Obs and Gynae Yr 4 B - O&G Pre-block assessment flashcard with explanations (76%)

Question 1

* 1. A 31 year old woman attends her GP surgery for the result of her routine cervical smear test. She has no significant past medical history. The cervical smear shows severe dyskaryosis. (TRUE OR FALSE) a) She is likely to have an underlying cervical cancer. b) The next step is a repeat smear in 6 months time. c) The most likely aetiology is Human Papilloma Virus (HPV).

Answer 1

a) - False - Smear is a screening test for precancerous cells. Its likely with severe dyskaryosis that she has either CIN 2 or CIN 3. B) - False, Refer colposcopy (2 weeks) for assessment and treatment c) - True - Over 70% of CIN (cervical intraepithelial neoplasia) is attributed to HPV infection. HPV 16 and 18 most common.

Question 2

1. A 31 year old woman attends her GP surgery for the result of her routine cervical smear test. She has no significant past medical history. The cervical smear shows severe dyskaryosis. (TRUE OR FALSE) * d) Cervical Intraepithelial Neoplasia (CIN) usually arises in the transformation zone at the squamo-columnar junction. * e) She is likely to have an offensive vaginal discharge and post-coital bleeding.

Answer 2

d) True - This is the area that undergoes metaplasia from glandular to squamous epithelium. The transformation zone is therefore vulnerable to oncogenic stimuli. e) False - This woman is unlikely to have any symptoms with severe dysplasia - CIN is usually asymptomatic. However women with cervical cancer can present with abnormal vaginal bleeding and/or vaginal discharge.

Question 3

These two images were obtained at the time of diagnostic laparoscopy and demonstrate endometriosis. In this case the following symptoms are likely to be present: (TRUE OR FALSE) a) dysmenorrhoea b) inter-menstrual bleeding c) dyspareunia d) subfertility e) vaginal discharge

Answer 3

* a) T - Endometriosis can cause severe dysmenorrhoea, especially before the onset of menstruation & improving as menstruation ceases. * b) F - Endometriosis does not change the menstrual cycle and therefore does not cause IMB. * c) T - Endometriosis can cause deep dyspareunia, especially if involving the uterosacral ligaments. * d) T - Endometriosis especially if severe (as in this case) is associated with subfertility by causing damage to the fallopian tubes. * e) F - Endometriosis does not change the vaginal flora & therefore does not cause vaginal discharge.

Question 4

With regard to the anatomy of the pelvis, which of the following statements are correct? * a) When inserting a urinary catheter in the female, it must be remembered that the urethra measures 10cms in length. * b) The lymphatic drainage from the ovary is into the para-aortic nodes at the level of the first lumbar vertebra. * c) In pregnancy the uterus rises out of the pelvis by 8 weeks.

Answer 4

a) False - female urethra measures approx 4cm b) True - Ovarian artery arises from the aorta at L1/L2 and lymph drainage follows arterial supply c) The uterus remains a pelvic organ until 12 weeks. From this stage onward the uterus may be palpated abdominally.

Question 5

With regard to the anatomy of the pelvis, which of the following statements are correct? * d) The ureter lies on the lateral pelvic wall immediately posterior to the ovary.

Answer 5

d) True -The ureter enters the pelvis by crossing the birfurcation of the common iliac artery, downwards in front of the internal iliac artery and behind the ovary until it reached the ischial spine. It then travels beneath the uterine artery to enter the bladder.

Question 6

With regard to the anatomy of the pelvis, which of the following statements are correct? e) Fertilisation of the ovum occurs in the uterine (Fallopian) tube. f) The posterior fornix of the vagina is related to the peritoneal cavity (pouch of Douglas)

Answer 6

e) True - Ectopic pregnancies may develop within the uterine tube. f) True - Vaginal injury, damaging the posterior fornix will open the peritoneal cavity and facilitate the spread of infection to the cavity.

Question 7

In normal pregnancy: TRUE OR FALSE * Systolic ejection heart murmur is common * Plasma volume increases by 50% * Haemoglobin decreases during pregnancy * Blood pressure increases in second semester * Glomerular filtration rate decreases by full term * Thromboembolism is more 10 times more common

Answer 7

* In normal pregnancy there is an increase in plasma volume by 50% resulting in a physiological anaemia. Due to increase 30-45% increase in cardiac output, systolic ejection murmurs are common. * Blood pressure decreases from second trimester due to vasodilatation (uteroplacental circulation expands and TPR decreases) * Glomerular filtration increases to cope with the additional load of the fetus, resulting in a decrease in creatinine and urea levels. * Thromboembolism increase in pregnancy due to the thrombophilic state resulting from haemostatic and fibrinolytic changes.

Question 8

Placenta praevia is one of the major causes of APH. State which type of placenta praevia each description is describing * A) Reaches but does not cover the cervix. * B) Completely covers cervix and would cover the cervix even at full dilatation. * C) Covers the cervix but would not cover the cervix if fully dilated. * D) Encroaches on the lower uterine segment but does not reach the cervix.

Answer 8

A - Type II B - Type IV C - Type III D - Type I

Question 9

What clinical features are typical of antepartum haemorrhage (APH) due to placental abruption? TRUE OR FALSE * Tense uterus on palpation * Abnormal fetal lie * Abdominal Pain * Green vaginal discharge * Abnormal cardiotocograph (CTG)

Answer 9

Placental Abruption (PA) is premature separation of a normally implanted placenta. It is associated with vaginal bleeding rather than vaginal discharge. The blood loss may not be in keeping with the degree of hypovolaemic shock (concealed APH). Associated pain and on examination the uterus will be tense and tender. There may also be fetal distress as demonstrated by an abnormal CTG. A significant placental abruption might cause an intra-uterine death. (No abnromal foetal lie or green vaginal discharge)

Question 10

Insert the appropriate hormones / phase into the diagram of the menstrual cycle.

Answer 10

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Question 11

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Answer 11

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Question 12

Pre-eclampsia is a multisystem disorder. For each system what tests are required to assess the severity of the condition? * Neurological * Hepatic * Placental * Haematological * Renal

Answer 12

Neurological - Reflexes and clonus Hepatic - Aminotransferases are the liver specific enzymes so ALT (alanine aminotranferase) and AST (aspartate aminotransferase) - Many things raise ALP (liver, bone, placenta, kidney) Placental - Umbilical artery doppler Haematological - Platelet count - would expect low platelets Renal - Serum urate

Question 13

A 28 year old para 0+0 woman is seen in the ante-natal clinic at 35 weeks gestation. Her blood pressure is 140/100mmHg. What symptoms might she complain of that would suggest a diagnosis of pre-eclampsia? You may select a maximum of three answers. * Visual disturbance * Itch * Headache * Epigastic discomfort * Dysuria

Answer 13

Pre-eclampsia is a disorder that affects up to 10% of pregnant women. It is characterised by hypertension, oedema and proteinuria. Headache and visual disturbance are suggestive of the diagnosis. In addition the patient might complain of epigastric discomfort and feeling generally unwell. The patient might also report reduced fetal movements. Dysuria is suggestive of other causes of proteinuria such as a UTI. Pruritus, especially in the hands and feet is suggestive of obstetric cholestasis and in this condition there will be no hypertension.

Question 14

What is obstetric cholsestasis?

Answer 14

Obstetric cholestasis is a disorder that affects your liver during pregnancy. This causes a build-up of bile acids in your body. The main symptom is itching of the skin but there is no skin rash. The symptoms get better when your baby has been born.

Question 15

How is the diagnosis of labour confirmed? * Decelerations of the fetal heart * Cervical dilation * Descent of the fetal presenting part * Rupture of membranes * Regular uterine contractions

Answer 15

The diagnosis of labour can be suspected if a woman presents with show and rupture of membranes. However it can only be confirmed by the prescence of regular uterine contractions in conjunction with cervical dilation and descent of the fetal presenting part. Rupture of the membranes can occur prior to the onset of labour. Although decelerations of the fetal heart are frequently heard during labour, they are not diagnostic of labour.

Question 16

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Answer 16

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Question 17

What clinical features are typical of antepartum haemorrhage (APH) due to placenta praevia? TRUE OR FALSE Painless APH Abnormal fetal lie Tense uterus on palpation Pyrexia Fetal Distress

Answer 17

Painless APH - True Tense uterus on palpation - False Pyrexia - False Fetal Distress - False Abnormal fetal lie - True Bleeding from placenta praevia is due to separation of the placenta from the lower uterine segment as a result of the lower segment forming or the cervix dilating. This usually presents as small painless bleeds early in the third trimester of pregnancy, but can present with severe bleeding. Fetal distress is not usually seen. On examination the uterus will be soft and non-tender. Because the placenta implants in the lower uterine segment malpresentation and abnormal fetal lie are common. The condition is not associated with maternal pyrexia.

Question 18

Placenta praevia is when the placenta lies partially or wholly in the lower uterine segment. Placenta praevia is one of the major causes of antepartum haemorrhage. How is placenta praevia diagnosed? Abdominal Palpation Cardiotocograph Ultrasound Scan Vaginal Examination

Answer 18

If a patient presents with an antepartum haemorrhage DO NOT perform a vaginal examination until placenta praevia has been excluded. Vaginal examination in the presence of placenta praevia can result in massive haemorrhage. The diagnosis of placenta praevia might be suggested on abdominal palpation, but an ultrasound scan is required to confirm the diagnosis. Cardiotocograph is used for the assessment of fetal well-being.

Question 19

With regard to the anatomy of the pelvis, which of the following statements are correct? * a) During the administration of regional anaesthesia the pudendal nerve is approached as it passes in front of (anterior to) the ischial spine. * b) The levator ani muscles form the pelvic floor. * c) When inserting a bivalve speculum the gynaecologist must be aware that the vagina measures about 12cm.

Answer 19

a) False - The pudendal nerve passes behind and below the ischial spine. b) True - Weakness in these muscles may contribute to uterovaginal prolapse and stress incontinence. These conditions may be improved by strengthening the levator ani muscles with pelvic floor exercises. c) False - The vagina extends upward and backward, measuring about 8cm.

Question 20

With regard to the anatomy of the pelvis, which of the following statements are correct? d) The ovarian artery arises from the internal iliac artery. e) At ovulation, the ovum is extruded into the peritoneal cavity. f) As the ureter crosses the broad ligament to reach the base of the bladder, it lies superior to the uterine artery.

Answer 20

d) False - The ovarian artery arises from the aorta. (L1/L2) e) True - As the ovum is extruded into the peritoneal cavity, it is possible to develop an intra-peritoneal ectopic pregnancy. f) False - The ureter passes inferior to the uterine artery (water under the bridge) in the broad ligament, before running forward and lateral to the lateral fornix of the vagina.

Question 21

TRUE OR FALSE a) The lifetime risk of ovarian cancer is 20%. b) Approximately 40% of ovarian cancers are familial or hereditary. c) Metastatic cancer to the ovaries most commonly originates from the lung.

Answer 21

* a) False - The lifetime risk of developing ovarian cancer is less than 2%. * b) False - Approximately 5% of ovarian cancers are genetic, some of which are associated with the BRCA1 and BRCA2 genes. * c) False - The commonest cancers to metastasise to the ovaries are from the breast or gastrointestinal tract.

Question 22

TRUE OR FALSE d) The prognosis for ovarian cancer is 90% chance of 5 year survival. e) Ovarian cancer most commonly presents with non-specific symptoms.

Answer 22

d) False - Due to its late presentation, ovarian cancer is rarely curable. Most women with ovarian cancer die within 3 to 5 years of their initial presentation. e) True - Ovarian cancer usually presents late into the disease with intraperitoneal spread. This gives rise to diffuse non-specific symptoms such as abdominal bloating, dyspepsia and weight loss. Ovarian cancer may also initially present as a leg pain and swelling as a consequence of deep venous thrombosis (DVT).

Question 23

Please read the following statements and determine whether or not they are true or false. a) Gonorrhoea infection is a STI b) There is no association between subfertility and untreated gonorrhoea. c) There is no need to refer to the genito-urinary medicine clinic if the infection has been properly treated. d) Pelvic inflammatory disease is only caused by Gonorrhoeae and Chlamydia infections

Answer 23

a) True b) False - Untreated gonorrhoea infection can lead to acute PID resulting in severe adhesions and possible pyosalpinx which can lead to subfertility. c) False - It is important to refer any patient diagnosed with an STI to GUM clinic to screen for other STIs & contact tracing. d) False - STIs such as CT and NG have been identified as causative agents for PID. Mycoplasma genitalium and other anaerobes have also been implicated in the aetiology of the condition.

Question 24

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Answer 24

The partogram demonstrates failure to progess in labour. . There is failure of cervical dilatation and failure of descent of the fetal presenting part despite adequate uterine activity. * Point A amniotomy (artificial rupture of membranes) should be considered. * Point B consideration should be given to the administration of a syntocinon infusion. * 4 hours later at point C there is no progress. There is also a fetal tachycardia and the liquor is stained with meconium (M). The appropriate management in this situation is delivery of the fetus by C-section.

Question 25

Symptoms of Stress Urinary Incontinence include: TRUE OR FALSE Dysuria Nocturia Frequency Leakage of urine with urgency Urgency Leakage of urine with coughing

Answer 25

Dysuria - False (would think UTI) Nocturia - False (would think OAB) Frequency - False (Urge incontinence or OAB) Leakage of urine with urgency - False Urgency - False Leakage of urine with coughing - True

Question 26

What drug is administered for a woman with eclampsia to treat seizures and prevent further seizures? Labetolol Magnesium Sulphate Carbamezapine Phenytoin Diazepam

Answer 26

* Magnesium Sulphate is the anticonvulsant of choice for both the treatment of eclampsia and for the prevention of further seizures. * Phenytoin and Carbamazepine should not be used for the treatment of eclapmtic seizures. * Diazepam is occasionally used as a second line agent in eclampsia in a woman who continues to have seizures despite repeated bolus doses MgSO4 * Labetolol is a combined alpha(1) and beta(1/2) antagonist and is used as an antihypertensive.

Question 27

In pre-eclampsia significant proteinuria is defined as a concentration of greater than: 300mg/l 1gram/l 30mg/l 100mg/l

Answer 27

300mg/l

Question 28

A 32 year old para 1+0 woman is admitted at 40 weeks gestation in early labour. On admission, the cardiotocograph (CTG) is non-reassuring. Following assessment the decision is made to deliver the baby by emergency caesarean section. Which of these health professionals are required? Paediatrician Anaesthetist Anaesthetic Nurse Midwife Obstetrician Nurse Auxillary Domestic Assistant Operating Theatre Nurse

Answer 28

* Paediatrician , Anaesthetist , Anaesthetic Nurse , Midwife , Obstetrician , Nurse Auxillary , Domestic Assistant , Operating Theatre Nurse All true. The doctor is part of a large multidisciplinary team providing care for this patient and her child. Following delivery other health professionals will be involved including physiotherapists, breast-feeding support midwives, neonatal midwives, health visitors and the general practitioner.

Question 29

A small for gestational age fetus is one with an abdominal circumference below the XX centile. 95th 20th 50th 10th

Answer 29

A small for gestational age fetus is one with an abdominal circumference below the XX centile. 10th. About 70% of small for gestational age fetuses will be constitutionally small. While many of the remaining cases will be the result of IUGR, there are a number of other causes to consider such as wrong dates, aneuploidy, congenital infection, fetal anomalies and genetic syndromes, maternal conditions (EG connective tissue disease) and drugs (smoking / alcohol / Beta Blockers).

Question 30

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Answer 30

The symphyseal-fundal height is a clinical measure of fetal well-being. It is the distance measured from the uterine fundus in the midline to the upper border of the symphysis pubis. The main objective of symphyseal-fundal height measurement is to detect the pathologically small baby. Oligohydramnios - True Transverse Lie - True Intra-uterine growth restriction - True Multiple pregnancy - False Polyhydramnios - False

Question 31

Epidural anaesthesia is commonly used during labour. Please answer the following questions regarding this technique. TRUE OR FALSE * a) The epidural needle is inserted between the 1st and 2nd lumbar vertebrae. * b) A common side-effect of epidural analgesia is maternal hypotension

Answer 31

a) False. The epidural needle is commonly inserted between the 3rd and 4th lumbar vertebrae, as this is safely below the level that the spinal cord ends (L1/2) and is before the subarachnoid space ends (S2). b) True. Hypotension is a common side-effect due to vasodilation. It is therefore recommended that the mother receives 500-1000ml of crystalloid fluid prior to epidural insertion and that the fetal heart rate is continuously monitored using a CTG to assess for signs of fetal compromise.

Question 32

Epidural anaesthesia is commonly used during labour. Please answer the following questions regarding this technique. TRUE OR FALSE * c) Compared with spinal anaesthesia, epidural anaesthesia provides rapid onset dense anaesthesia that is ideal for a caesarean section.

Answer 32

c) False. Epidural anaesthesia spreads within the epidural space to emerging nerve roots. The onset of anaesthesia is quite slow, but the catheter can remain in situ and provide long term pain relief. However the analgesic effect can be inconsistent. Spinal anaesthesia is inserted with a fine needle into the subarachnoid space and provides a single injection with usually dense reliable anaesthesia. This is particularly useful for caesarean section.

Question 33

Epidural anaesthesia is commonly used during labour. Please answer the following questions regarding this technique. TRUE OR FALSE * d) The epidural needle is inserted into the subarachnoid space. * e) A recognised complication of epidural anaesthesia is post-partum headache. * f) To provide anaesthesia for the pain caused by uterine contractions, there must be block to nerve roots S2, 3 and 4.

Answer 33

d) False. The epidural catheter is inserted into the epidural space (the space within the vertebral canal lying outside the dura mater) and not into the subarachnoid space. The needle passes through the following structures: skin, superficial fascia, supraspinous ligament, interspinous ligament, ligamentum flavum and into the extradural space. For spinal anaesthesia a needle is inserted into the subarachnoid space and this usually provides reliable anaesthesia. This is particularly useful for caesarean section.

Question 34

Epidural anaesthesia is commonly used during labour. Please answer the following questions regarding this technique. TRUE OR FALSE e) A recognised complication of epidural anaesthesia is post-partum headache. f) To provide anaesthesia for the pain caused by uterine contractions, there must be block to nerve roots S2, 3 and 4.

Answer 34

e) True. Headache can occur due to inadvertent dural puncture resulting in cerebrospinal fluid leak. This can result in a decrease in CSF pressure, causing a headache on raising the head. f) False. The uterine nerve supply is from T10-12 (sympathetic nerves). L1 (ilio-inguinal nerve) to S2,3,4 (pudendal nerve) nerve root supply the vagina and labia.

Question 35

Consider how a cancer of each of the following structures would spread by lymphatic drainage. Match each anatomical structure to the lymph nodes that drain it. Ovary Cervix Bladder Fundus of uterus Labia minora

Answer 35

Ovary - Para-aortic nodes Cervix - Internal and external iliac nodes Bladder - Internal and external iliac nodes Fundus of uterus - Para-aortic nodes Labia minora - Superficial inguinal nodes

Question 36

Which of the following are risk factors for endometrial carcinoma? Early menopause Combined Hormone Replacement Therapy (HRT) Diabetes mellitus Polycystic ovarian syndrome (PCOS) Obesity

Answer 36

Early menopause - False Combined Hormone Replacement Therapy (HRT) - False Diabetes mellitus - True PCOS - True Obesity - True

Question 37

Please match the most appropriate description to the relevant stage of labour: Third stage Second stage First stage From full cervical dilatation until delivery of the baby From the onset of labour until full cervical dilatation From delivery of the baby until delivery of the placenta

Answer 37

First stage = From the onset of labour until full cervical dilatation (10cm) Second stage = From full cervical dilatation until delivery of the baby Third stage = From delivery of the baby until delivery of the placenta

Question 38

Term pregnancy is defined as between __ and ___ weeks gestation.

Answer 38

Pre-term is less than 37 weeks gestation. Post-term is more than 42 weeks gestation. A normal term pregnancy is therefore between 37 and 42 weeks gestation.

Question 39

Twin pregnancies are at increased risk of the following: TRUE OR FALSE Perinatal mortality Postmaturity Pre-eclampsia Intra-uterine growth restriction (IUGR) Placenta praevia

Answer 39

Pre-eclampsia - True Postmaturity - False Placenta praevia - True Intra-uterine growth restriction (IUGR) - True Perinatal mortality - True