Obs & Gynae COPY Flashcards
Cervical cancer is associated with..
HPV 16 and 18
Ix for cervical cancer
Urgent colposcopy
CT chest/abdomen/pelvis is used for staging
Abdominal bloating, pelvic discomfort and loss of appetite. On examination, there is an abdominal mass and ascites. Transvaginal ultrasound shows a complex cystic mass with solid components. What is the most likely diagnosis?
Ovarian cancer
Raised AFP, B-hCG and LDH point towards..
Germ-cell tumour - ovarian cancer
Tx for CIN 1
Regresses spontaneously so conservative management with repeat cytology in 6 months
Tx for CIN 2 - 3
LLETZ, cone biopsy or cryotherapy
Bloating, frequency and urgency
Ovarian cancer
Tx for PMS
Mild - regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
Moderate - new-generation combined oral contraceptive pill (COCP) eg Yasmin
Severe - SSRI (may be taken continuously or just during the luteal phase)
Lesion can consist of hair, skin, cartilage, teeth and thyroid tissue
Mature teratoma
Lesion looks like a fried egg
Dysgerminoma
Lesion has a complex papillary architecture, nuclear atypia and the presence of Psammoma bodies
Serous cystadenocarcinoma
Post menopausal women presenting with abnormal bleeding need to be worked up for..
Endometrial and cervical cancer
When a pregnancy is not seen on an early scan, a ______ should be performed
β-hCG
If it is more than 1500 mIU/ml, the pregnancy should be treated as _________. If it is lower than this, the test will be repeated in 48 h and the two numbers compared. If the second reading is less than half of the first reading, it is most likely a _________. If the second reading is more than double the first reading, it is most likely a _________ pregnancy. If the second reading is between half and double the first reading, it should be treated as an _________ pregnancy
If it is more than 1500 mIU/ml, the pregnancy should be treated as ectopic. If it is lower than this, the test will be repeated in 48 h and the two numbers compared. If the second reading is less than half of the first reading, it is most likely a miscarriage. If the second reading is more than double the first reading, it is most likely a viable pregnancy. If the second reading is between half and double the first reading, it should be treated as an ectopic pregnancy
Febrile and has signs of a recent sexually transmitted infection (new discharge and lower abdominal pain). Cervical motion tenderness
Pelvic inflammatory disease (PID)
When is surgical management indicated in an ectopic pregnancy?
The patient is in a large amount of pain
The mass is greater than 35mm
Ultrasound identifies a fetal heartbeat
Serum beta-human chorionic gonadotropin (B-hCG) levels are over 5000 IU/L
When are Mifepristone and Misoprostol used?
Mifepristone - termination of pregnancy to end the pregnancy
Misoprostol - expulsion of the products of conception.
Painless, skin-coloured papules in his genital area
Warts - HPV
Round, budding yeasts with pseudohyphae.
Candida albicans
Small, pear-shaped parasites with a single nucleus and flagella
Trichomonas vaginalis
Gram-negative intracellular diplococci
Neisseria gonorrhoea
Small, round, elementary bodies within infected cells.
Chlamydia trachomatis
Solitary, firm, non-tender ulcer that is usually located at the site of inoculation (genital, anal, or oral)
Syphilis - primary stage
The POP is used by women who..
Cannot use oestrogen, such as women who smoke >15 cigarettes a day, whom are over 35 and who experience migraine with aura
Which conditions test positive for CA-125?
Ovarian cancer
PID - bilateral abdominal pain and inter-menstrual bleeding + PMH of STIs
Mucopurulent discharge, cervical tenderness and lower abdominal pain are typical of..
Pelvic inflammatory disease - Chlamydia trachomatis
Vaginal discharge worse after bleeds, and an associated fishy odour
Bacterial Vaginosis
Which form of contraceptives prevent ovulation?
Progestogen-only pill, the combined oral contraceptive pill and the progestogen implant prevent ovulation
Maculopapular rash on the trunk, palms and soles, along with ulceration of the oral mucosa and a recent history of untreated chancre
Syphilis - secondary stage
A solitary indurated painless ulcer or ‘chancre’ at the site of inoculation
Syphilis - primary stage
Entropion and green discharge
Trachoma - Chlamydia trachomatis
Tender inguinal lymphadenopathy and a green urethral discharge
Neisseria gonorrhoeae
What is the window period fo 4th generation antigen and antibody test?
17.8 days (ranging from 13-26 days)
What is viral PCR used for?
To look for vertical transmission of HIV, from mother to child
Dendritic cell ulcer on fluorescein stain, which has a characteristic branched appearance
HSV keratitis - HIV
Multiple small round pearly lesions with a central area of umbilication
Molluscum contagiosum
What is a complication of bacterial vaginosis in pregnant women?
Increased risk of pre-term delivery
What is a complication of chlamydia and gonorrhoea in pregnant women?
Neonatal conjunctivitis
Guidelines if missed >2 COCP pills
If pills are missed in week 1: use emergency contraception if she had UPSI in pill free interval for 1 week
If pills are missed in week 2: no need for emergency contraception
If pills are missed in week 3: Take the last pill that was missed, finish the current pack and start the next pack immediately after.
Oral hairy leukoplakia
HIV
Gold standard investigation for confirming the diagnosis of PCP?
Bronchoalveolar lavage
Every patient who presents for a booking appointment should be tested for..
HIV
Smear displays 5 or more polymorphs per high power field, with no evidence of gram negative diplococci
Chlamydia
Which form of HRT is given for woman is at risk of VTE?
Transdermal
HRT decreases the risk of which two conditions?
Osteoporosis and colorectal cancer
Which HRT regime is recommended for women with menopausal symptoms who continue to have regular periods?
Monthly, cyclical (sequential) HRT - taking oestrogen throughout the menstrual cycle, with progesterone taken only in the last 14 days
Which HRT regime is recommended for women with menopausal symptoms who continue to have irregular periods?
3-monthly, cyclical (sequential) HRT - taking oestrogen throughout the 3 month period, with progesterone taken for approximately 14 days every 3 months
Oestrogen only HRT increases the risk of __________ cancer
Endometrial
What are the risks of oral HRT?
Breast cancer, endometrial cancer (if oestrogen given alone), and venous thromboembolism
When is progestrogen used in addition to oestrogen-only HRT?
If the patient has a uterus to reduce the risk of endometrial hyperplasia and endometrial cancer
Ix for menopause
> 45 - no Ix needed
<45 - two FSH bloods
Criteria for suspected endometrial cancer?
Aged over 55 with postmenopausal bleeding
Which method of delivery is offered for pregnant women with an undetectable viral load?
Vaginal delivery
Which method of delivery is offered for pregnant women with detectable viral load?
Caesarean section
Which dermatological condition is harmless in children, but could be an indication of HIV in adults?
Molluscum contagiosum
Which test is used for PCP?
Silver stain
Pregnant patient with light bleeding and no abdominal pain. Closed cervical os and ‘blighted’ ovum
Missed miscarriage
Anything that slows the ovum’s passage through the fallopian tube to the uterus is a risk factor for developing an ectopic pregnancy. An example of this is..
Pelvic inflammatory disease
Ix for endometriosis
Transvaginal US
Diagnostic laparoscopy
Tx for PID
Ceftriaxone (given intramuscularly) + doxycycline + metronidazole
Ofloxacin + metronidazole
Define gravidity
Number of times a woman has been pregnant, regardless of the outcome
Define parity
Total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks)
E.g: P(no.of live births) + (no. of losses)
When is serum progesterone levels used to check for ovulation?
7 days prior to the expected next period
Course of action if patch change is delayed at the end of week 1 or week 2
If delay is less than 48 hours, it should be changed immediately and no further precautions are needed
If delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse, then emergency contraception needs to be considered
Course of action if patch change is delayed at the end of week 3
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle
After giving birth, women require contraception after day..
21
When is the POP started in postpartum women (breastfeeding and non-breastfeeding)?
Can start at any time postpartum
After day 21 additional contraception should be used for the first 2 days
When is the COCP started in postpartum women (breastfeeding and non-breastfeeding)?
Contraindicated if breastfeeding < 6 weeks post-partum
If breastfeeding 6 weeks, then 6 months postpartum
Should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21 additional contraception should be used for the first 7 days
The FIGO staging system is used to stage endometrial and ovarian cancers
Pre menopausal women presenting with abnormal vaginal bleeding should have a ____________ test, post menopausal women presenting with abnormal bleeding need to be worked up for ____________ and ____________
Endometrial cancer work up includes a _____________ _____________ but for cervical cancer assessment _____________ is recommended.
Pre menopausal women presenting with abnormal vaginal bleeding should have a chlamydia test, post menopausal women presenting with abnormal bleeding need to be worked up for endometrial and cervical cancer
Endometrial cancer work up includes a transvaginal ultrasound but for cervical cancer assessment colposcopy is recommended
Unopposed oestrogen increases the risk of ___________ cancer, so oestrogen-only HRT shouldn’t be given to people with a ___________. The addition of progesterone to the HRT (oestrogen + progesterone) prevents the increase in ___________ cancer, but progesterone exposure increases the risk of ___________ cancer. On balance, the risks are less to give combined HRT to post-menopausal people with ___________, and oestrogen-only HRT if they’ve had a ___________
Unopposed oestrogen increases the risk of endometrial cancer, so oestrogen-only HRT shouldn’t be given to people with a womb. The addition of progesterone to the HRT (oestrogen + progesterone) prevents the increase in endometrial cancer, but progesterone exposure increases the risk of breast cancer. On balance, the risks are less to give combined HRT to post-menopausal people with wombs, and oestrogen-only HRT if they’ve had a hysterectomy
Stages of ovarian cancer
Stage 1 (1 word) = ovary
Stage 2 (2 words) = ovary + pelvis
Stage 3 (3 words) = ovary + pelvis + abdomen
Stage 4 = ovary + pelvis + abdomen + elsewhere
For ovarian cancer, the most common site for lymphatic spread is the ___________ lymph nodes. The most common site for haematological spread is the ___________
For ovarian cancer, the most common site for lymphatic spread is the para-aortic lymph nodes. The most common site for haematological spread is the liver.
Mx for simple endometrial hyperplasia without atypia
High dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
Mx for simple endometrial hyperplasia with atypia
Hysterectomy with bilateral salpingo-oophorectomy
Lactational amenorrhoea is a reliable method of contraception if the following criteria are fulfilled..
Baby under 6 months
Exclusively breastfeeding
Amenorrhoea
Gaps between feeds do not exceed 4 hours in the day or 6 hours at night
Differentiate between open and closed cervical os in miscarriages
Open = incomplete or inevitable miscarriage
Closed = complete, missed, threatened miscarriage
“Open your I’s”
Ix for reduced fetal movements if past 28 weeks gestation
1st: Doppler US, if no HB then immediate US
2nd: Doppler US, if HB present then CTG for 20 minutes
If concern persists then US within 24hrs, abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement
Ix for reduced fetal movements if between 24 and 28 weeks gestation
Handheld Doppler
Ix for reduced fetal movements if below 24 weeks gestation
Handheld Doppler
Ix if fetal movements have not yet been felt by 24 weeks
Onward referral should be made to a maternal fetal medicine unit
The COCP causes an increased risk of which type of cancer?
Breast and cervical cancer
When is a salpingectomy or salpingotomy used in the management of an ectopic pregnancy?
If the contralateral tube is healthy then salpingectomy may be the best option. However, if the contralateral tube is damaged, salpingotomy preserves the functional tube and helps minimise the risk of future infertility.
Sudden increases in the size of mum’s abdomen and/or any breathlessness in a monochorionic multiple pregnancy
TTTS - result of polyhydramnios affecting the recipient twin
Is the COCP C.I if breastfeeding?
Can do but follow up (UKMEC 2) - if breastfeeding 6 weeks - 6 months postpartum
Absolutely contraindicated (UKMEC 4) - if breastfeeding < 6 weeks post-partum
When is the IUD/IUS used postpartum?
Within 48 hours of childbirth or after 4 weeks
Menorrhagia, subfertility and an abdominal mass
Fibroids
Ix for fibroids
TVUS
Mx of menorrhagia secondary to fibroids
Levonorgestrel intrauterine system (LNG-IUS)
NSAIDs e.g. mefenamic acid
Tranexamic acid
COCP
Oral progestogen
Injectable progestogen
Medical mx to shrink/remove fibroids
GnRH agonists
Surgical mx to shrink/remove fibroids
Myomectomy
Hysteroscopic endometrial ablation
Hysterectomy
Uterine artery embolization
Which contraception can be carried out immediately after TOP?
IUD
If heavy menstrual cycles then IUS
What advice is given regarding air travel if > 37 week?
> 37 weeks with singleton pregnancy and no additional risk factors should avoid air travel women
What advice is given regarding air travel if > 32 week?
Uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks
Expectant management for a miscarriage
Waiting for 7-14 days for the miscarriage to complete spontaneously
In which situations are miscarriages better managed medically or surgically?
Increased risk of haemorrhage - late first trimester, coagulopathies or unable to have a blood transfusion
Previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)
Evidence of infection
Medical management for a miscarriage
Vaginal misoprostol with antiemetics and pain relief
Contact doctor if no bleeding in 24 hours
Surgical management for a miscarriage
Vacuum aspiration (suction curettage)
Or surgical management in theatre
Anemia cut off for first trimester?
< 110 g/L
Anemia cut off for second/third trimester?
< 105 g/L
Anemia cut off postpartum?
< 100 g/L
Differentiate between turner and kallman’s regarding FSH & LH levels
KALLman = FALL (Low FSH & LH)
TURNer = TURNed up (High FSH & LH)
↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A
Down’s syndrome
A combined/quadruple test is offered a from 14-20 weeks
Quadruple
A combined/quadruple test is offered between 10-13+6 weeks
Combined
M rules to classify cysts as malignant
Irregular, solid tumour
Ascites
At least 4 papillary structures
Irregular multilocular solid tumour with largest diameter ≥100 mm
Very strong blood flow
Antenatal routine tests
4 3 2 1
4 blood (FBC, rhesus, blood group, alloantibodies)
3 virus (hepB, HIV, syphilis) rubella no more
2 UTI (dipstick, culture)
1 full physical examination (breast, BMI, BP)
Induction oflabour
1) Membrane sweep - usually repeated if unsuccessful
2) Vaginal PGE2 - maximum of 2 doses, 6 hours apart. CTG is needed to monitor the fetus once contractions begin. Avoid this if uterine hyperstimulation (straight to
3) Amniotomy with syntocin
Which medication suppresses breastfeeding?
Cabergoline
Take MORE Folic acid (5mg) if…
M- Metabolic disease (diabetes or Coeliac)
O- Obesity
R- Relative or personal Hx of NTDs
E- Epilepsy (taking antiepileptic medications)
+ Sickle Cell and Thalassaemia
Drugs to avoid in breastfeeding
LAMBAST + 4C’s:
L - Lithium
A - Aspirin
M - Methotrexate
B - Benzodiazepines
A - Amiodarone
S - Sulphonylureas/sulphonamides
T - Tetracycline
4’Cs - Carbimazole, Ciprofloxacin, Chloramphenicol, Cytotoxics
Pruritus
Jaundice
Raised bilirubin
Obstetric cholestasis
Mx for intrahepatic cholestasis of pregnancy/obstetric cholestasis
Induction of labour at 37-38 weeks
Ursodeoxycholic acid
vitamin K supplementation
3 different types of placenta accreta
A - attach
I - invade
P - penetrate
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium
Mx for menorrhagia
Which hormone can cause breast cancer in excess?
Progesterone (the p is like reverse b)
Oestrogen, in excess, can cause which type of cancers?
Ovarian and Endomtrial: OEstrogen
Update: An increased risk of ovarian cancer has been suggested in some studies involving HRT use, but the overall evidence remains inconclusive
Which situations would warrant continuous CTG monitoring?
Suspected chorioamnionitis, sepsis, or a temperature of 38°C or above
BP 160/110 mmHg or above
Oxytocin
Significant meconium
Vaginal bleeding develops in labour
In a CTG, a HR of <100 is caused by..
Increased fetal vagal tone, maternal beta-blocker use
In a CTG, a HR of >160 is caused by..
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
In a CTG, a loss of baseline variability (<5) is caused by..
Prematurity, hypoxia
In a CTG, early deceleration is caused by..
Innocuous feature - indicates head compression
In a CTG, late deceleration is caused by..
Fetal distress e.g. asphyxia or placental insufficiency
In a CTG, variable deceleration is caused by..
Cord compression
Early onset GBS infection occurs within…
48h of birth
Surgical mx of PPH in order
Intrauterine balloon tamponade
B-Lynch suture
Stepwise uterine devascularisation
Uterine artery embolisation
Hysterectomy
During pregnancy, lithium is switched for..
An atypical antipsychotic
Right upper quadrant pain, which can radiate up to the shoulder + vaginal discharge and fever.
Fitz–Hugh–Curtis syndrome
For nulliparous and multiparous women, the recommended time for ECV is ____ and ____ weeks respectively
For nulliparous and multiparous women, the recommended time for ECV is 36 and 37 weeks respectively
What is a complete mole?
Occurs when one or two sperm fertilise an egg that contains no chromosomal material. Therefore there is no maternal chromosomal material. A placenta is formed but there is no embryo
What is a partial mole?
Occurs when two sperm fertilise a normal egg and instead of forming twins, there is an abnormal proliferation of tissue. There is embryonic tissue, but this is not a viable pregnancy.
Patient began to bleed after delivery and the uterine fundus is no longer palpable in the abdomen
Inversion of the uterus
Tx for inversion of the uterus
Johnson manoeuvre, hydrostatic methods, and laparotomy.
Ix for inversion of uterus
Mostly clinical but ultrasound imaging can be used to confirm the diagnosis
Occasional decelerations in the foetal heart rate with good recovery and no other signs of foetal distress
Normal labour variation
Persistent decelerations in the foetal heart rate, poor variability, or late decelerations
Foetal distress
Sudden prolonged decelerations in the foetal heart rate, often with a rapid recovery once the mother’s blood pressure is corrected
Maternal hypotension
A variability of 3 bpm for 30 minutes most likely indicates..
Foetus is asleep
A reduced variability of less than __bpm for over ___minutes is seen as worrying and if this continues for over ___minutes, it is considered abnormal
A reduced variability of less than 5 bpm for over 40 minutes is seen as worrying and if this continues for over 90 minutes, it is considered abnormal
Borderline fetal pH
7.21 to 7.24
Abnormal fetal pH
7.20 or below
Borderline fetal lactate
4.2 to 4.8 mmol/l
Abnormal fetal lactate
4.9 mmol/l or above
If the foetal blood sample result is abnormal..
Inform a senior obstetrician and the neonatal team
Talk to the woman about what is happening and take her preferences into account
Expedite the birth
If the foetal blood sample result is borderline and there are no accelerations in response to foetal scalp stimulation, consider..
Taking a second foetal blood sample no more than 30 minutes later
If the foetal blood sample result is normal and there are no accelerations in response to foetal scalp stimulation, consider..
Taking a second foetal blood sample no more than 1 hour later
Something coming forward
Rectocele
Something coming downards
Uterine prolapse
Effacement and dilatation up to 4cm
Latent first stage of labour
Regular painful contractions and progressive cervical dilatation from 4cm
Established first stage of labour
Full cervical dilatation, defined as 10cm, before or in the absence of involuntary expulsive contractions
Passive second stage of labour
Full cervical dilatation, defined as 10cm, active maternal pushing, and the baby is visible
Active second stage of labour
the period between the baby’s delivery and expulsion of the placenta and membranes
Third stage of labour
Placenta accreta occurs due to a risk factor of..
Old Caesarean scar
Which nerve injuries is most commonly seen as a complication to shoulder dystocia?
Erb’s palsy
MOA of mifepristone
Synthetic steroid that acts as an antiprogestogen. Progesterone is essential for a pregnancy to develop and continue so it stops the development of the pregnancy
MOA of misoprostol
Synthetic prostaglandin E1 analogue. It binds to smooth muscle cells within the myometrial layer of the uterus and increases the strength and frequency of contractions, it aids the expulsion of the pregnancy tissue.
Which drug can be used to improve the success rate of external cephalic version?
Beta-2 receptor agonists such as terbutaline, ritodrine and salbutamol
Which is a normal interpretation of a CTG in the first stage of labour?
Baseline rate: 125bpm
Variability: 15bpm
Accelerations: present
Decelerations: absent
Abdominal pain, menorrhagia, boggy’ uterus with subendometrial linear striations
Adenomyosis
Menorrhagia, anaemia, bulk-related symptoms e.g. bloating/urinary frequency
Uterine fibroids
Define pre-existing hypertension
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
Common long term complications of vaginal hysterectomy with antero-posterior repair include..
Enterocoele and vaginal vault prolapse
_____________ may occur acutely following hysterectomy, but it is not usually a chronic complication
Urinary retention
If a breastfed baby loses > 10% of birth weight in the first week of life then referral to a _____________ _____________ clinic may be appropriate
If a breastfed baby loses > 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate
No method of contraception is contraindicated by age alone. All methods are UKMEC1 except for..
COCP (UKMEC2 for women >= 40 years)
Depo-Provera (UKMEC2 for women > 45 years)
What are the three stages of postpartum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
_____________ antibodies are found in 90% of patients with postpartum thyroiditis
Thyroid peroxidase
Mx for postpartum thyroiditis
Thyrotoxic phase - propranolol
Hypothyroid phase - thyroxin
Posterior vaginal fornix tenderness due to involvement of the uterosacral ligament + uterine motion tenderness
Endometriosis
Cervical motion tenderness
PID
Around 50% of cord prolapses occur at..
Artificial rupture of the membranes
What causes primary dysmenorrhoea?
Endometrial prostaglandin production
Tx for Primary dysmenorrhoea
NSAIDs such as mefenamic acid and ibuprofen
COCP
What causes secondary dysmenorrhoea?
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Copper coils
Fibroids
Mx fo secondary dysmenorrhoea
Refer to gynae
Maternal diabetes causes polyhydramnios/oligohydramnios
Polyhydramnios
The COCP is protective against which cancer?
Ovarian and endometrial cancer
What is the most important sign to elicit in pre-eclampsia?
Brisk tendon reflexes - increased ICP/oedema resultant from severe hypertension compresses descending UMN of the corticospinal tracts, inciting hyper-reflexia as an early clinical sign
Which blood test is used to monitor treatment of DVT in pregnancy?
Anti-Xa but only if less than 50 kg and 90 kg or more or with other complicating factors (for example, with renal impairment or recurrent VTE)
Which SSRIs can be used during breastfeeding?
Sertraline or paroxetine
Screening for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome is offered between ___ and ___ weeks of pregnancy
Screening for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome is offered between 10 and 14 weeks of pregnancy
The fetal anomaly scan, checking the physical development of the baby, is offered at ___ weeks
The fetal anomaly scan, checking the physical development of the baby, is offered at 20 weeks.
Name the conditions for which screening should not be offered
Bacterial vaginosis
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B Streptococcus
Toxoplasmosis
There can be positional changes in fetal movement awareness, generally being more prominent during ___________ and less when ________ and ________
There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
Patient with anterior/posterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
Both alcohol and sedative medications like _______ or ______________ can temporarily cause reduced fetal movements
Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
Oligohydramnios/polyhydramnios can cause reduction in fetal movements
Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
Anterior/Posterior fetal position means movements are less noticeable
Anterior fetal position means movements are less noticeable
Up to 29% of women presenting with RFM have a _____ fetus
SGA
Examples of contraceptives that are unaffected by EIDs are…
Copper intrauterine device
Progesterone injection (Depo-provera)
Mirena intrauterine system
Hyperemesis gravidarum triad
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
The only form of contraception that is recommended by the as having no contraindication to a migraine with aura is..
Copper IUD
Problems with IUD?
Make periods heavier, longer and more painful
Problems with IUS?
Initial frequent uterine bleeding and spotting
After giving birth, women require contraception after day..
21
When is the POP pill started after birth?
Any time
When is the COCP pill started after birth?
UKMEC 4 - if breastfeeding < 6 weeks post-partum
UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum
Should not be used in the first 21 days - after day 21 use it with additional contraception for the first 7 days
When is the IUD/IUS started after birth?
48 hours of childbirth or after 4 weeks
Test results for premature ovarian insufficiency
raised FSH, LH levels
e.g. FSH > 40 iu/l
elevated FSH levels should be demonstrated on 2 blood samples taken 4–6 weeks apart
low oestradiol
e.g. < 100 pmol/l
Low levels of gonadotrophins indicate a ________ cause whereas raised levels suggest an __________ problem (e.g. Premature ovarian failure)
Hypothalamic
Ovarian
Primary amenorrhoea causes
gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen
Secondary amenorrhoea causes
hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis*
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)
Hormonal contraception can be started _____________ after using levornogestrel (Levonelle) for emergency contraception
Immediately
Contraception with the pill, patch or ring should be started _____________ after using ulipristal acetatefor emergency contraception
5 days
Lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Ectopic pregnancy
Associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Hydatidiform mole
Human chorionic gonadotropin (hCG) is a hormone first produced by the ________ and later by the ________ ________
Human chorionic gonadotropin (hCG) is a hormone first produced by the embryo and later by the placental trophoblast
Role of hCG
Prevent the disintegration of the corpus luteum
hCG levels peak around…
8-10 weeks gestation
Cyclical pelvic pain that is worse around periods. The pain starts 2 days before the period and lasts until several days after. Associated dyspareunia and has had some painful bowel movements
Endometriosis
Mx for endometriosis
NSAIDS/paracetamol
COCP or progesterone e.g. medroxyprogesterone acetate if no interest in starting a family
If fertility is a priority, then GnRH analogues
Laparoscopic excision or ablation of endometriosis plus adhesiolysis or ovarian cystectomy
Hypoechoic masses
Fibroids
Tx for ovarian torsion
Laparoscopy
Who gets intrapartum antibiotic prophylaxis?
Women who’ve had GBS detected in a previous pregnancy
Women with a previous baby with early- or late-onset GBS disease
Women in preterm labour regardless of their GBS status
Women with a pyrexia during labour (>38ºC)
Around 50% of cord prolapses occur at…
Artificial rupture of the membranes
Mx for cord prolapse
Patient is asked to go on ‘all fours’ - left lateral position is an alternative
Tocolytics to reduce uterine contractions
Retrofilling the bladder with 500-700ml of saline
Caesarian section is first-line method of delivery but an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low
Women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
Chorioamnionitis
Tx for Chorioamnionitis
Prompt delivery of the foetus (cesarean section if necessary) and intravenous antibiotics
Mx for Shoulder dystocia
HELPERR
H = call for Help immediately!
E = consider Episiotomy (continuous)
L = Legs! (McRobert’s)
P = Pressure! (suprapubic 30sec continuous then 30sec rocking)
E = ‘Enter’ manoeuvres
R = Remove posterior arm! (Pringles hand)
R = Rotate mum (on all four)
Course of action if the patch change is delayed at the end of week 1 or week 2
If <48 hours then it should be changed immediately and no further precautions are needed
If >48 hours then it should be changed immediately and a barrier method of contraception used for the next 7 days. If there was UPSI in last 5 days or intercourse during this extended patch-free interval then emergency contraception needs to be considered
Course of action if the patch change is delayed at the end of week 3
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle
Dilatation measurement of cervix during the first stage of labour
Latent phase = 0-3 cm dilation, normally takes 6 hours
Active phase = 3-10 cm dilation, normally 1cm/hr
Head enters pelvis in ____________ position. The head normally delivers in an ____________ position
Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position
_____________ is the most common cause of pelvic inflammatory disease
Chlamydia trachomatis
++ Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
Mx for PID
Oral ofloxacin + oral metronidazole
Or
IM ceftriaxone + oral doxycycline + oral metronidazole
Mx for primary dysmenorrhoea
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
Mx for secondary dysmenorrhoea
Referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
Indications for a forceps delivery
Fetal/maternal distress in the second stage of labour
Failure to progress in the second stage of labour
Control of head in breech deliver
Requirements for instrumental delivery
FORCEPS:
Fully dilated cervix the second stage of labour
OA position preferably. OP delivery is possible with Keillands forceps and ventouse
Ruptured Membranes
Cephalic presentation
Engaged presenting part i.e. head at or below ischial spines, the head must not be palpable abdominally
Pain relief
Sphincter (bladder) empty
More than 35 years old and smoking less than 15 cigarettes/day
BMI > 35 kg/m^2*
Family history of thromboembolic disease in first Degree relatives < 45 years
Controlled hypertension
Immobility e.g. wheel chair use
Carrier of known gene mutations associated with Breast cancer (e.g. BRCA1/BRCA2)
Current gallbladder disease
Which UKMEC is this?
UKMEC 3
More than 35 years old and smoking more than 15 cigarettes/day
Migraine with aura
History of thromboembolic disease or Thrombogenic mutation
History of stroke or ischaemic heart disease
Breast feeding < 6 weeks post-partum
Uncontrolled hypertension
Current breast cancer
Major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
Which UKMEC is this?
UKMEC 4
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC __ or __depending on severity
Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity
Contraceptives - time until effective (if not first day period):
instant: ?
2 days: ?
7 days: ?
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Anticholinergics for urge incontinence are associated with confusion in elderly people - ______________ is a preferable alternative
Anticholinergics for urge incontinence are associated with confusion in elderly people - mirabegron is a preferable alternative
Presence of slight proteinuria in isolation in pregnancy can be..
Physiological and does not mean pre-eclampsia is present
Management of chickenpox exposure in pregnancy
<20 wk non-immune: VZIg within 10 days
>20 wk non-immune: VZIg / acyclovir after 7-14 days
Management of chickenpox in pregnancy
< 20 wk - consider acyclovir with caution
>20 wk - acyclovir within 24hr of rash
1st and 2nd most common cause of placental rupture
1st - placental rupture
2nd - placental praevia
Fresh vaginal bleeds developing in labour could be a sign of…
Placental rupture or praevia
Intermenstrual bleeding, post-menopausal bleeding, menorrhagia or irregular bleeding
Endometrial hyperplasia
Risk factors for placental abruption
ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Trauma + Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
Abdominal distension, abdominal pain, and bowel and bladder dysfunction symptoms
Ovarian cancer
________ is a protective factor from Endometrial hyperplasia and HG
Smoking
VEAL CHOP
Variable decelerations –> Cord compression
Early decelerations –> Head compression
Accelerations –> Okay!
Late decelerations –> Placental Insufficiency
Asymmetrical uterus, abnormal myometrial echo texture and myometrial cysts
Adenomyosis
Adenomyosis/Endometriosis is typically seen in multiparous women towards the end of their reproductive years
Adenomyosis
Primary amenorrhoea, this is associated with the development of male secondary sexual characteristics in females (such as deep voice and hirsutism)
Congenital adrenal hyperplasia
Primary amenorrhoea. Increased testosterone and examination shows little to no axillary or pubic hair and bilateral lower pelvic masses
Androgen insensitivity syndrome
Secondary amenorrhoea. Anorexia or excessive exercise FSH and LH are decreased
Functional hypothalamic amenorrhoea
Primary amenorrhoea. No evidence of starting puberty, including axillary and pubic hair. Hypogonadism. FSH and LH would be elevated
Turner’s syndrome
Which incontinence is managed with pelvic retraining exercise?
streSSS incontinence = PelvisSSS i.e. pelvic retraining
Stress incontinence: caused by weak urethral sphincters which are controlled by pelvic floor muscles (which can be exercised)
Urge incontinence: caused by overactive detrusor muscle (which can be neurologically re-trained)
Vulval carcinoma vs VIN
Vulval carcinoma: lump or ulcer on the labia majora
inguinal lymphadenopathy
may be associated with itching, irritation
VIN: itching, burning
raised, well defined skin lesions
Only certain antibiotics that are ________________________ can decrease the effectiveness of hormonal contraceptives
Enzyme-inducing (such as rifampicin or rifabutin)
When is OGTT done?
Immediately after booking (if previous pregnancy had gestational diabetes) and at 24-28 weeks
COCP causes an increased risk of which cancer?
Breast and Cervical
COCP
COCP is protective against which cancer?
Ovarian and Endometrial
When in transverse lie, the foetus can be either _____________ (most common) where the foetus faces towards the mother’s back or _____________ where the foetus faces towards the mothers front
When in transverse lie, the foetus can be either ‘scapulo-anterior’ (most common) where the foetus faces towards the mother’s back or ‘scapulo-posterior’ where the foetus faces towards the mothers front
Contra-indications for ECV?
Three Ms:
Maternal rupture in the last 7 days
Multiple pregnancy (except for the second twin)
Major uterine abnormality
Heavy menstrual bleeding, discomfort during sexual intercourse (dyspareunia), and a feeling of abdominal bloating or fullness
Fibroids
The serum βhCG is 453,000 mIU/ml indicates a a diagnosis of…
300,000 mIU/ml is approximately the upper limit of expected βhCG in an…
The serum βhCG is 453,000 mIU/ml indicates a a diagnosis of complete hydatidiform mole
300,000 mIU/ml is approximately the upper limit of expected βhCG in an intrauterine pregnancy during weeks 9-12
When switching from an IUD to COCP no additional contraception is needed if removed day ____ of cycle
1-5 of cycle
Examples indications for a category 1 caesarean section include..
Suspected uterine rupture
Major placental abruption
Cord prolapse
Fetal hypoxia or persistent fetal bradycardia
The normal frequency of contractions is..
4 or less in the space of 10 minutes
Which contraceptive is given in migraines with aura?
POP (doesn’t have oestrogen)
The most common explanation for short episodes (< 40 minutes) of decreased variability on CTG is that the foetus is __________. However, if the decreased variability lasts for more than _____ minutes, we start to worry.
The most common explanation for short episodes (< 40 minutes) of decreased variability on CTG is that the foetus is asleep. However, if the decreased variability lasts for more than 40 minutes, we start to worry.
Definitive treatment for placenta praevia
C-section
Definitive treatment for placental abruption once the cardiotocograph has confirmed that there is no foetal distress
Vaginal delivery (so if not, then C-section)
To investigate a pregnancy of unknown origin, a b-hCG is performed 48 hours apart. If the levels fall then it is suggested that..
The foetus will not develop or there has been a miscarriage
To investigate a pregnancy of unknown origin, a b-hCG is performed 48 hours apart. If there is only a slight increase or a plateau then it suggests a..
Ectopic pregnancy
To investigate a pregnancy of unknown origin, a b-hCG is performed 48 hours apart. If there is a normal increase then it suggests that..
The foetus is growing normally, but does not exclude an ectopic pregnancy
How to investigate a pregnancy of unknown origin?
Perform serial serum B-hCGs 48 hours apart
Transvaginal ultrasound to potentially identify the location of the pregnancy
Mx of a prolonged second stage
Instrumental delivery
Caesarean section if instrumental delivery is not possible or contraindicated. However, a caesarean section in the second stage is associated with increased maternal morbidity
Give examples of pelvic organ prolapse in the anterior vaginal wall
Cystocele: bladder (may lead to stress incontinence)
Urethrocele: urethra
Cystourethrocele: both bladder and urethra
Give examples of pelvic organ prolapse in the posterior vaginal wall
Enterocele: small intestine
Rectocele: rectum
Give examples of pelvic organ prolapse in the apical vaginal wall
Uterine prolapse: uterus
Vaginal vault prolapse: roof of the vagina (common after hysterectomy)
Ix for genital prolapse
Detailed pelvic examination
Ultrasound or MRI in complex cases or for surgical planning
Urodynamic studies if there are co-existing urinary symptoms
Mx for pelvic prolapse
Lifestyle modification (weight loss, smoking cessation, avoiding heavy lifting) and pelvic floor exercises
Pessary use
Surgical repair - native tissue repairs or the use of mesh. Can be vaginal, abdominal, or laparoscopic/robotic
FIGO staging for 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
Amenorrhoea, abdominal and shoulder tip pain, abdominal distension and haemodynamic instability
Ruptured ectopic pregnancy
This is the most common cause of secondary postpartum haemorrhage is..
Postpartum endometritis
Broad-spectrum antibiotics and laxatives should be given post-operatively after surgical repair of a ______ degree tear
3rd/4th degree tear
Tender, woody uterus with no PV bleeding
Placental abruption
What is pre-term labour?
The onset of regular uterine contractions accompanied by cervical changes occurring before 37 weeks gestation
What is pre-term birth?
The delivery of a baby after 20 weeks gestation but before 37 weeks gestation
What is premature rupture of membranes?
The rupture of membranes at least one hour before the onset of contractions
What is prolonged premature rupture of membranes?
The rupture of membranes more than 24 hours before the onset of labour
What is preterm premature rupture of the membranes ?
Early rupture of the membranes before 37 weeks gestation
Ix for preterm delivery
Foetal fibronectin test - negative indicates a low risk of delivery occurring within the next 7-14 days
Mx for preterm labour
Corticosteroids
IV abx if GBS
Penicillin if no allergies
Tocolytic agent - Nifedipine
How to differentiate between a uterine prolapse and -celes?
Cervix is normal in a uterine prolapse
Often presents with sudden-onset abdominal pain, which typically starts during exercise (such as physical activity or sexual intercourse)
Ovarian cyst rupture
Women over the age of 45 with irregular bleeding should be investigated with..
TVUS to rule out endometrial hyperplasia/cancer
Causes of polyhydramnios
Maternal diabetes, foetal renal disorders or chromosomal disorders
The sudden onset of abdominal pain and loss of contractions during labour, especially in the context of previous caesarean section, strongly suggests…
Uterine rupture
Mx for lichen sclerosus
Topical corticosteroids to reduce inflammation and itching.
Avoidance of soaps in the affected areas to prevent further irritation.
Use of emollients to relieve dryness and soothe itching.
____________ can cause aqueductal stenosis leading to congenital hydrocephalus
Rubella
Raised testosterone and LH
Low sex hormone binding globulin (SHBG)
Normal FSH
PCOS
Mx for TTTS
Laser transection of the problematic vessels in-utero
In TTTS, both foetuses are at risk of developing…
Heart failure and hydrops
In TTTS, the donor twin suffers from…
High output cardiac failure due to severe anaemia
In TTTS, the recipient twin suffers from…
Fluid overload
Factors leading to a larger _______ increase the risk of pre-eclampsia. This includes ____________, ____________ and ____________
Factors leading to a larger placenta increase the risk of pre-eclampsia. This includes twin or multiple pregnancies, fetal hydrops and molar pregnancy
Clincal picture of unilateral pain and localised peritonism, combined with no evidence of ectopic pregnancy or acute inflammation
Ruptured ovarian cyst
Ix for a ovarian cyst
A pregnancy test to exclude an ectopic pregnancy
Diagnostic laparoscopy, particularly in cases where the patient is unstable
Mx for ovarian cyst
Conservative: monitoring and pain management
Laparoscopy or, in more severe cases, laparotomy
Contraception is not required for the first ___ weeks after delivery
Contraception is not required for the first 3 weeks after delivery
How to estimate due date?
First, determine the first day of your last menstrual period.
Next, count back 3 calendar months from that date.
Lastly, add 1 year and 7 days to that date.
Mx of pain in obstetrics
Nitrous Oxide (Entonox or ““gas and air””)
Simple analgesia: E.g., Paracetamol.
Opiate analgesia: Including Oral Codeine Phosphate and IV/IM Diamorphine.
Epidural analgesia: A powerful form of pain relief used during labour.
Pudendal nerve block: A form of regional anesthesia
Polyhydramnios/oligohydramnios increases the risk of a breech presentation
Polyhydramnios
Chronic history of lower abdominal pain. The pain is rated as 4/10 in severity and described as a dull ache that occurs for about two days during the middle of each menstrual cycle. Site of the pain can vary between the right and left; however, it is predominately right-sided.
Mittelschmerz
When attempting instrumental delivery, the procedure should be abandoned if there is no foetal descent following ___ pulls. A __________________ is the gold standard approach for surgical delivery following this
When attempting instrumental delivery, the procedure should be abandoned if there is no foetal descent following 3 pulls. A lower segment caesarean section is the gold standard approach for surgical delivery following this
In nulliparous women, external cephalic version can be offered as early as..
36 weeks
In multiparous women, external cephalic version shoud be offered at term, as early as..
37 weeks
What is the most common type of uterine fibroid?
Intramural fibroids
Foetal renal agenesis is a risk factor for..
Polyhydramnios
Give examples of DOACs
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
Anything ending with -ban
Give examples of LMWHs
Bemiparin, Certoparin, Dalteparin, Enoxaparin, Nadroparin, Parnaparin, Reviparin, and Tinzaparin
Anything ending with -rin
Mx for fibroadenoma <3cm
Watchful waiting without biopsy
Mx for fibroadenoma >4cm
Core biopsy to exclude a phyllodes tumour
Soft, fluctuant swellings. Halo sign
Breast cyst
Mx for breast cyst
Aspirated and following aspiration the breast re-examined to ensure that the lump has gone.
Postmenopausal women. Cheese like/thick and green in colour nipple discharge and slit like retraction of the nipple
Duct ectasia
Tx for duct ectasia
No treatment - self limiting
Blood stained nipple discharge +/- underlying mass or axillary lymphadenopathy
Carcinoma
Young patient with blood stained discharge but no palpable lump
Intraductal papilloma
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
Adenomyosis
Adenomyosis is characterized by the presence of endometrial tissue within the..
Myometrium
Ix for adenomyosis
TVUS
Alt. - MRI
Tx for adenomyosis
Symptomatic treatment - tranexamic acid to manage menorrhagia
GnRH agonists
Uterine artery embolisation
Hysterectomy - definitive
Fever or elevated WCC and CRP
Mastitis and cellulitis
Involves the nipple from onset and spreads to the areola and breast. It presents with an eczema-like rash over the nipple with discharge and/or nipple inversion
Paget’s disease of the breast
Progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP. Elevated CA 15-3
Inflammatory breast cancer
What is the most common type of breast cancer
Invasive ductal carcinomas - some may arise as a result of ductal carcinoma in situ (DCIS)
Surgical treatment for breast cancer in a patient with small breasts and a large tumour
Mastectomy +/- Reconstruction
Surgical treatment for breast cancer in a patient with large breasts AND a large primary lesion
Breast conserving surgery even with a relatively large primary lesion (tumours >4cm is the recommendation for mastectomy)
+/- Reconstruction
The main operations in common use of reconstruction
Latissimus dorsi myocutaneous flap and sub pectoral implants
Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps
What is the criteria to warrant a mastectomy
Mastectomy:
Multifocal tumour
Central
Large lesion in small breast
DCIS >4CM
What is the criteria to warrant a wide local excision
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
Breast that tends to occur for a few days at a time each month in both breasts
Cyclical mastalgia
Cyclical mastalgia + point tenderness of the chest wall
Tietze’s syndrome
Tx for cyclical mastalgia
Supportive bra + standard oral and topical analgesia
If no response after 3months, affecting quality of life/sleep:
Referral. Consider hormonal agents such as bromocriptine and danazo
REFER suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are..
Aged 30 and over and have an unexplained breast lump with or without pain
OR
Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
CONSIDER referral for suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are..
Skin changes that suggest breast cancer or
Aged 30 and over with an unexplained lump in the axilla
Consider non-urgent referral in people with suspected breast cancer if they are..
Aged under 30 with an unexplained breast lump with or without pain
Risk factors for hyperemesis gravidarum
NOIF
Nulliparity
Obesity
Increased levels of beta-hCG (multiple pregnancies and trophoblastic disease)
Family or personal history of NVP
What is the definitive indication for surgical management of an ectopic pregnancy?
> 35 mm in size or with a serum B-hCG >5,000IU/L
Bulky uterus
Fibroids
Give examples of liver enzyme inducing medications
RAPS
Rifampicin
Anticonvulsants: phenytoin, carbamazepine, phenobarbitone, and primidone
Spironolactone
Sudden, strong need to urinate and often does not make it to the toilet in time
Overactive/urge incontinence
Prior to surgery, women with no palpable axillary lymphadenopathy at presentation should have..
Pre-operative axillary ultrasound before their primary surgery
if negative then they should have a sentinel node biopsy to assess the nodal burden
Prior to surgery, women with palpable axillary lymphadenopathy at presentation should have..
Axillary node clearance is indicated at primary surgery
Axillary node clearance can cause…
Arm lymphedema and functional arm impairment
When is radiotherapy indicated in breast cancer?
After a woman has had a wide-local excision
After a women has had a mastectomy for T3-T4 tumours and for those with four or more positive axillary nodes
When is adjuvant hormonal therapy offered in breast cancer?
If tumours are positive for hormone receptors
Which adjuvant hormonal therapy is offered in post-menopausal women?
Aromatase inhibitors such as anastrozole (for ER +ve)
Which adjuvant hormonal therapy is offered in peri-menopausal women?
Tamoxifen
Side effects of tamoxifen?
Endometrial cancer, venous thromboembolism and menopausal symptoms
The most common type of biological therapy used for breast cancer is..
Trastuzumab (Herceptin)
What is the downside of using biological therapy in breast cancer?
It is only useful in the 20-25% of tumours that are HER2 positive
Trastuzumab cannot be used in patients with a history of..
Heart disorders
When is cytotoxic therapy used in breast cancer?
Either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion
OR
After surgery depending on the stage of the tumour e.g. if there is axillary node disease - FEC-D is used in this situation
Mx for hirsutism and acne in PCOS
COC
Eflornithine
Spironolactone, flutamide and finasteride may be used under specialist supervision
Mx for infertility in PCOS
Clomifene (risk of multiple pregnancy) +/- metformin if obese
Gonadotrophins
Is a pill free interval necessary when taking the COCP pill?
No - taking the COCP continuously, without a pill-free break
Is a withdrawal bleed from contraception a real period?
No. It is an artificial bleed - the body’s response to the withdrawal of hormones
In duct ectasia, patients with troublesome nipple discharge may be treated by..
Nicrodochectomy (if young) or total duct excision (if older)
Mx if bishop score is <6
Vaginal prostaglandins or oral misoprostol
Balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
Mx if bishop score is >6
Amniotomy and an intravenous oxytocin infusion
Bishop score
“Be Proactive, Let’s Induce Now, Baby’s Coming!”
Baby’s s
Pelvic dilation
Length of cervix
Is cervix soft?
Number (consistency) of cervix
Cervical station
What is the main pathology that ultrasound monitoring performed between 16 and 24 weeks gestation aims to detect?
Twin-to-twin transfusion syndrome
What is the main pathology that ultrasound monitoring performed between after 24 weeks gestation aims to detect?
Fetal growth restriction
Reddening and thickening (may resemble eczematous changes) of the nipple/areola
Paget’s disease of the breast
Obese women with large breasts. May follow trivial or unnoticed trauma. Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Fat necrosis
What is Carboplatin used for?
Triple negative breast cancer.
What is Docetaxel NOT used for?
Breast cancers that are sensitive to endocrine or HER2-targeted therapy
_____________ can be used as a short-term option to rapidly stop heavy menstrual bleeding
Norethisterone
What gets checked for in week 8 - 12?
What gets checked for in week 10 - 13+6 weeks?
Early scan to confirm dates, exclude multiple pregnancy
What gets checked for in week 11 - 13+6 weeks?
Down’s syndrome screening including nuchal scan
What gets checked for in 16 weeks?
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
What gets checked for in 18 - 20+6 weeks?
Anomaly scan
What gets checked for in 28 weeks?
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
What gets checked for in 34 weeks?
Routine care
Second dose of anti-D prophylaxis to rhesus negative women
Information on labour and birth plan
Two risk factors for placenta accreta
Previous caesarean-section
Previous pelvic inflammatory disease
____________ is the recommended treatment for delayed placental delivery in patients with placenta accreta
Hysterectomy
Mx for stage 1 cervical cancer
Gold standard of treatment is hysterectomy +/- lymph node clearance
Nodal clearance or radical trachelectomy for A2 tumours
For patients wanting to maintain fertility: cone biopsy with negative margins
The pain was initially periumbilical but is now worse in the lower abdomen
Appendicitis
Intermittent pain in the left iliac fossa for the past 3 months. The pain is often worse during intercourse. She also reports urinary frequency and feeling bloated. There is no dysuria or change in her menstrual bleeding
Why is this an ovarian cyst and NOT fibroids?
Patient’s too young for fibroids
Localised to one side
No menorrhagia
No palpable pelvic mass
Galactocele is due to occlusion of a _________ duct
Lactiferous
A galactocele can be differentiated from an abscess by the fact that a galactocele is usually..
Painless with no local or systemic signs of infection
Firm and non-tender, with no surrounding skin change. An ultrasound scan shows a well-circumscribed lesion and aspiration yields a white fluid
Galactocele
How is symphysis-fundal height in cm calculated after 20 weeks?
Symphysis-fundal height in cm = gestation in weeks (+/- 2cm)
The symphysis-fundal height (SFH) is measured from the top of the __________ to the top of the __________ in centimetres
The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres
Why are mammograms not typically the first line of investigation in women below the age of 40?
Because the dense breast tissue can make the results harder to interpret
First line of investigation in women below the age of 40 when suspecting a breast lump?
Ultrasound
Which contraceptives increase the risk of ectopics?
IUD
POP
Risk factors for ectopic pregnancy
E- endometreosis
C- Copper coil
T- Tube damage (PID, surgery)
O- Only progesterone pill
P- previous ectopic
IC- IVF
Which renal condition can increase the risk of PROM?
Pyelonephritis
T or F: An instrumental vaginal delivery is contra-indicated in cord prolapse
False - possible if the cervix is fully dilated and the head is low
Which breast condition is common in smokers and may present with recurrent infections?
Periductal mastitis
if it’s subareolar swelling, it’s a duct ectasia/periductal mastitis
Duct ectasia
if it’s periareolar swelling, it’s a duct ectasia/periductal mastitis
Periductal mastitis
Discharge in a multiparous postmenopausal woman. Nipple retraction but no bleeding
Duct ectasia
Premenopausal smoker with signs of inflammation. Nipple retraction but no bleeding
Periductal mastitis
Sudden breast pain then becomes painless and tends to be self-limiting. Presents as a red cord-like fibrous band
Mondor’s
Tx for periductal mastitis
Co-amoxiclav
____________ disease of the breast is a localised thrombophlebitis of a breast vein
Mondor’s
Neither periductal/ductal mastitis cause bleeding. If it’s bleeding it’s either ________ (older woman) or ________ ________ (young woman)
Neither periductal/ductal mastitis cause bleeding. If it’s bleeding it’s either cancer (older woman) or intraductal papilloma (young woman)
The first onset of fetal movements is known as quickening. This usually occurs between ______ weeks gestation, and increase until ___ weeks gestation at which point the frequency of movement tends to plateau
The first onset of fetal movements is known as quickening. This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau
Multiparous women will usually experience fetal movements from _______ weeks gestation. Towards the end of pregnancy, fetal movements should not reduce
Multiparous women will usually experience fetal movements from 16-18 weeks gestation. Towards the end of pregnancy, fetal movements should not reduce
How often is depo provera given?
Every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions
What is a disadvantage of depo provera?
Cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
Which contraceptive causes weight gain?
Depo provera
Depo provera can increase the risk of which condition?
Osteoporosis
Depo provera is contra-indicated in which type of cancer?
Breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3
Outline the conditions for UKMEC 3
“Old Smokers Find Chairs Comfortable Inside Galleries”
O: >35 years old and BMI > 35 kg/m
S: <15 cigarettes/day
F: family history of thromboembolic disease in first-degree relatives <45 years
C: immobility (e.g., wheelchair use)
C: controlled hypertension
I: BRCA1/BRCA2
G: current gallbladder disease
Outline the conditions for UKMEC 4
“SMASH BUBP”
S: >35 years old and smoking >15 cigarettes/day
M: migraine with aura
A: history of thromboembolic/arterial disease or thrombogenic mutation
S: history of **stroke or ischaemic heart disease
H: high uncontrolled BP
B: breastfeeding < 6 weeks post-partum
U: major su**rgery with prolonged immobilization
**B: **current breast cancer
P: positive antiphospholipid antibodies (e.g., in SLE)
What are the side effects for GnRH agonists?
menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
Smoking is anti-oestrogenic and ___________ cancer is oestrogen-dependent
Endometrial
Mx of endometrial cancer
Localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy
Patients with high-risk disease may have postoperative radiotherapy
Mx of endometrial cancer in frail elderly women not considered suitable for surgery
Progestogen therapy
After managing an incomplete miscarriage, a pregnancy test should be performed at..
3 weeks
What are surgical options for a miscarriage?
Vacuum aspiration (suction curettage) or surgical management in theatre
Mx of septic miscarriage
Manual vacuum aspiration under local anaesthetic
Differentiate between incomplete and complete mole
“Incomplete Mix - Two Dads, One Mama Fix.”
“Complete Clone - Father’s Genes All Alone.”
What type of hydatidiform mole presents with snowstorm appearance?
Complete
What type of hydatidiform mole presents with foetal parts?
Incomplete
Uterus size greater than expected for gestational age
Complete hydatidiform mole
Abnormally high serum hCG
Complete hydatidiform mole
What does the following US show?
Complete hydatidiform mole - snowstorm appearance
What does the following US show?
Ovarian torsion - whirlpool sign
What are the three components of the RMI?
US findings, menopausal status and CA125 levels
In patients with urinary incontinence, make sure to rule out a UTI and diabetes mellitus using..
Urinalysis
Recurrent vaginal candidiasis is defined as ___ or more episodes per year
4 or more
Ix for recurrent thrush
Compliance with previous treatment should be checked
Confirm the diagnosis of candidiasis
High vaginal swab for microscopy and culture
Blood glucose test to exclude diabetes
Tx for recurrent thrush
Induction: oral fluconazole every 3 days for 3 doses
Maintenance: oral fluconazole weekly for 6 months
When is a TVUS indicated in menorrhagia?
Intermenstrual or postcoital bleeding
Pelvic pain and/or pressure symptoms
Abnormal pelvic exam findings
Next step if serum progestogen is <16
Repeat, if consistently low refer to specialist
Next step if serum progestogen is 16 - 30
Repeat
Next step if serum progestogen is >30
Indicates ovulation
Is there any COCP - St Johns wort interaction?
Yes - use condoms
Which contraceptives should be stopped at 50 years?
Depo-Provera
COCP
Which contraceptives should be stopped after 2 years of amenorrhoea in <50?
Non-hormonal (e.g. IUD, condoms, natural family planning)
Which contraceptives should be stopped after 1 year of amenorrhoea in >50?
Non-hormonal (e.g. IUD, condoms, natural family planning)
Which contraceptives can be continued beyond 50 years?
Implant, POP, IUS
If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
MOA if on COCP/POP and >50 years old
COCP: switch to non-hormonal or progestogen-only method
Depo-Provera: switch to either a non-hormonal method and stop after 2 years of amenorrhoea
OR
Switch to a progestogen-only method. If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years. If not amenorrhoeic consider investigating abnormal bleeding pattern
What is the BP target when treating pre-eclampsia?
<135/85
Contraception for transgender patients assigned female at birth and with a uterus
POP
IUS
Contraception for transgender patients assigned male at birth
Condoms
Course of action if missed a traditional POP (Micronor, Noriday, Nogeston, Femulen) <3 hours
No action required, continue as normal
Course of action if missed a traditional POP (Micronor, Noriday, Nogeston, Femulen) >3 hours
Take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
Continue with rest of pack
Extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Course of action if missed a erazette (desogestrel) POP <12 hours
No action required, continue as normal
Course of action if missed a erazette (desogestrel) POP >12 hours
Take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
Continue with rest of pack
Extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Ix for PPROM
Sterile speculum examination (to look for pooling of amniotic fluid in the posterior vaginal vault)
If pooling of fluid not observed then test the fluid for placental alpha microglobulin-1 protein (PAMG-1 e.g. AmniSure) or insulin-like growth factor binding protein‑1
US may be useful to show oligohydramnios
_____________ should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Glibenclamide/Glipizide
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
How often should a pregnant woman test blood glucose levels throughout her pregnancy?
Daily fasting, pre-meal and 1-hour post-meal bed time tests
Which chronic condition increases the risk of miscarriage?
All of them eg diabetes
Which uterine or cervical problems increases the risk of miscarriage?
Certain uterine abnormalities (Mullerian duct anomalies, large cervical cone biopsies)
Normal laboratory findings in pregnancy
Reduced urea, reduced creatinine, increased urinary protein loss
Fixed retroverted uterus
Endometriosis - the inflammation causes adhesions which results in the uterus being fixed and retroverted
Mx for a potential ectopic pregnancy and is <6 weeks
If bleeding, but NO pain or risk factors for ectopic pregnancy:
Return if bleeding continues or pain develops
Repeat a urine pregnancy test after 7–10 days and to return if it is positive, a -ve test means that the pregnancy has miscarried
What can cause cervical ectropion?
Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use)
Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a __________ incision. Smaller lesions may be removed using a __________
Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome
A fibroadenoma greater than 4cm attracts a recommendation for core biopsy to exclude a..
Phyllodes tumour
Tx for Fat necrosis
Imaging and core biopsy
Tx for duct papilloma
Microdochectomy
Periductal mastitis is associated with..
Smoking
Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated
Galactorrhoea
Mx for non-malignant nipple discharge involves excluding…
endocrine disease
Chronic breast or axillary sinus
Tuberculosis
Paget’s disease differs from eczema of the nipple in that it involves…
The nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema)
1st: bimanual uterine compression if can’t rub up contraction
2nd: Oxytocin (Syntocin) THEN Ergometrine unless the patient has hypertension
3rd: IM Carboprost
4th: Intramyometrial Carboprost
5th: Rectal Misoprostol (Or sublingual)
6th: Balloon Tamponade
7th: B-Lynch suture, ligation of uterine/iliac arteries
8th: life-saving emergency hysterectomy
Ectopic pregnancy is more dangerous if in..
Isthmus
In an ectopic pregnancy, __________ invades the tubal wall, producing bleeding which may dislodge the embryo
In an ectopic pregnancy, trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo
Tumour composed of both stromal and epithelial fragments. The tumour cells are often described as growing in a ‘leaf like’ pattern
Phyllodes tumour
Tumour shows irregularly distributed cells which form no obvious pattern, with atypically large nuclei. The basement membrane is not breached.
Ductal carcinoma in situ
Tumour shows abnormal proliferation of lobular cells which are small and round and arranged in a uniform pattern. They would also infiltrate the basement membrane
Invasive lobular carcinoma
Tumour shows an abnormal proliferation of small, round, lobular cells arranged in a uniform pattern. There would be no infiltration of the basement membrane
Lobular carcinoma in situ
Tumour shows irregularly distributed cells which form no obvious pattern, with atypically large nuclei. The basement membrane is breached
Invasive ductal carcinoma
What is the most common type of breast cancer?
Invasive ductal carcinoma
There are specific conditions in a patient’s family history that may consider them at higher risk for breast cancer, which warrant referral from primary care. These include…
Breast cancer in a first-degree male relative of any age
Breast cancer in a first-degree relative under the age of 40
Bilateral breast cancer in a first-degree relative under the age of 50
Breast cancer in two first-degree relatives
Smooth palpable lump that is growing in size
Malignant phyllodes tumour
A __________________ is an accumulation of pus in the area of the breast and develops as a complication of infectious mastitis. It is more frequently seen in primiparous women
A lactational breast abscess is an accumulation of pus in the area of the breast and develops as a complication of infectious mastitis. It is more frequently seen in primiparous women
TNM scoring system for breast cancer
N1: <4 lymph nodes
N2: 4-9 local lymph nodes (axillary or internal mammary)
N3: spread to supra- or infra-clavicular lymph nodes
Visible and palpable cord-like structure in the axillary region, as well as a sensation of tightness and pulling in the chest area, restricted shoulder movement, and pain
Axillary web syndrome
Swelling, discomfort, and a sensation of heaviness in the affected arm
Lymphoedema
Irregular, hard 3cm shaped lump in the lower lateral right breast. On putting the patient’s hands on her hips the lump appears fixed to deep tissue
Invasive breast cancer (fixed to pectoralis major)
Trauma to the breast tissue. Mammography shows an area of coarse, calcified tissue that may mimic the appearance of breast cancer
Fat necrosis of the breast
Lymphoedema vs seroma
Lymphoedema: gradual (18–24 months post-surgery) and widespread
Seroma: rapid (7–10 days post-surgery) and localised
Fluctuant tender lump with overlying erythema in a woman that recently gave birth
Breast abscess
Wilson criteria for screening
- Should be an important health problem
- Natural history of the condition should be understood
- There should be a recognisable latent or early symptomatic stage
- There should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
- There should be an accepted treatment recognised for the disease
- Treatment should be more effective if started early
- There should be a policy on who should be treated diagnosis and treatment should be cost-effective
- Case-finding should be a continuous process
Abx for group B strep
Benzylpenicillin
Abx for PPROM
Erythromycin
Abnormal cells will appear ________ when acetic acid is applied to the cervix
White
Aqueous iodine (also known as Lugol’s iodine) is used during colposcopy as part of cervical cancer screening. It will stain normal cells _________, but it is not taken up by cancerous cells, which appear __________ under microscopy
Aqueous iodine (also known as Lugol’s iodine) is used during colposcopy as part of cervical cancer screening. It will stain normal cells black/brown, but it is not taken up by cancerous cells, which appear yellow under microscopy
Which maternal drugs can cause oligohydramnios?
Prostaglandin inhibitors and ACE-inhibitors
Which fetal urine abnormalities can cause oligohydramnios?
Renal agenesis
Polycystic kidneys or urethral obstruction)
Which maternal conditions can cause oligohydramnios?
Hypertension, pre-eclampsia, maternal smoking and placental abruption
Clubbed feet, facial deformity, congenital hip dysplasia
Fetal compression due to oligohydramnios
Pulmonary hypoplasia in the fetus
Lack of amniotic fluid due to oligohydramnios
Ix for oligohydramnios
Ultrasound, which shows a reduced amniotic fluid index (AFI) or single deepest pocket (SDP)
Tx for oligohydramnios
Maternal rehydration
Amnioinfusion
Delivery
Differentiate between primary and secondary dysmenorrhoea
Primary: pain occurs before the start of menstruation
Secondary: pain starts with the onset of menstruation
Discharging sinus
Periductal mastitis
Tx for Triple-negative breast cancer
Neoadjuvant chemotherapy followed by surgery and adjuvant therapy
Raised FSH/LH
Reduced oestradiol level
Premature ovarian insufficiency
____________ is a protective factor for breast cancer
Breast-feeding is a protective factor for breast cancer
Ix for malignant phyllodes tumours
Mammography
Biopsy
Mx for malignant phyllodes tumours
Small tumours (<2cm): wide local excision, ensuring clear margins
Larger tumours: mastectomy
Thickened area of breast tissue alongside changes to the nipple or to the skin. It is difficult to detect using a mammogram and most women have a MRI scan of their breast to confirm/exclude the diagnosis.
Invasive lobular carcinoma
________ of the nipple can occur after puerperal mastitis is treated with antibiotics
Candida
Painful and itchy nipples, with flaky and cracked skin around the areola. Baby has white patches on his tongue
Candida of the nipple
Mobile, cyst-like lesion which can be tender - recently ceased breastfeeding
Galactocele
Patients with troublesome nipple discharge due to duct ectasia may be treated by ______________ (if young) or ______________ (if older)
Microdochectomy (if young)
Total duct excision (if older)
Reassurance if they’re not too fussed about it
What would help a pregnant woman quit smoking?
NRT
Hyperemesis gravidarum, diagnostic criteria triad
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
Mode of delivery if viral load is less than 50 copies/ml at 36 weeks
Vaginal delivery
Mode of delivery if viral load is more than 50 copies/ml at 36 weeks
C-section
Zidovudine infusion should be started four hours before
Zidovudine is usually administered orally to the neonate if maternal viral load is _________ Otherwise __________ should be used. Therapy should be continued for 4-6 weeks
Zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks
Conservative management for a prolapse
Weight loss, pelvic floor muscle exercises
Ring pessary
Surgery
Surgical option for a cystocele/ cystourethrocele
Anterior colporrhaphy, colposuspension
Surgical option for a uterine prolapse
Hysterectomy, sacrohysteropexy
Surgical option for a rectocele
Posterior colporrhaphy
Risk factor for placenta accreta
C section due to scarring and abnormal adherence of the placenta to the myometrium
Individuals who have been treated for CIN1, CIN2, or CIN3 should be invited _________ after treatment for a test of cure repeat cervical sample in the community
6 months
The latest gestational age where an abortion is legal from..
28 weeks to 24 weeks
An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to..
The physical or mental health of the mother or the existing children of the family
What are the legal requirements for an abortion?
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
Which medications are used in a medical abortion?
Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later
Rhesus negative women with a gestational age of ____ weeks or above having a medical TOP should have anti-D prophylaxis
10 weeks
Prior to surgical abortion, medications are used for…
Cervical priming
Option for surgical abortion up to 14 weeks
Vacuum aspiration (MVA) or electric vacuum aspiration (EVA)
Option for surgical abortion 14-24 weeks
Cervical dilatation and evacuation using forceps
When is a multi-level pregnancy test done after an abortion?
In 2 weeks
Following a surgical abortion, which contraceptive can be inserted immediately after evacuation of the uterine cavity?
IUD/IUS
Which type of bleeding is considered a red flag?
Intermenstrual
Postcoital bleeding
Major causes of bleeding in the first trimester
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
Major causes of bleeding in the second trimester
Spontaneous abortion
Hydatidiform mole
Placental abruption
Major causes of bleeding in the third trimester
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Ectopic pregnancy
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
Hydatidiform mole
Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus with normal lie and presentation. Fetal heart may be distressed
Placental abruption
Vaginal bleeding, no pain. Non-tender uterus but lie and presentation may be abnormal
Placental praevia
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
Vasa praevia
Ix for androgen insensitivity syndrome
Buccal smear or chromosomal analysis to reveal 46XY genotype
After puberty, testosterone concentrations are high-normal
Mx for androgen insensitivity syndrome
Counselling - raise the child as female
Bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
Oestrogen therapy
Which procedures can cause Asherman’s syndrome
Pregnancy-related dilatation and curettage
Uterine surgery (e.g. myomectomy)
Several pelvic infection (e.g. endometritis)
Ix for Asherman’s syndrome
Hysteroscopy
Hysterosalpingography
Sonohysterography
MRI scan
Tx for Asherman’s syndrome
Dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common
Which structure is affected in Sheehan’s syndrome?
Anterior pituitary gland - avascular necrosis
Which hormones are affected by Sheehan’s syndrome?
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin
Released from anterior pituitary gland
Which hormones are NOT affected by Sheehan’s syndrome?
Oxytocin
Antidiuretic hormone (ADH)
Released from posterior pituitary gland
Mx of Sheehan’s syndrome
Oestrogen and progesterone (until menopause)
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone
If an imperforate hymen is not treated retrograde menstruation could occur leading to…
Endometriosis
Girls will still menstruate, but can have difficulty with intercourse or tampon use
Perforate transverse vaginal septae
Which condition would present similarly to imperforate hymen?
Imperforate transverse vaginal septae
The upper vagina, cervix, uterus and fallopian tubes develop from the…
Paramesonephric ducts (Mullerian ducts)
Bacterial vaginosis is a loss of which bacteria?
Lactobacilli - makes the environment more acidic (pH <4.5) so prevents other bacteria from growing there
Fishy-smelling, watery grey or white vaginal discharge
Bacterial vaginosis
Clue cells on microscopy mean..
Bacterial vaginosis
Ix for bacterial vaginosis
Vaginal pH
Vaginal swab
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
Thin, white homogenous discharge
Clue cells on microscopy
Vaginal pH > 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)
Tx for bacterial vaginosis if asymptomatic
No treatment
Tx for bacterial vaginosis if symptomatic
Oral metronidazole
Topical metronidazole or topical clindamycin as alternatives
Painful ulcer and tender lymphadenopathy
Chancroid
Painless ulcer and non-tender lymphadenopathy
Syphilis
Painless ulcer and tender lymphadenopathy
Lymphogranuloma venereum
Painful genital blisters or sores, fever, headache, muscle aches and swollen glands in the groin area
Genital herpes
The ____________ is the contraceptive of choice amongst the epileptic population
Injection
If a smear displays 5 or more polymorphs per high power field, with no evidence of gram negative diplococci, the current guidance is to treat for ____________ infection empirically with ____________
If a smear displays 5 or more polymorphs per high power field, with no evidence of gram negative diplococci, the current guidance is to treat for chlamydia infection empirically with Doxycycline
Snowstorm appearance of axillary lymph nodes
Extracapsular breast implant rupture
Pain during pregnancy + hard and tender uterus
Placental abruption
Which form of contraceptive can be used in a PMH of PID?
Injectable/implantable contraceptive
Which form of contraceptive can be used in a PMH of gastric sleeve/bypass/duodenal switch?
Nexplanon implantable contraceptive
Braxton hicks occurs in the last ______ weeks of pregnancy
Four
During labour, head enters pelvis in ____________ position. The head normally delivers in an ____________
During labour, head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position
Main ovarian cancer sx
BEAT
B- bloating
E- eating difficulty (getting full more quickly)
A- abdominal or pelvic pain/mass
T- toilet changes (change in bowel/urinary habits)
Grey, gelatinous surface
Mucinous carcinoma
Bilateral nipple discharge is unlikely to be associated with..
Breast cancer - most likely hormonal changes especially if they’re young (due to puberty)
Which type of breast cancer presents with a discrete lump?
Invasive ductal carcinoma
Which type of breast cancer presents with an area of thickened breast tissue?
Invasive lobular carcinoma
There are two ways routine anti-D prophylaxis can be given: a one-dose injection between ____ and ____ weeks of pregnancy or two doses of injections at ____ weeks and ____ weeks of pregnancy
One-dose injection between 28 and 30 weeks of pregnancy
Two doses of injections at 28 weeks and 34 weeks of pregnancy
Skin lesions in newborn + some degree of congenital deformity (for instance hypoplastic limbs, neurological impairment)
Varicella Zoster Virus
Where are subserosal fibroids located?
Below the outer serosa of the uterus
Where are pedunculated fibroids located?
On a ‘stalk’ and are protruding into the uterine cavity
Where are submucosal fibroids located?
Below the endometrium
Where are transmural fibroids located?
Within the wall of the myometrium of the uterus
How does the cervical os look like in pregnancy compared to non-parous?
Parous: Slit-like
Non-parous: Pin-point
SCJ distance is increased/decreased in pregnancy?
Increased
Conditions for IOL
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
Components of a bishop score
Pregnancy Can Enlarge Dainty Stomachs! (Position, Consistency, Effacement, Dilation, Station)
Options for IOL
Membrane sweep
Vaginal prostaglandin E2 (if doesn’t work then cervical ripening balloon, if can’t use E2 then artificial rupture of membranes with an oxytocin infusion)
Two methods of monitoring IOL
Bishop score
CTG
Main complication of IOL iwth vaginal prostaglandins
Uterine hyperstimulation
Criteria for uterine hyperstimulation
Individual uterine contractions lasting more than 2 minutes in duration
More than five uterine contractions every 10 minutes
Uterine hyperstimulation can lead to ____________
Uterine rupture
Tx for uterine hyperstimulation
Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline
Which parameters are checked every four hours during labour?
Maternal BP and temp
VE
Maternal urine for ketones and protein
Which parameters are checked every 15 min during labour?
FHR
Which parameters are checked every 30 min during labour?
Contractions
Which parameters are checked every 60 min during labour?
Maternal pulse rate
Which risk factors can cause uteroplacental insufficiency and therefore oligohydramnios?
Hypertension, pre-eclampsia, maternal smoking and placental abruption
Which medications can cause oligohydramnios?
Prostaglandin inhibitors and ACE-inhibitors
Complications of oligohydramnios due to fetal compression?
Clubbed feet, facial deformity, congenital hip dysplasia
Complications of oligohydramnios due to lack of amniotic fluid?
Pulmonary hypoplasia in the fetus
A combination of fetal compression and lack of amniotic fluid is called…
Potter syndrome
Ix for oligohydramnios
US - amniotic fluid index (AFI) or single deepest pocket (SDP)
Mx for oligohydramnios
Maternal rehydration
Amnioinfusion
Delivery: IOL or c-section
Uterus which feels tense or large for dates and it may be difficult to feel the foetal parts on palpation of the abdomen
Polyhydramnios
Two main causes of polyhydramnios
Increased foetal urination
Reduced foetal swallowing
What causes increased foetal urination?
Maternal diabetes mellitus
Foetal renal disorders/anaemia
Twin-to-twin transfusion syndrome
What causes reduced foetal swallowing?
Oesophageal or duodenal atresia
Diaphragmatic hernia
Anencephaly
Chromosomal disorders
Tx for polyhydramnios
Management of any underlying causes (e.g. in maternal diabetes) and amnio-reduction in severe cases
Which contraceptive method is avoided in breast cancer?
Any hormonal one
Opt for copper coil or barrier methods
Which contraceptive method is avoided in cervical/endometrial cancer?
Intrauterine system (i.e. Mirena coil)
Which contraceptive method is avoided in Wilson’s disease?
Copper coil
The combined contraceptive pill can be used up to age ___ years, and can treat _____________ symptoms
The combined contraceptive pill can be used up to age 50 years, and can treat perimenopausal symptoms
The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of ____________
The progestogen injection (i.e. Depo-Provera) should be stopped before 50 years due to the risk of osteoporosis
Women that are amenorrhoeic (no periods) when taking progestogen-only contraception should continue until either..
FSH blood test results are above 30 IU/L on two tests taken six weeks apart (continue contraception for 1 more year)
55 years of age
Which contraceptive options are offered to women under 20?
Combined/POP
Progesterone implant - long acting reversible
Coils - risk of expulsion
The _____________ and _______ are considered safe in breastfeeding and can be started at any time after birth
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth
_____________ condoms can be used in latex allergy
Polyurethane condoms can be used in latex allergy
Using ________________ can damage latex condoms and make it more likely they will tear
Oil-based lubricants
Diaphragms and cervical caps are fitted before having sex, and are left in place for at least ___ hours after. They should be used with ____________ gel the further reduce the risk of pregnancy
Diaphragms and cervical caps are fitted before having sex, and are left in place for at least 6 hours after. They should be used with spermicide gel the further reduce the risk of pregnancy
What are dental dams?
Used during oral sex to provide a barrier between the mouth and the vulva, vagina or anus to prevent infections
Which COCP is used first line due to reduced risk of VTE?
Microgynon or loestrin
Which COCP is used first line for premenstrual syndrome?
Yasmin
Which COCP is used first line for acne and hirsutism?
Dianette (but higher risk of VTE so stop after 3 months)
COCP carries a small increased risk of ___________ and ___________ cancer, returning to normal ten years after stopping
Breast and cervical cancer
When using COCP, _______________ is common in the first three months and should then settle with time
Unscheduled bleeding
The COCP reduces the risk of which conditions?
Endometrial, ovarian and colon cancer
Benign ovarian cysts
Is additional contraception required when started the COCP?
No if started day 1-5 of menstrual cycle
If > day 5 then condoms for the first 7 days
When switching between COCPs, finish one pack, then start the new pill pack..
Immediately without pill free interval
When switching from a POP they can switch at any time but _________________ is required
7 days of extra contraception (i.e. condoms)
When switching from desogestrel to COCP, they can switch…
Immediately, and no additional contraception is required
Which conditions can reduce the effectiveness of COCP?
Vomiting, diarrhoea and medications (P450 inducers)
Smoking and Drinking in Barb’s and John’s Car Rifs her Phen
The only UKMEC 4 criteria for the POP is..
Active breast cancer
The traditional progestogen-only pill (Norgeston or Noriday) cannot be delayed by more than..
3 hours
The desogestrel-only pill (Cerazette) cannot be delayed by more than..
12 hours
Starting the POP on day 1 to 5 of the menstrual cycle means the woman is protected __________
Immediately
If the POP is started > 5day then additional contraception is required for _________
48 hours
POPs can be switched immediately without…
Extra contraception
When switching from a COCP to a POP, they can start without additional contraception if..
Have taken the COCP consistently for more than 7 days (they are in week 2 or 3 of the pill pack)
Are on days 1-2 of the hormone-free period following a full pack of the COCP
Common side effect of starting POP
Unscheduled bleeding in the first three months
The POP has a small increased risk of..
Ovarian cysts
Ectopic pregnancy with traditional POPs
Breast cancer, returning to normal ten years after stopping
Which method of contraception is unsuitable for those who wish to get pregnant in the near term?
Progestogen-only injection (Depo-Provera/Sayana-Press)
The Progestogen-only injection is given at ________ intervals and contains _______________
12-13 week intervals
Medroxyprogesterone acetate (a type of progestin
Noristerat is an alternative to the DMPA that contains _________ and works for ______ weeks. This is usually used as a ______ term interim contraception (e.g. after the partner has a ______)
Noristerat is an alternative to the DMPA that contains norethisterone and works for eight weeks. This is usually used as a short term interim contraception (e.g. after the partner has a vasectomy)
UKMEC 4 for progesterone only injection
Active breast cancer
UKMEC 3 for progesterone only injection
Ischaemic heart disease and stroke
Unexplained vaginal bleeding
Severe liver cirrhosis
Liver cancer
The DMPA can cause ___________. This is something to consider in older women and patients on ___________ for asthma or inflammatory conditions
The DMPA can cause osteoporosis. This is something to consider in older women and patients on steroids for asthma or inflammatory conditions
When is DMPA started?
1-5
if > day 5 then seven days of extra contraception
Signs and symptoms for DMPA
Weight gain
Acne
Reduced libido
Mood changes
Headaches
Flushes
Hair loss (alopecia)
Skin reactions at injection sites
The depot injection may be associated with a very small increased risk of ________ and ________ cancer
Breast and cervical cancer
Irregular bleeding can occur in the first ____ months of taking DMPA. The _________ can be taken alongside this to help settle the bleeding
Irregular bleeding can occur in the first six months of taking DMPA. The COCP can be taken alongside this to help settle the bleeding
Benefits for DMPA
Improves dysmenorrhoea and endometriosis symptoms
Reduces the risk of ovarian and endometrial cancer + severity of sickle cell crisis
The progestogen only implant lasts for _________
3 years
UKMEC 4 for progestogen only implant
Active breast cancer
When is the progestogen only implant used?
Day 1-5
iF > 5 days then additional contraception for 7 days
Benefits for progestogen only implant
It can improve dysmenorrhoea (painful menstruation)
It can make periods lighter or stop all together
Drawbacks of It can improve dysmenorrhoea (painful menstruation)
It can make periods lighter or stop all together
Worsening of acne
Problematic bleeding (add COCP for three months)
The implant can become impalpable or deeply implanted. Women are advised to ________________ occasionally, and if it becomes impalpable, ________________ is required until it is located
Rarely the implant can become impalpable or deeply implanted. Women are advised to palpate the implant occasionally, and if it becomes impalpable, extra contraception is required until it is located.
The copper coil can lead to..
PID
Levonorgestrel is not known to be harmful when breastfeeding, and breastfeeding can continue (unlikely __________)
Ulipristal
The combined pill or progestogen-only pill can be started ___________ after taking levonorgestrel
Immediately
The combined pill or progestogen-only pill can be started ________ after taking Ulipristal
5 days
Ulipristal should be avoided in..
Severe asthma
Breastfeeding for 1 week
Contraindications for coils
PID or infection
Immunosuppression
Pregnancy
Unexplained bleeding
Pelvic cancer
Uterine cavity distortion (e.g. by fibroids)
There may be some temporary crampy period type pain after insertion of coils. _________ may be used to help
NSAIDs
Women need to be seen 3 to 6 weeks after insertion of coils to check the _______. They should be taught to feel the _______ to ensure the coil remains in place
Women need to be seen 3 to 6 weeks after insertion of coils to check the threads. They should be taught to feel the strings to ensure the coil remains in place
Before the coil is removed, women need to __________ or ___________, or there is a risk of pregnancy. The strings are located and slowly pulled to remove the device
Before the coil is removed, women need to abstain from sex or use condoms for 7 days, or there is a risk of pregnancy. The strings are located and slowly pulled to remove the device
When the coil threads cannot be seen or palpated, three things need to be excluded…
Expulsion
Pregnancy
Uterine perforation
Ix for non-visible threads
US
Abdominal and pelvic xray to look for a coil in the abdomen or peritoneal cavity after a uterine perforation
Hysteroscopy or laparoscopic surgery may be required
Copper coil may reduce the risk of..
Endometrial and cervical cancer
The _____ is commonly used for contraception, menorrhagia and endometrial protection for women on HRT
LNG-IUS
The LNG-IUS can be inserted up to day __ of the menstrual cycle. If it is inserted after day __, __________ needs to be reasonably excluded, and __________ is required
The LNG-IUS can be inserted up to day 7 of the menstrual cycle. If it is inserted after day 7, pregnancy needs to be reasonably excluded, and extra protection (i.e. condoms) is required for 7 days
Benefits for LNG-IUS
Make periods lighter or stop altogether
May improve dysmenorrhoea or pelvic pain related to endometriosis
Problematic bleeding in LNG-IUS
First 6 months + can use COCP alongside this
Actinomyces-like organisms are often discovered incidentally during smear tests in women with an..
Intrauterine device (coil)
Tx for Actinomyces-like organisms
Removal of the intrauterine device
MOA of COCP
Inhibits ovulation
MOA of POP
Thickens cervical mucus
MOA for POP - desogestrel
Primary: Inhibits ovulation
Also: thickens cervical mucus
MOA for injectable contraceptives
Primary: Inhibits ovulation
Also: thickens cervical mucus
MOA for implant
Primary: Inhibits ovulation
Also: thickens cervical mucus
MOA for IUD
Decreases sperm motility and survival
MOA for IUS
Primary: Prevents endometrial proliferation
Also: Thickens cervical mucus
MOA for Levonorgestrel
Inhibits ovulation
MOA for ulipristal
Inhibits ovulation
MOA for IUD
Primary: Toxic to sperm and ovum
Also: Inhibits implantation
What would warrant continuous CTG monitoring during labour?
Suspected chorioamnionitis, or > 38°C
BP > 160/110 mmHg
Oxytocin use
Significant meconium
Fresh vaginal bleeding that develops in labour
Multiparous woman towards end of reproductive years. US shows asymmetrical uterus, abnormal myometrial echo texture and myometrial cysts
Adenomyosis
Which NSAID is not recommended in pregnancy?
Mefenamic acid
Fixed, retroverted uterus
Endometriosis
Incomplete emptying of urine
Overflow incontinence
A high voiding detrusor pressure with a low peak flow rate is indicative of…
Bladder outlet obstruction (Overflow incontinence)
High beta hCG
Low TSH
High thyroxine
Molar pregnancy
A spot urine protein:creatinine ratio of __mg/mmol or more is used as the threshold for proteinuria in pregnancy
30mg/mmol or more
__________ should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services
Vesicovaginal fistulae
Candidial infection (‘thrush’) is often precipitated or exacerbated by…
Recent antibiotic exposure
Menorrhagia, anaemia, bulk-related symptoms e.g. bloating/urinary frequency
Fibroids
Risk factors for placental abruption
ABRUPTION
Abruption previously
Blood pressure (i.e. hypertension or pre-eclampsia)
Ruptured membranes, either premature or prolonged
Uterine injury (i.e. trauma to the abdomen- C-section)
Polyhydramnios
Twins or multiple gestation/multiparity
Infection - chorioamnionitis;
Older age (>35 years old)
Narcotic (i.e. cocaine, amphetamines, smoking)
A cyst on US that has thin walls with no internal structures
Follicular cysts
_____________cysts are often seen in early pregnancy
Corpus luteum cysts
Give two types of sex-cord-stromals tumours seen in women
Sertoli–Leydig cell tumours and granulosa cell tumours
Which cyst causes:
A deep voice
Enlarged clitoris
Facial hair
Loss in breast size
Stopping of menstrual periods
Sertoli–Leydig cell tumours
Which cyst causes the following symptoms due to high oestrogen?
Abnormal uterine or postmenopausal bleeding
Increased abdomen size
Irregular menstrual cycles or absence of menses
Tender or sore breasts
Granulosa cell tumours
Factors that will reduce the risk of ovarian cancer
Anything that decreases ovulations
Later onset of periods (menarche)
Early menopause
Any pregnancies
Use of the combined contraceptive pill
Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour. These are..
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
Mx for a simple ovarian cysts in premenopausal women that is <5cm
Always resolve within three cycles. They do not require a follow-up scan
Mx for a simple ovarian cysts in premenopausal women that is 5cm-7cm
Routine referral to gynaecology and yearly ultrasound monitoring
Mx for a simple ovarian cysts in premenopausal women that is >7cm
MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound
Ovarian fibroma (a type of benign ovarian tumour)
Pleural effusion
Ascites
Meig’s Syndrome
A fibroid that is within the myometrium is called..
Intramural
A fibroid that is below the outer layer of the uterus is called..
Subserosal
A fibroid that is below the lining of the uterus is called..
Submucosal
A fibroid that is on a stalk is called..
Pedunculated
Ix for fibroids
Hysteroscopy if submucosal + heavy bleeding
Pelvic US if large
MRI scanning before surgery
Surgical options for managing smaller fibroids with heavy menstrual bleeding are..
Endometrial ablation
Resection of submucosal fibroids during hysteroscopy
Hysterectomy
Surgical options for larger fibroids are..
Uterine artery embolisation
Myomectomy
Hysterectomy
Pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever
Red Degeneration of Fibroids
Risk factors of cervical cancer
Non-engagement with cervical screening
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
Which contraceptive can increase the risk of cervical cancer?
COCP (if more than five years)
Outline the CIN grading system
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
FIGO staging for 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
Mx for cervical intraepithelial neoplasia and early-stage 1A
LLETZ or cone biopsy
Mx for 1B - 2A cervical cancer
Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Mx for 2B - 4A cervical cancer
Chemotherapy and radiotherapy
Mx for 4B cervical cancer
Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
Risk factors for endometrial cancer
Unopposed oestrogen
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
Protective factors against endometrial cancer
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
FIGO staging for 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
A Krukenberg tumour refers to a metastasis in the ovary, usually from a…
Gastrointestinal tract cancer (particularly the stomach)
“Signet-ring” cells on histology
Krukenberg tumours
Risk factors for ovarian cancer
Early-onset of periods
Late menopause
No pregnancies
Protective factors for ovarian cancer
Combined contraceptive pill
Breastfeeding
Pregnancy
Around 90% of vulval cancers are __________ carcinomas. Less commonly, they can be malignant __________
Around 90% of vulval cancers are squamous cell carcinomas. Less commonly, they can be malignant melanomas
Uterosacral nodularity and tenderness
Endometriosis
Three types of breech
Frank: longitudinal lie, hips flexed and knees extended
Complete: longitudinal lie, hips and knees flexed
Footling: foot or 2 feet first
Mx for missed miscarriage
Mifepristone
Misoprostol 48 hours later
Mx for incomplete miscarriage
Single dose of misoprostol
47XXY
Klinefelter syndrome
46XY
Androgen insensitivity syndrome
45XO
Turner syndrome
Rupture of membranes followed by painless vaginal bleeding and fetal bradycardia
Vasa praevia
Vasa Praevia -blood comes from foetus. Foetus is stressed with bradycardia, late decelerations etc
Placenta Praevia - blood mostly comes from mother. Foetus isn’t stressed
Vulval carcinomas vs Vulval intraepithelial neoplasia
Vulval carcinoma: commonly ulcerated and can present on the labium majora
VIN: white or plaque like and don’t tend to ulcerate
Ultrasound revealed a solid collection of echoes with numerous small anechoic spaces
Hydatidiform mole
Which contraceptive has a reduced effectiveness if interacted with rifampicin-like abx/st johns worts?
COCP
Which conditions cause a increase in AFP?
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
Which conditions cause a decrease in AFP?
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus
Calculate weight loss percentage in someone that went from 75 to 68 kgs
75 - 68
7/75 x 100
9.3% weight loss
Endometriosis vs adenomyosis regarding fertility and imaging findings
E: subfertility. either nothing or clumps of tissue on TVUS
A: had children before. Boggy uterus on TVUS
Placental praevia vs vasa praevia
PP: Painless vaginal bleeding with a history of c-section. No foetal distress
VP: Bradycardia, rupture of membranes, painless vaginal bleeding triad. Foetal distress
Rokitansky’s protuberance
Teratomas (dermoid cysts)
When is axillary node clearance indicated?
If more than three lymph nodes affected
If less than 3 then no action
Post-coital bleeding in premenopausal women + COCP
Cervical ectropion
Post-coital bleeding, vaginal dryness or painful intercourse
Endometrial cancer
Narrowing of the introitus
Diminished labial subcutaneous fat
Desiccated vaginal mucosa
Reduced tone of vaginal musculature
Atrophic vaginitis
ALT/AST greater than that of ALP
Raised white cell count and potential clotting abnormalities
Acute fatty liver of pregnancy
High ALP and GGT, with a lesser rise in ALT
Intrahepatic cholestasis of pregnancy
The only time hormonal contraception can be used after ulipristal immediately instead of 5 days is..
After they meet ALL conditions:
A patient must already be established on the COCP
COCP must be restarted after a pill-free interval
Pills must be missed later than the first week of pill takin
Enzyme inducing CYP450 drugs
CRAP GPs
Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
CYP450 inhibitors
SICKFACES.COM
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Contraceptives that are unaffected by EIDs
Copper intrauterine device
Progesterone injection (Depo-provera)
Mirena intrauterine system
Who gets Fibroadenosis
Tends to present in older women described as painful and lumpy, often worse around menstruation
Contraception for patients assigned female at birth and with a uterus
Progesterone only contraceptives
IUS/injections can suspend menstruation
Can use IUD but that exacerbated menstrual bleeding
Contraception for patients assigned male at birth
Condoms
Can use oestradiol, GnRH, finasteride or cyproterone acetate as it may lower sperm count but unreliable
Tx for endometritis
Refer to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
Cervical smears should be delayed until ____ months after birth, miscarriages and terminations
3 months
Drugs avoided in pregnancy
LAMBAST+ 4C’s
Lithium
Aspirin
Methotrexate
Amiodarone
Sulphonylureas/sulphonamides
Tetracyclines
Chloramphenicol, cytotoxics, ciprofloxacine, carbimazole
The main risks associated with lithium use during pregnancy include..
High likelihood of congenital abnormalities - Ebstein’s anomaly
Increased risk of miscarriage
Lithium side effects
LITHIuM:
Leucocytosis
Insipidus
Tremor (fine)
Hypothyroid
Increased weight
Metallic taste
Women of child bearing age should take __________ if commenced on lithium, which is generally avoided in pregnancy due to the high risk of development of __________ __________ in the first trimester
Women of child bearing age should take contraception if commenced on lithium, which is generally avoided in pregnancy due to the high risk of development of cardiac malformations in the first trimester
Risk factors for ectopic
E- Endometreosis
C- Copper coil
T- Tube damage (PID, surgery)
O- Only progesterone pill
P- Previous ectopic
I- IVF
C- Chlamydia
Which RA drugs can be used during pregnancy?
Sulfasalazine
Hydroxychloroquine
Low-dose corticosteroids
NSAIDs may be used until 32 weeks due to the risk of early close of the ductus arteriosus
Sex cord stromal tumours (Thecomas, Fibromas, Sertoli cell and granulosa cell tumours) are associated with __________________
Sub-type Granulosa cell tumours are associated with the development of __________________
Sex cord stromal tumours (Thecomas, Fibromas, Sertoli cell and granulosa cell tumours) are associated with an increased production of hormones
Sub-type Granulosa cell tumours are associated with the development of endometrial hyperplasia
Women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
Chorioamnionitis
Comedo necrosis
Ducal carcinoma in situ
Calcification is seen in ductal/ lobular
Ductal carcinoma in situ
Grey, gelatinous surface
Mucinous carcinomas
Need for contraception after the menopause
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
Normally, fundal height growth is ___ per week. After 24 weeks you would only expect the fundal height to increase by ___ a week
Normally, fundal height growth is 2cm per week. After 24 weeks you would only expect the fundal height to increase by 1cm a week
Down’s syndrome: quadruple test result
“Hi is High up”
↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A
In patients with urinary incontinence, make sure to rule out a..
UTI and diabetes mellitus using urinalysis
At which week does the uterus extend up to the umbilicus?
20 weeks gestation
After what period of time would continued lochia warrant further investigation with ultrasound?
6 weeks
______________ should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services
Vesicovaginal fistulae
‘Beads-on-a-string’
Chronic salpingitis
Hypoechoic masses
Fibroids
Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective..
Decidua basalis
Cyst lined by ciliated cells (similar to Fallopian tube)
Serous cystadenoma
Psammoma bodies seen (collection of calcium)
Serous cystadenocarcinoma
Cyst lined by mucous-secreting epithelium (similar to endocervix)
Mucinous cystadenoma
May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)
Mucinous cystadenocarcinoma
Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei
Brenner tumour
Account for 90% of germ cell tumours. Contain a combination of ectodermal (e.g. hair), mesodermal (e.g. bone) and endodermal tissue
Teratoma
Most common malignant germ cell tumour
Histological appearance similar to that of testicular seminoma
Associated with Turner’s syndrome
Typically secrete hCG and LDH
Dysgerminoma
Typically secrete AFP
Schiller-Duval bodies on histology are pathognomonic
Yolk sac tumour
Rare tumour that is part of the spectrum gestational trophoblastic disease
Typically have increased hCG levels
Often characterised by early haematogenous spread to the lungs
Choriocarcinoma
Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults
Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)
Granulosa cell tumour
Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome
Sertoli-Leydig cell tumour
Associated with Meigs’ syndrome (ascites, pleural effusion)
Solid tumour consisting of bundles of spindle-shaped fibroblasts
Typically occur around the menopause, classically causing a pulling sensation in the pelvis
Fibroma
Metastases from a gastrointestinal tumour resulting in a mucin-secreting signet-ring cell adenocarcinoma
Krukenberg tumour
Causes of an increased nuchal translucency include
Down’s syndrome
Congenital heart defects
Abdominal wall defects
Causes of hyperechogenic bowel
Cystic fibrosis
Down’s syndrome
Cytomegalovirus infection
Smoking + mammary duct fistula+ discharging sinus
Periductal mastitis
What is the most likely cause of delayed menarche in a girl that has developed secondary sexual characteristics?
Constitutional delay
Cervical screening in pregnancy is usually delayed until ___ months post-partum unless missed screening or previous abnormal smears
3
Cervical screening in HIV patients
Annual cervical cytology
It is said that the best time to take a cervical smear is around..
Mid-cycle
________ is co-infected with gonorrhoea
Chlamydia trachomatis
Diffuse abdominal pain that later localises to the right iliac fossa
Pain reproduced in the right iliac fossa by palpation of the left iliac fossa (Rovsings sign)
Appendicitis
Right iliac fossa pain but this would be mild, and not associated with nausea and vomiting.
Mittelschmerz
“Ovulation pain”
Tx of nipple candidiasis whilst breastfeeding should involve __________ for the mother and __________ for the baby
Miconazole cream for the mother and nystatin suspension for the baby
Breast pain/discomfort worse just before a feed. Infant may find it difficult to attach and suckle
Fever may be present but settles within 24 hours
Engorgement
Nipple pain often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema
Nipple pain resolves when nipples return to normal colour
Raynaud’s disease of the nipple
Tx of Raynaud’s disease of the nipple
Minimise exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking
If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license)
Often asymptomatic in women. If symptomatic, the patient may experience dyspareunia or dysuria. It may lead to pelvic inflammatory disorder and infertility.
Chlamydia trachomatis
Which contraceptives are UKMEC2 for migraines with aura?
IUS
Progesterone only methods
Which contraceptives are UKMEC1 for migraines with aura?
IUD
Women who are between 16-32 weeks pregnant are offered which vaccines?
Pertussis and influenza
Tx for primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
Elective C-section
PO aciclovir three times daily until delivery
Women with recurrent herpes who are pregnant should be treated with…
Suppressive therapy and be advised that the risk of transmission to their baby is low
HIV seroconversion occurs from..
3-12 weeks
Blood should be tested for parvovirus B19 specific IgM and IgG
IgG positive & IgM negative - ?
IgG negative & IgM positive - ?
IgG negative & IgM negative - ?
IgG positive & IgM negative - shows immunity to parvovirus. Reassure, no further action
IgG negative & IgM positive - non-immune. Recent parvovirus infection in last 4 weeks. Refer immediately for further tests/fetal medicine
IgG negative & IgM negative - repeat test in 4 weeks. If both tests still negative, this confirms susceptibility, but no recent infection. Reassure, further action required only if subsequent exposure occurs
Continuous CTG monitoring if any of the following are present or arise during labour..
Suspected chorioamnionitis or sepsis, or >38°C
>160/110 mmHg
Oxytocin
Significant meconium
Fresh vaginal bleeding that develops in labour
If there is evidence of infection and haemodynamic instability in the context of a miscarriage, _________ would be an appropriate management. The patient’s infection should also be treated appropriately with IV antibiotics and fluids as needed
Surgical intervention with vacuum aspiration
Amniocentesis: ______ weeks
CVS: ______ weeks
Amniocentesis: 16-20 weeks
CVS: 11-14 weeks
Secondary PPH occurs between 24 hours - ___ weeks. It is typically due to _________ or _________
Secondary PPH occurs between 24 hours - 6 weeks. It is typically due to retained placental tissue or endometritis
Hypo vs hyperthyroidism
Which contraceptive to give if seeking control over menstrual bleeding schedules?
Combined oral contraceptive pill with a 7-day pill-free interval between every 3 packs
Mx of placental abruption if <36 with fetal distress
Immediate caesarean
Mx of placental abruption if <36 with no fetal distress
Observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Mx of placental abruption if >36 with fetal distress
Immediate caesarean
Mx of placental abruption if >36 with no fetal distress
Deliver vaginally
Mx of placental abruption + fetus is dead (rip)
Induce vaginal delivery
Factors that are associated with an increased risk of miscarriage
Increased maternal age
Smoking, drinking, drugs, caffeine
Obesity
Infections and food poisoning
Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes
Ibuprofen, methotrexate and retinoids
Unusual shape or structure of womb
Cervical incompetence
Women with asymptomatic bacterial vaginosis do not usually require treatment unless they are..
Undergoing termination of pregnancy
Ix for galactocele
No imaging needed
T or F: Gillick competence is used in medical law to decide whether a child is able to CONSENT to their own medical treatment, but a minor cannot REFUSE treatment that is deemed in their best interest
True
High LH
Low testosterone
Primary hypogonadism (Klinefelter’s syndrome)
Low LH
Low testosterone
Hypogonadotrophic hypogonadism (Kallman’s syndrome)
High LH
Normal/high testosterone
Androgen insensitivity syndrome
Low LH
High testosterone
Testosterone-secreting tumour
Often taller than average
Lack of secondary sexual characteristics
Small, firm testes
Infertile
Gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels
Klinefelter’s syndrome - 47 XXY
Klinefelter’s diagnosis is by..
Chromosomal analysis
Delayed puberty
Hypogonadism, cryptorchidism
Anosmia
Sex hormone levels are low
LH, FSH levels are inappropriately low/normal
Patients are typically of normal or above average height
Kallman’s syndrome
Mode of inheritance in Kallman’s syndrome
X-linked recessive trait
Mode of inheritance in Androgen insensitivity syndrome
X-linked recessive
Androgen insensitivity syndrome is diagnosed by..
Buccal smear or chromosomal analysis to reveal 46XY genotype
Worrying symptoms suggestive of an ectopic
If a woman has a positive pregnancy test and any of the following she should be referred immediately to an early pregnancy assessment service:
- pain and abdominal tenderness
- pelvic tenderness
- cervical motion tenderness
Breast feeding is generally considered safe for mothers taking antiepilepticswith the possible exception of the..
Barbiturates
It is advised that pregnant women taking phenytoin are given __________ in the last month of pregnancy to prevent clotting disorders in the newborn
Vitamin K
Common long term complications of vaginal hysterectomy with antero-posterior repair include…
Enterocoele and vaginal vault prolapse
Urinary retention may occur acutely following hysterectomy
T or F: NO radiotherapy for mastectomies!! Only WLE
True
Classical grading of placenta praevia
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
Surgical management of ectopic pregnancy:
________ if haemodynamically unstable
________ if haemodynamically stable
Open if haemodynamically unstable
Laparoscopic if haemodynamically stable
Do a ___________ in incontinence if unsure what’s wrong (bladder diary inconclusive)
Urodynamic study
Risk of venous thromboembolism in HRT is increased by the addition of a..
Progestogen
___________ HRT does not appear to increase the risk of VTE
Transdermal
Women requesting HRT who are at high risk for VTE should be referred to ___________ before starting any treatment (even transdermal)
Haematology
Levonorgestrel efficacy is greatest when taken within ___ hours, and no later than ___ hours, post-intercourse
Levonorgestrel efficacy is greatest when taken within 12 hours, and no later than 72 hours, post-intercourse
__________ is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
Planned VBAC
C.I for planned VBAC
Previous uterine rupture or classical caesarean scar
Indications for c-section
Absolute cephalopelvic disproportion
Placenta praevia grades 3/4
Pre-eclampsia
Post-maturity
IUGR
Fetal distress in labour/prolapsed cord
Failure of labour to progress
Malpresentations: brow
Placental abruption: only if fetal distress; if dead deliver vaginally
Vaginal infection e.g. active herpes
Cervical cancer (disseminates cancer cells)
C- section grades
1 - Immediate threat to the life of the mother or baby: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia. Delivery should occur within 30 minutes of making the decision
2 - Maternal or fetal compromise which is not immediately life-threatening, delivery of the baby should occur within 75 minutes of making the decision
3 - Delivery is required, but mother and baby are stable
4 - Elective caesarean
Women _____ weeks with singleton pregnancy and no additional risk factors should avoid air travel
> 37
Women with uncomplicated, multiple pregnancies should avoid travel by air once ____ weeks
> 32
Risk of prematurity
Increased mortality depends on the gestation
Respiratory distress syndrome
Intraventricular haemorrhage
Necrotizing enterocolitis
Retinopathy of prematurity
Hearing problems
Chronic lung disease, hypothermia, feeding problems, infection, jaundice
One of the contributing factors of visual impairment in babies born before 32 weeks gestation is thought to be…
Over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization)
For babies who are born to mothers who are hepatitis B surface antigen positive, or are known to be high risk of hepatitis B, should receive the…
First dose of hepatitis B vaccine soon after birth
Those born to mother’s who are surface antigen positive should also receive ________________ within 12 hours of birth. The baby should then further receive a second dose of hepatitis B vaccine at 1-2 months and at 6 months
0.5 millilitres of hepatitis B immunoglobulin
___________ typically cause an irregularly shaped enlarged uterus because they form discrete masses
Uterine fibroids
___________ leads to a more symmetrical enlargement of the uterus as there is diffuse thickening of the uterine wall
Adenomyosis
Types of uterus:
Placental abruption
Adenomyosis
Fibroids
Placental abruption - woody (plank)
Adenomyosis (>30) - boggy (bAggy)
Fibroids - bulky (bulky fitness)
Starting POP if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the..
End of a pill packet (i.e. Day 21)
_______________ methods of contraception are safe to use as contraception alongside sequential HRT (not the injection due to risk of osteoporosis)
Pill or implant progestogen-only
__________ is the first-line treatment for overweight or obese women with polycystic ovarian syndrome (PCOS) who are struggling to conceive. If this fails - either because the woman is unable to lose weight or because she cannot conceive in spite of losing weight - then ___________ can be added as an adjunct
Weight loss
Metformin
When to do pregnancy tests in miscarriage/TOP?
Miscarriage - multi-pregnancy test 3 weeks
TOP - multi-pregnancy test 2 weeks, Urinary pregnancy tests can be positive up to 4 weeks post-termination
If sperm conc 10-15 million - recheck in ________
If sperm conc <5 million - recheck ________
If sperm conc 10-15 million - recheck in 3 months
If sperm conc <5 million - recheck immediately
__________ insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia
Long-acting
Anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after____ weeks’ gestation
10+0
The combination of a persistent lump spanning at least one menstrual cycle and the irregularity point to a diagnosis of….
Cancer
Non-surgical management for fibroids causing abnormal bleeding and under 3cm in size with no uterine distortion.
NSAIDs, anti-fibrinolytics, combined hormonal contraception, and Levonorgestrel-releasing intrauterine system (Mirena)
Surgical management for fibroids causing symptoms due to their mass effect
Myomectomy, ablation, uterine artery embolisation, and hysterectomy
During a lower segment Caesarian section, the following lies in between the skin and the fetus:
Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
________ cancer increased risk with all HRT
Ovarian
_____ slightly increased risk with oral oestrogen HRT
Stroke
___________ combined HRT may be associated with a slight increase in risk
Coronary heart disease
Examples of GnRH agonists are…
Goserelin and leuprorel
Examples of GnRH antagonists are….
Cetrorelix, degarelix, and ganirelix
Drug given if hypertensive + proteinuria during labour
Labetalol (<135/85)
Tx for cystocele/cystourethrocele
Anterior colporrhaphy, colposuspension
Tx for uterine prolapse
Hysterectomy
Tx for rectocele
Posterior colporrhaphy
The ____________ is the LARC of choice is young people
Progesterone-only implant (Nexplanon)
___________ is often the site of origin of many ‘ovarian’ cancers
Distal end of the fallopian tube
Stereotypical PCOS results
Raised LH:FSH ratio
Testosterone may be normal or mildly elevated
SHBG is normal to low
Antibiotics which are cautioned or contra-indicated in breastfeeding
Ciprofloxacin (potential joint problems)
Nitrofurantoin (G6PD deficiency)
Teicoplanin
Clindamycin (antibiotic-associated colitis)
Co-trimoxazole
The ectocervix is lined with _____________, correlating clinically with ~80% of cervical cancers
Stratified squamous non-keratinized epithelium
80% cervical cancers are stratified squamous non-keratinized epithelium
Simple columnar epithelium may be found within the…
Cervical os
Adenocarcinomas are derived from _________ epithelium
Columnar
Histopathology of malignancy
Abnormal tissue architecture
Coarse chromatin
Invasion of basement membrane
Abnormal mitoses
Angiogenesis
De-differentiation
Areas of necrosis
Nuclear pleomorphism
Distinguish invasive malignancy from in situ disease
__________ has teratogenic properties and may cause hand, nose, and eye defects and growth retardation
Warfarin
_________ get deposited in the teeth and bones and therefore may cause discolouration of the teeth and bone defects
Tetracyclines
The ______________ is located in the paramedian area of the midbrain and pons
Medial longitudinal fasciculus
_________ infections are a cause of neonatal cataracts
TORCH
Toxoplasmosis, others (syphilis, hepatitis B), rubella, cytomegalovirus, herpes simplex
Hypergonadotropic hypogonadism
Turner’s syndrome
C section wound infection
Tenderness upon palpation of the affected area
MOA of Raloxifene
Complete antagonism of the oestrogen receptor
MOA of Tamoxifen
Partial antagonism of the oestrogen receptor
MOA of Anastrazole
Reducing peripheral synthesis of oestrogen
When are antibiotics indicated in mastitis?
Systemically unwell
Nipple fissure present
Symptoms do not improve after 12-24 hours of effective milk removal
Culture indicates infection
What is the least common type of prolapse?
Urethrocele/Enterocele - herniation of the pouch of Douglas, including small intestine, into the vagina
Risk factors for Urogenital prolapse
Increasing age
Multiparity, vaginal deliveries
Obesity
Spina bifida
sensation of pressure, heaviness, ‘bearing-down’
urinary symptoms: incontinence, frequency, urgency
Urogenital prolapse
Glisson’s Capsule
Fitz-Hugh-Curtis syndrome - Hepatic adhesions
What is type 1 FGM?
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy)
What is type 2 FGM?
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision)
What is type 3 FGM?
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation)
What is type 4 FGM?
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterisation
Types of tocolytics
Betamimetics (such as terbutaline)
Magnesium sulfate
Prostaglandin inhibitors (like indomethacin, ketorolac)
Calcium channel blockers (such as nifedipine)
Nitrates (like nitroglycerine)
Oxytocin receptor blockers (such as atosiban)
High pressure exerted by a vacuum during a ventouse delivery can cause bleeding in the neonate
_____________ or more severely, __________ haemorrhage, can be exacerbated in the context of neonatal thrombocytopenia
Cephalohaematoma
Subgaleal haemorrhage
Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign
If the patient becomes dangerously thrombocytopenic, she will usually be treated with __________ and a diagnosis of ____ assumed. Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for ______________ for confirmation
Steroids
ITP
Serum antiplatelet antibodies
Tx for cervical cancer if confined to uterus <3mm deep
1A1:
Not aiming fertility/gold standard: hysterectomy +/- lymph node clearance
Aiming fertility: Cone biopsy
Tx for cervical cancer if confined to uterus 3-5 mm deep
1A2:
Nodal clearance +/- Radical trachelectomy
Tx for cervical cancer if confined to uterus larger than 7 mm wide and <4cm diameter
1B1:
Radiotherapy + chemotherapy (Cisplatin)
Tx for cervical cancer if confined to uterus larger than 7 mm wide and >4cm diameter
1B2:
Radical hysterectomy with pelvic lymph node dissection
Tx for cervical cancer if extension of tumour beyond cervix but not to the pelvic wall
II
Radiotherapy + chemotherapy (Cisplatin)
If hydronephrosis - nephrostomy
Tx for cervical cancer if extension of tumourbeyond the cervix and to the pelvic wall
III
Radiotherapy + chemotherapy (Cisplatin)
If hydronephrosis - nephrostomy
Tx for cervical cancer if extension of tumour beyond the pelvis with involvement of bladder or rectum
IVA
Radiotherapy + chemotherapy (Cisplatin)
Tx for cervical cancer if extension of tumour beyond the pelvis with involvement of distant sites outside the pelvis
IVB
Palliative chemotherapy
Mx of recurrent cervical cancer
Primary surgical treatment: offer chemoradiation or radiotherapy
Primary radiation treatment: offer surgical therapy
Complications of cone biopsies and radical trachelectomy
Preterm birth in future pregnancies
Complications of radical hysterectomy
Ureteral fistula
Short term complications of radiotherapy
Diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness
Long term complications of radiotherapy
Ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema
Breast lump imaging in <35 years old
US
Breast lump imaging in >35 years old
Mammogram
High/moderate risk factors for pre-eclampsia
CTG findings
Contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent
False Labor
Stages of labour
Stage 1: from the onset of true labour to when the cervix is fully dilated
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
Stage 2: from full dilation to delivery of the fetus
Stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
What type of HRT is used if menstruated less than a year ago?
Cyclical combined HRT
What type of HRT is used if menstruated more than a year ago?
Continuous combined HRT
Early referral for infertility should be considered when..
Women with breast cancer and no palpable axillary lymphadenopathy at presentation should have..
Pre-operative axillary ultrasound before their primary surgery
If a pre-operative axillary ultrasound is negative then they should have a sentinel node biopsy to assess the nodal burden
__________ is a risk factor for the development of mastitis
Smoking
Mx for a potential ectopic pregnancy and is >6 weeks
TVUS
Fundal height growth of 2cm per week. After _______weeks you would only expect the fundal height to increase by 1cm a week.
24
IUD insertion is contraindicated in active _________________ and active _________________
IUD insertion is contraindicated in active pelvic inflammatory disease and active sexually transmitted infections
Shoulder dystocia secondary to a macrosomic child = _________’s palsy
Erb’s palsy
Shoulder dystocia - posterior dislocation so internally rotated and addu
