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Medicine > Obs and Gynae > Flashcards

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
Q

Which of the following is not a structure derived from the endoderm?

A. Pancreas

B. Thyroid

C. Liver

D. Kidneys

A

D - these are a mesodermal structure

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26
Q

Which of the following is not of endodermal origin?

A. Duodenum

B. Liver

C. Lungs

D. Heart

A

D

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27
Q

Which of the following is not a mesodermal structure?

A. Heart

B. Bone

C. Blood

D. Nervous system

A

D

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28
Q

List 3 structures of ectodermal origin.

A

Hair
Nails
Teeth
CNS

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29
Q

What cells become the placenta?

A

Chorion frondosum - cells located near connecting stalk of developing embryo

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30
Q

What structure is the umbilical cord derived from?

A. Chorion frondosum

B. Mesoderm

C. Yolk sac

D. Connecting stalk

A

D

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31
Q

What is the pathophysiology of pre-eclampsia in embryological development?

A

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

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32
Q

State 5 functions of the placenta.

A

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

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33
Q

What side effects may progesterone cause in pregnancy?

A

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)

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34
Q

A mother is experiencing recurrent genital herpes, would her foetus be protected and why?

A

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.

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35
Q

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.

A

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

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36
Q

Why may linea nigra and melasma occur in pregnancy?

A

Increased MSH from the anterior pituitary results in pigmentation of the skin

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37
Q

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

A

D - CO is increased

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38
Q

Which of the following is not a renal change in pregnancy?

A. Increased eGFR

B. Increased aldosterone

C. Decreased protein excretion

D. Physiological hydronephrosis

A

C - increased proteinuria (<0.3g/24 hours)

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39
Q

Which of the following is not a haematological change in pregnancy?

A. Erythropoeisis

B. Increased fibrinogen

C. Increased white blood cells

D. Normal ALP

A

D - ALP may increase up to x4 due to placental secretion

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40
Q

Which of the following is not a dermatological change observed in pregnancy?

A. Striae gravidarum

B. Melasma

C. Palmar erythema

D. Jaundice

A

D - may indicate obstetric cholestasis

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41
Q

If the cervix is 7cm dilated, what stage of pregnancy are they at?

A. Second

B. Third

C. First

D. Fourth

A

C - <10cm = stage 1

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42
Q

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

A

B

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43
Q

What supportive measures may be used to manage Braxton-Hicks contractions?

A

Hydration

Relaxing

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44
Q

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

A

D - the latent phase is ‘late’ thus slower, at 0.5cm/hour

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45
Q

What are the three Ps of the second stage of labour?

A

Passenger> Size; attitude (posture); lie and presentation

Passage: size + shape of pelvis

Power: strength of uterine contractions

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46
Q

What is the difference between a complete breech presentation and a frank breech presentation?

A

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)

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47
Q

What are the cardinal movements of labour?

A

Engagement

Descent

Flexion

IR

Extension

ER

Expulsion

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48
Q

How can you characterise descent?

A

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

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49
Q

What is the indication for active management of the third stage of labour?

What does this involve?

A

Haemorrhage

60 minute delay of placental delivery

Deliver of IM Oxytocin to stimulate myometrial contraction + umbilical cord traction

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50
Q

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

A

D

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51
Q

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

A

B

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52
Q

Which of the following is not a cause of primary amenorrhoea?

A. Congenital malformation of genital tract

B. Contraception

C. CAH

D. Imperforate hymen

A

B

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53
Q

Which of the following is an unlikely cause of IMB?

A. STI

B. Malignancy

C. Ectropion

D. Tampon insertion

A

D - unlikely to cause bleeding between periods. Would be inserted during period and not likely to cause trauma resulting in bleeding

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54
Q

Give 3 causes of dysmenorrhoea.

A 
Copper coil 
Fibroids
Endometriosis 
PID 
STI 
Malignancy (cervical/ovarian)
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55
Q

Give 3 causes of postcoital bleeding.

A

Trauma
Atrophic vaginitis
STI
Malignancy

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56
Q

Give 10 causes of pelvic pain in a female.

A 
IBS 
IBD
Prolapse 
Pelvic adhesions
Appendicitis
Dysmenorrhoea 
Mittelschmerz
PID
UTI 
Ectopic pregnancy
Ovarian torsion
Endometriosis
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57
Q

Give 5 causes of pruritus vulvae.

A 
STI
Irritants - soaps, underwear
Candidiasis 
Eczema
Lichen sclerosus (white plaques and itch) 
Stress
Vulval malignancy
Urinary/faecal incontinence
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58
Q

How may amenorrhoea be classified?

A

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)

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59
Q

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

A

B - pregnancy until proven otherwise

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60
Q

Which of the following is not a hypogonadotropic hypogonadism?

A. Hypopituitarism

B. Cystic fibrosis

C. Turner’s Syndrome

D. Kallman Syndrome

A

C - this is a hypergonadotropic hypogonadism due to gonads failing to respond to gonadotrophin stimulation

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61
Q

What clinical features are associated with Kallman Syndrome?

A

Anosmia + Amenorrhoea

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62
Q

Which investigations may be used in a patient with amenorrhoea?

A 
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
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63
Q

How may you medically manage a Prolactinoma?

A

DA agonists to suppress PL secretion e.g. Bromocriptine

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64
Q

How often are withdrawal bleeds required in women with PCOS and why?

A

3-4 months to reduce risk of endometrial hyperplasia and endometrial cancer

Done via medoxyprogesterone (14 days) or COCP regularly

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65
Q

What are the clinical features of premenstrual syndrome?

A

anxiety
stress
fatigue
mood swings

bloating
breast pain

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66
Q

How can you manage premenstrual syndrome?

A

Supportive: sleep; exercise; smoking cessation; frequently and balanced meals
+
Medical: COCP; SSRI

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67
Q

What phase of the menstrual cycle is premenstrual syndrome experienced?

A

Luteal phase, prior to endometrial breakdown

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68
Q

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?

A

Dysfunctional uterine bleeding

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69
Q

How may menorrhagia be managed?

A

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)
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70
Q

What surgical management of menorrhagia exists?

A

Balloon thermal ablation/Endometrial ablation

Hysterectomy

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71
Q

Which ethnic minority is associated with uterine fibroids?

A

Afro-caribbean women

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72
Q

Why may polycythaemia be a clinical feature of uterine fibroids?

A

Ectopic EPO production

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73
Q

What is the gold-standard investigation to confirm Uterine fibroids?

A. Surgical exploration

B. TV-US

C. Transabdominal Ultrasound

D. Clinical examination

A

B

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74
Q

What is the gold-standard management of menorrhagia secondary to fibroids?

A. Ullipristal

B. NSAIDs

C. LNG-IUS

D. Uterine artery embolisation

A

C

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75
Q

What treatment may be used to shrink/remove fibroids?

A

Medical: Gorsorelin
±
Surgical: Myomectomy; Hysteroscopic endometrial ablation; Hysterectomy; Uterine artery embolisation

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76
Q

What are the RFs of red degeneration?

A

2nd/3rd trimester pregnancy

Large leiomyoma (>5cm)

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77
Q

What is the management of a uterine fibroid that is 4cm?

A

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

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78
Q

What are the complications of fibroids?

A 
Menorrhagia continued - iron deficiency anaemia 
Reduced fertility
Pregnancy complications 
Constipation
Urinary outflow obstruction
UTIs
Red degeneration
Torsion
Malignancy - leiomyosarcoma
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79
Q

What are the clinical features of red degeneration of fibroids?

A

N/V
Severe abdominal pain
Low-grade fever
Tachycardia

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80
Q

What is the gold-standard investigation for endometriosis?

A

Laparoscopy

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81
Q

Give 5 clinical features of endometriosis.

A

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

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82
Q

What is the first line management of endometriosis?

A

NSAIDs/Paracetamol

COCP/Progesterone

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83
Q

When should a patient be referred to gynaecology for endometriosis?

What may they do?

A

Failed analgesia/hormonal Tx or fertility concerns

Medical: GnRH analogues

or

Surgery: Laparoscopic excision; Laser ablation

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84
Q

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

A

C

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85
Q

What is the gold-standard diagnosis of adenomyosis?

A

Histological examination as shows endometrial tissue in the myometrium

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86
Q

What are the associations of adenomyosis?

A 
Infertility
Miscarriage
Pre-term birth
SGA
PPROM
Malpresentation
LUTS
PPH
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87
Q

When is contraceptive recommended in menopause?

A

12 months following last period if >50

24 months following last period if <50 years

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88
Q

What are the clinical features of menopause?

A

Change in menstruation - oligomenorrhoea; amenorrhoea

Vasomotor symptoms - hot flushes; night sweats

Urogenital changes - vaginal dryness and atrophy; urinary frequency

Psychological - mood change

OP
IHD

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89
Q

How is menopause diagnosed?

A

Absence of period for 12 months with the presence of perimenopausal symptoms and the absence of an unlikely diagnosis

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90
Q

How is menopause managed?

A

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

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91
Q

Why is oral oestrogen contraindicated in women without a TAH?

A

Risk of endometrial cancer

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92
Q

What are the risks associated with HRT?

A

VTE

Stroke

CHD

Breast cancer

Ovarian cancer

Endometrial cancer

Risk can be mitigated with topical/transdermal HRT

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93
Q

What difference does tapering HRT compared to a sudden reduction in HRT make?

A

Gradual reduction (tapering) reduces risk of recurrence in short-term but long-term no difference in symptom control

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94
Q

When should a woman be referred to secondary care?

A

She should be referred to secondary care if treatment has been ineffective, if there are ongoing side effects or if there is unexplained bleeding.

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95
Q

A woman asks what the causes of her postmenopausal bleeding may be. What do you tell her?

What investigations would you conduct?

A

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)
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96
Q

When is the defined period of perimenopause?

A

Symptomatic onset to 12 months following the last period

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97
Q

What are the long term complications of menopause?

A

Reduced oestrogen levels thus impact on BMD and atherosclerosis so:
Osteoporosis
Ischaemic Heart Disease

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98
Q

How is menopause managed?

A

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

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99
Q

What are the indications for HRT?

A

Vasomotor symptoms such as flushing, insomnia and headaches

Premature menopause

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100
Q

What is the benefit of using Tibolone as HRT?

A

Both oestrogenic and progesterogenic activity with androgenic activity also

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101
Q

What route of HRT is preferable in a woman at risk of VTE?

A

Transdermal route

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102
Q

What are the contraindications of HRT?

A

History of breast cancer
Current breast cancer

Oestrogen-sensitive cancer

Undiagnosed vaginal bleeding

Untreated endometrial hyperplasia

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103
Q

What are the risks of HRT?

A

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

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104
Q

What is premature ovarian insufficiency?

A

Reduction in oestrogen and elevated FSH/LH prior to 40 years.

1% prevalence

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105
Q

Give 5 causes of premature ovarian insufficiency.

A

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

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106
Q

What type of hormonal disturbance is seen in premature ovarian insufficiency?

A. Hypergonadotropic hypogonadism

B. Hypogonadotropic hypogonadism

C. Hypergonadotropic hypergonadism

D. No change

A

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

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107
Q

Which of the following is not a clinical feature of premature ovarian insufficiency?

A. Oligomenorrhea

B. Vaginal dryness

C. Hot flushes

D. Pregnancy

A

D

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108
Q

How is premature ovarian insufficiency managed?

A

HRT - treat like menopause

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109
Q

What is the diagnostic criteria for Premature Ovarian Insufficiency?

A

Younger than 40 years

Menstrual symptoms

Elevated FSH - >25IU/L on two consecutive samples 4 weeks apart

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110
Q

What is Premature Ovarian Insufficiency associated with?

A

CVD
Stroke

Osteoporosis

Cognitive impairment
Dementia

Parkinsonism

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111
Q

What is the pathophysiology regarding Premature ovarian insufficiency and Dementia?

A

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

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112
Q

What is the pathophysiology regarding Premature Ovarian Insufficiency and Parkinsonism?

A

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

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113
Q

What diagnostic criteria is used in Polycystic Ovarian Syndrome?

A

Rotterdam Criteria:

  • Multiple cysts (>12 with 2-9cm or 1 >9cm)
  • Oligoovulation/Anovulation
  • Hyperandrogenism (acne/hirsutism)
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114
Q

What are the clinical features of PCOS?

A
  • 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
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115
Q

Give 3 other causes of hirsutism.

A

Iatrogenic: Testosterone; Anabolic steroids; Glucocorticoids; Ciclosporin; Phenytoin

Ovarian/Adrenal tumours

Cushing’s Syndrome

Congenital Adrenal Hyperplasia

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116
Q

What is the pathophysiology regarding insulin resistance and androgen secretion in PCOS?

A

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)

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117
Q

Calculate the free androgen index of a patient with:

Total testosterone = 200

SHBG = 20

A

FAI = (T/SHBG) x 100

  = (200/20) x 100 = 10%

Normal can be 0.18-7%

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118
Q

What is the gold-standard investigation in PCOS?

A

TVUS

> 12 cysts of 2-9cm

or

1 cyst >10cm

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119
Q

What radiographic find may be seen in PCOS?

What imaging modality is this usually seen on?

A

“String of pearls” sign seen on TVUS

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120
Q

What is the screening test for diabetes mellitus in PCOS?

What are the criteria?

A

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

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121
Q

How is PCOS managed?

A

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)

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122
Q

What are the options for risk reduction of endometrial hyperplasia/cancer in PCOS?

A

Mirena coil - progestogen secretion

Cyclical progestogen (medroxyprogesterone acetate 10mg OD for 14 days)

COCP

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123
Q

What should be done in a woman with extended gaps (>3/12) or abnormal bleeding prior to pelvic ultrasound?

What is an abnormal finding?

A

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

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124
Q

How long is co-cyprindiol used for and why?

A

Used for 3 months usually then stopped due to risk of VTE

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125
Q

What are the clinical features of ovarian cysts?

A

Can be an incidental find - asymptomatic

Pelvic pain
Bloating
Abdominal fullness
Palpable pelvic mass

Symptoms related to the cyst

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126
Q

Give the types of Ovarian cysts and their key features.

A 
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)

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127
Q

State 5 RFs for Ovarian malignancy.

A 
Increasing age 
Post-menopausal
Increased number of ovulations 
Obesity 
HRT
Smoking 
Breastfeeding (reduces risk) 
BRCA1 / BRCA2
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128
Q

Which tumour marker is used for Ovarian cancer?

A

Ca125

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129
Q

Give 5 causes of raised Ca125.

A 
Endometriosis 
Fibroids
Adenomyosis 
Pelvic infection
Liver disease
Pregnancy
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130
Q

Which set of women with an ovarian cyst need no further investigation?

A

Premenopausal with <5cm cyst that is a simple, ovarian cyst

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131
Q

State the criteria for simple ovarian cyst management based on size in premenopausal women.

A

<5cm will resolve in 3 cycles

5-7cm requires yearly US-monitoring and gynaecology referral

> 7cm requires referral and MRI/surgical evaluation

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132
Q

What is the referral criteria of a cyst in a postmenopausal woman?

A

Urgent referral to gynaecology

Functional cyst less likely as circulating hormones are less

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133
Q

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

A

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134
Q

What are the clinical features of Meig’s Syndrome?

A

Pleural effusion

Ascites

Ovarian fibroma

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135
Q

Give 3 RFs for Ovarian Torsion

A

Ovarian mass

Pregnancy

Ovarian hyperstimulation syndrome

PCOS

Reproductive age

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136
Q

What is the gold-standard diagnosis of an ovarian torsion?

A

Laparoscopic surgery

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137
Q

How is an ovarian torsion managed?

A

Laparoscopic surgery: Detorsion ± Oophorectomy

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138
Q

What is the gold-standard diagnosis for Asherman’s Syndrome?

A

Hysteroscopy

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139
Q

How is Asherman’s Syndrome managed?

A

Dissection

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140
Q

Relate the pathophysiological cellular change to the clinical features of ectropion.

A

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

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141
Q

How is cervical ectropion managed?

A

Only problematic bleeding refer for cauterisation or cold coagulation via colposcopy

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142
Q

Explain the pathophysiology of a Nabothian cyst.

A

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.

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143
Q

What are the clinical features of a Nabothian Cyst?

A

Mnemonic: Nabothian causes Nae Bother

Incidental find
Small (2-3cm), white/yellow bump near the Os

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144
Q

How is a Nabothian cyst managed?

A

Diagnosis assured: assurance

Diagnosis uncertain: colposcopy/referral ± Excised/Biopsy

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145
Q

How can you categorise a pelvic organ prolapse?

A

Anterior vaginal wall prolapse: Cystocoele/Urethrocoele

Posterior vaginal wall prolapse: Rectocoele/Enterocoele

Total uterine prolapse

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146
Q

Give 5 RFs for pelvic organ prolapse.

A

Non-obstetric vs Obstetric RFs

SVD 
Macrosomia 
Multiple births 
Prolonged labour 
Surgery

Obesity
Spina bifida
CT diseases

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147
Q

What is the management of a pelvic organ prolapse?

A

Supportive: Weight loss; reduce caffeine; exercise; Pelvic floor exercises (stress); Pelvic training (urgency); Pessaries
+
Medical: Oestrogen
±
Surgery: Sacrocolpopexy; Uteroplexy; Sacrohysteropexy

+ Tx symptoms

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148
Q

How do you grade a pelvic organ prolapse?

A

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

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149
Q

What are the 3 types of urinary incontinence?

A

Urgency

Stress

Mixed

Overflow

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150
Q

How can you clinically assess the strength of pelvic muscle contraction?

A

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
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151
Q

What may urodynamic testing comprise of?

A

Cystometry

Uroflowmetry

Leak point pressure

Post-void residual bladder volume

Video urodynamic testing

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152
Q

What is the MOA of Mirabegron?

A

ß3 agonist, stimulating SNS and raising blood pressure - hypertension risk

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153
Q

What is the management of urge urinary incontinence?

A

Supportive: Reduce fluids; Reduce caffeine; Bladder retraining
+
Medical: Oxybutynin; Tolterodine; Mirabegron

±
Surgical: Botulinum type A toxin; Sacral nerve stimulation; Urinary diversion

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154
Q

What is the management of stress urinary incontinence?

A

Supportive: Caffeine reduction; reduced fluids; weight loss; Pelvic floor exercises
+
Medical: Duloxetine

±
Surgical: Colposuspension; Intramural urethral bulking; Tension-free Vaginal Tape

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155
Q

Outline the pathophysiology of atrophic vaginitis.

A

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.

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156
Q

How is atrophic vaginitis managed?

A

Supportive: Vaginal lubricant
+
Medical: Topical oestrogen

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157
Q

Where is a bartholin’s gland located?

A

Either side of posterior part of vaginal introitus

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158
Q

How is a Bartholin’s cyst managed?

A

Supportive: hygiene; warm compress ± Biopsy

± Abscess
Medical: ABX
+
Surgical: word catheter; marsupialisation

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159
Q

What are the clinical features of Lichen Sclerosus?

A

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
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160
Q

How is Lichen Sclerosus managed?

A

Topical steroids - clobetasol propionate 0.05% OD for 4/52 - then reduce frequency
+
Emollients

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161
Q

What are the complications of lichen sclerosus?

A

Squamous cell carcinoma of vulva (5%)

Pain and discomfort
Sexual dysfunction
Bleeding
Narrowing of vaginal/urethral openings

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162
Q

When might you consider the risk of FGM?

A

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

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163
Q

What are the complications of FGM?

A 
Pain
Bleeding
Infection
Urinary retention
Urethral damage 
UTI
Dysmenoorhoea 
Dyspareunia 
Infertility 
Psychological issues 
Reduced engagement with healthcare
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164
Q

How do you manage FGM?

A

Report to police if u18

Social services/paediatrics/gynaecology/counselling

Surgery: De-infibulation surgery (if type 3 FGM)

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165
Q

Where is the female reproductive system derived from?

What hormone dictates this?

A

Mullerian ducts (paramesonephric ducts)

No Y chromosome thus no SRY to code for TDF, reduced T and remains with Wolffian ducts degenerate

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166
Q

State 3 congenital structural abnormalities in Gynae.

A

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

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167
Q

How is Androgen insensitivity syndrome transmitted?

A

X-linked recessive

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168
Q

What genotype is a patient with Androgen Insensitivity Syndrome?

A. XO

B. XX

C. XY

D. XXY

A

C

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169
Q

How may a patient with androgen insensitivity syndrome present?

A

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)

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170
Q

How is androgen insensitivity syndrome managed?

A

MDT input

Bilateral orchidectomy

Oestrogen therapy

Vaginal dilators/vaginal surgery

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171
Q

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

A

Before 24 weeks, usually 6-9 weeks

Complicates up to 25% pregnancies

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172
Q

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

A

B

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173
Q

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

A

C

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174
Q

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

A

D

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175
Q

What is an absolute contraindication for injectable progesterone contraception?

A

Current breast cancer

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176
Q

When is external cephalic version conducted?

A

36 weeks

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177
Q

What is the most common form of Cervical Cancer?

A

Squamous cell cancer (derived from the ectocervix) ≈ 80%

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178
Q

Which serotypes of HPV are associated with cervical cancer?

A

HPV-16; HPV-18

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179
Q

Which of the following is the greatest risk factor for Cervical Cancer?

A. Smoking

B. COCP

C. High parity

D. HPV-18

A

D - others are all risk factors also

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180
Q

State 5 RFs for Cervical Cancer.

A 
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
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181
Q

What is the pathophysiology regarding E6 protein and cervical cancer?

A

Inhibits p53 tumour suppressor gene

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182
Q

What is the pathophysiology regarding E7 protein and cervical cancer?

A

E7 protein inhibits Rb tumour suppressor gene

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183
Q

How is CIN diagnosed?

A

Colposcopy (and biopsy)

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184
Q

What are the grades of CIN? State them.

A

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”)

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185
Q

What is the difference between dysplasia and dyskaryosis?

A

Dysplasia is abnormal changes in cells/tissue whereas dyskaryosis is a change in the cells

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186
Q

When is a woman invited for cervical screening?

A

25+

25-49 = 3 years

50-65 = 5 years

Mnemonic: 3 years in your 30s, 5 years in your 50s

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187
Q

Who may follow a different cervical screening routine? Give 3 examples.

A

HIV

Over 65 if not had one since 50

Immunosuppressed women

Pregnant women (3 months post-partum)

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188
Q

What are the benefits of LBC for smears?

A

Reduced rate of inadequate smears

Increased sensitivity and specificity

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189
Q

When is the best time to take a cervical smear?

A. Pre-cycle

B. Mid-cycle

C. End of cycle

D. Any time

A

B

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190
Q

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

A - return to routine recall

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191
Q

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

A

B - return to routine follow up

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192
Q

When should a patient on the test of cure pathway, following CIN be tested?

A

Test again in 6 months

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193
Q

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

A

D

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194
Q

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

A

C

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195
Q

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

A - test in 12 months

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196
Q

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

A - return to norma screening

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197
Q

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

A

D - repeat test again in 12 months

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198
Q

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

A

C

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199
Q

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

A

Return to normal recall of 3 years (for her age)

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200
Q

How is CIN treated?

A

LLETZ
/
Cryotherapy

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201
Q

What staging system is used in cervical cancer?

A

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

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202
Q

Give 5 side effects of radiotherapy.

A 
Short term:
Diarrhoea
Vaginal bleeding 
Radiation burns
Dysuria 
Tiredness/weakness

Long term:
Ovarian failure
Fibrosis of bowel/vagina/skin/bladder
Lymphoedema

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203
Q

An acetowhite finding may suggest?

A

Occurs in cells with increased nuclear: cytoplasmic ratio (more nuclear material) such as CIN and cervical cancer when stained with Acetic Acid

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204
Q

How does Schiller’s iodine test work in Colposcopy?

A

Iodine solution stains cervical cells - healthy cells go a brown colour.

Abnormal areas do not stain

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205
Q

Outline the LLETZ procedure.

A

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.

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206
Q

How may cervical cancer be managed?

A

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

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207
Q

What is pelvic exenteration?

A

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.

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208
Q

What is the role of Bevacizumab in ovarian cancer?

A

monoclonal antibody against VEGF-A which reduces neovascularisation, reducing cancer growth

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209
Q

What is the most common type of endometrial cancer?

A

Adenocarcinoma (80%)

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210
Q

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

A - late menopause is a RF

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211
Q

What proportion of endometrial hyperplasia goes on to develop endometrial cancer?

A

10%

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212
Q

Outline the pathophysiology regarding obesity and endometrial cancer?

A

WAT produces oestrogen in postmenopausal women via aromatase which converts androgens to oestrogen thus stimulates endometrial cells and increases the risk of endometrial hyperplasia

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213
Q

Why may Tamoxifen increase your risk of endometrial cancer?

A

anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. This increase the risk of endometrial cancer.

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214
Q

State 3 protective factors against endometrial cancer.

A

Smoking

Multiple pregnancies

Mirena coil

COCP

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215
Q

What is the referral criteria for endometrial cancer?

A

Postmenopausal bleeding

Unexplained vaginal discharge >55 years

Visible haematuria and raised platelets/anaemia/hyperglycaemia

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216
Q

What is a normal endometrial thickness?

A

<4mm

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217
Q

What is the staging system used in Endometrial cancer?

Outline it

A

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

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218
Q

How is endometrial cancer managed?

A

Stage 1/2
Surgery: TAH + BSO

Other: MDT treatment 
Radical hysterectomy (remove pelvic lymph nodes and surrounding tissue)
Radiotherapy
Chemotherapy 
Progesterone
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219
Q

What is the most common type of ovarian cancer?

A

Epithelial thus adenocarcinoma

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220
Q

State 5 RFs of Ovarian Cancer.

A 
Smoking
BRCA1 
BRCA2 
Early menarche 
Late menopause 
Nulliparity
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221
Q

Which tumour marker is representative of Ovarian Cancer?

A

Ca125

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222
Q

What may give an elevation in Ca125?

A 
Ovarian cancer 
Endometriosis 
Menstruation
Benign ovarian cysts 
PID 
Pregnancy
Uterine fibroids 
Liver disease
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223
Q

State 5 subtypes of epithelial cell tumours of the ovary.

A 
Serous tumours 
Clear cell tumours 
Endometrioid tumours 
Mucinous tumours 
Undifferentiated tumours
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224
Q

What is a Krukenberg tumour?

How do they appear on histology?

A

GI metastasis to the Ovary

Signet ring

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225
Q

What may be protective against Ovarian cancer?

A

COCP
Breastfeeding
Pregnancy

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226
Q

Why may an ovarian tumour cause hip pain?

What type of pain would this be? Specifically.

A

Ovarian tumour compressing the obturator nerve

Neuropathic due to neuropraxia.

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227
Q

What requires a 2 week urgent referral in the context of suspected ovarian cancer?

A 
Ascites
Pelvic mass (unexplained)
Abdominal mass
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228
Q

How is the risk of malignancy regarding ovarian mass calculated?

A

Risk of malignancy index (RMI):

  • Menopausal status
  • US findings
  • Ca125 level
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229
Q

How is an ovarian mass managed?

A

MDT management - surgery/chemotherapy

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230
Q

What is the most common type of vulval cancer?

A

Squamous cell carcinoma

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231
Q

State 3 RFs for vulval cancer.

A

Advanced age (>75 years old)
Immunosuppression
HPV
Lichen sclerosis

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232
Q

What proportion of lichen sclerosis results in vulval cancer?

A

5%

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233
Q

What are the types of vulval intraepithelial neoplasia?

A

High grade Vulval intraepithelial neoplasia - associated with HPV (35-50 years)

Differentiated Vulval intraepithelial neoplasia - associated with lichen sclerosus (50-60)

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234
Q

How may vulval cancer present?

A 
Vulval lump 
Ulceration
Bleeding 
Pain
Itching 
Lymphadenopathy in the groin
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235
Q

What classification system is used in vulval cancer?

A

FIGO system

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236
Q

How is vulval cancer managed?

A

MDT decision

Wide local excision ± Groin lymph node dissection 
±
Chemo
±
Radiotherapy
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237
Q

Which of the following pathogens does not cause bacterial vaginosis?

A. G vaginalis

B. M hominis

C. Prevotella

D. N gonorrhoea

A

D

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238
Q

What is the most common cause of bacterial vaginosis?

A. G vaginalis

B. M hominis

C. Prevotella

D. N gonorrhoea

A

A

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239
Q

What is the pathophysiology of Bacterial vaginosis?

A

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

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240
Q

Which of the following is not a risk factor for bacterial vaginosis?

A. IUS

B. Smoking

C. Vaginal douching

D. Multiple sexual partners

A

A - an IUD aka Copper coil is a risk factor for Bacterial vaginosis

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241
Q

What type of cells are seen on microscopy in Bacterial vaginosis?

A

Clue cells - epithelial cells that have bacteria stuck inside them

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242
Q

What is the diagnostic criteria of Bacterial vaginosis?

Outline it.

A

Amsel criteria

3/4 needed
White discharge
Clue cells
Vaginal pH >4.5 
Positive whiff test (add KOH causing fishy odour)
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243
Q

What is the management of bacterial vaginosis?

A

Metronidazole 7/7

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244
Q

What is the management of bacterial vaginosis in pregnancy?

A

Oral metronidazole

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245
Q

What should be avoided when taking Metronidazole?

A

Avoid alcohol due to metronidazole interaction with alcohol to cause a disulfiram-like reaction with N/V and flushing with potential for shock

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246
Q

Give 3 RFs for Thrush.

A

Uncontrolled diabetes mellitus
Increased oestrogen
Immunosuppression
Broad-spectrum ABX

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247
Q

How can you differentiate between bacterial vaginosis and candidiasis?

A

Vaginal pH swab - lower in candidiasis

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248
Q

What type of swab should be used in Thrush?

A

Vulvovaginal swab - charcoal swab

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249
Q

How is thrush managed?

A

Topical/Pessary antifungals e.g. Clotrimazole - cream, pessary

Oral antifungal (if complicated or refractory)

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250
Q

What advice should be given to sexually-active women taking topical antifungals for Thrush?

A

Use contraception for at least 5 days after use as anti fungal creams can damage latex condoms and prevent spermicides

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251
Q

What is the difference between charcoal swabs and NAAT swabs?

A

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

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252
Q

How is chlamydia managed?

A

Doxycycline 100mg BDS for 7 days

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253
Q

How do you manage chlamydia in pregnancy?

A

Erythromycin 500mg BDS for 7 days

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254
Q

Give 5 complications of Chlamydia.

A 
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
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255
Q

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

A

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256
Q

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

A

B

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257
Q

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

A

C

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258
Q

Outline the stages of lymphogranuloma venereum.

A

Primary = penile painless ulcer

Secondary = lymphadenitis

Tertiary = proctitis/proctocolitis

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259
Q

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

A

D - recommended by BASHH

Erythromycin, azithromycin and ofloxacin are alternatives

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260
Q

What is the morphology of gonorrhoea?

A

Gram-negative diplococcus bacteria

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261
Q

What is Reiters Syndrome?

A

Urethritis

Conjunctivitis

Arthralgia/Arthritis

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262
Q

How is gonorrhoea managed?

A

IM Ceftriaxone 1g STAT

Single dose of oral ciprofloxacin 500mg

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263
Q

When is a test of cure done in gonorrhoea?

A

14 days

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264
Q

Give 5 complications of gonorrhoea.

A 
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
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265
Q

What is the key feature of infection with M genitalium?

A

Urethritis

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266
Q

What is the management of Mycoplasma genitalium infection?

A

Doxycycline 100mg BDS for 7 days + Azithromycin 1g STAT with 500mg for 2/7

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267
Q

What may be used in complicated infections with Mycoplasma genitalium?

A

Moxifloxacin

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268
Q

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

A

B - younger age

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269
Q

What are the clinical features of PID?

A 
Pelvic/abdominal pain
Abnormal vaginal discharge 
Abnormal bleeding 
Dyspareunia 
Fever
Dysuria

Pelvic tenderness
Cervical motion tenderness
Inflamed cervix
Purulent discharge

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270
Q

How is PID managed?

A

Oral metronidazole + Oral doxycycline + IM Ceftriaxone

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271
Q

What tissue is affected in Fitz-Hugh-Curtis Syndrome?

A

Pelvic inflammation and infection of Glisson’s Capsule of the liver - resulting in adhesions of liver and peritoneum

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272
Q

What type of pathogen is Trichomoniasis caused by?

A. Bacteria

B. Virus

C. Fungi

D. Protozoa

A

D

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273
Q

Which of the following is not a potential consequence of Trichomonas?

A. Bacterial vaginosis

B. PID

C. Pre-term delivery

D. Reduced HIV risk

A

D - risk is increased due to vaginal mucosa damage

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274
Q

What cervical find is characteristic of Trichomonas?

A

Strawberry cervix

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275
Q

Which vaginal discharge is most likely to represent Trichomonas?

A. White

B. Green

C. Yellow-green

D. Translucent

A

C

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276
Q

How is Trichomonas managed?

A

Metronidazole

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277
Q

Which strain of Herpes is most likely to cause Genital herpes?

A

HSV-1

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278
Q

Which nerve ganglia are affected in genital herpes?

A

Sacral nerve ganglia

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279
Q

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?

A

Herpetic whitlow - painful skin lesion on digits

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280
Q

How is genital herpes managed?

A

Supportive: Saline bathing; Analgesia; Topical anaesthetic
+
Medical: Oral aciclovir

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281
Q

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

A

B - >28/40 + Primary Herpes infection requires Caeserean section

282
Q

How is Primary genital herpes contracted before 28 weeks gestation managed?

A

Oral aciclovir

283
Q

Which is the most common strain of HIV?

A

HIV-1

Note: HIV-2 is predominantly in West Africa

284
Q

How is HIV transmitted?

A

Blood-borne thus pregnancy; sexual activity or exposure prone procedure

285
Q

State 5 conditions associated with AIDS.

A 
PCP
Kaposi's sarcoma 
CMV infection
Candidiasis (oesophageal/bronchial)
Lymphoma 
Tuberculosis
286
Q

What specific antigen is tested for in HIV testing?

A

Antibody testing

p24 antigen

287
Q

When should you test for HIV in an asymptomatic individual following exposure?

A

4 weeks

288
Q

How long should oral antiretroviral therapy be taken following HIV exposure?

A

4 weeks

289
Q

When should serological testing following post-exposure prophylaxis be conducted?

A

12 weeks after completion

290
Q

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

A

B

<200 cells/mm3 = end-stage HIV (AIDS) thus high risk of opportunistic infections

291
Q

What is the prophylactic treatment against PCP in a patient with AIDS?

A

Co-trimoxazole

292
Q

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

A

C 50-1000 copies/mL requires C-section

293
Q

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

A

D - >1000copies/mL requires IV Zidovudine and C-section

294
Q

What are babies at low risk of HIV given?

A

<50 copies/mL requires Zidovudine for 4/52

295
Q

What are babies at high risk of HIV given as prophylaxis?

A

> 50 copies/mL are given Zidovudine + Lamivudine + Nevirapine for 4/52

296
Q

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

A

C

297
Q

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

A

298
Q

Outline the main differences between toxoplasmosis and primary CNS lymphoma.

A

Toxoplasmosis:
Multiple lesions
Ring/nodular enhancement
Thallium SPECT negative

Lymphoma
Single lesion
Solid homogeneous enhancement
Thallium SPECT positive

299
Q

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

A

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
Q

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

A

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
Q

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

A

D

302
Q

Which pathogen is associated with Kaposi Sarcoma?

A

HHV-8

303
Q

What pathogen is related to hairy leukoplakia?

A

EBV

304
Q

What pathogen is associated with PML?

A

Progressive Multifocal Leukoencephalopathy related to John Cunningham Virus

305
Q

At what CD4 count does CMV retinitis occur?

A

Generally at CD4 < 50 cells/mm3

306
Q

Which pathogen causes Syphilis?

A

Treponema pallidum

307
Q

What is the morphology of Treponema pallidum?

A

Spirochete that is spiral-shaped bacteria

308
Q

Outline the stages of Syphilis.

A

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
Q

Which of the following is not a classical feature of neurosyphilis?

A. Tabes dorsalis

B. Ocular syphilis

C. Paralysis

D. Paraesthesia

A

D

310
Q

What type of pupillary defect is associated with Syphilis?

A

Argyll-Robertson pupil - constricted pupil which accommodates when focusing on near object but does not react to light

311
Q

How is Syphilis managed?

A. IV Ceftriaxone

B. IM Ceftriaxone

C. IM Benzylpenicillin

D. Oral Doxycycline

A

C

312
Q

Which of the following is not a MOA of the COCP?

A. Inhibit endometrial proliferation

B. Thicken cervical mucus

C. Prevent ovulation

D. Spermicide

A

D

313
Q

Which of the following COCPs may be useful for treatment of acne?

A. Microgynon

B. Dianette

C. Yasmin

D. Cilest

A

B - contains Co-cyprindiol

314
Q

What are the benefits of the COCP?

A

Contraception
Rapid return to fertility
Improves premenstrual symptoms
Reduced risk of endometrial cancer, ovarian and colon cancer

315
Q

What are the side effects and risk of the COCP?

A 
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
Q

Which of the following is not an absolute contraindication for the COCP?

A. History of VTE

B. Liver cirrhosis

C. SLE

D. BMI > 30

A

D - BMI > 35 is a UKMEC 3, not a UKMEC 4

317
Q

A pill is started on day 7 of a cycle. What contraception is required?

A

Contraception for first 7 days if started after day 5 of cycle

318
Q

A pill is started on day 4 of a cycle. What contraception is required?

A

No contraception required if started on first 5 days of cycle

319
Q

When switching from desogestrel to COCP, what further measures may be required?

A

None as Desogestrel prevents ovulation thus no additional contraception requires

320
Q

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

A

321
Q

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.

A

Days 1-7 + >72 hours of pill = Emergency contraception considered

322
Q

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.

A

Days 8-14 with pills taken 1-7 means no need for emergency contraception

323
Q

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?

A

Missed pills in week 3 (Days 15-21) = finish current pack and start new pack the next day

324
Q

Which phase of the menstrual cycle is mimicked by Desogestrel?

A

Luteal phase, with progesterone inhibiting ovulation by mimicking pregnancy

325
Q

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

A

C - takes 48 hours for cervical mucous to thicken

326
Q

What are the side effects of POP?

A 
Unscheduled bleeding 
Irregular bleeding 
Amenorrhoea
Mastalgia 
Headaches
Acne
Ovarian cysts
Ectopic pregnancy (reduced ciliary action) 
Slightly increased risk of breast cancer
327
Q

A patient misses their Nogeston pill. They have not taken it for 28 hours.

What contraception is required?

A

Take missed pill and use condoms for 48 hours

328
Q

A patient has missed their Desogestrel pill by 38 hours. What contraception is required?

A

Take missed pill as soon as possible and normal pill

Extra precautions for 48 hours

329
Q

What is a UKMEC 4 contraindication for Depot injection?

A

Active breast cancer

330
Q

State 5 side effects of the progesterone only injection?

A 
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
Q

What is an absolute contraindication for the Nexplanon implant?

A

Active breast cancer

332
Q

What property of the Nexplanon implant makes it visible on X-Ray?

A

Barium sulphate added to make it radio-opaque

333
Q

Which of the following is not a contraindication of the coil?

A. Taking Clopidogrel

B. Fibroids

C. Pelvic cancer

D. PID

A

A

334
Q

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

A

C

335
Q

What is the MOA of the Copper coil?

A

Toxic to sperm

336
Q

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

A

B - may fall out in 10% of cases

337
Q

Which condition is the copper coil contraindicated in?

A. Haemachromatosis

B. Porphyria cutanea tarda

C. Wilson’s disease

D. Cystic fibrosis

A

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
Q

What may be seen in a smear of a woman with a coil?

A

Actinomyces-Like Organisms (ALO) on Smears - no treatment unless symptomatic

339
Q

What is the MOA of Ulipristal?

A

SERM

340
Q

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

A

C

341
Q

In which condition should Ulipristal be avoided?

A. COPD

B. Heart Failure

C. CKD

D. Severe asthma

A

D

342
Q

At what age should sexual intercourse raise a safeguarding red flag?

A

All intercourse in children under 13 years should be escalated as a safeguarding concern to a senior or designated child protection doctor

343
Q

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

A

D

344
Q

What initial investigations may you conduct in infertility?

A 
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
Q

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

A

D

Levels:
<16nmol/L

16-30nmol/L

> 30nmol/L

346
Q

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

A

D - there is a need for prophylactic ABX

347
Q

Which ways can sperm problems be managed in infertility?

A

Supportive: Diet; Smoking cessation; exercise
+
Surgical: Sperm retrieval; Surgical correction; IU insemination; ICSI; Donor insemination

348
Q

What is Oligospermia?

A

Reduced number of sperm such as <15million/mL

349
Q

What is normospermia?

A

Normal characteristics of sperm

Concentration (>15million/mL)
Number (>40 million per sample)
Motility (>40%)
Vitality (>60%)

350
Q

How may you categorise the causes of male infertility?

A

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
Q

What are the percentages of IVF being successful?

A

30%

352
Q

What are the processes of IVF?

A

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
Q

What are the risks of IVF?

A

Failure

Multiple pregnancy

Ectopic pregnancy

Ovarian hyperstimulation syndrome

354
Q

Outline the pathophysiology of Ovarian Hyperstimulation Syndrome.

A

Trigger injection (hCG) mimicking gonadotropins result in VEGF release from granulosa cells which increases vascular permeability resulting in fluid extravasation - presenting with shock.

355
Q

Which of the following is an assessment of OHSS development risk?

A. XR

B. US

C. Serum progesterone

D. Serum FSH

A

B - monitor follicles

356
Q

What is the management of OHSS?

A 
Supportive: Admission; Catheterise; Oral fluids;
\+
Medical: LMWH; IV Colloids
\+
Surgical: Paracentesis
357
Q

What is Young’s Syndrome?

A

Bronchiectasis
Chronic rhinosinusitis
Vas deference obstruction

358
Q

What can be used as a surrogate marker for intravascular fluid volume in OHSS?

A

Haematocrit (RBC concentration) as Hct increase correlates to less fluid in intravascular space

359
Q

What examination is not recommended in a suspected ectopic pregnancy?

A

Examine for cervical motion tenderness but do not examine for adnexal mass - risk of rupturing the ectopic pregnancy

360
Q

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

A

C

361
Q

At what rate does ßhCG increase roughly?

A

Doubles every 48 hours

362
Q

How may you manage an ectopic pregnancy?

A

ßhCG <1500IU/L
Supportive: Expectant management

ßhCG 1500-5000IU/L
Medical: Methotrexate

ßhCG >5000IU/L

363
Q

What are the common side effects of methotrexate?

A

PV bleed
N/V
Abdominal pain
Stomatitis

364
Q

What are the two categories of miscarriage?

A

Early = <12 weeks

Later = 12-24 weeks

365
Q

What is the gold-standard diagnosis for a miscarriage?

A

US

Mean gestational sac diameter
Foetal pole and crown-rump length
Foetal heartbeat (viable pregnancy) - usually seen when crown-rump length >7mm

366
Q

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

A

B

367
Q

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

A

C

368
Q

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

A

D

369
Q

What are the options for miscarriage management?

A

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
Q

Give 5 causes for recurrent miscarriage.

A 
Idiopathic 
Antiphospholipid syndrome 
SLE 
Hereditary thrombophilia 
Uterine abnormalities 
Genetic factors 
Chronic histolytic intervillositis 
Diabetes 
Thyroid disease (uncontrolled)
371
Q

What autoantibodies are present in Antiphospholipid syndrome?

A

Anti cardiolipin

Lupus anticoagulant

372
Q

What are the available methods of ToP?

A

<9 weeks
Medical: Mifepristone + Misoprostol

<13 weeks
Surgical: Dilation and suction

> 15 weeks
Surgical: Surgical dilation and evacuation

373
Q

Give 3 potential complications of abortion.

A 
Failure of abortion 
Iatrogenic damage
Bleeding
Pain
Infection
Psychological damage
374
Q

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

A - the act was altered to the 24th week

375
Q

What is the MOA of Misoprostrol?

A

PG analogue stimulating contractions

376
Q

What is the MOA of Mifepristone?

A

Progesterone antagonist which ripens uterus to misoprostol

377
Q

What proportion of pregnancies experience NVP?

A. 5%

B. 10%

C. 3%

D. 1%

A

D

378
Q

Which of the following is not associated with NVP?

A. Multiple pregnancies

B. Trophoblastic disease

C. Hypothyroidism

D. Nulliparity

A

C - Hyperthyroidism

379
Q

Give 3 conditions which smoking may reduce the incidence of?

A

Hyperemesis Gravidarum (NVP)

Ulcerative Colitis

Endometrial cancer

380
Q

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

A

D

Referral criteria:

  • Persistent vomiting
  • Loss of >5% body weight or ketonuria
  • Comorbidity which requires treatment
381
Q

What is the first line management in NVP?

A. Ondansetron

B. Metoclopramide

C. Cyclizine

D. P6 acupressure

A

C

Order: Cyclizine > Metoclopramide > Ondansetron > P6 acupressure

382
Q

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

A

D

383
Q

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

A

B - Vaginal bleeding is a feature

384
Q

Outline how a molar pregnancy can cause thyrotoxicosis?

A

hCG can mimic TSH which stimulates the TSH-R on thyroid follicular cells to cause T3 and T4 release

385
Q

What is a characteristic radiographic find of a Molar pregnancy?

A

Snowstorm pregnancy

386
Q

What is the difference between gravidity and parity?

A

Gravidity = number of times pregnant

Parity = number of foetuses born at 24+ weeks

387
Q

Outline the times for each trimester.

A

1st Trimester = 0-12 weeks

2nd Trimester = 13-26 weeks

3rd Trimester = 27+ weeks

388
Q

When is a booking visit conducted?

What is the purpose of the visit?

A

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
Q

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

A

D - HIV test is offered to all women but may not always be done

390
Q

When is the early scan conducted?

A

10-13+6 weeks

391
Q

WHen is a Down’s Syndrome screening conducted?

A

11-13+6 weeks

392
Q

When is an Anomaly scan conducted?

A

18-20+6 weeks

393
Q

When is SFH, BP and urine dipstick conducted?

A

28 weeks - 25 if Primip

394
Q

When is the first dose of anti-D prophylaxis given if rhesus negative?

A

28 weeks

395
Q

When is external cephalic version offered?

A

36 weeks

396
Q

What does routine care in antenatal care involve?

A

SFH, Blood pressure, urine dipstick

397
Q

Which two vaccines are offered to all pregnant women?

A

Whooping cough - 16 weeks

Influenza (Autumn; Winter)

398
Q

What supplements should be taken in pregnancy?

A

Folic acid 400mcg + Vitamin D 10mcg

Note: High risk of NTD requires 5mg of Folic Acid

399
Q

Which of the following is not a feature of Foetal Alcohol Syndrome?

A. Microcephaly

B. Smooth flat philtre

C. Learning disability

D. Hypertelorism

A

D

Features:
Microcephaly 
Thin upper lip
Flat philtre 
Short palpebral fissure 
Hearing difficulties 
Vision difficulties 
Cerebral palsy
400
Q

When is flying in pregnancy acceptable?

A

Up to 32 weeks in singleton

Up to 37 weeks in twin pregnancies

401
Q

What is done on booking bloods in the UK?

A

FBC

Thalassaemia + Sickle cell disease

Hepatitis B
Syphilis
–> HIV offered

402
Q

What is the threshold for offering Downs Syndrome Screening in a woman?

A

1 in 150 (5%)

403
Q

Which tests are conducted in the combined test?

A

US - nuchal translucency

Bloods - ßhCG + PAPP-A

404
Q

Which tests are done in the quadruple test?

What derangements may be seen in Down’s Syndrome?

A

ßhCG (elevated)
AFP (lower)
Oestriol (lower)
Inhibin-A (elevated)

405
Q

What occurs to the dose of levothyroxine in Hypothyroidism in Pregnancy?

A

Increase dose of thyroxine by 30-50% in pregnancy

Titrate based on TSH level - aim for low-normal TSH level

406
Q

Which antihypertensives may be used in pregnancy?

A

Labetalol

Dozasozin

Nifedipine

Levodopa

407
Q

Which of the following is not recommended to manage Epilepsy in Pregnancy?

A. Levetiracetam

B. Lamotrigine

C. Phenytoin

D. Carbamazepine

A

C

408
Q

What are the indications for giving Folic Acid 5mg in Pregnancy?

A 
Birth with NTD 
NTD when born 
BMI > 30kg/m2 
Epilepsy 
Diabetes
Sickle Cell Disease
409
Q

What is the first line management of Rheumatoid Arthritis in pregnancy?

A. Methotrexate

B. Sulfasalazine

C. Corticosteroids

D. Hydroxychloroquine

A

D - considered safe during pregnancy and 1st line

410
Q

What is the pathophysiology behind NSAIDs being avoided in pregnancy?

A

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
Q

What congenital abnormality is Lithium associated with?

A

Ebstein’s anomaly - tricuspid valve set inferiorly thus larger RA and smaller RV

412
Q

What are the features of Congenital Rubella Syndrome?

A

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
Q

What is the management of a G3P2 32+4 week woman who has chicken pox with confirmed VZV IgG levels?

A

Nothing

414
Q

What is the management of a G3P2 32+4 week woman who has chicken pox with no VZV IgG levels?

A

Give IV Varicella IgG - within 10 days of exposure

If >20 weeks and present within 24 hours, give Oral Aciclovir

415
Q

What does congenital Varicella Syndrome involve?

A 
Microcephaly
Hydrocephalus
Chorioretinitis 
Learning disability 
Scars/skin change in dermatomal distribution 
Limb hypoplasia
416
Q

What are the features of Congenital Toxoplasmosis?

A

Intracranial calcification
Hydrocephalus
Chorioretinitis

Mnemonic: ICH - Intracranial calcification + Chorioretinitis + Hydrocephalus

417
Q

What syndrome can Parvovirus B19 cause in a pregnant woman?

A

Mirror syndrome (mirroring pre-eclampsia) with hypertension + proteinuria

418
Q

What are the features of congenital Zika syndrome?

A

Microcephaly
SGA
Intracranial abnormalities: ventriculomegaly; cerebellar atrophy

419
Q

Outline the pathophysiology of Rhesus Incompatibility in Pregnancy.

A

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
Q

How is Rh incompatibility managed?

A

Anti-D injection at 28 weeks gestation

421
Q

How can you categorise causes of foetal growth restriction?

A

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
Q

What should be done regarding monitoring of foetal size should SFH <10th centile?

A

Serial growth scans with umbilical artery doppler

423
Q

Give 5 causes of foetal macrosomia.

A 
Constitutional 
Diabetes
Previous macrosomia 
Overdue
Maternal obesity 
Male baby 
Genetic condition e.g. PWS
424
Q

How is Foetal macrosomia investigated?

A

US- exclude polyhydramnios and EFW

OGTT

425
Q

What are the types of twins?

How are they seen on US scan?

A

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
Q

What is twin-twin transfusion syndrome?

What is a less severe version of this?

A

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
Q

Which of the following is not a risk factor for dizygotic twins?

A. Increasing maternal age

B. Multigravida

C. IVF

D. Caucasian

A

D - Afro-Caribbean race

428
Q

What is the management for a twin pregnancy?

A

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
Q

What is the treatment for a UTI in pregnancy?

A

Nitrofurantoin for 7 days

Note: Avoid in last trimester (26-40)

430
Q

When are women screened for anaemia in pregnancy?

A

Booking (10-12 weeks)

28 weeks

431
Q

What is the haemoglobin normal range for a pregnant woman in pregnancy?

A

Booking bloods >110g/L

28 weeks gestation >105g/L

432
Q

What is used as VTE Prophylaxis in pregnant women?

A

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
Q

How do you clinically assess for a DVT?

A

Pain on palpation

Pain on dorsiflexion (Homan’s Sign)

> 3cm difference when measuring 10cm inferiorly to tibial tuberosity at posterior compartment

434
Q

What is the difference between chronic hypertension and pregnancy-induced hypertension?

A

Chronic was present before 20 weeks, whereas pregnancy-induced hypertension is hypertension occurring after 20 weeks gestation without proteinuria

435
Q

What are the diagnostic criteria for Pre-eclampsia?

A

HTN (>140/90mmHg) +

Proteinuria 
Organ dysfunction (raised creatinine, elevated LFTs, seizures, thrombocytopenia, haemolytic anaemia) 
Placental dysfunction (FGR/abnormal Doppler)
436
Q

How may proteinuria in pre-eclampsia be quantified?

A

UACR >8mg/mmol

UPCR >30mg/mmol

437
Q

What biochemical marker can be tested to confirm Pre-eclampsia?

A

Placental growth factor (PlGF)

Protein released by placenta to stimulate new blood vessels thus in pre-eclampsia PlGF are low

438
Q

What is the prophylaxis for Pre-eclampsia?

A

Aspirin from week 12

Give aspirin should there be a high-risk factor or two moderate risk factors

439
Q

What is the medical management of pre-eclampsia?

A

Supportive: Decide whether to admit; BP monitored; US foetus; fluid restrict
+
Medical: Labetolol

± Eclampsia
Medical: IV Magnesium Sulphate

**Follow Eclampsia protocol

440
Q

What is HELLP syndrome?

A

Haemolysis
Elevated Liver enzymes
Low Platelets

A complication of Pre-eclampsia and Eclampsia

441
Q

What is the screening test for Gestational Diabetes?

Give the criteria

A

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
Q

How is Gestational Diabetes managed?

A

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
Q

When should a baby be delivered should a woman have pre-existing diabetes?

A

37-39 weeks

444
Q

What should be done if a baby’s blood sugar falls below 2mmol/L?

A

IV Dextrose

445
Q

What are the complications of gestational diabetes?

A 
Foetal macrosomia 
Neonatal hypoglycaemia 
Polycythaemia 
Jaundice 
Congenital heart disease
Cardiomyopathy
446
Q

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?

A

Polymorphic eruption of pregnancy

447
Q

Which LFT can increase up to 4x in pregnancy?

A

ALP - due to placental production

448
Q

What is the management of Obstetric Cholestasis?

A

Supportive: Emollients; Antihistamines; Vitamin K (if PT prolonged)
+
Medical: Ursodeoxycholic acid

449
Q

Outline the pathophysiology of acute fatty liver of pregnancy.

A

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
Q

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?

A

Acute fatty liver of pregnancy

451
Q

What is the management of Acute Fatty Liver in Pregnancy?

A

Prompt admission and delivery of the baby

452
Q

Give an example of a rash seen in pregnancy.

A

Atopic eruption of pregnancy - E type or P type

Melasma

Pyogenic granuloma

Pemphigoid gestationis

Polymorphic eruption of pregnancy

Meningococcal septicaemia

453
Q

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

A

C

454
Q

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

A

D

455
Q

what are the key features of placenta praaevia?

A

Painless PV Bleed

Uterus not tender

Foetal heart rate normal

456
Q

How is placenta praaevia managed?

A

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
Q

What sign is characteristically seen in vasa praaevia?

A

Foetal bradycardia

458
Q

Outline the pathophysiology of Vasa praevia.

A

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
Q

How is vasa praevia managed?

A

Corticosteroids + Elective CS at 34-36 weeks

If emergency:
Emergency CS

460
Q

How is a placental abruption managed?

A

Supportive: A-E assessment; Bloods; Crossmatch 4 units of blood; IV Fluids; CTG; Anti-D prophylaxis
+
Surgical: Emergency C-section

461
Q

A foot through the cervix with the leg extended is known as?

A. Complete breech

B. Incomplete breech

C. Extended breech

D. Footling breech

A

D

462
Q

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

A

B

463
Q

How may a Breech birth be managed?

A

Supportive: External cephalic version (ECV) at 36 weeks (nulliparous) or 37 weeks (birthed previously);
Terbutaline;
Anti-D prophylaxis and Kleihauer test

464
Q

What are the causes of cardiac arrest in Pregnancy?

A

Mnemonic: 4Ts and 4Hs

Toxin
Tension pneumothorax
Tamponade
Thrombosis

Hypovolaemia
Hyperkalaemia/Hypoglycaemia
Hypothermia
Hypoxia

465
Q

How do you manage a collapsed pregnant woman?

A

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
Q

Outline the stages of labour.

A

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
Q

How can you reduce the frequency of Braxton-Hicks contractions?

A

Hydration and relaxation

468
Q

What is a premature baby?

A

Baby born before 37 weeks

469
Q

How can you prevent preterm labour?

A

Vaginal progesterone

Cervical cerclage

470
Q

What markers are indicative of amniotic fluid?

A

IGFBP-1

PAMG-1

471
Q

What is the management of PPROM?

A

Supportive: ABX
+
Delivery at 34+ weeks

472
Q

What is the management of preterm labour?

A

Supportive: Foetal monitoring; Corticosteroids
+
Medical: Tocoylysis; IV Mag Sulph

473
Q

Give an example of tocolytic agents.

A

Terbutaline (ß2 agonist)

Nifedipine (CCB)

Atosiban (OT-R antagonist)

474
Q

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

A

D - monitor up to every 4 hours

Monitor:

  • Obs
  • Tendon reflexes
475
Q

What are the signs of magnesium toxicity in a pregnant woman?

A

RR depression
BP decreased
Absent reflexes

476
Q

What scoring system is used to determines need for induction of labour?

A

Bishops Score

Score of <5 = induction needed

Score of >8 = induction of labour occurring

477
Q

What are the potential options to induce labour?

A

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
Q

What are the main methods of monitoring during induction of labour?

A

CTG

Bishop score

479
Q

Give the complications of IoL.

A

Uterine hyperstimulation (5 in 10 mins or more than 2 mins)
Foetal compromise
Emergency Caesarean section
Uterine rupture

480
Q

What imaging modality is used in CTG?

A

US

481
Q

Give 5 indications for continuous CTG monitoring.

A 
Sepsis 
Maternal tachycardia (>100bpm)
Pre-eclampsia 
APH
Significant meconium 
Delay in labour 
Use of OT 
Disproportionate maternal pain
482
Q

What are the key features of a CTG?

Explain.

A

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
Q

Give 4 types of decelerations.

A 
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
Q

What is the rule of 3 for foetal bradycardia?

A

3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for delivery
12 minutes – deliver the baby (by 15 minutes)

485
Q

What is the MOA of Oxytocin?

A

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
Q

What medications can be used as a Tocolytic, reversing the effects of Oxytocin?

A

Atosiban

Nifedipine

487
Q

When is Ergometrine used?

A

In 3rd stage of labour during a PPH

488
Q

What are the side effects of Ergometrine?

A

Hypertension
Diarrhoea
Vomiting
Angina

489
Q

What medication is the combination of Ergometrine and Oxytocin?

A

Syntometrine

490
Q

How may Dinoprostone be administered?

A

Directly into the vagina

Pessary
Gel
Tablet

491
Q

What is the MOA of Nifedipine in Tocolysis?

A

CCB thus reduce smooth muscle contraction in BV and uterus

Treats hypertension
Tocolysis

492
Q

What is the MOA of Carboprost in labour?

A

Synthetic prostaglandin analogue thus binds to prostaglandin to stimulate uterine contraction in PPH

3rd line behind Ergometrine and OT

493
Q

Give 5 RFs for PPH

A 
Prolonged labour 
Previous PPH
Pre-eclampsia 
Increased maternal age 
Polyhydramnios 
Macrosomia
Placenta praaevia 
Placenta accrete 
Ritodrine (ß2 agonist)
494
Q

How is a PPH managed?

A

A-E management

IV Syntocinon 10U or IV Ergometrine 500mcg
±
IM Carboprost

± Failed medical
Surgery: IUB; Ligation of uterine artery; Hysterectomy

495
Q

What are the types of PPH?

A

Primary <24 hours

Secondary 24 hours - 12 weeks

496
Q

What is the MOA of TXA?

When may it be used in pregnancy?

A

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
Q

How can assessment of progression be surmised?

A

3Ps of parturition

Passenger
Passage
Power

498
Q

How long should the second stage last?

A

2 hour in nulliparous woman

1 hour in multiparous woman

499
Q

What factors make up Passenger in the 3Ps?

A

Size (large vs small)
Attitude (posture)
Lie (longitudinal; transverse; oblique)
Presentation (Cephalic; Shoulder; Face; Complete breech; Frank breech; Footing breech)

500
Q

How is failure to progression managed?

A

Amniotomy
OT infusion
Instrumental delivery
Caesarean section

501
Q

How long should the third stage of labour take?

A

30 mins if active

60 mins if physiological

502
Q

What are the analgesic options available in pregnancy?

A

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
Q

What are the adverse effects of an epidural block?

A 
Headache after insertion
Hypotension
Motor weakness 
Nerve damage 
Prolonged second stage 
Increased probability of instrumental delivery
504
Q

Give 3 RFs for umbilical cord prolapse.

A 
Prematurity 
Multiparity 
Polyhydramnios 
Twin pregnancy
Abnormal presentation 
Cephalopelvic disproportion
505
Q

How is an umbilical cord prolapse managed?

A

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
Q

What sign is suggestive of a shoulder presentation clinically?

A

Turtle-neck sign - head presents but retracts back into vagina

507
Q

How is a Shoulder dystocia managed?

A

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
Q

What are the potential complications of shoulder dystocia?

A

Foetal hypoxia
Brachial plexus injury and Erb’s palsy
Perineal tear
PPH

509
Q

What are the risks of an instrumental delivery?

A 
Perineal tear
Episiotomy
PPH
Injury to anal sphinter
Nerve injury 
Incontinence 
Cephalohaematoma 
Facial nerve palsy 
ICH
Skull fracture 
SCI
510
Q

What is the main complication of a venthouse delivery?

A

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
Q

What are the main risks of a forceps delivery to the baby?

A

Fat necrosis

Facial nerve palsy

512
Q

What nerve injuries may occur in an instrumental delivery?

A

Baby:
Facial nerve
Brachial plexus

Mother:
Femoral nerve
Obturator nerve

513
Q

Why may a foot drop occur in pregnancy?

A

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
Q

Which of the following does not increase the risk of perineal tears?

A. Nulliparity

B. Shoulder dystocia

C. Occipito-posterior position

D. Caucasian ethnicity

A

D - Increased with Asian ethnicities

515
Q

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

A

B

516
Q

A tear which includes the perineal muscles is said to be?

A. First degree

B. Third degree

C. Second degree

D. Fourth degree

A

C

517
Q

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

A

B

518
Q

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

A

B

519
Q

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

A

D

520
Q

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

A

C

521
Q

How is a perennial tear managed?

A

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
Q

How can you reduce the risk of perineal tears?

A

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
Q

What are the two ways to manage the 3rd stage of labour?

A

Physiological: placenta delivered by maternal effort without medications/cord traction

Active management of third stage: IM Oxytocin and careful traction

524
Q

What is the indication for active management of the 3rd stage of labour?

A

> 60 mins

PPH

525
Q

What is the criteria for a minor or major PPH?

A

Minor = <1000mL

Major = >1000mL

526
Q

What are the causes of a PPH?

A

Mnemonic: 4Ts

Tone
Trauma
Tissue
Thrombin

527
Q

How is a PPH managed?

A

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
Q

What are the risks of a Caesarean section?

A 
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
Q

Which incision may be used for a Caesarean section?

A

Pfannenstiel incision: curved incision two fingers above pubic symphysis

Joel-Cohen incision: straight incision slightly higher than Pfannenstiel incision

530
Q

What are the layers of the abdomen dissected during a Caesarean section?

A

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
Q

What are the key features of Chorioamnionitis?

A 
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
Q

How is chorioamnionitis managed?

A

Call for help

Start Sepsis Six (Fluids/ABX/O2 + Cultures/Urine/Lactate)

Follow local guidelines for ABX such as Pip/Taz + Gent

533
Q

What is the management of an Amniotic Fluid Embolism?

A

A-E

Call for help

MDT input

534
Q

What is the pathophysiology behind an Amniotic Fluid Embolism?

A

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
Q

What is the main risk factor for a Uterine Rupture?

A. Previous uterine surgery

B. Increased BMI

C. High parity

D. Previous Caesarean section

A

D

536
Q

How is a Uterine Rupture managed?

A

A-E

Call for help

Caesarean section + Stop bleeding + Hysterectomy

537
Q

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

A

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
Q

What does the 6 week postnatal check comprise of?

A 
General wellbeing 
Bleeding and menstruation
Scar healing 
Breastfeeding 
Mood and depression

BP
Urinalysis
FBG

539
Q

How long may lochia persist?

A

6 weeks

540
Q

When is fertility required post-partum?

A

21 days after giving birth

541
Q

Which method of contraception is not safe in breastfeeding?

A. POP

B. Implant

C. Copper coil

D. COCP

A

D - not for 6 weeks after childbirth

542
Q

When can the copper coil be inserted following childbirth?

A

<48 hours or >4 weeks postpartum

543
Q

How is postpartum endometritis caused?

A

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
Q

What is the gold-standard for diagnosing retained PoC?

A

US

545
Q

How is retained PoC managed?

A

Surgical removal: Evacuation of retained products of conception (ERPC)

546
Q

What is Asherman’s Syndrome?

A

Adhesions form within the uterus causing pain - treated by surgery

547
Q

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

A

C

548
Q

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

A

549
Q

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

A

B

550
Q

Why should an anaemic woman who has an infection not receive an iron infusion?

A

Many pathogens feed on iron thus IV Iron infusion can exacerbate the infection

551
Q

When may the baby blues occur?

A

< 7 days

552
Q

When does Postnatal depression tend to occur?

A

3 months

553
Q

What tool can be used to screen for postnatal depression?

A

Edinburgh Postnatal Depression Scale

554
Q

How is mastitis managed?

A

Supportive: Continue to breastfeed; hot packs; warm showers

± Failed supportive management
Medical: Flucloxacillin

555
Q

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

A

B

556
Q

Outline the pathophysiology of postpartum thyroiditis.

A

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
Q

What is the typical pattern to postpartum thyroiditis?

A

Thyrotoxicosis (<3mo.)
Hypothyroid (3-6mo.)
Normalisation (up to 12mo.)

558
Q

How is postpartum thyroiditis managed?

A

Treat according to phase - e.g. Levothyroxine for hypothyroidism or Propanolol for thyrotoxicosis

559
Q

What is Sheehan’s Syndrome?

How is it managed?

A

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
Q

What is the US threshold for an ectopic pregnancy determining surgical over medical management?

A

30mm

561
Q

What is the definition for pre-eclampsia?

A

HTN + Proteinuria

> 140/90mmHg and proteinuria >0.3g/L

> 20 weeks of pregnancy

562
Q

What are the potential complications of pre-eclampsia?

A 
Papilloedema 
Eclampsia 
Pulmonary oedema 
DIC 
Renal failure 
Liver failure 
Cerebral haemorrhage 
HELP syndrome 
Death

IUGR
Intrauterine death
Pre-term delivery

563
Q

What are the clinical features of pre-eclampsia?

A

Headache
Visual changes

RUQ/epigastric pain
Brisk reflexes

Proteinuria
Haemolysis; low platelets; elevated liver enzymes

564
Q

Which women should receive pre-eclampsia prophylaxis?

What is the prophylaxis?

A

1+ high risk factors

2+ moderate risk factors

75mg Aspirin from 12wk to birth

565
Q

Give two examples of high risk factors and two examples of moderate risk factors for pre-eclampsia.

A

High risk:
Hypertension
CKD
Autoimmune condition (including DM)

Moderate risk: 
1st pregnancy 
>40 years old
BMI >35
FHx pre-eclampsia 
Multiple pregnancy
566
Q

What is the management of pre-eclampsia?

A

Admission
+
Oral labetalol (or Nifedipine)

±
Steroids (lung maturity)
±
IV Magnesium Sulphate (seizure prevention)

±
Caesarean section

567
Q

Which ethnic group may have a higher incidence of obstetric cholestasis?

A

Asians

568
Q

What are the clinical features of obstetric cholestasis in pregnancy?

A

Pruritus
Jaundice

Raised sBr

569
Q

What is the management of cholestatic jaundice?

A

Cholestyramine
+
Induction of labour at 37/38 weeks

570
Q

How likely is cholestatic jaundice to occur in subsequent pregnancies?

A

45-90%

571
Q

What are the potential effects of diabetes mellitus in pregnancy on the mother? What would the potential effects be on the foetus?

A 
Mother: 
Diabetic nephropathy
Diabetic retinopathy
Risk of miscarriage 
Pre-eclampsia 
Operative delivery 
Foetus: 
Polydramnios 
Macrosomia 
Shoulder dystocia 
DDH 
Congenital abnormalities
572
Q

When is screening for gestational diabetes undertaken?

A

Booking AND 24-28 weeks

done by OGTT

573
Q

How can an OGTT be interpreted in the context of gestational diabetes?

A

“5, 6, 7, 8”

FPG: >5.6mmol/L

2-hour: >7.8mmol/L

574
Q

At what FPG threshold should insulin be started?

A

> 7mmol/L

575
Q

How is diabetes managed in pregnancy?

A

Increased insulin requirements
+
Induction of labour at 38/39wk

576
Q

What is the management of epilepsy in pregnancy?

A 
Folic acid 5mg 
\+
Continue medication (lamotrigine)
\+
Vitamin K from 36 weeks
577
Q

Why is vitamin K given in pre-eclampsia?

A

Reduce chances of haemorrhagic disease of the newborn

578
Q

What are the thresholds for anaemia in pregnancy?

A

1/3: <110

2/3 and 3/3: <105

579
Q

What is the management of anaemia in pregnancy?

A

Check at 16 and 28 weeks

Tx cause

580
Q

Why may Grave’s disease cause thyrotoxicosis in pregnancy?

A

Similarity between ßhCG and TSH receptor means elevated ßhCG in pregnancy binds to TSH receptor and causes thyrotoxicosis

581
Q

What is the treatment of a woman with hyperthyroidism in pregnancy?

A

Propylthiouracil (in first semester)

Carbimazole (in second semester)

582
Q

What is a potential side effect of Propylthiouracil?

A

Hepatic injury

583
Q

How do you treat hypothyroidism in pregnancy?

A

Levothyroxine and increase the dose by 50%

584
Q

How is a VTE managed in pregnancy?

A

LMWH

585
Q

When should VTE thromboprophylaxis be given in pregnancy?

A

Carry out risk factors

High risk or 4+ RFs = LMWH till 6wks postpartum

3+ RFs = LMWH from 28wks to 6wks postpartum

586
Q

Which anticoagulants are CI in pregnancy?

A

Warfarin

DOACs

587
Q

What can reduce vertical HIV transmission in pregnancy?

A

Antiretrovirals (and low viral count)
C-section
Neonatal antiretroviral therapy
Bottle feeding (do not breast feed)

588
Q

When would vaginal delivery be acceptable in a patient with HIV?

A

Viral load <50 copies/mL at 36 weeks

589
Q

What are the clinical features of rubella in a pregnant woman?

A

Maculopapular rash
Arthralgia
Lymphadenopathy

590
Q

What are the clinical features of a neonatal rubella infection?

A

Sensorineural hearing loss
Cataracts
CHDs

591
Q

What cardiac abnormality is most common in rubella infection?

A

PA stenosis

PDA

592
Q

What are the clinical features of foetal varicella syndrome?

A

Deafness
Limb hypoplasia
Skin scarring

593
Q

What is the management for a herpes infection in a pregnant woman?

A

C-section within 6 weeks of primary exposure

594
Q

What are the features of neonatal herpes virus?

A 
Herpes lesions at skin and mucosal membranes 
CNS disease (e.g. encephalitis)

Disseminated infection

595
Q

What are the clinical features of CMV infection?

A

Mnemonic: ‘CMV’

Calcification
Microcephaly
Visual changes (cataracts)

596
Q

What is the most common cause for early-onset neonatal sepsis?

A

GBS most common in first 3 days of life

597
Q

What is the most common cause of late-onset neonatal sepsis?

A

3 days to 30 days

S epidermis
P aeruginosa 
Klebsiella 
Enterobacter 
S aureus 
Enterococcus
598
Q

What are the potential adverse effects of Gentamicin?

A

Ototoxicity

Nephrotoxicity

599
Q

When is Gentamicin contraindicated?

A

Myaesthenia Gravis - reduces neuromuscular transmission

600
Q

What is the MOA of gentamicin?

A

Inhibition of 30s ribosomes to reduce bacterial protein synthesis

601
Q

What pregnancy tests are done in weeks 8-12 of gestation?

A

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
Q

What is done at 10-13+6 weeks?

A

Early scan - confirm dates

603
Q

What is done at week 11-13+6?

A

Down syndrome screening (triple test)

PAPP-A + ßhCG + Nuchal translucency

604
Q

What does the quadruple test consist of? When is it conducted?

A

15-20 wks

AFP, ßhCG, Inhibin-A, Oestriol

605
Q

What tests are done at 18-20+6 wks?

A

Anomaly scan

606
Q

What additional tests are done if the lady is primipara?

A

25 wk and 31wk ‘routine check’

607
Q

What is done at week 28?

A

routine care (SFH, blood, urine)
Anaemia check
RBC Alloantibodies

1st dose anti-D

608
Q

What is done at week 34?

A

Routine care

2nd dose anti-D

609
Q

What is done at week 36?

A

Information sharing

External cephalic version (if indicated)

610
Q

What is done at week 38?

A

Routine care

611
Q

Outline the pathophysiology of Rhesus incompatibility.

A

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
Q

When should anti-D immunoglobulin be given within 72 hours?

A 
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
Q

What antenatal checks are done at 8-12 weeks?

A

Booking visit: lifestyle; BP, urine dipstick, BMI

Bloods: FBC; Allotypes; Rh status; Blood group

BBV: Hep B, HIV, Syphilis

Urine culture

614
Q

What is done at 10-13+6 weeks antenatally?

A

Early pregnancy scan to confirm dates

615
Q

What is done at 11-13+6 weeks?

A

Down syndrome screening

ßhCG; PAPP-A and Nuchal Ligament

616
Q

What is done at 16 weeks?

A

Routine care (BP + Urine)

Share results

617
Q

What is done at 18-20+6 weeks?

A

Anomaly scan

618
Q

What is done at 28 weeks?

A

Routine care

Screen for bloods

Anti-D prophylaxis if Rhesus negative woman

619
Q

What happens at week 34 in the antenatal care plan?

A

Second dose of anti-D prophylaxis to rhesus negative woman

620
Q

What occurs at week 36 of the antenatal care time table?

A

External cephalic version

621
Q

What occurs at week 38 of antenatal care timetable?

A

Routine care

622
Q

What are the 3 types of monozygotic twins?

A

DCDA (<3 days)

MCDA (4-7 days)

MCMA (>8 days)

Conjoined twins (late)

623
Q

What are the clinical features of IUGR?

A

SGA on scans

SFH low

Low birth weight (<10th centime)

624
Q

What are the causes of intrauterine death? Give 3.

A

Foetal: Chromosomal abnormalities; Infection; Twin-twin transfusion syndrome

Maternal: Chronic disease; obstetric cholestasis; Rhesus disease; Thrombophilia

Placenta: Abruption; Pre-eclampsia; Smoking

625
Q

What is the gold-standard test for IUD?

A

USS

626
Q

What is the medical management of miscarriage?

A

Misoprostrol - contact doctor if bleeding hasn’t stopped in 24 hours

627
Q

What is the surgical management of a miscarriage?

A

Vacuum

D+C

628
Q

Outline the types of miscarriage.

A

Threatened = bleeding + Os closed + USS fine

Inevitable = heavy bleeding + Os open

Incomplete = pain + bleeding + Os open

Missed = gestational sac + Os closed

629
Q

Give 5 risk factors for placental abruption.

A 
Trauma 
Smoking 
Cocaine 
Antiphospholipid syndrome 
Hypertension 
Increasing maternal age
Multiparity
630
Q

Give 3 potential risk factors for preterm labour.

A 
Acute illness 
Low BMI 
Multiple pregnancy 
Polyhydramnios 
PROM

PMHx preterm
Smoking
Uterine abnormalities
Previous cervical injuries

631
Q

Discuss how you would interpret a CTG.

A

Mnemonic: DR C BRAVADO

Determine
Risk

Contractions

Baseline
RAte

Variability
Accelerations (>15bpm for >15 seconds)
Decelerations >15bpm for >15 seconds)
Overall impression

632
Q

Give 5 potential indications for induction of labour.

A 
Postmaturity (>40 weeks)
Obstetric cholestasis 
Failure to progress
Suspected IUGR
Gestational diabetes 
IUD
Pre-eclampsia 
Rhesus incompatibility
633
Q

What are the complications of induced labour?

A

Hyperstimulation
Prolonged contractions that are frequent (tachysystole)

Uterine rupture

634
Q

How would you manage a shoulder dystocia?

A

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
Q

Give 5 RFs for a PPH

A 
PMHx PPH 
Pre-eclampsia 
Prolonged labour
Polyhydramnios 
Emergency C section 
PP; PA; Placental accrete 
Macrosomia
636
Q

What are the options for managing a postpartum haemorrhage?

A

IV Syntocinon 10 U or IV Ergometrine 500mcg

or IM Carboprost

if that fails…

IU Balloon tamponade

637
Q

How may a PPH be classified?

A

Major: >1L

Minor: >500mL

Primary: <24hrs

Secondary: 1 day to 12 weeks

638
Q

What proportion of women experience the baby blues?

A

60-70%

639
Q

What are the clinical features of the baby blues?

A

Anxious
Tearful
Irritable

640
Q

What is the management of the baby blues?

A

Reassurance

Support

641
Q

What proportion of women experience postnatal depression?

A

10%

642
Q

What is the treatment for a patient with postpartum depression?

A

CBT/reassurance

SSRIs (Paroxetine) if severe

643
Q

What are the features involved in Puerperal psychosis?

A

Mood swings - psychotic features e.g. THREAD LESS features or impulsivity and energy

644
Q

What is the management for puerperal psychosis?

A

Hospital admission (Mother and Baby Unit)

645
Q

What is the reoccurrence rate of post-partum psychosis?

A

25-50%

646
Q

What are the associations of hyperemesis gravidarum?

A 
Multiple pregnancies 
Trophoblastic disease (molar pregnancy)
Hyperthyroidism 
Nulliparity 
Obesity
647
Q

What is associated with a decrease in hyperemesis gravidarum?

A

Smoking

648
Q

When should you refer for N/V in pregnancy?

A

Unable to keep down foods

> 5% BW despite anti-emetic treatment

Confirmed comorbidity e.g. cannot tolerate PO ABX for UTI

649
Q

What scoring system may be used in NVP?

A

PUQE score

650
Q

What is the management of Hyperemesis Gravidarum?

A

Drugs: Cyclizine

Supportive: Ginger and P6 wrist accupressure

651
Q

What are the potential complications of Hyperemesis Gravidarum?

A

Wernicke’s encephalopathy
Mallory-Weiss tears
Central pontine myelinolysis
ATN

SGA
Pre-term birth

652
Q

What is the gold standard test for Ectopic?

A

TVUS

653
Q

What are the management options for an ectopic pregnancy?

A

Expectant:
hCG <1000
Size <35mm
Asymptomatic

Medical: Methotrexate
hCG <1500
Size <35mm

Surgery: Salpingectomy
hCG >5000
Size >35mm
Pain

654
Q

What is the risk of a repeated ectopic in the future following an ectopic pregnancy?

A

10-15%

655
Q

What are the risk factors for Cervical cancer?

A 
HPV-16 and HPV-18
Smoking 
HIV 
Early first intercourse, many partners (young and early) 
High parity 
Lower socieconomic status 
COCP
656
Q

What is the gold standard for Cervical cancer treatment?

A

1 - radical excsision OR TAH + LN clearance

2 - TAH + LN clearance

3/4 - radiotherapy + chemo

657
Q

State 3 RFs for endometrial cancer.

A 
Obesity 
SERM 
Early menarche/late menopause
Oestrogen secreting tumours 
HRT 
Lynch syndrome
PCOS
658
Q

Which familial colorectal cancer syndrome is linked to Endometrial cancer?

A

Lynch syndrome

659
Q

What is the most common presenting symptom of endometrial cancer?

A

PMB

Intermenstrual bleeding (if premenopausal)

660
Q

What is the first line investigation for endometrial cancer?

A

TVUS

661
Q

What is the gold-standard investigation of endometrial cancer?

A

Hysteroscopy with endometrial biopsy

662
Q

What is the management of Endometrial cancer?

A

TAH + BSO

663
Q

What is the pathophysiology of a hydatidiform mole?

A

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
Q

What are the clinical features of a molar pregnancy?

A

Hyperemesis
Large for dates
High ßhCG

Hypertension and hyperthyroidism

665
Q

How is a molar pregnancy managed?

A

Referral to specialist centre

Contraception to avoid pregnancy for 12 months

666
Q

What condition may be developed following a molar pregnancy?

A

Choriocarcinoma

667
Q

What is the predominant cell type of vulval cancer?

A

Squamous cell carcinoma (80%)

668
Q

What are the risk factors for vulval carcinoma?

A

HPV infection
VIN
Immunosuppression
Lichen sclerosis

669
Q

What are the clinical features of a vulval carcinoma?

A

Lump/ulcer on labia majora
Inguinal lymphadenopathy
Itching/irritation

670
Q

What is the main causative organism of PID?

A

C trachomatis

671
Q

What are the clinical features of PID?

A 
Fever 
Abdo pain
Deep dyspareunia 
Discharge/menstrual irregularities
Cervical/vaginal discharge
672
Q

What are the clinical investigations in a suspected PID?

A

Rule out pregnancy with pregnancy test

VVS Swab + ask for a NAAT

673
Q

What is the treatment for PID?

A

Oral ofloxacin + Oral metronidazole

IM ceftriaxone + PO doxycycline + PO metronidazole

674
Q

What are the potential complications of PID?

A

Fitz-Hugh-Curtis syndrome

Infertility

Chronic pelvic pain

Ectopic pregnancy

675
Q

What are the clinical features of endometriosis?

A

Dysmenorrhoea
Deep dyspareunia
Chronic pelvic pain
Ovulation pain

Tenderness on examination

676
Q

What is the gold-standard investigation of endometriosis?

A

Laparoscopy

677
Q

What is the management of endometriosis?

A

NSAIDs/paracetamol

COCP

GnRH analogues (reduces oestrogen)

Surgery

678
Q

What are the clinical features of a Bartholin’s abscess?

A 
Pain
Swelling 
Dyspareunia 
Unilateral vulval swelling 
Abscess erythematous and tender to palpation
679
Q

What is the management of a Bartholin’s cyst?

A

Incision and drainage and marsupialisation (inner cyst wall sutured to skin)

680
Q

Give 3 causes of primary and secondary amenorrhoea.

A

Gonadal dysgenesis
Imperforate hymen
CAH
Congenital malformation of genital tract

Hypothalamic amenorrhoea 
PCOS 
Hyperprolactininaemia 
POF
Thyrotoxicosis 
Sheehan's syndrome 
Asherman's syndrome
681
Q

What is the MOA of the COCP?

A

Inhibit ovulation

682
Q

What are the potential side effects of the COCP?

A

VTE risk

Breast cancer and cervical cancer risk

683
Q

What is the MOA of the POP?

A

Thickens cervical mucous

684
Q

What are the side effects of POP and IUS?

A

Irregular menstrual bleeding

685
Q

How should you advise a girl starting on the COCP?

A

First 5 days of cycle fine

If after, 7 days of condoms, covered

686
Q

If a woman misses two of her COCPs in week 2 of her pack, what advice would you give?

A

Take missed pill, continue, no need for emergency contraception

687
Q

If a woman misses two of her COCPs in week 3 of her pack, what advice would you give?

A

Finish current pack then start new pack newt day thus omit the pill-free interval

688
Q

When can a woman start her POP regarding condom usage?

A

Need condoms for 2 days

689
Q

What options of emergency contraception are there?

A

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
Q

What would a hormone profile show in a menopausal woman?

A

Raised LH and raised FSH

Low oestrogen

691
Q

How should HRT be given?

A

Oestrogen deficient therefore oestrogen but must not be unopposed oestrogen

Topical
SSRIs

Combined patch
Oestrogen + IUS

Other combinations

692
Q

What are the risks of HRT?

A

Endometrial cancer
CVD/CVI
VTE
Gallbladder disease

693
Q

What is ovarian hyperstimulation syndrome?

A

Following IVF, hyper stimulated ovaries release vasoactive products which cause capillary permeability and potential pulmonary, renal and VTE risks

694
Q

What are the clinical features of ovarian hyperstimulation syndrome?

A

Abdominal pain
Bloating
N/V

HF presentation

VTE

695
Q

What are the RF for an ovarian torsion?

A

Pregnancy
OHS
Ovarian mass

696
Q

What are the clinical features of an ovarian torsion?

A

Abdo pain - colicky
N/V
Distressed

Adnexal tenderness

697
Q

What is shown on a US in an ovarian torsion?

A

Whirlpool sign

698
Q

What is the diagnostic and gold standard management for a patient with Ovarian torsion?

A

Laparoscopy

699
Q

What is the commonest form of ovarian cyst?

A

Follicular cyst

700
Q

Which cyst, if ruptured may cause pseudomyxoma peritonei?

A

Muscinous cystadenoma

Medicine (18 decks)

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