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Finals: Speciality Blocks > ObGyn > Flashcards

ObGyn Flashcards

1
Q

Molar pregnancy classically presents after how many weeks gestation

A

14

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2
Q

Name some of the symptoms of molar pregnancy?

A

1) Extreme morning sickness (due to high levels of b-hCG)
2) Heat intolerance and anxiety (due to the b-HCG mimicking TSH properties inducing a state of hyperthyroidism)
3) Vaginal bleeding

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3
Q

“Snowstorm” appearance on pelvic ultrasound is diagnostic of which condition?

A

Molar pregnancy

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4
Q

What most useful marker to monitor the treatment of molar pregnancy?

A

Beta human chorionic gondatotropin (b-HCG) to ensure that there is no foetal tissue remaining after evacuation of the products of conception

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5
Q

What is it important to monitor beta human chorionic gondatotropin (b-HCG) whilst treating a molar pregnancy?

A

To minimise the risk of developing choriocarcinoma

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6
Q

CA-125 is a marker of which kind of ObGyn cancer?

A

Ovarian cancer

Often used to monitor response to treatment and recurrence

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7
Q

Management of molar pregnancy

A

Managed by suction evacuation followed by serial beta hCG measurements and surveillance registration

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8
Q

What is the most common cause of postpartum haemorrhage

A

Uterine atony - the failure for the uterus to contract after delivery due to a lack of tone in the uterine muscle.

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9
Q

What is the major risk factor for uterine atony

A

Uterine over-distension, as seen in multiple pregnancy

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10
Q

Define Postpartum haemorrhage (PPH)

A

The loss of at least 500ml of blood within the first 24 hours of delivery.

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11
Q

The 4 causes of postpartum haemorrhage (PPH)

A

4 ‘T’s

Tone (uterine atony) - failure of the uterus to contract after delivery

Trauma either birth canal injury or tear.

Tissue - retainment of placental or foetal tissue

Thrombin i.e. coagulopathies

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12
Q

Clinical examination signs of uterine atony (postpartum haemorrhage)

A

Soft and high position of the uterus

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13
Q

Which type of contraception is contraindicated by current pelvic infection

A

IUS (intrauterine system that releases progesterone)
IUD (intrauterine device which releases copper)

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14
Q

How long can the Intra-uterine device stay for

A

Up to 10 years

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15
Q

What is the most effective form of emergency contraception

A

Intra-uterine device

Prevents implantation and can be used 120 hours after the first episode of UPSI or after the earliest expected date of ovulation.

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16
Q

Name an absolute contraindication for vaginal birth after caesarean

A

Classic caesarean section scar (vertical)

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17
Q

What type of miscarriage
Cervical os is closed
Gestational sac and fetal pole within the uterus

A

Threatened miscarriage

A process of miscarriage that has started but not yet progressed and thus the foetus remains viable

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18
Q

What type of miscarriage

Cervical os is closed
Uterus contains foetal tissue but no foetal heart beat
No vaginal bleeding

A

Missed miscarriage

Products of conception in the uterus with absent of foetal heartbeat indicating the foetus has died.

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19
Q

Define miscarriage

A

Involuntary spontaneous pregnancy loss <24 weeks gestation

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20
Q

What type of miscarriage

Cervical os open
Vaginal bleeding present
Foetal heartbeat on US
Products of contraception are in the uterus

A

Inevitable miscarriage

Foetus is currently alive i.e. no expulsion of products of conception, but the pregnancy will not continue and will proceed to incomplete or complete miscarriage

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21
Q

What type of miscarriage

Cervical os open
Vaginal bleeding present
No foetal heartbeat on US
Products of contraception are within the cervical canal or uterus

A

Incomplete miscarriage

No viable pregnancy is present but the products of conception remain in the uterus

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22
Q

What type of miscarriage

Cervical os closed
Vaginal bleeding present
No foetal heartbeat on US
Products of contraception are completely outside of the uterus

A

Complete miscarriage

The complete passage of all products of conception i.e. uterus is empty, and the cervix is closed

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23
Q

What are the three features to check on a trans-vaginal ultrasound scan to assess foetal viability in a miscarriage

A

Mean gestational sac diameter
Foetal pole
Foetal heart beat

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24
Q

What is the triad of features of hyperemesis gravidarum

A

5% prepregnancy weight loss
Dehydration
Electrolyte imbalance

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25
Q

What is the first line medication used for hyperemesis gravidarum

A

Antihistamines such as oral promethazine or oral cyclizine
Aim to control the nausea and vomiting

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26
Q

What is the classic presentation of Fitz-Hugh-Curtis syndrome

A

Right upper quadrant pain, sometimes associated with shoulder tip pain due to irritation of the diaphragm.
Commonly a complication of pelvic inflammatory disease, where adhesions (bands of scar tissue) form due to inflammation of the liver capsule

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27
Q

Name a potential complication of pelvic inflammatory disease

A

Chronic pelvic pain (40%)
Infertility (15%)
Ectopic pregnancy (1%)
Fitz-Hugh-Curtis syndrome (where adhesions (bands of scar tissue) form due to inflammation of the liver capsule)

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28
Q

How is Fitz-Hugh-Curtis syndrome definitively diagnosed

A

Laparoscopy

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29
Q

What are two common causes of pelvic inflammatory disease

A

Chlaymidia trachomatis (39%)
Neiserria Gonorrhoea (14%)

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30
Q

What is the name of the diagnostic criteria for Polycystic ovary syndrome

A

Rotterdam diagnostic criteria

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31
Q

PCOS can be diagnosed if two of the following criteria are present.
Name the 3 criteria

A

Polycystic ovaries on transabdominal and transvaginal ultrasound
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism

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32
Q

Name a complication of polycystic ovary syndrome

A

Infertility

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33
Q

What is the most common organism that causes septic arthritis

A

Staphylococcus Aureus

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34
Q

Name some of the NICE red flags for ovarian malignancy

A

Abdominal distension (bloating)
Feeling full (early satiety)
Loss of appetite
Pelvic or abdominal pain
Increased urinary urgency and/or frequency
Older age (>50)

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35
Q

What examination and management option are all women offered at 40 weeks gestation

A

Vaginal examination and membrane sweep

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36
Q

How are Bartholin’s gland abscess managed

A

Incision and drainage, with insertion of a word catheter to encourage marsupialisation
Oral antibiotics are usually sufficient to treat the infection

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37
Q

Contraction of chickenpox during the first trimester of pregnancy can lead to congenital varicella syndrome in the newborn due to the virus’ teratogenic effects. Typical features include low birth weight, limb hypoplasia, skin scarring, microcephaly and eye defects.

What medication should be given to the mother within 24 hours of the rash developing to prevent the baby from developing features such as limb hypoplasia, skin scarring and eye defects.

A

Acyclovir

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38
Q

What are the 4 characteristic features of antiphospholipid syndrome

A

CLOT:
Clots e.g. DVT
Livedo reticularis (mottled, lace-like appearance of the skin on the lower limbs)
Obstetric loss i.e.recurrent miscarriages
Thrombocytopenia (low platelet count)

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39
Q

Likely Dx:

Age between 30-50
Overweight
Menorrhagia
Dysmenorrhoea
Abdominal discomfort
Uterus can be palpated above the symphysis pubis

A

Uterine fibroids

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40
Q

Likely Dx:

Itching sensation around vulva
Thick creamy discharge
Negative whiff test

A

Genital candidiasis i.e. thrush

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41
Q

What is the recommended first line treatment for genital candidiasis

A

Single dose of oral fluconazole 150mg

Often it is patient preference - the mainstay is antifungal treatment

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42
Q

What type of bacteria is gonorrhoea

A

Intracellular gram-negative diplococci

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43
Q

What type of infection is the most common cause of pelvic inflammatory disease

A

Gonorrhoea

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44
Q

What is first line imaging investigation for a breast limb in under 40 years old

A

Ultrasound scan

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45
Q

What timescale should the booking visit be performed in pregnancy

A

8 - 12 weeks

The visit includes BP, urine dipstick, BMI check. Bloods include FBC, blood group, rhesus status, red cell alloantibodies, hepatitis B, syphilis, rubella, HIV test is offered, and urine culture

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46
Q

What is the timeframe for Down’s syndrome screening including nuchal scan

A

11 - 13 + 6 weeks

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47
Q

Mixing of RhD+ foetal blood with a RhD- mother who has already been sensitised before to RhD.

What is the complication that can occur as a result?

A

Haemolytic disease of the newborn

This is when the woman’s anti-D antibodies cross the placenta and enter foetus circulation, which contains RhD+ blood and bind to the antigens, causing the foetal immune system to attack and destroy its own RBCs.

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48
Q

Rhesus D- women are routinely offered anti-D prophylaxis to prevent haemolytic disease of the newborn.

When is the doses of anti-D prophylaxis given to rhesus negative women

A

Offered two doses in total = 28 and 34 weeks.

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49
Q

What is the timeframe for the anomaly scan to be performed during pregnancy

A

18-20 + 6 weeks

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50
Q

What are the criteria to be referred for further investigations (if they are trying for a baby)

A

Regular unprotected intercourse for 1 year, without a successful pregnancy

If they have known risk factors for infertility you may consider earlier referral

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51
Q

Define Placenta praevia

A

Placenta overlying the internal cervical os

Placenta praevia is where the placenta is fully or partially attached to the lower uterine segment. It is an important cause of antepartum haemorrhage – vaginal bleeding from week 24 of gestation until delivery.

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52
Q

Define antepartum haemorrhage

A

Vaginal bleeding from weeks 24 of gestation until delivery

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53
Q

What is the main risk factor for placenta praevia

A

Previous caesarean section

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54
Q

Vasa praevia is characterised by a triad of

A

(i) Vaginal bleeding
(ii) Rupture of membranes
(iii) Foetal compromise e.g. abnormal CTG

The bleeding occurs following membrane rupture when there is rupture of the umbilical cord vessels, leading to loss of fetal blood and rapid deterioration in fetal condition.

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55
Q

What test is used to determine the amount of feto-maternal haemorrhage and thus the dose of Anti-D required for the maternal Rhesus -ve

A

Kleihauer test

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56
Q

What investigation is used to definitive diagnosis placenta praevia

A

Transvaginal ultrasound

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57
Q

Likely Dx:

Painless vaginal bleeding after 24 weeks of pregnancy

A

Placenta praevia

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58
Q

If patient has known placenta praevia, how must she deliver?

A

Via Caesarean section aim for an elective caesarean section at 37-38 weeks gestation however low threshold for emergency due to risk of significant bleeding

Vaginal delivery is contraindicated with placenta praevia due to risk of significant haemorrhage

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59
Q

Management if mother presents not in labour with suspected placenta praevia.

A

ABC approach, resuscitation and stabilisation

IIf stable, perform urgent transvaginal ultrasound to diagnose placenta praevia. Consider corticosteroids if between 24-34 weeks gestation and there is risk of preterm labour

If the bleeding is not controlled, immediate caesarean section required

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60
Q

Characteristics of the third stage of labour

A

Period between the baby’s delivery and the expulsion of the placenta and membranes

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61
Q

How is the delivery of the placenta commonly managed

A

Manually by controlled cord traction.

This must be gentle, or else there is increased risk of causing complications such as uterine inversion and postpartum haemorrhage.

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62
Q

The delivery of the placenta is commonly managed manually by controlled cord traction. This must be gentle, or else there is increased risk of causing complications.

What two complications can occur

A

Uterine inversion

Postpartum haemorrhage

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63
Q

Characteristics of the latent first stage of labour

A

Regular painful contractions

Cervical changes, including effacement and dilatation up to 4cm

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64
Q

Characteristics of the established first stage of labour

A

Regular painful contractions

Progressive cervical dilatation to 4cm

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65
Q

Name the two stages of the first stage of labour

A

Latent first stage (0-4cm)

Established first stage (4-10cm)

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66
Q

Characteristics of the active second stage of labour

A

Full cervical dilatation i.e. 10cm

Active maternal pushing

Baby is visible

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67
Q

Characteristics of the passive second stage of labour

A

Full cervical dilatation i.e. 10cm

No active maternal pushing yet i.e. involuntary expulsive contractions

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68
Q

Name the two stages of the second stage of labour

A

Passive second stage (no active maternal pushing)

Active second stage (active maternal pushing and the baby is visible)

NOTE: she is in the second stage when the cervix is fully dilated i.e. 10cm

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69
Q

Characteristics of the third stage of labour

A

Period between the baby’s delivery and the expulsion of the placenta and membranes

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70
Q

How many stages of labour are there

A

3

First stage is split into: latent and established

Second stage is split into: passive and active

Third stage

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71
Q

Why do you not carry out a vaginal examination in any antenatal haemorrhage

A

They require a transvaginal ultrasound to rule out placenta praevia

This is due to the risk of inducing further haemorrhage

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72
Q

Name an infection that is a relative indication for C section

A

Active Herpes Simplex Virus (HSV) infection

Vaginal examination should be avoided in HSV as a measure to prevent ascending infection

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73
Q

Medication used for post-exposure HIV prophylaxis in an infant born to a low-risk mother (i.e. low viral load, <50 HIV RNA copies/mL)

A

Zidovudine

Also used for the management of untreated women presenting in labour at term, and is given intravenously throughout labour.

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74
Q

Management of a pregnancy women with newly diagnosed HIV

A

Start antiretroviral therapy (ART) as soon as possible

Tenofovir disoproxil/emtricitabine is a common first-line regime

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75
Q

If the mother’s HIV viral load is <50. Can she have a normal vaginal delivery?

A

Yes
Normal vaginal delivery can be recommended and supported

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76
Q

If the mother’s HIV viral load is >50.
Can she have a normal vaginal delivery?

A

Not recommended

An elective caesarean section is recommended

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77
Q

Can a women with HIV breastfeed?

A

Recommended not to

The safest way to feed infants born to women with HIV is with formula milk, as there is no on-going risk of HIV exposure after birth

However women with a low viral load on cART who choose to breastfeed should be informed of the risk of transmission, but supported to breastfeed if they wish, alongside additional monitoring

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78
Q

How and when invited for cervical screening

A

Women between the ages of 25 and 64 years

Every 5 year

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79
Q

What is the purpose of the cervical screening i.e. smear test

A

Testing for the presence of human papilloma virus (HPV), which is the main cause of cervical cancer

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80
Q

What two human papilloma virus (HPV) stains account for the majority of the cervical cancers

A

HPV 16 and 18

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81
Q

What medication is the recommended first-line anti-hypertensive agent in the management of pre-eclampsia

A

Oral labetalol

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82
Q

The definitive treatment of eclampsia is the delivery of the baby.

What other medication should be considered to prevent and treatment of eclamptic seizures

A

Intravenous magnesium sulphate should also be given and continued for 24 hours following the last seizure

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83
Q

What is the first line treatment of atrophic vaginitis

A

Characterised by inflammation and thinning of the genital tissues due to a fall in oestrogen levels, hence is most common after menopause.

Topical oestrogen

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84
Q

Likely Dx:

Post menopausal woman with vaginal dryness and thinning of the vaginal skin

A

Atrophic vaginitis

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85
Q

‘Woody uterus’ in pathognomoic of what condition

A

Placental abruption (the premature separation of the placenta from the uterine wall)

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86
Q

Likely Dx:

Pregnant women at term with severe abdominal pain with woody uterus and no vaginal bleeding

May have features of shock

A

Placental abruption (the premature separation of the placenta from the uterine wall)

Shock is very common as there is often a large blood loss even when there is not a lot of blood loss vaginally because the blood mostly remains between the placenta and the uterine wall and so external losses can be minimal

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87
Q

When should woman that is RhD -ve ben given anti-D after the onset of placental abruption

A

Within 72 hours

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88
Q

What is the biggest risk factor for a baby developing Group B Streptococcus

A

Previous baby with Group B Streptococcus infection

About 50% of infants born to women who carry GBS will go on to become carriers and less than 1% become ill with the infection themselves

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89
Q

Management of pregnant women at risk of developing Group B Streptococcus infection e.g. had a previous baby with GBS infection

A

Intrapartum antibiotics prophylactically
Intrapartum meaning given from the onset of labour until full delivery

First line benzylpenicillin

This is only for those undergoing vaginal delivery. Not required for C section

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90
Q

What patient groups are offered intrapartum antibiotics prophylaxis against GBS

A

Women with risk factors for developing GBS infection

AND

All women in preterm labour regardless of their GBS status

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91
Q

What is the first-line manoeuvre in shoulder dystocia

A

McRobert’s manoeuvre i.e. mother put into hyperflex and abduction of the her legs

Increases the relative anterior-posterior diameter of the pelvis

This may be accompanied with applied suprapubic pressure

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92
Q

Define category 1 caesarean section

A

Immediate threat to the life of mother or baby and delivery should expedite immediately within 30 minutes

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93
Q

Define category 2 caesarean section

A

Poses no immediate life-threatening event to the mother or baby, but urgent delivery is required (preferably between 60 and 75 minutes)

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94
Q

Define category 3 caesarean section

A

Early delivery is required (within 24 h), but there is no evidence of maternal or foetal compromise

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95
Q

HELLP syndrome.

What does HELLP stand for?

A

Haemolysis (anaemia)
Elevated Liver enzymes
Low platelets

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96
Q

HELLP syndrome is a complication of what condition

A

Complication of preeclampsia caused by elevated blood pressure in pregnancy

Most likely to occur immediately after the baby is delivered

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97
Q

Likely Dx:

Pregnant women in third trimester

Painless jaundice

Pruritus in hands and feet

Elevated bilirubin

LFT normal

A

Intrahepatic cholestasis of pregnancy

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98
Q

Risk factors for postpartum hemorrhage

A

High parity

Bleeding disorder e.g. von Willebrand disease

Pre-eclampsia

Multiple pregnancy

Gestational hypertension

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99
Q

What is the active management of the third stage of labor

A

Prophylactic uterotonic

Early cord clamping

Controlled cord traction to deliver the placenta

Oxytocin helps to contract the uterus, thereby preventing bleeding

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100
Q

Name the four causes of postpartum haemorrhage (PPH)

A

4 ‘T’s.

Tone (uterine atony) - failure of the uterus to contract after delivery.

Trauma - may come from a birth canal injury or tear

Tissue - retained placental or foetal tissue can lead to continued bleeding

Thrombin - coagulopathies can lead to continued bleeding due to a failure of clotting.

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101
Q

Define delayed puberty

A

Absence of menstruation and secondary sexual characteristics by age 13

OR

Absence of menstruation but with normal secondary sexual characteristics by age 15

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102
Q

What are uterine fibroids

A

Benign smooth muscle tumours of the myometrium of the uterus

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103
Q

What is the gold standard investigation for uterine fibroids

A

Trans-vaginal ultrasound - used to assess the size and location of the fibroids.

MRI is used if ultrasound is not detailed enough to assess the fibroid for surgery.

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104
Q

What is the first line non-surgical management option for uterine fibroids

A

Levonorgestrel-releasing intrauterine system (Mirena)

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105
Q

What is the first line management option for uterine fibroids in patients trying for a baby

A

Myomectomy - surgical removal of the fibroid from the uterine wall, and is generally fertility-sparing.

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106
Q

What medication is used in the treatment of dysmenorrhoea

A

Mefenamic acid

Dysmenorrhoea refers to painful menstruation

“MP is a pain”

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107
Q

What medication is used in the treatment of menorrhagia

A

Tranexamic acid

Menorrhagia refers to heavy periods

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108
Q

What is the most common cause of delayed puberty

A

Constitutional delay

Watch and wait approach

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109
Q

Most appropriate next step:

Smear: positive for HPV but negative cytology

A

Repeat smear in 12 months

12 months time:
If the sample is negative for HPV at 12 months, patients can be returned to routine recall.
Patients who remain positive for HPV, who still have normal cytology at 12 months should have a repeat smear test in another 12 months.

24 months time:
Patients who are then negative for HPV at 24 months can return to routine recall.
Patient who remains positive for HPV at 24 months (regardless of cytology result) should be referred to colposcopy

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110
Q

Risk factors for gestational diabetes

A

Previous gestational diabetes

Family history of diabetes (first generation)

Previous macrosomic baby of >4.5 kg

BMI >30

111
Q

Investigating a patient for gestational diabetes with a risk factor of gestational diabetes (that is not previous gestation diabetes)

A

Oral glucose tolerance test at 24-28 weeks

112
Q

Investigating a patient for gestational diabetes with a risk factor of previous gestation diabetes

A

Oral glucose tolerance test as soon as possible after the booking visit

Additional oral glucose tolerance test at 24-28 weeks if the first one is normal

113
Q

Name a foetal complication of gestational diabetes

A

Macrosomia (birthweight >4kg) - due to excess maternal blood glucose crossing the placenta and inducing increased neonatal insulin production.

Pre-term delivery

Hypoglycaemia in the baby shortly after birth (due to sustained high foetal insulin levels after delivery) - if severe may lead to hypoglycaemic seizures

Increased risk of developing type 2 diabetes (later in life)

114
Q

Name a maternal complication of gestational diabetes

A

Increased risk of :-
Hypertension
Pre-eclampsia
Developing type 2 diabetes
Increased risk of gestational diabetes in future pregnancies

115
Q

How is gestational diabetes managed

A

Low glycaemic index diet, plus metformin and insulin if required.

116
Q

Cervical motion tenderness is pathognomonic of what condition?

A

Pelvic inflammatory disease (PID)

117
Q

How is pelvic inflammatory disease diagnosed

A

Clinical diagnosis

118
Q

Likely Dx:

Bilateral abdominal pain

Cervical motion tenderness

Fever

A

Pelvic inflammatory disease

119
Q

Likely Dx:

Pt with previous sexually transmitted infection or known pelvic inflammatory disease (PID) presenting with right upper quadrant pain

A

Fitz Hugh Curtis syndrome

This is secondary to inflammation of the liver capsule

Often caused in PID or a STI

120
Q

How is pelvic inflammatory disease managed

A

Combination of antibiotics

AND

Analgesia

Review in 4 weeks

121
Q

What are the two most common organisms that causes pelvic inflammatory disease

A

Gonorrhoea and Chlamydia

122
Q

What supplement is given to women during pregnancy

A

Folic acid

To prevent neural tube defects within the first 12 weeks of pregnancy.

Higher doses are given to mothers who suffer from conditions that are at a higher risk of causing NTDs e.g. coeliac disease, diabetes, thalassaemia trait, obesity, taking antiepileptic drugs, family history of NTDs

123
Q

What vitamin is given in the end stages of the third trimester to reduce the risk of haemorrhagic disease of the newborn

A

Vitamin K injection

124
Q

Criteria for lactational amenorrhoea

A

Exclusively breastfeeding and no menstruation

Up until 6 months postpartum

125
Q

When can the Combined oral contraceptive pill be started postpartum

A

> 6 weeks postpartum if they are not breastfeeding

126
Q

What are the three contraindications for foetal blood sampling

A

Foetal blood sampling (FBS) is indicated when there is a suspicious cardiotocograph (CTG)

Contraindications include:
i) Prolonged decelerations on CTG
ii) Maternal infection e.g. HIV, herpes simplex
iii) Prematurity (<34 weeks)

127
Q

Abnormal CTG -> Foetal blood sample is taken and shows:

pH < 7.20 (normal ≥7.25)
OR
Lactate is >4.9mmol/L (normal ≤ 4.1 mmol/L)

What is the next step of management

A

Urgent delivery

The sample indicates the foetus is acidotic, implying hypoxia and therefore needs urgent delivery

128
Q

Abnormal CTG -> Foetal blood sample is taken and shows:

pH 7.21-7.24 (normal ≥7.25)
OR
Lactate is 4.2-4.8 mmol/L (normal ≤ 4.1 mmol/L)

What is the next step of management

A

Repeat the test in 30 minutes

Although not a great sample it is reasonable to retest in the first instance

129
Q

First-line investigation for endometrial cancer

A

Transvaginal ultrasound to assess endometrial thickness.

130
Q

Triple test screening for chromosomal abnormalities shows:

Low alphafetoprotein (AFP)
Low unconjugated oestradiol (uE3)
High human chorionic gonadotrophin beta-subunit (HCG)

A

Down syndrome

Congenital abnormality caused by a trisomy of chromosome 21

131
Q

Name an abnormality seen with Down Syndrome

A

Congenital heart defects
Neural defects
Flat occiput
Upslanting palpebral fissures
Small, low-set ears

132
Q

What is the recommended screening test for Down Syndrome

A

Combined test, that include :-

Nuchal translucency using ultrasound scan

PAPP-A hormone (level reduced in pregnancy affected with Down’s syndrome)

Beta-hCG hormone (raised in pregnancy affected by Down’s syndrome)

133
Q

Define pre-eclampsia

A

New onset hypertension that occurs after 20 weeks gestation and the co-existence of ≥1 of the following conditions: proteinuria, maternal organ dysfunction, neurological complications, haematological complications or uteroplacental dysfunction

134
Q

Drugs to avoid in breastfeeding

A

LAMBAST:

Lithium
Amiodarone
Methotrexate
Benzodiazepines
Aspirin
Sulfonamides
Tetracyclines

135
Q

What condition is most likely to occur in future pregnancies after a Caesarean section

A

Increased risk of placenta accreta i.e. the abnormal implantation of the placenta into the uterine wall, a common site being the old Caesarean scar

136
Q

What is the gold standard investigation to diagnose endometriosis?

A

Laparoscopy

Allows direct visualisation of the pelvis and, therefore, endometriotic deposits. It also has the added benefit of enabling immediate treatment of endometriosis at the time of diagnosis with techniques such as ablation or surgical excision of endometriotic lesions

137
Q

What kind of beta HCG can be used to exclude a ruptured ectopic pregnancy in a women of childbearing age

A

Urine beta HCG

It is enough to confirm pregnancy

138
Q

What are the 3 management options for ectopic pregnancy

A

Conservative management - closely followed up with repeat B-hCG tests. Rarely used.

Medical management - methotrexate (one off dose).
If the initial dose of methotrexate has failed to treat the ectopic, a second dose of methotrexate or surgical management may be indicated

Surgical management - often salpingectomy where the fallopian tube containing the ectopic is removed. In cases where the ectopic is in a woman with only one functioning fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed.

139
Q

Why is it recommended that patients undergo Salpingectomy for ectopic pregnancy

A

Salpingectomy - removal of the affected fallopian tube with the ectopic pregnancy within it.

Salpingotomy - removal of the ectopic pregnancy only. Carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are performed to exclude any trophoblastic tissue still within the fallopian tube

140
Q

What blood test is the most specific for intrahepatic cholestasis of pregnancy

A

Bile salts - raised

141
Q

What is the name of the diagnostic criteria for polycystic ovary syndrome

A

Rotterdam diagnostic criteria

Diagnosed if two of the following are present:
Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
Oligo-/anovulation
Clinical or biochemical features of hyperandrogenism

142
Q

What medication may be used to reduce hirsutism and induce regular menstruation in patients with polycystic ovary syndrome

A

Co-cyprindrol

143
Q

Define Secondary amenorrhoea

A

Absence of menstruation for 6 months or longer in a woman with previously present menstrual cycles

144
Q

What is the most common cause of secondary amenorrhoea

A

Pregnancy

145
Q

Management of active primary herpes lesions are present on the mother at term

A

Offer the patient oral aciclovir and an elective Caesarian section

Aciclovir can be offered to treat the current presentation

C section to reduce the risk of vertical transmission to the foetus at delivery

146
Q

How often should patients with HIV be screened by the cervical smear test

A

Annual cervical screening is recommended as they are at a higher risk of cervical cancer

147
Q

Management of non-immune pregnant woman exposed to varicella zoster virus

A

Prophylactic varicella zoster immunoglobulin vaccine OR given antivirals 7-14 days after exposure (aciclovir)

Varicella zoster virus = chickenpox

If serology shows the mother is non-immune (varicella-antibody negative) then varicella zoster immunoglobulin vaccine prophyalxis.

The neonate should be monitored and given IV acyclovir following delivery

148
Q

What is the next appropriate management step for any patient with antepartum haemorrhage (even despite normal obs)

A

Transfer to hospital where clinical history, abdominal examination and speculum examination should be performed

If haemodynamic compromised = major haemorrhage resuscitation

149
Q

Diagnosis of premature ovarian insufficiency

A

Clinical features of menopause e.g. vaginal dryness, hot flushes and secondary amenorrhoea

PLUS

TWO elevated serum follicle-stimulating hormone (FSH) levels
- samples taken 4–6 weeks apart
- raised FSH indicates menopause
- two samples to ensure the first was not an anomalous

150
Q

How are patients with premature ovarian insufficiency managed

A

Hormone replacement therapy (HRT) until at least the age of normal menopause, unless the risks of HRT treatment outweigh the benefits.

151
Q

Premature ovarian insufficiency is defined as menopause in a woman aged below what age?

A

40 years

152
Q

Name the causes of polyhydramnios

A

Mnemonic DITCH:
Diabetes
Idiopathic/infection
Twins
Congenital abnormalities
Heart failure

153
Q

What medication can be used to manage polyhydramnios

A

NSAIDs, especially indomethacin

Work in reducing foetal urine output due to their prostaglandin inhibition. Reducing prostaglandin subsequently reduces bloodflow to the glomerulus of the kidney and as a result, reduces foetal urine output and thus the amount of amniotic fluid

154
Q

Define prelabour rupture of membranes at term

A

PROM at term
The rupture of the amniotic membranes before the onset of labour after 37 weeks gestation

155
Q

Complications of pre-labour rupture of membranes at term

A

Increased risk of neonatal infection and chorioamnionitis (infection of the placenta and amniotic fluid) due to ascending infection

To reduce the chance of infection if labour does not commence within 24 hours, induction of labour should be offered.

156
Q

What investigation can be carried out to confirm the diagnosis of pre-labour rupture of membranes at term

A

Actim-PROM vaginal swab

157
Q

Likely Dx:

Bloating/abdominal discomfort in a patient that has recently underwent egg retrieval procedure

A

Ovarian hyperstimulation syndrome

Known side effect of fertility treatments

Conservative management plus thromboprophylaxis (as ovarian hyperstimulation syndrome is a hypercoagulable state)

158
Q

At what gestation should anti-D be administered for prophylaxis for RhD -ve mothers

A

28 and 34 weeks

159
Q

What are the criteria used to diagnose gestational diabetes?

A

Fasting plasma glucose level of 5.6 mmol/l or above

OR

2-hour plasma glucose level of 7.8 mmol/l or above

(remember the numbers 5,6,7,8)

160
Q

Indications for elective caesarean section

A

Abnormal presentation e.g. breech or transverse

Twin pregnancy if first twin is not cephalic

Maternal HIV (with a detectable viral load)

Primary genital herpes in third trimester

Placenta praevia

Anatomical reasons

161
Q

Define gravidity

A

The number of times a woman has been pregnant.

162
Q

Define parity

A

The number of times a woman has given birth to a foetus with a gestational age of >24 weeks, regardless of whether this was a live birth or stillbirth

163
Q

Likely Dx:

Baby with jaundice within 24 hours after birth
At least the second pregnancy

A

Rhesus haemolytic disease of the newborn

164
Q

What is the gold standard investigation for rhesus haemolytic disease of the newborn

A

Direct Coombs test -> positive

Direct Coombs test is used to detect antibodies or complement proteins attached to the surface of red blood cells

165
Q

Most appropriate management plan if women with a breech presentation at 36 weeks

A

Offer a planned external cephalic version (ECV)

Procedure is performed around weeks 37-39 and aims to manually turn the foetus into a cephalic presentation.

Most babies that are breech will naturally turn to a cephalic presentation by week 36, but are unlikely to spontaneously turn beyond 36 weeks

166
Q

Management of asymptomatic bacteriuria in pregnancy

A

Oral antibiotics are recommended in asymptomatic bacteriuria in pregnancy to prevent progression to pyelonephritis and increased risk of preterm labour

167
Q

Likely Dx:

Fever
Secondary postpartum haemorrhage (>24 hrs after delivery)
Offensive vaginal discharge

A

Endometritis - endometrial infection

This may be due to retained placental tissue becoming infected and preventing full contraction of the uterus

168
Q

Contraindications for vaginal delivery

A

Previous history of uterine rupture

Classical (vertical) caesarean section scar

Other condition that would normally contraindicate a vaginal delivery e.g. major placenta praevia, “footlong” breech presentation

169
Q

What is the most common type of ovarian cyst?

A

Follicular cyst

Occur during the menstrual cycle when a follicle does not release an egg in ovulation. They are usually harmless and will self-resolve.

170
Q

Likely Dx:

Youngish woman

Vulval mass
Swelling and mildly tenderness

A

Bartholin’s gland cyst

171
Q

Likely Dx:

Youngish woman

Vulval mass which is extremely painful

A

Bartholin’s gland abscess

172
Q

First line treatment for Bartholin’s gland cyst

A

Incision and drainage

Antibiotics in cases of abscess

173
Q

LH, FSH and oestradiol levels in premature ovarian insufficiency?

A

Raised LH
Raised FSH
Low oestradiol

174
Q

What is the initial management to prevent cord compression in cord prolapse

A

Keep the cord warm and mother goes onto a knee–chest position

175
Q

What is the definitive management of cord prolapse

A

Caesarean section

176
Q

What is the function of Tocolytics in labourx

A

Used to minimise contractions.

It can delay delivery while waiting for the caesarean section to occur.

177
Q

What is the only surgical option available that will preserve fertility to manage fibroid

A

Myomectomy

178
Q

Symptomatic ovarian fibroids that are greater than how many cm are normally treated with surgery

A

3cm

179
Q

Clinical features of ovarian fibroids

A

Often asymptomatic

When symptoms occur, they usually involve menstrual dysfunction, in the form of menorrhagia and dysmenorrhoea.

If large enough, the fibroid may distort the uterine cavity to such extent they interfere with fertility.

180
Q

Define secondary postpartum haemorrhage

A

Vaginal bleed from 24h to 6 weeks after delivery).

Loss of at least 500ml of blood within the first 24 hours of delivery is postpartum haemorrhage (PPH)

181
Q

What medication can be used to improve the success rate of external cephalic version for breech presentation?

A

Beta-2 receptor agonists e.g. terbutaline

Can improve success rate as they cause relaxation of uterine muscles

182
Q

Describe the medical termination of pregnancy

A

Mifepristone, a progesterone antagonist, blocks the progesterone required for continuation of the pregnancy

Misoprostol, a prostaglandin analogue. Causes smooth muscle contractions of the myometrium, resulting in expulsion of uterine contents.

183
Q

Describe the surgical management of the termination of pregnancy

A

Suction termination
OR
Dilatation and evacuation/curettage ‘D&C’

184
Q

Name the five ‘categories’ for requesting termination of pregnancy

A

i) Pregnancy < 24 weeks + 6 and continuing with the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family.

ii) Termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

iii) Continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated

iv) Substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

185
Q

What is the most common type of uterine fibroid?

A

Intramural fibroid

186
Q

Likely Dx:

Postmenopausal woman
Vulval soreness, burning, pruritis and bleeding

A

Vulval carcinoma

187
Q

The majority of vulval carcinomas are?

A

Squamous cell carcinomas and occur on the labia majora

188
Q

What are the main risk factors for vulval carcinomas?

A

Human papillomavirus (HPV) infection

Chronic inflammation, e.g., lichen sclerosus

Age

189
Q

Gold standard way to diagnose vulval carcinomas

A

Biopsy

190
Q

The main treatment option for simple cases of primary vulval cancer

A

Radical/wide local excision

The mainstay of treatment for vulval carcinomas is surgical removal

191
Q

Likely Dx:

Sudden-onset stabbing abdominal pain in either the right or left iliac fossa

Associated vomiting episodes due to the severity of the pain

Negative urine BCG

A

Ovarian torsion

Ovarian torsion is an emergency where the ovary twists around its ligaments, cutting off its blood supply

192
Q

What is the normal lining of the ectocervix?

A

Stratified squamous

193
Q

Which medication is typically administered intra-operatively to aid delivery of the placenta?

A

IV Oxytocin

194
Q

You are considering surgical management in a woman with fibroids. She still wishes to have children. What is the most suitable option?

A

Myomectomy

195
Q

Which type of breech presentation is where both legs are flexed at the hips and knees?

A

Complete breech

196
Q

Misoprostol is used in the medical management of miscarriage. What type of medication is it?

A

Prostaglandin analogue

197
Q

What type of breech presentation is where both legs are flexed at the hip and extended at the knees?

A

Frank (extended) breech

198
Q

What type of breech presentation is where one or both legs extended at the hip, so that the foot is the presenting part?

A

Footling breech

199
Q

What type of virus is HIV?

A

Single stranded RNA virus

200
Q

Why can’t d-dimer be used to diagnose a VTE in pregnancy?

A

A raised D-dimer can be normal in pregnancy. As D-dimer is an acute phase reactant, it can be raised in conditions other than VTE, so it’s use in the diagnosis of VTE is not reliable

201
Q

What is the most common site of ectopic pregnancy?

A

Fallopian tube

202
Q

What is the correct definition of recurrent miscarriage?

A

≥3 consecutive pregnancies that end in miscarriage

203
Q

Where is LH produced in the body?

A

Anterior pituitary

204
Q

Which hormone is endometriotic tissue most responsive to?

A

Oestrogen

205
Q

What is adenomyosis?

A

Presence of functional endometrial tissue within the uterine myometrium

206
Q

What is the most common position of the foetal head?

A

Occipito-anterior (the foetal occiput facing anteriorly)

207
Q

A women receives VTE prophylaxis antenatally. How long should this be continued following delivery?

A

Continued for 6 weeks after delivery, as the post-partum period is associated with the highest risk of VTE.

208
Q

What is the role of an episiotomy in the management of shoulder dystocia?

A

Allows better access for manoeuvres

209
Q

What is third line therapy for hyperemesis gravidarum?

A

IV hydrocortisone
Once symptoms improve, convert to prednisolone PO and gradually reduce dose until lowest maintenance dose is reached

210
Q

What is first line therapies for hyperemesis gravidarum?

A

Cyclizine
Prochlorperazine
Promethazine
Chlorpromazine

211
Q

What are the second line therapies for hyperemesis gravidarum?

A

Metoclopramide (maximum 5 days due to risk of extrapyramidal side effects)
Domperidone
Ondansetron

212
Q

What is the correct category for an elective Caesarean section?

A

Category 4

Emergency procedures are sub-classified into categories 1 - 3

213
Q

Uterine fibroids are a benign tumour of which tissue?

A

Smooth muscle

214
Q

What is the standard initial treatment for gestational diabetes?

A

Metformin

Insulin would be started on diagnosis if the fasting glucose is >7mmol/L or later in pregnancy if glucose is high or fetal abdominal circumference >95th centile.

215
Q

How is oligohydramnios defined?

A

Amniotic fluid index <5th centile for the gestational age

Oligohydramnios refers to a low level of amniotic fluid during pregnancy

216
Q

What is the epithelial lining of the endocervix?

A

Columnar

217
Q

First line treatment for symptomatic cervical ectropion?

A

Cervical ectropion occurs when there is eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu.

First line is to stop any oestrogen containing medications – most commonly the combined oral contraceptive pill

218
Q

If symptoms of cervical ectropion persist despite stopping oestrogen containing medications what is the next best management option

A

Ablation of the columnar epithelium e.g. cryotherapy or electrocautery

219
Q

What is the role of Kleihauer test in maternal isoimmunisation?

A

Assesses the prescence of fetal blood in the maternal circulation

220
Q

What tissue is sampled in an amniocentesis?

A

Amniotic fluid

221
Q

Which antibiotic should be added in cases of endomyometritis?

A

If there is suspicion of infection of the deeper uterine muscle (tender uterus) or overt sepsis, gentamicin should be added for additional antimicrobial cover

222
Q

What is the main risk of amniocentesis?

A

Miscarriage

223
Q

What is the definitive management of a uterine rupture?

A

Delivery by C-section and repair of the rupture

224
Q

What is the usual first-line therapy in lichen sclerosus?

A

Topical steroids

225
Q

What structure is the fetal station measured in relation to?

A

Ischial spines

226
Q

What is the recommended treatment for antiphospholipid syndrome during pregnancy?

A

Anticoagulant e.g. low molecular weight heparin

AND

Anti-platelet agent e.g. low dose aspirin

227
Q

In a woman with drug-managed gestational diabetes, what are the recommendations for delivery?

A

Deliver at 37-38 weeks

228
Q

What is the standard initial treatment for iron deficiency anaemia?

A

Oral iron supplementation

A parental iron infusion (Ferrinject) can be considered if compliance with oral treatment is poor or there is evidence of malabsorption.

229
Q

Which complication is most associated with an amnioreduction?

A

Rapid loss of amniotic fluid can cause the placenta to come away from the wall of the uterus, causing placental abruption.

230
Q

What is the main mechanism of action of the intrauterine system (Mirena®)?

A

Thins the endometrium, inhibiting implantation, but it also thickens cervical mucus which reduces sperm motility.

231
Q

What procedure is offered first line in a prolonged pregnancy?

A

Induction of labour is offered first-line in a post-dates pregnancy.

If the patient declines an induction they should be offered twice weekly monitoring.

232
Q

What is the definitive diagnosis for a cervical polyp?

A

Histological examination after removal

233
Q

During labour, what examination is used to assess the position of the fetal head

A

Vaginal examination

234
Q

Which host cells are targeted by HIV?

A

CD4

235
Q

Why are elective Caesarean sections typically planned for >39 weeks gestation?

A

Reduce risk of respiratory distress in newborn

For those where delivery needs to be expedited prior to 39 weeks’ gestation, the administration of corticosteroids to the mother should be considered

236
Q

Which syndrome describes the development of intrauterine adhesions?

A

Asherman’s syndrome is an acquired condition causing intrauterine adhesions and can be caused by surgery on the uterus, pelvic infections, or treatment for cancer.

237
Q

Bishop score of what is a prerequisite for induction of labour with an amniotomy?

A

Bishop score >7

238
Q

What is the mainstay of induction of labour, and are the preferred primary method as advised by NICE guidelines (2008)

A

Vaginal prostaglandins

Prostaglandins act to prepare the cervix for labour by ripening it, and also have a role in the contraction of the smooth muscle of the uterus

239
Q

What are the three main methods of induction

A

vaginal prostaglandins (mainstay treatment)
amniotomy
membrane sweep

240
Q

Amniotomy is a method of induction of labour. What is often given alongside it?

A

Infusion of artificial oxytocin (Syntocinon) - acting to increase the strength and frequency of contractions. The aim is to start low and titrate upwards until there are 4 contractions every 10 minutes.

An amniotomy is where the membranes are ruptured artificially using an instrument called an amnihook. As with a membrane sweep, this process releases prostaglandins in an attempt to expedite labour. It is only performed when the cervix has been deemed as ‘ripe’ (see Bishop Score > 7)

241
Q

When is membrane sweep offered

A

At 40 and 41 weeks’ gestation to nulliparous women

At 41 weeks to multiparous women.

242
Q

What scoring system is used to assess ‘cervical ripeness‘ based on measurements taken during vaginal examination. It is checked prior to induction, and during induction to assess progress.

A

Bishop score

243
Q

What is the definitive treatment of adenomyosis?

A

Hysterectomy

Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus

244
Q

In women at risk of uterine rupture, what is used to monitor the fetus?

A

Cardiotocography (CTG)

245
Q

Which is a serious complication of breech presentation?

A

Cord prolapse

246
Q

Which trimester of pregnancy does hyperemesis gravidarum usually peak in?

A

First

Reaches a peak in the 9th week, and usually settles by the 20th week.

247
Q

Which point during pregnancy carries the greatest risk of developing a VTE?

A

Postpartum

248
Q

Which investigation provides the definitive diagnosis of miscarriage?

A

Transvaginal ultrasound scan

249
Q

In the most common form of shoulder dystocia, what does the anterior fetal shoulder become impacted against?

A

Pubic symphysis

250
Q

What medications can be used to manage obesity in PCOS?

A

Orlistat

Pancreatic lipase inhibitor which can be used to manage obesity in PCOS

251
Q

What is polyhydramnios?

A

Amniotic fluid index >95th centile

252
Q

What is the upper gestational age limit for a pregnancy loss to be classified as a miscarriage?

A

24 weeks

253
Q

Why is induction of labour offered to women with a prolonged gestation?

A

Reduce risk of stillbirth

254
Q

What is primary dysmenorrhoea?

A

Menstrual pain with no underlying pelvic pathology

255
Q

Hyperemesis gravidarum is thought to be due to increased levels of which hormone?

A

b-hCG (hormone released by the placenta)

256
Q

PCOS is characterised by high levels of which hormone?

A

Testosterone

257
Q

Which two medications are normally given in cases of preterm prelabour rupture of membranes?

A

Antibiotics and steroids

Antibiotics: oral erythromycin should be given for 10 days as they are at an increased risk of infection

Steroids are given to drive development of surfactant in the fetal lungs

258
Q

definition of a secondary post-partum haemorrhage?

A

Bleeding from 24 hours after delivery to 12 weeks postpartum

259
Q

Definition of post-partum haemorrhage

A

Loss of >500ml blood within 24 hours of delivery

260
Q

What contraception is first line treatment for menorrhagia

A

Intra-uterine system (IUS) should be offered as the first-line

Menorrhagia - heavy periods

261
Q

Serum progesterone is taken to confirm ovulation in patients who are struggling to conceive. It should be taken when during the menstrual cycle

A

7 days before the next expected period to coincide with ovulation.

262
Q

What is placenta percreta

A

Characterised by chorionic villi that invade the perimetrium (outermost layer of the uterus)

263
Q

What is placenta accreta

A

Attachment of the placenta to the myometrium.

As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage

3 types:
Accreta - Attaches only to the myometrium
INcreta - INvades into the myometrium
PERcreta - gets to the PERimetrium

264
Q

Renal agenesis (Potter sequence) can cause oligohydramnios.

How does it cause it?

A

Renal agenesis causes the fetus not to produce urine, hence the liquid inside the sac will be diminished causing oligohydramnios.

265
Q

Next step in a patient who have two consecutive HPV results unavailable or inadequate cytology results

A

Refer to colposcopy

266
Q

What is the first-line investigation for preterm prelabour rupture of the membranes

A

Speculum examination - sign of preterm prelabour rupture of the membranes is pooling of amniotic fluid in the posterior vaginal vault

267
Q

Painless vaginal bleeding during pregnancy is pathognomonic of what condition

A

Placenta praevia

It is when the placenta is lying wholly or partly in the lower uterine segment

268
Q

First line investigation for placenta praevia

A

Transvaginal ultrasound

269
Q

After taking ulipristal acetate women should wait how long before starting regular hormonal contraception

A

5 days

270
Q

What is the bacterium that causes Group B Streptococcal disease (GBS)

A

Streptococcus agalacticae

271
Q

How long after levonorgestrel (Levonelle) for emergency contraception can you restart hormonal contraception

A

Immediately - no need to wait

272
Q

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l - what medication should be started?

A

Insulin +/- metformin

273
Q

Children under the age of what years are considered unable to consent for sexual intercourse and hence consultations regarding this age group should automatically trigger child protection measures regardless of Gillick competent

A

13

Finals: Speciality Blocks (11 decks)

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