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Phase 3a > Obs and Gynae > Flashcards

Obs and Gynae Flashcards

1
Q

Define Pre-eclampsia

A

New onset Hypertension (>140/80mmHg) after week 20 of pregnancy + either proteinurea or evidence of maternal organ dysfunction

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2
Q

What proteinuria findings are required for a pre-eclampsia diagnosis?

A

Either;

Urine Protein:creatinine ratio >30mmol/L
or
Albumin:creatinine ratio >8mmol/L

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3
Q

What types of maternal organ dysfunction are required for a diagnosis of pre-eclampsia?

A

Kidney - Renal dysfunction
Liver - Liver dysfunction (raised ATP/AAT)
Brain - Neurological dysfunction (stroke, blurred vision, ect)
Blood - Haematological disease (DIC, Thrombocytopenia, haemolysis)
Uterus - Uterine dysfunction - still birth, abnormal uterine artery doppler

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4
Q

Give some symptoms of pre-eclampsia (5)

A

Severe headache
Vomiting
Severe pain below ribs
Vision problems - Blurry/flashing lights
Sudden onset swelling of hands, feet or face

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5
Q

What is the target BP for pre-eclamptic patients?

A

135/85mmHg

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6
Q

What prophylactic management is given to pre-eclamptic patients? And what criteria must they fulfull?

A

Aspirin (75-150mg) from week 12 to birth.

Criteria;
x1 High risk factor OR >1 moderate risk factor

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7
Q

Give 5 high risk factors for pre-eclampsia

A

Previous hypertensive disease during pregnancy
Chronic kidney disease
Diabetes
Autoimmune disease - SLE/Antiphospholipid syndrome
Chronic hypertension

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8
Q

What are the 1st, 2nd and 3rd line therapies for chronic hypertension in pregnancy?

A

1st - Labetalol
2nd - Nifedipine
3rd - Methyl-dopa

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9
Q

What antihypertensive treatments are contraindicated in pregnancy? (5)

A

ACEi
ARBs
Statins
Thiazides
Thiazide diruetics

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10
Q

Give 6 moderate risk factors for pre-eclampsia

A

Nulliparus
Age >40
BMI >35
>10 year gap between pregnancies
Family history of hypertensive disease during pregnancy
Multi-fetal pregnancy

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11
Q

Define uterine fibroid

A

A benign tumour of the uterine myometrium

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12
Q

What are uterine fibroids composed of and what is their transverse appearance?

A

Whorled appearance.

Composed of smooth muscle cells and fibrous connective tissue

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13
Q

Describe the 3 types of uterine fibroid

A

Intermural - Restricted to myometrium
Submucosal - Involves endometrium, may bulge into uterine cavity
Subserosal - Bulges outside of uterus (may press on surrounding organs)

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14
Q

What is the name of the opening between the fallopian tubes and the uterine cavity?

A

Tubal Ostia

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15
Q

Give symptoms of uterine fibroids (3)

A

Heavy (sometimespainful) menses (>7 days bleeding)

Pressure symptoms;
- Rectum (constipation)
- Bladder (frequency)
- Ureter (hydronephrosis - flank pain)

Subfertility
- Submucosal can block tubal ostia
- Subserosal can inhibit implantation

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16
Q

Give a complication of uterine fibroids

A

Degenerations;
Red degenerations - Decreased blood flow - Presents with uterine pain and tenderness

Hyaline or cystic degenerations - fluid filled.

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17
Q

Investigations for uterine fibroid diagnosis (2)

A

Transvaginal Ultrasound. MRI if US intolerated

FBC - anaemia

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18
Q

Give some treatment options for uterine fibroids.

A

Monitor - Monitor size and growth (if asymptomatic)

Medical - GnRH agonist- Leuprorelin

Surgical - Hysteroscopic myomectomy (preserves fertility)
- Uterine artery embolisation (doesn’t preserve fertility)
- Hysterectomy

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19
Q

For the treatment of uterine fibroids, why would uterine artery embolization be favoured over a hysteroscopic myomectomy?

A

Favoured in high risk patients;
- Obese
- Chronic Hypertension
- Diabetes

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20
Q

How does Leuprorelin work and what are it’s main side effects?

A

GnRH agonist. Induces a temporary menopausal state by inhibiting the production of oestrogen.

Main side effects; osteoporosis, hot flushes, depression

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21
Q

What testing should be offered to rule out pre-eclampsia between 20 and 35 weeks in women with chronic hypertension?

A

Placental Growth Factor (PIGF) testing

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22
Q

What 3 clinical features must be present for diagnosis of hyperemesis gravidarum?

A

5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance

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23
Q

What electrolyte imbalances are commonly seen in hyperemesis gravidarum?

A

Hyponatraemia and Hypochloraemia

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24
Q

Give 5 clinical features of hyperemesis gravidarum

A

5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance (hyponatraemia/hypochloremia)

Ketosis

Hypovolemia

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25
Q

Give 5 risk factors for hyperemesis gravidarum

A

Trophoblastic disease (choriocarcinoma)
- Will present with a high Beta HCG level)

Multiple pregnancies

Hyperthyroidism

Nulliparity

Obesity

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26
Q

What are the 1st and 2nd line treatments for hyperemesis gravidarum?

A

1st line - Antihistamines - Oral Cyclazine or Promethazine

2nd line - Antiemetics - Ondanstatron or Metoclopromide

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27
Q

Why is metoclopromide use limited to 5 days?

A

Can cause extrapyramidal side effects (such as eyes locking in one place)

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28
Q

What risk does ondanstatron use bring during pregnancy?

A

Increased risk of fetus developing cleft lip/palate

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29
Q

Give 5 complications of hyperemesis gravidarum

A

Wernicke’s encephalopathy

Mallory weiss tear

Central pontine myelinolysis

Acute tubular necrosis

Fetus; small for gestational age, pre-term birth

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30
Q

Name 2 methods of emergency hormonal contraception.

A

Emergency Pill - Levonorgestrel

Morning-after pill - Ulipristal

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31
Q

What is the maximum timeframe that levonorgestrel (emergency pill) can be taken in?

A

Within 72 hours of unprotected sexual intercourse.

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32
Q

What is the maximum timeframe that ulipristal (morning after pill) can be taken in?

A

No later than 120 hours after intercourse

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33
Q

How long after ulipristal (morning after pill) use can hormonal contraception be restarted?

A

5 days after Ulipristal use

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34
Q

How long should breastfeeding be delayed after ulipristal (morning after pill) use?

A

1 week after Ulipristal use

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35
Q

What conditions are required to make Lactational amenorrhea an effective contraceptional method?

A

Amenorrhea + Baby Aged <6 months + Exclusively Breast Feeding

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36
Q

Give 3 advantages and disadvantages of lactational amenorrhea as an effective contraceptional method.

A

Advantages;

LAM is effective for up to 6 months post partum.

It encourages breast feeding for up to 6 months post partum

Can be used immediately after childbirth

Disadvantages;

Doesn’t protect against STIs (inc HIV)

Becomes unreliable after 6 months when other foods get introduced

Frequent breast feeding can be inconvenient

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37
Q

Give 2 long term complications of hysterectomy with antero-posterior repair

A

Enterocoele (small bowel prolapse

Vaginal vault prolapse

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38
Q

How is vaginal vault prolapse managed?

A

Sacrocolpopexy (using mesh to lift top of vagina and adhere to sacrum)

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39
Q

Name and describe 2 types of breech presentation

A

Frank breech (Hips flexed and knees extended)

Footling breech (feet are positioned next to buttocks- carried higher morbidity)

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40
Q

What management is recommended is fetus is breech at 36 weeks gestation? and when do NICE recommend it’s use?

A

External cephalic version (ECV)

NICE recommend ECV is offered from 36 weeks in nulliparous and from 37 weeks in multiparous.

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41
Q

If a baby is in breech position at the time of delivery, what method of delivery is recommended?

A

Caesarean section

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42
Q

Give 6 contraindications to External Cephalic Version (ECV)

A

Where caesarean delivery is required

Antepartum haemorrhage within last 7 days

Abnormal cardiotocography

Major uterine anomaly

Ruptured membranes

Multiple pregnancy

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43
Q

What is the ectocervix and what cell type is it made up of?

A

Outer part of the cervix that opens into the vagina

Stratified Squamous Non Ketatinized Epithelium

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44
Q

What is the endocervix and what cell type is it made up of?

A

The opening of the cervix that leads to the uterus

Mucus secreting simple columnar epithelium.

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45
Q

Which of the 4 breast quadrants is most common for malignancies to present?

A

Superior lateral quadrant (axillary tail)

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46
Q

What congenital abnormality does folic acid help prevent?

A

Neural tube defects (i.e spina bifida)

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47
Q

What groups of women are at increased risk of neural tube defects? (6)

A

Previous child with NTD

Diabetes mellitus

Women on antiepileptics

Obese

HIV +ve taking co-trimoxazole

Sickle Cell

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48
Q

Give 4 causes of folic acid deficiency

A

Phenytoin

Methotrexate

Pregnancy

Alcohol excess

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49
Q

What type of anaemia occurs in folic acid deficiency?

A

Macrocytic, megaloblastic anaemia

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50
Q

Define endometrial hyperplasia

A

Irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio

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51
Q

What is the most common clinical feature of endometrial hyperplasia?

A

Abnormal uterine bleeding

(Heavy, intermenstrual, irregular, unscheduled (on HRT) or post-menopausal bleeding)

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52
Q

Give 5 risk factors for endometrial hyperplasia

A

Obesity

Anovulation (PCOS or Perimenopause)

Oestrogen secreting tumours - Granulosa cell tumours

Drug induced (tamoxifen or oestrogen replacement)

Post-menopause

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53
Q

What are the 2 types of endometrial hyperplasia

A

Endometrial hyperplasia without atypia

Atypical hyperplasia

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54
Q

What are the 1st, 2nd and 3rd line diagnostic tests (confirms diagnosis) for endometrial hyperplasia

A

1st line - Endometrial Biopsy (Dilation and Curettage)

2nd line - Diagnostic Hysteroscopy (if biopsy is inconclusive or if hyperplasia is in a polyp)

3rd line - Transvaginal Ultrasound Scan

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55
Q

What finding on a transvaginal ultrasound scan would suggest endometrial cancer?

A

Endometrial thickness >3/4mm

(caveat - cut off may be larger in women on HRT or Tamoxifen presenting with abnormal uterine bleeding)

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56
Q

What is the 1st and 2nd line medical therapy for endometrial hyperplasia WITHOUT atypia

A

1st line - Levonorstegrel-releasing intrauterine system (LNG-IUS)

2nd line - Oral Progesterone (Medroxyprogesterone/norethisterone)

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57
Q

What is the 1st line treatment for heavy menstrual bleeding?

A

1st line - Levonorstegrel-releasing intrauterine system (LNG-IUS)

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58
Q

Describe how women with endometrial hyperplasia without atypia should be monitored following treatment.

A

Endometrial surveillance should be conducted at 6 monthly intervals.

At least 2 consecutive 6 monthly negative biopsies are required for discharge.

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59
Q

What is the 1st line treatment for atypical endometrial hyperplasia?

A

Total hysterectomy

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60
Q

What monitoring requirement is required for women with endometrial hyperplasia wishing to conceive?

A

Disease regression should be achieved in at least 1 sample before attempting to conceive.

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61
Q

For a woman with endometrial hyperplasia on sequential HRT, how should her HRT treatment be changed?

A

Change from sequential to continuous progestogen (i.e using LNG-IUS or oral)

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62
Q

Give 4 tumour markers for endometrial cancer

A

CA-125, CA15-3, CEA, Prolactin

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63
Q

What medications are known to increase the risk of endometrial hyperplasia and cancer? (2)

A

Tamoxifen (breast cancer treatment)

Aromatase inhibitors (anastrozole, exemestane and letrozole)

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64
Q

What is tamoxifen and what is it’s MOA?

A

Selective oestrogen receptor modulator that inhibits proliferation of breast cancer by competitive antagonism of oestrogen receptors.

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65
Q

Why does tamoxifen promote development of fibroids, endometrial polyps and hyperplasia?

A

Acts as a partial agonist to oestrogen receptors in the vagina and uterus.

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66
Q

What hormone is responsible for endometrial hyperplasia?

A

Oestrogen

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67
Q

What hormone is responsible for endometrial shedding?

A

Progesterone

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68
Q

When does conception occur and how is a pregnant woman’s estimated due date calculated?

A

Conception occurs 2 weeks after the patient’s last period.

Calculation.
1. Determine first day of last menstrual period.

  1. Count back 3 months from that date.
  2. Add 1 year and 7 days to that date
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69
Q

What does the ectoderm give rise to?

A

Skin, Peripheral + Central nervous system, eyes and inner ears

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70
Q

What does the mesoderm give rise to?

A

Heart and circulatory system, bones, ligaments, kidneys and reproductive system

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71
Q

What does endoderm give rise to?

A

Lungs and intestines

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72
Q

What cells produce Beta human chorionic gonadotrophin (Beta-HCG)?

A

Trophoblastic cells of the placenta

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73
Q

Give 2 functions of beta HCG in early pregnancy?

A

Signals ovaries to stop releasing eggs.

Increases production of oestrogen and progesterone

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74
Q

What hormone is responsible for oedema in pregnancy? And why?

A

Corticotrophin Releasing Hormone (CRH).

Stimulates ACTH production (especially aldosterone and cortisol)

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75
Q

What is the most common type of anaemia in pregnancy?

A

Iron deficiency anaemia

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76
Q

What haematological finding would be seen in iron deficiency anaemia?

A

Microcytic hypochromic blood film .

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77
Q

When should pregnant women be screened for anaemia?

A

Early pregnancy (at booking appointment) and at 28 weeks.

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78
Q

What is the treatment for iron deficiency anaemia?

A

Low dose iron supplementation - 200mg Ferrous Sulphate daily

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79
Q

What is the 2nd most common form of anaemia in pregnancy?

A

Folate deficiency anaemia

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80
Q

What haematological finding would be seen in folate deficiency anaemia?

A

Macrocytic anaemia

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81
Q

What is the treatment for folate deficiency anaemia in pregnancy?

A

Folic acid 5mg per day

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82
Q

If a woman is <20 weeks pregnant and is not immune to varicella zoster virus (but is exposed), what treatment should they be given?

A

Varicella zoster immunoglobulin (VZIG) given ASAP

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83
Q

If a woman is >20 weeks pregnant and is not immune to varicella zoster virus (but is exposed), what treatment should they be given?

A

Varicella zoster immunoglobulin (VZIG) OR Antiviral (Acyclovir) 7-14 days after exposure

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84
Q

Give 5 symptoms of premenstural dysmorphic disorder

A

Depressed mood and irritability

Abdominal bloating

Fatigue

Breast tenderness

Headaches

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85
Q

During what phase of the menstrual cycle does premenstural dysmorphic disorder (and PMS) tend to present?

A

During the luteal phase (Day 14-28 - Post ovulation)

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86
Q

What physiological change happens during the luteal phase?

A

Endometrial lining of the uterus gets

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87
Q

What cell type does FSH bind to? and what do they stimulate production of?

A

Granulosa cells.

Stimulates production of aromatase, leading to production of oestrogen

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88
Q

What cell type does LH bind to? and what do they stimulate production of?

A

Theca cells.

Promotes production of Androstenedione, which later becomes oestrogen.

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89
Q

Where is progesterone produced? (2)

A

Corpus luteum

Placenta (at 8-12 weeks)

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90
Q

Name 3 forms of oestrogen and describe where their produced

A

E2 - Estradiol (most active)

E1 - Estrone (fat cells and adrenal glands)

E3 - Estriol (placenta)

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91
Q

What is the dominant form of oestrogen in the menopause?

A

Estrone (produced by fat cells and adrenal glands)

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92
Q

What is the dominant form of oestrogen during pregnancy?

A

Estriol (produced by the placenta)

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93
Q

Give 2 protective features of oestrogen

A

Cardioprotective (makes walls of blood vessels more flexible and lowers LDL levels)

Osteoprotective (sustains bone density)

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94
Q

What anticoagulation treatment should be offered to pregnant women at high risk of DVT? and why?

A

Low Molecular Weight Heparin

Warfarin can cross the placenta and is teratogenic

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95
Q

What treatment can be given to reverse the effects of LMWH in pregnant women?

A

Protamine sulfate

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96
Q

Give 3 side effects of protamine sulfate

A

Sudden fall in BP

Bradycardia

Pulmonary hypertension

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97
Q

When (in weeks) is the anomaly scan performed?

A

20 weeks

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98
Q

When (in weeks) is the first dose of Anti D prophylaxis given to rhesus negative women?

A

28 weeks

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99
Q

When (in weeks) is the early scan to confirm dates performed?

A

10 - 13+6 weeks

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100
Q

If a 37 week pregnant woman presents with severe pre-eclampsia (acute severe headache, vomiting, blurred vision and hypertension (>140/90) what is the appropriate management?

A

IV Magnesium Sulphate and plan immediate delivery

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101
Q

What is the appropriate management for any new hypertension (>140/90) after 20 weeks gestation + proteinuria?

A

Emergency referral to obstetrics

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102
Q

What is shoulder dystocia

A

Complication of vaginal cephalic delivery whereby the anterior fetal shoulder becomes stuck on the maternal pubic symphesis

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103
Q

What manoeuvre is performed to manage shoulder dystocia in pregnancy?

A

McRoberts’ manoeuvre (patient is asked to lie on their back with their legs pushed outwards and up towards their chest)

(hips fully flexed and abducted)

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104
Q

What additional measure can aid the effectiveness of a McRoberts’ manoeuvre?

A

Suprapubic pressure

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105
Q

What medication can be used to suppress lactation?

A

Cabergoline

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106
Q

What is the moa of cabergoline?

A

Dopamine receptor agonist which inhibits prolactin production, causing suppression of lactation.

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107
Q

What medication is given to soften the cervix in induction of labour?

A

Misoprostol (prostaglandin E1)

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108
Q

What medication is given to treat severe cholestasis during pregnancy?

A

Ursodeoxycholic acid

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109
Q

What supplementation should pregnant obese women be given? (BMI >30)

A

5mg folic acid

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110
Q

Define endometriosis

A

Endometriosis describes the growth of ectopic endometrial tissue outside of the uterine cavity

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111
Q

What is the gold standard investigation for endometriosis?

A

Laparoscopy

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112
Q

Give 4 symptoms of endometriosis

A

Chronic pelvic pain (worsens before onset of menses)

Dysmenorrhea

Dyspareunia

Subfertility

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113
Q

Give 2 clinical features you may find on examination of a patient with endometriosis.

A

Uterosacral ligament nodularity (on bimanual examination)

Pelvic mass (ovarian endometriomas - ‘chocolate cysts’)

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114
Q

What are the 1st, 2nd and 3rd line treatments for endometriosis?

A

1st - NSAIDs and/or Paracetamol

2nd - Combined Oral Contraceptive Pill or Progesterones

3rd - GnRH analogues (i.e leuprorelin)

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115
Q

Describe adenomyosis

A

Adenomyosis is characterised by the presence of endometrial tissue within the myometrium (due to hyperplasia of the endometrial basal layer)

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116
Q

Give 3 risk factors for adenomyosis

A

Multiparity (more common in multiparous women towards the end of their reproductive age)

Uterine fibroids

Endometriosis

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117
Q

Give 4 clinical features of adenomyosis

A

Dysmenorrhoea (painful menses)

Abnormal uterine bleeding

Chronic pelvic pain (aggravated during menses)

Globular, uniformly large uterus that is soft but tender on palpation

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118
Q

What may a transvaginal ultrasound/MRI show for a patient with adenomyosis? (2)

A

Asymmetric myometrial wall thickening.

Myometrial cysts

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119
Q

What hormone stimulates the proliferation of endometrium in endometriosis?

A

Oestrogen

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120
Q

What 2 bacteria most commonly cause pelvic inflammatory disease?

A

Neisseria Gonorrhoeae and Chlamydia trachomatis

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121
Q

What kind of bacteria is Neisseria gonorrhoeae and what type of agar can it be grown on?

A

Gram negative diplococcus

Grown on Chocolate Agar

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122
Q

Give 2 risk factors for PID

A

Multiple sexual partners/unprotected sex

History of prior STIs

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123
Q

Give 4 complications of PID

A

Fitz-High-Curtis syndrome (right upper quadrant pain, associated with peri-hepatitis)

Ectopic pregnancy

Tubo-ovarial abscess

Tubal infertility

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124
Q

What bacteria is associated with Fitz-Hugh-Curtis syndrome in PID?

A

Chlamydia trachomatis

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125
Q

What tests would you perform in a patient with PID to exclude other causes of their symptoms? (3)

A

Pregnancy test - Exclude ectopic pregnancy

High vaginal swab - Exclude bacterial vaginosis and candidiasis

Microscopy - Look for endocervical or vaginal pus cells (if absent, PID is unlikely)

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126
Q

Give 5 clinical signs of PID on examination

A

Lower (bilateral) abdominal tenderness

Adnexal tenderness

Cervical motion tenderness

Uterine tenderness (on bimanual examination)

Abnormal cervical or vaginal mucopurulent discharge (on speculum examination)

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127
Q

Give 4 differentials for PID

A

Ectopic Pregnancy

Ruptured corpus luteal cyst

Acute appendicitis

UTI

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128
Q

What is the antibiotic treatment regimen for treating PID?

A

Single IM dose of ceftriaxone + Oral Doxycycline (100mg) + Oral Metronidazole (400mg)

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129
Q

What type of antibiotic is ceftriaxone and give 3 side effects

A

Cephalosporin.

Abdo pain, Diarrhoea, agranulocytosis (rare)

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130
Q

What type of antibiotic is doxycycline and give 3 side effects

A

Tetracycline

Angioedema, Diarrhoea, Henoch-Schonlein purpura (IgA vasculitis rash)

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131
Q

Give 2 side effects of metronidazole

A

Dry mouth and myalgia (muscle ache)

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132
Q

What type of antibiotics are Ofloxacin and Levofloxacin and give 3 side effects

A

Quinolones
Decreased appetite, GI discomfort, QT prolongation

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133
Q

Give 3 symptoms of long QT

A

Syncope

Palpitations

Dizziness

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134
Q

What 3 symptoms primarily make up interstitial cystitis?

A

Urinary frequency, urgency and suprapubic pelvic pain (pain is relieved by voiding and worsened by bladder filling)`

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135
Q

What are the 3 types of ovarian cyst?

A

Follicular cyst (most common)

Corpus luteum cysts

Dermoid cysts (most likely to cause torsion)

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136
Q

Give 5 risk factors for ovarian cysts

A

Early menarche

Endometriosis

Polycystic ovarian syndrome

Pregnancy (3rd trimester)

Tamoxifen treatment

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137
Q

Give 3 clinical features of ovarian cysts

A

Pelvic pain

Bloating and early satiety

Palpable adnexal mass

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138
Q

What is the 1st line investigation for ovarian cysts?

A

Transvaginal Ultrasound

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139
Q

What is the most sensitive marker for epithelial ovarian cancer?

A

Human Epididymis Protein 4 (HE4)

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140
Q

Ovarian cysts of what size typically cause ovarian torsion?

A

> 6cm

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141
Q

Give 4 clinical features of ovarian torision.

A

Sudden onset pelvic/lower abdo pain

Nausea, vomiting or diarrhoea

Abdominal/pelvic tenderness

Palpable adnexal mass +/- tenderness (on palpation)

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142
Q

What is the most common type of ovarian cyst?

A

Follicular cyst

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143
Q

Give 2 risk factors for ovarian torsion

A

Ovarian Cysts >6cm

Dermoid cysts

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144
Q

What type of ovarian cysts is most likely to present with intraperitoneal bleeding?

A

Corpus luteal cyst

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145
Q

What effect does hyperandrogenism (in PCOS) have on insulin sensitivity

A

Increases insulin resistance, leading to hyperinsulinemia (increasing risk of developing type 2 diabetes)

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146
Q

What criteria must a patient fulfil to be diagnosed with metabolic syndrome?

A

3/5 of the following;

Elevated waist circumference (>88cm for women and >102cm for men)

Elevated triglycerides (>150mg/dl) or drug treatment for elevated triglycerides (fibrates/omega 3 acid ethyl esters)

Low HDL cholesterol (<40mg/dl for men, <50mg/dl for women) or drug treatment for low HDL

Elevated blood pressure or on antihypertensive treatment

Elevated fasting glucose (>100mg/dl) or drug treatment for elevated glucose

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147
Q

Give 4 diseases associated with PCOS

A

Metabolic syndrome

Insulin resistance (type 2 diabetes)

Endometrial cancer (due to unopposed oestrogen activity)

Non alcoholic fatty liver disease

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148
Q

Give 4 clinical features of PCOS

A

Irregular menses

Female of reproductive age (symptoms start at time of puberty)

Infertility

Skin conditions (acanthosis nigricans, hirsutism, acne, oily skin)

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149
Q

What medication can mask the symptoms of PCOS?

A

Oral contraceptives

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150
Q

What features are required for diagnosis of PCOS? (once other causes of irregular menses and hyperandrogenism have been excluded)

A

Infrequent/no ovulation (characterised by irregular menses)

Clinical and/or biochemical signs of hyperandrogenism (skin changes or increased total/free testosterone)

Polycystic ovaries on ultrasound scan

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151
Q

How are polycystic ovaries defined on US scan?

A

Defined as presence of 12 or more follicles (measuring 2-9mm in diameter) in one or both ovaries and/or increased ovarian volume >10cm3)

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152
Q

Give 4 other causes of hyperandrogenism in a patient with suspected PCOS and features that would help you exclude them.

A

Congenital Adrenal Hyperplasia (ambiguous genitalia)

Cushing disease (increased 24 hour urine free cortisol)

Hypothyroidism (increased TSH)

Acromegaly (increased IGF-1)

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153
Q

Suggest 2 biochemical markers which may be raised in PCOS

A

Raised LH/FSH

Raised testosterone

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154
Q

How is type 2 diabetes risk assessed in patients with PCOS with risk factors? (what are the risk factors) (3)

A

75 mg Oral glucose tolerance test.

Risk factors for use include;

Obesity (BMI >25kg)

Not Obese (BMI <25Kg) but have additional risk factors (>40 yrs old, history of gestational diabetes or FH or type 2 diabetes)

Non Caucasian ethnicity

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155
Q

How are symptoms of oligo/amenorrhoea managed in PCOS?

A

Prescribed medroxyprogesterone to induce withdrawal bleed, then refer for transvaginal US to assess endometrial thickness.

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156
Q

What is defined as prolonged amenorrhoea in PCOS?

A

<1 period every 3 months

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157
Q

What should pregnant women with PCOS be screened for? and how is this conducted?

A

Gestational diabetes

Offer 75g oral glucose tolerance test before 20 weeks gestation (if not performed preconception)

All pregnant women with PCOS should be offered OGTT at 24-28 weeks gestation

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158
Q

What stage of gestation should pregnant women with PCOS be offered OGTT?

A

24-28 weeks gestation

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159
Q

For a PCOS patient with infertility desiring fertility, what is the most appropriate management? (lifestyle changes, 1st line, 2nd line and adjunct)

A

Healthy lifestyle +/- weight loss

1st line - Letrozole

1st line - Clomifene

2nd line - Follitropin (gonadotrophin)

Adjunct - Metformin

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160
Q

What is the MOA for letrozole?

A

Selectively inhibits aromatase in peripheral tissues (thus blocking production of oestrogen)

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161
Q

What is the MOA for clomifene?

A

Non steroidal anti-oestrogen.

Stimulates the pituitary gland to increase secretions of FSH and LH, leading to increased negative feedback, thus blocking further oestrogen release

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162
Q

What is the 1st line treatment for a PCOS patient not desiring fertility?

A

Low Dose Combined Oral Contraceptive Pill

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163
Q

What class of drug is Drospirenone? (oral contraceptive pill)

A

Spironolactone analogue (has anti-androgen properties)

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164
Q

What should you do if Female Genital Mutilation is confirmed in a girl under 18?

A

Report to the medical team AND police within 1 month of confirmation

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165
Q

Define type 1 FGM

A

Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)

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166
Q

Define type 2 FGM

A

Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora

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167
Q

Define type 3 FGM

A

Narrowing of the vaginal orifice with creation of a covering seal by cutting or appositioning the labia minora/majora, with or without excision of the clitoris (infibulation)

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168
Q

Define type 4 FGM

A

All other harmful procedures to the female genitalia for non-medical purposes (pricking, piercing, incising, scraping, cauterization)

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169
Q

Name the top 3 countries where FGM is most prevalent

A

Somalia, Guinea, Djibouti

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170
Q

Name 3 common short term complications of FGM

A

Haemorrhage

Urinary retention

Genital swelling

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171
Q

Name 3 common long term complications of FGM

A

UTIs

Dyspareunia

Bacterial vaginosis

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172
Q

Define Turner’s Syndrome

A

Chromosomal disorder caused by either the presence of only one X chromosome or due to a deletion of the short arm of one of the X chromosomes

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173
Q

How is Turner’s syndrome denoted

A

45,XO or 45,X

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174
Q

What is the ‘classic’ presentation of Turner’s syndrome? (7)

A

Female
Webbed neck
Short Stature
Primary Amenorrhoea
Congenital Heart Defects
Poor social skills
Delayed/absent puberty

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175
Q

What congenital heart defects are common in Turner’s Syndrome? (2)

A

Coarctation of the aorta

Bicuspid Aortic Valve

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176
Q

What 4 conditions are Turner’s Syndrome Patients more at risk of developing?

A

Crohn’s disease

Autoimmune thyroiditis

Hypothyroidism

Horseshoe Kidney

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177
Q

What is the gold standard diagnostic test for Turner’s syndrome?

A

Karyotype testing

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178
Q

What gonadotrophin levels indicate ovarian failure in Turner’s Syndrome? (2)

A

High FSH

Low AMH (anti mullerian hormone)

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179
Q

Give 4 pharmaceutical managements for Turner’s Syndrome

A

Growth Hormone - Somatropin

Weight/height gain - Oxandrolone

Low dose oestrogen - Estradiol

Ovarian HRT - Oestrogen + Progesterone

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180
Q

Turner’s Syndrome - What murmur would be heart in a patient with a bicuspid aortic valve?

A

Ejection Systolic Murmur

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181
Q

What syndrome is a common complication of infertility treatment? and how may it present?

A

Ovarian hyperstimulation syndrome.

Sudden onset (following egg retrieval) abdominal discomfort/distension, nausea and vomiting

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182
Q

Name 2 medications that may increase the risk of developing ovarian hypersensitivity syndrome

A

Gonadotropin

hCG

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183
Q

What forms of contraception are contraindicated in breast cancer? What should be offered instead?

A

All forms of hormonal contraception.

Offer Copper Intrauterine Device

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184
Q

Define Sheehan’s Syndrome

A

Aka Postpartum Hypopituitarism.

Describes decreased function of the pituitary gland following ischeamic necrosis due to hypovolaemic shock following birth.

Suspect in patients who suffered significant post-partum haemorrhage

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185
Q

Give 6 symptoms and 1 risk factor for Sheehan’s syndrome

A

Weight Gain

Hair Loss

Constipation

Feeling cold all the time

Amenorrhea

Struggle breast feeding

Risk factor ; Hypovolemia following severe post-partum haemorrhage

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186
Q

What form of HRT is the safest against Venous Thromboembolism?

A

Transdermal HRT

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187
Q

Give 3 common side effects of HRT

A

Nausea

Breast Tenderness

Fluid retention and weight gain

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188
Q

Give 3 possible complications of HRT

A

Increased risk of breast cancer

Increased risk of endometrial cancer

Increased risk of venous thromboembolism

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189
Q

When can the Combined Oral Contraceptive Pill be restarted after pregnancy? and why?

A

Restart after 3 weeks (21 days) due to increased risk of VTE post-partum

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190
Q

What 2 medications are present in the COCP

A

Ethinylestradiol and Levonorgestrel

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191
Q

Define premature ovarian failure (POF)

A

Cessation of menses for 1 year before the age of 40. May be preceded by irregular menstrual cycles

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192
Q

Give 3 strong risk factors for premature ovarian failure

A

Positive family history

Chemotherapy/radiation (breast cancer)

Autoimmune disease

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193
Q

What pathogen causes cervical cancer? (2)

A

HPV 16 and HPV 18

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194
Q

Describe 2 features of a threatened miscarriage

A

Painless vaginal bleeding before 24 weeks (typically occurs at 6-9 weeks)

Cervical os is closed

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195
Q

Describe 2 features of an inevitable miscarriage

A

Cervical os is open

Heavy bleeding with clots and pain

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196
Q

What investigation is used to identify placenta praevia?

A

Transvaginal Ultrasound Scan

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197
Q

Describe the management of post partum haemorrhage (1st, 2nd and 3rd line)

A

Immediate management - ABCDE and resuscitation

1st - Palpate uterus and catheterisation

2nd - IV oxytocin

3rd - Intrauterine balloon tamponade

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198
Q

What medication is given to facilitate the delivery of the placenta and prevent post partum haemorrhage?

A

Oxytocin/ergometrine

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199
Q

What 2 agents can be used to initiate labour?

A

Prostaglandin E1 (misoprostol)

Prostaglandin E2 (Dinoprostone)

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200
Q

What is a tocolytic? Give 3 examples

A

Agents used to suppress premature labour.

Indomethacin, Salbutamol and Terbutaline

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201
Q

What agent is used in medical abortion?

When is it’s use contraindicated? (2)

A

Mifepristone

Contraindicated in; Ectopic pregnancy and Acute Porphyria

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202
Q

How long after pregnancy can a patient restart the progestogen-only pill?

A

Immediately

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203
Q

When should a cervical smear be rescheduled to for pregnant women?

A

Until 12 weeks post-partum

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204
Q

Describe 3 stages of ovarian cancer

A

Stage 1 - Confined to the Ovaries

Stage 2 - Local Spread Within the Pelvis

Stage 3 - Spread beyond the pelvis to the abdomen

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205
Q

Give 3 tests used to Confirm Down’s Syndrome in Pregnancy (following a positive screen) and state when they can be used.

A

Cell Free Fetal DNA Testing (From <10 weeks gestation)

Chorionic Villous Sampling (from 13-15 weeks gestation)

Aminocentesis (from 15 weeks gestation - as dangerous in 1st trimester)

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206
Q

What pathogen is responsible for genital warts (aka condylomata acuminata)?

A

HPV 6 and HPV 11

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207
Q

What prophylaxis should a woman whom just experienced an inevitable miscarriage be given and why?

A

Anti-D immunoglobulin.

Due to potentially being exposed to fetal blood

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208
Q

What is the 1st line investigation for women presenting with menorrhagia with significant dysmenorrhoea (pain) or a bulky, tender uterus?

A

Transvaginal Ultrasound
(symptoms suggest adenomyosis)

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209
Q

What dose of folic acid should be given to low risk pregnancy women?

A

400mcg folic acid daily before conception to week 12

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210
Q

What dose of folic acid should be given to high risk pregnant women? and what constitutes high risk?

A

5mg folic acid daily before conception to week 12

MORE
M-Metabolic Disease (diabetes or Coeliac)
O- Obesity
R - Relative or personal Hx of Neural Tube Defects
E - Epilepsy (taking antiepileptic medications)

+Sickle Cell and Thalassaemia

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211
Q

In Cervical Smear testing, if a smear comes back hrHPV positive, what is the next step?

A

Cytology

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212
Q

In Cervical Smear testing, if a smear comes back hrHPV positive, but the cytology comes back negative, what is the next step?

A

Repeat smear test in 12 months

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213
Q

In Cervical Smear testing, if a positive smear is repeated in 12 months and it comes back hrHPV positive, and the cytology comes back positive, what is the next step?

A

Colposcopy

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214
Q

What is the 1st line investigation for women unable to conceive after 1 year of unprotected sex?

A

Day 21 progesterone test (conduct 7 days before period)

Tells us if the patient is actually ovulating

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215
Q

Hyperemesis Gravidarum treatment.

In which patients is cyclazine and promazine contraindicated? (4)

What should be used instead?

A

Hepatic impairment

Epilepsy

Urinary retention

Asthma, bronchitis or bronchiectasis (promethazine)

Prochlorperazine should be given instead

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216
Q

Hyperemesis Gravidarum treatment.

In which patients is metoclopromide and ondanstatron contraindicated? (3)

A

Long QT syndrome (ondanstatron)

Epilepsy (metoclopromide)

GI haemorrhage, obstruction or perforation (metoclopromide)

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217
Q

How long does it take for IUD (copper coil) to become an effective means of contraception?

A

Instantly?

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218
Q

How long does it take the Progesterone-only pill to become an effective means of contraception?

A

2 days

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219
Q

How long does it take for the combined oral contraceptive pill, implant and intrauterine system (hormonal coil) to become an effective means of contraception?

A

7 days

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220
Q

When is the booking appointment during pregnancy?

A

10 weeks

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221
Q

Define gestational diabetes and when it most commonly presents.

A

Gestational diabetes is defined as hyperglycaemia during pregnancy.

Most commonly occurs between weeks 24-28

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222
Q

What 2 assessments should diabetic patients be offered before/during pregnancy

A

Diabetic retinopathy assessment

Diabetic nephropathy assessment

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223
Q

What 3 nephrology results would suggest referral to a nephrologist before pregnancy?

A

Serum creatinine >120micromol/L

Urinary albumin:creatinine >30mg/mol

eGFR <45mil/min/1.73m2

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224
Q

What is the target blood glucose and HbA1c for a type 1 diabetic before pregnancy. (3)

A

Fasting plasma glucose - 5-7mmol/L on waking

Plasma glucose - 4-7mmol/L before meals at other times of day

HbA1c - <48mmol/mol

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225
Q

What is the 1st choice long acting insulin during pregnancy?

A

Isophane insulin (NPH insulin)

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226
Q

Give 5 risk factors for gestational diabetes

A

BMI >30kg

Previous macrosomic baby weighing >4.5kg

Previous gestational diabetes

Family history of diabetes (in 1st degree relative)

Afro/Caribbean ethnicity

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227
Q

On routine antenatal scan, what regent strip test results would warrant further testing to exclude gestational diabetes?

A

Glycosuria of 2+ or above on 1 occasion

Glycosuria of 1+ or above on 2 or more occasions

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228
Q

What test results are required to diagnose gestational diabetes? (2)

A

Fasting plasma glucose of >5.6mmol/L

OR

2 hour plasma glucose level of >7.8mmol/L

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229
Q

What investigations should be performed on a pregnant woman with risk factors for gestational diabetes?

A

75g 2 hour Oral Glucose Tolerance Test

Offer at 24-28 weeks

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230
Q

What investigations should be performed on a pregnant woman with a history of previous gestational diabetes?

A

Early self-monitoring of blood glucose

OR

OGTT asap after booking (whether in 1st or 2nd trimester) and further OGTT at 24-28 weeks if the first result is normal

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231
Q

What is the target fasting glucose level for pregnant women with any form of diabetes? (3)

A

Fasting <5.3mmol/L

AND

1 hour after meal = 7.8mmol/L
or
2 hours after meals = 6.4mmol/L

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232
Q

What is the plasma glucose target for a pregnant woman with diabetes on insulin?

A

> 4mmol/L

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233
Q

What should NOT be used to measure kidney function in pregnancy?

A

eGFR

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234
Q

How is fetal growth and wellbeing monitored for pregnant women with diabetes?

A

Ultrasound is used to measure fetal growth and amniotic fluid volume.

Conducted every 4 weeks from 28-36 weeks

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235
Q

What is the 1st, 2nd and 3rd line management for women with gestational diabetes with a fasting plasma glucose <7mmol/L

A

1st line - Lifestyle modification (improving diet, weight and exercise)

2nd line - Metformin (if blood glucose targets aren’t met in 1-2 weeks)

3rd line - Insulin (if blood glucose targets aren’t met with metformin)

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236
Q

What insulins are used during pregnancy? (2)

A

Long acting insulin - Isophane Insulin

Rapid acting insulin analogues - Aspart and Lispro

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237
Q

What prophylactic medication is given to pregnant women with diabetes to prevent NTDs?

A

5mg folic acid/day until 12 weeks gestation

238
Q

What is the 1st line management for women with gestational diabetes with a fasting plasma glucose >7mmol/L

A

Insulin +/- metformin + lifestyle modification

239
Q

What criteria must a pregnant woman with diabetes fulful to be offered Countinuous Subcutaneous Insulin Infusion (insulin pump)? (2)

A

Are using multiple daily injections of insulin

AND

Do not achieve blood glucose control without significant disabling hypoglycaemia

240
Q

Give 5 complications of gestational diabetes

A

Fetal macrosomia

Shoulder dystocia

Fetal hypoglycaemia

Pre-eclampsia

Diabetic fetopathy

241
Q

When should a retinal assessment be offered to pregnant women with pre-existing diabetes? When/why should it be repeated?

A

10 weeks

28 weeks

Repeat at 16-20 weeks if diabetic retinopathy is found at 10 weeks.

242
Q

When is US monitoring of fetal growth and amniotic fluid volume offered to pregnant women with diabetes?

A

28 weeks (repeated every 4 weeks)

243
Q

What type of deficiency can metformin cause? (what condition does it cause?)

A

Vitamin B12 deficiency

(macrocytic anaemia)

244
Q

How long may a pregnancy test stay positive after a termination of pregnancy?

A

Up to 4 weeks

245
Q

What does it suggest if a pregnancy test remains positive >4 weeks after a termination of pregnancy (2)

A

Incomplete abortion

Persistent trophoblast

246
Q

What 3 findings on a combined screening test (12 weeks) would suggest a fetus has Down’s syndrome?

A

Raised beta-HCG

Low PAPP-A

Ultrasound - Shows thickened nuchal translucency

247
Q

If a placenta previa (low lying) is found at the 20 week scan, what is the next point of action?

A

Rescan at 32 weeks

248
Q

What grade placenta previa warrants C-section?

A

III/IV at 32 and 36-37 week scans

249
Q

For how long is the Copper Intrauterine Device effective?

A

5-10 years

250
Q

Describe the need for contraception after the menopause in >50 and <50 year olds

A

> 50 - Use contraception for 12 months after last period

<50 - Use contraception for 24 months after last period

251
Q

What is HELLP Syndrome? and what are it’s features?

A

Severe form of pre-eclampsia.

H - Haemolysis
EL - Elevated liver enzymes
LP - Low platelets

Hypertension with proteinuria and epigastric/upper abdominal pain are also common

252
Q

What is the gold standard investigation to diagnose placenta praevia?

A

Transvaginal Ultrasound

253
Q

By when should most women feel their baby moving/kicking?

A

24 weeks

254
Q

What medication is present in the implantable contraceptive?

A

Etonogestrel

255
Q

Where is the implantable contraceptive usually implanted?

A

Subdermal, non-dominant arm

256
Q

Why can the progestrogen only pill be started immediately post partum?

A

Because it doesn’t contain oestrogen, therefore doesn’t carry a risk of suppressing milk production or increasing risk of venous thromboembolism

257
Q

Give 1 contraindication for epidural anaesthesia during labour

A

Coagulopathy

258
Q

Define premature ovarian failure.

Results from what test (taken when) would suggest this diagnosis?

A

Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40

Elevated FHS levels (>30IL/U) in 2 samples taken 4-6 weeks apart

259
Q

What ovarian pathology is associated with Meigs syndrome?

A

Ovarian fibroma

260
Q

What symptoms are seen in Meigs syndrome?

A

Benign pelvic mass - Ovarian Fibroma

Ascites

Pleural effusion

261
Q

What is the most common side effect of the progestogen only pill?

A

Irregular vaginal bleeding

262
Q

Give 5 indications for the induction of labour

A

Prolonged pregnancy (>42 weeks)

Prelabour premature rupture of membranes after 34 weeks or at term

Diabetic mother >38 weeks

Pre-eclampsia, eclampsia or HELLP syndrome

Rhesus incompatibility

263
Q

Give 7 contraindications for induction of labour

A

History of uterine rupture, previous high risk cesarean delivery

Placenta previa

Vasa previa

Transverse fetal lie

Cord prolapse

Active maternal genital herpes

Non-reassuring fetal heartbeat

264
Q

What is the Bishops score and what are it’s interpretations?

A

Score used to assess whether induction of labour is required.

Score <5 indicates labour is unlikely to start without induction

Score >=8 indicates that the cervix is ripe so there is high chance of spontaneous labour or response to interventions that may induce labour.

265
Q

What 5 parameters are used in the Bishop score?

A

Cervical position

Cervical consistency

Cervical effacement

Cervical dilation

Fetal station

266
Q

What stimulates the release of Oxytocin? (2)

A

Nipple stimulation

Stretching of cervix/vagina (i.e in membrane sweep)

267
Q

What are the main effects of Oxytocin? (2)

A

Promotes uterine contractions during labour

Facilitates milk ejection reflex via myoepithelial cell contraction

268
Q

What is misoprostol an analogue of?

A

Prostaglandin E1

269
Q

Give 4 main effects of Misoprostol.

A

Relaxes vascular smooth muscle (vasodilation)

Increases uterine tone and softens the cervix (during labour)

Reduces gastric acid production

Stimulates production and secretion of mucous

270
Q

Give 5 methods of inducing labour

A

Membrane sweep

Vaginal prostaglandin E1 - Misoprostol

Maternal oxytocin infusion

Amniotomy (‘breaking of waters’)

Cervical ripening balloon

271
Q

What is the main complication of induction of labour and how is it defined?

A

Uterine hyperstimulation.

Defined as prolonged and frequent uterine contractions (tachysystole)

272
Q

How is uterine hyperstimulation managed? (2)

A

Removing vaginal prostaglandins (misoprostol) and stopping oxytocin infusion

Use of Tocolytics - Terbutaline sulfate (Beta-mimetic)

273
Q

What is Terbutaline Sulfate used for in pregnancy?

A

To manage uterine hyperstimulation

274
Q

Give 5 contraindications of Terbutaline Sulfate use.

A

Placental Abruption

Antepartum haemorrhage

Eclampsia

History of cardiac disease

Hypertension

275
Q

What is the main side effect of Terbytaline Sulfate?

A

Hypokalaemia (potentiated by theophylline use - think asthmatic)

276
Q

Give 3 indications for forceps use in labour

A

Fetal/Maternal distress during second stage of labour

Failure to progress in second stage of labour

Breech presentation

277
Q

Name 3 types of forceps and their uses

A

Piper - Used to deliver fetal head during breech delivery

Kielland - Enables rotation and traction of the fetal head

Simpson - Only enables traction of the fetal head

278
Q

Describe stage 1 of labour

A

From the onset of true labour to when the cervix is fully dilated (10cm)

279
Q

Describe stage 2 of labour

A

From full dilation to delivery of the fetus

280
Q

Describe stage 3 of labour

A

From delivery of the fetus to when the placenta and membranes have been completely delivered

281
Q

Describe the latent phase of stage 1 of labour (3)

A

Occurs during the onset of labour and ends at 6cm of cervical dilation

Characterised by mild, infrequent, irregular contractions

Change in cervical dilation <1cm/hour

282
Q

Describe the active phase of stage 1 of labour

A

Occurs after the latent phase at >6cm cervical dilation.

Ends with complete (~10cm) cervical dilation.

Change in cervical dilation 1-4cm/hour

283
Q

Give 2 methods of placental expulsion (3rd stage of labour)

A

Fundal massage (induces uterine contractions and stops bleeding)

Active management - Oxytocin (administered after cutting umbilical cord)

284
Q

Define premature rupture of membranes (PROM)

A

Describes rupture of membranes occurring before the onset of labour at term

285
Q

Give 5 risk factors for PROM

A

Ascending infection (common)

Smoking

Multiple pregnancy

Previous pre-term delivery

Previous PROM

286
Q

List 3 complications of PROM

A

Pulmonary hypoplasia (underdevelopment of fetal lungs)

Chorioamnionitis (leading to premature labour/preterm birth, fetal distress and/or sepsis)

Umbilical cord prolapse

287
Q

Describe the management of PROM (3)

A

Oral erythromycin - Given for 10 days

IM corticosteroids - To reduce risk of respiratory distress syndrome

Consider delivery at 34 weeks gestation

288
Q

Define Preterm premature rupture of membranes (PPROM)

A

Describes rupture of membranes before onset of uterine contractions AND before 37 weeks gestation

289
Q

Define pre-term labour

A

Describes regular uterine contractions with cervical effacement (thinning), dilation or both, before 37 weeks gestation

290
Q

Define pre-term birth

A

Describes live birth between 20 - 36+6 weeks gestation

291
Q

What prophylaxis is given to women at risk of preterm labour/birth? (2)

A

Vaginal progesterone

Prophylactic cervical cerclage

292
Q

Premature labour prophylaxis is given to women who have both what?

A

A history of spontaneous preterm birth (up to 34 weeks pregnancy) or loss (from 16 weeks)

AND

Transvaginal ultrasound scan (between 16-24 weeks) showing cervical length of <25mm

293
Q

Give 1 clinical feature of PPROM

A

Sudden ‘gush’ of pale yellow/clear fluid from the vagina (pooling)

294
Q

How is PPROM diagnosed?

A

Speculum examination

295
Q

PPROM - On speculum examination pooling is present, what is the appropriate management?

A

Offer erythromycin (prophylaxis for intrauterine infection)

Consider oral penicillin if erythromycin contraindicated

296
Q

PPROM - On speculum examination NO pooling is present, what is the appropriate management?

A

Perform IGF-1 or Placental Alpha Macroglobulin 1 testing of vaginal fluid

Factors normally present in amniotic fluid

297
Q

What combination of tests are used to diagnose intrauterine infection in PPROM (3)

A

CRP

White Cell Count

Measure Fetal Heart Rate - Cardiotocography

298
Q

Define tocolysis

A

Tocolysis describes using medications to delay the delivery of a fetus in a woman presenting with pre-term contractions

299
Q

What is the 1st line tocolytic and at what stage gestation is it offered?

A

Nifedipine (calcium channel blocker)

Offered for women between 24-26 weeks with intact membranes whom are suspected pre-term labor

300
Q

What tocolytic is offered if Nifedipine is contraindicated?

A

Atosiban (Oxytocin receptor antagonists)

Nifedipine may be contraindicated in cardiac disease

301
Q

Give 4 contraindications for tocolysis

A

Maternal drug interactions (i.e Myasthenia Gravis for Magnesium Sulphate or Aortic insufficiency for calcium channel blockers)

Chorioamnionitis

Antepartum haemorrhage with hemodynamic instability

Severe pre-eclampsia/eclampsia

302
Q

If a woman has PPROM after 34 weeks and is positive for Group B Streptococcus, what should be offered?

A

Immediate induction of labour or C-Section

303
Q

What is the most effective method of emergency contraception?

A

Copper IUD

304
Q

When can the copper IUD be offered as emergency contraception? (2)

A

Up to 5 days after unprotected sex OR up to 5 days after estimated ovulation

305
Q

How do urlipristal and levonorgestrel work as contraceptions?

A

Inhibit ovulation

306
Q

What biomarker is raised in neural tube defects?

A

Alpha Feto protein

307
Q

Define grade 1 (minor) placenta praevia

A

Placenta does not cover internal cervical os but ilying low

308
Q

Define grade 2 (marginal) placenta praevia

A

Lower edge of placenta reaches the internal os

309
Q

Define grade 3 (partial) placenta praevia

A

Lower edge of the placenta partially covers the internal cervical os

310
Q

Define grade 4 (complete) placenta praevia

A

Placenta lies completely over the internal cervical os

311
Q

In PPROM what should be administered antenatally to reduce the risk of respiratory distress syndrome?

A

IM corticosteroids

312
Q

How long before elective surgery should the COCP be stopped? What should be offered instead?

A

4 weeks before

Switch to Progestogen only pill

313
Q

What 1st line treatment for hyperemesis gravidarum is contraindicated in asthma? What should you give instead?

A

Promazine

Give Prochlorperazine instead

314
Q

Between what ages does cervical cancer most commonly present?

A

25-29

315
Q

What is the most common type of cervical cancer?

A

Squamous Cell Carcinoma (80%)

316
Q

Give 6 risk factors for cervical cancer

A

Early onset of sexual activity (before 18)
HPV infection
Multiple sexual partners
History of STDs
Immunosuppression
Smoking

317
Q

How is cervical cancer classified? Describe each classification (3)

A

Classified as CIN I-III (cervical intraepithelial neoplasia)

o CIN-I – Mild dysplasia (involves 1/3 of the basal epithelium)

o CIN-II – Moderate dysplasia (involves <2/3 of the basal epithelium)

o CIN -III – Severe irreversible dysplasia (involves >2/3 of the basal epithelium)

318
Q

What term is used to describe the pre-malignant epithelial dysplasia seen in the early stages of cervical cancer?

A

Cervical intraepithelial neoplasia (CIN)

319
Q

Where does cervical cancer most commonly arise?

A

Transformation zone - Location between the endocervix and ectocervix

320
Q

Give 4 early symptoms of cervical cancer

A

Abnormal vaginal bleeding (post coital spotting)

Abnormal vaginal discharge (blood-stained or purulent malodorous discharge)

Dyspareunia

Pelvic pain

321
Q

Give 3 late symptoms of cervical cancer (Stage 4)

A

Hydronephrosis (flank pain)

Bladder/Bowel obstruction

Fistula formation

322
Q

Screening for cervical cancer is offered to all women between what ages?

A

25-64

323
Q

How often is cervical cancer screening performed? (2)

A

25-49 - 3 yearly screening

50-64 - 5 yearly screening

324
Q

Give 2 special considerations for cervical screening

A

Pregnancy - Screening is delayed until 3 months post-partum, unless missed screening or previous abnormal smears

Never been sexually active - Considered very low risk

325
Q

What is the HPV first system?

A

Means that a cervical smear sample is first tested for HPV. If this is positive only then is a cytological examination performed.

326
Q

If a cervical smear returns positive, what should be arranged?

A

Cytology

327
Q

If cytology returns abnormal (following positive smear test), what should be arranged>

A

Colposcopy

328
Q

Describe the Test of Cure (TOC) process for cervical cancer.

A

Patients being treated for CINI-III should be invited for a smear test 6 months after treatment

329
Q

What staging is used to stage Cervical Cancer?

A

FIGO staging

330
Q

Describe FIGO Stage IA cervical cancer (3)

A

o Confined to cervix
o Only visible on microscopy
o <7mm wide

331
Q

Describe FIGO Stage IB cervical cancer (3)

A

o Confined to cervix
o Clinically visible
o >7mm wide

332
Q

Describe FIGO Stage II cervical cancer (3)

A

o Extension of tumour beyond cervix but not to pelvic wall
o A = Upper 2/3 of vagina
o B = Parametrial involvement

333
Q

Describe FIGO Stage III cervical cancer (4)

A

o Extension of tumour beyond cervix to the pelvic wall
o A = lower 1/3 of vagina
o B = Pelvic side wall
o Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III

334
Q

Describe FIGO Stage IV cervical cancer

A

o Extension of tumour beyond pelvis or involvement of bladder or rectum
o A = Involves bladder or rectum
o B = Involves distant sites outside the pelvis

335
Q

If cervical cancer is causing hydronephrosis or a non-functioning kidney, what FIGO stage is it considered?

A

Stage III

336
Q

What treatment is offered for patients with IA cervical cancer desiring fertility?

A

Cone biopsy with negative margins

337
Q

Give 2 complications of surgery for cervical cancer

A

Cone biopsies and radical trachelectomies can increase risk of pre-term birth in future pregnancies

Radical hysterectomies can cause ureteral fistulas

338
Q

Give 4 short term complications of cervical cancer radiotherapy

A

Diarrhoea

Vaginal bleeding

Radiation burns

Pain on micturition

339
Q

Give 3 long term complications of cervical cancer radiotherapy

A

Ovarian failure

Fibrosis of bowel/skin/bladder/vagina

Lymphoedema

340
Q

What type of epithelial cell develops after HPV infection? (Cervical cancer)

A

Koilocytes

341
Q

Give 4 characteristics of Koilocytes (HPV infection)

A

Enlarged nucleus

Irregular nuclear membrane contour

Nucleus stains darker than normal (hyperchromasia)

A perinuclear halo may be seen

342
Q

Give 8 risk factors for Endometrial Cancer

A
  • Obesity
  • Nulliparity
  • Early menarche
  • Late menopause
  • Unopposed oestrogen (HRT)
  • Diabetes mellitus
  • Tamoxifen
  • PCOS
343
Q

What histological type of endometrial cancer is most common?

A

Adenocarcinoma

344
Q

Give 4 clinical features of endometrial cancer

A

Painless vaginal bleeding (early stage)

Post-menopausal bleeding

Pelvic pain

Palpable mass (uterine, fixed uterus, adnexal ect)

345
Q

What is the 1st line investigation for endometrial cancer? What subsequent test is used to confirm the diagnosis?

A

Transvaginal ultrasound (>4mm thickness)

Hysteroscopy with endometrial biopsy

346
Q

What is the treatment for endometrial cancer (women whom can tolerate surgery)?

A

Total abdominal hysterectomy with bilateral salpingo-oophorectomy

347
Q

What is the treatment for endometrial cancer (women whom cannot tolerate surgery)?

A

Progestogen

348
Q

Give 2 factors that are protective against endometrial cancer

A

Smoking

Combined Oral Contraceptive Pill

349
Q

Give 1 complication of endometrial cancer.

A

Pyometra (accumulation of pus in the uterine cavity)

350
Q

Anatomically, where is ovarian cancer most likely to present?

A

Distal end of the fallopian tube

351
Q

What type of cancer are the majority of ovarian cancers?

A

Serous carcinomas (epithelial in origin)

352
Q

Give 4 risk factors for ovarian cancer

A

Positive family history (BRCA1 or BRCA2 genes)

Many ovulations (early menarche, late menopause, nulliparity)

Have never used the COCP

Increasing age

353
Q

Give 4 clinical features of ovarian cancer

A

Pelvic bloating/distension

Non-specific pelvic pain

Urinary frequency or urgency

Early satiety or diarrhoea

354
Q

Give 3 extra-pelvic symptoms of ovarian cancer

A

Pleural effusion (right sided)

Ascites

Bowel Obstruction

355
Q

What biomarker is usually raised in ovarian cancer?

A

CA-125

356
Q

What should be arranged if CA-125 is >35IU/mL in suspected ovarian cancer?

A

Urgent ultrasound of abdomen and pelvis

357
Q

Give 2 factors that are protective against ovarian cancer

A

Combined Oral Contraceptive Pill (fewer ovulations)

Many pregnancies

358
Q

What is the most common type of breast cancer?

A

Invasive ductal carcinomas

359
Q

What is Ductal Carcinoma In situ (DCIS)? (3)

A

Describes a non-invasive ductal carcinoma of breast tissue.

Characterised by no penetration of the basement membrane and the absence of stromal invasion.

Is preceded by ductal atypia.

360
Q

Give 1 subtype of DCIS and describe how it’s characterised

A

Comedocarcinoma

Characterised by central necrosis

361
Q

Name 4 types of breast cancer

A

Invasive Ductal Carcinoma (most common)

Invasive lobular carcinoma

Ductal carcinoma in-situ (DCIS)

Lobular carcinoma in situ (LCIS)

362
Q

What may be seen on mammography in DCIS?

A

Grouped microcalcifications

363
Q

Give 4 clinical features of breast cancer

A

Lumps (Hard, irregular, painless or fixed in place)

Nipple retraction, inversion or blood tinged discharge

Skin dimpling or oedema (Peau d’orange)

Axillary Lymphadenopathy

364
Q

Give 5 risk factors for breast cancer

A

Female

Increased oestrogen exposure

Family history (BRCA1/2 genes)

Smoking

Obesity

365
Q

What chromosome is BRCA1 located?

A

Chromosome 17

366
Q

What chromosome is BRCA2 located?

A

Chromosome 13

367
Q

Between what ages is breast cancer screening (mammography) offered and repeated for women?

A

Offered between ages of 50-70. Mammography is offered every 3 years

368
Q

What is the referral wait time and criteria for suspected breast cancer? (2)

A

2 week wait

Unexplained breast lump in patients >30

Unexplained nipple changes in patients >50 (discharge, retractions ect)

369
Q

What criteria would make a patient high risk for breast cancer? (4)

A

1st degree relative with breast cancer <40 years old

1st degree male relative with breast cancer

1st degree relative with bilateral breast cancer, first diagnosed <50 years old

2 1st degree relatives with breast cancer

370
Q

Give 2 medications used for breast cancer chemoprevention (in high risk patients) and state whom they are offered to.

A

Tamoxifen - Offered to premenopausal women

Anastrozole (aromatase inhibitor) - Offered to postmenopausal women

371
Q

Give 1 contraindication for Anastrozole use as a chemopreventant.

A

Severe osteoporosis

372
Q

What 3 factors make up the triple diagnostic assessment in breast cancer?

A

Clinical assessment (history and examination)

Imaging (ultrasound or mammography)

Biopsy (fine needle aspiration or core biopsy)

373
Q

What 3 receptors are sampled for in all invasive breast cancers?

A

Oestrogen receptors (ER)

Progesterone Receptors (PR)

Human Epidermal Growth Factor 2 (HER2)

374
Q

Describe lymph node assessment in breast cancer (imagining used (2) and management offered (2)) (4)

A

Ultrasound of the axilla (looking for abnormal lymph nodes)

If abnormal lymph nodes are found, an Ultrasound guided needle biopsy is performed

If -ve then sentinel node biopsy is performed during surgery

If +ve then axillary clearance is performed during surgery

375
Q

Give 1 common complication of axillary clearance

A

Chronic lymphoedema in affected arm

376
Q

How is chronic lymphoedema managed following axillary clearance? (3)

A

Massage techniques (manual lymphatic drainage)

Compression bandages

Weight loss (if overweight)

377
Q

Name 2 tools used to predict prognosis/survival in Breast Cancer

A

PREDICT

Nottingham Prognostic Index (NPI)

378
Q

What 10 factors does PREDICT measure (breast cancer)

A

o DCIS or LCIS
o Age at diagnosis
o Post menopausal
o ER status
o HER2/ERRB2 status
o Ki-67 status
o Invasive tumour size (mm)
o Tumour grade
o Detected by
o Positive nodes

379
Q

In what individuals is PREDICT (breast cancer) less accurate? (3)

A

Women <30 with ER positive breast cancer

Women >70

Women with tumours >50mm

380
Q

How is the Notingham Prognostic Index (NPI) calculated?

A

Uses tumour size x 0.2 + lymph node score + grade score

381
Q

How is the lymph node score (NPI) calculated? (3)

A

Lymph nodes involved 0 = score 1 (grade 1)

Lymph nodes involved 1-3 = score 2 (grade 2)

Lymph nodes involved >3 = score 3 (grade 3)

382
Q

What is the % 5 year survival for an NPI Score 2.0-2.4? (lowest)

A

93%

383
Q

What is the % 5 year survival for an NPI Score 2.5-3.4?

A

85%

384
Q

What is the % 5 year survival for an NPI Score 3.5-5.4

A

70%

385
Q

What is the % 5 year survival for an NPI Score >5.4 (highest)

A

50%

386
Q

What 4 organs does breast cancer commonly metastasize?

A

2Ls 2Bs

Lungs
Liver
Bones
Brain

387
Q

What criteria would suggest having a mastectomy over breast conserving surgery (wide local excision) (5)

A

Multifocal tumour

Central Tumour

Large Lesion in a small breast

DCIS >4cm

Patient choice

388
Q

What criteria would suggest having Breast Conserving Surgery (wide local excision) over a mastectomy? (5)

A

Solitary lesion

Peripheral tumour

Small lesion in a large breast

DCIS <4cm

Patient choice

389
Q

In breast cancer, who may tamoxifen therapy be offered to? (2)

A

Men and post-menopausal women with ER positive invasive breast cancer

Women at low risk of disease recurrence or when aromatase inhibitors aren’t tolerated

390
Q

In breast cancer, who may aromatase inhibitors (anastrozole) be offered to?

A

Offered to women at medium-high risk of disease recurrence

391
Q

When should tamoxifen be switched to an aromatase inhibitor?

A

After 5 years of treatment

392
Q

Give 4 complications of endocrine therapy in breast cancer (tamoxifen/aromatase inhibitors) (4)

A

Endometrial cancer

Osteoporosis

Toxicity

Phlebitis (inflammaiton of a vein)

393
Q

Name 2 types of breast reconstruction

A

Latissimus dorsi myocutaneous flap

Sub perctoral implants

394
Q

What are the 1st and 2nd line investigations for breast cancer during pregnancy?

A

1st line - Ultrasound

2nd line - Mammography (if ultrasound indicates cancer)

395
Q

Why is ultrasound guided biopsy favoured over cytology in breast cancer diagnosis during pregnancy?

A

Proliferative changes during pregnancy render cytology inconclusive

396
Q

Why should breast reconstruction be delayed in pregnancy (breast cancer)

A

To avoid prolonged anaesthesia

397
Q

In breast cancer, if pre-operative axillary ultrasound is negative, what should be offered?

A

Sentinel node biopsy

398
Q

In breast cancer, if pre-operative axillary ultrasound is positive, what should be offered?

A

Axillary node clearance

399
Q

Radiotherapy is contraindicated in pregnancy (until delivery of the fetus), unless? (2)

A

Life saving

To preserve organ function (spinal cord compression)

400
Q

What 2 breast cancer medications are contraindicated in pregnancy?

A

Tamoxifen

Trastuzumab (MAB against HER2/neu receptor)

401
Q

What type of drug is Trastuzumab? (breast cancer)

A

MAB against HER2/neu

402
Q

When can women start breast feeding after tamoxifen/trastuzumab treatment?

A

14 days after stopping the drug

403
Q

Describe a missed (delayed) miscarriage (3)

A

Light vaginal bleeding/discharge symptoms which disappear

Closed cervical os

Gestational sac containing dead fetus <20 weeks without symptoms of expulsion

404
Q

Describe features of an incomplete miscarriage (3)

A

Not all products of conception have been expelled

Pain and vaginal bleeding

Cervical os is open

405
Q

What triad of symptoms is typically seen in Shaken Baby Syndrome?

A

Retinal Haemorrhages

Subdural haematoma

Encephalopathy

406
Q

What are the requirements for forceps use in pregnancy? (FORCEPS)

A

Fully dilated (in 2nd stage of labour)

Occiput Anterior Position

Ruptured Membranes

Cephalic presentation

Engaged presenting part (i.e head at or below ischial spines)

Pain relief

Sphincter (bladded) empty

407
Q

Women taking hepatic enzyme anti-epileptic drugs (e.g carbamazepine, phenytoin ect) during pregnancy should be offered what?

A

Vitamin K (10mg daily) in last 4 weeks of pregnancy.

Should also be given to the baby post natally to reduce haemorrhagic disease`

408
Q

What normal physiological respiratory changes occur in pregnancy? (4)

A

Tidal volume increase > respiratory rate

Arterial pO2 increases

pCO2 + bicarbonate decreases (compensatory respiratory alkalosis)

PEFR/FEV remain normal

409
Q

Describe NSAID use during pregnancy (2)

A

Safe during 1st and 2nd trimester

Should be avoided during 3rd trimester as can cause premature closure of Ductus Arteriosus

410
Q

How does pregnancy increase VTE risk? (2)

A

Increased levels of Factor X, VII and fibrinogen

Decreased levels of protein S activity

411
Q

Give 4 high risk factors for VTE during pregnancy. How is this managed?

A

Management - LMWH prophylaxis (Enoxaparin) + 6 weeks post-partum

High risk factors;

History of >1 VTE

Unprovoked or oestrogen related VTE

Thrombophillia + VTE or Family History

Antithrombin III deficiency

412
Q

What investigations should be arranged in a pregnant women with suspected VTE? (4)

A

ABG

ECG

CXR

Duplex US of deep veins

413
Q

If a pregnant women >20 weeks presents within 24 hours of chicken pox symptoms (rash), what should be given?

A

Oral acyclovir

414
Q

Give 2 LMWHs used for VTE prophylaxis in pregnancy

A

Dalteparin

Enoxaparin

415
Q

If a pregnant woman presents with >4 VTE risk factors, what is the most appropriate management?

A

Immediate treatment with LMWH continued for 6 weeks post-partum

416
Q

If a woman presents with <3 VTE risk factors, what is the most appropriate management?

A

Begin LMWH prophylaxis from 28 weeks pregnancy and continue for 6 weeks post partum

417
Q

Define antepartum haemorrhage

A

Describes bleeding from or in the genital tract occurring from 24 weeks pregnancy and prior to birth of the baby.

418
Q

Define placental abruption

A

Describes the premature separation of a normally located placenta from the uterine wall, before the delivery of a fetus

419
Q

Name and describe 2 forms of placental abruption

A

Revealed- Blood tracks between the membranes and escapes through the vaginal and cervix

Concealed - Blood collects behind the placenta, providing no evidence of vaginal bleeding

420
Q

Describe 3 clinical features distinguishing between placental abruption vs praevia

A

Abruption;
Shock out of keeping with visible blood loss

Pain constant

Tender, tense uterus

Praevia;
Shock in proportion to visible blood loss

No pain

Uterus not tender

421
Q

What should women with antepartum haemorrhage be given on admission (non-acute)

A

If shocked - Give fresh ABO Rh compatible or o Rh -ve blood until systolic BP >100mmHg

422
Q

Describe the acute management of placental abruption (severe bleeding) (3)

A

Intravenous Insertion (fluids)

Take bloods and lift legs

Give supplemental oxygen

423
Q

Describe Disseminated Intravascular Coagulation

A

Describes a dysregulation in coagulation (clot formation) and fibrinolysis (clot breakdown) resulting in widespread clotting with bleeding

424
Q

What factor is a key mediator of DIC?

A

Tissue factor

425
Q

What blood results would you expect to see in DIC? (4)

A

Thrombocytopenia (low platelets)

Increased PT and aPTT (takes longer for blood to clot)

Low Fibrinogen

Increased D-Dimer

426
Q

Name 1 complication of concealed placental abruption

A

DIC - Due to release of coagulation factors

427
Q

Give 9 risk factors for placental abruption (ABRUPTION)

A

A - Abruption previously
B - Blood pressure (hypertension/pre-eclampsia)
R - Ruptured membranes (premature or prolonged)
U - Uterine injury (trauma to abdomen)
P - Polyhydraminos
T - Twins/multiple gestation)
I - Infection (chorioamnionitis)
O - Older age (>35)
N - Narcotic use (cocaine/amphetamines/smoking)

428
Q

How are minor, major and massive antepartum haemorrhages defined?

A

Minor - Blood loss <50ml and has settled

Major - Blood loss 50-1000ml with no signs of clinical shock

Massive - Blood loss >1000ml and/or signs of clinical shock

429
Q

Give 5 risk factors for placenta previa

A

Prior Placenta Previa

IVF treatment

Advanced maternal age

Caesarean section (uterine scarring)

Miscarriages/induced abortions

430
Q

Define placenta succenturia

A

Separate (succenturiate) lobe away from the main placenta. Can fail and separate normally and cause PPH

431
Q

Define placenta accreta, increta and percreta

A

Describes abnormal adherence of the placenta to the uterus.

Accreta - When placenta attaches too deeply to uterine awall, attaching to superficial layer of the myometrium

Increta - If myometrium is infiltrated

Percreta - If penetration reaches the serosa

432
Q

How is placenta accreta diagnosed?

A

Doppler US

433
Q

What is vasa praeva

A

When umbilical cord vessels that usually run in the fetal membranes cross the internal os of the cervix and rupture spontaneously during early labour

434
Q

If vasa praeva is suspected, what test should be conducted?

A

Test blood for fetal haemoglobin

435
Q

How is post-partum haemorrhage defined?

A

Defined as blood loss of >500ml from genital tract after delivery of the fetus

436
Q

What is the Obstetric Shock index and how is it calculated? What is normal?

A

Used to detect haemodynamic instability and hypovolemia.

Calculated by; heart rate/systolic blood pressure

Normal = 0.7-0.9

437
Q

Define primary and secondary post-partum haemorrhage

A

Primary - Haemorrhage within the first 24 hours of delivery

Secondary - Haemorrhage between 24 hours to 12 weeks after delivery

438
Q

Give 4 causes of primary post-partum haemorrhage

A

Poor uterine tone

Tears or trauma

Retained tissue

Coagulopathy

439
Q

Give 3 causes of secondary post-partum haemorrhage

A

Endometritis

Pseudo-aneyrusm, uterine artery

Retained tissue

440
Q

What are the 1st and 2nd line drugs used to manage post-partum haemorrhage?

A

1st line - Oxytocin/ergometrine infusion

2nd line - Tranexamic acid

441
Q

What is the 1st line surgical management for post-partum haemorrhage caused by uterine atony?

A

Intrauterine balloon tamponade

442
Q

Give 5 major risk factors for Sudden Infant Death Syndrome

A

Putting the baby to sleep prone

Parental smoking

Prematurity

Bed sharing

Hyperthermia (over-wrapping) or head covering

443
Q

Give 3 protective factors for Sudden Infant Death Syndrome

A

Breastfeeding

Room sharing

The use of dummies

444
Q

What term is used to describe the fetal head in relation to the ischial spine?

A

Station

445
Q

Neonatal respiratory distress syndrome occurs due to a deficiency in what product?

A

Surfactant

446
Q

What cell type produces surfactant?

A

Type II pneumocytes

447
Q

Give 2 risk factors for neonatal respiratory distress syndrome and explain why they are risk factors.

A

Prematurity - Because surfactant production begins at 20 weeks and it’s distribution begins at 28-32 weeks.

Maternal diabetes mellitus - Because this leads to increased fetal insulin which inhibits surfactant synthesis.

448
Q

Give 5 clinical features of neonatal respiratory distress syndrome

A

Maternal history of premature birth

Symptoms presenting shortly after birth

Signs of respiratory distress (tachypnea, nasal flaring, intercostal recessions)

Cyanosis

Hypoxia (+/- respiratory acidosis)

449
Q

What appearance may be seen on X-ray in neonatal respiratory distress syndrome?

A

Ground glass appearance

450
Q

Give 2 complications of neonatal respiratory distress syndrome

A

Bronchopulmonary dysplasia

Pneumothorax

451
Q

What 5 reflexes are tested in a NIPE?

A

Moro reflex

Suckling reflex

Rooting reflex

Grasp reflex

Stepping reflex

452
Q

What 4 domains are screened during the NIPE?

A

Eyes

Heart

Hips

Testes

453
Q

What is the primary purpose of examining the eyes in a NIPE?

A

To screen for congenital cataracts (Opacity within the lens of the eye)

454
Q

Give 5 risk factors for eye/visual problems in a newborn

A

First degree relative with ocular condition (i.e aniridia (absent iris), coloboma (malformation of the eye) or retinoblastoma (malignant retinal tumour)

Prematurity

Genetic syndromes (trisomy 21)

Port wine stain involving eyelids (can lead to glaucoma)

Maternal exposure to viruses during pregnancy (rubella and cytomegalovirus)

455
Q

What examination finding would be present in congenital cataracts?

A

Completely or partially obstructed red reflex (causes leukocoria - white reflection)

456
Q

When (in weeks) is the anomaly performed?

A

20 weeks

457
Q

What conditions are screened for in the anomaly scan? (7)

A

Edwards’(T18) and Patau’s (T13)

Anencephaly

Spina bifida

Cleft lip

Congenital diaphragmatic hernia

Congenital heart disease

Exomphalos

458
Q

Give 3 NIPE hip risk factors

A

1st degree relative with hip problems in early life

Breech presentation at or after 36 weeks, irrespective of presentation at birth or mode of delivery (inc successful ECV)

Breech presentation at time of birth between 28 weeks and term

459
Q

What is the proimary purpose of examining the testes in NIPE?

A

Screening for bilateral/unilateral undescended testes

460
Q

What cancer is associated with undescended testes?

A

Seminoma (germ cell tumour of testicle)

461
Q

What condition is associated with bilateral undescended testes?

A

Congenital adrenal hyperplasia (ambiguous genitalia)

462
Q

What are the components of the Apgar score?

A

Quick way of evaluating health of newborn

Pulse
Respiratory effort
Colour
Muscle tone
Reflex irritability

463
Q

What is the most common liver disease of pregnancy? When does it typically present?

A

Obstetric cholestasis

Presents in 3rd trimester

464
Q

Give 3 clinical features of obstetric cholestasis?

A

Pruritis (on palms and soles)

No rash

Raised bilirubin

465
Q

What investigations should be arranged in suspected obstetric cholestasis? (4)

A

Test for viral hepatitis

Liver Function Tests

Autoimmune screen

Ultrasound of liver

466
Q

How is obstetric cholestasis managed? (3)

A

Ursodeoxycholic acid (for itchiness)

Weekly liver function tests

Women are induced at 37 weeks

467
Q

What is the most common cause of early onset severe infection in neonatal period?

A

Group B streptococcus infection

468
Q

Give 4 risk factors for group B streptococcus infection

A

Prematurity

Prolonged rupture of membranes

Previous sibling GBS infection

Maternal pyrexia (secondary to chorioamnionitis)

469
Q

How can GBS infection present in neonates?

A

Pneumonia

Meningitis

Septicaemia

470
Q

What is given for GBS prophylaxis? (1st line, 2nd line)

A

1st line - Benzylpenicillin

2nd line - Clindamycin

471
Q

Define acute fatty liver of pregnancy. When does it commonly arise?

A

Describes a rare-life threatening obstetric emergency characterised by extensive fatty infiltration of the liver, resulting in acute liver failure.

Commonly arises in 3rd trimester

472
Q

Give 5 clinical features of acute fatty liver of pregnancy

A

Sudden onset of jaundice

Right upper quadrant pain, nausea and vomiting

Headache

Hypoalbuminemia > ascites

Concurrent pre-eclampsia

473
Q

What test is used to diagnose acute fatty liver of pregnancy? What will it show?

A

Liver ultrasound. Shows hepatic steatosis

474
Q

Give 4 blood results for acute fatty liver of pregnancy

A

Hypoglycaemia

Uraemia

Raised WBC

Raised LFTs (ALT/AST)

475
Q

What is used to assess severity of nausea and vomiting in pregnancy?

A

Pregnancy-Unique Quanitification of Emesis (PUQE) score

476
Q

oDefine complex ovarian cyst. How should the be treated? What tests should be performed? (3)

A

Describes a cyst containing a solid mass or which is multi-loculated.

Should be treated as malignant until proven otherwise.

Test for serum CA-125, aFP and bHCG

477
Q

What is the 1st line antibiotic for Group B streptococcal prophylaxis?

A

Benzylpenicillin

478
Q

What is the 2nd line antibiotic for group be streptococcal prophylaxis? (Non penicillin allergy and penicillin allergy allergy)

A

Non-penicillin allergy - Cephalosporin

Penicillin allergy - Vancomycin

479
Q

When should bacteriological testing be performed in high risk GBS women?

A

35-37 weeks gestation or 3-5 weeks prior to expected delivery date

480
Q

What is the 1st line medical therapy for IBS? (2)

A

Loperamide (decreases frequency of diarrhoea) and Buscopan (manages stomach cramps)

481
Q

Give 3 contraindications for Buscopan (IBS treatment)

A

Glaucoma

Myasthenia gravia

Bowel obstruction

482
Q

Where does vulval carcinoma tend to present?

A

Labium majora (with ulceration)

483
Q

Name 4 sex cord stromal tumours (hormone related)

A

Thecoma (stromal)
Fibroma (stromal)
Sertoli cell tumour (sex cord)
Granulosa cell tumour (sex cord)

484
Q

What ovarian tumour is associated with the development of endometrial hyperplasia?

A

Granulosa cell tumours

(remember, granulosa cells produce oestrogen, oestorgen promotes endometrial thickening)

485
Q

Adding what to HRT increases risk of breast cancer?

A

Progesterone

486
Q

In cervical cancer screening, if 2 consecutive inadequate samples are acquired then what is the next step?

A

Colposcopy

487
Q

In cervical cancer screening, if one inadequate sample is acquired, what is the next step?

A

Repeat sample in 3 months

488
Q

What is the Pearl Index?

A

Describes the number of pregnancies that happen for one method of contraception per 100 women over a year.

i.e Pearl Index of 0.2 = 2/1000 women/year become pregnant using this form of contraception.

489
Q

How may imperforate hymen present?

A

Primary amenorrhoea (no periods <14 years old)

Cyclical pain (in absence of periods)

Bluish bulging membrane on physical examination

490
Q

What pathogen commonly causes thrush?

A

Candida albicans

491
Q

Give 4 clinical features of thrush (vaginal candidiasis)

A

Cottage cheese, non-offensive discharge

Vulvitis (superficial dyspareunia, dysuria)

Itch

Vulval erythema, fissuring, satellite lesions

492
Q

How is vaginal candidiasis managed?

A

1st line - Oral fluconazole (single dose)

2nd line - Clotrimazole intravaginal pessary

Vulval symptoms? - Add Topical imidazole

493
Q

How is vaginal candidiasis managed in pregnancy?

A

Oral treatments are contrindicated

Clotrimazole pessary (Only use local treatments (cream/pessaries)

494
Q

How is vaginal candidiasis diagnosed?

A

High vaginal swab for microscopy and culture

495
Q

What should be excluded in patients with vaginal candidiasis?

A

Diabetes - Blood glucose test

496
Q

How is fetal hypoxia defined on CTG? (6)

A

One of more of the following;

Baseline bradycardia (<110)
Baseline tachycardia (>160)
Loss of variability (<5bom)
Early decelerations
Late decelerations
Variable decelerations

497
Q

Describe category 1 C-section. Give 3 indications. When should delivery occur?

A

Conducted if there is an immediate threat to maternal/fetal life.

Indications include
- Suspected uterine rupture
- Major placental abruption
- Fetal hypoxia

Baby should be delivered within 30 minutes

498
Q

Describe category 2 C-section. When should delivery occur?

A

Maternal or fetal compromise that is not immediately life threatening

Delivery should occur within 75 minutes

499
Q

What term is used to describe post-partum bleeding?

A

Lochia

500
Q

What period of time would continued lochia warrant further investigation with ultrasound?

A

6 weeks

501
Q

What form of contraception is associated with weight gain?

A

Injectable contraceptive (Depo-provera)

502
Q

What type of ovarian cysts is referred to as a chocolate cyst?

A

Endometriotic cyst

503
Q

What is the most common type of ovarian cancer?

A

Serous carcinoma

504
Q

What is the most appropriate management of umbilical cord prolapse?

A

Avoid touching the cord and keep it warm

505
Q

Define polyhydraminos

A

Excess amniotic fluid volume for gestational age. Results in uterine distention.

506
Q

Give 3 fetal causes of polyhydraminos

A

Gastrointestinal - Oesophageal atresia, duodenal atresia/stenosis

CNS - anencephaly (due to defective fetal swallowing centre), Fetal ADH deficiency (leading to reduced urination)

Multiple pregnancy

507
Q

Give 2 maternal causes of polyhydraminos

A

Diabetes mellitus

Rh incompatibility

508
Q

How is polyhydraminos managed?

A

Amnioreduction (drainage of excess amniotic fluid)

509
Q

Define oligohydramnios?

A

Amount of amniotic fluid is less than expected for gestational age

510
Q

Give 4 fetal causes of oligohydraminos

A

Urethral obstruction

Bilateral renal agenesis (congenital absence of one or both kidneys)

Edwards syndrome (trisomy 18)

TORCH infections

511
Q

Give 4 maternal causes of oligohydraminos

A

Placental insufficiency

Late/post-term pregnancy (>42 weeks)

PROM

Pre-eclampsia

512
Q

What investigation is used to assess oligohydraminos?

A

Ultrasound (determines amniotic fluid volume/fetal abnormalities)

513
Q

How is oligohydraminos managed?

A

Amnioinfusion (infusion of fluid into amniotic cavity through amniocentesis)

514
Q

Define chorioamnionitis

A

Describes infection of the amniotic fluid, fetal membranes and placenta

515
Q

Name 2 bacteria that most commonly cause chorioamnionitis

A

Ureaplasma urealyticum (50%)

Mycoplasma hominis (30%)

516
Q

Give 3 risk factors for chorioamnionitis

A

Prolonged labor

Premature rupture of membranes (PROM)

STDs/Frequent UTIs

517
Q

Give 4 clinical features of chorioamnionitis (maternal/fetal)

A

Maternal;

Fever
Tachycardia
Uterine tenderness
Malodorous/purulent amniotic fluid/discharge

Fetal;
Fetal tachycardia (>60/min on CTG)

518
Q

Describe the difference between primary and secondary dyspmenorrhoea

A

Primary - Describes painful menstruation in the absence of underlying pelvic pathology. Pain occurs with onset of menstruation

Secondary - Describes painful menstruation secondary to underlying pelvic pathology (such as endometriosis, fibroids or polyps). Pain typically occurs before the start of menstruation

519
Q

How should hypothyroidism be managed in pregnancy (early i.e 7 weeks)?

A

Increase levothyroxine levels (even if euthyroid) by 25mcg and repeat thyroid function tests in 4 weeks.

Conducted as there is a physiological increase in serum free thyroxine until weel 12 of pregnancy.

520
Q

Define overactive bladder/urge incontinence

A

Describes detrusor overactivity.

Patients haver the urge to urinate quickly followed by leakage (may be a few drops to complete bladder emptying)

521
Q

Describe stress incontinence

A

Describes leaking small amounts of urine when coughing or laughing

522
Q

What 4 investigations would you conduct in a patient presenting with urinary incontinence?

A

Bladder diary (minimum of 3 days)

Vaginal examination (to exclude pelvic organ prolapse)

Urine dipstick/culture

Urodynamic studies

523
Q

How is urge incontinence managed? (1st and 2nd lines)

A

Bladder retraining (minimum of 6 weeks)

Bladder stabilising drugs (anti-muscainics)

1st line - Oxybutynin

2nd line - Tolterodine (antimuscarinic) or Mirabegron (beta 3 agonist) - consider in frail old patients

524
Q

In whom may oxybutynin be contraindicated? What can be given instead (for urge incontinence)

A

Frail old patients

Mirabegron (beta 3 agonist)

525
Q

What is the 1st and 2nd line treatment for stress incontinence?

A

1st - Pelvic floor muscle training (8 contractions, 3 times per day for 3 months)

2nd line - Duloxetine (SNRI)

526
Q

Give 4 side effects of Oxybutynin

A

Antimuscarinic;
Dry mouth
Constipation
Flushing
Dizziness/drowsiness

527
Q

What pathogen causes vaginal thrush?

A

Candida albicans

528
Q

Name 4 factors that increase the risk of developing vaginal thrush

A

Diabetes mellitus

Drugs (antibiotics/steroids)

Pregnancy

Immunosuppression (HIV)

529
Q

Give 4 clinical features of vaginal thrush

A

‘cottage cheese’ (non-offensive discharge)

Vulvitis (superficial dyspareunia, dysuria)

Itch

Vulval erythema, fissuring, satellite lesions

530
Q

What are the 1st and 2nd line treatments for vaginal thrush?

A

1st - Fluconazole (oral)

2nd - Clotrimazole pessary (if oral is contraindicated)

531
Q

What is used to treat vulval symptoms in vaginal thrush?

A

Topical imidazole

532
Q

How is thrush treated in pregnancy?

A

Oral treatments are contraindicated.

Offer local cream or pessaries

533
Q

Define recurrent vaginal candidiasis

A

Defined as 4 or more episodes per year

534
Q

Describe the induction-maintenance regime for recurrent vaginal candidiasis

A

Induction - Oral fluconazole every 3 days for 3 doses

Maintenance - Oral fluconazole weekly for 6 months

535
Q

How may ovarian torsion appear on US scan?

A

Whirlpool sign

536
Q

How may chronic salpingitis appear on US scan?

A

Beads-on-string sign

537
Q

How may fibroids appear on US scan?

A

Hypoechoic mass

538
Q

How may hydatifiform mole present on US scan?

A

Snow storm appearance

539
Q

What are the NICE guidelines on contraception use in post-menopausal women?

A

Women using non-hormonal methods can be advised to stop contraception after 1 year of amenorrhoea if aged >50, or 2 years in women aged <50

540
Q

Give 7 absolute contraindications to COCP use (UKMEC4)

A

Known or suspected pregnancy

Smoker >35 who smokes >15/day

Obesity

Breastfeeding <6 weeks post-partum

Fx of thrombosis before 45

Breast cancer or cancer within last few years

BRCA genes

541
Q

Give 5 situations where the disadvantages of contraceptive use outweigh the advantages (UKMEC3)

A

Breast feeding > 6 weeks post-partum

Previous arterial or venous clots

Continued use after heart disease or stroke

Migraine with aura

Active disease of liver or gallbladder

542
Q

Give 2 situations where the advantages of contraceptive use outweigh the disadvantages (UKMEC2)

A

Initiation after current or previous MI/stroke

Multiple risk factors for cardiovascular disease

543
Q

Describe the management of post-natal depression (with symptoms)

A

Seek advice from specialist perinatal mentalhealth team

1st line - Paroxetine or sertraline (SSRIs) for breastfeeding women

544
Q

Describe the 3 stages of post-partum thyroiditis

A

Thyrotoxicosis > Hypothyroidism > Normal thyroid function

545
Q

How is the thyrotoxic phase of postpartum thyroiditis managed?

A

Propranolol

546
Q

How is the hypothyroid phase of post-partum thyroiditis managed?

A

Thyroxine

547
Q

Where is the most common site of an ctopic pregnancy?

A

Ampulla of the fallopian tube

548
Q

Name 6 drugs contraindicated in breast feeding

A

Antibiotics - Ciprofloxacin, tetracycline, sulphonamides

Psychiatric drugs - Lithium, Benzodiazepines

Aspirin

Carbimazole

Methotrexate

Amiodarone

549
Q

What tests are routinely performed in the 10 week booking appointment? (4)

A

4 3 2 1

4 - Blood (FBC, Rhesus, Blood group, Alloantibodies)

3 - Virus (hepB, HIV, syphilis)

2 - UTI (dipstick, urine culture)

1 - Full physical examination (Pelvicm breast, BMI, BP)

550
Q

What is the 1st investigation to order in a pregnant women presenting with reduced fetal movements?

A

Handheld doppler (auscultate fetal heart rate)

Used to confirm fetal heartbeat

551
Q

If a handheld doppler doesn’t find a foetal heart beat, what investigation should be performed?

A

Ultrasound

552
Q

What is the 1st line non-hormonal treatment for menorrhagia (for women trying for a family)

A

Tranexamic acid

553
Q

If a woman positive for Hepatitis B gives birth, what treatment should be given to the baby?

A

Hep B vaccine + 0.5ml HBIG within 12 hours + Further hep B vaccine at 1-2 months and 6 months

554
Q

What tests are important to conduct in patients with urinary incontinence? (stress incontinence) (3)

A

Urine dipstick and culture

Diabetes - HbA1c

3 day bladder diary

555
Q

Use of ulipristal should be used with caution in which patients?

A

Patients with severe asthma (controlled by oral steroids)

556
Q

What normally happens to blood pressure during pregnancy?

A

Falls in the first half of pregnancy before rising to pre-pregnancy levels before term

557
Q

When can the injectable implant be adminsitered in post-partum women? (breastfeeding and non breastfeeding)

A

Non breastfeeding - Immediately

Breastfeeding - After 4 weeks

558
Q

What anti-diabetic medication should be avoided in breastfeeding? What is safe?

A

Sulphonylureas (Gliclazide)- can cause neonatal hypoglycemia

Metformin is safe

559
Q

If 1 COCP pill is missed (any time in the cycle) what should occur?

A

Take the last pill, even if it means taking 2 pills in one day, then continue taking pills daily, one each day.

No additional contraception needed

560
Q

If 2 COCP pills are missed in the 1st week 1 of menstrual cycle, what should happen?

A

Take 2 pills, leave any earlier missed pills and then continue taking pills daily (one a day)

Emergency contraception should be considered if woman has unprotected sex in the pill free interval/week 1

561
Q

If 2 COCP pills are missed in week 2 of the menstrual cycle, what should happen?

A

Take 2 pills, leave any earlier missed pills and then continue taking pills daily (one a day)

After 7 days of taking COCP, no emergency contraception needed

562
Q

If 2 COCP pills are missed in week 3 of the menstrual cycle, what should happen?

A

Take 2 pills, leave any earlier missed pills and then continue taking pills daily (one a day)

Woman should finish pills in current pack, and start a new pack the next day (omitting the pill free interval).

563
Q

Ondanstetron use during pregnancy is associated with an increased risk of what?

A

Fetus developing cleft palate/lip

564
Q

What may increase risk of developing cervical ectropion?

A

COCP due to increased oestrogen levels.

565
Q

Rectoceles are caused by a defect in what?

A

Posterior vaginal wall

566
Q

Cystoceles are caused by a defect in what?

A

Anterior abdominal wall

567
Q

A patient with a history of neonatal sepsis (caused by group B strep) asks what can be given to prevent this happening again in a 2nd pregnancy? How sis this managed?

A

Maternal IV antibiotics (benzylpenicillin) during labour

568
Q

Define PPH

A

500ml of blood loss 24 hours since delivery of the baby

569
Q

Describe the biosynthesis of estradiol

A

Cholesterol > Pregnenolone > Androstenedione

Then splits into 2;

Androstenedione > Testosterone > Estradiol (catalysed by aromatase - stage 2)

or

Androstenedione > Estrone (1) > Estradiol (E2)
(catalysed by aromatase - stage 1)

570
Q

What enzyme catalyses the conversion of androstenedione to testosterone?

A

17 HDS3

571
Q

What enzyme catalyses conversion of estrone to estradiol?

A

17 HSD1

572
Q

What enzyme catalyses the conversion of testosterone to estradiol?

A

Aromatase (CYP19)

573
Q

What enzyme catalyses the conversion of androstenedione to estrone?

A

Aromatase (CYP19)

574
Q

Name 5 criteria that would warrant expectant management of an ectopic pregnancy

A

An unruptured embryo

Size <35mm

Have no heart beat

Be asymptomatic

Have a B-hCG of <10000IU/L and declining

575
Q

If a patient suddenly collapses after rupture of membranes, what is the most likely diagnosis?

A

Amniotic fluid embolism

576
Q

Define amniotic fluid embolism

A

Describes when fetal cells/amniotic fluid enters the mothers blood stream, causing an adverse reaction

577
Q

Give 4 clinical features of amniotic fluid embolism

A

Majority of cases occur in labour

Chills, shivering, sweating

Coughing

Hypotension, cyanosis and tachycardia

578
Q

In whom does atrophic vaginitis commonly present?

A

Post-menopausal women

579
Q

Give 3 clinical features of atrophic vaginitis

A

Vaginal dryness

Dyspareunia

Occasional spotting

580
Q

What are the 1st and 2nd line treatments for atrophic vaginitis?

A

1st line - Topical oestrogen

Adjuncts - Lubricants and moisturizers

581
Q

Woman presents with continuous dribbling incontinence after prolonged labour, what is the most likely diagnosis?

A

Vesicovaginal fistula

582
Q

Name 4 ways to assess foetal growth

A

Measure femur length on US

Measure foetal abdominal circumference (AC) on US

Measurement of size of uterus on abdominal examination

Palpation of the foetal head on abdominal examination

583
Q

Give 5 benign/malignant causes of a raised CA-125

A

Adenomyosis

Ascites

Endometriosis

Menstruation

Cancer (ovarian, breast, endometrial)

584
Q

Give 4 risk factors for ectopic pregnancy

A

Age <18 at first sexual intercourse

Black race

Smoking

Use of Contraceptive Intrauterine Device

585
Q

Give 4 consequences of androgen insensitivity syndrome

A

AMH is secreted by the fetal testes

Development of the testes does not require presence of androgens

In the embryo the testes develop normally

Regression of mullerian structures occurs

586
Q

Descruibe the physiology of testes development

A

Testes develop under the influence of the SRY gene on Y chromosome. Does not require presence of androgens.

587
Q

What does the Wolffian duct develop into during embryogenesis?

A

Male differentiation occurs when Wolffian duct is exposed to testosterone.

Develops into;

Ejaculation ducts, Epididymis, Rete testes, Ductus deferens and seminal vesicles

588
Q

What is the most common type of vaginal cancer?

A

Secondary (metastatic) vaginal cancer

Commonly metastasizing from the cervix or endometrium

589
Q

What amniotic fluid index (AFI) would diagnose polyhydraminos?

A

> 24cm (or 2000ml)

590
Q

What amniotic fluid index would diagnose oligohydraminos?

A

<5cm (or <200ml)

591
Q

Give 4 roles of metformin in PCOS treatment

A

Reduces appetite

Decreases androgen production

Decreases LH from anterior pituitary

Decreases sex-hormone binding globulin in the liver

592
Q

What is the most important treatable cause of recurrent miscarriage?

A

SLE associated with Antiphospholipid syndrome

Phase 3a (6 decks)

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