Obs And Gynae Flashcards
(321 cards)
1
Q
What is Turner’s syndrome?
A
Condition in females in which a X chromosome is completely or partially missing
2
Q
What is klinfelter’s syndrome?
A
Boys are born with an extra X chromosome i.e. XXY
This is the most common genetic cause of male infertility
3
Q
What is Kallman’s syndrome?
A
A type of hypogondatrophic hypogandism characterised by a loss of smell and absent/delayed puberty.
4
Q
What is Y chromosome microdeletion?
A
Genetic condition characterised by missing genes in Y chromosome (Can lead to impaired sperm production and male infertility- it is the second most common genetic cause of male infertility).
5
Q
What do leydig cells do?
A
Their main function is testosterone or androgen production (found in the testicular interstitial tissue)
6
Q
Where in the testicles is sperm produced?
A
seminiferous tubules
7
Q
What is obstructive azoospermia?
A
No issues with sperm production but sperm isn’t present in ejaculate due to obstruction.
8
Q
At what point in time do the ovaries contain the greatest number of germ cells?
A
7 months after gestation
9
Q
What is the corpus albicans?
A
Scar tissue that forms after ovulation. The corpus luteum stops producing progesterone (which helps maintain the pregnancy) and starts to degenerate forming the corpus albicans.
10
Q
Wha do the paramesonephric ducts give rise to?
A
In females this forms the uterine tubes, the uterus and the upper portion of the vagina
(mesonephric ducts degenerate due to the absence of male androgens)
11
Q
What does the mesonephric duct give rise to?
A
The epididymis, ductus deferents and the seminal vesicle in males
12
Q
What does the urogenital sinus give rise to?
A
The lower vagina, vulva and urethra
13
Q
Up to how many days can research on human embryos be performed?
A
21 days
14
Q
A couple attend an infertility clinic. The man had a vasectomy 5 years ago and was shown to be azoospermic following this.
What treatment option should be offered initially?
A
ICSI treatment with sperm obtained by surgical sperm aspiration
15
Q
A couple attend an infertility clinic. Investigations for the man show he has obstructive azoospermia.
Which genetic condition is the most likely cause of this condition?
A
Cystic fibrosis.
Explanation;
In klinefelter’s men are unable to make sperm (due to increased levels of FSH and LH causing hyalinisation and fibrosis of the seminiferous tubules that usually produce sperm)
In Kallman’s, fertility is affected due to the lack of puberty
Microdeletion in Y chromosome leads to little to no sperm production
Turner’s syndrome only affects women and leads to an X chromosome being completely or partially missing- many of these women will have primary ovarian insufficiency
CF causes abnormal development of the vascular deferens, epididymis and seminal vesicle (this is obstructive because the person is infertile but not sterile i.e. sperm is still being produced)
16
Q
A couple are undergoing IVF and are booking to attend for embryo transfer.
At which stage in embryo development is embryo transfer most successful?
A
Blastocyst (ball of rapidly cluster of cells made by fertilised egg)
These happens around day 6 to day 10/12 after an embryo is fertilised
17
Q
A woman presents in her 3rd trimester with pelvic pain. What structures relax in pregnancy, which could be contributing to her pelvic pain?
A
Pelvic inlet
18
Q
You are observing a woman in the 2nd stage of labour. You can see the vertex advancing. Which structures on the fetal skull outline the vertex?
A
Anterior and posterior fontanelles and the parietal eminences
19
Q
How does Candida albicans typically present?
A
-Thick, white discharge that does not typically smell
-Vulval and vaginal itching, irritation or discomfort
20
Q
How does bacterial vaginosis typically present?
A
The standard presenting feature of bacterial vaginosis is a fishy-smelling watery grey or white vaginal discharge. Half of women with BV are asymptomatic.
21
Q
A non-sexually active woman presents with a vaginal discharge which contains bubbles and has an offensive smell. What is the most likely infection and how would you treat it?
A
Bacterial vaginosis- give Metronidazole
MUST mention to patient not to drink alcohol on it
22
Q
How long does the Luteal phase last? And what happens during it?
A
The Luteal phase is the second half of the menstrual cycle- it lasts 15-28 days.
During this phase, the follicle that burst and released the egg (during ovulation) develops into a small yellow structure, or cyst, called the corpus luteum.
23
Q
A 17 yr old presents looking for emergency contraception. She had unprotected sexual intercourse 23 hours ago. Her last bleed was approximately 1 week ago. She has been using the combined patch but forgot to put this back on after a 7-day patch free interval. She was meant to restart using the patch 5 days ago but only remembered to restart it 2 days ago. She does not wish to have a cu IUD fitted even though she is fully aware this would be the most effective method. Which emergency contraception would you advise?
A
Give levonorgestrel emergency contraception and advise her to carry on the patch and that she can rely on this again, for contraception, in 5 days
Explanation:
Ulipristal acetate is more effective that levonorgestrel ad emergency contraception but will require her to stop using hormonal contraception for 5 days. Whereas with levonorgestrel she can use her patch immediately after taking it (it won’t work as well for 5 days but it will be better than her not having any hormonal contraception for 5 days before she can even start taking the patch).
24
Q
How soon after childbirth can you get pregnant?
A
After 21 days
25
How soon after an abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease can you get pregnant?
5 days
26
Up to how long after unprotected sexual intercourse does the copper IUD work as emergency contraception?
A copper intra-uterine contraceptive device can be inserted up to 120 hours (5 days) after the first unprotected sexual intercourse in a natural menstrual cycle, or up to 5 days after the earliest estimated date of ovulation (i.e. within the minimum period before implantation)
27
Which method of hormonal emergency contraception is the most effective?
Ulipristal acetate (especially after 72 hours but also generally)
28
What contraceptives are suitable for smokers?
Smokers over 35 can use IUD, IUS, progesterone injection, progesterone only pill, hormonal implant.
This is because other contraceptives can increase risk of cardiovascular issues in smokers.
29
What contraceptives are contraindicated in patients on liver enzyme inducers (such as carbamazepine)?
Combined hormonal contraceptive patches, POP, hormonal implant, vaginal rings or COCP- these are all made less effective by liver enzyme inducing drugs
These following contraceptives are appropriate for patients on liver enzyme inducers as they bypass the liver: IUD, IUS (the hormones are absorbed directly into the uterus) and the progesterone only injection (this is absorbed into bloodstream)
30
A 35-year-old woman seeks contraception. She has heavy and painful periods. She smokes 10 cigarettes daily. Her BMI is 33 and BP 128/70. She is taking a drug for epilepsy that is a liver enzyme inducer. Which of the following options would be the best contraceptive for this woman?
IUS
31
A 21 year old presents with sudden onset of break though bleeding on her pill taking days with a 30mcg combined pill. She has been taking this regularly and has not missed any pills in the last couple of months. She has not had any diarrhoea or vomiting in the last few weeks. She is taking the pill via the standard regime ie 21 days followed by a 7 day break. She has been taking the pill for the past 5 months. There have been a couple of episodes of post coital bleeding in last few weeks. How would you manage this patient?
Take a full sexual history and offer STI screening. Ask about any potential interacting drugs. Offer a pregnancy test. Examine the cervix for any local cause of bleeding.
32
A 46 year old is looking for contraception. She has a BMI of 42 and smokes 20 cigarettes/day . She has a history of pelvic inflammatory disease. She also has a multiple fibroid uterus including intramural and submucous fibroid. What would you advice?
POP
High BMI and smoking at aged over 35 are contraindications for COCP
Hormonal contraceptives make periods more manageable which can be good for managing fibroids
Oral hormonal contraceptives are protective against pelvic inflammatory disease.
33
An 18 year old woman presents to the termination of pregnancy clinic requesting a termination. You observe the nurse performing an ultrasound to assess the gestation of the pregnancy. What is the legal limit for a social termination of pregnancy?
23 weeks + 6 days
34
You are an FY2 in Obstetrics and gynaecology. You are covering the gynaecology assessment unit. You are asked to sign the “green form” (HSA1 form). How many signatures are required on this form before a termination can take place.
2
35
A 20yo woman presents 1 day after a medical termination of pregnancy. She is passing large blood clots and has lost around 500ml of blood so far. You conscientiously object to termination of pregnancy. What would you do next?
Treat her as you would anyone else, this is an emergency
36
A 28-year old MSM (man who has sex with men) presents to the sexual health clinic with a 2 week history of sore throat, fever and a rash on his chest. He last had sex 1 week ago with a regular male partner of 4 months with whom he has condomless receptive and insertive anal sex. He last had sex with a different person 1 year previously. On examination his BP and pulse are normal, his temperature is 37.9, he has small shotty neck nodes bilaterally, erythematous but not enlarged tonsils with no pus and a fine maculopapular rash to his chest. The patient is worried he may have HIV. A near-patient rapid 4th generation HIV Antibody/antigen test is non-reactive.
How do you explain the result and further management to the patient?
His symptoms may be due to Primary HIV infection and venous blood should be obtained and sent to the laboratory for HIV antibody/antigen testing.
A near-patient rapid 4th generation HIV Antibody/antigen test can detect HIV after a month of contracting it.
Venous blood HIV antibody/antigen testing can detect HIV within 18 to 45 days of exposure.
Nucleic acid testing (NAT) can detect HIV infection 10-33 days after exposure.
37
A patient presents with fishy malodorous discharge. It is grey and whitish in colour. She is very bothered with the discharge. You have taken a swab. What is the most likely diagnosis?
Bacterial vaginosis
Bacterial vaginosis presents with fishy smelling discharge and grey/whitish colour.
Candidiasis presents with creamy white discharge and redness.
Trichomonas is yellowish/green discharge with itchiness and soreness.
HPV presents with warts.
Genital herpes presents with sore ulcerated lesions.
38
A 16 year old girl is seen by her GP with some vaginal discharge. Her observations are normal. A swab test shows presence of Chlamydia. What is the best antibiotic treatment for her?
Doxycycline
39
What STI is strawberry cervix (Colpitis macularis) associated with?
trichomoniasis
40
The preferred test for Chlamydia in an asymptomatic female is?
First void urine NAAT
41
Which of the following contributes to the development of HIV antiretroviral resistance?
A
Syphilis coinfection has a negative impact of the effectiveness of antiretrovirals but not resistance
Early diagnosis improves life expectancy.
Protease inhibitors have lower incidence of drug resistance in treatment nbiave patients i.e. patients on ARTs for the first time.
42
A 32 year old lady has been seen in the unplanned pregnancy assessement clinic.The report shows an intrauterine sac measuring 40 mmx 32 mmx 25 mm. The most likely diagnosis is
Missed Miscarriage
An intrauterine sac over 25mm with no evidence of yolk sac or embryo is diagnostic of early pregnancy loss.
43
With regards combined oral contraceptive (COCP) pills. Which of these statements is correct?
A
COCP increases risk of breast cancer and decreased risk of ovarian and uterine cancer.
44
A 16 year old girl is seen by her GP. She complains of some vaginal discharge. Her observations are normal. A swab test shows presence of Chlamydia. What is the best antibiotic treatment for her from the options below?
Azithromycin
Doxycycline is first line but azithromycin can also be prescribed.
45
Which of the statements with regards combined oral contraceptive pills is NOT true?
E
46
What is the most common type of vulval cancer? And at what age does it usually present?
Squamous cell carcinoma.
Usually diagnosed between ages 65-74.
47
Which HPV strains are responsible for the majority of cancers?
16 and 18
48
What cancers are HPV related?
Anal, penile, vulval, vaginal, oropharyngeal, cervical (anal and cervical have 90% and above cases that are caused by HPV
49
What conditions are primarily HPV 6 and HPV 11 responsible for?
Majority of cases of genital warts
50
Which statement regarding vulval squamous cell carcinoma associated with usual type VIN is incorrect?
C
HPV 6 and 11 are v. Commonly associated with genital warts but are low risk strains of HPV.
The main strains of HPV that cause cancer are 16 and 18.
51
Which statement regarding vulval squamous cell carcinoma associated with usual type VIN is incorrect?
C
HPV 6 and 11 are v. Commonly associated with genital warts but are low risk strains of HPV.
The main strains of HPV that cause cancer are 16 and 18.
52
Which of the following is not a subtype of endometrial carcinoma?
53
An ovarian mucinous cystadenoma is
C
These are usually multilocular huge cysts with smooth surfaces.
54
An ovarian mucinous cystadenoma is
C
These are usually multilocular huge cysts with smooth surfaces.
55
A large endometriotic (chocolate) cyst…
C
Benign conditions associated with CA125 increase: menstruation, pregnancy, benign pelvic tumors, pelvic inflammatory diseases, ovarian hyperstimulation syndrome, peritonitis, and many diseases leading to pleural effusion or ascites
These are cysts formed in endometriosis. They are filled with dark brown endometrial fluid.
56
The condition most likely to be associated with a normal CA125 level
D
57
Which of the following statements regarding endometriosis is true?
A
58
Which of the following muscles covers the majority of the pelvic side wall?
C
Levator ani forms the pelvic floor.
It predominantly consist of pubococcgeus. Most posterior part of Levator ani is iliococcgeus.
59
Lymph from the gonads drains to which of the following lymph node groups?
Lumbar lymph nodes
Lumbar lymph nodes supply the retroperitoneum, gonads (Testes and ovaries), adrenal glands, superior third of the ureter. These lymph nodes are also partly responsible for drainage of the fundus of the uterus and fallopian tubes.
60
The risk of malignancy index (RMI) for calculating the likelihood of ovarian cancer is calculated according to the following
D
61
Young girl with RIF pain and shoulder tip pain, last period was over a month ago. What is this a typical presentation for?
Ectopic pregnancy
62
What is the most significant maternal complication of PPROM (preterm premature rupture of membranes)?
Chorioaminonitis (intra-amniotic infection)
63
How can ectopic pregnancy be managed?
Methotrexate Or surgery (if it’s large, surgery is needed)
64
When is it appropriate to do expectant management of an ectopic pregnancy?
65
What is the recommended amount of folic acid for pregnant patients/women trying to conceive that are on anticonvulsants?
5mg a day 12 weeks prior to gestation (if posssible) and throughout gestation
66
Why is it unacceptable to do a pelvic examination in a suspected ectopic pregnancy?
Internal palpation could result in rupturing the ectopic
*Note: any woman of child-bearing age with abdominal pain has an ectopic pregnancy until proven otherwise*
67
A 33-year-old woman presents to A&E with vaginal bleeding and mild left iliac fossa pain. Her last menstrual period was 8 weeks ago. Abdominal examination reveals mild, diffuse tenderness. On bimanual examination, there is mild tenderness in the left adnexa. On speculum examination, the cervical os is open. Her blood pressure is 118/78 mmHg and her heart rate is 88 bpm. Serum beta human chorionic gonadotropin (b-hCG) is 2500 IU/l. Transvaginal ultrasound shows a 20 mm mass in the left fallopian tube.
What condition is this a classical presentation of? And how would you manage it?
Ectopic pregnancy- child bearing age, amenorrhoea, adnexal mass, mass in fallopian tube
Methotrexate then monitor beta hcg fall and make suree pregnancy is being passed
68
When is surgical management used for an ectopic pregnancy?
The patient is:
-in significant pain
-adnexal mass >35 mm
- b-hCG level >5000 IU/l
-or foetal heartbeat present on ultrasound
69
A 23 year old female attends Accident and Emergency with lower abdominal pain and vaginal bleeding. Bimanual examination reveals cervical motion tenderness. A positive b-HCG test confirms pregnancy. AN ectopic pregnancy is suspected.
Which of the following is the most likely predisposing risk factor for ectopic pregnancy?
-multiparity
-PID
-history of cholecystectomy
-PCOS
PID
*Note: PID and POP slow down rate of ovum transport so they increase risk of ectopic pregnancy*
70
Where does pain typically localise in ruptured ovarian cyst?
right or left iliac fossa pain
71
Amenorrhoea, abdominal and shoulder tip pain, abdominal distension and haemodynamic instability are all common presenting characteristics of what?
Ruptured ectopic pregnancy
72
Why might ruptured ectopic pregnancy cause shoulder tip pain?
Diaphragm irritation
73
unilateral cramping pain, amenorrhea for 6 weeks, scant vaginal bleeding of dark brown colour and previous history of pelvic inflammatory disease all points towards… what diagnosis?
Ectopic pregnancy
74
A 24-year-old woman attends A&E with sudden-onset severe lower abdominal pain that radiates to her shoulder tip. She says that this began 2 h ago, and has been associated with some brown watery vaginal discharge. A transvaginal ultrasound scan identifies an ectopic pregnancy in the left fallopian tube, with no heartbeat seen in the embryo. A serum beta-human chorionic gonadotrophin (β-hCG)is 7500 IU/l. She has no significant past medical history and has never had an ectopic pregnancy before. What is the most appropriate management?
-expectant management
-intramuscular methotrexate
-mifepristone and misoprostol
-left salpingectomy
-left salpingotomy
75
A 28-year-old woman has a human chorionic gonadotropin (β-hCG) blood test after her pregnancy was not seen on a transvaginal ultrasound scan, despite a positive pregnancy test. Her first result is 1100 mIU/ml. At 48 h later, the β-hCG is 1700 mIU/ml. She asks what this means for her pregnancy. What should she be told?
-This is most likely a molar pregnancy
-This is most likely a viable pregnancy too small to be seen
-This is most likely a false positive pregnancy test
-This is most likely an ongoing miscarriage
-This is most likely a ectopic pregnancy
76
A 34-year-old woman presents to the early pregnancy unit with vaginal bleeding that started 2 hours ago. It is light in nature and she has mild abdominal cramps. She suspects that she is roughly 8 weeks pregnant, and has only had mild morning sickness so far this pregnancy. The doctor refers her for a transvaginal ultrasound scan, and whilst waiting for this asks permission to perform a speculum examination in the presence of a chaperone. On examination, there is evidence of blood in the vagina, and the cervical os appears to be open. The ultrasound scan is performed, which excludes an ectopic pregnancy. The doctor explains these findings to the patient, and explains the management options going forward.
What is the most appropriate next step in the management of this patient?
Expectant management
77
A 28-year-old lady presents to the Emergency Gynaecology Unit (EGU) with a 3-day history of dark vaginal bleeding and dull lower abdominal pain. She states that her last period was 7 weeks ago. Her past medical history is significant for a left-sided tubo-ovarian abscess that required surgery.
A pregnancy test is positive and a transvaginal ultrasound shows a foetus implanted in the right fallopian tube. A foetal heartbeat is detected.
Which of the following is the next best step in management?
-intratubal methotrexate
-misoprostol
-right sided salpingostomy
-right sided salpingectomy
-expectant management
78
A 26-year-old woman presents 5 weeks into her pregnancy with abdominal pain localising to her right iliac fossa and a small amount of vaginal bleeding. Her past medical history includes pelvic inflammatory disease and a previous termination at 10 weeks.
Her serum βHCG is 1600 IU/l and a transvaginal ultrasound demonstrates a 28mm mass in her right fallopian tube, with no free fluid in the abdomen and no intrauterine pregnancy.
Her observations are as follows: RR 16, HR 78, BP 128/74 mmHg, SpO2 98%, T 36.7 C.
What is the most appropriate first line management for this patient?
-laparaotomy and salpingotomy
-repeat beta serum hcg in 48 hours
-IM methotrexate
-laparotomy and salpingectomy
-expectant management
79
In what demographic is cervical ectropion more common?
Adolescents and women taking combined hormonal contraception
80
A 16 year old girl presents to her GP with post-coital bleeding. She is sexually active, and uses the combined oral contraceptive pill. She also reports some episodes of unprotected sex. She denies any vaginal discharge or abdominal pain.
On speculum examination there is a ring of red mucosa around the cervical os. A cervical smear is taken and sent for analysis.
Which of the following is the most likely diagnosis?
81
What is the most common cause of post-coital bleeding in premenopausal women?
Ectropion
82
What is the following describing “appears as a bright red area surrounding the cervical os, which is areas of columnar epithelium on the ectocervix at the transformation zone”?
Cervical ectropion
83
True or false, cervical ectropion is more common in pregnant women?
True
84
In an inevitable miscarriage is the cervical os open or closed?
Open
85
A 23 year old lady presents to the emergency department with a 2 day history of abdominal pain. She has no past medical or surgical history. Her urinary pregnancy test is positive. On examination, her vital signs are within the normal range, and right adnexal tenderness is elicited on bimanual examination. Admission blood shows a serum beta hCG level of 13283 IU/L. She has a transvaginal ultrasound which confirms the presence of an ectopic pregnancy.
What is the most common site of an ectopic pregnancy?
-isthmus
-ampulla
-fimbria
-ovarian
-cervical
86
What is Pyosalpinx?
Pus filled fallopian tube making it distend
87
A 23 year old woman presents to the Emergency Department with severe abdominal pain. She has a history of pelvic inflammatory disease (PID) three years ago, which was successfully treated with antibiotics.
Her blood pressure is 120/85 mmHg and her temperature is 39.4 degrees Celsius. The abdomen is rigid. Vaginal examination elicits cervical excitation.
What is the mostly appropriate investigation?
Patient likely has PID
The most appropriate investigation to confirm this is transvaginal ultrasound.
88
A 25 year old female presents to A&E with severe right sided abdominal pain that started 5 hours ago. She has no urinary symptoms or changes in bowel habit.
On examination, she is febrile and has severe pain on palpation of the right upper quadrant of her abdomen. Vaginal examination reveals cervical excitation. Liver function tests are normal. A pregnancy test was negative.
What complication of PID is this patient presenting with?
fitz hugh curtis syndrome a.k.a perihepatitis
89
What combination of antibiotics is usually given to treat pelvic inflammatory disease?
90
What conditions would you expect to present with cervical motion tenderness a.k.a cervical excitation?
PID, ectopic pregnancy, endometriosis, ovarian torsion, appendicitis (this list is not exhaustive)
91
A 44 year old female presents to the Emergency Department complaining of abnormally heavy menstrual bleeding. She has associated abdominal pain and pain on urination. She also has a fever and blood tests show a raised ESR, CRP and leukocytosis. Given the most likely diagnosis, what investigation will be confirmatory?
92
A 28-year-old woman presents to her GP with abdominal discomfort, nausea and vomiting over the last few days. She also informs the doctor that she thinks she’s put on about 4kg of weight over the same time frame. She has a history of pelvic inflammatory disease, and is currently having in-vitro fertilisation.
On examination, her abdomen is distended.
What is the most likely diagnosis?
93
What is chandelier’s sign?
Chandelier’s sign
94
A 28-year-old woman attends her GP with a 5-day history of bilateral lower aching abdominal pain. It is not associated with any urinary or bowel symptoms. Her vital signs are within normal range, except for a fever of 38.2 °C. On examination, she reports generalised tenderness in the lower abdomen, but there are no skin changes or masses. On bimanual examination, there is cervical excitation, and a thick white discharge is noted on the glove afterwards. Which of the following investigations will most likely identify the probable diagnosis?
-cervical smear test
-nucleic acid amplification test (NAAT) vulvovaginal swab
-pregnancy test
-urine culture
-high vaginal swab culture
95
Are multiparity and the oral contraceptive pill risk factors for endometriosis?
No, they are protective factors against endometriosis
96
A 21-year-old woman is being treated empirically for pelvic inflammatory disease (PID) through her sexual health clinic. She has had multiple sexual partners over the past six months and has not always used condoms. She is awaiting the results of her endocervical and high vaginal swabs.
What is the most common causative organism implicated in PID?
Chlamydia trachomatis
97
A 28-year-old lady presents to the Emergency Gynaecology Unit (EGU) with a 3-day history of dark vaginal bleeding and dull lower abdominal pain. She states that her last period was 7 weeks ago. Her past medical history is significant for a left-sided tubo-ovarian abscess that required surgery.
A pregnancy test is positive and a transvaginal ultrasound shows a foetus implanted in the right fallopian tube. A foetal heartbeat is detected.
Which of the following is the next best step in management?
-intratubal methotrexate
-vaginal misoprostol
-expectant management
-right-sided salpingectomy
-right-sided salpingostomy
98
Which of the following is not considered to be an oestrogen dependent cancer?
Breast cancer
Ovarian cancer
Cervical cancer
Endometrial cancer
Cervical cancer
All the others are oestrogen dependent
99
Which cancers does COCP reduce the risk of? Which cancers does it increase the risk of?
Increases Cervical and breast cancer risk.
It increases cervical cancer risk due to cervical cells becoming more susceptible to HPV infection.
Decreases endometrial and ovarian cancer risks due to ovulating less. Also decreases colorectal cancer risk (oestrogen and progesterone alter bile synthesis and secretion so there is lower conc of bile in the colon and less chance of carcinogenesis).
100
What type of anaerobe is chlamydia?
obligate intracellular gram-negative bacteria
101
A 35-year-old lady attends her GP worried that she might have lymphoma. She states that for the last few months she has experienced night sweats that have become more frequent. On further questioning, she denies any weight loss, fevers, unexplained weight loss or lumps anywhere that are concerning her. She explains that she has noticed that her periods have become more irregular recently, and she has not had a period for 3 months. The GP explains that they think lymphoma is unlikely but that she would like to perform a blood test investigate her suspected diagnosis of premature menopause.
What abnormalities would you expect to see on the blood test for this patient to confirm a diagnosis of premature ovarian insufficiency?
102
A 35-year-old woman presents to her General Practitioner for the insertion of a contraceptive coil. She is nulliparous and has a regular menstrual cycle. She states her periods are heavy, lasting approximately 9 days, and are associated with significant dysmenorrhoea. A bimanual examination is performed, which reveals a significantly enlarged uterus with no tenderness.
A pelvic ultrasound is performed, which reveals a large uterine fibroid confined to the myometrial layer of the uterus.
Which type of uterine fibroid does this patient have?
Intramural fibroids- most common type of uterine fibroid. Confined to the myometrial layer of the uterus.
Subserosal fibroids develop within the outer layer of the uterus, known as the serosa.
Submucosal fibroids develop just below the endometrial layer of the uterus and protrude into the uterine cavity.
Pedunculated fibroids are suspended on a stalk. Subserosal and submucosal fibroids may be pedunculated and protrude into the pelvic or uterine cavities.
103
A 38-year-old woman with endometriosis presents to her GP. She has been suffering from cyclical pelvic pain of severity 4/10. The pain occurs for a few days prior to the onset of menstruation. She has a past medical history of a peptic ulcer disease. She has one daughter, and is trying for another child.
Which of the following is the best management option for her pain?
-GnRH agonist
-mefanamic acid
-paracetamol
-referral for laparoscopic ablation
-referral for hysterectomy and salpingo-oopherectomy with excision of endometriosis lesions
Paracetamol
Avoid mefanamic acid in patient with PUD because it is an NSAID so will increase risk of GI bleeds
104
When is mid-Luteal phase progesterone used as an investigation?
In infertility to establish whether a woman is ovulating, if she is progesterone will be high mid Luteal phase.
105
An elevated FSH on two blood samples 4–6 weeks apart is diagnostic of what?
Premature ovarian insufficiency
106
A 36-year-old female, gravida 3 and para 2+1, who is 37 weeks' pregnant, arrives at the Emergency Department with vaginal bleeding and abdominal pain. She states that this is her third pregnancy and she has pre-eclampsia, controlled by labetalol.
The antenatal examination revealed a normal lie of the foetus and a tense, woody uterus.
A foetal Doppler was done which could not locate the foetal heartbeat. A cardiotocography was then attached illustrating no foetal distress at present.
Given the information, what is the definitive treatment for this patient?
107
A 32-year-old woman at 28 weeks gestation presents with painless, bright red vaginal bleeding. She has no history of abdominal trauma, and the bleeding is not associated with contractions. The foetus is in a normal position, and the woman's vital signs are stable.
Which condition is most likely responsible for her bleeding?
Placenta previa
Placenta praevia occurs when the placenta partially or completely covers the cervical os, which can lead to painless, bright red vaginal bleeding in the second or third trimester, without associated contractions.
108
What is the Kleihauer test for?
To measure amount of fetal haemoglobin transferred to the mother and thus calculate the required dose of anti-D immunoglobulin in rhesus negative mothers
109
A 42-year-old woman attends the gynaecology department following the results of her transvaginal ultrasound scan. She states that she has had heavy, painful periods over the last 5 years. This started shortly after the birth of her third child for which she underwent a caesarean section. She does not take any regular medication. When asked, she states that she plans to try and conceive within the next few years. The consultant explains the results of the scan and advises on treatment options.
What is the most appropriate management plan to control this patient's symptoms?
110
In which of the following obstetric scenarios is a digital vaginal examination an appropriate part of the workup?
111
What is Hyperemesis gravidarum? And how is it treated?
Intractable vomiting before 20 weeks leading to triad of dehydration, electrolyte disturbance and weight loss.
Early signs include ketonuria and 5% of overall pregnancy weight loss.
First line treatment is antihistamines. E.g. using either cyclizine or promethazine in combination with pyridoxine (Vitamin B6)
112
A 42-year-old woman is 33 weeks pregnant when she presents to her GP with intense pruritus in her palms and soles. A blood test reveals elevated bile acids. Which of the following is most correct regarding management of this patient?
113
A 35 year old woman is in labour. It is a cephalic vaginal delivery. After successful delivery of the head, the head of the fetus begins retracting and extending again when the mother pushes.
Which of the following are risk factors for this condition which can be identified during booking?
-macrosomia
-maternal diabetes mellitus
-transverse lie
-maternal BMI < 25
-small pelvis with an oval brim
114
A 32-year-old primigravida woman has been in labour for several hours. She is currently 10 cm dilated, and her contractions have become more intense. She feels a strong urge to push during each contraction.
What stage of labour is she in?
115
A 28-year-old para 4 has just delivered her twin babies. The attending midwife is examining the placenta when she notices that the mother's bed sheets are becoming soaked in blood.
What is the most likely cause of this patient's postpartum haemorrhage?
116
What are the risks factors for acute fatty liver of pregnancy?
-first pregnancy
-twins
-having a boy
-thin
117
What does HELLP syndrome stand for?
This is a complication of pre-eclampsia
Haemolysis
EL- Elevated Liver enzyme
LP-low platelet count
118
The following is the classic triad of clinical features for what condition: vaginal bleeding, rupture of membranes and foetal bradycardia?
Vasa previa- Fetal vessels crossing or running in close proximity to the inner cervical os. These vessels course within the membranes (unsupported by the umbilical cord or placental tissue) and are at risk of rupture when the supporting membranes rupture.
119
What is placenta praevia? How does it present and how is it managed?
Placenta praevia (PP) is a pregnancy complication where the placenta lies low in the uterus and may cover the cervix. It is typically characterized by painless, bright red vaginal bleeding after 24 weeks of gestation and may lead to malpresentation of the foetus.
In labour this is managed as an emergency C section
120
What are the three branches of the pudendal nerve?
Perineal, inferior rectal nerve and dorsal nerve of the clitoris
121
True or false, CIN I regresses spontaneously?
True-
CIN I does usually regress and so is carefully monitored
Meanwhile, CIN II and CIN III are more likely to develop into cancer so LLETZ is performed using diathermy
CIN III is carcinoma in situ as it hasn’t reached the basement membrane but is occupying the full thickness of the cervical epithelium
122
When is vaginal vault prolapse most likely to occur?
Post hysterectomy (uncommon)
123
True or false; endometriosis is associated with superficial dyspareunia?
False
Endometriosis and PID are associated with deep dyspareunia (deeper pelvic pain on sexual intercourse).
Dermatological conditions, STIs and vulvodynia can cause superficial dyspareunia.
124
A 31-year-old, gravida 2 and para 1, 25-week-pregnant female presents to the GP for advice regarding chickenpox. She informs you that her daughter has developed chickenpox following another child's birthday party. She cannot remember having chickenpox as a child. She has no visible rash. Her blood is tested and shows absence of varicella antibodies. What is the next step in her management?
If it’s within 10 days after exposure or rash appears, give varicella antibodies. If not, give aciclovir
This is v. Important because varicella in adults can lead to pneumonia, encephalitis and hepatitis
125
A 67 year old lady is newly diagnosed with ovarian cancer. She asks if there was anything that could have made her more likely to develop this type of cancer.
Which of the following options is a risk factor for ovarian cancer?
-early menarche
-COCP
-multiple pregnancies
-early menopause
-breastfeeding
126
A 25-year-old woman attends the emergency department complaining of a painful cyst in her vulva. The cyst has been present for 2 days but was initially only mildly tender. This morning, it has become much more painful and she has developed a fever. On examination, a 2 cm tender cyst is noted to the right of the vaginal introitus. It is hot and tender to touch. What is the most likely causative organism?
E. coli-
The most likely diagnosis here is a Bartholin's cyst that has become infected. This is often due to E. coli; however, mixed organisms may also be found.
127
Non-cancerous growths of fibroepithelial tissue within the uterus are called what?
Fibroids
128
A 65-year-old female presents with vulval itching, pain and abnormal vaginal discharge. She also reports noticing a vulval growth that has been present for several months. What is the most likely diagnosis?
129
True or false; tamoxifen is used in the treatment of breast cancer but also increases the risk of endometrial cancer
True- Tamoxifen is a selective estrogen receptor modulator (SERM)
it acts against growth promoting effects of oestrogen in breast tissue but mimics the effects of oestrogen in uterus and bones.
Meanwhile, Anastrozole is an aromatase inhibitor and works to lower levels of oestrogen in the body so is used similarly in treating breast cancer but doesn’t increase endometrial cancer risk
130
True or false; you can diagnose menopause clinically without doing blood tests?
True- ONLY if the patient is over 45, in under 45s you need 2 FSH blood tests
131
A neonate born minutes ago is undergoing their first baby examination. The midwife reports that the baby's right arm is in abnormal position where the elbow is in an extended position with the wrist flexed in a waiter tip position.
On review of the notes, it seems that the baby's shoulder became stuck around the mother's perinuem, requiring traction and further manoeuvres to deliver the baby.
Which nerve injury is most commonly seen as a complication to shoulder dystocia?
132
A 22 year old woman attends her GP 35 weeks into her first pregnancy with symptoms of dysuria and urinary frequency. She is otherwise well, her obs are within normal range and she is hoping for a spontaneous vaginal delivery at term. She is diagnosed with a urinary tract infection and is prescribed oral Cephalexin. Her GP receives the result of her urinalysis and culture a few days later and it shows the following:
Blood: negative Leukocytes: ++++ Nitrites: positive Protein: + Ketones: negative Glucose: negative pH: 4.9
Culture: Postive
Group B Streptococcus (GBS): >100,000 CFU/ml
What is the best management plan for this patient?
*note: this is really important as it can cause very serious issues in mum and baby if IV antibiotics aren’t given during labour, including sepsis, meningitis and pneumonia in baby as a result of early onset Group B strep disease of the newborn*
133
Who is most susceptible to uterine rupture?
multiparous women who have had undergone a previous Caesarean section
134
You meet a 37-year-old woman on labour ward who is 40+5 weeks gestation and has elected to be induced. You return shortly after induction to find the patient is barely responsive and visibly dyspnoeic.
Your colleage takes some observations which show the patient is hypoxic and hypotensive. You suspect an amniotic fluid embolism.
Which of the following is the most appropriate next step in management?
135
A 25 year old woman presents to her GP as she has only had 3 periods over the last 7 months. She has been trying to become pregnant for the last year and not been successful. On examination, she has high BMI and some hyperpigmentation and thickening of the skin across the back of her neck and in both Axilla.
What is the most likely diagnosis?
PCOS.
136
Bilirubin and ALP are also raised. What is the likely diagnosis?
137
A 64 year old woman arttents the outpatient gynaecology clinic with persistent soreness and itching of the vulva. She denies any abnormal vaginal discharge. On examination, she’s found to have 1cm ulcerated lesion on the labia majora. What’s the most likely diagnosis?
138
139
140
141
A 31 year old primigravida female of 33 week’s gestation presents to A&E with significant abdominal pain. She informs you that she has been vomiting since this morning and is experienceing severe headaches associated with poor vision.
She is afebrile. Her heart rate is 82 bpm, respiratory rate is 14 breaths/min and blood pressure is 12/97 mmHg. There’s pitting oedema on her lower extremities and tenderness to her right upper quadrant of her abdomen.
Results of tests are shown in the image.
142
A 27 year old nulliparous female, who is 21 weeks’ pregnant, presents to her US scan. The radiographer informs her that her baby is in breech presentation and she will need to speak to the doctor regarding external cephalic version.
How early can an external; cephalic version be offered for nulliparous women with a breech presentation baby?
36 weeks
143
A 26 year old woman presents to the GP with a 3 week history of vulval itching. She also reports some pain during sex. She has tried oral clotrimazole, but there has been no improvement. On examination, there are white patches on the labia minora.
Given the likely diagnosis, which of the following is the most appropriate management?
144
A 35 year old woman presents to her GP at 18 weeks gestation. She has not recieved any antenatal care so far in her pregnancy. Her GP explains that she is eligible for antenatal screening to assess for foetal chromosomal abnormalities, which she agrees to. A blood sample is taken and sent for quadruple testing.
Which chromosomal abnormality/abnormalities are tested for in the quadruple test?
145
What does the combined test entail and when is it carried out?
US to assess Michael translucency and blood test to assess PAPP-A and beta HCG.
This is done 10-14 weeks gestation and tests for Downs, Edward and Patau’s.
146
True or False, Cri du chat, Turner’s syndrome and klinefelters syndrome are screened for routinely at 20 weeks
False- these syndromes are not routinely screened for
147
What is the first line treatment for endometriosis?
Paracetamol and/or ibuprofen should be given for a short trial e.g. 3 months for pain treatment
148
A 45 year old woman with a known history of uterine fibroids presents to the emergency department with severe abdominal pain, vaginal bleeding and a low-grade fever. US shows an enlarged uterus with multiple hypoechoic lesions and a CT scan reveals a large haematoma in the pelvis. What is the most likely diagnosis?
Uterine fibroid degeneration
149
How would vertical transmission of chlamydia trachomatis via birth canal present?
Vertical transmission of chlamydia trachomatis via birth canal presents either as ophthalmia neonatorum 6-21 days after birth (purulent discharge from the eyes) or Pneumonitis at 3-12 weeks after birth.
150
How does listeria transmitted via the placenta or birth canal present?
Sepsis or meningitis 2 weeks after birth
Note: the mother will likely experience diarrhoea or flu like illness when getting infected (typically by contaminated food).
151
152
What is the most common cause of postmenopausal bleeding?
Vaginal atrophy
153
Is cervical cancer more likely to cause post menopausal bleeding or premenopausal abnormal bleeding?
Cervical cancer can cause both but is most commonly associated with premenopausal abnormal bleeding
154
A 24 year old nulliparous female attends her 28 weeks’ antenatal appointment. She is feeling well and her pregnancy and past medical history are unremarkable. She does note that she has had increasing urinary frequency and feels extremely thirsty.
What are the criteria used to diagnose gestational diabetes?
Blood glucose level 7.8mmol/l or above 2 hours post glucose load or fasting plasma glucose of 5.6mmol/l or above
155
What is pregnancy induced hypertension and how is it treated?
BP is higher than 140/90mmHg in a pregnant woman with normal bp at booking, asymptomatic and no evidence of proteinuria.
Antihypertensive therapy, close monitoring of blood pressure and urinalysis once or a twice a week. FBCs, Us & Es, LFTs and coagulation profile will also be needed.
156
How is pre-eclampsia diagnosed? List the criteria
Systolic BP more than equal to 140mmHg and/or diastolic greater than equal to 90 mmHg with either evidence of proteinuria, systemic involvement (deranged coagulation, abnormal kidney or liver function tests) or symptoms (headache, visual disturbance, epigastric pain, peripheral oedema, breathlessness)
157
A 40 year old primiparous woman is going for her 11 week antenatal appointment. Her pregnancy was the result of successful IVF treatment. Two separate gestational sacs are seen on ultrasound, suggesting a twin pregnancy. The mother is worried about the implications of her having a multiple pregnancy.
Which types of twins are associated with the greatest risk of complications?
-all types carry the same risk
-monozygotic, dichorionic-diamniotic twins
-dizygotic twins
-monochorionic monoamniotic twins
-monochorionic diamniotic twins
158
What’s considered a post term pregnancy? And how is it managed?
Beyond 42 weeks
Mx: membrane sweep at 41 weeks and induction of labour if the sweep is unsuccessful
*cervical membrane sweep causes prostaglandin release increasing the likelihood for spontaneous labour*
159
160
What is a blighted ovum?
161
What condition is mostly to cause this presentation?
Hypothyroidism
*note: this condition is not associated with acne but acne is commonly seen in this age group*
162
What is the corkscrew manoeuvre used for and how is it performed?
Second line management in shoulder dystocia.
Apply pressure in front of one of the baby’s shoulders whilst simultaneously applying pressure behind the other shoulder. This manoeuvre is an attempt to rotate the baby 180 degrees.
163
164
What appointment are pregnant women supposed to have at 16 weeks?
Meet with community midwife to document bp and urinalysis
165
Who meets their community midwife at 25 weeks and what happens in this appointment?
Only nulliparous women.
BP is measured and urinalysis is done.
Symphysial fundal height is also measured for the first time and plotted against a personalised growth chart and used for monitoring foetal growth.
166
What occurs during the 28 week appointment for pregnant women?
BP is measured and urinalysis is done.
Symphysial fundal height is also measured and plotted against personalised growth chart to monitor foetal growth.
If a woman has rhesus negative blood group she’ll get offered her first dose of anti-D prophylaxis in this appointment.
167
168
169
G6 P3 + 2
170
True or false, vitamin A is a recommended pregnancy supplement?
False- vitamin A is teratogenic
vitamin A should be avoided in pregnancy as should consumption of products high in vitamin A
171
A 34 year women G3P2 is undergoing labour at 41 weeks gestation. She has a history of two previous uncomplicated vaginal deliveries. After 20 minutes of pushing, the midwife notices a visible umbilical cord in the vagina. The patient is prepared for an emergency caesarean section. Which of the following is the next best step in the management of this patient?
-lie flat on her back
-McRobert’s manoeuvre
-ask her to stand
-ask patient to get on all fours, on knees and elbows
-apply fundal pressure
172
A 34-year-old lady has just delivered her baby. She suddenly develops sudden onset shortness of breath, chest pain, and hypotension. There are no signs of uterine bleeding.
Which complication is most likely responsible for these symptoms?
173
A 40 year old woman who is 25 weeks pregnant has been referred to the antenatal clinic after her GP noticed that her symphysis-fundal height measured 28cm. This is her first pregnancy and she has a past medical history of diabetes and asthma. She had a combined screening test which gave a low risk for chromosomal abnormality. She tearfully admits that she has been having the odd cigarette when her husband isn’t home and now worries that she has harmed her baby. A fetal ultrasound is carried out which confirms that she has polyhydramnios.
Which factor is most likely contributing to the polyhydramnios?
174
A newborn check is carried out on an infant who was delivered vaginally 24 hours ago at 37 weeks gestation. There were no complications during the pregnancy. On examination there is bilateral loss of the red reflexes, purpuric skin lesions covering the torso and a continuous “machine-like” murmur heard on cardiac auscultation. An immediate automated otoacoustic emission test is requested which returns an abnormal result. What is the likely diagnosis?
175
A 32-year-old primigravida woman presents for her routine antenatal appointment at 36 weeks of gestation. The foetal position is found to be breech during the examination.
What is the most appropriate management option for this woman?
Offer external cephalic version (ECV)
The most appropriate management option for a breech baby at 36 weeks gestation is to offer an external cephalic version (ECV). ECV is a procedure that aims to turn the foetus into a head-down position to facilitate vaginal delivery. It has a success rate of 50-60% and can decrease the need for a caesarean section.
176
A 32-year-old woman presents to her general practitioner due to irregular periods and excess body hair. She also reports that she and her husband have been trying for a baby for the past 12 months with no success. An abdominal examination is unremarkable; however, her GP calculates her body mass index (BMI) to be within the obese category. Her GP suspects a diagnosis of polycystic ovary syndrome (PCOS).
Which criteria are used to diagnose PCOS?
The Rotterdam criteria are used to diagnose PCOS.
The criteria state that a patient must have two out of three of the following to make a diagnosis:
Oligo-/anovulation Clinical or biochemical evidence of hyperandrogenism Polycystic ovaries or an increased ovarian volume on ultrasound.
177
A 28-year-old woman presents to the gynaecology assessment unit with vaginal bleeding. She is currently 10 weeks pregnant. She reports no abdominal pain, no urinary symptoms and no fever. A vaginal speculum examination shows a closed cervical os and no obvious cause of her bleeding. An abdominal ultrasound scan shows a viable pregnancy within the uterus.
What is the most likely diagnosis?
Threatened miscarriage
Threatened miscarriage is diagnosed when there is vaginal bleeding in the presence of a viable pregnancy in the first 24 weeks of gestation.
178
A 36 year old woman G3P2 with placenta praevia presents for her foetal growth scan. Ultrasound scan shows the placenta involving more than half of the myometrium but has not invaded past it. She denies any symptoms. Her previous history includes two deliveries done via Caesarean section.
Which of the following explains the ultrasound findings?
-vasa praevia
-placenta percreta
-placenta praevia
-placenta increta
-placental abruption
179
A 35 year old female has just delivered her first baby. She is wondering if any of the drugs she is taking are unsafe to continue whilst breast feeding.
Which of the following drugs is contraindicated in breastfeeding?
-Aminophylline
-amiodarone
-trimethoprim
-digoxin
-sodium valproate
180
A 31-year-old primigravida female who is 25 weeks' pregnant arrives at the Antenatal Clinic for her results following her oral glucose tolerance test last week. The midwife reveals that her fasting levels is 7.0 mmol/l and informs the patient she likely has gestational diabetes. The midwife explains the importance of having a tight control with lifestyle modification and medication. The woman becomes quite anxious as her father suffers with type 2 diabetes and knows it can cause many complications.
Which of the following is not a foetal complication of gestational diabetes?
-erb’s palsy
-potter syndrome
-hypertrophic cardiomyopathy
-macrosomia
-hypoglycaemia
181
A 28-year-old woman presents to clinic after being informed that she is having twins (monochorionic diamnionic) and that there is evidence of twin to twin transfusion syndrome (TTTS). Which of the following statements regarding this condition is true?
-the recipient twin is more likely to survive to birth
-The donor twin is not at risk of developing heart failure
-The recipient twin is at risk of developing foetal hydrops
-One of the foetuses usually develop normally
-There is currently no treatment available
182
A 19-year-old woman presents to her GP practice complaining of heavy periods. She started menstruating 6 years ago and has been troubled by heavy periods for most of that time. She can often soak through pads within an hour on the first few days of her period and passes blood clots. She describes no recent change to her weight but states that she feels tired most of the time. On bimanual examination, the uterus is nonbulky and on speculum examination the cervix is visualised with no evidence of pathology. A coagulation screen is sent:
Prothrombin time 13 s (12.0–14.8 s)
Prothrombin ratio 1.0 (0.9–1.1)
Activated partial prothrombin time 47 s (27.0–41.0 s)
Bleeding time: prolonged
What is the most likely cause of this woman's menorrhagia?
183
A 35 year old primiparous woman is seen by the obstetrician following an uncomplicated vaginal delivery at 39 weeks gestation. On examination, she has a perineal tear which extends through the perineal skin, muscles, fascia and a quarter of the thickness of the external anal sphincter.
What degree is this perineal tear classified as? A 35 year old primiparous woman is seen by the obstetrician following an uncomplicated vaginal delivery at 39 weeks gestation. On examination, she has a perineal tear which extends through the perineal skin, muscles, fascia and a quarter of the thickness of the external anal sphincter.
What degree is this perineal tear classified as?
Third degree 3 (a)
184
A 29-year-old nulliparous woman is 34 weeks pregnant and presents to her GP with a two day history of flu-like illness and painful vesicular lesions around her vagina. Given the most likely diagnosis, which of the following best represents the most appropriate course of action regarding further management of her pregnancy?
Offer the patient oral aciclovir and an elective Caesarian section
The most likely diagnosis here is herpes simplex virus. As such, aciclovir can be offered to treat the current presentation and a Caesarian section will greatly reduce the risk of vertical transmission to the foetus at delivery.
185
A 28 year old woman is attending a colposcopy appointment following her borderline smear test which tested positive for HPV DNA.
If there are any abnormal cells within the transformation zone, what colour will these stain following an iodine solution stain application?
Yellow
Aqueous iodine (also known as Lugol's iodine) is used during colposcopy as part of cervical cancer screening. It will stain normal cells black/brown, but it is not taken up by cancerous cells, which appear yellow under microscopy.
186
A 31-year-old female, gravida 3, para 2, has just had her baby by spontanoues vaginal delivery. However, she continues to bleed, even after complete delivery of placenta and membranes.
A postpartum haemorrhage protocol is initiated by rubbing up uterine fundus and emptying her bladder with Foley catheter. Pharmacological managements are further initiated, but she continues to bleed. A decision was made to bring her to the theatre for surgical intervention.
Which initial surgical interventions is the most appropriate?
Intrauterine balloon tamponade
Additional management options are: B lynch suture followed by stepwise uterine devascularisation
187
In what condition does ‘turtle neck’ sign present?
Shoulder dystocia
turtle neck sign” is caused by retraction of the fetal head against the perineum
188
A 28 year old G2P1 presents to the antenatal clinic in her second trimester to follow up on the results of the ultrasound scan done recently. The diagnosis of polyhydramnios is confirmed.
Which of the following is a risk factor for polyhydramnios?
-Oesophageal atresia
-Foetal renal agenesis
-Intrauterine growth restriction
-Premature rupture of membranes
-Post-term gestation
189
What causes polyhydramnios?
190
At what age is cervical cancer most common?
Cervical cancer has a bimodal age incidence profile with one peak at age 25–29 and a secondary peak at age 80–84.
191
Up to how many weeks gestational can medical termination of pregnancy be carried out?
Mifepristone and misoprostol are safe and effective for medical abortion up to 24 weeks gestation, although the success rates decrease with increasing gestational age.
192
A 27-year-old woman presents to the gynaecology clinic with a 6-month history of heavy menstrual bleeding, increased urinary frequency and constipation. A transvaginal ultrasound scan identifies a 10 cm submucosal fibroid. She has no significant past medical history and would like to start a family in the next few years. Which of the following is the most appropriate management of this patient?
-COCP
-Tranexamic acid
-myomectomy
-mirena coil
-hysterectomy
193
A 70 year old female presents to her GP with superficial dyspareunia. She also reports discomfort in the vaginal area, with a frequent need to pass urine. She has had three urinary tract infections over the last year. On examination, there is evidence of vaginal dryness.
What is the first line treatment in the management of this condition?
Vaginal oestrogen ring
194
What nutrients are typically low in breastmilk?
Vitamin D, K, iron and iodine
Newborns are prophylactically injected with intramuscular vitamin K immediately after birth to prevent haemorrhagic disease of the newborn (vitamin K deficiency bleeding). Vitamin K is responsible for the production of clotting factors II, VII, IX and X, and its deficiency can lead to intracranial, intrathoracic and intra-abdominal bleeding.
195
A 24 year old female is referred to gynaecology clinic with painful periods. She also describes pain when having sex. She has a regular twenty-eight day cycle and does not experience heavy bleeding. She has had one sexual partner for the past four years and has not been experiencing any other symptoms.
PV examination reveals a normal sized uterus with no ovarian masses. Speculum examination shows no abnormality.
What is the most likely diagnosis?
Endometriosis
There are many clues in this question that point to endometriosis: young female with dysmenorrhoea and dyspareunia, normal sized uterus (less likelihood of fibroids) and a normal speculum examination (less likelihood of cervical cancer/ectropion/infection).
196
What is the definition of primary amenorrhoea?
This is the failure to establish menstruation by the expected time of menarche. This is defined as by the age of 16 in those with normal secondary sexual characteristics and by the age of 14 in those with no secondary sexual characteristics.
197
A 35-year-old woman is undergoing investigations due to difficulty conceiving for the past two years. She reports infrequent periods and excess body hair. Her BMI is within the obese category. It is suspected that she has polycystic ovary syndrome (PCOS) however, she is awaiting blood test results to confirm the diagnosis.
Which of the following results is typically seen in PCOS?
-Raised testosterone, normal sex hormone binding globulin (SHBG), raised luteinising hormone (LH) and normal follicle-stimulating hormone (FSH)
-Raised testosterone, low sex hormone binding globulin (SHBG), raised luteinising hormone (LH) and normal follicle-stimulating hormone (FSH)
-Raised testosterone, low sex hormone binding globulin (SHBG), normal luteinising hormone (LH) and normal follicle-stimulating hormone (FSH)
198
A 27-year-old female, gravida 2, para 1, presents to the antenatal clinic for a routine check-up. She is currently 36 weeks' pregnant and reports feeling well throughout with no acute symptoms. Her past medical history is unremarkable, but she is allergic to penicillin.
Urinalysis demonstrates ++ for leukocytes and ++ for nitrites.
What is the most appropriate next step in managing this patient?
-cefalexin
-co-amoxiclav
-nitrofurantoin
-trimethoprim
199
A 28 year old woman attends A&E with breathlessness, abdominal pain and vomiting. She has been undergoing fertility treatment privately, and 5 days ago had an egg retrieval procedure which yielded 22 eggs and was uncomplicated.
Her observations are as follows:
Pulse 80
Blood pressure 90/70
Respiratory rate 20
SpO2 97% on air
Temperature 36.7
On examination, her abdomen is distended and tense but not peritonitic. Her chest is clear with reduced breath sounds at both bases.
Urinary HCG is negative.
What is the most likely diagnosis?
200
True or false, smoking and childbearing increase the risk of endometrial cancer?
False- they decrease it
201
A 22 year old primiparous woman delivers a baby at 37 weeks on the labour ward. On examination of the newborn infant, there are several vesicular lesions around his eyes, mouth and scalp. The mother’s notes report that three weeks ago she developed an infection and was subsequently advised for a caesarean section at term, which she declined. She was then offered intrapartum IV acyclovir which she also declined. Given this information, what is the most likely causative organism of this baby’s symptoms?
202
A 25-year-old woman who has oligomenorrhoea and acne is referred for ultrasound of her ovaries. The ultrasound reveals multiple cysts on the ovaries and she is diagnosed with polycystic ovary syndrome.
She is prescribed a 12-day course of medroxyprogesterone 10mg daily which induces a withdrawal bleed and she is sent for an ultrasound to assess the endometrial thickness. The endometrium is found to be thickened.
What is the most appropriate next step in her management?
Refer for endometrial sampling
f the medroxyprogesterone failed to induce a bleed or the endometrium was thickened then the next step is to refer for endometrial sampling in order to exclude endometrial hyperplasia or cancer
203
A 32-year-old, gravida 3 para 2, is admitted to the Maternity Ward after her membrane ruptures at home. She has a history of gestational diabetes which was diagnosed at 30 weeks' gestation and is being managed with insulin. She has had a prolonged first stage of labour and is now in stage 2.
On examination, the foetal head is crowning and is delivered, however there is difficulty delivering the rest of the foetus. The head then retracts back into the perineum. The midwife gets the mother to reposition by flexing her thighs tightly towards her abdomen.
What else can be done to improve the effectiveness of this manoeuvre?
204
A 56 year old lady attends the GP complaining of vaginal dryness and pain whilst having sex. She says this is putting a strain on her relationship with her husband. She has no urinary symptoms, hot flushes or night sweats.
Her periods have been becoming less frequent over the past few years. She now has a period every three to four months. She is on no medication currently.
What is the best treatment for this lady's issues?
Vaginal moisturiser and lubricants
This lady has presented with urogenital menopausal symptoms. She has no vasomotor or cognitive symptoms. It is important that we do not overtreat patients and give them systemic treatment (such as Hormone Replacement Therapy (HRT)) when local treatments are equally/more effective. With this in mind, vaginal moisturisers and lubricants will help alleviate her dryness and help with her dyspareunia (pain during sexual intercourse). It also won't subject this lady to the side effects associated with HRT.
205
What role does mefanamic acid have in the treatment of fibroids? How is this different to tranexamic acid?
Mefanamic acid treats symptoms of dysmenorrhea and tranexamic acid treats symptoms of menorrhagia.
206
Blood loss >500 ml, 48 hours following delivery- would this be considered a primary or secondary post partum haemorrhage?
Secondary
defined as abnormal bleeding of the genital tract from 24 hours until 6 weeks post-partum
207
A 28 year old G2P1 female on a labour ward complains of bleeding following a recent delivery. She appears unwell and needs immediate treatment. Post-partum haemorrhage (PPH) seems to be the likely cause.
Which of the following defines a major primary post-partum haemorrhage?
208
A 30 year old primiparous woman at 37 weeks gestation is having regular uterine contractions which are 15 minutes apart. Speculum examination shows clear fluid pooled in the vagina and a digital examination shows that the cervix is fully effaced and 5cm dilated. The cervix has been dilating around 1cm every 2 hours. Fetal presentation is cephalic and fetal station is -2.
Which stage of labour is this woman experiencing?
209
A 12-year-old girl is brought to her GP with a 4-day history of gradual-onset worsening abdominal pain and bloating. The pain is constant and is not associated with eating, urinating or passing stool. She has not started her periods yet and has never had sexual intercourse. Her vital signs are within normal ranges. On palpation, there is generalised abdominal pain but no masses are felt. On genital examination, breast development and pubic hair are seen. A blue and bulging membrane is overlying the vagina, with a mass protruding from behind. What is the most likely diagnosis?
Imperforate hymen
The blue and bulging membrane with a mass protruding from behind is a classic finding in an imperforate hymen. This girl has likely started her periods, but the hymen is imperforate. This has caused a backlog of blood through the vagina, causing abdominal pain.
210
A 39-year-old woman presents to her General Practitioner with a three-month history of bleeding during sexual intercourse. Aside from coital bleeding, she has a regular menstrual cycle and uses the combined oral contraceptive pill. She has had 4 casual male partners in the past three months. She denies vaginal discharge or any other symptoms. She is otherwise well, and her weight is stable. She has never attended for a smear test. A speculum examination reveals a grossly abnormal cervix where the os is obscured by a growth which bleeds on contact.
What is the most likely diagnosis?
211
What is the corkscrew manoeuvre used for?
Second line manoeuvre in shoulder dystocia management.
Apply pressure in front of one of the baby’s shoulder whilst applying pressure behind the other shoulder simultaneously. Thus, attempting to rotate the baby 180 degrees.
212
What is an episiotomy?
A small incision is made in the perineum to increase the amount of space within the vagina. This can be used to facilitate the corkscrew manoeuvre in shoulder dystocia management but it doesn’t work without the manoeuvre. I.e. the episiotomy alone isn’t managing anything.
213
214
215
Define menopause
216
217
How is placenta previa managed?
218
What causes costochondritis in the third trimester of pregnancy? How does the pain present?
Seen in the third trimester of pregnancy due to expansion of the ribcage as a result of hormonal changes.
The pain is sharp, aching or pressure-like and reproduced on palpation or inhaling deeply.
219
220
What’s the most appropriate first line management for premenstrual syndrome?
COCP with no pill free interval
221
222
How is pre-eclampsia managed?
-Aspirin is used for prophylaxis
-labetalol is first line treatment
-nifedipine can be used in people who have asthma or other contraindications for beta blockers
can also use methyldopa and hydralazine
-magnesium sulphate is used to treat eclampsia seizures
-curative treatment is delivery of the placenta
223
224
225
226
227
How is gestational diabetes diagnosed?
228
229
Describe a footling beech?
230
What is placenta accreta?
Normal implantation of the placenta into the uterine wall.
C section increases the risk of this and it’s usually at the site of an old C section scar.
231
-maternal age 25-35 years
-oligohydraminos
-smoking
-normal BMI
-singleton pregnancy
Smoking - especially before 28 weeks gestation
Other risk factors are: - extremes of maternal age- less than 18 or more than 40 years old
-polyhydramnios
-low BMI
And obesity
-multiple pregnancy
232
-maternal age 25-35 years
-oligohydraminos
-smoking
-normal BMI
-singleton pregnancy
Smoking - especially before 28 weeks gestation
Other risk factors are: - extremes of maternal age- less than 18 or more than 40 years old
-polyhydramnios
-low BMI
And obesity
-multiple pregnancy
233
Classical features are opposite to placental abruption i.e. painless vaginal bleeding, mild cramps or backache, relaxed uterus (soft, non-tender). In placenta praevia bleeding is uncontrolled (volume of bleeding correlates to degree or severity of loss).
234
Compare Brixton hicks contractions to labour contractions? Think how long do contractions last and how far apart are they
235
How does placental abruption present?
Classical features of placental abruption are vaginal bleeding with pain, reduced foetal movement and a tense, firm and tender uterus.
236
What is HELLP syndrome?
Haemolysis, elevated liver enzymes and low platelets- this is a severe, rare complication of pre-eclampsia.
Complications include disseminated intravascular coagulation and potential placental abruption due to uncontrolled bleeding.
The only treatment is expediting delivery.
237
Describe a normal CTG in early pregnancy.
Normal foetal heart rate is 110-160bpm
Variability should be between 5 and 25 bpm.
Accelerations should be present.
Decelerations shouldn’t be present in early labour.
238
Menorrhagia, bulky uterus on examination and a history of infertility are highly suggestive of what condition? And why would a transvaginal ultrasound be used?
Uterine fibroids
Transvaginal ultrasound should be organised to determine the presence of uterine fibroids, size and whether they are submucosal, intramural or subserosal.
239
240
Which of the following antibiotics is recommended once PPROM is established?
Erythromycin
241
A 56 year old woman presents to her GP with an itch in her groin, which is especially worse at night. Examination of the anogenital area reveals several white thickened plaques.
Which of the following is the most likely diagnosis?
242
NSAIDs are safe to use in pregnancy unlike opioids, true or false?
False- NSAIDs (e.g. naproxen, ibuprofen and diclofenac) are teratogenic such as risk of premature closure of foetal ductus arteriosus in utero, resistant pulmonary hypertension of the newborn and delayed onset of labour.
Opioids have embryotoxic effects.
243
Which of the following is an absolute contraindication for vaginal birth after Caesarean?
-lack of availability of pelvic x ray
-classical Caesarean section scar (vertical)
-prior greater than 3 lower segment Caesarean sections
-lack of previous vaginal delivery history
-breech presentation
classical Caesarean section scar (vertical)
244
A recently new mother presents to the general practice as she has been suffering with poor sleep. She explains that she has been struggling to sleep since the baby was born 3 weeks ago, getting roughly 4 hours a night. She begins to cry and say that it has been very overwhelming, and she does not feel cut out to be a mother. She goes on to explain that everyone thinks that she is a bad mother and that she sees them talk about her behind her back. When questioning her about this, she explains that her mother-in-law is out to get her, and she is trying to take her baby away. She states that for the past 3 weeks she has avoided meeting up with her family and friends as she does not want to face criticism and has had intrusive thoughts recently about ending her life. Based on this information, what is the best course of action for this patient?
245
how does ovarian torsion present?
It usually presents as sudden-onset abdominal pain in either the right or left iliac fossa, depending on which ovary is affected. The pain is often described as stabbing and can make patients vomit with its severity.
246
A 46 year old woman who is 7 weeks pregnant presents to her GP with vaginal bleeding. She also complains of severe nausea and vomiting over the last few days.
On examination, the symphysis-fundal height is 14cm. She is referred to the Early Pregnancy Assessment Unit where she has a trans-vaginal ultrasound, which is difficult to interpret but does identify some fetal tissue in the uterus.
What is the most likely diagnosis?
Partial molar pregnancy
The constellation of symptoms of vaginal bleeding, hyperemesis, and a uterus larger than expected for gestational age, are together suggestive of gestational trophoblastic disease. As there is fetal tissue present in the uterus then this is a partial molar pregnancy
247
A 31-year-old woman presents at 4 weeks of pregnancy with some minor vaginal bleeding. She has no tenderness on abdominal examination. Pelvic examination reveals some cervical motion tenderness. She is referred for a pelvic ultrasound which does not identify any masses or active pregnancy. A serial serum beta-human chorionic gonadotropin (B-hCG) measurement is taken at 0h and 48h:
0h: 24 IU/L
48h: 56 IU/L
What is the most appropriate next step in management of this patient?
The pregnancy is likely intrauterine, order another ultrasound to confirm at a later date
The high proportional increase in B-hCG (more than double over 48 hours) is suggestive that the embryo is successfully growing and is most likely to be located within the uterus. Another ultrasound at a later date when the fetus should be larger and easier to identify would confirm this result
An ectopic pregnancy would be likely if there was only a slight increase in B-hCG over 48 hours. Rarely, the B-hCG may have increased significantly in an ectopic so it cannot be completely excluded.
248
A 36-year-old woman, G5P3+1, presents to the Emergency Department (ED) at 35 weeks gestation. She complains of a three hour history of cramping abdominal pain and moderately severe back pain. She is apyrexial and does not report urinary symptoms. Her observations show a blood pressure of 100/60 mmHg and heart rate of 100/min. Abdominal examination shows a gravid uterus consistent with gestation with palpable uterine contractions. Pelvic examination shows blood and dark clots in the vaginal vault.
What is the most likely cause of her presentation?
249
A 32-year-old nulliparous woman, who is 36 weeks' pregnant, presents for external cephalic version after discovering her baby is in breech presentation.
What drugs can be used to improve the success rate of external cephalic version?
According to Royal College of Obstetricians, a tocolytic agent with beta-mimetic effect (ie. beta-2 receptor agonists such as terbutaline, ritodrine and salbutamol) can be used to improve the success rate of external cephalic version, as they cause relaxation of uterine muscles. Potential side effects include tachycardia, palpitation and flushing.
250
A 31-year-old woman presents to the Maternity Assessment Unit (MAU) as she thinks her waters may have broken. She is 38 weeks pregnant and thus far has had an uncomplicated pregnancy. She reports no abdominal pain, no vaginal bleeding and no urinary symptoms. She is feeling well in herself and is afebrile. On speculum examination, a small amount of fluid can be seen in the posterior vaginal fornix, and the cervical os is closed. The midwife suspects a diagnosis of pre-labour rupture of membranes.
What investigation can be carried out to confirm this diagnosis?
Actim-PROM vaginal swab
Actim-PROM vaginal swab detects insulin-like growth factor binding protein-1 (IGFBP-1) in vaginal fluid. The concentration of IGFBP-1 is much higher in the amniotic fluid than in the maternal blood. Therefore, a positive Actim-PROM suggests pre-labour rupture of membranes.
251
A 38-year-old female who is 33 weeks' pregnant arrives at the Emergency Department complaining of a few hours’ history severe abdominal pain and vaginal bleeding. She states that this is her third pregnancy. She has a past medical history of hypertension, for which she takes labetalol. She smokes three cigarettes per day.
Abdominal examination reveals normal lie of the foetus; however, the abdomen feels tense and woody. The foetal heartbeat is observed as difficult to distinguish.
Given the information, what is the patient's most likely diagnosis?
Placental abruption
Placental abruption is one of the main causes of antipartum haemorrhage after 24 weeks of pregnancy. Common symptoms include vaginal bleeding associated with abdominal pain and contractions in the second half of pregnancy. Typical examination findings refer to a tense, ‘woody’ uterus which is characteristic of placental abruption. It is associated with increased perinatal mortality and morbidity. Risk factors include smoking, trauma, hypertension and cocaine use.
252
A 39-year-old female, gravida 4 and para 2+1, attends the Antenatal Clinic for her anomaly scan at 20 weeks. The report is shown below:
No abnormalities discovered during scan at present, however placenta localisation shows sign of adherence directly to superficial myometrium; however, it has not penetrated through to the muscle.
Which of the following conditions is the patient most likely to be diagnosed with?
253
A 22 year old woman attends at week 29 of her second pregnancy due to some mild post-coital vaginal bleeding. The bleeding occurred immediately following intercourse and has now entirely settled.
She is otherwise well and her pregnancy is progressing normally.
You perform a speculum examination to exclude preterm labour or ongoing antepartum haemorrhage.
Speculum examination shows the presence of an odourless clear-white watery fluid in the posterior vaginal vault. Is this finding normal or abnormal? What condition might it suggest?
The presence of a watery fluid pooling in the posterior vaginal vault may indicate premature prelabour rupture of membranes (PPROM). It is important to elicit any history of vaginal fluid loss and consider performing a fibronectin test to assess for PPROM
254
A 36-year-old para 2 woman is in active labour with regular contractions. She is 6cm dilated when she suddenly complains of intense abdominal pain and loss of contractions. The midwife is unable to obtain a trace through cardiotocography.
Her past medical history includes hypertension and a previous caesarean section for foetal distress.
What is the most appropriate management?
*note: oxytocin is contraindicated as it will increase the strength of contractions which can worsen uterine rupture*
255
For what condition does massaging the uterus to encourage contractions potentially helpful?
Uterine atony
256
1.A 64-year-old woman presents to her GP complaining of the sensation of ‘something coming
down’ in her pelvis for the past six months. There is no associated pain or vaginal bleeding, and no
urinary or bowel symptoms. The patient describes an altered sensation during intercourse. She had a
hysterectomy four years ago.
Which is the most likely diagnosis?
A. Haemorrhoid
B. Cystocele
C. Uterovaginal prolapse
D. Rectocele
E. Vault prolapse
E
257
1.A 64-year-old woman presents to her GP complaining of the sensation of ‘something coming
down’ in her pelvis for the past six months. There is no associated pain or vaginal bleeding, and no
urinary or bowel symptoms. The patient describes an altered sensation during intercourse. She had a
hysterectomy four years ago.
Which is the most likely diagnosis?
A. Haemorrhoid
B. Cystocele
C. Uterovaginal prolapse
D. Rectocele
E. Vault prolapse
E
258
A 23-year-old woman attends her GP wishing to be prescribed contraception. She currently uses
condoms during sexual intercourse with her long-term partner but would like to stop using them.
She is planning to have children in the future.
She has a past medical history of migraines with aura and heavy menstrual periods.
What does the GP prescribe her?
A. Copper IUD
B. Tubal ligation
C. Advises to continue using condoms and doesn’t prescribe anything
D. Progesterone only pill
E. Combined oral contraceptive pill
259
A 26-year-old woman comes into your GP practice with thin, watery, fishy-smelling vaginal
discharge. She denies any itch, pain or discomfort. This is her first episode of these symptoms.
What would you prescribe her?
A. Clindamycin
B. Metronidazole
C. Clotrimazole
D. Doxycycline
E. Ceftriaxone
Metronidazole
Patient has bacterial vaginosis and this is treated with metronidazole in Tayside.
260
A 30-year-old woman has amenorrhoea and low libido. She is also producing a milky discharge from
her nipples. Imaging shows a 4mm mass on her pituitary gland.
Given the likely diagnosis, what is the most appropriate management?
A. Bromocriptine
B. Cabergoline
C. Lanreotide
D. Trans-sphenoidal surgery
E. Sandostatin
This is most likely a prolactinoma so give cabergoline
261
A 62-year-old lady presents to the GP worried about a lump she found in her breast. She noticed
the lump two weeks ago and thinks it has grown since. There are no skin changes but on
examination a smooth solid lump is palpable with mild lymphadenopathy. She is worried because
her sister died of cancer 2 years ago.
How should this patient be investigated?
A. Watchful wait and come back in two weeks
B. Wait until routine mammogram is due
C. Routine referral to the breast clinic
D. Refer for urgent ultrasound scan
E. Urgent referral for triple assessment at the breast clinic
E
urgent referral for triple assessment. This patient has a family history of breast cancer and fast
growing palpable lump. It is a potential malignancy until proven otherwise so needs urgent referral especially given her family history. Triple assessment is gold standard – clinical assessment, imaging
and biopsy if required.
262
How is Downs syndrome screened for in first trimester?
If you’re between 11 and 14 weeks pregnant, you’ll be offered a blood test combined with a nuchal translucency (NT) ultrasound scan.
If you’re between 14 and 20 weeks pregnant, you’ll be offered a blood test on its own for Down’s syndrome only.
263
What does the 20 weeks appointment look for?
264
What are the 4 causes of post partum haemorrhage?
265
What information do you need to tell patients when prescribing POP?
Take POP at the same time everyday. If you miss a pill by 3 hours for traditional one or 12 hours for desogestrel pill, you need 48 hours emergency contraception from when you remember to take your missed pill. Take the pill as soon as possible when you remember and the next one at the usual time. Will need emergency contraception if you’ve had sex in the 48 hours after missing the pill. Need to take the pill everyday with no breaks between packs. Vomiting or severe diahorrea can make pill less effective.
266
If you take COCP from day 6 of your cycle when are you protected?
You are protected from pregnancy after you have taken COCP 7 days in a row. If you start COCP from day 1-5 of your period you are protected immediately.
267
If you vomit within 3 hours of taking COCP what should you do?
Take another one and then take your next pill at your usual time
268
What advice do you give patients that missed 1 or more COCP?
1 pill in a pack missed- take the missed one and carry on taking pills as normal
Between 2-7, depends on the week of the pack
Week 1 of the pack- may need emergency contraception and will need additional contraception for the next 7 days. Take missed pill and carry on taking pills as normal.
Week 2- don’t need emergency contraception but do need additional a contraception for 7 days
Week 3- no emergency contraception but extra contraception for 7 days, if 21 pill pack finish pack and start new pack, if 28 day pack only take active pills and then move on to next pack- won’t have pill free period or inactive pill period.
269
What antibiotic is given to treat chlamydia?
Doxycycline
270
Who should be offered retesting after chlamydia treatment?
Repeat testing should be:
-Offered to all people under the age of 25 years diagnosed with chlamydia 3–6 months after completion of treatment to check for re-infection.
-Considered for people over the age of 25 years who are at high risk of re-infection.
271
What test is done for bacterial vaginosis?
Examination may reveal a thin, white, homogeneous discharge coating the walls of the vagina and vestibule. Tests for BV involve checking the pH of the vaginal discharge, and/or sending a sample of the discharge to the lab for Gram-stain and microscopy.
272
What is the gestational limit for an abortion?
Up to 23 weeks and 6 days
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-Vacuum aspiration is typically done at up to 14 weeks if the
re is an Incomplete miscarriage oR leftover products of conception
-Dilatation and evacuation are done at 14 weeks to 24 weeks
274
Up until how many weeks can dilitation and cutterage be performed? Is this the same for dilitation and evacuation?
D&C is offered at up to 14 weeks
D&E is offered at 14 - 24 weeks.
275
What is the triple assessment?
Physical exam, mammogram and ultrasound done for detecting breast cancer
276
A 26-year-old woman presents to her GP with a 5 week history of worsening dull pelvic pain and smelly discharge. She has had a hormonal intrauterine device in situ for one year and does not menstruate with this. She has had the human papilloma virus vaccine but has not yet had any smear tests. What is the most likely diagnosis?
Question 2 Select one:
-Pelvic inflammatory disease
-Cervical ectropion
-Ectopic pregnancy
-Inflammatory bowel disease
-Cervical cancer
PID
Cervical ectropion is typically asymptomatic, however, some patients notice unusual discharge or unexplained vaginal bleeding
Ectopic, IBS and cervical cancer don’t explain the smelly discharge
277
A 34-year-old lady presents to the gynaecology department complaining of heavy, painful periods, and difficulty conceiving. She is concerned, as she and her husband would like to start a family soon. On further investigation, an ultrasound scan reveals a 4.5cm submucosal uterine fibroid. Which one of the following treatments is most appropriate to treat her fibroids?
Select one:
-Hysterectomy
-Mirena coil
-Myomectomy
-Tranexamic acid
-Hysteroscopic endometrial ablation
Myomectomy is the only treatment known to potentially improve fertility in patients with fibroids.
This can be done for all types of uterine fibroids that are large (more than 3cm) as these are more likely to affect fertility.
The large fibroid in this case is likely distorting the shape of the uterine cavity and affecting her fertility. Hysterectomy and endometrial ablation are not suitable as the patient would like to maintain her fertility. The mirena coil and tranexamic acid would provide symptomatic relief but have no affect on fertility. Myomectomy is likely to be successful for submucosal fibroids which reduce fertility through preventing implantation.
278
What is adenomyosis?
A condition where endometrial tissue is found in the myometrium.
279
A 24year old lady presents to her GP with cyclical pelvic pain associated with dyspareunia and dysmenorrhea.
On examination, she has a fixed, retroverted uterus. Which investigation is most useful?
Select one:
-FBC to check haemoglobin levels.
-Abdominal ultrasound scan
-Pelvic MRI
-Transvaginal ultrasound scan
-Laparoscopy
*Remember: in terms of not confusing PCOS and endometriosis, PCOS presents with an ovulation or oligovulation (irregular or absent periods will be seen), hyperandrogenism and polycystic ovaries (at least 2 out of three needs to be present for diagnosis).*
Laparoscopy is the gold standard investigation for suspected endometriosis and can be combined with biopsy and histological verification of endometrial glands and/or stroma. A Full blood count would only confirm that the patient is anaemic secondary to heavy menstrual loss. Abdominal ultrasound may be useful additional test and rule out important differentials (e.g. fibroids).
The correct answer is: Laparoscopy
280
A 30-year-old lady presents to the gynaecological outpatient department after she presented to her GP complaining of inability to conceive despite attempting for 2 years. A trans-vaginal ultrasound scan is performed, and the report is given below:
A single 5cm by 7cm septated cyst is seen on the inferior aspect of the right ovary. The left ovary is normal in size and morphology.
What further management would you suggest for this patient?
Select one:
-Perform a serum CA-125, alpha feto-protein and beta HCG and book for elective cystectomy
-Commence metformin
-Perform an ultrasound guided fine need aspiration of the cyst for cytology
-Book for a bilateral salpingo-oopherectomy (BSO)
-Reassurance and review with repeat ultrasound in 8 weeks
Complex cysts are defined as cysts containing solid mass or those which are multi-loculated, and should be treated as malignant until proven otherwise. RCOG Green-top guidelines No. 62, recommend serum CA125, alpha fetoprotein and beta-HCG are performed for all pre-menopausal women with a complex ovarian cysts. Aspiration is associated with a higher rate of recurrence and spillage into the peritoneal cavity which may spread malignant cells, therefore cystectomy is better than aspiration. Removing the patient’s ovaries and tubes is a drastic operation and may not be appropriate in such a young female, especially without further investigation. There is no evidence that the patient has features of PCOS therefore metformin is not necessary. If the cyst was smaller in size and a simple cyst (thin walled, non-loculated, option D would be appropriate)
The correct answer is: Perform a serum CA-125, alpha feto-protein and beta HCG and book for elective cystectomy
281
You are seeing a 37-year-old pre-menopausal woman in gynae clinic who was diagnosed with adenomyosis two years ago. She has trialed multiple hormonal therapies over the past two years but has had limited success and has also experienced some undesirable side effects. She now wishes to discuss options for surgical treatment.
Which of the following options would be a suitable treatment to offer?
Select one:
-Endometrial ablation
-Hysterectomy
-Myometrial ablation
-Uterine artery embolization
-Uterine myomectomy
The only definitive treatment for adenomyosis is hysterectomy.
282
A 38-year-old woman with a 4.5cm fibroid has been listed for a myomectomy following a 5 month history of heavy menstrual bleeding, What drug should be prescribed to be taken whilst awaiting surgery?
Select one:
-Tranexamic acid
-Oral progestogen
-Oral contraceptive pill
-Gonadotrophin-release hormone analogue
-Mirena IUS
GnRH analogues can be used to reduce the size of fibroids before surgery. NICE guidelines NG88 suggest GnRH or ulipristal acetate for fibroids ≥3cm in diameter. A Mirena IUS is not indicated when the uterus is distorted with a fibroids more than 3cm in diameter.
The correct answer is: Gonadotrophin-release hormone analogue
283
A 27-year-old woman complains of spasmodic pains in the left iliac fossa. These pains have been present for the past six months and sometimes radiate to the back. She often feels bloated, particularly around her period. She describes her bowels as being 'stubborn' but does not take a regular laxative. Vaginal and abdominal examination is unremarkable. What is the most likely diagnosis?
Select one:
-Diverticulitis
-Pelvic inflammatory disease.
-Irritable bowel syndrome
-Endometriosis
-Ovarian torsion
There are no risk factors to suspect PID in this patient, and she has not reported vaginal discharge, irregular bleeding or unprotected sexual intercourse. Diverticulitis is less common in young individuals, endometriosis whilst possible is less likely as her symptoms are mainly bowel related. Ovarian torsion would present with sudden severe onset pain.
The correct answer is: Irritable bowel syndrome
284
True or false, LMWH should be avoided in pregnancy?
False- LMWH and unfractionated heparin are considered the safest anticoagulants for pregnant women.
*DOACs and NOACs should be avoided*
285
What’s chorionic villus sampling? And what is it used for?
Diagnostic test done between 10-13 weeks of gestation. Chorionic villus is sampled and tissue is analysed to look for genetic abnormalities.
286
Why is uterine massage done post partum?
To encourage the uterus to continue to contract to prevent post partum haemorrhage.
287
Postpartum, when does the uterus stop becoming palpable?
About 2 weeks postpartum, it will have returned to the true pelvis
288
When can medical termination of pregnancy take place?
Between 10+1 weeks and 23+6 weeks gestation
289
How do mifepristone and misprostol work?
290
When is the first dose of anti-D prophylaxis administered to rhesus negative women?
28 weeks
291
How is cord prolapse managed?
Emergency Caesarean section- this is a category 1 C section due to immediate threat to life of mother and baby.
Cord prolapse can cause foetal hypoxia.
Need to keep cord wet and warm with minimal handling to prevent vasospasm. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord. Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.
292
What category C section does pre-eclampsia fall under?
Category 3
293
How does fifth’s disease present and what re the complications of this in pregnancy?
Rash of arms and legs and joint pain
Complications in pregnancy- foetal anaemia, hydrops foetalis, miscarriage
Low reticulocyte count and postive anti-parovirus B19 IgM antibody will likely be present
294
A pregnant woman, at 40 weeks gestation, phones her hospital because she is now experiencing long, painful uterine contractions after a long day of milder and less regular contractions. One hormone is central to this physiological process. Where is its target site of action?
Cell-surface receptors on myometrial cells
295
The cervix dilates and softens under the influence of what during labour?
Prostaglandins
296
A 37 year old woman attends the walk-in sexual health clinic after forgetting to take her last Progesterone-only pill. She usually takes Micronor (Norethisterone) once a day. Her last pill was due four hours ago. She has not had any unprotected sexual intercourse this month.
What is the most appropriate advice to give?
297
A 59 year old woman presents to her GP complaining of an itchy, red left nipple for the last 2 months. She denies any other symptoms and has no significant medical history. On examination, there is the nipple appears scaly, with mild ulceration and erythema, and a 1.5cm hard lump behind the nipple. What is the most likely diagnosis?
298
A 42-year-old woman is referred to a breast clinic after finding a hard, irregular, 1 cm lump in her left breast. A triple assessment is carried out, and breast cancer cells are found in four axillary lymph nodes. There is no evidence of metastasis.
What is her TMN score?
299
Options:
-Chlamydia trachomatis
-Escherichia coli
-Neisseria gonorrhoeae
-Proteus mirabilis
300
A 62-year-old woman presents to her doctor with a 3-month history of bloating, early satiety, change in bowel habit, and weight loss. A physical exam revealed an irregular adnexal mass and shifting dullness. Serum levels of CA-125 were markedly raised and her doctor orders a pelvic ultrasound scan. She is then referred to the regional gynaecological cancer centre for a staging laparotomy and her surgeon informs her that her cancer has spread to her lymph nodes.
What is the most likely group of lymph nodes that this patient's condition has spread to?
301
A 25-year-old female is being investigated for an irregular looking cyst on her right ovary. AFP levels are raised. A biopsy of the cyst is taken and the report is shown below:
Biopsy report: Schiller-Duval bodies are seen
Which of the following ovarian tumours has this lady developed?
302
A 27-year-old new mother presents to the GP with painful breasts. She gave birth 3 weeks ago via vaginal delivery. She has been exclusively breastfeeding. Over the past week, she has noticed that her left breast has become very painful and swollen.
On examination, the left breast is erythematous, and fissuring of the nipple can be seen.
Given the likely diagnosis, what is the best course of treatment for this patient?
303
A 50-year-old female undergoes a mastectomy for the treatment of breast cancer. Several weeks after the surgery, she reports a feeling of tightness and pulling in the chest area, as well as limited range of motion in the affected arm. On examination, there is a visible and palpable cord-like structure in the axillary region, as well as thickening and tightening of the skin in the chest area.
What is the most likely complication of this surgical procedure?
304
A 53 year old woman is diagnosed with a 3cm T2N0M0 ductal carcinoma in the upper medial left breast. She is otherwise fit and well. What is the most appropriate management of this patient?
305
A 35-year-old woman presents to the GP surgery with a new lump in her left breast.
On examination, she appears well. In the left breast, you feel a hard, freely movable, and well-circumscribed mass in the upper outer quadrant. It has a diameter of 3 cm. Physical examination of the right breast reveals no abnormalities.
Which of the following is the next best step in the management of this patient?
306
A 62 year old post-menopausal woman presents to the emergency department with a rash, abdominal pain, and arthralgia. She was diagnosed with oestrogen receptor-positive breast cancer 2 years ago, and has been taking several medications since then. On examination, she has a mildly tender abdomen, and a non-blanching purpuric rash across her lower limbs. The remainder of her examination and vital signs are unremarkable.
What medication has she likely been taking?
307
A 36-year-old woman attends her GP worried about breast cancer. She is asymptomatic but states she has a family history of breast cancer.
Which of the following circumstances in her family history would merit referral to secondary care?
A 36-year-old woman attends her GP worried about breast cancer. She is asymptomatic but states she has a family history of breast cancer.
Which of the following circumstances in her family history would merit referral to secondary care?
-Her aunt had bilateral breast cancer aged 39
-Her mother had bilateral breast cancer aged 65
-Her father had unilateral breast cancer aged 51
-Her mother had unilateral breast cancer aged 46
-Her cousin had unilateral breast cancer aged 25
308
A 36-year-old man is referred for genetic counselling due to a strong family history of breast cancer. His mother was diagnosed aged 38 and his sister was diagnosed aged 32. After extensive discussions, he decides to go ahead with genetic testing and is found to be a carrier of the BRCA2 gene.
Which of the following cancers is he at increased risk of developing due to this mutation?
-Renal cell carcinoma
-colorectal cancer
-thyroid cancer
-testicular cancer
-prostate cancer
309
A 42 year old woman visits her GP concerned about breast cancer. Her 43 year old friend has just been diagnosed with invasive breast cancer and she would like to know more about breast cancer screening. Women of what age range are invited to breast cancer screenings and how often do they occur?
In England all women aged 50-70 are invited to have screening every 3 years
310
A 29-year-old woman presents to the GP with a new breast lump. On examination, there is a firm, smooth, 2 cm lump in the upper outer quadrant of her left breast. It is highly mobile with well-defined borders. It is not painful, and there are no overlying skin changes.
Which is the most appropriate management?
Urgent referral to the outpatient breast clinic
Needle aspiration
Routine referral to the outpatient breast clinic
Referral for surgical excision
Antibiotics
311
A 55-year-old woman presents to the GP with nipple changes. Over the past two months, she has noticed that her left nipple has developed an itchy rash. On examination, there is a dry, erythematous rash around the left nipple. On palpation, there is a lump underneath the nipple.
Which of the following is most likely to be the underlying diagnosis?
Ductal carcinoma in situ (DCIS)
Intraductal papilloma
Nipple eczema
Mammary duct ectasia
Fat necrosis of the breast
312
A 53 year old woman presents to her GP with a one week history of bloody discharge from her left nipple. She has no other past medical history. She is post-menopausal. She denies any other symptoms. On examination, there are no abnormalities on inspection, and there are no lumps on palpation.
What is the next step in her management?
2 week wait referral for clinical assessment, mammography and biopsy
This is the correct answer. NICE recommends a 2 week wait referral for triple assessment for all patients above 50 years old presenting with unilateral nipple discharge. Mammograms are the preferred imaging modality in this age group.
313
Describe the three stages of syphillis
primary- painless solitary genital ulcer
secondary- symmetrical maculopapular rash, and lymphadenopathy
tertiary- may present with gummatous disease, cardiovascular complications, and neurological implications
314
how is syphillis diagnosed and managed?
diagnosis is serological testing and management is typically penicillin based
315
what antibiotics do you give to treat chlamydia?
doxycycline (azithromycin if penicillin allergic)
316
A 28 year old female presents to Accident & Emergency with three days of fever, lower abdominal pain, and deep dyspareunia. She tells you she has recently had treatment one month ago for Chlamydia, but did not complete the course of antibiotics. She has had at least 7 sexual partners in the last three months and has not used any barrier methods of contraception. She has not had sex since her diagnosis of Chlamydia. She has no other medical history and has no drug allergies. On examination, she is vomiting and unable to tolerate any oral intake. She has a fever of 38.9 degrees.
Which of the following is the best treatment?
IV Ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 days)
317
first line antibiotics for pyelonephritis/complicated UTI
cotrimoxazole or coamoxiclav
318
endometrial thickness of greater than how many mm warrants hysteroscopy in a postmenopausal woman presenting with new onset postmenopausal bleeding?
5mm or more
319
Serous Cystadenocarcinoma is a common epithelial ovarian cancer subtype characterised by the presence of what on histology?
Psamomma bodies
320
First line management for fibroids under 3 cm?
IUS
321
How long after birth, miscarriages or terminations are cervical smears done?
3 months
