Obstetrics & Gynaecology

Question 1

List the functions of oestrogen

Answer 1

Development of internal/external genitalia, breasts, female fat distribution.
Follicle growth, endometrial proliferation, increase myometrial excitability.
Upregulates oestrogen, LH, progesterone receptors
Feedback inhibition of FSH and LH, then LH surge
Stimulates prolactin secretion
Decreases prolactin action on breasts.
Increase transport proteins, serum hormone binding globulin, increase HDL, reduce LDL.

Question 2

List the physiological changes in pregnancy

Answer 2

Haematology
* Increased plasma volume by 50%
* Increased fibrinogen by 50%
* Increased clotting factors VII, IX, X
* Decreased platelets
* Decreased haemoglobin
* Venous stasis
Respiratory
* Increased oxygen consumption by 20%
* Increased minute ventilation by 40~50% (via increased tidal volume)
* Increased PO2
* Decreased PCO2
* Decreased forced vital capacity by third trimester
Cardiac
* Increased cardiac output by 40%
* Increased stroke volume
* Increased heart rate by 10-20 bpm
* Decreased blood pressure in the first and second trimesters
* Decreased systemic vascular resistance by 25~30%
* Decreased serum colloid osmotic pressure by 10~15%
Renal
* Increased renal blood flow by 60~80%
* Increased glomerular filtration rate
* Increased protein excretion up to 300mg/24h
* Decreased serum creatinine
* Glycosuria
* Physiological hydronephrosis
Gastroenterology
* Decreased gut motility
* Increased alkaline phosphate
* Decreased albumin by 20~40%
Endocrine
* Impaired glucose tolerance
* Insulin resistance
* Increased prolactin
* Increased cortisol
* Increased renin, angiotensin, aldosterone
General
* Fatigue
* Weight gain
* Nausea/vomiting
* Constipation
* Breathlessness
* Palpitations
* Ankle oedema
Skin
* Palmar erythema
* Dry skin
* Telangiectasia
* Pruritus

Question 3

List the functions of progesterone during the luteal phase

Answer 3

(Prepares uterus for implantation)
Stimulates endometrial glandular secretions and spiral artery development
Increases thick cervical mucus and inhibits sperm entry into uterus
Prevents endometrial hyperplasia
Increases body temperature
Decreases oestrogen receptor expression
Decreases gonadotropin (LH, FSH) secretion

Question 4

List the functions of progesterone during pregnancy

Answer 4

Maintains endometrial lining and pregnancy
Reduce myometrial excitability, thus reduce contraction, frequency and intensity
Reduce prolactin action on breasts

Question 5

List the oestrogen synthesis pathway from cholesterol

Answer 5

Cholesterol
Pregnenolone
Progesterone
17a-Hydroxypregnenolone
17a-Hydroxyprogesterone
Dehydroepiandrosterone
Androstenedione
Testosterone
Estrone, beta-Estradiol
Estriol

Question 6

List the functions of FSH

Answer 6

Stimulates follicular growth and development.
Binds exclusively to granulosa cells in the growing follicle.
Stimulates receptors for LH.

The granulosa cells produce oestrogen, feedbacks on the pituitary to suppress FSH
Only the dominant follicle will get enough FSH to continue development.

Question 7

List the functions of LH

Answer 7

Stimulates ovulation
Reactivation of meiosis I
Sustains corpus luteum development

Question 8

What is prolactin release stimulated by

Answer 8

Oestrogen
Phenothiazine
Reserpine
Methyltyrosine

Question 9

What is prolactin release inhibited by

Answer 9

Dopamine
Bromocriptine
Cabergoline

Question 10

What is the effect of hyperprolactinemia on ovulation

Answer 10

Hyperprolactinemia prevents ovulation by an inhibitory effect on hypothalamic GnRH production and release.
Important cause of secondary amenorrhoea and infertility.

Question 11

List the three stages of labour

Answer 11

First stage
Regular painful contractions until cervix fully dilates and no longer palpable.
* Slow latent phase - the cervix becomes effaced and shortens from 3 cm in length and dilates up to 5 cm.
- <20 hrs in nulliparous, <14 hrs in multiparous
* Active phase - the cervix dilates from 5cm to full dilatation 10cm.
- 1.2 cm/hr in nulliparous, 1.5 cm/hr in multiparous

Second stage
From full cervical dilatation to delivery of the foetus.
* Pelvic (passive) phase - head descends in the pelvis
* Perineal (active) phase - mother gets a stronger urge to push and the fetus is delivered with the force of the uterine contractions and the maternal bearing-down effort

Third stage
From the delivery of the newborn to delivery of the placenta and membranes.

Question 12

List the clinical signs of the onset of labour

Answer 12

Regular, painful uterine contractions that increase in frequency, duration and intensity.
Passage of blood-stained mucus from the cervix (show)
Rupture of the foetal membranes

Question 13

Give the definition for pre-labour rupture of membranes

Answer 13

Latent period between rupture of membranes to onset of painful uterine contractions more than 4 hours

Question 14

List the hormonal changes during initiation of labour

Answer 14

Progesterone withdrawal
Increase in oestrogen and prostaglandin action
Increased foetal cortisol
Increased local activity of prostaglandins

Question 15

List the mechanisms of labour

Answer 15

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

Question 16

List the mechanisms of the third stage of labour

Answer 16

(A) separation of the placenta from the uterine wall
(B) expulsion into the lower uterine segment and upper vagina
(C) complete expulsion of the placenta and membranes from the genital tract

Question 17

List the signs of placental separation

Answer 17

trickling of bright blood
lengthening of the umbilical cord
elevation of the uterine fundus within the abdominal cavity

Question 18

When is third stage considered abnormal

Answer 18

If the placenta is not expelled within 30 minutes

Question 19

When does preterm labour occur?

Answer 19

Between 24 and 37 weeks gestation.

Question 20

Give the classification for premature labour

Answer 20

Moderate to late preterm: 32~37 weeks’ gestation
Very preterm: 28 weeks’ to <32 weeks’ gestation
Extremely preterm: <28 weeks’ gestation.

Question 21

List the causes for preterm labour

Answer 21

Antepartum haemorrhage
Multiple pregnancy
Infection
Polyhydramnios
Socioeconomic

Question 22

Give the risk factor for PPROM

Answer 22

Infection
* Group B haemolytic streptococci
* C. trachomatis
* Bacterial vaginosis

Question 23

List the management for PPROM

Answer 23

Antibiotics - erythromycin for 10 days after diagnosis of PPROM
Intrapartum antibiotic prophylaxis
Antenatal corticosteroids - dexamethasone
Magnesium sulfate (Neuroprotection)
Prophylactic tocolysis - Nifedipine

Question 24

Give the presentation for PPROM

Answer 24

Sudden loss of amniotic fluid from vagina
Nitrazine-positive (blue) fluid
Ferning on microscopy

Question 25

List the investigations to predict premature labour

Answer 25

Cervical length on transvaginal ultrasound - <2 cm are associated with higher risks of delivery Foetal fibronectin Insulin-like growth factor binding protein-1 (IGFBP-1) test Placental alpha microglobulin-1 (PAMG-1) test

Question 26

List the indications for induction of labour

Answer 26

Prolonged pregnancy (> 42 weeks) Pre-eclampsia Placental insufficiency and intrauterine growth restriction Antepartum haemorrhage * Placental abruption * Uncertain origin Rhesus isoimmunisation Diabetes mellitus Chronic renal disease

Question 27

List the methods for induction of labour

Answer 27

Prostaglandin E2 pessaries Syntocinon + Fore/hindwater rupture of membranes

Question 28

Define Cord presentation

Answer 28

Any part of the cord lies alongside or in front of the presenting part.

Question 29

List the management for cord presentation

Answer 29

Reduce pressure on the cord by * Knee-chest position * Buttocks elevated by pillows or head tilt in a trolley * Filling the urinary bladder Tocolytic - terbutaline

Question 30

When may episiotomy be indicated during a normal vaginal delivery

Answer 30

Perineum begins to tear Perineal resistance prevents delivery of the head Concern for the foetal wellbeing requires expedited birth

Question 31

List the management for abnormal third stage of labour

Answer 31

Intramuscular oxytocin (10I/U) Late clamping (>2 minutes) and cutting of the cord When signs of placental separation are seen, the placenta is delivered by controlled cord traction (Brandt-Andrews technique).

Question 32

List the risk factors for anal sphincter damage

Answer 32

Large baby (>4kg) First vaginal delivery Instrumental delivery Occipitoposterior position Prolonged second stage Induced labour Epidural anaesthesia Shoulder dystocia Midline episiotomy

Question 33

Define frank (extended breech)

Answer 33

The legs lie extended along the fetal trunk and are flexed at the hips and extended at the knees. The buttocks will present at the pelvic inlet.

Question 34

Define flexed breech

Answer 34

The legs are flexed at the hips and the knees with the fetus sitting on its legs so that both feet present to the pelvic inlet.

Question 35

Define knee or footling presentation

Answer 35

One or both of the lower limbs of the fetus are flexed and breech of the baby is above the maternal pelvis. Part of the fetal lower limb (usually feet) descends through the cervix into the vagina.

Question 36

Why is there decrease in systemic vascular resistance during pregnancy

Answer 36

Progesterone

Question 37

Why is there reduced functional residual capacity in pregnancy

Answer 37

Elevation of diaphragm

Question 38

List the physiology of gallbladder disease in pregnancy

Answer 38

Decreased gallbladder emptying due to progesterone Increased oestrogen cause increased cholesterol production in the third trimester

Question 39

List the thyroid changes in pregnancy, give the mechanisms

Answer 39

Increased total T4, unchanged free T4 * b-HCG stimulates thyroid hormone production in the first trimester * Oestrogen stimulates TBG, thyroid increases hormone production to maintain steady free T4 levels Decreased TSH * Increased b-HCG and thyroid hormone suppress TSH production

Question 40

List the metabolic effects of human placental lactogen

Answer 40

Human placental lactogen causes pancreatic B cell hyperplasia, leads to increased insulin secretion and insulin resistance Insulin resistance causes increased lipolysis, proteolysis, blood glucose (adequate foetal metabolism) GDM arises when maternal pancreatic function does not overcome insulin resistance

Question 41

Define normal contraction

Answer 41

3~5 contractions in 10 minutes, lasts for 45 seconds

Question 42

What may be offered if foetal tachysystole / tetanic (>2min) during contractions

Answer 42

Terbutaline (tocolytic)

Question 43

List the tocolytics and their contraindications

Answer 43

Ritodrine * CI: tachycardia, poorly controlled diabetes mellitus Nifedipine * CI: hypotension, heart disease Magnesium * CI: myasthenia gravis Indomethacin * CI: pregnancy after 32 weeks as closes PDA Atosiban (oxytocin antagonist)

Question 44

List the management approaches to foetal tachysystole

Answer 44

Discontinue uterotonics Lateral decubitus positioning Tocolysis

Question 45

List the components in Bishop score

Answer 45

Dilation Position of cervix Effacement Station Cervical consistency A Bishop score of 8 or greater is considered to be favourable for induction or spontaneous delivery.

Question 46

What does station 0 in Bishop score indicate?

Answer 46

The ischial spines are halfway between the pelvic inlet and outlet. At zero station, the foetal head is at the level of the ischial spines.

Question 47

Give signs of False (Braxton Hicks) contraction

Answer 47

Irregular, infrequent labour Weak strength None to mild pain No cervical change

Question 48

List the adverse drug reactions to epidural anaesthesia

Answer 48

Hypotension Systemic toxicity High spinal / total spinal - depression of cervical spinal cord and brainstem activity Postdural puncture headache

Question 49

When does engagement of foetal head occur?

Answer 49

Stage 1 latent phase

Question 50

List the management for abnormal stage 1 latent phase

Answer 50

If absent: balloon catheter If water didn’t break - amniotomy Oxytocin

Question 51

List the disorders and management of the active phase of labour

Answer 51

Protraction - oxytocin * Cervical change slower than expected * Inadequate contractions Arrest - caesarean delivery * No cervical change >4 hours + adequate contraction * No cervical change >6 hours + inadequate contractions

Question 52

Define second stage arrest of labour

Answer 52

Insufficient foetal descent after pushing for >3 hrs in nulliparous or >2 hrs in multiparous

Question 53

List the aetiology of second stage arrest of labour

Answer 53

Cephalopelvic disproportion Malposition Inadequate contractions Maternal exhaustion

Question 54

Give management options for second stage arrest of labour

Answer 54

Operative vaginal delivery Caesarean delivery

Question 55

Give management options for abnormal third stage of labour

Answer 55

Uterine massage and controlled cord traction Oxytocin Manual extraction Surgery

Question 56

Give the management for preterm labour with high risk of imminent delivery

Answer 56

Dexamethasone IV antibiotics for GBS prophylaxis - benzylpenicillin / clindamycin Tocolysis - nifedipine Magnesium sulphate

Question 57

List the management for PPROM

Answer 57

<34 weeks reassuring * Expectant management * Erythromycin 10 days * Antenatal corticosteroids - dexamethasone <34 weeks non-reassuring * Delivery * Erythromycin 10 days * Antenatal corticosteroids - dexamethasone * Magnesium sulphate if <32 weeks - neuroprotection 34~37 weeks * Delivery * GBS prophylaxis - benzylpenicillin * Antenatal corticosteroids - dexamethasone

Question 58

List the risk factors for intrapartum fever (endometritis/chorioamnionitis)

Answer 58

Prolonged rupture of membranes (>18hrs) PPROM Prolonged labour Internal foetal/uterine monitoring devices Repetitive vaginal examinations Genital tract pathogens

Question 59

List the presentation of intrapartum fever (endometritis/chorioamnionitis)

Answer 59

Maternal fever Plus one of the following: * Foetal tachycardia >160 bpm for at least 10 minutes * Maternal leukocytosis * Maternal tachycardia * Purulent amniotic fluid * Uterine fundal tenderness

Question 60

List the management for intrapartum fever (endometritis/chorioamnionitis)

Answer 60

Ampicillin + gentamicin/clindamycin Delivery

Question 61

List the risk factors for postpartum endometritis

Answer 61

Caesarean/operative vaginal delivery Chorioamniotis Group B streptococcus colonisation Prolonged rupture of membranes

Question 62

List the clinical features for postpartum endometritis

Answer 62

Fever >24hr postpartum Uterine fundal tenderness Purulent lochia

Question 63

Give the management for postpartum endometritis

Answer 63

Clindamycin + gentamicin

Question 64

List the complications for surgical induction of labour

Answer 64

Hyperstimulation Prolapse of the cord Infection

Question 65

Define third- and fourth-degree injuries

Answer 65

3a: < 50% of the external sphincter is disrupted 3b: > 50% of the external sphincter is disrupted 4: both the external and internal sphincters are disrupted

Question 66

List the risk factors for breech presentation

Answer 66

Advanced maternal age Multiparity Uterine didelphys, septate uterus Uterine leiomyomas Foetal anomalies eg. anencephaly Preterm (<37 weeks) Oligo/polyhydramnios Placenta praevia

Question 67

List the management for breech presentation

Answer 67

Caesarean delivery External cephalic version

Question 68

List the complications of external cephalic version

Answer 68

cord entanglement placental abruption rupture of the membranes

Question 69

List the indications for C-section

Answer 69

Non-reassuring foetal status (foetal distress) Abnormal progress in the first/second stages of labour (dystocia) Intrauterine growth restriction (poor placental function) Malpresentations: breech, transverse lie, brow Placenta praevia, abruptio placentae, severe antepartum haemorrhage Previous caesarean section Severe pre-eclampsia and other maternal medical disorders Cord presentation and prolapse

Question 70

List the classifications for C-section

Answer 70

Category 1 - immediate threat to life of the woman/foetus Category 2 - maternal/foetal compromise but not immediately life threatening Category 3 - no maternal/foetal compromise but early delivery required Category 4 - elective planned C section

Question 71

List the complications for C-section

Answer 71

Perioperative haemorrhage Injury to bladder / ureters Wound / uterine cavity infection Secondary postpartum bleeding DVT / PE

Question 72

List the predisposing factors for shoulder dystocia

Answer 72

Macrosomic infants >4.5 kg Prolonged second stage of labour Assisted vaginal delivery

Question 73

Give the approach for shoulder dystocia

Answer 73

McRobert’s manoeuvre The woman is placed in the recumbent position with the hips slightly abducted and acutely flexed with the knees bent up towards the chest. Apply suprapubic pressure on the anterior shoulder to displace it downwards and laterally. Make / extend an episiotomy. Insert a hand into the vagina and rotate the foetal shoulders to the oblique pelvic diameter. Deliver the posterior arm by flexing it at the elbow and sweeping the arm across the chest.

Question 74

Define primary postpartum haemorrhage

Answer 74

Bleeding from the genital tract > 500mL in the first 24 hours after delivery.

Question 75

List the causes for primary postpartum haemorrhage

Answer 75

4T: Tone, Tissue, Trauma, Thrombin Uterine atony (75~90%) * uterine overdistension - multiple pregnancy, polyhydramnios * prolonged labour, instrumental delivery * antepartum haemorrhage: placenta praevia, abruption * multiparity * multiple fibroids, uterine abnormalities General anaesthesia * episiotomy * lacerations to perineum, vagina, cervix * uterine rupture and caesarean scar dehiscence * haematomas of the vulva, vagina and broad ligament Genital tract trauma Tissue - retained placenta Thrombin acquired in pregnancy * HELLP syndrome * Sepsis * Disseminated intravascular coagulation (DIC)

Question 76

List the management for primary postpartum haemorrhage if the placenta is retained

Answer 76

Massage the uterus to ensure it is well contracted. Attempt delivery of the placenta by controlled cord traction. If this fails, proceed to manual removal of the placenta under spinal, epidural or general anaesthesia when the mother is adequately resuscitated.

Question 77

List the management for PPH due to uterine atony

Answer 77

First line: IV oxytocin + IV fluid with balanced crystalloids (Ringer's lactate) + slow IV Tranexamic acid 1g + uterine massage List of uterotonics: * IV Oxytocin 5 units * IV Ergometrine 0.2mg * IM Carboprost every 15 minutes for a maximum of eight doses * Misoprostol 800μg sublingual

Question 78

List the mechanisms of actions and contraindications for uterotonics

Answer 78

Ergometrine * Stimulates uterine smooth muscle and vascular alpha1 receptors, causes sustained vasoconstriction and bleeding resolution * CI: hypertension, cardiovascular disease Carboprost * Prostaglandin F2-alpha agonist in the uterine myometrium, stimulatesuterine contractions * CI: asthma, hypertension, active cardiac, hepatic, pulmonary disease Misoprostol * Prostaglandin E1 agonist in the uterine myometrium.

Question 79

List the surgical techniques for primary postpartum haemorrhage

Answer 79

Bimanual compression of the uterus (8–10 minutes) Uterine tamponade with balloon catheters Uterine compression sutures Internal iliac and uterine artery ligation Major vessel embolisation Total/subtotal hysterectomy

Question 80

Give the STASIS algorithm for severe refractory PPH

Answer 80

S - Shift the patient to the operating room for improved visualisation. T - Rule out retained tissue, trauma. Employ balloon tamponade. A - Apply surgical compression sutures to achieve haemostasis. S - Systemic devascularisation by O'Leary, ovarian, hypogastric, quadruple, internal iliac sutures I - Interventional radiology S - Subtotal/total hysterectomy

Question 81

Define secondary postpartum haemorrhage

Answer 81

Abnormal vaginal bleeding occurring at any subsequent time in the puerperium up to 6 weeks after delivery

Question 82

List the causes of secondary postpartum haemorrhage

Answer 82

Retained placental tissue Intrauterine infection Trophoblastic disease Intrauterine arteriovenous malformation

Question 83

Define placenta accreta spectrum

Answer 83

Abnormal invasion of trophoblastic tissue into the uterine wall. Placenta attaches to the myometrial layer of the uterus

Question 84

List the risk factors for placenta accreta spectrum

Answer 84

Prior C-section/uterine surgery (uterine scarring impairs decidualization) Placenta praevia Increased maternal age Multiparity

Question 85

List the types of placenta accreta spectrum

Answer 85

Placenta accreta (most common) - Attaches to myometrium (instead of overlying decidua basalis) without invading it Placenta increta - Partially invades into myometrium Placenta percreta - Completely invades through myometrium and serosa, sometimes extend into adjacent organs

Question 86

Give the investigation for placenta accreta spectrum

Answer 86

Colour flow doppler ultrasound

Question 87

Give the presentations for placenta accreta spectrum

Answer 87

Difficulty separating placenta from uterus after foetal delivery Severe post-partum haemorrhage upon attempted manual removal of placenta

Question 88

List the causes for antepartum haemorrhage

Answer 88

Placenta praevia Vasa praevia Uterine rupture Abruptio placentae Cervical polyps Cervicitis Cervical dilation Bloody show

Question 89

Give the definition for antepartum haemorrhage

Answer 89

Bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.

Question 90

List the risk factors for uterine rupture

Answer 90

Prior uterine surgery eg. C-section, myomectomy Induction of labour / prolonged labour Congenital uterine anomalies Foetal macrosomia

Question 91

List the clinical presentations for uterine rupture

Answer 91

Painful vaginal bleeding, increased with contractions Intra-abdominal bleeding (hypotension, tachycardia) Loss of intrauterine pressure Foetal heart decelerations Loss of foetal station Palpable foetal parts on abdominal examination

Question 92

Define placenta praevia and low lying placenta

Answer 92

Placenta praevia - placenta is directly covering the cervical os. Low-lying placenta - placental edge is <2 cm from the cervical os.

Question 93

Give the management for uterine rupture

Answer 93

Laparotomy for delivery and uterine repair

Question 94

Define vasa praevia

Answer 94

Foetal vessels lie over the internal cervical os

Question 95

List the risk factors for vasa praevia

Answer 95

Placenta praevia Multiple gestations IVF Succenturiate placental lobe - smaller accessory placental lobe that is separate to the main disc of the placenta

Question 96

List the clinical presentations for vasa praevia

Answer 96

Painless vaginal bleeding with ROM / contractions Foetal bradycardia, sinusoidal pattern Foetal demise

Question 97

Give the management for vasa praevia

Answer 97

Emergency caesarean delivery

Question 98

List the risk factors for placenta praevia

Answer 98

Advanced maternal age Multiparity Smoking , Illicit drug use Miscarriages / abortions Assisted conception Deficient endometrium due to * Uterine scar (previous C sections) * Endometritis * Manual removal of placenta * Curettage * Submucous fibroid

Question 99

Give the typical symptom in placenta praevia

Answer 99

Second / third-trimester PAINLESS vaginal bleeding

Question 100

Give the investigation for placenta praevia

Answer 100

Transabdominal ultrasound

Question 101

Define abruptio placentae

Answer 101

The premature separation of a normally located placenta from the uterine wall that occurs before delivery of the foetus.

Question 102

Give the types of abruptio placentae

Answer 102

Revealed - blood escapes through vagina Concealed - bleeding occurs behind the placenta, no evidence of bleeding from the vagina

Question 103

List the symptoms of abruptio placentae

Answer 103

Abdominal pain Uterine contractions Uterine tenderness Vaginal bleeding (revealed)

Question 104

List the foetal heart rate monitoring abnormalities that suggest an abruption

Answer 104

Late/variable decelerations Loss of variability Sinusoidal foetal heart rate tracing Foetal bradycardia (<110 bpm)

Question 105

List the investigations for abruptio placentae

Answer 105

Haemoglobin (Hb) Haematocrit (Hct) Coagulation studies Kleihauer-Betke (K-B) test in Rh-negative women Transabdominal ultrasound

Question 106

List the transabdominal ultrasound signs in abruptio placentae

Answer 106

Retroplacental haematoma (hyperechoic, isoechoic, hypoechoic) Pre-placental haematoma (jiggling appearance with a shimmering effect of the chorionic plate with foetal movement) Increased placental thickness and echogenicity Subchorionic collection Marginal collection

Question 107

Give the typical symptoms for cyclical breast pain

Answer 107

Starts during the luteal phase of the cycle (<2 weeks before menses), increases until menstruation begins, and improves after menses. Dull, heavy, aching Usually bilateral May be poorly localised and extend to the axilla

Question 108

Give the criteria for suspected cancer pathway referral (for an appointment within 2 weeks)

Answer 108

> 30 years + unexplained breast lump with/without pain > 30 years + unexplained lump in the axilla. > 50 years + discharge, retraction, or other concerning changes in one nipple only Has skin changes suggestive of breast cancer.

Question 109

List the causes for non-cyclical breast pain

Answer 109

Mastitis. Pregnancy. Trauma. Fibrocystic disease. Malignancy. Stretching of Cooper's ligaments. Diabetic mastopathy. Extra-mammary causes: Musculoskeletal conditions * Costochondritis * Soft tissue injury * Rib or vertebral fracture Fibromyalgia Herpes zoster Referred pain * Ischaemic heart disease * Peptic ulcer * Gallstones * Gastro-oesophageal reflux

Question 110

List the management for cyclical breast pain

Answer 110

Paracetamol / ibuprofen NSAIDs

Question 111

Where is lactational abscess commonly localised

Answer 111

In the peripheral region of the breast, more commonly in the upper and outer quadrant.

Question 112

Where is non-lactational abscess commonly localised

Answer 112

In the central/subareolar or lower quadrants of the breast

Question 113

List the causes for lactational mastitis

Answer 113

Milk stasis Infection - S aureus, including MRSA

Question 114

List the causes for non-lactational mastitis

Answer 114

Central/subareolar infection * Periductal mastitis * Duct ectasia Peripheral non-lactating infection * Diabetes mellitus * Rheumatoid arthritis * Trauma * Corticosteroid treatment Granulomatous mastitis - autoimmune reaction to substances secreted from the mammary ducts Infectious mastitis * S. aureus * Enterococci * Anaerobic bacteria (Bacteroides spp. anaerobic streptococci)

Question 115

List the predisposing factors for granulomatous mastitis

Answer 115

Corynebacterium spp. Childbirth Oral contraceptive use Trauma Autoimmune disease Hyperprolactinaemia Tuberculosis Sarcoidosis Diabetes mellitus

Question 116

List the complications for mastitis

Answer 116

Breast abscess Mammary duct fistula Sepsis Scarring Additional infections * Necrotizing fasciitis * Skin infections at extramammary sites (S. aureus mastitis)

Question 117

List the typical symptoms of mastitis

Answer 117

Painful breast. Fever / general malaise. Tender, red, swollen, hard area of the breast, usually in a wedge-shaped distribution.

Question 118

List the features for periductal mastitis

Answer 118

Periareolar inflammation (with/without associated mass) Established abscess Nipple retraction at the site of the diseased duct Central breast pain Greenish discharge from the nipple.

Question 119

List the features for granulomatous mastitis

Answer 119

Firm, unilateral breast mass Breast distortion Nipple retraction Skin thickening Axillary adenopathy Ulceration Large area of infection with multiple simultaneous peripheral abscesses

Question 120

List the typical symptoms of breast abscess

Answer 120

History of mastitis / breast abscess. Fever, general malaise Painful, swollen lump in the breast + redness, heat, and swelling of the overlying skin. On examination, the lump may be fluctuant with skin discolouration.

Question 121

Give the investigation for mastitis

Answer 121

Breast milk culture

Question 122

List the differential diagnoses for breast pain with lactation

Answer 122

Full / Engorged breasts Blocked duct Galactocele Infection of the mammary ducts

Question 123

List the differential diagnoses for breast pain not associated with lactation

Answer 123

Breast cancer * Ductal cancer * Inflammatory breast cancer * Paget's disease of the nipple Duct extasia Cellulitis Fibroadenosis Ruptured breast cyst Necrotising fasciitis of the breast Fat necrosis of the breast

Question 124

List the differential diagnoses for nipple pain

Answer 124

Poor infant attachment Candidal infection Bacterial infection Blanching Eczema Raynaud's disease

Question 125

List the management options for lactational mastitis

Answer 125

First line = flucloxacillin 500mg 4/day for 10–14 days Alternatives: Erythromycin 250–500mg 4/day for 10–14 days Clarithromycin 500mg 2/day for 10–14 days Second line = co-amoxiclav 500/125 mg 3/day for 10–14 days

Question 126

List the management options for non-lactational mastitis

Answer 126

First line: co-amoxiclav 500/125mg 3/day for 10–14 days Alternatives: Erythromycin (250–500mg 4/day) + metronidazole (400mg 3/day) for 10–14 days Clarithromycin (500mg 2/day) + metronidazole (400mg 3/day) for 10–14 days

Question 127

Give the most common female malignancy

Answer 127

Breast cancer

Question 128

Give the five-year survival rate for breast cancer

Answer 128

85%

Question 129

Give the characteristics for ductal cancer, inflammatory breast cancer, Paget's disease of the nipple

Answer 129

Ductal cancer - breast pain, bloody discharge Inflammatory breast cancer - rapid onset warmth of the breast, diffuse redness, and oedema (orange skin [peau d'orange] appearance) Paget's disease of the nipple - itchy, red rash, bleeding on the nipple, breast burning sensation

Question 130

List the risk factors for breast cancer

Answer 130

BRCA1 and BRCA2 mutations Other associated genetic mutations * NF1 (Neurofibromatosis type 1) * PTEN (Cowden syndrome) * STK11 (Peutz-Jeghers syndrome) * TP53 (Li-Fraumeni syndrome) Exogenous oestrogen and progestin * HRT * Hormonal contraception

Question 131

Which subtype of breast cancer is associated with BRCA1 mutations

Answer 131

Basal type tumours

Question 132

Which subtypes of breast cancer is associated with shorter disease-free survival

Answer 132

Basal type and HER2+ tumours

Question 133

Which subtype of breast cancer is associated with a longer disease-free survival

Answer 133

Luminal A tumours

Question 134

List the symptoms for breast cancer

Answer 134

Increasing size of the mass Axillary lymphadenopathy Nipple discharge, retraction Skin thickening / discoloration * Tethering * Peau d’orange Retraction, inversion, or scaling of the nipple

Question 135

Give the first line imaging investigation for breast cancer

Answer 135

Mammography

Question 136

Give the gold standard investigation for breast cancer

Answer 136

Image-guided core biopsy

Question 137

Describe the breast screening programme

Answer 137

3 yearly routine for women aged 50–70 years

Question 138

List the benefits of breast screening

Answer 138

Early detection of breast cancer. Reduction in breast cancer mortality.

Question 139

List the cons for breast screening

Answer 139

Pain and discomfor - mammography. Over-diagnosis - unnecessary treatment. False-positive mammograms - unnecessary further investigations. Psychological distress - false-positive result. False reassurance - missed cancer and incorrect diagnosis.

Question 140

Give the classifications for ovarian cancer

Answer 140

Epithelial carcinomas - six major histotypes * Serous (70~85%) * Mucinous * Endometrioid * Clear cell * Transitional cell * Other Non-epithelial cancers * Germ cell tumours * Sex cord/stromal cell tumours

Question 141

Where may ovarian cancer spread to

Answer 141

Intraperitoneal structures and organs (intestinal obstruction and cachexia) Liver Para-aortic lymph nodes Lung (pleural effusions)

Question 142

List the risk factors for ovarian cancer

Answer 142

Increasing age Genetic factors * Gene mutations - BRCA1/2 * Family history of ovarian cancer / cancer Conditions that increase the number of ovulatory cycles * Nulliparity * Early menarche / Late menopause Hormone replacement therapy Medical conditions * Cancer * Endometriosis Lifestyle * Smoking * Obesity * Occupational exposure to asbestos

Question 143

What is the risk of ovarian cancer reduced by

Answer 143

A higher number of pregnancies. Breastfeeding. Combined oral contraceptive pill Tubal ligation and hysterectomy.

Question 144

List the symptoms for ovarian cancer

Answer 144

In any woman (particularly > 50) if any of the following symptoms are persistent/frequent (particularly > 12/month): * Abdominal distension (bloating). * Feeling full (early satiety) / loss of appetite. * Pelvic/abdominal pain. * Increased urinary urgency/frequency. In any woman > 50 years, if symptoms suggestive of irritable bowel syndrome within the last 12 months. Other symptoms * Abnormal/postmenopausal bleeding. * Gastrointestinal symptoms (dyspepsia, nausea, bowel obstruction). * Shortness of breath (pleural effusion).

Question 145

List the investigations for ovarian cancer

Answer 145

Serum CA125 - Raised (> 35 IU/mL) Abdominal and pelvis ultrasound

Question 146

List the other causes of a raised serum CA125

Answer 146

Peritoneal trauma, disease, irritation. Other cancers * Primary peritoneal cancer * Lung cancer * Pancreatic cancer Ovarian cyst torsion, rupture, haemorrhage. Endometriosis. Pelvic inflammatory disease Pregnancy. Heart failure.

Question 147

Define Meigs syndrome

Answer 147

Ascites and pleural effusion associated with benign, usually solid ovarian tumour, most commonly ovarian fibroma

Question 148

Where do most cases of cervical cancer originate from

Answer 148

ecto- or endocervical mucosa in the 'transformation zone' (the area of the cervix between the old and new squamocolumnar junction)

Question 149

List the types of cervical cancer

Answer 149

Squamous cell carcinoma (70–80%) Adenocarcinoma (20–25%) Adenosquamous carcinoma Neuroendocrine tumours Undifferentiated carcinoma

Question 150

Give the cause of cervical cancer

Answer 150

Human papillomavirus (subtypes 16 and 18)

Question 151

List the risk factors for acquiring HPV infection

Answer 151

Early age of first sexual intercourse. Multiple sexual partners or a high-risk sexual partner. Lack of barrier contraception. History of STI History of HPV-related vaginal / vulvar dysplasia. Immunocompromise

Question 152

List the factors which increase the risk of HPV progression to cervical cancer

Answer 152

Co-infection with other STIs. High parity (> 5 full-term births) and young age at first birth (< 17 years). Combined oral contraceptives use > 5 years Smoking Family history in a first-degree relative. Immunocompromise

Question 153

List the symptoms for cervical cancer

Answer 153

Persistent unexplained abnormal vaginal, intermenstrual, postcoital bleeding Persistent unexplained vaginal discharge Pelvic pain, dyspareunia Postmenopausal bleeding and not taking HRT Postmenopausal bleeding and taking HRT * increase in heaviness, duration of bleeding or irregular bleeding * bleeding beyond 6 months or bleeding after a spell of amenorrhoea

Question 154

List the examination findings in cervical cancer

Answer 154

Inflamed/friable appearance with contact bleeding Visible ulcerating/necrotic lesion on the cervix. Enlarged, indurated inguinal and supraclavicular lymph nodes in advanced disease

Question 155

Give the first line investigation for cervical cancer

Answer 155

Colposcopy

Question 156

Give the gold standard investigation for cervical cancer

Answer 156

Biopsy

Question 157

List the colposcopy findings for cervical cancer

Answer 157

abnormal vascularity white change with acetic acid (cervical intraepithelial neoplasia) pre-cancerous abnormalities may not stain with iodine visible exophytic lesions

Question 158

Give the complications for advanced cervical cancer

Answer 158

Non-specific * Loss of appetite * Unexplained weight loss * Fatigue Pain * Enlarged para-aortic/supraclavicular lymph nodes, bony metastases * Pelvic/back pain - pelvic side wall infiltration * Flank/loin pain - hydroureter, hydronephrosis Renal failure - bilateral ureteric obstruction Severe haemorrhage - erosion and bleeding from major pelvic vessels Fistulae * Vesicovaginal fistula - continual passage of urine through the vagina, incontinence * Rectovaginal fistula - passage of faeces through the vagina Lymphoedema

Question 159

Define cervical intraepithelial neoplasia

Answer 159

Abnormal changes of the cells that line the cervix, typically caused by HPV infections (16 and 18).

Question 160

How may cervical cancer be prevented

Answer 160

HPV vaccination for girls aged 12–13 years (before sexually active)

Question 161

Give the grading for cervical intraepithelial neoplasia

Answer 161

CIN1 (low-grade squamous intraepithelial lesions) ⅓ of the thickness of the surface layer of the cervix is affected. Morphological correlates of HPV infections CIN2 ⅔ of the thickness of the surface layer of the cervix is affected. Correlates of cervical pre-cancers CIN3 (high-grade / severe dysplasia, stage 0 cervical carcinoma in situ) The full thickness of the surface layer is affected. Correlates of cervical pre-cancers

Question 162

Describe the NHS cervical screening programme

Answer 162

24.5 years - the first invitation is issued to ensure that the screening test can be completed by their 25th birthday. 25–49 years - recall every 3 years 50–64 years - recall every 5 years People > 65 years - if a recent cervical cytology sample is abnormal, or they have not had a cervical screening test since 50 years of age and they request one.

Question 163

What is the most common subtype of endometrial cancer

Answer 163

Endometrioid carcinoma of the uterine corpus

Question 164

Define endometrial hyperplasia

Answer 164

Proliferation of endometrial glands resulting in a greater gland-to-stroma ratio than is observed in normal endometrium.

Question 165

List the risk factors for endometrial cancer

Answer 165

Obesity (most important) Age > 50 years Endometrial hyperplasia Unopposed endogenous oestrogen * Anovulation * PCOS * Nulliparity * Early menarche, late menopause * Granulosa cell tumours Unopposed exogenous oestrogen - hormone replacement therapy Tamoxifen use in post-menopausal women Familial cancer syndromes * Lynch syndrome * Cowden syndrome

Question 166

Give the feature of Lynch syndrome

Answer 166

hereditary non-polyposis colorectal cancer - family history of colorectal, endometrial, ovarian cancer

Question 167

Give the feature of Cowden syndrome

Answer 167

PTEN tumour suppressor gene mutation - increased risk for endometrial, breast, thyroid, colorectal, and renal cancer

Question 168

Give the symptom in endometrial cancer

Answer 168

Postmenopausal vaginal bleeding

Question 169

Give the first line investigation and findings in endometrial cancer

Answer 169

Transvaginal ultrasound * Thickened endometrial stripe (>4 mm) * Vascular mass

Question 170

Give the pathophysiology of erythroblastosis fetalis

Answer 170

Maternal IgG crosses the placenta and attaches to foetal RBCs that have expressed the antigen. These RBCs are then sequestered by macrophages in the foetal spleen, where extravascular haemolysis occurs, producing foetal anaemia. The foetus attempts to compensate by increasing extramedullary haematopoiesis. Results in * Hepatosplenomegaly * Portal hypertension * Cardiac compromise * Tissue hypoxia * Hypoviscosity * Increased brain perfusion Extreme foetal haemoglobin deficits of ≥70 g/L can ultimately lead to hydrops fetalis and intrauterine foetal death.

Question 171

List the risk factors for maternal sensitisation to RhD antigen

Answer 171

History of delivery Rh+ve foetus to Rh-ve mother Fetomaternal haemorrhage Invasive foetal procedures Placental trauma Abortion

Question 172

Give the investigation for Rh disease

Answer 172

Blood type and antibody screening At the first antenatal visit, all women are screened for ABO blood group, Rh type, and RBC antibodies Repeated RhD-antibody testing for all unsensitised RhD-ve women at 24-28 weeks’ gestation

Question 173

How is fetomaternal haemorrhage assessed

Answer 173

Rosette test If results +ve, Kleihauer-Betke (acid elution) test / flow cytometry measure the amount of foetal blood in the maternal circulation

Question 174

Give the signs of foetal anaemia

Answer 174

Elevate peak systolic velocity in the middle cerebral artery Ultrasound * Subcutaneous oedema * Ascites * Pleural / Pericardial effusion

Question 175

Give the foetal signs of Rhesus sensitisation

Answer 175

Elevated middle cerebral artery peak systolic velocity Elevated amniotic bilirubin levels

Question 176

What food should be avoided in pregnancy

Answer 176

Food that may contain Listeria * Soft mould-ripened cheeses * Unpasteurized milk or cheese * Pate High levels of vitamin A from liver / liver products - increased the risk of birth defects Fish containing relatively high levels of methylmercury Limit caffeine intake

Question 177

List the effects of listeria infection in pregnancy

Answer 177

miscarriage stillbirth severe illness in the newborn

Question 178

List the effects of high levels of methylmercury in the womb

Answer 178

affect the nervous system of the foetus, potentially increasing the risk of learning or behavioural problems.

Question 179

When is higher dose of folic acid recommended

Answer 179

Previously infant with a neural tube defect Antiepileptic medications Diabetes Coeliac disease Sickle-cell disease, thalassaemia BMI over 30 kg/m2

Question 180

List the ultrasound parameters used for assessment of gestational age

Answer 180

Gestational sac diameter: 4.5~6 weeks Crown-rump length: 7~14 weeks Biparietal diameter, head/abdominal circumference, femur length: 14+ weeks

Question 181

List the screening parameters in the second trimester

Answer 181

MSAFP bHCG Oestriol Inhibin A

Question 182

List the quadruple screening results in Trisomy 18, 21, and neural tube defect

Answer 182

Trisomy 18 * Decreased MSAFP * Decreased bHCG * Decreased estriol * Normal inhibin A Trisomy 21 (if it has 'h' then it's high) * Decreased MSAFP * Increased bHCG * Decreased estriol * Increased inhibin A Neural tube defect * Increased MSAFP * Normal bHCG * Normal estriol * Normal inhibin A

Question 183

List the causes for increased MSAFP

Answer 183

Open neural tube defects Ventral wall defects (omphalocele, gastroschisis) Multiple gestation

Question 184

List the causes for decreased MSAFP

Answer 184

Aneuploidies (trisomy 18, 21)

Question 185

Give the pathophysiology for pre-eclampsia

Answer 185

Failure of normal trophoblast invasion, leading to maladaptation of maternal spiral arterioles.

Question 186

Give the definition for pre-eclampsia

Answer 186

New onset hypertension (>140/90) after 20 weeks of pregnancy + coexistence at least one of: Proteinuria Renal insufficiency (creatinine > 90 micromol/litre, 1.02 mg/100 ml). Liver involvement * Elevated transaminases AAT/AST > 40 IU/litre * RUQ / epigastric pain Neurological complications * Eclampsia (seizure) * Altered mental status * Blindness * Stroke * Clonus * Severe headaches * Persistent visual scotomata Haematological complications * Thrombocytopenia * Disseminated intravascular coagulation * Haemolysis Uteroplacental dysfunction * Foetal growth restriction * Abnormal umbilical artery doppler waveform analysis * Stillbirth

Question 187

Give the cardinal symptoms of pre-eclampsia

Answer 187

Severe headaches Visual problems (blurred vision, flashing lights, double vision, floating spots) Persistent new epigastric / RUQ pain Vomiting. Breathlessness. Sudden swelling of the face, hands, or feet.

Question 188

List the presentations for HELLP syndrome

Answer 188

Epigastric/right upper quadrant pain Nausea, vomiting Jaundice

Question 189

List the risk factors for pre-eclampsia

Answer 189

A history of hypertensive disease during a previous pregnancy Chronic kidney disease Autoimmune disease * Systemic lupus erythematosus * Antiphospholipid syndrome Type 1/2 diabetes. Chronic hypertension First pregnancy. Multiple pregnancy Pregnancy interval of more than 10 years. Aged >40 years BMI > 35 kg/m2 Family history

Question 190

List the maternal complications of pre-eclampsia

Answer 190

Eclamptic seizures Acute renal failure Liver dysfunction Coagulation abnormalities

Question 191

List the causes of death related to pre-eclampsia

Answer 191

Intracranial haemorrhage Cerebral infarction, oedema Acute respiratory distress syndrome Pulmonary oedema Hepatic rupture, failure/necrosis

Question 192

List the pregnancy/foetal/neonatal complications from pre-eclampsia

Answer 192

Placental abruption IUGR Preterm delivery Stillbirth Neonatal death

Question 193

List the investigations for pre-eclampsia

Answer 193

Urine dipstick for protein and measure blood pressure at each antenatal visit

Question 194

Give the management for pre-eclampsia

Answer 194

Aspirin 75-150 mg daily from 12 weeks' gestation until birth

Question 195

Give the management options for chronic hypertension, or new hypertension before 20 weeks' gestation

Answer 195

Labetalol Nifedipine Methyldopa

Question 196

List the maternal pregnancy related risks due to hypertension

Answer 196

Superimposed preeclampsia Postpartum haemorrhage Gestational diabetes Abruptio placentae Caesarean delivery

Question 197

List the foetal pregnancy related risks due to hypertension

Answer 197

Foetal growth restriction Oligohydramnios Preterm delivery Perinatal mortality

Question 198

List the management options for seizures in pregnancy

Answer 198

IV magnesium sulphate

Question 199

What is the most common cause of early-onset severe infection in the neonatal period

Answer 199

Group B Streptococcus

Question 200

List the electrolyte abnormalities seen in hyperemesis gravidarum

Answer 200

hypoNa+, K+, Cl- metabolic alkalosis

Question 201

What treatment is recommended for postmenopausal women with ER+ve breast cancer

Answer 201

Aromatase inhibitors * Letrozole * Anastrozole

Question 202

What treatment is recommended for premenopausal women with ER+ve breast cancer

Answer 202

Tamoxifen (Selective oestrogen receptor modulator)

Question 203

Give the definition for full dilation of cervix

Answer 203

10 cm

Question 204

List the scores in Bishop components

Answer 204

Dilation (cm) 0 - Closed 1 - 1~2 2 - 3~4 3 - 5~6 Position of cervix 0 - Posterior 1 - Mid position 2 - Anterior Effacement (%) 0 - 0~30 1 - 40~50 2 - 60~70 3 - 80 Station 0 - -3 1 - -2 2 - -1, 0 3 - 1. 2 Cervical consistency 1 - Firm 2 - Medium 3 - Soft

Question 205

List the parameters in 1st trimester screening

Answer 205

Ultrasound nuchal translucency PAPP-A (Pregnancy associated plasma protein-A) hCG

Question 206

When may lower levels of PAPP-A be observed

Answer 206

Pre-eclampsia Lower birth weight baby Preterm birth Mid trimester miscarriage

Question 207

List the causes of increased hCG, decreased PAPP-A and thickened nuchal translucency

Answer 207

Down’s Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) - hCG lower

Question 208

List the possible results for combined and quadruple antenatal screening

Answer 208

'lower chance': 1 in >150 chance 'higher chance': 1 in <150 chance

Question 209

What will happen if a woman has a 'higher chance' results on combined or quadruple antenatal tests

Answer 209

offered a second screening test (Non-invasive prenatal screening test) or a diagnostic test (amniocentesis, chorionic villus sampling).

Question 210

Define Non-invasive prenatal screening test (NIPT)

Answer 210

analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free foetal DNA, cffDNA)

Question 211

Give the percentile threshold for small for gestational age

Answer 211

<10 percentile

Question 212

Give the definitions for symmetrical and asymmetrical small for gestational age

Answer 212

Symmetrical: foetal head circumference and abdominal circumference are equally small * Generally due to an early insult during pregnancy (first trimester) Asymmetrical: abdominal circumference relatively decreased than head circumference * Usually happens later in pregnancy

Question 213

List the causes for symmetrical SGA

Answer 213

Idiopathic Chromosomal and congenital abnormalities Toxins - alcohol, heroin TORCH infection * Toxoplasmosis * Others (HIV, syphilis, parvovirus, varicella zoster, listeria) * Rubella * CMV * Herpes Malnutrition

Question 214

List the causes for asymmetrical SGA

Answer 214

Placental insufficiency Pre-eclampsia Chromosomal and congenital abnormalities Toxins - smoking, heroin

Question 215

List the maternal factors for placental insufficiency

Answer 215

Low pre-pregnancy weight Substance abuse Autoimmune disease Renal disease Diabetes Chronic hypertension

Question 216

List the investigations for placental insufficiency

Answer 216

Ultrasound Foetal anatomical survey Uterine artery doppler Karyotyping Infection screen

Question 217

List the neonatal complications for SGA

Answer 217

Birth asphyxia Meconium aspiration Hypothermia Hypo/hyperglycemia Polycythemia Retinopathy of prematurity Persistent pulmonary hypertension Pulmonary haemorrhage Necrotising enterocolitis

Question 218

List the types of multiple gestations

Answer 218

Monochorionic, monoamniotic Monochorionic, diamniotic Dichorionic, diamniotic

Question 219

Give an ultrasound sign for Monochorionic, diamniotic twin

Answer 219

T-sign at intertwin membrane

Question 220

Give an ultrasound sign for Dichorionic, diamniotic twin

Answer 220

Lambda sign at intertwin membrane

Question 221

List the maternal complications for multiple gestations

Answer 221

Hyperemesis gravidarum Preeclampsia Gestational diabetes mellitus Iron-deficiency anaemia

Question 222

List the foetal complications for multiple gestations

Answer 222

Congenital anomalies Foetal growth restriction Preterm delivery Malpresentation Twin-twin transfusion syndrome - monochorionic twins Monoamniotic twins * Conjoined twins * Cord entanglement

Question 223

List the risk factors for multiple gestations

Answer 223

Increased maternal age Increased parity Fertility enhancing therapies Family history

Question 224

Define twin-twin transfusion syndrome

Answer 224

Blood from the placental arteries of one twin is shunted into the placental veins of the other twin

Question 225

List the presentations for donor and recipient twin in Twin-twin transfusion syndrome

Answer 225

Donor twin Renal failure Oligohydramnios Low-output heart failure Foetal growth restriction Recipient twin Polycythemia Polyhydramnios Cardiomegaly High-output heart failure Hydrops fetalis

Question 226

Approximately how much women experience nausea and vomiting in pregnancy

Answer 226

75%

Question 227

When does nausea and vomiting in pregnancy typically onset and resolve?

Answer 227

Typically begins between 4~8 weeks after the last menstrual period and resolves in the second trimester.

Question 228

List the associated factors with nausea and vomiting in pregnancy

Answer 228

Progesterone Oestrogen hCG Helicobacter pylori

Question 229

List the conditions increasing incidence of hyperemesis gravidarum

Answer 229

Multiple gestation Gestational trophoblastic disease Triploidy Trisomy 21, 18 Hydrops fetalis

Question 230

List the clinical classifications of nausea and vomiting in pregnancy

Answer 230

NVP without volume depletion NVP with volume depletion and electrolyte imbalance Hyperemesis gravidarum

Question 231

Give the clinical definition for hyperemesis gravidarum

Answer 231

Persistent vomiting Volume depletion Electrolyte imbalance Ketosis >5% weight loss

Question 232

List the non-medical management options for nausea and vomiting in pregnancy without volume depletion

Answer 232

Dietary modification * Smaller, more frequent meals * Foods that taste bland * Low in fat and high in carbohydrates Alternative treatments - acupressure, acupuncture, ginger

Question 233

List the first line medical management options for nausea and vomiting in pregnancy without volume depletion

Answer 233

pyridoxine (vitamin B6) + doxylamine (antihistamine) antihistamines: oral cyclizine / promethazine phenothiazines: oral prochlorperazine / chlorpromazine

Question 234

Give the management for nausea and vomiting in pregnancy with volume depletion

Answer 234

IV fluids * Ringer’s lactate * Normal saline * 5% dextrose-saline Thiamine - prevent Wernicke's encephalopathy Parenteral antiemetic therapy - ondansetron

Question 235

Why is there increased risk of urinary tract infection in pregnancy

Answer 235

Increase in progesterone causes 1. Ureteral smooth muscle relaxation 2. Ureteral dilation 3. Physiological hydronephrosis and stasis.

Question 236

List the complications of UTI in pregnancy

Answer 236

Increased risk of preterm delivery Low birth weight baby Acute pyelonephritis

Question 237

List the common causative pathogens for UTI in pregnancy

Answer 237

E coli Klebsiella Enterbacter Group B streptococcus

Question 238

List the management for UTI in pregnancy

Answer 238

Cefalexin 500mg 3 times a day for 7 days. Amoxicillin 500mg 3 times a day for 7 days. Nitrofurantion 100mg modified-release twice daily for 7 days (avoid in the third trimester). Trimethoprim 200mg twice daily for 7 days (avoid in the first trimester).

Question 239

Define asymptomatic bacteriuria. What is it usually due to

Answer 239

presence of significant levels of bacteria in the urine of a person without signs or symptoms of UTI Usually due to commensal colonisation

Question 240

List the management for asymptomatic bacteriuria

Answer 240

Nitrofurantoin 100 mg modified-release twice a day for 7 days. Amoxicillin 500 mg three times a day for 7 days (only if susceptibility). Cephalexin 500 mg twice a day for 7 days.

Question 241

List the clinical features of peripartum cardiomyopathy

Answer 241

Heart failure during the last month of pregnancy / within 5 months following delivery LV systolic dysfunction with LVEF < 45% Absence of other causes of heart failure Absence of heart disease prior to final month of pregnancy (dilated cardiomyopathy)

Question 242

What is peripartum cardiomyopathy associated with

Answer 242

mitral regurgitation

Question 243

List the maternal and foetal complications of cyanotic heart disease in pregnancy

Answer 243

Maternal Thromboembolism Fluctuations in systemic vascular resistance * Heart failure * Cerebral vascular changes Foetal Spontaneous abortion Premature labour Intrauterine growth restriction Perinatal mortality

Question 244

Give the maternal and foetal complications for sickle cell disease in pregnancy

Answer 244

Obstetric complications * Spontaneous abortion * Pre-eclampsia, eclampsia * Abruptio placentae * Antepartum bleeding Foetal complications * Foetal growth restriction * Oligohydramnios * Preterm birth

Question 245

List the factors which reduce the chance of vertical transmission of HIV in pregnancy

Answer 245

maternal/neonatal antiretroviral therapy caesarean delivery bottle feeding

Question 246

When is vaginal and C section recommended for HIV in pregnancy

Answer 246

Vaginal delivery is recommended if viral load < 50 copies/ml at 36 weeks Otherwise caesarian section is recommended Zidovudine infusion should be started 4 hours before beginning the caesarean section

Question 247

Describe the neonatal HIV antiretroviral therapy

Answer 247

Zidovudine orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART Therapy continued for 4-6 weeks.

Question 248

Which side is DVT more common in pregnancy. Why?

Answer 248

The left leg (ratio 9:1) than the right Gravid uterus compresses the left common iliac vein, which lies under the right common iliac artery.

Question 249

List the risk factors for venous thromboembolism in pregnancy

Answer 249

Previous venous thromboembolism Thrombophilia Active medical disease * Inflammatory bowel disease * Systemic lupus erythematosus * Pyelonephritis * Nephrotic syndrome Age >35 years Obesity Parity ≥3 Smoking Gross varicose veins Dehydration, hyperemesis gravidarum, ovarian hyperstimulation syndrome Multiple pregnancy Current pre-eclampsia Caesarean section Prolonged labour (>24h) Stillbirth Preterm birth Postpartum haemorrhage (>1 L/requiring transfusion) Surgery in pregnancy or the puerperium Paraplegia, immobility

Question 250

Why are D dimers not useful in pregnancy

Answer 250

Levels are often raised

Question 251

List the managements for thromboembolic diseases in pregnancy

Answer 251

≥4 risk factors - low molecular weight heparin (enoxaparin) continued until 6 weeks postnatal 3 risk factors - low molecular weight heparin (enoxaparin) from 28 weeks continued until 6 weeks postnatal. Avoid warfarin and new oral anticoagulants

Question 252

In what population is postpartum thyroiditis more common in

Answer 252

family history of hypothyroidism, thyroid peroxidase antibodies type 1 diabetes

Question 253

When does postpartum thyroiditis usually present. What is it caused by

Answer 253

Between 3 and 4 months postpartum. Caused by a destructive autoimmune lymphocytic thyroiditis

Question 254

When is gestational diabetes most often recognised

Answer 254

24 to 28 weeks of gestation.

Question 255

List the risk factors for gestational diabetes

Answer 255

Obesity Age Prior GDM Previous macrosomic baby (>4.5 kg) Non-white ancestry Family history T2DM Polycystic ovarian syndrome (insulin resistance + obesity)

Question 256

List the complications of hyperglycemia in late pregnancy

Answer 256

Macrosomia Neonatal hypoglycaemia, hypocalcaemia, hyperbilirubinemia Adverse maternal outcomes * Gestational hypertension * Pre-eclampsia * Caesarean delivery.

Question 257

Give the symptoms for gestational diabetes

Answer 257

Polyuria, polydipsia

Question 257

Give the investigation for gestational diabetes

Answer 257

75-g 2-hour oral glucose tolerance test (OGTT) at 24 to 28 weeks GA in any woman with one or more of: * BMI >30 kg/m² * A previous baby weighing ≥4.5 kg * A first-degree relative with diabetes * Ethnic origin associated with high prevalence of diabetes.

Question 257

What does a 75-g 2-hour oral glucose tolerance test involve

Answer 257

Taking a fasting plasma glucose sample after an overnight fast, giving the woman a 75-g oral glucose solution to drink and then taking a second plasma glucose level after 2 hours.

Question 258

Give the diagnostic criteria for GDM

Answer 258

'5678' Fasting plasma glucose >= 5.6 mmol/L 2-hour plasma glucose >= 7.8 mmol/L

Question 259

List the common skin changes that occur in pregnancy

Answer 259

Striae Spider naevi Melasma (pigmentation on the face) Linea nigra (midline pigmentation on the abdomen)

Question 260

Give the presentation of atopic eruption of pregnancy

Answer 260

Usually starts on the abdomen in the third trimester but may persist for some months after delivery. Clustered excoriated papules (prurigo-like lesions) occur on abdomen and extensor surfaces of limbs.

Question 260

Give the management for atopic eruption of pregnancy

Answer 260

Topical steroids and oral antihistamines Topical benzoyl peroxide; hydrocortisone creams

Question 261

Give the presentation of polymorphic eruption of pregnancy

Answer 261

Intensely itchy rash that starts on abdomen, often within striae, in third trimester Associated with multiple births

Question 261

Give the management for pemphigoid gestationis

Answer 261

systemic steroid therapy

Question 261

List the obstetric complications for SLE nephritis in pregnancy

Answer 261

Persistent foetal bradycardia Caesarean delivery Pre-eclampsia Foetal growth restriction Foetal demise

Question 261

Give the presentation for Pemphigoid gestationis

Answer 261

Often starts around umbilicus with itchy, inflamed papules; then blistering appears and eruption may become generalized Onset in the first/second trimester; typically flares postpartum

Question 261

What may pemphigoid gestationis be associated with

Answer 261

Prematurity and stillbirth Transplacental passage of pathogenic IgG antibodies can lead to transient blistering in the neonate

Question 262

What DMARDs may be allowed in pregnancy

Answer 262

Sulfasalazine Hydroxychloroquine Azathioprine Ciclosporin Biological agents (infliximab, adalimumab)

Question 263

What DMARDs are contraindicated in pregnancy

Answer 263

Mycophenolate mofetil Methotrexate Leflunomide Cyclophosphamide

Question 264

Give the medical method of abortion

Answer 264

Mifepristone followed by misoprostol taken 24~48 hours apart. Most people will pass the pregnancy within 4–6 hours of taking misoprostol

Question 265

List the anatomical locations of ectopic pregnancy

Answer 265

Most ectopic pregnancies (97%) occur in the fallopian tube ampulla (73.3%) isthmus (12.5%) fimbria (11.6%) interstitium and cornua (2.6%) Non-tubal implantation sites Ovary (3.2%) Abdomen (1.3%) Cervix (< 1%) Caesarean section scar (< 1%) Cornua of a unicornuate/bicornuate uterus

Question 266

Which anatomical location of ectopic pregnancy has the highest risk of rupture

Answer 266

Isthmus of fallopian tube

Question 267

Where does ectopic pregnancy most commonly occur

Answer 267

Ampulla of fallopian tube

Question 268

Define heterotopic pregnancy

Answer 268

coexistence of both an intrauterine pregnancy and an ectopic pregnancy

Question 269

List the risk factors for ectopic pregnancy

Answer 269

(tubal epithelial damage) Previous pelvic surgery * Sterilisation * Tubal reconstruction * Caesarean section Previous ectopic pregnancy Hx. pelvic inflammatory disease Hx. infertility Assisted reproduction techniques (IVF) Salpingitis Maternal age >35 years Black ethnicity Smoking Maternal in-utero exposure to diethylstilbesterol Multiple sexual partners Intrauterine contraception

Question 270

When do symptoms of ectopic pregnancy usually occur?

Answer 270

6 to 8 weeks after the last normal menstrual period

Question 271

List the symptoms for ectopic pregnancy

Answer 271

Abdominal/pelvic pain Amenorrhoea/missed period Vaginal bleeding (with/without clots) Less common: Breast tenderness. GI symptoms (diarrhoea/vomiting). Dizziness, fainting, syncope. Shoulder tip pain (diaphragm irrtation due to blood leakage from the implantation site) Urinary symptoms Passage of tissue Rectal pressure/pain on defecation

Question 272

Give the gold standard investigation for ectopic pregnancy

Answer 272

transvaginal ultrasound

Question 273

Define pregnancy of unknown location

Answer 273

positive pregnancy test but no visible evidence of the location of the pregnancy on an ultrasound scan

Question 274

Give the first line medical management for ectopic pregnancy

Answer 274

Medical: parenteral methotrexate Surgical: salpingectomy / salpingotomy

Question 275

Give the criteria for medical management of ectopic pregnancy

Answer 275

Women able to return for follow up and have all of the following: No significant pain. Unruptured ectopic pregnancy with adnexal mass <35mm + no visible heartbeat. Serum hCG < 1500 IU/L. No intrauterine pregnancy

Question 276

Give the criteria for surgical management of ectopic pregnancy

Answer 276

Women unable to return for follow up after methotrexate / have an ectopic pregnancy and any of the following: Significant pain. Adnexal mass >35 mm Foetal heartbeat visible on ultrasound Serum hCG level >5000 IU/L

Question 277

List the pregnancy and non-pregnancy related causes of bleeding in the first and second trimester

Answer 277

Pregnancy-related causes Miscarriage Molar pregnancy Ectopic pregnancy Non-pregnancy-related causes Urethral bleeding. Haemorrhoids. Trauma of the cervix, vagina, or vulva. Cancer of the cervix, vagina, or vulva. Vaginitis. Cervicitis, cervical ectropion, cervical polyps.

Question 278

List the pregnancy and non-pregnancy related causes of abdominal pain in the first and second trimester

Answer 278

Pregnancy-related causes Miscarriage Ectopic pregnancy Ruptured ovarian corpus luteal cyst. Pregnancy-related degeneration of a fibroid Non-pregnancy-related causes Pelvic inflammatory disease. Ovarian cyst (torsion, rupture, bleeding). Torsion of a fibroid. Pelvic vein thrombosis. Musculoskeletal pain. Urinary tract infection Irritable bowel syndrome. Diverticular disease. Constipation. Bowel obstruction. Adhesions. Appendicitis. Renal colic.

Question 279

Give the pathophysiology of complete hydatidiform moles

Answer 279

Complete hydatidiform moles have a 46 XX or 46 XY karyotype that is derived entirely of paternal DNA. This is typically the result of fertilisation of either a chromosomally empty egg with a haploid sperm that then duplicates its chromosomes by two sperm. Do not contain histological or macroscopical evidence of fetal parts, fetal circulation, and fetal red blood cells.

Question 280

Give the pathophysiology of partial hydatidiform moles

Answer 280

Partial hydatidiform moles contain karyotype of either 69 XXX or 69 XXY (both maternal and paternal genetic material) Usually arises from fertilisation of a haploid ovum by either * a single sperm with duplication of paternal haploid chromosomes * two sperm. May contain histological/macroscopical evidence of fetal parts, fetal circulation, and fetal RBC.

Question 281

List the medical sequelae caused by higher elevations in serum hCG levels seen in complete molar pregnancies

Answer 281

hyperemesis gravidarum early-onset gestational hypertension pre-eclampsia theca lutein cysts hyperthyroidism

Question 282

List the presentations of molar pregnancies

Answer 282

First trimester of pregnancy Missed menstrual period Positive urine test for pregnancy Vaginal bleeding Elevated serum hCG levels Commonly at the extremes of reproductive life (<20 or >35 years) Exacerbated symptoms of pregnancy (abnormally high serum hCG levels) * Hyperemesis gravidarum * Hyperthyroidism - palpitations, insomnia, diarrhoea * Early-onset pre-eclampsia - headache, photophobia Uterus larger than GA Increased vascular flow in uterus on ultrasound High-output cardiac failure - dyspnoea and respiratory distress Dyspnoea may also be due to (more common in complete hydatidiform mole) * trophoblastic emboli * pulmonary metastases Pelvic pain (ovarian theca lutein cysts)

Question 283

What differentiates molar pregnancy from thyrotoxicosis due to Graves' disease.

Answer 283

Absence of ophthalmopathy

Question 284

Why are there signs of thyrotoxicosis in molar pregnancies

Answer 284

Due to molecular homology between subunits of thyroid-stimulating hormone and hCG, serum hCG may stimulate the production of thyroid hormone

Question 285

List the investigations for molar pregnancy

Answer 285

Ultrasound screening in the first trimester of pregnancy - increased vascular flow Serum hCG excessive proliferation (often >100,000 IU/L) Pelvic ultrasound

Question 286

List the pelvic ultrasound features in molar pregnancy

Answer 286

Diffuse echogenic snow-storm pattern (intermingling of hydropic villi and blood clots) Smaller volume of abnormal placenta with partial foetal development, without foetal cardiac activity (partial molar pregnancy) Cystic enlargement of the ovaries - theca lutein cysts

Question 287

Give the definitions for primary and secondary infertility

Answer 287

Primary - in couples who have never conceived. Secondary - in couples who have conceived at least once before (with the same or different sexual partner).

Question 288

Define group I ovulation disorders. List the causes

Answer 288

hypothalamic-pituitary failure causing hypogonadotropic hypogonadal anovulation * Hypothalamic amenorrhoea (low BMI, excessive exercise) * Kallmann syndrome [associated with anosmia] (Hypogonadotropic hypogonadism)

Question 289

Define group II ovulation disorders. List the causes

Answer 289

hypothalamic-pituitary-ovarian axis dysfunction causing normogonadotropic normalestrogenic anovulation * Hyperprolactinaemic amenorrhoea * Polycystic ovary syndrome

Question 290

Define group III ovulation disorders. List the causes

Answer 290

ovarian failure causing hypergonadotropic hypoestrogenic anovulation * Premature ovarian insufficiency * Low oestrogen level * Turner syndrome

Question 291

List the warning signs of shoulder dystocia

Answer 291

Prolonged first/second stage of labour Retraction of foetal head into perineum (turtle sign)

Question 292

What nerves are damaged in Klumpke Palsy

Answer 292

C8-T1

Question 293

What nerves are damaged in Erb Palsy

Answer 293

C5-6

Question 294

How is Moro reflex elicited. What are its three components?

Answer 294

Pull up on the infant's arms while in a supine position and letting go of the arms causing the sensation of falling Components 1. spreading out the arms (abduction) 2. pulling the arms in (adduction) 3. crying (usually)

Question 295

What may cause absence or premature disappearance of the Moro reflex

Answer 295

birth injury birth asphyxia intracranial hemorrhage infection brain malformation general muscular weakness of any cause spastic cerebral palsy

Question 296

List the signs of Erb's palsy

Answer 296

"Waiter's tip" * Extended elbow * Pronated forearm * Flexed wrist and fingers Reduced Moro and bicep reflexes on affected side Intact grasp reflex

Question 297

What may asymmetric Moro reflex be due

Answer 297

Damage to a peripheral nerve, cervical cord Fracture of the clavicle

Question 298

List the signs of Klumpke palsy

Answer 298

"Claw hand" (Ulnar C8-T1 palsy) * Extended wrist * Hyperextended metacarpophalangeal joints * Flexed interphalangeal joints * Absent grasp reflex Horner syndrome (ptosis, miosis) Intact Moro and biceps reflexes

Question 299

List the signs of fractured clavicle / humerus in birth injury

Answer 299

Clavicular/upper arm crepitus, bony irregularity Decreased Moro reflex due to pain on affected side Intact biceps and grasp reflexes

Question 300

List the tubal causes for infertility in women

Answer 300

Pelvic inflammatory disease Acute salpingitis Endometriosis Tubal surgeries / sterilisation Ischaemia nodules Polyps / mucus Tubal spasm Congenitally abnormal tubes

Question 301

List the uterine / peritoneal causes for infertility in women

Answer 301

Uterine abnormalities * Adhesions * Polyps * Septae Uterine fibroids Peritoneal factors * Peritubular adhesion * Altered tubal motility * Fimbrial end blockage

Question 302

List the ovulatory causes for infertility in women

Answer 302

Group I ovulation disorders * Hypothalamic amenorrhoea (low BMI, excessive exercise) * Hypogonadotropic hypogonadism (Kallmann syndrome [associated with anosmia]) Group II ovulation disorders * Hyperprolactinaemic amenorrhoea * Polycystic ovary syndrome Group III ovulation disorders * Premature ovarian insufficiency * Low oestrogen level * Turner syndrome Endocrine disorders * Hyper/hypothyroidism * Cushing’s syndrome * Congenital adrenal hyperplasia Chronic debilitating disease * Uncontrolled diabetes * Cancer * AIDS * End-stage kidney disease * Malabsorption

Question 303

List the testicular causes for infertility in men

Answer 303

Primary testicular failure Cryptorchidism Testicular torsion Trauma Orchitis Chromosome disorders * Y chromosome deletions * Klinefelter syndrome XXY Systemic disease Radio/chemotherapy Varicocele Endocrinopathies - low testosterone levels * Hyperprolactinaemia * Kallmann syndrome

Question 304

List the obstructive azoospermia causes for infertility in men

Answer 304

Congenital * Congenital bilateral absence of vas deferens * Prostatic cysts (Mullerian cysts) * Idiopathic epididymal obstruction Epididymal / prostatic infections Vasectomy Surgical complications (inguinal hernia repair, orchiopexy for undescended testicles) CFTR mutation

Question 305

List the ejaculatory causes for infertility in men

Answer 305

Premature/Delayed/Retrograde/Painful ejaculation Anejaculation Anorgasmia Haematospermia Erectile dysfunction

Question 306

List the abnormal sperm function and quality causes for infertility in men

Answer 306

Kartagener syndrome (immotile cilia syndrome) Antisperm antibodies Urogenital tract * Prostatitis * Orchitis * Epididymitis Anabolic steroids

Question 307

List the investigations for infertility in women

Answer 307

Mid-luteal (day 21 of 28) phase progesterone - confirm ovulation Gonadotropin (FSH, LH) TFT Prolactin Screen for chlamydia Hysterosalpingography/contrast ultrasonography Diagnostic laparoscopy (with comorbid conditions) - assess tubal/other pelvic abnormalities

Question 308

List the investigations for infertility in men

Answer 308

Semen analysis * If the result of the first semen sample is abnormal, order a repeat test. * Testing repeated 3 months after the initial test to allow time for the cycle of spermatozoa to be completed. Screen for chlamydia Microbiology Sperm culture Endocrine tests Imaging of the urogenital tract Testicular biopsy

Question 309

List the medical managements for infertility

Answer 309

Clomifene (stimulate gonadotropins) - anovulation If clomiphene-resistant - gonadotropins Pulsatile gonadotropin-releasing hormone Dopamine agonists

Question 310

List the complications of assisted conception

Answer 310

Ovarian hyperstimulation syndrome Ectopic pregnancy Pelvic infection Multiple births

Question 311

List the assisted reproduction techniques

Answer 311

Intrauterine insemination In vitro fertilisation Intracytoplasmic sperm injection Donor insemination Oocyte donation

Question 312

How is intrauterine insemination performed

Answer 312

Timed to coincide with ovulation Sperm is placed in the woman's uterus using a fine plastic tube Low doses of ovary-stimulating hormones (oral anti-oestrogens / gonadotropins) given to maximise pregnancy rates.

Question 313

How is IVF performed. When is it suitable?

Answer 313

Retrieval of one or more ova combined with sperm and incubated for 2–3 days The resultant embryo is then injected into the uterus via the cervix. Suitable for * women who have blocked fallopian tubes * men with a minor degree of subfertility * unexplained infertility * unsuccessful with other techniques

Question 314

How is Intracytoplasmic sperm injection performed. When is it suitable?

Answer 314

Injecting an individual sperm directly into the ovum to bypass natural barriers that prevent fertilisation. The embryo is then transferred into the uterus. Suitable when * the man has a very low sperm count * problems maintaining an erection and ejaculation (eg. diabetes, spinal cord injury)

Question 315

How is Donor insemination performed. When is it suitable?

Answer 315

Insemination of sperm, from a donor, into a woman via her vagina into the cervical canal or into the uterus itself. Suitable when * the man has no (very few) sperm * vasectomy * infectious disease (eg. HIV) * high risk of transmitting a genetic disorder to the offspring

Question 316

How is Oocyte donation performed. When is it suitable?

Answer 316

Stimulation of the donor's ovaries and collection of ova. The donated ova are then fertilised by the recipient's partner's sperm. After 2–3 days, the embryos are transferred to the uterus of the recipient via the cervix after hormonal preparation of the endometrium. Suitable when * ovarian failure (premature, after radiotherapy / chemotherapy) * bilateral oophorectomy * gonadal dysgenesis, eg. Turner's syndrome * risk of transmitting a genetic disorder * IVF failure

Question 317

List the risk factors for ovarian hyperstimulation syndrome

Answer 317

Previous history Young age Lean physique Polycystic ovary syndrome Multiple pregnancies

Question 318

What is ovarian hyperstimulation syndrome

Answer 318

Iatrogenic, potentially life-threatening complication of superovulation caused by vasoactive products released by hyperstimulated ovaries

Question 319

List the symptoms and signs for Ovarian hyperstimulation syndrome

Answer 319

Mild - abdominal bloating, mild abdominal pain. Moderate - nausea, vomiting, increased abdominal discomfort. Severe - oliguria, generalised oedema, abdominal pain/distension (enlarged ovaries and acute ascites), hydrothorax Critical - oligo/anuria, tense ascites / large hydrothorax, thromboembolism, acute respiratory distress syndrome

Question 320

List the onset times for Ovarian hyperstimulation syndrome

Answer 320

Early - within 9 days after the ovulatory dose of hCG Late - endogenous hCG stimulation arising from successful implantation

Question 321

Define miscarriage. Give its classification by time of onset

Answer 321

Spontaneous loss of pregnancy before the foetus reaches viability (24 weeks). Early - < 13 weeks of gestation Late - 13~24 weeks of gestation

Question 322

List the stages of miscarriage and their presentation

Answer 322

Threatened miscarriage * Painless vaginal bleeding, typically at 6~9 weeks * Bleeding often less than menstruation * Cervical os is closed * Complicates up to 25% of all pregnancies * Pregnancy may continue Inevitable miscarriage * Pregnancy is in the process of physiological expulsion from within the uterine cavity. * Pregnancy will not continue and will proceed to incomplete or complete miscarriage. Incomplete miscarriage * Heavy bleeding with clots and pain * Cervical os is open Complete miscarriage * All products of conception have been expelled * Pain and vaginal bleeding * Cervical os is open

Question 323

List the presentation for missed miscarriage

Answer 323

A gestational sac with dead foetus on ultrasound <20 weeks without symptoms of expulsion May have light vaginal bleeding/discharge and symptoms of pregnancy disappear. Painless Cervical os is closed

Question 324

Define anembryonic pregnancy

Answer 324

Gestational sac is >25 mm but no visible embryonic/foetal part

Question 325

Define Recurrent miscarriage

Answer 325

Loss of three or more pregnancies before 24 weeks of gestation.

Question 326

Give the most common cause of spontaneous pregnancy loss in the first trimester

Answer 326

foetal chromosomal abnormalities

Question 327

List the risk factors for miscarriage

Answer 327

Advanced maternal (> 35 years) / paternal (> 45 years) age Congenital uterine anomalies (septate / bicornuate uteri) Maternal endocrine disorders * Polycystic ovary syndrome * Diabetes mellitus * Thyroid disease Vitamin D deficiency Previous miscarriage Maternal lifestyle * Smoking/Alcohol * Increased caffeine * Obesity

Question 328

List the risk factors for recurrent miscarriage

Answer 328

Chromosomal abnormalities Parental chromosomal anomaly eg. Robertsonian translocations Increased sperm DNA fragmentation Blood clotting factors * Antiphospholipid syndrome * Factor V Leiden mutation * Hyperhomocysteinemia Polycystic ovary syndrome Uncontrolled thyroid disorders Prolactin imbalances BMI <19 / >25

Question 329

What's Asherman’s syndrome

Answer 329

Trauma to the endometrial lining during a curettage procedure, causes: * Infertility * Recurrent miscarriage * High-risk pregnancies

Question 330

Give the typical history of miscarriage

Answer 330

Pregnant/symptoms of pregnancy (amenorrhoea, breast tenderness) in the first 24 weeks, presents with vaginal bleeding, with/without pain Bleeding is typically scanting Lower abdominal cramping pain/backache after bleeding

Question 331

Give the management for threatened miscarriage

Answer 331

Vaginal micronized progesterone 400 mg twice daily

Question 332

What is the first line management for confirmed diagnosis of miscarriage

Answer 332

expectant management

Question 333

Give the medical management for missed miscarriage

Answer 333

200 microgram oral mifepristone + 800 micrograms of misoprostol (vaginal, oral, or sublingual) 48 hours later

Question 334

Give the medical management for Incomplete miscarriage

Answer 334

single dose of misoprostol 600 micrograms (vaginal, oral, or sublingual)

Question 335

When is medical management for miscarriage indicated

Answer 335

ongoing symptoms after 14 days of expectant management

Question 336

Give the mechanism of action for mifepristone

Answer 336

Progesterone and glucocorticoid hormone antagonist. Progesterone inhibition releases endogenous prostaglandins from endometrium/decidua - induces bleeding during luteal phase and early pregnancy Glucocorticoid receptor antagonist - treat hypercortisolism in non-pituitary cushing syndrome

Question 337

Give the mechanism of action for Misoprostol

Answer 337

Synthetic prostaglandin E1 analog Binds to smooth muscle cells in the uterine lining to increase the strength and frequency of contractions as well as degrade collagen and reduce cervical tone

Question 338

List the contraindications for oestrogen therapies

Answer 338

Migraine with aura Smoking Ischaemic heart disease Stroke Deep venous thrombosis Major surgery with prolonged immobilisation (oestrogen-containing contraceptives stopped 4~6 weeks before) Severe cirrhosis / liver tumour Poorly controlled hypertension (≥160/100 mmHg) Postnatal < 21 days Breast cancer

Question 339

Define Pelvic inflammatory disease. What does it include?

Answer 339

Infection of the upper genital tract, typically affects sexually active young women. Infection spreads upwards from the vagina and endocervix due to genital tract epithelium damage, causing: Endometritis Salpingitis Parametritis Oophoritis Tubo-ovarian abscess Pelvic peritonitis

Question 340

What is the most common cause for Pelvic inflammatory disease

Answer 340

Chlamydia trachomatis

Question 341

List the common causative organisms for Pelvic inflammatory disease

Answer 341

Chlamydia trachomatis Neisseria gonorrhoeae Mycoplasma genitalium

Question 342

List the risk factors for Pelvic inflammatory disease

Answer 342

Sexual behaviour Recent instrumentation of the uterus / interruption of the cervical barrier * Termination of pregnancy * IU device insertion * Hysterosalpingography/hysteroscopy. * IVF assisted reproductive techniques.

Question 343

List the complications for Pelvic inflammatory disease

Answer 343

Ectopic pregnancy Pelvic peritonitis and sepsis Tubo-ovarian abscess Perihepatitis (Fitz-Hugh-Curtis syndrome) Tubal factor infertility Chronic pelvic pain (Scarring and adhesions following acute infection)

Question 344

What pathogen is Perihepatitis (Fitz-Hugh-Curtis syndrome) associated with

Answer 344

Chlamydia trachomatis

Question 345

How does Perihepatitis (Fitz-Hugh-Curtis syndrome) present

Answer 345

Pleuritic right upper quadrant pain, which may be referred to the right shoulder

Question 346

List the presentations for Pelvic inflammatory disease Tubo-ovarian abscess

Answer 346

Fever Systemic illness Severe pelvic pain Subsequent rupture and sepsis

Question 347

How does Pelvic inflammatory disease cause Tubal factor infertility

Answer 347

Salpingitis with subsequent scarring and adhesions Cause fallopian tubes obstruction / selective loss of ciliated epithelial cells along the fallopian tube Impairs ovum transport

Question 348

List the symptoms for Pelvic inflammatory disease

Answer 348

Pelvic/lower abdominal pain Deep dyspareunia Secondary dysmenorrhoea Abnormal vaginal bleeding (Intermenstrual/Postcoital/Heavy menstrual bleeding) Abnormal vaginal/cervical mucopurulent discharge RUQ/right shoulder pain (perihepatitis) Systemic symptoms * Fever * Nausea, vomiting * Malaise

Question 349

List the investigations for PID

Answer 349

Vaginal swabs Wet-mount vaginal smear - PID unlikely if pus cells absent Blood tests * Elevated leukocyte count * Elevated ESR/CRP STI screen - HIV, hepatitis serology, syphilis serology

Question 350

List the common findings on CT for pelvic inflammatory disease

Answer 350

Free fluid in the pouch of Douglas Pelvic fat stranding Tubo-ovarian abscesses Fallopian tube thickening >5mm

Question 351

Give the management for gonococcal PID

Answer 351

Single IM ceftriaxone 1g, followed by Oral doxycycline 100mg 2/day + metronidazole 400mg 2/day for 14 days.

Question 352

Give the first line management for non-gonococcal PID

Answer 352

Single IM ceftriaxone 1g, followed by Oral doxycycline 100mg twice daily + metronidazole 400 mg twice daily for 14 days.

Question 353

Give the second line management for non-gonococcal PID

Answer 353

Oral ofloxacin 400mg 2/day + oral metronidazole 400mg 2/day for 14 days Oral levofloxacin 500mg 1/day + oral metronidazole 400mg 2/day for 14 days Oral moxifloxacin 400mg 1/day for 14 days

Question 354

Give the management for Mycoplasma genitalium PID

Answer 354

Oral moxifloxacin 400mg 1/day for 14 days

Question 355

Give the definition for primary amenorrhoea

Answer 355

15/16 years in girls with normal secondary sexual characteristics (eg. breast development) 13/14 years in girls with no secondary sexual characteristics

Question 356

Give the definition for Secondary amenorrhoea

Answer 356

cessation of previously established menstruation for 3 cycles / 6 or more months

Question 357

List the causes of primary amenorrhoea

Answer 357

Constitutional delay Pregnancy Outflow tract abnormalities * Imperforate hymen. * Transverse vaginal septum. * Müllerian agenesis Ambiguous genitalia * 5-alpha-reductase deficiency. * Congenital adrenal hyperplasia. * Androgen insensitivity syndrome. Premature ovarian insufficiency * Turner's syndrome [46X] * Chemotherapy * Pelvic radiation * Autoimmune disease Stress, excessive exercise, weight loss (functional hypothalamic amenorrhoea). Hyperprolactinaemia Chronic systemic illness * uncontrolled diabetes * severe renal and cardiac disorders * coeliac disease * cancer * tuberculosis Hypothalamic-pituitary axis dysfunction * hypothalamic or pituitary tumours * cranial irradiation * infection or head injury * Kallman's syndrome * empty sella syndrome * Laurence–Moon–Biedl syndrome * Präder–Willi syndrome Endocrine disorders * Hypo/hyperthyroidism. * Cushing's syndrome. * Androgen-secreting tumours. * Polycystic ovary syndrome

Question 358

List the complications for amenorrhoea

Answer 358

Osteoporosis and fractures Cardiovascular disease Infertility Psychological distress

Question 359

Define Premature ovarian insufficiency

Answer 359

loss of ovarian activity < 40 years

Question 360

List the Causes of secondary amenorrhoea

Answer 360

Physiological * Pregnancy. * Lactation. * Menopause. Premature ovarian insufficiency * Idiopathic early menopause. * Genetic / chromosomal abnormalities. * Chemo/radiotherapy. * Autoimmune disease. * Surgery Functional hypothalamic amenorrhoea Chronic systemic illness * Severe cardiac, renal, or liver disease * Inflammatory bowel disease * Coeliac disease * AIDS * Cancer Cranial irradiation, infection or head injury. CNS tumours (craniopharyngiomas, metastases). Pituitary causes * Prolactinoma * Hypopituitarism (eg. post-TBI). * Sheehan's syndrome. * Sarcoidosis. * Tuberculosis. Uterine causes * Cervical stenosis. * Asherman's syndrome Polycystic ovary syndrome Contraceptives Antipsychotics (increased prolactin levels) Illicit drugs (cocaine, opiates) Surgery Endocrine * Thyroid disease (hypot/hyperthyroidism). * Uncontrolled diabetes. * Cushing's syndrome. * Adrenal insufficiency. * Late-onset congenital adrenal hyperplasia. * Androgen-secreting tumours of the ovary or adrenal gland

Question 361

List the investigations for amenorrhoea

Answer 361

Urinary pregnancy test. Oestradiol Total testosterone levels Pelvic ultrasound Prolactin levels > 1000 mlU/L Thyroid-stimulating hormone levels FSH, LH Coeliac screen

Question 362

List the pelvic ultrasound findings in primary amenorrhoea

Answer 362

Uterus present * outflow obstruction (imperforate hymen, transverse vaginal septum) * polycystic ovary syndrome * Turner's syndrome (46XO, streak ovaries) * Gonadal agenesis (46XX / 46XY) - no secondary sexual characteristics Uterus absent

Question 363

List the differentials for primary amenorrhoea with normal LH and FSH

Answer 363

Outflow obstruction Functional hypothalamic amenorrhoea PCOS

Question 364

What may primary amenorrhoea with Short stature + high FSH and LH levels indicate

Answer 364

Turner's syndrome.

Question 365

What may primary amenorrhoea with Short stature + low FSH and LH levels indicate

Answer 365

intracranial lesion eg. hydrocephalus.

Question 366

What may primary amenorrhoea with Normal height + high FSH and LH levels indicate

Answer 366

ovarian failure

Question 367

What may primary amenorrhoea with Normal height + low FSH and LH levels indicate

Answer 367

constitutional delay weight loss anorexia nervosa

Question 368

What may primary amenorrhoea with high testosterone levels indicate

Answer 368

Late-onset congenital adrenal hyperplasia Cushing's syndrome Androgen insensitivity (46XY genotype, female phenotype) Androgen-secreting tumour Moderate level - PCOS

Question 369

List the Causes of prolactinaemia

Answer 369

Pituitary adenoma Empty sella syndrome Hypothyroidism Pregnancy/breastfeeding. PCOS Drugs * Antipsychotics (risperidone) * Antidepressants (SSRI) * Antiemetics (metoclopramide/domperidone) Renal impairments Needle phobia/traumatic venesection Vigorous exercise within 30 minutes of blood sample

Question 370

Normal menstrual cycle: How long does it last? How long does bleeding last? How much blood loss?

Answer 370

21–35 days long Bleeding lasting an average of 5–7 days Blood loss between 25–80 ml

Question 371

List the causes for menorrhagia

Answer 371

Uterine and ovarian pathologies * Uterine fibroids * Endometrial polyps * Cancer of the ovary, uterus, cervix, endometrium * Endometriosis and adenomyosis * Polycystic ovary syndrome * Pelvic inflammatory disease Systemic conditions * Hypothyroidism * Hyperprolactinaemia * Diabetes mellitus * von Willebrand disease * Liver / renal disease Intrauterine contraceptive device Medications * Anticoagulants * Antiplatelets * NSAIDs * SSRIs * Oral contraceptive pill * Herbal supplements

Question 372

Give the complication for menorrhagia

Answer 372

Iron deficiency anaemia

Question 373

List the investigations for menorrhagia

Answer 373

FBC - iron deficiency anaemia Pregnancy test Vaginal/cervical swab - infection Thyroid function tests Tests for coagulation disorders Hysteroscopy - fibroids, polyps, endometrial pathology Pelvic ultrasounds - large fibroids, pelvic mass Transvaginal ultrasound - adenomyosis

Question 374

List the features that trigger suspected cervical cancer pathway referral

Answer 374

Pelvic mass + any other features of cancer (unexplained bleeding/weight loss). Aged > 55 years with post-menopausal bleeding (unexplained vaginal bleeding > 12 months after menopause). On examination, the appearance of the cervix is consistent with cervical cancer.

Question 375

Give the first line management for amenorrhoea

Answer 375

levonorgestrel intrauterine system - Releases a daily dose 20 micrograms of levonorgestrel (an androgenic progestin)

Question 376

List the hormonal and non-normal management options for Menorrhagia

Answer 376

Hormonal * Combined hormonal contraception (oestrogen + progestogen) * Cyclical oral progestogen (norethisterone) Non-hormonal * Tranexamic acid * NSAIDs (mefenamic acid)

Question 377

List the surgical options for Menorrhagia

Answer 377

Endometrial ablation Uterine artery embolization Myomectomy Hysterectomy

Question 378

Give the pathophysiology for Primary dysmenorrhoea

Answer 378

Before menstruation begins, progesterone levels drop, causing endometrial cells to release prostaglandins. Prostaglandins stimulate uterine myometrial contractions, leading to decreased blood flow, uterine hypoxia, and pain. Further effects of prostaglandins on smooth muscles may manifest as gastrointestinal symptoms.

Question 379

List the risk factors for Primary dysmenorrhoea

Answer 379

Heavy menstrual flow Earlier menarche Nulliparity Family history of dysmenorrhoea Emotional stress BMI < 20 kg/m2 Smoking History of sexual abuse

Question 380

List the causes for secondary dysmenorrhoea

Answer 380

Endometriosis/adenomyosis Fibroids (myomas) Pelvic inflammatory disease Ectopic pregnancy Ovarian/cervical cancer Intrauterine device insertion

Question 381

What is the mean age of natural menopause in the UK?

Answer 381

51 years

Question 382

List the presentations of perimenopause

Answer 382

Menstrual cycle length may shorten to 2–3 weeks or lengthen to many months Menstrual blood loss commonly increases slightly

Question 383

Why is there vasomotor symptoms including hot flushes and night sweats in menopause

Answer 383

Decreasing oestrogen levels cause minor increases in core body temperature Trigger excessive thermoregulatory reaction Promote heat dissipation by peripheral vasodilatation and sweating.

Question 384

List the Risk factors for premature or early menopause

Answer 384

Early menarche Nulliparity/low parity Smoking (strong dose-response effect) Underweight

Question 385

List the causes for Premature ovarian insufficiency

Answer 385

Genetic * Strong maternal family history * Galactosaemia * X chromosome defects Autoimmune * T1DM * Addison’s disease * Thyroid disorders Infection * Tuberculosis * Mumps Iatrogenic * Chemo/radiotherapy * Treatment with gonadotropin-releasing hormone analogues (eg. breast cancer) * Surgery eg. bilateral oophorectomy.

Question 386

List the complications of menopause

Answer 386

Osteoporosis Cardiovascular diseases Stroke Genitourinary syndrome of menopause

Question 387

List the signs and symptoms of menopause

Answer 387

Hot flushes/night sweats (vasomotor symptoms, May be triggered by food and alcohol) Cognitive impairment and mood disorders * Anxiety * Low mood, mood swings * Irritability * Sleep disturbance * Reduced quality of life Genitourinary syndrome of menopause * Vulvovaginal irritation * Discomfort, burning, itching, dryness * Dyspareunia * Reduced libido * Dysuria * Urinary frequency and urgency * Recurrent lower urinary tract infections Altered sexual function Joint and muscle pains Headaches Fatigue

Question 388

Give the management for menopause

Answer 388

Hormone replacement therapy (Oral/transdermal combined oestradiol + progestogen preparation)

Question 389

List the contraindications for HRT

Answer 389

Oestrogen-dependent cancers * breast * ovarian * endometrial (uterine) Undiagnosed vaginal bleeding Untreated endometrial hyperplasia Venous thromboembolism (unless on anticoagulant) Arterial thromboembolic disease (angina, MI) Active liver disease with abnormal LFT Pregnancy Thrombophilic disorder

Question 390

What does HRT increase the risks of

Answer 390

Venous thromboembolism Coronary heart disease and stroke Type 2 diabetes Dementia Breast cancer

Question 391

What are the benefits associated with HRT

Answer 391

Reduce fragility fractures Improve muscle mass and strength

Question 392

List the adverse effects from HRT

Answer 392

Oestrogen-related adverse effects * Fluid retention * Bloating * Breast tenderness/enlargement * Nausea * Headaches * Leg cramps * Dyspepsia * Exacerbate angioedema Progestogen-related adverse effects * Fluid retention * Breast tenderness * Headaches, migraine * Mood swings * Premenstrual syndrome-like symptoms * Depression * Acne vulgaris * Lower abdominal, back pain Vaginal bleeding problems * Unscheduled vaginal bleeding (common within first 3 months) * Monthly cyclical regimens produce regular withdrawal bleeding towards the end of the progestogen phase.

Question 393

List the characteristics of Polycystic ovary syndrome

Answer 393

Hyperandrogenism * Acne * Hirsutism Ovulation disorder - oligo/amenorrhoea Central obesity Acanthosis nigricans Polycystic ovarian morphology on ultrasound

Question 394

List the pathophysiology for PCOS

Answer 394

Insulin resistance and consequent compensatory hyperinsulinemia * Reduced production of sex hormone-binding globulin (SHBG) in the liver * More testosterone is available in the blood in the biologically active unbound form Increased androgen production * Stops follicular development and causes anovulation and menstrual disturbance. Increased serum LH levels * When the concentration of LH increases relative to that of FSH, the ovaries preferentially synthesise androgens from androgen precursors rather than oestrogens. Increased serum oestrogen levels * As a result of continued exposure to oestrogen unopposed by progestogen, the endometrium may become hyperplastic. * In addition, testosterone is converted to oestrogen in peripheral fat.

Question 395

List the complications for PCOS

Answer 395

Infertility Cardiovascular disease Glucose intolerance / T2DM Obstructive sleep apnoea Psychological disorders Pregnancy complications Endometrial cancer Non-alcoholic fatty liver disease

Question 396

List the investigations and findings in PCOS

Answer 396

Moderately elevated testosterone Low sex hormone-binding globulin (SHBG) - surrogate measurement for hyperinsulinaemia Elevated free androgen index - 100*(total testosterone/SHBG) Rule out other causes of oligo/amenorrhoea: * LH/FSH * Prolactin * TSH Ultrasound - presence of >20 follicles in >1 ovary Transvaginal ultrasound - assess endometrial thickness

Question 397

List the management for PCOS

Answer 397

Combined oral contraceptive: 30 micrograms oestrogen + norethisterone/levonorgestrel Metformin

Question 398

What can be given to prevent endometrial hyperplasia in PCOS?

Answer 398

Cyclical progestogen - medroxyprogesterone 10mg daily for 14 days every 1-3 months Low-dose combined oral contraceptive Levonorgestrel-releasing intrauterine device

Question 399

List the classification of ovarian cysts

Answer 399

Physiological * Follicular cysts * Endometriotic cysts * Corpus luteum cysts * Theca lutein cysts Infectious - abscess Benign neoplastic * Fibroma * Adenofibroma * Serous / mucinous cystadenoma * Thecoma * Mature cystic teratoma (dermoid cyst) * Brenner’s tumour Malignant neoplastic * Serous / mucinous cystadenocarcinoma * Endometrioid carcinoma * Immature teratoma Metastatic - most commonly: * Endometrial * Colonic * Gastric cancer

Question 400

Give the pathophysiology of follicular cysts

Answer 400

Develop in response to gonadotropin stimulation and as a variation of the normal physiological process of follicle growth and atresia.

Question 401

Give the pathophysiology of Corpus luteum cysts

Answer 401

Evolve from mature Graafian follicles approximately 2~4 days after ovulation. Vascularisation and spontaneous capillary bleed fills the cystic cavity, creating pressure. Rupture is possible at this point. Eventually, the blood is replaced by clear serous fluid.

Question 402

Give the pathophysiology of Theca lutein cysts

Answer 402

Arise from ovarian theca lutein cells and luteinised granulosa cells responding to stimulation by gonadotropins/bHCG.

Question 403

List the risk factors for ovarian cysts

Answer 403

Pre-menopause Early menarche First trimester of pregnancy Infertility treatments eg. gonadotropins Polycystic ovary syndrome Tamoxifen Endometriosis

Question 404

List the symptoms for ovarian cysts

Answer 404

Chronic pelvic pain Bloating and early satiety Palpable adnexal mass

Question 405

What investigation to order for ovarian cysts?

Answer 405

Transvaginal ultrasonography

Question 406

List the complications for ovarian cysts

Answer 406

Rupture of a corpus luteum cyst Dermoid cyst rupture - peritonitis Ovarian torsion - abdominal pain and fever

Question 407

What may predispose rupture of a corpus luteum cyst

Answer 407

Sexual intercourse Exercise Pelvic examination Days 20~26 of a normal menstrual cycle

Question 408

List the risk factors for ovarian torsion

Answer 408

Ovarian mass Large ovary size Abnormally long fallopian tube, mesosalpinx, mesovarium

Question 409

List the symptoms for ovarian torsion

Answer 409

Sudden onset, severe pelvic / abdominal pain Palpable adnexal mass Nausea and vomiting Diarrhoea Rebound/guarding Localised/diffuse/adnexal tenderness Cervical motion tenderness Fever

Question 410

Give the first line investigation and findings in ovarian torsion

Answer 410

Unilaterally enlarged ovary Whirlpool sign (twisting of the thickened vascular pedicle of the enlarged ovary) Free fluid in the pelvis

Question 411

Define hirsutism

Answer 411

Growth of excess terminal hair in androgen-dependent areas in women (face, chest, abdomen, lower back, upper arms, and thighs)

Question 412

List the causes of hirsutism

Answer 412

Polycystic ovary syndrome Non-classical congenital adrenal hyperplasia. Androgen-secreting tumour. Cushing's syndrome. Acromegaly. Hyperprolactinaemia. Thyroid disorders. Drugs * Anabolic steroids * Ciclosporin * Danazol * Phenytoin, sodium valproate * Tamoxifen

Question 413

List the signs for Androgen-secreting tumour

Answer 413

Sudden onset/rapid progression of hair growth Progression despite treatment Signs of virilization * hair loss from the scalp * voice deepening * Increased muscle bulk * clitoromegaly Pelvic / abdominal mass.

Question 414

List the investigations for hirsutism

Answer 414

Elevated serum total testosterone level (reliable specialty assay) Early morning serum total and free testosterone Early morning 17-hydroxyprogesterone levels in the follicular phase

Question 415

List the first line management for hirsutism

Answer 415

Combined oral contraceptive - oestrogen (ethinylestradiol) + progestogen (levonorgestrel, norethisterone, desogestrel, gestodene, drospirenone)

Question 416

What can be given for facial hirsutism

Answer 416

Topical eflornithine

Question 417

List the causes for hypertrichosis

Answer 417

Congenital * Hurler's syndrome * Trisomy 18 syndrome * Foetal alcohol syndrome Certain conditions * Hypothyroidism * Porphyrias * Epidermolysis bullosa * Anorexia nervosa * Malnutrition * Dermatomyositis * Following a severe head injury Drugs * Minoxidil * Ciclosporin * Glucocorticoids * Phenytoin

Question 418

Define Adenomyosis

Answer 418

Invasion of endometrial glands and stroma into myometrium with surrounding smooth muscle hyperplasia.

Question 419

List the symptoms and signs of Adenomyosis

Answer 419

Typically occurs in parous women Usually diagnosed in the fourth decade Condition regresses after menopause Heavy menstruation bleed and dysmenorrhoea of increasing severity Symmetrically enlarged and tender uterus

Question 420

List the medical treatments for adenomyosis

Answer 420

Levonorgestrel-releasing intrauterine system Prostaglandin synthetase inhibitors

Question 421

List the investigations for adenomyosis

Answer 421

Transvaginal ultrasound MRI

Question 422

Define Endometriosis

Answer 422

Growth of endometrium-like tissue outside the uterus. Hormone mediated, associated with menstruation.

Question 423

Where may endometriosis be distributed

Answer 423

Most commonly distributed in the pelvis * Ovaries * Uterosacral ligaments * Pouch of Douglas (rectouterine pouch) * Rectum and sigmoid colon * Bladder * Distal ureter Extrapelvic deposits * Bowel * Diaphragm * Umbilicus * Pleural cavity

Question 424

List the risk factors for Endometriosis

Answer 424

Early menarche/Late menopause. Delayed childbearing. Nulliparity. Family history. Vaginal outflow obstruction. White ethnicity. Low BMI. Autoimmune disease Late first sexual encounter. Smoking.

Question 425

List the complications for Endometriosis

Answer 425

Endometriomas (ovarian cysts containing blood and endometriosis-like tissue) Infertility Adhesion formation Bowel obstruction Chronic pain Reduced quality of life

Question 426

List the symptoms for Endometriosis

Answer 426

Chronic pelvic pain (> 6 months cyclical/continuous pain) Dysmenorrhoea Deep dyspareunia Period-related/cyclical GI symptoms, painful bowel movements Period-related/cyclical urinary symptoms, blood in urine/pain passing urine Infertility with >1 above

Question 427

List the signs for endometriosis

Answer 427

Abdominal masses Reduced organ mobility and enlargement Tender nodularity in the posterior vaginal fornix Visible vaginal endometriotic lesions

Question 428

Give the gold standard investigation for endometriosis

Answer 428

laparoscopic visualisation of the pelvis

Question 429

Give the first line investigation for endometriosis

Answer 429

Transvaginal ultrasound

Question 430

List the medical management options for endometriosis

Answer 430

Combined oral contraceptive (30 micrograms oestrogen + norethisterone/levonorgestrel) Progestrogen GnRH agonist (leuprolide)

Question 431

List the surgical management options for endometriosis

Answer 431

Laparoscopic excision Ablation of endometriosis Hysterectomy

Question 432

Give the pathophysiology for Fibroids (uterine leiomyomas)

Answer 432

Proliferation of a mixture of smooth muscle cells and fibroblasts, which form hard, round, whorled tumours in the myometrium.

Question 433

List the classification and presentations for Fibroids (uterine leiomyomas)

Answer 433

Subserosal * Develop near the outer serosal surface of the uterus and extend outside the uterus into the peritoneal cavity. * Commonly asymptomatic or minimally symptomatic even when relatively large. When sufficiently large they may cause symptoms due to pressure on adjacent structures. Intramural * Develop within the myometrium without extending predominantly into the uterine cavity or peritoneal cavity. * Cause heavy menstrual bleeding and dysmenorrhea by interfering with the constriction of blood vessels during menstruation. Submucosal * Develop near the inner mucosal surface of the uterus and extend into the uterine cavity. * Even relatively small submucosal fibroids may cause significant heavy menstrual bleeding, dysmenorrhea, or reduce fertility.

Question 434

List the risk factors for Fibroids (uterine leiomyomas)

Answer 434

Increasing age during reproductive years until the menopause. Early menarche Nulliparity Older age at first pregnancy Comorbidities * Obesity * Diabetes * Hypertension Black and asian Family history

Question 435

List the complications for Fibroids (uterine leiomyomas)

Answer 435

Iron deficiency anaemia Infertility Compression of adjacent organs by large fibroids * Recurrent urinary tract infection * Urinary retention * Hydronephrosis Pregnancy complications * Miscarriage * Fibroid vascular infarction - acute pain * Caesarean/instrumental delivery. * Foetal malpresentation. * Preterm delivery. Torsion of a pedunculated fibroid (subserosal/submucosal fibroids) Hemoperitoneum (spontaneous rupture of fibroids)

Question 436

List the Typical symptoms for Fibroids (uterine leiomyomas)

Answer 436

Menorrhoea, dysmenorrhoea Dyspareunia Infertility Pelvic pain, pressure, discomfort Abdominal discomfort, bloating, back pain Urinary symptoms * Frequency, urgency * Urinary incontinence, retention * Increased risk of UTI Bowel symptoms * Bloating * Constipation, painful defecation

Question 437

List the signs for uterine fibroids

Answer 437

Firm, enlarged, irregularly shaped, non-tender uterus on pelvic examination.

Question 438

List the investigations for Fibroids (uterine leiomyomas)

Answer 438

Ultrasound Pelvic MRI

Question 439

Give the medical management for Fibroids (uterine leiomyomas)

Answer 439

Gonadotropin-releasing hormone analogues (induce menopause)

Question 440

Give the surgical management options for Fibroids (uterine leiomyomas)

Answer 440

Myomectomy Hysterectomy Endometrial ablation

Question 441

In what population does Atrophic vaginitis often occur

Answer 441

postmenopausal women

Question 442

List the presentations for Atrophic vaginitis

Answer 442

Vaginal dryness Dyspareunia Occasional spotting Pale and dry on examination

Question 443

List the treatments for Atrophic vaginitis

Answer 443

vaginal lubricants and moisturisers topical oestrogen cream

Question 444

What is Prepubertal atrophic vaginitis caused by

Answer 444

Lack of vaginal oestrogen. This results in an infection-prone alkaline environment, as oestrogen increases levels of lactobacilli which facilitate the conversion of glucose to lactic acid.

Question 445

List the causative factors for Bacterial vaginosis

Answer 445

Loss of lactobacilli Vaginal pH increases to > 4.5 Overgrowth of predominantly anaerobic organisms * Gardnerella vaginalis * Mycoplasma hominis * Prevotella species * Mobiluncus species

Question 446

List the contributing factors for bacterial vaginosis

Answer 446

Sex * Being sexually active * Multiple male sexual partners * Female partners * Sexual relationships with more than one person. * Recent change in sexual partner. * Certain sexual behaviours * Not using condoms and menstruation Douching Herpes simplex virus 2 seropositivity Copper intrauterine contraceptive device Smoking Genital hygiene (not washing vaginal region, infrequent change of underwear) Ethnicity (more prevalent in black women)

Question 447

List the Factors that reduce the risk of developing bacterial vaginosis

Answer 447

Circumcised partner Consistent condom use Hormonal contraception

Question 448

List the complications for Bacterial vaginosis

Answer 448

Increased risks of * HIV * Chlamydia, gonorrhoea, trichomoniasis, HSV-2 * Pelvic inflammatory disease Obstetric and gynaecological * Late miscarriage. * Spontaneous abortion. * Preterm labour and delivery. * Preterm premature rupture of membranes. * Low birth weight baby. * Postpartum endometritis. * Post caesarean delivery wound infections * Post-surgical infections.

Question 449

Give the symptoms for Bacterial vaginosis

Answer 449

~50% asymptomatic. Fishy-smelling, thin, grey/white homogeneous vaginal discharge Not associated with itching/soreness

Question 450

List the investigations for Bacterial vaginosis

Answer 450

pH of discharge: pH > 4.5 Sample of discharge for Gram-staining and microscopy STI screen * Chlamydia and gonorrhoea - vulvovaginal swab * Trichomoniasis - swab taken from the posterior fornix * Blood tests for HIV and syphilis

Question 451

Give the first line management for Bacterial vaginosis. What is an alternative?

Answer 451

Oral metronidazole 400mg 2/day 5-7 days. Alternative = Oral clindamycin

Question 452

List the Causative microorganisms in Vulvovaginal candidiasis

Answer 452

Candida albicans C. glabrata C. tropicalis

Question 453

Define Recurrent Vulvovaginal candidiasis infection

Answer 453

four or more symptomatic episodes in one year, with at least two episodes confirmed by microscopy or culture when symptomatic

Question 454

List the Risk factors for recurrent vulvovaginal candidiasis

Answer 454

Treatment non-compliance Recent antibiotic use within three months (change in vaginal flora) Local irritants (soaps, shampoos, shower gels/douching) Persistent infection with Candida species Infection with non-albicans Candida species Azole-resistant Candida species (Candida glabrata) Immunosuppression Endogenous and exogenous oestrogen

Question 455

List the symptoms and signs for vulvovaginal candidiasis

Answer 455

Symptoms * Vulval/vaginal itch and irritation * Non-offensive, thick, white, curd-like vaginal discharge * Superficial dyspareunia * Dysuria Sign * Erythema * Vaginal fissuring/oedema * Satellite lesions, vulvar excoriation

Question 456

Give the first line investigation in vulvovaginal candidiasis

Answer 456

High vaginal swab of vaginal secretions for microscopy

Question 457

Give the first line management and alternative for acute Vulvovaginal candidiasis infection

Answer 457

First line: fluconazole 150mg oral capsule single dose Alternative: clotrimazole 500mg intravaginal pessary single dose

Question 458

Give the first line management for acute Vulvovaginal candidiasis infection during pregnancy

Answer 458

clotrimazole pessary 500mg intravaginally at night for up to 7 consecutive nights

Question 458

Give the first line management and alternative for recurrent Vulvovaginal candidiasis infection

Answer 458

First line: Induction: 3x oral fluconazole 150mg (every 72 hours) Maintenance: oral fluconazole 150 mg 1/week for six months Alternative: Induction: clotrimazole 500mg intravaginal pessary 7~14 days Maintenance: * Clotrimazole 500mg intravaginal pessary 1/week for six months * Oral itraconazole 50–100mg daily for six months

Question 459

Give the first line management for chronic Vulvovaginal candidiasis infection during pregnancy

Answer 459

Induction: clotrimazole pessary 500mg intravaginally at night Maintenance: one clotrimazole pessary 500mg intravaginally at night 1/week for six months

Question 460

List the Fluconazole contraindications

Answer 460

Acute porphyria Pregnant Breastfeeding

Question 461

Define complicated and uncomplicated chlamydia

Answer 461

Uncomplicated - infection has not ascended to the upper genital tract. Complicated - infection has spread to the upper genital tract, causing PID in women and epididymo-orchitis in men.

Question 462

List the risk factors for Chlamydia

Answer 462

Under 25 years. New sexual partner. More than one sexual partner in the last year. Inconsistent condom use.

Question 463

List the complications for Chlamydia

Answer 463

Pelvic inflammatory disease Epididymo-orchitis Lymphogranuloma venereum Sexually acquired reactive arthritis Perihepatitis (Fitz-Hugh-Curtis syndrome) Adverse outcomes in pregnancy * premature rupture of membranes, preterm delivery, low birth weight * intrapartum pyrexia, late postpartum endometritis. * Infections of the eyes, lungs, nasopharynx, and genitals in the neonate Conjunctivitis Anxiety and psychological distress

Question 464

List the symptoms for chlamydia in sexually active women

Answer 464

Sexually active women Increased vaginal discharge Post-coital/intermenstrual bleeding Purulent vaginal discharge Mucopurulent cervical discharge Deep dyspareunia Dysuria Pelvic pain and tenderness Cervical motion tenderness Inflamed/friable cervix (bleed on contact)

Question 465

List the symptoms for chlamydia in sexually active men

Answer 465

Dysuria Mucoid/mucopurulent urethral discharge Urethral discomfort/urethritis Epididymo-orchitis Reactive arthritis

Question 466

List the Symptoms of lymphogranuloma venereum (LGV)

Answer 466

Tenesmus. Anorectal discharge (often bloody) and discomfort. Diarrhoea, altered bowel habit.

Question 467

Give the gold standard investigation for chlamydia

Answer 467

Nucleic acid amplification tests Women: vulvo-vaginal swab Men: first-catch urine sample

Question 468

Give the first line and alternative management for chlamydia

Answer 468

First line: doxycycline 100mg 2/day 7 days Alternative: * azithromycin 1g oral single dose 1 day, followed by 500mg oral 1/day for 2 days * erythromycin 500mg 2/day for 10–14 days

Question 469

Give the management options for chlamydia in pregnancy

Answer 469

Azithromycin, 1 g orally for 1 day, then 500 mg orally once daily for 2 days Erythromycin 500 mg twice daily for 14 days Amoxicillin 500 mg three times a day for 7 days

Question 470

What is Gonorrhoea caused by

Answer 470

gram-negative diplococci Neisseria gonorrhoeae.

Question 471

List the risk factors for gonorrhoea

Answer 471

Young age (15–24 years). New sexual contact in the last year, or more than one partner in the last year Inconsistent condom use. Men who have sex with men (MSM). Current / prior history of sexually transmitted infection (risk factor for repeat infections). History of sexual / physical abuse. Previous incarceration. Deprivation

Question 472

List the complications of Gonorrhoea in men

Answer 472

Epididymitis / orchitis Prostatitis Urethral stricture. Infection of Mullerian or Cowper glands.

Question 473

List the complications of Gonorrhoea in women

Answer 473

Pelvic inflammatory disease Fitz-Hugh-Curtis syndrome Pregnancy complications * spontaneous abortion * premature labour / rupture of membranes * perinatal mortality * gonococcal conjunctivitis in the newborn

Question 474

List the signs of Disseminated gonorrhoea

Answer 474

Septic arthritis Polyarthralgia Tenosynovitis Petechial/pustular skin lesions Endocarditis Meningitis

Question 475

List the clinical features of gonorrhoea in men

Answer 475

2~8 days after exposure Mucopurulent / purulent urethral discharge Dysuria No frequency / urgency

Question 476

List the clinical features of gonorrhoea in women

Answer 476

Dysuria without urinary frequency Increased / altered vaginal discharge Lower abdominal pain Intermenstrual bleeding / menorrhagia Dyspareunia

Question 477

Give the gold standard investigation for gonorrhoea

Answer 477

Gold standard: nucleic acid amplification tests (NAATs) / culture Women: vulvovaginal swab Men: first pass urine specimen

Question 478

Give the management for gonorrhoea

Answer 478

Ceftriaxone 1g IM single dose

Question 479

What is Trichomoniasis caused by

Answer 479

Flagellated protozoan Trichomonas vaginalis

Question 480

List the complications for Trichomoniasis in women

Answer 480

Pelvic inflammatory disease Alterations to the normal vaginal flora (bacterial vaginosis) HIV transmission Infertility Perinatal complications (preterm delivery/low birthweight) Postpartum sepsis Increased risk of cervical cancer

Question 481

List the complications for Trichomoniasis in men

Answer 481

Acute and chronic prostatitis. Facilitation of HIV transmission Increased risk of prostate cancer. Infertility

Question 482

List the systems and signs for Trichomoniasis

Answer 482

Symptom * Up to 50% asymptomatic * Vaginal discharge - frothy and yellow-green, fishy odour * Vulvar itching, soreness, ulceration * Dysuria * Lower abdominal pain Signs * Yellow-green, frothy discharge with a fishy odour * Inflammation of the vulva and vagina - strawberry cervix

Question 483

List the investigations for trichomoniasis

Answer 483

pH of the vaginal discharge > 4.5 Women: High vaginal swab for bacterial culture in Amies transport medium with charcoal. Men: urethral swab / first-void urine for culture and/or microscopy STI screen * Chlamydia * Gonorrhoea * HIV * Syphilis * Hepatitis

Question 484

What is the common cause of genital herpes simplex in the UK

Answer 484

HSV1

Question 485

What is More likely to cause recurrent genital herpes infection

Answer 485

HSV-2

Question 486

How long is the HSV-2 incubation period

Answer 486

Incubation period 2 days ~ 2 weeks

Question 487

How is HSV transmitted

Answer 487

Mucosal surfaces/breaks in skin by direct contact with infected secretions Asymptomatic but infectious viral shedding

Question 488

List the risk factors for Herpes simplex infection

Answer 488

Age Female sex History of other STIs Multiple sexual partners Unprotected sexual contact Men who have sex with men HIV / immunocompromised

Question 489

List the risk factors for reactivation of latent HSV and recurrent infection

Answer 489

Local trauma UV light HIV/immunocompromised

Question 490

List the complications for Neonatal HSV infection

Answer 490

Jaundice Encephalitis Disseminated infection with multiorgan involvement

Question 491

List the symptoms for HSV infection. Give the natural history

Answer 491

Multiple painful genital blisters which quickly burst to leave erosions and ulcers on the external genitalia, perineum, perianal region. * Lesions typically develop 4~7 days after exposure to HSV infection. * Prodromal tingling or burning pain in the genital area, lower back, buttocks, or upper thighs may occur up to 48 hours before lesions appear in recurrent episodes. * A primary episode can last up to 3 weeks, often more severe than a recurrent episode which typically heals within 6~12 days. Dysuria, vaginal/urethral discharge. Headache, malaise, fever (systemic symptoms more common with first episode).

Question 492

List the signs of HSV infection

Answer 492

Bilateral redness, vesicles, blisters, ulcers Lesions on the upper thighs, buttocks Tender bilateral inguinal lymphadenopathy Herpes proctitis in MSM

Question 493

How do recurrent HSV episodes present

Answer 493

Less severe, unilateral, and localised to the same area (dermatome) during each episode. (Following primary infection, the virus becomes latent in local sensory ganglia where it persists lifelong.)

Question 494

List the first line options for HSV infection

Answer 494

aciclovir 400 mg three times a day for 5 days valaciclovir 500 mg twice a day for 5 days

Question 495

List the infective causes for vaginal discharge

Answer 495

Non-sexually transmitted * Bacterial vaginosis. * Vulvovaginal candidiasis. Sexually transmitted * Chlamydia trachomatis. * Neisseria gonorrhoeae. * Trichomonas vaginalis.

Question 496

List the non-infective causes for vaginal discharge

Answer 496

Inadequate hygiene. Retained foreign body. Irritant and allergic vaginitis. Behçet's syndrome. Desquamative inflammatory vaginitis. Erosive lichen planus. Vaginal fistula. Gynaecological cancers. Genitourinary syndrome of menopause.

Question 497

How does Desquamative inflammatory vaginitis present

Answer 497

Purulent and copious discharge. Dyspareunia, dysuria, bleeding after intercourse, malodour, and vulval symptoms (irritation, burning, dryness, or itching). Vaginal petechiae

Question 498

How does Erosive lichen planus present with vaginal discharge

Answer 498

Very itchy and painful. Affected mucosa is bright red and raw.

Question 499

List the investigations for Vaginal discharge

Answer 499

pH of vaginal discharge High vaginal swabs

Question 500

List the aetiologies for Abnormal uterine bleeding

Answer 500

(PALM-COEIN) Polyp Adenomyosis Leiomyoma Malignancy and hyperplasia Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not otherwise classified

Question 501

Define chronic Abnormal uterine bleeding

Answer 501

Bleeding from the uterine body/corpus that is abnormal in frequency, regularity, duration, volume + present for most of the past 6 months.

Question 502

List the medical management options for acute Abnormal uterine bleeding

Answer 502

Tranexamic acid Hormone treatments * IV conjugated oestrogen * Combined oral contraceptive * Progestogen-only hormone based treatment

Question 503

List the first line and second line management options for Chronic Abnormal uterine bleeding

Answer 503

First line: levonorgestrel intrauterine device Second line: Combined oestrogen and progestogen

Question 504

What anatomical determinant can be compromised due to damage during childbirth leading to a higher likelihood of prolapse in subsequent pregnancies?

Answer 504

Uterosacral Ligament

Question 505

How is physiological splitting of S2 mediated in a pregnant woman at gestational age 36 weeks?

Answer 505

Delayed closure of the pulmonary valve during inspiration 1. Increase in blood return to the right side of the heart, due to the negative intrathoracic pressure 2. Increased right ventricular stroke volume, which takes longer to eject, causing delayed closure of the pulmonary valve.

Question 506

What microorganism commonly causes postpartum infection

Answer 506

Streptococcus agalactiae Gram-positive, catalase negative, beta-hemolytic

Question 507

Define postpartum depression

Answer 507

Significant depressive symptoms persisting >2 weeks, including persistent tearfulness, apathy, insomnia, anhedonia and an impaired ability to care for self or baby. Typically occurs within the first 6 weeks postpartum, can appear up to one year after childbirth.

Question 508

What is the most common cause of anaemia in pregnancy and the postpartum period?

Answer 508

Iron deficiency anaemia

Question 509

What may aspirin at 81 mg/day prevent

Answer 509

Preeclampsia IUGR

Question 510

Where is progesterone produced from in pregnancy

Answer 510

Syncytiotrophoblast cells of the placenta

Question 511

What may nitrofurantoin use at the third trimester cause

Answer 511

Haemolytic anaemia due to G6PD deficiency

Question 512

List the compilations of pregnant women with SLE

Answer 512

Frequent lupus flares Increased risk of venous thromboembolism Renal abnormalities Congenital heart block in the foetus

Question 513

Describe the immunological change associated with pregnancy

Answer 513

Shift from T1 mediated to T2 mediated immunity

Question 514

What medication is used after pre-eclampsia has developed

Answer 514

Magnesium sulphate

Question 515

When should foetal movements be established by

Answer 515

24 weeks GA Usually occurs between 18-20 weeks gestation, and increases until 32 weeks (plateau).

Question 516

Define reduced foetal movements

Answer 516

<10 movements within 2 hours (in pregnancies past 28 weeks gestation)

Question 517

List the risk factors for reduced foetal movements

Answer 517

Posture Distraction Placental position Medication * Alcohol * Sedative: opiates/benzodiazepines Anterior foetal position Obese Oligo/polyhydramnios Small for gestational age foetus

Question 518

List the investigations in reduced foetal movements for >28 weeks GA

Answer 518

First line: handheld Doppler - confirm foetal heartbeat. * If no foetal heartbeat - immediate ultrasound * If foetal heartbeat is present, CTG at least 20 minutes to monitor fetal heart rate, exclude fetal compromise If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound: * abdominal circumference * estimated foetal weight (to exclude SGA) * amniotic fluid volume

Question 519

Give the first line investigation for premature prelabour rupture of membranes

Answer 519

sterile speculum examination - pooling of amniotic fluid in the posterior vaginal vault

Question 520

List the complications for premature prelabour rupture of membranes

Answer 520

Foetal: prematurity, infection, pulmonary hypoplasia Maternal: chorioamnionitis

Question 521

What is the most important parameter to monitor when administering magnesium sulphate for eclampsia

Answer 521

Respiratory rate

Question 522

What parameters need to be monitored when

Answer 522

Respiratory rate Urine output Reflexes Oxygen saturation

Question 523

List the drugs contraindicated in breastfeeding

Answer 523

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

Question 524

Give the mechanism of metformin

Answer 524

Increases peripheral insulin sensitivity

Question 525

What is the first-line treatment for magnesium sulphate induced respiratory depression

Answer 525

Calcium gluconate

Question 526

What is the preferred method of induction of labour if the Bishop score is ≤ 6

Answer 526

Vaginal PGE2 or oral misoprostol

Question 527

What should women with severe premenstrual symptoms be managed with

Answer 527

SSRIs

Question 528

What is the first line pharmacological treatment for adults with nausea and vomiting in pregnancy, or hyperemesis gravidarum

Answer 528

Promethiazine

Question 529

What is a contraindication for using epidural anaesthesia during labour?

Answer 529

Coagulopathy

Question 530

What may be used in patients with stress incontinence who don't respond to pelvic floor muscle exercises and decline surgical intervention

Answer 530

Duloxetine

Question 531

Give the for first-line treatment for urge incontinence and stress incontinence

Answer 531

Urge incontinence: bladder retraining Stress incontinence: pelvic floor muscle training

Question 532

List the risk factors for cervical ectropion

Answer 532

(Elevated oestrogen levels) Ovulatory phase Pregnancy Combined oral contraceptive pill

Question 533

List the features in cervical ectropion

Answer 533

vaginal discharge post-coital bleeding

Question 534

Give the first line treatment for primary dysmenorrhea

Answer 534

Mefenamic acid

Question 535

What day will progesterone levels peak in a 35 day cycle

Answer 535

28

Question 536

Give the The RCOG 'Air Travel and Pregnancy' Guidance

Answer 536

women with uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks

Question 537

What score is used to classify the severity of nausea and vomiting in pregnancy

Answer 537

Pregnancy-Unique Quantification of Emesis (PUQE) score

Question 538

What is Mittelschmerz

Answer 538

Benign preovulatory lower abdominal pain that occurs midcycle (between days 7 and 24) in women

Question 539

Give the typical history in ectopic pregnancy

Answer 539

6-8 weeks amenorrhoea with lower abdominal pain and later develops vaginal bleeding

Question 540

List the complications of intrahepatic cholestasis of pregnancy

Answer 540

Intrauterine foetal demise Preterm delivery Meconium-stained amniotic fluid Neonatal respiratory distress syndrome

Question 541

Give the delivery plan for intrahepatic cholestasis of pregnancy

Answer 541

Delivery at 37 weeks - induction of labour planned at 37-38 weeks

Question 542

Give the presentations of intrahepatic cholestasis of pregnancy

Answer 542

Develops in 3rd trimester Generalised pruritus, worse on hands and feet RUQ pain

Question 543

What is the only non-surgical management option recommended for stress incontinence, following a failed course of pelvic floor exercises.

Answer 543

duloxetine

Question 544

What is the preferred method of smoking cessation in pregnant women

Answer 544

Nicotine replacement therapy

Question 545

List the indications for category 1 C section

Answer 545

Suspected uterine rupture Major placental abruption Cord prolapse Foetal hypoxia Persistent foetal bradycardia

Question 546

What vaccine should not be administered to women known to be pregnant or attempting to become pregnant, be it separately or combined.

Answer 546

MMR

Question 547

If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l, what drug should be started

Answer 547

immediate insulin (+/- metformin)

Question 548

What may be used in endometriosis if NSAIDs/COCP have not controlled symptoms

Answer 548

GnRH analogues

Question 549

Give the stereotypical history in ruptured ovarian cyst

Answer 549

Sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity

Question 550

What is the procedure to treat pre-cancerous changes of the cervix

Answer 550

Large loop excision of transformation zone (LLETZ)

Question 551

Give the advice for methotrexate before attempting to conceive

Answer 551

Methotrexate must be stopped at least 6 months before conception in both men and women

Question 552

Within what time frame should category 1 caesarean section occur

Answer 552

30 minutes

Question 553

Within what time frame should category 2 caesarean section occur

Answer 553

75 minutes

Question 554

Give the pathophysiology of cervical ectropions

Answer 554

Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

Question 555

When is the earliest time a woman can be offered ECV

Answer 555

36 weeks

Question 556

List the common long term complications of vaginal hysterectomy with antero-posterior repair

Answer 556

Enterocoele Vaginal vault prolapse