Obs and Gynae

Question 1

Hyperemesis Gravidarum is most pronounced in the ____ trimester (____ weeks). It can be distinguished from normal/physiological vomiting during pregnancy by 3 specific criteria:

____

____

____

Answer 1

1st trimester

0-13 weeks

>5% weight loss pre-pregancy

Clinical dehydration

Electrolyte Imbalance

Question 2

Hyperemesis Gravidarum can lead to complications including:

Answer 2

Severe Dehydration

Anaemia

Malnutrition

Depression

Venous Thromboembolsim

Electrolyte imbalance (e.g hyponatraemia or wernicke’s encephalopathy)

Mallory-Weiss tear

Question 3

Management of Hyperemesis Gravidarum includes:

Answer 3

1st line: Cyclizine / Promethazine / Prochlorperazine (dopamine antagonists)

2nd line: Metaclopramide (dopamine and 5HT antagonist)

3rd line: Odansetron (to be given with caution as can cause cleft palate if given in first trimester)- 5HT antagonist.

*can also giver ginger supplements and acupuncture to help vomiting*

If patients are severely dehydrated, have ketonuria (+3) and/or severe electrolyte imbalance – Admit to hospital.

Always consider psychological effects Hypermesis Gravidarum (i.e vomiting 10 times daily) could have on patient.

Question 4

Misscarriage: Spontaneous death of foetus in utero before ____ gestation.

5 Types:

Answer 4

24 weeks - abdo pain and bleeding

OS open: I+I

Inevitable - Open cervical OS. Likely to dispel pregnancy without medical intervention. POC not seen.

Incomplete - Same as above but POC can be seen in vaginal canal

OS closed: TMC

Threatened - Abdo pain and vaginal bleeding but gestational sac and foetal heartbeat seen on TV ultrasound.

Missed - Patients didnt realise they were pregnant and present with Abdo pain and vaginal bleeding. The uterus still contains foetal tissue, but the foetus is no longer alive (i.e no foetal heartbeat on TV ultrasound). Cervical os closed.

Complete - Abdo pain and vaginal bleeding but the patient has passed foetal tissue. Cervical os is closed and no heartbeat or sac on TV ultrasound. No POC visible.

Septic - Abdo pain and vaginal bleeding but also gestational sac becomes infected. Patients likely to show systemic signs of sepsis.

Question 5

Screening for down syndrome is done at weeks ___ and uses an algorithm that includes 4 main components. Name them.

Answer 5

10-14

Nuchal Translucency (> 6mm indicates possible down syndrome)

B-HCG (Very High in DS)

PAPP-A (low)

Maternal age

Question 6

If patients miss their original Down Syndrome screening (i.e combined test 10-13 weeks), they can do another test (quad test) from ____ weeks which includes 3/4 components. Name them.

______ (up to 15 weeks only) and ______ (16+ weeks) are two tests that can be offered to confirm diagnosis if tests above indicate a high risk of DS.

Answer 6

14-20 Weeks

B-HCG -very high

Unconjugated Oestriol - low

Alpha FetoProtein (AFP) - low

+/- Inhibin A - low

NIPT - Non Invasive Prenatal Testing is now also an option and more accurate than the quad and combined test. But suspicion of trisomy 21 needs to be high to qualify for this test.

Chorionic Villous Sampling (up to 15 weeks only)

Amniocentesis (16+ weeks)

*both carry risk of misscarriage* (CVS higher risk)

Question 7

Gestational Hypertension

Defined as blood pressure **_____** with no concomitant ____ after 20 weeks’ gestation in a woman with no PMH of hypertension.

Remember a blood pressure > _____ requires treatment, whilst a blood pressure >____ requires admission to hospital.

Management:

1st line:

2nd line:

Answer 7

>140/90 mmHg

Proteinuria

>150/100 mmHg

> 160/110 mmHg

Labetalol (b-blocker and thus contrindicated in asthma)

Nifedipine (ca channel blocker)

Question 8

Gold standard investigation for Endometriosis:

Answer 8

Diagnostic Laporoscopy

Question 9

3 types of emergency contraception:

Answer 9

Levonorgestrel (Progestogen) - must be taken no later than 72 hours post sexual intercourse.

EllaOne (Ulipristal acetate) - Preferred in patients with a high BMI. Must be within 5 days.

*both these oral forms work by inhibiting ovulation* - (if ovulation has already occured then they are not effective)

Gold standard is actually Copper IUD - spermicidal and causes endometritis. Must be within 5 days. *Only method that works after ovulation*. NB - not to be used if patient is pregnant Urine B-HCG.

Downsides - Permanent and invasive

https://cks.nice.org.uk/topics/contraception-emergency/

Question 10

______ hormone: Produced by granulosa cells of ovary. Good marker of ovarian reserve

Answer 10

Anti-Mullerian

Question 11

Menopause < 40 yo can be investigated by checking which hormone?

Answer 11

FSH

*oestrogen low and so FSH not inhibited at pituitary*

Question 12

Syphilis

STI caused by _______ bacteria

Primary syphilis – Painless ulcer (_____) and regional lymphadenopathy (inguinal)

Secondary syphillis - _____ involvement and _____ (attached)

Tertiary syphilis – Neurosyphilis, Cardiovascular , _____ syphilis (_____ lesions with centre of necrotic tissue)

*also important to note that syphillis has an older demographic to Chlamydia/Gonorrhoea, primarily affecting men between the ages of ____ , much like mycoplasma genitalium.

Answer 12

Treponema Pallidum

Chancre

Multisystem

Condylomata

Gummatous / Granulomatous

25-40

Classically, syphilitic aneurysms occur in 90% of cases on the thoracic aorta, and in 10% in the abdominal aorta

Question 13

Post- menopausal bleeding is often benign (ex. _____ ) however a significant proportion of cases can be endometrial cancer and so further investigation with _____ is necessary

If TV ultrasound shows endometrial thickness > ____ then a ___ is needed to determine whether thickness is due to endometrial hyperplasia or endometrial cancer

Biopsy with no ____ indicates hyperplasia with a very low risk of associated cancer and so patient can be treated with ____ (ex. Oral or IUD ______ ) to reduce endometrial thickness. Patient should be reviewed in ____ with TV ultrasound and further biopsy.

Biopsy with ____ suggests high risk of progressing to endometrial cancer and 1^st line management in post- menopausal women is a ____ . Endometrial ___ is also an option.

However, in younger reproductive females who would like to preserve fertility (ex. ____ patient more likely to get endometrial cancer), conservative management with ____ can be considered with patient reviewed (i.e TV ultrasound and biopsy every ____ )

Answer 13

Atrophic vaginitis

Transvaginal ultrasound

>4mm

biopsy

atypia

progestogens

levonorgestrel

6 months

Atypia

Total hysterectomy

Ablation

PCOS

Progestogens

3 months

Question 14

_____ , _____ and _____ can all increase the risk of endometrial cancer as they provide unopposed levels of oestrogen stimulation to the endometrium.

Answer 14

COOP

Obesity

Type 2 Diabetes Mellitus

Question 15

Itching of the hands and soles of feet (particularly) at night with no rash is a common presentation of obstetric cholestasis (i.e blocking of the biliary tree). This leads to high levels of circulating ____ which causes itching to the skin.

If rash is present it suggests a ______.

Due to obstruction in the biliary tree, there is also a higher level of circulating bilirubin and this leads to____ , _____ and ____.

Low levels of bile salts in the intestine also reduces the ability of the intestine to absorb ____ soluble vitamins such as ____ , and thus may lead to a _____ - Dangerous in the event of a bleed.

Answer 15

Bile salts

Polymorphic eruption of pregnancy - no blisters / pemphigoid gestationis - blisters (autoimmune skin eruption - more common in people with graves etc.)

Jaundice, pale stools, and dark urine

Fat soluble

Vitamin K

Coagulopathy (High INR/high PT)

Question 16

• Obstetric cholestasis is associated with an increased risk of ____, ____, and _____.

Answer 16

Pre-mature birth, **stillbirth** and meconium passage.

Question 17

In obstetric cholestasis remember that patients will have deranged ____ and increased levels of circulating bile salts on blood investigation.

**Remember** it is normal for ___ to rise in pregnancy as the ____ produces it. Thus an isolated rise in ___ is normal in pregnancy and not indicative of pathology

Answer 17

LFTs

ALP

Placenta

ALP

Question 18

Management in obstetric cholestasis includes:

_____ improves LFTs, bile salts and symptoms.

_____ and _____ can also provide symptomatic relief.

Condition resolves after _____.

Answer 18

Ursodeoxycholic acid

Emollients and anti-histamines

Delivery

Question 19

Pelvic Inflammatory disease can lead to____, ___ and ____ and so should be treated immediately.

Answer 19

Subfertility, ectopic pregnancy and chronic pelvic pain

Question 20

Treatment of Pelvic Inflammatory Disease in the non septic patient is with oral _______ therapy.

Answer 20

Triple antibiotic therapy (Ceftriaxone / Doxycycline and Metronidazole) and review within 3 days.

Treatment of PID in the septic patient needs IV antibiotic therapy.

Question 21

An important differential in PID to consider is a ____ . This is a late complication of PID and is life threatening condition if ruptures as can cause sepsis. _____ used to rule this out.

Answer 21

**Tubo-ovarian abcess **

TV Ultrasound

Question 22

Patients who have previously suffered from gestational diabetes during pregnancy should have a ______ as soon as possible after ____ booking visit. If glucose tolerance is ok at this point, they should be retested at 24 weeks.

Patients that have an increased preponderance to develop GD (____, _____, _____) and ethnicities such as should also have a _____ at ____ weeks.

Patients with pre-existing Type 1 and 2 DM should have their Hba1c tested at booking visit. Check _____ and fundoscopy for retinopathy as in general, Insulin resistance is ____ during pregnancy.

Answer 22

2hr Oral Glucose Tolerance Test (OGTT)

9/10 week

2hr OGTT

(Obesity, Macrosomic baby, Familial history of GDM)

Afro-Caribbeans, South Asians, and middle easterns

24 weeks

Renal function

Increased

Question 23

Stress incontinence risk factors:

Answer 23

Age

Obesity

Multiparity

Traumatic delivery

Gynae surgery

Question 24

Treatment for stress incontinence:

Answer 24

1st line: Pelvic floor exercises (3-month with physiotherapist)

2nd line: Duloxetine (SNRI)

3rd line: Surgery

Question 25

All TORCH congenital infections can present with non-specific symptoms such as:

Answer 25

Petechiae and purpura Hepatosplenomegaly Jaundice Seizures Small for gestational age (SGA) Haemolytic anaemia

Question 26

Toxiplasmosis Gondii causes a classic triad of symptoms: It also presents with a ____ rash.

Answer 26

1. Intracranial calcifications (diffuse as opposed to CMV which are paraventricular) 2. Hydrocephalus (vs. microcephalus in CMV) 3. Chorioretinitis (also in CMV) Blueberry muffin

Question 27

Toxiplasmosis gondii is a ____ that can be picked up from \_\_\_, \_\_\_\_, \_\_\_\_\_, and _____ . Usually the mother is asymptomatic, and the earlier the infection in pregnancy the lower the risk of transmission to the foetus. Highest transmission is in the ____ trimester. Increases risk of \_\_\_\_\_, \_\_\_\_\_, and _____ .

Answer 27

Parasite Raw vegetables, Uncooked meats, Unpasteurised goat's milk, and Cat faeces. 3^rd Trimester. Misscarriage, stillbirth and preterm.

Question 28

In toxiplasmosis gondii, only ___ % are symptomatic at birth. Patients can go on to develop \_\_\_, \_\_\_, \_\_\_, and \_\_\_.

Answer 28

25% Developmental delay Epilepsy Blindness Deafness

Question 29

Bacteria Listeria Monocytogenes can be passed from mother to foetus via ingestion of \_\_\_\_\_. Defining characteristics include:

Answer 29

\*\*soft cheese\*\* Spontaneous abortion Pustular lesions Neonatal meningitis Sepsis

Question 30

**Rubella** (aka german measles) is Viral infection caused by the *rubella virus* that occurs in unvaccinated mothers who present with \_\_\_, ____ and \_\_\_.

Answer 30

Unvaccinated Non-specific rash Fever Lymphadenopathy

Question 31

Rubella infection in the mother is most dangerous in the first ___ weeks, as beyond this point it is unlikely to be transmitted to the foetus.

Answer 31

16 weeks (90% of infections are transmitted to foetus in the 8-10 weeks of pregnancy)

Question 32

The classic triad of rubella infection in the newborn is:

Answer 32

Cardiac abnormalities (ex. PDA - continuous **"machine like" murmur**) Cataracts Deafness

Question 33

**Cytomegalovirus (CMV) :** * Only ___ symptomatic at birth, causes **long-term complications such as:**

Answer 33

10% * Intrauterine growth restriction (like rubella) * Chorioretinitis (like toxiplasmosis) * Periventricular calcifications * Microcephaly * Sensorineural deafness (like rubella) \*\*Remember **C** for **C**ephalus/**C**horioretinitis/**C**alcifications **M** for **M**icro and **V** for peri**V**entricular calcifications.\*\*

Question 34

The average age of the natural menopause is ____ years, but can occur much earlier or later. Menopause occurring before the age of 45 is called ______ and before the age of 40 is ____ .

Answer 34

51 Early menopause Premature menopause \*Generally, women having an early or premature menopause are advised to take HRT until approximately the average age of the menopause, for both symptom control and bone protective effect\*

Question 35

Risks associated with HRT (X6):

Answer 35

**_Endometrial Cancer_** (reduced by giving progestogen) **_VTE_ (**not with patch) **_CVD/Stroke_** (only if _started_ in women \>60/ stroke not increased w/ patch) **_Breast Cancer_** (risk goes up slightly - no increase in mortality - because patients have hormone receptors and thus wide range of therapies available) Very small increased risk of **_ovarian cancer_** after 5yrs of therapy and \>50yrs old. (1 more per 1000) **_Gallbladder disease_** (increased in all HRT)

Question 36

\_\_\_\_\_ phase is always 14 days long in the menstrual cycle.

Answer 36

Luteal

Question 37

Contraceptions that stop bleeding/menstruation (i.e amenorrhoea)

Answer 37

IUS (progestogen) POP DMPA (depot-medroxyprogesterone acetate) - depot - most effective at causing amenorrhoea - 45% after 12 months. \*any of the progestogen only contraceptives\*

Question 38

Vaginal atrophy/vaginal dryness treatment

Answer 38

Topical Lubricants Local Oestrogen pessary/cream

Question 39

A woman is considered potentially fertile for: * _____ yrs after her last menstrual period if she is less than 50 yrs. * ____ yrs after last period if \> 50 yrs.

Answer 39

2 yrs 1 yr

Question 40

Premature ovarian failure needs to be identified and treated due to risk of:

Answer 40

CVD Stroke Osteoporosis Cognitive impairment Dementia Parkinsonism \*Premature ovarian insufficiency is **defined as menopause before the age of 40 years**\* [https://zerotofinals.com/obgyn/gynaecology/prematureovarianinsufficiency/](https://zerotofinals.com/obgyn/gynaecology/prematureovarianinsufficiency/)

Question 41

Which HRT method does not confer an increased risk of VTE?

Answer 41

Transdermal Patch

Question 42

Diagnosis of premature ovarian failure: Based on a combination of oligomenorrhoea / amenorrhoea of more than ____ duration associated with elevated gonadotropins (\_\_\_\_ \>\_\_\_ iu/l) on at least ___ occasions measured ___ weeks apart in women under the age of 40.

Answer 42

4 months’ 40 Two 4-6

Question 43

Menopause can be diagnosed clinically diagnosed clinically after ___ months of amenorrhoea in a woman aged over ___ yrs.

Answer 43

12 months 45 yrs

Question 44

Non-pharmacological treatment of menopause?

Answer 44

Lifestyle: Stop Smoking Stop Alcohol Stop Caffeine Sleeping in cold room / wear lighter clothes/ Sleep hygiene Exercise (bone and CVS health) CBT Weight loss (reduces breast cancer risk)

Question 45

Symptoms of menopause:

Answer 45

_Vasomotor_ - Hot flushes/Night Sweats/Palpitations _Psychological_ - Low mood / Anxiety / Reduced libido _Local_ - Vaginal dryness/ Atrophy / Itchiness / Urinary incontinence / dysparunia / UTI's

Question 46

Non-hormonal pharmacological treatment of menopause?

Answer 46

SSRI/SNRI (Fluoxetine / citalopram/ Venlafaxine) Vaginal lubricant Clonidine (for vasomotor symptoms) Gabapentin (hot flushes) Complimentary symptoms (ex isoflavones/ red clover/ black cohosh)

Question 47

Pharmacological treatment of menopause?

Answer 47

HRT (oestrogen +/- progesterone) \*Women _with a uterus_ - give _progesterone_ to negate increased risk of endometrial cancer with unoppossed oestrogen exposure\* \*Women without a uterus can have oestrogen only therapy\*

Question 48

Mirena coil (IUS w/ progestogen) : Length of action for contraception ____ yrs. Length of action for HRT ____ yrs.

Answer 48

5 yrs 4 yrs

Question 49

If you remember one thing about HRT for your exams, remember the basics of choosing the HRT regime. Women with a uterus require endometrial protection with \_\_\_\_\_, whereas women without a uterus can have oestrogen-only HRT. Women that still have periods should go on ___ HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than ___ months without periods should go on continuous combined HRT

Answer 49

Progesterone Cyclical 12

Question 50

There are some essential contraindications to consider in patients wanting to start HRT:

Answer 50

Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy

Question 51

To follow the ____ Guidelines, the young person must: * The young person ____ the professional’s advice. U * The young person cannot be\_\_\_\_ to inform their parents or let the healthcare professional discuss it. P * The young person is likely to begin, or to continue having, _____ with or without contraceptive treatment.S * Unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to ____ S * The young person’s best _____ require them to receive contraceptive advice or treatment with or without parental consent. I UPSSI

Answer 51

**Fraser** Guidelines Understands Persuaded Sexual intercourse Suffer. Interests During a consultation it is intergral to **assess for coercion or pressure** to take contraception (from an older partner for example) as this may raise safeguarding concerns.

Question 52

Injection/ depot Pros: Cons:

Answer 52

**Pros:** Amenorrhoea (\>45%) Can be used in breast feeding Doesn't require daily adherence **Cons:** Permanent Fertility (at least 12 months to return) Weight gain BMD (shouldnt be given to \<20 yr olds) No protection from STI

Question 53

Implant Pros: Cons:

Answer 53

Pros: 3yrs Cons: Irregular bleeding Bruising/Painful/ Surgical incision to take out/ Can migrate/ Scar

Question 54

IUD (copper coil)

Answer 54

Pros: Emergency Contraception Long Acting (5-10 yrs) No Hormones Cons: HMB Pain Invasive Fitting issues (Can be expelled/ can cause uterine perforation/ hypotensive shock) Ectopic (slight increase)

Question 55

IUS (mirena/jaydess) Pros: Cons:

Answer 55

Pros: Amenorrhoea Regulates menorrhagia (1st line) Local effect only Fertility returns straight away once removed Cons: Invasive

Question 56

Which class of medications is important to ask about when assessing suitability for contraception?

Answer 56

Anti-epileptics (ex. lamotrigine and carbamezapine - CYP450).

Question 57

Women ovulate __ days before last mentrual period. This is why its important to know cycle length.

Answer 57

14 days. For example 21 days cycle (ovulate at 8 days) 28 day cycle (ovulate at 14 days) 30 day cycle (ovulate at 16 days) \*Luteal phase is always 14 days\*

Question 58

Female fertility can be checked by measuring the level of _____ 7 days before menstruation because this is when its at its peak (mid luteal phase), and indicates that _____ has occurred.

Answer 58

Progesterone Ovulation

Question 59

Tubal patency can be observed using ____ and ____ .

Answer 59

Ultrasound Xray (surgery also possible)

Question 60

**Termination of pregnancy** * \< 10 weeks a _____ **or medical termination** with \_\_\_\_and \_\_\_\_ * 10- ___ weeks a _____ surgery is recommended. Sometimes misoprostol is used in addition to soften the cervix. * 14- 24 weeks a ______ and _____ technique - aspiration, forceps and ultrasound. * If **Ectopic** use **\_\_\_\_\_.**

Answer 60

Vaccum aspiration **Mifepristone** and **Misoprostol** 14 weeks Vacuum aspiration Dilatation and evacuation Methotrexate

Question 61

What is the 1st line analgesic that is safe to use in pregancy?

Answer 61

Paracetamol is safe throughout pregnancy.

Question 62

NSAIDs are **teratogenic**: increased risk of _____ if used **in early pregnancy.** If used after ____ **weeks** NSAIDs can close ductus arteriosus and can also cause ______ **of the newborn** and \_\_\_\_\_. Codeine: **not** generally recommended during pregnancy, especially in 3^rd trimester as cause _____ and ____ syndrome.

Answer 62

Misscarriage 30 **Persistent pulmonary hypertension** **Oligohydramnious**. Respiratory distress Neonatal withdrawal

Question 63

Change in bowel habit / bloating / early satiety / fullness / loss of appetite / weight loss / vaginal bleeding / Pelvic or abdominal pain/ polyuria are all important symptoms to rule out in a post-menopausal woman as they may indicate ovarian cancer. \*\*\_\_\_\_\_ and _____ are signs of late stage disease. \*\*

Answer 63

Polyruia Change in bowel habit

Question 64

RMI - \_\_\_\_\_ Includes 3 factors **\_\_\_\_\_** x **\_\_\_\_\_** x\_\_\_\_\_ If RMI gives a high score - **\_\_\_/\_\_\_** imaging determines extent of disease. This determines type of surgery and whether patient needs (Neo) adjuvant chemotherapy.

Answer 64

RISK MALIGNANCY INDEX (RMI): **Menopause status** x **Ca125** x **TV ultrasound** MRI/CT

Question 65

\_\_\_Obesity\_ , ____ , _____ , \_\_\_\_, and _____ further compounds the already increased risk of a VTE in pregnancy. Treatment: _____ (i.e \_\_\_\_\_) for at least ____ months and up to ___ weeks post-partum. Investigation: \*\*\_\_\_\_\_ \*\*. Unless patient is exhibiting signs of a PE (breathlessness/Tachycardic/Tachypnoiec/chest pain/dizziness/palpitations) - ECG/Chest x-ray/ VQ scan/ CTPA

Answer 65

Obesity Multiple pregnancies (i.e twins) **Assisted reproductive technology (i.e IVF)** Age (\>35 yo) Family history *Low molecular weight heparin* Enoxaparin 3 months 6 weeks Duplex-ultrasound (Doppler + Normal ultrasound)

Question 66

HRT Reduces the risk of (X2):

Answer 66

Osteoporosis Colon cancer (up to X 1/3)

Question 67

**Cardiotocography (CTG)** **\*Remember –** **DR C BRVADO**

Answer 67

# **D**efine **R**isk : why is the patient on a CTG monitor? **C**ontractions - can have up to 5 in 10 minutes **B**aseline **R**ate: 110-160 bpm **A**ccelerations: Rise of 15 bpm for 15 seconds or more. Usually have 2 every 15 minutes and are close to the contractions. **V**ariabilty: 5-25 bpm **D**ecelerations: Reduction of 15bpm for 15 seconds or more **O**verall Impression

Question 68

Cardiotocography (CTG): **Baseline bradycardia**:\_\_\_\_, \_\_\_\_, or \_\_\_\_. **Baseline Tachycardia**:\_\_\_\_, \_\_\_\_, or \_\_\_\_\_\_. **Reduced Baseline Variability**: _____ or \_\_\_\_\_. **Early Deceleration**: \_\_\_\_\_. **Late deceleration**: ____ (e.g \_\_\_\_). **Variable deceleration**: \_\_\_\_\_.

Answer 68

**Baseline bradycardia:** Cord prolapse, epidural/spinal anaesthesia, rapid foetal descent. **Baseline Tachycardia:** Mother usually pyrexic, baby is hypoxic, or prematurity **Reduced Baseline Variability:** Hypoxic, premature **Early Deceleration**: Benign sign that baby’s head is compressed during descent. **Late deceleration**: Fœtal distress (ex.asphyxia) **Variable deceleration**: Cord compression

Question 69

**Cervical ectropion** Exposure and migration of ____ (columnar epithelium) to ____ (squamous epithelium) caused by **high levels of** _____ **exposure.** (Ex. \_\_\_, \_\_\_\_, \_\_\_\_\_) and exposure to more ____ environment of vagina. Diagnosis of exclusion as need to exclude cervical cancer with a smear.

Answer 69

Endocervix Ectocervix **Oestrogen** (ex. COOP, Puberty, Pregnancy) acidic May cause visible erythematous ring (differential cervical cancer/dysplasia), post-coital vaginal bleeding and mucous discharge but most often is symptomless. Contact Trauma from sexual intercourse also an important differential.

Question 70

Induction of labour steps (4X) 1. _____ (\_\_\_hrs) 2. _____ (every \_\_\_hrs) 3. _____ (w/ \_\_\_\_) 4. _____ (IV/IM) Syntocinon infusion needs to be judiciously titrated with _____ as it can cause ____ and \_\_\_\_.

Answer 70

1. Prostaglandin Pessary (24hrs) 2. Prostaglandin gel (every 6 hrs) 3. Artificial Rupture of Membranes (AROM - w/ Amnihook) 4. Syntocinon (IV/IM) Frequency of contractions Uterine hyperstimulation Foetal distress

Question 71

**Missed Oral Contraception** * COOP: Take last missed pill, prescribe emergency contraception, and advise against sexual intercourse/additional contraceptive measures for ___ days. * POP: Take last missed pill, avoid sexual intercourse/use additional contraceptive measures for next ___ hrs. If patient has sex in this period prescribe emergency contraception (i.e levonorgestrel, ulipristal)

Answer 71

7 days 48 hrs

Question 72

Loss of \>\_\_\_ ml blood is considered a Post Partum Haemorrhage (PPH). Loss of ____ is considered a major PPH

Answer 72

500 ml 1000 ml/1L

Question 73

PPH Management: 1. \_\_\_\_ 2. \_\_\_\_ 3. \_\_\_\_ 4. \_\_\_\_ 5. \_\_\_\_ \*\*Can also use ______ instead of syntocinon, but contraindicated with patients w/ ____ or ____ during pregnancy as they **raise blood pressure**.\*\*

Answer 73

1. Syntocinon (IV/IM) 2. Carboprost (prostaglandin) 3. Balloon Tamponade 4. B-Lynch Suture 5. Hysterectomy **ergometrine/syntometrine (uterine smooth muscle stimulants)** hypertension pre-eclampsia

Question 74

**\*\*Syntocinon**: is an ____ *analogue* and works by \_\_\_\_\_\_. \*\***Carboprost** (Prostaglandin E2 receptor causes _____ ) needs to be carefully monitored in ____ as it can cause _____ \*\*.

Answer 74

## Footnote **increasing the intracellular level of Ca²⁺.** myometrial contraction asthmatics bronchoconstriction

Question 75

**Bartholin’s Cyst.** Common benign lesion caused by _____ and subsequent dilatation of \_\_\_\_. * Usually affects women of _____ years. * Often painless, but patients (often recurrent) can also present with erythematous, tender lump called bartholin’s abcess, which can give systemic symptoms (i.e fever). * Bartholin’s cyst can be treated with\_\_\_\_ and \_\_\_\_. * Bartholin’s abcess needs\_\_\_\_\_ and either ____ for \_\_\_\_weeks, or \_\_\_\_.

Answer 75

obstruction bartholin’s gland reproductive (20-30) Bartholin's cyst: warm baths and simple analgesia. broad spectrum antibiotics balloon catheterization for 4-6 weeks Marsupialisation

Question 76

* ____ is a normal bleeding process that occurs in the ___ weeks after delivery. * ____ may make the condition worse. * ____ should be avoided in this period as they pose a serious infection risk.

Answer 76

Lochia 4-6 weeks * Consists of blood, mucous, products of conception and so can be quite clotty and red at first and relatively heavy. This later (over a number of weeks) becomes brown and lighter. * Breastfeeding may make the condition worse as it activates a neuroendocrine reflex arc that stimulates the uterus to contract. * Patients should avoid using tampons as this presents a serious risk of infection.

Question 77

Endometritis: Inflammation of the endometrium that often occurs \_\_\_. * Usually caused by ____ and gram negative microbes. * Presentation: 2-3 days of \_\_\_\_\_\_\_, period cramps, \_\_\_\_, uterine tenderness and fever. * Treatment: \_\_\_\_\_.

Answer 77

after delivery Group B strep foul-smelling bloody discharge lower abdominal pain co-amoxiclav (amoxicillin/clavulanic acid)

Question 78

**Urge Incontinence/OAB** * Treated usually with ____ of bladder training. * If this is not successful then anticholinergics ( \*\*antimuscarinics\*\*) such as \_\_\_\_, \_\_\_\_\_, and ____ can be added. * However, remember **antimuscarinics are contra-indicated in \_\_\_\_.** In these patients a _____ can be used.

Answer 78

Antimuscarinics: **oxybutynin**, **tolterodine** and **darifenacin** **Elderly patients** as they can increase likelihood of having a fall. **B3-agonist -** **mirabegron**

Question 79

**Indications for forceps delivery.**

Answer 79

**FORCEPS :** **F**ully Dilated **O**ccipito-anterior position **R**uptured Membranes **C**ephalic presentation **E**ngaged presenting part (\*remember 3/5 or 2/5 suggests baby is engaged within pelvis) **P**ain relief adequate **S**phincter (empty bladder)

Question 80

**Vulvovaginal Candidiasis** * Caused by \_\_\_\_ * Presents with « ____ and ____ » Treated with intra-vaginal ____ antifungal ___ containing \_\_\_\_.

Answer 80

*Candida albicans* Itching and white curd-like discharge Pessary/cream Clotrimazole

Question 81

Anaemia in pregnancy is very common due to an \_\_\_\_. This gives a concomittant low _____ . ____ however is expected to increase.

Answer 81

Increased plasma volume Haemoglobin concentration MCV

Question 82

Idiopathic thrombocytopaenia purpura (ITP) is a condition in which autoantibodies attack the ____ present on ___ cells. This leads to a dramatic loss of circulating platelets in the ____ trimester. Important to pick up ITP as it can cause neonatal thrombocytopaenia and thus increases the risk of _____ in the fœtus

Answer 82

Antigens Platelet 1^st intracranial haemorrhage

Question 83

What are the 1st and 2nd line treatments for Idiopathic Thrombocytopaenia in pregnancy?

Answer 83

* 1^st line: S**teroids** * 2^nd Line: **IVIG**

Question 84

Platelet count at term is important as **\>70X10⁹ needed for \_\_\_\_** and **\>50X10⁹** is needed for \_\_\_\_.

Answer 84

**epidural** **safe delivery**

Question 85

**Gestational thrombocytopaenia** is a most **often asymmptomatic drop in platelet count that occurs in most pregnancies (**drop of ~ 10%) It is unlikely to lead to a platelet number below 70X10⁹/L. Most often occurs in the \*\_\_\_ trimester\*.

Answer 85

3rd

Question 86

**Pregnancy of unknown location (PUL)** * B-HCG \< ____ unlikely to see pregnancy on ultrasound. * B-HCG \>\_\_\_\_ should be able to see prenancy on ultrasound. * If B-HCG ____ in \_\_\_\_hrs this indicates a **Intra-Uterine Pregnancy.** * If B-HCG ____ in 48hrs, this indicated a **Miscarriage.** * If B-HCG is in between these two windows, this indicated an \_\_\_.

Answer 86

1000 IU/L 1500 IU/L **increases by \>63% in 48 hrs - Intruterine pregnancy** **decreases by \>50% in 48hrs - Miscarriage.** **Ectopic Pregnancy.**

Question 87

A ___ is taken at booking visit (\_\_\_\_ weeks) to identify any clinically relevant asymptomatic bacteria (ex E.coli). This is because asymptomatic bacteriuria (UTI) is associated with ___ and ____ during pregnancy.

Answer 87

Midstream urine sample (MUS) 8-10 weeks Preterm Pyelonephritis

Question 88

What is the 1st line treatment for a UTI in pregnancy?

Answer 88

Nitrofurantoin

Question 89

Which antibiotics are contraindicated in pregancy?

Answer 89

Trimethoprim (causes folate deficiency and thus neural tube defects) Doxycycline (teratogenic and also must be avoided in children)

Question 90

**Cervical smear screening:** **Age _____ : Every ____ years.** **Age ____ : Every ___ years.**

Answer 90

25-50 3 yrs 50-65 5 yrs

Question 91

Grades of CIN or \_\_\_\_\_, are determined by how many layers of the _____ are affected by ____ and how severely the dyskarytotic the cells are. (i.e abnormal \_\_\_\_:\_\_\_\_\_ ratio).

Answer 91

Cervical Intraepithelial Neoplasia Squamous Epithelium Dyskaryosis Cytoplasmic : Nucleus

Question 92

Pelvic Floor Prolapse Risk Factors:

Answer 92

Child birth (multiparous) Traumatic/Forceps/Episiotomy High BMI Gynaelogical/Pelvic organ surgery Menopause (lack of oestrogen causes reproductive organ atrophy) Connective Tissue Disorder (Ehlers-Danlos syndrome)

Question 93

Complications of an epidural:

Answer 93

Urinary retention Hypotension Spinal Headache Respiratory Depression of Foetus due to opioid. Epidural **complications** : * \*\*Urinary retention\*\* as neural output to bladder is blocked * \*\*Hypotension\*\* as anaesthetic can block sympathetic output and thus cause widespread vasodilation (thus always monitor BP during epidural) * \*\*Spinal headache\*\* as accidental penetration of subarachnoid space causes leakage of CSF * \*\*Opioid\*\* as could reach the baby and cause respiratory depression.

Question 94

Monochorionic pregnancies need to be monitored every __ weeks from ___ weeks of gestation to scan for abnormalities. Whereas Dichorionic pregnancies need to be scanned every ___ weeks from ___ weeks gestation

Answer 94

2 16 4 20

Question 95

Causes of Pathological/Abnormal Uterine Bleeding:

Answer 95

Remember "PALM COIEN" **_PALM (Structural Causes)_** **P**olyp **A**denomyosis **L**eiomyoma (Fibroids/leiomyomata) ![]() **M**alignancy **_COEIN (Non-structural causes)_** **C**oagulopathy (ex. Leukaemia -low platelet count / Drugs - warfarin or heparin / Von Willebrand Disease) **O**vulatory (PCOS these patients more at risk of endometrial cancer due to unopposed oestrogen action). When ovulation fails, the corpus luteum does not form and progesterone is not produced. The endometrium then continues to proliferate in the second half of the cycle as well as in the first half (due to unopposed oestrogen produced from follicles in the ovaries). This leads to a bulky endometrium. This is eventually shed and results in heavy and prolonged bleeding often occurring at a longer interval than the normal cycle. **E**ndometrial (endometritis secondary to chlamydia infection / Endocrine) **I**atrogenic (COCP/Progestogens/Implants/IUD) à wait 3 months to see if it settles and if not use NSAID or Anti-fibrinolytic (tranexamic acid) **N**ot otherwise classified (arterio-venous malformation / uterine isthmocoele or C-section scar defect)

Question 96

Fetal squamous cells in maternal blood vessels is confirmatory for \_\_\_\_.

Answer 96

Amniotic Fluid Embolism The risk of fetal and maternal blood mixing is highest during the 3rd trimester and delivery. **Foetal cells act as thrombogenic factors**. While this condition is rare, it carries a very high mortality and even those who survive tend to have severe deficits including neurological defects. Acute shortness of breath, tachycardia, and tachypnoea, wedge-shaped infarction on chest x-ray. The resultant hypoventilation is causing the hypoxia. Our maon differential at this stage is PE as pregnancy is a hypercoagulable state and there is an increased risk of thrombus formation, thereby increased risk of embolisation.

Question 97

Somatic innervation to the bladder is via the \_\_\_, \_\_\_, and ___ nerves. Autonomic nerves travel in these nerve fibres too. Bladder filling leads to detrusor relaxation (\_\_\_\_) coupled with sphincter contraction. The _____ nervous system causes detrusor contraction and sphincter relaxation. Overall control of micturition is centrally mediated via centres in the \_\_\_\_.

Answer 97

Pudendal, Hypogastric and Pelvic Sympathetic Parasympathetic Pons

Question 98

Pre-Eclampisa: De Novo ___ after ___ weeks pregnancy **_and_ \_\_\_\_\_\_.** Aetiology unclear but due to increased ____ in the ____ arteries supplying the placenta, release of ____ , and ____ dysfunction.

Answer 98

**Hypertension** **20** **Proteinuria** vascular resistance spiral arteries inflammatory cytokines endothelial

Question 99

Risk factors for pre-eclampsia:

Answer 99

Biggest risk factor is **Chronic disease:** **Diabetes (Type 1 and 2)** /Chronic Hypertension or Hypertension in previous pregnancy/CKD/Autoimmune disease: Antiphospholipid syndrome + SLE Lower risk factors: * FH (If you have 1^st degree relative you are 25% more likely) * Obese * Multiple pregnancies (twins etc) * Older mother * 1^st time mother * 10 yr pregancy interval

Question 100

Common presenting features of PCOS.

Answer 100

Oligomenorrhoea Subfertility Acne Hirsuitism Obesity Mood swings/depression/anxiety Male pattern baldness Acanthosis nigricans (secondary to insulin resistance)

Question 101

Which criteria is used to diagnose PCOS?

Answer 101

Rotterdam diagnostic criteria Assuming that other causes have been excluded, PCOS can be 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_

Question 102

What investigations can be done in someone you suspect has PCOS?

Answer 102

**Bloods**: ## Footnote _LH:FSH ratio_**:** Increased (\>2). This is also helpful in excluding menopause where the ratio is normal. (**FSH often normal**) _Total testosterone_: normal/slightly raised _Fasting and oral glucose tolerance tests_: helps diagnose insulin resistance. Other tests that might be indicated if other pathologies are suspected include: _TFTs (_thyroid dysfunction) _17-hydroxyprogesterone levels_ (CAH) _Prolactin_ (hyperprolactinaemia) _DHEA-S and free androgen index_ (androgen secreting tumours) _24-hour urinary cortisol_ (Cushing's syndrome) **Imaging:** Transabdominal and transvaginal _ultrasound_: Shows increased ovarian volume and multiple cysts.

Question 103

Management of PCOS:

Answer 103

**Conservative:** Weight loss and exercise control Education about increased cardiovascular, diabetes and endometrial cancer risks. **Pharmacological treatment for women _not_ planning pregnancy:** *_Co-cyprindrol_* - Useful for reducing hirsutism and inducing regular menstruation. _Combined Oral Contraceptive Pill (COCP)_ - Used to reduce irregular bleeding and protects against endometrial cancer. _Metformin_ - Helps with menstrual regularity, hirsutism and acne. **Pharmacological treatment for women wishing to conceive** _Clomiphene_ - Induces ovulation and improves conception rates. _Metformin_ - Can be used with/out clomiphene to increase the chances of a pregnancy. _Ovarian drilling_ - is a 2nd line laparoscopic surgical procedure where diathermy or laser is used to damage the hormone producing cells of the ovary. _Gonadotrophins_ - Can induce ovulation if clomiphene and metformin have failed.

Question 104

What happens at the booking appointment (10 weeks)?

Answer 104

Comprehensive History Baseline Blood tests Urinalysis Blood pressure BMI Ultrasound

Question 105

Contraindications to vaginal delivery after C section:

Answer 105

Previous Classical (vertical scar) C-section Previous Uterine Rupture Usual contraindications to vaginal delivery (placenta praevia) \*VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries.

Question 106

\*VBAC usually has a success rate of around ___ . \*

Answer 106

\*VBAC usually has a success rate of around 60-80%. Thus, there is still a risk of having to perform an emergency Caesarean section. Risk is increased with increasing number of prior Caesarean deliveries. \*

Question 107

Risk Factors for ectopic pregnancy.

Answer 107

Pelvic inflammatory disease Pelvic surgery IUS/IUD Assisted reproduction e.g. IVF \***Anything that slows the ovum's passage through the fallopian tube to the uterus is a risk factor for developing an ectopic pregnancy**\*

Question 108

Indications for a caesarian section:

Answer 108

Abnormal presentation (breech or transverse) Twins (if first twin is not cephalic) HIV positive mother Primary Genital Herpes in first trimester (recurrent herpes is safe to deliver vaginally) Placenta Praevia Anatomical Reasons

Question 109

First Stage of Labour: ## Footnote \_\_\_\_ phase: ____ cm cervical dilation w/ irregular contractions and dilation of \_\_\_cm/hr \_\_\_ phase: ___ cm cervical dilation w/ regular contractions and dilation of ___ cm/hr \_\_\_ phase: ___ cm cervical dilation w/ regular strong contractions and dilation of ___ cm/hr

Answer 109

The first stage of labour is from the onset of labour (true contractions) until the cervix is fully dilated to 10cm. It involves cervical dilation (opening up) and effacement (getting thinner). **The “show” refers to the mucus plug in the cervix,** which prevents bacteria from entering the uterus during pregnancy, falling out and creating space for the baby to pass through. The first stage has three phases: **Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.** **Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.** **Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.**

Question 110

Prolonged rupture of membranes (PROM) : Amniotic sac ruptures more than \_\_\_hrs before delivery.

Answer 110

18hrs

Question 111

Tocolysis involves using medications to stop uterine contractions. ____ is the medication of choice for tocolysis. \_\_\_\_\_ is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Answer 111

Nifedipine, a calcium channel blocker. Atosiban

Question 112

Induction of labour can be used where patients go over the due date. IOL is offered between ____ weeks gestation.

Answer 112

41 and 42 weeks

Question 113

The ____ score is a scoring system used to determine whether to induce labour. Five things are assessed and given a score based on different criteria: A score of ___ or more predicts a succesful induction of labour.

Answer 113

The Bishop score is a scoring system **used to determine whether to induce labour.** Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13): **Pregnancy Can Enlarge Dainty Stomachs!** * **Position** * **Consistency** * **Effacement** * **Dilation** * **Station** - Fetal station refers to where the presenting part is in your pelvis \*A score of 9 or more predicts a successful induction of labour and a likely vaginal delivery. A score below this suggests cervical ripening may be required to prepare the cervix.\* **1 point is added** to the score for each of the following: Presence of **pre-eclampsia** Each **previous vaginal delivery** **1 point is subtracted** for each of the following: **Post-dates pregnancy** **No previous vaginal deliveries** **Premature pre-term rupture of membranes**

Question 114

200mg ___ Mifepristone followed by ___ micrograms Misoprostol vaginally ___ hours later can be given to terminate pregnancies from weeks 10-24.

Answer 114

Oral 800mg misoprostol 36-48

Question 115

Terbutaline is a \_\_\_\_. It is used for ___ in uterine hyperstimulation.

Answer 115

Beta 2 (adrenergic) agonist Tocolysis

Question 116

Carboprost is a ____ analogue. It is given as a deep ____ injection in postpartum haemorrhage when ergometrine and oxytocin have failed. Crucially it needs to be used with extreme caution in patients who have _____ , as it can cause a life threatening exacerbation.

Answer 116

Prostaglandin Intramuscular Asthma

Question 117

Tranexamic acid is a ____ . It binds to ___ preventing its breakdown to the enzyme \_\_\_\_. This enzyme breaks down blood clots.

Answer 117

antifibrinolytic fibrinogen plasmin

Question 118

What is the most significant risk factor for an umbilical cord prolapse? How does this present? What is the management of this condition?

Answer 118

Abnormal lie (i.e unstable/transverse/oblique) after 37 weeks Foetal distress on the CTG/Vaginal or speculum examnination can confirm Emergency C-section

Question 119

\_\_\_\_\_ involves hyperfelxion of the mother at the hip (bringing knees to abdomen). This provides a posterior pelvic tilt, lifting the pubic symphisis up and out of the way.

Answer 119

McRoberts Manoevre (**1st line** management in shoulder dystocia)

Question 120

\_\_\_\_\_ manoevre involves reaching into the vagina and putting pressure on the posterior aspect of the baby's anterior shoulder to force it down and under the pubic symphysis.

Answer 120

Rubin's Manoevre

Question 121

\_\_\_\_ maneouvre involves pushing the baby's head back into the vagina so that it can be delivered by emergency C-section

Answer 121

Zavanelli

Question 122

The key complications of shoulder dystocia are:

Answer 122

Foetal hypoxia Erb's plasy (brachial plexus injury - C5-C6) Perineal tears Post-partum haemorrhage

Question 123

A single/stat dose of ____ is used after _____ delivery to reduced the risk of maternal infection.

Answer 123

Co-amoxiclav Instrumental

Question 124

Epidural carries an increased risk of ____ delivery.

Answer 124

Instrumental

Question 125

The key risks to the baby to remember in instrumental delivery are:

Answer 125

Cephalohaematoma (ventouse) Facial Nerve Palsy (forceps)

Question 126

Instrumental dleivery can cause damage to which two nerves in the mother. This usually resolves over 6-8 weeks.

Answer 126

Obturator Femoral

Question 127

Classification of perineal tears. 1st degree: 2nd degree: 3rd degree: 4th degree:

Answer 127

**1st degree:** _Junction between frenulum of labia minora and superficial skin_ **2nd degree:** _Perineal muscles_ (not including anal sphincter) **3rd degree**: _Anal sphincters_ **A:** \< 50% External anal sphincter **B:** \>50% External anal sphincter **C:** Both _external and internal_ anal sphincter affected **4th degree**: _Mucosa_

Question 128

What are the advantages of active management of the 3rd stage of labour? Name the two measures that consitute active management.

Answer 128

Shortens 3rd stage (~half an hour) Reduces the risk of bleeding or post-partum haemorrhage Intramuscular dose of oxytocin Umbilical cord traction (during uterine contractions)

Question 129

Post-partum haemorrrhage classifications

Answer 129

500ml after vaginal delivery 1000ml after caesarian Minor \<1000mls Major \>1000mls Moderate 1000-2000mls Severe \>2000mls

Question 130

4 causes of PPH can be remembered with a mnemonic: Which one is the most common?

Answer 130

PPH **4Ts** **Tone** (atony _most common cause)_ **Trauma** (e.g perineal tear) **Tissue** (retained placenta/POC- endometritis) **Thrombin** (bleeding disorder)

Question 131

Intravenous infusion of oxytocin is given as \_\_\_units in ___ mls.

Answer 131

40 units 500mls

Question 132

Primary post-partum haemorrhage is bleeding within ___ hrs. Secondary post-partum haemorrhage is bleeding within ___ hrs to ___ wks.

Answer 132

24 hrs 24hrs -12 weeks

Question 133

There are four categories of emergency caesarean section: **Category 1**: There is an immediate threat to the life of the mother or baby. Decision to delivery time is \_\_\_minutes. **Category 2:** There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is ___ minutes. **Category 3:** Delivery is required, but mother and baby are stable. **Category 4:** This is an elective caesarean, as described above.

Answer 133

There are four categories of emergency caesarean section: **Category 1**: There is an immediate threat to the life of the mother or baby. Decision to delivery time is **30 minutes.** **Category 2**: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is **75 minutes.** **Category 3**: Delivery is required, but mother and baby are stable. **Category 4:** This is an elective caesarean, as described above.

Question 134

The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions: \_\_\_\_ is a curved incision two fingers width above the pubic symphysis \_\_\_\_\_\_\_ is a straight incision that is slightly higher (this is the recommended incision)

Answer 134

The most commonly used skin incision is a transverse lower uterine segment incision. There are two possible incisions: **Pfannenstiel incision** is a curved incision two fingers width above the pubic symphysis **Joel-cohen incision** is a straight incision that is slightly higher (_this is the recommended incision_)

Question 135

Contraindications to vaginal birth after C- section (VBAC).

Answer 135

Previous uterine rupture Previous classical/longitudinal scar c-section Other reasons for not having a vaginal delivery (ex. placenta praevia)

Question 136

Two key causes of sepsis in pregnancy are: \_\_\_\_ and \_\_\_\_.

Answer 136

Two key causes of sepsis in pregnancy are: Chorioamnionitis Urinary tract infections

Question 137

All patients admitted to maternity inpatient units, such as at the antenatal ward and labour ward, will have monitoring on a MEOWS chart. MEOWS stands for \_\_\_\_\_\_. This includes monitoring their physical observations to identify signs of sepsis.

Answer 137

**MEOWS - Maternity early obstetric warning system.**

Question 138

3 options for treating a uterine inversion:

Answer 138

**Johnson Manoevre** (_manually pushing the uterus back into position_. held in place for several minutes with concomitant oxytocin infusion) **Hydrostatic methods** (inflating the uterus with fluid) **Surgery** (laporotomy and uterus pulled back to normal position)

Question 139

Management of GBS infection

Answer 139

Intrapartum antibiotics Penicillin Vancomycin (if penicillin is contraindicated)

Question 140

\_\_\_\_ syndrome is a complication associated with oligohydramnios. It is a fetal condition which presents with _____ and various structural malformations as a result of compression in utero.

Answer 140

**Potter's syndrome** is a complication associated with oligohydramnios not polyhydramnios. It is a fetal condition which presents with **pulmonary hypoplasia** and various structural malformations as a result of compression in utero.

Question 141

Folic Acid ____ per day has been shown to reduce the occurrence of neural tube defects and should be recommended to all woman pre-pregnancy and up to ____ weeks gestation.

Answer 141

400 micrograms 12 weeks gestation

Question 142

Contraception is not required for the first ___ weeks after delivery

Answer 142

Contraception is not required for the first **3 weeks** after delivery

Question 143

Lactational amenorrhoea method may be used as contraception postpartum. However, is is time-limited and can only be used for the first \_\_\_\_ postpartum.

Answer 143

6 months

Question 144

Absolute contraindications to breastfeeding are:

Answer 144

absolute contraindications to breastfeeding are: Infants of **mothers with TB infection** Infants of **mothers with uncontrolled/unmonitored HIV** Infants of **mothers who are taking medications** which may be harmful e.g. amiodarone/lithium/methotrexate/gliptins (e.g sitagliptin)

Question 145

NICE recommends that with women a risk factor besides previous gestational diabetes should be offered an oral glucose tolerance test at ____ weeks. In the case of previous history of gestational diabetes, they are offered an oral glucose tolerance test as soon as possible after the booking visit followed by an additional test at 24-28 weeks if the first one is normal.

Answer 145

NICE recommends that with women a risk factor besides previous gestational diabetes should be offered an oral glucose tolerance test at **24-28 weeks**. In the case of **previous history of gestational diabetes**, they are offered an oral glucose tolerance test **as soon as possible after the booking visit** followed by an additional test at 24-28 weeks if the first one is normal.

Question 146

In this first stage of labour, contractions should be approximately ____ per ___ minute period, lasting ____ seconds.

Answer 146

3-5 contracitons per 10 minutes lasting 30-60 seconds

Question 147

Women with gestational diabetes should give birth no later than ____ weeks of gestation

Answer 147

40+6 weeks

Question 148

The symptoms of extreme morning sickness, heat intolerance, anxiety, and vaginal bleeding all suggest ____ which classically presents after ____ weeks gestation.

Answer 148

Molar Pregnancy 14 weeks B-hCG levels are often much higher than would be expected in a normal pregnancy. Trans-vaginal ultrasound is also used which in a complete molar pregnancy may show a '**snowstorm**' appearance, low resistance of blood vessel flow, and absence of a foetus.

Question 149

What is the management of an eclamptic seizure?

Answer 149

IV Magnesium Sulphate (4g over 15 minutes) - loading dose Maintenance dose - 1g/hr for 24hrs after seizure

Question 150

\_\_\_\_ Rule, the expected delivery date (EDD) is calculated by adding ___ months to the __ plus ___ days

Answer 150

**Naegele's** Rule, the EDD is calculated by adding **9 months** to the **LMP** plus **7** days

Question 151

\_\_\_\_ , especially in trace amounts, is a common finding during pregnancy as there is an increased ____ and a reduction in tubular reabsorption of filtered glucose.

Answer 151

Glucosuria Glomerular filtration rate

Question 152

When is the first dose of anti-D prophylaxis administered to rhesus negative women?

Answer 152

28 weeks / 6 months

Question 153

A prolonged 2nd stage of labour is defined as ___ hours or more from full dilatation in a nulliparous woman with epidural anaesthesia.

Answer 153

Three A prolonged 2nd stage of labour is defined as _\_\_three\__ hours or more from **full dilatation** in a **nulliparous woman** with **epidural anaesthesia.**

Question 154

Woody uterus' in pathognomoic of \_\_\_\_

Answer 154

Placental Abruption Remember with placental abruption the bleeding may be concealed and thus not PV.

Question 155

80% of cervical cancers are ____ cancer. ____ is the next most common type. Rarely there exists other forms such as ____ cancer.

Answer 155

**Squamous cell carcinoma** Adenocarcinoma (2nd most common) Small cell cancer

Question 156

HPV promotes the development of cancer by inhibiting tumour suppressor genes ___ and \_\_\_. HPV produces two proteins that inhibit these tumour suppressor genes - ___ and \_\_\_.

Answer 156

p53 and **pRb**. (**pat rabbit**) E6 suppresses p53 E7 suppresses pRb.

Question 157

Cervical cancer risk factors:

Answer 157

**High Sexual Activity** (early stage of activity/no.partners/no partners of partner/not using condoms) **Non-adherence to cervical screening** **Family history** **Smoking** **Immunosuppression** **HIV** (cervical smear every year) **COCP** (if greater than 5 years of use) Increased number of **full term pregancies** **Diethylbestro**l during foetal development (used to prevent misscarriage before 1971)

Question 158

CIN is sometimes called \_\_\_\_

Answer 158

Cervical carcinoma in situ

Question 159

\_\_\_\_ (\_\_\_) is a monoclonal antibody used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It targets ____ and may also be seen in the treatment of wet age-related macular degeneration.

Answer 159

Bevacizumab (Avastin) VEGF - A

Question 160

Around 80% of endometrial cancers are \_\_\_\_. It is an _____ dependent cancer.

Answer 160

Adenocarcinoma Oestrogen-dependent cancer - oestrogen stimulates growth of endometrial cancer cells.

Question 161

Endometrial hyperplasia is a ___ condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time. Less than ___ % go on to become endometrial cancer. There are two types of endometrial hyperplasia to be aware of: \_\_\_\_ and \_\_\_\_.

Answer 161

precancerous 5 Hyperplasia without atypia Atypical hyperplasia Endometrial hyperplasia is a precancerous condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time. Less than 5% go on to become endometrial cancer. There are two types of endometrial hyperplasia to be aware of: Hyperplasia without atypia Atypical hyperplasia

Question 162

Endometrial Hyperplasia may be treated using:

Answer 162

Intrauterine System (i.e mirena coil) Continuous oral Progestogens (.eg medroxyprogesterone/levonorgestrel)

Question 163

Endometrial cancer and hyperplasia risk factors:

Answer 163

Older age **Obesity** Oestrogen window (Early mearche/late menopause) PCOS _Nulliparous or few pregnancies_ Oestrogen only hormone replacement therapy Tamoxifen (anti-oestrogen in breast but oestorgen mimetic in the endometrium and thus causes hypertrophy - increases E.cancer risk 2-3 fold) **Factors not related to oestrogen exposure:** Diabetes (insulin stimulates endometrial cell growth) _HNPCC or Lynch syndrome_

Question 164

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is: Postmenopausal bleeding (more than ___ months after the last menstrual period) NICE also recommends referral for a ______ in women over ____ years with: Unexplained \_\_\_\_\_\_ Visible _____ **plus** raised platelets, anaemia or elevated glucose levels.

Answer 164

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is: Postmenopausal bleeding (more than **12** months after the last menstrual period) NICE also recommends referral for a **transvaginal ultrasound** in women over **55 years** with: Unexplained **vaginal discharge** Visible **haematuria** plus raised platelets, anaemia or elevated glucose levels

Question 165

There are three investigations to remember for diagnosing and excluding endometrial cancer:

Answer 165

**Transvaginal ultrasound** for endometrial thickness (**normal is less than 4mm** post-menopause) **Pipelle biopsy**, which is highly sensitive for endometrial cancer making it useful for excluding cancer **Hysteroscopy with endometrial biopsy**

Question 166

The usual treatment for stage 1 and 2 endometrial cancer is a \_\_\_\_\_. Other treatment options depending on the individual presentation include:

Answer 166

The usual treatment for stage 1 and 2 endometrial cancer is a **total abdominal hysterectomy with bilateral salpingo-oophorectomy**, also known as a TAH and BSO (removal of uterus, cervix and adnexa). A **radical hysterectomy** involves also removing the **pelvic lymph nodes, surrounding tissues and top of the vagina** **Radiotherapy** **Chemotherapy** **Progesterone** may be used as a hormonal treatment to slow the progression of the cancer

Question 167

Around 90% of vulval cancers are _____ carcinomas. Less commonly they can be \_\_\_\_.

Answer 167

Squamous cell Malignant melanomas

Question 168

Risk factors for vulval cancer:

Answer 168

Increasing age (particularly \> 75) Lichen sclerosis (around 5% get vulval cancer) Immunosuppression HPV infection

Question 169

\_\_\_\_\_\_\_ (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia). High grade squamous intraepithelial lesion is a type of VIN associated with _____ that typically occurs in younger women aged _____ years. Differentiated VIN is an alternative type of VIN associated with _____ and typically occurs in ____ women (aged _____ years).

Answer 169

Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia). **High grade squamous intraepithelial lesion** is a type of VIN associated with **_HPV infection_** that typically occurs in **_younger women aged 35 – 50_** years. **Differentiated VIN** is an alternative type of VIN associated with **_lichen sclerosus_** and typically occurs in **_older_** women (aged **_50 – 60_** years).

Question 170

Treatment for vulval cancer:

Answer 170

* Wide local excision possibly involving lymph nodes * Chemotherapy * Radiotherapy

Question 171

Treatment for VIN :

Answer 171

Watch and wait Wide local excision Imuiquimod Laser ablation

Question 172

Investigations for establishing diagnosis of vulval cancer:

Answer 172

Biopsy Sentinel node biopsy Further Imaging (CT abdomen/pelvis for staging)

Question 173

Risk factors for shoulder dystocia:

Answer 173

Previous shoulder dystocia (10X risk) Diabetes Obesity (high BMI) Twins Inducing labour Oxytocin drip Prolonged 1st or 2nd stage of labour Instrumental delivery

Question 174

Signs of Magnesium sulfate toxicity

Answer 174

Poor urinary output Respiratory depression Hypo or areflexia.

Question 175

Complications of Pre-eclampsia

Answer 175

Peripheral Oedema (often pulmonary and cerebral) Renal failure HELLP syndrome

Question 176

For cord prolapse if theyre dilated (i.e \>10cm) then you have to \_\_\_\_. If they are not (i.e 4cm etc) then they need \_\_\_\_\_.

Answer 176

Deliver to be taken to theatre for C-section.

Question 177

3 foetal shunts

Answer 177

Ductus Venosus Foramen Ovale Ductus Arteriosus

Question 178

2/3 of multiple pregancies are ____ whilst a 1/3 are Monozygotic. Of these monozygotic pregnancies 30% are \_\_\_\_\_ 70% are \_\_\_\_ 1% are \_\_\_\_ and 0.1% are \_\_\_\_.

Answer 178

Dizygotic 30% are **DCDA** - dichorionic (2 placentas) diamniotic (2 amniotic sacs) 70% are **MCDA** - Monochorionic (one placenta) Diamniotic (2 amniotic sacs) 1% are **MCMA** - Monochorionic Monoamniotic and 0.1% are conjoined twins.

Question 179

Multiple pregnancy is increased in \_\_\_\_\_.

Answer 179

Assisted Reproductive Technology (ART)

Question 180

The timeline for each pregnancy begins on the \_\_\_\_\_.

Answer 180

1st day of the last menstrual period.

Question 181

Foetal movements begin from about ____ weeks gestation

Answer 181

20

Question 182

Before 10 weeks - ____ clinic Offer a baseline assessment and plan the pregnancy Between 10 and 13 + 6 - \_\_\_\_ An accurate gestational age is calculated from the ____ (CRL), and multiple pregnancies are identified 16 weeks - Antenatal appointment Discuss results and plan future appointments Between 18 and 20 + 6 - \_\_\_\_ An ultrasound to identify any anomalies, such as heart conditions 25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks - Antenatal appointments Monitor the pregnancy and discuss future plans

Answer 182

Booking Dating scan Crown Rump Length (CRL) Anomaly scan

Question 183

There are two vaccines offered to all pregnant women: \_\_\_\_\_\_ from 16 weeks gestation \_\_\_\_\_ when available in autumn or winter. Live vaccines, such as the _____ vaccine, are avoided in pregnancy.

Answer 183

There are two vaccines offered to all pregnant women: **Whooping cough** (pertussis) from 16 weeks gestation **Influenza (flu**) when available in autumn or winter Live vaccines, such as the **MMR** vaccine, are avoided in pregnancy.

Question 184

A Nuchal Translucency \> ___ indicates possible down syndrome.

Answer 184

6mm

Question 185

Obstetric cholestasis is associated with _____ and _____ . Planning delivery for 37-38 weeks allows adequate development of the foetus without unnecessarily prolonging the risk of spontaneous death

Answer 185

spontaneous foetal death maternal haemorrhage

Question 186

Signs of placental separation and imminent placental delivery: Gush of blood \_\_\_\_ of the umbilical cord \_\_\_\_\_ of the uterus in the abdomen

Answer 186

Lengthening Ascension

Question 187

Meconium is the first faeces passed by a newborn, in contrast to later faeces it is usually very thick and _____ in colour. It is usually passed after delivery. The presence of meconium in the amniotic fluid may lead to development of ______ (MAS).

Answer 187

dark green meconium aspiration syndrome Sometimes it may be expelled prior to birth into the amniotic fluid, which is known as “meconium stained liquor”. MAS is caused by passage of the meconium from the amniotic fluid into the foetal lungs. This can cause blockage and inflammation of the airways and is associated with significant morbidity and mortality.

Question 188

What is the management of patients with hypothyroidism during pregnancy?

Answer 188

In hypothryopid pregancies, NICE recommends **increasing levothyroxine by 25 mcg as soon as pregnancy is confirmed** despite a euthyroid state and **rechecking TFTs in 4 weeks.** This patient is currently euthyroid but because of her pregnancy, needs an increased dose of levothyroxine. The explanation for this is that in **pregnancy there is a physiological increase in serum free thyroxine until the 12th week of pregnancy as the foetus is dependent on mother's circulating thyroxine until the 12th week of development when the foetal thyroid develops.**

Question 189

Menorrhagia is defined as blood loss during a menstrual period to which a patient's quality of life is affected. In about half of cases, there is no underlying pathology and this is referred to as \_\_\_\_\_\_.

Answer 189

Dysfunctional uterine bleeding.

Question 190

Amniotic fluid is important for the development of the fetal lungs thus oligohydramnios can lead to\_\_\_\_\_.

Answer 190

fetal pulmonary hypoplasia.

Question 191

3 examples of ____ bacteria associated with bacterial vaginosis are:

Answer 191

Anaerobic **_Gardnerella Vaginalis_** (most common) **Mycoplasma Hominis** **Prevotella**

Question 192

Remember that ____ on microscopy mean bacterial vaginosis.

Answer 192

Clue cells ## Footnote Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.

Question 193

Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment. \_\_\_\_\_ is the antibiotic of choice for treating bacterial vaginosis. It specifically targets _____ bacteria. It can be given orally or via a \_\_\_\_. \_\_\_\_ is an alternative but is a less optimal choice of antibiotic

Answer 193

Metronidazole Vaginal gel Anaerobic Clindamycin

Question 194

Whenever prescribing metronidazole advise patients to avoid ____ for the duration of treatment.

Answer 194

**Alcohol** This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. **Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.**

Question 195

The National Chlamydia Screening Programme (NCSP) aims to screen every sexually active person under the age of ___ or when they\_\_\_\_.

Answer 195

25 Change partner Everyone that tests postive shuld be re-screened 3 months later to ensure they havent picked up the infection again (it is _NOT_ to see if the treatment has worked)

Question 196

Name the two different types of swab that can be used to test for STI's?

Answer 196

Charcoal Swabs Nucleic Acid Amplification Tests (NAATs)

Question 197

1st line for treating uncomplicated Chlamydia infection \_\_\_\_\_

Answer 197

Doxycycline 100mg twice daily for 7 days.

Question 198

Doxycycline is contraindicated in pregnancy and breast feeding and thus an alternative option in the treatment of chlamydial infection is\_\_\_\_

Answer 198

Azithromycin/Erythromycin/Amoxicllin A test of cure should only be done in cases of rectal chlamydia.

Question 199

\_\_\_\_\_\_ (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages: Doxycycline 100mg twice daily for ____ days is the first-line treatment for LGV. Erythromycin, azithromycin and ofloxacin are alternatives.

Answer 199

**Lymphogranuloma Venereum** (LGV) **21 days** The **primary stage i**nvolves a **painless ulcer** (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex. The **secondary stage** involves **lymphadenitis.** This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected. The **tertiary stage** involves **inflammation of the rectum (proctitis) and anus**. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.

Question 200

For uncomplicated _gonorrhoeal_ infection 1st line therapy is: \_\_\_\_ if sensitivities are **not** known. \_\_\_\_ if sensitivites are known.

Answer 200

Ceftriaxone (IM) if not known Ciprofloxacin (Oral)if known

Question 201

A key complication of gonnococcal conjunctivits to remember is neonatal conjunctivitis (i.e \_\_\_\_\_) as this is a medical emergency and may cause sepsis, perforation of the eye and blindness.

Answer 201

Ophthalmia Neonatorum

Question 202

The absence of ___ cells on microscopy is useful for excluding PID.

Answer 202

Pus cells

Question 203

\_\_\_\_\_ syndrome is a complication of PID and is caused by inflammation and infection of the \_\_\_\_, which lead to ____ between the liver and peritoneum. This syndrome can lead to ___ pain which can be referred to the ____ if there is diaphragmatic irritation. Laporoscopy can be used to visualise and also treat the adhesions via adhesiolysis.

Answer 203

Fitz-Hugh-Curtis syndrome Liver Capsule Adhesions RUQ Shoulder tip Bacteria can spread via the peritoneum/lymph/blood.

Question 204

Trichomonas vaginalis is a type of ____ spread through sexual intercourse. Trichomonas is classed as a **protozoan**, and is a **single-celled** organism with flagella. Flagella are appendages stretching from the body, similar to limbs. Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism Examination of the cervix can reveal a characteristic “\_\_\_\_\_\_ ” (also called colpitis macularis). Treatment is with \_\_\_\_\_.

Answer 204

Parasite Strawberry cervix Metronidazole

Question 205

The herpes simplex virus can also cause aphthous ulcers (small painful oral sores in the mouth), ____ (inflammation of the cornea in the eye) and _____ (a painful skin lesion on a finger or thumb).

Answer 205

herpes **keratitis** herpetic **whitlow**

Question 206

HSV-1 is most associated with \_\_\_\_. HSV-2 typically causes \_\_\_\_.

Answer 206

Cold Sores (Most common cause of _genital herpes_ via oro-genital sex) Genital Herpes (HSV-2 is usally a cause of _re-infection_ (i.e reactivation of a previous infection ) Incubation - few days to 3 weeks But this is not a hard rule and either strain can cause either cold sores or gential herpes.

Question 207

Treatment of genital herpes is with ___ .

Answer 207

**Aciclovir (**400mg TDS for 5-10 days) Alternatives are valaciclovir/famciclovir **Non-Pharmacological:** Analgesia Saline Bathing Local anaesthetic gel - Lidocaine 5% medicated plaster (Versatis®)\* is licensed for the symptomatic relief of neuropathic pain Warm water urination (in shower) Counsel on risk of infection to others Counsel on pregnancy \*Refractive/recurrent disease can be treated with long term aciclovir - 3-12 months\*

Question 208

Pregnant Women (before ___ weeks) that are asymptomatic with genital herpes infection can have a vaginal delivery provided it is 6 weeks after the initial infection. If symptomatic a ___ is recommended. In addition if women contract the virus after 28 weeks a ____ is also recommended.

Answer 208

28 C -section X2 Aciclovir is safe to use during preganncy and is given during the initial infection and prophylactically in pregnancy.

Question 209

A single deep _____ dose of ____ is the standard treatment for syphillis.

Answer 209

Intramuscular (IM) Benzathine Benzylpenicillin (penicillin)

Question 210

What are the 3 steps to consider when choosing a HRT formulation?

Answer 210

1. **Are the symptoms local?** Local: Use topical oestrogen cream/tablets 2. **Does the woman have a uterus?** Yes: Use combined HRT No: Use Oestrogen only 3. **Has the woman had a period in the last 12 months?** Yes: Use cyclical pregestogen (given 10-14 days per month) No: Use Continuous Progestogen (If under 50 only given if no period for \> 24 months as can cause irregular breakthrough bleeding prompting investigation elsewhere) .

Question 211

The Mirena coil is licenced for ____ yrs for endometrial protection (i.e in a combined HRT regimen)

Answer 211

4 Years.

Question 212

The ____ cells of the ovaries respond to LH and FSH to secrete oestrogen.

Answer 212

Theca Granulosa Cells

Question 213

Puberty Starts at age ____ in girls and ____ in boys. Girls have an earlier pubertal growth spurt. Puberty usually takes about ___ yrs from start to finish.

Answer 213

8-14 in girls 9-15 in boys 4 years

Question 214

\_\_\_\_ is the enzyme in adipose tissue responsible for the creation of oestrogen, and thus the reason overweight children often enter puberty at an earlier age.

Answer 214

Aromatase

Question 215

Puberty in girls usually begins with ____ and is followed by ____ , and finally menarche.

Answer 215

Breast budding Pubic hair

Question 216

The Stage of Pubertal development can be measured using the ____ scale which is based on the findings of sexual characteristics.

Answer 216

Tanner Scale

Question 217

\_\_\_\_ ovarian cancer is the most common type of ovarian cancer of all ovarian tumours. _____ is the most common subtype of epithelial ovarian cancer and is characterised by the presence of ____ on histology.

Answer 217

Epithelial Serous cystadenocarcinoma Psammoma bodies

Question 218

The symptoms of reduced libido, galactorrhoea (bilateral milky discharge from the breasts that is not associated with pregnancy or lactation) and amenorrhoea are highly suggestive of \_\_\_\_\_.

Answer 218

Hyperprolactinaemia.

Question 219

Category 1 (immediate) Caesarean section should be performed where there is evidence or clinical suspicion of \_\_\_\_.

Answer 219

Acute foetal compromise (eg. cord prolapse)

Question 220

Ovarian torsion is a gynaecological emergency and diagnostic delay can lead to a loss of the ovary due to compromised blood supply. It usually presents with sudden onset, unilateral pain in the right or left iliac fossa. This is often severe, constant and accompanied with nausea & vomiting. A raised CRP and white cell count is suggestive of an underlying inflammatory response. The ____ sign is a characteristic sign of ovarian torsion that can be seen on ultrasound or CT scan. It demonstrates the twisting of the ovarian ___ .

Answer 220

'Whirlpool' Pedicle

Question 221

\_\_\_\_ is the most effective method of preventing GBS infection in the newborn.

Answer 221

Intra-partum antibiotic prophylaxis Antibiotics (commonly a penicillin) are given **intravenously** during labour and delivery if **risk factors** for GBS infection are present

Question 222

Macrosomia refers to a birthweight of greater than \_\_\_.

Answer 222

4.5kg

Question 223

Any invasive uterine procedure is a potential sensitising event, thus any rhesus negative woman undergoing procedures such as amniocentesis or chorionic villus sampling must be given ____ (in addition to the routine doses).

Answer 223

Anti-D prophylaxis

Question 224

Cervical ectropion is particularly more common in ____ , during pregnancy, and in women taking combined hormonal contraception. The high levels of ___ trigger an enlargement of the cervix, causing eversion of the endocervical canal, which appears as a red ring.

Answer 224

Adolescents Oestrogen

Question 225

Patients with severe pre-eclampsia should have blood tests\_\_\_\_ to anticipate if a patient is developing HELLP syndrome, a complication of pre-eclampsia involving\_\_\_ , elevated liver enzymes and low platelets.

Answer 225

Three times per week Haemolysis

Question 226

Risk Factors for Ovarian Cancer

Answer 226

Older age Smoking Greater number of ovulations (early menarche, late menopause) Obesity HRT BRCA 1 and 2 genes

Question 227

Uterine hyper-stimulation is defined as greater than __ contractions occurring within ___ and is due to administration of ___ or oxytocin for induction of labour.

Answer 227

5 within 10 minutes prostaglandins

Question 228

\_\_\_\_ is mid-cycle ovulatory pain and it is common. The pain is due to rupture of the Graafian (dominant) follicle, each month, which results in the release of an ovum into the fallopian tube. The pain can vary from being right-sided to left-sided depending on which ovary is ovulating that month. Duration of pain can vary from minutes up to a few days and it can be controlled using simple analgesics such as paracetamol and NSAIDs.

Answer 228

Mittelschmerz

Question 229

External cephalic version is usually offered at ___ weeks and involves applying pressure to the maternal abdomen in an attempt to “turn” the baby.

Answer 229

36 weeks

Question 230

The uterus usually returns to its non-pregnant size by ___ weeks post-partum

Answer 230

4 weeks

Question 231

\_\_\_\_ rule is used to calculate the EDD based on the first day of the woman's last menstrual period (LMP). The calculation is to add __ and ___ days to the first day of the LMP and subtract three months.

Answer 231

Naegele’s one year and 7 days

Question 232

Tocolysis 1st line?

Answer 232

**Oral** Nifedipine Other agents that can be used: IV Atosiban (Oxytocin receptor antagonist) IV Terbutaline (beta-agonist and thus off label due to cardiovascular risk - smooth muscle relaxation) Indomethacin (NSAID)

Question 233

Contraindications to Tocolysis

Answer 233

* Greater than **34 weeks** gestation * Non-reassuring cardiotocograph, fatal foetal anomaly or intrauterine death * **Intrauterine growth restriction** or **placental insufficiency** * Cervical dilation **greater than 4cm** * **Chorioamnionitis** * Maternal factors such as **pre-eclampsia**, **ante-partum haemorrhage**, **haemodynamic instability** The drug-specific contraindications should also be considered, for example cardiac disease such as severe hypotension or heart failure is a contraindication to nifedipine.

Question 234

Layers to go through on a C-section

Answer 234

Skin - subcutaneous fat - rectus sheath - rectus abdominus muscle - peritoneum - uterine myometrium - amniotic sac

Question 235

Female causes of Infertility:

Answer 235

Female **Ovulatory Dysfunction:** * Age * PCOS * Premature Ovarian Failure * Cushing's syndrome * Pituitary Tumours * Hyperprolactinaemia * Turner's/Kleinfelters syndrome * Sheehan's Syndrome (pituitary infarction) **Structural:** * Endometriosis * Pelvic Inflammatory Disease * Asherman's Syndrome (Intrauterine adhesions) * Bicornuate Uterus * Fibroids * Cervical Damage (ex. cone biopsy)

Question 236

Male causes of Infertility:

Answer 236

**General** * Obesity * Smoking * Excessive alcohol * Compressive issues (Sitting down all day/tight underwear) * Anabolic steroids * Ilicit drug use **Testicular Factors** * Varicocele * Cryptorchidism (undescended testes) * Testicular Cancer * Kleinfelter's syndrome **Genital Tract** * Congenital genital tract disorders * Disorders of ejaculation * Obstruction of the ejaculatory system (conegnital or acquired)

Question 237

What is Dysfunctional Uterine Bleeding?

Answer 237

The cause of up to 50% of Menorrhagia (mentrual bleeding affecting QOL). Means there is **no underlying pathology**

Question 238

Which types of twins are associated with the greatest risk of complications?

Answer 238

Monochorionic Monoamniotic \*Monochorionic monoamniotic twins are identical (monozygotic) twins that share the same amniotic sac. These share a placenta with two separate umbilical cords. These types of twins are at high risk of developing complications such as cord entanglement (because there is no membrane separating the two umbilical cords), cord compression, twin-to-twin transfusion syndrome and pre-term birth.

Question 239

The COCP is absolutely contraindicated in women who are breast feeding ___ weeks post partum

Answer 239

The COCP is absolutely contraindicated in women who are breast feeding **\< 6 weeks post partum** (UKMEC 4)

Question 240

Absolute Contraindications to COCP (UKMEC 4)

Answer 240

* **Family history** of early age **VTE** (\<45 years) * Ongoing or previous **Breast cancer** * **Pregnancy** * **Obesity** * **Breast feeding** (**\< 6 weeks** post partum) * **BRCA** genes

Question 241

\_\_\_ are the recommended contraceptives as they can be started any time following delivery. IUD/IUS may also be used but must be fitted withing ___ hrs of delivery or ___ weeks after delivery.

Answer 241

**POP and Implant** \<48hrs \>4 weeks Basically **cannot insert in 48hrs - 4 week window** post partum

Question 242

Which treatments offer the best chance of preventing further miscarriage in a patient with anti-phospholipid syndrome?

Answer 242

Antiplatelet (Aspirin) _AND_ Anticoagulant (i.e LMWH) \*not only do yopu want reduced platelet aggregation/activity but when they **do** aggregate, it is important that the clotting cascade doesn't work and thus the fibrin meshwork isnt formed.\*

Question 243

Bacterial vaginosis (BV) typically presents with a copious _____ with a characteristic ___ odour. It does **not** normally cause vulval itch. It is caused by an overgrowth of **anaerobic bacteria** in the vagina. BV should always be treated in pregnancy as it may confer a greater risk of _____ or \_\_\_\_. BV is treated in pregnancy with either intravaginal gel (e.g. _____ or _____ ) or oral _____ .

Answer 243

Bacterial vaginosis (BV) typically presents with a **copious watery grey-white discharge with a characteristic 'fishy' odour.** It does not normally cause vulval itch. It is caused by an overgrowth of anaerobic bacteria in the vagina. BV should always be treated in pregnancy as it may confer a greater risk of **premature birth or miscarriage.** BV is treated in pregnancy with either intravaginal gel (e.g. **Metronidazole or Clindamycin)** or **oral Metronidazole.**

Question 244

For nulliparous and multiparous women, the recommended time for ECV is ____ and ___ weeks respectively

Answer 244

36 and 37 weeks

Question 245

What drug class is Clomiphene and when is it given?

Answer 245

Clomiphene is an **anti-oestrogen** (selective oestrogen receptor modulator) and is **given daily** from day **2-6 of the cycle**. It is used to treat **anovulation.** Works by reducing circulating oestrogen activity, thereby reducing the suppression of the HPA and subsequently FSH/LH.

Question 246

Which of the following is the reason for taking high dose folic acid?

Answer 246

**Obesity (**BMI **\> 30)** **Folic acid is converted to tetrahydrofolate (THF),** which is involved in the **synthesis of DNA and RNA**. Deficiency in folic acid can cause neural tube defects (NTD). Obese women with a BMI \> 30 kg/m2 are at a higher risk of conceiving a child with neural tube defects and are recommended to take _**5 mg** of folic acid from before conception until the 12th week of pregnanc_y. All women should take _400 mcg folic acid until the 12th week (normal dose - 400mcg)_ of pregnancy. Other risk factors include previous pregnancy with NTD, family history of NTD, use of antiepileptic drugs, coeliac disease, diabetes, and thalassaemia traits.

Question 247

A potential side effect of ferrous sulphate in the treatment of menorrhagia is the development of \_\_\_\_\_.

Answer 247

A potential side effect of ferrous sulphate is the development of **dark stool (harmless)** Remember poo after guinness is black because of iron.

Question 248

Passage of fetal and placental tissue during a miscarriage can appear as ____ tissue and be accompanied by blood clots.

Answer 248

**Greyish**

Question 249

Prior to attempting an instrumental delivery, a nerve block is performed to provide regional analgesia. Which nerve is blocked in this circumstance?

Answer 249

Pudendal Nerve \*Lidocaine is injected 1–2cm medially, and below the right and left ischial spines transvaginally with a specially designed pudendal needle.\*

Question 250

After evacuation of a hydatidiform mole, the levels of b-hCG are expected to fall and pregnancy should be avoided for 1 year. However, if they fail to drop, _____ should be suspected.

Answer 250

**Malignant Choriocarcinoma**

Question 251

What is the classical triad of amniotic fluid embolism and when is it most likely to occur?

Answer 251

The classic triad involves **coagulopathy, hypoxia and hypotension**. Amniotic fluid embolism is most likely to occur **during or shortly after labour.** The pathophysiology is not completely understood.

Question 252

What is the classical clinical triad of vasa praevia?

Answer 252

The classical triad of clinical features is **rupture of membranes**, **painless vaginal bleeding**, and **fetal bradycardia** (fetal heart rate \<100bpm). It presents with rupture of membranes _followed immediately_ by vaginal bleeding. \*Vasa praevia is a condition where the fetal blood vessels (which are unprotected by the umbilical cord) run close to or across the internal cervical os. This is dangerous as rupture of membranes can cause rupture of the fetal vessels and subsequent fetal haemorrhage.\*

Question 253

Jaundice within 24 hrs of birth is always \_\_\_\_

Answer 253

Pathological

Question 254

What is the most appropriate initial management of an inverted uterus (often following an active 3rd stage of labour)?

Answer 254

**Johnson's Manoevre**: Immediately replace the fundus through the cervix with the palm of the hand, followed by two large bore cannullas This is because a tight ring forms around the uterus and this must be prevented as soon as possible.

Question 255

CVS is typically offered between ___ weeks gestation whilst amniocentesis can be offered from ___ weeks

Answer 255

CVS : **11-13 weeks** Amniocentesis : **15 weeks** Remember there is a risk of **foetal limb abnormalities if CVS is performed before 11 weeks.**

Question 256

What is the treatment for Herpes Simplex Virus infection?

Answer 256

**Oral** Acyclovir IV acyclovir is only used in systemic/disseminated disease (i.e fever/multiple mucosal sites/meningitis)

Question 257

What criteria is used to make a diagnosis of Bacterial Vaginosis? What are the components of this criteria and how many are needed to make a diagnosis?

Answer 257

**Amstel Criteria** for Bacterial Vaginosis In order to diagnose bacterial vaginosis, the Amstel criteria are used. **Three out of four features are needed** to confer a diagnosis: **Vaginal pH \>4.5** **Homogenous grey discharge** **Whiff test** - 10% potassium hydroxide produces fishy odour **Clue cells** present on wet mount (i.e microscopy)

Question 258

What is the treatment of bacterial vaginosis?

Answer 258

The treatment of choice is **Metronidazole or Clindamycin.** The treatment used in _pregnancy_ is **Metronidazole.**

Question 259

What is the most appropriate hormonal contraception to use in a patient with a history of epilepsy?

Answer 259

**Depo - provera** (medroxyprogesterone acetate) **injection** does not go through first pass metabolism and thus does not induce the CYP450 enzymes like many epileptic drugs. This means that its concentration is unaffected by anti-epileptics unlike COCP. Need to avoid 1st pass metabolism (i.e Ingestion)

Question 260

Emergency Contraception options:

Answer 260

**IUD/Copper coil** - Can be taken within **5 days** of UPSI **Ella One -** Can also be taken within **5 days** of UPSI **Levonelle** - Can be taken within **3 days** of UPSI (_not as effective as ella one_)

Question 261

The ______ reaction is a classical reaction to ___ treatment in syphilis infection, characterized by fever, rash, rigors and tachycardia.

Answer 261

**Jarisch-Herxheimer** **Penicillin** It is thought that as the bacteria are lysed by the antibiotic, they secrete an **endotoxin** which can cause an **inflammatory response** It does not occur in all cases, but it is imperative to _warn patients_ that this may occur during treatment. Reassure and dicharge with analgesia unless very ill in which case consider admission.

Question 262

What are the HIV opportunistic infections and their associated CD4 count?

Answer 262

CD4 **\< 200 cells/mm**³ : Fungal infections such as PCP (pneumocystic jiroveci) and Candidiasis CD4 **\< 100 cells/mm**³ : Cryptococcal Meningitis CD4 **\< 50 cells/mm³**: Cerebral Toxoplasmosis / Progressive Multifocal Leukoencephalopathy (PML) / Disseminated Mycobacterium Avium Complex (MAC) / CMV retinitis. CD4 cells/mm³ \> 200 and low viral load (i.e RNA) : Same susceptibility to infection as the normal population and thus Streptococcal Pneumonia and **TB** etc are the most likely organisms \***TB can be contracted at any CD4 level**\*

Question 263

What is the gold standard for diagnosis of HIV infection?

Answer 263

**HIV antibody and HIV antigen test.** Need to wait at least 4 weeks after intial transmission before these tests are suitable as it takes time to develop the viral load and the subsequent antibody response (I.e **seroconversion**) Often means patients need to be re-tested weeks later. It is thus common practice to test at **4 weeks** _and_ at **3 months**.

Question 264

What is the treatment of uncomplicated Gonorrhoea?

Answer 264

\*\* Most regimes give **IM Ceftriaxone 1 g** if sensitivities are NOT known\*\* **Oral Ciprofloxacin (500mg)** if sensitivites are known (azithromycin covers potential chlamydia infection)

Question 265

UKMEC 4 / Absolute Contraindications to COCP.

Answer 265

**Uncontrolled Hypertension** (Particularly \>160/100) History of **VTE** **Migraine w/ aura** **Major Surgery** w/ prolonged immobility **CVD** - IHD/AF/Cardiomyopathy/Vascular Disease/Stroke **Smoking \> 15/day** _and_ **aged \>35** **Liver Cirrhosis** and Liver **tumours** **Systemic lupus erythematosus** (SLE) / **Antiphospholipid syndrome** \*It is worth noting that **Obesity (BMI \>35) is UKMEC 3** and thus the risks outweigh the benefits\*

Question 266

After the last period contraception is required for ___ yrs in a woman \<50 and for ___ yrs in a woman \> 50.

Answer 266

2 1

Question 267

Lactational amenorrhoea is over 98% effective as contraception for up to ___ months after birth.

Answer 267

6 months

Question 268

Benefits of COCP

Answer 268

**Very effective** (99% perfect use / 91% typical use) **Rapid return of fertility** once stopped Improves **Premenstrual Syndrome/symptoms, Menorrhagia and Dysmenorrhoea** Reduced risk of **Endometrial, Ovarian and Colon cancer** Reduced risk of **Benign Ovarian Cysts**

Question 269

It is recommended to start the COCP on the ___ day of the cycle. Protection is conferred when starting the pill up to day __ of the cycle withoput any need for additional contraception. If starting outside of this window, barrier protection should be used for the first ___ days of consistent pill use.

Answer 269

It is recommended to start the COCP on the **1st day of the cycle**. Protection is conferred when starting the pill up to **day 5** of the cycle withoput any need for additional contraception. If starting outside of this window, barrier protection should be used for the first **7 days** of consistent pill use.

Question 270

The only UKMEC 4 for the Implant and Depo is \_\_\_\_.

Answer 270

Active **Breast Cancer**

Question 271

The traditional POP (i.e Norgestron / Noriday) cannot be delayed by more than ___ hrs or it is considered a 'missed pill'. The ____ -only pill cannot be delayed by more than ___ hrs.

Answer 271

3 hrs Desogestrel 12 hrs

Question 272

It takes ____ hours before the progestogen-only pill thickens the cervical mucus enough to prevent sperm entering the uterus, protecting against pregnancy. The combined pill takes ____ days before the woman is protected from pregnancy, as it works by inhibiting ovulation rather than thickening the cervical mucus. Therefore, additional contraception is required for 48 hours with the POP and seven days with the COCP when starting after day 5 of the menstrual cycle. Both can be started within the first 5 days of the menstrual cycle and work immediately, as it is very unlikely a woman will ovulate this early in the cycle.

Answer 272

It takes **48 hours** before the progestogen-only pill **thickens the cervical mucus enough to prevent sperm entering the uterus,** protecting against pregnancy. The combined pill takes seven days before the woman is protected from pregnancy, as it works by inhibiting ovulation rather than thickening the cervical mucus. Therefore, **additional contraception** (i.e condoms) is required for 48 hours with the POP and seven days with the COCP **when starting after day 5** of the menstrual cycle. Both can be started within the first 5 days of the menstrual cycle and work immediately without the need for additional contraception, as it is very unlikely a woman will ovulate this early in the cycle. Remember however that the patient may need emergency contraception depending on sexual activity in the preceding days. **Sex since missing pill or sex within 48hrs of starting pop.**

Question 273

\_\_\_\_ is the implant used in the UK, it contains ___ mg of \_\_\_\_

Answer 273

**Nexplanon** **68mg** **Etonogestrel** (progestin)

Question 274

Implant and the Depot (DMPA) need extra contraception (i.e condoms) for ___ days if started after day 5 of the cycle.

Answer 274

7 days

Question 275

Benefits and Drawbacks of the Implant

Answer 275

**Benefits:** Permanent (3 yrs) and doesn't require adherence (perfect use and typical use both 99%) Can improve painful bleeding (i.e dysmenorrhoea) Can reduce bleeding and even amenorrhoea Does not cause weight gain Does not cause loss of BMD Does not increase risk of DVT No restrictions for obese patients **Drawbacks:** Invasive and insertion can be painful Can migrate and become impalpable (needs X-ray or ultrasound investigation) Does not protect against STI Can worsen acne Can cause problematic bleeding Implant can fracture or bend

Question 276

Contraindications to insertion of the IUS/IUD?

Answer 276

Pelvic Inflammatory disease or local infection (i.e STI etc) Immunosuppresion Uterine cavity distortion (fibroids etc) Pelvic cancer Pregnancy Unexplained bleeding

Question 277

The copper coil is notably contraindicated in ____ disease

Answer 277

Wilson's disease

Question 278

Benefits and Drawbacks of Copper Coil

Answer 278

**Benefits:** Permanent for 5-10 yrs depending on device Doesnt need adherence Very effective - 99% Perfect and typical use No Hormones (no VTE or cancer increase risk) Immediately effective once inserted May reduce endometrial/cervical cancer risk **Drawbacks:** Invasive Has certain risks w/ insertion (i.e bleeding/pain/uterine perforation/PID) Infection risk Menorrhagia or intermenstrual bleeding (often settles) No STI protection Increased risk of an Ectopic Can fall out (5%)

Question 279

All IUS devices provide contraception protection for ___ yrs except for ____ which provides protection for ___ yrs.

Answer 279

**5 yrs** **Jaydess** **3 yrs**

Question 280

Mirena and ___ coils are both licenced for menorrhagia. The Mirena coil can also be used for ____ .

Answer 280

Levosert HRT

Question 281

The IUS device can be inserted up to day ___ of the menstrual cycle without the need for additional contraception. If insertion is after this point, then exclude pregnancy and provide extra contraception for ___ days.

Answer 281

7 7

Question 282

Benefits and Drawbacks of IUS

Answer 282

**Benefits:** Can reduce menorrhagia/dysmenorrhoea and Pelvic pain related to endometriosis No BMD loss No increased risk of VTE No restrictions in Obesity **Drawbacks:** Invasive and requires procedure Does not protect against STI's Can cause spotting or irregular bleeding Ectopic risk Increase incidence of Ovarian cysts Systemic absorption can cause acne/breast tenderness and headaches Can fall out (5%) Can cause pelvic pain

Question 283

\_\_\_\_ organisms are often found incidentally in patients during a smear test when patients have a coil. Unless causing symptoms, this does not need to be treated.

Answer 283

**Actinomyces-like organisms** (ALO's)

Question 284

Ulipristal is of the _____ class and is contraindicated in which two conditions?

Answer 284

**Selective progesterone receptor modulator** (SPRM) **Breast feeding** (cannot breast feed for a week) **Asthma**

Question 285

What is the 1st line treatment of Pneumocystis Pneumonia in HIV patients?

Answer 285

**Co-trimoxazole** Side effects include: * Stevens-Johnson syndrome/TEN * Drug-induced lupus * Agranulocytosis

Question 286

What is the classical triad of pneumocystis pneumonia infection?

Answer 286

**Fever** **Non productive cough** (however can have superimposed bacterial infection) **Exertional breathlessness** associated with onset of infection \*\*\*Exertional breathlessness is a specific sign for PCP, and is used to stratify severity\*\*\*. On examination, the chest is often clear, however sometimes there are end inspiratory crackles present.

Question 287

The ___ sign is pathognomic of LGV (Lymphogranuloma Venereum)

Answer 287

"**Groove**" Sign LGV (subtype of chlamydia infection) begins with a painless ulcer which progresses to form painful inguinal buboes, causing the characteristic "groove" sign. This may be accompanied by **fever** and **malaise**. **Men who have sex with men** (MSM) are at **higher risk** of LGV.

Question 288

Missed pill rules: Use emergency contraception if she had UPSI in pill free interval. Week \_ No need for emergency contraception. Week \_ Take the last pill that was missed, finish the current pack and start the next pack immediately after. Week \_\_\_.

Answer 288

1 2 3

Question 289

\_\_\_\_ is first line for strong opioid analgesia in the **latent** first stage of labour.

Answer 289

**Diamorphine IM** It has the advantage of a rapid duration of onset (within 20 minutes) and lasts for 2-4 hours. Although **spinal epidural** is a valid form of analgesia, it is usually **not sited until the woman is in 'established labour'.**

Question 290

In HIV infection, ff the mother's viral load is \< ___ , a ___ delivery can be used. If the viral load is greater than this, a ___ is recommended

Answer 290

50 Normal Vaginal Delivery C-section

Question 291

What is the 1st line treatment for trichomoniasis (a flagellated single cell parasite of the protozoan species) infection?

Answer 291

**Metronidazole** (remember this is the same treatment for BV which is an important differential)

Question 292

CD4 count

Answer 292

500 cells/mm³ cART (combined antiretroviral therapy)

Question 293

An ovarian cyst is most likely to rupture during \_\_\_\_.

Answer 293

**Physical activity** (e.g. sexual intercourse, exercise).

Question 294

Genital warts are primarily caused by ____ serotypes 6 and 11.

Answer 294

Human Papilloma Virus

Question 295

Management of genital warts Depends on the wishes of the patient. If the patient is not concerned about their appearance, a conservative approach can be adopted. If there is concern, keratinised lesions can be removed using ____ whilst non keratinised lesions can be removed using \_\_\_\_\_, imiquimod or sinecatechins. The likelihood of recurrence is high.

Answer 295

Cryotherapy Podophyllotoxin

Question 296

\_\_\_\_\_ is the most common cause of epididymoorchitis in **older males**, which is often associated with urinary tract infections.

Answer 296

E.coli

Question 297

NICE recommend the use of ____ in the treatment of vaginal candidiasis in pregnancy

Answer 297

**Intravaginal clotrimazole**

Question 298

Changes to maternal physiology to consider when prescribing

Answer 298

This can also be described as pharmacokinetics as this is what the body does to the drug during pregnancy. i.e **Absorption** **Distribution** **Metabolism** **Excretion**

Question 299

Which contraceptives are a good alternative to COCP (lots of drug interactions) when prescribing in pregnancy?

Answer 299

Progesterone Only Pill IUD

Question 300

Pharmacokinetics can be described as \_\_\_\_ whilst Pharmacodynamics can be described as \_\_\_\_

Answer 300

Pharmacokinetics - what the body does to the drug Pharmaco**d**ynamics - what the **d**rug does to the body

Question 301

Pharmacokinetics during pregnancy

Answer 301

Note that not only is metabolism altered during pregnancy, **but renal clearance is also increased** dramatically due to the increased circulating blood flow and thus GFR. To summarize in pregnancy: Reduced/Slowed **Absorption** Increased Volume of **Distribution** (remember increased circulating blood volume and Fat:Water ratio) **Metabolism** and **Excretion**

Question 302

What are the main CYP450 enzymes

Answer 302

Percentage of drugs metabolised by these CYP450 subtypes: **CYP3A4 - 55%** **CYP2D6 - 30%** \* Concentrations of both these CYP450 enzymes **increases** during pregnancy leading to increased metabolism and thus renal clearance. This leads to a suboptimal concentration of the drug and thus therapeutic benefit\* CYP2D9 (10%) **CYP1A2** (3%) - \***Note this enzyme decreases** during pregnancy and thus can lead to toxicity of drugs administered that are also induced by CYP450\*

Question 303

Medications to avoid during pregnancy (teratogens)

Answer 303

**ACEIs -** Renal dysfunction, skull ossification. **Aminoglycosides -** Deafness, vestibular damage. **Cytotoxic drugs -** Multiple defects, abortion. **Anti-thyroid drugs** - Foetal goitre. **Carbamazepine -** Neural tube defects. **Diethylstilboestrol -** Vaginal carcinoma. **Lithium -** CVS defects (_Ebstein anomaly_ - abnormal *tricuspid* valve_)_ **Phenytoin-** Foetal hydantoin syndrome. **Retinoids** - Craniofacial, cardiac & CNS defects. **Sodium valproate -** Neural tube defects. **Warfarin -** Foetal warfarin syndrome.

Question 304

Drugs to avoid in 3rd trimester

Answer 304

**•Tetracyclines:** Tooth discolouration. **•Warfarin:** Foetal intracranial haemorrhage. **•Androgens:** Masculinisation of female foetus. **•NSAIDs**: Closure of foetal ductus arteriosus. **•Opioids**: Withdrawal effects in neonate. **•Theophylline:** Neonatal irritability. **•SSRIs:** Neonatal irritability.

Question 305

\_\_\_ and ___ are the anti-epileptics considered to be safe in pregnancy (usual maintenance dose). Soldium valproate can only be used if there is a _____ but is generally contraindicated unless prescribed under the guidance of a specialist due to its teratogenic effects.

Answer 305

**Lamotrigine** (more evidence) \> **Levetiracetam** **Valproate pregnancy prevention programme** in place

Question 306

What is the diagnostic test of choice for soemone suspected of having Chlamydia infection?

Answer 306

NAAT (Nucleic acid amplification test)

Question 307

1st line antibiotic for the treatment of chlamydia?

Answer 307

Doxycycline (100mg BD 7 days) \*Azithromycin no longer recommended due to bacterial resistance\*

Question 308

For \< ____ yo repeat screening is offered for chlamydia infection. This is to test for re-infection (not whether treatment has worked for original infection).

Answer 308

25's

Question 309

\_\_\_\_\_ (LGV) is a sexually transmitted disease, found in tropical areas. Chlamydia trachomatis serovars ____ cause lymphatic destruction of genital tissues,leading to a painless non-indurated lesion on the penis, followed by the '\_\_\_\_ sign'. This is swelling of the inguinal ligament, leading to noticeable grooves above and below. **Investigations** Diagnosis is carried out using PCR (NAAT) of the ulcers **Management** Treatment is with \_\_\_\_

Answer 309

**Lymphogranuloma Venereum** **L1/L2/L3** **Groove** **Doxycycline.** \*LGV has a slightly older demographic than other STI's affecting primarily men between the ages of 25-40\*

Question 310

\_\_\_ sign is when an inguinal lymphoadenopathy (AKA a BUBO) is split by poubarts ligament and is pathognomonic of ____ infection.

Answer 310

Groove Sign Lymphogranuloma Venereum

Question 311

How do we investigate a patient with suspected gonorrhoea?

Answer 311

NAAT Microscopy is possible unlike chlamydia and you may see gram negative diplococci however whilst microscopy is 90% sesistive in men with discharge it is only 50% sensitive for women. - Anyone with a positive NAAT needs to be swabbed in an areas of sexual contact for culture.

Question 312

\_\_\_\_ (1st line) and ___ are the antibiotics of choice in gonorrhoeal infection. A test of cure is recommended ___ weeks after treatment to monitor disease clearance and decide on whether the antibiotic regimen used was effective or needs altering

Answer 312

The current guidance on treatment recommends treatment with both **Ceftriaxone (1st line)** and **Azithromycin (lots of resistance to this strain atm)** to cover possible Chlamydia co-infection A test of cure is recommended to monitor disease clearance **2 weeks after treatment** and decide on whether the antibiotic regimen used was effective or needs altering. All partners should be notified with permission from the patient. Partners only treated empirically if they have **had sex in last 14 days**

Question 313

Complications of STI's (Chlamydia and Gonorrhoea)

Answer 313

**PID** (sepsis - subfertility - Ectopic risk) **Epididymo-Orchitis** (EO) SARA (Sexually Acquired **Reactive Arthritis**) **Perihepatitis** (_Fitz-Hugh-Curtis syndrome_) **HIV risk** Gonorrhoea can also cause a disseminated rash. _Untreated_ gonorrhoea can lead to major complications, such as: Infertility in women: Gonorrhoea can spread into the uterus and fallopian tubes, causing pelvic inflammatory disease (PID). PID can result in _scarring of the tubes, greater risk of pregnancy complications and infertility_. Infertility in men: Gonorrhoea can cause a small, coiled tube in the rear portion of the testicles where the sperm ducts are located (epididymis) to become inflamed (epididymitis). _Untreated epididymitis can lead to infertility._ Infection that spreads to the joints and other areas of the body: The bacterium that causes _gonorrhoea can spread through the bloodstream and infect other parts of your body_, including your joints. _Fever, rash, skin sores, joint pain, swelling and stiffness_ are possible results. _Increased risk of HIV/AIDS_: Having gonorrhoea makes you more susceptible to infection with human immunodeficiency virus (HIV), the virus that leads to AIDS. People who have both gonorrhoea and HIV are able to pass both diseases more readily to their partners.

Question 314

\_\_\_\_\_ is a tiny bacteria that can cause a non specific urethritis and can present similarly to other STI's like gonorrhoea and chlaymdia. However it is often asymptomatic. Can be tested for using ____ and is treated similarly to chlamydia in uncomplicated infection with \_\_\_\_. However Complicated infection needs to be managed with a different antibiotic called \_\_\_\_

Answer 314

**Mycoplasma Genitalium** **NAAT** **Doxycyline + Azithromycin** **\*\*****Moxifloxacin\*\*** (14 days OD)

Question 315

Primary syphillis often present around ___ weeks after initial infection with a \_\_\_\_.

Answer 315

**3 weeks** **Chancre** **\***often described as **single painless indurated\***

Question 316

Secondary syphillis most commonly presents around ____ after initial infection. Most common symptom is a _____ (75%) Wart like lesions called \_\_\_\_\_ _Mucocutaneous lesions_ (6-30%) Generalised l**_ymphadenopathy_** (50-86%) _Multi-system involvement_- Sore throat, malaise, weight loss, fever, musculoskeletal.

Answer 316

**3 months** **Maculopapular Rash** **_\*\*Condylomata lata\*\*_** Multisystem involvement can also lead to _nephritis/hepatitis_ etc and often can cause _neurological symptoms_ (tinnitus/ocular syphillis/stroke)

Question 317

_Tertiary Syphillis_ leads to: **Cardiovascular** (\_\_\_\_ yrs after initial infeciton) * Symptomatic/complicated in 10% * Ascending aorta: dilatation & aortic regurgitation * Rarely: coronary ostial stenosis, saccular aneurysm \_\_\_\_\_ (2-15 years after inital infection) • ____ lesions with central necrosis

Answer 317

**10-30** **Gummatous** **Granulomatous**

Question 318

**Neurosyphillis (3 types)**  _____ (15-25 years) Lightening pains, sensory ataxia, _____ Pupil  **General Paresis** (10-25 years) Progressive severe _dementia_ with _seizures_  **Meningo-vascular** (2-7 years) Often affects _younger_ patients \_\_\_\_ artery most commonly affected Focal arteritis leading to ischaemic stroke Prodrome of headache, labile emotions, insomnia

Answer 318

**Tabes Dorsalis (type of neurosyphillis)** **Argylle- Robertson** pupil (_dilates to accommodation but not light_) MCA -middle cerebral artery

Question 319

Syphillis can be diagnosed using ____ microscopy or \_\_\_\_.

Answer 319

**\*\*_Dark Ground_\*\*** Microscopy (useful only for penile chancres) **NAAT** (pcr) Cna also do serology (i.e blood test)

Question 320

The _____ reaction is a classical reaction to penicillin treatment in syphilis infection. The reaction occurs within ____ hours and is characterized by **fever, rash, rigors and tachycardia.** It is thought that as the bacteria are lysed by the antibiotic, they secrete an _endotoxin which can cause an inflammatory response_ It does not occur in all cases, but it is imperative to warn patients that this may occur during treatment.

Answer 320

**Jarisch-Herxheimer** **24 hours** Management Should a patient experience serious symptoms, it is advisable to **admit and monitor the patient and hydrate as required** Jarisch Herxheimer reaction (JHR) is a transient clinical phenomenon that occurs in patients infected by spirochetes who undergo antibiotic treatment. The reaction occurs within 24 hours of antibiotic treatment of spirochete infections, including **syphilis, leptospirosis, Lyme disease, and relapsing feve**

Question 321

Syphillis follow up: **Primary Syphilis** • All partners in last \_\_\_\_ **Secondary and Early latent Syphilis** • All partners in last \_\_\_ **Late Latent and Tertiary Syphilis** • Guided by previous serology but potentially all previous partners \*Serology is monitored for 12 months whilst on treatment to see that levels of bacteria are falling appropriately\*

Answer 321

**3 months** **2 years**

Question 322

Clinical Features of HSV

Answer 322

**Genital ulcers** (painful) **Dysuria** **Mouth ulcer**s **Prodromal illness** (fever flu like symptoms) Vaginal or Penile **discharge** **Lymphadenopathy** (first episode bilateral - recurrent infection - unilateral)

Question 323

Extragenital manifestations of HSV?

Answer 323

**Neurological:** Meningitis Encephalitis **Dermatological:** \**_dermatitis herpetiformis_*\* \*_herpetic whitlow_\* **Ophthamological:** Herpetic eye disease (_dendritic_ corneal ulcers)

Question 324

Diagnosis of HSV is made using \_\_\_

Answer 324

1st line: ***Viral PCR of skin lesions*** Can also used: Serology - IgG Sometimes culture can be used

Question 325

Pregnant women with HSV are offered ____ at 36 weeks gestation to minimise risk of passing to fetus.

Answer 325

**Aciclovir** \*Risk of neonatal herpes is much increased if mother acquires HSV during pregnancy. This is because there is not enough time to produce the IgG antibody that would protect the baby\* - in this case **aciclovir and C-Section** would be offered to mother to reduce the risk of transmission.

Question 326

**HPV** \_\_\_\_\_ (low risk strains often cause benign neoplasia ex. **condylomata**) \_\_\_ (high risk strains often cause Intraepithelial Neoplasia in the vulva, cervix, anus etc)

Answer 326

**6 and 11** **16 and 18** (McCarthy and Schneiderlinn) ***Cervarix*** (bivalent) immunises against two types: 16 and 18. ***Gardasil***: protects against 6, 11, 16 and 18

Question 327

Management of HPV (genital)?

Answer 327

**Cryotherapy** (irritates and stimulates surrounding skin mounting immune response) **Topical Agents** (Imiquimod) **Electro-cautery** **Surgery** **Nothing** (30% wil disappear) \*Gynae referral if suspect Intraepithelial Neoplasia\*

Question 328

All acute hepatitis infections are notifiable illnesses for public health.

Answer 328

Question 329

Hepatitis B Serology Interpretation: Surface antigen (HBsAg) – \_\_\_\_\_ E antigen (HBeAg) – \_\_\_\_\_ Core antibodies (HBcAb) – ____ (acute infection antibody ___ Chronic infection antibody \_\_\_) Surface antibody (HBsAb) – \_\_\_\_\_ Hepatitis B virus DNA (HBV DNA) – \_\_\_\_\_

Answer 329

**Surface antigen** (HBsAg) – **active infection** **Envelope antigen** (HBeAg) – marker of viral replication and implies **high infectivity** **Envelope antibody** (HBeAb) **- stopped replicating** **Core antibodies** (HBcAb) – implies **past or current infection (IgM** high in **acute infection / IgG** high in **chronic or cleared** infection ) **Surface antibody** (HBsAb) – implies vaccination or past or current infection **Hepatitis B virus _DNA_** (HBV DNA) – this is a direct count of the viral load \*remember Hep B is only DNA virus\*

Question 330

Management of Hepatitis B

Answer 330

_Antivirals_ 1st line: **Peginterferon** 2nd line: **Tenofovir or entecavir** Also **screen for co-infection of Hep D** and **Refer to Hepatology**

Question 331

Hepatitis B is the only ____ virus.

Answer 331

**DNA**

Question 332

Which type of hepatitis does not have an available vaccine?

Answer 332

Hepatitis C This disease is now CURABLE with antiviral treatment

Question 333

Investigations in Hep C infection?

Answer 333

Hep C Antibody Hep C RNA load (PCR)

Question 334

Acute and Chronic Hepatitis C Infection features: Most infections are _____ , and only ____ clear the virus. ___ go on to develop chronic infection Patients with chronic infection have persistently high LFTs, and ____ develops in 20-30%. 1-4% of patients with cirrhosis develop ____ , and 2-5% develop liver failure.

Answer 334

**asymptomatic** **15-25%** **75%** **cirrhosis** **hepatocellular carcinoma**

Question 335

Most common type of vulval cancer?

Answer 335

**Squamous cell carcinoma** Possible to also get: Adenocarcinoma (bartholin's/Paget's - premalignant condition) Basal Cell Carcinoma Malignant Melanoma \*thing to remember with vulval cancer is its essentially a skin cancer\*

Question 336

2 biggest risk factors for vulval cancer?

Answer 336

**Lichen Planus**/**Lichen Sclerosis** (5% Lifetime Risk) _and_ **HPV** (16, 18 and 32)

Question 337

Fetal heartbeat can be heard via TV ultrasound from as early as ____ weeks

Answer 337

**6 Weeks**

Question 338

Management of Misscarriage

Answer 338

Question 339

Most common site of ecotpic pregnancy?

Answer 339

Ampulla of fallopian tube

Question 340

Clinical presentation of Ectopic

Answer 340

Remember blood is usually brown due to decidua breaking down

Question 341

Management of Ectopic Pregnancy

Answer 341

**Medical Management:** _1st line_ (unless patient very unwell) - one-off dose of ***_methotrexate_***. (The woman is required to come to a follow-up appointment) If the initial dose of methotrexate has failed to treat the ectopic they will require either a second dose of methotrexate or surgical management. **Surgical Management:** Surgical management is recommended if the patient would be unable to attend follow-up or if the ectopic is advanced. An advanced ectopic is indicated if any of the following are present: The patient is in a **significant amount of pain** There is an **adnexal mass of size ≥35mm** **B-hCG levels are ≥5000IU/L** (consult local guidelines) **Ultrasound** identifies a **foetal heartbeat** Surgical management is often in the form of a _salpingectomy_ where the Fallopian tube containing the ectopic is removed, **unless only one functioning Fallopian tube, and they wish to remain fertile**, a _salpingotomy_ may be done where only the ectopic is removed. Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are done to exclude any trophoblastic tissue still within the Fallopian tube.

Question 342

Classic presentation of Placental abruption

Answer 342

Remember often much more **painful** than placenta praevia * Can be _concealed_ and thus get _no blood_ * Woody as in hard because of uterine spasms (contracted muscle)

Question 343

Risk factors for placenta praevia

Answer 343

Main one is Previous C-Section

Question 344

Management of pre-eclampsia

Answer 344

1st line: **Labetalol** (contraindicated in asthma) - Nifedipine/Methyldopa **Delivery**

Question 345

Biggest risk factor for Uterine rupture? (occurs during delivery - no contractions/pain)

Answer 345

Vaginal delivery after previous C-Section

Question 346

Management of a Uterine Rupture?

Answer 346

**Emergency Laporotomy**

Question 347

What is the main differential for a amniotic fluid embolism?

Answer 347

**PE** \*Remember Amniotic Fluid Embolism is extremely rare\* Management: **Delivery** (Category 1 C-Section) and **Resus** mother

Question 348

What is the management of Shoulder Dystocia?

Answer 348

**Call for help** Ask mother to **stop pushing** 1st line - **McRoberts Manoevre** (90% successful) 2nd line: All-fours position Internal rotational manoeuvres: Woods' screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back. Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest.

Question 349

If External Cephalic Version (ECV) at 37 weeks is declined, what risk is the pregancy at?

Answer 349

**Umbilical Cord Prolapse** High risk of fetal mortality as placental blood supply is compromised (often bradycardia on ECG)