Obs And Gynae

Question 1

What is the most common type of ovarian cyst?

Answer 1

Follicular cyst
This is due to non rupture of the dominant follicle or failure of atresia in a non dominant follicle
It commonly regresses after several menstrual cycles

Question 2

What is a corpus luteum cyst and how does this present?

Answer 2

During the menstrual cycle if the pregnancy doesn’t occur the corous luteum usually breaks down and dissapears, if this doesn’t happen the corpus luteum may fill with blood or fluid and form a corpus luteal cyst,
More likely to present with intraperitoneal bleeding than follicular cysts

Question 3

What is a dermoid cyst?

Answer 3

Benign germ cell tumour
Also called a mature cystic teratomas
Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
Most common benign ovarian tumour in women under 30
Usually diagnosed at 30
Usually asymptomatic, torsion is more likely than with ovarian tumours

Question 4

What are the benign epithelial tumours.

Answer 4

These tumours arise from the ovarian surface epithelium
Serous cystadenoma = the most common type which bears resemblance

Mucinous cystadenoma

Question 5

What medication can be used to suppress lactation?

Answer 5

Dopamine receptor agonist, dopamine inhibits prolactin production and therefore suppresses lactation

Cabergoline is an example of a dopamine receptor agonist

Question 6

What would you treat a white ‘curdy’ vaginal discharge with?

Answer 6

This type of discharge indicates a candidiasis infection caused by candida albicans
Candidiasis presents with this itching alongside itching and reddening around the vagina. The pH of the discharge will be <4.5
The most appropriate treatment for vaginal candidiasis is clotrimazole vaginal application

Question 7

How do you treat Bacterial vaginosis (fishy odour) and trichomonas vaginalis (strawberry cervix)?

Answer 7

Metronidazole

Question 8

What is used to treat chlamydia?

Answer 8

Oral doxycycline

Question 9

What is used to treat gonorrhoea?

Answer 9

IM ceftriaxone

Question 10

What conditions predispose someone to candidiasis?

Answer 10

diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV

Question 11

What are the features of candidiasis?

Answer 11

‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

Question 12

What is the management of candidiasis?

Answer 12

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
high vaginal swab for microscopy and culture
consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
induction: oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months

Question 13

Why is reduced fetal movements a problem?

Answer 13

Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

Question 14

How many movements in a fetus should cause concern?

Answer 14

the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.

Question 15

What are the risk factors for reduced fetal movement?

Answer 15

Fetal movements should be established by 24 weeks gestation.

Reduced fetal movements is a fairly common presentation, affecting up to 15% of pregnancies. 3-5% of pregnant women will have recurrent presentations with RFM.

Risk factors for reduced fetal movements
Posture
There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
Distraction
Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
Placental position
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
Medication
Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
Fetal position
Anterior fetal position means movements are less noticeable
Body habitus
Obese patients are less likely to feel prominent fetal movements
Amniotic fluid volume
Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
Fetal size
Up to 29% of women presenting with RFM have a SGA fetus

Question 16

What layers do obstreticians cut through in a C section?

Answer 16

Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus

Question 17

What are the serious risk factors of a C section?

Answer 17

Maternal:
emergency hysterectomy
need for further surgery at a later date, including curettage (retained placental tissue)
admission to intensive care unit
thromboembolic disease
bladder injury
ureteric injury
death (1 in 12,000)

Future pregnancies:
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)

Question 18

What are the frequent risk factors of a caesarean?

Answer 18

Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)

Fetal:
lacerations, one to two babies in every 100

Question 19

When would you recommend vaginal birth after caesarean?

Answer 19

If a women has had a previous caesarean section due a factor such as fetal distress the majority of obstetricians would recommend a trial of normal labour
around 70-75% of women in this situation have a successful vaginal delivery
contraindications include previous uterine rupture or classical caesarean scar

Question 20

How do you diagnose pre diabetes?

Answer 20

Pre-diabetes is diagnosed on HbA1c of 42 to 47 mmol/mol (6.0 to 6.4%). It is important to remember once a woman has been diagnosed with gestational diabetes, she remains ‘high risk for diabetes mellitus’ for life and should receive a yearly HbA1c

Question 21

Nancy is a 29-year-old lady who has given birth to a baby boy 3 days ago and is keen to discuss future contraception. She was previously on the combined pill but is keen to avoid using anything if she can. She is not breast-feeding. How long after giving birth does she not require any contraception?

Answer 21

Nancy can be informed that she does not require contraception up to 21 days after giving birth.

Prior to Day 21 postpartum no contraceptive methods are required. In non-breastfeeding women, ovulation may occur as early as Day 28. As sperm can survive for up to 7 days in the female genital tract, contraceptive protection is required from Day 21 onwards if pregnancy

Question 22

Can you use POP after childbirth?

Answer 22

the FSRH advise ‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
after day 21 additional contraception should be used for the first 2 days
a small amount of progestogen enters breast milk but this is not harmful to the infant

Question 23

When can you use COCP after childbirth?

Answer 23

absolutely contraindicated - UKMEC 4 - if breast feeding < 6 weeks post-partum
UKMEC 2 - if breast feeding 6 weeks - 6 months postpartum*
the COC may reduce breast milk production in lactating mothers
may be started from day 21 - this will provide immediate contraception
after day 21 additional contraception should be used for the first 7 days

Question 24

When can you start IUS/IUD?

Answer 24

The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after 4 weeks.

Question 25

How effective is lactational amenorrhoea method?

Answer 25

Lactational amenorrhoea method (LAM)
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

Question 26

What is an inter pregnancy interval of less than 12 months between childbirth and conceiving again associated with?

Answer 26

An inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birthweight and small for gestational age babies.

Question 27

What contraception may cause a delay in fetility?

Answer 27

With progesterone only injectable contraception there can be a delay in return to natural fertility of up to 12 months. The other methods are not associated with such a delay.
Depo provera

Question 28

You are the junior doctor on the labour ward, and are called to a 27-year-old’s first delivery. She underwent spontaneous preterm rupture of membranes at 34 weeks, and now the umbilical cord is palpable vaginally above the level of the introitus.

How should you manage?

Answer 28

This is a case of cord prolapse, which occurs after membrane rupture when the umbilical cord descends below the presenting part of the fetus. It can lead to fetal hypoxia and death due to the cord being compressed or going into spasm.

1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery
2: Correct, to avoid compression
3: The patient is advised to go onto all fours
4: The cord should not be pushed back into the uterus
5: Immediate Caesarean section is the delivery method of choice

Question 29

When can copper IUD be used up till?

Answer 29

The copper intrauterine device can be used as emergency contraception if it is inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date.

The mirena coil is not used as emergency contraception.

Question 30

A 23-year-old woman who is 24 weeks pregnant presents to the emergency department with a 48-hour history of epigastric pain and severe headache, that has increased in severity. On examination, she has a heart rate of 110 beats/min, a respiratory rate of 21 /min, a temperature of 36.8ºC, mild pitting oedema of the ankles and brisk tendon reflexes.

Given the likely diagnosis of pre-eclampsia, what is the most important sign to elicit?

Answer 30

Brisk reflexes are commonly associated with pre-eclampsia and are more specific than the other answers, which are general clinical signs.

Discuss (6)
Improve

Question 31

What are the classification of perineal tears?

Answer 31

• 1st degree = tear within vaginal mucosa only
• 2nd degree = tear into subcutaneous tissue
• 3rd degree = laceration extends into external anal sphincter
• 4th degree = laceration extends through external anal sphincter into rectal mucosa

Question 32

What are the risk factors for a perineal tear?

Answer 32

primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery

Question 33

What are the causes of baseline bradycardia and baseline tachycardia on cardiotocography?

Answer 33

Bradycardia :

Baseline bradycardia Heart rate < 100 /min Increased fetal vagal tone, maternal beta-blocker use

Tachycardia:

Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

Question 34

Normally on cardiotocography the basline variability should be >5, what is indicated if the baseline variability is lost and it is <5beats/min?

Answer 34

Prematurity

Hypoxia

Question 35

Is an early decompression normal?

Answer 35

Yes its usually an innocolous feature and indicates head compression

It is when the heart rate decelerates and commences with the onset of contraction and returns to normal on the completion of the contraction

Question 36

What is a late deceleration and what does it indicate?

Answer 36

Indicates fetal distress e.g. asphyxia or placental insufficiency

Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction

Question 37

What is meant by variable decelerations?

Answer 37

Decelerations independent of contractions

May indicate cord compression

Question 38

What pain relief can be otthered in labour?

Answer 38

There are a number of anaesthetic techniques during labour which can be broadly classified as regional and non-regional, with non-regional being the most widely used. Non-regional anaesthetics include inhaled nitrous oxide, and systemic analgesics such as pethidine. Regional techniques include epidural anaesthesia, which has been shown to be extremely effective in pain management, however there is an association with prolongation of labour and increased operative vaginal delivery. No association between epidural analgesia and an increased risk of Caesarean delivery or post-partum backache has been found.

Question 39

What are the signs of pregnancy?

Answer 39

Regular and painful uterine contractions
Show (shedding of mucous plug)
Rupture of the membranes
Shortening and dilation of the cervix

Question 40

How do you monitor labour?

Answer 40

FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours

Question 41

AFP is a protein producdd by the developing fetus, what causes an increase in this?

Answer 41

Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

Question 42

How do you manage cord compression?

Answer 42

Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

Question 43

After what gestation can hypertension/pre eclampsia be diagnosed?

Answer 43

Pre-eclampsia and gestational hypertension would only occur after 20 weeks gestation. Pre-eclampsia with significant proteinuria, gestational hypertension without.

Question 44

Diagnosing miscarriage…

Answer 44

Complete miscarriage is a spontaneous abortion with expulsion of the entire fetus through the cervix.
Pain and uterine contractions stop after fetus has been expelled.
Diagnosis: U/S shows an empty uterus

Question 45

How would you deal withsomeo

Answer 45

Complex cysts - defined as cysts containing a solid mass, or those which are multi-loculated - should be treated as malignant until proven otherwise. The Royal College of Obstetricians and Gynaecologists Green-top Guidelines (No. 62) recommend that a serum CA-125, αFP and βHCG are performed for all pre-menopausal women with complex ovarian cysts. Aspiration of cysts is associated with higher rate of recurrence and increased spillage into the peritoneal cavity, which may disseminate possible malignant cells, hence the guideline prefers cystectomy over aspiration.

Question 46

A 29-year-old nulliparous female presents to gynaecology clinic with a history of worsening menstrual pain for three years. There is no relief from ibuprofen. She is sexually active with her husband and reports pain during intercourse. Dysuria and urgency in urination are also present. She has been trying to conceive for the past two years, but failed. On examination, her uterus is of normal size. Rectovaginal exam reveals uterosacral nodularity and tenderness.

Answer 46

Complex cysts - defined as cysts containing a solid mass, or those which are multi-loculated - should be treated as malignant until proven otherwise. The Royal College of Obstetricians and Gynaecologists Green-top Guidelines (No. 62) recommend that a serum CA-125, αFP and βHCG are performed for all pre-menopausal women with complex ovarian cysts. Aspiration of cysts is associated with higher rate of recurrence and increased spillage into the peritoneal cavity, which may disseminate possible malignant cells, hence the guideline prefers cystectomy over aspiration.

Question 47

What are the complications of myomectomY?

Answer 47

Commonly adhesions

Less common= uterine perforation and bladder damage

Question 48

What is chorioamnionitis?

Answer 48

Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

Question 49

On examination there is marked uterine tenderness and an offensive brown vaginal discharge is noted. Blood pressure is 134/93 mmHg and the maternal heart rate is 110 beats per minute. Blood results are significant for a white cell count of 18.5 * 109/l. The baseline fetal heart rate is 170 beats per minute. What is the most likely diagnosis?

Answer 49

The question points towards an infective process in this patient, as indicated by maternal fever, tachycardia and neutrophilia (note that the normal range is elevated during pregnancy). Chorioamnionitis is a clinical diagnosis and is suggested by uterine tenderness and foul-smelling discharge. Baseline fetal tachycardia supports the diagnosis. The aetiology in this case is likely to involve prolonged premature rupture of membranes. The mention of previous uterine fibroids is a distractor - fibroids may undergo red degeneration during pregnancy, which can present with fever, pain and vomiting, but usually in the first or second trimester.

Question 50

How can you treat resp depression caused by mag sulphate?

Answer 50

Calcium gluconate

Question 51

A 25-year-old G1P0 woman who is 30 weeks pregnant presents to her GP complaining of intense itching of her palms. She also complains of fatigue but has been struggling with this throughout her pregnancy. On examination, you cannot see any rash on her hands.

Given the likely diagnosis, which of the following is she at an increased risk of?

Answer 51

The correct answer is ‘stillbirth’.

This patient is likely to be suffering from intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis). Patient’s typically present in the third trimester with intense itching that is generally worst on the palms of the hands and soles of the feet. It is not associated with a rash. Intrahepatic cholestasis of pregnancy increases the risk of stillbirth.

Question 52

Lisa is a 43-year-old mother who would like to discuss options for contraception. She has previously tried the combined pill and the progesterone-only pill and did not get along with them. She is keen to avoid coils. Her current medications include long-term rifampicin and fexofenadine. Which contraceptive option would be most appropriate?

Answer 52

The Depo-Provera injection is a safe long-term choice to use in patients taking enzyme-inducers as it is least likely to be affected and should therefore be the most appropriate choice.

Question 53

What are the causes of increased nuchal translucency?

Answer 53

Down’s syndrome
congenital heart defects
abdominal wall defects

Question 54

What are the causes of hypoechoic bowel?

Answer 54

cystic fibrosis
Down’s syndrome
cytomegalovirus infection

Question 55

How does ovarian hyperstimulation syndrome present?

Answer 55

This is a typical presentation of ovarian hyperstimulation syndrome with ascites, vomiting and diarrhoea and high haematocrit. Ovarian hyper stimulation syndrome is a potential side effect of ovulation induction.

Ovulation induction may be performed with a number of different medications. Gonadotrophin therapy is associated with an increased risk of ovarian hyper stimulation syndrome compared to clomiphene citrate or raloxifene, letrozole or anastrozole. Therefore, gonadotrophin therapy is the most likely medication she was given.

Question 56

A 35-year-old obese gravida 3 para 2 has developed a swollen and tender left leg; she is currently at 32 weeks of gestation and started on the appropriate treatment regimen. Due to her weight, the clinician decides to monitor her treatment with a specific blood test. Which blood test is this?

Answer 56

The guidance also states that: ‘Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE).’ and that ‘Routine platelet count monitoring should not be carried out.’

Question 57

What should you do if you are seeing a patient you suspect to have preterm prelabour rupture of membranes?

Answer 57

A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection. Ultrasound may also be useful to show oligohydramnios.

Question 58

How do you manage P-PROM?

Answer 58

admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Question 59

What are the complications of PPROM?

Answer 59

fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis

Question 60

A 32-year-old female presents to the obstetric department in labour at 41 weeks gestation. Examination at 36 weeks gestation identified a breech presentation which was successfully managed with an external cephalic version (ECV). Labour progresses without complication, and the baby is born via vaginal delivery. A newborn infant examination is subsequently conducted, and no abnormal findings are detected.
What should you do?

Answer 60

All breech babies at or after 36 weeks gestation require an ultrasound scan for developmental dysplasia of hip screening at 6 weeks regardless of mode of delivery

Question 61

When do patients with previous histories of gestational diabetes have an oral glucose tolerance test?

Answer 61

A patient with a previous history of gestational diabetes will have an oral glucose tolerance test as soon as possible after the time of booking. Other patients at risk of gestational diabetes will have their oral glucose tolerance test at 24-28 weeks.

Question 62

How can the risk for placental abruption be remembered?

Answer 62

A= previous abruption
B= blood pressure (hypertension/pre eclampsia)
R= ruptured membranes (either premature or prolonged)
U= uterine injury (trauma to abdomen)
P= polyhydramnios
T= twins/multiple gestation
I= infection in uterus, especially chorioamnionitis
O= older age (>35)
N= narcotic use (cocaine and amphetamines, as well as smoking)

Question 63

What is meconium aspiration syndrome?

Answer 63

Meconium aspiration syndrome refers to respiratory distress in the newborn as a result of meconium in the trachea. It occurs in the immediate neonatal period. It is more common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks. It causes respiratory distress, which can be severe. Higher rates occur where there is a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse.