O+G 6 Flashcards
1
Q
What are the investigations for PCOS?
A
- pelvic ultrasound: multiple cysts on the ovaries
- FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
- check for impaired glucose tolerance
2
Q
A 43-year-old woman presents as she has not had a period for the past six months. She is concerned that she may be going through an ‘early menopause’. How is premature ovarian failure defined?
A
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
3
Q
A 17-year-old girl presents due to painful periods. These have been present for the past three years and are associated with a normal amount of blood loss. Her periods are regular and there is no abnormal bleeding. She is not yet sexually active. What is the most appropriate first-line treatment?
A
Ibuprofen
NSAIDs are offered first-line as they will inhibit prostaglandin synthesis, one of the main causes of dysmenorrhoea pains.
4
Q
What are the categories of dysmenorrhoea?
A
Primary
In primary dysmenorrhoea there is no underlying pelvic pathology. It affects up to 50% of menstruating women and usually appears within 1-2 years of the menarche. Excessive endometrial prostaglandin production is thought to be partially responsible.
Secondary
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period.
5
Q
What are the features and management for primary dysenorrhoea?
A
Features
- pain typically starts just before or within a few hours of the period starting
- suprapubic cramping pains which may radiate to the back or down the thigh
Management
- NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
- combined oral contraceptive pills are used second line
6
Q
What causes pain in secondary dysmenorrhoea?
A
- endometriosis
- adenomyosis
- pelvic inflammatory disease
- intrauterine devices
- fibroids
7
Q
What’s the most common cause of anovulatory infertility?
A
PCOS 80%
8
Q
What’s the incidence of PCOS?
A
5% of women
9
Q
How is PCOS diagnosed?
A
It is diagnosed when a patient has at least two of the following:
- polycystic ovary on ultrasound
- irregular periods (>35 days apart)
- hirsutism
10
Q
What are the complications of PCOS?
A
- obesity
- type 2 diabetes
- subfertility
- miscarriage
- endometrial cancer
11
Q
When is clomifene given for PCOS fertility?
A
days 2 to 6 of each cycle to initiate follicular maturation.
If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles.
It is limited to 6 months use and increases the risk of multiple pregnancy to 11%.
12
Q
When is medical management used for PCOS?
A
Once appropriate lifestyle changes have been made. These include:
- weight loss (as increasing body weight leads to increased insulin and androgen levels)
- exercise
- cessation of smoking
13
Q
When can metformin be used to treat PCOS? Is it better or worse than clomifene? What factors does it affect?
A
Metformin can be used as an alternative to clomifene, or in addition to it if it fails to induce ovulation.
When used alone it has a lower live birth rate compared to clomifene, but increases the effectiveness of clomifene in clomifene-resistant women.
It also treats hirsutism and may reduce the risk of gestational diabetes and early miscarriage.
14
Q
What’s the second line treatment for PCOS fertility treatment? What can you do if this fails?
A
Second-line treatments include ovarian diathermy and gonadotropin induction. Gonadotropin induction involves a daily subcutaneous injection of recombinant or purified urinary FSH and/or LH. This stimulates follicular growth and is monitored by ultrasound. Once a follicle has reached approximately 17mm in size, the process of ovulation is artificially stimulated by injection of hCG or LH.
IVF if this doesn’t work
15
Q
If the combined oral contraceptive pill (COCP) is used to regulate menstruation for PCOS what must you do?
A
Ensure three to four bleeds necessary every year to protect the endometrium.
16
Q
What can be used to treat menstrual irregularity and hirsutism, with the addition of acne?
A
co-cyprindiol
17
Q
How do you differentiate between gestational thrombocytopenia and immune thrombocytopenia?
A
Differentiating between ITP and gestational thrombocytopenia is difficult and often relies on a careful history. Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign. If the patient becomes dangerously thrombocytopenic, she will usually be treated with steroids and a diagnosis of ITP assumed. Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for serum antiplatelet antibodies for confirmation.
18
Q
Does gestational or immune thrombocytopenia affect the neonate? What can be done?
A
Gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta.
Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated.
Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia.
19
Q
How do you differentiate clinically between a galactocoele and mastitis?
A
Galactoceles can be clinically differentiated from a breast abscesses because they are painless and non-tender on examination, and there will be no local or systemic signs of infection.
20
Q
When do galactocoeles usually occur and what causes them?
A
Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast.
21
Q
What’s the surgical treatment for a vaginal vault prolapse?
A
sacrocolpoplexy
22
Q
How do you surgically treat a cystocele?
A
Anterior colporrhaphy is when the vaginal wall is repaired following a cystocele.
23
Q
What is urogenital prolapse? What proportion of women get it? What are the types?
A
- In urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls. - It probably affects around 40% of postmenopausal women
Types
- cystocele, cystourethrocele
- rectocele
- uterine prolapse
- less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)
24
Q
Risk factors for urogenital prolapse?
A
- increasing age
- multiparity, vaginal deliveries
- obesity
- spina bifida
25
What's the presentation of urogenital prolapse?
- sensation of pressure, heaviness, 'bearing-down'
| - urinary symptoms: incontinence, frequency, urgency
26
What are the management and surgical options for urogenital prolapse?
Management
- if asymptomatic and mild prolapse then no treatment needed
- conservative: weight loss, pelvic floor muscle exercises
- ring pessary
- surgery
Surgical options
- cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- uterine prolapse: hysterectomy, sacrohysteropexy
- rectocele: posterior colporrhaphy
27
What cancers does the COCP increase/decrease the chance of?
- increased risk of breast and cervical cancer
| - protective against ovarian and endometrial cancer
28
A 52-year-old journalist presents with a 6/12 history of hot flushes and vaginal dryness. Her last menstrual period was 13 months ago and she has no significant medical or surgical history. After discussing all of her menopause treatment options, she opts for an oestrogen only preparation. Which additional treatment (if any) would she be recommended to combine this with?
The Mirena intrauterine system is licensed for use as the progesterone component of HRT for 5 years
29
What proportion of menopausal women have symptoms for which they seek treatment?
25% usually vasomotor
30
What are the hormonal methods for treating menopausal symptoms?
- hormone replacement therapy: most effective
| - tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
31
What are the non-hormonal treatments for vasomotor symptoms experienced in menopause?
- selective serotonin reuptake inhibitors and venlafaxine
- clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea
- a progestogen such as norethisterone
32
What can b used to treat the vaginal symptoms of menopause?
- vaginal atrophy may be helped by topical oestrogens
| - if the symptoms are predominately vaginal dryness then a vaginal lubricant or moisturizer
33
A 27-year-old female asks for advice regarding the Mirena (intrauterine system). What is the most likely effect on her periods?
Initially irregular bleeding later followed by light menses or amenorrhoea
34
A 27-year-old female presents to her GP as she missed her desogestrel contraceptive pill (progestogen only) this morning and is unsure what to do. She normally takes the pill at around 0900 and it is now 1430. What advice should be given?
Take missed pill now and no further action needed
As desogestrel has a 12-hour window this patient should take the pill now with no further action being needed
35
What advice should be given if a woman forgets to take a progesterone only pill?
There are two types of POP!
'Traditional' POPs (Micronor, Noriday, Nogeston, Femulen)
- If less than 3 hours late no action required, continue as normal
- If more than 3 hours late (i.e. more than 27 hours since the last pill was taken) action needed - see below
Cerazette (desogestrel)
- If less than 12 hours late no action required, continue as normal
- If more than 12 hours late (i.e. more than 36 hours since the last pill was taken) action needed - see below
Action required, if needed:
- take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
- continue with rest of pack
- extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
36
What are the traditional POPs?
- Micronor
- Noriday
- Nogeston
- Femulen
37
A 20-year-old model comes to see you as she would like to start using contraception. She tells you 'staying slim is part of my job' she is reluctant to use anything which may cause weight gain.
Whichmethod of contraception is proven to be associated with weight gain?
Depo Provera (Medroxyprogesterone acetate)
38
You are in your GP practice and are counselling a 25-year-old female about the contraceptive patch.
What is the correct way to utilise the contraceptive patch effectively?
Change patch weekly with a 1 week break after 3 patches
This form of combined contraception is becoming increasingly common as the patch change can be delayed for up to 48 hours without the need for additional contraception. This reduces human error in contraceptive effectiveness.
39
You are seeing a woman for her 6-week follow up appointment following a normal vaginal delivery. She wishes to cease breastfeeding as her baby requires specialised formula feeds.
Which medication can be used to suppress lactation in this case?
Cabergoline is the medication of choice in suppressing lactation when breastfeeding cessation is indicated
40
How does cabergoline work?
Cabergoline is a dopamine receptor agonist which inhibits prolactin production causing suppression of lactation.
41
What is misoprostol used for?
Misoprostol is used to soften the cervix in induction of labour.
42
What are the ways of stopping lactation?
- stop the lactation reflex i.e. stop suckling/expressing
- supportive measures: well-supported bra and analgesia
- cabergoline is the medication of choice if required
43
A woman of child bearing age comes into your GP surgery. She wishes to try to conceive for a baby in one years time and does not wish to conceive sooner due to barrister exams she has this year. She ideally wants to fall pregnant soon after her exams. Which of the follow methods of contraception is most associated with delayed return to fertility?
```
Intrauterine system
Condoms
Combined oral contraceptive pill
Depo-Provera
Progesterone only pill
```
Depo-Provera
44
How long does it typically take to conceive after stopping the COCP?
typically 1 month
45
What condition is associated with high ALT e.g. 500 u/l?
Acute fatty liver of pregnancy
46
What is the 3rd stage of labour?
What is active management and why is it recommended?
What drugs are used/avoided in active management?
The third stage of labour is measured from the birth of the baby to the expulsion of the placenta and membranes. Active management of this stage is recommended in order to reduce post-partum haemorrhage (PPH) and the need for blood transfusion post delivery.
Active management lasts less than 30 minutes and involves the following:
- Uterotonic drugs
- Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
- Controlled cord traction after signs of placental separation
Guidelines suggest the use of 10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of the anterior shoulder.
Ergometrine should not be given in the presence of hypertension. Also oxytocin causes less nausea and vomiting.
47
A 23-year-old female presents to your GP clinic on Monday morning, worried as she took off her week 2 contraceptive patch on Friday evening, and she was unable to obtain a replacement over the weekend. She has not been sexually active in the last 10 days.
What is the most appropriate action to take?
No emergency contraception required, but apply new patch and advise barrier contraception for the next 7 days
48
What type of contraceptive is the vaginal ring?
combined hormonal contraceptive (CHC)
49
A 25-year-old woman is investigated for acute pelvic pain and is diagnosed as having pelvic inflammatory disease. What is the most common cause of pelvic inflammatory disease in the UK?
Chlamydia trachomatis
50
What is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation leading to the creation of adhesions?
Fitz-hugh curtis syndrome
51
A 21-year-old woman has an ectopic pregnancy confirmed by ultrasound. However, the ultrasound report simply states the ectopic pregnancy is located within the 'right fallopian tube' but does not offer more specific information. You decide to call the ultrasound department seeking clarification of the precise location as you know this will influence management.
Ectopic pregnancy in which of the following locations is most associated with an increase risk of rupture?
```
Fimbriae
Cervix
Isthmus
Ampulla
Interstitium
```
Isthmus
52
What's the most common site for an ectopic pregnancy? Where is a danger?
- 97% are tubal, with most in ampulla
- more dangerous if in isthmus
- 3% in ovary, cervix or peritoneum
53
What would you expect to see in vulval carcinoma, melanomas and vulval intraepithelial neoplasia?
Vulval carcinomas are commonly ulcerated and can present on the labium majora. Melanomas are usually pigmented. Vulval intraepithelial neoplasia tend to be white or plaque like and don't tend to ulcerate.
54
What are the risk factors for vulval carcinoma?
- age
- Human papilloma virus (HPV) infection
- Vulval intraepithelial neoplasia (VIN)
- Immunosuppression
- Lichen sclerosus
55
A 36-year-old pregnant patient is admitted to the labour ward after her waters break and she begins to experience contractions. She is 39 weeks pregnant and was diagnosed with gestational hypertension at 25 weeks. The doctor decides to continuously monitor the foetus throughout labour. After seeing the CTG tracing, he tells the mother that he must call for senior obstetrician review due to a potentially worrying feature which has persisted for 20 minutes.
Which of the following is he most likely to have seen on the CTG?
```
Multiple accelerations
Variability <5bpm
Decelerations with contractions
Foetal heart rate >110
Foetal heart rate <160
```
Variability <5bpm
56
What is normal variation on CTG?
5-25bpm
57
What are features of a normal CTG?
- accelerations present
- variability >5bpm
- no decelerations
- HR 110-160
- normal to see decelerations with contractions, as long as they resolve by the end of the contraction
58
What are the stages of ovarian cancer?
Confined to the ovaries (Stage 1)
Local spread within the pelvis (Stage 2)
Spread beyond the pelvis to the abdomen (Stage 3)
59
What's the most common cell of origin for ovarian cancer?
90% epithelial, with 70-80% of cases being due to serous carcinomas
60
Risk factors for ovarian cancer
- family history: mutations of the BRCA1 or the BRCA2 gene
| - many ovulations*: early menarche, late menopause, nulliparity
61
What are the clinical features of ovarian cancer?
Clinical features are notoriously vague:
- abdominal distension and bloating
- abdominal and pelvic pain
- urinary symptoms e.g. Urgency
- early satiety
- diarrhoea
62
How would you investigate and diagnose ovarian cancer?
Investigations
- NICE recommend a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level
- if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered
Diagnosis is difficult and usually involves diagnostic laparotomy
63
Management of ovarian cancer
usually a combination of surgery and platinum-based chemotherapy
64
What's the prognosis of ovarian cancer?
- 80% of women have advanced disease at presentation
| - the all stage 5-year survival is 46%
65
A 26-year-old pregnant woman with type 1 diabetes asks you how often she should test blood glucose levels throughout her pregnancy?
Daily fasting, pre-meal, 1-hour post-meal and bedtime tests
66
What's the condition?
A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding. Her last period was 8 weeks ago. On examination her cervix is tender to touch
Ectopic pregnancy
67
What is antepartum haemorrhage?
bleeding after 24 weeks
68
What are the major causes of bleeding in each of the 3 trimesters?
1st trimester (1-12 weeks)
- Spontaneous abortion
- Ectopic pregnancy
- Hydatidiform mole
2nd trimester (13-26 weeks)
- Spontaneous abortion
- Hydatidiform mole
- Placental abruption
3rd trimester (27-term)
- Bloody show
- Placental abruption
- Placenta praevia
- Vasa praevia
69
What is the typical presentation of an ectopic pregnancy?
- Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later.
- Shoulder tip pain and cervical excitation may be present
70
What's the typical presentation of a hydatidiform mole?
- Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis.
- The uterus may be large for dates
- serum hCG is very high
71
What's the typical presentation of a placental abruption?
- Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss.
- Tender, tense uterus with normal lie and presentation.
- Fetal heart may be distressed
72
What's the typical presentation of placenta praevia?
- Vaginal bleeding, no pain.
| - Non-tender uterus but lie and presentation may be abnormal
73
What's the typical presentation of vasa praevia?
- Rupture of membranes followed immediately by vaginal bleeding.
- Fetal bradycardia is classically seen
74
What forms of contraception can be taken beyond age 50 and when can you stop taking them?
- Implant, POP, IUS Can be continued beyond 50 years
- If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
- If not amenorrhoeic consider investigating abnormal bleeding pattern
75
How would you manage the following situation?
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well.
Urinary dye studies
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
76
How would you manage the following situation?
A 56-year-old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive.
Urodynamic studies
Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.
77
What's the most likely diagnosis?
A 31-year-old woman complains of intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
Ovarian cyst
Large ovarian cysts may lead to abdominal swelling and pressure effects on the bladder.
78
What's the most likely diagnosis?
A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse.
Endometriosis
79
What's the condition?
Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise.
Nausea and vomiting are common
Unilateral, tender adnexal mass on examination
Ovarian tortion
80
What's the condition?
Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur
Cervical excitation may be found on examination
PID
81
A 40-year-old woman presents to the emergency department with a 48-hour history of steadily worsening perineal pain, which is now so severe she is in agony sitting down or walking. She has no history of fever.
Perineal examination demonstrates a unilateral fluctuant mass which is exquisitely tender within the labium majus. The overlying skin is erythematous.
What is the definitive treatment for this condition?
Definitive treatment of Bartholin's abscess: marsupialisation whereby the cyst is opened and the edges sutured, forming an "open pocket" or "pouch."
82
What are the treatment options for a bartholin's abscess?
- antibiotics
- by the insertion of a word catheter
- by a surgical procedure known as marsupialization.
83
What are the common long term complications of vaginal hysterectomy with antero-posterior repair?
- enterocoele
| - vaginal vault prolapse
84
What can raise the CA125 levels?
- Endometriosis
- menstruation
- benign ovarian cysts
85
What should you use to treat hypertension in pregnancy?
- consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold
- oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used
- delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario
86
A 29-year-old woman who has been suffering with severe dysmenorrhoea for years is seen at the gynaecological clinic. The consultant believes she may have adenomyosis, but wishes to confirm this diagnosis and rule out any other pathology before commencing treatment. Which is the best imaging technique for diagnosing the suspected condition?
The best imaging technique for diagnosing adenomyosis is MRI
87
What delivery should be given to an HIV positive mother and what treatment is given to the baby?
Mode of delivery
- vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
- a zidovudine infusion should be started four hours before beginning the caesarean section
Neonatal antiretroviral therapy
- zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
88
How would you manage a woman with an enlarged ovary on US?
Management depends on the age of the patient and whether the patient is symptomatic. It should be remembered that the diagnosis of ovarian cancer is often delayed due to a vague presentation.
Premenopausal women
- a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as 'simple' then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Postmenopausal women
- by definition physiological cysts are unlikely
- any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
89
A Cardiotocogram (CTG) is performed on a 34-year-old female at 40 weeks gestation who has attended labour ward in spontaneous labour. The CTG shows a fetal heart rate of 150bpm. There is good variability in fetal heart rate, and it is a low risk pregnancy. The midwife rings you concerned that there are late decelerations present on the CTG trace. Which is the most appropriate next step in management?
Late decelerations on CTG are a pathological finding and urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis. A pH of >7.2 in labour is considered normal. Urgent delivery should be considered if there is fetal acidosis. Although the normal fetal heart rate and variability is reassuring, the late decelerations are a concerning feature which needs to be quickly investigated and managed.
90
What are the predisposing factors for vaginal candidiasis?
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV, iatrogenic
91
What are the features of vaginal candidiasis?
- 'cottage cheese', non-offensive discharge
- vulvitis: dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
92
What are the management options for vaginal candidiasis?
Options include local or oral treatment:
- local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
- oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
- if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
93
What should you do for recurrent vaginal candidiasis?
- compliance with previous treatment should be checked
- confirm initial diagnosis i.e. high vaginal swab
- exclude differential diagnoses such as lichen sclerosus
- exclude predisposing factors
- consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months
94
A 29-year-old woman presents with dysuria and frequency four weeks after giving birth. The antenatal period and delivery were unremarkable. She is exclusively breastfeeding her child at the current time. Abdominal examination is unremarkable and she is apyrexial. A urine dipstick shows blood +, protein +, leucocytes +++ and nitrites positive. What is the most appropriate management?
Trimethoprim is considered safe to use in breastfeeding women.
95
What's the incidence of premature ovarian failure?
1 in 100 women
96
What causes premature ovarian failure?
- idiopathic - the most common cause
- chemotherapy
- autoimmune
- radiation
97
What proportion of women have an induced labour?
20%
98
What are the indications for induction of labour?
- prolonged pregnancy, e.g. > 12 days after estimated date of delivery
- prelabour premature rupture of the membranes, where labour does not start
- diabetic mother > 38 weeks
- rhesus incompatibility
99
What are the methods for inducing labour?
- membrane sweep
- intravaginal prostaglandins
- breaking of waters
- oxytocin
100
What are the features of IBS?
classic ABC features of irritable bowel syndrome:
- Abdominal pain
- Bloating
- Change in bowel habit.
101
A 27-year-old is found to have a blood pressure of 165/111 mmHg and ++proteinuria on urinalysis on a routine visit to the antenatal clinic. Her consulting doctor is worried about pre-eclampsia and admits her to the obstetrics assessment unit. She has recently moved here and therefore her medical notes are not accessible. She is quite fit and well and does not take any medications apart from her blue and brown inhalers. She has recently completed a 5-day course of steroids after being hospitalised for a severe exacerbation of asthma.
Which is the choice of drug for managing her hypertension?
Nifedipine. Labetalol is contraindicated for asthmatics
102
What are the types of FGM?
Type 1
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
Type 4
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
103
A 72-year-old woman with ovarian cancer is seen in the gynaecological oncology clinic. There, the consultant talks through her pre-surgical prognosis, based on her risk malignancy index (RMI). What are the three components of the RMI?
Risk malignancy index (RMI) prognosis in ovarian cancer is based on:
- US findings
- menopausal status
- CA125 levels
104
A 32-year-old woman attends labour ward at 42+6 weeks as she has still not gone into labour. Her Bishops score is worked out as a 4. What is the appropriate management?
Induction of labour
- a score of < 5 indicates that labour is unlikely to start without induction
- a score of > 9 indicates that labour will most likely commence spontaneously
- a score of <6 indicates that cervical ripening may be required.
105
How is the Bishop's score calculated?
Cervical position
- 0 Posterior
- 1 Intermediate
- 2 Anterior
Cervical consistency
- 0 Firm
- 1 Intermediate
- 2 Soft
Cervical effacement
- 0 0-30%
- 1 40-50%
- 2 60-70%
- 3 80%
Cervical dilation
- 0: <1 cm
- 1: 1-2 cm
- 2: 3-4 cm
- 3: >5 cm
Fetal station
- 0: -3
- 1: -2
- 2: -1, 0
- 3: +1,+2
106
What is recommended for nausea and vomiting during pregnancy?
- natural remedies - ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE
- antihistamines should be used first-line (BNF suggests promethazine as first-line)
