Obs and Gynae Flashcards
1
Q
In which conditions may cervical excitation be seen?
A
STI
PID
Ectopic pregnancy
2
Q
What is the difference between endometriosis and adenomyosis?
A
Endometriosis - endometrial tissue outside of uterus
Adenomyosis - invasion of endometrial tissue into myometrium
3
Q
Describe the symptoms of endometriosis.
A
Dyspareunia
Abdominal pain
Menorrhagia
Dyschezia
Chronic pelvic pain
Haematuria
4
Q
How does endometriosis appear on ultrasound?
A
Normal appearance
5
Q
How is endometriosis diagnosed?
A
Laparoscopy with biopsy
6
Q
What is the 1st line treatment for endometriosis?
A
NSAIDs and/or paracetamol
7
Q
What are the 2nd and 3rd line treatments for endometriosis?
A
2nd: Tricyclic OCP or POP
3rd: GnRH agonists
8
Q
What are chocolate cysts?
A
Endometriomas - fill with blood due to response to hormones
9
Q
How is menorrhagia defined?
A
Blood loss considered excessive to the woman
10
Q
Why is transvaginal USS an important investigation to carry out for menorrhagia?
A
Rule out structural abnormalities e.g. fibroids
11
Q
What is dysfunctional uterine bleeding?
A
Bleeding occurring outside of the normal menstrual cycle
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
13
Q
What are the treatment options for menorrhagia if contraception is needed?
A
1st: Mirena IUS
2nd: COCP
3rd: long-acting progestogens
14
Q
What is primary dysmenorrhoea?
A
Menstrual pain which is not associated with pathology - pain before period manifests as suprapubic cramping pains
15
Q
What are the treatment options for primary dysmenorrhoea?
A
1st: NSAIDs e.g. mefenamic acid
2nd: COCP
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
17
Q
Describe the risk factors for developing adenomyosis.
A
Multiparity
Uterine surgery
Previous C section
18
Q
What is the curative management of adenomyosis?
A
Hysterectomy
19
Q
What is an alternative management option of adenomyosis?
A
GnRH agonists
20
Q
How is adenomyosis diagnosed?
A
Histology at hysterectomy
21
Q
How might the uterus appear in a patient with adenomyosis?
A
Enlarged, boggy uterus
22
Q
What is a long term complication associated with the curative treatment of adenomyosis?
A
Vaginal vault prolapse, enterocoele
23
Q
How is vaginal vault prolapse managed?
A
Sacrocolpoplexy
24
Q
What is a fibroid?
A
Benign leiomyoma (smooth muscle tumours) of myometrium
25
What is the curative treatment of fibroids?
Hysterectomy
26
Describe the medical management available for fibroids.
IUS
GnRH agonists
POP, COCP
27
What size is the cut-off for medical management of fibroids?
< 30mm
28
What surgical option is available for fibroids > 30mm with wishes to conserve fertility?
Myomectomy
29
What are the 3 types of fibroids?
Intramural
Sub mucosal
Sub serosal
30
What is the gold standard investigation for fibroids?
TVUSS
31
Appearance of fibroid on ultrasound
Hypoechoic mass
32
Describe the epidemiology of fibroids.
Reproductive age
Afro-Caribbean women
33
What is red degeneration?
Fibroid haemorrhages into tumour - commonly occurs during pregnancy
34
What is a contraindication for IUS use in a patient with fibroids?
The fibroids distort the uterine cavity
35
Describe the pathophysiology of PCOS.
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
36
Describe the epidemiology of PCOS.
5-20% of reproductive age women
37
What is the name of the criteria followed for PCOS diagnosis? What are the criteria?
Rotterdam criteria
Oligomenorrhoea
Hyperandrogenism
Polycystic ovaries
38
Polycystic ovaries - Rotterdam criteria
> 12 cysts on imaging
OR
Ovarian volume > 10 cm3
39
What is the difference between PCOS and PCO?
PCO only fulfills 1 of 3 Rotterdam criteria
40
Describe the potential features of a patient with PCOS.
Hirsutism
High BMI
Oligomenorrhoea
Dysmenorrhoea
Infertility
41
Management of hirsutism due to PCOS
1st: COCP
2nd: Topical eflornithine / Spironolactone
42
Describe the hormone profile results for someone with PCOS.
↑↑ LH : FSH ratio
FSH normal
↑ androstenedione
43
Ovarian hyperthecosis
Hyperandrogenaemia in postmenopausal women
Presence of luteinised theca cell nests in the ovarian stroma
[Testosterone] much higher than in PCOS
44
State 2 methods of ovarian induction.
Letrozole
Clomifene
Gonadotropin therapy
45
Describe the mechanism of letrozole.
Aromatase inhibitor - reduces -ve feedback to pituitary - ↑ FSH
46
Describe the mechanism of clomiphene citrate.
Selective oestrogen receptor modulator (SERM) - acts of hypothalamus and blocks -ve feedback - ↑ GnRH pulse frequency - ↑ FSH & LH
47
Which form of ovarian induction carries the highest risk of ovarian hyperstimulation syndrome?
Gonadotropin therapy
48
What is ovarian hyperstimulation syndrome?
Formation of multiple cystic spaces within enlarged ovaries - fluid shift to extra-vascular space
49
How is OHSS managed?
Fluid & electrolytes
Anti-coagulation therapy
Pregnancy termination
50
What is the most common cause of ovarian enlargement in women of reproductive age?
Follicular cyst
51
What is Meig’s syndrome a triad of?
Fibromas, ascites, pleural effusion
52
What is the most common benign ovarian tumour in women under 25?
Dermoid cyst (teratoma)
53
Which type of ovarian cyst contains Rokitansky’s protuberance on histology?
Dermoid cyst (teratoma)
54
Which cyst, if ruptured, can cause pseudomyxoma peritonei?
Mucinous cystadenoma
55
State an indication that an ovarian cyst should be biopsied.
Irregular solid tumour, ascites, 4 papillary structures or more, irregular multilocular, strong blood flow
56
State 2 complications which can arise from cysts.
Haemorrhagic
Cyst rupture
Ovarian torsion > 5cm
57
Describe the appearance of corpus luteum cysts on ultrasound.
Spider web appearance + ring of fire (blood flowing around cyst)
58
Describe the typical presentation of a ruptured ovarian cyst.
Sudden, severe unilateral pain
Maximal onset
Following sex/strenuous activity
59
Describe what can be seen on ultrasound in ruptured ovarian cysts.
Free fluid in pelvic cavity
60
Describe how corpus luteal cysts form.
Dominant follicle ruptures but closes again
61
Describe how follicular cysts form.
Dominant follicle fails to rupture
Normal LH surge doesn’t happen
62
Describe how theca lutein cysts form.
Pregnancy, usually bilateral
Overstimulation of hCG – growth of theca cells
More likely to develop in GTD and multiple pregnancy
63
How is ovarian torsion managed?
Laparoscopic detorsion
/ salpingo-oophorectomy
64
State 3 risk factors for ovarian torsion.
Reproductive age
Pregnancy
OHSS
65
What may be visible on ultrasound of the ovaries in ovarian torsion?
Oedema + blood pooling
Whirlpool sign
66
What is the most common type of ovarian cancer?
Serous epithelial ovarian cancer - 90%
Post-menopausal women
67
Most common type of ovarian cancer in pre-menopausal women
Germ cell ovarian tumour
68
Appearance of serous cystadenoma on histology
Psammoma bodies
Nuclear atypia
Complex papillary architecture
69
5 risk factors for the development of ovarian cancer.
Postmenopausal
Endometriosis
PCOS
BRCA1/2
Nulliparity / late menopause / early menarche
HNPCC (Lynch syndrome)
70
3 symptoms of ovarian cancer.
Bloating
Early satiety
Diarrhoea
Pelvic/abdominal pain
Mass
71
What investigation is 1st line for ovarian cancer?
CA125
72
Which investigation is diagnostic for ovarian cancer?
Diagnostic laparotomy + biopsy
73
How should suspected ovarian cancer be managed?
CA125 first, if mass/ascites if present then urgent referral to gynae
74
3 signs of metastatic disease of epithelial ovarian cancer.
Ascites
Pleural effusion
Lymphadenopathy
75
2 protective factors of ovarian cancer.
COCP
Multiparity
Breastfeeding
76
3 benign causes of raised CA125.
Endometriosis
Menstruation
Benign ovarian cysts
Ascites
Diverticulosis
Heart failure
Fibroids
77
2 germ cell tumours
Teratoma
Dysgerminoma
Yolk sac tumour
Choriocarcinoma
78
2 sex cord-stromal tumours
Thecoma
Fibroma
Granulosa cell tumour
Sertoli Leydig tumour
79
4 risk factors for endometrial cancer
Tamoxifen
PCOS
HNPCC
Obesity
Diabetes
Nulliparity / late menopause
HRT
Pelvic irradiation
80
2 protective factors of ovarian cancer
Multiparity
COCP
81
Classical symptom of endometrial cancer
Post menopausal bleeding - 10% will be EC
82
Differential for PMB
Atrophic vaginitis
83
How should suspected endometrial cancer be managed?
Urgent 2ww referral to gynae
84
What are the 1st and 2nd line investigations for endometrial cancer?
1st: TVUSS
2nd: hysteroscopy with endometrial biopsy
85
How can localised endometrial cancer be managed?
Hysterectomy with bilateral salpingo-oophorectomy
86
Which HPV serotypes are associated with cervical cancer?
16, 18 and 33
87
3 risk factors for cervical cancer
Early first intercourse
Multiparity
COCP
STIs
Smoking
88
Which oncogenes are inhibited by HPV? Which genes are affected by the oncogenes?
16 inhibits E6 - inhibits p53 TSG
18 inhibits E7 - inhibits RB TSG
89
What is the screening timetable for cervical cancer?
3 yearly: 25-49 years old
5 yearly: 50-64 years old
90
How should an inadequate sample be managed in cervical cancer screening?
Repeat 3 months
91
How should 2 inadequate samples be managed in cervical cancer screening?
Colposcopy
92
How should a positive HPV sample with normal cytology be managed in cervical cancer screening?
Repeat 12 months
93
How should abnormal cytology in cervical cancer screening be managed?
Colposcopy
94
How should 2 repeat HPV +ve samples with normal cytology be managed in cervical cancer screening?
Colposcopy
95
How is CIN 1 treated?
Conservative
Repeat cytology 6/12/24 months later
96
CIN 1 regression rate
57% regress
97
How is CIN 2/3 treated?
LLETZ - large loop excision of transformation zone
98
What is considered in RMI in ovarian cancer investigations?
Risk of malignancy index:
CA125
USS findings
Menopausal status
99
How should HIV +ve patients be followed up for cervical screening?
Annual cytology
100
What is the most common type of vulval cancer?
Squamous cell carcinoma
80%
101
3 risk factors for vulval cancer
HPV
Immunosuppression
Lichen sclerosis
VIN
> age
102
Which HPV serotypes are associated with vaginal cancer?
6 and 11
103
Classic triad of presentation of vulval cancer
Older woman
Labial lump
Inguinal lymphadenopathy
104
Where is an ectopic pregnancy most likely to be?
Ampulla
105
Which location is an ectopic pregnancy associated with the greatest mortality due to rupture risk?
Isthmus
? /interstitium
106
6 risk factors for ectopic pregnancy
Damage to tubes e.g. STI/PID
IUS/IUD
Endometriosis
Age < 18 first intercourse
IVF
Smoking
POP
Black race
107
Describe the pain associated with ectopic pregnancy.
Constant
1st symptom
Lower abdominal
108
Gold standard investigation for ectopic pregnancy
TVUSS
109
Contraindication to medical management for ectopic pregnancy
Liver and renal dysfunction are contraindications to use of methotrexate
110
3 indications for surgical management of ectopic pregnancy
Size > 35mm
Foetal heartbeat present
hCG > 5000IU/L
111
2 surgical options for ectopic pregnancy + which is 1st line + exception
1st: Salpingectomy - removal of fallopian tube (unless other tube is compromised + patient wishes to conserve fertility)
2nd: Salpingotomy - creation of opening in fallopian tube
112
How often is hCG measured after surgery for ectopic pregnancy?
Salpingectomy - single measurement after
Salpingotomy - weekly until undetectable
113
When is anti-D indicated in the management of ectopic pregnancy?
Surgical management
Rhesus -ve mother
114
Medical management for ectopic pregnancy
Methotrexate
115
hCG values for management in ectopic pregnancy
< 1000 - expectant
< 1500 - medical
> 5000 - surgical
116
Complete hydatidiform mole karyotype
46 (all paternal) XX or XY
Empty egg fertilised by 1 sperm that duplicated or by 2 sperm
117
Partial hydatidiform mole karyotype
69 XXX or XXY or XYY
Ovum fertilised by 2 sperm
118
Clinical manifestations of hydatidiform mole
Exaggerated pregnancy symptoms - hyperemesis
Uterus large for gestational age
Less common:
HTN
Hyperthyroidism
Ovarian cysts
Pre-eclampsia < 20 weeks gestation
119
Ultrasound appearance of hydatidiform mole - compare complete and partial
Snowstorm appearance
Complete: no foetal tissue
Partial: foetal tissue present
120
How long should conception be avoided after a hydatidiform mole?
12 months
121
How should patients be managed after molar pregnancies are initially managed?
Partial: measure hCG 4 weeks later
Complete: measure monthly for 6 months
122
What complications can arise as a result of molar pregnancies?
Choriocarcinoma
123
How does choriocarcinoma present?
Heavy bleeding in womb
o To lungs: coughing etc.
o To abdomen: stomach pain etc.
o To vagina: heavy bleeding, lump etc.
124
Why may hyperthyroidism be seen in a patient with a gestational trophoblastic disorder
hCG mimics TSH
125
How should miscarriage be followed up after treatment?
Pregnancy test 3 weeks later (after medical/surgical treatment or bleeding subsides after expectant)
Return to hospital if present
126
Explain the mechanism of misoprostol for miscarriage
Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contraction – expulsion
127
Contraindication to medical management for miscarriage
Infection
Coagulopathy PMH / increased risk of haemorrhage (past 1st trimester)
Previous adverse experience with pregnancy e.g. stillbirth, miscarriage
Late 1st trimester
(NICE)
128
Medical management for miscarriage
Misoprostol
129
Threatened miscarriage
Cervical os closed
Normal gestational sac
Painless vaginal bleeding
130
Incomplete miscarriage
Process ongoing
Not all PoC removed
Pain and bleeding
Cervical os open
131
At what stage has incomplete miscarriage progressed to complete miscarriage?
When all products of conception have passed through
And when cervical os is closed
132
Missed (delayed) miscarriage
Asymptomatic usually
Foetus dead
Cervical os closed
133
Inevitable miscarriage
Cervical os open
Heavy bleeding with clots + pain
Leads to eventual complete miscarriage
134
2 methods of surgical management of miscarriage.
Manual vacuum aspiration - local anaesthetic
Electric vacuum aspiration - general anaesthetic
135
How long after miscarriage can a pregnancy test remain positive?
4 weeks
136
Asherman's syndrome
Intrauterine adhesions following dilation and curettage
Prevents endometrium from responding to oestrogen normally
Menstrual disturbance, infertility or recurrent pregnancy loss
137
Medication for recurrent miscarriage due to antiphospholipid syndrome
LMWH and aspirin
138
5 risk factors for miscarriage
Age > 35
Previous miscarriage
Chronic conditions e.g. T1DM
Uterine/cervical problems
Smoking/alcohol/illicit drugs
Under/overweight
Invasive prenatal tests
139
Termination of pregnancy management
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
140
When is anti-D indicated in termination of pregnancy?
Rhesus -ve and > 10 weeks
141
Diagnosing menopause
Retrospective
1 year amenorrhoea
142
Pathophysiology of menopause
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
143
Risk of unopposed oestrogen HRT
Endometrial cancer
144
Risk of combined oestrogen and progesterone HRT
Decreased risk of EC
Increased risk of BC
Increased stroke
Increased IHD
145
2 contraindications to HRT
Current, past or suspected breast cancer
Undiagnosed vaginal bleeding
146
Indication for transdermal HRT
Patient preference
DVT history
147
HRT and colorectal cancer risk
Decreased risk
148
How long is contraception for if going through menopause?
Needed for:
24 months if < 50,
12 months if > 50
149
Stress incontinence medical management
Duloxetine
150
Urge incontinence medical management
1st: Oxybutynin
2nd: Mirabegron
151
Mechanism of duloxetine
Increases synaptic [noradrenaline and serotonin] within pudendal nerve - increases stimulation of urethral striated muscles within sphincter
152
Mechanism of oxybutynin
M3 antagonist
153
Contraindication to use of oxybutynin for urge incontinence
Glaucoma
154
Mechanism of mirabegron
Beta 3 agonist
155
How long should pelvic floor training be carried out for before moving to medical management for stress incontinence?
3 months
156
How long should bladder retraining be carried out for before moving to medical management for urge incontinence?
6 weeks
157
Why is urine dipstick and culture carried out for incontinence?
Rule out UTI and DM (neurogenic bladder)
158
What investigation should be carried out if a patient presents with incontinence alongside a history of prolonged labour?
Urinary dye studies due to risk of fistula
159
Management of urogenital prolapse
No treatment if asymptomatic
1st: conservative - pelvic floor exercises, weight loss
2nd: vaginal pessary
3rd: surgical
160
Urogenital prolapse: anterior vaginal wall
Cystocele: bladder (may lead to stress incontinence)
Urethrocele: urethra
Cystourethrocele: both bladder and urethra
Colporrhapy
161
Urogenital prolapse: posterior vaginal wall
Enterocele: small intestine
Rectocele: rectum
Posterior colporrhaphy
162
Urogenital prolapse: apical vaginal wall
Uterine prolapse: uterus
Hysterectomy/sacrohysteropexy
Vaginal vault prolapse: roof of vagina (common after hysterectomy)
Sacrocolpoplexy
163
Most common causative organism of PID
Chlamydia trachomatis
164
Pathophysiology of PID
Ascending infection from endocervix
165
Presentation of PID
Deep dyspareunia
Fever
Lower abdominal pain
Dysuria
Discharge
166
Confirmatory diagnosis PID
High vaginal swab for STIs
167
Antibiotics used in PID
IM ceftriaxone and oral doxycycline and metronidazole
OR
Oral ciprofloxacin and metronidazole
168
How should IUS/IUD be managed in PID?
Leave in situ if infection present
169
Indication for admission with PID
Temp > 38
170
What is Fitz-Hugh-Curtis syndrome?
Perihepatitis arising from inflammation of liver capsule
171
Fitz-Hugh-Curtis syndrome investigations
USS to rule out stones
Normal LFTs
Laparoscopy shows adhesions
172
What advice for conception would you give to a couple?
Folic acid
Intercourse 2-3x a week
Healthy weight
Smoking cessation
173
2. Name 3 genetic conditions which affect fertility.
CF
Turner's
Kallman's
174
Give 3 examples of tubal causes of infertility.
Infections
Endometriosis
Iatrogenic
175
When should a semen analysis be repeated if results are abnormal?
After 3 months
176
How long should someone be abstinent before semen analysis?
3-5 days of abstinence
177
Factors which warrant early referral for infertility F/M
F
> 35 years old
Menstrual disorder
Previous surgery
Previous STI/PID
M
Genital pathology
Previous STI
Systemic illness
Abnormal genitalia examination
178
Class 1 ovulatory disorder
Hypogonadotropic hypogonadal anovulation
179
Class 2 ovulatory disorder
Normogonadotropic normoestrogenic anovulation
PCOS
180
Class 3 ovulatory disorder
Hypergonadotropic hypoestrogenic anovulation
Premature ovarian insufficiency
Require IVF in most cases
181
Ovarian induction 1st, 2nd and 3rd line
Exercise and weight loss
Letrozole
Clomiphene citrate
182
Letrozole side effect
Fatigue
Dizziness
183
Clomiphene citrate side effect
Hot flushes
184
How many weeks of amenorrhoea are needed to diagnose premature ovarian syndrome?
4 months
185
Diagnosis of premature ovarian syndrome
FSH >30IU/L
2 samples 4-6 weeks apart
186
Management of premature ovarian syndrome
Cyclical combined HRT until 51 years old
187
3 causes of secondary amenorrhoea
Sheehan syndrome
Asherman syndrome
Prolactinoma
Anorexia nervosa
188
Sheehan syndrome hormone profile
Low FSH, LH, ACTH
Low cortisol, oestradiol
Low or normal TSH and low T3/4
189
Sheehan syndrome hormone profile
Low FSH, LH
Low oestradiol
Normal TFTs
190
Sheehan syndrome hormone profile
Low FSH, LH, ACTH
Low cortisol, oestradiol
Low or normal TSH and low T3/4
191
Most common cause of post-coital bleeding
Ectropion
192
Cervical ectropion pathophysiology
Transformation zone: stratified squamous epithelium meets columnar epithelium of the cervical canal
Larger area of columnar epithelium on ectocervix due to elevated oestrogen levels
193
Management of PMS
1st: Regular high-carb meals
2nd: New generation COCP e.g. Yasmin
3rd: SSRI if severe
194
Primary amenorrhoea + regular painful cycles
Imperforate hymen
195
Causes of primary amenorrhoea
Constitutional delay
Imperforate hymen
Turner's syndrome
Androgen insensitivity syndrome
Mayer-Rokitansky-Küster-Hauser syndrome
196
Management of androgen insensitivity syndrome
Raise as female
Bilateral orchidectomy
Oestrogen therapy
197
Karyotype of androgen insensitivity syndrome
46 XY
198
Presentation of androgen insensitivity syndrome
Groin swellings - undescended testes
Primary amenorrhoea
Tall + long limbs
199
Risk associated with untreated primary amenorrhoea
Osteoporosis
200
Inheritance of androgen insensitivity syndrome
X-linked recessive
201
Bartholin's gland location and function
Within vestibule, lateral to introitus
Secretes lubricating fluid
202
Bartholin's gland cyst presentation
Duct becomes blocked
Palpable swelling and pain at site
203
Bartholin's gland abscess presentation
Cyst becomes infected, extreme pain and erythema
Rarely, systemic upset
204
Bartholin's gland cyst management
Non-surgical: Insertion of balloon catheter
Surgical: Marsupialisation - incision and drainage, stitches to make permanent opening
205
Bartholin's cyst infection: most likely organism
E. Coli
206
Combined test for Down's syndrome + results + week
PAPP-A - down
Thickened nuchal translucency
HCG - up
11-13+6 weeks
207
Triple/quadruple test for Down's syndrome + results + week
HCG - up
Inhibin-A (QUADRUPLE) - up
AFP - down
Oestriol - down
15-20 weeks
208
Chorionic venous sampling - weeks + risks
11-13 weeks
Risk of foetal limb abnormalities
209
Amniocentesis - weeks + risks
15-20 weeks
Miscarriage
210
3 causes of raised AFP during antenatal screening
Multiple pregnancy
Neural tube defects
Abdominal wall defects
Patau syndrome
211
3 causes of thickened nuchal translucency
Down's
Congenital heart defect
Abdominal wall defect
212
3 causes of hyperechogenic bowel
CF
Down's
CMV infection
213
Quadruple test results for neural tube defects
Raised AFP
Normal inhibin A, HCG and oestriol
214
Quadruple test results for Edward's syndrome
HCG - down
Inhibin-A - normal
AFP - down
Oestriol - down
215
4 causes of folic acid deficiency
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
Obesity
216
When is a higher dose of folic acid indicated?
5mg if higher risk of neural tube defects
BMI > 30
Antiepileptic medication
Coeliac disease
Diabetes
Thalassaemia trait
History of NTD
217
Management of lithium in pregnancy
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
218
How long is folic acid taken for in pregnancy?
Until 12 weeks pregnant
219
How long is vitamin D taken for in pregnancy?
Throughout pregnancy
220
Hb cut off for iron supplementation in 1st trimester
110
221
Hb cut off for iron supplementation in 2nd and 3rd trimester
105
222
Hb cut off for iron supplementation in postpartum period
100
223
Booking visit
8-12 weeks
Bloods
Urine dipstick
BMI
1st screen for anaemia
Test for HIV, syphilis, Hep B, rubella
224
Naegele's rule
LMP + 9 months + 7 days ( I think?)
225
Early scan
10-13+6 weeks
Confirm dates
Exclude multi pregnancy
226
Anomaly scan
18-20+6 weeks
227
Anti-D routine doses in pregnancy
28 weeks
34 weeks
Any other sensitising event
228
Vaccines in pregnancy
Pertussis
Influenza
229
Absolute contraindications to breastfeeding
Mother has TB
Mother has unmonitored HIV
230
Symphysis-fundal height
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
Drugs to avoid when breastfeeding
Aspirin
Amiodarone
Benzodiazepines
Carbimazole
Ciprofloxacin
Codeine
Lithium
Methotrexate
Naproxen
Tetracyclines
Sulphonamides
Sulphonylureas
232
Pregnancy-induced hypertension
HTN > 20 weeks gestation
233
Epidemiology of pre-eclampsia
5% all pregnancies
234
High-risk factors for pre-eclampsia
CKD
HTN previous pregnancy
Autoimmune disorder
T1DM / T2DM
Chronic HTN
235
Moderate risk factors for pre-eclampsia
Primiparous
Multiple pregnancy
Age > 40
BMI > 35
FHx pre-eclampsia
Pregnancy interval > 10 years
236
PLGF
Placental growth factor
Gold standard? in diagnosing pre-eclampsia
237
Moderate risk factors for pre-eclampsia
Primiparous
Multiple pregnancy
Age > 40
BMI > 35
FHx pre-eclampsia
Pregnancy interval > 10 years
238
Medication for pre-eclampsia / pregnancy-induced hypertension
1st: Labetalol
2nd: Nifedipine
239
Blood pressure values in pre-eclampsia
>140/90
OR
>30 systolic / >15 diastolic from baseline
240
Clinical manifestations of pre-eclampsia
Hyperreflexia
Headache
Oedema
Reduced foetal movements
241
How is eclampsia treated?
MgSO4
Delivery is the most important
242
Medication to reverse respiratory depression caused by MgSO4
Calcium gluconate
243
Medication for those high-risk of pre-eclampsia
Aspirin from 12 weeks onwards
244
Monitoring of pre-eclampsia
LFTs, FBC, U&Es 3x a week
245
1st step management of pre-eclampsia
Emergency referral to obstetrics
246
Blood results of acute fatty liver
High LFTs: rise in ALT/AST higher than ALP
High WCC
247
Presentation of acute fatty liver of pregnancy of pregnancy
N+V
Jaundice
RUQ pain
DIC
Oliguria
248
HELLP syndrome
Haemolysis
Elevated liver enzymes
Low platelets
249
Management of HELLP syndrome
Delivery
250
Which rhesus status needs treatment?
Rhesus negative
251
3 sensitisation events
Placental abruption
Trauma
Amniocentesis
Ectopic pregnancy
Miscarriage/ToP/intrauterine death
Vaginal bleeding > 12 weeks
Vaginal bleeding with pain
252
Pathophysiology of rhesus disease
Rhesus -ve mum produced antibodies against rhesus +ve baby antigens
Can attack baby's RBCs and cause haemolytic disease during sensitising events
253
Kleihauer test
Used during sensitising events
To gauge the dose of anti-D required
254
Anaemia cut-offs in pregnancy
1st trimester < 110
2nd/3rd trimester < 105
Postpartum < 100
255
Anaemia screening in pregnancy
Booking visit
28 weeks
256
Treatment of anaemia in pregnancy
Oral ferrous sulphate until 3 months after deficiency is corrected
257
Management of chickenpox exposure < 20 weeks
VZIG within 10 days of contact and before rash
If rash developed - give oral aciclovir
258
Management of chickenpox exposure > 20 weeks
Aciclovir within 10 days contact or 24 hours of rash
259
Management of foetus infected with chickenpox
IV acyclovir following delivery
260
Amniotic fluid embolism associated risk factors
SROM while inducing
Increasing age
261
Amniotic fluid embolism symptoms
Sweating
Anxiety
Cyanosis
Coughing
262
How is amniotic fluid embolism managed?
ABCDE
Oxygen
263
When should foetal movements be established by?
24 weeks
264
1st line management of reduced foetal movements
Handheld doppler
265
2nd line management of reduced foetal movements
No heartbeat: USS
Heartbeat: CTG 20 minutes
266
Management of bacteriuria in pregnancy
Confirm with second culture
Begin culture dependent antibiotic
267
Risks associated with asymptomatic bacteriuria
Premature labour
Spontaneous miscarriage
268
Antibiotics for UTI in pregnancy
1st: nitrofurantoin but avoid at term
2nd: amoxicillin / cefalexin
amoxicillin - only if culture results available
for 7 days
269
Risk associated with trimethoprim in pregnancy
Neural tube defects
270
Risk associated with nitrofurantoin in pregnancy
3rd trimester - can cause haemolysis of the newborn
271
Investigating PE in pregnancy
ECG + CXR
If DVT diagnosed no more investigations needed for PE
272
Investigating DVT in pregnancy
Duplex ultrasound
273
How is DVT treated in pregnancy?
LMWH
274
Major risk factors for VTE in pregnancy
Previous unprovoked VTE
Admission for hyperemesis gravidarum
OHSS
275
Regular risk factors for VTE in pregnancy
BMI > 30
Parity > 3
Smoker
Varicose veins
Current pre-eclampsia
Immobility
FHx unprovoked VTE
Low risk thrombophilia
IVF
276
Indications for LMWH for prophylaxis of VTE
3 regular risk factors
LMWH from 28 weeks
4 regular risk factors or 1 major risk factor
LMWH from LMP
277
Monitoring of LMWH in pregnancy
Anti-Xa assay
278
Causes of cord prolapse
Abnormal presentation
PROM
Multiple pregnancy
Polyhydramnios
IUGR
Placenta praevia
AROM
279
Pathophysiology of AROM causing cord prolapse
Baby not engaged in pelvis when membrane is ruptured
Cord suspends below baby to become compressed
280
Management of cord prolapse
Shout for help
Push presenting part of foetus back to avoid compression
All fours
Tocolytics
Infuse fluid into bladder
C-section
281
Handling cord in cord prolapse
Don't do this!
Associated with vasopasm which can lead to foetal hypoxia
282
How is occult cord prolapse managed?
Left lateral position
Normal delivery unless foetal distress
283
Transverse lie epidemiology
1 in 300 at term
284
Risk factors for transverse lie
Polyhydramnios
Foetal abnormalities
Multiple pregnancy
Prematurity
Fibroid/other pelvic tumours
285
Transverse lie abdominal palpation
Head and buttocks not palpable at each end of uterus
286
Management of transverse lie beyond 36 weeks
ECV up to early labour if amniotic sac intact
Otherwise elective C section
287
2 contraindications to ECV
ROM in last 7 days
Multiple pregnancy (except 2nd twin)
Major uterine abnormality
Oligohydramnios
288
Which malpresentation is associated with highest morbidity and mortality?
Footling breech
289
Risk factors for malpresentation
Polyhydramnios
Fibroids
Preterm
Foetal abnormality
Placenta praevia
290
When is ECV offered to women
36 weeks primiparous
37 weeks multiparous
291
Complication of ECV
Placental abruption
292
Breech epidemiology
25% of pregnancies at 28 weeks
3% term
293
Types of breech
Footling
Frank
Complete
Incomplete
294
Oligohydramnios AFI
< 5 cm
295
Definition of SGA
< 10th centile
296
Difference between SGA and IUGR
SGA - compared to population
IUGR - compare to parent heights
297
Causes of symmetrical vs asymmetrical IUGR
Symmetrical:
Infection
Asymmetrical:
Pre-eclampsia
Renal/cardiac disease
Substance abuse
298
Causes of oligohydramnios
PROM
Post-term gestation
IUGR
Foetal renal agenesis
Uteroplacental insufficiency - smoking
299
Oligohydramnios vs polyhydramnios abdominal palpation
Poly: difficult to feel foetal parts
Oligo: foetal parts feel more prominent
300
Potter sequence clinical manifestations
Bilateral renal agenesis
Oligohydramnios
Pulmonary hypoplasia
Downward epicanthal folds
301
Describe the mechanism by which oligohydramnios can cause foetal pulmonary hypoplasia
Amniotic fluid needed for foetal lung development
302
Causes of polyhydramnios - excessive production of amniotic fluid
Maternal DM
Macrosomia
Foetal renal disorder
Foetal anaemia
Twin-to-twin transfusion syndrome
303
Causes of polyhydramnios - insufficient removal of amniotic fluid
Oesophageal/duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
304
Most common cause of polyhydramnios
Idiopathic 50%
305
Polyhydramnios AFI
> 25cm
306
Polyhydramnios maternal complications
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
Polyhydramnios foetal complications
Pre-term labour and delivery
Premature rupture of membranes
Placental abruption
Malpresentation of foetus
Umbilical cord prolapse
308
Twin-to-twin transfusion syndrome prevalence
10-15% of monochorionic pregnancies
309
Twin-to-twin transfusion syndrome pathophysiology
Anastomoses of umbilical vessels
310
Twin-to-twin transfusion syndrome risks (donor and recipient comparison)
Both - HF & hydrops foetalis
Donor - high output cardiac failure
Recipient - fluid overload
311
Twin-to-twin transfusion syndrome prognosis
High mortality for both but donor more likely to survive
312
Twin-to-twin transfusion syndrome management
Laser transection of vessels in utero
313
How many attempts should be made with instrumental delivery before resorting to LSCS?
3 pulls attempted
314
Requirements for instrumental delivery
Fully dilated cervix - 2nd stage of labour reached
OA position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty - catheterisation
315
Which form of instrumental delivery is most likely to cause haemorrhage in newborn?
Ventouse
316
Caput succedaneum
Crosses Suture lines
Resolves within days (Calms Soon)
Present at birth
317
Cephalohaematoma
Parietal region usually, doesn't cross suture lines
Months to resolve
Develops several hours after birth
318
Risk factors for placental abruption
Pre-eclampsia
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age
Polyhydramnios
319
Typical placental abruption presentation
Woody/tense uterus
Pain + PV bleeding
320
Importance of monitoring glucose when giving steroids
Steroids can cause hyperglycaemia in diabetics
321
Management of placental abruption < 34 weeks
Immediate C section in foetal distress
Steroids and close observation if no foetal distress
322
Investigation of choice for placenta praevia
TVUSS
323
Diagnosis of placenta praevia
20 week anomaly scan
324
Follow-up management for placenta praevia after diagnosis
TVUSS at 32 weeks
Elective C section
325
Risk factors for placenta praevia
Previous placenta praevia
Previous C section (embryo more likely to implant on lower segment scar)
Endometrium damage
Multiple pregnancy
Maternal smoking
IVF
326
Presentation of placenta praevia
Painless bleeding
327
Patient presents with painless bleeding after 24 weeks which has not stopped - how should they be managed?
C section
328
Patient presents with painless bleeding after 24 weeks which has since stopped - how should they be managed?
Admit for observation
329
Grade I placenta praevia
Placenta reaches lower segment but not internal osf
330
Grade II placenta praevia
Placenta reaches internal os but does not cover it
331
Grade III placenta praevia
Placenta covers internal os before dilation
332
Grade IV placenta praevia
Placenta completely covers internal os
333
What is vasa praevia?
Foetal blood vessels run close to orifice of uterus
334
Typical presentation of vasa praevia
Following ROM
Foetal bradycardia
Vaginal bleeding
335
Placenta accreta
Chorionic villi attach onto myometrium
336
Risk factors for placenta accreta
Previous uterine surgery
Maternal age > 35
IVF
Previous PID/STI
337
Placenta increta
Chorionic villi invade into myometrium
338
Placenta percreta
Chorionic villi invade through myometrium
339
Placenta accreta management
Elective C-section and hysterectomy
Delay placental delivery in 3rd stage
340
Risk factors for placenta accreta
C section
Pelvic inflammatory disease
341
Shoulder dystocia risk factors
Macrosomia (maternal DM)
Previous Hx
Obesity
342
Most common mechanism of shoulder dystocia
Anterior shoulder impacted behind pubic symphysis
343
Management of shoulder dystocia
Call for help
Stop pushing
McRobert's - legs hyperflexed at hips
Internal manoeuvres
Switch to all fours and repeat
Cleidotomy
Zanvanelli manoeuvre
Symphysiotomy
344
Complications of shoulder dystocia
Brachial plexus injury
Cerebral palsy
Perinatal mortality
PPH
Periventricular damage
345
Periventricular damage
Hypoxia during prolonged delivery
Causes spastic diplegia - scissor walking
346
Labour monitoring - foetal heart rate
Every 15 minutes with Pinard
Or continuously with CTG
347
Labour monitoring - contractions
Every 30 minutes
348
Labour monitoring - maternal pulse
Every hour
349
Labour monitoring - maternal BP and temp
Every 4 hours
350
Labour monitoring - maternal urine
Every 4 hours
Ketones and protein
351
Labour stage 1
Onset of true labour to when the cervix is fully dilated
352
Contractions during first stage of labour
Latent: ~1 minute every 3-5 minutes
Active: 60-90 seconds every 0.5-2 minutes
353
Cervical dilation during first stage of labour
Latent: 0-3cm
Active: 6-10cm
Primiparous 0.5cm per hour
Multiparous 1cm per hour
354
Foetal movements in second stage labour
Descent
Engagement
Flexion
Internal rotation
Extension
Restitution
Expulsion
355
Timing classification of prolonged second stage labour
Nulliparous > 3 hours with epidural, 2 without
Multiparous > 2 hours with epidural, 1 without
356
Physiological third stage labour timing
30 minutes - 1 hour
357
Signs of third stage labour
Gush of blood
Lengthening of umbilical cord
Ascension of uterus in abdomen
358
What is cord traction?
Controlled cord traction in 3rd stage
Oxytocin
359
Complications of cord traction for third stage labour
Uterine inversion
PPH
360
CTG: normal HR
110-160
361
CTG: normal variability
5 to 25
362
CTG: causes of baseline tachycardia
Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity
363
CTG: causes of baseline bradycardia
Maternal beta-blocker use
Increased foetal vagal tone
364
CTG: early deceleration
Head compression
365
CTG: late deceleration
Placental insufficiency
366
Bishop score components
Pregnancy Can Enlarge Dainty Stomachs
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Foetal station
367
Management options for induction of labour
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
Induction of labour complication
Uterine hyperstimulation
369
Uterine hyperstimulation features
> 5 contractions in 10 minutes
370
Uterine hyperstimulation complication
Uterine rupture
371
Uterine hyperstimulation management
Remove vaginal prostaglandins/stop oxytocin
Tocolysis with terbutaline
372
Investigation of premature rupture of membranes
Sterile speculum examination
- Pooling of amniotic fluid in posterior vaginal fault
373
Management of premature rupture of membranes
10 day oral erythromycin
Steroids
374
1st line tocolytic for pre-term labour
Oral nifedipine
375
When can tocolytics be used?
24-33+6 weeks
376
PPROM vs PROM
PPROM - preterm and prelabour
PROM - prelabour
377
Maternal complication of PROM
Chorioamnionitis
378
Presentation of chorioamnionitis
Pyrexia
Foul smelling discharge
Uterine tenderness
Baseline foetal tachycardia
379
Management of chorioamnionitis
IV antibiotics broad spectrum
Prompt delivery/C section
380
Risk of using co-amoxiclav in pregnancy
Necrotising enterocolitis
381
Diagnostic criteria for hyperemesis gravidarum
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
382
RCOG admission guidelines for hyperemesis gravidarum
Ketonuria and/or weight loss 5%
Unable to keep down anti-emetics
Comorbidity e.g. UTI
383
Hyperemesis gravidarum + ataxia/confusion/opthalmoplegia
Wernicke's encephalopathy
384
Protective factor for hyperemesis gravidarum
Smoking
385
Risk factors for hyperemesis gravidarum
Multiple pregnancy
Trophoblastic disease
Obesity
Primiparous
Hyperthyroidism
386
Hyperemesis gravidarum scoring system
PUQE - pregnancy unique quantification of emesis scoring system
387
IV fluids used for hyperemesis gravidarum
Saline + correct electrolyte deficiency
388
Consequences of using dextrose for hyperemesis gravidarum
Can precipitate Wernicke's encephalopathy
389
1st line medication for hyperemesis gravidarum
Cyclizine
Promethazine (prochlorperazine alternative)
390
2nd line medication for hyperemesis gravidarum
Metoclopramide
Ondansetron
391
Hyperemesis gravidarum epidemiology
1% of pregnancies
392
Caution when taking metoclopramide for hyperemesis gravidarum
Avoid use for > 5 days - extrapyramidal side effects
393
Caution when taking ondansetron for hyperemesis gravidarum
1st trimester - cleft palate risk
394
Perineal tears medical management
Laxatives
Pain relief
395
1st degree perineal tear + management
Vaginal mucosa
No management needed
396
2nd degree perineal tear + management
Perineal muscle
Suturing on ward
397
3rd degree perineal tear (a, b, c) + management
Extends to external anal sphincter
Repair in theatre
398
4th degree perineal tear + management
Anal sphincter + rectal mucosa
Repair in theatre
399
Most common cause of antepartum haemorrhage
50% idiopathic
400
Time classification of antepartum haemorrhage
> 24 weeks pregnant
401
Causes of antepartum haemorrhage
Idiopathic 50%
Placenta praevia
Placenta abruption
Cervical ectropion
Vasa praevia
402
Postpartum haemorrhage volume classification
Primary > 500ml
Secondary > 1000ml
403
Postpartum haemorrhage timing classification
Primary within 24 hours
Secondary within 24 hours - 3 months
404
Most common cause of postpartum haemorrhage
Uterine atony
405
Management of uterine atony
Bimanual massage
Oxytocin
Carboprost
Ergometrine
Misoprostol PR
Intrauterine balloon tamponade
Haemostatic suturing
406
Contraindication to carboprost
Asthma
407
Causes of PPH
Tissue - retained PoC
Tone - uterine atony
Trauma - instrumental delivery, macrosomia
Thrombin - coagulopathy
408
PPH leading to impaired milk production causes...
Sheehan's syndrome
409
Obstetric cholestasis epidemiology
1%
3rd trimester
Most common cause of liver disease of pregnancy
410
Obstetric cholestasis management
Ursodeoxycholic acid - symptomatic
Weekly LFTs, bilirubin (check guidance)
Induction at 37 weeks
Vitamin K at birth
411
Postnatal management of obstetric cholestasis
Follow up with LFTs 4 weeks postnatally to ensure resolution
412
Risks associated with obstetric cholestasis
Stillbirth - higher bile acid levels and comorbidiites increase risk
Prematurity
Recurrence
413
Itch in pregnancy differentials
Obstetric cholestasis
Atopic eruption of pregnancy
Polymorphic eruption of pregnancy
Pemphigoid gestationis
414
Polymorphic eruption of pregnancy
3rd trimester
Itchy papules, on striae gravidarum first
Widespread eczematous rash with fluid-filled vesicles
415
Polymorphic eruption of pregnancy treatment
Emollients
Corticosteroids
416
Atopic eruption of pregnancy
Similar presentation to eczema
Face, neck, chest & flexor surfaces
417
Atopic eruption of pregnancy treatment
Emollients
Corticosteroids
418
Pemphigoid gestationis
Itchy rash around umbilicus
Forms blisters
419
Pemphigoid gestationis treatment
Antihistamines
Topical steroids (or systemic if severe)
420
Stages of postpartum thyroiditis
Thyrotoxicosis
Hypothyroidism
Normal thyroid function
421
Postpartum thyroiditis management
Propanolol for thyrotoxicosis
Levothyroxine for hypothyroidism
Do not give carbimazole
422
Management of pre-existing hypothyroidism in pregnancy
Increase levothyroxine 50% (25mcg) when pregnant
423
OGTT for gestational diabetes
24-28 weeks
Booking visit if risk factors present
424
Risk factors for gestational diabetes
BMI > 30
Previous GD
Previous macrosomia
Ethnicity
1st degree relative diabetes
425
Gestational Diabetes: fasting blood glucose cut off for treatment
5.6 mmol/L
426
1 hour after meal blood glucose cut off for treatment
7.8 mmol/L
427
2 hours after meal blood glucose cut off for treatment
6.4 mmol/L
428
Stepwise management of gestational diabetes
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
Indication to go straight to metformin for gestational diabetes
Fasting blood glucose > 7mmol/L OR evidence of complications e.g. macrosomia/polyhydramnios
430
Indication for induction of labour in gestational diabetes
41 weeks
431
GBS risk of reinfection
50%
432
When is GBS investigated?
Swabs at 35-37 weeks
Only if GBS +ve in previous pregnancy
433
Management of Group B Strep in pregnancy
Intrapartum antibiotic prophylaxis (IAP) during labour
IV Benzylpenicillin
or vancomycin
434
Indication for testing for GBS in pregnancy + when
Previous GBS pregnancy
At 35-37 weeks
435
Indication to give IAP for GBS in pregnancy
Previous GBS infection
>38 fever in labour
436
Management of suspected rubella infection in pregnancy
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
At what point in pregnancy is highest risk should they contract rubella?
1st trimester
438
Risk of complications of rubella infection in first trimester
Up to 90%
439
Management of suspected rubella infection in pregnancy
Discuss with local Health Protection Unit immediately
Don't give MMR during pregnancy
440
Congenital rubella syndrome manifestations
Sensorineural deafness
Eye abnormalities
Congenital heart disease
LBW
441
What infections are tested for routinely in pregnancy?
HIV
Hepatitis B
Syphilis
442
Vertical transmission rate of Hep B without intervention
20%
90% if +ve for HBeAg
443
Management of hepatitis B infection in pregnancy + breastfeeding rules
HBV IgG and HBV vaccination within 24 hours of delivery
Safe to breastfeed
444
Congenital CMV manifestations
LBW
Microcephaly
Seizures
Hearing loss
Vision loss
Petechial rash
445
Congenital chlamydia manifestations
Pneumonia
Conjunctivitis
Chorioamnionitis
446
Congenital Parvovirus B19 manifestations
Hydrops foetalis
Miscarriage/stillbirth
Hepatomegaly
447
At what point in pregnancy would mothers be at highest risk of intrauterine foetal death should they contract Parvovirus B19?
< 20 weeks
448
Congenital VZV manifestations
Limb defects
Ocular defects
449
Congenital HSV manifestations
Microcephaly
Very LBW
Vesicular rash
Preterm
450
Management of HSV in pregnancy
Parenteral acyclovir to baby after birth
Elective C section
451
Congenital syphilis manifestations
Blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
Rhagades
Keratitis, saber shins, saddle nose, deafness
Generalised lymphadenopathy
Rash
Hepatosplenomegaly
452
Congenital toxoplasmosis manifestations
Hydrocephalus – tense fontanelle
Chorioretinitis – pigmentation and depigmentation on retinal surface
Cerebral calcification
453
Pregnancy: Management of toxoplasmosis infection
Spiramycin
Sulfadiazine + pyrimethamine shouldn't be used late pregnancy
454
Classic caesarean section scar implications
Future pregnancies must be elective C section
At 37 weeks
Or 36 weeks for uncomplicated monochorionic twin pregnancy
455
Category 1 C section
Immediate threat to life of mother or baby
456
Category 2 C section
Within 75 minutes
Compromise but not immediately life-threatening
457
Absolute contraindications to VBAC (vaginal birth after caesarean)
Classical caesarean scar
Previous uterine rupture
458
Prophylactic medication for C section
Omeprazole
459
Screening tool for postnatal depression
Edinburgh scale
460
Management of postpartum psychosis
Admission to mother and baby unit
461
Medical management of postnatal depression
SSRIs - sertraline or paroxetine
Present in breast milk but not thought to be harmful
462
1st line management of postnatal depression
CBT
463
Postpartum psychosis recurrence rate
25-50% in future pregnancies
464
Breast cancer screening
50-70 every 3 years
After 70 they can make their own appointments
Mammogram
465
Breast cancer 2 ww referral indications
> 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
Triple assessment breast cancer
Clinical examination
Radiological examination
Core needle biopsy
467
BRCA inheritance
Autosomal dominant
468
Breast cancer risk factors
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
Indications for MRI for breast investigation
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
Indications for mastectomy
Patient preference
Tumour > 4cm
Multifocal/multicentric
BRCA
Contraindication to radiotherapy
Failed conservation surgery
Inflammatory breast cancer
471
Contraindications to radiotherapy
Previous chest radiotherapy
Unable to lie flat
Ataxia telangiectasia homozygotes
Li Fraumeni syndrome
472
ER+ breast cancer hormonal treatment
Premenopausal - tamoxifen
Postmenopausal - anastrozole
473
HER+ breast cancer hormonal treatment
Trustuzamab (herceptin)
474
Tamoxifen mechanism
Oestrogen receptor anatagonist
475
Side effect of tamoxifen
Hot flushes
Nausea
Bleeding
Weight gain
DVT risk
En ca
476
Side effect of trustuzamab
Cardiac dysfunction
Teratogenicity
477
Anastrozole mechanism
Aromatase inhibitor
478
Side effect of anastrozole
Hypo-oestrogenism - hot flushes, fatigue, osteoporosis
479
Complications associated with axillary node clearance for breast cancer
Lymphoedema
480
Phyllode's tumour presentation
Fast-growing, smooth, hard, mobile mass - often impalpable due to distribution
40s-50s
481
In situ vs invasive histology breast cancer
In situ - confined within basement membrane
482
Medullary carcinoma histology
Large pleomorphic nuclei - forming sheets of anaplastic cells
483
Mucinous carcinoma appearance
Grey, gelatinous surface
Soft consistency
484
Paget's disease of the nipple
Eczema-like rash
Nipple discharge - often bloody
Nipple changes
485
4 causes of nipple discharge
Mammary duct ectasia
Intraductal papilloma
Hyperprolactinaemia
Galactorrhoea
Carcinoma
Physiological
486
Mammary-duct ectasia presentation
Perimenopausal
Thick, sticky green discharge
Nipple inversion
487
Differentiating duct ectasia and breast abscess
Duct ectasia - not hot to touch, typically older
488
Intraductal papilloma presentation + management
Single duct discharge
Often clear, can be bloody
Younger patients
Microdocechtomy
489
5 benign breast lumps
Fibroadenoma
Fibroadenosis
Mastitis
Breast abscess
Galactocele
Fat necrosis of the breast
490
Galactocele associations
Recently stopped breastfeeding
Aspiration shows white fluid
No signs of infection
491
Mastitis risk factors + presentation
Breastfeeding/smoking
Swollen, erythematous breast
492
Mastitis 1st management
Continue breastfeeding and use simple analgesia + warm compress
493
Mastitis indications for antibiotics + which antibiotics
Systemically unwell
Nipple fissure
Symptoms persist past 12-24 hours
Culture indicates infection
Lactational:
Flucloxacillin/erythromycin
Periductal:
Co-amoxiclav
494
Breast abscess causative organism + presentation
Complication of mastitis
Staph aureus
Painful erythematous breast
495
Breast abscess management
Oral/IV Abx according to local guidelines
Incision and drainage/needle aspiration
496
Fibroadenosis
AKA fibrocystic disease causing cyclical mastalgia
497
Radial scar pathophysiology + mammogram findings
Idiopathic sclerosing hyperplasia of breast ducts
Star shaped lesion and translucent centre
498
Breast cyst epidemiology + appearance on ultrasound
Perimenopausal women
Soft, fluctuant swellings
Distended and involuted lobules
Halo sign
499
Breast cyst management
If symptomatic
Aspirate cyst
500
Fibroadenoma features
Discrete, non-tender, highly mobile lumps
501
Fibroadenoma management
Surgical excision if >3cm
502
Implant rupture ultrasound findings
Snowstorm appearance
503
Transgender breast cancer screening
Offered after taking feminising hormones for at least 2 years
504
Levonorgestrel mechanism
Inhibits ovulation and implantation
505
Levonorgestrel brand names
Hana
Levonelle
506
Indications for changing standard dose of levonorgestrel
BMI > 26 or weight > 70kg
507
Time frame for levonorgestrel
72 hours
508
Restarting contraception after levonorgestrel
Immediately
509
Ulipristal mechanism
Inhibits ovulation
510
Ulipristal brand names
EllaOne
511
Contraindication to ulipristal
Asthmatic
512
Time frame for ulipristal
120 hours
513
Effect of ulipristal on breastfeeding
Delay for one week
514
Restarting contraception after ulipristal
Start 5 days after
As hormonal contraception can reduce ability of ulipristal to delay ovulation
515
Most effective form of emergency contraception
Intrauterine device
516
Time frame for use of IUD as EC
Up to 5 days after UPSI or after likely ovulation date
517
Contraindication to use of IUD
STI or PID
518
Contraception delays in fertility
Depo: 1 year
COCP: 6 months
519
Mechanism of the implant and depo injection
Inhibitis ovulation
Thickens cervical mucus
520
IUS mechanism
Suppresses endometrial proliferation
Thickens cervical mucus
521
Implant: time effective + location
3-4 years
Subdermal, non-dominant arm
522
Implant: mangement of irregular bleeding
3 months of COCP
523
UKMEC 1 contraception for migraine with aura
IUD
524
Increased risk associated with COCP
DVT
Breast cancer
Cervical cancer
525
Contraindication to oral contraception
Gastric sleeve/bypass/duodenal switch
526
Missed pills: POP
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
Missed pills: POP window times
Traditional: 3 hours
Desogestrel: 12 hours
Drospirenone: 24 hours
528
Lamotrigine effect on POP
Increases plasma levels of progestogen
529
Best time to start POP in cycle
Day 1 drospirenone
Days 1-5 all other POP
530
General switching rules to POP from other contraception
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
Contraception > 55
Not needed even if still bleeding
532
POP follow up appointments
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
COCP UKMEC 3
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
COCP UKMEC 4
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
Management of COCP before surgery
Stop 4 weeks before and then restart 2 weeks after full mobilisation
536
Breast feeding 6 weeks - 6 months on COCP UKMEC score
UKMEC 2
537
COCP as post-partum contraception
After 3 weeks EXCEPT:
6 weeks if breastfeeding, C section or other VTE risk factors
538
IUD as post-partum contraception
< 48 hours or > 4 weeks
Risk of expulsion
539
Implant as post-partum contraception
Start any time
540
Lactational amenorrhoea as post-partum contraception
If exclusively breastfed (or almost exclusively >85%), can act as contraception for up to 6 months
98% effective
541
When is post-partum contraception needed?
21 days post-partum
542
COCP as post-partum contraception
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
Puerperal pyrexia time frame + management
First 14 days post-partum > 38ºc
Antibiotics: IV clindamycin + gentamicin
544
Puerperal pyrexia causes
Endometritis
UTI
Wound infections
Mastitis
VTE
545
Exomphalos vs gastrochisis
Gastrochisis without peritoneal covering
546
Exomphalos associations
Beckwith-Wiedemann syndrome
Down's syndrome
Cardiac and kidney malformations
547
Exomphalos management
Elective C section
Staged repair
548
Thrush in pregnancy management
Local treatments
549
BV in pregnancy risk
Preterm birth
550
Trichomoniasis pregnancy risk
Preterm birth
Vertical transmission
LBW
551
Contraindication to use of oxybutynin for urge incontinence
Glaucoma
552
Management of pre-existing hyperthyroidism in pregnancy
Stop carbimazole
Start propylthiouracil
553
Chandelier sign
Cervical excitation
