Obstetrics and Gynaecology Flashcards

Question

Menopause

Answer 1

Menopause- the point at which menstruation stops. The diagnosis is made made after a woman has had no periods for 12 months. The average age is 51 Postmenopausal- the period from 12 months after the final menstrual period onwards. Perimenopause- includes the time leading up to the last menstrual period, and the 12 months afterwards. Premature menopause- menopause before the age of 40 years. It is the result of premature ovarian insufficiency. Perimenopausal symptoms A lack of oestrogen in the perimenopausal period leads to symptoms of: Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido NB- vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment Risks A lack of oestrogen increases the risk of certain conditions: Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence Investigations; Clinical diagnosis in over 45's. FSH should be checked in women under 45 NB- contraception in women 40+ (they are still fertile), >50, 12 months from LMP, <50, 24 months from LMP Management of symptoms; -Supportive- No treatment/ CBT/ vaginal moisturisers -Medical- Hormone replacement therapy (HRT), SSRI antidepressants, Testosterone (reduced libido) , Vaginal oestrogen (vaginal dryness and atrophy)

Answer 2

Menopause before the age of 40 years Characterised by hypergonadotropic hypogonadism. Hormonal analysis will show: -Raised LH and FSH levels (gonadotropins) -Low oestradiol levels Causes; Idiopathic (the cause is unknown in more than 50% of cases) Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease Genetic, with a positive family history or conditions such as Turner’s syndrome Infections such as mumps, tuberculosis or cytomegalovirus Management- HRT

Answer 3

Women with a uterus require endometrial protection with progesterone, whereas women without a uterus can have oestrogen-only HRT. Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT. Benefits; -Improved vasomotor and other symptoms of menopause (including mood, urogenital and joint symptoms) -Improved quality of life -Reduced the risk of osteoporosis and fractures Risks; -Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk) -Increased risk of endometrial cancer (women with a womb need progesterone too, to oppose oestrogen) -Increased risk of venous thromboembolism (use patches not pills) -Increased risk of stroke and coronary artery disease with long term use in older women -The evidence is inconclusive about ovarian cancer, and if there is an increase in risk, it is minimal NB- no increased risk in women under 50 and oestrogen-only doesn't increase risk of CVD Contradictions to HRT; -Undiagnosed abnormal bleeding -Endometrial hyperplasia or cancer -Breast cancer -Uncontrolled hypertension -Venous thromboembolism -Liver disease -Active angina or myocardial infarction -Pregnancy NB- too much, have a look at 0-finals before counselling

Answer 4

a common condition causing metabolic and reproductive problems in women. Presentation; Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern Complications; Insulin resistance and diabetes Acanthosis nigricans Cardiovascular disease Hypercholesterolaemia Endometrial hyperplasia and cancer Obstructive sleep apnoea Depression and anxiety Sexual problems Rotterdam Criteria The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: -Oligoovulation or anovulation, presenting with irregular or absent menstrual periods -Hyperandrogenism, characterised by hirsutism and acne -Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3) Investigations; Bedside- speculum and bimanual examination Bloods- Testosterone, Sex hormone-binding globulin, LH, FSH, Prolactin, TSH Imaging and specialist- TV USS, OGTT (insulin resistance) NB- raised LH, and the raised LH:FSH ratio, and string of pearls appearance or ovarian volume of more than 10cm3 on USS Management; Supportive- weight loss, exercise, smoking cessation Medical- (anti CVD medications), COCP (hirsutism and acne) NB- if infertility is an issue, weight loss should help, but also referral to fertility service may be necessary (also involve specialist, clomiphene may help)

Answer 5

The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation. Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. Features; Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, vague symptoms: -Pelvic pain -Bloating -Fullness in the abdomen -A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) -Pressure effects on bladder -Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst. Investigations; Bedside- Bloods- Ca125 (LDH, aFP, bHCG if under 40) Imaging and specialist- TV USS Management; -Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. -5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring. -More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound. Surgery- if large cyst or enlarging NB- cysts in post menopausal women need referral to specialist Complications (acute abdominal pain); -Torsion -Haemorrhage into the cyst -Rupture, with bleeding into the peritoneum Meig's syndrome; -Ovarian fibroma (a type of benign ovarian tumour) -Pleural effusion -Ascites NB- cysts that are not simple on imaging always need further assessment

Answer 6

The vast majority of ovarian cysts in premenopausal women are benign. Cysts in postmenopausal women are more concerning for malignancy and need further investigation (referral to gynaecology) Patients with multiple ovarian cysts or a “string of pearls” appearance to the ovaries cannot be diagnosed with polycystic ovarian syndrome unless they also have other features of the condition. Features; Most ovarian cysts are asymptomatic. Cysts are often found incidentally on pelvic ultrasound scans. Occasionally, vague symptoms: -Pelvic pain -Bloating -Fullness in the abdomen -A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas) -Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst. Investigations; Bedside- Bloods- Ca125 (LDH, aFP, bHCG if under 40) Imaging and specialist- TV USS Management; -Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan. -5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring. -More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound. Surgery- if large cyst or enlarging NB- cysts in post menopausal women need referral to specialist Complications (acute abdominal pain); -Torsion -Haemorrhage into the cyst -Rupture, with bleeding into the peritoneum Meig's syndrome; -Ovarian fibroma (a type of benign ovarian tumour) -Pleural effusion -Ascites

Answer 7

Sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting. May be a palpable mass and localised tenderness Investigations; Bedside- pregnancy test, obs Bloods- other causes of acute abdomen Imaging and s- TV USS (whirlpool sign), laparoscopy Management- laparoscopic surgery to untwist/remove the ovary NB- usually due to underlying structural abnormality eg. ovarian cyst. Always have ectopic pregnancy as a differential too

Answer 8

Adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus. Features; Secondary amenorrhoea Significantly lighter periods Dysmenorrhoea Infertility. Investigations; -Hysteroscopy -Hysterosalpingography -MRI scan NB- management is adhesiolysis performed during hysteroscopy

Answer 9

When the columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix). Features; -asymptomatic found incidentally during speculum examination) -vaginal discharge -vaginal bleeding -dyspareunia -postcoital bleeding Management; Asymptomatic ectropion require no treatment. Ectropion will typically resolve as the patient gets older, stops the pill or is no longer pregnant. Having a cervical ectropion is not a contraindication to the combined contraceptive pill. Problematic bleeding-cauterisation of the ectropion using silver nitrate or cold coagulation during colposcopy NB- cervical ectropion is different to CIN

Answer 10

fluid-filled cysts often seen on the surface of the cervix. Asymptomatic and no treatment required Rarely, use colposcopy and get a biopsy to exclude other diagnoses

Answer 11

Descent of the pelvic organs into the vagina Features; -A feeling of “something coming down” in the vagina -A dragging or heavy sensation in the pelvis -Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention -Bowel symptoms, such as constipation, incontinence and urgency -Sexual dysfunction, such as pain, altered sensation and reduced enjoyment - a lump or mass in the vagina, some will already be pushing it back up themselves. -prolapse will become worse on straining or bearing down. Management; Supportive- physiotherapy, weight loss, incontinence pads, vaginal pessaries (ie. ring) Medical- vaginal oestrogen creams Surgical- surgical repair (vaginal vault prolapse- sacroplexy)

Answer 12

Overactivity of the bladder. Sudden need to run to the toilet Management; Supportive- Bladder retraining (gradually increasing the time between voiding) for at least six weeks Medical- Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin or mirabegron Surgical- botox into bladder wall, urinary diversion, sacral nerve stimulation etc.

Answer 13

Due to weakness of the pelvic floor and sphincter muscles. This allows urine to leak at times of increased pressure on the bladder. The typical description of stress incontinence is urinary leakage when laughing, coughing or surprised. NB- can have mixed stress and urge incontinence Management; Supportive- Avoiding caffeine, diuretics and overfilling of the bladder, weight loss (if appropriate), supervised pelvic floor exercises Medical- duloxetine Surgical- eg. tension free vaginal tape, colposuspension etc. NB- continuous dribbling suggests a vesicovaginal fistula and necessitates urological dye studies

Answer 14

Can occur when there is chronic urinary retention due to an obstruction to the outflow of urine. It can occur with anticholinergic medications, fibroids, pelvic tumours and neurological conditions such as multiple sclerosis, diabetic neuropathy and spinal cord injuries

Answer 15

Bedside- bladder diary, tracking fluid intake and episodes of urination and incontinence over at least three days, urine dipstick (infection, microscopic haematuria etc.) Imaging and specialist- bladder scan for post-void residual bladder volume, urodynamic testing eg. Cystometry (stop anticholinergics 5 days before)

Answer 16

Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen (typically during the menopause) Features; -Itching -Dryness -Dyspareunia (discomfort or pain during sex) -Bleeding due to localised inflammation Examination of the labia and vagina will demonstrate: -Pale mucosa -Thin skin -Reduced skin folds -Erythema and inflammation -Dryness -Sparse pubic hair Management; Supportive- vaginal lubricants Medical- topical oestrogens (contraindications- breast cancer, angina and VTE)

Answer 17

When ducts supplying the Bartholin glands become blocked Features; -Swelling is typically unilateral and forms a fluid-filled cyst between 1 – 4 cm. -Cysts can become infected, forming a Bartholin’s abscess (hot, tender, red and potentially draining pus) Management; Supportive- good hygiene, analgesia and warm compresses Medical- ABX for an abscess Surgical- surgical drainage (marsupialisation or a word catheter)

Answer 18

A chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. The condition may be asymptomatic, or present with several symptoms: Itching Soreness and pain possibly worse at night Skin tightness Painful sex (superficial dyspareunia) Erosions Fissures NB- the Koebner phenomenon refers to when the signs and symptoms are made worse by friction to the skin eg. tight underwear that rubs the skin, urinary incontinence and scratching. Areas commonly affected- labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men (foreskin and glans of the penis) Investigations; Clinical diagnosis, but may want to do a biopsy to exclude malignancy Management; Supportive- emollients, regular review by dermatologist/ gynaecologist (risk of SCC of vulva) Medical- topical steroids eg. Clobetasol propionate 0.05% (dermovate). NB- cannot be cured, but can be treated

Answer 19

Most commonly SCC (then adenocarcinoma). Associated with HPV Risk factors; -HPV (16,18,33) (unvaccinated) -Smoking -HIV (patients with HIV are offered yearly smear tests) -Combined contraceptive pill use for more than five years -Increased number of full-term pregnancies -Family history -Exposure to diethylstilbestrol during fetal development -Non engagement with screening -Early first intercourse, many sexual partners Features; Asymptomatic (picked up on screening) Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) Vaginal discharge Pelvic pain Dyspareunia (pain or discomfort with sex) Investigations; 2 WEEK WAIT PATHWAY Bedside- obs, speculum and bimanual examination Bloods- usual pannel Specialist- colposcopy with LLETZ (biopsy) Management (MDT) Supportive- Medical- chemo and radio Surgical- LLETZ/cone biopsy (if stage 1 and wishing to maintain fertility)/complete cervical removal

Answer 20

Cause cervical, anal, vulval, vaginal, penis, mouth and throat cancers. HPV is primarily a sexually transmitted infection. The important ones to remember are type 16 and 18 Increased risk of catching HPV occurs with: Early sexual activity Increased number of sexual partners Sexual partners who have had more partners Not using condoms HPV Vaccine The HPV vaccine is ideally given to girls and boys before they become sexually active. The intention is to prevent them contracting and spreading HPV once they become sexually active. The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18: Strains 6 and 11 cause genital warts Strains 16 and 18 cause cervical cancer

Answer 21

The samples are initially tested for high-risk HPV before the cells are examined. If the HPV test is negative (the person does not have HPV), the cells are not examined, the smear is considered negative, and the woman is returned to the routine screening program. If cells are examined, they are observed for dyskaryosis (precancerous changes) The cervical screening program involves performing a smear for women (and transgender men that still have a cervix): Every three years aged 25 – 49 Every five years aged 50 – 64 There are some notable exceptions to the program: -Women with HIV are screened annually -Women over 65 may request a smear if they have not had one since aged 50 -Women with previous CIN may require additional tests (e.g. test of cure after treatment) -Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant) -Pregnant women due a routine smear should wait until 12 weeks post-partum Management following a smear result; -Inadequate sample – repeat the smear after at least three months (2x inadequate samples, then colposcopy) -HPV negative – continue routine screening -HPV positive with normal cytology – repeat the HPV test after 12 months; if the repeat test is now hrHPV -ve → return to normal recall if the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later: If hrHPV -ve at 24 months → return to normal recall if hrHPV +ve at 24 months → colposcopy -HPV positive with abnormal cytology – refer for colposcopy NB- always test HPV first, then cytology if needed

Answer 22

During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas. Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are: CIN I: mild dysplasia CIN II: moderate dysplasia CIN III: severe dysplasia (cervical carcinoma in situ) NB- try not to get mixed up between dysplasia found during colposcopy and dyskaryosis on smear results. Large Loop Excision of the Transformation Zone (LLETZ) (loop biopsy)- to remove abnormal epithelial tissue on the cervix. Cone biopsy- a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer.

Answer 23

An oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells. Typically adenocarcinoma Risk Factors (all about unopposed oestrogen aka. without progesterone); -Increased age -Earlier onset of menstruation -Late menopause -Oestrogen only hormone replacement therapy -No or fewer pregnancies -Obesity -Polycystic ovarian syndrome -Tamoxifen -2 factors not related to unopposed oestrogen include T2DM and HNPCC/Lynch syndrome Features; -Postmenopausal bleeding (endometrial cancer until proven otherwise) -Postcoital bleeding -Intermenstrual bleeding -Unusually heavy menstrual bleeding -Abnormal vaginal discharge -Haematuria -Anaemia -Raised platelet count Investigations; 2 WEEK WAIT PATHWAY Bedside- speculum and bimanual examination Bloods- routine panel Imaging- TV USS (endometrial thickness), Pipelle biopsy, hysteroscopy with biopsy Management; Supportive- Medical- progesterone (may slow progression), chemo and radio Surgical- total abdominal hysterectomy with bilateral salpingo-oophorectomy Protective factors against endometrial cancer include: -Combined contraceptive pill -Mirena coil -Increased pregnancies -Cigarette smoking

Answer 24

Risk Factors -Age (peaks age 60) -BRCA1 and BRCA2 genes (consider the family history) -Increased number of ovulations -Obesity -Smoking -Recurrent use of clomifene Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include: -Early-onset of periods -Late menopause -No pregnancies Protective Factors (reduced number of ovulations) -Combined contraceptive pill -Breastfeeding -Pregnancy Features; Ovarian cancer can present with non-specific symptoms. In older women, keep the possibility of ovarian cancer in mind and have a low threshold for considering further investigations. Symptoms that may indicate ovarian cancer include: Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites Hip or groin pain (if pressing on obturator nerve) Investigations; Bedside- speculum and bimanual investigations, obs etc. Bloods- Ca125, usual panel, aFP, HCG (if under 40) Imaging- TV USS, biopsy (laparoscopy), staging CT, paracentesis with cytology (if ascites present) NB- carry out physical exam first, if there is ascites or a mass, refer urgently to gynae (2ww). If no ascites/mass, do Ca125 first, if raised, then do a scan: if scan suggests cancer, refer to gynae on a 2ww pathway Management; Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy. Causes of a raised Ca125; -Endometriosis -Fibroids -Adenomyosis -Pelvic infection -Liver disease -Pregnancy -Ovarian cancer The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: -Menopausal status -Ultrasound findings -CA125 level

Answer 25

Typically SCC Risk Factors; -Advanced age (particularly over 75 years) -Immunosuppression -Human papillomavirus (HPV) infection -Lichen sclerosus Features; -Vulval lump -Ulceration -Bleeding -Pain -Itching -Lymphadenopathy in the groin Vulval cancer most frequently affects the labia majora, giving an appearance of: -Irregular mass -Fungating lesion -Ulceration -Bleeding Investigation; 2 WEEK WAIT PATHWAY Bedside- obs, exam etc. Bloods- usual panel Specialist- biopsy of lesion, sentinel node biopsy (spread), staging CT Management (MDT); -Wide local excision to remove the cancer -Groin lymph node dissection -Chemotherapy -Radiotherapy

Answer 26

a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia). A biopsy is required to diagnose VIN. A specialist will coordinate management. Treatment options include: Watch and wait with close followup Wide local excision (surgery) to remove the lesion Imiquimod cream Laser ablation

Answer 27

Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35 General pre-conception advice; -The woman should be taking 400mcg folic acid daily -Aim for a healthy BMI -Avoid smoking and drinking excessive alcohol (both) -Reduce stress as this may negatively affect libido and the relationship -Aim for intercourse every 2 – 3 days -Avoid timing intercourse Investigations; Bedside- BMI, observations, physical exam, chlamydia screen Bloods- rubella immunity in mother, female hormone testing (FSH, LH, progesterone, TFT, anti-mullerian, prolactin) Specialist- semen analysis, TV USS (ovaries), Hysterosalpingogram (patency of the fallopian tubes), laparoscopy and dye (adhesions) General management for anovulation (apart from treating underlying cause); Supportive- weight loss, smoking cessation Medical- clomifene, letrozole, gonadotrophin analogues Specialist- surgery to restore normal anatomy eg. adhesions NB- consider things like IVF Management of Sperm Problems; -Surgical sperm retrieval -Surgical correction of an obstruction -Intra-uterine insemination -Intracytoplasmic sperm injection (ICSI) -Donor insemination with sperm from a donor NB- measure serum progesterone 7 days prior to expected next period (day 21 if 28 day cycle)

Answer 28

Factors affecting sperm quality; Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine Pre-testicular causes; -Pathology of the pituitary gland or hypothalamus -Suppression due to stress, chronic conditions or hyperprolactinaemia -Kallman syndrome Testicular causes; Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer Klinefelter syndrome Y chromosome deletions Sertoli cell-only syndrome Anorchia (absent testes) Post-testicular causes; Damage to the testicle or vas deferens from trauma, surgery or cancer Ejaculatory duct obstruction Retrograde ejaculation Scarring from epididymitis, for example, caused by chlamydia Absence of the vas deferens Investigations; USS testicles Hormonal analysis with LH, FSH and testosterone levels Genetic testing Further imaging, such as transrectal ultrasound or MRI Vasography, which involves injecting contrast into the vas deferens and performing xray to assess for obstruction Testicular biopsy

Answer 29

could be a counselling station (NHS)

Answer 30

a complication of ovarian stimulation during IVF infertility treatment. It is associated with the use of human chorionic gonadotropin (hCG) Features; Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE) Management; Oral fluids Monitoring of urine output Low molecular weight heparin (to prevent thromboembolism) Ascitic fluid removal (paracentesis) if required IV colloids (e.g. human albumin solution) NB- Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.

Answer 31

An overgrowth of bacteria in the vagina, specifically anaerobic bacteria. It is not a sexually transmitted infection. It is caused by a loss of the lactobacilli “friendly bacteria” in the vagina. Risk Factors; -Multiple sexual partners (although it is not sexually transmitted) -Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) -Recent antibiotics -Smoking -Copper coil Features; -fishy-smelling watery grey or white vaginal discharge Investigations; Bedside- speculum examination, vaginal pH (>4.5), high vaginal charcoal swab for MCS (clue cells on microscopy), exclude STI's eg. chlamydia and gonorrhoea Management- asymptomatic, none required, symptomatic, metronidazole (avoid alcohol) Complications; Increased risk of catching sexually transmitted infections, including chlamydia, gonorrhoea and HIV. It is also associated with several complications in pregnant women: Miscarriage Preterm delivery Premature rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis

Answer 32

Bacterial infection by yeast candida Risk Factors; -Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) -Poorly controlled diabetes -Immunosuppression (e.g. using corticosteroids) -Broad-spectrum antibiotics Presentation; -Thick, white discharge that does not typically smell -Vulval and vaginal itching, irritation or discomfort More severe infection can lead to: -Erythema -Fissures -Oedema -Pain during sex (dyspareunia) -Dysuria -Excoriation Investigations (typically clinical); -Bedside- speculum exam, vaginal pH (<4.5), high vaginal charcoal swab for MCS Management (antifungals); -Antifungal cream (i.e. clotrimazole) inserted into the vagina with an applicator -Antifungal pessary (i.e. clotrimazole) -Oral antifungal tablets (i.e. fluconazole) (no oral medication if pregnant, use a pessary) NB- warn women that antifungal creams and pessaries can damage latex condoms and prevent spermicides from working, so alternative contraceptive is required for at least five days after use. NB- Canesten duo is an OTC remedy Recurrent Disease; -Blood glucose test to exclude DM -Induction-maintenance regimen

Answer 33

The majority of cases of chlamydia in women are asymptomatic. Consider chlamydia in women that are sexually active and present with: Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria) Consider chlamydia in men that are sexually active and present with: Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis It is worth considering rectal chlamydia and lymphogranuloma venereum in patients presenting with anorectal symptoms, such as discomfort, discharge, bleeding and change in bowel habits. Examination Findings; Pelvic or abdominal tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Investigation; Bedside- speculum exam, vaginal pH, high vaginal charcoal swab for MCS, vulvovaginal swab (or cervical/urinary/urethral) with NAAT Management; Supportive- abstain from sex for a week, refer to GUM for contact tracing, test and treat for other STI's, provide advice on how to avoid future infections, safeguarding if children Medical- doxycycline 100mg twice a day for 7 days (Doxycycline is contraindicated in pregnancy and breastfeeding- use azithromycin) Complications; Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis Pregnancy-related complications include: Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis Neonatal infection (conjunctivitis and pneumonia) Contact tracing; for men with urethral symptoms: all contacts since, and in the four weeks prior to, the onset of symptoms for women and asymptomatic men all partners from the last six months or the most recent sexual partner should be contacted contacts of confirmed Chlamydia cases should be offered treatment prior to the results of their investigations being known (treat then test)

Answer 34

Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages: The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex. The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected. The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion. Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH. Erythromycin, azithromycin and ofloxacin are alternatives.

Answer 35

Chlamydia can infect the conjunctiva of the eye. Conjunctival infection is usually as a result of sexual activity, when genital fluid comes in contact with the eye, for example, through hand-to-eye spread. It presents with chronic erythema, irritation and discharge lasting more than two weeks. Most cases are unilateral. Chlamydial conjunctivitis occurs more frequently in young adults. It can also affect neonates with mothers infected with chlamydia. Gonococcal conjunctivitis is a crucial differential diagnosis and should be tested.

Answer 36

Features; Female genital infections can present with: Odourless purulent discharge, possibly green or yellow Dysuria Pelvic pain Male genital infections can present with: Odourless purulent discharge, possibly green or yellow Dysuria Testicular pain or swelling (epididymo-orchitis) NB- Rectal infection may cause anal or rectal discomfort and discharge, but is often asymptomatic. Pharyngeal infection may cause a sore throat, but is often asymptomatic. Prostatitis causes perineal pain, urinary symptoms and prostate tenderness on examination. Conjunctivitis causes erythema and a purulent discharge Investigations; Bedside- speculum exam, vaginal pH, high vaginal charcoal swab for MCS, vulvovaginal swab (or cervical/urinary/urethral) with NAAT Management; Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known (local guidelines). For uncomplicated gonococcal infections: -A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known -A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known NB- if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used NB- all patients should have a follow up “test of cure” given the high antibiotic resistance. NB- Supportive- abstain from sex for a week, refer to GUM for contact tracing, test and treat for other STI's, provide advice on how to avoid future infections, safeguarding if children Complications; Pelvic inflammatory disease Chronic pelvic pain Infertility Epididymo-orchitis (men) Prostatitis (men) Conjunctivitis Urethral strictures Disseminated gonococcal infection Skin lesions Fitz-Hugh-Curtis syndrome Septic arthritis Endocarditis

Answer 37

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

Answer 38

A bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection Features; Most cases of MG do not cause symptoms. But it can cause; Urethritis Epididymitis Cervicitis Endometritis Pelvic inflammatory disease Reactive arthritis Preterm delivery in pregnancy Tubal infertility Investigations (nucleic acid amplification tests (NAAT)); -First urine sample in the morning for men -Vaginal swabs (can be self-taken) for women Management (need both); -Doxycycline 100mg twice daily for 7 days then (not pregnancy/breastfeeding) -Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides)

Answer 39

inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections: Neisseria gonorrhoeae (more severe PID) Chlamydia trachomatis (most common) Mycoplasma genitalium Presentation Women may present with symptoms of: Pelvic or lower abdominal pain Abnormal vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria Examination findings may reveal: Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Patients may have a fever and other signs of sepsis. Investigations; Bedside- pregnancy test to rule out ectopic, speculum exam, vaginal pH, high vaginal charcoal swab for MCS (rule out BV, candidiasis, trichomonas- often negative), vulvovaginal swab (or cervical/urinary/urethral) with NAAT (rule out chlamydia/gonorrhoea) Management; GUM specialist- local guidelines (below), contact tracing etc. 2 medical options; 1) oral ofloxacin + oral metronidazole 2) intramuscular ceftriaxone + oral doxycycline + oral metronidazole NB- severe cases may require admission to hospital omplications Sepsis Abscess Infertility Chronic pelvic pain Ectopic pregnancy Fitz-Hugh-Curtis syndrome Fitz-Hugh-Curtis Syndrome Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood. Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Answer 40

a type of parasite spread through sexual intercourse Trichomonas can increase the risk of: Contracting HIV by damaging the vaginal mucosa Bacterial vaginosis Cervical cancer Pelvic inflammatory disease Pregnancy-related complications such as preterm delivery. Features Asymptomatic Vaginal discharge (frothy, yellow-green, fishy smell) Itching Dysuria (painful urination) Dyspareunia (painful sex) Balanitis (inflammation to the glans penis) On examination; Strawberry cervix (colpitis macularis) Investigations -Bedside: speculum exam, vaginal pH (>4.5), high vaginal charcoal swab for MCS Management Supportive- GUM: contact tracing Medical- Metronidazole

Answer 41

The herpes simplex virus (HSV) is commonly responsible for both cold sores (herpes labialis) and genital herpes. HSV-1- cold sores HSV-2- genital herpes Features; -Ulcers or blistering lesions affecting the genital area -Neuropathic type pain (tingling, burning or shooting) -Flu-like symptoms (e.g. fatigue and headaches) -Dysuria (painful urination) -Inguinal lymphadenopathy Investigations; -Bedside- speculum exam, viral swab Management; Supportive- GUM clinic (contact tracing), clean area with warm water, analgesia, wear loose clothing, avoid intercourse whilst symptomatic Medical- acyclovir (virus) Pregnancy; If after 28 weeks- acyclovir and C section If before 28 weeks- acyclovir (vaginal delivery if at least 6 weeks between delivery and infection)

Answer 42

Caused by bacterium Treponema pallidum Transmission; Oral, vaginal or anal sex involving direct contact with an infected area Vertical transmission from mother to baby during pregnancy Intravenous drug use Blood transfusions and other transplants (although this is rare due to screening of blood products) 5 stages- 1/2/latent/3/neuro Features; 1- painless genital ulcer/local lymphadenopathy 2- Maculopapular rash, wart-like lesions around the genitals and anus, fever, lymphadenopathy, alopecia, oral lesions, buccal 'snail track' ulcers (30%) condylomata lata (painless, warty lesions on the genitalia ) 3- gummatous lesions (granulomas), aortic dissection, neurosyphilis Neuro- Headache, altered behaviour, dementia, tabes dorsalis, ocular syphilis, paralysis, sensory impairment, Argyll-Robertson pupil (accommodates (distance) but doesn't react to light) Investigations; non-treponemal tests and treponemal tests Positive non-treponemal test + positive treponemal test consistent with active syphilis infection Positive non-treponemal test + negative treponemal test consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above) Negative non-treponemal test + positive treponemal test : consistent with successfully treated syphilis Management; Supportive- GUM eg; -Full screening for other STIs -Advice about avoiding sexual activity until treated -Contact tracing -Prevention of future infections Medical- one dose of IM benzathine benzylpenicillin the Jarisch-Herxheimer reaction is sometimes seen following treatment -fever, rash, tachycardia after the first dose of antibiotic -in contrast to anaphylaxis, there is no wheeze or hypotension -only antipyretics if needed

Answer 43

When a pregnancy is implanted outside the uterus. The most common site is a fallopian tube (ampulla, dangerous if isthmus). Typically presents around 6 – 8 weeks gestation. Risk Factors; Previous ectopic pregnancy Previous PID Previous surgery to the fallopian tubes Intrauterine devices (coils) Older age Smoking Endometriosis IVF Features; Missed period Constant lower abdominal pain in the right or left iliac fossa Vaginal bleeding Lower abdominal or pelvic tenderness Cervical motion tenderness (pain when moving the cervix during a bimanual examination) Dizziness Shoulder tip pain (peritonitis) Diarrhoea/rectal pain- blood can irritate the pouch of Douglas NB- always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain. NB- never feel for an adnexal mass (risk of rupture) Investigations; Bedside- pregnancy test, observations, physical exam etc. Bloods- ABG, FBC, UE, bHCG etc. Imaging- TV USS ( “blob sign”, “bagel sign” or “tubal ring sign” or pseudogestational sac in uterus) HCG hCG will roughly double every 48 hours If pregnancy of unknown location; -A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy (above 1500, pregnancy should be visible on the scan) -A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. -A fall of more than 50% is likely to indicate a miscarriage Management; -Refer to gynae/ early pregnancy assessment unit -Expectant management (awaiting natural termination) -Medical management (IM methotrexate, no pregnancy for 3 months afterwards) -Surgical management (salpingectomy or salpingotomy) Criteria for expectant management: Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 1500 IU / l Criteria for methotrexate are the same as expectant management, except: HCG level must be < 5000 IU / l Confirmed absence of intrauterine pregnancy on ultrasound Criteria for surgical management; Pain Adnexal mass > 35mm Visible heartbeat HCG levels > 5000 IU / l NB- Anti-rhesus D prophylaxis is given to rhesus negative women Either salpingectomy (first line), or salpingotomy (if other tube looks damaged)

Answer 44

The spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation. Definitions; Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive Inevitable miscarriage – vaginal bleeding with an open cervix Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus Anembryonic pregnancy – a gestational sac is present but contains no embryo Investigations; TV USS (if recurrent- refer to recurrent miscarriage clinic for tests eg. antiphospholipid syndrome) Management; Early pregnancy assessment unit (they will need to come back to confirm the pregnancy has ended) 1) Expectant- wait 7-14 days Situations where expectant wouldn't be appropriate; -Increased risk of haemorrhage (coagulopathy, late first trimester) -Previous adverse pregnancy outcome -Evidence of infection 2) Medical- vaginal misoprostol (contact if no bleeding within 24 hours) 3) Surgical- vacuum aspiration under local anaesthetic as an outpatient (or surgical management in theatre) More than 6 weeks; -Expectant -Medical (misoprostol) -Surgical (manual or electric vacuum aspiration)- Anti-rhesus D prophylaxis is given to rhesus negative women

Answer 45

The key side effects of misoprostol are: Heavier bleeding Pain Vomiting Diarrhoea

Answer 46

When retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage- risk of infection. Management; Medical management (misoprostol) Surgical management (evacuation of retained products of conception) NB- endometriosis is a complication

Answer 47

Three or more consecutive miscarriages. Investigations are initiated after: -Three or more first-trimester miscarriages -One or more second-trimester miscarriages Causes; Idiopathic (particularly in older women) Antiphospholipid syndrome Hereditary thrombophilias (eg. factor V leiden) Uterine abnormalities (eg. fibroids) Genetic factors in parents (e.g. balanced translocations in parental chromosomes) Chronic histiocytic intervillositis Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE) Investigations; Antiphospholipid antibodies Testing for hereditary thrombophilias Pelvic ultrasound Genetic testing of the products of conception from the third or future miscarriages Genetic testing on parents

Answer 48

An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of: -The woman -Existing children of the family An abortion can be performed at any time during the pregnancy if: -Continuing the pregnancy is likely to risk the life of the woman -Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman -There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped The legal requirements for an abortion are: -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 Medical Abortion; It involves two treatments: -Mifepristone (anti-progestogen) -Misoprostol (prostaglandin analogue) 1 – 2 day later Mifepristone is an anti-progestogen medication that blocks the action of progesterone, halting the pregnancy and relaxing the cervix. NB- from 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion. NB- Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis (or having a surgical TOP) Surgical abortion; -cervical dilation with suction/vacuum aspiration (<14 weeks) or evacuation with forceps/cutterage (>14 weeks) NB- need to check pregnancy has ended in 4 weeks (may still have positive pregnancy tests until then) Complications; Bleeding Pain Infection Failure of the abortion (pregnancy continues) Damage to the cervix, uterus or other structures

Answer 49

Protracted nausea and vomiting of pregnancy More than 5 % weight loss compared with before pregnancy Dehydration Electrolyte imbalance Investigations; Bedside- urinalysis (ketonuria and elevated specific gravity), H. pylori breath test Bloods- FBC (normal), UE’s (hyponatraemia, elevated urea and creatinine), LFT (normal), serum ketones (elevated) Further imaging if necessary eg. Abdominal ultrasound Management; Supportive- Assess severity with the Pregnancy-Unique Quantification of Emesis Score (PUQE), fluids, oral antiemetics at home (antihistamine eg. cyclizine, not severe) Medical- admission considered if- can’t keep fluids down/ ketones 2+/ electrolyte imbalances/ other medical conditions (may need IV fluids and antiemetics/ VTE prophylaxis) NB- ondansetron and metoclopramide are used 2nd line (metoclopramide- not more than 5 days due to EPSE's)\ Associations; multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity NB- smoking is associated with a reduced incidence NB- if severe or prolonged it can also result in vitamin and mineral deficiencies. In this case, the patient has presented with diplopia and ataxia suggestive of Wernicke's encephalopathy. Therefore, supplementation of thiamine (Vitamin B1) with a vitamin B and C complex (e.g. Pabrinex) is indicated.

Answer 50

A type of tumour that grows like a pregnancy inside the uterus. A complete mole- when two sperm cells fertilise an ovum that contains no genetic material. These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form. A partial mole- when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form. Features; More severe morning sickness Vaginal bleeding Uterus size greater than expected for gestational age Abnormally high hCG Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4) Investigations; USS- snowstorm appearance of the pregnancy (with biopsy when pregnancy has passed) NB- TVUSS or abdominal USS? Management; -Surgical evacuation of uterus (send mole for histology) -Monitor hCG levels -Refer to the gestational trophoblastic disease centre for follow up -contraception for the next 12 months?

Answer 51

Last menstrual period (LMP) refers to the date of the first day of the most recent menstrual period Gestational age (GA) refers to the duration of the pregnancy starting from the date of the last menstrual period The first trimester start of pregnancy until 12 weeks gestation. The second trimester is from 13 weeks until 26 weeks gestation. The third trimester is from 27 weeks gestation until birth. NB- fetal movements start from around 20 weeks Key Milestones (see 0-finals) Additional Milestones; Additional appointments for higher risk or complicated pregnancies Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks) Anti-D injections in rhesus negative women (at 28 and 34 weeks) Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan Serial growth scans are offered to women at increased risk of fetal growth restriction Routine Antenatal Appointments Discuss plans for the remainder of the pregnancy and delivery Symphysis–fundal height measurement from 24 weeks onwards Fetal presentation assessment from 36 weeks onwards Urine dipstick for protein for pre-eclampsia Blood pressure for pre-eclampsia Urine for microscopy and culture for asymptomatic bacteriuria Vaccines; -Whooping cough (pertussis) from 16 weeks gestation -Influenza (flu) when available in autumn or winter Live vaccines, such as the MMR vaccine, are avoided in pregnancy.

Answer 52

Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects) Take vitamin D supplement (10 mcg or 400 IU daily) Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses) Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome) Don’t smoke (smoking has a long list of complications, see below) Avoid unpasteurised dairy or blue cheese (risk of listeriosis) Avoid undercooked or raw poultry (risk of salmonella) Continue moderate exercise but avoid contact sports Sex is safe Flying increases the risk of venous thromboembolism (VTE) Place car seatbelts above and below the bump (not across it) Foetal Alcohol Syndrome; Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye to the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy Flying in Pregnancy; -37 weeks in a single pregnancy -32 weeks in a twin pregnancy After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well and there are no additional risks. Smoking in Pregnancy; Fetal growth restriction (FGR) Miscarriage Stillbirth Preterm labour and delivery Placental abruption Pre-eclampsia Cleft lip or palate Sudden infant death syndrome (SIDS)

Answer 53

Education What to expect at different stages of pregnancy Lifestyle advice in pregnancy (e.g. not smoking) Supplements (e.g. folic acid and vitamin D) Plans for birth Screening tests (e.g. Downs screening) Antenatal classes Breastfeeding classes Discuss mental health Booking Bloods -Blood group, antibodies and rhesus D status -Full blood count for anaemia -Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) Patients are also offered screening for infectious diseases, by testing antibodies for: -HIV -Hepatitis B -Syphilis Other Measures Weight, height and BMI Urine for protein and bacteria Blood pressure Discuss female genital mutilation Discuss domestic violence NB- risk assessment is completed (for VTE, diabetes etc.)

Answer 54

Combined Test -First line and the most accurate screening test. It is performed between 11 and 14 weeks -USS (nuchal translucency- greater than 6mm) -Maternal blood tests: Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk Triple Test -Between 14 and 20 weeks gestation. -Beta-HCG -Alpha-fetoprotein (AFP) -Serum oestriol– lower result indicates a greater risk NB- quadruple test: also measures inhibin-A (higher=greater risk) The screening tests provide a risk score for the fetus having Down’s syndrome. When the risk of Down’s is greater than 1 in 150 (occurs in around 5% of tested women), the woman is offered amniocentesis or chorionic villus sampling. NB- maternal age is also factored into the risk tool NB- Edwards: everything low, normal inhibin . NTD's: isolated raised AFP

Answer 55

Medications that should be stopped as they may cause congenital abnormalities: ACE inhibitors (e.g. ramipril) Angiotensin receptor blockers (e.g. losartan) Thiazide and thiazide-like diuretics (e.g. indapamide) Medications that are not known to be harmful: Labetalol (a beta-blocker – although other beta-blockers may have adverse effects) Calcium channel blockers (e.g. nifedipine) Alpha-blockers (e.g. doxazosin)

Answer 56

Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy Sodium valproate and phenytoin are avoided

Answer 57

Methotrexate is avoided sulfalazine hydroxychloroquine and steroids are safe

Answer 58

Avoid; -NSAID -ACE-i/ARB -Opiates -Warfarin -Lithium, phenytoin -Valproate -Isotretinoin -Methotrexate -DOACs' (use LMWH) NB- be careful with Beta blockers (FGR- use labetolol) and SSRI's (cardiac malformation)

Answer 59

In pregnancy, there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome Mothers that have previously had chickenpox are immune and safe. When in doubt, IgG levels for VZV can be tested (this is first line). A positive IgG for VZV indicates immunity. Women that are not immune to varicella may be offered the varicella vaccine before or after pregnancy. Exposure to chickenpox in pregnancy: -if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible (up to 10 days) -if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure Chickenpox infection in pregnancy; -oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash -if the woman is < 20 weeks the aciclovir should be 'considered with caution'

Answer 60

Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods. Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.

Answer 61

Infection with the Toxoplasma gondii parasite is usually asymptomatic. It is primarily spread by contamination with faeces from a cat that is a host of the parasite. When infection occurs during pregnancy, it can lead to congenital toxoplasmosis. The risk is higher later in the pregnancy. NB- pregnant women should avoid blue cheese and cat litter trays/faeces

Answer 62

Rhesus-D positive women- no additional treatment Anti-D injections are given routinely on two occasions to Rhesus negative mothers: -28 weeks gestation -Birth (if the baby’s blood group is found to be rhesus-positive) And in situations where sensitisation could occur (within 72 hours); -Antepartum haemorrhage -Amniocentesis procedures -Abdominal trauma Kleihauer Test After 20 weeks gestation, the Kleinhauer test is performed to see how much fetal blood has passed into the mother’s blood, to determine whether further doses of anti-D are required. Investigations; all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood, fetal cells are resistant

Answer 63

It is important to note the difference between small for gestational age (SGA) and fetal growth restriction (FGR). Small for gestational age simply means that the baby is small for the dates, without stating why. The fetus may be constitutionally small, growing appropriately, and not at increased risk of complications. Alternatively, the fetus may be small for gestational age due to pathology (i.e. FGR- placental or non-placental driven), with a higher risk of morbidity and mortality.

Answer 64

Causes of Macrosomia Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby Risks The risks to the mother include: Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare) The risks to the baby include: Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) Neonatal hypoglycaemia Obesity in childhood and later life Type 2 diabetes in adulthood

Answer 65

Asymptomatic Bacteriuria Asymptomatic bacteriuria refers to bacteria present in the urine, without symptoms of infection. Pregnant women with asymptomatic bacteriuria are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently at risk of preterm birth. Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S). Pregnant women with asymptomatic bacteriuria are treated with ABX, then there is a test for cure ie. another MSU sample is sent for MCS to determine whether treatment has been effective Features of UTI/pyelonephritis- the usual Management; -7 days of ABX -Trimethoprim (avoid in first trimester- folate antagonist) -Nitrofurantoin (avoid in 3rd trimester- neonatal haemolysis, and generally try and avoid)

Answer 66

During pregnancy, the plasma volume increases. This results in a reduction in the haemoglobin concentration. The blood is diluted due to the higher plasma volume. Features Often anaemia in pregnancy is asymptomatic. Women may have: Shortness of breath Fatigue Dizziness Pallor Palpitations The MCV guides aetiology; -Low MCV may indicate iron deficiency -Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy -Raised MCV may indicate B12 or folate deficiency Women are offered haemoglobinopathy screening (thalassaemia) but not haemanitics NB- All women should already be taking folic acid 400mcg per day anyway. Women with folate deficiency are started on folic acid 5mg daily. Cut off's to determine whether someone requires oral iron (ferrous fumerate)- should continue for 3 months after level normalises; First trimester < 110 g/L Second/third trimester < 105 g/L Postpartum < 100 g/L

Answer 67

Risk Factors Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy Situations where prophylaxis should be started; -28 weeks if there are three risk factors -First trimester if there are four or more of these risk factors (and of course situations where there is surgery/hospital admission etc.) Investigations; -ECG/CXR/ compression duplex ultrasound (if signs of a DVT)/VQ scan (preferred over CTPA) Management; Supportive- anti embolic stockings, pneumatic calf compression (if contraindication to LMWH) Medical- LMWH eg. enoxaparin, dalteparin from 28 weeks to 6 weeks postnatally (post partum is high risk time. If really high risk, start right away) NB- risk can be deduced at the booking visit NB- no DOAC's or warfarin in pregnancy NB- D dimer often raised in pregnancy anyway so it is of little use

Answer 68

Pre-eclampsia- new high blood pressure (hypertension) in pregnancy with end-organ dysfunction Chronic hypertension- HTN that exists before 20 weeks gestation and is longstanding. Gestational hypertension- HTN occurring after 20 weeks gestation, without proteinuria. Features a triad of: Hypertension Proteinuria Oedema Eclampsia- when seizures occur as a result of pre-eclampsia. High-risk factors are: Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease Moderate-risk factors are: Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia Features/Presentation; Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (this is due to liver swelling) Oedema Reduced urine output Brisk reflexes Investigations; The NICE guidelines (2019) advise a diagnosis can be made with a: Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies) Screening; All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with: Blood pressure Symptoms Urine dipstick for proteinuria Management; Women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth ≥ 1 high risk factors ≥ 2 moderate factors When pre-eclampsia is suspected; -Refer to specialist -Admit if BP is greater than 160/110even if no proteinuria (keep overnight for observation- follow up regularly in community until birth) -Oral labetalol (or nifedipine if asthmatic) -Delivery of baby- definitive management (same day if over 34 weeks and necessary) NB- secondary care assessment for all women with new onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic) after 20 weeks of pregnancy.

Answer 69

Treatment is IV Mg sulphate calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 70

Risk factors; Previous gestational diabetes Previous macrosomic baby (≥ 4.5kg) BMI > 30 Ethnic origin (black Caribbean, Middle Eastern and South Asian) Family history of diabetes (first-degree relative) NB- Anyone with risk factors should be screened with an oral glucose tolerance test at 24 – 28 weeks gestation. Women with previous gestational diabetes also have an OGTT soon after the booking clinic, and again at 24-28 weeks if negative) Outcome of OGTT; fasting glucose is >= 5.6 mmol/L 2-hour glucose is >= 7.8 mmol/L An OGTT is also performed when there are features that suggest gestational diabetes: Large for dates foetus Polyhydramnios (increased amniotic fluid) Glucose on urine dipstick Management; Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin (short-acting) Fasting glucose above 7 mmol/l: start insulin ± metformin Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin NB- a sulfonylurea is suggested as an option for women who decline insulin or cannot tolerate metformin. NB- only short acting, never long acting Target blood sugars; Fasting 5.3 mmol/l 2 hour after meals 6.4 mmol/l NB- trace glycosuria is common in pregnancy due to the increased GFR and reduction in tubular reabsorption of filtered glucose

Answer 71

They should take 5mg folic acid from preconception until 12 weeks gestation. Women with existing type 1 and type 2 diabetes should aim for the same target insulin levels as with gestational diabetes. Women with type 2 diabetes are managed using metformin and insulin, and other oral diabetic medications should be stopped. Retinopathy screening at booking visit and 28 weeks NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6). A sliding-scale insulin regime is considered during labour for women with type 1 diabetes. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. This is also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes. Neonatal Complications; Neonatal hypoglycaemia (aim for BM greater than 2) Polycythaemia (raised haemoglobin) Jaundice (raised bilirubin) Congenital heart disease Cardiomyopathy Target blood sugars; Fasting 5.3 mmol/l 2 hour after meals 6.4 mmol/l

Answer 72

Features; Itching (pruritis)-particularly affecting the palms of the hands and soles of the feet. Fatigue Dark urine Pale, greasy stools Jaundice Investigations Bedside Bloods- LFT's and bile acids (ALT, AST and GGT raised. ALP is raised due to PLACENTAL PRODUCTION) Management; Supportive- induction of labour at 37-38 weeks is common practice, emollients for skin itch Medical- ursodeoxycholic acid, vitamin K supplementation

Answer 73

A rare complication which may occur in the third trimester or the period immediately following delivery. Features abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia Investigations ALT is typically elevated e.g. 500 u/l NB- if liver failure may have abnormal coagulation and other deranged liver enzymes Management support care once stabilised delivery is the definitive management NB- in your exams, elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential.

Answer 74

Atopic eruption of pregnancy is the commonest skin disorder found in pregnancy it typically presents as an eczematous, itchy red rash. no specific treatment is needed Polymorphic eruption of pregnancy pruritic condition associated with last trimester lesions often first appear in abdominal striae management depends on severity: emollients, mild potency topical steroids and oral steroids may be used Pemphigoid gestationis pruritic blistering lesions often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy oral corticosteroids are usually required

Answer 75

Describes a placenta lying wholly or partly in the lower uterine segment. Usually migrates out of the way Risks; multiparity multiple pregnancy embryos are more likely to implant on a lower segment scar from previous caesarean section IVF Features; shock in proportion to visible loss no pain uterus not tender lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large Investigations; Bedside- NO BIMANUAL EXAM (may rupture) Bloods Imaging- usually picked up at 20 week USS (TV USS helps with localisation) Management; Low lying at 20 weeks- rescan at 34 weeks Final USS at 36-7 weeks- elective caesarean section for grades III/IV between 37-38 weeks (if labour prior to elective date- emergency c section (risk of PPH)) Placenta praevia with bleeding admit ABC approach to stabilise the woman if not able to stabilise → emergency caesarean section if in labour or term reached → emergency caesarean section

Answer 76

Where the foetal vessels travel across the internal cervical os Risks; Low lying placenta IVF pregnancy Multiple pregnancy Presentation; Asymptomatic Antepartum haemorrhage Pulsatile vessels on cervical examination Fetal distress and dark-red bleeding occur following rupture of the membranes (waters break, then blood) Fetal bradycardia is classically seen Management; Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation (emergency if antepartum haemorrhage occurs)

Answer 77

Describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space Risks; proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age polyhydramnios uterine injury/infection Clinical features; shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria Management; The initial steps with major or massive haemorrhage are: Urgent involvement of a senior obstetrician, midwife and anaesthetist 2 x grey cannula Bloods include FBC, UE, LFT and coagulation studies Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring of the fetus Close monitoring of the mother USS (check it isnt placenta previa) Fetus alive and < 36 weeks fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks fetal distress: immediate caesarean no fetal distress: deliver vaginally Fetus dead induce vaginal delivery

Answer 78

Describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage. Risks; previous caesarean section placenta praevia NB- usually asymptomatic and diagnosed on routine scans. Management can be expectant or surgical; Hysterectomy with the placenta remaining in the uterus (recommended) Uterus preserving surgery, with resection of part of the myometrium along with the placenta Expectant management, leaving the placenta in place to be reabsorbed over time Expectant management comes with significant risks, particularly bleeding and infection.

Answer 79

Risk factors; uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality (e.g. CNS malformation, chromosomal disorders) prematurity (due to increased incidence earlier in gestation) Management; -if < 36 weeks: many fetuses will turn spontaneously -if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women -if the baby is still breech then delivery options include planned caesarean section or vaginal delivery Contraindications to ECV: where caesarean delivery is required antepartum haemorrhage within the last 7 days abnormal cardiotocography major uterine anomaly ruptured membranes multiple pregnancy ECV Women are given tocolysis to relax the uterus before the procedure. Tocolysis is with subcutaneous terbutaline. Terbutaline is a beta-agonist similar to salbutamol. It reduces the contractility of the myometrium, making it easier for the baby to turn. Rhesus-D negative women require anti-D prophylaxis when ECV is performed. A Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.

Answer 80

Defined as the birth of a dead fetus after 24 weeks gestation. Stillbirth is the result of intrauterine fetal death (IUFD). It occurs in approximately 1 in 200 pregnancies. Causes; Unexplained (around 50%) Pre-eclampsia Placental abruption Vasa praevia Cord prolapse or wrapped around the fetal neck Obstetric cholestasis Diabetes Thyroid disease Infections, such as rubella, parvovirus and listeria Genetic abnormalities or congenital malformations Factors that increase the risk of stillbirth include: Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back (as opposed to either side) There are three key symptoms to always ask during pregnancy. Women would report these immediately if they occur: -Reduced fetal movements -Abdominal pain -Vaginal bleeding NB- with parental consent, the child can be tested afterwards to determine any possible cause of stillbirth

Answer 81

The three major causes of cardiac arrest in pregnancy to remember are: Obstetric haemorrhage Pulmonary embolism Sepsis leading to metabolic acidosis and septic shock Obstetric haemorrhage is a major cause of severe hypovolaemia and cardiac arrest. Remember the causes of massive obstetric haemorrhage: Ectopic pregnancy (early pregnancy) Placental abruption (including concealed haemorrhage) Placenta praevia Placenta accreta Uterine rupture

Answer 82

Complications of PPROM -fetal: prematurity, infection, pulmonary hypoplasia -maternal: chorioamnionitis Investigations; A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection. Ultrasound may also be useful to show oligohydramnios. Management; -admission -oral erythromycin and corticosteroids -delivery should be considered at 34 weeks

Answer 83

Indications; prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery prelabour premature rupture of the membranes, where labour does not start diabetic mother > 38 weeks pre-eclampsia rhesus incompatibility Bishop Score; Used to help assess the whether induction of labour will be required. It has the following components: -Cervical position, consistency, effacement, dilation -Fetal station Interpretation -a score of < 5 indicates that labour is unlikely to start without induction -a score of ≥ 8 indicates that the cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour Methods; 1- membrane sweep (adjunct, done before formal induction) 2- vaginal prostaglandin E2 (PGE2) (preferred method) 3- maternal oxytocin infusion 4- amniotomy ('breaking of waters') 5- cervical ripening balloon Main complication- uterine hyperstimulation (stop provoking agents, tocolysis with terbutaline) NB- NICE guidelines if the Bishop score is ≤ 6 vaginal prostaglandins or oral misoprostol mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean if the Bishop score is > 6 amniotomy and an intravenous oxytocin infusion

Answer 84

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery

Answer 85

Involves the umbilical cord descending ahead of the presenting part of the fetus. Risk Factors; prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie NB- 50% of cord prolapses occur at artificial rupture of the membranes NB- The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus. Management; -On all fours (elbows and knees) -presenting part of the fetus (not the cord itself) may be pushed back into the uterus to avoid compression (not the cord itself, just the fetus) -retrofilling the bladder with 500-700mls saline -tocolytics (terbutaline) -Emergency C section NB- there should be minimal handling and it should be kept warm and moist to avoid vasospasm ie. can only touch presenting part of foetus, not umbilical cord

Answer 86

When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered Risk Factors; fetal macrosomia high maternal body mass index diabetes mellitus prolonged labour Management; Non surgical- McRoberts' manoeuvre (knees to abdomen) Surgical- Episiotomy Complications; maternal postpartum haemorrhage perineal tears fetal brachial plexus injury neonatal death

Answer 87

NB- one dose of maternal co-amoxiclav is given post-instrumental delivery to reduce maternal infections Indications; Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions Epidural Key risks to baby -Cephalohaematoma with ventouse -Facial nerve palsy and fat necrosis with forceps -Intracranial haemorrhage with both

Answer 88

Risks; First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries Classification; First-degree – injury limited to the frenulum of the labia minora and superficial skin (no repair) Second-degree – including the perineal muscles (repair on ward) Third-degree – including the anal sphincter (repair in theatre) Fourth-degree – including the rectal mucosa (repair in theatre) General management; Supportive- physiotherapy Medical- ABX/ laxatives (constipation) NB- episiotomies are done when perineal tears are pre-emepted (so that there is a controlled widening, not random, potentially tearing into rectal mucosa)

Answer 89

Refers to bleeding after delivery of the baby and placenta. Classification; 500ml after a vaginal delivery 1000ml after a caesarean section Primary- within 24 hours, secondary- after 24 hours (most likely due to infection- TV USS, swabs (organism) IV ABX, surgical evacuation etc.) Causes (4 T's); T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder) Risk factors; Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in the second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery General anaesthesia Episiotomy or perineal tear Prevention of PPH Treating anaemia Giving birth with an empty bladder Active management of the third stage Intravenous tranexamic acid can be used during caesarean section in higher-risk patients Stabilisation of Patient; Resuscitation with an ABCDE approach Lie the woman flat, keep her warm and communicate with her and the partner Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) NB- may need to active major haemorrhage protocol Treatment to stop the bleeding; Mechanical (catheter/ rubbing uterus) Medical (TXA/ergotomine/oxytocin (syntocinon or Syntometrine /misoprostol) Surgical (Intrauterine balloon tamponade/ B lynch suture/ uterine artery ligation/ hysterectomy)

Answer 90

Chorioamnionitis (occurs whilst the mother is pregnant, so early intervention required to protect unborn child) Urinary tract infections

Answer 91

NB- usually around the time of labour Risks; Increasing maternal age Induction of labour Caesarean section Multiple pregnancy Presentation; Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest NB- no tests and management is supportive (get seniors, ICU etc.)

Answer 92

Risks; Vaginal birth after caesarean (VBAC) Previous uterine surgery (caesarean section) Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions Features; Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse NB- acutely unwell mother and abnormal CTG Management; Medical- resuscitation and transfusion Surgical- emergency C section, repair uterus etc.

Answer 93

Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). The absence of periods related to breastfeeding is called lactational amenorrhoea. Bottle-feeding women will begin having menstrual periods from 3 weeks onwards. This is unpredictable, and periods can be delayed or irregular at first.

Answer 94

Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point. Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods). The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth. The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks), but if bottle-feeding, it can be used after day 21 Copper coil/IUD- either within 48 hours or after 4 weeks of delivery

Answer 95

Most common after caesarean section (give ABX prophylactically) Features; Foul-smelling discharge or lochia Bleeding that gets heavier or does not improve with time Lower abdominal or pelvic pain Fever Sepsis Investigations; Bedside- vaginal swabs, urine MCS Bloods- systemic compromise Imaging- TV USS (rule out retained products of conception) Management- sepsis 6

Answer 96

NB- placenta accreta is a major risk factor Features; Vaginal bleeding that gets heavier or does not improve with time Abnormal vaginal discharge Lower abdominal or pelvic pain Fever (if infection occurs) Investigations Bedside- speculum and bimanual Bloods- systemic compromise Imaging- TV USS Management; Surgical- Evacuation of retained products of conception NB- key complications are endometritis and Asherman's syndrome

Answer 97

Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months) Hb under 90 g/l – consider an iron infusion in addition to oral iron Hb under 70 g/l – blood transfusion in addition to oral iron (the same threshold for non ACS transfusion) NB- active infection is a contraindication to iron transfusion (pathogens proliferate)

Answer 98

Management; Mild cases may be managed with additional support, self-help and follow up with their GP Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit NB- The Edinburgh Postnatal Depression Scale may be used to screen for depression:

Answer 99

NB- psychosis in postpartum period Admission to the mother and baby unit Cognitive behavioural therapy Medications (antidepressants, antipsychotics or mood stabilisers) Electroconvulsive therapy (ECT) NB- 25-50% risk of recurrence following future pregnancies

Answer 100

Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker) Hypothyroidism: levothyroxine NB- no Carbimazole

Answer 101

a rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland (NB- only affects the anterior pituitary) The anterior pituitary releases: Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Luteinising hormone (LH) Growth hormone (GH) Prolactin (NB posterior hormones, ADH and oxytocin are spared) Features; Reduced lactation (lack of prolactin) Amenorrhea (lack of LH and FSH) Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH) Hypothyroidism with low thyroid hormones (lack of TSH) Management (replace lost hormones); Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause) Hydrocortisone for adrenal insufficiency Levothyroxine for hypothyroidism Growth hormone

Answer 102

Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects. Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy. In patients assigned male at birth, oestradiol, gonadotrophin-releasing hormone analogues, finasteride or cyproterone acetate, there may be a reduction or cessation of sperm production, however, the variability of the effects of such therapy is such that they cannot be relied upon as a method of contraception. NB- condoms or surgical procedures are thus recommended

Answer 103

More than 6 weeks- refer to early pregnancy assessment service Less than 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly (return if bleeding persists, pregnancy test 1 week later (may have miscarried))

Answer 104

Delayed puberty with short stature Turner's syndrome Prader-Willi syndrome Noonan's syndrome Delayed puberty with normal stature polycystic ovarian syndrome androgen insensitivity Kallman's syndrome Klinefelter's syndrome

Answer 105

Management; -simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months (the levonorgestrel intra-uterine system may be used) -atypia: hysterectomy is usually advised (with bilateral salpingooophorectomy)

Answer 106

Causes; -Vaginal atrophy -Endometrial hyperplasia -HRT -Cancer eg. cervical, uterine, vaginal, vulval, and ovarian -Trauma -Coagulopathies Investigations; 2 WEEK WAIT (OVER 55 WITH A POST MENOPAUSAL BLEED) Bedside- speculum and bimanual examination Bloods- Ca125, FBC and coagulation studies Imaging- TV USS, biopsy, CT if necessary

Answer 107

Increased AFP Neural tube defects (meningocele, myelomeningocele and anencephaly) Abdominal wall defects (omphalocele and gastroschisis) Multiple pregnancy Decreased AFP Down's syndrome Trisomy 18 Maternal diabetes mellitus

Answer 108

Placental abruption; shock out of keeping with visible loss pain constant tender, tense uterus (woody) normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria Placenta praevia; shock in proportion to visible loss no pain uterus not tender* lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large

Answer 109

Around 1 in 10 breastfed babies lose more than the 'cut-off' 10% threshold in the first week of life. This should prompt consideration of the above breastfeeding problems. The infant should also be examined to look for any underlying problems. NICE recommends an 'expert' review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory

Answer 110

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines, clozapine aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone

Answer 111

Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Answer 112

All women should take 400mcg of folic acid until the 12th week of pregnancy women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy women are considered higher risk if any of the following apply: -either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD -the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. -the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more). Causes of folic acid deficiency: phenytoin methotrexate pregnancy alcohol excess

Answer 113

typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. NB- differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Answer 114

Streptococcus agalacticae women who've had GBS detected in a previous pregnancy shou d be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date IAP should be offered to women with a previous baby with early- or late-onset GBS disease IAP should be offered to women in preterm labour regardless of their GBS status women with a pyrexia during labour (>38ºC) should also be given IAP benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Answer 115

an acronym for Hemolysis, Elevated Liver enzymes, and a Low Platelet count. It is a serious condition that can develop in the late stages of pregnancy. NB- overlap with pre-eclampsia Features; nausea & vomiting right upper quadrant pain lethargy Investigations; bloods: Hemolysis (FBC), Elevated Liver enzymes, and a Low Platelet count Treatment; delivery of the baby

Answer 116

babies born to mothers who are chronically infected with hepatitis B or to mothers who've had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 117

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarean section is recommended ART used for 4-6 weeks in UK- women shouldn't breastfeed

Answer 118

Labour may be defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part Signs of labour include; regular and painful uterine contractions a show (shedding of mucous plug) rupture of the membranes (not always) shortening and dilation of the cervix Labour may be divided in to three stages; stage 1: from the onset of true labour to when the cervix is fully dilated 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 Monitoring in Labour; FHR monitored every 15min (or continuously via CTG) Contractions assessed every 30min Maternal pulse rate assessed every 60min Maternal BP and temp should be checked every 4 hours VE should be offered every 4 hours to check progression of labour Maternal urine should be checked for ketones and protein every 4 hours

Answer 119

premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia

Answer 120

obese women should take 5mg of folic acid, rather than 400mcg all obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made NB- no need to diet during pregnancy, but they can keep active and undertake low-intensity exercise

Answer 121

increased mortality depends on the gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice Hearing problems Retinopathy of prematurity

Answer 122

Defined as a temperature of > 38ºC in the first 14 days following delivery. Causes: endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism NB- admit for IV antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 123

Should be established by 24 weeks (if not, refer to foetal medicine) Investigations; First line- handheld doppler (foetal heartbeat) Then use immediate USS if no heartbeat

Answer 124

Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping between 4-6 weeks following birth. The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn't stop, she should seek medical help. NB- lochia is investigated with USS after 6 weeks

Answer 125

Features -small (2 - 5 mm) fleshy protuberances which are slightly pigmented -may bleed or itch Treatment -multiple, non-keratinised warts: topical podophyllum -solitary, keratinised warts: cryotherapy

Answer 126

blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars rhagades (linear scars at the angle of the mouth) keratitis saber shins saddle nose deafness

Answer 127

Referred to as chocolate cysts

Answer 128

Follicular cysts commonest type of ovarian cyst commonly regress after several menstrual cycles Corpus luteum cyst during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst (more likely to bleed)

Answer 129

Dermoid cyst also called mature cystic teratomas (may contain skin appendages, hair and teeth) most common benign ovarian tumour in woman under the age of 30 years bilateral in 10-20% usually asymptomatic. Torsion is more likely than with other ovarian tumours Serous cystadenoma bilateral in around 20% Mucinous cystadenoma second most common benign epithelial tumour they are typically large and may become massive if ruptures may cause pseudomyxoma peritonei

Answer 130

Sertraline or paroxetine

Answer 131

a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes ie. woman reports an episode of urinary incontinence and discharge (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

Answer 132

8-12 weeks (booking visit) bloods and urine (anaemia, haemoglobinopathy, rhesus status, red cell autoantibdoies, hep B, HIV, syphillis, urine culture for asymptomatic bacteriuria) 10-14 weeks scan to confirm dates (exclude multi-pregnancy) 11- 13+6 combined test (bloods and nuchal translucency- trisomy's 13 18 21) 18-21 weeks anomaly scan 20 weeks quadruple test (blood test only, and only for Down's syndrome)- if not able to have combined screening NB- woman doesn't have to have any screening she doesn't want 28 weeks second anaemia, haemoglobinopathy, red cell autoantibodies test 1st does anti D 34 weeks 2nd dose anti D 36 (or 37 weeks if not first pregnancy) ECV

Answer 133

Painful- HSV1/2, chancroid Painless- Treponema pallidum (syphilis), LGV

Answer 134

Divided into 3 categories Pre-existing HTN (use labetalol, nifedipine) Gestational (pregnancy induced) HTN (140/90 or >30 systolic/ >15 diastolic increase from booking BP) Pre-eclampsia (end organ dysfunction eg. proteinuria, oedema)- after 20 weeks NB- BP usually falls in early pregnancy and creeps back up again to booking levels in the third trimester

Answer 135

Investigations -FBC -TFT's -routine TVUSS if symptoms (for example, intermenstrual or postcoital bleeding, pelvic pain and/or pressure symptoms) suggest a structural or histological abnormality (other indications include abnormal pelvic exam findings) Management Does not require contraception NSAID (mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well)) or tranexamic acid 1 g tds. Requires contraception intrauterine system (Mirena) should be considered first-line (levonorgestrel) combined oral contraceptive pill long-acting progestogens (depo-provera)

Answer 136

Category 1 an immediate threat to the life of the mother or baby examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia delivery within 30 minutes Category 2 maternal or fetal compromise which is not immediately life-threatening delivery within 75 minutes Category 3 delivery is required, but mother and baby are stable Category 4 elective caesarean

Answer 137

planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery (after 2- not as safe, and you should give birth in hospital, not at home, but it is her choice)- if first baby was c-section, probably should give birth in hospital too (not at home) around 70-75% of women in this situation have a successful vaginal delivery contraindications include previous uterine rupture or classical caesarean scar (midline abdomen, unlike Ange's)

Answer 138

latent phase = 0-3 cm dilation, normally takes 6 hours active phase = 3-10 cm dilation, normally 1cm/hr

Answer 139

can be active or passive if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section episiotomy may be necessary following crowning associated with transient fetal bradycardia

Answer 140

Both in third trimester AFL- more severe illness, liver enzymes raised (ALT) IC- bilirubin raised (not liver enzymes), severe pruritus

Answer 141

Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations: delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required) external cephalic version (ECV) antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling abdominal trauma

Answer 142

suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant (as it is a live vaccine) NB- congenital rubella syndrome: sensorineural deafness, cataracts, CHD, growth retardation

Answer 143

cystic fibrosis Down's syndrome cytomegalovirus infection

Answer 144

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above severe hypertension 160/110 mmHg or above oxytocin use the presence of significant meconium fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014

Answer 145

Co-amoxiclav Penicillin allergy- erythromycin (when not pregnant and penicillin allergy- use doxycycline)

Answer 146

NB- bleeding after 28 weeks Placenta previa Vasa previa (bradycardia) Placental abruption Cervicitis eg. STI

Answer 147

1st trimester Spontaneous abortion Ectopic pregnancy Hydatidiform mole 2nd trimester Spontaneous abortion Hydatidiform mole Placental abruption 3rd trimester Bloody show Placental abruption Placenta praevia Vasa praevia STI

Answer 148

Screened for between 16-24 weeks in monochorionic pregnancies

Answer 149

Advantages; highly effective (failure rate < 1 per 100 woman years) doesn't interfere with sex contraceptive effects reversible upon stopping usually makes periods regular, lighter and less painful reduced risk of ovarian, endometrial - this effect may last for several decades after cessation reduced risk of colorectal cancer may protect against pelvic inflammatory disease may reduce ovarian cysts, benign breast disease, acne vulgaris Disadvantages; people may forget to take it offers no protection against sexually transmitted infections increased risk of venous thromboembolic disease increased risk of breast and cervical cancer increased risk of stroke and ischaemic heart disease (especially in smokers) temporary side-effects such as headache, nausea, breast tenderness may be seen

Answer 150

UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method UKMEC 2: advantages generally outweigh the disadvantages UKMEC 3: disadvantages generally outweigh the advantages UKMEC 4: represents an unacceptable health risk Examples of UKMEC 3 conditions include; 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 Examples of UKMEC 4 conditions include; 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) NB- Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity

Answer 151

1 pill missed -take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day 2 pills missed -take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day -the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. -if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 -if pills are missed in week 2 (Days 8-14): if taken them all in week 1, then nothing needed -if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 152

Levonorgestrel can be used more than once in a menstrual cycle if clinically indicated hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception Increased BMI- double dose Ulipristal Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period caution should be exercised in patients with severe asthma can be used more than once in the same cycle If breastfeeding, must stop for 5 days post-ulipristal IUD must be inserted within 5 days of UPSI, or if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date Can't be used if active STI/PID

Answer 153

if not inserted on day 1 to 5 of a woman's menstrual cycle Immediate contraception- copper IUD 2 days- POP 7 days- COCP/injection/implant/IUS

Answer 154

irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time (12 months) NB- can't be used in women with breast cancer

Answer 155

IUD can be relied upon immediately following insertion the majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years IUS can be relied upon after 7 days the most common IUS (i.e. Mirena® - levonorgestrel 20 mcg/24 hrs) is effective for 5 years

Answer 156

Require contraception after day 21 POP -'postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.' COCP absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum if breastfeeding can be used after 6 weeks the COCP may reduce breast milk production in lactating mothers should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum IUD can be inserted within 48 hours of childbirth or after 4 weeks. Lactational amenorrhoea 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum

Answer 157

no effect on the POP be careful with COCP/POP and rifampicin

Answer 158

Traditional If less than 3 hours late no action required, continue as normal If more than 3 hours late (i.e. more than 27 hours since the last pill was taken) action needed - see below Cerazette (desogestrel) If less than 12 hours late no action required, continue as normal If more than 12 hours late (i.e. more than 36 hours since the last pill was taken) action needed - see below Action required, if needed: 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 If had sex after missing pill- emergency contraception

Answer 159

COCP Microgynon Loestrin Cilest Yasmin Marvelon Dianette POP Traditional progestogen-only pill (e.g. Norgeston or Noriday) Desogestrel-only pill (e.g. Cerazette)

Answer 160

Bonus points for the student if they check with the patient if she is happy for IVF to be written in the notes. It is a legal requirement to get permission from the patient to write about IVF in the patients notes.

Answer 161

Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN Having a positive result means that the obstetric team can optimise everything, in case the lady does go into premature labour ie. administering steroids to help with neonatal lung maturity. NB- the lady may complain of tightening's Management; -Admit for 2 doses IM steroids and monitor BMs closely, adjusting pump accordingly

Answer 162

Think is it COCP or POP (there are differences)

Answer 163

split into 3 stages, and length does vary but you can expect it to usually last anywhere from 14-20 hours (but that's only a rough estimate) 1st stage- onset of true contractions to when cervix is fully dilated -12-15hrs primip, 7hrs multip -regular painful contractions, and your cervix starts to dilate as foetal head descends into pelvis -show: mucus plug -waters break- rupture of membranes around the baby -if taking a long time, they may offer an induction ie. vaginal pessary or artificial rupturing the membranes -complications- foetus presents the wrong way ie. breech (should know this beforehand though) 2nd stage- full cervical dilation to delivery of baby -1hr primip, 30 mins multip -foetus folds head in and descends further, engages with pelvis -baby then roatates -baby then extends his neck back -and then head is delivered, and baby rotates again into their normal position and is back to its normal position in a process called restitution -delivery of shoulders, and rest of baby -during this stage you will have desire to bear down or push may feel like you need to open bowels, you can push when midwives tell you) -main complication is delayed second stage or foetal distress, perhaps due to shoulder dystocia or failure to rotate properly -interventions: instrumental delivery or c section 3rd stage- passage of placenta -active management: 10 mins, without: 30mins/1hr -gush of blood, and cord will lengthen -can be passive or active: passive management lets the placenta pass naturally, whereas active management involves 3 things 1) drug to make the uterus contract (eg. syntocinon (oxytocin)), 2) clamping and cutting the cord early, 3) cord traction (pulling the cord and placenta out, the blood vessels in womb connected to placenta then start to close). NB- slightly more blood loss with passive third stage (compared to active), but after pain isn't as bad (can be slightly more painful with active management) -complications- PPH, retained placenta, inversion of uterus (put hand on tummy to stop it) -interventions- may need to suck retained products out

Answer 164

2xlarge bore cannulas, FBC, group and save, clotting Give fluids Administer oxygen Foetal monitoring NB- if PPH, consider blood transfusion, medical/surgical interventions to stem the bleeding

Answer 165

stop 4 weeks before, start 2 weeks after

Answer 166

3xTrisomies (combined and quadruple tests) Sickle cell/thalassaemia (fill out a family questionnaire and screening for these conditions is decided based upon the questionnaire results) (then there are other tests ie. for infections blood group etc, and NTD's (genetic defect) can also be looked for during the anomaly scan))

Answer 167

FORCEPS mnemonic Fully dilated cervix generally the second stage of labour must have been reached OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure 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 this will usually require catheterization

Answer 168

FORCEPS mnemonic Fully dilated cervix generally the second stage of labour must have been reached OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure 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 this will usually require catheterization

Answer 169

Contraceptive implant

Answer 170

3-month course of the combined oral contraceptive pill

Answer 171

If a woman has a 'higher chance' results she will be offered a second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS). Given the non-invasive nature of NIPT and extremely high sensitivity and specificity, it is likely this will be the preferred choice for the vast majority of women. NB- sensitivity and specificity are very high for trisomy 21 (>99%)

Answer 172

increased risk of orofacial malformations ie. cleft lip and palate

Answer 173

Vaginal atrophy (refer all over 55 to secondary service however) It is essential to remember that all patients with PMB, even if vaginal atrophy seems likely, should be urgently referred to secondary care to rule out endometrial cancer, as they can co-exist. However, most patients do not have endometrial cancer.

Answer 174

pregnancy SLE, anti-phospholipid syndrome tuberculosis leprosy malaria HIV

Answer 175

Can be raised during pregnancy, so consider intrahepatic cholestasis of pregnancy when ALP is raised along with bilirubin and mild ALT/AST increase

Answer 176

Suspect ovarian cancer in any woman >= 50 years of age presenting with symptoms suggestive of irritable bowel syndrome in the last 12 months. IBS rarely presents for the first time in this age group

Answer 177

Stopped because of increased risk of stroke Switch to POP (not allowed oestrogen)

Answer 178

Copper intrauterine device Progesterone injection (Depo-provera) Mirena intrauterine system

Answer 179

For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed. Missed 1-2 weeks If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed. If the 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 during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered. Missed 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. Missed patch-free week 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.

Answer 180

any combined preparation (COCP, pill, patch)- you'll have a withdrawal bleed (usually lighter than normal period)

Answer 181

Mirena can be used as progesterone component for combined HRT but only for 4 years (not 5, like in contraception)

Answer 182

CVS more accuarte, can be done from 11-13 weeks (1-2% miscarriage) Amniocentesis can be done from 15 weeks (1% miscarriage)