Obs and Gynae

Question 1

Abdo pain DDX in preggers and timing if known

Answer 1

Non Gyane

UTI
Pyelonephritis
Cholesystitis
Appendicitis
Pancreatitis
Ligament strain 
Rectus sheath haematoma
Gastroenteritis

Gynae

Miscarriage
Pre Eclampsia
Ovarian cyst rupture/ torsion 
Uterine torsion 
Uterine rupture T3
Fibroids T2
Abruption

Question 2

Presentation of cholecystitis in preggers and management

Answer 2

Presentation
		Less likelly jaudice
		Pain, nausea and vomiting
	Diagnosis
		If appendicitis cannot be ruled out (presence of stone?) then lapaoroscopy
	Management
		Conserve
		Severe then lap chole - some risk of miscarriage/ pre term labour

Question 3

Presentation, DDX adn Management of pyelonephritis in preggers

Answer 3

More common in congenital renal abnormalities, neuropathic bladder and stone
	Presentation
		Frequency
		Urgency
		May not have other symptoms
		May be severe with
			Tachy
			Vomiting
			Loin pain
	DDX 
		Hyperemesis gravidarum
	Management
		Blood and urine culture
		IV cefuroxime (2nd)
If septic - stat gentamicin

Question 4

management of UTI in preggers

Answer 4

Management
Trimethaprim CI in T1
Nitrofluratoin CI in T3 (neonatal haemolytic anaemia)
Cefalexin (1st gen) first line
Argument for treasting asymptomatic bacteriuria due to risk of UTI
Follow up post cystiits with MSU to ensure resolution

Question 5

Classical presentation of abruption adn complications

Answer 5

The triad 
		Abdo pain
		Uterine rigidity 
		Vaginal bleeding
	1 in 200 preggers
	Comps
		DIC - high rate up to 50%
		PPH
High fetal loss

Question 6

Uterine perforation presentation

Answer 6

abdominal pain (may be vague)
		Tenderness (over scar)
		PV bleed (may be absent)
		Late T3/ Labour
		Signs
			Shock
			Maternal hypertension
			Cessation of contraction
			Dissapearence of presenting part of baby during labour
			Fetal distress (CTG)
		Post partum
Failure of PPH to cease with well contracted uterus

Question 7

Uterine perforation RFs

Answer 7

C section - scar pain
Obstruction
High foceps delivery - (CI above ischael spine)Internal version - manual turning via vagina
Obstructed in multiparous - especially if oxytocin used
Previous cervical/ uterine surgery
Breech extractaction

Question 8

Management of uterine perforation

Answer 8

If in labour then cat 1 CS
High flow O2
Crossmatch 6 units and fast transfusion
Repair may be possible unless involves cervix or vagina in which case hysterectomy
Post op abx - cef and metro?

Question 9

Uterine torsion patho

Answer 9

When it rotates >90 deg
Adrenax mass
Fibroids
Congential asymmetrical uterine anomalies

Question 10

Uterine torsion presention

Answer 10

Mid to late preggers
		Abdo pain
		Shock
		Tenderness
Urinary retention

Question 11

Management of uterine torsion

Answer 11

Resus
Catheter ( may shows location of uterus)
Diagnostic lapaotomy
LSCS

Question 12

Fibroids presentation in preggers

Answer 12

Abdo pain
		\+/- vomiting and low grade fever
		Localised peritoneal tenderness
			Last half of preggers or puerperium
Large for dates

Question 13

Fibroids pathophysiology and investigation in preg

Answer 13

RF
		Afro Carribean
		Increase in size during preggers/ T2
	Investigation
		US
		Colour flow Doppler - Fibroids vs Myometrium
	Patho
		If pedunculated may become tort
		Red degendeation in 50% preggers= thrombosis of capsular vessels followed by venous enghorement and inflammation = pain

Question 14

Fibroids management in preg

Answer 14

Bed rest and analgesia (resolution =4-7 days
Most in body so do not obstruct(tend to rise in preggers)
Obstructed = CS

Question 15

OVarian torsio/ cyst rupture patho

Answer 15

x Uterine cysts are very common
>5cm troublesome unless symptomatic
Uterus growing raises and displaces ovaries
Venous return becoming oedematous eventually impeding arterial

Question 16

Benign cyst presentation

Answer 16

Asymptomatic
			Chronic pain with full ache
			Irregular vaginal bleed
			Abdo swelling or mass (if malig then ascites)
Unilateral iliac fossa pain

Question 17

Presentation torsion/ rupture

Answer 17

Torsion = severe pain and vomiting
Improve over 24hr as ovary starts to due
Rupture = torsion symptoms with shock/ ?bleeding

	Examination
		Adnexal mass
		Cervical excitation Bleeding/ discharge

Question 18

Investigations of benign cysts

Answer 18

TVS
			Malignant (multilocaular cyst, wall projections, solid areas, mets, ascites, bilateral lesion
		Transabdo imagin
		ing if large
		>7cm then ?MRI
Staging CT/ MRI

Question 19

management of acute torsion/rupture

Answer 19

Acute pain

Urgent laparoscopy after TVS

Question 20

Management of benign cysts

Answer 20

Pre menopausal
			Preserve fertility and exclude malig
			Nothing if <5 cm and non malig.
			Follow up
			Vs laparoscopy (avoid spilling)
		Post meno
			Risk of Malignancy Index
			Repeat TVS and CA125 to folow up every 4 months
			Bilater oophorectomy
			High risk = staging

Question 21

Fibroids patho and natural history and RFs

Answer 21

Benign SM tumours, 20% of white and 50% of black women
Normally regress after menopause

RF
AfroCarribean
Age - response to puberty/ oestrogen

Question 22

Fibroids Symptoms

Answer 22

may be asymptomatic
menorrhagia
lower abdominal pain: cramping pains, often during menstruation
bloating
urinary symptoms, e.g. frequency, may occur with larger fibroids
subfertility

Question 23

Diagnosis fibroids

Answer 23

TV US

Question 24

Management fibroids

Answer 24

Management
symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
other options include tranexamic acid, combined oral contraceptive pill etc
GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment
Hot flushes
Osteoporosis
surgery is sometimes neede if >3cm/ distoring uterine cavity: myomectomy, hysterscopic endometrial ablation, hysterectomy
uterine artery embolization
GnRhH before surgery to shrink

Question 25

Comps of fibroids

Answer 25

red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Question 26

Presentaiton of endometrial hyperlasia

Answer 26

IMB PMBMenorrhagia Dysmenorrhea

Question 27

Management of endometrial hyperplasia

Answer 27

``` Management Simple High dose prog every 3-4 months Levonorgestrel IUD Rebiopsy after 6-12months Atypia Hysterectomy with bilat salpingo oophorectomy (risk of malignant progression ```

Question 28

Chronic pelvic pain cause

Answer 28

Physical: IBS, interstitial cystitis, Chronic infection e.g. PID, endometriosis/adenomyosis, Neuopathic pain form previous laproscopies. Psychosexual: Depression, child abuse, Emotional problems, stress

Question 29

Chronic pelivc pain management

Answer 29

Mnaagement MDT Consider GnRH analogie to supress ovaries if cylical, can predict outcome of hysterectomy DDX Pelvic congestion/ migraines (treat with migrain treatment) ``` BIo Exploration of depressive symptoms - SSRI? Trial of GnRH anologue as pain is cyclical Psycho CBT Pain clinic referral Social Exercise Diet Cognitive methods e.g. meditation ``` If GnRH does not improve symptoms oophorectomy less likely to work. If not then could trial a neuropathic pain modifier e.g. amitryptilline before offering surgery

Question 30

Pathology/ RF endometrial hyperplasia

Answer 30

Abnormal proliferation of endometrium in excess if norm RF for endometrial cancer Continuous ostrogen = RF Obestity

Question 31

Diagnosis of endometrial hyperplasia

Answer 31

``` Types - histology Simple Complex Simple atypical Foci of atypical that may lead to ca in older personsHR Complex atypical ``` Diagnosis Histological diagnosis

Question 32

Miscarriage diagnoses

Answer 32

Threatened - bleeding and or pain and preggers Likely to mischarriage Closed cervix Up to 24 weeks Inevitable miscarriage Open cervical Os even if viable preggers with fetal heart beat POC may not be pased by inevitably will Incomplete miscariage Some POC have been passed Tissues and blood clot remain within uterus Cervix stays open Complete miscarriage Only say for fact if you have a scan prior showing a fetus Cervix now closed Resolution of symptoms No strict USS diagnosis CRL >7mm or gestational sac >25mm with no cardiac miscarriage is diagnostic of a miscarriage Septic miscarriage Infected More likely if didnt present with miscarriage and incomplete occured with infection of POC Rare if TOP is legal

Question 33

Miscarriage US classoifed

Answer 33

Missed miscarriage/ early fetal demise# (not recognised) Failed preggers with no cardiac pulsitation on USS Blighted ovum/ Anembryonic pregnancy Failed preggers with empty gestation sac (previosly chorionic cavity identiyable at 3-5 weeks) Incomplete miscarriage/ Retained products of conception Echogenic mass of blood clot and tissue within the uterine cavity >20mm in AP diameter Complete miscarriage May be preggers of unknown location Empty uterine cavity roughly <20mm AP Must have seen IUP intrauterine preg or PUL preg unknow location

Question 34

Causes of miscarriage

Answer 34

``` Chromosomal abnormality (most T1 = aneuploidy) Congenital abnormality Maternal disease (10% in T1) DM Acute illness Uterine anomalies Thrombophilia / APLS T2 =Cervical weakness, uterine abnormality or maternal disease, infection (CMV) ```

Question 35

RFs miscarriage

Answer 35

``` Advancing maternal age 40 Previous miscarriage (3 = recurrent and threshold for investigation) Smoking Alchol (moderate to heavy) and drug use NSAIDs adn Aspirin Street drugs Folate def Consanguinity - cousins marrying DM ```

Question 36

Conservative management missed Miscarriage

Answer 36

x Wait and watch Usually POC pass over 2 weeks but can be longer Step in after 2 weeks due to risk of infection Must have 24hr access to gynae service Adv Avoid rsks Can be at home Disadv Pain and bleeding can be unpredictable Takes longer May be unsuccessful Unpredictable - may be sudden heavy bleeding

Question 37

Medical management missed miscarriage

Answer 37

Day 1 :Mifepristone (antiprogesterone - like with CL causes shedding?). Day 3: Misoprostol (prostaglandin) - Adv 85% effective Avoids surgery Outpatient Disadv Pain and bleeding may be unpleasant and or severe ADR drugs Need for emergency surgical management (SERPC)

Question 38

Moa Mifepristone

Answer 38

Blocks prog causing decidual degen (part of endometrium that forms placenta, cervical softening and dilation, release of prostglandings and increase sensitivity to contractile effect of prostaglandins. Decidual breakdown leads to trophoblack detachment, Decreased HCG and therefore Decrease progesterone from Corpus luteumx

Question 39

MoA Misoprostol

Answer 39

causes contraction along with dilation and softening of cervix

Question 40

Surgical management of miscarriage

Answer 40

``` Suction curette to empty uterus 5 minutes under GA Day case Physically normall after 24 hrs Bleeding 24 hrs... Disadv Harder to do after 12 weeks due to suction method Perforation, bowel bladder Damage to cervix Asherman's syndrome = severe pevic infection, adhesions which block menstruation, pain during ovulation/ menstruation Cervical weakness Anaesthetic risk ```

Question 41

What is recurrent miscarriage

Answer 41

Loss of >=3 consecutive preggers with same partner

Question 42

Causes of recurrent miscarriage and management brief

Answer 42

x Balanced (Robertsonian translocations) Mother is phenotypically nomral btu 50-75% of games are unbalance Refer to clinical geneticist PIGD has LOWER rates of healthy pregnancy than natural conception Uterine anomalies E..g septum which can be removed Increased risk of uterine rupture with hystroscopy Antiphospholipid syndrome Bacterial vaginosis and T2 loss Thrombophilia e.g. Factor V Leiden mutation Alloimmune causes (both parents have same HLA alleells so cant protect fetus)

Question 43

Diagnosis of APLS

Answer 43

3 miscarraiges in 10 weeks 1 fetal loss >10 weeks 1 normal birth with severe PE or FGR

Question 44

Management of APLS

Answer 44

x Give aspirin from day of prositive preggers test Give LMWH from FHR seen Monitor Liver birth rate 80%

Question 45

General management of recurrent miscarriage and investigation. outcome

Answer 45

Miscarriage clinic Test for APLA Thrombophilia screen Pelvic US and consider further if abnormal Karyotype fetal products in products of conception 75% achieve ongoing preggers with supportive care only

Question 46

Diagnosis of PUL

Answer 46

No IU conception or ectopic on TVS but a positive preggers test

Question 47

Cause of PUL

Answer 47

x Too small for TVS e.g. less skilled scanner Complete miscarriage Ectopic Failing PUL (never seen but self resolveing) Rare = HCG secreting tumour Persistent PUL Rare plateu of HCG without and trophoblastic seen on TVS or diagnostic laparoscopy or uterine currettage

Question 48

Management PUL

Answer 48

HCG monitoring >66% rise in 48hrs reassuring (should double). Rescan at HCG=1500 (predicted) or 2 weeks <66% rise in 48hrs Monitor untill <15ui and contact senior Flucuating HCG continue expectant management or offer methotrexate Progesterone <20 suggests failing pregnancy, if asymptomatic repeat hCG in 7 days

Question 49

Ectopic investigation

Answer 49

FBC, G&S (unless acute the cross match 6 units) Urine PT TVSbHCG Serum progesterone If not TVS then consider laparoscopy vs conservative

Question 50

Location of most ectopics

Answer 50

``` Tubal (99) Ampullar (55) Fimbrial Less rare types e.g. Cornua Ovarian (0.5) Abdominal Cercival Uterine diverticulum, intramural, rudimentary horn - split off part due to Mallarian defect and bicornuate uterus (cornual)/ scar Heterotopic with IVF, ovuation induction. (ectopic and intrauterine together) ```

Question 51

Risk factors for ectopic pregnancy

Answer 51

``` 1/3 have no risk factors Previous ectopic Tubal surgery e.g. Sterilization or reversal Tubal pathology Previous PID/ endometrosis Preggers with Cu IUCD POP Tobacco smoking Previous ectopic ```

Question 52

Presentation of ectopic preggers

Answer 52

``` Unilateral pain RIF/LIF Irregular PV spotting/ bleeding Fainting, dizziness (rupture) Shoulder tip pain GI symptoms N&V although usually not prominent with low bHCG ```

Question 53

Management ectopics

Answer 53

Expectant - where HCG falling Increasingly offered 24 hr access to gynae services Medical Criteria to meet Methotrexate single dose Follow up bHCG 25% need repeat MTX - 3 month contraception Longer resolution and follow up, avoid preggers for 3-6/12 months ADR: conjunctivitis, stomatitis, diarrhoea, abdo pain Surgical Laparoscopic/ laparotomy Salpingectomy (removal)/ otomy (incision) Ectomy If controlateral tube is patent Salpingotomy more persistent trophoblast rates and subsequent ectopcs (if woman wants more and other tube damaged) Follow up with HcG Invasive tissues If clinically unwell or patient unwell Need to get all trophoblastc tissue to prevent re surgery

Question 54

Criteria for conservative management and medical management

Answer 54

expectant management of an ectopic pregnancy can only be performed for 1) An unruptured embryo 2) <30mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of <200IU/L and declining 6) Understand risks and willing for regular follow up Medical management of an ectopic pregnancy can only be performed for 1) An unruptured embryo 2) <30mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of <3000IU/L and declining Understand risks and willing for regular follow up

Question 55

What is gestational disease

Answer 55

A spectrum of disorders of trophoblastic development arising from abnormal fertilsation.

Question 56

Types of mole

Answer 56

``` Potentially pre-malignant Hydratidiform Mole/ Molar pregnacy Complete mole - empty egg, 1sperm Benign Paritial mole (egg and 2 sperm) more common Triploid e.g. 69XXX Less malignant and slower growing ``` Maligant Invasive mole Choriocarcinoma

Question 57

Mole features

Answer 57

``` Bleedingin in T1 or early T2 Exaggerated symptoms e.g. hyperemesis Uterus large for dates Very high hCG (mimic TSH) Hypertension and hyperthyroidism may be seen No pain/ Aysymptomatic ```

Question 58

Management of a mole

Answer 58

SERPC 3 national GTD centres Postal follow-up of serum and urine serial bHCG Anti D Contraception to avoid preggers in 12 months

Question 59

Hyperemesis gravidum presentation (when)

Answer 59

``` Excessive nausea and vomiting in early pregnancy (although a very common in pregnancy and usually normal) Usually 6-12 weeks Dehydration Deranged bloods Ketosis Weight loss Nutritional deficiency Complications of all of above ```

Question 60

Pathology of hyperemesis theories

Answer 60

Elevated HCG More common in twin/molar preggers Same alpha subunit TSH - linked to thyrotoxicosis Elevated oestrogen/ progesterone Helicobacter pylori - subclinical infection activitaed by altered immunity in preggers Psychological Difference in different pop and cultures

Question 61

DIagnosis of hyperemesis

Answer 61

Hyperemesis gravidarum, diagnostic criteria triad: 5% pre-pregnancy weight loss dehydration electrolyte imbalance

Question 62

DDX hyperemesis

Answer 62

``` Diagnosis of exlusion Normally no abso pain DDX infection UTI Gastroentertis Appendicitis Pancreatitis DDX metabolic Biochemical thyrotoxicosis Graves disease Addisons DKA Drugs Antibiotics, iron preps Tumours Hydratiform mole formation Choriocarcinoma Teratoma with elements of choriocarcinoma Germ cell tumours Islet cell tumour ```

Question 63

Hyperemesis investigations

Answer 63

``` Urine PT Ketonria UTI Bloods FBC Haematocrit Ues K+ especially - Addisons and vomiting LFT and amylase TFT HCG USS exclude GTD/ multiple pregnacy ```

Question 64

Hyperemesis complications

Answer 64

Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis (Na? low) Paralysis, dysphagia, dysarthria, neuro symptoms acute tubular necrosis fetal: small for gestational age, pre-term birth

Question 65

Management hyperemesis

Answer 65

``` Rehydration - not with glucose as can precipitate Weernicke's, replace K Vitmains and nutrients Thiamine replacement and folic acid Vitamins B and C (Pabrinex) if Wernicke's enceph) Often cant tolerate oral Antiemetics Parenteral route initially Ranitidine Thromboprophylaxis Rarely Steroids - appetite stimulation TPN/ JEG Termination ```

Question 66

Diagnosis of mole

Answer 66

Suspected on scan | Confirmed on histology only

Question 67

6 week PV bleed history questions

Answer 67

``` Bleeding - how much and clots How many pads/ soaking etc Dizziness (from this) Spotting Gi symptoms Diarrhoea Rectal pressure (can get due to irritation from ectopic) Pain Shoulder tip pain ``` Preggers - may need to get parents or partner out LKMP Previous ectopic/miscarrage Planned unplanned unwanted PMHx - DM SH Consanguinous marriage Smoker Drugs

Question 68

6 week PV bleed investigation

Answer 68

``` Bloods Coag clotting UE FBC Serum HCG Disrimminatory level >1500 Serial measurements- dobling time/rate of change Serum Prog >30 = likely viable or not Cautious on these predictions in early Blood group Rhesus status for surgey Imaging US scan Trans-abdominal (TA) Trans-vaginal (TV) Easier to see Free fluid = bleeding Urine Preggers test ```

Question 69

Define abortion

Answer 69

Termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability (24 weeks/20 weeks)

Question 70

Complications of induced abortion public health worldwide

Answer 70

``` Comps worldwide Haemorrhage Infection DIC GA ```

Question 71

Abortion law in UK

Answer 71

HSA 1 form must be signed by two doctors Premises approved by secretary of state Social abortion clause C & D - pregnancy <24 weeks unless fetal abnormality Consent 16-18 can consent as young people Less than 16 can consent to contraception/ including abortion Competency as per Gillick case, can consent tomedicak treatment Frasier allow medical practitioner to provide contraception advice <16. ensures confidentiality

Question 72

Abortion proceedures <9 weeks

Answer 72

Early medical abortion (EMA) using mifepristone (antiprogesterone) + prostaglandin. Person signing is taking responsibility Conventional suction TOP should be avoided (higher failure) Earlier surgical abortion - manual vacuum aspiration (MVA), US guided/ checking falling HCG post abortion etc

Question 73

Abortion proceedures 9-24 weeks

Answer 73

7-15 weeks Early medical TOP (EMTOP) up to 9 preferred Surgical preferred 9-15 via suction TOP Cervical prep with prostaglandin is an option pror to surgery and routine for nulliparous women or >10 week with multiparous Greater risk with high BMI Medical abortion for 9-15 - may be pain/ bleeding for a few weeks but safe >15/13 weeks Surgical by D&E - dilation and excision receded by cervical prep Beyond 18 is a 2 stage procedure >21 Medical top with Urea and KCL prior Induciton of labour with prostaglandins

Question 74

Alternate medical methods

Answer 74

Cervagem (prostaglandin analogue) more expensive not used | Highly effective

Question 75

Contra indications to medial abortion

Answer 75

``` Suspected ectopic prep Any risk of heavy bleeding Chronic renal failure Mifepristone -similar to aldosterone and electrolyte Hepatic falure (bleeding) Severe asthma or COAD CVD/ Prosthesis Long term steroids - electrolyte Allergy to Mifegyne (Mifepristone) Haemorrhagic disorders and treatment with anticoagulants ```

Question 76

Complications of abortion

Answer 76

Low risk of haemorrhage, increases with weeks 4.5% get sepsis Can give prophylactic abc Uterine performation Cervical tears Dilated with prostagladin to prevent And widened with dilator Can tear wall causing bleeding or incontinence Failure (<1%) Post abortion Sepsis Trauma during cervical dilatation and curettage Fundal perforation with suction curette Uterine perforation and suction of a loop of bowel

Question 77

PReventions of complicaiton of abortion

Answer 77

Early referral within 5 weeks Counselling for risk and options Day care procedure if possible under LA Patient info written and verban Investigation: STI screenig, Rh factor, FBC, blood group, BBVs US scan Cervial priming for STOP with dilator - prostaglandin Trained personal TOP

Question 78

After care of surgical abortion

Answer 78

Anti D for Rh -ve Abx propho - STI - metronidazole 1g rectally at time of abortion and doxy 100mg BD orally for 7 days or azythromycin 1g orally on day of abortion Verbal and written info and comps and actions No sex/ tampons for 2 weeks Future contraceptive plans- prescribe where appropriate Follow up 2 weeks Contacts for physical and emotional help Communication with appropriate health professionals

Question 79

Describe rhythm method theory

Answer 79

``` Calender/ rhythm/ safe period 14 days fixed 7 days ovulation time Rhythm method (sperm survival of 7 days – ovulation on day 14-15) based on temp) Fertilie if sex between 8-19 ```

Question 80

Other "natural" contraceptions

Answer 80

``` Cervical mucus assessment BBT - temp Breast feeding 90% contraception in first 6 months Withdrawal Persona - LH surge Expensive and misleading ```

Question 81

MoA COCP

Answer 81

1 ovulation suppression (primary) 2 penetration of Cx mucus 3 prevention of blastocyst implantation

Question 82

Types of COCP

Answer 82

Phasic (fixed dose) Biphasic Triphasic ED - 7 days of placebo pulls

Question 83

CI COCP

Answer 83

``` Hypertension Migraine Smoker >35 History of Cerbro or CVD Breast cancer DM with retinopathy/ comp Severe cirrhosis Gallbladder disease History of OCP related cholestasis ? CYP modifiers ```

Question 84

ADRs Oestrogen

Answer 84

Bloatedness, breast fullness leg cramps, headache, PV bleed, VTE, Migraines worse,

Question 85

ADRs Progesteron

Answer 85

xIrritability, weight gain, hirtsuitism, irregular periods, premenstrual depression, low mood, low libido, breast tenderness

Question 86

Beneftits of COCP

Answer 86

Less bleeding, regular, less anaemic, less dysmenorrhoea Endometriosis - less pain, less dysperiunea Premenstrual tension- less PID - less risk Fewer Ectopic pregers due to anovulation Less benign breast disease Less functional ovarian cyst Ovarian, endometrial and colorectal Ca less

Question 87

Long term health risks COCP

Answer 87

Increased risk of breast and cervical ca, VTE, stroke, IH

Question 88

Other methods of oestrogen delivery as contraception

Answer 88

``` Patch Delay of 48hrs then barrier for 7 and consider emergency contraception NuvaRing (oestrogen ring) Lunelle injection monthly combined Lovelle vaginal combined pills ```

Question 89

IUD time span, use and SE

Answer 89

``` Up to 10 yrs Above 40 can be longer and can leave Copper Licensed for emergency contraception and better Instant Primarily prevent fertilisation May also prevent implantation ``` Bleeding pattern change - heavier with copper Progesterone - risk of ovarian cysts increased Explosion PID Rare: uterine perforation

Question 90

Nexplanon MoA, use, when is it effective

Answer 90

Releasing Etonogestron over 3 years Ovulation suppression main Takes 7 days Effective imediately if <5 days inserted after period

Question 91

Mirena use and when is it effective

Answer 91

Up to 5 yrs 20mg LNG / day Not for emergency Takes 7 days

Question 92

MoA of oral levonorgestal emergency

Answer 92

Emergency Oral levonorgestrel 1.5mg stat | Anti ovulation

Question 93

History regarding prenatal diangosis and why

Answer 93

Maternal age Maternal disease DM First few weeks of control really important (6 weeks heart is formed) Epilepsy Medication esp in 1st trimester Folic acid 5mg per day start from planning prior to birth Previous obs history Child with aneuploidy (abnormal number of chromo) Genetic disorder Structural abnormality Consanguinity Are you and your partner related? Parent with known balanced translocation Exposure in pregnancy-drug related malformations Antiepileptics Warfarin Vit A - acne Intrauterine infection Rubella CMV Ask have you been unwell recently or travelled? If seroconvert first time during pregnancy Pass to embryo May get long term sequelae (1-2%) e.g. Sensorineural defness or learning disability Parvovirus Zika Recent travel

Question 94

Maternal blood screen for prenatal dianosis

Answer 94

Haemoglobinopathy Thalassaemia Sickle cell disease VDRL/ RPR screening - Venereal disease research laboratory Syphilis HIV, Hep B AFP screening Produced in fetal liver and small bowel Raised level associated with open neural tube defect, gastroschisis (unlike exomphalos no peritoneum and not a herniation through umbilicus), cystic hygroma, congenital nephrosis, teratoma, fetal infection, oesophageal atresia, late preggers probs too Maternal Rhesus antibody Anti D at 28 and 32 offered for second pregges to prevent risk Combined first trimester serum screening for Trisomy 21, 18 and 13 Look for free foetal DNA from blood system from October 2018

Question 95

Describe Down's screening - combined test

Answer 95

Combined test detects 75%, 3% FP Uses NT, hCG and preg associated plasma protein a PAPA, woman's age 11-13+6. Higher rates for trisomy 18 and 13

Question 96

Other causes for raised nuchal lucency?

Answer 96

ystic hygroma (lymph sac in neck), cardiac malformations, thoracic compressive syndromes- congenital diaohragmatic hernia, congenital infections

Question 97

Cut off for blood test for Down's Screening

Answer 97

1 in 150 before further is offered

Question 98

Dating scan purpose

Answer 98

ibilitity - HB Accurate dating Detection of fetal abnormalities Anencephaly Large anterior abdo wall defects Cystic hygroma Nuchal translucency Twin determination and chorionicity Cytocitiy Zygocity - 2 completly split - monozygous same egg and sperm 2 sepearate egg and sperm then dizigous Chorionicity = number of placentas One egg and one sperm split, own membrane and own placenta Dichorionic, diamniotic monochorionic (one placenta) Diamniotic (2 sacs) Most monozygotic twin preggers Monochorionic, monoamniotic have high mortality due to cords getting twisted Worst is when babies don't separate = conjoined twins, higher mort Can only tell chorionicity and amniocity on scan unless opposite sex or sharing placenta

Question 99

Anomaly scan purpose

Answer 99

``` bility Measurements (growth) Liquor volume Fetal anatomy Placental location Previa - can cover internal os - life threatening bleed Assessment of normal variants/ soft markers for aneuploidy, renal-pelvic dilatation, choroid plexus cysts •nuchalfold •short femur •choroidplexus cysts •echogenic focus in heart •dilated renal pelvis •talipes equinovarus (club foot) Not perfect detection. CVD particularly low Normal shaped cerebellum 98% of spinal sbifida ruled out DM can have sacral probs Frontal bossing Absent nasal bone - downs Cleft lip Normal variants Nuchal fold >6mm Ventriculomegaly ```

Question 100

When is amniocentesis performed? facts too

Answer 100

After 15 weeks gestation] Under direct US 15-20ml using a 22G needle Culture of amniocytes, harvesting and banding Karyotyping p to 3 weeks 1% risk of miscarriage also preterm delivery and chronic liquor leak

Question 101

Indications for amniocentesis

Answer 101

Assessment of fetal karyotupe if risk of Downs, USS findings, parental translocation, maternal request Measurement of AFP and ACHE (being negative) - ?congenital nephrosis Virology screen PPROM (Preterm (<37week) prematuure rupture of membranes) to rule out chorioamnionitis Loss of barrier so can get infected OD 450 (amniotic bilirubin scan)-haemolytic disease

Question 102

Use of Chorionic Villus Sampling, risks, when is it performed, how,

Answer 102

``` Results = 1 week, (can be 2 days) After 10 weeks ideally US guided TA or Tcervical 2 cell lines True mosaic or contamination ```

Question 103

Risks of CVS

Answer 103

``` 1% get mosaic result from placental mosacism Mum contamination (false positive) 1% risk of failure Transmission of BBV 1-2% Miscarriage ```

Question 104

How to terminate >21

Answer 104

Painful As part of procedure do KCl inject into heart Distressing for parents if baby has signs of life Induction of labour with prostaglandins preceded by fetocide after 22 weeks of gestation in many countries PEG2 - Oxytocin after ROM

Question 105

Explain PIGD

Answer 105

``` FISH analysis At 8 cell satage Indication Known parental translocation Increased age FH X linked recessive ```

Question 106

Explain quadruple test

Answer 106

Quadruple test 16 weeks Dating scan, AFP, unconjugated estriol, BHCG, inhibin A, womens age 15-20 weeks

Question 107

Integrated test

Answer 107

Expensive | NT and PAPP-A in 1st then quaruple in 2nd

Question 108

How long is a normal cycle

Answer 108

* Length 24-32 (not normal to be 28 every time over years) | * Regularity best between 20-40, longer after menarche, shorter pre-menopause

Question 109

Normal cause for PCB and follow up

Answer 109

post coital bleed, normally cervix as lesions of vagina rare and epithelium thick. Check smears and lesion on cervix

Question 110

Cause of menorrhagia

Answer 110

``` ○ Abnormal clotting § Von Willebrands, thrombocytopenia, platelet disorders, coat disorder, leukaemia ○ Pathology § Fibroids (benign tumour of muscle § Adenomyosis/ endometriosis § IUCD - copper makes heavier § PID § Polyps -heavy ○ Metabolic/ Medical § Hypothyroid § Liver disease § SLE § Cancer Polyps/ pro contraception • DUB ○ 60% primary menorrhagia ○ Dysfunctional uterine bleeding ○ Diag by exclusion No recognisable pathology, preggers or general condition disorder ```

Question 111

Risk factors for Menorrhagia

Answer 111

• Age 40_ • Correlation in twins - hereditary • +Ve parity Uterine pathology fibroid or endometrial abnormality, endometrial cancer in post menopausal

Question 112

Brief history menorrhagia

Answer 112

History How much Clots Flooding Subjective vs objective assessment ○ Only 50% with subjective menorrhagia have > normal loss Only 60% of women with MBL >80ml consider their periods heavy

Question 113

Investigations into menorrhagia

Answer 113

``` Hb TFTs and coag if needed Pregnancy test TVUS Investigations futher • Hysteroscopy +/- Biopsy • Cancer rare in menstruating but increases towards menopaus ○ Smear if due • Consider STI screen Subserous vs submucosal fibroid - more bleeding ```

Question 114

Treatment of menorrhagia (with 1st 2nd and 3rd line)

Answer 114

* Tranexamic acid - antifibrinolytic (2nd or for baby) * NSAID/ Fenamates (not in handbook) • Progestrogens ○ Norethisterone (not in handbook) ``` ○ Mirena-IUCD ○ Depot/ IM prog 3rd § Irreg bleeding ○ OCP 3rd • GnRH analogues ``` ``` • Ulipristal acetate Surgical ○ Hysterectomy - dont need ovaries § Risks □ ○ Endometrial ablation § Resection § Roller ball § Laser - old § Cold coat § Microwave § Balloon- thermal current - common § Radio frequency (controlled thermal damage)- also common. 1-2mins ```

Question 115

MoA and SE transexamic acid

Answer 115

x ○ Inhibit plasminogenhibition of tPA and uPA thus reduce fibronoylsis ○ Reduce 50% of MBL ○ Side effect nausea, dizziness, tinnitus, dont give to us of PE DVT etc

Question 116

MoA and efficacy of NSAID/ Fenamate for menorrhagia

Answer 116

○ Inhibit PG and binding to PGE2 § Reduce platelet aggregation ○ Reduce MBL by 20-44.5% ○ Pain killer too

Question 117

Efficacy and ADR of Norethisterone for menorrhagia

Answer 117

§ No literal administration § 21/28 with a break reduce MBL § Nause, headache, bloated ness, weight weigh, skin rash, adverse on lipids, breast tenderness (think early prey symptoms/ last half)

Question 118

Efficacy of Mirena IUCD for menorrhagia

Answer 118

``` 1st line 80% reduction 3 months, 97% at 1 year) § 5 years § Major reduction in MBL § Some BTB (break through bleed( § Not increase ectopic or PID ```

Question 119

GnRh analogue mOA and ADR

Answer 119

○ Large dose actually inhibits pit (after brief stimulation) ○ = menopause ○ Hot flushes, osteoporosis ○ Temporary?

Question 120

Ulipristal acetate MoA and ADR

Answer 120

○ Prog antagonist ○ Help shrink fibroids and may help fibroids ○ Can grow back after ○ abdominal pain; acne; breast pain; dizziness; endometrial thickening; headache; hot flushes; hyperhidrosis; malaise; menstrual disturbances; myalgia; nausea; oedema; ovarian cyst (including rupture); pelvic pain; uterine haemorrhage

Question 121

Risks of hysterectomy

Answer 121

Bleeding, Bowel, bladder, ureter damage, infection e.g. peritonitis, wound infection, Scarring, VTE, early menopause (with ovaries).

Question 122

Effectiveness of endometrial ablation for menorrhagia

Answer 122

Expect 30% amen, 30% failure, 40% llight

Question 123

Causes of amenorrhea

Answer 123

``` Pathological Brain - Pit/ hypothalmic □ Stress □ Psychoactive drugs ○ Cryptomenorrhea (hidden) e.g. imperforate hymen ○ Uterine/ endometrial/ Ovaries • Physiological ○ Prepubertal ○ Preg ○ Menopause ```

Question 124

Cause/ pathology of PCOS

Answer 124

○ Heterogenous endocrine disorder with unknown aetiology ○ FAmilial clustering/ RF ○ 90% Amennorhea ○ US - string of pearls = diag • Patho ○ Recruit follicles which get stuck and dont get to follicular ovulation stage ○ Each produce oestrogen and androgen ○ No prog so no ovulation and infertile ○ Ovarian theaca cell hyperplasia leading to enlargement with icing sugar coating ○ Tendency to DM due to insulin resistance ○ Characterised by § Hypersecretion of androgens § Increased pilsatile secretion of LH § Theca cell (follicle) hyperplasia leading to ovarian enlargement § Anovulation Insulin resistance

Question 125

Clinical features of PCOS

Answer 125

``` ○ Oligo/ amen ○ Dysfunctional uterine bleeding ○ Obesity ○ Hurtsuitis ○ Acne ○ INfert String of pearls ```

Question 126

Biochemical features PCOS

Answer 126

§ Increased LH/FSH § Decreased Sex Hormone Binding Blobulin (SHBG) § Raised free androgen index (FAI) Increased serum insulin

Question 127

DDX PCOS

Answer 127

``` ○ Anovulatiory cycles ○ CAH - congenital adrenal hyperplasia ○ Androgen secreting tumours ○ Cushings’s syndromes (also oligo) ○ Hypothalamic dysfunction ○ Female athlete triad ○ Eating disorder ○ Hyperprolactineamia Thyroid disorders ```

Question 128

Long term comps PCOS

Answer 128

``` ○ MIscarriage ○ Gestational diabetes ○ NIDDM ○ Hypertension ○ CVD Endometrial hyperplasia/ carcinoma (oestrogen) Ovarian ca ```

Question 129

Management PCOS

Answer 129

``` ○ Weight adjustment ○ COCP ○ Cyproterone acetate d ○ Cyclical progestogen ○ Metform ○ Ovulation induction in fertility § Something citrate Ovarian drilling ```

Question 130

What is cypropterone acetate and important ADR

Answer 130

§ Antiandrogen § Normal ones can cause meningioma § Some prog functions § With oestrogen

Question 131

Causes of dysmennorhea

Answer 131

``` Primary dysmennorhea Often with anovulation after menarchy Excessive prostagladins = contractions and ischaemic pain Secondary Adenomyosis Endometriosis PID Fibroids Ovarian cancer (less likely endometrial) ```

Question 132

Treatment dysmennorhea

Answer 132

``` Primary NSAIDs e.g. mefanamic acid Paracetamol If ovulatory cycle then COCP can help Hyoscine butylbromide (SM anti-spasmodics) unreliable Secondary Treat cause IUCDs can increase- levonogesterol may help ```

Question 133

Absolute CI OCP

Answer 133

``` Migraine with aura Breastfeeding <6 weeks post-partum Age 35 or over smoking 15 or more cigarettes/day Systolic 160mmHg or diastolic 95mmHg Vascular disease History of VTE Current VTE (on anticoagulants) Major surgery with prolonged immobilisation Known thrombogenic mutations Current and history of ischaemic heart disease Stroke (including TIA) Complicated valvular and congenital heart disease Current breast cancer Nephropathy/retinopathy/neuropathy Other vascular disease Severe (decompensated) cirrhosis Hepatocellular adenoma Hepatoma Raynaud's disease with lupus anticoagulant Positive antiphospholipid antibodies ```

Question 134

Define menopause and peri-menopause

Answer 134

Permanent cessation of menstruation due to the loss of ovarian follicular activity (12 months amen) • Peri menopause- the period from the beginning of symptoms of approaching menopause and ending 12 months after the final menstrual period

Question 135

Symptoms of menopause

Answer 135

``` ○ Hot flush and sweats ○ Irritability ○ Lack of conc ○ depression ○ Loss of libido ○ INcrease bone loss ○ Increase CVD risk ○ Vaginal dryness ○ Dowager’s hump due to osteoporosis and spontaneous collapse § Resp function too ```

Question 136

Diagnosis menopause

Answer 136

``` ○ Age ○ Cessation of menstruation ○ Atophy ○ ? Role of hormone profile - NICE do not recommend ○ ? Role of ovarian biopsy DDX thyroid and psych ```

Question 137

Management options menopause

Answer 137

○ Diet and exercise ○ ERT and prog if they have a uterus = HRT § Prog reduce the increased risk of endometrial hyperplasia and carcinoma with unopposed oestrogen in non-hysterectimized women ○ E.g. Stradiol or premarin and meedroxyprogesterone acetate, Duphaston (Provera), ○ Sequential or continuous § Retro gem cont with 12-14 of prog causing bleeding, less prog so possible less CVD risk § Continue less likely for period ○ COCP Monophasis or triphasic

Question 138

Risks and beenfits of HRT

Answer 138

``` ○ Risks of HRT § Unapposed oestrogen: □ Endometrial cancer □ Ovarian cancer? § Breast cancer § IHD ? § Gall blasser § Stroke § VTE § Uterine bleed § Lipid profile neg affected § Thrombophilia profile neg affected ○ Benefits Less vasomotor symptoms Improvement in urogenital and sexual function symptoms Osteoporotic fracture reduction (only if lifelong and sustained) Reduced Colorectal cacner by 1/3 ?alz ?CVD, Ovarian Alz ```

Question 139

Cyclical vs combined HRT?

Answer 139

x Women should be prescribed cyclical combined HRT if their LMP was less than 1 year ago and continuous combined HRT if they have: taken cyclical combined for at least 1 year or it has been at least 1 year since their LMP or it has been at least 2 years since their LMP, if they had premature menopause (menopause below the age of 40)

Question 140

Route for HRT

Answer 140

``` ○ Oral ○ Transdermal ○ Implant ○ Transvaginal ○ Nasal ○ Local ○ Patch Prog: Transderm, oral, IUS ```

Question 141

Symptom specific treatment alternatives to HRT

Answer 141

``` • Prevention of osteoporosis ○ Bisphosphonates ○ Calcium and Vit D ○ Raloxifene § SERM § Increase hot flush and VTE § Less action on breast and uterine bleeding ○ Exercise • Vaginal dryness - lubricants or vaginal oestrogen transderm • Vasomotor symptoms ○ SSRI ○ Clonidine (less efficacy) - alpha 2 in brain stem cuasing less TPR ( Gabapentin ```

Question 142

Contraception around menopause

Answer 142

x • Stop <50 years is amenorrhic 2 years • Stop >50 if 1 year Stop COCP in >50 after 2 years post amen or POP

Question 143

Diagnosis of hypertension in preggers

Answer 143

>=140/90 on 2 occasions more than 4 hrs apart or a single reading of the diastolic BP >110 Korotkoff phase V should be used (when it stops as per normal)

Question 144

What is significant proteinuria? | Next investigations?

Answer 144

• 2+ more of protein on urinanalysis is significant • Protein:creatinine ratio is acceptable measure ○ <30mg/mol implies non-significant proteinuria ○ >30 prompt 24hr urine collection • >300mg in 24hrs is abnormal MSU and C&S but infection unlikely if absence of symptoms (more likely to be preeclampsia)

Question 145

Classifcation of hypertensive disorders of preggers?

Answer 145

• Preeclampsia (only cause in T3) • Gestation hypertension/ proteinuria (only one possible) • Chronic hypertension • Pre-eclampsia superimposed on chronic hypertension (15-25% of chronic hypertensive cases) Differentiating this from gestational hyp can be difficult as pre eclamp can be without proteinuria

Question 146

Normal variation of BP in preggers?

Answer 146

Drops MAP by -5mmHg from 0 to 21 weeks then returns to normal by 40

Question 147

Risks, and urate in chronic hypertension in preggers?

Answer 147

• Risks are mainly related to superimposed PET (pre eclapmptic toxaemia • Normal urate • WIth proteinuria IUGR common Abortion 1/50

Question 148

BP target in chronic/ secondary hypertension in preggers?

Answer 148

xKeep BP in all women below 150/100 with urgent treatment If BP >140/90 on 2 occasions then transfer to consultant led labour ward Agitation and restlessness is sign of underlying problem in women with HYT

Question 149

Define pre eclampsia

Answer 149

○ Miltisystem disorder ○ Usually recognised by new onset hypertension (140/90) and protein urea (>300mg) in the second half of preggers that resolves after delivery Can occur with or without HYT or without or with/out proteinuria but will have other symptoms

Question 150

Pathophysiology of pre eclampsia

Answer 150

○ Two stage placental disease concept § Abnormal trophoblastic invasion and adaptation of spiral arteries □ Converts muscular layer to trophoblast cells (dilated) - Trophoblast fails to invade maternal spiral arterioles □ If not then poor dilation and resistance to blood flow □ Reduction of vasodilators PGI2 and NO in endothelium □ Maternal plasma vol fails to expand □ Placenta fails to be a low pressure supply system § Placental ischaemia affecting maternal and fetal circ e.g. HYT to compensate

Question 151

Complications of pre eclampsia

Answer 151

``` • CNS ○ MAP >125 then intracranial haemorrhage/ cortical blindness risk ○ Cerebral oedema/ eclampsia • Renal ○ Renal tubular necrosis, renal cortical necrosis • Resp ○ Pulmonary oedema ○ ARDS • Liver ○ Haemorrhage beneath capsule ○ Hepatic rupture ○ Acute fatty liver of preggers ○ HELLP § Hemolysis § Elevated liver enzymes (EL) § Low platelet count (LP) • Thrombosis ○ High risk ○ Microangiopathic haemolysis/ DIC • PLacenta infarction/ placental abruption • Fetus ○ FGR - fetal growth restriciton ○ Preterm death Preterm labour ```

Question 152

Risk factors for pre eclampsia

Answer 152

``` ○ Socio-demograph § Age >40 § SESEthnicity § Smoking reduces risk? ○ Preggers § Nulliparous § Multiple preggs § Previous pre eclapsia § Hydrops (oedema/ fluid in fetal compartment e.g. rhesus disease), trophoblastic diseas ○ Medical Hx § PAst HYT (on pill too) § FHx Lupus or CKD or other systemic/ autoimmune ```

Question 153

Clinical features of pre eclampsia and biochem

Answer 153

``` • Symptoms ○ Headache ○ Visual disturbance ○ Epigastric pain (not sure why) ○ Oedema, can be usual too, non dependent ie..e face and hands in pre eclampsia only ○ Vomiting • Signs ○ Hyper reflexia/clonus ○ Oedema Epigastric tenderness and RUQ ``` ``` ○ Abnormal blood results § Raised urea and creatinine § Raised urate § Low platelets Elavated ALT/AST ```

Question 154

INvestigation (asessment of risk)

Answer 154

``` • Bedside ○ Blood pressure level § Diastolic for preeclampsia § Systolic for maternal morbidity ○ Proteinuria § Fetal risk § Protein:creatinine ratio • Bloods ○ FBC - anaemia, Platelet count ○ Ues Uric acid ○ LFTs ○ +/- coag screen - PT, APTT (DIC) • Fetal movements ○ Slowing of movements not good as non essential activity reduced • CTG ○ Cardiac topograph ○ Only if reduced movement • Umbilical Doppler ○ Notching • US ○ Fetal size - FGR ○ Liquor Volume • If baby well on admission Can prolong pregnancy if mother stable ```

Question 155

Managment pre eclampsia

Answer 155

``` • Early intervention ○ IF BP >140/90 refer ○ Antenatal Day Assessment Units ○ Closer monitoring ○ Assess the need for therapy • Admit if ○ BP >170/110 ○ OR ○ BP >140/90 and Sig symptoms § Proteinuria 2+/300 § Sig symptoms • Meds ○ Acute then Oral Labetalol first line if >160/110 § Also hydralazine or nifidipine • Chronic meds ○ Labetalol ○ If not the methyldopa or nifidipine rolongation of preggers • If no convulsions • A few days allows use of steroids Ø A week may increase fetal survaval Ø However ○ Fetal signs of compromise, delivery is necessary ○ Better small and healthy than big and compromised Ø Deliver on labour ward ```

Question 156

Prevention pre eclampisa

Answer 156

• Antenatal care appropriate ○ Appropriate RFs indentified in T1 (before onset) ○ After 20 weeks monthly visits or fortnightly after 34 in primigravida ○ Clear history • Primary ○ Rest and exercise (not strong) ○ Ca shops but no effect on baby outcome ○ No benefit of Vt C and E Low dose aspirin if high risk women

Question 157

Fetal risks of severe hypertension in preggers

Answer 157

``` • Direct effect of disease ○ Intra-uterine growth restriction • From intervention ○ Premature delivery ○ Intervention ○ Cerebral haemorrhage ○ Pneumothorax • Related to both Cerebral palsy ```

Question 158

MoA, use, ADR and CI methyldopa

Answer 158

§ Methyldopa □ NOt if history of dep □ Stop PN due to risk of PN dep □ ADR tiredness/dry mouth/ GI/ dep Mechanism - metabolised to methynoradrenaline and stimulates alpha adrenergic receptors 250mg BD increased over 2 days up to 3g CI - history of depression, pheochromocytoma, acute porphyrias

Question 159

MoA labetalol, ADR, CI

Answer 159

Alpha and beta blocker □ Combined beta alpha blocker □ Not in T1DM as prevents hypos or asthma ADR - scalp tingling/ headaches/ wakness/ liver damage/ GI disturbances

Question 160

Postnatal BP monitoring after PE.

Answer 160

○ Daily BP monitoring for 2 days post birth ○ Once 3-5 days after birth Medical review 2 weeks after transfer

Question 161

Define eclampsia

Answer 161

Generalised convulsions during preggers, labour or <=7 days postpartum and not caused by epilepsy or other neurological disorder

Question 162

Pathophysiology of eclampsia (3 theory_

Answer 162

More sensitive to vasoconstrictors Prothrombotic - microthrombi reduce perfusion Leaky caps - increased in ISF, cerebral oedema

Question 163

Management of exlampsia

Answer 163

``` A-E appraoch Catheterise for urine output - Restrict fluids to <80ml/hr Labetalol 20mg IVI (or hydralazine) ○ Magnesium sulphate § Prevention (IVI) - high risk § Treatment ○ Senior review ○ Deliver once stable Neuroimaging should be performed urgently in any women with focal neurology or not recovered from seizure ```

Question 164

Complications of eclampsia

Answer 164

○ Cardiac failure and pulmonary oedema Plasma protein less and cap leakage MM 2-4% mort and baby 10-30%

Question 165

Define infertility and infecundity

Answer 165

Infertility Inability of a couple to conceive after 12 months+ of unprotected intercourse (6 months for women over 35) Infecundity (the inability of a couple to produce live birth) Potential e.g. how much people can, natural ability to reproduce

Question 166

Caues infertility broadly

Answer 166

``` Ovulation defect Male factor Tubal disease Unexplained (25% each) Endometriosis (prev in infertile increased) Uterine factors Other ```

Question 167

When are women most fertile and when does this start to decline?

Answer 167

Most fertile 20-31More pronounced post 37 and steep after 40

Question 168

Male and female factors that warrant early investigation

Answer 168

``` Male Cryptorchidism Chemi-Radiotherapy Previous urogenital surgery History of STDs Varicocele Abnormal semen analysis Female Age >35 Previous ectopic Known tubal disease History of PID/ STDs Tubal or pelvic surgery Chemo-Radiotherapy Amenorrhoea Olygomenorrhoea ```

Question 169

Causes of anovulation (ovaries)

Answer 169

``` PCOS 2 of 3 criteria Causes 80% String of pearls Weight related Either obese or under weight Ovarian failure Removed Chemo Autoimmune ovarian dysfunction Hyperprolactinaemia ```

Question 170

Tubal pathology causing infertility

Answer 170

PID most common chlamyd or gonn Adhesion e.g. endo Congenital abnormality

Question 171

History infertility

Answer 171

``` Age Duration of fertility Type of infertility Menstrual cycle - ovulating? Tubal surgery/ PID Menorrhagia/ Dysmenorrhoea/ pelvic pain Pelvic surgery ``` How often having sex

Question 172

Examination findings infertility

Answer 172

``` BMI (19-30 for NHS funding) Body hair distribution Galactorrhoea Secondary sexual characteristics Pelvic Structural abnormalities fixed or tender uterus Abdominal Swabs clamyd and gonn ```

Question 173

History male

Answer 173

General health Alcohol/ smoking Previous surgery Previous infection e.g. mumps in adulthood Surgery e.g. Hernia History of undescended or trauma in childhood Sexual dysfunction - erectile/ ejaculatory Undescended testes

Question 174

Examination in male

Answer 174

Scrotum - varicocele Testicular size Position - undescended testes Prostate - chronic infection

Question 175

Investigation in female

Answer 175

Female - Follicular LH, FSH (Day 2) Luteal phase prog (D21 - week before period) Rubella status 5%not vaccinated/ with cover Give 2 vaccines Avoid preggers for 2 months due to live vaccine If in preggers then discuss with local health protection unnit and post natal MMR Tests of tubal patency Hysterosalpingogram (uses dye) XR Diagnostic laproscopy and dye (if ?tubal patency) HyCoSy hystero-salpingo contrast sonography (sane as hysterosalpingogram but with US) Additional Clamyd Female - pelvic US - also for PCOS Hysteroscopy (not needed routinely) Prolactin/ TFTs (not needed routine) Testosterone/ SHBG/ Free androgen binding index (NNR)

Question 176

Investigation in male

Answer 176

Semen analysis x1 if normal If abnormal then repeat after 70 days due to sperm cycle Normally >20mil/ml, normal motility >50%, normal morph >30%, Volume >2ml Antisperm antibodies Mixed agglutination reaction/ immunobead tests Occurs from sperm in ummune system e.g. anal sex, blood-testis barirer e.g. surgery or orchitiis Only affect if in repro tract FSH/LH/ Testosterone FSH >20/30 then primary testicular failure FSH 1-10 = likely obstruction Vasogram FSH low then hypogondaism US seminal vesicles and prostate

Question 177

Management of fertility in PCOS

Answer 177

Weight loss Clomiphene citrate for PCOS (SER) Antioestrogen drug to reduce level -causing stimulation of FSH and LF stimulating follicular growtg via neg feedback inhibition Days 2-6 of cycle 50mg OD Need to monitor follicular growth via US Gonadotrophins/ pulsatile GNRH 2nd line or if low oestrogen with normal FSH Injected and expensive, needs US monitoring for hyperstimulation Metformin Help with weightloss and possibly ovulation but off licence Laproscopic ovarian drilling Needlepoint diathermy into ovary to try to reduce LH. 50% success and lasts for 12-18months

Question 178

Risks of fertility treatment in POCS

Answer 178

x Risks Hyperstimulation of ovary: Bloating, nausea, SOB, Pleural effusion, excessive weight gain Twins

Question 179

Management of infertility in prolactin, weight, male factors, or if no cause found

Answer 179

``` Dopamine probs (hyperprolactinaemia) Agonists e.g. Bromocriptine/ cabergoline Weight 18-30 BMI Tubal Surgery IVF Male factor IVF/ IUI intrauterine insemination Lifestyle - smoking, weight ICSI - intracytoplasmic sperm injection (one by one) Donor insemination ``` ``` No cause 2 years of trying Folic acid BMI Regular sex every 2-3 days Smoking/ drinking advice ```

Question 180

Aeitiology endometriosis

Answer 180

Outside of endometrium Predominantly in pelvis Responds to cyclical hormonal changes Can achieve preggers too Rare post menopausal - oestrogen dependent Aetiology - multiple theories Retrograde menstruation - most blood comes out butmay go retrograde and deposit in abdomen Coelomic metaplasia Metaplasic change in peritoneum (Coelomic) which will or won't accept retrograde menstruation May spread haematological or lymphatic and can be found anywhere

Question 181

Presentation endometriosis

Answer 181

Asymptom Most common is dysmenorrhoea Cyclical May be constnd lower abdo pain due to adhesions Dyschezia (pain on defication) Heavy period Dyspareunia Epistaxis, rectal bleeding, PCB- post coital bleeding with period Little correlation between symptom and severity of disease Infert - exact mechanism unknown

Question 182

Examination of endometriosis

Answer 182

``` NAD Thickened/ nodular uterosacral ligs Fixed retroverted uterus Uterine/ovarian enlargement Forniceal tenderness Uterine tenderness ```

Question 183

Investigation endometriosis

Answer 183

``` Vulval/ cervical swabs - CT and NG NAAT Bloods if ?PID e.g. dysmennorrhea WCC, CRP - PID CA125 - Endometriosis and malignancy TVUS - Fibroids (unlikely), ovarian endometriotic cysts Laproscopy and biopsy Active endometriosis - Powder-burn spots Chocolate cysts Inactive endometriosis Scars Pertioneal defects ```

Question 184

Management endometriosis

Answer 184

Cure not guaranteed Varying treatmetn Depends on fertility issues Type and severity of symptoms Therapies tried and failed Patients wishes No baby wanted COCP - supress ovulation Continuous prog therapy (MPA) Medroxyprogesterone acetate IUS GnRH analogues (nasal spray/ implants += HRT add back therapy Osteoporosis after 6 months Danazol androgenergic+ antiestogen Severe androgenic side effects Given in PCOS for andrenergic stuff too Wanting the babez Mefenamic acid (not great in preggers) (painful period )/ transexamic acid (heavy) Symptomatic benefit Surgical Laparoscopic - diathermy, laser TAH + BSO (ovaries too due to oestrogen) Rsk of bladder, ureteric, bowel injury Risk of subtotal hysterectomy/ role of HRT Fertility Cant give hormones as will negatively addect fert Only do laprascopic diathermy ablation or cystectomy Assisted hormones Clomiphene citrate Gonadotrophs/ pulsitile GnRh Can give mefenamic acid or transexamic acid Mefanamic mid cycle will block ovulation

Question 185

Adenomyosis RF

Answer 185

Multiparous towards end of reproductive life

Question 186

Adenomyosis presentation

Answer 186

Endometrial tissue within myometrium dysmenorrhoea menorrhagia enlarged, boggy uterus

Question 187

Adenomyosis diagnosis

Answer 187

Diagnosed by histology post hysterectomy or MRI or 3D/4D scan

Question 188

Managemet HELLP

Answer 188

MG SO4 IV dexamethason Control of BP Replacement of blood products

Question 189

Presentation vulva ca

Answer 189

``` Pruritus Bleeding Discharge Signs Ulcer - rolled edges Mass Inguinal nodes (met cancer) ```

Question 190

RFs vulval ca

Answer 190

``` 50% due to HPV Elderly HPV, HIV, SLE, Iatrogenic immunosupression Smoking 95% squamous ```

Question 191

Investigation vulval cancer

Answer 191

x` Biopsy Ketes Punch Biopsy Forceps Push into skin and twist Get a bit of normal and a bit of abnormal

Question 192

Staging of vulval cancer

Answer 192

Stage 1- 1mm including epidermis and portion of epidermis Stage 2 = 3cm penetration Stage 3 = invasion

Question 193

Management of vulval cancer

Answer 193

``` Bloods FBC G&S Clotting Ues Imaging ECG CXR CT to see extent of involvement Management 1 - wide local incision. If 1mm go 1.5mm. Advances Radical vulvectomy Removal of whole perineum and lymph nodes Butterfly exision ```

Question 194

Cervical cancer screening method

Answer 194

PAP smear and liquid based cytology | Calassification/ reporting - dyskaryosis and invasion

Question 195

Frequency of cervical screenign

Answer 195

Age 25-50 every 3 50-65 every 5 +65 selected patients only

Question 196

When to refer for culposcopy?

Answer 196

Inadequate or boarderline on 3 occassions | Dyskaryosis on 1 occasion or abnormal glandular cell

Question 197

Abnormal findings on culposcopy Location and diagnosis of Cervical intraepithelial neoplasia

Answer 197

x Low power binocular microscopy of cervix Look for feature suggestive of CIN or invasion Abnorm vasc pattern e.g. mosicism Abnormal staing of tissue (aceto-white, brown iodine) Especially at junction

Question 198

Treatmetn of CIN 1-3

Answer 198

``` CIN 1 - most regresses Mananagement of CIN II 2 week wait Treatment e.g. punch biopsy and cold coagulation 6 month follow up screen CIN III See-and-treat Desrtuctive Cryocautery Diathermy Laser vaporisation Excisitional (LLETZ = best), cold knife cone Follow up colposcopy 6 months Annually for 10 yearsafter ```

Question 199

Prevention of HPV

Answer 199

Gardasil: 6,11,16,18 • Cervarix:16 & 18 3 IM injections giving 5 years protection

Question 200

Pathophysiology of HPV in cervical and histological diagnosis

Answer 200

``` x Most common cause is HPV causing koilocytosis Most the time regressed to norml a Unlikely with immunosuppression CIN1 - basal layers metaplasia CIN2 More meta CIN3 from base outwards (see below) Invasive Whole progression takes years 2/3 squamous 15% adeno Squamous 90%/ Adeno 10% ```

Question 201

RF cervical ca

Answer 201

``` Age 45-55 Young age at first intervourse Multiple sexual partners Long term COCP Immunosuppression/ HIVHPV: STI Smoking ```

Question 202

Presentation of cervical ca

Answer 202

``` PCB Intramenstual bleeding - between periods Discharge/ odour PMB None Advanced Fistulae Renal failure Nerve root pain Lower limb oedema Signs Visible or palpable lesion ```

Question 203

Spread of cervical cancer and consequent symptoms/comps

Answer 203

``` Lateral pelvic wall locally to uterer Posterior or anterior to Retum/Bladder Local to Uterus or Vagina Ureter Hydronephrosis Uraemia AKI Colicky pains Retention Haematuria Bowel Blood Tenesmus Constipation ```

Question 204

Management of establish cervical ca by stage

Answer 204

1a - microinvasion but confired to cervic Large loop excision of transformation zone (LLETZ) Heated wire - superficial area scraped off I-Iia - beyond cervix but not pelvic side wall or lower 1/3 vagina Radical surgery/ radiotherpay Total abdonimal hysterectopy Bilater salinpingectomy (Tubectomy = tying tubes, salpingectomy = entire tubes) >Iia - (III = pelvic spread, IV = distant spread) Chemoradiotherapy Surgery just increases mortality and morbidity Radical trachelectomy = cervicectomy

Question 205

Complications of cervical ca treatment

Answer 205

``` Surgery Infection VTEHaemorrhage Vesicovaginal fistula Bladder dysfunctionLymphocyst formationShort Vagina Radiotherapy Vaginal dryness Vaginal stenosis Radiation cystitis Radiation proctitis Loss of ovarian function ```

Question 206

Uterine/ endometrial cancer pathophysiology and types

Answer 206

Most from endometrium | Adenocarcinoma

Question 207

Risk factors for endometrial cancer

Answer 207

``` Tamoxifen - more sensitive to effects of oestrogen in uterus Unopposed oestroogen - hyperplastic Exogenous Obesity (36%) PCOS Nullip Late menopause Tamoxifen DM PCOS/HNPCC/ Lynch ```

Question 208

Protective against endometrial ca

Answer 208

COCP/ POP | HRT combined

Question 209

Presentation endometrial ca

Answer 209

PMB (most common) - 10% with have malig Irregular periods - if in perimenopausal period IMB Normal exam

Question 210

Diagnosis of endometrial ca

Answer 210

``` US - thickening of endometrium TV best >3mm is abnormal >5mm cut off Biopsy - diagnosis Hysteroscopy Or D&C - dilation of cervic and curretage Pipelle biospy - push catheter in and shave bit off - outpatient try first CT and MRI - staging ```

Question 211

Where can mets occur

Answer 211

``` Rare with type 1 Intraperitoneal Lung Bone Brain Type 2 Mets more likely CT Chest Abdo Pelvis MR Pelvis ```

Question 212

Staging of endometrial FIGO

Answer 212

``` x FIGO 1- Limited to myometrium (80%) 2- Cervical spread 3- Uterine serosa Ovaries Tubes Vagina Pelvic/ para-aortic LN 4- Bldder/ bowel Distant mets ```

Question 213

Management endometrial cancer

Answer 213

``` Surgical hysterectomy BSO Total with cervix Sub total is just uterus Total hysterectomy with bilat salphingo oophorectomy Radiotherapy Adjuvent Neoadjuvent Primary Hormonal Progestatgens (oral or intauterine) Only some are response - prog opposes oestrogen and prevents growth Chemo if admanced Combination if more advanced Prognosis Ia >90% 5 year All 65% ```

Question 214

Ovarian ca presentation

Answer 214

``` Bloating Clothes tight Vague symptoms Loss of apetit/ early saity Silent Dyspepsia Unfreq Mass/ascites/ cachexia/ breasts Pain Anorexia N&V Weight loss Vaginal bleeding Change in bowel habit (rare) ```

Question 215

Spread of ovarian ca/ staging

Answer 215

Later get omental caking | Initially local invasion

Question 216

RFs ovarian cancer

Answer 216

``` Repro Early menarche 11yrs Lat menopause >49 Nullip Frequent trauma to epithelial surface 60-70s HRT Oval induction Familiar BRACA1/2 HNPCC Family history Decreased risk COCP Preggers Breastfeeding Hysterectomy Oophorectomy Sterilisation ```

Question 217

Types of ovarian cancer

Answer 217

``` Surface epithelium (85-90%) Epithelial tumours Most common Serous/ mucinous/ endometriod/ Clear/ transition. S&M most common Can be benign or malignant Germ cell Follicle cells Dysgermnioma Yolk Sac Choriocarcinoma Dermoid (benign teratoma) most common More commonly benign Stroma Sex cord-stromal Thecoma Granulosa cell Sertoli-Leydig cell Fibroma Secondary malig Gastric cancers Lymphomas No pre malignant stage ```

Question 218

Investigations ovarian cax

Answer 218

Bloods FBC, UE, LFT Ca125 (Epithelial), ``` CEA Imaging TVA (TV US) CXR (pre op) CT to assess peritoneal, omental and retroperitoneal disease ```

Question 219

Down side to CA125

Answer 219

``` xUp to 80% EOC Poor specificity premenopausal Also in Ca pancreas, breast colon, lung Menstruation, PID, Endometriosis Liver disease, ascities, pleural and pericardial effusion Recent laparotomy ```

Question 220

Staging of ovarian cacner

Answer 220

1 - Ovaries 2 - pelvic organs 3 - Peritoneal cavity, omentum, lymph 4- Distant mets, liver parenchyma, lung

Question 221

Treatment ovarian cancer

Answer 221

``` Epithelial Surgery and chemo Staging laparotomy TAH & BSO and debulking Platinum (Cisplatin, carboplatin) and Taxane (paclitaxel) (MOA = microtubual formation in cell division) If one ovary then just oophorectomy is possible Non-epithelial Young women Extremly chemo-sensitive Conservative/ chemo Recurrent disease = palliative chemo ```

Question 222

Define small for dates and large for dates

Answer 222

Describes anthropometric variables (AC or EFW) <10th pop centile for gestational weight >95th centile = Large for dates 2

Question 223

How is growth assessed in preggers

Answer 223

Abdo palpation. Umbilicus 20weeks - 1cm each way 20-30% sensitivity 20 weeks and at the xiphoid sternum from 36 weeks. Head free until 37 in nulliparous but less in multiparous SFH 30-40% sensitivity US measurement Sensitivity 90-95% Commonly used head circ abdo circ and femur length

Question 224

How customised are growth charts?

Answer 224

To mother based on ethnicity, BMI | X used along dotted line (average)

Question 225

Risks of SFD

Answer 225

FD disproportionately to perinatal morbid and mort Main contributor to association is FGR rather than SFD Means can FGR can decrease at one point and risk increases but SFD may be more due to a normal FGR earlier Increased morbidity and mortality is a result of intrauterine hypoxia, acidaemia, prematurity (often iatrogenic) and neonatal complications

Question 226

Causes of small for dates

Answer 226

``` Normal small Constitutionally small, healthy baby Abnormal small Chromosmomal abnormlaities (T2), syndromes (from beginnning), congenital malormations (from beginning) Infected Small Infection during preggers (CMV often) Check Igs - depends when. Some IgA can linger though so not sure when occurred Can measure retrospectively with kept booking bloods Starved Small Placental FGR Poor placentation (T3) Smoking Materal disease (T3) Multiple preggers Wrong Small Incorrect Dates or measurements ```

Question 227

Placental factors on size- adequate transfer dependent on?

Answer 227

Uteroplacental blood flow from uterine artery to placena (which artery which) Fetoplacental blood flow (umbilical to placent) Villous structure (interface of maternal and fetal blood) Tunic media in spiral arteries normally destroyed - no control ie free flow. In preeclampsia it is still there ie vasoconstriction still occurs

Question 228

Investigation into placental FGR and when

Answer 228

Doppler of uterine artery ie blood flow impedence Can see flow in systole and diastole Severe reverse flow in diastale IN 24-26 weeks Good NPV, Poor PPV Mainly tertiary if mother has history of SGA babies Stage 1 - flow in both Stage 2 - flow in systole - diastolic effected - diastolic notching Stage 3 - reverse flow in diastole

Question 229

Signs of cause of SGA on US

Answer 229

Placenta - low liver glycogen so asymetrical growth restriciton Liquor volume - go down in placenta Centile position UmA doppler - small placena MCA doppler - in brainz, shunting to brain if low supply. High shows fetal redistribution

Question 230

Signs if aneuploidy/ infection

Answer 230

Markedly small, velocity may be reduced, symmetrical growth Variable amniotic fluid - normal or increased Normal UMA Doppler

Question 231

Signs of placental IUGR

Answer 231

Reduced amnio ASymmetrical FGR MCA increased High resistance UMA flow and decreasing BPP (abnormal)

Question 232

How to monitor if SFD e.g. different way

Answer 232

Assess material RFs Assess for presence of maternal disease Continue monitoring for pre-eclampsia with BP and urine checks in reguar intervals ``` Fetal surveillance Serial growth measrements every 2-4 weeks Fetal wellbeing surveillance Maternal perception of movements Not always reliable Maternal doppler Amniotic volume measurements Biophysical profile Umbilical artery only good in high risk Better predictor of abnormal CTG and NICU (Neonatal intensive care) on admission Uterine doppler Good for screening not surveillance Notching = high risk MCA Increased flow is danger to baby Surveillance useful Should increase in T3 Venous doppler Information about the 'pump' Ductus venosus RHF - evidence in ductus venosus Waveform deterioration predicts chages in BPS (biopsysical profile score/ manning score) ```

Question 233

When to delivery FGR??

Answer 233

Normal UAD - delay delivery until >37 weeks AREDF - (absent or resversed end-diastolic flow in the umbicial artery) if gestation >34/40 even if normal additional assessment <34 if CTG abnormal, BPP (biophysical profle on CTG and 4 Us parameters e.g. actvity) abnormal or other Doppler parameters abnormal Mode depends on gestation, presentation, foetal condition and maternal factors

Question 234

Risks of preterm delivery/ FGR baby?

Answer 234

Increased need for resus Hypothermia and hypoglycaemia RDS & NEC (necrotizing enerocolitis

Question 235

Cause of large for dates?

Answer 235

Uterine fibroids Pelvic mass Polyhydramnios Maternal obesity ``` Why is the fetus large? Maternal Daibetes Obesity Increased materal age Multiparity Large status Fetal Consitiutional Male gender Postmaturity Genetic disorder (Beckwith Wiedeman) ```

Question 236

Implications of LFD

Answer 236

``` Maternal Prolonged labour Operative delivery Postpartum haemorrhage Genital tract trauma ``` ``` Fetal Birth injury Perinatal asphyxia from difficult delivery Shoulder dystocia/Erb’s palsy Hypoglycaemia Childhood obesity Metabolic syndrome ```

Question 237

Management LFD

Answer 237

Exclude maternal diabetes Absence of polyhydramnios treat as normal (due to polyuria in baby) Maternal diabetes and macrosomia offer C section Early recourse to intervention where there is delay in labour - mainly due to shoulder dystocia Monito hypoglycaemia in neonatal period

Question 238

Long term risks of SGA and LGA

Answer 238

LGA - More risk of metabolic | SGA - More risk of HYT and DM and CVD

Question 239

How does diabteres cause SGA?

Answer 239

Diabetes can affect placenta - microvasc disease (IDDM) and cause SGA

Question 240

When to give steroids?

Answer 240

<35 weeks and inducing then give steroids | If CTG - heart rate tracing abnormal then inducing

Question 241

Risk factors for GRF

Answer 241

``` Mother Age BMI Smoking (highest lifestyle factor) Alcohol Substance abuse Domestic Violence Due to abruptions Trauma/ haemorrhage into placenta Prescription and OTC drugs High altitude Pregnancy Previous FGR Highest Recurrent fetal loss Second highest Previous unexplained SB Raised AFP Infetion Placental pathology (praevia cirumvallata) Medical History Hypertension Haemoglobinopathies APLS Collagen vasc disorders Renal disease ```

Question 242

Innervation of bladder

Answer 242

``` Autonomic parasympathetic S2,3,4 Contract detrusor muscle during voiding Forms reflex Some higher control Sympathetic fibres T12-L2 Sphincter muscles mediated by sympathetic T12-L2 Relax detrusor and constrict sphincter Brain affects this UMN palsy - causes detrusor hyperreflexia Voluntary control Somatic S2,3,4 to external sphincter/ pelvic floor during storage, relaxation during voiding Pelvic nerve Contains sensory efferent And Parasympathetic Hypogasric nerve Sympathetic ```

Question 243

Forces involved in continence

Answer 243

Bladder pressures Detrusor Abdo pressure (weight coughing sneezing) Urethral Abdo pressure (above pelvic floor) - unless prolapse Urethral pressure from sphincter Pelvic floor if functioning properly - blood supply also affects Abdo cancels out in the above formula Pelvic floor - neck can slip under pelvic floor and Abdo pressure only acting on bladder not urethral making incontinence more likely. Detrusor overactivity e.g. MNS - if everything in tact may just get urge

Question 244

Incontinence history questions including specific questions

Answer 244

``` Symptoms Urgency - overwhelming desire to void Urge incontinence (leak) - associatd with leak Stress incontinence (leak when coughing) Frequency >8 per day Nocturia >2 per night Hesitancy - delay in commencing stream Dysuria - brief discomfort while/ after voiding History Stress or urge symptoms predominant - many have mixed Urge suggests detrusor overactivity Stress suggests Overfilled bladder e.g. stricture How frequent are symptoms Severity measures Amount Pad use, size and number Lifestyele modifications - e.g. Toilet mapping Fluid intake Associated symptoms Prolapse Faecal symptoms (up to 75%) Obstetric history Birthweight Forceps delivery Perineal trauma duration of second stage Previous surgery Hysterectomy Pelvic floor repair Incontinence ops Medical and fam Lung disease - bronchiectasis - coughing CTD Diabetes Hypertension - diuretics Move diuretic Doxazacin - alpha blocker\ ```

Question 245

Examination incontinence

Answer 245

``` Obesity Scars Abdo/pelvic massess Visible incontinence Prolapse - cough or bend down Pelvic floor tone from inside the vagina Mobile bladder neck - positional May be prolapse - cystocoele, urethrocoele Urodynamic stress CNS Middle years - MS Urge Often littlle leakage May be leakage on coughing Signs of CNS involvement e.g. MS ```

Question 246

Normal birth weight

Answer 246

2.5-4.5kg (3.5 normal) 5.5-10lb

Question 247

Investigation incontinence urge

Answer 247

Urinalysis Screen for infection - UTI could contribute to urge and leak Sign of stone/tumor Active infection can cause false dig at cytometry of detrusor over-activity so must check first Mid stream specimen far better than catheter but still false pos If using reagent strip Pos with symptoms = treat Pos without symptoms = formal MSSU - midstream specimen of urine Diaries 3-7 days Intake, functional bladder vol and freq Intake excessive >2l Confirm symptoms Used as adjunct to bladder drill Inclides drinks Amount of urine passed And leak or change pad Pad tests Object measure of leakage Duration 1 hr to 24 hrs Shorter test of dubious value Poor reproducibility 24 hr at home is best >50g unlikely to get better without surgery <50g then physio etc amy help US (bladder scan) Indicated in urge incontinence to find post void residule urine. ``` Qualiative tools May capture QoL issues Disease specifc QoL questionnaries King's Health care BFLUTs IIQ and UDI Generic SF 36 Few data on outcomes ```

Question 248

Investigation if incontinence and recurrent UTI, haematuria or pain. advantages?

Answer 248

``` IVP (Intravenous pyelogram) Investigation Recurrent UTI Haematuria PAin Recurrent UTI, haematuria, pain Painfulbladder syndrome? IVP producedure IV Contrast Xray before (check stone) During (filtering and should show blockages) After voiding (shows any incomplete emptying) Some risks but picks up more stones than US ``` ``` Cystoscopy Indications Haematuraia Recurrent UTI Painful bladder "sensory urgency" LA or GA Allows biopsies ```

Question 249

Investigation stress incontinence

Answer 249

``` Urinalysis Screen for infection - UTI could contribute to urge and leak Sign of stone/tumor Active infection can cause false dig at cytometry of detrusor over-activity so must check first Mid stream specimen far better than catheter but still false pos If using reagent strip Pos with symptoms = treat Pos without symptoms = formal MSSU - midstream specimen of urine Diaries 3-7 days Intake, functional bladder vol and freq Intake excessive >2l Confirm symptoms Used as adjunct to bladder drill Inclides drinks Amount of urine passed And leak or change pad Pad tests Object measure of leakage Duration 1 hr to 24 hrs Shorter test of dubious value Poor reproducibility 24 hr at home is best >50g unlikely to get better without surgery <50g then physio etc amy help ``` ``` Qualiative tools May capture QoL issues Disease specifc QoL questionnaries King's Health care BFLUTs IIQ and UDI Generic SF 36 Few data on outcomes ```

Question 250

Causes of Urodynamic stress incontinence

Answer 250

Commonest in women Sphincter not sufficient for abdo pressure ``` Causes Incompetent urethral sphincter Childbirth Menopause Prolapse Chronic cough Positional displacement - (most) - neck below floor during cough Intrinsic weakness (few) ```

Question 251

Detrusor overactivity causes/ RFs/ triggers

Answer 251

POORLY UNDERSTOOD Pressure from detrusor > spjincter tone HISTORY of childhood aneuresis (involuntary at night)/ UTIs May be post incontinence surgey May be neurological disease Commonest in men - prostate/ obstruction Neurogenic detrusor overactivity is common Triggers Running water Key in door Washing hands

Question 252

Cystometry overactivity

Answer 252

``` Functional test of bladder funciton Capacity Flow rate and voiding function Demonstrate leakage with intravesical pressure - during voiding Objective diagnosis - if unclear Not fool proof Exaimine pressure during cycle Measure pressure through small pressure in bladder Abdo pressure in rectuum Bladder- abdo = detrusor pressure Detrusor over time Cough checks Normally 0 as muscle is quiescent throughout - actively relax Record urine passed/ leaked Fill with saline at room temp 50ml/min Ask to report all bladded sensation Normally aware at 150ml = first desire May be suppressed, CNS? Strong desire More difficult to suppress and may reappear and become stronger May be able to distract Urgency Subjective - distractions affect too Inflammation then symptoms at lower vol e.g. Cystitis ```

Question 253

General incontinence treatmetn

Answer 253

``` General Pelvic floor first Continence care/ bladder care - 1.5-2.5l fluid a day Tea, coffee, alcohol avoid Mobility aids or downstairs toilets Pads, bedpans, commodes ```

Question 254

UDSI treatment non surgical

Answer 254

(Systems of stress dont need urodynamics before surgery unless other symptoms) Physio Examined to ensure pelvic floor correctly (just telling is ineffective in 40% due to wrong muscles) Effective in 50-70% Use biofeedback Cones - retain heavier cone using pelvic floor muscles (same efficacy of exercises) Electrical stimulation Meds Duloxetine 40mg 80% women say sig help

Question 255

MoA duloxetine

Answer 255

xreuptake inhibited or 5HT adn NA in Onuf's nucleus in sacral spinal cord (pudendal nerve), increases external (striated) sphincter tone and improved bladder capacity

Question 256

ADR duloxitine

Answer 256

Abdo pain, abnormal dreams, anxiety, GI upset, Diarrhoea/ Constipation, Sympathetic: Sweating, palpitation, insomnia, anxiety, tremor,

Question 257

Surgical UDSI treatmetn inclujding comps

Answer 257

``` Tension free vaginal tape most common Day case Less comps Bladder injury Outside peritoneum Tape exposed - chronic pain, surgery to correct LA Burch colposuspesion Old Suture in vaginal fascia Also treat cystocoele (prolapse Comps Voiding difficulty Detrusor overactivity Enterocoele formation Other tapes Transobturator tapes Diff route Periurethral injections Collagen Silicone PVC 50-75% success Can be repeated NOT anterior repair ```

Question 258

Detrusor overactivity management non surgical

Answer 258

``` Difficult to treat Behavioural therapies Bladder retraining first line Bladder drills Alarms and timers Contraction of pelvic floor reduces sensation Electrical stimulation High frequency applied to pudendal nerves Success 75% Often must be repeated Drug treatment Ach - muscarinic recptors 25-50% efficacy Poor compliance ```

Question 259

Types of muscurinic antagonists

Answer 259

``` Oxybutynin Severe SE Drymouth Tolterodine Specific to muscarinic receptor Less side effects Slow release available Solifenacin As effective as tolterodine Less side effects Trospium Second line drug Propiverine Second line ```

Question 260

Detrusor overactivity management surgical

Answer 260

``` Botulinum Good for nerogenic DOA Not as good for idiopathic Surgery End stage Clam enterocystoplasty Augments bladder size by adding in some ileum Self catherisation 5% malignant change at 10 yrs Urinary diversion Ileostomy Continent reservoir diversion ```

Question 261

Mixed incontinence treatmetn

Answer 261

Individualised discussion Conserve measures for stress Can consider surgery - urgency persists in up to 70%

Question 262

Prolapse predisposing factors

Answer 262

``` Age Menopause Parity CTD Obesity Smoking ```

Question 263

Symptoms prolapse

Answer 263

``` "something coming down" Backache or lower abdo pain Urinary incontience Faecal incontinence Difficulty with micturition or defacation Bleeding/ discharge Apareunia Inability to perform sex# ```

Question 264

Type of prolapse

Answer 264

Cystocele: Bladder bulges into vagina due to weakness in wall Rectocele: Posterior vaginal wall prolapse, Rectum buldges into vagina Enterocele: Herniation of peritoneal sac between vagina and rectum (often with bowel)

Question 265

Degrees of uterine prolapse

Answer 265

1st - cervix visible when perineum depressed (contained within vagina) 2nd- Cervix prolapsed through introitus (entrance) with fundus remaining in pelvis 3rd degree - procidentia (complete prolapse), entire uterus is outside

Question 266

Treatmetn of prolapse

Answer 266

``` Nothing Pessaries Easy and effective Minimal SE Ridgid block into vagina Also support bladder -may help stress incontinence Surgery Remove lump Restore organs to correct places Correct incontinence Preserve sexual finciton Wide range of procedures Comps Recurrent prolapse 10-15% Haemorrhage and Vault haematoma Vault infection DVT New incontinence Ureteric or bladder injury ```

Question 267

Other causes of incontinence e.g. continuous dribbling in african, post STI in male, Function incontinence.

Answer 267

``` Continuous dribbling Vesicovaginal fistula if prolonged labour from foreign country Post STI in male Stricture Functional incontinence Brain pathology Overflow Prostate ```

Question 268

RFs perinatal mental health

Answer 268

``` <16 Unrealistic ideas of motherhood Pre existing MHI FH MH Volatile or absent family relationships Social isolaton - foreign language Lack of positive support partner Poor or inadequate antenatal care Preg Comps Social problem ``` ``` Access care not good e.g. Substance misuse Migrant, asylum seeker, refugee <20 Domestic abuse Poverty Homeless ```

Question 269

Ways to risk assess and detect early perinatal metnal health

Answer 269

``` Brief screen in antenatal booklet (Whooley and Arrol) Can develop later Also GAD 2 - 2 item If high then GAD 7 Also Edinburgh postnatal depression scale EPDS (14-15) and Becks depression inventory ```

Question 270

Prevention of mental health post partum

Answer 270

Preconceptual counselling in psych patients Contraception use and pregnancy plans Implications of preggers and childbirth on mental illness and risk of relapse ``` Prevention Use the lowest possible dose Pre conceptual counselling Risk assess ante and post Education of HCPs Specialist mental healthcare team Protocols/ Guidelines for mgx of women at risk Documented mgx plan of at risk patients Antenatal and parenting classes Provision of home help and lengthening of hospital stays ```

Question 271

What is postpartum blues, treatment

Answer 271

Some alteration in their emotional state between the 3rd and 10th day postpartum Mild to significant Drop in progesterone Self-limiting 48hrs to 2 weeks Reassurance and support - health visitor Anxious, tearfull irritable

Question 272

Postnatal depression syptoms and onset and treatment

Answer 272

Mild in 7% Labile mood, irrtability, probs with coping and anxiety, symptoms similar to depression Can start first week postpartum - peak at 3 months Psychological as effective as antidepressants Preventative strategies are modified antenatal classes and postnatal peer support groups. Severe major postnatal depresson Affects 3-5% of all women Develops in early weeks post-delivery 1st 3 weeks rest between 10-12 week Symptoms are overt guilt, worthlessness, anxiety, panic attacks, anorexia, loss of concentration, anhedonia 1/3 obsessional thoughts of harm coming to baby Mangaement CBT SSRI 6 month therapy Recurrence risk 30-50%

Question 273

Puerperal psychosis symptoms and onset

Answer 273

Psychiatric emergency 1-2 per 1000 deliveries A third are manic and 2/3 depressive psychosis Abrupt onset by day 5 Peak onset at 2 weeks May present later - 3 months Irritablity, insomina, labile mood and behaviours, disorganised behaviour, delusions, hallucinations, high risk of suicide, disorientation

Question 274

Treatment puerperal psychosis

Answer 274

Manage MDT in mother baby unit Good recovery Emergency referral to specialist team Target affective symptoms: mood stabilizaer/ antidepressant/ ECT Target psychotic symptoms: 2nd gen atypical antipsychotic and long acting benzo Therapy, reassurance, emoptional support (family) MDT - health visitors, community psychiatric nurse High risk then admit to mother baby psych unit Risk of recurrence is 50% higher if preggers within 2 years of recurrence

Question 275

Lithium in pregnancy

Answer 275

Lithium, - ebsteins anomaly and neonatal hypothyroidism (offered cardiac scan), hypotonia, poor reflexes and arrhythmia Weened over 4 weeks if discovered use in preggers

Question 276

SSRI use in pregnancy, paroxetine adn fluocetine

Answer 276

SSRI - miscarriage, LBW and pulmonary hypertension Paroxetine - fatal cardiac death/ defect Fluoxetine is safer Antidep and antipsych can cause withdrawal e.g. Relucant to feed etc SSRI withdraw normally self limiting Poor adaptation Jitteriness Irritability Poor gaze control Can adjust feeding to avoid dose of drug Paroxetine worst Longer withdrawral for fluoxetine but thought to be best Treatmetn rarely needed Breast feed ok

Question 277

Olanzapine in preggers

Answer 277

GDM, Fetal macrosomia | Antidep and antipsych can cause withdrawal e.g. Relucant to feed etc

Question 278

Anti-epileptics/ mood stabilisers in pregnancy

Answer 278

Carbamazepine = cleft lip Lamotrigene risk of Steven Johnson Antimanic - sedation, poor feeding, behavioural effects, develomental milestone, long term

Question 279

Benzos in prenancy

Answer 279

Lorazepam/ Zolpidem ok as shorter half life

Question 280

SSRIs and TCAs that are ok in preg

Answer 280

FINA - Fluoxitine, imipramine, noritramine, amitriptalline OK

Question 281

What is first stage of labour? how long?

Answer 281

Cervix up to 10cm dilation Length starts at 4cm Before is latent - regular contraction but not effacing Mucus plug comes out - is it snotting like nose or fresh bleeding

Question 282

Passage in labour?

Answer 282

``` Pelvis unliekely cause unless RTA but rare Cervix - may have scarred, may tear Vaginal septums - just tear FGM - nasty tear to bladder and bowel Deinfibulation to open up and prevent tears Soft tissues Lower uterine segment Cervix Vagina Vulva (external female sex organs) Pelvic floor Perineum ```

Question 283

The powers in labour?

Answer 283

Fundal dominance of contractions The uterus polarises into an upper segment and lower segment Contractions are rhythmic and occur every 3-4 minute (2-3 in 10) and every 2-3 minutes in advanced labour (3-5). Note 5 is probably too much - slow up syncioxtocin

Question 284

The passenger in labour? / terms

Answer 284

Lie Long Oblique Transverse Presntation Ceohalic Vertex (occoiput leading - most common cephalic) Brow Face Breech Shoulder Denominator - part of fetus used as reference point to describe position in materal pelvis (occiput, mentum, sacrum, acromino) usually occiput OP really slows labour down Position Relation of denominator to maternal pelvis Occipitoanterior, occipitotransverse, occipitoposterior ``` Moulding of fetal cranium + depending on how much you can get finger through Shows last trick has been used. +3 due to malposition Capput Egg head going down within 24 Engagement How much can feel out of pelvis Usually 2/3 fifths Usually occurs in 3 term Nulitips usually not until larbor ```

Question 285

Mechanism of labour

Answer 285

``` Engagement Flexion So occipital presentation Descent Internal rotation Extension External rotation (shoulders through spine) ```

Question 286

Monitoring during labour including drugs

Answer 286

``` Obs Hydration Analgesia Pethidine Gas and air Water Antacids Risk of theatre Bladder care Position Not flat - hypensensitive due to major vessels Sitting up - left lateral tilt 3rd stage Active management Oxytocics and controlled cord traction Waiting can take 45mins Perineum ``` ``` Fetal wellbeing Fetal heart monitoring 15mins in first stage Continuous in high risk Colour of liquid Clear or straw If blood If meconeum then monitor ```

Question 287

Describe station in labour

Answer 287

``` widest part of head (biparietal diameter) to ischeal spine - can be plus too If through should be vaginal If not through then C seciton an option Low risk 0.5 cm per hr dilation Different in high risk = 1cm/hr ```

Question 288

Define failure to progress?

Answer 288

``` x 1hr after full dilation call doctor 2hr if epidural Indications Lots of caput moulding Haematuria Maternal Exhaustion 20 hours or more if you are a first-time mother, and 14 hours or more if you have previously given birth ```

Question 289

Causes of failure to progress

Answer 289

``` Powers Ineffective uterine activityy Hypotonic contractions Incoordinate contractions ?Dehydration, exhaustion, ketosis ``` ``` Passage Abnormal bony pelvis Cervical dystocia - rigid/ edematous Mechanical obstruction Rigid Perineum ``` ``` Passenger Macrosomia Hydrocephalus Abnormal diameter presenting Abnormal attitude, malpresentation or malposition ```

Question 290

Management of powers in failure to progress

Answer 290

``` xManagement Hydration Analgesia Amniotomy Oxytocin infusion Delivery if appropriate ```

Question 291

Management of passage in failure to progress

Answer 291

x Managemnt C section Episiotomy

Question 292

Management of passenger in failure to progress

Answer 292

``` Management C section Correct malposition Instrumental delivery x ```

Question 293

Dangers of breech

Answer 293

``` C section 5-10x less liely to have mort and morbidity Often with twin - i.e. second Undiagnosed breech with emergency Probs Cord prolapse With or before fetus Compromises blood flow to fetus Trapped aftercomng head Intracranial haemorrhage Internal injuries Usually iatrogenic ```

Question 294

Indications of suspected fetal compromise

Answer 294

Passage of meconium Non reasuring CTGs Good NPV Poor PPV High sensitivity, low specificity Confirmed by fetal acid-base (fetal scalp blood sampling) If unable to perform FBS, delivery by speediest route Baseline tachy or brady Reduced beat-to-beat variability (flat) Absence of acceleration (non-reactive) Presence of deceleration

Question 295

Causes of fetal compromise

Answer 295

``` Uterine hypersimulation (iatrogenic from oxytocin) Hypotension Poor fetal tolerance of labour (IUGR) Cord compression Infection Maternal disease ```

Question 296

Management of suspected fetal compromise

Answer 296

Rectify reversible causes e.g. Maternal hypotension Left lateral position Stop oxytocics Confirm compromise by blood sampling where possible deliver by speediest route if unable to correct or if significant acidosis

Question 297

Risks of VBAC

Answer 297

2/1000 chance of death instead of 1/1000 Risks Emergency C section Uterine scar dehiscence/ rupture 0.5-1% Risk higher with more than one previous CS

Question 298

Common precautions with VBAC

Answer 298

IV access and G&S Continuous electrical fetal monitoring Avoid prolonged labour Augmentation/ induction should be senior decision only More likely with placenta previa

Question 299

Placental invasion disease

Answer 299

Accreta into muscle - placenta attaches to myometriua as opposed to just decidua basalis Increta Villi invade myometrium Perccreta - adjacent organ (bladder) Invade through perimetrium/ serosa Risk of bleeding so interventional radiologist and vasc surgeons

Question 300

Operative delivery of baby instrumental indications

Answer 300

If retinal detachment, Pneumothorax and dont want to push too hard Failure to progress in 2nd stage Fetal distress in 2nd stage

Question 301

Complications of operative instrumental

Answer 301

``` x Failure Fetal trauma Maternal trauma Postpartum haemorrhage Urinary retention ```

Question 302

Pre requisits for instrumental

Answer 302

``` Trained operator Full dilatation Absent membranes Cephalic presentation Clearly defined position Presenting part engaged No evidence of CPD = Cephalopelvic disproportion (obstruction) - cant have everything on head Adequate analgiesia Peudendal nerve block may help Empty bladder ```

Question 303

C section indications

Answer 303

``` Failure to progress Fetal distress Maternal reasons Malpresentation/ Malposition Failed instrumental delivery ```

Question 304

Complications c section

Answer 304

``` Transient tachypnea of newborn (TTN) Retained fetal lung fluid, supportive tx abx O2 Haemorrhage Infection Bladder/ bowel injury Thromboembolic disease Requirement for blood transfusion Fetal trauma ```

Question 305

Shoulder dytocia definition

Answer 305

Inability to deliver shoulders after delivery of head | Anterior shoulder does not enter the pelvic inlet

Question 306

Shoulder dystocia Risks

Answer 306

``` Fetal death Asphyxia with resulting hypoxic damage Birth trauma (erbs - waiters tip internal rotated, fracture) Maternal trauma PPH ```

Question 307

RF shoulder dystocia

Answer 307

Macrosomic fetus DM High maternal BMI Prolonged labourRotational instrumental delivery

Question 308

Managemnet shoulder dystocia

Answer 308

Episiotomy McRoberts position Flex and abduct hips Other obstetric manoeuvres

Question 309

Breech RFs

Answer 309

``` Uterine fibroids/ malformation Placenta previa Polyhydramnios/ oligohydramnios Fetal abnormality e.g. CNS malformation or chromosomal disorder Prematurity ```

Question 310

Management of Breech

Answer 310

``` x External cephalic version Elective C section Vaginal breech delivery <36 weeks most will turn spontaneously 36 weeks then external cephalic version 60% success 37 in multipaous women Still breech then planned c section or Vaginal ```

Question 311

Physiological causes of lumps

Answer 311

``` Coronal papillae Vulval papillae Keratotic wart Fordyce spots Haemangiokeratoma Hair follicles Pearly penile papules Scrotal follicles Skin tags Tyson's glands Vestibular papillosis ```

Question 312

PAthological ddx lumps on perineum

Answer 312

``` Penile (meatal) warts Molluscum Contagiosum Lichen planus Secondary syphilis (above) (Condylomata lata) Carcinoma in situ VIN ```

Question 313

Presentation of genital warts

Answer 313

``` Keratinised (dry/ hairy skin) Non keratinised (warm/moist/ nonhairy) Aymptomatic Painless Itching "sore" Bleeding from urethra or anus (internal lesion) Distorion of urine flow (internal lesion) Anus ```

Question 314

Pathophysiology of genital warts - how common is HPV infection? method of infection

Answer 314

``` HPV 1% have genital warts 25% no contact 60% prior infection 14% The rest subclinical infection 60% infectivity rate during sex Incubation long from 2 weeks to 8 months 4 months mean Replicate in basal layer, assemble in ```

Question 315

Management of warts. Order of success and recurrence

Answer 315

Explaination - implication on health etc Condoms useless Asymptomatic viral shedding Phsyological impact/ counselling Cryotherapy, podophyllotoxin and imiquimod all as effective (Podo may be more), imiqui lowest recurrence then cryto then podo

Question 316

Podophyllotoxin MoA, Use.

Answer 316

``` Non keratinised Podophyllotixin MoA Antimitotic Followed by local tissue necrosis HPV-infected cells reduce and warts shrink Solution (penile) or cream (vulval) Use 4-5/52 3/7 a week followed by 4/7 rest Avoid sex after (damage condoms) ```

Question 317

Imiquimod moa, use

Answer 317

MoA Stimulates innate and aquired immune response NKC activity and macrophage NO secretion Augments T cell activity and B cell proliferation and differentiation Induces cytokine production Interferones, TNFa and IL2 Not directly antiviral (maybe why it is better at remission? Use 3/7 for 16weeks

Question 318

LN2 best for which type of warts?

Answer 318

Keratinised

Question 319

Management of cervical warts

Answer 319

Gynae for colposcopy

Question 320

Managemetn of warts in preggers?

Answer 320

``` Often first presentation More difficult to treat Low risk of vertical transmission Home therapies are teratogenic Spontaneous resolution in puerperium Cryo only treatement (needs weekly) Risks RLP - round ligament pain Obstruction Treatment Cryoablation Surgical removal/ LSCS if extreme Avoid topicals ```

Question 321

When to refer for warts treatment?

Answer 321

``` Unsure of diag Cercial or vaginal warts Intrameatal or anal warts Not responding to treatment <16 Other genital symptoms Increased chance of other infection MSM Non-UK partner ```

Question 322

Sexual history PC female and tactics

Answer 322

Explain confidentiality Maintain privacy Simple language ``` Vagnal discharge - not neccessarily STI e.g. Thrush BV Genital lumps Warts Intermenstrual and post-coital bleeding Deep and superficial dyspareunia Location of pain Enters = superficial e.g. Thrush Deep inside = PID Dysuria and urinary frequency Abdominal pain PID Ectopic Rectal symptoms ```

Question 323

Sexual history PC male

Answer 323

``` Urethral discharge Dysuria and freq Genital lumb Testicular pain/swelling Swelling Epidydimal orchitis Rectal symptoms MSM ```

Question 324

Other reasons male and female present GUM

Answer 324

``` Females STI contact/ sexual assaults/ contraception/ TOP/sexual dysfunction Males MSM Sexual dysfunction and assaults ```

Question 325

Gyane history female GUM

Answer 325

``` Gynae Preggers Normal Still birth Miscarriage Menstual Reg How long LMP Heavy/ painful Smear Contraception What ```

Question 326

Social history for GUM

Answer 326

``` Alc Smoke Recreational drugs IVDU Chem sex - sex on drugs Domestic violence ```

Question 327

Sexual hisotry GUM

Answer 327

``` Past history of STI Last episode of sex How long getting STI to picking up on test = window. Clamyd and Gonn = 2 weeks to show up. Reg/ casual/ one off Male/ Female partner Sexual Contact - regular or contact Casual high suspicion of STI Difficulty with partner notification Duration of relationship Shorter then higher risk Sex with condoms Type of sex Particularly MSM Insertive/ receptive, active/ passive, top/ bottom Partner symptoms Partner details for contact BBI risk assessment How many partners in last 6 months - Hep C IVDU Partner IVDU MSM Women ask if parter MSM Where are partners/ patient from Africa risk Partners have virus Viral load Treatment Immunosupresed Blood products before 1985 Paid for sex or been paid for sex Tattoos/ piercing abroad PEP - limits risk fo getting HIV from sex ```

Question 328

Male sexual examination

Answer 328

``` Feelin in inguinal or groin region Insepect pubic area and scrotum Scratch Rashes Inspect penic Fully retract foreskin Palpate scrotal contents Tenderness over epidydimis = epidydimal orchitis MSM Perianal Anal/ rectal examination with proctoscope and for swbas ```

Question 329

Investigation male and time to show on test

Answer 329

``` Urine - Chlam + Gonn Discharge - on slide - evidence on Gonn Culture plate for Gonn - abx Blood HIV - window 1 month (no longer 6 months) Syph Hep B + C Hep B - 2 month Hep C - 6months MSM swabs from rectum and pharyngeal ```

Question 330

Female exanination

Answer 330

``` Lithotomy position Visulisation Inspect and palpate inguinal region Inspect public area, labia majora, minora and perianal areas Speculum exam Lube on Insert sideways When in rotate 90 deg and open See cervix Any bleeding Collect discharge from posterior fornix Bimanual exam Abdo pain Vaginal Same- 2 fingers 90degrees Push against cervic - pain -cervical something Analrectal in left lateral Oral cavity Skin Lymphoreticular system Eyes Joints Reactive arthritis ```

Question 331

Investigation female STI

Answer 331

High vaginal loop swab and pH - TV, BV, Candida Vivovaginal swab dual NAAT - Chlamyd and gonn Bloods Optional High vaginal charcole - MC+S, candida Gon ciltures - urethral and endocervical DGM - Dark gram microscopy Dark lesion?Shancre HSV PCR - ulcer Urinalysis Preggers test Self take a lt of swabs

Question 332

Causative organisms of PID

Answer 332

Chlamyd - risk increases with subsequent infection ?Hypersensitivity response Gonn more severe - attach to host cell via pili Neutrophilic infiltrate and abscess formation Gonn symptoms more likely than Chlamydia More systemic symptoms Tubo-ovarian cyst 10-40% untreated in chlamyd = PID Anaerobes etc in older women and of lesser importance Mycoplasmal PID Mild/ moderate similar to chlamyd

Question 333

Symptoms PID

Answer 333

``` Cervical Inflam Tenderness Discharge Deep dyspareunia Endometritis Menstrual irreg Menorragic IMB Secondary dysmennorhea PCB Midline abdon pain Not related to menses Constant Worse during or after sex Salpingitis Erythema Edema Exudate - discharge Lowblat abdo pain Peritonitis/ Appendicitis/ Perisigmoiditis/ perihepatitis Systemic Fever Asymptomatic ```

Question 334

Complications PID

Answer 334

``` Fitz-Hugh-Curtis Capsule of liver infalmmed Chlamydia mostly Cause adhesion - Violin-string adhesions Tubo- ovarian abscess Chronic pelvic pain Infert - Adhesions Increased episodes increases riks of tubal occlusion with each infection Increased risk of ectopic preggers In adnexae Recurrence Women with HIV have more severe symptoms ```

Question 335

Differentials PID

Answer 335

``` UTI/ Cystitis GI IBSIBDApprendicitis Gynae Ovarian cyst (torsion or rupture) Endometriosis Ectopic ```

Question 336

RFs PID

Answer 336

``` Young age Low SES Multople partners <25 yrs Low educational attainment TOP/ misscariate Instrumentation of uterus (loss of barrier of cervix) Barrier methods of contracep (decrease risk) Hormonal (increase)Timing of menses Appendicitis Coil insertion Low SES New sexual partner ```

Question 337

Signs PID

Answer 337

``` Cervical excitation Bimanual - pain, tenderness Lower abdo tenderness - bilateral Adnexal mass Tubes - either side of uterus) (abscess) ```

Question 338

Diagnosis PID

Answer 338

``` Clinical diagnosis difficult Uterine/adnexal tenderness or cervical motion tenderness can be diagnostic Cervical discharge Do not wait if high suspicion despite no investigation results Bedside Obs - oral temp >38.3 Bloods ESR CRP WCC Only if mod/ severe PID Imaging not usefel TVS Hydrosalpinx/free fluid/ abscess MRI/CT may confirm other DDX Neither is routine Procedural Preggers test most important Swabs Test for CT, NG, MG (myocplasma but not very available) vulvovaginal/ endocervical NAAT for CT and NG Culture for NG WBCs/ saline microscopy (Vaginal wet mount) of discharge - Absences of vaginal/ endocervical pus cells has high NPP for BV, TV and Candida Absence does not exclude as not swabbing higher infection site Definitive with laparoscopy Endometrial biopsy possible Doppler flow studies possible ```

Question 339

Management PID

Answer 339

``` Rest Analgesia Broad spectrum abx IV if temp >38 Admit fo obs if severe disease, preggers or suspected tubo ovarian abscess Abstinence until both partners treated ``` Empirial treatment Low threshold for treatment as delay may lead to worse outcome Esp if RFs, new onset lower bilat abdo pain, tenderness Unless Preggers ... Several regimens to cover common organisms over 2 weeks e.g: 500 mg IM ceftriaxone - gonn (also with erythro due to resistence) 100mg bd Doxy - chlamyd and inflam 400mh bd Metron - anaerobes Moxifloxacin if mycoplasma suspected IV until 24 hrs post improvement clinically Contact tracing with full screen and minimum treatment of Azithro 1g stat

Question 340

When to hospitalised PID

Answer 340

``` Surgical emergency Acutely unwell Not tolerate oral Not respond oral Abscess Pressers ```

Question 341

Follow up PID

Answer 341

``` 72hrs If no improvement - remove IUC if in sity (risk of preggers in last 7/7 adn consider emergency contra) - normally just leave in Consider IV 2-4weeks Ensure symptoms resolved Check compliance Metronidazole not nice Folllow up contacts and screening ```

Question 342

Surgical manage,ent PID

Answer 342

Surgical management Laparoscopic drainage +/- division of adhesion US guided drainage of cervical collections

Question 343

PID in pregnancy

Answer 343

Uncommon Cervical plug prevents infection Associated with increase in maternal and fetal morbid`ity IV therapy recommended

Question 344

Pathophysiology of hSV, types and stages

Answer 344

Herpes is seasonal September/October to March/April Herpes = to creep in latin (histological = dendritic) ``` Herpes - morbidity for life assocaited with infidelity Skin to skin transmission First episode followed by recurrences Asymptomatic carriage Pathogen Icubation 3-14days 4 stages Initially Tiny vesicar lesion Become blisters Ulcerate Resolve 2-3 weeks in primary Recurrence 2-3 days long, max 5 days Erosive vs ulcerated lesion Loss of epidermis only (erosive) - blisters Ulcer - both layers lost HSV 1 more common fron sex (i think) but both possible HSV 2 mouth??? Herpetic whitlow = finger or thumb - extrasexual ```

Question 345

Presentation HSV

Answer 345

``` Excruciatingly painful Dysuria When urine touches thighs or labia outside body - peeing on glass No frequency-rather desire not to pass urine Local A rash Leisons May just be within cervix DDX cervical cancer - stops girl going throgh cervical cancer May have discharge Can be analgenital Even without anal sex Systemc Myalgia Headache Tiredness (Fluy) Used any chemical agents recently Exlude chemical dermatitis Cervicitis May or may not get dicharge ```

Question 346

Examination HSV

Answer 346

Vulval swelling Multiple lesions with dendritric appearence Different lesions at different stages May just see oedema or swelling or no ulceration

Question 347

Investigation HSV

Answer 347

``` Swab - can do self swab Nucleic acid amplification technology Full STD screen Sypis serology Suspect unless proven otherwise On the rise HIV antibody test PCR Highly sensitivty ```

Question 348

Recurrence and prev of types of HSV

Answer 348

``` Types Type 2 higher recurrence Normally 4 in first year Type 1 Morecommon ```

Question 349

Managment HSV

Answer 349

Sick note/rest Analgesia Saline washing - urinate in bath or topical lignocaine gel If retention may need suprapubic catheterise Systemic antiviral 5 days Aciclovir or valaciclovir (way more expensive) Vaseline Avoid sexual contact Maximal benefit after 5 days. Natural history is self limiting

Question 350

Complications HSV

Answer 350

``` Urinary retention Adhesions - vaginas needed release Men frenulum repair Meningism Emotional distress Recurrence Herpes encephaltis Erosive vulvitis ```

Question 351

Is HSV serology useful?

Answer 351

xMany asymptomatic shedders 50% women 60% men seroconvert without being recognised Explains why serology is a waste of time Condoms only reduce if sore on glands or shaft

Question 352

HSV in pregnancy

Answer 352

HSV in preggers If recurrent episode low risk Primary infection in last trimester- C section Not enough time for antibody transfer NO place for swabbing in last trimester Occasional use prophylactic therapy in last trimester Discordant couples (one with one without) no UPSI (unprotected sex) in preggers Only time HSV serology considered Want to ensure its not first presentation Otherwise child gets herpes encephalitis - 80% mortality IF man herpes positive then ask to not have unproteced sex

Question 353

DDX HSV (genital soreness)

Answer 353

``` UTIThrush Rampant rabbit Sex toy can cause too Fixed drug eruptions Pheophylinnes Barbiturates Bechets Apthosis T cell triggered e.g. nutrition def Trauma Stress Hormones Allergies Genetics Lichen planus Pemphigus Malignance Trauma -physical/ chemical dermatitis Herpes zoster VIN/ CIN ```

Question 354

Syphilis pathology inc incubation

Answer 354

Treponema Pallidum Primary Icubation 9-90 days Secondary Incubation 6weeks to 6 months

Question 355

Presentation syphilis (stages)

Answer 355

Primary Chancre (painless ulcer) Oral Genital Perianal Lymphadenopathy Secondary Systemic symptoms Papular lesions on trunc Mucous patches on tongue Macular papular but on hands and feet Alopecia - eye brows too Chancre mucous membrane and scrotum Tertiary CVD - aortitis Neurology- asymptomatic, tabes dorsalis, dementia

Question 356

Diangosis syphilis

Answer 356

Dark ground microscopy Shooting stars Treponemal PCR STI Scren

Question 357

DDX syphilis

Answer 357

``` Haemophilus ducreyi/ chancroid Lymphogranuloma Venerum Granuloma inguinale Scabies Phthirus pubis Apthous ulcer ``` Behcets Recurrent orogenital ulceration Fixed drug eruption Erosive balanitis (nonspecific) Inflammation Environment Physical trauma Infection Extramammary Pagets disease

Question 358

What is haemophilus ducreyi?

Answer 358

Irregular painful ulcers Necrotising base Management Macrolide e.g. azithro

Question 359

What is lymphogranuloma venerum

Answer 359

Chlamydia tachomatis L1,2,3 serovars Small non-secript ulcer followed by florid (unilateral) lymphadenopathy and ano-genital syndrome

Question 360

Granuloma inguinale?

Answer 360

AKA donovanosis Klebsiella glandulomatis "beefy ulceration"

Question 361

Scabies on genitals

Answer 361

Crusted, inducated lesions on genitals Itchy

Question 362

Phthirus pubis?

Answer 362

Pubic hair - crab lice

Question 363

Causes of erosive balanitis?

Answer 363

Inflammation Environment Physical trauma Infection

Question 364

NAtural history typhilis

Answer 364

Primary and scondary may last 2 yrs - infections Latent Tertiary Tabes CVS

Question 365

Managemtn syphilis

Answer 365

Benzathine Penicillin IM stat If tertiary ten IV penicillin

Question 366

How long after birth need no contraception?

Answer 366

21 days

Question 367

Risk of transmission of BBV from needlestick

Answer 367

Hep B 1 in 3 Hep C 1 in 30 HIV 1 in 300

Question 368

Management of needlestick injury general

Answer 368

First aid measurement Wash and encourage to bleed (don't rub) Inform senior - relieved from duties Incident reporting later Risk assess by occupational health or GU doctor May need HIV post-exposure prophylaxis - start within 1 hr May need HBV booster Source patient RFs Known positives Viral load Big factor Nature of exposure Hollow vs solid needle Size of bore Gloves Skin puncture/ broken skin/ intact skin/ mucous membrane Time to first aid measures Recipient HBV vaccine status

Question 369

Management of specifiv BBV from needlestick

Answer 369

HIV PEP (post exposure prophylaxis) for 28 days Triple anti-retroviral drugs Start within 72 hrs (earlier better) Hep B May need booster immunisation May need HBIG If incompletely vaccinated/ poor responder and if patient HBSAg positive Hep C None available

Question 370

Testing post needle stick

Answer 370

HIV HBsAg HCV - Anti- HCV initially Recipeint Original blood sample sored Further tests at 6,12,24 weeks depending on curcumstances Waiting Safe sex Good infection control Avoid blood donation

Question 371

How does HIV cause harm?

Answer 371

nto host DNA Reverse transcripase to make DNA from genomic RNA

Question 372

Acute ilness in HIV? when?

Answer 372

Seroconversion illness (50-70% After 2-6 weeks)

Question 373

Long term consequences of HIV infection

Answer 373

Opportunistic infections TB Candida, pneumocystis Viral (HSV, CMV) Protoxoal Toxoplasma CNS - encephalopathy Malignancy -lymphoma, Kaposi sarcoma Wasting syndrome Weight loss >10% with diarrhea or chronic weakness and doccumented fever >30 days not attributable to concurrent condition

Question 374

How to test for HIV

Answer 374

4th gen combo assay (EIA Detects Anti-HIV antibodies Detects p24 antigen Shorter window period -2 weeks (4 weeks to be safe) Confirmatory test in lab if positive - immunoblot Look for other antigen RNA detection by PCR for viral load Second sample to confirm patient ID

Question 375

Pregnancy treatment HIV

Answer 375

Pregnancy Give antivirals HAART to mother throughout pregnancy Risk of premature labour and GDM Delivery If viral load <50 then vaginal ok If above 50 or not on HAART then C section Postpartum Avoid breast feeding (Carbergoline to supress lactation) HAART/ Zidovudine to baby within 4 hrs If high risk give Co-trimoxazole (PCP)

Question 376

Managemnt and monitoring in HIV

Answer 376

Highly active anti-retroviral therapy (HAART) Monitoring HIV viral load CD4 counts +/-HIV genotypic +/- drug resistance testing Routing bloods Hep B/c, EBV, CMV, TB Treat/ prevent opportunistic infections HAART Monitor CD4 and viral loads ?monthly at first then?6 monthly Refer to counseling for psychological suppport Advice regarding potential partner notification Counsel risk of opportunistic infection adn advise seeing help Management of CVD risk factors - higher risk of CVD Manage of bone diesease RFs e.g. smoking, alcohol, vit D

Question 377

Hepatitis presentation acute

Answer 377

Fever RUQ Jaundioce Malaise Anorexia, nasuea Dark urine, pale stool Fulminant hep - transplant? Cant distinguish from features Suportive management

Question 378

Hep B pathogen and problems

Answer 378

Partially ds DNA Symptomatic (incubation 2-6 months) <10% children, 30-50% adults Acute hep Fulminant hep Asymptomatic 1% mort Chronic hep 90% infants, <3% adults Asymptomatic or symptomatic carrier Cirrhosis HCC (100x risk)

Question 379

definition of acute vs chronic hep B

Answer 379

Acute vs chronic Hep B is <>6 moths

Question 380

Markers of current infection HBV

Answer 380

HBsAg = current infection (Ag = component of virus) Anti HBc - current or previous infection

Question 381

Marker of current or previous infection HBV

Answer 381

HBsAg = current infection (Ag = component of virus) Anti HBc - current or previous infection

Question 382

Marker of immunisation

Answer 382

Anti HBs - Immunisation

Question 383

Markers of infection

Answer 383

E antigen - high infectivity Anti-Hbe - high infectivity resolved

Question 384

Markers of body response to HBV

Answer 384

IgM = first reponse IgG = subsequent response

Question 385

Prevention of HBV

Answer 385

Lifestyle Vaccine 0,1,6 month doses Check anti HBs Pre and post exposure HBIG Post exposure prophylaxis Neonates of infected mother Needlestick

Question 386

When might one use HBIG?

Answer 386

Lifestyle Vaccine 0,1,6 month doses Check anti HBs Pre and post exposure HBIG Post exposure prophylaxis Neonates of infected mother Needlestick

Question 387

Management of HBV

Answer 387

Admit if unwell Refer to ID/ Hep/ GuM Notify PHE Full serological testing Baseline FBC LFT Clotting AFP Liver US Immunisations Hep A Houshold against Hep B Lifestyle Avoid transmission to others Avoid alcohol Breastfeed ok if baby immnunised Antvirals Speciialist

Question 388

bREAST feeding in HBV

Answer 388

fine

Question 389

Management of Hep B in preggers

Answer 389

If mopther is surgace antigen pos then give Hep vaccine and 0.5ml HBIG within 12 hours of birth and further vaccine at 1-2 months and 6 months Not trasmitted by breast feeding unlike HIV

Question 390

Hep D who gets? presentation

Answer 390

Defective virus only funciton if HBsAg present BBV Co-infection with HBV More sympotmatic More likely to appear clear With chronic HBV Symptomatic flare High risk of chronic liver disease

Question 391

HCV pathogen presentation

Answer 391

Enveloped single-stranded RNA Acute Asymptomatic or mild -6 week incubation (2-26) 20% Clear infection 80% progress to chronic infection Cirrhosis HCC

Question 392

Serology HCV

Answer 392

Anti-HCV used Marks current or past infection Postiivite after 4-10weeks Antiody provides incomplete protection and reinfection is possible HCV RNA Distinguish current from past infection If present then infectious

Question 393

Management HCV

Answer 393

Lifestyle Weight loss Avoid alcohol Smoking Vaccine Hep A and B Acute Monitor to check clearance Drugs Sofosbuvir etc, older e.g. pegylated interferon and ribavirin Chronic Monitor for liver fibrosis and HCC

Question 394

Hep A and E transmission, presentation, RFs, prevention

Answer 394

Faeco-oral transmission (Or blood rare) Acute Asymtpomatic Or symptoms 2-8weeks Severity more with age Pregnant have high mortality No Chronic RF Travel MSM IVDU Prevention Hep A vaccine

Question 395

Foetal FFN?

Answer 395

Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN