O&G Flashcards

Question

Normal mensturation cut offs

Answer 1

Menarche \<16y Menopause \>45y Mensturation \<8d Blood loss \<80ml Cycle length 23-25 No IMB

Answer 2

Heavy menstrual bleeding

Answer 3

Bleeding between periods

Answer 4

Periods outside of the range of 23-35d with a variability of \>7d between the shortest and longest cycle

Answer 5

Periods stop for 6m or more.

Answer 6

Irregular periods, \>35d-6m

Answer 7

Bleeding 1 year after the menopause

Answer 8

Painful periods

Answer 9

Psychological and physical symptoms worse during the luteal phase

Answer 10

Excessive bleeding in otherwise normal menstrual cycle Excessive menstrual blood loss that interferes with the woman's physical, emotional, social and material QoL +/- other smyptoms \>80mL (corresponds to the maximum amount that a woman on a normal diet can lose without becoming Fe deficient)

Answer 11

1/3rd women complain of HMB Fibroids= 30% HMB Polyps= 10% HMB Thyroid disease, haemostatic disorders and anticoagulant therapy.

Answer 12

Bleeding in malignancy tends to be irregular

Answer 13

Menstrual calendar. Flooding and passage of large clots. Contraception. Anemia. Pelvic signs often absent. Irregular enlargement of the uterus suggests fibroids. Tenderness without enlargement suggests adenomyosis.

Answer 14

FBC: to check patient's Hb TFTs/Coagulation: to exclude systemic causes (if there are factors indicating this may be the case) Transvaginal USS of hte pelvis: to exclude local organic causes (endometiral thickness, exclude fibroid, mass and detect larger intrauterine polyps (+/- biopsy or hysterectomy if USS is inconclusive)

Answer 15

Endometrial thickness \>10mm ?Polyp Woman \>40 with recent onset menorrhagia Treatment failure/ineffective treatment Before insertion of IUS if cycle not regular Prior to endometiral ablation/diathermy as tissue will not be available for pathology If abnormal uterine bleeding has resulted in acute admission

Answer 16

Exclude pathology Depends on woman's contraceptive needs. 1st line= intrauterine system- not option for woman who wishes to conceive . 90% reduction in blood loss. 2nd line: antifibrinolytics (tranexamic acid) taken during menstruation only. 50% reduction in blood loss NSAIDs (mefanamic acid) inhibit prostaglandin synthesis reducing blood loss by around 30%. NB also useful for dysmenorrhoea. Combined OCP- lighter mesntruation but less effective if pelvic pathology is present. 3rd line: progestogens, high dose orally or by IM will cuase amenorrhoea but bleeding follows withdrawl. GnRH agonists: produces amenorrhoea. Duration is limited to 6 months unless add-back HRT used. **_Sx_** *Hysterposcopic:* Polyp removal (if caused by local abnormalities) Endometrial ablation technique Transcervical resection of fibroid (TCRF). *More radical:* Myomectomy Hysterectomy: Uterine artery ambolisation

Answer 17

Progestogen impregnated IUD is a coil that reduces menstural flow with fewer Ses. Highly effective alternative to medical and surgical treatment. It is contraceptive and also provides the progestogen component of HRT. Distinguish from Cu IUDs that may increase menstrual loss

Answer 18

Hysterposcopic: Polyp removal (if caused by local abnormalities) Endometrial ablation technique: removal/destruction of endometrium- satisfcation is less than with hysterectomy. Most appropriate in older women with pure menorrhagia. Non sterilising. Transcervical resection of fibroid (TCRF). More radical: Myomectomy: removal of fibroids from the myometrium: open or laparoscopic (\<4fibroids, \<8cm diameter). Used if fibroids causing symptoms but fertility is still required. GnRH agonists can be used to reduce size of fibroids first. Hysterectomy: last resort. Uterine artery ambolisation: treats menorrhagia for women who want to retain their uterus.

Answer 19

1st line: IUS 2nd line: antifibrinolytics, NSAIDs, OCP 3rd line: progestogens, GnRH analogues

Answer 20

Just after menarche and before the menopause

Answer 21

Anovulatory Pathological: Non malignant Fibroids, uterine and cervical polyps, adenomyosis, ovarian cysts and chronic pelvic infection. Malignant: Overain, cervical and most particulalry endometrial

Answer 22

FBC: to asssess the effect of blood loss Ix to exclude malignancy: Cerbical smear USS of the cavity for women \>35 with irregular/IMB and in younger women if treatment has failed, will also detect uterine fibroid or ovarian mass. Endometrial biopsy

Answer 23

Rx where no anatomical cause is detected 1st line: IUS or OCP. 2nd line: 2nd line Rx for menorrhagia Sx: Cervicaly polyp can be excised.

Answer 24

Absence of menstruation 1o= hasn't started by 16, may be manifestation of delayed puberty in which secondary sexual characteristics are not present by age 14. If 2o sexual characteristics are present, problem of menstrual outflow is more likely. 2o= 6m without menstruation in previosly normal mensturation Oligomenorrhoea: \>35d-6m

Answer 25

Physiological Pathological

Answer 26

Pregnancy, after the menopause, during lactation, constitutional dleay

Answer 27

Hypothalamus: Hypothalamic hypogonadism. Pituitary: hyperprolactinaemia; rarer= other pituitary tumours, Sheehan's syndrome Adrenal/Thyroid; hypo/hyperthyroid. CAH/virilising tumours Ovary: * Acquired: PCOS, premature menopause, rare virilizing tumours* * Congnetial: Turner's (most common), other forms of gonadal dysgenesis* Outflow problems: * Congenital: Primary amenorrhoea with normal secondary sexual characteristics. Imperforate hymen and transverse vaginal septum. Rokitansky's syndrome* * Acquired: Usually secodary. Cervical stenosis, Asherman's syndrome, endometrial resection or ablation* Drugs: e.g. antipsychotics, GnRH analgoues, progestogens

Answer 28

Common, usually due to psychologica, lowe weight or excessive exercise Tumours are a rare cause and may be excluded by MRI. GnRH and FSH/LH and oestradiol are reduced. Bone density may be reduced if there has been prolonged hypo-oestrogenism. Oestrogen replacement (+progesterone for endometrial protection) i.e. OCP/HRT

Answer 29

Usually caused by pituitary hyperplasia or adenomas Rx: bromocriptine, carbegoline or Sx

Answer 30

Hyperprolactinaemia leading to amenorrhoea

Answer 31

45 XO Short stature, poor secondary sexual characteritsics, normal intelligence. Most common congenital ovarian cause of amenorrhoea

Answer 32

Accumulation of menstrual flow in the vagina or uterus To outflow tract obstruction by either imperforate hymen or transverser vaginal septum

Answer 33

Mullerian agenesis Congential malformation characterised by failures of Mullerian duct development resulting in a missing uterus and variable degrees of vaginal hypoplasia. Mullerian agenesis is the aetiology in 15% of cases of primary amenorrhoea

Answer 34

Consequence of excessive curettage in ERPC performed following miscarriage or delivery. Asherman's syndrome, also known as intrauterine adhesions, is a condition where the cavity of the uterus develops scar tissue (adhesions).

Answer 35

Treat underlying cause Asses # risk. Correct any VitDD and ensure adequate Ca intake. Consider HRT.OCP if amenorrhoea persists for more than 12m

Answer 36

Persistently elevated FSH and LH in woman younger than 40y/o

Answer 37

Recent Hx of uterine or cervical Sx or severe pelvic infection (endometritis)

Answer 38

Vaginal bleeding following intercourse that is not menstrual loss Except for first intercourse, this is always abnormal and cervical carcinoma must be excluded.

Answer 39

When the cervix is not covered in health suqamous epithelium it is more likely to bleed after mild trauma.

Answer 40

Cervical ectropions Benign polyps Invasive cervical cancer (cervicitis, vaginitis (atrophic)

Answer 41

Cervical inspection + smear. Polyp- avulsed and sent to histology. Ectropion can be frozen with cryotherapy. Abnormal smear-\> colposcopy

Answer 42

Painful menstruation. Associated with high PG levels in the endometrium and is due to contraction and uterine ischaemia.

Answer 43

Primary: when no orgnaic cause is found. Secondary: when pain is due to pelvic pathology. Fibroids, adenomyosis, endometriosis, PID, ovariant tumours,

Answer 44

Primary usually coincides with the start of mensturaiton and is very common, particularly in adolescents. Responds to NSAIDs and ovulation suppresions e.g. OCP. Pelvic pathology more likely if medical treatment fails. Secondary: pain often precedes and is relieved by onset of menstruation. Deep dyspareunia and menorrhoagia or irregular mensturation are common. P USS and laparoscopy useful.

Answer 45

When menstruation occurs before the age of 10 and/secondary sexual characteristics are evident before age of 8.

Answer 46

In 80% no pathological cause is found. Central causes: increased GnRH secretion: meningitis, encephalitis, CNS tumours, hydrocephaly and hypothyroieism may prevent normal prepuberatl inhibition of hypothalamic GnRH release. Rx: Ovarian/adrenal causes: increased oestrogen secretion: hormone producing tumours of the ovary/adrenal glands. Regression occurs after removal. McCune-Allbright syndrome.

Answer 47

Bone and ovarian cysts Cafe au lait sports Precocious puberty

Answer 48

GnRH agonists used to inhibit sex hormone secretion causing regression of secondary sexual health characteristics For increased oestrogen secretion cypropterone acetate (antiandrogenic progestogen) can be used

Answer 49

Recessive inheritance. Defective cortisol production usually as a result of 21-hydroxylase deficiency. ACTH exess causes incresed androgen production. Presents at birth with ambiguous genitalia. GC deficiency may cause Addisonian crisis. May present at puberty with enlarged clitoris and amenorrhoea. Cortisol and MC replacemant.

Answer 50

Occurs when male has cell receptor insensitvity to androgen which are peripherally converted to oestrogens. Individual appears to be female. Presentation is with amenorrhoea. Uterus absent, rudimentary testes present which are removed due to possible malginant change.

Answer 51

Psychological, behavioural and physical symptoms that are experienced on a regular basis during te luteal phase of te mesntrual cycle and often resolve by the end of menstruation.

Answer 52

Cyclical nature rather than symptoms themselves that enable diagnosis. Tnesion, irritability, aggressoin, depression, loss of control. Bloatedness, GI upset, Breast pain

Answer 53

Menstrual diaries. Psychological evaluation as depression and neurosis may present at PMS

Answer 54

SSRIs either continuously or intermittently in the second half of the cycle. OCP. GnRH agonists and add back oestrogens. Supplements: evening primrose oil is good for breast tenderness. Pyridoxine 50mg BD can help but may cause neuropathy in excess Vitex agnus-castus extract.

Answer 55

Superiorly: fundus Laterally to fundus= cornu which is the communication with the fallopiam tubes Supported at the inferior end by the uterosacral and cardinal ligaments. Anteverted in 80% Wall is made of smooth muscle which is lined by endometrium (glandular epithelium) Serosa= peritoneum posteriorly. Also covers the uterus down to the bladder. Laterally the peritoneum is continuouous with the broad ligaments that run between the uterus and pelvic side wall. These are continuous with the fallopian tubest and round ligaements suepriorly and inferiroly contain the uterine blood supply, ureturs and parametrium

Answer 56

From uterine arteries Pass over the ureturs laterally to the cervix. Pass inferiroly and superiorly supplying the myometrium and endometrium. Anastamose at the cornu with the ovarian blood supply. Inferiorly anastamose with the blood supply to the upper vagina. Lymph to EI Nodes.

Answer 57

Spiral and basal arterioles. Spiral= important in mensturation and nourishment of growing fetus. After ovulation under the influence of progesterone during the luteal phase the glands swell and blood uspply increases.

Answer 58

Leiomyomata, bening tumours of the myometrium 25% of wmeon. More common near menopause, Afrocaribbean and in FHx. Less common in parous women and those who have taken OCP or injectable progestogens

Answer 59

Subsersal Intramural Submucosal may form intracavity polyps

Answer 60

Oestrogen and progesterone dependant Fbiroids regress after menopause

Answer 61

50% asymptomatic and discovered at pelvic/abdo exams. Symptoms relate to site rather than size Menstrual problems (30%): menorrhagia, unchanged timing of menses. IMB may occur if fibroid is submucosal or polypoid. Erratic bleeding Pain: dysmenorrhoea, seldom cause pain unless torsion, red degeneration or sarcomatous chnage occur Pressure effects: large fibroids pressing on bladder can cause frequency/urinary retnetion. Hydronephrosis due to ureteric compressoin. Fertility impairment due to obstruction of the tubal ostia or submucous fibroids preventing implamantation. Intramural fibroids that aren't distorting the cavity can also reduce fertility through an unknown mechanism.

Answer 62

Solid mass palpable on pelvic/abdo examination which arises from pelvis and is continuous with the uterus. Multiple small fibroids cause irregular knobbly enlargement of the uterus.

Answer 63

Enlargement: can be very slow. Often stop and calcify after menopause although HRT may stimulate further growth. Enlarge in pregnancy. Pedunculated fibroids may undergo torsion Degenerations: result of inadequate blood supply. Red degeneration (more common in pregnancy): pain + uterine tenderness, haemorrhage and necrosis Hyaline/cystic degeneration the fibroid is soft and partly liquefied. Malignancy: 0.1% are leiomyosarcomata. may be malignant change or de novo transformation of myometrium

Answer 64

Premature labour Malpresentations Transverse lie Obstructed labour PPH Red degeneration Pedunculated fibroids may tort in post partum period

Answer 65

Dx: USS bu MRI/Laparoscopy may be required to distinguish from ovarian mass Adenomyosis can exist as a fibroid like mass (MRI ddx) Hysteroscopy/hysterosalpingogram to assess distortion of the uterine cavity- if fertility is an issue. To establish fitness: Hb may be low due to vaginal bleeding, may also be high

Answer 66

They can secrete EPO

Answer 67

Asymptomatic with small/slow-growing: no treatment Large fibroids that are not removed should be serially measured by examination or USS. Menorrhagia associated fibroids: \<3cm without distortion of uterine cavity, determine whether woman wants to conceive and use treatment options for menorrhagia: LNG-IUS. Tranexamic, NSAID or OCPs Norethisterone/Depoprovera (Progestetone) \>3cm: refer: Sx intervention. In interim can try NSAIDs/Tranexamic acid. Compressive symptoms: refer Fertility/obstetric symptoms: refer

Answer 68

Hysteroscopic: fibroid polyp or small submucous fibroid can be resected. Pretreatment with GnRH agonist for 1-2m can shrink the fibroid, reduce vasculairy and thin the endometirum making resection easier and safer Myomectomy: open or laparoscopic. NB heavy blood loss and small fibroids may be missed. Myomectomy performed if medical treatment has failed but preservation of reproductive function is required. Preceded by 2-3m of GnRH agonist. Perioperative injection of vasopressin into the myometrium reduces blood loss. Adhesions can form at site of myomectomy which can reduce fertility if affecting the endometrial cavity or fallopian tubes. if the endometrial cavity is opened during myomectomy, C-section is indicated in future pregnancy due to risk of rupture. Radical hysterectomy: Pretreatment with GnRH, common indication. Laparoscopic, vaginal or open. Other treatmnents: UAE Ablation

Answer 69

Prsece of endometirum and its underlying stroma in the myometrium. Found in 40% of hysterectomy specimens. Associated with endometriosis and fibroids. Symptoms subside postmenopausally.

Answer 70

Endometrial tissues grows into the myometrium. Occassionally may show varying degrees of atypia or invasion

Answer 71

Symptoms may be absent but painful, regular, heavy menstruation is common. Uterus is mildly enlarged and tender

Answer 72

Not easily diagnosed on USS but can be diagnosed on MRI

Answer 73

IUS OCP +/- NSAIDs may control the menorrhagia or dysmenorrhoea but hysterectomy often required. Oestrogen dependant.

Answer 74

Secondary to STI, as a complication of surgery (C-section and intrauterine procedure) or because of foreign tissue e.g. IUD and RPC. Infection in the postmenopausal uterus is commonly due to malginancy

Answer 75

Tender uterus with pelvic and systemic infection

Answer 76

Pus accumulates in uterus and is unable to escape

Answer 77

Antibiotics ERPC

Answer 78

Small bening tumours that grow in to the uterine cavity. Most are endometrial although some come from submucous fibroid. Often found in patients on tamoxifen for breast Ca. Occassionally contian endometrial hyperplasia or carcinoma. Dx at USS/hysteroscopy

Answer 79

Endometrial carcinoma

Answer 80

Highest prevalence \>60 15% occur premenopausally. \<1% \<35y/o Usually presents early. Adenocarcinoma of columnar gland cells \>90%. Rest is adenosquamous carcinoma- poorer prognosis

Answer 81

high oestrogen: progesterone When oestrogen therapy is used unopposed by progestogens

Answer 82

Exogenous: oestrogens without a progestogen Tamoxifen (acts as an agonist in the postmenopausal uterus) Endogenous: Obesity PCOS as it is associated with prolonged amenorrhoea. Nulliparity Late menopause Ovarian granulosa cell tumours (oestrogen secreting) Misc: DM, HTN. Lynch Type 2 syndrome: familal non-polyposis colonic, ovarian and endometrial carcinoma. OCP and pregnancy

Answer 83

Cystic hyperplasia-\> Endometrial hyperplasia with atypia May cause menstrual abnormalities or PMB Often coexists (40%) with carcinoma elsewhere in the uterine cavity

Answer 84

PMB: 10% risk of carcinoma. Likelihood that PMB is due to cancer rather than unknown or benign causes increases with age. Premenopausal patients have irregular or IMB or occasionally recent-onset menorrhagia. Cervical semar may contain abnormal columnar cells. Ex: pelvis often appears normal. Atrophic vaginitis may coexist

Answer 85

Through the moymetrium to the cervix and upper vagina. May be ovarian involvement. Lymphatic spread to pelvci then para-aortic nodes. Staging is surgical and histological and includes LN involvement

Answer 86

Only possible post hysterectomy 1: lesions confined to uterus A: \<0.5 myometrial invasion. B: \>0.5 myometrial invasion Stage 2: as above but in cervix too Stage 3: Tumour invades through the uterus. A: invades serosa or adnexae B: vaginal/parametrial involvement Ci: pelvic node involvement Cii: para-aortic involvement Stage 4: further spread A: bowel or bladder B: distant mets

Answer 87

USS/hysteroscopy- biopsy required to make diagnosis MRI performe din all patients or if spread is suspected due to other symptoms. CXR to exclude extrapulmonary sprad FBC, RFT, glucose testing. ECG

Answer 88

Sx: 75% present with Stage 1. Hysterectomy and bilatreal salpingooophorectomy (BSO) is performed either open or laparoscopically. Routine lymphadenectomy is not beneficial in early stage disase. RTx: External beam radiography used following hysterectomy for those at high risk of LN involvement but not in those with early stage disease. RFs: deep myometrial spread, poor hisotlogy or grade, cerbical stromal involvement. Vaginal vault therapy. Other: Progestogens seldom used. CTx may have a role in high risk early stage and advanced disease.

Answer 89

Recurrency common at the vaginal vault. Older age Advanced stage Deep myometrial invasion in Stage 1 and 2 High tumour grade Adenosquamous hisotlogy

Answer 90

Rare Leiomyosarcomas: malignant fibroid Endometrial stromal tumours: most common in perimenopausal woman Mixed mullerian tumours: derived from the embryological elements of the uterus and more common in old age. Usually present with irregular/PMB or rapid painful enlargement of a fiborid Treatment with hysterectomy. RTx/CTx can be used adjuvantly but 5 year survival is 30%

Answer 91

1: 85 2: 70 3-4: 50 4:25 Overall 75

Answer 92

NSAIDs as they will inhibit PG synthesis, one of the main cuauses of dysmenorrhoea pains.

Answer 93

Urge: bladder retrianing Stress: pelvic floor muscle training

Answer 94

Overactive bladder/urge incontinence: due to detrusor overactivity Stress incontinence: leaking small amounts when coughing or laughing Mixed incontinence Overflow incontinence: due to bladder outlet obstruction e.g. prostate englargement

Answer 95

Bladder diaries (\>3d) Vaginal examination to exclude cystocele Urine dipstick and culture

Answer 96

Conservative: bladder rtraining (lasts for minimum of 6w, idea is to gradually increase the intervals between voiding) Rx: Bladder stabilising drugs: antimuscarinic is first line. Sx: sacral nerve

Answer 97

Pelvic floor muscle training (minimum of 3 months) Srugical procedures e.g. retropubic mid-uretthral tape procedures

Answer 98

Physiological TV BV Gonorrhoea, Chlamydia (rarely PC), ectropion, foreign body, Cervical Ca

Answer 99

Cottage cheese Vulvitis Pruritis

Answer 100

Offesnive, yellow/green, frothy d/c Vulvovaginitis Strawberry cervix

Answer 101

Offesnive, thin, white/grey, fishy d/c

Answer 102

Mild suprapubic pain at 10w USS

Answer 103

Bearing down, heaviness, dragging sensation

Answer 104

PID and ectopic pregnancy

Answer 105

Amenorrhoea Abdo pain Vaginal bleeding In combination with shoulder tip pain- peritoneal bleed

Answer 106

Threatened Missed (delayed) Inevitabel incomplete

Answer 107

Painless vaginal bleeding before 24w (typically 6-9w) Bleeding often less than mensturation Cervical os is closed Complicates 25% of pregnancies

Answer 108

A gestational sac which contains a dead fetus before 20w without symptoms of expulsion Mother may have light vaginal bleeding/discharge and symptoms of pregnancy which disappear Typically painless Cervical os is closed When the gestational sac is \>25mm and no embryonic/foetal part can be seen it is sometimes described as a blighted ovum or anembryonic pregnancy

Answer 109

Heavy bleeding with clots and pain Cervical os open

Answer 110

Not all products of conception have been expelled Pain and vaginal bleeding Cervical os open

Answer 111

Spontaenous abortion with expulsion of the entire foetus through the cervice Pain and uterine contractions stop after the foetus has been expelled Dx: USS shows an empty uterus

Answer 112

In a female with postmenopausal bleeding (PMB), the diagnosis is endometrial cancer until proven otherwise. Although all the options can result in PMB, the question states the most important one to rule out, which in this case would be endometrial adenocarcinoma due to its strong association with PMB and the importance of an early diagnosis prognostically. In addition, the patient in this question has two risk factors for endometrial adenocarcinoma - hypertension and obesity. Other risk factors include diabetes mellitus, polycystic ovarian syndrome, tamoxifen use, late menopause and high levels of oestrogen.

Answer 113

Exclud pregnancy Gonadotrophins: low levels indicate hypothalamic cause whereas high levels suggest an ovarian problem (e.g. premature ovarian failure) Prolactin Androgen levels: raised may be seen in PCOS Oestradiol TFTs

Answer 114

Cyclical abdo pain and deep dyspareunia, may be associated with fertility problems

Answer 115

Physiological: follicular, corpus luteum cyst Benign germ cell tumours: dermoid cyst Benign epithelial tumours: serous cystadenoma, mucinous cystadenoma

Answer 116

Commonest type of ovarian cyst Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle Commonly regress after several menstrual cycles

Answer 117

If pregnancy doesn't occur corpus luteum cyst usually breaks down and disappears, if this doesnt occur the corpus luteum may fill with blood or fluid and form a cyst. More likely to present with intraperitoneal bleed than physiological cysts.

Answer 118

Mature cystic teratomas: lined with epithelial tissue Most comon benign ovarian tumour in woman under 30 years. Bilateral in 10-20% Usually asymptomatic Torsion is more likely than with other ovarian tumours

Answer 119

Most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer Bilateral in around 20%

Answer 120

Second most common benign epithelial tumour Large and amy become massive If ruptures may cause pseudomyxoma peritonei

Answer 121

Pseudomyxoma peritonei (PMP) is a clinical condition caused by cancerous cells (mucinous adenocarcinoma) that produce abundant mucin or gelatinous ascites.[1] The tumors cause fibrosis of tissues and impede digestion or organ function, and if left untreated, the tumors and mucin they produce will fill the abdominal cavity. This will result in compression of organs and will destroy the function of colon, small intestine, stomach, or other organs. Prognosis with treatment in many cases optimistic,[2] but the disease is lethal if untreated, with death by cachexia, bowel obstruction, or other types of complications. Disease most commonly caused by appendiceal primary cancer

Answer 122

A healthy couple can expect to take up to one year to conceive. Investigations are therefore usually performed after one year of regular attempts to conceive. It may however be prudent to address any mechanical reasons that are preventing the couple from conceiving, hence the sexual intercourse history.

Answer 123

Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years

Answer 124

Male factor (30%) Unexplained (20%) Ovulation failure (20%) Tubal damage (15%) Other causes (15%) Semen analysis Serum progesterone 7d prior to expected next period

Answer 125

Repeat, if consistently low refer to specialist

Answer 126

Indicates ovulation

Answer 127

Folic acid BMI 20-25 Advise regular sexual intercourse very 2-3d Smoking/drinking advice

Answer 128

Moderate dyskaryosis: consistent with CINII, refer to colposcopy Severe dyskaryosis: Consistent with CINIII refer to colposcopy Suspected Invasive Ca: refer for urgent colposcopy Inadequate: repeat smear, if 3 inadequate samples-\> colposcopy

Answer 129

16, 18 & 33

Answer 130

Chlamydia- most common N. Gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Answer 131

Lower abdo pain Fever Deep dsypareunia Dyuria and menstrual irregularities may occur Vaginal or cervical discharge Cervical excitation

Answer 132

Screen for chlamydia and Dx

Answer 133

Rx: oral ofloxacin + metronidazole or IM ceftriaxome and oral doxy and oral metronidazole In mild cases of PID, IUD may be left in, however more recent guidelines suggest that removal of IUD may be assocaiteed with better ST outcomes

Answer 134

Infertility Chronic pelvic pain ectopic pregnancy

Answer 135

Inflammation/infection of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surroudning peritoneum. Usually as a result of ascending infection from the endocervix.

Answer 136

If a cervical smear shows borderline or mild (low grade) dyskaryosis, the laboratory will also test the cytology sample for human papillomavirus (HPV). If HPV is found, the woman will be referred for colposcopy within 8 weeks. If HPV is not found, the woman will be returned to the routine screening programme

Answer 137

Imaging reveals a "boggy" uterus with subendometrial linear striations

Answer 138

3/4 of: thin, white homogenous d/c clue cells on microscopy: stippled vaginal epithelial cells Vaginal pH \>4.5 Positive whiff test

Answer 139

Any ovarian mass in a post-menopausal woman needs to be investigated.- refer to gynae

Answer 140

USS Unilocular- more likely to be physiological or benign Complex- multilocular- more likely to be malignant

Answer 141

Depends on age and symptoms. Premenopausal: conservative approach esp \<35 as malignancy is less common. If the cyst is small (\<5cm) and reported as simple- likely to be benign. Repeat USS in 8-12 w Postmenopausal: physiological cysts are unlikely any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment

Answer 142

Serum Ca125 USS Menopausal findigns

Answer 143

Premature menopausal symptoms Elevated gonadtrophin levels \<40y/o

Answer 144

Idiopathic Chemotherapy Autoimmune Radiation

Answer 145

Climacteric symptoms: hot flushes, night sweats Infertility Secondary amenorrhoea Raised FSH, LH

Answer 146

Small dose of oestrogen combined with progestogen (in women with a uterus)

Answer 147

Nausea Breast tenderness Fluid retention and weight gain

Answer 148

Increaed risk of breast Ca (increased by addition of a progestogen) Incresed risk of endometrial reduced by addition of a progestogen. Additional risk eliminated if a progestogen is given continuously. Increased risk of VTE, increased by addition of a progestogen Increased risk of stroke Increased risk of IHD if taken more than 10 years after menopause

Answer 149

After HRT has been stopped for 5 years

Answer 150

Asymptomatic in ~70% of women and 50% of men Women: cervicitis (discharge, bleeding), dysuria Men: urethral d/c, dysuria

Answer 151

Epididymitis PID Endometritis Increased incidence of ectopic pregnancies Infertility Reactive arthritis Perihepatitis (Fitz-Hugh Curtis Syndrome)

Answer 152

NAAT Urine: first void urine sample, vulvovaginal or cervical swab

Answer 153

Doxycycline (7d) or azithromycin (1d) If pregnant than erythromycin or amoxicillin For women and asymptomatic men: all partners from 6 months should be contacted For men: all partners from the 4 weeks prior to symptoms Contacts should be treated presumptively

Answer 154

2-3cm long made up predominantly of elastic connective tissue. Attached posteriorly to the sacrum by the uterosacral ligaments and laterally to the pelvic wall by the cardinal ligaments. Lateral to the cervix is the parametrium which contains conective tissue, uterine vessels and the ureturs

Answer 155

Columnar (glandular) epithelium Continuous with the vagina, covered in squamous epithelium Squamocolumnar junction

Answer 156

Durign puberty and pregnancy, partial eversion of the cervix occurs. The lower pH of the vagina causes the exposed area of clumnar epithelium to undergo metaplasia to squamous epithelium Cells undergoing metaplasia are vulnerable to agents that induce neoplastic change and cervical carcinoma typically originates from this area.

Answer 157

Upper vaginal branches of the uterine artery Obturator and itnernal and external iliac nodes, then to common iliac and para-aortic nodes

Answer 158

Lymph and locally by direct invasion into the uterus, vagina, bladder and rectum

Answer 159

When the columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix. Due to eversion and is a normal finding in younger women Those who are pregnant/taking the pill Aysmtpomatic, may cause post-coital bleeding.

Answer 160

Cryotherapy following colposcopy to exclude carcinoma. Exposed columnar epithelium is also prone to infection

Answer 161

Rare Results from STD Ulceration and infection occasionally found in severe degrees of prolapse when the cervix protrudes

Answer 162

Chronic inflamamtion/infection, often of an ectropion Causes vaginal discharge and may cause inflammatory smears Cryotherapy +/- antibiotics dependant on culture

Answer 163

Benign tumours of the endocervical epithelium More common in women \>40 May be asymptomatic or cause IMB/PCB Small polyps are aveulsed and examined. Still need to Ix bleedign abnormalities.

Answer 164

Occur where squamous epitelium has formed by metaplasia over endocevical cells. The columnar cell secreaions are trappped and form retention cysts whcih appear as white/opaque swellings on the ectocervix. Treatment not required unles symptomatic

Answer 165

Nabothian follicle

Answer 166

Cervical ectropion

Answer 167

Cervical intraepithelial neoplasia Presence of aytpical cells within the squamous epithlium Dyskaryotic exchibiting larger nuclei with frequent mitosis

Answer 168

CIN-I: mild dysplasia, atypical cells found in the lower third of the epithelium CIN-II: moderate dysplasia, atypical cells foudn in the lower 2/3rds of the epithelium CIN-III: Severe dysplasia, abnormal cells occupy the full thickness of the epithelium= Carcinoma in situ. Malginancy ensures if these abnromal cells invade through the BM

Answer 169

1/3rd will develop cervical cancer over the next 10 years.

Answer 170

Least malignant potential, can progress but commonly regresses spontaneously.

Answer 171

\<45, 25-29 years old

Answer 172

Types 16, 18, 31 and 33 13/130 different strains, are considered high risk

Answer 173

Types 16 and 18 as they are responsible for 75 of cervical cancer cases.

Answer 174

OCP Smoking Immunocompromised

Answer 175

Every 3 years 25-49 Every 5 years 50-64 \>65: offer if they have not had a cervical screenign test since 50 years old or a recent cervical cytology sample is abnormal

Answer 176

Cervical glandular intraepithelial neoplasia Adenocarcinoma of the cervix of endometrium should be excluded using both colposcopy and endocervcal curettage or with cone biopsy. Hysteroscopy can be used.

Answer 177

Normal: continue with normal screening Borderline/mild dyskaryosis: HPV triage: if negative, back to routine recall. If +ve-\> colposcopy Moderate dyskaryosis: colposcopy Severe dyskaryosis: urgen colposcopy CGIN: colposcopy, if abnormality not found-\> hysteroscopy

Answer 178

LLETZ (large loop excision of transformation zone) aka diatheyrmy loop excision.

Answer 179

Postoperative haemorrhage- uncommon Risk of subsequent preterm delivery is increased

Answer 180

Assume they have cancer- reassure about early warning cells. CINIII- without treatment she has a 30% chance of developing cancer over 8-15 years.

Answer 181

Adenocarcinoma

Answer 182

When there are no symtposm but the diagnosis is made by biopsy or LLETZ

Answer 183

PCB, IMB, PMB, an offensive vaginal discharge. Pain is not an early features but later disease which involves ureturs, bladder, rectum and nerves can cause: uraemia, haematuria, rectal bleeding an pain. Smears have usually been missed. Ulcer or mass may be vissible or palpable on the cervix

Answer 184

Locally: parametrium and vagina and then to the pelvic side wall. Lymphatic spread to the pelvic nodes is an early feature. Ovarian spread is rare with squamous. Haematological spread is later.

Answer 185

Stage 1: confined to cervix Stage 2: Invasion into the vagina but not the pelvic side wall Stage 3: invasion of the lower vagina or pelvic wall or causing ureteric obstruction Stage 4: invasion of blddder or rectal mucosa or beyond the true pelvis

Answer 186

Dx: Tumour biopsy Vaginal and rectal ecam to assess teh size of the lesion and local invasion. Examination under anaesthetic is performed Cystoscopy for bladder involvement. MRI detects size, spread and LN involvement. To assess patient's fitness for sx: CXR, FBC and U&Es.

Answer 187

Stage 1ai with cone biopsy.: postoperative haemorrhage and preterm labour are the main complications. Simple hysterectomy preferred in older women.

Answer 188

Sx or CTx CTx or RTx if: +ve LNs on MRI or after lymphadenectomy. If LNs -ve as an alternative to hysterectomy Surgical resection margins not clear Palliation for bone bain/haemmorrhage. Sx: Wertheim's hysterectomy if LNs not involved. Ovarias left in young monan with squamous carcinoma. Cx: haemorrhage, ureteric and bladder damage, lymphocyst Radical trachedectomy is less invasive procedure for women who wish to conserve fertility. (LNs negatvie|)

Answer 189

Radical abdominal hysterectomy Involves node clearance, hysterectomy and removal of parametrium and upper 1/3rd of vagina Younger women with squamous carcinom are left with ovaries

Answer 190

Removal of 80% of cervix and upper vagina To preserve fertility

Answer 191

RTx and CTx with platinum agents

Answer 192

CTx/RTx Pelvic exenteration can be considered if the disease is central.

Answer 193

Removal of the vagina, the uterus and cervix, the bladder and or the rectum

Answer 194

95 80 60 10-30 +ve 40 -ve 80 Overall 65

Answer 195

LN +ve Advanced stage Large priamry Poorly differentiated tumour Early recurrence

Answer 196

uraemia due to ureteric obstruction

Answer 197

ai \<3mm depth, \<7mm across aii \<5mm depth, \<7mm across bi clnically visible lesion, greater than ai \<4cm in greatest dimension bii clinically visible lesin, \<4cm

Answer 198

ai Involvement of upper 2/3rds of vagina without parametrial invasion \<4cm aii \<4cm b Invasion of parametrium

Answer 199

Pesronal details PC/HPC Hx of present pregnancy Past obstetric Hx Other Hx: past gynaecological hx, PMH, ROS, DHx, FHx, Social Hx, Allergies, VTE risk

Answer 200

Why is she in hospital? Common reasons: HTN, pain, antepartum haemorrhage, unstable lie, possible ROM. If the pregnancy has hitherto been uncomplicated, mention this

Answer 201

Dates: What was the first day of her LMP What was the length of her menstrual cycle, regular? How many weeks gestation (38w= 36w since conception) EDD: Nagle's rule Complications of pregnancy: bleeding, HTN, DM, anaemia, urinary infections, conern about fetal growth, other problems. Ask about hospital admissions during the pregnancy Tests: what tests have been performed e.g. USS, blood tests, prenatal Dx tests

Answer 202

Subtrate 3m from the date of the LMP, add 7d anjd one year. NB if a cycle \<28d, the EDD will be later and needs to be adjusted (add the number of days \>28 to the date calculated using Nagle's rule. Same applies if shorter.

Answer 203

Measurement of crown-rump length between w9 + 14 Head circumference between 14-20w if no early scan and LMP unknown. NB of little use after 20w.

Answer 204

Her cycles can be anovulatory and LMP is less useful

Answer 205

Details of past pregnancies in chronological order. Mode and gestation of delivery, if operative, why? Birth weight and sex of the baby Mother/baby had any Cxs? Parity Gravidity

Answer 206

Number of times a woman has delivered potentially viable babies (\>24w) Suffix denotes number of pregnaniecs that have miscarried or been terminated prior to 24w.

Answer 207

Never delivered a potentially live baby, she may have had miscarriages or abortions

Answer 208

Delivered at least one baby at 24w or more

Answer 209

Describes the number of times a woman has been pregnant.

Answer 210

Last cervical smear Treated for an abnormal smear Prior contraception Difficulty conceiving

Answer 211

Surgeries CHD HTN DM Psychiatric disease Epilepsy

Answer 212

FHx of twins? DM HTN Pre-eclampsia Auto-immune disease VTE or thrombophilia Any inherited disorders

Answer 213

Smoke Drink Drugs Stable relationship? Social support Domestic abuse

Answer 214

Dates, twins Well-being by assessing size and liquor To check lie, presentation and engagement

Answer 215

General examination Abodminal Examination Consider examination of fundi, reflexes, T, epigastrium, legs, chest etc.

Answer 216

Appearance, T, oedema, anaemia Height and weight Chest, breasts, CVS examined BP and urinalysis Diastolic BP is recorded at as Korotkoff V: when the sound disappears

Answer 217

Semi-prone. Exposed from below the breasts to the symphysis pubis. Later pregnancy can include left lateral tilt to avoid aortocaval compression Uterus normally palpable at 12-14w. 20w: umbilicus

Answer 218

Incorrect dates, full bladder, multiple pregnancy, uterine fibroids, pelvic mass

Answer 219

I: size of pregnant uterus, look for striae, linea nigra and scars in the suprapubic area. Fetal movements often visible in later pregnancy Palpation: us the fetus adequately grown, is liquor volume normal? what is the lie? What is the presentation? Ausculation: listening over the anterior shoulder the fetal heart should be heard with a Pinard's stethoscope, should be 110-160bpm

Answer 220

1. Find the funduse using the fingers and the ulnar border of the left hand. Measure the distance to the pubic symphysis with a tape measure. (after 24w this corresponds to the gestation +/- 2cm. Best for small for dates but only 70% sensitive. Look for tenderness or uterine irritability 2. Use both hands to palpate down the fetus towards the pelvis using dipping movements to palpate the fetal parts and liquor volume. Polyhydramnios: bag will be tense and will need to dip far to feel anything. Head can be balloted, breech is softer and cannot be balloted. Lie: longitudinal, transverse, oblique (head/buttocks palpable in one of the iliac fossae) 3. Turn to face the pelvis and press both hands firmly down to assess the presentation. Engagement of the head occurs when the widest diameter descends into the pelvis and is describe as fifths palpable.

Answer 221

2/5ths= engaged

Answer 222

Grasp the presenting fetal part between the thumb and index finger of the examining hand. Uncomfortable and seldom necessary

Answer 223

Uterine Size: fundus palpable at 12-14w. Umbilicus at 20w. Xiphoid sternum at 36w. Fundal height increases 1cm/week after 24w Presentation: Breech in 20% at 28w. 3% after 37 Engagement: usual in nulliparoius after 37w. Multiparous often not engaged

Answer 224

24-37w \<34w

Answer 225

Prematurity accounts for 80% of NICU occupancy 20% of perinatal mortality up to 50% of cerebal palsy Chronic lung disease Blindness Minor disability

Answer 226

1/3rd handicapped 1/3rd will die

Answer 227

Infection Endometritis C-section

Answer 228

Previous Hx Lower socioeconomic class Extremes of materanl age Short inter-pregnancy interval Maternal medical disease: renal failure, diabetes, thyroid disease Pregnancy complications: pre-eclampsia, IUGR, male fetal gender, raised Hb, STIs and vaginal infection (BV), previous cerbical surgery, multiple pregnancy, uterine abnormalities, fibroids, UTIs, polyhydramnios, congenital fetal abnormalities, APH

Answer 229

Delivery before 34w occurs in 20% of twins and is the mean delivery of triplets Excess liquor, polyhydramnious has the same effect, probably largely mediated by increased stretch

Answer 230

More common when fetus is at risk: pre-eclampsia and IUGR or there is infection Placental abruption often followed by labour Iatrogenic preterm delivery aims to improve upon this mechanism

Answer 231

Uterine abnormalities e.g. fibroids or congenital abnormalities Cervical incompetence: some follows previous surgery for CIN or multiple dilatations of the cervix, but in others cause is unknown

Answer 232

Chorioamnionitis, offensive liquor, neonatal sepsis and endometritis

Answer 233

BV, GBS, Trichomonas, Chlamdyia, (commensals) Coexisting cervical component

Answer 234

Those at increased risk Particulalry those with previous Hx of late miscarriage or preterm labour Most women are not identified as high risk on Hx alone

Answer 235

Cervical length on transvaginal sonography is sensitive and specific Defined as from the external to the internal os

Answer 236

Cervical cerclage (vaginal or abdominal route) usually preprgancny. Ca be used as prophylaxis, prevention or as a "rescue suture" when an incompetent cervix is dilated or Transvaginal progesterone suppositaries or ?antibiotics or fetal reduction or treatment of polyhydramnios through needle aspiration or NSAIDs (if fetal surveillance is intensive) as they reduce fetal urine output or treatment of medical disease

Answer 237

Vaginal progesterone or prophylactic cerclage to women: with Hx of spontaneous preterm birth or midtrimester loss between 16 and 34w and in whome a TVUS has been carried out between 16 and 24w of pregnancy and has revealed a cervical length \<25mm Prophylactic vaginal progesterone to women with no Hx of spontaenous preterm bith or miscarriage in whom a TVUS has been performed and reveals a cervical length of \<25mm Consider cerclage in women who have had a TVUS which reveals a cervical length \<25mm and who have had P-PROM or Hx of cervical trauma

Answer 238

16-24w 25mm

Answer 239

Can cause premature closure of the FDA

Answer 240

Signs of infection or active vaginal bleeding or uterine contractions 16-27+6w with a dilated cervix and exposed unruptured fetal membranes.

Answer 241

Painful contractions, these will stop spontaneously in half of women With cervical incompetence, painless cervical dilatation may occur and woman may experience a dull suprapubic ache or increased discharge Antepartum haemorrhage and fluid loss are common, the latter suggesting ROM

Answer 242

Fever Lie and presentation may be checked Digital vaginal examination is performed unless the membranes have rupture An effaced or dilating cervix confirm the Dx but the course of preterm labour is unpredictable

Answer 243

Cardiotocography and USS to assess fetal state To assess likelihood of delivery: if cervix is effaced fetal fibronectin is helpful. TVS of cerbical length is alos predictive, \>15mm means unlikely Look for infection: vaginal swabs, CRP, WCC (NB steroids will cause it to rise)

Answer 244

Steroids given 24-34w, in those presenting with contraction these can be restricted to women who are fibronectin +ve or have a short cervix, these reduce perinatal morbidity and mortality by promoting pulmonary maturity. NB glucose control. As they take 24h to take effect delivery is often delayed using tocolysis. Repeated doses not recommended Tocolysis: nifedipine or atosiban (oxytocin-R antag) can be given to allow steroids time to act or to allow transfer to a unit with NICU. Delay rather than stop labour and shouldn't be used for more than 24h. Detect and prevent infection Mg Sulphate: neuroprotective for the neonate if given prior to delivery. NB toxic in OD. Mode of delivery in preterm labour

Answer 245

Vaginal delviery reduces NRDS. Caesarian undertaken only for obstetric indications. Breech is more common in preterm laour Conduct of delivery: membranes are notruptured in membrane. Labour may be slow allowing steroids more time to act. Forceps rather than ventouse are used. Unless immedaite resuscitation is required the cord should not be clamped for 45s. Antibiotics are recommended in actual as opposed to threatened preterm labour due to increased risk and morbidity of GBS

Answer 246

\<30w clinically suspected preterm labour: treat \>30w: TVU measurment of cervix, \>15mm unlikely preterm labour. Think of alternative dxs. \<15mm treat for preterm If TVS not available, fetal fibronectin +ve: treat, -ve: unlikely in preterm. Do not use TVS and fetal fibronectin in combination to Dx preterm labour

Answer 247

Nifedipine or oxytocin antagonist (atosiban) Maternal corticosteroids Mg Sulphate

Answer 248

Membranes rupture beofre labour at \<37w All the causes of preterm labour may be indicated It occurse before 1/3rd of preterm deliveries

Answer 249

Preterm deelivery and follows within 48h of \>50% of cases Infection of fetus or placenta (chorioamnionitis) or cord (funisitis) is common. May be the cause and thus occur before or it may follow Prolapse of the umbilical cord may occur rarely Absence of liquor \<24w can result in pulmonary hypoplasia and postural deformities

Answer 250

Gush of clear fluid followed by further leaking Ex: lie and presentation are checked. Dx is with a pool of fluid in the posterior fornix on speculum examination Digital examination to exclude cord prolapse if the presentation is not cephalic

Answer 251

Contractions or abdo pain Fever Tachycardia Uterine tenderness Coloured or offesnive liquor

Answer 252

Speculum examination, if pooling not observed consider IGF binding proetin 1 test or placental microglobulin-1 test of vaginal fluid If the results are positive, in conjunction with clinical presentation, offer management in keeping with woman having P-PROM, If negative, unlikely she has P-PROM

Answer 253

Balance risk of infection with risk of preterm delivery. Identify infection: CRP, WCC, CTG, do not use in isolation Prophylactic antibiotics: Erythromycin (250mg QDS for \<10d or until labour). If erythromycin is CIed consider oral penicllin. Close maternal and fetal surveillance, if gestation reaches 36w, induce labour

Answer 254

Increases risk of NEC in neonate.

Answer 255

Normally falls to a minmum in the second trimester by about 30/15 Occurs in both normal and chronically hypertensive women due to a reduction in SVR Rises again by term to normal pre-pregnant levels

Answer 256

\<0.3g/24h

Answer 257

When the blood pressure rises by 140/90 Can be either pre-eclampsia or transient HTN Normally after 20 weeks

Answer 258

HTN and proteinuria (\>0.3g/24h) Appears in hte second half of pregnacny normally with oedema Occasionally proteinuria is absent in early stage of disease

Answer 259

BP \>140/90 before pregnancy or before 20w gestation or if the woman is on antiHTNs May be 1o or 2o to other disease May also be pre-exisitng proteinuria because of renal disease

Answer 260

6x risk of "superimposed" preeclampsia

Answer 261

HTN normally precedes proteinuria which is a relatively late sign Variability in time and severity of presentation. The degree of HTN can be used to help asses it Early onset disease tends to be more severe, after delivery may take up to 24h for "cure"

Answer 262

6% of nulliparous. Less common in multiparous unless additional risk factors are present

Answer 263

15% but can be up to 50% if there has been severe disease before 28w.

Answer 264

Stage 1: occurs before 20w. Incomplete invasion of spiral arterioles by trophoblasts leading to decreased uteroplacental blood flow. Stage 2: manifestation of disease. Ischaemic placenta induces widespread endothelial cell damage causing vasoconstriction, increased permeability and clotting dysfunction.

Answer 265

Nulliparity Previous Hx FHx Old maternal age Disorders characterised by microvascular disease: chronic HTN, chronic renal disease, SCD. DM Pregnancies with large placenta: Twin pregnancies, molar, fetal hydrops Autoimmune disease (esp antiphospholipid) Renal disease Obesity

Answer 266

\>140/90= mild \>150/100= modetae \>160/100= severe Mild: proteinruia and mild/modearate HTN Moderate: proteinuria and severe HTN with no maternal complications Severe: proteinuria and HTN \<34w or with maternal complications

Answer 267

Trace: seldom significant +1: possible significant, quantify +2: likely significant, quantify PCR \>30mg/noml: confirmed significant proteinuria 24h collection: \>0.3g.24h

Answer 268

Usually asymptomatic, headache, drowsiness, visual disturbances, N+V or epigastric pain may occur at late stage HTN usually first sign but occasionally absent Oedema may be massive, not postural or of sudden onset Epigastric tenderness suggestive of impending complications Urine dipstick

Answer 269

Eclampsia: grand mal seizures. Mortality can result from hypoxia and concomitant complications. Rx with Mg SO4 CBA: results from failure of cerebral blood flow autoregulation, antiHTNsives can help Liver and coag problems: HELLP syndrome. DIC, liver failure and rupture may occur. Treatment is supportive and may incude MgSO4 prophylaxis Renal failure: fluid balance monitoring, may require haemodialysis Pulmonary oedmea: Severe pre-eclamptic is particulalry vulnerable to fluid overload. PO treated with O2 and frusemide, assisted ventilation. ARDS may develop.

Answer 270

Perinatal mortality and morbidity are all increased. Stil birth \<34w: IUGR, spontaneous preterm labour. Preterm devliery often required Term: affects grwoth less but still associated with increased morbidity and mortality At all gestations there is an increased risk of placental abruption

Answer 271

If dipstick positive exclude UTI with cultures and quantiy proteins. Blood tests: Hb often high, uric acid elevated. Rapid fall in platelets suggests impending HELLP. ALTs suggest impending liver test or help. LDH levels rise with liver disease and haemolysis RFT: rapidly rising creatinine suggests severe Cxs and renal failure Fetal: USS, umbilical artery doppler and if abnromal CTG to evaluate fetal well-being

Answer 272

Haemolysis Elevated Liver enzymes Low Platelets

Answer 273

HTN and urinaylsis checks in all pregnant women, esp those at high risk. Most common is uterine artery Doppler at 23w.

Answer 274

High risk women: 75mg of aspirin OD from 12w until birth of baby

Answer 275

HTN disease during previous pregnancy, CKD, Autoimmune disease, DM, chronic HTN= High risk first pregnancy, \>40y/o, pregnancy interval of more than 10 years, \>BMI, FHx, multiple pregnancy= moderate risk, \>1 of these=aspirin

Answer 276

Mild, moderate or sever HTN= admission Significant proteinuria Following admission, should have regular BP monitoring, repeat quanitifcation of proteinuria not necessary. Montor RFT, FBC, LEs

Answer 277

Labetalol Moderate and severe, to keep DBP between 80-100 and systolic to \<150

Answer 278

Anticonvulsants: IV Mg SO. Loading dose of 4g followed by a 24hr infusion Anti-HTNs: labetalol (oral or IV), hydralazine (+/- hydralazine) (IV), nifedipine Corticosteroids for fetalo lung maturation: betamethasone (if \<34w)

Answer 279

Severe respiratory depression and hypotension Preceded by loss of patellar reflexes NB renal impairment, stop

Answer 280

\<34w: after discussion with neonatal and anaesthetists and course of corticosteroids if sever HTN develops refractory to Rx. Maternal or fetal indications. \>34w when BP has been controlled and if corticosteroid course complete 34-36+6: depnding on fetal condition \>37w: within 24-48h of onset

Answer 281

\<34w: Csec \>34w: labour can be induced with PGs, epidural analgesisa helps reduce BP. Use anti-HTNs determine need for haematological and biopchemical tests. Do not rountiely limit second stage of labour. if HTN is severe and refractory to treatment, recommend operative birth

Answer 282

BP: monitor, ask about symptoms each time BP is measured. Monitor bloods Monitor fluid balance. NB PO and ARDS. If urine output is persistently low, use CVP monitoring. If CVP is high (overload) frusemide. If low, fluid but not albumin. If normal and oliguria persists renal failure is likely, K levels indicate need for dialysis BP maintained at 140/90, postnatal treatment is with beta-blocker, nifedipine and ACEI can be seocodn line

Answer 283

Obesity, DM, renal disease (PCD, RAS, chronic pyelo) Rarer include phaeo, Cushing's, cadiac, coarctation

Answer 284

Fundal changes, renal bruit, radiofermoal delay.

Answer 285

To identify secondary HTN, exlude Pheoe as maternal mortality is very high (24h VMA) Look for coexistant disease through renal USS and RFTs Identify pre pregnancy degree of proteinuria to alloiw compairosn later in the pregnancy

Answer 286

Stop ACEI and ARBs due to teratogenicity. Labetalol. Nifedipine second line. Keep dietary Na low. Kepp BP \<150/100. If HTN is severe and refractory offer birth. Screen for pre-ecl Low dose aspirin.

Answer 287

Take account of additional RFs If HTN is sever admit until moderate levels. Monitor proteinruia at each visit. Labetalol, second line nifedipine, methyldopa Do not offer birth to \<36w unless HTN is severe.

Answer 288

Bleeding from genital tract after 24w gestation.

Answer 289

Undetermined origin, placental abruption, placenta praevia Incidental genital tract pathology, uterine rupture, vasa preavia, placenta praevia

Answer 290

Occurs when the placenta is implanted in the lower segment of the uterus Complicates 0.4% of pregnancies at term. At 20w the placenta is low-lying in many more pregancies but appears to move upwards as the pergnancy continues, only 1 in 10 apparently low-lying placenta will be praevia at term.

Answer 291

Marginal (I-II): placenta in lower segment, not over os Major: placenta completely or partially covering os

Answer 292

Twins, age of mothers, uterine scarring

Answer 293

Obstructs engagement of the head, may necessitate C-sec and cause transverse lie Haemorrhage can be severe and may continue during and after delivery as the lower segement is less able to contract and constrict the maternal blood supply. If placenta implants in previous c-sec scar it may be so deep as to prevent placental separation or even penetrate through the uterine wall into the surrounding structures such as the bladder (placenta accreta and placenta percreta respectively). May provoke massive haemorrhage at delivery and require hysterectomy.

Answer 294

Intermittenet painless bleeds which increase in frequency and intensity over several weeks. (1/3rd won't have experienced bleeding before delivery) Ex: breech presentation and transverse lie. No fetal head engagement. Vaginal examination can provoke massive bleeding and is never performed in a woman who is bleeding vaginally until placenta praevia has been excluded. May be found incidentally on USS

Answer 295

USS Most diagnosed prior to bleeding, if low lying placenta has been dxed at a 2nd trimester USS this is repeated vaginally at 32w to exclude praevia. A placenta \<2cm from the itnernal os is likely to be praevia at term. If close to a previous c-sec scar, 3-d power USS is best to determine if there is placenta accreta. CTG FBC: clotting studies and cross-match

Answer 296

Admit all women with bleeding. If placenta praevia is found on USS women often stay in hospital until delviery due to risk of haemorrhage. Blood kept available. IV access maintained Steroids if \<34w. If asymptomatic can delay until 37w. Delivery: C-sec at 39w by most senior person available. Intra-operative and PPH are common. May be emergency if bleeding is severe. Accreta or percreta should have been anticipated although it may occur without invasion through a scar. Uterine incision should be made away from the placenta which can be left in situ or hysterectomy. Treatment of haemorrhage can be with compression of the scar after placental removal through a Rusch balloon. Alternatively, hysterectomy

Answer 297

When part or all of the placenta separates before fetal delivery. Occurs in 1% of pregnancies

Answer 298

Placenta separating may lead to considerable maternal bleeding. Can lead to further placental separation and acute fetal distress. Blood revealed as APH May also enter the liquor Or the moyemtrium (visible haemorrhage is absent in 20%)

Answer 299

Revealed Concealed: bleed into the myometrium

Answer 300

Fetal death (30% of proven abruptions) Haemorrhage often necessitates blood transfusion: DIC and renal failure may lead to maternal death

Answer 301

**IUGR** **Pre-ecl** **Pre-existing HTN** **Maternal smoking** **Hx of placental abruption (6% risk)** Autoimmune diesase Cocaine usage Multiple pregnancy High maternal parity Trauma Sudden reduction in uterine volume (ROM in woman with polyhydramnios)

Answer 302

Painful bleeding, often dark. Degree of vaginal bleeding does not reflect severity of the abruption. If pain occurs alone= concealed Ex: tachycardia suggests profound blood loss. hypotension after massvie loss, uterine tender and often contracting. In severe cases the uterus is woody hard and the fetus difficult to palpate. Fetal heart tones abnormal/absent. If coagulation failure has occured, widespread bleeding is evident

Answer 303

Clinical dx Ixs help to establish severity and plan resuscitation CTG: fetal heartbeat, ferquent uterine activity USS may be used to estimate fetal weight and exclude placenta previa but abruption may not be visible. FBC, coagulation screen, cross-match. Catheterisation with hourly UO, regular FBC, Us&Es, CVP monitoring may be required in severe cases.

Answer 304

Maternal collapse Coagulopathy Fetal distress/demise Woddy hard uterus Poor UO or renal failure Degree of vaginal loss is unhelpful

Answer 305

Admit if pain and uterine tenderness. IV fluids. Steroids if gestation \<34w. Blood transfusion. Opiate analagesia. Delivery: depends on fetal state and gestation: Fetal distress: emergency C-sec No fetal distress but gestation is \>37w induction of labour with amniotomy. Monitor mother and fetal distress. If fetaus is dead: coagulopathy is also likely. Blood products given and labour induced. If there is no fetal distress, pregnacny is preterms and abruption appears to be minor, steroids and pregnancy -\> high risk . PPH is the majory risk

Answer 306

APH small and painless without placenta praevia, may be difficult to find a cause. USS little help.

Answer 307

Occurs when fetal BS runs in the membranes in front of the presenting part. rare but occur when the umbilical cord is attached to the membranes rather than the palcenta. Can be detected on USS. When membranes rupture, the vessel may rupture too. Typical presentation is painless, moderate baginal bleeding at amniotomy or SROM which is accompanied by severe fetal distress.

Answer 308

Cervical carcinoma can present in pregnancy. If a cervical smear is overdue the woman with small recurrent or postcoital haemorrhage should undergo speculum exmaintions.

Answer 309

When additional manoeuvres are required after normal downward traction has failed to deliver the shoulders after the head has delivered 1 in 200 deliveries Characteristically results in Erb's palsy (waiter's tip) from excessive traction on the neck leading to damage to the brachial plexus. Delay and unskilled attempts at delivery can be lethal (can be as short as 5 minutes from head to shoulder delivery)

Answer 310

Large baby (\>4kg although this only accounts for half of all cases) Previous shoulder dystocia Raised maternal BMI Labour induction Low height Maternal diabetes Instrumental delivery Most cases considered unpreventable due to poor ability to predict and the prevention involves C-section

Answer 311

Rapid and skilled intervention Sequence of actions: Because obstruction is at the pelvic inlet, excessive traction is useless. Senior help. Gentle downward traction Legs are hyperextended onto the abdomen Suprapubic pressure applied This method works in 90% alternative methods if this fails involve internal manoeuvres necessitating episiotomy: If the shoulders are transverese, pressure behind the anterior shoulder will rotate it to the widest diameter, combined with pressure on the anterior part of the posterior shoulder (Wood's screw) can force delivery. If this fails, posterior arm is grasped and by extension at the elbow the hand is brought down. The trunk will either follow or rotation of the body using the arm is performed. Last resorts: symphysiotomy Lateral replacement of the urethra with a metal catheter Zavanelli maneuvre: replacement of the head and C-section, usually irreversible fetal damage has occured by this point.

Answer 312

Leg hyperextnension used in shoulder dystocia

Answer 313

Pressure on anterior shoulder and pressure on anterior part of posterior shoulder used in shoulder dystocia

Answer 314

Reducing head back into uterus prior to c-sec in shoulder dystocia

Answer 315

Occurs after ROM Umbilical cord descends below the presenting part. Untreated the cord will be compressed or go into spasm and the baby will rapidly become hypoxic. 1 in 500 deliveries

Answer 316

Preterm labour Breech presentation Polyhydramnios Abnormal lie Twin pregnancy (\>50% occur at artificial amniotomy)

Answer 317

Fetal heart rate abnormality Vaginal palpation of the cord or its appearance at the introitus

Answer 318

Presenting part must be prevented from compressing the cord: pushed up by the examining finger or tocolytics e.g. terbutaline are given. If the cord is out of the introitus it should be kept warm and moist but not forced back inside. Patient should go on all fours whilst preparation of delivery is undertaken. C-sec usually used but instrumental vaginal delivery is appropriate when the cervix is fully dilated.

Answer 319

When liqupr enters the maternal circulation causing anaphylaxis with sudden dyspnoea, hypoxia and hypotension. Often accompanied by seizures and cardiac arrest. Acute heart failure is evident. Extremely rare but serious as often causes death. If patient survives for \>30mins she develops DIC, PO and ARDS.

Answer 320

Membrane rupture, during labour, C-sec, TOP. Multiple mild predisposing factor: strong contractions in the presence of polyhydramnios. Prevention impossible

Answer 321

NB often confused with other causes of collapse and with eclampsia. ABC resusc. O2 and CVP monitoring. Blooods for clotting, FBC, U&Es, cross match. Blood and FFP will be required. ICU admission.

Answer 322

Can be de novo or an old scar. Fetus is extruded. Uterus contracts and bleeds from rupture site causing acue fetal hypoxia and massive internal maternal haemorrhage. Rupture of a lower trasnverse C-sec scar is usually less severe than others as the lower segment is not very vascular. Occurs in 1/1500 pregnancies. and in 0.7% of women who attempt a vaginal delivery after a single previous lower C-sec. Dx made from fetal HR abnormalities, constant lower abdo pain, vaginal bleeding, contraciton cessation, maternal collapse.

Answer 323

Labours with a scarred uterus Classical C-sec or deep myotomy. Rupture before labour is rare Neglected obstrcuted labour is rare in the West. Congenital uterine abnormalities occasionally cause rupture before labour. Preventive mesaures include avoidance of induction and caution when using oxytocin in women with previous C-sec.

Answer 324

Maternal resus with IV fluid and bloods Bloods taken fro clotting, Hb, X-match Urgent laparotomy for fetal delivery and repair/removal of uterus. Uterine rupture has a high recurrence rate

Answer 325

When the fundus inverts into the uterine cavity. Usually follows traction on the placenta and occurs in 1 in 20000 deliveries Haemorrhage, pain and profound shock. Brief immediate attempt to push the fundus up via the vagina. If not, GA and replacement performed with hydrosstatic pressure of several litres of salin which is run past a clenched fist at the introitus.

Answer 326

Maternal epilepsy Exlampsia Hypoxia of any cause

Answer 327

Assume pre-eclampsia, Mg sulphate ABC

Answer 328

Excessive doses or inadvertent IV doses of LA can cause transient cardiac, respiratoey and neurological consequences

Answer 329

When cord prolapse is diagnosed before full dilatation, assistance should be immediately called and preparations made for immediate birth in theatre. T here are insufficient data to evaluate manual replacement of the prolapsed cord above the presenting part to allow continuation of labour. This practice is not recommended . To prevent vasospasm, there should be minimal handling of loops of cord lying outside the vagina. To prevent cord compression, it is recommended that the presenting part be elevated either manually or by filling the urinary bladder. Cord compression can be further reduced by the mother adopting the knee–chest or left lateral (preferably with head down and pillow under the left hip) position. Tocolysis can be considered while preparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to prevent compression mechanically, particularly when birth is likely to be delayed. Although the measures described above are potentially useful during preparation for birth, they must not result in unnecessary delay.

Answer 330

Detect and manage pre-existing maternal disorders that may affect outcome of pregnancy Prevent or detect and manage maternal complications of pregnancy " fetal compications Detect congenital fetal problems Plan with mother the circumstancs of delivery to ensure maximum safety for the mother and baby Provide education and advice regarding lifestyle and 'minor' conditions of pregnancy

Answer 331

Previous pregnancies: implications Health check: better performed before conception Rubella status Strict preconceptual glucose control in diabetics to reduce the incidence of congenital abnormalities Medication optimisation Folic acid supplementation e.g. 0.4mg/day preconceptually. Advice regarding smoking, ETOH, drugs

Answer 332

Should be before 10 weeks gestation To secreen for potential cxs that may arise during pregnancy: Risk assessment using Hx and Ex. Decide about type and frequency of antenatal care: need to be constantly re-evaluation as the pregnancy proceeds. Check pregnancy gestation and arrange prenatal screening General health chec,

Answer 333

\<17y/o \>35y/o are at greater risk of obstetric and mediocal cxs. Chromosomal abnormalities increase with age

Answer 334

Many obstetric disorders have a small but significant recurrence rate include: preterm labour, small for dates, IUGR, stillbirth, APH, PPH, some congenital abnromalities, rhesus disease, pre-eclampsia, GDM

Answer 335

Hx of subferitility increases perinatal risk: IVF/augmentatin of fertilisation increases likelihood of multiple pregnancy. Previous uterine surgery (e.g. myomectomy) may be an indication for elective C-section Cervical smear Hx

Answer 336

HTN, DM, autoimmune disease, Hbopathy, thromboembolic disease, CVD, R disease or other serios diseases are at an increased risk of pregancy problems. Direct questions re: depression are useful

Answer 337

DM in first degree relative increases rsik of GDM HTN, thromboembolic, autoimmune disease and pre-eclampsia are also familial

Answer 338

General health and nutritional status BMI Baseline BP Incidental disease may be detected e.g. breast carcinoma Abdo examination: limited before third trimester. Uterus palpable from 12w. Fetal heart can be ausucltated at this point. If no recent smear, usually performed 3 months post-natally.

Answer 339

USS: 11-13+6 to date using crown-rump length. Also detects multiple pregnancy and allows screening for nuchal translucency. DS screen: nuchal translucency, beta-hCG and pregnancy-associated plasma protein A (PAPPA) = combined test Bloods: FBC (?anaemia). Serum Abs (anti-D) to identify those at risk of intrauterine isoimmunisation. GGT (in those at risk, normally perforemd later in pregnancy). Syphillis test (VDRL). Rubella immunity checked (vaccination postnatally). HIV and HBV screening. Hb electrophoresis. Screening for infections implicatd in preterm labour (e.g. Chlamydia, BV). Urine MC+S because asymptomatic bacteruria in pregnancy can lead to pyelnephritis in (20%) Urinalysis for glucose, protein and nitrites Folic acid supplementation 0.4mg/d Vit d supplementation 10 microg/d recommended for women \>30BMI, SEA or afrocarribean origin or with low sunlight absoprtion. Fe supplementation should not be routine

Answer 340

2500 Avoided or \<1 unit Smoking cessation with nicotine replacement therapy Dental cehck up advised Coitus is not contraindicated unless: placenta praevia, or ROMed. Listeriosis is avoided by drinking pasteurised milk and avoiding soft and blue cheese, pate and undercooked or partially cooked prepared foods. Salmonella avoided by cooking eggs and poultry well. Eservices advised. Above and below the bump.

Answer 341

Communiy: core team of midwives. Women can be referred to hospital Consultant-led care Risk assessment for VTE should be considered

Answer 342

20w: enables detection of most structural fetal abnormalities.

Answer 343

Doppler of the uterine arteries at 23w can be used as a screening test for IUGR and pre-eclampsia. Not performed routinely but in htose at risk

Answer 344

Uncomplicated: 10 for nulliparous. 7 for multiparous More frequent visits are appropriate for many "high-risk" pregnancies.

Answer 345

BP Urine dip-\> urine culture/analysis if abnormality found Abdominal exam: lie, engagement (unimportant until 36w) Fetal heart

Answer 346

Results of screening tests for chromosomal abnormalities. R/v of booking bloods.

Answer 347

Anomaly scan Repeat scan arranged at 32w if low-lying placenta

Answer 348

Exclusion of early onset pre-eclampsia (only in nulliparous)

Answer 349

Fundal height FBC and Abs GTT is perforemd if indicated Anti-D given to rhesus-negative women

Answer 350

Fundal height, R/v of bloods from 28w (nulliparous only)

Answer 351

Fundal height measured Fetal lie and presentation Referral for external cephalic version if presentation if breech (ECV) Pelvic examination inappropriate unless induction is complicated or there is suspicion of obstruction (and placenta praevia has been excluded)

Answer 352

Fundal height measure and fetal lie and presentation checked Membrane sweeping is offered as is induciton of labour by 42w.

Answer 353

Common Scleare checked for jaundice and LFTs and bile acids assessed NB although rare liver issue in pregnancy may bpresent with itching

Answer 354

Formerly pubic symphysis dysfunction Common and causes varying degrees of discomfort PT, corsets, analgesics and even crutches may be used Care with leg abduction required

Answer 355

Affects 70%, most marked in supine position Extra pillows are helpful. Diet modification. Antacids can be used Ranitidine in severe cases (NB pre-eclampsia can present with epigastric pain)

Answer 356

Universal and may cause sciatica Most cases resolve after delivery PT, advice on posture and lifting, a firm mattress and corset may all felp

Answer 357

Common and exacerbated by oral Fe. High fibre intake. Stool softners can be used.

Answer 358

Common, worsens towards the end (unreliable sign of pre-eclampsia). Sudden increase warrants assessment and FU of BP and urinalyis. Benign oedema is helped by raising feet. Diuretics should not be given.

Answer 359

Affects 30% of women. Treatments unproven but NaCl, Ca salts or quinine may be tried

Answer 360

Due to fluid retention compressing the median nerve. Seldom severe, usually temporary. Splinting of the wrists may help.

Answer 361

DDue to candida infection Common and difficult to treat Itchy, non-offensive, white-grey discharge. Imidazole vaginal pessaires (e.g. clotrimazole) can be used for symptomatic infection.

Answer 362

Common, NB often incorrectly attributed to anaemia.

Answer 363

Gain 10-15kg

Answer 364

Uterus increases weight from 50g-1000g Muscle hypertrophy, increased blood flow and contractility. Cervix softens and may start to efface late in third trimester

Answer 365

50% increase in blood volume Increased red cell mass Decreased Hb Increased WCC

Answer 366

CO: 40% increase Peripheral resitance: 50% reduction BP: falls in mid-regnancy.

Answer 367

Tidal volume: 40% increase No change in RR

Answer 368

Renal blood flow: 40% increase in GFR so creatinine/urea decreased Reduce motility: delayed gastric emptying and constipation Enlargement of thyroid.

Answer 369

w1-12 13-27 28-birth

Answer 370

Cervical position Cervical consistency Cervical effacement Cervical dilation Fetal station \<5- indicates labour unlikely to start without induction \>9- indicates htat labour will most likely commence spontaneously.

Answer 371

present in 25% at 28w. Only occurs in 3% of babies near term

Answer 372

Frank: hips flexed and knees fully extended Footling: one or both feet come first with the bottom at a higher position (rare but carries a higher perinatal morbidity)

Answer 373

Uterine malformations: fibroids Placenta praevia Poly/oligohydramnios Fetal abnromality (e.g. CNS malformation, chromosomal disorders). Prematurity (due to increased incidence earlier in gestation)

Answer 374

Fetaus may turn spontaneously. ECV: success rate of around 60% (RCOG recommend ECV should be offered from 36w in nulliparous and 37 in parous) Planned C-sec or vaginal

Answer 375

Planned C-sec carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth There is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born

Answer 376

Indication for C-sec irrespective of fetal presentation (e.g. placenta praevia) Severe oligohydramnios or ROM Nonreassuring fetal monitoring test results Hyperextended fetal head Significant fetal or uterine anomaly PLacental abruption Multiple gestation (can be considered for the second twin after delivery of the first twin)

Answer 377

Maternal HTN Maternal obesity fetal growth restriction Oligohydramnios Previous C-sec.

Answer 378

holestasis of pregnancy is characterised by severe pruritis, whereas acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea). With a normal FBC and viral screen a diagnosis of HELLP syndrome or viral hepatitis is unlikely.

Answer 379

Intrahepatic cholestasis of pregnancy: caused by impaired bile flow. Leads to build up of bile salts which can then deposit in the skin as well as the placenta. Can be uncomfortable for mohter but may also cause sudden asphyxial events in fetus leading to anoxia and death. pruritus: typically worse on palms, soles and abodmen bilirubin \< 100 occurs in 2nd and 3rd trimester Increased risk of preterm birth Mx: induction at 37w. Ursodeoxycholic acid Vit K supplementaiton

Answer 380

Rare complication which may occure in third trimester or immediately following delivery Abdo pain, N+V, headache, jaundice, hypoglycaemia, severe disease may result in pre-eclampsia ALT typically elevated e.g. 500u/l Mx: supportive care, stabilised: delivery is the definitive manageemtn NB Gilbert's and DJS may be exacerbated during pregnancy

Answer 381

From the ovarian artery which anastamoses with branches of the uterine artery in the broad ligament. Overy lie the uretur in the ovarian fossa. Attached to the broad ligament by the mesovarium, the pelvic side wall by the infundibulopelvic ligament and to the uterus by the ovarian ligament

Answer 382

The outer cortex which is covered by germinal epithelium

Answer 383

Outer cortex: germinal epithelium Inner medulla: connective tissue and bvs Cortex contains the follicles and theca cells.

Answer 384

Granulosa cells in the growing follicles and also by theca cells Rare tumours of these cells secrete oestrogens.

Answer 385

Multiple enlarge every month under influence of FSH Onle one reaches 20mm and ruptures in response to mid cycle LH surge Collapsed follicle becomes a corpus luteum and continues to produce oestrogen and progesterone to maintain the endometrium. If no implantation occurs the corpus luteum involutes and hormone levels decline. If fertilisation occurs hCG from the trophoblast maintains the corpus luteum's function and hormone production until 7-9w when the placenta takes over. Follicular and lutein cysts result from persistence of these structures in nonpregnant women.

Answer 386

Often silent and detected either when they are very large and cause abdominal distension or on USS. Acute presentation is associated with "accidents"

Answer 387

Rupture of cyst into the peritoneal cavity. Haemaorrhage into a cyst or peritoenal cavity Torsion of the pedcile

Answer 388

Rupture of the cyst contents into the peritoneal cavity causes intense pain. This is especially the cause with an endometrioma or dermoid cyst.

Answer 389

Can occur into a cyst or the peritoneal cavity. Often causes pain. Peritoneal cavity haemorrhage can occasionally cause hypovolaemic shock

Answer 390

Torsion of the pedicle (which is bulky due to the cyst) causes infarction of the ovary and tube and severe pain. Sx and detorsion required urgently to save the ovary

Answer 391

Causees oligomenorrhoea, hirsutism and subfertility. Actually small multiple, poorly developed follicles rather than cysts

Answer 392

Because they may undrego malignant change

Answer 393

Epithelial tumours Germ cell tumours Sex cord tumours

Answer 394

Follicular/lutein cysts Dermoid cysts Endometriomas Benign epithelial tumour

Answer 395

Benign epithelial tumour Malignancy

Answer 396

Postmenopausal Histology may demonstrate borderline malignancy where malignant histological features are seen without invasion. Such tumours may become frankly malignant and Sx is advised

Answer 397

Close observation following removal of the cysts or affected ovary to retain fertility with close observation. Recurrence as a borderline or invasive tumour can occur up to 20y later

Answer 398

Serous adenocarcinoma (50% of malignant neoplasms of the ovary) derives from the peithelial. Serous cystadenoma

Answer 399

10% Mucinous cystadenoma can become very large and are less frequently malignant.

Answer 400

Pseudomyxoma peritonei Abdominal cavity fills with gelatinous mucin secretions. Appendieal primary should be excluded.

Answer 401

25% Similar histologically to endometrial carcinoma. with which it is associated in 20%

Answer 402

Clear cell carcinoma (epithelial tumours) \<10%

Answer 403

Rare small and usually benign tumours of the ovarian epithelium

Answer 404

Epiethlium 50% 10% 25% (associated with endometrial carcinoma in 20% of cases) \<10%

Answer 405

From undifferentiated primordial germ cells of the gonad

Answer 406

Dermoid cyst Undifferentiated primordial germs cells of the gonad. Common benign tumours arising in young premenopasual women. May contain fully differentiated tissue from all cell lines. Commonly bilateral, seldom large, asymptomatic. May rupture. The solid teratoma

Answer 407

Female equivalent of the seminoma. Very rare, most common ovarian malignancy in younger women. Senesitive to RTx

Answer 408

Dysgerminoma

Answer 409

From the stroma of the gona Granulosa cell tumours Tehcomas Fibromas

Answer 410

Sex cord tumour. Usually malignant but slow growing Rare and found in postmenopausal women. Stimulation of the endometrium may cause bleeding, endometrial hyperplasia, endometrial malignancy and precocious puberty (rarely in young girls)

Answer 411

Secrete high livels of oestrogen and inhibin which can cause bleeding endometrial hyperplasia malignancy

Answer 412

Serum inhibin used to monitor for recurrence

Answer 413

Rare usually benign Can secrete oestrogens or androgens

Answer 414

Rare and benign tumours of the sex cord Can cause Meig's

Answer 415

Ascites and usually right pleural effusions are found in conjunction with a small ovarian mass. Effusion is benign and cured by removal of the mass

Answer 416

10% of malignant ovarian masses Breast GIT

Answer 417

Mets to ovary from gut which contain "signet-ring" cells. Primary malignancy may be difficult to detect and has very poor px

Answer 418

Endometriosis can cause altered blood to accumulate in "chocolates cysts" In the ovary these are called endometriomas. Rupture is painful though uncommon "Tumour-like condition"

Answer 419

Follicular and lutein cysts are persistently enlarged follicles and CL respectively. Only found in premenopausal women. Protected against by OCP. Lutein cysts. "Tumour-like condition"

Answer 420

Symptomatic treatment. If asymptomatic, cyst is observed with serial USS. Due to remote possibility of malignancy, if an apparent functional cyst \>5mm persists beyond 2 months measure CA125 and consider laparoscopy to remove or drain the cyst

Answer 421

\<35% Due to its silent nature

Answer 422

Rates increase with age \>80% in women \>50 Highest age-specific incidence rates in 80-84 OCP use may be protective

Answer 423

Relate to number of ovulations: Early menarche Late menopause Nulliparity Familial: BRCA1 or 2 (also associated with breast), HNPCC (Lynch, lifetime incidence of bowel 80%) (if \>2 relatives are affected the lifetime risk is 13%) if BRCA1: 50%.

Answer 424

Pregnancy Lactation Use of pill

Answer 425

Generally foer ealry malignant rather than premalignant Those with BRCA1 and 2 are offered yearly TVUSS and CA125 or prophylactic SPO

Answer 426

Vague/ absent, 70% present with Stage 3-4 disease Warning signs; Persistent abdominal distension (bloating) Feeling full (early satiety) +/- loss of appetite Pelvic or abdo pain Increased urinary urgency and or frequency Vaginal bleeding Ask about breast/GI symptoms as ovarian mass may be met from these sites. NB for overlap with IBS although this usually presents in younger women. Must exclude ovarian cancer in older women.

Answer 427

Cachexia Large abdo or pelvic mass (very large masses are less likely to be malignant) Ascites Breasts should be examined.

Answer 428

Rapid growth \>5cm Ascietes Advanced age Bilateral masses Solid or septate nature on USS Increased vasculatiry

Answer 429

Usually spreads directly within the pelvis and abdomen (transcoelomic spread) Lymapthic and histological spread can occur. Staging is surgical and histological.

Answer 430

Stage 1: macroscopically confined to ovaries. 1a: one ovary affected, capsule intact 1b: both ovaries affected, capsule intact 1c: one/both, capsule not intact, or malignant cells in the abdominal cavity (ascites). Stage 2: disease beyond ovaries, confined to pelvis Stage 3: disease is beyond the pelvis but confined to the abdomen (frequent involvement of the omentum, small bowel and peritoneuM) Stage 4: disease is beyond abdomen e.g. lungs or liver parenchyma

Answer 431

CA125 should measured in women \>50 with abdominal symptoms. \>35IU/mL USS of abdomen or pelvis If this dentifies ascites or pelvic or abdo mass, urgent referral to secondary care

Answer 432

CA125 measured if not already done so Measure AFP and hCG as they are at increased risk of germ cell tumours.

Answer 433

RMI= U x Mx CA125 U scored 1 point for: multilocular cysts, solid areas, metastases, ascites, bilateral lesions. M menopausal status: 1= pre, 3= menopausal. CA125= serum level.

Answer 434

\>250-\> referred to MDT CT TAP may be performed, but staging usually established surgically.

Answer 435

Assess fitness for surgery Midline laparatomy allows assessment of abdo and pelvis Total hysterectomy with BSO and partial omentectomy perfromed. Stage 1: sample retroperitoneal LNs Stage 2 or greater they are all removed through block dissection. Uterus and unilateral ovary may be preserved in younger women following laparoscopic Sx looking to maintain fertility however they require extensive f/u

Answer 436

Confirmed tissue dx. Very early, no CTx Stage 1c: carboplatin 2-4 carboplatin +/- paclitaxel. NB 2/3rds of women with initial response to CTx relapse within 2 years of completing treatment

Answer 437

Only used for dysgerminomas

Answer 438

Advanced stage Poorly differentiated tumours Clear Cell tumorus Slow/poor response to CTx Bowel obstruction or perf

Answer 439

Analgesic ladder, co-analgesics such as antidepressants steroids and cytotoxics may be used. Antiemetics: anticholinergics, antihistamines, dopamine antagonists or 5HT-3 antags (ondanstrenon) High dose progestogens may be helpful. RTx can be used. Ascites: repeated paracentesis. Obstruction can be managed at home and resolution occurs in 1/3rd spontaneously. If partial: metoclopramide (pro-motility and antiemetic) + stool obstructers with enemas for constipation and a trial of dexmethasone. Complete obstruction: cyclizine and odansetron for N+V with hyoscine for spasm. Surgical palliation indicated with acute, single-sight obstruction, may involve insertion of stents. Terminal distress: good symptom control with anxiolytics and analgesics without oversedation

Answer 440

Active total care of the patient whose disease is incurable Increase QoL Address symptoms

Answer 441

NSAIDs: mefanamic acid and ibuprofen effective in up to 80% ofr women. Combined OCP= second line

Answer 442

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. 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 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. Causes include: endometriosis adenomyosis pelvic inflammatory disease intrauterine devices\* fibroids

Answer 443

Levonorgestrel (single does of a progesterone) Ulipristal (progesterone R modulator)

Answer 444

should be taken as soon as possible - efficacy decreases with time must be taken within 72 hrs of unprotected sexual intercourse (UPSI)\* single dose of levonorgestrel 1.5mg (a progesterone) mode of action not fully understood - acts both to stop ovulation and inhibit implantation 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 2 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated \*may be offered after this period as long as the client is aware of reduced effectiveness and unlicensed indication

Answer 445

a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended may reduce the effectiveness of combined oral contraceptive pills and progesterone only pills caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle is not recommended breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Answer 446

Intrauterine device (IUD) ## Footnote must be inserted within 5 days of UPSI, or if a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date may inhibit fertilisation or implantation prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection is 99% effective regardless of where it is used in the cycle may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Answer 447

NICE published guidance in 2010 on the management of hypertension in pregnancy. They also made recommendations on reducing the risk of hypertensive disorders developing in the first place. Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. High risk groups include: hypertensive disease during previous pregnancies chronic kidney disease autoimmune disorders such as SLE or antiphospholipid syndrome type 1 or 2 diabetes mellitus 75mg Aspirin

Answer 448

Causes overactive bladder (OAB)/urge incontinence: due to detrusor over activity stress incontinence: leaking small amounts when coughing or laughing mixed incontinence: both urge and stress overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement

Answer 449

bladder diaries should be completed for a minimum of 3 days vaginal examination to exclude cystocele urine dipstick and culture

Answer 450

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant: bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinic is first-line surgical management: e.g. sacral nerve stimulation If stress incontinence is predominant: pelvic floor muscle training (for a minimum of 3 months) surgical procedures: e.g. retropubic mid-urethral tape procedures

Answer 451

'Cottage cheese' discharge Vulvitis Itch

Answer 452

Offensive, yellow/green, frothy discharge Vulvovaginitis Strawberry cervix

Answer 453

Offensive, thin, white/grey, 'fishy' discharge

Answer 454

Common causes physiological Candida Trichomonas vaginalis bacterial vaginosis Less common causes Gonorrhoea Chlamydia can cause a vaginal discharge although this is rarely the presenting symptoms ectropion foreign body cervical cancer

Answer 455

Ectopic pregnancy UTI Appendicitis PID Ovarian torsion Miscarriage

Answer 456

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding Shoulder tip pain and cervical excitation may be seen

Answer 457

Dysuria and frequency are common but women may experience suprapubic burning secondary to cystitis

Answer 458

Pain initial in the central abdomen before localising to the right iliac fossa Anorexia is common Tachycardia, low-grade pyrexia, tenderness in RIF Rovsing's sign: more pain in RIF than LIF when palpating LIF

Answer 459

Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities may occur Cervical excitation may be found on examination

Answer 460

Usually sudden onset unilateral lower abdominal pain. Onset may coincide with exercise. Nausea and vomiting are common Unilateral, tender adnexal mass on examination

Answer 461

Vaginal bleeding and crampy lower abdominal pain following a period of amenorrhoea

Answer 462

Endometriosis IBS Ovarian Cyst Urogenital prolapse

Answer 463

Chronic pelvic pain Dysmenorrhoea - pain often starts days before bleeding Deep dyspareunia Subfertility

Answer 464

Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit Features such as lethargy, nausea, backache and bladder symptoms may also be present

Answer 465

Unilateral dull ache which may be intermittent or only occur during intercourse. Torsion or rupture may lead to severe abdominal pain Large cysts may cause abdominal swelling or pressure effects on the bladder

Answer 466

Seen in older women Sensation of pressure, heaviness, 'bearing-down' Urinary symptoms: incontinence, frequency, urgency

Answer 467

Nausea and vomiting are very common in pregnancy, with 70-85% of pregnant women affected. Most cases are mild and do not require treatment, however anti-emetics may be considered if symptoms are persistent, severe and preventing daily activities. Suitable anti-emetics include cyclizine, metoclopramide, prochlorperazine, promethazine, chlorpromazine, domperidone and ondansetron. There is no evidence to suggest that any one of these drugs works better than another.

Answer 468

Epilepsy affects 0.5% of pregnant women. It is a significant cause of maternal death, and so antiepileptic treatment is continued during pregnancy. However, antiepileptic drugs increase the risk of congenital abnormalities, particularly neural tube defects. Carbamazepine and lamotrigine are the safest drugs to prescribe, whereas sodium valproate should be avoided. This is because it is associated with a higher rate of congenital abnormalities and lower intelligence in children.

Answer 469

Proplthiouricil

Answer 470

Nitrofuratonin is preferred Followed by trimethoprim and then cefalexin. NB Nitrofurantoin should be avoided at term due to risk of neonatal haemolysis Trimethoprim should be avoided during early pregnancy due to its action as a folic acid antagonist

Answer 471

Indications 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

Answer 472

Method membrane sweep intravaginal prostaglandins breaking of waters oxytocin

Answer 473

The woman is having migraines with aura - a condition that can increase using the COCP. Women who have migraine with aura should stop the pill immediately - this is because the oestrogen component of the COCP can increase the risk of the women having an ischaemic stroke. A progesterone-only contraceptive pill is therefore the only alternative contraceptive medication that can be prescribed, as the others have oestrogen.

Answer 474

maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding)

Answer 475

all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situati

Answer 476

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

Answer 477

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.

Answer 478

The following question tests the understanding of secondary prevention of women with pre-eclampsia. There is A level data showing that low-dose aspirin started at 12-14 weeks' gestation is more effective than placebo at reducing occurrence of pre-eclampsia in women at high risk, reducing perinatal mortality and reducing the risk of babies being born small for gestational age . There is some evidence that low molecular weight heparin might reduce the placental insufficiency seen in pre-eclampsia, but long-term safety studies are not yet available. Labetalol and methyldopa are both common antihypertensive drugs used in the acute management of pre-eclampsia, however are not given prophylactically and do not reduce intrauterine growth retardation. Similarly to LMWH, unfractionated heparin has not been proven to prevent the development uteroplacental insufficiency.

Answer 479

can either be offered induction of labour approximately 24 hours later or managed expectantly. Induction is often with vaginal PGE2.

Answer 480

The most appropriate first line investigation in this patient is a day 21 progesterone. This is a non-invasive test and can tell you whether the patient is actually ovulating. Both serum prolactin and thyroid function tests are not recommended unless patient's have a specific reason for being tested i.e. a pituitary tumour or signs of overt thyroid disease.

Answer 481

Risks to the mother 5 times greater risk of pneumonitis Fetal varicella syndrome (FVS) risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities Other risks to the fetus shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester severe neonatal varicella: if mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 482

Management of chickenpox exposure if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

Answer 483

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm vaginal bleeding: usually less than a normal period, may be dark brown in colour history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination Examination findings abdominal tenderness cervical excitation (also known as cervical motion tenderness) adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

Answer 484

adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended

Answer 485

obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome

Answer 486

Asherman's syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.

Answer 487

exclude pregnancy with urinary or serum bHCG gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) prolactin androgen levels: raised levels may be seen in PCOS oestradiol thyroid function tests

Answer 488

hypothalamic amenorrhoea (e.g. Stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis\* Sheehan's syndrome Asherman's syndrome (intrauterine adhesions)

Answer 489

first degree: superficial damage with no muscle involvement second degree: injury to the perineal muscle, but not involving the anal sphincter third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS): 3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Answer 490

Risk factors for perineal tears primigravida large babies precipitant labour shoulder dystocia forceps delivery

Answer 491

Mastitis affects around 1 in 10 breast feeding women. The BNF advises to treat 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection'. The first-line antibiotic is flucloxacillin for 10-14 days. Breast feeding or expressing should continue during treatment. Referral to hospital for review by the surgical team is only appropriate if a breast abscess is suspected. This patient has no palpable lump therefore an abscess is unlikely.

Answer 492

Infected nipple fissure not improving after 12-24h following effective milk removal Breast milk culture positive Fluclox for 10-14d Erythromycin or clarithromycin if penallergic

Answer 493

diabetes mellitus drugs: antibiotics, steroids pregnancy immunosuppression: HIV, iatrogenic

Answer 494

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

Answer 495

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 (see above) consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months

Answer 496

The combined test is recommended at 10-14 weeks gestation. It involves an ultrasound scan for nuchal translucency and a blood test for levels of Beta-human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein A (PAPP-A). In pregnancies with Down Syndrome, PAPP-A is low and beta-hCG raised. If the window for the combined test was missed, at 14-20 gestation, the quadruple test will be offered. This involves a blood test for levels of alfa-fetoprotein (AFP), unconjugated oestriol, beta-hCG and inhibin A. In pregnancies with Down Syndrome, AFP and unconjugated oestriol are low and beta-hCG and inhibin A are raised.

Answer 497

a short-term option to rapidly stop heavy menstrual bleeding.

Answer 498

Group B streptococcus is a bacteria which is put of the natural gut flora and can colonise the vagina. About 50% of babies born to women who carry Group B streptococcus will become carriers themselves but less than 1% will be ill themselves. The largest risk factor for a baby developing Group B streptococcus growth is the mother having a previous baby who has grown it - the risk is increased by a factor of 10. High risk women should be treated with intrapartum antibiotics, this reduces the risk of the baby developing Group B streptococcus. There is no need for antibiotics prior to labour. Having a vaginal or rectal swab will not change management as intrapartum antibiotics would still be recommended even if they were negative. Women who have known GBS carrier status prior to this pregnancy, but have not had a baby with a GBS pregnancy there is not a requirement for IV antibiotics during labour unless another risk factor is present. Offer intrapartum antibiotic prophylaxis using intravenous benzylpenicillin to prevent early-onset neonatal infection for women who have had: a previous baby with an invasive group B streptococcal infection group B streptococcal colonisation, bacteriuria or infection in the current pregnancy.

Answer 499

Benzylpenicllin Clindamycin if penallergic

Answer 500

IV benzylpenicillin and gentamicin

Answer 501

Risk factors for Group B Streptococcus (GBS) infection: prematurity prolonged rupture of the membranes previous sibling GBS infection maternal pyrexia e.g. secondary to chorioamnionitis Women found to have GBS infection in the antenatal period should be treated with intravenous antibiotics during labour. This has been shown to reduce early-onset GBS disease in the neonate

Answer 502

Area of skin that stretches from the labie majora laterally to mons pubis anteriorly and the perieneum posteriorly. Overlaps the vestibule, the area between the labia minora and the hymen with surrounds the urethral and vaginal orifices

Answer 503

Squamous epithelium Bladder and urethra Upper third is the pouch of Douglas, lower posterior wall close to the rectum Most occurs via the femoral via the inguinal LNs and to the EIA nodes of the pelvis

Answer 504

Pruritus Soreness Burning Superficial dyspareunia

Answer 505

Infections: Candidiasis (+ vaginal d/c) Vulval warts Pubic lice/scabies Dermatological disease: Any condition esp eczma, psoriasis, lichen simplex, lichen sclerosus, lichen planus, contact dermatitis Neoplasia: Carcinoma Premlaignant disease (vulval intraepithelial neiplasia

Answer 506

AKA chronic vulval dermatitis Chronic inflammatory skin condition Presents with severe intractable pruritus, especially at night Labia majora typically inflamed and thicekend with hyper and hypopigmentation. Symptoms can exacerbated by chemical or contact dermatitis May be exacerbated by chemical or contact dermatitis. Linked to stress/ low Fe stores, Vulval biopsy indicated if biopsy in doubt Irritants such as soap should be avoided Emollionts, moderately potent steroid creams and antihistamines

Answer 507

Affects skin anywhere on the body but particulalry mucosal surfaces Presents with flat, papular purphlish lesions. Can be erosive and more commonly assoicated with pain than pruritus Treatment is with high-potency steroid creams: potent – such as betamethasone dipropionate very potent – such as clobetasol propionate Topical calcineurin inhibitors may be used as second-line therapy Systemic corticosteroids may be used for short periods in severe ongoing disease

Answer 508

Vulval epithelium is thin with loss of collagen. May have autoimmune basis and thyroid disease and vitiligo may coexist. Typically postmenopausal. Causes severe pruritis which may be worse at night. Uncontrollable scratiching may cause trauma. Pink-white papules with coalesce. May cause inflammatory adhesions Vulval carcinoma may develop in 5%. Biopsy important to exclude carcinom. treatment with ultra-potent topical steroids.

Answer 509

Vulvar dysaesthesiia (AKA) Dx of exclusion. No evidence of vulavl disease Can be provoked or spontaneous and subdivided into to site: local or generalised. Hx of UTI, OCP, psychosexual disorders. Topical agents tend to be unhelpful. Oral durgs e.g. amitriptyline or gabapentin used

Answer 510

Burning pain that is more common in older patients

Answer 511

Causes superficial dyspareunia or pain using tampons and is more common in younger women in whom introitus damage must be excluded.

Answer 512

Irritation and soreness of the vulva and anus rather than discharge. topical or oral antifungal therapy may be necessary

Answer 513

Blockage of ducts of the glands behind the labia manora causes cyst formation. Infection may occur with Staphy or E Coli and an abscess forms. Treatment is with incision and drainage and marsupialisation.

Answer 514

Where an incision is sutured open to reduce the risk of re-formation

Answer 515

Commonly follows childbirth. Overtightening, incorrect apposition at perineal repair or extensive scar tissue can cause superficial dyspareuina. If the introitus is too tight, vaginal dilators or surgey can be used

Answer 516

The Fenton’s procedure (also called Fenton's repair) is an operation to remove scar tissue and widen the vaginal opening when a woman experiences persistently painful sexual intercourse. Health problems that may require a Fenton’s procedure include: * Lichen planus of the vulva or vagina * Lichen sclerosus of the vulva * Previous surgery on the genitals that results in painful intercourse * Childbirth tears * Episiotomy complications * Radiotherapy to the genitals

Answer 517

Often mistaken for a prolapse

Answer 518

When columnar epithelium is found in the normally squamous epithelium of the vaginal. Occurs in women whose mothers received diethylstillboestrol in pregnancy Can turn malignant (clear cell carcinoma of the vagina) although often spontaenously resolves. Women with DES exposure in utero undergo annual screening by colposcopy.

Answer 519

Presence of atypical cells in the vulval epithelium Usual: nearly all VIN is usual. Associated with HPV, CIN, smoking and chornic immunosuppression, Nay be mutlifocal and varied aappearaence. Associated with warty or basaloid SCC. Differentiated: associated with lichen sclerosis, seen in older women, usually unfocal, linked to keratinisiing SCC of the vulva. Higher risk of progression to cancer thean for VIN.

Answer 520

Pruritus or pain common: emollients or mild topical steroid may help. Gold standard is local surgical excision for symptomatic relief, to confirm histology and exclude invasive disease. 15% of women undergoing excision have unrecongised invasive disease. Therefore if conservative management is used, adequate biopsies must be taken.

Answer 521

Vulval Intraepithelial Neoplasia

Answer 522

5% of genital tract cancers. Most common \>60y/o

Answer 523

95% are SCC. Melanomas, BCC, adenocarcinomas and others accoutn for the rest.

Answer 524

VIN is premalignant. However it often arises de novo Associated with lichen sclerosis, ummonsuppresion, smoking and paget's disease of the vulva

Answer 525

Extramammary Paget’s disease (EMPD), also extramammary Paget disease, is a rare, slow-growing, usually noninvasive intraepithelial (in the skin)adenocarcinoma outside the mammary gland and includes Paget's disease of the vulva and the extremely rare Paget's disease of the penis

Answer 526

Pruritus Bleeding or d/c Mass Malignancy often presents late due to unnoticed lesions or embarrassment

Answer 527

Ulcer or mass Most commonly on the labia majora or clitoris. Inguinal LNs may be enlarged, hard and nodal

Answer 528

Local and via LN-\> superfiical then deep inguinal nodes-\> femoral-\> EIA. Contralateral spread may occur Staging is surigcal and histological 50% present with Stage 1 disease

Answer 529

Stage 1: a: Tumour confined to vulva/perineum, \<2cm in size with stromal invasion \<1mm. Negative nodes. b: Tumour confined to vulva perineum, \>2cm in size or with stromal invasion \>1mm. negative nodes. Stage 2: tumour of any size with adjacent spread, negative nodes. Stage 3: tumour of any size with positive inguinofemoral nodes. Stage 4: tumours invades upper urethra/vagina/rectum, bladder, bone or distant metastases (IVA vs IVB)

Answer 530

Biopsy Fitenss for surgery: CXR, EXG, FBC, U&E, X match

Answer 531

Stage 1a: wide local excision For other stages: WLE and groin lymphadenectomy through skin-sparing incisions. If the tumours doesn't extende to within 2cm of midline unilateral excision of LNs has emerged. This has replaced the radical vulvectomy. Cxs: wound break down, infection, lymphoaedma, lymphocyst formation and sexual and body image probelms. RTx may be used for large tumours prior to Sx.

Answer 532

Many patients die from other age-related disease Surival at Stage 1: \>90% Stage 3-4: 40%

Answer 533

Common and arises from local infiltration from cervix, endometrium or vulva or from metastatic spread from cervix, endometrium or GI tumours

Answer 534

2% of all genital tract malignancies. Affects oder women and is usually squamous. Presents with bleeding or discharge and a mass or ulcer is evident. Treatment with intravaginal RTx or radical surgery. Survival at 5y: 50%

Answer 535

Most common in the late teenage years. Most are a rare Cx of DES prescription to mother during pregnacies to try to prevent miscarriage in 1950-70. Radical surgery and RTx: good survival

Answer 536

Maternal illness may be worse e.g. varicella Maternal complications: HIV infection implicated in pre-eclampsia Preterm labour Vertical transmission can cause miscarriage, can be teratogenic or damage developed organ or can cause serious infection in child. Neurologic damage is more common in present of bacterial infrection Antibiotic usage may be limited by potential adverse effects on foetus.

Answer 537

Herpesvirus transmitted by personal contact. Up to 1% of women develop CMV infection, usually subclinical in pregnancy. Common cause of handicap and deafness

Answer 538

Vertical transmission occurs in 40% 10% of infected neonates are symptomatic at birth with IUGR, pneumonia and thrombicytopenia. Most of these will develop serious neurological sequelae: hearing, visual and mental impairment or die Asympthomatic neonates are at risk of deafness.

Answer 539

USS abnromalities inconsitently present but include intracranial or hepatic calcification. Most diagnoiesd using CMV testing. CMV IgM remains positive a long time after infection, which could predate pregnancy, titres willl rise and IgG avidity will be low with recent infection. If maternal infection confirmed: amniocentesis \>6w post maternal infection will confirm or refute vertical trnsmission

Answer 540

Most infected neonates are not seriously affected. Close surveillance for USS abnormlities and fetal blood sampling at 32w may help determine those at greatest risk for severe sequelae. No prenatal treatment and termination may be offered. Routine screening not advised.

Answer 541

Responsible for most genital herpes Less than 5% of pregnant women have a history of prior infection but man more have Abs

Answer 542

Not teratogenic. Neonatal infeciton is rare but has a high mortality. Vertical transmission occurs at vaginal delivery, particularly if vesicles are present. More likely to occur in context of recent maternal infection because the fetus will not have maternal Abs (Risk \>40%)

Answer 543

Cliinically and swabs are of little use

Answer 544

Referral to GU clinic C-section for those delivering within 6w of primary attack and those with genital lesions from primary infection at time of infection. Risk is less in recurrent herpes and they can have normal labour. Daily aciclovir in late pregnancy may reduce the frequency of recurrences at term. Exposed neonates are given IV aciclovir.

Answer 545

LP shuld be performed Aciclovir IV until infection excluded

Answer 546

Congenital rublleea is very rare in UK due to immunisation

Answer 547

Maternal infection causes multiple fetal abnromalities including deafness, cardiac disease, eye problems, rmental retardation. Probability and severity decreases with advancing gestation. At 9w the risk is 90% if after 16w risk is very low.

Answer 548

If a non-immune woman develoips Rubella before 16w, TOP offered. Screening routine at booking to identify those in need of vaccination after end of pregnancy. Rubella vaccine is live and thus contraindicated in pregnancy.

Answer 549

Caused by T. gondii Follows contact with cat faeces, soil or eating infected meat. Infection in pregnancy occurs in 0.2% of women in UK but is more common in europe

Answer 550

Fetal infection occurs in \<50% More common as pregnancy progresses. Earlier infection leads to more severe sequelae: mental retardation, convulsions, spasiticities and visual impairment.

Answer 551

USS may show hydrocephalus Maternal infection diagnosed after IgM testing. Flase positives and negatives are common Can be diagnosed or excluded using amniocentesis after 20w.

Answer 552

Health education to reduce risk of toxoplasmosis Spiromycin intiated once maternal infection confirmed. Additional combination therapy may be used following confirmation of vertical transmission although TOP may be requested.

Answer 553

Chickenpox in pregnancy is rare but can cause severe maternal illness

Answer 554

Teratogenicity is a rare consequence of early pregnacny infection (which is immediately treated with oral aciclovir). Maternal infection in the 4w preceding pregnancy may cause severe neonatal infection, this is most common if delivery occurs within 5d or 2d before maternal symptoms

Answer 555

Ig used to prevent and aciclovir to treat infection. Pregnant women exposed are tested to confirm immunity. Ig recommended if they are non-immune Aciclovir if infection occurs. In late pregnancy neonates delivered in the risk period are given Ig. closely monitored and aciclovir if infection occurs.

Answer 556

Asymptomatic bacturia: MSU Chlamydia (\<25y/o) HBV HIV Rubella Syphillis

Answer 557

As they are clinically indistinguishable.

Answer 558

Paracetamol Ibuporfen may be considered but should not be used beyoind 27w gestation.

Answer 559

Infects 0.26% of pregnant women and more during epidemics Slapped cheek is calssic but many have arthralgia or are asymptomatic

Answer 560

Virus suppresses fetal erythropoiesis causing anaemia and variable degrees of thrombocytopenia Fetal death occurs in 10% of pregnancies usually before 20w

Answer 561

Where materanl exposure or syymtpoms have occurred maternal IgM testing will prompt fetal surveillance Anaemia is detectable on USS as increased blood flow velocity in the fetal middle cerebral arteral and subsequently as oedema (fetal hydrops) from fetal heart failure. Maternal testing may also follow identification hydrops Hydrops and anaemia spontaneously resolves in 50%

Answer 562

Mothers infected are regulalry sacanned Where hydrops is detected, in utero transfusion is given is this is severe. Evidence of severe disease being associated with neurological damage

Answer 563

Caused by carriage of Streptococcus agalactiae which is asymptomatic in about 25% of pregnant women

Answer 564

The fetus can be infected during labour after ROM. Most commmon in pre term labour or PROM. Maternal fever Early onset GBS occurs in 1 in 500 neonates. Causes severe illness and has a 6% mortality in term and 18% mortality in preterm. IV benzyl can prevent vertical transmission

Answer 565

Previously affected neonate Positive urinary culture for GBS Preterm labour ROM \>18h Maternal fever in labour Treatment is usual for incidental GBS carriage.

Answer 566

Strategy 1= treatment based on RFs Strategy 2: screening with vaginal and rectal swabs at 35-37w Treat with IV benzlypenicillin in labour if swabs positive or RFs present

Answer 567

Persitent HBV infeciton presint in 1% of pregnant women up to 25% in those from Asia and Africa. Degree of infectivity depends on Ab status. HBsAb are immunologically cured and of low infectivity. Those with surface Ag but not Ab and those with E Ag are more infectious

Answer 568

Vertical transmission occurs at delivery. 90% of infected neonates become chronic carriers compared to 10% of adults

Answer 569

Neonatal immunisation reduces the risk of infection by over 90%. Maternal screening is routine in Offer tenofovir disoproxil to women with HBV DNA greater than 107 IU/ml in the third trimester to reduce the risk of transmission of HBV to the baby UK Advise women that there is no risk of transmitting HBV to their babies through breastfeeding if guidance on hepatitis B immunisation has been followed, and that they may continue antiviral treatment while they are breastfeeding.

Answer 570

Does not hasten progression to AIDS Increased incidence of pre-eclampsia (may be increased by ARTs) Gestational diabetes may be more commmon

Answer 571

Stillbirth, pre-eclampsia, IUGR and prematurity more problem Congenital abnormalities aren't and ARTs not teratogenic NB Folic acid antagonists may be prescribed to HIV infected women. The most important risk is of vertical transmission, beyond 36w, intrapartum or during breastfeedings. 25% of infected neonates develop AIDS by 1y, 40% will develop AIDS by 5y

Answer 572

HIV +ve women should be managed in conjunction with their physician and have regular CD4 and viral load tests. Prophylaxis against PCP if low CD4 Drug toxicity monitored with LFT, RFT, Hb and blood glucose. Ix for genital tract infections. HAART including zidovudine which reduces viraemia and maternal disease and should be continued throughout pregnancy and delivery. Neonate treated for the first 6w. Therapy in women not already taking HAARTs is usally started at 28w. C-section Reduces vertical transmission to \<1%

Answer 573

Traditionally responsible for puerperal sepsis. Most common bacterium associated with maternal death in which sepsis is the leading cause (50%). Caused by strep pyogenes, NB sore throat. Infection during as opposed to after pregnancy is usally from children. Chorioamnionitis. abdo pain, diarrhoea and severe sepsis may ensue. Infected fetus usually dies in utero Early recognition, culture and high dose antibiotics and ITU required in severe cases..

Answer 574

Immunisation recommended Oseltamivir and zanamivir Admit esp if respiratory symptoms

Answer 575

Active disease in pregnacny usually causes miscarriage, severe congenital disease or stillbirth Benzylpenicillin will prevent but not reverse fetal damage. VDRL used for screening/ PCR

Answer 576

Tuberculin testing is safe BCG is live and contraindicated. Dx in late pregnancy is associated with prematurity and IUGR. Treatment with first line drugs and vitamin B6 is safe in pregnancy Streptomycin is contraindicated

Answer 577

Vertical transmission occurs in 6% and is increased by HIV coinfection and high viral load. Infected neonates are prone to chronic hepatitis. C-sec doesn't reduce vertical transmission. Screening restricted to high risk groups

Answer 578

Severe anaemia and other problems are more common

Answer 579

IUGR and stillbirth are more common Congenital malaria complicates 1% of affected pregnancies Artemisin combination therapy appears safe. Intermittent preventative treatment of 2 dosease at least a month apart can prevent maternal and neonatal infection

Answer 580

Gram negative bacillus found in pates, soft cheeses and prepacked meals Causes nonspecific febrile illness. If bacteraemia occurs in pregnancy then a potentially fatal infection of the fetus may occur. Blood cultures Avoidance of high risk food.

Answer 581

Associated with preterm labour and neonatal conjunctivitis.

Answer 582

azithromycin or erythromycin. NB tetracycline causes fetal tooth discolouration

Answer 583

Cephalosporins due to high prevalence of penicllin resistance

Answer 584

Gardnerella vaginalis and mycoplasma hominis Preter, labour and late miscarriage more common Screning and treatment with oral clindamycin reduces the risk of preterm birth.

Answer 585

Voluntary control of urine release achieved by the bladder and urethra Normal function of the filling phase relies upon adequate bladder capacity and competent urethral sphincter. Normal function of the voiding phase is dependant upon detrusor contractility and coordinated urethral relaxation. Bladder has a smooth muscle wall: detrusor muscle Can store around 500mL or urine although first urge to void is at 200mL. Drained by the urethra which is 4cm long and has a muscular wall and external orifice in the vestibule

Answer 586

PNS: aids voiding SNS: prevent Afferent fibres respond to bladder wall distension Effeerent PNS bass back to the detrusor muscle and cause contraction. Efferent SNS fibres also pass to the detrusor and are inhibted. This is the micturition reflex and is controlled at the level of the pons. The cerebral cortex modulates this through relaxation or contraction of the pelvic floor and the striated muscle of the urethra

Answer 587

Prssure in the urethra being greater than in hte bladder. Bladder pressure is influenced by detrusor pressure and intra-abdominal pressure. Urethral pressure is influenced by the inherent urethral muscle tone and by external pressure (pelvic floor and intra-abdominal pressure). The detrusor muscle is expandable, as bladder fills there is no increase in pressure. Increases in abdominal pressure are transmitted equally to the bladder and upper urethra. Therefore coughing does not normally lead to urinary incontinence.

Answer 588

When bladder pressure exceeds urethral pressure. Achieved volunterily by simultaenous drop in urethral pressure (partly due to pelvic floor relaxation) and in bladder pressure due to detrusor contraction.

Answer 589

Uncontrolled increases in detrusor pressure Increased intra-abdominal pressure transmitted to bladder but not urethra Rarer causes include urine bypassing the sphincter through a fistula Or pressure overwhelming the sphincter due to overfilling of thbladder due to neurogenic causes Or outflow obstruction leading to overflow incontiinece

Answer 590

Increased bladder pressure beyond that of the normal urethra due to OAB or urinary urge incontinence (previously called detrusor instability) i

Answer 591

Incontininece, normally as a consequence of the urethral neck slipping from the abdomen. Bladder pressure therefore exceeds urethral pressure when intra-abdominal pressure is raised. This is most commonly caused by urinary stress incontince

Answer 592

Incontinence Daytime frequency Nocturia Nocturnal enuresis Urgency Bladder pain Urethral pain Dysuria Haematuria

Answer 593

The complaint of involuntary urinary leakage wihich can be divided into stress incontinence and urge incontinence.

Answer 594

Number of times a women voids during waking hours Normall 4-7 Increased daytime frequency defined by patients perception

Answer 595

Having to wake at night one or more times to void \<70y/o \>1 per night= abnormal

Answer 596

Urinary incontinence during sleep

Answer 597

Sudden compelling desire to pass urine, which is difficult to deter. Most frequently secondary to detrusor overactivity Inflammatory bladder conditions may also present with this

Answer 598

Supra or retropubic. Pain occurs with bladder filling and is relieved by emptying it. Pain is indicative of an intravesical pathology such as interstitial cystitis or malignancy

Answer 599

Pain felt in the bladder or urethra on passing urine, most frequently associated with UTI

Answer 600

Blood, glucose, protein, leucocytes and nitrites Nitrites suggestive of infection, if +ve MCS Glycosuria suggests diabetes Haematuria suggests bladder carcinoma or calculi

Answer 601

When a patient keeps a record for a week of the time and volume of fluid intake and micturition

Answer 602

Exclude chornic urinary retention

Answer 603

Directly measures via a catheter, the pressure in the bladder while the bladder is filled and provoked with coughing. A pressure transducer also placed in vagina or rectum to measure abdominal pressuor.

Answer 604

Subtraction of the abdominal pressure from the vescile pressure. Should not normally alter with filling or provocation

Answer 605

Urodynamic stress incontinence

Answer 606

Detrusor overactivity

Answer 607

Excludes incomplete bladder emptying. Checks for congenital abnromalities or abnormalities of the kidneys

Answer 608

With the use of contrast the integrity and route of the uretur is examined

Answer 609

BLue dye is instilled into the bladder, leakage from places other than the urether i.e. fistulae can be seen

Answer 610

Complaint of involuntary leakage of urine on effort or exertion, on sneezing or coughing. Once it has been confirmed by urodynamic studies As a result of urethral sphincter weakness, can only be made with certainty after cystometry.

Answer 611

50% Occurs to verying degress in more than 10% of women

Answer 612

Pregnancy and vaginal delivery Esp: prolonged labour, forceps delivery Obestity and age. Prolapse commonly exists but is not always related. Previous hysterectomy (when indication was not for prolapse or urianry symptoms) may predispose to USI

Answer 613

Increase in intra-abdominal pressure, normally the bladder neck is equally compressed and its pressure rises so the P difference remains unchanged. If the bladder neck has slipped below the pelvic floor because its supports are weak it will not be compressed. If the rest of the urethra are unable to compensate the bladder pressure exceeds urethral pressure and incontinence results.

Answer 614

Disruption of patients life Stress incontinence predominantes, may also complain of frequency, urgency or urge incontinence. It is important to have the patient prioritise her symptoms as treatment for USI vs OAB differs. Faecal incontinence may coexist (perineal tear during childbirth)

Answer 615

Sim's speculum, often but not invariable reveals a cystocoele or urethrocoele. Leakage of urine with coughing may be seen. Abdo palpation to exclude bladder distension.

Answer 616

Urine dipstick Bladder diaries Can measure post-void residual volume by bladder scan Try conservative management before: Cystometry is required to exclude overactive bladder is considered or if overactive bladder symptoms fail to respond to medical treatment

Answer 617

Positive for leucocytes and nitrites with symtpoms; send an MSU for MCS and start empirical antibitotics. Symptomatic and negative test for leucoytes or nitrites send an MSU for MCS and consider empirical antibiotics If asymptomatic with postivie L and N, do not offer antibiotics without the results of MSU If asymptomatic and negative for either L or N do not send for MCS as unlikely UTI

Answer 618

Conservative: Modification of fluid intake Lose weight if obese Cause of chronic cough can be reduced e.g. smoking. 1st line Pelvic floor muscle training Medical: [Duloxetine (not routinely used as second line treatment unless woman prefers not to have surgery] 2nd line Sxical: Considered when conservative measures have failed and woman's QoL is being signficantly impact. Need to be clear that USI is the cause Mid-urethral sling using tension free tape and trans-obturator baginal tape are first line with cure rates up to 90% If sx fails, artifical urinary sphincter may be considered.

Answer 619

SNRI that enhances urethral striated sphincter activity Associated with significant and dose-dependant reduction in frequency of incontinence episodes. Can cause nausea, dyspepsia, dry mouth, dizziness, insomnia or drowsiness

Answer 620

Bladder perforation Postoperative voiding difficulty Bleeding Infection de novo detrusor overactivty and suture or mesh erosion

Answer 621

Tension-free vaginal tape: synthetic polypropylene tape placed in a U-shape under the midurethra ander LA or GA, tension adjusted as woman coughs Cystouerthroscopy is performed to ensure there has been no damage to bladder or urethra

Answer 622

Transobturator tape Similar to TVT with different insertion methd (via the transobturator foramen) Reduced risk of bladder perf as retropubic space isn't entered.

Answer 623

Injection of bulking agents for the treatment of USI. Has a low immediate success rate but low morbidity so may be appropriate in patients where surgery has failed or very elderly patients.

Answer 624

Stress incontinence is a symptom USI is a disorder diagnosed only following cystometry

Answer 625

Urgency with or without urge incontinence, usually with frequency or nocturia in the absence of proven infection.

Answer 626

Urodynamic diagnosis characterised by involuntary detrusor contractions during the filling phase which may be spontaenous or provoked by coughing.

Answer 627

causes 35% of female incontinence

Answer 628

Can follow operations for USI in which case it may be caused by bladder neck obstruction. May occasionally occur in hte context of detrusor overactivity occuring the presence of a neuropathy e.g. MS or SC injury

Answer 629

Detrudor contraction normally felt as urgency. If strong enough it causes the bladder pressure to overcome the urethral pressure and the patient leaks= urge incontinence. Can occur spontaneously or with provocation e.g. rise in IAP.

Answer 630

Urgency and urge incontinence Frequency Nocturia Stress incontinence also common Some patients leak at night or at orgasm Hx of childhood enuresis is common Faecal urgency

Answer 631

often normal but an incidental cystocoele may be present

Answer 632

Urine dip Urine diary: frequent passage of small volumes of urine, particularly at night and may show high intake of caffeine containing drinks. After lifetyle changes and trial of Rx, cystometry

Answer 633

Lifestlye changes: Reduce fluid intake, obesity, avoiding caffeine, drugs that alter bladder function such as diuretic and antipsychotics should be reviewed. Conservative: 1st line Bladder training lasting a minimum of 6 weeks Medical: Muscarinic antagonists 2nd line: Oxybutynin or toiterodine or darifenacin, offer durg with lowest acquisition cost 3rd line: oestrogens, mirabegron for symptomatic control Sxical (only after cystometry): Botulinum toxin injection Percutnaeous nerve stimulation Clam augmentation ileocystoplasty is used only for very severe and resistant symptoms, woman has to be willing to self catheterise Urinary diversion (last ditch)

Answer 634

Suppress detrusor overactivity Block muscarinic receptors that mediate detrusor smooth-muscle contraction relaxing the detrusor muscle Dry mouth, dizziness (oxybutynin), constipation, blurred vision, drosiness and dizziness. Have also been known to induce delerium

Answer 635

Many women develop bladder filling symptoms after menopause Improves symptoms of vaginal atrophy. Can reduce symptoms of urgency, urge incontinence, frequency and notcuria

Answer 636

Blocks NMJ transmission causing weakness Injected cystoscopicall into the detrusor muscles with sparing of the trigonium. Lasts 6m on average. Voiding dysfunction and urinary retention

Answer 637

Continuous stimulation of hte S3 nerve root via an electrical pulse generator improves the ability to suppress detrusor contractions

Answer 638

UTI Bladder pathology Pelvic mass Overactive bladder USI

Answer 639

Combination of USI and OAB Dx made at cytometry Most bothersome symptom treated first

Answer 640

Patient unable to pass urine for 12h or more. Catheterisation producing as much or more urine than bladder capacity Painful unless due to epidural anaesthesia or failure of the afferent pathway

Answer 641

Childbirth: epidural, vulval or perineal pain Sx Drugs such as anticholinergics Retroverted gravid uterus Pelvic mass Neurological disease Catheterisation for 48h whilst cause is treated

Answer 642

1% of incontinence Bladder overdistension eventually causes overflow Can be due to urethral obstruction or detrusor inactivity Pelvic masses and incontinence sx are the most common causes of urethral obstruction Autonomic neuropathies e.g. DM or previous overdistension of the bladder can cause detrusor inactivity. Presentation may mimic stress incontinence or loss may be continuous Examination reveals a distended non-tender bladder Dx with USS or catheter after micturition

Answer 643

PBS= suprapubic pain due to bladder filling accompanied by other symptoms e.g. frequency in the absence of UTI Dx of interstital cystitis reserved for pateitns with painful bladder who have characteristic cystoscopic and histological features. Treatments include dietary modificatiion, bladder training, TCAs, analgesics and intravesical drug infusion

Answer 644

Vesicovaginal Urethrovaginal Commonly as a result of obstructed labour in the developing world, in West normally due to Sx, RTx or Ca. Ix with CTU or cystoscopy. Sx often required

Answer 645

1. urethrovaginal 2. vesicovaginal 3. vesicouterine 4. ureterovaginal

Answer 646

Anaemia in pregnancy is defined using different cut off values than in non-pregnant women and varies according to trimester. British Committee for Standards in Haematology (BCSH) guidance gives the following values: first trimester Hb less than 110 g/l second/third trimester Hb less than 105 g/l postpartum Hb less than 100 g/l

Answer 647

Royal College of Obstetricians and Gynaecologists (RCOG) guidelines advise for normocytic or microcytic anaemia a trial of oral iron should be considered as the first step, and further investigations only required if no rise in haemaglobin after 2 weeks. Parenteral iron is only indicated if oral iron is not tolerated, absorbed, patient is not compliant or they are near term and there is insufficient time for oral iron to be effective. Blood transfusion is inappropriate at a slighlty low level of haemoglobin without active bleeding.

Answer 648

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space 1/200 pregnancies

Answer 649

Cause - not known but associated factors: proteinuric hypertension multiparity maternal trauma increasing maternal age

Answer 650

Clinical features 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 Presents with sudden abdominal pain in the third trimester. On examination the mother can be seen to be in extreme pain and cold to touch. Bleeding is present in 80% of cases. Absence of visible bleeding does not rule out this diagnosis. Risk factors include: maternal hypertension (common), cocaine, trauma, uterine overdistension, tobacco and previous placental abruption.

Answer 651

Causative organisms Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Answer 652

Features lower abdominal pain fever deep dyspareunia dysuria and menstrual irregularities may occur vaginal or cervical discharge cervical excitation

Answer 653

screen for Chlamydia and Gonorrhoea

Answer 654

due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ' Removal of the IUD should be considered and may be associated with better short term clinical outcomes'

Answer 655

Complications infertility - the risk may be as high as 10-20% after a single episode chronic pelvic pain ectopic pregnancy

Answer 656

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix

Answer 657

Spontaneous abortion Ectopic pregnancy Hydatidiform mole

Answer 658

Spontaneous abortion Hydatidiform mole Placental abruption

Answer 659

Bloody show Placental abruption Placenta praevia Vasa praevia

Answer 660

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

Answer 661

Vaginal bleeding, no pain. Non-tender uterus\* but lie and presentation may be abnormal \*vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage

Answer 662

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

Answer 663

Failure of oral antiemetics to control symptoms, ketonuria and weight loss (\>5% of pre pregnancy body weight) are all reasons to refer a woman to gynaecology for urgent assessment and intravenous fluids. It is particularly important to keep a low threshold for referral if the woman has a concurrent condition which may be affected by prolonged nausea and vomiting (for example diabetes).

Answer 664

Hyperemesis gravidarum describes excessive vomiting during pregnancy. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks\*. \*and in very rare cases beyond 20 weeks

Answer 665

Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth

Answer 666

antihistamines should be used first-line (BNF suggests promethazine as first-line) ginger and P6 (wrist) acupressure: NICE Clinical Knowledge Summaries suggest these can be tried but there is little evidence of benefit admission may be needed for IV hydration

Answer 667

Oral aciclovir 400 mg TDS (three times daily) until delivery is recommended in the RCOG guidelines for women who present with a primary herpes infection in their third trimester of pregnancy, especially if the woman is expected to deliver within 6 weeks.

Answer 668

IV aciclovir for the mother or for the infant is only recommended if there has been a preterm pre-labour rupture of membranes or a spontaneous vaginal delivery in the presence of a primary herpes infection.

Answer 669

toxoplasmosis, other, rubella, CMV, herpes

Answer 670

It can be difficult to differentiate between a primary infection and a recurrent infection and the guidelines recommend suppressive therapy for both infections after 36 weeks until delivery. Recommended method of delivery in a primary infection is a Caesarean section. For a recurrent infection the risk of transmission is low due to maternal antibodies and a Caesarean section is not recommended.

Answer 671

Management gingivostomatitis: oral aciclovir, chlorhexidine mouthwash cold sores: topical aciclovir although the evidence base for this is modest genital herpes: oral aciclovir. Some patients with frequent exacerbations may benefit from longer term aciclovir

Answer 672

IM ceftriaxone + oral azithromycin The 2011 British Society for Sexual Health and HIV (BASHH) guidelines recommend ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections

Answer 673

The correct answer is Oral metronidazole The 'strawberry cervix' is actually quite rare outside of examinations - some studies suggest only 2% of patients with Trichomonas vaginalis have this finding

Answer 674

Oral metronidazole

Answer 675

Amsel's criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present: thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH \> 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour)

Answer 676

ABC IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms IM carboprost other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Answer 677

occurs between 24 hours - 12 weeks\*\* due to retained placental tissue or endometritis

Answer 678

occurs within 24 hours affects around 5-7% of deliveries most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors

Answer 679

Initiating labour

Answer 680

Tocolytics

Answer 681

Medical abortion

Answer 682

oxytocin / ergometrine is commonly used to encourage smooth muscle contraction in uterine blood vessels, reducing the risk of postpartum haemorrhage.

Answer 683

Independent of contractions May indicate cord compression

Answer 684

Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction Indicates fetal distress e.g. asphyxia or placental insufficiency

Answer 685

Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction Usually an innocuous feature and indicates head compression

Answer 686

Heart rate \< 100 /min Increased fetal vagal tone, maternal beta-blocker use

Answer 687

Heart rate \> 160 /min Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

Answer 688

\< 5 beats / min Prematurity, hypoxia

Answer 689

Primary postpartum haemorrhage is defined as the loss of 500ml or more from the genital tract within 24 hours of the birth of a baby. This can be further defined as minor haemorrhage (500-1000ml) or major haemorrhage (\>1000ml), and causes 6 deaths/million deliveries. Causes can be grouped into the 'four T's': tone tissue (retained placenta) trauma thrombin (coagulation abnormalities)

Answer 690

Vitamin A is teratogenic in high doses, and pregnant women should not exceed a daily intake of \>10,000IU. Women are therefore advised to avoid any supplements containing vitamin A, such as normal multivitamin tablets, in pregnancy (NHS Choices). However, as supplements in the UK are now limited to a maximum vitamin A content of 6,000IU, if they have been taking one it should not be cause for concern. Pregnant women are also advised to avoid eating liver, as it has high levels of vitamin A. Vitamin A is a fat soluble vitamin. Functions converted into retinal, an important visual pigment important in epithelial cell differentiation antioxidant Consequences of vitamin A deficiency night blindness

Answer 691

Side-effects nausea breast tenderness fluid retention and weight gain Potential complications increased risk of breast cancer: increased by the addition of a progestogen increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously increased risk of venous thromboembolism: increased by the addition of a progestogen increased risk of stroke increased risk of ischaemic heart disease if taken more than 10 years after menopause Breast cancer in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer the increased risk relates to duration of use breast cancer incidence is higher in women using combined preparations compared to oestrogen-only preparations the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT

Answer 692

Parity is the number of pregnancies a woman has had which have been carried to a viable age; in the UK this is 24 weeks. The number after '+' is the number of pregnancies which have not been carried to a viable age. It can be thought of the number of fetuses/babies which have come from her, in contrast to gravida which is the number of times the uterus has contained a foetus. For example twins are counted as Gravida 1 Parity 2. Parity also does not increase until the foetus is born but gravida technically increases from conception (though in practice from a woman's first appointments with her doctor).

Answer 693

Potential complications epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome)

Answer 694

Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease(PID) named after the two physicians, Thomas Fitz-Hugh, Jr and Arthur HaleCurtis who first reported this condition in 1934 and 1930 respectively.[1][2][3] It involves liver capsule inflammation[4]leading to the creation of adhesions.

Answer 695

Investigation traditional cell culture is no longer widely used nuclear acid amplification tests (NAATs) are now rapidly emerging as the investigation of choice urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique

Answer 696

Associated factors multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section

Answer 697

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.

Answer 698

A BZD e.g. midazolam

Answer 699

should be given once a decision to deliver has been made in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 700

galactosaemia viral infections - this is controversial with respect to HIV in the developing world. This is because there is such an increased infant mortality and morbidity associated with bottle feeding that some doctors think the benefits outweigh the risk of HIV transmission

Answer 701

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. Between 10% and 25% of women using a POP will discontinue this method within 1 year as a result of these bleeding patterns.

Answer 702

Starting the POP if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21) Taking the POP should be taken at same time everyday, without a pill free break (unlike the COC) Missed pills if \< 3 hours\* late: continue as normal if \> 3 hours\*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours

Answer 703

Other potential problems diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above antibiotics: have no effect on the POP\*\* liver enzyme inducers may reduce effectiveness e.g. rifampicin discussion on STIs

Answer 704

if \< 3 hours\* late: continue as normal if \> 3 hours\*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours

Answer 705

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)

Answer 706

In surgical management of an ectopic pregnancy then Anti-D immunoglobulin should be administered. Anti-D is not required in circumstances where a medical management of the ectopic has been used, nor for treatment of pregnancy of unknown location.

Answer 707

Direct Coombs: Is a investigation used to look for autoimmune haemolytic anaemia, Indirect: Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.

Answer 708

pregnant women are almost 20 times more likely to develop listeriosis compared with the rest of the population due to changes in the immune system fetal/neonatal infection can occur both transplacentally and vertically during child birth complications include miscarriage, premature labour, stillbirth and chorioamnionitis diagnosis can only be made from blood cultures treatment is with amoxicillin

Answer 709

CSF may reveal a pleocytosis, with 'tumbling motility' on wet mounts

Answer 710

IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic uterine perforation: up to 2 per 1000 insertions the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

Answer 711

instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS

Answer 712

Diagnostic laparoscopy

Answer 713

medical: symptomatic management e.g. with combined oral contraceptive pill. GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy uterine artery embolization

Answer 714

Presence and growth of tissue similar to endometrium outside of the uterus 1-2% of women are diagnosed and peak is between 30 and 45. Although prevalence may be 1-20%, asymptomatic

Answer 715

Uterosacral ligaments and on or behind the ovaries Occasionally it affects the umbilicus or abdominal wound scars, vagina, bladder rectum, even lungs Oestrogen dependent, regresses after menopause and during pregnancy. Acucumulated altered blood is dark brown and can form a chocolate cyst (endometrioma) in the ovarias. Can cause inflammation with progressive fibrosis and adhesions, in the most severe form the entire pelvis is frozen due to adhesion

Answer 716

Retrograde menstruation More distant foci may be through mechanical, lymphatic or blood-borne spread. Degree of inherited predisposition NB poor symptomatic correlation with extent of disease

Answer 717

May be asymptomatic Causes chronic pelvic pain, usually cyclical Dysmeorrhoea before the onset of mensturation Dyspareunia Subfertility Dyschezia Menstrual probloms Rupture of chocolate cyst: acute pain, may be first symptom Cyclical haematuria, rectal bleeding or bleeding from the umbilicus are uncommon and suggestive of severe disease

Answer 718

VE@ tenderness and or thickening behind the uterus or in the adnexa In severe cases the uterus may be retroverted and immobile A rectovaginal nodule of enodmetriosis may be apparent on digital examination or visible on speculm. With mild endometriosis the pelvis feels normal

Answer 719

Laparoscopy with visualisation and biopsy active lesions are red or punctate marks White scars or brown spots represent less active endometriosis TVU may be useful to dx/exclude endometriomas and may also suggest the presence of adenomyosis although MRI is a better investigation for this. If theere is clinical evidence of deeply infiltrating endometriosis extent of involvement can be examined with MRI, Intravenous pyelogram and barium studies CA125 may be raised but of little diagnostic merit

Answer 720

Symptoms after severeal years of painless periods Pelvic examinatoin likely to be normal Pelvis USS likely to be normal

Answer 721

Asymptomatic do not require treatment although nb in the low risk of missing ovarian ca Symptomatic relief: Pain: offer NSAID e.g. ibuprofen naproxen or mefenamic acid. Paracetamol if NSAIDs CIed. Rx (NB should be in women who do not wish to conceive): Trial hormonal treatment: COCP (not suitable for older women or smokers) Progestogen preparations: denogestrel or IUS cyclical or continuous. Side effects may be severe. GnRH analgoues: induce temprorary menopausal state so side effects mimic the menopause although add back HRT can minimise these If woman does not want hormonal contraception offer an oral progestogen e.g. medroxyprogesterone Sxical: diathermy ec can be used at laparascopy using see and treat approach. (This may improve conception rates) BSO

Answer 722

Ovarian endometrioma

Answer 723

Will need HRT However if endometriosis remains then there is risk of malignant change in ectopic endometrium Consideration should be given to providing a combined preparation

Answer 724

Found in 25% of diagnostic laps for subfertility.

Answer 725

Intermittent or constant pain in the lower abdomen or pelvis with \>6m duration not occuring exclusively with mesntruation or intercourse Can present in primay care as migraine, low back pain and affects 15% of adult women

Answer 726

Exclude pathological causes Through TVU, MRI or lap as appropriate

Answer 727

Varies over menstrual cycle: endometriosis, adenomyosis (oestrogen important as condition not typically seen in postmenopausal and suppression of ovarian activity cures 2/3rds). Adhesions: ovarian tissue can become trapped followiing Sx and cause cyclical pain IBS Interstitial cystitis. Psychological factors.

Answer 728

Depends on cause ?IBS: antispasmodics, analgesia Cyclical pain: therapeutic trial using COCP or GnRH analogue with add back HRT for 3-6m before laparscipy. IUS

Answer 729

Whether symptomatic or asymptomatic it is important to treat urinary tract infections in pregnancy to prevent progression to pyelonephritis. As trimethoprim is a folate antagonist it should be avoided in the first trimester - this is the time when the neural tube forms and there is a risk of teratogenicity. The other antibiotics listed are not contraindicated in the first trimester. However, erythromycin is not typically used to treat urinary tract infections, and nitrofurantoin should be avoided close to full term as there is a risk of causing neonatal haemolysis. Sulfonamides and quinolones should also be avoided in pregnancy. (BNF 5.1.13)

Answer 730

Describes a spectrum of disorders originating from the placental trophoblast: complete hydatidiform mole partial hydatidiform mole choriocarcinoma

Answer 731

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

Answer 732

Features bleeding in first or early second trimester exaggerated symptoms of pregnancy e.g. hyperemesis uterus large for dates very high serum levels of human chorionic gonadotropin (hCG) hypertension and hyperthyroidism\* may be seen \*hCG can mimic thyroid-stimulating hormone (TSH)

Answer 733

Management urgent referral to specialist centre - evacuation of the uterus is performed effective contraception is recommended to avoid pregnancy in the next 12 months Around 2-3% go on to develop choriocarcinoma

Answer 734

n a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

Answer 735

First stage is broken into two stages: Latent: Time taken for the cervix to completely efface and dilate to 3cm Active: From 3cm to 10cm

Answer 736

Second stage is from 10cm to delivery of the baby 2 hours is the maximum recommended in multiparous women 3 hours is the maximum recommended in nulliparous women Remember, in the context of an epidural, 1 hour of passive second stage (without pushing) is advised

Answer 737

Third stage is from delivery of the baby to delivery of the placenta and membranes Third stage is from delivery of the baby to delivery of the placenta and membranes Active: Uses uterotonics, clamping of the cord and controlled cord traction Meds include syntocinon and ergometrine: syntometrine, or oxytocin They are generally given as the anterior shoulder is born Physiological: The cord is only clamped when pulseless in the absence of medications and the placenta delivered through maternal efforts alone Should be converted to active management if placenta not delivered in 1hr

Answer 738

Active: Uses uterotonics, clamping of the cord and controlled cord traction Meds include syntocinon and ergometrine: syntometrine, or oxytocin They are generally given as the anterior shoulder is born

Answer 739

Labour may be defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part Signs of labour include regular and painful uterine contractions a show (shedding of mucous plug) rupture of the membranes (not always) shortening and dilation of the cervix

Answer 740

Implanon was a non-biodegradable subdermal contraceptive implant which has been replaced by Nexplanon. From a pharmacological perspective Nexplanon is the same as Implanon. The two main differences are: the applicator has been redesigned to try and prevent 'deep' insertions (i.e. subcutaneous/intramuscular) it is radiopaque and therefore easier to locate if impalpable Contraindications UKMEC 3\*: ischaemic heart disease/stroke (for continuation, if initiation then UKMEC 2), unexplained, suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer, positive antiphospholipid antibodies\*\* UKMEC 4\*\*: current breast cancer . \*proven risks generally outweigh the advantages \*\*there is some contradiction in the guidance issued by the FSRH but their most recent document (revised 2010) lists positive antiphospholipid antibodies as UKMEC 3 \*\*\*a condition which represents an unacceptable risk if the contraceptive method is used

Answer 741

Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions. It occurs in around 1% of women Causes antiphospholipid syndrome endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome uterine abnormality: e.g. uterine septum parental chromosomal abnormalities smoking

Answer 742

Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of monochorionic twin pregnancies. The two fetuses share a single placenta, meaning that blood can flow between the twins. In TTTS, one fetus, the 'donor' receives a lesser share of the placenta's blood flow than the other twin, the 'recipient'. This is due to abnormalities in the network of placental blood vessels. The recipient may become fluid-overloaded whilst the donor can become anaemic. One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems. In severe cases, TTTS can be fatal for one or both fetuses. TTTS usually occurs in early or mid-pregnancy, thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition. After 24 weeks the main purpose of ultrasound examinations is to detect fetal growth restriction.

Answer 743

The incidence of multiple pregnancies is as follows twins: 1/105 triplets: 1/10,000 Twins may be dizygotic (non-identical, develop from two separate ova that were fertilized at the same time) or monozygotic (identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic

Answer 744

Monoamniotic monozygotic twins are associated with: increased spontaneous miscarriage, perinatal mortality rate increased malformations, IUGR, prematurity twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)

Answer 745

previous twins family history increasing maternal age multigravida induced ovulation and in-vitro fertilisation race e.g. Afro-Caribbean

Answer 746

Antenatal complications polyhydramnios pregnancy induced hypertension anaemia antepartum haemorrhage Fetal complications - perinatal mortality (twins \* 5, triplets \* 10) prematurity (mean twins = 37 weeks, triplets = 33) light-for date babies malformation (\*3, especially monozygotic) Labour complications PPH increased (\*2) malpresentation cord prolapse, entanglement

Answer 747

Management rest ultrasound for diagnosis + monthly checks additional iron + folate more antenatal care (e.g. weekly \> 30 weeks) precautions at labour (e.g. 2 obstetricians present) 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks

Answer 748

Infertility weight reduction if appropriate the management of infertility in patients with PCOS should be supervised by a specialist. There is an ongoing debate as to whether metformin, clomifene or a combination should be used to stimulate ovulation a 2007 trial published in the New England Journal of Medicine suggested clomifene was the most effective treatment. There is a potential risk of multiple pregnancies with anti-oestrogen\* therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence metformin is not a first line treatment of choice in the management of PCOS metformin is also used, either combined with clomifene or alone, particularly in patients who are obese gonadotrophins

Answer 749

General weight reduction if appropriate if a women requires contraception then a combined oral contraceptive (COC) pill may help regulate her cycle and induce a monthly bleed (see below) Hirsutism and acne a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism if doesn't respond to COC then topical eflornithine may be tried spironolactone, flutamide and finasteride may be used under specialist supervision

Answer 750

Topical podophyllum or cryotherapy are first choice Imiquimod is ssecond line

Answer 751

The menopause is a retrospective diagnosis and is said to occurred 12 months after the last menstrual period. Women who menopause under the age of 50 require contraception for at least 2 years after their last menstrual period. Those over the age of 50 require only 1 year of contraception. In view of this, it would be inappropriate to say this lady does not require any contraception because she is protected. Similarly prescribing the COCP for only 12 months would be equally inappropriate. The fact that she is also a smoker would mean that the risks outweigh the benefits of the COCP as she is over the age of 35. Hormone replacement therapy should not be used solely as a form of contraception and barrier methods are less effective than the other types of contraception listed thus the most appropriate answer is the IUS. This will take the patient through the menopause and can be used for 7 years (off-licence) or 2 years after her last menstrual period.

Answer 752

Take folic acid 5mg per day before pregnancy (Risk of congenital defects in non-epileptic mothers 1-2%, in mothers taking antiepileptic medication rises to 3-4%)

Answer 753

The November 2013 issue of the Drug Safety Update also carried a warning about new evidence showing a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate. The update concludes that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.

Answer 754

Management antihistamines should be used first-line (BNF suggests promethazine as first-line) ginger and P6 (wrist) acupressure: NICE Clinical Knowledge Summaries suggest these can be tried but there is little evidence of benefit admission may be needed for IV hydration

Answer 755

Causes no identifiable pathology is found in around 50% of cases cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill cervicitis e.g. secondary to Chlamydia cervical cancer polyps trauma

Answer 756

Rhesus negative woman - anti-D at 28 + 34 weeks NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks

Answer 757

Maternal complications polyhydramnios - 25%, possibly due to fetal polyuria preterm labour - 15%, associated with polyhydramnios Neonatal complications macrosomia (although diabetes may also cause small for gestational age babies) hypoglycaemia (secondary to beta cell hyperplasia) respiratory distress syndrome: surfactant production is delayed polycythaemia: therefore more neonatal jaundice malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy) stillbirth hypomagnesaemia hypocalcaemia shoulder dystocia (may cause Erb's palsy)

Answer 758

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. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Answer 759

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above severe hypertension 160/110 mmHg or above oxytocin use the presence of significant meconium fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014 Fresh vaginal bleeds developing in labour could be a sign of placental rupture (the most common cause of antepartum haemorrhage) or placental praevia (second most common cause of antepartum haemorrhage) and therefore monitoring of the baby is required.

Answer 760

This scenario is classed as a major post partum haemorrhage (PPH) due to an estimated blood loss of greater than 1000 mls. An ABCD approach should be instituted with prompt senior involvement. As this is a major PPH, group and save is inappropriate. Tranexamic acid is an antifibrinolytic which may be used in vaginal bleeding secondary to heavy menstrual bleeding, but has no role in PPH. The causes of PPH can be divided into four T's (uterine Tone, Tissue, Trauma and Thrombin). In uterine atony bimanual uterine compression should be trialed first and a Foley catheter passed to ensure an empty bladder. Uterine balloon tamponade is a suitable first line surgical management, but pharmacological measures should be trialled first. These include a bolus of intravenous syntocinon (repeated if necessary), followed by ergometrine, syntocinon infusion and carboprost in turn. A fluid challenge should be instituted in the first instance while blood products are awaited. The RCOG state that up to 3.5L of warmed crystalloid can be infused at an appropriate rate while waiting for blood products.

Answer 761

If 1 pill is missed (at any time in the cycle) take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day no additional contraceptive protection needed If 2 or more pills missed take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH:'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed' if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception\* if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 762

1 - no restrictions on the use of contraceptive method 2 - advantages of contraceptive method generally outweigh the theoretical and proven risks 3 - theoretical and proven risks generally outweigh the advantages of the contraceptive method, can still be given based on expert clinical judgement 4 - condition that poses unacceptable risk if the contraceptive method is used

Answer 763

Migraine with aura Breastfeeding \<6 weeks post-partum Age 35 or over smoking 15 or more cigarettes/day Systolic 160mmHg or diastolic 95mmHg Vascular disease History of VTE Current VTE (on anticoagulants) Major surgery with prolonged immobilisation Known thrombogenic mutations Current and history of ischaemic heart disease Stroke (including TIA) Complicated valvular and congenital heart disease Current breast cancer Nephropathy/retinopathy/neuropathy Other vascular disease Severe (decompensated) cirrhosis Hepatocellular adenoma Hepatoma Raynaud's disease with lupus anticoagulant Positive antiphospholipid antibodies

Answer 764

Unopposed oestrogen increases the risk of endometrial cancer and remains elevated for 5 or more years after stopping therapy The risk is not eliminated completely with additional sequential progestogen No increased risk has been found with continuous combined HRT Risk of ovarian cancer is higher the longer HRT is taken. But when the HRT is stopped, the risk goes back down to normal over a few years Venous thromboembolism risk is more than doubled with HRT but absolute risk remains small Risk of breast cancer is increased as it simulated delaying menopause. Every year the menopause is naturally delayed, the risk increases by 2.8% With HRT the risk is increased by 2.3% by year The risk of gallbladder disease is increased in women taking HRT - though this risk may be reduced with transdermal administration

Answer 765

Management ## Footnote ciprofloxacin used to be the treatment of choice. However, there is increased resistance to ciprofloxacin and therefore cephalosporins are now used the 2011 British Society for Sexual Health and HIV (BASHH) guidelines recommend ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections if ceftriaxone is refused or contraindicated other options include cefixime 400mg PO (single dose)

Answer 766

Gonorrhoea

Answer 767

Disseminated gonococcal infection (DGI) and gonococcal arthritis may also occur, with gonococcal infection being the most common cause of septic arthritis in young adults. The pathophysiology of DGI is not fully understood but is thought to be due to haematogenous spread from mucosal infection (e.g. Asymptomatic genital infection). Initially there may be a classic triad of symptoms: tenosynovitis, migratory polyarthritis and dermatitis. Later complications include septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)

Answer 768

Key features of disseminated gonococcal infection tenosynovitis migratory polyarthritis dermatitis (lesions can be maculopapular or vesicular)

Answer 769

Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

Answer 770

The measurement of the symphysis-fundal height in centimetres should closely match the foetal gestational age in weeks within 1 or 2 cm from 20 weeks gestation Anything less= small for dates Anything more= polyhydramnios

Answer 771

Inhibits ovulation The Faculty for Sexual and Reproductive Health (FSRH) state Progestogen-only injectable contraception works primarily by inhibiting ovulation.

Answer 772

The Faculty for Sexual and Reproductive Health (FSRH) state All POPs alter cervical mucus to prevent sperm penetration into the upper reproductive tract. In addition, traditional POPs inhibit ovulation but this can be variable.

Answer 773

The Faculty for Sexual and Reproductive Health (FSRH) state Most of the contraceptive effect of the LNG-IUS is mediated via its progestogenic effect on the endometrium which prevents implantation.

Answer 774

Post-partum haemorrhage should be managed with an ABC approach. This lady is symptomatic and hypotensive. It would be most appropriate to commence a fluid challenge in the first instance whilst awaiting help from your registrar. A blue cannula (22G) however will only provide a flow rate of 31 mL/minute. Insertion of a large bore cannula is thus the priority in this lady who is actively bleeding. A vaginal examination may also prove useful, as you may find that there are retained products of conception in the cervix causing a vasovagal reaction leading to hypotension. However, your registrar would be able to provide you with assistance to perform that after you have begun fluid resuscitation.

Answer 775

Blue 22G (very small - for difficult hand veins) Pink 20G (small - suitable for the majority of patients that require IV fluids) Green 18G (average sized - suitable for IV fluids and smaller blood transfusions) Grey 16G (large - for use in large blood transfusions and emergency use) Brown 14G (very large and painful - again, for emergency use)

Answer 776

This patient has a confirmed ectopic pregnancy. There is no evidence the pregnancy has ruptured but definitive treatment is still the safest course. Expectant management of ectopics may be an option in those without acute symptoms and declining beta-HCG levels. Close monitoring is essential and intervention is advised if symptoms manifest or beta-HCG levels begin to rise. The presence of a fetal heart beat makes both conservative and medical management unlikely to be successful and also risky in terms of rupture, which would be a medical emergency. Surgical removal of the ectopic is the most appropriate option here. If the contralateral tube is healthy then salpingectomy may be the best option. However, if the contralateral tube is damaged, salpingotomy preserves the functional tube and helps minimise the risk of future infertility.

Answer 777

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 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

Answer 778

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

Answer 779

The first step in the investigation of possible endometrial cancer is to preform a trans-vaginal ultrasound scan to measure the endometrial thickness. Different hospitals have different cut-offs for endometrial thickness and further investigation. If the endometrial lining is thickened then a hysteroscopy will be preformed and an endometrial biopsy taken. Treatment for endometrial cancer is usually laparoscopic hysterectomy with bilateral salpingo-oophorectomy, with or without radiotherapy.

Answer 780

The RCOG has produced guidelines suggesting the following classification of perineal tears: first degree: superficial damage with no muscle involvement second degree: injury to the perineal muscle, but not involving the anal sphincter third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS): 3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Answer 781

Previous STI \>35y/o Previous pelvic Sx Abnormal genital examination Amenorrhoea

Answer 782

Previous Sx on genitali Varicocele Significant systemic illness Abnormal genital examination Previous STI

Answer 783

Management benzylpenicillin alternatives: doxycycline the Jarisch-Herxheimer reaction is sometimes seen following treatment. Fever, rash, tachycardia after first dose of antibiotic. It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment. The 2008 British Association for Sexual Health and HIV (BASHH) guidelines recommend IM benzathine penicillin G in this scenario. Doxycycline should not be used in pregnancy. Immunoglobulins are used to provide protection against viral illnesses such as rubella.

Answer 784

RCOG guidelines clearly state that the definitive diagnosis of placenta praevia is through ultrasound scan imaging. There is no screening programme for placenta praevia , however the UK National screening committee supports local practices which during the routine 20 week scan, comment and look for evidence of the placenta covering the cervical os. Transvaginal ultrasound scans be safely performed at 20 weeks, in addition to the abdominal ultrasound scan to help improve the accuracy of localisation and RCOG guidelines state that they should be used to confirm the diagnosis of placenta praevia

Answer 785

1: Correct, 75% of patients present with stage 1 disease, which is generally treated with a hysterectomy and bilateral salpingo-oophorectomy. 2: Endometrial biopsy is required for diagnosis. 3: Radiotherapy is used more often than chemotherapy, particularly in treating high-risk patients post-hysterectomy or in pelvic recurrence. 4. Routine lymphadenectomy is not usually beneficial. 5. Progestogens are now seldom used in treatment.

Answer 786

1: Correct. 2: Delivery is possible in the OP position, however labour is likely to be longer and more painful. 3: Augmentation should be used if progress is slow. 4: Kielland's forceps are associated with the most successful outcomes, however require particular expertise. 5: Generally, women will experience an earlier urge to push in OP than OA.

Answer 787

This question concerns complications that may arise during IVF. The most unlikely answer is hyperemesis gravidarum as the patient is not currently pregnant. Given the patient's reason for IVF (tubal disease) - PID may seem like a reasonable answer however it would be likely that this patient would have already been screened for this disease prior to the commencement of IVF and have been appropriately treated. A ruptured cyst would present with a much more acute picture of pain and systemic signs/symptoms. Obstruction may be on a list of differentials considering the patient's past medical history however in the scenario this patient's Crohn's is well-controlled and the patient would present with central colicky pain and bile-stained vomiting. Thus in this scenario ovarian hyperstimulation syndrome is a much more likely diagnosis. This is associated typically with the use of human chorionic gonadotrophin (HCG) in the maturation of follicles during IVF. It presents with lower abdominal discomfort, nausea, vomiting and abdominal distension. Patients may also develop ascites, hypotension and in serious cases acute respiratory distress syndrome and venous thromboembolism. Patients are treated with fluid replacement and thromboprophylaxis. Note: The actual effect on azathioprine during pregnancy is not fully known - the BNF suggests there are some reports of an association between low birth weight and premature births and exposure to the drug however most physicians would advise women with Crohn's disease that are on maintenance treatment with azathioprine to continue taking this drug as the risk of harm from a flare up of Crohn's disease outweighs the risk of harm of taking this medicine.

Answer 788

Cx seen in some forms of infertility treatment, presence of high levels of luteinized cysts within the ovaries results in high levels of oestrogens and progesterone and also VEGF which leads to increased membrane permeability and loss of fluid from the intravascular compartment. More likely to be seen following gonadotrophin or hCG treatment, more rare in clomifene therapy

Answer 789

Mild: Abdo pain, bloating Moderate: Mild+ N+V, USS evidence of ascites Severe: Moderate + clinical evidence of ascites, oliguria, HCt \>45% hypoproteinaemia. Crticial: Severe + thromboembolism, ARDS, anuria, tense ascites

Answer 790

An NSAID not recommended in pregnancy

Answer 791

Plasminogen activator inhibtor that acts as an antifibrinolytic to prevent heavy menstrual bleeding. Used when a patient wishes to conceive and there is no dysmenorrhoea

Answer 792

Myomectomy is the only treatment option here that will also retain this lady's fertility. Depending on the operation performed, and whether the uterine cavity was entered, the lady would need counselling in regards to delivery, since often a caesarean section is advised due to risk of uterine rupture. GnRH agonists effectively turn off the ovaries, which causes the fibroids to shrink and therefore are easier to remove surgically. On stopping the medication, the fibroids grow back. As this treatment turns off the ovaries, it inhibits ovulation and therefore means that pregnancy is not possible during this time. As a treatment on its own, it would not be suitable in this case as it causes temporary infertility and fibroid regrowth on cessation. However, if combined with a myomectomy, it would provide a suitable treatment option. Endometrial ablation destroys the endometrial lining, therefore meaning that an embryo would not be able to implant. Uterine artery embolisation is not recommended if trying to conceive as it cuts down the blood supply to the uterus significantly, therefore meaning that the fetus would be unable to implant and grow. Ulipristal acetate is a selective progesterone receptor modulator. It is used pre-operatively for women with fibroids as it has been proven to shrink them, thus making surgery easier. This medication affects fertility, thus is not suitable for women trying to get pregnant, unless (like GnRH agonists) it is used for a short period in combination with surgery.

Answer 793

To prevent compression of the IVC reducing venous return to the hear

Answer 794

ECG and CXR in all patients If CXR normal, compression duplex doppler. CXR normal-\> V/Q CXR abnormal-\> CTPA NB d-dimer is usually raised in first trimester of pregnancy and is thus not useful.

Answer 795

CTPA slightly increases the lifetime risk of maternal breast cancer(increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation

Answer 796

V/Q scanning carries a slightly increased risk of childhood cancercompared with CTPA (1/280,000 versus less than 1/1,000,000)

Answer 797

Used to determine provision of COCP to children under 16y the young person understands the professional's advice the young person cannot be persuaded to inform their parents the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent

Answer 798

Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children.

Answer 799

The National Institute for Health and Care Excellence recommends that for women without previous history of severe depression, the first line treatment for moderate to severe depression in pregnancy or the post-natal period should be a high intensity psychological intervention (such as CBT). If this is refused, or symptoms do not improve, then an antidepressant should be used. NICE suggests a selective serotonin re-uptake inhibitor (SSRI) or tricyclic antidepressant (TCA). Mindfulness may be useful for women with persistent subclinical depressive symptoms. You would only need to involve social services if you felt that someone in the household may be at risk. According to the British National Formulary (BNF) zopiclone should be avoided whilst breast feeding as it is present in breast milk

Answer 800

Occurs in the last 4 weeks of pregnancy Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.

Answer 801

Braxton Hicks contractions, also known asprodromal labor or practice contractions, or false labor, are sporadic uterine contractions that sometimes start around six weeks into a pregnancy. However, they are not usually felt until the second trimester orthird trimester of pregnancy. [1]

Answer 802

This is a case of cord prolapse, which occurs after membrane rupture when the umbilical cord descends below the presenting part of the fetus. It can lead to fetal hypoxia and death due to the cord being compressed or going into spasm. 1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery 2: Correct, to avoid compression 3: The patient is advised to go onto all fours 4: The cord should not be pushed back into the uterus 5: Immediate Caesarean section is the delivery method of choice

Answer 803

RR \>60 Grunting HR \<100 \>160 CRT \>3 T \>38 or 37.5 on 2 occasions 30 minutes apart SaO2 \<95 Central cyanosis

Answer 804

Reversal of a left to right shunt in a congenital heart defect due to pulmonary hypertension which has occurred as a result of remodelling of pulmonary microvasculature? VSD, ASD, PDA Original murmur may disappear Cyanosis Clubbing RV failure Haemoptysis, embolism Heart-lung transplant required

Answer 805

Eisenmenger's syndrome is the correct answer as it has a maternal mortality ranging from 30% to 50%, with a 50% risk of foetal loss if the mother survives. It occurs when a long standing left to right shunt reverses; not only are mother and baby at risk of hypoxaemia but also of thromboembolic events. Isolated VSDs are well tolerated during pregnancy, provided it is not associated with pulmonary hypertension or eisenmenger's, and so considered a low-risk lesion PDA during pregnancy is not associated with additional maternal risk, provided the shunt is small to moderate and the pulmonary artery pressures are normal. Percutaneous closure is now considered first-line therapy, and it is reasonable to close even asymptomatic small PDAs. Following repair of more significant PDAs, women are at no additional risk for complications during pregnancy. Coarctation is well tolerated during pregnancy, although hypertension, heart failure, angina, and aortic dissection are possible complications. Coarctation can be associated with intracerebral aneurysms, which may rupture during pregnancy. It is therefore considered to be a moderate-risk lesion, even when repaired. In chronic mitral regurgitation, the physiologic reduction in SVR partially compensates for the additional volume overload generated by the regurgitant valve. Should heart failure occur, it can be treated safely with nitrates, hydralazine and dihydropyridine calcium channel-blocking agents. It is considered a low risk lesion, especially after repair.

Answer 806

a nicotinic receptor partial agonist has been shown in studies to be more effective than bupropion nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline contraindicated in pregnancy and breast feeding

Answer 807

a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist should be started 1 to 2 weeks before the patients target date to stop small risk of seizures (1 in 1,000) contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication

Answer 808

Pregnant women NICE recommended in 2010 that all pregnant women should be tested for smoking using carbon monoxide detectors, partly because 'some women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.'. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services. Interventions the first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing or structured self-help and support from NHS Stop Smoking Services the evidence for the use of NRT in pregnancy is mixed but it is often used if the above measures failure. There is no evidence that it affects the child's birthweight. Pregnant women should remove the patches before going to bed as mentioned above, varenicline and bupropion are contraindicated

Answer 809

Uterine atony is the most common cause of primary postpartum haemorrhage. It entails failure of the uterus to contract fully following the delivery of the placenta, which hinders the achievement of haemostasis. Uterine atony is associated with overdistension, which may be due to multiple gestation, macrosomia, polyhydramnios or other causes. In addition to the usual steps taken in an episode of PPH (including an ABC approach if the patient is unstable), the following management should be initiated in sequence: bimanual uterine compression to manually stimulate contraction intravenous oxytocin and/or ergometrine intramuscular carboprost intramyometrial carboprost rectal misoprostol surgical intervention such as balloon tamponade

Answer 810

ABC Bimanual uterine compression IV oxytocin and or ergometrine IM carboprost Intramyometrial carboprost Rectal misoprostol Balloon Tamponade In sequence

Answer 811

Low alpha fetoprotein (AFP) Low oestriol High human chorionic gonadotrophin beta-subunit (-HCG) Low pregnancy-associated plasma protein A (PAPP-A) Thickened nuchal translucency

Answer 812

If serum CA 125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis If the ultrasound suggests ovarian cancer, refer the woman urgently. For any woman who has normal serum CA125 (less than 35 IU/ml), or CA125 of 35 IU/ml or greater but a normal ultrasound: clinicians should assess her carefully for other clinical causes of her symptoms and investigate if appropriate. If no other clinical cause is apparent, they should advise her to return to her GP if her symptoms become more frequent and/or persistent. Referral to the gynaecology clinic is not warranted at this time. While bladder retraining is a treatment option for overactive bladder syndrome; it is not the most appropriate approach to dealing with this patient's symptoms. From above we can see that referral for an ultrasound would be necessary if CA 125 was raised to sufficient levels but this is not the case. Re-testing CA 125 would also be of no value at this time. In this case, a thorough assessment for alternative causes of this patient's symptoms is the best form of action at this stage.

Answer 813

UKMEC 3: the COCP and POP UKMEC 2: implant UKMEC 1: Depo-Provera, IUD, IUS

Answer 814

UKMEC 3: the COCP UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

Answer 815

24-37w Most important before 34w as neonatal risks are greater.

Answer 816

Can be as a result of spontaneous labour or can be iatrogenic (obstetric induction due to maternal/fetal risks)

Answer 817

Accounts for 80% of NICE occupancy 20% of perinatal mortality 50% of cerebal palsy Chronic lung ndisease Blindness Minor disability Earlier the gestation the greater the risk to the fetus

Answer 818

24w: 1/3rd of neonates die, 1/3tf handicapped by 32w both of these risks are less than 5%

Answer 819

Infection Endometritis post natally

Answer 820

Previous Hx Socioeconomic class Maternal age Short inter-pregnancy interval Maternal medical disease e.g. renal failure, DM, thyroid disease Preganancy complications: pre-eclampsia, IUGR, male fetus Raised Hb STIs BV Previous cervical Sx Multiple pregnancy Uterine abnormalities and fibroids UTI Polyhydramnios Congenital fetal abnromalities APH

Answer 821

Too many defenders: Multiple pregnancy, excess liquor. Probably largely mediated by increased stretch Defenders jumpm out: Fetal surivavl response: pre-eclampsia, IUGR, infection, placental abruption Poor castle design: Uterine abnormalities Cerbical incompetence Enemy knock down walls: Infection, may be subclinical, BV, GBS, Trichomonmas and Chlamydia Poor dental health

Answer 822

Those with risk factors Previous Hx of late miscarriage or prteterm labour Often not identified on history alone

Answer 823

TVS: cervical length is both sensitive and specific

Answer 824

Limited to women at high risk, strategies should begin by 12w Cervix: cervical cerclage either vaginally or abdominally. Prepregnancy and laparoscopy. Progesterone supplementation: low risk women with short cervix on USS may benefit Infection: screening and treatment of UTIs and BV Fetal reduction: higher order multiple reduction at 10-14w Polyhydramnios: needle aspiration (amnioreduction) or if fetal surveillance is intesive NSAIDs which reduce fetal urine output and cause premature closure of fetal PDA Treatment of medical disease e.g. thyroid disease

Answer 825

Elective., 12-14w Scanned regulalry and used if significant shortening Rescue

Answer 826

Increases risk of preterm labour

Answer 827

Painful contractions (stop spontaneously in 50%) and labour will not continue until term Painless cervical dilatation may occur in cervical incompetence or the woman may experience a dull suprapubic ache APH and fluid loss common Fever Lie and presentation checked with palpation DVE is performed unless membranes have ruptured. Effaced or dilating cervix confirms dx but the course of preterum labour is unpredictable

Answer 828

CTG + USS to assess fetal state Fetal fibronectin can be useful. Negative= unlkely delivery. TVS may be used \>15mm means delivery unlikely To look for infection: vaginal swabs, maternal CRP, WCC NB steroids

Answer 829

Occurs when the mother mounts an immune response against antigens on fetal RBCs that enter her circulation. Resulting Abs then cross the placenta and cause fetal RBC destruction

Answer 830

ABO and rhesus genotype Rhesus system consists of 3 linked gene pairs. Aone allele of each pair is dominant to the other. C, D, E. An individual inherits one allele of each pair from each parent in Mendelian fashion D is most significant. Dd/DD express the D antigent and are D rhesus positive. dd= Rhesus negative and will recognise the D antigen as foreign if they are exposed to it

Answer 831

Small amounts of fetal blood and cross te placenta during uncomplicated pregnancies and particularly at sensitising events at delivery. If fetus is D-rhesus positive and mother is D-rhesus negative the mother will create anti-D Abs

Answer 832

Immunity is permanent and if the mother's immune system is exposed again to the antigen e.g. a subsequent pregnancy, large amounts of Abs are rapidly created. They can cross the plaecnta and bind to fetal RBCs which are then destroyed in the fetal reticuloendothelial system. This causes haemolytic anaemia and ultimately death. Rhesus haemolytic disease. A similar immune response can be mounted against other RBC antigens

Answer 833

Anti-C Anti-Kell (not a rhesus) Esp. after blood transfusion

Answer 834

TOP or ERPC after miscarriage Ectopic pregnancy Vaginal bleeding \<12w or heavy ECV Invasive uterine procedure e.g. amniocentesis or CVS Intrauterine death Delivery

Answer 835

Produciton of maternal anti-D can be prevented by the administration of exogenous anti-D to the mother This mops up fetal RBCs that have crossed the placenta by binding to their Ags, preventing maternal immune recognition. Anti-D usually given even if both parents are known to be rhesus negative due to possibilty of non-paternity NB Anti-D is pointless if sensitisation has already occurred

Answer 836

Anti-D should be given to all women who are rhesus negative at 28w. Also given to such women within 72h of any sensitising event.

Answer 837

Not required for spontaneous miscarriage before 12+0 unless there is intrumentation of the wob In pregnancies \<12w anti-D indicated in ectopic, molar, TOP and intrauterine bleeding where this is heavy, repeated or associated with abdominal pain.

Answer 838

Ectopic or TOP regardless of method of management NB NICE recommends not offering anti-D if ectopic is medically managed although there is no clear evidence to support this

Answer 839

For potentially sensitising events between 12 and 20 weeks of gestation, a dose of 250 IU should be administered within 72 hours of the event. Women who are RhD negative presenting with continual uterine bleeding between 12 and 20 weeks of gestation should be given at least 250 IU anti-D Ig, at a minimum of six-weekly intervals. A maternal blood group and antibody screen should be undertaken to determine or confirm the RhD group and check for the presence of immune anti-D in these cases. If anti-D is identified, further history should be obtained and investigation undertaken to determine if this is immune or passive. If this is not clear then the women should be offered anti-D prophylaxis, as the assumption should be made that it is passive.

Answer 840

Within 72h of sensitising event FMH is required to detect fetal cells in maternal circulation and to estimate the volume of FMH to calculate additional anti-D dosease.

Answer 841

Fetal maternal haemorrhage, used to determine the degree of fetal blood loss into the maternal circulation \>20w to determine anti-D dosing

Answer 842

Booking and 28w: check for Abs Rhesus negative: give anti-D at 28w, after any bleeding or protentially sensitising event and after delivery if fetaus is positive

Answer 843

Mild: neonatal jaundice only More sufficient haemolysis may cause neonatal anaemia. More severe: in utero anaemia-\> cardiac failure ascites and oedema-\> hydrops. Death will follow.

Answer 844

Worsesns as maternal Ab production increases

Answer 845

Identifiaction of women at risk Assessing if how severely the fetus is anaemic In utero blood transufion or delivery

Answer 846

Unsensitised women screened at 28w. If anti-D levels \<10IU/mL, significant fetal problem unlikely, checked every 2-4w \>10IU/mL further investigation Anti-Kell Abs less predictive of severity and USS used earlier

Answer 847

USS Doppler USS of the peak velocity in systle (PSV) in the fetal MCA has high sensitivity for significant anaemia in \<36w. Used fortnightly in at-risk pregnancies Very severe anaemia (\<5g/dL) is detectable as fetal hydrops or excessive fetal fluid. US-guided blood sampling can be used to confirm suspected fetal anaemia.

Answer 848

Fetal blood sampling is performed with rhesus negative, high Hct, CMV-negative blood ready to be injected down needle if anaemia si confirmed. This proicess will need to be continued until delviery at 36w. All neonates born to rehus-negative women should have the blood group checked, FBC, blood film and bilirubin to detect degrees of isoimmunisation

Answer 849

Describes the relationship of the fetus to the long axis of the uterus

Answer 850

Longitudinal Transverse or Oblique

Answer 851

1 in 200 births Before term it is normal

Answer 852

Circumstances that allow more room to turn: e.g. polyhydramnios, high parity (more lax uterus) are the most common causes resulting in an unstable or constantly changing lie Conditions that prevent turning: Fetal and uterine abnormalities and twin pregnancies Conditions that prevent engagement: Placenta praevia, pelvic tumours or uterine deformities Unstable lie in nulliparous women is rare

Answer 853

If the head or breech cannot enter the pelvis, labour cannot deliver the fetus. An arm or the umbilical cord may prolapse when membranes rupture If neglected, obstruction eventually causes uterine rupture

Answer 854

Head in flank= transverse Head in one iliac foss= oblique

Answer 855

No management required before 37w unless the woman is in labour Agter 37w woman is admitted incase of ROM, USS performed to exclude particular causes e.g. polyhydramnios and placenta praevia ECV unjustified as fetus turns back. If spontaneous version occurs and persists for 48h the mother is discharged. An abnormal lie will usually stabilise before 41w. At 41w or if the woman is in labour the persistently abnromal lie is delivered by Caesarean.

Answer 856

Presentation of the buttocks Occurs in 3% of term pregnancies. More common earlier in pregnancy therefore more common in preterm labour

Answer 857

70% has both legs extended at the knee

Answer 858

15% Has both legs flexed at the knee

Answer 859

15% One or both feet present below the buttocks

Answer 860

No cause found in most Previous breech has occurred in 8% Prematurity Conditions that prevent movement or head engagement are more common

Answer 861

Only important from 37w or if patient is in labour Upper abo discomofort common Hard head normally palpable and balottable at the fundus USS confirms Dx and can help detect fetal abnormalitiy, pelvic tumour or placenta praevia and ensures the prequisites for ECV are met

Answer 862

Perinatal and long-term morbidity and mortality are increaesd Fetal abnromalities are more common but even normal breech babies have higher rate of LT neurological handicap which is independent from the mode of delivery. Labour has potential hazards: increased risk of cord prolapse. Also risk of trapped head.

Answer 863

ECV from 37w Caesareab section (if ECV has failed or is contraindicated) Vaginal delivery

Answer 864

Attempt to turn the baby to a cephalic presentaiton. Reduces the number of breech presentations at term. Success rate is 50% 3% of successfully turned breeches will turn back. Where ECV fails, only 3% will turn spontaneously before delivery

Answer 865

Without anaesthetic Made easier with administration of a tocolytic if uterine tone is high or an initial attempt has failed. Breech disengaged from the pelvis and pushed upwards and to the side. USS guided CTG straight after Anti-D for rhesus negative women.

Answer 866

Risk very low Placental abruption and uterine rupture have been reported. Risk of emergency C-section

Answer 867

Low succes rates seen in nulliparous Caucasions Where the breech is engaged Head not easily palpable Uterine tone high Obese women Liquor volume reduced

Answer 868

C-section required anyway e.g. placenta praevia Twins Membranes ruptured APH within last 7d Abnromal CTG Major uterine abnromalitiy

Answer 869

Small for dates with abnormal doppler Proteinuric pre-eclampsia Oligohydramnios Major fetal abnormalities Scarred uterus Unstable lie

Answer 870

C section Reduces mortality by 1% and ST morbidity but does not affect LT outcomes. Maternal morbidity is not increased. NB 1/3rd of attempted vaginal breech deliveries ends with emergency C-sections.

Answer 871

Contraindications to vaginal delivery Contracted pelvis Footling breech Large baby \>3800g Growth restricted baby Hyperextended fetal neck in labour Lack of suitably trained clinician Previous C-section

Answer 872

Pushing not encouraged until the buttocks are visible CTG Epidural common In 30% there is slow cervical dilatation in the frist stage or particularly poor descent in the second. Oxytocin not advised-\> C-section

Answer 873

Injudicious traction causing extension of the head. Once the buttocks distend the perineum an episiotomy may be made but is not essential.

Answer 874

Fetus delivers as far as the umbilicus with maternal effort Legs can flexed out of the vagina whilst the back is kept anterior, Once the scapula is visible the arms are hooked down by sweeping it across the chest If arms cannot be reached as they are extended superiorrly, Lovset's procedure is required. Once the back of the neck is visible, the operator supports the entire weight of the fetus on one palm and forearm, with their finger in its mouth to guide the head over the perineum and maintain flexion. The other hand presses against the occiput. If this fails, forceps.

Answer 875

Required in breech if arms are extended above the head. Hands placed around the body with the thumbs on the sacrum, rotating the baby 180 degrees clockwise then counter-clockwise with gentle downward traction. Allows the shoulders to enter the pelvis

Answer 876

Used in breech to deliver the head: Operator supports the entire weight of the fetus on one palm and forearm. Finger in mouth to guide head over the perinum and maintain flexion. Other hand presses against the occiput

Answer 877

Aim is to prevent fetal and maternal morbidity. Shape of the pelvis will only allow delviery if the head it posterior or occasionally anterior

Answer 878

Non-rotational Only suitable when the baby's head is occipitoanterior

Answer 879

Rotational forceps allowing a malpositioned head to be rotated by the operator to the OA position before the application of traction.

Answer 880

Failure: both methods can fail Maternal Cxs and need for analgesia are greater with forceps. Either instrument can cause vaginal laceration, blood loss or third-degree tears. Cervical and uterine tears are very rare. Fetal complications: worse with the vventous. Lives a chignong which diminishes over hours. Scalps lacerations, cephalohaematomata are more common with ventous Facial bruising, nerve damage and even skull and neck fractures occur with injudicious use of forceps and prolonged traction by either instrument is dangerous. Chaning instrument: associated with increased fetal trauma and is only appropriate if a ventouse has achieved descent to pelvic outlet but is then replaced by a low cavity forceps delivery.

Answer 881

Prolonged second stage: most common indication Fetal distress; more common in the second stage Prophylactic use indicated to prevent pushing in some women who have medical problems e.g. cardiac disease or HTN In breech delivery to control the head

Answer 882

1h of pushing has failed to deliver the baby If the mother is exhausted it may be performed earlier The length of the passive second stage is less important

Answer 883

All labours: continuous support with delivery in the most comfortable maternal position possible. Epidural, analgesia, CTG, and induction predispose to instrumental delivery.

Answer 884

Epidural increases the risk of instrumental delivery. If used, maternal pushing should be delayed at least an hour after the diagnosis of second stage unless the head is visible. Oxytocin should be considered if descent of the head is poor (Nulliparous women)

Answer 885

Position and descent of the head. With either instrument, if moderate traction does not produce immediate and progressive descent, C-section is indicated

Answer 886

Head below the level of the ischial spines with bony prominences palpable vaginally on the lateral wall of the mid pelvis and is usually OA. Forceps/ventouse are appropriate. Pudendal block with perineal infiltration is usually sufficient.

Answer 887

Head is not palpable adominally but is at or just below the level of the ischial spines. Epidural or spinal. Trialled in theatre if there is doubt about the potential success. May be OA, OT or OP

Answer 888

Forceps or ventouse

Answer 889

Usually this is as a result of insufficient descent of the head to make it rotate. Descent achieved with ventouse with rotation resulting Non-rotational forceps are contraindicated. Rotational forceps may be able to achieve rotation in situ followed by descent.

Answer 890

Often accompanied by extension of the fetal haed. 1/5th may still be abdominally palpable. Need for instrumental delivery is unsuual in multiparous women and if required this position should be suspected. Requires rotation 180deg, Klielland's most effective.

Answer 891

Head must not be palpable abdominally Head must be at or below the level of the ischial spines Cervix must be fully dilated, with the second stage reached. Position of the head must be known Adequate analgesia Bladder should be empty Delivery for a valid reason

Answer 892

Ventous causes: Higher failure rate More fetal trauma no difference in APGAR Less maternal trauma.

Answer 893

Lower segment Caesarean section in which the abdominal wall is opened with a suprapubic transverse incision and the lower segment of the uterus is also incised transversely to deliver the baby

Answer 894

Extreme prematuirty Multiple fibroids Transverse fetus

Answer 895

Prolonged first stage Fetal distress

Answer 896

Diagnosed when dilatation is not imminenet by 12h or earlier if labour was initially rapid. Occasionally ful dilatation is achieved but not all of the criteria for instrumental delivery are met.

Answer 897

Powers: inefficient uterine action Passenger: malposition or malpresentation Passage: pelvic abnormalities and cephalo-pelvic disproportion

Answer 898

39w If earlier, steroids should be considered

Answer 899

Placenta praevia Severe antenatal fetal compromise Uncorrectable abnormal lie Previous vertical C-section Gross pelvic deformity

Answer 900

Breech Severe IUGR Twin pregnancy DM and other diseases Previous C-sec Older nulliparous patients.

Answer 901

Severe pre-eclampsia and IUGR

Answer 902

Emergency: immediate threa to mother or fetus e.g. severe fetal distress Urgent: maternal/fetal compromise that is not immediately life threatening e.g. dystocia Scheduled: needing early delivery but no compromise Elective: at time to suit mother and team Peri/post-mortem: for fetus and mother during maternal arrest or for fetus after maternal death

Answer 903

Greater than with a vaginal delivery. Greater when in labour rather than elective. Haemorrhage and the need for transfusion Uterine or wound infection (20%) Bladder/bowel damage. VTE Prophylactic antibiotics and thromboprophylactic measures. 1/5000 will die after caesarean

Answer 904

Increased risk of fetal respiratory morbidity at any gestation and should not be before 39w in uncomplicated pregnancy for this reason. Fetal lacerations rre rare Bonding and breastfeeding affected by emergency procedures. Neonatal morbidity and mortality is increased with elective C-section.

Answer 905

Become increasingly difficult Increase in stilbirths in subsequent pregnancies Increased incidence of placenta praevia, also increased risk of placenta accreta or percreta (best diagnosed with 3D power Doppler)

Answer 906

Most senior person with anaesthetic support Cross match blood Facilities for internal iliac or uterine artery embolisation are advised Uterine incision should avoid the placenta, which can be left in situ or hysterectomy performed. In less severe cases compression of the placenta with a Rusch balloon may alleviate or reduce haemorrhage. Ultimately delay in performing hysterectomy can be lethal.

Answer 907

Process whereby the fetus and placenta are expelled from the uterus, usually between 37 and 422 gestation Dx: painful uterine contractions accompany dilatation and effacement of the cervix

Answer 908

Stage 1: initiation to full dilatation 2: Dilatation to fetus delivery 3: Delivery of fetus to delivery of placenta

Answer 909

Powers Passage Passenger

Answer 910

Once labour is established the uterus contract 45-60s every 2-3 minutes This pulls the cervix up: effacement and causes dilatation, this is aided by the pressure of the head as the uterus pushes the head down into the pelvis. Poor uterine activity is a commmon feature of nulliparous women and in induced labour but is rare in multiparous women

Answer 911

Bony pelvis Soft tissues

Answer 912

Inlet: transverse diameter is 13cm, wider than the 11cm AP diameter Mid-cavity: is almost round, transverse and AP diameters are similar Outlet: AP (12.5cm) is greater than the transverse (11cm) In the lateral wall of the round mid-pelvis, the ischial spines are palpable vaginally and are used as landmarks to assess the head's descent.

Answer 913

Level of the descent of the head Measured in relation to the ischial spines Station 0 means the head is above the level of the spines +2 means it is 2 below -2 means it is 2 above

Answer 914

Cerbical dilatation is prerequisite for delivery and is dependant on contractions. Pressure of head and the ability of the cervix to soften allows distension. The soft tissues of the vagina and perineum need to be overcome in the second stage.

Answer 915

Attitude Position Size

Answer 916

Anterior fontanelle

Answer 917

The area between the occipit (posterior fontanelle) and the bregma (anterior fontanelle)

Answer 918

Degree of flexion of the head on the neck Maximum flexion keeping the head bowed- vertex presentation. Presenting diameter is 9.5cm running from the anterior fontanelle to below the occiput at the back. Aextension results in a larger diameter

Answer 919

Extension of the fetal head by over 90 degrees, increases the diameter to 13cm.

Answer 920

Extension by 120 degrees.

Answer 921

The degree of rotation of the head on the neck. If the sagittal suture is transverse, the fetal head will fit the pelvic inlet best. At the outlet the saggital suture must be vertical for the head to fit. Therefore the head must rotate 90 degrees during labour.

Answer 922

OA: occipitut anterior OP in 5% is more difficult.

Answer 923

Non-rotation and that delivery without assistance is impossible.

Answer 924

Compression of the fetal head due to the sutures allowing the bones of the head to come together Pressure of the scalp on the cervix to cause localised swelling or caput.

Answer 925

Presentation: i.e. cephalic or breech Presenting part: lowest part of the fetus palpable e.g. vertex, brow, face Position: OA, OT, OP Attitude: degree of flexion

Answer 926

Engagement in OT Descent and flexion Rotation 90 deg to OA Descent Extension to deliver Restitution and delivery of shoulder

Answer 927

A pink/white mucus plug form the cerivx and or rupture of membranes

Answer 928

Latent phase: cervix dilates slowly for first 3cm Active phase: average dilatation is at a rate of 1cm/h in nulliparous and 2cm/h in multiparous Active first stage should not normally last longer than 12h

Answer 929

Passive: lasts from full dilation until the head reaches the pelvic floor and the woman experienes the desire to push. Rotatio and flexion are commonly completed, may last a few minutes Active: when the mother is pushing/ Fetus is delviered on average after 40 minutes or 20 minuts (multip vs nullip). If it takes \>1h spontaenous delivery becomes decreasingly likely.

Answer 930

As the head reaches the perineum it extends to come up and out of the pelvis Perineum stretches and often tears Episiotomy is indicated if progress is slow or in fetal distress The head then restitutes, rotating 90 degress to adopt the transverse position in which it entered the pelvis With the next contraction, the shoulders the deliver, with the anterior shoulder coming under the pubic symphysis first, usually aided by lateral body flexion in a posterior direction. Posterior shoulder delivery is aided by flexion in an anterior direction

Answer 931

15 mins \<500mL blood loss Uterine muscle fibres contract to compress the BVs formerly supplying the placenta

Answer 932

Intact in 1/3rd of nullips and in 1/2 of multips

Answer 933

Artificial initiation of labour= induction Augmentation= strengthening the contractions of established labour

Answer 934

Favourability of the cervix (Bishop's score)

Answer 935

Natural Medical: PGs Oxyotcin following amniotomy Surgical: Amniotomy

Answer 936

PGE2 (2mg) Inserted into posterior vaginal fornix, best method in most nullips and multips (unless te cervix is very favourable) Either starts labour or improves the ripeness of the cervix to allow amniotomy. If one dose doesn't improve cervical ripeness, a second dose may be given \>6h later providing there is no uterine activity. \>2 doses are not helpful

Answer 937

Forewaters are ruptured with an amnihook (ARM) Oxytocin infusion is usually started within 2h if labour has not ensued. Oxyotcin alone may be used if ROM has already occurred

Answer 938

Cervical sweeping: passing a finger through the cervix and stripping between the membranes at the lower segment of the uterus. At 40w this reduces the chance of induciton and postdates pregnancy

Answer 939

Prolonged pregnancy Suspected growth restriction PROM Pre-eclampsia Medical disease: HTN and DM

Answer 940

High risk situations e.g. prolonged pregnancy Suspected IUGR Compromise APH Poort Ob Hx PROM

Answer 941

Pre-eclampsia Maternal disease e.g. DM

Answer 942

Social In utero death

Answer 943

Acute fetal compromise Abnormal lie Placenta praevia Pelvic obstruction or deformity Usually considered inappropriate after \>1 C-sect

Answer 944

One previous C-sec (increased scar rupture rate) Prematurity

Answer 945

Because of both the indication and the use of drugs, the fetus is at increased risk during induction CTG following induction with Pg (1hr) or when they stimulate uterine activity Oxyoticn also warrants CTG monitoring Induction increases the time spent in early labour

Answer 946

Failure/slow start of labour due to ineffcient uterine activity Risk of instrumental delivery or C-section is higher Uterine overactivity: fetal distress and uterine rupture Umbilical cord prolapse at amniotomy PPH more likely IP and PP infection also more likely Prematurity due to acciden e.g. incorrect gestation Amniotic fluid embolism (if Oxyotcin used and ARM not performed)

Answer 947

Vaginal delivery after C-section: Vertical uterine scar Multiple previous Caesareans (\>2)

Answer 948

60-80% of women will deliver vaingally, others will require an emergency C-sec Factors associated with increased success: Spontaneous labour Inter-pregnancy interal \<2y Low age and BMI Previous Vaginal delivery Previous C-sec was elective or for fetal distress. Smaller subsequent fetus and engagement of the head

Answer 949

Vaginal delivery safest, emergency C sec least safe. Risk of blood transfusion or uterine infection higher Serious maternal morbidity is greater with increasing number of C-secs: placenta accreta

Answer 950

Higher mortality as risk of antepartum stillbirth elminiated by 39w elective C sec Uterine rupture

Answer 951

TTN is higher in elective C-secs Fetal morbidity is increased with increasing number of prior caesareans

Answer 952

Hospital delivery and CTG monitoring advised Induction avoided Augmentation also increases the risk of scar rupture Epidural safe but labour should not be prolonged Scar rupture presents as fetal distress accompanied by scar pain, contraction cessation, vaginal bleeding and maternal collapse. Immediate laparotomy if rupture suspected

Answer 953

Rupture of membranes without onset of labour Different from PPROM: prelabour preterm rupture of membranes

Answer 954

Leaking of liquor but membranes remain in front of the fetal head

Answer 955

Cord prolapse: rare, usually a Cx of transverse lie or breech Risk of infection, increased by vaginal examination, GBS presence, increased duration of membrane rupture

Answer 956

Confirmation Lie and presentation checked DVE avodied, may be performed if risk of cord prolapse or fetal distress Vaginal swab Fetal auscultation or CTG Induce or await onset of labour

Answer 957

Does not increase risk of C-sec and associated with a lower chance of maternal infection and of NICE admission, particularly if GBS carrier Only 20% do not enter labour spontaenously Maternal pulse, T and fetal HR measured every 4h. Meconium or infection warrants induction. After 18h: antibiotic prophylaxis vs GBS and induction

Answer 958

18h vs GBS and induce labour

Answer 959

Possible increased risk of preterm labour Use with caution Clindamycin Safe to breastfeed

Answer 960

Nil known risks Safe

Answer 961

Nil known Safe

Answer 962

Safe Nil known risks

Answer 963

Possible increased neonatal risk if preterm birth- NEC Use with caution Penicllins Safe to breastfeed

Answer 964

Discolour teeth if 2nd trimester Avoid Erythromycin as alternative Safe to breastfeed

Answer 965

Folic acid antagonist Avoid in pregnancy Cephalosporins as an alternative Safe

Answer 966

Paracetamol best used, codeine if more severe

Answer 967

Closure of fetal DA. Fetal IUGR Possible cerebral haemorrhage Caution (avoid for analgesia) Monitor fetus with USS Paracetamol Safe to breast feed

Answer 968

Nil known risk Use if high risk of pre-eclampsia Alternatives NA Safe to breastfeed

Answer 969

Nil known risk Safe Safe to breastfeed

Answer 970

Maternal/fetal dependancy Only if severe pain or drug dependancy Methadone if opiate addict Beware accumulation in breast feeding

Answer 971

Teratogenic Risk of fetal haemorrhage Only use if artifical heart valves and with specialist advice LMWH Safe to breast feed

Answer 972

Maternal bleeding in OD Safe for fetus Use if indicated Safe to breast feed

Answer 973

Best use paracetamol, plus codeine if more severe

Answer 974

Probably underused Warfarin only used in exceptional circumstances

Answer 975

Fetal renal failure Teratogenic Avoid in pregnancy Methyldopa as alternative Captopril is safe for breast feeding

Answer 976

Nil known risk Best 1st line Safe to breast feed

Answer 977

Possible IUGR if early Caution, 3rd line Methyldopa as alternative Safe to breast feed

Answer 978

Nil known risk Best second line e.g. nifedipine Safe to breast feed

Answer 979

Maternal hypovolaemia Avoid in pregnancy Methyldopa as alternative Safe to breast feed

Answer 980

Use if indicated Monitor thyroid

Answer 981

Fetal hypothyroidism Use minimal dose Monitor thyroid

Answer 982

Fetal hypothyroidism, aplasia cutis Use minimum dose Propylthiouracil as alternative Monitor thyroid

Answer 983

Maternal hypoglycaemia Use with usual precautions Safe to breast feed

Answer 984

Probably safe Use with caution Insulin as alternative Safe to breast feed

Answer 985

Nil known effects Continue, monitor leveles Probably safe

Answer 986

Minimal risk Continue if indicated Safe to breastfeed

Answer 987

No fetal effects Maternal GDM, HTN Use minimum dose Safe to breastfeed

Answer 988

Largely safe Use if high risk of relapse Fluoxetine as an alternative Safe to breast feed

Answer 989

Paroxetine teratogenic (3% risk), others probably safe Use if high risk of relapse, fluoxetine preferentially Safe to breast feed

Answer 990

Teratogenic (10% risk) Use only if high risk of relapse Alternatives difficult Watch for toxicity

Answer 991

Possibly mildly teratogenic although largely unknown Usually continue due to risk of relapse but avoid clozapine Alternatives difficult Probably safe to breast feed

Answer 992

Impaired childhood cognition, cognition teratogenic (4-9% risk) Minimise combinations and consider cahgne if \<12w Carbamezapine as an alternative Safe to breast feed

Answer 993

Teratogenic (3% risk) Usually continue Safe to breast feed

Answer 994

Teratogenic (1-5% risk) Usually continue Safe to breast feed

Answer 995

Best sorted preconception Seizure control imperative Minimise combinations and doses High dose folic acid

Answer 996

Nil known risk with single course Use if high risk for preterm labour Betamethasone best NA NA

Answer 997

Nil known risk at anti-asthmatic doses Use if indicated Safe to breast feed

Answer 998

Safe Use for cholestasis

Answer 999

10.5-14 Higher with supplementation High Hb associated with worse perinatal outcomes, rapid drop in platelets suggestive in PET

Answer 1000

5-11 Levels unchanged in pregnancy but rise in labour

Answer 1001

100-450 Slight drop towards term

Answer 1002

11-22 Slightly lower in early pregnancy 43-45 Slightly lower in early pregnancy 0-4 Aim for 1.5-2 if replacement therapy NB: undertreated and subclinical hypothyroidism associated with cognitive deficit in childhood

Answer 1003

2.8-3.8 Lowered in pregnancy 50-80 Lowered in pregnancy x100, should ve Unchanged K usually slighlty low in pregnancy Slightly raised protein excretion Increased renal excretion in pregnancy, high creatinine/uric acid common with PET

Answer 1004

\<500 Raised \<30 Reduced \<35 Reduced 28-37 Reduced Rapid rise in liver enzymes common with complications of PET

Answer 1005

\>30, elevated, no clinical use in pregnancy

Answer 1006

\<8, unchanged by pregnancy

Answer 1007

\<6: fasting \<8 after food Slight fall in pregnancy Tight glucose control improves outcomes with maternal diabetes.

Answer 1008

Irregular bleeding associated with hormonal contraception

Answer 1009

Bleeding problems are more common with progestogen-only methods: COCP POCP Contraceptive depot IUS Emergency hormonal contraception

Answer 1010

6w period following delivery when the body returns to its preprgenant state Maternal morbidity and mortality associated with pregnancy is highest during this period

Answer 1011

Uterus contracts and the BVs that supplied the placenta occlude Uterine size reduces over 6w and shouldn't be palpable abdominally within 10d Contractions or after pains may be felts for 4d. Os closes by 3d Lochia, cervical discahrge may be bloo stained for 4w. Menstruation delayed by lactation but occurs after 6w if woman is not lactating

Answer 1012

CO and BV decrease to prepregnant levels within a wekk Loss of oedema can take up to 6w BP normalises within 6w

Answer 1013

Physiological dilatation of pregnancy reduces over 3m GFR decreases

Answer 1014

U+Es return to normal Hb and HCt rise thie haemoconcentration WCC falls Platelets and clotting factors rise, predisposing to thrombosis

Answer 1015

Do not separate mother and baby Early mobilisation Couneselling Check uterine involution, lochia, BP, pulse, T daily Analgesia may be required for perineal pain which can be helped through pelvic floor exercises FBC, Fe if appropriate in conjunction with laxatives Discussion of delivery Psych referral if indicated by history

Answer 1016

Dependant on prolactin (ant pit) which stimulats milk secretion. Levels of prolactin in conjunction with the decline in oestrogen and progesterone promote milk secretion Oxytocin from post pit stimulations ejection in respoonse to suckling which also stimulates prolactin release Can produce up to 1000ml Since oxytocin is controlled by hypo, emotional or physical stress may inhibit

Answer 1017

A yellow fluid contianing fat-laden cells, proteins (IgAs) and minerals which is passed for the first 3d before the milk comes in

Answer 1018

Baby's lower lip should be planted below the nipple so the entire nipple is drawn into the mouth.

Answer 1019

To reduce the chances of haemorrhagic disease of the newborn

Answer 1020

Protextion against infeciton in neonate Bonding Protection against Ca in mother £

Answer 1021

Lactation not adequate alone. Usually started 4-6w post delivery Combined contraceptive suppresses lactation and contraindicated if breastfeeding Progesterone only safe IUD safe: screen for infeciton. Insert at end of third stage or at 6w

Answer 1022

Loss of \>500mL blood \<24h after delivery \<1000mL after C-sec Occurs in 10%

Answer 1023

Retained placenta Uterine causes Vaginal causes Cervical tears Coagulopathy

Answer 1024

Occurs in 2.5% of deliveries. Partial separation can cause blood to accumulate in the uterus, which will rise Collapse may occur in the absence of external loss

Answer 1025

Account for 80% Uterus fails to contract either due to atony, retained placenta Atony is more common with prolonged labour, grand multparity and overdistension of the uterus and fibroids

Answer 1026

Accounts for about 20% Bleed from perineal tear or episiotomy may be obvious but bleed from higher vaginal tear must be considered, especially after instrumental

Answer 1027

Rare but associated with precipitate labour and instrumental delivery

Answer 1028

Congenital disorders Anticoagulant therapy DIC

Answer 1029

Oxytocin in 3rd stage of labour decrease incidence by 60% As effective as ergometrine

Answer 1030

Causes vomiting and is contraindicated in HTNive women

Answer 1031

Previous hx Previous C sec Coagulation defefct or anticoagulant therapy Instrumental/C-sec Retained placenta APH Polyhydramnios, multiple pregnancy Grand multiparity Uterine malformation or fibroids Prolonged/induced labour

Answer 1032

Blood loss should be minimal after placental delivery Enlarged uterus suggest uterine cause Inspect vaginal walls and cervix for tears May be abdominal blood loss e.g. uterine rupture without pain or overt bleeding

Answer 1033

ABC: nursed flat, cross matched blood. Restore BV. Page anaesthetist, haematologists, seniors Retained placenta should be removed manually if there is bleeeding if it is not expelled within 60mins of delivery Identify and treat cause: examination Bimanual uterine compression Oxytocin and or ergometrine given to contract the uterus If this fails examination under anaesthetic performed for retained placental fragment and inspect of the vagina If uterine atony persists, PgF2 injected into myometrium Persistent haemorrhage despite medical treatment requires surgery. May be compressed using Rusch balloon if bleeding from placental bed alone B-Lynch (brace suture may be used) Uterine artery embolisation Hysterectomy if these fail

Answer 1034

Excessive blood loss occuring 24h-6w after delivery

Answer 1035

Due to endometritis +/- retained placental tissue Rarely incidental gnaecological pathology or gestational trophoblastic disease Uterus enlarged and tender with an open internal cervical os.

Answer 1036

Vaginal swab Blood count Cross-match USS: although difficult to differentiate between blood clot and retained placental tissue Antibiotics ERPC may be used if bleeding is heavy and acute. Chronic can be managed with antibiotics alone. Histlogical examination of evacuated tissues will exclude gestational trophoblastic disease

Answer 1037

Endometritis due to reatined tissue causes bleeding that slows but does not stop with antibiotics and gets worse again once the course is finished

Answer 1038

\>38 in first 14d

Answer 1039

Infection: genital tract sepsis. Most common after C-sec. Prophylactic antibiotics reduce this DVT often causes low grade pyrexia

Answer 1040

GAS Staph E. Coli

Answer 1041

Lochia may be offesnive Uterus enlarged and tender Urinary infection, chest infeciton, mastitis, perineal infection and wound infection are alos common.

Answer 1042

Bloods Urine High vaginal Fetal cultures Broad spectrum antibiotics

Answer 1043

50%. Early mobilisation and hydration importatnt for all women

Answer 1044

Temporary emotional lability, affect 50% of women. Support and reassurance

Answer 1045

Postpartum thyroiditis

Answer 1046

See a psychiatrist before delivery MDT plan for postnatal discharge arranged

Answer 1047

Takes 25h before illness improves. BP peaks 4-5d post delivery and may need treatment for weeks. Fluid balance, renal funciton and UO should be monitored. BP and hpatic/cardiac failures Continue BP measurements for 5d postnatally

Answer 1048

Retention of urine UTI Incontinence

Answer 1049

Common after delivery, may not be painful after epidural. May present with frequency, stress incontinence or severe abdominal pain. Infection, overflow incontinence and permanent voiding difficulties may follow. Strict fluid charts and abdominal palpation help to identify. Postmicturition USS can be used to assess the residual volume Treatment is with catheteritsation

Answer 1050

Occurs in 20% of women Overflow and infection should be excluded using postmicturition ultrasound or catheterisation and an MSU Symptoms of stress incontinence usually improve with pelvic floor exercises

Answer 1051

Perineal trauma: repaired Pain: persists more than 8w in 10%. Superficial dyspareunia is common. Diclofenac is effective. Paravaginal haematoma: excrutiating pain te perinum a few hours after delivery., sometimes identified on USS. Drained under anaesthetic

Answer 1052

Constipation and haemorrhoids: laxatives Incontinence of faeces or flatus

Answer 1053

Affects 4% of women mostly transiently Can be caused by pudendal nerve or anal sphincter damage. Anal manometry and ultrasound used to assess and managed on basis of symptoms. Formal repatir may be required after which deliveries should be by C-sec

Answer 1054

Forceps Large babies Shoulder dstocia Persistent OP position

Answer 1055

Lactobacillus Acidic pH \<4.5 In prepubertal girls and postmenopausal women, lack of oestrogen results in a thin, atrophic epithelium with a higher pH and reduced resistance to infection

Answer 1056

Infection with Candida albicans Most common cause of vaginal infection and found in up to 20% of women, often asymptomatically. Cotttage cheese discahrge Vulval irritaiton and itching. Superficial dyspareunia and dysuria may occur. Vagina and or vulva are inflamed or red

Answer 1057

Pregnancy DM Use of antibiotics

Answer 1058

Topical imidazole (e.g. clotrimazole) or oral fluconazole.

Answer 1059

When normal latcobacilli ar eovergrown by a mixed flora including anaerobes, Garderella and Mycoplasma hominis Found in 12% of women Grey-white discharge Vagina not red or itchy Fishy odor from amines released by bacterial proteolysis

Answer 1060

Raised vaginal pH Positive whiff test (when 10% KOH added) Presence of clue cells

Answer 1061

Metronidzaole or clindamycin cream

Answer 1062

Can cause secondary infection in PID Also an association with preterm labour

Answer 1063

Foreign body. May also be due to atrophic vaginitis due to low oestrogen levels

Answer 1064

Occurs as a rare complication of a retained, hyperabsorbable tampon Toxin producing Staph aureus.: high fever, hypotension and multisystem failure Abx and ICU

Answer 1065

Screen for concurrent disease Regular sexual partner should also be screened and treated. Partner notification Maintenance of confidentiality. Education Barrier methods of contraception

Answer 1066

May be asymptomatic Urethritis and vaginal discharge

Answer 1067

Pelvic infection (may be silent) Can cause tubal damage leading to subfertility or chornic pelvic pain. Can also cause Reiter;s yndrome

Answer 1068

Azithromycin or doxycylcine

Answer 1069

Urethritis Conjunctivitis Arthritis (see, pee, climb a tree)

Answer 1070

Chlamydia trachomatis

Answer 1071

Neisseria gonorrhoeae

Answer 1072

Asymptomatic in women, vaginal discharge, urethritis, bartholinitis and cervicitis can occur. Pelvis commonly infected

Answer 1073

Vacteraemia Acute monoarticular septic arthritis

Answer 1074

Azithromycin or ceftriaxone

Answer 1075

Genital warts

Answer 1076

Topical podophyllin or imiquimod cream

Answer 1077

HSV Type 2. Although Type 1 implication increasing.

Answer 1078

Primary infeciton is the worst with multiple small painful vesicles and ulcers around the introitus. Local lymphadenoapthy, dysuria and systemic symptoms are common. Secondary bacterial infection, aspetic meningitis or urinary retention may also occur.

Answer 1079

Aciclovir (also valaciclovir or famciclovir) used in severe infections

Answer 1080

Treponema pallidum

Answer 1081

Solitary, painless, vulval ulcer (chancre)

Answer 1082

Untreated primary, secondary may develop weeks later: Rash, IFV-like symtpoms and warty genital or perioral growths (condylomata lata) Latent syphillis follows

Answer 1083

AR Dementia Tabes dorsalis Gummata in skin and bone.

Answer 1084

IM penicillin

Answer 1085

Trichomonas vaginalis Flagellate protozoan

Answer 1086

Grey-green offesnive discharge Vulval irritaiton Superficial dyspaerunia Cervicitis has a punctuate erythematous ("strawberry") appearance)

Answer 1087

Metronidazole

Answer 1088

Haemophils ducreyi

Answer 1089

Chlamydia subtypes

Answer 1090

Calymmatobacterium granulomatis

Answer 1091

Herpes Syphillis Chancroid Lymphogranuloma venereum Donovanosis

Answer 1092

Development of opportunisitc infections or malignancy CD4 \<200

Answer 1093

Yearly due to increased risk of lesion progression

Answer 1094

Infection confined to the cavity of the uterus which, if left untreated, commonly spreads to the utereus Often the result of either instrumentation of the uterus or as a complication of pregnancy or both.

Answer 1095

E Coli BV Staph Clostridia Chlamydia Gonococcus

Answer 1096

Persistent and heavy vaginal bleeding accompanied by pain Uterus is tender and the cervical os is commonly open Fever may be absent byt septicaemia can ensure.

Answer 1097

Vaginal and cervical swabs FBC Pelvis USS (not very reliable) Empirial antibiotics ERPC

Answer 1098

Traditionally describes sexuallly transmitted pelvic infection, endometritis usually co-exists

Answer 1099

Almost never occurs in the presence of a viable pregnancy

Answer 1100

Sexual factors (80%) Multiple partners No use of barrier protection COCP and Mirena IUS are protective.

Answer 1101

Usually spontaneous Can be the result of uterine instrumentation e.g. TOP, ERPC, Lap and dye test, intrauterine devices Or complicatins of childbirth and miscarriage (infection often caused by non-sexually transmitted bacteria) Descending infection from the appendix may also occur

Answer 1102

Frequently polymicrobial Chlamydia (60%) (asymptomatic- symptoms commonly due to secondary infection) Gonococcus (acute presentation)

Answer 1103

Endometritis Bilateral salpingitis Ovary sparing normally Fitz-Hugh- Curtis syndomr

Answer 1104

Many have no smyptoms and present later with subfertility and or menstrual problems Bilateral lower abdominal pain with deep dyspareunia is the hallmark Usually with abnormal vaginal bleeding or discharge

Answer 1105

Tachycardia, high fever, signs of lower abdominal peritonism with bilateral adnexal tenderness and cervical excitation Pelvic abscess may be palpable

Answer 1106

Pain on movement of the cervix

Answer 1107

Endocervical swabs for Chlamydia and gonococcus Blood cultures WBC CRP Pelvis USS helps to exclude abscess or ovarian cyst

Answer 1108

Laparoscopy with fimbrial biopsy and culture

Answer 1109

Analgesic Parenteral cephalosporin e.g. IM ceftriaxone + foxy and metronidazole or ofloxacin and metronidazole Admit Dx should be reviewed if no significant improvement in 24h and a laparoscopy performed Pelvis abscess may requrie drainage. NB rupture of a large pelvis abscess may be life-threatening

Answer 1110

Early: formation of abscess or pyosalmpinx Later: tubal obstruction and subfertility. Ectopic pregnancy x6 more common following pelvic infection Chance of tubal damage following one episode of acute PID is 12%

Answer 1111

Persisting infection and is the result of non/inadequate treatment of PID) Dense pelvic adesions and fallopians may be obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx).

Answer 1112

Chronic pelvic pain or dysmenorrhoea Deep dyspareunia Heavy + irregular menstruation Chronic vaginal discharge Subfertility May have similar examination feature sto endometriosis

Answer 1113

PID Endometriosis

Answer 1114

Laparoscopy as culture is often negative.

Answer 1115

Analgesics Abx of evidence of active infection. Adhesiolysis Salpingectomy

Answer 1116

Silent (chlamydia) Bilateral pain Caginal discharge Cervical excitation Adnexal tenderness Fever WCC and CRP raised

Answer 1117

Usually non-offensive Increases around ovulation, during prgnancy and in women taking COCP. Exposure of columnar epithelium in cervical eversion and ectropion may cause discharge one infection has been exluded.

Answer 1118

?Fallopian tube carcinoma

Answer 1119

Suggestive of cervical carcinoma but any genital tract malignancy may be responsible.

Answer 1120

Occurs within 7d of delivery

Answer 1121

Fetus delivered after 24w

Answer 1122

Death within 28d of delivery

Answer 1123

Fetus born with no signs of life \<24w. (if born with signs of life \<24w classified as a neonatal death)

Answer 1124

Sum of stillbirths and early neonatal deaths per 1000 total births Excludes those that are due to congenital malformations

Answer 1125

Extended Wigglesworth and supplemented by the Obstetric Aberdeen classification sysytem

Answer 1126

Preterm delivery

Answer 1127

\>10% stillbirths

Answer 1128

Occurs in 10%

Answer 1129

Unexplained antepartum stillbirth IUGR Prematurity Congenital anomalies Intrapartum hypoxia APH

Answer 1130

Death of a woman during pregnancy or within 42d of its cessation from any cause related to or aggravated by the pregnacny

Answer 1131

After 42d post-delivery and \<1y

Answer 1132

Obstetric complication vs previous or new disease but not the result of pregnancy

Answer 1133

Socioeconomic Obstetric Pre-existing health Level of care Reporting methods

Answer 1134

Extremes of maternal age High parity Multiple pregnancy Multiple previous C-sec

Answer 1135

Haemorrhage Obstructed labour infection Severe pre-ecl and the consequences of illegal abortion

Answer 1136

Sepsis: most common cause VTE Haemorrhage Hypertensive disease: mostly as a result of ICH Other causes: disorders of early pregnancy (ectopic), genital tract infeciton, amniotic fluid embolism, anaesthesia, acute fatty liver, genital tract trauma

Answer 1137

Cardiac disease: acquired and congenital disease Psychiatric disease Other: drug?ETOH related death, domestic violence, epilepsy and ICH

Answer 1138

Child has capacity Try to get child to discuss with parent Be convinced that the child's physical or mental health will ne affected without the treatment and it is in the child's best interests to have the treatment without parental knowledge

Answer 1139

A doctor is not guilty of negligence if he or she has acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular art.

Answer 1140

T, pulse, BP should be monitored If circumstances predispose to abnormalities e.g. epidural, this should be more frequent

Answer 1141

Hypotension managed with fluids and ephidrine

Answer 1142

By maintaing left lateral tilt Women should not go through labour flat on their back

Answer 1143

Dehydration is common IV fluids necessary in epidrual

Answer 1144

Aspiration of stomach content into the lungs during anaesthesia Most common cause of maternal aneasthetic death. Cyanosis. Tachycardia. Massive pulmonary oedema. Bronchospasm, which occurs often (unlike with amniotic fluid embolism). Hypotension. Hypovolaemia with haemoconcentration (the reactive transudation of fluid into the lungs contributes to this).

Answer 1145

Eating is often discouraged during labour Ranitidine may be given to reduce stomach acidity

Answer 1146

\>37.5 Associated with increased risk of neonatal illness and is not always as a result of chorioamnionitis More common with epidrual anaesthesia and prolonged labour. Cultures of vagina, urine and blood are taken. Antipyretics often administered Antibiotics warranted if fever reaches 38deg or there are other risk factors for sepsis

Answer 1147

Neglected retention of urine can irreversibly damage the detrusor muscle. Epidural usually removes bladder sensation Catheterisation may be needed but not necessarey for all. Women should be encouraged to micturate during labour

Answer 1148

The partogram

Answer 1149

Progression in dilatation of the cervix +/- descent of the head Assessed on VE and plotted against time.

Answer 1150

Inefficient uterine action. Common in nullips and inductions but rarer in multips

Answer 1151

Augmentation initially with amniotomy Then qith oxytocin

Answer 1152

Occurs with excessively strong or frequent or prolonged contractions. Fetal distress occurs as placental bloo flow is diminished Associated with placental abruption, with too much oxytocin or as a side effect of PG administration to induce labour.

Answer 1153

If there is no evidence of abruption a tocolytic e.g. sablutaoml can be given IV or subcut C-section usually indicated due to fetal distress

Answer 1154

First stage: slow progress usually due to inefficient uterine action. Augmentation can sometimes correct passenger probelsms of attitude or position. ARM may be used If ARM fails to produce further cervical dilatation in 1-2h oxytocin may be used and titrated up. CTG monitoring is advised Nullips are at less risk of uterine rupture

Answer 1155

Will usually increase dilatation within 4h if it is going to be succesfull

Answer 1156

If descent is poor, oxytocin should be started and pushing delayed by 2h If epidural has been used, the urge to push characteristic of second stage may be diminshed

Answer 1157

If lasts longer than 1h, spontaneous delivery becomes less likely because of maternal exhaustion. Fetal hypoxia and maternal trauma are also more common. If the head is distending the perineum, episiotomy can be performed. If not, instruments may be used

Answer 1158

Slow progress is unusual. Uterus likely to be effective. Therefore failure to progress is more likely to be the fetal head: its attitude or position Multip also more prone to rupture. Augmentation with oxytocin may only be performed after careful exclusion of malpresentation.

Answer 1159

Longer More painful Backache Early desire to push, If progress in labour is normal, no action is needed as OP may spontaenously revert to OP. If labour is slow, augmentation is used. If the position is persistent, delivery will be face to pubis and completed by flexion rather than extension. C-section may be required. If associated with prolonged second stage, instrumental delivery usually achieved with rotation to OA using ventouse or Kielland's

Answer 1160

If vaginal delivery has not been achieved after 1h of pushing in the second stage. Usually associated with poor powers so rotation with traction may be required Ventouse

Answer 1161

Fetal compromise more common. If the chin is anterior, mento-anterior, delivery may be possible. If the chin is mento-posterior, extension of the head over the perineum is impossible and C-section indicated

Answer 1162

Powers: inefficient uterine action Passenger: fetal size, OT, OP, disorder of flexion e.g. brow Passage: cephalo-pelvic disproportion, cervix

Answer 1163

Retrospective dx made on the inability to deliver a particular fetus despite: presence of adequate uterine activity absence of maposition or presentation. Slightly more likely with very large babies, sort women or where the head remains high in a nullip at term.

Answer 1164

Found in 50-80% of caucasian women. Arthropod (20%) has a narrower inlet with a transverse diameter less than the AP diameter. Android pelvis is heart shaped. Platypelloid levis: oval shape of the inlet persists with the mid pelvis

Answer 1165

RIckets and osteolmalacia Poorly healed pelvic fractures Spinal abnormalities Poliomyelitis Congenital malofrmations

Answer 1166

Fetal hypoxia Infeciton/inflammation in labour Meconium aspiration Trauma Fetal blood loss

Answer 1167

Hypoxia that may result in fetal damage or death if not reversed or the fetus delivered urently.

Answer 1168

\<7.2 Neurological damage becomes common when it is \<7

Answer 1169

Placental abruption Hypertonic uterine states Use of oxytocin Prolapse of the umibilcal cord Maternal hypotension

Answer 1170

Long labour Mecnoium Use of epidruals and oxytocin IUGR Pre-ecl

Answer 1171

Color of liquor FHR CTG Fetal ECG monitoring Fetal blood sampling

Answer 1172

4x increase in perinatal mortality. Indication for caution and hence closer surveillance with a CTG as: Fetus may aspirate it Hypoxia is more likely

Answer 1173

Auscultated every 15 mins during first stage Every 5 mins during the second Using Pinard's or Doppler for 60s after a contraction. Distressed fetus normally exhibits abnormal HR patterns which can be heard. Appropriate monitoring for low risk pregnancies. CTG indicated if abnormalities are detected

Answer 1174

Delivery expedited by fastest route possible

Answer 1175

DR: Define risk: other factors e.g. meconium, fever, IUGR C: Contaction per 10 minutes BR: Baseline rate 110-160bpm Tachys associated with fever, fetal infection, fetal hypoxia. Steep sustained deterioration in rate suggests acute fetal distress V Variability: ST variation in FHR should be \>5bpm except during fetal sleep which normally lasts 45 minutes, reduced variability suggests hypoxia A: Accelerations of fetal heart with movements or contractions D: decelerations. Early are synchronous with contractions and are a normal response to head compression. Variable decelerations vary in timing and classically reflect cord compression which can ultimately cause hypoxia Late: persist after the contraction and are suggestive of fetal hypoxia O: Overall assessment

Answer 1176

Contractions \>5/10 minutes

Answer 1177

\>5bpm except during sleep. Prolonged reduction in variability suggests hypoxia

Answer 1178

Synchronous with contractions as a normal response to head compression

Answer 1179

Vary in timing and may reflect cord compression which may ultimately cause hypoxia

Answer 1180

Persist after the contraction is completed and are suggested of fetal hypoxia

Answer 1181

Level 1: intermittenet auscultation, if abnromal, meconium, long or high risk, proceed to Level 2: continuous CTG. If sustained bradycardia, delvier. Level 3: Fetal blood sampling, if abnormal proceed to Level 4: delivery

Answer 1182

Reduces maternal mobility Increases obstetric intervention No proven reduction in mortality or LT handicap More puerperal sepsis

Answer 1183

Left lateral psotion O2 and IV fluids Stop oxytocin infusion with B2 agonists VE to exclude cord prolapse or rapid progress FBS and delivery expedited if \<7.2 If FHR pattern continues or deteriorates a second sample will be needed

Answer 1184

Strong risk factor for seizures, fetal death and cerebal palsy even in the absence of evidence of infection. Combination with fetal hypoxia is particulalry dangerous.

Answer 1185

Aspiration by fetus into lungs where it causes a chemical pneumonitis More common in the presence of fetal hypoxia Where the meconium is thick, amnioinfusion of saline reducs the incidence of meconium aspiration although questions remain around maternal safety and this is rarely performed

Answer 1186

Vasa praevia Feto-maternal haemorrhage Placental abruption

Answer 1187

NO and O2: Gas and air Can casue light headed ness, nausea and hyperventilation

Answer 1188

Pethidine or meptid are widely used Easy administration Analgesic efect may lead to sedation or confusion. Antiemetics usually needed. Opiates can cause respiratory depression in newborn and reversal with naloxone may be indicated

Answer 1189

Hypotension Total spinal analgesia causing respiratory paralysis (rare)

Answer 1190

Low-cavity instrumental vaginal deliveries bilateral injection around the pudendal nerve where it pases by the ischial spine

Answer 1191

L3 and L4 LA injection into the epidural space. Complete sensory and partial motor blockade from the upper abdomen downwards may occur

Answer 1192

If labour is long HTNive women Abolish a premature urge to push Analgesia for insrumental or C-sect

Answer 1193

Increased midwifery supervision of BP and HR Woman bed bound Urinary retention Maternal fever is more common Instrumental (but not CS) more common Transient hypotension (minimised by IV fluids) Transient fetal bradycardia although rarely precipitates fetal distress

Answer 1194

Sepsis Coaglopathy or anticoagulant therapy (unless LMWH) Active neurological disease Spinal abnormalities Hypovolaemia

Answer 1195

Spinal tap Total spinal analgesia Hypotension LA toxicity Higher instrumental delivery rate Poor mobility Urinary retention Maternal fever

Answer 1196

Inadvertent puncture of the dura mater causing CSF leakage Leads to severe headache, characteristically worse when sitting up

Answer 1197

Normal to wait an hour before pushing in second stage Encouraged to push 3 times for 10 seconds during every contraction

Answer 1198

Perineum infiltrated with LA Cut made with scissors from the fourchette to the mother's right side of the perineum

Answer 1199

Gentle contunous traction on cord Suprapubic pressure to prevent uterine inversion

Answer 1200

3rd stage longer than 30 minutes Oxytocin infusion started and injected into the vein of the cord and milked up In the absence of bleeding, can be left for 1h

Answer 1201

Injury to skin only

Answer 1202

Involving the perianal muscles but not anal sphincter

Answer 1203

Involving anal sphincter complex 3a: \<50% of external anal sphincter 3b: \>50% of external anal shpincter 3c: internal anal sphincter also involved

Answer 1204

Involving anal sphincter and epithelium

Answer 1205

Sutured under LA Absorbable material used/ Continueous sutures used

Answer 1206

Occur in 1-3% Sphincter repaired under epidural and spinal anaesthetic Torn ends of the external sphincter are mobilised and sutured usually overlapping Internal sphincter requires seperate suturing if damaged. Antibiotics and laatives given PT assessment 30% have incontinence of flatus or faecas or urgency

Answer 1207

Forceps Large babies Nulliparity And the now obsolete midline episiotomy

Answer 1208

Early diagnosis of labour 2-hourly VEs Early correction of slow progress with amniotomy and oxytocin C section by 12h if delivery not imminent.

Answer 1209

Woman's request Low risk 37-41w Cephalic Clear liquor Normal FHR All maternal obs normal

Answer 1210

Abdominal route through a lower tranverse incision (Pfannsteil) or vertical midline Vaginal route Laparoscopic

Answer 1211

Rigid or flexible hysteroscope passed through the cervix Cavity distended using CO2 or saline Can be performed without anaesthetic, cervical LA block or under GA Used as an adjunct to endometrial biopsy

Answer 1212

Transcervical resection of endometrium

Answer 1213

Transcervical resection of fibroid

Answer 1214

Uterine perforation Fluid overload

Answer 1215

With bleeding that is heavy but regular and painless In women approaching menopause Doesn't ensure sterility NB biopsy to be taken before diatherym

Answer 1216

Used in laparscopy to insufflate the abdomen with CO2

Answer 1217

When dye is passed through the cervix to assess tubal patency

Answer 1218

Better visualisation of tissues Less tissue handling Less infection Reduced hopsital stay Faster postoperative recovery with less pain

Answer 1219

Menstural disorders Fibroids Endometriosis Chronic PID Treatment of pelvic malignancy Prolapse PPH

Answer 1220

1: Blood: anastamosis between uterine and ovarain arteries, if hte ovaries are removed the ovarian artery and vein ar ligated instead Round ligament 2: Blood: main uterine artery Cardinal ligament. Bladder dissected off the cervix and upper vagina to prevent injury to it or the ureters 3: Cervicovaginal branches of the uterine artery Uterosacral ligament

Answer 1221

TAH VH Lap H Wertheim's H

Answer 1222

Cervix is reatined

Answer 1223

Uterine prolapse

Answer 1224

Laparoscopically assisted vaginal hysterectomy

Answer 1225

Involves removal of hte parametrium Upper third of the vagina Pelvic LNs Indication is Stage 1a(ii)-2 cervical carcinoma

Answer 1226

Radical hysterectomy performed vaginally

Answer 1227

Mortality: 1 in 10000 Immediate: haemorrhage, bladder or uteric injury Postoperative: VTE, apin, retention and infetion of urine. Wound and chest infection. Pelvic haematoma. LMWH and prophylactic antibiotics Long term: prolapse, genuine stress incontinence, premature menopause, pain and psychosexual problems

Answer 1228

Dilatation and curettage Cervix dilated with steel rods Hegar dilators of increasing size Endometrium is curetted to biopsy it This is diagnostic procedure inferior to hysteroscopy and is not commonly performed

Answer 1229

Surgery for CIN Involves using cutting diathermy under LA to remove the transformation zone of the cerix Increases risk of subsequent preterm delivery

Answer 1230

Removal of the transformation zone and the enodcervix by making a circular ct Used to stage early cervical carcinoma and is sufficient for Stage 1ai Increased cervical damage means there is a significant risk of subsequent preterm delivery

Answer 1231

Excision of prolapsed vaginal wall and plication of the bladder base and fascia Vagina then closed

Answer 1232

Levator ani on each side plicated

Answer 1233

Whether the patient is sexually active as it may lead to overtightening of the vagina Other complications include urinary retention

Answer 1234

Re-suspension of the prolapsed uterus using a strip of non-absorbable bifurcated mesh to lift the uterus and hold it in place One end is attached to the cervix and the other to the anterior longitudinal ligament over hte sacrum.

Answer 1235

Used for prolapse of the vaginal vault after hysterectomy Mesh attached from vaginal vault to the sacrum

Answer 1236

Tension free vaginal tape Vertical incision made on the anterior vaginal wall over the midurethral section. Lateral dissection around hte urethra Tape is introduced vaginally with trocards entering the retropubic space. Cystoscopy performed to ensure there is no bladder perforation. If the tape is over tightened, acute urinary retention may occur

Answer 1237

Involves dissection into the extraperitoneal space over the bladder and anterior vaginal wall. Vaginal wall on either side of the bladder neck is hitched up to the iliopectineal ligaement on either side of the pubic symphysis. Usually performed for failed tape procedures

Answer 1238

Myomectomy Uterine artery embolisation (for women who do not want a hysterectomy but do not wish to preserve fertility) Hysterectomy

Answer 1239

Adhesions Uterine rupture during labour Perioperative haemorrhage: requiring transfusion and rarely, hysterectomy

Answer 1240

Stop OCP 4w prior to major abdominal surgery If HRT is not stopped, LMWH must be used All mobilised early and given TEDs LMWH given according to risk assessment

Answer 1241

Minor surgery or major surgey \<30 mins with no risk factors

Answer 1242

Consider Teds or subcut LMWH for Sx \>30 mins Obesity Gross varicose veins Current infection Prior immobility Major current illness

Answer 1243

Use LMWH for 5d or until mobile for C sx Prolonged Sx History of DVT Thrombophilia \>3 moderate risk factors

Answer 1244

Indwelling transurethral catheter

Answer 1245

Following surgery for genuine stress incontinence so that the ability to pass urine urethrally can be assessed before catheter removal

Answer 1246

Unexplained Preterm delivery IUGR Congenital abnormalities Intrapartum including hypoxia Placental abruption

Answer 1247

Prematurity IUGR Infection Pre-ecl Congenital abnormalities Intrapartum fetal distress Postnatal events Autoimmune disease Multiple pregnanc Placental abruption

Answer 1248

Small for dates Weight of the fetus is less than the tenth centile for its gestation, if at term 2.7kg

Answer 1249

Describes fetuses that have failed to reach their own "growth potential" In utero growth is slowed May end up SFD

Answer 1250

Chronic situation when conditions for normal growth and neurological development are not optimum. Most identfiiable causes involve poor nutrient transfer through the placenta: placental dysfunction. Commonly there is IUGR but this may also be absent.

Answer 1251

Identify high risk pregnancy Monitor the fetus for growth and well being Intervene at an appropriate time balancing the risk of in utero compromise against those of intervention/prematurity

Answer 1252

Poor past obstetric history or very small baby Maternal disease Assisted conception Extremes of reproductive age Heavy smoking or drug abuse

Answer 1253

HTN, proteinuria Vaginal bleeding SFD baby Prolonged pregnancy Multiple pregnancy

Answer 1254

Cervical scan at 23w Uterine artery Doppler Maternal blood tests e.g. PAPP-A

Answer 1255

Placental hormone the maternal level of which is reduced in the first trimester with chromosomal abnormallities Used as a DS screnning Low level also constitutes a high risk for IUGR, placental abruption and consequent stillbirth

Answer 1256

Uterine circulation develops a low resistancei in pregnancy. Abnormal waverforms at 23w suggest failure of low resistance circulation and identifies 75% of pregnancies at risk of adverse neonatal outcomes in the early third trimester esp: pre-ecl, IUGR, palcental abruption. Most sensitive at 23w

Answer 1257

Measurement of the symphysis fundal height

Answer 1258

USS asessment of fetal growth, which are subsequently recorded on centile charts. Rate of growth can be determined by previous scans Pattern of smallness may often help e.g. the fetal abdomen will often stop enlarging before the head which is spared: asymmetrical growth restriction Allows for consitutional non-pathological determinents of fetal grwoth Benefits: serial USS safe and useful. Limitations: one-off USS in later pregnancy are of limited benefit

Answer 1259

Reduced flow in umbilical artery in fetal diastole compared to systole suggests placental dysfunction.

Answer 1260

Umbilical artery waveforms help identify which small fetuses are actually growth restricted and therefore copromosied. Also predates CTG abnormalities and correlates well with severe compromise. Limitations: Doppler is not a useful screening tool in low-risk pregnancies

Answer 1261

So all major fetal vessels can be seen but the most commonly measured are the MCA and the ductus venosus, With fetal compromise, the MCA often develops a low resistance pattern in comparison to the thoracic aorta or the renal vessels- head sparing effect. Velocity of flow also increases with fetal anaemia. Benefits: use is restricted to high-risk preegnancies and specific situtations. Limitations: routine use does not reduce perinatal mortality or morbidity

Answer 1262

Suggests reduced resistance in the fetal MCA. Suggests head sparing Indicative of fetal compromise

Answer 1263

Limb movements Tone Breathing movements Liquor volume Scored 2 each out of 8 CTG also included and the score is out of 10 Low score suggests fetal compromise Benefits: it is useful in high-risk pregnacny where CTG or doppler give equivocal results. Limitations: time consuming and of little use in low risk pregnancy

Answer 1264

The mother records the number of individual movements that she experiences every day Benefits: most compromised features have reduced movements in the days or hours before demise, reduction in fetal movements is an indication for more sophisticated testing. Limitations: compromised fetuses stop moving only shortly before death, of limited benefit in reducing perinatal mortality

Answer 1265

\<10th centile \<3rd centile i.e. 97th centile

Answer 1266

Affect growth and birth weight without causing IUGR Low maternal height and weight Asian Female fetal gender All associated with smaller babies

Answer 1267

Pre-existing maternal disease Maternal pregnancy complications Multiple pregnancy Smoking Drug usage Infection eg. CMV Extreme malnutrition Congenital (chromosomal included) abnormalities Male obesity DM and Male gender All assocaited with increased risk of adverse outcomes

Answer 1268

Stillbirth Cerebal palsy Preterm delivery: both iatrogenic and spontaenous Maternal risks

Answer 1269

Made using ultrasound. Umbilical artery doppler Amniotic fludi volume (often reduced) with fetal redistribution of blood flow apaprent in MCA CMV infection or chromosomal abnormality testing may be indicated CTG: only become abnormal when severe compromise or fetal distress is present

Answer 1270

Growth recheced at fortnightly fetus Small but consistently growing fetus with normal umbilical artery doppler values does not need internvention

Answer 1271

Small for dates with abnormal Doppler values is delivered if beyond 36w Induction or c-sect required

Answer 1272

Aim is to prevent in utero demise or neurological damage with ongoing placental dysfunction whil maximising the gestation to avoid cxs of prematurity. IUGR fetus with anbormal doppler values is reviewed twice a week. I fabsent end-diastolic flow is seen the mother is admitted, given steroids if pre-34w and has a daily CTG A severely preterm IUGR is delayed until the CTG or fetal dopplers become abnormal.

Answer 1273

Fetus's weight or estimated weight is below the tenth/fifth/third centile

Answer 1274

Implies compromise: growth has slowed or is less than expected, taking into account constitutional factors

Answer 1275

\>42w NB risks of perinatal mortality and morbidity start between 41 and 42w.

Answer 1276

0. 35 at 37w 2. 12 at 43w

Answer 1277

Stillbirth Neonatal illness and encephalopathy Meconium passage Dx of fetal distress

Answer 1278

From 41w: examine patient vaginally and induce, unless cervix very unfavourable or patient prefers to wait If no indcution: sweep cervix and arrange daily CTG If CTG abnormal: delivery by c-sect

Answer 1279

1 in 80 1 in 1000

Answer 1280

2/3rds of all multiple pregnancies or triplets results from fertilisation of different oocytes by different sperm May be of different sex and are no more genetically similar than siblings from different pregnancies

Answer 1281

Result from mitotic division of a single zygote into identical twins. Whether they share the same amnion or placenta depends on the time at which division occured

Answer 1282

Dichorionic diamniotic MZ twins. When division occurs before day 3: leads to twins with separate placentas and amnions

Answer 1283

Monochroionic diamniotic MZ twins Occurs with division between d4 and 8 Leads to twins with a shared placenta but separate amnions

Answer 1284

Monochroionic monoamniotic twins Occurs with later division (9-13d) and is very rare Twins have a shared placenta and single amniotic sac

Answer 1285

Monochorionic twins have a higher fetal loss rate, particulalry before 24w

Answer 1286

MCDA (70%) DCDA (30%) MCMA: very rare

Answer 1287

Assisted conception Genetic factors Increasing maternal age Parity Geenrally affect DZ twins

Answer 1288

Vomiting may be more marked in early pregnancy Uterus is large for dates. May feel multiple fetal poles in later pregnancies

Answer 1289

Virtually all obstetric risks are exagerrated in multiple pregnancies Maternal: GDM and pre-ecl more common Anaemia: greater increase in blood volume and dilutional effect and also becuase more Fe and folic acid are needed. Fetal: Twins have greater mortality (x6) LT handicap (5x increase) Triplets fare worse with 18x risk of ganidcap Preterm delivery, IUGR, monochorionicity

Answer 1290

Miscarriage: first trimester death. Late miscarriage more common in MC twins Preterm labour: main cause of perinatal mortality. 40% of twins and 80% triplet pregnancies deliver \<36w. IUGR Congenital abnormalities are more common per baby in dichorionic Co-twin death: if one of a pair of DC twins dies, the other usuallly survies although the risk of preterm delivery is increased

Answer 1291

Result largely from the shared blood supply in the single placenta. Twin-twin transfuision syndrome IUGR Co-twin death Monoamniotic twins

Answer 1292

Occurs only in 15% of MCDA twins Results from unequeal blood distribution through vascular anastamoses of the shared placenta. One twin is volume depleted and develpops anaemia, IUGR and oligohydramnios. The other gets fluid overloaded and may develop polycytheamia, cardiac failure and massive polyhydramnios. Both twins are at very high risk of in utero death or severely preterm delivery. Even with optimal treatment, survival of both twins occurs in 50% with one twin in 80%. 10% of survivors have neurological disability

Answer 1293

Quintero system 1-5

Answer 1294

Where the umbilical artery waveform of the smaller twin is very erratic (selective IUGR with intermittenet absent or reversed end diastolic flow- sIUGR with iAREDF) which may be the result of superficial artery artery anastomoses. Sudden in utero death occurs in up to 20%

Answer 1295

The drop in BP of the dead twin allows acute transfusion of blood from one to the other which may rapidly lead to hypovolaemia and in 30% death or neurological damage

Answer 1296

Not only the placenta but the amniotic sac is also shared. The cords are always entangled. In utero demise is sudden.

Answer 1297

Malpresentation of the first twin occurs in 20% Second twin has an increased risk of death after the first has been delivered because of cord prolapse, hypoxia, tetanic uterine contraction, placental abruption, may present as a breech PPH more common.

Answer 1298

High risk pregnancy Fe and folic acid supplementation prescribed. Selective reduction can be discussed, only indicated in twins when one of them has a congenital abnormalitiy. Transvaginal US of cervical length may identify those at most risk of preterm delivery. Idenfy IUGR

Answer 1299

Sign of dichorionic twins Dividing membrane is thicker as it meets the placenta

Answer 1300

Thin dividing memrane as it meets the placenta. MZ twins

Answer 1301

Laser photocoagulation of the placental anastomoses in a fetal medicine centre is the preferred treatment.

Answer 1302

Mode: C-sect: reduces risk of death and hypoxia in second twin. vaginal can be discussed when the first fetus is cephalic, regardless of the lie of the second. Method: Induction or C-sec is usualy at 37-38w (DC) or 34-37w(MC) after which time perinatal mortality is increased. CTG monitoring due to increased risk of fetal hypoxia, particularly for the second twin.

Answer 1303

First as normal Second: Maternal contractions often diminish after the first twin. Usually these return after a few miinutes, oxytocin can be started if not. Lie of the second twin is cehcked and ECV performed if not longitudinal. Once the head or breech enters the pelvis, the membranes are ruptured and pushing again beings. Delivery usually achieved within 20 mins of the first. Excessive delay is associated with increased mortality.

Answer 1304

Performed under general, epidural or spinal anaesthesia. Involves inserting a hand into the uterus, grasping the feet and guiding them down.

Answer 1305

Structural Chromosomal Inherited or as a result of intrauterine infection or durg exposure

Answer 1306

Affect 2% of all pregnancies 1% major

Answer 1307

Cheap High sensitivity and specificity Is safe Must also be an acceptable diagnostic test Condition must be serious enough to warrant testing

Answer 1308

Screening teast is available for all women and gives a measure of the risk of the fetus being affected by a particular disorder A diagnostic test is performed on women with a "high risk" to confirm or refute the possibility e.g. this fetus doesn't have down syndrome

Answer 1309

Proprotion of subjects with the condition classified by a test as screen positive for a condition

Answer 1310

Probability that a subject who is screen negative will not have the condition

Answer 1311

Proportion of subjects without the condition who are classified as screen negative

Answer 1312

The proportion of subjects who are classified as high risk by a tst

Answer 1313

Probability that a subject who is screen positive will have the condition

Answer 1314

In neural tube defects. May also indicate a higher risk of third trimester Cxs Seldom used as USS is more accurate

Answer 1315

beta-HCG PAPP-A AFP Oestriol Inhibin A Results can be integrated with other risk factors e.g. amternal age and USS measurements to screen for trisomies 21, 18, 13

Answer 1316

Greater risk of DS Also indicates a higher risk of structural (particulalry cardiac) abnormalities in addition, 50% of fetuses with trisomies have structural abnormalities e.g. exomphalos

Answer 1317

11 and 14w

Answer 1318

Space between skin and soft tissue overlying the cervical spien

Answer 1319

May be the result of a fetal abnoramlity Warrants a repeat, detailed USS examination

Answer 1320

Diagnostic test involving removal of amniotic fuid using a USS guided fine gauge needle. Safest performed at 15w 1% miscarry

Answer 1321

Infections e.g. CMV and toxoplasmosis Inherited disorders e.g. sickle-cell anaemia, thalassaemia, CF

Answer 1322

Involves biopsy of the trophoblast by passing a fine gauge needle through the abdominal wall or cervix and into the placenta after 11w. Higher miscarriage rate than amniocentesis Can be performed at 11w.

Answer 1323

Trisomy 21 Usually the result of non-dysjunction at meiosissis May arise as a result of a balanced chromosomal translocation in the parents. More common with advancing maternal age.

Answer 1324

Mental retardation Characteristic facies: epicanthic folds and flat facial profile Congenital cardiac disease (50%) Abundant neck skin Intestinal stenosis Umbilical hernia hypotonia Predisposition to leukaemia Simian palmar crease Recurrence rate is low unless it is the result of a balanced partental translocation

Answer 1325

Thickened nuchal translucenecy Some structural abnormalities Absent or shortened nasal bone TR

Answer 1326

Low PAPP-A (1st trimester) Low AFP (1st/2nd trimester) Low oestriol High inhibin High HCG

Answer 1327

Edward's syndrome

Answer 1328

Patau's syndrome

Answer 1329

Patau's syndrome | (Trisomy 13)

Answer 1330

Polydactyly Microcephaly and mental retardation Clef-lip and palate Cardiac defects Renal defects Umbilical hernia Rocker-bottom feet

Answer 1331

Patau (Trisomy 13)

Answer 1332

Edwards syndrome | (Trisomy 18)

Answer 1333

Prominent occiput Mental retardation Low set ears Short neck Overlapping fingers Mircognathia Congenital heart defects Renal malformation Limited hip abductio

Answer 1334

47 XXY Males have normal intellect, small testes, infertile

Answer 1335

45 XO Affected individuals are female, infertile but with preserved intellect

Answer 1336

Blood test at 16w using AFP, hCG and oestriol Not hugely accurate, should only be used when screening occurs later than 14w

Answer 1337

Maternal age PAPP-A Beta-hCG Nuchal translucency as measured by USS at 11-14w

Answer 1338

Result of failure of closure of the neural tube. Neural tissue often exposed allowing degradation. Best known examples are spina bifida (severe disability), anaencephaly (incompatible with life(

Answer 1339

Preconceputal folica cid supplementation for 3months at 0.4mg/d

Answer 1340

1 in 200 Recurrent NTDs occur in 1 in 10 pregnancies but this risk is greatly reduced by high dose folic acid.

Answer 1341

Often due to NTDs, aqueduct stenosis or agenesis fo the copus callosum Px depends on severity and cause

Answer 1342

Cause abnormal posture and are usualy lethal Polyhydramnios follows impaired swallowing

Answer 1343

Anencephaly

Answer 1344

Occur in 1% of pregnancies More common in women with congenital cardiac disease or women who have had previously affected offsrping and when other structural/chromosomal abnormalities are present.

Answer 1345

Medical: Steroids to mature lungs Antiarrythmic drugs NSAIDs for polyhydramnios Surgical: Laser treatment for TTTS Amnioreduction for polyhydramnios Pleuramniotic shunt for hydrops/effusions Vesicoamniotic shunt for urethral valves Bllod/platelet transfusion Tracheal occlusion for diaphragmatic hernia Valvoplasty for critical AS Cord occlusion of monochorionic twins Open: Neural tube defect surgery

Answer 1346

Partial extrusion of the abdominal contents in the peritoneal sac Fifty percent of affected infants have chromosomal problem and amniocentesis is offered. Isolated, small defects have a good prognosis after postnatal surgery.

Answer 1347

Exomphalos

Answer 1348

Free loops of bowel in the amniotic cavity and is assoicated with ohter abnormalities. More common when the mother is very young Postnatal surgery is indicated: \>90% survive

Answer 1349

Gastroschisis

Answer 1350

Cause the abdominal contents to herniate into the chest leading to pulmonary hypoplasia Associated abnromalities are common. 60% with isolated defects survive. In utero tracheal occlusion can improve prognosis in severe cases

Answer 1351

May cause pulmonary hypoplasia and hydrops. in utero shunting isuseful

Answer 1352

Congenital cystic adenomatous malformations and pulmonary sequestrations are visisble as solid or cystic masses of varying sizes. Px usually good

Answer 1353

Stomach non-visible or small. Polyhydramnios

Answer 1354

Duodenal atreasia,c aused by stomach and dilated upper duodenum. DS very common Polyhydramnios

Answer 1355

Dilated bowel +/- polyhydramnios Meconium ileus due to CF is common

Answer 1356

Can be mild to severe Unilateral or bilateral Due to obstructino or reflux More prone to infection and therefore renal damage

Answer 1357

Obstruct the male urethra, cause oligohydramnios, bladder and renal dilation and damge which can range from lethal to renal failure in adulthood.

Answer 1358

Affect the limbs, when they are lethal e.g. thanatophoric dysplasia, chest is frequently small

Answer 1359

Amniotic bands- constriction deformities involving the amnion

Answer 1360

Occurs when fluid accumulates in two or more areas in the fetus. Has a high mortality and is rarer in late pregnancy due to its high mortality

Answer 1361

Immune: anaemia and haemolysis (e.g. rhesus) Non-immune: 1. Chromsomal e.g. DS 2. Cardiac abnromalities or arrythmias 3. Structural abnromalities e.g. pleural effusion can cause hydrops 4. Anaemia causing cardiac failure (e.g. parvovirus infection), FMH or fetal alpha thalassaemia major 5. TTTS

Answer 1362

USS assessment: MCA Kleihauer and aprvovirus, CMV and toxoplasmosis testing Fetal blood sampling

Answer 1363

Only possible where anaemia (transfusion) or compression by fluid collection e.g. pleural effusion (vesicoamniotic shunting) have caused hydrops

Answer 1364

Increased liquor volume. Deepest liquor pool \>10cm

Answer 1365

Idiopathic Maternal disorders (established and GDM), renal failure Twins (esp TTTS) Fetal anomaly (particuallry upper GI obstructions or inability to swallow)

Answer 1366

Maternal discomfort Large for dates Taut uterus Difficult palpation of fetal parts

Answer 1367

Preterm labour Maternal discomfort Abnormal lie Malpresentation

Answer 1368

To diagnose fetal anomaly: detailed USS To diagnose DM: maternal blood glucose To reduce liquor: If \<34w and severe, amnioreduction, or use of NSAIDs to reduce fetal urine output Consider steroids if \<34w Delivery: vaginal unless persistent unstable lie or other obstetric indication

Answer 1369

Induces fetal hyperinsulinaemia leading to fetal fat deposition and excessive growth-\> macrosmia

Answer 1370

Altered carbohydrate metabolism and the antaonistic effects of human placental lactogen, progesterone and cortisol. Pregnancy is diabetogenic.

Answer 1371

Threshold for glycosuria decreases, therefore glucose in urine may occur at physiological blood concentrations

Answer 1372

Insulin requirements increase

Answer 1373

Carbohydrate intolerance which is diagnosed in pregnancy and may or may not resolve after pregnancy

Answer 1374

Fasting plasma glucose level of \>5.6 2 hour plasma glucose level of \>7.8 after a 75g glucose load (GTT)

Answer 1375

T1DM and T2DM are similalrly effected. GDM less so Congenital abnormalities: neural tube and cardiac defects and are related to periconceptual glucose control Preterm labour Reduced fetal lung maturity Raised birthweight: dystocia and birth trauma Fetal compromise Fetal disress Sudden fetal death are more common

Answer 1376

Fetal pancreatic islet cell hyperplasia leads ot hyperinsulinaemia and fat deposition Leads to incresased UO and polyhydramnios

Answer 1377

INsulin requirements increase DKA rare Hypoglycaemia may result from attempts to achieve optimum glucose control Infection: UTI, wound or endometrial more common Pre-ecl more common Pre-existing IHD aggravated C-sect or instrumental delivery more likely. Diabetic nephropathy associated with poorer fetal outcomes but doesn't deteriorate in pregnancy **Diabetic retinopathy often deteriorates and may need to be treated in pregnancy**

Answer 1378

Baseline RFTs, BP and retina Glucose optimised 5mg folic acid/d BP control with labetalol or methyldopa

Answer 1379

BMI \>30 Previous macrosmic baby Previous unexplained still birth Previous GDM First degree relative with GDM Family origin with high prevalence of DM

Answer 1380

Non-drug treatment: lifestyle changes Medication: Offer metformin if lifestyle changes do not impact on blood glucose levels in 1-2w Insulin as alternative to metformin. If fasting glucose above 7, insulin and metformin. NB advise women to always have fasting acting glucose source available

Answer 1381

Normal USS Fetal echocardiography is also indicated.

Answer 1382

75mg daily from 12w

Answer 1383

By 39w. Offer C-sect if fetal weight exceeds 4kg Glucose levels maintained by sliding scale of insulin and dextrose infusion during labour

Answer 1384

Hypoglycaemia due to its accustomisation to hyperglycaemia RDS occurs even after 38w.

Answer 1385

Dose of insulin can be changed to prepregnant doses

Answer 1386

Risk factors Polyhydramnios Persistent glycosuria (2+ on 1 occasion or 1+ on 2 occassions)

Answer 1387

OGTT at 3m 50% will be diagnosed as diabetic within the next 10y

Answer 1388

40% increase in CO. 40% increase in BV 50% reduction in SVR BP drops, flow rate increases. Increased blood flow produces a flow murmur

Answer 1389

Left axis shift Inverted T waves

Answer 1390

Fludi balance monitoring Elective epidural analgesia Elective forceps delivery helps avoid the additional stress of pushing Antibiotics for those at risk of endocarditis

Answer 1391

Do not usually cause complicatiosn

Answer 1392

High maternal mortality rate (40%) Pregnancy contraindicated and usually terminated

Answer 1393

Severe disease causes an inability to increase cardiac output when required and should be corrected before pregnancy. Beta-blockade often used Epidrual analgesia is contraindicated. Thromboprophylaxis required for aortic valves

Answer 1394

Should be treated before pregnancy In severe stenosis HF may develop late in pregnancy and beta blockade should be used. Artificial metal valves are particularly prone to thrombosis and warfarin is used after the first 12w despite risk to fetus

Answer 1395

Rare cause of HF specific to pregnancy Develops in the last month or the first 6m after pregnancy in the absence of a recognisable cause. Cause of maternal death and leads to permanent LVD in \>50% Treatment is supportive with diruetics and ACEI

Answer 1396

Doesn't need to be a change in control as medication generally safe Women on LT steroids require an increased dose in labour because the chronically suppressed addrenal cortex is unable to produce adequate steroids for the stress of labour

Answer 1397

Folic acid 5mg daily 36w: Oral vit K Fetal echocardiography and anomaly scan are important to exclude fetal abnormalities

Answer 1398

High perinatal mortality. Even subclinical hypothyroidism is associated with: miscarriage preterm delivery intellectual impairment in childhood Also associated with an increased risk of pre-eclampsia, particulalry if antithroid antibodies are pregsent. TSH monitored

Answer 1399

Antithyroid Abs in mother suffering from Graves disease that cross the placenta

Answer 1400

Risk of thyrotoxicosis: acute symptoms and HF usually near or at delivery. Treated with PTU rather than carbimazole

Answer 1401

Used to treat hyperthyroidism in pregnancy Can cross the placenta and occasionally causes neonatal hypothyroidism

Answer 1402

Common and can cause postnatal depression Risk factors: Antithyroid Abs T1DM Transient and usually subclinical hyperthyroidism usually about 3 months postpartum, folled by 4 months of hypothyroidism which is permanent in 20%

Answer 1403

Acute hepatorenal failure, DIC and hypoglycemia Early symptoms: malaise, vomiting, jaundice and vague epigastric pain. Early dx and prompt delivery essential. Correction of clotting defects and hypoglycaemia Supportive treatment with blood products, fluid blanace and occasionally dialysis

Answer 1404

Vit K 10mg/d to reduce risk of haemorrhage Ursodeoxychlic acid Induction at 38w

Answer 1405

Due to increased sensitivity to the cholestatic effects of oestrogen

Answer 1406

1+ clinical criteria: Vascular thrombosis 1+ death of fetus \>10w Pre-ecl or IUGR requiring delivery \<34w 3+ fetal losses \<10w, otherwise unexplained With laboratory criteria: Lupus anticoagulant or high anticardiolipin Abs or anti-b2 glycoprotein Ab (Measured twice \>3m apart)

Answer 1407

Due to placental thrombosis: Recurrent miscarriage IUGR Early pre-ecl Fetal loss rate is high

Answer 1408

2% of pregnant women have the Abs Mx with aspirin and LMWH and is restricted to those with the syndrome. Pregnancy is managed as a high risk, with serial USS and elective induction of labour at least by term. Postnatal anticoagulation

Answer 1409

Inadvisable if creatinine level is \>200mmol as renal function often deteriorates late in the pregnancy

Answer 1410

CKD present \<20w

Answer 1411

Pre-ecl IUGR Polyhydramnios Preterm delivery

Answer 1412

USS for fetal growth RFTs Screen for UTIs Control of HTN Dialysis Vaginal delivery appropriate

Answer 1413

Associated with preterm labour and increased perinatal morbidity and mortality Asymptomatic bacteriuria affects 5% but is more likely (20%) to lead to pyelonephritis in pregnancy

Answer 1414

ECG changes of normal pregnancy can mimic those of a PE

Answer 1415

More is needed than in nonpregnant women as clearance is more rapid

Answer 1416

Maternal: High risk of thromboembolism, pre-ecl, DM C-sec, wound infections, difficult sx, PPH, maternal death Fetal: Higher rate of congenital abnromalities, DM and pre-ecl x2-3 perinatal mortality

Answer 1417

Preconceptual advise 5mg folic acid High risk if \>35BMI: screen for GDM, and BP surveillance. BMI \>40 require formal anaesthetic risk assessment

Answer 1418

Well or at low risk of relapse, stop Li Unwell or at high risk, continue Li with blood monitoring due to increased excretion during pregnancy Higher risk of maternal sucidie and postnatal medication is important

Answer 1419

May cause cardiac defects and is not advised

Answer 1420

Usually avoided

Answer 1421

Not teratogenic, use associated with: preterm delivery, IUGR, stillbirth, developmental delay and SIDS Methadone maintenance

Answer 1422

Probably teratogenic and can cause childhood intellectual impairment. Associated with IUGR and placental abruption as well as preterm delivery, stillbirth and SIDS COunsellying

Answer 1423

Teratogenic: cardiac defects, gastroschisis Pregnancy cxs similar to that of cocaine Counselling

Answer 1424

Associated with facial clefts, cause neonatal hypotonia

Answer 1425

Facial abnormalities IUGR Microcephaly Developmental delay \>18 units per day

Answer 1426

Encompass lesser variants of fetal alcohol syndrome

Answer 1427

Dose dependent Increased risk of Miscarraige IUGR Preterm birth Placental abruption Stillbirth SIDS

Answer 1428

Folic acid deficiency may coexist Symptoms absent until Hb \<9 MCV reduces but may initially be normal Ferritin levels reduced Treatment is with oral Fe, can cause GI upset In severe cases IV Fe is quicker

Answer 1429

Meat, particulalry kidney, and liver, eggs, green vegetables

Answer 1430

lightly cooked or raw green vegetables. Fish

Answer 1431

2 alpha 2 beta

Answer 1432

2 alpha 2 gamma

Answer 1433

More frequent crises Pre-ecl Thrombosis Infections

Answer 1434

Miscarraige IUGR Preterm labour Death

Answer 1435

Regular exchange blood transfusions Infection screening Hydration Folic acid supplementation Fe avoided because of overload

Answer 1436

Time beginning with the first features of the approaching menopause e.g. vasomotor symtpoms and mesntural irregulatiry and ends 12 months after the last menstrual period

Answer 1437

Following BSO

Answer 1438

Premature ovarian failure Infections Autoimmune disease CTx Ovarian dysgensis Metabolic disease

Answer 1439

Oocyte donation for fertility treatment HRT until 50

Answer 1440

Endometrial carcinoma Cervical carcinoma Premalignant endometrial hyperplasia with cytological atypia

Answer 1441

Investiage to exclude endometrial cancer or (uncommonly) a divertiuclar avscess draining via the uterus or vagina

Answer 1442

Endometrial carcinoma Endometrial hyperplasia +/- atypia and polyps Cervical carcinoma Atrophic vaginitis Cervicitis Ovarian Ca Cervical polyps

Answer 1443

Bimanual and pseculum +/- cervical smear TVS to measure endometrial thickness, thickened endometrial cavity or fluid filled cavity: malignancy, hyperplasia or polyps

Answer 1444

Early: psychological symptoms Intermediate: skin atrophy, genital tract atrophy, urinary tract atrophy Late: Cerebrovascular accidents, cardiac disease, bony fractures

Answer 1445

Hot flushes and night sweats May begin before periods stop and are usually present for less than 5y

Answer 1446

Dyspareunia Cessation of sexual activity Itching Burning Dryness Urinary symptoms: frequency, urgency, notcuria, incontinence, recurrent infection

Answer 1447

Between days 2 and 5 of the cycle to aboid the mid cycle preovulatory increase and the luteal phase suppression

Answer 1448

Produced by small ovarian follicles and give a direct measurement of ovarian reserve, low levels are consistent with ovarian failure. AMH levels are stable throughout the menstrual cycle and so can be measured on any day

Answer 1449

FSH (AMH) TFTs Catecholamnies LH, oestradiol and progesterone

Answer 1450

Spine may have falsely increased values due to osteophytes from OA, kyphosis, scoliosis and aortic calcification

Answer 1451

Oestrogen alone in women who have had a hysterectomy Combined with progestogens in those who ahve not.

Answer 1452

Oral Transdermal Subcut Orally Transdermally IUS

Answer 1453

Because of their greater metabolic impact

Answer 1454

Oestradioll, oestrone, oestriol Synthesised from plants

Answer 1455

levonorgestrel Norethisterone

Answer 1456

Synthetic steroid compound that is inert but is converted in vivo to metabolites with oestrogenic, progestogenic, and andorgenic actions. Used in post-menopausal women who desire amenorrhoea and treats vasomotor, psychological and libido problems Conserves bone mass

Answer 1457

Used in women after hysterectomy May be concenrs about a remnant of endometrium in the cervical stump if it was a subtotal hysterectomy. If this is suspected, presence or absence of bleeding following HRT is a useful test

Answer 1458

10-14d every 4w or 1`4d every 13w Leads to monthly bleeds or 3 monthly bleeds

Answer 1459

Used every day Leads to no bleeds

Answer 1460

During the perimenopausal period if there is menorrhagia

Answer 1461

Continuous combined regmines because of the lack of induced bleeding and because it may reduce the risk of endometrial cancer Continuous combined therapy induces endometrial atrophy. IU delivery may be used but can be technically difficult in older women

Answer 1462

Vaginal administration by cream or pessary (oestriol) or oestradiol by table ot ring

Answer 1463

Oestrogen reduces vasomotor symptoms Oestrogens also reduced vaginal atrophic symptoms May improve sexuality Testosterone can be added

Answer 1464

HRT reduces the risk of #s

Answer 1465

HRT reduces the risk of CRC by 1/3rd

Answer 1466

Combined but not oestrogen only HRT increases risk Risk fallson stopping combined therapy and normalises after 5y

Answer 1467

Unopposed oestrogen replacement therapy increases endometrial cancer risk

Answer 1468

HRT increases risk of VTE x2

Answer 1469

Oral HRT increases risk of gallbladder disease

Answer 1470

Progestogens Clonidine: of lmited value SSRIs: are ffective in ST Gabapentin may be effective

Answer 1471

e.g. alendronate, risendronate and ibandronate Used in prevention and treatment of osteoporosis Princple adverse effect is irritation of the upper GI May affect fetal skeleton, so aren't advised in women wishing to conceive

Answer 1472

Decreases the risk of osteoporotic vertebral and hip #s

Answer 1473

Selective oestrogen receptor modulator, reduces the incidence of osteoporosis-related vertebral 's

Answer 1474

RANKL Ab Used whe bisphosphonates are contraindicated

Answer 1475

The contents of hte uterus are infected causing endometritis. Vaginal loss is usually offensive, uterus is tender and a fever may be present. If plevic infection occurs there is abdominal pain and peritonsim

Answer 1476

Isolated non-recurring chromosomal abnormalities.

Answer 1477

USS: will show uterine contents. If in doubt, the scan should be repeated 1w later. Bloods: HCG levels (if raised and no intrauterine gestational sac is visible, ectopic) FBC Rhesus group

Answer 1478

Admit: if ectopic, septic or heavy bleeding Resus: contents in cervical os. IM ergometrine will reduce bleeding but is only used if the fetus is non-viable If there is a fever, swabs for culture and IV antibiotics Anti-D is gient to women who are rhesus negative

Answer 1479

90% of women in whom fetal heart activity is detected at 8w will not miscarry

Answer 1480

Expectant Medical: prostaglandins Surgical: ERPC

Answer 1481

Vaginal bleeding with expectant or medical management can be heavy Risks of expectant/medical management include need for surgical evacuation, risk of infection is not incresed. Infection may become systemic leading to endotoxic shock

Answer 1482

Miscarriage was not result of anything they did Reassurance as to the high chance of successful pergnancies is important Referral to a support group

Answer 1483

Antiphospholipid Abs: LMWH and aspirin Chromsoomal defects: parental karyotyping, CVS or amniocentesis. Use of donor oocytes Anatomical: uterine abnormalities (USS or hysterosalpingoram), cervical incompetence (\>16w) Infection Obesity Smoking PCOS Excess caffeiene intake Higher maternal age

Answer 1484

Suction curettaeg (7-13w) Dilatation and evacuation (\>13w) Antibiotic cover required for both

Answer 1485

Antiprogesterone: mifepritsone + prrostaglandin (mifeprostol, gemeprost, PGE1 analogues (36-48h later) is the most effective in \<7w and can be used up to 9w Prostaglandin alone can be used Byeond 22w: KCI injected into the umbilical vein or fetal heart

Answer 1486

Haemorrhage Infection Uterine perforation Cervical trauma Failure

Answer 1487

Fallopian tube (95%)

Answer 1488

Lower abdominal pain Scanty dark vaginal bleeding Pain may be initially colicky (as the tube tries to exude the sca) and then become constant Syncopal episodes and shoulder tip pain suggests intraperitoneal blood loss

Answer 1489

Pregnancy test USS: TV Quantitative serum hCG is useful if the uterus is empty ifmaternal \>1000IU then if a uterine pregnancy were present it should be visible on TVS. If the level is lower but rises more than 66% in 48h, an earlier but intrauterine pregnancy is normal. Declining or slower rising levles of hCG suggest an ectopic or nonviable intrauterine pregnancy

Answer 1490

When an intrauterine and an ectopic pregnacny coexist

Answer 1491

NBM ABC FBC and cross-match Pregnancy test USS Laparoscopy or medical management if criteria met.

Answer 1492

10% chance a repeat surgery for persisting ectopic is required- detected by failure of serum hCG to fall on follow up. Increased risk of repeat ectopic as damaged tube remains

Answer 1493

If the ectopic is unruptured, with no cardiac activity and an hCG level \<3000 IU Methotrexate as a systemic sinlg edose can be used. Serial hCGs are used to confrm that trophoblastic tissue has gone. SSecond dose may be required.

Answer 1494

If the ectopic is small and unrupture or if the location of the pregnancy is not clear and hCG le3vles are low and declining. Careful observation may suffice

Answer 1495

Serial hCG to confirm resolution. 70% will have subsequent successful pregnancy following salpingectomy

Answer 1496

When N+V is so severe as to cause severe dehydration, weight loss or electrolyte disturbance.

Answer 1497

Nausea and occasional morning vomiting 50% pregnant women No treatment required

Answer 1498

More persistent vomiting 5% pregnant women Often admitted to hsopital

Answer 1499

Hyperemesis gravidarum

Answer 1500

Exclude predisposing conditions: UTI, multiple or molar pregnancy IV rehydration Antiemetics: promethyazine or cyclizine metoclopramide second line Thiamine Steroids in severe cases

Answer 1501

Trohpohblastic tissue which is part of the blastocyst that normally invades the endometrium proliferates in a more aggressive way than is normal: hCG secreted in excess Prolifreation can be localised and noninvasive. May also have characteristics of malignant tissue, invasive in the uterus alone= invasive mole. If metastasises= choreocarcinoma

Answer 1502

Entirely paternal in origin. When one sperm fertilises an empty oocyte and undergoes mitosis. Result is diploid tissue, usually 46XX

Answer 1503

Triploid, derived from two sperms entering one oocyte. Variable evidence of a foetus

Answer 1504

When there is evidence of persistence of gestational trophoblastic disease (hydatidiofrm mole, invasive mole, choriocarcinoma), commonly defined as elevation of hCG.

Answer 1505

Heavy vaginal bleeding, hyperemesis Uterus large for dates, pre-eclampsia and hyperthyroidism can occur

Answer 1506

Complete hydatidiform mole

Answer 1507

Trophoblastic tissue removed by ERPC and diagnosis confirmed histologically Bleeding often heavy Serial hCG levels taken, pesristent or rising levels are suggestive of malignancy. Pregnancy and COCP avoided until hCG levels are normal as they may increase the need for CTx

Answer 1508

Recurrence of molar pregnancy occurs in 1 in 60, after every subsequent pregnancy, further hCG samples are required to exclude disease recurrence GTN (molar pregnancy only accounts for 50% as malignancy may also follow miscarriages and normal pregnancy, usualy presents as persistent vaginal bleeding)

Answer 1509

Highly malignant but very sensitive to CTx Patients are risk stratified Low risk: methotrexate and folic acid High risk: Combination CTx

Answer 1510

Primary: female never conceived Secondary: previously conceived even if the pregnancy ended in miscarraige or TOP

Answer 1511

1: Egg must be produced (anovulation) 2. Adequate sperm must be released (Male factor) 3. Sperm must reach the egg (fallopain tube damage, 25%, sexual 5% and cervical 5% problems may also prevent fertilisation) 4. Fetilised egg must implant

Answer 1512

Ovulatory 30% Male 25% Tubal 25% Coital 5% Cervical \<5% Unxeplained 30% Because more than one cause may be present, the percentage total is \>100%

Answer 1513

Mainly due to reduced genetic quality of remaining oocytes rather than ovulatory problems

Answer 1514

The largest follicle with sufficeient gonadotrophin receptors which competes with the other follicles for diminishing stimulating hormones. It is the most likely to survive and continue growth. Development is coregulated by inhibin B which also suppresses FSH

Answer 1515

D21 progesterone (or progesterone 7d before the end of the cycle) 2. USS can monitor follicular growth: not performed 3. Over the counter LH predictor kits that analyse urine 4. Temperature charts

Answer 1516

Characteristic TVS appearnace of \>12 small follciles in an enlarged ovary. Found in 20% of women, the majority of whom have regular ovulatory cycles. Development of other features leads to diagnosis of full syndrome

Answer 1517

\>2 of: ``` PCO on USS Irregular periods (\>35d) ``` Hisutism: clinical (acne or hirsutism) and or biochemical (raised testosterone)

Answer 1518

Disordered LH production with peripheral insulin resistance Combination of raised LH and insulin acitng on PCO leads to increased ovarian androgen production.

Answer 1519

Bllods: FSH investigated (raised in ovarian failure, low in hypothalamic disease, normal in PCOS), Prolactin (to exclude a prolactinoma) and TSH. Serum testosterone. LH USS Other: DM screening and abnormal lipids or FHx of CVD

Answer 1520

None Subfertility Oligomenorrhoea or amenorrhoea Hisutism and or acne Obesity Miscarriage

Answer 1521

50% develop T2DM 30% develop GDM Endometrial C more common in women with many years of amenorrhoea due to unopposed oestrogen action

Answer 1522

Advice re diet and exercise which should result in reduction of insulin levels and improvement in all PCOS symptoms Treatment with COCP will regulate mesntruation and treat hirsutism At least three to four bleeds per year, whether spontaenous or induced, are necessary to protect hte endomertium Cyproterone acetate (anti-androgen) or spironolactone are effective treatments for hisutsim but conception must be avoided. Metformin can be used (also promotes ovulation)

Answer 1523

Hyptholamus: Hypothalamic hypogonadism: reduction in GnRH causes amenorrhoea. Occurs with anoerxia nervosa. Kallman's syndrome (can be treated with exogenous gonadotrophins- bone protection with OCP or HRT required) Pituitary: Hyperprolacinaemia: suppresses GnRH release (CT indicated if neurological symptoms are present) treated with dopamine antagonist restores ovulation. Sx needed if this fails Pituitary damage: pressure from tumours, Sheehan's Ovarian: Preamture ovarian failure Gonadal dysgenesis Luteinised unruptured follicle syndrome Thyroid: Hyper or hypo Androgen secreting tumours

Answer 1524

Occurs when GnRH secreting neurones fail to develop

Answer 1525

Osteoporosis LT managed by OCP or HRT

Answer 1526

Present whena a follicle develops but the egg is never released

Answer 1527

Advice regarding risks Folic acid Restoration of normal weight Treat specific causes Smoking should cease

Answer 1528

Clomifene: first line ovulation induction drug in PCOS. Limited to 6m used. Anti-oestrogen. Only given at start of the cycle from 2-6 Metformin: second line (has a lower live birth rate compared to clomifene) although it doesn't increase the risk of multiple pregnancy Increases the effectiveness of clomifene in clomifene resistant women. Laparoscopic ovarian diathermy: as effective as gonadotrophis and with lower multiple pregnancy rate. Can also check tubal patency during the procedure Gonadotrophins

Answer 1529

Given for 6m and at the start of the cylce from days 2 to 6. Monitored by TVS to assess ovarian response and endometrial thickenss. If no respons than the dose can be increased from 50 to 100 and even 150mg/day If three or more follicles develop then cycle cancellation indicated to reduce the risk of multiple pregnancy. Leads to endometrial thinning

Answer 1530

Used when clomifene has failed but also in hypothalamic hypogonadism Mutliple pregnanices are a consideration so a low-dose step up regiment is followed. Once a follicle is of sufficient size, ovulation can be stimulated by injection of hCG or recombinant LH. GnRH pumps can be used to stimulate FSH and LH production form the pituitary in a physiological manner.

Answer 1531

Mutliple pregnancy: more likely with clomifene or gonadotrophins but not metformin Ovarian hyperstimulation syndrome: gonadtrophins and rarely clomifene overstimulates the follicles which can get very large and painful (more common during IVF) Ovarian and breast carcinomas: generally not a risk

Answer 1532

Risk factors include gonadotrophin stimulation, age \<35y, previous OHSS, ovaries of PCO morphology Prevention includes using lowest effective gonadotrophin doses, USS monitoring, coasting (withdrawing gonadotrophins for a few days) or cancelling IVF cycle. In severe cases hypovolaemia, electrolyte disturbances, ascites, thromboembolism and pulmonary oedema may develop. OHSS can be fatal Admission may be required: restoration of intravascular volume, electrolyte monitoring, analgesia and thromboprophylaxis

Answer 1533

Pituitary LH and FSH LH acts via testosterone production in the Leydig cells of the testis FSH controls sertoli cells which are involved in synthesis and transport of sperm Takes 7d for sperm to develop fully

Answer 1534

Sample produced by mastrubation with last ejaculation having occurred 2-7d previously. Must be analysed within 1-2h of produciton Abnormal analysis must e repeated after 12w. If persistently abnormal, examination and investigations of the male must follow.

Answer 1535

\>1.5ml \>15m \>32%

Answer 1536

No sperm present

Answer 1537

Absent or low motility

Answer 1538

Unknown Smoking/ETOH/drugs/chemicals/inadequate local cooling Genetic Antisperm Abs

Answer 1539

Semen: if abnormal repeat and examine scrotum and optimise lifestyle factors If oligospermic then: intrauterine insemination If moderate to severe oligospermia: IVF with intracytoplasmic sperm inection If azoospermic: examine for presence of vas deferens, check karyotype, CF, hormone profile, surgical sperm retreival

Answer 1540

Idiopathic Drug exposure: sulfasalzine, anabolic steroids Varicocoele Antisperm Abs Other causes: infection, mumps orchitis, testicular abnormalities, obstruction to delivery (e.g. congenital absence of the vas deferens), hypothalamic problems, Kallman's, hyperprolactinaemia, rterograde ejaculation (due to neurological disease secondary to DM or TURP)

Answer 1541

hypogonadotrophic hypogonadism

Answer 1542

Primary testicular failure e.g. due to: cryptorchidism, surgery, RTx or CTx.

Answer 1543

Infection: PID: main cause. If there are peritubal adhesions or clubbed and closed fimbrial ends, laparsocopic adhesiolysis and salpingostomy can be performed. Ectopic rates increased Endometriosis Previous surgery/sterilisation

Answer 1544

Antibody production Infection in hte vagina or verxi that prevents adequate mucus Cone biopsy IUI to bypass cervix often used

Answer 1545

Lap and dye Hysterosalpingogram

Answer 1546

Hysterosalpingogram Radio-opaque contrast injected through the cervix. Spillage from the fimbrial end can be seen on XR. Can also be done transvaginally.

Answer 1547

AMH Must be present for IVF to be performed i.e. premature ovarian failure cannot use IVF

Answer 1548

Multiple follicular development Ovulation and egg collection Fertilisation and culture Embryo transfer

Answer 1549

Superovulation Egg collection: intraperitoneal haemorrhage and pelvic infection may complicated the USS-guided aspiration of mature follicles necessary for IVF Pregnancy: increased multiples, rates of ectopics, increased perinatal mortality and morbidity.

Answer 1550

The risk of pregnancy per 100 women years of using the given contraceptive

Answer 1551

Malabsorption can reduce th efficacy of oral contraception Alternative methods should be used such as combined patches, progesterone only injectables and implants Depo-provera should not be a first line option as it increases the risk of osteoporosis

Answer 1552

21d Combined pill reduces breast milk volume and should be avoided 6w postpartum and is relatively contraindicated 6-6m post partum. Progestogen only methods have no effect and can be used in the 6 weeks postpartum

Answer 1553

\<50y/o: continue contraception for at least 2y after the LMP \>50y/o at least 1y,

Answer 1554

Progestogen as a tablet: progestogen only pill (mini pill) Progestogen as a depot: Nexplanon, Depo-Provera or in the levonorgesrel containing IUS 3: Combined hormonal contraception: COC Transdermal patch Vaginal ring

Answer 1555

Exerting negative feedback on gonadotrophin release inhibiting ovulation. Also thin the endometrium and thicken cervical mucus

Answer 1556

3w on, 1w off Most contain synthetic oestrogens: ethinyldoestradiol Bleeding occurs at the end of the pill packet due to withdrawal of hormonal inhibition. Pill packets can be taken back to back to reduce the frequency of the withdrawal bleed

Answer 1557

Natural oestrogen found in some new types of COC

Answer 1558

Monophasic containing same dose of both hormones every day. Standard dose pill: 30-40 Low dose: 20 Usual choice is 30-35 ug Bleeding determined by type of progestogen rather than oestrogen dose or the phasic regmin

Answer 1559

Natural oestrogen combined with a synthetic progestogen: dienogest Four phases of oestrogen and progestogen dose over 26 days followed by 2 fill days.

Answer 1560

Depression PMS-tension like symptoms Bleeding, amenorrhoea Acne Breast discomfort Weight gain Reduced libido

Answer 1561

Nausea Headaches Increased mucus Fluid retention and weight gain HTN Breast tenderness and fullness Bleeding

Answer 1562

Menstrual cycle control Menorrhagia PMS symptoms Dysmenorrhoea Acne/hirsutism Prevention of recurrent simple ovarian cysts

Answer 1563

If woman suffering from D+V or taking some oral antibiotics. Should follow missed pill instructions for day of the illness If she vomits within 2h of taking the pill she should take another one or follow the rules for missed pill If she is taking broad spectrum antibiotics she should use condoms for the course and for 7d post course If she takes liver inducing drugs, increased dose may be required

Answer 1564

One or two missed pills nayhere in the pack not a problem Only one pill can be missed Forgotten pill should be taken ASAP and pack cntinued as normal but should use condoms for 7d. If there are less than seven pills remaining in the packet, avoid a pill-free break by running straight into the next packet.

Answer 1565

Normally stopped 4 weeks before. Not discontinued before minor surgery

Answer 1566

Advise of major cxs and benefits Stop smoking Advise to seek medical attention if symptoms suggestive of major cxs Advise re absorption issue Stress the importance of F/U and BP monitoring

Answer 1567

VTE and MI (multiplied by smoking, obestity), more common with 3rd generation pills. Cerebrovascular accident Focal migraine HTN Jaundice Liver, cervical and breast carcinoma

Answer 1568

Hx of VTE Hx of cerebrovascular accidant, IHD, HTN Migraine with aura Active breast/endometrial cancer Inherited thrombopilia Pregnancy Smokers \>35, smoking \>15/d BMI \>40 DM with vascular Cxs Acute/chronic liver disease

Answer 1569

Smokers Chronic inflammatory disease Renal impairment, DM Age \>40 BMI 35-40 Breastfeeding up to 6m postpartum

Answer 1570

Consider changing the pill to one containing a more potent progestogen or using an increased strength for ethinyloestradiol.

Answer 1571

Contraceptive Non-contraceptive benefits: Regular, less painful and lighter mesntruation Protection against simple ovarian cysts, benign breast cysts, fibroids and endometriosis. May improve features of PCOS. Reduced risk of PID Reduction in incidence of ovarian, endometrial and bowel carcinoma

Answer 1572

Adhesive patch that releases ethinyloestradiol and the progestogen norelgestromin. A new patch is applied weekly for 3 consecutive weeks then replaced. This is followed by a patch free week

Answer 1573

Combined transdermal patch

Answer 1574

Combined vaginal ring

Answer 1575

Latex free, releases a daily dose of ethinyloestradiol and progestogen. Inserted and worn for 3w Removed to allow for a 7d ringe free break and a withdrawal bleed. New ring is then inserted. Reduced synthetic oestrogen side effects. Shouldn't be remved during intercourse

Answer 1576

Contains a low dose (350mg norethisterone) and must be taken every day without a break and at the same time +/-3h MOA: makes cervical mucus hostile to sperm and inhibits ovulation in 50% Progestogenic side effects: vaginal spotting, PMS-like symptoms Functional ovarian cysts can occur. Can be used in those in whom COCP is contraindicated.

Answer 1577

Not taken within 3h Another should be taken ASAP and condoms used for 2d

Answer 1578

A different POP, contains a higher dose and inhibits ovulation in 90% of cycles. More effective and can be taken within a 12h window

Answer 1579

Bypass portal circulation Similar MOA to minipill Ovulation normally also prevented. Also protect against functional ovarian cysts and ectopic pregnancy.

Answer 1580

Contains medroxyprogesterone acetate Administered by IM very 3m. Often causes irregular bleeding in the first weeks but this is usually followed by amenorrhoea. Bone density decreases over first 2-3y then stabilises and is regiained after stopping. Other methods are preferred in teenagers to allow them to reach peak bone mass. Useful during lactation

Answer 1581

Alternative depot injection with similar efficacy to Depo-Provera. Lasts 8w Recommended as a ST interim contraceptive.

Answer 1582

Single 40mm rod containing progestogen inserted into the upper arm using LA. Lasts 3y Side effects include progestogenic symptoms, irregular bleeding especially in the first year.

Answer 1583

Contains a single 1.5mg dose of levonorgestrel Morning after pill. Taken within 24h and no later than 72 Affects sperm function and endometrial reciptivity. 95% success if used within 24h 58% if delayed until 72h Vomiting may occur plus menstrual distrubances

Answer 1584

Selective progesterone receptor modulator (like mifepristone) Prevents or delays ovulation Can be used up to 120h after unprotected intervourse. It will reduce the effectiveness of progesterone containing contraceptives and so women should use condoms or avoid unprotected intercourse until the next period.

Answer 1585

Usually prevents implantation and is the most efficacious method Can be inserted up to 5d after either the episode of intercourse or the expected day of ovulation. Antibiotic prophylaxis usually given at the time of insertion

Answer 1586

2-15 per 100 woman years

Answer 1587

Operate primarily by preventing fertilisaiton with the Cu ions being toxic to sperm Also block implantation Copper either wound around an inert frame which sits within the uterine cavity or threads which are attached to the fundus

Answer 1588

IUD that contain the progestogen levonorgestrel Released locally over 5y Known as the IUS. Contraceptive effects are local through changes to the cervical mucus and uterotubal fluid which impair sperm migration coupled with endometrial changes, impeding implantation. Also reduces menstrual loss and pain. Systemic side effects are low. Irregular ligt bleeding is the main problem

Answer 1589

Pain or cervical shock: due to inreased vaginal tone can complicate insertion, devices can be expelled within first month. Perforation of the uterie wall can occur at insertion or afterwards. Expulsion or preforation will cause the threads to disappear but they may also have been cut too short. If the threads are not visible- USS, if it is not present then an XR will reveal whether it is in the abdomen. Heavier or more painful menstruation can occur (with non-progestogen devices) Increased risk of PID if women have symptomatic STIs when the coil is inserted. Increased risk of infection Increased risk of ectopic pregnancy if pregnancy does occur, although the risk of ectopic pregnancy is lower than in a woman using no contraception. If not ectopic, IUD should be removed to reduce the risk of miscarraige

Answer 1590

Endometrial or cervical cancer Undiagnosed vaginal bleeding Active/recent pelvic infection Current breast cancer (for progesteogen IUS) Pregnancy

Answer 1591

Previous ectopic Exessive menstrual loss (unless IUS0 Multiple sexual partners Young/nullip Immunocompromised

Answer 1592

Advise of major risks Seek medical help if: IMB Experiences pelvic pain or a vaginal discharge If she feels she might be pregnant Advise to check for strings after each period

Answer 1593

Filshie clips that are applied to the fallopian tubes laparoscopically, occluding the lumen.

Answer 1594

Transcervical sterilisation: Hysteroscopic placement of microinserts into the proximal part of each tubal lumen Inserts expand, causing fibrosis and occlusion of the lumen, which is confirmed 3m later with a hysterosalpingogram

Answer 1595

Not possible with hysteroscopic Not guaranteed with Filshie clips Not available on the NHS

Answer 1596

Endometriosis: presence and grwoth of tissue similar to endometrium outside of the uterus. Adenoymosis: growth of endometrial tissue in myomterium

Answer 1597

This woman has entered the postmenopausal period as she has not had a period for 12 months. Even though she is postmenopausal she still requires contraception because she is under the age of 50. Guidelines advise: 'Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.' (FSRH) A copper coil is the best option for this woman because of her past history of breast cancer. All other methods, as they are hormonal, are a UKMEC Category 3, and this may be considered an unacceptable risk.

Answer 1598

COCP use in the perimenopausal period may help to maintain bone mineral density COCP use may help reduce menopausal symptoms a pill containing 40 years

Answer 1599

Normal Non-reassuring Abnormal

Answer 1600

Pelvic inflammatory disease is an absolute contraindication to the insertion of a copper IUD. Women at risk, such as those with multiple sexual partners or symptoms suggestive of pelvic inflammatory disease, should be tested and, if necessary, treated for any infections which could cause pelvic inflammatory disease such as Chlamydia trachomatis and Neisseria gonorrhoeae . Testing for these infections is done using endocervical swabs. Insertion of a copper IUD is in itself a risk for developing pelvic inflammatory disease, however this risk is low in women who are at low risk of sexually transmitted infections.

Answer 1601

Make periods heavier, longer and more painful IUS associated with inital frequent uterine bleeding and spotting Uterine perforation Increased risk of ectopic pregnancies (in women using contraception, NB lower than in woman not using contraception) Increased risk of PID for 20d after insertion Risk of insertion in 1/20

Answer 1602

This patient does not have any menstrual problems and wants short-term cessation of her menses. Norethisterone 5 mg three times a day is licensed for the postponement of periods, and is often prescribed to women who wish not to have a period when going on holiday. It must be started three days prior to the expected onset on menstruation. Menstruation resumes as normal two to three days after stopping the tablets. Note that this is a high dose and should not be used for longer than it is needed i.e. in the short-term. You may wish to read the following article regarding the risk of venous thromboembolism with norethisterone Norethisterone 5 mg TDS can also be used to rapidly stop heavy menstrual bleeding.

Answer 1603

Planned vaginal birth after caesarean (VBAC) is contraindicated in patients with previous classical caesarean scars, previous episodes of uterine rupture and patients with other contraindications to vaginal birth (e.g. placenta praevia). Women with two or more previous caesarean sections may be offered VBAC. The other options in this question are not absolute contraindications.

Answer 1604

absolute CPD placenta praevia grades 3/4 pre-eclampsia post-maturity IUGR fetal distress in labour/prolapsed cord failure of labour to progress malpresentations: brow placental abruption: only if fetal distress; if dead deliver vaginally vaginal infection e.g. active herpes cervical cancer (disseminates cancer cells)

Answer 1605

DVT/PE PPH Infeciton: wound, endometritis, UTI Retained placental tissue, ileus, ureteric trauma, transient abdominal distension

Answer 1606

by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.

Answer 1607

According to NICE guidelines, bradycardia or a single prolonged deceleration that persists for \>3 minutes or more is an abnormal CTG results and indicates the need for urgent investigation.

Answer 1608

The correct answer is 3.) most cases of PPH have no identifiable risk factors. In terms of the other options, active management of the third stage of labour has been shown to lower maternal bleeding and reduce the risk of PPH. Similarly, prophylactic oxytocics are routinely used in third stage management as they have been shown to effectively reduce risk of PPH. Oxytocin is 1st line in the management of PPH and has been shown to be more effective than misoprostol. While age is a risk factor for PPH, it is not the strongest risk factor.

Answer 1609

The copper IUD can be fitted at any point during the menstrual cycle. It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum. Note the importance of advising the patient to refrain from intercourse or use adequate contraception to prevent pregnancy until the IUD is fitted.

Answer 1610

Although the thyroid function tests are normal, thyroxine demands increase during pregnancy, and most woman require their dose increased by at least 25-50 micrograms levothyroxine. Therefore, it would be sensible to increase the dose to 100 micrograms in this case.

Answer 1611

at least 25-50 micrograms levothyroxine'\* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value

Answer 1612

iron: absorption of levothyroxine reduced, give at least 2 hours apart

Answer 1613

4w For the first 3w the patch is worn every day and needs to be changed each week During the 4th week if the patch is not worn there will be a withdrawal bleed

Answer 1614

If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed. If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.

Answer 1615

The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed. If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.

Answer 1616

The full blood count confirms a normocytic anaemia. Folate and B12 deficiency cause megaloblastic anaemia which is characterised by macrocytosis. Iron deficiency and thalassaemia typically cause microcytosis. Therefore, based on the MCV it can be inferred that sickle cell disease is the most likely answer. In addition, the Howell-Jolly bodies suggest hyposplenism which can occur in Sickle cell disease due to splenic infarctions. The high reticulocyte count suggests increased destruction (e.g. haemolysis) or increased loss (e.g. bleeding) of red cells. Sickle cell disease results in a chronic haemolytic anaemia due to premature destruction of abnormally shaped red cells. This would result in a high reticulocyte count.

Answer 1617

Within the abnormal category lie the following: Heart rate - \>180 BPM or \<100 BPM Variability - Less than 5 for over 90 minutes Decelerations - Non-reassuring variable decelerations for over 30 minutes since starting conservative measures to improve occuring with over 50% of contractions OR late decelerations present for over 30 minutes not improving with conservative measures occurring with over 50% of contractions OR bradycardia or a single prolonged deceleration lasting 3 minutes or more.

Answer 1618

Primary amenorrhoea can be diagnosed in women above the age of 14 with no secondary sexual characteristics, or above the age of 16 with secondary sexual characteristics. Primary amenorrhoea is commonly constitutional and has a familial distribution; in these cases there is no anatomical or physiological abnormality and patients will generally start menstruating by the age of 18. Lack of breast or body hair development suggests this is true primary amenorrhoea and so warrants investigation. Acne and facial hair may suggest virilisation, e.g. in polycystic ovarian syndrome. In a woman who is sexually active, pregnancy may be a cause of amenorrhoea and should always be excluded. Cyclical abdominal pain associated with amenorrhoea may suggest an anatomical abnormality such as an imperforate hymen.

Answer 1619

Fully dilated cervix generally the second stage of labour must have been reached OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure Ruptured Membranes Cephalic presentation Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally Pain relief Sphincter (bladder) empty this will usually require catheterization

Answer 1620

Condoms work as a barrier contraceptive and do not affect ovulation and hence do not delay fertility. The intrauterine system (IUS) works by thickening cervical mucous and in some women may prevent ovulation, however the majority of women still ovulate. After removal of the IUS the majority of women regain fertility immediately. The combined oral contraceptive pill can delay return to normal menstrual cycle in some women but the majority will be able to conceive within a month of stopping. The progesterone only pill is less likely to delay return to normal cycle as it does not contain oestrogen. Because Depo-Provera lasts up to 12 weeks, it can take several months for the body to return to the normal menstrual cycle and hence delay fertility. For this reason, it is the least appropriate method for this woman who wants to return to ovulatory cycles immediately.

Answer 1621

Irregular bleeding Weight gain May potentially increase risk of osteoporosis: only used in adolescents if no alternative Not quickly reversible and there is a variable return to fertility

Answer 1622

the government now recommend pregnant women should not drink. The wording of the official advice is 'If you are pregnant or planning a pregnancy, the safest approach is not to drink alcohol at all, to keep risks to your baby to a minimum. Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink the greater the risk.'

Answer 1623

This question tests your knowledge of the Hepatitis B vaccine schedule in baby's born at risk of developing hepatitis B. For babies who are born to mothers who are hepatitis B surface antigen positive, or are known to be high risk of hepatitis B, should receive the first dose of hepatitis B vaccine soon after birth and those born to mother's who are surface antigen positive should also receive 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth. The baby should then further receive a second dose of hepatitis B vaccine at 1-2 months and at 6 months.

Answer 1624

The answer here is intrahepatic cholestasis of pregnancy. This is a common cause of itch in the third trimester of pregnancy. It will give a cholestatic picture of liver function tests (LFTs) with a high ALP and GGT, with a lesser rise in ALT. Patients may also be jaundiced with right upper quadrant pain and steatorrhoea. Ursodeoxycholic acid is a common treatment. The cholestatic LFTs could indicate biliary colic, however the absence of abdominal pain here makes it very unlikely. Acute fatty liver of pregnancy also occurs in the third term of pregnancy but a hepatic picture would be expected on LFTs, with a rise in ALT/AST greater than that of ALP, a raised white cell count and potential clotting abnormalities. This condition is rare and patients are likely to be unwell with nausea, vomiting, jaundice and possible encephalopathy. In HELLP syndrome you would see a haemolytic anaemia, the mild anaemia seen here does not correlate with this and also low platelets not seen here. This lady is not hypertensive and does not have any other features of pre-eclampsia so this is unlikely. In late pre-eclampsia a hepatic derangement of LFTs might be seen.

Answer 1625

pre-eclampsia and HELLP syndrome are known causes of placental abruption, which typically presents with hyperreflexia. HELLP syndrome can be ruled out since the full blood count shows no indication of anaemia or low platelets as would be expected in this condition. Dilated pupils + hyperreflexia seen on physical examination point towards cocaine abuse. Heroin abuse would often present with pinpointed pupils and has not been associated with an increased risk of placental abruption. Although pre-eclampsia in pregnancy is associated with an increased risk of placental abruption, the findings on physical exam are more consistent with that of cocaine abuse. Disseminated intravascular coagulopathy is a complication placental abruption, not an underlying cause. Additionally, the normal partial thromboplastin time (PTT) and activated partial thromboplastintime (APTT) decrease the likelihood of underlying DIC.

Answer 1626

Increased risk of miscarriage Increased risk of pre-term labour Increased risk of stillbirth IUGR Increased risk of sudden unexpected death in infancy

Answer 1627

Fetal alcohol syndrome (FAS) learning difficulties characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures IUGR & postnatal restricted growth microcephaly Binge drinking is a major risk factor for FAS

Answer 1628

Maternal risks hypertension in pregnancy including pre-eclampsia placental abruption Fetal risk prematurity neonatal abstinence syndrome

Answer 1629

Risk of neonatal abstinence syndrome

Answer 1630

One of the first things that needs to be insured is that women who have been diagnosed with gestational diabetes should discontinue the blood-glucose lowering therapy immediately after the birth. Before discharge the BGL must be tested to ensure there is no persisting hyperglycaemia Remind women who suffered gestational diabetes during pregnancy of the symptoms of hyperglycaemia Explain the risk of gestational diabetes in future pregnancies Offer lifestyle advice to those whose BGL have returned to normal after delivery Offer a fasting plasma glucose test 6-13 weeks after the birth - this usually takes place at the 6 week post-natal check at the GP

Answer 1631

This woman requires emergency contraception because she had several episodes of unprotected sexual intercourse (UPSI) and has missed pills in her current packet of COCP. It is not clear if she has real contraceptive cover due to her poor compliance with taking the COCP. The copper-bearing intrauterine device (Cu-IUD) is the best method for this woman as she has presented 4 days after UPSI. It is difficult to assess her expected ovulation date as her periods could be withdrawal bleeds from her intermittent COCP use. The Cu-IUD has a low documented failure rate so women should initially be offered this as a means of emergency contraception. It also serves the dual purpose of long-term reversible contraception which may benefit this woman as she has difficulty taking the COCP. As this woman has poor compliance she should first be offered a pregnancy test before insertion of Cu-IUD. As this woman has presented within 120 hours of UPSI she can be offered ulipristal acetate (ellaOne) but this would be a second choice to a Cu-IUD. Levonorgestrel (Levonelle One) is not indicated for use after 72 hours of UPSI. Mirena coil is not used for emergency contraception.

Answer 1632

SSRIs are taken safely by many women during pregnancy. The associated effect on the foetus is centred around the instant withdrawal that occurs at birth, and the baby may be initially jittery and hypotonic, rather than with any neural tube malformations.

Answer 1633

all women should take 400mcg of folic acid until the 12th week of pregnancy women at higher risk of conceiving a child with a NTD should take 5mg of folic acid until the 12th week of pregnancy women are considered higher risk if any of the following apply: → either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD → the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. → the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Answer 1634

Chlamydia infection in pregnancy is associated with premature delivery, amnionitis and puerperal infection. If cervical chlamydia infection is present at delivery, there is a high likelihood of neonatal chlamydia. Neonatal chlamydia can include complications such as conjunctivitis and pneumonia. Patients should be referred to a sexual health clinic for a full sexual health screen and for contact tracing. Suitable treatments in pregnancy include erythromycin, amoxicillin or azithromycin. Doxycycline is contraindicated in pregnancy due to the risk of teeth and bone abnormalities in the fetus. Repeat testing sometime after completion of treatment is recommended in pregnancy to ensure therapeutic cure.

Answer 1635

This is a typical history of retained products, which can happen after caesarean section if care is not taken to make sure that all the placental membranes are removed. The uterus does not contract down well as the products are still in the cavity, and the discharge is offensive suggesting that the products have become infected. This lady needs and urgent examination under anaesthesia to remove the products. The products often pass by themselves without the need for anaesthesia, however after day 1 this is unlikely so intervention is needed. Sometimes a scan would be done before but with a history this clear, it is not necessary. It is also hard to pick up products on scan sometimes as they can be very small. A speculum examination would be helpful to show is the os was still open, however the os remains open in heavy bleeding so this information would not give us a diagnosis. IV antibiotics are probably needed in this case, however the infection will not resolve until the products are removed and therefore surgery is also needed. An MRI is not helpful in this situation as it is not useful for detecting intrauterine pathology, and would probably take a long time to organise which is unhelpful in this acute situation.

Answer 1636

Important points: A pregnant woman with abdominal trauma should have Rhesus testing asap because women who are Rhesus-negative should be given anti-D to prevent Rhesus isoimmunization.

Answer 1637

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.

Answer 1638

From the clinical picture, you should have a differential diagnosis of Turner's syndrome. Patients with Turner's syndrome are prone to have bicuspid aortic valve, aortic valve stenosis and/or aortic coarctation. For this reason, you would be expecting to hear a systolic murmur which is loudest over the aortic region.

Answer 1639

Clearly you would want more information about sexual history for this lady, and in all likelihood would send triple swabs regardless. However, a diagnosis of Gonorrhoea is unlikely given the healthy looking cervix. You would also expect a more green and purulent discharge for Gonorrhoea rather than a watery discharge. Gonorrhoea is particularly problematic as it can present with a normal examination, however is not often associated with an odour. In a similar line, you would expect to see more problems with the cervix for a diagnosis of Chlamydia and a more mucopurulent discharge. Chlamydia can also cause cervical excitation which this lady does not have. Herpes simplex doesn't tend to cause vaginal discharge, and would instead present as a crop of ulcers or tingling type sensations around the vulva. Patients can have a flu like illness, and may have some lymphadenopathy. For candidiasis, or thrush, you would expect a lot more itching in the history. It would also be more likely to have a thick creamy consistency like cottage cheese. There is a higher probability with thrush that you would get vulval irritation. Bacterial vaginosis is the most likely diagnosis on balance. It gives a characteristic fishy odour, and is often a thin watery discharge that can have a green or white hue. It often doesn't cause irritation or soreness, and can be completely asymptomatic. Diagnosis would be confirmed with a vaginal pH \> 4.5 and clue cells on microscopy.

Answer 1640

Guidelines issued by the Royal College of Obstetricians and Gynaecologists state that women who present with first-episode genital herpes during their third trimester should be managed with daily suppressive oral aciclovir 400mg until delivery. Delivery should be by caesarean section due to a high risk of neonatal HSV (herpes simplex virus) transmission. It can be difficult to clinically distinguish between primary and recurrent episodes of genital herpes. If a patient has not noticed the symptoms in the past it is recommended that management is initiated on the assumption that it is the first episode. Type-specific HSV antibody testing can be performed in order to confirm or refute this, but this can take 2-3 weeks to yield results - hence the recommendation to initiate the above management plan which can later be modified if appropriate.

Answer 1641

There are no antidepressants licensed for use during pregnancy, however it is not uncommon for medication to be continued if a patient is already taking it and is likely to struggle without it. Phenelzine is a monoamine-oxidase inhibitor (MAOI). The BNF strongly advises that MAOIs be avoided in pregnancy due to an increased risk of neonatal malformations. Maternal hypertensive crisis has also been reported in association with this class of antidepressant. Fluoxetine and sertraline are selective serotonin reuptake inhibitors. They are associated with a small increased risk of congenital heart disease and can cause neonatal withdrawal symptoms. Imipramine and amitriptyline are tricyclic antidepressants. Imipramine use during pregnancy is associated with a wide range of neonatal symptoms including tachycardia and respiratory depression.

Answer 1642

The clinical presentation in this question is consistent with that of a molar pregnancy. A basic understanding of physiology is needed to answer this question correctly. Molar pregnancies are characterised by significantly high levels of beta hCG for gestational age, and are therefore used as a tumour marker of gestational trophoblastic disease. The biochemical structure of beta hCG is very similar to that of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). That being said, high levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). This can result in signs and symptoms of thyrotoxicosis. High levels of T4 and T3 have a negative feedback effect on the pituitary gland to stop secretion of TSH, causing and overall reduction in TSH levels.

Answer 1643

The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (\<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of \<1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with methotrexate as long as the patient is willing to attend for follow-up. Methotrexate is an antimetabolite chemotherapeutic drug. It interferes with DNA synthesis and disrupts cell multiplication^1 thus preventing the pregnancy from developing. The other treatment option is laparoscopic salpingectomy (or salpingotomy where there is risk of infertility). This should be offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is \>1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.

Answer 1644

On ultrasound, the mole appears as a solid collection of echoes with numerous small anechoic spaces which resembles a bunch of grapes (also known as 'snow-storm' appearance).

Answer 1645

The E6 protein binds to p53, preventing it from halting cell division. The E7 protein binds to pRb. The Human Papilloma Virus (HPV) is the causative agent in almost all cervical carcinomas. It is spread easily via sexual transmission, and although most types do not cause cancer, persistence of high-risk oncogenic types, such as 16, 18, 33 and 45 cause cell transformation and neoplasia. The aim of the cervical screening programme is to prevent cervical intraepithelial neoplasia from progressing to cancer. HPV itself is a double-stranded DNA virus, consisting of an icosahedral capsid (encoded by L1 and L2) and proteins E1-E7 (involved in replication and cell transformation). HPV invades keratinocytes of the skin and mucous membranes and uses the host DNA replication machinery to replicate itself. HPV enters the basal compartment and as the surface cells naturally shed, the HPV infected cells migrate upwards and begin to replicate, resulting in a huge increase in viral copy number. Normally, the E2 protein blocks the E6 and E7 proteins, but when HPV DNA integrates into host cell DNA, E2 is inhibited. The E6 protein inhibits the tumour suppressor p53 and the E7 protein inhibits pRb, enabling uncontrolled cell division. HPV evades the immune response as there is no active cytolysis, it is not blood borne, it can disable antigen presenting cells and inhibit interferon synthesis. Most people do eventually mount an immune response to HPV. It is not known why some people are persistently infected with HPV, but it could be related to an inherent problem in immunity, as well as other co-factors, such as smoking and multiparity. The HPV vaccine consists of the L1 nucleocapsid protein (Gardasil uses L1 proteins from 6, 11, 16 and 18), which is non-oncogenic. Intramuscular injection of the vaccine means that stromal dendritic cells encounter the protein, producing a robust antibody response against L1, thus protecting against HPV infection.

Answer 1646

UKMEC1 - No restriction UKMEC2 - Advantages \> Disadvantages UKMEC3 - Disadvantages \> Advantages UKMEC4 - Unacceptable risk

Answer 1647

- \> 35 years old and smoker of \< 15 cigarettes per day - BMI \> 35 - Migraine with no aura - Family history of deep vein thrombosis or pulmonary embolism in first degree relative \< 45 years old - Controlled hypertension - Immobility e.g. Wheelchair use - Breast feeding and 6 weeks to 6 months postpartum

Answer 1648

- \>35 years old and smoker of \> 15 cigarettes per day - migraine with aura - Personal history of deep vein thrombosis or pulmonary embolism - Personal history of stroke or ischaemic heart disease - Uncontrolled hypertension - Breast cancer - Recent major surgery with prolonged immobilisation - Breast feeding and \< 6 weeks postpartum

Answer 1649

Breast tissue in premenopausal women is highly sensitive to radiation; in the long-term, CTPA confers a 14% increased risk against the background for breast cancer in pregnant women who are under 40 years old and should therefore be avoided. In 2012 NHS costing report documented the cost of a V/Q scan as £162 with CTPA as £100; both cost an additional £20 each for reporting. There is often more disagreement between radiologists as to the presence or absence of a PE on V/Q scan and so results are given as high or low probability in the context of a scoring system such as the Wells score. Radiation exposure to the fetus with V/Q scans and CTPA are equivocal

Answer 1650

Travel to malarial areas should ideally be avoided during pregnancy. However, if travel is unavoidable then the benefits of taking prophylaxis are usually considered to outweigh the risks. Mefloquine is recommended by the Royal College of Obstetricians and Gynaecologists (RCOG) as the drug of choice for prophylaxis in the second and third trimesters. Although chloroquine is considered to be relatively safe, the RCOG states that with very few areas in the world free from chloroquine-resistance, mefloquine is essentially the only drug considered safe for prophylaxis in pregnant travellers. Doxycycline, like other tetracyclines, should be avoided in pregnancy due to effects on skeletal development and discoloration of teeth. Piperaquine has been found to be teratogenic in animal studies. There is insufficient information about the effect of atovaquone in pregnancy.

Answer 1651

Footling presentations are a rare but the most risky form of breech- there is a 5-20% risk of cord prolapse, which can obstruct foetal blood flow and is an obstetric emergency. 40% of babies are breech at 20 weeks but only 3% at term- there is still plenty of room for the foetus to turn around and resolve to head down. In occipitoposterior presentation the posterior fontanelle is found in the posterior quadrant of the pelvis; greater rotation is required so labour is usually longer. There is a greater rate of intervention- 22% require forceps and 5% require caesarean section. Face presentations normally occur by chance when the head extends rather than flexes as it engages. 99% rotate so the chin lies behind the symphysis and the head can be born by flexion; in 1%the chin rotations to the sacrum and caesarean section is indicated. Transverse lie is where the shoulder is presenting. It occurs in multiparous women due to their uterine muscles being less tight than a nulliparous woman. Extracephalic version may be attempted from 32 weeks and thus is manageable at 30 weeks.

Answer 1652

This question tests the understanding of the management of ectopic pregnancy. According to the NICE guidelines, systemic methotrexate should be offered to women who have all of the following No significant pain An unruptured ectopic pregnancy with adnexal mass less than 35mm with no visible heart beat A serum hCG less than 1,500 IU/liter No intrauterine pregnancy ( as confirmed by ultrasound) In addition to the criterion mentioned above, it is important to be familiar with the contraindications of using methotrexate. Once given, the patient should have her beta-hCG levels measured twice (at day 4 and day 7). Normally, beta-hCG levels rise on day 4 compared to pre-treatment levels. This is due to the death of trophoblastic cells. A second beta-hCG level should therefore be taken at day 7 and ensure that levels are dropping. Although a second dose of methotrexate is a common approach ,it should only be considered if the beta-hCG levels do not fall \>15% on day 7 compared with day 4. Laparoscopic surgery is preferred in women with ruptured ectopic pregnancy not meeting the criteria for medical treatment. The decision to have a salpingotomy over salpingectomy depends on the condition of the contralateral tube and desire for future fertility. In this scenario, laparoscopic surgery should be considered if medical therapy with methotrexate fails. An emergency laparotomy is not indicated in this patient, as she is stable.

Answer 1653

CF Down's CMV

Answer 1654

Down's Congenital Abdominal wall defects

Answer 1655

A subarachnoid haemorrhage (SAH) is a type of stroke which is usually the result of bleeding from a berry aneurysm in the Circle of Willis. Key clinical features include a sudden onset headache which reaches maximum severity in seconds to minutes ('thunderclap headache') and meningitic symptoms (for example photophobia and neck stiffness).

Answer 1656

Subfertility DM Stroke and TIA Coronary artery disease Obstructive sleep apnoea Endometrial Ca

Answer 1657

Cardiotocography (CTG) is used to assess foetal well being by measuring the foetal heart rate and maternal contractions. A normal trace is reassuring but an abnormal trace can require further monitoring or require additional investigations. There are four important features when interpreting a CTG: Baseline foetal heart rate Baseline variability Presence of accelerations Presence/absence of decelerations The CTG described in this case has 2 non-reassuring features - the foetal heart rate is 175 bpm and there are variable decelerations. This makes the CTG abnormal but it does not require urgent intervention as there is no bradycardia or prolonged late decelerations. NICE guidelines suggest that conservative measures should be initiated and a foetal blood sample should be taken in order to determine the next step in management. Planning for delivery will be discussed with the consultant obstetrician after the foetal blood sample is obtained. While oxytocin may help to initiate contractions in order to move into the 2nd stage of labour, this should not be done until foetal well being is confirmed through foetal blood sample.

Answer 1658

Should have a voiding detrusor pressure risk of \<70cm Peak flow rate of \>15ml/s High voiding detrusor pressure with low peak flow rate is indicative of bladder outflow obstruction

Answer 1659

The answer here is chronic hypertension. At 16 weeks gestation, this lady is too early into her pregnancy to have developed any of the pregnancy related causes of hypertension. The small amount of protein in her urine may also indicate relatively long standing hypertension. Intermittent frontal headaches are a common occurrence and are not a sign of pre-eclampsia in this case. Pre-eclampsia and gestational hypertension would only occur after 20 weeks gestation. Pre-eclampsia with significant proteinuria, gestational hypertension without. Nephrotic syndrome would be associated with a larger degree of proteinuria.

Answer 1660

This is a question regarding management of menorrhagia. In this scenario, this lady most likely has uterine fibroids and is therefore appropriately being sent for transvaginal ultrasound for further assessment. NICE Clinical Knowledge Summaries dictate that tranexamic acid or NSAIDs are the most suitable 1st line agents to use to manage symptoms while awaiting results of investigations. Since the patient does not have pelvic pain, tranexamic acid is most appropriate. It would not be appropriate to insert a levonorgestrel releasing IUS before delineating the anatomy in someone whom you're suspicious of fibroids.

Answer 1661

Ovarian torsion can only be definitively diagnosed invasively. Laparoscopy (keyhole) is the usual method of surgery and allows diagnosis by visual inspection and also allows management with detorsion. Laparotomy (open) is another option for surgery but is usually reserved for patients with suspected or confirmed malignancy to prevent seeding and malignant spread. Laparotomy may also be used for those patients in whom laparoscopy may be difficult, for example due to size, either obesity or small size in infants. Ultrasound is the imaging modality of choice to confirm clinical suspicion of ovarian torsion, but cannot provide a definitive diagnosis. Combining transvaginal with transabdominal methods of ultrasound provides the best images of reproductive organs. Features on ultrasound include visualisation of the twisting of vessels (whirlpool sign), ovarian oedema, and reduced blood flow to and within the ovary when examining with colour Doppler. Diagnostic reliability of non-invasive imaging is also dependent on sonographer/radiologist expertise. CT would show similar findings to ultrasound, but this is more costly and has the added risk of radiation. In a CT with contrast, there would be lack of enhancement of the affected ovary. A CT without contrast is appropriate for imaging renal stones but would not demonstrate ovarian torsion or structural changes within organs very well. N.B. Differential diagnoses for this presentation would be appendicitis and ectopic pregnancy. These can be ruled out from the history. Appendicitis: Abdominal pain was localised since onset to the right iliac fossa rather than starting as diffuse and localising later on. There is no diarrhoea. There is no fever. Ectopic pregnancy: There is no vaginal bleeding. This patient is on the contraceptive implant.

Answer 1662

The findings in this case are classical of placenta praevia. 1. These investigations would be used to partly investigate pre-eclampsia 2: Vaginal examinations should always be avoided in a pregnant woman with unexplained vaginal bleeding 3: Correct, this should show a low-lying placenta 4: Vaginal investigations should always be avoided in a pregnant woman with unexplained vaginal bleeding 5: This would elicit any fetal distress, however would not confirm a diagnosis of placenta praevia

Answer 1663

The correct answer here is discharge the patient back to her GP, while obviously telling the patient to report back if she has any further episodes of vaginal bleeding. The combination of the endometrium being thin on scan and there being no histological evidence of abnormal tissue is reassuring enough to say at the moment her risk of endometrial cancer is low. Pipelle biopsies are shown to have a very high sensitivity in detecting endometrial cancer (\>99%). Without any further episodes of vaginal bleeding repeating a pipelle in 3 months is not indicated. As the sensitivity of pipelle biopsy is so high, a hysteroscopy and endometrial biopsy is not needed in this case. This is an invasive procedure, which is uncomfortable as an outpatient and therefore often needs a general anaesthetic, which carries further risks. Sometimes a hysteroscopy and endometrial biopsy is needed, for example if the pipelle is not possible in the outpatient setting (e.g. due to patient not tolerating it, a stenosed cervix etc.) or if there is other pathology, for example polyps, which need to be visualised. Ultrasound scanning has not been shown to be a reliable screening test for endometrial cancer, and therefore repeating the ultrasound scans is not helpful. There is no need to follow the patient up in 1 year, as if she does not have any further episodes of bleeding the risk of endometrial cancer remains low. It is however very important to explain to the patient that even though this time she was low risk, she could be in early stages or still go on to develop endometrial cancer, and therefore she should see her GP immediately about any further episodes of vaginal bleeding.

Answer 1664

Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the treatment of choice for stage I and II endometrial carcinoma. Provera is a progesterone used as a hormonal treatment for endometrial carcinoma - it acts by slowing the growth of malignant cells in the endometrium. Wertheim's radical hysterectomy includes removal of lymph nodes and is used to treat stage IIB endometrial carcinoma.

Answer 1665

Hydroxychloroquine is considered safe during pregnancy

Answer 1666

methotrexate is not safe in pregnancy and needs to be stopped at least 3 months before conception

Answer 1667

patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation

Answer 1668

NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus

Answer 1669

Considered safe

Answer 1670

Is not considered safe

Answer 1671

Syntocinon is a synthetic oxytocin analogue and is the drug of choice for stimulating labour when the contractions are considered too weak.

Answer 1672

Take missed pill as soon as possible and advise condom use until pill taking re-established for 48 hours

Answer 1673

An incomplete miscarriage occurs when some, but not all, of the products of conception are expelled from the uterus. Retained products of conception pose an infection risk to the mother and so should be treated promptly. Bleeding in miscarriage can be serious and physiological signs of shock should not be missed. The National Institute of Health and Care Excellence (NICE) recommends that during an incomplete miscarriage, medical management of miscarriage should be offered where 'expectant management' is unacceptable to the patient. A single dose of misoprostol 600 micrograms as a vaginal pessary is first line medical management of an incomplete miscarriage. If this is not tolerated then oral administration is acceptable. Other management options include manual vacuum aspiration under local anaesthetic and surgical management under general anaesthetic. Medical management as opposed to expectant management is often offered to women who have previously had a traumatic experience of pregnancy, such as a previous miscarriage or still birth.

Answer 1674

HPV, the causative agent of cervical cancer, can be transmitted during lesbian sex. Lesbian and bisexual women should therefore have cervical screening as normal. Unfortunately the uptake amongst lesbian women is around 10 times worse than the general female population, sometimes as a consequence of incorrect advice from healthcare professionals.

Answer 1675

Anti-muscarinic used in treatment of detrusor muscle over-activity

Answer 1676

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.

Answer 1677

As the fibroid is less than 3 cm medical treatment can be tried. NICE Clinical Knowledge Summaries recommend an intrauterine system initially, which will also provide contraception.

Answer 1678

Indomethacin to reduce foetal urine output Laser obliteration of placental vascular communications Selective foetal reduction After birth, the donor may require blood transfusions to treat anaemia. The recipient twin may need exchange transfusions/ heart failure medications.

Answer 1679

When prescribing the oral contraceptive pill there are a number of risk factors that must be screened for. These risk factors are split into a four point scale with level 4 being considered an unacceptable health risk. All answer except for Systemic Lupus Erythematosus are considered level 3 where the disadvantages generally outweigh the advantages but prescription can be given if deemed appropriate.

Answer 1680

Offer treatment to all pregnant women with symptomatic bacterial vaginosis (BV). If a pregnant woman is incidentally found to have BV and has no symptoms, discuss with the woman's obstetrician whether treatment is appropriate. Oral metronidazole is the treatment of choice. High-dose regimens are not recommended during pregnancy. Intravaginal metronidazole gel or clindamycin cream are alternative choices if the woman prefers a topical treatment or is unable to tolerate oral metronidazole. Oral clindamycin is not widely recommended in primary care because of an increased risk of pseudomembranous colitis.

Answer 1681

These are the various sites of ectopic pregnancy and their prevalence in % : tubal ectopic: 93-97% ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics interstitial ectopic/cornual ectopic: 3-4%; also essentially a type of tubal ectopic ovarian ectopic/ovarian pregnancy; 0.5-1% cervical ectopic/cervical pregnancy; rare \<1% scar ectopic: site of previous Caesarian section scar; rare abdominal ectopic: rare; ~1.4%

Answer 1682

Oral contraceptives should be used with caution in patients with a history of inflammatory bowel disease affecting the small bowel due to the risk of malabsorption. There is no evidence to suggest that the efficacy of the Evra patch is reduced.

Answer 1683

This woman has been treated for cervical intraepithelial neoplasia (CIN) at her colposcopy appointment. She requires follow-up to determine if the lesion has been adequately treated. Women who have been treated for CIN II should be offered cervical screening at 6 months and 12 months post-treatment. This should then be followed by annual screening for a total of 10 years. If a woman has a positive-test after treatment they should return to colposcopy.

Answer 1684

The correct answer is that the patient may be continued on metformin but that the gliclazide must be stopped. In the management of type 2 diabetes in pregnancy 'women with pre-existing diabetes can be treated with metformin, either alone or in combination with insulin'. While it is likely that the patient will be required to switch to insulin it is not an absolute requirement. Both gliclazide and liraglutide are contraindicated in pregnancy.

Answer 1685

NICE guidelines suggest that a woman who has been called for routine screening wait until 12 weeks post-partum for her cervical smear. If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.

Answer 1686

Anti-epileptics in pregnancy can be a tricky subject. Many are known to cause severe congenital defects (both structural and intellectual) and as such the first line of care is good contraceptive advice and planning with the patient in question. This is however, not always possible and there will always be cases where a patient becomes pregnant whilst on anti-epileptic medication prior to consulting with a doctor. The recent MBRRACE-UK and the NICE clinical guidelines both state that most women with epilepsy and of child bearing age are currently prescribed lamotrigine and during pregnancy this may require a dose increase. Phenytoin, phenobarbitone and sodium valproate are all known to have an adverse effect on cognitive abilities and therefore are usually avoided unless absolutely necessary. Lamotrigine, carbamazepine and levetiracetam are known to have the smallest effects on the developing foetus, however all epileptics who are either pregnant or are planning to become pregnant should be referred to specialist care as soon as possible.

Answer 1687

Microgynon 30 would be contraindicated in this lady as she is over 35 years old and smokes \>15 cigarettes per day. Depo-provera could be used, but can be associated with prolonged amenorrhoea up to 1 year after discontinuation, which would not suit this lady who wants to try for a family in 1 year. The insertion of both Mirena and Implanon and subsequent removal in the space of a year is likely to be more of a burden to this lady than taking an oral contraceptive over the same time period. Cerazette, a progesterone only pill, is not contraindicated and can easily be stopped in 1 year.

Answer 1688

describes a very rare situation in which there are simultaneous ectopic and uterine pregnancies. It is usually treated by surgical removal of the ectopic pregnancy.

Answer 1689

If any doubt about previous chickenpox- urgently check Ab titres If the pregnant womanm is not immune she should be given VZIG which is effective up to 10 days post exposure Should be prescribed oral acyclovir if present within 24h of rash onset

Answer 1690

Vasa praevia describes a complication in which fetal blood vessels cross or run near the internal orifice of the uterus. The vessels can be easily compromised when supporting membranes rupture, leading to frank bleeding. The classic triad of vasa praevia is rupture of membranes followed by painless vaginal bleeding and fetal bradycardia. Unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant. The two conditions may be difficult to distinguish in acute clinical situations, but for examination purposes a preceding rupture of membranes will usually be emphasised. Although ultrasound scans can detect vasa praevia, many cases are undetectable antenatally.

Answer 1691

Immune thrombocytopenia (ITP) is an autoimmune condition that can occasionally complicate pregnancies, especially if there is placental passage of maternal antiplatelet antibodies. The high pressure exerted by the vacuum during a ventouse delivery can cause bleeding in the neonate. Cephalohaematoma or more severely, subgaleal haemorrhage, can be exacerbated in the context of neonatal thrombocytopenia. Fetal blood sampling and forceps might be used with caution but would not be as high-risk. A Caesarean section would pose a greater risk to the mother, rather than the neonate.

Answer 1692

The correct answer is Losartan. Losartan is an ARB which are contraindicated in pregnancy unless absolutely essential and not recommended in breast feeding. The other options; Enalapril, Nifedipine, Labetalol and Atenolol are all safer in breast feeding.

Answer 1693

Oligohydraminos is a conditions where there is a deficiency of amniotic fluid during pregnancy. This can often present as smaller symphysiofundal height. Renal agenesis is a cause of oligohydraminos (abnormally low volume of amniotic fluid) as the amniotic fluid is mainly derived from foetal urine

Answer 1694

NICE define delay in the established first stage of labour as: Cervical dilatation of less than 2cm in 4 hours for first labours Cervical dilatation of less than 2cm in 4 hours or a slowing in the progress of labour for second or subsequent labours.

Answer 1695

Women who are HIV positive are at an increased risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer due to a decreased immune response and decreased clearance of the human papilloma virus. (1) HIV positive women who have low-grade lesions (CIN1) do not clear these lesions and these can progress to high-grade CIN or cervical cancer. Even those women who are effectively treated with antiretrovirals have a high risk of abnormal cytology and an increased risk of false-negative cytology. (1) Women with HIV should be offered cervical cytology at diagnosis.. Cervical cytology should then be offered annually for screening.

Answer 1696

BV is characterised by an overgrowth of mainly anaerobic organisms. It is a common cause of vaginal discharge and is not considered to be a sexually transmitted infection. Approximately 50% of women are asymptomatic. When symptoms are present, BV is characterised by a fishy-smelling vaginal discharge. Symptomatic BV in pregnancy is associated with late miscarriage and preterm delivery. Treatment should be offered to all pregnant woman who are symptomatic. This consists of oral metronidazole 400mg twice daily for 5-7 days (2grams stat dose is not recommended in pregnancy). Treatment is considered on a individual basis for pregnant woman with BV who are asymptomatic. This is because evidence suggests that identification and treatment of asymptomatic pregnant women does not lower the risk of preterm births.

Answer 1697

All woman who are taking an enzyme-inducing drug (EID) (carbamazepine is an example of an EID) should be advised to use a reliable contraceptive that is unaffected by EIDs. Examples of contraceptives that are unaffected by EIDs are: Copper intrauterine device Progesterone injection (Depo-provera) Mirena intrauterine system The copper intra-uterine device is usually the preferred option, as it is a non-hormonal method. In the above scenario, the patient is obese with a BMI of 39 kg/m². Therefore, the contraceptive injection (Depo-Provera) would not be the most suitable option. This is because it is associated with weight gain (2-3kg over 1 year). In patients on EIDs who wish to take the COCP (providing there are no contraindications) it is important to inform them that the effectiveness is decreased and there is an increased risk of pregnancy. It is recommended that the dose of oestrogen is increased to 50mcg with no pill-free interval, or reduced to 4 days from 7 days (to reduce the chance of ovulation). In addition, barrier methods would also be advised. This applies when the patient is on an EID and for 4 weeks after stopping. In patients on EIDs who wish to take the POP or progesterone implant, then additional barrier contraception would be required while using EIDs and for 4 weeks after stopping. Note - rifampicin and rifabutin are potent EIDs and require longer periods of using barrier contraception after stopping (8 weeks). If emergency contraception is required, the copper intra-uterine device is again the best option. If levonorgestrel (Levonelle) is used, then double the standard dose is recommended. Ulipristal acetate (ellaOne) is not recommended.

Answer 1698

Prior to Day 21 postpartum no contraceptive methods are required. In non-breastfeeding women, ovulation may occur as early as Day 28. As sperm can survive for up to 7 days in the female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy is to be avoided.

Answer 1699

Female genital mutilation (FGM) is a criminal act. The GMC has now issued guidance that all cases of FGM must be reported to the police in under 18s. The mandatory duty does not apply in over 18s. It also does not apply if a doctor can identify that another doctor has already made a report to the police in connection with the same act of FGM. Providing symptomatic treatment only would be in breach of GMC guidance and would put your registration at risk. Calling in the family for discussion may not be appropriate and may lead to further distress for the patient. You would still need to make a police report. Contacting child protection services may be an additional necessary step, but it is imperative that a police report is made in the first instance. Referring to secondary care for investigation may be useful for treating any symptoms of FGM, but again a police report needs to be made.

Answer 1700

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).

Answer 1701

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).

Answer 1702

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).

Answer 1703

All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.

Answer 1704

For a woman with a personal or family history of thromboembolic disease, offer lifestyle advice or non-hormonal therapies. For vasomotor symptoms, consider a 2 week trial of Paroxetine/ Fluoxetine/ Citalopram/ Venlafaxine or a 24 week trial of Clonidine. If these measures are inadequate and the woman requires treatment, refer to a specialist in thrombophilia.

Answer 1705

Offer active third stage due to the higher risk of PPH

Answer 1706

Impaired glucose tolerance 2hour glucose greater than or equal to 7.8 Diabetes random gluocse greater than or equaly to 7 or 2 hour glucose greater than or equal to 7.8

Answer 1707

Phyisological, due to dilatation across the tricuspid vavle causing mild regurgitant flow.

Answer 1708

First trimester: highest risk of teratogenicity- fetal warfarin syndrome Still exists in mid and third triemsters

Answer 1709

Fetal warfarin syndrome

Answer 1710

Mother should have BP checked before fetal CTG as it is not possible to deliver the fetus until the mother is stable

Answer 1711

Antibiotics Induce labour No steroids

Answer 1712

Listeriosis

Answer 1713

Impetigo herpetiformis

Answer 1714

Pemphiogid gestationis

Answer 1715

Prurigo gestationis

Answer 1716

Pre-meal: \<5.5 1 hour post meal \<7.8