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Obs and Gynae Flashcards

1
Q

Outline the Hypothalamic-Pituitary-Gonadal Axis in females.

A

Hypothalamus releases GnRH which stimulates the Anterior Pituitary to produce and release LH and SH

FSH binds to granulosa cells to drive follicle development in the ovaries, oestrogen and inhibin secretion

LH binds to theca cells to produce testosterone

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2
Q

At what level does Inhibin inhibit FSH at?

A

Anterior pituitary

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3
Q

At what level does oestrogen inhibit the HPG axis?

A

Hypothalamus

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4
Q

What is the most common form of oestrogen in the body?

A

17-beta oestradiol

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5
Q

Where is progesterone produced?

A

Corpus luteum - following ovulation

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6
Q

At what point of gestation does progesterone production site switch?

A

Placenta at 10 weeks

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7
Q

Which hormone has a role in thermoregulation?

A. Oestrogen

B. LH

C. FSH

D. Progesterone

A

D

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8
Q

What is the relationship between body fat and puberty in young girls?

A

Body fat = WAT = aromatase which produces oestrogen

BMI&raquo_space;> = precocious puberty e.g. PCOS

BMI «< = delayed puberty e.g. Anaemia; Anorexia

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9
Q

What staging system may be used in female puberty?

A

Tanner Staging

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10
Q

What hormonal changes occur during puberty?

A

Oestrogen increase

GnRH

FSH

LH

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11
Q

What is the event determining the phases of the menstrual cycle?

A

Ovulation

Follicular phase (1-14)

Luteal phase (14-28)

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12
Q

What follicular transition does FSH catalyse?

A

Secondary follicle to Antral follicle (Graafian follicle)

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13
Q

What hormone is responsible for ovulation?

A

LH causes the dormant follicle to release an ovum

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14
Q

What structure becomes the corpus luteum?

A

The follicle releasing the ovum becomes the corpus luteum, severing high levels of progesterone

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15
Q

Which structure is responsible for ßhCG release early on in pregnancy?

A

Syncytiotrophoblast

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16
Q

What is the structure of the primordial follicle?

A

Pregranulosa cells surround with a layer of basal lamina

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17
Q

What are the layers of the primary follicle?

A

3 layers:

  • Oocyte
  • Zona pellucida
  • Granulosa cells
  • Theca cells
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18
Q

what type of epithelium is present in a primary follicle?

A

Simple Cuboidal Epithelium - secreting into the zona pellucida

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19
Q

What is the outer layer of a primary follicle?

A

Theca layer - theca externa (CT) and theca interna (androgen hormones)

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20
Q

Outline the physiology of ovulation.

A

The LH surge results in LH binding to the theca externa which causes CT and SMC to contract which results in the follicle rupturing

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21
Q

What layers of the follicle does the sperm penetrate to fertilise the egg?

A

Corona radiata and zona pellucida

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22
Q

Which part of the blastocyst binds to the endometrium?

A

The syncytiotrophoblast

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23
Q

What are the layers of the chorion?

A

Cytotrophoblast

Syncytiotrophoblast

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24
Q

Outline the process of embryo development.

A

The morula becomes a blastocyst. The blastocyst comprises of an embryo blast, a blastocoele and trophoblast.

The syncytiotrophoblast layer (of the trophoblast) implants into the endometrium.

The embyroblast (ICM) splits into two sacs of the yolk sac and amniotic sac. The embryonic disc separates these two areas.

5 weeks gestation, embryonic disc develops into a foetal pole with 3 layers: ectoderm, mesoderm and endoderm

6 weeks, foetal heart develops (mesoderm) and begins to beat. The spinal cord and muscles develop.

At 8 weeks, all major organs have begun to develop

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25
Which of the following is not a structure derived from the endoderm? A. Pancreas B. Thyroid C. Liver D. Kidneys
D - these are a mesodermal structure
26
Which of the following is not of endodermal origin? A. Duodenum B. Liver C. Lungs D. Heart
D
27
Which of the following is not a mesodermal structure? A. Heart B. Bone C. Blood D. Nervous system
D
28
List 3 structures of ectodermal origin.
Hair Nails Teeth CNS
29
What cells become the placenta?
Chorion frondosum - cells located near connecting stalk of developing embryo
30
What structure is the umbilical cord derived from? A. Chorion frondosum B. Mesoderm C. Yolk sac D. Connecting stalk
D
31
What is the pathophysiology of pre-eclampsia in embryological development?
The formation of lacunae involves trophoblast invasion of the endometrium which results in spiral arteries breaking down to form lacunae. Blood flows into lacunae via uterine arteries, drained by uterine veins. Improper lacunae formation results in pre-eclampsia with elevated SVR in spiral arteries thus rise in maternal blood pressure
32
State 5 functions of the placenta.
Respiration: oxygen supply via uterine arteries and umbilical vein. HbF has higher affinity cf adult Hb thus O2 dissociation curve shifted to LHS. Nutrition: glucose, vitamins, minerals (or other substances...harmful) Excretion: urea and creatinine Endocrine: hCG; Oestrogen; progesterone Immunity: Abs
33
What side effects may progesterone cause in pregnancy?
Potent vasodilator Relaxation of uterine muscle GORD (relaxation of cardiac sphincter) GI dysmotility Headache Strengthen pelvic wall muscles Prevent lactation Immunosuppression (prevent maternal rejection of trophoblast)
34
A mother is experiencing recurrent genital herpes, would her foetus be protected and why?
In recurrent genital herpes, the mother is producing antibodies to the HSV which may cross the placenta and protect the baby. This immunity is not conferred in the absence of reinfection to the mother as Abs are not being produced.
35
A 34 y/o F patient (G3P2) is pregnant (G32+4). Her PMHx consists of asthma and rheumatoid arthritis. However, she reports an improvement in her joint pain. Explain why this may be.
In pregnancy, the anterior pituitary secretes increased ACTH, prolactin and MSH. ACTH elevation increases cortisol and aldosterone secretion which can partially alleviate symptoms of autoimmune conditions
36
Why may linea nigra and melasma occur in pregnancy?
Increased MSH from the anterior pituitary results in pigmentation of the skin
37
Which of the following is not a cardiovascular change during pregnancy? A. Increased plasma volume B. Decreased peripheral vascular resistance C. Varicose veins D. Decreased cardiac output
D - CO is increased
38
Which of the following is not a renal change in pregnancy? A. Increased eGFR B. Increased aldosterone C. Decreased protein excretion D. Physiological hydronephrosis
C - increased proteinuria (<0.3g/24 hours)
39
Which of the following is not a haematological change in pregnancy? A. Erythropoeisis B. Increased fibrinogen C. Increased white blood cells D. Normal ALP
D - ALP may increase up to x4 due to placental secretion
40
Which of the following is not a dermatological change observed in pregnancy? A. Striae gravidarum B. Melasma C. Palmar erythema D. Jaundice
D - may indicate obstetric cholestasis
41
If the cervix is 7cm dilated, what stage of pregnancy are they at? A. Second B. Third C. First D. Fourth
C - <10cm = stage 1
42
If the placenta has not been delivered, what stage of pregnancy is the lady in? A. First B. Second C. Third D. None of the above
B
43
What supportive measures may be used to manage Braxton-Hicks contractions?
Hydration Relaxing
44
Which of the following statements is false? A. The latent phase is from 0-3cm of cervical dilation with irregular contractions B. The active phase is from 3-7cm cervical dilation with regular contractions C. The transition phase occurs from 7-10cm dilation with strong and regular contractions D. The latent phase progresses at 1cm per hour
D - the latent phase is 'late' thus slower, at 0.5cm/hour
45
What are the three Ps of the second stage of labour?
Passenger> Size; attitude (posture); lie and presentation Passage: size + shape of pelvis Power: strength of uterine contractions
46
What is the difference between a complete breech presentation and a frank breech presentation?
In a complete breech, the hips and knees are flexed (cannonball position) whilst in a frank breech the hips are flexed and the knees are extended (bottom first)
47
What are the cardinal movements of labour?
Engagement Descent Flexion IR Extension ER Expulsion
48
How can you characterise descent?
Descent can be determined by position of baby's head in relation to maternal ischial spines during descent phase (cm) -5 = high up in pelvic inlet 0 = head at ischial spines +5 = foetal head descended
49
What is the indication for active management of the third stage of labour? What does this involve?
Haemorrhage 60 minute delay of placental delivery Deliver of IM Oxytocin to stimulate myometrial contraction + umbilical cord traction
50
Which of the following is not a cause of secondary amenorrhoea? A. Cushing's Disease B. Contraception C. Low body weight in the 20s D. Imperforate hymen
D
51
Which of the following is not a cause of secondary amenorrhoea? A. Cushing's Disease B. CAH C. Low body weight in the 20s D. PCOS
B
52
Which of the following is not a cause of primary amenorrhoea? A. Congenital malformation of genital tract B. Contraception C. CAH D. Imperforate hymen
B
53
Which of the following is an unlikely cause of IMB? A. STI B. Malignancy C. Ectropion D. Tampon insertion
D - unlikely to cause bleeding between periods. Would be inserted during period and not likely to cause trauma resulting in bleeding
54
Give 3 causes of dysmenorrhoea.
``` Copper coil Fibroids Endometriosis PID STI Malignancy (cervical/ovarian) ```
55
Give 3 causes of postcoital bleeding.
Trauma Atrophic vaginitis STI Malignancy
56
Give 10 causes of pelvic pain in a female.
``` IBS IBD Prolapse Pelvic adhesions Appendicitis Dysmenorrhoea Mittelschmerz PID UTI Ectopic pregnancy Ovarian torsion Endometriosis ```
57
Give 5 causes of pruritus vulvae.
``` STI Irritants - soaps, underwear Candidiasis Eczema Lichen sclerosus (white plaques and itch) Stress Vulval malignancy Urinary/faecal incontinence ```
58
How may amenorrhoea be classified?
Primary (no menstruation by 15 + secondary sexual characteristics OR no menstruation by 13 with no secondary sexual characteristics) Secondary: cessation for 3-6 months (normal periods) or 6-12 (oligomenorrhoea)
59
What is the initial investigation to conduct in a 30 year old female presenting with amenorrhoea? A. Gonadotrophins B. ßhCG C. Prolactin D. Androgen levels
B - pregnancy until proven otherwise
60
Which of the following is not a hypogonadotropic hypogonadism? A. Hypopituitarism B. Cystic fibrosis C. Turner's Syndrome D. Kallman Syndrome
C - this is a hypergonadotropic hypogonadism due to gonads failing to respond to gonadotrophin stimulation
61
What clinical features are associated with Kallman Syndrome?
Anosmia + Amenorrhoea
62
Which investigations may be used in a patient with amenorrhoea?
``` Pregnancy test FBC U+Es Anti-TTG/anti-EMA (Coeliac) FSH/LH TFTs IGF-I (GH deficiency) Testosterone (PCOS; Androgen insensitivity; CAH) Genetic testing (Turner's syndrome) XR (constitutional delay) Pelvic-US MRI-Brain ```
63
How may you medically manage a Prolactinoma?
DA agonists to suppress PL secretion e.g. Bromocriptine
64
How often are withdrawal bleeds required in women with PCOS and why?
3-4 months to reduce risk of endometrial hyperplasia and endometrial cancer Done via medoxyprogesterone (14 days) or COCP regularly
65
What are the clinical features of premenstrual syndrome?
anxiety stress fatigue mood swings bloating breast pain
66
How can you manage premenstrual syndrome?
Supportive: sleep; exercise; smoking cessation; frequently and balanced meals + Medical: COCP; SSRI
67
What phase of the menstrual cycle is premenstrual syndrome experienced?
Luteal phase, prior to endometrial breakdown
68
A 34 year old woman is presenting with menorrhagia for the 3/12. She has had the same partner for the last 12 years and is monogamous. She uses barrier contraception and has no other symptoms. PV examination is unremarkable. Her pregnancy test is negative. Her bloods are unremarkable as are swabs. What is your differential?
Dysfunctional uterine bleeding
69
How may menorrhagia be managed?
Decide on whether contraception is required. Required: - IUS (mirena coil) - COCP - LARC with progesterone Not required: - Mefenamic acid 500mg TDS (if pain) - TXA (no pain)
70
What surgical management of menorrhagia exists?
Balloon thermal ablation/Endometrial ablation Hysterectomy
71
Which ethnic minority is associated with uterine fibroids?
Afro-caribbean women
72
Why may polycythaemia be a clinical feature of uterine fibroids?
Ectopic EPO production
73
What is the gold-standard investigation to confirm Uterine fibroids? A. Surgical exploration B. TV-US C. Transabdominal Ultrasound D. Clinical examination
B
74
What is the gold-standard management of menorrhagia secondary to fibroids? A. Ullipristal B. NSAIDs C. LNG-IUS D. Uterine artery embolisation
C
75
What treatment may be used to shrink/remove fibroids?
Medical: Gorsorelin ± Surgical: Myomectomy; Hysteroscopic endometrial ablation; Hysterectomy; Uterine artery embolisation
76
What are the RFs of red degeneration?
2nd/3rd trimester pregnancy Large leiomyoma (>5cm)
77
What is the management of a uterine fibroid that is 4cm?
Uterine fibroids >3cm requires a referral to a gynaecologist Supportive: NSAIDs; Mefenamic acid (pain); TXA (no pain) + Medical: Mirena coil; COCP ± Surgical: Myomectomy; Hysterectomy; Uterine artery embolisation
78
What are the complications of fibroids?
``` Menorrhagia continued - iron deficiency anaemia Reduced fertility Pregnancy complications Constipation Urinary outflow obstruction UTIs Red degeneration Torsion Malignancy - leiomyosarcoma ```
79
What are the clinical features of red degeneration of fibroids?
N/V Severe abdominal pain Low-grade fever Tachycardia
80
What is the gold-standard investigation for endometriosis?
Laparoscopy
81
Give 5 clinical features of endometriosis.
Chronic pelvic pain Dysmenorrhoea Deep dyspareunia Subfertility Urinary symptoms (dysuria; urgency; haematuria) Dyschezia Tender nodularity in posterior vaginal fornix and visible vaginal endometriosis lesions may be observed
82
What is the first line management of endometriosis?
NSAIDs/Paracetamol COCP/Progesterone
83
When should a patient be referred to gynaecology for endometriosis? What may they do?
Failed analgesia/hormonal Tx or fertility concerns Medical: GnRH analogues or Surgery: Laparoscopic excision; Laser ablation
84
A 42 year old lady G3P2 presents with painful menstruation and heavy bleeding for 8/12. She is on no contraception, has one partner, has no discharge or pruritus. She reports no risky behaviour. O/E she has an enlarged boggy uterus. What is your DDx? A. Fibroids B. Endometriosis C. Adenomyosis D. Menopause
C
85
What is the gold-standard diagnosis of adenomyosis?
Histological examination as shows endometrial tissue in the myometrium
86
What are the associations of adenomyosis?
``` Infertility Miscarriage Pre-term birth SGA PPROM Malpresentation LUTS PPH ```
87
When is contraceptive recommended in menopause?
12 months following last period if >50 24 months following last period if <50 years
88
What are the clinical features of menopause?
Change in menstruation - oligomenorrhoea; amenorrhoea Vasomotor symptoms - hot flushes; night sweats Urogenital changes - vaginal dryness and atrophy; urinary frequency Psychological - mood change OP IHD
89
How is menopause diagnosed?
Absence of period for 12 months with the presence of perimenopausal symptoms and the absence of an unlikely diagnosis
90
How is menopause managed?
Supportive: exercise; weight management; stress reduction; sleep; vaginal lubricant; self-help + Medical: topical/TD oestrogen (if uterus present); oral oestrogen (if hysterectomy); SSRIs Tx other Sx
91
Why is oral oestrogen contraindicated in women without a TAH?
Risk of endometrial cancer
92
What are the risks associated with HRT?
VTE Stroke CHD Breast cancer Ovarian cancer Endometrial cancer Risk can be mitigated with topical/transdermal HRT
93
What difference does tapering HRT compared to a sudden reduction in HRT make?
Gradual reduction (tapering) reduces risk of recurrence in short-term but long-term no difference in symptom control
94
When should a woman be referred to secondary care?
She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.
95
A woman asks what the causes of her postmenopausal bleeding may be. What do you tell her? What investigations would you conduct?
Numerous causes for postmenopausal bleeding, more commonly vaginal atrophy, HRT side effect, endometrial hyperplasia, trauma, bleeding disorders Or more worryingly, endometrial cancer, ovarian cancer, cervical cancer or vulval cancer. Hx + CEx Ix: - Urgent referral if >55 years - FBC - CA-125 - TV-US (>5mm thickness or high clinical suspicion) - Endometrial biopsy (hysteroscopy or aspiration biopsy)
96
When is the defined period of perimenopause?
Symptomatic onset to 12 months following the last period
97
What are the long term complications of menopause?
Reduced oestrogen levels thus impact on BMD and atherosclerosis so: Osteoporosis Ischaemic Heart Disease
98
How is menopause managed?
Manage with supportive (lifestyle) changes, HRT and non-HRT - largely treating the symptoms of menopause Supportive: Regular exercise; weight loss; stress coping mechanisms; counselling + Medical: HRT; vaginal oestrogen; SSRIs
99
What are the indications for HRT?
Vasomotor symptoms such as flushing, insomnia and headaches Premature menopause
100
What is the benefit of using Tibolone as HRT?
Both oestrogenic and progesterogenic activity with androgenic activity also
101
What route of HRT is preferable in a woman at risk of VTE?
Transdermal route
102
What are the contraindications of HRT?
History of breast cancer Current breast cancer Oestrogen-sensitive cancer Undiagnosed vaginal bleeding Untreated endometrial hyperplasia
103
What are the risks of HRT?
VTE - no increased risk with transdermal Stroke CHD - combined HRT may be associated with slightly increased risk Breast cancer - risk of dying not increased Ovarian cancer CVD + Cancer Mnemonic: HRT is associated with the 2 C's
104
What is premature ovarian insufficiency?
Reduction in oestrogen and elevated FSH/LH prior to 40 years. 1% prevalence
105
Give 5 causes of premature ovarian insufficiency.
Idiopathic (most common - 50%) Iatrogenic: Bilateral oophorectomy; Radiotherapy; Chemotherapy Infection e.g. Mumps; TB; CMV Autoimmune conditions: Thyroid; T1DM; Coeliac; Adrenal insufficiency Genetic: Turner's Syndrome
106
What type of hormonal disturbance is seen in premature ovarian insufficiency? A. Hypergonadotropic hypogonadism B. Hypogonadotropic hypogonadism C. Hypergonadotropic hypergonadism D. No change
B - Hypogonadism results in lock of negative feedback on the pituitary gland, thus HPG axis is accelerated leading to excess GnRH with subsequent LH and FSH produced
107
Which of the following is not a clinical feature of premature ovarian insufficiency? A. Oligomenorrhea B. Vaginal dryness C. Hot flushes D. Pregnancy
D
108
How is premature ovarian insufficiency managed?
HRT - treat like menopause
109
What is the diagnostic criteria for Premature Ovarian Insufficiency?
Younger than 40 years Menstrual symptoms Elevated FSH - >25IU/L on two consecutive samples 4 weeks apart
110
What is Premature Ovarian Insufficiency associated with?
CVD Stroke Osteoporosis Cognitive impairment Dementia Parkinsonism
111
What is the pathophysiology regarding Premature ovarian insufficiency and Dementia?
Oestrogen has beneficial effects on the brain in a cellular and molecular manner thus reduced oestrogen may compromise these effects. ∆ Synaptic plasticity Cerebral blood flow Anti-oxidative effect Anti-atherogenic effect - improves endothelial cell function; reduces SMC proliferation and reduces inflammation
112
What is the pathophysiology regarding Premature Ovarian Insufficiency and Parkinsonism?
Oestrogen has a beneficial effect on neurological functioning at the cellular, molecular and tissue level. A reduction in these, reduces the neuronal functioning. Reduced protection against neurotoxic substances Reduced anti-oxidative effects Reduced neurotrophic factors Reduced protection of dopaminergic neurones
113
What diagnostic criteria is used in Polycystic Ovarian Syndrome?
Rotterdam Criteria: - Multiple cysts (>12 with 2-9cm or 1 >9cm) - Oligoovulation/Anovulation - Hyperandrogenism (acne/hirsutism)
114
What are the clinical features of PCOS?
- Oligomenorrhoea/Amenorrhoea - Anovulation thus Infertility - Obesity - Hirsutism - Acne - Hair loss in a male pattern (androgenic alopecia) Other: - Insulin resistance/Diabetes mellitus - Acanthosis nigricans - Dyslipidaemia - OSA - Metabolic syndrome - Sexual problems - Mood disorder
115
Give 3 other causes of hirsutism.
Iatrogenic: Testosterone; Anabolic steroids; Glucocorticoids; Ciclosporin; Phenytoin Ovarian/Adrenal tumours Cushing's Syndrome Congenital Adrenal Hyperplasia
116
What is the pathophysiology regarding insulin resistance and androgen secretion in PCOS?
Insulin resistance results in hyperinsulinaemia due to increased pancreatic secretion. The excess insulin can promote androgen release from ovaries and adrenal glands. Additionally insulin depresses SHBG from the liver. 1) Increased androgens 2) Reduced SHBG (thus increased FAI)
117
Calculate the free androgen index of a patient with: Total testosterone = 200 SHBG = 20
FAI = (T/SHBG) x 100 = (200/20) x 100 = 10% Normal can be 0.18-7%
118
What is the gold-standard investigation in PCOS?
TVUS >12 cysts of 2-9cm or 1 cyst >10cm
119
What radiographic find may be seen in PCOS? What imaging modality is this usually seen on?
"String of pearls" sign seen on TVUS
120
What is the screening test for diabetes mellitus in PCOS? What are the criteria?
OGTT with 75g glucose bolus then measure 2 hours later Impaired fasting glucose = 6.1-6.9mmol/L before glucose drink Impaired glucose tolerance = 7.8-11.1mmol/L Diabetes = >11.1mmol/L
121
How is PCOS managed?
Largely managing symptoms and risk reduction Supportive: weight loss; diet management; exercise; smoking cessation; anti-hypertensives; statins ± BMI > 30 - Orlistat ± Infertility - Weight reduction - Clomiphene (SERM) - Letrozole (aromatase inhibitor) - IVF - Laparoscopic drilling ± Hirsutism - Co-cyprindiol - Topical eflornithine - Laser hair removal - Finasteride ± Acne - COCP (Co-cyprindiol)
122
What are the options for risk reduction of endometrial hyperplasia/cancer in PCOS?
Mirena coil - progestogen secretion Cyclical progestogen (medroxyprogesterone acetate 10mg OD for 14 days) COCP
123
What should be done in a woman with extended gaps (>3/12) or abnormal bleeding prior to pelvic ultrasound? What is an abnormal finding?
In order to assess endometrial thickness, cyclical progestogen such as medroxyprogestorone acetate 10mg PO OD 14 days should be used prior to TVUS Abnormal finding = >10mm Finding of >10mm warrants a biopsy
124
How long is co-cyprindiol used for and why?
Used for 3 months usually then stopped due to risk of VTE
125
What are the clinical features of ovarian cysts?
Can be an incidental find - asymptomatic Pelvic pain Bloating Abdominal fullness Palpable pelvic mass Symptoms related to the cyst
126
Give the types of Ovarian cysts and their key features.
``` Follicular cyst (thin wall and empty) Corpus luteum (delayed menstruation) ``` Serous cystadenoma (looks like a serous carcinoma; bilateral 20%) Mucinous cystaednoma (large; rupture may cause psuedomyxoma peritonei) Dermoid cyst (teratoma, derived from germ cell - % torsion) Sex cord/Stromal tumour Endometrioma (chocolate cyst)
127
State 5 RFs for Ovarian malignancy.
``` Increasing age Post-menopausal Increased number of ovulations Obesity HRT Smoking Breastfeeding (reduces risk) BRCA1 / BRCA2 ```
128
Which tumour marker is used for Ovarian cancer?
Ca125
129
Give 5 causes of raised Ca125.
``` Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy ```
130
Which set of women with an ovarian cyst need no further investigation?
Premenopausal with <5cm cyst that is a simple, ovarian cyst
131
State the criteria for simple ovarian cyst management based on size in premenopausal women.
<5cm will resolve in 3 cycles 5-7cm requires yearly US-monitoring and gynaecology referral >7cm requires referral and MRI/surgical evaluation
132
What is the referral criteria of a cyst in a postmenopausal woman?
Urgent referral to gynaecology Functional cyst less likely as circulating hormones are less
133
Which of the following is least commonly associated with ovarian cysts? A. All of the below B. Pseudomyxoma peritonei C. Haemorrhage D. Cushing's disease
A
134
What are the clinical features of Meig's Syndrome?
Pleural effusion Ascites Ovarian fibroma
135
Give 3 RFs for Ovarian Torsion
Ovarian mass Pregnancy Ovarian hyperstimulation syndrome PCOS Reproductive age
136
What is the gold-standard diagnosis of an ovarian torsion?
Laparoscopic surgery
137
How is an ovarian torsion managed?
Laparoscopic surgery: Detorsion ± Oophorectomy
138
What is the gold-standard diagnosis for Asherman's Syndrome?
Hysteroscopy
139
How is Asherman's Syndrome managed?
Dissection
140
Relate the pathophysiological cellular change to the clinical features of ectropion.
Elevated oestrogen levels (COCP/premenopausal) are associated with metaplasia of cervical epithelia. Simple columnar epithelium migrates inferiorly, replacing previously Stratified squamous epithelia. The simple columnar epithelia is predominantly for secretory function, thus more fragile. This results in vagina discharge and post-coital bleeding
141
How is cervical ectropion managed?
Only problematic bleeding refer for cauterisation or cold coagulation via colposcopy
142
Explain the pathophysiology of a Nabothian cyst.
Simple columnar epithelia of the endocervix produces cervical mucus. When the squamous epithelium blocks the mucus-secreting columnar epithelium, mucous aggregates to form a cyst.
143
What are the clinical features of a Nabothian Cyst?
Mnemonic: Nabothian causes Nae Bother Incidental find Small (2-3cm), white/yellow bump near the Os
144
How is a Nabothian cyst managed?
Diagnosis assured: assurance Diagnosis uncertain: colposcopy/referral ± Excised/Biopsy
145
How can you categorise a pelvic organ prolapse?
Anterior vaginal wall prolapse: Cystocoele/Urethrocoele Posterior vaginal wall prolapse: Rectocoele/Enterocoele Total uterine prolapse
146
Give 5 RFs for pelvic organ prolapse.
Non-obstetric vs Obstetric RFs ``` SVD Macrosomia Multiple births Prolonged labour Surgery ``` Obesity Spina bifida CT diseases
147
What is the management of a pelvic organ prolapse?
Supportive: Weight loss; reduce caffeine; exercise; Pelvic floor exercises (stress); Pelvic training (urgency); Pessaries + Medical: Oestrogen ± Surgery: Sacrocolpopexy; Uteroplexy; Sacrohysteropexy + Tx symptoms
148
How do you grade a pelvic organ prolapse?
Pelvic organ prolapse quantification (POP-Q) System Grade 0 = normal Grade 1 = 1cm from introits Grade 2 = 1cm either side Grade 3 = 1cm outside Grade 4 = full descent with eversion of vagina
149
What are the 3 types of urinary incontinence?
Urgency Stress Mixed Overflow
150
How can you clinically assess the strength of pelvic muscle contraction?
Modified Oxford Grading system in a bimanual examination. ``` 0 = no contraction 1 = flicker 2 = weak 3 = moderate, with resistance 4 = good, with resistance 5 = strong contraction, firm squeeze and drawing inwards ```
151
What may urodynamic testing comprise of?
Cystometry Uroflowmetry Leak point pressure Post-void residual bladder volume Video urodynamic testing
152
What is the MOA of Mirabegron?
ß3 agonist, stimulating SNS and raising blood pressure - hypertension risk
153
What is the management of urge urinary incontinence?
Supportive: Reduce fluids; Reduce caffeine; Bladder retraining + Medical: Oxybutynin; Tolterodine; Mirabegron ± Surgical: Botulinum type A toxin; Sacral nerve stimulation; Urinary diversion
154
What is the management of stress urinary incontinence?
Supportive: Caffeine reduction; reduced fluids; weight loss; Pelvic floor exercises + Medical: Duloxetine ± Surgical: Colposuspension; Intramural urethral bulking; Tension-free Vaginal Tape
155
Outline the pathophysiology of atrophic vaginitis.
The epithelial lining of the vagina and urinary tract responds to oestrogen by becoming thicker, more elastic and producing secretions. As women enter the menopause, oestrogen levels fall, resulting in the mucosa becoming thinner, less elastic and more dry. The tissue is more prone to inflammation. There are also changes in the vaginal pH and microbial flora that can contribute to localised infections.
156
How is atrophic vaginitis managed?
Supportive: Vaginal lubricant + Medical: Topical oestrogen
157
Where is a bartholin's gland located?
Either side of posterior part of vaginal introitus
158
How is a Bartholin's cyst managed?
Supportive: hygiene; warm compress ± Biopsy ± Abscess Medical: ABX + Surgical: word catheter; marsupialisation
159
What are the clinical features of Lichen Sclerosus?
Chronic inflammation with plaques, excoriations and thickened skin ``` Itching Soreness (worse at night) Skin tightness Painful sex Erosions Fissures Koebner phenomenon (worse from trauma) ``` ``` Porcelain white Shiny Tight Thin Raised ```
160
How is Lichen Sclerosus managed?
Topical steroids - clobetasol propionate 0.05% OD for 4/52 - then reduce frequency + Emollients
161
What are the complications of lichen sclerosus?
Squamous cell carcinoma of vulva (5%) Pain and discomfort Sexual dysfunction Bleeding Narrowing of vaginal/urethral openings
162
When might you consider the risk of FGM?
Pregnant women with FGM with a possible female child Siblings or daughters of women or girls affected by FGM Extended trips with infants or children to areas where FGM is practised Women that decline examination or cervical screening New patients from communities that practise FGM
163
What are the complications of FGM?
``` Pain Bleeding Infection Urinary retention Urethral damage ``` ``` UTI Dysmenoorhoea Dyspareunia Infertility Psychological issues Reduced engagement with healthcare ```
164
How do you manage FGM?
Report to police if u18 Social services/paediatrics/gynaecology/counselling Surgery: De-infibulation surgery (if type 3 FGM)
165
Where is the female reproductive system derived from? What hormone dictates this?
Mullerian ducts (paramesonephric ducts) No Y chromosome thus no SRY to code for TDF, reduced T and remains with Wolffian ducts degenerate
166
State 3 congenital structural abnormalities in Gynae.
Bicornuate Uterus (two uteruses - heart shape) Imperforate hymen (primary amenorrhoea) Transverse vaginal septa (perforate or imperforate) Vaginal hypoplasia/agenesis (failure of Mullerian ducts to develop
167
How is Androgen insensitivity syndrome transmitted?
X-linked recessive
168
What genotype is a patient with Androgen Insensitivity Syndrome? A. XO B. XX C. XY D. XXY
C
169
How may a patient with androgen insensitivity syndrome present?
Inguinal hernia Primary amenorrhoea Female phenotype externally (no testosterone receptor gene) Ambiguous genitalia Raised LH N/Raised FSH N/raised T (for a male) Raised E (for a male)
170
How is androgen insensitivity syndrome managed?
MDT input Bilateral orchidectomy Oestrogen therapy Vaginal dilators/vaginal surgery
171
A 30 year old lady G3P2 presents with PV bleeding at 8+4 in her pregnancy. The bleeding is less than her usual menstruation. The cervical os is closed. What type of miscarriage is this? A. Threatened B. Missed C. Inevitable D. Incomplete miscarriage
A Before 24 weeks, usually 6-9 weeks Complicates up to 25% pregnancies
172
A 30 year old lady G3P2 presents with painless PV bleeding at 8+4 in her pregnancy. The bleeding is less than her usual menstruation. The cervical os is closed. US shows no foetal heart rate with no embryonic foetal part. What type of miscarriage is this? A. Threatened B. Missed C. Inevitable D. Incomplete miscarriage
B
173
A 30 year old lady G3P2 presents with painful PV bleeding at 8+4 in her pregnancy. The bleeding is more than her usual menstruation. The cervical os is open. What type of miscarriage is this? A. Threatened B. Missed C. Inevitable D. Incomplete miscarriage
C
174
A 30 year old lady G3P2 presents with pain PV bleeding at 18+4 in her pregnancy. The bleeding is less than her usual menstruation. The cervical os is open. US shows some PoC in the uterus. What type of miscarriage is this? A. Threatened B. Missed C. Inevitable D. Incomplete miscarriage
D
175
What is an absolute contraindication for injectable progesterone contraception?
Current breast cancer
176
When is external cephalic version conducted?
36 weeks
177
What is the most common form of Cervical Cancer?
Squamous cell cancer (derived from the ectocervix) ≈ 80%
178
Which serotypes of HPV are associated with cervical cancer?
HPV-16; HPV-18
179
Which of the following is the greatest risk factor for Cervical Cancer? A. Smoking B. COCP C. High parity D. HPV-18
D - others are all risk factors also
180
State 5 RFs for Cervical Cancer.
``` HPV-16; HPV-18 - produce oncogenes E6 (inhibits p53) and E7 (inhibits RB suppressor gene) High parity HIV Lower socioeconomic status COCP Early first intercourse Numerous sexual partners ```
181
What is the pathophysiology regarding E6 protein and cervical cancer?
Inhibits p53 tumour suppressor gene
182
What is the pathophysiology regarding E7 protein and cervical cancer?
E7 protein inhibits Rb tumour suppressor gene
183
How is CIN diagnosed?
Colposcopy (and biopsy)
184
What are the grades of CIN? State them.
CIN I = mild dysplasia affecting 1/3 thickness CIN II = moderate dysplasia, affecting 2/3 thickness of epithelial layer CIN III = severe dysplasia, likely to progress to cancer if untreated ("cervical carcinoma in situ")
185
What is the difference between dysplasia and dyskaryosis?
Dysplasia is abnormal changes in cells/tissue whereas dyskaryosis is a change in the cells
186
When is a woman invited for cervical screening?
25+ 25-49 = 3 years 50-65 = 5 years Mnemonic: 3 years in your 30s, 5 years in your 50s
187
Who may follow a different cervical screening routine? Give 3 examples.
HIV Over 65 if not had one since 50 Immunosuppressed women Pregnant women (3 months post-partum)
188
What are the benefits of LBC for smears?
Reduced rate of inadequate smears Increased sensitivity and specificity
189
When is the best time to take a cervical smear? A. Pre-cycle B. Mid-cycle C. End of cycle D. Any time
B
190
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV negative. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
A - return to routine recall
191
A 52 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV negative. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
B - return to routine follow up
192
When should a patient on the test of cure pathway, following CIN be tested?
Test again in 6 months
193
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV positive. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
D
194
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV negative. The cytology is abnormal, showing high-grade dyskaryosis. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
C
195
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV positive. The cytology is normal. What should happen now? A. Test in 12 months B. Test in 5 years C. Test in 3 years D. Examine cytology of cells
A - test in 12 months
196
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV positive. Cytology is normal. A test 12 months later shows hrHPV negative. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
A - return to norma screening
197
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV positive. Cytology is normal. A test 12 months later shows hrHPV positive. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Test in 12 months
D - repeat test again in 12 months
198
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV positive. Cytology is normal. A repeat test 12 months ago then showed HPV positive. A further 12 months on, she is HPV positive. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
C
199
A 32 year old female attends for her routine smear. She has an uncomplicated PMHx. She is fit and healthy, working as a receptionist in the local law firm. The sample is HPV positive. Cytology is normal. A test 12 months later shows hrHPV positive. 12 months from this hrHPV is negative again. What should happen now? A. Test in 3 years B. Test in 5 years C. Colposcopy D. Examine cytology of cells
Return to normal recall of 3 years (for her age)
200
How is CIN treated?
LLETZ / Cryotherapy
201
What staging system is used in cervical cancer?
Figo IA = confined to cervix and <7mm wide IB = cervix, clinically visible or >7mm II = tumour extends beyond cervix but not pelvic wall III = extension of tumour beyond pelvic wall IV = extends beyond pelvis or involve bladder or rectum
202
Give 5 side effects of radiotherapy.
``` Short term: Diarrhoea Vaginal bleeding Radiation burns Dysuria Tiredness/weakness ``` Long term: Ovarian failure Fibrosis of bowel/vagina/skin/bladder Lymphoedema
203
An acetowhite finding may suggest?
Occurs in cells with increased nuclear: cytoplasmic ratio (more nuclear material) such as CIN and cervical cancer when stained with Acetic Acid
204
How does Schiller's iodine test work in Colposcopy?
Iodine solution stains cervical cells - healthy cells go a brown colour. Abnormal areas do not stain
205
Outline the LLETZ procedure.
Loop biopsy under local anaesthetic during colposcopy procedure. Wire with diathermy (electrical current) used to remove abnormal epithelial tissue on the cervix. Post-procedure may involve bleeding for several weeks.
206
How may cervical cancer be managed?
CIN: LLETZ/Cone biopsy Stage 1b-2a: Radical hysterectomy and lymph node removal with chemo and radiotherapy Stage 2b-4a: Radiotherapy and chemotherapy Stage 4b = MDT treatment
207
What is pelvic exenteration?
operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life.
208
What is the role of Bevacizumab in ovarian cancer?
monoclonal antibody against VEGF-A which reduces neovascularisation, reducing cancer growth
209
What is the most common type of endometrial cancer?
Adenocarcinoma (80%)
210
Which of the following is not a risk factor for endometrial cancer? A. Early menopause B. Earlier onset of menstruation C. Nulliparity D. PCOS
A - late menopause is a RF
211
What proportion of endometrial hyperplasia goes on to develop endometrial cancer?
10%
212
Outline the pathophysiology regarding obesity and endometrial cancer?
WAT produces oestrogen in postmenopausal women via aromatase which converts androgens to oestrogen thus stimulates endometrial cells and increases the risk of endometrial hyperplasia
213
Why may Tamoxifen increase your risk of endometrial cancer?
anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. This increase the risk of endometrial cancer.
214
State 3 protective factors against endometrial cancer.
Smoking Multiple pregnancies Mirena coil COCP
215
What is the referral criteria for endometrial cancer?
Postmenopausal bleeding Unexplained vaginal discharge >55 years Visible haematuria and raised platelets/anaemia/hyperglycaemia
216
What is a normal endometrial thickness?
<4mm
217
What is the staging system used in Endometrial cancer? Outline it
FIGO Stage 1 = confined to uterus Stage 2 = invades cervix Stage 3 = invades ovaries, fallopian tubes, vagina or lymph nodes Stage 4 = invades bladder, rectum or beyond pelvis
218
How is endometrial cancer managed?
Stage 1/2 Surgery: TAH + BSO ``` Other: MDT treatment Radical hysterectomy (remove pelvic lymph nodes and surrounding tissue) Radiotherapy Chemotherapy Progesterone ```
219
What is the most common type of ovarian cancer?
Epithelial thus adenocarcinoma
220
State 5 RFs of Ovarian Cancer.
``` Smoking BRCA1 BRCA2 Early menarche Late menopause Nulliparity ```
221
Which tumour marker is representative of Ovarian Cancer?
Ca125
222
What may give an elevation in Ca125?
``` Ovarian cancer Endometriosis Menstruation Benign ovarian cysts PID Pregnancy Uterine fibroids Liver disease ```
223
State 5 subtypes of epithelial cell tumours of the ovary.
``` Serous tumours Clear cell tumours Endometrioid tumours Mucinous tumours Undifferentiated tumours ```
224
What is a Krukenberg tumour? How do they appear on histology?
GI metastasis to the Ovary Signet ring
225
What may be protective against Ovarian cancer?
COCP Breastfeeding Pregnancy
226
Why may an ovarian tumour cause hip pain? What type of pain would this be? Specifically.
Ovarian tumour compressing the obturator nerve Neuropathic due to neuropraxia.
227
What requires a 2 week urgent referral in the context of suspected ovarian cancer?
``` Ascites Pelvic mass (unexplained) Abdominal mass ```
228
How is the risk of malignancy regarding ovarian mass calculated?
Risk of malignancy index (RMI): - Menopausal status - US findings - Ca125 level
229
How is an ovarian mass managed?
MDT management - surgery/chemotherapy
230
What is the most common type of vulval cancer?
Squamous cell carcinoma
231
State 3 RFs for vulval cancer.
Advanced age (>75 years old) Immunosuppression HPV Lichen sclerosis
232
What proportion of lichen sclerosis results in vulval cancer?
5%
233
What are the types of vulval intraepithelial neoplasia?
High grade Vulval intraepithelial neoplasia - associated with HPV (35-50 years) Differentiated Vulval intraepithelial neoplasia - associated with lichen sclerosus (50-60)
234
How may vulval cancer present?
``` Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin ```
235
What classification system is used in vulval cancer?
FIGO system
236
How is vulval cancer managed?
MDT decision ``` Wide local excision ± Groin lymph node dissection ± Chemo ± Radiotherapy ```
237
Which of the following pathogens does not cause bacterial vaginosis? A. G vaginalis B. M hominis C. Prevotella D. N gonorrhoea
D
238
What is the most common cause of bacterial vaginosis? A. G vaginalis B. M hominis C. Prevotella D. N gonorrhoea
A
239
What is the pathophysiology of Bacterial vaginosis?
Lactobacilli usually produce lactic acid which drops pH <4.5 however a reduction in lactobacilli results in proliferation of other bacteria which allows other bacteria to multiply
240
Which of the following is not a risk factor for bacterial vaginosis? A. IUS B. Smoking C. Vaginal douching D. Multiple sexual partners
A - an IUD aka Copper coil is a risk factor for Bacterial vaginosis
241
What type of cells are seen on microscopy in Bacterial vaginosis?
Clue cells - epithelial cells that have bacteria stuck inside them
242
What is the diagnostic criteria of Bacterial vaginosis? Outline it.
Amsel criteria ``` 3/4 needed White discharge Clue cells Vaginal pH >4.5 Positive whiff test (add KOH causing fishy odour) ```
243
What is the management of bacterial vaginosis?
Metronidazole 7/7
244
What is the management of bacterial vaginosis in pregnancy?
Oral metronidazole
245
What should be avoided when taking Metronidazole?
Avoid alcohol due to metronidazole interaction with alcohol to cause a disulfiram-like reaction with N/V and flushing with potential for shock
246
Give 3 RFs for Thrush.
Uncontrolled diabetes mellitus Increased oestrogen Immunosuppression Broad-spectrum ABX
247
How can you differentiate between bacterial vaginosis and candidiasis?
Vaginal pH swab - lower in candidiasis
248
What type of swab should be used in Thrush?
Vulvovaginal swab - charcoal swab
249
How is thrush managed?
Topical/Pessary antifungals e.g. Clotrimazole - cream, pessary Oral antifungal (if complicated or refractory)
250
What advice should be given to sexually-active women taking topical antifungals for Thrush?
Use contraception for at least 5 days after use as anti fungal creams can damage latex condoms and prevent spermicides
251
What is the difference between charcoal swabs and NAAT swabs?
Charcoal allows for microscopy, culture and sensitivity (MCS) whereas NAAT looks to amplify the genetic material (RNA or DNA) which is used for chlamydia and gonorrhoea. NAAT can be performed from VVS; ECS or FPU
252
How is chlamydia managed?
Doxycycline 100mg BDS for 7 days
253
How do you manage chlamydia in pregnancy?
Erythromycin 500mg BDS for 7 days
254
Give 5 complications of Chlamydia.
``` PID Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis ``` ``` Preterm delivery PROM Microsomia Postpartum endometritis Neonatal conjunctivitis e.g. Trachoma ```
255
A male presents with a painless ulcer on the penis. NAAT show chlamydia. What stage of lymphogranuloma venereum has he got? A. Primary stage B. Secondary stage C. Tertiary stage D. None of the above
A
256
A male presents with a lymphadenitis in the inguinal region. NAAT show chlamydia. What stage of lymphogranuloma venereum has he got? A. Primary stage B. Secondary stage C. Tertiary stage D. None of the above
B
257
A male presents with a proctitis and tenesmus. NAAT show chlamydia. What stage of lymphogranuloma venereum has he got? A. Primary stage B. Secondary stage C. Tertiary stage D. None of the above
C
258
Outline the stages of lymphogranuloma venereum.
Primary = penile painless ulcer Secondary = lymphadenitis Tertiary = proctitis/proctocolitis
259
How is lymphogranuloma venereum managed? A. Doxycycline 100mg BDS for 7 days B. Erythromycin 500mg BDS for 7 days C. Erythromycin 500mg ODS for 14 days D. Doxycycline 100mg BDS for 21 days
D - recommended by BASHH Erythromycin, azithromycin and ofloxacin are alternatives
260
What is the morphology of gonorrhoea?
Gram-negative diplococcus bacteria
261
What is Reiters Syndrome?
Urethritis Conjunctivitis Arthralgia/Arthritis
262
How is gonorrhoea managed?
IM Ceftriaxone 1g STAT Single dose of oral ciprofloxacin 500mg
263
When is a test of cure done in gonorrhoea?
14 days
264
Give 5 complications of gonorrhoea.
``` Conjunctivitis Arthritis Urethritis Septic arthritis Endocarditis Disseminated gonococcal infection ``` PID Chronic pelvic pain Infertility Fitz-Hugh-Curtis Syndrome Epididymo-orchitis Prostatitis Urethral strictures ``` Chorioamnionitis Premature delivery PROM Ophthalmia neonatorium Sepsis ```
265
What is the key feature of infection with M genitalium?
Urethritis
266
What is the management of Mycoplasma genitalium infection?
Doxycycline 100mg BDS for 7 days + Azithromycin 1g STAT with 500mg for 2/7
267
What may be used in complicated infections with Mycoplasma genitalium?
Moxifloxacin
268
Which of the following is not a risk factor for Pelvic Inflammatory Disease? A. Multiple sexual partners B. Middle aged C. IUD D. Not using barrier contraception
B - younger age
269
What are the clinical features of PID?
``` Pelvic/abdominal pain Abnormal vaginal discharge Abnormal bleeding Dyspareunia Fever Dysuria ``` Pelvic tenderness Cervical motion tenderness Inflamed cervix Purulent discharge
270
How is PID managed?
Oral metronidazole + Oral doxycycline + IM Ceftriaxone
271
What tissue is affected in Fitz-Hugh-Curtis Syndrome?
Pelvic inflammation and infection of Glisson's Capsule of the liver - resulting in adhesions of liver and peritoneum
272
What type of pathogen is Trichomoniasis caused by? A. Bacteria B. Virus C. Fungi D. Protozoa
D
273
Which of the following is not a potential consequence of Trichomonas? A. Bacterial vaginosis B. PID C. Pre-term delivery D. Reduced HIV risk
D - risk is increased due to vaginal mucosa damage
274
What cervical find is characteristic of Trichomonas?
Strawberry cervix
275
Which vaginal discharge is most likely to represent Trichomonas? A. White B. Green C. Yellow-green D. Translucent
C
276
How is Trichomonas managed?
Metronidazole
277
Which strain of Herpes is most likely to cause Genital herpes?
HSV-1
278
Which nerve ganglia are affected in genital herpes?
Sacral nerve ganglia
279
A patient presents with a painful skin lesion on a finger. They are known to be positive for HSV-2. What is the likely lesion called?
Herpetic whitlow - painful skin lesion on digits
280
How is genital herpes managed?
Supportive: Saline bathing; Analgesia; Topical anaesthetic + Medical: Oral aciclovir
281
A woman who is 32 weeks pregnant experiences a primary attack of herpes featuring gingivostomatitis, cold sores and genital ulceration. What is the best management option? A. Oral aciclovir and wait B. Caeserean section C. Induction of labour D. Supportive management
B - >28/40 + Primary Herpes infection requires Caeserean section
282
How is Primary genital herpes contracted before 28 weeks gestation managed?
Oral aciclovir
283
Which is the most common strain of HIV?
HIV-1 Note: HIV-2 is predominantly in West Africa
284
How is HIV transmitted?
Blood-borne thus pregnancy; sexual activity or exposure prone procedure
285
State 5 conditions associated with AIDS.
``` PCP Kaposi's sarcoma CMV infection Candidiasis (oesophageal/bronchial) Lymphoma Tuberculosis ```
286
What specific antigen is tested for in HIV testing?
Antibody testing p24 antigen
287
When should you test for HIV in an asymptomatic individual following exposure?
4 weeks
288
How long should oral antiretroviral therapy be taken following HIV exposure?
4 weeks
289
When should serological testing following post-exposure prophylaxis be conducted?
12 weeks after completion
290
At what cell count do patients become high risk of opportunistic infections? A. 400 cells/mm3 B. 150 cells/mm3 C. 350 cells/mm3 D. 250 cells/mm3
B <200 cells/mm3 = end-stage HIV (AIDS) thus high risk of opportunistic infections
291
What is the prophylactic treatment against PCP in a patient with AIDS?
Co-trimoxazole
292
A G3P2 pregnant woman who is 34+5 has a viral load of 500. What is the best mode of delivery for her? A. SVD B. Forceps C. Caeserean section D. Caeserean + IV Zidovudine
C 50-1000 copies/mL requires C-section
293
A G3P2 pregnant woman who is 34+5 has a viral load of 1200. What is the best mode of delivery for her? A. SVD B. Forceps C. Caeserean section D. Caeserean + IV Zidovudine
D - >1000copies/mL requires IV Zidovudine and C-section
294
What are babies at low risk of HIV given?
<50 copies/mL requires Zidovudine for 4/52
295
What are babies at high risk of HIV given as prophylaxis?
>50 copies/mL are given Zidovudine + Lamivudine + Nevirapine for 4/52
296
A patient presents with headache, confusion and drowsiness. They have a PMHx of HIV. CT shows multiple ring enhancing lesions. What is your differential? A. Meningitis B. Encephalitis C. Toxoplasmosis D. Cerebral abscess
C
297
A patient presents with headache, confusion and drowsiness. They have a PMHx of HIV. CT shows multiple ring enhancing lesions. What is your management? A. Sulfadiazine and Pyrimethamine B. Sulfadiazine C. IV Ceftriaxone D. Tenofovir
A
298
Outline the main differences between toxoplasmosis and primary CNS lymphoma.
Toxoplasmosis: Multiple lesions Ring/nodular enhancement Thallium SPECT negative Lymphoma Single lesion Solid homogeneous enhancement Thallium SPECT positive
299
A patient presents with a headache, fever and nausea. They have had a seizure. Their PMHx is HIV. CT shows meningeal enhancement with cerebral oedema. CSF has a positive Indian ink test. What is your diagnosis? A. Encephalitis B. Cryptococcus C. PML D. AIDS dementia complex
B most common fungal infection of CNS headache, fever, malaise, nausea/vomiting, seizures, focal neurological deficit CSF: high opening pressure, India ink test positive CT: meningeal enhancement, cerebral oedema meningitis is typical presentation but may occasionally cause a space occupying lesion
300
A patient presents with an acute onset behavioural change with some visual impairment. CT shows multiple lesions, which are not enhanced. MRI shows demyelination of white matter. What is your diagnosis? A. Encephalitis B. Cryptococcus C. PML D. AIDS dementia complex
C widespread demyelination due to infection of oligodendrocytes by JC virus (a polyoma DNA virus) symptoms, subacute onset : behavioural changes, speech, motor, visual impairment CT: single or multiple lesions, no mass effect, don't usually enhance. MRI is better - high-signal demyelinating white matter lesions are seen
301
A patient presents with an acute onset behavioural change with motor impairment. CT shows cortical atrophy and no other changes What is your diagnosis? A. Encephalitis B. Cryptococcus C. PML D. AIDS dementia complex
D
302
Which pathogen is associated with Kaposi Sarcoma?
HHV-8
303
What pathogen is related to hairy leukoplakia?
EBV
304
What pathogen is associated with PML?
Progressive Multifocal Leukoencephalopathy related to John Cunningham Virus
305
At what CD4 count does CMV retinitis occur?
Generally at CD4 < 50 cells/mm3
306
Which pathogen causes Syphilis?
Treponema pallidum
307
What is the morphology of Treponema pallidum?
Spirochete that is spiral-shaped bacteria
308
Outline the stages of Syphilis.
Primary = painless ulcer (chancre) Secondary = systemic symptoms of skin and mucosa Latent = symptoms disappear and become asymptomatic - Early < 2 years - Late > 2 years Tertiary = development of gummas (mass of granulomatous tissue) Neurosyphilis = CNS
309
Which of the following is not a classical feature of neurosyphilis? A. Tabes dorsalis B. Ocular syphilis C. Paralysis D. Paraesthesia
D
310
What type of pupillary defect is associated with Syphilis?
Argyll-Robertson pupil - constricted pupil which accommodates when focusing on near object but does not react to light
311
How is Syphilis managed? A. IV Ceftriaxone B. IM Ceftriaxone C. IM Benzylpenicillin D. Oral Doxycycline
C
312
Which of the following is not a MOA of the COCP? A. Inhibit endometrial proliferation B. Thicken cervical mucus C. Prevent ovulation D. Spermicide
D
313
Which of the following COCPs may be useful for treatment of acne? A. Microgynon B. Dianette C. Yasmin D. Cilest
B - contains Co-cyprindiol
314
What are the benefits of the COCP?
Contraception Rapid return to fertility Improves premenstrual symptoms Reduced risk of endometrial cancer, ovarian and colon cancer
315
What are the side effects and risk of the COCP?
``` Breakthrough bleeding Mastalgia Mood change Headaches Hypertension VTE Risk of breast and cervical cancer (returns to normal after 10 years) Small increased risk of MI/Stroke ```
316
Which of the following is not an absolute contraindication for the COCP? A. History of VTE B. Liver cirrhosis C. SLE D. BMI > 30
D - BMI > 35 is a UKMEC 3, not a UKMEC 4
317
A pill is started on day 7 of a cycle. What contraception is required?
Contraception for first 7 days if started after day 5 of cycle
318
A pill is started on day 4 of a cycle. What contraception is required?
No contraception required if started on first 5 days of cycle
319
When switching from desogestrel to COCP, what further measures may be required?
None as Desogestrel prevents ovulation thus no additional contraception requires
320
A patient misses their COCP but has taken their last pill 48 hours ago. She had unprotected sex last night. What form of contraception is required? A. Take missed pill and normal pill B. No additional pill needed C. Emergency contraception required D. Obs and Gynae referral
A
321
If 2 or more pills have been missed or it has been more than 72 hours since taking last COCP, what contraceptive advice should be given? The patient is in Day 6 of their cycle.
Days 1-7 + >72 hours of pill = Emergency contraception considered
322
If 2 or more pills have been missed or it has been more than 72 hours since taking last COCP, what contraceptive advice should be given? The patient is in Day 9 of their cycle.
Days 8-14 with pills taken 1-7 means no need for emergency contraception
323
If 2 or more pills have been missed or it has been more than 72 hours since taking last COCP, what contraceptive advice should be given? The patient is in Day 19 of their cycle. The patient has taken their pills from days 1-16. What contraceptive advice would you give?
Missed pills in week 3 (Days 15-21) = finish current pack and start new pack the next day
324
Which phase of the menstrual cycle is mimicked by Desogestrel?
Luteal phase, with progesterone inhibiting ovulation by mimicking pregnancy
325
A patient begins the Desogestrel pill on day 6 of her cycle. What contraception is required? A. None B. Contraception for 7 days C. Contraception for 48 hours D. Contraception for 24 hours
C - takes 48 hours for cervical mucous to thicken
326
What are the side effects of POP?
``` Unscheduled bleeding Irregular bleeding Amenorrhoea Mastalgia Headaches Acne ``` ``` Ovarian cysts Ectopic pregnancy (reduced ciliary action) Slightly increased risk of breast cancer ```
327
A patient misses their Nogeston pill. They have not taken it for 28 hours. What contraception is required?
Take missed pill and use condoms for 48 hours
328
A patient has missed their Desogestrel pill by 38 hours. What contraception is required?
Take missed pill as soon as possible and normal pill Extra precautions for 48 hours
329
What is a UKMEC 4 contraindication for Depot injection?
Active breast cancer
330
State 5 side effects of the progesterone only injection?
``` Weight gain Acne Reduced libido Mood changes Headaches Flushes Hair loss (alopecia) Skin reactions at injection sites Reduced BMD - OP risk increased Increased risk of breast cancer Increased risk of cervical cancer ```
331
What is an absolute contraindication for the Nexplanon implant?
Active breast cancer
332
What property of the Nexplanon implant makes it visible on X-Ray?
Barium sulphate added to make it radio-opaque
333
Which of the following is not a contraindication of the coil? A. Taking Clopidogrel B. Fibroids C. Pelvic cancer D. PID
A
334
When the coil is removed, what contraception is required? A. None B. Condoms for 5 days C. Condoms for 7 days D. None of the above
C
335
What is the MOA of the Copper coil?
Toxic to sperm
336
Which of the following is not a drawback of the copper coil? A. Surgical procedure required B. May fall out in 10% of cases C. Increased risk of ectopic pregnancies D. May worsen intermenstrual bleeding
B - may fall out in 10% of cases
337
Which condition is the copper coil contraindicated in? A. Haemachromatosis B. Porphyria cutanea tarda C. Wilson's disease D. Cystic fibrosis
C - Wilson’s disease is a condition where there is excessive accumulation of copper in the body and tissues. Examiners like to add questions on this, as it requires knowledge of the copper coil and Wilson’s disease.
338
What may be seen in a smear of a woman with a coil?
Actinomyces-Like Organisms (ALO) on Smears - no treatment unless symptomatic
339
What is the MOA of Ulipristal?
SERM
340
When can a woman commence contraception following the use of Ulipristal? A. Immediately and use 7 days of barrier contraception B. Wait 3 days C. Wait 5 days and use 7 days of barrier contraception D. Wait 7 days and use 7 days of barrier contraception
C
341
In which condition should Ulipristal be avoided? A. COPD B. Heart Failure C. CKD D. Severe asthma
D
342
At what age should sexual intercourse raise a safeguarding red flag?
All intercourse in children under 13 years should be escalated as a safeguarding concern to a senior or designated child protection doctor
343
What proportion of couples cannot conceive after 1 year of regular, unprotected sex? A. 1 in 5 B. 1 in 4 C. 1 in 8 D. 1 in 7
D
344
What initial investigations may you conduct in infertility?
``` LH/FSH Progesterone (on day 21) Anti-Mullerian Hormone (indication of ovarian reserve - made by granulosa cells) Prolactin TFTs ``` Semen analysis US-Pelvis Laparoscopy Hysterosalpingogram
345
A woman is struggling to conceive with her partner. A progestogen sample is taken which shows 8nmol/L. What is the next action? A. Reassurance B. Repeat C. Ovulation has occurred, tell her D. Repeat and refer to specialist if low
D Levels: <16nmol/L 16-30nmol/L >30nmol/L
346
Which of the following is not true of a Hysterosalpingogram? A. Tubal cannulation is conducted under XR Guidance B. Contrast medium is injected through a small tube inserted into the cervix C. The dye fills the peritoneal cavity D. There is no need for prophylactic antibiotics
D - there is a need for prophylactic ABX
347
Which ways can sperm problems be managed in infertility?
Supportive: Diet; Smoking cessation; exercise + Surgical: Sperm retrieval; Surgical correction; IU insemination; ICSI; Donor insemination
348
What is Oligospermia?
Reduced number of sperm such as <15million/mL
349
What is normospermia?
Normal characteristics of sperm Concentration (>15million/mL) Number (>40 million per sample) Motility (>40%) Vitality (>60%)
350
How may you categorise the causes of male infertility?
Pre-testicular: Pathology of the pituitary gland or hypothalamus Suppression due to stress, chronic conditions or hyperprolactinaemia Kallman syndrome ``` Testicular: Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer ``` Post-testicular: Damage to the testicle or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis, for example, caused by chlamydia Absence of the vas deferens (may be associated with cystic fibrosis) Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)
351
What are the percentages of IVF being successful?
30%
352
What are the processes of IVF?
Suppress menstrual cycle: GnRH agonist/GnRH antagonist - Give GnRH agonist in luteal phase thus stimulate FSH and LH which negatively feeds back to hypothalamus to suppress GnH - Give GnRH antagonist submit from day 5-6 of ovarian stimulation to reduce LH Ovarian stimulation: FSH injection over 10-14 days then hCG injection 36 hours before egg injection (acts as LH as 'trigger injection') Oocyte collection: TVUS to collect via needle aspirate of follicle Oocyte insemination: sperm added to oocyte in HA culture Embryo culture: Culture dish from day 2-5 Embryo transfer: Select and transfer via US-guided catheter Pregnancy: Test at day 16 after egg collection
353
What are the risks of IVF?
Failure Multiple pregnancy Ectopic pregnancy Ovarian hyperstimulation syndrome
354
Outline the pathophysiology of Ovarian Hyperstimulation Syndrome.
Trigger injection (hCG) mimicking gonadotropins result in VEGF release from granulosa cells which increases vascular permeability resulting in fluid extravasation - presenting with shock.
355
Which of the following is an assessment of OHSS development risk? A. XR B. US C. Serum progesterone D. Serum FSH
B - monitor follicles
356
What is the management of OHSS?
``` Supportive: Admission; Catheterise; Oral fluids; + Medical: LMWH; IV Colloids + Surgical: Paracentesis ```
357
What is Young's Syndrome?
Bronchiectasis Chronic rhinosinusitis Vas deference obstruction
358
What can be used as a surrogate marker for intravascular fluid volume in OHSS?
Haematocrit (RBC concentration) as Hct increase correlates to less fluid in intravascular space
359
What examination is not recommended in a suspected ectopic pregnancy?
Examine for cervical motion tenderness but do not examine for adnexal mass - risk of rupturing the ectopic pregnancy
360
Which of the following is not a risk factor for an ectopic pregnancy? A. Smoking B. PID C. Progesterone injection D. Previous fallopian tube surgery
C
361
At what rate does ßhCG increase roughly?
Doubles every 48 hours
362
How may you manage an ectopic pregnancy?
ßhCG <1500IU/L Supportive: Expectant management ßhCG 1500-5000IU/L Medical: Methotrexate ßhCG >5000IU/L
363
What are the common side effects of methotrexate?
PV bleed N/V Abdominal pain Stomatitis
364
What are the two categories of miscarriage?
Early = <12 weeks Later = 12-24 weeks
365
What is the gold-standard diagnosis for a miscarriage?
US Mean gestational sac diameter Foetal pole and crown-rump length Foetal heartbeat (viable pregnancy) - usually seen when crown-rump length >7mm
366
A woman is worried about a miscarriage following some bleeding in week 6. US shows the foetus present and pelvic exam shows a closed cervix. What type of miscarriage is this? A. Missed B. Threatened C. Inevitable D. Incomplete miscarriage
B
367
A woman is worried about a miscarriage following some bleeding in week 6. US shows the foetus present and pelvic exam shows an open cervix. What type of miscarriage is this? A. Missed B. Threatened C. Inevitable D. Incomplete miscarriage
C
368
A woman is worried about a miscarriage following some bleeding in week 6. US shows the no present and pelvic exam shows a closed cervix. What type of miscarriage is this? A. Missed B. Threatened C. Incomplete D. Complete miscarriage
D
369
What are the options for miscarriage management?
Less than 6 weeks = expectant management More than 6 weeks = 1) Expectant (if no risk factors for heavy bleeding or infection) Repeat urine pregnancy test 3 weeks after symptoms settle 2) Medical (misoprostol) - stimulate uterine contractions 3) Surgery (manual/electrical vacuum aspiration)
370
Give 5 causes for recurrent miscarriage.
``` Idiopathic Antiphospholipid syndrome SLE Hereditary thrombophilia Uterine abnormalities Genetic factors Chronic histolytic intervillositis ``` ``` Diabetes Thyroid disease (uncontrolled) ```
371
What autoantibodies are present in Antiphospholipid syndrome?
Anti cardiolipin Lupus anticoagulant
372
What are the available methods of ToP?
<9 weeks Medical: Mifepristone + Misoprostol <13 weeks Surgical: Dilation and suction >15 weeks Surgical: Surgical dilation and evacuation
373
Give 3 potential complications of abortion.
``` Failure of abortion Iatrogenic damage Bleeding Pain Infection Psychological damage ```
374
Which of the following is not a feature of the Abortion Act 1967? A. Pregnancy has not exceeded 28th week B. Continuation of pregnancy would be greater than if risk were terminated C. Termination necessary to prevent grave permanent injury to woman D. Risk to life of current children
A - the act was altered to the 24th week
375
What is the MOA of Misoprostrol?
PG analogue stimulating contractions
376
What is the MOA of Mifepristone?
Progesterone antagonist which ripens uterus to misoprostol
377
What proportion of pregnancies experience NVP? A. 5% B. 10% C. 3% D. 1%
D
378
Which of the following is not associated with NVP? A. Multiple pregnancies B. Trophoblastic disease C. Hypothyroidism D. Nulliparity
C - Hyperthyroidism
379
Give 3 conditions which smoking may reduce the incidence of?
Hyperemesis Gravidarum (NVP) Ulcerative Colitis Endometrial cancer
380
Which of the following would not require referral and admission? A. Unable to keep down liquids or oral antiemetics B. Continued vomiting with loss of weight loss of 10% C. Comorbidity requiring treatment D. Throwing up 3 times in 1 hour
D Referral criteria: - Persistent vomiting - Loss of >5% body weight or ketonuria - Comorbidity which requires treatment
381
What is the first line management in NVP? A. Ondansetron B. Metoclopramide C. Cyclizine D. P6 acupressure
C Order: Cyclizine > Metoclopramide > Ondansetron > P6 acupressure
382
Which of the following statements are true regarding molar pregnancy? A. Complete mole is a single sperm fertilising an empty ovum B. Partial mole is when 2 sperm fertilise an empty ovum C. A complete mole contains some foetal material D. A partial mole contains some foetal material
D
383
Which of the following is not typical of a molar pregnancy? A. More morning sickness B. No vaginal bleeding C. Abnormally high hCG D. Thyrotoxicosis
B - Vaginal bleeding is a feature
384
Outline how a molar pregnancy can cause thyrotoxicosis?
hCG can mimic TSH which stimulates the TSH-R on thyroid follicular cells to cause T3 and T4 release
385
What is a characteristic radiographic find of a Molar pregnancy?
Snowstorm pregnancy
386
What is the difference between gravidity and parity?
Gravidity = number of times pregnant Parity = number of foetuses born at 24+ weeks
387
Outline the times for each trimester.
1st Trimester = 0-12 weeks 2nd Trimester = 13-26 weeks 3rd Trimester = 27+ weeks
388
When is a booking visit conducted? What is the purpose of the visit?
8-12 weeks General history: diet, alcohol, smoking, folic acid, vitamin D, antenatal General checks: BP, urine, BMI Booking bloods: FBC, blood group, Rh, red cell alloantibodies, Hb-opathies; Hepatitis B; syphilis; HIV test offered Urine culture
389
Which of the following is not always done at a booking visit? A. Test for hepatitis B B. Urine culture C. Test for red cell alloantibodies D. HIV test
D - HIV test is offered to all women but may not always be done
390
When is the early scan conducted?
10-13+6 weeks
391
WHen is a Down's Syndrome screening conducted?
11-13+6 weeks
392
When is an Anomaly scan conducted?
18-20+6 weeks
393
When is SFH, BP and urine dipstick conducted?
28 weeks - 25 if Primip
394
When is the first dose of anti-D prophylaxis given if rhesus negative?
28 weeks
395
When is external cephalic version offered?
36 weeks
396
What does routine care in antenatal care involve?
SFH, Blood pressure, urine dipstick
397
Which two vaccines are offered to all pregnant women?
Whooping cough - 16 weeks Influenza (Autumn; Winter)
398
What supplements should be taken in pregnancy?
Folic acid 400mcg + Vitamin D 10mcg Note: High risk of NTD requires 5mg of Folic Acid
399
Which of the following is not a feature of Foetal Alcohol Syndrome? A. Microcephaly B. Smooth flat philtre C. Learning disability D. Hypertelorism
D ``` Features: Microcephaly Thin upper lip Flat philtre Short palpebral fissure Hearing difficulties Vision difficulties Cerebral palsy ```
400
When is flying in pregnancy acceptable?
Up to 32 weeks in singleton Up to 37 weeks in twin pregnancies
401
What is done on booking bloods in the UK?
FBC Thalassaemia + Sickle cell disease Hepatitis B Syphilis --> HIV offered
402
What is the threshold for offering Downs Syndrome Screening in a woman?
1 in 150 (5%)
403
Which tests are conducted in the combined test?
US - nuchal translucency Bloods - ßhCG + PAPP-A
404
Which tests are done in the quadruple test? What derangements may be seen in Down's Syndrome?
ßhCG (elevated) AFP (lower) Oestriol (lower) Inhibin-A (elevated)
405
What occurs to the dose of levothyroxine in Hypothyroidism in Pregnancy?
Increase dose of thyroxine by 30-50% in pregnancy Titrate based on TSH level - aim for low-normal TSH level
406
Which antihypertensives may be used in pregnancy?
Labetalol Dozasozin Nifedipine Levodopa
407
Which of the following is not recommended to manage Epilepsy in Pregnancy? A. Levetiracetam B. Lamotrigine C. Phenytoin D. Carbamazepine
C
408
What are the indications for giving Folic Acid 5mg in Pregnancy?
``` Birth with NTD NTD when born BMI > 30kg/m2 Epilepsy Diabetes Sickle Cell Disease ```
409
What is the first line management of Rheumatoid Arthritis in pregnancy? A. Methotrexate B. Sulfasalazine C. Corticosteroids D. Hydroxychloroquine
D - considered safe during pregnancy and 1st line
410
What is the pathophysiology behind NSAIDs being avoided in pregnancy?
NSAIDs reduce prostaglandin production. PG important in maintaining Ductus Arteriosus PG important in softening cervix PG important in stimulating uterine contractions NSAID administration may result in aberration of these processes
411
What congenital abnormality is Lithium associated with?
Ebstein's anomaly - tricuspid valve set inferiorly thus larger RA and smaller RV
412
What are the features of Congenital Rubella Syndrome?
Congenital deafness Congenital blindness (cataracts) Congenital heart disease Learning disability Mnemonic: 'See no evil, hear no evil, speak no evil' due to hearing loss, sight loss and learning disability
413
What is the management of a G3P2 32+4 week woman who has chicken pox with confirmed VZV IgG levels?
Nothing
414
What is the management of a G3P2 32+4 week woman who has chicken pox with no VZV IgG levels?
Give IV Varicella IgG - within 10 days of exposure If >20 weeks and present within 24 hours, give Oral Aciclovir
415
What does congenital Varicella Syndrome involve?
``` Microcephaly Hydrocephalus Chorioretinitis Learning disability Scars/skin change in dermatomal distribution Limb hypoplasia ```
416
What are the features of Congenital Toxoplasmosis?
Intracranial calcification Hydrocephalus Chorioretinitis Mnemonic: ICH - Intracranial calcification + Chorioretinitis + Hydrocephalus
417
What syndrome can Parvovirus B19 cause in a pregnant woman?
Mirror syndrome (mirroring pre-eclampsia) with hypertension + proteinuria
418
What are the features of congenital Zika syndrome?
Microcephaly SGA Intracranial abnormalities: ventriculomegaly; cerebellar atrophy
419
Outline the pathophysiology of Rhesus Incompatibility in Pregnancy.
Rh neg. and Rh pos. baby results in foetal-maternal transmission of Rh pos. RBCs which stimulate the mother to produce Anti-Rhesus-D Abs (sensitisation). In subsequent pregnancies, maternal anti-Rh-D Abs cross placenta into foetus which attaches to foetal RBCs stimulating an immune response in haemolytic disease of the newborn
420
How is Rh incompatibility managed?
Anti-D injection at 28 weeks gestation
421
How can you categorise causes of foetal growth restriction?
Placenta-driven Non-Placenta driven ``` Placenta driven: Idiopathic Pre-eclampsia Smoking Alcohol Anaemia Malnutrition Infection Maternal health conditions ``` ``` Non-placental driven: Genetic abnormalities Structural abnormalities Foetal infection Errors of metabolism ```
422
What should be done regarding monitoring of foetal size should SFH <10th centile?
Serial growth scans with umbilical artery doppler
423
Give 5 causes of foetal macrosomia.
``` Constitutional Diabetes Previous macrosomia Overdue Maternal obesity Male baby Genetic condition e.g. PWS ```
424
How is Foetal macrosomia investigated?
US- exclude polyhydramnios and EFW OGTT
425
What are the types of twins? How are they seen on US scan?
Twins characterised by chorionicity (own placenta) and amnionicity (amniotic sac) Monochorionic monoamniotic = no membranes Monochorionic diamniotic = T sign (membrane between twins) Dichorionic diamniotic = lamb sign (membrane between twins)
426
What is twin-twin transfusion syndrome? What is a less severe version of this?
Connection of blood supply between foetuses if placenta shared (MCDA or MCMA). Recipient gets most blood and fluid overload thus HF and polyhydramnios whilst donor has growth restriction with anaemia and oligohydramnios. Twin anaemia polycythaemia sequence - one becomes anaemic whilst other becomes polycytheamic
427
Which of the following is not a risk factor for dizygotic twins? A. Increasing maternal age B. Multigravida C. IVF D. Caucasian
D - Afro-Caribbean race
428
What is the management for a twin pregnancy?
Supportive: Rest; US; Weekly antenatal care; precautions at labour; Deliver by 38 weeks + Medical: Additional Iron + Folate MCMA delivered by 32-34 weeks C/S DCDA + MCDA delivered by 37-38 weeks
429
What is the treatment for a UTI in pregnancy?
Nitrofurantoin for 7 days Note: Avoid in last trimester (26-40)
430
When are women screened for anaemia in pregnancy?
Booking (10-12 weeks) 28 weeks
431
What is the haemoglobin normal range for a pregnant woman in pregnancy?
Booking bloods >110g/L 28 weeks gestation >105g/L
432
What is used as VTE Prophylaxis in pregnant women?
LMWH 1st Trimester if 4+ RFs 28 weeks if 3 RFs ``` RFs Parity ≥ 3 Age ≥ 35 years old Smoking BMI > 30 FHx VTE Thrombophilia Immobility Reduced mobility Gross varicose veins Pre-eclampsia IVF pregnancy ```
433
How do you clinically assess for a DVT?
Pain on palpation Pain on dorsiflexion (Homan's Sign) >3cm difference when measuring 10cm inferiorly to tibial tuberosity at posterior compartment
434
What is the difference between chronic hypertension and pregnancy-induced hypertension?
Chronic was present before 20 weeks, whereas pregnancy-induced hypertension is hypertension occurring after 20 weeks gestation without proteinuria
435
What are the diagnostic criteria for Pre-eclampsia?
HTN (>140/90mmHg) + ``` Proteinuria Organ dysfunction (raised creatinine, elevated LFTs, seizures, thrombocytopenia, haemolytic anaemia) Placental dysfunction (FGR/abnormal Doppler) ```
436
How may proteinuria in pre-eclampsia be quantified?
UACR >8mg/mmol UPCR >30mg/mmol
437
What biochemical marker can be tested to confirm Pre-eclampsia?
Placental growth factor (PlGF) Protein released by placenta to stimulate new blood vessels thus in pre-eclampsia PlGF are low
438
What is the prophylaxis for Pre-eclampsia?
Aspirin from week 12 Give aspirin should there be a high-risk factor or two moderate risk factors
439
What is the medical management of pre-eclampsia?
Supportive: Decide whether to admit; BP monitored; US foetus; fluid restrict + Medical: Labetolol ± Eclampsia Medical: IV Magnesium Sulphate **Follow Eclampsia protocol
440
What is HELLP syndrome?
Haemolysis Elevated Liver enzymes Low Platelets A complication of Pre-eclampsia and Eclampsia
441
What is the screening test for Gestational Diabetes? Give the criteria
OGTT Fasting <5.6mmol/L 2 hours <7.8mmol/L Mnemonic: Remember '5-6, 7-8 for 5.6 and 7.8mmol/L as fasting and 2-hour respectively'
442
How is Gestational Diabetes managed?
1) Diet + Exercise trial (1-2 weeks) 2) Metformin 3) Insulin FBG >7mmol/L or FBG >6mmol/L AND foetal macrosomia then start Insulin ± Metformin
443
When should a baby be delivered should a woman have pre-existing diabetes?
37-39 weeks
444
What should be done if a baby's blood sugar falls below 2mmol/L?
IV Dextrose
445
What are the complications of gestational diabetes?
``` Foetal macrosomia Neonatal hypoglycaemia Polycythaemia Jaundice Congenital heart disease Cardiomyopathy ```
446
A patient presents with itching on the volar surfaces, fatigue and dark urine. Additionally they appear slightly yellow. You notice an urticarial rash on the abdomen. What is your differential?
Polymorphic eruption of pregnancy
447
Which LFT can increase up to 4x in pregnancy?
ALP - due to placental production
448
What is the management of Obstetric Cholestasis?
Supportive: Emollients; Antihistamines; Vitamin K (if PT prolonged) + Medical: Ursodeoxycholic acid
449
Outline the pathophysiology of acute fatty liver of pregnancy.
Impaired processing of FAs in he placenta due to LCHAD deficiency which results in accumulation of FAs in the liver with subsequent steatosis and steatohepatitis
450
A G3P2 woman who is 32+4 pregnant presents with nausea and vomiting. She appears notably yellow with abdominal pain and ascites. Bloods show raised ALT and AST with reduced platelets. What is your differential?
Acute fatty liver of pregnancy
451
What is the management of Acute Fatty Liver in Pregnancy?
Prompt admission and delivery of the baby
452
Give an example of a rash seen in pregnancy.
Atopic eruption of pregnancy - E type or P type Melasma Pyogenic granuloma Pemphigoid gestationis Polymorphic eruption of pregnancy Meningococcal septicaemia
453
On US-Scan it is noted that placenta is present in the lower uterus, reaching the internal os but does not cover it. What is your differential? A. Placental abruption B. Placenta praevia grade I C. Placenta praevia grade II D. Placenta praevia grade III
C
454
On US-Scan it is noted that placenta is present in the lower uterus, reaching the internal os and does cover it. What is your differential? A. Placental abruption B. Placenta praevia grade I C. Placenta praevia grade II D. Placenta praevia grade III
D
455
what are the key features of placenta praaevia?
Painless PV Bleed Uterus not tender Foetal heart rate normal
456
How is placenta praaevia managed?
Supportive: Scan at 34 weeks, then at 36 weeks (plan delivery); Corticosteroids from 34 wks; Planning C-section + Delivery: Grade 1 = attempt SVD Grade 3/4 = planned C section
457
What sign is characteristically seen in vasa praaevia?
Foetal bradycardia
458
Outline the pathophysiology of Vasa praevia.
Foetal vessels are exposed, external to the umbilical cord 1) Velamentous umbilical cord: umbilical cord inserts into chorioamniotic membrane with foetal vessel travelling unprotected through membranes prior to joining placenta 2) Accessory placental lobe (succenturiate lobe) connects foetal vessels running through chorioamniotic membranes between placental lobes Usually foetal vessels run in umbilical cord with Wharton's jelly surrounding
459
How is vasa praevia managed?
Corticosteroids + Elective CS at 34-36 weeks If emergency: Emergency CS
460
How is a placental abruption managed?
Supportive: A-E assessment; Bloods; Crossmatch 4 units of blood; IV Fluids; CTG; Anti-D prophylaxis + Surgical: Emergency C-section
461
A foot through the cervix with the leg extended is known as? A. Complete breech B. Incomplete breech C. Extended breech D. Footling breech
D
462
A baby is positioned with one leg flexed at the hip and other extended at the knee. What position is this? A. Complete breech B. Incomplete breech C. Extended breech D. Footling breech
B
463
How may a Breech birth be managed?
Supportive: External cephalic version (ECV) at 36 weeks (nulliparous) or 37 weeks (birthed previously); Terbutaline; Anti-D prophylaxis and Kleihauer test
464
What are the causes of cardiac arrest in Pregnancy?
Mnemonic: 4Ts and 4Hs Toxin Tension pneumothorax Tamponade Thrombosis Hypovolaemia Hyperkalaemia/Hypoglycaemia Hypothermia Hypoxia
465
How do you manage a collapsed pregnant woman?
Supportive: Call for help; A-E; LLD position (reduce aortocaval compression) Consider: A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta Early intubation to protect the airway Early supplementary oxygen Aggressive fluid resuscitation (caution in pre-eclampsia) Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR
466
Outline the stages of labour.
First stage: first contraction to 10cm cervical dilation - Latent phase: 0-3cm with irregular contractions - Active phase: 3-7cm with regular contractions Second stage: 10cm to delivery of baby Third stage: Delivery of placenta
467
How can you reduce the frequency of Braxton-Hicks contractions?
Hydration and relaxation
468
What is a premature baby?
Baby born before 37 weeks
469
How can you prevent preterm labour?
Vaginal progesterone Cervical cerclage
470
What markers are indicative of amniotic fluid?
IGFBP-1 PAMG-1
471
What is the management of PPROM?
Supportive: ABX + Delivery at 34+ weeks
472
What is the management of preterm labour?
Supportive: Foetal monitoring; Corticosteroids + Medical: Tocoylysis; IV Mag Sulph
473
Give an example of tocolytic agents.
Terbutaline (ß2 agonist) Nifedipine (CCB) Atosiban (OT-R antagonist)
474
What monitoring is required for magnesium toxicity given in premature babies? A. No monitoring needed B. Daily C. Four times daily D. Six times daily
D - monitor up to every 4 hours Monitor: - Obs - Tendon reflexes
475
What are the signs of magnesium toxicity in a pregnant woman?
RR depression BP decreased Absent reflexes
476
What scoring system is used to determines need for induction of labour?
Bishops Score Score of <5 = induction needed Score of >8 = induction of labour occurring
477
What are the potential options to induce labour?
Membrane sweep: finger into cervix to stimulate PGE2 (Dinoprostone): PGE2 stimulates cervix and uterus to cause onset of labour Cervical ripening balloon (CRB): silicone balloon into cervix which dilates the cervix Artificial rupture of membranes + OT infusion: used after PGE2 or if PGE2 already used Oral mifepristone (anti-progesterone) + Misoprostol (PGE2) = induce labour where intrauterine foetal death occurred
478
What are the main methods of monitoring during induction of labour?
CTG Bishop score
479
Give the complications of IoL.
Uterine hyperstimulation (5 in 10 mins or more than 2 mins) Foetal compromise Emergency Caesarean section Uterine rupture
480
What imaging modality is used in CTG?
US
481
Give 5 indications for continuous CTG monitoring.
``` Sepsis Maternal tachycardia (>100bpm) Pre-eclampsia APH Significant meconium Delay in labour Use of OT Disproportionate maternal pain ```
482
What are the key features of a CTG? Explain.
Mnemonic: DR C BRAVADO Define Risk: High vs Low risk Contractions (big peaks): Duration/Intensity e.g. 2 in 10, lasting 1 minute Baseline RAte: over 10 minute period Variability: 5-25bpm normal - reassuring, non-reassuring or abnormal Accelerations: >15bpm or >15 seconds cf baseline = reassuring when with contractions Decelerations: <15bpm or <15 seconds cf baseline. May occur when uterine contractions begin and recover when uterine contraction stops Overall impression
483
Give 4 types of decelerations.
``` Early = gradual dips corresponding to uterine contractions Late = gradual fall after uterine contraction - indicate hypoxia Variable = abrupt decelerations unrelated to uterine contractions with fall of more than 15bpm from baseline, lasting less than 2 minutes Prolonged = 2-10 minutes with drop of >15 bpm from baseline indicating compression of umbilical cord causing foetal hypoxia ```
484
What is the rule of 3 for foetal bradycardia?
3 minutes – call for help 6 minutes – move to theatre 9 minutes – prepare for delivery 12 minutes – deliver the baby (by 15 minutes)
485
What is the MOA of Oxytocin?
OT binds to OT-R in the myometrium of the uterus to stimulate contractions OT binds to OT-R in myoepithelial cells of breast which stimulates contraction of the mammary glands
486
What medications can be used as a Tocolytic, reversing the effects of Oxytocin?
Atosiban Nifedipine
487
When is Ergometrine used?
In 3rd stage of labour during a PPH
488
What are the side effects of Ergometrine?
Hypertension Diarrhoea Vomiting Angina
489
What medication is the combination of Ergometrine and Oxytocin?
Syntometrine
490
How may Dinoprostone be administered?
Directly into the vagina Pessary Gel Tablet
491
What is the MOA of Nifedipine in Tocolysis?
CCB thus reduce smooth muscle contraction in BV and uterus Treats hypertension Tocolysis
492
What is the MOA of Carboprost in labour?
Synthetic prostaglandin analogue thus binds to prostaglandin to stimulate uterine contraction in PPH 3rd line behind Ergometrine and OT
493
Give 5 RFs for PPH
``` Prolonged labour Previous PPH Pre-eclampsia Increased maternal age Polyhydramnios Macrosomia Placenta praaevia Placenta accrete Ritodrine (ß2 agonist) ```
494
How is a PPH managed?
A-E management IV Syntocinon 10U or IV Ergometrine 500mcg ± IM Carboprost ± Failed medical Surgery: IUB; Ligation of uterine artery; Hysterectomy
495
What are the types of PPH?
Primary <24 hours Secondary 24 hours - 12 weeks
496
What is the MOA of TXA? When may it be used in pregnancy?
Antifibrinolytic which binds to plasminogen to prevent it converting to plasmin thus reduced dissolving of fibrin clot. Prevention of clot breakdown May be used in PPH
497
How can assessment of progression be surmised?
3Ps of parturition Passenger Passage Power
498
How long should the second stage last?
2 hour in nulliparous woman 1 hour in multiparous woman
499
What factors make up Passenger in the 3Ps?
Size (large vs small) Attitude (posture) Lie (longitudinal; transverse; oblique) Presentation (Cephalic; Shoulder; Face; Complete breech; Frank breech; Footing breech)
500
How is failure to progression managed?
Amniotomy OT infusion Instrumental delivery Caesarean section
501
How long should the third stage of labour take?
30 mins if active 60 mins if physiological
502
What are the analgesic options available in pregnancy?
Simple analgesia: Paracetamol early in labour Entonox (NO:O2): taken during contractions for short term relief IM Pethidine/Diapmorphine: IM injection for anxiety and distress PCA with IV Remifentanil: careful monitoring from anaesthetist should adverse effects occur - -> RR drop Tx with Naloxone - -> Bradycardia Tx with Atropine Epidural: injection of levobupivicaine + fentanyl into the epidural space (outside dura mater)
503
What are the adverse effects of an epidural block?
``` Headache after insertion Hypotension Motor weakness Nerve damage Prolonged second stage Increased probability of instrumental delivery ```
504
Give 3 RFs for umbilical cord prolapse.
``` Prematurity Multiparity Polyhydramnios Twin pregnancy Abnormal presentation Cephalopelvic disproportion ```
505
How is an umbilical cord prolapse managed?
Supportive in stages Mnemonic: Push, Pre-heat, Place 4s, Prevent contractions; Pee Presenting part of foetus can be pushed back to avoid compression Cord past level of introitus, keep warm and avoid vasospasm Place patient on all 4s Tocolytics to reduce uterine contractions Retrofilling the bladder (500mL saline) elevates preventing part
506
What sign is suggestive of a shoulder presentation clinically?
Turtle-neck sign - head presents but retracts back into vagina
507
How is a Shoulder dystocia managed?
Mnemonic: HELPERR ``` Help Evaluate for episiotomy Legs to McRoberts position Pressure: Suprapubic pressure Enter manoeuvres: Internal rotation (Rubins or Wood's screw manoeuvre or Zavanelli manoeuvre) Remove posterior arm Roll patine onto all fours ```
508
What are the potential complications of shoulder dystocia?
Foetal hypoxia Brachial plexus injury and Erb's palsy Perineal tear PPH
509
What are the risks of an instrumental delivery?
``` Perineal tear Episiotomy PPH Injury to anal sphinter Nerve injury Incontinence ``` ``` Cephalohaematoma Facial nerve palsy ICH Skull fracture SCI ```
510
What is the main complication of a venthouse delivery?
Cephalohaematoma - collection of blood between skull and periosteum thus does not cross suture lines Caput Succadeum - collection of blood between skin and periosteum thus crosses suture lines
511
What are the main risks of a forceps delivery to the baby?
Fat necrosis | Facial nerve palsy
512
What nerve injuries may occur in an instrumental delivery?
Baby: Facial nerve Brachial plexus Mother: Femoral nerve Obturator nerve
513
Why may a foot drop occur in pregnancy?
The lumbosacral plexus may be compressed by the fetal head during the second stage of labour. Injury to this network of nerves nerve can cause foot drop and numbness of the anterolateral thigh, lower leg and foot. OR Common perineal nerve compressed by head of fibula when in lithotomy position Therefore... Neuropraxia of the sacral nerves resulting in damage to Deep Peroneal Nerve (L4-S1) with numbness of anterolateral thigh, lower leg and foot
514
Which of the following does not increase the risk of perineal tears? A. Nulliparity B. Shoulder dystocia C. Occipito-posterior position D. Caucasian ethnicity
D - Increased with Asian ethnicities
515
A tear limited to the frenulum of the labia majora is said to be? A. Second degree B. First degree C. Third degree D. Fourth degree
B
516
A tear which includes the perineal muscles is said to be? A. First degree B. Third degree C. Second degree D. Fourth degree
C
517
A tear which includes the perineal muscles and <50% of the EAS? A. First degree B. Third degree (a) C. Third degree (b) D. Fourth degree
B
518
A tear which includes the perineal muscles and more than 50% of the EAS is said to be? A. First degree B. Third degree (b) C. Third degree (c) D. Fourth degree
B
519
A tear which includes the perineal muscles and more than 50% of the EAS as well as the rectal mucosa is said to be? A. First degree B. Third degree (b) C. Third degree (c) D. Fourth degree
D
520
A tear which includes the perineal muscles, more than 50% of the EAS and the IAS is said to be? A. First degree B. Third degree (b) C. Third degree (c) D. Fourth degree
C
521
How is a perennial tear managed?
Supportive: ABX; Laxatives; Physiotherapy; FU ± Surgery... First degree: Supportive Second degree: Suturing on ward Third degree: Repair in theatre Fourth degree: Repair in theatre
522
How can you reduce the risk of perineal tears?
Perineal massage: massage perineum from week 34 onwards to prepare for stretch of tissues Episiotomy: mediolateral episiotomy (45 degree incision) under LA to avoid damaging anal sphincter
523
What are the two ways to manage the 3rd stage of labour?
Physiological: placenta delivered by maternal effort without medications/cord traction Active management of third stage: IM Oxytocin and careful traction
524
What is the indication for active management of the 3rd stage of labour?
> 60 mins PPH
525
What is the criteria for a minor or major PPH?
Minor = <1000mL Major = >1000mL
526
What are the causes of a PPH?
Mnemonic: 4Ts Tone Trauma Tissue Thrombin
527
How is a PPH managed?
Supportive: A-E; cross-match blood; blood tests; IV fluids; Oxygen; FFP; Rubbing uterus or Catheterisation + Tx cause (tissue/tone/thrombin/trauma) ± Medical: OT/Ergometrine/Carboprost/Misoprostol/TXA ± Surgical: IUB; Uterine artery ligation; B-Lynch suture; Hysterectomy
528
What are the risks of a Caesarean section?
``` Emergency hysterectomy Need for further surgery Bladder injury Ureteric injury ICU admission Death (1 in 12 000) ``` ``` Need for another C section Wound discomfort Readmission to hospital Haemorrhage Infection ```
529
Which incision may be used for a Caesarean section?
Pfannenstiel incision: curved incision two fingers above pubic symphysis Joel-Cohen incision: straight incision slightly higher than Pfannenstiel incision
530
What are the layers of the abdomen dissected during a Caesarean section?
Skin Subcutaneous tissue Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles) Rectus abdominis muscles (separated vertically) Peritoneum Vesicouterine peritoneum (and bladder) – the bladder is separated from the uterus with a bladder flap Uterus (perimetrium, myometrium and endometrium) Amniotic sac
531
What are the key features of Chorioamnionitis?
``` non-specific sepsis signs: Fever/Tachycardia/Hypotension/Hypoxia/ Increased respiratory effort/ Altered consciousness/ Reduced urine output/ foetal compromise on CTG + Abdominal pain Uterine tenderness Vaginal discharge ```
532
How is chorioamnionitis managed?
Call for help Start Sepsis Six (Fluids/ABX/O2 + Cultures/Urine/Lactate) Follow local guidelines for ABX such as Pip/Taz + Gent
533
What is the management of an Amniotic Fluid Embolism?
A-E Call for help MDT input
534
What is the pathophysiology behind an Amniotic Fluid Embolism?
The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism. The mortality rate is around 20% or above.
535
What is the main risk factor for a Uterine Rupture? A. Previous uterine surgery B. Increased BMI C. High parity D. Previous Caesarean section
D
536
How is a Uterine Rupture managed?
A-E Call for help Caesarean section + Stop bleeding + Hysterectomy
537
Which of the following is not a standard method of managing a Uterine Inversion? A. Johnson Manoeuvre B. Hydrostatic methods C. Surgery D. Wood's Screw manoeuvre
D - Wood's Screw manoeuvre performed with a Rubins whereby hand is placing pressure on anterior aspect of posterior shoulder to rotate the baby
538
What does the 6 week postnatal check comprise of?
``` General wellbeing Bleeding and menstruation Scar healing Breastfeeding Mood and depression ``` BP Urinalysis FBG
539
How long may lochia persist?
6 weeks
540
When is fertility required post-partum?
21 days after giving birth
541
Which method of contraception is not safe in breastfeeding? A. POP B. Implant C. Copper coil D. COCP
D - not for 6 weeks after childbirth
542
When can the copper coil be inserted following childbirth?
<48 hours or >4 weeks postpartum
543
How is postpartum endometritis caused?
It can occur in the postpartum period, as infection is introduced during or after labour and delivery. The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.
544
What is the gold-standard for diagnosing retained PoC?
US
545
How is retained PoC managed?
Surgical removal: Evacuation of retained products of conception (ERPC)
546
What is Asherman's Syndrome?
Adhesions form within the uterus causing pain - treated by surgery
547
A woman has a postpartum Hb of 97g/L. What is your management option? A. Iron infusion B. Blood transfusion C. Oral iron D. Watch and wait
C
548
A woman has a postpartum Hb of 87g/L. What is your management option? A. Iron infusion B. Blood transfusion C. Oral iron D. Watch and wait
A
549
A woman has a postpartum Hb of 67g/L. What is your management option? A. Iron infusion B. Blood transfusion C. Oral iron D. Watch and wait
B
550
Why should an anaemic woman who has an infection not receive an iron infusion?
Many pathogens feed on iron thus IV Iron infusion can exacerbate the infection
551
When may the baby blues occur?
< 7 days
552
When does Postnatal depression tend to occur?
3 months
553
What tool can be used to screen for postnatal depression?
Edinburgh Postnatal Depression Scale
554
How is mastitis managed?
Supportive: Continue to breastfeed; hot packs; warm showers ± Failed supportive management Medical: Flucloxacillin
555
A woman presents with sore nipples which are tender and itchy. On examination you see cracked areolas. She has been breastfeeding for 1/12. What is your management? A. Topical miconazole 2% to woman B. Topical miconazole 2% to woman and baby C. Oral ketoconazole D. Supportive management
B
556
Outline the pathophysiology of postpartum thyroiditis.
Pregnancy has an immunosuppressant effect which prevents foetal rejection however increased immune system activity results in antibodies to the thyroid gland - under or over-activity
557
What is the typical pattern to postpartum thyroiditis?
Thyrotoxicosis (<3mo.) Hypothyroid (3-6mo.) Normalisation (up to 12mo.)
558
How is postpartum thyroiditis managed?
Treat according to phase - e.g. Levothyroxine for hypothyroidism or Propanolol for thyrotoxicosis
559
What is Sheehan's Syndrome? How is it managed?
PPH causes reduced intravascular volume with hypoperfusion to the pituitary gland thus reduced hormonal secretion giving off endocrine symptoms: - Reduced lactation - Amenorrhoea - Adrenal insufficiency - Hypothyroidism Tx derangement
560
What is the US threshold for an ectopic pregnancy determining surgical over medical management?
30mm
561
What is the definition for pre-eclampsia?
HTN + Proteinuria >140/90mmHg and proteinuria >0.3g/L >20 weeks of pregnancy
562
What are the potential complications of pre-eclampsia?
``` Papilloedema Eclampsia Pulmonary oedema DIC Renal failure Liver failure Cerebral haemorrhage HELP syndrome Death ``` IUGR Intrauterine death Pre-term delivery
563
What are the clinical features of pre-eclampsia?
Headache Visual changes RUQ/epigastric pain Brisk reflexes Proteinuria Haemolysis; low platelets; elevated liver enzymes
564
Which women should receive pre-eclampsia prophylaxis? What is the prophylaxis?
1+ high risk factors 2+ moderate risk factors 75mg Aspirin from 12wk to birth
565
Give two examples of high risk factors and two examples of moderate risk factors for pre-eclampsia.
High risk: Hypertension CKD Autoimmune condition (including DM) ``` Moderate risk: 1st pregnancy >40 years old BMI >35 FHx pre-eclampsia Multiple pregnancy ```
566
What is the management of pre-eclampsia?
Admission + Oral labetalol (or Nifedipine) ± Steroids (lung maturity) ± IV Magnesium Sulphate (seizure prevention) ± Caesarean section
567
Which ethnic group may have a higher incidence of obstetric cholestasis?
Asians
568
What are the clinical features of obstetric cholestasis in pregnancy?
Pruritus Jaundice Raised sBr
569
What is the management of cholestatic jaundice?
Cholestyramine + Induction of labour at 37/38 weeks
570
How likely is cholestatic jaundice to occur in subsequent pregnancies?
45-90%
571
What are the potential effects of diabetes mellitus in pregnancy on the mother? What would the potential effects be on the foetus?
``` Mother: Diabetic nephropathy Diabetic retinopathy Risk of miscarriage Pre-eclampsia Operative delivery ``` ``` Foetus: Polydramnios Macrosomia Shoulder dystocia DDH Congenital abnormalities ```
572
When is screening for gestational diabetes undertaken?
Booking AND 24-28 weeks done by OGTT
573
How can an OGTT be interpreted in the context of gestational diabetes?
"5, 6, 7, 8" FPG: >5.6mmol/L 2-hour: >7.8mmol/L
574
At what FPG threshold should insulin be started?
>7mmol/L
575
How is diabetes managed in pregnancy?
Increased insulin requirements + Induction of labour at 38/39wk
576
What is the management of epilepsy in pregnancy?
``` Folic acid 5mg + Continue medication (lamotrigine) + Vitamin K from 36 weeks ```
577
Why is vitamin K given in pre-eclampsia?
Reduce chances of haemorrhagic disease of the newborn
578
What are the thresholds for anaemia in pregnancy?
1/3: <110 2/3 and 3/3: <105
579
What is the management of anaemia in pregnancy?
Check at 16 and 28 weeks Tx cause
580
Why may Grave's disease cause thyrotoxicosis in pregnancy?
Similarity between ßhCG and TSH receptor means elevated ßhCG in pregnancy binds to TSH receptor and causes thyrotoxicosis
581
What is the treatment of a woman with hyperthyroidism in pregnancy?
Propylthiouracil (in first semester) Carbimazole (in second semester)
582
What is a potential side effect of Propylthiouracil?
Hepatic injury
583
How do you treat hypothyroidism in pregnancy?
Levothyroxine and increase the dose by 50%
584
How is a VTE managed in pregnancy?
LMWH
585
When should VTE thromboprophylaxis be given in pregnancy?
Carry out risk factors High risk or 4+ RFs = LMWH till 6wks postpartum 3+ RFs = LMWH from 28wks to 6wks postpartum
586
Which anticoagulants are CI in pregnancy?
Warfarin DOACs
587
What can reduce vertical HIV transmission in pregnancy?
Antiretrovirals (and low viral count) C-section Neonatal antiretroviral therapy Bottle feeding (do not breast feed)
588
When would vaginal delivery be acceptable in a patient with HIV?
Viral load <50 copies/mL at 36 weeks
589
What are the clinical features of rubella in a pregnant woman?
Maculopapular rash Arthralgia Lymphadenopathy
590
What are the clinical features of a neonatal rubella infection?
Sensorineural hearing loss Cataracts CHDs
591
What cardiac abnormality is most common in rubella infection?
PA stenosis PDA
592
What are the clinical features of foetal varicella syndrome?
Deafness Limb hypoplasia Skin scarring
593
What is the management for a herpes infection in a pregnant woman?
C-section within 6 weeks of primary exposure
594
What are the features of neonatal herpes virus?
``` Herpes lesions at skin and mucosal membranes CNS disease (e.g. encephalitis) ``` Disseminated infection
595
What are the clinical features of CMV infection?
Mnemonic: 'CMV' Calcification Microcephaly Visual changes (cataracts)
596
What is the most common cause for early-onset neonatal sepsis?
GBS most common in first 3 days of life
597
What is the most common cause of late-onset neonatal sepsis?
3 days to 30 days ``` S epidermis P aeruginosa Klebsiella Enterobacter S aureus Enterococcus ```
598
What are the potential adverse effects of Gentamicin?
Ototoxicity Nephrotoxicity
599
When is Gentamicin contraindicated?
Myaesthenia Gravis - reduces neuromuscular transmission
600
What is the MOA of gentamicin?
Inhibition of 30s ribosomes to reduce bacterial protein synthesis
601
What pregnancy tests are done in weeks 8-12 of gestation?
Booking visit: diet; alcohol; smoking; folic acid; vitamin D; antenatal classes Booking bloods/urine: Bloods: FBC, blood group, Rh status, Red cell alloantibodies, Haemaglobinopathies BBV: HIV, syphilis and Hep B Urine: Asymptomatic bacteriuria
602
What is done at 10-13+6 weeks?
Early scan - confirm dates
603
What is done at week 11-13+6?
Down syndrome screening (triple test) PAPP-A + ßhCG + Nuchal translucency
604
What does the quadruple test consist of? When is it conducted?
15-20 wks AFP, ßhCG, Inhibin-A, Oestriol
605
What tests are done at 18-20+6 wks?
Anomaly scan
606
What additional tests are done if the lady is primipara?
25 wk and 31wk 'routine check'
607
What is done at week 28?
routine care (SFH, blood, urine) Anaemia check RBC Alloantibodies 1st dose anti-D
608
What is done at week 34?
Routine care 2nd dose anti-D
609
What is done at week 36?
Information sharing External cephalic version (if indicated)
610
What is done at week 38?
Routine care
611
Outline the pathophysiology of Rhesus incompatibility.
Rhesus negative mother with Rhesus positive baby results in anti-D IgG antibodies when foetal blood crosses into maternal circulation. In subsequent pregnancies, this can cross the placenta and cause haemolysis in the foetus
612
When should anti-D immunoglobulin be given within 72 hours?
``` Delivery of Rh+ve infant ToP Miscarriage if gestation >12 weeks Ectopic pregnancy if managed surgically External cephalic version (in case of leak) APH Amniocentesis/CVS/Foetal blood sampling (leak) Abdominal trauma (leak) ```
613
What antenatal checks are done at 8-12 weeks?
Booking visit: lifestyle; BP, urine dipstick, BMI Bloods: FBC; Allotypes; Rh status; Blood group BBV: Hep B, HIV, Syphilis Urine culture
614
What is done at 10-13+6 weeks antenatally?
Early pregnancy scan to confirm dates
615
What is done at 11-13+6 weeks?
Down syndrome screening ßhCG; PAPP-A and Nuchal Ligament
616
What is done at 16 weeks?
Routine care (BP + Urine) Share results
617
What is done at 18-20+6 weeks?
Anomaly scan
618
What is done at 28 weeks?
Routine care Screen for bloods Anti-D prophylaxis if Rhesus negative woman
619
What happens at week 34 in the antenatal care plan?
Second dose of anti-D prophylaxis to rhesus negative woman
620
What occurs at week 36 of the antenatal care time table?
External cephalic version
621
What occurs at week 38 of antenatal care timetable?
Routine care
622
What are the 3 types of monozygotic twins?
DCDA (<3 days) MCDA (4-7 days) MCMA (>8 days) Conjoined twins (late)
623
What are the clinical features of IUGR?
SGA on scans SFH low Low birth weight (<10th centime)
624
What are the causes of intrauterine death? Give 3.
Foetal: Chromosomal abnormalities; Infection; Twin-twin transfusion syndrome Maternal: Chronic disease; obstetric cholestasis; Rhesus disease; Thrombophilia Placenta: Abruption; Pre-eclampsia; Smoking
625
What is the gold-standard test for IUD?
USS
626
What is the medical management of miscarriage?
Misoprostrol - contact doctor if bleeding hasn't stopped in 24 hours
627
What is the surgical management of a miscarriage?
Vacuum D+C
628
Outline the types of miscarriage.
Threatened = bleeding + Os closed + USS fine Inevitable = heavy bleeding + Os open Incomplete = pain + bleeding + Os open Missed = gestational sac + Os closed
629
Give 5 risk factors for placental abruption.
``` Trauma Smoking Cocaine Antiphospholipid syndrome Hypertension Increasing maternal age Multiparity ```
630
Give 3 potential risk factors for preterm labour.
``` Acute illness Low BMI Multiple pregnancy Polyhydramnios PROM ``` PMHx preterm Smoking Uterine abnormalities Previous cervical injuries
631
Discuss how you would interpret a CTG.
Mnemonic: DR C BRAVADO Determine Risk Contractions Baseline RAte Variability Accelerations (>15bpm for >15 seconds) Decelerations >15bpm for >15 seconds) Overall impression
632
Give 5 potential indications for induction of labour.
``` Postmaturity (>40 weeks) Obstetric cholestasis Failure to progress Suspected IUGR Gestational diabetes IUD Pre-eclampsia Rhesus incompatibility ```
633
What are the complications of induced labour?
Hyperstimulation Prolonged contractions that are frequent (tachysystole) Uterine rupture
634
How would you manage a shoulder dystocia?
Mnemonic: HELPERR ``` Help Evaluate for episiotomy Legs to McRoberts Pressure (suprapubic) Enter manoeuvres (internally rotate) Remove posterior arm Roll patient onto all fours and begin the cycle ```
635
Give 5 RFs for a PPH
``` PMHx PPH Pre-eclampsia Prolonged labour Polyhydramnios Emergency C section PP; PA; Placental accrete Macrosomia ```
636
What are the options for managing a postpartum haemorrhage?
IV Syntocinon 10 U or IV Ergometrine 500mcg or IM Carboprost if that fails... IU Balloon tamponade
637
How may a PPH be classified?
Major: >1L Minor: >500mL Primary: <24hrs Secondary: 1 day to 12 weeks
638
What proportion of women experience the baby blues?
60-70%
639
What are the clinical features of the baby blues?
Anxious Tearful Irritable
640
What is the management of the baby blues?
Reassurance | Support
641
What proportion of women experience postnatal depression?
10%
642
What is the treatment for a patient with postpartum depression?
CBT/reassurance SSRIs (Paroxetine) if severe
643
What are the features involved in Puerperal psychosis?
Mood swings - psychotic features e.g. THREAD LESS features or impulsivity and energy
644
What is the management for puerperal psychosis?
Hospital admission (Mother and Baby Unit)
645
What is the reoccurrence rate of post-partum psychosis?
25-50%
646
What are the associations of hyperemesis gravidarum?
``` Multiple pregnancies Trophoblastic disease (molar pregnancy) Hyperthyroidism Nulliparity Obesity ```
647
What is associated with a decrease in hyperemesis gravidarum?
Smoking
648
When should you refer for N/V in pregnancy?
Unable to keep down foods >5% BW despite anti-emetic treatment Confirmed comorbidity e.g. cannot tolerate PO ABX for UTI
649
What scoring system may be used in NVP?
PUQE score
650
What is the management of Hyperemesis Gravidarum?
Drugs: Cyclizine Supportive: Ginger and P6 wrist accupressure
651
What are the potential complications of Hyperemesis Gravidarum?
Wernicke's encephalopathy Mallory-Weiss tears Central pontine myelinolysis ATN SGA Pre-term birth
652
What is the gold standard test for Ectopic?
TVUS
653
What are the management options for an ectopic pregnancy?
Expectant: hCG <1000 Size <35mm Asymptomatic Medical: Methotrexate hCG <1500 Size <35mm Surgery: Salpingectomy hCG >5000 Size >35mm Pain
654
What is the risk of a repeated ectopic in the future following an ectopic pregnancy?
10-15%
655
What are the risk factors for Cervical cancer?
``` HPV-16 and HPV-18 Smoking HIV Early first intercourse, many partners (young and early) High parity Lower socieconomic status COCP ```
656
What is the gold standard for Cervical cancer treatment?
1 - radical excsision OR TAH + LN clearance 2 - TAH + LN clearance 3/4 - radiotherapy + chemo
657
State 3 RFs for endometrial cancer.
``` Obesity SERM Early menarche/late menopause Oestrogen secreting tumours HRT Lynch syndrome PCOS ```
658
Which familial colorectal cancer syndrome is linked to Endometrial cancer?
Lynch syndrome
659
What is the most common presenting symptom of endometrial cancer?
PMB Intermenstrual bleeding (if premenopausal)
660
What is the first line investigation for endometrial cancer?
TVUS
661
What is the gold-standard investigation of endometrial cancer?
Hysteroscopy with endometrial biopsy
662
What is the management of Endometrial cancer?
TAH + BSO
663
What is the pathophysiology of a hydatidiform mole?
Benign tumour of trophoblastic material formed from empty egg fertilised with single sperm thus duplicates on its own so 46 chromosomes of paternal origin
664
What are the clinical features of a molar pregnancy?
Hyperemesis Large for dates High ßhCG Hypertension and hyperthyroidism
665
How is a molar pregnancy managed?
Referral to specialist centre Contraception to avoid pregnancy for 12 months
666
What condition may be developed following a molar pregnancy?
Choriocarcinoma
667
What is the predominant cell type of vulval cancer?
Squamous cell carcinoma (80%)
668
What are the risk factors for vulval carcinoma?
HPV infection VIN Immunosuppression Lichen sclerosis
669
What are the clinical features of a vulval carcinoma?
Lump/ulcer on labia majora Inguinal lymphadenopathy Itching/irritation
670
What is the main causative organism of PID?
C trachomatis
671
What are the clinical features of PID?
``` Fever Abdo pain Deep dyspareunia Discharge/menstrual irregularities Cervical/vaginal discharge ```
672
What are the clinical investigations in a suspected PID?
Rule out pregnancy with pregnancy test VVS Swab + ask for a NAAT
673
What is the treatment for PID?
Oral ofloxacin + Oral metronidazole IM ceftriaxone + PO doxycycline + PO metronidazole
674
What are the potential complications of PID?
Fitz-Hugh-Curtis syndrome Infertility Chronic pelvic pain Ectopic pregnancy
675
What are the clinical features of endometriosis?
Dysmenorrhoea Deep dyspareunia Chronic pelvic pain Ovulation pain Tenderness on examination
676
What is the gold-standard investigation of endometriosis?
Laparoscopy
677
What is the management of endometriosis?
NSAIDs/paracetamol COCP GnRH analogues (reduces oestrogen) Surgery
678
What are the clinical features of a Bartholin's abscess?
``` Pain Swelling Dyspareunia Unilateral vulval swelling Abscess erythematous and tender to palpation ```
679
What is the management of a Bartholin's cyst?
Incision and drainage and marsupialisation (inner cyst wall sutured to skin)
680
Give 3 causes of primary and secondary amenorrhoea.
Gonadal dysgenesis Imperforate hymen CAH Congenital malformation of genital tract ``` Hypothalamic amenorrhoea PCOS Hyperprolactininaemia POF Thyrotoxicosis Sheehan's syndrome Asherman's syndrome ```
681
What is the MOA of the COCP?
Inhibit ovulation
682
What are the potential side effects of the COCP?
VTE risk | Breast cancer and cervical cancer risk
683
What is the MOA of the POP?
Thickens cervical mucous
684
What are the side effects of POP and IUS?
Irregular menstrual bleeding
685
How should you advise a girl starting on the COCP?
First 5 days of cycle fine If after, 7 days of condoms, covered
686
If a woman misses two of her COCPs in week 2 of her pack, what advice would you give?
Take missed pill, continue, no need for emergency contraception
687
If a woman misses two of her COCPs in week 3 of her pack, what advice would you give?
Finish current pack then start new pack newt day thus omit the pill-free interval
688
When can a woman start her POP regarding condom usage?
Need condoms for 2 days
689
What options of emergency contraception are there?
Levornogestrel - take within 72 hours Single dose 1.5mg Ullipristal - take within 5 days CI in asthma Breastfeeding delayed 1 week IUD - copper IUD as spermatotoxic; insert within 5 days of UPSI
690
What would a hormone profile show in a menopausal woman?
Raised LH and raised FSH | Low oestrogen
691
How should HRT be given?
Oestrogen deficient therefore oestrogen but must not be unopposed oestrogen Topical SSRIs Combined patch Oestrogen + IUS Other combinations
692
What are the risks of HRT?
Endometrial cancer CVD/CVI VTE Gallbladder disease
693
What is ovarian hyperstimulation syndrome?
Following IVF, hyper stimulated ovaries release vasoactive products which cause capillary permeability and potential pulmonary, renal and VTE risks
694
What are the clinical features of ovarian hyperstimulation syndrome?
Abdominal pain Bloating N/V HF presentation VTE
695
What are the RF for an ovarian torsion?
Pregnancy OHS Ovarian mass
696
What are the clinical features of an ovarian torsion?
Abdo pain - colicky N/V Distressed Adnexal tenderness
697
What is shown on a US in an ovarian torsion?
Whirlpool sign
698
What is the diagnostic and gold standard management for a patient with Ovarian torsion?
Laparoscopy
699
What is the commonest form of ovarian cyst?
Follicular cyst
700
Which cyst, if ruptured may cause pseudomyxoma peritonei?
Muscinous cystadenoma

Medicine (18 decks)

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