Obs and Gynae Flashcards by Sheryl O'Hare

Why is toxoplasmosis important in pregnancy?

Can cause congenital infections

problems with baby eyes
reduces IQ
still birth

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Which food stuffs should be avoided in order to avoid toxoplasmosis?

Raw or undercooked meat

Unpasteurised milk

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Neural tube defects can occur in faetal alcohol syndrome. True or false?

False

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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

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If patient is rhesus negative, what do you do?

Give anti-D

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What haemoglobinopathies are screened for in pregnancy?

Sickle cell anaemia

thalasaemia

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What is PAPP-A?

screening for downs syndrome - not diagnostic

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Diagnostic tests for Downs Syndrome?

Amniocentesis

CVS

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Which 3 trisomies are screened for?

Trisomy 18 (edwards syndrome)
Trisomy 13 (patous syndrome)
Trisomy 21 (downs syndrome)

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Downs syndrome is associated with increased maternal age. True or false?

True

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At what week is the anomaly scan carried out?

Week 20

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What is gastroschisis?

Abdo wall not formed properly.

Good prognosis

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What is omphalocele?

Poot prognosis

Associated with significant genetic abnormalities

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Which medicine could prevent anencephaly and spina bifida?

Folic acid

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What is the normal dose of folic acid pre-pregnancy?

400

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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

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haemolytic disease of the newborn has been eradicated due to the use of anti-D. True or false?

False

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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)

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Sickle cell disease is associated with African/ afro-carribean origin. True or false?

True

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Mum Rh+ve, will she mount a response even if baby is Rh-ve?

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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

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If mum on her back, how should the baby come out? head first looking up/down?

Head first looking down

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Opiates slow/speed up labour?

Slows

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does epidural anaesthesia increase the risk of needing a C section?

just increases the risk of assisted vaginal delivery (woman less lokely to push)

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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 placenta not 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

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?

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)

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.

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

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

In a multiparous patient, delay is diagnosed when the active second stage has lasted X hours

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

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 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 ```

``` 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 ```

``` 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 ```

``` 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 ```

``` 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 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 ```

``` 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 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 ```

``` 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 ```

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