O&G: rules

Question 1

Maternal risk factors

Answer 1

Age (less than 16 years or more than 35 years).
Low socio-economic status.
Parity (none or more than five births).
Previous pregnancy problems.
Maternal substance abuse
Drugs (teratogens)
BMI < 20 or > 30
Comorbidities - e.g, asthma, cyanotic CHD, HTN, pre-eclampsia, DM, CKD, SLE, APLS, SCD
Infections: TORCH, malaria, tuberculosis, UTI and BV

Question 2

Foetal risk factors

Answer 2

Chromosomal abnormalities - eg, trisomies 13, 18, or 21,
Genetic syndromes - eg, Russell-Silver syndrome, Rubinstein-Taybi syndrome, Dubowitz’s syndrome, Seckel’s syndrome, Fanconi’s syndrome.
Major congenital anomalies - eg, tracheo-oesophageal fistula, congenital heart disease, congenital diaphragmatic hernia, abdominal wall defects (omphalocele or gastroschisis), neural tube defect (eg, anencephaly), anorectal malformation.
Multiple gestation.
Congenital infections (TORCH syndrome, malaria, congenital HIV infection, syphilis).
Metabolic disorders - eg, congenital lipodystrophy, galactosaemia, generalised gangliosidosis type I, hypophosphatasia, fetal phenylketonuria

Question 3

Foetal distress: assessment and management

Answer 3

Assess - CTG, movements

Manage - ROM, IOL and CS if urgent

Question 4

Active management of labour.

PROGRESS

Answer 4

Pain relief adequate
Rate - contractions, FHR
Oxytocin
Glandins (PGE2)
Rupture membranes
Examine vagina
Support (one-to-one)
Sweep

Question 5

Gynae malignancy:

Stages 1 - 4 (typically)

Answer 5

Stage 1: confined
Stage 2 - 3: local spread, local invasion
Stage 4: invasion to bowel/bladder or distant mets.

Question 6

Cervical cancer

Dyskariosis to CIN

Answer 6

Mild ~ CIN 1
Moderate ~ CIN 2
Severe ~ CIN 3

Question 7

Types of hysterectomy

Answer 7

• Subtotal: uterus
• Total: uterus and cervix
• TAH + BSO: uterus, cervix, tubes and ovaries
• Radical: as above, with regional lymph nodes and wide excision

Question 8

Fertility preserving treatments:

a) Cervical cancer (stage 1A)
b) Endometrial cancer (stage 1A)
c) Endometriosis
d) Fibroids

Answer 8

a) Cervicectomy
b) Progestogens
c) Endometriata removal
d) Myomectomy

Question 9

Gynae malignancy: histology

a) Ovarian
b) Endometrial
c) Cervical

Answer 9

a) Epithelial (most common: serous)
b) Adenocarcinoma
c) Squamous cell

Question 10

Ovarian cancer:

a) Signs on USS (MASS)
b) Treatment
c) Intra-operative procedure to tests for malignancy
d) Risk of malignancy index (RMI)

Answer 10

a) Multilocular cyst, Ascites, Solid areas, Spread (intra-abdominal metastases)
b) TAH with BSO
c) Peritoneal washings

d) RMI = U x M x CA125
- U = USS features (score 0 - 5)
- M = menopausal status (pre = 1; post* = 3)
- CA125

• post menopausal = no period for > 1 year or >50 and had a hysterectomy

Question 11

Menopause

a) Define
b) Presentation
c) Early = ? (diagnosis?)

Answer 11

a) Permanent cessation of menstruation resulting from loss of ovarian follicular activity
- 12 consecutive months of amenorrhoea (or onset of symptoms if hysterectomy)

b) Amenorrhoea, hot flushes, tired, irritable, vaginal atrophy, dyspareunia, urinary symptoms
c) < 40 - diagnose with low FSH on two samples a month apart

Question 12

HRT

a) If hysterectomy
b) If no hysterectomy - why?
c) Types - choice? risk of DVT etc.
d) Other treatments to give for menopause
e) Duration
f) Risks

Answer 12

a) Oestrogen alone if hysterectomy
b) Oestrogen + progesterone if not as this reduces risk of endometrial hyperplasia/carcinoma
c) Oestrogens can be oral, transdermal, subcutaneously (implant)
d) Other things to use: tibolone, androgens (used to improve libido), vaginal oestrogens

e) Up to 51 in premature menopause, otherwise advise 5 years
f) Breast cancer (combined HRT), Endometrial cancer (oestrogen only HRT), VTE (oral > transdermal), Gall bladder disease (oral), CV disease (combined), Stroke (oral)

Question 13

Investigating amenorrhoea

Answer 13

Bedside.

• Height and weight
• Pregnancy test

Bloods.

• FSH/LH levels , Prolactin levels
• Total testosterone/sex-hormone binding globulin levels
• Thyroid function (if clinically indicated)

Imaging.
- Pelvic USS if PCOS suspected

Question 14

Menorrhagia management

a) Trying to conceive
b) Not trying to conceive

Answer 14

a) TxA, NSAIDs (mefenamic)

b) IUS (Mirena) - 1st line

Question 15

Dysmenorrhoea management

a) Trying to conceive
b) Not trying to conceive

Answer 15

a) NSAIDs (ibuprofen/mefenamic)

b) COCP - also regulate cycle

Question 16

Investigating dysmenorrhoea

Answer 16

• Examination (abdo, speculum, bimanual)
• swabs if STI risk,
• pelvic US,
• diagnostic laparoscopy

Question 17

Investigating abnormal PV bleed

Answer 17

• Assess effect of blood loss- FBC
• TFT/clotting
• FSH/LH levels if menopause suspected
• Cervical smear if required
• USS of uterine cavity (Endometrial biopsy if abnormal)
• Beta-hCG (ectopic, miscarriage)

Question 18

Pelvic ligaments

Answer 18

Broad
Round
Suspensory
Ovarian

Question 19

Fibroids.

a) Risk factors
b) Protective factors

Answer 19

a) Oestrogen (nulliparous, early puberty), Afro-Caribbean descent, Family history
b) COCP, parity, late menarche, breastfeeding

Question 20

Uterine abnormalities

a) Result from…?
b) Example

Answer 20

a) Results from differing degrees of failure of fusion of Müllerian ducts
b) Bicornuate, arcuate

Question 21

Investigating suspected endometrial Ca

Answer 21

Transvaginal US scan (PMB)
Endometrial biopsy (hysteroscopy/ Pipelle)
- Indications:
Endometrium >4mm thick on TVUS if post menopausal
Endometrium >10mm thick on TVUS if premenopausal
Multiple episodes of PMB

Question 22

PCOS:

a) Rotterdam criteria (PCO)
b) Ix
c) Rx if wishing to conceive
d) Rx if not wishing to conceive
e) Complications

Answer 22

a) Polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3).
Clinical and/or biochemical signs of hyperandrogenism
Oligo-ovulation or anovulation.

b) LH:FSH ratio, testosterone and SHBG, USS ovaries, lipids and glucose
c) Conservative, COCP, metformin, co-cyprindrol (for hirsutism and acne)
d) Conservative, Clomifene, metformin
e) Infertility, miscarriage, menstrual issues, weight gain, T2DM

Question 23

Ovarian cyst

a) Most common types in i) 40 - 50, ii) 20 - 40
b) Presentation
c) Ix
d) Rx - 1st line? 2nd line? Torsion

Answer 23

a) i) Serous cystadenomas, ii) Mucinous cystadenomas
b) Asymptomatic, pressure symptoms, dyspareunia, acute (torsion, rupture)

c) Pregnancy test, urinalysis, FBC and CRP
TVUS, CA125 (in older women), AFP (if complex and worried about germ cell tumour)

d) Watchful waiting, then surgery if persisting.
Torsion - oopheropexy or salpingo-oopherectomy if severe/necrotic

Question 24

Prolapse

a) Three types
b) Degrees of uterine prolapse
c) Presentation
d) Causes
e) Investigation and management

Answer 24

a) Anterior wall (cystocele), posterior wall (rectocele), uterine prolapse

b) - 1st (cervix into vagina),
- 2nd (cervix to level of introitus),
- 3rd (cervix outside vagina, i.e. below introitus),
- 4th (whole uterus outside vagina - complete procidentia)

c) Dragging, dyspareunia, stress incontinence

d) PROLAPSE:
o      Pregnancy
o	Race (Caucasian)
o	Oestrogen low/ obesity 
o	Labour
o	Age/ anatomy
o	Pelvic surgery 
o	Strain (cough, constipation)
o	Elastin/collagen (e.g. EDS)

e) - Sims’ speculum to assess
- Conservative (weight loss, stop smoking, pelvic floor exercises),
- vaginal pessary
- surgical repair + vaginal mesh

Question 25

CTG interpretation
(DR C BRAVADO)

Answer 25

• Define Risk - maternal (GDM, smoking), obstetric (pre-eclampsia, induction of labour, IUGR, PROM, foetal abnormalities, etc.)
• Contractions - duration and intensity (over 10 mins)
• Baseline RAte - normal (110 - 160)
• Variability - normal (5 - 25)
• Accelerations - present (normal), absent (only normal if no other abnormal CTG features)
• Decelerations - early (may be physiological), late (pathological), prolonged (pathological)
• Overall impression - reassuring, non-reassuring or abnormal

Question 26

CTG: baseline rate

a) Normal range
b) Tachycardia (causes?)
c) Mild bradycardia (causes?)
d) Severe bradycardia (causes?) - treatment?

Answer 26

a) 110 - 160
b) > 160: hypoxia, chorioamnionitis, hyperthyroid, anaemia
c) 80 - 100 (for > 3 mins): post-term gestation
d) < 80 (for > 3 mins): FOETAL HYPOXIA - prolonged cord compression, cord prolapse, maternal seizures. If cause not found/treated - immediate delivery

Question 27

CTG: variability

a) Why is it good?
b) Causes of reduced variability - 1 normal, 4 pathological
c) If reduced variability and late decelerations - likely cause?
d) Sinusoidal pattern

Answer 27

a) Foetus adapting to environment well with every beat
b) Foetus sleeping (should last < 40 mins), foetal acidosis, drugs (opiates, MgSO4), prematurity
c) Foetal acidosis secondary to hypoxia
d) Indicates severe foetal hypoxia. Poor outcome, requires immediate CS

Question 28

CTG: accelerations

a) Define
b) Presence of accelerations good?

Answer 28

a) Abrupt increase of FHR > 15 bpm for > 15 seconds

b) Yes. If absent, but other features in CTG normal then this is okay.

Question 29

CTG: decelerations

a) Define
b) Early - due to…?
c) Late (causes?)
d) Prolonged (management?)
e) Variable decelerations
f) If late decelerations present - what investigation should be done? If this is abnormal, what should be performed?

Answer 29

a) Abrupt decrease of FHR > 15 bpm for > 15 seconds
b) Normal physiological response to maternal contractions causing raised foetal ICP and increasd vagal tone. Resolves once uterine contraction ends
c) Begin at peak uterine contraction and recover after the contraction has ended. Indicate uteroplacental insufficiency (e.g. pre-eclampsia, maternal hypotension) causing foetal hypoxia and acidosis
d) > 3 mins: emergency CS
e) Usually caused by umbilical cord compression
f) Foetal blood sampling. If acidosis - emergency CS

Question 30

Gynaecological history.

a) Pain history - key things to ask (SOCRATES)
b) Bleeding types
c) Other gynae symptoms
d) Systemic symptoms
e) In a gynae history, what 3 things MUST you ask?
f) Elaborate on these 3 components
g) PMHx/ PSHx
h) Obstetric history
i) DHx
j) FHx
k) SHx

Answer 30

a) - Cyclical pain? (coincides with period),
- Types: dyspareunia, pelvic pain, dysmenorrhoea
- Radiation to shoulder tip (?ectopic)

b) - Normal period (?dysmenorrhoea, menorrhagia)
- Inter-menstrual bleed (IMB) - STI, ?malignancy
- Post-coital bleed (PCB) - ?cervical Ca, STI
- Post-menopausal bleed (PMB) - ?endometrial Ca

c) - PV discharge - ?STI, malignancy (ask about colour, blood, smell, sexual hx)
- Vulval skin changes - ?infection, lichen sclerosis

d) - Urinary/bowel - ?pressure effects (eg. fibroid), prolapse, bloating/IBS (?ovarian)
- Systemic - fever (?PID), shock (?bleed, ectopic), weight loss (?malignancy), tiredness/SOB (?anaemia)

e) - LAST MENSTRUAL PERIOD (LMP),
- CONTRACEPTION, and
- CERVICAL SMEAR

f) Menstrual hx.
- Duration (ave: 5), frequency (ave: 21 - 35), menarche, menopause, flow (flooding?), associated symptoms

Contraception hx.
- type, barriers?, sexual partners, need for emergency

Cervical smear hx.
- last smear, any abnormal results?, HPV vaccine status?

g) - PMHx - pregnancies, ectopics. miscarriages, STIs, malignancy, bleeding disorders, VTE, migraine w. aura
- PSHx - abdominal/pelvic, LETZ, hysterectomy, CS

h) - Gravidy, parity
- Current pregnancy? - symptoms, scans, plans
- Previous pregnancies - dates, deliveries, complications

i) - Hormonal - HRT, contraception, etc.
- Other - TB drugs (affect COCP), recent ABx (?thrush)

j) - Malignancy - ?BRCA - ovary, endometrial, breast
- Bleeding disorder/ thrombophilia (?VTE)

k) - Smoking (>35 + 15/day = no COCP), alcohol, obesity (?PCOS)