Obstetrics & Gynaecology Flashcards

Question

Stages of Labour

Answer 1

**_First Stage (3 Phases)_** *Latent phase* **_*0 to 3cm* dilation_** of the cervix. This _progresses at around **0.5cm per hour**_. There are ***irregular*** contractions. *Active phase* (pushing) **_*3cm to 7cm* dilation_** of the cervix. This _progresses at around **1cm per hour**_, and there are ***regular*** contractions. *Transition phase* **_*7cm to 10cm* dilation_** of the cervix. This _progresses at around **1cm per hour**_, and there are ***strong and regular*** contractions. Delay in the first stage of labour is considered when there is either: ***Less than 2cm of cervical dilatation in 4 hours*** *Slowing of progress in a multiparous women* **_Second Stage_** _10cm dilatation of the cervix to delivery of the baby._ Dependent on the 3 P's. **Delay** in the second stage is when the *active second stage (pushing)* lasts over: ***2 hours* in a nulliparous woman** ***1 hour* in a multiparous woman** **_Third Stage_** _Delivery of the baby to delivery of the placenta_ Delay in the third stage is defined as: ***\>30 minutes with active management*** ***\>60 minutes with physiological management***

Answer 2

**Physiological management** Uterotonic drugs (oxytocin) are not used The cord is not clamped until the pulsations have ceased The placenta is delivered by maternal effort **Active management** Includes prophylactic administration of oxytocin (10 units) or Syntometrine (ergometrine in combination with oxytocin) Cord clamping and cutting Controlled cord traction Bladder emptying (catheterisation).

Answer 3

**Uterine hyperstimulation** Refers to prolonged and frequent uterine contractions - sometimes called tachysystole potential consequences intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia uterine rupture (rare) **Management** *removing the vaginal prostaglandins* if possible and stopping the oxytocin infusion if one has been started ***Tocolysis with terbutaline***

Answer 4

**Epidemiology** Amniotic sac rupture before the onset of labour and in a preterm pregnancy (\< 37 weeks gestation). **Aetiology** Fetal: prematurity, infection, pulmonary hypoplasia Maternal: chorioamnionitis **Clinical Features** Pooling of amniotic fluid **Investigations** Speculum examination AVOID DIGITAL EXAM (infection) **Management** Prophylactic antibiotics **erythromycin 250mg** qds for ten days, or until labour is established if within ten days. **Induction of labour** may be offered ***from 34 weeks*** to initiate the onset of labour. **Antenatal corticosteroids** (reduce risk of respiratory distress syndrome)

Answer 5

Definition: cervical dilatation **\< 2cm in 4 hours** during active labour **Main Options** Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes Oxytocin infusion Instrumental delivery Caesarean section **Oxytocin is used first-line** to stimulate uterine contractions during labour. It is started at a low rate and titrated up at intervals of at least 30 minutes as required. The aim is for 4 – 5 contractions per 10 minutes. Too few contractions will mean that labour does not progress. Too many contractions can result in fetal compromise, as the fetus does not have the opportunity to recover between contractions.

Answer 6

**Cephalic presentation** head is first **Shoulder presentation** shoulder is first **Breech presentation** _Legs are first_. This can be: **Complete breech** – with hips and knees flexed (like doing a cannonball jump into a pool) *_C-Section_* **Frank breech** – with hips flexed and knees extended, bottom first **Footling breech** – with a foot hanging through the cervix

Answer 7

**FORCEPS (mnemonic)** **F**ully dilated cervix (10cm) **O**ccipitoanterior position (Occipitoposterior position is possible with Kielland forceps and ventouse). The position of the head must be known as incorrect placement can lead to maternal and fetal trauma **R**uptured membranes **C**ephalic presentation **E**ngaged presenting part – the fetal head must not be palpable abdominally and must be below the ischial spines **P**ain relief **S**phincter (bladder) empty – will need catheterisation.

Answer 8

Prematurity (\<34weeks) Face presentation Suspected fetal bleeding disorder such as Haemophilia Fetal predisposition to fracture e.g. osteogenesis imperfecta Maternal HIV or Hepatitis C.

Answer 9

**Standard indications include :** failure to progress in 2nd stage Fetal distress Maternal exhaustion **Special indications (reasons the 2nd stage may need to be shortened) include:** maternal cardiac disease severe PET/eclampsia intra-partum haemorrhage umbilical cord prolapse in 2nd stage.

Answer 10

**Epidemiology** male fetuses predisposed **Aetiology** transverse lie (20% ) / footling breech (15%) / prematurity / abnormality / 2nd twin / multiparity / low birth weight (\<2.5kg) / placenta praevia / long umbilical cord / high fetal station **Clinical Features** abdo exam: ill-fitting (one possible cause) VE: check after rupture of artificial membrane OVERT : cord can be palpated in vaginal canal OCCULT: (hesrt rate changes) dropping cord FUNIC: loops of cord - palpated through membrane **Management** **OVERT**: 1. oxygen 4-6L/minute 2. (see image) 3. Emergency C-section 4. Terbutaline 0.25mg subcutanesouly 5. Vaginal delivery only if delivery imminent (cervix fully dilated) 6. Ensure resus is available if needed post-delivery **OCCULT:** 1. place mom in left lateral position 2. fetal herat rate normal = labour with Oxygen admin. + fetal heart rate monitored 3. fetal heart rate abnormal = C-section FUNIC: decision between C-sec. prior to membrane rupture OR ARM (artificial membrane rupture) + prep C-section (in case cord becomes overt **Complications** death [https://stmungos-ed.com/weekly-themes/obstetrics-gynaecology](https://stmungos-ed.com/weekly-themes/obstetrics-gynaecology)

Answer 11

**Epidemiology** Macrosomia secondary to gestational diabetes. Women should be counselled of this risk. **Aetiology** Anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered **Clinical Features** Difficulty delivering the face and head, and obstruction in delivering the shoulders after delivery of the head. There may be **failure of restitution**, where the head remains face downwards (occipito-anterior) and does not turn sideways as expected after delivery of the head. The **turtle-neck sign** is where the head is delivered but then retracts back into the vagina. **Management** Get help (anaesthetics and paediatrics) **McRoberts manoeuvre** involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way. _Pressure to the anterior shoulder_ involves pressing on the suprapubic region of the abdomen. This puts pressure on the posterior aspect of the baby’s anterior shoulder, to encourage it down and under the pubic symphysis. **Episiotomy** **Rubins manoeuvre** **Wood’s screw manoeuvre** **Complications** Fetal hypoxia (and subsequent cerebral palsy) **Brachial plexus injury** and **Erb’s palsy** (nerve roots _C5 & C6_) Perineal tears Postpartum haemorrhage **[https://stmungos-ed.com/weekly-themes/obstetrics-gynaecology](https://stmungos-ed.com/weekly-themes/obstetrics-gynaecology)**

Answer 12

**Epidemiology** **RFs include:** Low lying placenta, IVF pregnancy & multiparity **Aetiology** _Fetal vessels_ are within the fetal membranes (chorioamniotic membranes) and travel _across the internal cervical os._ **Two forms:** **Type I** – fetal vessels are _exposed as a velamentous umbilical cord_ **Type II** – fetal vessels are _exposed as they travel to an accessory placental lobe_ **Clinical Features** Vasa praevia may be diagnosed by _US during pregnancy_. This is the ideal scenario, as it _allows a planned C-section_ to reduce the risk of haemorrhage. However, ultrasound is _not reliable_, and it is often not possible to diagnose antenatally. It may present with _antepartum haemorrhage_, with bleeding during the _2nd or 3rd trimester_ of pregnancy. It may be detected by _vaginal examination during labour_, when pulsating fetal vessels are seen in the membranes through the dilated cervix. Finally, it may be _detected during labour_ when _fetal distress_ and _dark-red bleeding_ occur following rupture of the membranes. This carries a very high fetal mortality, even with emergency caesarean section. **Management** **Asymptomatic women** **Corticosteroids**, given _from 32 weeks gestation_ to mature the fetal lungs **Elective C-section**, planned for _34 – 36 weeks_ gestation **Antepartum Haemorrhage** _Emergency C-section_ is required to deliver the fetus before death occurs. After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.

Answer 13

**Epidemiology** Amniotic fluid embolisation is a rare (2 per 100,000 deliveries) but severe condition **Aetiology** Amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery. The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism. The mortality rate is around 20% or above. **Risk Factors** Increasing maternal age Induction of labour C-Section Multiple pregnancy **Clinical Features** Amniotic fluid embolisation usually presents around the time of labour and delivery, but can be postpartum. It can present similarly to _sepsis, PE or anaphylaxis_, with an acute onset of symptoms of: Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest **Management** Supportive Medical emergency – _get help immediately_. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to ICU. The initial management of any acutely unwell patient is with an **ABCDE** approach, assessing and treating: **A** – Airway: Secure the airway **B** – Breathing: Provide oxygen for hypoxia **C** – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage **D** – Disability: Treat seizures and consider other neurological deficits **E** – Exposure

Answer 14

**Epidemiology** Antepartum haemorrhage is defined as _bleeding after 24 weeks_. **Aetiology** local bleeding or problems with the placenta. Placental problems include placental abruption, placenta praevia and vasa praevi **Clinical Features** **Minor APH**: \< 50 mls and stopped **Major APH**: _50-1000 mls_, _NO sign of shock_ **Massive APH**: _\>1000 mls_ OR _signs of shock_. **Investigations** The assessment of any APH should involve a good history, examination and initiating early management. **Basic observations:** are there features of shock? **Abdominal palpation:** does the uterus feel stony hard suggesting abruption? **Speculum:** is the source obvious in vagina, on cervix or coming through external os? **Consider cervical assessment:** is this early labour? Do not perform vaginal examination if known placenta praevia. **Management** _ABCDE_ approach Fluid resuscitation Blood products (as needed) Escalate to multidisciplinary seniors (obstetrics, anaesthetics, midwifery, neonatal). Mother and baby stable - discuss with a consultant, consider induction of labour Induction of labour is by artificial rupture of membranes & syntocinon The aim should be for a vaginal delivery if possible The same management is considered if the mother is stable with intrauterine death (IUD) Mother and baby unstable - discuss with consultant, emergency C-section Anticipate post-partum haemorrhage

Answer 15

**Epidemiology** Pospartum haemorrhage (PPH) is defined as vaginal bleeding _from delivery of baby to 24hrs postpartum_. Leading cause of maternal death worldwide. **Aetiology** PPH can be classified as either primary or secondary. **Primary PPH**: is defined as vaginal bleeding that _occurs from delivery of baby to 24 hrs postpartum_. **Secondary PPH**: is defined as vaginal bleeding from _24 hrs postpartum to 12 weeks postpartum_. **Primary PPH causes include 4 T's:** **T**one **(most common)**: reduction in _uterine tone_, typically the result of _prolonged labour, macrosomia, twins, uterine anomalies_ or _polyhydraminos_. ‘Active’ management of the third stage reduces the risk (IM Oxytocin, Controlled cord traction (CCT) of placenta to aid delivery) **T**rauma**:** usually due to _episiotomy_, _extensive perineal tears_ or _uterine_ _rupture_. **T**issue**:** refers to _retained placenta_ and _placenta_ _accreta_ (invades . **T**hrombin**:** refers to either _pre-existing_ or _newly developed_ _coagulopathies_. Coagulopathies may also result from significant APH or PPH! **Secondary PPH** occurs due to retained products of conception and endometritis (endometrial infection). **Clinical Features** Severity **Minor:** 500-1000mls **Moderate:** 1000-2000mls **Severe:** \> 2000mls. **General Management** Anticipate those at higher risk: Deliver on a doctor-led unit IV access Bloods: FBC, G&S, Crossmatch in labour **Specific Management (Primary PPH)** **Uterine massage:** placing one hand on lower abdomen and performing _repetitive massage and squeezing_ movements **Bimanual compression:** place one hand on the lower abdomen and one hand in the vagina. Push against the body of the uterus with the hand in the vagina, while the other hand compresses the fundus. **Uterotonic Drugs:** _IV syntocino_n (oxytocin) 10 units or _IV ergometrine_ 500 micrograms _IM carboprost_ _(_avoid in asthmatics_)_ the RCOG state that the _intrauterine balloon tamponade_ is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage **Other surgical options:** B-Lynch suture, ligation of the uterine arteries or internal iliac arteries **Tranexamic Acid** **Massive Obstetric Haemorrhage Call (2222)** **Uncontrolled haemorrhage** (large volumes of blood loss) then a _hysterectomy_ is sometimes performed as a life-saving procedure **Secondary PPH** In cases of secondary PPH, it is important to _assess for infection_ with _high vaginal and endocervical swabs_. Concurrently, an _US_ should be completed looking for any _RPOC or collections_. Mothers may need _antibiotics +/- surgical evacuation_ of retained products of conception (ERPC).

Answer 16

**Epidemiology** Bleeding in early pregnancy is defined as vaginal bleeding \< 24 weeks. **Aetiology** miscarriage ectopic pregnancy implantation bleeding cervical ectropion vaginitis trauma polyps **Clinical Features** **Management** **\>= 6 weeks gestation** If the pregnancy is \> 6 weeks gestation (or of uncertain gestation) and the woman _has bleeding_ she should be referred to _EPAC_. **\< 6 weeks gestation** If the pregnancy is \< 6 weeks gestation and women have _bleeding_, but _NO pain or risk factors for ectopic pregnancy_, then they can be _managed_ _expectantly_. These women should be advised: to _return if bleeding continues or pain_ develops to _repeat a urine pregnancy test after 7–10 days_ and to return if it is positive a negative pregnancy test means that the pregnancy has miscarried

Answer 17

Eclampsia **AVOID:** IV Lorazepam. **USE:** IV magnesium sulphate Genito-urinary Infections (pregnancy & breastfeeding) **AVOID:** Doxycycline. **USE:** Azithromycin **Drugs to AVOID:** NSAIDs (premature closure of DA) ACE-I & ARBs (hypcalvaria & olgohydraminos) Opiates (NAS - withdrawal) Sodium Valporate (NTDs) Lithium (Ebstein's anomaly) Isotretinoin (Roaccutane; miscarriage) SSRIs - must be balanced with risks and benefits

Answer 18

**Indications for Anti-D** _Within 72 hours_ of _sensitising event_ (e.g. fetal-maternal haemorrhage) Pregnancy \< 12 weeks if _ectopic, molar, therapeutic termination_ Prophylactic dose at 28 weeks or at 28 and 34 weeks (no previous sensitisation) _Within 72 hours_ of delivery if _neonate is rhesus positive_ based on cord blood Intrauterine death and no fetal sample possible

Answer 19

Mnemonic (**FORCEPS**) **F**ully dilated cervix generally the second stage of labour must have been reached **O**A position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure **R**uptured Membranes **C**ephalic presentation **E**ngaged presenting part i.e. head at or below ischial spines the _head must not be palpable abdominally_ **P**ain relief **S**phincter (bladder) empty this will usually require catheterization

Answer 20

**Epidemiology** Vaginal candidiasis ('thrush') is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species. **Aetiology** The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop: _diabetes mellitus_ drugs: antibiotics, steroids _pregnancy_ _immunosuppression_: HIV **Clinical Features** 'cottage cheese', non-offensive discharge vulvitis: superficial dyspareunia, dysuria itch vulval erythema, fissuring, satellite lesions may be seen **Investigations** A _high vaginal swab is NOT routinely_ indicated if the clinical features are consistent with candidiasis **Management** options include local or oral treatment local treatments include clotrimazole pessary (e.g. _clotrimazole 500mg_ PV stat) oral treatments include _itraconazole 200mg PO_ bd for 1 day OR _fluconazole 150mg_ PO stat if _pregnant then only local treatments_ (e.g. cream or pessaries) may be used - oral treatments are contraindicated **Recurrent vaginal candidiasis** BASHH define recurrent vaginal candidiasis as _4 or more episodes/year_ compliance with previous treatment should be checked confirm the diagnosis of candidiasis _high vaginal swab for microscopy and culture_ consider a _blood glucose test_ to exclude diabetes exclude differential diagnoses such as lichen sclerosus consider the use of an induction-maintenance regime **Induction:** _oral fluconazole every 3 days for 3 doses_ **Maintenance:** oral fluconazole weekly for 6 months

Answer 21

The referral criteria for a _2-week-wait urgent cancer referral_ for endometrial cancer is: _Postmenopausal bleeding_ (more than 12 months after the last menstrual period) NICE also recommends referral for a _TVUS in women \> 55 years_ with: Unexplained _vaginal discharge_ _Visible haematuria_ plus raised platelets, anaemia or elevated glucose levels

Answer 22

**Epidemiology** Cancer of the endometrium. **Aetiology** Predominantly adenocarcinoma (80%). Oestrogen-dependent cancer. Be aware of endometrial hyperplasia (typical or atypical) - precancerous condition which involves thickening of the endometrium. Can be treated using progestogens: IUS (mirena) or oral progestogens (medroxyprogesterone or levonorgestrel). Main RFs related to unopposed oestrogen: _Increased age_ Earlier onset of menstruation _Late menopause_ Oestrogen-only HRT No or fewer pregnancies _Obesity_ (adipose produces oestrogen) _PCOS (_corpus luteum fails to secrete progesterone) _Tamoxifen_ (oestrogenic effects on endometrium) Additionally: TIIDM, HNPCC/Lynch syndrome. **Protective Factors:** COCP Mirena coil Increased pregnancies Cigarette smoking **Clinical Features** _PMB_ PCB IMB Unusually HMB Abnormal vaginal discharge Haematuria Anaemia Raised platelet count **Investigations** TVUS (_\<4mm_ is normal post-menopause) Pipelle biopsy Hysteroscopy (endometrial biopsy) **Management** _Staging_ 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 The usual treatment for stage 1 and 2 endometrial cancer is a _total abdominal hysterectomy with bilateral salpingo-oophorectomy_, also known as a TAH and BSO (removal of uterus, cervix and adnexa). Other treatment options depending on the individual presentation include: A _radical hysterectomy_ involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina _Radiotherapy_ _Chemotherapy_ Progesterone may be used as a hormonal treatment to slow the progression of the cancer

Answer 23

**Simple endometrial hyperplasia _without atypia_:** high dose progestogens with _repeat sampling in 3-4 months_. The levonorgestrel IUS may be used. **Atypia:** hysterectomy is usually advised

Answer 24

**Epidemiology** Affects younger women (25-29) of reproductive years. Squamous (80%) and adenocarcinoma (20%). **Aetiology** Strongly associated with HPV serotypes 16, 18 & 33 (inhibit tumour suppressor genes p53 and pRb with E6 and E7 proteins respectively). Other RFs: Smoking HIV (offered yearly smear) _Early first intercourse_, _many sexual partners_ _High parity_ Lower socioeconomic status COCP (\>5 years) **Clinical Features** Asymptomatic Abnormal vaginal bleeding (IMB, PCB or PMB) Vaginal discharge Pelvic pain Dyspareunia (pain or discomfort with sex) **Investigations** Speculum examination Colposcopy (urgent cancer referral) if any of the following features observed: Ulceration Inflammation Bleeding Visible tumour **Management** Stage-dependent **CIN & early-stage 1A:** _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:** combination of surgery, radiotherapy, chemotherapy and palliative care **Advanced:** Pelvic exenteration is an operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life. **Metastatic/Recurrent: Bevacizumab (Avastin)** is a mAb that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer. It targets VEGF-A, which is responsible for the development of new blood vessels.

Answer 25

Cervical intraepithelial neoplasia (CIN) is a grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening). The grades are: **CIN I:** mild dysplasia, 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:** severe dysplasia, _very likely to progress to cancer_ if untreated CIN III is sometimes called cervical carcinoma in situ.

Answer 26

**Epidemiology** Affects up to 50% of menstruating women and usually appears _within 1-2 years of the menarche_. **Aetiology** Excessive endometrial prostaglandin production **Investigations** Clinical diagnosis. **Clinical Features** Excessive pain during the menstrual period Pain typically starts just before or within a few hours of the period starting Suprapubic cramping pains which may radiate to the back or down the thigh **Management** _NSAIDs_ such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production _COCP_ are used second line

Answer 27

**Epidemiology** Secondary dysmenorrhoea typically develops _many years after the menarche_ and is the result of an _underlying pathology_. **Aetiology** Endometriosis Adenomyosis PID IUD (copper coil) Fibroids **Investigations** Clinical diagnosis. **Clinical Features** Excessive pain during the menstrual period In contrast to primary dysmenorrhoea the pain usually _starts 3-4 days before_ the _onset of the period_ **Management** Referall to gynaecology.

Answer 28

**Epidemiology** Late presentation due to non-specific symptoms. 70% of patients present with advanced disease. RFs (increased ovulation) include: Age (peaks age 60) _BRCA1 and BRCA2_ genes (consider the family history) Increased number of ovulations _Obesity_ _Smoking_ Recurrent use of _clomifene_ _Early menarche_ _Late menopause_ _Nullparity_ (no pregnancies) **Aetiology** 3 Main types _Epithelial Cell Tumours_: commonest form Dermoid Cysts (Germ Cell tumours): _benign teratomas_ formed from germ cells. Contain various types of tissue (skin, teeth, hair, bone). Associated with ovarian torsion. May cause raised aFP and hCG. _Sex Cord-Stromal Tumours:_ rare tumours which can be benign or malignant. Arise from stroma (connective tissue) or sex cords (embryonic). Several types including sertoli-leydig cell tumours and granulosa cell tumours. _Metastasis:_ from cancer elsewhere. _Krunkenberg tumour_ refers to metastasis in the ovary, usually from _GI tract cancer_. Characteristic _'signet-ring' appearance_ on histology. _Protective factors:_ COCP, Breastfeeding and pregnancy. **Investigations** The initial investigations in primary or secondary care are: _CA125_\* blood test (\>35 IU/mL is significant) - non-specific test _Pelvic ultrasound_ The risk of malignancy index (RMI) estimates the risk of an ovarian mass being malignant, taking account of three things: Menopausal status, US findings & CA125 level Women _under 40 years_ with a _complex ovarian mass_ (solid and irregular) require tumour markers for a possible germ cell tumour: _Alpha-fetoprotein (α-FP)_ _Human chorionic gonadotropin (HCG)_ \*Can be raised in endometriosis, fibroids, adenomyosis, pelvic infection, LD or pregnancy. **Clinical Features** _Non-specific_ features of abdo bloating, early satiety, poor appetite, pelvic pain, urinary symptoms (frequency/urgency), weight loss, abdo/pelvic mass and ascites. NB: an ovarian mass may press on the obturator nerve and cause referred hip or groin pain (the obturator nerve passes along the inside of the pelvis, lateral to the ovaries, where an ovarian mass can compress it). _Indications for Urgent referral (2-week)_ Ascites Pelvic mass (unless clearly due to fibroids) Abdominal mass **Management** Gynae MDT - surgery and chemotherapy The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage ovarian cancer. A very simplified version of this staging system is: 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 29

**Epidemiology** RFs include: Not using barrier contraception, Multiple sexual partners, Younger age, Existing STIs, Previous PID and IUD (copper coil). **Aetiology** Infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of _tubular infertility_ and _chronic pelvic pain_. **Most cases caused by one of the STIs:** _Neisseria gonorrhoeae_ tends to produce more severe PID _Chlamydia trachomatis_ _Mycoplasma genitalium_ **Less commonly be caused by non-STIs, such as:** _Gardnerella vaginalis_ (associated with bacterial vaginosis) _Haemophilus influenzae_ (a bacteria often associated with respiratory infections) _Escherichia coli_ (an enteric bacteria commonly associated with urinary tract infections) **Clinical Features** Pelvic or lower abdominal pain Abnormal _vaginal discharge_ _Abnormal bleeding_ (IMB or PCB) Pain during sex (dyspareunia) Fever Dysuria **Examination findings may reveal:** Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Patients may have a fever and other signs of sepsis. **Investigations** Testing for causative organisms and other STIs: _NAAT swabs_ for gonorrhoea and chlamydia NAAT swabs for Mycoplasma genitalium if available HIV test Syphilis test H_igh vaginal swab_ for _BV, candidiasis and trichomoniasis_. A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID. A _pregnancy test_ should be performed on sexually active women presenting with lower abdominal pain to _exclude an ectopic pregnancy_. _Inflammatory markers_ (CRP and ESR) are raised in PID and can help support the diagnosis. **Management** Refer to _GUM specialist_ service for management and _contact tracing_. BASSH suggest: _IM Ceftriaxone_ (gonorrhoea coverage), _Doxycycline_ (chlamydia and mycoplasma genitalium) and _Metronidazole_ (anaerobes i.e. gardnerella vaginalis).

Answer 30

A complication of PID. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood. Results in RUQ pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Answer 31

**Epidemiology** **Aetiology** **Clinical Features** **Investigations** **Management** **Management**

Answer 32

**Epidemiology** Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with _proteinuria._ It occurs after 20 weeks gestation. **Aetiology** Spiral arteries of the placenta form abnormally (due to impaired lacunae formation), leading to a high vascular resistance in these vessels and ultimately poor placental perfusion leading to oxidative stress, systemic inflammation and imaired endothelial function. **Clinical Features** Triad of HT, Proteinuria and Oedema **Investigations** All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with: Blood pressure Symptoms Urine dipstick for proteinuria Diagnosis of Pre-eclampsia involves: _BP 140/90_ PLUS any of: _Proteinuria_ (1+ or more on urine dipstick) _Organ dysfunction_ (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) _Placental dysfunction_ (e.g. fetal growth restriction or abnormal Doppler studies) **Management** **Prophylaxis:** _Aspirin from 12 weeks_ until birth in women with a _single high risk factor_ or _two or more moderate_ risk factors. **_Medical management of pre-eclampsia is with:_** _Labetolol_ is first-line as an antihypertensive _Nifedipine_ (modified-release) is commonly used second-line _Methyldopa_ is used third-line (needs to be stopped within two days of birth) _IV hydralazine_ may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia _IV magnesium sulphate_ is given during labour and in the 24 hours afterwards to prevent seizures _Fluid restriction_ is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload **Following delivery:** Enalapril (first-line) Nifedipine or amlodipine (first-line in black African or Caribbean patients) Labetolol or atenolol (third-line) **Eclampsia** Eclampsia refers to the seizures associated with pre-eclampsia. _IV magnesium sulphate_ is used to manage seizures associated with pre-eclampsia. **HELLP Syndrome** HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics: _Haemolysis_ _Elevated Liver enzymes_ _Low Platelets_

Answer 33

_High-risk factors:_ Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease _Moderate-risk factors:_ Older than 40 BMI \> 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia These risk factors are used to determine which women are offered aspirin as prophylaxis against pre-eclampsia. Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

Answer 34

**Epidemiology** Hypertension occurring after 20 weeks gestation, without proteinuria. **Clinical Features** systolic \> 140 mmHg or diastolic \> 90 mmHg or an increase above booking readings of \> 30 mmHg systolic or \> 15 mmHg diastolic **Investigations** All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with: BP Symptoms Urine dipstick for proteinuria **Management** **Prophylaxis:** women who have either _1 high RF_ or _2 or more moderate RFs_ for developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby. **Medical management of pre-eclampsia is with:** _Labetolol_ is first-line as an antihypertensive _Nifedipine_ (modified-release) is commonly used second-line _Methyldopa_ is used third-line (needs to be stopped within two days of birth) _IV hydralazine_ may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia _IV magnesium sulphate_ is given during labour and in the 24 hours afterwards to prevent seizures _Fluid restriction_ is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload **Following delivery:** Enalapril (first-line) Nifedipine or amlodipine (first-line in black African or Caribbean patients) Labetolol or atenolol (third-line)

Answer 35

**Epidemiology** Significant cause of death in obstetrics. **Aetiology** _{RFs for VTE in pregnancy:} _Smoking _{Parity ≥ 3} _{Age > 35 years} _{BMI > 30} _{Reduced mobility} _{Multiple pregnancy} _{Pre-eclampsia} _{Gross varicose veins} _Immobility _{Family history of VTE} _{Thrombophilia} _{IVF pregnancy} **Clinical Features** _DVT _{Unilateral calf/leg swelling (>3 cm difference between calves)} _{Dilated superficial veins} _{Tenderness to the calf (particularly over the deep veins)} _Oedema _{Colour changes to the leg} _PE _SOB _{Cough with or without haemoptysis} _{Pleuritic chest pain} _Hypoxia _{Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)} _{Raised RR} _{Low-grade fever} _{Haemodynamic instability causing hypotension} **Investigations** _Doppler US_ for DVT - repeat US at day 3 & 7 in patients with negative US but high index of suspicion _Chest X-ray_ and _ECG_ for suspected PE. _{NB: Patients with a suspected DVT and PE should have a Doppler ultrasound initially, and if a DVT is present, they DO NOT require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same.} **Definitive diagnosis** _CTPA_ with contrast - increased risk of maternal breast cancer. _V/Q Scan_ - deficit in perfusion will be observed. Increased risk of childhood cancer. **Management** **Prophylaxis with LMWH** (enoxaparin, dalteparin and tinzaparin) _28 weeks_ if there are _three RFs_ _First trimester_ if there are _four or more of these RFs_ _LMWH_ should be _started immediately_, before confirming the diagnosis in patients _where DVT or PE is suspected and there is a delay_ in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis. **Contraindications to LMWH** Intermittent pneumatic compression Anti-embolic compression stockings **Massive PE and Haemodynamic compromise** Unfractionated heparin Thrombolysis Surgical embolectomy

Answer 36

**Epidemiology** Frequently seen in post-menopausal women. Peak incidence 50-60 years. **Aetiology** Caused by reduction in levels of oestrogen. The vaginal mucosa becomes drier, thinner and more easily broken, which can lead to epithelial irritation and inflammation. **Clinical Features** Vaginal dryness Local irritation (pruritus, pressure and burning) Painful intercourse Vaginal bleeding (PCB or haematuria) Urinary symptoms - increased frequency, recurrent UTIs, incontinence (stress and urge) Vaginal discharge (white or yellow) **Investigations** Pelvic examination with bimanual and speculum. _TVUS_ - _\>4mm_ is considered _abnormal_ in post-menopausal women in which case _pipelle biopsy_ is indicated. **Management** **1st Line:** Topical oestrogens - creams, rings and pessaries (take 3 weeks to have any effect). Considered safe long-term. Systemic HRT - side-effects/risks will need to be discussed. Topical oestrogens may be required alongside as HRT can cause vaginal dryness. Other options include topical lubricants and moisturisers.

Answer 37

**Epidemiology** Gestational diabetes refers to diabetes triggered by pregnancy. **Aetiology** Reduced insulin sensitivity during pregnancy, resolves following birth. **Clinical Features** Large for dates fetus and macrosomia (risk of shoulder dystocia). Increased risk of T2DM following pregnancy. Polyhydramnios (increased amniotic fluid) Glucose on urine dipstick **Investigations** Individuals with RFs\* should be screened with an _Oral Glucose Tolerance Test (OGTT)_ at 24-48 weeks gestation. \*Includes Previous gestational diabetes Previous macrosomic baby (_≥ 4.5kg_) _BMI \> 30_ Ethnic origin (_black Caribbean_, _Middle Eastern_ and _South Asian_) _FHx of diabetes_ (first-degree relative) **Normal results are:** _Fasting:_ \< 5.6 mmol/l _At 2 hours:_ \< 7.8 mmol/l Remember as 5-6-7-8. **Management** **Fasting glucose \< 7 mmol/l:** trial of _diet and exercise for 1-2 weeks_, followed by _metformin, then insulin_ **Fasting glucose \>7 mmol/l:** start _insulin ± metformin_ **Fasting glucose \> 6 mmol/l plus macrosomia (or other complications):** start _insulin ± metformin_ _Glibenclamide (a sulfonylurea)_ is suggested as an option for women who _decline insulin or cannot tolerate metformin_. _Blood sugar level targets_ Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l _Avoiding levels of 4 mmol/l or below_

Answer 38

Before becoming pregnant, women with existing diabetes should aim for good glucose control. They should take _5mg folic acid from preconception until 12 weeks gestation_. Women with existing TI & TIIDM should aim for the same target insulin levels as with gestational diabetes\*. Women with TIIDM are managed using metformin and insulin, and other oral diabetic medications should be stopped. **Blood sugar level targets\*** Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l Avoiding levels of 4 mmol/l or below Retinopathy screening should be performed shortly after booking and at 28 weeks gestation. This involves referral to an ophthalmologist to check for diabetic retinopathy. Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required. NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth upto 40 + 6). A _sliding-scale insulin_ regime is considered _during labour_ for women with _T1DM_. A dextrose and insulin infusion is titrated to blood sugar levels, according to the local protocol. Also considered for _women with poorly controlled blood sugars with gestational or type 2 diabetes_.

Answer 39

**Epidemiology** Average _age of 51 years_, although this can vary significantly. **Aetiology** Menopause is a retrospective diagnosis, made after a woman has had _no periods for 12 months_. It is defined as a permanent end to menstruation. Menopause is caused by a _lack of ovarian follicular function_, resulting in changes in the sex hormones associated with the menstrual cycle: _Oestrogen and progesterone levels are low_ _LH and FSH levels are high_, in response to an _absence of negative feedback_ from oestrogen due to decline in ovarian follicles. _Risks _{Cardiovascular disease and stroke} _Osteoporosis _{Pelvic organ prolapse} _{Urinary incontinence} **Clinical Features** A lack of oestrogen in the perimenopausal period leads to symptoms of: _Hot flushes_ _Emotional lability_ or low mood Premenstrual syndrome _Irregular periods_ Joint pains Heavier or lighter periods Vaginal dryness and atrophy _Reduced libido_ **Investigations** **Clinical Diagnosis alone (no Ix required):** A diagnosis of perimenopause and menopause can be made in women _\>45 years with:_ Typical symptoms Ammenorhoea for 12m and not using hormonal contraception Symptoms alone if no uterus **FSH blood test:** Women aged \>45 with atypical symptoms Women \<40 years with suspected Premature Ovarian Insufficiency (POI) Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle **Management** Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment. Management of symptoms depends on the severity, personal circumstances and response to treatment. Options include: _No treatment_ _Hormone replacement therapy_ (HRT) _Tibolone_, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) _Clonidine_, which act as agonists of alpha-adrenergic and imidazoline receptors _Cognitive behavioural therapy_ (CBT) _SSRI_ antidepressants, such as fluoxetine or citalopram _Testosterone_ can be used to treat reduced libido (usually as a gel or cream) _Vaginal oestrogen cream_ or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) _Vaginal moisturisers_, such as Sylk, Replens and YES **Lifestyle Measures** Hot flushes and night sweats — regular exercise, weight loss (if applicable), wearing lighter clothing/layers of clothing, turning down central heating, sleeping in a cooler room, using fans, reducing stress, and avoiding possible triggers (such as spicy foods, caffeine, smoking, and alcohol). See the CKS topics on Obesity, Smoking cessation, and Alcohol - problem drinking for more information. Sleep disturbances — avoiding exercise late in the day and maintaining a regular bedtime. See the CKS topic on Insomnia for more information. Low mood and anxiety — adequate sleep, regular physical activity, and relaxation exercises. Cognitive symptoms — exercise and good sleep hygiene.

Answer 40

Women need to use effective contraception for: **\<50 years**: t_wo years after LMP_ **\>50 years**: _one year after LMP_ Good contraceptive options (UKMEC 1; no restrictions) for women approaching the menopause are: Barrier methods Mirena or copper coil POP Progesterone (Nexplanon) implant Progesterone depot injection (\<45 years; over this age is associated with osteoporosis and weight gain) Sterilisation

Answer 41

**Epidemiology** **Aetiology** **Clinical Features** **Investigations** **Management**

Answer 42

**Epidemiology** Obstetric cholestasis is a relatively common complication of pregnancy, occurring in around 1% of pregnant women. It usually develops later in pregnancy (i.e. Third trimester - after 28 weeks), and is thought to be the result of increased oestrogen and progesterone levels. **Aetiology** In obstetric cholestasis, the _outflow of bile acids is reduced_, causing them to _build up in the blood_, resulting in the classic symptoms of itching (pruritis). Obstetric cholestasis is associated with an _increased risk of stillbirth_. **Clinical Features** _Itching (pruritis)_ is the main symptom, particularly affecting the _palms of the hands and soles of the feet_. Other symptoms are related to cholestasis and outflow obstruction in the bile ducts: Fatigue Dark urine Pale, greasy stools Jaundice **Investigations** Obstetric cholestasis will cause: Abnormal liver function tests (LFTs), mainly ALT, AST and GGT Raised bile acids TOM TIP: It is _normal for alkaline phosphatase (ALP) to increase in pregnancy_. This is because the placenta produces ALP. A rise in ALP without other abnormal LFT results is usually due to placental production of ALP, rather than liver pathology. **Management** **1st Line:** Ursodeoxycholic acid Symptoms of itching can be managed with: _Emollients_ (i.e. calamine lotion) to soothe the skin _Antihistamines_ (e.g. chlorphenamine) can help sleeping (but does not improve itching) _Water-soluble vitamin K_ can be given if clotting (prothrombin time) is deranged _Planned delivery after 37 weeks_ may be considered, particularly when the LFTs and bile acids are severely deranged

Answer 43

**Epidemiology** Rare condition that occurs in the third trimester of pregnancy. **Aetiology** Rapid accumulation of fat within the liver cells (hepatocytes), causing acute hepatitis. There is a high risk of liver failure and mortality, for both the mother and fetus. Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency resulting in impaired fatty acid metabolism. Autosomal recessive. **Clinical Features** The presentation is with vague symptoms associated with hepatitis : General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia (lack of appetite) _Ascites_ **Investigations** LFTs will reveal _raised ALT and AST._ TOM TIP: In your exams, elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential. **Management** Acute fatty liver of pregnancy is an _obstetric emergency_ and _requires prompt admission and delivery of the baby_. Most patients will recover after delivery. Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

Answer 44

**Epidemiology** Pregnant women are at higher risk of developing lower urinary tract infections and pyelonephritis. **Aetiology** Commonest causes are E.Coli & Klebsiella pneumoniae (gram-negative anaerobic rod). Risk of pre-term delivery. **Clinical Features** _Lower urinary tract infections_ present with: Dysuria (pain, stinging or burning when passing urine) Suprapubic pain or discomfort Increased frequency of urination Urgency Incontinence Haematuria _Pyelonephritis presents_ with: Fever (more prominent than in lower urinary tract infections) Loin, suprapubic or back pain (this may be bilateral or unilateral) Looking and feeling generally unwell Vomiting Loss of appetite Haematuria Renal angle tenderness on examination **Investigations** Pregnant women are tested for _asymptomatic bacteriuria_ at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S). **Management** Urinary tract infection in pregnancy requires _7 days of antibiotics_. The antibiotic options are: _Nitrofurantoin_ (**avoid in the third trimester**) _Amoxicillin_ (only after sensitivities are known) _Cefalexin_ _{Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).} _{Trimethoprim needs to be avoided in the first trimester as it is works as a folate antagonist. Folate is important in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.}

Answer 45

**Epidemiology** Half of women with BV are asymptomatic. **Aetiology** Overgrowth of bacteria in the vagina, specifically anaerobic bacteria. Reduced numbers of lactobacilli, leads to more alkaline environment. Organisms: Gardnerella vaginalis (most common) Mycoplasma hominis Prevotella species RFs. Multiple sexual partners (although it is not sexually transmitted) Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) Recent antibiotics Smoking Copper coil **Clinical Features** _Fishy-smelling watery grey or white vaginal discharge_. Itching, irritation and pain are not typically associated with BV and suggest an alternative cause or co-occurring infection. **Investigation** A _speculum examination_ can be performed to confirm the typical discharge, complete a high vaginal swab and exclude other causes of symptoms. **Management** Asymptomatic BV does not usually require treatment. Additionally, it may resolve without treatment. _Metronidazole\*_ is the antibiotic of choice for treating bacterial vaginosis. Metronidazole specifically targets anaerobic bacteria. This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice. \*Avoidance of alcohol is necessary - causes a disulfiram-like reaction (n/v, flushing, shock)

Answer 46

**Epidemiology** Usually after a course of antibiotics. **Aetiology** Vaginal candidiasis is commonly referred to as “thrush”. It refers to vaginal infection with a yeast of the Candida family. Commonest is _Candida albicans_. **Clinical Features** _Thick, white discharge_ that does not typically smell _Vulval and vaginal itching_, irritation or discomfort **Investigation** Often treatment for candidiasis is _started empirically_, based on the presentation. Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between BV and trichomonas (pH \> 4.5) and candidiasis (pH \< 4.5). _A charcoal swab with microscopy_ can confirm the diagnosis. **Management** Treatment of candidiasis is with antifungal medications. These can be delivered in several ways: _Antifungal cream_ (i.e. clotrimazole) inserted into the vagina with an applicator _Antifungal pessary_ (i.e. clotrimazole) _Oral antifungal tablets_ (i.e. fluconazole) Warn women that antifungal creams and pessaries _can damage latex condoms and prevent spermicides from working_, so alternative contraceptive is required for at least five days after use.

Answer 47

**Epidemiology** Chlamydia is the most common sexually transmitted infection in the UK and a significant cause of infertility. **Aetiology** Chlamydia trachomatis is a _gram-negative bacteria_. It is an _intracellular organism_, meaning it enters and replicates within cells before rupturing the cell and spreading to others. Being young, sexually active and having multiple partners increase the risk of catching the infection. A large number of cases are asymptomatic (50% in men and 75% in woman). Asymptomatic patients can still pass the infection on. **Clinical Features** The majority of cases of chlamydia in women are _asymptomatic_. **Consider chlamydia in women that are sexually active and present with:** _Abnormal vaginal discharge_ Pelvic pain _Abnormal vaginal bleeding_ (IMB or PCB) _Painful sex_ (dyspareunia) Painful urination (dysuria) **Consider chlamydia in men that are sexually active and present with:** _Urethral discharge_ or discomfort _Painful urination (dysuria)_ _Epididymo-orchitis_ _Reactive arthritis_ It is worth considering _rectal chlamydia_ and **lymphogranuloma venereum** in patients _presenting with anorectal symptoms_, such as discomfort, discharge, bleeding and change in bowel habits. **_Examination Findings_** Pelvic or abdominal tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge **Investigation** _Nucleic acid amplification (NAAT)_ swabs are used to diagnose chlamydia. This can involve a: Vulvovaginal swab Endocervical swab First-catch urine sample (in women or men) Urethral swab in men Rectal swab (after anal sex) Pharyngeal swab (after oral sex) **Management** First-line for uncomplicated chlamydia infection is _doxycycline 100mg_ twice a day for 7 days. _Doxycycline is contraindicated in pregnancy and breastfeeding_. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are: _Azithromycin 1g stat_ then 500mg once a day for 2 days _{Erythromycin 500mg four times daily for 7 days} _{Erythromycin 500mg twice daily for 14 days} _{Amoxicillin 500mg three times daily for 7 days} _{Other factors to consider are:} _{Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection} _{Refer all patients to genitourinary medicine (GUM) for contact tracing and notification of sexual partners} _{Test for and treat any other STIs} _{Provide advice about ways to prevent future infection} _{Consider safeguarding issues and sexual abuse in children and young people}

Answer 48

**Epidemiology** Being young, sexually active and having _multiple partners_ increases the risk of infection with gonorrhoea. _Having other STIs_, such as chlamydia or HIV, also increases the risk. There is a high level of antibiotic resistance to gonorrhoea. **Aetiology** Neisseria gonorrhoeae is a _Gram-negative diplococcus bacteria_. It infects _mucous membranes with a columnar epithelium_, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It _spreads via contact with mucous secretions_ from infected areas. **Clinical Features** Infection with gonorrhoea is _more likely to be symptomatic than infection with chlamydia_. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. **Female genital infections can present with:** _Odourless purulent discharge_, possibly _green or yellow_ _Dysuria_ _Pelvic pain_ **Male genital infections can present with:** _Odourless purulent discharge_, possibly _green or yellow_ _Dysuria_ _Testicular pain or swelling_ (epididymo-orchitis) **Rectal infection** may cause anal or rectal discomfort and discharge, but is often asymptomatic. **Pharyngeal infection** may cause a _sore throat_, but is _often asymptomatic_. **Prostatitis** causes _perineal pain, urinary symptoms and prostate tenderness_ on examination. **Conjunctivitis** causes _erythema_ and a _purulent discharge_. **Investigation** **NAAT** is use to detect the RNA or DNA of gonorrhoea. Genital infection can be diagnosed with _endocervical, vulvovaginal or urethral swabs_, or in a _first-catch urine sample_. **Rectal and pharyngeal swab** are recommended in _all MSM_, and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas. **Charcoal endocervical swab** should be taken for _microscopy, culture and antibiotic sensitivities_ before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance. **Management** _{Patients should be referred to GUM clinics (or local equivalent) to coordinate testing, treatment and contact tracing. Management depends on whether antibiotic sensitivities are known.} For uncomplicated gonococcal infections: A single dose of **_IM ceftriaxone 1g_** if the _sensitivities are NOT known_ A single dose of **oral ciprofloxacin 500mg** if the _sensitivities ARE known_ _if ceftriaxone is refused_ (e.g. needle-phobic) then **oral cefixime 400mg** (single dose) + **oral azithromycin 2g** (single dose) should be used _{All patients should have a follow up “test of cure” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least:} _{72 hours after treatment for culture} _{7 days after treatment for RNA NATT} _{14 days after treatment for DNA NATT} _{Other factors to consider are:} _{Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection} _{Test for and treat any other sexually transmitted infections} _{Provide advice about ways to prevent future infection} _{Consider safeguarding issues and sexual abuse in children and young people} A key complication to remember is **gonococcal conjunctivitis in a neonate**. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ophthalmia neonatorum. This is a **medical emergency** and is associated with _sepsis, perforation of the eye and blindness_.

Answer 49

**Epidemiology** STI **Aetiology** Bacteria that causes non-gonococcal urethritis **Clinical Features** Most cases are asymptomatic. Similar presentation to Chlamydia. Key feature is _urethritis_. Other features: Epididymitis Cervicitis Endometritis Pelvic inflammatory disease Reactive arthritis Preterm delivery in pregnancy Tubal infertility **Investigation** NAAT First urine sample in the morning for men Vaginal swabs (can be self-taken) for women The guideline recommends checking every positive sample for macrolide resistance, and performing a “test of cure” after treatment in every positive patient. **Management** BASHH guidelines (2018) recommend a course of _doxycycline_ followed by _azithromycin_ for uncomplicated genital infections: _Doxycycline 100mg twice daily for 7 days_ then; _Azithromycin 1g stat then 500mg once a day for 2 days_ (unless it is known to be resistant to macrolides) _Moxifloxacin_ is used as an alternative or in _complicated infections_. _Azithromycin alone is used in pregnancy and breastfeeding_ (remember doxycycline is contraindicated).

Answer 50

**Epidemiology** STI **Aetiology** Parasite spread through sexual intercourse. Trichomonas is classed as a _protozoan_, and is a single-celled organism with flagella. _Lives in the urethra_ of men and women and the vagina of women. Trichomonas can increase the risk of: _Contracting HIV_ by damaging the vaginal mucosa _BV_ _Cervical cancer_ _PID_ Preterm delivery **Clinical Features** Up to 50% of cases of trichomoniasis are _asymptomatic_. When symptoms occur, they are _non-specific_: Vaginal discharge Itching Dysuria (painful urination) Dyspareunia (painful sex) Balanitis (inflammation to the glans penis) The typical description of the vaginal discharge is _offensive_ _frothy and yellow-green_, although this can vary significantly. It may have a _fishy smell_. Examination of the cervix can reveal a **characteristic _“strawberry cervix”_** (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry. Testing the vaginal pH will reveal a raised ph (above 4.5), similar to BV. **Investigation** The diagnosis can be confirmed with a standard _charcoal swab with microscopy_. **Women:** Swabs should be taken from the _posterior fornix_ of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative. **Men:**_Urethral swab or first-catch urine_ **Management** Patients should be referred to a GUM specialist service for diagnosis, treatment and contact tracing. Treatment is with _metronidazole_.

Answer 51

**Epidemiology** Common **Aetiology** HSV is spread through direct contact with affected mucous membranes or viral shedding in mucous secretions. HSV-1; cold sores _HSV-2_; genital herpes - STI via oro-genital sex **Clinical Features** Patients affected by herpes simplex may display no symptoms, or develop symptoms months or years after an initial infection when the latent virus is reactivated. The symptoms of an initial infection with genital herpes usually appear within two weeks. The initial episode is often the most severe, and recurrent episodes are milder. **Signs and symptoms include:** _Ulcers_ or _blistering lesions_ affecting the genital area _Neuropathic_ type pain (tingling, burning or shooting) _Flu-like_ symptoms (e.g. fatigue and headaches) _Dysuria_ (painful urination) _Inguinal lymphadenopathy_ Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly. **Investigation** Clinical diagnosis Viral PCR **Management** Referral to GUM _Aciclovir_ Additional measures, including to manage the symptoms include: Paracetamol Topical lidocaine 2% gel (e.g. _Instillagel_) Cleaning with warm salt water Topical vaseline Additional oral fluids Wear loose clothing Avoid intercourse with symptoms

Answer 52

**Epidemiology** **Aetiology** RNA retrovirus. _HIV-1 is the most common type_, and HIV-2 is rare outside West Africa. The virus _enters and destroys the CD4 T-helper cells_ of the immune system. An initial _seroconversion flu-like illness occurs within a few weeks_ of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency. Immunodeficient patients develop AIDS-defining illnesses and opportunistic infections. This progression occurs potentially years after the initial infection. **Transmission** _{Unprotected anal, vaginal or oral sexual activity} _{Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission)} _{Mucous membrane, blood or open wound exposure to infected blood or bodily fluids, for example, through sharing needles, needle-stick injuries or blood splashed in an eye} **Clinical Features** An initial _seroconversion flu-like illness occurs within a few weeks_ of infection. The infection is then asymptomatic until the condition progresses to immunodeficiency. Immunodeficient patients develop AIDS-defining illnesses and opportunistic infections. This progression occurs potentially years after the initial infection. **Investigation** **Antibody testing** is the typical screening test for HIV. May be negative for the first 3 months due to seroconversion. This is a simple blood test. Patients can request an antibody testing kit online for self sampling at home, which they post to the lab for testing. **p24 antigen testing**, checking directly for this _specific HIV antigen_ in the blood. This can give a positive result earlier in the infection compared with the antibody test. **PCR testing** for the _HIV RNA levels_ tests directly for the number of viral copies in the blood, giving a viral load. **Management** **Monitoring** _CD4 Count_ _{The CD4 count is the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection:} _{500-1200 cells/mm3 is the normal range} _{<200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections} _Viral Load (VL)_ _{Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.} **Antiretroviral therapy (ART)** Two NRTIs (e.g. tenofovir and emtricitabine) plus a third agent. **Additional Management** ^{Prophylactic co-trimoxazole (Septrin) is given to patients with a CD4 <200/mm3 to protect against pneumocystis jirovecii pneumonia (PCP).} ^{HIV infection increases the risk of developing CVD. Patients with HIV have close monitoring of cardiovascular RFs and blood lipids. Appropriate treatment (e.g. statins) may be required to reduce their risk of developing cardiovascular disease.} ^{Yearly cervical smears are required for women with HIV. HIV predisposes to developing human papillomavirus (HPV) infection and cervical cancer, so female patients need close monitoring to ensure early detection of these complications.} ^{Vaccinations should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid live vaccines.}

Answer 53

**Epidemiology** STI **Aetiology** Syphilis is caused by bacteria called _Treponema pallidum_. This bacteria is a _spirochete_, a type of _spiral-shaped bacteria_. The bacteria gets in through _skin or mucous membranes_, replicates and then disseminates throughout the body. The incubation period between the initial infection and symptoms is _21 days_ on average. **Transmission** ^{Oral, vaginal or anal sex involving direct contact with an infected area} ^{Vertical transmission from mother to baby during pregnancy} ^IVDU ^{Blood transfusions and other transplants (although this is rare due to screening of blood products)} **Clinical Features** **Primary syphilis** _{A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks.} _{Local lymphadenopathy} **Secondary syphilis** _{Typically starts after the chancre has healed, with symptoms of:} _{Maculopapular rash} _{Condylomata lata (grey wart-like lesions around the genitals and anus)} _{Low-grade fever} _{Lymphadenopathy} _{Alopecia (localised hair loss)} _{Oral lesions} **Tertiary syphilis** _{Can present with several symptoms depending on the affected organs. Key features to be aware of are:} _{Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones)} _{Aortic aneurysms} _{Neurosyphilis} **Neurosyphilis** _{Can occur at any stage if the infection reaches the CNS, and present with symptoms of:} _Headache _{Altered behaviour} _Dementia _{Tabes dorsalis (demyelination affecting the spinal cord posterior columns)} _{Ocular syphilis* (affecting the eyes)} _Paralysis _{Sensory impairment} _{*Argyll-Robertson pupil is a specific finding in neurosyphilis. It is a constricted pupil that accommodates when focusing on a near object but does not react to light. They are often irregularly shaped. It is commonly called a “prostitutes pupil” due to the relation to neurosyphilis and because “it accommodates but does not react“.} **Investigation** _{Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis.} _{Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing.} Samples from sites of infection can be tested to confirm the presence of T. pallidum with: **Dark field microscopy** **Polymerase chain reaction (PCR)** **Management** _{All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need:} _{Full screening for other STIs} _{Advice about avoiding sexual activity until treated} _{Contact tracing} _{Prevention of future infections} A single deep **IM dose of benzathine benzylpenicillin (penicillin)** is the standard treatment for syphilis. Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. _Ceftriaxone, amoxicillin and doxycycline are alternatives_.

Answer 54

There are two types of swabs involved in sexual health testing: **Charcoal swabs** **Nucleic acid amplification test (NAAT) swabs** **Charcoal swabs** Allow for _microscopy_, _culture_ and _sensitivities_. _{Charcoal swabs look like a long cotton bud that goes into a tube with a black transport medium at the end. The transport medium is called Amies transport medium, and contains a chemical solution for keeping microorganisms alive during transport.} _{Microscopy involves gram staining and examination under a microscope. A stain is used to highlight different types of bacteria with different colours.} Charcoal swabs can be used for endocervical swabs and high vaginal swabs (HVS). Charcoal swabs can confirm: _BV_ _Candidiasis_ _Gonorrhoeae_ (specifically _endocervical_ swab) _Trichomonas vaginalis_ (specifically a swab from the _posterior fornix_) Other bacteria, such as group B streptococcus (GBS) **Nucleic acid amplification tests (NAAT)** Check directly for the _DNA or RNA_ of the organism. NAAT testing is used to test specifically for _chlamydia and gonorrhoea_. _{They are not useful for other pelvic infections (except where specifically testing for Mycoplasma genitalium). In women, a NAAT test can be performed on a vulvovaginal swab (a self-taken lower vaginal swab), an endocervical swab or a first-catch urine sample. The order of preference is endocervical, vulvovaginal, and then urine. In men, a NAAT test can be performed on a first-catch urine sample or a urethral swab. It is worth noting that the NAAT swabs will specify on the packet whether the swabs are for endocervical, vulvovaginal or urethral use. A specific kit is used for first-catch urine NATT testing.} _{Rectal and pharyngeal NAAT swabs can also be taken to diagnose chlamydia in the rectum and throat. Consider these swabs where anal or oral sex has occurred.} Where gonorrhoea is suspected or demonstrated on a NAAT test, an endocervical charcoal swab is required for microscopy, culture and sensitivities.

Answer 55

Disseminated gonococcal infection (GDI) is a complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes: Various non-specific **_skin lesions_** **_Polyarthralgia_** (joint aches and pains) **_Migratory polyarthritis_** (arthritis that moves between joints) **_Tenosynovitis_** **_Systemic symptoms_** such as fever and fatigue

Answer 56

**Epidemiology** _Risk of neonatal herpes simplex infection_ contracted during labour and delivery. Neonatal herpes simplex infection has _high morbidity and mortality._ After an initial infection with genital herpes, the woman will develop antibodies to the virus. During pregnancy, these _antibodies can cross the placenta into the fetus_. This _gives the fetus passive immunity_ to the virus, and protects the baby during labour and delivery. **Management** Pregnancy depends on whether it is the first episode of genital herpes (primary infection) or recurrent genital herpes. **Primary genital herpes contracted \<28 weeks gestation** _{Aciclovir followed by regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery.} _{Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection).} _{Caesarean section is recommended when symptoms are present.} **Primary genital herpes contracted \>28 weeks gestation** _{Aciclovir followed immediately by regular prophylactic aciclovir.} _{Caesarean section is recommended in all cases to reduce the risk of neonatal infection.} **Recurrent genital herpes in pregnancy (known to have genital herpes before the pregnancy)** _{Carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery.} _{Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery.}

Answer 57

**Preventing Transmission During Birth** Viral load will determine the mode of delivery: _\<50 copies/ml:__Normal vaginal delivery_ is recommended _\>50 copies copies/ml_ & all women with _\> 400 copies/ml:_ _C-Section_ _Unknown viral load_ or there are _\>10000 copies/ml_: _IV zidovudine_ given during C-section **Prophylaxis treatment may be given to the baby, depending on the mothers viral load:** Low-risk babies (\<50 copies/ml): _zidovudine_ for four weeks High-risk babies (\>50 copies/ml): _zidovudine, lamivudine and nevirapine_ for four weeks **Breast Feeding** _HIV can be transmitted during breastfeeding_, even if the mother’s viral load is undetectable. Breastfeeding is _**NOT** recommended_ for mothers with HIV. However, if the mother is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team. **Post-Exposure Prophylaxis (PEP)** Can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours). The sooner it is started, the better. A risk assessment of the probability of developing HIV should be balanced against the side effects of PEP. PEP involves a combination of ART therapy. The current regime is _Truvada (emtricitabine and tenofovir) and raltegravir_ for _28 days_. HIV tests are done immediately and also a minimum of 3 months after exposure to confirm a negative status. Individuals should _abstain from unprotected sexual activity for a minimum of three months_ until confirmed as negative.

Answer 58

**Epidemilology** _6 & 11:_ causes genital warts _16 & 18_: linked to a variety of cancers, most notably cervical cancer **Aetiology** **Clinical Features** **Investigations** **Management**

Answer 59

**Epidemiology** Defined as not starting menstruation: _By 13 years_ when there is _no other evidence of pubertal development_ _By 15 years_ of age where there are _other signs of puberty_, such as breast bud development **Aetiology** **Clinical Features** **Investigations** **Management**

Answer 60

**Epidemiology** **Aetiology** **Clinical Features** **Investigations** **Management**