Obs and Gynae Flashcards
A 75 year old IDDM has recently been on a course of antibiotics for a chest infection. She has been to her GP complaining of a thick white smelly vaginal discharge
a. Candida Albicans
b. Retained Tampon
c. Granulation Tissue
d. Cervical Carcinoma
e. Vesicovaginal Fistula
f. Bacterial Vaginosis
g. Uterine Carcinoma
h. Ring Pessary
i. Chlamydia Trachomatis
j. Post-menopausal Atrophic Changes
Candida Albicans - yeast like fungus, most common cause of vaginal infection
Candidiasis is more common in diabetics, the obese, pregnancy, when antibiotics have been given or when immunity has been compromised. It tends to present with irritation and soreness of the vulva and anus (inflamed and red), and a ‘cottage cheese’ discharge. Superficial dyspareunia and dysuria may occur.
Diagnosis is established by culture and topical imidazole (e.g. clomtrimazole - Canesten) or vaginal pessaries (imidazole) or oral fluconazole may be required.
A 45 year old has been referred to the hospital with a history of intermittent offensive brown vaginal discharge and post-coital bleeding. She has not attended for cervical smear test for the past 10 years
a. Candida Albicans
b. Retained Tampon
c. Granulation Tissue
d. Cervical Carcinoma
e. Vesicovaginal Fistula
f. Bacterial Vaginosis
g. Uterine Carcinoma
h. Ring Pessary
i. Chlamydia Trachomatis
j. Post-menopausal Atrophic Changes
Cervical Carcinoma - CIN is the pervasive stage therefore the risk factors are the same: smoking, COCP, immunosuppression, HPV is found in all cervical cancers. Most common when screening has been inadequate, and immunosuppression (HIV, steroids) accelerates the process of invasion from CIN.
90% are squamous, also adenocarcinoma.
May present with PCB or IMB, offensive discharge
Screening: 3 yearly 25-49; 5 yearly 50-64, colposcopy if abnormal - LBC
A 55 year old has had an abdominal hysterectomy 2 months ago. She has started noticing clear watery vaginal discharge
a. Candida Albicans
b. Retained Tampon
c. Granulation Tissue
d. Cervical Carcinoma
e. Vesicovaginal Fistula
f. Bacterial Vaginosis
g. Uterine Carcinoma
h. Ring Pessary
i. Chlamydia Trachomatis
j. Post-menopausal Atrophic Changes
Vesicovaginal Fistula: an abnormal connection between the urinary tract and vagina. The most common are vesicovaginal and urethrovaginal fistulae. In the developing world they are common as a result of obstructed labour. In the West they are rare and usually due to surgery, radiotherapy or malignancy. Investigation is with a CT urogram or cystoscopy.
A 22 year old gives a history of grey coloured vaginal discharge, which smells unpleasantly strong but does not itch. It seemed to be associated with the use of barrier contraception
a. Candida Albicans
b. Retained Tampon
c. Granulation Tissue
d. Cervical Carcinoma
e. Vesicovaginal Fistula
f. Bacterial Vaginosis
g. Uterine Carcinoma
h. Ring Pessary
i. Chlamydia Trachomatis
j. Post-menopausal Atrophic Changes
Bacterial Vaginosis (Gardnerella or anaerobic vaginosis) - where normal lactobacilli are overgrown by a mixed flora including anaerobes, Gardnerella and Mycoplasma hominis. A grey, white discharge is present, but the vagina is not red or itchy. There is a characteristic fishy odour from amines released by bacterial proteolysis. Diagnosis is established by a raised vaginal pH, the typical discharge, a positive 'whiff' test (KOH added to secretions) and the presence of 'Clue cells' (epithelial cells studded with Gram variable coccobacilli) on microscopy. Treatment involves metronidazole or clindamycin cream. These bacteria can cause secondary infection in PID and there is also an association with pre-term labour and miscarriage - screening and treatment reduces the risk of preterm birth if used before 20 weeks in woman with a history of preterm birth. The normal vagina is lined by squamous epithelium, richly colonised by bacterial flora, predominantly Lactobacillus, and has an acidic pH (
A 26 year old who has been IDDM since the age of 10 is failing to progress in labour
a. Cervical fibroid
b. Persistant OP position
c. Previous Pelvic fracture
d. Fetal Macrosomia
e. Irregular Contractions
f. Breech Position
g. OT position
h. Rickets
i. Transverse Lie
j. Face Presentation
Fetal Macrosomia
Raised metal blood glucose levels induce metal hyperinsulinaemia, causing metal fat deposition and excessive growth (macrosomia)
Fetal Complications of DM:
- Congenital abnormalities: particularly neural tube and cardiac defects are 3-4X more common in established diabetics and are related to peri-conceptual glucose control.
- Preterm Labour: natural or induced occurs in 10% of established diabetics, and metal lung maturity at any given gestation is less than non-diabetic pregnancies.
- Birthweight: increased - fetal pancreatic islet cell hyperplasia leads to hyperinsulinaemia and fat deposition. This leads to increased urine output and polyhydramnios is common
- Dystocia and birth trauma are more common
- Fetal compromise, fetal distress in labour and sudden fetal death are more common (particularly in 3rd Trimester poor glucose control)
Delivery should be at 39 weeks, during labour glucose levels are maintained with a sliding scale of insulin and dextrose infusion
The neonate commonly develops hypoglycaemia because it has become accustomed to hyperglycaemia and so has high insulin levels
Risk factors for GDM: previous GDM, previous foetus >4.5kg, previous unexplained still birth, first degree relative with diabetes, BMI>30, racial origin, polyhydramnios, persistent glycosuria.
Shoulder dystocia: when additional manoeuvres are required after normal downward traction has failed to deliver the shoulders after the head has delivered. Excessive traction on the neck damages the brachial plexus causing Erb’s Palsy (waiter’s tip) which is permanent in about 50% of cases. Mean time from delivery of the head to delivery of the shoulders should be less than 5 minutes.
Risk Factors: large baby (>4kg), previous shoulder dystocia, increased maternal BMI, labour induction, low height, maternal diabetes, instrumental delivery
HELPERR: Call for help, evaluate for episiotomy, legs in McRoberts position, Suprapubic pressure, enter for manoeuvres (Woodscrew, reverse woodscrew and Rubin 2), Remove the posterior arm, Repeat/Roll onto all fours
Last resorts include symphisiotomy (after lateral replacement of the urethra with a metal catheter, and the Zavanelli manoeuvre
A primiparous patient with a term pregnancy and cephalic presentation. Over the past 4 hours she has remained at 4cm dilatation on vaginal examination. She is not yet requiring analgesia
a. Cervical fibroid
b. Persistant OP position
c. Previous Pelvic fracture
d. Fetal Macrosomia
e. Irregular Contractions
f. Breech Position
g. OT position
h. Rickets
i. Transverse Lie
j. Face Presentation
Irregular Contractions - she is a primp, and not requiring analgesia yet so is not yet experiencing proper contractions.
Once labour is established, the uterus contracts for 45-60 seconds about every 2-3 minutes. This pulls the cervix up (effacement - normally a tubular structure, the cervix is drawn up into the lower segment and becomes flat) and causes dilatation, aided by the pressure of the head as the uterus pushes the head down into the pelvis, this is commonly accompanied by a ‘show’ or pink/white mucus plug from the cervix, and/or rupture of the membranes, causing release of liquor. Poor uterine activity is a common feature of the nulliparous woman and in induced labours.
Involuntary contractions of uterine smooth muscle occur throughout the third trimester and are often felt as Braxton Hicks contractions. Labour is diagnosed when painful, regular contractions lead to effacement and dilatation of the cervix
Movements of the fetal head:
- Engagement in OT
- Descent and Flexion
- Rotation 90 degrees to OA
- Descent
- Extension to deliver
- Restitution and delivery of shoulders
1st Stage: Diagnosis of labour until cervix is fully dilated (10cm) - the descent, flexion and internal rotation occur to a varying degree. Membranes normally rupture prior to or during this stage. Latent phase is where the cervix dilates slowly (3cm) and may take several hours. The active phase follows, averaging 1cm/hour in nulliparous women, 2cm/hour in multiparous women. The active first stage should not normally last longer than 12 hours.
2nd Stage: From full dilation to delivery - descent, flexion and rotation are all complete and followed by extension as the head delivers. Passive stage is from full dilatation to when head reaches the pelvic floor and the women experiences a desire to push. The active stage is when the mother is pushing with contractions, the speed of delivery should be
A 35 year old Nigerian woman who is in spontaneous labour. She has a history of having a myomectomy for previous menorrhagia and is progressing slowly in labour
a. Cervical fibroid
b. Persistant OP position
c. Previous Pelvic fracture
d. Fetal Macrosomia
e. Irregular Contractions
f. Breech Position
g. OT position
h. Rickets
i. Transverse Lie
j. Face Presentation
Cervical Fibroid - Leiomyomata, benign tumours of the myometrium, common near menopause, in Afro-Caribean women and those with a FH. Less common in parous women, those who have taken COCP or injectable contraceptives.
In pregnancy fibroids can cause premature labour, malpresentation, transverse lie, obstructed labour and postpartum haemorrhage.
Red degeneration is common in pregnancy and can cause severe pain. Fibroids should not be removed at C-section as bleeding can be heavy. Pedunculate fibroids may tort postpartum
A 40 year old grand multiparous woman who has attended labour ward at term with a 3 hour history of regular contractions and no PV loss. On abdominal palpation there is nothing in the maternal pelvis
a. Cervical fibroid
b. Persistant OP position
c. Previous Pelvic fracture
d. Fetal Macrosomia
e. Irregular Contractions
f. Breech Position
g. OT position
h. Rickets
i. Transverse Lie
j. Face Presentation
Transverse Lie: lie refers to the relationship between the foetus and the long axis of the uterus. if longitudinal the head and buttocks are palpable at each end (therefore presentation is cephalic or breech). If transverse lie, the foetus is lying across the uterus and the pelvis will be empty. If oblique the head or buttocks are palpable in one of the iliac fossa. Abnormal lie occurs in 1 in 200 births and is more common in early pregnancy (normal if before term).
Therefore preterm labour is more commonly complicated by an abnormal lie than labour at full term.
Polyhydramnios (more room to turn) or high parity (more lax uterus) are the most common causes, frequently resulting in an unstable lie.
Conditions that prevent turning e.g. fetal and uterine abnormalities and twin pregnancies may cause persistent transverse lie, as well as many conditions that prevent engagement, such as placenta praevia and pelvic tumours or uterine deformities. Unstable lie in nulliparous women is rare.
No management is required in transverse or unstable lie before 37 weeks unless the woman is in labour. After 37 weeks the woman is usually admitted to hospital in case the membranes rupture and USS to rule out possible causes (placenta praevia, polyhydramnios)
A 28 year old multiparous patient has had a long latent phase of labour and is not progressing at more than 1cm per hour
a. Cervical fibroid
b. Persistant OP position
c. Previous Pelvic fracture
d. Fetal Macrosomia
e. Irregular Contractions
f. Breech Position
g. OT position
h. Rickets
i. Transverse Lie
j. Face Presentation
Persistant OP position - can be associated with labour abnormalities and maternal and neonatal complications (eg, birth trauma, neonatal acidosis). Commonly prolongs 1st and 2nd stage of labour leading to an increase rate of interventions, such as artificial rupture of membranes, oxytocin augmentation, and operative delivery (vaginal, abdominal), and the mothers experience more delivery-related complications, such as anal sphincter injury
Risk factors: Nulliparity, Maternal age greater than 35 years, Obesity, African-American race, Previous OP delivery, Decreased pelvic outlet capacity, Gestational age ≥41 weeks, Birthweight ≥4000g, Prolonged first and/or second stage of labor
Fifteen to 20 percent of term cephalic fetuses are in occiput posterior (OP) position before labor and approximately 5 percent are OP at delivery. Most fetuses rotate to occiput anterior (OA) position, some maintain a persistent OP position, and others rotate from OA to OP position.
There is no effective method to facilitate rotation from occiput posterior to occiput anterior before labour.
Foetus with Down’s Syndrome
a. Maternal ALT 60iu/L
b. Maternal HbA1c = 15%
c. Fetal Hb 3g/dl, positive Coombs Test
d. Parvovirus IgM positive, IgG negative
e. Maternal Rubella IgG positive
f. 24 hour urinary protein 5.1g/L
g. Fetal Karyotype 47XY
h. Fetal Karyotype 45XO
i. 24 hour urinary protein 0.2g/L
Fetal karyotype 47XY - trisomy 21
((Trisomy 18 - Edwards, Trisomy 13 - Patau’s, 47XXY - Klinefelters, 45XO - Turner’s)
Down syndrome is the most common chromosome abnormality among live births and the most frequent form of intellectual disability caused by a demonstrable chromosomal abnormality. The syndrome is characterized by moderate to severe learning disability (average IQ approximately 40) in combination with short stature, characteristic facial features, heart defects (40 to 50 percent of cases), intestinal malformations (10 percent of cases), problems with vision and hearing (50 percent of cases), an increased frequency of infection, and other health problems.
The first trimester combined test: nuchal translucency (NT), maternal age, gestational age (by crown-rump length) combined with the serum markers pregnancy-associated plasma protein-A (PAPP-A) and free or total beta human chorionic gonadotropin (beta-hCG). Screening can be performed at 9 to 13 weeks of gestation with free beta-hCG or at 11 to 13 weeks with total beta-hCG.
The full integrated test consists of ultrasound measurement of nuchal translucency at 10 to 13 weeks, PAPP-A obtained at 10 to 13 weeks, and alpha fetoprotein (AFP), unconjugated estriol (uE3), hCG, and inhibin A obtained at 15 to 18 weeks. At detection rates of 85 or 95 percent, the full integrated test has the lowest false positive rate among Down syndrome screening tests, leading to the lowest rate of procedure-related losses per woman screened.
The quadruple test is the best available screening test for women who present for prenatal care in the second trimester. At 15 to 18 weeks of gestation (but as late as 22 weeks), the serum markers AFP, uE3, hCG, and inhibin A are measured in maternal serum.
Patients who screen positive are offered fetal karyotype determination for definitive diagnosis.
In the first trimester, karyotype is obtained by CVS - biopsy of the trophoblast by passing a fine gauge needle through the abdominal wall or cervix into the placenta (after 11weeks) - i.e. before amniocentesis and allows earlier identification of an abnormal foetus, at a time when abortion could be performed under GA. Miscarriage rate is higher than amniocentesis (because it is performed earlier, when spontaneous miscarriage is more likely to happen)
In the second trimester, amniocentesis is performed to obtain fetal cells for chromosomal analysis. Amniocentesis involves removing amniotic fluid using a fine gauge needle under USS guidance, it is safest performed from 15 weeks and can also be used to diagnose other chromosomal abnormalities and infections (CMV, toxoplasmosis) and inherited disorders (sickle cell, thalassaemia and cystic fibrosis). 1% miscarry after amniocentesis.
FISH and PCR are used to diagnose common abnormalities within 48 hours
Pre-eclampsia
a. Maternal ALT 60iu/L
b. Maternal HbA1c = 15%
c. Fetal Hb 3g/dl, positive Coombs Test
d. Parvovirus IgM positive, IgG negative
e. Maternal Rubella IgG positive
f. 24 hour urinary protein 5.1g/L
g. Fetal Karyotype 47XY
h. Fetal Karyotype 45XO
i. 24 hour urinary protein 0.2g/L
24 hour urinary protein 5.1g/L
Pre-eclampsia is a multi-system disease that usually manifests as hypertension (BP >140/90) and proteinuria (>0.3g/24hours, 3+ on dipstick, PCR>30mg/nmol). Increased vascular resistance accounts for the hypertension, increased vascular permeability for proteinuria, reduced placental blood flow of IUGR and reduced cerebral perfusion for eclampsia.
Pre-eclampsia affects 6% of nulliparous women, and there is a 15% recurrence rate.
In normal pregnancy, trophoblastic invasion of the spiral arteries leads to vasodilatation of vessel walls. In pre-eclampsia this invasion is incomplete, and the impaired maternofetal trophoblast interaction may be caused by altered immune responses - the result is decreased utero-placental blood flow. The ischaemic placenta induces wide spread endothelial cell damage, causing vasoconstriction, increased vascular permeability and clotting dysfunction.
Predisposing factors: nulliparity, previous/FH pre-eclampsia, lon inter-pregnancy interval, obesity, extremes of maternal age (particularly >40years), disorders characterised by microvascular disease (chronic hypertension, chronic renal disease, sickle cell disease, diabetes, AI disease, APL syndrome), pregnancies with a larger placenta (twins, fetal hydrops, molar pregnancy)
Intra-uterine Fetal Infection
a. Maternal ALT 60iu/L
b. Maternal HbA1c = 15%
c. Fetal Hb 3g/dl, positive Coombs Test
d. Parvovirus IgM positive, IgG negative
e. Maternal Rubella IgG positive
f. 24 hour urinary protein 5.1g/L
g. Fetal Karyotype 47XY
h. Fetal Karyotype 45XO
i. 24 hour urinary protein 0.2g/L
Parvovirus IgM positive, IgG negative
B19 virus infects 0.25% of pregnant women. A ‘slapped cheek’ appearance is typical (erythema infectiosum) but may have arthralgia or be asymptomatic.
Neonatal/fetal effects: virus suppresses fetal erythropoesis causing anaemia, varying degrees of thrombocytopenia also occur. Fetal death occurs in 10% of pregnancies, usually with infection before 20 weeks gestation
Fetal anaemia is detectable on USS, initially as increased blood flow velocity in the fetal MCA and subsequently as oedema (fetal hydrops) from cardiac failure. Spontaneous resolution of anaemia and hydrops occurs in about 50%
Management: infected mother’s are regularly scanned to look for anaemia, where hydrops is detected in utero transfusion is given if severe.
Obstetric Cholestasis
a. Maternal ALT 60iu/L
b. Maternal HbA1c = 15%
c. Fetal Hb 3g/dl, positive Coombs Test
d. Parvovirus IgM positive, IgG negative
e. Maternal Rubella IgG positive
f. 24 hour urinary protein 5.1g/L
g. Fetal Karyotype 47XY
h. Fetal Karyotype 45XO
i. 24 hour urinary protein 0.2g/L
Maternal ALT 60iu/L Characterised by itching of palms of hands and soles of feet, without a skin rash, but with abnormal LFTs, due to abnormal sensitivity to the cholestatic effects of oestrogens. It is familial and tends to re-occur (50%). It is associated with a increased risk of sudden stillbirth (around 1% - likely due to toxic effects of bile salts, possibly precipitating fetal arrhythmia) and preterm delivery. Serum bile acids are raised. There is an increased tendency to haemorrhage so vitamin K 10mg/day is given from 36 weeks. Ursodeoxycholic acid (UDCA) relieves itching and may reduce obstetric risks. USS and CTG are poor at predicting adverse outcomes.
Rhesus Isoimmunisation
a. Maternal ALT 60iu/L
b. Maternal HbA1c = 15%
c. Fetal Hb 3g/dl, positive Coombs Test
d. Parvovirus IgM positive, IgG negative
e. Maternal Rubella IgG positive
f. 24 hour urinary protein 5.1g/L
g. Fetal Karyotype 47XY
h. Fetal Karyotype 45XO
i. 24 hour urinary protein 0.2g/L
Fetal Hb 3g/dl, positive Coombs Test
Occurs when the mother mounts an immune response against fetal red cells that enter her circulation, the resulting antibodies then cross the placenta and cause fetal red blood cell destruction.
The most significant is Rhesus D gene, D is dominant to d. Rhesus negative = dd, and their immune system will recognise the D antigen as foreign if they are exposed to it. Small amounts of blood cross the placenta and enter the maternal circulation in normal pregnancy, and particularly at sensitising events (delivery, TOP, miscarriage or threatened miscarriage after 12 weeks, ERPOC, Ectopic pregnancy, ECV, Invasive uterine procedure - CVS, amniocentesis, vaginal bleeding). If the foetus is D rhesus positive and the mother is D rhesus negative, the mother will mount an immune response (sensitization) creating anti-D antibodies. Immunity is permanent and if the mother’s immune system is again exposed the the antigen (e.g. subsequent pregnancy), a large number of anti-bodies are rapidly created, these can cross the placenta and bind to the fetal rbcs which are then destroyed in the fetal reticuloendothelial system. This can cause haemolytic anaemia and ultimately death (rhesus haemolytic disease). A similar immune response can be mounted against other red blood cell antigens - the most important antibodies are anti-c and anti-kell (a non-rhesus antibody), particularly after blood transfusion
Anti-D is given to all Rhesus negative mothers to ‘mop up’ fetal red cells that cross the placenta by binding to their antigens, preventing recognition by the mothers immune system - 1500IU at 28 weeks or within 72 hours of a sensitising event, although benefit can still be gained within 10 days. Postnatally the neonate’s blood group is checked and if rhesus positive, anti-D is given to the mother within 72 hours of delivery. A Kleihauer test, to assess the number of fetal cells in the maternal circulation is also performed within 2 hours of birth to detect occasional larger fetomaternal haemorrhages that may require larger doses of anti-D to mop up (unnecessary if neonate is rhesus negative). Also check FBC and bilirubin of neonate.
Manifestations of rhesus disease: Haemolysis! If mild will cause neonatal jaundice, or there may be sufficient to cause neonatal anaemia (haemolytic disease of the newborn). More severe disease causes in utero anaemia and, as this worsens cardiac failure, ascites and oedema (hydrous) and fetal death follows. Rhesus disease usually worsens with successive pregnancies as maternal antibody production increases.
Treatment of fetal anaemia: in utero transfusion
15% of caucasian women are rhesus negative
Maternal Diabetes
a. Maternal ALT 60iu/L
b. Maternal HbA1c = 15%
c. Fetal Hb 3g/dl, positive Coombs Test
d. Parvovirus IgM positive, IgG negative
e. Maternal Rubella IgG positive
f. 24 hour urinary protein 5.1g/L
g. Fetal Karyotype 47XY
h. Fetal Karyotype 45XO
i. 24 hour urinary protein 0.2g/L
Maternal HbA1c = 15%
Glucose tolerance decreases in pregnancy due to altered carbohydrate metabolism and antagonistic effects of human placental lactogen, progesterone and cortisol.
NICE: fasting glucose level >7.0mmol/L or >7.8mmol/L 2 hours after a 75g glucose load (GTT) - screening at 28 weeks or at 18 weeks if history of GDM. Aim for HbA1c
55 year old woman with a history of loss of urine on coughing and bending. Urodynamic studies show no evidence of detrusor instability
a. Multiple Sclerosis
b. Urinary Tract Infection
c. Genuine Stress Incontinence
d. Idiopathic Detrusor Overactivity
e. Sensory Urgency
f. Fibroids
g. Fistula
h. Bladder Tumour
i. Prolapsed Disc
j. Detrusor Overactivity secondary to menopause
Genuine stress Incontinence (a symptom 50% incontinence) - Involuntarily leaking urine on effort of exertion, or sneezing or coughing (COPD), and when confirmed on urodynamic studies it is called urodynamic stress incontinence (USI). It commonly arises as a result of urethral sphincter weakness.
On Cystometry (urodynamic studies):
- No increase in detrusor press with filling
- No detrusor contraction with coughing
- Urine flow with cough
Aetiology: pregnancy and vaginal delivery, particularly prolonged labour and forceps delivery, obesity and age (post menopausal). Prolapse commonly co-exists but is not always related. Previous hysterectomy may predispose to USI.
When there an increase in intra-abdominal pressure (“stress”) the bladder is compressed and its pressure rises. Normally the bladder neck is as equally compressed so that the pressure difference is unchanged - urethral pressure = bladder pressure. However if the bladder neck has slipped below the pelvic floor (due to weak supports), and the pelvic floor is unable to compensate, the bladder pressure is greater than the urethral pressure and incontinence results.
Faecal incontinence may also co-exist (also due to childbirth). Examination with a Sims speculum often reveals a cystocoele or urethrocoele.
Management:
- Lifestyle (obesity, COPD, asthma, fluid intake)
- Conservative: strengthen pelvic floor 3 months supervised physiotherapy (PFMT), at least 8 contractions, 3 times per day. Vaginal cones.
- Medical: Duloxetine (moderate to severe USI) serotonin and NA reuptake inhibitor (SNRI) that enhances urethral striated sphincter activity via a centrally mediated pathway. Causes a dose-dependent decrease in frequency of incontinence episodes. Nausea is a common side effect (25%), as well as dyspepsia, dry mouth, dizziness, insomnia and drowsiness
- Surgical: When conservative measures have failed and QoL is compromised. TVT is first line, with cure rates up to 90% - polyprolene tape in a U shape under the mid urethra via a small vaginal anterior wall incision - minimally invasive. Colposuspension if fails.
A 26 year old presents with a 5 day history of worsening urinary frequency, nocturia and dysuria. Urinary testing indicates proteinuria
a. Multiple Sclerosis
b. Urinary Tract Infection
c. Genuine Stress Incontinence
d. Idiopathic Detrusor Overactivity
e. Sensory Urgency
f. Fibroids
g. Fistula
h. Bladder Tumour
i. Prolapsed Disc
j. Detrusor Overactivity secondary to menopause
Urinary Tract Infection - asymptomatic bacteriuria affects 5% of women, but increases to 20% in pregnancy.
Pyelonephritis affects 1-2% of women and is more likely to occur in pregnancy, causing loin pain, rigors, vomiting and a fever - requires IV antibiotics. E.coli accounts for 75% and is often resistant to amoxicillin.
A 60 year old presents with a 6 week history of urgency and nocturia and urge incontinence
a. Multiple Sclerosis
b. Urinary Tract Infection
c. Genuine Stress Incontinence
d. Idiopathic Detrusor Overactivity
e. Sensory Urgency
f. Fibroids
g. Fistula
h. Bladder Tumour
i. Prolapsed Disc
j. Detrusor Overactivity secondary to menopause
Idiopathic Detrusor Overactivity - a urodynamic diagnosis characterized by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked.
Overactive Bladder = urgency, with/without urge incontinence, usually with frequency or nocturia, in the absence of proven infection. 35% female incontinence.
Most commonly idiopathic, may occur following operations for USI as a result of neck of bladder obstruction, or as a result of underlying neuropathy (MS, spinal cord injury).
Detrusor contraction is normally felt as urgency, and leaking occurs if bladder pressure overcomes the urethral pressure (may be exacerbated by increased intra-abdominal pressure - and so can be confused with stress incontinence)
History of childhood enuresis is common, examination often normal.
Small frequent volumes of urine, high caffeine intake, cystometry demonstrates contractions on filling or provocation.
Conservative: decreased fluid intake, caffeine reduction, review diuretic/antipsychotic use. Bladder training
Medical: anti-cholinergics (anti-muscarinics) suppress detrusor activity - they block the muscarinic receptors that mediate detrusor smooth muscle contractions, relaxing the detrusor muscles
Botulinum toxin: blocks neuromuscular transmission, causing affected muscle to become weak. It is injected cytoscopically under local or general anaesthetic into the detrusor muscle into 10-30 different locations, sparing the trigonum. The most common complication is voiding dysfunction and urinary retention, which usually resolves as the effects of the treatment decline
A 30 year old woman from Somalia, 6 weeks post part, arrived in the UK 2 weeks ago, gives a history of feeling continually damp down below
a. Multiple Sclerosis
b. Urinary Tract Infection
c. Genuine Stress Incontinence
d. Idiopathic Detrusor Overactivity
e. Sensory Urgency
f. Fibroids
g. Fistula
h. Bladder Tumour
i. Prolapsed Disc
j. Detrusor Overactivity secondary to menopause
Fistula - abnormal connections between the urinary tract and other organs. The most common are vesicovaginal and urethrovaginal fistulae. In the developing world they are common as a result of obstructed labour; whereas in the West they are rare and due to surgery, radiotherapy or malignancy. Investigation is with CT urogram or cystoscopy. Whilst small fistulae may resolve spontaneously, surgery is usually required.
A 53 year old woman presents with a 6 week history of hot flushes, sweats and vaginal dryness and urinary frequency
a. Multiple Sclerosis
b. Urinary Tract Infection
c. Genuine Stress Incontinence
d. Idiopathic Detrusor Overactivity
e. Sensory Urgency
f. Fibroids
g. Fistula
h. Bladder Tumour
i. Prolapsed Disc
j. Detrusor Overactivity secondary to menopause
Detrusor Overactivity secondary to menopause
Many women develop bladder filling symptoms after the menopause. Oestrogen treatment in postmenopausal women improves symptoms of vaginal atrophy, such as vaginal dryness and irritation. Vaginal oestrogen administration reduces symptoms of urgency, urge incontinence, frequency and nocturia
A 29 year old needle-phobic who is 8 weeks post partum and breast feeding would like reliable contraception
a. COCP
b. POP
c. Mirena
d. Laparoscopic Sterilisation
e. Diaphragm
f. Condoms
g. Copper IUD
h. COCP + condoms
i. Depot
j. Hysteroscopic Sterilisation
Mirena - Levonorgestrel-releasing IUD: LNg20 IUD initially releases 20 mcg of levonorgestrel daily, declining to 10 to 14 mcg per day after five years. Like the copper IUD, the stem contains barium sulfate so it can be detected by x-ray, and it does not contain latex.
The progestin effect is primarily local. The plasma concentration of levonorgestrel is far lower than the endometrial concentration and varies among patients. It is 100 to 200 pg/mL within the first few weeks of use, with a gradual decline over time and wide individual variation. This level is much less than that associated with progestogen-only pills (1500 to 2000 pg/mL), but high enough to cause systemic side effects in some users, and to suppress ovulation. Serum estradiol levels are not affected.
With perfect use, the probability of pregnancy in the first year is 0.1 percent; comparable to that with sterilization procedures. he LNg20 IUD is approved for up to five years of use.
Advantages: highly effective, dramatic reduction in menstrual blood loss, protective against PID
Disadvantages: persistent spotting/bleeding in first month of use, progestogenic side effects (acne, breast tenderness), no protection against STIs.
Mode of action: all IUDs cause an inflammatory response in the endometrium which prevent implantation. Whereas copper bearing IUDs work primarily by a toxic effect on sperm which prevents fertilisation, the Mirena prevents pregnancy primarily by a local hormonal effect on the cervical mucus and endometrium.
Contraindications: previous PID or ectopic pregnancy, known malformations of the uterus.
Although IUDs increase the risk of PID in the first few weeks after insertion, the long term risk is similar to that of women not using any form of contraception
A 40 year old smoker who has completed her family and wants definitive contraception. She has a history of COPD and PID
a. COCP
b. POP
c. Mirena
d. Laparoscopic Sterilisation
e. Diaphragm
f. Condoms
g. Copper IUD
h. COCP + condoms
i. Depot
j. Hysteroscopic Sterilisation
Hysteroscopic Sterilisation
For an older woman wanting definitive contraception with a complete family sterilisation is the answer. COPD means intubation will be difficult in this patient and previous PID means there may be adhesions and scar tissue, so a hysteroscopic procedure is preferral.
Sterilisation involves the mechanical blockage of both Fallopian tubes to prevent sperm reaching and fertilising the oocyte.
A thorough discussion of the risks, benefits, and alternatives to permanent sterilization should take place and informed consent obtained.
Surgical sterilization is safe (complication rate less than 1 percent) and effective (overall 10-year probability of pregnancy 18.5 per 1000 procedures). Pregnancies occurring after tubal ligation are more likely to be ectopic.
The procedure should be considered permanent. Reversal may be successful, but requires major surgery, is costly, and may not be covered by medical insurance. Regret after sterilization may be related to young age, conflicted feelings at the time of surgery, or a subsequent change in marital status.
Laparoscopic sterilization techniques and sterilization by minilaparotomy have comparable safety and efficacy. The choice of method should be based upon the clinical situation and patient and physician preference.
Women who have undergone tubal ligation are less likely to develop ovarian cancer and pelvic inflammatory disease, but may have a slightly higher rate of future hysterectomy.
A 19 year old student who had Chlamydia in the past is attending for her second termination and wants to discuss contraception. She does not have a regular partner
a. COCP
b. POP
c. Mirena
d. Laparoscopic Sterilisation
e. Diaphragm
f. Condoms
g. Copper IUD
h. COCP + condoms
i. Depot
j. Hysteroscopic Sterilisation
COCP and condoms - at risk of STIs Oral contraceptives (OCs) have several mechanisms of action, including suppression of hypothalamic gonadotropin-releasing hormone (GnRH) and pituitary gonadotropin secretion - FSH and LH. The most important mechanism for providing contraception is inhibition of the midcycle LH surge, so that ovulation does not occur. Combination OCs are potent in this regard, but progestin-only pills are not. Peripheral effects include making the endometrium atrophic and hostile to an implanting embryo and altering cervial mucus to prevent sperm ascending into the uterine cavity. Absolute Contraindications: Circulatory disease (IHD, CVA, significant HTN, thrombosis, any acquired or inherited pro-thrombotic tendency, any significant RF for CVD), acute or severe liver disease, oestrogen dependent neoplasms (particularly breast cancer), focal migraine Relative Contraindications: generalized migraine, long term immobilization, irregular vaginal bleeding (until a diagnosis has been made), less severe CVD RFs (DM, obesity, smoking) Oestrogens induce a pro-thrombotic tendency. The higher the dose of oestrogen, the greater the risk VTE - normal population 5 per 100,000; 30 per 100,000 COC, 60 per 100,000 for pregnant women. Drug interactions: enzyme inducing drugs (e.g. anti-epileptic medications) may decrease the efficacy, and some broad spectrum anti-biotics can alter intestinal absorption of COC and reduce its efficacy. COC can also be used to treat heavy, painful periods, will improve PMS and reduce the risk of PID. COC offers longterm protection against both endometrial and ovarian cancers and can be used as a treatment for acne
A 30 year old who is 4 weeks post partum having previously fallen pregnant whilst on the COCP and is currently breast feeding. She does not intend to fall pregnant for the next 2 years. She has a history of submucosal fibroids distorting the uterine cavity
a. COCP
b. POP
c. Mirena
d. Laparoscopic Sterilisation
e. Diaphragm
f. Condoms
g. Copper IUD
h. COCP + condoms
i. Depot
j. Hysteroscopic Sterilisation
Depot - obviously patient is unreliable at taking medication if she has fallen pregnant whilst on the COCP! If she has a distorted uterine cavity then she isn’t a candidate for an IUD. There is no indication that she has finished her family and so sterilisation isn’t appropriate.
Depot medroxyprogesterone acetate (DMPA) is an injectable, progestin-only contraceptive that provides highly effective, relatively long-acting (three months), reversible contraception.
DMPA is a good contraceptive option for the following groups of women:
- Women who do not want to take a contraceptive pill daily
- Women who have a contraindication to, or wish to avoid, an estrogen-containing contraceptive
- Women who would like to eliminate regular menses
- Adolescents who may not consistently remember to use types of contraception that require frequent administration
- Institutionalized adolescents and women who have difficulty using other forms of contraception
- Wheelchair-bound adolescents and women
DMPA primarily acts by inhibition of gonadotropin secretion, thereby inhibiting follicular maturation and ovulation. The inhibition of ovarian function results in a hypoestrogenic state, which inhibits endometrial proliferation and renders the endometrium less receptive to implantation. Progestins also cause changes in cervical mucus (thicker and less permeable to sperm) and tubal motility (reduced ciliary action) that are unfavorable to sperm migration, thus inhibiting fertilization.
The ideal time to initiate DMPA is within seven days of the onset of menses. This approach increases the certainty that the patient is not pregnant at the time of injection and prevents ovulation during the first month of use, so that back-up contraception is unnecessary. Most women have pharmacologically active drug levels and relatively impermeable cervical mucus within 24 hours after injection.
Fertility is not fully re-established until 18 months after the last injection.
Side effects: Irregular bleeding/spotting, amenorrhoea, weight changes, headache, mood changes.
A 27 year old in a stable relationship with a history of DVT. She has a septate uterus. She has a regular partner and would like to get pregnant in 1 year.
a. COCP
b. POP
c. Mirena
d. Laparoscopic Sterilisation
e. Diaphragm
f. Condoms
g. Copper IUD
h. COCP + condoms
i. Depot
j. Hysteroscopic Sterilisation
POP - not suitable for oestrogen only contraceptives, not suitable for IUD, regular partner, depot would affect fertility for 18 months following stoppage. Can come off POP straight away and start getting pregnant.
Progestin-only contraceptive pills are an option for women who need to avoid estrogen but want to take a contraceptive pill. The “minipill” has a dose of progestin that is close to the threshold of contraceptive efficacy (norethindrone 0.35 mg); therefore, these pills should be taken at the same time each day and are taken every day without a pill-free interval. Variation of only a few hours in administration can reduce contraceptive effectiveness so women should be prepared to use a back-up method not only if one pill is missed, but also if there is a greater than three-hour delay in taking the pill.
POPs work by thickening cervical mucus, suppressing ovulation, and thinning the endometrium. In contrast to estrogen-progestin oral contraceptive pills and desogestrel POPs, ovulation is not consistently suppressed with norethindrone POPs. Therefore, the effects of norethindrone POPs on cervical mucus and endometrium are the critical factors in prevention of conception. Within hours of administration, all POPs reduce the volume of cervical mucus and increase its viscosity, which prevents sperm from passing through the cervical canal and endometrial cavity. These changes persist for 20 hours.
A 26 year old with 2 previous terminations of pregnancy who presents 1 day post unprotected sex with her long term boyfriend
a. COCP
b. POP
c. Mirena
d. Laparoscopic Sterilisation
e. Diaphragm
f. Condoms
g. Copper IUD
h. COCP + condoms
i. Depot
j. Hysteroscopic Sterilisation
Copper IUD - has use as an emergency contraceptive if used within 72 hours, previous TOP indicate she’s unreliable at medication
Primarily act by preventing fertilisation, with the copper being toxic to sperm, and they also act to block implantation.
Absolute Contraindications to IUD: endometrial/cervical cancer, undiagnosed vaginal bleeding, active/recent pelvic infection, pregnancy
Complications of IUD:
Pain/cervical shock (due to increased vagal tone) can complicate insertion.
The device may be expelled (usually in 1st month).
Perforation of the uterine wall may occur at insertion, or the device may migrate through the wall afterwards (threads will disappear).
If pregnancy occurs it is more likely to be an ectopic.
A 72 year old who went through the menopause at the age of 49 is referred to the gynaecology clinic with superficial dyspareunia
a. Fibroids
b. PID
c. Bacterial Vaginosis
d. Atrophic Vaginitis
e. Vaginismus
f. Ectropion
g. Endometriosis
h. Thrush
i. Retroverted Uterus
j. Sexual Abuse
Atrophic Vaginitis: this is due to oestrogen deficiency and is common before the menarche, during lactation and after the menopause. Treatment is with oestrogen cream or systemic HRT.
May also have a clear discharge, with redness and raised pH, but no itching or odour.
A 28 year old is referred to the gynaecology clinic with dyspareunia. She cannot tolerate a speculum or VE
a. Fibroids
b. PID
c. Bacterial Vaginosis
d. Atrophic Vaginitis
e. Vaginismus
f. Ectropion
g. Endometriosis
h. Thrush
i. Retroverted Uterus
j. Sexual Abuse
Vaginismus - involuntary contraction of the muscles of the pelvic floor surrounding the vaginal orifice, which prevents insertion of an object (penis, digit, instrument). It is considered related to spasm of the perineal and/or levator muscles. Primary vaginismus may be related to psychological issues, while secondary vaginismus usually represents a conditioned response to pain from a physical cause or new relationship issues.
It is important to look for a physical condition, such as infection or inflammatory dermatitis, which may have triggered the pain. If a known cause is identified, both the cause, as well as the pain of pelvic floor/vaginismus, require treatment.
A 28 year old is referred to the gynaecology clinic with superficial dyspareunia. On special examination you note thick white discharge and she mentions she also has vulval priuritis
a. Fibroids
b. PID
c. Bacterial Vaginosis
d. Atrophic Vaginitis
e. Vaginismus
f. Ectropion
g. Endometriosis
h. Thrush
i. Retroverted Uterus
j. Sexual Abuse
Thrush: thick white ‘cottage cheese’ discharge with vulval irritation, redness and itching, normal pH and odour, superficial dyspareunia and dysuria may occur.
Infection with candida albicans, a yeast like fungus, is a common cause of vaginal infection (up to 20% of women), often without symptoms.
Risk Factors: pregnancy, diabetes, use of antibiotics, immunocompromised patients, HIV, transplant patients
Diagnosis is established by culture and treatment is with topical imidazoles (clotrimazole - Canesten) or oral fluconazole.
A 35 year old with 2 previous terminations presents with a 1 year history of deep dyspareunia. She does not have a regular partner and has a Mirena for contraception and to manage her menorrhagia
a. Fibroids
b. PID
c. Bacterial Vaginosis
d. Atrophic Vaginitis
e. Vaginismus
f. Ectropion
g. Endometriosis
h. Thrush
i. Retroverted Uterus
j. Sexual Abuse
PID - Pelvic inflammatory disease or salpingitis typically describes sexually transmitted pelvic infections, and endometritis (infection confined to the cavity of the uterus) often co-exists. It is an ascending infection of bacteria in the vagina and cervix - sexual factors account for 80%
Hallmark presentation: bilateral lower abdominal pain, deep dyspareunia, usually with abnormal vaginal bleeding or discharge; but many have no symptoms and present later with sub fertility or menstrual problems; cervical excitation, adnexal tenderness, fever, raised WBC and CRP
Risk factors: younger, poorer, sexually active nulliparous women, multiple partners, not using barrier contraception
COCP and Mirena is partly protective
Pelvic infection almost never occurs in the presence of a viable pregnancy
Spread of previously asymptomatic STI’s to the pelvis is usually spontaneous, but can occur following uterine instrumentation (TOP, ERPC, laparoscopy and dye test, IUDs) and/or complications of childbirth and miscarriage - in these instances infection is often due to introduction of non-sexually transmitted bacteria. Descending infection from local organs (appendix) may also occur.
Infection is frequently polymicrobial, with chlamydia (often asymptomatic, symptoms if present are often due to secondary infection) and gonococcus (acute presentation) the principal sexually transmitted culprits
Fitz-Hugh-Curtis syndrome: perihepatitis, RUQ pain due to adhesions, easily visible at laparoscopy between the liver and anterior abdominal wall
A 28 year old is referred to the gynaecology clinic with deep dyspareunia and cyclic pelvic pain
a. Fibroids
b. PID
c. Bacterial Vaginosis
d. Atrophic Vaginitis
e. Vaginismus
f. Ectropion
g. Endometriosis
h. Thrush
i. Retroverted Uterus
j. Sexual Abuse
Endometriosis - presence of endometrial glands and stroma at extrauterine sites. These ectopic endometrial implants are usually located in the pelvis, but can occur nearly anywhere in the body.
Endometriosis is a common, benign, chronic, estrogen-dependent disorder. It can be associated with many distressing and debilitating symptoms, such as pelvic pain, severe dysmenorrhea, dyspareunia and infertility, or it may be asymptomatic, and incidentally discovered at laparoscopy or exploratory surgery.
Retrograde menstruation may play a pathophysiologic role in the development of endometriosis. If so, anatomic alterations of the pelvis that increase tubal reflux of menstrual endometrium should increase a woman’s chance of developing endometriosis.
The most common sites of endometriosis, in decreasing order of frequency, are the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligaments
A 29 year old patient, who is breast feeding presents 3 days after caesarean section, with offensive lochia and lower abdominal pain
a. Small Bowel Obstruction
b. Retained products of conception
c. Pancreatitis
d. Cholecystitis
e. Ruptured Pelvic Ulcer
f. Constipation
g. Coagulopathy
h. Endometritis
i. Perineal Breakdown
j. Small Bowel Injury
k. Paralytic Ileus
l. Menstruation
Endometritis - infection confined to the cavity of the uterus alone. If untreated, spread of the infection into the pelvis is common. It is often the result of either instrumentation or a complication of pregnancy. It is common after Csection and after miscarriage and TOP, particularly if some products of conception are retained. Infecting organisms include chlamydia and gonococus, although the organisms of bacterial vaginosis and E.coli, staphylococci and even clostridia may be implicated.
Presents with persistent and often heavy vaginal bleeding, often accompanied with pain, the uterus is tender and the cervical os is commonly open. A fever may initially be absent but septicaemia may ensue. Investigations include vaginal and cervical swabs, FBC.
Broad spectrum antibiotics are given, ERPC is then performed if symptoms do not subside or there is evidence of ‘products’ in the uterus at examination.
Lochia can be normal to some degree as long as it is watery and not odorous
A 29 year old, who is not breast feeding, presents 6 weeks after a vaginal delivery with PV bleeding
a. Small Bowel Obstruction
b. Retained products of conception
c. Pancreatitis
d. Cholecystitis
e. Ruptured Pelvic Ulcer
f. Constipation
g. Coagulopathy
h. Endometritis
i. Perineal Breakdown
j. Small Bowel Injury
k. Paralytic Ileus
l. Menstruation
Menstruation - not breast feeding therefore no lactational amenorrhoea
A 29 year old presents 7 days after a caesarean section with acute onset abdominal pain, anorexia and nausea. She was discharged on paracetamol and diclofenac. On examination her pulse is 110bpm and her abdomen is rigid
a. Small Bowel Obstruction
b. Retained products of conception
c. Pancreatitis
d. Cholecystitis
e. Ruptured Pelvic Ulcer
f. Constipation
g. Coagulopathy
h. Endometritis
i. Perineal Breakdown
j. Small Bowel Injury
k. Paralytic Ileus
l. Menstruation
Ruptured Pelvic Ulcer - she is showing signs of peritonitis and shock.
Diclofenac is a huge risk factor for peptic ulcers and is no longer prescribed unless with omeprazole. Unlikely to be small bowel injury from Csection as presentation is 7 days later.
A 29 year old presents 4 days after vaginal delivery with heavy vaginal bleeding and passing large clots like ‘pieces of liver’ PV
a. Small Bowel Obstruction
b. Retained products of conception
c. Pancreatitis
d. Cholecystitis
e. Ruptured Pelvic Ulcer
f. Constipation
g. Coagulopathy
h. Endometritis
i. Perineal Breakdown
j. Small Bowel Injury
k. Paralytic Ileus
l. Menstruation
Retained Products of Conception - placental and/or fetal tissue that remains in the uterus after a spontaneous pregnancy loss (miscarriage), planned pregnancy termination, or preterm/term delivery. The presence of RPOC after a spontaneous pregnancy loss distinguishes an incomplete from a complete miscarriage. Symptoms include uterine bleeding, pelvic pain, fever, and/or uterine tenderness. These clinical findings are nonspecific; moreover, as it is normal to have some postabortal bleeding and discomfort.
A reasonable approach is to assume that bleeding is probably abnormal if it is heavy (ie, has the potential to result in anemia [passage of large clots or flow that is significantly greater than menses, or not diminishing over time]) or prolonged (ie, lasting longer than three weeks).
Menses typically resume by six weeks post miscarriage or pregnancy termination. If the patient fails to menstruate by this time, viable trophoblastic tissue may be present.
In stable afebrile patients with persistent abnormal bleeding over three or more weeks and inconclusive findings on ultrasound examination, serially monitoring hCG levels may identify a plateau or rise, which suggests residual, viable trophoblast related to ectopic pregnancy, ongoing intrauterine pregnancy, or gestational trophoblastic disease.
Patients who are hemodynamically unstable due to excessive uterine bleeding after miscarriage or pregnancy termination should be stabilized with fluid and blood products, as needed, and undergo urgent surgical intervention
Patients with uncomplicated endometritis (low grade fever, mild uterine tenderness, empty uterus on ultrasound examination) are managed with a trial of broad spectrum antibiotics, with coverage of anaerobes (eg, cefotetan [2 g intravenously] plus doxycycline [100 mg intravenously or orally] every 12 hours).
A 29 year old presents 3 days post emergency caesarean section with abdominal distension, nausea and vomiting and constipation. She has not passed flatus or opened her bowels since the operation.
a. Small Bowel Obstruction
b. Retained products of conception
c. Pancreatitis
d. Cholecystitis
e. Ruptured Pelvic Ulcer
f. Constipation
g. Coagulopathy
h. Endometritis
i. Perineal Breakdown
j. Small Bowel Injury
k. Paralytic Ileus
l. Menstruation
Paralytic Ileus - very common compared to obstruction. Bowel injury would lead to pain and would present faster than 3 days.
Postoperative paralytic ileus refers to obstipation and intolerance of oral intake due to nonmechanical factors that disrupt the normal coordinated propulsive motor activity of the gastrointestinal tract following abdominal or nonabdominal surgery. There is general consensus that some degree of postoperative ileus is a normal obligatory and physiologic response to abdominal surgery. Physiologic postoperative ileus is generally a benign condition that resolves without serious sequelae. However, when ileus is prolonged, it leads to patient discomfort, dissatisfaction, and prolonged hospitalization, and must be differentiated from mechanical bowel obstruction or other postoperative complications.
A 35 year old Afro-Caribbean patient with a history of chronic hypertension presents at 35 weeks gestation with epigastric/RUQ pain, headache and flashing lights. Her BP is 170/120, urine, 3+ protein. She is tender over the right upper quadrant. Her Hb is 8.9g/dL, MCV 82, platelets 90x109/L
a. Iron Deficiency
b. Folate Deficiency
c. Vitamin B12 Deficiency
d. Thalassaemia
e. Sickle Cell
f. Leukaemia
g. Alcohol Abuse
h. Haemolysis
i. Aplastic Anaemia
j. Upper GI bleed
k. Anaemia of Chronic Disease
Haemolysis - HELLP syndrome
Haemolysis (dark urine, raised LDH, anaemia), Elevated liver enzymes (epigastric pain, liver failure, abnormal clotting), Low platelets (normally self limiting - microangiopathic blood smear)
Predisposing factors: nulliparity, previous/FH eclampsia, long inter-pregnancy interval, obesity, extremes of maternal age, disorders characterized by microvascular disease (diabetes, HTN, sickle cell disease, AI disease, chronic renal disease, anti-phospholipid syndrome) and pregnancies witha larger placenta (twins, fetal hydrops, molar pregnancy).
HELLP is a complication of pre-eclampsia when it causes liver and coagulation problems. DIC, liver failure and liver rupture may also occur. The woman typically experience epigastric pain, and it may occur postnatally in a previously well woman. Treatment is supportive and includes magnesium sulfate prophylaxis against eclampsia.
A 44 year old patient who has 2 children all of which are under foster care is a late booker and presents with her social worker for a booking appointment at 20 weeks. Her Hb is 8.9g/dL, MCV 100, platelets 101x109/L (pre-pregnancy Hb 9.2g/dL, MCV 104, platelets 108x109/L)
a. Iron Deficiency
b. Folate Deficiency
c. Vitamin B12 Deficiency
d. Thalassaemia
e. Sickle Cell
f. Leukaemia
g. Alcohol Abuse
h. Haemolysis
i. Aplastic Anaemia
j. Upper GI bleed
k. Anaemia of Chronic Disease
Alcohol Abuse - suggestion of alcoholism by social issues, macrocytic anaemia with low platelets
Lower limit of normal Hb in pregnancy is 11.0g/dL (due to haemodilution that isn’t adequately compensated for by the increased red cell mass)
If iron deficient women don’t tend to be symptomatic until Hb
A 33 year old Turkish patient with a booking Hb of 9.2g/dL, MCV 70, platelets 180x109/L
a. Iron Deficiency
b. Folate Deficiency
c. Vitamin B12 Deficiency
d. Thalassaemia
e. Sickle Cell
f. Leukaemia
g. Alcohol Abuse
h. Haemolysis
i. Aplastic Anaemia
j. Upper GI bleed
k. Anaemia of Chronic Disease
Thalassaemia - patient is Turkish, with a microcytic anaemia - likely Beta thalasaemia.
Beta thalassaemia results from impaired B chain synthesis, occurs largely in people of South East Asian and Mediterranean origin. Homozygous individuals are usually affected by iron overload and so pregnancy is unusual, but folic acid without oral iron is needed. Heterozygous women have a chronic anaemia, which can worsen during pregnancy.
Alpha thalassaemia results from impaired synthesis of the A chain in the Hb molecule - 4 genes are responsible for a chain synthesis. Those with 4 a chain deletions die in utero (hydrops fetalis), heterozygotes have 1 or 2 gene deletions and are usually anaemic, requiring folic acid and iron supplementation. South East Asian origin.
Prenatal diagnosis using CVS by mutation analyis from PCR amplified DNA must be offered if the partner is heterozygous for either the B or A form.
A 39 year old Nigerian patient with a booking Hb of 8.9g/dL, MCV 80, platelets 180x109/L. Blood film reveals target cells
a. Iron Deficiency
b. Folate Deficiency
c. Vitamin B12 Deficiency
d. Thalassaemia
e. Sickle Cell
f. Leukaemia
g. Alcohol Abuse
h. Haemolysis
i. Aplastic Anaemia
j. Upper GI bleed
k. Anaemia of Chronic Disease
Sickle Cell - recessive disorder due to abnormal B chain formation in the Hb molecule, resulting in an abnormal Hb molecule of 2 alpha chains and 2 sickle chains. It tends tro be found in people of Afro-Caribean origin.
A further mutation of the Beta chain (C) is also found. Haemoglobin electrophoresis is now performed in the UK on all pregnant women. Partners of heterozygotes are also tested and if positive prenatal diagnosis for homozygousity is offered.
Homozygotes only have HbS and HbC and many have been affected by crises of chest pain and a fever, and chronic haemolytic anaemia their entire life. In pregnancy maternal complications include more frequent crises, pre-eclampsia, thrombosis and infections. Fetal complications are miscarriage, IUGR, preterm labour and death. Regular exchange blood transfusions, screening for infection and maintenance of hydration are needed. Folic acid supplements are given and iron is avoided because of overload.
Heterozygotes have 35% HbS and usually have no problems, but may develop crises under extreme conditions.
A 23 year old with SLE with a booking Hb of 9.2g/dL. MCV 90, platelets 320x109/L. Her haematinics are normal.
a. Iron Deficiency
b. Folate Deficiency
c. Vitamin B12 Deficiency
d. Thalassaemia
e. Sickle Cell
f. Leukaemia
g. Alcohol Abuse
h. Haemolysis
i. Aplastic Anaemia
j. Upper GI bleed
k. Anaemia of Chronic Disease
Anaemia of Chronic Disease: is suspected in a patient with a chronic infectious, inflammatory, or malignant condition who has a mild to moderate normocytic, normochromic anemia.
Diagnosis:
●Low serum iron
●Normal to low serum transferrin (total iron binding capacity)
●Normal to increased serum ferritin
●Elevated erythrocyte sedimentation rate and/or C-reactive protein
Thought to primarily reflect a reduction in RBC production by the bone marrow. There may also be a small component due to mild shortening of RBC survival. A number of factors are thought to contribute to this hypo proliferative state:
- Abnormal iron metabolism with reduced absorption of iron from the gastrointestinal tract and trapping of iron in macrophages. This results in reduced plasma iron levels (hypoferremia), making iron unavailable for new hemoglobin synthesis
- Inability to increase erythropoiesis in response to anemia. Serum erythropoietin (EPO) levels are somewhat elevated in ACD, but there is virtually no increase in erythropoiesis. The decreased bone marrow responsiveness to erythropoietin is mediated by inflammatory cytokines, especially IL-1 beta and TNF-alpha
First-line therapy is directed at the underlying cause of the ACD.
A 35 year old who is 30 weeks pregnant presents with heavy PV bleeding. She has had 5 previous C-sections and has just transferred care from Nigeria. She remembers that there was an abnormality on her anomaly scan, for which she required a follow up scan at 32 weeks
a. Placental Abruption
b. Intracranial Haemorrhage
c. Placenta Praevia
d. Pulmonary Embolism
e. Sepsis
f. PPH
g. Hepatic Rupture
h. Eclampsia
i. Tension Pneumothorax
j. Scar Dehiscence
k. Amniotic Fluid Embolism
Placenta Praevia - should be suspected in any woman beyond 20 weeks of gestation who presents with painless vaginal bleeding. For women who have not had a second trimester ultrasound examination, antepartum bleeding after 20 weeks of gestation should prompt sonographic determination of placental location before digital vaginal examination is performed because palpation of the placenta can cause severe hemorrhage.
Previous placenta previa, previous cesarean deliveries, infertility treatment, advanced maternal age, previous intrauterine surgery and multiple gestation are major risk factors for placenta previa.
The diagnosis of placenta previa is based upon identification of placental tissue covering or proximate to the internal cervical os on transvaginal ultrasound examination
The management goals in women with asymptomatic placenta previa are to:
●Determine whether the previa resolves with increasing gestational age
●Reduce the risk of bleeding
●Reduce the risk of preterm birth
A 35 year old with chronic hypertension is sent to triage by the community midwife with a BP of 220/130, flashing lights and a frontal headache. As she arrives in triage she falls to the ground and starts shaking.
a. Placental Abruption
b. Intracranial Haemorrhage
c. Placenta Praevia
d. Pulmonary Embolism
e. Sepsis
f. PPH
g. Hepatic Rupture
h. Eclampsia
i. Tension Pneumothorax
j. Scar Dehiscence
k. Amniotic Fluid Embolism
Eclampsia - refers to the occurrence of one or more generalized convulsions and/or coma in the setting of preeclampsia and in the absence of other neurologic conditions. An eclamptic seizure occurs in 0.5 percent of women with nonsevere preeclampsia and 2 percent of women with severe disease. Just over one-third of cases occur at term, developing intrapartum or within 48 hours of delivery.
An eclamptic seizure is typically tonic-clonic and lasts 60 to 75 seconds. Symptoms that may occur before the seizure include persistent frontal or occipital headache, blurred vision, photophobia, right upper quadrant or epigastric pain, and altered mental status. In up to one-third of cases, there is no proteinuria or blood pressure is less than 140/90 mmHg prior to the seizure. The goals of management are to stabilize the mother, prevent recurrent convulsions, treat severe hypertension to prevent cerebral hemorrhage, and initiate delivery of the fetus.
Give a loading dose of magnesium sulfate 6 g intravenously over 15 to 20 minutes, followed by 2 g/hour administered as a continuous intravenous infusion.
In women with severe hypertension, administer hydralazine or labetalol to achieve a systolic pressure of 140 to 155 mmHg and diastolic pressure of 90 to 105 mmHg.
Delivery is the only curative treatment, but this does not necessarily preclude induction of labor. Cesarean delivery is a reasonable option for women less than 32 weeks of gestation who have an unfavorable cervix. After a seizure, we suggest waiting 15 to 20 minutes and until the mother and fetus show signs of recovery (control of convulsions; mother oriented to name, time, and place; fetal heart rate reassuring) before proceeding to surgery
A 35 year old is sent to triage 3 days post emergency caesarean section with chest pain, shortness of breath and a pulse of 120bpm. As she arrives in triage she collapses to the ground.
a. Placental Abruption
b. Intracranial Haemorrhage
c. Placenta Praevia
d. Pulmonary Embolism
e. Sepsis
f. PPH
g. Hepatic Rupture
h. Eclampsia
i. Tension Pneumothorax
j. Scar Dehiscence
k. Amniotic Fluid Embolism
Pulmonary Embolism - the leading cause of mortality during pregnancy and the puerperium (postpartum period), responsible for 20 to 30 percent of maternal deaths.
PE has a wide variety of presenting features, ranging from no symptoms to shock or sudden death. This nonspecific presentation is magnified during pregnancy due to an overlap with symptoms due to the normal physiologic changes of pregnancy. PE should be suspected in patients with any one or combination of the following symptoms: acute-onset dyspnea, pleuritic pain, and hemoptysis.
All patients with suspected PE should have a chest radiograph:
- For pregnant patients with suspected PE, in whom the chest radiograph is normal, we suggest V/Q scan rather than CTPA.
- For pregnant patients with suspected PE, in whom the chest radiograph is abnormal, we suggest CTPA rather than V/Q scan.
Tx: subcut LMWH (enoxaparin)
A 35 year old is sent to maternity triage 3 days post emergency caesarean section for prolonged rupture of membranes and failure to progress. She is feeling unwell, with anorexia and feeling feverish. Her HR is 120bpm, BP 90/50 and temperature 38.7. She collapses as the nurse is connecting the IV fluids
a. Placental Abruption
b. Intracranial Haemorrhage
c. Placenta Praevia
d. Pulmonary Embolism
e. Sepsis
f. PPH
g. Hepatic Rupture
h. Eclampsia
i. Tension Pneumothorax
j. Scar Dehiscence
k. Amniotic Fluid Embolism
Sepsis - fever, tachycardia, low BP, feeling unwell
Prolonged rupture of membranes is a risk factor for infection.
Premature rupture of the membranes (PROM) refers to rupture of the fetal membranes prior to the onset of labor or regular uterine contractions. It occurs in 8 percent of pregnancies at term.
The initial evaluation of all pregnancies in which PROM is suspected should include confirmation of membrane rupture, confirmation of gestational age, and assessment of fetal well-being. The need for group B streptococcal chemoprophylaxis should also be determined.
A 35 year old primp admitted with an APH has just had a difficult forceps delivery followed by a shoulder dystocia and a 3rd degree tear. She is awaiting transfer to theatre to repair the tear when she starts bleeding heavily and collapses. Her pulse is 130bpm, BP 90/50, temperature 37.6
a. Placental Abruption
b. Intracranial Haemorrhage
c. Placenta Praevia
d. Pulmonary Embolism
e. Sepsis
f. PPH
g. Hepatic Rupture
h. Eclampsia
i. Tension Pneumothorax
j. Scar Dehiscence
k. Amniotic Fluid Embolism
Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or cesarean delivery. It is a major cause of maternal morbidity. PPH is defined as primary or secondary: primary PPH occurs in the first 24 hours after delivery (also called early PPH) and secondary PPH occurs 24 hours to 12 weeks after delivery - Uterine atony was the most common cause of PPH. The Royal College of Obstetricians and Gynaecologists (RCOG) classifies PPH as minor (500 to 1000 mLs) or major (>1000 mLs), with further subdivisions of major hemorrhage as moderate (1000 to 2000 mLs) or severe (>2000 mLs) Normally, hemostasis occurs upon placental separation because the placenta completely separates from the uterus, the myometrium contracts and constricts the vessels supplying the placental bed, and coagulation pathways activate and form clot at the site of previous placental attachment. PPH results from a disturbance in one or more of these events. These disturbances include incomplete placental separation (eg, defective decidualization resulting in placenta accreta), defective myometrial contraction (atony), and bleeding diatheses (eg, acquired or inherited factor deficiencies, thrombocytopenia, drugs that affect coagulation), as well as trauma. Although uterine atony is the most common cause of PPH, it is often responsive to therapy and thus not the most common reason for massive transfusion after delivery
RISK FACTORS: ●Retained placenta ●Failure to progress during the second stage of labor ●Placenta accreta ●Lacerations ●Instrumental delivery ●Large for gestational age newborn (eg, >4000 g) ●Hypertensive disorders ●Induction of labor ●Augmentation of labor with oxytocin Sheehan's = a complication of PPH
A 35 year old with a previous C-section is admitted in active labour. Syntocinon is used to augment labour and she has an instrumental delivery because of evidence of fetal distress (metal tachycardia). Whilst repairing the episiotomy the mother becomes tachycardic, hypotensive and collapses. She is taken to theatre urgently.
a. Placental Abruption
b. Intracranial Haemorrhage
c. Placenta Praevia
d. Pulmonary Embolism
e. Sepsis
f. PPH
g. Hepatic Rupture
h. Eclampsia
i. Tension Pneumothorax
j. Scar Dehiscence
k. Amniotic Fluid Embolism
Scar Dehiscence -
Uterine rupture refers to complete disruption of all uterine layers, including the serosa. It is a life-threatening pregnancy complication for both mother and fetus. Other adverse outcomes include complications related to severe hemorrhage, bladder laceration, hysterectomy, and neonatal morbidity related to intrauterine hypoxia. Most uterine ruptures in resource-rich countries are associated with a trial of labor after cesarean delivery (TOLAC), with the risk increased by syntocinon use.
By comparison, uterine dehiscence generally refers to an incomplete, and frequently clinically occult, uterine scar separation where the serosa remains intact and is not usually associated with hemorrhage or adverse maternal or perinatal outcomes
A 25 year old who is 6/40 presents with PV spotting. She has had multiple episodes in the last 2 months, usually post-coitally. Ultrasound examination reveals an ongoing pregnancy.
a. Threatened Miscarriage
b. Ectopic Pregnancy
c. Cervical Cancer
d. Complete Miscarriage
e. Menstruation
f. Cervical Polyp
g. New Pregnancy
h. Molar Pregnancy
i. Incomplete Miscarriage
j. Inevitable Miscarriage
k. Retained Products of Conception
l. Missed Miscarriage
Cervical Polyp - bleeding post-coitally has been occurring for 2 months (i.e. prior to start of pregnancy) therefore is unlikely to be pregnancy related. Cervical polyps occur in about four percent of women of reproductive age. They are most common in women in their 40s and 50s who have had more than one child. Polyps almost never occur in young women prior to the start of menstruation. Polyps are also common during pregnancy. This may be caused by an increase in the hormone estrogen.
A 25 year old who had a MTOP at 9/40. She thinks she passed a sac following the misoprostol and at her telephone follow-up at 2 weeks her bleeding had resolved. She now presents to A&E 3 weeks later with a 5 day history of bleeding and crampy lower abdominal pain and a positive pregnancy test
a. Threatened Miscarriage
b. Ectopic Pregnancy
c. Cervical Cancer
d. Complete Miscarriage
e. Menstruation
f. Cervical Polyp
g. New Pregnancy
h. Molar Pregnancy
i. Incomplete Miscarriage
j. Inevitable Miscarriage
k. Retained Products of Conception
l. Missed Miscarriage
Retained Products of Conception - refers to placental and/or fetal tissue that remains in the uterus after spontaneous pregnancy loss (miscarriage), planned pregnancy termination, or preterm/term delivery.
RPOC present with uterine bleeding, pelvic pain, fever, and/or uterine tenderness. These clinical findings are nonspecific; moreover, some postabortal bleeding and discomfort are normal. If viable trophoblastic tissue is present, the patient may not resume normal menstrual cycles after six weeks of follow-up. The presence of a focal echogenic abnormality in the endometrium, particularly with evidence of blood flow by Doppler imaging, is the best test for prediction of retained products of conception. Patients who are hemodynamically unstable from hemorrhage or septic should undergo prompt surgical evacuation. Sepsis should also be treated with broad spectrum intravenous antibiotics.
A 25 year old Asian patient who is 16/40 pregnant presents with an isolated episode of PV spotting. The uterus is palpable per abdomen and the FH is auscultated with sonicaid
a. Threatened Miscarriage
b. Ectopic Pregnancy
c. Cervical Cancer
d. Complete Miscarriage
e. Menstruation
f. Cervical Polyp
g. New Pregnancy
h. Molar Pregnancy
i. Incomplete Miscarriage
j. Inevitable Miscarriage
k. Retained Products of Conception
l. Missed Miscarriage
Threatened Miscarriage
Uterine bleeding in the presence of a closed cervix and sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity is diagnostic of threatened miscarriage. The term “threatened” is used to describe these cases because miscarriage does not always follow uterine bleeding in early pregnancy, even after repeated episodes or large amounts of bleeding. Uterine bleeding in these cases is likely due to disruption of decidual vessels at the maternal-fetal interface. These separations generally cannot be visualized by ultrasound, but sometimes appear as a subchorionic hematoma. Management is expectant
An 18 year old who is 13/40 presents to A&E with PV spotting. On VE the uterus palpates 10/40. The os is closed. She is due for her first USS tomorrow
a. Threatened Miscarriage
b. Ectopic Pregnancy
c. Cervical Cancer
d. Complete Miscarriage
e. Menstruation
f. Cervical Polyp
g. New Pregnancy
h. Molar Pregnancy
i. Incomplete Miscarriage
j. Inevitable Miscarriage
k. Retained Products of Conception
l. Missed Miscarriage
Missed Miscarriage (also called a delayed miscarriage) refers to in-utero death of the embryo or fetus prior to the 20th week of gestation, with retention of the pregnancy for a prolonged period of time. Women may notice that symptoms associated with early pregnancy (eg, nausea, breast tenderness) have abated and they don’t “feel pregnant” anymore. Vaginal bleeding may occur. The cervix usually remains closed. Ultrasound reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity. Management may be expectant or a medical or surgical intervention to complete the miscarriage can be undertaken.
An 18 year old who is 10/40 presents to A&E with hyperemesis. This is her 7th presentation. On VE the uterus palpates 13/40. The os is closed. She is due for her first USS tomorrow
a. Threatened Miscarriage
b. Ectopic Pregnancy
c. Cervical Cancer
d. Complete Miscarriage
e. Menstruation
f. Cervical Polyp
g. New Pregnancy
h. Molar Pregnancy
i. Incomplete Miscarriage
j. Inevitable Miscarriage
k. Retained Products of Conception
l. Missed Miscarriage
Molar Pregnancy: Complete and partial hydatidiform moles are usually benign forms of gestational trophoblastic disease (GTD). These tumors develop as a result of an aberrant fertilization event leading to proliferative trophoblastic tissue. Invasive mole, choriocarcinoma, and placental site trophoblastic tumors (PSTTs) are malignant. All can develop after a molar pregnancy, but choriocarcinoma and PSTT also occur after spontaneous or induced abortion, ectopic pregnancy, or preterm/term pregnancy.
The two main risk factors for GTD are extremes of maternal age (over age 35 or under 20) and previous GTD.
All GTDs are associated with an elevated serum human chorionic gonadotropin (hCG) concentration. Vaginal bleeding, an enlarged uterus, and pelvic discomfort are the most common clinical manifestations. Serum hCG is often much higher in patients with GTD than in those with intrauterine or ectopic pregnancies. In contrast to all other types of GTD, a partial mole contains a fetus, and fetal cardiac activity may be detected.
A 36 year old who is 37 weeks pregnant and has a history of pregnancy induced hypertension presents with acute onset abdominal pain and PV bleeding. She is tachycardic and there is evidence of fetal distress
a. DIC
b. Vasa Praevia
c. Cervical Ectropion
d. Thrush
e. Cervical Cancer
f. Threatened Miscarriage
g. Placenta Praevia
h. Placental Abruption
i. Fibroids
j. Show
Placental Abruption - bleeding at the decidual-placental interface that causes partial or total placental detachment prior to delivery of the fetus. The diagnosis is typically reserved for pregnancies over 20 weeks of gestation. The major clinical findings are vaginal bleeding and abdominal pain, often accompanied by hypertonic uterine contractions, uterine tenderness, and a non-reassuring fetal heart rate (FHR) pattern.
Most placental abruptions are related to a chronic pathologic vascular process, but some are due to acute events, such as trauma or vasoconstriction. The immediate cause of placental separation is rupture of maternal blood vessels in the decidua basalis. The subsequent release of tissue factor and generation of thrombin lead to many of the clinical sequelae of acute abruption. The detached portion of the placenta is unable to exchange gases and nutrients; when the remaining fetoplacental unit is unable to compensate for this loss of function, the fetus becomes compromised.
A retroplacental clot is the classic ultrasound finding of placental abruption, but is not always present. When placental separation exceeds 50 percent, acute disseminated intravascular coagulation and fetal death are common.
Women with placental abruption are at several-fold higher risk of abruption in a subsequent pregnancy, especially if the abruption was severe.
A 23 year old who is 37 weeks pregnant presents with post coital bleeding. This is her 3rd presentation. On examination her SFH is 36cm, the uterus is soft and her observations are normal and the FHR is 145bpm
a. DIC
b. Vasa Praevia
c. Cervical Ectropion
d. Thrush
e. Cervical Cancer
f. Threatened Miscarriage
g. Placenta Praevia
h. Placental Abruption
i. Fibroids
j. Show
Cervical Ectropion - occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu. The everted epithelium has a reddish appearance similar to granulation tissue, and may be covered by a yellow turbid discharge. Ectropion is common in adolescents. After adolescence, it may be observed in women who are pregnant or taking estrogen-progestin contraceptives or who had a cervical laceration during labor and delivery.
A 42 year old IVF patient is 36 weeks pregnant, her membranes rupture as she walks into antenatal clinic and you notice she is bleeding PV. Her uterus us soft. Her pulse is 80bpm, FHR 60
a. DIC
b. Vasa Praevia
c. Cervical Ectropion
d. Thrush
e. Cervical Cancer
f. Threatened Miscarriage
g. Placenta Praevia
h. Placental Abruption
i. Fibroids
j. Show
In vasa previa, fetal blood vessels are present in the membranes covering the internal cervical os. The membranous vessels may be associated with a velamentous umbilical cord (type 1 vasa previa) or they may connect the lobes of a bilobed placenta or the placenta and a succenturiate lobe (type 2 vasa previa).
The prevalence of vasa previa is approximately 1 in 2500 deliveries, but is much higher in pregnancies conceived following use of assisted reproductive technologies (prevalence as high as 1 in 202)
The prenatal diagnosis of vasa previa is based upon characteristic sonographic findings (membranous vessels that cross the internal cervical os). In the absence of prenatal sonographic diagnosis, a clinical diagnosis of vasa previa should be suspected in the setting of vaginal bleeding that occurs upon rupture of the membranes and is accompanied by fetal heart rate abnormalities, particularly a sinusoidal pattern or bradycardia. Fetal exsanguination can occur within minutes.
A 34 year old who is 24 weeks pregnant has just had a course of antibiotics for a UTI presents to MDCU with a thick white vaginal discharge mixed with pink blood.
a. DIC
b. Vasa Praevia
c. Cervical Ectropion
d. Thrush
e. Cervical Cancer
f. Threatened Miscarriage
g. Placenta Praevia
h. Placental Abruption
i. Fibroids
j. Show
Thrush - Candida is considered part of the normal vaginal flora, but overgrowth of the organism and penetration of superficial epithelial cells can result in vulvovaginitis.
Candida Albicans - yeast like fungus, most common cause of vaginal infection
Candidiasis is more common in diabetics, the obese, pregnancy, when antibiotics have been given or when immunity has been compromised. It tends to present with irritation and soreness of the vulva and anus (inflamed and red), and a ‘cottage cheese’ discharge. Superficial dyspareunia and dysuria may occur.
Diagnosis is established by culture and topical imidazole (e.g. clomtrimazole - Canesten) or vaginal pessaries (imidazole) or oral fluconazole may be required.
Risk Factors: pregnancy, diabetes, use of antibiotics, immunocompromised patients, HIV, transplant patients
A 36 year old who is 39 weeks pregnant in her first pregnancy passes a ‘jelly-like’ bloody discharge per vagina. FH is 145bpm. She is having irregular tightenings
a. DIC
b. Vasa Praevia
c. Cervical Ectropion
d. Thrush
e. Cervical Cancer
f. Threatened Miscarriage
g. Placenta Praevia
h. Placental Abruption
i. Fibroids
j. Show
Show - this lady has reached term, and is beginning to experience contractions, therefore a ‘show’ of bloody mucus is normal!
A 55 year old patient on combined cyclical HRT presents with irregular PV bleeding. Pipelle biopsy is taken on day 24 of the pack
a. Proliferative Endometrium
b. Simple Hyperplasia
c. Decidua
d. Secretory Endometrium
e. Complex Hyperplasia
f. Trophoblast
g. Atrophic Endometrium
h. Adenocarcinoma
Secretory Endometrium - as this patient is on HRT a biopsy of the endometrium at day 24 will show similar results to that of a woman menstruating i.e. secretory endometrium
An 86 year old patient presents with an isolated episode of post-menopausal bleeding. USS shows an endometrial thickness of 3mm. D&C is undertaken. Currettings are sent to histopathology
a. Proliferative Endometrium
b. Simple Hyperplasia
c. Decidua
d. Secretory Endometrium
e. Complex Hyperplasia
f. Trophoblast
g. Atrophic Endometrium
h. Adenocarcinoma
Atrophic Endometrium - PMB is a red flag symptom, and should be considered cancer until proven otherwise - occurs in about 10%. However, as this is an isolated episode, and further investigations have shown an endometrial. The most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium. In the early menopausal years, endometrial hyperplasia, polyps, and submucosal fibroids are also common etiologies.
Postmenopausal bleeding (PMB) refers to any uterine bleeding in a menopausal woman (other than the expected cyclic bleeding that occurs in women taking sequential postmenopausal hormone therapy).
Investigations:
Full history: dyspareunia, dryness, FH
BMI, DM, tamoxifen (increased risk cancer),
TVUS >4-5mm or focal increased echogenicity or persistent bleeding requires a biopsy.
There is also a second peak in cervical cancer incidence at 60-64 years so women need cervical cancer screening as part of the evaluation of abnormal bleeding, as it can be difficult to distinguish between endocervical and upper uterine bleeding.
A 28 year old with retained products of conception post medical termination opts for an ERCP. The sample is sent to histopathology
a. Proliferative Endometrium
b. Simple Hyperplasia
c. Decidua
d. Secretory Endometrium
e. Complex Hyperplasia
f. Trophoblast
g. Atrophic Endometrium
h. Adenocarcinoma
Trophoblast - The term retained products of conception (RPOC) refers to placental and/or fetal tissue that remains in the uterus after a spontaneous pregnancy loss (miscarriage), planned pregnancy termination, or preterm/term delivery. The presence of RPOC after a spontaneous pregnancy loss distinguishes an incomplete from a complete miscarriage. The characteristic clinical manifestations of RPOC include one or more of the following: uterine bleeding, pelvic pain, fever, and/or uterine tenderness. These clinical findings are nonspecific; moreover, it is normal to have some postabortal bleeding and discomfort. The presence of a focal echogenic abnormality in the endometrium, particularly with evidence of blood flow by Doppler imaging, is the best test for prediction of retained products of conception. However, the decision to intervene should be based on clinical need rather than on an isolated ultrasound finding.
Trophoblasts are specialized cells of the placenta that play an important role in embryo implantation and interaction with the decidualised maternal uterus.
Failure of the trophoblast to invade sufficiently is important in the development of some cases of pre-eclampsia.
A 41 year old with an ectopic pregnancy has a salpingectomy and a D&C. The endometrial currettings are sent for histopathology
a. Proliferative Endometrium
b. Simple Hyperplasia
c. Decidua
d. Secretory Endometrium
e. Complex Hyperplasia
f. Trophoblast
g. Atrophic Endometrium
h. Adenocarcinoma
Decidua is the term for the uterine lining (endometrium) during a pregnancy, which forms the maternal part of the placenta. It is formed under the influence of progesterone and forms highly characteristic cells.
A 66 year old with a BMI of 66 presents with a 10 year history of postmenopausal bleeding. USS shows a thickened cystic endometrium. A D&C is performed
a. Proliferative Endometrium
b. Simple Hyperplasia
c. Decidua
d. Secretory Endometrium
e. Complex Hyperplasia
f. Trophoblast
g. Atrophic Endometrium
h. Adenocarcinoma
Adenocarcinoma - Endometrial carcinoma typically presents with abnormal uterine bleeding and is most common in women who are postmenopausal and with increasing age in premenopausal women.
Risk Factors: Obese, PMB, thickened cystic endometrium indicates adenocarcinoma
Endometrial sampling is the gold standard for evaluation for endometrial neoplasia. For postmenopausal women, transvaginal ultrasound evaluation of endometrial thickness may be used as an initial study to evaluate for endometrial neoplasia in selected women. For these women, it is reasonable to defer endometrial sampling if the endometrial thickness is
A 21 year old who has a 2 year history of sub fertility. Her cycles vary from 33-40 days. Her husband has a semen analysis which was normal.
a. Laparotomy
b. Anti-Mullerian Hormone
c. Hysterosalpingogram
d. Laparoscopy
e. Semen Analysis
f. Laparoscopy and Dye Test
g. HVS
h. Luteinizing Hormone
i. Day 21 progesterone
j. Triple Swabs
k. Hysteroscopy
l. Prolactin
m. Mumps IgG
n. Varicella IgG
o. Rubella IgG
Day 21 Progesterone - Non-invasive, first female investigation, want to know if she’s ovulating
Infertility is a unique medical condition because it involves a couple, rather than a single individual. It is defined as failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35 years of age; and after six months of regular intercourse without use of contraception in women 35 years and older.
Some causes of infertility are easily identifiable, such as azoospermia (no sperm cells in the ejaculate), longstanding amenorrhea, or bilateral tubal obstruction. However, the situation is less clear in most couples: the sperm may be reduced in number, but are not absent; there may be oligomenorrhea with some ovulatory cycles; the woman may have partial tubal obstruction; or a menstrual history may suggest intermittent ovulation.
The following tests are useful in most couples with infertility:
●Semen analysis to assess male factors
●Menstrual history, assessment of LH surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function
●Hysterosalpingography to assess tubal patency and the uterine cavity.
●Day 3 serum FSH and estradiol levels.
A 22 year old with sub fertility. She has regular menstrual cycles and no medical problems. Her partner is also healthy and had the usual childhood illnesses including chickenpox and mumps
a. Laparotomy
b. Anti-Mullerian Hormone
c. Hysterosalpingogram
d. Laparoscopy
e. Semen Analysis
f. Laparoscopy and Dye Test
g. HVS
h. Luteinizing Hormone
i. Day 21 progesterone
j. Triple Swabs
k. Hysteroscopy
l. Prolactin
m. Mumps IgG
n. Varicella IgG
o. Rubella IgG
Semen Analysis - Mumps viral infections in adolescent and adult males carry an up to 30% risk that the testes may become infected (orchitis or epididymitis), which can be quite painful; about half of these infections result in testicular atrophy, and in rare cases sterility can follow
Infertility is a unique medical condition because it involves a couple, rather than a single individual. It is defined as failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35 years of age; and after six months of regular intercourse without use of contraception in women 35 years and older.
Some causes of infertility are easily identifiable, such as azoospermia (no sperm cells in the ejaculate), longstanding amenorrhea, or bilateral tubal obstruction. However, the situation is less clear in most couples: the sperm may be reduced in number, but are not absent; there may be oligomenorrhea with some ovulatory cycles; the woman may have partial tubal obstruction; or a menstrual history may suggest intermittent ovulation.
The following tests are useful in most couples with infertility:
●Semen analysis to assess male factors
●Menstrual history, assessment of LH surge in urine prior to ovulation, and/or luteal phase progesterone level to assess ovulatory function
●Hysterosalpingography to assess tubal patency and the uterine cavity.
●Day 3 serum FSH and estradiol levels.
A 23 year old with sub fertility. She presents with her husband who she met when she was 21 whilst working as a 18-30 holiday rep in Malia. She has regular cycles and has been having unprotected intercourse. She has only ever used the COCP and IUCD for contraception
a. Laparotomy
b. Anti-Mullerian Hormone
c. Hysterosalpingogram
d. Laparoscopy
e. Semen Analysis
f. Laparoscopy and Dye Test
g. HVS
h. Luteinizing Hormone
i. Day 21 progesterone
j. Triple Swabs
k. Hysteroscopy
l. Prolactin
m. Mumps IgG
n. Varicella IgG
o. Rubella IgG
Hysterosalpingogram - this woman has risk factors for STI’s and therefore PID.
Tubal disease and pelvic adhesions prevent normal transport of the oocyte and sperm through the fallopian tube. The primary cause of tubal factor infertility is pelvic inflammatory disease caused by pathogens such as chlamydial or gonorrhea. Other conditions that may interfere with tubal transport include severe endometriosis (see ‘Endometriosis’ below), adhesions from previous surgery or nontubal infection (eg, appendicitis, inflammatory bowel disease), pelvic tuberculosis, and salpingitis isthmica nodosa (ie, diverticulosis of the fallopian tube).
A 35 year old with a 5 year history of sub fertility. She suffers from dysmenorrhea, which was previously managed with the Mirena. She gets severe cyclic pain and dyschezia. Her partner has a 5 year old boy from a different relationship.
a. Laparotomy
b. Anti-Mullerian Hormone
c. Hysterosalpingogram
d. Laparoscopy
e. Semen Analysis
f. Laparoscopy and Dye Test
g. HVS
h. Luteinizing Hormone
i. Day 21 progesterone
j. Triple Swabs
k. Hysteroscopy
l. Prolactin
m. Mumps IgG
n. Varicella IgG
o. Rubella IgG
Laparascopy and Dye Test
Dx: Endometriosis
Mechanisms which decrease fertility in women with endometriosis include anatomic distortion from pelvic adhesions, damage to ovarian tissue by endometrioma formation and surgical resection, and the production of substances such as cytokines and growth factors which impair the normal processes of ovulation, fertilization, and implantation.
Although endometriosis impairs fertility, it does not usually completely prevent conception. A combination of surgery, ovulation induction plus intrauterine insemination, and in vitro fertilization can be used to help these women conceive.
For women with minimal/mild endometriosis at diagnostic laparoscopy, we recommend ablation or excision of endometriosis implants (Grade 1A). Postoperatively, women under age 35 may attempt timed intercourse for up to six months. If they fail to conceive, we suggest ovulation induction plus intrauterine insemination (IUI) (Grade 2C). For women over age 35, ovulation induction plus IUI may be initiated after three to six months of timed intercourse or immediately after surgery, given the decreased fecundity in older women. (See ‘Mild/minimal disease’ above.)
For young women with moderate/severe endometriosis at laparoscopy, we suggest resection of endometriosis and adhesions (Grade 2C). If surgical resection of advanced disease is successful, we suggest ovulation induction plus IUI (Grade 2C). This can be initiated immediately after surgery or after three to six months of attempting to conceive.
A 28 year old with a 2 year history of sub fertility. She has been amenorrheic for the last year. She has PMHx of schizophrenia for which she is on medication. Her partner has a normal semen analysis.
a. Laparotomy
b. Anti-Mullerian Hormone
c. Hysterosalpingogram
d. Laparoscopy
e. Semen Analysis
f. Laparoscopy and Dye Test
g. HVS
h. Luteinizing Hormone
i. Day 21 progesterone
j. Triple Swabs
k. Hysteroscopy
l. Prolactin
m. Mumps IgG
n. Varicella IgG
o. Rubella IgG
Prolactin - Hyperprolactinemia in premenopausal women causes hypogonadism, with symptoms that include infertility, oligomenorrhea, or amenorrhea, and less often galactorrhea.
●A serum prolactin concentration greater than 100 ng/mL (100 mcg/L SI units) is typically associated with overt hypogonadism, subnormal estradiol secretion and its consequences, including amenorrhea, hot flashes, and vaginal dryness.
●Moderate degrees of hyperprolactinemia, eg, serum prolactin values of 50 to 100 ng/mL (50 to 100 mcg/L SI units), cause either amenorrhea or oligomenorrhea.
●Mild degrees of hyperprolactinemia, eg, serum prolactin values of 20 to 50 ng/mL (20 to 50 mcg/L SI units), may cause only insufficient progesterone secretion and, therefore, a short luteal phase of the menstrual cycle. Mild hyperprolactinemia can cause infertility even when there is no abnormality of the menstrual cycle; these women account for about 20 percent of those evaluated for infertility.
A search for the cause of the hyperprolactinemia should begin with the history. One should inquire about pregnancy (nonpathologic hyperprolactinemia) and medications that can cause hyperprolactinemia (such as estrogen, neuroleptic drugs such as risperidone, metoclopramide, antidepressant drugs, cimetidine, methyldopa, reserpine, and verapamil). One should also inquire about headache, visual symptoms, symptoms of hypothyroidism, and a history of renal disease
A 25 year old presents to her GP as she has been trying to conceive for the last 6 months. She is anxious as her sister who is 42 has been having difficulty conceiving and is undergoing IVF.
a. Laparotomy
b. Anti-Mullerian Hormone
c. Hysterosalpingogram
d. Laparoscopy
e. Semen Analysis
f. Laparoscopy and Dye Test
g. HVS
h. Luteinizing Hormone
i. Day 21 progesterone
j. Triple Swabs
k. Hysteroscopy
l. Prolactin
m. Mumps IgG
n. Varicella IgG
o. Rubella IgG
Rubella IgG - she has only been trying for 6 months - need to be trying for at least 1 year before qualify for any further investigations. Therefore do minimal, i.e. check rubella immunity
A 27 year old female presents with a 10 month history of amenorrhoea and infertility.
Investigations show:
E2 = 80; Prolactin = 980; LH = 2.1; FSH = 3.3; Testosterone = 1.5
Normal Range: E2 130-800 pmol/L; Prolactin 50-450 mIU/L; LH 2-20 IU/L; FSH 2-20 IU/L; Testosterone
Prolactinoma - high prolactin is due to pregnancy or prolactinoma
Prolactin appears to cause amenorrhea by suppressing hypothalamic GnRH secretion, leading to low gonadotropin and estradiol concentrations. Unlike the other pituitary hormones, prolactin release is mostly controlled by inhibition, primarily by hypothalamic dopamine. The negative regulation by dopamine is so potent that disruption of the pituitary stalk, by trauma or a large tumor, leads to hyperprolactinaemia.
DIAGNOSIS — Once pregnancy and Asherman syndrome have been excluded, all of the remaining causes of amenorrhea are associated with anovulation due to hypothalamic, pituitary, or ovarian disorders.
All women with high serum prolactin values should undergo pituitary MRI unless a very clear explanation is found for the elevation (eg, underlying hypothyroidism or antipsychotic drug use). The goal of imaging is to evaluate the possibility of a hypothalamic or pituitary lesion.
A 33 year old female presents with a 9 month history of amenorrhoea, hair loss and facial acne.
Investigations show:
E2
Ovarian Tumour - when testosterone is >4 then worry about testosterone secreting tumours
Ovarian cancer is the second most common gynecologic malignancy and the most common cause of gynecologic cancer death. Epithelial ovarian cancer, the most common histologic type (95 percent of cases) of ovarian cancer, typically presents at an advanced stage, which contributes to its poor prognosis.
RMI I is a product of the ultrasound scan score (U), menopausal status (M), and serum CA 125 level (RMI I = U x M x CA 125). The NICE guidelines advise that all women with an RMI I score of ≥200 should be referred to a specialist.
Normal lab results and history of uterine instrumentation —Evaluation for Asherman syndrome (intrauterine adhesions) should be performed.
A 21 year old with a 2 year history of amenorrhoea and fatigue
Investigations show:
E2
Premature Ovarian Failure
High serum FSH concentrations suggesting primary ovarian insufficiency (premature ovarian failure). 46,XX primary ovarian insufficiency is defined as the development of hypergonadotropic hypogonadism before the age of 40 years in women who have a normal karyotype [1]. The presenting symptoms are similar to those of menopause.
Women with primary ovarian insufficiency should receive estrogen therapy for prevention of bone loss. This can be either an oral contraceptive (if the patient is having intermittent ovarian function and does not wish to become pregnant), or replacement doses of estrogen and progestin.
In its fully developed form, it is associated with oligomenorrhea or amenorrhea, symptoms of estrogen deficiency, and gonadotropin levels in the menopausal range before age 40 years.
Menopause is a reflection of complete, or near complete, ovarian follicular depletion, with resulting hypoestrogenemia and high follicle-stimulating hormone (FSH) concentrations.
A 22 year old with Primary Amenorrhoea presents to her GP
Investigations show:
E2
Turner’s Syndrome - A high serum FSH concentration indicates primary ovarian insufficiency (premature ovarian failure). A karyotype should then be considered to look for Turner syndrome (including mosaicism). The karyotype may demonstrate complete or partial deletion of the X chromosome, and it provides a precise diagnosis for many women. More importantly, a karyotype will help rule out the presence of any Y chromosome material, which, as noted above, makes gonadectomy mandatory.
It is the most common sex chromosome abnormality (loss of part or all of an X chromosome), affects approximately 1 in every 2500 liveborn female newborns. It is a disorder of growth and development that is almost always associated with short stature and primary amenorrhea due to early ovarian failure.
Girls/women with Turner syndrome whose karyotype includes a Y chromosome (such as 45,X/46,XY mosaicism) are at increased risk for gonadoblastoma, a neoplasm that occurs in dysgenetic gonads.
Patients with Turner syndrome are at increased risk for cardiovascular morbidity, presumably due to their risk of cardiovascular malformations, renal abnormalities, and hypertension. Abnormalities include aortic valvular disease, aortic arch anomalies (primarily coarctation), systemic venous abnormalities, ventricular septal defects, and hypoplastic left heart syndrome. Patients are at risk for aortic dissection, particularly during pregnancy.
The diagnosis of Turner syndrome is sometimes made at birth in the patient with classic physical features such as webbed neck and congenital lymphedema. Other patients are diagnosed later, when they present with either growth failure in childhood, failure to enter or complete puberty, or early ovarian failure.
A 18 year old presents with a 4 month history of weight gain, amenorrhoea and hirsuitism
E2 = 550; Prolactin = 500; LH = 8.8; FSH = 3.2; Testosterone = 3.1
Normal Range: E2 130-800 pmol/L; Prolactin 50-450 mIU/L; LH 2-20 IU/L; FSH 2-20 IU/L; Testosterone
PCOS - diagnosis = Rotterdam criteria(2/3):
●Oligo- and/or anovulation
●Clinical and/or biochemical signs of hyperandrogenism
●Polycystic ovaries (by ultrasound)
Depending upon the clinical picture, a high serum androgen value may be consistent with the diagnosis of PCOS or may raise the question of an androgen-secreting tumor of the ovary or adrenal gland. Tumors are typically associated with the rapid onset of virilizing symptoms and, in some cases, with glucocorticoid excess. Hyperandrogenism may be diagnosed by either clinical (acne, hirsutism, or male-pattern hair loss) or biochemical (elevated serum androgen concentration) criteria. Therefore, a patient with oligomenorrhea and clinical evidence of hyperandrogenism but normal serum androgen concentrations is still considered to have PCOS.
Treatment of hyperandrogenism is directed toward achieving the woman’s goal (eg, relief of hirsutism, resumption of menses, fertility) and preventing the long-term consequences of polycystic ovary syndrome (PCOS; eg, endometrial hyperplasia, obesity, and metabolic defects). For women with PCOS, the type of therapy depends upon whether fertility is desired - clomiphene citrate. Once the diagnosis of PCOS is made, cardiometabolic risk assessment should include measurement of blood pressure and body mass index, fasting lipid profile, and an oral glucose tolerance test.
A 25 year old 6 months postnatally who is concerned her periods have not returned. She had a PPH at delivery.
E2 = 1050; Prolactin = 1000; LH = 2; FSH = 2; Testosterone = 2.1
Normal Range: E2 130-800 pmol/L; Prolactin 50-450 mIU/L; LH 2-20 IU/L; FSH 2-20 IU/L; Testosterone
Pregnancy - high prolactin is either due to pregnancy or prolactinoma! Combined with a high oestrogen level it indicates pregnancy!
A 33 year old Asian patient with a booking Hb of 8g/dL, MCV 86, WCC 7.8 and platelets 250 x 109/dL. What is the most appropriate next step
a. Commence high dose folic acid
b. Organised an urgent iron infusion
c. Commence iron supplementation
d. Check Hb electrophoresis and haematinics
e. Urgent referral to Haematology
Check Hb electrophoresis and haematinics
Which of the following is the UK definition of perinatal mortality rate?
a. Number of deaths from 22 completed weeks gestation and deaths in the first week of life per 1000 live births
b. Number of deaths from 24 completed weeks gestation and deaths in the first week of life per 1000 live births
c. Number of deaths from 22 completed weeks gestation and deaths in the first month of life per 1000 births
d. Number of deaths in the first 7 days of life per 1000 live births
e. Number of deaths in the first month of life per 1000 live births
Number of deaths from 24 completed weeks gestation and deaths in the first week of life per 1000 live births
Which of the following is the UK Enquiry definition of maternal mortality rate?
a. The number of direct and indirect maternal deaths per 100 maternities
b. The number of direct and indirect maternal deaths per 100,000 maternities
c. The number of direct and indirect maternal deaths per 100,000 live births
d. The number of direct and indirect maternal deaths per 100 maternities
e. Deaths from obstetric causes per 100,000 estimated pregnancies
The number of direct and indirect maternal deaths per 100,000 maternities
Regarding the most recent confidential enquiry into maternal deaths, which one of the following is true?
a. The main cause of maternal deaths is amniotic fluid embolism
b. Sepsis is the leading cause of maternal deaths
c. Pre-eclampsia is the leading cause of maternal deaths
d. Thrombo-embolism is the leading cause of maternal deaths
e. Sepsis is the leading cause of direct maternal deaths
Sepsis is the leading cause of direct maternal deaths
Which of the following is NOT one of the top five causes of maternal deaths in the UK?
a. Cardiac Disease
b. Indirect Neurological Conditions
c. Sepsis
d. Pre-eclampsia and eclampsia
e. Haemorrhage
Haemorrhage
The principle supports of the uterus are:
a. The iliosacral ligaments
b. The pyriformis muscle
c. the transverse cervical ligaments
d. the infundibular ligaments
e. the uterosacral ligaments
CE
The principal supports of the uterus are the transverse cervical ligaments (cardinal ligaments), uterosacral ligaments and the round ligament. The infundibular ligaments attach the ovaries to the posteo-lateral wall of the uterus. The pyriformis muscle lines the lateral wall of the pelvis overlying the iliosacral ligament.
Which of the following statements are true?
a. The ovary is attached to the lateral pelvic side wall
b. The ureter lies beneath the uterine artery
c. The mucosa of the fallopian tubes is lined by ciliated cells
d. The pouch of Douglas lies between the bladder and the uterus
e. The polar body of the oocyte contains 23 chromosome
FTTFT - BCE
The ovary is attached to the uterus by the infundibular ligament, the mesovarium and it’s blood supply, which arises from the renal arteries. The pouch of Douglas is posterior to the uterus, lying between the rectum and the uterus. Immediately following the LH surge, the oocyte completes the first stage of meiosis extruding the first polar body, which is 23 chromosomes - haploid
A 46 year old woman who has been happily married for 18 years complains of irregular vaginal bleeding. Which 5 of the following should be performed as first-line investigations?
a. FBC
b. Urea and electrolytes
c. Cervical smear
d. Cervical swab for chlamydia
e. Transvaginal ultrasound scan
f. Hysteroscopy and endometrial biopsy
g. Endometrial biopsy
h. Speculum examination
i. Digital vaginal examination
j. Group and save
CEFHI
In a woman over 40 irregular vaginal bleeding may be due to any of the following:
- Cervical ectropion
- Cervical Polyp
- Cervical Cancer
- Endometrial Hyperplasia (cystic or atypical)
- Endometrial Polyp
- Submucosal fibroid
- Endometrial Cancer (rare)
It is unlikely that she has PID, and chlamydia rarely causes irregular vaginal bleeding. A speculum examination is an opportunity to detect cervical abnormalities and perform a smear. A digital VE will detect an enlarged uterus, suggestive of fibroids. Endometrial biopsy alone is not indicated in women under 40 because the risk of malignancy is greatly reduced. A TVUS will detect endometrial polyps, submucosal fibroids and measure the endometrial thickness. A hysteroscopy and endometrial biopsy is the gold standard for detecting endometrial abnormalities in women over 40
In a sagittal cross section of the pelvis:
a. The urethra lies anterior to the upper third of the vagina
b. The urethra lies anterior to the lower third of the vagina
c. The bladder when empty lies below and anterior to the uterine body
d. The bladder when empty lies parallel and anterior to the uterine body
e. The rectum lies posterior to the body of the uterus
BCE
The urethra is only 3.5cm long and is anterior to the lower third of the vagina. The bladder when empty lies below the uterovesical fold, which arises from the junction between the uterine body and the cervix
Which of the following structures lie within the broad ligament?
a. The fallopian tube
b. The ureter
c. The uterine artery
d. The ovarian artery
e. The superior vesical artery
AC
The broad ligament is made of 2 layers of peritoneum that covers the fallopian tube, round ligament, and down the side of the uterus to the cervix where anteriorly it merges into the uterovesical fold, and posteriorly to the peritoneum of the pouch of Douglas. The ureter, superior vesicle artery and the ovarian artery are all retroperitoneal. The uterine artery is a branch of the internal iliac artery, and runs between the leaves of the broad ligament along the lateral wall of the uterus
Match the following A-E to five of the statements below:
a. FSH
b. Oestradiol
c. Progesterone
d. Testosterone
e. The first meiotic division
- Is completed following the LH surge
- Is produced by the adrenal gland
- Is completed during the neonatal period
- Is inhibited by estradiol
- Decreases mid cycle
- Is a precursor of estradiol
- Is inhibited by GnRH
- Is produced throughout the cycle
- Is produced in the secretory phase
- Is secreted by the hypothalamus
A - 4, B - 8, C - 9, D - 6, E - 1
Testosterone is produced by the theca cells and converted to estradiol by aromatase. Estradiol is secreted throughout the menstrual cycle, initially by the granulosa cells in the developing follicle, and then by the corpus luteum, changing the endometrium from proliferative to secretory. The LH surge triggers the final stage of the 1st meiotic division, whilst fertilisation causes the second meiotic division with the extrusion of the polar body by uneven division of the cytoplasm. GnRH is secreted by the hypothalamus in a pulsatile manner and stimulates the production and release of FSH and LH in the anterior pituitary gland. Androgen precursors are secreted by the adrenals, but estradiol is only produced in the ovary.
Complications of laparoscopy include perforation of the:
a. gall bladder
b. urinary bladder
c. uterus
d. inferior vesical artery
e. inferior epigastric artery
BCE
Trocars places in the iliac fossae can perforate the inferior epigastric artery, while one placed centrally can perforate the bladder. The uterus can be perforated by a sound placed in the uterus to move it around
In the follicular phase of the menstrual cycle:
a. The granulosa cells produce androstenedione and testosterone
b. The endometrial glands become straight
c. Oestradiol inhibits the production of LH
d. The thecal cells produce estradiol and secrete follicular fluid
e. The nucleus of the oocyte contains 23 chromosomes
BC
The granulosa cells produce estradiol, while the thecal cells produce the androgens androstenedione and testosterone. Prior to the LH surge the oocyte contains 46 chromosomes. The LH surge occurs at the end of the follicular phase.
In embryo development:
a. beta-hCG is produced by the fallopian tube from the moment of fertilisation
b. The blastocyst divides into 2 halves, one forming the embryo, the other the placenta
c. The villi of the developing embryo invade the maternal capillaries
d. The fetal heart starts to beat at around 5 weeks after LMP
e. Haemoglobin F has a lesser affinity for oxygen than haemoglobin A
BD
beta-hCG is produced by the developing trophoblast of the embryo. The developing trophoblastic villi of the placenta invade into the maternal capillary bed so that the endotheliums of the maternal and fetal capillaries are in close contact, but the integrity of the maternal capillaries remains and there is no direct circulation between the maternal and fetal circulations at any time. HbF differes from HbA by 25% of it’s amino acids - this allows the oxygen dissociation curve of HbF to move to the left of HbA so that for any given p(O2) concentration, HbF has a higher affinity for oxygen than HbA.
After birth, which of the following changes occur in the fetus?
a. The foramen ovale closes, allowing the entire blood volume to circulate into the pulmonary artery
b. Lung fluid is forced out of the fetal alveoli with the first few breaths
c. The ductus arteriosus opens
d. HbF is replaced by HbA
e. The umbilical vein and artery remain open for several weeks
ABD
The foramen ovale, the ductus arteriosus and the umbilical veins and arteries close within a few hours of birth. The breakdown of fetal blood cells in the first few days of life allows HbF to be replaced by HbA with it’s lower affinity for oxygen. This may lead to a physiological jaundice in the newborn
Best matched statements about beta-hCG (5)
a. beta-hCG begins to rise 2 weeks after fertilisation
b. beta-hCG is measured using a monoclonal antibody radioimmunoassay
c. It is a hormone secreted by the trophoblastic cells of the developing placenta
d. The beta sub-unit is the same as TSH and FSH
e. A low level of beta-hCG is associated with an increased risk of a baby with Down’s syndrome
f. The half life of beta-hCG in plasma is 96 hours
g. A high level of beta-hCG is associated with a hydatidiform mole
h. Serial beta-hCG measurements are useful in the diagnosis of ectopic pregnancy
i. beta-hCG is a polypeptide protein produced by the hypothalamus
j. A high level of beta-hCG is associated with multiple pregnancy
ACGHJ
beta-hCG is a polypeptide protein, produced by the trophoblastic cells of the developing placenta. It has a half life in plasma of 48 hours. It shares a beta sub-unit with LH. It is measured using a monoclonal ELISA test. beta-hCG levels are raised in multiple pregnancies, Down’s syndrome, hydatidiform mole, choriocarcinoma, some gonadoblastomas and dysgerminomas. In ectopic pregnancy beta-hCG increases at a slower rate than ongoing intrauterine pregnancy (doubles every 48 hours)
Which of the following statements are true regarding LH and FSH?
a. They are glycoproteins
b. They are continuously secreted by the pituitary gland
c. LH stimulates the formation of a corpus luteum
d. LH and FSH increases in the middle of the cycle
e. The LH surge occurs in the middle of a 28 day cycle and lasts for 3 days
ACDE
LH and FSH are two glycoproteins secreted by the pituitary gland in response to a GnRH pulse and thus have a pulsatile pattern of secretion themselves. In the middle of a 28 day cycle/at ovulation (day 14) - there is a sudden and large increase in the secretion of FSH and LH, the LH surge lasts for 3 days. LH luteinizes the granulosa cells, which start to produce progesterone in the corpus luteum
Mark as true the five best matched statements about the menopause:
a. The current average age of menopause in the US is 51 years
b. LH levels rise before FSH levels
c. The ovaries become more resistant to the action of FSH
d. FSH levels rise before LH levels
e. Menopausal women are prone to vertebral crush fractures
f. The rish of MI is reduced is menopausal women
g. Lack of oestrogen leads to osteopenia
h. Variation in cycle lengths is more common around the time of the menopause
i. High FSH levels cause hot flushes
j. Menopausal women rarely complain of dyspareunia
ACDEH
The current average age of the menopause is 51 years old. The ovaries gradually become more resistant to the action of FSH, so oestrogen concentrations remain low because few or no follicles develop. This leads, by negative feedback to an increase in FSH concentrations. Low oestrogen levels cause hot flushes (not FSH), and osteoporosis with a loss of trabecular bone leading to vertebral crush fractures and fractures of the neck of femur. In addition atrophic vaginitis is common, often causing dyspareunia because of lack of vaginal secretions and poor elasticity of the vagina.
A 26 year old primigravid woman at 10 weeks gestation visits her midwife for a routine booking appointment. She has sickle cells anaemia. Her partner’s sickle cell status is HbAS. What are the chances of her baby having sickle cell disease?
a. 1 in 8
b. 1 in 4
c. 1 in 5
d. 1 in 2
e. 1 in 3
D
This baby can only inherit HbS from its mother, but can inherit either HbS or HbA from it’s father. This gives a 1 in 2 chance of the baby having sickle cell disease
Which one of the following statements about amniotic fluid is correct?
a. The volume of amniotic fluid has no prognostic value in pregnancy
b. An increased amniotic fluid volume may be associated with fetal chromosomal abnormalities
c. A decreased amniotic fluid volume may be associated with fetal chromosomal abnormalities
d. Amniotic fluid is derived solely from the amnion at 36 weeks
e. Amniotic fluid contains bilirubin in healthy pregnancies
C
Amniotic fluid volume is often decreased in fetuses that are hypoxc. An increase in amnniotic fluid volume is associated with some congenital abnormalities, while a decreased volume is found in babies with trisomy 13, 16 and 18, who often have renal agenesis. Bilirubin is only found in babies with hydropic disease of the newborn, most commonly due to rhesus isoimmunisation
Which of the following disorders are inherited as an autosomal dominant disorder?
a. Sickle cell disease
b. Duchenne muscular dystrophy
c. Haemophilia
d. Huntingdon’s chorea
e. Cystic Fibrosis
D
Sickle cell disease and cystic fibrosis are autosomal recessive, whilst Duchenne muscular dystrophy and haemophilia are X-linked recessive disorders.
The greatest contribution to vaginal lubrication comes from?
a. Fluid from Skene’s glands
b. Mucus produced by endocervical glands
c. Viscous fluid from Bartholin’s glands
d. Transudate-like material from the vaginal walls
e. The uterine wall
D
Skene’s glands are associated with the urethra. The uterine wall does not produce secretions. The endocervical glands and Bartholin’s glands are not significant contributors to vaginal lubrication.
A woman presents to A&E 15 days post C-section. She complains of persistent vaginal bleeding. Her temperature is 37.5, pulse 88bpm, BP 110/76mmHg. What is the most likely diagnosis? a. Mastitis b. Endometritis c. Retained products of conception d. Wound infection e. Wound haematoma
B
Mastitis, wound infections or haematomas will give a pyrexia, but are not associated with prolonged vaginal bleeding. It is rare for POC to be found following a C-section since the cavity is checked at the time of operation. Endometritis is common following a C-section
