Obs and Gynae Yr 4 C - O&G Post-block assessment flashcard with explanations (77%)

Question 1

Read the following statements and determine whether they are true or false. * a) HIV is the most common virus associated with cervical pathology. * b) Cervical smear screening should be offered to all sexually active women including teenagers. * c) Cervical smear is the first choice investigation in women with clinically suspected cervical cancer. * d) Cervical cancer can present with recurrent post-coital bleeding.

Answer 1

a) - False - HPV is the most common virus associated with cervical pathology b) False - Cervical smear screening should be offered to all sexually active women aged 25 to 64 c) False - Cervical smear is the screening tool to detect pre-cancerous changes. Cervical biopsy should be performed in women with suspected cervical cancer. d) True - Cervical cancer can present with irregular vaginal bleeding including post-coital bleeding and vaginal bleeding in pregnancy.

Question 2

Which of the following are risk factors for cervical cancer? Alcohol Cervical warts Use of condom Obesity Smoking Multiple sexual partners

Answer 2

Risk factors for cervical cancer * Cervical warts * Smoking * Multiple sexual partners Alcohol, use of condom and obesity are not risk factors for cervical cancer

Question 3

Please answer the following questions are about menstrual bleeding. a) The typical menstrual cycle ranges from 21-35 days. b) Menorrhagia is defined as blood loss over 250ml per cycle. c) During the first 2 years after menarche most cycles are anovulatory. d) Menorrhagia can be the initial presenting complaint in a women infected with a STI

Answer 3

a) True b) False - Menorrhagia is defined as blood loss >80ml of blood - most women will become anaemic with this volume of mnstrual loss c) True - Regular ovulation does not usually start until approximately 2 years after menarche. d) True - Sexually transmitted infections can present with menorrhagia. In particular an infection with Chlamydia can commonly present in this way.

Question 4

Image shows a TVUS picture of a uterus with a large fibroid. This 35 year-old nulliparous woman complains of menorrhagia and infertility. Which of the following are appropriate treatments? a) Mirena intra-uterine system b) Mefenamic Acid c) Hysterectomy d) Tranexamic Acid e) Sulfasalazine

Answer 4

a) False - effective for menorrhagia treatment, less so in large fibrois - wouldnt use in this case due to contraceptive effects b) True - NSAIDs such as mefenamic acid are effective in the treatment of menorrhagia and dysmenorrhoea. c) False - Not appropriate in this case, as this woman wishes to preserve her fertility. However myomectomy could be considered. d) True - Tranexamic Acid is an antifibrinolytic drug that can reduce menstrual bleeding e) False- Sulfaslazine used in IBD

Question 5

5. 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 5

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 6

5. 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 6

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. It is important that the gynaecologist knows the anatomy of the ureter within the pelvis well, as this may be damaged during pelvic surgery.

Question 7

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

Answer 7

Fetal Distress - False Tense uterus on palpation - False Painless APH - True Pyrexia - False Abnormal fetal lie - True

Question 8

Why is there bleeding from placental praevia? What are the signs and symptoms again?

Answer 8

The bleeding 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 There is uusally no feotal stress, maternal pyrexia and a SNT uterus. Because the placenta implants in the lower uterine segment malpresentation and abnormal fetal lie are common.

Question 9

With regard to the use of clomiphene citrate in the management of subfertility: * a) Clomiphene citrate is an anti-oestrogen * b) Clomiphene citrate is used in the management of subfertility associated with tubal disease * c) Side effects of clomiphene citrate include hot flushes and night sweats

Answer 9

a) True - Clompihene citrates main mechanism of action is anti-oestrogenic, causing circulating levels of LH (lutinising hormone)and FSH (follicular stimulating hormone) to rise. b) False - Clomiphene citrate is used in the management of anovulatory infertility, dues to conditions such as polycytic ovarian syndrome. c) True - Clomiphene citrate has anti-oestrogenic properties and as a result may cause menopausal symptoms.

Question 10

With regard to the use of clomiphene citrate in the management of subfertility: * d) Complications of clomiphene citrate administration include multiple pregnancy and ovarian hyperstimulation syndrome * e) Premature ovarian failure is one of the long-term complications of clomiphene citrate administration

Answer 10

d) True - There is a 5-10% risk of multiple pregnancy. Rarely ovarian hyperstimulation syndrome can occur, especially if there is a history of PCOS. It is recommended that ultrasound monitoring is performed during the initial treatment cycle. e) False - The long-term risks following clomiphene citrate administration include an increased risk of ovarian cancer. Although it is an anti-oestrogen there is no evidence of an increased risk of premature ovarian failure with long-term use

Question 11

Which of the following criteria are used to diagnose polycystic ovarian syndrome? hyperprolactinaemia clinical or biochemical hyperandrogenism oligo/amenorrhoea obesity polycystic ovaries on ultrasound

Answer 11

In order to diagnose polycystic ovarian syndrome (PCOS) a woman must have 2 out of 3 of the following features: 1. Clinical hyperandrogenism (hirsutism / acne) or biochemical hyperandrogenism (elevated free androgen index / reduced sex hormone binding globulin) 2. Oligo/amenorrhoea 3. Polycystic ovaries on ultrasound scan. Obesity and hyperprolactinaemia are often associated with PCOS but they are not diagnostic

Question 12

With regard to the management of pelvic organ prolapse: * a) Anterior repair is usually performed for a rectocoele. * b) A woman with an asymptomatic cystocoele should be managed by pelvic floor surgery. * c) Antimuscarinic drugs are commonly prescribed for pelvic organ prolapse.

Answer 12

a) False - Anterior repair is usually performed for cystocoele. b) False - Patient is asymptomatic so no intervention is needed. c) False - Antimuscarinic drugs are used for urge urinary incontinence / over active bladder syndrome.

Question 13

With regard to the management of pelvic organ prolapse: * d) Pelvic floor exercises are effective in the management of procidentia. * e) Using a vaginal pessary is the management of choice in an elderly woman who has a procidentia and is medically unfit for surgery. * f) Obesity, chronic cough and constipation are risk factors for pelvic organ prolapse.

Answer 13

d) False - Pelvic floor exercises are effective for the management of stress urinary incontinence. e) True - Vaginal pessaries are effective in the conservative management of pelvic organ prolapse. f) True - Any factor that increases intra-abdominal pressure will increase the risk of pelvic organ prolapse.

Question 14

What is the most effective method contraception? What is the failure route of female and male sterilisation?

Answer 14

Most effective method = the implant 0.05% failure rate (5 in 10,000) Male sterilisation failure rate = 0.15% (15 in 10,000) Female sterilisation failure rate = 0.5% (1 in 200, 50 in 10,000)

Question 15

Female laparoscopic sterilisation. Please answer the following questions (true/false): * a) There is a 3 / 1000 risk of emergency laparotomy. * b) Failure rate is least of any form of contraception. * c) Laparoscopic sterilisation can be considered reversible, as the success rates from a reversal of sterilisation are greater than 90%. * d) Laparosocpic sterilisation is relatively contraindicated in women with BMI of over 40 * e) Female sterilisation can be performed at the at the same time as caesarean section.

Answer 15

a) True - This is related to injury to blood vessels, bowel or bladder, which can be difficult to repair laparoscopically. b) False - Laparoscopic sterilisation has a 1: 200 failure rate. Both vasectomy and implant are better c) False - Sterilisation should be considered irreversible, as a reversal of sterilisation is a major surgical procedure with low success rates ( d) True - Difficult and has a higher complication rate. e) True - In certain circumstance it is appropriate to perform tubal ligation at the same time as caesarean section. However the failure rates and regret rates are higher.

Question 16

Consent to surgery or intervention: * a) Damage to the bowel at the time of hysterectomy can be repaired without written consent. * b) Tissue for research purposes can be kept without specific consent.

Answer 16

a) True: Doctor need to act in the patient’s ‘best interest’ which means any treatment that is necessary to ‘’preserve the life, health or wellbeing of the patient and for the patient’s welfare’. b) False: Consent must be obtained when tissue is to be used for research purpose. Women must however be made aware that tissue and samples may be removed in the course of the procedure for which consent is being obtained. The advice given to the woman must include the examination of the these tissues and the woman should be informed that blocks and slides will be retained while the remaining samples is destroyed. The retained tissue may be used for education and training.

Question 17

Consent to surgery or intervention: c) A woman refuses caesarean section despite fetal distress, her partner can overrule her decision. d) In a Jehovah witness who has written documentation of declining blood transfusion in any circumstances, has a massive haemorrhage during a hysterectomy, a doctor can authorise for emergency blood transfusion to save her life. e) Consent must be sought from parent in order to perform a post-mortem for an unexplained stillbirth.

Answer 17

c) False: An unborn child has no ‘legal personality’ and cannot for its own protection be regarded as a different person from its mother. Relatives have no right to consent on behalf of a competent patient. d) False: If a competent woman refuses any treatment even after full consultation and explanation of the consequences, her wishes must be respected. e) True.

Question 18

Please match the following early pregnancy ultrasound images to the most likely diagnosis: * Hydaditiform mole * Ectopic pregnancy * Missed miscarriage * Intruteruine pergnancy

Answer 18

a) A hydatidiform mole is a tumour from benign proliferation of trophobalstic tissue. The chorionic villi become grossly swollen, giving a snowstorm appearance on ultrasound scan. b) An ectopic pregnancy is a pregnancy located outside the uterus, most commonly in fallopian tube. This ultrasound scan shows an enlarged uterus, with thickened endometrium and a pseudosac (irregular sac like structure, created by decidual reaction) and an extrauterine pregnancy seen within the fallopian tube. Free fluid (haemoperitoneum) in the pelvis may also be seen (but is not present in this scan picture).

Question 19

Please match the following early pregnancy ultrasound images to the most likely diagnosis:

Answer 19

c) A missed miscarriage or blighted ovum is a pregnancy in which embryonic or early fetal death has occurred. On ultrasound scan no fetal pole can be seen. However, one has to be certain distinguish an early normal pregnancy from an anembryonic pregnancy. In an ongoing pregnancy, once the mean sac diameter is over 18mm on transvaginal scan, a fetal pole should be visualised. d) Intrauterine pregnancy.

Question 20

A 60 year old woman presents with an abdomino-pelvic mass. On examination there is also evidence of ascites. The following investigations are appropriate: * a) Hysteroscopy * b) Blood test for CA125 * c) Pelvic X-ray * d) Sigmoidoscopy * e) Cytology of aspirated ascitic fluid

Answer 20

a) False - Hysteroscopy is an appropriate investigation for a woman with post-menopausal bleeding. b) True - CA125 is elevated in some ovarian cancers and also can also be used to monitor treatment. c) False - A pelvic x-ray is not a good form of imaging to help differentiate the cause of an abdomino-pelvic mass. A pelvic ultrasound scan is a more appropriate investigation. CT scan might also be useful. d) False - Sigmoidoscopy is usually only indicated if bowel symptoms are present. e) True - Cytology of ascitic fluid might be indicated, especially if imaging of the pelvis does not identify the aetiology of the mass.

Question 21

The following histolopathology images demonstrate abnomalities of the cervix. Please match each histopathology image of the cervix with the correct diagnosis: Invasive squamous carcinoma of the cervic (poorly differentiated) Moderate dysplasia CIN II Severe dysplasia CIN III Normal ectocervicx

Answer 21

a) - Moderate dysplasia CIN II b) Severe dysplasia CIN II Both will require treatment - LLetz or Cold coagulation probably

Question 22

The following histolopathology images demonstrate abnomalities of the cervix. Please match each histopathology image of the cervix with the correct diagnosis: Invasive squamous carcinoma of the cervix (poorly differentiated) Moderate dysplasia CIN II Severe dysplasia CIN III Normal ectocervicx

Answer 22

c) Invasive squamous carcinoma of the cervix - poorly differentiated The tumour is poorly differentiated since there is no evidence of pink staining keratin formation characteristic of well differentiated squamous carcinoma. d) Normal ectocervix

Question 23

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Answer 23

The correct answer is Neisseria Gonnorrhoea.

Question 24

With regard to endometrial carcinoma: a) Most endometrial carcinoma occurs in pre-menopausal women. b) Endometrial stromal carcinomas are the commonest tumours of the endometium. c) Presentation is usually with abdominal pain & swelling. d) Five year survival is 90%

Answer 24

a) False - The majority of endometrial carcinoma (80%) occurs in post-menopausal women. It is rare before 40 years old. b) False - Endometrial adenocarninoma is by far the commonest type and is derived from the glandular elements of the endometrium. c) False - Presentation is usually with abnormal vaginal bleeding. d) False - The 5 year survival (all cases) is approximately 65%.

Question 25

Please select the principal professional to manage the following cases: a) A woman with an ovarian cyst that is strongly suggestive of malignancy. b) A woman with stage III cervical cancer. c) A woman with a strong family history of ovarian and breast cancer, requests advice with regard to her risk of developing ovarian cancer. d) A woman with heavy menstrual bleeding and fibroids who does not want a hysterectomy would like to discuss fibroid embolisation.

Answer 25

a) - Gynaecological Oncologist b) - Radiotherapist c) - Geneticist d) - Radiologist

Question 26

Urge urinary incontinence can be managed by the following: Anterior colporrhaphy Intrauterine progesterone only device (Minera Intra-Uterine System) Antimuscarinic drugs such as oxybutynin Bladder drill Cystoscopy

Answer 26

Anterior colporrhaphy - False Intrauterine progesterone only device (Minera Intra-Uterine System) - False Cystoscopy - False Antimuscarinic drugs such as oxybutynin - True Bladder drill - True

Question 27

A 38 year old woman attends a gynaecology clinic with heavy periods. Her periods are painful for the first 2 days of menstruation. She is otherwise healthy, with no other symptoms of note. Her last cervical smear was normal 6 years ago. Examination is normal, including a normal pelvic examination. Which of the following investigations are appropriate? Thyroid hormone levels Pelvic x-ray Cystoscopy Cervical smear Full blood count

Answer 27

Thyroid hormones should only be checked if there are symptoms suggestive of thyroid disease. A cervical smear should be taken as part of the routine screening programme every 3 to 5 years. Cystoscopy should not be performed, as is an assessment of bladder pathology. A pelvic x-ray would not a helpful investigation of menstrual dysfunction. A full blood count should be performed to assess for anaemia due to menorrhagia. CERVICAL SMEAR AND FBC - TRUE

Question 28

The combined oral contraceptive pill (COCP) is contraindicated in the following: a) Woman with a body mass index (BMI) of over 39kg/m2 b) Before laparoscopic sterilisation c) Blood pressure of 160/115mmhg d) Frequent tension headaches e) Varicose veins

Answer 28

a) True - COCP is contraindicated in severe obesity due to the increased risk of arterial disease. As well as in women with moderate obesity (BMI > 34) and an additional risk factor, b) False - Usual practice to stop 6 weeks before major surgery, laproscopic sterilisation is a minor surgery. c) True - In women with hypertension there is an increase risk of arterial disease and therefore COCP is contraindicated. d) False - COCP is contraindicated in women with migraine, but is not contraindicated in tension headaches. e) False

Question 29

Regarding termination of pregnancy: a) A 13 year old girl can consent for termination of pregnancy b) Her mother must be informed before the procedure takes place c) She can refuse to take antibiotics if she is found to have an sexually transmitted infection

Answer 29

a) True - In Scotland, the Age of Legal Capacity Scotland Act 1991 stated that a person under the age of 16 shall have legal capacity to consent on his own behalf to any surgical, medical or dental procedure or treatment where, in the opinion of a qualified medical practitioner attending him, he is capable of understanding the nature and possible consequences of his procedure or treatment. b) False - see explanation for question a). c) True - see explanation for question a).

Question 30

Regarding termination of pregnancy: d) It is only the clinician who can decide whether a 14 year old is capable of consenting to any procedure e) The pregnancy has NOT exceeded its 24 weeks and the continuance of the pregnancy would involve risk to the life to the woman greater than if the pregnancy were terminated is a statutory ground for terminating the pregnancy according to the Abortion Act

Answer 30

d) False - qualified medical practitioner is not confined to doctors and includes dentists, nurses and others who are medically qualified to treat patients. e) False - There is no limit of gestation where the risk is to the life of the woman involved.

Question 31

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Answer 31

Non-reassuring This cardiotogograph (CTG) shows a fetal tachycardia, with reduced variability and late decelerations. This is non-reassuring and is an indication for further assessment / delivery of the fetus. Other methods used to identify intra-partum fetal distress include Fetal ST analysis and fetal blood sampling (FBS) and pH assessment.

Question 32

What fetal measurements are taken on ultrasound at 28 weeks to assess fetal growth? * Crown Rump Length * Cerebellum Diameter * Abdominal Circumference * Femur Length * Head Circumference

Answer 32

True At 28 weeks gestation the fetal ABDOMINAL CIRCUMFERENCE is used to identify the small for dates fetus. Fetal HEAD CIRCUMFERENCE measurements should also be performed. Disparity between the head and abdominal circumference measurements suggests IUGR (asymmetrical). FEMUR LENGTH may also be measured at this gestation and is used with other biometric measurements to calculate estimated fetal weight. False The crown rump length is used in the first trimester to assess gestational age. The trans-cerebellar diameter is not routinely measured but may be assessed at the time of the 20 week ultrasound scan in the detection of fetal abnormalities.

Question 33

Vulval warts found in a 25 year old patient.Please read the following statements and determine whether or not they are true or false. * a) These lesions may also be seen in the cervix. * b) Human papilloma virus (HPV) is the cause of this condition. * c) Podophyllin can be applied to genital warts during pregnancy. * d) It is important to enquire about cervical smear history, particularly in this case.

Answer 33

a) True - Genital warts can also occur in the cervix, the peri-anal region and in the mouth. b) True - HPV is commonly associated with genital warts, especially types 6 and 11. c) False - Genital warts are commonly traeted with topical podophyllin. This is applied to the affected area but is contraindicated in pregnancy. Genital warts can also be treated with local ablation techniques using laser or diathermy. d) True - There is an association with HPV infection and the development of cervical cancer.

Question 34

According to SIGN guidelines on the investigation of Post-Menopausal Bleeding (PMB): a) Dilatation and curettage (D&C) is the first line method of investigating PMB. b) Transvaginal ultrasonography can reliably assess the endometrial thickness. c) Hysteroscopy and biopsy is the gold standard investigation for a woman with PMB.

Answer 34

a) False - This technique is blind and the operator cannot assess whether or not lesions have been missed. Therefore this should not be used as the first line method of investigating PMB. - TVUS is probably first line b) True c) True

Question 35

According to SIGN guidelines on the investigation of Post-Menopausal Bleeding (PMB): d) Out-patient hysteroscopy is not as accurate as in-patient hysteroscopy under general anaesthetic. e) Transvaginal ultrasonography is the first line investigation in post-menopausal women on tamoxifen who experience vaginal bleeding.

Answer 35

d) False - Out-patient hysteroscopy appears to have accuracy and patient acceptability that is equivalent to in-patient hysteroscopy under general anaesthetic. e) False - Ultrasonography is poor at differentiating potential cancers from other tamoxifen-induced endometrial thickening because of the distorted endometrial architecture associated with long-term tamoxifen use. - straight to hysteroscopy and biopsy

Question 36

Which of these are risk factors for developing endometrial cancer? a) Cigarette smoking b) Combined oral contraceptive pill c) Obesity d) Nulliparity e) Treatment with clomiphene citrate for ovulation induction

Answer 36

a) False - Smoking does not increase the risk of endometrial Ca, but does increase risk of cervical. b) False - The combined oral contraceptive pill reduces the risk of endometrial cancer. c) True - Obesity increases the risk of endometrial cancer due to the increase in peripheral conversion of adrenal androgens to oestrogens that occurs predominately in adipose tissue. d) True - Endometrial cancer is less common in multiparous women, those that breast-feed their children for a prolonged period and also in those women who have an early menopause. e) False - Does not increase the risk of endometrial Ca, but with prolonged administration there is an increased risk of a woman developing ovarian Ca.

Question 37

Which health professional is most likely to perform the following? Resuscitate a pre-term infant Provide initial breast-feeding support Conduct a vaginal breech delivery Carry out low-risk antenatal care Perform an operative vaginal delivery Instruct pelvic floor exercises post-natally Insert an epidural anaesthetic Repair a third degree perineal tear

Answer 37

* Resuscitate a pre-term infant - Pediatrician * Provide breast-feeding support - Midwife * Conduct avaginal breech delivery - Obstetrician * Carry out low-risk antenatal care - Community Midwife * Perform an operative vaginal delivery - Obstetrician * Instruct pelvic floor exercises post-natally - Physiotherapist * Insert an epidural anaesthetic - Anaesthetist * Repair a third degree perineal tear - Obstetrician

Question 38

Polyhydraminos can be caused by the following: Maternal diabetes mellitus Triplet pregnancy Indomethacin Fetal tracheo-oesophageal fistula Post dates pregnancy

Answer 38

Conditions that decrease fetal swallowing, are associated with polyhydramnios, such as anencephaly and tracheo-oesophageal fistula. Other conditions known to cause polyhydramnios include maternal diabetes mellitus and multiple pregnancy. Conditions that decrease fetal renal function are associated with oligohydramnios, such as maternal use of non-steriodal anti-inflammatory drugs (ie indomethacin) and renal agenesis (Potter syndrome).

Question 39

A 26 year old nulliparous woman presents with a 3 year history of subfertility. Day 21 serum progesterone levels confirm that she is ovulating. Her husband has a normal semen analysis. She has no significant past medical history other than a history of pelvic inflammatory disease. a) Chlamydia is the most common cause of tubal damage. b) In this case a hysterosalpingogram (HSG) is the most apppropriate method to check for tubal patency.

Answer 39

a) True b) False - Diagnostic laparoscopy and dye hydrotubation is recommended in the investigation of subfertility in a woman with risk factors for tubal disease such as pelvic inflammatory disease.

Question 40

A 26 year old nulliparous woman presents with a 3 year history of subfertility. Day 21 serum progesterone levels confirm that she is ovulating. Her husband has a normal semen analysis. She has no significant past medical history other than a history of pelvic inflammatory disease. * c) In this case if investigations confirm that this woman has bilateral tubal occlusion, ovulation induction with clomiphene citrate is indicated. * d) This patient should be advised of the risk of ectopic pregnancy if she falls pregnant.

Answer 40

c) False - If there is evidence of bilateral tubal occlusion then in-vitro fertilisation (IVF) should be the management of choice. Clomiphene citrate is used in the management of anovulatory subfertility that is associated with disorders such as polycystic ovarian syndrome (PCOS). d) True- There is approximately a 10% risk of ectopic pregnancy in woman with tubal disease.