Obs and Gynae Flashcards

Question

Which COCP is recommended first-line in PMS?

Answer 1

RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone (less breast swelling, water retention and bloating)

Answer 2

On average, women lose 40 ml of blood during menstruation. Excessive menstrual blood loss involves more than an 80 ml loss.

Answer 3

The diagnosis is based on symptoms, such as changing pads every 1 – 2 hours, bleeding lasting more than seven days and passing large clots. A diagnosis can be made based on a self-report of “very heavy periods”. Heavy menstrual periods can have a significant impact on quality of life.

Answer 4

Dysfunctional uterine bleeding (no identifiable cause) Extremes of reproductive age Fibroids Endometriosis and adenomyosis Pelvic inflammatory disease (infection) Contraceptives, particularly the copper coil Anticoagulant medications Bleeding disorders (e.g. Von Willebrand disease) Endocrine disorders (diabetes and hypothyroidism) Connective tissue disorders Endometrial hyperplasia or cancer Polycystic ovarian syndrome

Answer 5

Pelvic examination with a speculum and bimanual should be performed, mainly to assess for fibroids, ascites and cancers. Full blood count should be performed in all women with heavy menstrual bleeding, to look for iron deficiency anaemia.

Answer 6

Suspected submucosal fibroids Suspected endometrial pathology, such as endometrial hyperplasia or cancer Persistent intermenstrual bleeding

Answer 7

Possible large fibroids (palpable pelvic mass) Possible adenomyosis (associated pelvic pain or tenderness on examination) Examination is difficult to interpret (e.g. obesity) Hysteroscopy is declined

Answer 8

Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding) Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Answer 9

Mirena coil (first line) Combined oral contraceptive pill Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism) Progesterone only contraception may also be tried, as it can suppress menstruation. This could be the progesterone-only pill or a long-acting progesterone (e.g. depo injection or implant).

Answer 10

The final options when medical management has failed are endometrial ablation and hysterectomy. Endometrial ablation involves destroying the endometrium. The first generation of ablative techniques involved a hysteroscopy and direct destruction of the endometrium. This has been replaced by second generation, non-hysteroscopic techniques that are safer and faster. A typical example of one of these techniques involves passing a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining. This is called balloon thermal ablation.

Answer 11

Fibroids are benign tumours of the smooth muscle of the uterus. They are also called uterine leiomyomas. Oestrogen sensitive

Answer 12

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. Pelvic ultrasound is the investigation of choice for larger fibroids. MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Answer 13

For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding: Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus Symptomatic management with NSAIDs and tranexamic acid Combined oral contraceptive Cyclical oral progestogens More than 3cm = referral to gynaecology

Answer 14

Uterine artery embolisation Myomectomy (surgically removing the fibroid via laparoscopic (keyhole) surgery or laparotomy (open surgery). Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.) Hysterectomy

Answer 15

GnRH agonists, such as goserelin or leuprorelin. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

Answer 16

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply.

Answer 17

Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy.

Answer 18

Severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia.

Answer 19

Endometriosis can be asymptomatic in some cases, or present with a number of symptoms: Cyclical abdominal or pelvic pain Deep dyspareunia (pain on deep sexual intercourse) Dysmenorrhoea (painful periods) Infertility Cyclical bleeding from other sites, such as haematuria There can also be cyclical symptoms relating to other areas affected by the endometriosis: Urinary symptoms Bowel symptoms

Answer 20

Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.

Answer 21

Endometriosis is a condition where there is ectopic endometrial tissue outside the uterus. A lump of endometrial tissue outside the uterus is described as an endometrioma.

Answer 22

Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil.

Answer 23

Adenomyosis refers to endometrial tissue inside the myometrium (muscle layer of the uterus). It is more common in later reproductive years and those that have had several pregnancies (multiparous). It occurs in around 10% of women overall.

Answer 24

Painful periods (dysmenorrhoea) Heavy periods (menorrhagia) Pain during intercourse (dyspareunia)

Answer 25

Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis. MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable.

Answer 26

Same as HMB

Answer 27

Menopause is a retrospective diagnosis, made after a woman has had no periods for 12 months. It is defined as a permanent end to menstruation.

Answer 28

Perimenopause refers to the time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards. This is typically in women older than 45 years.

Answer 29

Premature menopause is menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

Answer 30

Menopause is caused by a lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle: Oestrogen and progesterone levels are low LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

Answer 31

Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido

Answer 32

Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence

Answer 33

Weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.

Answer 34

Premature ovarian insufficiency is defined as menopause before the age of 40 years. It is the result of a decline in the normal activity of the ovaries at an early age. It presents with early onset of the typical symptoms of the menopause.

Answer 35

Premature ovarian insufficiency is characterised by hypergonadotropic hypogonadism. Under-activity of the gonads (hypogonadism) means there is a lack of negative feedback on the pituitary gland, resulting in an excess of the gonadotropins (hypergonadotropism). Hormonal analysis will show: Raised LH and FSH levels (gonadotropins) Low oestradiol levels

Answer 36

Premature ovarian insufficiency presents with irregular menstrual periods, lack of menstrual periods (secondary amenorrhea) and symptoms of low oestrogen levels, such has hot flushes, night sweats and vaginal dryness.

Answer 37

NICE guidelines on menopause (2015) say premature ovarian insufficiency can be diagnosed in women younger than 40 years with typical menopausal symptoms plus elevated FSH. The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.

Answer 38

Management involves hormone replacement therapy (HRT) until at least the age at which women typically go through menopause. HRT reduces the cardiovascular, osteoporosis, cognitive and psychological risks associated with premature menopause. It is worth noting there is still a small risk of pregnancy in women with premature ovarian failure, and contraception is still required.

Answer 39

There may be an increased risk of venous thromboembolism with HRT in women under 50 years. The risk of VTE can be reduced by using transdermal methods (i.e. patches).

Answer 40

Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT.

Answer 41

Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds.

Answer 42

Continuous combined HRT

Answer 43

Clonidine act as an agonist of alpha-2 adrenergic receptors and imidazoline receptors in the brain. It lowers blood pressure and reduces the heart rate, and is also used as an antihypertensive medication. It can be helpful for vasomotor symptoms and hot flushes, particularly where there are contraindications to using HRT.

Answer 44

Common side effects of clonidine are dry mouth, headaches, dizziness and fatigue. Sudden withdrawal can result in rapid increases in blood pressure and agitation.

Answer 45

Replacing hormones in premature ovarian insufficiency, even without symptoms Reducing vasomotor symptoms such as hot flushes and night sweats Improving symptoms such as low mood, decreased libido, poor sleep and joint pain Reducing risk of osteoporosis in women under 60 years

Answer 46

Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk) Increased risk of endometrial cancer Increased risk of venous thromboembolism (2 – 3 times the background risk) Increased risk of stroke and coronary artery disease with long term use in older women The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal

Answer 47

Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps

Answer 48

Mood swings Bloating Fluid retention Weight gain Acne and greasy skin

Answer 49

Patches, due to the reduced risk of VTE

Answer 50

IUD, e.g. the Mirena coil

Answer 51

irregular, infrequent ovulation

Answer 52

Irregular, infrequent menstrual periods

Answer 53

Male sex hormones, e.g. testosterone

Answer 54

The growth of thick dark hair, often in a male pattern, for example, male pattern facial hair

Answer 55

The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: Oligoovulation or anovulation, presenting with irregular or absent menstrual periods Hyperandrogenism, characterised by hirsutism and acne Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

Answer 56

Infertility Obesity Hair loss in a male pattern Insulin resistance

Answer 57

Insulin resistance

Answer 58

Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids Ovarian or adrenal tumours that secrete androgens Cushing’s syndrome Congenital adrenal hyperplasia

Answer 59

Raised luteinising hormone ** Raised LH to FSH ratio (high LH compared with FSH) ** Raised testosterone Raised insulin Normal or raised oestrogen levels

Answer 60

The follicles may be arranged around the periphery of the ovary, giving a “string of pearls” appearance.

Answer 61

The diagnostic criteria are either: 12 or more developing follicles in one ovary Ovarian volume of more than 10cm3

Answer 62

7mmol/l or higher

Answer 63

Plasma glucose at 2 hours of 7.8 – 11.1 mmol/l

Answer 64

Plasma glucose at 2hrs above 11.1mmol/l

Answer 65

Weight loss is a significant part of the management of PCOS. Weight loss alone can result in ovulation and restore fertility and regular menstruation, improve insulin resistance, reduce hirsutism and reduce the risks of associated conditions. Orlistat may be used to help weight loss in women with a BMI above 30. Orlistat is a lipase inhibitor that stops the absorption of fat in the intestines.

Answer 66

Under normal circumstances, the corpus luteum releases progesterone after ovulation. Women with PCOS do not ovulate (or ovulate infrequently), and therefore do not produce sufficient progesterone. They continue to produce oestrogen and do not experience regular menstruation. Consequently, the endometrial lining continues to proliferate under the influence of oestrogen, without regular shedding during menstruation. This is similar to giving unopposed oestrogen in women on hormone replacement therapy. It results in endometrial hyperplasia and a significant risk of endometrial cancer.

Answer 67

Options for reducing the risk of endometrial hyperplasia and endometrial cancer are: Mirena coil for continuous endometrial protection Inducing a withdrawal bleed at least every 3 – 4 months with either: Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) Combined oral contraceptive pill

Answer 68

Women with extended gaps between periods (more than three months) or abnormal bleeding need to be investigated with a pelvic ultrasound to assess the endometrial thickness. Cyclical progestogens should be used to induce a period prior to the ultrasound scan. If the endometrial thickness is more than 10mm, they need to be referred for a biopsy to exclude endometrial hyperplasia or cancer.

Answer 69

The combined oral contraceptive pill is first-line for acne in PCOS. Co-cyprindiol may be the best option as it has anti-androgen effects; however, there is a significantly increased risk of venous thromboembolism. Also treat hirtuism.

Answer 70

Lactate dehydrogenase (LDH) Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)

Answer 71

The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: Menopausal status Ultrasound findings CA125 level

Answer 72

Meig’s syndrome involves a triad of: Ovarian fibroma (a type of benign ovarian tumour) Pleural effusion Ascites Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.

Answer 73

The main presenting feature is sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting. The pain is not always severe, and ovarian torsion can take a milder and more prolonged course. Occasionally, the ovary can twist and untwist intermittently, causing pain that comes and goes.

Answer 74

On examination there will be localised tenderness. There may be a palpable mass in the pelvis, although the absence of a mass does not exclude the diagnosis.

Answer 75

Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow. Laparoscopic surgery

Answer 76

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus.

Answer 77

Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with: Secondary amenorrhoea (absent periods) Significantly lighter periods Dysmenorrhoea (painful periods) It may also present with infertility.

Answer 78

There are several options for establishing a diagnosis of intrauterine adhesions: Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed MRI scan

Answer 79

Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). The lining of the endocervix becomes visible on examination of the cervix using a speculum. This lining has a different appearance to the normal endocervix.

Answer 80

Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests. Ectropion may present with increased vaginal discharge, vaginal bleeding or dyspareunia (pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes of postcoital bleeding.

Answer 81

Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill. Problematic bleeding is an indication for the treatment of cervical ectropion. Treatment involves cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy.

Answer 82

Nabothian cysts are often found incidentally on a speculum examination. They do not typically cause any symptoms. Rarely, when they are very large, they may cause a feeling of fullness in the pelvis.

Answer 83

Where the diagnosis is clear, women can be reassured, and no treatment is required. They do not cause any harm and often resolve spontaneously. If the diagnosis is uncertain, women can be referred for colposcopy to examine in detail. Occasionally they may be excised or biopsied to exclude other pathology. Rarely they may be treated during colposcopy to relieve symptoms.

Answer 84

Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagin

Answer 85

Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.

Answer 86

A feeling of “something coming down” in the vagina A dragging or heavy sensation in the pelvis Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention Bowel symptoms, such as constipation, incontinence and urgency Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Answer 87

Conservative management Vaginal pessary Surgery

Answer 88

The typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access.

Answer 89

Urge incontinence is caused by overactivity of the detrusor muscle of the bladder.

Answer 90

Stress incontinence is due to weakness of the pelvic floor and sphincter muscles

Answer 91

Overflow incontinence can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. Chronic urinary retention results in an overflow of urine, and the incontinence occurs without the urge to pass urine.

Answer 92

Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying.

Answer 93

Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen. It occurs in women entering the menopause

Answer 94

Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation

Answer 95

Vaginal lubricants can help symptoms of dryness. Topical oestrogen can make a big difference in symptoms. Options include: Estriol cream, applied using an applicator (syringe) at bedtime Estriol pessaries, inserted at bedtime Estradiol tablets (Vagifem), once daily Estradiol ring (Estring), replaced every three months

Answer 96

The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.

Answer 97

Bartholin’s cysts will usually resolve with simple treatment such as good hygiene, analgesia and warm compresses. Incision is generally avoided, as the cyst will often reoccur. A biopsy may be required if vulval malignancy needs to be excluded (particularly in women over 40 years).

Answer 98

A Bartholin’s abscess will require antibiotics. A swab of pus or fluid from the abscess can be taken to culture the infective organism and check the antibiotic sensitivities. E. coli is the most common cause. Send specific swabs for chlamydia and gonorrhoea.

Answer 99

An autoimmune condition, a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.

Answer 100

Lichen simplex is chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

Answer 101

Lichen planus is an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

Answer 102

The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms: Itching Soreness and pain possibly worse at night Skin tightness Painful sex (superficial dyspareunia) Erosions Fissures

Answer 103

The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

Answer 104

Lichen sclerosus is usually managed and followed up every 3 – 6 months by an experienced gynaecologist or dermatologist. Potent topical steroids are the mainstay of treatment. The typical choice is clobetasol propionate 0.05% (dermovate). Steroids are used long term to control the symptoms of the condition. They also seem to reduce the risk of malignancy. Emollients

Answer 105

The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva.

Answer 106

The police if the patient is under 18

Answer 107

The female internal organs do not develop because the testes produce anti-Müllerian hormone, which prevents males from developing an upper vagina, uterus, cervix and fallopian tubes.

Answer 108

Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes. Alternatively, it presents at puberty with primary amenorrhoea.

Answer 109

Bilateral orchidectomy (removal of the testes) to avoid testicular tumours Oestrogen therapy Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length

Answer 110

The upper vagina, cervix, uterus and fallopian tubes

Answer 111

HPV type 16 and 18, as they are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine. Children aged 12 – 13 years are vaccinated against certain strains of HPV to reduce the risk of cervical cancer and genital warts.

Answer 112

P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.

Answer 113

Increased risk of catching HPV occurs with: Early sexual activity Increased number of sexual partners Sexual partners who have had more partners Not using condoms Non-engagement with cervical screening is a significant risk factor. Many cases of cervical cancer are preventable with early detection and treatment of precancerous changes.

Answer 114

Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) Vaginal discharge Pelvic pain Dyspareunia (pain or discomfort with sex)

Answer 115

Ulceration Inflammation Bleeding Visible tumour

Answer 116

Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are: CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated CIN III: severe dysplasia, very likely to progress to cancer if untreated CIN III is sometimes called cervical carcinoma in situ.

Answer 117

Every three years aged 25 – 49 Every five years aged 50 – 64

Answer 118

Adenocarcinoma

Answer 119

Endometrial cancer is cancer of the endometrium, the lining of the uterus

Answer 120

Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation. Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg. It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (the second half of the menstrual cycle). Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum. Without developing a corpus luteum during the menstrual cycle, progesterone is not produced, and the endometrial lining has more exposure to unopposed oestrogen.

Answer 121

Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen. Adipose tissue is the primary source of oestrogen in postmenopausal women. Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen. Androgens are produced mainly by the adrenal glands. In women with more adipose tissue, and therefore more aromatase enzyme, more of these androgens are converted to oestrogen. This extra oestrogen is unopposed in women that are not ovulating (e.g. PCOS or postmenopause), because there is no corpus luteum to produce progesterone.

Answer 122

The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding.

Answer 123

Transvaginal ultrasound

Answer 124

A pipelle biopsy can be taken in the outpatient clinic. It involves a speculum examination and inserting a thin tube (pipelle) through the cervix into the uterus. This small tube fills with a sample of endometrial tissue that can be examined for signs of endometrial hyperplasia or cancer. Pipelle biopsy is a quicker and less invasive alternative to hysteroscopy for excluding cancer in lower-risk women.

Answer 125

The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa).

Answer 126

Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.

Answer 127

The initial investigations in primary or secondary care are: CA125 blood test (>35 IU/mL is significant) Pelvic ultrasound

Answer 128

Menopausal status Ultrasound findings CA125 level

Answer 129

Around 90% are squamous cell carcinomas.

Answer 130

Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).

Answer 131

Vulval cancer may present with symptoms of: Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin

Answer 132

Irregular mass Fungating lesion Ulceration Bleeding

Answer 133

The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic. Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection.

Answer 134

Multiple sexual partners (although it is not sexually transmitted) Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) Recent antibiotics Smoking Copper coil

Answer 135

Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.

Answer 136

Bacterial vaginosis gives “clue cells” on microscopy. Clue cells are epithelial cells from the cervix that have bacteria stuck inside them, usually Gardnerella vaginalis.

Answer 137

Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment. Metronidazole is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.

Answer 138

Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Answer 139

Thick, white discharge that does not typically smell Vulval and vaginal itching, irritation or discomfort

Answer 140

Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator Antifungal pessary (i.e. clotrimazole) Oral antifungal tablets (i.e. fluconazole) Canesten Duo is a standard over-the-counter treatment worth knowing. It contains a single fluconazole tablet and clotrimazole cream to use externally for vulval symptoms.

Answer 141

Warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use.

Answer 142

Chlamydia trachomatis is a gram-negative bacteria. It is an intracellular organism, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility.

Answer 143

Chlamydia Gonorrhoea Syphilis (blood test) HIV (blood test)

Answer 144

This program aims to screen every sexually active person under 25 years of age for chlamydia annually or when they change their sexual partner. Everyone that tests positive should have a re-test three months after treatment. This re-testing is to ensure they have not contracted chlamydia again, rather than to check the treatment has worked.

Answer 145

Nucleic acid amplification tests (NAAT) check directly for the DNA or RNA of the organism. NAAT testing is used to test specifically for chlamydia and gonorrhoea. In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample. The order of preference is endocervical, vulvovaginal, and then urine. In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab.

Answer 146

Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria)

Answer 147

Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis

Answer 148

First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days. Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are: Azithromycin 1g stat then 500mg once a day for 2 days Erythromycin 500mg four times daily for 7 days

Answer 149

A test of cure is not routinely recommended. However, a test of cure should be used for rectal cases of chlamydia, in pregnancy and where symptoms persist.

Answer 150

Pelvic inflammatory disease Chronic pelvic pain Infertility

Answer 151

Neisseria gonorrhoeae is a gram-negative diplococcus bacteria.

Answer 152

Odourless purulent discharge, possibly green or yellow Dysuria Testicular pain or swelling (epididymo-orchitis)

Answer 153

Odourless purulent discharge, possibly green or yellow Dysuria Pelvic pain

Answer 154

NAAT tests are used to check if a gonococcal infection is present or not by looking for gonococcal RNA or DNA. They do not provide any information about the specific bacteria and their antibiotic sensitivities and resistance. This is why a standard charcoal swab for microscopy, culture and sensitivities is so essential, to guide the choice of antibiotics to use in treatment.

Answer 155

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Answer 156

All patients should have a follow-up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least: 72 hours after treatment for culture 7 days after treatment for RNA NAAT 14 days after treatment for DNA NAAT

Answer 157

A key complication to remember is gonococcal conjunctivitis in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

Answer 158

Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes: Various non-specific skin lesions Polyarthralgia (joint aches and pains) Migratory polyarthritis (arthritis that moves between joints) Tenosynovitis Systemic symptoms such as fever and fatigue

Answer 159

Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection. There are developing problems with antibiotic resistance, particularly with azithromycin. Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.

Answer 160

Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves nucleic acid amplification tests (NAAT) to look specifically for the DNA or RNA if the bacteria.

Answer 161

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.

Answer 162

Pelvic or lower abdominal pain Abnormal vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria

Answer 163

Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Patients may have a fever and other signs of sepsis.

Answer 164

A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.

Answer 165

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.

Answer 166

Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Answer 167

Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella.

Answer 168

Vaginal discharge Itching Dysuria (painful urination) Dyspareunia (painful sex) Balanitis (inflammation to the glans penis)

Answer 169

The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.

Answer 170

Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry. Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.

Answer 171

Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing. Treatment is with metronidazole.

Answer 172

HSV-1 is most associated with cold sores. It is often contracted initially in childhood (before five years), remains dormant in the trigeminal nerve ganglion and reactivates as cold sores, particularly in times of stress. Genital herpes caused by HSV-1 is usually contracted through oro-genital sex, where the virus spreads from a person with an oral infection to the person that develops a genital infection.

Answer 173

HSV-2 typically causes genital herpes and is mostly a sexually transmitted infection. It can also cause lesions in the mouth.

Answer 174

Ulcers or blistering lesions affecting the genital area Neuropathic type pain (tingling, burning or shooting) Flu-like symptoms (e.g. fatigue and headaches) Dysuria (painful urination) Inguinal lymphadenopathy

Answer 175

Where appropriate, patients should be referred to a genitourinary medicine (GUM) specialist service. Aciclovir is used to treat genital herpes. There are various aciclovir regimes listed in the BNF, depending on the individual circumstances.

Answer 176

Primary genital herpes contracted before 28 weeks gestation is treated with aciclovir during the initial infection. This is followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery. Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection). Caesarean section is recommended when symptoms are present. Primary genital herpes contracted after 28 weeks gestation is treated with aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection. Recurrent genital herpes in pregnancy, where the woman is known to have genital herpes before the pregnancy, carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery. Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery. - After an initial infection with genital herpes, the woman will develop antibodies to the virus. During pregnancy, these antibodies can cross the placenta into the fetus. This gives the fetus passive immunity to the virus, and protects the baby during labour and delivery.

Answer 177

Mother to child at any stage of pregnancy, birth or breastfeeding

Answer 178

Antibody testing is the typical screening test for HIV. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing.

Answer 179

Testing for the p24 antigen, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test.

Answer 180

PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.

Answer 181

500-1200 cells/mm3

Answer 182

Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections

Answer 183

Prophylactic co-trimoxazole (Septrin) is given to patients with a CD4 under 200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).

Answer 184

No. HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable. Breastfeeding is not recommended for mothers with HIV. However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.

Answer 185

Syphilis is caused by bacteria called Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body.

Answer 186

Primary syphilis can present with: A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy

Answer 187

Secondary syphilis typically starts after the chancre has healed, with symptoms of: Maculopapular rash Condylomata lata (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 188

Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of: Headache Altered behaviour Dementia Tabes dorsalis (demyelination affecting the spinal cord posterior columns) Ocular syphilis (affecting the eyes) Paralysis Sensory impairment

Answer 189

Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.

Answer 190

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.

Answer 191

All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need: Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.

Answer 192

The woman should be taking 400mcg folic acid daily Aim for a healthy BMI Avoid smoking and drinking excessive alcohol Reduce stress as this may negatively affect libido and the relationship Aim for intercourse every 2 – 3 days Avoid timing intercourse

Answer 193

High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.

Answer 194

Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

Answer 195

A hysterosalpingogram is a type of scan used to assess the shape of the uterus and the patency of the fallopian tubes. Not only does it help with diagnosis, but it also has therapeutic benefit. It seems to increase the rate of conception without any other intervention.

Answer 196

Clomifene is an anti-oestrogen (a selective oestrogen receptor modulator). It is given on days 2 to 6 of the menstrual cycle. It stops the negative feedback of oestrogen on the hypothalamus, resulting in a greater release of GnRH and subsequently FSH and LH.

Answer 197

Ovarian drilling involves laparoscopic surgery. The surgeon punctures multiple holes in the ovaries using diathermy or laser therapy. This can improve the woman’s hormonal profile and result in regular ovulation and fertility.

Answer 198

Have a low threshold for suspecting an ectopic pregnancy, even in atypical presentations. Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain. The classic features of an ectopic pregnancy include: Missed period Constant lower abdominal pain in the right or left iliac fossa Vaginal bleeding Lower abdominal or pelvic tenderness Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Answer 199

A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube. Sometimes a non-specific mass may be seen in the tube. When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign” (all referring to the same appearance). A mass representing a tubal ectopic pregnancy moves separately to the ovary. The mass may look similar to a corpus luteum; however, a corpus luteum will move with the ovary. Features that may also indicate an ectopic pregnancy are: An empty uterus Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)

Answer 200

A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.

Answer 201

The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy. A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l. A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review. A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete. Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.

Answer 202

All ectopic pregnancies need to be terminated. An ectopic pregnancy is not a viable pregnancy. There are three options for terminating an ectopic pregnancy: Expectant management (awaiting natural termination) Medical management (IM methotrexate) Surgical management (salpingectomy or salpingotomy)

Answer 203

Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long.

Answer 204

Vaginal bleeding with a closed cervix and a fetus that is alive

Answer 205

Vaginal bleeding with an open cervix

Answer 206

Retained products of conception remain in the uterus after the miscarriage

Answer 207

The fetus is no longer alive, but no symptoms have occurred

Answer 208

Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen. A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.

Answer 209

The NICE guidelines (2019) suggest referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding. There are three options for managing a miscarriage: Expectant management (do nothing and await a spontaneous miscarriage) Medical management (misoprostol) Surgical management

Answer 210

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.

Answer 211

A key complication is endometritis (infection of the endometrium) following the procedure.

Answer 212

Low dose aspirin Low molecular weight heparin (LMWH)

Answer 213

Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix.

Answer 214

Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy. The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus: More than 5 % weight loss compared with before pregnancy Dehydration Electrolyte imbalance

Answer 215

The severity of N&V during pregnancy can be assessed using the Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15: < 7: Mild 7 – 12: Moderate > 12: Severe

Answer 216

Prochlorperazine (stemetil) Cyclizine Ondansetron Metoclopramide Ranitidine or omeprazole can be used if acid reflux is a problem.

Answer 217

A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy.

Answer 218

A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form. A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.

Answer 219

More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Answer 220

Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy. Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.

Answer 221

The second trimester is from 13 weeks until 26 weeks gestation.

Answer 222

It is worth noting that fetal movements start from around 20 weeks gestation, and continue until birth.

Answer 223

There are two vaccines offered to all pregnant women: Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter Live vaccines, such as the MMR vaccine, are avoided in pregnancy.

Answer 224

NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis). They are particularly avoided in the third trimester, as they can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.

Answer 225

The use of opiates during pregnancy can cause withdrawal symptoms in the neonate after birth. This is called neonatal abstinence syndrome (NAS). NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.

Answer 226

Lithium is particularly avoided in the first trimester, as this is linked with congenital cardiac abnormalities. In particular, it is associated with Ebstein’s anomaly, where the tricuspid valve is set lower on the right side of the heart (towards the apex), causing a bigger right atrium and a smaller right ventricle.

Answer 227

Isotretinoin is a retinoid medication (relating to vitamin A) that is used to treat severe acne. It should be prescribed and monitored by a specialist dermatologist. Isotretinoin is highly teratogenic, causing miscarriage and congenital defects. Women need very reliable contraception before, during and for one month after taking isotretinoin.

Answer 228

When a woman that is rhesus-D negative becomes pregnant, we have to consider the possibility that her child will be rhesus positive. It is likely at some point in the pregnancy (i.e. childbirth) that the blood from the baby will find a way into the mother’s bloodstream. When this happens, the baby’s red blood cells display the rhesus-D antigen. The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens. Usually, this sensitisation process does not cause problems during the first pregnancy. During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis). The red blood cell destruction caused by antibodies from the mother is called haemolytic disease of the newborn.

Answer 229

Prevention of sensitisation is the mainstay of management. This involves giving intramuscular anti-D injections to rhesus-D negative women. There is no way to reverse the sensitisation process once it has occurred, which is why prophylaxis is so essential. The anti-D medication works by attaching itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed. This prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen. It acts as a prevention for the mother becoming sensitised to the rhesus-D antigen. Anti-D injections are given routinely on two occasions: 28 weeks gestation Birth (if the baby’s blood group is found to be rhesus-positive) Anti-D injections should also be given at any time where sensitisation may occur, such as: Antepartum haemorrhage Amniocentesis procedures Abdominal trauma

Answer 230

The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required. The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.

Answer 231

Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR), is when there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta.

Answer 232

Placenta mediated growth restriction Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

Answer 233

Babies are defined as being large for gestational age (also known as macrosomia) when the weight of the newborn is more than 4.5kg at birth. During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.

Answer 234

Shoulder dystocia

Answer 235

Nitrites are a more accurate indication of infection than leukocytes.

Answer 236

Check for intrinsic factor antibodies

Answer 237

All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily.

Answer 238

Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.

Answer 239

Haemolysis Elevated Liver enzymes Low Platelets

Answer 240

The NICE guidelines (2019) advise a diagnosis can be made with a: Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Answer 241

Urine protein:creatinine ratio (above 30mg/mmol is significant) Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Answer 242

Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with: A single high-risk factor Two or more moderate-risk factors

Answer 243

OGTT Normal results are: Fasting: < 5.6 mmol/l At 2 hours: < 7.8 mmol/l

Answer 244

Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin Fasting glucose above 7 mmol/l: start insulin ± metformin Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

Answer 245

Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required.

Answer 246

Women with existing type 1 and type 2 diabetes should aim for the same target insulin levels as with gestational diabetes. A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol.

Answer 247

If you remember two complications of gestational diabetes, remember macrosomia and neonatal hypoglycaemia. Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.

Answer 248

Obstetric cholestasis is also known as intrahepatic cholestasis of pregnancy. Chole- relates to the bile and bile ducts. Stasis refers to inactivity. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby.

Answer 249

Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet. Other symptoms are related to cholestasis and outflow obstruction in the bile ducts: Fatigue Dark urine Pale, greasy stools Jaundice

Answer 250

Abnormal liver function tests (LFTs), mainly ALT, AST and GGT Raised bile acids

Answer 251

Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms. Symptoms of itching can be managed with: Emollients (i.e. calamine lotion) to soothe the skin Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching) Delivery at 37 weeks to reduce risk of stillbirth

Answer 252

Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta. Autosomal recessive condition

Answer 253

The presentation is with vague symptoms associated with hepatitis : General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia (lack of appetite) Ascites

Answer 254

Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery. Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Answer 255

Low-lying placenta is used when the placenta is within 20mm of the internal cervical os Placenta praevia is used only when the placenta is over the internal cervical os

Answer 256

The three causes of antepartum haemorrhage (painless vaginal bleeding in pregnancy) to remember are placenta praevia, placental abruption and vasa praevia. These are serious causes with high morbidity and mortality.

Answer 257

Causes of spotting or minor bleeding in pregnancy include cervical ectropion, infection and vaginal abrasions from intercourse or procedures.

Answer 258

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 259

The 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia.

Answer 260

For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), the RCOG guideline (2018) recommends a repeat transvaginal ultrasound scan at: 32 weeks gestation 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery) Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery. Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os). Depending on the position of the placenta and fetus, different incisions may be made in the skin and uterus, for example, vertical incisions. Ultrasound may be around the time of the procedure to locate the placenta. Emergency caesarean section may be required with premature labour or antenatal bleeding.

Answer 261

The fetal vessels consist of the two umbilical arteries and single umbilical vein.

Answer 262

In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.

Answer 263

Vasa praevia may be diagnosed by ultrasound during pregnancy. This is the ideal scenario, as it allows a planned caesarean section to reduce the risk of haemorrhage. However, ultrasound is not reliable, and it is often not possible to diagnose antenatally. It may present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy. It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section.

Answer 264

For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend: Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation Where antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs. After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.

Answer 265

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

Answer 266

Sudden onset severe abdominal pain that is continuous

Answer 267

Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Answer 268

Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond Placenta increta is where the placenta attaches deeply into the myometrium Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 269

Antenatal steroids are given to mature the fetal lungs before delivery.

Answer 270

Ideally, placenta accreta is diagnosed antenatally by ultrasound. This allows planning for birth. MRI scans may be used to assess the depth and width of the invasion.

Answer 271

The options during caesarean are: Hysterectomy with the placenta remaining in the uterus (recommended) Uterus preserving surgery, with resection of part of the myometrium along with the placenta Expectant management, leaving the placenta in place to be reabsorbed over time Expectant management comes with significant risks, particularly bleeding and infection.

Answer 272

The legs are fully flexed at the hips and knees

Answer 273

One leg flexed at the hip and extended at the knee

Answer 274

Also known as frank breech, with both legs flexed at the hip and extended at the knee

Answer 275

With a foot is presenting through the cervix with the leg extended

Answer 276

Babies that are breech before 36 weeks often turn spontaneously, so no intervention is advised. External cephalic version (ECV) can be used at term (37 weeks) to attempt to turn the fetus. Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section. Vaginal delivery needs to involve experienced midwives and obstetricians, with access to emergency theatre if required. Overall, vaginal birth is safer for the mother, and caesarean section is safer for the baby. There is about a 40% chance of requiring an emergency caesarean section when vaginal birth is attempted.

Answer 277

External cephalic version is used in babies that are breech: After 36 weeks for nulliparous women (women that have not previously given birth) After 37 weeks in women that have given birth previously

Answer 278

Women are given tocolysis to relax the uterus before the procedure. Tocolysis is with subcutaneous terbutaline. Terbutaline is a beta-agonist similar to salbutamol. It reduces the contractility of the myometrium, making it easier for the baby to turn. Rhesus-D negative women require anti-D prophylaxis when ECV is performed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Answer 279

Stillbirth is defined as the birth of a dead fetus after 24 weeks gestation. Stillbirth is the result of intrauterine fetal death (IUFD). It occurs in approximately 1 in 200 pregnancies.

Answer 280

US - visualises the fetal heartbeat

Answer 281

Thrombosis (i.e. PE or MI) Tension pneumothorax Toxins Tamponade (cardiac)

Answer 282

Hypoxia Hypovolaemia Hypothermia Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities

Answer 283

Obstetric haemorrhage Pulmonary embolism Sepsis leading to metabolic acidosis and septic shock

Answer 284

Ectopic pregnancy (early pregnancy) Placental abruption (including concealed haemorrhage) Placenta praevia Placenta accreta Uterine rupture

Answer 285

After 20 weeks gestation, the uterus is a significant size. When a pregnant woman lies on her back (supine), the mass of the uterus can compress the inferior vena cava and aorta. The compression on the vena cava is most significant, as it reduces the blood returning to the heart (venous return). This reduces the cardiac output, leading to hypotension. In some instances, this can be enough to lead to the loss of cardiac output and cardiac arrest.

Answer 286

The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.

Answer 287

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta Early intubation to protect the airway Early supplementary oxygen Aggressive fluid resuscitation (caution in pre-eclampsia) Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR - to improve the survival of the mother

Answer 288

First stage – from the onset of labour (true contractions) until 10cm cervical dilatation Second stage – from 10cm cervical dilatation until delivery of the baby Third stage – from delivery of the baby until delivery of the placenta

Answer 289

Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Answer 290

Braxton-Hicks contractions are occasional irregular contractions of the uterus. They are usually felt during the second and third trimester. Women can experience temporary and irregular tightening or mild cramping in the abdomen. These are not true contractions, and they do not indicate the onset of labour. They do not progress or become regular. Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.

Answer 291

Prematurity is defined as birth before 37 weeks gestation.

Answer 292

Vaginal Progesterone Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation. Cervical Cerclage Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.

Answer 293

Preterm prelabour rupture of membranes is where the amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation).

Answer 294

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days. Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Answer 295

Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Answer 296

An example regime would be two doses of intramuscular betamethasone, 24 hours apart.

Answer 297

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

Answer 298

Reduced respiratory rate Reduced blood pressure Absent reflexes

Answer 299

The Bishop score is a scoring system used to determine whether to induce labour. A score of 8 or more predicts a successful induction of labour.

Answer 300

Membrane sweep involves inserting a finger into the cervix to stimulate the cervix and begin the process of labour. It can be performed in antenatal clinic, and if successful, should produce the onset of labour within 48 hours. A membrane sweep is not considered a full method of inducing labour, and is more of an assistance before full induction of labour. It is used from 40 weeks gestation to attempt to initiate labour in women over their EDD. Vaginal prostaglandin E2 (dinoprostone) involves inserting a gel, tablet (Prostin) or pessary (Propess) into the vagina. The pessary is similar to a tampon, and slowly releases local prostaglandins over 24 hours. This stimulates the cervix and uterus to cause the onset of labour. This is usually done in the hospital setting so that the woman can be monitored before being allowed home to await the full onset of labour. Cervical ripening balloon (CRB) is a silicone balloon that is inserted into the cervix and gently inflated to dilate the cervix. This is used as an alternative where vaginal prostaglandins are not preferred, usually in women with a previous caesarean section, where vaginal prostaglandins have failed or multiparous women (para ≥ 3). Artificial rupture of membranes with an oxytocin infusion can also be used to induce labour, although this would only be used where there are reasons not to use vaginal prostaglandins. It can be used to progress the induction of labour after vaginal prostaglandins have been used.

Answer 301

Individual uterine contractions lasting more than 2 minutes in duration More than five uterine contractions every 10 minutes

Answer 302

Fetal compromise, with hypoxia and acidosis Emergency caesarean section Uterine rupture

Answer 303

Removing the vaginal prostaglandins, or stopping the oxytocin infusion Tocolysis with terbutaline

Answer 304

It is worth remembering that the CTG is reassuring when there are no decelerations, early decelerations or less than 90 minutes of variable decelerations with no concerning features.

Answer 305

Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.

Answer 306

Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.

Answer 307

Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.

Answer 308

Oxytocin stimulates the ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding. Induce labour Progress labour Improve the frequency and strength of uterine contractions Prevent or treat postpartum haemorrhage

Answer 309

Ergometrine is derived from ergot plants. It stimulates smooth muscle contraction, both in the uterus and blood vessels. This makes it useful for delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. It is only used after delivery of the baby, not in the first or second stage.

Answer 310

Due to the action on the smooth muscle in blood vessels and gastrointestinal tract, it can cause several side effects, including hypertension, diarrhoea, vomiting and angina. It needs to be avoided in eclampsia, and used only with significant caution in patients with hypertension.

Answer 311

A PGE2. This is used for induction of labour, and can come in one of three forms: Vaginal pessaries (Propess) Vaginal tablets (Prostin tablets) Vaginal gel (Prostin gel)

Answer 312

Prostaglandins act as vasodilators, and lower blood pressure. NSAIDs such as ibuprofen and naproxen inhibit the action of prostaglandins. As a result, NSAIDs can increase blood pressure. NSAIDs are generally avoided in pregnancy, and also after delivery in women with raised blood pressure (although research has shed doubt on whether the effects on blood pressure is significant enough to justify avoiding them). NSAIDs (e.g. ibuprofen and mefenamic acid) are useful in treating dysmenorrhoea (painful periods), as they reduce the painful cramping of the uterus during menstruation.

Answer 313

Terbutaline is a beta-2 agonist, similar to salbutamol. It stimulates beta-2 adrenergic receptors. It acts on the smooth muscle of the uterus to suppress uterine contractions. It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.

Answer 314

Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate. Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.

Answer 315

Tranexamic acid is an antifibrinolytic medication that reduces bleeding. It binds to plasminogen and prevents it from converting to plasmin. Plasmin is an enzyme that works to dissolve the fibrin within blood clots. Fibrin is a protein that helps hold blood clots together. Therefore, by decreasing the activity of the enzyme plasmin, tranexamic acid helps prevent the breakdown of blood clots.

Answer 316

Nausea, lightheadedness and sleepiness

Answer 317

Women need urgent anaesthetic review if they develop significant motor weakness (unable to straight leg raise). The catheter may be incorrectly sited in the subarachnoid space (within the spinal cord), rather than the epidural space.

Answer 318

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery

Answer 319

Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

Answer 320

Emergency caesarean section. Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.

Answer 321

Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary. McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. Pressure to the anterior shoulder involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis.

Answer 322

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin Second-degree – including the perineal muscles, but not affecting the anal sphincter Third-degree – including the anal sphincter, but not affecting the rectal mucosa Fourth-degree – including the rectal mucosa

Answer 323

3A – less than 50% of the external anal sphincter affected 3B – more than 50% of the external anal sphincter affected 3C – external and internal anal sphincter affected

Answer 324

First-degree tears usually do not require any sutures. When a perineal tear larger than first degree occurs, the mother usually requires sutures to correct the injury. A third or fourth-degree tear is likely to need repairing in theatre.

Answer 325

Perineal massage is a method for reducing the risk of perineal tears. It involves massaging the skin and tissues between the vagina and anus (perineum). This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.

Answer 326

Active management of the third stage is where the midwife or doctor assist in delivering of the placenta. It involves a dose of intramuscular oxytocin to help the uterus contract, and careful traction to the umbilical cord to guide the placenta out of the uterus and vagina. Active management shortens the third stage and reduces the risk of bleeding, but can be associated with nausea and vomiting.

Answer 327

500ml after a vaginal delivery 1000ml after a caesarean section

Answer 328

Minor PPH – under 1000ml blood loss Major PPH – over 1000ml blood loss --> Moderate PPH – 1000 – 2000ml blood loss --> Severe PPH – over 2000ml blood loss

Answer 329

T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder)

Answer 330

a full bladder reduces uterine contraction and can increase risk of PPH

Answer 331

Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) Catheterisation (bladder distention prevents uterus contractions)

Answer 332

Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).

Answer 333

There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes.

Answer 334

There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes.

Answer 335

Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.

Answer 336

Chorioamnionitis UTI

Answer 337

Amniotic fluid embolisation usually presents around the time of labour and delivery, but can be postpartum. It can present similarly to sepsis, pulmonary embolism or anaphylaxis, with an acute onset of symptoms of: Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest

Answer 338

Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Answer 339

Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of: Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Answer 340

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Answer 341

General wellbeing Mood and depression Bleeding and menstruation Scar healing after episiotomy or caesarean Contraception Breastfeeding Fasting blood glucose (after gestational diabetes) Blood pressure (after hypertension or pre-eclampsia) Urine dipstick for protein (after pre-eclampsia)

Answer 342

After 21 days

Answer 343

Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).

Answer 344

The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks). The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.

Answer 345

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus. Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.

Answer 346

The standard management of postpartum retained products of conception is to remove them surgically. Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”. Two key complications are: Endometritis Asherman’s syndrome

Answer 347

Active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.

Answer 348

Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months) Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject) Hb under 70 g/l – blood transfusion in addition to oral iron

Answer 349

Around three months after birth

Answer 350

Low mood, anhedonia (lack of pleasure in activities), low energy

Answer 351

The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression. There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

Answer 352

Puerperal psychosis is a rare but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as: Delusions Hallucinations Depression Mania Confusion Thought disorder

Answer 353

SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome). It presents in the first few days after birth with symptoms such as irritability and poor feeding. Neonates are monitored for this after delivery. Supportive management is usually all that is required.

Answer 354

Both the mother and baby need treatment, or it will reoccur. Treatment is with: Topical miconazole 2% after each breastfeed Treatment for the baby (e.g. miconazole gel or nystatin)

Answer 355

Patients with abnormal thyroid function tests in the postpartum period require referral to an endocrinologist for specialist management. Typical treatment is with: Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker) Hypothyroidism: levothyroxine

Answer 356

Sheehan’s syndrome is a rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland. Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary, and cell death. Sheehan’s syndrome only affects the anterior pituitary gland. Therefore, hormones produced by the posterior pituitary are spared.

Answer 357

Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Luteinising hormone (LH) Growth hormone (GH) Prolactin

Answer 358

Reduced lactation (lack of prolactin) Amenorrhea (lack of LH and FSH) Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH) Hypothyroidism with low thyroid hormones (lack of TSH)