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Medicine > Obstetrics & Gynaecology > Flashcards

Obstetrics & Gynaecology Flashcards

1
Q

List the functions of oestrogen

A

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.

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2
Q

List the physiological changes in pregnancy

A

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

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3
Q

List the functions of progesterone during the luteal phase

A

(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

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4
Q

List the functions of progesterone during pregnancy

A

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

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5
Q

List the oestrogen synthesis pathway from cholesterol

A

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

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6
Q

List the functions of FSH

A

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.

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7
Q

List the functions of LH

A

Stimulates ovulation
Reactivation of meiosis I
Sustains corpus luteum development

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8
Q

What is prolactin release stimulated by

A

Oestrogen
Phenothiazine
Reserpine
Methyltyrosine

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9
Q

What is prolactin release inhibited by

A

Dopamine
Bromocriptine
Cabergoline

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10
Q

What is the effect of hyperprolactinemia on ovulation

A

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

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11
Q

List the three stages of labour

A

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.

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12
Q

List the clinical signs of the onset of labour

A

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

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13
Q

Give the definition for pre-labour rupture of membranes

A

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

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14
Q

List the hormonal changes during initiation of labour

A

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

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15
Q

List the mechanisms of labour

A

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

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16
Q

List the mechanisms of the third stage of labour

A

(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

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17
Q

List the signs of placental separation

A

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

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18
Q

When is third stage considered abnormal

A

If the placenta is not expelled within 30 minutes

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19
Q

When does preterm labour occur?

A

Between 24 and 37 weeks gestation.

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20
Q

Give the classification for premature labour

A

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

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21
Q

List the causes for preterm labour

A

Antepartum haemorrhage
Multiple pregnancy
Infection
Polyhydramnios
Socioeconomic

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22
Q

Give the risk factor for PPROM

A

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

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23
Q

List the management for PPROM

A

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

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24
Q

Give the presentation for PPROM

A

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

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25
Q

List the investigations to predict premature labour

A

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

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26
Q

List the indications for induction of labour

A

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

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27
Q

List the methods for induction of labour

A

Prostaglandin E2 pessaries
Syntocinon + Fore/hindwater rupture of membranes

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28
Q

Define Cord presentation

A

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

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29
Q

List the management for cord presentation

A

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

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30
Q

When may episiotomy be indicated during a normal vaginal delivery

A

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

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31
Q

List the management for abnormal third stage of labour

A

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).

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32
Q

List the risk factors for anal sphincter damage

A

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

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33
Q

Define frank (extended breech)

A

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.

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34
Q

Define flexed breech

A

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.

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35
Q

Define knee or footling presentation

A

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.

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36
Q

Why is there decrease in systemic vascular resistance during pregnancy

A

Progesterone

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37
Q

Why is there reduced functional residual capacity in pregnancy

A

Elevation of diaphragm

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38
Q

List the physiology of gallbladder disease in pregnancy

A

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

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39
Q

List the thyroid changes in pregnancy, give the mechanisms

A

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

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40
Q

List the metabolic effects of human placental lactogen

A

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

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41
Q

Define normal contraction

A

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

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42
Q

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

A

Terbutaline (tocolytic)

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43
Q

List the tocolytics and their contraindications

A

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)

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44
Q

List the management approaches to foetal tachysystole

A

Discontinue uterotonics
Lateral decubitus positioning
Tocolysis

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45
Q

List the components in Bishop score

A

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.

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46
Q

What does station 0 in Bishop score indicate?

A

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.

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47
Q

Give signs of False (Braxton Hicks) contraction

A

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

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48
Q

List the adverse drug reactions to epidural anaesthesia

A

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

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49
Q

When does engagement of foetal head occur?

A

Stage 1 latent phase

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50
Q

List the management for abnormal stage 1 latent phase

A

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

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51
Q

List the disorders and management of the active phase of labour

A

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

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52
Q

Define second stage arrest of labour

A

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

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53
Q

List the aetiology of second stage arrest of labour

A

Cephalopelvic disproportion
Malposition
Inadequate contractions
Maternal exhaustion

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54
Q

Give management options for second stage arrest of labour

A

Operative vaginal delivery
Caesarean delivery

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55
Q

Give management options for abnormal third stage of labour

A

Uterine massage and controlled cord traction
Oxytocin
Manual extraction
Surgery

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56
Q

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

A

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

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57
Q

List the management for PPROM

A

<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

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58
Q

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

A

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

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59
Q

List the presentation of intrapartum fever (endometritis/chorioamnionitis)

A

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

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60
Q

List the management for intrapartum fever (endometritis/chorioamnionitis)

A

Ampicillin + gentamicin/clindamycin
Delivery

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61
Q

List the risk factors for postpartum endometritis

A

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

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62
Q

List the clinical features for postpartum endometritis

A

Fever >24hr postpartum
Uterine fundal tenderness
Purulent lochia

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63
Q

Give the management for postpartum endometritis

A

Clindamycin + gentamicin

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64
Q

List the complications for surgical induction of labour

A

Hyperstimulation
Prolapse of the cord
Infection

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65
Q

Define third- and fourth-degree injuries

A

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

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66
Q

List the risk factors for breech presentation

A

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

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67
Q

List the management for breech presentation

A

Caesarean delivery
External cephalic version

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68
Q

List the complications of external cephalic version

A

cord entanglement
placental abruption
rupture of the membranes

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69
Q

List the indications for C-section

A

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

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70
Q

List the classifications for C-section

A

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

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71
Q

List the complications for C-section

A

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

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72
Q

List the predisposing factors for shoulder dystocia

A

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

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73
Q

Give the approach for shoulder dystocia

A

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.

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74
Q

Define primary postpartum haemorrhage

A

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

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75
Q

List the causes for primary postpartum haemorrhage

A

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)

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76
Q

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

A

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.

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77
Q

List the management for PPH due to uterine atony

A

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

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78
Q

List the mechanisms of actions and contraindications for uterotonics

A

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.

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79
Q

List the surgical techniques for primary postpartum haemorrhage

A

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

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80
Q

Give the STASIS algorithm for severe refractory PPH

A

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

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81
Q

Define secondary postpartum haemorrhage

A

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

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82
Q

List the causes of secondary postpartum haemorrhage

A

Retained placental tissue
Intrauterine infection
Trophoblastic disease
Intrauterine arteriovenous malformation

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83
Q

Define placenta accreta spectrum

A

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

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84
Q

List the risk factors for placenta accreta spectrum

A

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

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85
Q

List the types of placenta accreta spectrum

A

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

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86
Q

Give the investigation for placenta accreta spectrum

A

Colour flow doppler ultrasound

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87
Q

Give the presentations for placenta accreta spectrum

A

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

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88
Q

List the causes for antepartum haemorrhage

A

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

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89
Q

Give the definition for antepartum haemorrhage

A

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

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90
Q

List the risk factors for uterine rupture

A

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

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91
Q

List the clinical presentations for uterine rupture

A

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

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92
Q

Define placenta praevia and low lying placenta

A

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

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93
Q

Give the management for uterine rupture

A

Laparotomy for delivery and uterine repair

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94
Q

Define vasa praevia

A

Foetal vessels lie over the internal cervical os

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95
Q

List the risk factors for vasa praevia

A

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

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96
Q

List the clinical presentations for vasa praevia

A

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

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97
Q

Give the management for vasa praevia

A

Emergency caesarean delivery

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98
Q

List the risk factors for placenta praevia

A

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

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99
Q

Give the typical symptom in placenta praevia

A

Second / third-trimester PAINLESS vaginal bleeding

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100
Q

Give the investigation for placenta praevia

A

Transabdominal ultrasound

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101
Q

Define abruptio placentae

A

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

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102
Q

Give the types of abruptio placentae

A

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

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103
Q

List the symptoms of abruptio placentae

A

Abdominal pain
Uterine contractions
Uterine tenderness
Vaginal bleeding (revealed)

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104
Q

List the foetal heart rate monitoring abnormalities that suggest an abruption

A

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

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105
Q

List the investigations for abruptio placentae

A

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

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106
Q

List the transabdominal ultrasound signs in abruptio placentae

A

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

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107
Q

Give the typical symptoms for cyclical breast pain

A

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

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108
Q

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

A

> 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.

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109
Q

List the causes for non-cyclical breast pain

A

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

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110
Q

List the management for cyclical breast pain

A

Paracetamol / ibuprofen
NSAIDs

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111
Q

Where is lactational abscess commonly localised

A

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

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112
Q

Where is non-lactational abscess commonly localised

A

In the central/subareolar or lower quadrants of the breast

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113
Q

List the causes for lactational mastitis

A

Milk stasis
Infection - S aureus, including MRSA

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114
Q

List the causes for non-lactational mastitis

A

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)

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115
Q

List the predisposing factors for granulomatous mastitis

A

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

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116
Q

List the complications for mastitis

A

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

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117
Q

List the typical symptoms of mastitis

A

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

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118
Q

List the features for periductal mastitis

A

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.

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119
Q

List the features for granulomatous mastitis

A

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

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120
Q

List the typical symptoms of breast abscess

A

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.

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121
Q

Give the investigation for mastitis

A

Breast milk culture

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122
Q

List the differential diagnoses for breast pain with lactation

A

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

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123
Q

List the differential diagnoses for breast pain not associated with lactation

A

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

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124
Q

List the differential diagnoses for nipple pain

A

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

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125
Q

List the management options for lactational mastitis

A

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

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126
Q

List the management options for non-lactational mastitis

A

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

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127
Q

Give the most common female malignancy

A

Breast cancer

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128
Q

Give the five-year survival rate for breast cancer

A

85%

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129
Q

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

A

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

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130
Q

List the risk factors for breast cancer

A

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

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131
Q

Which subtype of breast cancer is associated with BRCA1 mutations

A

Basal type tumours

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132
Q

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

A

Basal type and HER2+ tumours

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133
Q

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

A

Luminal A tumours

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134
Q

List the symptoms for breast cancer

A

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

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135
Q

Give the first line imaging investigation for breast cancer

A

Mammography

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136
Q

Give the gold standard investigation for breast cancer

A

Image-guided core biopsy

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137
Q

Describe the breast screening programme

A

3 yearly routine for women aged 50–70 years

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138
Q

List the benefits of breast screening

A

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

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139
Q

List the cons for breast screening

A

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.

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140
Q

Give the classifications for ovarian cancer

A

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

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141
Q

Where may ovarian cancer spread to

A

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

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142
Q

List the risk factors for ovarian cancer

A

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

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143
Q

What is the risk of ovarian cancer reduced by

A

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

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144
Q

List the symptoms for ovarian cancer

A

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).

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145
Q

List the investigations for ovarian cancer

A

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

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146
Q

List the other causes of a raised serum CA125

A

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.

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147
Q

Define Meigs syndrome

A

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

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148
Q

Where do most cases of cervical cancer originate from

A

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

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149
Q

List the types of cervical cancer

A

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

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150
Q

Give the cause of cervical cancer

A

Human papillomavirus (subtypes 16 and 18)

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151
Q

List the risk factors for acquiring HPV infection

A

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

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152
Q

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

A

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

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153
Q

List the symptoms for cervical cancer

A

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

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154
Q

List the examination findings in cervical cancer

A

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

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155
Q

Give the first line investigation for cervical cancer

A

Colposcopy

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156
Q

Give the gold standard investigation for cervical cancer

A

Biopsy

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157
Q

List the colposcopy findings for cervical cancer

A

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

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158
Q

Give the complications for advanced cervical cancer

A

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

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159
Q

Define cervical intraepithelial neoplasia

A

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

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160
Q

How may cervical cancer be prevented

A

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

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161
Q

Give the grading for cervical intraepithelial neoplasia

A

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

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162
Q

Describe the NHS cervical screening programme

A

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.

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163
Q

What is the most common subtype of endometrial cancer

A

Endometrioid carcinoma of the uterine corpus

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164
Q

Define endometrial hyperplasia

A

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

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165
Q

List the risk factors for endometrial cancer

A

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

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166
Q

Give the feature of Lynch syndrome

A

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

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167
Q

Give the feature of Cowden syndrome

A

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

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168
Q

Give the symptom in endometrial cancer

A

Postmenopausal vaginal bleeding

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169
Q

Give the first line investigation and findings in endometrial cancer

A

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

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170
Q

Give the pathophysiology of erythroblastosis fetalis

A

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.

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171
Q

List the risk factors for maternal sensitisation to RhD antigen

A

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

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172
Q

Give the investigation for Rh disease

A

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

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173
Q

How is fetomaternal haemorrhage assessed

A

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

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174
Q

Give the signs of foetal anaemia

A

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

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175
Q

Give the foetal signs of Rhesus sensitisation

A

Elevated middle cerebral artery peak systolic velocity
Elevated amniotic bilirubin levels

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176
Q

What food should be avoided in pregnancy

A

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

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177
Q

List the effects of listeria infection in pregnancy

A

miscarriage
stillbirth
severe illness in the newborn

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178
Q

List the effects of high levels of methylmercury in the womb

A

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

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179
Q

When is higher dose of folic acid recommended

A

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

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180
Q

List the ultrasound parameters used for assessment of gestational age

A

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

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181
Q

List the screening parameters in the second trimester

A

MSAFP
bHCG
Oestriol
Inhibin A

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182
Q

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

A

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

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183
Q

List the causes for increased MSAFP

A

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

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184
Q

List the causes for decreased MSAFP

A

Aneuploidies (trisomy 18, 21)

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185
Q

Give the pathophysiology for pre-eclampsia

A

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

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186
Q

Give the definition for pre-eclampsia

A

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

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187
Q

Give the cardinal symptoms of pre-eclampsia

A

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.

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188
Q

List the presentations for HELLP syndrome

A

Epigastric/right upper quadrant pain
Nausea, vomiting
Jaundice

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189
Q

List the risk factors for pre-eclampsia

A

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

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190
Q

List the maternal complications of pre-eclampsia

A

Eclamptic seizures
Acute renal failure
Liver dysfunction
Coagulation abnormalities

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191
Q

List the causes of death related to pre-eclampsia

A

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

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192
Q

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

A

Placental abruption
IUGR
Preterm delivery
Stillbirth
Neonatal death

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193
Q

List the investigations for pre-eclampsia

A

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

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194
Q

Give the management for pre-eclampsia

A

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

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195
Q

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

A

Labetalol
Nifedipine
Methyldopa

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196
Q

List the maternal pregnancy related risks due to hypertension

A

Superimposed preeclampsia
Postpartum haemorrhage
Gestational diabetes
Abruptio placentae
Caesarean delivery

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197
Q

List the foetal pregnancy related risks due to hypertension

A

Foetal growth restriction
Oligohydramnios
Preterm delivery
Perinatal mortality

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198
Q

List the management options for seizures in pregnancy

A

IV magnesium sulphate

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199
Q

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

A

Group B Streptococcus

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200
Q

List the electrolyte abnormalities seen in hyperemesis gravidarum

A

hypoNa+, K+, Cl-
metabolic alkalosis

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201
Q

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

A

Aromatase inhibitors
* Letrozole
* Anastrozole

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202
Q

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

A

Tamoxifen (Selective oestrogen receptor modulator)

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203
Q

Give the definition for full dilation of cervix

A

10 cm

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204
Q

List the scores in Bishop components

A

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

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205
Q

List the parameters in 1st trimester screening

A

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

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206
Q

When may lower levels of PAPP-A be observed

A

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

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207
Q

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

A

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

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208
Q

List the possible results for combined and quadruple antenatal screening

A

‘lower chance’: 1 in >150 chance
‘higher chance’: 1 in <150 chance

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209
Q

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

A

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

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210
Q

Define Non-invasive prenatal screening test (NIPT)

A

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

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211
Q

Give the percentile threshold for small for gestational age

A

<10 percentile

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212
Q

Give the definitions for symmetrical and asymmetrical small for gestational age

A

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

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213
Q

List the causes for symmetrical SGA

A

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

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214
Q

List the causes for asymmetrical SGA

A

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

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215
Q

List the maternal factors for placental insufficiency

A

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

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216
Q

List the investigations for placental insufficiency

A

Ultrasound
Foetal anatomical survey
Uterine artery doppler
Karyotyping
Infection screen

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217
Q

List the neonatal complications for SGA

A

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

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218
Q

List the types of multiple gestations

A

Monochorionic, monoamniotic
Monochorionic, diamniotic
Dichorionic, diamniotic

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219
Q

Give an ultrasound sign for Monochorionic, diamniotic twin

A

T-sign at intertwin membrane

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220
Q

Give an ultrasound sign for Dichorionic, diamniotic twin

A

Lambda sign at intertwin membrane

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221
Q

List the maternal complications for multiple gestations

A

Hyperemesis gravidarum
Preeclampsia
Gestational diabetes mellitus
Iron-deficiency anaemia

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222
Q

List the foetal complications for multiple gestations

A

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

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223
Q

List the risk factors for multiple gestations

A

Increased maternal age
Increased parity
Fertility enhancing therapies
Family history

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224
Q

Define twin-twin transfusion syndrome

A

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

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225
Q

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

A

Donor twin
Renal failure
Oligohydramnios
Low-output heart failure
Foetal growth restriction

Recipient twin
Polycythemia
Polyhydramnios
Cardiomegaly
High-output heart failure
Hydrops fetalis

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226
Q

Approximately how much women experience nausea and vomiting in pregnancy

A

75%

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227
Q

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

A

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

228
Q

List the associated factors with nausea and vomiting in pregnancy

A

Progesterone
Oestrogen
hCG
Helicobacter pylori

229
Q

List the conditions increasing incidence of hyperemesis gravidarum

A

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

230
Q

List the clinical classifications of nausea and vomiting in pregnancy

A

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

231
Q

Give the clinical definition for hyperemesis gravidarum

A

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

232
Q

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

A

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

233
Q

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

A

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

234
Q

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

A

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

235
Q

Why is there increased risk of urinary tract infection in pregnancy

A

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

236
Q

List the complications of UTI in pregnancy

A

Increased risk of preterm delivery
Low birth weight baby
Acute pyelonephritis

237
Q

List the common causative pathogens for UTI in pregnancy

A

E coli
Klebsiella
Enterbacter
Group B streptococcus

238
Q

List the management for UTI in pregnancy

A

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).

239
Q

Define asymptomatic bacteriuria. What is it usually due to

A

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

240
Q

List the management for asymptomatic bacteriuria

A

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.

241
Q

List the clinical features of peripartum cardiomyopathy

A

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)

242
Q

What is peripartum cardiomyopathy associated with

A

mitral regurgitation

243
Q

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

A

Maternal
Thromboembolism
Fluctuations in systemic vascular resistance
* Heart failure
* Cerebral vascular changes

Foetal
Spontaneous abortion
Premature labour
Intrauterine growth restriction
Perinatal mortality

244
Q

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

A

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

245
Q

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

A

maternal/neonatal antiretroviral therapy
caesarean delivery
bottle feeding

246
Q

When is vaginal and C section recommended for HIV in pregnancy

A

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

247
Q

Describe the neonatal HIV antiretroviral therapy

A

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

248
Q

Which side is DVT more common in pregnancy. Why?

A

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.

249
Q

List the risk factors for venous thromboembolism in pregnancy

A

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

250
Q

Why are D dimers not useful in pregnancy

A

Levels are often raised

251
Q

List the managements for thromboembolic diseases in pregnancy

A

≥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

252
Q

In what population is postpartum thyroiditis more common in

A

family history of hypothyroidism, thyroid peroxidase antibodies
type 1 diabetes

253
Q

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

A

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

254
Q

When is gestational diabetes most often recognised

A

24 to 28 weeks of gestation.

255
Q

List the risk factors for gestational diabetes

A

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

256
Q

List the complications of hyperglycemia in late pregnancy

A

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

257
Q

Give the symptoms for gestational diabetes

A

Polyuria, polydipsia

257
Q

Give the investigation for gestational diabetes

A

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.

257
Q

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

A

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.

258
Q

Give the diagnostic criteria for GDM

A

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

259
Q

List the common skin changes that occur in pregnancy

A

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

260
Q

Give the presentation of atopic eruption of pregnancy

A

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.

260
Q

Give the management for atopic eruption of pregnancy

A

Topical steroids and oral antihistamines
Topical benzoyl peroxide; hydrocortisone creams

261
Q

Give the presentation of polymorphic eruption of pregnancy

A

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

261
Q

Give the management for pemphigoid gestationis

A

systemic steroid therapy

261
Q

List the obstetric complications for SLE nephritis in pregnancy

A

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

261
Q

Give the presentation for Pemphigoid gestationis

A

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

261
Q

What may pemphigoid gestationis be associated with

A

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

262
Q

What DMARDs may be allowed in pregnancy

A

Sulfasalazine
Hydroxychloroquine
Azathioprine
Ciclosporin
Biological agents (infliximab, adalimumab)

263
Q

What DMARDs are contraindicated in pregnancy

A

Mycophenolate mofetil
Methotrexate
Leflunomide
Cyclophosphamide

264
Q

Give the medical method of abortion

A

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

265
Q

List the anatomical locations of ectopic pregnancy

A

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

266
Q

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

A

Isthmus of fallopian tube

267
Q

Where does ectopic pregnancy most commonly occur

A

Ampulla of fallopian tube

268
Q

Define heterotopic pregnancy

A

coexistence of both an intrauterine pregnancy and an ectopic pregnancy

269
Q

List the risk factors for ectopic pregnancy

A

(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

270
Q

When do symptoms of ectopic pregnancy usually occur?

A

6 to 8 weeks after the last normal menstrual period

271
Q

List the symptoms for ectopic pregnancy

A

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

272
Q

Give the gold standard investigation for ectopic pregnancy

A

transvaginal ultrasound

273
Q

Define pregnancy of unknown location

A

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

274
Q

Give the first line medical management for ectopic pregnancy

A

Medical: parenteral methotrexate
Surgical: salpingectomy / salpingotomy

275
Q

Give the criteria for medical management of ectopic pregnancy

A

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

276
Q

Give the criteria for surgical management of ectopic pregnancy

A

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

277
Q

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

A

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.

278
Q

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

A

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.

279
Q

Give the pathophysiology of complete hydatidiform moles

A

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.

280
Q

Give the pathophysiology of partial hydatidiform moles

A

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.

281
Q

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

A

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

282
Q

List the presentations of molar pregnancies

A

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)

283
Q

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

A

Absence of ophthalmopathy

284
Q

Why are there signs of thyrotoxicosis in molar pregnancies

A

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

285
Q

List the investigations for molar pregnancy

A

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

286
Q

List the pelvic ultrasound features in molar pregnancy

A

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

287
Q

Give the definitions for primary and secondary infertility

A

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

288
Q

Define group I ovulation disorders. List the causes

A

hypothalamic-pituitary failure causing hypogonadotropic hypogonadal anovulation

  • Hypothalamic amenorrhoea (low BMI, excessive exercise)
  • Kallmann syndrome [associated with anosmia] (Hypogonadotropic hypogonadism)
289
Q

Define group II ovulation disorders. List the causes

A

hypothalamic-pituitary-ovarian axis dysfunction causing normogonadotropic normalestrogenic anovulation

  • Hyperprolactinaemic amenorrhoea
  • Polycystic ovary syndrome
290
Q

Define group III ovulation disorders. List the causes

A

ovarian failure causing hypergonadotropic hypoestrogenic anovulation

  • Premature ovarian insufficiency
  • Low oestrogen level
  • Turner syndrome
291
Q

List the warning signs of shoulder dystocia

A

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

292
Q

What nerves are damaged in Klumpke Palsy

A

C8-T1

293
Q

What nerves are damaged in Erb Palsy

A

C5-6

294
Q

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

A

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)

295
Q

What may cause absence or premature disappearance of the Moro reflex

A

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

296
Q

List the signs of Erb’s palsy

A

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

297
Q

What may asymmetric Moro reflex be due

A

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

298
Q

List the signs of Klumpke palsy

A

“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

299
Q

List the signs of fractured clavicle / humerus in birth injury

A

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

300
Q

List the tubal causes for infertility in women

A

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

301
Q

List the uterine / peritoneal causes for infertility in women

A

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

302
Q

List the ovulatory causes for infertility in women

A

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

303
Q

List the testicular causes for infertility in men

A

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

304
Q

List the obstructive azoospermia causes for infertility in men

A

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

305
Q

List the ejaculatory causes for infertility in men

A

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

306
Q

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

A

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

307
Q

List the investigations for infertility in women

A

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

308
Q

List the investigations for infertility in men

A

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

309
Q

List the medical managements for infertility

A

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

310
Q

List the complications of assisted conception

A

Ovarian hyperstimulation syndrome
Ectopic pregnancy
Pelvic infection
Multiple births

311
Q

List the assisted reproduction techniques

A

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

312
Q

How is intrauterine insemination performed

A

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.

313
Q

How is IVF performed. When is it suitable?

A

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

314
Q

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

A

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)

315
Q

How is Donor insemination performed. When is it suitable?

A

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

316
Q

How is Oocyte donation performed. When is it suitable?

A

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

317
Q

List the risk factors for ovarian hyperstimulation syndrome

A

Previous history
Young age
Lean physique
Polycystic ovary syndrome
Multiple pregnancies

318
Q

What is ovarian hyperstimulation syndrome

A

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

319
Q

List the symptoms and signs for Ovarian hyperstimulation syndrome

A

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

320
Q

List the onset times for Ovarian hyperstimulation syndrome

A

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

321
Q

Define miscarriage. Give its classification by time of onset

A

Spontaneous loss of pregnancy before the foetus reaches viability (24 weeks).

Early - < 13 weeks of gestation
Late - 13~24 weeks of gestation

322
Q

List the stages of miscarriage and their presentation

A

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

323
Q

List the presentation for missed miscarriage

A

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

324
Q

Define anembryonic pregnancy

A

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

325
Q

Define Recurrent miscarriage

A

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

326
Q

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

A

foetal chromosomal abnormalities

327
Q

List the risk factors for miscarriage

A

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

328
Q

List the risk factors for recurrent miscarriage

A

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

329
Q

What’s Asherman’s syndrome

A

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

330
Q

Give the typical history of miscarriage

A

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

331
Q

Give the management for threatened miscarriage

A

Vaginal micronized progesterone 400 mg twice daily

332
Q

What is the first line management for confirmed diagnosis of miscarriage

A

expectant management

333
Q

Give the medical management for missed miscarriage

A

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

334
Q

Give the medical management for Incomplete miscarriage

A

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

335
Q

When is medical management for miscarriage indicated

A

ongoing symptoms after 14 days of expectant management

336
Q

Give the mechanism of action for mifepristone

A

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

337
Q

Give the mechanism of action for Misoprostol

A

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

338
Q

List the contraindications for oestrogen therapies

A

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

339
Q

Define Pelvic inflammatory disease. What does it include?

A

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

340
Q

What is the most common cause for Pelvic inflammatory disease

A

Chlamydia trachomatis

341
Q

List the common causative organisms for Pelvic inflammatory disease

A

Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium

342
Q

List the risk factors for Pelvic inflammatory disease

A

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

343
Q

List the complications for Pelvic inflammatory disease

A

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)

344
Q

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

A

Chlamydia trachomatis

345
Q

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

A

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

346
Q

List the presentations for Pelvic inflammatory disease Tubo-ovarian abscess

A

Fever
Systemic illness
Severe pelvic pain
Subsequent rupture and sepsis

347
Q

How does Pelvic inflammatory disease cause Tubal factor infertility

A

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

348
Q

List the symptoms for Pelvic inflammatory disease

A

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

349
Q

List the investigations for PID

A

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

350
Q

List the common findings on CT for pelvic inflammatory disease

A

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

351
Q

Give the management for gonococcal PID

A

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

352
Q

Give the first line management for non-gonococcal PID

A

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

353
Q

Give the second line management for non-gonococcal PID

A

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

354
Q

Give the management for Mycoplasma genitalium PID

A

Oral moxifloxacin 400mg 1/day for 14 days

355
Q

Give the definition for primary amenorrhoea

A

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

356
Q

Give the definition for Secondary amenorrhoea

A

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

357
Q

List the causes of primary amenorrhoea

A

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

358
Q

List the complications for amenorrhoea

A

Osteoporosis and fractures
Cardiovascular disease
Infertility
Psychological distress

359
Q

Define Premature ovarian insufficiency

A

loss of ovarian activity < 40 years

360
Q

List the Causes of secondary amenorrhoea

A

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

361
Q

List the investigations for amenorrhoea

A

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

362
Q

List the pelvic ultrasound findings in primary amenorrhoea

A

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

363
Q

List the differentials for primary amenorrhoea with normal LH and FSH

A

Outflow obstruction
Functional hypothalamic amenorrhoea
PCOS

364
Q

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

A

Turner’s syndrome.

365
Q

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

A

intracranial lesion eg. hydrocephalus.

366
Q

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

A

ovarian failure

367
Q

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

A

constitutional delay
weight loss
anorexia nervosa

368
Q

What may primary amenorrhoea with high testosterone levels indicate

A

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

369
Q

List the Causes of prolactinaemia

A

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

370
Q

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

A

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

371
Q

List the causes for menorrhagia

A

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

372
Q

Give the complication for menorrhagia

A

Iron deficiency anaemia

373
Q

List the investigations for menorrhagia

A

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

374
Q

List the features that trigger suspected cervical cancer pathway referral

A

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.

375
Q

Give the first line management for amenorrhoea

A

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

376
Q

List the hormonal and non-normal management options for Menorrhagia

A

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

377
Q

List the surgical options for Menorrhagia

A

Endometrial ablation
Uterine artery embolization
Myomectomy
Hysterectomy

378
Q

Give the pathophysiology for Primary dysmenorrhoea

A

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.

379
Q

List the risk factors for Primary dysmenorrhoea

A

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

380
Q

List the causes for secondary dysmenorrhoea

A

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

381
Q

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

A

51 years

382
Q

List the presentations of perimenopause

A

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

383
Q

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

A

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

384
Q

List the Risk factors for premature or early menopause

A

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

385
Q

List the causes for Premature ovarian insufficiency

A

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.

386
Q

List the complications of menopause

A

Osteoporosis
Cardiovascular diseases
Stroke
Genitourinary syndrome of menopause

387
Q

List the signs and symptoms of menopause

A

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

388
Q

Give the management for menopause

A

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

389
Q

List the contraindications for HRT

A

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

390
Q

What does HRT increase the risks of

A

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

391
Q

What are the benefits associated with HRT

A

Reduce fragility fractures
Improve muscle mass and strength

392
Q

List the adverse effects from HRT

A

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.

393
Q

List the characteristics of Polycystic ovary syndrome

A

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

394
Q

List the pathophysiology for PCOS

A

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.

395
Q

List the complications for PCOS

A

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

396
Q

List the investigations and findings in PCOS

A

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

397
Q

List the management for PCOS

A

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

398
Q

What can be given to prevent endometrial hyperplasia in PCOS?

A

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

399
Q

List the classification of ovarian cysts

A

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

400
Q

Give the pathophysiology of follicular cysts

A

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

401
Q

Give the pathophysiology of Corpus luteum cysts

A

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.

402
Q

Give the pathophysiology of Theca lutein cysts

A

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

403
Q

List the risk factors for ovarian cysts

A

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

404
Q

List the symptoms for ovarian cysts

A

Chronic pelvic pain
Bloating and early satiety
Palpable adnexal mass

405
Q

What investigation to order for ovarian cysts?

A

Transvaginal ultrasonography

406
Q

List the complications for ovarian cysts

A

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

407
Q

What may predispose rupture of a corpus luteum cyst

A

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

408
Q

List the risk factors for ovarian torsion

A

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

409
Q

List the symptoms for ovarian torsion

A

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

410
Q

Give the first line investigation and findings in ovarian torsion

A

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

411
Q

Define hirsutism

A

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

412
Q

List the causes of hirsutism

A

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

413
Q

List the signs for Androgen-secreting tumour

A

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.

414
Q

List the investigations for hirsutism

A

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

415
Q

List the first line management for hirsutism

A

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

416
Q

What can be given for facial hirsutism

A

Topical eflornithine

417
Q

List the causes for hypertrichosis

A

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

418
Q

Define Adenomyosis

A

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

419
Q

List the symptoms and signs of Adenomyosis

A

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

420
Q

List the medical treatments for adenomyosis

A

Levonorgestrel-releasing intrauterine system
Prostaglandin synthetase inhibitors

421
Q

List the investigations for adenomyosis

A

Transvaginal ultrasound
MRI

422
Q

Define Endometriosis

A

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

423
Q

Where may endometriosis be distributed

A

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

424
Q

List the risk factors for Endometriosis

A

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

425
Q

List the complications for Endometriosis

A

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

426
Q

List the symptoms for Endometriosis

A

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

427
Q

List the signs for endometriosis

A

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

428
Q

Give the gold standard investigation for endometriosis

A

laparoscopic visualisation of the pelvis

429
Q

Give the first line investigation for endometriosis

A

Transvaginal ultrasound

430
Q

List the medical management options for endometriosis

A

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

431
Q

List the surgical management options for endometriosis

A

Laparoscopic excision
Ablation of endometriosis
Hysterectomy

432
Q

Give the pathophysiology for Fibroids (uterine leiomyomas)

A

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

433
Q

List the classification and presentations for Fibroids (uterine leiomyomas)

A

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.

434
Q

List the risk factors for Fibroids (uterine leiomyomas)

A

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

435
Q

List the complications for Fibroids (uterine leiomyomas)

A

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)

436
Q

List the Typical symptoms for Fibroids (uterine leiomyomas)

A

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

437
Q

List the signs for uterine fibroids

A

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

438
Q

List the investigations for Fibroids (uterine leiomyomas)

A

Ultrasound
Pelvic MRI

439
Q

Give the medical management for Fibroids (uterine leiomyomas)

A

Gonadotropin-releasing hormone analogues
(induce menopause)

440
Q

Give the surgical management options for Fibroids (uterine leiomyomas)

A

Myomectomy
Hysterectomy
Endometrial ablation

441
Q

In what population does Atrophic vaginitis often occur

A

postmenopausal women

442
Q

List the presentations for Atrophic vaginitis

A

Vaginal dryness
Dyspareunia
Occasional spotting
Pale and dry on examination

443
Q

List the treatments for Atrophic vaginitis

A

vaginal lubricants and moisturisers
topical oestrogen cream

444
Q

What is Prepubertal atrophic vaginitis caused by

A

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.

445
Q

List the causative factors for Bacterial vaginosis

A

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

446
Q

List the contributing factors for bacterial vaginosis

A

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)

447
Q

List the Factors that reduce the risk of developing bacterial vaginosis

A

Circumcised partner
Consistent condom use
Hormonal contraception

448
Q

List the complications for Bacterial vaginosis

A

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.

449
Q

Give the symptoms for Bacterial vaginosis

A

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

450
Q

List the investigations for Bacterial vaginosis

A

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

451
Q

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

A

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

Alternative = Oral clindamycin

452
Q

List the Causative microorganisms in Vulvovaginal candidiasis

A

Candida albicans
C. glabrata
C. tropicalis

453
Q

Define Recurrent Vulvovaginal candidiasis infection

A

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

454
Q

List the Risk factors for recurrent vulvovaginal candidiasis

A

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

455
Q

List the symptoms and signs for vulvovaginal candidiasis

A

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

456
Q

Give the first line investigation in vulvovaginal candidiasis

A

High vaginal swab of vaginal secretions for microscopy

457
Q

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

A

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

458
Q

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

A

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

458
Q

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

A

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

459
Q

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

A

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

460
Q

List the Fluconazole contraindications

A

Acute porphyria
Pregnant
Breastfeeding

461
Q

Define complicated and uncomplicated chlamydia

A

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.

462
Q

List the risk factors for Chlamydia

A

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

463
Q

List the complications for Chlamydia

A

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

464
Q

List the symptoms for chlamydia in sexually active women

A

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)

465
Q

List the symptoms for chlamydia in sexually active men

A

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

466
Q

List the Symptoms of lymphogranuloma venereum (LGV)

A

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

467
Q

Give the gold standard investigation for chlamydia

A

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

468
Q

Give the first line and alternative management for chlamydia

A

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

469
Q

Give the management options for chlamydia in pregnancy

A

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

470
Q

What is Gonorrhoea caused by

A

gram-negative diplococci Neisseria gonorrhoeae.

471
Q

List the risk factors for gonorrhoea

A

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

472
Q

List the complications of Gonorrhoea in men

A

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

473
Q

List the complications of Gonorrhoea in women

A

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

474
Q

List the signs of Disseminated gonorrhoea

A

Septic arthritis
Polyarthralgia
Tenosynovitis
Petechial/pustular skin lesions
Endocarditis
Meningitis

475
Q

List the clinical features of gonorrhoea in men

A

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

476
Q

List the clinical features of gonorrhoea in women

A

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

477
Q

Give the gold standard investigation for gonorrhoea

A

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

478
Q

Give the management for gonorrhoea

A

Ceftriaxone 1g IM single dose

479
Q

What is Trichomoniasis caused by

A

Flagellated protozoan Trichomonas vaginalis

480
Q

List the complications for Trichomoniasis in women

A

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

481
Q

List the complications for Trichomoniasis in men

A

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

482
Q

List the systems and signs for Trichomoniasis

A

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

483
Q

List the investigations for trichomoniasis

A

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

484
Q

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

A

HSV1

485
Q

What is More likely to cause recurrent genital herpes infection

A

HSV-2

486
Q

How long is the HSV-2 incubation period

A

Incubation period 2 days ~ 2 weeks

487
Q

How is HSV transmitted

A

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

488
Q

List the risk factors for Herpes simplex infection

A

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

489
Q

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

A

Local trauma
UV light
HIV/immunocompromised

490
Q

List the complications for Neonatal HSV infection

A

Jaundice
Encephalitis
Disseminated infection with multiorgan involvement

491
Q

List the symptoms for HSV infection. Give the natural history

A

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).

492
Q

List the signs of HSV infection

A

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

493
Q

How do recurrent HSV episodes present

A

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.)

494
Q

List the first line options for HSV infection

A

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

495
Q

List the infective causes for vaginal discharge

A

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

496
Q

List the non-infective causes for vaginal discharge

A

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.

497
Q

How does Desquamative inflammatory vaginitis present

A

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

498
Q

How does Erosive lichen planus present with vaginal discharge

A

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

499
Q

List the investigations for Vaginal discharge

A

pH of vaginal discharge
High vaginal swabs

500
Q

List the aetiologies for Abnormal uterine bleeding

A

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

501
Q

Define chronic Abnormal uterine bleeding

A

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

502
Q

List the medical management options for acute Abnormal uterine bleeding

A

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

503
Q

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

A

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

504
Q

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

A

Uterosacral Ligament

505
Q

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

A

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.

506
Q

What microorganism commonly causes postpartum infection

A

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

507
Q

Define postpartum depression

A

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.

508
Q

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

A

Iron deficiency anaemia

509
Q

What may aspirin at 81 mg/day prevent

A

Preeclampsia
IUGR

510
Q

Where is progesterone produced from in pregnancy

A

Syncytiotrophoblast cells of the placenta

511
Q

What may nitrofurantoin use at the third trimester cause

A

Haemolytic anaemia due to G6PD deficiency

512
Q

List the compilations of pregnant women with SLE

A

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

513
Q

Describe the immunological change associated with pregnancy

A

Shift from T1 mediated to T2 mediated immunity

514
Q

What medication is used after pre-eclampsia has developed

A

Magnesium sulphate

515
Q

When should foetal movements be established by

A

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

516
Q

Define reduced foetal movements

A

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

517
Q

List the risk factors for reduced foetal movements

A

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

518
Q

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

A

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

519
Q

Give the first line investigation for premature prelabour rupture of membranes

A

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

520
Q

List the complications for premature prelabour rupture of membranes

A

Foetal: prematurity, infection, pulmonary hypoplasia
Maternal: chorioamnionitis

521
Q

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

A

Respiratory rate

522
Q

What parameters need to be monitored when

A

Respiratory rate
Urine output
Reflexes
Oxygen saturation

523
Q

List the drugs contraindicated in breastfeeding

A

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

524
Q

Give the mechanism of metformin

A

Increases peripheral insulin sensitivity

525
Q

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

A

Calcium gluconate

526
Q

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

A

Vaginal PGE2 or oral misoprostol

527
Q

What should women with severe premenstrual symptoms be managed with

A

SSRIs

528
Q

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

A

Promethiazine

529
Q

What is a contraindication for using epidural anaesthesia during labour?

A

Coagulopathy

530
Q

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

A

Duloxetine

531
Q

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

A

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

532
Q

List the risk factors for cervical ectropion

A

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

533
Q

List the features in cervical ectropion

A

vaginal discharge
post-coital bleeding

534
Q

Give the first line treatment for primary dysmenorrhea

A

Mefenamic acid

535
Q

What day will progesterone levels peak in a 35 day cycle

A

28

536
Q

Give the The RCOG ‘Air Travel and Pregnancy’ Guidance

A

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

537
Q

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

A

Pregnancy-Unique Quantification of Emesis (PUQE) score

538
Q

What is Mittelschmerz

A

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

539
Q

Give the typical history in ectopic pregnancy

A

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

540
Q

List the complications of intrahepatic cholestasis of pregnancy

A

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

541
Q

Give the delivery plan for intrahepatic cholestasis of pregnancy

A

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

542
Q

Give the presentations of intrahepatic cholestasis of pregnancy

A

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

543
Q

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

A

duloxetine

544
Q

What is the preferred method of smoking cessation in pregnant women

A

Nicotine replacement therapy

545
Q

List the indications for category 1 C section

A

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

546
Q

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

A

MMR

547
Q

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

A

immediate insulin (+/- metformin)

548
Q

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

A

GnRH analogues

549
Q

Give the stereotypical history in ruptured ovarian cyst

A

Sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity

550
Q

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

A

Large loop excision of transformation zone (LLETZ)

551
Q

Give the advice for methotrexate before attempting to conceive

A

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

552
Q

Within what time frame should category 1 caesarean section occur

A

30 minutes

553
Q

Within what time frame should category 2 caesarean section occur

A

75 minutes

554
Q

Give the pathophysiology of cervical ectropions

A

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

555
Q

When is the earliest time a woman can be offered ECV

A

36 weeks

556
Q

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

A

Enterocoele
Vaginal vault prolapse

557
Q
A

Medicine (8 decks)

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