O+G 7 Flashcards
Which cysts are sometimes referred to as chocolate cysts due to the external appearance?
Endometriotic cyst
A 35-year-old lady and her husband present to the rheumatology clinic. They both suffer from rheumatoid arthritis which is well controlled by medication. They would like to start a family and would like to know if they need to make any changes to their medication. They are both taking methotrexate. Which one of the following would be the most appropriate advice?
Methotrexate: must be stopped at least 3 months before conception in both men and women
Which drugs for RA can be taken during pregnancy?
sulfasalazine and hydroxychloroquine
How often is the Depo Provera (medroxyprogesterone acetate) injectable contraceptive given?
Every 12 weeks
On routine antenatal swabs, a mother is found to be colonised with Group B Streptococcus. However, she did not receive adequate intrapartum antibiotic prophylaxis and she delivers a healthy baby girl by vaginal delivery. Her baby does not require any resuscitation and remains well in the post natal ward. The mother is eager for discharge home. What is the most appropriate course of action with regards to her child?
Maternal colonisation with group B streptococcus is a minor risk factor for early onset sepsis in the newborn. Newborns with only one minor risk factor for early onset sepsis should remain in hospital for at least 24 hours with regular observations. Two or more minor risk factor or one red flag warrant empirical antibiotic therapy with Benzylpenicillin and Gentamicin and a full septic screen. Red flags include the following:
- Suspected or confirmed infection in another baby in the case of a multiple pregnancy
- Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]
- Respiratory distress starting more than 4 hours after birth
- Seizures
- Need for mechanical ventilation in a term baby
- Signs of shock
A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?
Admit her for at least 48 hours and prescribe antibiotics and steroids
A 28-year-old woman presents the Emergency Department at 35-weeks gestation with lower abdominal pain and vaginal bleeding. She is alert and responsive. Physical examination revealed a heart rate of 115 bpm, blood pressure of 90/60 mmHg and O2 saturation of 99%. On neurological exam, her pupils were dilated and her reflexes were brisk.
Hb 115 g/l Platelets 250 * 109/l WBC 5 * 109/l PT 12 seconds APTT 30 seconds
Which of the following underlying conditions would most likely explain the findings on physical exam?
Cocaine abuse
A 29-year-old woman goes into labour. The midwife examines her and states that the head is now at the level of ischial spine. What terminology is used to describe the head in relation to the ischial spine?
Station
A 27-year-old woman attends colposcopy as she had moderate dyskaryosis on her recent cervical smear. On colposcopy she has aceto-white changes and a punch biopsy followed by cold coagulation. Histology of the biopsy shows CIN II. When should she next be offered cervical screening?
Women who have been treated for CIN II should be offered cervical screening at 6 months through cervical screening and a HPV test of cure.
If a woman has a positive-test after treatment they should return to colposcopy.
A woman presents to have a Nexplanon (etonogestrel) inserted. Where is the most appropriate place to insert the implant?
Subdermal, non-dominant arm
A 23-year-old woman who is 10 weeks pregnant presents with severe vomiting. She is now having difficulty keeping down fluids and a dipstick of her urine shows ketones ++. Which one of the following is not associated with an increased risk of this condition?
Smoking is associated with a decreased incidence of hyperemesis gravidarum
A woman who is 12 weeks pregnant presents as she is concerned following a recent antenatal scan. The scan has reportedly shown increased nuchal translucency. Other than Down’s syndrome, which other condition is associated with this finding?
Congenital heart defects
Abdominal wall defects
What are the causes of hyperechogenic bowel?
- cystic fibrosis
- Down’s syndrome
- cytomegalovirus infection
What is placental abruption?
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
What’s the incidence of placental abruption?
1/200
What’s the cause of placental abruption?
Cause - not known but associated factors:
- proteinuric hypertension
- multiparity
- maternal trauma
- increasing maternal age
What are the clinical features of placental abruption?
- shock out of keeping with visible loss
- pain constant
- tender, tense uterus
- normal lie and presentation
- fetal heart: absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
A 23-year-old woman is counselled by her doctor regarding contraceptive options. What is the most common adverse effect experienced by women using a progestogen only pill?
Irregular bleeding
Women should be advised about the likelihood and types of bleeding patterns expected with POP use. As a general guide:
- 20% of women will be amenorrhoeic
- 40% will bleed regularly
- 40% will have erratic bleeding.
A 27 year old woman attends her GP with breast pain. She is 2 weeks postpartum and is exclusively breastfeeding. She complains of a 3 day history of worsening right sided breast pain, which has not improved with continued feeding and expressing. On examination, she appears well, her temperature is 38ºC. There is a small area of erythema superior to the right nipple, which is tender to touch. She has no known allergies.
What would be the most appropriate management?
Oral flucloxacillin and encourage to continue breastfeeding
First-line conservative management includes analgesia and encouraging effective milk removal (continue breastfeeding or expressing from affected side) in order to prevent further milk stasis. It is also important to ensure that there is correct positioning and attachment when feeding.
If symptoms do not improve after 12-24 hours of conservative management then antibiotics should be prescribed. First-line choice is oral flucloxacillin (500mg four times a day for 14 days) or erythromycin if penicillin allergic. Second-line choice is co-amoxiclav.
A 25-year-old present 8 weeks after her last menstrual period. She complains of severe nausea, vomiting and vaginal spotting. Pregnancy test was positive and transvaginal ultrasound showed an abnormally enlarged uterus. What would you expect levels of BHCG, TSH and T4 to be in this patient?
High beta hCG
low TSH
high thyroxine
What’s the most likely diagnosis?
jaundice, mild pyrexia, hepatitic LFTs (ALT above 500), hypoglycaemic, raised WBC, coagulopathy and steatosis on imaging.
acute fatty liver of pregnancy
A 45-year-old woman has come into your post-menopausal bleed clinic. When taking a history, you ask about her medical history and family history for things that may increase her risk of endometrial cancer. Which of the following is associated with increased risk of endometrial cancer?
Anorexia nervosa Familial adenomatous polyposis HNPCC/Lynch syndrome Intrauterine system (Mirena coil) Use of combined oral contraceptive pill
HNPCC/Lynch syndrome is a strong risk factor for endometrial cancer.
What risks are assoicated with termination of pregnancy?
- Infection can happen in up to 10% of TOP cases. Antibiotics are given to reduce the risk of infection. Signs and symptoms of an infection are unlikely to occur so soon after the procedure.
- Retained tissue pregnancy occurs in less than 1% of cases.
- Haemorrhage occurs in less than 1% of cases, but is more likely to occur in pregnancies greater than 20 weeks gestation.
- Failure occurs in less than 1% of cases.
- Injury to the cervix occurs in less than 1% of cases.
What methods are used to terminate a pregnancy?
The method used to terminate pregnancy depend upon gestation
- less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
- less than 13 weeks: surgical dilation and suction of uterine contents
- more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces ‘mini-labour’)
What is the abortion act?
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
- that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
- that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
- that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
- that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
A 25-year-old woman is to have an elective laparoscopic cholecystectomy in 8 weeks time. She takes no medications other than the combined oral contraceptive pill. What should be done with regards to her pill and her upcoming surgery?
Stop the pill 4 weeks before surgery and restart 2 weeks after surgery
During a lower segment Caesarian section which layers will you cut through?
- Superficial fascia
- Deep fascia
- Anterior rectus sheath
- Rectus abdominis muscle
- Transversalis fascia
- Extraperitoneal connective tissue
- Peritoneum
- Uterus
What are the indications for a c-section?
Emergency c-section?
Instrumental delivery?
Elective
Absolute
- absolute CPD (cephalopelvic disproportion)
- fetal distress in labour/prolapsed cord
- uncorrectable abnormal lie
- previous classical CS
- placenta praevia grades 3/4
Relative
- breech
- severe IUGR
- multiple pregnancy
- medical comorbidities
- previous 3/4th degree tear with symptoms
- previous LSCS
- macrosomic baby
- maternal request
- primary genital herpes in 3rd trimester
- delivery before 34 weeks
- cervical cancer (disseminates cancer cells)
Emergency
- prolonged first stage (not fully dilated after 12 hours in established labour)
- fetal distress if CS is quickest option or instrumental delivery not possible
- failure of labour to progress
- placental abruption: only if fetal distress; if dead deliver vaginally
Instrumental
- prolonged second stage (if baby not delivered after 1hr active pushing or 2hr primips)
- fetal distress (CTG/FBS)
An 18-year-old attends her GP the morning after unprotected sexual intercourse (UPSI). She would like emergency contraception to ensure she is not pregnant. A pregnancy test is negative. Which is the most appropriate next step in management?
- a copper intrauterine contraceptive device (copper coil)
- an oral progesterone-only contraceptive (levonorgestrel)
- a selective progesterone receptor modulator (ulipristal acetate)
These both act to prevent a fertilised ovum being implanted.
For how many hours after unprotected sex can levonorgestrel be given?
72 hours
What is danazol used for?
Danazol is a derivative of ethisterone. It can be used to treat endometriosis and fibrocystic breast disease. It will not prevent implantation and can cause virilisation of female fetuses, so is contraindicated in pregnancy.
A 34-year-old lady presents to the gynaecology department complaining of heavy, painful periods, and difficulty conceiving. She is concerned, as she and her husband would like to start a family soon. On further investigation, an ultrasound scan reveals a 4.5cm submucosal uterine fibroid. Which treatment is most appropriate to treat her fibroids?
The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future
A 22-year-old female has a Nexplanon inserted. For how long will this provide effective contraception?
3 years
What is lochia and how long after birth might it persisit?
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
A 32-year-old 1 week post-partum female presents to her local emergency department with a few days history of vaginal bleeding: initially bright red blood which has now changed in colour to become brown. She is changing her sanitary pads once every 3 hours and is worried that the caesarean section birth has caused damage to her womb. On examination she is visibly distressed but afebrile. She is normotensive with a heart rate of 95 beats per minute and a respiratory rate of 19 breaths per minute. Abdominal examination does not cause pain and reveals a caesarean section scar which is pink and not tender. What is the most appropriate management at this stage?
Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping. The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn’t stop, she should seek medical help. In this case the volume is not excessive and there are no concerning features to the lochia or abnormal observations.
What is puerperal pyrexia?
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
What causes puerperal pyrexia and how do you manage it?
Causes:
- endometritis: most common cause
- urinary tract infection
- wound infections (perineal tears + caesarean section)
- mastitis
- venous thromboembolism
Management
- if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
An 18-year-old girl presents to her GP with discharge. She reports a new sexual partner with whom she is not using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports no other symptoms of note. What is the most likely diagnosis?
Candida albicans
Cottage-cheese like discharge is almost pathognomonic of thrush
What are the features of candida albicans?
- ‘cottage cheese’, non-offensive discharge
- vulvitis: dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky’s protuberance. What is the most likely diagnosis?
Teratomas (dermoid cysts)
What is a Rokitansky protuberance?
The inner lining of every mature cystic teratoma contains single or multiple white shiny masses projecting from the wall toward the centre of the cysts. When hair, other dermal appendages, bone and teeth are present, they usually arise from this protuberance. This protuberance is referred to as the Rokitansky protuberance.
A 17-year-old Somali girl has presented to the emergency department with recurrent urinary tract infections. On examination, with a chaperone, you notice the girl may have had a clitoridectomy. You believe the girl has been subjected to female genital mutilation (FGM). She asks for antibiotics and for no one else to be informed. As well as treating the infection, what should you do?
Inform the medical team and the police
The Good Medical Council (GMC) state that we should report all known cases of FGM in under-18s to the police, either by calling 101 or through existing local routes.
Give examples of LARCs
Long-acting methods of reversible contraception (LARCs)
- implantable contraceptives
- injectable contraceptives
- intrauterine system (IUS): progesterone releasing coil
- intrauterine device (IUD): copper coil
A 22-year-old woman has just had an artificial rupture of membranes in order to augment a slowly progressing labour. Her partner is helping her move into a more comfortable position when she suddenly becomes breathless and collapses from the bed. She is unconscious and unresponsive with a blood pressure of 82/50 mmHg and a heart rate of 134 beats per minute. What is the most likely diagnosis?
A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism.
