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OBG Flashcards

1
Q

What may be the features of a uterus on examination in adenomyosis?

A

classically ‘boggy/bulky’ most likely to be tender

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2
Q

How is a diagnosis of adenomyosis made?

A

US +- MRI

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3
Q

What are 5 treatment options in adenomyosis if patient wishes to remain fertile?

A
  1. NSAIDs
  2. Hormonal therapies - OCPs, IUS, danazol, aromatase inhibitors
  3. MRI/US guided high-intensity US thermo-ablation
  4. Uterine artery embolisation
  5. adenomyomectomy surgery
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4
Q

What are 2 options for adenomyosis treatment in women who do not wish to preserve fertility?

A
  1. endometrial ablation
  2. hysterectomy
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5
Q

What is the most common non-obstetric surgical emergency in pregnancy?

A

appendicitis

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6
Q

How may the presentation of appendicitis differ in pregnancy?

A

most often close to McBurney point BUT can move cephalad e.g. R flank / RUQ; tenderness may be less prominent as uterus lifts abdo wall away; classically
* 1st trimester: pain RLQ
* 2nd trimester: umbilicus
* 3rd trimester: RUQ

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7
Q

What 3 things should be done in all cases of suspected ectopic pregnancy?

A
  1. admit as emergency
  2. if confirmed - anti-rhesus D prophylaxis
  3. manage it: expectantly, medically or surgically
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8
Q

What are the expectant vs medical vs surgical management of ectopic pregnancy?

A
  1. expectant: admit and observe 48h (if low risk, low bHCG and no pain)
  2. medical: methotrexate
  3. surgical: laparoscopic approach preferred -> salpingectomy (salpingotomy i.e. keep the tube if RFs for reduced fertility)
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9
Q

What are 10 indications for anti-D treatment in Rh D negative women?

A
  1. delivery of Rhesus +ve infant (live or stillborn)
  2. spontaneous miscarriage if followed by medical or surgical evacuation
  3. spontaneous complete miscarriage >12 weeks
  4. threatened miscarriage >12 weeks
  5. ectopic pregnancy managed surgically
  6. external cephalic version
  7. antepartum haemorrhage
  8. amniocentesis, CVS, fetal blood samplling
  9. abdo trauma
  10. having surgical or medical termination of pregnancy (unless have Abs) [ANY TOP]
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10
Q

What are 9 physiological changes of pregnancy?

A
  1. Rise in prolactin
  2. Rise in plasma volume by 50%
  3. Hb drops (dilution)
  4. WCC, platelets, ESR rise
  5. Cardiac output increases (increased stroke volume + HR)
  6. Urinary frequency increases - increased pressure on bladder and GFR
  7. BP drops during 2nd trimester, increases to normal third
  8. Ventilation and tidal volume increase
  9. Chloasma and scalp hair loss
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11
Q

What are 2 basic investigations to perform for infertility?

A
  1. Semen analysis
  2. Serum progesterone 7 days before menstruation (day 21 of 28 day cycle)
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12
Q

How is serum progesterone acted on in infertility?

A

<16 repeat, if consistently low refer to specialist
16-30 repeat
>30 indicates ovulation

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13
Q

What is the commonest type of ovarian cancer?

A

epithelial (90%) - 70-80% of cases = serous carcinoma

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14
Q

In addition to ovarian cancer what are 4 things that can cause a raised CA125?

A
  1. endometriosis
  2. benign ovarian cysts
  3. menstruation
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15
Q

At what threshold should US be organised based on CA125?

A

CA125 >35

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16
Q

What is the treatment for ovarian cancer?

A

combination of surgery and platinum based chemotherapy

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17
Q

What antiemetic is recommended first line for nausea/vomiting in pregnancy?

A

promethazine (ginger and acupuncture to p6 [wrist] also noted)

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18
Q

At what point after giving birth do women require contraception?

A

Day 21

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19
Q

What is the guidance for POP use after giving birth?

A

Can be started any time; additional contraception should be used for first 2 days after day 21

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20
Q

How long may it take for fertility to return after Depo Provera (medroxyprogesterone acetate) injections are stopped?

A

12 months

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21
Q

What is the main mechanism of action of Depo Provera?

A

Inhibition of ovulation (also cervical mucus thickening and endometrial thinning)

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22
Q

Which antibiotic drugs are safe to give mothers who are breastfeeding?

A
  • penicillins
  • trimethoprim
  • cephalosporins
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23
Q

Which antibiotics are contraindicated in mothers who are breastfeeding?

A
  • ciprofloxacin
  • tetracyclines
  • sulphonamides
  • chloramphenicol
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24
Q

What are 9 additional drugs that should be avoided in breastfeeding mothers (as well as certain antibiotics)?

A
  • amiodarone
  • aspirin
  • benzodiazepines
  • carbimazole
  • clozapine
  • cytotoxic drugs
  • lithium
  • methotrexate
  • sulphonylureas
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25
Q

What are 2 endocrine drugs safe in breastfeeding?

A
  • glucocorticoids (lower doses)
  • levothyroxine
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26
Q

What are 2 AEDs safe for breastfeeding?

A
  • valproate
  • carbamazepine
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27
Q

What psychiatric medications can be given in breastfeeding mothers?

A
  • tricyclic antidepressants
  • antipsychotics (not clozapine)
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28
Q

Which anticoagulants can be given in breastfeeding mothers?

A

Warfarin & heparin

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29
Q

What is the management of premature ovarian insufficiency?

A

Combined HRT or COCP until age 51

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30
Q

What is the definition of premature ovarian insufficiency?

A

Onset of menopausal symptoms and raised gonadotropin levels aged < 40 years

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31
Q

What are 7 causes of premature menopause?

A
  • idiopathic
  • bilateral oophorectomy (also hysterectomy with preservation of ovaries)
  • radiotherapy
  • chemotherapy
  • infection e.g. mumps
  • autoimmune disorders
  • resistant ovary syndrome - due to FSH receptor abnormalities
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32
Q

What blood tests are required to diagnose premature ovarian insufficiency?

A

Elevated FSH/LH levels e.g. FSH >40 - raised FSH needs to be demonstrated on 2 blood tests 4-6 weeks apart
Low oestradiol <100

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33
Q

What is pre-menstrual syndrome?

A

symptoms during luteal phase (for the ~2 weeks before period starts) - mood swings, trouble sleeping, anxiety, bloating, breast tenderness, headaches

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34
Q

What is the treatment for pre-menstrual syndrome?

A

COCP (also cyclic or continuous antidepressants, CBT, dietary supplements)

first line is lifestyle advice

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35
Q

What is the first line treatment for menorrhagia?

A

LNG-IUS if require contraception, mefenamic acid or TXA if not

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36
Q

What is the primary mechanism of action of COCP?

A

inhibits ovulation by acting on HPA to suppress LH and FSH

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37
Q

What is the primary mechanism of action of the POP (apart from desogestrel)?

A

thickens cervical mucus

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38
Q

What is the primary mechanism of the implantable contraceptive (etonogestrel)?

A

inhibits ovulation (also thickens cervical mucus)

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39
Q

What is the primary mechanism of action of the intrauterine contraceptive device?

A

decreases sperm motility and survival

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40
Q

What is the primary mechanism of action of the intrauterine system (IUS)?

A

prevents endometrial proliferation (also thickens cervical mucus)

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41
Q

What are the phases of the menstrual cycle?

A
  • menstruation: days 1-4
  • follicular phase (proliferative phase): days 5-13
  • ovulation: day 14
  • luteal phase (secretory phase): days 15-28
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42
Q

What is going on in terms of ovarian histology during the follicular (proliferative) phase?

A

A number of follicles develop, one of which will become dominant around the mid-follicular phase

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43
Q

What is the ovarian histology during the luteal (secretory) phase?

A

Corpus luteum

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44
Q

What happens to endometrial histology during the follicular (proliferative) phase?

A

endometrial proliferation

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45
Q

What happens to endometrial histology during the luteal (secretory) phase?

A

endometrium changes to secretory lining under the influence of progesterone

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46
Q

What happens to homrone levels during the follicular (proliferative) phase?

A
  • Rise in FSH - results in development of follicles
  • Follicles secrete oestroadiol
  • When egg matured, secretes enough oestradiol to trigger acute release of LH which leads to ovulation
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47
Q

What happens to hormone levels during the luteal (secretory) phase?

A
  • progesterone is secreted by the corpus luteum, rises throughout this phase
  • if feritlisation doesn’t occur - coprus luteum degenerates, progesterone levels fall
  • oestradiol levels also rise again during this phase
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48
Q

What happens to cervical mucus during the follicular (proliferative) phase?

A

Following menstruation, it is thick and forms a plug across the external os; just prior to ovulation, it becomes clear, aceullular and low viscosity, stretchy (spinnbarkeit)

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49
Q

What happens to cervical mucus during the luteal (secretory) phase?

A

thick, scant and tacky

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50
Q

What happens to basal body temperature during the follicular (proliferative) phase?

A

falls prior to ovulation due to influence of oestradiol

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51
Q

What happens to basal body temperature during the secretory (luteal) phase?

A

Rises following ovulation in response to higher progesterone levels

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52
Q

What is placental abruption?

A

separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

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53
Q

What are 5 factors associated with placental abruption?

A
  1. proteinuric hypertension
  2. cocaine
  3. multiparity
  4. maternal trauma
  5. increasing maternal age
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54
Q

What are 6 clinical features in keeping with placental abruption?

A
  1. shock out of keeping with visible loss
  2. pain constant
  3. tender, tense (woody) uterus
  4. normal lie and presentation
  5. fetal heart: absent/distressed
  6. coagulation problems
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55
Q

What are 5 causes of recurrent miscarriage?

A
  1. antiphospholipid syndrome
  2. endocrine disorders: poorly controlled diabetes mellitus/ thyroid disorders, PCOS
  3. uterine abnormality e.g. uterine septum
  4. parental chromosomal abnormalities
  5. smoking
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56
Q

What is the management of asymptomatic bacteriuria in pregnancy?

A

screened + treated (associated with premature delivery + low birthweight)

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57
Q

What is the

A
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58
Q

What is first and second line treatment for primary dysmenorrhea?

A

First line: NSAIDs like mefenamic acid, ibuprofen
Second line: COCP

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59
Q

What is the key step in management for secondary dysmenorrhea?

A

Refer to gynaecology

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60
Q

How does the timing of pain differ in primary and secondary dysmenorrhoea?

A

More likely to be 3-4 days before onset of period if secondary; in primary, occurs with or just before period starting

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61
Q

What are 4 HPV strains most linked to cervical cancer?

A

16, 18, 31, 33

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62
Q

What are 9 risk factors for cervical cancer?

A
  1. HPV - 16, 18, 31, 33
  2. smoking
  3. HIV
  4. young age first coitus
  5. high number sexual partners
  6. young age first pregnancy
  7. high parity
  8. low socioeconomic class
  9. sexula partner with multiple sexual partners
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63
Q

Why is young age of first coitus a risk factor for cervical cancer?

A

adolescent cervix is more susceptible to carcinogenic stimuli as squamous metaplasia in the transformation zone is active during this time

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64
Q

Why is young age at first pregnancy a risk factor for cervical cancer?

A

metaplasia most active during first pregnancy

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65
Q

What can cause ovarian hyperstimulation syndrome (OHSS)? Give 3 examples

A

some forms of infertility treatment
1. gonadotropin or hCG treatment
2. clomifene (rare)
3. IVF

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66
Q

What happens for someone to develop OHSS?

A

thought that presence of multiple luteinised cysts in ovaries causehigh levels of oestrogens, progesterone + VEGF - increased membrane permeability, loss of fluid from intravascular compartment

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67
Q

What are 8 features of OHSS?

A
  1. abdominal pain
  2. abdominal bloating / ascites
  3. nausea / vomiting
  4. oliguria / anuria
  5. raised haematocrit >45%
  6. hypoproteinaemia
  7. VTE
  8. ARDS
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68
Q

How is OHSS severity categorised?

A
  • mild: abdo pain, bloating
  • moderate: nausea + vomiting, ascites on US
  • severe: clinical ascites, oliguria, haematocrit >45%, hypoproteinaemia
  • critical: VTE, ARDS, anuria, tense ascites
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69
Q

What is menometrorrhagia?

A

heavy and prolonged bleeding that occurs at irregular intervals

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70
Q

What is the definition of secondary amenorrhoea?

A

periods that were previously regular stop for 3 or more months

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71
Q

What is the only combined contraceptive patch licensed for use in the UK?

A

Evra patch

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72
Q

How does use of the contraceptive patch work?

A
  • patch cycle lasts 4 weeks
  • for first 3 weeks, patch worn every day, changed each week
  • during 4th week patch not worn
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73
Q

What is the advice regarding delayed contraceptive patch change?

A
  • delayed end of week 1 or 2: if delay < 48h: immediate change, no further precautions; if > 48h: change immediately, barrier 7 days, EC if UPSI
  • end of week 3: remove old patch ASAP, new patch applied on usual cycle start day for next cycle (even if withdrawal bleeding); no additional contraception needed
  • if application delayed at of patch-free week: additional barrier for 7 days following any delay
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74
Q

What are the 4 Ts of postpartum haemorrhage?

A
  1. Tone - uterine atony
  2. Trauma - e.g. perineal tear
  3. Tissue - retained placeneta
  4. Thrombin - clotting / bleeding disorder
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75
Q

What is the commonest cause of postpartum haemorrhage?

A

uterine atony (tone)

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76
Q

What is the definition of postpartum haemorrhage?

A

loss of >500ml after vaginal delivery
* Primary: within first 24h
* Secondary: between 24h - 6 weeks

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77
Q

What are the 2 commonest causes of secondary PPH?

A
  1. retained placental tissue
  2. endometritis
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78
Q

What are 9 risk factors for primary PPH?

A
  1. previous PPH
  2. prolonged labour
  3. pre-eclampsia
  4. increased maternal age
  5. polyhydramnios
  6. emergency C-section
  7. placenta praevia, planceta accreta
  8. macrosomia
  9. effect of parity - nulliparity now thought to be risk factor
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79
Q

What are 3 ways that the management of PPH can be divided?

A
  1. Mechanical
  2. Medical
  3. Surgical
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80
Q

What does mechanical management of PPH involve?

A
  • palpate uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
  • catheterisation to prevent bladder distension and monitor UO
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81
Q

What are 5 aspects of the medical management of primary PPH?

A
  1. IV oxytocin - slow IV injection, then IV infusion
  2. Ergometrine slow IV or IM
  3. Carboprost IM then intramyometrial
  4. Misoprostol sublingual or rectal
  5. ?possible role for tranexamic acid

Given in sequence

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82
Q

When is ergometrine (used in PPH) contraindicated?

A

if there is a history of hypertension

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83
Q

When is carboprost (used in PPH) contraindicated?

A

asthma

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84
Q

What is the first line surgical option for PPH where uterine atony is the only/main cause?

A

intrauterine balloon tamponade

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85
Q

What are 4 surgical options for management of PPH?

A
  1. intrauterine balloon tamponade
  2. B-Lynch suture
  3. Ligation of uterine arteries or internal iliac arteries
  4. Hysterectomy - if severe and would be life-saving procedure
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86
Q

What is the basic pathophysiology of Rhesus antibodies and pregnancy?

A
  • rhesus system is the most important antigen found on red blood cells; D antigen most important of rhesus system
  • if Rh -ve mother has Rh +ve child, leak of fetal red blood cells may occur - causes antibodies in mother
  • in later pregnancies these can cross placenta and cause haemolysis in fetus
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87
Q

How is rhesus status in pregnant women managed?

A
  • test for D antibodies in all Rh -ve mothers at booking
  • give anti-D immunoglobulin to non-sensitised Rh -ve mothers at 28 and 34 weeks (or just 28 weeks depending on region)
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88
Q

What is the management of babies born to Rh -ve mothers?

A

should all have cord blood taken at delivery for FBC, blood group & direct Coombs test

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89
Q

What does the direct Coombs test involve for a baby born to a Rh -ve mother?

A

direct antiglobulin, will demonstrate antibodies on RBCs of baby

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90
Q

Waht does a Kleihauer test involve?

A

add acid to maternal blood, fetal cells are resistant

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91
Q

What are the signs of a fetal affected by haemolysis secondary to Rhesus D antibodies?

A
  • oedematous - hydrops fetalis
  • jaundice, anaemia, hepatosplenomegaly
  • heart failure
  • kernicterus
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92
Q

What is the treatment for haemolytic disease of the newborn?

A

transfusions, UV phototherapy

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93
Q

What treatment is offered for women at risk of pre-eclampsia?

A

aspirin 75mg OD from 12 weeks until birth of baby

1 or more high risk factors, 2 or more moderate

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94
Q

What is the management of hypertension in pregnancy?

A
  • systolic >140 or diastolic >90
  • increase above booking reasons of >30 systolic or >15 diastolic
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95
Q

What is the management of hypertension in pregnancy?

A
  • oral labetalol first line
  • oral nifedipine (e.g. if asthmatic) and hydralazine
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96
Q

What is the first line medical management of primary postpartum haemorrhage?

A

IV oxytocin ( oxytocin-> ergometrine-> carboprost [IM > intramyometrial], rectal misoprostol)

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97
Q

What is the preferred treatment option for DVT in pregnancy?

A

subcut LMWH

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98
Q

What are is the legislation re: termination of pregnancy?

A

Abortion Act 1967
- upper limit 24 weeks unless threat to life of woman / extreme physical or mental injury / severe fetal abnormality
2 medical professionals must sign legal document (1 in emergency)
Before 24 weeks permitted if:
- risk of physical or mental injury to mother greater than if pregnancy terminated / to existing children
- termination necessary to prevent grave permanent injury to physical or mental health of woman
- if child were born would suffer significant abnormalities as to be seriously handicapped

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99
Q

What are the medical options for termination of pregnancy?

A

Mifepristone followed by prostaglandins (e.g. misprostol) 48 hours later

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100
Q

What must be done after a medical TOP?

A

Multi level pregnancy test 2 weeks later (bhCG level not just positive/negative)

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101
Q

What are the rules for anti-D prophylaxis for TOP?

A

Give anti-D if having TOP after 10 weeks gestation

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102
Q

What are the options for surgical TOP?

A
  • transcervical procedure: manual vacuum aspiration, electric vacuum aspiration, dilatation and evacuation
  • cervical priming with misoprostol +- mifepristone
  • under LA/ conscious sedation + LA, deep sedation, general anaesthesia
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103
Q

What is the commonest type of ovarian cyst?

A

Follicular cyst

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104
Q

What is the cause of follicular cysts?

A

Due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle

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105
Q

What is the usual outcome of follicular cysts?

A

Commonly regress after several menstrual cycles

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106
Q

What are two types of functional (physiological) cysts?

A

Follicular and corpus Luteum

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107
Q

What is a corpus luteum cyst?

A

Usually breaks down and disappears if pregnancy doesn’t occur - if it doesn’t, fills with blood or fluid and cyst forms

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108
Q

What type of physiological ovarian cyst is more like to cause intra-peritoneal bleeding?

A

Corpus luteum cyst

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109
Q

What is the main benign germ cell ovarian tumour?

A

Dermoid cyst

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110
Q

What is the key type of benign germ cell tumour of the ovaries?

A

Dermoid cyst (mature cystic teratoma)

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111
Q

What is the most common benign ovarian tumour in women under 30?

A

Dermoid cyst

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112
Q

Which ovarian tumour is most commonly associated with torsion?

A

Dermoid cyst

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113
Q

What are 2 types of benign epithelial tumours of the ovary?

A
  1. Serous cystadenoma
  2. Mucinous cystadenoma
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114
Q

What is the commonest type of benign epithelial ovarian tumour?

A

Serous cystadenoma (commonly mistaken for serous carcinoma)

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115
Q

What can happen if a mucinous cystadenoma ruptures?

A

Can cause pseudomyxoma peritonei

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116
Q

What is the commonest identifiable cause of podtcoital bleeding?

A

Cervical ectropion (unidentifiable is single commonest)

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117
Q

What are the next steps if cervical screening (for hrHPV) is positive?

A
  • cytology - if abnormal - colposcopy
  • if cytology normal - repeat hrHPV screen at 12 months
  • if hrHPV positive at repeat - cytology - if normal again repeat hrHPV at 12 months
  • if third hrHPV positive - colposcopy
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118
Q

What happens if hrHPV screen is inadequate?

A

Repeat 3 months - if still inadequate colposcopy

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119
Q

What is the treatment of cervical intra-epithelial neoplasia (CIN)?

A

Large loop excision of transformation zone (LLETZ)

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120
Q

What risk is associated with intrahepatic cholestasis of pregnancy?

A

increased risk of premature birth

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121
Q

What is the management of intrahepatic choelstasis of pregnancy?

A
  1. induction of labour at 37-38 weeks (common practice, may not be evidence based)
  2. ursodeoxycholic acid
  3. vitamin K supplementation
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122
Q

What is the rate of recurrence of intrahepatic cholestasis of pregnancy in subsequent pregnancies?

A

45-90%

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123
Q

How is a diagnosis of gestation diabetes made?

A
  • fasting glucose >5.6
  • OGTT glucose >7.8
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124
Q

What are 5 risk factors for gestational diabetes?

A
  1. BMI >30
  2. previous macrosomic baby (4.5kg or more)
  3. previous GD
  4. 1st degree relative with diabetes
  5. family origin with high prevalence of diabetes e.g. Soutu Asian, Caribbean, middle Eastern
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125
Q

When should screening for gestational diabetes be performed?

A
  • ASAP after booking in women with previous GD AND at 24-28 weeks if first test normal
  • OGTT 24-28 weeks in woemnw tih any risk factors
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126
Q

What is the management of gestational diabetes?

A
  • if plasma glucose <7 - trial of diet and exercise. if glucose targets not met at 1-2 weeks - metformin. still not met - short-acting insulin added to metformin
  • if plasma glucose >7 - insulin
  • if plasma glucose 6-6.9 + complications (macrosomia, hydramnios) - insulin
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127
Q

What drug should be offered for women with GD who cannot tolerate metformin / fail to meet glucose targets with metformin but decline insulin?

A

glibenclamide

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128
Q

How should medications be changed in pregnancy for women with pre-existing diabetes mellitus?

A
  • stop oral hypoglycaemics apart from metformin + commence insulin
  • folic acid 5mg/day
  • detailed anomaly scan 20 weeks including 4 chamber view of heart + outflow tracts
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129
Q

What are the targets for self-monitoring of pregnant women (both pre-existing and gestational diabetes)?

A
  • fasting: 5.3
  • 1 hour after meals: 7.8
  • 2 hours after meals: 6.4
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130
Q

What are the classic examination findings in endometriosis?

A

reduced organ mobility, tender nodularity in posterior vaginal fornix, visible vaginal endometriotic lesions

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131
Q

What are the investigations for endometriosis?

A

laparoscopy is gold standard; little role of investigation in primary care, if sx significant - refer for definitive diagnosis

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132
Q

What is the recommended first line treatment for endometriosis?

A

NSAIDs and / or paracetamol
if analgesia doesn’t help - COC or progestogens e.g. medroxyprogesterone acetate

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133
Q

What are 3 secondary care treatment options for endometriosis?

A
  1. GnRH analogues - induce pseudomenopause due to low oestrogen levels
  2. surgery - laparoscopic excision or ablation of endometriosis + adhesiolysis
  3. ovarian cystectomy for endometriomas
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134
Q

What are 3 situations when expectant miscarriage (watch + wait) is not appropriate + should be managed medically or surgically?

A
  1. increased risk of haemorrhage - late first trimester, coagulopathies or unable to have transfusion
  2. previous adverse and/or traumatic experience associated with pregnancy e.g. stillbirth, miscarriage, APH
  3. evidence of infection
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135
Q

What is the medical management of miscarriage?

A

vaginal misoprostol (prostaglandin analogue) binds to myometrial cells to cause strong myometrial contractions + expel tissue

+ antiemetics + pain relief

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136
Q
A
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137
Q

What is the surgical management of miscarriage?

A

vacuum aspiration (suction curettage, done in OPA under LA) or management in theatre

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138
Q

What supplements are recommended in uncomplicated pregnancy?

A

Folic acid 400mcg and vitamin D 10 mcg

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139
Q

What is shoulder dystocia?

A

complication of vaginal cephalic delivery
entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered
usually due to impaction of the anterior fetal shoulder on the maternal pubic symphysis

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140
Q

What are 4 risk factors for shoulder dystocia?

A
  1. Fetal macrosomia
  2. High maternal BMI
  3. DM
  4. Prolonged labour
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141
Q

What is first line management of shoulder dystocia during delivery?

A

McRoberts manoeuvre- flexing and abduction of mothers hips, increases the relative anterior-posterior angle of the pelvis

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142
Q

What 3 things might be considered for shoulder dystocia if mcroberts doesn’t work?

A
  1. Episiotomy
  2. Symphysiotomy
  3. Zavanelli manoeuvre
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143
Q

How does cerazette differ from other POP types?

A

12 hour window rather than 3 hours to take pill

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144
Q

What is the mechanism of cerazette?

A

= desogestrel, inhibits ovulation (secondarily caused thicker mucus secretion)

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145
Q

Until what time post-partum do women not need contraception?

A

day 21

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146
Q

When can the POP be started as contraception for women postpartum?

A

any time postpartum

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147
Q

For how long should additional contraception be used if the POP is initiated post-partum?

A

if initiated after day 21 - additional contraception for 2 days

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148
Q

What is the advice for COCP in women breastfeeding postpartum?

A
  • UKMEC 4 if breastfeeding <6 weeks postpartum
  • UKMEC2 if breastfeeding 6weeks - 6 months
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149
Q

When can COCP be started postpartum in women NOT breastfeeding?

A

should not be used in first 21 days due to increased VTE risk postpartum

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150
Q

For how long should additional contraception be used if the COCP is started after day 21 postpartum (in a non-breastfeeding woman)?

A

7 days

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151
Q

When can IUD or IUS be used postpartum for contraception?

A

within 48h OR after 4 weeks

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152
Q

How effective is the lactational amenorrhoea method?

A

98% effective if woman fully breastfeeding (no supplementary feeds), amenorrhoeic and <6 months post partum

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153
Q

What are 3 risks of a short inter-pregnancy interval (<12 months)?

A
  1. increased risk of preterm birth
  2. low birth weight
  3. small for gestational age (SGA) babies
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154
Q

How frequent is cervical screening?

A
  • 25-49y: every 3y
  • 50-64y: every 5y
  • 65y: only if 2 of last 3 tests was abnormal
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155
Q

Why must aspirin be avoided in breastfeeding women?

A

risk of Reye’s syndrome; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infants if neonatal vitamin K stores are low

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156
Q

Why must aspirin be avoided in breastfeeding women?

A

risk of Reye’s syndrome; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infants if neonatal vitamin K stores are low

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157
Q

How does the risk of pregnant women developing listeriosis (caused by Listeria monocytogenes) compare to the general population?

A

20x greater in pregnancy

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158
Q

How can feral/neonatal infection with Listeria occur?

A

Transplacentally or vertically during childbirth

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159
Q

How can Listeria infection spread to the fetus/newborn in pregnant women?

A

Transplacentally or vertically during birth

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160
Q

How can Listeria infection spread to the fetus/newborn in pregnant women?

A

Transplacentally or vertically during birth

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161
Q

What are 4 complications of Listeria infection of the newborn?

A
  1. Miscarriage
  2. Preterm labour
  3. Stillbirth
  4. Chorioamnionitis
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162
Q

What is the only way that a diagnosis of Listeria infection (Listeriosis) can be made in pregnant women?

A

Blood cultures

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163
Q

What is the treatment of listeriosis in pregnant women?

A

Amoxicillin

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164
Q

What is the primary mode of action of the copper IUD?

A

Decreased sperm motility and survival preventing fertilisation

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165
Q

What is the mechanism of action of the IUS for contraception?

A

Prevents endometrial proliferation and causes cervical mucous thickening

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166
Q

How long is it before the IUD vs IUS can be relied upon for contraception?

A

Immediate for IUD, after 7 days for IUS

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167
Q

How long does the copper IUD last for?

A

5 years if copper just on stem; up to 10 on arms of the T as well

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168
Q

How long does the Mirena IUS last for?

A

5 years

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169
Q

If used as endometrial protection for women taking oestrogen only HRT how long is the Mirena IUS licensed for?

A

4 years

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170
Q

What increased the risk of uterine perforation with the IUS/IUD?

A

Breastfeeding (normally risk is 2 in 1000)

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171
Q

What increases the risk of perforation with IUS/IUD?

A

Pregnancy (normally risk is 2 per 1000)

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172
Q

What is the rate of expulsion if IUS/IUD?

A

1 in 20 (highest risk in first 3 months)

173
Q

What are the respective levonorgestrel levels of kyleena, jaydess and Mirena?

A

Kyleena - 19.5mg
Jaydess - 13.5mg
Mirena - 52mg

174
Q

What is the advice for switching between types of COCP with different progesterones?

A

BNF suggests omitting pill free interval when switching (FSRH contradicts)

175
Q

What is the advice for switching between types of COCP with different progesterones?

A

BNF suggests omitting pill free interval when switching (FSRH contradicts)

176
Q

What is the advice for switching between types of COCP with different progesterones?

A

BNF suggests omitting pill free interval when switching (FSRH contradicts)

177
Q

What is Sheehan’s syndrome?

A
  • anterior pituitary avascular necrosis due to significant blood loss - classically postpartum haemorrhage
  • leads to reduced hormone production (FSH and LH) - resulting in amenorrheoa
  • reduced lactation due to reduced PRL
  • adrenal insuffiiency + adrenal crisis due to low ACTH (and consequently low cortisol)
  • hypothyroidism (reduced TSH)
178
Q

What is the management of Sheehan’s syndrome?

A

specialist endocrinologist manages it; replace missing hormones with oestrogen, progesterone, hydrocortisone, leothyroxine and growth hormone

179
Q

What is Asherman’s syndrome?

A

symptomatic adhesions (synechiae) within uterus following damage e.g. after pregnancy-related dilatation and curettage (retained productions of conception, myomectomy) and after endometritis/pelvic infection

180
Q

What are 4 symptoms of Asherman’s syndrome?

A
  1. secondary amenorrhoea
  2. lighter periods
  3. dysmenorrhoea
  4. infertility
181
Q

What is the definition of primary amenorrhoea?

A

failure ot establish menstruation by 15y in girls with normal secondary sexual characeristics (e.g. breast development), or by 13 years if no secondary sexual characteristics

182
Q

What are 7 causes of secondary amenorrhoea (after pregnancy excluded)?

A
  1. hypothalamic amenorrhoea (secondary stress, excessive exercise)
  2. polycystic ovarian syndrome (PCOS)
  3. hyperprolactinaemia
  4. premature ovarian failure
  5. thyrotoxicosis
  6. Sheehan’s syndrome
  7. Asherman’s syndrome
183
Q

What are 6 initial investigations in primary/secondary amenorrhoea?

A
  1. exclude pregnancy with urinary/serum bHCG
  2. FBC, U+Es, coeliac screen, TFT
  3. gonadotrophins (to determine hypothalamic vs. ovarian cause)
  4. prolactin
  5. androgen levels (raised in PCOS)
  6. oestradiol
184
Q

What are 9 UKMEC4 (absolute contraindications) for COCP?

A
  1. > 35y and smoking >15/day
  2. migraine + aura
  3. history of thromboembolic disease or thrombogenic mutation
  4. history of stroke or IHD
  5. breastfeeding <6w postpartum
  6. uncontrolled hypertension
  7. current breast cancer
  8. major surgery with prolonged immobilisation
  9. positive antiphospholipid antibodies (e.g. in SLE)
185
Q

What is the management of ovarian cysts in pre-menopausal women?

A
  • if cyst small (<5cm) + simple (unilocular) - repeat US in 8-12 weeks
  • consider gynaecology referral if persists
186
Q

What is the management of ovarian cysts in postmenopausal women?

A

by definition, physiological cysts unlikely - refer to gynaecology for assessment (regardless or nature or size)

187
Q

What daily supplementation is recommended for breastfeeding women?

A

vitamin D 10mcg/ day

vitamin B12 if eat a vegan diet

188
Q

What HPV strains are responsible for genital warts?

A

types 6 + 11

189
Q

Which 4 types of HPV strains are including in the standard Gardasil vaccination used in the UK?

A
  • 6
  • 11
  • 16
  • 18

(quadrivalent)

190
Q

What advice should be given to pregnant women for avoiding infection?

A
  • advise how to avoid risk of listeriosis, salmonella and toxoplasmosis
  • avoid unpasteurised milk and soft cheeses
  • avoid undercooked meat and poultry, raw seafood
  • avoid excess liquorice
  • avoid excess caffeine
  • wash fruit and vegetables before eating them
  • avoid deli meats
  • avoid raw eggs
191
Q

What is the advice regarding intercourse during pregnancy?

A

reassure that intercourse thought to be safe during pregnancy

192
Q

What is the advice about car travel to give to women who are pregnant?

A

seat belt should go above and below hump, not over it

193
Q

How effective is the cervical screening programme at detecting cervical adenocarcinoma?

A

not effective - they are frequently undetected

194
Q

What is the approach to cervical screening following pregnancy?

A

it is delayed until 3 months post partum unless missed screening or previous abnormal smears

195
Q

When is the best time thought to be to take a cervical smear?

A

mid-cycle

196
Q

What are 2 differences between nexplanon and implanon?

A
  1. the nexplanon applicator has been resgiend to try and prevent deep insertions (e.g. subcutaneous/IM)
  2. it is radiopaque and therefore easier to locate if impalpable
197
Q

What is the mechanism of action of Nexplanon?

A
  • slowly releases progestogen hormone etonogestrel
  • prevent ovulation - main mechanism
  • also thicken cervical mucus
198
Q

How long does Nexplanon last?

A

3 years

199
Q

Can nexplanon be used if there is a past history of thromboembolism, mgiraine etc.?

A

yes (doesn’t contain oestrogen)

200
Q

How soon after termination of pregnancy can Nexplanon be used?

A

can be inserted immediately following termination of pregnancy

201
Q

Do additional contraceptives need to be used with Nexplanon after insertion and for how long?

A

yes for first 7 days if not inserted on day 1 to 5 of a woman’s menstrual cycle

202
Q

What is the main adverse effect of nexplanon?

A

irregular/heavy bleeding

203
Q

How can irregular/heavy bleeding with nexplanon sometimes be managed?

A

using a co-prescription of the combined oral contraceptive pill

204
Q

Which drugs can influence the effectiveness of nexplanon?

A

enzyme-inducing drugs e.g. rifampicin, certain antieplieptics

205
Q

What is UKMEC 4 with nexplanon?

A

current breast cancer

206
Q

When should menorrhagia be investigated further?

A

if symptoms suggestive structural or histological abnormality: IMB, PCB, pelvic pain and/or pressure symptoms

207
Q
A
208
Q

How long do menopausal symptoms typically last for?

A

7 years

209
Q

What are the lifestyle modifications to help manage different symptoms of the menopause?

A
  • hot flushes: regular exercise, weight loss and reduce stress
  • sleep disturbance: avoid late evening exercise, good sleep hygiene
  • mood: sleep, regular exercise + relaxation
  • cognitive sx: regular exercise and good sleep hygiene
210
Q

What are 4 contraindications to HRT?

A
  1. current or past breast cancer
  2. oestrogen-sensitive cancer
  3. undiagnosed vaginal bleeding
  4. untreated endometrial hyperplasia
211
Q

What are 5 key risks of HRT?

A
  1. VTE (if oral; no increased risk if transdermal)
  2. stroke
  3. coronary heart disease
  4. breast cancer
  5. ovarian cancer
212
Q

What are 3 non-HRT drug options for the management of vasomotor menopause symptoms

A
  1. fluoxetine
  2. citalopram
  3. venlafaxine
213
Q

What non-HRT drug treatments can be used for vaginal dryness?

A

vaginal lubricant or moisturiser

214
Q

What can be used to treat urogenital atrophy?

A

vaginal oestrogen (appropriate if taking HRT or not)

215
Q

How long may HRT be required for vasomotor symptoms?

A

2-5 years with regular attempts to discontinue

216
Q

What is the approach to stopping HRT and what should the woman be counselled?

A

gradually reduce - tell women this limits recurrence only in short term; in long term there is no difference in symptom control

217
Q

What are 3 situations when menopausal patients should be referred to secondary care?

A
  1. treatment ineffective
  2. ongoing side effects
  3. unexplained bleeding
218
Q

What is the definition of premature ovarian insufficiency?

A

the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years

219
Q

What are 7 causes of premature menopause?

A
  1. idiopathic (commonest, may be familial)
  2. bilateral oophorectomy
  3. radiotherapy
  4. chemotherapy
  5. infection e.g. mumps
  6. autoimmune disorders
  7. resistant ovsry syndrome - FSH receptor abnormalities
220
Q

How should FSH and LH be tested for in suspected premature ovarian failure?

A

should be demonstrated on 2 blood samples taken 4-6 weeks apart

221
Q

What is the management of premature ovarian failure?

A

hormone replacement therapy or COCP until age 51y (average menopause)

222
Q

What is the commonest adverse effect of the POP?

A

Irregular vaginal bleeding

223
Q

When is additional contraception needed when starting the POP?

A
  • if commenced from day 1 - 5 no additional contraception needed
  • additional contraception needed for first 2 days in all other cases
224
Q

What advice is given for switching from COCP to POP?

A

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)

225
Q

Does POP have a pill free break?

A

No - unlike COCP

226
Q

What are the missed pill rules for POP?

A
  • if < 3 hours late: continue as normal
  • if > 3 hours: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
  • (12 hours for cerazette)
227
Q

What virus causes rubella?

A

togavirus

228
Q

What is the a) incubation period and b) infectoius period in rubella?

A
  • a) 14-21 days
  • b) from 7 days before symptoms appear to 4 days after onset of rash
229
Q

What are the features of congenital rubella syndrome?

A
  • sensorineural deafness
  • congenital cataracts
  • congenital heart disease (e.g. patent ductus arteriosus)
  • growth retardation
  • hepatosplenomegaly
  • purpuric skin lesions
  • ‘salt and pepper’ chorioretinitis
  • microphthalmia
  • cerebral palsy
230
Q

What condition is it difficult to distinguish rubella from clinically?

A

Parvovirus B19

231
Q

What tests can help a diagnosis of rubella in a pregnant mother?

A

IgM antibodies raised in women recently exposed

232
Q

What are 3 aspects of the management of rubella in pregnancy?

A
  1. discuss with local Health Protection Unit
  2. if woman doesn’t have immunity (although not routinely checked), keep away from people who may have rubella
  3. non-immune mothers should be offered MMR vaccination in the post-natal period
233
Q

What is a rule of thumb for working out the symphysio-fundal height in pregnancy?

A

after 20 weeks, SFH = gestational age in weeks (to within 2 cm)

234
Q

When is test of cure performed in pregnancy for chlamydia that has been treated?

A

6 weeks post infection

235
Q

What are the cut offs when women should receive oral iron to treat anaemia in pregnancy?

A
  • first trimester: <110
  • second/third: <105
  • postpartum: <100

oral ferrous sulphate or ferrous fumarate

236
Q

What is the Bishop score used for?

A

used to help assess whether induction of labour will be required

237
Q

What are 5 components of the Bishop score?

A
  1. cervical position
  2. cervical consistency
  3. cervical effacement (get thinner due to stretch)
  4. cervical dilation
  5. fetal station
238
Q

How is the Bishop score interpreted?

A
  • <5 indicates labour unlikely to start without induction.
  • 8 or more: cervical is ripe, or favourable - high chance of spontaneous labour, or response to interventions to induce labour
239
Q

What are 6 possible methods for induction of labour?

A
  1. Membrane sweep
  2. Vaginal prostaglandin E2 (PGE2) (aka dinoprostone)
  3. Oral prostaglandin E1 (misoprostol)
  4. Maternal oxytocin infusion
  5. Amniotomy
  6. Cervical ripening balloon
240
Q

What does the membrane sweep for induction of labour involve?

A
  • examining finger is passed through cervix to rotate against wall of uterus - separates chorionic membrane from decidua
  • done at 40- and 41-week visit in nulliparous women, 41-weeks in parous women
241
Q

Is the membrane sweep offered for induction of labour in isolation?

A

no - adjunct

242
Q

What should be offered prior to induction of labour with the membrane sweep method?

A

vaginal examination

243
Q

What does use of the cervical ripening balloon involve for induction of labour?

A

passed through endocervical cancel and gently inflated to dilate cervix

244
Q

How is the Bishop score used to guide induction of labour methods?

A
  • if 6 or less: vaginal prostaglandins or oral misoprostol; consider balloon catheter if risk of hyperstimulation / previous C section
  • > 6: amniotomy and IV oxytocin infusion
245
Q

What is the main complication of induction of labour?

A
  • uterine hyperstimulation - prolonged and frequent contractions (aka tachysystole)
  • may interrupt blood flow to intervillous space over time, can result in fetal hypoxaemia and acidaemia; also uterine rupture
246
Q

What is the management of uterine hyperstimulation due to induction of labour?

A

remove vaginal prostaglandins, stop oxytocin infusion; consider tocolysis

247
Q

When do progesterone levels peak?

A

day 21 (during luteal phase)

248
Q

What proportion of fetuses are breech at 28 weeks vs near term?

A

25% at 28 weeks, 3% near term

249
Q

What is the commonest type of breech fetus and what is this?

A

frank breech - hips flexed and knees fully extended

250
Q

What is a rare type of breech presentation that carries a higher perinatal morbidity?

A

footling breech - one or both fet come first with bottom at higher position

251
Q

What are 5 risk factors for breech presentation?

A
  1. uterine malformations, fibroids
  2. placenta praevia
  3. polyhydramnios or oligohydramnios
  4. fetal abnormality e.g. CNS malformation, chromosome disorder
  5. prematurity (increased incidence earlier in gestation)
252
Q

What complication in pregnancy is more common in breech fetuses?

A

cord prolapse

253
Q

What is the management of a breech fetus?

A
  • if <36 weeks - many will turn spontaneously, observe
  • if breech 36 weeks and above in nullips, 37 and above in multips - external cephalic version
  • if unsuccessful - planned C section or vaginal delivery
254
Q

What is the success rate of external cephalic version?

A

60%

255
Q

What are 6 absolute contraindications to ECV?

A
  1. where caesarean delivery required
  2. APH within last 7 days
  3. abnormal CTG
  4. major uterine anomaly
  5. ruptured membranes
  6. multiple pregnancy
256
Q

What are 5 key risks of smoking during pregnancy?

A
  1. increased risk of miscarriage
  2. increased risk of pre-term labour
  3. increased risk of stillbirth
  4. IUGR
  5. increased risk of sudden unexpected death in infancy
257
Q

What are 4 risks of alcohol during pregnancy?

A

termed Fetal alcohol syndrome
1. learning difficulties
2. characteristic facies: smooth philtrum, thin vermilion (upper lip), small palpebral fissures, epicanthic folds, microcephaly
3. IUGR
4. Postnatal restricted growth

258
Q

What are 2 maternal risks of cocaine use during pregnancy?

A
  1. hypertension, pre-eclampsia
  2. placental abruption
259
Q

What are 2 fetal risks of cocaine use during pregnancy?

A
  1. prematurity
  2. neonatal abstinence syndrome
260
Q

What is the risk of heroin use during pregnancy?

A

neonatal abstinence syndrome

261
Q

What are 2 substances that can cause neonatal abstinence syndrome?

A
  1. heroin
  2. cocaine
262
Q

What is the most important factor in deciding whether to decide whether to start HRT?

A

vasomotor symptoms (flushing, insomnia, headaches)

263
Q

What is the most important reason for giving HRT to younger women going through premature menopause?

A

preventing development of osteoporosis

264
Q

What type of oestrogens are used in HRT?

A

‘natural’ oestrogens - oestradiol, oestrone, conjugated oestrogen
(not synthetic oestrogens - e.g. ethinylestradiol, in COCP)

265
Q

What type of progestogens are used in HRT?

A

synthetic (medroxyprogesterone, norethisterone, levonorgestrel, drospirenone), IUS

266
Q

What is tibolone?

A

synthetic compound with oestrogen, progestogenic and androgenic activity

267
Q

How do you decide between continuous or cyclical HRT?

A

in perimenopausal women still having periods / for 12 months afterwards - cyclical HRT (produces predictable withdrawal bleeding)
if postmenopausal (no periods for 12 months) - continuous

268
Q

When during pregnancy should folic acid be taken?

A

from 3 months before conception to week 12

269
Q

What are 8 critiera that mean a pregnant woman should take higher dose folic acid during pregnancy (5mg rather than 400mcg)?

A
  1. either partner has a neural tube defect
  2. previous pregnancy affected by NTD
  3. FH of NTD
  4. mother taking antiepileptic drugs
  5. mother has coeliac disease
  6. diabetes
  7. thalassaemia trait
  8. woman is obese (BMI >30)
270
Q

What is the investigation of choice in ectopic pregnancy?

A

transvaginal ultrasound

271
Q

What are 6 criteria for surgical management of ectopic pregnancy?

A
  1. size >35mm
  2. can be ruptured
  3. pain
  4. visible fetal heartbeat
  5. hCG >5000
  6. compatible with another intrauterine pregnancy
272
Q

What are 6 criteria for expectant management of ectopic pregnancy?

A
  1. size < 35mm
  2. unruptured
  3. asymptomatic
  4. no fetal heartbeat
  5. hCG < 1000
  6. compatible if another intrauterine pregnancy
273
Q

What are 6 criteria for medical management of ectopic pregnancy?

A
  1. size <35mm
  2. unruptured
  3. no significant pain
  4. no fetal heartbeat
  5. hCG < 1500
  6. NOT suitable if intrauterine pregnancy
274
Q

What are the 3 things that form the triad of pre-eclampsia?

A
  • new-onset hypertension >140/90 after 20 weeks of pregnancy
  • proteinuria (PCR >30 = significant)
  • oedema
  • other organ involvement e.g. renal insufficiency (creat >90), liver, neurological, haematological, uteroplacental dysfunction
275
Q

What are 5 potential consequences of pre-eclampsia?

A
  1. eclampsia / altered mental status / blindness / stroke / clonus / severe headaches / persistent visual scotomata
  2. fetal complications - IUGR, prematurity
  3. liver involvement - raised transaminases
  4. haemorrhage - placental abruption, intra-abdo, intra-cerebral
  5. cardiac failure
276
Q

What are 6 neurological complications of pre-eclampsia other than eclampsia (seizures)?

A
  1. altered mental status
  2. blindness
  3. stroke
  4. clonus
  5. severe headaches
  6. persistent visual scotomata
277
Q

What are 2 fetal complications of pre-eclampsia?

A
  1. IUGR
  2. prematurity
278
Q

What are 3 forms of haemorrhage that can occur as a result of pre-eclampsia?

A
  1. placental abruption
  2. intra-abdominal
  3. intra-cerebral
279
Q

What are 8 features of severe pre-eclampsia?

A
  1. hypertension >160/110 + proteinuria
  2. proteinuria: dipstick ++/+++
  3. headache
  4. visual disturbance
  5. papilloedema
  6. RUQ/epigastric pain
  7. hyperreflexia
  8. platelet count <100, abnormal LFTs or HELLP
280
Q

What are 5 high risk factors for pre-eclampsia?

A
  1. hypertensive disease in previous pregnancy
  2. chronic kidney disease
  3. autoimmune disease e..g SLE, antiphospholipid
  4. T1/T2DM
  5. chronic hypertension
281
Q

What are 6 moderate risk factors for pre-eclampsia?

A
  1. first pregnancy
  2. age 40 years or older
  3. pregnancy interval >10 years
  4. BMI >35
  5. FH pre-eclampsia
  6. multiple pregnancy
282
Q

What is the management of pregnant women with BP >160/110?

A

admission for observation

283
Q

What is the first line medication treatment for pre-eclampsia? What is the definitive management?

A
  • oral labetalol (nifedipine / hydralazine if asthmatic)
  • delivery of baby is definitive
284
Q

What are 2 types of cancer that the COCP increases the risk of?

A
  1. breast cancer
  2. cervical cancer
285
Q

When is additional contraception needed when starting COCP?

A
  • if within first 5 days of cycle (period) - none
  • otherwise - for first 7 days
286
Q

What are 3 situations where the efficacy of the COCPD may be reduced?

A
  1. vomiting within 2 hours of taking
  2. medication inducing diarrhoea / vomiting e.g. orlistat
  3. liver enzyme-inducing drugs
287
Q

A surge of which hormone causes ovulation?

A

LH

288
Q

What is the definition of threatened miscarriage?

A
  • painless vaginal bleeding < 24 weeks (usually 6- 9 weeks)
  • cervical os closed
289
Q

What proportion of pregnancies are complicated by threatened miscarriage?

A

up to 25%

290
Q

What is the definition of missed (delayed miscarriage)?

A
  • gestational sac containing dead fetus < 20 weeks without symptoms of expulsion
  • may be light vaginal bleeding / discharge
  • cervical os closed
291
Q

What is meant by a blighted ovum, or missed pregnancy?

A
  • type of missed miscarriage
  • when gestational sac >25mm and no embryonic / fetal part seen, sometimes described as ‘blighted ovum’ or ‘anembryonic pregnancy’
292
Q

What is an inevitable miscarriage?

A
  • heavy bleeding with clots and pain
  • cervical os open
293
Q

What is the definition of incomplete miscarriage?

A
  • not all products of conception have been expelled
  • pain and vaginal bleeding
  • cervical os open
294
Q

When does the booking visit occur?

A

8 - 12 weeks (ideally < 10)

295
Q

What 8 things are done at the booking visit?

A
  1. general information on diet, smoking etc.
  2. BP
  3. urine dip
  4. BMI check
  5. FBC, glood group, rhesus status, red cell alloantibodies, haemoglobinopathies
  6. hep B, syphilis
  7. HIV
  8. urine culture - asymptomatic bacteriuria
296
Q

When is the dating scan performed?

A

10 - 13+6 weeks

297
Q

When is Down’s syndrome screening performed?

A

11 - 13+6 weeks

298
Q

When is the anomaly scan performed?

A

18 - 20+6 weeks

299
Q

When is a second, third and fourth BP and urine dipstick performed in pregnancy?

A

16 weeks, 25 weeks, 28 weeks

300
Q

When is symphysis-fundal height measured for the first time in primips vs multips?

A

25 weeks (28 weeks in multips)

301
Q

When is discussion about options for prolonged pregnancy held?

A

40 weeks if primip, 41 weeks if multip

302
Q

What are 4 common side effects of HRT?

A
  1. nausea
  2. breast tenderness
  3. fluid retention
  4. weight gain
303
Q

What are 5 potential risks of HRT?

A
  1. increased risk of breast cancer (due to progestogen)
  2. endometrial cancer (reduced with addition of progestogen)
  3. VTE (increased by progestogen, eliminated with transdermal)
  4. stroke
  5. IHD if >10 y after menopause
304
Q

When does the first screen for anaemia and alloantibodies take place in pregnancy?

A

8 - 12 weeks (booking visit)

305
Q

At what 2 points in pregnancy is the woman screened for anaemia?

A
  • booking 8-12 weeks
  • 28 weeks
306
Q

When is referral to a specialist generally warranted in a couple struggling to conceive?

A

after regular intercourse for 12 months

307
Q

What are 7 indications to consider early referral to fertility services in couples struggling to conceive?

A
  1. female age > 35 years
  2. amenorrhoea
  3. previous pelvic / genitalia surgery
  4. previous STI in male / female
  5. abnormal genital examination in male / female
  6. varicocele
  7. significant systemic illness in male
308
Q

When is the combined test for Down syndrome screening, including nuchal scan?

A

11-13+6 weeks

309
Q

When can the triple or quadruple tests be offered for Down syndrome during pregnancy?

A

between 15 and 20 weeks

310
Q

What are 4 risk factors for ovarian cancer?

A
  1. BRCA1 or BRCA2 gene
  2. early menarche
  3. late menopause
  4. nulliparity

latter 3 - increased ovulations

311
Q

What test is diagnostic of ovarian cancer?

A

diagnostic laparotomy

CA125 and US for workup

312
Q

What is the only effective treatment for large uterine fibroids causing problems with fertility if the woman wishes to conceive in the future?

A

myomectomy

313
Q

What is the prevalence of uterine fibroids?

A

in later reproductive years:
* White: 20%
* Afro-Caribbean: 50%

314
Q

What are 5 features of uterine fibroids?

A
  1. can be asymptomatic
  2. menorrhagia, IDA
  3. bulk-related: ower abdo pain, bloating, urinary sx
  4. subfertility
  5. rare: polycythaemia (Autonomous EPO production)
315
Q

How is a diagnosis of fibroids made?

A

TVUS

316
Q

What is the maangement of asymptomatic fibroids?

A

no treatment other than periodic review to monitor size and growth

317
Q

What are 6 options for management of menorrhagia secondary to fibroids?

A
  1. IUS (CI if distortion of uterine cavity)
  2. NSAIDs
  3. TXA
  4. COCP
  5. POP
  6. injectable progestogen
318
Q

What are 3 groups of treatment to shrink / remove fibroids?

A
  1. Medical - GnRH agonists
  2. Surgical - myomectomy, endometrial ablation, hysterectomy
  3. Uterine artery embolisation
319
Q

What is 1 medical treatment to shrink / remove fibroids?

A
  1. GnRH agonists
    (ulipristal no longer used - liver toxicity)
320
Q

When are GnRH agonists used to treat fibroids?

A

short-term due to side effects e.g. menopausal sx and loss of bone mineral density

321
Q

What are 3 surgical options to shrink / remove fibroids?

A
  1. myomectomy
  2. endometrial ablation
  3. hysterectomy
322
Q

What is the prognosis of untreated fibroids?

A

generally regress after menopause

323
Q

What is red degeneration of fibroids?

A

haemorrhage into the tumour - commonly occurs during pregnancy

324
Q

What are 7 maternal risks of obesity during pregnancy?

A
  1. miscarriage
  2. VTE
  3. gestational diabetes
  4. pre-eclampsia
  5. dysfunctional labour, induced labour
  6. postpartum haemorrhage
  7. wound infection
325
Q

What are 6 fetal risks of maternal obesity during pregnancy?

A
  1. congenital anomaly
  2. prematurity
  3. macrosomia
  4. stillbirth
  5. increased risk of obesity and metabolic disorders in childhood
  6. neonatal death
326
Q

What advice should be given to obese women who become pregnant?

A

explain it poses a risk to health of them and their child - but should not diet while pregnant, risk will be managed by the health professionals

327
Q

What management should be offered to obese women who are pregnant?

A
  • 5mg folic acid from conception to end of first trimester
  • OGTT for gestational diabetes 24-48 weeks
  • if BMI >35 - birth in consultant led obstetric unit
  • if BMI >40 antenatal consultation with obstetric anaesthetic + plan made
328
Q

What is the guidance for obese women who are pregnant re: folic acid?

A

5mg from conception to end of first trimester

329
Q

How long should contraception be used in the perimenopausal period?

A
  • for 12 months after last period if > 50 years
  • 24 months if < 50 years
330
Q

What are the features of bleeding due to hydatidiform mole?

A
  • bleeding in first or early second trimester
  • exaggerated pregnancy symptoms - hypermesis
  • large for dates uterus
  • high serum hCG
331
Q

What are the features of placental abruption vs placenta praevia?

A
  • abruption - constant lower abdo pain, placenta praevia painless
  • abruption - may be more shocked than suggested by visible blood loss; vaginal bleeding occurs in placenta praevia
  • tense, tender uterus with normal lie and presentation in abruption but may be abnormal in PP (high presenting part)
  • fetal heart may be distressed in abruption
332
Q

What are 2 classic features of vasa praevia?

A
  1. rupture of membranes followed immediately by vaginal bleeding
  2. fetal bradycardia
333
Q

What is the guidance for investigation in primary care of antepartum haemorrhage?

A

vaginal examination shouldn’t be performed in primary care - women with placenta praevia may haemorrhage

334
Q

What is a risk to the mother of getting chickenpox during pregnancy?

A

5x greater risk of pneumonitis

335
Q

What are 5 risks to the fetus of chickenpox during pregnancy?

A

Fetal varicella syndrome
1. skin scarring
2. eye defects (microphthalmia)
3. limb hypoplasia
4. microcephaly
5. learning disabilities

also risks of shingles in infancy / severe neonatal varicella if late in mother

336
Q

What is the first step if a pregnant mother is exposed to chickenpox during pregnancy and is unsure about previously having chickenpox?

A

urgently check maternal blood for varicella antibodies

337
Q

What is the management of exposure by pregnant women to chickenpox without previous chickenpox?

A
  • oral aciclovir at 7 - 14 days after exposure (not immediately)
338
Q

What is the management a pregnant woman who develops chickenpox during pregnancy?

A
  • seek specialist advice
  • oral aciclovir if present > 20 weeks and within 24h of onset of rash
  • if < 20 weeks - consider aciclovir ‘with caution’
339
Q

What should you advise if 1 COCP is missed?

A

take last pill even if it means taking 2 in one day then continue taking one daily; no additional contraceptive needed

340
Q

What should you advise if 2 or more COCP doses are missed in week 1 and she has had UPSI?

A
  • emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
  • use condoms or abstain from sexn until has taken pills for 7 consecutive days
  • take last pill even if it means taking 2 in 1 day
341
Q

What should you advise if 2 or more COCP doses are missed in week 2 and she has had UPSI?

A

after seven consecutive days of taking the COC there is no need for emergency contraception

342
Q

What should you advise if 2 or more COCP doses are missed in week 3 and she has had UPSI?

A

she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

343
Q

What is the advice for folic acid in pregnant epileptic women?

A

shouhld all take 5mg OD

344
Q

What is the risk of sodium valproate in pregnancy?

A

neural tube defects + neurodevelopmental delay

345
Q

What is the advice re carbamazepine in pregnancy?

A

considered least teratogenic of older antiepileptics

346
Q

What is the advice re phenytoin in pregnancy?

A
  • associated with cleft palate
  • if taking during pregnancy, should be given vit K in last month to prevent clotting disorders in newborn
347
Q

What is the risk of lamotrigine in pregnancy?

A
  • rate of congenital malformations low
  • dose may need to be increased in pregnancy
348
Q

What are 3 features associated with placenta praevia?

A
  1. multiparity
  2. multiple pregnancy
  3. embryos more likely to implant on lower segment scar from previous C section
349
Q

What part of routine antenatal care may pick up placenta praevia?

A

20 week abdominal US

350
Q

What is the best test to diagnose placenta praevia?

A

transvaginal US

351
Q

What are the 4 features of classifical grading of placenta praevia?

A
  • I: reaches lower segment but not internal os
  • II: reaches internal os but doesn’t cover
  • III: covers internal os before dilation but not when dilated
  • IV: (major): completely covers internal os
352
Q

What 2 medications should be administered to a woman in premature labour?

A
  1. tocolysis
  2. steroids - for fetal lung maturation
353
Q

What are 11 risks of prematurity?

A
  1. increased mortality
  2. respiratory distress syndrome
  3. intraventricular haemorrhage
  4. necrotising enterocolitis
  5. chronic lung disease
  6. hypothermia
  7. feeding problems
  8. infection
  9. jaundice
  10. retinopathy of prematurity
  11. hearing problems
354
Q

How can you distinguish between vulval carcinomas and vulval intraepithelial neoplasia?

A
  • vulval carcinomas are commonly ulcerated
  • vulval intraepithelial neoplasia - white or plaque-like lesions, don’t ulcerate
355
Q

What causes the majority of vulval cancers?

A

squamous cell carcinoma

356
Q

What are 5 risk factors for vulval carcinoma?

A
  1. HPV
  2. vulval intraepithelial neoplasia
  3. immunosuppression
  4. lichen sclerosus
  5. age
357
Q

What is hydrops fetalis?

A
  • can be caused by severe anaemia e.g. due to viral suppression of fetal erythropoiesis by parvovirus B19
  • anaemia leads to heart failure
  • leads to accumulation of fluid in fetal serous cavities
  • e.g. asites, pleural and pericardial effusions
358
Q

What is the treatment of hydrops fetalis?

A

intrauterine blood transfusions

359
Q

At what point during pregnancy is intrahepatic cholestasis of pregnancy typically seen?

A

third trimester

360
Q

What is the most common liver disease of pregnancy?

A

intraheptic cholestasis of pregnancy

361
Q

What are 3 points of the management of obstetric cholestasis?

A
  1. ursodeoxycholic acid - symptomatic
  2. weekly LFTs
  3. induction at 37 weeks
362
Q

What is a complication of cholestasis of pregnancy?

A

increased rate of stillbirth

not associated with maternal morbidity

363
Q

When does acute fatty liver of pregnancy typically occur?

A

third trimester or period immediately following delivery

364
Q

What is the management of acute fatty liver of pregnancy?

A

supportive care
once stabilised - definitive management is delivery

365
Q

What are the 3 key features of HELLP syndrome?

A

haemolysis, elevated liver enzymes, low platelets

366
Q

What are the 3 diseases of the spectrum of festational trophoblastic disorders?

A
  1. complete hydatidiform mole
  2. partial hydatidiform mole
  3. choriocarcinoma
367
Q

What is a complete hydatidiform mole?

A
  • 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
368
Q

What are 5 key features of a hydatidiform mole?

A
  1. bleeding in first or early secsond trimester
  2. exaggerated pregnancy sx e.g. hyperemesis
  3. uterus large for dates
  4. high serum hCG
  5. HTN and hyperthyroidism (hCG can mimic TSH)
369
Q

What are 2 features of a the management of a complete hydatidiform mole?

A
  1. urgent referral to specialist centre - evacuation of uterus
  2. effective contraception to avoid pregnancy in next 12 months
370
Q

What proportion of patients with complete hydatidiform mole go on to develop choriocarcinoma?

A

2-3%

371
Q

What is a partial hydatidiform mole?

A
  • normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes.
  • DNA is both maternal and paternal in origin
  • Usually triploid - e.g. 69 XXX or 69 XXY.
  • fetal parts may be seen
372
Q

What is the key risk factor for chorioamnionitis?

A

premature rupture of membranes

373
Q

What is the management of chorioamnionitis in a pregnant mother?

A
  • if > 34 weeks - prompt delivery (via C section if necessary) - close monitoring if < 34w
  • broad spectrum IVAB e.g. co-amoxiclav, amox + metronidazole
374
Q

What is the normal fetal heart rate?

A

100-160 bpm

375
Q

What are 2 possible causes of baseline bradycardia on a fetal CTG (<100)?

A
  1. increased fetal vagal tone
  2. maternal beta blocker use
376
Q

What is meant by a late deceleration on CTG?

A

deceleration of the heart rate which lags behind the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction

377
Q

What are 4 causes of baseline tachycardia on CTG?

A
  1. maternal pyrexia
  2. chorioamnionitis
  3. hypoxia
  4. prematurity
378
Q

What are 2 causes of loss of baseline variability (<5 beats / min) on fetal CTG?

A
  1. prematurity
  2. hypoxia
379
Q

What can cause early deceleration on CTG?

A

usuaully innocuous - indicates head compression

380
Q

What is meant by early deceleration on CTG?

A

deceleration of the heart rate which commences with onset of a contraction and returns to normal on completion of the contraction

381
Q

What does a late deceleration on fetal CTG indicate?

A

fetal distress e.g. asphyxia or placental insufficiency

382
Q

What is meant by variable decelerations on CTG and what can this indicate?

A

slowing of fetal heart rate independent on contractions - may indicate cord compression

383
Q

What are 5 causes of oligohydramnios?

A
  1. PROM
  2. Potter sequence - bilateral renal agenesis + pulmonary hypoplasia
  3. IUGR
  4. Post-term gestation
  5. Pre-eclampsia
384
Q

What is the definition of oligohydramnios?

A

reduced amniotic fluid < 500ml at 32-36 weeks and amniotic fluid index < 5th percentile

385
Q

How does tracheo-oesopahgeal fistula affect amniotic fluid volume?

A

causes polyhydramnios

386
Q

What are 8 risk factors for endometrial cancer?

A
  1. nulliparity
  2. early menarche / late menopause
  3. unopposed oestrogen e.g. HRT
  4. obesity
  5. diabetes mellitus
  6. polycystic ovarian syndrome
  7. tamoxifen
  8. hereditary non-polyposis colorectal carcinoma
387
Q

What are 3 protective factors for endometrial cancer?

A
  1. multiparity
  2. COCP
  3. smoking
388
Q

What first line and subsequent investigations must be done in suspected endometrial cancer?

A
  • first line: transvaginal US (endometrial thickness <4mm has strong negative predictive value)
  • hysteroscopy with endometrial biopsy
389
Q

What is the management of endometrial cancer?

A
  1. localised disease is treated with total abdominal hysterectomy + bilateral salpingo-oophorectomy
  2. patients with high-risk disease may have postoperative radiotherapy
  3. Progestogen therapy sometimes used in frail elderly women not suitable for surgery
390
Q

What type of lifestyle advice should be given first line in premenstrual syndrome?

A

sleep, exercise, smoking, alcohol, regular (2-3 hourly) small balanced meals rich in complex carbohydrates

391
Q

What is a contraindication to the use of tibolone?

A

within 12 months of LMP - may cause irregular bleeding

Others: 1. breast ca
2. Hormone dependent tumours
3. Thromoboembolic disorders

392
Q

What are 2 side effects of clonidine?

A

dry mouth and dizziness

393
Q

What is first line treatment of VTE in pregnancy?

A

LMWH

*Warfarin teratogenicity in first trimester and fetal haemorrhage in third trimester.

394
Q

What is the diagnostic triad for hyperemesis gravidarum?

A
  • weight loss >5% baseline
  • dehydration (may result in increased hematocrit)
  • electrolyte disturbance (Common abnormalities include hypokalemia, hyponatremia, and metabolic alkalosis (from vomiting). Ketosis may also be present due to starvation.)
395
Q

What is the relationship between smoking and hyperemesis gravidarum?

A

smoking associated with lower risk of hypermesis.

*Nicotine may reduce HCG levels.

396
Q

What are 3 indications for admission in hyperemesis gravidarum?

A
  1. Continued N+V + unable to keep down liquids or oral antiemetics
  2. Continued N+V with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
  3. Confirmed or suspected comorbidity (e.g. unable to tolerate oral abx for UTI)

+ lower threshold if comorbidity e.g. diabetes

397
Q

What are 4 steps to the management of hyperemesis gravidarum?

A
  1. simple measures - avoid triggers, bland food, ginger, P6 (wrist) acupuncture
  2. first line: antihistamines/phenothiazines
  3. second line: ondansetron, metoclopramide, domperidone
  4. admission, IV hydration
398
Q

What is the first line drug treatment for hypermesis gravidarum?

A
  • antihistamines: oral cyclizine or promethazine
  • phenothiazines: oral prochlorperazine or chlorpromazine
  • combination drug doxylamine/ pyridoxine
399
Q

What are the second-line drug options to treat hyperemesis gravidarum?

A
  • oral ondansetron
  • oral domperidone or metoclopramide (5 day smax - EPSEs)
400
Q

What is the risk of ondansetron use in pregnancy?

A

in first trimester - risk of cleft palate

401
Q

What is the standard screening test for Down syndrome?

A
  • nuchal translucency measurement AND
  • serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
402
Q

What screening test results are suggestive of Down syndrome, from the combined test?

A
  • increased beta HCG
  • reduced PAPP-A
  • thickened nuchal transclucency
403
Q

What is offered to women for Down syndrome screening in pregnancy if they present late, and when?

A
  • quadruple test (alfa-feto protein, unconjugated oestriol, hCG, inhibin A)
  • 15-20 weeks
  • DS suggested by raised hCG and inhibin, reduced AFP, unconjugated oestriol)
404
Q

What does NIPT for Down screening involve?

A
  • analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
  • cffDNA derives from placental cells and is usually identical to fetal DNA

*not diagnosti5dc; need for invasive testing like amniocentesis and CVS.

high sensitivity and specificity

405
Q

What is a mnemonic to remember drugs contraindicated in breastfeeding?

A

BREAST MLCCC
* B: bromocriptine, benzodiazepines
* R: radioactive drugs, rizatriptan
* E: ergometrine
* A: aspirin, amiodarone, alcohol, atropine
* S: sulphonamides, sulphonylureas
* T: tetracyclines, (iso)tretinoin
* M: methotrexate
* L: lithium
* C: ciprofloxacin
* C: carbimazole
* C: chloramphenicol

406
Q

What is a management of a blocked duct in a breastfeeding woman?

A

continue breastfeeding, seek advice re: positioning of the baby
breast massage

407
Q

What is the management of nipple candidiasis in breastfeeding mother?

A
  1. treat mother + baby for nipple candidiasis + breast feeding should continue
  2. mother - miconazole, baby - nystatin for oral mucosa
408
Q

What is the first line treatment for mastitis in breast feeding women?

A
  • flucloxacillin 10-14 days
  • breastfeeding or expressing should continue during treatment
409
Q

What are 3 indications to treat mastitis in a breastfeeding mother?

A
  1. systemically unwell
  2. nipple fissure present
  3. symptoms don’t improve after 12-24h of effective milk removal or culture indicates infection
410
Q

What is the cause of bilateral breast pain and redness in the first few days after an infant is born, with pain worst just before a feed?

A

breast engorgement

411
Q

What may help relieve the pain of breast engorgement in a breastfeeding mother?

A

hand expression of milk

412
Q

What is the presentation of Raynaud’s disease of the nipple in a breastfeeding woman?

A

intermittent pain present during + immediately after feeding; blanching of nipple, followed by cyanosis + or erythema

413
Q

What are the treatment options for Raynaud’s disease of the nipple?

A
  • minimising cold exposure
  • heat packs after breastfeed
  • avoiding caffeine
  • stop smoking
  • specialist input: oral nifedipine (off license)
414
Q

What are 3 types of skin disorders in pregnancy?

A
  1. Atopic eruption of pregnancy
  2. Polymorphic eruption of pregnancy
  3. Pemphigoid gestationis
415
Q

What is the commonest skin disorder of pregnancy?

A

Atopic eruption of pregnancy

416
Q

What are 3 key differences between polymorphic eruption of pregnancy and pemphigoid gestationis?

A
  1. PEP occurs in abdominal striae, PG is in periumbilical region, can spread to trunk/back/buttocks/arms
  2. PG lesions are blistering
  3. PEP in 3rd trimester, PG in 2nd and 3rd
  4. PEP treated with emollients/topical steroid/PO steroid, PG always with oral steroid
417
Q

What are 6 examination findings which are the normal physiological changes of pregnancy (considered pathological otherwise)?

A
  1. increased heart rate (and increase in stroke volume = inc CO)
  2. decreased BP in 1st/2nd trimesters
  3. bounding / collapsing pulse
  4. ejection systolic murmur (>90% of women)
  5. loud firs theart sound / sometimes third heart sound
  6. increase in tidal volume (but not resp rate)
418
Q

What type of metabolic abnormality is normal in pregnancy?

A

mild fully compensated respiratory alkalosis

419
Q

What happens to thyroid function during pregnancy?

A
  • increase in total T4 and T3 in first half of pregnancy, but normal/slightly low free hormone due to increased TBG binding
  • normal ranges of T4 and T3 slightly low in 2nd + 3rd trimester
  • TSH production stimulated after first trimester only slightly - large rise indicates iodine deficiency
420
Q

Why are pregnant women at increased risk of renal stones?

A

increased urinary calcium excretion in pregnancy

421
Q

What are 4 ECG changes considered normal in pregnancy?

A
  1. LAD
  2. small Q waves and inverted T wave in lead III
  3. ST depression and inversion or flattening of T wave in inferior and lateral leads
  4. atrial and ventricular ectopics
422
Q

What are 3 changes that would be seen on spirometry in pregnancy?

A
  1. increased tidal volume
  2. increased vital capacity
  3. reduced residual volume

RR doesn’t change

423
Q

What is the mechanism of action of levonorgestrel (levonelle) pill for emergency contraception?

A

delays ovulation - prevents follicular rupture and causes luteal dysfunction

424
Q

How many days from conception does it take for serum hCG to be detectable?

A

11 days (in 98% of patients)

425
Q

What are the rules for gravida / para shorthand?

A
  • G = total number of pregnancies
  • includes current pregnancy
  • if multiple e.g. twins - counts as one
  • includes any miscarriages
  • P = X + Y
  • X = number of pregnancies beyond 24 weeks (twins count as 1, still birth >24w counts as 1 )
  • Y = any miscarriages/terminations/ectopics <24w
426
Q

What weeks are considered pre term and post-term?

A
  • pre term: < 37
  • post term: >42
427
Q

What is the recommended management of hyperthyroidism e.g. Graves disease in pregnancy?

A
  • trimester 1 / attempting conception: propylthiouracil
  • trimester 2/3: carbimazole
428
Q

What is the next step if a woman has a ‘higher chance’ of a baby with Down syndrome from initial screening tests (combined or quadruple testing)?

A
  • 2nd screening test: non-invasive prenatal test NIPT
  • diagnostic test: CVS, amniocentesis
429
Q

What is the management of suspected pre-eclampsia?

A

emergency secondary care assessment for any woman in whom it is suspected

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