Obstetrics and gynaecology

Question 1

Fibroids (Leiomyomas)

Answer 1

A: Benign tumours originiating in the uterine myometrium.
20% of women, more common in afro-carribeans

S: Menorrhagia, dysmenorrhoea, abdomen pain, red degeneration mass on pelvic exam.

D: USS pelvis.

T: Analgesia and rest. Surgical removal may be needed.

Question 2

Placental abruption

Answer 2

A: Placental lining separates from uterine wall > 20 weeks. Commonest cause of late partum bleeding.
Trauma, HTN, coagulopathy, smoking.

S: Painful PV bleeding, enlarged, hard uterus, abdo tenderness, contraction.

D: Ultrasound

T: Immediate delivery may be required

Question 3

Placenta praevia

Answer 3

A: Placenta is attached to uterine wall close to or overlying cervix. Leading cause of antepartum (just before childbirth) haemorrhage.

S: Asymptomatic/painless bleeding

D: Ultrasound

T: Caesarian section delivery.

Question 4

Ectopic pregnancy

Answer 4

A: 98% are in fallopian tubes, also ovary, cervical and abdominal. Risk factors include: Pelvic inflammatory disease, use of intraauterine device, tubal surgery, infertility or history.

S: Abdomen pain, pelvic pain, PV bleeding. Rupture can cause pain, bleeding to abdomen and hypovalemic shock.

D: B-HCG, transvaginal US, diagnostic laparotomy.

T: Methotrexate
Laparascopic salpingectomy, laparotamy if patient unstable.

Question 5

(Pre) Eclampsia

Answer 5

A: Eclampsia is pre-eclampsia with the addition of tonic-clonic seizures. PE effects 10% of pregnant women.

S: HTN (>140/90) plus proteinuria (>0.3g/L).
Malaise, vomiting, hyperreflexia.

D: BP, urinalysis, US.

T: Delivery is curative, magnesium sulphate helps prevent seizures. anti - HTN medication.

C: Mother: HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), papilloedema, DIC, cerebral haemorrhage, renal failure, liver failure, death.

Foetus: Intrauterine growth restriction, death.

Question 6

Hyperenesus Gravidarum

Answer 6

A: severe morning sickness is a result of high B-HCG, affecting 0.3-2%.

S: nausea, vomiting, dehydration, electrolyte imbalance.

D: Clinical, confirm pregnancy.

T: Fluids, anit-emetics and electrolyte replacement.

Question 7

Umbilical cord prolapse

Answer 7

A: The umbilical cord descends through the cervix ahead of the foetus, obstructing oxygen and blood supply.

S: Palpable or visible cord outside of uterus

D: Clinical

T: Emergency C-section

Question 8

Post-partum haemorrhage

Answer 8

A: Primary = >500ml blood loss 500ml > 24 hours

Caused by the 4 T’s:

• Tissue (retained from placenta or foetus)
• Tone (inability of uterus to contract)
• Trauma
• Thrombin (coagulopathies)

T: IV oxytocin, transfusion, uterine artery embolisation.

Question 9

Pelvic Inflammatory Disease

Answer 9

A: Inflammation of uterus, fallopian tubes or ovaries. Usually due to ascending bacterial infection (neisseria gonorrhoea or chlamydia trachomatis)

S: Lower abdo pain, vaginal discharge, pyrexia, PV bleeding, painful intercourse.

D: High vaginal swab, pelvic ultrasound.

T: Oral or IV antibiotics (eg ceftriaxone or metronidazole)

Question 10

Cervical intra-epithelial neoplasm

Answer 10

A: Dysplasia (pre-malignant) of squamous cells in the cervix. Increased risk with HPV (16 & 18) infection, smoking and multiple sexual partners.

S: Usually asymptomatic

D: Cervical smear

T: At earlier stages: Conservative management and regular smears
At later stages: Large loop excision of the transformation zone.

Question 11

Endometriosis

Answer 11

A: Presence of endometrial tissue outside of the uterus producing an inflammatory reaction, usually in ovaries, pelvis and abdomen.

S: May be asymptomatic but has a classic triad of pelvic pain, pain during intercourse, difficulty conceiving.

D: Laparoscopy is gold standard, US/MRI pelvis.

T: Oral contraceptive pill, GnRH analogues such as Zoladex (Goserelin Acetate) or Prostap (Leuprorelin Acetate)

Question 12

Polycystic Ovarian Syndrome

Answer 12

A: Genetic component
Criteria is 2/3 of POS (Polycystic ovaries on US, Oligo/anovulation, Signs of androgen excesss (hirsutism))

S: Oligo/amenorrhea, infertility, hirsutism, acne, obesity.

D: US pelvis, glucose tolerance test, sex-hormone binding globulin.

T: Oral contraceptives, metformin, spironolactone, eflornifine cream (for facial hair), clomiphene (for help getting pregnant)

Question 13

Cervical cancer

Answer 13

A: 90% are squamous, 10% are adenocarcinoma
HPV, smoking, HIV.

S: Vaginal bleeding, hard-craggy bleeding cervix on pelvic exam. Can be asymptomatic at first.

I: Cervical biopsy, CT/MRI pelvis

T: Hysterectomy and lymphadenectomy, with chemotherapy and radiotherapy

Question 14

Endometrial cancer

Answer 14

A: 95% adenocarcinoma
Obesity, HRT, early menarche, late menopause, Tamoxifen.

S: Usually appears in first few years after menopause. Vaginal bleeding, anaemia

D: Endometrial biopsy, transvaginal US, CT/MRI pelvis

T: Hysterectomy with bilateral salpingo-oopherectomy and radiotherapy.

Question 15

Ovarian cancer

Answer 15

A: 90% epithelial cell adenocarcinoma
Genetic BRCA 1/2, infertile women, endometriosis, HRT, nulliparity

S: Asymptomatic or abdo pain, bloating, vaginal bleeding, weight loss, increased urinary symtpoms

D: US pelvis, CT/MRI pelvis, CA125 tumour marker

T: Hysterectomy and bilateral salpingo-oopherectomy with lymphadenectomy and radiotherapy