O & G

Question 1

Antenatal Clinic History

Answer 1

PC - 4 questions: PV Bleeding/ Discharge, Abdominal pain, Fetal Movements, Rupture of membranes

HPC:

i) Previous Pregnancies - Number, Birth method, Complications, BW, Post-natal complications

ii) LMP

iii) Preference for delivery

iv) Maternal Factors - HTN, DM, Maternal Age, GDM, PET, Obesity, PMH, FH - SFD, GDM, previous scans, clinics, hyperemesis gravidarum, folic acid

DH - Any medications, any allergies, latex and penicillin

FH - Anything, miscarriage, SFD

SH- Alcohol, Smoking, Drugs, Domestic Abuse, Other children

Question 2

Small For Dates Management

Answer 2

Small for Dates: <10th Centile for gestation / 2.7kg at term

Investigations

SFH - SFD (Follows own trajectory) or IUGR ( Drops along the centiles)

Uterine Artery Doppler (most sensitive at 23 weeks) - Look for reversal of blood flow in diastolic waveform

Fetal MCA (most sensitive at 23 weeks)

Ultrasound: Amnotic Fluid, Fetal MCA, Tone, Breathing Movements, Limb Movements

SFH
Screen for infections (amniocentesis)

Karyotyping

Mx

Re-check fortnightly for fetal growth if SFD/ Re-check twice a week for IUGR

CTG - continuous/intermittent

No intervention required - for normal umbilical artery doppler.

If abnormal - Umbilical artery doppler is abnormal —> admit and if pre-34 weeks steroids and prepare for delivery with constant monitoring

Admit for neonotal care postpartum

Question 3

Fetal measurement paramaters

Answer 3

6-13 weeks - CRL

14-20 weeks - BPD

>24 weeks - SFH

Question 4

Risks of SFD

Risks of IUGR

Answer 4

SFD

• Constiutional (Maternal height, weight, asian, female)
• Materna Disease (renal, autoimmune)

IUGR

• Maternal pregnancy complications - PET
• Mutiple pregnancy
• Substance abuse/ smoking/ alcohol
• Infection - CMV

Question 5

Focused Gynae History

Answer 5

i) Pregnancies
ii) Discharge
iii) Bleeding - normal, abnormal, clots, flooding
iv) Dyspareunia
vi) Pain
vii) PCB, IMB, PMB, Cyclical Pain, Dyspareunia
viii) Smear history - abnormal smears + treatment

Sex History - Sexual partners in the last six months, STI?, Partners had STI? Barrier Protection? STI Screening?

PMH - Autoimmune, Cancers, Menorrhagia, Dysmneorrhoea, Gynae procedures etc.

PSH

FH - Genital breast cancers, gynaecological concerns

SH - Alcohol, Smoking, Psychological

Offer - STI Screening, Contraception and Leaflets

Question 6

Smear Counselling

Colposcopy Management

i) Punch
ii) LLETZ
iii) Cone biopsy

Answer 6

Smears: 25-49 = 3 yearly. 50-64 = 5 yearly. 65< only offered if haven’t had smear in last 10 years/ if last smear test was abnormal or if currently symptomatic/clinical suspicion

Borderline/ Mild Dyskaryosis - HPV Negative = Discharge to routine recall

Borderline / Mild (CIN1) - HPV Positive = Colposcopy within 8 weeks

Moderate (CIN2) = Colposcopy within 4 weeks

Severe Dyskaryosis (CIN3) = colposcopy within 2 weeks

Colposcopy

i) This involves using a small camera to have a look at the cervical opening. Small sample will be taken might be painful
ii) Acetic Acid stains the abnormal cells and iodine stains normal cells
ii) There might be some bleeding, advised to not have intercourse for 2 days after and avoid strenuous exercise

LLETZ

• Sever Dyskaryosis at smear. CIN II/III at punch biopsy.
• Uses a small electrical instrument to remove part of the cervix.
• Risks - preterm delivery, infection, haemorrahge
• Six month follow up - test of cure: review LLETZ biopsy histology and repeat cervical smear again + HPV

- Three outcomes :

i) Biopsy shows clear margins, no dyskaryosis and no HPV then goes back to routine follow up.

ii) Not clear excision then back to LLETZ.

iii) Clear excision but new SMEAR has HPV/ dyskaryosis then back to colposcopy

Cone Biopsy

Used to treat 1 a i) –> Removes ectocervix + some of endocervix

-Risks - preterm delivery, infection, haemorrahge

always offer To Take Away information (leaflets)

Question 7

Different types of swab

a) Endocervical
b) High Vaginal
c) Vulval

Answer 7

a) Endocervical - Involves LBC for Chlamydia, Gonorrhoea and Smear testing
b) High Vaginal - BV and Trichomonas
c) Vulval - BV and Trichomonas

Question 8

Dyskaryosis

vs

CIN

Answer 8

Dyskaryosis - The finding of abnormal cell types in LBC

CIN - Tissue sample finding of dysplasia in situ (I: 1/3 , II: 2/3 and III: 3/3)

Question 9

STI Management

+
partner tracing

Answer 9

PID Protocol

14 Days - Oral Oflaxacin + Oral Metronidazole

IM Ceftriaxone + 14 days Oral Doxy + Oral Met

Syphyllis

Benpen/ Gent / Doxy

Gonorrhoea - Ceftriaxone + Azithromycin ( 1 Dose + 1 Pill)

Chlamydia - Azithromycin/ Doxy

BV + Trichomonas - Metronidazole

Question 10

CA 125

Sensitivity

Specificity

Answer 10

Sensitivity - 81%

Specificity - 75%

Question 11

Ovarian Cancer Management

Answer 11

Examination - Pelvic + Bi Manual +/- SPeculum

Investigations - Blood Tests: CA-125, AFP + HCG - Germ Cell, LDH

Imaging - USS

Surgery - Stages 1a and 1b surgery no chemo. Stages 1c and above surgery and chemo

Question 12

Pelvic Inflammatory Disease

Hx

Rx

Answer 12

Hx

Discharge, pain : SOCRATES, quantify discharge or blood

Long term partner/ casual partners: how many how long

Have you ever had sex with someone knowing they have an STI/ HIV/ Hepatitis

Have you had sex with a sex worker

Have you had an STI Check before (and partner)

Have you ever felt pressured into having sex

PMH, PSH, SH - Smoking, Alcohol, FH, DH - Pill, In Situ devices.

Rx

Oral Oflaxacin + Met (14 Days)/ IM Cef (once) + Met and Doxy for 14 days

Contact Tracing - 6 months - any woman, men with upper genital tract invovlement. 4 weeks - asymptomatic men or urethritis.

Abstain from sex until treatment course completed.

Barrier protection and contraception

Safety Net - if experiencing gynaecological or psychosexual issues.

Risks of PID - Common - pain, discharge Severe - ectopic and infertility

Question 13

Placenta Praevia

Hx

Mx

VIVA

Answer 13

Hx

• Gravida/ Parity
• Gestational Age/ LMP
• Quantify Bleeding if present
• Discharge, pain, recent intercourse, Waters broken, other complications
• Fetal Movements

HPC - Scans, past appointments, STIs, previous period questions (IMB, PCB, Dyspareunia, menorrhagia etc)

PMH , PSH, Drug History, SH (alcohol, drugs), FH

Mx

• ABCDE, Admit, Call Senior
• Abdo examination, urine dip, BP
• CTG/ Pinnard/Doppler
• IV Access - FBC, G&S, U&E, LFT, Clotting, Rhesus, Ultrasound Scan
• Serial Scans - Long term Management, Safety Net, Discuss delivery plans

VIVA

Placenta Praevia Grading

I - Near os

II- Partly covering os

III- Completely covering os

IV - completely covering os even when dilated

Question 14

What to give to pre-term mothers/ neonates

Answer 14

Steroids

Antibiotics

MgSO4 (Consider)

Immediately to NICU especially if before 34 weeks (24 hours)

Question 15

DVT/PE Pathway

Answer 15

ABCDE, FBC, Clotting Studdies, Us and Es, LFTs, NOT D DIMER. ECG, ABG, CTG

i) Venus Duplex Scan - If positive —> Start management immediately. If negative–>

ii) CXR —> Abnormal –> CTPA / Normal —-> VQ Scan, if VQ Scan is abnormally CTPA

Management:

LMWH - Subcut (enoxiparin/clexane) - Titrated against women’s booking weight. Continued for entire pregnancy and stopped when she goes into labour

Restarted after labour then continued for six weeks or until three months. Not contraindicated in breastfeeding.

Question 16

Signs of pulmonary embolism

Answer 16

Pleuritic Chest Pain

Leg Pain

Breathlessness

Question 17

Prolapse Stages

Answer 17

I - Cervix drops into the vagina

II - Cervix out of the vaginal opening

III - Cervix is outsode of the vagina

IV - Procedentia

Question 18

Incontinence

Dx

Mx

Rx

Answer 18

Dx - Urge (Can’t make it) vs Stress (Leaks)

Bladder Diaries first line

If first line treatment fails then urodynamic studies

What are urodynamic studies:

• Fill bladder and vagina or rectum with fluid –> pressure probe ( Detressur pressure = Bladder - rectal pressure)
• Look for unsynchronised detrussor contrations = Detrussor Overactivity
• Look for leak when cough and NO detrussor contraction = Urodynamic Stress Incontinence

Post micturation ultrasound volume (stones, anomalies). FIlling and voiding studies.

Mx/Rx

Urge - Bladder Retraining —>

Conservative —->

Oxybutynin, Tolterodine —->

Sacral Nerve Stimulation / Clam Ileocystoplasty

Stress- Pelvic floor muscles (8 contractions ,3 times a day for 3 months) + Conservative +

—> Medical: Duloxetine

—>Surgery (TVT, TOT and plication)

Question 19

GDM

Hx

Dx

Mx

Cx

Answer 19

Hx:

Dates etc.

Previous clinics - BP readings, glucose readings, SFH

Sx - polyuria and polydypsia

Dx:

16 week GTT is warranted if: if past history of GDM or Macrasomia

28 week GTT with RFs: obesity, FHx DM, Stillbirth, Race, Macrosomia

or Urine dip: 2x + or 1 x ++

USS - look for polyhdramnios

Mx:

2 weekly monitoring

Target <7.8 post prandial

Measure glucose: morning, before meals and after meals

Fasting: <7.0 - diet and exercise, then metformin then insulin ( 2 weeks reviews)

Fasting: >7.0, start insulin)

Hba1c?

Teams : Dibaetic nurse, dietician,

Intrapartum - CTG, Maternal BMs, IV insulin pump, induction (39 weeks)

Postpartum - Stop IV Insulin, Subcutaneous Insulin after birth, Paediatrics team

Neonatal hypoglycaemia: 2x<2.6/ <1.6

Cx: Pre-Ecclampsia, Macrsomia, PPH, Shoulder Dystocia, Diabetes (30%),

Question 20

Vomiting in early pregnancy

DDX

History

Dx

Mx

Answer 20

DDx - Pregnancy related (hyperemesis gravidarum) + Molar Pregnancy / non related vomiting

History - Excessive vomiting, ask for LMP, contraception, blood in vomit, triggers for vomiting

Dx - Clinical Examination (Assess for hydration status), Urine test (pregnancy and ketones), FBC, U&Es, B HCG, USS (if thinking about molar pregnancy), Repeat B HCg if worried about ectopic if no findings on ultrasound scan.

Mx - Psychosocial management, Dehydrated - IV Fluids, Vitamins - Thiamine, Steroids.

Counsel regarding the pregnancy

Question 21

ROM/ PROM/ P-PROM

Answer 21

Hx - Sudden gush, Pink Plug, Lots of fluid, Maybe associated with contractions, what were you doing at the time, whe ndid it happen, sexual intercourse history, gynae history, can be due to - infection, pre-eclampsia, placenta praevia, placental abruption.

Extra questions - blood, fever, fetal movements, pregnancy up-to-date, previous scans, exclude vasa praevia and placenta praevia. No contractions!

Dx - Clinical, ROM-Test (if not likely), FFT (if not ruptured but looking for risks)

FBC, WCC (look for infeciton as high cause of ROM), CRP, G&S/ Cross match - PPH

Abdominal examination, Cusco speculum examination (looking for pooling of fluid, consider sterile speculum), Kleihauher Test (If Rh Negative/ or can prophylactically give 500 iu Anti-D),

Fetal monitoring - CTG

If >36 weeks

Induce if not in labour after 18 hours

If >34 weeks

Admit, and if 18 hours elapse and no spontaneous labour consider inducing. Sometimes wait and monitor for signs of infection or fetal distress at which point delivery is considered to allow fetal maturation.

24-34 weeks

Steroids + Antibiotics ( Erythromycin)

Cervical Length (If more than 15mm do an FFT. If positive FFT/ or cervical length less than 15mm then –>

+ Tocolytics (If going into labour (FFT/ Cervical Length)

If Choriamionitis/ Fetal distressed is suspected —> C Section

Question 23

Placental Abruption

Hx

Dx

Mx

Answer 23

Hx - Painful abdomen, PV Bleeding (might be concealed so no bleeding), Fetal Movements reduced, ++ Fetal Haemorrahge can lead to haemodynamic instability, Rhesus status (Kleihauher Test), what was she doing, elicit history of (drug, smoking, alcohol use, pre eclampsia)

Bleeding - when, how much, how long

Dx- ABCDE Management, Iv Fluid resuss, CTG, Abdominal Exam (tender, tense abdomen), Cusco Speculum (pool of blood),

USS to confirm and assess viability. Emergency –> Mention you would involve a senior obstetrician as soon as possible to discuss expediting delivery.

FBC, WCC, CRP, Blood Cultures ( think about infection), G and save/ Cross match for maternal haemorrhage

Mx - Emergency. ABCDE management. Senior obstetrician for emergency c section. IV Fluid recussitation. Analgesia, Anti- D if required.

If <34 weeks - consider Betamethasone, antibiotics + (MgSO4)

Question 24

Pre-Ecclampsia

Answer 24

Hx: Headaches/Random finding/ High blood pressure finding/ Epigastric Pain/ Reduced fetal movements/ Pre-existing HTN/ DM/ GDM/ Anti phospholipid syndrome etc.

Rarely - seizures, muscle weakness

Dx: 0.3g/24hour urinary collection of protein/ ++ once or + on multiple occasions on urine dip/ >30 PCR/ Hyperreflexia/ Maybe SFD/ Oedema/ Mild: >140 Moderate: >150 Severe: 160

Mx: On presentation - Admite for a period monitorin (usually 24 hours). Then administration of Anti-HTNives (i) labetalol ii) Nifedipine iii) methyldopa iv) hydralazine. Aim for <140. Screen for HELLP Syndrome

Monitoring - twice weekly for blood pressure and urine .

23 week - Potential screen for IUGR with Uterine artery doppler (reversed diastolic flow) / MCA doppler (raised peak systolic flow)

Consultant led birth plan - needs to be in hospital, consider epidural due to the hypertension.

Higher likelihood of PPH - so needs active management of third stage of labour

If Ecclamptic - MgSO4 to neuroprotect mother and baby. Needs to be delivered by c section as an emergency. Consider pre-term birth protocol

If >160 (or high) : C - Section due to unwanted effects of maternal effort. Once again consider pre-term birth protocol

Question 25

Menorrhagia / Abnormal Bleeding

Hx

Dx

Management

Answer 25

Hx: Cycle length

How long do you bleed for,

Clots/Flooding

How many pads

When did it start

Pain

Discharge

Screen for anaemia

Screen for STI risk

Psychosocial impact

Contraception

Pregnant?

Smears?

PCB, IMB, Dyspareunia, PMB

DDx: Dysfunctional Uterine Bleeding, Fibroids, Platelet Dysfunction, Infection, Malignancy, Polyps (older women)

Examinations: Abdominal (Enlarged uterus, tenderness), Pelvic Examinations (Bimanual and speculum) , Swabs

Investigations: Urine Dip, Pregnancy Test, Temperature, FBC, CRP, ESR, Rapid antigen tests for organisms, USS?, Laproscopic with fimbrial biopsy for treatment resistant PID

Testing for bleeding/ platelet disorders in primary menorrhagia

Mx:

Dysfunctional Uterine Bleeding -

Fertility sparing - Tranexamic Aid, NSAIDS.

Non- fertilty sparing - LNG-IUS (with endometrial biopsy first), COCP, GnRH, Injectable progesterones,

surgical - hysterectomy, uterine artery emboliation, ablation

Fibroids - See fibroid card.

STI - See STI Card

Malignancy - see malignancy card. USS and Hysteroscopy + Endometrial Biopsy

Question 26

Ovarian Ca

Hx

Dx

Mx

Answer 26

Hx

>50

Bloating, early satiety, pelvic pain, urinary symptoms, bowel sx, weight loss, recent UTIs (obstructioN)

RFs: FH (BRCA1, BRCA2), Oestrogen Exposure (nulliparity, early menarche, late menopause, HRT, tamoxifen)], not breastfeeding

Dx:

Examination: abdominal, bimanual

Investigations: CA125 (>35) (epithelial), (CEA (mucinous))

If <40 - bHCG (embryonal, choriocarcinoma), AFP( endodermal sinus, embryonal), Inhibin ( granulosa cell), LDH (dysgerminoma),

FBC, ESR, U&Es, LFTs (metastatic spread)

USS

RMI - post menopausal = 3 x Worrying features x CA-125

Staging:

1: a) One ovary - capsule intact b) Both ovaries - capsule intact c) capsule not intact

2: a) uterus/ fallopian tubes. b) other pelvic tissues c) a or b + in peritoneal fluid

3: to peritoneum + lymph nodes

4: outside of pelvis and abdomen

Mx:

Stage 1: Surgical management: oopherectomy/ excision. If high grade = carboplatin six cycles

Stage 2-4: Surgical management: resection of all cancerous tissue + paclitaxel

Question 27

Antenatal

Hx

Dx

Answer 27

Questions for antenatal consultation:

Gravida and parity

Gestational Age/ LMP (Nagle’s Rule)

Fetal Movements

Discharge, bleeding, pain, hyperemesis, ROM (bloody show)

Booking Visits?

BP? Urine Dip? GDM Risk?

Screen for psych

PMH,PSH, DH (folic acid, penicillin allergy, latex allergy), FH (pre-term, pre eclampsia, HTN, DM, miscarriage) SH (Domestic abuse, alcohol, smoking, drug use)

Examination:

Pregnant Abdo exam + Doppler/ Pinnard

BP,

Urine Dip,

USS if indicated

Speculum + swabs if indicated

Question 28

Ectopic

Hx

Dx

Mx

Answer 28

Hx

Abdominal pain, severe, peritonism, shoulder tip pain, diorrhae, Amenorrhoea (LMP)

RFs- Coil, uterine abnormalities, smoking, Previous gynae surgery, Previous history of ectopic, PID, STIs, Assisted Conception

Dx - Avoid abdo exam due to rupture risk

ABCDE. Observations.

Pregnancy Test

If worried about rupture - Fast Scan, ABG and cross match

TVUS, FBC, CRP, ESR, B-HCG (serial B-HCG to make sure it decreases)

Most commonly in the ampula of the fallopian tube

Mx

Surgical Indications: >35mm, pain, haemodynamically unstable, Beta HCG >1500, fluid in the pouch

Medical Indications: Serial HCG monitoring, 15% require second dose and some people require surgery.

Make sure they can come back to hospital for another pregnancy test.

70% go onto have another successful pregnancy

Complications: Immediate - risks of surgery, perforation, loss of fallopian tube, infection

Long term - adhesions, damage to abdominal organs, incontinence, subfertility, risk of ectopic pregnancy

Question 29

CTG Findings

Answer 29

Pathological

>3 minutes bradycardia

Reduced variability for more 90 minutes

Late decelerations >30 minutes

Suspicious

Baseline rate high (160-180)

Baseline variability <5 (30-90 minutes)

Variable decelerations or late decelerations for less than 30 minutes

Question 30

TOP

Abortion Act

Answer 30

PC: Hx, Screen for non-consensual, for risk, for abuse, Previous TOPs, clotting disorders, IUD in place, endocrine problems

Before (medical and surgical) :

Scan to assess pregnancy- Rule out miscarriage and ectopic

Counsellor involved because can be long term traumatic effects

Contraception -Can be inserteid while doing termination

Bloods - RhD Negative given anti-D

Prophylactic antibiotics

During:

Medical: <13 weeks

Mifipristine and Misoprostol.

Surgical: >13weeks

Dilatation and vacuum/suction (before 14 weeks)

Dilation and evacuation (after 15 weeks)

If >22 weeks:

Fetacide (potassium chloride)

Complications:

Common - bleeding (safety net for severe bleeding) , infection

Rare - failure, prolonged bleeding, uterine perforation, miscarriage,

Contraindications:

Chronic Adrenal Failure

Clotting Disorders

IUD in place - must be taken out before TOP

Ectopic

Abortion act:

<24 weeks: harm to mother, harm to fetus (physical, psychological harm to mother, fetus or any existing children)

>24 weeks: grave danger or injury to the fetus or the mother

Question 31

Emergency Contraception

Answer 31

Fraser:

Do you understand why im talking about contraception?

Cannot be persuaded to inform parents?

Likely to continue having intercourse?

Physical/mental health liely to suffer?

Extra:

Talk about boyfriend, age and consensual.

<13 with someone >16 is crime.

Currently on contraception?

Ovulation Inhibitors (95%)

Ulipristal Acetate - can only be used once in a cycle. 120 hours. Progresterone receptor modulator. Breast pain, N&V

Levonorgestel - N&V, Breast Pain. Can take another one if vomited out within 3 hours. 72 hours

Fetacidal (thickens cervical mucus)

Copper COil (99%)

- contraindicated in ectopic history, current PID,

-120 hours

Four extra things

safety net - for fever, bleeding, abdominal pain

Offer long term contraception

screen for STIs

Test of pregnancy - 2 weeks time

Question 32

Rhesus D

Answer 32

On Anti - D antibody testing at booking and at 28 weeks:

>4 iu/ml = moderate risk

>15 iu/ ml = severe risk

If deteted before 28 weeks testing should occur every 4 weeks until 28 weeks and then every 2 weeks thereafter

Cord blood taken at birth to assess for anti-D antibodies.

Cell saver - 1500 iu anti-D

Sensitising Events: Give anti -D within 72 hours

250 iu 12-20 weeks

500iu >20 weeks + kleihauher test

medical interventions (chorionic villus sampling, amniocentesis or external cephalic version)

terminations

late miscarriages

antepartum haemorrhage

abdominal trauma

Question 34

Secondary Amennorhea

Answer 34

DDx -

Physiological - menopause, breastfeeding, pregnancy

Hypothalamic - low weight, exercise

Pituitary - hyperprolactinaemia (can be secondary to hypothyroidisM), pituitary failure, sheehan’s

Adrenal - CAH, virilising tumours

Ovarian - PCOS, premature menopause, virilising tumours

Outflow - Asherman’s, Cervical stenosis , endometrial surgery

Dx:

21 Day Progesterone ( 7 days before start of new cycle) - If <30 then consider anovulation

FSH/ LH - Day 3 - if low then pituitary failure, if high then ovarian failure

TFTs

Pituitary Function testing

Testosterone - if high PCOS

Oestrogen - If low suggests premature ovarian failure

Question 35

Primary Amenorrhoea

Answer 35

Hypothalamic - Low weight, exercise , consitutional delay

Adrenal - CAH

Congenital - Turner’s, Kallman’s (GnRH deficiency)

Outflow - Imperforate hymen, Transverse Vaginal Septum, Rokitansky’s syndrome (failure of mullerian duct development resulting in missing uterus and variable degrees of vaginal hypoplasia )