Obs and Gynae Flashcards
Why is toxoplasmosis important in pregnancy?
Can cause congenital infections
- problems with baby eyes
- reduces IQ
- still birth
Which food stuffs should be avoided in order to avoid toxoplasmosis?
Raw or undercooked meat
Unpasteurised milk
Neural tube defects can occur in faetal alcohol syndrome. True or false?
False
What are the routine blood tests taken at booking (around 12 weeks) of pregnancy?
FBC - looking for anaemia Syphilis - to treat it (if there) blood group - check if patient is rhesus negative HIV Hb - check for haemaglobinopathies
If patient is rhesus negative, what do you do?
Give anti-D
What haemoglobinopathies are screened for in pregnancy?
Sickle cell anaemia
thalasaemia
What is PAPP-A?
screening for downs syndrome - not diagnostic
Diagnostic tests for Downs Syndrome?
Amniocentesis
CVS
Which 3 trisomies are screened for?
Trisomy 18 (edwards syndrome) Trisomy 13 (patous syndrome) Trisomy 21 (downs syndrome)
Downs syndrome is associated with increased maternal age. True or false?
True
At what week is the anomaly scan carried out?
Week 20
What is gastroschisis?
Abdo wall not formed properly.
Good prognosis
What is omphalocele?
Poot prognosis
Associated with significant genetic abnormalities
Which medicine could prevent anencephaly and spina bifida?
Folic acid
What is the normal dose of folic acid pre-pregnancy?
400
At 19 weeks, a Rh-ve woman who has had PV bleeding requires anti-D. True or false?
True
- should be given after 12 weeks
haemolytic disease of the newborn has been eradicated due to the use of anti-D. True or false?
False
is anti-d given routine to any rhesus negative women?
Yes, as long as the woman has no D antigens (ie unless she has already mounted an immune response)
Sickle cell disease is associated with African/ afro-carribean origin. True or false?
True
Mum Rh+ve, will she mount a response even if baby is Rh-ve?
No
If a baby is at risk of having foetal anaemia, how is this identified? and how do you manage?
Titres of antibiody are going up from mum blood test
Can then do an in-utero transfusion
If mum on her back, how should the baby come out? head first looking up/down?
Head first looking down
Opiates slow/speed up labour?
Slows
does epidural anaesthesia increase the risk of needing a C section?
No
just increases the risk of assisted vaginal delivery (woman less lokely to push)
Umbilical artery carries oxygenated blood from the foetus to the placenta. True or false?
False
- deoxygenated
Ductus arteriosis shunts pulmonary artery to what?
Descending aorta
What type of decelerations are physiological
Early decelerations
- Sign of baby being compressed by uterine contractions
What are the signs of cerebral irritation in pre-eclampsia?
Hyper-reflexia
Clonus
Confusion
Classical features of pre-eclampsia (3)
Raised BP
Significant proteinuria
Oedema
What blood test should be sent if you suspect someone has pre-eclampsia?
FBC - Hb, platelet
Coag
What are the foetal risks to pre-eclampsia
IUGR
Still birth
often needs pre-term delivery
When placenta lies over cervix what is this?
Placenta praevia
Placenta praevia is typically painless/painful?
Painless
Placenta abruption is typically painless/painful?
Painful
Mother with small amount of bleeding, painless
However, severe foetal distress
What is the likely issue?
Vasa pravia
If you get a group and save for a patient, how long does this last for?
72 hours
In an emergency, what type of blood can be used universally?
O-ve
In a massive antepartum haemorrhage, which types of blood products may need to be used?
Red cells
Platelets
Cryo - for fibrinogen
What are the safest type of twins to carry?
- dichorionic
- monochorionic
Dichorionic
What significant complication can you get from carrying monochorionic twins?
twin to twin transfusion
What is the main cause of a port partum haemorrhage?
Atonic uterus
uterotonic management
Rub the uterus up and down Oxytocin - offered to all women that deliver Ergometrine Oxytocin infusion Carboprost Misoprostol
All women are offered oxytocin at delivery. Why is this
It reduces the risk (by 50%)of post partum haemorrhage
What time of day is best to take a pregnancy test?
In the morning, first urine. As urine is more concentrated
In a bimanual vaginal examination, which areas are you assessing? (4)
Vulva/external vagina Cervix Uterus Adnexa - ovaries / fallopian tubes / pouch of douglas Any additional significant findings
In speculum examination, what is the redder area around the cervical os called?
Ectropion
Which age of women get a cervical smear
25-64
Cervical smear positive + no abnormal cells identified. What is management
Recall in 1 year
Cervical smear positive + presence of abnormal cells. What is the next thing to do?
Colposcopy
What colour is a vaginal swab?
Name 2 conditions it screens for?
Vaginal swab - blue
Screens for
- bacterial vaginosis
- trichomonas vaginalis
What colour is a vulvo-vaginal swab?
Name 2 conditions it is used to screen for?
Vulvo-vaginal swab - orange
Screens for
- chlamydia
- gonorrhoea
What are the 4 T causes of post partum haemorrhage
Tone
Trauma
Tissue
Thrombin
What is the first line treatment of post partum haemorrhage
Uterine massage
- helps the uterus to contract to reduce bleeding after placenta has been delivered
Why is oxybutynin not the first line medication used in the treatment of urge incontinence in the elderly?
Can cause cognitive impairment
Patient with nocturia. Which medication might be usefull?
Desmopressin
Which area of the cervix is particularly vulnerable to HPV infection
Transformation zone
If you are doing speculum examination and about to do a smear but the cervix is clearly abnormal (looks malignant). What do you do?
DO NOT do the smear test
Refer urgently to the 2 week wait cancer referral
25 year old P0 patient goes for routine cervical screening. Results suggest CIN1. Outline the treatment
Follow up at 12 months with repeat smear
Follow up at 24 months with repeat smear.
If normal by that point, back to routine smear
If persistent low grade abnormality at 2 years then treat (excision or ablation)
What might mosaicism and punctuation in the cervix suggest
Severe dyskaryosis
Why do you try and do ablation instead of LETZ in young female
Risks of pre-term labour
Try to do ablation instead of LETZ in young woman. But why might you have to do LETZ?
If severe CIN3
Patient presents for TOP (21 year old student PO0+0 around 6/7 weeks gestation. What are key points to cover in Hx
LMP Menstrual cycle Previous pregnancies and outcomes Any current pregnancy symptoms Reason for termination How she feels about pregnancy Contraception Asthmatic ? (use of prostaglandins) Allergies SHx
Patient presents for TOP (21 year old student PO0+0 around 6/7 weeks gestation. What are key points to cover in investigation
US - confirm pregnancy and gestation
Bloods - check if rhesus -ve / HIV / Syphilis
Swab - STI
If exclusively breastfeeding, you can’t get pregnant. True or false?
True (i think?)
If patient is anaemic prior to having TOP procedure, what should you do?
IV iron
Young female recently entered new sexual relationship. with malodourous discharge and cervical excitation, non specific abdominal tenderness
Pelvic inflammatory disease
Stress incontinence tried conservative messares, not worked, what Ix do you do?
Urodynamics
- to prove the woman has urodynamic proven stress incontinence
First line anticholinergic medication for urge incontinence?
Tolteridone
- not oxybutynin because of cognitive impairment
When about to start mirabegron, what do you need to check with the patient?
If they have uncontrolled hypertension
Surgery is more common in urge/stress incontinence?
Stress
WHat is the only surgical treatment to remember for urge incontinence?
Botox
Chronic lower pelvic pain - nothing helps
Difficult to manage
No abnormalities on investigations
Rule out all differentials - what do you think is going on?
Functional - bladder pain syndrome
What is the name of a stage 4 prolapse (everything hanging out)
Procidentia
Where should the leading edge of the vagina be (ie what -cm) in relation to the interoitus in normal woman?
-3cm above the interoitus
a child who has not yet reached the age of 13 is
incapable of consenting to any form of sexual activity. True or false?
True
- referral to child protection
What are the 3 features needed to give you a diagnosis of hyperemesis gravidarum?
5% weight loss
dehydration
electrolyte imbalance
First line treatment option for hyperemesis gravidarum
Antiemetics
- antihistamine type (cyclizine, promethazine)
- prochloperazine
Can give oral / IV / IM
Second line treatment option for hyperemesis gravidarum
Metoclopramide (beware of extrapyramidal SEs)
Odansetron
Why is odanetron rarely used in pregnancy
risk of cleft palate
Third line treatment option for hyperemesis gravidarum
Steroids
What do you need to be aware of when prescribing steroids in pregnancy and what additional measures do you need to take?
Measure foetal growth - growth scans
Possibility of pre term delivery
Which analgesia should you not prescribe in pregnant patients and why?
NSAIDs
- closure of ductus arteriosus
- reduction in foetal urine production –> less amniotic fluid
Is NSAID safe in breast feeding?
Yes
Methotrexate and pregnancy
Anyone who is on methotrexate must stop for 3 months before conceiving
What are the 3 IV antibiotics used for severe pelvic inflammatory disease
IV ceftriaxone 2g BD +
IV metronidazole +
PO doxycycline
Can you insert a coil at C section?
Yes
Woman gives birth and intends on breast feeding. She wants to take COCP. IS this possible and why?
No
Can only take after 6 weeks
Miss C is a 28 year old para 0. She has come to see you in clinic today as she is experiencing heavy menstrual bleeding. She is currently trying to conceive. Her past medical history includes polycystic ovarian syndrome and childhood asthma. Her BMI is 29 and her mother has had a DVT in the past. Miss C is not currently on any medications.
Miss C describes an irregular cycle ranging from 28 to 42 days. While she is menstruating she finds they are incredibly painful and she often floods through her underwear despite wearing a tampon and pad having to change them upwards of 6 x a day. A TVUSS shows a normal uterus with polycystic ovaries.
What treatment options ar available
Tranexamic acid for 3-4 days during menstruation
Folic acid
In pregnant woman what should ramipril be switched to?
Labetolol
In pregnant woman who is asthmatic, what should ramipril be switched to?
nifedipine
If a patient is known to have essential hypertension. Which medication should you start during pregnancy (from about 12 weeks onwards)?
Aspirin
In the first trimester, pregnant women have a lower/higher Hb level physiologically?
Why is this?
LOWER Hb level in first trimester
- increased cardiac output, increases plasma volume which reduces Hb by dilution
When does implantation bleeding typically occur?
About 10 days after ovulation, when fertilised egg attaches to uterine wall
Name 3 possible causes of recurrent misscarriage
APS
Thrombophilia
Balanced translocation
In molar pregnancy, HCG is often very high / low?
High
A 35 year old woman contacts the gynaecology ward reporting vaginal bleeding. She is pregnant. She is incredibly anxious as she had a miscarriage last year.
She tells you she has no pain and has had the same pad on for 2 hours although it is fresh red. Her pregnancy test was positive 5 days ago and her LMP was 6 weeks ago with a 28 day cycle.
Do you want to see her the same day and what advice will you give her?
No
- bleeding but NOT in pain
Advice
- return if bleeding continues / if pain occurs
- repeat urine pregnancy test in 7-10 days (return if +ve)
- negative pregnancy test means she has misscarried
Transvaginal US scan or transabdominal US scan for misscarriage?
Transvaginal US scan
If on US no foetal HR detected but CRL > 7mm then what is likely
misscarriage
Potential outcomes of a pregnancy of unknown location
Ectopic
Missed Misscarriage
Intrauterine
Potential outcomes of a pregnancy of unknown location
Ectopic
Missed Misscarriage
Intrauterine
A 35 year old woman contacts the gynaecology ward reporting vaginal bleeding. She is pregnant. She is incredibly anxious as she had a miscarriage last year. She tells you she has pain in her left side for the last 3 days. Her LMP was 5th December with a 28 day cycle. Her pregnancy test was positive 5 weeks ago. She is awaiting a follow-up consultation in the fertility clinic as she had an x-ray test which said she might have a “blocked tube” but missed her period while waiting to be seen.
Do you want to see her the same day and what advice will you give her?
Yes
- this is ?ectopic pregnancy so woman must be seen urgently
- she is in pain
Which medical management is used for ectopic pregnancy?
Methotrexate
Monitoring HCG levels in ?ectopic pregnancy. What would you expect?
HCG levels drop by 15% each 48 hrs
Patient has pregnancy of unknown location. She is seen by the registrar, HCG levels taken and the plan is made for out-patient follow-up. What will this involve and what would you say to the patient?
HCG outcomes:
Come back in 48 hours for repeat HCG blood tests
HCG outcomes
HCG doubles - intrauterine pregnancy
HCG reduces by 50% - misscarraige
HCG increases slowly - ectopic
A 21 year old woman has been an in patient on the gynaecology ward with hyperemesis requiring IV fluid hydration. It has been a struggle to control her vomiting but she has now not vomited for several hours on a combination of 2 anti-emetics. She is 11+4 weeks by dates.
She is fit for discharge. The early pregnancy clinic is able to scan her. You are asked to review her scan report before she goes home: A/V uterus is enlarged and contains a multiple cystic structures measuring 65x40x35mm
What is likely diagnosis?
molar pregnancy
Almost half of shoulder dystocias occur in normal birth weights. True or false?
True
Which position do you get the patient into if ?shoulder dysctocia
McRoberts position
Name 3 potential complications to foetus in shoulder dystocia
Foetal hypoxia
Brachial plexus nerve palsy (erbs or klumpkes)
Reduced foetal blood pH
Injury to C8, T1 is erb’s / klumpkes palsy?
What will position be?
Klumpkes palsy
claw hand
What is the window period for chlamydia/gonorrhoea?
14 days
What is the window period for syphilis / hep B
3 months - due blood test 3 months after exposure
What is the window period for HIV
45 days
MSM should get offered which 3 vaccinations
HPV
Hep A
Hep B
22 year old woman presents with bleeding after sex and change in vaginal discharge. She has never had a smear but would be interested to have one because her aunty had cervical cancer and she have heard that it runs in families.
Should you carry out a smear test?
Why/why not?
No
Do bimanual vaginal examination and have a look but no smear necessary
Common to have changes in the cervix under age of 25 so won’t give accurate result
If you’re not within screening age you do not need a smear test. True or false?
True
What is the most effective form of emergency contraception
Coil (IUD)
Why should the depo injection only be given to women OVER the age of 18
Can alter bone development
With which emergency contraception (LNG / UPA) can you quick start any method of contraception afterwards?
LNG
- UPA is an anti-progesterone whereas the pill has progesterone can cancel out effects
Uterotonics should / should not be given in second stage labour
Should not be given
Woman has been actively pushing for 90 mins with no sign of imminent delivery. If her contractions have gone off, what should you give?
Syntocinin - increases the power and strength of contractions
Spontaneous delivery but placentanot delivered 40 mins later and EBL 500ml with ongoing bleeding. What is the likely diagnosis and what is the management plan?
Diagnosis: retained placenta -> PPH
Management:
- FBC, G+S, coag screen
- Prophylactic administration of syntometerine OR
- Oxytocin 10 units
- Cord clamping and cutting, controlled cord traction
Shoulder dystocia - highlight 4 potential risks to mother
PPH due to uterine atony
Perineal tears
Uterine rupture
Transient femoral neuropathy
Shoulder dystocia - highlight 3 potential risks to baby
Hypoxia
Brachial plexus injury
reduced foetal blood pH
Breech presentation - highlight 3 potential risks to baby
Cord prolapse
Head entrapment
Perinatal morbidity
Shoulder dystocia -> tried mcrobert’s position but not working -> what do you move on to
Suprapubic pressure (try and dislodge anterior shoulder)
If both mcrobert’s postion and suprapubic pressure fails, what is the next step?
internal manouvres
A woman presenting with a footling breech should be offered a vaginal delivery. True or false
False
- Elective caesarean section
A woman presenting with a frank breech should be offered a vaginal delivery. True or false?
True
If at 36 weeks, a woman has an uncomplicated singleton BREECH pregnancy, what should be offered?
External cephalic version (ECV)
+ discussion regarding mode of delivery
If at 36 weeks, a woman has an uncomplicated singleton BREECH pregnancy and is offered ECV but DECLINES it, what should be done?
Elective caesarian section
The diagnosis of breech presentation during labour is a contraindication for vaginal breech birth. True or false?
False
36 year old type 1 diabetic at 36 weeks presents for
routine growth scan rv. She describes reduced fetal
movements over the last 48 hours and hypoglycaemic
episodes.
You request a ctg and the midwife returns to you
fifteen minutes later to ask you to review it: HR 170,
no variability, no accels, deep late decelerations
How do you proceed?
Category 1 c section (delivery within 30 mins)
42 year old prim at 30 weeks referred as measuring
small for dates
Scan shows baby measures below the 5th centile for
gestation but otherwise appears well (liquor and flows
normal).
How do you proceed antenatally?
What is the labour plan?
Weekly BP and urine
2 weekly US scan
SVD with IOL and continuous CTG ideally
Elective C section is not done before X weeks?
39 weeks
Patient’s with epilepsy should receive what during pregnancy?
High dose folic acid (5mg)
Patient with gestational diabetes has a 50% chance of developing type 2 diabetes in later life. True or false?
True
What does HELLP syndrome start for?
Haemolysis
Elevated liver enzymes
Low platelets
Which antihypertensives can you give IV in pregnancy
IV labetolol
IV hydralazine
under 34 weeks with pre-eclampsia and baby needs delivered. Which delivery method?
C-section
over 34 weeks with pre-eclampsia and baby needs delivered. Which delivery method?
IOL vaginal birth
First line sepsis antibiotic management in an obstetric woman that is NOT penicillin allergic?
Co-amoxiclav
What is first line sepsis antibiotic management in an obstetric woman that is penicillin allergic?
Clindamycin + Gentamicin
D-dimer is useful in pregnancy. True or false?
False
For breech presentation, what is external cephalic version?
Manually turning the foetus into a cephalic presentation
In foetal hypoxia, the umbilical artery INCREASES/DECREASES its resistance?
Increases
In foetal hypoxia, the middle cerebral artery INCREASES/DECREASES its resistance?
Decreases
What is the first line antibiotic used to prevent ascending infections leading to chorinoaminonitis?
erythromycin
membranes are ruptured followed by small amount of dark vaginal bleeding and is accompanied by an acute fetal bradycardia and decelerations - what does this make you think of
Vasa preavia
Vasa previa is maternal/foetal blood loss?
Foetal
acute constant abdominal pain even when the uterus is relaxed which may be referred to the should tip suddenly collapse and on abdominal palpation, fetal parts will be felt easily. What is likely diagnosis?
Uterine rupture
Getting chicken pox in pregnancy is worse if you get it at an early/late gestation?
Early = worse
pregnant women who are not sure if they have had chicken pox, or never had chicken pox and have been in contact with a child or adult with chicken pox - how should you manage this?
A blood test to check IgG antibodies to varicella zoster virus will confirm immunity to the virus.
If a pregnant woman is not immune to varicella zoster virus and has had significant exposure what should be done?
she should be offered varicella-zoster immunoglobulins (VZIG) as post-exposure prophylaxis as soon as possible (within 10 days)
Which condition can cause hearing loss, visual impairment or blindness, mild to severe learning difficulties and epilepsy in an infected fetus
CMV
jaundice, petechial rash, hepatosplenomegaly, microcephaly and infants born small for gestational age all point towards
Congenital CMV infection
Parovirus B19
Slapped cheek syndrome
Parovirus B19 is associated with hydrops fetalis. True or false?
True
- accumulation of fluid in at least 2 compartments
Women who are not immune to rubella and contract this within the first trimester are at risk of ?
Misscarriage
Woman with HIV cannot have vaginal delivery. True or false? Why?
False
- Provided the woman has a viral load of <50copies/ml, she can be offered vaginal delivery. Otherwise caesarean section is protective to the baby.
WHat is the leading cause of maternal death?
VTE/DVT
Suspect DVT in pregnant woman, what investigation do you want to do?
Duplex US
What is the agent of choice for antenatal thromboprophylaxis?
LMWH
Warfarin is contraindicated in breast feeding. True or false?
False
A small for gestational age fetus has an estimated fetal weight or abdominal circumference below which centile?
10th
What is there a risk of in a baby that has been delivered by a mother with gestational diabetes?
Risk of neonatal hypoglycaemia
Risk of duodenal atresia in what?
Polyhydramnios
What is the main risk of vaginal delivery after a C section
Uterine rupture
Patient with pre-eclampsia. If BP is a problem during labour, what could you do?
Give epidural - reduces BP
Anterior pituitary gland releases FSH and LH. What do these hormones act on
FSH: granulosa cells - oestrogen and inhibin
LH: theca cells - androgens which get converted to oestrogen (by aromatisation)
Inhibin: selectively inhibits FSH/LH at the anterior pituitary?
FSH
What is the best predictor of imminent ovultion?
LH surge
Where does progesterone come from?
Secreted from corpus luteum in secretory phase of menstrual cycle
Progesterone production peaks X days before the start of the next menses
7
- this is useful in assessment of infertility to check if ovulation has occurred
Name a prostaglandin inhibitor which is widely used for heavy menstrual bleeding
- how does it work
Mefenamic acid
- acts by increasing the ratio of vasoconstrictor to the vasodilator
What is the first line treatment of dysfunctional uterine bleeding
Progestogen releasing IUCD
Name 4 possible treatment options (in order) for dysfunctional uterine bleeding
Progestogen releasing IUCD
COCP
Anti-fibrinolytics (eg tranexamic acid)
NSAIDs (eg mefanamic acid)
When is tranexamic acid taken?
During menstruation ONLY
Woman with dysfunctional uterine bleeding but she is hoping to conceive soon. Which treatment would be best for her?
Tranexamic acid or mefenamic acid
When is mefenamic acid taken?
During menstruation ONLY
Woman with dysfunctional uterine bleeding and severe pain associated but she is hoping to conceive soon. Which treatment would be best for her?
Mefenamic acid
Name an example of a GnRH analogue
Groselin
GnRH analogues are only used short term. Why?
Risk of osteoporosis
Women thinking of surgical management for dysfunctional uterine bleeding must make sure their family is complete. True or false?
True
Name 4 potential causes of intermenstrual bleeding
Polyps
Cervical ectropion
Malignancy
Pelvic inflammatory disease
How do GnRH analgogues work?
They mimic the GnRH hormone and when given continuously, will downregulate the pituitary and decrease FSH and LH and decrease oestrogen and progesterone levels.
women over the age of 55 with PMB should be investigated when? what method? and why?
within 2 weeks by transvaginal ultrasound for endometrial cancer
What is the most common cause of post menopausal bleeding?
Atrophic vaginitis
What is always the first line investigation for post menopausal bleeding?
Transvaginal US
Patient with PMB goes for TVUSS. Reveals endometrial thickness >4mm. What is done?
Further investigations required - endometrial biopsy
Management of atrophic vaginitis (2)
Vaginal oestrogen creams
Vaginal lubricants
In PCOS Testosterone levels are normal/high/low SHBG levels are normal/high/low LH levels are normal/high/low FSH levels are normal/high/low
Testosterone - high
SHBG - low
LH - high
FSH - normal/low
What is first line treatment of PCOS for infertility
Clomifene
blocks oestrogen negative feedback effect on hypothalamus resulting in more pulsatile GnRH secretion and therefore FSH and LH
What is the first line treatment of PCOS for acne and hirsutism
Co-cyrprindol (Dianette)
In endometriosis what is the position of the uterus usually?
Retroverted
Patient presents with with dysmenorrhoea, dyspareunia and heavy periods. Endometriosis is suspected. Which investigation will confirm the diagnosis?
Diagnostic laparoscopy
First line treatment for dysmenorrhoea
Mefanamic acid (NSAID)
Second line treatment for dysmenorrhoea
COCP
Premature menopause occurs if menopause happens before the age of
40
What is the treatment of lichen sclerosus
High dose steroids
What is the name of the surgical procedure to remove bartholins gland abscess
marsupialization
First line treatment for uterine fibroids
Mirena IUD
US shows a classic whirlpool sign with which gynae pathology?
Ovarian torsion
The majority of APH causes are associated with the placenta. True or false?
True
It is relatively common to have a low lying placenta at the 20 week anomoly scan. True or false?
True
- so no further imaging is required UNLESS the placenta is completely covering the cervical os
Under what condition can women with placenta praevia have a vaginal delivery
If placenta is over 2cm away from cervical os
Painless bright red vaginal bleeding in third trimester of pregnacny
placenta praevia
Why should you not perform a vaginal examination until placenta praevia is ruled out?
Severe haemorrhage may be provoked if blood vessels are lying across the os
Woman in 3rd trimester presents with pain and a bulky tense uterus and has some dark red vaginal bleeding. What is most likely
Placental abruption
Woman in 3rd trimester gets vaginal examination. Feeling of cord pulsating. What may the diagnosis be?
Vasa praevia
Bleeding from vasa praevia is usually painful/painless?
Painless
Commonest cause of amenorrhoea at the hypothalamic level
anorexia / bulaemia
excessive exercise
Large bleed post partum can cause which syndrome
Sheehan’s syndrome
High LH
High FSH
low oestrodiol
Premature ovarian failure
Genetic cause of premature ovarian failure
Turner’s syndrome
Oestrodiol should be high/low in menopause
Low
In ovary, cyst over which size is of clinical significance?
5cm
Initial investigation of chronic pelvic pain?
US
Ground glass appearance of ovarian cyst on US scan - which condition
Endometrioma
Means you can see blood products within the cyst
GnRH analogue puts patient through artificial menopause. True or false?
True ?
This 45 year old patient has had a 6 months
of inter-menstrual bleeding. A Hb has been checked and is
120, which is stable. She has been commenced on the
progesterone only pill but not finding it any use. No pain, normal smear. Examination normal. List 3 investigations?
High vaginal swab
TVUS
Endometrial biopsy
32 year old lady who has presented with heavy menstrual bleeding. She says her periods have always been heavy but she is now flooding through clothes. An HB was checked and is 120. She has been commenced on tranexamic acid and mefenamic acid but remains symptomatic. On examination: 12 week size mobile uterus No adnexal masses or tenderness Cervix normal
What is likely diagnosis?
Uterine fibroids likely
22 year old patient with a pelvic mass. No pain, otherwise well. On examination there was a smooth mobile mass felt and GP requested US. USS - 8cm complex mass arising from the left ovary. Right
ovary visualised and normal. Uterus normal. There is no free fluid seen. What is the likely diagnosis?
dermoid cyst
You receive a call from a midwife on the postnatal
ward:
“Please can you review a 22 year old patient who is feeling unwell. She is 1 day post SVD and had a 300ml blood loss at the time. She has just passed a clot weighing 200ml. She is clammy and feels faint and the uterine fundus is felt above the umbilicus.”
What is likely diagnosis?
How would you manage this patient
Diagnosis: PPH
Management:
- IV access and cross match
- expel clots by uterine massage and uterotonics
- IV fluids
- tranexamic acid
You receive a call from the ambulance crew:
“We have attended a 20 year old patient with sudden
onset, severe abdominal pain radiating to her shoulder and dizziness. She is around 6 weeks pregnant. This is her first pregnancy.”
What is the likely diagnosis?
Ruptured ectopic pregnancy
Midwife calls from labour ward:
“Please can you come and review room 6 who is “breathing funny”. She is a spontaneous labourer with group B strep so is having benzylpenicillin as per protocol. She pressed the buzzer to say she felt breathless. She is making a funny noise when she is breathing.”
What is likely diagnosis?
How would you manage?
Anaphylaxis
Stop antibiotics
O2
IM adrenaline 500mcg repeat after 5 mins if necessary
A 29 year old nulliparous student reports gradually increasing left lower abdominal pain for 7 months. Pain becomes severe during sex. She has regular menstrual cycle and has been trying to get pregnant with her partner for two years.
US: Retroverted uterus, normal left ovary. Right ovary containing 3.1x2.5x3.5cm simple fluid filled ovarian cyst.
Diagnostic laparoscopy: abnormality at pouch of douglas.
What is the diagnosis?
Deep infiltrating endometriosis
32 yo with 8 year-long lower abdominal pain, pain on defecation and painful periods. She has 1 child and is no longer in relationship. Recently she had to reduce her working hours due to pain.
US: Anteverted uterus, right ovary not visualised. Left ovary containing 7x4x6cm fluid filled cyst of ground glass echogenicity. There are no papillary projections or solid components within the cyst.
What is likely diagnosis?
Endometrioma (chocolate cyst)
First line management of endometriosis
Pain relief and COCP
If there’s a <5cm fluid filled ovarian cyst in an otherwise healthy person, what do you do?
Nothing
A 30 year old women attends GP surgery with 12 month history secondary amenorrhoea. She has recently married and is keen to conceive. History and investigations are normal apart from elevated FSH (40iu/l) and LH. She fails to have a withdrawal bleed after progesterone treatment. What is the likely diagnosis and what management should be discussed?
Premature ovarian failure
Tx: HRT, egg donation
A 43 year old attends with a history of increasing infrequent periods, her LMP being 8 months ago. She is concerned regarding her obesity (BMI 39) and increasing facial hair. Investigation reveal slightly raised PRL, testosterone and LH.
What is the likely diagnosis?
what treatment would you recommend?
Diagnosis: PCOS
Treatment:
- weight loss
- do not give COCP due to weight, POP instead
- ovulation induction
A 22 year old presents with a 14 month history of amenorrhoea, since stopping OCP. She previously had regular periods. She is slim (BMI 18) and has recently started to train for a marathon. Investigations show low LH and FSH and no bleed after progesterone treatment. Counsel her about probable diagnosis and management.
Diagnosis: hypothalamic-pituitary axis failure
hypotrophic hypogonadism
Treatment:
Weight gain, less exercise
COCP
GnRH analogues initially stimulate/repress anterior pituitary hormone function (FSH/LH)
GnRH analogues are continuously/intermittently released which means that over time they stimulate/repress anterior pituitary hormone function (FSH/LH)
GnRH analogues initially STIMULATE anterior pituitary hormone function (FSH/LH)
GnRH analogues are CONTINUOUSLY released which means that over time they REPRESS anterior pituitary hormone function (FSH/LH)
If analgesia / COCP doesn’t work in endometriosis treatment, what may be used?
GnRH analogues
Where does spermatogenesis take place?
Seminiferous tubules
Tuboovarian abscess management
antibiotics
In PCOS, there is over-production / under-production of oestrogen?
Over-production
Premature ovarian failure
FSH levels
LH levels
Oestradiol levels
FSH high
LH high
Oestradiol low
What is the definition of infertility
- eg hoe many months
Failure to conceive despite regular unprotected sex for 12 months in the absence of known reproductive pathology
Congenital rubella syndrome
Small head (microencephaly)
patent ductus arteriosus
blind (due to cataract)
Pelvic inflammatroy disease short term complications
Tubo ovarian abscess
If progesterone is more than X nanomoles 7 days before end of cycle, it is a good evidence of egg release (ie ovulation is occurring)
30
abdominal and/or pelvic pain,
dyspareunia, dysmenorrhea, intermenstrual bleeding and unusual vaginal discharge these symptoms make you think
Possible pelvic inflammatory disease
What is the treatment of pelvic inflammatory disease (which antibiotics)?
Ofloxacilin
Metronidazole
What are the 2 methods of assessing tubal patency in females?
Laparoscopy
Hysterosalpinogram
In a woman with possible tubal disease or pelvic
inflammation, such as PID or a known previous pelvic pathology, such as ectopic pregnancy, which investigation for tubal patency should be used
- laparoscopy
- hysterosalpinogram
Laparoscopy
How long can sperm live for in the female genital tract and what are the implications of this in terms of family planning?
Live for 7 days
Don’t have unprotected sex at least 7 days before ovulation (and for 2 days after ovulation)
An increase in temperature 3 days in a row could indicate that fertility has increaed/decreased?
Decreased
If the COCP is started before 21 days post partum it is immediately effective. True or false?
True
If you miss 1 COCP what do you do
Take the pill as soon as you remember (even if it means taking 2 in the same day)
No additional contraception needed
If you miss 2 COCP what do you do
Take the last pill even if 2 pills are taken in 1 day and omit any earlier missed pills.
Use condoms or abstain from sex until pill has been taken 7 days in a row
COCP vaginal ring - If the ring remains out of the vagina for more than X hours, contraceptive protection may be
reduced.
3
What is the most effective conraception option
Sube dermal implant
Which emergency contraceptive may reduce the effect of othr hormonal contraception (eg the pill)
UPA (ella one)
- restart hormonal contraception 5 days after tking the UPA
Breastfeeding is effective (98%) protection against unwanted pregnancy, but very strict criteria have to be met for it to work effectively;
• Only effective up to X months postnatally
• Must be exclusively breastfeeding (at least every 4 hours during the day and at least every 6 hours during the night)
• Fully amenorrhoeic
6 months
Which contraceptive should be avoided for the first three weeks postpartum in all women
COCP
For breastfeeding women wanting to restart COCP, how long will they have to wait?
At least 6 weeks post partum
Medical abortion is achieved by using a combination of oral X, followed 48 hours later by a second drug Y.
X = mifepristone (antiprogesterone) Y = misoprostol (prostaglandin)
women who are less than X weeks gestation,
can choose to administer medication themselves at home for TOP
less than 10 weeks
When does PRIMARY PPH occur
In first 24 hours following birth
post partum hypopituitarism
Sheehan’s syndrome
What do you give women with severe pre-eclampsia
Magnesium sulphate
Who is most likely to have reduced urine output
- post GA
- post spinal
Post spinal. Bladder is asleep. can get acute urinary retention
Id you do dilation and curetage to scrape inside of the urerus to empty out eg miscarriage then you can cause bands of endometrium and adhesions. What syndrome can this cause
Ashermans syndrome
Active managmeent of 3rd stage of labour increases/decreases risk of PPH
Decreases risk by up to 50%
What is the main predictor of downs syndrome?
Maternal age
Patient gets downs syndrome screening at booking scan….comes back ‘high risk’, what are the next options?
NIPT
Amniocentesis
Chorionic villous sampling
Name the 4 main purposes of the booking scan in pregnancy
to check if there is a foetus in utero
to check how many foetuses there are
date the pregnancy (by measuring the CRL)
measure the nuchal translucency (if pt wants to be screened for trisomy)
NIPT an be carried out from at least X week gestation
10
If you have a BRCA1 mutation, what are the chances of you developing breast cancer?
80%
What do you do if cord presentation is palpated on vaginal examination?
STOP - to prevent rupture of membranes
monitor foetal HR
Notify obstetric team
Which maternal infection is a cause of a maculopapular rash which in clinically indistinguishable from parvo virus without serological testing. Is a cause of
congenital infection if developed in first trimester?
In the UK population herd immunity was
achieved by vaccination out with pregnancies and
vaccination is now no longer offered. Is a cause of
stillbirth and miscarriage.
Rubella
Is a cause of potentially severe congenital infection,
miscarriage and stillbirth. 60 % population
immune. May cause microcephaly, chorioretinitis,
IUGR and severe mental disability. Infections cause
a mild non-specific illness or can be asymptomatic.
There is no vaccination.
CMV
Is a cause of fetal varicella syndrome if contracted
before 20 weeks gestation. This can be prevented
by use of VZV immunoglobulin to those pregnant
women who are susceptible and have been in
contact with the infection. Most of the population
is immune. Babies can be born with skin scarring
in dermatomal distribution, neurological
abnormalities, hypoplastic limbs and eye defects.
Pregnant women are at risk of pneumonia and
hepatitis in this infection. Vaccine available.
chicken pox
Is a cause of a maculopapular rash which in
clinically indistinguishable from rubella without
serological testing. 50% of the population are
immune. Is a cause of fetal anaemia. Usually a mild
self -limiting condition but can cause
polyarthropathy syndrome and anaemia. There is
no vaccination.
Parovirus
Is a cause of non-specific coryzal symptoms and
fever. Is a cause of mortality, IUGR and PTL in
pregnant women if contracted. Vaccine available.
Influenza
When is ‘prolonged labour’ diagnosed?
When less than 2cm dilation in 4 hour period during active labour
Outline 1st, 2nd and 3rd stage of labour
1st stage: onset of regular painful contractions -> full dilation of cervix
- early latent phase: cervix becomes effaced -> 4cm
- active phase: from 4cm -> full dilation
2nd stage:
full dilation -> delivery
3rd stage:
time between delivery of foetus and delivery of placenta
n a nulliparous patient, delay is diagnosed when the active second stage has reached X hours
2
In a multiparous patient, delay is diagnosed when the active second stage has lasted X hours
1
Outline components of active 3rd stage labour (4)
Uterotonics (eg oxytocin 10 units or syntometrine) before the cord stops pulsating
catheterisation (bladder emptying)
deferred clamping and cutting of cord
controlled cord traction
When is 3rd stage of labour changed from physiological management -> active management (3)
If placenta and membranes haven’t been delivered in over 1 hour
Excessive bleeding
The parent’s desire shorter duration
Delay in the 3rd stage is diagnosed if not completed within:
X minutes of physiological management;
X minutes of active management
60 mins physiological
30 mins active
As labour is approaching (ie with advancing gestation)
- progesterone levels: increase/decrease
- oestrogen levels: increse/decrease
- prostaglandin levels: increase/decrease
Progesterone - decrease
oestrogen - increase
prostaglandin - increase
What promotes prostaglandin release
Oxytocin
Failure to progress is defined as
less than 2cm dilatation in 4hours
Name an example of rotational forceps
Kielland’s forceps
When might rotational forceps be used
Should be used in theatre with anaesthesia
Give an example of outlet forceps
Wrigley’s forceps
Name 2 exmaples of midcavity / lowcavity forceps /
Neville-Barnes
Andersons
Fetal scalp is visible without separating the labia - which forceps should you use
Wrigley’s (outlet)
Which type of forceps Can be used for lift-out deliveries at caesarean sections
Wrigley’s (outlet)
Use d-dimer in pregnancy. True or false?
False
- elevated in pregnancy
Suspicion of DVT in pregnancy. What do you do?
Doppler US
LMWH
Repeat the doppler US in a week if first doppler -ve
Chest x-ray is safe in pregnancy. True or false?
True
Which imaging modality do we use in pregnancy to investigate for PE?
VQ scan
- radiation dose to mother’s breast tissue is much lower
- does have an effect on the foetus.
Can you diagnose a PE with a VQ scan?
Yes
What is first line imaging for ?suspected PE
CXR
- if clear -> VQ scan
- if not clear -> CTPA
are troponins useful in pregnancy?
Yes
List 2 indicators of significant depressive disorder post childbirth
New and persistent expressions of incompetency as a mother
Estrangement from the infant
if someone is taking a medication that is safe for use in pregnancy, it will also be safe for use in breast feeding. True or false?
True
Name 5 medications which should be avoided in pregnancy
ACE inhibitors NSAIDs Warfarin (especially in first trimester) Methotrexate Lithium (may be used)
If a patient had a previous C section, what are her options for next pregnancy birth?
Elective c section at 39 weeks
Vaginal delivery in labour suite
- continuous CTG monitoring to detect foetal distress (may be first sign of uterine rupture)
For patients having vaginal birth after C section, why should you not use too many uterotonics?
don’t want to push uterine scar
How would you deliver a patient that has a history of uterine rupture
Must be C section
Do not have vaginal delivery
If a patient has had over X c sections, they should not have a vaginal birth
3
Which ‘booking bloods’ are done
STI screening: HIV, Hep B, Syphilis
FBC: check Hb levels (check for anaemia)
G+S: blood type, rhesus status, identify if woman has red cell antibodies
Congenital infections (CMV, rubella, parovirus, zica, chickenpox) are routinely screened for. True or false?
False
If you have detected foetal anaemia, what is the treatment?
In utero transfusion
Is a TVUS safe in pregnancy?
Yes
When may TVUS be useful in pregnancy?
IN placenta praevia
What is the purpose of giving folic acid
To reduce neural tube defects
Which 2 vaccines should be given during pregnancy
Flu vaccine
Whooping cough vaccine
If a woman is getting an elective c section, which gestation should this be carried out at
39 weeks
Why is epidural sometimes used in pre-eclamptic patients
reduces BP (vasodilator) higher risk of needing C section
Name 3 standard indications for operative vaginal delivery
Failure to progress second stage
Foetal distress
Maternal exhaustion
What mode of delivery is associated with less perineal trauma
- ventouse delivery
- forceps delivery
Ventouse delivery
How does caput succedaneum come about?
Pressure of the presenting part against the cervix
Soft puffy swelling, skin over swelling may look bruised, often with moulding
What does induction of labour involve
Involves artificially initiating uterine activity with the aim of achieving vaginal delivery.
Name 4 indications for IOL
Prolonged pregnancy (beyond 42 weeks)
Pre eclampsia
Placental insufficiency and IUGR
Ante partum haemorrhage: placental abruption
During labour the cervix should be firm/soft?
Soft
Name 3 methods of IOL
Sweep - finger into cervix to separate foetal membranes from lower segment
artificial ROM
Medical induction - using syntocinon
Why is the use of prostaglandins contraindicated in those with a previous uterine scar
risk of hyperstimulation and uterine rupture.
How often are measurements for parotogram taken
Hourly
name some examples of narcotic analgesia which can be prescribed during labour
Morphine
Rimifentanil
Pethidine
Name an inhalational analgesia in labour
Entonox (gas and air)
Why is spinal anaesthesia not used for pain control in labour?
Because epidural analgesia is more safe and has the ability to be topped up with suitable doses or as continuous infusion to get pain relief over a long period of time
Women who are healthy and have had an uncomplicated pregnancy should be offered and recommended which method of foetal assessment in labour
intermittent auscultation to monitor fetal well-being. This should be performed using a Doppler ultrasound or Pinard stethoscope.
- carried out every 15 mins during first stage
- carried out every 5 mins during second stage
Maternal indications for CTG
Labour <37 weeks or >42 weeks induced labour administration of oxytocin pre-eclampsia maternal illness (diabetes / epilepsy / cardiac abnormality) ante/intra partum haemorrhage previous uterine scar epidural
Foetal indications for CTG
IUGR oligo/poly hydramnios malpresentation meconium stained liquor multiple pregnancy reduced foetal movements
Once the membranes rupture, the colour of the liquor may indicate fetal well-being. Which colour would potentially worry you
Meconium stained liquor - foetal distress
meconium can be normal in labour. True or false?
True
If concerned about the baby, what might be done?
Foetal blood sampling
What does a CTG tell you about contractions
Only the frequency, not the strength or effectiveness
What is the range for good variability on a CTG?
Between 5-25 beats
WHich are more worring: early devels or late decels
Late decels
- especially if slow to recover
Name 2 features of a CTG that indicate emergency c section
Late decelerations - lasting 3 mins or more
terminal bradycardia - foetal HR below 110 for over 10 mins
What does foetal scalp blood sampling look for and when may it be indicated
Acidosis (check for hypoxia)
Indicated if worrying features on CTG (but if extremely worrying features on CTG then go straight to c section)
Late decels present for below 30 mins on a CTG. Which category
- normal
- suspicious
- pathological
Suspicious
- if late decels present for more than 30 mins then change to pathological
Sinusoidal pattern seen on CTG, what do you do?
urgent C section
What foetal scalp pH urges you to deliver urgently by c section
less than 7.2
normal foetal pH is between 7.25-7.35
sudden development of acute respiratory distress and cardiovascular collapse in a patient in labour or in one who has recently delivered. It often presents as acute hypotension, respiratory distress and acute hypoxia during labour or delivery or within 30min of delivery. - what is the likely diagnosis>
amniotic fluid embolism
If cardiac output is not restored after 3 minutes of CPR in a woman who is still pregnant what should be done
fetus should be delivered by c-section as this will improve the effectiveness of maternal resuscitation efforts and may save the baby
WHat is the treatment for pelvic inflammatory disease (which 3 antibiotics)
IV cefuroxime
IV metronidazole
Oral doxycycline
A 32 year old was admitted 3 hours ago with lower
abdominal pain. She thinks she is around 6 weeks
pregnant. She has brown discharge PV. This is her 1st
pregnancy. She has had no previous surgeries and
currently taking no medication. She had chlamydia
last year. She was assessed over night by the ST1 and
was found to be clinically stable. Her obs are
currently: Pulse 110bpm, BP 122/81, RR 18, Temp
36.8. An HCG was done and is 120.
What is likely diagnosis and why?
What investigations should be done?
Ectopic pregnancy - increased risk due to previous chlamydia infection
If stable - urgent US
If not stable - diagnostic laparoscopy +/- surgical managmeent of ectopic pregnancy
Which type of chemotherapy is first line in ovarian cancer?
Carboplatin
If patient is resistant to chemotherapy for ovarian cancer, what treatment is used?
Tamoxifen
Hyperemesis gravidarum diagnostic triad
at least 5% weight loss
electrolyte imbalance
dehydration
Which class of medications is used first line in hyperemesis gravidarum?
anti histamines
What is the recommended management for postmenopausal women with atypical endometrial hyperplasia
total hysterectomy with bilateral salpingo-oophorectomy
What is the first-line treatment in endometrial hyperplasia without atypia
A levonorgestrel-releasing intrauterine system such as the Mirena coil
the COCP is contraindicated <6 weeks postpartum. true or false?
True
What is the treatment for vaginal vault prolapse
sacrocolpoplexy
56 year old woman para 2+1
menopause age 51
1 week of vaginal bleeding “like a period”
O/E: well, no abdo swelling
VE: normal vagina and cervix, normal anteverted uterus .
What is likely idagnosis?
Endometrial polyps
Patient age 65 para 3+2
Menopause age 48.
Spotting of blood from vagina for past 3 weeks
OE: punctate red spots on vaginal wall and cervix. What is the likely diagnosis?
Atrophic vaginitis
Which hormone is involved in milk production?
Prolactin
Which hormone is involved in milk ejection?
Oxytocin
Name 2 supplements breast fed babies should get
Vitamin D
Vitamin B
baby that is small for gestational age crosses centiles. True or false?
False
- below 10th centile but doesn’t cross centiles
SGA baby or IUGR baby, which 2 medications is mother given and at which gestation?
Steroids (up to week 36) to promote foetal lung maturity
Magnesium sulphate (up to 32 weeks) provides neural development
RBC volume increases or decreases during pregnancy
RBC volume increases
Hb volume increases or decreases during pregnancy
Hb decreases (diluted by presence of more RBCs)
In which trimester are you most likely to be hypertensive in pregnancy?
3rd trimester
How do you test the robustness of a screening test?
Sensitivity and specificity
True +ves : sensitivity / specificity?
Sensitivity
True -ves : sensitivity / specificity ?
Specificity
What is considrred to be a NORMAL value for nuchal translucency?
Less than 3.5mm
Where is anti-D preferably administered?
Deltoid muscle
Where does the ovarian artery arise from?
Abdominal aorta - L2 level
What is the inferior epigastric artery a branch of ?
External iliac artery
Woman in labour has 3rd degree perineal tear. Which anaesthesia is needed?
Spinal (regional)
Woman in labour has 2nd degree perineal tear. Which anaesthesia is needed?
Local anaesthetic
Why might baby have a respiratory acidosis?
Cord compression
??which surgery can be done for prolapse?
Vaginal hysterectomy + sacrospinous fixation
How do you urgently manage a baby with patent ductus arteriosus?
Prostaglandin inhibitor
When a baby is born, how does the composition of Hb change? when does the composition reach adult level?
Hb composition: production of gamma chains stops at birth and is replaced with production of beta chains
Takes 6 months to reach adult level
What is the time period for physiological jaundice?
3 days -> 14 days
Which nerve exits greater sciatic foramen -> curves round sacrospinous ligament -> enters lesser sciatic foramen?
Pudendal nerve
If a pudendal nerve block is performed during labour, are the uterine contractions affectd?
No, contractions are under hormonal control. Pudendal nerve block blocks the sensation from the uterus
Which nerve block could be performed to abolish sensation from the anterior aspect of the perineum ?
spinal anaesthesia
What is the main side effect to think about with spinal anaesthetic / epidural anaesthetic?
Headache
If bHCG is very very high, what could you be thinking?
Molar pregnancy
Salpingotomy vs salpingectomy
Salpingotomy - open up the uterine tube and take the pregnancy out. Only done if patient has 1 tube
Salpingectomy - removal of the uterine tube for good. IVF is the only option moving forward
Hormone replacement therapy (HRT) without the addition of progesterone will increase the risk of which cancer
Endometrial
Who should get oestrogen only HRT
Women with no uterus
Most common site of ectopic pregnancy
Ampulla of the uterine tube
If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l , what treatment is used
insulin +/- metformin
What is more preferable for a family who are complete
- vasectomy
- female sterilisation
Vasectomy
- doesn’t need GA
Young patient (16) wants long acting contraception (but reversible). What is first line?
Depot injection
In a woman with a normal intact uterus, you should not use unopposed oestrogen HRT. True or false?
True
- DO NOT USE UNOPPOSED OESTROGEN as this can lead to endometrial hyperplasia (putting an increased risk of endometrial cancer)
Since a woman with an intact uterus should not have unopposed oestrogen HRT, what should you do?
add in progesterone
Which imaging investigation is done for PCOS?
TVUSS
Presence of WHAT on ultrasound in the context of an ectopic pregnancy is an indication for surgical management
foetal heartbeat
Pregnant obese women (BMI >30 kg/m2), should be given high dose 5mg folic acid. True or false?
True
The correct position for women who have a cord prolapse is
On all 4s
What is the first line treatment for primary dysmenorrhoea
NSAIDs such as mefanamic acid
Which is more likely to ulcerate: vulval carcinoma OR VIN?
Vulval carcinoma
Dont use LNG / UPA if a patient has asthma?
UPA
Which of these would most likely cause a delay in returning to normal fertility?
- progresterone only implant
- COCP
- progesterone only injectable contraception
- POP
progesterone only injectable contraception
Intrahepatic cholestasis of pregnancy increases the risk of
Stillbirth
Vaginal hysterectomy is a suitable treatment for which one of the following:
- cervical cancer
- CIN3
- uterine prolapse
- molar pregnancy
Uterine prolapse
24 weeks gestation, diagnosed withGBS on high vaginal swab. What is correct treatment:
- amoxicillin 5 days
- Intrapartum IV benzylpenicillin to mother
- IV benzylpenicillin to baby after delivery
Intrapartum IV benzylpenicillin to mother
Complete mole always need ssurgical evacuation. True or false?
True
Fibroids are most commonly seen in pre menopausal or post menopausal patients?
Pre-menopausal symptoms
Post menopausal woman with a “fibroid” what would you need to rule out?
Leiomyosarcoma
Endometrial cancer
First line management of fibroid under 3cm
mirena coil
2nd line: tranexamic acid / NSAID, COCP
First line management of fibroid over 3cm
Tranexamic acid / NSAID
uterine artery embolisation
Pre-menopausal female with simple ovarian cyst that is over X cm offer surgery
over 7cm
What is a complex ovarian cyst
May be solid areas within it
may be some papillary projections
If a pre-menopausal female has a simple cyst that is symptomatic, what should you do?
Offer surgery if symptomatic
Pre-menopausal complex ovarian cysts - what should you check
Always check tumour markers
- CA125
- AFP
- bHCG
- LDH
Post menopausal ovarian cysts are always abnormal. True or false?
True
smear test: HPV negative, what happens
new guidance
Recall in 5 years (irrespective of age)
this is the new guidance
smear test: HPV positive, what happens
new guidance
Refer for Cytology
HRT protects against osteoporosis. True or false?
True
Who gets cyclical HRT
Women who are peri-menopausal, still getting sporadic periods so not deemed menopausal
WOmen who have a uterus need oestrogem / progesterone?
Progesterone
Women who have had a hysterectomy…do they need progesterone?
No, can be given oestrogen only
Which classification process do you use for pelvic prolapse?
POP-Q
Isolated cystocele - what type of surgery?
Anterior repair
Sacrospinous fixation can be done under spinal. Why might this be useful
If patient has a prolapse and is for surgery with lots of comorbidities
For stress incontinence, medication is last line. True or false?
True
Stress incontinence management
Pelvic floor exercises lifestyle (weight) incontinence ring vaignal oestrogen Surgery: - bulking agents (close the urethra to prevent leakage) - fascial sling - colposuspension
Stress incontinence management
Pelvic floor exercises lifestyle (weight) incontinence ring vaignal oestrogen Surgery: - bulking agents (close the urethra to prevent leakage) - fascial sling - colposuspension
Post menopausal woman with severe itching, trauma and skin splitting excoriation. What is likely diagnosis?
Lichen sclerosus
What is management of lichen sclerosus
Very potent steroid for 6 weeks - dermovate
Gynae post op complications 0-24 hours - name 2
Primary haemorrhage (tachycardia, hypotension) UTI
Gynae post op complications 24 hours - 5 days - name 2
infection (pelvis, chest, urine)
thrombosis (DVT, PE)
Direct injury (perforation eg bowel, bladder)
Pregnant women can receive the MMR vaccine. True or false?
False
- the MMR vaccine is live
When might anti-D be required for Rh -ve wman who has miscarried (ie which week)
If over 12/40 weeks
If patient has an ectopic pregnancy and surgical managment is required. if they have a normal contralateral tube, what is done
- salpingotomy
- salpingectomy
Salpingectomy
Smear test: HPV +ve, cytology +ve , what should you do?
Refer for colposcopy
Smear test: HPV +ve, cytology -ve, what should you do?
*new guidance *
Recheck in 12 months
Which HRT is recommended for women who are post menopausal
- sequential HRT
- continuous combined HRT
Continuous combined HRT
How often are pessaries often changed?
Every 6 months
A 39 year old lady presents with intermittent right sided pelvic pain for the past 3 months. A transvaginal USS has shown a right sided multiloculated ovarian cyst, measuring 5cm with solid areas. There is no ascites present. What is the most appropriate next investigations? A ca125, AFP, LDH, bHCG B ca125 C CT scan D MRI scan E Refer to gyn onc MDT
A
A 26 year old lady presents with vaginal spotting at estimated 6 weeks gestation. She is otherwise well. She has an ultrasound, which shows an intrauterine pregnancy will a CRL measuring 5mm and no FH. What would you advice?
A Surgical management of miscarriage
B Medical management of miscarriage
C Repeat USS in 7-10 days
D Repeat urinary pregnancy test in 2 weeks
E Book for booking USS when estimated 12 weeks gestation
C
- since CRL <7mm need to repeat
A 68 yo lady presents with a vulval itch, particularly at night. On examination, you see bright white areas on the vulva in a figure of 8 distribution and labial resorption. What medication would you prescribe to improve her symptoms? A Hydrocortisone B Dermovate C Tacrolimus D Hydrocortisone E Elocon
B
- this condition is lichen sclerosis
A 25 year old lady attends her GP practice for a routine smear. The result is HPV positive. What will be the next step? A Repeat HPV 12 months B Colposcopy C Routine recall 5 years D Routine recall 3 years E Cytology
E
A 33 year old lady presents following the birth of her second child with something coming down. She is fit and well otherwise. On examination, there is descent of the posterior vaginal wall to -2cm of the introitus. What is the best management option? A Vaginal pessary B Vaginal oestrogen C Anterior repair D Pelvic floor exercises E Colpocleisis
D
A 33 year old lady presents with heavy menstrual bleeding. She has had her Hb checked and is not anaemic and has had an USS which shows an intramural fibroid measuring 2cm. She is otherwise fit and well. What treatment would you recommend? A Tranexamic acid B Endometrial ablation C Uterine artery ablation D Mirena coil E Hysterectomy
D
A 40 year old lady has a 8cm subserosal fibroid. She has associated urinary frequency. She is currently anaemic and wishes definitive treatment. She has been counselled and decided to retain her uterus and undergo a laparoscopic myomectomy. Which medication would you recommend pre operatively to improve her fibroid symptoms? A Tranexamic acid B NSAIDs C GnRH agonist D Iron E Cyclical progesterone
C
- shrinks the fibroid
A 26 yo lady presents 7 days after laparoscopic excision of endometriosis with right loin pain. The operation notes states that the dissection was difficult due to dense adhesions, particularly when mobilising the right ovary. There was bleeding in the right pelvic side wall and bipolar diathermy was used to stem the bleeding. What is the most likely diagnosis? A Ongoing bleeding in the side wall B Bowel injury C Bladder injury D Left ureteric injury E Right ureteric injury
E
You are asked to see a woman 6 hours after a total abdominal hysterectomy who is feeling generally unwell. She is feeling dizzy and has worsening abdominal pain. Her BP is 80/40 and pulse is 120 bpm. What is the most likely diagnosis? A Haemorrhage B Urinary tract infection C Bowel injury D Bladder injury E Ureteric injury
A
A 62 yo lady is referred from the surgical team. She has diverticulitis and on CT, a 3cm simple ovarian cyst was noted on the left side. There were no concerning features. What test would you recommend? A HCG B AFP C LDH D ca125 E USS
D
A 14 yo lady is referred by paediatrics with acute pelvic pain. On examination, she is generally tender with signs of peritonism. An USS is performed and shows a simple ovarian cyst on the left side, measuring 6cm. What is the most appropriate management plan? A Cystectomy B Oopherectomy C Analgesia D Discharge E Repeat ultrasound in 1 year
A
A 62 yo lady is referred from the surgical team. She has diverticulitis and on CT, a 3cm simple ovarian cyst was noted on the left side. There were no concerning features. A ca125 is checked and is 25. What is the most appropriate management plan? A USS and ca125 in 3 months B Discharge C Refer to gyn onc MDT D USS in 1 year E Refer to benign gynae team
D
A 26 yo lady presents to A&E with lower right sided abdominal pain and brown vaginal discharge. She also reports right shoulder tip pain. Her last menstrual period was 6 weeks ago and she has regular cycles. Urinary pregnancy test is positive. An USS shows an empty uterus, a 2cm mass in the right adnexa and free fluid. She has cervical motion tenderness on examination and her pulse is 120bpm. What is the most appropriate management plan? A Analgesia and observe B Repeat USS in 7-10 days C Serum HCG D Methotrexate E Laparoscopy and surgical management
E
What are the management options for pre-menstrual syndrome?
Lifestyle changes
COCP
CBT
SSRIs
Name 5 causes of secondary amenorrhoea
Excessive exercise Low BMI Pituitary tumour PCOS Primary ovarian failure
Ovarian pathology in post menopausal woman. RMI less than 200. What do you do?
Refer to general gynae
Ovarian pathology in post menopausal woman. RMI over 200. What do you do?
Refer to cancer MDT gynae
Develop a differential diagnosis list for a woman presenting with bloating, abdominal distension and/or a pelvic mass.
Ovarian cancer
Fibroids
Benign ovarian cyst
In PCOS, the oestrogen levels are high/low?
High
TOP at home can be done up to which gestation?
11+6
was 9+6 pre covid
After TOP, when should you take urine pregnancy test
After 3 weeks. If still positive then get in contact
What are the management options for pre-menstrual syndrome?
Lifestyle changes
COCP
CBT
SSRIs
Name 5 causes of secondary amenorrhoea
Excessive exercise Low BMI Pituitary tumour PCOS Primary ovarian failure
Ovarian pathology in post menopausal woman. RMI less than 200. What do you do?
Refer to general gynae
Ovarian pathology in post menopausal woman. RMI over 200. What do you do?
Refer to cancer MDT gynae
Develop a differential diagnosis list for a woman presenting with bloating, abdominal distension and/or a pelvic mass.
Ovarian cancer
Fibroids
Benign ovarian cyst
In PCOS, the oestrogen levels are high/low?
High
TOP at home can be done up to which gestation?
11+6
was 9+6 pre covid
After TOP, when should you take urine pregnancy test
After 3 weeks. If still positive then get in contact
Common site for pre-eclampsia abdominal pain
RUQ / epigastric pain
- due to liver capsule stretch
Bloods for pre-eclampsia
FBC
U+E
LFT
