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Medicine > Obs and Gynae > Flashcards

Obs and Gynae Flashcards

1
Q

In which conditions may cervical excitation be seen?

A

STI
PID
Ectopic pregnancy

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2
Q

What is the difference between endometriosis and adenomyosis?

A

Endometriosis - endometrial tissue outside of uterus
Adenomyosis - invasion of endometrial tissue into myometrium

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3
Q

Describe the symptoms of endometriosis.

A

Dyspareunia
Abdominal pain
Menorrhagia
Dyschezia
Chronic pelvic pain
Haematuria

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4
Q

How does endometriosis appear on ultrasound?

A

Normal appearance

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5
Q

How is endometriosis diagnosed?

A

Laparoscopy with biopsy

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6
Q

What is the 1st line treatment for endometriosis?

A

NSAIDs and/or paracetamol

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7
Q

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

A

2nd: Tricyclic OCP or POP
3rd: GnRH agonists

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8
Q

What are chocolate cysts?

A

Endometriomas - fill with blood due to response to hormones

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9
Q

How is menorrhagia defined?

A

Blood loss considered excessive to the woman

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10
Q

Why is transvaginal USS an important investigation to carry out for menorrhagia?

A

Rule out structural abnormalities e.g. fibroids

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11
Q

What is dysfunctional uterine bleeding?

A

Bleeding occurring outside of the normal menstrual cycle

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12
Q

What is the treatment for menorrhagia if contraception is not needed?

A

NSAIDs
1st: tranexamic acid
2nd: mefenamic acid - good if pain present

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13
Q

What are the treatment options for menorrhagia if contraception is needed?

A

1st: Mirena IUS
2nd: COCP
3rd: long-acting progestogens

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14
Q

What is primary dysmenorrhoea?

A

Menstrual pain which is not associated with pathology - pain before period manifests as suprapubic cramping pains

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15
Q

What are the treatment options for primary dysmenorrhoea?

A

1st: NSAIDs e.g. mefenamic acid
2nd: COCP

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16
Q

What are the treatment options for PMS?

A
  • Lifestyle: regular, frequent meals high in carbs
  • Moderate symptoms: new generation COCP e.g. Yasmin
  • SSRIs e.g. fluoxetine suitable during luteal phase or continuously
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17
Q

Describe the risk factors for developing adenomyosis.

A

Multiparity
Uterine surgery
Previous C section

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18
Q

What is the curative management of adenomyosis?

A

Hysterectomy

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19
Q

What is an alternative management option of adenomyosis?

A

GnRH agonists

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20
Q

How is adenomyosis diagnosed?

A

Histology at hysterectomy

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21
Q

How might the uterus appear in a patient with adenomyosis?

A

Enlarged, boggy uterus

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22
Q

What is a long term complication associated with the curative treatment of adenomyosis?

A

Vaginal vault prolapse, enterocoele

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23
Q

How is vaginal vault prolapse managed?

A

Sacrocolpoplexy

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24
Q

What is a fibroid?

A

Benign leiomyoma (smooth muscle tumours) of myometrium

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25
Q

What is the curative treatment of fibroids?

A

Hysterectomy

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26
Q

Describe the medical management available for fibroids.

A

IUS
GnRH agonists
POP, COCP

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27
Q

What size is the cut-off for medical management of fibroids?

A

< 30mm

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28
Q

What surgical option is available for fibroids > 30mm with wishes to conserve fertility?

A

Myomectomy

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29
Q

What are the 3 types of fibroids?

A

Intramural
Sub mucosal
Sub serosal

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30
Q

What is the gold standard investigation for fibroids?

A

TVUSS

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31
Q

Appearance of fibroid on ultrasound

A

Hypoechoic mass

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32
Q

Describe the epidemiology of fibroids.

A

Reproductive age
Afro-Caribbean women

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33
Q

What is red degeneration?

A

Fibroid haemorrhages into tumour - commonly occurs during pregnancy

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34
Q

What is a contraindication for IUS use in a patient with fibroids?

A

The fibroids distort the uterine cavity

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35
Q

Describe the pathophysiology of PCOS.

A

Excess LH produced -> excess androstenedione produced by theca cells - which is too much for the granulosa cells to convert to oestrogen
Excess androstenedione converted to estrone - negative feedback for FSH
No LH surge - no ovulation! – oligomenorrhoea

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36
Q

Describe the epidemiology of PCOS.

A

5-20% of reproductive age women

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37
Q

What is the name of the criteria followed for PCOS diagnosis? What are the criteria?

A

Rotterdam criteria

Oligomenorrhoea
Hyperandrogenism
Polycystic ovaries

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38
Q

Polycystic ovaries - Rotterdam criteria

A

> 12 cysts on imaging
OR
Ovarian volume > 10 cm3

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39
Q

What is the difference between PCOS and PCO?

A

PCO only fulfills 1 of 3 Rotterdam criteria

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40
Q

Describe the potential features of a patient with PCOS.

A

Hirsutism
High BMI
Oligomenorrhoea
Dysmenorrhoea
Infertility

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41
Q

Management of hirsutism due to PCOS

A

1st: COCP
2nd: Topical eflornithine / Spironolactone

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42
Q

Describe the hormone profile results for someone with PCOS.

A

↑↑ LH : FSH ratio
FSH normal
↑ androstenedione

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43
Q

Ovarian hyperthecosis

A

Hyperandrogenaemia in postmenopausal women

Presence of luteinised theca cell nests in the ovarian stroma

[Testosterone] much higher than in PCOS

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44
Q

State 2 methods of ovarian induction.

A

Letrozole
Clomifene
Gonadotropin therapy

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45
Q

Describe the mechanism of letrozole.

A

Aromatase inhibitor - reduces -ve feedback to pituitary - ↑ FSH

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46
Q

Describe the mechanism of clomiphene citrate.

A

Selective oestrogen receptor modulator (SERM) - acts of hypothalamus and blocks -ve feedback - ↑ GnRH pulse frequency - ↑ FSH & LH

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47
Q

Which form of ovarian induction carries the highest risk of ovarian hyperstimulation syndrome?

A

Gonadotropin therapy

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48
Q

What is ovarian hyperstimulation syndrome?

A

Formation of multiple cystic spaces within enlarged ovaries - fluid shift to extra-vascular space

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49
Q

How is OHSS managed?

A

Fluid & electrolytes
Anti-coagulation therapy
Pregnancy termination

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50
Q

What is the most common cause of ovarian enlargement in women of reproductive age?

A

Follicular cyst

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51
Q

What is Meig’s syndrome a triad of?

A

Fibromas, ascites, pleural effusion

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52
Q

What is the most common benign ovarian tumour in women under 25?

A

Dermoid cyst (teratoma)

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53
Q

Which type of ovarian cyst contains Rokitansky’s protuberance on histology?

A

Dermoid cyst (teratoma)

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54
Q

Which cyst, if ruptured, can cause pseudomyxoma peritonei?

A

Mucinous cystadenoma

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55
Q

State an indication that an ovarian cyst should be biopsied.

A

Irregular solid tumour, ascites, 4 papillary structures or more, irregular multilocular, strong blood flow

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56
Q

State 2 complications which can arise from cysts.

A

Haemorrhagic
Cyst rupture
Ovarian torsion > 5cm

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57
Q

Describe the appearance of corpus luteum cysts on ultrasound.

A

Spider web appearance + ring of fire (blood flowing around cyst)

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58
Q

Describe the typical presentation of a ruptured ovarian cyst.

A

Sudden, severe unilateral pain
Maximal onset
Following sex/strenuous activity

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59
Q

Describe what can be seen on ultrasound in ruptured ovarian cysts.

A

Free fluid in pelvic cavity

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60
Q

Describe how corpus luteal cysts form.

A

Dominant follicle ruptures but closes again

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61
Q

Describe how follicular cysts form.

A

Dominant follicle fails to rupture
Normal LH surge doesn’t happen

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62
Q

Describe how theca lutein cysts form.

A

Pregnancy, usually bilateral
Overstimulation of hCG – growth of theca cells
More likely to develop in GTD and multiple pregnancy

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63
Q

How is ovarian torsion managed?

A

Laparoscopic detorsion
/ salpingo-oophorectomy

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64
Q

State 3 risk factors for ovarian torsion.

A

Reproductive age
Pregnancy
OHSS

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65
Q

What may be visible on ultrasound of the ovaries in ovarian torsion?

A

Oedema + blood pooling
Whirlpool sign

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66
Q

What is the most common type of ovarian cancer?

A

Serous epithelial ovarian cancer - 90%
Post-menopausal women

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67
Q

Most common type of ovarian cancer in pre-menopausal women

A

Germ cell ovarian tumour

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68
Q

Appearance of serous cystadenoma on histology

A

Psammoma bodies
Nuclear atypia
Complex papillary architecture

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69
Q

5 risk factors for the development of ovarian cancer.

A

Postmenopausal
Endometriosis
PCOS
BRCA1/2
Nulliparity / late menopause / early menarche
HNPCC (Lynch syndrome)

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70
Q

3 symptoms of ovarian cancer.

A

Bloating
Early satiety
Diarrhoea
Pelvic/abdominal pain
Mass

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71
Q

What investigation is 1st line for ovarian cancer?

A

CA125

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72
Q

Which investigation is diagnostic for ovarian cancer?

A

Diagnostic laparotomy + biopsy

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73
Q

How should suspected ovarian cancer be managed?

A

CA125 first, if mass/ascites if present then urgent referral to gynae

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74
Q

3 signs of metastatic disease of epithelial ovarian cancer.

A

Ascites
Pleural effusion
Lymphadenopathy

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75
Q

2 protective factors of ovarian cancer.

A

COCP
Multiparity
Breastfeeding

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76
Q

3 benign causes of raised CA125.

A

Endometriosis
Menstruation
Benign ovarian cysts
Ascites
Diverticulosis
Heart failure
Fibroids

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77
Q

2 germ cell tumours

A

Teratoma
Dysgerminoma
Yolk sac tumour
Choriocarcinoma

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78
Q

2 sex cord-stromal tumours

A

Thecoma
Fibroma
Granulosa cell tumour
Sertoli Leydig tumour

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79
Q

4 risk factors for endometrial cancer

A

Tamoxifen
PCOS
HNPCC
Obesity
Diabetes
Nulliparity / late menopause
HRT
Pelvic irradiation

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80
Q

2 protective factors of ovarian cancer

A

Multiparity
COCP

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81
Q

Classical symptom of endometrial cancer

A

Post menopausal bleeding - 10% will be EC

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82
Q

Differential for PMB

A

Atrophic vaginitis

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83
Q

How should suspected endometrial cancer be managed?

A

Urgent 2ww referral to gynae

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84
Q

What are the 1st and 2nd line investigations for endometrial cancer?

A

1st: TVUSS
2nd: hysteroscopy with endometrial biopsy

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85
Q

How can localised endometrial cancer be managed?

A

Hysterectomy with bilateral salpingo-oophorectomy

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86
Q

Which HPV serotypes are associated with cervical cancer?

A

16, 18 and 33

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87
Q

3 risk factors for cervical cancer

A

Early first intercourse
Multiparity
COCP
STIs
Smoking

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88
Q

Which oncogenes are inhibited by HPV? Which genes are affected by the oncogenes?

A

16 inhibits E6 - inhibits p53 TSG
18 inhibits E7 - inhibits RB TSG

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89
Q

What is the screening timetable for cervical cancer?

A

3 yearly: 25-49 years old
5 yearly: 50-64 years old

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90
Q

How should an inadequate sample be managed in cervical cancer screening?

A

Repeat 3 months

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91
Q

How should 2 inadequate samples be managed in cervical cancer screening?

A

Colposcopy

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92
Q

How should a positive HPV sample with normal cytology be managed in cervical cancer screening?

A

Repeat 12 months

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93
Q

How should abnormal cytology in cervical cancer screening be managed?

A

Colposcopy

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94
Q

How should 2 repeat HPV +ve samples with normal cytology be managed in cervical cancer screening?

A

Colposcopy

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95
Q

How is CIN 1 treated?

A

Conservative
Repeat cytology 6/12/24 months later

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96
Q

CIN 1 regression rate

A

57% regress

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97
Q

How is CIN 2/3 treated?

A

LLETZ - large loop excision of transformation zone

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98
Q

What is considered in RMI in ovarian cancer investigations?

A

Risk of malignancy index:
CA125
USS findings
Menopausal status

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99
Q

How should HIV +ve patients be followed up for cervical screening?

A

Annual cytology

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100
Q

What is the most common type of vulval cancer?

A

Squamous cell carcinoma
80%

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101
Q

3 risk factors for vulval cancer

A

HPV
Immunosuppression
Lichen sclerosis
VIN
> age

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102
Q

Which HPV serotypes are associated with vaginal cancer?

A

6 and 11

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103
Q

Classic triad of presentation of vulval cancer

A

Older woman
Labial lump
Inguinal lymphadenopathy

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104
Q

Where is an ectopic pregnancy most likely to be?

A

Ampulla

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105
Q

Which location is an ectopic pregnancy associated with the greatest mortality due to rupture risk?

A

Isthmus

? /interstitium

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106
Q

6 risk factors for ectopic pregnancy

A

Damage to tubes e.g. STI/PID
IUS/IUD
Endometriosis
Age < 18 first intercourse
IVF
Smoking
POP
Black race

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107
Q

Describe the pain associated with ectopic pregnancy.

A

Constant
1st symptom
Lower abdominal

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108
Q

Gold standard investigation for ectopic pregnancy

A

TVUSS

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109
Q

Contraindication to medical management for ectopic pregnancy

A

Liver and renal dysfunction are contraindications to use of methotrexate

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110
Q

3 indications for surgical management of ectopic pregnancy

A

Size > 35mm
Foetal heartbeat present
hCG > 5000IU/L

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111
Q

2 surgical options for ectopic pregnancy + which is 1st line + exception

A

1st: Salpingectomy - removal of fallopian tube (unless other tube is compromised + patient wishes to conserve fertility)
2nd: Salpingotomy - creation of opening in fallopian tube

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112
Q

How often is hCG measured after surgery for ectopic pregnancy?

A

Salpingectomy - single measurement after
Salpingotomy - weekly until undetectable

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113
Q

When is anti-D indicated in the management of ectopic pregnancy?

A

Surgical management
Rhesus -ve mother

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114
Q

Medical management for ectopic pregnancy

A

Methotrexate

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115
Q

hCG values for management in ectopic pregnancy

A

< 1000 - expectant
< 1500 - medical
> 5000 - surgical

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116
Q

Complete hydatidiform mole karyotype

A

46 (all paternal) XX or XY
Empty egg fertilised by 1 sperm that duplicated or by 2 sperm

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117
Q

Partial hydatidiform mole karyotype

A

69 XXX or XXY or XYY
Ovum fertilised by 2 sperm

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118
Q

Clinical manifestations of hydatidiform mole

A

Exaggerated pregnancy symptoms - hyperemesis
Uterus large for gestational age

Less common:
HTN
Hyperthyroidism
Ovarian cysts
Pre-eclampsia < 20 weeks gestation

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119
Q

Ultrasound appearance of hydatidiform mole - compare complete and partial

A

Snowstorm appearance

Complete: no foetal tissue
Partial: foetal tissue present

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120
Q

How long should conception be avoided after a hydatidiform mole?

A

12 months

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121
Q

How should patients be managed after molar pregnancies are initially managed?

A

Partial: measure hCG 4 weeks later
Complete: measure monthly for 6 months

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122
Q

What complications can arise as a result of molar pregnancies?

A

Choriocarcinoma

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123
Q

How does choriocarcinoma present?

A

Heavy bleeding in womb
o To lungs: coughing etc.
o To abdomen: stomach pain etc.
o To vagina: heavy bleeding, lump etc.

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124
Q

Why may hyperthyroidism be seen in a patient with a gestational trophoblastic disorder

A

hCG mimics TSH

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125
Q

How should miscarriage be followed up after treatment?

A

Pregnancy test 3 weeks later (after medical/surgical treatment or bleeding subsides after expectant)
Return to hospital if present

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126
Q

Explain the mechanism of misoprostol for miscarriage

A

Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contraction – expulsion

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127
Q

Contraindication to medical management for miscarriage

A

Infection
Coagulopathy PMH / increased risk of haemorrhage (past 1st trimester)
Previous adverse experience with pregnancy e.g. stillbirth, miscarriage
Late 1st trimester
(NICE)

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128
Q

Medical management for miscarriage

A

Misoprostol

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129
Q

Threatened miscarriage

A

Cervical os closed
Normal gestational sac
Painless vaginal bleeding

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130
Q

Incomplete miscarriage

A

Process ongoing
Not all PoC removed
Pain and bleeding
Cervical os open

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131
Q

At what stage has incomplete miscarriage progressed to complete miscarriage?

A

When all products of conception have passed through
And when cervical os is closed

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132
Q

Missed (delayed) miscarriage

A

Asymptomatic usually
Foetus dead
Cervical os closed

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133
Q

Inevitable miscarriage

A

Cervical os open
Heavy bleeding with clots + pain
Leads to eventual complete miscarriage

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134
Q

2 methods of surgical management of miscarriage.

A

Manual vacuum aspiration - local anaesthetic
Electric vacuum aspiration - general anaesthetic

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135
Q

How long after miscarriage can a pregnancy test remain positive?

A

4 weeks

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136
Q

Asherman’s syndrome

A

Intrauterine adhesions following dilation and curettage
Prevents endometrium from responding to oestrogen normally

Menstrual disturbance, infertility or recurrent pregnancy loss

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137
Q

Medication for recurrent miscarriage due to antiphospholipid syndrome

A

LMWH and aspirin

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138
Q

5 risk factors for miscarriage

A

Age > 35
Previous miscarriage
Chronic conditions e.g. T1DM
Uterine/cervical problems
Smoking/alcohol/illicit drugs
Under/overweight
Invasive prenatal tests

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139
Q

Termination of pregnancy management

A

Mifepristone (antiprogesterone)
then
Misoprostol (prostaglandin) 36-48 hours later

Anti-D if rhesus -ve and > 10 weeks gestation

If > 15 weeks - surgical dilatation and evacuation of contents

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140
Q

When is anti-D indicated in termination of pregnancy?

A

Rhesus -ve and > 10 weeks

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141
Q

Diagnosing menopause

A

Retrospective
1 year amenorrhoea

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142
Q

Pathophysiology of menopause

A

Depletion of primordial follicles at ~ 40 years in ovaries
Decrease in follicular oestrogen production
Gradual increase in FSH & LH – due to lack of negative feedback provided by oestrogen
Decrease secretion of inhibin - further increase in FSH
Increase in FSH - rapid increase in oestrogen secretion from existing follicles - shorter menstrual cycles
Fewer follicles so increase in FSH no longer stimulates an increase in oestrogen – occurring 6-12 months pre-menopause
Decrease in oestrogen and lack of ova - menopause

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143
Q

Risk of unopposed oestrogen HRT

A

Endometrial cancer

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144
Q

Risk of combined oestrogen and progesterone HRT

A

Decreased risk of EC
Increased risk of BC
Increased stroke
Increased IHD

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145
Q

2 contraindications to HRT

A

Current, past or suspected breast cancer
Undiagnosed vaginal bleeding

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146
Q

Indication for transdermal HRT

A

Patient preference
DVT history

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147
Q

HRT and colorectal cancer risk

A

Decreased risk

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148
Q

How long is contraception for if going through menopause?

A

Needed for:
24 months if < 50,
12 months if > 50

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149
Q

Stress incontinence medical management

A

Duloxetine

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150
Q

Urge incontinence medical management

A

1st: Oxybutynin
2nd: Mirabegron

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151
Q

Mechanism of duloxetine

A

Increases synaptic [noradrenaline and serotonin] within pudendal nerve - increases stimulation of urethral striated muscles within sphincter

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152
Q

Mechanism of oxybutynin

A

M3 antagonist

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153
Q

Contraindication to use of oxybutynin for urge incontinence

A

Glaucoma

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154
Q

Mechanism of mirabegron

A

Beta 3 agonist

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155
Q

How long should pelvic floor training be carried out for before moving to medical management for stress incontinence?

A

3 months

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156
Q

How long should bladder retraining be carried out for before moving to medical management for urge incontinence?

A

6 weeks

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157
Q

Why is urine dipstick and culture carried out for incontinence?

A

Rule out UTI and DM (neurogenic bladder)

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158
Q

What investigation should be carried out if a patient presents with incontinence alongside a history of prolonged labour?

A

Urinary dye studies due to risk of fistula

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159
Q

Management of urogenital prolapse

A

No treatment if asymptomatic
1st: conservative - pelvic floor exercises, weight loss
2nd: vaginal pessary
3rd: surgical

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160
Q

Urogenital prolapse: anterior vaginal wall

A

Cystocele: bladder (may lead to stress incontinence)
Urethrocele: urethra
Cystourethrocele: both bladder and urethra

Colporrhapy

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161
Q

Urogenital prolapse: posterior vaginal wall

A

Enterocele: small intestine

Rectocele: rectum
Posterior colporrhaphy

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162
Q

Urogenital prolapse: apical vaginal wall

A

Uterine prolapse: uterus
Hysterectomy/sacrohysteropexy

Vaginal vault prolapse: roof of vagina (common after hysterectomy)
Sacrocolpoplexy

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163
Q

Most common causative organism of PID

A

Chlamydia trachomatis

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164
Q

Pathophysiology of PID

A

Ascending infection from endocervix

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165
Q

Presentation of PID

A

Deep dyspareunia
Fever
Lower abdominal pain
Dysuria
Discharge

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166
Q

Confirmatory diagnosis PID

A

High vaginal swab for STIs

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167
Q

Antibiotics used in PID

A

IM ceftriaxone and oral doxycycline and metronidazole
OR
Oral ciprofloxacin and metronidazole

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168
Q

How should IUS/IUD be managed in PID?

A

Leave in situ if infection present

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169
Q

Indication for admission with PID

A

Temp > 38

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170
Q

What is Fitz-Hugh-Curtis syndrome?

A

Perihepatitis arising from inflammation of liver capsule

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171
Q

Fitz-Hugh-Curtis syndrome investigations

A

USS to rule out stones
Normal LFTs
Laparoscopy shows adhesions

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172
Q

What advice for conception would you give to a couple?

A

Folic acid
Intercourse 2-3x a week
Healthy weight
Smoking cessation

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173
Q
  1. Name 3 genetic conditions which affect fertility.
A

CF
Turner’s
Kallman’s

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174
Q

Give 3 examples of tubal causes of infertility.

A

Infections
Endometriosis
Iatrogenic

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175
Q

When should a semen analysis be repeated if results are abnormal?

A

After 3 months

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176
Q

How long should someone be abstinent before semen analysis?

A

3-5 days of abstinence

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177
Q

Factors which warrant early referral for infertility F/M

A

F
> 35 years old
Menstrual disorder
Previous surgery
Previous STI/PID

M
Genital pathology
Previous STI
Systemic illness
Abnormal genitalia examination

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178
Q

Class 1 ovulatory disorder

A

Hypogonadotropic hypogonadal anovulation

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179
Q

Class 2 ovulatory disorder

A

Normogonadotropic normoestrogenic anovulation
PCOS

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180
Q

Class 3 ovulatory disorder

A

Hypergonadotropic hypoestrogenic anovulation
Premature ovarian insufficiency
Require IVF in most cases

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181
Q

Ovarian induction 1st, 2nd and 3rd line

A

Exercise and weight loss

Letrozole

Clomiphene citrate

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182
Q

Letrozole side effect

A

Fatigue
Dizziness

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183
Q

Clomiphene citrate side effect

A

Hot flushes

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184
Q

How many weeks of amenorrhoea are needed to diagnose premature ovarian syndrome?

A

4 months

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185
Q

Diagnosis of premature ovarian syndrome

A

FSH >30IU/L
2 samples 4-6 weeks apart

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186
Q

Management of premature ovarian syndrome

A

Cyclical combined HRT until 51 years old

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187
Q

3 causes of secondary amenorrhoea

A

Sheehan syndrome
Asherman syndrome
Prolactinoma
Anorexia nervosa

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188
Q

Sheehan syndrome hormone profile

A

Low FSH, LH, ACTH
Low cortisol, oestradiol
Low or normal TSH and low T3/4

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189
Q

Sheehan syndrome hormone profile

A

Low FSH, LH
Low oestradiol
Normal TFTs

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190
Q

Sheehan syndrome hormone profile

A

Low FSH, LH, ACTH
Low cortisol, oestradiol
Low or normal TSH and low T3/4

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191
Q

Most common cause of post-coital bleeding

A

Ectropion

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192
Q

Cervical ectropion pathophysiology

A

Transformation zone: stratified squamous epithelium meets columnar epithelium of the cervical canal

Larger area of columnar epithelium on ectocervix due to elevated oestrogen levels

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193
Q

Management of PMS

A

1st: Regular high-carb meals
2nd: New generation COCP e.g. Yasmin
3rd: SSRI if severe

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194
Q

Primary amenorrhoea + regular painful cycles

A

Imperforate hymen

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195
Q

Causes of primary amenorrhoea

A

Constitutional delay
Imperforate hymen
Turner’s syndrome
Androgen insensitivity syndrome
Mayer-Rokitansky-Küster-Hauser syndrome

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196
Q

Management of androgen insensitivity syndrome

A

Raise as female
Bilateral orchidectomy
Oestrogen therapy

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197
Q

Karyotype of androgen insensitivity syndrome

A

46 XY

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198
Q

Presentation of androgen insensitivity syndrome

A

Groin swellings - undescended testes
Primary amenorrhoea
Tall + long limbs

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199
Q

Risk associated with untreated primary amenorrhoea

A

Osteoporosis

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200
Q

Inheritance of androgen insensitivity syndrome

A

X-linked recessive

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201
Q

Bartholin’s gland location and function

A

Within vestibule, lateral to introitus
Secretes lubricating fluid

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202
Q

Bartholin’s gland cyst presentation

A

Duct becomes blocked
Palpable swelling and pain at site

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203
Q

Bartholin’s gland abscess presentation

A

Cyst becomes infected, extreme pain and erythema
Rarely, systemic upset

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204
Q

Bartholin’s gland cyst management

A

Non-surgical: Insertion of balloon catheter
Surgical: Marsupialisation - incision and drainage, stitches to make permanent opening

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205
Q

Bartholin’s cyst infection: most likely organism

A

E. Coli

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206
Q

Combined test for Down’s syndrome + results + week

A

PAPP-A - down
Thickened nuchal translucency
HCG - up

11-13+6 weeks

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207
Q

Triple/quadruple test for Down’s syndrome + results + week

A

HCG - up
Inhibin-A (QUADRUPLE) - up
AFP - down
Oestriol - down

15-20 weeks

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208
Q

Chorionic venous sampling - weeks + risks

A

11-13 weeks

Risk of foetal limb abnormalities

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209
Q

Amniocentesis - weeks + risks

A

15-20 weeks

Miscarriage

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210
Q

3 causes of raised AFP during antenatal screening

A

Multiple pregnancy
Neural tube defects
Abdominal wall defects
Patau syndrome

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211
Q

3 causes of thickened nuchal translucency

A

Down’s
Congenital heart defect
Abdominal wall defect

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212
Q

3 causes of hyperechogenic bowel

A

CF
Down’s
CMV infection

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213
Q

Quadruple test results for neural tube defects

A

Raised AFP
Normal inhibin A, HCG and oestriol

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214
Q

Quadruple test results for Edward’s syndrome

A

HCG - down
Inhibin-A - normal
AFP - down
Oestriol - down

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215
Q

4 causes of folic acid deficiency

A

Phenytoin
Methotrexate
Pregnancy
Alcohol excess
Obesity

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216
Q

When is a higher dose of folic acid indicated?

A

5mg if higher risk of neural tube defects

BMI > 30
Antiepileptic medication
Coeliac disease
Diabetes
Thalassaemia trait
History of NTD

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217
Q

Management of lithium in pregnancy

A

Stop lithium (over 4 weeks) during 1st trimester and gradually switch to antipsychotic

If lithium is continued, as low dose as possible + drink plenty of water

Stop lithium in labour

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218
Q

How long is folic acid taken for in pregnancy?

A

Until 12 weeks pregnant

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219
Q

How long is vitamin D taken for in pregnancy?

A

Throughout pregnancy

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220
Q

Hb cut off for iron supplementation in 1st trimester

A

110

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221
Q

Hb cut off for iron supplementation in 2nd and 3rd trimester

A

105

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222
Q

Hb cut off for iron supplementation in postpartum period

A

100

223
Q

Booking visit

A

8-12 weeks

Bloods
Urine dipstick
BMI
1st screen for anaemia
Test for HIV, syphilis, Hep B, rubella

224
Q

Naegele’s rule

A

LMP + 9 months + 7 days ( I think?)

225
Q

Early scan

A

10-13+6 weeks
Confirm dates
Exclude multi pregnancy

226
Q

Anomaly scan

A

18-20+6 weeks

227
Q

Anti-D routine doses in pregnancy

A

28 weeks
34 weeks
Any other sensitising event

228
Q

Vaccines in pregnancy

A

Pertussis
Influenza

229
Q

Absolute contraindications to breastfeeding

A

Mother has TB
Mother has unmonitored HIV

230
Q

Symphysis-fundal height

A

From top of pubic bone to top of uterus in cm
Matches gestational age in weeks to within 2 cm after 20 weeks
E.g. if 24 weeks normal SFH = 22 to 26 cm

231
Q

Drugs to avoid when breastfeeding

A

Aspirin
Amiodarone
Benzodiazepines
Carbimazole
Ciprofloxacin
Codeine
Lithium
Methotrexate
Naproxen
Tetracyclines
Sulphonamides
Sulphonylureas

232
Q

Pregnancy-induced hypertension

A

HTN > 20 weeks gestation

233
Q

Epidemiology of pre-eclampsia

A

5% all pregnancies

234
Q

High-risk factors for pre-eclampsia

A

CKD
HTN previous pregnancy
Autoimmune disorder
T1DM / T2DM
Chronic HTN

235
Q

Moderate risk factors for pre-eclampsia

A

Primiparous
Multiple pregnancy
Age > 40
BMI > 35
FHx pre-eclampsia
Pregnancy interval > 10 years

236
Q

PLGF

A

Placental growth factor
Gold standard? in diagnosing pre-eclampsia

237
Q

Moderate risk factors for pre-eclampsia

A

Primiparous
Multiple pregnancy
Age > 40
BMI > 35
FHx pre-eclampsia
Pregnancy interval > 10 years

238
Q

Medication for pre-eclampsia / pregnancy-induced hypertension

A

1st: Labetalol
2nd: Nifedipine

239
Q

Blood pressure values in pre-eclampsia

A

> 140/90

OR

> 30 systolic / >15 diastolic from baseline

240
Q

Clinical manifestations of pre-eclampsia

A

Hyperreflexia
Headache
Oedema
Reduced foetal movements

241
Q

How is eclampsia treated?

A

MgSO4
Delivery is the most important

242
Q

Medication to reverse respiratory depression caused by MgSO4

A

Calcium gluconate

243
Q

Medication for those high-risk of pre-eclampsia

A

Aspirin from 12 weeks onwards

244
Q

Monitoring of pre-eclampsia

A

LFTs, FBC, U&Es 3x a week

245
Q

1st step management of pre-eclampsia

A

Emergency referral to obstetrics

246
Q

Blood results of acute fatty liver

A

High LFTs: rise in ALT/AST higher than ALP
High WCC

247
Q

Presentation of acute fatty liver of pregnancy of pregnancy

A

N+V
Jaundice
RUQ pain
DIC
Oliguria

248
Q

HELLP syndrome

A

Haemolysis
Elevated liver enzymes
Low platelets

249
Q

Management of HELLP syndrome

A

Delivery

250
Q

Which rhesus status needs treatment?

A

Rhesus negative

251
Q

3 sensitisation events

A

Placental abruption
Trauma
Amniocentesis
Ectopic pregnancy
Miscarriage/ToP/intrauterine death
Vaginal bleeding > 12 weeks
Vaginal bleeding with pain

252
Q

Pathophysiology of rhesus disease

A

Rhesus -ve mum produced antibodies against rhesus +ve baby antigens
Can attack baby’s RBCs and cause haemolytic disease during sensitising events

253
Q

Kleihauer test

A

Used during sensitising events
To gauge the dose of anti-D required

254
Q

Anaemia cut-offs in pregnancy

A

1st trimester < 110
2nd/3rd trimester < 105
Postpartum < 100

255
Q

Anaemia screening in pregnancy

A

Booking visit
28 weeks

256
Q

Treatment of anaemia in pregnancy

A

Oral ferrous sulphate until 3 months after deficiency is corrected

257
Q

Management of chickenpox exposure < 20 weeks

A

VZIG within 10 days of contact and before rash
If rash developed - give oral aciclovir

258
Q

Management of chickenpox exposure > 20 weeks

A

Aciclovir within 10 days contact or 24 hours of rash

259
Q

Management of foetus infected with chickenpox

A

IV acyclovir following delivery

260
Q

Amniotic fluid embolism associated risk factors

A

SROM while inducing
Increasing age

261
Q

Amniotic fluid embolism symptoms

A

Sweating
Anxiety
Cyanosis
Coughing

262
Q

How is amniotic fluid embolism managed?

A

ABCDE
Oxygen

263
Q

When should foetal movements be established by?

A

24 weeks

264
Q

1st line management of reduced foetal movements

A

Handheld doppler

265
Q

2nd line management of reduced foetal movements

A

No heartbeat: USS
Heartbeat: CTG 20 minutes

266
Q

Management of bacteriuria in pregnancy

A

Confirm with second culture
Begin culture dependent antibiotic

267
Q

Risks associated with asymptomatic bacteriuria

A

Premature labour
Spontaneous miscarriage

268
Q

Antibiotics for UTI in pregnancy

A

1st: nitrofurantoin but avoid at term
2nd: amoxicillin / cefalexin
amoxicillin - only if culture results available
for 7 days

269
Q

Risk associated with trimethoprim in pregnancy

A

Neural tube defects

270
Q

Risk associated with nitrofurantoin in pregnancy

A

3rd trimester - can cause haemolysis of the newborn

271
Q

Investigating PE in pregnancy

A

ECG + CXR
If DVT diagnosed no more investigations needed for PE

272
Q

Investigating DVT in pregnancy

A

Duplex ultrasound

273
Q

How is DVT treated in pregnancy?

A

LMWH

274
Q

Major risk factors for VTE in pregnancy

A

Previous unprovoked VTE
Admission for hyperemesis gravidarum
OHSS

275
Q

Regular risk factors for VTE in pregnancy

A

BMI > 30
Parity > 3
Smoker
Varicose veins
Current pre-eclampsia
Immobility
FHx unprovoked VTE
Low risk thrombophilia
IVF

276
Q

Indications for LMWH for prophylaxis of VTE

A

3 regular risk factors
LMWH from 28 weeks

4 regular risk factors or 1 major risk factor
LMWH from LMP

277
Q

Monitoring of LMWH in pregnancy

A

Anti-Xa assay

278
Q

Causes of cord prolapse

A

Abnormal presentation
PROM
Multiple pregnancy
Polyhydramnios
IUGR
Placenta praevia
AROM

279
Q

Pathophysiology of AROM causing cord prolapse

A

Baby not engaged in pelvis when membrane is ruptured
Cord suspends below baby to become compressed

280
Q

Management of cord prolapse

A

Shout for help
Push presenting part of foetus back to avoid compression
All fours
Tocolytics
Infuse fluid into bladder
C-section

281
Q

Handling cord in cord prolapse

A

Don’t do this!
Associated with vasopasm which can lead to foetal hypoxia

282
Q

How is occult cord prolapse managed?

A

Left lateral position
Normal delivery unless foetal distress

283
Q

Transverse lie epidemiology

A

1 in 300 at term

284
Q

Risk factors for transverse lie

A

Polyhydramnios
Foetal abnormalities
Multiple pregnancy
Prematurity
Fibroid/other pelvic tumours

285
Q

Transverse lie abdominal palpation

A

Head and buttocks not palpable at each end of uterus

286
Q

Management of transverse lie beyond 36 weeks

A

ECV up to early labour if amniotic sac intact
Otherwise elective C section

287
Q

2 contraindications to ECV

A

ROM in last 7 days
Multiple pregnancy (except 2nd twin)
Major uterine abnormality
Oligohydramnios

288
Q

Which malpresentation is associated with highest morbidity and mortality?

A

Footling breech

289
Q

Risk factors for malpresentation

A

Polyhydramnios
Fibroids
Preterm
Foetal abnormality
Placenta praevia

290
Q

When is ECV offered to women

A

36 weeks primiparous
37 weeks multiparous

291
Q

Complication of ECV

A

Placental abruption

292
Q

Breech epidemiology

A

25% of pregnancies at 28 weeks
3% term

293
Q

Types of breech

A

Footling
Frank
Complete
Incomplete

294
Q

Oligohydramnios AFI

A

< 5 cm

295
Q

Definition of SGA

A

< 10th centile

296
Q

Difference between SGA and IUGR

A

SGA - compared to population
IUGR - compare to parent heights

297
Q

Causes of symmetrical vs asymmetrical IUGR

A

Symmetrical:
Infection

Asymmetrical:
Pre-eclampsia
Renal/cardiac disease
Substance abuse

298
Q

Causes of oligohydramnios

A

PROM
Post-term gestation
IUGR
Foetal renal agenesis
Uteroplacental insufficiency - smoking

299
Q

Oligohydramnios vs polyhydramnios abdominal palpation

A

Poly: difficult to feel foetal parts
Oligo: foetal parts feel more prominent

300
Q

Potter sequence clinical manifestations

A

Bilateral renal agenesis
Oligohydramnios
Pulmonary hypoplasia
Downward epicanthal folds

301
Q

Describe the mechanism by which oligohydramnios can cause foetal pulmonary hypoplasia

A

Amniotic fluid needed for foetal lung development

302
Q

Causes of polyhydramnios - excessive production of amniotic fluid

A

Maternal DM
Macrosomia
Foetal renal disorder
Foetal anaemia
Twin-to-twin transfusion syndrome

303
Q

Causes of polyhydramnios - insufficient removal of amniotic fluid

A

Oesophageal/duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders

304
Q

Most common cause of polyhydramnios

A

Idiopathic 50%

305
Q

Polyhydramnios AFI

A

> 25cm

306
Q

Polyhydramnios maternal complications

A

Respiratory compromise - pressure on diaphragm
UTIs - pressure on urinary system
Worsening GORD, constipation, stretch marks
Higher incidence of C section
Higher risk of amniotic fluid embolism

307
Q

Polyhydramnios foetal complications

A

Pre-term labour and delivery
Premature rupture of membranes
Placental abruption
Malpresentation of foetus
Umbilical cord prolapse

308
Q

Twin-to-twin transfusion syndrome prevalence

A

10-15% of monochorionic pregnancies

309
Q

Twin-to-twin transfusion syndrome pathophysiology

A

Anastomoses of umbilical vessels

310
Q

Twin-to-twin transfusion syndrome risks (donor and recipient comparison)

A

Both - HF & hydrops foetalis
Donor - high output cardiac failure
Recipient - fluid overload

311
Q

Twin-to-twin transfusion syndrome prognosis

A

High mortality for both but donor more likely to survive

312
Q

Twin-to-twin transfusion syndrome management

A

Laser transection of vessels in utero

313
Q

How many attempts should be made with instrumental delivery before resorting to LSCS?

A

3 pulls attempted

314
Q

Requirements for instrumental delivery

A

Fully dilated cervix - 2nd stage of labour reached
OA position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty - catheterisation

315
Q

Which form of instrumental delivery is most likely to cause haemorrhage in newborn?

A

Ventouse

316
Q

Caput succedaneum

A

Crosses Suture lines
Resolves within days (Calms Soon)
Present at birth

317
Q

Cephalohaematoma

A

Parietal region usually, doesn’t cross suture lines
Months to resolve
Develops several hours after birth

318
Q

Risk factors for placental abruption

A

Pre-eclampsia
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age
Polyhydramnios

319
Q

Typical placental abruption presentation

A

Woody/tense uterus
Pain + PV bleeding

320
Q

Importance of monitoring glucose when giving steroids

A

Steroids can cause hyperglycaemia in diabetics

321
Q

Management of placental abruption < 34 weeks

A

Immediate C section in foetal distress
Steroids and close observation if no foetal distress

322
Q

Investigation of choice for placenta praevia

A

TVUSS

323
Q

Diagnosis of placenta praevia

A

20 week anomaly scan

324
Q

Follow-up management for placenta praevia after diagnosis

A

TVUSS at 32 weeks
Elective C section

325
Q

Risk factors for placenta praevia

A

Previous placenta praevia
Previous C section (embryo more likely to implant on lower segment scar)
Endometrium damage
Multiple pregnancy
Maternal smoking
IVF

326
Q

Presentation of placenta praevia

A

Painless bleeding

327
Q

Patient presents with painless bleeding after 24 weeks which has not stopped - how should they be managed?

A

C section

328
Q

Patient presents with painless bleeding after 24 weeks which has since stopped - how should they be managed?

A

Admit for observation

329
Q

Grade I placenta praevia

A

Placenta reaches lower segment but not internal osf

330
Q

Grade II placenta praevia

A

Placenta reaches internal os but does not cover it

331
Q

Grade III placenta praevia

A

Placenta covers internal os before dilation

332
Q

Grade IV placenta praevia

A

Placenta completely covers internal os

333
Q

What is vasa praevia?

A

Foetal blood vessels run close to orifice of uterus

334
Q

Typical presentation of vasa praevia

A

Following ROM
Foetal bradycardia
Vaginal bleeding

335
Q

Placenta accreta

A

Chorionic villi attach onto myometrium

336
Q

Risk factors for placenta accreta

A

Previous uterine surgery
Maternal age > 35
IVF
Previous PID/STI

337
Q

Placenta increta

A

Chorionic villi invade into myometrium

338
Q

Placenta percreta

A

Chorionic villi invade through myometrium

339
Q

Placenta accreta management

A

Elective C-section and hysterectomy
Delay placental delivery in 3rd stage

340
Q

Risk factors for placenta accreta

A

C section
Pelvic inflammatory disease

341
Q

Shoulder dystocia risk factors

A

Macrosomia (maternal DM)
Previous Hx
Obesity

342
Q

Most common mechanism of shoulder dystocia

A

Anterior shoulder impacted behind pubic symphysis

343
Q

Management of shoulder dystocia

A

Call for help
Stop pushing
McRobert’s - legs hyperflexed at hips
Internal manoeuvres

Switch to all fours and repeat

Cleidotomy
Zanvanelli manoeuvre
Symphysiotomy

344
Q

Complications of shoulder dystocia

A

Brachial plexus injury
Cerebral palsy
Perinatal mortality
PPH
Periventricular damage

345
Q

Periventricular damage

A

Hypoxia during prolonged delivery
Causes spastic diplegia - scissor walking

346
Q

Labour monitoring - foetal heart rate

A

Every 15 minutes with Pinard
Or continuously with CTG

347
Q

Labour monitoring - contractions

A

Every 30 minutes

348
Q

Labour monitoring - maternal pulse

A

Every hour

349
Q

Labour monitoring - maternal BP and temp

A

Every 4 hours

350
Q

Labour monitoring - maternal urine

A

Every 4 hours
Ketones and protein

351
Q

Labour stage 1

A

Onset of true labour to when the cervix is fully dilated

352
Q

Contractions during first stage of labour

A

Latent: ~1 minute every 3-5 minutes
Active: 60-90 seconds every 0.5-2 minutes

353
Q

Cervical dilation during first stage of labour

A

Latent: 0-3cm

Active: 6-10cm
Primiparous 0.5cm per hour
Multiparous 1cm per hour

354
Q

Foetal movements in second stage labour

A

Descent
Engagement
Flexion
Internal rotation
Extension
Restitution
Expulsion

355
Q

Timing classification of prolonged second stage labour

A

Nulliparous > 3 hours with epidural, 2 without
Multiparous > 2 hours with epidural, 1 without

356
Q

Physiological third stage labour timing

A

30 minutes - 1 hour

357
Q

Signs of third stage labour

A

Gush of blood
Lengthening of umbilical cord
Ascension of uterus in abdomen

358
Q

What is cord traction?

A

Controlled cord traction in 3rd stage
Oxytocin

359
Q

Complications of cord traction for third stage labour

A

Uterine inversion
PPH

360
Q

CTG: normal HR

A

110-160

361
Q

CTG: normal variability

A

5 to 25

362
Q

CTG: causes of baseline tachycardia

A

Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity

363
Q

CTG: causes of baseline bradycardia

A

Maternal beta-blocker use
Increased foetal vagal tone

364
Q

CTG: early deceleration

A

Head compression

365
Q

CTG: late deceleration

A

Placental insufficiency

366
Q

Bishop score components

A

Pregnancy Can Enlarge Dainty Stomachs
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Foetal station

367
Q

Management options for induction of labour

A

Bishop score is ≤ 6
1st line: Membrane sweep (can do two)
2nd line: Vaginal prostaglandin gel/pessary
3rd line: Cervical ripening balloon

Bishop score is ≥ 6:
1st line: Membrane sweep
2nd line: Oxytocin infusion + amniotomy

368
Q

Induction of labour complication

A

Uterine hyperstimulation

369
Q

Uterine hyperstimulation features

A

> 5 contractions in 10 minutes

370
Q

Uterine hyperstimulation complication

A

Uterine rupture

371
Q

Uterine hyperstimulation management

A

Remove vaginal prostaglandins/stop oxytocin
Tocolysis with terbutaline

372
Q

Investigation of premature rupture of membranes

A

Sterile speculum examination
- Pooling of amniotic fluid in posterior vaginal fault

373
Q

Management of premature rupture of membranes

A

10 day oral erythromycin
Steroids

374
Q

1st line tocolytic for pre-term labour

A

Oral nifedipine

375
Q

When can tocolytics be used?

A

24-33+6 weeks

376
Q

PPROM vs PROM

A

PPROM - preterm and prelabour
PROM - prelabour

377
Q

Maternal complication of PROM

A

Chorioamnionitis

378
Q

Presentation of chorioamnionitis

A

Pyrexia
Foul smelling discharge
Uterine tenderness
Baseline foetal tachycardia

379
Q

Management of chorioamnionitis

A

IV antibiotics broad spectrum
Prompt delivery/C section

380
Q

Risk of using co-amoxiclav in pregnancy

A

Necrotising enterocolitis

381
Q

Diagnostic criteria for hyperemesis gravidarum

A

5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance

382
Q

RCOG admission guidelines for hyperemesis gravidarum

A

Ketonuria and/or weight loss 5%
Unable to keep down anti-emetics
Comorbidity e.g. UTI

383
Q

Hyperemesis gravidarum + ataxia/confusion/opthalmoplegia

A

Wernicke’s encephalopathy

384
Q

Protective factor for hyperemesis gravidarum

A

Smoking

385
Q

Risk factors for hyperemesis gravidarum

A

Multiple pregnancy
Trophoblastic disease
Obesity
Primiparous
Hyperthyroidism

386
Q

Hyperemesis gravidarum scoring system

A

PUQE - pregnancy unique quantification of emesis scoring system

387
Q

IV fluids used for hyperemesis gravidarum

A

Saline + correct electrolyte deficiency

388
Q

Consequences of using dextrose for hyperemesis gravidarum

A

Can precipitate Wernicke’s encephalopathy

389
Q

1st line medication for hyperemesis gravidarum

A

Cyclizine
Promethazine (prochlorperazine alternative)

390
Q

2nd line medication for hyperemesis gravidarum

A

Metoclopramide
Ondansetron

391
Q

Hyperemesis gravidarum epidemiology

A

1% of pregnancies

392
Q

Caution when taking metoclopramide for hyperemesis gravidarum

A

Avoid use for > 5 days - extrapyramidal side effects

393
Q

Caution when taking ondansetron for hyperemesis gravidarum

A

1st trimester - cleft palate risk

394
Q

Perineal tears medical management

A

Laxatives
Pain relief

395
Q

1st degree perineal tear + management

A

Vaginal mucosa
No management needed

396
Q

2nd degree perineal tear + management

A

Perineal muscle
Suturing on ward

397
Q

3rd degree perineal tear (a, b, c) + management

A

Extends to external anal sphincter
Repair in theatre

398
Q

4th degree perineal tear + management

A

Anal sphincter + rectal mucosa
Repair in theatre

399
Q

Most common cause of antepartum haemorrhage

A

50% idiopathic

400
Q

Time classification of antepartum haemorrhage

A

> 24 weeks pregnant

401
Q

Causes of antepartum haemorrhage

A

Idiopathic 50%
Placenta praevia
Placenta abruption
Cervical ectropion
Vasa praevia

402
Q

Postpartum haemorrhage volume classification

A

Primary > 500ml
Secondary > 1000ml

403
Q

Postpartum haemorrhage timing classification

A

Primary within 24 hours
Secondary within 24 hours - 3 months

404
Q

Most common cause of postpartum haemorrhage

A

Uterine atony

405
Q

Management of uterine atony

A

Bimanual massage
Oxytocin
Carboprost
Ergometrine
Misoprostol PR
Intrauterine balloon tamponade
Haemostatic suturing

406
Q

Contraindication to carboprost

A

Asthma

407
Q

Causes of PPH

A

Tissue - retained PoC
Tone - uterine atony
Trauma - instrumental delivery, macrosomia
Thrombin - coagulopathy

408
Q

PPH leading to impaired milk production causes…

A

Sheehan’s syndrome

409
Q

Obstetric cholestasis epidemiology

A

1%
3rd trimester
Most common cause of liver disease of pregnancy

410
Q

Obstetric cholestasis management

A

Ursodeoxycholic acid - symptomatic
Weekly LFTs, bilirubin (check guidance)
Induction at 37 weeks
Vitamin K at birth

411
Q

Postnatal management of obstetric cholestasis

A

Follow up with LFTs 4 weeks postnatally to ensure resolution

412
Q

Risks associated with obstetric cholestasis

A

Stillbirth - higher bile acid levels and comorbidiites increase risk
Prematurity
Recurrence

413
Q

Itch in pregnancy differentials

A

Obstetric cholestasis
Atopic eruption of pregnancy
Polymorphic eruption of pregnancy
Pemphigoid gestationis

414
Q

Polymorphic eruption of pregnancy

A

3rd trimester
Itchy papules, on striae gravidarum first
Widespread eczematous rash with fluid-filled vesicles

415
Q

Polymorphic eruption of pregnancy treatment

A

Emollients
Corticosteroids

416
Q

Atopic eruption of pregnancy

A

Similar presentation to eczema
Face, neck, chest & flexor surfaces

417
Q

Atopic eruption of pregnancy treatment

A

Emollients
Corticosteroids

418
Q

Pemphigoid gestationis

A

Itchy rash around umbilicus
Forms blisters

419
Q

Pemphigoid gestationis treatment

A

Antihistamines
Topical steroids (or systemic if severe)

420
Q

Stages of postpartum thyroiditis

A

Thyrotoxicosis
Hypothyroidism
Normal thyroid function

421
Q

Postpartum thyroiditis management

A

Propanolol for thyrotoxicosis
Levothyroxine for hypothyroidism

Do not give carbimazole

422
Q

Management of pre-existing hypothyroidism in pregnancy

A

Increase levothyroxine 50% (25mcg) when pregnant

423
Q

OGTT for gestational diabetes

A

24-28 weeks

Booking visit if risk factors present

424
Q

Risk factors for gestational diabetes

A

BMI > 30
Previous GD
Previous macrosomia
Ethnicity
1st degree relative diabetes

425
Q

Gestational Diabetes: fasting blood glucose cut off for treatment

A

5.6 mmol/L

426
Q

1 hour after meal blood glucose cut off for treatment

A

7.8 mmol/L

427
Q

2 hours after meal blood glucose cut off for treatment

A

6.4 mmol/L

428
Q

Stepwise management of gestational diabetes

A

1-2 weeks lifestyle modification
Metformin
Short-acting insulin (1st line if fasting blood glucose > 7mmol/L OR evidence of complications e.g. macrosomia/polyhydramnios)

429
Q

Indication to go straight to metformin for gestational diabetes

A

Fasting blood glucose > 7mmol/L OR evidence of complications e.g. macrosomia/polyhydramnios

430
Q

Indication for induction of labour in gestational diabetes

A

41 weeks

431
Q

GBS risk of reinfection

A

50%

432
Q

When is GBS investigated?

A

Swabs at 35-37 weeks
Only if GBS +ve in previous pregnancy

433
Q

Management of Group B Strep in pregnancy

A

Intrapartum antibiotic prophylaxis (IAP) during labour
IV Benzylpenicillin
or vancomycin

434
Q

Indication for testing for GBS in pregnancy + when

A

Previous GBS pregnancy
At 35-37 weeks

435
Q

Indication to give IAP for GBS in pregnancy

A

Previous GBS infection
>38 fever in labour

436
Q

Management of suspected rubella infection in pregnancy

A

Discuss with local Health Protection Unit immediately
Don’t give MMR during pregnancy - can be given before/after pregnancy in 2 doses 3 months apart

437
Q

At what point in pregnancy is highest risk should they contract rubella?

A

1st trimester

438
Q

Risk of complications of rubella infection in first trimester

A

Up to 90%

439
Q

Management of suspected rubella infection in pregnancy

A

Discuss with local Health Protection Unit immediately
Don’t give MMR during pregnancy

440
Q

Congenital rubella syndrome manifestations

A

Sensorineural deafness
Eye abnormalities
Congenital heart disease
LBW

441
Q

What infections are tested for routinely in pregnancy?

A

HIV
Hepatitis B
Syphilis

442
Q

Vertical transmission rate of Hep B without intervention

A

20%
90% if +ve for HBeAg

443
Q

Management of hepatitis B infection in pregnancy + breastfeeding rules

A

HBV IgG and HBV vaccination within 24 hours of delivery
Safe to breastfeed

444
Q

Congenital CMV manifestations

A

LBW
Microcephaly
Seizures
Hearing loss
Vision loss
Petechial rash

445
Q

Congenital chlamydia manifestations

A

Pneumonia
Conjunctivitis
Chorioamnionitis

446
Q

Congenital Parvovirus B19 manifestations

A

Hydrops foetalis
Miscarriage/stillbirth
Hepatomegaly

447
Q

At what point in pregnancy would mothers be at highest risk of intrauterine foetal death should they contract Parvovirus B19?

A

< 20 weeks

448
Q

Congenital VZV manifestations

A

Limb defects
Ocular defects

449
Q

Congenital HSV manifestations

A

Microcephaly
Very LBW
Vesicular rash
Preterm

450
Q

Management of HSV in pregnancy

A

Parenteral acyclovir to baby after birth
Elective C section

451
Q

Congenital syphilis manifestations

A

Blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
Rhagades
Keratitis, saber shins, saddle nose, deafness
Generalised lymphadenopathy
Rash
Hepatosplenomegaly

452
Q

Congenital toxoplasmosis manifestations

A

Hydrocephalus – tense fontanelle
Chorioretinitis – pigmentation and depigmentation on retinal surface
Cerebral calcification

453
Q

Pregnancy: Management of toxoplasmosis infection

A

Spiramycin

Sulfadiazine + pyrimethamine shouldn’t be used late pregnancy

454
Q

Classic caesarean section scar implications

A

Future pregnancies must be elective C section

At 37 weeks
Or 36 weeks for uncomplicated monochorionic twin pregnancy

455
Q

Category 1 C section

A

Immediate threat to life of mother or baby

456
Q

Category 2 C section

A

Within 75 minutes
Compromise but not immediately life-threatening

457
Q

Absolute contraindications to VBAC (vaginal birth after caesarean)

A

Classical caesarean scar
Previous uterine rupture

458
Q

Prophylactic medication for C section

A

Omeprazole

459
Q

Screening tool for postnatal depression

A

Edinburgh scale

460
Q

Management of postpartum psychosis

A

Admission to mother and baby unit

461
Q

Medical management of postnatal depression

A

SSRIs - sertraline or paroxetine
Present in breast milk but not thought to be harmful

462
Q

1st line management of postnatal depression

A

CBT

463
Q

Postpartum psychosis recurrence rate

A

25-50% in future pregnancies

464
Q

Breast cancer screening

A

50-70 every 3 years
After 70 they can make their own appointments
Mammogram

465
Q

Breast cancer 2 ww referral indications

A

> 30 with unexplained breast lump
50 with following symptoms in 1 nipple only: discharge, retraction etc.

Consider if:
There are skin changes suggesting breast cancer
>30 with unexplained lump in axilla

466
Q

Triple assessment breast cancer

A

Clinical examination
Radiological examination
Core needle biopsy

467
Q

BRCA inheritance

A

Autosomal dominant

468
Q

Breast cancer risk factors

A

BRCA1/2
Obesity
Nulliparity, early menarche, late menopause
1st degree relative with premenopausal BC
Combined HRT, COCP
Not breastfeeding
Ionising radiation
p53 gene mutations
Past BC
Previous surgery for benign disease

469
Q

Indications for MRI for breast investigation

A

BRCA gene carriers
Implants
Dense breasts
Li Fraumeni syndrome

Assess extent of lobular variant breast cancer - diffuse spreading pattern

Assess disease prior to neoadjuvant chemotherapy

470
Q

Indications for mastectomy

A

Patient preference
Tumour > 4cm
Multifocal/multicentric
BRCA
Contraindication to radiotherapy
Failed conservation surgery
Inflammatory breast cancer

471
Q

Contraindications to radiotherapy

A

Previous chest radiotherapy
Unable to lie flat
Ataxia telangiectasia homozygotes
Li Fraumeni syndrome

472
Q

ER+ breast cancer hormonal treatment

A

Premenopausal - tamoxifen

Postmenopausal - anastrozole

473
Q

HER+ breast cancer hormonal treatment

A

Trustuzamab (herceptin)

474
Q

Tamoxifen mechanism

A

Oestrogen receptor anatagonist

475
Q

Side effect of tamoxifen

A

Hot flushes
Nausea
Bleeding
Weight gain
DVT risk
En ca

476
Q

Side effect of trustuzamab

A

Cardiac dysfunction
Teratogenicity

477
Q

Anastrozole mechanism

A

Aromatase inhibitor

478
Q

Side effect of anastrozole

A

Hypo-oestrogenism - hot flushes, fatigue, osteoporosis

479
Q

Complications associated with axillary node clearance for breast cancer

A

Lymphoedema

480
Q

Phyllode’s tumour presentation

A

Fast-growing, smooth, hard, mobile mass - often impalpable due to distribution
40s-50s

481
Q

In situ vs invasive histology breast cancer

A

In situ - confined within basement membrane

482
Q

Medullary carcinoma histology

A

Large pleomorphic nuclei - forming sheets of anaplastic cells

483
Q

Mucinous carcinoma appearance

A

Grey, gelatinous surface
Soft consistency

484
Q

Paget’s disease of the nipple

A

Eczema-like rash
Nipple discharge - often bloody
Nipple changes

485
Q

4 causes of nipple discharge

A

Mammary duct ectasia
Intraductal papilloma
Hyperprolactinaemia
Galactorrhoea
Carcinoma
Physiological

486
Q

Mammary-duct ectasia presentation

A

Perimenopausal
Thick, sticky green discharge
Nipple inversion

487
Q

Differentiating duct ectasia and breast abscess

A

Duct ectasia - not hot to touch, typically older

488
Q

Intraductal papilloma presentation + management

A

Single duct discharge
Often clear, can be bloody
Younger patients

Microdocechtomy

489
Q

5 benign breast lumps

A

Fibroadenoma
Fibroadenosis
Mastitis
Breast abscess
Galactocele
Fat necrosis of the breast

490
Q

Galactocele associations

A

Recently stopped breastfeeding
Aspiration shows white fluid
No signs of infection

491
Q

Mastitis risk factors + presentation

A

Breastfeeding/smoking
Swollen, erythematous breast

492
Q

Mastitis 1st management

A

Continue breastfeeding and use simple analgesia + warm compress

493
Q

Mastitis indications for antibiotics + which antibiotics

A

Systemically unwell
Nipple fissure
Symptoms persist past 12-24 hours
Culture indicates infection

Lactational:
Flucloxacillin/erythromycin

Periductal:
Co-amoxiclav

494
Q

Breast abscess causative organism + presentation

A

Complication of mastitis
Staph aureus

Painful erythematous breast

495
Q

Breast abscess management

A

Oral/IV Abx according to local guidelines
Incision and drainage/needle aspiration

496
Q

Fibroadenosis

A

AKA fibrocystic disease causing cyclical mastalgia

497
Q

Radial scar pathophysiology + mammogram findings

A

Idiopathic sclerosing hyperplasia of breast ducts

Star shaped lesion and translucent centre

498
Q

Breast cyst epidemiology + appearance on ultrasound

A

Perimenopausal women
Soft, fluctuant swellings
Distended and involuted lobules

Halo sign

499
Q

Breast cyst management

A

If symptomatic
Aspirate cyst

500
Q

Fibroadenoma features

A

Discrete, non-tender, highly mobile lumps

501
Q

Fibroadenoma management

A

Surgical excision if >3cm

502
Q

Implant rupture ultrasound findings

A

Snowstorm appearance

503
Q

Transgender breast cancer screening

A

Offered after taking feminising hormones for at least 2 years

504
Q

Levonorgestrel mechanism

A

Inhibits ovulation and implantation

505
Q

Levonorgestrel brand names

A

Hana
Levonelle

506
Q

Indications for changing standard dose of levonorgestrel

A

BMI > 26 or weight > 70kg

507
Q

Time frame for levonorgestrel

A

72 hours

508
Q

Restarting contraception after levonorgestrel

A

Immediately

509
Q

Ulipristal mechanism

A

Inhibits ovulation

510
Q

Ulipristal brand names

A

EllaOne

511
Q

Contraindication to ulipristal

A

Asthmatic

512
Q

Time frame for ulipristal

A

120 hours

513
Q

Effect of ulipristal on breastfeeding

A

Delay for one week

514
Q

Restarting contraception after ulipristal

A

Start 5 days after
As hormonal contraception can reduce ability of ulipristal to delay ovulation

515
Q

Most effective form of emergency contraception

A

Intrauterine device

516
Q

Time frame for use of IUD as EC

A

Up to 5 days after UPSI or after likely ovulation date

517
Q

Contraindication to use of IUD

A

STI or PID

518
Q

Contraception delays in fertility

A

Depo: 1 year
COCP: 6 months

519
Q

Mechanism of the implant and depo injection

A

Inhibitis ovulation

Thickens cervical mucus

520
Q

IUS mechanism

A

Suppresses endometrial proliferation

Thickens cervical mucus

521
Q

Implant: time effective + location

A

3-4 years
Subdermal, non-dominant arm

522
Q

Implant: mangement of irregular bleeding

A

3 months of COCP

523
Q

UKMEC 1 contraception for migraine with aura

A

IUD

524
Q

Increased risk associated with COCP

A

DVT
Breast cancer
Cervical cancer

525
Q

Contraindication to oral contraception

A

Gastric sleeve/bypass/duodenal switch

526
Q

Missed pills: POP

A

Take 1 pill
Continue with pack
+ precautions until pill taking re-established for 2/7 days
EC needed if UPSI within 2/7 days of restarting POP

527
Q

Missed pills: POP window times

A

Traditional: 3 hours
Desogestrel: 12 hours
Drospirenone: 24 hours

528
Q

Lamotrigine effect on POP

A

Increases plasma levels of progestogen

529
Q

Best time to start POP in cycle

A

Day 1 drospirenone
Days 1-5 all other POP

530
Q

General switching rules to POP from other contraception

A

UPSI – switch to original contraception for 7 days then restart immediately + 2/7 days precaution

HFI day 1 = cycle day 1

Weeks 2-3 (week 1 is HFI) - start POP immediately (as long as previous 7 days effective)

531
Q

Contraception > 55

A

Not needed even if still bleeding

532
Q

POP follow up appointments

A

10-12 weeks after 1st appointment
Then annually

BP + BMI
Assess for new risk factors
Adverse effects
Taking correctly
Knowledge of managing missed pills
Remind of drug interactions
Advice of LARCs

533
Q

COCP UKMEC 3

A

Smoking < 15 cigarettes, > 35 years old
Age > 35
Immobility
BRCA
Current gallbladder disease
Controlled hypertension
FHx DVT in 1st degree relative < 45 years old

534
Q

COCP UKMEC 4

A

Smoking > 15 cigarettes, > 35 years old
Migraine with aura
History of VTE/stroke/IHD
Breast feeding < 6 weeks postpartum
Current breast cancer
Major surgery with prolonged immobility
Positive antiphospholipid antibodies e.g. SLE

535
Q

Management of COCP before surgery

A

Stop 4 weeks before and then restart 2 weeks after full mobilisation

536
Q

Breast feeding 6 weeks - 6 months on COCP UKMEC score

A

UKMEC 2

537
Q

COCP as post-partum contraception

A

After 3 weeks EXCEPT:

6 weeks if breastfeeding, C section or other VTE risk factors

538
Q

IUD as post-partum contraception

A

< 48 hours or > 4 weeks
Risk of expulsion

539
Q

Implant as post-partum contraception

A

Start any time

540
Q

Lactational amenorrhoea as post-partum contraception

A

If exclusively breastfed (or almost exclusively >85%), can act as contraception for up to 6 months
98% effective

541
Q

When is post-partum contraception needed?

A

21 days post-partum

542
Q

COCP as post-partum contraception

A

Contraindicated
May reduce breast milk production
Wait at least 3 weeks – VTE risk
OR 6 weeks if breastfeeding
After day 21, 7 days additional contraception needed

543
Q

Puerperal pyrexia time frame + management

A

First 14 days post-partum > 38ºc

Antibiotics: IV clindamycin + gentamicin

544
Q

Puerperal pyrexia causes

A

Endometritis
UTI
Wound infections
Mastitis
VTE

545
Q

Exomphalos vs gastrochisis

A

Gastrochisis without peritoneal covering

546
Q

Exomphalos associations

A

Beckwith-Wiedemann syndrome
Down’s syndrome
Cardiac and kidney malformations

547
Q

Exomphalos management

A

Elective C section

Staged repair

548
Q

Thrush in pregnancy management

A

Local treatments

549
Q

BV in pregnancy risk

A

Preterm birth

550
Q

Trichomoniasis pregnancy risk

A

Preterm birth
Vertical transmission
LBW

551
Q

Contraindication to use of oxybutynin for urge incontinence

A

Glaucoma

552
Q

Management of pre-existing hyperthyroidism in pregnancy

A

Stop carbimazole
Start propylthiouracil

553
Q

Chandelier sign

A

Cervical excitation

Medicine (13 decks)

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