Obstetrics and Gynaecology Flashcards

Question

What is a concealed placental abruption?

Answer 1

Blood accumulates behind placenta with no obvious external bleeding.

Answer 2

- Firm, ‘woody’ tense uterus. - Fetal distress or absent heart beat

Answer 3

Clinical diagnosis Vital signs - BP, HR, oxygen sats, temp, RR. Bloods - FBC, U&Es, LFTs (pre- eclampsia/HELLP), clotting, G&S. CTG - To monitor the foetus

Answer 4

- Resuscitation e.g. IV fluids, blood products - Anti-D if mother Rhesus Negative - Steroids if birth <34 weeks expected for fetal lung develop and reduce RDS

Answer 5

1. No fetal or maternal distress/compromise - induction of labour 2. Fetal distress/maternal compromise - immediate c-section

Answer 6

- Major haemorrhage - Shock - DIC - Premature birth - Stillbirth - Placental insufficiency > intrauterine growth restriction

Answer 7

Placenta accreta is a spectrum of abnormal placenta adherence to the uterus. 1. Placenta accreta 2. Placenta Increta 3. Placenta percreta

Answer 8

The villi of the placenta attaches to the myometrium of the uterus without deep invasion.

Answer 9

The placenta villi extend into the myometrium of the uterus but do not reach the uterine serosa.

Answer 10

The villi penetrate the myometrium, reaching the uterine serosa (perimetrium) and potentially adjacent organs.

Answer 11

- Previous placenta accreta - Previous c-section - Placenta praevia - Uterine abnormality e.g. fibroids - Maternal age: >35 - Multiparity

Answer 12

PAINLESS vaginal bleeding, usually in third trimester. However, it may be asymptomatic.

Answer 13

- Seen at 20-week ultrasound scan. - FBC to assess Hb if acute bleed - Group + save - if patient considered for transfusion

Answer 14

- Delivery at 35 - 36+6 weeks so any haemorrhage can be managed - Hysterotomy after delivery to prevent severe haemorrhage

Answer 15

- PPH due to retained placenta - Disseminated intravascular coagulopathy (DIC)

Answer 16

- 8-10w. - Offer general lifestyle advice. - Comprehensive obstetric history and examination. - Check for bloods, HIV, Hep.B, Syphilis, Rubella.

Answer 17

Implantation of the placenta in the lower uterine segment, potentially causing partial or complete covering of the internal os.

Answer 18

Low lying placenta but does not cover os. Grade 1 - encroaches lower uterus, but does not reach internal os Grade 2 - reaches internal os but does not cover it

Answer 19

Placenta covers internal os Grade 3 - partially cover Grade 4 - completely covers

Answer 20

- Previous C-section - Multiparity - Age >40, - Smoking - uterine abnormalities (e.g. fibroids)

Answer 21

Painless vaginal bleeding.

Answer 22

- Non-tender uterus - Vaginal bleeding - Abnormal lie/presentation Do not do a vaginal examination (can worsen bleeding)

Answer 23

20 week anomaly scan.

Answer 24

If bleeding: - Vital signs - BP, HR, oxygen sats, temp, RR. - Bloods - FBC, U&Es, LFTs ( pre- eclampsia/HELLP), clotting, G&S. - 1st line: - uterine USS - site of the placenta and grade. - CTG - To monitor the fetus.

Answer 25

If identifed at anomoly scan - repeat ultrasound at 32 weeks then 36 weeks if still there. If still praevia at 36 weeks weeks - planned C-section.

Answer 26

Major haemorrhage at delivery - death :(

Answer 27

When the presenting part of the fetus (the lowest part) is the legs and bottom.

Answer 28

- Complete breech - legs are fully flexed at the hips and knees - Incomplete breech, with one leg flexed at the hip and extended at the knee - Extended/frank breech - both legs flexed at the hip and extended at the knee - Footling breech - foot presenting through the cervix with the leg extended

Answer 29

≤ 36 weeks - watch and wait as most turn spontaneously From 36 weeks for nulliparous women and 37 weeks for multiparous women: - external cephalic version (ECV)

Answer 30

Vaginal or C-section delivery led by experienced obstetricians and midwives

Answer 31

Normal pregnancy~ 40 weeks following LMP. 1st: LMP - 12 weeks gestation 2nd: 13 weeks - 27 weeks gestation 3rd: 28 weeks to giving birth

Answer 32

Gravidity is the total number of pregnancies a woman has had, regardless of outcome.

Answer 33

Parity is the total number of pregnancies that a woman carried over the threshold of viability (24+0 in the UK), including stillborns.

Answer 34

- Blood volume increases: RBC, WBC & platelets increase; - Albumin, Urea & Creatinine decrease - Increased Cardiac Output - Increased tidal volume (lung capacity) - Increased skin pigmentation - Breast & nipple enlargement - Increased GFR - Water retention - Increased temperature - Decreased gut motility

Answer 35

- From 37 weeks-42 weeks - Below 37 weeks - preterm labour

Answer 36

- Fetal presenting part **engages** in pelvis - Prostaglandins stimulate cervix effacement (thin, shorten and soften) - Pressure on cervix stimulates oxytocin release from pituitary (+ve feedback loop) - Oxytocin stimulates uterine contractions from fundus, increasing in strength and frequency

Answer 37

- Show (mucus plug from the cervix) - Rupture of membranes - Regular, painful contractions - Dilating cervix on examination

Answer 38

From onset of true contractions to 10cm dilated. Most likely will rupture membranes during this stage.

Answer 39

- Latent phase: cervix dilates up to the first 3-4cm, typically slow - Active phase: 4 - 10cm , regular contractions, 1cm/hr

Answer 40

10cm cervical dilation to delivery of baby

Answer 41

3Ps - Power - uterine contractions - Passage - size & shape of mother's pelvis - Passenger - attitude (posture), lie, presentation, size

Answer 42

The completed birth of the baby to the delivery of the placenta.

Answer 43

- Dose of IM oxytocin given to mother to help uterus contract and expel placenta. - Controlled cord traction - pulling umbilical cord while carefully guiding the placenta out - Initiated if haemorrhage or > 60 min delay in placenta delivery

Answer 44

The use of medications to stimulate the onset of labour.

Answer 45

- Vaginal prostaglandin E2 (dinoprostone): tablet (Prostin) or vaginal pessary (Propess) - Propess releases local prostaglandins over 24 hours > stimulates cervix and uterus to cause the onset of labour. - Cervical ripening balloon (CRB) - inserted into the cervix and gently inflated to dilate the cervix. - Artificial rupture of membranes with an oxytocin infusion - used to progress labour after vaginal prostaglandins

Answer 46

- Cardiotocography (CTG) assesses the fetal heart rate and uterine contractions - Bishop score

Answer 47

Bishop's score is used to determine whether to induce labour. > 8 predicts successful induction < 8 cervical ripening might needed to prep cervix

Answer 48

Most women will give birth within 24 hours of IOL: - Further vaginal prostaglandins - Artificial rupture of membranes and oxytocin infusion - Cervical ripening balloon (CRB) - Elective caesarean section

Answer 49

Uterine hyperstimulation - prolonged and frequent contractions, causing fetal distress and compromise.

Answer 50

- Removing the vaginal prostaglandins, or stopping the oxytocin infusion - Tocolysis with terbutaline (nice recommend nifedipine (myometrium relaxation) - Emergency C-section

Answer 51

Spontaneous termination of a pregnancy. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.

Answer 52

- Advancing maternal age: > 35 - Previous miscarriage - Lifestyle: smoking, alcohol during pregnancy

Answer 53

- Missed miscarriage - Threatened miscarriage - Inevitable miscarriage - Incomplete miscarriage - Complete miscarriage - Recurrent

Answer 54

The fetus is no longer alive, but no symptoms have occured.

Answer 55

Mild vaginal bleeding +/- abdo pain, closed cervical os and a fetus that is alive.

Answer 56

Heavy vaginal bleeding with pain + clots with open cervical os, leads to complete or incomplete miscarriage.

Answer 57

- Pain and vaginal bleeding, cervical os open. - Products of conception are retained after miscarriage

Answer 58

A full miscarriage has occurred, and there are no products of conception left in the uterus.

Answer 59

≥ 3 consecutive miscarriages before 24 weeks of gestation.

Answer 60

Transvaginal ultrasound scan to confirm viability of pregnancy. Checks for fetal heartbeat, size and pole

Answer 61

- Expectant (do nothing and awaiting spontaneous miscarriage) - Medical - Surgical

Answer 62

Expectant provided no other risk factors (e.g. previous ectopic)

Answer 63

NICE recommends referral to early pregnancy assessment service (EPAU) They will carry out a USS to determine location and viability of the pregnancy Consider and exclude ectopic always

Answer 64

Monitoring and analgesia (paracetamol - NSAIDs best avoided)

Answer 65

- Medical management (misoprostol) - Surgical management (evacuation of retained products of conception) Analgesia (paracetamol) and counselling

Answer 66

Analgesia (paracetamol) and counselling

Answer 67

Find and treat underlying cause (e.g. antiphospholipid syndrome)

Answer 68

In the UK, anti-D immunoglobulin are offered to rhesus-negative women following surgery to manage miscarriage.

Answer 69

First-line for women without risk factors for heavy bleeding or infection. 1 – 2 weeks are given to allow the miscarriage to occur spontaneously. A repeat urine pregnancy test 3 weeks after to confirm that miscarriage is complete.

Answer 70

Dose of Misoprostol - oral or vaginal suppository. Misoprostol - prostaglandin analogue and binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions.

Answer 71

- Manual vacuum aspiration under local anaesthetic as an outpatient - Electric vacuum aspiration under general anaesthetic This is done to remove retained products of conception.

Answer 72

New hypertension that occur in pregnant women, with proteinuria (>300mg/24 hrs) and end-organ dysfunction, that occur after 20 weeks gestation.

Answer 73

High risk: - Pre-exisiting HTN, diabetes, SLE, CKD etc. - Pre-eclampsia in a previous pregnancy Moderate risk: - Nulliparity - FHx of pre-eclampsia - Older than 40 - BMI > 35 - Multiple pregnancy High risk for pre-eclampsia if one high, or two moderate RFs Refer high risk women to urgent secondary care review

Answer 74

- BP ≥ 140/90mmHg - Urinalysis ≥ 300 mg of protein in 24 hours; or protein:creatinine ratio ≥ 30mg/mmol; or albumin:creatinine ratio ≥ 8mg/mmol - Fetal ultrasound

Answer 75

- Outpatient - Aim for < 135/85mmHg - Bloods 2x week (FBC, LFTs and renal function) - Offer medication if BP persistently ≥ 140/90mmHg - Admission if clinical concern for mother or baby

Answer 76

Hospital admission for monitoring

Answer 77

- Admission if BP > 160/110 mmHg - If BP < 160/110mmHg depending on clinical concern for mother and baby's wellbeing - Monitor BP at least 48 hours - Urine dipstick testing is not routinely necessary (the diagnosis is already made) - Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed every two weeks

Answer 78

- Aim for > 135/85 mmHg - Admission if > 160/110 mmHg - Urine dipstick testing at least weekly - Monitoring of blood tests weekly (FBC, U+E, LFTs) - Monitoring fetal growth by serial growth scans - PlGF (placental-growth factor) testing on one occasion

Answer 79

Aspirin from 12-week gestation for women with - A single high-risk factor - Two or more moderate-risk factors

Answer 80

< 34 weeks - monitor and only plan delivery if evidence of maternal/fetal compromise. Give magnesium sulfate (prevent seizures) and corticosteroid if delivery likely. 34 - 37 weeks - same as above, give corticosteroid if delivery likely. > 37 weeks - plan delivery

Answer 81

Symptoms: - Headaches - Visual disturbance - Epigastric or RUQ pain (liver swelling/HELLP) - Vomiting Signs: - BP ≥ 140/90mmHg, severe is 160/110mmHg - Proteinuria - Oedema of face, hands or feet

Answer 82

Maternal: Eclampsia (seizure resulting from pre-eclampsia), HELLP syndrome, stroke Fetal: intrauterine growth restriction, preterm delivery, placental abruption

Answer 83

Eclampsia is pre-eclampsia with seizures. Treated with magnesium sulphate

Answer 84

Haemolysis, Elevated Liver enzymes, and Low Platelets. Pre-eclampsia with thrombotic microangiopathy

Answer 85

A termination of pregnancy (TOP), or abortion, involves an elective procedure to end a pregnancy.

Answer 86

1967 Abortion Act. Altered by the **1990 Human Fertilisation and Embryology Act** - latest gestational age where an abortion is legal changed from 28 weeks to 24 weeks.

Answer 87

Continuing the pregnancy poses greater risk to the physical or mental health of the woman or existing children than a TOP.

Answer 88

- Risk to life of the woman - Risk of “grave permanent injury” to the physical or mental health of the woman - Substantial risk of serious handicap to the child due to physical or mental abnormalities

Answer 89

Two registered medical practitioners, and undertaken in an NHS hospital or approved premise by a registered medical practitioner.

Answer 90

Self-referral , GP , or GUM clinic . Marie Stopes UK is a charity providing TOP, remotely for women less than 10 weeks gestation Doctors who conscientiously object to TOP should ensure a woman has access to services through another doctor or self-referral.

Answer 91

First-line: pregnancy test: urinary or serum beta-human chorionic gonadotropin (beta-hCG) Ultrasound: to confirm the location of and to date the pregnancy

Answer 92

Mifepristone (anti-progestogen) - halts the pregnancy and relaxes the cervix. Misoprostol (prostaglandin analogue) 1 – 2 day later = prostaglandin analogue, which soften the cervix and stimulate uterine contractions to expel products of conception. >10 weeks onwards additional misoprostol doses are given until complete expulsion.

Answer 93

Where the cervix is softened and dilated prior to surgical TOP. Examples include misoprostol, mifepristone or osmotic dilators .

Answer 94

Vacuum aspiration, where pregnancy is terminated via suction. Local or general anesthesia.

Answer 95

Cervical dilatation and evacuation using forceps or D + C (dilation + curettage)

Answer 96

Rhesus negative women having a surgical TOP from 10 weeks gestation onwards. The NICE guidelines (2019): consider in women less than 10 weeks gestation.

Answer 97

Pre-existing diabetes mellitus (type 1 or type 2) or gestational diabetes mellitus (GDM), which develops during pregnancy. GDM is due to insulin resistance due to hormonal changes and increased demand for insulin production.

Answer 98

- BMI >=30 - Previous GDM - Advanced maternal age: >40 - Ethnicity: South Asian, Black Afro-Caribbean, Middle Eastern - Previous child born large: >4.5kg

Answer 99

Symptoms: - Increased thirst (polydipsia) - Increased urination (polyuria) - Fatigue - Dry mouth - Blurred vision Sign: - Large for dates uterus

Answer 100

At risk: OGTT at the booking appointment and again at 24-28 weeks if first test negative OGTT is oral glucose tolerance test - 75g glucose after overnight fast and blood glucose measured after 2 hours. Fasting glucose > 5.6mmol/L or 2 hours glucose > 7.8mmol/L is diagnostic As easy as 5,6,7,8

Answer 101

- Blood glucose>7mmol= insulin - Blood glucose <7mmol: - Lifestyle modifications: diet, regular exercise, self monitoring of blood glucose - Medication: metformin or g lienclamide (sulfonylurea)if lifestyle changes insufficient

Answer 102

Before pregnancy - aim for good glucose control, 5 mg folic acid from preconception to 12 weeks gestation Retinopathy screening shortly after booking and 28 weeks. Referral to an ophthalmologist to check for diabetic retinopathy. EXAM FAV! NICE advise 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. Also considered if poorly controlled GDM/T2DM

Answer 103

8 to 12 weeks

Answer 104

- General history and assess for risks e.g. gestational diabetes and pre-eclampsia - BMI, BP, urine dip (protein in urine) - Bloods: FBC, blood group and rhesus status - Screening: foetal anomalies, sickle cell anaemia, thalassaemia, HIV, hep B, syphilis, chlamydia, gonorrhea, group B strep.

Answer 105

Ultrasound: - Gestational age - Detect multiple pregnancy Combined screening test: Down’s, Edward’s and Patau’s syndrome

Answer 106

- First line and most accurate for Down syndrome - Fetal nuchal translucency (thickness of an area of fetal neck tissue - > 6mm indicates Downs) on USS - Blood β-hCG level (higher = more risk) - Pregnancy associated plasma protein-A (PAPP-A) (lower = more risk)

Answer 107

Only involves maternal blood tests: - Beta-HCG – a higher result indicates greater risk - Alpha-fetoprotein (AFP) – a lower result indicates a greater risk - Serum oestriol (female sex hormone) – a lower result indicates a greater risk

Answer 108

Appointment with the midwife. Reassess risk of pre-eclampsia and foetal growth restriction, BP and urine dipstick

Answer 109

Second scan (anomaly scan) Ultrasound to locate placenta and screening for further foetal anomalies

Answer 110

Downs syndrome if nuchal translucency can't be measured or > 14 weeks gestation Measures: - Maternal serum alpha-fetoprotein (lower = more risk) - total hCG (higher = more risk) - unconjugated oestriol (uE3) (lower = more risk) - inhibin-A (higher = more risk)

Answer 111

Midwife appointment only if nulliparous. - History and examination - Measure symphysis-fundal height (SFH) - BP and urine dipstick

Answer 112

- History and examination - Measure SFH - Enquire about foetal movements - BP & urine dipstick - Bloods: FBC, blood group and antibodies - Anti-D if rhesus negative

Answer 113

Only if nulliparous, appointment with midwife - History and examination - Measure SFH - Enquire about foetal movements - BP - Urine dipstick

Answer 114

- History and examination - Measure SFH - Enquire about foetal movements - BP, urine dipstick - Anti-D if rhesus negative

Answer 115

- History and examination - Abdominal examination to determine presentation - Measure SFH - Enquire about foetal movements - BP & urine dipstick

Answer 116

- History and examination - Abdominal examination to determine presentation - Measure SFH - Enquire about foetal movements - BP, urine dipstick - Discuss prolonged pregnancy

Answer 117

- History and examination - Abdominal examination to determine presentation - Measure SFH - Enquire about foetal movements - BP & urine dipstick

Answer 118

- Midwife appointment: History and examination - Abdominal examination to determine presentation - Measure SFH - Enquire about foetal movements - BP & urine dipstick - Offer membrane sweep (artifical rupture of memebrane)

Answer 119

- Edwards’ syndrome - Patau’s syndrome - Anencephaly - Spina bifida - Gastroschisis/exomphalos - Congenital heart disease

Answer 120

A pregnancy with more than one fetus.

Answer 121

- Monozygotic: identical twins (from a single zygote) - Dizygotic: non-identical (from two different zygotes) - Monoamniotic: single amniotic sac - Diamniotic: two separate amniotic sacs - Monochorionic: share a single placenta - Dichorionic: two separate placentas

Answer 122

Diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

Answer 123

Diagnosed at the dating ultrasound scan (between 10 and 13 + 6). USS also used to determine: - Gestational age - Number of placentas (chorionicity) and amniotic sacs (amnionicity) - Risk of Down’s syndrome (as part of the combined test)

Answer 124

- Anaemia - Polyhydramnios (increased amniotic fluids) - Hypertension - Preterm birth - C-section - PPH

Answer 125

- Miscarriage - Stillbirth - Twin-twin transfusion syndrome - Congenital abnormalities

Answer 126

Occurs when the fetuses share a placenta. One fetus (recipient) receives most of the blood supply, while the other fetus (donor) is starved of blood. Recipient becomes fluid overloaded > heart failure & polyhydramnios. Donor has growth restriction, anaemia and oligohydramnios.

Answer 127

Mother referred to tertiary specialist fetal medicine centre. In severe cases, laser treatment to destroy the connection between the two blood supplies.

Answer 128

Managed by a specialist obstetrics team. Additional monitoring for anaemia, with FBC at booking clinic, 20 weeks and 28 weeks Additional USS to look out for growth restriction, growth disparities and TTTS - 2 weekly scans from 16 weeks for monochorionic twins - 4 weekly scans from 20 weeks for dichorionic twins

Answer 129

Monoamniotic twins = elective c-section between 32 and 33 + 6 weeks. Diamniotic twins - aim to deliver between 37 and 37 + 6 weeks: - Try VD if presenting twin cephalic - C-section might be required for second baby after - Elective C-section offered if presenting twin not cephalic

Answer 130

When the umbilical cord descents through the cervix alongside or past the presenting foetal part in the presence of ruptured membranes. Obstetric emergency > cord compression = loss of blood supply to foetus

Answer 131

General: - Multiparity - Low birth weight (<2.5kg) - Preterm labour (<37weeks) - Malpresentation Procedure-related: - ECV - Artificial rupture of membrane (ARM)

Answer 132

Symptoms: cord felt in vagina Signs: cord seen in the vagina, abnormal foetal HR pattern Although sometimes, no clinical signs or symptoms and fetal HR pattern normal

Answer 133

- Vaginal/speculum examination: check for cord prolapse 4-hourly in labour, and after SROM. - Fetal heart auscultation: after VE in labour and SROM. - Cardiotocography (CTG): abnormal foetal heart rate is non-specific sign

Answer 134

Obstetric emergency that require IMMEDIATE delivery of fetus. 1. Elevate fetal presenting part - prevent cord compression 2. C-section if VD not imminent: - Category 1 (within 30 minutes) if abnormal fetal HR pattern - Category 2 (within 75 minutes): if foetal HR pattern remains normal with continuous CTG monitoring

Answer 135

Fetal complications depends on time interval between cord prolapse and delivery - Birth asphyxia - Hypoxic brain injury - Cerebral palsy - Perinatal death

Answer 136

Class I: BMI 30-34.9 Class II: BMI 35-39.9 Class III: BMI ≥40

Answer 137

VTE can occur as a DVT or PE during pregnancy. Pregnancy is a hypercoagulable state due an increase in clotting factors and decreased fibrinolysis.

Answer 138

Obesity in pregnancy can lead to insulin resistance, increased pro-inflammatory markers, and increased risk of hypertension.

Answer 139

Highest risk period is postpartum. - History of VTE - Immobility - Age: >35 - Obesity: BMI>30 - Smoking - C-section - Pre-eclampsia

Answer 140

Affects about 1 in 5 women in pregnancy. Risk factors include sedentary lifestyle, high calorie diet, socio-economic status, and genetic disposition.

Answer 141

- Leg pain: typically unilateral - Leg swelling - Calf tenderness - Erythema + warmer in affected area - Oedema: >3cm difference between symptomatic calf and contralateral limb

Answer 142

1st line: BMI: height and weight Consider: - Oral glucose tolerance test: >= 7.8mmol/l is diagnostic of GDM. - All women with obesity should have a GTT at 24-28 weeks as they are at increased risk of gestational diabetes. - Lipid profile

Answer 143

Symptoms - Pleuritic chest pain - sharp chest pain on inhale and exhale - Shortness of breath Signs: - Tachypnoea - Tachycardia - Hypotension - Haemoptysis

Answer 144

First-line: - Lifestyle modifications: diet and exercise counselling Folic acid: 5mg, from 1 month pre-conception - end of first trimester Second-line: - Metformin: if GDM present and not managed by lifestyle modifications

Answer 145

DVT: Doppler ultrasound. If negative, repeat on day 3 and 7 in high-risk patients. PE: 1st line: - Chest xray - ECG Gold standard: - CT pulmonary angiogram (CTPA)

Answer 146

Anaemia is defined as a low concentration of haemoglobin in the blood. Pregnant women are screened for anaemia at the booking appointment and 28-weeks gestation. During pregnancy, plasma volume increases, and so haemoglobin concentration reduces. This alongside increased demand for B12 also can cause B12 deficiency.

Answer 147

Low molecular weight heparin (LMWH), such as dalteparin. dose based on woman's weight at booking clinic. Start immediately at diagnosis until six-weeks postnatally.

Answer 148

Often asymptomatic, women might have: Shortness of breath Fatigue Dizziness Pallor

Answer 149

Life-threatening scenario. - Unfractionated heparin - Thrombolysis - Surgical embolectomy

Answer 150

Booking bloods > 110 g/l 28 weeks gestation > 105 g/l Post partum > 100 g/l

Answer 151

1st line: LMWH (e.g. dalteparin) from 28 weeks gestation if 3 risk factors, in the first trimester if ≥4 risk factors. Continue until 6-week postnatal with pause during labour.

Answer 152

The mean cell volume (MCV) can indicate the cause of the anaemia: - Low MCV: iron deficiency - Normal MCV: physiological anaemia due to the increased plasma volume of pregnancy - Raised MCV: B12 or folate deficiency

Answer 153

When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.

Answer 154

1. Iron: iron replacement (e.g. ferrous sulphate 200mg 3x daily). 2. B12: seek specialist haemologist advice: - Intramuscular hydroxocobalamin injections - Oral cyanocobalamin tablets 4. Folate: - All women: folic acid 400mcg per day. If folate deficiency present then folic acid 5mg daily. Thalassaemia and Sickle Cell Anaemia: managed jointly with a specialist haematologist. They require high dose folic acid (5mg), close monitoring and transfusions when required.

Answer 155

- Difficulty with delivering head and face - Failure of restitution, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. - Turtle-neck sign: where tje head is delivered but then retracts back into the vagina.

Answer 156

Obstetrics emergency - led by experienced midwives and obstetricians. - Sound the alarm and call for help - Episiotomy - surgical incision of the perineum and the posterior vaginal wall. - McRoberts manoeuvre - mother in knee to chest position to lift pubic symphysis out of the way. - Rubins manoeuvre - reaching into vagina to put pressure on baby's shoulders to help it move under the pubic symphysis. Wood’s screw manoeuvre during Rubins manoeuvre. The other hand puts pressure on the baby's shoulders to rotate baby to help delivery. - Zavanelli manoeuver - pushes baby back in to prepare for emergency c-section.

Answer 157

- Fetal hypoxia (and subsequent cerebral palsy) - Perineal tears - Postpartum haemorrhage

Answer 158

A c-section is a surgical operation to deliver the baby via an incision in the abdomen and uterus. Emergency or elective.

Answer 159

Category 1 - Immediate threat to the life of the woman or fetus. Delivery in 30 mins. Category 2 - Maternal or fetal compromise that is not immediately life-threatening. Delivery within 75 mins Category 3 - no maternal or fetal compromise but needs early delivery Category 4 - elective

Answer 160

Performed with spinal anesthesia and usually after 39 weeks gestation. - Previous caesarean - Placenta praevia - Breech presentation - Other malpresentations: e.g. unstable lie (fluctuates from oblique, cephalic, transverse etc.) - Cervical cancer

Answer 161

Regional anaesthetic – ‘topped-up’ epidural or a spinal anaesthetic. Sometimes GA is needed if concerns about fetal wellbeing (cat 1 sections). GA faster than spinal anaesthetics.

Answer 162

Usually a transverse lower uterine segment incision using scalpel - Joel-cohen incision. Blunt dissection is then used after to separate the remaining layers of the abdominal wall and uterus. The baby is delivered by hand/forceps with pressure on the fundus. The uterus is sutured closed inside the abdomen.

Answer 163

1. Skin 2. Subcutaneous tissue 3. Fascia / rectus sheath (the aponeurosis of the transversus abdominis and external and internal oblique muscles) 4. Rectus abdominis muscles 5. Peritoneum 6. Vesicouterine peritoneum – a flap separating uterus and bladder 7. Uterus (perimetrium, myometrium and endometrium) 8. Amniotic sac

Answer 164

- H2 receptor antagonists (e.g. ranitidine) or PPI (e.g. omeprazole) before the procedure to prevent aspiration pneumonitis - Prophylactic antibiotics - Oxytocin during the procedure to < risk of PPH - VTE prophylaxis with LMWH

Answer 165

- Early mobilisation - Anti-embolism stockings - LMWH (e.g. dalteparin)

Answer 166

AUB is any variance of the normal menstrual cycle, which is defined by four parameters (frequency, regularity, duration, and volume). Acute or chronic

Answer 167

- Polyps - Fibroids - Malignancy + hyperplasia: all gynae cancer (e.g. endometrial)

Answer 168

- Use of medication - particularly hormonal contraception or drugs interfering with the hypothalamic-pituitary-ovarian axis (such as SSRIs). - Pregnancy-related bleeding - mandatory to rule out pregnancy in AUB! - Traumatic injury during intercourse and sexual abuse

Answer 169

- Women at the extremes of reproductive age (just after puberty and before menopause) - Polycystic ovary syndrome - Obesity

Answer 170

Pregnancy test (urine or blood beta-hCG level) - mandatory to rule out pregnancy in women of reproductive age even if on contraception. FBC - diagnosis of anaemia important in determining severity of AUB.

Answer 171

Emergency management of excessive AUB: - IV conjugated oestrogen, or combined oral contraceptive, or a progestogen-only treatment. - Tranexamic acid - prevents excessive bleeding Medical ongoing management: - Intrauterine device - mirena coil releases progesterone to stop AUB Surgical management if above insufficient: - Dilation and curettage (D&C) - cervix dilated and endometrium scraped with spoon-like instrument

Answer 172

The pelvic floor is made up of layers of muscles which support the bladder, bowel and uterus.

Answer 173

- Uterine prolapse - the uterus descends into the vagina. - Vault prolapse - occurs in women who have had a hysterectomy, the top of the vagina (vault) descends in the vaginal canal. - Rectoceles - a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Associated with constipation. - Cystoceles - a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. -

Answer 174

- Multiple vaginal deliveries - Advanced age and postmenopause status - Obesity - Chronic respiratory disease causing coughing - Chronic constipation causing straining

Answer 175

- 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/mass in vagina, worse on straining or bearing down.

Answer 176

1. Patient empty bladder 2. Patient in dorsal or left lateral position 3. Sim’s speculum is held on the anterior vaginal wall to examine for a rectocele, and the posterior wall for a cystocele. 4. Patient asked to cough or “bear down” to assess the full descent of the prolapse.

Answer 177

For women with mild symptoms, or if vaginal pessaries and surgery are contraindicated. - Physiotherapy (pelvic floor exercises) - Weight loss - Management of stress/urge incontinence - reduce caffeine intake, anticholinergic agents - Vaginal oestrogen cream

Answer 178

- Vaginal pessaries: inserted into vagina to provide extra support to the pelvic organs. - Significant improvement in symptoms - Types include ring and donut pessaries - Change every 3 months

Answer 179

Surgery is the gold-standard treatment for pelvic organ prolapse, including: - Pelvic floor repair - Hysterectomy

Answer 180

- Pain, bleeding, infection, DVT - Damage to the bladder or bowel - Recurrence of the prolapse - Altered experience of sex

Answer 181

Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver. The condition resolves after delivery of the baby.

Answer 182

Presents usually in third trimester. - Itching (pruritis) = main symptom - Fatigue - Dark urine - Pale, greasy stools - Jaundice

Answer 183

- Bile acid levels: - ≥ 10 micromol and < 40 micromol (mild) - ≥ 40 micromol/L and <100 micromol/L (moderate) - ≥100 micromol/L (severe) - LFTs: deranged ALT, AST and GGT. - Placenta produces ALP, so raised ALP with otherwise normal LFTs is likely due to this

Answer 184

- 1st line: emollient - Consider: sedating antihistamine (chlorphenamine), does not help itching but improves sleep - In women with severe obstetric cholestasis - induction or elective c-section from 35 weeks, as they are at higher risk of stillbirth.

Answer 185

Congenital malformations that result from incomplete closure of the neural tube during embryonic development. The neural tube starts to form in early pregnancy and closes about 4 weeks after conception.

Answer 186

- Anencephaly - most of the brain and skull is missing and incompatible with life - Spina bifida = "split spine": - Spina bifida occulta: mild form of spina bifida with no visible protrusion. - Meningocele: protrusion of meninges through a spinal defect, but the spinal cord remains in place - Myelomeningocele : protrusion of the spinal cord and meninges through a defect in the vertebral column.

Answer 187

- Folic acid deficiency during pregnancy - Maternal diabetes - Maternal obesity - Previous child with NTD - Use of valproate or carbamazepine

Answer 188

Myelomeningocele (spina bifida aperta) is the most severe form and so it has the most clinical feature: Symptoms - Weakness of the lower limbs - Bowel and bladder incontinence - Reduced sensation of the lower limbs

Answer 189

- Sac-like protrusion over lower part of spine: in meningocele/myelomeningocele - Benign skin features over lower part of spine: skin tags, dimples, hairy patches - Enlarged head: caused by hydrocephalus - Hyperreflexia and hypertonia of the lower limbs: predominantly myelomeningocele

Answer 190

- Antenatal triple/quadruple test between 15 - 20 weeks - Antenatal ultrasound - locate NTD

Answer 191

- Folic acid supplement - at least one month before conception to 12 weeks (400 mcg or 5mg if risk factors) - MDT approach with paeds, neurosurgery, ortho and genetic counselling - Surgical repair for myelomeningoceles - Regular monitoring with specialist neurosurgeon through adulthood.

Answer 192

Defect of the abdominal wall that occur in utero, and result in herniation of abdominal contents without a sac.

Answer 193

Defect of the abdo wall of neonates that result in the protrusion of abdominal content into a peritoneal sac.

Answer 194

- Maternal smoking - Maternal age < 20

Answer 195

- Maternal smoking - Maternal age > 35

Answer 196

The lack of a protective membrane covering the abdominal contents ,meams that a inflammatory film/peel forms around the contents > intestinal atresia (bowel obstruction due to congenital causes) due to ischaemia and significant fluid imbalance and heat loss!!

Answer 197

They are abdominal wall defect ranging from 4 to 12 cm in size, usually located centrally. The abdominal contents have a protective membranous covering in utero, the intestines are usually healthy at birth.

Answer 198

- Elevated maternal alpha fetoprotein - Positive antenatal USS - fluid-filled bowel loops floating freely in amniotic fluid, or even intestinal atresia.

Answer 199

- Antenatal USS - abdominal masses outside abdominal wall - Fetal chromosomal abnormalities - if omphalocele confirmed on USS then amniocentesis to detect trisomy 13, 18 and 21 etc. as they are associated

Answer 200

- Acute: fluid resus, temperature stabilisation and bowel protection - Surgical repair - Postsurgical NG tube and parenteral nutrition

Answer 201

- Acute: fluid resus, temperature stabilisation - Intact membrane: NG tube to decompress bowel - Ruptured membrane: bowel protection + surgical repair - Parenteral nutrition

Answer 202

A hole in the septum between the two ventricles. Classified as a cyanotic heart disease as it creates a right-left shunt whereby blood bypasses the lungs iand into the systemic circulation.

Answer 203

- Associated with genetic conditions such as Downs syndrome - Can occur after MI as ischaemia can damage the ventricular septum.

Answer 204

- Often asymptomatic and presents in adulthood. - Might be detected at antenatal scan as a murmur. - Pan-systolic murmur more at left lower sternal border in 3rd/4th ICS +/- systolic thrill on palpation. Note: ddx for pan-systolic murmur include VSD, mitral regurgitation and tricuspid regurgitation.

Answer 205

- Diagnostic test of choice : Echocardiogram - CXR - cardiomegly - ECG - not diagnostic but provides evidence of chamber enlargement if present

Answer 206

Small = observation Medium/large = transvenous catheter closure via the femoral vein or open-heart surgery. Prophylactic abx if undergoing surgery as increased risk of infective endocarditis.

Answer 207

Rhesus antigen is a type of antigen present on some fetal RBCs. Rhesus (Rh) incompatibility is a condition where an Rh-negative mother carrying an Rh-positive fetus can produce antibodies against paternally derived Rh antigens on fetal red blood cells. These antibodies can cross the placental membrane and destroy fetal RBCs.

Answer 208

Times when maternal blood is mixed with fetal blood, thus providing opportunity for the maternal anti-rhesus antibodies to develop against paternally derived Rh antigens on fetal RBCs. This does not usually cause problems in the first pregnancy, but will do so in subsequent pregnancies.

Answer 209

- Miscarriage > 12 weeks - Abdominal trauma e.g. placental abruption - At birth

Answer 210

This is done at the booking appointment between 8 - 10 weeks by determining mother's blood type. If mother is rhesus negative then prophylaxis is given regardless of the fetal rhesus status.

Answer 211

IM anti-D injections, this prevents sensitisation by attaching to rhesus-D antigens on fetal RBCs in maternal circulation, causing them to be destroyed. S0 the maternal immune system does not create antibodies against the rhesus-D antigen. - Anti-D injections are given routinely on two occasions and sensitisation events: - 28 weeks gestation - Birth (if the baby’s blood group is found to be rhesus-positive)

Answer 212

Haemolytic disease of the fetus and newborn, also known as erythroblastosis fetalis.

Answer 213

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

Answer 214

- Pre-eclampsia - Maternal smoking - Maternal alcohol - Mternal anaemia - Malnutrition - Maternal/fetal infection

Answer 215

- Small for gestational age - < 10th percentile - Reduced amniotic fluid volume - Reduced fetal movements - Abnormal CTGs

Answer 216

- Fetal death or stillbirth - Birth asphyxia (lack of O2)

Answer 217

- Cardiovascular disease, particularly hypertension - Type 2 diabetes - Obesity - Mood and behavioural problems

Answer 218

- Previous SGA baby - Antepartum haemorrhage - Antiphospholipid syndrome - Pre-eclampsia - >35 - Obesity - Smoking - Diabetes + GD - Existing hypertension - Multiple pregnancy

Answer 219

Low-risk - symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards. SFH < 10th centile = serial growth scans with umbilical artery doppler (pre-eclampsia monitoring) Women with one major or multiple minor risk factors are booked for serial growth scans with umbilical artery doppler.

Answer 220

- Pre-eclampsia risk = aspirin - Stop smoking - Identify cause for SGA e.g. bloods and urine dipstick for pre-eclampsia - Early delivery where growth is static, or there are other concerns (e.g. abnormal doppler)

Answer 221

Labour that occurs between 24 to 37 weeks gestation.

Answer 222

The World Health Organisation classify prematurity as: - Under 28 weeks: extreme preterm - 28 – 32 weeks: very preterm - 32 – 37 weeks: moderate to late preterm Babies are considered non-viable < 23 weeks.

Answer 223

- Preterm prelabour rupture of membrane (P-PROM) - Advanced cervical dilation - Uterine contractions - Cervical length < 2cm

Answer 224

Vaginal progesterone as gel or pessary, maintains pregnancy and prevents labour Offered to women with cervical length < 25mm on vaginal USS between 16 - 24 weeks gestation Cervical Cerclage - a stitch is put in the cervix to add support and keep it closed, removed when woman goes into labour or reaches term Offered to women as above or previous premature birth or cervical trauma e.g. colposcopy “Rescue” cervical cerclage offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.

Answer 225

P-PROM is where the amniotic sac ruptures, before the onset of labour and in a preterm pregnancy. Ix: speculum exam > pooling of amniotic fluid in vagina Mx: prophylactic abx (e.g. erythromycin) to prevent chorioamnionitis and induction of labour offered from 34 weeks

Answer 226

Regular painful contraction (>1 in 10) and cervical dilatation, without rupture of the amniotic sac.

Answer 227

- Clinical assessment includes a speculum examination to assess for cervical dilatation. - < 30 weeks - clinical assessment enough to offre management of preterm labour - > 30 weeks gestation, a transvaginal ultrasound to determine cervical length. - <15mm = preterm labour management - > 15mm = preterm labour is unlikely

Answer 228

- CTG (cardiotocogram) - Tocolysis with nifedipine to suppress labour - Maternal corticosteroids < 35 weeks to help fetal lung development - IV magnesium sulphate: < 34 weeks to reduce risk of cerebral palsy - Delayed cord clamping to increase blood supply to baby

Answer 229

A tear that occurs in the perineum when external vaginal opening is too narrow to accommodate the baby.

Answer 230

- First-degree – limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin - Second-degree – including the perineal muscles, but not affecting the anal sphincter - Third-degree – including the anal sphincter, but not affecting the rectal mucosa - 3A – less than 50% of the external anal sphincter affected - 3B – more than 50% of the external anal sphincter affected - 3C – external and internal anal sphincter affected - Fourth-degree – including the rectal mucosa

Answer 231

- Nulliparity - Large babies ≥ 4kg - Shoulder dystocia - Asian ethnicity - Occipito-posterior position

Answer 232

A cut in the perineum made by an obstetrician or midwife in anticipation of needing additional room for delivery. - Local anaesthetics - Cut at 45 degrees to avoid damaging the anal sphincter- mediolateral episiotomy. - The cut is sutured after delivery.

Answer 233

- First-degree tears usually does not require surgery. - Second-degree = suture - A third or fourth-degree tear = repair in theater Additional measures: - Broad-spectrum antibiotics - Laxatives - Physiotherapy to reduce the risk and severity of incontinence - Followup to monitor complications

Answer 234

Short term: pain, infection, bleeding Long-term: - Urinary/anal incontinence - Altered bowel habit (3rd and 4th) - Sexual dysfunction and dyspareunia (painful sex) - Mental health impact

Answer 235

- In utero - intrapartum (during childbirth) - Breastfeeding postnatal if maternal viral load uncontrolled

Answer 236

This bacteria usually harmlessly colonises the GI and GU tract, but can cause severe infection for mother and baby due to transmission during delivery. Cause of neonatal sepsis

Answer 237

- Needle sharing with IVDUs - Unprotected receptive penile-vaginal/anal intercourse - High maternal viral load (perinatal transmission) - Absence of antenatal maternal antiretroviral therapy

Answer 238

Vertical transmission during childbirth.

Answer 239

- Maternal HIV-1/HIV-2 antigen/antibody enzyme-linked immunosorbent assay (ELISA) - Neonatal HIV DNA or RNA PCR

Answer 240

- Positive GBS culture in current or previous pregnancy - Previous birth resulting in neonatal GBS infection - Pre-term labour - Prolonged rupture of membranes

Answer 241

- Pregnant women should continue their anti-retrovirals (ART) - For women with viral load >1000 copies/mL at 38 weeks or more = c-section and ART - Infants born to HIV-infected mothers: postnatal ART

Answer 242

In the UK, women are not routinely screened for GBS as colonisation status can change throughout pregnancy. If a pregnant woman is suspected of having GBS, then bloods such as FBC, U+E, serum creatinine to check for sepsis as they are deranged in sepsis.

Answer 243

- Pregnant women should continue their anti-retrovirals (ART) - For women with viral load >1000 copies/mL at 38 weeks or more = c-section and ART - Infants born to HIV-infected mothers: postnatal ART

Answer 244

Maternal: UTI, chorioamnionitis, postnatal endometritis Newborn: sepsis, pneumonia, meningitis

Answer 245

A condition that occurs due to a cytomegalovirus (CMV) infection in the mother during pregnancy.

Answer 246

- Intrapartum prophylactic abx (NICE recommends Benzylpenicillin and getamacin) during labour and delivery if risk factors. - Abx choice depends on allergy history, antimicrobial susceptibility testing, and the potential effects on the fetus or breast milk. - Always follow local guidelines

Answer 247

The virus is mostly spread via the infected saliva or urine of asymptomatic children. Most cases of CMV in pregnancy do not cause congenital CMV.

Answer 248

- Fetal growth restriction - Microcephaly - Hearing loss - Vision loss - Learning disability - Seizures

Answer 249

Congenital rubella syndrome is caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy. The risk is highest before ten weeks gestation.

Answer 250

Women who are planning to get pregnant getting the MMR (mumps, measles and rubella) vaccine. Pregnant women should not receive this as live vaccine - instead, given after childbirth.

Answer 251

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

Answer 252

- Serology tests to confirm rubella infection. - Audiology tests for hearing impairment - Ophthalmology review - Echocardiography for congenital heart defects

Answer 253

- Supportive - Regular monitoring and followup

Answer 254

Toxoplasmosis infection is usually an asymptomatic, and it is caused by the toxoplasma gondii parasite. Infected cat faeces are a common way of transmitting the infection. Congenital toxoplasmosis is when it is passed from mother to fetus.

Answer 255

- Intracranial calcification - Hydrocephalus - Chorioretinitis (inflammation of the choroid and retina in the eye

Answer 256

- Antenatal ultrasound - foetal abnormalities - Amniocentesis with PCR - Maternal IgM testing to check for previous exposure - Foetal blood test

Answer 257

The antibiotic spiramycin

Answer 258

Neonatal herpes simplex virus (HSV) infection is a potentially severe condition in newborns that can occur during delivery. It is transmitted from the mother to baby when the baby comes in contact with primary vesicles in the maternal genital tract during delivery.

Answer 259

- Vesicular lesions on the skin, eye, or oral mucosa - Severe cases: seizures, encephalitis or sepsis

Answer 260

- PCR - MRI in case of encephalitis

Answer 261

Maternal: elective caesarean section or intrapartum IV acyclovir if primary lesions present at term or primary outbreak within 6 weeks of labour Neonatal: parenteral acyclovir

Answer 262

Parvovirus B19 infection typically affects children. Self-limiting, and the rash (characteristric macular erythrometheous facial rash) and symptoms usually fade over 1 – 2 weeks.

Answer 263

Particularly in first and second trimester: - Miscarriage or fetal death - Severe fetal anaemia - Hydrops fetalis (fetal heart failure) - Maternal pre-eclampsia-like syndrome

Answer 264

Starts with non-specific viral symptoms. 2 - 5 days: macular, erythromathous rash on one or both cheeks - "slapped cheeks" appearance. Then reticular (net-like) mildly erythematous rash affecting the trunk and limbs, can be raised and itchy.

Answer 265

Parvovirus infects the erythroid progenitor cells in the fetal bone marrow and liver. These cells produce red blood cells, and the infection causes them to produce faulty red blood cells that have a shorter life span > anaemia > heart failure, referred to as hydrops fetalis.

Answer 266

An immunological disorder that occurs when a rhesus negative mother becomes sensitised to her baby's rhesus positive blood cells in utero, and her body mounts an immune response to the fetal RBCs.

Answer 267

It occurs due to immune response because of rhesus or ABO blood group incompatibility between the mother and foetus. Sensitisation events are responsible for fetal blood entering maternal circulation.

Answer 268

- Hydrops foetalis (HF) appearing as foetal oedema seen on antenatal ultrasound - Neonatal jaundice - Foetal anaemia causing skin pallor - Hepatosplenomegaly - Severe oedema if HF in utero

Answer 269

- Direct Antiglobulin Test (DAT)/ DIrect Coombs Test on fetal blood sample, to see if antibodies mounted against RBCs - Liver function tests (LFTs) to check for complications

Answer 270

- Intrauterine blood transfusions - Early delivery if severe Postnatal: - Phototherapy or exchange transfusion to manage high bilirubin - Immunoglobulin administration to prevent further haemolysis - Regular follow-up to assess developmental issues

Answer 271

Thalassemia: also presents with anaemia, hepatosplenomegaly, and jaundice

Answer 272

It is an assisted vaginal delivery using a ventouse suction cup or forceps.

Answer 273

Based on the clinical judgement of the midwife or obstetrician during 2nd stage of labour. Key indications: - Failure to progress - more likely if epidural - Fetal distress - abnormal CTG - Maternal exhaustion

Answer 274

- Cephalohaematoma (blood between skull and periosteum (membrane around the bones)) with ventouse - Facial nerve palsy with forceps

Answer 275

- Postpartum haemorrhage - Perineal tears - Bladder or bowel incontinence - Nerve injury (obturator or femoral nerve)

Answer 276

- Unengaged fetal head in singleton pregnancies. - Breech and face and most brow presentations. - Preterm gestation (<34 weeks) for ventouse. - Cord prolapse with fetal compromise

Answer 277

Baby blues affect > 50% of women in the first week after birth, particularly first-time mothers. - Mood swings - Low mood - Anxiety - Irritability - Tearfulness

Answer 278

- Significant hormonal changes - Recovery from birth - Sleep deprivation - The responsibility of caring for the neonate - Establishing feeding

Answer 279

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

Answer 280

It is depression that women experiencing after giving birth, it usually starts to affect mothers 3 months after birth. Symptoms should last at least two weeks before a diagnosis is made.

Answer 281

Similar to depression that occur outside of pregnancy. - Low mood - Anhedonia (lack of pleasure in activities) - Low energy

Answer 282

Screening questions: - During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and - "During the past month, have you often been bothered by having little interest or pleasure in doing things? - Edinburgh Postnatal Depression Scale (EPDS) score > 11 suggestive of depression

Answer 283

- History of depression, or anxiety - Recent stressful life events - Poor social support - Stopping psychopharmacological treatments

Answer 284

- Mild cases - additional support, self-help and GP followup - Moderate cases - antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy Severe cases - specialist psychiatry services NICE recommends speaking to specialist perinatal mental health team before starting mum on antidepressants.

Answer 285

A condition where endometrium-like tissue grows outside of the uterine cavity.

Answer 286

- Dysmenorrhoea (painful period) - Dyspareunia (deep) - Subfertility - Cyclical rectal bleeding (if growth on bowel) or blood in urine - Pelvic exam: palpable tender nodules on ovaries or surrounding ligaments

Answer 287

- Reproductive age - FHx of endometriosis - Nulliparous

Answer 288

- 1st line: Transvaginal ultrasound - Gold standard: laparoscopy - allows visualisation and immediate treatment such as ablation

Answer 289

Medical Management - Analgesia: paracetamol or NSAIDs - COCP Surgical Management - Diathermy (heat) of lesions - Ovarian cystectomy - Laparoscopic excision/ablation if patient wants to maintain fertility

Answer 290

- Primary dysmenorrhea - Uterine conditions r.g. fibroids - PID

Answer 291

A malignancy that originates from the endometrium, the inner lining of the uterus.

Answer 292

Exposure to unopposed estrogen: - Nulliparity - Obesity - Early menarche - Late menopause - Polycystic ovary syndrome

Answer 293

- Postmenopausal bleeding (endometrial cancer until proven otherwise) - Intermenstrual bleeding - Pelvic pain - Abdominal discomfort or bloating - Weight loss - Anaemia Bimanual exam - enlarged uterus or no change

Answer 294

1st line: tranvaginal USS - detects endometrial thickness, >5mm = further Ix Gold standard: hysteroscopy and endometrial biopsy

Answer 295

Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 296

Stage 1- 2: Hysterectomy with bilateral salpingo-oophorectomy - (removal of uterus, cervix and adnexa). Stage 3 - 4: - Radical hysterectomy - removal of pelvic lymph nodes, surrounding tissues and top of the vagina - Radiotherapy + Chemotherapy - Progesterone - slow cancer progression

Answer 297

Pot-menopausal bleeding (more than 12 months since LMP)

Answer 298

Dysmenorrhoea is pain that occurs in conjunction with menstruation, where this pain becomes severe or debilitating.

Answer 299

Primary: idiopathic and in absence of pelvic pathology Secondary: due to underlying pathology e.g. endometriosis, uterine fibroids, PID

Answer 300

- Pelvic pain - Nausea - Vomiting - General malaise - Diarrhoea - Fatigue

Answer 301

- Exclude STIs - Abdo exam: tenderness/mass, - Bimanual examination: cervical tenderness - Pelvic ultrasound if suspect underlying pathology (e.g. fibroids, endometriosis)

Answer 302

Medical management - NSAIDs - COCP - Progestogen-only pill - Levonorgestrel (progesterone)-releasing IUD (e.g. Mirena©) Surgical management - Endometrial ablation or hysterectomy

Answer 303

When a fertilised egg implants outside the uterus. The most common site is a fallopian tube. other sites include entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.

Answer 304

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

Answer 305

Always ask about the possibility of pregnancy, missed periods and recent unprotected sex in women presenting with lower abdominal pain! Classic 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) Also ask about: - Dizziness or syncope (blood loss) - Shoulder tip pain (bleeding irritated diaphragm)

Answer 306

- Pregnancy test to confirm pregnancy - Transvaginal ultrasound to locate the pregnancy - Women with pelvic pain or tenderness and a positive pregnancy test need to be referred to an early pregnancy assessment unit (EPAU) or gynaecology service.

Answer 307

- Pelvic pain and tenderness and positive pregnancy test

Answer 308

Awaiting natural termination Criteria: - Close follow up and monitoring of hCG levels to ensure successful termination - Adnexal mass < 35mm - No visible heartbeat - No significant pain - HCG level < 1500 IU / l

Answer 309

- IM Methotrexate (teratogenic) - Criteria same as expectant except: - HCG level must be < 5000 IU / l - Confirmed absence of intrauterine pregnancy on ultrasound

Answer 310

Criteria: - Pain - Adnexal mass > 35mm - Visible heartbeat - HCG levels > 5000 IU / l - Laparoscopic salpingectomy - removal of affected fallopian tube - Laparoscopic salpingotomy - excision of the ectopic pregnancy while preserving the fallopian tube

Answer 311

Infertility is the diminished ability of a couple to conceive a child over a two year period. Start investigations if the couple has been trying for 12 months without success, after 6months if the woman is over 35 as the ovarian reserves might be reduced and time is more precious

Answer 312

Factors affecting natural fertility include: - Increasing age - Obesity - Smoking - Excessive alcohol - Genetic causes: Turner's syndrome (XO) - Ovulation/endocrine disorders: e.g. PCOS - Tubal abnormalities: adhesions secondary to PID Uterine abnormalities: e.g. fibroids , endometriosis Testicular disorders: testicular cancer, oligospermia, premature or retrograde ejaculation

Answer 313

- Semen analysis - Serum progesterone 7 days prior to expected period, usually D21, as progesterone is released by the corpus luteum so increase on D21 = ovulation has occured - FSH levels: high = low ovarian reserve as the pituitary release more FSH in an attempt to stimulate the ovaries - High LH indicate PCOS - Anti-Mullerian hormone, high = good ovarian reserve - TFT - BMI

Answer 314

- Transvaginal ultrasound scan: To identify uterine abnormalities - Hysterosalpingography: Assess tubal patency. - Laparoscopy and dye: Assess tubal patency in presence of co-morbidities (e.g. PID, ectopic pregnancy, endometriosis).

Answer 315

Lifestyle: weight loss, smoking cessation Medical: - Clomifene to stimulate ovulation - Gonadotropins if resistant to clomifene Tubal: - Laparoscopic surgery to remove endometriosis/adhesions - IVF Uterine: - Surgery to correct polyps, fibroids etc. Sperm: - Surgical sperm retrieval - Surgical correction e.g. vas deferens blockage - Intrauetrine insemination

Answer 316

A type of cancer that occurs in the cells of the cervix. Most are squamous cell carcinoma, followed by adenocarcinoma

Answer 317

Human papilloma virus (HPV) - particularly type 16 and 18 = ~70% cervical cancers. HPV vaccine offered to girls and boys aged 12 - 13

Answer 318

Stage 1: Confined to the cervix Stage 2: Invades the uterus or upper 2/3 of the vagina Stage 3: Invades the pelvic wall or lower 1/3 of the vagina Stage 4: Invades the bladder, rectum or beyond the pelvis

Answer 319

Increased risk of catching HPV: - Increased number of sexual partners - Early sexual activity Non-engagement with cervical screening Other: - Smoking - Family history - Immunosuppression

Answer 320

Non-specific, examine cervix with speculum - Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) - Abnormal vaginal discharge - Pelvic pain - Dyspareunia (pain or discomfort with sex)

Answer 321

- Ulceration - Inflammation - Bleeding - Visible tumour

Answer 322

Purpose: detects dyskaryotic cells which are pre-cancerous allowing early treatment Target group: women (and trans men with a cervix) between 25 - 64 25 - 49: every 3 years 49 - 64: every 5 years

Answer 323

- Inadequate - Normal - Borderline - Mild dyskaryosis - Moderate dyskaryosis - Severe dyskaryosis - Possible invasive squamous cell carcinoma - Possible glandular neoplasia Tested for HPV status HPV-negative: return to routine screening HPV-positive with normal cytology = repeat after 12 months Abnormal cytology = colposcopy Inadequate = repeat in 3 months

Answer 324

1st line: urgent colposcopy Cancer staging: CT chest, abdo, pelvis

Answer 325

Cervical intraepithelial neoplasia (CIN) used to grade the level of dysplasia (premalignant changes) found at colposcopy1 - CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment - CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated - CIN III or cervical carcinoma in situ.: severe dysplasia, very likely to progress to cancer if untreated | 1 different from dyskaryotic changes at screening

Answer 326

- Early-stage 1A: large loop excision of the transformation zone (LLETZ) or cone biopsy - Stage 1B – 2A: radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy - Stage 2B – 4A: Chemotherapy and radiotherapy - Stage 4B: surgery, radiotherapy, chemotherapy and palliative care - Pelvic exenteration (removal of all pelvic organs) might be used to for advanced disease - Bevacizumab (Avastin) = mAb with chemo for metastatic or recurrent ## Footnote LLETZ = wire loop with electrical current (diathermy) to remove abnormal epithelial tissues on cervix

Answer 327

- Endometrial cancer - Cervical polyps

Answer 328

Psychological, physical, and behavioural symptoms that occur in the luteal phase of the menstrual cycle and cause distress or disruption to the patient's life.

Answer 329

- Mood swings and irritability - Depression and anxiety - Fatigue and sleep problems - Bloating, breast tenderness, headaches, joint/muscle pain - Changes in appetite and food cravings

Answer 330

- Comprehensive patient history - Clinical diagnosis - Ask patient to keep symptom diary for at least 2 menstrual cycles to help confirm diagnosis

Answer 331

Non-pharmacological: - Improve diet, exercise, smoking cessation, reduce alcohol - Stress reduction: relaxation techniques - Cognitive behavioural therapy Pharmacological: - COCP - GnRH analogues: effectively induce a menopausal state - SSRIs and SNRIs

Answer 332

An ovarian cyst is a fluid-filled sac that develop in the ovaries. Functional ovarian cysts related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women - mostly benign. Postmenopausal women - concern for malignancy and needs Ix.

Answer 333

- Asymptomatic - Acute unilateral pelvic pain - suggestive of haemorrhage rupture, ovarian torsion Signs if rupture: - Intra-peritoneal haemorrhage with haemodynamic compromise

Answer 334

- Ovarian cancer - Ovarian torsion - Ectopic pregnancy - Appendicitis

Answer 335

Red flag symptoms for malignancy: Abdominal bloating, reduced appetite, weight loss, ascites, lymphadenopathy 1st line - Pregnancy test to exclude ectopic -Transvaginal USS - Serum CA-125 in suspected malignancy and all PM women

Answer 336

Pre-menopausal: - <5cm resolve without treatment - 5 - 7 cm: routine referral to gynae and yearly ultrasound - > 7cm: consider MRI scan or surgical evaluation Postmenopausal: - Raised CA125 = 2WW - Normal CA 125 and cyst < 5cm = ultrasound every 4 - 6 months Surgical management: - Persistent/enlarging cysts = laparoscopic ovarian cystectomy

Answer 337

Menopause is the permanent cessation of menstruation, defined by ≥ 12 months of amenorrhea in otherwise healthy women ≥ 45. Perimenopause is the time around menopause, where women experience vasomotor symptoms and irregular periods.

Answer 338

Ovarian follicular failure leading to oestrogen deficiency. - Oestrogen and progesterone level: low - LH and FSH levels are high, in response to an absence of negative feedback from oesterogen

Answer 339

In the ovaries, the maturation of primordial follicles to primary and secondary follicles is always occurring independently of the menstrual cycle. FSH stimulates the further development of secondary follicles, and as the follicles mature, the granulosa cells around them release oestrogen. Oestrogen = negative feedback to pituitary and reduces LH and FSH release Menopause starts with a decline in ovarian follicle development = reduced production of oestrogen. During perimenopause, the lowered levels of oestrogen = no negative feedback = increased LH and FSH Failing follicle development = anovulation = irregular menstrual cycles No oestrogen = no endometrium development = amenorrhoea Lower levels of oestrogen also cause the perimenopausal symptoms.

Answer 340

45 - 55 ≤40 = premature menopause due to premature ovarian insufficiency

Answer 341

Vasomotor symptoms: hot flushes, night sweats Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm, dyspareunia Psychological symptoms: depression, anxiety, mood swings, lethargy, reduced concentration

Answer 342

- Thyroid disease - Depression - Premature ovarian insufficiency

Answer 343

≥ 45 = clinical diagnosis FSH blood test to help with the diagnosis in: - Women under 40 years with suspected premature menopause - Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 344

- HRT - oestrogen oral, transdermal or topical - cyclical if still having periods, continuous if stopped. - Progesterone to counteract unopposed oestrogen - SSRIs - CBT - Vaginal moisturers Women need to use effective contraception for: - Two years after the last menstrual period if < 50 One year after the last menstrual period > 50

Answer 345

Fibroids are benign smooth muscle tumours originating from the myometrium of the uterus. Common in women older than 30, with peak incidence in their 40s

Answer 346

- Intramural - within the myometrium - can distort uterine shape - Subserosal - just below the outer layer of the uterus - can grow large and fill abdo cavity - Submucosal - below the endometrium

Answer 347

- Often asymptomatic - Heavy menstrual bleeding (menorrhagia) is most common - Dysmenorrhea - Urinary/bowel symptoms due to pelvic pressure/fullness

Answer 348

Endometriosis

Answer 349

- Hysteroscopy initial Ix for submucosal fibroids with menorrhagia - Transvaginal & transabdo ultrasound for larger fibroids - Endometrial biopsy - MRI before surgery to determine size, shape and blood supply of the fibroids

Answer 350

Less than 3 cm + no uterine distortion + heavy menstrual bleeding: - Mirena coil (1st line) - NSAIDs and tranexamic acid Symptomatic fibroids = medical management above or surgery Surgery = - Myomectomy - Ablation - Uterine artery embolisation - Hysterectomy -

Answer 351

Inflammation and infection of the organs of the pelvis, it spreads from the cervix.

Answer 352

- Chlamydia trachomatis - Neisseria gonorrhoeae

Answer 353

- Not using barrier contraception - Multiple sexual partners - Younger age - Existing STI - Previous PID

Answer 354

- Pelvic or lower abdominal pain - Abnormal vaginal discharge - Intermenstrual or postcoital bleeding - Dyspareunia - Fever - Dysuria

Answer 355

- Pelvic tenderness - Cervical motion tenderness (cervical excitation) - Inflamed cervix (cervicitis)

Answer 356

- Appendicitis - Endometriosis - Ectopic pregnancy

Answer 357

- Nucleic acid amplification test (NAAT) swabs for gonorrhoea and chlamydia - Pregnancy test to exclude ectopic - WWC, CPR for infection

Answer 358

- Referred to a genitourinary medicine (GUM) specialist service - Empirical antibiotics - Abx depends on local guidelines but generally: - IM ceftriaxone 1g once + Doxycycline + Metronidazole Severe cases -sepsis or pregnant - Hospital for IV abx

Answer 359

Severe form of nausea and vomiting in pregnancy (NVP). The RCOG guideline (2016) criteria are “protracted (prolonged)” NVP plus: - More than 5 % weight loss compared with before pregnancy - Dehydration - Electrolyte imbalance

Answer 360

1st line: conservative - smaller portions, avoid triggers, sour liquids better than water, ginger Medical - Pyridoxine and/or doxylamine Acute management - IV fluids, antiemetics, U+E monitoring, thiamine, anti-thrombotic stockings

Answer 361

a malignant growth that primarily affects the skin of the vulva - most commonly squamous cell carcinoma.

Answer 362

- A lump with/wo lymphadenopathy - Vulval itching or discomfort - A non-healing ulcer - Vulval pain - thickening or changes in color of vulvar skin - Abnormal bleeding or discharge

Answer 363

- Lichen sclerosus - Bartholin's cyst

Answer 364

- Vulvar examination - then biopsy if suspected malignancy?

Answer 365

Simple: radical or local wide excision Advanced: surgery + radiotherapy +/- chemo

Answer 366

Menorrhagia is excessive menstrual bleeding that significantly impacts a woman's life.

Answer 367

Local: endometriosis, adenomyosis, fibroids Systemic: Bleeding disorders (e.g. VWB), hypothyroidism, obesity

Answer 368

Age at menarche Cycle length, days menstruating and variation Intermenstrual bleeding and post coital bleeding Contraceptive history Sexual history Possibility of pregnancy Plans for future pregnancies Cervical screening history Migraines with or without aura (for the pill) Past medical history and past drug history Smoking and alcohol history Family history

Answer 369

Fibroids Adenomyosis Endometrial polyps Endometrial can er

Answer 370

- Pelvic exam - speculum and bimanual - Bloods - FBC for anaemia, coagulation screen, TFT - Swabs - infection - Hysteroscopy - if suspect submuscosal fibroids, endometrial cancer - Pelvic + transvaginal USS - large fibroids, adenomyosis

Answer 371

Non-hormonal: - Tranexamic acid (antifibrinolytic – reduces bleeding) -Mefenamic acid (NSAID – reduces bleeding and pain) Hormonal: - Mirena coil (first line) - Combined oral contraceptive pill Refer to secondary care if ineffective or fibroids > 3cm. Surgery: Endometrial ablation or hysterectomy

Answer 372

Chlamydia Trachomatis

Answer 373

- Sexual contact - Vertical (mother to baby)

Answer 374

- Under 25 - New sexual partner - >1 sexual partner/year - Not using condoms

Answer 375

- 70% asymptomatic - dysuria, - pelvic pain - post coital/intermenstrual bleeding

Answer 376

- 50% symptomatic - Urethral discharge - Dysuria - Testicular pain

Answer 377

- Epididymo-orchitis - Pelvic inflammatory disease (1-30%) - Infertility - Ectopic pregnancies

Answer 378

- Nucleic acid amplification technique (NAAT) sensitivity 96-98%, specificity >95%

Answer 379

- Doxycycline 100mg BD for 7 days - Doxycycline contraindicated in pregnancy Alternative regimens: Azithromycin 1G OD day 1, 500mg OD day 2+3 Advice: - No sexual contact for 1 week - Contact tracing Test of cure: - Retest in 3 months if under 25. - Test of cure (TOC) in 6 weeks if pregnant or rectal infection

Answer 380

Neisseria Gonorrhoea (gram-negative diplococcus) Transmission: sexual contact, vertical

Answer 381

- 50% asymptomatic, - 50% mucopurulent discharge - pelvic pain (25%) - dysuria (12%)

Answer 382

Asymptomatic (<10%) Mucopurulent discharge (80%) Dysuria (50%)

Answer 383

Epididymo-orchitis in men, pelvic inflammatory disease in women

Answer 384

- microscopy (sensitivity 90-95% if discharge present, 50% if not) - nucleic acid amplification technique (NAAT) sensitivity >96% - culture (important due to increasing antibiotic resistance with GC)

Answer 385

- Ceftriaxone 1g IM (mixed with 3.5msl 1% lidocaine) · - Ciprofloxacin 500mg PO stat FIRST-LINE where sensitivities available prior to treatment

Answer 386

- No sexual contact for 1 week after patient and their partner are treated - PIL leaflet on condition - Health advisor for contact tracing. Test of cure: 2 weeks after treatment

Answer 387

Urethritis is inflammation of the urethra. 50% no cause found 45% chlamydia trachomatis 10-25% Mycoplasma genitalium

Answer 388

- Sexually active, - - Unprotected sex - Homo/bisexual - Aged <35 - Multiple partners

Answer 389

- Asymptomatic - Urethral discharge - Dysuria

Answer 390

- Microscopy: gram stained urethral smear (diagnose if >5 pus cells per film) - Culture - First pass urine (FPU) to test for GC/CT and Mycoplasma - Urinalysis · - MSU

Answer 391

- Doxycycline 100mg BD 7 days Advice: - No sexual contact for 1 week after treatment for themselves and their partner - PIL leaflet on condition - Contact slip for partner notification

Answer 392

Trichomonas vaginalis (TV) -flagellated protozoon Transmission: sexual contact Treatment: · metronidazole 400mg PO BID x 7 days Advice: · no sexual contact for 1 week after patient and partner treated · PIL on condition · See health advisor for contact tracing Test of cure: · Only if pregnant as these is some evidence TV can cause pre-term birth

Answer 393

- Asymptomatic (10-50%) - Yellow frothy discharge - itching - Dysuria - Pelvic pain - Strawberry cervix on examination

Answer 394

- asymptomatic (15-50%), urethral discharge, dysuria, frequency

Answer 395

- Charcoal swab from posterior fornix in females and examined under microscope - Urethral/first catch urine culture in males

Answer 396

- Metronidazole 400mg PO BID x 7 days Advice: - No sexual contact for 1 week after patient and partner treated - PIL on condition - See health advisor for contact tracing Test of cure: - Only if pregnant as these is some evidence TV can cause pre-term birth

Answer 397

Ovarian cancer is a malignancy originating from various cell types found within the ovary. Most common is epithelial ovarian tumours.

Answer 398

Exposure to unopposed oestrogen - HRT, obesity, numerous ovulations (early menarche/late menopause) - Older age - Smoking - BRCA 1 and 2 genes. - ↑ ovulation: early menarch, late menopause, nulliparity - Recurrent clomifene use Protective factors include: - Childbearing (parity) - Breastfeeding - Early menopause - Use of combined oral contraceptive pill (COCP)

Answer 399

**Epithelial ovarian tumours** Originate from the epithelium which lines the fimbria of the fallopian tubes or the ovaries **Germ cell tumours** Originate from the germ cells in the embryonic gonad **Sex cord cell tumours** Originate from connective tissue, less aggressive than epithelial cell tumours

Answer 400

Initial - CA125 blood test (>35 IU/mL is significant) - Pelvic ultrasound The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: - Menopausal status - Ultrasound findings - CA125 level Further investigations in secondary care include: - CT scan to establish the diagnosis and stage the cancer - Histology (tissue sample) using a CT guided biopsy - Paracentesis (ascitic tap) for cancer cells

Answer 401

Further Ix before referral, particularly important in women > 50 with new symptoms of: - Abdominal discomfort - Bloating - Early satiety - Urinary frequency or change in bowel habits In later stages, the disease may cause, any of these symptoms = 2WW referral! - Ascites (due to vascular growth factors increasing vessel permeability) - Pelvic, back and abdominal pain - Palpable abdominal or pelvic mass

Answer 402

- Fibroids - Ovarian cysts - Endometrial cancer

Answer 403

- Stage 1: Confined to the ovary - Stage 2: Spread past the ovary but inside the pelvis - Stage 3: Spread past the pelvis but inside the abdomen - Stage 4: Spread outside the abdomen (distant metastasis)

Answer 404

- Managed by gynaecology oncology MDT - Early disease: removal of the uterus, ovaries, Fallopian tubes - Adjuvant chemotherapy

Answer 405

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

Answer 406

If vaginal pH >4.5, normal vaginal flora (lactobacilli) dominated by anaerobes, e.g., gardnerella vaginalis causing symptoms of bacterial vaginosis. Not sexually transmitted

Answer 407

- Asymptomatic (50%) - Thin white offensive smelling vaginal discharge (not associated with soreness, itching or irritation).

Answer 408

Gram stained vaginal smear - Grade I (normal – only lactobacilli seen) - Grade II (intermediate – mixed flora, some lactobacilli present) - Grade III (bacterial vaginosis- few/no lactobacilli seen on slide) Or charcoal HVS or self taken low-vaginal swab for microscopy "Clue cells" on microscopy = BV, common MCQ

Answer 409

- If asymptomatic, no treatment needed. Might resolve spontaneously. - Abx of choice for anaerobic bacteria: Metronidazole orally or vaginal gel Advice: - Written and verbal information on prevention e.g. washing only with water, avoiding soaps/shower gels/bubble bath, avoiding washing hair in bath

Answer 410

Candida albicans (80-92%), not sexually transmitted

Answer 411

- Uncontrolled diabetes mellitus - Immunosuppression - Hyperoestrogenaemia (including HRT and the COCP) - Broad-spectrum antibiotics

Answer 412

- Vulval itch and soreness - Vaginal discharge (typically curdy, non-offensive) - Superficial dyspareunia - External dysuria

Answer 413

- Red skin, Swelling, irritation - Soreness and Itchiness - Phimosis (tight foreskin) - Dysuria - Dyspareunia Chronic/ recurrent infection in men can lead to phimosis

Answer 414

- Routine microscopy - Microscopy, culture, and sensitivity (black charcoal swab)

Answer 415

Canesten duo OTC, contains - Clotrimazole pessary 500mg - Clotrimazole 2% vaginal cream For men - Clotrimazole 1% cream Advice: wash only with water, avoid bubble baths/shower gels, wear cotton underwear.

Answer 416

Herpes simplex virus (HSV) - HSV type 1- the usual cause of oral herpes (cold sores) - HSV type 2- historically associated with sexual transmission (note either type can cause both oral and genital herpes)

Answer 417

HSV is spread through direct contact with affected mucous membranes or viral shedding in mucous secretions. Viral shedding and transmission can occur even if an individual is asymptomatic. Following primary infection, virus becomes latent in sensory ganglia, periodically reactivating to cause symptomatic lesions or asymptomatic viral shedding

Answer 418

- Asymptomatic (80%) - Painful blisters and ulcers, - Dysuria - Tender inguinal lymphadenitis - Discharge, fever, myalgia

Answer 419

Urinary retention, aseptic meningitis, adhesions

Answer 420

Ask about sexual contacts, including those with cold sores, to establish a possible source of transmission. They may have caught the infection from someone unaware they are infected and not experiencing any symptoms. Clinical diagnosis through history and examination - HSV DNA detection by PCR - Sites to be sampled by swab: base of ulcer

Answer 421

- Primary herpes - Aciclovir 400mg TDS for 5 days, topical anaesthetic agents e.g. Instillagel prn. - Recurrences of herpes – Aciclovir 800mg TDS for 2 days - If >6 outbreaks a year consider suppressive therapy with Aciclovir 400mg BD for 12 month - Hospitalisation if urinary retention for catheterisation.

Answer 422

Human papillomavirus (HPV) Transmission: skin to skin contact

Answer 423

- Most asymptomatic - Can appear from 3 weeks to years after exposure to the virus - More common in pregnancy due to immune suppression - Fleshy lumps, itching, distorted flow of urine if present in urethra

Answer 424

- Podophyllotoxin (Warticon) - antiviral cream - Imiquimod (Aldara): stimulate local immune response - Cryotherapy : three freeze thaw cycles weekly

Answer 425

- Treponema pallidum: Gram -ve spirochete - Transmission: sexual, vertical

Answer 426

- Primary - Secondary - Early latent - Late latent - Tertiary - Neurosyphilis - infection of the CNS with neuro symptoms. Ary

Answer 427

Chancre - painless ulcer develops at site of invasion, 10-90 days post-exposure +/- local lymphadenopathy

Answer 428

- Maculopapular rash on trunk, palms and soles - Generalised adenopathy - Condylomata lata (lesions - secondary manifestation of syphilis) - Snail track ulcers - Moth-eaten alopecia

Answer 429

Asymptomatic Early = within 2 years of infection Late = after 2 years

Answer 430

Cardiovascular - Aortic incompetence, LVH, aneurysms Gummatous lesions: - Chronic painless nodules that break down into ulcers which heal slowly, osteitis

Answer 431

Complication of syphilis: can occur at any time and include meningitis, optic neuritis, sensorineural hearing loss. Specific pupil sign - Argyll-Robertson pupil - a constricted pupil that accommodates when focusing on a near object but does not react to light. (Prostitute pupil because "it accommodates but does not react")

Answer 432

Screening: antibody testing - treponemal EIA, TPPA Samples from sites of infection tested via: - Darkfield microscopy - Polymerase chain reaction (PCR) The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) = non-specific but sensitive. Detects number of antibodies againist syphilis infection, higher numbers = greater chance of active infection

Answer 433

Early: Benzylpenicillin (penicillin G) stat IM single dose Late: IM Pen G for 2 to 3 weeks Neurosyphilis = IV pen G 10 - 14 days Penicillin allergy = doxycycline or tetracycline

Answer 434

- At 3, 6, 12 months - Discharge if adequate response - if indicated, six monthly until VDRL negative - 4x or higher increase in VDRL titre = reinfection or treatment failure = retreatment

Answer 435

Retrovirus human immunodeficiency virus (type 1 and type 2) - type 1 most common Transmission: any sexual contact, needle sharing, needle stick injury, vertical, blood transfusion

Answer 436

1. acute infection: often asymptomatic 2. seroconversion (2-6 weeks post exposure): myalgia, fever, rash, severe sore throat 3. Asymptomatic phase: loss of CD4 cells, persistent generalised lymphadenopathy (30%) 4. AIDS: CD4 count <200 x 106/L, fatal if untreated

Answer 437

- Point of care test for HIV antibody, window period of 90 days, so retest after 90 days post unprotected sex - Blood sample for type 1 and type 2 HIV antigen/antibody - window period of 45 days, retest 7 weeks after unprotected sex - If +ve HIV test, need repeat test to confirm the diagnosis

Answer 438

CD4 count and viral load (aim is undetectable viral load)

Answer 439

- HAART (highly active anti-retroviral therapy) - Recommendations to begin HAART at point of diagnosis - NRTIs (nucleoside analogue reverse transcriptase inhibitors) - PI (protease inhibitor) - NNRTIs (non- nucleoside analogue reverse transcriptase inhibitors) - Integrase inhibitors

Answer 440

These illnesses are associated with end-stage HIV, when the CD4 count is so low that it allows for unusual opportunistic infections and malignancies to appear: - Kaposi’s sarcoma - Pneumocystis jirovecii pneumonia (PCP - fungal) - Cytomegalovirus infection - Candidiasis (oesophageal or bronchial) - Lymphomas - Tuberculosis

Answer 441

PEP (post exposure prophylaxis): - 28-day course of anti-retroviral drugs to prevent HIV, must be given within 72 hours of exposure otherwise not effective PrEP (Pre-Exposure Prophylaxis): - Anti-retroviral therapy for MSM at high risk of HIV transmission, aims to reduce transmission - Given as event-based or daily treatment with single tablet co-formulation Tenofovir/Emtricitabine

Answer 442

Transmission: Sexual transmission, parenteral (blood, blood products, IVDUs), vertical Incubation period: 40-160 days

Answer 443

- Asymptomatic in 10-50% of adults in the acute phase – especially if HIV +ve - Most people fully recover from the infection within 1-3 months. - 5-15% become chronic hepatitis B carriers, usually asymptomatic – may have fatigue, loss of appetite

Answer 444

Serology - HBV surface antigen (HBsAg)- active infection - Surface anti-body (HBsAb) – implies vaccination or past or current infection as HBsAg given in vaccination - Core antibodies (HBcAb) – implies past or current infection

Answer 445

- Acute phase: rest, hydration, admission to hospital if severely unwell - Chronic infection may require anti-viral treatment via specialist clinic Advice: - Avoid unprotected sexual contact until patient is non-infectious/partners successfully vaccinated) - Hep B is a notifiable disease - Contact tracing to include any sexual contact or needle sharing during infectious period

Answer 446

Engerix B 1ml - Routine (0,1,6 months) - Super accelerated course (0,7,21 days + 1 yr booster) for sexual assault/recent high-risk exposure Check Hep B sAb 8 weeks after last vaccine, if >10 then immune, if <10, need repeat course/booster and recheck

Answer 447

- Fulminant hepatitis (< 1%) - liver failure - Chronic infection i.e. >6 months (5-10%) - If pregnant: risk of miscarriage/premature labour in acute infection

Answer 448

Transmission: Parenteral, vertical, rarely sexually transmitted (<1%) Incubation: 4-20 weeks, serology is usually positive 3 months after exposure but can take up to 9 months

Answer 449

Similar to hep B, about 60% are asymptomatic

Answer 450

- 50-85% become chronic carriers - Severe liver disease (30%), hepatocellular carcinoma, - Pregnancy – miscarriage and pre-term birth risks

Answer 451

- Sex workers, - IVDU - Victims of sexual assault - HIV +ve MSM (and their partners), - Born outside of W Europe/Australia/ North America - Blood transfusions, tattoos, piercings, acupuncture, dental procedures done abroad

Answer 452

- Hepatitis C antibody is the screening test - Hepatitis C RNA testing is used to confirm the diagnosis of hepatitis C, calculate the viral load and identify the genotype

Answer 453

Refer to gastro/hepatology for treatment and for counselling on transmission (not to donate blood/tissues/semen), and alcohol abstinence. No vaccine for hep C.

Answer 454

Vasa praevia is an obstetric emergency where foetal vessels run near or across the internal cervical os, placing them at risk of rupture during membrane rupture.

Answer 455

- Painless vaginal bleeding - Rupture of membranes - Foetal bradycardia or death

Answer 456

Antenatal diagnosis with transabdominal or transvaginal ultrasonography

Answer 457

Elective caesarean section before ROM, around 35-36 weeks of gestation. Emergency caesarean section if mother goes into labour or ROM

Answer 458

LAMBAST - Lithium - Amiodarone - Methotrexate - Benzodiapizines - Aspirin - Sulfonamides - Tetracyclines

Answer 459

HBV IgG and HBV vaccination within 24 hours of delivery

Answer 460

- Breasts sits in front of the chest wall - Made up of mostly adipose tissue - The areola surrounds the nipple - Behind the nipples are the ducts, which leads into the lobules where breast milk is produced

Answer 461

- Most significant: breast cancer - Fibroadenoma - Fibrocystic breast changes - Breast cysts - Fat necrosis - Lipoma - Galactocele

Answer 462

Triple assessment is standard practice to exclude or diagnose breast cancer: - Clinical assessment (history and examination - Imaging (USS or mammogram) - Histology (fine needle aspiration or core biopsy

Answer 463

- Hard, irregular, painless lumps that are fixed in place - Lumps tethered to the skin or chest wall - Nipple retraction - Skin dimpling or oedema (peau d'orange) - Lymphadenopathy especially in the axilla

Answer 464

- An unexplained breast/axillary lump aged ≥ 30 - Unilateral nipple changes in patients aged ≥ 50 (discharge, retraction or other changes) - Skin changes suggestive of breast cancer

Answer 465

- Female (99% of breast cancers) - Increased oestrogen exposure (earlier onset of periods and later menopause) - More dense breast tissue (more glandular tissue) - Obesity - Smoking - Family history (first-degree relatives) - HRT

Answer 466

BRCA = BReast CAncer gene BRCA1 and 2 = tumour suppressor genes Mutations = increased breast and ovarian cancer risk

Answer 467

- 70% breast cancer by 80 - 50% ovarian cancer - Increased bowel and prostate cancer risk

Answer 468

- 60% breast cancer by age 80 - 20% ovarian cancer

Answer 469

- Ductal carcinoma in situ (DCIS) - Lobular Carcinoma in situ (LCIS) - Invasive Ductal Carcinoma - Invasive lobular carcinoma (ILC) - Inflammatory breast cancer - Paget's Disease of the Nipple

Answer 470

- Pre-cancerous or cancerous epithelial cells of the breast ducts - Localised to a single area - Often picked up by mammogram screening - Potential to spread locally over years - Potential to become an invasive breast cancer (around 30%) - Good prognosis if full excised and adjuvant treatment

Answer 471

- Pre-cancerous condition in typically pre-menopausal women - Asymptomatic and undetectable on mammogram - Incidental detected on breast biopsy - Increased risk of breast cancer (30%) - Managed with close-monitoring (6 monthly exams and yearly mammograms)

Answer 472

- NST = no special/specific type - Originates in cells from the breast ducts - Most invasive breast cancers are this type - Seen on mammograms

Answer 473

- 1-3% of breast cancers - Presents similarly to a breast abscess or mastitis - Swollen, warm, tender breast with pitting skin (peau d’orange) - Does not respond to antibiotics - Worse prognosis than other breast cancers

Answer 474

- Looks like eczema of the nipple/areolar - Erythematous, scaly rash Indicates breast cancer involving the nipple - May represent DCIS or invasive breast cancer - Requires biopsy, staging and treatment, as with any other invasive breast cancer

Answer 475

Mammogram every 3 years for women aged 50 to 70 years in the UK

Answer 476

- A first-degree relative with breast cancer, diagnosed under 40, or bilateral breast cancer under 50 - Two first-degree relatives with breast cancer - Referral to secondary care breast clinic or specialist genetic clinic - Genetic counselling

Answer 477

- Young women generally have more dense breasts with more glandular tissue - USS in young women, good at differentiating solid vs cystic lumps (e.g. under 30 years old) - Mammograms more effective in older women, calcification missed by USS

Answer 478

- Annual mammogram - Chemoprevention (Tamoxifen if premenopausal or Anastrozole if postmenopausal) - Risk reducing bilateral mastectomy or bilateral oophorectomy (removing ovaries)

Answer 479

Common benign tumours of stromal/epithelial breast duct tissue Small and mobile (breast mouse) Common in younger women (20 - 40) as responds to oestrogen and progesterone

Answer 480

- Painless - Smooth - Round - Well-circumscribed - Firm - Mobile - ≤3cm

Answer 481

Variation of normal and not considered a disease. The connective tissues (stroma), ducts and lobules of the breast responds to oestrogen and progesterone and becomes fibrous and cystic - fluctuates with the menstrual cycle

Answer 482

- Lumpiness - Breast pain or tenderness (mastalgia) - Fluctuation of breast size - Symptoms occur before menstruating (within 10 days) and resolve after menstruation

Answer 483

- Exclude cancer - Wear supportive bra - NSAIDs e.g. ibuprofen - Avoid caffeine - Apply heat

Answer 484

- Benign, individual and fluid-filled lumps - Most common cause of breast lumps, 30 - 50 - Can be painful - Might fluctuate in size over the menstrual cycle

Answer 485

- Smooth - Well-circumscribed - Mobile - Possibly fluctuant

Answer 486

- Might increase the risk of breast cancer - Need assessment to exclude cancer - imaging, aspiration or excision

Answer 487

They are localised degeneration and scarring of the fat tissue in the breast that cause a benign lump.

Answer 488

- Oil cysts (contains liquid fat) - Localised trauma - Radiotherapy - Surgery This triggers an inflammatory reaction with fibrosis and necrosis of fat tissue.

Answer 489

- Painless - Firm - Irregular - Fixed in local structures - Might be skin dimpling or nipple inversion

Answer 490

- Exclude breast cancer - Ultrasound or mammogram shows similar appearance to breast cancer Histology (fine needle aspiration or core biopsy) to confirm diagnosis

Answer 491

- After excluding breast cancer, treat conservatively, might resolve spontaneously over time - Surgical excision if needed

Answer 492

- Benign tumours of adipose tissue - They can occur anywhere on the body with adipose tissue

Answer 493

- Soft - Painless - Mobile - Do not cause skin changes

Answer 494

- Conservative treatment with reassurance - Surgical removal if needed

Answer 495

Galactoceles occur in women that are lactating, often after stopping breastfeeding Breast milk-filled cysts that occur with a lactiferous duct is blocked

Answer 496

- Firm, mobile, painless lump usually under the areola

Answer 497

- Benign and usually resolves without any treatment - Drain with needle - They can become infected and require antibiotics

Answer 498

2Ls , 2Bs - L – Lungs - L – Liver - B – Bones - B – Brain

Answer 499

- Breast cancer cells can have receptors that can be targeted with breast cancer treatment - Oestrogen receptors (ER) - Progesterone receptors (PR) - Human epidermal growth factor (HER2) Triple-negative = do not have any of the receptors

Answer 500

- MDT involvement - Surgery - Chemo/Radiotherapy - Hormone therapy

Answer 501

- Breast-conserving (wide local excision) usually with radiotherapy - Mastectomy - Axillary clearance of lymph nodes (causes chronic lymphoedema)

Answer 502

Oestrogen-receptor positive: - Tamoxifen for premenopausal women - blocks oestrogen receptors in breast tissue and stimulates oestrogen receptors in the uterus and bones (prevents osteoporosis but increases risk of endometrial cancer) - Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole) - aromatase converts androgen to oestrogen, main source of oestrogen in fat tissue after menopause REMEBER THEM

Answer 503

Trastuzumab (Herceptin) Pertuzumab (Perjeta) combined with Trastuzumab Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers.

Answer 504

- Surveillance mammograms yearly for 5 years - Individual care plans

Answer 505

- Immediate reconstruction - Delayed reconstruction - Breast implants or flap reconstruction (using tissue from another part of the body)

Answer 506

Inflammation of the breast tissue and is a common complication of breastfeeding, it can occur with or without associated infection

Answer 507

Obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent blockage

Answer 508

- Painful breast - Fever and/or general malaise - A tender, red, swollen, and hard area of the breast, usually in a wedge-shaped distribution Features indicating infection (hard to tell): - Nipple fissure that looks infected - Purulent discharge - Symptoms not improving after 12 - 24 hours

Answer 509

Usually clinical dx If infection suspected, then a sample of milk sent for culture and sensitivities.

Answer 510

If caused by duct blockage, then conservative: - Continued breastfeeding - Expressing milk - Breast massage - Heat pack - Simple analgesia - Warm showers If ineffective or suspected infection then: - Flucloxacillin - Erythromycin if penicillin allergy

Answer 511

- Analgesia - Abx (broad-spetrum co-amoxiclav, or erythromycin/clarithromycin + metronidazole) - Tx underlying cause e.g. candida/eczema

Answer 512

Breast abscess, which might require surgical incision and drainage

Answer 513

Yeast infection that can occur often after a course of antibiotics for mastitis. It can cause recurrent mastitis.

Answer 514

- Sore nipples bilaterally, particularly after feeding - Nipple tenderness and itching - Cracked, flaky or shiny areola - Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Answer 515

Both the mother and baby need treatment - Topical miconazole 2% after each breastfeed - Treatment for the baby (e.g. miconazole gel or nystatin)

Answer 516

A collection of pus within an area of the breast, usually caused by a bacterial infection: - Lactational abscess - Non-lactational abscesses

Answer 517

- Key risk factor: smoking - Damage to the nipple provides bacterial entry - Breast disease e.g. cancer can affect drainage of the breast

Answer 518

- Most common is staphylococcus aureus - Streptococcal species - Enterococcal species - Anaerobic bacteria

Answer 519

- Acute onset (within a few days) - History of recent mastitis or prior breast abscess - Fever and/or malaise present or subsided if abx for infective mastitis - Painful, swollen lump in the breast with redness, heat and swelling of overlying skin - Key feature on examination = swollen, fluctuant, tender lump within the breast

Answer 520

- Referral to hospital on-call surgical team for - USS confirmation Drainage with needle aspiration or surgical incision and drainage - Microscopy, culture and sensitivities - Antibiotics - Continue breastfeeding or express milk

Answer 521

- Gram-positive (staph aureus, streptococcal and enterococcal) = penicillin - Flucloxacillin for staph aureus skin condition (remember this!) - Anaerobic bacteria = co-amoxiclav +/- metronidazole

Answer 522

A warty lesion that grows within one of the ducts in the breast Results from proliferation of epithelial cells Non-cancerous but associated with atypical hyperplasia or breast cancer

Answer 523

- Peak between 35 - 55 of age - Often asymptomatic, incidental finding on mammogram or USS - Nipple discharge (clear or blood-stained) - Tenderness or pain - A palpable lump

Answer 524

Triple assessment to exclude cancer: - Clinical assessment (history and examination) - Imaging (ultrasound, mammography and MRI) - Histology (core biopsy or vacuum-assisted biopsy)

Answer 525

Complete surgical excision, and then the removed tissue is examined for atypical hyperplasia or cancer that the biopsy might have missed

Answer 526

HIT APE H - HCG I - Inhibin A T - Thickened nuchal translucency Down: A - AFP P - PAPP-A E - Estriol

Answer 527

PCOS is a common condition in women, causing metabolic and reproductive problems. Characteristic features include: - Multiple ovarian cysts - Infertility - Oligomenorrhoea - Hyperandrogenism - Insulin resistance

Answer 528

Common exam question! Rotterdam criteria used for making dx of PCOS, diagnosis if two out of three criteria met: - Oligoovulation or anovulation, presenting with irregular or absent menstrual periods - Hyperandrogenism - characterised by hirsutism (thick black hair growth in a male pattern) and acne) - Polycystic ovaries on USS or ovarian volume of > 10cm3

Answer 529

- Oligomenorrhoea or amenorrhoea - Infertility - Obesity (in about 70% of patients with PCOS) - Hirsutism - Acne - Hair loss in a male pattern Other features: - Insulin resistance and diabetes - Acanthosis nigricans (thickened, rough skin typically in body folds, associated with insulin resistance)

Answer 530

- Medications e.g. corticosteroids - Ovarian or adrenal tumours that secrete androgens - Cushing's syndrome

Answer 531

Insulin resistance is major part of PCOS When the body is insulin-resistant, the pancreas has to produce more insulin to stimulate response from cells. Insulin promotes release of androgens from ovaries and adrenal glands, so insulin resistance = higher androgen (e.g. testosterone) levels. Therefore, high levels of insulin contributes to halting follicle development in the ovaries = anovulation and multiple partially developed follicles (polycystic ovaries on scan)

Answer 532

NICE guidelines recommend the following bloods: - Testosterone - Sex hormone-binding globulin (suppresses androgen function) - Luteinizing hormone - Follicle-stimulating hormone - TSH

Answer 533

TOM TIP: key to remember for exams is raised LH and raised LH:FSH ratio - Raised luteinising hormone - Raised LH to FSH ratio (high LH compared with FSH) - Raised testosterone - Raised insulin - Normal or raised oestrogen levels

Answer 534

Transvaginal ultrasound, the follicles might be arranged around the ovary - "string of pearls" appearance Dx criteria either: - 12 or more developing follicles in one ovary OR - Ovarian volume of more 10cm3 Also, test for diabetes using oral glucose tolerance test

Answer 535

If the couple has been trying for 12 months without success. 6 months if woman is over 35 as ovarian reserves will be reduced.

Answer 536

Quesmed Conservative - weight loss, exercise, healthy diet, education on increased CVD, diabetes and endometrial cancer risk Medical if not planning pregnancy - Co-cyprindol: reduces hirsutism and promotes regular menstruation - COCP: regulates menstrual cycle, protection against endometrial cancer meno - Metformin: helps regulate menstruation, reducing hirsutism and acne Medical if planning pregnancy - Clomiphene - induces ovulation - Metformin - improves chance of pregnancy. Alone or with clomiphene Gonadotrophins - if above ineffective

Answer 537

- Sperm problems (30%) - Ovulation problems (25%) - Tubal problems (15%) - Uterine problems (10%) - Unexplained (20%) - 40% of infertile couples have a mix of male and female causes.

Answer 538

- Sperm problems (30%) - Ovulation problems (25%) - Tubal problems (15%) - Uterine problems (10%) - Unexplained (20%) - 40% of infertile couples have a mix of male and female causes.

Answer 539

- 400mcg folic acid daily - Healthy BMI - Avoid smoking and drinking - Avoid stress - Intercourse every 2 to 3 days - Avoid timing intercourse