OBGYN DAY 2 COPY Flashcards
1
Q
A 27-year-old female presents to her general practitioner complaining of vaginal itchiness and discharge. On examination, the doctor can observe an inflamed vulva and some white, thick vaginal discharge. The cervix looks normal and there is no pain on bimanual examination. A high vaginal swab shows a pH of 4.3.
She has a past medical history of asthma, well-controlled with salbutamol, and has no known allergies.
What is the most likely diagnosis?
What is the treatment?
A
White ‘curdy’ vaginal discharge with pH <4.5 is likely to be candidiasis
The correct treatment is oral itraconazole
2
Q
How would Trichomonas vaginalis present?
How is it treated?
A
Offensive, yellow-green discharge, and strawberry cervix.
It is treated using Oral metronidazole.
3
Q
How would Bacterial vaginosis present?
How is it treated?
A
Bacterial vaginosis presents with offensive thin, white-grey, ‘fishy’ discharge.
It is treated using Oral metronidazole.
4
Q
What do Trichomonas and Bacterial Vaginosis have in common?
(3)
A
raised pH
offensive discharge
treated with metronidazole
5
Q
How do BV and Trichmonas present differently?
(3)
A
Bacterial Vaginosis:
- Thin, white discharge
- “Clue” cells on microscopy
Trichomonas:
- Strawberry Cervix
- Frothy yellow/green discharge
6
Q
What are the risks of bacterial vaginosis in pregnancy?
(4)
A
results in an increased risk of preterm labour,
low birth weight and chorioamnionitis,
late miscarriage
7
Q
Why does bacterial vaginosis result in a raised pH
A
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
8
Q
What is oral itraconazole commonly used to treat?
A
vaginal candidiasis
9
Q
How is vaginal candidiasis treated?
(3)
A
- local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
- oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
- if pregnant then only local treatments
10
Q
What is Recurrent vaginal candidiasis?
What action should be taken?
(3)
A
BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- confirm the diagnosis of candidiasis
- exclude differential diagnoses such as lichen sclerosus
- consider the use of an induction-maintenance regime
11
Q
What can Topical clindamycin be used to treat?
A
used to treat bacterial vaginosis presenting with offensive thin, white-grey, ‘fishy’ discharge when oral therapy is contraindicated.
12
Q
What can Topical metronidazole be used to treat?
A
Topical metronidazole can be used to treat bacterial vaginosis presenting with offensive thin, white-grey, ‘fishy’ discharge when oral therapy is contraindicated.
13
Q
What are the clinical features of Vaginal candidiasis?
(4)
A
- ‘cottage cheese’, non-offensive discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
14
Q
Your next patient in an antenatal clinic is a woman who is 30 weeks pregnant. Which of the finding during your examination would you be concerned with?
15
Q
After 24 weeks what is the expected fundal height growth per week?
A
After 24 weeks you would only expect the fundal height to increase by 1cm a week.
16
Q
At how many weeks would you expect the fundus to be palpable
a) at the umbilicus
b) sternum
A
- You would expect the fundus to be palpable at the umbilicus from 20 weeks
- and at the xiphoid sternum from 36 weeks
17
Q
When is a breech position a problem?
(2)
A
Breech presentation is common before 34 weeks and only becomes a concern in women who go into preterm labour
18
Q
What are the three characteristics of asthma?
A
hypersensitivity
IgE mediated
Mucous secretion
19
Q
What are asthma triggers?
(5)
A
dust
pollen
exercise
cold
beta blockers
20
Q
When does the nuchal scan occur?
A
12 weeks
21
Q
Which week does the anomaly scan take place?
A
20 Weeks
22
Q
What is external cephalic version and when is it offered?
A
External cephalic version is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first
36 weeks
23
Q
What might U&Es be important in asthmatic patients?
A
Salbutamol decreases potassium concentration in the blood
24
Q
Which appointments occur at 28 and 34 weeks?
(2)
A
anti Rh prophylaxis injections
eclampsia screening
25
Which of the following is the best way to detect ovulation?
Day 21 progesterone test is the most reliable test to confirm ovulation
## Footnote
\> 30 nmol/l
26
What is the luteal phase?
| (2)
It occurs after the ovary releases an egg
it lasts 14 days
27
Infertility: initial investigations
| (2)
* semen analysis
* serum progesterone 7 days prior to the expected next period. For a typical 28 day cycle, this is done on day 21.
* *Level****Interpretation**\< 16 nmol/lRepeat, if consistently low refer to specialist16 - 30 nmol/lRepeat\> 30 nmol/lIndicates ovulation
28
Treatment of acute asthma
| (5)
29
Why might you check a patient's gonadatropins?
to measure the regularity of the menstrual cycle
30
Which signs indicate ovulation?
The use of **basal body temperature charts** and **cervical mucus thickness** do not reliably predict ovulation and are not recommended.
31
What is the definition of pre-eclampsia?
Pre-eclampsia is defined as new-onset BP ≥ 140/90 mmHg after 20 weeks AND ≥ 1 of proteinuria, organ dysfunction
32
What is the triad of pre-eclampsia?
* new-onset hypertension
* proteinuria
* oedema
33
How is pre-eclampsia managed?
| (3)
* women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
* oral **labetalol** is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
* delivery of the baby is the most important and definitive management step.
34
What are the clinical features of severe pre-eclampsia?
(7)
Features of severe pre-eclampsia
* hypertension: typically \> 160/110 mmHg and proteinuria as above
* proteinuria: dipstick ++/+++
* headache
* visual disturbance
* papilloedema
* RUQ/epigastric pain
* hyperreflexia
* platelet count \< 100 \* 106/l, abnormal liver enzymes or HELLP syndrome
35
[Left occiput posterior](https://www.passmedicine.com/question/questions.php?q=0#)
36
A 26-year-old woman presents to rheumatology clinic asking for advice as she would like to start a family.
She and her partner both have rheumatoid arthritis, treated with weekly methotrexate. She was told when she started the medication that she would need advice regarding pregnancy.
What advice should you give?
[The patient and her partner will both need to wait 6 months after stopping methotrexate before conceiving](https://www.passmedicine.com/question/questions.php?q=0#)
Methotrexate: must be stopped at least 6 months before conception in both men and women
37
What is the effect of methotrexate?
| (3)
* Methotrexate is teratogenic because its inhibition of dihydrofolate reductase affects DNA synthesis.
* This particularly affects the rapidly dividing cells of the fetus, but there is also evidence that its effects on DNA synthesis can damage various semen parameters.
* Therefore both partners must stop methotrexate for 6 months before conceiving.
38
A nurse informs you of a 28-year-old woman who is 24 weeks pregnant. He says that she has a blood pressure reading of 155/90 mmHg. Her previous blood pressure 2 days ago was 152/85 mmHg. She was previously healthy prior to becoming pregnant.
What is the first line management in this situation?
This woman has moderate gestational hypertension. According to the current guidelines, the first line treatment is Oral labetalol.
39
A woman who is 14 weeks pregnant presents as she came into contact with a child who has chickenpox around 4 days ago. She is unsure if she had the condition herself as a child. Blood tests show the following:
## Footnote
Varicella IgMNegativeVaricella IgGNegative
What is the most appropriate management?
Chickenpox exposure in pregnancy \<= 20 weeks - if not immune give VZIG
40
What is FVS?
Fetal varicella syndrome (FVS)
* risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
* studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks
* features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
41
How should chickenpox exposure be managed during pregnancy?
* if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies
* if the pregnant woman \<= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible - RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure
* if the pregnant woman \> 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
42
Ectopic pregnancy in which location is most associated with an increased risk of rupture?
isthmus
43
A 32 year-old lady has a diagnosis of fibroids and has been trying for a baby for 18 months. She has been under investigation at the sub-fertility clinic and no abnormality has been found except for three uterine fibroids, for which she does not have any symptoms. Her partner has had sperm analysis which found no abnormality.
Which of the following treatments are most appropriate in this situation?
The only effective treatment for large fibroids causing problems with fertility is **myomectomy** if the woman wishes to conceive in the future
44
What is the function of GnRH agonists?
GnRH agonists effectively turn off the ovaries, which causes the fibroids to shrink and therefore are easier to remove surgically.
45
What is the function of Ulipristal acetate?
Ulipristal acetate is a selective progesterone receptor modulator. It is used pre-operatively for women with fibroids as it has been proven to shrink them, thus making surgery easier.
This medication affects fertility, thus is not suitable for women trying to get pregnant, unless (like GHRH agonists) it is used for a short period in combination with surgery.
46
Which antenatal test results would be seen in Down's syndrome?
Down's syndrome is suggested by
* ↑ HCG,
* ↓ PAPP-A,
* thickened nuchal translucency
Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
47
A 26-year-old woman, who is 12-weeks pregnant, attends routine clinic for her combined screening test. She is counselled on the implications of the test and consents. Her results are as follows, summarised:
## Footnote
B-HCGHighPAPP-ALowNuchal translucencyThickened
She is called to discuss the implications of these results, including the high probability of Down's syndrome. Which two other syndromes would also present with similar findings during combined screening?
Down's syndrome combined screening: trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
48
A 64-year-old woman presents with a 1 month history of post-menopausal bleeding. Her only medication is aspirin 75 mg once daily. An ultrasound scan of the uterus shows an endometrial lining thickness of 4.1 mm. An endometrial pipelle biopsy is taken but is inconclusive. What is the next step?
[Hysteroscopy with biopsy](https://www.passmedicine.com/question/questions.php?q=0#)
49
A 57-year-old nulliparous female is seen in the gynaecology outpatient department with a 2-month history of postmenopausal bleeding. She has a past medical history of type 2 diabetes mellitus. Her last menstrual period was 4 years ago.
Transvaginal ultrasound shows an endometrial thickness of 8mm and the results of a pipelle biopsy are reported as follows:
'There is evidence of increased gland-to-stroma ratio, with some evidence of nuclear atypia'.
What is the most appropriate management option?
A total hysterectomy with bilateral salpingo-oophorectomy, in addition, is advisable for all postmenopausal women with atypical endometrial hyperplasia, due to the risk of malignant progression
50
What is hyperemesis gravidarum and what increases the risk?
“morning sickness”
Smoking is associated with a decreased incidence of hyperemesis gravidarum
It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks\*.
51
Management of morning sickness (4)
* antihistamines should be used first-line (BNF suggests promethazine as first-line). Cyclizine is also recommended by Clinical Knowledge Summaries (CKS)
* ondansetron and metoclopramide may be used second-line
* ginger and P6 (wrist) acupressure: CKS suggest these can be tried but there is little evidence of benefit
* admission may be needed for IV hydration
52
Complications of morning sickness
(5)
* Wernicke's encephalopathy
* Mallory-Weiss tear
* central pontine myelinolysis
* acute tubular necrosis
* fetal: small for gestational age, pre-term birth
53
A 26-year-old primigravida woman presents for an ultrasound scan at 34 weeks gestation. It is discovered that her baby is in the breech position.
What is the most appropriate course of action?
External cephalic version is recommended if the foetus is breech at 36 weeks
54
A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?
Menorrhagia - intrauterine system (Mirena) is first-line
55
Which medication is known to causes folate deficiency?
Phenytoin
Folate deficiency associated with anti-epileptic medications is complex, however, it is believed that phenytoin induces intestinal pH changes affecting the enterohepatic circulation of folate.
56
What is movicol and what is a known side effect?
Movicol is a laxative that is used for the relief of constipation.
Laxative use can occasionally be associated with vitamin D deficiency - this is mainly due to laxative abuse or excessive consumption.
57
A 32-year-old woman attends your clinic as she is 8 weeks pregnant and wants a termination of pregnancy. After assessing her and counselling her about the options available to her, she decides she would like a medical termination of pregnancy.
Which medications would you use to facilitate this?
Medical abortions are undertaken using **mifepristone** followed by at least one episode of **prostaglandins** and are appropriate at any gestation
58
What are the methods of termination of pregnancy and at which dates is each used?
* **less than 9 weeks**: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions
* **less than 13 weeks**: surgical dilation and suction of uterine contents
* **more than 15 weeks**: surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour')
59
A 40-year-old woman who has recently had a positive pregnancy test has come to visit her GP seeking advice for her pregnancy. She is 4 weeks pregnant and this is her first pregnancy. She states that she is anxious regarding the possibility of pre-eclampsia, as well as all the information she has seen online. A routine check is done and she appears well. The patient's BMI is measured and calculated as 36 kg/m².
What is the correct advice to give to this patient with regards to medication or supplements she needs to take?
A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth
60
A 33-year-old woman presents to her general practitioner for a routine antenatal visit. She is 22 weeks pregnant. It is her first pregnancy and it has been uncomplicated thus far. She does not have any significant past medical history and does not take any regular prescribed medications. She does not smoke cigarettes or drink alcohol.
Her blood pressure is 148/92 mmHg. This is confirmed on repeat assessment and was previously within normal limits in early pregnancy.
On examination, there is no oedema and her reflexes are normal.
Urinalysis is as follows:
## Footnote
ProteinnegativeBloodnegativeLeucocytesnegativeGlucosenegativeNitritesnegative
What is the most appropriate management?
Labetalol is first-line for pregnancy-induced hypertension
61
A neonate is born at 38 weeks gestation via spontaneous vaginal delivery. The birth weight was 4.5kg. In the newborn postnatal check the attending doctor notes that there is adduction and internal rotation of the right arm. What is the most likely diagnosis?
**Erb's palsy** occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the 'waiter's tip'.
62
Define foetal macrosomia
A baby is diagnosed with foetal macrosomia if they have a birth weight \>4kg regardless of their gestational age.
63
During a subfertility clinic you are asked to take a menstrual cycle history from a 30-year-old in order to establish on what day her mid-luteal progesterone level needs to be done. You clarify that the woman has a regular 35 day cycle.
On which day would you carry out mid-luteal progesterone level?
The correct answer here is on Day 28 - this is 7 days before the end of the lady's regular cycle when progesterone levels should be tested.
An individual who has a normal 28-day cycle would be tested on Day 21.
64
What counseling advice should be given to couples trying to conceive?
(4)
* folic acid
* aim for BMI 20-25
* advise regular sexual intercourse every 2 to 3 days
* smoking/drinking advice
65
What are the risks/benefits of the combined oral contraceptive pill?
| (2)
Cons
* increased risk of **breast** and **cervical cancer**
* increased risk of venous thromboembolic disease
Pros
* protective against **ovarian** and **endometrial cancer**
* usually makes periods regular, lighter and less painful
66
In fertility clinic, when should progesterone levels be checked?
7 days before the end of the cycle
67
You are a first-year doctor working in obstetrics and gynaecology. You are the first on the scene after an emergency call to midwife led delivery.
The delivery has not progressed for some time and midwife explains this is a case of shoulder dystocia. You decide to perform **McRobert's manoeuvre**.
What position should the woman be in to achieve this?
[Supine with both hips fully flexed and abducted](https://www.passmedicine.com/question/questions.php?q=0#)
68
What is McRobert's manoeuvre?
When is it indicated?
The McRobert's manoeuvre is a simple and effective intervention in **shoulder dystocia**.
The maneuver increases the mobility at the sacroiliac joints aiding rotation of the pelvis and allowing the release of the fetal shoulder. It is very important that additional help is called as the first step following recognition of shoulder dystocia.
69
What are the risk factors for shoulder dystocia?
Key risk factors
* fetal macrosomia (hence association with maternal diabetes mellitus)
* high maternal body mass index
* diabetes mellitus
* prolonged labour
70
A 76-year-old woman attends clinic complaining of ongoing urinary incontinence. It is worse when she laughs or coughs. On initial examination, she had a normal pelvic examination, urine dipstick and urine microscopy culture and sensitivities. Four months ago she started supervised pelvic floor exercises and although she noted a slight improvement in incontinence, she still feels her symptoms are affecting her quality of life. Referral for consideration of surgery was discussed but she would prefer medical management.
Which medication is most appropriate to manage her symptoms?
**Duloxetine** may be used in patients with stress incontinence who don't respond to pelvic floor muscle exercises and decline surgical intervention
71
What is **Duloxetine used to treat?**
Duloxetine may be used in patients with stress incontinence who don't respond to pelvic floor muscle exercises and decline surgical intervention.
72
What are antimuscarinics used to treat?
Antimuscarinics are used to manage patients with **urge incontinence** who do not respond to, or alongside, bladder training.
NICE recommend oxybutynin (immediate-release), tolterodine (immediate-release), or darifenacin (once daily preparation) first-line.
73
A 20-year-old female presents with a 3-month history of abdominal pain. Abdominal ultrasound shows an 8cm mass in the right ovary. Histopathological analysis reveals Rokitansky's protuberance.
What is the most likely diagnosis?
**Teratomas** (dermoid cysts) are benign neoplasms derived from multiple germ cell layers.
Due to their germ cell origin a range of tissues can be produced within them including skin, hair, blood, fat, bone, nails, teeth, cartilage, and thyroid tissue.
74
What is Rokitansky's protuberance?
In [gynecology](https://en.wikipedia.org/wiki/Gynecology), a **Rokitansky nodule** is a mass or lump in an [ovarian](https://en.wikipedia.org/wiki/Ovarian) [teratomatous](https://en.wikipedia.org/wiki/Teratoma) [cyst](https://en.wikipedia.org/wiki/Cyst).
75
Risk of malignancy index (RMI) is calculated using which blood test?
serum CA-125
76
A 42-year-old woman who is 12 weeks pregnant attends the antenatal clinic to discuss the results of her combined screening for Down's syndrome.
Her obstetrician explains that tests are suggestive of a trisomy, but it is more likely trisomy 18 (Edward's syndrome) or trisomy 13 (Patau syndrome) rather than trisomy 21 (Down's syndrome).
What part of the combined test could differentiate these trisomies?
Down's syndrome combined screening: trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
77
How does nuchal translucency vary in all three trisomies?
Nuchal translucency is thickened to the same amount in all 3 of the trisomies
78
A 17-year-old female comes to your GP clinic. She has recently travelled to Egypt to see her family, and now has come to visit as she is suffering with per vaginal bleeding and urinary incontinence.
She consents to examination with a chaperone present and you identify signs that suggest there have been recent trauma to the genitalia. You suspect this is a case of female genital mutilation.
What is the most appropriate course of action?
Female genital mutilation (FGM) is a criminal act. The GMC has now issued guidance that all cases of FGM must be reported to the police in under 18s.
79
A 47-year-old patient has asked to discuss the result of her latest smear test. It demonstrated normal cytology and was negative for high-risk human papillomavirus (hrHPV). Her previous smear 12 months prior demonstrated normal cytology but was positive for hrHPV.
What should you advise the patient following her latest smear test result?
Cervical cancer screening: if 1st repeat smear at 12 months is now hrHPV -ve → return to routine recall
80
You are called to review a woman in the maternity ward who is 3 days post-partum complaining of ongoing vaginal bleeding and passage of clots. You explain that lochia is normal in the post-partum period and can be expected to continue for some time.
After what period of time would continued lochia warrant further investigation with ultrasound?
An ultrasound is indicated if lochia persists beyond 6 weeks
81
Define Puerperium
Puerperium is the period of approximately six weeks after childbirth during which time the woman's reproductive organs return to normal. Lochia is a normal part of this process.
82
A 45-year-old woman has come into your post-menopausal bleed clinic. When taking a history, you ask about her medical history and family history for things that may increase her risk of endometrial cancer.
Which condition is associated with an increased risk of endometrial cancer?
HNPCC/Lynch syndrome is a strong risk factor for endometrial cancer
83
What are the key features of endometrial cancer?
(3)
* postmenopausal bleeding is the classic symptom
* premenopausal women may have a change intermenstrual bleeding
* pain and discharge are unusual features
84
How are suspected endometrial cancers investigated?
(3)
* women \>= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
* first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (\< 4 mm) has a high negative predictive value
* hysteroscopy with endometrial biopsy
85
How is endometrial cancer managed?
| (2)
* localised disease is treated with **total abdominal hysterectomy with bilateral salpingo-oophorectomy**. Patients with high-risk disease may have post-operative radiotherapy
* **progestogen therap**y is sometimes used in frail elderly women not consider suitable for surgery
86
Which two factors are protective against endometrial cancer?
(2)
The **combined oral contraceptive pill** and **smoking** are protective
87
A 72-year-old nulliparous female presents with post menopausal bleeding. She reports that her last cervical screening was 14 years ago. On examination she is found to be obese and hypertensive.
What is the most important diagnosis to rule out?
In a female with postmenopausal bleeding (PMB), the diagnosis is **endometrial cancer** until proven otherwise.
88
What are the risk factors for endometrial cancer?
(9)
* obesity
* nulliparity
* early menarche
* late menopause
* unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
* diabetes mellitus
* tamoxifen
* polycystic ovarian syndrome
* hereditary non-polyposis colorectal carcinoma
89
A 57-year-old lady presents to the postmenopausal bleed clinic with a 2 week history of light vaginal bleeding, and mild pain on intercourse. She is otherwise well. On vaginal examination she is tender and has slight dryness.
What should be done next in clinic?
Endometrial cancer must be ruled out, and the first line investigation for this is always TVUS.
While this is most likely atrophic vaginitis, it still must be investigated to rule this out.
**Once a TVUS is done, if it comes back normal then either discharge with cream or referral to HRT clinic would be the most appropriate, but TVUS must be done first. If it is abnormal (\>4mm), then endometrial biopsy would be done.**
90
What are the features of Atrophic vaginitis?
| (3)
* Atrophic vaginitis often occurs in women who are post-menopausal women.
* It presents with vaginal dryness, dyspareunia and occasional spotting.
* On examination, the vagina may appear pale and dry.
91
What is the treatment for atrophic vaginitis?
Treatment is with vaginal **lubricants** and **moisturisers** - if these do not help then topical **oestrogen** **cream** can be used.
92
A 51-year-old female presents to a GP with hot flushes, irritability & a 7 month history of lighter periods. She has also noticed that they have become more irregular. The GP decides she is perimenopausal. Because she has not had a total abdominal hysterectomy, she is started on sequential combined HRT - Elleste duet tablets (estradiol + norethisterone). The GP discusses the risks.
Which of the following is most important to mention as a risk for the norethisterone (progesterone) component?
HRT: adding a progestogen increases the risk of breast cancer
93
A 32-year-old female patient attends clinic. She is 33 weeks pregnant and so far has had no complications with the pregnancy. However, she is now worried as she feels that her baby's usual kicking and moving has reduced over the past few days. She has not noticed any other symptoms of concern and otherwise feels well. She has no significant past medical history, nor family history. She has had two previous uncomplicated pregnancies.
Physical examination is unremarkable, and observations are stable and within normal parameters. A handheld Doppler scan is performed; no fetal heartbeat is detected.
What is the next step in management?
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered
94
A 31-year-old woman presents to her GP with progressively worsening menstrual pain that usually commences a few days before her period. She tried to take paracetamol and ibuprofen to alleviate the pain, but they are not effective in doing so. She also describes extreme discomfort when she has penetrative sex.
Digital vaginal examination reveals nodularity and marked tenderness in the posterior fornix of the cervix. Bimanual examination reveals a fixed, retroverted uterus.
What is the most likely diagnosis?
Which investigation is considered the gold standard?
95
What are the clinical features of Endometriosis?
* chronic pelvic pain
* dysmenorrhoea - pain often starts days before bleeding
* deep dyspareunia
* subfertility
* non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
* on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
96
What is the gold standard investigation for endometriosis?
laparoscopy
97
What are the management options for endometriosis?
(2)
* **NSAIDs and/or paracetamol** are the recommended first-line treatments for symptomatic relief
* if analgesia does help then hormonal treatments such as the **combined oral contraceptive pill or progestogens** e.g. medroxyprogesterone acetate should be tried
98
You are a junior doctor working in a GP practice. A 13-year-old girl comes to see you requesting a prescription for the oral contraceptive pill. On further questioning, she tells you she has a sexual relationship with her 14-year-old boyfriend. She is refusing to speak to her parents about it and states that she will continue having sex even if she doesn't get the pill and she understands the risks associated with this. She is otherwise well with no history of migraines and she has normal blood pressure. What do you do?
[Give her a prescription for the contraceptive pill but encourage her to discuss this with a parent](https://www.passmedicine.com/question/questions.php?q=0#)
99
What are the “Fraser guidelines”?
| (5)
'You can provide contraceptive, abortion and STI advice and treatment, without parental knowledge or consent, to young people under 16 provided that:
* They understand all aspects of the advice and its implications
* You cannot persuade the young person to tell their parents or to allow you to tell them
* In relation to contraception and STIs, the young person is very likely to have sex with or without such treatment
* Their physical or mental health is likely to suffer unless they receive such advice or treatment, and
* It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent
100
What dietary advice should be given during pregnancy?
* **folic acid 400mcg** should be given from before conception until 12 weeks to reduce the risk of neural tube defects. Certain women may require higher doses (women who take antiepileptics)
* **iron supplementation should not** be offered routinely
* **vitamin A** supplementation (intake above 700 micrograms) might be teratogenic. Liver is high in vitamin A so consumption should be avoided
* **vitamin D**: 'women should be advised to take a vitamin D supplement (10 micrograms of vitamin D per day), as found in the Healthy Start multivitamin supplement. Women who are not eligible for the Healthy Start benefit should be advised where they can buy the supplement'. Particular care should be taken with higher risk women (i.e. those with darker skin or who cover their skin for cultural reasons)
101
A 49-year-old patient presents with hot flushes and mood swings. She has no previous medical history or family history. She has been amenorrheic since her Mirena (levonorgestrel) coil was placed 2 years ago.
She would like to consider HRT with the least side effects.
**Oestrogen patch**
The patient requires combined HRT as she has a uterus, so requires progesterone for protection of the endometrial lining against estrogen. However, the patient has a Mirena coil in situ, which is the only form of contraception licensed to be used as the progesterone component in HRT. It is licensed for 4 years if used as HRT.
Therefore the patient only requires oestrogen preparation only.
Transdermal oestrogen such as patches and gels do not have an increased risk of deep vein thrombosis, compared to oral oestrogen preparations.
102
A 55-year-old woman presents with mood swings and night sweats for the last few years which she has managed herself. She reports her last period was over 1 year ago but reports some vaginal bleeding a few days ago. She is not on any contraception.
Which HRT should she have?
**HRT contraindicated****33%**
## Footnote
Undiagnosed vaginal bleeding is a contraindication. This woman has achieved her menopause as she has been amenorrheic for over 1 year, but per vaginal bleeding post menopause warrants further urgent investigation.
103
A 48-year-old woman presents with perimenopausal symptoms. Apart from suffering from migraines with aura, she does not have any relevant medical history. She has a family history of deep vein thrombosis (DVT). The patient's last menstrual periods are irregular, the last one being 3 months ago. She is not currently on any contraception.
Which HRT is best for her?
**Topical cyclical combined HRT**
* Migraine with aura is not a contraindication for HRT, unlike with the combined oral contraceptive pill, however, topical preparations are preferred rather than oral.
* This patient has a uterus, so combined oestrogen and progesterone treatment is required. The oestrogen replaces the oestrogen deficiency that occurs during menopause but also causes endometrial hyperplasia. Using progesterone with the oestrogen protects against this.
* As the patient has a family history of DVT, topical HRT is preferred here as there is no increased DVT risk compared to oral preparations.
* Menopause is defined as amenorrhea for \>1 year, where a continuous regime can be used (oestrogen and progesterone daily).
* This patient has not yet achieved her menopause, so a cyclical regime should be used (oestrogen daily, but progesterone used for a few weeks in the cycle).
104
Contraindications for menopausal HRT
| (4)
* Current or past breast cancer
* Any oestrogen-sensitive cancer
* Undiagnosed vaginal bleeding
* Untreated endometrial hyperplasia
105
A 52-year-old lady with a body mass index of 32kg/m² and type 2 diabetes mellitus comes to see you. She has had a Mirena coil (levonorgestrel-releasing intrauterine system) in place for the last 4 years and has been amenorrhoeic since 3 months post insertion. Over the last month, she has had a 3-day episode of vaginal bleeding and 2 episodes of post-coital bleeding.
What is the most appropriate next step in management?
The answer in this case is to refer the patient to the postmenopausal bleeding clinic for endometrial biopsy. Guidance from the Faculty of Sexual and Reproductive Health suggests that 'endometrial biopsy should be considered in women aged 45 years using hormonal
contraception who present with persistent problematic bleeding or a change in bleeding pattern'.
106
An 18-year-old female presents to the local sexual health clinic following unprotected sexual intercourse. The intercourse happened four days ago. She is not on any form of contraception. Her past medical history includes asthma, well-controlled with salbutamol. The patient would rather have an oral form of contraception as opposed to an invasive form.
What is the most appropriate management plan?
* The correct answer is to prescribe ulipristal. This patient is inquiring about emergency contraception for unprotected sexual intercourse that happened 96 hours ago. Ulipristal (a selective progesterone receptor modulator) can be prescribed up to 120 hours following the intercourse.
* Levonorgestrel must be taken within 72 hours of UPSI
107
You are called to see a lady who has delivered her second child 2 hours ago. The baby was term, weighed 4.1kg, and was healthy. The labour was natural, lasted 6 hours, and she chose to have a physiological third stage. The nurse tells you she thinks she has lost approximately 800ml of blood, but her observations are stable and the bleeding appears to be slowing.
What is the most common cause of her blood loss?
[Uterine atony](https://www.passmedicine.com/question/questions.php?q=0#)
108
# Define post partum haemorrhage
Primary postpartum haemorrhage is defined as the loss of **500ml or more from the genital tract within 24 hours** of the birth of a baby. This can be further defined as minor haemorrhage (500-1000ml) or major haemorrhage (\>1000ml), and causes 6 deaths/million deliveries.
109
What are the causes of primary post partum haemorrhage?
Causes can be grouped into the 'four T's':
* tone
* tissue (retained placenta)
* trauma
* thrombin (coagulation abnormalities)
110
You are reviewing a patient who is 35 weeks pregnant with her third child. Her second child had neonatal sepsis caused by *Group B Streptococcus*. She had an appointment with an obstetrician last week who has suggested that she should have antibiotics in labour to prevent this from happening again.
Which intravenous (IV) antibiotic should this lady receive?
Benzylpenicillin is the antibiotic of choice for GBS prophylaxis
111
Which infection is most likely to cause bacterial sepsis in premature newborns?
group b strep
Maternal intravenous antibiotics in labour are recommended for all women who have had a previous baby with early- or late-onset GBS disease.
The antibiotic of choice is IV benzylpenicillin.
112
A 40-year-old woman presents on the fifth day after a normal delivery. Her husband has brought her in to accident and emergency, after he noticed an abrupt change in her behaviour. He describes her as confused and restless. On mental state examination she describes racing thoughts, low mood and suicidal ideation. Pressurised speech is also evident. What is the most likely diagnosis?
Puerperal psychosis is a condition characterised by an acute onset of a manic or psychotic episode shortly after childbirth. An abrupt change in mental state is a red flag for puerperal psychosis.
113
Define Puerperal psychosis
Puerperal psychosis is a condition characterised by an acute onset of a manic or psychotic episode shortly after childbirth. An abrupt change in mental state is a red flag for puerperal psychosis.
114
What is the mode of action of the Combined oral contraceptive pill
inhibits ovulation
115
What is the mode of action of the Progestogen-only pill (excluding desogestrel)
Thickens cervical mucus
116
What is the mode of action of the Desogestrel-only pill
Primary: Inhibits ovulation
Also: thickens cervical mucus
117
What is the mode of action of the **Injectable contraceptive** (medroxyprogesterone acetate)
Primary: Inhibits ovulation
Also: thickens cervical mucus
118
What is the mode of action of the Implantable contraceptive (etonogestrel)
Primary: Inhibits ovulation
Also: thickens cervical mucus
119
What is the mode of action of the **Intrauterine contraceptive device**
Decreases sperm motility and survival
120
What is the mode of action of the **Intrauterine system (levonorgestrel)**
* *Primary**: Prevents endometrial proliferation
* *Also**: Thickens cervical mucus
121
What is the mechanism of Levonorgestrel emergency contraceptive?
inhibits ovulation
122
What is the mechanism of Ulipristal emergency contraceptive?
inhibits ovulation
123
A 53-year-old woman presents with **urgency and frequency**. Two weeks ago she consulted with a colleague as she felt **'dry' during intercourse**. She has been treated for **urinary tract infections** on multiple occasions in the past but urine culture is always negative. Her only medication is **continuous hormone replacement therapy**.
A vaginal examination is performed which shows no evidence of vaginal atrophy and no masses are felt. An ultrasound is requested:
Both kidneys, spleen and liver are normal size. Outline of the bladder normal. 5 cm complex ovarian cyst noted on left ovary. Right ovary and uterus normal
What is the most appropriate next step?
Any ovarian mass in a post-menopausal woman needs to be investigated.
124
How are ovarian cysts managed?
**_Premenopausal women_**
* a conservative approach may be taken for younger women (especially if \< 35 years) as malignancy is less common. If the cyst is small (e.g. \< 5 cm) and reported as 'simple' then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
**_Postmenopausal women_**
* by definition physiological cysts are unlikely
* any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynecology for assessment
125
A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test.
Which blood test is this?
[Anti-Xa activity](https://www.passmedicine.com/question/questions.php?q=0#)
126
You review a 34-year-old woman who is 13 weeks pregnant. During her previous pregnancy she developed pre-eclampsia and had to have a caesarean section at 36 weeks gestation. Her blood pressure both following the last pregnancy and today is normal.
Which one of the following interventions should be offered to reduce the risk of developing pre-eclampsia again?
[Low-dose aspirin](https://www.passmedicine.com/question/questions.php?q=0#)
127
A 25-year-old medical student has attended her GP practice for her first smear test. She is interested in the testing process and understands that the sample is initially tested for high risk strains of HPV. The student asks the practice nurse what will happen if the smear test is found to be positive in the laboratory.
If the smear test is found to be high risk HPV (hrHPV) positive, what test will be performed next?
If a cervical smear sample is hrHPV +ve then it is examined cytologically
## Footnote
Cervical smear samples are initially tested for high risk HPV (hrHPV). Cytology testing will only be performed if the sample is found to be hrHPV positive. If the sample is hrHPV negative, cytology testing is not required.
128
A woman who is 34 weeks pregnant is admitted to the obstetric ward. She has been monitored for the past few weeks due to pregnancy-induced hypertension but has now developed proteinuria. Her blood pressure is 162/94 mmHg. Which drug is most appropriate to commence?
Labetalol is first-line for pregnancy-induced hypertension
129
An 18-year-old female presents to her GP as she has missed one of her Microgynon 30 pills yesterday morning. She has taken Microgynon for the past 2 years and is currently 4 days into a packet of pills. She had sexual intercourse last night and is unsure what to do. She took yesterday's pill and today's pill this morning. What is the correct management?
If 1 pill is missed (at any time in the cycle)
* take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
* no additional contraceptive protection needed
130
What would you advise a patient who has missed two oral contraceptives before UPSI?
* **if pills are missed in week 1 (Days 1-7)**: emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
* **if pills are missed in week 2 (Days 8-14)**: after seven consecutive days of taking the COC there is no need for emergency contraception\*
* **if pills are missed in week 3 (Days 15-21)**: she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
131
A 38-year-old new mother is brought into the GP by her husband a month after giving birth. He is concerned about her current mood and states she has slept and ate very little since the baby was born.
What is the best next step?
[Ask the mother to complete the 'Edinburgh depression scale](https://www.passmedicine.com/question/questions.php?q=0#)
132
A 36-year-old woman has delivered her second child at 38 weeks gestation. She had a physiological third stage of labour without drugs. Five minutes after delivery she has a sudden gush of approximately 750 mL of blood. Her vital signs are stable. How should she be initially managed?
An atonic uterus is far the most likely cause of primary post-partum haemorrhage. Due to the degree of blood loss this woman should be advised to have **Syntometrine** or **oxytocin** to contract her uterus.
133
A 29-year-old female patient has a telephone consultation with her GP, worried about an incident that occurred two days ago. She is currently 18 weeks pregnant, with no complications thus far. She works in a children's nursery. Her boss called her today, informing her that one of the children she had cared for, two days prior, has since developed a chickenpox rash. The patient is worried about the impact that this exposure may have on her pregnancy. She feels well in herself and has no symptoms, nor rash. She is uncertain of whether or not she had chickenpox herself as a child.
What is the most appropriate management?
Given that the patient is asymptomatic, and uncertain about her immune status, antibodies should be checked and the result awaited, before taking action.
Giving varicella-zoster immunoglobulin (VZIG) now would be appropriate if she was certain that she has never had chickenpox herself.
134
Risk factors for ovarian cancer
Risk factors
* family history: mutations of the BRCA1 or the BRCA2 gene
* many ovulations\*: early menarche, late menopause, nulliparity
135
A 22-year-old lady presents to the general practitioner for advice about her current contraception, microgynon 30. She went away for a few days this week and forgot to bring her pill packet resulting in her missing pills. The last pill she took was 76 hours ago, and she is unsure what to do now. The missed pills were from week 3 of her pack and she has not missed any other pills this month. She has had intercourse in the last week for which she did not use barrier contraception.
What advice should you give her?
[Take 2 pills today, then finish the current pack, omit the pill-free interval and start the new pack immediately](https://www.passmedicine.com/question/questions.php?q=0#)
136
define Placental abruption
Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
137
How is placental abruption managed?
**_Fetus alive and \< 36 weeks_**
* fetal distress: immediate caesarean
* no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
**_Fetus alive and \> 36 weeks_**
* fetal distress: immediate caesarean
* no fetal distress: deliver vaginally
**_Fetus dead_**
* induce vaginal delivery
138
A 34-year-old woman attends a routine antenatal clinic at 16 weeks gestation.
She has no significant past medical history but suffers with occasional frontal headaches.
She is noted to have a blood pressure of 148/76mmHg.
Urinalysis reveals;
## Footnote
pH6.5Protein+1Nitrates0Leuc0Blood0
What is the most likely diagnosis?
chronic hypertension
139
You review the blood results taken from a pregnant woman at her booking visit. In addition to the standard antenatal bloods she also had her rubella status checked as she didn't have the MMR vaccine as a child. She is now 11 weeks pregnant and currently well.
## Footnote
Rubella IgGNOT detected
What is the most appropriate course of action?
[Advise her of the risks and the need to keep away from anyone who has rubella](https://www.passmedicine.com/question/questions.php?q=0#)
* MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
140
When does the anomaly scan occur?
18 - 20+6 weeks
141
When does nuchal screening take place?
11 - 13+6 weeks
142
When does the booking visit take place?
8 - 12 weeks
143
A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.
What is the most appropriate management for prophylaxis of Rhesus sensitisation?
[One dose of Anti-D immunoglobulin followed by a Kleihauer test](https://www.passmedicine.com/question/questions.php?q=0#)
144
What is a Kleihauer test?
A Kleihauer test is a test for FMH which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.
145
A 63-year-old nulliparous lady presents to her general practitioner with symptoms of abdominal bloating and diarrhoea. She has a family history of irritable bowel syndrome. On examination, the abdomen is soft and non-tender with a palpable pelvic mass. Which one of the following is the most suitable **next step**?
If suspicion of ovarian cancer but there is an abdominal or pelvic mass, CA125 and US test can be bypassed and the patient directly referred to gynaecology
146
A 42-year-old female has just delivered her second and final child at 41 weeks gestation. She has currently been in the third stage of labour for 64 minutes. She has so far lost 2800ml of blood. Her previous baby was delivered by elective caesarean-section. Her only past medical history is pelvic inflammatory disease.
Due to her risk factors, an antenatal ultrasound was performed and confirmed the underlying diagnosis. Unfortunately, the results of this scan had not been seen by the delivery team until now.
What is the most definitive treatment of the underlying problem?
hysterectomy
147
A 23-year-old woman presents because she is suffering from a low mood for around 1 week every month, just before her period begins. She states that she feels tearful and lacks motivation, these symptoms improve when her period starts. The symptoms bother her but are not impacting her work or personal life.
She has a 28-day regular cycle, does not have heavy or painful periods and denies any inter-menstrual bleeding. She is in a long term relationship and uses condoms for contraception. She does not want to conceive in the next few years.
What treatment should you offer for relief of her premenstrual symptoms?
Premenstrual syndrome: a new-generation combined oral contraceptive pill may be helpful
148
A 23-year-old woman presents because she is suffering from a low mood for around 1 week every month, just before her period begins. She states that she feels tearful and lacks motivation, these symptoms improve when her period starts. The symptoms bother her but are not impacting her work or personal life.
She has a 28-day regular cycle, does not have heavy or painful periods and denies any inter-menstrual bleeding. She is in a long term relationship and uses condoms for contraception. She does not want to conceive in the next few years.
What treatment should you offer for relief of her premenstrual symptoms?
Premenstrual syndrome: a new-generation combined oral contraceptive pill may be helpfu
