OBSGYN

Question 1

Risk factors for endometriosis

Answer 1

Reproductive age group

Positive family Hx

Nulliparity

Question 2

Endometriosis symptoms

Answer 2

Dysmenorrhoea Chronic or cyclic pelvic pain Dyspareunia Sub-fertility Dysuria, dyschezia, haematuria, haematochezia Pelvic mass (Ovarian involvement)

Question 3

Endometriosis investigations

Answer 3

TVUS Laparoscopy

Question 4

Endometriosis management (medical & surgical)

Answer 4

NSAIDs COCP Oral progestins/ implanon Mirena IUD Surgical removal

Question 5

Endometriosis recurrence rate after surgery

Answer 5

~20%

Question 6

Most common organisms involved in PID

Answer 6

Chlamydia Gonorrhoea BV organisms

Question 7

PID risk factors

Answer 7

Prior chlamydia or gonorrhoea infection Young age at onset of sexual activity Unprotected sex multiple partners Prior Hx PID IUD use Instrumentation of cervix (e.g. D&C)

Question 8

PID clinical features

Answer 8

Abnormal vaginal bleeding Dyspareunia Vaginal discharge Dysuria Lower abdo or pelvic pain Fever Lower back pain

Question 9

PID investigations

Answer 9

Vaginal and cervical swabs Bloods (CRP) STI screening USS or MRI

Question 10

PID management (mild/moderate & severe)

Answer 10

Mild/moderate: Oral Abx (azithromycin 1g, doxycycline, metronidazole, + ceftriaxone IM if gonorrhoea suspected) Severe: Cefotaxime IV, metronodazole IV, azithromyin IV + oral doxycycline

Question 11

PID complications

Answer 11

Tubo-ovarian abscess Infertility due to adhesions and tubal occlusion Chronic pelvic pain Ectopic pregnancy

Question 12

Innervation of muscle of pelvic floor and vulval skin

Answer 12

Pudendal nerves S2,S3,S4

Question 13

Innervation of mons and labia

Answer 13

Ilioinguinal and genitofemoral nerves L1, L2

Question 14

Visceral innervation of pelvic contents

Answer 14

SNS to T10 and L1

Question 15

Aetiology of primary dysmenorrhoea

Answer 15

Excess of endometrial prostaglandins (PGE2 & PGF2-a)

Question 16

Clinical features of primary dysmenorrhoea

Answer 16

Cramping Worse on first few days of menstruation Bilateral Can be associated with nausea, vomiting, diarrhoea, headache

Question 17

Medical management of primary dysmenorrhoea

Answer 17

NSAIDs COCP Progesterone only methods (implanon, POP, depo-provera)

Question 18

Mechanism of pain of primary dysmenorrhoea

Answer 18

Progesterone –> Excess prostaglandins –> increased myometrial contraction –> increased uterine pressure (>arterial pressure) –> ischaemia –> anaerobic metabolite accumulation –> type C fibre activation –> Pain

Question 19

Risk factors for GDM

Answer 19

>25BMI Age >40 Previous GDM PCOS Family Hx Black, Islander, Middle Eastern Previous Hx macrosomia Medications: Corticosteroids, antipsychotics

Question 20

Effects of pregnancy on diabetes

Answer 20

1st half –> Improvement in glucose tolerance (foetal demands and reduced appetitie) 2nd half –> Placental hormones (esp. hPL) have anti-insulin effect After –> Return to pre-pregnancy state May be more rapid progression of microangiopathy

Question 21

Effects of diabetes on pregnancy

Answer 21

Pre-eclampsia Polyhydraminos Preterm labour Placental insufficiency Infections (UTI, Vaginal candidiasis)

Question 22

Effects of diabetes on newborn

Answer 22

Macrosomia 2x risk congenital malformations (NTDs, VSDs, aortic coarctation) Increased tendency for hypocglycemia and respiratory distress Birth injury (from macrosomia) Prematurity Perinatal mortality increased

Question 23

Explain GDM screening

Answer 23

26 to 28 weeks OGTT 75g glucose Fasting glucose (if ≥5.1mmol/L GDM( 1 hr glucose (if ≥10mmol/L GDM) 2 hr glucose (if ≥8.5mmol/L GDM)

Question 24

Diabetes in pregnancy surveillance

Answer 24

Home BGL monitoring: Fasting and 2hrs after every meal Maintain fasting BGL

Question 25

GDM post-pregnancy follow up

Answer 25

OGTT 6 weeks postpartum

Question 26

At how many weeks can pre-eclampsia be diagnosed?

Answer 26

After 20 weeks

Question 27

What is hypertension and proteinuria before 20 weeks classified as?

Answer 27

Pre-existing hypertension

Question 28

Risk factors for pre-eclampsia

Answer 28

Antiphospholipid antibodies Previous pre-eclampsia Pre-gestational diabetes Multiple pregnancy BMI \>26 Age \<18 or \>40 Nulliparity Family hx of pre-eclampsia CKD Pre-existing HTN

Question 29

Basic pathophysiology of pre-eclampsia

Answer 29

* Abnormal placental vasculature * Placental under-perfusion, hypoxia and ischaemia * Release of circulating antiangiogenic factors and other substances that cause widespread maternal systemic endothelial dysfunction (increased vascular permeabiliy, vasoconstriction, activation of coaagulation system, microangiopathic haemolysis) * HTN, proteinuria, and other clinical manifestations of pre-eclampsia result

Question 30

Clinical features of pre-eclampsia

Answer 30

* CVS: Severe hypertension, persistent and/or severe headache * Neurological: Brisk reflexes, visual abnormalities (scotoma, photophobia, bluirred vision), ankle clonus * GIT: RUQ pain due to stretching of liver capsule as a result of bleeding * Resp: Pulmonary oedema (in severe form of disease)

Question 31

Laboratory abnormalities in pre-eclampsia

Answer 31

* Microangiopathichaemlytic anaemia (abnormal peripheral smear & elevated bilirubin) * Thrombocytopenia * Increased P:Cr (\>30mg per mmol creatinine) * Proteinuria * Increased LDH (raised in haemolysis) * Elevated liver enzymes & bilirubin

Question 32

Investigations for pre-eclampsia

Answer 32

* **Blood** * FBC * EUC * LFTs * LDH * Coagulation profile * **Urine** (dip, spot [P:Cr], MSSU for microscopy) * **Baby** (CTG, USS of foetal growth, umbilical artery flow, amniotic fluid volume)

Question 33

Medications for acute management of HTN associated with pre-eclampsia

Answer 33

* Labetalol (IV) * Nifedipide (oral) * Hydralazine (IV)

Question 34

Medications for ongoing (non-acute) management of HTN associated with pre-eclampsia

Answer 34

* Methyldopa * Labetalol * Nifedipine

Question 35

Complications of pre-eclampsia of foetus and mother

Answer 35

**Mother** * Eclampsia * Multiple organ dysfunction * Bleeding * Coagulation disorders (DIC) * Maternal death (most frequently due to cerebral bleeding) **Foetus** * IUGR * Foetal death * Need for preterm delivery

Question 37

Risk factors for eclampsia

Answer 37

* Antiphospholipid antibodies * Previous pre-eclampsia * BMI\>26 * Pre-gestational diabetes * Multiple pregnancy * Age \<18 or \>40 * Nulliparity * Family Hx pre-eclampsia * Pre-existing hypertension * CKD

Question 38

Pathophysiology of eclampsia

Answer 38

* Autoregulation of cerebral blood flow is dysregulated due to changes from HTN

Question 39

Clinical features of eclampsia

Answer 39

* HTN * Visual changes * Headache * RUQ or epigastric pain * Can be asymptomatic

Question 40

Management of eclampsia

Answer 40

* ABCs (including IV access, sunction of vomit etc) * MgSO₄ administration (IV) - and should be given for 24h after the last seizure * Control HTN * Delivery (no role for continuation of pregnancy once eclampsia has occurred)

Question 41

Caesarean section informed consent (refer to relevant document on G-drive / Yr3Core folder)