Obstetrics and Gynaecology Short

Question 1

Breech presentation

Answer 1

When the presenting part of the foetus is the buttocks or feet

Most spontaneously correct to cephalic by 36 weeks

Offer external cephalic version (ECV) at 36 weeks if primiparous, 37 weeks if multiparous

Absolute contraindications: C-section indicated for any other reason, APH < 7 days, non-reassuring CTG, placental abruption or placenta praevia, uterine abnormality

Question 2

Ovarian cancer

Answer 2

RIsk factors: unopposed exposure to oestrogen
Key features: abdominal discomfort, bloating, early satiety, urinary frequency/bowel habit changes

2ww if ascites, pelvic or abdominal mass (late signs)

Ix: combination of CA-125 (>35 IU/mL), pelvic ultrasound and menopausal status then CT staging and biopsy for histology

Stages:
- 1: confined to ovary
- 2: spread beyond ovary but within pelvis
- 3: spread beyond pelvis but within abdomen
- Spread beyond abdomen (distant metastasis

Mx: gynae oncology MDT, combination of surgery and chemotherapy

Question 3

Endometrial cancer

Answer 3

Key features: PMB = endometrial cancer until proven otherwise, intermenstrual bleeding, pelvic pain, abdo discomfort/bloating, weight, anaemia

RFs: unopposed oestrogen e.g. PCOS, no or fewer pregnancies, early menarch, late menopause, obesity

Protective factors: mirena coil, COCP, multiparity, smoking

Dx: 1st line: TV USS, thickness >5mm = hysteroscopy and biopsy

Stage:
1- confined to uterus
2- to cervix
3- to ovaries, fallopian tubes or lymph nodes
4- bladder, rectum or beyond pelvis

Mx: radial hysterectomy with bilateral salping-oophorectomy (removal of uterus, cervix and adnexa)

Question 4

Termination of pregnancy

Answer 4

• < 24 weeks gestation if elective
• Any gestation if risk to mother’s life,, risk of serious handicap, grave danger to mother’s physical/mental health

Medical:

Mifepristone (progesterone antagonist - stops pregnancy) and misoprostol (prostaglandin analogue to expel)

Surgical: vacuum aspiration or dilatation and curettage

Question 5

Fat necrosis of the breast

Answer 5

Benign tumour caused by adipose tissue necrosis in the breast, common in obesity

Features: mimics malignancy - firm, irregular lump, inflamed/warm/red overlying skin

2WW criteria NICE

• > 30 with unexplained breast lump
• > 50 with nipple changes (skin changes, discharge, retraction)

Question 6

Placental abruption

Answer 6

The detachment of the placenta from uterine wall. Obstetric emergency!

RFs: previous PA, pre-eclampsia, smoking, cocaine, maternal age > 35

Revealed: bleeding is seen from the vagina

Concealed: bleeding is hidden behind the placenta and no bleed externally

Key features: tense, firm, woody uterus. Foetal distress.

Dx: clinical dx, vital signs (BP, HR,RR, SpO2), bloods: FBC, U+E, LFTs, coagulation screen, group and save

Mx:
- Foetal distress or maternal compromise = emergency C-section
- No foetal distress or maternal compromise = induction of labour

Question 7

Pre-eclampsia

Answer 7

New HTN in pregnant woman (140/90 or more) with proteinuria and end-organ dysfunction occurring after 20 weeks gestation.

RFs: high: existing HTN, SLE or SKD, previous pre-eclampsia, moderate: FHx, nulliparity, BMI 30 or more.

High risk = 1 high or 2 moderate

Key features: headache, vomiting, blurred vision, swelling of face, hands and feet

Dx: BP: 140/90 or more AND EITHER proteinuria (+1 on dipstick)), OR end-organ dysfunction (e.g. raised creatinine)) OR placental dysfunction (e.g. abnormal doppler)

Proteinuria = protein: creatinine > 30mg/mmol, or albumin: creatinine > 8mg/mmol

Mx: admit if 160/110 or more

Outpatient: 2x weekly FBC, LFTs and U+Es, BP monitoring at least every 48 hours, ultrasound monitoring of foetus, amniotic fluid and dopplers every 2 weeks, BP control <1350/85, offer medication if persistently 140/90 or over,

High risk = secondary care review + aspirin as prophylaxis from 12 weeks gestation

Labetalol as antihypertensive if established pre-eclampsia

Delivery: <34 weeks up to 37 weeks = monitor and deliver if foetal/ maternal compromise, give IV corticosteroids and Mg sulphate. > 37 weeks = delivery

Question 8

Breast cancer type + risk factors

Answer 8

RFs: female (99%), BRCA 1 and 2 gene, FHx (first degree), more dense (glandular) tissue, obesity, smoking

• Ductal carcinoma in-situ (DCIS) - pre-cancerous originating from epithelial cells
• Lobular carcinoma in-situ (LCIS) - precancerous often in pre-menopausal women
• Invasive ductal carcinoma NST - most common type of invasive breast cancer, from breast ducts
• Invasive lobular carcinoma - 10%, from breast lobules
• Inflammatory breast disease - presents like mastitis or abscess. Warm, swollen, tender, peau d’orange skin, not responsive to abx
• Paget’s disease of the nipple - erythematous, scaly skin around the nipple/areola, presents like eczema. Often DCIS

Question 9

Breast cancer investigations

Answer 9

NICE 2ww criteria:

> 30 with unexplained breast lump
50 with unexplained unilateral nipple changes
30 with unexplained lump in axilla

Breast clinic for triple assessment

1. History and clinical examination
2. Ultrasound (younger) or mammogram (older)
3. Core biopsy and histology

Question 10

Breast cancer management

Answer 10

• Wide local excision + radiotherapy
• Mastectomy with immediate or delayed reconstruction
• Neoadjuvant/adjuvant chemotherapy

Breast cancer receptors

• Oestrogen receptor (ER): tamoxifen for pre-menopausal, letrozole or anastrozole for post-menopausal
• Progesterone receptor (PR)
• Human epidermal growth factor (HER2) - Trastuzumab (cardiac monitoring needed)

Question 11

Fibroadenoma

Answer 11

Highly mobile, firm, painless, well-circumscribed lump in the breast - “breast mouse”

Common in pre-menopausal women as they respond to oestrogen

Usually < 3cm

Question 12

Menopause

Answer 12

Defined as at least 12 months after last menstrual period, the time leading up to menopause is peri-menopause

Symptoms: hot flushes, low mood, emotional liability, joint pain, reduced libido, vaginal dryness and atrophy

Dx: 45 or over = clinical, FSH for < 40 suspected premature ovarian failure or 40 - 45 with perimenopausal symptoms

FSH + LH high and oestrogen low

Mx: none, HRT, SSRI, CBT, vaginal oestrogen creams, vaginal moisturisers

Contraception: > 50 for one year after LMP, <50 for two years after LMP

Question 13

Placenta praevia

Answer 13

Low-lying placenta (grade 1/2), placeta praevia is when it covers the internal os, usually detected at 20-week anomaly scan

RFs: previous C-section, multiparity, older maternal age, maternal smoking, uterine abnormalities e.g. fibroids)

Key feature: painless vaginal bleeding

Grade 1: encroaches internal os, but does not reach it

Grade 2: reaches internal os but does not cover it

Grade 3: partially covers

Grade 4: completely covers

Mx: monitor and repeat TV USS at 32 and 36 weeks

If 34 - 35+6 weeks - then corticosteroids in case of preterm delivery

Planned delivery considered at 36 - 37 weeks to reduce risk of APH

Emergency c-section might be needed, with blood transfusions, intrauterine balloon tamponade etc.

Question 14

Ectopic pregnancy (definitely going to be in exams according to the guy who writes the exams)

Answer 14

When an embryo implants outside of the uterus, most commonly the ampulla of the fallopian tube.

RFs: previous ectopic, PID, previous surgery to fallopian tubes, intrauterine devices (coils), older age, smoking

Key features: all child-bearing age females with lower abdominal pain, think ectopic! Missed period, lower abdominal pain in either LIF or RIL, right shoulder tip pain, vaginal bleedingm cervical moption tenderness

Ix: urine beta-hCG, ultrasound to locate pregnancy

Positive pregnancy test + abdo pain/tenderness = referral to Early Pregnancy Assessment Unit

Question 15

Management of ectopic pregnancy

Answer 15

Expectant management if

• Follow-up possible to ensure successful termination
• Unruptured
• B-hCG < 1500UI/L
• adnexal mass < 35mm
• No significant pain
• No visible heartbeat

Medical management with IM methotrexate same as expectant but:

• B-hCG < 5000 UI/L
• Confirmed absence of intrauterine pregnancy by USS

Surgical management with salpingotomy or salpingectomy if:

• Anyone that does not meet criteria for expectant or medical mx:
• Pain
• Visible heartbeat
• Adnexal mass > 35mm
• B-hCG > 5000UI

Question 16

Urinary incontinence

Answer 16

Urge - uncontrollable need to urinate leading to involuntary leak of urine = overactivity of the detrusor muscle

Stress - urine leak during times of increased abdominal pressure e.g. laughing or coughing = weakness of pelvic floor

Mixed - mixture of both

Overflow - urinary retention leading to leakage from overflow of urine

RFs: perineal tears, post-menopausal status, multiparity, pelvic floor surgery, pelvic organ prolapse, neuro conditions e.g. MS

Dx: bladder diary, urine dipstick for infection, post-void residual bladder volume - scan to measure volume left after voiding

Mx: stress: avoid caffeine, pelvic floor exercises, lose weight, duloxetine (SNRI)

Urge: bladder retraining, oxybutynin (anticholinergic), Botox injections

Question 17

Fibrocystic changes of the breast

Answer 17

When breast tissue becomes fibrous (hard and irregular) and cystic (fluid-filled), in response to differing levels of oestrogen and progesterone and fluctuates through the menstrual cycle.

Key features: lumpiness, pain/tenderness (mastalgia), fluctuations in breast size

Mx: supportive bra, NSAIDs, apply heat, avoid caffeine, tamoxifen or danazol under specialist

Question 18

Polycystic ovarian syndrome

Answer 18

Rotterdam criteria:

• Anovulation/oligo-ovulation
• Hyperandrogenism (hirsutism, oligomenorrhoea and acne)
• polycystic ovaries or ovarian volume > 10cm3 on USS

Other features: acanthosis nigricans, obesity, sub/infertility, mood disorders

Insulin resistance is present, high levels of insulin contributes to halting follicular development and increase androgen production = worsening PCOS symptoms.

Dx: LH:FSH raised, testosterone: normal/slightly raised, fasting and OGTT for insulin resistance

Mx:
- Lifestyle changes

• Co-cyprindrol: reduces hirsutism and regulates menstruation
• COCP regulates menstrual cycle + endometrial cancer protection
• Metformin to regulate menstrual cycle and enhance fertility
• Clomiphene to induce ovulation if trying to conceive

Question 19

Cervical cancer

Answer 19

HPV 16 and 18

90% squamous cell carcinoma

Risk factors: non-engagement with screening, sexual activity at younger age, multiple sexual partners, smoking, FHx, immunosuppression

Clinical features: non-specific, abnormal vaginal discharge, post-cortical bleeding, urinary/bowel changes, suprapubic pain.

O/E with speculum: white/red patches on cervix, pelvic mass

Dx: FBC (anaemia), LFTs (liver involvement), U+Es (renal involvement), colposcopy for biopsy and CT staging

Stages:

1. confined to cervix
2. spreads to uterus or upper 2/3 vagina
3. spreads to pelvic wall or lower 1/3 vagina
4. Bladder, rectum or beyond pelvis

Mx:

• Cervical intraepithelial neoplasia and early stage 1a: LLETZ
• Advanced but still early stage: radical trachelectomy (removal of cervix and surrounding tissue)
• Stage 1B - 2A: radical hysterectomy with local lymph node removal + chemo + radiotherapy
• Stage 2B - 4A: chemo and radiotherapy
• Stage 4B: palliative care with surgery, radiotherapy, chemo

Question 20

What is cervical intraepithelial neoplasia

Answer 20

Grade of cervical epithelial dysplasia found on colposcopy, not to be confused with dyskaryosis on cervical screening.

CIN I: mild dysplasia affecting 1/3 thickness of epithelium, likely to return to normal without tx

CIN II: moderate dysplasia, affecting 2/3 thickness of epithelium, likely to progress to cancer if untreated

CIN III (cervical carcinoma in situ): severe dysplasia, very likely to progress to cancer if untreated

Question 21

Miscarriage

Answer 21

RFs: previous miscarriage, older maternal age, maternal smoking and alcohol during pregnancy

Early = up to 12 weeks

Late = 12 - 24 weeks

Question 22

Types of miscarriage

Answer 22

• Missed - foetus is no longer alive but no symptoms have occurred
• Threatened - mild vaginal bleeding +/- abdominal pain cervical os is closed and foetus is alive
• Inevitable - heavy vaginal bleeding + abdominal pain + clots, cervical os is open, leading to complete or incomplete miscarriage
• Complete - miscarriage has occurred with no products of conception left
• Incomplete - vaginal bleeding + abdominal pain, miscarriage occurred but retained products of conception
• Recurrent: 3 or more miscarriages before 24 weeks gestation

Question 23

Dx and Mx of miscarriage

Answer 23

Dx: TV USS to confirm viability and check size, heartbeat and pole

Mx:

• Expectant: 1 - 2 weeks allowed for products to pass, repeat urine BhCG after 3 weeks
• Medical: misoprostol (prostaglandin analogue) orally or vaginal pessary: heavier bleed, pain, vomiting, diarrhoea
• Surgical: manual or electric vacuum aspiration, offer anti-D for women undergoing this

If no risks of heavy bleeding or infection = expectant management

If > 6 weeks with bleeding = refer to EPAU

Threatened - monitoring and analgesia (paracetamol)

Complete - counselling and analgesia (paracetamol)

Incomplete- medical/surgical (+curettage) + counselling + analgesia

Recurrent - find underlying cause (e.g. antiphospholipid syndrome)

Question 24

Ovarian cyst

Answer 24

Fluid-filled sacs on ovaries, functional cysts respond to fluctuations in menstrual cycle = pre-menopausal women

Follicular cysts = most common

Post-menopause, cysts = Ix for ?malignancy

Key features, asymptomatic, pelvic pain, bloating, abdo fullness, palatable mass if large

Risks of ovarian torsion or rupture

Always keep ovarian cancer in mind, rule out red flags (bloating, early satiety, change in urinary/bowel habit, weight loss, ascites, lymphadenopathy , assess risk factors and protective factors

Mx:

Pre-menopausal:

• < 5cm = resolve within 3 cycles
• 5 - 7cm = routine gynae referral + yearly USS
• > 7cm - MRI scan or surgical evaluation

Post-menopausal:

• CA-125 and gynae referral
• Normal CA-125 and <5cm = USS every 4 - 6 months
• Abnormal CA-125 = gynae
• Growing cysts = surgical intervention (laparoscopic ovarian cystectomy +/- oophorectomy

Question 25

Gestational diabetes

Answer 25

New onset diabetes during pregnancy

RFs: previous gestational diabetes, previous macrosomia (>4.5kg), BMI > 30, Ethnicity (Afro-Caribbean, Middle Eastern, South Asian), FHx (first degree)

Previous GDM = OTTG at booking

Otherwise high-risk at 24 - 28 weeks

Fasting glucose 5.6 mmol/L or more

OTTG (75g glucose drink then measure blood glucose after 2hrs) = 7.8mmol/L or more

Mx:

Fasting glucose > 7mmol/L = insulin

Fasting glucose < 7mmol/L: trial lifestyle changes for 1 - 2 weeks then metformin if ineffective

Post-natal complication: neonatal hypoglycaemia if <2mmol/L = IV dextrose + nasogastric feeding), macrosomia (>4.5kg), jaundice (raised bilirubin), congenital heart disease

Question 26

Pre-existing diabetes 1 and 2 in pregnancy

Answer 26

• 5mg folic acid
• Same insulin target levels as GDM
• Type 1 = insulin, type 2 = metformin + insulin (stop all other meds)
• Retinopathy screening = refer to ophthalmology for diabetic retinopathy

Planned delivery 37 - 38+6 weeks

Sliding scale of insulin regime for type 1 diabetes during delivery

Question 27

Placenta accreta

Answer 27

When there is abnormal adhesion of the placenta to the uterine wall. Major cause of PPH!

RFs: previous placenta acrreta, previous endometrial curettage (e.g. miscarriage/abortion), previous C-section, multigravida, LLP/placenta praevia, increased maternal age

Key features: usually asymptomatic, maybe bleeding in third trimester, antenatal ultrasound

Accreta - when the placental villi attaches to the myometrium surface

Increta - when the placental villi invade through the myometrium but does not invade past it

Percenta - when the placental villi invades past the myometrium and the serosa (perimetrium) reaching other organs e.g. bladder

Mx: planned delivery between 35 - 36+6 weeks and antenatal steroids for foetal lung maturation

MDT, might need blood transfusion, intensive care for mother and baby, complex uterine surgery

During C-section, hysterectomy or uterine preserving surgery might be required

Question 28

Induction of labour

Answer 28

If 41 - 42 weeks, pre-eclampsia, diabetes, foetal death then IOL

Bishop score 8 or more = IOL likely successful, less than 8 = cervical priming needed

Membrane sweep from 40 weeks to try and induce labour within 48 hours

Vaginal pessary (Propess) or tablet (prostin) = vaginal prostaglandin E2 stimulates cervical effacement and uterine contraction

Artificial rupture of membrane with oxytocin infusion - after vaginal prostaglandin have been tried

Oral mifepristone and oral misoprostol if intrauterine foetal death

Monitoring using CTG (foetal HR and uterine contractions) + bishop score

Risk is uterine hyperstimulation (prolonged and frequent contractions) - remove vaginal prostaglandin/stop oxytocin infusion, tocolysis with terbutaline

Question 29

Intrauterine growth restriction (IUGR)

Answer 29

Two types:

• Placenta mediated: idiopathic, pre-eclampsia, maternal smoking+ alcohol, anaemia, malnutrition, infection, maternal health conditions

Non-placenta mediated: genetic abnormalities, foetal infections

Features: oligohydramnios, abnormal dopplers, reduced foetal movement, abnormal CTGs

Question 30

Short and long-term complications of IUGR

Answer 30

Short term complication
- Foetal stillbirth/death
- Birth asphyxia
- Hypothermia
- Hypoglycaemia

Long-term complication
- CVD - particularly HTN
- Diabetes
- Obesity
- Mood and behavioural issues

Question 31

Small for gestational age baby (SGA)

Answer 31

Risk factors:
- Previous SGA
- Pre-eclampsia
- Antepartum haemorrhage
- Obesity, hypertension, pre-existing diabetes (metabolic syndrome)
- Smoking
- Older mother > 35
- Antiphospholipid syndrome

Mx: Low-risk: SFH measurement from 24 weeks.

If 3 or more minor RFs, one or more major RFs = serial growth scans with umbilical artery doppler

Consider early delivery if growth static or other problems e.g. abnormal doppler results

Question 32

Vulvar cancer

Answer 32

Most common squamous cell carcinoma

Clinical features: non-healing, ulcer, itching, vulvar pain , =/- lymphadenopathy

Dx: examination of vulva, CT chest, abdomen and pelvis for staging, biopsy to confirm Dx

Mx: stage 1a = wide local excision, more advanced cases need radial vulvectomy and neoadjuvant chemo. Palliative radiotherapy

Question 33

Congenital rubella syndrome

Answer 33

Triad of cataracts, sensorineural hearing loss and congenital heart disease. Blueberry muffin rash

Serology testing of rubella-specific IgM antibodies

Management: MDT - ophthalmology for eye review, cardiology for heart defect, audiology for hearing. Regular follow-up

Question 34

Fibroids

Answer 34

Benign tumours of the smooth muscle of the uterus, oestrogen sensitive

• Intramural - within the myometrium
• Submucosal - just under the endometrium
• Subserosal - just under the perimetrium (serosa)

Key feature: menorrhagia (heavy menstrual bleeding), sub/infertility if large enough, urinary/bowel symptoms

Ix: bimanual exam, transvaginal USS for size and location of fibroids

Management: < 3cm, no distortion and menorrhagia = Mirena coil 1st line, NSAIDs + TXA, COCP

< 3cm + distortion: endometrial ablation, resection in colposcopy

> 3cm +/- distortion - refer to gynae for Ix and Mx:

• Mirena coil
• NSAIDs and TXA
• COCP
• uterine artery embolization
• Myomectomy/hysterectomy

Can give goserelin (GnRH agonist) to women with menorrhagia before surgery to help with bleed

Question 35

Red degeneration of fibroids

Answer 35

Ischaemia, infarction and necrosis of a fibroid due to disrupted blood supply.

Presents as severe abdominal pain and low-grade fever, tachycardia and vomiting, likely 2nd or 3rd trimester

Mx: supportive, rest, fluid and analgesia

Question 36

Intraductal papilloma

Answer 36

Warty lesion that grows inside one of the breast ducts, proliferation of ductal cells

Key features: clear or blood-stained discharge, but often asymptomatic and incidentally found on USS or mammogram

Benign but associated atypical hyperplasia and breast cancer

Dx: triple assessment

MX: surgical excision

Question 37

Mastitis

Answer 37

Mastitis is inflammation of breast tissue with/without infection, can be caused by duct obstruction

• Erythematous, swollen, tender, hard wedge-shaped area on breast
• Fever
• Painful breast

Common in breastfeeding mothers = lactational mastitis

Infective if fever, purulent discharge +/-nipple fissure

Mx: continue breastfeeding, heat packs, express milk, massage, resolve within 12 - 24 hours, if not then flucloxacillin

If non-lactational = analgesia, antibiotics tx underlying eczema or candida infection (broad-spectrum e.g. co-amoxiclav + erythromycin + metronidazole)

Question 38

Breast abscess

Answer 38

Collection of pus in area of breast, can be lactational or non-lactational

Most common cause = staphylococcus aureus

ACUTE = presents within a few days

Key features: swollen, fluctuant (movable fluid on palpation), tender lump, pain, fever, malaise

Mx:
- Continue feeding + expressing
- Refer to on-call surgery team
- Abx
- USS to confirm Dx
- Drainage via needle aspiration or surgical incision + drainage
- Microscopy, culture and sensitivities

Question 39

Pelvic inflammatory disease

Answer 39

STI that spreads from vagina into cervix and upper genital tracts

Causes: 20% caused by chlamydia and gonorrhoea

Dx: clinical dx based on symptoms: bilateral abdominal pain, abnormal vaginal discharge, post-coital bleeding, fever, dysuria, adnexal tenderness, cervical motion tenderness

Mx: IM single dose ceftriaxone + doxycycline + metronidazole

Question 40

Endometriosis

Answer 40

When endometrial tissue grows outside of the uterus - fallopian tubes, bladder, bowel

Key features: dysmenorrhoea, deep dyspareunia, infertility

Ix: transvaginal USS is 1st line, diagnostic laparoscopy is gold standard and can excise/ablate the abnormal tissue

Mx:

• Medical mx: paracetamol/NSAIDs, mefenamic acid, COCP
• Surgical: ablation/excision of endometrial tissue, hysterectomy

Question 41

Pelvic organ prolapse

Answer 41

Pelvic floor - muscle that supports the pelvic organs (uterus, bladder, rectum) , that could become weak leading to the collapse of the pelvic organs.

RFs: multiple vaginal/instrumental deliveries, advanced age, post=menopausal status, chronic disease causing cough, chronic constipation, obesity

Uterine prolapse - uterus descends into vagina
Vault - after hysterectomy, top of vagina descends into vagina
Cystocele - defect in anterior vagina wall allowing bladder to prolapse
Rectocele - defect in posterior vaginal wall allowing rectum prolapse

Key features - feeling of something coming down, heavy dragging sensation, worse on coughing, urinary incontinence, retention, weak stream etc./constipation

Dx: clinical examination via SIm’s speculum

Mx: pelvic floor exercises, lifestyle changes, weight loss, vaginal pessaries to support pelvic floor (shapes include rings, donuts, shelf, cube), surgery = include hysterectomy? (vaginal mesh = avoid according to NICE!)

Question 42

Infertility

Answer 42

Inability of a couple to conceive over 2 years, refer to fertility services after 12 months. If over 35, refer after 6 months.

RFs/causes: advancing age, obesity, genetic abnormalities e.g. 45XO, endometriosis (uterine), fibroids (uterine), PCOS (endocrine), testicular disorders: testicular cancer, oligospermia, retrograde or premature ejaculation

Ix: 7 days before period progesterone (increased if ovulation occurred), FSH high and oestrogen low = ovarian failure. LH:FSH ratio high = PCOS, semen analysis

Secondary care Ix: TV USS, laparoscopy and dye in presence of PID, endometriosis etc.

Mx:
- Conservative: weight loss, reduce stress, exercise, folic acid
- Medical: clomiphene
- Surgical: endometrial ablation/diathermy, removal of fibroids, adhesion in PID, IVF
- Male: surgical sperm retrieval, correct structural defect e.g. blocked vas deferens, intrauterine insemination

Question 43

Herpes simplex virus

Question 44

Chlamydia

Answer 44

Chlamydia trachomatis

RFs: not using barrier conception, multiple sexual partners, under 25

Key features: most asymptomatic in women, dysuria, abnormal vaginal discharge, pelvic pain. In men, most are asymptomatic, dysuria, non-specific uteritis, urethral discharge/discharge

Dx: women: vulvovaginal or endocervical swab for NAAT test (DNA/RNA of chlamydia), men: urethral swab

Mx: doxycycline for 7 days, contraindicated in pregnancy and breastfeeding (azithromycin), no sex for 7 days of tx, refer to GUM for contact tracing

Complications: PID, ectopic pregnancy, epididmyo-orchitis, reactive arthritis

Question 45

Gonorrhoea

Answer 45

Neisseria gonorrhoea, gram-negative diplococcus

RFs: multiple sexual partners, not using barrier contraception

Key features:

• Women (50% symptomatic): odourless purulent yellow/green discharge, dysuria, pelvic pain
• Men (90% symptomatic: odourless purulent yellow/green urethral discharge, dysuria, testicular inflammation/swelling (epididymo-orchitis)

Dx: endocervical, vulvovaginal or urethral swab for NAAT, AND charcoal swab for microscopy, culture and sensitivities due to increased antibiotics resistance

Mx: single dose of IM ceftriaxone if sensitivities not known, single dose 500mg oral ciprofloxacin if sensitivities known, refer to GUM for diagnosis, treatment and contact tracing

Complications: PID, infertility, Fitz-Hugh-Curtis syndrome (liver capsule inflammation + adhesions), epididymo-orchitis, septic arthritis, neonatal conjunctivitis

Question 46

Trichomoniasis

Answer 46

Trichomonas vaginalis, flagellated protozoa

Key features: up 50% asymptomatic, fishy-smelling, frothy + yellow/green discharge, itching, dysuria, balanitis (inflammation of glans penis), strawberry cervix

Dx: charcoal swab from posterior fornix of vagina, urethral swab or first catch urine in men - sent for microscopy, culture and sensitivities

Mx: GUM referral for diagnosis, treatment and contact tracing, tx is with metronidazole

Question 47

Perineal tears

Answer 47

Tear in the perineum during delivery, different degrees

RFs: Asian ethnicity, nulliparity, instrumental, macrosomia, shoulder dystocia

• 1st: external perineum affected
• 2nd: perineal muscle affected
• 3(a): less than 50% of external anal sphincter affected
• 3(b): more than 50% of external anal sphincter
• 3(c): external and internal anal sphincter affected
• 4th degree: rectal mucosa affected

Mx: episiotomy is a perineal cut made anterolaterally to give more space 1st degree: conservative. 2nd: sutures, 3rd - 4th might need repair in theatre

Complications: pain, bleeding, infection, urinary incontinence, anal incontinence (3rd/4th), sexual dysfunction and dyspareunia, mental health impacts

Question 48

Adenomyosis

Answer 48

Endometrial tissue in the myometrium

Key features: menorrhagia, dysmenorrhoea, dyspareunia, infertility, miscarriage, preterm birth, PPROM

Dx: TV USS is 1st line, histology of uterus after hysterectomy is gold standard

Mx: same as menorrhagia

1st line if not wanting pregnancy = Mirena coil

2nd line: COCP or cyclical oral progesterone

1st line if wanting to get pregnant:
- Tranexamic acid if no pain - anti-fibrinolytics
- Mefenamic acid if pain - NSAIDs

Specialist consideration: GnRH to induce menopause like state, uterine artery embolization, endometrial ablation, hysterectomy

Question 49

Cord prolapse

Answer 49

When the umbilical cord descends past the foetal presenting part into the vagina, after rupture of membrane

Biggest RF is foetus in abnormal lie (unstable, transverse, oblique etc.) after 37 weeks, space for cord to descend

Key features: non-reassuring CTG, foetal compromise

Dx: vaginal examination or speculum examination to confirm Dx

Mx: emergency c-section as compromised foetal blood supply = foetal hypoxia, keep cord warm, minimal handling as can cause vasospasm during transfer to theatre. Mother in left lateral position or knee-chest position to reduce pressure on the cord

Question 50

Candidiasis

Answer 50

Yeast infection of the vagina, most common candida albicans

RFs: increased oestrogen exposure (e.g. pregnancy), uncontrolled diabetes

Key features: thick, white vaginal discharge, vulvar itching/discomfort

Dx: clinical and speculum examination

Mx: anti-fungal vaginal pessary (e.g. clotrimazole), anti-fungal cream (clotrimazole) - NICE recommends single intravaginal dose of clotrimazole (5g 10% at night) or a single dose of clotrimazole pessary

Canesten duo is OTC tx, fluconazole pessary and clotrimazole pessary

Question 51

Preterm premature rupture of membrane (PPROM)

Question 52

Antepartum haemorrhage

Answer 52

Most significant causes are placenta praevia, placenta abruption and vasa praevia - associated with high mortality and morbidity

Question 53

Postpartum haemorrhage

Answer 53

Vaginal delivery > 500ml
Caesarean > 1000ml: subdivided into moderate: 1000 - 2000ml, major: > 2000ml

Primary PPH: within 24 hrs of delivery
Secondary PPH: 24 hrs to 12 weeks after delivery

RFs: previous PPH, placenta acrreta, prolonged third stage, multiple pregnancy, pre-eclampsia, obesity, perineal tear or episiotomy

Causes: 4 Ts: Tone - atony (uterus not contracting), Trauma, Tissue (retained placenta), Thrombin (underlying clotting disorder)

Mx:

ABCDE, 2x large bore cannula, fluid resus if shock (tachycardia, hypotensive), group and save and cross match 4 units, oxygen (regardless of sats)

Stop bleeding:

• Rubbing uterus through the abdomen
• Catheterisation (full bladder helps to stem blood loss)
• Uterotonic drugs: e.g. oxytocin inclusion (40 units over 500ml)
• Misoprostol (sublingual) (prostaglandin analogue to stimulate uterine contractions)
• IV TXA - antifibrinolytic to stop bleeding

Surgical: haemostatic sutures, intrauterine balloon tamponade, hysterectomy (last resort)

Secondary PPH likely due to retained placenta or endometritis, USS for retained product and surgical evaluation. Endocervical or high vaginal swab for infection and abx

Question 54

Vasa praevia

Answer 54

When the foetal vessels (two umbilical arteries and one vein) pass over the internal cervical os during pregnancy.

Usually vessels are protected by placenta or umbilical cord, but in vasa praevia, they are exposed.

Risk of rupture when membrane ruptures

Ideally detected on antenatal USS, presents as bleeding in second or third trimester, or detected on vaginal examination at labour as pulsating vessels through membrane

If bleeding after rupture of membrane, then very bad prognosis even with emergency C-section

Mx: corticosteroid from 32 weeks, planned elective c-section from 34 - 36 weeks

Emergency c-section if APH

Question 55

Hyperemesis gravidarum

Answer 55

Severe nausea and vomiting during pregnancy (beyond what is normal):

• More than 5% weight loss from before pregnancy
• Clinical dehydration
• Electrolyte imbalance

Graded with Pregnancy-Unique Quantification of emesis, out of 15

< 7 = mild
7 - 12 = moderate
> 12 = severe

Mild = oral emetics

• Prochlorperazine
• Cyclizine
• Ondansetron
• Metoclopramide

Consider admission
- Ketone in urine dipstick (2+)
- Unable to keep fluids or anti-emetics down
- 5% weight loss compared to pre-pregnancy
- Any other medical conditions that need tx

Mx in hospital: IV fluids with added potassium chloride and anti-emetics (prochlorperazine), daily U+E checks while on IV therapy, thiamine supplement, thromboembolism prophylaxis - compression stockings and LMWH

Question 56

Ovarian torsion

Answer 56

Twisting of an ovary = ischaemia/necrosis of ovary

Key features: severe, sudden onset abdominal pain, low-grade fever, nausea and vomiting, palpable mass if due to mass and tenderness

Dx:

• Transvaginal (transabdominal if not possible) is 1st line, “whirlpool” sign due to free fluid in pelvis and oedema of the ovary.
• Laparoscopic surgery is definitive diagnosis

Mx: detorsion and oophorectomy

Question 57

Antenatal appointments

Answer 57

• Booking appointment - 8 - 10 weeks
• Dating scan - 11 + 2 - 14+1 weeks
• 16 weeks - antenatal appointment to discuss results and plan for future
• 18 - 20 weeks - anomaly scan

25, 28, 31, 34, 36, 28, 40, 41 and 42

Additional milestones:

• OGTT at 24 - 28 weeks
• Anti-D immunisation at 28 and 34 weeks
• USS at 32 weeks for placenta praevia identified at anomaly scans

Routine appointment:

• Urine dipstick for pre-eclampsia
• BP for pre-eclampsia
• Urine for microscopy and culture for asymptomatic bacteriuria
• Measure SFH from 24 weeks
• Ask about baby’s movements
• Abdominal exam for foetal presentation from 36 weeks

Question 58

Screening tests for Down’s syndrome

Answer 58

Combined test (11 - 13 weeks): nuchal translucency, pregnancy-associated plasma protein-A (PPAP-A), B-hCG

Triple test: B-hCG, AFP and unconjugated oestriol

Quadruple test
- Inhibin A
- B-HCG
- AFP
- Unconjugated oestriol

UP: HIT, DOWN: APE

Question 59

Preterm prelabour rupture of membrane

Answer 59

Amniotic sac rupture before 37 weeks gestation.

Ix: speculum examination reveals a pool of amniotic fluid in the vagina

Mx: prophylactic erythromycin 250mg 4x a day for 10 days to prevent chorioamnionitis

Question 60

Bacterial vaginosis

Answer 60

Caused by an imbalance in the vaginal bacterial flora. Usually dominated by lactobacillus, keeps vaginal pH <4.5.

Not STI

But BV = taken over by anaerobes e.g. Gardnerella vaginalis

RFs: multiple sexual partners, recent antibiotics, excessive cleaning products on vagina, smoking, copper coil

Dx: strong, fishy smell, swab and pH paper, pH > 4.5, charcoal swab taken during speculum exam or self, clue cells under microscopy

Mx: metronidazole or clindamycin, advise not to irrigate vagina and only use water to clean so not to disrupt the natural flora