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OBGYN Flashcards

1
Q

VTE prophylaxis in OBGYN pre-op patients?

A

low molecular weight heparin
- once daily
- no routine monitoring
- lower risk of heparin induced thrombocytopenia compared to unfractionated heparin.

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2
Q

What vaccines are offered to pregnant women in UK?

A

Influenza Vaccine
Pertussis Vaccine (whooping cough) - given between 16-32 weeks, combined with polio/diphtheria/tetanus.

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3
Q
  • Abdominal pain
  • Vaginal bleeding
  • Reduced fetal movement
  • woody hard uterus

Diagnosis and initial step?

A

PLACENTAL ABRUPTION
- Initial step: CTG
If normal > US
If fetal distress > C section

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4
Q

What is the best medication for hypertension in pregnancy?

A

1st: Labetalol (NOT IN ASTHMA)
2nd: Nifedipine
3rd: Methyldopa (risk of postnatal depression)
All 3 are safe in pregnancy/breastfeeding but first choice is Labetalol.

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5
Q
  • Lower abdominal pain/suprapubic tenderness
  • Fever
  • vaginal discharge
  • Rigidity
  • Cervical excitation/cervical motion tenderness- deep dyspareunia

Diagnosis and initial step?

A

PELVIC ABSCESS/TUBO-OVARIAN ABSCESS
complication of PID

In ER > TVS, if painful then abdominal and pelvic US
- multilocular complex adnexal mass with debris, septations and irregular thick walls.

If pregnancy test positive > Ectopic

Endocervical swab can also be done but takes days to get results.

PID
- cause: chlamydia trachomatis (common) and Neisseria gonorrhea

MX OF PID

outpatient
- IM ceftriaxone 500mg/1000mg + oral doxycycline 100mg BID + oral metronidazole 400mg BID for 14 days.
- Ofloxacin + metronidazole orally for 14 days

inpatient
- IV ceftriaxone 500mg + IV doxycycline + oral doxy and metro for 14 days
- IV ofloxacin + IV metronidazole for 14 days

complication of PID: Fitz-Hugh-Curtis syndrome&raquo_space;> RUQ pain + aggravated on breathing/coughing + referred to right shoulder.

CERVICITIS

  • Chlamydia > doxycycline 100mg BID for 7 days.
    Azithromycin 1g for day 1 then 500mg for 2 days.
  • Neisseria gonorrhea > IM ceftriaxone 1000mg
    if susceptible to ciprofloxacin, then 500mg oral single dose.
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6
Q
  • needs long term contraception
  • does not wish to have more children
  • fibroids distorting uterine cavity
  • does not remember to take pills

What is the best contraception?

A

NEXPLANON
68mg Etonogestrel
should be changed after 3 years.

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7
Q

Hypertension in pregnancy
- chronic
- gestational
- pre-eclampsia
- severe pre-eclampsia
- eclampsia
- HELLP

A
  • chronic: >140/90, <20 weeks
  • gestational: >140/90, >20 weeks
  • pre-eclampsia: >140/90, >20 weeks, proteinuria, headaches, swollen hands and feet, dipstick 2 +
    24 hr urine protein >/= 0.3g
    Protein: Creatinine (PCR) >/= 30mg/mmol
    Albumin: Creatinine >/= 8mg/mmol
  • severe pre-eclampsia: >160/110, headaches, visual scotoma, epigastric pain, hyperreflexia, high creatinine, high LFT, low platelets
  • eclampsia: pre-eclampsia + seizures
  • HELLP: Hemolysis, elevated liver enzymes, low platelets.

MX
- booking blood pressure is important to compare.
- dipstick 1 + and everything else normal > assess within 7 days
- dipstick 2 + and everything else is normal > refer to obstetric unit for same day
- severe pre-eclampsia > IV magnesium sulphate
- definitive management is delivery of baby
- women at risk of pre- eclampsia should take 75-150mg aspirin daily from 12 weeks’ gestation till delivery.

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8
Q

Types of Miscarriage
- Threatened
- Misses/Delayed
- Inevitable
- Incomplete
- Complete

A

Miscarriage = spontaneous loss in <24 weeks
- Threatened: vag bleed +HR present + os closed
- Misses/Delayed: loss of fetus<20 weeks without symptoms + may or may not bleed + os closed
- Inevitable: os open + vag bleed
- Incomplete: not all products have been expelled
- Complete: everything has been expelled

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9
Q

<20 weeks pregnant
- nausea
- vomiting
- fluid/food intolerance
- lethargy
- urine ketones
- tachycardia
- weight loss
- dehydration

Diagnosis and management?

A

HYPEREMESIS GRAVIDARUM

MX
1st: IV fluids (0.9% Nacl + KCl/Hartmans/Ringers)
2nd: antiemetics
- chlorpromazine, Pro chlorperazine cyclizine, promethazine
- metoclopramide, ondansetron
3rd: steroids (hydrocortisone)
4th: Parenteral nutrition

others: LMWH (Dalteparin), Thiamine (reduce risk of Wernicke’s encephalopathy)

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10
Q

What is the best contraception for perimenopausal symptoms?

A

Cyclical HRT

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11
Q

What is the best contraception for a young girl (around 15 yrs) who is not sexually active and has symptoms of dysmenorrhea, menorrhagia and irregular periods?

A

COCP

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12
Q
  • Irregular PAINLESS 1st trimester bleed
  • hyperemesis
  • uterus large for date
  • passage of products of contraception
  • “snowstorm appearance” on US
  • “Large theca lutein cysts”

Diagnosis and management?

A

MOLAR PREGNANCY
- partial: hcg MAY be normal (above 25 IU/l is positive)
- complete: snowstorm appearance, theca lutein cysts, hcg levels very high.

MX
- Suction curettage and histology for diagnosis
- 2 weekly serum hcg levels until normal
- advised not to conceive until normal
- contraception for 6 months
- after chemo contraception for 1 year

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13
Q
  • ONE SIDED abdominal pain
  • vaginal spotting
  • LMP 6-8 weeks ago
  • TVS inconclusive
  • hcg positive

Diagnosis?

A

ECTOPIC PREGNANCY
- common between 6 to 8 weeks
- fallopian tubes stretch causing cervical motion tenderness
If stable > hcg levels
- hcg should be more than 1500 to diagnose ectopic pregnancy.
If unstable> LAPAROTOMY

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14
Q
  • Palpable uterine mass
  • decreased fertility
  • prolonged heavy periods

Diagnosis and management?

A

UTERINE FIBROIDS

Types
- sub mucosal: beneath endometrium, bulge into cavity, decreases fertility
- intramural: within muscular wall, MOST COMMON
- sub serosal: external, project outside of uterus

MX
if asymptomatic > follow up annually

if menorrhagia >

LNG-IUS (if cavity intact)
Tranexamic acid/NSAIDS/COCP
Norethisterone, long-acting progestogen injection

if severe menorrhagia > ulipristal acetate

SX
most successful > hysterectomy (pre op GnRh)

preserver fertility > myomectomy (bestone but has risk of uterine rupture during pregnancy), artery embolization.

others > ablation (<3 cm only, does not preserve fertility)

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15
Q

What contraception is used in patient with hx of sickle cell disease?

A

Depot medroxyprogesterone acetate

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16
Q

What contraception is used if patient is not sexually active and complaints of menorrhagia?

A

1st: IUS - Mirena
2nd: Tranexamic acid

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17
Q

What contraception can be used if patient complaints of dysmenorrhea only?

A

Mefenamic acid + COCP

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18
Q

What contraception can be used if patient complaints of dysmenorrhea and menorrhagia?

A

Tranexamic acid + NSAIDS

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19
Q

What contraception should be used to stop heavy bleeds RAPIDLY?

A

Norethisterone 5mg TID for 10 days

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20
Q

What contraception should be used if patient complaints of menorrhagia + dysmenorrhea + fibroid not distorting cavity?

A

IUS - Mirena

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21
Q

What contraception is used within 72 hrs of unprotected sex?

A

Levonelle pill

22
Q

What contraception is used within 120 hrs of unprotected sex?

A

IUCD or EllaOne pill

23
Q
  • increased urine frequency
  • dysuria
  • urgency
  • lower abdominal pain (suprapubic/costovertebral)
  • fever, chills, rigor
  • nausea and vomiting
  • urine smell or color changes
  • urine dipstick shows nitrates and leukocytes positive
  • pregnancy test positive
  • hcg levels high

Diagnosis and management?

A

UTI
most common organism: Ecoli
urine test: >10*5 bacteria cfu/ml

RISK FACTORS
- female
- pregnancy
- new partner
- sexually active
- familial/genetic
- immunocompromised
- anatomic abnormality
- catheterization

INVESTIGATION
rapid > urine dipstick (not in pregnant or catheterized)
midstream urine for culture
US

MX
- if pregnant >
if susceptible then cefalexin for 7 days
AVOID trimethoprim in 1st trimester (risk of neural tube defects)
AVOID nitrofurantoin at term(risk of neonatal hemolysis)
If only trimethoprim is option give along with 5mg folic acid

  • if non pregnant > trimethoprim/nitrofurantoin for 3 days
  • if man >
    trimethoprim/nitrofurantoin for 7 days
24
Q

What is the ABSOLUTE risk of ectopic pregnancy while using IUS contraception?

A

None of the contraception increase the absolute risk of ectopic pregnancy.
IUS is about 5% risk.

25
Q

Missed pill rules

A

21/7 regime for COCP
- if one pill missed > have that pill ASAP even if 2 pills a day and continue as normal, no additional contraception.
- if two or more pills missed > take pill ASAP even if 2 a day

week 1 pill + UPSI: emergency contraception
week 2 pill: no UPSI for 7 days
week 3 pills: finish pack, omit pill free interval and start next one.

POP
taken same time daily

  • traditional POP >3 hrs late: take pill ASAP (if more than one, missed take only one) and no USPI for 48 hrs.
    if USPI during missed pill and within 48 hrs of restarting POP > emergency contraception
  • Desogestrel (cerazette) >12 hrs late: same as above.
26
Q
  • Postmenopausal bleed
  • Tamoxifen for breast cancer

Risk of developing?

A

ENDOMETRIAL CANCER

RISK FACTORS
- Tamoxifen
- obesity
- nulliparity
- early menarche
- late menopause
- unopposed estrogen (add progestogen to reduce this risk)
- DM
- PCOS

INVESTIGATION
1st: TVS (>4mm thickness abnormal)
2nd: hysteroscopy with endometrial biopsy for diagnosis.

27
Q
  • post emergency LSCS bleed
  • fever
  • fouls smelling discharge
  • tender bulky uterus
  • placenta and membranes completely removed at time of delivery
  • US shows uterus empty

Diagnosis?

A

ENDOMETRITIS

RISK FACTORS
- emergency LSCS
- curettage
- PROM
- prolonged labor
- multiple pelvic exams
- internal fetal monitoring (scalp electrodes/intrauterine)

MX
co-amoxiclav (Uk guidelines)
gentamycin + clindamycin (WHO guidelines)
gentamycin + cefotaxime + metronidazole (RCOG guidelines)

28
Q
  • Rh negative mother
  • father status unknown
  • no IM injection in previous pregnancy
  • baby develops jaundice

Diagnosis?

A

Rh incompatibility
- Rh negative mother delivers Rh positive baby
- anti D IgG antibodies formed in mother, causes hemolysis in future pregnancies.

PREVENTION
- Test for anti D antibodies in Rh negative mothers
- if not previously sensitized > single dose of anti D immunoglobulin at 28 weeks/ two doses 28 and 34 weeks
if previously sensitized > no need of anti D

EMERGENCY ANTI D (within 72 hrs)
- delivery of Rh-positive baby (live/stillborn)
- miscarriage> 12 weeks
- termination/evacuation
- blunt abdominal trauma
- ectopic pregnancy
- ECV
- antepartum hemorrhage
- chorionic villus sampling/amniocentesis/fetal blood sampling

MX
- if unborn (hydrops fetalis, heart failure) > intrauterine blood transfusion
- if born (anemia, jaundice, hepatosplenomegaly) > Phototherapy, blood transfusion, exchange transfusion.

29
Q

Pregnant woman with seizures, headache, visual disturbance and abdominal pain.

Diagnosis?

A

ECLAMPSIA

MX
- MgSO4 4mg in 100ml 0.9% NS IV over 5-15 mins loading dose
- 1mg/hr for next 24 hrs following last seizure
- recurrent: 2-4mg again over 5-10 mins

29
Q

CTG shows baseline 150bpm, variability of less than 5 for 30 mins, no accelerations or decelerations. What is the next step?

A

1 non reassuring factor: change position, IV fluids, reduce oxytocin if ongoing, start tocolytics.

Normal bpm: 110-160
Non-Reassuring bpm: 100-109 or 161-180
Normal variability: 5-25
Non-Reassuring variability: <5 for 30-50 mins/ >25 for 15-25 mins
Normal decelerations: none
Reassuring decelerations: late in 50% for less than 30 mins with no bleeding

If 2 non reassuring factors/1 abnormal factor > expedite birth and conservative mx

30
Q
  • elderly woman with CA- 125 positive (>35)
  • abdominal bloating
  • loss of appetite
  • early satiety
  • normal abdominal and pelvic exam

Diagnosis?
What is the next step?
Should we refer to gynecology immediately?

A

OVARIAN CANCER

RISK FACTORS
- age
- BRCA1 and BRCA2
- family hx
- nulliparity
- smoking
- obesity

PROTECTIVE FACTORS
- COCP
- Pregnancy

MX
If CA 125 raise > Urgent US
If US abnormal > urgent referral to gynecology

BUT IF PATIENT HAS PELVIC/ABDOMINAL MASS OR ASCITES&raquo_space;» REFER TO GYNECOLOGY IMMEDIATELY (skip CA125 and US)

31
Q
  • pregnant woman with post coital bleed
  • fetal US and heartbeat normal
  • placenta anterior and high
  • os closed
  • abdomen soft non tender

Diagnosis?

A

CERVICAL ECTROPION
- columnar epithelium replaces squamous epithelium.
- red ring around os.
- post coital bleed
- excess non purulent discharge
- enlarges due to excess estrogen.

RISK FACTOR
- pregnancy
- COCP

MX
- cervical smear to ensure it is normal
- treated if bothersome
- silver nitrate cautery, diathermy, cryotherapy.

32
Q
  • young woman
  • stopped COCP
  • amenorrhea
  • US normal
  • low FSH, LH, Estrogen
  • TFT normal

Diagnosis?

A

POST PILL AMENORRHOEA

  • for up to 6 months
  • due to suppression of pituitary gland

MX
- waiting for period
- if patient anxious/wants to conceive, we can start medication after 3 months itself.
- Clomiphene citrate

33
Q

What is the main cause of cervical cancer?

A

main cause: HPV
others: smoking, multiple sexual partners, immunosuppression, COCP (don’t ever ask to stop COCP as risk is very minute).

34
Q

First investigation in patient with menorrhagia with no other symptoms?

A

Full blood count

menorrhagia + recurrent nose bleeds/bruises + family hx of coagulation disorders > Coagulation screen

menorrhagia + palpable uterine mass suspecting fibroids > US

35
Q
  • near term pregnant woman comes with leaking clear fluids
  • fever and sweating
  • suprapubic tenderness
  • small for date uterus
  • CTG shows fetal tachycardia

Diagnosis?

A

CHORIOAMNITIS
due to prolonged rupture of membranes

36
Q
  • continuous leak of urine from vagina
  • hx of hysterectomy

Diagnosis?

A

VESICOVAGINAL FISTULA

CAUSES:
- cancer
- hysterectomy
- pelvic radiotherapy
- difficult vaginal delivery

37
Q
  • heavy vaginal bleeding
  • uterine thickness > 12mm
  • diagnosis of benign endometrial hyperplasia without atypia
  • does not plan on having more children

Management?

A

LNG- IUS

38
Q

UKMEC 1 contraception in migraine with aura?

A

IUCD

39
Q

white cheesy discharge + vaginal itching

Diagnosis?

A

VAGINAL THRUSH- candidiasis

40
Q
  • tender white plaques on vulva
  • itchy
  • worse at night
  • hx of diabetes

Diagnosis?
Management?

A

LICHEN SCLEROSUS

MX
- topical steroids
- follow up in 3 and 6 months (may progress to squamous cell carcinoma)

41
Q
  • woman <40 yrs old didn’t have period for 10 months
  • worried about early menopause

What test would you order?

A

PREMATURE OVARIAN FAILURE

  • serum FSH
  • diagnosis: 2 levels of > 25 IU/L taken 4 weeks apart
  • can have hx of chemo or radiotherapy

MX
- HRT till 51 yrs old

42
Q
  • placental abruption leading to stillborn
  • placenta delivered intact

What factor would lead to postpartum hemorrhage?

A

Disseminated intravascular coagulation.

43
Q
  • chronic cyclical pelvic pain
  • dysmenorrhea
  • taken NSAIDS
  • painful sex
  • COCP used but no benefit
  • no urinary pr bowel symptoms

Diagnosis?

A

ENDOMETRIOSIS

TVS can be done but can be normal in some cases.

gold standard: Laparoscopy for diagnosis and treatment

MX
1st: NSAIDS
2md: COCP
3rd: LNG-IUS

44
Q

postmenopausal woman wants prophylaxis from recurrent UTIs

Management?

A

1st: Topical vaginal estrogen tablets
2nd: antibiotic prophylaxis

45
Q
  • patient with urge incontinence
  • wets herself before she reaches the toilet

Management?

A

1st: modify fluid intake, reduce caffeine and alcohol, bladder training. (for 6 weeks)
2nd: Antimuscarinic (anticholinergic) drugs to reduce involuntary contractions of detrusor muscle.
- oxybutynin (avoided in frail older women)
- tolterodine
- darifenacin
- mirabegron (costly, so not 1st line)

46
Q

What is the best contraception for a young girl (around 15 yrs) who is not sexually active and has symptoms of dysmenorrhea only?

A

Mefenamic acid -NSAIDS

47
Q

What is the best and most specific modality in determining viability of fetus in 1st trimester?

A

TVS

48
Q
  • patient with stress incontinence

Management?

A

1st: pelvic floor exercises (8 contractions TID for 3 months)
2nd: Retropubic mid-urethral tape
3rd: Duloxetine (if not suitable for surgery)

49
Q
  • 2nd or 3rd trimester
  • severe itching
  • excoriations on trunk
  • no rash

Diagnosis?
Investigation?

A

INTRAHEPATIC CHOLESTASIS OF PREGNANCY- obstetrics cholestasis

Investigation of choice: Liver function test

ALP physiologically raised in pregnancy but ALP and AST both will be raised in IHC.

Most sensitive + specific: serum bile acids ( >/= 19 micromol/L)

Diagnosis: LFT + bile acid

Associated risk: stillbirth

MX
- monitor LFTS and bile acid after one week
- topical emollients (calamine lotion, chlorpheniramine maleate/piriton)
- Ursodeoxycholic acid (does not reduce risk of stillbirth)
- early induction of labor if moderate/severe case
- if prolonged prothrombin time&raquo_space;> vitamin K daily

50
Q

IUD thread not found.

Management?

A

1st: speculum examination
2nd: exclude pregnancy.
3rd: TVS/Pelvic US
4th: abdominal Xray (in cases with acute abdomen > suspect uterine perforation&raquo_space; laparoscopic removal)

Depending how question is phrased a COCP may be the answer.

51
Q
A

PLAB (6 decks)

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