O&G Flashcards
1
Q
What is the most common cause of vaginal candidiasis?
A
Candida albicans
1
Q
What are the risk factors for vaginal candidiasis?
A
Diabetes mellitus,
Antibiotics, steroids
Pregnancy
Immunosuppression: HIV
2
Q
What is the first line management for vaginal candidasis?
A
Single dose oral fuconazole 150 mg
OR clotrimazole 500 mg intravaginal pessary is first line is contraindicated
3
Q
What is the first line management for endometriosis if analgesia is ineffective?
A
Combined oral contraceptive pill or progestogens
4
Q
What is the gold standard investigation for diagnosing endometriosis?
A
Laparoscopy
5
Q
What is the fasting glucose diagnosis threshold for gestational diabetes mellitus?
A
> 5.6 mmol/L
6
Q
How long does the progestogen-only pill take to become effective?
A
48 hours
7
Q
What muscarinic antagonist is prescribed to manage urgency incontinence, despite bladder retraining?
A
Oxybutynin, tolterodine
8
Q
What is the endocrine complication associated with severe PPH?
A
Sheehan’s syndrome
9
Q
Which dose of folic acid should be prescribed in women who are on antiepileptics and are attempting to conceive?
A
5 mg folic acid
9
Q
Which drug is prescribed to manage infertility in PCOS?
A
Clomifene
10
Q
When is folic acid advised in pregnancy?
A
From conception to the 12th week
11
Q
What threshold of fasting blood glucose indicates insulin administration?
A
> 7 mmol/L
12
Q
When are OGTT investigations performed for screening gestational diabetes in a patient with a previous GDM?
A
Immediately, and at 24-28 weeks.
13
Q
When is breast feeding an absolute contraindication to COCP use (UKMEC 4)?
A
<6w post partum
14
Q
What should be administered to a rhesus-negative mother undergoing surgical removal of an ectopic pregnancy?
A
Anti-D immunoglobulin
15
Q
At what stage should a serum progesterone level be measured for assessing ovulation?
A
7 days prior to the expected next period
16
Q
First line investigation for pregnancy exposure to varicella zoster (with uncertain background)?
A
IgG VZ antibodies (<100 = high risk)
17
Q
Define Asherman’s syndrome
A
Intrauterine adhesions/scar tissue resulting in dysfunctional endometrium - typically followers dilation and curettage.
18
Q
Which thromboprophylaxis should be prescribed in high risk pregnant women?
A
Low molecular weight heparin
19
Q
What is the management for positive group B strep in pregnancy?
A
Intrapartum IV benzylpenicillin
20
Q
First line SSRI in postpartum depression
A
Sertraline (not fluoxetine)
21
Q
What is the management for breech position at 36w?
A
External cephalic version
22
Q
What is the first line non-hormonal management for menorrhagia?
A
Tranexamic acid
23
What is the management for Premenstrual dysphoric disorder?
Sertraline
24
What is the second line management for stress incontinence after a trial of pelvic floor muscle training (3 months)?
Duloxetine
25
Tamoxifen increases which type of cancer?
Endometrial cancer - behaves as an oestrogen receptor agonist on endometrial cells.
26
When is an anomaly scan performed?
18 - 20+6 weeks
27
What drug is prescribed to ripen the cervix during induction of labour (Bishop Score <7)?
Vaginal prostaglandin
28
What is the complication of cholestastic disease of pregnancy?
Stillbirth
29
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
30
What is the largest risk factor for cord prolapse?
* Rupture of membranes
31
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.
32
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.
33
What foetal presentation is associated with cord prolapse?
Severe prolonged foetal bradycardia
Moderate to severe variable decelerations
Risk of foetal hypoxia
34
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
35
What is the emergency management option for cord prolapse?
Emergency caesarean section
* Keep cord warm and wet – minimal handing (handling causes vasospasm) – urinary catheter.
36
In cord compression, what position is recommended for the mother?
Left lateral position
Knee-chest position
37
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.
38
What is the main cause of atrophic vaginitis?
Menopause
39
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.
40
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.
41
What is the 1st line treatment for atrophic vaginitis?
Non-hormonal vaginal moisturisers and lubricants
42
What is the 2nd line treatment option for atrophic vaginitis?
Vaginal oestrogen therapy
43
What is the normal microbiome of the vagina?
Lactobacillus
44
What does Lactobacillus produce?
Hydrogen peroxide and lactic acid
45
Which bacteria is implicated in the pathogenesis of bacterial vaginosis?
Gardnerella vaginalis
46
What type of bacteria is Gardnerella vaginalis?
Anaerobic gram-negative rod
47
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.
48
What happens to the vaginal pH in BV?
>4.5
49
What are the protective factors associated with BV?
use of hormonal contraception
consistent condom use
Circumcised partner
50
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.
51
What are the four investigations for diagnosing BV?
Vaginal swab
pH test - >4.5
Positive white-amine test
Sample for gram-staining and microscopy
52
What microscopy findings are observed in bacterial vaginosis?
Clue cells on saline wet mount
stippled vaginal epithelial cells >20%
53
Which criteria is commonly used to diagnose BV?
Amsel's criteria
54
What are the four parameters of Amsel's criteria?
1. Homogenous, thin, grayish-white discharge coating the vaginal walls.
2. Vaginal pH >4.5
3. Positive whiff-amine test
4. Clue cells on saline wet mount
Only need 3 out of the 4
55
What is the 1st line ABx for BV?
Oral metronidazole 400 mg BD for 5-7 days.
56
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.
57
What are the complications associated with BV during pregnancy?
Late miscarriage, preterm birth, PROM and postpartum endometritis.
58
What is the cause of Trichomonas Vaginalis?
Protozoan trichomonas vaginlias
59
What are the risk factors of Trichomonas Vaginalis?
Sexually active women <25 years (>1 partner in the last 12 months + history of STI)
60
What clinical presentation differentiates between TV and BV?
Vulval itching and soreness
61
What type of vaginal discharge is seen in Trichomonas Vaginalis?
Frothy and yellow-green malodorous discharge
62
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
63
On examination of the vulva and cervix, what characteristic features are seen?
Strawberry Cervix
64
A strawberry cervix is associated with what pathology?
Trichomonas Vaginalis
65
If Trichomonas Vaginalis is suspected what is the management referral?
Refer to the GUM clinic for confirmed diagnosis
66
What type of swab is recommended for Trichomonas Vaginalis?
High vaginal swab from the posterior fornix
+ STI tests for chlamydia, gonorrhoea, HIV and syphillis
67
What is the diagnostic test for Trichomonas Vaginalis?
Microscopy of a wet mount slide - revealing motile trophozoites
68
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.
69
Is a STAT dose prescribed in Trichomonas Vaginalis during pregnancy?
No, offer 5-7 400 mg prescription of metronidazole
70
What advice is given to women with Trichomonas Vaginalis?
Sexual abstinence for at least 1 week and for partners to complete treatment + contact tracing.
71
What are perinatal complications associated with Trichomonas Vaginalis?
Preterm delivery
Low birthweight infant
72
What type of bacteria is chlamydia?
An obligate intracellular gram-negative bacterium
73
What is uncomplicated Chlamydia ?
Has not ascended to the upper genital tract
74
What does ascending Chlamydia cause?
Pelvic inflammatory disease
75
Which is the most common infected anatomic site for Chlamydia ?
Cervix
76
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.
77
What are the symptoms of lymphogranuloma venereum?
Tenesmus
Anorectal discharge
Diarrhoea
Altered bowel habit
78
What is the first-line investigation for Chlamydia?
Vulvovaginal or endocervical swab or first-catch urine
NAAT positive
79
What is the antibiotic of choice for the management of Chlamydia ?
Doxycycline
80
What is the starting dose for doxycycline for Chlamydia ?
100 mg BD for 7 days
81
Which ABx for Chlamydia is contraindicated in pregnancy?
Doxycycline
82
Direct microscopy in Chlamydia reveals what?
Neutrophils - in non-gonococcal urethritis
83
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
84
What is the second line ABx for Chlamydia ?
Azithromycin
85
When is the test of cure performed for Chlamydia ?
5 weeks (and avoid sexual intercourse until treatment has completed)
86
How far back should contact tracing go for Chlamydia ?
6 months
87
What are the complications associated with Chlamydia ?
Pelvic inflammatory disease
Endometritis
Increased incidence of ectopic pregnancy
Infertility
Reactive arthritis
Fitz-Hugh Curtis Syndrome (perihepatitis)
88
When does annual screening for Chlamydia begin in sexually active women?
<25 years of age
89
What type of bacteria is Gonorrhoea?
Gram-negative intracellular coccus
90
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.
91
What are the presenting features of cervicitis in Gonorrhoea?
o ~70% are asymptomatic.
o Vaginal pruritus
o Mucopurulent discharge
o Examination – cervix is friable.
92
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
93
What does a bimanual examination assess for?
Perform bimanual examination for cervical motion tenderness, uterine tenderness, and adnexal tenderness.
94
What is the first-line investigation for suspected Gonorrhoea ?
Vulvovaginal swab for nucleic acid amplification testing (NAAT)
95
What is the antibiotic of choice for antimicrobial susceptible Gonorrhoea ?
Ciprofloxacin 500 mg Oral - Stat
96
What is the first -line antibiotic for the management of Gonorrhoea ?
Ceftriaxone 1g single dose IM
97
When is a test of cure performed in Gonorrhoea ?
1 week follow-up (avoid sex for 7 days and initiate contact tracing)
98
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
99
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).
100
Define Pelvic Inflammatory Disease
PID -Infection of the upper genital tract in sexually active young women, ascending from the vagina and endocervix.
101
What are the two most common pathogens implicated in the pathology of pelvic inflammatory disease?
Neisseria gonorrhoeae and chlamydia trachomatis (most common)
102
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.
103
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.
104
What is the clinical presentation of Fitz-Hugh Curtis Syndrome?
RUQ pain/right shoulder pain due to perihepatitis
105
What are the diagnostic criteria for pelvic inflammatory disease on bimanual examination (/3)?
1. Uterine tenderness
2. Cervical motion tenderness
3. Adnexal tenderness - a sensitive marker for endometritis
106
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
107
On a wet mount vaginal smear, what is revealed in PID?
Pus cells
108
What imaging modality is used to detect for tubo-ovarian abscess secondary to PID?
TVUSS
109
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).
110
What are the three outpatient antibiotics prescribed to patients with PID?
1. Ceftriaxone 1 g - Single IM dose
2. Oral doxycycline 100 mg BD for 14 days
3. Oral metronidazole 400 mg BD for 14 days
111
What is the advice pertaining to IUD/Copper coils in patients with PID?
For moderate symptoms - remain in situ
Severe -Removed
112
What is the alternative antibiotic regimen for pelvic inflammatory disease?
* Oral ofloxacin 400 bd
* + Oral metronidazole 400 mg BD for 14 days
113
When should patients with PID be followed-up post ABx management?
Within 72 hours
114
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
115
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
116
When should a follow-up be arranged to ensure for resolution of PID?
2-4 weeks
117
What is the antibiotic prescribed to a partner within 6 months of disease onset in contact tracing?
Doxycycline for 7 days
118
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.
119
What is Cervical intraepithelial neoplasia (CIN)?
A pre-malignant condition referring to dysplastic change to the squamous epithelium of the ectocervix
120
What type of cells lines the ectocervix?
squamous epithelium.
121
What type of cells line the endocervix?
glandular epithelium (columnar)
122
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
123
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)
124
What does Cervical intraepithelial neoplasia (CIN) stage 3 refer to?
3. 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.
125
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.
126
Which HPV is carcinogenic for CIN?
HPV 16 and 18
127
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.
127
When is the national vaccination for HPV adminstered?
For girls and boys aged 12-13 years old.
128
What HPV subtypes are vaccinated against?
HPV subtypes 6, 11, 16 and 18
129
When does cervical screening begin?
Age - 25 years
130
How frequent is cervical cancer screening for 25 to 49 year olds?
Every 3 years
131
How frequent is cervical cancer screening for 50-65 year olds?
Every 5 years
132
How frequent should you screen a patient for cervical cancer with a positive HPV/HIV status?
Every year
133
If there is an inadequate cervical smear, when should the next one be?
In 3 months
134
How many inadequate cervical smears warrants a colposcopy?
3
135
When should a cervical smear be conduced postpartum?
3 months post partum
136
For borderline/mild dyskaryosis on cervical smear, what is the next-step investigation?
HPV testing - followed by colposcopy if positive
137
For Moderate to severe dyskaryosis/CN II/III, what is the next step investigation?
Urgent colposcopy
138
What does dyskaryosis refer to?
Abnormal nuclei
139
What is the first line management for CIN I?
Repeat smear in 12 months
140
What is the first line surgical intervention for CIN?
Large loop excision of the transformation zone (LLETZ)
141
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
142
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
143
What obstetric risks are associated with Large loop excision of the transformation zone (LLETZ)?
Mid-trimester miscarriage
144
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.
145
What obstetric risk is associated with a cone biopsy?
Preterm delivery
146
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
147
If hysterectomy for CIN , what type of smear is performed at 6m and 18m?
Vault smear
148
Where does cervical cancer originate from (anatomy)?
Transformation zone
149
What are the risk factors for cervical cancer?
* Risk factors: HPV-related, oral contraceptive use, intrauterine device, cigarette smoking and low socioeconomic status.
150
Which HPV subtypes predispose patients to developing cervical cancer?
HPV types 16 and 18
151
What is the median age of diagnosis for cervical cancer?
50 years
152
What is the most common histological type of cervical cancer?
Squamous cell carcinoma (80%)
Adenocarcinoma (20%)
153
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.
154
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)
155
What urgent investigations are performed for cervical cancer?
Urgent colposcopy and MRI
156
What are the diagnostic changes observed in cervical cancer?
Abnormal vascularity
White change with acetic acid
Visible exophytic lesions
157
What change is observed with acetic acid in cervical cancer?
White change
158
What staging system is used to classify cervical cancer?
FIGO
159
What is FIGO stage I for cervical cancer?
Carcinoma is confined to the cervix
160
What is FIGO stage II for cervical cancer?
Carcinoma invades beyond the uterus, but NOT into the lower third vagina
161
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.
162
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.
163
What is the management for StageIA1 (micro invasive disease) cervical cancer?
Loop electrosurgical excision and conization.
164
If a woman does not want to preserve fertility, what is the management for cervical IA1?
Simple hysterectomy
165
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
166
For stage IA2-IB2 tumours measuring >4 cm, what is the first-line management for cervical cancer?
Consider adjuvant chemotherapy or radiotherapy
167
For <4cm cervical tumours desiring fertility, what is the first line surgical management (Stage IA2-IB2)?
Radica trachelectomy
168
What are the surgical risks associated with radical trachelectomy?
o Bladder dysfunction (atony) -Common
o Sexual dysfunction
o Lymphoedema
May require intermittent self-catheterisation
169
What is the first-line management for IB3-IVA locally advanced disesae?
Chemoradiation - external beam radiotherapy
Intracavity radiotherapy
170
What is the preferred chemotherapy drug for cervical cancer?
Cisplatin
171
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
172
What is type 1 endometrial cancer?
(SEM)
Secretory
Endometrioid
Mucinous carcinoma
173
What type of cancers is type 1 endometrial cancer?
Oestrogen-driven, affecting young patients and is low-grade
174
What are the two most common mutations implicated in endometrial cancer?
PTEN and P13KCA
175
What are the 2 main subtypes of type II endometrial cancer?
SC
Uterine papillary serous carcinoma
Clear cel carcinoma
176
What is the main mutation associated with serous carcinoma?
p53
177
What classification system is used for endometrial cancer?
FIGO
178
What is the most common histological subtype of endometrial cancer?
Adenocarcinoma
179
What is the peak incidence of endometrial cancer?
60-70 years
180
What is the main aetiology driving the development of endometrial cancer?
Long-term exposure to increased unopposed oestrogen
181
What are the risk factors of endometrial cancer?
Chronic anovulation
Obesity
Lynch Syndrome
Early menarche, late menopause
Tamoxifen
TD2M, PCOS
182
What are the protective factors of endometrial cancer?
Oestrogen-progestin or Progestin-only contraceptives (protective against oestrogen-driven carcinomas (Grades 1-2)).
183
Which clinical feature warrants further referral for suspected endometrial cancer?
Abnormal uterine bleeding
184
Post-menopausal bleeding warrants what?
2ww referral to gynaecologist
185
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).
186
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.
187
What is the first line investigation for suspected endometrial cancer?
Pelvic transvaginal ultrasound
188
What is normal endometrial thickness
<4 mm
189
What level of endometrial thickness is highly sensitive for endometrial cancer?
>5 mm
190
What is the definitive diagnostic investigation for confirming endometrial cancer?
Outpatient hysteroscopy
with endometrial biopsy
191
What is the management for stage 1 endometrial cancer?
Total abdominal hysterectomy and bilateral salpingo-oophorectomy and peritoneal washings.
192
What is the surgical management for stage 2+ endometrial cancer?
* Radical hysterectomy (including cervix)
* Radiotherapy adjunct.
193
What hormonal therapy is available for young women desiring for conception with endometrial cancer?
High dose oral and intrauterine progestins (LNG-IUS)
194
What are the common sites of endometriosis?
Pelvis, on the ovaries, peritoneum, uterosacral ligaments, and pouch of Douglas.
195
What is the definition of endometriosis?
Endometriosis is characterised by the growth of endometrium-like tissue outside the uterus.
196
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).
197
What are the protective factors of endometriosis?
Fruit/veg; multiparity, Omega 3, prolonged lactation/breastfeeding.
198
Which ovarian cancer is associated with endometriosis?
Clear cell ovarian carcinoma
199
What is Sampson's theory?
Retrograde menstruation and implantation may be the cause.
200
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.
201
What are the three types of endometriosis?
1. Endometrioma (ovarian cysts)
2. Superficial peritoneal lesions (located on the pelvic organ or peritoneum)
3. Deep infiltrative endometriosis.
202
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.
203
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
204
A fixed retroverted uterus in endometriosis is suggestive of what?
Ectopic tissue on uterosacral ligament
205
What is the first-line investigation for suspected endometriosis?
TVUSS
206
What is the diagnostic investigation for endometriosis?
Laparoscopic visualisation of the pelvis.
207
Red vesicles or punctuate marks on the peritoneum in endometriosis is indicative of what?
Active lesions
208
What is the first line pain relief management for endometriosis?
Short trial of paracetamol or NSAIDs (3 months)
209
What adjunctive medication to pain killers can be prescribed as first-line non-hormonal medication in endometriosis?
Tranexamic acid
210
What is the first-line hormonal management for endometriosis?
Combined oral contraceptive pill, or progestogen (depot-provera or Mirena coil)
211
How long should hormonal treatment should be prescribed as a first line trial?
3 months
212
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
213
What is the preferred surgical intervention for mild endometriosis?
Laparoscopic ablation
214
What is the radical surgical option for endometriosis?
* Hysterectomy with BSO
215
For patients with endometriosis desiring conception, what is the surgical management?
Laparoscopic ablation + endometrioma cystectomy
216
What is the pre-operative management prescribed to patients undergoing surgery for endometriosis?
GnRH analogues (e.g., leuprorelin)
217
What side effects are associated with using GnRh analogues?
pseudo-menopause
Menopause-like side effects: hot flushes, night sweats
218
What co-existing conditions are associated with endometriosis?
IBS and constipation in up to 80%
219
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
220
Name the two layers of endometrial hyperplasia?
Functional - glands and stroma
Basal - regenerates the functional layer after each menstrual cycle
221
What are the risk factors of endometrial hyperplasia?
Prolonged exposure to oestrogen
222
In which phase during the menstrual cycle is associated with oestrogen stimulating growth of endometrial glands?
Proliferative phase
223
Which ratio is raised in endometrial hyperplasia?
High gland: stroma ratio
224
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
225
Why does obesity cause endometrial hyperplasia?
Adipose tissue converts androgens to oestrogen
226
Why do granulosa-cell tumours increase the risk of endometrial hyperplasia?
Oestrogen secreting tumours
227
Why do cystic follicles increase the risk of endometrial hyperplasia?
Secretes oestrogen
Chronic anovulation and no progesterone-secreting luteal bodies
228
Which breast cancer drug increases the risk of endometrial hyperplasia (and why?)
Tamoxifen
- Blocks oestrogen receptors + stimulates oestrogen receptors.
229
What is the presentation of endometrial hyperplasia?
* Menorrhagia – heavy or prolonged menstrual bleeding
* Metrorrhagia
* Amenorrhea
230
What is the first line of investigation for suspected endometrial hyperplasia?
Transvaginal ultrasound
231
What is the threshold for prompting 2nd line investigations for endometrial hyperplasia?
>4 mm
232
What is the gold-standard investigation for endometrial hyperplasia?
Outpatient hysteroscopy with a pipelle biopsy
233
What is simple endometrial hyperplasia?
Normal stroma : gland ratio
234
What is complex hyperplasia?
Increased gland : stroma ratio (large and hyperchromatic nucleus)
Associated with nuclear atypia
235
What is the risk of developing endometrial cancer in patients with hyperplasia with nuclear atypia?
30%
236
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
237
How frequent should endometrial surveillance be in a patient with EH without atypia?
Every 6 months
2 negative biopsies - discharge
238
What is the first line medical management for EH without atypia?
Oral progesterone - continuous
239
What is the fertility non-sparing treatment option for EH with atypia?
Total hysterectomy + BSO if post-menopausal
240
What is the fertility-sparing treatment option for EH with atypia?
2nd line: Oral progestogens, routine surveillance with biopsies
241
How many consecutive negative biopsies are required for discharge in a patient with EH?
2
242
Define a uterine fibroid
A benign smooth muscle tumour of the uterus - leiomyoma - monoclonal proliferation of smooth muscle cells and fibroblasts
243
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
244
What are the protective factors associated with uterine fibroids?
Smoking
Multiparity
COCP
245
What are the four types of fibroids?
Subserosal
Intramural
Submucosal fibroid
Pedunculated fibroids
246
Where do subserosal fibroids develop?
Develop in the wall of the uterus.
247
Where do intramural fibroids develop?
From myometrial cells at the perimetrium | can detach from uterus.
248
Where do submucosal fibroids develop?
From myometrial cells below the endometrium.
249
What are pedunculated fibroids?
Can grow into the cavity of the uterus.
250
What is red-generation in regards to fibroids?
Coagulative necrosis in pregnancy , cystic change
251
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.
252
On bimanual examination, what are the positive findings associated with fibroids?
Firm, enlarged, and irregularly shaped non-tender uterus
253
What is the first line investigation for fibroids?
Transvaginal ultrasound - to assess size and location
254
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.
255
For fibroids <3 cm in size, what is the first line management?
IUS - Mirena coil
256
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
257
What medication is used to manage pain associated with fibroids?
Mefenamic acid / NSADIs
258
Mefenamic is contraindicated in what disorder?
IBD
259
What class of drug is Transexamic acid ?
Antifibrinolytic - 1 TDS
260
What is the fertility sparing surgical option for the management of fibroids?
Myomectomy
260
Transexamic acid is contraindicated in what?
Renal impairment, thrombotic disease
261
What is the non-fertility-sparing definitive surgical option for fibroid treatment?
Hysterectomy
262
If surgery is not tolerated or unsuitable, what alternative approach is indicated for the management of fibroids?
Uterine artery embolisation
263
How does uterine artery embolisation work?
Catheter reduces blood flow to fibroids – atrophy.
264
What class of drug is ulipristal?
Selective progesterone receptor modulator
265
What medication is prescribed pre-operatively to shrink fibroids?
GnRH analogues
266
What are the side effects associated with the use of GnRH analogues?
Chemical menopause - Hot flushes, sweating, vaginal dryness, osteoporosis
267
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.
268
Describe the pathophysiology of cervical ectropion
Migration of endocervix columnar cells from the transformation zone to the ectocervix
269
What type of cells line the endocervix?
Columnar cells
270
What histopathological change occurs in cervical ectropion?
Metaplastic change of squamous to columnar cells
271
What are the symptoms of cervical ectropion?
Intermenstrual bleeding, post-coital bleeding, and increased discharge (most common identifiable cause of post-coital bleeding).
272
What are the risk factors associated with cervical ectropion?
Linked to oestrogen - pregnancy and COCP
273
What is the management of cervical ectropion?
Reassurance, cauterisation, cryotherapy.
274
Definition of cervical polyps
Overgrowth of endocervical columnar epithelium - benig and solitary
275
What is the diagnostic investigation for endometrial polyps?
1st line = TVUSS
Gold-standard - outpatient hysteroscopy and saline - infusion sonography
276
What is the surgical management for symptomatic endometrial polyps?
Polypectomy
277
What is the latin name of anogenital warts?
Condylomata acuminate
278
What is the common site of anogenital warts?
Vaginal introitus
279
What HPV subtypes are indicated in the development of anogenital warts?
HPV subtypes 6 and 11
280
What are the high risk HVP subtypes?
16 and 18
281
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.
282
What is the characteristic appearance of genital warts?
Cauliflower growths
283
What is the management for genital warts?
Referral to sexual health specialist
284
What is the first line management for genital warts (non-keratainised)?
Topical podophyllotoxin
285
What is the first line of management for keratinisied external genital and perianal warts?
Imiquimod
286
What is the surgical management for keratinisied genital warts?
Ablative methods (cryotherapy, excisions, and electrocautery)
287
What is type 1 FGM?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
288
What is type II FGM?
Partial or total removal of the clitoris and the labia minora (with or without excision of the labia majora)
289
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).
290
What is type IV FGM?
Type IV: Other harmful procedures – pricking, piercing, incising, scraping and cauterisation.
291
What clinical features are associated with FGM?
Presentation:
* Constant pain,
* Dyspareunia
* Bleeding, cysts, abscesses
* Incontinence
* Depression, flashbacks, self-harm.
292
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.
293
What is the management for a patient <18 years presenting with FGM?
Report to the police and social services
294
What is the management for a patient >18 years presenting with FGM?
No obligatory duty to report Offer Deinfibulation.
295
What are the complications associated with FGM?
Repeated infections Infertility, life threatening complications during labour, childbirth.
296
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
297
What are the clinical features associated with PMS?
1. Mood swings
2. Anergia
3. Breast tenderness
4. Anxiety
5. Changes in appetite
6. Headache
7. Disturbed sleep
8. Poor concentration
9. Bloating
298
What is the first line investigation for suspected PMS?
Symptom diary - minimum over 2 cycles
299
What is the first line management for moderate PMS?
COCP - yasmin - paracetamol or NSAIDs
consider CBT
300
What is severe PMS?
Premenstrual dysphoric disorder (Withdrawal from activities, prevent normal functioning)
301
What is the first line management for severe PMS?
Sertraline
302
What are the three classifications of ovarian tumours?
1. Epithelial surface derived tumours
2. Germ cell tumours
3. Sex-cord stromal tissues
303
What are the risk factors associated with ovarian tumours?
Increased ovulation - nulliparity, early menarche, and late menopause
304
Which genes are implicated in increasing the risk of ovarian tumours?
BRCA1/2, MSH2, MLH1
305
What genetic syndrome is associated with increasing ovarian tumour development?
Lynch Syndrome
306
Which mutations are associated with Lynch syndrome?
MSH2 and MLH1
307
Which type of ovarian tumour is the most common?
Epithelial
308
Which type of ovarian tumour is most common in postmenopausal women?
Epithelial ovarian tumour
309
What are the most common epithelial tumours?
Serous cystadenoma
Mucinous cystadenoma
310
What are malignant serous epithelial ovarian tumours associated with on histology?
Psammoma body
311
Definition of Psammoma body?
Plaques with calcium and cellular deposits
312
What are mucinous cystadenomas?
Associated with mucous filled cysts (ovarian epithelial tumour)
313
What complication are malignant mucinous epithelial ovarian tumours associated with?
pseudomyxoma peritonei.
314
What is pseudomyxoma peritonei?
Mucinous material collecting within the peritoneal cavity
315
Name the four types of epithelial ovarian tumours?
1. Serous cystadenoma
2. Mucinous cystadenoma
3. Endometrioid
4. Transitional cell
316
Name the characteristic cysts associated with endometrioid tumours?
Chocolate cysts
317
What are Brenner tumours?
Transitional ovarian tumours - coffee bean nuclei
318
What histological finding (nuclei) is found in Brenner tumours?
Coffee Bean Nuclei
319
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.
320
What are the common benign ovarian tumours associated in women <30 years of age?
Teratoma
321
What are common types of germ cell ovarian tumours?
Teratoma (dermoid cyst)
Dysgerminoma
Yolk sac tumour
Choriocarcinoma
322
Which type of ovarian tumour is associated with thyroid tissue?
Struma-Ovarri Tumour - causes hyperthyroidism
(Associated with mature cystic teratoma)
323
What is the most common germ cell tumour associated in children?
Yolk Sac tumour
324
What types of bodies are associated with yolk ovarian tumours?
Schiller–Duval Bodies
325
What are Schiller–Duval Bodies?
Rings of cells around a central blood vessel.
326
What cell do choriocarcinoma derive from?
Syncytiotrophoblast cells
327
What do choriocarcinoma secrete?
Beta-hcg
328
Which type of germ-cell ovarian cancer is most malignant?
Dysgerminoma
329
what are the four common sex-cord stromal ovarian cancers?
1. Fibroma - no endocrine function
2. Thecoma - Oestrogen
3. Granulosa cell tumour - Oestrogen
4. Sertoli-Leydig cell tumour - androgens variable
330
Which cell does LH stimulate?
Theca cells
331
What do theca cells produce?
Androgens
332
What effect does FSH have?
Oestradiol production via stimulating aromatase activity
333
Call-Exner bodies are associated with which type of Sex-cord stromal ovarian cancer?
Granulosa-theca cell cancer
334
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
335
What is Meigs syndrome?
Tumour causing transudative fluid accumulation - pleural effusion and ascites.
336
What histological finding is associated with Sertoli-Leydig cells?
Reinke Crystals - Pink crystals
337
What first-line tumour marker should be performed in a patient with suspected ovarian cancer?
Serum CA-125
338
What is the diagnostic threshold for serum CA-125 in ovarian cancer?
>35 IU/L
339
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
340
What factors can cause an falsely raised CA-125?
Pregnancy, endometriosis, and alcoholic liver disease, heart failure
341
Which risk index is used to determine the risk associated with ovarian tumours?
Risk of Malignancy Index (RMI)
342
What are the three parameters included in the RMI?
1. Menopausal status
2. USS features – Ultrasound abdomen and pelvis
3. CA125
343
A threshold RMI score of what is considered high-risk for ovarian cancer?
>250 IU/L
344
What type of neoadjuvant chemotherapy is administered in ovarian cancer?
Platinum-based compounds with paciltaxel
345
What are the common platinum-based chemotherapy compounds implicated in the management of ovarian cancer?
Carboplatin
346
What are the three chemotherapy and immunotherapy agents indicated in the management of ovarian cancer?
Carboplatin
Paciltaxel
Bevacizumab
347
What is the mechanism of action of carboplatin in the management of ovarian cancer?
Cross-linkage of DNA leading to cell cycle arrest
348
How does Paclitaxel work in the management of ovarian cancer?
Microtubular damage resulting in cell division inhibition
349
What are the side effects associated with the use of Paclitaxel in ovarian cancer?
Loss of body hair
350
What medication is given to reduce hypersensitivity reactions and side effects associated with Paclitaxel?
Steroids
351
What is the definitive surgical approach for ovarian cancer?
Laparotomy (TAH + BSO omentectomy + extra debulking)
352
Define ovarian torsion:
Ovarian torsion – refers to complete or partial rotation of the ovary on its ligamentous supports Common gynaecological emergencies.
353
Which ligament suspends the ovary?
Suspensory ligament
354
Which ovarian ligaments are implicated in the pathogenesis of ovarian tumours (name 2)?
Utero-ovarian ligament
infundibulopelvic ligament
355
Which ovary (right or left) is most likely affected by ovarian torsion?
Right due to longer utero-ovarian ligament
356
What is adnexal torsion?
Fallopian tube + ovarian twisting
357
What are the risk factors for ovarian torsion?
Ovarian cysts, tumours
Long ovarian ligaments
Pregnancy
Tubal ligation
358
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
359
What first-line investigation should be performed in a patient presenting with features of ovarian torsion?
Urine hCG test to exclude for pregnancy
360
What is the first line diagnostic investigation for a patient with suspected ovarian torsion?
Ultrasound with Doppler
361
What sign is demonstrated by an ultrasound with Doppler in ovarian torsion?
Whirlpool sign
362
What is the diagnostic test for confirming ovarian torsion?
Diagnostic laparoscopy + perform detorsion
363
What is the therapeutic management to alleviate ovarian torsion?
laparoscopic detorsion
364
What is the management of ovarian torsion with a viable adnexa without pathology?
1. Oophoropexy – fix the ovary to the pelvic sidewall or round ligament (Limit range of motion).
a. Indicated: Contralateral ovary is absent or repeated torsion.
365
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.
366
What is the surgical management indicated for a patient with a non-viable adnexa in ovarian torsion?
* Oophorectomy or salpingectomy
367
What are the four types of urinary incontinence?
1. Stress
2. Urge
3. Mixed
4. Overflow
368
What is stress incontinence?
Leakage on effort or exertion e.g., sneezing or coughing.
369
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.
370
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.
371
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).
372
What are the causes of urgency urinary incontinence?
Idiopathic | Parkinson’s disease, MS or pelvic injury.
373
What is overflow urinary incontinence?
a. Detrusor underactivity or bladder outlet obstruction - Urine leakage.
374
What medications are associated with causing overflow urinary incontinence?
ACEi, antidepressants, antihistamines, antimuscarinic, AP, beta-adrenergic agonists, opioids, sedatives.
375
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)
376
What is the first line set of investigations indicated in a patient presenting with urinary incontinence?
1. Urine dipstick to exclude UTI + DM
2. Bladder diary (min 3 days)
3. Speculum examination to exclude pelvic organ prolapse
377
What is the minimum time period for a bladder diary?
3 days
378
What testing is indicated in a patient presenting with mixed urinary incontinence?
Urodynamic studies (assessment of 3 pressures)
379
Which type of exercises is used to assess the contraction of the pelvic floor?
Kegel exercise
380
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.
381
What grading system is used to assess for urinary incontinence?
Oxford Grading System
382
What postpartum complication is associated with incontinence?
Vesicovaginal fistula
383
What is the first line management indicated for stress urinary incontinence?
3-month trial of supervised pelvic floor muscle training
384
What lifestyle advice is provided to patients with stress urinary incontinence?
Lifestyle advice on: Caffeine intake, fluid intake, weight loss (<30 BMI), smoking cessation.
385
What is the second line management for stress urinary incontinence (medical)?
Duloxetine
386
What is the first line management for urgency incontinence?
Bladder training for 6 weeks
387
What is the second line of management following bladder training for urgency incontinence?
Oxybutynin
388
What class of drug is oxybutynin?
Antimuscarinic
389
What are the adverse effects associated with oxybutynin ?
Dry mouth and constipation
390
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.
391
What is the definition of menorrhagia (mL)?
>80 mL of blood and duration of more than 7 days
392
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.
393
What is the first line blood test indicated for investigating Menorrhagia ?
FBC - assess for IDA
+ Pregnancy test
Test for coagulation disorders
394
What IX (imaging) for Menorrhagia ?
TVUSS
395
What are the two cancer referral criteria for Menorrhagia ?
Pelvic mass + unexplained bleeding or weight loss
Women aged >55 years with postmenopausal bleeding
396
What is the first line management for Menorrhagia (with no identified pathology, + fibroids <3 cm)?
Levonorgestrel intrauterine system (LNG-IUS)
397
What is the non-hormonal management for menorrhagia?
Tranexamic acid 1g TDS or NSAID | Mefenamic acid 500 mg TDS.
398
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
399
Which emergency contraception is administered within the first 72 hours of UPSI?
Levonorgestrel
400
Mechanism of action for Levonorgestrel?
Inhibits ovulation and implantation
401
What singe dose is prescribed for Levonorgestrel as emergency contraception?
1.5 mg
402
What dose is prescribed for Levonorgestrel indicated for UPSI (BMI >26)?
Double dose
403
When can Ulipristal be prescribed?
Within 5 days (120 hours) of unprotected sexual intercourse
404
What is the mechanism of action for Ulipristal ?
Selective progesterone receptor modulator (EllaOne) - inhibits ovulation
405
What dose of Ulipristal is prescribed as emergency contraception?
30 mg oral dose
406
What is the contraindication for Ulipristal as emeregency contraception?
Asthma
407
What is the preferred emergency contraception?
Intrauterine Device - copper coil
408
When must the IUD be inserted to be an effective mode of emergency contraception?
Within 5 days or up to day 19.
409
When must a pregnancy test be performed following emergency contraception?
3 weeks after UPSI
410
What is the mode of action of the Copper IUD as emergency contraception?
Prevents implantation of fertilized ovum, toxic to sperm and eggs.
411
What is the most common type of vulval cancer?
Squamous cell carcinomas
412
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.
413
What is the premalignant condition prior to the development of vulval cancer?
Vulval Intraepithelial Neoplasia
414
A high-grade squamous intra-epithelial lesion (VIN) is associated with what?
HPV infection
415
What is the diagnostic investigation to confirm Vulval Intraepithelial Neoplasia?
Biopsy (+ sentinel node biopsy)
416
What is the management for VIN?
Watch-and-wait; wide local excision, imiquimod cream, laser ablation
417
Which anatomical site is commonly affected by vulval cancer?
Labia majora
418
For suspected vulval cancer, what is the confirmatory diganostic test?
Biopsy + sentinel lymph node biopsy
CT
419
What is the first line surgical management for vulval cancer?
Vulvectomy + bilateral inguinal lymphadenopathy
420
For stage 1a vulval cancer what is the surgical management?
Wide local excision
421
What is the surgical management for stage >1a vulval cancer?
Radical vulvectomy
422
What is the definition of adenomyosis?
The presence of endometrial tissue inside the myometrium - more common in later reproductive years
423
What is the presentation of Adenomyosis?
* Dysmenorrhoea (Painful periods)
* Menorrhagia
* Dyspareunia
424
What are the examination findings for adenomyosis?
An enlarged, boggy and tender uterus
425
What is the first line of investigation for suspected adenomyosis?
Transvaginal ultrasound
426
On ultrasound what distinct appearance is demonstrated?
'Venetian blind appearance'* Heterogenous myometrium:
o Streaky shadowing
o Asymmetric myometrial thickness
o Myometrial cysts
427
What is the gold-standard investigation for confirming adenomyosis?
Outpatient hysteroscopy with histological examination (biopsy)
428
What is the first line of medical management for a patient with adenomyosis?
Tranexamic acid - reduce bleeding
Mefenamic acid - reduce pain
429
For when contraception is desired, what is the first line medical management for adenomyosis?
Mirena coil
COCP
Cyclical oral progestogens
430
What is the definitive management for adenomyosis?
* Hysterectomy - causes infertility
431
What is the fertility-sparing surgical management for adenomyosis?
Uterine artery embolisation
432
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
433
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%)
434
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).
435
Why is timed intercourse not recommended in the management for infertility?
Timed intercourse – coincide with ovulation – can lead to stress and pressure.
436
What does a raised FSH indicate in a patient presenting with infertility?
Poor ovarian reserve - consider AMH
437
Which is an accurate marker of ovarian reserve and is released by granulosa cells?
Anti-Mullerian Hormone
438
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)
439
A raised LH in a female presenting with infertility suggests what diagnosis?
Polycystic ovarian syndrome
440
What are the two outpatient diagnostic investigations for a patient with infertility?
* Hysterosalpingogram
. * Laparoscopy and Dye Test
441
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.
442
What dye is used in a
Laparoscopy and Dye Test?
Methylene blue - injected into the uterus to assess for tubal obstruction
443
Which anti-oestrogen drug is prescribed to support fertility?
o Clomifine
444
What drug class is prescribed to stimulate ovulation in clomifene-resistant patients?
Gonadotrophins
445
Define Asherman's syndrome
Asherman syndrome is characterised as intrauterine adhesions/synechiae occurring when scar tissue forms inside the uterus/cervix.
446
Which surgical procedure is implicated in perpetuating Asherman's syndrome?
Dilation and curettage for ToP or incomplete miscarriage or for retained products of conception
447
What are the three main aetiological causes for Asherman's?
1. Post-operative (Dilation and curettage).
2. Pelvic infection (Endometritis)
3. Myomectomy
448
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
449
What is the gold-standard investigation for Asherman's syndrome?
Hysteroscopy
450
What is the management Asherman's syndrome?
Hysteroscopy - Dissection of the adhesions
451
What are the complications associated with Asherman's syndrome?
* Repetitive pregnancy loss/abortions.
* Infertility
* Abnormal placentation
452
What is the common position of a Bartholin's cyst (Clock face)?
4 and 8 o clock
453
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.
454
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.
455
What are the risk factors for Bartholin's cyst?
* Nulliparous
* Previous Bartholin’s cyst
* Sexually active (STIs)
456
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.
457
What are the three symptoms associated with a Bartholin's abscess?
Hot
Tender
Purulent
458
What is the conservative approach for a Bartholin's cyst?
Good hygiene, analgesia and warm compress
Spontaneous drainage - Sitz baths and analgesia
459
What is the definitive management for a Bartholin's cyst?
Words Catheter
460
What is the management for a Bartholin's abscess?
Incision and drainage
Marsupialisation
461
What is the characteristic appearance of lichen sclerosus?
Patches of shiny ‘porcelain-white’ skin affecting the labia, perineum and perianal area.
462
What are the autoimmune risk factors for lichen sclerosus?
T1DM, alopecia, hypothyroid, and vitiligo
463
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
464
What is the Koebner phenomenon in Lichen Sclerosus?
Refers to when symptoms are worsened by friction to the skin.
465
What is the topical management for lichen sclerosus?
High potency steroids (Clobetasol propionate) for 3 months
466
What is the 2nd line management for lichen sclerosus?
Topical calcineurin inhibitors and imiquimod
467
What is the complication associated with lichen sclerosus?
Vulval squamous cell carcinoma
468
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).
469
The Wolffian duct forms what?
Vas deferens in men
470
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
471
On examination what feature is observed in an imperforate hymen?
Haematocolpos
472
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).
473
What is the definitive management for an imperforate hymen?
* Hymenectomy using cruciate or annular incisions.
* Hymenectomy using electrocautery.
* Carbon dioxide laser treatment
474
What is the main complication associated with an uncorrected imperforate hymen?
Endometriosis as a result of retrograde menstruation
475
What are the two types of physiological ovarian cysts?
Follicular
Luteal
476
What is the most common type of ovarian cyst in postmenopausal women?
Graafian follicle cyst
477
What is a follicular cyst?
Failure to rupture during ovulation - follicular cysts form due to inadequate LH surge or excessive FSH simulation
478
Which cells line follicular cysts?
Granulosa cells
479
How long do corpus luteal cysts last?
14 days
480
What hormone do corpus luteal cysts secrete?
Progesterone
481
When do corpus luteal cysts typically occur?
In the first trimester of pregnancy
482
Corpus luteal cysts are lined by what type of cells?
Luteal cells
483
Which type of cyst is formed as a result of overstimulation in elevated Hcg levels?
Theca luteal cysts
484
What are the complications associated with follicular and corpus luteal cysts?
Transformation into a haemorrhagic cyst
485
What complication is associated with mucinous cystadenoma cysts?
Pseudomyxoma peritonei
486
Struma ovarri tumours are associated with which type of cyst?
Dermoid cysts - mature cystic teratomas
487
What term describes multiple white shiny masses that protrude out of dermoid cysts?
Rokitansky protuberances
488
What is the presentation of an ovarian cyst rupture?
Lower abdominal pain - sudden acute - nausea + vomiting
489
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
490
What is the management for an asymptomatic <10 mm ovarian cyst?
Serial monitoring with TVUSS - spontaneous resolution
491
What are the indications for surgical cyst removal?
Ovarian torson
Adnexal mass
Acute abdominal pain
Suspected malignancy i
492
What is a cystocele?
Bladder prolapse – herniation and descent of the bladder through the anterior wall of the vagina.
493
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
494
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.
495
What questionnaire is used to assess for pelvic prolapse related symptoms?
Pelvic floor impact questionnaire (PFIQ)
496
What position is recommended for examining cystocele?
dorsal lithotomy position and diagnosed using the POPQ
497
What staging scale is used to assess for cystocele?
POPQ
498
Which speculum is used to assess for cystocele?
Sims speculum
499
What is the conservative approach for managing cysotcele?
Vaginal pessaries
Kegel exercises for stage 1-2 prolapse
500
What is the surgical management for cystocele?
Anterior colporrhapy - anterior repair
OR
Sacral colpopexy
501
What is the definitive surgical management for a uterine prolapse?
Hysterectomy, sacrohysteropexy
502
In what women does a vault prolapse occurs in?
Occurs in women that have had a hysterectomy and no longer have a uterus
503
What is a rectocele?
Posterior vaginal wall defect – allowing the rectum to prolapse into the vagina – associated with constipation.
Can cause faecal loading
504
What is the surgical management of a rectocele?
Posterior colporrhaphy
505
Which criteria is used for the diagnosis of PCOS?
Rotterdam criteria
506
What are the three parameters included in the Rotterdam Criteria?
* Hyperandrogenism (clinical or biological)
* Polycystic ovaries
* Irregular menstrual periods
507
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
508
What is the main risk associated with PCOS?
Endometrial cancer
509
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
510
How is ovarian androgen production increased in PCOS?
Insulin -> Increased LH --> Increased androgen production
511
What happens to Sex-hormone binding globulin in PCOS?
Decreases - increases bioavailability of testosterone
512
What happens to FSH in PCOS?
Reduces aromatase activity within granulosa cells
513
What is the presentation of PCOS?
* Hyperandrogenism
- Acne
- Female pattern hair loss
- Hirsutism
* Menstrual irregularities:
- Oligomenorrhoea, amenorrhoea and infertility
514
What are the indirect clinical signs of insulin resistance associated with PCOS?
Obesity, and acanthosis nigricans.
515
Which ultrasound sign is observed in PCOS?
Pearl necklace sign
516
What is the diagnostic threshold for US ovarian follicles?
>20 in one ovary
517
What is the free-androgen index?
100 x total testosterone/SHBG value
518
What are the signs of virilisation?
deep voice, reduced breast size, increased muscle bulk and clitoral hypertrophy
519
Is virilisation observed in PCOS (and what else in)?
No.
Seen in: congenital adrenal hyperplasia, Cushing’s syndrome or an androgen-secreting tumour
520
What testosterone level is associated with virilisation?
>5 nmol/L
521
What is the first line clinical management for PCOS?
COCP
522
What is the off-label clinical drug prescribed as part of the management of PCOS?
Metformin
523
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%
524
What drug is prescribed to induce a withdrawal bleed for prolonged amenorrhoea?
Cyclical progestogen (medroxyprogesterone 10 mg daily for 14 days)
525
What type of drug is clomifene?
Anti-oestrogen (prescribe for up to 6 months)
526
What class of drug is letrozole?
Aromatase inhibitor
527
What is the risk associated with the use of gonadotrophins in PCOS?
Ovarian hyperstimulation syndrome
528
What is the surgical option indicated in the management of PCOS?
Laparoscopic ovarian drilling
529
What is the range for impaired fasting glucose?
6.1 to 6.9 mmol/L
530
What is the range for impaired glucose tolerance?
7.8 to 11.1 mmol/L
531
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.
532
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
533
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.
534
What is the presentation of cord prolapse?
Severe prolonged foetal bradycardia + moderate-to-severe decelerations.
535
What is the complication associated with cord prolapse?
Foetal hypoxia
536
How is an antepartum cord prolapse diagnosed?
Ultrasound with colour flow Doppler studies
537
How is a cord prolapse diagnosed?
Vaginal examination - visualisation or palpation of the umbilical cord ahead of the presenting part.
538
What position should the mother adopt for cord prolapse?
Knee-to-chest position or left lateral position - presenting part can be pushed superiorly
539
What is the definitive management for cord prolapse?
Emergency caesarean section
540
Which class of medication is administered in cord prolapse to reduce uterine contractions?
Tocolytics
541
What are the two most common tocolytics prescribed to management cord prolapse?
Nifedipine
Atosiban
542
What class of drug is Atosiban?
Oxytocin receptor antagonist
543
Which trimester does an ectopic pregnancy typically occur in?
First trimester
544
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.
545
Where do most ectopic pregnancies occur?
Fallopian tube - ampulla
546
Which part of the fallopian tube is associated with the highest risk of rupture?
Isthmus
547
What is the triad of symptoms associated with ectopic pregnancy?
1. Abnormal vaginal bleeding – intermittent.
2. Pelvic pain
3. Adnexal mass
548
Site of referred pain in ectopic pregnancy?
Shoulder tip pain
549
Presentation of ectopic pregnancy
2. Abnormal vaginal bleeding – intermittent.
3. Pelvic pain
4. 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
550
What are the signs and symptoms of a tubal rupture in ectopic pregnancy?
Vomiting and diarrhoea, shoulder pain
Pallor, tachycardia, hypotension, shock or collapse
551
What is the first line investigation for suspected ectopic pregnancy?
Transvaginal ultrasound
552
What investigation is indicated to detect for a pregnancy of unknown location?
Serial beta-hCG
553
An increase in serum beta-hCG by what % is suggestive of a developing pregnancy?
>63%
554
A decrease in serum bhCG by 50% is indicative of what?
Miscarriage
555
What features are assessed in a TVUSS for suspected ectopic pregnancy?
Foetal pole and heartbeat
556
What two radiological signs are suggestive of a tubal pregnancy on TVUSS?
Bagel sign and blob sign
557
What scan is used to investigate and detect a caesarean scar?
MRI
558
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
559
A pregnancy by how many weeks gestation warrants an urgent referral to the EPU for suspected ectopic preganncy?
>6 weeks
560
What medical drug is indicated for the management of an ectopic pregnancy?
Methotrexate
561
Management of an ectopic pregnancy for a clinically stable and pain free woman?
Expectant management
562
Adnexal mass diameter threshold for surgical management of ectopic pregnancy?
>35 mm
563
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
564
What are the two surgical options for ectopic pregnancy?
Salpingectomy
Salpingotomy
565
Viable contralateral fallopian tube, surgical management for ectopic pregnancy?
Salpingectomy
566
What intramuscular prophylaxis is prescribed for surgical management of ectopic pregnancy?
Anti-D immunoglobulin for all rhesus-negative women
567
What is the increased risk for future ectopic pregnancies in a previous ectopic?
15%
568
Definition of placenta praevia?
The placenta presents in the lower uterus – covering the internal cervical Os – typically diagnosed in the second trimester.
569
What are the three types of placenta praevia?
1. Complete
2. Partial
3. Marginal - extends within 2 cm of the cervical Os
570
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.
571
What is the most common clinical presentation for placenta praevia?
Painless vaginal bleeding
572
When is placenta praevia typically diagnosed?
2nd or 3rd trimester bleeding
(Absence of uterine tenderness)
573
What is the first line investigation for suspected placenta praevia?
Uterine ultrasound with colour flor Doppler analysis
574
What test is used to determine the quantity of foetal blood in maternal circulation?
Kleihauer test
575
What mode of delivery is recommended for placenta praevia?
caesarean section
576
When is the low-lying placenta scan?
20 weeks
577
When is the rescan for placenta praevia?
at 32 weeks, followed by a rescan at 36 weeks
578
What is the management of placenta praevia at 36 weeks?
caesarean section
579
What medications are prescribed at 34-36 weeks for placenta praevia?
Antenatal corticosteroids with tocolysis
580
What is the first line management for symptomatic (bleeding) placenta praevia?
Admission for 48 hours for observation
581
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
582
What are the foetal complications associated with placenta praevia?
IUGR, death
583
Maternal complications with placenta praevia?
antepartum haemorrhage and postpartum haemorrhage, DIC, hysterectomy
584
Define Vasa Praevia
Foetal blood vessels are present in the membranes covering the internal cervical os, unprotected by placental tissue or Wharton’s Jelly.
585
What substance protects the umbilical cord?
Wharton's jelly
586
'Umbilical cord inserts into the chorioamniotic membranes – vessels travel unprotected before joining the placenta'
Name this type of umbilical cord?
Velamentous umbilical cord
587
What type of haemorrhage occurs when the placental vessels rupture?
Benckiser’s haemorrhage
588
What are the risk factors associated with vasa praevia?
Risk factors:
* Placental praevia
* IVF pregnancy
* Multiple pregnancy
* Foetal anomaly (bilobed placenta or succenturiate lobes)
589
What is the typical presentation of vasa praevia?
Fresh PV bleeding + foetal bradycardia.
590
What CTG trace is associated with vasa praevia?
Decelerations, bradycardia, sinusoidal trace, foetal demise.
591
What is the definitive management for vasa praevia?
Elective caesarean section – planned for 34-36 weeks’ gestation.
592
What term describes placental separation from the wall of the uterus during pregnancy >24 weeks?
Placental abruption
593
What are the two types of placental abruption?
Concealed OR Revealed
594
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
595
What type of uterus finding on palpation is observed in placental abruption?
A woody abdomen on palpation - hypertonic
596
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.
597
Definition of massive haemorrhage (mL blood loss threshold)?
>1000 mL
598
Management for severe placental abruption?
* Severe - ABC, emergency CS, 2x wide bore cannula, fluids, blood transfusions, correct coagulopathies.
o FBC, G&S, crossmatch, steroids
599
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.
600
Foetal complications associated with placental abruption?
Birth asphyxia, death
601
Time period postpartum for primary PPH?
24 hours after vaginal delivery
602
Define time period/interval for secondary PPH
24 hours and 12 weeks
603
Volume of blood loss to define primary PPH
>500 mL
604
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
605
What are the 4 Ts for PPH
Tone
Trauma
Tissue
Thrombin
606
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).
607
What is the management of uterine atony causing PPH?
Fundal massage
608
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
609
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
610
What is the management of tissue induced PPH?
Retained tissue extractions
611
Which clotting disorders are associated with an increased suspcetibility of PPH?
o Von Willebrand Disease, haemophilia, DIC, ITP, TTP, aspirin use.
612
What are the two most common causes of secondary PPH?
1.Endome tritis
2. Retained products of conception
613
Presentation of PPH (1000-1500 mL blood loss):
Weakness, sweating, tachycardia (100-120 beats/minute), tachypnoea
614
At what level of blood loss is the following presentation expected: Restlessness, confusion, pallor, oliguria, tachycardia, cool and clammy skin?
1500 - 2000 mL
615
What is the first step in the management of post partum haemorrhage?
Bimanual compression and IM/IV syntocinon (oxytocin)
616
Which kind of drug is first prescribed in the management of PPH?
Oxytocin
617
Syntometrine is contraindicated in what conditions?
Asthma and hypertension
618
What is the risk associated with oxytocin infusion?
Uterine hyperstimulation syndrome
619
Following a slow IV infusion of oxytocin, what is step 2 for PPH?
IM-ergometrine/syntometrine
620
Step III for PPH management?
IM carbopost
621
Step IV for PPH?
Intrauterine balloon tamponade (bakri balloon)
622
Which is the first line surgical management for PPH?
B-lynch suture - bilateral internal iliac ligation
623
What is the final surgical option for PPH?
Hysterectomy
624
What are the short-term complications associated with gestational diabetes?
Hypertensive disorders
Large gestational weight
Polyhydramnios
Shoulder dystocia
Foetal/neonatal cardiomyopathy
Stillbirth
625
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
626
What is the threshold HbA1c level for the diagnosis of gestational diabetes?
>48 mmol/L (>6.5%)
627
Which two tests are diagnostic for gestational diabetes?
1. Fasting plasma glucose > 5.6 mmol/L
2. 2-hour 75g OGTT >7.8 mmol/L
628
When is the 2-hour 75g OGTT performed during antenatal care?
24-28 weeks
629
Threshold for fasting plasma glucose for GDM?
>5.6 mmol/L
630
Threshold for 2-hour OGTT for GDM?
>7.8 mmol/L
631
Referral following diagnosis of gestational diabetes?
Joint diabetes and antenatal clinic within 1 week
632
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)
633
If the target blood glucose is not met within 2 weeks, despite lifestyle interventions in GDM, what is the next line of management?
Metformin
634
What is the indication for inititataing insulin for the management of GDM?
Fasting blood glucose >7 mmol/L
635
Name 2 rapid-acting insulin analogues
Aspart
Lispro
636
Target fasting blood glucose?
<5.3 mmol/L
637
When is an elective birth planned for patients with GDM?
Between 37-38+6 weeks
638
What is the maximum limit for delivery for patients with GDM?
40+6 weeks
639
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.
640
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.
641
What are the risk factors for perineal tears?
* Nulliparity
* Large babies >4 kg
* Shoulder dystocia
* Asian ethnicity
* Occipito-posterior position
* Instrumental deliveries
642
What type of perineal tear is limited to the frenulum of the labia minora and superficial skin?
First degree tear
643
Which type of tear includes the perineal muscles (does not affect the anal sphincter)?
Second degree tear
644
Which type of perineal tear includes the anal sphincter <50%?
Type 3a
645
What is a type 3b perineal tear?
>50% of the external anal sphincter.
646
Which type of perineal tear involves the rectal mucosa?
Fourth degree
647
How is a 2nd degree perineal tear managed?
Suturing of the perineal muscle
648
Management of 3rd and 4th degree perineal tear
Surgical repair + post-operative broad spectrum antibiotics
649
Which drug is prescribed first for a medical termination of pregnancy?
Mifepristone (200 mg)
650
What class of drug is Mifepristone?
A progesterone analogue - blocks progesterone required for the continuation of pregnancy
651
How is misoprostol administered?
Vaginal/buccal/sublingual
652
How long following Mifepristone, should misoprostol be prescribed?
24-48 hours later
653
Name the two drugs indicated for a medical termination of pregnancy?
Mifepristone (200 mg) and Misoprostol
654
What class of drug is Misoprostol?
A prostaglandin analogue - induces smooth muscle contraction of the myometrium for uterine expulsion
655
Management of termination of pregnancy for 0-9 weeks?
Outpatient management (pass within 4 hours)
656
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
657
When does the terminated foetus pass once medical management is initiated, as an outpatient?
4 hours
658
When does the terminated foetus pass once medical management is initiated, as an inpatient?
Pass within 8 hours
659
Maximum number of doses of misoprostol?
5 (repeat dose 3-hourly)
660
What fetiticcie drug is used to terminate the foetus >22 weeks?
Intracardiac potassium chloride or digoxin
661
Surgical management for ToP <14 weeks?
Misoprostol (400 mcg vaginal/sublingual - dilate),
ERPC (vacuum aspiration) +
hCG level.
662
Surgical management of choice for ToP >14 weeks?
Dilatation and evacuation/curettage.
663
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.
664
When should a pregnancy test be performed following an abortion?
2-3 weeks
665
When should hormonal or intrauterine contraceptive devices be used following a surgical ToP?
within 5 days post-surgical
666
BP threshold (systolic and diastolic) for pre-eclampsia?
>140/90 mmHg
667
When (gestational weeks) is pre-eclampsia diagnosed?
>20 weeks
668
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.
669
What is the definition of severe pre-eclampsia?
>160/110 mmHg
670
How is foetal growth restriction monitored?
Umbilical artery dDoppler waveform analysis (PI, end-diastolic flow)
671
Definition of pre-existing hypertension in pregnancy?
Hypertension before 20 weeks of pregnancy
672
What is the difference between gestational hypertension and pre-eclampsia?
PE is associated with significant proteinuria and signs of organ dysfunction
673
Proteinuria threshold for pre-eclampsia?
Protein >0.3 g in 24 hours
674
What are the neurological symptoms associated with pre-eclampsia?
Eclampsia, blind, stroke, clonus, severe headache, visual scotomata
675
Define HELLP syndrome?
“Haemolysis, Elevated Liver enzymes, and Low Platelets” [SEVERE FORM OF PRE-ECLAMPSIA]
676
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
677
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
678
What is the absolute contraindication for the progesterone only pill?
Active breast cancer
679
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
680
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
681
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.
682
Define HELLP syndrome
HELLP Syndrome (severe form of pre-eclampsia):
* Haemolysis
* Elevated liver enzymes
* Low platelet syndrome
683
What is the first line investigation for pre-eclampsia?
Urine dipstick (screening for proteinuria >1)
684
What is the threshold for PCR to quantify proteinuria in pre-eclampsia?
>30 mg/mmol
685
Which factor can be used to investigate pre-eclampsia?
Placental growth factor
(low in pre-eclampsia)
686
How frequent should foetal ultrasound monitoring be performed in patients with pre-eclampsia?
Two weekly
687
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
688
What is the first line management for pre-eclampsia?
Labetalol 100 mg BD
689
What is the first-line drug for pre-eclampsia with history of asthma?
Nifedipine
690
What drug is used at term instead of nifedipine for pre-eclampsia?
Methyldopa (nifedipine causes tocolysis)
691
What drug should be prescribed in patients with brisk reflexes and pre-eclampsia?
IV magnesium sulphate
692
Which admission criteria is used for pre-eclampsia?
PREP-S or fullPIERS
693
What is the third line drug for pre-eclampsia?
Methyldopa
694
How frequently should FBC, LFTs and renal function be monitored in severe pre-eclampsia >160/110?
Three times a week
695
How frequently should FBC, LFTs and renal function be monitored in moderate pre-eclampsia?
Twice a week
696
When should birth be induced in pre-eclampsia?
>37 weeks
697
What is the reversing agent for magnesium sulphate?
Calcium gluconate 10 mL 10% over 10 minutes
698
Which tocolytic is contraindicated in severe pre-eclampsia?
Ergometrine
699
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
700
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
701
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.
702
What sign is seen in shoulder dystocia?
* Turtle-neck sign
703
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.
704
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:
705
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
706
What is Zavanelli manouevre?
Push baby’s head back Caesarean section.
707
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.
708
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.
709
Time frame for miscarriage?
Miscarriage – Spontaneous loss of pregnancy from the time of conception until 24 weeks of gestation.
710
Definition of recurrent miscarriage?
Loss of 3 or more pregnancies <24 weeks of gestation.
711
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).
712
Type of miscarriage:
'non-viable pregnancy is identified on ultrasound without associated pain or bleeding'
Missed (delayed/silent)
712
Cervical os in threatened miscarriage?
Clossed
713
Cervical os in ineviiable miscarriage?
Open
714
What is the most common cause of miscarriage in the first trimester?
Chromosomal abnormalities
715
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
716
Which infections are associated with an increased risk of miscarriage?
Listeria monocytogenes, CMV, toxoplasma gondii, HSV
717
Which blood clotting disorders are associated with an increased risk of miscarriage?
Antiphospholipid syndrome, Factor V Leiden mutation and hyperhomocysteinaemia.
718
1st line investigation for miscarriage?
Transvaginal ultrasound – Detect foetal heart rate, CRL and look for gestational sac.
719
How many weeks gestation to warrant early pregnancy unit referral with history of vaginal bleeding?
>6 weeks
720
What is the first line management for a confirmed diagnosis of miscarriage?
Expectant management
721
What is the management for >6 weeks with bleeding or signs of miscarriage?
Refer to EPU
722
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.
723
When is medical management indicated in miscarriage?
Ongoing symptoms after 14 days of expectant management
724
When should a pregnancy test be conducted following medical management of miscarriage?
3 weeks
725
What are the two surgical options for miscarriage?
Manual vacuum aspiration
Surgical ERPC
726
What is the first line managemof ent for retained products miscarriage?
Expectant management 7-14 days
727
For miscarriage <6w gestation, when should a pregnancy test be performed?
7-10 days (negative - miscarriage)
728
What should be prescribed for recurrent MC?
Low-dose aspirin and LMWH if thrombophilia
729
When does Hyperemesis Gravidarum typically occur?
4-7th week
730
When does Hyperemesis Gravidarum typically resolve?
By 16-20th week
731
What are the risk factors associated with Hyperemesis Gravidarum?
Molar pregnancies
Multiple pregnancies
History of HG
Obesity
First-pregnancy
Migraines
History of motion sickness
732
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.
733
Which questionnaire is used to assess fo the severity foofr hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE)
734
What is the severe PUQE threshold for hyperemesis gravidarum?
13
735
Urine dipstick finding for Hyperemesis Gravidarum?
Ketonuria
736
What is the management for mild-moderate Hyperemesis Gravidarum?
Reassurance - resolution by 16-20 weeks
737
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
738
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).
739
Examples of antihistamine anti-emetic:
* Prochlorperazine (5-10 mg PO)
* Promethazine (12.5-25 mg) – Can cause QT prolongation.
* Chlorpromazine (10-25 mg)
740
What are the side effects associated with antihistamine anti-emetics?
Drowsiness, dizziness, dry mouth, fatigue, constipation.
741
What are the 2nd line anti-emetics for Hyperemesis Gravidarum?
Ondansetron - do not prescribe >5 days
742
What adverse effect is associated with ondansetron?
Cleft palate
743
What is the maximum duration of metoclopramide in hyperemesis gravidarum?
5 days
744
What adverse effects are associated with hyperemesis gravidarum?
Extrapyramidal side effects
- Can cause oculogyric crisis in young patients <25 years old.
745
What is the third line drug management for hyperemesis gravidarum?
Corticosteroids - hydrocortisone
746
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.
747
What % weight loss results in admission for hyperemesis?
>5%
748
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
749
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).
750
Which clotting factors are raised in venous thromboembolism?
Raised FVII, FVIII, VWF, PAI-1, PA-2, fibrinogen,
751
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
752
What is a high risk factor for VTE in pregnancy?
Previous VTE
753
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.
754
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
755
What is the first line investigation (RCOG 2015) for suspected DVT in pregnancy?
Compression Duplex ultrasound
756
What IX performed with suspected PE?
CXR and ECG
757
Gold-standard investigation for PE in pregnancy? (2)
CTPA and VQ scan
758
Complication associated with CTPA?
Increased risk of maternal breast cancer
759
Complication associated with VQ scan in pregnancy?
Increased risk of childhood cancer
760
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
761
Duration of LMWH postpartum for VTE?
6 weeks postpartum
762
Total duration of LMWH therapy?
3 months
763
Management for VTE if LMWH is contraindicated?
Mechanical prophylaxis if LMWH is contraindicated:
Intermittent pneumatic compression
Anti-embolic compression stockings
764
Management for VTE for massive PE and haemodynamic compromise?
Unfractionated heparin, thrombolysis and surgical embolectomy
765
What is the immediate DVT treatment in pregnancy?
LMWH
766
For VQ scan - what are the risks for VTE management?
childhood malignancy – avoid breastfeeding for 12 hours (express and discard).
767
>weeks gestation for obstetric cholestasis?
28 weeks
768
Risk factors for obstetric cholestasis?
Previous obstetric cholestasis
Family history
Ethnicity (South Asian, Chilean, Bolivian)
Multiple pregnancies
769
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
770
What are the investigations for obstetric cholestasis?
LFTs - raised ALP (obstructive)
Bile salts
771
What is the immediate management for obstetric cholestasis?
Arrange same-day referral to a local maternity unit for obstetric cholestasis
772
What is the symptomatic management for obstetric cholestasis?
Ursodeoxycholic Acid
Vitamin K supplementation
Sedating antihistamines
Topical emollients
773
When is induction of labour recommended for obstetric cholestasis?
At 37 weeks
774
Complications of obstetric cholestasis?
Preterm birth
Intrauterine death
Severe liver impairment
PPH
Meconium passage – ingestion.
Foetal distress
775
When does foetal movements typically begin?
16 to 24 weeks
776
What type of care is delivered for obstetric choleastasis?
Consultant led antenatal care
777
What are the weekly investigations performed for obstetric choleastasis?
LFTs including bile acid concentrations until delivery
778
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
779
Which topical emollients are prescribed for the management of obstetric cholestasis?
Menthol 0.5% with aqueous cream
780
Which drug provides symptomatic relief in obstetric cholestasis?
Ursodeoxycholic acid (does not reduce adverse perinatal outcomes)
781
When should planned birth be advised if serum bile contraction is >100 umol/L?
At 35-36 weeks' gestation
782
At what bile acid concentration threshold results in an increased risk fo stillbirth?
>100 umol/L
783
When should immediate delivery be planned in obstetric cholestasis?
Past 35 weeks' and bile acid serum concentration >100 umol/L
784
What is the supportive care for acute fatty liver during pregnancy?
Admit ITU - early liaison with liver team
785
Which neonatal deficiency is associated with acute fatty liver of pregnancy?
LCHAD deficiency in the foetus (autosomal recessive)
786
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
787
What are the clinical features for acute fatty liver of pregnancy?
* Nausea/Vomiting
* Abdominal Pain
* Malaise and fatigue
* Anorexia
* Ascites
* Jaundice
788
What are the liver function tests associated with acute fatty liver of pregnancy?
ALT and AST - raised
Elevated uric acid
789
Criteria for acute fatty liver of pregnancy?
Swansea Criteria
790
What is the definitive management for acute fatty liver disease?
Foetal monitoring + prompt delivery
791
What are the complications with acute fatty liver of pregnancy?
Disseminated intravascular coagulation.
Death
Prognosis: Maternal mortality 10-20% perinatal mortality 20-30%.
792
Which organism is implicated in syphillis?
Treponema pallidum
793
How is syhillis transmitted?
Vertical transmission - direct contact with an infected area (oral, vaginal or anal sex)
794
What is the primary presentation of syphillis?
Pain ulcer – Chancre (Genital area) – Resolves within 3-8 weeks.
795
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
796
What is the first line investigation for Syphillis?
Darkfield microscopy and serology + full sexual health screen
797
What is the routine antenatal screening for syphilis during pregnancy?
Serology testing - detects treponemal antibodies - enzyme immunoassay
798
What are the non-treponemal tests for syphillis?
Rapid plasmin reagin
VDRL
799
What is the management for early Syphilis for the 1st and 2nd trimester?
Benzathine-pen (IM STAT) or doxycyline
800
What is the late trimester management for Syphilis ?
Benzathine-pen
801
What is the add-on therapy for neurosyphilis?
Prednisolone - 24 hours prior to avoid Jerish-Herxheimer reation
802
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)
803
Primary amenorrhoea and undescended bilateral testes are associated with what diagnosis?
Androgen insensitivity syndrome
804
When is a pregnancy test performed following a miscarriage?
3 weeks after management
805
What adjunctive medication to misoprostol is prescribed for miscarriage management?
Analgesia and anti-emetics
806
What is the most common risk factor for transient tachypnoea of the newborn?
C-section
807
When taking ulipristal acetate as emergency contraception, when can hormonal contraception begin
5 days
808
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
809
What is the first line drug for pregnancy-induced hypertension?
Labetalol
810
What is the clinical definition of menopause?
> 12 months of amenorrhoea since last menstrual period.
811
What is the average age of menopause?
51 years
812
What is the age threshold for POI?
<40 years of age
813
What are the primary causes of POI?
Fragile X, Turner’s
Enzyme deficiencies – Galactosaemia
Autoimmune diseases – Hypothyroidism, Addison’s.
814
What are the secondary causes of menopause?
* Chemotherapy, radiotherapy, Surgical BSO
815
Which cell secretes oestrogen?
Granulosa cell
816
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
817
Which investigation is recommended in women aged 40-45 years with menopausal symptoms?
Serum FSH
818
When should a second FSH test be performed?
FSH 4-6 weeks apart.
819
Which screening investigations are performed for >65 year olds (menopause)?
DXA test to assess bone marrow density (screening for osteoporosis)
820
What is the first line HRT preparation indicated for menopause? (with uterus)
o Combined (Oestrogen + progesterone – Elleste Duet) – protects the endometrium
821
Which HRT preparation is associated with a reduced VTE risk?
Transdermal oestrogen patch
822
When starting HRT, when should the patient be reviewed?
3 months and then annually thereafter
823
What is the BMI cut off for initiating the transdermal patch?
>30
824
Which HRT type is indicated for post-hysterectomy women?
Elleste solo - oestrogen only
825
What SSRI is recommended to treat vasomotor symptoms?
Fluoxetine, citalopram
826
In a women with existing tamoxifen, which, drug is recommended instead to control vasomotor symptoms?
Citalopram, clonidine or gabapentin
827
What is the first line drug to control uro-genital symptoms associated with menopause?
* Low-dose vaginal oestrogen first line
828
For patients experiencing peri-menopausal symptoms, which type of HRT is recommended?
Cyclical/Sequential Pattern (SCT)
829
For monthly sequential pattern HRT, when is progesterone administered?
For the last 14 days of the month
830
For 3-monthly SCT, when is progesteron given?
For the last 14 days
831
Which cancer risk is associated with oestrogen-only HRT (2 types)?
Breast cancer, endometrial cancer
832
Which cancer risk is increased on the combined HRT preparation?
Breast cancer
833
When during menopause, is the greatest risk of VTE on oral HRT?
Within the first 12 months
834
What are the three common oestrogenic side effects associated with HRT?
Breast tenderness, nausea, headaches
835
What are the three common progestogenic side effects associated with HRT?
Fluid retention, mood swings, depression
836
When should unscheduled vaginal bleeding be investigated upon initiating HRT?
>6 months
837
What is the contraception advice for women after their last menstural period >50 years of age?
Contraception is not required after a year
838
How many years should contraception be used in women <50 years?
2 years
839
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
840
Where do hydatidiform moles originate from?
Villous trophoblast
841
What is a complete mole?
Empty egg with 2 sperm - (dispermic) or duplication of haploid genome of a single sperm
842
What is a partial mole?
Complete ovum with 2 sperm - triploid
843
Which tumour marker is significantly raised in Gestational Trophoblastic Disease?
hCG
844
What is the most common cause of Gestational Trophoblastic Disease?
Molar pregnancy
845
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)
846
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
847
A sudden increase in abdominal size in addition to an enlarged uterus and hyperemesis gravidarum should suspect what?
Molar pregnancy
848
What is the first line investigation for a suspected molar pregnancy?
Quantitative serum hCG test
849
What is the 2nd line investigation for suspected molar pregnancy?
Transvaginal ultrasound
850
What is the characteristic sonographic appearance visualised in a molar pregnancy?
Snowstorm appearance/Cluster of grapes
851
What is the definitive diagnostic investigation for a molar pregnancy?
Histological examination
852
What is the first line management for a a molar pregnancy?
Uterine evacuation by suction curettage
853
Which drug is given for a molar pregnancy
Methotrexate
854
For non-chemotherapy managed molar pregnancies, when should pregnancy be avoided until?
6 months after
855
Minimum avoidance of pregnancy duration for chemotherapy treated molar pregnancy?
12 months
856
IUD advice for treated molar pregnancy?
* Avoid IUDs until hCG normalised
857
What prophylaxis is administered after an evacuation of a molar pregnancy?
Anti-D prophylaxis
858
When should a urinary pregnancy test be performed after the management of a molar pregnancy?
After 3 weeks
859
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..
860
What cancer risk is associated with a complete molar pregnancy?
choriocarcinoma
861
What is the threshold for first trimester anaemia?
<110 g/L
862
What is the threshold for second trimester anaemia?
<105 g/L
863
When are pregnant women first screened for anaemia?
At the booking appointment ~8-12 weeks
864
When are pregnant women screened for the second time for anaemia?
At 28 weeks
865
What is the threshold for anaemia postpartum?
100 g/L
866
Threshold for urgent anaemia referral in pregnancy?
<70 g/L
867
Which medication should be given for anaemia during pregnancy?
* Oral ferrous sulphate or ferrous fumarate
868
What are the side effects with taking oral ferrous sulphate for anaemia in pregnancy?
Black tools, constipation, abdominal pain
869
When should haemoglobin be tested for, following treatment of anaemia in pregnancy?
2-3 weeks
870
Minimum duration of oral ferrous sulphate?
3 months and until 6 weeks post-partum
871
Which dose of folic acid is given for patients with underlying sickle cell anaemia or thalassaemia?
5 mg folic acid
872
Consultant or mid-wife led delivery for anaemia in pregnancy?
Consultant led due to risk of PPH
873
How often should a group and screen be performed in high risk pregnancies?
Once a week to exclude new antibody formation
874
What is the blood product of choice for pregnant women?
ABO-, Rhesus-, Kell-.
875
What is the dose of folic acid given for eclamptic patients?
5 mg folic acid
876
What are the complications associated with folic acid deficiency during pregnancy on the neonate?
Neural tube defects including spina bifida
877
Which anti-epileptic drugs are safe to use during pregnancy?
levetiracetam, lamotrigine and carbamazepine
878
What are the complications associated with the use of phenytoin during pregnancy?
Cleft lip and palate
879
What should happen to anti-epileptic therapy prior to conception?
Refer to epilepsy specialist (do not change)
880
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
881
When should magnesium sulphate be continued following a seizure?
24 hours after the last seizure or delivery
882
What is the major risk associated with the use of magnesium sulphate?
respiratory depression
883
What is the anti-dote for magnesium sulphate toxicity?
10mL 10% of calcium gluconate over 10 minutes
884
What is the definitive management for eclampsia?
Expedite delivery
885
What is the genotype for androgen insensitivity syndrome?
46 XY
886
What is the inheritance pattern for androgen insensitivity syndrome?
X-linked recessive
887
What is the pathogenesis for androgen insensitivity syndrome?
End-organ resistance to testosterone
888
Which hormone prevents the development of the female internal organs in a male?
Anti-mullerian hormone
889
What is the diagnostic investigation for androgen insensitivity syndrome?
Buccal smear or chromosomal analysis
890
What is the most common cause of chorioamnionitis?
Prolonged duration of labour or rupture of membranes
891
Which chart is used to assess the patient with chorioamnionitis?
MEOWS chart
892
What is the gold standard investigation for chorioamnionitis?
Amniotic fluid culture
893
What is the first line antibiotic therapy for chorioamnionitis?
Benzylpenicillin + gentamicin + metronidazole.
894
When should induction of labour be considered for a patient with chorioamnionitis?
After 34 weeks' gestation - steroids for 34-37 weeks
895
Category 1 c- section - time?
Within 30 minutes
896
Category 2 c-section time?
Within 75 minutes
897
What is the recommended incision for a c-section?
Joel-cohen incision - straight
898
Which name denotes a curved incision above the pubic symphysis during a c-section?
* Pfannenstiel incision
899
What are the 8 layers of dissection for a c-section?
1. Skin
2. Subcutaneous tissue
3. Fascia/rectus sheath (aponeurosis of the transversus abdominis and external and internal oblique muscles)
4. Rectus abdominis muscle
5. Peritoneum
6. Vesicouterine peritoneum (and bladder)
7. Uterus (perimetrium, myometrium, and endometrium).
8. Amniotic sac
900
What is the risk during a c-section?
aspiration pneumonitis
901
What prophylaxis is given for aspiration pneumonitis during a c-section?
H2 receptor antagonist e.g., ranitidine or omeprazole
902
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)
903
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
904
What is the average success rate of VBAC?
72-75%
905
What is the success rate for VBAC following a previous successful vaginal birth?
9 in 10
906
What is the risk associated with induction of labour following a c-section?
2-3 increased risk of uterine rupture
907
What are the absolute contraindications for a VBAC?
Contraindications:
* Previous uterine rupture
* Classical caesarean scar (a vertical incision)
* Placenta praevia
908
What % of VBAC patients require an emergency c-section?
25%
909
When is prelabour rupture of membranaes?
After 37 weeks , before the onset of labour
910
When is prematurity defined?
Before 37 weeks of gestation
911
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.
912
What prophylactic gel can be given to patients for preterm labour - to maintain the pregnancy and reduce myometrium activity?
Vaginal progesterone
913
What cervical length is the threshold for preterm labour prophylaxis?
<25mm
914
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.
915
What prophylactic intervention for preterm labour can be done for women with previous premature birth or cervical trauma?
Cervical cerclage
916
What is the first line investigation for p-PROM?
sterile speculum examination
917
If pooling of fluid is not observed following p-prom which two tests are performed?
1. Insulin-like growth factor-binding protein-1: Raised protein concentration in amniotic fluid.
2. Placenta alpha macroglobulin-1 (PAMG-1)
918
What are the complications associated with p-prom?
placental abruption and chorioamnionitis
919
Following p-prom how long should a patient be admitted and monitored for?
Admission for 48 hours and prepare for delivery
920
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
921
Which antibiotic is prescribed following pprom?
* Erythromycin 250 mg QDS for 10 days
922
Which maternal corticosteroid is given for foetal lung maturation following pprom?
2 x 12 mg doses 12 hours apart of betamethasone
923
What is prescribed as neuroprotection for a neonate if birth is expected within the next 24 hours <34 weeks?
Magnesium sulphate
924
What is the management plan for pprom >34 weeks if positive group b strep?
Immediate induction of labour with intrapartum benzylpenicillin
925
Which test is used as an alternative to vaginal ultrasound to assess for premature labour?
Foetal fibronectin
926
What is the cut-off of foetal fibronectin in suspected premature labour?
>50 g/L - likely
927
What tocolytic agent is recommended for premature labour?
Nifedipine - consider atosiban
928
What is the mechanism of action for atosiban?
Oxytocin receptor antagonist
929
When should tocolytics be used (in weeks gestation) for preterm labour?
Between 24-33+6 weeks to allow the use of maternal corticosteroids
930
What is the limit weeks of gestation to prescribe magnesium sulphate?
<34 weeks - to reduce the risk of developing cerebral palsy
931
Cord clamping protocol for premature labour?
Delayed cord clamping/cord milking
932
What is the first choice drug for vaginal candidiasis during pregnancy?
Clotrimazole pessary or cream
933
What is the first line therapy for vaginal candidiasis in a non-pregnant woman?
Oral fluconazole 150 mg single dose or itraconazole
934
What is the definition of recurrent vaginal candidiasis according to BASHH guidelines?
4 or more episodes a year
935
What two investigations are recommended for patients with recurrent vaginal candidiasis?
Blood glucose to exclude diabetes
High vaginal swab for m&c
936
When is induction of labour offered normally?
At 41-42 weeks' gestation
937
When should induction of labour be offered for patients with obstetric cholestasis?
At 37 weeks
938
Which scoring system is used to assess the likelihood of successful induction?
Bishop score
939
What are 5 parameters for bishop score?
1. Foetal station (Scored 0-3)
2. Cervical position (Scored 0-2)
3. Cervical dilatation (Scored 0-3)
4. Cervical effacement (Scored 0-3)
5. Cervical consistency (Scored 0-2)
940
Which bishop score predicts a successful induction of labour?
8 or more
941
What is the bishop score threshold for starting vaginal prostaglandins?
6 or less
942
Foetal station refers to which landmark?
Ischial spines (zero - level of the ischial spine)
943
Foetal station of -2 = what?
2 cm above the ischial spines
944
What is given to ripen the cervix?
Vaginal prostaglandins
945
When is vaginal prostaglandins not recommended?
VBAC - risk of hyperstimulation
946
What should be offered first if the Bishop score is >6 for induction of labour?
Artifical rupture of membranes
947
Following an artificial rupture of membranes, what intervention is administered 2 hours later for induction of labour?
IV oxytocin infusion
948
What intervention is offered >40 weeks for induction of labour?
Membrane sweep
949
What is dinoprostone?
Vaginal prostaglandins E2
950
What is the alternative to vaginal prostaglandins for induction of labour?
Cervical ripening balloon
951
What is the risk of amniotomy if the presenting part is high?
Umbilical cord prolapse
952
When is an oxytocin infusion offered followed an amniotomy in IoL?
2 hours after the membranes have rupture
953
What is the goal contraction rate during second phase labour?
3-4 contractions/10 minutes
954
Which drug is used to induce labour if there is an intrauterine foetal death?
Oral mifepristone and misoprostol
955
When induction labour what type of monitoring should be performed?
CTG
956
How contractions in 10 is equal to uterine hyperstimulation syndrome?
5 or more
957
What are the consequences associated with uterine hyperstimulation syndrome?
Foetal hypoxia
Uterine rupture
958
Which tocolytic is prescribed for managing uterine hyperstimulation syndrome?
terbutaline
959
Which congenital infection is associated with PDA?
Rubella
960
Which congenital infection is associated with cerebral calcifications, chorioretinitis and hydrocephalus?
Congenital toxoplasmosis
961
Which drug is given to the baby in a PCR +ve mother for toxoplasmosis?
Spiramycin
962
What viral strain of HHV is CMV?
HHV-5
963
Which intra-uterine infection is most commonly associated with hearing loss?
Congenital CMV
964
What is the management for congenital rubella if detected positive IgM <18 weeks
Termination of pregnancy
965
What is the next step in confirmed rubella infection in a mother?
Notify HPU and refer to foetal medicine
966
What is the hallmark feature of congenital CMV?
* Hearing
967
What foetal abnormalities are associated with congenital cytomegalovirus?
: Intracranial calcifications, ventriculomegaly, lenticulostriate vasculopathy, occipital horn anomalies, echogenic bowel, hepatomegaly, and pericardial effusion.
968
What referral should be made if congenital CMV is detected during pregnancy?
Refer to the foetal medicine specialist
969
Frequency of ultrasound surveillance for CMV in pregnancy?
fetal US every 2-4 weeks from diagnosis
970
Which type of antibodies are diagnostic for primary CMV infection in pregnancy?
IgM antibodies
971
How is a foetal diagnosis made for congenital CMV?
amniocentesis
972
What is the symptomatic management for congenital CMV neonatal infection?
postanal valganciclovir/ganciclovir for the first 4 weeks of life
973
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.
974
An amniotic fluid index > cm is indicative of polyhydramnios?
> 25 cm
975
What is the management for polyhydramnios?
* Reductive amniocentesis for TTS
976
What is the histopathology of a choriocarcinoma?
Large eosinophilic smudgy multinucleated cells with large hyperchromatic nuclei.
977
What is the management for a low risk choriocarcinoma?
Methotrexate
978
What is the management for a high risk choriocarcinoma?
Chemotherapy
979
What investigation should be performed for suspected choriocarcinoma?
quantitative hCG levels
980
What term denotes placental invasion of the myometrium?
Placenta increta
981
What term denotes placental invasion through the endometrium
Placenta accreta
982
What term denotes placental penetration through the myometrium into the serosa?
Placenta precreta
983
What is the biggest risk factor associated with placenta accreta?
previous c-section
984
What investigation is performed to diagnose placenta accreta as part of the antenatal screening?
Ultrasound examination
985
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.
986
When should a planned delivery be performed for confirmed placenta accreta?
35 to 36+6 weeks
987
What is the surgical approach for placenta accreta?
Caesarean section hysterectomy
988
What are the risk factors for postpartum endometritis?
* Caesarean delivery
* Intrapartum intraamniotic infection
* Prolonged rupture of membranes
989
What is the classical presentation of postpartum endometritis?
Foul-smelling lochia and uterine tenderness, early onset fever within 48 hours
990
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.
991
A firm mobile painless lump deep to the areola in a lactating woman is associated with what diagnosis?
Galactocele
992
What is the management for a galactocele?
* Fine needle aspiration
993
What are the three most common causes of bleeding in the first trimester of pregnancy?
1. Miscarriage
2. Ectopic pregnancy
3. Hydatidifiorm
994
What are the common causes of third trimester associated bleeding in pregnancy?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
995
What is the admission criteria for a patient with antenatal haemorrahge?
Admit for 48 hours with regular monitoring and observation including CTG
996
Which breech term denotes a foot presenting through the cervix with the leg extended?
Footling breech
997
What are the risk factors associated with breech presentation?
* Uterine malformations
* Fibroids
* Placenta praevia
* Poly/oligohydramnios
* Foetal anomaly
* Prematurity
998
What is the management for breech if detected <36 weeks of gestation?
re-scan at 36 weeks - if breech perform ECV
999
What type of pregnancy is a breech presentation?
High risk - performed with attendant neonataologist
1000
When should an ECV be performed in a nulliparous woman?
At 36 weeks
1001
When should an ECV be performed in a multiparous woman?
At 37 weeks
1002
What class of drug is administered prior to an ECV?
Tocolysis - terbutaline
1003
What test should be performed when performing an ECV?
Kleiheur test - followed by anit-D prophylaxis
1004
Which manoeuvre is performed during a vaginal delivery of a breech presentation baby?
Lovset manoeuvre and Mauricea–Smellie–Veit impressions
1005
Which position should a mother be when delivering a breech presentation baby vaginally?
Lithotomy position
1006
What is an absolute contraindication for a vaginal delivery for breech presentation?
Footling breech
1007
What are the significant risks and complications associated with breech?
Cord prolapse
Plancental central abruption
PROM
APH
foetal distress
1008
What is the preferred mode of delivery for breech presentation?
Elective c-section
1009
What does power denote?
Uterine contractions
1010
Which term denotes the size, presentation and position of the baby?
Passenger
1011
What is the maximum dilation of the cervix for latent phase of 1st stage labour?
3 cm
1012
What is the dilation rate for latent phase first stage labour?
0.5 cm/hour
1013
What is the cervical dilation rate for active phase of first stage labour?
1 cm an hour
1014
What is the maximal dilation of the cervix?
10 cm
1015
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
1016
What is the most common cause of failure to progress in a woman?
hypocontractile uterine activity
1017
What is the maximum time for second stage labour in a nulliparous woman before being considered as a delay?
2 hours
1018
Delay in hours for am multiparous woman during the second stage?
1 hour
1019
If there are signs of progress after 1 hour what should be recommended (in a nulliparous woman)?
Encourage the woman to continue pushing
1020
If there are no signs of progress during the second stage of labour, and membranes are intact, what should be done?
consider amniotomy
1021
If birth is not imminent in a nulliparous woman after 2 hours of pushing, what is the next stage?
Refer for senior review
1022
In a multiparous woman, if there are no signs of progress after 30 minutes, what should be offered?
Amniotomy
1023
What should be offered after amniotomy and no signs of progress?
Oxytocin infusion (requires an in-person assessment by an obstetrician)
1024
What is the maximum length for third stage of labour in active management?
30 minutes
1025
Physiological labour, what hour threshold = delayed?
1 hour
1026
What are the two modes of instrumental delivery?
Ventouse suction cup or forceps
1027
What intervention is indicated if there is prolonged second stage of labour with the head presenting?
Episiotomy with instrumental delivery
1028
Which Abx is indicated following post-instrumental delivery?
IV co-amoxiclav within 6 hours of cord clamping
1029
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).
1030
Which neonatal complication is associated with ventouse assisted delivery?
Cephalhematoma
1031
Which neonatal complication is associated with forceps assisted delivery?
Facial nerve palsy
1032
Which two nerves are commonly injured during instrumental delivery (maternal)?
Femoral - nerve compression = loss of patella reflex
Obturator - weakness of hip adduction
1033
At what stage of labour is an episiotomy performed?
Second stage of labour
1034
What type of incision is performed for an episistiomy?
Mediolateral incision - directed to the right side at 45 and 60 degrees
1035
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
1036
What is DR for DR C BRAVADO?
Define risk - the indications of performing the CTG
1037
What is the average number of contractions?
3 to 5 contractions in 10 minutes
1038
What is the average baseline foetal rate?
110-160 bpm
1039
What cause of foetal HR variability <45 minutes followed by a normal CTG trace?
Foetal sleep cycle
1040
What is the normal foetal heart rate variability over 5-10 minutes?
5 - 25
1041
What are the non-reassuring foetal heart rate thresholds?
100-109 and 161 to 180
1042
What is an abnormal baseline rate on CTG?
<100 or >180
1043
What are the causes of early decelerations?
Physiological - compression of the fetal head on the vagus nerve
1044
What are the causes of late decelerations?
Foetal hypoxia
1045
What are the causes of variable decelerations?
Intermittent cord compression
1046
Prolonged decelerations for 2-10 minutes indicate what?
Cord compression
1047
What CTG pattern indicates foetal compromise?
Sinusoidal CTG
1048
What is the average duration of stage 1 labour in a nulliparous woman?
8 hours
1049
What phase of labour after 10 cm dilation is associated with no maternal urge to push?
Passive phase of 2nd stage of labour
1050
What is the maximum allowance of failure to progress in the second stage of labour if on epidural?
+1 hour
1051
How frequently should the fetal heartbeat be auscultated for 1 minute?
Every 5 minutes
1052
What dose of oxytocin should be given for active management for the third stage of labour?
a. 10 iU oxytocin IM
1053
When should oxytocin be given for active management in the third stage of labour?
Once the anterior shoulder is delivered
1054
What action is performed to reduce the incidence of PPH during the third stage of labour?
Controlled cord clamping
1055
What are the two most common causes of prolonged third stage of labour?
Uterine atony and placenta accreta
1056
What investigation is performed for suspected cerebral venous sinus thrombosis?
CT venography or MRV
1057
What is the management for cerebral venous sinus thrombosis in pregnancy?
Anticoagulation with LMWH (treatment dose of enoxaparin)
1058
Which is the first line painkiller for migraine in pregnancy?
Paracetamol
1059
Which derm condition is associated with plagues in the stretch marks with peri-umbilical sparing?
Polymorphic Eruption of Pregnancy
1060
What is the first line management for Polymorphic Eruption of Pregnancy?
Topical corticosteroids and oral anti-histamines
1061
What bullous autoimmune sub-epidermal dermatosis occurs in the third trimester resulting in urticarial plaques including around the umbilicus?
Pemphigoid Gestationis
1062
What autoantibody is implicated in Pemphigoid Gestationis?
IgG-mediated against hemidesmisomes
1063
What foetal complications are associated with Pemphigoid Gestationis?
Preterm delivery and low birth weight
1064
What is the diagnostic investigation for Pemphigoid Gestationis?
* Direct immunofluorescence
1065
What is the management for mild Pemphigoid Gestationis?
Emollients and topical steroids
1066
Which type of umbilical cord predisposes to an increased risk to Twin to twin transfusion syndrome?
* Velamentous umbilical cord insertion
1067
What sign, detected on ultrasound is associated with dichorionic diamniotic twins?
Lambda sign
1067
T sign on ultrasound is associated with with which type of twins?
Monochorionic twins (thin dividing membrane results in T sign)
1068
Which complication is associated with the recipient twin in Twin to twin transfusion syndrome?
Polyhydraminios
1069
Which type of twins are more at risk for Twin to twin transfusion syndrome?
monochorionic diamniotic twins
1070
What maternal signs are associated with TTTS?
Rapid weight gain, swelling and pain.
1071
What is the frequency of monitoring for twins?
Every 2 weeks from 16 weeks of gestation
1072
What is the recommended approach for treating TTTS?
Fetoscopic laser photocoagulation
1073
What approach is indicated for correcting polyhydramnios?
Amnioreduction
1074
What is the rule for missing 2 pills in the first week of the COCP?
Consider emergency contraception
1075
How long does the COCP take effect?
7 days
1076
If 2 or more pills are missed in week 2 - action?
No need for emergency contraception (take the last pill)
1077
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
1078
What is the absolute contraindication for all forms of hormonal contraception (UKMEC 4)?
Breast cancer
1079
Which type of contraception is recommended for patients with breast cancer?
Copper intrauterine device
1080
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)
1081
What common side effect is associated with intrauterine systems following insertion?
Irregular bleeding within the first 6 months
1082
What does the depo-provera injection include?
medroxyprogesterone acetate 150 mg
1083
What is the mechanism of action of the depo-provera contraception?
Inhibits ovulation and thickens cervical mucous
1084
How frequently should the depo-provera contraception be adminsitered?
Every 12 weeks (3 months)
1085
Which form of contraception is associated with a delay in return to fertility?
Depo-provera injection (up to 12 months)
1086
Which adverse effects are associated with the depo-provera injection?
Irregular bleeding, weight gain, increased risk of osteoporosis
1087
When is COCP effective immediately?
If started on days 1-5 of the menstrual cycle
1088
Which form of contraception is associated with significant weight gain?
Depo-provera injectable contraceptive
1089
What is the mechanism of action of the intrauterine device as contraception?
Prevention of fertilisation by decreased sperm motility and survival
1090
What effect does Levonorgestrel have in the IUS?
Thickens cervical mucous and prevents endometrial proliferation
1091
How long does the implantable contraception work for?
Long-acting for 3 years
1092
Can the implantable contraception be used in patients with migraines with aura?
Yes - does not contain oestrogen
1093
How long does the implantable contraception take to work (fi not inserted on days 1-5)?
7 days- advice barrier contraception
1094
What are the adverse effects associated with the implantable contraception?
irregular bleeding - managed with COCP
progestogen effects - headache, nausea, breast pain
1095
Which drugs interact with the implantable contraception?
* Enzyme-inducing drugs – anti-epileptic and rifampicin can reduce efficacy
1096
When can the progesterone-only pill be given post-partum?
Any time
1097
When can contraception not be used unti?
Until day 21 postpartum
1098
When should COCP not be used postpartum?
Within the first 21 days or <6 weeks breastfeeding
1099
When can the IUD/IUS be inserted post-partum?
Inserted within 48 hours or after 4 wees
1100
How long can lactational amenorrhoea work for?
Exclusive breastfeeding for 6 months without a period
1101
When should the COCP be started during the cycle?
First 5 days of the cycle (5 days - immediate effect)
1102
When should the COCP be discontinued before surgery?
4 weeks before
1103
Which phase of the menstural phase does the COCP work on?
Follicular phase
1104
How long does the patch be applied for?
3 weeks
1105
How frequently should the combined hormonal patch be replaced?
Every week
1106
What is the MoA for the combined hormonal transdermal patch?
Inhibition of ovulation
1107
If there is a delayed change of the patch <48 hours, what is the action?
Immediate change
1108
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)
1109
Delayed patch change at the end of the patch-free week?
Change the patch and use barrier contraception for 7 days
1110
How long does it take for the transdermal contraception patch to work?
7 days
1111
What is the mechanism of action for the progesterone only pill?
Thickens cervical mucous
1112
How long is the combined hormonal vaginal ring worn for?
21 days
1113
How long does it take for the progesterone-only pill to work if started after 5 days of the cycle?
48 hours
1114
What are the 2 main advantages associated with the progesterone only pill?
1. Can be used in breast-feeding individuals
2. Efficacy not reduced by antibiotics
1115
What is the window for missed pills for traditional POP?
3 hours
1116
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
1117
What is the window for missed pills for the cerazette POP?
12 hour window
1118
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
1119
How long should the intrauterine devices and coils be inserted for?
up to 5 years
1120
When is the foetus engaged?
When it is <2/5ths palpable or less above the pelvic brim
1121
What position is the head when it enters the pelvic inlet?
Occipito-transverse position
1122
what is the first stage of the mechanism of labour?
Engagement
1123
What follows engagement in the mechanisms of labour?
Flexion
1124
What does flexion do in the mechanism of labour?
Decreases the circumference of the fetal head to the sub-occiptobregmatic (9.5 cm)
1125
What stage follows flexion in the mechanism of labour?
Internal rotation
1126
During internal rotation, the foetus moves into which position?
into the occipito-anterior position
1127
What term describes the clinical visualisation of the foetal head at the vulva?
Crowning
1128
What happens after internal rotation of the foetus?
Extends - extension of the foetal neck once the head is visible beyond the labia
1129
What happens following extension?
External rotation and restitution - the head rotates to align with the shoulders
1130
What follows external rotation in the mechanism of labour?
Anterior shoulder delivery followed by posterior and trunk delivery
1131
When is the combined test for Down's syndrome performed?
11 - 13+6 weeks
1132
What three parameters are assessed in the combined test for Down's syndrome?
Raised hCG
Low PAPP-A
Nuchal translucency - raised
1133
What is the hCG level for Edward's and Patau syndrome?
Low
1134
What four parameters are assessed in the quadruple test?
AFP
Unconjugated oestradiol
hCG
Inhibin
1135
Which two parameters are raised on the quadruple test in Downs syndrome?
Inhibin A and hCG
1136
When is the quadruple test offered?
At 15-20 weeks
1137
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
1138
What diagnostic test for Down's syndrome is performed at 10-12 weeks?
* Chorionic villus sampling
1139
Which test for Down's syndrome is the most sensitive?
* Amniocentesis
1140
When is Amniocentesis performed during pregnancy?
15-18 weeks’
1141
When does postnatal depression first occur?
>2 weeks
1142
What scale is used to assess for postnatal depression?
Edinburgh Postnatal Depression Scale
1143
What is the first line management for moderate to severe postnatal depression?
High intensity psychological intervention e.g,, CBT or SSRI or both
1144
What is the management for mild-to-moderate postnatal depression?
Referral for facilitated self-help
1145
When should a follow-up for postnatal depression be made?
within 2 weeks of referral
1146
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
1147
Severe depression pre-pregnancy and now pregnant management (on existing SSRI)?
Continue current medication + high intensity CBT
1148
What effect does paroxetine have in the first trimester of pregnancy?
Increased risk of cardiovascular malformations
1149
What effect can SSRIs have if used >20 weeks' gestation?
Persistent pulmonary hypertension and neonatal withdrawal syndrome
1150
What is the management for baby blues?
Reassurance
1151
What is the follow-up for a patient with baby blues?
Follow-up diagnostic interview within 2 weeks.
1152
What HIV RNA copies/mL threshold indicates the need for vaginal delivery?
<50 HIV RNA copies/mL at 36 weeks
1153
What is the mode of delivery for HIV >50 RNA copies?
Elective c-section at 36 weeks
1154
Which intrapartum drug infusion is initiated in HIV pregnancy?
Zidovudine infusion
1155
What is the breast-feeding advice for HIV positive mothers?
Breast feeding is not recommended due to vertical transmission
1156
Which antiviral drug is recommended in the first trimester of HIV positive patients?
Tenofovir
1157
What immediate postpartum management is indicated for neonates of HIV positive mothers?
Wash baby and immediate cord clamping
1158
How long should zidovudine monotherapy be commenced for neonates born to HIV positive players?
2-4 weeks
1159
Which type of neonatal herpes is associated with the best prognosis?
1. Disease localised to the skin, eyes and/or mouth
1160
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
1161
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
1162
Management for third trimester genital herpes in pregnancy?
C-section and oral acyclovir 400 mg TDS until delivery
1163
At what weeks of gestation is fetal varicella syndrome at it's highest risk?
<28 weeks' gestation
1164
What is the post-exposure varicella prophylaxis for mothers?
Acyclovir 800 mg QDS on days 7-14 post-exposure or Varicella-zoster immunoglobulin
1165
What is the first line investigation to assess varicella immunity status in pregnant mothers?
Varicella antibodies (IgM) <100
1166
When should VSIG be administered following exposure to varicella?
Within 10 days of varicella exposure
1167
Confirmed chickenpox immunity is decided by?
confirmed chickenpox, shingles or 2 documented doses of varicella vaccine
1168
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
1169
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
1170
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
1171
What hepatitis antigen is screened for in pregnant women?
hepatitis B surface antigen
1172
When is HBV screening performed during pregnancy?
At the initial booking appointment - 10 weeks
1173
What are the indications for starting tenofovir for HepB in mothers?
HBV DNA >200,000 IU/L or quantitative HBsAg > 104 IU/L.
1174
Which hepatitis variant is associated with adverse outcomes during pregnancy?
Hep E
1175
What are the complications of active hepatitis B infection during preganncy?
HELLP syndrome and hepatic flares
1176
What intrapartum management is recommended for HepB positive patients?
Active labour management is encouraged if there is a spontaneous rupture of membranes
1177
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
1178
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)
1179
What is the complication of a parvovirus b19 infection during pregnancy?
hydrops fetalis
1180
What screening investigations should be performed for positive parvovirus B19 infections during pregnancy
- Serial foetal ultrasound and Doppler Assessment
1181
What is the definitive management for placental abruption?
Immediate laparotomy
1182
Why are NSAIDs contraindicated in pregnancy/
Due to premature closure of the ductus arteriosus
1183
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
1184
Which blood thinners are not recommended in pregnancy?
DOACs and Warfarin
1185
When are foetal movements first felt?
at ~16-24 weeks
1186
When is the symphysis fundal height first measured?
at 24 weeks, and every 2 weeks after that
1187
When is the booking appointment?
At 10 weeks
1188
When should the OGTT first be performed in a woman with previous gestational diabetes?
At booking and again at 24-28 weeks
1189
A woman with no previous GDM but risk factors, OGTT when?
24-28 weeks
1190
For one major risk factor for pre-eclampsia, what should be offered?
low dose 75-150 mg of aspirin from 12 weeks
1191
What is the standard dose of folic acidduring pregnancy?
400 ug OD from pre-conception until 12 weeks
1192
What three infections are screened during the booking appointment in pregnancy?
Hepatitis B, syphillis, and HIV
1193
When is the dating scan performed?
11+2 to 14+1
1194
When are red cell alloantibodies first screened for?
At the booking appointment
1195
When is used to determine the date of gestation during the dating scan?
Crown-Rump Length
1196
When should the pertussis vaccine be given during pregnancy?
Following 16 weeks of gestation
1197
When is the anomaly scan performed?
18+0 - 20+6
1198
What does the anomaly scan detect?
Placenta location
1199
When should a second scan for the placenta location be offered following the anomaly scan?
32 weeks of gestation
1200
What three investigations should always be offered at GP reviews?
BP, BMI, Urine dip
Also measure SFH
1201
When is the first dose of Anti-D prescribed?
28 weeks of gestation
1202
When is the second dose of Anti-D prescribed?
At 34-weeks
1203
What is the management for asymptomatic bacteriuria in pregnancy?
1st line - nitrofurantoin for 7 days or amoxicillin 500 mg or cefalexin 500 mg
1204
Which antibiotic is contraindicated at term or labour for active UTI?
Nitrofurantoin
1205
What is the main cause of infectious mastitis?
Staphylococcus aureus
1206
What are the two different types of mastitis?
Periductal mastitis
Granulomatous mastitis
1207
Which type of mastitis is assocaited with nipple retraction?
Periductal mastitis
1208
When shoulder a breast milk culture be indicated for mastitis?
* Severe or recurrent mastitis
* Hospital-acquired infection is likely
* Severe deep burning breast pain
1209
What is the first line management for lactating women with mastitis?
Reassurance and continue breastfeeding
1210
Which antibiotic is recommended for the management for lactational mastitis?
Flucloxacillin 500 mg
1211
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
1212
What is the first line management for breast abscess?
* Ultrasound-guided needle aspiration + culture of fluid.
1213
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.
1214
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.
1215
What BMI threshold is considered a moderate risk factor for pre-eclampsia?
35
1216
What BMI threshold is associated with requiring 5 mg folic acid dose?
30
1217
What is the management for BMI >40 in obesity during pregnancy?
Refer to an obstetric anaesthetist for antenatal assessment
1218
What is the mode of delivery for monochorionic diamniotic twins?
elective caesarean section between 32 and 33+6 weeks.
1219
When should a routine ultrasound scan be performed during pregnancy?
18 and 20+6 weeks
1220
When should foetal ultrasound monitoring begin for twin pregnancies?
16 weeks ,for every 2 weeks
1221
What support group is available for multiple pregnancies?
Twins and Multiple Birth Association (TAMBA)
1222
How is TTTS staged?
Quintero system + umbilical artery Doppler velocities
1223
What is the mode of delivery recommended for diamniotic twins?
Vaginal
1224
Which antithyroid drug is preferred during the first trimester of pregnancy?
Propylthiouracil
1225
Which drug is recommended to manage postpartum thyroiditis?
propranolol
1226
Which drug should be avoided (used in PPH) for pregnant women with asthma?
carboprost
1227
Which drug is used to expedite an intrauterine death?
* Induction of labour – mifepristone and a prostaglandin preparation (misoprostol).
1228
How is a stillbirth confirmed?
Real-time ultrasonography – Direct visualisation of the fetal heart.
1229
What threshold denotes small for gestational age (kg)?
<10th centile – less than 2.5 kg.
1230
What are the 2 parameters used to assess for foetal growth restriction?
Abdominal circumference and estimated foetal weight.
1231
When should an uterine doppler be performed in high risk groups?
20-24 weeks
1232
When is an umbilical artery Doppler performed in high risk patients?
>24 weeks
1233
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
1234
What is the main cause of symmetrical IUGR?
Congenital infections
1235
What are the worse prognostic factors associated with IUGR on umbilical artery Doppler?
Reverse End diastolic flow and absent end diastolic flow
1236
When should delivery be performed when IUGR is confirmed?
>34 weeks + mag sulphate if under <32 weeks
1237
