Obs and Gynae Flashcards

Question

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

Answer 1

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.

Answer 2

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.

Answer 3

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.

Answer 4

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.

Answer 5

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.

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

Menstruation - not breast feeding therefore no lactational amenorrhoea

Answer 10

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.

Answer 11

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).

Answer 12

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.

Answer 13

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.

Answer 14

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

Answer 15

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.

Answer 16

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.

Answer 17

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.

Answer 18

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

Answer 19

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

Answer 20

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)

Answer 21

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.

Answer 22

``` 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 ```

Answer 23

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

Answer 24

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.

Answer 25

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.

Answer 26

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

Answer 27

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.

Answer 28

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.

Answer 29

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.

Answer 30

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.

Answer 31

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.

Answer 32

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

Answer 33

Show - this lady has reached term, and is beginning to experience contractions, therefore a 'show' of bloody mucus is normal!

Answer 34

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

Answer 35

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.

Answer 36

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.

Answer 37

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.

Answer 38

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

Answer 39

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.

Answer 40

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.

Answer 41

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).

Answer 42

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.

Answer 43

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

Answer 44

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

Answer 45

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.

Answer 46

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.

Answer 47

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.

Answer 48

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.

Answer 49

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.

Answer 50

Pregnancy - high prolactin is either due to pregnancy or prolactinoma! Combined with a high oestrogen level it indicates pregnancy!

Answer 51

Check Hb electrophoresis and haematinics

Answer 52

Number of deaths from 24 completed weeks gestation and deaths in the first week of life per 1000 live births

Answer 53

The number of direct and indirect maternal deaths per 100,000 maternities

Answer 54

Sepsis is the leading cause of direct maternal deaths

Answer 55

Haemorrhage

Answer 56

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.

Answer 57

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

Answer 58

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

Answer 59

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

Answer 60

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

Answer 61

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.

Answer 62

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

Answer 63

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.

Answer 64

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.

Answer 65

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

Answer 66

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)

Answer 67

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

Answer 68

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.

Answer 69

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

Answer 70

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

Answer 71

D Sickle cell disease and cystic fibrosis are autosomal recessive, whilst Duchenne muscular dystrophy and haemophilia are X-linked recessive disorders.

Answer 72

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.

Answer 73

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

Answer 74

BE E.coli is a normal GI commensal. Staphylococcus aureus is a normal commensal of the skin and if found in the vagina causes toxic shock syndrome. Candida albicans is a yeast that causes thrush.

Answer 75

BC Vaginal examination at a routine antenatal visit is unnecessary and uncomfortable. Cardiotocography is indicated if there is any concern about fetal well being, e.g. if the mother reports reduced fetal movements. Haemoglobin is checked at the booking, 26-28 weeks and 32-34 weeks. Urinanalysis and listening to the fetal heart with a hand held doppler device or Pinard's stethescope are performed at every antenatal visit

Answer 76

BEGHJ GDM is the onset of diabetes in pregnancy and usually arises beyond 28 weeks. Women who are at risk of developing GDM include those with a 1st degree relative with T2DM (not T1DM). Persistent glucose levels over 8 mmol/L increases the chance of the baby becoming macrosomic (fetal abdominal circumference >90th centile) and of intrauterine death beyond 40 weeks. The renal threshold for releasing glucose into the urine is lower in pregnancy, and so it is more common for the urine to be positive for glucose in pregnancy. Women with T1DM prior to pregnancy have a 3 fold increased risk of congenital abnormality if their diabetes is poorly controlled.

Answer 77

BCD Danazol may masculinise a female fetus. Women on warfarin should be changed to heparin during the first trimester of pregnancy whilst organogenesis is occuring. All anti-epileptic drugs are teratogenic. However sodium valproate is the least teratogenic and the risk of an epileptic fit to the fetus and the mother may outweigh the teratogenic risk. The teratogenicity of ACE inhibitors has not fully been established so they are not used in pregnancy in case they have a teratogenic potential

Answer 78

DE Pregnancy induced hypertension without proteinuria most commonly arises at term. It can be safely treated with methyldopa while awaiting spontaneous labour. The fetus is usually normally grown, and there is no increased risk of intrauterine death or cephalo-pelvic disproportion.

Answer 79

CE The early signs of pregnancy include breast tenderness, secondary amenorrhoea, urinary frequency and nausea. Varicose veins may arise de novo, or become symptomatic in pregnancy, but they are not typical of early pregnancy

Answer 80

ABCDE Due to limited resources, routine fetal echocardiography is not offered to all women. High risk patients such as those included above, in addition to other maternal diseases (connective tissue disorder, phenylketonuria, rubella, parvovirus and coxsackie virus), detection of another anomaly, raised nuchal thickness, fetal arrhythmia, hydrops and polyhydramnios should be referred for fetal echocardiography

Answer 81

A A significantly raised AFP is most likely to indicate a neural tube defect. Ventral wall defects are much less common than NTDs. A dating scan at 11 weeks is one of the most accurate ways of determining gestation so it is highly unlikely that the raised level is secondary to 'wrong dates.' Bleeding in pregnancy is not associated with a raised AFP. AFP usually falls following demise of the foetus.

Answer 82

B At 28 weeks, around 10% of babies are presenting breech. By term (37 completed weeks of pregnancy) only 3% are still breech. Only a few babies will spontaneously turn after 37 weeks, so ECV should be offered between 37 and 39 weeks

Answer 83

A The first stage of labour is divided into the latent phase and the active phase. The latent phase involves effacement (shortening and thinning) and dilatation of the cervix to 3cm. The active phase involves the dilatation of the cervix from 3cm to 10cm. The transitional phase is used to describe the last stages of the active phase as the cervix becomes fully dilated. The second stage of labour is from full dilatation to the delivery of the baby, and the 3rd stage is the delivery of the placenta

Answer 84

BD The chances of a successful vaginal birth following a c-section (VBAC) for a non recurrent cause is 70%. The risk of wound dehiscence is 1-2% (increased to 4-5% if syntocinon is used)

Answer 85

CE In a woman who has an epidural, standard practice is to wait one after after full dilatation to start the active phase of the second stage (pushing). Decisions regarding mode of delivery are usually made after one hour of pushing - 2 hours after full dilatation. In situation A, the head may rotate to OA with pushing and therefore achieve a normal vaginal delivery. Assisted vaginal delivery is contraindicated if the fetal head is palpable per abdomen since it increases the risk of fetal and maternal birth trauma.

Answer 86

CEHIJ The criteria for attempting a vaginal delivery include full engagement of the head (0/5 palpable per abdomen, below the spines vaginally). The cervix should be fully dilated, there should be no signs of obstruction (overlapping sagittal suture is a sign of outlet obstruction), the mother should have an empty bladder (emptied within the last 30 mins or catheterised), and there should be adequate analgesia (epidural or pudendal block).

Answer 87

AC Induction of labour is contraindicated in breech presentations at term because of the risk of entrapment of the after-coming head. In placenta praevia cervical dilatation will cause bleeding by shearing off the placental bed. Induction of labour is routinely offered to women who are more than 10 days beyond their expected date of delivery (post maturity) or at 40 weeks for women with GDM because of the small increased risk of intrauterine death. Induction of labour is offered to women with PET at term in order to reduce the risk of eclampsia.

Answer 88

AE In the last two triennia, thromboembolic disease and hypertensive disease of pregnancy have been the two commonest causes of maternal death. The others listed are all important causes of maternal death, with haemorrhage and AF-embolism at 3rd and 4th

Answer 89

BE Miscarriage is defined as the loss of a pregnancy before 24 weeks gestation. The definition was changed in 1994 following changes to the Abortion Act. Maternal mortality is expressed either as deaths per 1000 births, or 100,000 maternities

Answer 90

E The most likely diagnosis is that this woman has lichen sclerosus. The ulcerated area may be malignant so an urgent vulval biopsy is indicated

Answer 91

AD Babies born to mothers with pregnancy induced hypertension do not have an increased risk of problems in the neonatal period

Answer 92

D There is no indication for ablation of the whole endometrium in this woman. Danazol and progestogens are used to treat endometrial hyperplasia

Answer 93

B Mild dyskaryosis can revert to normal in a young woman after 6 months and therefore a repeat smear in 6 months time is appropriate. Colposcopy is indicated if the second smear is positive, or if she also tested positive for high risk HPV (16 and 18). Loop excision is rarely indicated in mild dyskaryosis, the majority can be successfully treated with cold coagulation

Answer 94

CD DUB is defined as heavy, regular menstruation without any pathological cause detected (on history, examination or investigation). Fibroids are a pathological cause of menorrhagia and are often associated with heavy regular menstruation. Hysteroscopy and endometrial biopsy are only indicated in women over the age of 40, or if an abnormality is detected on TVUS.

Answer 95

CD Antifibrinolytic agents work by stopping fibrinolysis of the clots in the spiral arterioles. This is effective in 50% of cases and decreases the menstrual loss by up to 40% in women proven to have heavy periods. They have a limited number of minor side effects, can be taken safely with NSAIDs and are taken only during menstruation

Answer 96

ABCE Klinefelter's syndrome carries the karotype XXY and is associated with azoospermia or severe oligospermia. Absent vas deferens does not allow the sperm to leave the testicle and leads to azoospermia. Smoking and drinking both affect spermatogenesis. Chemotherapy for leukamia at puberty is associated with male subfertility

Answer 97

C | Endometrial ablation is only indicated if no pathological cause for menorrhagia has been found

Answer 98

BCEFJ In addition, the discussion should include other forms of contraception, including vasectomy for her partner. The stability of the relationship should also be explored because she is below the age of 30. There is no indication for the woman to stop the OCP as the operation is performed as a day case. Stopping the OCP increases the risk of failure of the operation as the woman may have already conceived at the time of the operation, even if the pregnancy test is negative. A pregnancy test should always be performed on the day of the operation. The three essential facts that the woman must be told, and must be recorded in the notes: 1. Risk of failure is 1:300 2. Procedure is permanent and irreversible 3. She may require a mini-laparotomy The remainder are best practise

Answer 99

D These are the tumour markers for epithelial ovarian cancer which is the commonest form of ovarian cancer in older women. Those listed in A are markers for germ cell tumours which are commoner in younger women.

Answer 100

C Submucosal fibroids become quiescent following the menopause and usually calcify. There is no evidence of increased endometrial cancer in women with fibroids. Ovarian cancer rarely, if ever presents with PMB. Cervical ectropion is a condition of younger women. Vaginal cancer is rare and usually presents with vaginal discharge

Answer 101

A Antibiotic therapy may give some relief but the abscess recurs shortly afterwards. Excision can cause scarring and pain, and is reserved for recurrent abscesses. The eversion at the edges at marsupialisation prevents the abscess from resealing and recurring

Answer 102

E Ovarian cancer rarelt causes significant symptoms until its later stages, which explains the late presentation and therefore poor prognosis for these women

Answer 103

D Stage Ia and Ib refers to tumour confined within the cervix. Stage II is spread into the parametrium or beyond the upper third of the vagina. Stage III is spread outside the pelvis, but within the abdomen. Stage IV is spread beyond the abdominal cavity. Hydronephrosis in cervical carcinoma is most commonly caused by the expansion of the tumour to the pelvic side walls causing obstruction of the ureter. Since the ureter is retroperitoneal and its obstruction causes renal pelvis dilatation this is considered extension beyond the pelvis.

Answer 104

CD Endometrial carcinoma is associated with unopposed oestrogen, whose early manifestations include endometrial polyps, cystic hyperplasia and atypical endometrial hyperplasia

Answer 105

1C, 2H, 3I, 4B, 5A GnRH is released in a pulsatile fashion from the hypothalamus and acts on the pituitary to increase FSH and LH secretion from the pituitary. Low concentrations of oestradiol have a direct stimulating effect on FSH but not LH! prolactin id raised in the post partum period so that lactation can occur. TSH levels remain normal in pregnancy, although thyroid binding globulin rises. In women dihydroepiandrostenedione is a steroid produced predominantly by the adrenal gland, while testosterone is produced by the thecal cells in the ovary. Oestradiol is produced by aromatisation of testosterone in the granulosa cells; and progesterone is produced by the granulosa cells after exposure to LH

Answer 106

AD The ovary had an outer cortex and an inner medulla. It is attached to the back of the broad ligament by a gold of peritoneum called the mesovarium, which carries part of the blood supply, lymphatic drainage and nerve supply. Thecal cells convert cholesterol to androgens under the control of LH. Granulosa cells then convert androgens to oestradiol under the control of FSH.

Answer 107

CE The main ovarian arterial supply arises from the aorta, just above the inferior mesenteric artery (although the exact location is variable from individual to individual). The ovary is supplied by the ovarian artery and arcuate artery arising from the uterine artery. The venous drainage on the right is directly into the IVC, but on the left is into the left renal vein.

Answer 108

AC A past history of PID increases the risk of future episodes, and the IUCD is associated with an increased risk of PID. A previous pregnancy with an IUCD is not a contraindication, but it is unlikely that a woman who has previously fallen pregnant while using an IUCD will accept it as a reliable form of contraception. Following endometritis after pregnancy there is no increased risk with an IUCD provided the infection has been adequately treated.

Answer 109

BE Smooth muscle is found around the internal and external os, which act like sphincters. In the non-pregnant state, the cervix consists mostly of connective tissue (collagen). In late pregnancy, the matrix of connective tissue becomes softer with a greater water content. The cervical canal is lined by columnar epithelium, the external surface of the cervix is covered by squamous epithelium.

Answer 110

BD The inferior epigastric is a branch of the EXTERNAL iliac artery. The inferior mesenteric and the ovarian artery are branches from the AORTA

Answer 111

ABDE At ovulation there is a reversal of peristalsis The ampulla is the commonest site within the Fallopian tube for fertilisation to take place. Oestrogen reduces the motility of the tube. The Fallopian tube has 4 parts, going from the uterus to the ovary: intramural (cornual), isthmus, ampulla, infidibulum which ends with the fimbriae.

Answer 112

D Maternal CO rises by 40% during pregnancy. The increased circulating volume is due to an increase in plasma volume (and there is a dilution anaemia - although red cell mass does increase, it doesn't to the same extent as the increase in circulating volume). Only treat anaemia when Hb

Answer 113

``` A: 2 B: 1 C: 10 D: 6 E: 4 ``` Progesterone relaxes the myometrium and exerts a negative feedback on LH. Testosterone and androstenedione are produced by thecal cells from cholesterol (in response to LH), and then converted to estradiol by granulosa cells in response to FSH. The placenta is sampled in CVS, and the amniotic fluid sampled in amniocentesis. The number of placental lobules is fixed by 12 weeks from the LMP. The genital organs are differentiated by 8 weeks from LMP. Human placental lactogen alters glucose and insulin

Answer 114

DEFIJ The normal duration of the follicular phase is between 9 and 18 days, while the luteal phase is more constant at 12-14 days, therefore ovulation is usually assumed to occur 14 days prior to the next period (30-14 = 16). Ovulation usually occurs at estradiol levels of 800-1200pmol/L and a follicular diameter of 18-25mm. The high levels of estradiol trigger the LH surge which luteinises the granulosa cells to start producing progesterone as well as estradiol. Ovulation may occur from either ovary and commonly alternates.

Answer 115

BCE Progesterone levels rise in the luteal phase of the menstrual cycle. In pregnancy the corpus luteum is maintained by the action of hCG, so progesterone levels remain high and rise in the early stages of pregnancy. In abnormal pregnancies, the progesterone levels tend to be low and this can be of diagnostic assistance in ectopic pregnancy and miscarriage. Choriocarcinoma is associated with raised levels of hCG and so progesterone levels are often high.

Answer 116

BCDE After the follicle ruptures, it changes to becomes the corpus luteum, which secretes progesterone under the stimulation of LH. If pregnancy does not result then the corpus luteum starts to degenerate, this withdraws hormonal support from the endometrium and menstruation begins.

Answer 117

ACDFI Oestrogen and progesterone are both essential in the normal development of the endometrium and initiation of menstruation. Abnormal oestrogen and progesterone levels and their timing during the menstrual cycle may lead to abnormal menstruation. Spasm of the arterioles appears to be under the control of prostaglandins in the endometrium. Local clotting mechanisms are important for menstrual flow. Fibrinolysis leads to the breakdown of clots which normally close the arterioles. Menstrual loss is also dependent on the speed of endometrial regeneration, which is dependent on oestrogen. Prolonged exposure of the endometrium to unopposed oestrogen increases the risk of endometrial carcinoma. Ovulation leads to the normal development of the endometrium and normal menstruation. The average menstrual blood loss is 30mL, with a range of 15-180mL

Answer 118

B The relationship between the dysplasia seen on a cervical smear is not absolute, which is why women with abnormal smears are referred to colposcopy clinic for further examination and a cervical biopsy or loop excision of the TZ. In CIN1, a proportion of women will revert to having normal cervical cells with no treatment, whilst those with CIN3 commonly go on to develop cervical cancer. CIN is associated with HPV16 & 18, sexually associated not an STI, and so CIN and cervical cancer are very rare in women who are virgo intacta.

Answer 119

CE The respiratory rate increases secondary to the effect of progesterone CO increases from 4L to 6L (40%) Renal flow increases by 30-50%

Answer 120

A - Cystic fibrosis: AR AD: Huntingdon's chorea and Hurler's syndrome Androgen insensitivity syndrome is due to a deletion in the androgen receptor gene on the X chromosome. von Willebrand's disease is a variation of haemophilia (reduced factor 9) and is usually X-linked.

Answer 121

ADE As the uterus grows, the diaphragm is unable to descend during inspiration. The increased total circulating blood volume increases the left ventricular volume. Changes in the collagen of the aorta and the position of the heart unfolds the aortic arch

Answer 122

BE Stage 1 disease is carcinoma confined to the endometrium, with no invasion into the myometrium. It usually presents with PMB. Squamous cell cancer is more common in cervical cancer, whereas endometrial cancer is commonly adenocarcinoma

Answer 123

1B; 2G; 3H; 4I; 5J There are many factors that are thought to precipitate the onset of labour. These include a drop in progesterone and relaxin, release of cortisol from the fetal adrenals, an increase in prostaglandin production by the placenta and release of oxytocin by the maternal pituitary. Stimulation of the nipples release oxytocin from the pituitary and is called the 'let-down' reflex during lactation. Bromocriptine is a dopamine agonist used for treating hyperprolactinaemia to inhibit prolactin production. Prostaglandins are associated with a change in the collagen matrix of the cervix

Answer 124

AC HSV2 causes genital herpes. HPV is associated with an increased risk of developing cervical cancer. HIV is associated with an increased risk of intrauterine death of an otherwise normal baby. The most severe chicken pox occurs if the infant is born within 7 days of onset of the maternal rash. Fetal Varicella Syndrome: T1 - no increase in spontaneous miscarriage rate, but characterised by skin scarring in a dermatomal distribution, microphthalmia, chorioretinitis, cataracts, hypoplasia of the limbs, neurological abnormalities. The risk of FVS if a mother develops chickenpox is approximately 0.2% under 13 weeks of gestation, and 2% at 13-20 weeks of gestation Parvovirus: Infection in the first 20 weeks of pregnancy carries an increase of 9% in the risk of intrauterine death, and a 3% risk of hydrops fetalis. Of these, 50% die. Intrauterine transfusion reduces mortality rate. This typically occurs 3-5 weeks after the onset of maternal symptoms.

Answer 125

ACD Duodenal atresia is diagnosed by seeing a double bubble in the fetal stomach. Exomphalos is a defect in the anterior abdominal wall of the bowel and/or liver visible in a sac outside the body of the foetus. Renal agenesis is usually associated with anhydramnios which raises the suspicion of the ultrasonographer to look carefully for the presence of the kidneys and bladder. Tracheosophageal fistulae are only occasionally detected on USS. Major cardiac abnormalities should be detected, but the final diagnosis should be made at 24 weeks from a detailed fetal cardiac ultrasound in a specialist unit.

Answer 126

ABDGI Women with pre-eclampsia should be delivered vaginally if at all possible - they are more likely to end up with a C-section but they do not have to be delivered by C-section. Epigastric pain is a sign of hepatic capsule oedema and impending liver abnormalities as part of the HELLP syndrome. Pre-eclampsia is associated with an increased risk of DVT and DIC, as well as placental abruption. Pre-eclampsia most commonly arises after 36 weeks of pregnancy. Magnesium sulphate is used in fulminating pre-eclampsia when there is a risk that women may develop eclampsia. First line treatment for hypertension includes methyldopa, nifedipine and hydralazine. Oedema is often present in pre-eclampsia but is not diagnostic.

Answer 127

ABC Most women have a physiological anaemia in pregnancy due to an increased circulating plasma volume. The normal range in pregnancy is 105-125g/L. Below this value iron supplementation should be offered, a transfusion is not warranted at term unless the women is symptomatic (rare above 80g/L). Systemic iron is more appropriate but some women have an anaphylactic reaction to IM iron. B1 deficiency is very rare in pregnancy and is usually secondary to excess alcohol intake or a pathological process. Sickle cell disease and beta thalassaemia are both associated with an anaemia in pregnancy.

Answer 128

C | There is no evidence that strict bed rest reduces the risk of miscarriage. Smoking is associated with IUGR

Answer 129

E Routine anomaly scanning should detect 100% of foetuses with anencephaly and up to 92% of spina bifida cases. The prognosis in spina bifida depends on the level and length of the defect. Foetuses with spina bifida at L4/5 have a very high chance of survival into adulthood life, although they may be incontinent and have partial lower limb paralysis. Pre-conceptual folic acid has been shown to significantly reduce the risk of neural tube defects

Answer 130

C All women who are rhesus negative should be given 500IU anti-D if they have an APH. They do not require a transfusion unless the blood loss is significant and they are very anaemic

Answer 131

E Placenta previa usually presents with painless vaginal bleeding. Placenta accreta (myometrium), increta (deep myometrium) and percreta (peritoneum) are terms which describe the depth of invasion of the placenta into the myometrium - the placenta is abnormally strongly attached to the uterine wall. Placental abruption: separation of the placenta before delivery of the foetus (mortality 15%). May be concealed (20%) or revealed (80%). Presents with vaginal bleeding, abdominal pain, uterine contractions, shock and fetal distress. Woody hard tender uterus.

Answer 132

BE This women is probably having a placental abruption and may go into shock. She should have a FBC and cross match 2 units of blood. Peripheral venous access is essential and 2 units of gelofusine (not normal saline) should be infused to maintain her intravascular circulating volume until blood is available. A CTG is indicated immediately to determine whether or not the baby is alive or showing signs of hypoxia. A CVP may be needed later but is not the first line of action.

Answer 133

C | The Bishops score is used to assess the cervix prior to IOL, and the score determines the method of IOL.

Answer 134

ABC 10% of pregnancies are breech at 32 weeks, but this reduces to 2-3% at term because of spontaneous cephalic version. Breech presentation is associated with fetal congenital dislocation of the hips and neural tube defects

Answer 135

DE Breast feeding has been shown to increase the risk of vertical transmission of HIV from mother to baby. Antiretroviral agents have not been shown to be teratogenic, and reduce the risk of vertical transmission from 25% to 8%.

Answer 136

BC There is no evidence that a RML episiotomy reduces the risk of 3rd degree tears. Midline 2nd degree tears have been shown to heal faster than RML episiotomies. Assisted vaginal deliveries with a ventouse can be performed without recourse to an episiotomy as the ventouse does not increase the diameter of the fetal head. An episiotomy does allow the baby to be delivered faster in the presence of fetal distress. In the case of a shoulder dystocia an episiotomy allows internal manipulation of the shoulders to expedite delivery, although there is no evidence that it increases the chances of delivering the shoulders using MacRobert's manoeuvre or suprapubic pressure.

Answer 137

D The most likely diagnosis and the one that must be excluded is obstetric cholestasis, which is known to increase the risk of intrauterine death. The diagnosis is made on abnormal LFTs and raised bile acids

Answer 138

CDE Colostrum in the first few days and breast milk contain active white cells, macrophages, IgA, IgG and lactoferrin which are all anti-infective agents which protect the baby during the early weeks and months of life from bacterial and viral infections. Breast feeding reduces the risk of breast cancer in later life, while pregnancy reduces the risk of ovarian cancer.

Answer 139

ACDE Smoking and anorexia are both associated with IUGR leading to premature delivery for fetal reasons. Smoking is associated with increased risk of spontaneous pre-term labour. Essential HTN increases the risk of early onset pre-eclampsia leading to delivery for maternal reasons and is also associated with IUGR. Obesity is associated with an increased risk of developing GDM, but not pre-term delivery.

Answer 140

C Candidiasis can affect the pharynx and mouth, but rarely causes oral or genital ulcers, a pyrexia or lymphadenopathy. Gonorrhoea can present with pyrexia but does not cause ulcers. Syphilis causes oral and genital ulcers with lymphadenopathy, but not typically a high fever. Trichomonas presents with vaginal discharge and no other symptoms.

Answer 141

B GSUI is caused by descent of the bladder neck below the levator ani sling when intra-abdominal pressure is increased (laughing, coughing, sneezing). DI presents with frequency and urgency. Neurogenic bladders typically present with retention/overflow incontinence. Pyelonephritis presents with a pyrexia, frequency, loin pain, renal colic. UTI presents with frequency and dysuria.

Answer 142

AC Benign teratomas are more common in women under the age of 25 than older women. They have an increased risk of torsion, but rarely rupture because they have a thickened capsule. They can be diagnosed on plain AXR because they commonly contain teeth which are radio-opaque. They do not interfere with ovulation and therefore do not present with amenorrhoea.

Answer 143

D Ovarian cysts in early pregnancy are usually physiological (corpus luteum) and are necessary for the continuance of the pregnancy. They usually resolve spontaneously in the 2nd trimester

Answer 144

ACD | Menorrhagia is defined as blood loss of >80mL per menstrual cycle. Sterilisation does not cause heavy periods.

Answer 145

C | PCOS accounts for 70% of anovulatory subfertility

Answer 146

BC Endometriosis classically causes cyclical abdominal pain and often dyspareunia. It rarely affects tubal function or ovulation but is associated with subfertility

Answer 147

D In an ectopic pregnancy it is quite common for women to have some vaginal bleeding at around the expected time of menstruation even though they are pregnant. A positive pregnancy test with unilateral pelvic pain and cervical excitation is highly suggestive of an ectopic pregnancy.

Answer 148

J | Torsion of an ovarian cyst is commonly associated with nausea and vomiting, as is appendicitis.

Answer 149

A | The lack of cervical excitation and a pyrexia with nausea and vomiting is suggestive of appendicitis

Answer 150

G Bilateral tenderness with a high temperature suggests PID Notes: Endometriosis symptoms tend to arise in the late luteal phase.

Answer 151

B Platinum based drugs are the 1st line treatment for ovrian cancer. carboplatin is less nephrotoxic and neurotxic than cisplatin and is now the platinum based drug of choice with taxol (NICE 2002)

Answer 152

AD HPV RNA has been found in 80% of cases of cervical squamocarcinoma. Stage I and II are treated with surgery. Stage III disease is treated with radiotherapy as cervical squamocarcinoma is not very senstive to chemotherapy, although it is sometimes used to debulk the tumour prior to surgery

Answer 153

B Progestogens are the most effective because endometrial carcinoma is oestrogen dependent. it also has minimal side effects compared to the other chemotherapeutic agents

Answer 154

BD Echogenic foci in a cyst are always considered pathological and removal is recommended. In a woman of 53, there is increased risk of ovarian cancer, while a woman of 23 is more likely to have a dermoid cyst.

Answer 155

DE Urinary rentention can occur in the first few days following a vaginal hysterectomy, but is not a recognised long term complication.

Answer 156

D This is the treatment of choice for endometrial carcinoma stage I and II. Wertheim's hysterectomy is a radical hysterectomy which includes cervical lymphadenectomy and is the treatment of choice in cervical cancer stage Ib.

Answer 157

ACD The transverse diameter of the pelvis averages 13cm, but the longest axis of the pelvis rotates through 90 degrees, not 120 degrees. The outlet of the pelvis s diamond shaped with its longest axis running A-P.

Answer 158

BFGHJ GnRH is a small polypeptide produced by the HYPOthalamus. It flows through the pituitary portal system to stimulate the secretion of FSH and LH from the pituitary gland. GnRH is released in pulses every 90 minutes and this pulsatile secretion is vital for continued reproductive function. Continuous GnRH secretion leads to decreased stimulation of the pituitary. Because of this GnRH agonist can be used in the treatment of benign gynaecological disease, such as endometriosis. The secretion of GnRH is controlled by feedback of oestrogen and progesterone from the ovary.

Answer 159

BDE Doderlein's bacilli reduce the pH of vaginal secretions. Oestrogen and progesterone both reduce the motility of the Fallopian tube. Progesterone reduces the contractility of the myometrium, whilst oestrogen increases it. Oestrogen reduces the viscosity of cervical and vaginal secretions, in order to allow sperm to travel more easily into the uterus

Answer 160

AB Vulva = inguinal LNs Cervix & uterus = internal iliac nodes

Answer 161

E The transformation zone is formed by squamous metaplasia of columnar cells that line the cervical canal. Usually the TZ lies just inside the cervical canal. Under the influence of oestrogen (in pregnancy, COCP use) the TZ extends onto the surface of the cervix (ectropion), but never into the vaginal fornices.

Answer 162

CE Fertilisation usually takes place in the ampulla region of the Fallopian tube. A single spermatozoon penetrates the zona pellucida of the oocyte, not the polar body, which regresses soon after fertilisation. The embryo implants between 6-8 days after fertilisation. Progesterone is essential for the changes in the arterioles and glands of the uterus to produce spiralling and secretion of glycogen for the nutrition of the developing embryo in the tube and uterus. Decidualisation of the endometrium is also controlled by progesterone and mucopolysaccharides secreted on the surface of the embryo

Answer 163

CD The umbilical cord contains 2 arteries and 1 vein. The fetal surface of the placenta is covered by the amnion - the chorion is fused at the edges of the placental disc. Oxygenated blood is carried along the umbilical artery into the right side of the heart and onto the left side via the foramen ovale. In order to prevent pulmonary hypertension, the ductus arteriosus runs between the pulmonary artery and the aorta so that only a small amount of oxygenated blood from the right side reaches the pulmonary circulation.

Answer 164

AD Vaginal discharge changes throughout the menstrual cycle. In the early follicular phase and are luteal phase there is often very little discharge, which, if present, is usually thick and white. Mid-cycle the discharge becomes less viscid and acellular allowing the sperm to flow through more easily. In the luteal phase the discharge is usually thick and creamy white

Answer 165

AC Oestradiol is the main steroid hormone secreted by the developing follicle. It controls the growth of the endometrium in the follicular phase of the cycle, mainly by increasing the number of cells (proliferation). Secretion of oestrogen is controlled by FSH and LH. Oestrogen levels are at their lowest premenstrually, and at their highest at the time of ovulation

Answer 166

C - Candida

Answer 167

H Spirochaetes can be detected by dark field microscopy in primary syphilis, whilst serum tests are used to detect secondary syphilis. Staph aureus is a common commensal on the skin which may cause toxic shock syndrome if the vagina becomes infected

Answer 168

I Trichomonas

Answer 169

B - Beta haemolytic streptococcus

Answer 170

A Bacterial vaginosis/Gardnerella are commonly associated with clue cells (vaginal epithelial cells with a stippled cytoplasm). Tuberculosis is a mycobacterium that may rarely cause PID Chlamydia is detected using and enzyme linked immune assay or fluorescent monoclonal anti-bodies on a smear Gonorrhoea is a gram positive coccus which grows in Stewarts medium.

Answer 171

D LDH, hCG and AFP are associated with choriocarcinoma, teratomas and dysgerminomas. CEA is most commonly used in the detection of gastric and colon tumours

Answer 172

AC The red cell mass is increased, but there is a relative anaemia because of the increase in plasma volume. The renal threshold for glucose is decreased, so it is more common to find glucose in the urine of pregnant women, even if they are not diabetic. The renal reabsorption is increased by 30-50%

Answer 173

BD A woman is defined as being post-menopausal if she has not had a period for 12 months. Withdrawal of oestrogen causes changes to the urethral and vaginal epithelimum, causing irritation, dryness and dyspareunia. Heavy irregular vaginal bleeding is quite common around the time of the menopause because the endometrium is exposed to oestrogens, even though the ovaries are no longer ovulating. FSH levels rise before LH levels

Answer 174

BDE Trisomy is a recognised cause of spontaneous miscarriage, so the risk of trisomy decreases with increasing gestational age of the foetus. Down's syndrome is only one of the trisomies, so the risk for all trisomies is greater at all ages. The age of the father does not seem to increase the risk of trisomy

Answer 175

D - Identifies a group at high risk of neural tube defect. AFP levels are raised in normal pregnancy but are significantly raised in women who have a foetus with a NTD and decreased in a Down's foetus.

Answer 176

E - Hepatitis B is rarely transmitted to the foetus in utero, but may be in the immediate neonatal period, so immunisation is recommended in neonates born to hepatitis B positive mothers.

Answer 177

B Rubella infection in the second trimester is associated with deafness, blindness and mental retardation. Cardiac abnormalities are associated with the major trisomies and there is an increased risk in women with poorly controlled T1DM. Gestational DM is associated with macrosomia

Answer 178

I - anti-D should be given to all Rhesus negative women after a sensitising event and routinely at 28 and 34 weeks (500u)

Answer 179

H Toxoplasmosis can cause fetal mental retardation, IUGR and intrauterine death and is transmitted from the faeces of cats - so women are advised not to handle cat litter trays. Dog faeces can cause trachoma in young children

Answer 180

BE The risk of Down's syndrome starts to rise from the age of 36 at conception, at 32 the risk from age alone is around 1:600. The risk of Down's syndrome does not increase with the number of pregnancies, although many women having their 4th child are over the age of 36. Women with a family history of haemophilia are usually offered CVS because this can be performed earlier, and it is easier to do a PCR on a CVS sample than from the squames obtained at amniocentesis. AN amniocentesis can be used if a NTD is suspected for the measurement of AFP, rather than chromosomes since NTDs are rarely associated with a chromosomal abnormality.

Answer 181

ACD Fetal movements are a good indicator of fetal well being. The Cardiff kick chart asks women to mark the time each day when they have felt the baby kick 10 times. A reduction in liquor volume is an indication that the baby may be becoming hypoxic and is often associated with IUGR. Umbilical artery waveforms are used to detect foetuses which are hypoxic. Absent end-diastolic flow and reverse end diastolic flow are signs that the foetus is probably becoming hypoxic. Amniocentesis is used to detect chromosomal abnormalities, infection, jaundice secondary to haemolytic disease of the newborn, and rarely these days to see if the lungs are mature using the lecithin:sphingomyelin ratio - it is not used to detect hypoxia. Abdominal palpation is relatively poor at detecting IUGR, and, unless fetal movements are felt, is not a good measure of fetal well being

Answer 182

AC Measurement of fetal abdominal circumference does not accurately predict shoulder dystocia, although can be used to identify a group of babies that may be at increased risk. The fetal AC is used to detect macrosomia in GDM, and IUGR in women with pre-eclampsia, where the AC may be reduced relative to the head circumference

Answer 183

ACDGI Teenage pregnancies have an increased prevalence of pre-eclampsia or pregnancy induced hypertension compared with women aged 20-34. A 1st degree relative with T2DM increases the risk of the mother developing GDM because the family may have a genetic predisposition to insulin resistance. A 1st degree relative with T1DM does not increase the risk of developing complications in pregnancy. Essential HTN at booking increases the risk of complications in pregnancy, particularly GDM and PET. Women with a low BMI are at increased risk of having a SGA baby. Sickle cell trait in either parent or a family history of Huntingdons chorea does not increase the risk of maternal complications, although genetic counselling with regard to risk to the foetus inheriting sickle cell anaemia (AR) or huntington's chorea (AD) should be offered.

Answer 184

ABC Cardiac abnormalities are associated with an increased nuchal translucency measurement because of early onset fetal hydrops. Routine anomaly USS detect 40-61% of serious cardiac anomalies. Fetal cardiac echocardiography is required for an accurate diagnosis

Answer 185

B Renal agenesis occurs in 1:3000-10,000 births. Recurrence rate is 2-5%. Unilateral renal agenesis is more common than bilateral agenesis. Renal agenesis is associated with early onset oligohydramnios and pulmonary hypoplasia. It is not an inherited disorder. It is a common feature of trisomy 13 and 16, but is virtually never seen in babies with Down's syndrome. Bilateral renal agenesis is universally fatal shortly after birth

Answer 186

A This women does not have sickle cell disease so she does not require any medical intervention. Genetic counselling will inform her of the risk for her child having sickle cell anaemia so she can decide whether or not to have a CVS to determine whether the child has sickle cell anaemia or not.

Answer 187

B Beta haemolytic streptococci are found as a normal commensal in 10% of women. CIN-1 does not cause spontaneous vaginal bleeding, whilst a polyp may. Preterm premature rupture of membranes is not a cause of bleeding unless there is placental abruption or prevue associated with it BV = fishy odour discharge, clue cells, sexually associated

Answer 188

E After 4 hours one would expect the cervical dilatation to be 8cm (1cm/hour). Plotting the cartogram would show that the women had reached the action line. Since the membranes are intact the next step would be to rupture the membranes. A membrane sweep is performed if a women has not gone into spontaneous labour at term plus 5-9 days to try and encourage onset (70% of women will go into spontaneous labour within 48 hours). Prostin is used to induce labour and never used in active labour. Syntocinon should not be started with the membranes intact.

Answer 189

ABD Mifepristone and misoprostal are used for medical terminations of pregnancy and for IOL in cases of intrauterine death (not normal) at any gestation. Misoprostal alone is being increasingly used for IOL because it is much cheaper than prostin and as effective. Syntocinon alone should not be used if the membranes are intact. Artificial rupture of membranes is used if the cervix is already dilated (Bishop's score > 6) - most commonly in multigravida women

Answer 190

BC Vaginal breech delivery can be considered at term in a normally growth foetus presenting as an extended breech, provided the onset of labour is spontaneous and progress in labour is normal. IOL is contraindicated in breech presentations, particulalrly when the cervix is found to be unfavourable (Bishop's score

Answer 191

AD Hyperactivity and confusion are symptoms of postnatal psychosis rather than depression. Nausea is not a symptom of post natal depression and is rare in the post natal period

Answer 192

BCE Although steroids increase the risk of infection, the benefit of steroid administration for the foetus is much greater than the risk to the mother of sepsis and should therefore be given to all women in premature labour. The main benefits to the foetus are a reduction in the risk of developing severe respiratory distress syndrome and intraventricular haemorrhage. Recent guidelines from RCOG state steroids should be given to all women in labour at less than 37 completed weeks of gestation

Answer 193

C The most likely diagnosis and the one that must be excluded is obstetric cholestasis which is known to increase the risk of intrauterine death. Eczema and psoriasis do cause itching but are usually present prior to pregnancy and are associated with well recognised rashes. Cholelithiasis and jaundice are rarely precipitated by pregnancy

Answer 194

D Suction to the airways causes a bradycardia, and unless there is thick meconium the priority is to give the baby oxygen via a mask. 5 breaths from a 250mL bag via a face mask is the recommended first step to clear fluid from the lungs. Cardiac massage is not recommended as the HR is greater than 100

Answer 195

BCD HIV testing is not universal yet in England and Wales, but is highly recommended in areas with a high prevalence (inner cities). Early consultant involvement in high risk cases has been recommended in every Confidential Enquiry and has finally resulted in consultants being present during the day on the majority of labour wards. Thromboprophylaxis has been shown to reduce the incidence of post-partum thrombosis and antibiotics reduce the incidence of postpartum sepsis. Increased ante-natal care in the community was recommended by Baroness Cumberlidge, but has yet to prove that it reduces maternal mortality

Answer 196

CD The aim of emergency contraception is to prevent implantation of a fertilised ovum. Clomiphene is used to induced ovulation. The combined pill when taken correctly prevents ovulation but does not prevent implantation of a fertilised ovum. Danazol is a progestogen and doesn't prevent implantation.

Answer 197

ABD | The labia major are equivalent to the scrotal skin in the male. The clitoris is the penile equivalent in a female

Answer 198

A This woman has candidiasis as her primary diagnosis. A topical anti-fungal is the treatment of choice. Oral anti-fungals are 2nd or 3rd line therapy

Answer 199

A The normal range for the duration of the menstrual cycle is 26-32 days. Acne is very common in teenagers. Following prolonged use of Depo-provera amenorrhoea is common and it can take up to 18 months for ovulation to resume on a regular basis

Answer 200

D The history is suggestive of obstructed outflow to menstrual blood. Haematocolpos (secondary to cervical stenosis) is a very rare congential abnormality, whilst imperforate hymen is more common. Endometriosis, bicornuate uterus and dermoid cysts are not a cause of primary amenorrhoea.

Answer 201

ACE Evidence shows that NSAIDs decrease menstrual loss by 30% in women proven to have heavy periods. In contrast cyclical progestogens and the POP have been shown to be ineffective. Antifibrinolytics (tranexamic acid) reduces blood loss by up to 40%. The COCP is highly effective in women with no contraindications.

Answer 202

BD Turner's syndrome girls have streak gonads that do not produce oestrogen or oocytes so there is no negative feedback on the pituitary. Women with PCOS may have a raised LH, but still have a normal FSH. Women with androgen insensitivity syndrome have normal male testosterone levels (unless they have had a gonadectomy) but have no ability to respond to the testosterone, so there is no negative feedback on the pituitary. If they have had a gonadectomy then the levels are raised as per Turner's syndrome

Answer 203

E - Clomiphene achieves ovulation in 70% of women with PCOS.

Answer 204

G. In-vitro fertilisation has a higher success rate and lower ectopic pregnancy rate than tubal surgery for bilateral tube damage.

Answer 205

FSH - Women with hypogonadotrophic hypogonadiam have a 90% chance of becoming pregnant with FSH injections.

Answer 206

B | Men with Klinefelter's cannot use their own sperm (if they have any) as there is a high risk of trisomy.

Answer 207

H. Intracytoplasmic sperm injection is successful as a treatment for oligospermia.

Answer 208

ABE Endometriosis will not be cured by hysterectomy alone, removal of ovaries is required as well. Since DUB is not associated with any pathology, more conservative methods of treatment should be offered before hysterectomy is performed.

Answer 209

E - Omentectomy, TAH and bi-lateral salpingo-oophorectomy Ovarian cysts should always be presumed to be malignant in post-menopausal women. An omental metastases confirms the diagnosis of ovarian cancer. Surgery therefore includes removal of ovaries, tube, uterus and omentum.

Answer 210

B. Examination under anaesthesia, hysteroscopy and endometrial biopsy This remains the staging priced of choice because the examination will reveal any parametrial involvement which alters the stage of disease and subsequent therapy. A formal endometrial biopsy is essential rather than an endometrial sample obtained using a pipelle or Vabra cannula

Answer 211

C. Hysterectomy and bilateral salpingoopherectomy, internal, external iliac and obturator lymphadenectomy Inguinal lymph nodes are removed in cases of vulval carcinoma. In cervical carcinoma all pelvic LNs are removed

Answer 212

A. Simple vulvectomy and bilateral inguinal lymphadenectomy The lymphatic drainage of the vulva is to the inguinal LNs. Even if there is no clinical evidence of lymphatic involvement the inguinal LNs should be removed.

Answer 213

AC - Dysgerminomas and Dermoid Cysts Granulosa cells tumours secrete oestrogen. Mucinous cystadenoma is a benign epithelial cell ovarian cyst. Dermoid cysts contain well-differentiated embryonic tissues including teeth, bone, neural tissue, renal tissue etc.

Answer 214

CD - Presence of an intrauterine device and multiple sexual partners are risk factors for PID Although some young women tend to have more sexual partners, age alone does not increase the risk per se. Oral contraceptives protect against PID by thickening the vaginal secretions. Barrier contraception is the most effective preventative measure against PID

Answer 215

CDE - Missing pills at the end of a packet, or failing to start a new packet on time increases the pill free interval and allows the ovary time to ovulate. Antibiotics can increase the GI transit time and decrease absorption of the pill making it less effective.

Answer 216

BE The COCP is associated with an increased risk of developing HTN and thrombosis thus making these 2 pre-existing conditions absolute contra-indications for the COCP

Answer 217

ADE Warfarin is used to treat proven thrombo-embolic disease. The majority of women with recurrent miscarriage associated with anti-phospholipid syndrome have not had a proven DVT or PE. Warfarin is contraindicated in these early stages of pregnancy so heparin is used in prophylactic doses. This has been shown to improve the take home baby rate from 10% to 40% in such women. Miscarriage is significantly commoner in women over the age of 38.

Answer 218

E The 2 membranous areas are called fontanelles. The anterior one is diamond shaped, whilst the posterior one is triangle shaped. The largest diameter is the mentovertical diameter (brow presentation). The submentobregmatic diameter is a face presentation, but has the same diameter as the suboccipitobregmatic diameter (vertex presentation). The suboccipito-frontal diameter is only very slightly larger than a vertex presentation and does not normally cause a problem