnerable to complete occlusion (compression of all three vessels), or partial occlusion (compression of the umbilical vein) or vasospasm of the umbilical artery
What is the main risk factor associated with cord prolapse?
Obstetric interventions (50%) - artificial rupture of membranes, cervical ripening with a balloon catheter, induction of labour.
What is the presentation of cord prolapse?
Severe prolonged foetal bradycardia + moderate-to-severe decelerations.
What is the complication associated with cord prolapse?
Foetal hypoxia
How is an antepartum cord prolapse diagnosed?
Ultrasound with colour flow Doppler studies
How is a cord prolapse diagnosed?
Vaginal examination - visualisation or palpation of the umbilical cord ahead of the presenting part.
What position should the mother adopt for cord prolapse?
Knee-to-chest position or left lateral position - presenting part can be pushed superiorly
What is the definitive management for cord prolapse?
Emergency caesarean section
Which class of medication is administered in cord prolapse to reduce uterine contractions?
Tocolytics
What are the two most common tocolytics prescribed to management cord prolapse?
Nifedipine
Atosiban
What class of drug is Atosiban?
Oxytocin receptor antagonist
Which trimester does an ectopic pregnancy typically occur in?
First trimester
What are the risk factors for ectopic pregnancy?
o Prior ectopic pregnancy
o Prior pelvic infection (PID, tubo-ovarian abscess, salpingitis)
o Prior sterilisation procedure, tuboplasty or surgery.
o Prior caesarean section
o Infertility Cigarette use
o Age >35 years
o Multiple lifetime partners
o Intrauterine contraception – if pregnancy occurs with IUC in situ.
Where do most ectopic pregnancies occur?
Fallopian tube - ampulla
Which part of the fallopian tube is associated with the highest risk of rupture?
Isthmus
What is the triad of symptoms associated with ectopic pregnancy?
- Abnormal vaginal bleeding – intermittent.
- Pelvic pain
- Adnexal mass
Site of referred pain in ectopic pregnancy?
Shoulder tip pain
Presentation of ectopic pregnancy
- Abnormal vaginal bleeding – intermittent.
- Pelvic pain
- Adnexal mass
* Abdominal tenderness
o Diffuse or localised to one side.
* Adnexal tenderness
* Amenorrhoea
o Occurs 6-8 weeks after the last normal menstrual period.
* Abnormal vaginal bleeding
* Peritoneal signs
* Adnexal mass
* Enlarged uterus.
* Shoulder pain
* Tissue passage
What are the signs and symptoms of a tubal rupture in ectopic pregnancy?
Vomiting and diarrhoea, shoulder pain
Pallor, tachycardia, hypotension, shock or collapse
What is the first line investigation for suspected ectopic pregnancy?
Transvaginal ultrasound
What investigation is indicated to detect for a pregnancy of unknown location?
Serial beta-hCG
An increase in serum beta-hCG by what % is suggestive of a developing pregnancy?
> 63%
A decrease in serum bhCG by 50% is indicative of what?
Miscarriage
What features are assessed in a TVUSS for suspected ectopic pregnancy?
Foetal pole and heartbeat
What two radiological signs are suggestive of a tubal pregnancy on TVUSS?
Bagel sign and blob sign
What scan is used to investigate and detect a caesarean scar?
MRI
What are the admission criteria ectopic pregnancy?
- Haemodynamic unstable (pallor, tachycardia, hypotension, shock, and collapse).
- Early pregnancy assessment service (for bleeding during pregnancy AND):
o Pain
o A pregnancy of 6 weeks’ gestation or more
o A pregnancy of uncertain gestation
A pregnancy by how many weeks gestation warrants an urgent referral to the EPU for suspected ectopic preganncy?
> 6 weeks
What medical drug is indicated for the management of an ectopic pregnancy?
Methotrexate
Management of an ectopic pregnancy for a clinically stable and pain free woman?
Expectant management
Adnexal mass diameter threshold for surgical management of ectopic pregnancy?
> 35 mm
What is the surgical criteria for ectopic pregnancy?
Indications:
Significant pain
Adnexal mass >35 mm
Foetal heartbeat visible on USS.
Serum hCG >1500 IU/L
What are the two surgical options for ectopic pregnancy?
Salpingectomy
Salpingotomy
Viable contralateral fallopian tube, surgical management for ectopic pregnancy?
Salpingectomy
What intramuscular prophylaxis is prescribed for surgical management of ectopic pregnancy?
Anti-D immunoglobulin for all rhesus-negative women
What is the increased risk for future ectopic pregnancies in a previous ectopic?
15%
Definition of placenta praevia?
The placenta presents in the lower uterus – covering the internal cervical Os – typically diagnosed in the second trimester.
What are the three types of placenta praevia?
- Complete
- Partial
- Marginal - extends within 2 cm of the cervical Os
What are the risk factors for placenta praevia?
- Multiple placenta (twins or triplets)
- Placenta > surface area
- Maternal age >35
- Intrauterine fibroids
- Maternal smoking
- Previous caesarean section, uterine scar, manual removal of placenta, submucous fibroid, curettage, endometritis.
What is the most common clinical presentation for placenta praevia?
Painless vaginal bleeding
When is placenta praevia typically diagnosed?
2nd or 3rd trimester bleeding
(Absence of uterine tenderness)
What is the first line investigation for suspected placenta praevia?
Uterine ultrasound with colour flor Doppler analysis
What test is used to determine the quantity of foetal blood in maternal circulation?
Kleihauer test
What mode of delivery is recommended for placenta praevia?
caesarean section
When is the low-lying placenta scan?
20 weeks
When is the rescan for placenta praevia?
at 32 weeks, followed by a rescan at 36 weeks
What is the management of placenta praevia at 36 weeks?
caesarean section
What medications are prescribed at 34-36 weeks for placenta praevia?
Antenatal corticosteroids with tocolysis
What is the first line management for symptomatic (bleeding) placenta praevia?
Admission for 48 hours for observation
Management for symptomatic placenta praevia
A-E approach; large bore cannulae, IV access + fluids;
Anti-D
Steroids between 24-34
CTG + umbilical artery Doppler
Serial growth scans
Consider emergency c-section if unstable
What are the foetal complications associated with placenta praevia?
IUGR, death
Maternal complications with placenta praevia?
antepartum haemorrhage and postpartum haemorrhage, DIC, hysterectomy
Define Vasa Praevia
Foetal blood vessels are present in the membranes covering the internal cervical os, unprotected by placental tissue or Wharton’s Jelly.
What substance protects the umbilical cord?
Wharton’s jelly
‘Umbilical cord inserts into the chorioamniotic membranes – vessels travel unprotected before joining the placenta’
Name this type of umbilical cord?
Velamentous umbilical cord
What type of haemorrhage occurs when the placental vessels rupture?
Benckiser’s haemorrhage
What are the risk factors associated with vasa praevia?
Risk factors:
* Placental praevia
* IVF pregnancy
* Multiple pregnancy
* Foetal anomaly (bilobed placenta or succenturiate lobes)
What is the typical presentation of vasa praevia?
Fresh PV bleeding + foetal bradycardia.
What CTG trace is associated with vasa praevia?
Decelerations, bradycardia, sinusoidal trace, foetal demise.
What is the definitive management for vasa praevia?
Elective caesarean section – planned for 34-36 weeks’ gestation.
What term describes placental separation from the wall of the uterus during pregnancy >24 weeks?
Placental abruption
What are the two types of placental abruption?
Concealed OR Revealed
What are the risk factors associated with placental abruption?
Risk Factors:
* Previous placental abruption
* Pre-eclampsia
* Bleeding early in pregnancy
* Trauma
* Polyhydramnios – premature rupture of membranes, rapid loss of fluid.
* Multiple pregnancies
* Foetal growth restriction
* Multigravida
* Increased maternal age,
* Smoking
* Cocaine or amphetamine use
What type of uterus finding on palpation is observed in placental abruption?
A woody abdomen on palpation - hypertonic
What is the characteristic presentation of placental abruption?
Presentation
* Sudden onset severe abdominal pain that is continuous,
* Vaginal bleeding (antepartum haemorrhage)
* Shock (hypotension and tachycardia)
* CTG abnormalities Foetal distress
* ‘Woody abdomen’ on palpation – hypertonic tender uterus.
Definition of massive haemorrhage (mL blood loss threshold)?
> 1000 mL
Management for severe placental abruption?
- Severe - ABC, emergency CS, 2x wide bore cannula, fluids, blood transfusions, correct coagulopathies.
o FBC, G&S, crossmatch, steroids
Management for mild placental abruption?
- Mild - If preterm and stable, conservative management with close monitoring:
o Admit: 48 hours or until bleeding stops.
o Anti-D immunoglobulin by Kleiheur test.
Foetal complications associated with placental abruption?
Birth asphyxia, death
Time period postpartum for primary PPH?
24 hours after vaginal delivery
Define time period/interval for secondary PPH
24 hours and 12 weeks
Volume of blood loss to define primary PPH
> 500 mL
Risk factors for PPH
- Retained placenta/membranes.
- Prolonged labour
- Placenta accreta spectrum
- Lacerations
- Hypertensive disorders (Preeclampsia, eclampsia, HELLP (Haemolysis elevated liver enzymes, low platelets).
- Previous PPH
- Macrosomia
- Fibroids
- Grand multiparity
What are the 4 Ts for PPH
Tone
Trauma
Tissue
Thrombin
Most common cause of PPH?
Uterine atony (~70%)
Reduced uterine contractions resulting in impaired uterine artery clamping (within the first 24 hours – avoid oxytocin with delivery of anterior shoulder or placenta).
What is the management of uterine atony causing PPH?
Fundal massage
What are the main causes of trauma indu-cing PPH?
o Incision from caesarean section.
o Transit of baby through the vaginal canal – haematoma (severe pain + persistent bleeding).
o Medical instrumentation – forceps, vacuum extraction, episiotomy
What are the tissue causes implicated in PPH?
o Placenta accreta – placenta invades myometrium – does not easily separate.
o Retained blood clots in atonic uterus.
o Gestational trophoblastic neoplasia
o Traction on umbilical cord
What is the management of tissue induced PPH?
Retained tissue extractions
Which clotting disorders are associated with an increased suspcetibility of PPH?
o Von Willebrand Disease, haemophilia, DIC, ITP, TTP, aspirin use.
What are the two most common causes of secondary PPH?
1.Endome tritis
2. Retained products of conception
Presentation of PPH (1000-1500 mL blood loss):
Weakness, sweating, tachycardia (100-120 beats/minute), tachypnoea
At what level of blood loss is the following presentation expected: Restlessness, confusion, pallor, oliguria, tachycardia, cool and clammy skin?
1500 - 2000 mL
What is the first step in the management of post partum haemorrhage?
Bimanual compression and IM/IV syntocinon (oxytocin)
Which kind of drug is first prescribed in the management of PPH?
Oxytocin
Syntometrine is contraindicated in what conditions?
Asthma and hypertension
What is the risk associated with oxytocin infusion?
Uterine hyperstimulation syndrome
Following a slow IV infusion of oxytocin, what is step 2 for PPH?
IM-ergometrine/syntometrine
Step III for PPH management?
IM carbopost
Step IV for PPH?
Intrauterine balloon tamponade (bakri balloon)
Which is the first line surgical management for PPH?
B-lynch suture - bilateral internal iliac ligation
What is the final surgical option for PPH?
Hysterectomy
What are the short-term complications associated with gestational diabetes?
Hypertensive disorders
Large gestational weight
Polyhydramnios
Shoulder dystocia
Foetal/neonatal cardiomyopathy
Stillbirth
What are the risk factors for developing gestational diabetes?
- FHx of diabetes (1st- degree relative)
- Pre-pregnancy BMI > 30 kg/m2
- Older maternal age (>35 years)
- Previous GDM (~40% risk recurrence)
- PCOS
- Previous birth of an infant >4 kg
- Asian ethnicity
What is the threshold HbA1c level for the diagnosis of gestational diabetes?
> 48 mmol/L (>6.5%)
Which two tests are diagnostic for gestational diabetes?
- Fasting plasma glucose > 5.6 mmol/L
- 2-hour 75g OGTT >7.8 mmol/L
When is the 2-hour 75g OGTT performed during antenatal care?
24-28 weeks
Threshold for fasting plasma glucose for GDM?
> 5.6 mmol/L
Threshold for 2-hour OGTT for GDM?
> 7.8 mmol/L
Referral following diagnosis of gestational diabetes?
Joint diabetes and antenatal clinic within 1 week
What is the first line manageof ment for gestational diabetes (blood glucose <7 mmol/L)?
Dietary and lifestyle advice (Change in diet and exercise – CDE – 2-week trial)
If the target blood glucose is not met within 2 weeks, despite lifestyle interventions in GDM, what is the next line of management?
Metformin
What is the indication for inititataing insulin for the management of GDM?
Fasting blood glucose >7 mmol/L
Name 2 rapid-acting insulin analogues
Aspart
Lispro
Target fasting blood glucose?
<5.3 mmol/L
When is an elective birth planned for patients with GDM?
Between 37-38+6 weeks
What is the maximum limit for delivery for patients with GDM?
40+6 weeks
Intra-partum for GDM?
Monitor capillary plasma glucose every hour during labour and birth for women with diabetes and maintain between 4 mmol/L and 7 mmol/L.
Postpartum care for gestational diabetes?
Discontinue all blood glucose-lowering therapy immediately after birth.
* Offer fasting plasma glucose test 6-13 weeks after birth to exclude diabetes.
o 6-6.9 mmol/L – high risk of T2DM.
What are the risk factors for perineal tears?
- Nulliparity
- Large babies >4 kg
- Shoulder dystocia
- Asian ethnicity
- Occipito-posterior position
- Instrumental deliveries
What type of perineal tear is limited to the frenulum of the labia minora and superficial skin?
First degree tear
Which type of tear includes the perineal muscles (does not affect the anal sphincter)?
Second degree tear
Which type of perineal tear includes the anal sphincter <50%?
Type 3a
What is a type 3b perineal tear?
> 50% of the external anal sphincter.
Which type of perineal tear involves the rectal mucosa?
Fourth degree
How is a 2nd degree perineal tear managed?
Suturing of the perineal muscle
Management of 3rd and 4th degree perineal tear
Surgical repair + post-operative broad spectrum antibiotics
Which drug is prescribed first for a medical termination of pregnancy?
Mifepristone (200 mg)
What class of drug is Mifepristone?
A progesterone analogue - blocks progesterone required for the continuation of pregnancy
How is misoprostol administered?
Vaginal/buccal/sublingual
How long following Mifepristone, should misoprostol be prescribed?
24-48 hours later
Name the two drugs indicated for a medical termination of pregnancy?
Mifepristone (200 mg) and Misoprostol
What class of drug is Misoprostol?
A prostaglandin analogue - induces smooth muscle contraction of the myometrium for uterine expulsion
Management of termination of pregnancy for 0-9 weeks?
Outpatient management (pass within 4 hours)
What is the management for a termination of pregnancy at 9-24 weeks?
Medical management inpatient; repeat misoprostol 3-hourly (max 5 doses); pass within 8 hours
When does the terminated foetus pass once medical management is initiated, as an outpatient?
4 hours
When does the terminated foetus pass once medical management is initiated, as an inpatient?
Pass within 8 hours
Maximum number of doses of misoprostol?
5 (repeat dose 3-hourly)
What fetiticcie drug is used to terminate the foetus >22 weeks?
Intracardiac potassium chloride or digoxin
Surgical management for ToP <14 weeks?
Misoprostol (400 mcg vaginal/sublingual - dilate),
ERPC (vacuum aspiration) +
hCG level.
Surgical management of choice for ToP >14 weeks?
Dilatation and evacuation/curettage.
What are the complications associated with termination of pregnancy?
- Infection (10%), bleeding (1%), damage to local structures, failure, and anaesthetic complications.
- Cervical trauma (increased risk of cervical incompetence with late termination.
- Retained products of conception
- Uterine perforation.
- Vaginal bleeding – heavy with clots, some bleeding up to 2 weeks; bad period-like cramping pain.
When should a pregnancy test be performed following an abortion?
2-3 weeks
When should hormonal or intrauterine contraceptive devices be used following a surgical ToP?
within 5 days post-surgical
BP threshold (systolic and diastolic) for pre-eclampsia?
> 140/90 mmHg
When (gestational weeks) is pre-eclampsia diagnosed?
> 20 weeks
What are the signs of end-organ dysfunction in pre-eclampsia?
- Proteinuria
- Maternal organ dysfunction
- Renal insufficiency (creatinine >90 micromol/L)
- Liver involvement (elevated ALT, AST >40 IU/L)
- Neurological complications:
o Eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, or persistent visual scotomata. - Haematological complications:
o Thrombocytopenia, DIC, haemolysis.
What is the definition of severe pre-eclampsia?
> 160/110 mmHg
How is foetal growth restriction monitored?
Umbilical artery dDoppler waveform analysis (PI, end-diastolic flow)
Definition of pre-existing hypertension in pregnancy?
Hypertension before 20 weeks of pregnancy
What is the difference between gestational hypertension and pre-eclampsia?
PE is associated with significant proteinuria and signs of organ dysfunction
Proteinuria threshold for pre-eclampsia?
Protein >0.3 g in 24 hours
What are the neurological symptoms associated with pre-eclampsia?
Eclampsia, blind, stroke, clonus, severe headache, visual scotomata
Define HELLP syndrome?
“Haemolysis, Elevated Liver enzymes, and Low Platelets” [SEVERE FORM OF PRE-ECLAMPSIA]
What are the high risk factors for pre-eclampsia?
Pre-eclampsia in previous pregnancy
Chronic kidney disease
Autoimmune disease (SLE, antiphospholipid syndrome)
T1DM, T2DM
Chronic hypertension
What are the moderate risk factors for pre-eclampsia?
Primigravid
Age >40 years
BMI >35
Pregnancy interval >10 years
Fhx of pre-eclampsia
Multiple pregnancy
What is the absolute contraindication for the progesterone only pill?
Active breast cancer
A 32-year-old pregnant female is due to have an induction of labour at 38 weeks gestation due to cholestasis of pregnancy. She undergoes a pelvic examination and a Bishop’s score of 4 is calculated. What treatment is most suitable?
Vaginal prostaglandin
A 65-year-old woman presents to the clinic with a history of postmenopausal spotting. She reports recent vaginal discomfort and irritation over the past week. Her medical and drug history are unremarkable, as is her physical examination.
What is the most likely cause of her menstrual spotting?
Vaginal atrophy
What is the clinical presentation of pre-eclampsia?
- Severe headaches (increasing frequency unrelieved by regular analgesics)
- Visual problems (blurred vision, flashing lights, double vision, or floating spots)
- Persistent new epigastric pain
- Vomiting
- Breathlessness
- Sudden swelling of the face, hands, or feet (cerebral oedema Eclampsia)
o Due to increased vascular permeability and reduced oncotic pressure secondary to proteinuria.
Define HELLP syndrome
HELLP Syndrome (severe form of pre-eclampsia):
* Haemolysis
* Elevated liver enzymes
* Low platelet syndrome
What is the first line investigation for pre-eclampsia?
Urine dipstick (screening for proteinuria >1)
What is the threshold for PCR to quantify proteinuria in pre-eclampsia?
> 30 mg/mmol
Which factor can be used to investigate pre-eclampsia?
Placental growth factor
(low in pre-eclampsia)
How frequent should foetal ultrasound monitoring be performed in patients with pre-eclampsia?
Two weekly
What is the prophylaxis management for pre-eclampsia (high risk or 2 moderate risk factors)?
75-150 mg daily aspirin from 12 weeks gestation until birth
What is the first line management for pre-eclampsia?
Labetalol 100 mg BD
What is the first-line drug for pre-eclampsia with history of asthma?
Nifedipine
What drug is used at term instead of nifedipine for pre-eclampsia?
Methyldopa (nifedipine causes tocolysis)
What drug should be prescribed in patients with brisk reflexes and pre-eclampsia?
IV magnesium sulphate
Which admission criteria is used for pre-eclampsia?
PREP-S or fullPIERS
What is the third line drug for pre-eclampsia?
Methyldopa
How frequently should FBC, LFTs and renal function be monitored in severe pre-eclampsia >160/110?
Three times a week
How frequently should FBC, LFTs and renal function be monitored in moderate pre-eclampsia?
Twice a week
When should birth be induced in pre-eclampsia?
> 37 weeks
What is the reversing agent for magnesium sulphate?
Calcium gluconate 10 mL 10% over 10 minutes
Which tocolytic is contraindicated in severe pre-eclampsia?
Ergometrine
What is the postnatal discharge criteria for pre-eclampsia?
o No symptoms of pre-eclampsia
o Blood pressure <150/100mmHg (with or without treatment)
o Blood test results are stable or improving
Which drugs are not recommended during breastfeeding (anti-hypertensives)?
- Avoid diuretic treatment
- NOT recommended when breastfeeding:
o ARBs
o ACE inhibitors (except enalapril and captopril)
o Amlodipine
What is shoulder dystocia?
When the anterior shoulder of the baby becomes occluded behind the pubic symphysis of the pelvis, after the head has been delivered.
* An obstetric emergency.
What sign is seen in shoulder dystocia?
- Turtle-neck sign
What is the first step intervention for shoulder dystocia?
McRoberts’s Manoeuvre – Involves hyperflexion of the mother at the hip (bringing her knees to the abdomen) Posterior pelvic tilt ~90% success and apply suprapubic pressure.
2nd step for shoulder dystocia following McRoberts
- Evaluate for Episiotomy – enlarge the vaginal opening and reduce the risk of perineal tears.
o Rubin’s manoeuvre:
Which manoeuvre describes the following for shoulder dystocia management:
‘Involves reaching into the vagina and putting pressure on the posterior aspect of the anterior shoulder to help it move under the pubic symphysis’.
Rubin Manoeuvre
What is Zavanelli manouevre?
Push baby’s head back Caesarean section.
What are the common neonatal complications associated with shoulder dystocia?
- Brachial plexus injury in 2.3% to 16%.
- Humerus, and clavicle fractures.
- Pneumothorax
- Hypoxic brain damage.
What are the maternal complications associated with shoulder dystocia?
Maternal Complications:
* PPH
* 3rd to 4th degree tears
* Uterine rupture
* Cervical tears
* Sacroiliac joint dislocation
* Bladder rupture
* Vaginal lacerations.
Time frame for miscarriage?
Miscarriage – Spontaneous loss of pregnancy from the time of conception until 24 weeks of gestation.
Definition of recurrent miscarriage?
Loss of 3 or more pregnancies <24 weeks of gestation.
What is a threatened miscarriage?
Clinical features indicate that a pregnancy is in the process of physiological expulsion within the uterine cavity (bleeding from closed cervix).
Type of miscarriage:
‘non-viable pregnancy is identified on ultrasound without associated pain or bleeding’
Missed (delayed/silent)
Cervical os in threatened miscarriage?
Clossed
Cervical os in ineviiable miscarriage?
Open
What is the most common cause of miscarriage in the first trimester?
Chromosomal abnormalities
What are the risk factors for miscarriage?
Risk factors:
* Advanced maternal age - >35 years (men >45 years)
* Polycystic ovarian syndrome, DM, thyroid disease
* Vitamin D deficiency
* Black ethnicity
* Previous miscarriage
* Uterine anomalies
o Septate uterus
o Submucosal leiomyoma (submucosal fibroid)
* 10-14 weeks – Chorionic villus sampling | Amniocentesis at week 15 Trauma and infection risk.
* Infections- Listeria monocytogenes, CMV, toxoplasma gondii, HSV
Which infections are associated with an increased risk of miscarriage?
Listeria monocytogenes, CMV, toxoplasma gondii, HSV
Which blood clotting disorders are associated with an increased risk of miscarriage?
Antiphospholipid syndrome, Factor V Leiden mutation and hyperhomocysteinaemia.
1st line investigation for miscarriage?
Transvaginal ultrasound – Detect foetal heart rate, CRL and look for gestational sac.
How many weeks gestation to warrant early pregnancy unit referral with history of vaginal bleeding?
> 6 weeks
What is the first line management for a confirmed diagnosis of miscarriage?
Expectant management
What is the management for >6 weeks with bleeding or signs of miscarriage?
Refer to EPU
What is the medical management for miscarriage?
200 mg oral mifepristone + 800 micrograms of misoprostol (48 hours) | Indications: Ongoing symptoms after 14 days of expectant management. – pregnancy test after 3 weeks.
When is medical management indicated in miscarriage?
Ongoing symptoms after 14 days of expectant management
When should a pregnancy test be conducted following medical management of miscarriage?
3 weeks
What are the two surgical options for miscarriage?
Manual vacuum aspiration
Surgical ERPC
What is the first line managemof ent for retained products miscarriage?
Expectant management 7-14 days
For miscarriage <6w gestation, when should a pregnancy test be performed?
7-10 days (negative - miscarriage)
What should be prescribed for recurrent MC?
Low-dose aspirin and LMWH if thrombophilia
When does Hyperemesis Gravidarum typically occur?
4-7th week
When does Hyperemesis Gravidarum typically resolve?
By 16-20th week
What are the risk factors associated with Hyperemesis Gravidarum?
Molar pregnancies
Multiple pregnancies
History of HG
Obesity
First-pregnancy
Migraines
History of motion sickness
What are the three diagnostic criteria for Hyperemesis Gravidarum?
o Prolonged, persistent, and severe nausea and vomiting unrelated to other causes.
o Weight loss (>5% of pre-pregnancy weight)
o Dehydration and electrolyte imbalance.
Which questionnaire is used to assess fo the severity foofr hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE)
What is the severe PUQE threshold for hyperemesis gravidarum?
13
Urine dipstick finding for Hyperemesis Gravidarum?
Ketonuria
What is the management for mild-moderate Hyperemesis Gravidarum?
Reassurance - resolution by 16-20 weeks
What is the supportive management options for mild-moderate Hyperemesis Gravidarum?
- Rest, avoiding odours, heat, and noise; eating plain biscuits and crackers in the morning; try eating bland, frequent protein-rich meals.
- Ginger
What anti-emetic management options are prescribed for hyperemesis gravidarum?
1st line: Oral Promethazine or Cyclizine (Reassess after 24 hours) – antihistamines (Combination therapy Cyclizine + anti-emetic).
Examples of antihistamine anti-emetic:
- Prochlorperazine (5-10 mg PO)
- Promethazine (12.5-25 mg) – Can cause QT prolongation.
- Chlorpromazine (10-25 mg)
What are the side effects associated with antihistamine anti-emetics?
Drowsiness, dizziness, dry mouth, fatigue, constipation.
What are the 2nd line anti-emetics for Hyperemesis Gravidarum?
Ondansetron - do not prescribe >5 days
What adverse effect is associated with ondansetron?
Cleft palate
What is the maximum duration of metoclopramide in hyperemesis gravidarum?
5 days
What adverse effects are associated with hyperemesis gravidarum?
Extrapyramidal side effects
- Can cause oculogyric crisis in young patients <25 years old.
What is the third line drug management for hyperemesis gravidarum?
Corticosteroids - hydrocortisone
What is the management for moderate-severe hyperemesis gravidarum?
Ambulatory care (EPU)
Admission Criteria:
* Unable to tolerate oral antiemetics or keep down any fluids.
* >5% weight loss
* Ketones are present – 2+ on urine dipstick (Ketonuria is no longer an indicator of severity – RCOG 2024)
* Diabetes lowers the threshold for admission.
What % weight loss results in admission for hyperemesis?
> 5%
What is the management on admission for hyperemesis gravidarum?
IV normal saline with KCl, thiamine (vitamin B1) supplementation + PPI
IV antiemetics
Reassess in 24 hours
What are the complications associated with hyperemesis gravidarum?
- Weight loss
- Dehydration
- Electrolyte imbalance – Hyponatraemia, hypokalaemia, or metabolic Hypochloraemic alkalosis.
- Acute kidney injury
- Abnormal LFTs
- Nutritional and vitamin deficiencies – Vitamin B6, vitamin B12 deficiency (peripheral neuropathy); B1 (Wernicke’s encephalopathy).
Which clotting factors are raised in venous thromboembolism?
Raised FVII, FVIII, VWF, PAI-1, PA-2, fibrinogen,
Risk factors for VTE in pregnancy?
Risk Factors:
* Smoking
* Parity >3
* Age >35 years
* BMI >30
* Reduced mobility
* Multiple pregnancy
* Pre-eclampsia
* Gross varicose veins
* Immobility
* Family history of VTE
* Thrombophilia
* IVF pregnancy
What is a high risk factor for VTE in pregnancy?
Previous VTE
Presentation of DVT in pregnancy?
– Unilateral.
o Calf swelling
o Dilated superficial veins.
o Calf tenderness
o Oedema
>3 cm difference between calves is significant.
o Colour changes to the leg.
Pulmonary embolism presentation in pregnancy?
o Dyspnoea
o Haemoptysis
o Pleuritic chest pain
o Hypoxia
o Tachycardia
o Raised respiratory rate
o Low-grade fever
o Hypotension
What is the first line investigation (RCOG 2015) for suspected DVT in pregnancy?
Compression Duplex ultrasound
What IX performed with suspected PE?
CXR and ECG
Gold-standard investigation for PE in pregnancy? (2)
CTPA and VQ scan
Complication associated with CTPA?
Increased risk of maternal breast cancer
Complication associated with VQ scan in pregnancy?
Increased risk of childhood cancer
What is the management for VTE in pregnancy?
Low molecular weight heparin until the end of pregnancy and at least 6 weeks post-partum and at least 3 months of total treatment
Duration of LMWH postpartum for VTE?
6 weeks postpartum
Total duration of LMWH therapy?
3 months
Management for VTE if LMWH is contraindicated?
Mechanical prophylaxis if LMWH is contraindicated:
Intermittent pneumatic compression
Anti-embolic compression stockings
Management for VTE for massive PE and haemodynamic compromise?
Unfractionated heparin, thrombolysis and surgical embolectomy
What is the immediate DVT treatment in pregnancy?
LMWH
For VQ scan - what are the risks for VTE management?
childhood malignancy – avoid breastfeeding for 12 hours (express and discard).
> weeks gestation for obstetric cholestasis?
28 weeks
Risk factors for obstetric cholestasis?
Previous obstetric cholestasis
Family history
Ethnicity (South Asian, Chilean, Bolivian)
Multiple pregnancies
Characteristic finding for obstetric cholestasis?
Pruritus (intractable, in soles and palms) with excoriations + worse at night.
* No rash
* Raised bilirubin (Jaundice ~10%)
* Anorexia, malaise, abdominal pain.
* Dark urine, pale stools, and steatorrhoea.
Itch with pill
What are the investigations for obstetric cholestasis?
LFTs - raised ALP (obstructive)
Bile salts
What is the immediate management for obstetric cholestasis?
Arrange same-day referral to a local maternity unit for obstetric cholestasis
What is the symptomatic management for obstetric cholestasis?
Ursodeoxycholic Acid
Vitamin K supplementation
Sedating antihistamines
Topical emollients
When is induction of labour recommended for obstetric cholestasis?
At 37 weeks
Complications of obstetric cholestasis?
Preterm birth
Intrauterine death
Severe liver impairment
PPH
Meconium passage – ingestion.
Foetal distress
When does foetal movements typically begin?
16 to 24 weeks
What type of care is delivered for obstetric choleastasis?
Consultant led antenatal care
What are the weekly investigations performed for obstetric choleastasis?
LFTs including bile acid concentrations until delivery
What are the supportive management options for obstetric choleastasis?
Wearing cool, loose, cotton clothing, soaking in a cool bath and applyngign ice packs for short periods to the affected areas
Which topical emollients are prescribed for the management of obstetric cholestasis?
Menthol 0.5% with aqueous cream
Which drug provides symptomatic relief in obstetric cholestasis?
Ursodeoxycholic acid (does not reduce adverse perinatal outcomes)
When should planned birth be advised if serum bile contraction is >100 umol/L?
At 35-36 weeks’ gestation
At what bile acid concentration threshold results in an increased risk fo stillbirth?
> 100 umol/L
When should immediate delivery be planned in obstetric cholestasis?
Past 35 weeks’ and bile acid serum concentration >100 umol/L
What is the supportive care for acute fatty liver during pregnancy?
Admit ITU - early liaison with liver team
Which neonatal deficiency is associated with acute fatty liver of pregnancy?
LCHAD deficiency in the foetus (autosomal recessive)
What are the risk factors associated with acute fatty liver of pregnancy?
Nulliparity
Multiple pregnancies
Low maternal BMI
Male foetus
Pre-eclampsia
Male foetal sex, previous AFLP
What are the clinical features for acute fatty liver of pregnancy?
- Nausea/Vomiting
- Abdominal Pain
- Malaise and fatigue
- Anorexia
- Ascites
- Jaundice
What are the liver function tests associated with acute fatty liver of pregnancy?
ALT and AST - raised
Elevated uric acid
Criteria for acute fatty liver of pregnancy?
Swansea Criteria
What is the definitive management for acute fatty liver disease?
Foetal monitoring + prompt delivery
What are the complications with acute fatty liver of pregnancy?
Disseminated intravascular coagulation.
Death
Prognosis: Maternal mortality 10-20% perinatal mortality 20-30%.
Which organism is implicated in syphillis?
Treponema pallidum
How is syhillis transmitted?
Vertical transmission - direct contact with an infected area (oral, vaginal or anal sex)
What is the primary presentation of syphillis?
Pain ulcer – Chancre (Genital area) – Resolves within 3-8 weeks.
What are the secondary manifestations of syphilis?
- Secondary (4-10 weeks after chancre) syphilis – Systemic symptoms of the skin and mucous membranes:
o Maculopapular rash
o Condylomata lata (grey wart-like lesions around genitals and anus).
o Low-grade fever
o Lymphadenopathy
o Alopecia (localised hair loss)
o Oral lesions
What is the first line investigation for Syphillis?
Darkfield microscopy and serology + full sexual health screen
What is the routine antenatal screening for syphilis during pregnancy?
Serology testing - detects treponemal antibodies - enzyme immunoassay
What are the non-treponemal tests for syphillis?
Rapid plasmin reagin
VDRL
What is the management for early Syphilis for the 1st and 2nd trimester?
Benzathine-pen (IM STAT) or doxycyline
What is the late trimester management for Syphilis ?
Benzathine-pen
What is the add-on therapy for neurosyphilis?
Prednisolone - 24 hours prior to avoid Jerish-Herxheimer reation
What are complications associated with Syphilis in pregnancy?
Complications (of pregnancy) Congenital syphilis (PTL, still-birth, miscarriage)
* Rash on soles of feet and hands
* Bloody rhinitis
* Hepatosplenomegaly
* Glomerulonephritis
* Hutchinson’s teeth (smally, widely spaces, notched)
* Frontal bossing of skull. Saddle-nose deformity
* Saber’s shins (anterior bowing of shins)
Primary amenorrhoea and undescended bilateral testes are associated with what diagnosis?
Androgen insensitivity syndrome
When is a pregnancy test performed following a miscarriage?
3 weeks after management
What adjunctive medication to misoprostol is prescribed for miscarriage management?
Analgesia and anti-emetics
What is the most common risk factor for transient tachypnoea of the newborn?
C-section
When taking ulipristal acetate as emergency contraception, when can hormonal contraception begin
5 days
A primiparous woman who is 34 weeks pregnant presents to triage worried about fetal movements. Normally she can feel her fetus kick frequently throughout the day but she hasn’t felt anything for the last four hours.
What is your first step in managing this patient?
Handheld Doppler to assess for foetal heart rate
What is the first line drug for pregnancy-induced hypertension?
Labetalol
What is the clinical definition of menopause?
> 12 months of amenorrhoea since last menstrual period.
What is the average age of menopause?
51 years
What is the age threshold for POI?
<40 years of age
What are the primary causes of POI?
Fragile X, Turner’s
Enzyme deficiencies – Galactosaemia
Autoimmune diseases – Hypothyroidism, Addison’s.
What are the secondary causes of menopause?
- Chemotherapy, radiotherapy, Surgical BSO
Which cell secretes oestrogen?
Granulosa cell
What are the symptoms associated with menopause?
- Hot flashes/Night sweats (vasomotor symptoms) Sleeping disturbances.
o ~ Last 2-4 minutes – associated with sweating, anxiety, or palpitations.
o Triggered by: Spicy food and alcohol. - Vaginal dryness Dyspareunia (urogenital atrophy)
- Vulvovaginal irritation, discomfort, burning.
- Reduced libido
- Dysuria, frequency, and urgency
- Mood swings, anxiety, irritability, and reduced QoL.
- Joint pains
Which investigation is recommended in women aged 40-45 years with menopausal symptoms?
Serum FSH
When should a second FSH test be performed?
FSH 4-6 weeks apart.
Which screening investigations are performed for >65 year olds (menopause)?
DXA test to assess bone marrow density (screening for osteoporosis)
What is the first line HRT preparation indicated for menopause? (with uterus)
o Combined (Oestrogen + progesterone – Elleste Duet) – protects the endometrium
Which HRT preparation is associated with a reduced VTE risk?
Transdermal oestrogen patch
When starting HRT, when should the patient be reviewed?
3 months and then annually thereafter
What is the BMI cut off for initiating the transdermal patch?
> 30
Which HRT type is indicated for post-hysterectomy women?
Elleste solo - oestrogen only
What SSRI is recommended to treat vasomotor symptoms?
Fluoxetine, citalopram
In a women with existing tamoxifen, which, drug is recommended instead to control vasomotor symptoms?
Citalopram, clonidine or gabapentin
What is the first line drug to control uro-genital symptoms associated with menopause?
- Low-dose vaginal oestrogen first line
For patients experiencing peri-menopausal symptoms, which type of HRT is recommended?
Cyclical/Sequential Pattern (SCT)
For monthly sequential pattern HRT, when is progesterone administered?
For the last 14 days of the month
For 3-monthly SCT, when is progesteron given?
For the last 14 days
Which cancer risk is associated with oestrogen-only HRT (2 types)?
Breast cancer, endometrial cancer
Which cancer risk is increased on the combined HRT preparation?
Breast cancer
When during menopause, is the greatest risk of VTE on oral HRT?
Within the first 12 months
What are the three common oestrogenic side effects associated with HRT?
Breast tenderness, nausea, headaches
What are the three common progestogenic side effects associated with HRT?
Fluid retention, mood swings, depression
When should unscheduled vaginal bleeding be investigated upon initiating HRT?
> 6 months
What is the contraception advice for women after their last menstural period >50 years of age?
Contraception is not required after a year
How many years should contraception be used in women <50 years?
2 years
What are the 9 contraindications of HRT?
- Breast cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia/endometrial cancer
- Previous or current venous thromboembolism (DVT, PE – unless on anticoagulant therapy)
- Pregnancy
- Uncontrolled hypertension
- Thrombophillic disorder
- Acute liver disease
Where do hydatidiform moles originate from?
Villous trophoblast
What is a complete mole?
Empty egg with 2 sperm - (dispermic) or duplication of haploid genome of a single sperm
What is a partial mole?
Complete ovum with 2 sperm - triploid
Which tumour marker is significantly raised in Gestational Trophoblastic Disease?
hCG
What is the most common cause of Gestational Trophoblastic Disease?
Molar pregnancy
What are the risk factors associated with Gestational Trophoblastic Disease?
- Extremes of reproductive age
- Previous GTD
- Ethnicity (Japanese, Asians, Native American Indian)
- Diet (low beta-carotene, low saturated fat)
What is the diagnosis of the following symptoms:
Missed menstrual periods – positive pregnancy test.
* Signs and symptoms consistent with pregnancy
o Bleeding – due to separation of the molar villi from the underlying decidua – prune juice appearance.
o Pelvic discomfort/pain
o Hyperemesis gravidarum
o Enlarged uterus – Ultrasound reveals a uterine size > expected gestational age – uterine enlargement.
o Sudden increase in abdominal size.
Molar pregnancy
A sudden increase in abdominal size in addition to an enlarged uterus and hyperemesis gravidarum should suspect what?
Molar pregnancy
What is the first line investigation for a suspected molar pregnancy?
Quantitative serum hCG test
What is the 2nd line investigation for suspected molar pregnancy?
Transvaginal ultrasound
What is the characteristic sonographic appearance visualised in a molar pregnancy?
Snowstorm appearance/Cluster of grapes
What is the definitive diagnostic investigation for a molar pregnancy?
Histological examination
What is the first line management for a a molar pregnancy?
Uterine evacuation by suction curettage
Which drug is given for a molar pregnancy
Methotrexate
For non-chemotherapy managed molar pregnancies, when should pregnancy be avoided until?
6 months after
Minimum avoidance of pregnancy duration for chemotherapy treated molar pregnancy?
12 months
IUD advice for treated molar pregnancy?
- Avoid IUDs until hCG normalised
What prophylaxis is administered after an evacuation of a molar pregnancy?
Anti-D prophylaxis
When should a urinary pregnancy test be performed after the management of a molar pregnancy?
After 3 weeks
Which service should be offered to patients with a molar pregnancy?
trophoblastic screening centre – depending on the hCG level at 56 days of the pregnancy event..
What cancer risk is associated with a complete molar pregnancy?
choriocarcinoma
What is the threshold for first trimester anaemia?
<110 g/L
What is the threshold for second trimester anaemia?
<105 g/L
When are pregnant women first screened for anaemia?
At the booking appointment ~8-12 weeks
When are pregnant women screened for the second time for anaemia?
At 28 weeks
What is the threshold for anaemia postpartum?
100 g/L
Threshold for urgent anaemia referral in pregnancy?
<70 g/L
Which medication should be given for anaemia during pregnancy?
- Oral ferrous sulphate or ferrous fumarate
What are the side effects with taking oral ferrous sulphate for anaemia in pregnancy?
Black tools, constipation, abdominal pain
When should haemoglobin be tested for, following treatment of anaemia in pregnancy?
2-3 weeks
Minimum duration of oral ferrous sulphate?
3 months and until 6 weeks post-partum
Which dose of folic acid is given for patients with underlying sickle cell anaemia or thalassaemia?
5 mg folic acid
Consultant or mid-wife led delivery for anaemia in pregnancy?
Consultant led due to risk of PPH
How often should a group and screen be performed in high risk pregnancies?
Once a week to exclude new antibody formation
What is the blood product of choice for pregnant women?
ABO-, Rhesus-, Kell-.
What is the dose of folic acid given for eclamptic patients?
5 mg folic acid
What are the complications associated with folic acid deficiency during pregnancy on the neonate?
Neural tube defects including spina bifida
Which anti-epileptic drugs are safe to use during pregnancy?
levetiracetam, lamotrigine and carbamazepine
What are the complications associated with the use of phenytoin during pregnancy?
Cleft lip and palate
What should happen to anti-epileptic therapy prior to conception?
Refer to epilepsy specialist (do not change)
What is the first line drug for the management of eclampsia in pregnancy?
IV magnesium sulphate 4g over 5-10 minutes followed by a 1g/hour infusion
When should magnesium sulphate be continued following a seizure?
24 hours after the last seizure or delivery
What is the major risk associated with the use of magnesium sulphate?
respiratory depression
What is the anti-dote for magnesium sulphate toxicity?
10mL 10% of calcium gluconate over 10 minutes
What is the definitive management for eclampsia?
Expedite delivery
What is the genotype for androgen insensitivity syndrome?
46 XY
What is the inheritance pattern for androgen insensitivity syndrome?
X-linked recessive
What is the pathogenesis for androgen insensitivity syndrome?
End-organ resistance to testosterone
Which hormone prevents the development of the female internal organs in a male?
Anti-mullerian hormone
What is the diagnostic investigation for androgen insensitivity syndrome?
Buccal smear or chromosomal analysis
What is the most common cause of chorioamnionitis?
Prolonged duration of labour or rupture of membranes
Which chart is used to assess the patient with chorioamnionitis?
MEOWS chart
What is the gold standard investigation for chorioamnionitis?
Amniotic fluid culture
What is the first line antibiotic therapy for chorioamnionitis?
Benzylpenicillin + gentamicin + metronidazole.
When should induction of labour be considered for a patient with chorioamnionitis?
After 34 weeks’ gestation - steroids for 34-37 weeks
Category 1 c- section - time?
Within 30 minutes
Category 2 c-section time?
Within 75 minutes
What is the recommended incision for a c-section?
Joel-cohen incision - straight
Which name denotes a curved incision above the pubic symphysis during a c-section?
- Pfannenstiel incision
What are the 8 layers of dissection for a c-section?
- Skin
- Subcutaneous tissue
- Fascia/rectus sheath (aponeurosis of the transversus abdominis and external and internal oblique muscles)
- Rectus abdominis muscle
- Peritoneum
- Vesicouterine peritoneum (and bladder)
- Uterus (perimetrium, myometrium, and endometrium).
- Amniotic sac
What is the risk during a c-section?
aspiration pneumonitis
What prophylaxis is given for aspiration pneumonitis during a c-section?
H2 receptor antagonist e.g., ranitidine or omeprazole
What are the major maternal complications associated with a c-section?
- Emergency hysterectomy
- Need for further surgery at a later date, including curettage (retained placental tissue).
- Admission to ICU.
- Thromboembolic disease
- Bladder injury
- Ureteric injury
- Death (1 in 12,000)
What are the risks associated with a c-section on future pregnancies?
- Increased risk of uterine rupture during subsequent pregnancies/deliveries.
- Increased risk of antepartum stillbirth.
- Increased risk in subsequent pregnancies of placenta praevia and placenta accreta
What is the average success rate of VBAC?
72-75%
What is the success rate for VBAC following a previous successful vaginal birth?
9 in 10
What is the risk associated with induction of labour following a c-section?
2-3 increased risk of uterine rupture
What are the absolute contraindications for a VBAC?
Contraindications:
* Previous uterine rupture
* Classical caesarean scar (a vertical incision)
* Placenta praevia
What % of VBAC patients require an emergency c-section?
25%
When is prelabour rupture of membranaes?
After 37 weeks , before the onset of labour
When is prematurity defined?
Before 37 weeks of gestation
What are the risk factors associated with premature labour?
- Smokers
- Previous LLETZ
- STI/UTI/Infection (20 to 40%)
- Previous P-PROM
- Multiparity
- Polyhydraminos – stretch mechanoreceptors.
- Cervical incompliance
- Mechanical: Fibroids, polyhydraminos, multiple pregnancy, fully dilated caesarean.
What prophylactic gel can be given to patients for preterm labour - to maintain the pregnancy and reduce myometrium activity?
Vaginal progesterone
What cervical length is the threshold for preterm labour prophylaxis?
<25mm
What are the indications for vaginal progesterone prophylaxis in pregnancy?
o Hx of spontaneous preterm birth (<34 weeks); mid-trimester loss (>16 weeks) and/or cervical length<25 mm on TVUSS.
What prophylactic intervention for preterm labour can be done for women with previous premature birth or cervical trauma?
Cervical cerclage
What is the first line investigation for p-PROM?
sterile speculum examination
If pooling of fluid is not observed following p-prom which two tests are performed?
- Insulin-like growth factor-binding protein-1: Raised protein concentration in amniotic fluid.
- Placenta alpha macroglobulin-1 (PAMG-1)
What are the complications associated with p-prom?
placental abruption and chorioamnionitis
Following p-prom how long should a patient be admitted and monitored for?
Admission for 48 hours and prepare for delivery
What outpatient investigations are performed following a p-prom?
- 2-6x daily temperatures at home
- Low threshold for attending hospital
- Day/care maternity/triage/AN ward
Which antibiotic is prescribed following pprom?
- Erythromycin 250 mg QDS for 10 days
Which maternal corticosteroid is given for foetal lung maturation following pprom?
2 x 12 mg doses 12 hours apart of betamethasone
What is prescribed as neuroprotection for a neonate if birth is expected within the next 24 hours <34 weeks?
Magnesium sulphate
What is the management plan for pprom >34 weeks if positive group b strep?
Immediate induction of labour with intrapartum benzylpenicillin
Which test is used as an alternative to vaginal ultrasound to assess for premature labour?
Foetal fibronectin
What is the cut-off of foetal fibronectin in suspected premature labour?
> 50 g/L - likely
What tocolytic agent is recommended for premature labour?
Nifedipine - consider atosiban
What is the mechanism of action for atosiban?
Oxytocin receptor antagonist
When should tocolytics be used (in weeks gestation) for preterm labour?
Between 24-33+6 weeks to allow the use of maternal corticosteroids
What is the limit weeks of gestation to prescribe magnesium sulphate?
<34 weeks - to reduce the risk of developing cerebral palsy
Cord clamping protocol for premature labour?
Delayed cord clamping/cord milking
What is the first choice drug for vaginal candidiasis during pregnancy?
Clotrimazole pessary or cream
What is the first line therapy for vaginal candidiasis in a non-pregnant woman?
Oral fluconazole 150 mg single dose or itraconazole
What is the definition of recurrent vaginal candidiasis according to BASHH guidelines?
4 or more episodes a year
What two investigations are recommended for patients with recurrent vaginal candidiasis?
Blood glucose to exclude diabetes
High vaginal swab for m&c
When is induction of labour offered normally?
At 41-42 weeks’ gestation
When should induction of labour be offered for patients with obstetric cholestasis?
At 37 weeks
Which scoring system is used to assess the likelihood of successful induction?
Bishop score
What are 5 parameters for bishop score?
- Foetal station (Scored 0-3)
- Cervical position (Scored 0-2)
- Cervical dilatation (Scored 0-3)
- Cervical effacement (Scored 0-3)
- Cervical consistency (Scored 0-2)
Which bishop score predicts a successful induction of labour?
8 or more
What is the bishop score threshold for starting vaginal prostaglandins?
6 or less
Foetal station refers to which landmark?
Ischial spines (zero - level of the ischial spine)
Foetal station of -2 = what?
2 cm above the ischial spines
What is given to ripen the cervix?
Vaginal prostaglandins
When is vaginal prostaglandins not recommended?
VBAC - risk of hyperstimulation
What should be offered first if the Bishop score is >6 for induction of labour?
Artifical rupture of membranes
Following an artificial rupture of membranes, what intervention is administered 2 hours later for induction of labour?
IV oxytocin infusion
What intervention is offered >40 weeks for induction of labour?
Membrane sweep
What is dinoprostone?
Vaginal prostaglandins E2
What is the alternative to vaginal prostaglandins for induction of labour?
Cervical ripening balloon
What is the risk of amniotomy if the presenting part is high?
Umbilical cord prolapse
When is an oxytocin infusion offered followed an amniotomy in IoL?
2 hours after the membranes have rupture
What is the goal contraction rate during second phase labour?
3-4 contractions/10 minutes
Which drug is used to induce labour if there is an intrauterine foetal death?
Oral mifepristone and misoprostol
When induction labour what type of monitoring should be performed?
CTG
How contractions in 10 is equal to uterine hyperstimulation syndrome?
5 or more
What are the consequences associated with uterine hyperstimulation syndrome?
Foetal hypoxia
Uterine rupture
Which tocolytic is prescribed for managing uterine hyperstimulation syndrome?
terbutaline
Which congenital infection is associated with PDA?
Rubella
Which congenital infection is associated with cerebral calcifications, chorioretinitis and hydrocephalus?
Congenital toxoplasmosis
Which drug is given to the baby in a PCR +ve mother for toxoplasmosis?
Spiramycin
What viral strain of HHV is CMV?
HHV-5
Which intra-uterine infection is most commonly associated with hearing loss?
Congenital CMV
What is the management for congenital rubella if detected positive IgM <18 weeks
Termination of pregnancy
What is the next step in confirmed rubella infection in a mother?
Notify HPU and refer to foetal medicine
What is the hallmark feature of congenital CMV?
- Hearing
What foetal abnormalities are associated with congenital cytomegalovirus?
: Intracranial calcifications, ventriculomegaly, lenticulostriate vasculopathy, occipital horn anomalies, echogenic bowel, hepatomegaly, and pericardial effusion.
What referral should be made if congenital CMV is detected during pregnancy?
Refer to the foetal medicine specialist
Frequency of ultrasound surveillance for CMV in pregnancy?
fetal US every 2-4 weeks from diagnosis
Which type of antibodies are diagnostic for primary CMV infection in pregnancy?
IgM antibodies
How is a foetal diagnosis made for congenital CMV?
amniocentesis
What is the symptomatic management for congenital CMV neonatal infection?
postanal valganciclovir/ganciclovir for the first 4 weeks of life
What are the most common causes of polyhydramnios?
- Foetal swallowing defect – Inability of amniotic fluid absorption.
- TORCH infections
- Chromosomal abnormalities
- Twin-to-twin transfusion syndrome
- Gestational diabetes, and alloimmunization.
An amniotic fluid index > cm is indicative of polyhydramnios?
> 25 cm
What is the management for polyhydramnios?
- Reductive amniocentesis for TTS
What is the histopathology of a choriocarcinoma?
Large eosinophilic smudgy multinucleated cells with large hyperchromatic nuclei.
What is the management for a low risk choriocarcinoma?
Methotrexate
What is the management for a high risk choriocarcinoma?
Chemotherapy
What investigation should be performed for suspected choriocarcinoma?
quantitative hCG levels
What term denotes placental invasion of the myometrium?
Placenta increta
What term denotes placental invasion through the endometrium
Placenta accreta
What term denotes placental penetration through the myometrium into the serosa?
Placenta precreta
What is the biggest risk factor associated with placenta accreta?
previous c-section
What investigation is performed to diagnose placenta accreta as part of the antenatal screening?
Ultrasound examination
What is the presentation of placenta accreta in the third trimester?
o Sudden severe pelvic-suprapubic abdominal pain
o Vaginal bleeding
o Preterm labour or prelabour rupture of membranes.
When should a planned delivery be performed for confirmed placenta accreta?
35 to 36+6 weeks
What is the surgical approach for placenta accreta?
Caesarean section hysterectomy
What are the risk factors for postpartum endometritis?
- Caesarean delivery
- Intrapartum intraamniotic infection
- Prolonged rupture of membranes
What is the classical presentation of postpartum endometritis?
Foul-smelling lochia and uterine tenderness, early onset fever within 48 hours
What is the antibiotic choice for postpartum Endometritis?
IV ABx – Gentamicin 5 mg/kg IV every 24 hours OR ampicillin 2g IV every 6 hours.
A firm mobile painless lump deep to the areola in a lactating woman is associated with what diagnosis?
Galactocele
What is the management for a galactocele?
- Fine needle aspiration
What are the three most common causes of bleeding in the first trimester of pregnancy?
- Miscarriage
- Ectopic pregnancy
- Hydatidifiorm
What are the common causes of third trimester associated bleeding in pregnancy?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
What is the admission criteria for a patient with antenatal haemorrahge?
Admit for 48 hours with regular monitoring and observation including CTG
Which breech term denotes a foot presenting through the cervix with the leg extended?
Footling breech
What are the risk factors associated with breech presentation?
- Uterine malformations
- Fibroids
- Placenta praevia
- Poly/oligohydramnios
- Foetal anomaly
- Prematurity
What is the management for breech if detected <36 weeks of gestation?
re-scan at 36 weeks - if breech perform ECV
What type of pregnancy is a breech presentation?
High risk - performed with attendant neonataologist
When should an ECV be performed in a nulliparous woman?
At 36 weeks
When should an ECV be performed in a multiparous woman?
At 37 weeks
What class of drug is administered prior to an ECV?
Tocolysis - terbutaline
What test should be performed when performing an ECV?
Kleiheur test - followed by anit-D prophylaxis
Which manoeuvre is performed during a vaginal delivery of a breech presentation baby?
Lovset manoeuvre and Mauricea–Smellie–Veit impressions
Which position should a mother be when delivering a breech presentation baby vaginally?
Lithotomy position
What is an absolute contraindication for a vaginal delivery for breech presentation?
Footling breech
What are the significant risks and complications associated with breech?
Cord prolapse
Plancental central abruption
PROM
APH
foetal distress
What is the preferred mode of delivery for breech presentation?
Elective c-section
What does power denote?
Uterine contractions
Which term denotes the size, presentation and position of the baby?
Passenger
What is the maximum dilation of the cervix for latent phase of 1st stage labour?
3 cm
What is the dilation rate for latent phase first stage labour?
0.5 cm/hour
What is the cervical dilation rate for active phase of first stage labour?
1 cm an hour
What is the maximal dilation of the cervix?
10 cm
What is classified as failure/slow to progress during the first stage of labour in multiparous women?
2 cm of cervical dilation in 4 hours
What is the most common cause of failure to progress in a woman?
hypocontractile uterine activity
What is the maximum time for second stage labour in a nulliparous woman before being considered as a delay?
2 hours
Delay in hours for am multiparous woman during the second stage?
1 hour
If there are signs of progress after 1 hour what should be recommended (in a nulliparous woman)?
Encourage the woman to continue pushing
If there are no signs of progress during the second stage of labour, and membranes are intact, what should be done?
consider amniotomy
If birth is not imminent in a nulliparous woman after 2 hours of pushing, what is the next stage?
Refer for senior review
In a multiparous woman, if there are no signs of progress after 30 minutes, what should be offered?
Amniotomy
What should be offered after amniotomy and no signs of progress?
Oxytocin infusion (requires an in-person assessment by an obstetrician)
What is the maximum length for third stage of labour in active management?
30 minutes
Physiological labour, what hour threshold = delayed?
1 hour
What are the two modes of instrumental delivery?
Ventouse suction cup or forceps
What intervention is indicated if there is prolonged second stage of labour with the head presenting?
Episiotomy with instrumental delivery
Which Abx is indicated following post-instrumental delivery?
IV co-amoxiclav within 6 hours of cord clamping
What are the risk associated with an instrumental delivery?
- Postpartum haemorrhage
- Episiotomy
- Perineal tears
- Injury to the anal sphincter
- Incontinence of the bladder or bowel
- Nerve injury (Obturator or femoral nerve).
Which neonatal complication is associated with ventouse assisted delivery?
Cephalhematoma
Which neonatal complication is associated with forceps assisted delivery?
Facial nerve palsy
Which two nerves are commonly injured during instrumental delivery (maternal)?
Femoral - nerve compression = loss of patella reflex
Obturator - weakness of hip adduction
At what stage of labour is an episiotomy performed?
Second stage of labour
What type of incision is performed for an episistiomy?
Mediolateral incision - directed to the right side at 45 and 60 degrees
What are the indications for performing an episiotomy?
o Operative vaginal delivery e.g., forceps or vacuum extractor in women with a narrow vaginal outlet.
o Shoulder dystocia
o History of FGM
What is DR for DR C BRAVADO?
Define risk - the indications of performing the CTG
What is the average number of contractions?
3 to 5 contractions in 10 minutes
What is the average baseline foetal rate?
110-160 bpm
What cause of foetal HR variability <45 minutes followed by a normal CTG trace?
Foetal sleep cycle
What is the normal foetal heart rate variability over 5-10 minutes?
5 - 25
What are the non-reassuring foetal heart rate thresholds?
100-109 and 161 to 180
What is an abnormal baseline rate on CTG?
<100 or >180
What are the causes of early decelerations?
Physiological - compression of the fetal head on the vagus nerve
What are the causes of late decelerations?
Foetal hypoxia
What are the causes of variable decelerations?
Intermittent cord compression
Prolonged decelerations for 2-10 minutes indicate what?
Cord compression
What CTG pattern indicates foetal compromise?
Sinusoidal CTG
What is the average duration of stage 1 labour in a nulliparous woman?
8 hours
What phase of labour after 10 cm dilation is associated with no maternal urge to push?
Passive phase of 2nd stage of labour
What is the maximum allowance of failure to progress in the second stage of labour if on epidural?
+1 hour
How frequently should the fetal heartbeat be auscultated for 1 minute?
Every 5 minutes
What dose of oxytocin should be given for active management for the third stage of labour?
a. 10 iU oxytocin IM
When should oxytocin be given for active management in the third stage of labour?
Once the anterior shoulder is delivered
What action is performed to reduce the incidence of PPH during the third stage of labour?
Controlled cord clamping
What are the two most common causes of prolonged third stage of labour?
Uterine atony and placenta accreta
What investigation is performed for suspected cerebral venous sinus thrombosis?
CT venography or MRV
What is the management for cerebral venous sinus thrombosis in pregnancy?
Anticoagulation with LMWH (treatment dose of enoxaparin)
Which is the first line painkiller for migraine in pregnancy?
Paracetamol
Which derm condition is associated with plagues in the stretch marks with peri-umbilical sparing?
Polymorphic Eruption of Pregnancy
What is the first line management for Polymorphic Eruption of Pregnancy?
Topical corticosteroids and oral anti-histamines
What bullous autoimmune sub-epidermal dermatosis occurs in the third trimester resulting in urticarial plaques including around the umbilicus?
Pemphigoid Gestationis
What autoantibody is implicated in Pemphigoid Gestationis?
IgG-mediated against hemidesmisomes
What foetal complications are associated with Pemphigoid Gestationis?
Preterm delivery and low birth weight
What is the diagnostic investigation for Pemphigoid Gestationis?
- Direct immunofluorescence
What is the management for mild Pemphigoid Gestationis?
Emollients and topical steroids
Which type of umbilical cord predisposes to an increased risk to Twin to twin transfusion syndrome?
- Velamentous umbilical cord insertion
What sign, detected on ultrasound is associated with dichorionic diamniotic twins?
Lambda sign
T sign on ultrasound is associated with with which type of twins?
Monochorionic twins (thin dividing membrane results in T sign)
Which complication is associated with the recipient twin in Twin to twin transfusion syndrome?
Polyhydraminios
Which type of twins are more at risk for Twin to twin transfusion syndrome?
monochorionic diamniotic twins
What maternal signs are associated with TTTS?
Rapid weight gain, swelling and pain.
What is the frequency of monitoring for twins?
Every 2 weeks from 16 weeks of gestation
What is the recommended approach for treating TTTS?
Fetoscopic laser photocoagulation
What approach is indicated for correcting polyhydramnios?
Amnioreduction
What is the rule for missing 2 pills in the first week of the COCP?
Consider emergency contraception
How long does the COCP take effect?
7 days
If 2 or more pills are missed in week 2 - action?
No need for emergency contraception (take the last pill)
If 2 or more pills are missed in week 3 on the COCP, what is the action?
Finish the pills in the current pack, start the neck pack and omit the pill-free interval
What is the absolute contraindication for all forms of hormonal contraception (UKMEC 4)?
Breast cancer
Which type of contraception is recommended for patients with breast cancer?
Copper intrauterine device
What are the UKMEC 4 categories for contraception?
c. >35 years of age + >15 cigarettes/day
d. Migraine with aura
e. History of thromboembolic disease or thrombogenic mutation
f. History of stroke or ischaemic heart disease
g. Breastfeeding <6 weeks post-partum
h. Uncontrolled hypertension
i. Current breast cancer
j. Major surgery with prolonged immobilisation
k. Positive antiphospholipid antibodies (SLE)
What common side effect is associated with intrauterine systems following insertion?
Irregular bleeding within the first 6 months
What does the depo-provera injection include?
medroxyprogesterone acetate 150 mg
What is the mechanism of action of the depo-provera contraception?
Inhibits ovulation and thickens cervical mucous
How frequently should the depo-provera contraception be adminsitered?
Every 12 weeks (3 months)
Which form of contraception is associated with a delay in return to fertility?
Depo-provera injection (up to 12 months)
Which adverse effects are associated with the depo-provera injection?
Irregular bleeding, weight gain, increased risk of osteoporosis
When is COCP effective immediately?
If started on days 1-5 of the menstrual cycle
Which form of contraception is associated with significant weight gain?
Depo-provera injectable contraceptive
What is the mechanism of action of the intrauterine device as contraception?
Prevention of fertilisation by decreased sperm motility and survival
What effect does Levonorgestrel have in the IUS?
Thickens cervical mucous and prevents endometrial proliferation
How long does the implantable contraception work for?
Long-acting for 3 years
Can the implantable contraception be used in patients with migraines with aura?
Yes - does not contain oestrogen
How long does the implantable contraception take to work (fi not inserted on days 1-5)?
7 days- advice barrier contraception
What are the adverse effects associated with the implantable contraception?
irregular bleeding - managed with COCP
progestogen effects - headache, nausea, breast pain
Which drugs interact with the implantable contraception?
- Enzyme-inducing drugs – anti-epileptic and rifampicin can reduce efficacy
When can the progesterone-only pill be given post-partum?
Any time
When can contraception not be used unti?
Until day 21 postpartum
When should COCP not be used postpartum?
Within the first 21 days or <6 weeks breastfeeding
When can the IUD/IUS be inserted post-partum?
Inserted within 48 hours or after 4 wees
How long can lactational amenorrhoea work for?
Exclusive breastfeeding for 6 months without a period
When should the COCP be started during the cycle?
First 5 days of the cycle (5 days - immediate effect)
When should the COCP be discontinued before surgery?
4 weeks before
Which phase of the menstural phase does the COCP work on?
Follicular phase
How long does the patch be applied for?
3 weeks
How frequently should the combined hormonal patch be replaced?
Every week
What is the MoA for the combined hormonal transdermal patch?
Inhibition of ovulation
If there is a delayed change of the patch <48 hours, what is the action?
Immediate change
If there is a delayed patch change >48 hours in week 1 or 2, what should be performed?
Change immediate and barrier protection for 7 days (and consider emergency contraception if UPSI within previous 5 days)
Delayed patch change at the end of the patch-free week?
Change the patch and use barrier contraception for 7 days
How long does it take for the transdermal contraception patch to work?
7 days
What is the mechanism of action for the progesterone only pill?
Thickens cervical mucous
How long is the combined hormonal vaginal ring worn for?
21 days
How long does it take for the progesterone-only pill to work if started after 5 days of the cycle?
48 hours
What are the 2 main advantages associated with the progesterone only pill?
- Can be used in breast-feeding individuals
- Efficacy not reduced by antibiotics
What is the window for missed pills for traditional POP?
3 hours
if 2 or more POP pills are missed >3 hours, what is the next action?
Take the pill, emergency contraception and barrier contraception for 2 days
What is the window for missed pills for the cerazette POP?
12 hour window
What are the side effects associated with the depo-provera injection?
Weight gain, bone mineral loss, irregular periods, nervousness, skin rashes or spotty darkening of the skin and increased body hair + osteoporosis; cannot be used with current/past breast cancer
How long should the intrauterine devices and coils be inserted for?
up to 5 years
When is the foetus engaged?
When it is <2/5ths palpable or less above the pelvic brim
What position is the head when it enters the pelvic inlet?
Occipito-transverse position
what is the first stage of the mechanism of labour?
Engagement
What follows engagement in the mechanisms of labour?
Flexion
What does flexion do in the mechanism of labour?
Decreases the circumference of the fetal head to the sub-occiptobregmatic (9.5 cm)
What stage follows flexion in the mechanism of labour?
Internal rotation
During internal rotation, the foetus moves into which position?
into the occipito-anterior position
What term describes the clinical visualisation of the foetal head at the vulva?
Crowning
What happens after internal rotation of the foetus?
Extends - extension of the foetal neck once the head is visible beyond the labia
What happens following extension?
External rotation and restitution - the head rotates to align with the shoulders
What follows external rotation in the mechanism of labour?
Anterior shoulder delivery followed by posterior and trunk delivery
When is the combined test for Down’s syndrome performed?
11 - 13+6 weeks
What three parameters are assessed in the combined test for Down’s syndrome?
Raised hCG
Low PAPP-A
Nuchal translucency - raised
What is the hCG level for Edward’s and Patau syndrome?
Low
What four parameters are assessed in the quadruple test?
AFP
Unconjugated oestradiol
hCG
Inhibin
Which two parameters are raised on the quadruple test in Downs syndrome?
Inhibin A and hCG
When is the quadruple test offered?
At 15-20 weeks
If the combined or quadruple suggest an increased risk of developing Down’s syndrome, what test should be offered next?
Non-invasive prenatal screening test (NIIPT) or amniocentesis/CVS
What diagnostic test for Down’s syndrome is performed at 10-12 weeks?
- Chorionic villus sampling
Which test for Down’s syndrome is the most sensitive?
- Amniocentesis
When is Amniocentesis performed during pregnancy?
15-18 weeks’
When does postnatal depression first occur?
> 2 weeks
What scale is used to assess for postnatal depression?
Edinburgh Postnatal Depression Scale
What is the first line management for moderate to severe postnatal depression?
High intensity psychological intervention e.g,, CBT or SSRI or both
What is the management for mild-to-moderate postnatal depression?
Referral for facilitated self-help
When should a follow-up for postnatal depression be made?
within 2 weeks of referral
What is the management for perinatal depression for a patient already on an anti-depressant?
perinatal mental health team - advice to gradually reduce and consider switching to high intensity CBT
Severe depression pre-pregnancy and now pregnant management (on existing SSRI)?
Continue current medication + high intensity CBT
What effect does paroxetine have in the first trimester of pregnancy?
Increased risk of cardiovascular malformations
What effect can SSRIs have if used >20 weeks’ gestation?
Persistent pulmonary hypertension and neonatal withdrawal syndrome
What is the management for baby blues?
Reassurance
What is the follow-up for a patient with baby blues?
Follow-up diagnostic interview within 2 weeks.
What HIV RNA copies/mL threshold indicates the need for vaginal delivery?
<50 HIV RNA copies/mL at 36 weeks
What is the mode of delivery for HIV >50 RNA copies?
Elective c-section at 36 weeks
Which intrapartum drug infusion is initiated in HIV pregnancy?
Zidovudine infusion
What is the breast-feeding advice for HIV positive mothers?
Breast feeding is not recommended due to vertical transmission
Which antiviral drug is recommended in the first trimester of HIV positive patients?
Tenofovir
What immediate postpartum management is indicated for neonates of HIV positive mothers?
Wash baby and immediate cord clamping
How long should zidovudine monotherapy be commenced for neonates born to HIV positive players?
2-4 weeks
Which type of neonatal herpes is associated with the best prognosis?
- Disease localised to the skin, eyes and/or mouth
What is the management for genital maternal herpes (first episode) before 28 weeks?
Oral acyclovir (400 mg TDS, for 5 days)
And prescribe 400 mg TDS from 36 weeks
When should an elective c-section be considered, in a mother presenting with genital herpes?
From 28 weeks of gestation or within 6 weeks of expected date of delivery
Management for third trimester genital herpes in pregnancy?
C-section and oral acyclovir 400 mg TDS until delivery
At what weeks of gestation is fetal varicella syndrome at it’s highest risk?
<28 weeks’ gestation
What is the post-exposure varicella prophylaxis for mothers?
Acyclovir 800 mg QDS on days 7-14 post-exposure or Varicella-zoster immunoglobulin
What is the first line investigation to assess varicella immunity status in pregnant mothers?
Varicella antibodies (IgM) <100
When should VSIG be administered following exposure to varicella?
Within 10 days of varicella exposure
Confirmed chickenpox immunity is decided by?
confirmed chickenpox, shingles or 2 documented doses of varicella vaccine
What is the management for active varicella infection in pregnant mothers after 20 weeks?
oral acyclovir >20 weeks pregnancy within 24 hours onset of rash
What is the postnatal management for a neonate born to a varicella zoster infected mother within 7 days?
Reassurance unless symptomatic due to maternal varicella antibodies crossing the placenta
What is the delivery advice if the varicella infection occurs in the last 4 weeks of pregnancy in a mother?
Elective delivery should be delayed until 7 days after the onset of the rash to allow for passive transfer of maternal antibodies
What hepatitis antigen is screened for in pregnant women?
hepatitis B surface antigen
When is HBV screening performed during pregnancy?
At the initial booking appointment - 10 weeks
What are the indications for starting tenofovir for HepB in mothers?
HBV DNA >200,000 IU/L or quantitative HBsAg > 104 IU/L.
Which hepatitis variant is associated with adverse outcomes during pregnancy?
Hep E
What are the complications of active hepatitis B infection during preganncy?
HELLP syndrome and hepatic flares
What intrapartum management is recommended for HepB positive patients?
Active labour management is encouraged if there is a spontaneous rupture of membranes
What is the post-partum management for all babies born to HepB positive mothers?
immediate post-exposure prophylaxis (monovalent HepB vaccine +/- hepatitis B immunoglobulin), within 24 hours of life
What should be administered as PEP within the first 24 hours to neonates both to Maternal HBeAg positive and anti-be negative mothers?
intramuscular hepatitis B immunoglobulin (HBIG)
What is the complication of a parvovirus b19 infection during pregnancy?
hydrops fetalis
What screening investigations should be performed for positive parvovirus B19 infections during pregnancy
- Serial foetal ultrasound and Doppler Assessment
What is the definitive management for placental abruption?
Immediate laparotomy
Why are NSAIDs contraindicated in pregnancy/
Due to premature closure of the ductus arteriosus
Why are ACE inhibits and ARBs contraindicated during pregnancy?
Oligohydramnios
Miscarriage/IUD
Hypocalvaria (incomplete formation of the skull bones)
Renal failure in the neonate
Neonatal hypotension
Which blood thinners are not recommended in pregnancy?
DOACs and Warfarin
When are foetal movements first felt?
at ~16-24 weeks
When is the symphysis fundal height first measured?
at 24 weeks, and every 2 weeks after that
When is the booking appointment?
At 10 weeks
When should the OGTT first be performed in a woman with previous gestational diabetes?
At booking and again at 24-28 weeks
A woman with no previous GDM but risk factors, OGTT when?
24-28 weeks
For one major risk factor for pre-eclampsia, what should be offered?
low dose 75-150 mg of aspirin from 12 weeks
What is the standard dose of folic acidduring pregnancy?
400 ug OD from pre-conception until 12 weeks
What three infections are screened during the booking appointment in pregnancy?
Hepatitis B, syphillis, and HIV
When is the dating scan performed?
11+2 to 14+1
When are red cell alloantibodies first screened for?
At the booking appointment
When is used to determine the date of gestation during the dating scan?
Crown-Rump Length
When should the pertussis vaccine be given during pregnancy?
Following 16 weeks of gestation
When is the anomaly scan performed?
18+0 - 20+6
What does the anomaly scan detect?
Placenta location
When should a second scan for the placenta location be offered following the anomaly scan?
32 weeks of gestation
What three investigations should always be offered at GP reviews?
BP, BMI, Urine dip
Also measure SFH
When is the first dose of Anti-D prescribed?
28 weeks of gestation
When is the second dose of Anti-D prescribed?
At 34-weeks
What is the management for asymptomatic bacteriuria in pregnancy?
1st line - nitrofurantoin for 7 days or amoxicillin 500 mg or cefalexin 500 mg
Which antibiotic is contraindicated at term or labour for active UTI?
Nitrofurantoin
What is the main cause of infectious mastitis?
Staphylococcus aureus
What are the two different types of mastitis?
Periductal mastitis
Granulomatous mastitis
Which type of mastitis is assocaited with nipple retraction?
Periductal mastitis
When shoulder a breast milk culture be indicated for mastitis?
- Severe or recurrent mastitis
- Hospital-acquired infection is likely
- Severe deep burning breast pain
What is the first line management for lactating women with mastitis?
Reassurance and continue breastfeeding
Which antibiotic is recommended for the management for lactational mastitis?
Flucloxacillin 500 mg
What are the indications for commencing antibiotic therapy in lactational mastitis?
- Nipple fissure that is infected
- Symptoms have not resolved/worse after 12-24 hours despite effective milk removal
- Breast milk culture is positive
What is the first line management for breast abscess?
- Ultrasound-guided needle aspiration + culture of fluid.
What is the main sign for a breast abscess?
- Fever/general malaise.
- A painful swollen lump in the breast, redness, heat, and swelling of the overlying skin.
- Lump may be fluctuant with skin discolouration.
What are the signs suggestive of infectious mastitis?
- A nipple fissure
- Purulent discharge
- Influenza-like symptoms and pyrexia >24 hours.
- Breast discomfort.
- Symptoms not improving after 12-24 hours despite effective milk removal.
What BMI threshold is considered a moderate risk factor for pre-eclampsia?
35
What BMI threshold is associated with requiring 5 mg folic acid dose?
30
What is the management for BMI >40 in obesity during pregnancy?
Refer to an obstetric anaesthetist for antenatal assessment
What is the mode of delivery for monochorionic diamniotic twins?
elective caesarean section between 32 and 33+6 weeks.
When should a routine ultrasound scan be performed during pregnancy?
18 and 20+6 weeks
When should foetal ultrasound monitoring begin for twin pregnancies?
16 weeks ,for every 2 weeks
What support group is available for multiple pregnancies?
Twins and Multiple Birth Association (TAMBA)
How is TTTS staged?
Quintero system + umbilical artery Doppler velocities
What is the mode of delivery recommended for diamniotic twins?
Vaginal
Which antithyroid drug is preferred during the first trimester of pregnancy?
Propylthiouracil
Which drug is recommended to manage postpartum thyroiditis?
propranolol
Which drug should be avoided (used in PPH) for pregnant women with asthma?
carboprost
Which drug is used to expedite an intrauterine death?
- Induction of labour – mifepristone and a prostaglandin preparation (misoprostol).
How is a stillbirth confirmed?
Real-time ultrasonography – Direct visualisation of the fetal heart.
What threshold denotes small for gestational age (kg)?
<10th centile – less than 2.5 kg.
What are the 2 parameters used to assess for foetal growth restriction?
Abdominal circumference and estimated foetal weight.
When should an uterine doppler be performed in high risk groups?
20-24 weeks
When is an umbilical artery Doppler performed in high risk patients?
> 24 weeks
What are the parameters that indicate IUGR on umbilical artery Doppler?
o Reverse end-diastolic flow (EDF)
o Raised pulsatility index (PI)
o Absent end-diastolic flow
What is the main cause of symmetrical IUGR?
Congenital infections
What are the worse prognostic factors associated with IUGR on umbilical artery Doppler?
Reverse End diastolic flow and absent end diastolic flow
When should delivery be performed when IUGR is confirmed?
> 34 weeks + mag sulphate if under <32 weeks
