Obs & Gynae Flashcards
1
Q
What are the indications for surgical management of ectopic pregnancies?
A
> 35 mm b
Beta-hCG levels > 5000 IU/L
Foetal heartbeat
-> Salpingectomy is first-line for women with no risk factors for infertility
-> If do then Saplingotomy
2
Q
What are the indications for expectant management vs medical management of an ectopic pregnancy?
A
hCG <1,500IU/L = medical management (methotrexate)
hCG <1,000IU/L = watch 7 wait for 48hrs
3
Q
What are the emergency contraception options?
A
IUD, oral progesterone-only contraceptive (levonorgestrel) or a selective progesterone receptor modulator (ulipristal acetate)
4
Q
Which contraception should be prescribed post-partum?
A
Progesterone only pill
5
Q
What are the indications for a salpingotomy as the treatment for an ectopic pregnancy?
A
PMH affecting their fertility or tubes
6
Q
What is the most common cause of mastitis and breast abscesses?
A
Staph aureus (common when breast feeding)
7
Q
At what size should breast fibroadenomas be surgically removed?
A
> 3cm
8
Q
How should breast cysts be managed?
A
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
9
Q
What are the indications for antibiotic use in mastitis?
A
Symptoms not improving after 12-24 hours despite effective milk removal and/or breast milk culture positive
10
Q
How should mastitis be treated?
A
Flucloxacillin for 10-14 days.
Breastfeeding or expressing should continue during treatment.
11
Q
What is Paget’s disease of the nipple?
A
Eczematoid change of the nipple associated with an underlying breast malignancy.
12
Q
What are the indications for a mastectomy over a wide local excision?
A
Multifocal tumour, Central tumour, Large lesion in small breast, DCIS >4cm
13
Q
What are the management options for stress incontinence?
A
Pelvic floor muscle training (1st line)
Surgical (retropubic mid-urethral tape procedures) or duloxetine
14
Q
What are the management options for urge incontinence?
A
Bladder retraining (1st line)
Oxybutynin (antimuscarinics are first-line)
15
Q
What antibiotic should be prescribed for a UTI in pregnancy?
A
1st line - Nitrofurantoin (not a term)
2nd line - amoxicillin or cefalexin
16
Q
What triad must be met before diagnosing Hyperemesis gravidarum?
A
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
17
Q
What is the 1st line treatment for Hyperemesis gravidarum?
A
1st line - Oral cyclizine or oral promethazine (antihistamines)
18
Q
What is the 2nd line treatment for Hyperemesis gravidarum?
A
2nd line - ondansetron and metoclopramide
19
Q
Should women have cervical screening when pregnant?
A
Cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
20
Q
What SSRIs are suitable for breastfeeding women?
A
Sertraline or paroxetine
21
Q
After how many weeks of gestation can someone be diagnosed with gestational diabetes?
A
20 weeks
22
Q
Which anticoagulant is safest to use in pregnancy?
A
Low molecular weight heparin
23
Q
What are the thresholds for diagnosing gestational diabetes?
A
fasting glucose is ≥ 5.6 mmol/L
2-hour glucose is ≥ 7.8 mmol/L
24
Q
At how many weeks is the combined test offered?
A
Between 11 - 13+6 weeks
25
At how many weeks is the quadruple test offered?
Between 15 - 20 weeks
26
What indicates an increased risk of down syndrome on the quadruple test?
↓ Alpha-fetoprotein, ↓ Unconjugated oestriol, ↑HCG, ↑ Inhibin A
27
What indicates an increased risk of Edward's syndrome on the quadruple test?
↓ AFP
↓ oestriol
↓ hCG
↔ inhibin A
28
What medication is the first line in the treatment of infertility in PCOS?
Clomifene
29
What medications can be used to treat PCOS?
Combined oral contraceptive
If contraindicated: Levonorgestrel-releasing intrauterine system
30
What treatment should be given if mothers who are hepatitis B surface antigen positive, or are known to be high risk of hepatitis B?
1st dose of hepatitis B vaccine soon after birth
Those born to mother's who are surface antigen positive should also receive 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth.
The baby should then further receive 2nd dose of vaccine at 1-2 months & 6 months.
31
How should eclampsia be treated?
Magnesium treatment should continue for 24 hours after delivery or after last seizure
32
What are the contraindications for HRT?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
33
What blood test can be done to measure if a woman is ovulating?
Day 21 progesterone
34
What should be done if you miss a pill on the progesterone-only pill?
< 3 hours late: continue as normal
> 3 hours: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions until 48 hours after
But if using desogestrel - only if >12hrs then precautions needed
35
For how long is additional protection required when starting the POP?
If started up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods should be used for the first 2 days.
36
What is the most common side-effect of the POP?
Irregular vaginal bleeding is the most common problem
37
What is the classic triad of Vasa Previa?
Rupture of membranes followed by painless vaginal bleeding and fetal bradycardia
38
What should be done if one COCP is missed?
Take the last pill, then continue taking pills daily
No additional contraceptive protection needed
39
Is emergency contraception required if 2 or more COCP are missed?
Week 1 (Days 1-7): emergency contraception if she had unprotected sex in the pill-free interval or in week 1
Week 2 (Days 8-14): no need for emergency contraception
Week 3 (Days 15-21): finish the pills in her current pack & start a new pack the next day; thus omitting the pill-free interval
40
What should be done if two COCP is missed?
- Take the last pill even if it means taking 2 pills in 1 day, leave any earlier missed pills then continue normally
- Use condoms or abstain from sex until she has taken pills for 7 days in a row
41
What investigation should be done for suspected placenta previa?
Transvaginal ultrasound scan - this is the gold standard investigation
42
How long does each contraceptive take to be effective?
Instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
43
What are the indications for an IGTT in weeks 24-28?
BMI above 30 kg/m²
Previous macrosomic baby weighing ≥ 4.5 kg
Previous gestational diabetes
Family history of diabetes (first‑degree relative)
An ethnicity with a high prevalence of diabetes
44
What are the features of the thyrotoxic phase of postpartum thyroiditis?
Painless goitre, palpitations, tremors, sweating, diarrhoea, weight loss & anxiety
45
How is the thyrotoxic & hypothyroidism phase of postpartum thyroiditis managed?
Thyrotoxic - Propranolol is typically used for symptom control
Hypothyroidism - thyroxine
46
What are the three stages of postpartum thyroiditis?
1. Thyrotoxic phase
2. Hypothyroidism
3. Normal thyroid function (usually)
47
When should rhesus-negative women get doses of anti-D?
1st dose - 28 weeks
2nd dose - 34 weeks
48
What is the cut-off for the treatment of anaemia in pregnancy?
First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L
49
How is a termination of pregnancy carried out?
< 9 weeks = mifepristone then 48hrs later misoprostol
> 9 weeks = surgical
50
What is the medical management of a miscarriage (if retained products of conception)?
Vaginal misoprostol
51
How should gestational diabetes be managed?
< 7 mmol/l a trial of diet and exercise should be offered
If target not met in 2 weeks = metformin
If still not met = insulin
≥ 7 mmol/l insulin should be started
52
What are the features of Bacterial vaginosis?
Offensive fishy smelling white/grey vaginal discharge
53
How do you treat Bacterial vaginosis?
Oral metronidazole for 5-7 days
54
What are the features of a Trichomonas vaginalis infection?
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
55
What are the features of vaginal candidiasis?
'Cottage cheese' discharge
Vulvitis
Itch
56
How do you treat vaginal candidiasis?
oral fluconazole 150 mg as a single dose first-line
57
How do you treat vaginal candidiasis in pregnant women?
clotrimazole 500 mg intravaginal pessary
58
How do you treat a Trichomonas vaginalis infection?
oral metronidazole for 5-7 days
59
What are the features of HELP syndrome?
Hemolysis, Elevated Liver enzymes, and a Low Platelet
60
When should intrapartum antibiotics be offered for Group Strep B prophylaxis?
Women with a previous baby with GBS disease
Women in preterm labour regardless of their GBS status
Women with a pyrexia during labour (>38ºC)
61
What intrapartum antibiotic should be offered for Group Strep B prophylaxis?
Benzylpenicillin
62
What is the 1st line treatment for menorrhagia vs dysmenorrhea?
IUS is 1st-line in the treatment of menorrhagia
Primary dysmenorrhoea = NSAIDs (ibuprofen, naproxen and mefenamic acid)
63
How should exposure to chickenpox in pregnancy be managed?
≤ 20 weeks = varicella-zoster immunoglobulin (VZIG)
> 20 weeks = either VZIG or antivirals (aciclovir) given days 7 - 14 after exposure
64
How should a confirmed chickenpox infection be managed in pregnancy?
Oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
65
Other than routinely, when should anti-D be given to (unsensitised) pregnant women?
Delivery of a Rh +ve infant (live or stillborn)
Termination or ectopic pregnancy (if managed surgically)
Miscarriage ( > 12 weeks) or abdominal trauma
External cephalic version
Antepartum haemorrhage
Amniocentesis, chorionic villus sampling, fetal blood sampling
66
What is the difference between pre-existing hypertension and gestational hypertension?
Pre-existing < 20 weeks
Gestational < 20 weeks
67
At how many weeks gestation can CVS and amniocentesis be performed?
CVS - 11 - 13+6 weeks
Amniocentesis - 15+ weeks
68
Which women need to take an increased folic acid dose?
Previous child with NTD
Diabetes mellitus
Women on antiepileptic
Obese (body mass index >30kg/m²)
HIV +ve taking co-trimoxazole
Sickle cell
69
How should obstetric cholestasis be managed?
Induction of labour at 37-38 weeks
70
How can premenstrual syndrome be managed?
Mild = lifestyle advice (regular, frequent, small, balanced meals rich in complex carbohydrates)
Moderate = new-generation combined oral contraceptive pill
Severe = SSRI
71
When can the COCP be used in the postpartum period?
Contraindicated if breastfeeding < 6 weeks post-partum
Can be used after 21 days
May reduce breast milk production in lactating mothers
72
When can the POP be used in the postpartum period?
Start the POP at any time postpartum
73
Women with autoimmune conditions are at risk of pre-eclampsia, what medication should they take during pregnancy?
75mg aspirin from 12 weeks to the term of pregnancy
74
How do you treat pre-eclampsia?
1. Delivery cure for pre-eclampsia. IV magnesium sulphate is used for eclampsia (seizure) prophylaxis.
2. After 34 weeks, same-day delivery is an option.
3. Labatolol or Nifedipine
4. Epidural anaesthesia should reduce blood pressure.
75
What should be done if the contraceptive patch change is delayed?
Delayed at the end of week 1 or week 2:
< 48hrs = no precautions
> 48hrs = barrier method 7 days
Delayed at the end of week 3:
New patch applied on the usual start day
Application delayed at end of patch-free week = barrier contraception 7 days
76
What does a raised Alpha-fetoprotein (AFP) indicate?
Neural tube defects or abdominal wall defects
77
When can Levonorgestrel be taken and are there any contraindications?
< 72 hours since intercourse
Hormonal contraception can be started straight after
78
When can Ulipristal be taken and are there any contraindications?
< 120 hours since intercourse
Hormonal contraception can be started 5 days after
Contraindicated in severe asthma
Breast feeding delayed 1 week
79
What are the different degrees of peritoneal tears?
1st degree - superficial damage & no muscle involvement
2nd degree - injury to perineal muscle, but not involving anal sphincter
3rd degree - involving the anal sphincter complex
4th degree - involving the anal sphincter complex & rectal mucosa
80
How should the different degrees of peritoneal tears be managed?
1st - no repair required
2nd - suturing on the ward by a suitably experienced midwife or clinician
3rd & 4th - require repair in theatre
81
How do you test for chlamydia?
for women: the vulvovaginal swab is first-line
for men: the urine test is first-line
Then nuclear acid amplification tests (NAATs)
82
How do you treat chlamydia?
Doxycycline (7 day course) if first-line
If pregnant then azithromycin or erythromycin
83
How do you manage a post-partum haemorrhage?
1. Lie them flat, warmed crystalloid infusion
2. Mechanical - palpate the uterine fundus and catheterise
3. Medical - IV oxytocin, ergometrine slow IV or IM, carboprost IM, misoprostol sublingual
4. Surgical - intrauterine balloon tamponade
84
What is the sign on USS of an ectopic pregnancy?
Tubal ring sign or bagel sign
85
What are the two most common types of cervical cancer?
Squamous cell cancer (80%)
Adenocarcinoma (20%)
86
What serotypes of HPV are the biggest risk factors for cervical cancer?
Serotypes 16,18 & 33
87
Other than HPV what other risk factors for cervical cancer are there?
Smoking, HIV, early first intercourse, many sexual partners
high parity
lower socioeconomic status
COCP
88
What are the requirement for a forceps delivery?
Fully dilated cervix
OA position preferably
Ruptured Membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty
89
What is Erb's palsy and how does it present?
Occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia
Adduction and internal rotation of the arm, with pronation of the forearm (called the 'waiter's tip')
90
What feature in pregnancy may indicate twin-twin transfusion syndrome?
Sudden increases in the size of their abdomen and/or any breathlessness, which may be the result of polyhydramnios affecting the recipient twin
91
What is the definition of a miscarriage on USS?
A crown-rump length greater than 7mm with no cardiac activity is diagnostic of a miscarriage
92
What are the different types of miscarriage?
No cardiac activity & closed cervical os = Missed miscarriage
Cardiac activity & closed cervical os = Threatened miscarriage
Open os & PV bleeding = inevitable miscarriage
93
What is the recommended treatment for stage 1A cervical cancer?
Gold standard of treatment is hysterectomy +/- lymph node clearance
For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed
94
What is the recommended treatment for stage 1B cervical cancer?
Radiotherapy - bachytherapy or external beam radiotherapy
Chemo - Cisplatin is most commonly used
Radical hysterectomy with pelvic lymph node dissection
95
How should cervical intraepithelial neoplasia be managed?
Large loop excision of transformation zone (LLETZ)
96
How does physiological and active management of the third stage of labour differ?
Active:
Uterotonic drugs (IM oxytocin after delivery of anterior shoulder)
Clamping & cutting of the cord > 1 but < 5 mins
Controlled cord traction after signs of separation of the placenta.
Physiological:
No drugs
No clamping of umbilical cord until pulsing stops
Delivery placenta by maternal efforts
97
If a semen sample is found to be abnormal after how long should you repeat it?
3 months
98
What is the mode of action of each contraception?
Inhibits ovulation - COCP, Desogestrel, injectable & implant
Thickens cervical mucus - POP
Decreases sperm motility and survival - intrauterine device
Intrauterine system - Prevents endometrial proliferation
99
What are some of the most common causes of increased nuchal translucency?
Down's syndrome
congenital heart defects
abdominal wall defects
100
What are the 3 different types of placenta accreta?
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade the myometrium
percreta: chorionic villi invade through the perimetrium
101
What are some of the signs that may indicate shoulder dystocia?
Difficulty in delivery of the fetal head or chin.
Failure of restitution
‘Turtle Neck‘ sign
102
How do you manage shoulder dystocia?
1st line: MrcRoberts & Suprapubic pressure
2nd line (internal following episiotomy): posterior arm & internal rotation
Further options: cleidotomy, symphysiotomy or Zavenelli
103
How do you treat gonorrhoea?
IM ceftriaxone
104
What method can be used to induce labour?
1. Membrane sweep
2. Vaginal prostaglandin E2
3. Maternal oxytocin infusion
4. Amniotomy
5. Cervical ripening balloon
105
What does the Bishop score mean?
score of < 5 indicates that labour is unlikely to start without induction
score of ≥ 8 indicates high chance of spontaneous labour
106
In what time interval does a secondary PPH occur?
Secondary PPH occurs between 24 hours - 6 weeks
107
What causes a secondary PPH?
typically due to retained placental tissue or endometritis
108
What is the definition of a PPH?
>500ml in a vaginal delivery
>1000 in a caesarian
109
What is a severe PPH?
Blood loss ≥1500 mL
110
What are the absolute contraindications to the COCP?
1. > 35 yrs old & > 15 cigarettes a day
2. migraine with aura
3. History of VTE, stroke, current breast cancer or CHD
4. Breastfeeding < 6 month PP
5. Uncontrolled HPTN
6. + antiphospholipid antibodies
7. major surgery with prolonged immobilisation
111
How should simple endometrial hyperplasia be managed?
high dose progestogens with repeat sampling in 3-4 months.
The levonorgestrel intra-uterine system may be used
112
How should atypical endometrial hyperplasia be managed?
Hysterectomy advised
113
What are the risk factors for endometrial cancer?
Anovulation (oestrogen exposure) - low parity, early menarche, late menopause, PCOS, Tamoxifen, obesity
114
How do you diagnose endometrial cancer?
Transvaginal USS ≥4mm = endometrial biopsy with histology
115
What staging is used in endometrial cancer and what are the stages?
FIGO
I - Confined to the uterus
II - Extends to the cervix
III - Beyond uterus but confined to pelvis
IV - Involves bladder & bowel
116
How long must someone have pain for to be diagnosed with endometriosis?
Cyclical pain for at least 6 months
117
How should endometriosis be managed?
1. NSAIDS
2. COCP or IUD
3. GnRH antagnosit
118
How might chlamydia present?
Deep dyspareunia, yellow orderless vaginal discharge, PV bleeding, dysuria
119
How is each stage of endometrial cancer treated?
I - total hysterectomy
II - radical hysterectomy & removal pelvic lymph nodes
III & IV - de-bulking surgery
120
What are the primary and secondary features of syphilis?
primary - chancre and local lymphadenopathy
secondary - fevers, rash on trunk, palms & soles, condylomata lata (painless, warty lesions on the genitalia )
121
What are the Rotterdam criteria for PCOS?
2/3 of:
1. polycystic ovaries (either ≥12 follicles or increased ovarian volume [> 10 cm3]
2. Oligo-ovulation or anovulation
2. Clinical and/or biochemical signs of
hyperandrogenism - ↑ testosterone, ↑ LH, ↓ progesterone
122
What does ovarian torsion appear as on USS?
Whirlpool sign
123
What medication can be to suppress breast milk production?
Cabergoline
124
Which helps prevent MS relapses?
Monoclonal antibodies such as natalizumab
125
Which test is used to ensure enough anti-D immunoglobulin has been given to the mother?
Kleinhauer Test
126
What is a deceleration and what does it mean?
drop in fetal heart rate of 15bpm or more for over 15 seconds - generally abnormal
127
How should antiphospholipid syndrome be managed during pregnancy?
Aspirin + LMWH
128
What antibiotics CANNOT be prescribed in pregnancy?
Trimethoprim and tetracycline
