Obs and Gynae Flashcards

Question

What is some key information about Vaginal Pessaries?

Answer 1

* Should be removed and cleaned or changed periodically (every 4 months) * Can cause vaginal irritation and erosion over time * Oestrogen cream helps protect the vaginal walls from irritation

Answer 2

* Pain, bleeding, infection, DVT and risk of anaesthetic * Damage to the bladder or bowel * Recurrence of the prolapse * Altered experience of sex

Answer 3

Involuntary passage of urine

Answer 4

A chronic condition that results rom hyperactivity of the **detrusor muscle**. This is primarily characterised by **urinary urgency and urge incontinence**

Answer 5

* **Urinary Urgency** * **Urge Incontinence** * Frequency * Nocturia

Answer 6

* Typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. * Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access. * This can have a significant impact on their quality of life, and stop them doing work and leisure activities.

Answer 7

* **Urinary tract infections:** Characterised by dysuria, urgency, frequency, suprapubic pain and haematuria. * **Bladder stones:** Symptoms include lower abdominal pain, dysuria, intermittent stream, and blood in the urine. * **Interstitial cystitis:** Presents with symptoms such as chronic pelvic pain, a persistent, urgent need to urinate, and frequent urination. * **Diabetic neuropathy:** Can cause bladder dysfunction, resulting in symptoms like frequent urination and incontinence.

Answer 8

* **Urinalysis and culture:** To rule out infection * **Frequency/volume chart:** To assess the severity of the condition * **Urodynamics:** To evaluate bladder muscle function

Answer 9

**First Line: For at least 6 weeks:** * **Bladder retraining:** Which aims to increase the interval between voids, and suppress the urinary urge * **Behavioural modifications:** Such as reducing oral fluid intake, and avoiding caffeine and alcohol **Second Line:** * **Anticholinergic drugs:** Like oxybutynin, Tolterodine and solifenacin * **Mirabegron:** An alternative to anticholinergics * **Vaginal oestrogens:** Used if urogenital atrophy is a likely contributory factor **Invasive options when medical treatments fail** * **Botulism toxin:** Used specifically for refractory cases

Answer 10

* Oxybutynin * Tolterodine * Solifenacin

Answer 11

* Dry mouth and eyes * Urinary Retention * Constipation * Postural Hypotension * Cognitive decline and memory problems * Worsening of Dementia

Answer 12

A beta 3 agonist that stimulates the sympathetic nervous system causing relaxation of the bladder.

Answer 13

**Uncontrolled Hypertension.** * Since it stimulates the sympathetic nervous system it can lead to a raised blood pressure and can result in a hypertensive crisis! * Can also increase the risk of stroke and TIA

Answer 14

* **Botulinum toxin type A** injection into the bladder wall * **Percutaneous sacral nerve stimulation** involves implanting a device in the back that stimulates the sacral nerves * **Augmentation cystoplasty** involves using bowel tissue to enlarge the bladder * **Urinary diversion** involves redirecting urinary flow to a urostomy on the abdomen

Answer 15

The loss of control of urination leading to involuntary passage of urine

Answer 16

**Bladder function:** * Detrusor muscle remains relaxed to allow the bladder to fill with urine. * This relaxation is primarily mediated by the sympathetic nervous system (via the hypogastric nerve, which releases noradrenaline), acting on β-adrenergic receptors in the bladder wall. **Urethral function:** * The internal urethral sphincter (smooth muscle) remains contracted, and the external urethral sphincter (skeletal muscle) maintains voluntary closure, preventing urine leakage. * The sympathetic system helps keep the internal sphincter closed * The somatic nervous system (via the pudendal nerve) controls the external sphincter. **Nervous control:** * The pontine storage centre in the brainstem inhibits detrusor contraction during bladder filling * while sensory signals from the bladder stretch receptors are sent to the brain, indicating fullness without triggering voiding.

Answer 17

**Bladder function:** * When the bladder reaches a certain level of fullness, signals from the brain initiate the voiding phase. * The parasympathetic nervous system (via the pelvic nerve) stimulates the detrusor muscle to contract, increasing pressure in the bladder. **Urethral function:** * At the same time, the internal urethral sphincter relaxes, and the external urethral sphincter voluntarily relaxes to allow urine to flow through the urethra. **Nervous control:** * The pontine micturition centre coordinates this process, * Bladder contraction and sphincter relaxation. * Voiding occurs when detrusor pressure overcomes urethral resistance.

Answer 18

Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing * Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening * Somatic afferent - S2-4 pudendal - sensation of bladder fullness * Somatic efferent - S2-3 pudendal - closes / opens EUS.

Answer 19

1. Reflexive contraction of the pelvic floor muscles elevates the IUS. 2. Augmentation of pelvic floor muscle closure by suspensory ligaments. 3. Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure

Answer 20

* Stress incontinence * Urge incontinence * Overflow incontinence * Functional incontinence * Mixed incontinence

Answer 21

Caused by **Overactivity of the detrusor muscle.** This is also known as overactive bladder syndrome

Answer 22

Leaking of urine when intra-abdominal pressure is raised that puts pressure on the bladder. The pressure overcomes the mechanisms to maintain continence. **This occurs due to weakness of the pelvic floor and sphincter muscles**

Answer 23

* Childbirth (Especially vaginal) * Hysterectomy

Answer 24

**Anything that can increase abdominal pressure sufficiently** * Coughing * Laughing * Sneezing * Exercising

Answer 25

**Lifestyle Advice:** * Avoid caffeine, fizzy and sugary drinks * Avoid excessive fluid intake * Pelvic floor exercises (8x contractions x3 per day) **Medical Management:** * **Duloxetine** (only recommended if conservative management fails and the patient is not a surgical candidate) **Surgical Management:** * Pessaries * **Bulking agents** placed at the bladder neck * **Colposuspension and fascial slings** * **Mid urethral slings**

Answer 26

**Mid-urethral slings** is the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in closing the urethra.

Answer 27

Individual has the urge to pass urine but for whatever reason they are unable to access the necessary facilities and are aw a result incontinent.

Answer 28

* Sedating Medications * Alcohol * Dementias

Answer 29

Occurs when small amounts of urine leak without warning. This may happen when the pressure within the bladder overcomes the pressures of the outlet structure and thus urine leaks

Answer 30

* Underactivity of the detrusor muscle **such as from neurological damage** * Urinary outlet pressures are too high **Such as in constipation or prostatism** * Chronic urinary retention due to an obstruction. * Anti-cholinergic medications.

Answer 31

A combination of urge incontinence and stress incontinence. It is crucial to identify which of the 2 is having the more significant impact and address this first.

Answer 32

**First Line:** * **Medical history and Assessment** * **Physical Examination** * **Bladder Diary:** tracking fluid intake, episodes of urination and incontinence **over at least 3 days** * **Urinalysis and Urine-Dip stick:** To look for infection or other pathology **Second Line:** * **Urinary Stress Tests:** Cough stress test, empty supine stress test * **Cystometry and Cystogram:** Bladder scan to assess for bladder pressures when voiding or fistulas * **Urodynamics**

Answer 33

**Differentiate between Stress or Urge:** * Urinary leakage with coughing, laughing or sneezing (**Stress**) * Urinary leakage due to sudden urge to pass with loss of control (**Urge**) **Assess for Modifiable lifestyle factors:** * Caffeine consumption * Alcohol consumption * Medications (anticholinergics) * BMI **Assess the Severity:** * Frequency of urination * Frequency of incontinence * night-time urination * Use of pads and changes of clothing.

Answer 34

**Assessment of Pelvic Tone:** 0: No contraction 1: Faint contraction 2: Weak contraction 3: Moderate contraction with some resistance 4: Good contraction with resistance 5: Strong contraction, a firm squeeze and drawing inwards **Also examine for** * Pelvic organ prolapse * Atrophic vaginitis * Urethral diverticulum * Pelvic masses * urinary incontinence (asking the patient to cough)

Answer 35

* Patients with Urge incontinence **not responding to first line medical treatments** * Difficulties urinating * Urinary retention * Previous surgery in and around the pelvis * Unclear diagnosis

Answer 36

* Patients should stop taking anticholinergic and bladder related medications for **5 days before** testing. * A catheter is inserted into the bladder and the rectum and they measure the pressures for comparison. The bladder is filled with liquid and different measurements are taken.

Answer 37

* **Cystometry** measures the detrusor muscle contraction and pressure * **Uroflowmetry** measures the flow rate * **Leak Point Pressure** is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence. * **Poist-void residual bladder volume** tests for incomplete emptying of the bladder * **Video urodynamic testing** involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

Answer 38

Urinary tract stones or Urolithiasis refer to solid concretions or crystal aggregations formed in the urinary system from substances present in the urine

Answer 39

A condition characterised by severe pain caused by the presence of a stone in the urinary tract

Answer 40

* Common condition affecting 2-3% of western population * More common in males * More common in people **younger than 65**

Answer 41

**Calcium oxalate stones:** * Represent **85% of stones**. They are radiopaque, formed in variable urine pH, and majorly linked to **hypercalciuria**. **Calcium phosphate stones:** * Account for **10% of stones**. They are radiopaque and linked to **renal tubular acidosis type 1 & 3,** leading to increased urine pH and supersaturation of calcium and phosphate in the urine. **Cystine stones:** * Make up **1% of stones**. Characterised by a semi-opaque "ground glass" appearance, they result from inherited recessive inborn errors of metabolism causing disruption in cystine transport and decreased absorption from the renal tubule. **Uric acid stones:** * Comprise **5-10 of stones.** They are radiolucent, formed due to acid produced from **purine metabolism and precipitate when urinary pH is low.** They can be linked to diseases causing extensive tissue breakdown. **Struvite stones:** * Account for **2-20% of stones**. They are radiopaque and formed from magnesium, ammonium, and phosphate, often **associated with chronic UTIs from urease producing bacteria like ureaplasma, proteus.** **Indinavir stones:** * Associated with the antiretroviral protease inhibitor **Indinavir** used in HIV treatment. It can crystallize in renal tubules and result in renal stones. These stones are radiolucent on CTKUB.

Answer 42

**Hypercalcaemia/Hypercalciuria** Patients may present with symptoms of hypercalcaemia (**renal stones, painful bones, abdominal groans and psychiatric moans**) **3 Main causes of Hypercalcaemia:** * Calcium supplementation * Hyperparathyroidism * Cancer (Myeloma, Breast, Lung)

Answer 43

**Modifiable risk factors include:** * Obesity * Dehydration * Diet rich in oxalate-rich foods like fruits, nuts, and cocoa **Non-modifiable risk factors include:** * Previous stone disease * Anatomical abnormalities of the collecting system * Family history **Underlying medical conditions, such as:** * Hyperparathyroidism * Renal tubular acidosis * Myeloproliferative disorders * All chronic diarrhoeal conditions

Answer 44

Where the stone forms in the shape of the renal pelvis giving it a similar appearance to the antlers of a deer stag. Often associated with **Struvite stones**

Answer 45

* Unilateral **Colicky loin to groin pain** that can be excruciating (“worse than childbirth”) * Haematuria * Nausea or vomiting * Reduced urine output * Symptoms of sepsis (Fever), if infection is present

Answer 46

* **Pyelonephritis:** Presents with fever, flank pain, and urinary symptoms such as frequency, urgency, and dysuria. * **Appendicitis:** Presents with right lower quadrant pain, nausea, vomiting, and possibly fever. * **Diverticulitis:** Presents with left lower quadrant pain, fever, nausea, vomiting, and changes in bowel habits. * **Ovarian torsion:** Presents with acute lower abdominal pain, nausea, vomiting, and sometimes fever. * **Ectopic pregnancy:** Presents with lower abdominal pain, vaginal bleeding, and a positive pregnancy test. * **Abdominal aortic aneurysm:** Presents with central abdominal pain, pulsatile/expansile abdominal aorta and if ruptured, haemodynamic instability.

Answer 47

**Bedside investigations:** * Urinalysis to detect haematuria * Urine MC+S as there may be a co-existing infection/precipitant. * Observations to look for any signs of sepsis **Blood tests:** * Full Blood Count to detect any inflammatory response * Urea and Electrolytes to assess any impairment in renal function. * Calcium & Uric acid to identify underlying metabolic conditions predisposing to stone formation. **Radiological investigations:** * A **non-contrast helical CT KUB, the gold standard for identifying renal calculi.** * An x-ray for managing renal colic if there's a confirmed stone on CT KUB, **necessary for the use of extracorporeal shockwave lithotripsy.**

Answer 48

**Non-contrast CT Kidney, Ureter and Bladder (CTKUB)** is both the **initial** and **Gold standard investigation** * NICE recommend a CT within **24 hours** of presentation * BAUS recommend a CT within **14 hours** of admission

Answer 49

* **Analgesia:** NSAIDs such as **IM Diclofenac** * **Anti-emetics:** Metoclopramide, Cyclizine * **Antibiotics:** If infection is present * **Medical Expulsive Therapy:** Uses Tamsulosin to help passage of distal ureter stones < 5mm * **Watchful Waiting:** If stones are less than **5mm** * **Surgical Intervention:** required in larger stones **10mm** or more or ones that do not pass spontaneously. Also required if there is complete obstruction or infection.

Answer 50

**Stones < 2cm** * Extracorporeal shockwave lithotripsy (ESWL): shock waves fragment the stone to then be passed * **Ureteroscopy:** Treatment of choice for middle or distal ureteric stones and for **Pregnant women** **Stones > 2cm** * **Percutaneous nephrolithotomy:** for large stones or complex calculi like staghorn or cysteine. * **Open Stone surgery:** when other options have failed.

Answer 51

* **Significant risk of recurrent episodes** * Obstructive infection * Sepsis * Renal Failure

Answer 52

* Increase oral fluid intake (2.5 – 3 litres per day) * Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones) * Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation) * Reduce dietary salt intake (less than 6g per day) * Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)

Answer 53

Infrequent/irregular menstrual periods (fewer than 6-8 per year)

Answer 54

Absence of a menstrual period **Primary:** absence of a period at age 15 in the presence of normal secondary sexual characteristics **or** at age 13 with no secondary sexual characteristics **Secondary:** Absence of a period for 3 consecutive cycles in a women with a previously established menstrual cycle

Answer 55

* Constitutional delay (Familial) * Imperforate hymen * **Endocrinological:** Hypo-hyperthyroidism, Hyperprolactinaemia, Cushing's Syndrome * **Androgen Insensitivity Syndrome** * Turners syndrome

Answer 56

* **Pregnancy** (most common cause) * Breastfeeding * Menopause * Intrauterine adhesions leading to outflow tract obstruction **(Asherman's syndrome)** * Polycystic ovary syndrome (PCOS) * Drug-induced amenorrhoea (e.g. contraceptive use) * **Functional Hypothalamic Amenorrhoea:** Physical stress, excess exercise, and weight loss * **Pituitary gland pathology:** such as Sheehan syndrome or hyperprolactinaemia * **Hypothyroidism or hyperthyroidism**

Answer 57

An **X-linked Recessive** genetic condition where cells are unable to respond to androgen hormones due to **a lack of androgen receptors** This results in **Genetic Males** with a **Female Phenotype**

Answer 58

* Mutation in Androgen receptor gene on the **X chromosome** results in cells becoming unable to respond to androgens. * Excess androgens are converted to Oestrogen resulting in **female secondary sexual characteristics** (Previously known as **Testicular feminisation syndrome**) * Males are genetically XY with a female phenotype

Answer 59

* Female External Genitalia and Breast Development * Testes located within the abdomen or inguinal canal. * Absence of Female internal organs (Uterus, upper vagina, cervix, fallopian tubes and ovaries) due to the **testes producing anti-Mullerian hormone**. * Patients are taller than female average, with a lack of pubic hair, facial hair and male type muscle bulk.

Answer 60

High risk of Testicular cancer unless the testes are removed

Answer 61

* **Often presents in infancy** with **Inguinal hernias containing testes** * May present at puberty with **Primary Amenorrhoea**

Answer 62

**Exclude pregnancy** with urinary or serum bHCG **Full blood count** - anaemia **Urea & electrolytes** **Coeliac screen** **Thyroid function tests** **Gonadotrophins (LH/FSH):** * Low levels indicate a hypothalamic cause where as * Raised levels suggest an ovarian problem (e.g. Premature ovarian failure) * Raised if gonadal dysgenesis (e.g. Turner's syndrome) **Prolactin** for Hyperprolactinaemia **Androgen levels** * Raised levels may be seen in PCOS **Oestradiol** **Second Line:** * **Genetic Testing:** Identify chromosomal or genetic abnormalities * **Imaging:** To identify structural abnormalities

Answer 63

* Raised LH * Normal or raised FSH * Normal or Raised Testosterone levels (For a male) * Raised Oestrogen levels (For a male)

Answer 64

**Depends on the underlying cause** * **Hormone replacement therapy:** For hormonal imbalances * **Surgery:** For structural abnormalities * **Psychological support:** For conditions related to stress or eating disorders * **Lifestyle modifications:** For issues related to excessive exercise or low body weight * **Monitoring and regular follow-ups:** To assess effectiveness of treatment and adjust as necessary

Answer 65

MDT Specialist Coordination: Paediatrics, Gynaecology, Urology, Endocrinology, Clinical Psychology * **Bilateral Orchiectomy:** To avoid testicular tumours * **Oestrogen Therapy** * **Vaginal Dilators or Vaginal Surgery:** To create and adequate length vagina **Generally patients are raised as female but this is tailored to the individual**

Answer 66

They develop from the **paramesonephric ducts** (**Mullerian ducts**)

Answer 67

The testes in a male foetus produce Anti-Mullerian hormone which suppresses the growth of the paramesonephric ducts and so they do not form.

Answer 68

* Bicornuate Uterus * Uterus Agenesis * Imperforate Hymen * Transverse vaginal Septae * Vaginal Hypoplasia and Agenesis

Answer 69

* Uterus has 2 horns giving it a heart shaped appearance. * This can be associated with adverse pregnancy outcomes however successful pregnancies are generally expected.

Answer 70

* Miscarriage * Premature Birth * Malpresentation

Answer 71

Where the hymen at the entrance of the vagina is fully formed without an opening.

Answer 72

* May be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. * This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.

Answer 73

* Diagnosed during a **clinical examination** * Treatment is a **Surgical incision** to create an opening in the hymen.

Answer 74

* If not treated then **retrograde menstruation** could occur leading to **endometriosis** * Amenorrhoea

Answer 75

Caused by an error in development, where a septum (wall) forms transversely across the vagina. This septum can either be perforate (with a hole) or imperforate (completely sealed).

Answer 76

* **Perforate Septae:** Girls will menstruate but can have difficulty with intercourse or tampon use * **Imperforate Septae:** Presents similarly to an Imperforate Hymen

Answer 77

* Infertility * Pregnancy related complications * **Vaginal Stenosis** * **Recurrence of the Septae**

Answer 78

* Diagnosis is by **Examination, Ultrasound or MRI** * Treatment with with **Surgical Correction**

Answer 79

**Hypoplasia:** An Abnormally small vagina **Agenesis:** An absent vagina These occur due to failure of the Mullerian ducts to properly develop and are often associated with an absent uterus and cervix

Answer 80

The Mullerian Ducts fail to develop but not due to Anti-Mullerian Hormone. Therefore patients do not have Testes (like in AIS) but **do have Ovaries**

Answer 81

* **Vaginal Dilator** over a prolonged period of time to create and adequate vaginal size * **Vaginal Surgery** may be necessary

Answer 82

The first occurrence of Menstruation

Answer 83

Mean age 13 11-15 usually.

Answer 84

This term describes the permanent cessation of menstruation, characterised by **at least 12 months of amenorrhoea** in otherwise healthy women over the age of 45 who are not using hormonal contraception.

Answer 85

Between the ages of 45-55 with the average age being around 51-52 years old.

Answer 86

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

Answer 87

The period from 12 months after the final menstrual period

Answer 88

Menopause between the ages of 40-45 years old. **Premature Menopause** is the menopause occuring prior to the age of 40 and is due to ovarian insufficiency

Answer 89

Caused by ovarian failure which leads to oestrogen deficiency

Answer 90

* Primordial follicles mature into primary and secondary follicles independently of the menstrual cycle. * FSH stimulates secondary follicle development at the start of the menstrual cycle, leading to increased oestrogen production (granulosa cells). * At Menopause primordial follicle number is depleated leading to a decline in follicle development, reducing oestrogen production. * As oestrogen declines, the lack of negative feedback causes increased LH and FSH levels from the pituitary gland. * Reduced follicular development leads to anovulation, irregular cycles, amenorrhoea, and perimenopausal symptoms due to low oestrogen. * Without Oestrogen the endometrium does not develop eventually leading to a lack of menstruation (amenorrhoea)

Answer 91

Lower levels of Oestrogen

Answer 92

**Vasomotor Symptoms:** * Hot flushes * Night sweats * Irregular periods, Heavy or lighter periods * Joint Pains **Sexual Dysfunction:** * Vaginal dryness and atrophy * Reduced libido * Problems with Orgasm * Dyspareunia **Psychological Symptoms:** * Depression * Anxiety * Mood Swings, Low mood and emotional lability * Lethargy * Reduced Concentration

Answer 93

**Reduced oestrogen increases the risk of certain conditions:** * Cardiovascular disease and stroke * Osteoporosis due to increased bone turn over since normal oestrogen levels inhibit osteoclast activity * Pelvic Organ Prolapse * Urinary Incontinence

Answer 94

* **Thyroid disease:** symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle * **Depression:** exhibits mood swings, lethargy, reduced concentration * **Premature ovarian insufficiency:** can cause hot flushes, night sweats, vaginal dryness, and reduced libido

Answer 95

**Diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms without performing any investigations** NICE Guidelines (2015) recommend FSH Blood test to help with Diagnosis: * **Women under 40 years** with suspected premature menopause * **Women aged 40-45** with menopausal symptoms or a change in menstrual cycle * Elevated FSH level **(>30 IU/L)** may predict impending menopause after several months of amenorrhoea

Answer 96

**Two years** after the last menstrual period in women **under 50** **One year** after the last menstrual period in women **over 50**

Answer 97

Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms. This can make diagnosing menopause in women on hormonal contraception more difficult.

Answer 98

Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (under 45 years) Sterilisation

Answer 99

**Weight Gain and Reduce bone mineral density (osteoporosis)** This is why this form of contraception is unsuitable for women **Over 45 years old**

Answer 100

**Vasomotor symptoms likely resolve after 2-5 years without treatment** **Management of Symptoms depends on severity, personal circumstances and response to treatment** **First Line: Lifestyle Measures** * Regular Exercise * Weight Loss (as necessary) * Avoidance of triggers (Smoking, alcohol, spicy food) **Second line: Hormone replacement therapy (HRT)** * **Tibolone**, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) * **Clonidine**, which act as agonists of alpha-adrenergic and imidazoline receptors for flushing * **Cognitive behavioural therapy (CBT)** * **SSRI antidepressants**, such as fluoxetine or citalopram * **Testosterone** can be used to treat reduced libido (usually as a gel or cream) * **Vaginal oestrogen** cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) * **Vaginal moisturisers**, such as Sylk, Replens and YES

Answer 101

**Oestrogens:** Overcome oestrogen deficiency **Progesterone's:** Required for endometrial protection from unopposed systemic oestrogens * HRT can be given cyclically (for perimenopause) or continuously (for post menopause)

Answer 102

**Benefits** * Relief of Vasomotor symptoms * Relief of urogenital symptoms * Reduced risk of Osteoporosis **Risks** * Increased risk of Breast Cancer * Increased risk of Endometrial Cancer (**if given oestrogen alone**) * Increased risk of VTE

Answer 103

B – Breast cancer (current or history of) R – Recent heart attack (myocardial infarction) E – Endometrial cancer (current or untreated) A – Active liver disease S – Stroke (recent or history of) T – Thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism) C – Clotting disorder (e.g., thrombophilia, protein C/S deficiency) L – Liver disease (severe or active) O – Oestrogen-sensitive cancer (like ovarian cancer) T – Thrombosis risk (high risk for clot formation)

Answer 104

Refers to a condition where **endometrial tissue** is inside the **myometrium** (muscle layer of the uterus)

Answer 105

* More common in **later reproductive years** * More common in those **who have had several pregnancies (Multiparous)** * Occurs in around 10% of women * May occur alone or alongside endometriosis or fibroids

Answer 106

**Not fully Understood** * Multiple factors involved including **Sex hormones, trauma and inflammation** * Condition is hormone dependent

Answer 107

* **enlarged, boggy uterus** * Painful periods (dysmenorrhoea) * Heavy periods (menorrhagia) * Pain during intercourse (dyspareunia) * Infertility or pregnancy related complications * **1/3 of patients are asymptomatic**

Answer 108

**First Line:** * Transvaginal Ultrasound of the pelvis * MRI and Transabdominal ultrasound are alternatives if transvaginal is unsuitable **Gold Standard:** * Histological examination of the uterus after a hysterectomy * Not usually a suitable way of establishing the diagnosis for obvious reasons

Answer 109

**Depends on symptoms, age and plans for pregnancy** **Women does NOT want contraception** * **Tranexamic Acid** when there is no pain associated (antifibrinolytic) * **Mefenamic Acid** when there is pain associated (NSAID) **Women DOES want Contraception:** * **Mirena coil** - First Line * Combined Oral Contraceptive Pill (COCP) * Cyclical oral progestogens **Other options considered by specialist** * GnRH analogues to induce menopause like state * Endometrial ablation * Uterine artery embolisation * Hysterectomy

Answer 110

* Infertility * Miscarriage * Preterm birth * Small for gestational age * Preterm premature rupture of membranes * Malpresentation * Need for caesarean section * Postpartum haemorrhage

Answer 111

Where adhesions form within the uterus (intrauterine adhesions) following damage to the uterus that lead to outflow tract obstruction.

Answer 112

**Anything that creates scar tissue within the uterus causing adhesions that are normally not connected** * Pregnancy related **dilation and Curettage procedure** * Treatment of retained productions of conception (removing placental tissue left behind after birth) * Uterine surgery (myomectomy) * Pelvic infection (endometritis)

Answer 113

* Damage to the uterus causing scar tissue formation and subsequent adhesions. * Adhesions form **Physical Obstructions** and distort the pelvic organs * Leads to **menstruation abnormalities, infertility, recurrent miscarriages**

Answer 114

**Presents following recent dilatation and curettage, uterine surgery or endometritis with:** * **Secondary amenorrhoea** * Significantly lighter periods * Dysmenorrhoea * Infertility **Incidentally found adhesions that are asymptomatic are not classed as Asherman's Syndrome**

Answer 115

**History of uterine surgery** **Hysteroscopy** is **Gold Standard investigation** and can involve dissection and treatment of adhesions. **Others:** * Hysterosalpingography when contrast is injected into the uterus and imaged with X-rays * Sonohysterography uterus is filled with fluid and pelvic USS is performed * MRI Scan

Answer 116

* Dissecting the adhesions during hysteroscopy. * Reoccurrence of the adhesions after treatment is common

Answer 117

The **primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer.** Additional symptoms, depending on the underlying cause, may include: * **Pregnancy symptoms:** nausea, breast tenderness, increased urination, food cravings or aversions * **Menopause symptoms:** hot flashes, night sweats, sleep problems, mood changes * **Symptoms of PCOS:** acne, weight gain, hirsutism (excessive body hair), thinning hair * **Symptoms of pituitary gland issues:** headaches, vision problems, unexplained weight gain or loss

Answer 118

* Pregnancy test * **Hormone level checks:** including FSH, LH, TSH, prolactin, and testosterone * **Ultrasound** or other imaging studies, to identify potential structural abnormalities * Hysteroscopy, in cases where intrauterine adhesions are suspected

Answer 119

**Management of secondary amenorrhoea is determined by the underlying cause:** * **Pregnancy:** regular prenatal care * **Menopause:** hormone replacement therapy (HRT) if symptoms are troublesome * **PCOS:** lifestyle changes, hormonal contraceptives, and potentially metformin * **Asherman's syndrome:** surgical removal of adhesions and hormone therapy * **Drug-induced amenorrhoea:** discontinuing the offending drug if possible and safe to do so * **Conditions related to physical stress, weight loss, or excessive exercise:** lifestyle modifications and nutritional counselling.

Answer 120

A chronic inflammatory skin condition that presents with patches of **Porcelain-white** skin. It typically affects the genital and anal regions of the body: **labia, perineum, perianal skin, foreskin and glans penis**

Answer 121

* Typically affects women * Can affect men * Considered to be an **autoimmune condition** and therefore is associated with **T1DM, Alopecia, hypothyroid and vitiligo**

Answer 122

The cause of lichen sclerosus is currently unknown, but it is likely multifactorial. Potential contributing factors could include **autoimmune condition**, genetic predisposition, and hormonal factors. Some studies suggest a possible link with previous skin damage or trauma.

Answer 123

Lichen refers to a **flat eruption that spreads**. *It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.

Answer 124

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

Answer 125

Autoimmune condition (All the P's) Purple planar polygonal papules on extensor surfaces of the hand and **Wickham striae** in the mouth

Answer 126

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

Answer 127

The appearance of new skin lesions on areas of pre-existing dermatosis and cutaneous injury (skin trauma) This **occurs with Lichen Sclerosus**

Answer 128

Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears: * **“Porcelain-white” in colour** * Shiny * Tight * Thin * Slightly raised * There may be papules or plaques

Answer 129

* **Lichen planus:** Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin. * **Psoriasis:** Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back. * **Vitiligo:** Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.

Answer 130

**Primarily Clinical Diagnosis based on characteristic appearance of skin lesions** * Skin biopsy may be performed to confirm diagnosis * Blood tests may rule out other potential autoimmune conditions

Answer 131

**Lichen Sclerosus cannot be cured but symptoms are controlled and should be followed up every 3-6 months** **First Line** * **Potent Topical Steroids: Clobetasol propionate 0.05% (dermovate)** * Steroids used long term to control symptoms * Once daily for 4 weeks. Then gradually reduce frequency every 4 weeks to alternate days then twice weekly. * Daily steroids when condition flares * **Emollients** should be used regularly both with steroids and as part of maintenance * Avoidance of soaps in affected areas to prevent further irritation.

Answer 132

* **5% risk of developing squamous cell carcinoma of the vulva** * Pain and discomfort * Sexual dysfunction * Bleeding * Narrowing of the vaginal or urethral openings

Answer 133

**vulvovaginal atrophy** is inflammation and thinning of the genital tissues, dryness and atrophy of the vaginal mucosa due to **reduced oestrogen levels**

Answer 134

**Decrease in oestrogen levels** most commonly due to **menopause**

Answer 135

**Presents in post-menopausal women with:** * Itching and dryness * Loss of pubic hair * Dyspareunia (discomfort or pain during sex) * Post coital Bleeding due to localised inflammation * **recurrent UTIs or Stress incontinence** * Pelvic organ prolapse may also occur.

Answer 136

* **Postmenopausal bleeding:** malignancy, endometrial hyperplasia * **For genital itching/discharge:** sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes * **For narrowed introitus:** female genital mutilation * **For urinary symptoms:** urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis * **For dyspareunia:** malignancy, vaginismus

Answer 137

**Clinical Diagnosis** * **Clinical examination,** including speculum examination if tolerated, to look for vaginal signs of atrophy **Other tests:** * Transvaginal ultrasound and endometrial biopsy, **if necessary**, to exclude endometrial cancer * **An infection screen** if itching or discharge is present * A biopsy of any abnormal skin lesions, if needed

Answer 138

* Pale mucosa * Thin skin * Reduced skin folds * Erythema and inflammation * Dryness * Sparse pubic hair

Answer 139

**Hormonal treatment:** * **Topical oestrogen preparations:** * Estriol cream * Estriol pessaries * Estradiol Tablets * Estradiol ring **Non-hormonal treatments:** * **Lubricants such as Sylk, Replens, YES:**, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia * **Moisturisers**, which should be used regularly

Answer 140

* Active or history of hormone-dependent cancers * Undiagnosed vaginal bleeding. * Known hypersensitivity. * Severe liver disease

Answer 141

Malignant growth that primarily affects the skin of the vulva (the external part of the female genitalia). It can be host to various types of Skin cancers however **Squamous Cell Carcinoma** is the most prevalent.

Answer 142

* Rare gynaecological cancer accounting for 4% * Most commonly found in older women >60 (but can occur at any age) * **90% are Squamous Cell Carcinomas**

Answer 143

* Advanced age (particularly over 75 years) * Human papilloma virus (HPV) infection * Vulval intraepithelial neoplasia (VIN) * Immunosuppression * Lichen sclerosus

Answer 144

* Squamous Cell Carcinoma (**90%**) * Malignant Melanomas * Basal Cell Carcinoma

Answer 145

* **Vulval lump** * **Lymphadenopathy in the groin** * **Itching** * Ulceration * Bleeding * Pain

Answer 146

**Labia Majora**

Answer 147

* **Vulval intraepithelial neoplasia:** This precancerous condition can cause itching, burning, skin changes, and discomfort. * **Lichen sclerosus:** This condition can cause itching, pain, and white patches on the vulva. * **Bartholin's cyst:** This may present as a lump or swelling on the vulva, and can cause discomfort or pain.

Answer 148

**Physical Examination** Suspected vulval cancer should be referred on a **2-week-wait urgent cancer referral.** **Establishing the diagnosis and staging involves:** * **Biopsy of the lesion** * Sentinel node biopsy to demonstrate lymph node spread * Further imaging for staging (e.g. CT abdomen and pelvis)

Answer 149

**International Federation of Gynaecology and Obstetrics (FIGO)** Management of Vulval Cancer depends on the stage

Answer 150

**Depends on the Stage** * Wide local excision to remove the cancer * Groin lymph node dissection * Chemotherapy * Radiotherapy

Answer 151

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

Answer 152

* **High grade squamous intraepithelial lesion:** A type of VIN associated with **HPV infection** that occurs in younger women aged 35-50 years. * **Differentiated VIN:** Type of VIN associated with **lichen Sclerosus** and typically occurs in older women aged 50-60 years.

Answer 153

* Watch and wait with close follow-up * Wide local excision (surgery) to remove the lesion * Imiquimod cream * Laser ablation

Answer 154

Malignant proliferation of the cells of the Cervix (the lower part of the uterus that connects to the vagina)

Answer 155

* **3rd most common cancer worldwide and 4th biggest cause of cancer death** * Strongly associated with **Human papilloma virus (HPV)**

Answer 156

* Squamous Cell Carcinoma (**80%**) * Adenocarcinoma (**10-20%**) * Very rarely, **Small cell Cancer**

Answer 157

**Increased risk of catching HPV occurs with:** * Early sexual activity * Increased number of sexual partners * Sexual partners who have had more partners * Not using condoms **Non-engagement with cervical screening is a significant risk factor.** **Other risk factors are:** * Smoking * HIV (patients with HIV are offered yearly smear tests) * Combined contraceptive pill use for more than five years * Increased number of full-term pregnancies * Family history * Exposure to diethylstilbestrol

Answer 158

* HPV is a **Sexually Transmitted Infection** of the virus that is associated with **anal, vulval, vaginal, penile, mouth and throat cancers** * There are over 100 strains but the**HPV 16 and 18** are responsible for 70% of cervical cancers * HPV Infection spontaneously resolves **within 2 years in 90%** of women. At this point the risk returns to baseline.

Answer 159

Current NHS vaccine is **Gardasil** protecting against **HPV 6, 11, 16, 18, 31, 33, 45, 52, 58** * **HPV 6 and 11** cause **Genital Warts** * **HPV 16 and 18** cause **Cervical Cancer (plus others)** * Girls and boys are given the HPV vaccine around age **12-13 years old**

Answer 160

* HPV 16 and 18 produces two proteins (**E6 and E7**) that inhibit **tumour suppressor genes** respectively * **HPV 16 - E6** inhibits **p53** * **HPV 18 - E7** inhibits **pRb** * These cause dysregulated cell cycle regulation leading to the formation of a **pre-malignant monoclonal cell population** * This cell population is **cervical intraepithelial neoplasia (CIN)** which subsequently mutates further to become an invasive carcinoma

Answer 161

What is Cervical Intraepithelial Neoplasia (CIN) is a grading system for the level of **dysplasia and premalignant change in the cells of the cervix** CIN is diagnosed at **Colposcopy (not with cervical screening)**

Answer 162

* **CIN I:** mild dysplasia, affecting **1/3 the thickness** of the epithelial layer, likely to return to normal without treatment * **CIN II:** moderate dysplasia, affecting **2/3 the thickness** of the epithelial layer, likely to progress to cancer if untreated * **CIN III:** severe dysplasia, very likely to progress to cancer if untreated **CIN III is sometimes called cervical carcinoma in situ.**

Answer 163

Most cases are picked up **asymptomatically** during cervical screening or smears. * Abnormal bleeding (post-coital/intermenstrual/post menopausal) * Abnormal discharge

Answer 164

* **Vaginal discharge** * **Abnormal Vaginal Bleeding (e.g. postcoital or with micturition or defaecation)** * Dyspareunia * Vaginal discomfort * Urinary or bowel habit change * Suprapubic pain * Abnormal white/red patches on the cervix. * Pelvic bulkiness on PV examination * Mass felt on PR examination

Answer 165

* **Vaginitis:** itching, burning, pain, and abnormal discharge * **Cervical Ectropion** * **Nabothian cyst** * **Cervicitis:** abnormal discharge, pelvic pain, and postcoital bleeding * **Endometrial cancer:** abnormal vaginal bleeding, pelvic pain, and unintentional weight loss * **Cervical polyps:** abnormal vaginal bleeding, discharge, and pain during intercourse

Answer 166

* **Clinical History prompting Cervix examination with Speculum** +/- Swabs to exclude infection **If there is an abnormal appearance of the cervix suggestive of cancer:** * First line investigation is an **Urgent cancer referral for Colposcopy** for visualisation and biopsy of the cervix. * HPV testing * CT Chest, Abdomen and Pelvis is used for Cancer Staging

Answer 167

* Involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. * Stains such as **Acetic acid and Iodine solution** are used to identify abnormal areas * A Punch biopsy or LLETZ Biopsy can be performed to get a tissue sample

Answer 168

**Acetic Acid Stain:** * Abnormal cells appear white (**Acetowhite**) **Schiller's Iodine Test:** * Stains **healthy cells** of the cervix a **brown colour**. * **Abnormal** areas/cells will **not stain**

Answer 169

* Ulceration * Bleeding * Inflammation * Visible tumour

Answer 170

* Abnormal vascularity * White change with Acetic Acid * Exophytic Lesions

Answer 171

**FIGO system** **Stage 1:** Confined to cervix **Stage 2:** Extending into the uterus or upper 2/3 of the vagina **Stage 3:** Extending into lower third of the vagina or pelvic wall **Stage 4:** Spread beyond true pelvis or bladder / rectum involvement

Answer 172

**Cervical intraepithelial neoplasia and early-stage 1A:** * LLETZ or cone biopsy **Stage 1B – 2A:** * Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy **Stage 2B – 4A:** * Chemotherapy and radiotherapy * Bevacizumab (VEG-F inhibitor) **Stage 4B:** * Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

Answer 173

5 year survival drops significantly with an advanced stage. * Stage 1a: **98% 5 year survival** * Stage 4: **15% 5 year survival**

Answer 174

* **Monoclonal antibody** used in combination with other chemotherapies in the treatment of Metastatic or Recurrent Cancers. * It is a **Vascular Endothelial Growth Factor A Inhibitor (VEGF-A)** to reduce the development of new blood vessels from the cancer.

Answer 175

* A cone biopsy is a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer. * It involves a **general anaesthetic**. * The surgeon removes a cone-shaped piece of the cervix using a scalpel. * This sample is sent for histology to assess for malignancy

Answer 176

* Pain * Bleeding * Infection * Scar formation with stenosis of the cervix * Increased risk of miscarriage and premature labour

Answer 177

Also called a Loop Biopsy * Involves a **Local Anaesthetic** * Often performed during a **Colposcopy procedure** * Involves a wire loop with electrical current (diathermy) to remove the abnormal epithelial tissue on the cervix. * Electrical current cauterises the tissue and stops bleeding

Answer 178

* Bleeding and Abnormal discharge can occur for several weeks following a LLETZ procedure * Intercourse and tampon use after the procedure should be avoided to reduce infection * May increase the risk of **Preterm labour**

Answer 179

* For all Women and People (Transmen) with a cervix between the age of **25-64 years** * Cervical sample is taken and tested for **High -risk HPV viruses (hrHPV)**

Answer 180

* **3 yearly** for women aged **25-49** * **5 yearly** for women aged **50-64**

Answer 181

Aims to pick up precancerous changes in epithelial cells of the cervix. * Involves a **smear test** performed by a qualified practice nurse * Test consists of a **Speculum examination** and collection of cells from the cervix using a small brush. * The samples are initially tested for **high-risk HPV** before examination. * The cells are then examined under a microscopy using **liquid based cytology (LCB)** for **precancerous changes (dyskaryosis)** **If the HPV is negative then the cells are not examined**

Answer 182

**Smear Test for hrHPV:** * **Positive:** further testing is indicated with LBC * **Negative:** Return to normal recall (age based intervals) **1st Positive hrHPV:** * Use LBC to detect cellular atypia * **Cytology Positive:** Colposcopy is indicated * **Cytology Inadequate:** Cytology is repeated in **3 months** * Repeat cytology inadequate - refer for colposcopy * If Colposcopy is normal - test hrHPV in **12 months** * **Cytology Negative:** Perform 2nd hrHPV test in **12 months** **2nd hrHPV:** * **Negative:** return to normal recall * **Positive:** Offer 3rd hrHPV test in a further **12 months** (24 months after first positive test) **3rd hr HPV:** * **Negative:** Return to normal Recall * **Positive:** Refer to Colposcopy

Answer 183

* Inadequate * Normal * Borderline changes * Low-grade dyskaryosis * High-grade dyskaryosis (moderate) * High-grade dyskaryosis (severe) * Possible invasive squamous cell carcinoma * Possible glandular neoplasia * Infections such as bacterial vaginosis, candidiasis, trichomoniasis

Answer 184

* Women with HIV are screened annually * Women over 65 may request a smear if they have not had one since aged 50 * Women with previous CIN may require additional tests (e.g. test of cure after treatment) * Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant) * Pregnant women due a routine smear should wait until 12 weeks post-partum

Answer 185

Clinical condition defined as Heavy menstrual bleeding (excessive blood loss) during a menstrual period to the extent that it is affecting a woman's quality of life

Answer 186

It used to be 80ml. Now it is based on the subjective opinion of the woman

Answer 187

* Common gynaecological complaint * 50% of cases **no underlying pathology is found** and the condition is called **Dysfunctional Uterine/endometrial bleeding**

Answer 188

Menorrhagia (heavy menstrual periods) where there is no underlying pathology identified

Answer 189

**Local:** * **Dysfunctional Uterine Bleeding** * Fibroids * Adenomyosis * Endometrial polyps * Endometriosis * Pelvic inflammatory disease * PCOS * Contraceptives such as copper coil * Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding) **Systemic:** * Bleeding disorders * Hypothyroidism * Liver and kidney disease * Obesity

Answer 190

**Heavy or prolonged menstrual bleeding** **Other features:** (Due to Iron deficiency Anaemia) * Fatigue * Weakness * Shortness of Breath

Answer 191

Differentials that include abnormal uterine bleeding: * **Fibroids:** Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination. * **Adenomyosis:** Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse. * **Endometrial polyps:** Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding. * **Endometrial cancer:** Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.

Answer 192

* Age at menarche * Cycle length, days menstruating and variation * Intermenstrual bleeding and post coital bleeding * Contraceptive history * Sexual history * Possibility of pregnancy * Plans for future pregnancies * Cervical screening history * Migraines with or without aura (for the pill) * Past medical history and past drug history * Smoking and alcohol history * Family history

Answer 193

**Comprehensive History about bleeding** * **Laboratory investigations such as FBC** * **Pelvic examination with a speculum:** Should be performed unless there is a straightforward history without other risk factors or symptoms or they are young and not sexually active **Imaging Studies if Indicated:** * Hysteroscopy (outpatient) * Pelvic and Transvaginal Ultrasound **Additional Tests based on features:** * **Swabs** if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history) * **Coagulation screen** if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche * **Ferritin** if they are clinically anaemic * **Thyroid function tests** if there are additional features of hypothyroidism

Answer 194

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

Answer 195

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

Answer 196

**Exclude underlying pathology/Treat pathology first** **Women does NOT want Contraception:** * **Tranexamic acid** when no associated pain (antifibrinolytic – reduces bleeding) * **Mefenamic acid** when there is associated pain (NSAID – reduces bleeding and pain) **Women DOES want Contraception:** * **Mirena coil** (first line) * Combined oral contraceptive pill * Progesterone only contraception can be tried **Medical management Failed:** * **Hysterectomy** * **Endometrial Ablation** **Referral to Secondary Care:** * If treatment is unsuccessful * Symptoms are Severe * Large fibroids (>3cm)

Answer 197

Malignant proliferation that originals from the endometrium (the inner lining of the uterus) It is an Oestrogen Depending cancer meaning that oestrogen stimulates the growth of Endometrial cancer cells

Answer 198

* 6th Most commonly diagnosed cancer in women * 15th most common cancer * 80% of cases are **adenocarcinoma**

Answer 199

a **precancerous condition** that involves thickening of the endometrium * The risk factors, presentation, investigations are similar to Endometrial cancer * Most cases of Endometrial Hyperplasia will return to normal over time and **<5%** become endometrial cancer.

Answer 200

* Hyperplasia without **atypia** * **Atypical** Hyperplasia

Answer 201

**Without Atypical Cells:** * Reversal of risk factors: Weight loss, stopping HRT * Intrauterine System (IUS/Mirena coil) * Continuous Oral Progestogens (Medroxyprogesterone) **With Atypical Cells:** * Total Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO)

Answer 202

Anything that causes increased Exposure to **Unopposed Oestrogen** (Oestrogen without progesterone): * Increased Age * Nulliparity (never given birth or carried child) * Obesity * Diabetes * Early menarche * Late menopause * Polycystic ovary syndrome * Oestrogen-only hormone replacement therapy * Tamoxifen

Answer 203

Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation. Anovulation/oligoovulation means follicles don't develop No corpous luteum so no progesterone Unopposed oestrogen acting on endometrium

Answer 204

**Progestrogens** One of: * Combined Contraceptive Pill * Intrauterine System (Mirena coil) * Cyclical Progestogens

Answer 205

Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen. Adipose tissue is the primary source of oestrogen in postmenopausal women. Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen This extra Oestrogen is **unopposed** in women that are not ovulating (PCOS/post-menopause)

Answer 206

Tamoxifen has an anti-oestrogenic effect on breast tissue however it has an **oestrogenic effect** on the endometrium increasing the risk of endometrial cancer.

Answer 207

* Combined Contraceptive Pill * Mirena Coil * Increased Pregnancies * Cigarette Smoking

Answer 208

**Features vary but commonly include:** * **Postmenopausal Bleeding** * Postcoital bleeding * Intermenstrual bleeding * Unusually heavy menstrual bleeding * Abnormal vaginal discharge * Dyspareunia * Abdominal discomfort or bloating * Weight Loss * Haematuria * Anaemia * Raised platelet count

Answer 209

**This is endometrial cancer until proven otherwise** Other key risk factors include **obesity and diabetes**

Answer 210

* **Uterine fibroids:** Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation. * **Endometrial polyps:** Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause. * **Cervical cancer:** Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.

Answer 211

**Guidelines for a 2 week wait urgent Endometrial cancer referral:** * **Postmenopausal Bleeding** more than 12 months after the last menstrual period. NICE also recommends referral for **Transvaginal Ultrasound in women Over 55 years with:** * Unexplained vaginal discharge * Visible haematuria **Plus** raised platelets, anaemia, or elevated glucose levels

Answer 212

* First Line: **Transvaginal Ultrasound:** for endometrial thickness (normal is **less than 4mm post menopause**) * Second Line: Endometrial Biopsy * **Pipelle Biopsy:** highly sensitive for endometrial cancer * **Hysteroscopy** with endometrial biopsy

Answer 213

**FIGO System:** **Stage 1:** Confined to the uterus **Stage 2:** Invades the cervix **Stage 3:** Invades the ovaries, fallopian tubes, vagina or lymph nodes **Stage 4:** Invades bladder, rectum or beyond the pelvis

Answer 214

* **Progesterone:** May be used as a hormonal treatment to slow the progression of the cancer **Stage 1 and 2 Endometrial Cancer:** * **Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO):** Removal of uterus, cervix and adnexa **Later stages spread outside of the uterus:** * Combination of Hysterectomy, Radiotherapy, Chemotherapy

Answer 215

A gynaecological condition where ectopic endometrium-like tissue (Glands and stroma) , which typically lines the uterus, proliferates outside the uterine cavity. **Endometrioma:** A lump of endometrial tissue outside the uterus **Chocolate Cysts:** Endometriomas in ovaries **Adenomyosis:** Endometrial tissue within the myometrium of the uterus

Answer 216

*Approximately estimated to affect 10% of women in their reproductive years

Answer 217

**No clear cause** but several theories: * **Genetic component:** Though no specific genes are identified * **Retrograde menstruation** * **Coelomic metaplasia:** Cells outside of the uterus somehow change via metaplasia into endometrial cells * **Lymphatic or vascular dissemination of endometrial cells:** Cells spread similarly to cancer

Answer 218

* **Cyclical abdominal or pelvic pain** * **Dysmenorrhoea** * Dyspareunia * Sub/infertility * Cyclical bleeding from other sites (eg. rectal bleeding o haematuria) * Urinary and bowel symptoms * Palpable mass on examination (endometriomas) * Fixed retroverted uterus

Answer 219

* Retrograde menses/Sampsons * Metaplasia/Meyers * Haematogenous spread

Answer 220

* **Primary dysmenorrhoea:** characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology. * **Uterine conditions (e.g. fibroids, adenomyosis):** these can cause heavy menstrual bleeding and pelvic discomfort. * **Adhesions:** pelvic pain and possible bowel obstruction. * **Pelvic inflammatory disease (PID):** presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.

Answer 221

**Clinical Examination:** May identify endometriomas or deep nodules. **Transvaginal/Pelvic Ultrasound scan:** Often unremarkable however they may reveal large endometriomas or chocolate cysts **Referral to gynaecology for ultrasound or Laparoscopy:** Patients with severe persistent or recurrent symptoms of endometriosis should be referred. **Laparoscopic Surgery (Gold Standard):** Definitive diagnosis is established with a biopsy of lesion during Laparoscopy. Surgeons may also remove deposits of endometriosis to potentially improve symptoms.

Answer 222

**Laparoscopic Surgery** This however comes with risks of complications such as bowel perforation and therefore **is not the first line initial investigation**

Answer 223

**Initial management involves:** * Establishing a diagnosis * Providing a clear explanation * Listening to the patient, establishing their ideas, concerns and expectations and building a partnership * **First Line:** Analgesia as required for pain (**NSAIDs and paracetamol**) **Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy:** * **First line:** Combined oral contractive pill, which can be used back to back without a pill-free period if helpful * Progesterone only pill * Medroxyprogesterone acetate injection (e.g. Depo-Provera) * Nexplanon implant * Mirena coil * **Second Line:** GnRH agonists (Goserelin (Zoladex) or Leuprorelin (prostap)) **Surgical management options:** * Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) * Bilateral oophorectomy +/-Hysterectomy **Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.**

Answer 224

Benign smooth muscle tumours (uterine leiomyomas) originating from the myometrium of the uterus.

Answer 225

* Most prevalent benign uterine tumour in women * Leading cause for Hysterectomy * Very common affecting **40-60% of women in later reproductive years** * More common in black women

Answer 226

**Unknown but thought to be related to hormonal and environmental factors** **Oestrogen sensitive** meaning they grow in response to oestrogen

Answer 227

* **Intramural** means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. * **Subserosal** means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. * **Submucosal** means just below the lining of the uterus (the endometrium). * **Pedunculated** means on a stalk.

Answer 228

**Often Asymptomatic** **Symptoms:** * **Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom** * Prolonged menstruation, lasting more than 7 days * Abdominal pain, worse during menstruation * Bloating or feeling full in the abdomen * Urinary or bowel symptoms due to pelvic pressure or fullness * Deep dyspareunia (pain during intercourse) * Reduced fertility * Palpable mass on abdominal or pelvic exam

Answer 229

**Other causes of Menorrhagia and Dysmenorrhoea:** * **Endometrial polyps:** Present with irregular menstrual bleeding and spotting * **Endometriosis:** Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility

Answer 230

**First Line:** * Transvaginal/**Pelvic**/Abdominal Ultrasound scan * **Hysteroscopy** is initial investigation for **submucosal fibroids** presenting with menorrhagia **Second Line:** * MRI scan if ultrasound does not provide enough detail before considering surgical options

Answer 231

**Fibroids < 3cm:** * Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus * Symptomatic management with NSAIDs and tranexamic acid * Combined oral contraceptive * Cyclical oral progestogens **Surgical options for managing smaller fibroids** * Endometrial ablation * Resection of submucosal fibroids during hysteroscopy * Hysterectomy **Fibroids > 3 cm** women need referral to gynaecology for investigation and management. * Symptomatic management with NSAIDs and tranexamic acid * Mirena coil – depending on the size and shape of the fibroids and uterus * Combined oral contraceptive * Cyclical oral progestogens **Surgical options for larger fibroids are:** * Uterine artery embolisation * **Myomectomy** * Hysterectomy

Answer 232

* **Heavy menstrual bleeding, often with iron deficiency anaemia** * **Reduced fertility** * Pregnancy complications, such as miscarriages, premature labour and obstructive delivery * Constipation * Urinary outflow obstruction and urinary tract infections * **Red degeneration** of the fibroid * **Torsion** of the fibroid, usually affecting pedunculated fibroids * **Malignant change** to a leiomyosarcoma is very rare (<1%)

Answer 233

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. in pregnancy the fibroid outgrows blood supply causing Ischaemia and Infarction. Red degeneration is more likely to occur in **larger fibroids (above 5 cm)** during the **second and third trimester** of pregnancy.

Answer 234

Look out for the pregnant woman (2nd/3rd trimester) with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration. * **Severe abdominal pain** * Low grade fever * Tachycardia * Vomiting

Answer 235

**Supportive management** * Rest * Fluids * Analgesia

Answer 236

Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.

Answer 237

A type of tumour that grows like a pregnancy inside the uterus. This is known as a **Molar Pregnancy** It forms part of a spectrum of disorders known as **gestational trophoblastic disease** * Complete Hydatidiform Mole * Partial Hydatidiform Mole * Choriocarcinoma (cancer in the placenta)

Answer 238

**Complete Mole:** * Occurs when two sperm cells (or 1 which duplicates DNA) fertilise an ovum that contains no genetic material (an “empty ovum”). * These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole (46YY) * No foetal material will form. **Partial Mole:** * Occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. * The new cell now has three sets of chromosomes (triploidy (69 XXX or 69 XXY) * The cell divides and multiplies into a tumour called a partial mole. * In a partial mole, some foetal material may form.

Answer 239

Women at highest risk of developing a molar pregnancy are at the extreme ends of the fertility age range, specifically those under 16 years of age and over 45 years of age.

Answer 240

Molar pregnancy behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy: * More severe morning sickness * Vaginal bleeding * Increased enlargement of the uterus * Abnormally high hCG * Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Answer 241

* **Ectopic pregnancy:** Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea. * **Miscarriage:** Symptoms include vaginal bleeding, abdominal pain, and passage of tissue. * **Normal pregnancy:** Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.

Answer 242

**Molar pregnancy behaves like a normal pregnancy** However some indications include: * **B-hCG** Levels are often significantly higher than normally expected * **Transvaginal Ultrasound:** May show a **snowstorm appearance of pregnancy**, low resistance of blood vessel flow and absence of a foetus * **Histology may be used to confirm** after mole evacuation

Answer 243

**Immediate referral to a specialist centre for treatment** * **Evacuation of the uterus** to remove the mole (using suction curettage) which is sent for **histological examination** * Hysterectomy is a possibility if fertility preservation is not a concern * **Systemic Chemotherapy:** may be required if the mole has **metastasised**

Answer 244

* Bimonthly serum and urine hCG testing until levels are normal. * In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance. * In the case of a complete mole, monthly repeat hCG samples are sent for at least 6 months.

Answer 245

Pituitary tumours characterized by excessive production of prolactin (leading to hyperprolactinaemia), a hormone that plays a crucial role in lactation.

Answer 246

* The most common hormone-secreting tumours originating in the pituitary gland. * Can affect people of any age but more commonly diagnosed in adults

Answer 247

Multiple Endocrine Neoplasia (MEN) Type I

Answer 248

Microprolactinomas – smaller than 10 mm Macroprolactinomas – larger than 10 mm

Answer 249

**Both Genders:** * Reduced Libido * Headaches * Visual Field Defects (bitemporal hemianopia) **Women:** * Oligomenorrhoea/Amenorrhoea * Galactorrhoea (breast milk production outside of pregnancy or breastfeeding) * Infertility * Vaginal dryness **Men:** * Erectile dysfunction * Reduced facial hair growth * Gynaecomastia

Answer 250

* **Pregnancy Test:** Essential in women with childbearing potential presenting with breast milk production * **Blood Tests:** Serum Prolactin, U&Es, LFTs, TFTs * **MRI** scan is investigation of choice for diagnosing pituitary tumours

Answer 251

**Pharmacological:** * **Dopamine Agonists** (e.g. Cabergoline or Bromocriptine): These drugs reduce serum prolactin levels, alleviate galactorrhea, and restore gonadal function. * **Trans-sphenoidal Surgical Resection** is indicated when medical treatment fails to manage the tumour effectively. **Definitive treatment** * **Radiotherapy:** Reserved for cases where other treatments are unsuccessful.

Answer 252

* Hormonal imbalances * Recurrence of the tumour * Risks associated with surgical and radiation interventions

Answer 253

Malignant proliferation originating from various cell types within the ovary * 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas

Answer 254

* Epithelial Cell Tumours * Germ Cell Tumours * Sex Cord-Stromal tumour * Malignant (Krukenberg Tumour)

Answer 255

* Originate from the **epithelium which lines the fimbria of the fallopian tubes or the ovaries** * Epithelial tumours are partially cystic, and the cysts can contain fluid * The initial metastatic spread typically involves the **peritoneal cavity**, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm * **Around 90% of ovarian cancers are epithelial ovarian tumours.**

Answer 256

* Serous tumours (the most common) * Endometrioid carcinomas * Clear cell tumours * Mucinous tumours * Undifferentiated tumours

Answer 257

* Originate from the germ cells in the embryonic gonad (**Teratomas**) * May contain various tissue types such as **Skin, teeth, bone and hair** * Spread predominantly via the **lymphatic route** * Common in **young women** * Tumour markers include **alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG)**.

Answer 258

* Originate Granulosa/Theca (in women) or Leydig/Sertoli cells (In males) or are Fibromas * Make up less than 5% of tumours **Often produce Hormones:** * Granulosa: Oestrogen leading to precocious puberty * Leydig: Androgens leading to masculinising features and associated with Peutz Jegher Syndrome * Fibroma: Associated with Meigs Syndrome

Answer 259

**Ovarian Tumours may be due to metastasis from a cancer elsewhere in the body** * A **Krukenberg tumour** refers to a metastasis in the ovary, **usually from a gastrointestinal tract cancer, particularly the stomach.** * Krukenberg tumours have **characteristic “signet-ring” cells** on histology, which look like signet rings on under a microscopy.

Answer 260

**Occurs via Trans coelomic routes** (Across a body cavity) and thus can spread to the liver, bowel and associated mesentery

Answer 261

* Advanced age (peak age 60 years) * Smoking * Increased number of ovulations (early menarche, late menopause, no pregnancies) * Genetic predisposition **(BRCA 1 and 2 genes and family history)** * Obesity * Hormone replacement therapy (HRT) * Recurrent use of **clomiphene** (fertility drug)

Answer 262

**Factors that reduce lifetime ovulations** * Childbearing (parity) * Breastfeeding * Early Menopause * Combined oral contraceptive pill

Answer 263

**Often present late in disease progression with Non-specific symptoms** * Abdominal bloating * Early satiety (feeling full after eating) * Loss of appetite * Pelvic pain * Urinary symptoms (frequency / urgency) * Weight loss * Abdominal or pelvic mass * Ascites (due to VEGF increasing vessel permeability)

Answer 264

An Ovarian mass may press on the **obturator nerve** causing referred hip or groin pain.

Answer 265

* **Gastrointestinal conditions (e.g., irritable bowel syndrome):** Characterised by abdominal pain, bloating, and changes in bowel habits * **Fibroids:** May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation * **Ovarian cysts:** Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating * **Other cancers (e.g., bladder, endometrial):** May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms

Answer 266

**Direct Urgent 2-Week-Wait Referral** * Ascites * Pelvic Mass * Abdominal Mass **Carry out further Investigations before referral Starting with CA125 blood test** * New symptoms of IBS/change in bowel habit * Abdominal Bloating * Early Satiety * Pelvic Pain * Urinary frequency or urgency * Weight loss

Answer 267

**Initial Investigations:** * **CA125 Blood Test:** (> 35IU/ml is significant) Then * **Urgent Pelvic and Abdominal Ultrasound Scan** **Secondary Care:** * CT scan to establish the diagnosis and stage the cancer * Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy * Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells **Diagnosis is difficult and often done with diagnostic Laparoscopy** **Risk of Malignancy Index** **Women Under 40 years with complex ovarian mass:** * AFP and hCG tumour markers for possible **Germ cell tumour**

Answer 268

CA125 is a **tumour marker for epithelial cell ovarian cancer**. It is not very specific, and there are many non-malignant causes of a raised CA125: * Endometriosis * Fibroids * Adenomyosis * Pelvic infection * Liver disease * Pregnancy

Answer 269

Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Answer 270

**Managed by specialist gynaecology oncology MDT** **Surgery:** Radical Hysterectomy, BSO, Infracolic omentectomy are options if early stage **Chemotherapy:** Used an adjuvant to surgery. **Bevacizumab (anti-VEGF) may also be used

Answer 271

Fluid filled sac that develops within or on the surface of an ovary They can range in size and occur as a normal part of the menstrual cycle or as a result of an underlying condition.

Answer 272

* Very common in premenopausal women with most women experiencing at least one * Cysts in postmenopausal women are more concerning for malignancy and need further investigation * Majority of cysts in premenopausal women are **benign**

Answer 273

Can be caused by a variety of factors, including: * Hormonal imbalances * Endometriosis, * Pregnancy * Pelvic infection

Answer 274

Patients with multiple ovarian cysts may have a **String of pearls appearance to the ovaries** **This is not PCOS unless they have other features of the condition**

Answer 275

**Most ovarian cysts are Asymptomatic** May Cause: * Pelvic pain (often acute unilateral pain) * Bloating * Fullness in the abdomen * Palpable pelvic mass * **Intra-peritoneal haemorrhage with haemodynamic compromise**

Answer 276

**Functional Cysts:** * Follicular Cysts: Most common and harmless. they form due to failure to the follicle failing to rupture and release an egg. * Corpus Luteum Cysts: Occur when the corpus luteum fails to break down and fills with fluid. Often seen in early pregnancy **Non-Functional Cysts:** * Serous Cystadenoma: Benign tumours of the epithelial cells * Mucinous Cystadenoma: Can become huge and cause **psuedomyoxma peritoni** * Endometrioma: occurs with endometriosis * Malignant cysts: Dermoid/ Sex cord/Stromal

Answer 277

* **Ovarian torsion:** Characterised by sudden, severe pain, often accompanied by nausea and vomiting. * **Ectopic pregnancy:** Symptoms include abdominal pain, amenorrhea, and vaginal bleeding. * **Appendicitis:** Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.

Answer 278

**Detailed History and Examination:** to establish for features that may suggest malignancy **Pregnancy test:** Exclude ectopic pregnancy **Ultrasound Scan** if less than 5cm in premenopausal women then no further investigation needed. **Tumour Markers:** CA125, AFP, LDH, B-hCG

Answer 279

* Abdominal bloating * Reduce appetite * Early satiety * Weight loss * Urinary symptoms * Pain * Ascites * Lymphadenopathy

Answer 280

Estimates the risk of an ovarian mass being malignant, taking account of three things: * Menopausal status * Ultrasound findings * CA125 level

Answer 281

**Simple ovarian cysts in premenopausal women can be managed based on their size:** * **Less than 5cm cysts** will almost always resolve within three cycles. They do not require a follow-up scan. * **5cm to 7cm:** Require routine referral to gynaecology and yearly ultrasound monitoring. * **More than 7cm:** Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound. **Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist** **When there is a raised CA125, this should be a two-week wait suspected cancer referral** * Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.

Answer 282

* Torsion * Haemorrhage into the cyst * Rupture, with bleeding into the peritoneum

Answer 283

Triad of: * Ovarian fibroma (benign ovarian tumour) * Pleura effusion * Ascites **Treatment is removal of the tumour**

Answer 284

A condition where the ovary twists in relation to the surrounding connective tissue, the fallopian tube (Adnexa) and blood supply. **Adnexal torsion:** when the fallopian tube is involved

Answer 285

* Usually due to an **ovarian mass** (often > 5cm) such as a cyst or tumour. * Can occur with normal ovaries in girls **before menarche** when girls have a longer **infundibulopelvic ligaments**

Answer 286

* Ovarian mass: present in around 90% of cases of torsion * Being of a reproductive age * Pregnancy * Ovarian hyperstimulation syndrome

Answer 287

* Ovary twists around the adnexa and blood supply * Leads to ischaemia of the Ovary * If torsion persists then necrosis will occur and the function of the ovary will be lost * Ovarian torsion is **an emergency** where treatment delay can have significant consequences

Answer 288

* **Sudden onset severe unilateral pelvic pain** * Constant getting progressively worse * Associated with **Nausea and Vomiting** * Localised tenderness * May have a palpable mass * Vaginal examination may show adnexial tightness

Answer 289

**Pelvic Ultrasound** initial investigation of choice * Transvaginal is Ideal but Transabdominal can be used if transvaginal is not possible. * May show **"Whirlpool sign of free fluid"** in the pelvis and **Oedema** of the ovary **Laparoscopic Surgery is definitive diagnostic investigation**

Answer 290

* Patients need emergency admission under gynaecology for urgent investigation and management. * Depending on the duration and severity of the illness they require laparoscopic surgery to either: * **Un-twist** the ovary and fix it in place (detorsion) * **Remove** the affected ovary (oophorectomy)

Answer 291

* Delayed treatment can lead to loss of function of that ovary * If necrotic ovary is not removed it may lead to infection, abscess formation and sepsis

Answer 292

PCOS is the most common endocrine condition in women of reproductive age. The disorder is characterised by failure of follicles to release eggs leading to anovulation, hyperandrognism features and enlarged/multicystic ovaries

Answer 293

* **Anovulation:** refers to the absence of ovulation * **Oligoovulation:** refers to irregular, infrequent ovulation * **Amenorrhoea:** refers to the absence of menstrual periods * **Oligomenorrhoea:** refers to irregular, infrequent menstrual periods * **Androgens:** are male sex hormones, such as testosterone * **Hyperandrogenism:** refers to the effects of high levels of androgens * **Hirsutism:** refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair * **Insulin Resistance:** refers to a lack of response to the hormone insulin, resulting in high blood sugar levels

Answer 294

* Prevalent condition affecting up to 1/3 of women during their reproductive years

Answer 295

**Complex and Multifactorial (still unclear)** * Hormone imbalances, low oestrogen, high androgens and high insulin (with insulin resistance) leads to increased circulating androgens

Answer 296

**Rotterdam Criteria: requires at least 2 out of 3 key features:** * Oligoovulation or Anovulation * Biohemical evidence of Hyperandrogenism (hirsutism and acne) * Polycystic Ovaries on Ultrasound (> 12 cysts on imaging or ovarian volume > 10 cm3) **Having only one feature such as multiple ovarian cysts does not qualify for diagnosis of PCOS**

Answer 297

* **Oligomenorrhoea or amenorrhoea** * Sub/Infertility * Obesity (in about 70% of patients with PCOS) * **Hirsutism** * Acne * Acanthosis Nigricans * Mood changes including Anxiety and depression * Hair loss in a male pattern

Answer 298

* Insulin resistance and diabetes * Acanthosis nigricans * Cardiovascular disease * Hypercholesterolaemia * Endometrial hyperplasia and cancer * Obstructive sleep apnoea * Depression and anxiety * Sexual problems

Answer 299

* **Menopause:** characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems. * **Congenital adrenal hyperplasia (CAH):** presenting with signs of androgen excess like hirsutism, acne, and irregular periods. * **Hyperprolactinaemia:** symptoms include irregular periods, galactorrhoea, and infertility. * **Androgen-secreting tumours:** may cause virilisation, amenorrhoea, and hirsutism. * **Cushing's syndrome:** characterised by weight gain, purple stretch marks, and easy bruising.

Answer 300

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

Answer 301

When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin **promotes the release of androgens from the ovaries and adrenal glands.** Therefore, **higher levels of insulin result in higher levels of androgens** (such as testosterone). Insulin also **suppresses sex hormone-binding globulin (SHBG)** production by the liver. SHBG normally binds to androgens and suppresses their function. **Reduced SHBG further promotes hyperandrogenism in women with PCOS.** The **high insulin levels contribute to halting the development of the follicles** in the ovaries This leads to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan). **Diet, exercise and weight loss help reduce insulin resistance.**

Answer 302

**Blood Tests:** * **LH:** Raised * **LH:FSH Ratio** increased >2 aids in differentiating from menopause (ratio is normal) * **SHBG** is normal or low * **Total and Free Testosterone:** Raised **Other Blood Tests for Exclusion of conditions** * Insulin resistance (Fasting and OGTT) * Oestrogen Levels: Normal or Raised * TFTs: Exclude thyroid dysfunction * 17 Hydroxyprogesterone: Exclude CAH * Prolactin levels: Exclude hyperprolactinaemia * 24 Hour urinary cortisol: Exclude Cushing's **Imaging: Pelvic Ultrasound** * **Transvaginal Ultrasound** is Gold Standard * **String of Pearls Appearance** * **12** or more developing follicles in one ovary * Ovarian Volume > **10 cm3**

Answer 303

**Endometrial Cancer** Within the syndrome of PCOS it has multiple risk factors for Endometrial cancer including: * Obesity * Diabetes * Insulin Resistance * Amenorrhoea

Answer 304

**General Advice:** * Education and reduction of increased risks of CVD, DM, Endometrial cancer, Obesity * **Weight Loss**, * **Orlistat** may be used in BMI >30 * **Exercise**, * Smoking cessation, * Antihypertensives (if required), * Statins (if QRISK >10%) **Managing risk of Endometrial Cancer:** >3 month gap between periods or abnormal bleeding - **A withdrawal bleed required every 3-4 months** * Pelvic USS to measure endometrial thickness * If Contraception wanted: **Mirena coil/COCP** * If no Contraception wanted: **Medroxyprogesterone Acetate 10mg OD for 14 days** **Manage Infertility:** * 1st Line: Weight Loss * 2nd line: Clomifene/Letrozole (Metformin may also help) * 3rd line: IVF **Managing Hirsuitism:** * 1st Line: Shaving/hair removal * **3rd Gen COCP** (co-cyprindiol/Dianette) * Topical Elfornithine **Managing Acne:** * 1st Line: COCP * Topical Benzoyl Peroxide * Oral Tetracycline

Answer 305

* Weight loss * **Mirena coil** * **Inducing a withdrawal bleed** at least every 3-4 months using: * Cyclical Progestogens (medroxyprogesterone acetate 10mg OD for 14 days) * COCP

Answer 306

**1st Line:** Weight loss is the initial step for improving fertility **2nd Line:** * Letrozole * Clomiphene - induces ovulation by inhibiting oestrogen feedback on hypothalamus so increase FSH **3rd Line:** * Laparoscopic Ovarian Drilling * IVF

Answer 307

Weight loss may improve the symptoms of Hirsutism * **Co-cyprindiol (Dianette)** is a COCP liscenced for hirsutism and acne with anti-androgenic effects Others: * Topical Eflornithine * Electrolysis * Laser hair removal

Answer 308

Combined Oral Contraceptive Pill (COCP) is First line (**Co-cprindiol**). Other treatments: * Topical Adapalene (retinoid) * Topical Antibiotics (clindamycin + Benzoyl peroxide) * Topical Azelaic acid 20% * Oral Tetracycline antibiotics (lymecycline)

Answer 309

Significantly increased risk of **Venous Thromboembolism** * This contraindicated in increased risk of clots * Medication usually stopped after 3 months of use.

Answer 310

Inflammation and infection of the organs of the pelvis, caused by infection spreading up the vagina through the cervix and into the upper genital tract. **It is a significant cause of tubular infertility and chronic pelvic pain**

Answer 311

* **Endometritis:** is inflammation of the endometrium * **Salpingitis:** is inflammation of the fallopian tubes * **Oophoritis:** is inflammation of the ovaries * **Parametritis:** is inflammation of the parametrium, which is the connective tissue around the uterus * **Peritonitis:** is inflammation of the peritoneal membrane

Answer 312

**Most commonly via Sexually Transmitted Pelvic Infections:** * Neisseria gonorrhoeae (produces more severe PID) * Chlamydia trachomatis * Mycoplasma genitalium **Less commonly via non-sexually transmitted infections:** * Gardnerella vaginalis (associated with bacterial vaginosis) * Haemophilus influenzae * Escherichia coli

Answer 313

* Not using barrier contraception * Multiple sexual partners * Younger age * Existing sexually transmitted infections * Previous pelvic inflammatory disease * Intrauterine device (e.g. copper coil)

Answer 314

**Women may present with symptoms of:** * Pelvic or lower abdominal pain * Abnormal vaginal discharge * Abnormal bleeding (intermenstrual or postcoital) * Pain during sex (dyspareunia) * Fever * Dysuria **Examination findings may reveal:** * Pelvic tenderness * Cervical motion tenderness (cervical excitation) * Inflamed cervix (cervicitis) * Purulent discharge

Answer 315

* **Appendicitis:** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting. * **Ectopic Pregnancy:** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor. * **Endometriosis:** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation. * **Ovarian Cyst:** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination. * **Urinary Tract Infection:** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.

Answer 316

**Pelvic Examination** **High vaginal Swabs for causative organisms:** * NAAT swabs for gonorrhoea and chlamydia * NAAT swabs for Mycoplasma genitalium (if available) * HIV Test * Syphilis test **High vaginal swab** for BV, trichomoniasis and Candidiasis **Microscopy** for Pus cells **Blood Tests:** Inflammatory markers (CRP/ESR) can help support diagnosis **Pregnancy test:** To exclude ectopic pregnancy **Transvaginal Ultrasound** May be used

Answer 317

**Combination Antibiotics** * **Ceftriaxone** IM 1g Single dose (Cover for gonorrhoea) * **Doxycycline** 100mg BD for 2/52 (cover for chlamydia and Mycoplasma) * **Metronidazole** 400mg BD for 2/52 ( Cover for Gardnerella) **Alternative regime is Ofloxacin + Metronidazole** **Analgesia may be required** **Contact Tracing**

Answer 318

* Chronic pelvic pain (in around 40% of cases) * Infertility (approximately 15%) * Ectopic pregnancy (about 1%) * Sepsis * Abscess * **Fitz-Hugh-Curtis Syndrome** (about 10%)

Answer 319

Complication of PID, chlamydia and gonorrhoea where adhesions form between the liver capsule and the peritoneum causing inflammation and infection of the **liver capsule (Glisson's capsule)** This results in **right upper quadrant pain** in about **10% of patients**

Answer 320

Investigations include abdominal ultrasound to exclude stones. laparoscopy to diagnose, visualise and treat adhesions by **Adhesiolysis**

Answer 321

A transient mood disorder that typically manifests around **three days after childbirth**. It is characterized by irritability, anxiety about parenting skills, and tearfulness. The condition **typically resolves within two weeks** without medical intervention.

Answer 322

* Very common affecting up to 80% of women after childbirth * More commonly affects **first time mothers** * 10% of these women may develop a more severe form: **Postnatal Depression**

Answer 323

**not fully understood** * Likely due to hormonal changes that occur after childbirth including a rapid drop in oestrogen and progesterone. * Fatigue/sleep deprivation, physical discomfort after delivery and stress/challenges of caring for a new baby likely also contribute

Answer 324

**Presents within the first week after childbirth** * Mood swings * Low mood * Anxiety (about parenting) * Irritability * Tearfulness

Answer 325

**Postpartum blues should be differentiated from other postnatal mood disorders such as postnatal depression and postpartum psychosis. The primary distinguishing symptoms are:** * **Postnatal depression:** Persistent feelings of sadness, anxiety, or emptiness; difficulty bonding with the baby; severe mood swings; trouble eating, sleeping, or concentrating; and thoughts of harming oneself or the baby. * **Postpartum psychosis:** Severe confusion and disorientation, hallucinations and delusions, paranoia, and attempts to harm oneself or the baby.

Answer 326

**Clinical Diagnosis** * Routine screening at medical appointments is recommended by NICE to identify the approximately 10% of women who may develop postnatal depression following postpartum blues. * Use of tools such as the **Edinburgh Postnatal Depression Scale**

Answer 327

**Supportive measures and reassurance (that the condition is common)** * Symptoms are usually mild and only last **a few days**. * Baby blues tend to **resolve within two weeks of delivery without any treatment being required** * Mothers should be encouraged to seek help if they have symptoms persisting beyond 2 weeks

Answer 328

It's a significant mood disorder that can **develop at any time up to one year after the birth of a baby.** This condition represents a considerable aspect of maternal mental health and extends beyond the common "baby blues". Typically presenting with **persistent depressive symptoms** that may interfere with daily functioning and parenting.

Answer 329

* Affects approximated 10-20% of mothers within 1 year of childbirth * Rates vary depending on population, geographic location, socioeconomic status (low), History of mental health and lack of social support * Typically women are affected **around 3 months after birth**

Answer 330

Development of postpartum depression is multifactorial with a combination of **Biological, Psychological, and Social factors all contributing.**

Answer 331

* Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones. * Alterations in melatonin and cortisol rhythms and immune-inflammatory processes * Genetic predispositions

Answer 332

* A history of mood or anxiety disorders * Previous episodes of postpartum depression * Certain personality traits such as neuroticism * Psychological stress from the transition to parenthood * Unrealistic expectations of motherhood

Answer 333

* Lack of social support * Relationship issues, * Life stressors * Low socioeconomic status

Answer 334

**Classic triad of:** * **Low Mood** * **Anhedonia:** reduced enjoyment or interest in activities. * **Lowering of energy levels.** **Others:** * Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby) * Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.

Answer 335

**Baby blues** Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously. **Postpartum Psychosis** **Adjustment disorders** These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression. **Generalized Anxiety Disorder (GAD)**

Answer 336

**Edinburgh Postnatal Depression Scale (EPDS)** assess how the mother has felt over the past week with 30 questions. A cut-off score of **over 10 is used as a positive result.**

Answer 337

**First-line treatments**: * Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT). **Pharmacological treatments** * Antidepressants (**SSRIs**) considered in high risk cases **In severe cases** admission to a mother and baby inpatient mental health unit might also be necessary.

Answer 338

**SSRIs** such as: * Paroxetine * Sertraline **Due to their safety profile in breastfeeding as they have a low milk:plasma ratio** **Fluoxetine shouldn't be used due to its long half life**

Answer 339

**Also known as Puerperal Psychosis** It's a serious psychiatric disorder that typically develops within the first two weeks following childbirth. It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.

Answer 340

**unknown** but thought to be a combination of: * Genetic susceptibility * Hormonal Changes * Psychosocial stressors * Prior history of **severe mental illness significantly increases the risk**

Answer 341

* **Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder** * Family history of postpartum psychosis * Previous episode of postpartum psychosis

Answer 342

**Often between 2-3 weeks post partum** * Paranoia * Delusions (including Capgras Delusions) * Hallucinations * Manic episodes * Depressive episodes * Confusion

Answer 343

Postpartum depression with psychotic features

Answer 344

Diagnosis is **predominantly clinical**, based on the presenting signs and symptoms. It requires a thorough psychiatric evaluation. Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.

Answer 345

**Women with Postpartum Psychosis need urgent assessment and input from specialist mental health services** * Admission to **mother and baby unit** * Cognitive behavioural Therapy * May require pharmacotherapy with: * Antidepressant medications * Antipsychotic medications * Mood stabilisers in some instances Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby's role or identity).

Answer 346

The mother's breastfeeding status and the potential for the transfer of drugs to the nursing infant.

Answer 347

The mother and baby unit is a specialist unit for pregnant women and women that have given birth in the past 12 months. They are designed so that the mother and baby can remain together and continue to bond. Mothers are supported to continue caring for their baby while they get specialist treatment.

Answer 348

Women with existing mental health concerns before or during pregnancy are referred to **perinatal mental health services**. Advice and input from specialists can help manage decisions around ongoing medications such as **SSRIs, antipsychotics and lithium during pregnancy.** They also ensure that mothers are closely followed up after giving birth so management can be put in place early should these conditions occur.

Answer 349

**Neonatal abstinence syndrome/neonatal adaptation syndrome** * Presents in first few days after birth * Symptoms include irritability and poor feeding * Neonates are monitored for this after delivery * Treatment is supportive management

Answer 350

**Gynaecological Emergency** Where a fertilised egg or embryo implants and begins to grow **Outside of the uterine cavity**. Most common site is the **fallopian tube**

Answer 351

* **Fallopian tube (most common (97%))** * Ovary * Cervix * Abdomen

Answer 352

* Previous ectopic pregnancy * Previous pelvic inflammatory disease, STIs or Salpingitis (tubal inflammation) * Previous surgery to the pelvis (Especially the fallopian tubes) * Intrauterine devices in situ (coils) * Endometriosis * Older age * Smoking

Answer 353

* Fertilisation of the oocyte **typically takes place in the ampulla of the fallopian tube**; the conceptus must then travel into the endometrial cavity. * This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow. * Any **dysfunction in the tubal peristalsis** above due to e.g. tubal surgery, salpingitis, PID can prevent the conceptus from implanting in the correct place. * A pregnancy that implants in the fallopian tube will **grow and eventually lead to rupture and catastrophic bleeding.** * **Most tubal ectopics implant in the ampulla (widest point)**.

Answer 354

Around **6-8 weeks gestation**

Answer 355

* **Pelvic or abdominal pain** Often unilateral to the side of the ectopic (RIF/LIF) * Abnormal vaginal bleeding: **missed period or intermenstrual bleeding** * Cervical motion tenderness (**Chandeller sign**) where pain occurs when moving the cervix during a bimanual examination * **Haemodynamic instability** caused by blood loss if the ectopic ruptures * Dizziness or Syncope (due to blood loss) * Shoulder tip pain (blood irritating the diaphragm causing referred pain)

Answer 356

* Miscarriage * Appendicitis * Ovarian Torsion

Answer 357

**Any female of childbearing age presenting with abdominal pain should be offered a UPT (urine pregnancy test) to exclude ectopic pregnancy** * Urine Pregnancy Test (First Line) * **Transvaginal Ultrasound Scan** is investigation of choice to locate the pregnancy * Serial serum B-hCG if no pregnancy found of USS.

Answer 358

* A mass representing a tubal ectopic pregnancy **moves separately to the ovary**. * It may appear similar to the corpus luteum however this **will move with the ovary** **Other features indicative:** * An empty uterus * Fluid in the uterus (may be mistaken as a gestational sac)

Answer 359

**women with pelvic pain/tenderness and a positive pregnancy test need to be referred to an Early Pregnancy Assessment Unit (EPAU)** **All ectopic pregnancies need to be terminated (they are not viable)** **Options for terminating an Ectopic Pregnancy:** * Expectant management (awaiting natural termination) * Medical Management (methotrexate) * Surgical management (Salpingectomy or Salpingotomy)

Answer 360

**Criteria:** * Follow up needs to be possible to ensure successful termination * The ectopic needs to be unruptured * Adnexal mass < 35mm * No visible heartbeat * No significant pain * HCG level < 1500 IU / l **Women with Expectant management need careful follow up with close monitoring of hCG levels and quick/easy access to services if their condition changes**

Answer 361

**Criteria: Injection of Methotrexate** * Follow up needs to be possible to ensure successful termination * The ectopic needs to be unruptured * Adnexal mass < 35mm * No visible heartbeat * No significant pain * **HCG level < 5000 IU / l** * **Confirmed absence of intrauterine pregnancy on ultrasound** **Methotrexate is highly teratogenic** and is given as an **IM Injection** to halt the progress of pregnancy and results in spontaneous termination Women treated with Methotrexate are advised to **not get pregnant for 3 months following treatment** as the harmful effects of methotrexate may last this long

Answer 362

* Measure beta-hCG on days 0, 2, 4, and 7 * If drop of more than 15% from previous measurement, repeat weekly until beta-hCG is less than 20IU/L. * If not, refer for further management.

Answer 363

* Vaginal Bleeding * Nausea and Vomiting * Abdominal Pain * Stomatitis (inflammation of the mouth)

Answer 364

**Anyone that does not meet the criteria for expectant or medical management requires surgical** **Criteria for Surgical:** * Patient is **haemodynamically unstable** * Pain * Adnexal mass > 35mm * Visible heartbeat * HCG Levels > 5000 IU/l **Surgical Options:** * Laparoscopic salpingectomy (**first line treatment for ectopic pregnancy**) * Laparoscopic salpingotomy (used in women at increased risk of infertility due to damage to other fallopian tube) **Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy**

Answer 365

Increased risk of failure to remove the ectopic pregnancy with salpingotomy compared to salpingectomy. * 1 in 5 women having salpingotomy may need **further treatment with methotrexate or salpingectomy**

Answer 366

Diagnosed when a woman has a positive pregnancy test, but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal ultrasound.

Answer 367

* An early viable or failing intrauterine pregnancy * A complete miscarriage * An ectopic pregnancy

Answer 368

**Early viable or failing intrauterine pregnancy** * Signs and symptoms: Mild cramping, spotting or delayed menstruation. **Complete miscarriage** * Signs and symptoms: Severe abdominal pain, heavy bleeding, passage of tissue or clot-like material. **Ectopic pregnancy** * Signs and symptoms: Sharp or stabbing pain in the abdomen, light vaginal bleeding, dizziness or fainting.

Answer 369

**Serum hCG is tracked over time to monitor Pregnancy of Unknown Origin/Location** **Serum hCG level is repeated after 48 hours to measure change from baseline** **Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.** **The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.** **Rise of more than 63%:** * After 48 hours likely indicates an Intrauterine pregnancy. * Repeat Ultrasound scan after **1-2 weeks** to confirm intrauterine pregnancy * Pregnancy should be visible on USS once hCG > 1500 IU/ L **Rise of Less than 63%** * May indicate an Ectopic pregnancy. This patient needs close monitoring and review **Fall of More than 50%** * Likely to indicate a miscarriage * Urine pregnancy test should be performed after 2 weeks (confirms miscarriage is complete)

Answer 370

Miscarriage is defined as the spontaneous loss/termination of a pregnancy prior to 24 weeks gestation. **Early Miscarriage:** Before 12 weeks gestation **Later Miscarriage:** Between 12 and 24 weeks gestation

Answer 371

* 10% of recognised pregnancies end in miscarriage. * Number is likely higher as many occur without the women realising she in pregnant

Answer 372

thT foetus is no longer alive, but no symptoms have occurred and thus the miscarriage is often missed as the mother did not know that something was wrong. * a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion * mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature * cervical os is closed * when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'

Answer 373

vaginal bleeding with a closed cervix and a foetus that is alive

Answer 374

vaginal bleeding with an open cervix. Due to the cervix being open the miscarriage is inevitable.

Answer 375

retained products of conception remain in the uterus after the miscarriage * not all products of conception have been expelled * pain and vaginal bleeding * cervical os is open

Answer 376

A full miscarriage has occurred, and there are no products of conception left in the uterus

Answer 377

a gestational sac is present and is >25mm but contains no embryo

Answer 378

**Often Idiopathic** **Foetal Pathology:** * Genetic disorder * Abnormal development * Placental failure **Maternal Pathology:** * Uterine abnormality (Bicornuate uterus, Cervical insufficiency) * Cervical incompetence * Polycystic ovary syndrome * Poorly controlled diabetes * Poorly controlled thyroid disease * Anti-phospholipid syndrome, Factor V Leiden * Infections: Toxoplasmosis, Syphilis

Answer 379

* advanced maternal age, with women over 35 having a significantly higher risk * a history of previous miscarriages * previous large cervical cone biopsy **lifestyle factors:** * smoking * alcohol consumption * obesity **Medical conditions:** * uncontrolled diabetes * thyroid disorders,

Answer 380

**May be Asymptomatic** * Vaginal Bleeding * Pelvic Pain - Often reported to be worse than the pain of a usual period * Vaginal tissue loss

Answer 381

Main other differential for vaginal bleeding before 24 weeks gestation is an **Ectopic Pregnancy** * Both can present with pain and vaginal bleeding * Pain is often **the first symptom in an ectopic** * Vaginal bleeding is usually **larger in miscarriage**

Answer 382

**Transvaginal Ultrasound Scan: Investigation of choice** **Viability of Pregnancy features:** * Mean Gestational Sac Diameter * Foetal pole and crown-rump length * Foetal Heart Beat

Answer 383

* A foetal pole is expected once the mean gestational sac diameter is 25mm or more. * When there is a mean gestational sac diameter of **25mm or more, without a foetal pole**, the scan is repeated after one week before confirming an anembryonic pregnancy.

Answer 384

* A foetal heartbeat is expected once the **crown-rump length is 7mm or more.** * When the crown-rump length **is less than 7mm, without a foetal heartbeat,** the scan is repeated after at least one week to ensure a heartbeat develops * When there is a crown-rump length **of 7mm or more, without a foetal heartbeat**, the scan is repeated after one week before confirming a non-viable pregnancy. Pregnancy is considered viable when there is a foetal heart beat

Answer 385

Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be **managed expectantly** * Provided they have no pain and no other complications or risk factors (e.g. previous ectopic).

Answer 386

Expectant management before 6 weeks gestation involves: * Awaiting the miscarriage without investigations or treatment. * An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen. * A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. * When bleeding continues, or pain occurs, referral and further investigation is indicated.

Answer 387

**NICE 2019 suggests referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.** **Expectant Management: Watch and Wait** * First line for women without risk factors for heavy bleeding or infection * 1-2 weeks are given to allow the miscarriage to occur spontaneously * repeat UPT preformed **3 weeks after bleeding and pain settle to confirm miscarriage is complete** * Persistent or worsening bleeding require further assessment **Medical Management: 200mg Mifepristone followed by 800ug Misoprostol 48 hours later** * Used for a Missed Miscarriage * Can be a vaginal suppository or Oral dose **Surgical Management: Third line:** * Surgical Options Include: * **Manual Vacuum aspiration:** under local anaesthetic as outpatient * **Electric vacuum aspiration:** under general anaesthetic * Prostaglandins (misoprostol) are given before surgical management to soften the cervix. * Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage

Answer 388

* Heavier bleeding * Pain * Vomiting * Diarrhoea

Answer 389

An incomplete miscarriage occurs when retained products of conception (foetal or placental tissue) remain in the uterus after the miscarriage. **Retained products create a risk of infection.** **Options for an Incomplete Miscarriage:** * Medical management (misoprostol) * Surgical management (evacuation of retained products of conception)

Answer 390

Defined as the loss of 3 or more consecutive 1st trimester pregnancies. Defined as one or more second trimester pregnancies

Answer 391

* Antiphospholipid antibodies * Testing for hereditary thrombophilias * Pelvic ultrasound * Genetic testing of the products of conception from the third or future miscarriages * Genetic testing on parents

Answer 392

**The management is tailored to the contributing pathology:** **Genetic disorder** - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm **Uterine structural abnormality** - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment **Cervical incompetence** - regular ultrasound monitoring of the cervix. May use cervical cerclage **Polycystic ovary syndrome** - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective **Antiphospholipid syndrome** - heparin or low-dose aspirin **Thrombophilia** - heparin may increase the live birth rate **Diabetes** - improve glycaemic control

Answer 393

A termination of pregnancy (TOP) that is an elective procedure to end a pregnancy governed by the **1967 Abortion Act**

Answer 394

* Pregnancy has not exceeded 24 weeks gestation * **Continuing the pregnancy involves greater risk to the physical or mental health of:** * The woman * Existing children of the family The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.

Answer 395

* Continuing the pregnancy is likely to risk the life of the woman * Terminating the pregnancy will prevent **“grave permanent injury”** to the physical or mental health of the woman * There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Answer 396

* Two registered medical practitioners must sign to agree abortion is indicated * It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

Answer 397

* Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral. * Doctors who object to abortions should pass on to another doctor able to make a referral * **Marie Stopes UK** is a charity that provides abortion services * Women should be offered counselling and information to help decision making from a trained practitioner * **Informed consent is essential**

Answer 398

A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments: * Mifepristone (anti-progestogen) * Misoprostol (prostaglandin analogue) 1 – 2 day later **Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.**

Answer 399

Surgical abortion can be performed, depending on preference and gestational age, under: Local anaesthetic (+/-plus sedation) or General anaesthetic * Prior to surgical abortion, **medications are used for cervical priming.** This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators. **Surgical Options:** * Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks) * Cervical dilatation and evacuation using forceps (between 14 and 24 weeks) **Rhesus negative women having a surgical TOP should have anti-D prophylaxis if 10 weeks gestation or more**

Answer 400

* Inform women they may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks post procedure * UPT is performed 3 weeks after abortion to confirm completion * Support and counselling is offered

Answer 401

* Bleeding * Pain * Infection * Failure of the abortion (pregnancy continues) * Damage to the cervix, uterus or other structures * Psychological stress

Answer 402

Diabetes that is triggered by pregnancy due to **reduced insulin sensitivity** during pregnancy and resolves after birth.

Answer 403

* Approximately 5% of pregnancies are affected by GDM. * Second most common complication of pregnancy * Women diagnosed with GDM have an increased risk of developing T2DM * Up to a 50% chance of developing T2DM within 5-10 years postpartum

Answer 404

* BMI of > 30 kg/m² * previous macrosomic baby weighing 4.5 kg or above * previous gestational diabetes * first-degree relative with diabetes * family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 405

**Placental Hormones:** * human placental lactogen (hPL), progesterone, cortisol, and prolactin, have anti-insulin properties. * These hormones increase as the pregnancy progresses * Promote insulin resistance in the mother, ensuring that more glucose is available for the growing fetus. * By the third trimester, insulin resistance peaks, which can overwhelm the body’s ability to regulate blood sugar **Pancreatic Dysfunction:** * Imapired Beta-cell function * limits the ability to increase insulin production * Therefore cannot overcome the insulin resistance * leads to hyperglycaemia

Answer 406

**Often no noticeable symptoms** * Thirst * Polyuria * Fatigue

Answer 407

* **Type 1 or Type 2 Diabetes Mellitus:** Generally presents with symptoms outside of pregnancy, including potential weight loss * **Other forms of gestational hyperglycaemia:** These can be identified through early pregnancy HbA1c testing

Answer 408

* Women with **PMHx of GDM** should have OGTT performed **ASAP after booking and at 24-28 weeks if first test is normal** * Women with **any other** risk factors should be screened for GDM at **24-28 weeks** gestation * When there are features suggestive of GDM: * Large for dates fetus * Polyhydramnios (increased amniotic fluid) * Glucose on urine dipstick

Answer 409

**Oral Glucose Tolerance Test (OGTT):** Used in patients with **risk factors** for gestational diabetes or when there are features suggestive of GDM. **OGTT performed in the morning after fasting. Patient drinks 75g glucose drink and then blood sugar level is measured before and at 2 hours after.** **Gestational Diabetes:** * Fasting: **> 5.6 mmol/l** * At 2 hours: **> 7.8 mmol/l** (remember for GDM cut off is 5-6-7-8)

Answer 410

Patients with GDM need careful explanation about the condition and learn how to monitor and tract blood sugar **First Line:** * Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin if targets are not met. **Second Line:** * Fasting glucose above 7 mmol/l: start **insulin** ± metformin * Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin * Glibenclamide (a Sulfonylurea) Can be used if Insulin or Metformin are not tolerated **Postpartum management includes glucose testing to ensure resolution of GDM** **Women with GDM must also have 4 weekly USS to tract foetal growth at 28, 32 and 36 weeks**

Answer 411

4-weekly scans at: **28, 32 and 36 weeks** to monitor foetal growth

Answer 412

NICE 2015 Targets: * Fasting: 5.3 mmol/l * 1 hour post-meal: 7.8 mmol/l * 2 hours post-meal: 6.4 mmol/l * Avoiding levels of 4 mmol/l or below

Answer 413

* Pre-eclampsia * Developing T2DM (50% increased risk) * Increased risk of cardiovascular disease

Answer 414

**Key Complications:** * **Macrosomia leading to shoulder dystocia** * **Neonatal hypoglycaemia** **Others:** * Childhood Obesity (2x background risk) * Increased risk of Metabolic syndrome + associated complications * Polycythaemia (raised haemoglobin) * Jaundice (raised bilirubin) * Congenital heart disease * Cardiomyopathy

Answer 415

Babies born to mothers with GDM need close monitoring for neonatal hypoglycaemia with regular blood glucose checks and frequent feeds. * Maintain blood glucose **> 2mmol/l** * If it falls below this they may need **IV Dextrose of nasogastric feeding**

Answer 416

* Weight loss for women with **BMI of > 27** * Stop oral hypoglycaemic agents, apart from metformin, and commence insulin * **Folic acid 5 mg/day** from pre-conception to 12 weeks gestation * **Detailed anomaly scan at 20 weeks** including four-chamber view of the heart and outflow tracts **Retinopathy screening** performed at booking and at 28 weeks gestation **Planned delivery between 37 and 38+6**

Answer 417

**Both type I and type II diabetes should aim for the same target insulin levels as with gestational diabetes** NICE 2015 Targets: * Fasting: 5.3 mmol/l * 1 hour post-meal: 7.8 mmol/l * 2 hours post-meal: 6.4 mmol/l * Avoiding levels of 4 mmol/l or below

Answer 418

Metformin and Insulin. **Other oral diabetic medications should be stopped**

Answer 419

**Diabetic Retinopathy:** referral to ophthalmologist for diabetic retinopathy screening * Retinopathy Screening should be performed **shortly after Dating/Booking scan (11 and 14 weeks) and at 28 weeks gestation** * Pre-existing diabetes and pregnancy carries a risk of rapid progression of retinopathy

Answer 420

**Pre-existing Diabetes:** * Planned delivery between **37 and 38+6 weeks** **Gestational Diabetes:** * Women can give birth up to 40+6 weeks

Answer 421

**Sliding-scale insulin regime** considered during labour for women with T1DM. May also be considered for women with **poorly controlled** blood sugars with GDM or T2DM.

Answer 422

Refers to a pregnancy with **more than one foetus**

Answer 423

identical twins (from a single zygote)

Answer 424

non-identical (from two different zygotes)

Answer 425

Single amniotic sac

Answer 426

Two separate amniotic sacs

Answer 427

Share a single placenta

Answer 428

Two separate placentas

Answer 429

**Diamniotic, Dichorionic** Twin pregnancies as each foetus has their own nutrient supply.

Answer 430

**Usually diagnosed on the "booking/dating" ultrasound scan**

Answer 431

* **Dichorionic diamniotic** twins have a membrane between the twins, with a **lambda sign or twin peak sign** * **Monochorionic diamniotic** twins have a membrane between the twins, with a **T sign** * **Monochorionic monoamniotic** twins have no membrane separating the twins

Answer 432

* Anaemia * Polyhydramnios * Hypertension * Malpresentation * Spontaneous preterm birth * Instrumental delivery or caesarean * Postpartum haemorrhage

Answer 433

* Miscarriage * Stillbirth * Foetal growth restriction * Prematurity * **Twin-twin transfusion syndrome** * **Twin anaemia polycythaemia sequence** * Congenital abnormalities

Answer 434

Twin-twin transfusion syndrome occurs when the foetuses share a placenta. **It is called foeto-foetal transfusion syndrome in pregnancies with more than two foetuses.** When there is a connection between the blood supplies of the two foetuses, one foetus (the recipient) may receive the majority of the blood from the placenta, while the other foetus (the donor) is starved of blood. * The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. * The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the foetuses. **Women with Twin-Twin transfusion syndrome need to be referred to a tertiary specialist foetal medicine centre**

Answer 435

Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Answer 436

**Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:** * Booking clinic * 20 weeks gestation * 28 weeks gestation **Additional ultrasound scans are required in multiple pregnancy to monitor for foetal growth restriction, unequal growth and twin-twin transfusion syndrome:** * 2 weekly scans from 16 weeks for monochorionic twins * 4 weekly scans from 20 weeks for dichorionic twins

Answer 437

32 and 33+6 weeks

Answer 438

36 and 36+6 weeks

Answer 439

37 and 37 +6 weeks

Answer 440

Before 35 +6 weeks

Answer 441

Require **elective caesarean section between 32 and 33 +6 weeks**

Answer 442

**Aim to deliver between 37 and 37 +6 weeks** * **Vaginal delivery** is possible when the first baby has a cephalic presentation (head first) * **Caesarean section** may be required for the second baby after successful birth of the first baby * **Elective caesarean** is advised when the presenting twin is not cephalic presentation

Answer 443

Anaemia is defined as a low concentration of haemoglobin. In pregnancy, the **plasma volume increases** and thus there is a reduction in the concentration of haemoglobin leading to anaemia. It is important to optimise the treatment of anaemia in pregnancy so that the woman has reasonable reserves in cases there is significant blood loss during delivery

Answer 444

**Often asymptomatic** May present as: * Shortness of breath * Fatigue * Dizziness * Pallor

Answer 445

**Booking/dating Bloods:** > 110 g/l **28 Weeks Gestation:** > 105 g/l **Post-partum:** > 100 g/l **Women are also offered Haemoglobinopathy screening at the booking clinic for Thalassaemia and Sickle Cell Disease**

Answer 446

**Low MCV** Indicates Iron Deficiency Anaemia **Normal MCV:** Indicates a physiological anaemia due to increased plasma volume of pregnancy **Raised MCV:** Indicates B12 or Folate Deficiency

Answer 447

**Depends on the cause:** **Iron:** * Women with anaemia in pregnancy are started on iron replacement: **Ferrous sulphate 200mg 3x daily** * Women who are not anaemic but have low ferritin may also be started on supplementary iron. * Treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished **B12:** * The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). * **IM Hydroxocobalamin injections or Oral Cyanocobalamin Tables** **Folate:** * All women should already be taking folic acid **400mcg OD** * Women with folate deficiency are started on **folic acid 5mg daily**

Answer 448

Spina bifida is a neural tube defect characterised by incomplete development of the spinal column, resulting in herniation of the spinal cord.

Answer 449

* Incomplete fusion of the vertebrae, but with no herniation of the spinal cord * May be visible only as a small tuft of hair overlying the site

Answer 450

* Incomplete fusion of the vertebrae, with herniation of a meningeal sac containing CSF * Visible prominence at the site, but usually covered by skin

Answer 451

* Incomplete fusion of the vertebrae with herniation of herniation of a meningeal sac containing CSF and spinal cord. * Usually accompanied by other defects such as hydrocephaly or Chiari malformation * Visible prominence at the site, with exposed meninges

Answer 452

**All pregnant women, and those trying to conceive are recommended to take folic acid as this has been shown to decrease the risk of neural tube defects** * **400 ug/day from 3 months prior to conception, until 12 weeks gestation** * In women at **higher risk** (e.g. those with a child affected by a neural tube defect, or those on certain medications) are recommended a **higher dose of 5mg/day**

Answer 453

Usually diagnosed on prenatal scans

Answer 454

**Neurological:** * Motor deficits * Sensory deficits * Neurogenic bladder or bowel * Hydrocephalus * Seizures **Musculoskeletal:** * Increased risk of hip subluxation * Scoliosis * Contractures

Answer 455

* Primary neurosurgical repair * Orthopaedic surgery

Answer 456

High blood pressure that **exists before pregnancy or is diagnosed before 20 weeks gestation** and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.

Answer 457

When there is an onset of high blood pressure that occurs **after 20 weeks gestation without the presence of proteinuria**

Answer 458

Multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.

Answer 459

**Asymptomatic** * May have headaches and blurred vision

Answer 460

* **Preeclampsia:** Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation. * **Chronic Kidney Disease:** Typically presents with proteinuria, haematuria, and a rise in serum creatinine.

Answer 461

Gestational Hypertension must be **new onset after 20 weeks gestation WITHOUT proteinuria** * **Blood pressure Monitoring** * **Urinalysis:** To exclude proteinuria and subsequently Pre-eclampsia

Answer 462

* Discontinuation of some anti-hypertensive medications (**ACEis and ARBs**) to switch to pregnancy safe options. * **Regular Blood Pressure Monitoring** * **Regular Urinalysis at least weekly** * Monitoring Foetal growth by serial growth scans * PlGF testing on one occasion **Blood pressure control:** * **Gestational Hypertension > 150/100mmHg: Oral Labetalol** * Treating to aim for BP < 135/85mmHg * Admission for women with a BP above 160/110 mmHg * Gestational Hypertension (mild) of: 140/90 to 149/99mmHg: **No treatment other than regular monitoring** **Alternatives if Labetalol is not tolerated:** * **2nd Line:** Nifedipine. * **3rd Line:** Methyldopa

Answer 463

Pre-eclampsia refers to **new high blood pressure (hypertension)** in pregnancy with **end-organ dysfunction, notably with proteinuria** (protein in the urine). It occurs **after 20 weeks gestation**

Answer 464

When **seizures** occur as a result of Pre-eclampsia due to **cerebral vasospasm**

Answer 465

* Significant cause of **maternal and foetal morbidity and mortality** * Occurs after **20 weeks gestation**

Answer 466

**High-risk factors are:** * Pre-existing hypertension * Previous hypertension in pregnancy * Existing autoimmune conditions (e.g. systemic lupus erythematosus) * Diabetes * Chronic kidney disease **Moderate-risk factors are:** * Older than 40 * BMI > 35 * More than 10 years since previous pregnancy * Multiple pregnancy * First pregnancy * Family history of pre-eclampsia **Aspirin is given to women from 12 weeks until delivery for those with 1 Major or 2 moderate risk factors**

Answer 467

In normal pregnancy, the trophoblast cells (cells that form the placenta) invade the uterine lining and remodel the spiral arteries to become low-resistance vessels that supply adequate blood flow to the growing fetus. * In pre-eclampsia, **defective trophoblast invasion** leads to **incomplete** remodeling of the **spiral arteries**. As a result, these arteries **remain narrow and high-resistance**, limiting the blood supply to the placenta (a state called **uteroplacental ischemia**). * Placental hyoxia leads to oxidative stress and pro-inflammatory cytokines release. * This leads to **systemic inflammation and impaired endothelial cell function** resulting in the symptoms and complications of Pre-eclampsia

Answer 468

**Classical Triad:** * **Hypertension** * **Proteinuria** * **Peripheral Oedema** **Symptoms:** * Severe Headaches (potentially due to cerebral oedema) * Visual Disturbance (due to retinal artery vasospasm) * Epigastric pain (due to reduced blood flow to the liver causing injury and swelling of liver and capsule) * Drowsiness * Nausea and vomiting * Hyperreflexia

Answer 469

**Hypertension** * Oxidative stress on the placenta causes the release of **pro inflammatory cytokines** * These entre the mothers circulation and cause **endothelial cell dysfunction** * This results in **vasoconstriction and salt retention (at the kidneys)** leading to hypertension **Proteinuria** * **Local vasospasm and hypertension** will result in reduced blood flow to the kidneys. * The systemic inflammatory response may also lead to **glomerular changes and disruption of the basement membrane and podocytes** * This results in the leakage of proteins out the kidneys causing **proteinuria** **Peripheral Oedema** * Endothelial injury increases **vascular permeability** enabling water to leak out of blood vessels and into the surrounding tissues * Furthermore, the proteinuria leads to low protein concentrations within blood vessels reducing **the oncotic pressure** and hence leads to further water loss into tissues * This results in **generalised oedema** that is commonly seen in the **Legs, face and hands**. * Pulmonary oedema (causing cough and SOB) as well as cerebral oedema (causing headaches, confusion and **seizures**)

Answer 470

* **Eclampsia** (seizures due to cerebrovascular vasospasm) * Organ failure * Disseminated intravascular coagulation (DIC) * **HELLP syndrome** (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))

Answer 471

* **Intrauterine growth restriction (IUGR)** * Pre-term delivery * **Placental abruption** * Neonatal hypoxia

Answer 472

**Blood Pressure Monitoring** * Systolic BP > 140mmHg * Diastolic BP > 90mmHg * **Severe Pre-eclampsia:** Systolic >160mmHg and Diastolic >110mmHg **Urinalysis:** * Proteinuria **1+ or more** on urine dipstick * **Urine protein:creatinine ratio** > 30mg/mmol is significant * **Urine albumin:creatinine ratio** > 8mg/mmol is significant **Blood Tests:** * U&E, FBC, LFTs (To assess kidney function, liver function and clotting status)

Answer 473

NICE guidelines 2019 state diagnosis can be made with: * Hypertension (systolic >140mmHg/Diastolic >90mmHg) **PLUS any of:** * Proteinuria (1+ or more on urine dipstick) * Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) * Placental dysfunction (e.g. foetal growth restriction or abnormal Doppler studies)

Answer 474

**Prophylaxis:** * Aspirin (75mg - 150mg) from 12 weeks till birth * Women with 1 Major or 2 Minor RFs **Gestational HTN Monitoring:** * Treating to aim for a blood pressure below 135/85 mmHg * Admission for women with a blood pressure above 160/110 mmHg * Urine dipstick testing at least weekly * Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) * Monitoring fetal growth by serial growth scans * PlGF testing on one occasion (20-35 weeks) **Pre-eclampsia Dx Monitoring:** * Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S) * Blood pressure is monitored closely (at least every 48 hours) * Urine dipstick testing is not routinely necessary (the diagnosis is already made) * Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly **Management of BP:** * BP < 140/90: Rest, weight loss, exercise * BP > 150/100: Oral Labetalol * BP > 160/110: Admit Patient - Labetalol * 2nd Line: Nifedipine (Modified Release) * 3rd Line: Methyldopa * Severe HTN or Eclampsia: IV Hydralazine **Management During Labour:** * Fluid restriction if severe pre-eclampsia or eclampsia * BP Meds * IV Magnesium Sulphate in Labour and 24 hours after * Corticosteroids if premature birth planned **After Delivery** * Delivery is definitive Tx * BP monitored until normal * Switch to Enalapril

Answer 475

Consider early delivery at **37 weeks** if blood pressure cannot be controlled or complications occur. **Corticosteroids** should be given to the women having a premature birth **to help the foetal lungs mature**

Answer 476

Delivery of the foetus and placenta

Answer 477

Similar to Pre-eclampsia with additional **IV Magnesium Sulphate** to manage the seizures Also treat the cause (HTN) too so Labetalol/nifedipine.

Answer 478

Combination of features that occur as a complication of Pre-eclampsia and Eclampsia: **H**aemolysis **E**levated **L**iver enzymes **L**ow **P**latelets

Answer 479

* HELLP syndrome is relatively rare, affecting approximately 0.5-0.9% of all pregnancies. * Occurs in 10-20% of women with **severe pre-eclampsia or eclampsia** * However, it is a significant cause of maternal and perinatal morbidity and mortality.

Answer 480

* Reduced perfusion of the placenta and thus oxidative stress releasing inflammatory cytokines. * Hypertension and endothelial damage reduces blood flow to the liver causing injury and swelling. This results in **elevation of liver enzymes** and stretches the liver capsule causing **RUQ and epigastric pain** * Endothelial cell injury leads to formation of thrombi in vasculature **using up platelets making their numbers low** * Thrombi can act as blocks for RBCs which crash into them causing them to become damaged and **haemolyse**

Answer 481

Headache Nausea and/or vomiting Epigastric pain Right upper quadrant abdominal pain due to liver distension Blurred vision Peripheral Oedema

Answer 482

* Full blood count to assess for low platelet count and evidence of haemolysis * Liver function tests to assess for elevated liver enzymes * Coagulation studies to evaluate for disseminated intravascular coagulation * Ultrasound scans to assess for liver abnormalities and placental abruption

Answer 483

**Delivery of the baby and placenta** * Mothers may also require **blood transfusions** to manage anaemia and thrombocytopenia

Answer 484

Obstetric cholestasis, also known as **intra-hepatic cholestasis of pregnancy**, is a pregnancy-related hepatobiliary disorder that **typically manifests after the 24th week of gestation.** The condition is characterised by impaired bile flow leading to the accumulation of bile acids.

Answer 485

* Relatively common complication of pregnancy occuring in 1% * Develops later in pregnancy **(Typically after 24-28 weeks)** * More common in **South Asian Ethnicity**

Answer 486

Multifactorial: * Hormonal Factors such as **Increased oestrogen and Progesterone** thought to be main cause * Genetic factors * Environmental triggers

Answer 487

* Genetic and hormonal factors impair bile acid transport. * Accumulation of bile acids in the liver due to defective bile transport. * Increased serum bile acids cause pruritus and potential hepatocellular damage. * Placental dysfunction due to toxic effects of high bile acid levels can lead to fetal complications like preterm labor or stillbirth. **Obstetric cholestasis is associated with an increased risk of stillbirth.**

Answer 488

Obstetric cholestasis typically present later in pregnancy, particularly in the **third trimester**. **Itching (pruritis)** is the main symptom, particularly affecting the **palms of the hands and soles of the feet**. **Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:** * Fatigue * Dark urine * Pale, greasy stools * Jaundice * Abdominal Pain

Answer 489

* Polymorphic eruption of pregnancy * Pemphigoid gestationis.

Answer 490

* Gallstones * Acute fatty liver * Autoimmune hepatitis * Viral hepatitis

Answer 491

* **Serum Bile Acids:** Raised above 19 micromol/l * **LFTs:** Mainly ALT, AST and GGT **ALP typically rises in pregnancy due to it being produced by the placenta.**

Answer 492

**First Line:** * **Emollients:** soothe the skin * Vitamin K Supplementation * **Antihistamines: Chlorphenamine** to aid in sleeping (**Not improve itching**) **Second Line:** * **Ursodeoxycholic acid:** Improves LFTs, bile acids and symptoms and helps prevent **premature birth** **Induction of Labour at 37 weeks**

Answer 493

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

Answer 494

This occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin's gland.

Answer 495

This occurs when a cyst becomes infected, resulting in extreme pain, lymphadenopathy, erythema, and in rare cases, systemic upset.

Answer 496

The primary cause of Bartholin's gland cysts and abscesses is the blockage of the gland's duct. This blockage can be due to thick mucus, inflammation, trauma, or in rare cases, malignancy. Abscesses are typically caused by infection of a cyst, often with normal vaginal flora or sexually transmitted bacteria.

Answer 497

**Bartholin's gland cyst:** * Palpable swelling and without much pain at the site of the Bartholin's gland. **Bartholin's gland abscess:** * Extreme pain * lymphadenopathy * erythema, * rare cases, systemic upset such as fever and malaise.

Answer 498

* **Vaginal cysts:** Typically asymptomatic but can cause discomfort during sex or when sitting. * **Skene's duct cysts:** Located on either side of the urethra, can cause discomfort during sex or urination. * **Vulvar cancer:** Can present with a vulvar lump, itching, pain, or abnormal bleeding.

Answer 499

**Clinical diagnosis with a physical examination** * Cyst is often painless * Absess is often painful + lymphadenopathy **If postmenopausal then may require biopsy to exclude malignancy**

Answer 500

**Cysts:** * Good hygiene and warm compresses * Incision and Drainage is typically avoided due to likelihood of reoccurrence **Abscess:** * Antibiotics * **Surgical intervention may be required:** * **Word Catheter:** requires local anaesthetic * **Marsupialisation:** requires general anaesthetic

Answer 501

Also known as **Cot death** is the sudden unexplained death of an infant. It usually occurs within the first **six months of life**

Answer 502

* Putting the baby to sleep prone * Parental smoking * Co-sleeping in same bed * Prematurity * Hyperthermia (e.g. over-wrapping) or head covering (e.g. blanket accidentally moves)

Answer 503

* Put the baby on their back when not directly supervised * Breastfeeding * Keep their head uncovered * Place their feet at the foot of the bed to prevent them sliding down and under the blanket * Keep the cot clear of lots of toys and blankets * Maintain a comfortable room temperature (16 – 20 ºC) * Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes). * Room sharing **NOT BED SHARING**

Answer 504

* **Lullaby Trust** is a charity to help support families affected. * Bereavement services and counselling should also be available. * **Care of Next Infant (CONI) Team** supports parents with their next infant after SIDS including extra support and home visits and resuscitation training

Answer 505

**Follicular/Proliferative Phase** Days 1-14 **Luteal/Secretory Phase** Days 15-28

Answer 506

* Increased frequency of pulsatile GnRH secretion leads to an increase in LH, and an initial increase in FSH. * Oestrogen rises gradually as granulosa cells convert thecal androgens under the influence of FSH. Progesterone levels remain low after loss of corpus luteum. Moderate levels of oestrogen exert negative feedback on FSH secretion. * **Days 1-5:** Progesterone withdrawal due to degeneration of corpus luteum leads to sloughing of the stratum functionalis (a menstrual bleed). * **Days 6-14:** The endometrium undergoes its proliferative phase due to rising oestrogen levels. * Meanwhile, 15-20 early antral (tertiary) follicles undergo development. At approximately **day 7, a single dominant follicle is selected.** * It is thought that this occurs because rising oestrogen levels lower FSH levels through negative feedback - the dominant follicle is the one that can cope with lower FSH. * **Day 13** - Rising oestrogen levels reach a ‘tipping point’, at which their negative feedback on LH secretion is reversed - the LH surge occurs, stimulating the oocyte to complete meiosis I and form a single Graafian follicle. * **Day 14** - Ovulation - The secondary oocyte erupts from its follicle, carried by antral fluid.

Answer 507

* **Day 15** - the granulosa cells of the ruptured follicle become luteinised, forming the progesterone-secreting corpus luteum. * The corpus luteum’s progesterone acts upon the endometrium to cause it to enter its secretory phase - amongst other things, it secretes glycogen and mucous. * **Progesterone levels peak 7 days before** the next menstrual bleed - 7 days before CL completely degenerates. * High levels of progesterone increase the volume and viscosity of cervical secretions; this begins the formation of the protective operculum. * **After 10 days, if no conceptus has implanted**, the corpus luteum spontaneously regresses. This leads to diminishing progesterone levels: * Without progesterone’s negative feedback on the hypothalamus, GnRH release frequency increases and facilitates a rise in gonadotrophins. * Progesterone withdrawal also stimulates the stratum functionalis of the secretory endometrium to be shed. * As FSH and LH levels rise, and the menstrual bleed begins, the cycle restarts on Day 1.

Answer 508

* Copper intrauterine device (Cu-IUD) * **Barrier methods** e.g. male condom, female condom, diaphragm/cervical cap * **Surgical methods** e.g. tubal ligation, vasectomy * Lactational amenorrhoea * Fertility awareness methods (FAM)

Answer 509

* Combined Hormonal Contraception (CHC) * Combined Oral Contraceptive Pill (COCP) * Progesterone Only Pill (POP/Mini-pill) * Levonorgestrel Intrauterine System (LNG-IUS commonly known as **Mirena**) * Contraceptive Injection (Depo-Provera) * Contraceptive Implant

Answer 510

* Levonorgestrel Pill * Ulipristal Acetate Pill (**EllaOne**) * Copper Intrauterine Device (Cu-IUD)

Answer 511

**Mechanism:** Decreases sperm motility and Survival. Makes the endometrium less accepting of implantation **Efficacy:** 0.8% experience unintended pregnancy after 1 year **Advantages:** * Effective immediately on insertion (can be used in emergency). * No hormonal side effects. * High Efficacy **Absolute Contraindications:** * PID * Gonorrhoea/Chlamydia * Unexplained vaginal bleeding/endometrial cancer * postpartum/postabortion septicaemia * Gestational trophoblastic disease * Purulent cervicitis, Pelvic TB **Side Effects:** * Breakthrough bleeding. * Increased duration or heaviness of periods **Other:** * Classified as **Long-acting reversible contraceptive (LARC)** * Left in situ for **5 years** * Most effective form of emergency contraception. * The Cu-IUD is licensed for insertion 5 days post-ovulation.

Answer 512

**Mechanism:** Inhibits ovulation **Efficacy:** 0.03% failure rate if used perfectly but human error is important taking average unwanted pregnancy to 9% **Advantages:** * Rapidly reversible if unintended side effects * Regulars and tends to lighten periods **Absolute Contraindications:** * <6 weeks postpartum in breastfeeding women * Aged 35, smoking >15 cigarettes per day * Stage 2 hypertension (160/100) * History of VTE * Disease: Breast cancer, inherited thrombophilia e.g. Factor V Leiden, cardiomyopathy, cirrhosis, vascular disease, SLE, positive antiphospholipid antibodies. * Migraine with aura **Side Effects:** * Headache * Mood disturbance * Breakthrough bleeding

Answer 513

**Mechanism:** Thickens cervical Mucus **Efficacy:** 9% experience unintended pregnancy after 1 year. **Advantages:** * Rapidly reversible * Far fewer absolute contraindications than the combined pill **Absolute Contraindications:** * Breast Cancer **Side Effects:** * Breakthrough Bleeding **Other:** * Effective after 2 days of administration

Answer 514

**Mechanism:** Prevents endometrial proliferation and also thickens cervical mucus **Efficacy:** 0.2% unintended pregnancy after 1 year **Advantages:** * Extremely high efficacy * Can be left in situ for 3-5 years * Lightens periods * Systemic absorption is minimal, reducing systemic hormonal side effects **Absolute Contraindications:** * PID * Gonorrhoea or chlamydia * Unexplained vaginal bleeding / endometrial cancer * Postpartum / post-abortion septicaemia * Gestational trophoblastic disease * Purulent cervicitis, pelvic TB **Side Effects:** * Irregular Menstrual Bleeding

Answer 515

**Mechanism:** Inhibits Ovulation and also thickens cervical mucus (Medroxyprogesterone acetate) **Efficacy:** 6% experience unintended pregnancy after 1 year. **Advantages:** * Long acting - Requires injection every **12 weeks** **Absolute Contraindications:** * Breast Cancer **Side Effects:** * Amenorrhoea * Weight gain * Reduces BMD so cant be given to people beyond age 50

Answer 516

**Mechanism:** Inhibit Ovulation and also thickens cervical mucus **Efficacy:** 0.05% experience unintended pregnancy after 1 year **Advantages:** * Most effective contraception available. * Active for 3 years before replacement is required. **Absolute Contraindications:** * Breast Cancer **Side Effects:** * Irregular Menstrual Bleeding

Answer 517

**Mechanism:** * Inhibits ovulation * Can delay ovulation by 5 days (the viable lifespan of ejaculated sperm). * Not effective in the late luteal phase, in which case ulipristal acetate is required. **Efficacy:** * Effective up to **72 hours post UPSI** * Not effective if taken after ovulation has occurred

Answer 518

**Mechanism:** Inhibits ovulation **Efficacy:** * Effective up to **120 hours post UPSI** * Can delay ovulation even if LH surge has started * Remains effective in **late follicular phase** * Not effective if taken after ovulation * Contraception with pill, patch or ring should be restarded after **5 days** due to reduced effectiveness

Answer 519

* Offer most effective method (Cu-IUD) first line; * Can be taken either within 120 hours of first UPSI or within 120 hours of calculated date of ovulation; whichever is later. * If Cu-IUD not acceptable / appropriate, offer oral emergency contraception; * If within 72 hours of UPSI - offer LNG or UPA. * If 72-120 hours post-UPSI - offer UPA.

Answer 520

Fusion of haploid sperm and oocyte, typically occurring in the ampulla of the fallopian tube.

Answer 521

**1. Capacitation** - final stage of sperm maturation - involves exposure of receptor sites involved in zona pellucida penetration. **2. Acrosome reaction** - loss of the acrosome cap on the head of the sperm cell leads to release of lytic enzymes, which allows the sperm to penetrate the zona pellucida. **3. Adhesion and entry** - cell membranes of sperm and egg fuse, and the head of the sperm if phagocytosed - it then breaks down to release the sperm nucleus. **4. Cortical reaction** - modification of the zona pellucida to prevent polyspermy, induced by membrane fusion and mediated by cortical granules **5. Meiosis II** - the oocyte completes meiosis II (which until this point is arrested in metaphase II) to give the second polar body. **6. Syngamy** - the male and female pronuclei replicate DNA and shed their nuclear membranes as they move toward one another, before aligning at a common metaphase plate and undergoing mitosis

Answer 522

* **Day 6-7:** implantation of blastocyst into endometrium * **Week 3:** gastrulation - formation of trilaminar disc (endoderm, mesoderm, ectoderm) from the primitive streak * **Week 3-8:** beginning of development of organ systems * **Week 4:** neurulation - development of neural tube from the ectoderm * **Week 23:** generally considered to be the threshold of viability.

Answer 523

**Exchange:** * **gaseous:** Oxygen moves readily from maternal to foetal haemoglobin (HbF) due to HbF’s higher affinity. CO2 diffuses from foetal to maternal blood down the concentration gradient * **Nutritional:** Glucose moves from maternal to foetal circulation via facilitated diffusion; both amino acids and free fatty acids also cross from mother to foetus, the former through active transport. **Endocrine:** * **Human Chorionic Gonadotrophin (hCG)** Produced by trophoblast cells - maintains the corpus luteum to allow for sufficient progesterone production until the placenta takes over * **Human Placental Lactogen (hPL):** Increases maternal free fatty acid and insulin levels, as well as inducing maternal insulin resistance. * **Progesterone:** Inhibits uterine contractility and thickens endometrium * **Oestrogen:** Stimulates myometrial growth, oxytocin receptor synthesis and pregnancy related breast changes

Answer 524

**Metabolic** * Increased metabolism: The hormone thyroxine (T4) increases, enhancing metabolic activity. * Increased insulin resistance: Human placental lactogen (hPL), produced by the placenta, leads to insulin resistance to ensure more glucose is available for the fetus. * Weight gain: Estrogen and progesterone contribute to fat storage, while hPL shifts energy metabolism toward fat utilization to save glucose for the baby. **Blood** * Increased blood volume: Driven by estrogen, which stimulates the production of blood plasma and increased fluid reabsorption at the kidneys * Increased cardiac output: Progesterone relaxes smooth muscles, causing blood vessels to dilate, which reduces TPR increases blood flow, increases Venous reutrn, increased preload, SV and subsequently CO. * Increased clotting factors: Estrogen increases clotting factors to prepare for childbirth and reduce blood loss causing hypercoagulability * Hemodilution: Increased plasma volume (due to estrogen) results in a relative dilution of red blood cells, leading to physiological anemia. **Pulmonary (Lungs)** * Increased oxygen demand: Progesterone stimulates the respiratory centers in the brain, increasing the drive to breathe and ensuring more oxygen is available for both mother and baby. * Increased tidal volume: Progesterone also leads to deeper breathing by expanding the lungs' capacity. * Decreased lung capacity: This is more of a mechanical effect due to the growing uterus pushing against the diaphragm, though hormonal factors also contribute. **Nervous (Neurological)** * Pregnancy brain: Often linked to fluctuating levels of progesterone and estrogen, which may impact memory and concentration. * Increased risk of headaches and dizziness: Changes in blood pressure due to progesterone (vasodilation) and increased fluid retention from aldosterone can contribute to these symptoms. **Breasts:** * Ductal proliferation * Prolactin stimulates milk production from alveolar cells * Areola grow **Lower body (Renal, GI, Uterus)** * Kidneys: Increased blood flow to the kidneys is driven by progesterone and relaxin, which also cause dilation of the renal vessels, increasing the glomerular filtration rate (GFR). * GI system: Progesterone relaxes smooth muscle, slowing down digestion and causing nausea, heartburn, and constipation. The hormone hCG (human chorionic gonadotropin) is responsible for early pregnancy nausea. * Uterus growth: Estrogen promotes the growth of the uterine lining and stimulates the muscles of the uterus to expand during pregnancy. **Look (Skin)** * Hyperpigmentation: Melanocyte-stimulating hormone (MSH) increases, along with estrogen and progesterone, leading to darkening of the skin, especially on the face and abdomen (chloasma and linea nigra). * Stretch marks: These are largely due to physical stretching, but cortisol (which increases during pregnancy) may weaken skin fibers, making stretch marks more likely. * Increased oil production: Androgens (which rise slightly during pregnancy) stimulate the sebaceous glands, potentially causing acne. * Spider veins and varicose veins: The increase in blood volume and the relaxing effects of progesterone on blood vessels cause veins to enlarge and become more visible. * At 20 weeks, uterus can compress IVC in R. lateral position causing varicose veins and peripheral oedema.

Answer 525

**8 routine for parous women and 11 for nulliparous women** (Women who haven't given birth to a live baby.) Also possibility of a **41 week appointment** if women has not yet delivered Nulliparous women have an additional 3 at: **25 weeks, 31 weeks and 40 weeks**

Answer 526

**Before 10 weeks:** Booking Clinic **Between 10 and 13+6:** Dating Scan **16 weeks:** Antenatal appointment **18-20+6:** Anomaly Scan **Antenatal Appointments:** * 25 weeks (Nulliparous) * 28 weeks * 31 weeks (Nulliparous) * 34 weeks * 36 weeks * 38 weeks * 40 weeks (Nulliparous) * 41 weeks * 42 weeks

Answer 527

**All offered at the Booking visit** * Infectious Disease * Sickle Cell and Thalassaemia * Foetal Anomaly

Answer 528

* **HIV:** 25% risk of MTC transmission if untreated * **Syphilis:** Risk of miscarriage, stillbirth, congenital syphilis * **Hepatitis B:** 70-90% risk of MTC transmission if HBeAg positive

Answer 529

**Trisomy's 21 (Down's), 18 (Edwards') and 13 (Patau's)** All Screened for between 11-14 weeks **combined Test:** * b-HCG * Pregnancy Associated Plasma Protein-A (PAPPA) * Nuchal Translucency > 6mm If the mother is late-booking (>14+0) then the **quadruple test is used for T21:** * b-hCG * AFP * Inhibin A * Serum Unconjugated Oestriol **If high Chance of Anomaly (> 1/150) there are 3 options:** * No further testing * Non-invasive prenatal testing (NIPT) - Placental cell free DNA * Prenatal diagnosis (PND) - Chorionic villus sampling (11-14 weeks), Amniocentesis (15+ weeks)

Answer 530

Tests for Trisomy: **Trisomy 21 (Down's):** high b-hCG, Low PAPP-A, High NT Edwards and Pataus are similar to Downs but HCG is lower **Trisomy 18 (Edwards'):** Low b-hCG, Low PAPP-A, High NT **Trisomy 13 (Patau's):** Low b-hCG, Low PAPP-A, High NT

Answer 531

Normally occur between **37 and 42 weeks gestation**

Answer 532

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

Answer 533

The first stage of labour is defined as the period that starts with regular uterine contractions and ends when the cervix is fully dilated to 10cm. This stage can be further divided into: **Latent Phase:** * from 0 to 3cm dilation * Progresses at around 0.5cm per hour. * Irregular contractions. **Active Phase:** * from 3cm to 7cm dilation * progresses at around 1cm per hour * Regular contractions **Transition Phase:** * From 7cm to 10cm dilation * Progresses at around 1cm per hour * Strong and regular contractions.

Answer 534

**Hormonal Mechanisms** * **Oxytocin:** * Released by the posterior pituitary gland in response to uterine contractions. * Stimulates stronger and more frequent uterine contractions, which push the baby down and cause cervical dilation. * In a positive feedback loop, contractions stimulate the release of more oxytocin, which increases the strength and frequency of contractions. * **Prostaglandins:** * Produced by the uterine tissue, prostaglandins help to soften and thin (efface) the cervix. * They also assist in stimulating contractions and preparing the uterus for labor. * **Relaxin:** * Relaxin, a hormone released during pregnancy, loosens the pelvic ligaments and softens the cervix, helping with dilation and allowing the baby to pass through the birth canal. * **Estrogen and Progesterone:** * Towards the end of pregnancy, estrogen levels rise while progesterone levels drop. * Estrogen enhances the sensitivity of the uterus to oxytocin, stimulating contractions, * Progesterone (which maintained uterine relaxation during pregnancy) decreases, allowing labor to begin. **Uterine Contractions** * Contractions are the key driving force in the first stage of labor. * They start as mild and irregular in the latent phase, gradually becoming more intense, regular, and rhythmic during the active phase. * Each contraction pulls up the lower uterine segment and causes the cervix to thin (efface) and open (dilate). **Cervical Changes** * **Effacement:** * The cervix thins out from being thick and long to becoming soft and thin. * Effacement is measured in percentages, with 100% indicating complete thinning. * **Dilation:** * The cervix opens from 0 cm to 10 cm during the first stage of labor. * Dilation progresses slowly in the latent phase (0–4 cm) and then speeds up significantly in the active phase (4–10 cm).

Answer 535

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

Answer 536

**Signs of Labour:** * Show (mucus plug from the cervix) * Rupture of membranes * Regular, painful contractions * Dilating cervix on examination **Latent First stage:** is when there are both * Painful contractions * Changes to the cervix with effacement and dilation up to 4cm **Established first stage of labour:** is when there are both * Regular painful contractions * Dilation of the cervix from 4cm onwards

Answer 537

The second stage of labour is defined as the period beginning with complete cervical dilation and ending with the delivery of the foetus. **There are 7 Stages:** 1. **Descent:** * The baby’s head (providing it is in cephalic presentation) descends deeper into the pelvis until it is no longer palpable on abdominal examination. 2. **Flexion:** * The baby’s head flexes (chin to chest) * This gives the narrowest (suboccipitobregmatic) diameter. 3. **Internal rotation:** * Baby’s occiput rotates anteriorly from the lateral position to give the normal occipito-anterior position. 4. **Extension:** * Baby’s occiput contacts the maternal pubic rami * It then extends and crowns 5. **Restitution:** * Baby’s occiput re-aligns with its shoulders, which lie in between the anterior-posterior and lateral positions 6. **External rotation:** * Baby’s shoulders rotate into anterior-posterior position (i.e. perpendicular to mother’s). * At this point, the baby’s head is delivered * It is aligned with its shoulders, so the face looks laterally at the mother’s thigh. 7. **Delivery of shoulders:** * The anterior shoulder is delivered first from beneath the pubic ramus; * The head is then gently lifted anteriorly to deliver the posterior shoulder. * The rest of the baby’s body rapidly follows.

Answer 538

The period beginning at the delivery of the foetus and ending with the delivery of the placenta and foetal membranes. * This stage **generally occurs within 30 minutes of delivery of the baby.** **Physiological Management:** * Placenta is delivered bby maternal effort without medications or chord traction * This stage generally lasts within 30 minutes to an hour when allowed to occur naturally **Active Management:** * Assisted by doctor or midwife * Involves **administration of IM oxytocin** and **Traction of the umbilical cord** to guide placenta out of uterus.

Answer 539

**Routinely offered to all women to reduce the risk of postpartum haemorrhage** Initiated if: * Haemorrhage * More than a 60 minute delay in the delivery of the placenta (Prolonged third stage)

Answer 540

The medically initiated process of starting labour artificially. It is performed under specific circumstances to ensure the safety of the mother and the child.

Answer 541

* Post-dates/Prolonged pregnancy (>41 weeks gestation) * Prelabour rupture of membranes * Fetal growth restriction * Pre-eclampsia * Obstetric cholestasis * Existing diabetes * Intrauterine fetal death

Answer 542

* Placenta praevia * Malpresentations * Severe foetal compromise * Cord prolapse * Vasa previa * Previous classical/vertical incision during caesarean section * Multiple lower uterine segment caesarean sections * Transmissible infections e.g. herpes simplex

Answer 543

**Bishop Scoring System:** Score from 0-13 * Foetal station (scored 0 – 3) * Cervical position (scored 0 – 2) * Cervical dilatation (scored 0 – 3) * Cervical effacement (scored 0 – 3) * Cervical consistency (scored 0 – 2) **A score of 8 or more** the cervix is ripe and there is a high chance of spontaneous labour or response to induction of labour **A score below 5** suggests that labour is unlikely to start without induction

Answer 544

**Membrane Sweep** * Inserting a finger into the cervix to stimulate the cervix and begin the labour process * Labour should follow **within 48 hours if successful** * Is used from **40 weeks gestation** to attempt to initiate labour in women over their EDD (estimated delivery date) **Vaginal Prostaglandin E2 (Dinoprostone)** * Insert a Gel, Tablet or Pessary into the vagina to **slowly release local prostaglandins over 24 hours.** * Usually performed when there is a **Bishop Score < 6** **Cervical Ripening Balloon (CRB):** * Ballon inserted into the cervix to dilate it. * Used when vaginal prostaglandins are not preferred (risk of UHS) * Often done with prev caesarean section Hx or Para 3 **Amniotomy (Artificial Rupture of Membranes)** * May be done with/without **oxytocin infusion** * Only used where Vaginal Prostaglandins are not tolerated/successful * Used when the **Bishop Score > 6**

Answer 545

* Further vaginal prostaglandins * Artificial rupture of membranes and oxytocin infusion * Cervical ripening balloon (CRB) * Elective caesarean section

Answer 546

**Uterine Hyperstimulation:** This is where the contraction of the uterus is prolonged and frequent, causing foetal distress and compromise. 2 Criteria for Uterine Hyperstimulation: * Individual uterine contractions lasting more than 2 minutes in duration * More than five uterine contractions every 10 minutes

Answer 547

* Foetal compromise, with hypoxia and acidosis * Emergency caesarean section * Uterine rupture

Answer 548

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

Answer 549

* Take a history, Assess for risk factors and assess for pain * Pules, BP, Resp Rate, Urinalysis * Abdominal palpation to determine Lie, presentation, engagement and contraction strength * Vaginal examination to determine station, position, cervical effacement and dilation, presence or absence of membranes and caput or cranial moulding.

Answer 550

**Partogram** monitors first stage of labour **Progress:** * Cervical dilatation (measured by a 4-hourly vaginal examination) * Descent of the fetal head (in relation to the ischial spines) * Frequency and duration of contractions **Fetal Wellbeing:** * Fetal heart rate * Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium **Maternal Wellbeing:** * Maternal pulse, blood pressure, temperature and urine output * Drugs and fluids that have been given

Answer 551

**Low risk deliveries:** Intermittent Auscultation with a **Doppler Probe** **High risk Deliveries:** **Cardiotocograph (CTG)**

Answer 552

Used to measure the foetal heart rate and the contractions of the uterus. CTG Readouts are interpreted as: **Normal:** No non-reassuring features **Suspicious:** One non-reassuring feature **Pathological:** Two non-reassuring features **OR** one abnormal feature **Need for urgent Intervention:** Acute bradycardia or prolonged deceleration of more than 3 minutes

Answer 553

* **Contractions** – the number of uterine contractions per 10 minutes * **Baseline rate** – the baseline foetal heart rate * **Variability** – how the foetal heart rate varies up and down around the baseline * **Accelerations** – periods where the foetal heart rate spikes * **Decelerations** – periods where the foetal heart rate drops

Answer 554

**Baseline Heart Rate:** 110-160bpm **Decelerations (Drops of 15 bpm for 15s):** Absent **Accelerations (increases of 15 bpm for 15s):** Present **Baseline variability:** 5-25bpm

Answer 555

**Baseline Rate:** 100-109 / 160-179 **Baseline Variability:** <5 for 30-50 mins / >25 for <10mins **Decelerations:** * Repetitive Variable for < 30 mins * Variable for < 30 mins * Repetitive late for 30 mins **Accelerations:** Absent

Answer 556

**Baseline Rate:** <100/ >180 **Baseline Variability:** <5 for 50 mins / >25for >10mins / sinusoidal pattern **Decelerations:** * Repetitive variable with concerning characteristics >30 mins * Repetitive late > 30mins * 3 minutes of Bradycardia **Accelerations:** Absent

Answer 557

**Severe Foetal Compromise** Usually associated with severe foetal anaemia caused by **vasa praevia with foetal haemorrhage**

Answer 558

**Rule of 3s:** * **3 Minutes:** Call for help * **6 Minutes:** Move to theatre * **9 Minutes:** Prepare for delivery * **12 Minutes:** Deliver the baby (**by 15 Minutes**)

Answer 559

**DR** – **D**efine **R**isk (define the risk based on the individual woman and pregnancy before assessing the CTG) **C** – **C**ontractions **BRa** – **B**aseline **R**ate **V**– **V**ariability **A** – **A**ccelerations **D** – **D**ecelerations **O** – **O**verall impression (given an overall impression of the CTG and clinical picture)

Answer 560

* Understanding what to expect * Having good support * Being in a relaxed environment * Changing position to stay comfortable * Controlled breathing and relaxation techniques * Water births may help some women * TENS machines may be useful in the early stages of labour

Answer 561

**Simple Analgesia:** Paracetamol or Codeine (NSAIDS are avoided) **Gas and Air (Entonox):** 50% nitrous oxide and 50% oxygen used during contractions for short term pain relief **IM Opiates (Pethidine, Diamorphine):** Opioid medications given by IM injection **Patient Controlled Analgesia:** PCA using IV remifentanil

Answer 562

**Epidural** Local anaesthetic medications ((Levobupivacaine or bupivacaine combined with fentanyl injected into the epidural space at L3-4.

Answer 563

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

Answer 564

Women unable to straight leg raise is concerning. Suggests that the catheter for an epidural is incorrectly sited in the **subarachnoid space (within the spinal cord)**

Answer 565

* A VTE involves blood clots (thrombosis) developing within the circulation. * When they form within the venous system this is known as a **Deep Vein Thrombosis** (DVT). * The thrombosis can mobilise (embolisation) from the deep veins and travel to the lungs, where it becomes lodged in the pulmonary arteries, resulting in a **pulmonary embolism** (PE). * Thrombosis occurs as a result of stagnation of blood as well as in hyper-coagulable states, such as in pregnancy, making it much more likely.

Answer 566

* Pulmonary embolism is a significant cause of death in obstetrics. * The risk is significantly reduced with VTE prophylaxis. * The **risk is highest in the postpartum period**.

Answer 567

**Women with a previous VTE Hx are automatically considered high risk** **Thrombosis:** T – Thrombophilia: Inherited or acquired clotting disorders (antiphospholipid) H – History: Previous VTE or family history of thrombosis. R – Reduced mobility: Bed rest, hospitalization, or prolonged immobility. O – Obesity: Body mass index (BMI) >30 M – Maternal age: Age >35 years B – Birth (recent): Postpartum period, especially the first 6 weeks, is a high-risk period. and Parity > 3 O – Operative delivery: Cesarean section S – Smoking I – IVF S – Severe preeclampsia/pre eclampsia

Answer 568

**Immediately if women have prev Hx of VTE** * **28 weeks** if there are **three** risk factors * **immediately** if there are **four or more** of these risk factors * It is **stopped when the woman goes into labour** but can be started again immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals) * It is **continued for 6 weeks postnatally**.

Answer 569

**Low Molecular Weight Heparin (LMWH)**: * Enoxaparin * Dalteparin * Tinzaparin. If Heparin is contraindicated, **Mechanical prophylaxis** may be used: * Intermittent pneumatic compression (with equipment that inflates and deflates to massage the legs) * Anti-embolic compression stockings

Answer 570

* Calf or leg swelling * Dilated superficial veins * Tenderness to the calf (particularly over the deep veins) * Oedema * Colour changes to the leg Deep vein thrombosis is **almost always unilateral**

Answer 571

* Shortness of breath * Cough with or without blood (haemoptysis) * Pleuritic chest pain * Hypoxia * Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy) * Raised respiratory rate * Low-grade fever * Haemodynamic instability causing hypotension

Answer 572

**DVTs**: * Wells score 1 or less: D-dimer * Wells Score 2 or more: Duplex Ultrasound **PEs**: * Wells score 4 or less: D-Dimer * Wells Score >4: Immediate **CT pulmonary angiogram** (CTPA) or **Ventilation-perfusion (VQ) scan**.

Answer 573

CT pulmonary angiogram involves a **chest CT scan with an intravenous contrast** that highlights the pulmonary arteries to demonstrate any blood clots. This is usually the first choice for diagnostic of a PE (as opposed to a VQ Scan). This is the case because: * It tends to be more readily available * It provides a more definitive assessment * It gives information about alternative diagnoses such as pneumonia or malignancy.

Answer 574

* Ventilation-perfusion (VQ) scan involves using **radioactive isotopes** and a **gamma camera**, to **compare the ventilation with the perfusion of the lungs**. * First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation. Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared. * With a pulmonary embolism, there will be a **deficit in perfusion**, as the thrombus blocks blood flow to the lung tissue. This **area of lung tissue** will be **ventilated but not perfused**.

Answer 575

* CTPA carries a higher risk of breast cancer for the mother * VQ scan carriers a higher risk of childhood cancer for the fetus

Answer 576

As **pregnancy is a cause of a raised D-dimer**. So it cannot be used to screen for DVTs and PEs.

Answer 577

**Low molecular weight heparin (LMWH)** (e.g. enoxaparin, dalteparin and tinzaparin). * It should be **started immediately, before confirming the diagnosis** in patients where DVT or PE is suspected * LMWH is **continued for the remainder of pregnancy**, plus **six weeks postnatally**, **or three months in total** (whichever is longer). * After birth - swap to oral **Massive PEs are a medical emergency, and treatment can involve:** * Unfractionated heparin * Thrombolysis * Surgical embolectomy

Answer 578

Gonorrhoea is a **sexually transmitted infection** (STI) caused by the gram-negative diplococcus, **Neisseria gonorrhoeae**.

Answer 579

* It's most prevalent among young adults, specifically those aged 15–24 years. * Increased prevalence in men who have sex with men

Answer 580

**Women** * Odourless purulent discharge, possibly green or yellow * Dysuria * Pelvic pain **Male genital infections can present with:** * Odourless purulent discharge, possibly green or yellow * Dysuria * Testicular pain or swelling (epididymo-orchitis) **Extragenital complications can also be observed:** * Pharyngitis * Rectal pain an discharge * Disseminated infection.

Answer 581

* **Chlamydia trachomatis infection** Presents with similar symptoms such as discharge and dysuria, often co-infected with gonorrhoea. * **Trichomonas vaginalis infection** May present with pruritus, dysuria, and malodorous discharge. * **Bacterial vaginosis** Characterised by a fishy-smelling discharge, increased vaginal pH and positive 'whiff' test. * **Candidiasis** Symptoms include pruritus, burning sensation and thick, white, 'cottage cheese' like discharge.

Answer 582

**To determine Presence of Gonorrhoea** * NAAT test from Endocervical, vulvovaginal or ureathral swaps Or **First Catch Urine Sample** **For MC&S to guide Abx** * **Endocervical Charcoal Swab** taken for MC&S is also vital

Answer 583

If sensitivities are NOT known: **Single dose 1g IM Ceftriaxone** If sensitivities ARE known: **Single dose PO 500mg Ciprofloxacin** **All patients should have a test of cure** NAAT if Asymptomatic and Culture if Symptomatic * 72 hours after treatment for culture * 7 days after treatment for RNA NAAT * 14 days after treatment for DNA NAAT

Answer 584

* Increased risk of **miscarriage and premature birth**; due to pelvic inflammatory disease (PID). * There can also be **vertical transmission** of gonorrhea between the mother and newborn baby during vaginal delivery. * **neonatal conjunctivitis (gonnorhoea ophthalmia neonatorum)** * It can also cause future infertility

Answer 585

A genital chlamydia infection **sexually transmitted infection** caused by the obligate intracellular **bacterium Chlamydia trachomatis**.

Answer 586

* It is the **most common bacterial STI** in the UK. * Highest prevalence among **young sexually active adults**, specifically those aged **15 to 24 years** * Having multiple partners also increases the risk of catching the infection.

Answer 587

**Majority of cases are Asymptomatic** * Abnormal vaginal discharge * Pelvic pain * Abnormal vaginal bleeding (intermenstrual or postcoital) * Painful sex (dyspareunia) * Painful urination (dysuria) **Consider chlamydia in men that are sexually active and present with:** * Urethral discharge or discomfort * Painful urination (dysuria) * Epididymo-orchitis * Reactive arthritis **On Examination:** * Pelvic or abdominal tenderness * Cervical motion tenderness (cervical excitation) * Inflamed cervix (cervicitis) * Purulent discharge

Answer 588

* Preterm delivery * Premature rupture of membranes * Low birth weight * Postpartum endometritis * Ectopic pregnancy * Neonatal infection (conjunctivitis and pneumonia)

Answer 589

The differentials mainly incude other STIs such as: * **Gonorrhoea** Often asymptomatic but may cause urethral discharge, dysuria, intermenstrual or postcoital bleeding, and lower abdominal pain. * **Trichomoniasis** May cause pruritus, dysuria, and discharge in both men and women. * **Genital herpes** Characterised by painful vesicular lesions, dysuria, and flu-like symptoms.

Answer 590

**Nucleic acid amplification tests (NAAT)**. Which can involve a: * Vulvovaginal swab * Endocervical swab * First-catch urine sample (in women or men) * Rectal swab (after anal sex) * Pharyngeal swab (after oral sex)

Answer 591

First Line - **doxycycline 100mg twice a day for 7 days**

Answer 592

**Doxycycline is contraindicated in pregnancy and breastfeeding**. Alternatives include: * Azithromycin 1g stat then 500mg once a day for 2 days * Erythromycin 500mg four times daily for 7 days * Erythromycin 500mg twice daily for 14 days * Amoxicillin 500mg three times daily for 7 days

Answer 593

**No** Apart from in cases of: * Rectal Chlamydia * **Pregnancy** * when Symptoms persist

Answer 594

* Pelvic inflammatory disease * Chronic pelvic pain * Infertility * Epididymo-orchitis * **Conjunctivitis** - is usually as a result of sexual activity, when genital fluid comes in contact with the eye. * **Lymphogranuloma venereum** * **Reactive arthritis**

Answer 595

Symptoms last for **longer than 2 weeks**: * Chronic erythema * Irritation * Discharge Most cases are **unilateral** It occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia.

Answer 596

Caused by Chlamydia Serovars L1, 2 and 3 It is a condition affecting the **lymphoid tissue around the site of infection with chlamydia**. It most commonly occurs in men who have sex with men. **Stage 1:** * Small painless pustule which later forms an ulcer **stage 2:** * Painful inguinal lymphadenopathy * may occasionally form fistulating buboes **stage 3:** * Proctocolitis

Answer 597

1st Line - **Doxycycline 100mg twice daily for 21 days**

Answer 598

Syphilis is a **sexually transmitted infection** caused by the spirochete bacterium **Treponema pallidum**.

Answer 599

As stated, its caused by the bacterium Treponema pallidum. It can be transmitted by: * Through **direct contact with syphilis sores** during sexual activity. * Vertical transmission from an **infected mother to her unborn child**, resulting in **congenital syphilis** * Intravenous drug use * Blood transfusions and other transplants

Answer 600

There are three stages of Syphilis: **Primary Syphilis** * A painless genital ulcer (**chancre**). That spontaneously recovers within 3 – 8 weeks. The lesion is round, with an indurated base. * Local lymphadenopathy **Secondary Syphilis** - Typically starts after the chancre has healed. (Or 4-10 weeks post-primary infection). Presents with: * Symmetrical maculopapular rash, often involving the palms, soles, and face. * Condylomata lata (grey wart-like lesions around the genitals and anus) * Low-grade fever * Lymphadenopathy * Alopecia (localised hair loss) * Oral lesions **Tertiary Syphilis** - Can occur 20-40 years after the primary infection (in untreated patients). Presents with: * Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones) * Aortic aneurysms * Neurosyphilis **Neurosyphilis** - can occur at any stage if the infection reaches the central nervous system. Presents with: * Headache * Altered behaviour * Dementia * **Tabes dorsalis** (demyelination affecting the spinal cord posterior columns) * **Ocular syphilis** (affecting the eyes) * Paralysis * **Argyll-Robertson pupil**

Answer 601

**SYPHILIS** S – Saddle Nose and Snuffles Y – Yellowish Skin (Jaundice) P – Peg-shaped Teeth: Hutchinson's teeth: Peg-shaped, notched central incisors are a classic sign seen in late congenital syphilis. H – Hepatosplenomegaly I – Interstitial Keratitis L – Leg Bone Deformities: Saber shins: Bowing of the tibia (shin bone) due to abnormal bone development. I – Intellectual Disability and deafness S – Skin Rash and Scars (rhadages) at mouth

Answer 602

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

Answer 603

**Initial Screening tests:** * Non-specific Treponemal tests * Detect Antibodies produced against cardiolipid cholesteral lecithin antigens as a reslt of damage caused by T.pallidum * **VDRL (Venereal Disease Research Laboratory)** * **RPR (Rapid Plasma Reagin)** **Confirmatory Tests:** * Detect antibodies specific to the Bacterium * **TPPA (Treponema pallidum particle agglutination assay)** * **FTA-ABS (Fluorescent Treponemal Antibody Absorption)** * **EIA (Enzyme Immunoassay)** **Direct Samples:** * Sample from chancre can be taken * **Darkfield Microscopy** identifies T.pallidum from lesion

Answer 604

Primary, secondary, and early latent syphilis: * A **single dose of intramuscular penicillin G (benzathine benzylpenicillin)** is the first-line therapy. Tertiary and late latent syphilis or syphilis of unknown duration: * Requires a longer course of **intramuscular penicillin G for 2-3 weeks**. Neurosyphilis: * Treated with **intravenous penicillin G for 10-14 days** * Patients allergic to penicillin may be given doxycycline or tetracycline.

Answer 605

Bacterial vaginosis is a **bacterial imbalance of the vagina** caused by an **overgrowth of anaerobic bacteria** and a **loss of lactobacilli** (the dominant bacterial species responsible for maintaining an acidic vaginal pH). It is not a sexually transmitted infection but it increases the risk of developing an STI

Answer 606

* Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). * The acidic environment prevents other bacteria from overgrowing. * When there are **reduced numbers of lactobacilli** in the vagina, the **pH rises**. This more **alkaline environment** enables **anaerobic bacteria to multiply**.

Answer 607

* **Gardnerella vaginalis** (most common) * Mycoplasma hominis * Prevotella species Bacterial vaginosis can occur alongside STIs like candidiasis, chlamydia and gonorrhoea.

Answer 608

It is the most common cause of abnormal vaginal discharge in women of childbearing age.

Answer 609

* **Multiple sexual partners** (although it is not sexually transmitted) * **Excessive vaginal cleaning** (douching, use of cleaning products and vaginal washes) * Recent antibiotics * Smoking * Copper coil * **Pregnant women** are at increased risk of bacterial vaginosis due to hormonal changes. Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

Answer 610

* **fishy-smelling watery grey or white vaginal discharge** (fishy smelling particularly after intercourse) * Increased vaginal discharge * Vaginal itching or irritation may be present but is less common Half of women are asymptomatic

Answer 611

* **Vulvovaginal Candidiasis** Characterised by itching, burning, dyspareunia, and white, curd-like discharge. * **Trichomonas Vaginalis Infection** Presents with purulent, frothy, greenish discharge, pruritus, dyspareunia, and dysuria. * **Chlamydia or Gonorrhoea infection** May present with increased vaginal discharge and possibly lower abdominal pain, but are often asymptomatic. * **Atrophic Vaginitis** Most commonly seen in postmenopausal women, presenting with dryness, burning, dyspareunia, and thin, watery discharge.

Answer 612

**Speculum Examination + High vaginal swab with Charcoal Swab** The **Amsel Criteria** - Three out of the following 4 features need to be present: * Vaginal pH >4.5 (Vaginal swab with pH paper) * Homogenous grey or milky discharge * Positive whiff test (addition of 10% potassium hydroxide produces a fishy odour) * **Clue cells** present on wet mount (Microsopy)

Answer 613

* First line treatement - **Metronidazole** is given either orally(5-7/7) or intravaginally. * Second line management - **Clindamycin** * Asymptomatic BV does not usually require treatment You should also assess for the risk of STIs, as well as providing education about how to reduce the risk of recurrence.

Answer 614

**Alcohol** This is because alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Answer 615

Increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV. During **Pregnancy**: * Miscarriage * Preterm delivery * Premature rupture of membranes * Chorioamnionitis * Low birth weight * Postpartum endometritis

Answer 616

Trichomoniasis is a **sexually transmitted infection (STI)** caused by the flagellated protozoan parasite, **Trichomonas vaginalis**. It primarily infects the urogenital tract, and has an incubation period of around 7 days.

Answer 617

It is the most common non-viral STI globally.

Answer 618

**Women**: * **Profuse, frothy, yellow-green vaginal discharge** * **intense Vulval irritation/itching** * Dyspareunia (painful sex) * Asymptomatic presentation is also common (up to 50%) * **Strawberry Cervix** sign may be seen on examination * The vaginal pH will be raised (above 4.5) similar to bacterial vaginosis **Men** * Non-gonococcal urethritis * Balanitis (inflammation to the glans penis) * Also commonly asymptomatic

Answer 619

* Contracting HIV by damaging the vaginal mucosa * Bacterial vaginosis * Cervical cancer * Pelvic inflammatory disease * **Pregnancy-related complications** such as preterm delivery or low birth weight baby.

Answer 620

* Diagnostic - **Charcoal swab with microscopy** This should be taken from the posterior fornix of the vagina (behind the cervix) * **Urethral swab** or **first catch urine** is used in men

Answer 621

* **Bacterial vaginosis** Characterized by a fishy-smelling, grayish-white vaginal discharge and vaginal pH > 4.5 * **Candidiasis** Presenting with a thick, white, "cottage cheese" like vaginal discharge and vulval itching * **Gonorrhea or Chlamydia** These STIs may present with mucopurulent cervical discharge, cervical motion tenderness, and may also be asymptomatic.

Answer 622

**Oral metronidazole** Either **400–500mg twice a day for 5–7 days**, or a **single dose of 2g orally**. Its advised to abstain from sexual activity for at least one week, or until the patient and all partners have completed treatment.

Answer 623

**Lower Urinary Tract Infection** - Involves infection of the bladder, causing cystitis. **Upper Urinary Tract Infection** - Involves infection up to the kidneys, called pyelonephritis.

Answer 624

**Pregnant women are at higher risk** of developing both lower and upper UTIs UTIs during pregnancy increase the risk of: * Preterm delivery * As well as other adverse pregnancy outcomes, like low birth weight and pre-eclampsia.

Answer 625

* Asymptomatic bacteriuria refers to **bacteria present in the urine, without symptoms of infection**. * Pregnant women with asymptomatic bacteriuria are at a higher risk of developing UTIs, and subsequently at risk of preterm birth. * As a result, **pregnant women are tested at booking and routinely** throughout pregnancy (urine sample testing for microscopy, culture & sensitivity). * Urine testing of asymptomatic patients is not usually done (as it can lead to unescesary antibiotic use) but pregnant women are the exception due to the adverse outcomes associated with infection.

Answer 626

* Dysuria (pain, stinging or burning when passing urine) * Suprapubic pain or discomfort * Increased frequency of urination * Urgency * Incontinence * Haematuria

Answer 627

* Fever (more prominent than in lower urinary tract infections) * Loin, suprapubic or back pain (this may be bilateral or unilateral) * Looking and feeling generally unwell * Vomiting * Loss of appetite * Haematuria * Renal angle tenderness on examination

Answer 628

* **Mid-stream urine samples** are sent off for cultures and sensitivity testing.

Answer 629

* Mid-stream urine (as stated above) - In children, men and pregnant women * Urine Dipstick will be positive for nitrates and leukocytes (although this is unreliable in women older than 65 and those who are catheterised) * Blood tests if there are signs of systemic upset (FBC, U+E, and CRP, etc...) * Ultrasound scan of bladder/kidney (if there is concern about antecedents/complications (e.g.urinary retention/obstruction)

Answer 630

* **Escherichia coli** (E. coli) (Most common) * **Klebsiella pneumoniae** (gram-negative anaerobic rod) * Enterococcus * Pseudomonas aeruginosa * Staphylococcus saprophyticus * Candida albicans (fungal)

Answer 631

Urinary tract infection in pregnancy requires **7 days of antibiotics** * First Line - **Nitrofuratoin for 7 days** (although this needs to be avoided in the 3rd trimester) * Second Line - If nitrofuratoin is unsuitable then use **Amoxicillin or Cefelexin for 7 days**

Answer 632

As it is associated with an **increased a risk of neonatal haemolysis** (destruction of the neonatal red blood cells).

Answer 633

This is because it works as a **folate antagonist**. Folate is important in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.

Answer 634

If a non-immune woman contracts the varicella zoster virus (VZV) during the first trimester of her pregnancy, it can cause **Congenital varicella syndrome** in the foetus (as the virus can have **teratogenic effects**).

Answer 635

If maternal infection by VZV occurs, **Acyclovir** is the treatment of choice and should be **administered within 24 hours of the onset of the rash**

Answer 636

Premature ovarian insufficiency (POI) is a medical condition characterized by the **onset of menopause in a woman aged below 40 years**.

Answer 637

* **Idiopathic** (the cause is unknown in more than 50% of cases) * **Iatrogenic**, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) * **Autoimmune**, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease * **Genetic**, with a positive family history or conditions such as Turner’s syndrome * **Infections** such as mumps, tuberculosis or cytomegalovirus

Answer 638

Women with POI typically develop the same symptoms as those undergoing natural menopause, including: * **Vasomotor symptoms**: Hot flushes, night sweats * **Sexual dysfunction**: Vaginal dryness, reduced libido, problems with orgasm, dyspareunia * **Psychological symptoms**: Depression, anxiety, mood swings, lethargy, reduced concentration

Answer 639

* **Hypothyroidism**: Fatigue, weight gain, cold intolerance, depression, hair loss * **Hyperprolactinemia**: Irregular menstrual cycles, infertility, breast milk production not related to childbirth or nursing * **Polycystic Ovary Syndrome (PCOS)**: Irregular periods, hirsutism, obesity, infertility

Answer 640

* **Blood test for raised FSH levels**; indicative of the menopause (repeated on at least 2 separate occasions)

Answer 641

**Hormone Replacement Therapy or COCP** (HRT) until at least the age of normal menopause. * HRT is done, unless the risks of HRT outweigh the benefits * Psychological support should also be provided due to the potential mental health impacts of early menopause.

Answer 642

Oligohydramnios is defined as the presence of a **lower than normal volume of amniotic fluid within the uterus**.

Answer 643

**Reduced production of amniotic fluid from either less placental production or less urine prodution from fetus** **Fetal causes:** * Renal agenesis, * polycystic kidney disease, * urethral obstruction, * IUGR, * fetal demise. **Maternal causes:** * Dehydration, * hypertensive disorders, * diabetes, * uteroplacental insufficiency. **Placental causes:** * Placental abruption, * twin-to-twin transfusion syndrome (TTTS). **Post-term pregnancy** (beyond 42 weeks) **Rupture of membranes** (PPROM or amniotic fluid leakage). **Medications** (ACE inhibitors, NSAIDs).

Answer 644

**Potter Syndrome** which includes: * **Bilateral Renal Agenesis** * Clubbed feet, facial deformity, congenital hip dysplasia (Due to **foetal compression**) * Pulmonary hypoplasia (Due to **lack of amniotic fluid**) Potter syndrome is largely the result of reduced ""space"" surrounding the fetus as well as the lack of amniotic fluid for fetal lung growth and development.

Answer 645

**Polyhydramnios** - which is an overabundance of amniotic fluid.

Answer 646

Diagnosis is made via **ultrasound**: * This will show a reduced amniotic fluid index (AFI) or single deepest pocket (SDP) * **<500ml at 32-36 weeks** * **AFI <5th percentile**

Answer 647

Management depends on the underlying aetiology; but options include: * **Maternal rehydration** This may help to increase the amniotic fluid volume in mild cases of oligohydramnios. * **Amnioinfusion** This is the infusion of saline into the amniotic cavity to increase the volume of amniotic fluid. * **Delivery** In severe cases, or if the fetus is in distress, delivery may be the best option. This may be via induction of labour or caesarean section, depending on the clinical scenario.

Answer 648

Polyhydramnios is the presence of too much amniotic fluid within the uterus.

Answer 649

The causes of polyhydramnios can be split into causes due to **excessive production of amniotic fluid** or **insufficient removal of amniotic fluid**: **Execessive production** is caused by **increased foetal urination** which can be due to: * Idiopathic * Maternal diabetes mellitus * Rhesus incompatibility * Foetal anaemia * Twin-to-twin transfusion syndrome **Insufficient removal** is caused by **reduced foetal swallowing** which can be due to: * Fetal GI disorders (oesophageal atresia) * Fetal Neurological disorrders * Chromosomal disorders * Torch Infections

Answer 650

* A uterus that feels tense or is large for the date of gestation * Difficulty of feeling foetal parts upon palpation of the abdomen.

Answer 651

**Maternal complications**: * **respiratory compromise** due to increased pressure on the diaphragm * Increased risk of **urinary tract infections** * Worsening of other symptoms: gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks * Increased risk of caesarean section delivery * Increased risk of **amniotic fluid embolism**

Answer 652

**Foetal complications**: * Pre-term labour and delivery * Premature rupture of membranes * Placental abruption * Malpresentation of the foetus (the foetus has more space to “move” within the uterus) * Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Answer 653

* Management of the underlying cause (e.g. maternal diabetes) * **Amnio-reduction** in severe cases of polyhydramnios

Answer 654

This is when the foetus is in a different orientation other than facing head-first down the pelvic inlet as birth approaches.

Answer 655

Fetal presentation is the **orientation of the fetus** in the womb that determines which part of the fetus presents first at the pelvic inlet during childbirth.

Answer 656

**Cephalic Vertex presentation** Makes up 95% of pregnancies

Answer 657

**Breech Presentation** - Refers to the positioning of the fetus in a longitudinal lie with the buttocks or feet proximal to the cervix and the head near the fundus.

Answer 658

Around 20% of babies are in breech presentation at 28 weeks gestation. But the vast **majority of these revert to a cephalic presentation spontaneously**, and only 3% are breech at term. Other types of malpresentation (e.g. shoulder) are much rarer than breech presentations.

Answer 659

* **Complete (flexed) breech** – both legs are flexed at the hips and knees (fetus appears to be sitting ‘crossed-legged’). * **Frank (extended) breech** – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation. * **Footling breech** – one or both legs extended at the hip, so that the foot is the presenting part.

Answer 660

**Uterine**: * Multiparity * Uterine malformations (e.g. septate uterus) * Fibroids * Placenta praevia **Foetal**: * Prematurity * Macrosomia * Polyhydramnios (raised amniotic fluid index) * Twin pregnancy (or higher order) * Abnormality (e.g. anencephaly)

Answer 661

It is usually identified upon clinical examination: * Upon palpation of the abdomen the **round fetal head will be felt in the upper part of the uterus**, and an irregular mass (fetal buttocks and legs) in the pelvis. * The foetal **heart may be auscultated higher** on the maternal abdomen than usual * Sometimes it's not diagnosed until labour, where it can present with signs of foetal distress such as **meconium-stained liquor**. Diagnosis of Breech presentation is of limited clinical significance before 32-35 weeks gestation; as most likely the foetus will revert to cephalic presentation by birth.

Answer 662

**Ultrasound Scan**

Answer 663

* **Oblique lie** The fetus is positioned diagonally in the uterus, with the head or buttocks in one iliac fossa. * **Transverse lie** The fetus is positioned across the uterus, with the head on one side of the pelvis and the buttocks on the other. The shoulder is usually the presenting part. * **Unstable lie** This is where the presentation of the fetus changes from day-to-day.

Answer 664

* **External Cephalic Version (ECV)** This is the is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. It is offered to primiparous women at 36 weeks, and to multiparous women at 37 weeks. There is a 50% success rate (40% in primiparous, 60% in multiparous); and if successful, it can enable an attempt at vaginal delivery. * **Caesarean Section** If ECV is unsuccessful, contraindicated, or declined by the woman, current UK guidelines advise an elective Caesarean delivery. * **Vaginal Breech Birth** Some women may still choose to aim for a vaginal breech delivery. A footling breech is contraindicated however as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped.

Answer 665

* Transient fetal heart abnormalities (which revert to normal), * Persistent heart rate abnormalities (e.g fetal bradycardia) * Placental abruption.

Answer 666

* **Cord prolapse** - where the umbilical cord drops down below the presenting part of the baby, and becomes compressed. This occurs in 1% of breech presentations (Compared to 0.5% in cephalic presentations) Less common: * Fetal head entrapment * Premature rupture of membranes * Birth asphyxia – usually secondary to a delay in delivery. * Intracranial haemorrhage – as a result of rapid compression of the head during delivery.

Answer 667

Cephalopelvic disproportion occurs when there is **mismatch between the size of the fetal head and size of the maternal pelvis**, resulting in **"failure to progress"** in labor for mechanical reasons. This is a significant risk factor for post term pregnancies

Answer 668

* Uterine rupture is a complication of labour, where the **muscle layer of the uterus (myometrium) ruptures**. * Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.

Answer 669

There are two types: * **Incomplete (or uterine dehiscence) rupture** - The uterine serosa (perimetrium) surrounding the uterus remains intact. * **Complete rupture** - The serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

Answer 670

* **Previous Caesarean section** (The most significant) * Vaginal birth after caesarean (VBAC) * Previous uterine surgery * Increased BMI * High parity * Increased age * Induction of labour * Use of oxytocin to stimulate contractions

Answer 671

* The **scar on the uterus becomes a point of weakness**, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). * It is **extremely rare** for uterine rupture to occur in a patient that is **giving birth for the first time**.

Answer 672

It presents with an **acutely unwell mother**. It may occur with induction or augmentation of labour with: * Abdominal pain * Vaginal bleeding * **Ceasing of uterine contractions** * Hypotension * Tachycardia * Collapse

Answer 673

* **Placental abruption** Presents with abdominal pain +/- vaginal bleeding. The uterus is often described ‘woody’ and tense on palpation. * **Placenta praevia** Typically causes a painless vaginal bleeding. * **Vasa praevia** Characterised by a triad of ruptured membranes, painless vaginal bleeding, and fetal bradycardia.

Answer 674

* **Intrapartum Cardiotocography** (first line) - It is continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother's abdomen. Changes in fetal heart rate pattern and **prolonged fetal bradycardia** are early indicators for uterine rupture. * **Ultrasound** - Is diagnostic; features include abnormal fetal lie or presentation, haemoperitoneum and absent uterine wall.

Answer 675

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

Answer 676

Rupture of membranes (ROM): The amniotic sac has ruptured. Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously. Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour. Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm). Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

Answer 677

Regular uterine contractions, changes in cervical effacement or dilation (before 37 weeks gestation)

Answer 678

* **Overstretching of the uterus** Multiple pregnancy (commonly due to assisted conception) and polyhydramnios. * **Foetal risk conditions** Pre-eclampsia, intrauterine growth restriction, placental abruption. * **Uterus or cervical problems** Fibroids, congenital uterine malformation, short or weak cervix, previous uterine or cervical surgery. * **Infections** Chorioamnionitis, maternal or neonatal sepsis, bacterial vaginosis, trichomoniasis, Group B Streptococcus, sexually transmitted infections (e.g., Chlamydia), and recurrent urinary tract infections. * **Maternal co-morbidity** Hypertension, diabetes, renal failure, thyroid disease, etc.

Answer 679

**Vaginal Progesterone** **Cervical Cerclage** * A stitch put into the cervix to keep it closed which is removed when the woman goes into labour. * Given to people with prev. premature birth or cervical trauma.

Answer 680

**Less than 30 weeks gestation** * Clinical assessment alone is enough to offer management of preterm labour. **More than 30 weeks gestation** * Transvaginal ultrasound can be used to assess the cervical length * Alternative is **Foetal fibronectin test (fFN test)** * A negative fFN test indicates a low risk of delivery occurring within the next 7-14 days.

Answer 681

**Nifedipine** is a CCB that stops uterine contractions. **Atosiban** is an alternative (oxytoxin antagonist) * Used between 24 and 33+6 weeks * Used for a short time and may delay labour by 48 hours Often done to give time to administer Corticosteroids or to transfer the patient to a more appropriate unit

Answer 682

* PROM is a condition characterized by the **rupture of the amniotic membranes (or sac) before the onset of labour**. * If this occurs after 37 weeks gestation, it is know as **premature rupture of the membranes at term**. * If this occurs before 37 weeks however, it's known as **Preterm prelabour rupture of membranes (P‑PROM)**. * Most women with PROM at term will spontaneously start labour within 24 hours.

Answer 683

Exact cause isn't well understood; but can be due to a combination of: * Infection: Chorioamnionitis * Inflammation * Stress * Mechanical forces.

Answer 684

* Foul-smelling or greenish amniotic fluid * Maternal fever * Reduced foetal movements A digital vaginal examination should be avoided in the absence of labour. But the foetal heart should be monitored.

Answer 685

* **Urinary incontinence** This can be distinguished by the absence of amniotic fluid and the presence of urinary symptoms. * **Vaginal discharge or infection** This can be ruled out by the absence of foul-smelling or greenish discharge and the absence of other infection symptoms.

Answer 686

Investigations for PROM should focus on **assessing signs of infection and foetal distress**, including: * Monitoring maternal temperature * Assessing foetal movements * Monitoring foetal heart rate * Observing vaginal discharge **Sterile Speculum Examination** * Fluid pooling in the posterior vaginal vault **Ultrasound** * reduced amniotic fluid index

Answer 687

* If **labour does not commence within 24 hours**, **induction of labour should be offered**. * If there are any **signs of infection**, **immediate induction of labour should be commenced** under consultant guidance and a broad spectrum antibiotic should be given. * If there are any signs of foetal compromise, senior review is required to make a decision about whether immediate caesarean section is required. * Following delivery, even if both baby and mother are asymptomatic, they should be closely observed in hospital for 12 hours post-birth.

Answer 688

* **Chorioamnionitis** - due to ascending infection * **Preterm birth** - (and the associated complications) e.g. respiratory distress syndrome, necrotising enterocolitis, and foetal death * **Developmental problems** - E.g. pulmonary hypoplasia, facial and limb deformities due to compression in the uterus, and cord prolapse due to low levels of amniotic fluid.

Answer 689

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

Answer 690

* Abnormal presentations e.g. Breech, transverse lie * Prematurity * Multiparity * Polyhydramnios * Twin pregnancy * Cephalopelvic disproportion * Low birth weight (SGA)

Answer 691

* **Sudden change in the fetal heart rate pattern**, particularly variable or prolonged decelerations. * Feeling of the cord in the vagina or visible cord after rupture of membranes * Abnormal fetal heart rate detected on cardiotocography

Answer 692

* **Cardiotocography** - Umbilical cord prolapse should be suspected when there are signs of foetal distress on CTG. * **Vaginal examination** - Can then be used to diagnose a prolapsed cord (by confirming the presence of the umbilical cord in the birth canal)

Answer 693

When cord prolapse is diagnosed, swift action is vital to prevent fetal hypoxia and death: * **Emergency C-section** * **Presenting part of the fetus may be pushed back** into the uterus to avoid compression * If the cord is past the level of the introitus, there should be **minimal handling and it should be kept warm and moist to avoid vasospasm** * Patient goes onto **all fours until C-section**. Left lateral position may also be used. * **Tocolytics** (Terbutaline) may be used to reduce uterine contractions * Retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part

Answer 694

Instrumental delivery refers to a **vaginal delivery assisted by either a ventouse suction cup or forceps**. These tools are used to help in the delivery of the baby’s head.

Answer 695

10% of UK Births

Answer 696

* Failure to progress * Foetal distress * Maternal exhaustion * Control of the head in various fetal positions * The use of an epidural for analgaesia, increases the risk that an instrumental delivery may be nescesary.

Answer 697

* Postpartum haemorrhage * Episiotomy * Perineal tears * Injury to the anal sphincter * Incontinence of the bladder or bowel * **Nerve injury** (obturator or femoral nerve)

Answer 698

* **Cephalohaematoma** with ventouse * **Facial nerve palsy** with forceps Rarer (more serious complications): * Subgaleal haemorrhage (most dangerous) * Cerebral Palsy * Intracranial haemorrhage * Skull fracture * Spinal cord injury

Answer 699

* It is essentially a **suction cup on a cord**. * It goes on the baby’s head, and the doctor or midwife applies careful traction to the cord to help pull the baby out of the vagina. * Its main complication is a **cephalohaematoma** - Which involves a collection of blood between the skull and the periosteum.

Answer 700

* The forceps come as two pieces of curved metal that attach together, go either side of the baby’s head and grip the head in a way that allows the doctor or midwife to apply careful traction and pull the head from the vagina. * Main complication is **facial nerve palsy**, with **facial paralysis on one side**. * The forceps can also cause bruises on the baby's face

Answer 701

* Femoral nerve * Obturator nerve The nerve injury tends to recover over 6 – 8 weeks.

Answer 702

The Femoral nerve can be **compressed against the inguinal canal** during a forceps delivery resulting in nerve injury.

Answer 703

* Weakness of knee extension * Loss of the patella reflex * Numbness of the anterior thigh and medial lower leg.

Answer 704

The obturator nerve may be **compressed by forceps during instrumental delivery** or by the **fetal head during normal delivery**.

Answer 705

* Weakness of hip adduction and rotation * Numbness of the medial thigh

Answer 706

* Shoulder dystocia is a specific type of obstructed labour where the **anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis**, after the head has been delivered. * This is an obstectric emergency

Answer 707

* **Maternal gestational diabetes** * **Macrosomia** * Birthweight >4kg * Advanced maternal age * Maternal short stature or small pelvis * Maternal obesity * Post-dates pregnancy

Answer 708

* Difficult delivery of the foetal face or chin * Retraction of the foetal head back into the vagina, after its been delivered (**turtle-neck sign**) * **Failure of restitution** - where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. * Failure of descent of the foetal shoulders following delivery of the head.

Answer 709

Its an Obstetric emergency that needs prompt intervention to deliver the baby. There are various **manouvres** to help with this: * Call for Senior Help * **McRoberts manoeuvre** * Pubic Symphysis Pressure An episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. But this isn't always nescesary. **Other Manouvres** * **Rubins manoeuvre** * **Wood’s screw manoeuvre** * **Zavanelli manoeuver**

Answer 710

It involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.

Answer 711

It involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.

Answer 712

It is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery.

Answer 713

It involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.

Answer 714

* Placenta accreta refers to when the **placenta implants deeper than usual** onto the myometrium. * It is referred to as **placenta accreta spectrum**, as there is a spectrum of severity in how deep and broad the abnormal implantation extends. * it is due to defective decidua basalis

Answer 715

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

Answer 716

* **Previous C-Section** * **Previous placenta accreta** * Previous termination of pregnancy * Dilatation and curettage * Advanced maternal age * Low lying placenta or placenta praevia * Uterine structural defects

Answer 717

Defective Decidua Basalis This **deep implantation** makes it **very difficult for the placenta to separate during delivery**, leading to extensive bleeding (postpartum haemorrhage).

Answer 718

* It typically **doesn't cause any symptoms during pregnancy**. * It can present with bleeding (antepartum haemorrhage) in the third trimester. * It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It can cause **significant postpartum haemorrhage**.

Answer 719

Ideally it is diagnosed before birth with an **Antenatal Ultrasound**

Answer 720

* **Severe Postpartum Haemorrhage** * Preterm delivery * **Retained products of Conception** * Uterine rupture.

Answer 721

**Planned delivery between 35 and 36+6 weeks to prevent SROM** **Antenatal Steroids to help fetal lung maturation** **Delivery Options:** * **Elective Ceesarian Section with hysterectomy** is the safest management option. If preserving the patient's fertility is important to them, then the following can be attempted alongside the C-Section: * **Uterus preserving surgery**, with resection of part of the myometrium along with the placenta * **Expectant management**, leaving the placenta in place to be reabsorbed over time. But this comes with a significant risk of bleeding and infection.

Answer 722

* It's defined as the **placenta overlying the cervical os**. * This means that the placenta is attached in the lower portion of the uterus; lower than the presenting part of the fetus.

Answer 723

* **Low-lying placenta** - Is used when the placenta is within 20mm of the internal cervical os * **Placenta praevia** - Is used only when the placenta is over the internal cervical os **NOTE** A 4 stage grading system used to be used, but it's now considered outdated.

Answer 724

It's associated with increased morbidity and mortality for both the mother and fetus. Risks include: * **Antepartum haemorrhage** * Emergency caesarean section * Emergency hysterectomy * Maternal anaemia and transfusions * Preterm birth and low birth weight * Stillbirth

Answer 725

* Placenta praevia * Placental abruption * Vasa praevia

Answer 726

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

Answer 727

* **Bright red painless vaginal bleeding**. * shock in proportion to visible loss * no pain * uterus not tender * lie and presentation may be abnormal * fetal heart usually normal * coagulation problems rare * small bleeds before large

Answer 728

**1st Line:** Transvaginal Ultrasound scan * placenta praevia is often picked up on the routine 20 week abdominal ultrasound **Digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage** **Repeat TVUS for women with Low lying/ Placenta Praevia** at 20 week scan * At 32 weeks gestation * At 36 weeks gesteation (if present on 32 week scan)

Answer 729

* Repeat TVUS at 32 weeks and 36 weeks to guide delivery decisions * Give **Corticosteroids between 34-36 weeks** of gestation (to mature the foetal lungs, given the increased risk of preterm labour) * **Planned cesarean section** is adviced **between 36 and 37 weeks gestation**. (Its planned early to reduce the risk of spontaneous labour and bleeding). * In cases were premature labour or where antenatal bleeding occurs; an emergency Cesarean section will be required.

Answer 730

* Emergency caesarean section * Blood transfusions * Intrauterine balloon tamponade * Uterine artery occlusion * Emergency hysterectomy

Answer 731

* Placental abruption is the **premature separation of the placenta from the uterine wall during pregnancy**. * The site of attachment can bleed extensively after the placenta separates. Resulting in significant **Maternal Antepartum Haemorrhage**.

Answer 732

ABRUPTION: A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen); P for Polyhydramnios; T for Twins or multiple gravida; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 733

* **Sudden onset severe abdominal pain that is continuous** * **Vaginal bleeding** (However in concealed abruptions; the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. So the severity of the bleeding would be largely underestimated.) * Characteristic **'Woody' hard abdomen** (Uterus) - suggests a large haemorrhage * Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible * Abnormalities on the CTG indicating foetal distress

Answer 734

* **Spotting** - spots of blood noticed on underwear * **Minor haemorrhage** - less than 50ml blood loss * **Major haemorrhage** - 50 – 1000ml blood loss * **Massive haemorrhage** - more than 1000 ml blood loss, or signs of shock

Answer 735

* Urgent involvement of a senior obstetrician, midwife and anaesthetist * 2 x grey cannula * Bloods include FBC, UE, LFT and coagulation studies * Crossmatch 4 units of blood * Fluid and blood resuscitation as required * CTG monitoring of the fetus * Close monitoring of the mother

Answer 736

* There are no reliable tests for diagnosing placental abruption. * It is a **clinical diagnosis based on the presentation** * Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.

Answer 737

**Fetus alive and < 36 weeks** * fetal distress: Emergency caesarean Section * no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation **Fetus alive and > 36 weeks** * fetal distress: Emergency caesarean Section * no fetal distress: deliver vaginally **Fetus dead** Induce vaginal delivery **Antenatal Steroids:** Offered between 24-34+6 weeks **Rhesus D Negative:** Women require Anti-D prophylaxis using **Kleihauer test** to quantify dose required **Active management of third stage**

Answer 738

* Vasa praevia is a condition seen in obstetrics where the **foetal vessels**, (unprotected by the umbilical cord or placental tissue), **run dangerously close to or across the internal cervical os**. * These vessels are prone to rupture during the rupture of membranes, which can result in foetal haemorrhage and potentially foetal death.

Answer 739

* **Velamentous umbilical cord** (Type 1 Vasa Praevia) Is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta. * **An accessory lobe of the placenta** (Type 2 Vasa Praevia) (Also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.

Answer 740

* Low lying placenta * IVF pregnancy * Multiple pregnancy

Answer 741

**Often presents as antepartum haemorrhage in 2nd/3rd trimester or during labour** Classic **Triad** of: * Rupture of membranes often followed by: * Painless vaginal bleeding * Foetal bradycardia (or resulting foetal death)

Answer 742

* **Placenta praevia** Characterized by painless vaginal bleeding, but without the accompanying foetal bradycardia or death seen in vasa praevia. * **Abruptio placentae** Typically presents with painful vaginal bleeding, abdominal pain, and uterine tenderness and rigidity. Foetal distress is common.

Answer 743

* **Transabdominal or Transvaginal Ultrasound** * The majority of cases are diagnosed antenataly. * Although, it may only be diagnosed during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. * The later this is diagnosed, the greater the risk of foetal mortality.

Answer 744

* **Corticosteroids**, given from 32 weeks gestation to mature the fetal lungs * **Elective caesarean section**, planned for **34 – 36 weeks** gestation When **antepartum haemorrhage** occurs: * **Emergency caesarean section** is required to deliver the fetus before death occurs.

Answer 745

Postpartum haemorrhage (PPH) refers to **bleeding after delivery of the baby and placenta** (within 24 hours). To be classed as a PPH, there need to be a loss of: * **500ml** after a vaginal delivery * **1000ml** after a caesarean section

Answer 746

It is the most common cause of significant obstetric haemorrhage.

Answer 747

**Vaginal** > 500ml Blood loss **Caesarean** > 1000ml Blood loss Minor Vs Major: * **Minor PPH** – under 1000ml blood loss * **Major PPH** – over 1000ml blood loss Major PPH further classification: * **Moderate PPH** – 1000 – 2000ml blood loss * **Severe PPH** – over 2000ml blood loss Primary Vs Secondary: * **Primary PPH** - bleeding within 24 hours of birth * **Secondary PPH** - from 24 hours to 12 weeks after birth (**Infection and RPOC**)

Answer 748

The 4 Ts: **Tone (Uterine Atony)**: * Over-distension of the uterus: Multiple pregnancy, twin pregnancy, Polyhydramnios * Prolonged delivery causing muscle fatigue * Full bladder * Medications: Nifedipine, terbutaline, MgSO4 **Trauma** * C-Section * Instrumental Delivery * Episiotomy/perineal tears * Haematoma **Tissue**: * Retained products of pregnancy (placenta) * Placenta Accreta, increta, percreta **Thrombin**: * Coagulation disorders, Von willibrand, Placental abruption, Eclampsia/HELLP

Answer 749

* PPH in previous pregnancy * BMI >35 * Multiple pregnancy * Nulliparity * Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia * Delivery via Caesarean section * Induction of labour * Instrumented delivery (forceps or ventouse) and episiotomy * Prolonged labour (greater than 12 hours) * Macrosomia (>4kg baby) * Advanced maternal age

Answer 750

In **Primary PPH**: * Blood tests for Group/Save and Crossmatch In **Secondary PPH**: * Ultrasound looking for retained products * Endocervical/high vaginal swabs looking for infection

Answer 751

* Resuscitation with an ABCDE approach * Lie the woman flat, keep her warm and communicate with her and the partner * Insert two 14-gauge cannulas * Bloods for G&S, FBC, U&E and clotting screen * Group and cross match 4 units * **Warmed IV fluid** and **blood resuscitation** as required * **Oxygen** (regardless of saturations) * **Fresh frozen plasma** is used where there are clotting abnormalities or after 4 units of blood transfusion.

Answer 752

**Mechanical**: * **Fundal Massage** through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) * **Catheterisation** (bladder distention prevents uterus contractions) **Medical**: * **Oxytocin** (slow injection followed by continuous infusion) - 40mg in 500mls * **Ergometrine** (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) * **Carboprost**(intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) * **Misoprostol** (sublingual) is also a prostaglandin analogue and stimulates uterine contraction * **Tranexamic acid** (intravenous) is an antifibrinolytic that reduces bleeding **Surgical**: * **Intrauterine balloon tamponade** – inserting an inflatable balloon into the uterus to press against the bleeding * **B-Lynch suture** – putting a suture around the uterus to compress it * **Uterine artery ligation** – ligation of one or more of the arteries supplying the uterus to reduce the blood flow * **Hysterectomy** is the “last resort” but will stop the bleeding and may save the woman’s life

Answer 753

It depends on the cause: * Surgical evaluation of retained products of conception * Antibiotics for infection (endometritis)

Answer 754

This can occur when a **rhesus-D negative woman has a Rhesus-D positive baby**. (Rhesus incompatability) It is likely at some point in the pregnancy (i.e. childbirth) that the blood from the baby will find a way into the mother’s bloodstream. When this happens, the baby’s red blood cells display the rhesus-D antigen. The mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen. The mother has then become sensitised to rhesus-D antigens.

Answer 755

Examples of these **sensitisation events** include: * Antepartum haemorrhage * Placental abruption * Abdominal trauma * External cephalic version * Invasive uterine procedures such as amniocentesis and chorionic villus sampling * Rhesus positive blood transfusion to a rhesus negative woman * Intrauterine death, miscarriage or termination * Ectopic pregnancy * Delivery (normal, instrumental or caesarean section)

Answer 756

* Usually, the **sensitisation process does not cause problems during the first pregnancy**. * During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus. If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis). * The red blood cell destruction caused by antibodies from the mother is called **haemolytic disease of the newborn**.

Answer 757

All mothers should be tested for rhesus status and anti-D antibodies at booking **Prevention of sensitisation** - is the mainstay of management. This involves giving **intramuscular anti-D injections** to rhesus-D negative women. Anti-D injections are given **routinely** on two occasions: * 28 weeks gestation * 34 weeks gestation * Birth (if the baby’s blood group is found to be rhesus-positive) Anti-D injections should also be given at any time where sensitisation may occur, such as: * Antepartum haemorrhage * Termination of pregnancy (ectopic, miscarriage, TOP) * Amniocentesis procedures * Abdominal trauma * ECV Anti-D is given within **72 hours of a sensitisation event**..

Answer 758

* The Kleihauer test checks **how much fetal blood has passed into the mother’s blood during a sensitisation event**. * This test is used after **any sensitising event past 20 weeks gestation**, to assess whether further doses of anti-D is required.

Answer 759

A Puerperal infection is defined as an **infection of the genital tract** occurring **at labour or within 42 days** of the postpartum period.

Answer 760

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery. **Causes:** * Endometritis: most common * UTI * Wound infections (perineal tears/c-section * Mastitis * VTE

Answer 761

* **Cesarean section** (especially emergency or after labor) * Prolonged rupture of membranes (>18 hours) * Prolonged labor (>24 hours) * Multiple vaginal exams during labor * Manual removal of the placenta * **Retained products of conception** * Preexisting infections (e.g., bacterial vaginosis)

Answer 762

* It can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria. * It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea.

Answer 763

It can present from shortly after birth to several weeks postpartum, with: * **>38 degree fever in first 14 days** * Foul-smelling discharge or lochia * Bleeding that gets heavier or does not improve with time * Lower abdominal or pelvic pain * Fever * Sepsis

Answer 764

* Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors) * Urine culture and sensitivities * Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).

Answer 765

**Septic patients**: * SEPSIS SIX **Milder Infections**: * Referred to hospital for IV antibiotics * Clindamycin and Gentamicin until afebrile for 24 hours.

Answer 766

* Breast Cancer * Fibroadenoma * Breast Cysts/Abscess * Fibrocystic Breast Changes * Fat necrosis * Intraductal Papilloma * Lipoma * Duct Ectasia * Implants

Answer 767

Benign breast lump caused by localised degeneration and scarring of the Fat tissue in the breast **Triggers:** * Localised trauma * Radiotherapy/surgery * Inflammatory reaction **Does NOT** increase the risk of breast cancer

Answer 768

* Painless, Firm, Irregular lump * Fixed in local structures * There may be skin dimpling or nipple inversion

Answer 769

**Triple Assessment to rule out Breast CA** * Physical Examination * Imaging: Mammography/Ultrasound * Biopsy and Histology: Fine needle or core

Answer 770

* Mastitis is the **inflammation of the breast tissue**, which can be with or without an infection. * When associated with lactation in postpartum women, the condition is specified as puerperal mastitis.

Answer 771

**Lactational** Associated with Breast feeding **Non-lactational** is mastitis caused not in the context of breast feeding * Mastitis, (particularly puerperal mastitis), is a common condition among **postpartum women** * It typically occurs within the first six weeks postpartum, particularly in the second and third weeks. * It usually affects **first-time mothers** and those with a **history of mastitis** in previous pregnancies.

Answer 772

* Milk stasis from poor feeding or inadequate feeding * Staph aureus is most common organism invading through the nipple

Answer 773

* Poor breastfeeding technique * Nipple damage * Maternal stress * Previous history of mastitis * First time pregnancy * Smoking

Answer 774

* Breast pain and tenderness **(unilateral)** * Erythema in a focal area of breast tissue * Local warmth and inflammation * Nipple discharge * Fever * The condition is usually **unilateral** and tends to present within the **first week postpartum**. **Mastitis may develop into a breast absces** * manifesting as a fluctuant, tender mass with overlying erythema.

Answer 775

* **Breast abscess** Fluctuant mass, tenderness, overlying erythema, systemic signs of infection. * **Inflammatory breast cancer** Swelling, skin changes resembling orange peel, nipple inversion, axillary lymphadenopathy. * **Breast engorgement** Typically bilateral and associated with milk stasis, painful, and tense breasts.

Answer 776

* Diagnosis of mastitis is **primarily clinical** * An ultrasound may be useful in identifying an abcess if that is suspected

Answer 777

**First Line:** * Continue breastfeeding. (even if infection present) * Analgesia * Regular expression of milk and breast massage * A warm compresses **Second Line:** if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection' * **Antibiotics** * 1st Line is **oral flucloxacillin for 10-14 day** * Erythromycin in pen-allergy

Answer 778

* Candida infection of the nipple (often after a course of antibiotics). This can lead to **Recurrent mastitis** * Breast Abcess

Answer 779

* Sore nipples bilaterally, particularly after feeding * Nipple tenderness and itching * Cracked, flaky or shiny areola * May cause symptoms in the baby such as white patches in the mouth, tongue or nappy rash Its associated with oral thrush and candidal nappy rash in the infant.

Answer 780

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

Answer 781

A breast abscess is a **collection of pus within an area of the breast**, usually caused by a bacterial infection. This may be a: * **Lactational abscess** (associated with breastfeeding) * **Non-lactational abscess** (unrelated to breastfeeding) It often occurs as a result of infectious mastitis.

Answer 782

* **Staphylococcus aureus** (the most common) * Streptococcal species * Enterococcal species * Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Answer 783

* Alongside the features of Mastitis (mastalgia, warmth, erythema, swelling) * Purulent nipple discharge * The key feature that suggests a breast abscess is a **swollen, fluctuant, tender lump within the breast**. * As well as more generalised symptoms of infection like; Muscle aches, Fatigue, Fever, Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion).

Answer 784

* Referral to the on-call surgical team in the hospital for management * Antibiotics (Co-amoxicalv, Metronidazole) * Ultrasound (confirm the diagnosis and exclude other pathology) * Drainage (needle aspiration or surgical incision and drainage) * Microscopy, culture and sensitivities of the drained fluid **Women are advised to continue breastfeeding. They should regularly express breast milk if feeding is too painful, then resume feeding when possible.**

Answer 785

Breast Ultrasound

Answer 786

* Fibroadenomas are **common benign tumours of stromal and epithelial breast duct tissue**. * They originate from the lobules (the milk-producing glands of the breast) **Fibroadenomas are not usually associated with an increased risk of developing breast cancer.** * Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.

Answer 787

* More common in **younger women** (aged between **20 and 40**) * They're particularly common in periods of reproductive hormonal change such as **puberty, pregnancy, and perimenopause**.

Answer 788

* Exact cause is unclear * They respond to the **increased levels of female reproductive hormones** (oestrogen and progesterone). As they often grow in size during pregnancy, and shrink during menopause.

Answer 789

**Painless, Smooth, Round and Well circumscribed (well-defined borders) breast lump.** * Firm * Mobile (moves freely under the skin and above the chest wall) * Usually up to 3cm diameter **Not directly influenced by menstrual cycle unlike benign fibrocystic breast changes**

Answer 790

* **Breast cysts** These can be soft to firm, mobile, and round with distinct edges, similar to fibroadenomas. However, they may be tender and can fluctuate in size with the menstrual cycle. * **Invasive breast cancer** Typically presents with a hard, irregularly shaped, immobile mass. There may be associated nipple discharge, retraction or skin changes. * **Intraductal papilloma** Generally presents with nipple discharge, occasionally blood-stained, but may also have an associated palpable mass. * **Lipoma** Presents as a soft, mobile mass. Unlike fibroadenomas, lipomas can grow beyond 3cm and are typically painless.

Answer 791

While fibroadenomas are benign, patients usually undergo a **triple assessment** to exclude more serious pathology. This includes: * Clinical examination * Imaging (usually ultrasound and/or mammogram) * Needle biopsy (fine needle aspiration or core biopsy)

Answer 792

* **Conservative management** Many fibroadenomas do not require treatment and will regress naturally after menopause. * **Surgical excision** This may be required if the fibroadenoma is large, growing, causing significant symptoms, or if there is diagnostic uncertainty after triple assessment.

Answer 793

**No** * They are not usually associated with an increased risk of developing breast cancer. * Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.

Answer 794

Breast cysts are benign, individual, fluid-filled lumps of the breast.

Answer 795

* They are the **most common cause of breast lumps** * Occur most often between ages **30 and 50**, more so in the perimenopausal period.

Answer 796

The Lumps can be: * Possibly painful * Smooth * Well-circumscribed * Mobile * Possibly fluctuant They can also fluctuate in size over the menstrual cycle

Answer 797

All breast lumps should be investigated with **Triple Assessment** to exclude cancer): * Clinical examination * Imaging (usually ultrasound and/or mammogram) * Needle biopsy (fine needle aspiration or core biopsy)

Answer 798

* **Aspiration of the breast cyst** is the recommended treatment in symptomatic cases. * Repeat aspiration or excision may be required in cases of recurrent cysts * Non-symptomatic (non-painful) breast cysts do not need to be drained unless they bother the patient or cause concerns.

Answer 799

**Yes** Having a breast cyst may slightly increase someone's cancer risk

Answer 800

Mammary duct ectasia is a benign condition where there is dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.

Answer 801

* An intraductal papilloma is a **warty lesion that grows within one of the ducts in the breast**. * It is the result of the proliferation of epithelial cells. * They are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

Answer 802

Most common between 35-55 years

Answer 803

They may present with: * Nipple discharge (clear or blood-stained) * Breast tenderness or pain * A palpable lump They are often asymptomatic and can be picked up incidentally on mammograms or ultrasound.

Answer 804

Patients require **triple assessment** with: * Clinical assessment (history and examination) * Imaging (ultrasound, mammography and MRI) * Histology (usually by core biopsy or vacuum-assisted biopsy) **Ductography** may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).

Answer 805

* Intraductal papillomas require **complete surgical excision**. * After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Answer 806

* Breast cancer or carcinoma refers to a **malignant tumour originating from the cells of the breast tissue.**

Answer 807

* Breast cancer is the **most common form of cancer in the UK**. * It mostly affects women and is rare in men (about 1% of UK cases). * Around 1 in 8 women will develop breast cancer in their lifetime.

Answer 808

**BREAST CARE** **Females** B: BRCA1/BRCA2 gene mutations R: Radiation exposure to the chest E: Early menarche & late menopause (longer estrogen exposure) A: Advanced age S: Smoking and Supplemental Combined hormones (HRT) T: Time of first pregnancy (1st Pregnancy > 30 years or nulliparity) C: Contraceptive pills (long-term use) A: Alcohol intake R: Relatives with breast cancer (family history) E: Excess weight (obesity) and Exercise (lack of)

Answer 809

* BRCA refers to the **BR**east **CA**ncer gene. The BRCA genes are tumour suppressor genes. * Mutations in these genes lead to an increased risk of breast cancer (as well as ovarian and other cancers).

Answer 810

**BRCA1 gene** is on chromosome 17 * 70% will develop breast cancer by aged 80 * 50% will develop ovarian cancer * Also increased risk of bowel and prostate cancer **BRCA2 gene** is on chromosome 13 * 60% will develop breast cancer by aged 80 * 20% will develop ovarian cancer

Answer 811

* **Pagets disease of the Nipple** * **Inflammatory Breast Cancer** * Medullary breast cancer * Mucinous breast cancer * Tubular breast cancer * Multiple others

Answer 812

* Lumps that are hard, irregular, painless or fixed in place * Lumps may be tethered to the skin or the chest wall * Nipple retraction * Skin dimpling or oedema (peau d’orange) * Lymphadenopathy, particularly in the axilla

Answer 813

**Mammogram** is offered **every 3 years** to women aged **50-70 years** The screening aims to detect breast cancer early, which improves outcomes. **Annual Mammogram Screening may be provided to women deemed high risk**

Answer 814

* Anxiety and stress * Exposure to radiation during mammograms, with a very small risk of causing breast cancer * Missing cancer, leading to false reassurance * Unnecessary further tests or treatment where findings would not have otherwise caused harm

Answer 815

People who have: * A first-degree relative with breast cancer under 40 years * A first-degree male relative with breast cancer * A first-degree relative with bilateral breast cancer, first diagnosed under 50 years * Two first-degree relatives with breast cancer **Annual mammogram** screening is offered to women with increased risk. Potentially starting from aged 30, if high risk.

Answer 816

**Chemoprevention** may be offered: * Tamoxifen if premenopausal * Anastrozole if postmenopausal (except with severe osteoporosis) **Risk-reducing bilateral mastectomy** or **bilateral oophorectomy** (removing the ovaries) is also an option for women at high risk; but this is only suitable for a small subset of women.

Answer 817

**Two week wait referral** for: * An unexplained breast lump in patients aged 30 or above * Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes) * An unexplained lump in the axilla in patients aged 30 or above * Skin changes suggestive of breast cancer **NICE recommend considering non-urgent referral for unexplained breast lumps in patients under 30 years**

Answer 818

* **Fibroadenoma** Typically presents as a solitary, painless, and well-circumscribed breast lump in young women * **Cyst** Characterized by a round or oval, well-defined, and movable mass. It may be painful and size may vary with the menstrual cycle. * **Mastitis** Typically presents in breastfeeding women, characterized by a painful, warm, red breast often accompanied by systemic symptoms like fever. * **Lipoma** Presents as a soft, mobile, and painless lump.

Answer 819

Initial Investigations are with a **Triple Diagnostic Assessment**: * **Clinical assessment** (history and examination) * **Imaging** (ultrasound or mammography) * **Biopsy** (fine needle aspiration or core biopsy) Then once the woman has been diagnosed with breast cancer, then an **assessment of the Lymph nodes** is required: * Ultrasound of the axilla (armpit) * Ultrasound-guided biopsy of any abnormal nodes * A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Answer 820

**Ultrasound scans**: * Are used to assess lumps in younger women (e.g., under 30 years). * They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps. **Mammograms**: * Are generally more effective in older women due to less density in breast tissue * They can pick up calcifications missed by ultrasound. **MRI Scans** may be used: * For screening in women at higher risk of developing breast cancer (e.g., strong family history) * To further assess the size and features of a tumour

Answer 821

**Nottingham Prognostic Index (NPI)** * Uses Tumour Size, Lymph node score and Grade Score * Higher the grade the worse the prognosis **NPI Prognostic indicator** * NPI <2.4 = Excellent prognosis (Normal Population survival) * NPI <3.4 = Good prognosis (80% 10 year survival) * NPI <5.4 = Intermediate prognosis (50% 10 year survival) * NPI >5.4 = Poor prognosis (<20% 10 year survival)

Answer 822

Breast cancer can spread to anywhere in the body, whoever the most common locations are: **2Ls and 2Bs** * L – Lungs * L – Liver * B – Bones * B – Brain

Answer 823

* Oestrogen receptors (ER) * Progesterone receptors (PR) * Human epidermal growth factor (HER2) These receptors can be targeted with breast cancer treatments

Answer 824

**Triple-negative breast cancer** is where the breast cancer cells do not express any of the three typical receptors. (ER, PR or HER2) This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Answer 825

* Gene expression profiling involves **assessing which genes are present within the breast cancer** on a histology sample. * This helps predict the **probability that the breast cancer will reoccur** as a distal metastasis (away from the original cancer site) within 10 years. **The NICE guidelines recommend this for women with early breast cancers that are:** * ER positive but HER2 and lymph node negative * It helps guide whether to give additional chemotherapy.

Answer 826

Management will depend on the type of cancer and the patients preference but may involve: * surgery * radiotherapy * hormone therapy * biological therapy * chemotherapy

Answer 827

* General fatigue from the radiation * Local skin and tissue irritation and swelling * Fibrosis of breast tissue * Shrinking of breast tissue * Long term skin colour changes (usually darker)

Answer 828

* Fatigue * Hair loss * Easy bruising and bleeding * Infection * Anaemia * Nausea and vomiting * Appetite changes * Problems with concentration or memory.

Answer 829

* Hot flashes * Vaginal dryness or discharge * Menstrual changes * Fatigue * Mood changes * Osteoporosis. **Tamoxifen RFs** * Increased risk of endometrial cancer * VTE * Menopausal symptoms.

Answer 830

* Tamoxifen is a **selective oestrogen receptor modulator (SERM)**. * It either blocks or stimulates oestrogen receptors, depending on the site of action. * It **blocks oestrogen receptors in breast tissue**, and stimulates oestrogen receptors in the uterus and bones. * This means it **helps prevent osteoporosis**, but it does **increase the risk of endometrial cancer**.

Answer 831

* Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. * After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. * Aromatase inhibitors **work by blocking the creation of oestrogen in fat tissue**. * Examples include: letrozole, anastrozole or exemestane

Answer 832

Breast reconstructive surgery is offered to **all patients having a mastectomy**. There are two options: * **Immediate reconstruction** - done at the time of the mastectomy * **Delayed reconstruction** - which can be delayed for months or years after the initial mastectomy

Answer 833

After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are: * **Partial reconstruction** (using a flap or fat tissue to fill the gap) * **Reduction and reshaping** (removing tissue and reshaping both breasts to match.

Answer 834

* **Breast implants** (inserting a synthetic implant) * **Flap reconstruction** (using tissue from another part of the body to reconstruct the breast)

Answer 835

**Advantages** * Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. * It gives an acceptable appearance **Disadvantages** * Implants can feel less natural (e.g., cold, less mobile and static size and shape). * There can also be long-term problems, such as hardening, leakage and shape change.

Answer 836

* Latissimus Dorsi Flap * Transverse Rectus Abdominis Flap (TRAM Flap) * Deep Inferior Epigastric Perforator Flap (DIEP Flap)

Answer 837

* Lymphoedema is a **chronic condition caused by impaired lymphatic drainage of an area**. * Lymphoedema can occur in an entire arm **after breast cancer surgery on that side**, with removal of the axillary lymph nodes in the armpit. * lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become **swollen with excess, protein-rich fluid (lymphoedema)**. * Areas of lymphoedema are prone to infection

Answer 838

* Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) * Compression bandages * Specific lymphoedema exercises to improve lymph drainage * Weight loss if overweight * Good skin care

Answer 839

* **Pain**: Persistent or worsening pain at the surgical site. * **Bleeding**: Increased wound drainage, decreased blood pressure, increased heart rate. * **Infection**: Wound redness, swelling, pain, pus discharge, and fever. * **Seroma**: Swelling at the surgical site, fluid-filled lump. * **Displeasure with cosmetic outcome**: Patient dissatisfaction with the appearance of the breast after surgery.

Answer 840

* **Stroke**: Sudden onset of neurological deficits such as weakness, speech impairment, visual changes. * **Venous thromboembolism**: Swelling, pain, and redness in the leg (deep vein thrombosis); shortness of breath, chest pain, and rapid heart rate (pulmonary embolism). * **Myocardial infarction**: Chest pain, shortness of breath, sweating, nausea, and lightheadedness. * **Aspiration**: Sudden onset of coughing, wheezing, and difficulty breathing.

Answer 841

* **Lymphoedema**: Swelling of the arm, feeling of heaviness or tightness, restricted range of motion. * **Damage to brachial plexus**: Numbness, tingling, or weakness in the arm. * **Axillary artery/vein injury**: Swelling, pain, pallor, and decreased pulse in the arm.

Answer 842

Paget's disease of the nipple, also known as Paget's disease of the breast, is a rare condition **characterised by the presence of cancer cells in the skin of the nipple**. * This disease often suggests an underlying ductal carcinoma in situ (DCIS) or invasive breast cancer.

Answer 843

* Most common in Postmenopausal women * Only accounts for around 5% of breast cancers

Answer 844

* **Epidermotropic theory** - suggests that cancer cells from an underlying breast tumour migrate to the nipple. * **Intraepidermal origin theory** - which proposes the disease originates in the nipple itself.

Answer 845

* **Eczema-like rash** on the skin of the nipple and areola that is often itchy, red, crusty, and inflamed * Bloody nipple discharge * Burning sensation, increased sensitivity, or pain in the nipple * Changes to the nipple, such as retraction or inversion * Palpable breast lump (in some cases) * Non-healing skin ulcer (in some cases)

Answer 846

* **Atopic dermatitis (eczema)** Characterised by itchy, red, and inflamed skin, usually occurring in patches * **Contact dermatitis** Caused by irritants or allergens, presents with a red rash, itching, and possibly blisters * **Intraductal papilloma** Produces bloody nipple discharge but typically does not involve skin changes * **Mastitis or breast abscess** Presents with breast redness, swelling, pain, and possible fever; often related to breastfeeding * **Psoriasis** Presents with silvery scales on red, raised patches, often with itching or burning

Answer 847

* **Physical examination** of the breasts and lymph nodes * **Mammography** or **breast ultrasound** * **Punch Biopsy** of the affected skin and nipple discharge cytology * **MRI** may be used in certain circumstances to better assess the extent of disease

Answer 848

Management of Paget's disease of the nipple primarily involves **surgical intervention**. Approaches can include: * **Simple mastectomy**: Removal of the entire breast, including the nipple and areola * **Modified radical mastectomy**: Removal of the entire breast along with some of the axillary (underarm) lymph nodes * **Breast-conserving surgery** (lumpectomy): If the underlying cancer is small and limited Additionally, adjunctive treatments such as radiation therapy, chemotherapy, or hormonal therapy may be used depending on the characteristics of the underlying breast cancer.

Answer 849

* Vulvovaginal candidiasis, often referred to as a yeast infection, is an **inflammation of the vagina and the vulva** due to an **overgrowth of the yeast fungus**, primarily Candida Albicans. * Recurrent vulvovaginal candidiasis is defined as four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic.

Answer 850

* **Candida Albicans** is the main causative organism (causing 85-90% of cases) * Transmission is usually **non-sexual**

Answer 851

* diabetes mellitus * drugs: antibiotics, steroids * pregnancy * immunosuppression: HIV

Answer 852

* cottage cheese', non-offensive discharge * vulvitis: superficial dyspareunia, dysuria * itch * vulval erythema, fissuring, satellite lesions may be seen

Answer 853

* **Bacterial vaginosis** Characterised by greyish-white discharge, fishy odour, and absence of significant inflammation. * **Trichomoniasis** Presents with yellow-green, frothy discharge, dysuria, and itching. * **Chlamydia or Gonorrhoea** These sexually transmitted infections can cause similar symptoms such as discharge, but often also present with pelvic pain or bleeding. * **Genital herpes** Characterised by painful blisters or open sores in the genital area.

Answer 854

Routine **investigations are not typically required** for acute, uncomplicated vulvovaginal candidiasis cases. However, in instances where the **clinical presentation is unclear** or **recurrent episodes occur**, the following investigations may be necessary: * **Microscopy** - Detection of blastospores, pseudohyphae and neutrophils suggests Candida infection. * **Culture** - Recommended for recurrent vulvovaginal candidiasis cases to identify the Candida species.

Answer 855

**First Line:** * Oral fluconazole 150 mg as a single dose **Second line:** * clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated * If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal **if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated**

Answer 856

4 episodes per year **compliance with previous treatment should be checked** **Confirm the diagnosis of candidiasis** * high vaginal swab for microscopy and culture * consider a blood glucose test to exclude diabetes * exclude differential diagnoses such as lichen sclerosus **An induction-maintenance regime** * Induction: oral fluconazole every 3 days for 3 doses * Maintenance: oral fluconazole weekly for 6 months

Answer 857

* Balanitis is **inflammation of the glans penis**. * If the foreskin is also inflamed, the correct term is balanoposthitis, although balanitis is commonly used to refer to both.

Answer 858

* More common in Men than boys * It's uncommon in circumcised boys and men (circumcision reduces the risk of inflammatory skin conditions which may cause balanitis).

Answer 859

* **Diabetes mellitus**. * Use of oral antibiotics. * Poor hygiene in uncircumcised males. * Immunosuppression. * Chemical or physical irritation of glans.

Answer 860

**Infectious Causes**: * Candida infection * Staph Aureus * Anaerobic Bacteria **Dermatological Causes** * Circinate balanitis (Associated with reactive arthritis) * Psoriasis * Fixed drug eruption (especially with sulfonamides and tetracycline) **Other causes** * Intertrigo (alot of cases) * Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms. * Trauma * Severe oedema due to right heart failure. * Morbid obesity

Answer 861

* **Sore, inflamed and swollen glans/foreskin** * **Non-retractile foreskin (phimosis)**. * **itchy** * Penile ulceration. * Penile plaques. * Satellite lesions. * May be purulent and/or foul-smelling discharge (most common with streptococcal/anaerobic infection). * Dysuria. * Interference with urinary flow in severe cases. * Obscuration of glans/external urethral meatus. * Impotence or pain during coitus. * Regional lymphadenopathy.

Answer 862

Intertrigo is a common inflammatory skin condition that is caused by skin-to-skin friction (rubbing) that is intensified by heat and moisture.

Answer 863

* Blood/urine testing for glucose if diabetes mellitus is possible. * Swab of discharge for **microscopy, Gram staining, culture and sensitivity**.

Answer 864

**Caused by contact dermatitis**: * Avoid Triggers * Topical hydrocortisone 1% once daily (consider adding an imidazole cream), for up to 14 days. **Caused by Candidal infection** * Clotrimazole cream 1% or miconazole cream 2%; apply twice daily until symptoms have settled. * Alternative regimens: fluconazole 150 mg stat orally * Topical imidazole with 1% hydrocortisone if there is marked inflammation **Caused by Bacterial infection** * Common bacterial infection - flucloxacillin (or erythromycin in penicillin-allergic patients). * Anaerobic infection - metronidazole 400 mg twice-daily for one week **Surgery** * Is not often done, but surgical referral for consideration of circumcision if balanitis is recurrent or pathological phimosis is present.

Answer 865

* Chancroid is a **sexually transmitted infection (STI)** of the genital skin. * It is primarily caused by the **gram-negative bacillus Haemophilus ducreyi**.

Answer 866

* Most common in **tropical and subtropical regions** as well as **Greenland** * Sexual behaviour, poor living conditions, and a lack of public health infrastructure contribute to the increased incidence in these areas

Answer 867

* Chancroid is caused by an infection with the **gram-negative bacillus Haemophilus ducreyi**. * The bacterium is sexually transmitted and can cause a genital ulcer and inflammation of the inguinal lymph nodes. * Given its higher prevalence in other parts of the world, its important to ask patients about **recent travel**.

Answer 868

* Presents as a **painful, potentially necrotic genital lesion**; that may **bleed on contact**. * Painful lymphadenopathy, commonly known as "bubo," which may rupture and discharge pus. Symptoms often develop within 4-10 days after exposure to the bacterium.

Answer 869

* **Herpes Simplex Virus (HSV)** Presents with multiple, small, vesicular lesions that become ulcers, accompanied by systemic symptoms such as fever and malaise. * **Syphilis** Presents with a painless ulcer (chancre) and generalized non-tender lymphadenopathy. * **Lymphogranuloma Venereum (LGV)** Presents with a small painless ulcer or papule that often goes unnoticed, followed by painful inguinal lymphadenopathy ("bubo") similar to chancroid.

Answer 870

Diagnosis is usually based upon the clinical picture. But the following can confirm the diagnosis: * **Culture** - H. ducreyi is a fastidious organism and culture is often difficult and time-consuming. * **PCR (Polymerase Chain Reaction)** - PCR for H. ducreyi can be performed on genital ulcer specimens, providing a more rapid diagnosis.

Answer 871

* Single dose 500mg Ciprofloxacin or Single dose 250mg IM Ceftriaxone **Adjunctive therapy** can include: * Analgesics for pain control * Incision and drainage of buboes

Answer 872

* Lymphogranuloma venereum (LGV) is a **sexually transmitted infection**. * Predominantly caused by the **L1, L2, or L3 serovars of Chlamydia trachomatis**.

Answer 873

More common in Men who have sex with Men

Answer 874

Its caused by infection with the L1, L2, or L3 serovars of Chlamydia trachomatis, typically through sexual contact.

Answer 875

* **Painless genital ulcer** - Typically appears 3-12 days after infection. It might go unnoticed, particularly if it occurs inside the vagina * Inguinal lymphadenopathy, often noticeable * Proctitis, associated with rectal pain and discharge (in case of rectal infections) * Systemic symptoms can include fever and malaise

Answer 876

* **Primary syphilis** Presents with a solitary, painless genital ulcer (chancre) and regional lymphadenopathy * **Herpes simplex virus infection** Characterised by multiple painful vesicles or ulcers, systemic symptoms, and occasional inguinal lymphadenopathy * **Chancroid** Caused by Haemophilus ducreyi, it presents with painful genital ulcers and painful inguinal lymphadenopathy

Answer 877

**Polymerase chain reaction (PCR)**, are employed to detect C. trachomatis from a swab of the genital ulcer.

Answer 878

Its managed by anitibiotics. Common regimes include: * **Oral doxycycline** - 100 mg administered twice daily for 21 days * **Oral tetracycline** - 2 g administered daily for 21 days * **Oral erythromycin** - 500 mg given four times daily for 21 days

Answer 879

* Genital herpes is an **infectious disease** characterized by the appearance of **painful sores or ulcers on the genitals**. * It is caused by infection with the **herpes simplex viruses**, either HSV-1 or HSV-2.

Answer 880

More common in 15 - 24 year olds

Answer 881

* **HSV-1** - Is traditionally associated with oral herpes, but it is now the **most common cause of genital herpes** in the UK. * **HSV-2** - Was reviously the most common cause of genital herpes in the UK, it is more likely to cause recurrent anogenital symptoms.

Answer 882

* Asymptomatic presentation in some individuals * multiple painful Ulcers or blistering lesions affecting the genital area * Neuropathic type pain (tingling, burning or shooting) * Flu-like symptoms (e.g. fatigue and headaches) * Dysuria (painful urination) * Inguinal lymphadenopathy **Initial presentation is worst, Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.**

Answer 883

* Clinical history and examination * Swab from the base of the ulcer analysed using nucleic acid amplification tests (NAATs), the most effective method

Answer 884

**General measures include:** * Saline bathing * Analgesia * Topical anaesthetic agents e.g. lidocaine **Medication:** * Oral Aciclovir (400mg for 5 days) some patients with frequent exacerbations may benefit from longer-term aciclovir **Pregnancy:** * Elective caesarean section at 37 weeks if infected post 28 weeks. * Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low

Answer 885

* Genital warts, or anogenital warts, are a type of sexually transmitted infection characterised by **small, skin-colored or grey growths in the genital area**. * They are typically painless and present in regions traumatised during sexual intercourse.

Answer 886

* Unprotected sex * Multiple sexual partners * Immunosuppression * Starting sexual activity at a young age.

Answer 887

* They are caused by the **human papillomavirus (HPV)** * 90% of cases are attributed to attributed to **serotypes 6 and 11** * Transmission primarily occurs through direct skin-to-skin contact during sexual activity.

Answer 888

* **Painless lumps** on the genitals or anal area * The lumps are either skin coloured or grey * Lumps that are either **keratinised** (hard) or **non-keratinised** (soft) * Areas of the body that are traumatised during sexual intercourse are commonly affected

Answer 889

* **Molluscum contagiosum** Characterised by small, firm, round bumps with a central indentation. * **Condyloma lata (secondary syphilis)** Presents as large, flat, grey-white lesions, often with a moist surface. * **Genital herpes** Presents with painful blisters or open sores in the genital area. * **Skin tags** Small, soft, skin-colored growths that hang off the skin and can appear anywhere.

Answer 890

* Diagnosis is primarily clinical made through a detailed history and visual inspection of the warts. * But in uncertain cases the diagnosis can be confirmed through **biopsy and histopathological investigation**.

Answer 891

**Self Administered** Reassurance partner may not have cheated due to long latency of virus * **Podophyllotoxin** - a plant-based antiviral that can destroy wart tissue * **Imiquimod** -may weaken condoms **Specialist Treatments** * **Cryotherapy** (a process that freezes the wart using liquid nitrogen) or **ablative therapy** can be used to treat keratinised warts * **Trichloroacetic acid** - a chemical treatment that burns off warts. There is a high chance of reccurrence regardless of treatment.

Answer 892

* Primary HIV infection, or acute retroviral syndrome, is the phase that commences immediately after the **initial exposure to the Human Immunodeficiency Virus** (HIV). * This phase is characterised by a surge in viral replication and often coincides with the onset of clinical symptoms.

Answer 893

* HIV, specifically **HIV-1 and HIV-2**, are **RNA retroviruses** that cause primary HIV infection. * The virus enters and destroys the CD4 T-helper cells of the immune system. They are **transmitted through**: * Unprotected anal, vaginal or oral sexual activity * Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission) * Mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g., sharing needles, needle-stick injuries or blood splashed in an eye)

Answer 894

Typically presents experience as a **mild flu-like illness 2-6 weeks post-exposure**. But it can widely range in the serverity of symptoms. Classic presentation includes: * Fever * Lymphadenopathy * Maculopapular rash (commonly found on the upper chest) * Mucosal ulcers * Myalgia * Arthralgia * Fatigue * Some people can remain asymptomatic After this initial flu-like illness within the first few weeks of infection. The **infection is then asymptomatic until the condition progresses to immunodeficiency**. Disease progression may occur years after the initial infection.

Answer 895

* Symptom onset within 3 weeks of infection * Symptoms lasting longer than 2 weeks * Symptoms involving the central nervous system (CNS)

Answer 896

* **Influenza** Characterised by sudden onset fever, cough, headache, muscle and joint pain, severe malaise, sore throat, and a runny nose. * **Mononucleosis** (Epstein-Barr virus or cytomegalovirus) Typically presents with fever, pharyngitis, lymphadenopathy, and fatigue. * **Acute streptococcal pharyngitis** Symptoms include sore throat, fever, headache, abdominal pain, nausea, and vomiting. * **Viral hepatitis** May present with jaundice, fatigue, nausea, fever, and muscle aches.

Answer 897

**Serum HIV enzyme-linked immunosorbent assay (ELISA)** A positive result must be confirmed using a second test.

Answer 898

* HIV viral load * Full blood count * Lymphocyte subset panel (including **CD4 count**) * Screening for other sexually transmitted infections such as chlamydia, gonorrhoea, and syphilis * Screening for viral hepatitis * Kidney function tests * Liver function tests * Glucose * Lipids

Answer 899

Every patient is offered **Combination Antiretroviral Therapy** regardless of their viral load or CD4 count. There are several classes of ART drugs: * Protease inhibitors (PI) * Integrase inhibitors (II) * Nucleoside reverse transcriptase inhibitors (NRTI) * Non-nucleoside reverse transcriptase inhibitors (NNRTI) * Entry inhibitors (EI) The usual starting regime is: * **Two NRTIs** (e.g. **tenofovir plus emtricitabine**) * Plus a **third agent** (e.g. **bictegravir**). The aim of treatement **achieve a normal CD4 count and undetectable viral load**.

Answer 900

**Fourth-generation laboratory test for HIV** * Checks antibodies to HIV and the p24 antigen * It has a window period of 45 days, meaning it can take up to 45 days after exposure to the virus for the test to turn positive. * A negative result within 45 days of exposure is therefore unreliable **Point of care tests for HIV** * Only checks for HIV antibodies * Has a window period of 90 days

Answer 901

**CD4 Count** - gives the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection (and the development of an AIDs defining illness). * **500-1200 cells/mm3 is the normal range** * **Under 200 cells/mm3** puts the patient at high risk of opportunistic infections **HIV RNA per ml of blood** indicates the **viral load**. And is another way to monitor how well controlled a HIV infection is. An undetectable viral load means the level is below the recordable range (usually 20 copies/ml)

Answer 902

**Prophylactic co-trimoxazole** is given to **protect against pneumocystis jirovecii pneumonia (PCP)**

Answer 903

* AIDS is the **terminal stage of HIV infection** where combination antiretroviral therapy (cART) has not halted the spread of the virus. * It is defined by the **presence of an AIDS-defining illness alongside a CD4 count of less than 200 cells/mm³**.

Answer 904

Most common in Sub-Saharan Africa

Answer 905

* Kaposi’s sarcoma * Pneumocystis jirovecii pneumonia (PCP) * Cytomegalovirus infection * Candidiasis (oesophageal or bronchial) * Lymphomas * Tuberculosis

Answer 906

It depends on the specific AIDS defining illness that is present, which can include: * **Gastrointestinal symptoms** Such as dysphagia or odynophagia in oesophageal candidiasis * **Respiratory symptoms** In cases of Pneumocystis pneumonia or recurrent pneumonia * **Neurological symptoms** In cases of HIV encephalopathy, toxoplasmosis, or progressive multifocal leukoencephalopathy * **Skin lesions** In cases of Kaposi's sarcoma or lymphoma * **Visual symptoms** In cases of cytomegalovirus (CMV) retinitis.

Answer 907

* **HIV testing**: Primary diagnosis of HIV infection * **CD4 cell count**: To determine the progression of the disease * **Tests specific to AIDS-defining illnesses**: For example, bronchoscopy for suspected Pneumocystis pneumonia or biopsy for Kaposi's sarcoma

Answer 908

* **Combination antiretroviral therapy (cART)** To suppress HIV replication and slow disease progression * **Prophylaxis against opportunistic infections** Including Pneumocystis pneumonia and toxoplasmosis * **Treatment of AIDS-defining illnesses** Specific to the illness, for example, antifungal therapy for candidiasis or chemotherapy for lymphoma

Answer 909

* Correct use of condoms * Effective treatment combined with an undetectable viral load appears to prevent the spread of HIV, even during unprotected sex. * **Post-Exposure Prophylaxis (PEP)** - Can be used after exposure to reduce the risk of transmission. Its not 100% effective however and must be commenced within a short window of opportunity (less than 72 hours). * **Pre-exposure prophylaxis (PrEP)** is also available to take before exposure to reduce the risk of transmission.

Answer 910

**Emtricitabine or tenofovir** (Truvada).

Answer 911

* It involves a combination of Anti-retroviral therapy * **emtricitabine/tenofovir** (Truvada) and **raltegravir** for **28 days**. * The sooner PEP is started after exposure, the greater the chance it will work.

Answer 912

The HIV virus can transfer from mother to child at any stage of the pregnancy; however the **greatest risk is during delivery** (particularly a **vaginal delivery**) The mother's viral load affects what delivery type is reccomended: * **Under 50 copies/ml** - Normal vaginal delivery * **Over 50 copies/ml** - Pre-labour Cesaerean section is recommended **IV zidovudine** is given as an infusion during labour and delivery if the viral load is unknown or above 1000 copies/ml.

Answer 913

**Post Exposure Prophylaxis** * Low-risk babies (mother’s viral load is under 50 copies per ml) are given zidovudine for 2-4 weeks * High-risk babies are given zidovudine, lamivudine and nevirapine for four weeks

Answer 914

* **HIV can be transmitted during breastfeeding**. * Therefore the safest option is to **avoid breastfeeding alltogether** and to **use formula milk** (even if the mother's viral load is undetectable).

Answer 915

Erectile dysfunction (ED) is defined as the **consistent or recurrent inability to attain and/or maintain penile erection** sufficient for satisfactory sexual performance.

Answer 916

* It is more common in older men * It affects more than 50% of men aged over 60

Answer 917

* **Vascular disease** Atherosclerosis can lead to impaired blood flow to the penis, leading to ED. * **Autonomic neuropathy** This can cause penile denervation, most commonly seen in conditions like diabetes or with excessive alcohol intake. * **Medications** Certain drugs, such as antihypertensive agents, can cause ED. * **Psychogenic** Anxiety, depression, and other psychological factors can contribute to ED. * **Endocrine causes** Conditions like prolactinoma and hypogonadism can cause hormonal imbalances leading to ED. * **Pelvic surgery** Procedures involving the bladder, prostate, or other pelvic structures can damage nerves and blood vessels, leading to ED. * **Anatomical abnormalities** Conditions like Peyronie's disease, characterized by fibrous scar tissue inside the penis, can cause ED.

Answer 918

Primary symptom of erectile dysfunction is the **inability to achieve or maintain an erection sufficient for sexual intercourse**. This can also lead to: * Reduced sexual desire * Difficulty in ejaculation * Anxiety or depression related to sexual performance **Signs which suggest an organic cause**: * lack tumescence * slow-onset * normal libido. **Signs which suggest a psychogenic cause** * If situational * Acute onset * High levels of stress * Still having early morning erections.

Answer 919

* **Premature ejaculation** Characterized by uncontrolled ejaculation either before or shortly after sexual penetration. * **Hypogonadism** Characterized by low testosterone levels, resulting in low sex drive, fatigue, and mood changes. * **Peyronie's disease** Presents with a significant bend in the penis during erection, which can interfere with sexual function.

Answer 920

* **Detailed sexual and psychological history** to identify potential contributing factors. * **Blood tests** - Full blood count, urea and electrolytes, thyroid function tests, lipid profile, testosterone, and prolactin to evaluate overall health and hormonal status. * QRISK is also required to be calculated

Answer 921

* **Psychosexual therapy** To address any underlying psychological factors. * **Oral phosphodiesterase inhibitors** (e.g. **Sildenafil**) To enhance the effect of nitric oxide, increasing blood flow to the penis. * **Vacuum erection devices** To draw blood into the penis by applying negative pressure. * **Intra-cavernosal injections** To directly increase blood flow. * **Penile prostheses** For cases resistant to other treatments.

Answer 922

* **Priapism** * Headache * Flushing * Hypotension * Blue tinge to vision (little blue pill).

Answer 923

* Individuals taking nitrates * Hypertension/hypotension * Arrhythmias * Unstable angina * Stroke * Recent myocardial infarction.

Answer 924

**Sterile Speculum Examination:** look for pooling of amniotic fluid in posterior vaginal vault. Digital examination **Should be avoided** due to risk of infection **Second Line:** Fluid testing for: * Insulin Like Growth Factor Binding Protein (IGFBP-1) * Placental alpha microglobulin-1 protein (PAMG-1) **Ultrasound scan** may show oligohydramnios

Answer 925

**Prophylactic Antibiotics:** TDS 250mg Erythromycin for 10 days or until labour established **Induction of labour** may be offered from 34 weeks but try to get to 37 weeks.

Answer 926

**Maternal** * Postpartum haemorrhage * Perineal tears **Fetal** * Brachial plexus injury * **Erbs Palsy** Where damage to C5/6 leads to Internally rotated shoulder, Extended elbow, Flexed wrist facing backwards (pronated), Lack of movement in the affected arm * Neonatal death

Answer 927

**Maternal** * Shock * DIC * Renal failure * PPH **Fetal** * IUGR * Hypoxia * Death

Answer 928

**Wide Local Excision:** * Solitary Lesion * Small lesion in large breast * Peripheral Tumour * DCIS < 4cm **Mastectomy:** * Multifocal Tumour * Central Tumour * Large lesion in small breast * DCIS > 4cm

Answer 929

Women with **no palpable axillary lymphadenopathy** pre-operatively should have an Ultrasound. If negative then a **Sentinel node biopsy should be done** Women **With** palpable lymphadenopathy should have axillary node clearance at primary surgery. Side effects include: Lymphoedema, functional arm impairment

Answer 930

* Ulceration * Peau d'orange * Inflammatory Breast Cancer * Fixed to chest wall * Fixed and matted to axillary lymph nodes **This type of breast cancer is surgically incurable**

Answer 931

The term 'nausea and vomiting of pregnancy' (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition.

Answer 932

Most common between **8-12 weeks** but may persist up until 20 weeks

Answer 933

**Increased levels of beta-hCG** * Multiple pregnancies * Trophoblastic disease **Other:** * Nulliparity * Obesity * Thyrotoxicosis (mimic of TSH as bHCG) * Family or personal history of NVP **Smoking is associated with a decreased incidence of hyperemesis.**

Answer 934

**Triad of:** * 5% pre-pregnancy weight loss * Dehydration * Electrolyte imbalance

Answer 935

**pregnancy-Unique Quantification of Emesis (PUQE) Score**

Answer 936

* Unable to tolerate oral antiemetics or keep down any fluids * More than 5 % weight loss compared with pre-pregnancy * Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant) * Other medical conditions need treating that required admission

Answer 937

**Simple Measures:** * Rest and avoid triggers * **Ginger** * Acupressure on the wrist at the PC6 point (inner wrist) * Bland plain food **First Line Medications:** * Antihistamines: **Cyclizine** or Promethazine * Phenothiazines: Prochlorperazine or chlorpromazine **Second Line Medications:** * Oral Ondansetron * Oral Metoclopramide or Domperidone (only used for no more than 5 days) **Moderate/Severe to Admission:** * Maybe required for IV/IM anti-emetics * Normal saline **with added potassium** is used to rehydrate. * **Thiamine Supplementation** to prevent Wernicke's Korsakoff * VTE prophylaxis

Answer 938

Use in first trimester is associated with a small increased risk of **Cleft lip/palate**

Answer 939

May cause extrapyramidal effects so shouldnt be used for more than 5 days.

Answer 940

**Most Common:** * Dehydration * Weight loss * Electrolyte imbalances - notably hypokalaemia **Other Complications:** * AKI * Wernicke's encephalopathy * Mallory-weiss tear * VTE

Answer 941

Emotional and physical symptoms that women may experience in the **luteal phase or a normal menstrual cycle**

Answer 942

**Lifestyle advice** * Sleep * Exercise * Smoking and alcohol cessation * Small balanced meals with rich complex carbs **Moderate Symptoms** * 3rd Generation COCP **Severe Symptoms** * SSRIs such as fluoxetine taken during the luteal phase * Cognitive Behavioural Therapy

Answer 943

**Exclude Breast Cancer as it is a close mimic** * Do Triple Assessment to rule out **Once diagnosis is made** * Conservative management * May resolve spontaneously * May require surgery to remove if troublesome

Answer 944

**SMOKERS** and perimenopausal women

Answer 945

* Nipple discharge - white, grey, green * Tenderness or pain * Nipple retraction or inversion * A breast lump (pressure on the lump may produce nipple discharge)

Answer 946

* Reassurance after excluding cancer may be all that is required * Symptomatic management of mastalgia (supportive bra and warm compresses) * Antibiotics if infection is suspected or present * Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Answer 947

**Triple Assessment first** * Microcalcifications are a key finding to remember on a mammogram **Other Investigations:** * Ductography - contrast injected into abnormal duct and mammograms used to visualise * Nipple Discharge Cytology

Answer 948

**Silicon:** * Advantages: Less likely to fold or rupture. Feel more natural * Disadvantages: May cause lumps **Saline:** * Advantages: if they rupture, can be absorbed into the body safely * Disadvantage: More likely to go down/rupture **Both types of implants last about 10 years**

Answer 949

* Bleeding * Blood clots * Infection * Allergic reaction

Answer 950

* Obvious Scarring * Capsular contracture * Ruptured implant * Produce less breast milk when feeding * **BIA-ALCL (Breast implant associated, anaplastic large cell lymphoma)** * **Breast Implant Illness**

Answer 951

generalised lumpiness to the breast (Not a disease). The anatomy of the breast may become fibrous and cystic with changes in hormones and this can fluctuate with the menstrual cycle.

Answer 952

**Common in women of menstruating age** **Symptoms occur prior to menstruation and resolve as menstruation begins** **Will fluctuate with menstrual cycle** **Does not tend to affect post-menopausal women** Can affect different areas of the breast or both breasts with: * Lumpiness * Breast pain or tenderness (mastalgia) * Fluctuation of breast size

Answer 953

**Exclude Breast CA with Triple Assessment:** **Manage Symptoms of myalgia:** * Wearing a supportive bra * NSAIDs for pain * Avoiding caffeine is commonly recommended * Applying heat to the area * Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Answer 954

Fetus measuring < 10th centile for gestational age based on: **Estimated fetal weight (EFW)** **Fetal abdominal circumference**

Answer 955

Fetus is below the 3rd centile for gestational age

Answer 956

Birth weight less than 2500g

Answer 957

* Constitutionally small * Fetal growth restriction/Intrauterine Growth Restriction (IUGR)

Answer 958

When the fetus is small or not growing as expected dur to pathology reducing the amount of nutrients and oxygen delivered to the fetus through the placenta **constitutionally small means the baby is growing appropriately and matching the mother or others in the family. There is no pathological cause**

Answer 959

Placental mediated growth Restriction Non-placental mediated growth restriction

Answer 960

**Conditions that affect the transfer of nutrients across the placenta** * Idiopathic * Pre-eclampsia * Maternal smoking * Maternal alcohol * Anaemia * Malnutrition * Infection * Maternal health conditions

Answer 961

**Pathology of the fetus** * Genetic abnormalities * Structural abnormalities * Fetal infection * Errors of metabolism

Answer 962

* Fetal death or still birth * Birth asphyxia * Neonatal hypothermia * Neonatal hypoglycaemia

Answer 963

* CVD particularly Hypertension * T2DM * Obesity * Mood and behavioural problems

Answer 964

Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome

Answer 965

**low risk women** have SFH measured at every antenatal appointment from 24 weeks onwards. **Women with 1 major or 3 minor risk factors** will have serial growth scans and umbilical artery dopplers every 4 weeks from 28 weeks/

Answer 966

* Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity * Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery * Amniotic fluid volume

Answer 967

* Identifying those at risk of SGA * Aspirin is given to those at risk of pre-eclampsia * Treating modifiable risk factors (e.g. stop smoking) * Serial growth scans to monitor growth (eg. 4 weekly at 28 weeks) * Early delivery where growth is static, or there are other concerns

Answer 968

* Blood pressure and urine dipstick for pre-eclampsia * Uterine artery doppler scanning * Detailed fetal anatomy scan by fetal medicine * Karyotyping for chromosomal abnormalities * Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

Answer 969

**Planned early delivery** * Corticosteroids are given to help fetal lungs mature * Magnesium sulphate may be given for neuroprotection for gestations between 24-32 weeks

Answer 970

**Macrosomia** where the weight of the newborn is >4.5kg at birth. EFW above the 90th centile is considered LGA

Answer 971

* Constitutional * Maternal diabetes * Previous macrosomia * Maternal obesity or rapid weight gain * Overdue * Male baby

Answer 972

* **Shoulder dystocia** * Failure to progress * Perineal tears * Instrumental delivery or caesarean * **Postpartum haemorrhage** * Uterine rupture (rare)

Answer 973

* **Birth injury** (Erbs palsy, clavicular fracture, fetal distress and hypoxia) * Neonatal hypoglycaemia * Obesity in childhood and later life * Type 2 diabetes in adulthood

Answer 974

* Ultrasound to exclude polyhydramnios and estimate the fetal weight * Oral glucose tolerance test for gestational diabetes

Answer 975

* polymorphic eruption of pregnancy * Melasma * Pemphigoid Gestations

Answer 976

**First Trimester** Start - 12 weeks **Second Trimester** 13 weeks - 26 weeks **Third Trimester** 27 weeks - birth

Answer 977

From around 20 weeks gestation until birth

Answer 978

* Influenza (Flu) at any time during pregnancy * Pertussis from **16 weeks** gestation **Live vaccines** such as MMR are avoided

Answer 979

Women are offered **75-150mg Aspirin daily from 12 weeks gestation until birth** if they have: * One high-risk factor * More than one moderate-risk factors.

Answer 980

An itchy rash that tends to start in the **Third trimester** that usually begins on the abdomen

Answer 981

* Urticarial papules * Wheals (Raised itchy areas of skin) * Plaques

Answer 982

Topical emollients, oral antihistamines and topical steroids **Condition gets better towards the end of pregnancy and after delivery**

Answer 983

Increased pigmentation to patches of the skin on the face. Typically doesn't require treatment

Answer 984

Autoimmune skin condition occurring in pregnancy. Auto Abs damage connections between epidermis and dermis produced in response to placental tissue.

Answer 985

Maternal infection with the rubella virus **during the first 20 weeks of pregnancy**. The risk is highest before ten weeks gestation.

Answer 986

MMR vaccine to prevent congenital rubella syndrome When in doubt **rubella immunity** should be tested. If they do not have antibodies then they can be vaccinated with 2 doses of MMR 3 months apart.

Answer 987

**A Blind deaf neurotic duck** * Blind - congenital cateracts * Deaf - congenital deafness * Neurotic - learning disability * Duck - PDA and pulmonary stenosis

Answer 988

**Mother:** Varicella pneumonitis, Hepatitis or encephalitis **Fetal Varicella syndrome** **Severe neonatal varicella infection** if infected around delivery

Answer 989

* When the pregnant woman has previously had chickenpox, they are safe * When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe. * When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.

Answer 990

occurs in around 1% of cases of chickenpox in pregnancy. It occurs when **infection occurs in the first 28 weeks of gestation.**

Answer 991

**LIMBE** L: Limb Hypoplasia I: Intrauterine Growth Restriction (IUGR) M: Microcephaly (brain underdevelopment, hydrocephalus and LD) B: Blistering Skin Lesions E: Eye defects (cataracts and chorioretinitis)

Answer 992

Listeria is a **gram positive** bacteria that can easily lead to listeriosis in pregnant women

Answer 993

High rate of Miscarriage or fetal death Can cause severe neonatal infection

Answer 994

**unpasteurised dairy products** **Processed meats** Women are advised to avoid high risk foods such as blue cheese, camembert and brie

Answer 995

Primary treatment involves a combination of the antibiotics **ampicillin** and an **aminoglycoside**

Answer 996

**Janice, Peri and Cory are pure deaf** * Jaundice * Periventricular Calcifications and Microcephaly (and FGR) * Chorioretintis * Purpuric skin (and Thrombocytopenia) * Sensorineural deafness

Answer 997

Toxoplasma gondii parasite is usually asymptomatic Spread via contamination with faeces from a cat

Answer 998

* Intracranial Calcification * Hydrocephalus * Chorioretinitis

Answer 999

**Cory with the big head likes stiff calcium jerky** Cory (chorioretinitis) Big head (hydrocephalus) Stiff (spasticity) Calcium (cerebral calcifications) Jerky (seizures)

Answer 1000

**Affects first and second trimesters** * Miscarriage or fetal death * Severe fetal anaemia * **Hydrops Fetalis** (fetal heart failure) * **Mirror Syndrome**

Answer 1001

Maternal pre-eclampsia like syndrome: A rare complication of **hydrops fetalis** characterised by the triad: * Hydrops Fetalis * Placental Oedema * Oedema in the mother **PLUS features of hypertension and proteinuria** mirroring Pre-eclampsia

Answer 1002

* IgM to parvovirus, which tests for acute infection within the past four weeks * IgG to parvovirus, which tests for long term immunity to the virus after a previous infection * Rubella antibodies (as a differential diagnosis) **Treatment is supportive. Women with parvovirus B19 infection need a referral to fetal medicine to monitor for complications and malformations.**

Answer 1003

Host Aedes Mosquitos. It can be spread by sex with someone infected with the virus

Answer 1004

* Microcephaly * Fetal Growth Restriction * Intracranial abnormalities: Ventriculomegaly and cerebellar atrophy

Answer 1005

**Category 1:** * Within**30 mins** of decision * Immediate threat to life of women or fetus **Category 2:** * Within **75 mins** of decision * Maternal/fetal compromise but **not** immediately life threatening **Category 3:** * No compromise but early birth is indicated **Category 4:** * Elective - maternal choice

Answer 1006

* Previous caesarean * Symptomatic after a previous significant perineal tear * Placenta praevia * Placenta accreta spectrum * Vasa praevia * Breech presentation * Multiple pregnancy * Uncontrolled HIV infection * Cervical cancer

Answer 1007

* Fetal Bradycardia * Abruption * Uterine rupture * Cord Prolapse * Fetal pH < 7.2 * Failure of instrumental delivery

Answer 1008

**Maternal Complications** * General surgical risks (bleeding, infection, pain ,VTE) * Post partum Complications (haemorrhage, infeection, endometritis) * Damage to local Structures (Ureter, bladder, bowel, Blood vessels) * Effects on abdo organs (Ileus, adhesions, hernias) * Effects on future pregnancies ( Repeat c-section, uterine rupture, placenta praevia, still birth) **Effects on Baby:** * Risk of lacerations * Increased risk of **Transient Tachypnoea of the Newborn**

Answer 1009

**cystocele/cystourethrocele:** * anterior colporrhaphy, * colposuspension **uterine prolapse:** * hysterectomy, * sacrohysteropexy **rectocele:** * posterior colporrhaphy

Answer 1010

Mifepristone is an anti-progesterone that sensitises the myometrium to prostaglandins and induces breakdown of decidua basalis

Answer 1011

Misoprostol is a prostaglandin analogue that soften the cervix and stimulates uterine contractions.

Answer 1012

* Idiopathic (particularly in older women) * **Antiphospholipid syndrome** * **Hereditary thrombophilias** * **Uterine abnormalities** * Genetic factors in parents (e.g. balanced translocations in parental chromosomes) * Chronic histiocytic intervillositis * Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)

Answer 1013

Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage. **APLs Abx** * Anti-cardiolipin * Lupus anticoagulant * Anti-b2 Glycoprotein I **The risk of miscarriage in patients with antiphospholipid syndrome is reduced by using both:** * Low dose aspirin * Low molecular weight heparin (LMWH)

Answer 1014

* Uterine septum (a partition through the uterus) * Unicornuate uterus (single-horned uterus) * Bicornuate uterus (heart-shaped uterus) * Didelphic uterus (double uterus) * Cervical insufficiency * Fibroids

Answer 1015

Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death. The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.

Answer 1016

**Increased risk of haemorrhage** * she is in the late first trimester * if she has coagulopathies or is unable to have a blood transfusion **Previous adverse and/or traumatic experience associated with pregnancy** (for example, stillbirth, miscarriage or antepartum haemorrhage) **Evidence of infection**

Answer 1017

**NICE Guidelines 2019 and Placental Growth Factor (PlGF):** Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. * NICE recommend testing on one occasion during pregnancy in women suspected to have Pre-eclampsia between **20 and 35 weeks gestation to rule out pre-eclampsia** * **sFLT:PlGF ratio >85 is diagnostic**

Answer 1018

It prevents ovulation, thickens cervical mucus, and inhibits endometrial proliferation, reducing the chance of implantation.

Answer 1019

Unscheduled bleeding, breast pain, mood changes, headaches, and an increased risk of venous thromboembolism (VTE), breast and cervical cancer.

Answer 1020

My CUPLETS" M: Migraines with aura - Increased risk of stroke. C: Cardiovascular disease - Includes ischemic heart disease, uncontrolled hypertension, or history of stroke. U: Undiagnosed vaginal bleeding and Uncontrolled Hypertension - Needs to be investigated before starting COCP. P: Pregnancy - COCP should not be used during pregnancy. L: Liver disease - Severe liver disease, cirrhosis, or liver tumors can be worsened by the COCP. E: Estrogen-dependent cancers - History or risk of breast cancer or endometrial cancer. T: Thromboembolism - History of deep vein thrombosis (DVT) or pulmonary embolism (PE). S: Smoking (especially over the age of 35) - Increases the risk of cardiovascular complications.

Answer 1021

Start on the first day of the menstrual cycle for immediate protection. If started after day 5, use additional contraception for 7 days.

Answer 1022

It thickens cervical mucus and inhibits endometrial proliferatoin. **Desogestrel POP can inhibit ovulation**

Answer 1023

Irregular bleeding, breast tenderness, and mood changes.

Answer 1024

Breast cancer, severe liver disease, and undiagnosed vaginal bleeding.

Answer 1025

Start on the first day of the menstrual cycle for immediate protection. If started later, use additional contraception for 2 days.

Answer 1026

The IUD prevents fertilization by creating an environment toxic to sperm and preventing implantation.

Answer 1027

Heavier periods, cramping, and increased risk of infection and ectopic pregnancies

Answer 1028

Current pelvic infection, unexplained vaginal bleeding, wilsons disease, and uterine abnormalities

Answer 1029

Can be inserted at any time during the cycle if pregnancy is ruled out. No additional contraception is needed after insertion.

Answer 1030

It releases progesterone, thickening cervical mucus, thinning the endometrium, and inhibiting sperm movement.

Answer 1031

Irregular bleeding, headaches, breast tenderness, and mood changes.

Answer 1032

Current pelvic infection, breast cancer, and uterine abnormalities.

Answer 1033

Insert during the first 7 days of the cycle for immediate protection. If inserted later, use additional contraception for 7 days.

Answer 1034

It releases progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.

Answer 1035

Worsen bleeding, cause acne, weight gain, mood changes, and headaches.

Answer 1036

Breast cancer, severe liver disease, and unexplained vaginal bleeding.

Answer 1037

Insert during the first 5 days of the cycle for immediate protection. If inserted later, use additional contraception for 7 days.

Answer 1038

It releases progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.

Answer 1039

Irregular bleeding, weight gain, osteoporosis, mood changes, and delayed return of fertility.

Answer 1040

Breast cancer, severe liver disease, and unexplained vaginal bleeding.

Answer 1041

Given during the first 5 days of the cycle for immediate protection. If given later, use additional contraception for 7 days.

Answer 1042

It releases oestrogen and progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.

Answer 1043

Skin irritation, breast tenderness, mood changes, and headaches.

Answer 1044

Uncontrolled hypertension, migraines with aura, history of VTE, smokers over 35, and heart disease.

Answer 1045

Apply on the first day of the menstrual cycle for immediate protection. If started later, use additional contraception for 7 days.

Answer 1046

It releases oestrogen and progesterone, preventing ovulation, thickening cervical mucus, and thinning the endometrium.

Answer 1047

Vaginal irritation, breast tenderness, mood changes, and headaches.

Answer 1048

Uncontrolled hypertension, migraines with aura, history of VTE, smokers over 35, and heart disease.

Answer 1049

Insert on the first day of the menstrual cycle for immediate protection. If started later, use additional contraception for 7 days.

Answer 1050

It delays ovulation and may prevent implantation if taken before ovulation.

Answer 1051

Nausea, vomiting, fatigue, and irregular bleeding.

Answer 1052

Known pregnancy (though not harmful if taken in early pregnancy).

Answer 1053

Take within 72 hours of unprotected sex for the best effectiveness. No additional contraception is needed for the emergency method itself but use ongoing contraception afterward.

Answer 1054

Uncontrolled hypertension (particularly ≥160 / ≥100) Migraine with aura (risk of stroke) History of VTE Aged over 35 and smoking more than 15 cigarettes per day Major surgery with prolonged immobility Vascular disease or stroke Ischaemic heart disease, cardiomyopathy or atrial fibrillation Liver cirrhosis and liver tumours Systemic lupus erythematosus (SLE) and antiphospholipid syndrome

Answer 1055

**BRAVE MUm** **Booking Bloods:** * Blood group, antibodies and rhesus D status * Full blood count for anaemia * Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) * Infection Screen (HIV, Hep B, Syphilis) **Risk Assessment:** * Rhesus negative (book anti-D prophylaxis) * Gestational diabetes (book oral glucose tolerance test) * Fetal growth restriction (book additional growth scans) * Venous thromboembolism (provide prophylactic LMWH if high risk) * Pre-eclampsia (provide aspirin if high risk) **Advice:** * Lifestyle advice in pregnancy (e.g. not smoking) * Supplements (e.g. folic acid and vitamin D) * Antenatal classes * Breastfeeding classes * Discuss mental health **Vitals:** * Blood pressure * Weight, Height, BMI **Early Screening:** * Offer Early screening tests such as Downs and Arrange Dating Scan **Medical History:** * Past pregnancies * Prev. Mental health problems * Prev. GIH, GDM, * Pre-existing HTN or DM. **Urine Tests:** * Protein * Bacteruria * Glucose

Answer 1056

**Weeks 16, 25, 28, 31, 34, 36, 38, 40, 41,42** * Discuss plans for the remainder of the pregnancy and delivery * Symphysis–fundal height measurement from 24 weeks onwards * Fetal presentation assessment from 36 weeks onwards * Urine dipstick for protein for pre-eclampsia * Blood pressure for pre-eclampsia * Urine for microscopy and culture for asymptomatic bacteriuria

Answer 1057

* Additional appointments for higher risk or complicated pregnancies * Oral glucose tolerance test in women at risk of gestational diabetes (between **24 – 28 weeks**) * Anti-D injections in rhesus negative women (at **28 and 34 weeks**) * Ultrasound scan at **32 weeks** for women with placenta praevia on the anomaly scan * Serial growth scans are offered to women at increased risk of fetal growth restriction

Answer 1058

* Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects) * Take vitamin D supplement (10 mcg or 400 IU daily) * Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses) * Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome) * Don’t smoke (smoking has a long list of complications, see below) * Avoid unpasteurised dairy or blue cheese (risk of listeriosis) * Avoid undercooked or raw poultry (risk of salmonella) * Continue moderate exercise but avoid contact sports * Sex is safe * Flying increases the risk of venous thromboembolism (VTE) * Place car seatbelts above and below the bump (not across it)

Answer 1059

* Alcohol can cross the placenta, enter the fetus, and disrupt fetal development. * There is no safe level of alcohol in pregnancy. * Pregnant women are encouraged not to drink alcohol at all. * Small amounts are less likely to result in lasting effects. * The effects are greatest in the first 3 months of pregnancy.

Answer 1060

Miscarriage Small for dates Preterm delivery Fetal alcohol syndrome

Answer 1061

* Microcephaly (small head) * Thin upper lip * Smooth flat philtrum (the groove between the nose and upper lip) * Short palpebral fissure (short horizontal distance from one side of the eye to the other) * Learning disability * Behavioural difficulties * Hearing and vision problems * Cerebral palsy

Answer 1062

Smoking increases the risk of: * **Fetal growth restriction (FGR)** * Miscarriage * Stillbirth * Preterm labour and delivery * Placental abruption * Cleft lip or palate * **Sudden infant death syndrome (SIDS)** Smoking seems to reduce the risk of pre-eclampsia (although the risks of smoking in pregnancy very far outweigh any benefits)

Answer 1063

The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to: 37 weeks in a single pregnancy 32 weeks in a twin pregnancy

Answer 1064

* Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour * Bishop score before and during induction of labour to monitor the progress

Answer 1065

* Power (uterine contractions) * Passenger (size, presentation and position of the baby) * Passage (the shape and size of the pelvis and soft tissues)

Answer 1066

**Delay of First stage of Labour** * Less than 2cm of cervical dilation in 4 hours * Slowing of progress in a multiparous woman **When the active second stage (pushing) lasts over:** * 2 hours in a nulliparous woman * 1 hour in a multiparous woman

Answer 1067

3Ps: **Power:** * Strength of uterine contractions * If they are weak, oxytocin can be used to stimulate the uterus **Passenger: (SALP)** * Size: eg. macrosomic * Attitude: posture of fetus * Lie: Longitudinal, Transverse, Oblique * Presentation: Cephalic, Shoulder, Breech **Passage:** * Size and shape of the passageway (pelvis)

Answer 1068

Changing positions Encouragement Analgesia Oxytocin Episiotomy Instrumental delivery Caesarean section

Answer 1069

Defined as: * More than 30 minutes with active management * More than 60 minutes with physiological management **Active management involves intramuscular oxytocin and controlled cord traction.**

Answer 1070

* Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes * Oxytocin infusion * Instrumental delivery * Caesarean section

Answer 1071

Always advice avoiding chicken pox in pregnancy especially in first trimester due to risk of congenital varicella syndrome **When the pregnant woman has previously had chickenpox** * They are safe **When they are not sure about their immunity** * **test the VZV IgG levels.** * If positive, they are safe. * If not immune, treated with **IV varicella immunoglobulins as prophylaxis** against developing chickenpox. * This should be given within ten days of exposure. **If Infected** * Treat with Aciclovir within 24 hours

Answer 1072

Birth before 37 weeks gestation. Babies are considered non-viable below 23 weeks gestation. * Under 28 weeks: extreme preterm * 28 – 32 weeks: very preterm * 32 – 37 weeks: moderate to late preterm

Answer 1073

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

Answer 1074

**Speculum Examination:** Shows pooling of amniotic fluid in the posterior vaginal vault. Digital examination **Should be avoided** due to risk of infection **If in doubt:** * **Insulin-like growth factor-binding protein-1 (IGFBP-1)** is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes * **Placental alpha-microglobin-1 (PAMG-1)** is a similar alternative to IGFBP-1

Answer 1075

**Prophylactic antibiotics** should be given to prevent the development of chorioamnionitis. * NICE Recommend **erythromycin 250mg QDS for ten days, or until labour is established if within ten days.** * Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Answer 1076

Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

Answer 1077

**Antenatal Steroids:** * Given to women <36 weeks gestation * Help fetal lung maturation and prevent RDS * 2 doses IM Betamethasone 24 hours apart **Magnesium Sulphate:** * Helps protect fetal brain and reduce incidence of CP * Given within 24 hours of delivery for **Pre-terms < 34 weeks gestation**

Answer 1078

* Fetal Monitoring: **CTG or intermittent Auscultation** * Tocolysis with Nifedipine * Maternal Corticosteroids (offered before 35 weeks) * IV Magnesium Sulphate (offered before 34 weeks) * Delayed cord clamping/cord milking

Answer 1079

Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. Can be used as a **screening test used to assess the risk of preterm delivery after the onset of pre-term labour** A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.

Answer 1080

**Magnesium toxicity** at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are: * Reduced respiratory rate * Reduced blood pressure * Absent reflexes

Answer 1081

Often **retained Products of Conception** or **Infection** (such as endometritis)

Answer 1082

* Treat Anaemia (as haemorrhage if the patient is anaemic will have more severe consequences) * Give birth with an empty bladder (bladder distension prevents uterine contraction) * Active 3rd stage management * IV TXA during caesarean section

Answer 1083

**Affects the Ductal tissue or the Lobular tissue (Ductal or Lobular)** **Spread beyond the local tissue or not (in situ/Invasive)** * Ductal Carcinoma In Situ (DCIS) * Lobular Carcinoma In Situ (LCIS) * Invasive Ductal Carcinoma (Also called Non-special Type (NST)) * Invasive Lobular Carcinoma **Invasive Ductal Carcinoma (NST) is the most common type of Breast Cancer**

Answer 1084

* Presents similarly to a breast abscess or mastitis * Swollen, warm, tender breast with pitting skin (peau d’orange) * Does not respond to antibiotics * Worse prognosis than other breast cancers

Answer 1085

Sentinel node biopsy is performed during breast surgery for cancer. An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.

Answer 1086

TNM Staging: Investigations used: * Lymph node assessment and biopsy * MRI of the breast and axilla * Liver ultrasound for liver metastasis * CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis * Isotope bone scan for bony metastasis

Answer 1087

**Breast Conserving Surgery:** * Wide local excision * often coupled with radiotherapy **Mastectomy:** * May have immediate or delayed breast reconstruction **Axillary Node Clearance:** * Depends on Criteria * Increased risk of lymphoedema

Answer 1088

**Often used in patients with Breast Conserving Surgery** It can reduce the risks of reoccurrence Patients will have a course after surgery (eg. every day for 3 weeks)

Answer 1089

**Neoadjuvant therapy** – intended to shrink the tumour before surgery **Adjuvant chemotherapy** – given after surgery to reduce recurrence **Treatment** of metastatic or recurrent breast cancer

Answer 1090

**Oestrogen Positive (ER)** * Pre-menopausal women: **Tamoxifen** * Post-Menopausal Women: **Aromatase inhibitors (anastrozole)** **Biologic Therapy:** * **Trastuzumab** (Herceptin) used for HER2 positive tumours * Pertuzumab (another monoclonal Ab against HER2 * Neratinib (tyrosine kinase inhibitor to reduce growth in HER2 positive cases) **Trastuzumab cannot be used in patients with a history of heart disorders**

Answer 1091

**Aromatisation** accounts for the majority of oestrogen production in post-menopausal women from adipose tissue. Furthermore Tamoxifen increases the risk of Endometrial cancer due to the oestrogenic effects on the uterus and the lack of progesterone from the menstrual cycle

Answer 1092

All patients treated for breast cancer have surveillance mammograms yearly for 5 years (or longer if not yet reached the age for National Breast CA Screening)

Answer 1093

**Cyclical** Related to the menstrual cycle **Non-Cyclical**

Answer 1094

Symptoms typically occur **2 weeks before menstruation** Features: * Bilateral and generalised * Heaviness * Aching

Answer 1095

Common in women aged 40-50 Often no cause is found May be caused by: * Medications (e.g., hormonal contraceptive medications) * Infection (e.g., mastitis) * Pregnancy The pain may not originate in the breast but instead come from: * The chest wall (e.g., costochondritis) * The skin (e.g., shingles or post-herpetic neuralgia)

Answer 1096

**A breast pain diary** can help diagnose cyclical breast pain. The three main things to exclude when someone presents with breast pain are: * Cancer (perform a thorough history and examination) * Infection (mastitis) * Pregnancy (perform a pregnancy test)

Answer 1097

* Wearing a supportive bra * NSAIDs * Avoiding caffeine is commonly recommended * Applying heat to the area * Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Answer 1098

They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They present with a **firm, mobile, painless lump, usually beneath the areola.** They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.

Answer 1099

Rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise. Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal. Chemotherapy may be used in malignant or metastatic tumours.

Answer 1100

Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection.

Answer 1101

**Often Asymptomatic and presents similarly to Chlamydia** * **Urethritis** is a key feature May present with: * Epididymitis * Cervicitis * Endometritis * Pelvic inflammatory disease * Reactive arthritis * Preterm delivery in pregnancy * Tubal infertility

Answer 1102

**NAAT testing for DNA/RNA** * First Urine sample for men * Vaginal Swabs for women Checking every positive sample for macrolide resistance, and performing a “test of cure” after treatment in every positive patient.

Answer 1103

Guidelines recommend a course of **doxycycline followed by azithromycin** for uncomplicated genital infections: * **Doxycycline** 100mg twice daily for 7 days then; * **Azithromycin** 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides) **Moxifloxacin** is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

Answer 1104

Symptoms occur in the days prior to menstruation and improve once menstruation begins. **Emotional symptoms include:** * Anxiety * stress * fatigue * mood swings **Physical symptoms** * bloating * breast pain **Symptoms are not present before menarche, during pregnancy or after menopause. These are key things to note when you take a history.**

Answer 1105

**Symptom diary spanning two menstrual cycles.** * The symptom diary should demonstrate cyclical symptoms that occur just before, and resolve after, the onset of menstruation. **Definitive diagnosis by administering a GnRH analogues to halt the menstrual cycle** * temporarily induce menopause, to see if the symptoms resolve.

Answer 1106

Cervical ectropion occurs when the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). **Also called cervical erosion** The cells of the endocervix (columnar epithelial cells) are more fragile and prone to trauma. They are more likely to bleed with sexual intercourse. This means cervical ectropion often presents with postcoital bleeding.

Answer 1107

**Higher Oestrogen Levels** * Younger women * Combined Contraceptive Pill Use * Pregnancy

Answer 1108

The transformation zone is the border between the columnar epithelium of the endocervix (the canal), and the stratified squamous epithelium of the ectocervix (the outer area of the cervix visible on speculum examination). When the transformation zone is located on the ectocervix, it is visible during speculum examination as a border between the two epithelial types.

Answer 1109

Many cervical ectropion are asymptomatic, and they are found incidentally during speculum examination for other reasons, for example, smear tests. **May present with:** * **Postcoital bleeding.** (Intercourse is a common cause of minor trauma to the ectropion) * Vaginal discharge * Vaginal bleeding * Dyspareunia

Answer 1110

Asymptomatic ectropion require no treatment Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. **Problematic bleeding is an indication for the treatment of cervical ectropion** * Cauterisation of the ectropion **using silver nitrate or cold coagulation during colposcopy.**

Answer 1111

FGM involves surgically changing the genitals of a female for non-medical reasons.

Answer 1112

FGM usually occurs in girls before puberty.

Answer 1113

FGM is considered a form of child abuse and a safeguarding issue.

Answer 1114

FGM is illegal under the Female Genital Mutilation Act 2003.

Answer 1115

Healthcare professionals are legally required to report cases of FGM to the police.

Answer 1116

UNICEF provides information on the epidemiology of FGM.

Answer 1117

FGM is most common in many African countries, including Somalia, Ethiopia, Sudan, and Eritrea.

Answer 1118

Somalia has the highest levels of FGM.

Answer 1119

FGM is practiced in Yemen, Kurdistan, Indonesia, and parts of South and Western Asia.

Answer 1120

There are four types of FGM.

Answer 1121

Type 1 FGM involves the removal of part or all of the clitoris.

Answer 1122

Type 2 FGM involves the removal of part or all of the clitoris and labia minora. The labia majora may also be removed.

Answer 1123

Type 3 FGM involves narrowing or closing the vaginal orifice (infibulation).

Answer 1124

Type 4 FGM includes all other unnecessary procedures to the female genitalia.

Answer 1125

Coming from a community that practices FGM and having relatives affected by FGM are key risk factors.

Answer 1126

* Pregnant women with FGM and a possible female child, * siblings or daughters of affected women, * extended trips to areas where FGM is practiced, * refusal of examination or cervical screening, * new patients from communities that practice FGM.

Answer 1127

Pain, bleeding, infection, swelling, urinary retention, urethral damage, and incontinence.

Answer 1128

Vaginal infections, pelvic infections, urinary tract infections, dysmenorrhea, sexual dysfunction, infertility, pregnancy-related complications, psychological issues, and reduced engagement with healthcare.

Answer 1129

It is important to educate them because FGM is illegal in the UK and has serious health consequences.

Answer 1130

It is mandatory to report all cases of FGM in patients under 18 to the police.

Answer 1131

Social services, safeguarding, paediatrics, specialist gynaecology or FGM services, and counselling.

Answer 1132

Cases should be handled with careful consideration, possibly involving a risk assessment tool to decide on reporting to the police or social services.

Answer 1133

A referral should be made.

Answer 1134

It is a surgical procedure to correct narrowing or closure of the vaginal orifice in Type 3 FGM cases.

Answer 1135

No, performing re-infibulation is illegal.

Answer 1136

OHSS is a complication of ovarian stimulation during IVF infertility treatment, associated with the use of hCG to mature follicles during the final steps of ovarian stimulation.

Answer 1137

Human chorionic gonadotropin (hCG) is associated with the maturation of follicles in OHSS.

Answer 1138

The primary mechanism for OHSS is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles, which increases vascular permeability.

Answer 1139

VEGF increases vascular permeability, causing fluid to leak from capillaries, resulting in oedema, ascites, and hypovolaemia.

Answer 1140

OHSS is triggered by the “trigger injection” of hCG 36 hours before oocyte collection.

Answer 1141

The renin-angiotensin system is activated in OHSS, with raised renin levels correlating with the severity of the condition.

Answer 1142

Risk factors include younger age, lower BMI, raised anti-Müllerian hormone, higher antral follicle count, polycystic ovarian syndrome, and raised oestrogen levels during ovarian stimulation.

Answer 1143

They are monitored with serum oestrogen levels and ultrasound to monitor the number and size of follicles.

Answer 1144

Strategies include using the GnRH antagonist protocol, lower doses of gonadotrophins and hCG, and alternatives to hCG injections like a GnRH agonist or LH.

Answer 1145

Early OHSS presents within 7 days of the hCG injection.

Answer 1146

Late OHSS presents from 10 days onwards.

Answer 1147

Features include abdominal pain and bloating, nausea, vomiting, diarrhoea, hypotension, hypovolaemia, ascites, pleural effusions, renal failure, peritonitis, and a prothrombotic state.

Answer 1148

Severity is determined based on clinical features like abdominal pain, bloating, ascites, urine output, serum albumin levels, potassium, and haematocrit.

Answer 1149

Mild OHSS is characterized by abdominal pain and bloating.

Answer 1150

Moderate OHSS includes nausea, vomiting, and ascites seen on ultrasound.

Answer 1151

Severe OHSS features ascites, low urine output (oliguria), low serum albumin, high potassium, and raised haematocrit (>45%).

Answer 1152

Critical OHSS includes tense ascites, no urine output (anuria), thromboembolism, and acute respiratory distress syndrome (ARDS).

Answer 1153

Management is supportive, including oral fluids, monitoring urine output, low molecular weight heparin, ascitic fluid removal, and IV colloids.

Answer 1154

Mild to moderate cases are often managed as outpatients.

Answer 1155

Severe cases require hospital admission, while critical cases may require ICU admission.

Answer 1156

Raised haematocrit indicates less fluid in the intravascular space, which can be a sign of dehydration.

Answer 1157

85% of couples will conceive within a year of regular unprotected sex.

Answer 1158

1 in 7 couples will struggle to conceive naturally.

Answer 1159

Investigation and referral should start after 12 months of trying to conceive without success, or 6 months if the woman is older than 35.

Answer 1160

Sperm problems (30%), ovulation problems (25%), tubal problems (15%), uterine problems (10%), and unexplained causes (20%).

Answer 1161

40% of infertile couples have a mix of male and female causes.

Answer 1162

Take 400mcg folic acid daily, aim for a healthy BMI, avoid smoking and excessive alcohol, reduce stress, aim for intercourse every 2-3 days, and avoid timing intercourse.

Answer 1163

Timed intercourse can lead to increased stress and pressure in the relationship.

Answer 1164

Initial investigations include BMI measurement, chlamydia screening, semen analysis, female hormonal testing, and rubella immunity check.

Answer 1165

Serum LH and FSH on days 2-5, serum progesterone on day 21, anti-Mullerian hormone, thyroid function tests, and prolactin levels when indicated.

Answer 1166

High FSH suggests poor ovarian reserve.

Answer 1167

High LH may suggest polycystic ovarian syndrome (PCOS).

Answer 1168

A rise in progesterone indicates ovulation has occurred.

Answer 1169

Anti-Mullerian hormone indicates ovarian reserve, with high levels suggesting a good reserve.

Answer 1170

Ultrasound pelvis, hysterosalpingogram, and laparoscopy with dye test.

Answer 1171

A scan to assess the shape of the uterus and patency of the fallopian tubes, with both diagnostic and therapeutic benefits.

Answer 1172

There is a risk of infection, and antibiotics are often given prophylactically.

Answer 1173

Dye is injected into the uterus to see if it enters the fallopian tubes; it can also assess for endometriosis or adhesions.

Answer 1174

Options include weight loss, clomifene, letrozole, gonadotropins, ovarian drilling, and metformin.

Answer 1175

Clomifene is an anti-oestrogen that stimulates ovulation and is taken on days 2-6 of the menstrual cycle.

Answer 1176

Ovarian drilling is a laparoscopic procedure that improves hormonal balance to restore ovulation.

Answer 1177

Options include tubal cannulation, laparoscopy, and in vitro fertilisation (IVF).

Answer 1178

Surgery may be used to correct polyps, adhesions, or structural abnormalities.

Answer 1179

It is used when there is a blockage in the vas deferens and involves collecting sperm directly from the epididymis.

Answer 1180

ICSI involves injecting sperm directly into the cytoplasm of an egg, which is then implanted into the uterus.

Answer 1181

Donor insemination involves using sperm from a donor as an option for male factor infertility.

Answer 1182

They may need management of both the existing health condition and the pregnancy, typically by the obstetric team and a specialist.

Answer 1183

Untreated hypothyroidism can lead to miscarriage, anaemia, small for gestational age, and pre-eclampsia.

Answer 1184

With levothyroxine (T4), and the dose often needs to be increased by 25-50 mcg (30-50%). Treatment is adjusted based on TSH levels.

Answer 1185

ACE inhibitors (e.g., ramipril), angiotensin receptor blockers (e.g., losartan), and thiazide diuretics (e.g., indapamide).

Answer 1186

Labetalol, calcium channel blockers (e.g., nifedipine), and alpha-blockers (e.g., doxazosin).

Answer 1187

To reduce the risk of neural tube defects.

Answer 1188

Pregnancy may worsen seizure control due to stress, hormonal changes, and altered medication regimens.

Answer 1189

Levetiracetam, lamotrigine, and carbamazepine.

Answer 1190

It causes neural tube defects and developmental delays.

Answer 1191

The Prevent (valproate pregnancy prevention programme).

Answer 1192

It is an autoimmune condition that causes chronic inflammation of the synovial lining of joints, tendon sheaths, and bursa.

Answer 1193

It should be well controlled for at least three months before pregnancy.

Answer 1194

Symptoms often improve during pregnancy and may flare up after delivery.

Answer 1195

Hydroxychloroquine and sulfasalazine are considered safe.

Answer 1196

Methotrexate is contraindicated as it is teratogenic and can cause miscarriage and congenital abnormalities.

Answer 1197

Corticosteroids may be used during flare-ups.

Answer 1198

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

Answer 1199

Causes include unexplained (around 50%), pre-eclampsia, placental abruption, vasa praevia, cord prolapse or wrapped around the fetal neck, obstetric cholestasis, diabetes, thyroid disease, infections like rubella, parvovirus, and listeria, and genetic abnormalities or congenital malformations.

Answer 1200

Risk factors include fetal growth restriction, smoking, alcohol, increased maternal age, maternal obesity, twins, and sleeping on the back (as opposed to either side).

Answer 1201

A risk assessment for having a baby that is SGA or with fetal growth restriction (FGR) is performed on all pregnant women, with serial growth scans for those at risk.

Answer 1202

The three key symptoms are reduced fetal movements, abdominal pain, and vaginal bleeding.

Answer 1203

Ultrasound scan is the investigation of choice for diagnosing IUFD, used to visualize the fetal heartbeat.

Answer 1204

A repeat scan is offered to confirm the situation since passive fetal movements are possible after IUFD.

Answer 1205

Rhesus-D negative women require anti-D prophylaxis when IUFD is diagnosed, with a Kleihauer test used to determine the dose required.

Answer 1206

Vaginal birth is first-line unless there are reasons for a caesarean section. Women can choose between induction of labour or expectant management.

Answer 1207

Induction of labour involves using oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).

Answer 1208

Dopamine agonists like cabergoline are used to suppress lactation after stillbirth.

Answer 1209

Testing includes genetic testing of the fetus and placenta, postmortem examination of the fetus (including xrays), testing for maternal and fetal infection, and testing the mother for conditions like diabetes, thyroid disease, and thrombophilia.

Answer 1210

Identifying the cause of stillbirth can help reduce the risk in future pregnancies, and pregnancies are closely monitored in women with previous stillbirth.

Answer 1211

Sensitive breaking of bad news, emotional support, counselling for women, partners, and family members, support with individual wishes (such as seeing or naming the baby), and assistance with funeral arrangements and services.

Answer 1212

A perineal tear occurs when the external vaginal opening is too narrow to accommodate the baby, leading to tearing of skin and tissues as the baby’s head passes.

Answer 1213

Perineal tears can range from a graze to large tears involving the anal sphincter (third-degree) and rectal mucosa (fourth-degree).

Answer 1214

Risk factors include first births (nulliparity), large babies (over 4kg), shoulder dystocia, Asian ethnicity, occipito-posterior position, and instrumental deliveries.

Answer 1215

First-degree perineal tear involves injury limited to the frenulum of the labia minora and superficial skin.

Answer 1216

Second-degree perineal tear includes the perineal muscles but does not affect the anal sphincter.

Answer 1217

Third-degree perineal tear includes the anal sphincter but does not affect the rectal mucosa.

Answer 1218

Fourth-degree perineal tear includes the rectal mucosa.

Answer 1219

Third-degree tears can be subcategorized as: 3A (less than 50% of external anal sphincter affected), 3B (more than 50% of external anal sphincter affected), 3C (both external and internal anal sphincter affected).

Answer 1220

First-degree tears usually do not require any sutures.

Answer 1221

Tears larger than first-degree typically require sutures, while third or fourth-degree tears may need repairing in theatre.

Answer 1222

Additional measures include broad-spectrum antibiotics, laxatives, physiotherapy, and follow-up monitoring for complications.

Answer 1223

Women symptomatic after third or fourth-degree tears are offered an elective caesarean section in future pregnancies.

Answer 1224

Short-term complications include pain, infection, bleeding, and wound dehiscence or breakdown.

Answer 1225

Lasting complications can include urinary incontinence, anal incontinence, fistulas, sexual dysfunction, and psychological issues.

Answer 1226

An episiotomy is a surgical cut made in the perineum before delivery to provide additional room for the baby.

Answer 1227

An episiotomy is performed under local anaesthetic, with a cut made at around 45 degrees diagonally, avoiding damage to the anal sphincter.

Answer 1228

The cut is sutured after delivery.

Answer 1229

Perineal massage involves massaging the skin and tissues between the vagina and anus from 34 weeks onwards to reduce the risk of perineal tears.

Answer 1230

Always check the BNF, guidelines, and consult with seniors when in doubt.

Answer 1231

Examples include ibuprofen and naproxen.

Answer 1232

NSAIDs work by blocking prostaglandins, which are important for maintaining the ductus arteriosus and stimulating uterine contractions.

Answer 1233

They are avoided because they can cause premature closure of the ductus arteriosus in the fetus and delay labor.

Answer 1234

NSAIDs can cause premature closure of the ductus arteriosus and delay labor.

Answer 1235

They are used for hypertension, cardiac conditions, and migraine.

Answer 1236

Labetalol is the most frequently used beta-blocker in pregnancy.

Answer 1237

They can cause fetal growth restriction, hypoglycemia, and bradycardia in the neonate.

Answer 1238

They can cross the placenta and mainly affect the kidneys, reducing urine production, and may cause hypocalvaria.(fetal development issues)

Answer 1239

They can cause oligohydramnios, miscarriage or fetal death, hypocalvaria, renal failure in the neonate, and neonatal hypotension.

Answer 1240

It is a withdrawal syndrome in neonates caused by maternal opiate use, presenting 3-72 hours after birth with irritability, tachypnea, high temperatures, and poor feeding.

Answer 1241

It is teratogenic, crosses the placenta, and can cause fetal loss, congenital malformations, and bleeding complications.

Answer 1242

It can cause neural tube defects and developmental delays.

Answer 1243

The Prevent (valproate pregnancy prevention programme) ensures strict criteria are met to avoid pregnancy.

Answer 1244

Lithium is used as a mood stabilizer for patients with bipolar disorder, mania, and recurrent depression.

Answer 1245

It is linked with congenital cardiac abnormalities, especially Ebstein's anomaly.

Answer 1246

It is a congenital cardiac defect where the tricuspid valve is positioned lower, causing an enlarged right atrium and a smaller right ventricle.

Answer 1247

Levels should be monitored every four weeks, then weekly from 36 weeks.

Answer 1248

It enters breast milk and is toxic to the infant.

Answer 1249

Selective serotonin reuptake inhibitors (SSRIs) are most commonly used.

Answer 1250

They are linked with congenital heart defects when used in the first trimester and persistent pulmonary hypertension in the neonate with third-trimester use.

Answer 1251

There is a stronger link with congenital malformations.

Answer 1252

Neonates may experience withdrawal symptoms, usually mild and not requiring medical management.

Answer 1253

It is used to treat severe acne.

Answer 1254

It can cause miscarriage and congenital defects.

Answer 1255

Women need to use very reliable contraception before, during, and for one month after taking isotretinoin.

Answer 1256

Sepsis is a condition where the body launches a large immune response to an infection, causing systemic inflammation and affecting organ function.

Answer 1257

Severe sepsis occurs when sepsis results in organ dysfunction, such as hypoxia, oliguria, or raised lactate.

Answer 1258

Septic shock is defined as when arterial blood pressure drops, resulting in organ hypo-perfusion.

Answer 1259

Sepsis in pregnancy is a medical emergency that requires prompt recognition and management to reduce maternal and fetal morbidity and mortality.

Answer 1260

The two key causes of sepsis in pregnancy are chorioamnionitis and urinary tract infections.

Answer 1261

Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid, often occurring in later pregnancy and during labor.

Answer 1262

Chorioamnionitis can be caused by various bacteria, including gram-positive, gram-negative, and anaerobes.

Answer 1263

Patients are monitored on a MEOWS chart (maternity early obstetric warning system) to identify signs of sepsis.

Answer 1264

Non-specific signs include fever, tachycardia, raised respiratory rate, reduced oxygen saturations, low blood pressure, altered consciousness, reduced urine output, raised white blood cells, and evidence of fetal compromise on a CTG.

Answer 1265

Additional signs include abdominal pain, uterine tenderness, and vaginal discharge.

Answer 1266

Signs include dysuria, urinary frequency, suprapubic pain or discomfort, renal angle pain, and vomiting (with pyelonephritis).

Answer 1267

Tests include full blood count, U&Es, LFTs, CRP, clotting studies, blood cultures, and blood gas analysis.

Answer 1268

Additional investigations include urine dipstick and culture, high vaginal swab, throat swab, sputum culture, wound swab, and lumbar puncture.

Answer 1269

Senior obstetricians and midwives should be involved early in the care of these women.

Answer 1270

Early recognition and management, including continuous maternal and fetal monitoring, is essential.

Answer 1271

Emergency caesarean section may be indicated when there is fetal distress, guided by a senior obstetrician.

Answer 1272

General anesthesia is usually required, as spinal anesthesia is avoided.

Answer 1273

Local guidelines for antibiotic choices should be followed, with heavy-hitting antibiotics needed to cover gram-positive, gram-negative, and anaerobes.

Answer 1274

Examples include piperacillin and tazobactam plus gentamicin, or amoxicillin, clindamycin, and gentamicin.

Answer 1275

The septic six includes three tests: blood lactate level, blood cultures, and urine output, along with three treatments: oxygen to maintain saturations, empirical broad-spectrum antibiotics, and IV fluids.

Answer 1276

Most women receive routine midwife-led care.

Answer 1277

They may be transferred to the postnatal ward for a short period.

Answer 1278

Analgesia as required Help establishing breast or bottle-feeding Venous thromboembolism risk assessment Monitoring for postpartum haemorrhage Monitoring for sepsis Monitoring blood pressure (after pre-eclampsia) Monitoring recovery after a caesarean or perineal tear Full blood count check (after bleeding, caesarean or antenatal anaemia) Anti-D for rhesus D negative women (depending on the baby’s blood group) Routine baby check

Answer 1279

Help is provided to establish breast or bottle-feeding.

Answer 1280

Venous thromboembolism risk assessment is conducted.

Answer 1281

Monitoring for postpartum haemorrhage and sepsis is performed.

Answer 1282

Blood pressure is monitored.

Answer 1283

Recovery is monitored.

Answer 1284

It is checked after bleeding, caesarean, or antenatal anaemia.

Answer 1285

Anti-D may be administered depending on the baby's blood group.

Answer 1286

A routine baby check is conducted.

Answer 1287

General wellbeing Mood and depression Bleeding and menstruation Urinary incontinence and pelvic floor exercises Scar healing after episiotomy or caesarean Contraception Breastfeeding Vaccines (e.g. MMR)

Answer 1288

To assess the mother’s recovery and wellbeing, usually done alongside the newborn baby check.

Answer 1289

Topics include general wellbeing, mood, bleeding, scar healing, contraception, breastfeeding, fasting blood glucose, and blood pressure.

Answer 1290

Lochia is the vaginal bleeding that occurs after birth, consisting of blood, endometrial tissue, and mucus.

Answer 1291

Initially, lochia is dark red.

Answer 1292

Tampons should be avoided due to the risk of infection.

Answer 1293

Bleeding should settle within six weeks.

Answer 1294

Breastfeeding releases oxytocin, which causes the uterus to contract, possibly leading to more bleeding.

Answer 1295

They may not have regular periods for six months or longer, unless they stop breastfeeding. **Lactational Amenorrhoea**

Answer 1296

Bottle-feeding women may begin having periods from three weeks onwards.

Answer 1297

Fertility is considered to return after 21 days postpartum.

Answer 1298

After 21 days, women are considered fertile and need contraception.

Answer 1299

Lactational amenorrhea is over 98% effective for up to 6 months after birth.

Answer 1300

The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth. The combined contraceptive pill should be avoided in breastfeeding until 6 weeks after childbirth A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).

Answer 1301

It refers to pregnancy-related tissue remaining in the uterus after delivery, miscarriage, or termination.

Answer 1302

Placenta accreta is a significant risk factor.

Answer 1303

Yes, it may be present without any suggestive symptoms.

Answer 1304

* Vaginal bleeding that gets heavier or does not improve with time * Abnormal vaginal discharge * Lower abdominal or pelvic pain * Fever (if infection occurs)

Answer 1305

Abnormal vaginal discharge.

Answer 1306

Lower abdominal or pelvic pain.

Answer 1307

Fever may occur if infection develops.

Answer 1308

Ultrasound is the investigation of choice.

Answer 1309

Surgical removal is the standard management.

Answer 1310

Evacuation of retained products of conception.

Answer 1311

The cervix is gradually widened, and retained products are removed using vacuum aspiration and curettage.

Answer 1312

General anaesthetic is used for the procedure.

Answer 1313

It may be referred to as "dilatation and curettage."

Answer 1314

Endometritis and Asherman's syndrome.

Answer 1315

It is a condition where adhesions form within the uterus after curettage.

Answer 1316

It can damage the basal layer of the endometrium, causing abnormal healing and scar tissue formation.

Answer 1317

They can lead to infertility.

Answer 1318

They can form binding the uterine walls together or within the endocervix, sealing it shut.

Answer 1319

A rare complication of postpartum hemorrhage leading to avascular necrosis of the pituitary gland.

Answer 1320

A drop in circulating blood volume results in low blood pressure and reduced perfusion of the pituitary gland, causing ischaemia and cell death.

Answer 1321

Only the anterior pituitary gland is affected.

Answer 1322

No, hormones produced by the posterior pituitary are spared.

Answer 1323

The anterior pituitary receives blood from the hypothalamo-hypophyseal portal system, which is susceptible to rapid drops in blood pressure.

Answer 1324

The posterior pituitary has a better blood supply from various arteries and is not susceptible to ischaemia during blood pressure drops.

Answer 1325

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

Answer 1326

Oxytocin and antidiuretic hormone (ADH).

Answer 1327

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

Answer 1328

Management is under the guidance of a specialist endocrinologist and involves hormone replacement therapy.

Answer 1329

Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause) Hydrocortisone for adrenal insufficiency Levothyroxine for hypothyroidism Growth hormone

Answer 1330

A condition with changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease.

Answer 1331

Thyroid peroxidase antibodies.

Answer 1332

1. Thyrotoxicosis (first three months) 2. Hypothyroid (3-6 months) 3. Return to normal thyroid function (within one year)

Answer 1333

6-8 weeks after delivery for women with suggestive symptoms.

Answer 1334

Symptomatic control, such as propranolol (a non-selective beta-blocker). Levothyroxine.

Answer 1335

Annual monitoring is required, even after the condition resolves, to identify long-term hypothyroidism.

Answer 1336

They are monitored, and treatment is altered or stopped as the condition changes

Answer 1337

Semen analysis is used to examine the quantity and quality of semen and sperm and assess for male factor infertility.

Answer 1338

* Abstain from ejaculation for at least 3 days and at most 7 days * Avoid hot baths, sauna and tight underwear during the lead up to providing a sample * Attempt to catch the full sample * Deliver the sample to the lab within 1 hour of ejaculation * Keep the sample warm (e.g. in underwear) before delivery

Answer 1339

* Hot baths * Tight underwear * Smoking * Alcohol * Raised BMI * Caffeine

Answer 1340

A repeat sample is indicated after 3 months for borderline results or earlier (2-4 weeks) with very abnormal results.

Answer 1341

* Semen volume (more than 1.5ml) * Semen pH (greater than 7.2) * Concentration of sperm (more than 15 million per ml) * Total number of sperm (more than 39 million per sample) * Motility of sperm (more than 40% of sperm are mobile) * Vitality of sperm (more than 58% of sperm are active) * Percentage of normal sperm (more than 4%)

Answer 1342

Polyspermia (or polyzoospermia) refers to a high number of sperm in the semen sample (more than 250 million per ml).

Answer 1343

Normospermia (or normozoospermia) refers to normal characteristics of the sperm in the semen sample.

Answer 1344

Oligospermia (or oligozoospermia) is a reduced number of sperm in the semen sample, classified as: * Mild oligospermia (10 to 15 million / ml) * Moderate oligospermia (5 to 10 million / ml) * Severe oligospermia (less than 5 million / ml)

Answer 1345

Cryptozoospermia refers to very few sperm in the semen sample (less than 1 million/ml).

Answer 1346

Azoospermia is the absence of sperm in the semen.

Answer 1347

**Hypogonadotrophic Hypogonadism:** * Pathology of the pituitary gland or hypothalamus * Suppression due to stress, chronic conditions or hyperprolactinaemia * Kallman syndrome

Answer 1348

Testicular causes include: * Mumps * Undescended testes * Trauma * Radiotherapy * Chemotherapy * Cancer

Answer 1349

Post-testicular causes include: * Damage to the testicle or vas deferens from trauma, surgery or cancer * Ejaculatory duct obstruction * Retrograde ejaculation * Scarring from epididymitis, for example, caused by chlamydia * Absence of the vas deferens (may be associated with cystic fibrosis) * Young’s syndrome (obstructive azoospermia, bronchiectasis and rhinosinusitis)

Answer 1350

The initial steps include taking a history, conducting a physical examination, repeating the sample, and performing an ultrasound of the testes.

Answer 1351

Patients with abnormal semen results are referred to a urologist for further investigations.

Answer 1352

* Hormonal analysis with LH, FSH and testosterone levels * Genetic testing * Further imaging, such as transrectal ultrasound or MRI * Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction * Testicular biopsy

Answer 1353

Management options depend on the underlying cause and may include: * Surgical sperm retrieval where there is obstruction * Surgical correction of an obstruction in the vas deferens * Intra-uterine insemination involves separating high-quality sperm, then injecting them into the uterus * Intracytoplasmic sperm injection (ICSI) involves injecting sperm directly into the cytoplasm of an egg * Donor insemination involves sperm from a donor

Answer 1354

IVF involves fertilizing an egg with sperm in a lab, then injecting the resulting embryo into the uterus. It is a complicated and expensive process with strict funding criteria that vary by area. Couples are limited to a set number of cycles funded by the NHS.

Answer 1355

Each IVF attempt has a success rate of approximately 25-30% at producing a live birth.

Answer 1356

IUI is a more straightforward process that involves injecting sperm directly into the uterus, avoiding intercourse. It is used in cases such as donor sperm for same-sex couples, HIV (to avoid unprotected sex), and practical issues with vaginal sex.

Answer 1357

A cycle of IVF involves a single episode of ovarian stimulation and collection of oocytes (eggs). Multiple embryos may be produced and transferred separately during one cycle. Any unused embryos can be frozen for later use.

Answer 1358

* Suppressing the natural menstrual cycle * Ovarian stimulation * Oocyte collection * Insemination / intracytoplasmic sperm injection (ICSI) * Embryo culture * Embryo transfer *

Answer 1359

The natural menstrual cycle is suppressed using GnRH agonists or antagonists to prevent ovulation and ensure proper ovarian response. The choice of protocol depends on individual factors.

Answer 1360

The GnRH agonist protocol involves an injection of a GnRH agonist (e.g., goserelin) around 7 days before the expected menstrual period. It initially stimulates the pituitary gland, causing an increase in FSH and LH, but later suppresses GnRH production, preventing ovulation.

Answer 1361

The GnRH antagonist protocol involves daily subcutaneous injections of a GnRH antagonist (e.g., cetrorelix) starting from day 5-6 of ovarian stimulation. This prevents the release of LH and avoids ovulation.

Answer 1362

Ovarian stimulation uses medications (usually FSH) to promote the development of multiple follicles. This starts on day 2 of the menstrual cycle and continues for 10-14 days, monitored by transvaginal ultrasound. An hCG injection is given 36 hours before egg collection to trigger final maturation.

Answer 1363

Oocytes are collected under transvaginal ultrasound guidance, where a needle is inserted through the vaginal wall into the ovaries to aspirate fluid containing mature oocytes. This procedure is typically done under sedation.

Answer 1364

The male provides a semen sample around the time of oocyte collection, or frozen sperm may be used. The sperm is mixed with the egg in a culture medium to facilitate fertilization.

Answer 1365

ICSI is a technique used primarily for male factor infertility, where a single high-quality sperm is injected directly into the cytoplasm of the egg after oocyte collection.

Answer 1366

Fertilized eggs are incubated and observed for 2?5 days to monitor their development, typically until they reach the blastocyst stage around day 5.

Answer 1367

After 2?5 days, the highest quality embryos are selected, and a catheter is inserted under ultrasound guidance through the cervix into the uterus, injecting a single embryo. Generally, only one embryo is transferred, but two may be transferred for women over 35. Any remaining embryos can be frozen.

Answer 1368

A pregnancy test is performed around day 16 after egg collection. A positive result indicates successful implantation, while a negative result means implantation has failed.

Answer 1369

Progesterone is used from oocyte collection until 8-10 weeks of gestation, typically as vaginal suppositories, to mimic the natural progesterone produced during a typical pregnancy. After 8-10 weeks, the placenta takes over production, and the suppositories are stopped.

Answer 1370

* Failure * Multiple pregnancy * Ectopic pregnancy * Ovarian hyperstimulation syndrome

Answer 1371

* Pain * Bleeding * Pelvic infection * Damage to the bladder or bowel

Answer 1372

**Internal Os Open:** * Incomplete or Inevitable * If there is still a full fetus then it is inevitable, if there are only retained products then it is incomplete **Internal Os Closed:** * Threatened, Missed, Completed * Completed then symptoms have occurred and there is no fetus or tissue within the uterus * Threatened, vaginal bleeding and pain and the fetus still has a heart beat * Missed is when the fetus is dead, the mother may not have experienced symptoms and it requires evacuation.

Answer 1373

* Risk of Alopecia areata - General chemotherapy * Risk of Hot flushes and VTE - Tamoxifen * Risk of cardiotoxicity - Trastuzumab * Risk of peripheral neuropathy - Vincristine * Risk of Osteoporosis - Aromatase inhibitors