Obs and Gynae 1

Question 1

Investigations in suspected PPROM 3 steps

Answer 1

1. sterile speculum- to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
2. if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure®) or insulin-like growth factor binding protein‑1
3. ultrasound may also be useful to show oligohydramnios

Question 2

Management of PPROM (5)
1.
2.
3.
4.
5. Deliver at after….. weeks

Answer 2

1. admission
2. regular observations to ensure chorioamnionitis is not developing
3. oral erythromycin should be given for 10 days
4. antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
5. delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Question 3

What sign on a neonate is an adduction and internal rotation of the arm, with pronation of the forearm and what does it indicate?

Answer 3

Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia.

This classic physical position is commonly called the ‘waiter’s tip’.

Question 4

Talk me through the cervical smear pathway with these different outcomes:

1. Who gets tested and how often?
   4 categories someone can fit in!
2. If you keep getting +ve HPV but -ve cytology

The different scenarios regarding inadequate samples

Answer 4

1. Who gets tested and how often?
   - Up to 6 months before you turn 25
   - 25 to 49 = Every 3 years
   - 50 to 64 = Every 5 years
   - 65 or older = Only if 1 of your last 3 tests was abnormal
2. If you keep getting +ve HPV but -ve cytology

• Attend and +ve HPV -ve Cytology
• Repeat at 12 months: +ve HPV -ve Cytology
• Repeat at 12 months: Still +ve HPV -ve Cytology
• Send to colposcopy regardless of cytology

3. Inadequate samples
   - 1 inadequate samples = repeat in 3 months
   - 2 consecutive samples send for colposcopy

Question 5

Miscarriage has occured and decided to treat it expectantly, if this fails and need to treat it medically what do you give them? + route?

Answer 5

Vaginal misoprostol

Question 6

What is The main complication from induction of labour and what is its management?

med + eg. 3/4

Answer 6

uterine hyperstimulation which is characterised by too frequent or prolonged uterine contractions that can cause significant foetal distress. The treatment of uterine hyperstimulation requires administering tocolytic agents to relax the uterus and slow contractions.

eg. atosiban (oxytocin anatagonist), CCB Nifedipine, Indomethacin (NSAID), Mg Sulfate

Question 7

COCP increases the risk of which cancers and is protective against which cancers? Tip- think triangle

Answer 7

Increases risk- Breast and Cervical
Increase = big triangle

Protective- Ovarian and Endometrial
Decrease = Small triangle

Question 8

What is the name of the scale for assessing post-natal depression?

What score is seen as ‘depressive illness of varying severity’

Answer 8

Edinburgh Postnatal Depression Scale

> 13/30

Question 9

Baby blues
Typically seen in what days?
More common in who?
Presentation? (3)
Management

Answer 9

Days 3-7 postpartum
Primips
Anxious, tearful, irritable
Reassurance and support, health visitor

Question 10

Post natal depression

Typically seen in when?
Peaks when?
Management?
-
- Med can give 2 and avoid 1, why?

Answer 10

Most cases within a month
Peaks 3 months

Management
- CBT
- Med = SSRI IF SEVERE
- Sertraline
- Paroxetine- low milk:plasma
Both secreted in breast milk but not seen as harmful

• Avoid fluoxetine due to long half-life

Question 11

What is placenta accreta?
- due to..
- risk of….

Risk factors? (2)

Answer 11

Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of postpartum haemorrhage.

Risk factors
previous caesarean section
placenta praevia

Question 12

Trisomy 21 screening

Combined test

Triple test

Quadruple test

2 invasive tests (which is earlier and which later?)
1 Non invasive

Answer 12

Combined test - 10-13+6
- Low PAPPA
- HIGH B-HcG (B bumps = increase)
- Thickened nuchal translucency

Triple 14-20
- B-hCG High
- AFP - Low
- Ostrodiol- Low

Quad 14-20
- B-hCG High
- AFP - Low
- Ostrodiol- Low
- Inhibin A

2 invasive tests
- Chorionic villous sampling (before 15 weeks)
- Amniocentesis (used later)

1 Non invasive
- NIPT

Question 13

How is premature ovarian failure defined?

Answer 13

The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years. It occurs in around 1 in 100 women.

Question 14

GDM-
Patients with exisitng T2DM, how will their medication change?

What diabetes 2 drugs are CI in preg?

Answer 14

Can only be on metformin or insulin in preg, start metformin then see.

gliclazide and liraglutide are contraindicated in pregnancy.

Question 15

Unprotected sexual intercourse

Up to how long after can you use levonorgestrel pill?

Up to how long after can you use Ulipristal pill?

Answer 15

levonorgestrel pill- 72 hours

Ulipristal- up to 120 hours

Question 16

Levonorgestrel

mode of action not fully understood- acts both to stop ovulation and inhibit implantation
should be taken as soon as possible - efficacy decreases with time

Up to how long after can you use levonorgestrel pill?

Dose?
Double dose if?

Impact on vomiting?

Can it be used more than once in a menstrual cyle?

Does it impact starting any subsequent hormonal contraception?

Answer 16

Must be taken within 72 hours

single dose of levonorgestrel 1.5mg (a progesterone)
Double = BMI >26 or weight over 70kg

If vomiting occurs within 3 hours then the dose should be repeated

Can be used more than once in a menstrual cycle if clinically indicated

Yes- can be used more than once

No- hormonal contraception can be started immediately after using

Question 17

Ulipristal

MOA?

Dose?

Can be taken in what window?

Impact on subsquent hormonal contracpetion?

Contrainidications?

Impact on breast feeding?

Can it be used more than once in a menstrual cyle?

Answer 17

Primary mode of action is thought to be inhibition of ovulation

30mg oral dose

No later than 120 hours

Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period

CI- Severe asthma

Breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Yes- can be used more than once

Question 18

Emergency contraception- IUD
- Its the most effective + offer to everyone

Time wondow? (2)

What if patient wants it removed?

Answer 18

Must be inserted within 5 days, or
if a woman presents after more than 5 days then may be fitted up to 5 days after the likely ovulation date

may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Question 19

Which is the best imaging technique for diagnosing adenomyosis?

Answer 19

MRI pelvis

Question 20

Shoulder distocia manoeuvre
1. - Just name
2. Name + action
3. Name + action
4. Action

Answer 20

1. McRoberts position
2. Rubin manoeuvre (press on the posterior shoulder to allow the anterior shoulder extra room)
3. Wood’s screw manoeuvre- Hand in, attempt to rotate foetus 180 degrees.

Can try them when on all 4s

4. If this fails you need to push the head back in and do an emergency caesarean section.

Question 21

Contraception which are contra-indicated if the patient has had a previous gastric sleeve?

AND WHY?

Answer 21

COCP and POP options are inappropriate as oral options will have low EFFICACY in patients with gastric sleeves. Not seen with UKMEC as this covers safety not efficacy.

Question 22

Drugs which are contra-indicated in breast feeding

MAPSAACC

Answer 22

M- Methotrexate
A- Amiodarone (Class III anti-arrythmic used to treat life threatening VF etc)
P- Psych drugs- Lithium, clozapine, Benzos
S- Sulfonylureas (Used in diabetes eg. Gliclazide)

A- Antibiotics- ciprofloxacin (flouroquinolones), tetracycline (doxycylin), chloramphenicol (Used in eyes), sulphonamides (co-trimoxazole)
A- ACEi
C- Carbimazole (Used in hyperthyroidism- the block in block and replace)
C- Cytotoxic drygs

Question 23

According the PEARL index, COCP has a score of 0.2, what does this mean?

Answer 23

Pearl Index describes the number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year.

If the medication is adhered to perfectly, we would expect to see 0.2 pregnancies for every hundred women using the pill for one year - or 2 for every thousand.

Question 24

Risk malignancy index (RMI) prognosis in ovarian cancer, what’s it based on? (3)

Answer 24

US findings, menopausal status and CA125 levels

Question 25

Definitions of miscarriages:

Threatened miscarriage (2)

Missed (delayed) miscarriage (3)

Inevitable miscarriage (2)

Incomplete miscarriage (3)

Answer 25

Threatened miscarriage:
- painless bleeding < 24 wks typically 6-9 wk
- cervical os closed

Missed (delayed) miscarriage
- gestational sac which contains dead fetus < 20 wks WITHOUT symptoms of expulsion
- os closed
- If gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

Inevitable miscarriage
- heavy bleeding with clots and pain
- cervical os is open

Incomplete miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open

Question 26

IF preg lady has pre-existing hypertension what should be done with their med and what change to.

What if asthmatic?

Answer 26

Stop: ACEi, ARBs

Start Labetolol

Asthmatic- nifedipine and hydralazine

Question 27

How far does the placenta invade?
Accreta-
Increta-
Percreta-

Answer 27

accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis

increta: chorionic villi invade into the myometrium

percreta: chorionic villi invade through the perimetrium

Question 28

What is Ashermans Syn?

Answer 28

Asherman’s syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.

Question 29

If acute, ho can twin-twin transfusion syndrome present? (2)

Answer 29

report any sudden increases in the size of their abdomen and/or any breathlessness, which may be the result of polyhydramnios affecting the recipient twin.

Question 30

Re-currant vaginal candidiasis, what investigation should you do and why?

Management of barn door vaginal thrush?

1) First line + dose
2) If CI? + dose
3) If vulval symptoms….

If preg then….

Answer 30

HbA1c- A blood test to exclude diabetes should be considered in women with recurrent vaginal candidiasis

Management:
1) oral fluconazole 150 mg as a single dose first-line
2) clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated
3) If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal

if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Question 31

First trimester bleeding

Worrying symptoms suggestive of an ectopic-need immediate referral to EPAU: (3)

At what week do you send to EPAU is bleeding?

If <…. Weeks and bleeding but no pain or risk factors for ectopic, what should you do?
1.
2.
3.

Answer 31

• pain and abdominal tenderness
• pelvic tenderness
• cervical motion tenderness

> = 6 weeks gestation (or uncertain) send to EPAU to locate preg.

< 6 weeks + no pain + risk factors for ectopic:
1) Advise! come back if bleeding continues or pain
2) Repeat a urine pregnancy test after 7–10 days and to return if it is positive
3) a negative pregnancy test means that the pregnancy has miscarried

Question 32

After what week should you refer to obstetritian for lack of any/ first fetal movements?

If have felt movements after what week and how long should you further investigate the lack of movements?

Answer 32

• No movement by 24 weeks
• > 28 weeks and < 10 movements in 2 hours

Question 33

Umbilical cord prolapse

Risk factors 6

Protective factors 3

Answer 33

RFs
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie

Cephalic presentation, nulliparity and prolonged pregnancy all reduce the likelihood of umbilical cord prolapse

Question 34

What do you do if newborn male has undescended testicle?

Answer 34

review at 3 months
If not descended by around 3 months then referral should be considered for orchidopexy.