Obs & gynae Flashcards

Question

What are the two types or urinary incontinence?

Answer 1

--> urge incontinence --> Stress incontinence identifying which one determines the management

Answer 2

overactivtiy of the detrusor muscle of the bladder --> also known as overactive bladder

Answer 3

--> Suddenly feeling the urge to pass urine --> rushing to the bathroom and not arriving before urination occurs --> women always concious about going places with access to a toilet, impact on quality of life

Answer 4

--> Weakness of the pelvic floor muscles and the sphincter muscles ( the contents of the pelvis are held by a sling of muscles) --> allows urine to leak at times of increased bladder pressure --> such as laughing, coughing or when suprised

Answer 5

--> occurs when there is chronic urinary retention due to obstruction to the outflow of urine --> leads to overflow of urine without the urge to pass urine

Answer 6

anticholinergic medication --> fibroids --> pelvic tumours --> neurological conditions (MS, DN, spinal cord injuries) --> more common in males

Answer 7

--> Increased age --> Postmenopausal status --> Increase BMI --> Previous pregnancies and -----> vaginal deliveries --> Pelvic organ prolapse --> Pelvic floor surgery --> Neurological conditions, such as multiple sclerosis --> Cognitive impairment and dementia

Answer 8

--> Caffeine consumption --> Alcohol consumption --> medications --> BMI

Answer 9

Frequency of urination Frequency of incontinence Nightime urination Use of pads and change of clothing

Answer 10

--> assess pelvic tone --> examine for pelvic organ prolapse --> atrophic vagintiis --> urethral diverticulum --> pelvic mass --> strength of pelvic muscle contractions - bimanual examination - squeeze against fingers - modified oxford grading system --> ask patient to cough and watch for leackage

Answer 11

--> bladder diary should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. --> Urine dipstick testing should be performed to assess for infection, microscopic haematuria and other pathology. --> Post-void residual bladder volume should be measured using a bladder scan to assess for incomplete emptying. --> Urodynamic testing can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

Answer 12

--> need to stop taking anticholinergic medication and bladder medication around five days before --> thin catheter placed in the bladder and other in the rectum --> measures the pressures and compares --> cystometry - measures the detrusor muscle contraction and pressure --> uroflowmetry - measures the flow rate --> post-void residual volume

Answer 13

--> Avoiding caffeine, diuretics and overfilling of the bladder --> Avoid excessive or restricted fluid intake --> Weight loss (if appropriate) --> Supervised pelvic floor exercises for at least three months before considering surgery --> Surgery (Tension free vaginal tape and autologus sling procedures, last line - artifical urinary sphincter - pump in labia that inflates cuff around urethra --> Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Answer 14

--> Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line --> Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin ( have anticholinergic effects which include dry mouth, dry eyes, urinary retention, constipation and worsening of dementia) --> Mirabegron is an alternative to anticholinergic medications - contraindicated in uncontrolled hypertension Invasive procedures where medical treatment fails --> Botulinum toxin type A injection into the bladder wall --> Percutaneous sacral nerve stimulation involves implanting a device in the back that stimulates the sacral nerves --> Augmentation cystoplasty involves using bowel tissue to enlarge the bladder --> Urinary diversion involves redirecting urinary flow to a urostomy on the abdomen

Answer 15

paramesonephric ducts (Mullerian ducts)

Answer 16

produce anti-mullerian hormone

Answer 17

Congenital malformation of the uterus where there is two horns in the uterus giving the uterus a heart shape Can be picked up on pelvic ultrasound scan

Answer 18

--> miscarriage --> premature birth --> malpresentation

Answer 19

--> congenital abnormality where the hymen at the entrance of the vagina is fully formed without an opening

Answer 20

--> MAy be discovered when girls start to menstruate --> menses is sealed in the vagina --> cyclical pelvic pain and cramping --> without vaginal bleeding

Answer 21

Surgical excision to create an opening

Answer 22

--> retrograde menstruation (mesntrual blood backflowing into the fallopian tubes and the ovaries --> endometriosis

Answer 23

--> error in development where a septum (wall) forms transversely across the vagina --> can either be perforate or imperforate

Answer 24

--> when perforate, girls can still menstruate, but can have difficult intercourse or tampon use --> When imperforate presents as cyclical pelvic pain and cramps without menstruation

Answer 25

--> infertility --> pregnancy-related complications

Answer 26

--> diagnosis by examination, ultrasound or MRI --> Surgical correction - complications - vaginal stenosis or recurrence

Answer 27

Abnormally small vagina

Answer 28

--> absent vagina --> these occur due to failure of the mullerian ducts to develop properly and may be associated with an absent uterus and cervix

Answer 29

--> using a vaginal dilator over a prolonged period to create an adequate vaginal size, alternativley vaginal surgery

Answer 30

Cells are unable to respond to androgen hormones, due to a lack of androgen receptors X-linked recessive condition - caused by a mutation in the androgen receptor gene on the X chromosome

Answer 31

Lack of androgen receptors through mutations in the androgen receptor gene on the X chromosome Leads to extra androgens converted into oestrogen, resulting in female secondary sexual characterisitics - previously known as testicular feminisation syndrome

Answer 32

--> Patients are genetically male, with XY sex chromosomes --> absent response to testosterone and the conversion of extra testosterone leads to the conversion of extra into oestrogen --> results in femle phenotype externally --> male sexual characteristics do not develop and patients have normal female external genitalia and breast tissue --> tests in the abdomen or inguinal canal --> absence of female reproductive system as the testes prodcue anti-mullerian hormone - only lower vagina --> insensitivity to androgens leads to lack of pubic hari and, facial hari and male muscle development , slightly taller than average female and infertile with an increased risk of testicular cancer due to testes in abdo

Answer 33

--> micropenis --> clitomegaly --> bifid scrotum --> hypospadius --> diminished male characterisitics

Answer 34

--> often presents in infanct with inguinal hernias containing testes --> can present in puberty with primary amenorrhoea --> Hormone tests - Raised LH/ normal or raised FSH/ normal or raised testosterone levels (for a male)/ raised oestrogen levels (for a male)

Answer 35

--> MDT approach - paediatrics/ gynae/ urology/ endocrinolgist/ clinical psychologist --> bilateral orchidectomy- to avoid testicular tumours --> oestrogen therapy --> vaginal dilators or vaginal surgery to create an adequate vaginal length

Answer 36

GnRH, LH, FSH, oestrogen and progesterone

Answer 37

they increase leading to female secondary sexual characteristics, the onset of the menstrual cycle and the ability to conceive children

Answer 38

-->8-14 in girls --> 9-15 in boys --> takes around 4 years from start to finish --> girls have pubertal growth spurt earlier in puberty than boys

Answer 39

Aromatase is an enzyme found in adipose tissue, important in the creation of oestrogen

Answer 40

--> low birth weight --> chronic disease --> eating disorders --> athletes

Answer 41

--> development of breast buds --> followed by pubic hair --> onset of menstrual periods --> first episode of menstruation is called menarche --> menstrual cycles begin around two years from the start of puberty

Answer 42

Tanner staging uses - age, pubic hair and breast development

Answer 43

--> GH increases initially - causes a growth spurt during the initial phases of puberty --> hypothalamus starts to secrete GnRH, first during sleep and then throughout the day in later stages --> GnRH causes the releases of FSH and LH from the pituitary gland --> FSH and LH cause the ovaries to make oestrogen and progesterone. --> FSH levels plateau about a year before menarche --> LH levels continue to rise and spike just before they induce menarche

Answer 44

--> Retrospective diagnosis, made after a women has no periods for 12 months --> defined as a permanent end to to mesntruation

Answer 45

51 years- can vary significantly

Answer 46

Describes the period of 12 months after the final menstrual period onwards

Answer 47

refers to the time around menopause when the women is experiencing vasomotor symptoms and irregular periods. --> includes the time leading up to the last menstrual period, and the 12 months afterwards, typically in women older than 45

Answer 48

menopause before the age of 40 years --> Result of premature ovarian insufficiency

Answer 49

lack of ovarian follicular function, resulting in changes in the sex hormones associated with the menstrual cycle

Answer 50

--> oestrogen and progesterone are low --> LH and FSH are high, in response to an absence of negative feedback from the oestrogen

Answer 51

Usually: --> In ovaries, primordial follicles mature into primary and secondary follicles --> At the start of the menstrual cycle FSH stimulates the further development of the secondary follicles --> As the follicles grow the granulosa cells that surround them secrete increasing amounts of oestrogen In menopause: --> menopause begins when there is a decline in the development of the ovarian follicles --> without the growth of the follicles there is reduced production of oestrogen --> As the levels of oestrogen fall in the perimenopausal period there is an absence of negative feedback on the pituitary gland and increasing levels of LH and FSH --> failing follicular development means that ovulation dosent occur, leading to irregular periods --> without oestrogen the endometrium dosent develop and this leads to amenorrhoea and low levels of oestrogen cause the perimenopausal symptoms

Answer 52

--> Hot flushes --> Emotional lability or low mood --> Premenstrual syndrome --> Irregular periods --> Joint pains --> Heavier or lighter periods --> Vaginal dryness and atrophy --> Reduced libido

Answer 53

--> Cardiovascular disease and stroke --> Osteoporosis --> Pelvic organ prolapse --> Urinary incontinence

Answer 54

A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations. NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in: Women under 40 years with suspected premature menopause Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 55

increased risks and complications

Answer 56

Two years after the last menstrual period in women under 50 One year after the last menstrual period in women over 50

Answer 57

--> Barrier methods --> Mirena or copper coil --> Progesterone-only pill --> Progesterone implant --> Progesterone depot injection (under 45 years) --> Sterilisation

Answer 58

Aged over 40 and up to 50 years --> as the benefits usually outweigh the risks --> Consider combined oral contraceptive pill in women over 40 years containing norethisterone or levonorgestrel in women over 40 due to low risk of venous thromboembolism

Answer 59

--> Weight gain and osteoporosis --> Reduced bone mineral density means it is unsuitable for women over 45

Answer 60

--> Vasomotor symptoms are likely to resolve after 2-5 years without any treatment, management depends on the severity --> HRT --> Tibolone - a synthetic steroid hormone that acts as continuous combined HRT --> clonidine - agonist of alpha-adrenergic and imidazoline receptors --> CBT --> SSRI - fluoxetine or citalopram --> Testosterone - treats decreased libido --> vaginal oestrogen - helps with vaginal dryness and atrophy --> vaginal moisturisers

Answer 61

Endometrial tissue inside the myometrium (muscle layer of the uterus) --> condition is hormone dependent and usually gets better after menopause, similar to endometriosis and fibroids

Answer 62

Those who have had several pregnancies - 10% of women overall - >40 years old

Answer 63

--> Painful periods (dysmenorrhoea) --> heavy periods --> Pain during intercourse --> may present with infertility or pregnancy-related complications --> around a third of patients are asymptomatic --> examination can reveal an enlarged and tender uterus, feels more soft than an uterus with fibroids

Answer 64

--> transvaginal US - first line --> MRI and transabdominal ultrasound are second line --> Gold standard - perform a histological examination of the uterus after a hysterectomy

Answer 65

--> same treatment as for heavy menstrual bleeding --> if no contraception is wanted - Tranexamic acid when there is no associated pain ( antifibrinolytic - reduces bleeding) / mefenamic acid when there is associated pain (NSAID - reduced bleeding and pain) --> If contraception wanted - mirena coil (first-line)/ COCP/ cyclic oral progestogens --> Progesterone only meds such as the pill or depot may be useful --> others - GnRH analogues to induce a menopause-like state/ endometrial ablation/ uterine artery embolisation/ hysterctomy

Answer 66

Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage

Answer 67

--> Adhesions form within the uterus following uterus damage

Answer 68

--> after a pregnancy - related dilatation and curettage procedure ( scraping retained products of conception, can also happen after uterine surgery (myomectomy) or several pelvic infections (endometritis)

Answer 69

Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. The scar tissue also does not respond to oestrogen stimulus. These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages. Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.

Answer 70

--> Secondary amenorrhoea (absent periods) --> significantly lighter periods --> dysmenorrhoea - painful periods --> infertility

Answer 71

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed MRI scan

Answer 72

--> Dissecting adhesions during the hysteroscopy --> Reoccurence of the adhesions after treatment is common

Answer 73

--> Chronic inflammatory skin condition that presents with patches of white shiny porcelain-white skin --> commonly affects the labia, perineum, and perianal skin in the skin --> can also affect axilla and thighs --> thought to be an autoimmune condition associated with type 1 diabetes, alopecia, hypothyroid and vitiligo

Answer 74

--> Clinical diagnosis --> when doubt - vulval biopsy can confirm the diagnosis

Answer 75

flat eruption that spreads

Answer 76

chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin

Answer 77

autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

Answer 78

The typical presentation in your exams is a woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. The condition may be asymptomatic, or present with several symptoms: --> Itching --> Soreness and pain possibly worse at night --> Skin tightness --> Painful sex (superficial dyspareunia) --> Erosions --> Fissures The Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin. This occurs with lichen sclerosus. It can be made worse by tight underwear that rubs the skin, urinary incontinence and scratching.

Answer 79

Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears: “Porcelain-white” in colour Shiny Tight Thin Slightly raised There may be papules or plaques

Answer 80

--> potent topical steroids - clobetasol propionate 0.05% (dermovate) - control symptoms and reduce risk of malignancy --> regular emollient use

Answer 81

The critical complication to remember is a 5% risk of developing squamous cell carcinoma of the vulva. Other complications include: Pain and discomfort Sexual dysfunction Bleeding Narrowing of the vaginal or urethral openings

Answer 82

--> dryness and atrophy of the vaginal mucosa related to a lack of oestrogen --> genitourinary symptom of menopause

Answer 83

--> Epithelial lining of the vagina and urinary tracct responds to oestrogen by becoming thicker, more elastic and producing more secretions --> menopause, oestrogen levels fall and mucosa becomes thinner, less elastic and more dry, tissues prone to inflammation --> changes the vaginal pH and microbial flora that can contribute to localised infections --> oestrogen helps maitain healthy connective tissue around the pelvic organs and a lack of oestrogen can contribute to POP and stress incontinence

Answer 84

--> presents in postmenopausal women with symptoms of --> itching --> dryness --> dyspareunia - painful sex --> bleeding due to localised inflammation --> recurrent urinary tract infections, stress incontinece or POP

Answer 85

Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair

Answer 86

--> 90% squamous cell carcinomas --> less commonly they can be malignant melanomas

Answer 87

--> advanced age --> immunosuppression --> HPV - humanpapilloma virus infection --> lichen sclerosus - 5% of women with lichen sclerosus get vulval cancer

Answer 88

--> Premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer

Answer 89

--> Type of vulval intraepithelial neoplasia --> associated with HPV infections that typically occur in younger women aged 35-50 years

Answer 90

--> alternate type of VIN and associated with lichen sclerosis and typically occurs in older women 50-60

Answer 91

--> Watch and wait with close followup --> Wide local excision (surgery) to remove the lesion --> Imiquimod cream --> Laser ablation

Answer 92

--> may be an incidental finding in older women, for example, during catheterisation in a patient with dementia. --> Vulval lump --> Ulceration --> Bleeding --> Pain --> Itching --> Lymphadenopathy in the groin Vulval cancer most frequently affects the labia majora, giving an appearance of: --> Irregular mass --> Fungating lesion --> Ulceration --> Bleeding

Answer 93

--> 2ww referral --> Biopsy of the lesion and sentinel node biopsy - lymph node spread --> Further staging imaging such as CT of the abdomen and pelvis

Answer 94

International Federation of Gynecology and Obstetrics - FIGO system

Answer 95

--> wide local excision to remove the cancer --> groin lymph node dissection --> chemotherapy --> radiotherapy

Answer 96

--> younger women --> peaking in reproductive years

Answer 97

--> 80% are squamous cell carcinoma --> Adenocarcinoma next most common --> Small cell cancer rare

Answer 98

HPV - human papillomavirus

Answer 99

anal, vulval, vaginal, penis, mouth and throat cancers --> sexually transmitted infection

Answer 100

HPV inhibits the tumour suppressor genes

Answer 101

Increased risk of catching HPV --> early sexual activity --> Increased number of sexual partners --> Sexual partners who have had more partners --> Not using condoms Non-engagement with cervical screening --> Most cases are preventable with early detection and treatment Other risk factors --> smoking --> HIV --> combined oral contraceptive --> Increased number of full-term pregnancies --> family history --> Exposure to diethylstilbesterol during fetal development

Answer 102

--> may be detected during cervical smears in asymptomatic women --> abnormal vaginal bleeding - intermenstrual/postcoital/post-menopausal bleeding --> vaginal discharge --> pelvic pain --> dyspareunia - pain or discomfort with sex --> ulceration/inflammation.bleeding or visible tumour in the cervix

Answer 103

grading system for the level if dysplasia (premalignant change) in the cells of the cervix

Answer 104

through colposcopy

Answer 105

--> CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment --> CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated --> CIN III: severe dysplasia, very likely to progress to cancer if untreated CIN III is sometimes called cervical carcinoma in situ.

Answer 106

--> smear test --> aims to pick up precancerous changes (dyskaryosis) --> liquid-based cytology- brush into a preservation fluid --> initially tested for high-risk HPV before the cells are examined, if the sameple is negative the cells arn't examined and the women returned to the routine screening programme

Answer 107

Every three years aged 25 – 49 Every five years aged 50 – 64

Answer 108

Women with HIV are screened annually Women over 65 may request a smear if they have not had one since aged 50 Women with previous CIN may require additional tests (e.g. test of cure after treatment) Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant) Pregnant women due a routine smear should wait until 12 weeks post-partum

Answer 109

Inadequate Normal Borderline changes Low-grade dyskaryosis High-grade dyskaryosis (moderate) High-grade dyskaryosis (severe) Possible invasive squamous cell carcinoma Possible glandular neoplasia

Answer 110

--> Inadequate sample – repeat the smear after at least three months --> HPV negative – continue routine screening --> HPV positive with normal cytology – repeat the HPV test after 12 months --> HPV positive with abnormal cytology – refer for colposcopy

Answer 111

Involves inserting a speculum and a colposcope to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas. A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.

Answer 112

also known as loop biopsy --> loop of wire with diathermy to removal abnormal tissue of the cervix --> may result in pre-term labour

Answer 113

--> Treatment for cervical intraepithelial neoplasia and very early-stage cervical cancer --> General anesthetic - surgeon removes a cone-shaped piece of the uterus - sent to histology --> increased risk of misscarriage, premature labour, pain, bleeding, infection, and scar formation with stenosis of the cervix

Answer 114

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer: Stage 1: Confined to the cervix Stage 2: Invades the uterus or upper 2/3 of the vagina Stage 3: Invades the pelvic wall or lower 1/3 of the vagina Stage 4: Invades the bladder, rectum or beyond the pelvis

Answer 115

--> Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy --> Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy --> Stage 2B – 4A: Chemotherapy and radiotherapy --> Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy, and palliative care --> Pelvic exenteration - may be used in advanced cervical cancer - removal of most or all of the pelvic organs including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder, and rectum Bevacizumab - is a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer targets vascular endothelial growth factor a

Answer 116

--> before they become sexually active

Answer 117

Strains 6 and 11 cause genital warts Strains 16 and 18 cause cervical cancer

Answer 118

--> endometerial cancer

Answer 119

Endometrial cancer is cancer of the endometrium, the lining of the uterus. Around 80% of cases are adenocarcinoma. It is an oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells.

Answer 120

--> precancerous condition involving the thickening of the endometrium --> most cases of endometrial hyperplasia will return to normal overtime

Answer 121

--> hyperplasia without atypia --> atypical hyperplasia

Answer 122

progestogens --> intrauterine system - mirena coil --> continued oral progestogens - levonorgestrel

Answer 123

--> Patient's exposure to unopposed oestrogen, refers to oestrogen without progesterone Situations where there is an increased unopposed oestrogen --> increased age --> earlier onset of menstruation --> late menopause --> oestrogen-only HRT --> no or fewer pregnancies --> obesity --> polycystic ovarian syndrome --> tamoxifen --> diabetes

Answer 124

--> After ovulation, corpus luteum forms in the ovaries from the ruptured follicle that released the egg --> Corpus luteum produced progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (second half) --> PCOS - less likely to ovulate and form a corpus luteum, progesterone not produced --> endometrial lining has more exsposure to unopposed oestrogen

Answer 125

--> combined oral contraceptive pill --> an intrauterine system (mirena coil) --> cyclical progestogens

Answer 126

--> adipose tissue (fat) is a source of oestrogen. --> Adipose tissue is the primary source of oestrogen in postmenopausal women. --> Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen. --> Androgens are produced mainly by the adrenal glands. In women with more adipose tissue, and therefore more aromatase enzyme, more of these androgens are converted to oestrogen. --> This extra oestrogen is unopposed in women that are not ovulating (e.g. PCOS or postmenopause), because there is no corpus luteum to produce progesterone.

Answer 127

--> Combined contraceptive pill --> Mirena coil --> Increased pregnancies --> Cigarette smoking Smoking appears to be protective against endometrial cancer in postmenopausal women by being anti-oestrogenic. Interestingly, it is not protective against other oestrogen dependent cancers, such as breast cancer (where it increases the risk).

Answer 128

The number one presenting symptom of endometrial cancer to remember for your exams is postmenopausal bleeding. Endometrial cancer may also present with: Postcoital bleeding Intermenstrual bleeding Unusually heavy menstrual bleeding Abnormal vaginal discharge Haematuria Anaemia Raised platelet count

Answer 129

The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is: Postmenopausal bleeding (more than 12 months after the last menstrual period) NICE also recommends referral for a transvaginal ultrasound in women over 55 years with: Unexplained vaginal discharge Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Answer 130

Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause) Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer Hysteroscopy with endometrial biopsy

Answer 131

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer: Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 132

The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa). Other treatment options depending on the individual presentation include: A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina Radiotherapy Chemotherapy Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Answer 133

--> non- specific symptoms resulting in a worse prognosis --> more than 70% of women present with ovarian cancer once it has spread beyond the pelvis

Answer 134

Epithelial cell tumours (carcinoma) Dermoid cysts/ germ cell tumours Sex cord-stromal tumours metastasis

Answer 135

--> tumours arising from the epithelial cells of the ovary --> most common type --> subtypes include - serous tumours (most common)/ endometrioid carcinomas/ clear cell tumours/ mucinous tumours/ undifferentiated tumours

Answer 136

--> benign ovarian tumours - teratomas, they come from germ cells --> may contain various tissue types such as skin, hair, teetch, bone --> associated with ovarian torsion. --> germ cell tumours may cause a raised alpha-fetoprotein and hCG

Answer 137

--> rare tumours that can be benign or malignant - arise from stroma (connective tissue) or sex cords (embryonic structure associated with follicles) --> several types such as sertoli-leydig tumours and granulosa cell tumours

Answer 138

--> metastasis in the ovary usually from gastrointestinal tract cancer paritcularly the stomach

Answer 139

--> Age (peaks age 60) --> BRCA1 and BRCA2 genes (consider the family history) --> Increased number of ovulations --> Obesity --> Smoking --> Recurrent use of clomifene (infertility treatment which causes ovulation) Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include: -->Early-onset of periods --> Late menopause --> No pregnancies

Answer 140

Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk: Combined contraceptive pill Breastfeeding Pregnancy

Answer 141

Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include: --> Abdominal bloating --> Early satiety (feeling full after eating) --> Loss of appetite --> Pelvic pain --> Urinary symptoms (frequency / urgency) --> Weight loss --> Abdominal or pelvic mass --> Ascites An ovarian mass may press on the obturator nerve and cause referred hip or groin pain. The obturator nerve passes along the inside of the pelvic, lateral to the ovaries, where an ovarian mass can compress it.

Answer 142

Ascites Pelvic mass (unless clearly due to fibroids) Abdominal mass

Answer 143

CA-125 - cancer antigen 125

Answer 144

initial investigations in primary or secondary care are: --> CA125 blood test (>35 IU/mL is significant) --> Pelvic ultrasound The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: --> Menopausal status --> Ultrasound findings --> CA125 level Further investigations in secondary care include: --> CT scan to establish the diagnosis and stage the cancer --> Histology (tissue sample) using a CT guided biopsy, laparoscopy or laparotomy --> Paracentesis (ascitic tap) can be used to test the ascitic fluid for cancer cells Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour: --> Alpha-fetoprotein (α-FP) --> Human chorionic gonadotropin (HCG)

Answer 145

--> Endometriosis --> Fibroids --> Adenomyosis --> Pelvic infection --> Liver disease --> Pregnancy

Answer 146

The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is: Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Answer 147

Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.

Answer 148

--> where there is ectopic endometrial tissue outside the uterus

Answer 149

endometrioma

Answer 150

Chocolate cysts

Answer 151

--> genetic component --> retrograde menstruation - where ther endometrial lining flows back out into the pelvis and peritoneum --> embryonic cells destined to become endometrial tissue may remian outside the uterus --> may be spread of endometrial cells through the lympahtic system similar to cancer --> Cells outside the uterus someohow change - metaplasia

Answer 152

--> endometrial tissue respond to hormones same as in uterus --> during menstruation the endometrial tissue sheds and bleeds --> with endometriosis this bleeding causes irritation and inflammation of the tissues around the site of endometriosis --> results in cyclical, dull, heavy or burning pain during menstruation --> deposits of endometriosis in the bladder or the bowel can lead to blood in the urine or stool --> localised inflammation and bleeding can lead to adhesions, causes scar tissue - adhesions and binds the organs together --> adhesions lead to chronic - non-cyclical pain that can be sharp, stabbing or pulling and associted with nausea --> inferitlity due to adhesions blocking egg release and chcoloate cysts damaging eggs

Answer 153

--> Cyclical abdominal or pelvic pain --> Deep dyspareunia (pain on deep sexual intercourse) --> Dysmenorrhoea (painful periods) --> Infertility --> Cyclical bleeding from other sites, such as haematuria --> There can also be cyclical symptoms relating to other areas affected by the endometriosis: --> Urinary symptoms --> Bowel symptoms Examination may reveal: --> Endometrial tissue visible in the vagina on speculum examination, --> particularly in the posterior fornix --> A fixed cervix on bimanual examination --> Tenderness in the vagina, cervix and adnexa

Answer 154

Pelvic ultrasound may reveal large endometriomas and chocolate cysts. Ultrasound scans are often unremarkable in patients with endometriosis. Patients with suspected endometriosis need referral to a gynaecologist for laparoscopy. Laparoscopic surgery is the gold standard way to diagnose abdominal and pelvic endometriosis. A definitive diagnosis can be established with a biopsy of the lesions during laparoscopy. Laparoscopy has the added benefit of allowing the surgeon to remove deposits of endometriosis and potentially improve symptoms.

Answer 155

Initial management involves: -->Establishing a diagnosis --> Providing a clear explanation --> Listening to the patient, establishing their ideas, concerns and expectations and building a partnership --> Analgesia as required for pain (NSAIDs and paracetamol first line) Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy - Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil. The cyclical pain tends to improve after the menopause when the female sex hormones are reduced. Therefore, another treatment option for endometriosis is to induce a menopause-like state using GnRH agonists. Examples of GnRH agonists are goserelin (Zoladex) or leuprorelin (Prostap). They shut down the ovaries temporarily and can be useful in treating pain in many women. However, inducing the menopause has several side effects, such as hot flushes, night sweats and a risk of osteoporosis. Combined oral contractive pill, which can be used back to back without a pill-free period if helpful Progesterone only pill Medroxyprogesterone acetate injection (e.g. Depo-Provera) Nexplanon implant Mirena coil GnRH agonists Surgical management options: Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) Hysterectomy Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.

Answer 156

type of pituitary adenoma, a benign tumor of the pituitary gland

Answer 157

--> Size - microadenoma < 1cm and macroadenoma is > 1cm --> Hormonal status - secretory/ functioning adenoma produces an excess of a particular hormone and non-secretory adenoma does not produce a hormone to excess

Answer 158

--> prolactinomas are the most common --> produce prolactin

Answer 159

excess prolactin in women --> amenorrhoea --> infertility --> galactorrhoea --> osteoporosis excess prolactin in men --> impotence --> loss of libido --> galactorrhoea other symptoms may be seen with macroadenomas --> headache. --> visual disturbances (classically, a bitemporal hemianopia (lateral visual fields) or upper temporal quadrantanopia) symptoms and signs of hypopituitarism

Answer 160

--> symptomatic - dopamine agonists e.g cabergoline or bromocriptine which inhibits the release of prolactin from the pituitary gland --> surgery is performed for patients who cant tolerate or fail to respond to the medical therapy - trans-sphenoidal approach

Answer 161

benign tumors of the smooth muscle of the uterus - also called uterine leiomyomas --> very common --> more common in black women --> oestrogen sensitive

Answer 162

--> Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. --> Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. --> Submucosal means just below the lining of the uterus (the endometrium). --> Pedunculated means on a stalk.

Answer 163

Fibroids are often asymptomatic. They can present in several ways: --> Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom --> Prolonged menstruation, lasting more than 7 days --> Abdominal pain, worse during menstruation --> Bloating or feeling full in the abdomen --> Urinary or bowel symptoms due to pelvic pressure or fullness --> Deep dyspareunia (pain during intercourse) --> Reduced fertility --> Abdominal and bimanual examination may reveal a palpable pelvic mass or an enlarged firm non-tender uterus.

Answer 164

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. Pelvic ultrasound is the investigation of choice for larger fibroids. MRI scanning may be considered before surgical options, where more information is needed about the size, shape and blood supply of the fibroids.

Answer 165

For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding: --> Mirena coil (1st line) – fibroids must be less than 3cm with no distortion of the uterus --> Symptomatic management with NSAIDs and tranexamic acid --> Combined oral contraceptive --> Cyclical oral progestogens Surgical options for managing smaller fibroids with heavy menstrual bleeding are: --> Endometrial ablation --> Resection of submucosal fibroids during hysteroscopy --> Hysterectomy For fibroids more than 3 cm, women need referral to gynaecology for investigation and management. Medical management options are: --> Symptomatic management with NSAIDs and tranexamic acid --> Mirena coil – depending on the size and shape of the fibroids and uterus --> Combined oral contraceptive --> Cyclical oral progestogens Surgical options for larger fibroids are: --> Uterine artery embolisation - causes fibroid shrinkage --> Myomectomy - can improve fertility --> Hysterectomy --> GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery. They work by inducing a menopause-like state and reducing the amount of oestrogen maintaining the fibroid. Usually, GnRH agonists are only used short term, for example, to shrink a fibroid before myomectomy.

Answer 166

--> Heavy menstrual bleeding, often with iron deficiency anaemia --> Reduced fertility --> Pregnancy complications, such as miscarriages, premature labour and obstructive delivery --> Constipation --> Urinary outflow obstruction and urinary tract infections --> Red degeneration of the fibroid --> Torsion of the fibroid, usually affecting pedunculated fibroids --> Malignant change to a leiomyosarcoma is very rare (<1%)

Answer 167

--> ischemia, infarction and necrosis of the fibroid due to disrupted blood supply. --> more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy. --> Red degeneration may occur as the fibroid rapidly enlarges during pregnancy, outgrowing its blood supply and becoming ischaemic. It may also occur due to kinking in the blood vessels as the uterus changes shape and expands during pregnancy. --> Red degeneration presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia

Answer 168

--> infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum

Answer 169

--> ascending infection from the endocervix --> chlamydia trachomatis --> Neisseria gonorrhoea --> mycoplasma genitalium

Answer 170

--> lower abdominal pain --> fever --> deep dyspareunia --> Dysuria and menstrual irregularities may occur --> vaginal or cervical discharge --> cervical excitation

Answer 171

--> a pregnancy test should be done to exclude an ectopic pregnancy --> high vaginal swab -these are often negative --> screen for Chlamydia and Gonorrhoea

Answer 172

--> Have a low threshold for treatment due to the difficulty in an accurate diagnosis and the complications of untreated PID --> 1st line: Intramuscular ceftriaxone + oral doxycycline + oral metronidazole 2nd line: oral ofloxacin + oral metronidazole --> In mild cases of PID IUDs may be left in

Answer 173

--> Perihepatitis (Fitz-Hugh Curtis Syndrome) - occurs in around 10% of cases/ it is characterised by right upper quadrant pain and may be confused with cholecystitis --> Infertility - the risk may be as high as 10-20% after a single episode --> Chronic pelvic pain --> ectopic pregnancy

Answer 174

--> cysts related to fluctuating hormones of the menstrual cycle --> very common in premenopausal women (benign)

Answer 175

Malignancy

Answer 176

String of pearls

Answer 177

--> Most are asymptomatic --> vague pelvic pain --> vague bloating --> vague fullness in the abdomen --> a palpable pelvic mass (large cysts - mucinous cystadenomas)

Answer 178

--> ovarian torsion --> haemorrhage --> rupture of the cyst

Answer 179

--> follicular cysts - when the developing follicle fails to rupture and release the egg/ most common/ harmless and disappear after a few menstrual cycles/thin-walled and no internal structures. --> corpus luteum cysts - corpus luteum fails to break down and instead fills with fluid/ causes pelvic pain or delayed menstruation/ often in early pregnancy

Answer 180

--> Serous cystadenoma - benign tumour from epithelial cells --> Mucinous cystadenoma - benign tumour from epithelial - can be huge --> Endometrioma - lumps of endometrial tissue in the ovary - only in endometriosis - causes pain and disrupts ovulation --> Dermoid/germ cell tumours - benign tumours - teratomas (come from germ cells) can contain various tissues (hair, skin, teeth and bone) associated with ovarian torsion --> Sex cord-stromal tumours - rare - benign or malignant - from stroma (connective tissue) or sex cords (embryonic structures associated with follicles. - includes Sertoli-Leydig cell tumours and granulosa cell tumours

Answer 181

--> Age --> Postmenopause --> Increased number of ovulations --> Obesity --> Hormone replacement therapy --> Smoking --> Breastfeeding (protective) --> Family history and BRCA1 and BRCA2 genes

Answer 182

Later onset of periods (menarche) Early menopause Any pregnancies Use of the combined contraceptive pill

Answer 183

--> Premenopausal women with a simple ovarian cyst less than 5cm on ultrasound do not need further investigations. --> blood test - CA125 --> women under 40 with complex ovarian mass require tumour markers for possible germ cell tumour: Lactate dehydrogenase/ alpha-fetoprotein/ HCG --> Risk of malignancy index: menopausal status/ USS findings/ CA125 level

Answer 184

Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Answer 185

--> Possible ovarian cancer (complex cysts or raised CA125) requires a two-week wait referral to a gynaecological oncology specialist. --> Possible dermoid cysts require referral to a gynaecologist for further investigation and consideration of surgery. --> Simple ovarian cysts in premenopausal women can be managed based on their size: < 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. / 5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring/ More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound. Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months. Persistent or enlarging cysts may require surgical intervention (usually with laparoscopy). Surgery may involve removing the cyst (ovarian cystectomy), possibly along with the affected ovary (oophorectomy).

Answer 186

Torsion Hemorrhage into the cyst Rupture, with bleeding into the peritoneum

Answer 187

Meig’s syndrome involves a triad of: --> Ovarian fibroma (a type of benign ovarian tumor) --> Pleural effusion --> Ascites Meig’s syndrome typically occurs in older women. Removal of the tumour results in complete resolution of the effusion and ascites.

Answer 188

Ovarian torsion is a condition where the ovary twists in relation to the surrounding connective tissue, fallopian tube and blood supply (the adnexa).

Answer 189

--> Usually due to an ovarian mass larger than 5cm such as cyst or tumour ---> more likely with benign tumours and more likely to occur during pregnancy

Answer 190

Twisting of the adnexa and blood supply to the ovary leads to ischemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost. Therefore, ovarian torsion is an emergency, where a delay in treatment can have significant consequences. Prompt diagnosis and management is essential.

Answer 191

--> Sudden onset severe unilateral pelvic pain --> Nausea and vomiting --> localised tenderness --> palpable mass in the pelvis --> can be intermittent pain if the ovary and untwist spontaneously

Answer 192

Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible. It may show a “whirlpool sign”, free fluid in pelvis and oedema of the ovary. Doppler studies may show a lack of blood flow. The definitive diagnosis is made with laparoscopic surgery

Answer 193

--> may require laparoscopic surgery --> Untwist the ovary and fix in it place (detorsion) --> Remove the affected ovary (oophorectomy)

Answer 194

--> A delay in treating ovarian torsion can lead to loss of function. Other ovaries can compensate so fertility is not affected --> When necrotic ovary is removed it can become affected developing an abscess and this can lead to sepsis, it can also rupture resulting in peritonitis and adhesions

Answer 195

--> Common condition causing metabolic and reproductive problems in women --> Characteristic features of multiple ovarian cysts/ oligomenorrhoea/ hyperandrogenism and insulin resistance

Answer 196

Rotterdam criteria --> at least 2 out of 3 features --> Oligoovulation or anovulation - presenting with irregular or absent menstrual periods --> hyperandrogenism - hirsutisim and acne --> polycystic ovaries on ultrasound

Answer 197

--> Triad of - anovulation (oligomenorrhoea/amenorrhoea) / hyperandrogenism ( Hirsutism and acne)/ Polycystic ovaries on ultrasound --> infertility --> Hair loss in a male pattern --> insulin resistance and diabetes --> acanthosis nigricans (insulin resistance) --> endometrial hyperplasia and cancer --> cardiovascular disease --> hypercholesterolemia --> obstructive sleep apnoea --> depression and anxiety --> sexual problems

Answer 198

--> Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone, and anabolic steroids --> Ovarian or adrenal tumors that secrete androgens --> Cushing’s syndrome --> Congenital adrenal hyperplasia

Answer 199

Insulin resistance is a crucial part of PCOS. When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin promotes the release of androgens from the ovaries and adrenal glands. Therefore, higher levels of insulin result in higher levels of androgens (such as testosterone). Insulin also suppresses sex hormone-binding globulin (SHBG) production by the liver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promotes hyperandrogenism in women with PCOS. The high insulin levels contribute to halting the development of the follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan). Diet, exercise and weight loss help reduce insulin resistance.

Answer 200

BLOODS --> testosterone --> Sex hormone-binding globulin --> LH --> FSH --> Prolactin - might be slightly elevated --> TSH --> Raised LH --> Raised LH: FSH ratio --> Raised testosterone --> raised insulin --> normal or raised oestrogen levels --> TVU - the follicles may be arranged around the periphery of the ovary giving a string of pearls appearance - 12 or more developing follicles in one ovary or a ovarian volume >10cm3 --> Diabetes - 2hr OGTT --> Impaired fasting glucose – fasting glucose of 6.1 – 6.9 mmol/l (before the glucose drink) --> Impaired glucose tolerance – plasma glucose at 2 hours of 7.8 – 11.1 mmol/l --> Diabetes – plasma glucose at 2 hours above 11.1 mmol/l

Answer 201

reduce the risks associated with obesity, type 2 diabetes, hypercholesterolemia, and cardiovascular disease. These risks can be reduced by: Weight loss - significant management - can improve insulin resistance, reduce the risks of associated conditions and reduce hirsutism - orlistat for bmi >30 - lipase inhibitor stops fat absorption. Low glycaemic index, calorie-controlled diet Exercise Smoking cessation Antihypertensive medications where required Statins where indicated (QRISK >10%) Patients should be assessed and managed for the associated features and complications, such as: Endometrial hyperplasia and cancer Infertility Hirsutism Acne Obstructive sleep apnoea Depression and anxiety

Answer 202

Women with polycystic ovarian syndrome have several risk factors for endometrial cancer: Obesity Diabetes Insulin resistance Amenorrhoea

Answer 203

--> Normally corpus luteum secretes progesterone --> PCOS - anovulation - less progesterone - more unopposed oestrogen --> Continuous oestrogen leads to endometrial lining proliferation without regular shedding as there's no progesterone --> similar to unopposed oestrogen in women on HRT - leads to endometrial hyperplasia

Answer 204

--> pelvic ultrasound scan if extended gaps in periods or abnormal bleeding, cyclical progestogens are given to induce period before scan - if >10mm referred for biopsy --> Mirena coil for continuous endometrial protection --> Inducing a withdrawal bleed at least every 3 – 4 months with either: Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days)/ Combined oral contraceptive pill

Answer 205

--> Weight loss to help restore regular ovulation --> Clomifene --> laparoscopic ovarian drilling --> IVF --> if pregnant require OGTT at 24-28 weeks gestation

Answer 206

--> Weight loss --> Co-cyprinidiol is a COCP licensed for the treatment of hirsutism and acne - anti-androgenic effect. Increased risk of VTE so only 3 months of use allowed --> topical eflornithine --> electrolysis --> Laser hair removal --> Spironolactone (mineralocorticoid antagonist with anti-androgen effects) --> Finasteride (5α-reductase inhibitor that decreases testosterone production) --> Flutamide (non-steroidal anti-androgen) --> Cyproterone acetate (anti-androgen and progestin)

Answer 207

--> COCP first line --> Co-cyprinidiol - however increased risk for VTE despite anti-androgenic effect --> Topical adapalene (a retinoid) --> Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%) --> Topical azelaic acid 20% --> Oral tetracycline antibiotics (e.g. lymecycline)

Answer 208

--> type of tumour that grows like a pregnancy in the uterus --> known as molar pregnancy

Answer 209

--> Complete mole --> partial mole

Answer 210

--> Two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). --> These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. --> No fetal material will form.

Answer 211

--> two sperm cells fertilise a normal ovum (containing genetic material) at the same time. --> The new cell now has three sets of chromosomes (it is a haploid cell). --> The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form

Answer 212

--> behaves like a normal pregnancy. Periods will stop and the hormonal changes of pregnancy will occur. There are a few things that can indicate a molar pregnancy versus a normal pregnancy: --> More severe morning sickness --> Vaginal bleeding --> Increased enlargement of the uterus --> Abnormally high hCG --> Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4) --> Ultrasound of the pelvis shows a characteristic “snowstorm appearance” of the pregnancy. --> Provisional diagnosis can be made by ultrasound and confirmed with histology of the mole after evacuation.

Answer 213

Management involves evacuation of the uterus to remove the mole. The products of conception need to be sent for histological examination to confirm a molar pregnancy. Patients should be referred to the gestational trophoblastic disease centre for management and follow up. The hCG levels are monitored until they return to normal. Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.

Answer 214

--> low mood in first week or so after birth

Answer 215

--> Low mood seen in 1 in 10 women with a peak around 3 months after birth

Answer 216

seen in about 1 in 1000 women starting a few weeks after birth

Answer 217

Mood swings Low mood Anxiety Irritability Tearfulness

Answer 218

Significant hormonal changes Recovery from birth Fatigue and sleep deprivation The responsibility of caring for the neonate Establishing feeding All the other changes and events around this time

Answer 219

Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

Answer 220

Triad: --> Low mood --> Anhedonia (lack of pleasure in activities) --> Low energy --> typically seen 3 months after birth and should last at least 2 weeks after birth

Answer 221

--> Mild cases may be managed with additional support, self-help and follow-up with their GP --> Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy --> Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

Answer 222

Edinburgh Postnatal Depression Scale --> There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

Answer 223

--> Delusions --> Hallucinations --> Depression --> Mania --> Confusion --> Thought disorder --> 2-3 weeks after delivery - rare

Answer 224

--> Admission to the mother and baby unit --> Cognitive behavioural therapy --> Medications (antidepressants, antipsychotics or mood stabilisers) Electroconvulsive therapy (ECT)

Answer 225

--> Neonatal abstinence syndrome --> poor feeding and irritability --> supportive management

Answer 226

--> Pregnancy implanted outside the uterus

Answer 227

--> Fallopian tubes - most common --> fallopian tube (cornual region), ovary, cervix or abdomen

Answer 228

--> Previous ectopic pregnancy --> Previous pelvic inflammatory disease --> Previous surgery to the fallopian tubes --> Intrauterine devices (coils) --> Older age --> Smoking

Answer 229

--> around 6-8 weeks gestation --> missed period --> Constant lower abdominal pain in the right or left iliac fossa --> vaginal bleeding --. lower abdominal or pelvic tenderness --> Pain when moving the cervix during a bimanual examination --> Dizziness or syncope (hemorrhage) --> shoulder tip pain (peritonitis)

Answer 230

Transvaginal ultrasound scan

Answer 231

--> A gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tube --> empty uterus

Answer 232

A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. In this scenario, an ectopic pregnancy cannot be excluded, and careful follow-up needs to be in place until a diagnosis can be confirmed.

Answer 233

--> Tracking of hCG over time - repeated every 48 hours to measure change --> hCG doubles every 48 hours in normal pregnancy --> rise of more than 63% after 48 hours - indicated an intrauterine pregnancy and repeat ultrasound in 1-2 weeks. visible pregnancy intrauterine when the hCG is > 1500 --> Rise of < 63% after 48hrs- maybe ectopic - close review --> A fall of more than 50% - likely miscarriage - urine pregnancy test should be carried out in 2 weeks to confirm complete miscarriage

Answer 234

--> All ectopics need to be terminated --> Expectant - awaiting natural termination --> medical management - methotrexate --> surgical management - salpingectomy/salpingotomy

Answer 235

Follow-up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 1500 IU / l

Answer 236

Follow-up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 5000 IU / l confirmed absence of intrauterine pregnancy on USS

Answer 237

--.> highly teratogenic (harmful to pregnancy). It is given as an intramuscular injection into a buttock. This halts the progress of the pregnancy and results in spontaneous termination. Women treated with methotrexate are advised not to get pregnant for 3 months following treatment. This is because the harmful effects of methotrexate on pregnancy can last this long. Common side effects of methotrexate include: Vaginal bleeding Nausea and vomiting Abdominal pain Stomatitis (inflammation of the mouth)

Answer 238

Pain Adnexal mass > 35mm Visible heartbeat HCG levels > 5000 IU / l

Answer 239

Laparoscopic salpingectomy is the first-line treatment for ectopic pregnancy. This involves a general anaesthetic and key-hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube. Laparoscopic salpingotomy may be used in women at increased risk of infertility due to damage to the other tube. The aim is to avoid removing the affected fallopian tube. A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed. There is an increased risk of failure to remove the ectopic pregnancy with salpingotomy compared with salpingectomy. NICE state up to 1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy. Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy.

Answer 240

before 12 weeks gestation

Answer 241

between 12-24 weeks gestation

Answer 242

the fetus is no longer alive and no symptoms have occurred

Answer 243

Vaginal bleeding with closed cervix and foetus still alive

Answer 244

vaginal bleeding with open cervical os

Answer 245

retained products of conception remain in the uterus after miscarriage

Answer 246

No products of conception remain in the uterus

Answer 247

A gestational sac is present but contains no embryo

Answer 248

Transvaginal ultrasound --> Mean gestational sac diameter --> Fetal pole and crown-rump length - fetal pole expected when the mean gestational sac diameter is 25mm or more, if no fetal pole at 25mm gestational sac diameter it is repeated after a week to confirm anembryonic pregnancy --> Fetal heartbeat - expected when the crown-rump length is 7mm or more. if heartbeat the pregnancy is considered to be viable / when there is a crown-rump length of 7mm or more with no heartbeat the scan is repeated in a week's time to confirm a non-viable pregnancy

Answer 249

< 6 weeks gestation - presenting with bleeding - expectant providign no pain or other complications such as previous ectopic pregnancy - awaiting miscarriage without investigations or treatment - too small to see on USS. Repeat urine pregnanacy test performed after 7-10 days, if negative a miscarriage can be confirmed. if bleeding continues then further investigations > 6 weeks Expectant management (do nothing and await a spontaneous miscarriage) Medical management (misoprostol) Surgical management

Answer 250

Expectant management is offered first-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete. Persistent or worsening bleeding requires further assessment and repeat ultrasound, as this may indicate an incomplete miscarriage and require additional management.

Answer 251

Misoprostol is a prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. Medical management of miscarriage involves using a dose of misoprostol to expedite the process of miscarriage. This can be as a vaginal suppository or an oral dose. The key side effects of misoprostol are: Heavier bleeding Pain Vomiting Diarrhoea

Answer 252

misoprostol - prostaglandin can be given prior to surgery to soften the cervix Manual vacuum aspiration under local anesthetic as an outpatient Electric vacuum aspiration under general anaesthetic Anti-rhesus D prophylaxis is given to rhesus-negative women having surgical management of miscarriage.

Answer 253

Medical management (misoprostol) Surgical management (evacuation of retained products of conception) - curettage involved - key complication is endometritis - infection of endometrium

Answer 254

1967 abortion act

Answer 255

24 weeks - 1990 Human fertilisation and embryology act

Answer 256

--> greater risk to the physical and mental health of the women AND/OR existing children of the family

Answer 257

--> Continuing the pregnancy is likely to risk the life of the woman --> Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman --> There is a “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Answer 258

Two registered medical practitioners must sign to agree abortion is indicated It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

Answer 259

A medical abortion is most appropriate earlier in pregnancy but can be used at any gestation. It involves two treatments: Mifepristone (anti-progestogen) Misoprostol (prostaglandin analogue) 1 – 2 day later Rheusus negative women with gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis

Answer 260

Prior to surgical abortion, medications are used for cervical priming. This involves softening and dilating the cervix with misoprostol, mifepristone, or osmotic dilators. Osmotic dilators are devices inserted into the cervix, that gradually expand as they absorb fluid, opening the cervical canal. There are two options for surgical abortion: --> Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks) --> Cervical dilatation and evacuation using forceps (between 14 and 24 weeks) Rhesus-negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines say it should be considered in women less than 10 weeks gestation.

Answer 261

--> bleeding and abdominal cramps may continue for 2 weeks --> Urine pregnancy test is performed 3 weeks after the abortion

Answer 262

Bleeding Pain Infection Failure of the abortion (pregnancy continues) Damage to the cervix, uterus or other structures

Answer 263

Pregnancy of more than one fetus incidence has increased with the use of fertility treatments

Answer 264

Identical twins from a single zygote

Answer 265

non identical twins - from two different zygotes

Answer 266

single amniotic sac

Answer 267

two separate amniotic sacs

Answer 268

share a single placenta

Answer 269

two separate placentas

Answer 270

The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

Answer 271

Multiple pregnancy is usually diagnosed on the booking ultrasound scan. Ultrasound is also used to determine the: Gestational age Number of placentas (chorionicity) and amniotic sacs (amnionic) Risk of Down’s syndrome (as part of the combined test) When determining the type of twins using an ultrasound scan: Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign Monochorionic diamniotic twins have a membrane between the twins, with a T sign Monochorionic monoamniotic twins have no membrane separating the twins

Answer 272

--> Anaemia --> Polyhydramnios --> Hypertension --> Malpresentation --> Spontaneous preterm birth --> Instrumental delivery or caesarean --> Postpartum haemorrhage

Answer 273

--> Miscarriage --> Stillbirth --> Fetal growth restriction --> Prematurity --> Twin-twin transfusion syndrome --> Twin anaemia polycythemia sequence --> Congenital abnormalities

Answer 274

Twin-twin transfusion syndrome occurs when the fetuses share a placenta. It is called feto-fetal transfusion syndrome in pregnancies with more than two fetuses. When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. --> The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. --> The donor has growth restriction, anemia and oligohydramnios. There will be a discrepancy between the size of the fetuses. Women with twin-twin transfusion syndrome need to be referred to a tertiary specialist fetal medicine centre. In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.

Answer 275

Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Answer 276

The NICE guidelines (2019) on multiple pregnancy advise about additional management for multiple pregnancies. A specialist multiple pregnancy obstetric team manages women with a multiple pregnancy. Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at: Booking clinic 20 weeks gestation 28 weeks gestation Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome: 2 weekly scans from 16 weeks for monochorionic twins 4 weekly scans from 20 weeks for dichorionic twins Planned birth is offered between: 32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins Before 35 + 6 weeks for triplets Waiting beyond these dates is associated with an increased risk of fetal death. The timing of birth when there are complications is assessed on an individual basis. Corticosteroids are given before delivery to help mature the lungs.

Answer 277

between 32 and 33+6 weeks

Answer 278

between 37 and 37+6 weeks

Answer 279

--> Vaginal delivery is possible when the first baby has a cephalic presentation (head first) --> Caesarean section may be required for the second baby after the successful birth of the first baby --> Elective cesarean is advised when the presenting twin is not cephalic presentation

Answer 280

reduced insulin sensitivity during pregnancy and resolves after birth

Answer 281

--> large for dates fetus --> macrosomia --> Risk at birth for shoulder dystocia --> Longer-term women more likely to develop Type 2 diabetes after pregnancy

Answer 282

--> risk factors - OGTT at 24-28 weeks gestation --> previous gestational diabetes - have OGTT soon after the booking clinic

Answer 283

Previous gestational diabetes Previous macrosomic baby (≥ 4.5kg) BMI > 30 Ethnic origin (black Caribbean, Middle Eastern and South Asian) Family history of diabetes (first-degree relative)

Answer 284

--> large for date fetus --> polyhydramnios - increased amniotic fluid --> glucose on urine dipstick

Answer 285

An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours. Normal results are: Fasting: < 5.6 mmol/l At 2 hours: < 7.8 mmol/l Results higher than these values are used to diagnose gestational diabetes

Answer 286

They need four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation. The initial management suggested by the NICE guidelines (2015) is: --> Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin --> Fasting glucose above 7 mmol/l: start insulin ± metformin --> Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin. Women need to monitor their blood sugar levels several times a day. The NICE (2015) target levels are: Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l Avoiding levels of 4 mmol/l or below

Answer 287

5mg folic acid from preconception until 12 weeks of gestation

Answer 288

Metformin and insulin only all other diabetic medication stopped

Answer 289

--> retinopathy screening

Answer 290

37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6).

Answer 291

--> Neonatal hypoglycaemia --> Polycythaemia (raised haemoglobin) --> Jaundice (raised bilirubin) --> Congenital heart disease --> Cardiomyopathy --> macrosomia

Answer 292

new high blood pressure in pregnancy with end-organ dysfunction, notably with proteinuria

Answer 293

--> After 20 weeks gestation

Answer 294

When the spiral arteries of the placenta form abnormally leading to high vascular resistance in these vessels

Answer 295

--> maternal and fetal mortality --> maternal organ damage --> fetal growth restriction --> seizures - eclampsia --> early labour

Answer 296

--> triad of: Hypertension/ proteinuria/ oedema

Answer 297

Chronic hypertension is high blood pressure that exists before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.

Answer 298

--> Hypertension occurring after 20 weeks without proteinuria

Answer 299

When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels. Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually, they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation. When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

Answer 300

High-risk factors are: Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease Moderate-risk factors are: Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancies First pregnancy Family history of pre-eclampsia

Answer 301

Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (this is due to liver swelling) Oedema Reduced urine output Brisk reflexes

Answer 302

--> Systolic blood pressure above 140 mmHg/ Diastolic blood pressure above 90 mmHg PLUS any of: --> Proteinuria (1+ or more on urine dipstick) --> Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) --> Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies) Proteinuria can be quantified using: Urine protein:creatinine ratio (above 30mg/mmol is significant) Urine albumin:creatinine ratio (above 8mg/mmol is significant) The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia. Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.

Answer 303

All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with: Blood pressure Symptoms Urine dipstick for proteinuria Gestational hypertension (without proteinuria): Urine dipstick testing at least weekly Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile) Monitoring fetal growth by serial growth scans PlGF testing on one occasion Aim for a blood pressure below 135/85 mmHg Admit women with a blood pressure above 160/110 mmHg Preeclampsia is diagnosed, the general management is similar to gestational hypertension, except: Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S) Blood pressure is monitored at least every 48 hours Urine dipstick testing is not routinely necessary (the diagnosis is already made) Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

Answer 304

Prophylaxis: Aspirin (from 12wks) - for women with 1 high risk factor or 2+ moderate Medical management of pre-eclampsia is with: 1st line: Labetalol 2nd line Nifedipine (modified-release) - asthmatics! 3rd line: Methyldopa (needs to be stopped within two days of birth) Severe pre-eclampsia or eclampsia: IV hydralazine IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload Planned early birth may be necessary if the blood pressure cannot be controlled or complications occur. Corticosteroids should be given to women having a premature birth to help mature the fetal lungs.

Answer 305

Blood pressure is monitored closely after delivery. Blood pressure will return to normal over time once the placenta is removed. For medical treatment, NICE recommend after delivery switching to one or a combination of: Enalapril (first-line) Nifedipine or amlodipine (first-line in black African or Caribbean patients) Labetolol or atenolol (third-line)

Answer 306

Eclampsia refers to the seizures associated with pre-eclampsia.

Answer 307

IV magnesium sulphate

Answer 308

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics: Haemolysis Elevated Liver enzymes Low Platelets

Answer 309

--> Booking clinic --> 28 weeks gestation

Answer 310

Plasma volume increases

Answer 311

so that the women has reasonable reserves in cases of significant loss during delivery

Answer 312

often asymptomatic SOB Fatigue Dizziness Pallor

Answer 313

Booking appointment 28 weeks gestation postpartum

Answer 314

Low MCV may indicate iron deficiency Normal MCV may indicate physiological anaemia due to the increased plasma volume of pregnancy Raised MCV may indicate B12 or folate deficiency

Answer 315

haemoglobinopathy screening at the booking clinic for thalassaemia (all women) and sickle cell disease (women at higher risk). Both are causes of significant anaemia in pregnancy.

Answer 316

Iron Women with anaemia in pregnancy are started on iron replacement (e.g. ferrous sulphate 200mg three times daily). When women are not anaemic, but have a low ferritin (indicating low iron stores), they may be started on supplementary iron. B12 The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). Advice should be sought from a haematologist regarding further investigations and treatment of low B12 in pregnancy. Treatment options for low B12 are: Intramuscular hydroxocobalamin injections Oral cyanocobalamin tablets Folate All women should already be taking folic acid 400mcg per day. Women with folate deficiency are started on folic acid 5mg daily. Thalassaemia and Sickle Cell Anaemia Women with a haemoglobinopathy will be managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.

Answer 317

--> Stagnation of blood --> hyper-coagulable state are common in preg

Answer 318

-->Smoking --> Parity ≥ 3 --> Age > 35 years --> BMI > 30 --> Reduced mobility --> Multiple pregnancies --> Pre-eclampsia -->Gross varicose veins --> Immobility --> Family history of VTE --> Thrombophilia --> IVF pregnancy

Answer 319

--> 28 weeks if there are three risk factors --> First trimester if there are four or more of these risk factors

Answer 320

--> Hospital admission --> Surgical procedures --> Previous VTE --> Medical conditions such as cancer or arthritis --> High-risk thrombophilias --> Ovarian hyperstimulation syndrome

Answer 321

--> Low molecular weight heparin (enoxaparin/dalteparin/tinzaparin) --> started ASAP for very high-risk patients and at 28 weeks for high-risk --> continued throughout the antenatal period and for six weeks postnatally --> Prophylaxis temporarily stopped during labour and can be started immediately after delivery only if there is no PPH, spinal anesthesia and epidurals --> Mechanical prophylaxis may be considered in women with contraindications to LMWH. Intermittent pneumatic compression - inflates and deflates to massage legs and anti-embolic compression stockings

Answer 322

Calf or leg swelling - unilateral - more than 3cm difference between calves is sig Dilated superficial veins Tenderness to the calf (particularly over the deep veins) Oedema Colour changes to the leg

Answer 323

--> Shortness of breath --> Cough with or without blood (haemoptysis) --> Pleuritic chest pain --> Hypoxia --> Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy) --> Raised respiratory rate --> Low-grade fever --> Hemodynamic instability causing hypotension

Answer 324

--> LMWH started immediatley --> Doppler ultrasound - repeat on days 3 and 7 in patients with high suspicion --> CXR --> ECG --> Definitive diagnosis through CTPA ( slight increase in breast cancer) or VQ scan (childhood cancers)

Answer 325

D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.

Answer 326

Unfractionated heparin Thrombolysis Surgical embolectomy

Answer 327

Early onset infection - sepsis

Answer 328

--> Common bacteria found in the vagina and bowel flora --> Women act as carriers --> Infants may be exposed to GBS during labour

Answer 329

--> prematurity --> Prolonged rupture of the membranes --> Previous sibling GBS infection --> Maternal pyrexia e.g. secondary to chorioamnionitis

Answer 330

--> Women who've had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive --> if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date Offer IAP to women with: --> A previous baby with early- or late-onset GBS disease --> Preterm labour regardless of GBS status --> Pyrexia during labour (>38ºC) Benzylpenicillin is used for GBS prophylaxis

Answer 331

Overgrowth of anaerobic bacteria in the vagina

Answer 332

Loss of lactobacilli - friendly bacteria in the vagina

Answer 333

--> lactobacilli main component of healthy vaginal flora --> these bacteria produce lactic acid that keeps the vaginal pH low under 4.5 --> acidic environment prevents other bacteria from overgrowing --> More alkaline condtions enables anaerboic bacteria to multiply

Answer 334

--> Gardnerella vaginalis (most common) --> Mycoplasma hominis --> Prevotella species It is worth remembering that bacterial vaginosis can occur alongside other infections, including candidiasis, chlamydia and gonorrhoea.

Answer 335

--> Multiple sexual partners (although it is not sexually transmitted) --> Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) --> Recent antibiotics --> Smoking --> Copper coil Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

Answer 336

--> fishy-smelling pudda --> Watery grey or white vaginal discharge --> NOT associated with itching, irritation and pain

Answer 337

--> Swab and pH paper - normal vaginal pH is 3.5-4.5 and BV occurs with a pH over 4.5 --> vaginal swab - microscopy - can be high vaginal during speculum or self taken low vaginal - will show clue cells

Answer 338

--> metronidazole - targets anaerobic bacteria - oral or vaginal gel --> clindamycin alternative --> assess the risk of additional pelvic infections

Answer 339

Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Answer 340

--> increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV. DURING PREGNANCY --> Miscarriage --> Preterm delivery --> Premature rupture of membranes --> Chorioamnionitis --> Low birth weight --> Postpartum endometritis

Answer 341

Inflammation of the endometrium - usually by an infection

Answer 342

--> infection introduced during or after labour and delivery --> delivery opens the uterus to allow bacteria from the vagina to travel up and infect the endometrium

Answer 343

--> Caesarian section --> prophylactic abx given during caesarian section to reduce the risk

Answer 344

--> gram-negative, gram-positive and anaerobic bacteria. --> sexually transmitted infections such as chlamydia and gonorrhoea.

Answer 345

Pelvic inflammatory disease

Answer 346

--> Foul-smelling discharge or lochia --> Bleeding that gets heavier or does not improve with time --> Lower abdominal or pelvic pain --> Fever --> Sepsis

Answer 347

--> Vaginal swabs (including chlamydia and gonorrhea if there are risk factors) --> Urine culture and sensitivities --> USS may be used to rule out retained products of conception

Answer 348

Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics A combination of clindamycin and gentamicin is often recommended. Blood tests will show signs of infection (e.g. raised WBC and CRP). Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics. A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.

Answer 349

Infection of the bladder - cystitis

Answer 350

infection up to the kidneys, called pyelonephritis.

Answer 351

--> pre-term delivery --> other adverse pregnancy outcomes

Answer 352

LUTI and pyelonephritis - high risk of pre term birth

Answer 353

--> At booking and routinely throughout pregnancy MC&S Testing for bacteria in the urine of asymptomatic patients is not recommended as it may lead to unnecessary antibiotics. Pregnant women are an exception to this rule, due to the adverse outcomes associated with infection.

Answer 354

--> Dysuria (pain, stinging or burning when passing urine) --> Suprapubic pain or discomfort --> Increased frequency of urination --> Urgency --> Incontinence --> Haematuria

Answer 355

Fever (more prominent than in lower urinary tract infections) Loin, suprapubic or back pain (this may be bilateral or unilateral) Looking and feeling generally unwell Vomiting Loss of appetite Haematuria Renal angle tenderness on examination

Answer 356

Gram-negative rod shaped - E.Coli Klebsiella Pneumoniae

Answer 357

Urinary tract infection in pregnancy requires 7 days of antibiotics. The antibiotic options are: Nitrofurantoin (avoid in the third trimester) Amoxicillin (only after sensitivities are known) Cefalexin

Answer 358

Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).

Answer 359

First trimester Folate antagonist - can cause neural tube defects such as spina bifida - generally avoided

Answer 360

--> can lead to varicella pneumonitis, hepatitis or encephalitis --> fetal varicella syndrome --> severe neonatal varicella infection if mum is infected around delivery

Answer 361

--> Varicella IgG levels for VZV can be tested. --> Positive for IgG for VZV indicated immunity

Answer 362

Varicella vaccine before or after pregnancy

Answer 363

VZV IgG levels

Answer 364

--> IV varicella immunoglobulins as prophylaxis against developing chickenpox. --> This should be given within 10 days of exposure.

Answer 365

Oral aciclovir if they present within 24 hours and after 20 weeks gestation

Answer 366

When VZV infection during the first 28 weeks of gestation Occurs in 1% of pregnancies with VZV infection.

Answer 367

--> Fetal growth restriction --> Microcephaly, hydrocephalus and learning disability --> Scars and significant skin changes following the dermatomes --> Limb hypoplasia (underdeveloped limbs) --> Cataracts, inflammation in the eye (chorioretinitis) and micropthalmia

Answer 368

Reduced amniotic fluid - less than 500ml at 32-36 weeks gestation

Answer 369

--> premature rupture of membranes Potter sequence--> bilateral renal agenesis + pulmonary hypoplasia --> intrauterine growth restriction --> post-term gestation --> pre-eclampsia --> maternal medications - ACE inhibitors/NSAIDs

Answer 370

Excess amniotic fluid for gestational age --> can affect fetal development

Answer 371

Diabetes - chronic or gestational

Answer 372

Complication of labour when the muscle layer of the uterus myometrium ruptures

Answer 373

The uterine serosa (Perimetrium) surrounding the uterus remains intact

Answer 374

Serosa ruptures along with the myometrium and the contents of the uterus are released into the peritoneal cavity

Answer 375

--> Haemorrhage significant --> Baby may be released from the uterus into the peritoneal cavity --> high morbidity and mortality for the baby and the mother

Answer 376

The main risk factor for uterine rupture is a previous caesarean section. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time. The risk factors to consider are: Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 377

Uterine rupture presents with an acutely unwell mother and abnormal CTG. It may occur with induction or augmentation of labour, with signs and symptoms of: Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Answer 378

Uterine rupture is an obstetric emergency. Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Answer 379

Birth before 37 weeks gestation - the more premature a baby the worse the outcomes

Answer 380

below 23 weeks gestation - Generally from 23 to 24 weeks, resuscitation is not considered that do not show any signs of life.

Answer 381

Under 28 weeks

Answer 382

--> vaginal progesterone - gel or pessary - progesterone has a role in maintaining pregnancy and preventing labour by decreasing myometrium activity and preventing cervical remodeling - offered to women with cervical length less than 25mm on TVU and between 16 and 24 weeks gestation --> Cervical Cerclage - - stick in the cervix to add support and keep it closed - stitch removed when labour starts. offered for women with Cervical length less than 25mm between 16 and 24 weeks gestation who have had previous premature birth or cervical trauma such as colposcopy and cone biopsy Rescue cervical cerclage may be offered between 16 and 27 +6 weeks when there is cervical dilation without rupture of membranes

Answer 383

Speculum - pooling of amniotic fluid in the vagina When in doubt can perform insulin-like growth factor-binding protein 1 (IGFBP-1) and placental alpha-microglobin-1 (PAMG-1) - high concentrations in amniotic fluid

Answer 384

Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days. Induction of labour may be offered from 34 weeks to initiate the onset of labour.

Answer 385

regular painful contraction and cervical dilatation, without rupture of the amniotic sac.

Answer 386

--> Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour. --> More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely. Fetal fibronectin is an alternative test to vaginal ultrasound. Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.

Answer 387

--> Fetal monitoring (CTG or intermittent auscultation) --> Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour --> Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality --> IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain --> Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Answer 388

Stop uterine contractions

Answer 389

--> Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. --> Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.

Answer 390

Between 24 and 33+6 weeks gestation in pre-term labour to delay delivery and buy time for fetal development

Answer 391

Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation. --> IM dexamethasone two doses 24hrs apart

Answer 392

Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.

Answer 393

--> Reduced blood pressure --> Reduced respiratory rate --> Absent reflexes --> Calcium gluconate can be given if there is toxicity

Answer 394

The amniotic sac has ruptured spontaneously.

Answer 395

The amniotic sac has ruptured before the onset of labour.

Answer 396

The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

Answer 397

The amniotic sac ruptures more than 18 hours before delivery.

Answer 398

--> when the umbilical cord descends below the presenting part of the foetus and into the vagina through the cervix

Answer 399

--> Fetal hypoxia

Answer 400

when the fetus is in an abnormal lie after 37 weeks gestation - this provides space for the cord to prolapse below the presenting part --> in a cephalic lie the head descends into the pelvis without room for the umbilical cord

Answer 401

--> Should be suspected when there are signs of fetal distress on the CTG --> Can be diagnosed with vaginal examination --> Speculum examination can be used to confirm the diagnosis

Answer 402

--> Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby. Pushing the cord back in is not recommended. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm). --> When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord. Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.

Answer 403

--> vaginal delivery with assistance by either a ventouse suction cup or forceps to hlep with the delivery of the babies head

Answer 404

Co-amoxiclav

Answer 405

Failure to progress Fetal distress Maternal exhaustation Control of head in various fetal positions

Answer 406

Instrumental delivery

Answer 407

Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve)

Answer 408

Cephalohaematoma (collection of blood between the skull and periosteum) with ventouse Facial nerve palsy/ facial bruises with forceps

Answer 409

Subgleal haemorrhage - most dangerous Intracranial haemorrhage Skull fracture Spinal cord injury

Answer 410

The femoral nerve may be compressed against the inguinal canal during a forceps delivery. Injury to this nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg. The obturator nerve may be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.

Answer 411

Labour for the first time

Answer 412

Power (uterine contractions) Passenger (size, presentation and position of the baby) Passage (the shape and size of the pelvis and soft tissues)

Answer 413

Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Answer 414

Less than 2cm of cervical dilatation in 4 hours Slowing of progress in a multiparous women

Answer 415

--> 1st stage of labour --> Cervical dilation - measured every 4 hours vaginal examination --> descent of fetal head - in relation to ischial spines --> maternal BP, HR, temp and UO --> fetal heart rate --> frequency of contractions --> Status of membranes - presence of liquor - if stained with blood or meconium --> Drugs and fluid that may have been given Uterine contractions are measure in contractions per 10 minutes. When the midwife says “she is contracting 2 in 10”, it means she is having 2 uterine contractions in a 10 minute period. There are two lines on the partogram that indicate when labour may not be progressing adequately. These are labelled “alert” and “action”. The dilation of the cervix is plotted against the duration of labour (time). When it takes too long for the cervix to dilate, the readings will cross to the right of the alert and action lines. Crossing the alert line is an indication for amniotomy (artificially rupturing the membranes) and a repeat examination in 2 hours. Crossing the action line means care needs to be escalated to obstetric-led care and senior decision-makers for appropriate action.

Answer 416

from 10cm dilation to delivery of baby

Answer 417

Three p's --> Power - strength of uterine contractions - oxytocin infusion can be used to stimulate the uterus --> Passenger - size (shoulder dystonia) , attitude (posture, back rounded, limbs flexed), lie (longitudinal, transverse, oblique) , presentation (Cephalic, shoulder or breech) --> Passage - size and shape of passageway, mainly pelvis

Answer 418

2 hours for nulliparous women 1 hour for multiparous women

Answer 419

Changing positions Encouragement Analgesia Oxytocin Episiotomy Instrumental delivery Caesarean section

Answer 420

The third stage of labour is from delivery of the baby to delivery of the placenta

Answer 421

More than 30 minutes with active management (IM oxytocin and controlled cord traction) More than 60 minutes with physiological management

Answer 422

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes Oxytocin infusion - aim for 4-5 contraction every 10mins Instrumental delivery Caesarean section

Answer 423

Fetal compromise- no opportunity to recover between contractions

Answer 424

Placenta Implants deeper through the endometrium - into the myometrium and beyond - spectrum - due to defect in the endometrium - hard for the placenta to separate and can cause PPH

Answer 425

--> placenta implants in the surface of the myometrium, but not beyond

Answer 426

--> placenta implants deeply in the myometrium

Answer 427

--> placenta invades past the myometrium and perimetrium - potentially reaching other organs such as the bladder

Answer 428

Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Answer 429

Placenta accreta does not typically cause any symptoms during pregnancy. It can present with bleeding (antepartum haemorrhage) in the third trimester. It may be diagnosed on antenatal ultrasound scans, and particular attention is given to women with a previous placenta accreta or caesarean during scanning. It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage.

Answer 430

--> Ideally, placenta accreta is diagnosed antenatally by ultrasound. This allows planning for birth. MRI scans may be used to assess the depth and width of the invasion. A specialist MDT should manage women with placenta accreta. Patients may require additional management at birth due to the risk of bleeding and difficulty separating the placenta. This may include: Complex uterine surgery Blood transfusions Intensive care for the mother Neonatal intensive care Delivery is planned between 35 to 36 + 6 weeks gestation to reduce the risk of spontaneous labour and delivery. Antenatal steroids are given to mature the fetal lungs before delivery. The options during caesarean are: Hysterectomy with the placenta remaining in the uterus (recommended) Uterus preserving surgery, with resection of part of the myometrium along with the placenta Expectant management, leaving the placenta in place to be reabsorbed over time Expectant management comes with significant risks, particularly bleeding and infection. The RCOG guideline (2018) suggests that if placenta accreta is seen when opening the abdomen for an elective caesarean section, the abdomen can be closed and delivery delayed whilst specialist services are put in place. If placenta accreta is discovered after delivery of the baby, a hysterectomy is recommended.

Answer 431

placenta attached to the lower portion of the uterus, lower than the presenting part of the fetus

Answer 432

Placenta within 20mm of the internal cervical os

Answer 433

is used only when the placenta is over the internal cervical os

Answer 434

placenta praevia placental abruption vasa praevia

Answer 435

Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth

Answer 436

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 437

Asymptomatic painless antepartum haemorrhage bleeding later in pregnancy around or after 36 weeks

Answer 438

20 week anomaly scan used to assess the position of placenta and diagnosis

Answer 439

For women with a low-lying placenta or placenta praevia diagnosed early in pregnancy (e.g. at the 20-week anomaly scan), the RCOG guideline (2018) recommends a repeat transvaginal ultrasound scan at: 32 weeks gestation 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery) Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery. Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os). Depending on the position of the placenta and fetus, different incisions may be made in the skin and uterus, for example, vertical incisions. Ultrasound may be around the time of the procedure to locate the placenta. Emergency caesarean section may be required with premature labour or antenatal bleeding. The main complication of placenta praevia is haemorrhage before, during and after delivery. When this occurs, urgent management is required and may involve: Emergency caesarean section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy

Answer 440

Placental abruption refers to when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.

Answer 441

ABRUPTION: A = Abruption previously B = Blood pressure (i.e. hypertension or pre-eclampsia) R = Ruptured membranes, either premature or prolonged U = Uterine injury (trauma) P = Polyhydramnios T = Twins or multiple gestation I = Infection in the uterus, especially chorioamnionitis O = Older age (over 35 years old) N = Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 442

Sudden onset severe abdominal pain that is continuous Vaginal bleeding (antepartum haemorrhage) Shock (hypotension and tachycardia) Abnormalities on the CTG indicating fetal distress Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Answer 443

Spotting: spots of blood noticed on underwear Minor haemorrhage: less than 50ml blood loss Major haemorrhage: 50 – 1000ml blood loss Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

Answer 444

Concealed abruption is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage. Concealed abruption is opposed to revealed abruption, where the blood loss is observed via the vagina.

Answer 445

Fetus alive and < 36 weeks fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks fetal distress: immediate caesarean no fetal distress: deliver vaginally Fetus dead induce vaginal delivery

Answer 446

Vasa praevia is a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os. The fetal membranes surround the amniotic cavity and developing fetus. The fetal vessels consist of the two umbilical arteries and single umbilical vein. Vessels placed over the internal cervical os before the foetus

Answer 447

In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.

Answer 448

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 449

Low lying placenta IVF pregnancy Multiple pregnancy

Answer 450

Vasa praevia may be diagnosed by ultrasound during pregnancy. This is the ideal scenario, as it allows a planned caesarean section to reduce the risk of haemorrhage. However, ultrasound is not reliable, and it is often not possible to diagnose antenatally. It may present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy. It may be detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through the dilated cervix. Finally, it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section.

Answer 451

ASYMPTOMATIC --> corticosteroids - from 32 weeks gestation to mature fetal lungs --> Elective caesarean - 34-36 weeks gestation --> antepartum haemorrhage - emergency caesarean section

Answer 452

--> 500ml after a vaginal delivery --> 1000ml after a caesarean section

Answer 453

under 1000mls of blood loss

Answer 454

over 1000mls of blood loss

Answer 455

over 2000mls of blood loss

Answer 456

Bleeding within 24hrs of birth

Answer 457

from 24hrs to 12 weeks after birth

Answer 458

T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder)

Answer 459

--> Previous PPH --> Multiple pregnancy --> Obesity --> Large baby --> Failure to progress in the second stage of labour --> Prolonged third stage --> Pre-eclampsia --> Placenta accreta --> Retained placenta --> Instrumental delivery --> General anaesthesia --> Episiotomy or perineal tear

Answer 460

--> Treating anaemia during the antenatal period --> Giving birth with an empty bladder (a full bladder reduces uterine contraction) --> Active management of the third stage (with intramuscular oxytocin in the third stage) --> Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Answer 461

Resuscitation with an ABCDE approach Lie the woman flat, keep her warm and communicate with her and the partner Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 462

Mechanical Medical Surgical

Answer 463

--> Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) --> Catheterisation (bladder distention prevents uterus contractions)

Answer 464

--> Oxytocin (slow injection followed by continuous infusion) --> Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) --> Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) --> Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction --> Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

Answer 465

--> Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding --> B-Lynch suture – putting a suture around the uterus to compress it --> Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow --> Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Answer 466

--> retained products of conception --> infection - endometritis

Answer 467

Ultrasound - retained products of conception Endocervical and high vaginal swabs for infection

Answer 468

Surgical evaluation of retained products of conception Antibiotics for infection

Answer 469

below the 10th centile for their gestational age

Answer 470

--> Estimated fetal weight (EFW) --> Fetal abdominal circumference (AC) --> Customised growth charts used to assess the size of the foetus based on the mothers ehtnicity/ weight/height and parity

Answer 471

under the 3rd centile for gestational age

Answer 472

--> Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart --> Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)

Answer 473

small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta.

Answer 474

Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta: --> Idiopathic --> Pre-eclampsia --> Maternal smoking --> Maternal alcohol --> Anaemia --> Malnutrition --> Infection --> Maternal health conditions Non-placenta medicated growth restriction refers to pathology of the fetus, such as: --> Genetic abnormalities --> Structural abnormalities --> Fetal infection --> Errors of metabolism

Answer 475

--> Reduced amniotic fluid volume --> Abnormal Doppler studies --> Reduced fetal movements --> Abnormal CTGs

Answer 476

Short term complications of fetal growth restriction include: Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia Growth restricted babies have a long term increased risk of: Cardiovascular disease, particularly hypertension Type 2 diabetes Obesity Mood and behavioural problems

Answer 477

Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome

Answer 478

The critical management steps are: Identifying those at risk of SGA Aspirin is given to those at risk of pre-eclampsia Treating modifiable risk factors (e.g. stop smoking) Serial growth scans to monitor growth Early delivery where growth is static, or there are other concerns When a fetus is identified as SGA, investigations to identify the underlying cause include: Blood pressure and urine dipstick for pre-eclampsia Uterine artery doppler scanning Detailed fetal anatomy scan by fetal medicine Karyotyping for chromosomal abnormalities Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria) Early delivery is considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results). This reduces the risk of stillbirth. Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section.

Answer 479

Congenital deafness Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability

Answer 480

Low birth weight Purpuric skin lesions Sensorineural deafness Microcephaly Learning disability Seizures Visual impairement

Answer 481

--> Gardnerella vaginalis (most common) Mycoplasma hominis Prevotella species

Answer 482

--> Multiple sexual partners (although it is not sexually transmitted) --> Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) --> Recent antibiotics --> Smoking --> Copper coil --> Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

Answer 483

--> fishy smelling watery grey or white discharge

Answer 484

--> Vaginal pH testing using swab and pH paper - normal vaginal pH is 3.5-4.5 and BV occurs with a pH above 4.5 --> Charcoal vaginal swab can be a high vaginal swab/ self-taken low vaginal swab --> Clue cells on microscopy- gardnella vaginalis

Answer 485

metronidazole clindamycin is alternative

Answer 486

Alcohol - shock and angioedema

Answer 487

Bacterial vaginosis can increase the risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV. It is also associated with several complications in pregnant women: Miscarriage Preterm delivery Premature rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis

Answer 488

--> Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) --> Poorly controlled diabetes --> Immunosuppression (e.g. using corticosteroids) --> Broad-spectrum antibiotics

Answer 489

Thick, white discharge that does not typically smell Vulval and vaginal itching, irritation or discomfort

Answer 490

--> Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5). --> A charcoal swab with microscopy can confirm the diagnosis.

Answer 491

A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night A single dose of clotrimazole pessary (500mg) at night Three doses of clotrimazole pessaries (200mg) over three nights A single dose of fluconazole (150mg)

Answer 492

Type of parasite that spreads through sexual intercourse - protozoan lives in the urethra of men and women and vagina in women

Answer 493

Contracting HIV bacterial vaginosis cervical cancer PID pregnancy complications e.g preterm delivery

Answer 494

--> vaginal discharge (frothy and yellow/green can be fishy) --> itching --> dysuria --> dyspareunia --> balanitis --> strawberry cervix --> vaginal pH >4.5

Answer 495

--> The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope). --> Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative. --> A urethral swab or first-catch urine is used in men.

Answer 496

Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing. Treatment is with metronidazole.

Answer 497

Gram-negative bacteria

Answer 498

--> young --> sexually active --> multiple partners

Answer 499

National chlamydia screening programme --> screens sexually active person under 25 years annually --> when change of sexual partner --> postivie test - prompts re-test after 3 months after treatment

Answer 500

Chlamydia Gonorrhoea Syphilis (blood test) HIV (blood test)

Answer 501

The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with: --> Abnormal vaginal discharge --> Pelvic pain --> Abnormal vaginal bleeding (intermenstrual or postcoital) --> Painful sex (dyspareunia) --> Painful urination (dysuria) Consider chlamydia in men that are sexually active and present with: --> Urethral discharge or discomfort --> Painful urination (dysuria) --> Epididymo-orchitis --> Reactive arthritis It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits.

Answer 502

Pelvic or abdominal tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge

Answer 503

Nucleic acid amplification tests (NAAT) are used to diagnose chlamydia. This can involve a: Vulvovaginal swab Endocervical swab First-catch urine sample (in women or men) Urethral swab in men Rectal swab (after anal sex) Pharyngeal swab (after oral sex)

Answer 504

--> First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days. --> Azithromycin/Erythromycin/amoxicillin in pregnant or breastfeeding as doxycycline cant be taken in preg

Answer 505

Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis Pregnancy-related complications include: Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis

Answer 506

--> condition affecting the lymphoid tissue around the site of infection with chlamydia - common in men who have sex with men and three stages

Answer 507

The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex. The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected. The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.

Answer 508

--> Doxycycline 100mg twice daily for 21 days --> erythromycin and azithromycin are alternatives

Answer 509

--> Treponema pallidum --> Spirochete - spiral shaped bacteria

Answer 510

--> Oral, vaginal or anal sex involving direct contact with an infected area --> Vertical transmission from mother to baby during pregnancy --> Intravenous drug use --> Blood transfusions and other transplants (although this is rare due to screening of blood products)

Answer 511

Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals). Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage. Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards. Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications. Neurosyphilis occurs if the infection involves the central nervous system, presenting with neurological symptoms.

Answer 512

Primary syphilis can present with: A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy Secondary syphilis typically starts after the chancre has healed, with symptoms of: Maculopapular rash Condylomata lata (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions Tertiary syphilis can present with several symptoms depending on the affected organs. Key features to be aware of are: Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones) Aortic aneurysms Neurosyphilis Neurosyphilis can occur at any stage if the infection reaches the central nervous system, and present with symptoms of: Headache Altered behaviour Dementia Tabes dorsalis (demyelination affecting the spinal cord posterior columns) Ocular syphilis (affecting the eyes) Paralysis Sensory impairment

Answer 513

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis. Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing. Samples from sites of infection can be tested to confirm the presence of T. pallidum with: Dark field microscopy Polymerase chain reaction (PCR)

Answer 514

All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need: Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis.

Answer 515

HSV - HSV-2

Answer 516

virus becomes latent in the associated sensory nerve ganglia. Typically this is the trigeminal nerve ganglion with cold sores and the sacral nerve ganglia with genital herpes.

Answer 517

Cold sores- often contracted initially in childhood and remain dormant in the trigememinal nerve ganglion and reactivate as cold sores.

Answer 518

genital herpes - STI can cause lesions in the mouth

Answer 519

Patients affected by herpes simplex may display no symptoms, or develop symptoms months or years after an initial infection when the latent virus is reactivated. The symptoms of an initial infection with genital herpes usually appear within two weeks. The initial episode is often the most severe, and recurrent episodes are milder. Signs and symptoms include: Ulcers or blistering lesions affecting the genital area Neuropathic type pain (tingling, burning or shooting) Flu-like symptoms (e.g. fatigue and headaches) Dysuria (painful urination) Inguinal lymphadenopathy Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

Answer 520

The diagnosis can be made clinically based on the history and examination findings. A viral PCR swab from a lesion can confirm the diagnosis and causative organism.

Answer 521

Aciclovir is used to treat genital herpes. There are various aciclovir regimes listed in the BNF, depending on the individual circumstances. Alternatives are valaciclovir and famciclovir. Additional measures, including to manage the symptoms include: Paracetamol Topical lidocaine 2% gel (e.g. Instillagel) Cleaning with warm salt water Topical vaseline Additional oral fluids Wear loose clothing Avoid intercourse with symptoms

Answer 522

--> risk of neonatal herpes simplex infection - high morbidity and high mortality

Answer 523

Aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection

Answer 524

Young sexually active multiple partners other STI - chlamydia and HIV

Answer 525

--> STI --> Gram-negative diplococcus --> Infects mucous membranes with a columnar epithelium e.g urethra, rectum, conjunctiva, pharynx --> spreads via mucous secretions from infected areas

Answer 526

--> more likley to be symptomatic comapred to chlamydia infection Females --> odourless purulent discharge - green or yellow --> dysuria --> pelvic pain Males --> ouderless purulent discahrge possibily green or yellow --> dysuria --> testicular pain - epididymo-orchititis Prostatitis and conjunctivitis

Answer 527

NAAT - nucleic acid amplification testing - detects the RNA or NA of gonorrhoea --> first-catch urine sample --> rectal and pharyngeal swabs im all MSM --> Standard charcoal endocervical/ urethral swab for microscopy, culture and abx sensitivities. high rates of abx resistance

Answer 528

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known --> follow up test of cure

Answer 529

Pelvic inflammatory disease Chronic pelvic pain Infertility Epididymo-orchitis (men) Prostatitis (men) Conjunctivitis - neonates Urethral strictures Disseminated gonococcal infection Skin lesions Fitz-Hugh-Curtis syndrome Septic arthritis Endocarditis

Answer 530

Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes: Various non-specific skin lesions Polyarthralgia (joint aches and pains) Migratory polyarthritis (arthritis that moves between joints) Tenosynovitis Systemic symptoms such as fever and fatigu