Obs & Gynae Flashcards
What drug is used to reduce the risk of/ treat seizures in a pre-eclamptic woman?
Magnesium sulfate
At 5mins post birth what is a normal APGAR score?
> 7
A baby is 5 minutes old, crying strongly, pink centrally but blue in the peripheries. There is use of accessory muscles and strong breathing, a pulse of 110 and some limb movements, what is this babies APGAR score?
8/10
A= 1 (Blue peripheries) P= 2 (over 100) G= 2 (strong cry) A= 1 (some limb movement) R= 2 (strong resps)
Name 5 common drugs which could be used for the management of PPH?
Syntocinon Carboprost Syntometrine Ergometrine Misoprostol Transexamic acid
A woman presents at 24 weeks with a diffuse abdominal pain and a large for date pregnancy (fundal height 34cm). She is tender in the suprapubic area and has urinary frequency but no dysuria. She has a singleton pregnancy, what is the most likely cause of her pain?
Uterine fibroids
Very common, oestrogen dependent and so increase in size during pregnancy
Tx is best rest and analgesia
Does sexual intercourse increase the risk of miscarriage?
No - there is no evidence for this
A 28yoF has just had an ectopic pregnancy followed by a salpingectomy - how should she be counselled about future pregnancies? (3)
If other fallopian tube normal still good chances of conceiving
10% risk future pregnancies will be ectopic, so needs US at 7 weeks if gets pregnant again
Can start again straight away, no risk starting sooner
A 67 year old woman presents to GP asking if she needs a cervical smear test, she’s forgotten he last few and last attended when she was 52. Does she need a smear under the national screening program?
NO Starts at 25 3 yearly from 25-49 5 yearly from 49-65 After this only if not been screened since the age of 50 or if abnormal tests/ symptoms
A 67 year old woman presents to GP asking if she needs a cervical smear test, she’s forgotten he last few and last attended when she was 48. Does she need a smear under the national screening program?
YES Starts at 25 3 yearly from 25-49 5 yearly from 49-65 After this only if not been screened since the age of 50 or if abnormal tests/ symptoms
A culture from a patients vaginal discharge shows Gardenerella vaginalis and clue cells, what is the diagnosis and treatment?
Bacterial vaginosis
Tx: Metronidazole
A patient presents to the maternity triage department at 35 weeks with 500 ml of painless vaginal bleeding and a transverse lie on abdominal examination. MLD?
Placenta praevia classically presents as non-painful bleeding and may be associated with an abnormal lie as the low lying placenta may prevent engagement of the presenting part.
A rhesus negative G3P2 presents with post-coital bleeding. She had her Routine Antenatal Anti-D Ig Prophylaxis (RAADP) yesterday. Management with regard to her rhesus status? (3)
FBC, KLEIHAUER TEST & PROPHYLACTIC ANTI-D
Although she had her RAADP the previous day this should be considered separate from any sensitising event, and as she is Rh-ve requires Anti-D prophylaxis.
What is the Kleihauer test and what is it’s cut off value?
The Kleihauer test detects the presence of fetal red cells in the maternal circulation. If there is more than a 5ml estimated feto-maternal haemorrhage then a further dose of Anti-D will be needed.
What is the difference between primary and secondary arrest of labour?
Primary - Failure to progress in active phase
Secondary - Failure to progress in active phase following a previously normal progression
Name 3 risk factors for instrumental delivery?
Primiparous Epidural anaesthesia Large fetal size Maternal age >35 Induced labour Supine and lithotomy positions (upright or L lateral are much better)
What pneumonic is used to assess CTG traces?
DR C BRAVADO Dr- Define risk C- Contractions Bra- Baseline rate V- Variability A- Accelerations D - Deceleration's Overall
What are the three indications for operative vaginal delivery (assuming c-section not needed)?
- Presumed fetal compromise
- Maternal - to reduce effects of labour on pre-existing conditions such as cardiac or neurovascular disease
- Inadequate progress (definition discussed in other questions)
When is labour in the second stage classed as delayed?
Active second stage (add one hour if epidural)
- More than 2 hours in primip
- More than 1 hour in multip
What are the three most common adverse effects if there is a prolonged second stage?
Chorioamnionitis
Third/ fourth degree tears
Uterine atony
What are the requirements for an instrumental delivery?
FORCEPS F- Fully dilated cervix O- OA position R- Ruptured membranes C- Cephalic E- Engaged presenting part P- Pain relief S- Sphincter (bladder) is empty
When should operative vaginal delivery be abandoned?
No evidence of progressive decent following three contractions of correctly applied instrument by experienced operator
Name 3 complications of emergency cesarean in second stage of labour?
Uterine, cervical and high vaginal injuries
PPH/ needs transfusion
Sepsis
Increased LoS
Admission to intensive care (mum and baby)
You have made the decision to deliver. On examination, the head is 2/5th palpable abdominally, the cervix is fully dilated, the membranes are ruptured, the head is in a right occiptotransverse (ROT) position at -1 station with 2+ of moulding and 3+ of caput.
What mode of delivery would you choose?
Emergency cesarean!
If the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines, then this would be classed as high-cavity and not suitable for operative vaginal delivery
What is the advantage to performing ventouse over forceps?
Ventouse is less likely to be associated with maternal perineal or vaginal trauma
What is the advantage to using forceps over ventouse? (4)
Ventouse is more likely to fail
Ventouse more associated with cephalohaematoma and retinal haemorrhage and maternal worries about baby
A 36 year old mother with a BMI of 39 is at 35 weeks gestation. She has been having 4 weekly growth scans given her high risk status. However, as the baby began crossing centile lines this was moved to 2 weekly growth scans. This alongside SFH measurements have shown fairly static growth for the last three weeks. How should she be managed?
Deliver
(Give steroids if delivered by C/S)
High risk women who are >34 weeks and show static growth for more than 3 weeks should be delivered
When doing smears and swabs what order should they be performed in?
1st: Smear
2nd: High vaginal
3rd: Endocervical
The levator ani muscle is innervated by which nerves?
Pudendal nerve
S2,3,4
“S2,3,4 keeps the pelvis off the floor”
What is first line treatment of post-natal depression in a women who has had no previous history of depression?
CBT
- If this is refused then SSRI can be trialled
A 27 year old primiparous woman presents 4 days post birth feeling anxious, tearful and irritable. What is the most appropriate management?
Reassurance and support
Baby blues commonly occurs D3-D7. Anxiety, tearfulness and irritability. This is not postnatal depression and reassurance is the best management.
What percentage of women experience baby blues?
60-70%
Tend to last the first week post-partum
What percentage of women experience postnatal depression?
10%
In relation to birth, when are most cases of postnatal depression seen?
Start within first month and typically peak around 3 months.
What percentage of women experience puerperal psychosis?
0.2%
Onset usually in first 2-3 weeks following birth (severe mood swings and disorders of perception)
A 19-year-old primigravida at 9 weeks presents with vaginal bleeding and suprapubic pain. Tissue has passed through her vagina. The cervix is closed and blood is pooled in the vagina. Ultrasound shows an empty uterine cavity. What is the diagnosis?
Complete miscarriage
You are an FY-1 working in general practice. A 52-year-old lady comes in to see you with distressing hot flushes, these are worse at night and impacting her quality of life. She wants to discuss hormone replacement therapy (HRT). Her last period was 4 months ago. What is the main risk factor for oestrogen-only HRT as opposed to combined oestrogen and progesterone HRT?
Endometrial hyperplasia developed due to unopposed oestrogen stimulation
A 35-year-old nulliparous lady with Factor V Leiden has come for her first antenatal appointment; she has previously had an unprovoked venous thromboembolism (VTE). The attending doctor discusses thromboprophylaxis with her due to her history. Based on her risk, which treatment should be used?
LMWH antenatally + 6 weeks postpartum
What are the criteria for VTE prophylaxis at booking?
A woman with >4 RF’s should be immediately treated with LMWH until 6 weeks postpartum
A woman with 3 RF’s should be treated from 28 weeks until 6 weeks postpartum
A 27 year old at 36 weeks gestation develops a DVT. What is the most appropriate management?
LMWH for at least 5 days
Anti-coagulation treatment for at least 3 months as with all patients with provoked DVT
A young woman at 30 weeks gestation, presents with painless bright red vaginal bleeding, she reports two previous scanty episodes of painless vaginal bleeding, but feels that this episode has been much more severe.
What is the most likely diagnosis?
Placenta Praevia
The bleeding associated with placenta praevia is painless and usually bright red. Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red. The pattern of previous bleeding also favours placenta praevia.
What is vasa praevia and the common symptoms?
Sx: Painless bleed, fetal bradycardia, membrane rupture
Vasa praevia, also spelled vasa previa, is a condition in which babies’ blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.
A 23-year-old woman presents at 20 weeks gestation of her second pregnancy. She is complaining of lower backache, fever and a slight vaginal loss of cloudy white viscous fluid. On examination she has a pyrexia of 38.2 centigrade and a pulse of 98 beats/minute. Routine examination of the patient’s abdomen reveals that there is tenderness suprapubically. Speculum examination reveals a slightly open cervix and fluid draining. What is the most likely diagnosis?
Chorioamnionitis
An acute inflammation of the foetal amnion and chorion membranes, typically due to an ascending bacterial infection in the setting of membrane rupture. However, chorioamnionitis can also occur with intact membranes
What are the 4 main signs of Chorioamnionitis?
Key clinical features of chorioamnionitis include uterine tenderness, rupture of the membranes with a foul odour of the amniotic fluid and maternal signs of infection (for example tachycardia, pyrexia, and leukocytosis)
You are the junior doctor on the labour ward, and are called by a midwife to a delivery in which the baby’s head has been delivered, but the shoulders will not deliver with normal downward traction.
What is your first step in management?
Ask mother to hyperflex their legs and apply suprapubic pressure
(This is McRobert’s manouvere).
It works in 90% of cases and is the first line treatment for shoulder dystocia.
A 24-year-old woman presents to the emergency department with a 1 day history of nausea and severe constant pain localised since onset to the left iliac fossa. She had vomited once but has no other symptoms. She has a 28 day menstrual cycle, her last menstrual period started 7 days ago. She is sexually active and has always used condoms for contraception. There is no vaginal bleeding. What is the most likely diagnosis?
Ovarian torsion is the most likely diagnosis. This is common in women of reproductive age. Ovarian torsion is associated with iliac fossa pain that can radiate to the loin, groin or back. Nausea and vomiting are commonly associated symptoms. On examination the patient may have an adnexal mass, which is commonly an ovarian cyst or neoplasm, which has disrupted the normal lie of the ovary to cause the torsion. Patients also sometimes present with a low-grade fever, especially for longer durations of torsion where ovarian necrosis may be present.
A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?
IUS
A 27 year old woman presents with menorrhagia. What investigation should be performed?
FBC only (unless signs of structural or histological abnormality - i.e. intermenstrual or post-coital bleeding, pelvic pain or pressure symptoms).
A 27 year old woman presents with menorrhagia and postcoital bleeding. What is the most appropriate next step?
Arrange routine TVUS
A 27 year old woman presents with menorrhagia. She does not want children in the near future, what is the most appropriate management?
IUS
2nd: COCP
3rd: Long-acting progestogen (Depo-Provera)
A 27 year old woman presents with menorrhagia. She is currently trying for a baby, what is the most appropriate management?
Mefenamic acid (500mg TDS) - NSAID OR Tranexamic acid (1g TDS)
- Mefenamic acid is better if associated with pain
A patient has a very heavy menstrual bleed, and desperately needs it to stop ready for her gymnastics competition tomorrow. What can be given short term to stop the bleed?
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
What is the diagnostic criteria for PCOS?
Exclude other causes then 2 of 3 Rotterdam criteria is diagnostic:
• Polycystic ovaries (either >10cm3 or more than 12 peripheral follicles)
• Oligo-ovulation or anovulation (<9 periods/ year)
• Clinical (hirsutism, acne, alopecia) and/or biochemical (elevated free testosterone) hyperandrogenism
A woman presents at 34 weeks gestation with itching all over her body, she is otherwise well and has not noticed any rashes. What is MLD and suggested management?
Obstetric cholestasis
- Check LFT’s
- Ursodeoxycholic acid to relive symptoms
- Typically induced at 37 weeks
When is the combined test for Down Syndrome performed and what does it involve?
10-14 weeks (12 week scan normally)
- Nuchal translucency
- beta-hCG and PAPP-A
A woman is at 16 weeks gestation, and thus has missed the window for the combined DS test. What should be offered and what does it consist of?
Quadruple test (14-20 weeks)
- AFP
- beta-hCG
- unconjugated oestriol
- inhibin A
What is the first line treatment for pre-eclampsia (assuming 33 weeks gestation)?
Labetalol (unless asthma history, in which case nifidipine). Safe during breast feeding also.
Pre-eclampsia should be management conservatively until what point when same day delivery becomes an option?
34 weeks
Name 5 complications of pre-eclampsia
Eclampsia Prematurity and IUGR Placental abruption, intra-abdominal and inter-cerebral bleeds Heart failure HELPP syndrome
When would medication be started in pre-eclamptic patients?
Guidelines suggest aiming below 150/90
What is first line management for urge incontinence?
Bladder training (at least 6 weeks including increasing intervals and pelvic floor exercises)
What is second line management for urge incontinence
Anticholinergics
- Oxybutynin and tolterodine
(First is bladder training)
What is the main effect of prescribing oestrogen unopposed with progesterone?
Increased risk of endometrial proliferation (and endometrial cancer etc.)
How quickly is the implant (progesterone only) effective as contraception (2 answers)?
Immediate (if D1-5)
Need 7 days contraception if on any other day
Name 4 advantages to the progesterone implant?
- Highly effective
- Long-acting: lasts 3 years
- Doesn’t contain oestrogen so can be used if past history of thromboembolism, migraine etc
- Can be inserted immediately following a termination of pregnancy
Name 5 RF’s for endometrial cancer?
Obesity Nulliparity Early menarche Late menopause Unopposed oestrogen Diabetes PCOS
What is first line investigation in suspected endometrial cancer?
TVUS
(Endometrial thickness <4mm) has a high negative predictive value
A 24yo woman presents asking for the morning after pill, what are the two options and which is most effective?
EllaOne (Ulipristal) - Best
Levonelle (Levonorgestrel)
(note copper coil is the most effective method but is not a pill)
How soon after UPSI do each of the emergency contraception tablets have to be taken?
Levonelle - 72 hours
EllaOne- 120 hours
What 4 things should a patient who has just been given emergency contraception be counselled on?
STD Risk
SE (Nausea, tiredness, headache)
Signs of ectopic (pain, bleeding)
Referral to GUM
What is the definitive gold standard for emergency contraception?
Copper coil
- Have 120 hours
(EllaOne > Levongestrel if not wanting coil).
Name 3 brands of progesterone only pills?
Norgeston, Cerazette, Cerelle, Micronor, Noriday
What advice should a patient be given regarding taking their progesterone only pill (2)
Same time each day (3 hours)
Take every day with no breaks
How quickly is the POP effective?
D1-5: Immediate
Other: Condoms for 48 hours
What should a patient do if they have missed a dose of the POP? (2)
Take next dose as soon as remember (even if two in one day)
Use barrier methods for 48 hours
What advice should a girl be given when starting POP with regard to her periods?
Should make lighter
20% stop, 40% lighter, 40% no change
What are the four most common SE’s of the POP?
Most: Irregular bleeding
Other:
Breast tenderness, spotty skin and headaches
Should resolve within 3 months
A patient is start on the POP, when should you arrange to see her next?
10-12 weeks
Then every 12 months
What advice should women starting the POP be given regarding:
a- Surgery
b- Breast feeding
c- Breast cancer risk
a- Safe
b- Safe
c- Slightly increased
Give 3 examples of COCPs?
Microgynon, Tasmine, Cilest, Logynon
What advice should women be given regarding taking their COCP?
Doesn’t need to be same time each day
Take 21 days then 7 day break (unless ED version)
How quickly is the COCP effective?
D1-5: Immediate
Otherwise: 7 days condoms
What should a woman be advised regarding missing a dose of COCP?
Take as soon as remembered, even if two in one day
No additional barrier methods needed
If missed two or more (>48hours without) then need 7 days of condoms
A girl comes in requesting the pill to reduce her period pains, which is the better option of COCP and POP?
COCP
Makes periods shorter and lighter
What are the most common SE’s of the COCP?
Breast tenderness, headaches, nausea, spotting bleeds, mood swings
Should go away in 3 months but if not swap pill
What are the main disadvantages of the COCP?
Increased risk of thrombosis
Increase BP
Increase risk of breast cancer
Name 5 risk factors which go into UKMEC category 3 or 4 for COCP (suggesting risks outweight benefits)
Age > 50 BMI > 35 Smoker over age 35 Migraine with aura Hypertension Hx of VTE or FHx (<45) Hx of breast cancer Thrombophilia or Factor V leiden
How long does the implant last?
3 years (Although if taken out early fertility returns to normal in one month)
What is the first line treatment for menorrhagia in a women with no desire to have children?
Marina coil (IUS)
- Lasts 3-5 years
Periods become lighter, shorter and less painful
85% stop in first 6 months
What is the first line management of menorrhagia caused by a uterine fibroid (2cm)?
IUS (Marina)
Other options include:
- Transexamic acid
- COCP
What is the incidence of fibroids?
20% of white women and 50% of black women in later years (age 30-50)
When would surgery be considered for a uterine fibroid?
Enlarged uterine size
Pressure symptoms
Medical managment insufficient
Fertility is reduced
What are the main surgical treatment options for a women with severe fibroids if she does and doesn’t want to have kids?
Wants kids still - Myomectomy (best done laparoscopically)
Doesn’t want kids- Hysterectomy
A 29-year-old woman who is known to have HIV visits her general practitioner (GP) to discuss becoming pregnant. At present she is not on any antiretroviral (ARV) medications because her CD4 count is sufficiently high and viral load low. What advice should the GP give her about what treatment she may need in pregnancy or post-partum? (3)
Needs to start her ARV
May require caesarean
Don’t breastfeed
A 19 year old currently on Cerazette requires a 7 day course of amoxicillin for a LRTI. What advice should she be given regarding contraception?
None extra needed
Progestogen only pill + antibiotics - no need for extra precautions
What is the most common presentation of endometrial hyperplasia? (3)
Intermenstrual bleeding, post-menopausal bleeding, menorrhagia or irregular bleeding - strongly associated with obesity
You suspect a patient has endometrial hyperplasia, what is the most important investigation?
Endometrial biopsy (following hysteroscopy)
What is the management of endometrial hyperplasia without atypia?
Progesterones (IUS or pill) for at least 6 months with repeat biopsy at 6 months
What is the management of endometrial hyperplasia with atypia?
Hysterectomy
If wants kids treat with progesterones but advise hysterectomy as soon as possible
Which blood test can be used to differentiate between a complete miscarriage and an ectopic pregnancy?
Serum hCG.
Serial tests are required with two taken as close as possible to 48 hours apart:
>63% increase suggests ongoing pregnancy.
>50% decrease suggests pregnancy is unlikely to continue.
What is the greatest risk factor for developing hyperemesis gravidarum?
Twin pregnancy
What is the cut-off age for premature ovarian failure and what are the most common risk factors?
Age under 40
Strong RF’s: Chemo, radio, +veFHx, autoimmune disease
Which of the following is the most likely location of an ectopic pregnancy?
Ampulla of fallopian tube
A 22-year-old female presents with secondary amenorrhea, short stature, BMI of 31, a history of miscarriage 18 months ago and a recent diagnosis of hypertension.
What is the suspected diagnosis?
Turners Syndrome (single X chromosome)
Common features of the condition are short stature, gonadal dysgenesis, obesity and hypertension. Some Turner’s cases may conceive spontaneously and have miscarriages as streak ovaries may have limited ovulation function in early reproductive age. Confirmation of diagnosis requires karyotyping.
A 26-year-old female presents with amenorrhea for 12 months after stopping the contraceptive pill. She had regular withdrawal bleeds whilst she was on the pill. Her BMI is 33.
What is the most likely diagnosis?
PCOS
20% of women have PCOS. Raised BMI worsens the underlying insulin resistance.
In cases of endometriosis, what is the most appropriate form of tubal patency testing?
Diagnosistic laparoscopy
As well as checking the tubal patency, a laparoscopy would also allow the treatment of pelvic endometriosis and endometrioma.
A couple present with primary subfertility. The male is 34-years-old. He had a history of mumps when he was 14 years old. His semen analysis on two occasions showed azoospermia. FSH and LH levels are high and the serum testosterone concentration is low. He has a normal karyotype.
What is the most likely explanation?
Primary testicular failure
Mumps is associated with orchitis after puberty and can cause irreversible testicular damage
A couple present with a 12-month history of primary subfertility. The female is 36-years-old with regular cycles. The fallopian tubes are both patent. Ovulation was confirmed with progesterone testing in two cycles. The semen analysis is normal.
What is the next recommended step?
Proceed with IVF
As the female is over 35 it is not recommended to delay assisted conception treatment
What is the definition of oligozoospermia?
<15 million spermatazoa/ ml
not enough sperm viable
What is the definition of asthenozoospermia?
<32% motile speratozoa
sperm not motile
What is the definition of teratozoospermia?
<4% normal forms
abnormal sperm
A female with regular menses requires investigation for subfertility, what are you first investigations?
Progesterone (test 7 days before expected menses), should be over 30nmol/ml
FSH, LH and oestradiol to assess ovarian reserve
A female with irregular menses requires investigation for subfertility, what are you first investigations?
FSH and LH - pituitary function
Estrogen - ovarian function
Prolactin and free testosterone - Other causes of oligo/ amenorrhoea
What is first, second and third line treatment for subfertility due to anovulation (due to PCOS etc.)
1 - Clomiphene (D2-6 of cycle to simulate ovulation)
2- Injectable gonadotrophins (FSH)
3- Ovarian drilling
Who should be offered IVF and how many cycles?
(If other options failed)
Women under 40 = three cycles
Women over 40 = one cycle
When would an intra-cytoplasmic sperm injection be considered?
Azoospermia
Previous IVF has resulted in failed fertilisation
How does OHSS normally present? (5)
Ovarian hyper-stimulation syndrome
Lower abdominal pain, N+V, diarhoea, distension
Severe: Ascites, tachycardia, hypotension, oliguria
Name two anti-emetics safe in pregnancy (so used for HG etc.)
Cyclizine
Promethazine
How should mild/ moderate cases of OHSS be managed?
Paracetamol/ opiates
Cyclizine/ promethazine
How should severe cases of OHSS be managed?
ITU?
Monitor fluids and electrolytes, watch out for complications such as AKI, VTE and ARDS
A 26-year-old primip school teacher has come to see you 4 days after contact with a child who had a vesicular rash on his head and trunk. She is currently 16 weeks pregnant and apart from some morning sickness, has felt completely well in herself. Blood tests reveal she is non immune to varicella zoster virus. What would be the next step in your management plan?
Single Dose VZI
If the pregnant woman is not immune to varicella zoster virus (chicken pox) and she has had a significant exposure, she should be offered varicella-zoster immunoglobulin (VZIG) as soon as possible. VZIG is effective when given up to 10 days after contact
Can you perform re-infibulation for a woman who has experienced FGM and has asked for it to be sewn back up after delivery?
No
Reinfibulation is illegal and cannot be done under any circumstances
A 15-year-old comes in with right iliac fossa pain. She describes the pain as starting a few hours earlier when she was playing hockey and the pain has progressively got worse. She is Rovsing’s sign negative. An USS is done and free pelvic fluid is seen with a whirlpool sign. What is the most likely diagnosis?
Ovarian torsion
What are the most common long term risks associated with PCOS?
Subfertility
Endometrial cancer
High CVS risk
Name two risk factors for PCOS? What % of women are affected by PCOS?
RF: Fhx and early puberty
Affects around 20% of women
Name 5 presenting symptoms/ signs of PCOS?
Infertility Oligomenorrhoea (<9 periods/ yr) Acne or hirsutism Alopecia Obesity Mood symptoms
What is the first line treatments for PCOS (3)
Counselling (on long term risks) Weight loss (improves infertility, mood symptoms) COCP or coil (to prevent endometrial hyperplasia and cancer)
What is the function of the drug orlistat?
Aids weight loss in obese women with PCOS (increases insulin sensitivity)
A 24yo woman with PCOS is trying to conceive but struggling, what two drugs may be beneficial?
Clomifene
Metformin
What is the most common presentation of ovarian torsion (3)
Iliac fossa pain, progressively worse
N+V
Diarrhoea
(Whirlpool sign on US)
What investigations should be done for suspected ovarian torsion?
FBC
Pregnancy test
TVUS (or abdominal in child- look for whirlpool sign)
What is the management of ovarian torsion?
1st: Laparoscopic surgery
2nd: Laparotomy
Detorison is first line but if non-viable then do salpingo-oophrectomy
Name 5 causes of a raised CA-125?
Ovarian cancer Endometriosis PID Pregnancy Torsion or rupture of cyst Other cancers Heart failure
What are the immediate indications for a two week wait referral when suspecting ovarian cancer?
Ascites
Pelvic or abdominal mass
A 50yo patient presents with persistent bloating and early satiety. What is the most appropriate management?
1- Urgent CA-125
2- If over CA-125 is over 35 = do Pelvic/ abdo US
3- Calculate RMI
(CA125 x USS score x menopausal score)
4- If RMI >250 then refer to MDT
Name 5 risk factors for cervical cancer?
Smoking HIV Early first intercourse or many partners High parity Low SES COCP
What is first line treatment for menorrahagia both with (1) or without (2) pain if the woman does not want children?
1 and 2 = IUS
What is first line treatment for menorrahagia both with (1) or without (2) pain if the woman is trying for children?
1- Mefenamic acid if pain
2- Transexamic acid if no pain
(both started on D1 of period)
A 72-year-old nulliparous female presents with post menopausal bleeding. She reports that her last cervical screening was 14 years ago. On examination she is found to be obese and hypertensive. What is the most important diagnosis to rule out?
Endometrial adenocarcinoma
In a female with postmenopausal bleeding (PMB), the diagnosis is endometrial cancer until proven otherwise.
Hyperemesis gravidarum occurs in occurs in what percentage of pregnancies? At what gestation is it most common? What causes it?
1%
Most common between 8 and 12 but can last to 20 weeks
Due to high beta-hCG levels
A 34-year-old pregnant female at 12 weeks gestation presents with a two-week history of severe nausea and vomiting. On examination, the pulse is 110 beats/min and blood pressure 110/80 mmHg. It is also noted that the patient is experiencing diplopia and ataxia. Urinalysis demonstrates an increased specific gravity and 3+ ketones. Diagnosis and management (3)?
Hyperemesis gravidarum
1- Fluid Resus
2- Cyclizine
3- Pabrinex (to replace vitamins B and C) - note this patient shows signs of Wernicke’s encephalopathy (B1/ thiamine deficiency)
What is the most common side effect of the IUS for the first 6 months?
Irregular bleeding
A 26-year-old woman comes to see her GP after complaining of weight gain, hair loss, constipation and feelings of being cold all the time. She is also amenorrhoeic and struggled to breast feed after birth. She has no significant past medical history but during birth she suffered from a large amount of blood loss and subsequent hypovolaemic shock which required a 6 weeks hospital stay. MLD?
Sheehan’s syndrome
Postpartum hypopituitism
(Note amenorrhoea, galactorrhoea and hypothyroidism all together)
- Hypothyroidism on its own can also cause amenorrhoea
What does a bishop score measure and what are the cut offs?
Need for induction
0-5 = Labour unlikely to start spontaneously, induce 5-9 = Medical judgement >9 = Will start spontaneously, don't induce
What is the typical history of an ectopic pregnancy?
6-8 weeks of amenorrhoea
Lower abdo pain
Later vaginal bleeding
Should tip pain and cervical excitation also possible
What action should be taken with women who are at a moderate or high risk of pre-eclampsia?
Aspirin 75 mg OD
Taken from 12 weeks
A woman presents with a painless vaginal bleed at 36 weeks suggestive of placenta praevia. What is the first investigation for this and what should not be done?
1st: TVUS
Don’t do vaginal exam
How should a placenta praevia be managed if detected at 20 weeks?
Follow up scans (only 10% will still be low at term)
A 36yo multiparous woman presents with painless vaginal bleeding. She has had two previous caesarian sections and is currently 34 weeks. What is the most likely diagnosis?
Placenta accreta
If PP and previous caesareans treat as placenta accreta (will need to do hysterectomy, elective has better outcomes)
A woman at 36 weeks gestation was found to have a DVT. What is the management and when/ how would this condition be monitored?
LMWH
Only monitor if at extremes of body weight, renal impairment or recurrent VTE
- Anti-Xa activity is used to monitor
What is placenta accreta and what is the most important RF for placenta accreta?
Where placenta grows too deeply into uterine wall so doesn’t detach
RF: Previous c-sections
What are the definitions of pre-eclampsia and gestational hypertension?
After 20 weeks
BP > 140/90
Pre-eclampsia also has 1+ or more of protein
What are the most common symptoms of uterine fibroids?
Menorrhagia Lower abdominal pain Bloating Subfertility Urinary symptoms Suprapubic mass
What is your first line diagnostic investigation with suspected fibroids?
TVUS
What is first, second, third line management for uterine fibroids?
IUS
- Transexamic acid and COCP are other viable options
2- Short term GnRH agonists (Goserlin etc.) to shrink for 3-6 months prior to surgery (myomectomy)
(Gonadotropin releasing hormone causes FSH and LH to be released from pituitary and therefore inhibits oestrogen and progresterone, making fibroids smaller)
What gestation should Down’s syndrome screening with nuchal scanning be performed?
11-13+6 weeks
Who should receive AB prophylaxis for Group B Strep?
- Women who have had GBS in previous pregnancy
- Women in pre-term labour
- Women with pyrexia during labour
What AB is used for prophylaxis of GBS?
Benzylpenicillin
A 16 year old girl presents to her GP with abdominal pain which occurs at the end of each month. She has not started her periods yet, but has secondary sexual characteristics. Pregnancy test is negative and she is not sexually active. Which is the most likely diagnosis?
Imperforate hymen
A cervical smear is reported as Mild dyskaryosis (HPV positive), what is the most appropriate management?
Refer for colposcopy (routine)
A cervical smear is reported as moderate dyskaryosis, what is the most appropriate management?
Refer for coposcopy (2ww)
A cervical smear is reported as Mild dyskaryosis (HPV negative), what is the most appropriate management?
Very low risk of cancer, continue routine screening (3 or 5 years depending on age)
What is the first line contraceptive for those with severe PMS symptoms?
COCP
An 18-year-old girl presents to her GP with discharge. She reports a new sexual partner with whom she is not using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports no other symptoms of note. What is the most likely diagnosis?
Candida albicans
A 30 year old type 2 diabetic presents to the diabetics clinic advising that she wishes to become pregnant. The patient normally has good glycaemic control and is currently being treated with metformin and gliclazide. What advice should you give her about potential changes to her medication during pregnancy?
Can continue metformin but glicazide should be stopped
A 19-year-old woman at ten weeks gestation presents to her general practitioner with intermittent vaginal bleeding over the previous month and hyperemesis. Obstetric examination reveals a non-tender, large-for-dates uterus. These symptoms are strongly suggestive of which condition?
Molar pregnancy
A neonate is born at 38 weeks gestation via spontaneous vaginal delivery. The birth weight was 4.5kg. In the newborn postnatal check the attending doctor notes that there is adduction and internal rotation of the right arm. What is the most likely diagnosis?
Erb’s Palsy
Classic pattern of adduction and internal rotation of the arm
How early is HCG detectable in pregnancy?
D8 onwards
What is first line treatment for infertility in patients with PCOS?
Clomifene
And/ or metformin (especially if obese)
A 33-year-old woman is investigated for infertility. Laparoscopy is essentially normal. Hysterosalpingography shows blocked fallopian tubes bilaterally. MLD?
Pelvic inflammatory disease
A 27year old woman presents with breast pain. She is 2 weeks postpartum and exclusively breastfeeding. She has 3 days of worsening R breast pain. There is a small area of erythema superior to the R nipple, T is 38 and the breast is tender. What is MLD and management (2)?
Lactation mastitis
(Due to overproduction of milk - can be infectious or non infectious).
1st: Encourage feeding/ expressing from affected side
2nd: If no resolution in 12-24 hours give oral flucloxacillin 14 days (or erythromycin)
- Continue breast feeding
Name 5 differentials for a Post-Coital Bleed?
Infection Cervical ectropion Cervical/ endometrial polyps Vaginal cancer Cervical cancer Trauma
Name 5 differentials for an Intermenstrual Bleed?
Fibroids Endometriosis Cancer (endometrial/ cervical, vaginal) Infection Polyps (cervical/ endometrial) Cervical ectropion Vaginitis (after menopause)
What is the RCOG diagnostic criteria for hyperemesis gravidarum?
5% pre-pregnancy weight loss AND
Dehydration AND
Electrolyte imbalance
How many days following childbirth does a woman not need contraception?
21 days
Can ovulate as soon as D28 but sperm can survive 7 days inside female tract
What cancers is the COCP protective for?
Ovarian and endometrial
What is the NICE recommended test to confirm ovulation?
D21 progesterone (assuming 28 day cycle, if longer cycle then do 7 days before end)
What is the most common complication of a surgical TOP?
Infection (10%)
A woman collapses following an ARM for slowly progressing labour. BP 82/50 and pulse 134. MLD?
Amniotic fluid embolism
What factors make a cervical ectropian more likely? (3)
Ovulation
Pregnancy
COCP
What is the treatment for bacterial vaginosis?
Metronidazole
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation. MLD + Tx?
Trichomanas vaginalis
(With stawberry cervix)
Tx: Metronidazole
A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram negative diplococcus. MLD + Tx?
Gonorrhoea
Tx: Ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections.
What is the main mode of action of the majority of contraceptives?
Inhibits ovulation (Except, IUD which decreases sperm motility, POP which thickens cervical mucus and IUS which prevents endometrial proliferation)
What is the mechanism of the POP?
Thickens cervical mucus
If the LMP was less than one year ago and the uterus is still present, which form of HRT should be used?
Cyclical combined
- Cyclical because LMP was less than a year ago
- Combined because all women with a uterus should have combined
What scale is used to assess post-natal depression?
Edinburgh postnatal depression scale
A 32-year-old 1 week post-partum female presents to her local emergency department with a few days history of vaginal bleeding: initially bright red blood which has now changed in colour to become brown. She is changing her sanitary pads once every 3 hours and is worried that the caesarean section birth has caused damage to her womb. Obs are normal and abdominal examination does not cause pain and reveals a caesarean section scar which is pink and not tender. What is the most appropriate management at this stage?
Reassure, advise, discharge
This patient is describing lochia, the bleeding that presents for the first 2 weeks following giving birth, whether this is by vaginal birth or caesarian section. Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping.
A female presentation of vulvovaginitis, with offensive, yellow/green, frothy discharge and strawberry cervix is most likely to be what?
Trichomonas vaginalis
A woman presenting with an offensive, thin, white/grey, fishy discharge is likely to be what?
Bacterial vaginosis
A 19-year-old female starts Microgynon 30 (combined oral contraceptive pill) on day 8 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Time until effective (if not first day period):
Instant: IUD (intrauterine device- the coil)
2 days: POP (progesterone only)
7 days: COC (combined), injection, implant, IUS (homrone coil) ANSWER IS 7 DAYS
How do you differentiate between the different types of miscarriage?
Threatened (Os closed, fetus normal on USS)
Inevitable (Os open, fetus still in on USS)
Incomplete (Os open, some fetal loss on USS)
Complete (Os closed, no fetus on USS)
Missed (Os closed, fetus present but no sign of life on USS)
How do you determine between braxton-hicks contractions and labour?
Regular contractions (15-20mins apart, last 1min or so) is more likely labour
One off or irregular is braxton-hicks
What are the strains of HPV which cause cancer?
16 and 18
A 24-year-old woman who has just returned from holiday presents to your clinic 6 days after unprotected sexual intercourse. She reports having a regular 28-day cycle with ovulation around day 14. She is currently on day 16 of her cycle.
What would be the most appropriate method of emergency contraception for this patient?
Copper coil
An IUD can be inserted up to 5 days after the likely ovulation date in women presenting >5 days after UPSI and requesting emergency contraception
