OG Flashcards
(710 cards)
1
Q
Q: What is the only combined contraceptive patch licensed for use in the UK?
A
A: The Evra patch.
2
Q
Q: How long is the patch cycle for the Evra patch?
A
A: 4 weeks.
3
Q
Q: How often should the Evra patch be changed during the first 3 weeks of the cycle?
A
A: The patch should be changed once a week.
4
Q
Q: What happens during the 4th week of the Evra patch cycle?
A
A: The patch is not worn, and a withdrawal bleed occurs.
5
Q
Q: What should be done if the patch change is delayed at the end of week 1 or 2 and the delay is less than 48 hours?
A
A: The patch should be changed immediately, and no further precautions are needed.
6
Q
Q: What should be done if the patch change is delayed at the end of week 1 or 2 and the delay is greater than 48 hours?
A
A: The patch should be changed immediately, and a barrier method of contraception should be used for the next 7 days. Emergency contraception may also be needed if unprotected intercourse occurred in the last 5 days.
7
Q
Q: What should be done if patch removal is delayed at the end of week 3?
A
A: The patch should be removed as soon as possible, and a new patch should be applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
8
Q
Q: What should be done if patch application is delayed at the end of a patch-free week?
A
A: Additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
9
Q
Q: How does the combined oral contraceptive pill affect menstruation?
A
A: It usually makes periods regular, lighter, and less painful.
10
Q
Q: Which cancers have a reduced risk with the use of the combined oral contraceptive pill?
A
A: Reduced risk of ovarian, endometrial, and colorectal cancer.
11
Q
Q: What other protective health benefits does the combined oral contraceptive pill offer?
A
A: May protect against pelvic inflammatory disease, reduce ovarian cysts, benign breast disease, and acne vulgaris.
12
Q
Q: What vascular risks are associated with the combined oral contraceptive pill?
A
A: Increased risk of venous thromboembolic disease, stroke, and ischemic heart disease, especially in smokers.
13
Q
Q: Which cancers have an increased risk with the use of the combined oral contraceptive pill?
A
A: Increased risk of breast and cervical cancer.
14
Q
Q: What temporary side effects may occur with the combined oral contraceptive pill?
A
A: Headache, nausea, and breast tenderness.
15
Q
Q: Name a UKMEC 3 condition related to smoking.
A
A: More than 35 years old and smoking less than 15 cigarettes/day.
16
Q
Q: Name a UKMEC 3 condition related to body weight.
A
A: BMI > 35 kg/m².
17
Q
Q: Give two examples of UKMEC 3 conditions related to personal or family history of disease.
A
A: Family history of thromboembolic disease in first-degree relatives <45 years, controlled hypertension.
18
Q
Q: List two UKMEC 3 conditions related to genetic factors or mobility.
A
A: Carrier of BRCA1/BRCA2 mutations, immobility (e.g., wheelchair use).
19
Q
Q: Name a UKMEC 3 condition related to gallbladder disease.
A
A: Current gallbladder disease.
20
Q
Q: Name a UKMEC 4 condition related to smoking.
A
A: More than 35 years old and smoking more than 15 cigarettes/day.
21
Q
Q: What type of migraine is a UKMEC 4 contraindication?
A
A: Migraine with aura.
22
Q
Q: List three UKMEC 4 conditions related to cardiovascular or thrombotic history.
A
A: History of thromboembolic disease or thrombogenic mutation, history of stroke or ischemic heart disease, positive antiphospholipid antibodies (e.g., in SLE).
23
Q
Q: Name a UKMEC 4 contraindication related to breastfeeding.
A
A: Breastfeeding <6 weeks postpartum.
24
Q
Q: What hypertension status is a UKMEC 4 contraindication?
A
A: Uncontrolled hypertension.
25
Q: How effective is the combined oral contraceptive pill (COC) when taken correctly?
A: Over 99% effective.
26
Q: What are some potential risks associated with the COC?
A: Small risk of blood clots, very small risk of heart attacks and strokes, increased risk of breast and cervical cancer.
27
Q: When starting the COC within the first 5 days of the cycle, is additional contraception needed?
A: No, additional contraception is not needed.
28
Q: What should be done if starting the COC after the first 5 days of the cycle?
A: Use alternative contraception (e.g., condoms) for the first 7 days.
29
Q: How often should the COC be taken?
A: The pill should be taken at the same time every day.
30
Q: What are two alternative COC regimens suggested in the 2019 guidelines?
A: Never having a pill-free interval or 'tricycling' (three 21-day packs back-to-back before a 4- or 7-day break).
31
Q: Is intercourse during the pill-free interval safe?
A: Only if the next pack is started on time.
32
Q: Name three situations where COC efficacy may be reduced.
A: Vomiting within 2 hours of taking the pill, medications causing diarrhoea or vomiting (e.g., orlistat), and taking liver enzyme-inducing drugs.
33
Q: Which antibiotics still require extra precautions with the COC?
A: Enzyme-inducing antibiotics such as rifampicin.
34
Q: What should be done if 1 combined oral contraceptive pill (COC) is missed at any time in the cycle?
A: Take the last missed pill immediately, even if it means taking two pills in one day, then continue as usual. No additional contraceptive protection is needed.
35
Q: What should be done if 2 or more COC pills are missed?
A: Take the last missed pill immediately, even if it means taking two pills in one day, continue taking pills daily, and use condoms or abstain from sex until pills have been taken for 7 consecutive days.
36
Q: If 2 or more pills are missed in week 1 (Days 1-7), what additional precaution should be considered?
A: Emergency contraception should be considered if unprotected sex occurred during the pill-free interval or in week 1.
37
Q: If 2 or more pills are missed in week 2 (Days 8-14), is emergency contraception needed?
A: No, emergency contraception is not needed if pills have been taken for 7 consecutive days prior.
38
Q: What should be done if 2 or more pills are missed in week 3 (Days 15-21)?
A: Finish the current pack and start a new pack the next day, omitting the pill-free interval.
39
Q: Why does the FSRH advise 7 days of protection after missed pills, even in later weeks?
A: It serves as a backup in case further pills are missed.
40
Q: What are two benefits of COCP use in the perimenopausal period?
A: Helps maintain bone mineral density and may reduce menopausal symptoms.
41
Q: What is the recommended estrogen dose for COCP in women over 40?
A: Less than 30 µg ethinylestradiol.
42
Q: What is a key consideration for Depo-Provera use in women over 40?
A: It may delay the return of fertility for up to 1 year.
43
Q: How does Depo-Provera affect bone health?
A: It is associated with a small loss in bone mineral density, usually recovered after discontinuation.
44
Q: When can contraception be stopped for women under 50 using non-hormonal methods?
A: After 2 years of amenorrhoea.
45
Q: When can contraception be stopped for women over 50 using non-hormonal methods?
A: After 1 year of amenorrhoea.
46
Q: What is the guidance for COCP use in women ≥50 years?
A: Stop COCP and switch to a non-hormonal or progestogen-only method.
47
Q: What is the role of the progestogen-only pill (POP) with hormone replacement therapy (HRT)?
A: It can be used with HRT if the HRT includes a progestogen component but cannot protect the endometrium alone.
48
Q: Which contraceptive method is licensed to provide the progestogen component of HRT?
A: The intrauterine system (IUS).
49
Q: If a woman over 50 using an implant, POP, or IUS is amenorrhoeic, when can contraception be stopped?
A: Check FSH and stop after 1 year if FSH ≥ 30 IU/L or stop at age 55.
50
Q: What are the main categories of contraception?
A: Barrier methods, daily methods, and long-acting reversible contraception (LARCs).
51
Q: Name a barrier method of contraception and its mechanism of action.
A: Condoms – Physical barrier preventing sperm from reaching the egg.
52
Q: How does the combined oral contraceptive pill work?
A: Inhibits ovulation.
53
Q: Name two risks associated with the COCP.
A: Increased risk of venous thromboembolism and breast/cervical cancer.
54
Q: How does the standard progestogen-only pill work (excluding desogestrel)?
A: Thickens cervical mucus to prevent sperm penetration.
55
Q: What additional mechanism does the desogestrel-containing progestogen-only pill have?
A: Inhibits ovulation.
56
Q: How long does the injectable contraceptive medroxyprogesterone acetate (Depo-Provera) last?
A: 12 weeks.
57
Q: What is the primary mechanism of action of the implantable contraceptive (etonogestrel)?
A: Inhibits ovulation.
58
Q: How long does the contraceptive implant last?
A: 3 years.
59
Q: How does the copper intrauterine device (IUD) work?
A: Decreases sperm motility and survival.
60
Q: How does the intrauterine system (IUS) work?
A: Prevents endometrial proliferation and thickens cervical mucus.
61
Q: What is a common side effect of LARCs like the implant, IUS, and POP?
A: Irregular bleeding.
62
Q: How does the combined oral contraceptive pill (COCP) prevent pregnancy?
A: It inhibits ovulation.
63
Q: What is the primary mode of action of the standard progestogen-only pill (excluding desogestrel)?
A: Thickens cervical mucus.
64
Q: How does the desogestrel-only pill differ from other progestogen-only pills?
A: It primarily inhibits ovulation and also thickens cervical mucus.
65
Q: What is the primary mechanism of the injectable contraceptive (medroxyprogesterone acetate)?
A: Inhibits ovulation.
66
Q: How does the implantable contraceptive (etonogestrel) prevent pregnancy?
A: Primarily inhibits ovulation and also thickens cervical mucus.
67
Q: What is the mode of action of the copper intrauterine contraceptive device (IUD)?
A: Decreases sperm motility and survival.
68
Q: What is the primary mechanism of the intrauterine system (IUS, levonorgestrel)?
A: Prevents endometrial proliferation and thickens cervical mucus.
69
Q: How does levonorgestrel emergency contraception work?
A: Inhibits ovulation.
70
Q: What is the mode of action of ulipristal for emergency contraception?
A: Inhibits ovulation.
71
Q: How does the copper IUD work as emergency contraception?
A: It is toxic to sperm and ovum and also inhibits implantation.
72
Q: How does obesity affect the use of the combined oral contraceptive pill (COCP)?
A: Obesity increases the risk of venous thromboembolism in women taking the COCP.
73
Q: What is the UKMEC classification for women with a BMI of ≥35 kg/m² using the COCP?
A: UKMEC 3 (disadvantages generally outweigh the advantages).
74
Q: Why might the combined contraceptive transdermal patch be less effective in certain patients?
A: It may be less effective in patients who weigh over 90 kg.
75
Q: Why can't patients who have had a gastric sleeve, bypass, or duodenal switch use oral contraception?
A: Due to the lack of efficacy of oral contraception in these patients. This also includes emergency contraception.
76
Q: What is the recommended contraceptive method for all individuals at risk of sexually transmitted infections (STIs)?
A: Condoms and dental dams.
77
Q: What screening should be offered to all sexually active individuals with a uterus?
A: Cervical screening.
78
Q: What vaccinations should be offered to sexually active individuals?
A: Human papillomavirus (HPV) vaccinations and, for individuals engaging in anal sex or rimming, hepatitis A & B vaccinations.
79
Q: What should individuals at risk of HIV transmission be advised about?
A: The availability of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP).
80
Q: What contraceptive options are recommended for individuals who have had a hysterectomy and/or bilateral oophorectomy?
A: There is no need for contraception as these individuals are no longer at risk of pregnancy.
81
Q: What permanent contraception options may be considered for transgender individuals seeking them?
A: Fallopian tube occlusion or vasectomy.
82
Q: Does testosterone therapy provide protection against pregnancy in transgender men?
A: No, testosterone therapy does not provide protection against pregnancy.
83
Q: What is the recommended contraception for transgender men undergoing testosterone therapy?
A: Progesterone-only contraceptives, such as the intrauterine system (IUS) or injections, which may also suspend menstruation.
84
Q: What is the effect of estrogen-containing contraceptives in patients undergoing testosterone therapy?
A: Estrogen-containing contraceptives are not recommended as they can antagonize the effect of testosterone therapy.
85
Q: What is the recommended contraception for transgender men assigned female at birth but engaging in vaginal sex?
A: Condoms, as testosterone therapy does not prevent pregnancy.
86
Q: What should patients assigned male at birth who are undergoing hormone therapy for gender transition be advised regarding contraception?
A: Condoms should be recommended for individuals assigned male at birth who are engaging in vaginal sex to avoid the risk of pregnancy.
87
Q: What is the age of consent for sexual activity in the UK?
A: The age of consent for sexual activity in the UK is 16 years.
88
Q: What are the key points of the Fraser Guidelines?
Understand the professional's advice
Be unlikely to inform their parents
Be likely to continue or begin having sexual intercourse
Suffer physical or mental harm without contraceptive treatment
Have their best interests met by receiving contraceptive treatment without parental consent.
89
Q: What is the legal requirement if a child under the age of 13 years seeks contraception?
A: Children under 13 years are considered unable to consent for sexual intercourse, and consultations should automatically trigger child protection measures.
90
Q: How soon after unprotected sexual intercourse (UPSI) should young people be advised to get STI tests?
A: STI tests should be done 2 and 12 weeks after an incident of unprotected sexual intercourse (UPSI).
91
Q: What is the concern regarding the use of Depo-Provera (progesterone-only injections) in young people?
A: There are concerns about the effect of Depo-Provera on bone mineral density.
92
Q: What is the preferred long-acting reversible contraceptive method for young people?
A: The progesterone-only implant (Nexplanon) is the preferred LARC for young people.
93
Q: What is the mode of action of levonorgestrel in emergency contraception?
A: Levonorgestrel acts both to stop ovulation and inhibit implantation, although its mode of action is not fully understood.
94
Q: When should levonorgestrel be taken for emergency contraception?
A: Levonorgestrel should be taken as soon as possible, within 72 hours of unprotected sexual intercourse (UPSI). It may be offered after this period with reduced effectiveness and unlicensed indications.
95
Q: What should be done if vomiting occurs within 3 hours of taking levonorgestrel?
A: If vomiting occurs within 3 hours of taking levonorgestrel, the dose should be repeated.
96
Q: What is the dose of levonorgestrel for emergency contraception?
A: The standard dose of levonorgestrel is 1.5 mg, which should be doubled for women with a BMI >26 or weight over 70 kg, or if taking enzyme-inducing drugs.
97
Q: What is ulipristal and how does it work for emergency contraception?
A: Ulipristal is a selective progesterone receptor modulator (EllaOne) that primarily inhibits ovulation.
98
Q: When should ulipristal be taken for emergency contraception?
A: Ulipristal should be taken as soon as possible, and no later than 120 hours (5 days) after UPSI.
99
Q: Can levonorgestrel and ulipristal be used together for emergency contraception?
A: No, concomitant use of levonorgestrel and ulipristal is not recommended.
100
Q: What precautions should be taken when using ulipristal?
A: Ulipristal may reduce the effectiveness of hormonal contraception, and contraception with the pill, patch, or ring should be started 5 days after taking ulipristal. Barrier methods should be used during this period. Caution is advised in patients with severe asthma, and breastfeeding should be delayed for one week after taking ulipristal.
101
Q: What is the most effective method of emergency contraception?
A: The most effective method of emergency contraception is the copper intrauterine device (IUD), which is 99% effective.
102
Q: How soon must a copper IUD be inserted after UPSI?
A: A copper IUD must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date if the woman presents later.
103
Q: Can a copper IUD be used as long-term contraception?
A: Yes, a copper IUD can be left in situ for long-term contraception. If the patient wants it removed, it should be kept in place until the next period.
104
Q: When is a copper IUD recommended for emergency contraception?
A: A copper IUD should be offered to all women as the most effective method of emergency contraception if the criteria for insertion are met. If not, oral emergency contraception should be considered.
105
Q: What are the factors to consider when selecting contraception for women with epilepsy?
The effect of the contraceptive on the effectiveness of anti-epileptic medication.
The effect of anti-epileptic medication on the effectiveness of the contraceptive.
The potential teratogenic effects of anti-epileptic drugs if the woman becomes pregnant.
106
Q: What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine?
UKMEC 3: Combined oral contraceptive pill (COCP) and progestogen-only pill (POP).
UKMEC 2: Implant.
UKMEC 1: Depo-Provera, intrauterine device (IUD), intrauterine system (IUS).
107
Q: What is the UKMEC classification for women taking lamotrigine?
UKMEC 3: Combined oral contraceptive pill (COCP).
UKMEC 1: Progestogen-only pill (POP), implant, Depo-Provera, intrauterine device (IUD), intrauterine system (IUS).
108
Q: What is the primary mechanism of action of Nexplanon?
A: The primary mechanism of action of Nexplanon is preventing ovulation. It also works by thickening the cervical mucus.
109
Q: How long does Nexplanon last, and how effective is it?
A: Nexplanon lasts for 3 years and has a failure rate of 0.07/100 women-years, making it the most effective form of contraception.
110
Q: What are the advantages of using Nexplanon?
Highly effective with a low failure rate.
Long-acting (lasts 3 years).
Does not contain oestrogen, so can be used by women with a history of thromboembolism, migraine, etc.
Can be inserted immediately following a termination of pregnancy.
111
Q: What are the disadvantages of Nexplanon?
Requires a trained professional for insertion and removal.
Additional contraceptive methods are needed for the first 7 days if not inserted on days 1 to 5 of a woman's menstrual cycle.
112
Q: What are the main adverse effects of Nexplanon?
Irregular/heavy bleeding (sometimes managed with co-prescription of the combined oral contraceptive pill).
'Progestogen effects' such as headache, nausea, and breast pain.
113
Q: What drugs may interact with Nexplanon?
A: Enzyme-inducing drugs such as certain antiepileptics and rifampicin may reduce the efficacy of Nexplanon. Women should be advised to switch to a method unaffected by enzyme-inducing drugs or use additional contraception until 28 days after stopping the treatment.
114
Q: What are the contraindications for Nexplanon?
UKMEC 3: Ischaemic heart disease, stroke (for continuation, if initiation then UKMEC 2), unexplained/suspicious vaginal bleeding, past breast cancer, severe liver cirrhosis, liver cancer.
UKMEC 4: Current breast cancer.
115
Q: How often is Depo-Provera administered and what is its active ingredient?
A: Depo-Provera is administered as an intramuscular injection every 12 weeks and contains medroxyprogesterone acetate 150mg. It can be given up to 14 weeks after the last dose without the need for extra precautions.
116
Q: What is the primary mechanism of action of Depo-Provera?
A: Depo-Provera primarily inhibits ovulation. Secondary effects include thickening of cervical mucus and thinning of the endometrium.
117
Q: What are the disadvantages of using Depo-Provera?
The injection is not reversible once given.
There may be a delayed return to fertility, which could take up to 12 months.
118
Q: What are the common adverse effects of Depo-Provera?
Irregular bleeding.
Weight gain.
Potential increased risk of osteoporosis (should only be used in adolescents if no other contraceptive method is suitable).
Not quickly reversible, and fertility may take varying time to return.
119
Q: What are the contraindications for Depo-Provera?
UKMEC 4: Current breast cancer.
UKMEC 3: Past breast cancer.
120
Q: What is the primary mode of action of the IUD and IUS?
IUD: Prevents fertilization by decreasing sperm motility and survival, possibly due to copper ions.
IUS: Levonorgestrel prevents endometrial proliferation and causes cervical mucus thickening.
121
Q: What are the counseling points for IUD and IUS regarding reliability and duration?
IUD: Can be relied upon immediately following insertion. Copper IUDs are effective for 5 years, and some IUDs with copper on the stem and arms are effective for up to 10 years.
IUS: Can be relied upon after 7 days. The most common IUS (Mirenaµ) is effective for 5 years, and if used for endometrial protection in women taking oestrogen-only hormone replacement therapy, it is only licensed for 4 years.
122
Q: What potential problems can arise from using the IUD and IUS?
IUDs may make periods heavier, longer, and more painful.
The IUS may cause initial frequent uterine bleeding and spotting, but later results in intermittent light menses, less dysmenorrhoea, and in some cases, amenorrhoea.
Uterine perforation: up to 2 per 1000 insertions, higher in breastfeeding women.
Increased risk of ectopic pregnancy, though the absolute number of ectopic pregnancies is reduced compared to not using contraception.
Infection: small increased risk of pelvic inflammatory disease in the first 20 days post-insertion.
Expulsion: Risk is about 1 in 20, especially in the first 3 months.
123
Q: What are the major clinical indicators of fertility in natural family planning?
Changes in cervical mucus
Changes in the cervix
Changes in basal body temperature
124
Q: When should contraception be started after giving birth?
A: Contraception should be started after day 21 postpartum.
125
Q: What is the recommendation for starting the progestogen-only pill (POP) postpartum?
A: The POP can be started at any time postpartum; additional contraception should be used for the first 2 days.
126
Q: What is the UKMEC category for the combined oral contraceptive pill (COCP) for breastfeeding women less than 6 weeks postpartum?
A: UKMEC 4 (absolutely contraindicated).
127
Q: Why is the combined oral contraceptive pill (COCP) not recommended in the first 21 days postpartum?
A: There is an increased risk of venous thromboembolism during this time.
128
Q: What should be done when using the combined oral contraceptive pill (COCP) postpartum after day 21?
A: Additional contraception should be used for the first 7 days.
129
Q: When can an intrauterine device (IUD) or intrauterine system (IUS) be inserted postpartum?
A: It can be inserted within 48 hours of childbirth or after 4 weeks.
130
Q: What is the effectiveness of the lactational amenorrhoea method (LAM) for postpartum contraception?
A: LAM is 98% effective if the woman is fully breastfeeding, amenorrhoeic, and <6 months postpartum.
131
Q: What is the most common adverse effect of the progestogen-only pill (POP)?
A: Irregular vaginal bleeding.
132
Q: When should the progestogen-only pill (POP) be started to provide immediate contraception?
A: If commenced up to and including day 5 of the cycle.
133
Q: If switching from a combined oral contraceptive (COC) to the progestogen-only pill (POP), when will protection be immediate?
A: If the POP is continued directly from the end of the COC pill packet (i.e., Day 21).
134
Q: How should the progestogen-only pill (POP) be taken?
A: It should be taken at the same time every day, without a pill-free break (unlike the COC).
135
Q: What should be done if the progestogen-only pill (POP) is missed within 3 hours?
A: Continue taking the POP as normal.
136
Q: What should be done if the progestogen-only pill (POP) is missed by more than 3 hours?
A: Take the missed pill as soon as possible, continue with the rest of the pack, and use additional contraception (e.g., condoms) for 48 hours.
137
Q: How should the progestogen-only pill (POP) be managed if there is diarrhoea or vomiting?
A: Continue taking the POP but assume the pills have been missed, and follow the missed pill guidelines.
138
Q: Do antibiotics affect the effectiveness of the progestogen-only pill (POP)?
A: No, antibiotics have no effect on the POP, unless they alter the P450 enzyme system (e.g., rifampicin).
139
Q: How long can a missed progestogen-only pill (POP) be before additional precautions are needed?
A: If the pill is missed for more than 3 hours (or 12 hours for Cerazette), additional precautions should be used for 48 hours.
140
Q: What should be done if a traditional progestogen-only pill (POP) is missed by less than 3 hours?
A: No action is required, continue taking the pill as normal.
141
Q: What should be done if a traditional progestogen-only pill (POP) is missed by more than 3 hours?
A: Take the missed pill as soon as possible, and follow the missed pill instructions below.
142
Q: What should be done if Cerazette (desogestrel) is missed by less than 12 hours?
A: No action is required, continue taking the pill as normal.
143
Q: What should be done if Cerazette (desogestrel) is missed by more than 12 hours?
A: Take the missed pill as soon as possible, and follow the missed pill instructions below.
144
Q: What action should be taken if a progestogen-only pill (POP) is missed by more than 3 hours (traditional POPs) or 12 hours (Cerazette)?
A: Take the missed pill as soon as possible, take the next pill at the usual time (which may mean taking two pills in one day), continue with the rest of the pack, and use extra precautions (e.g., condoms) for 48 hours.
145
Q: What is adenomyosis?
A: Adenomyosis is the presence of endometrial tissue within the myometrium.
146
Q: What are the features of adenomyosis?
A: Dysmenorrhoea, menorrhagia, and an enlarged, boggy uterus.
147
Q: What is the first-line investigation for adenomyosis?
A: Transvaginal ultrasound is the first-line investigation.
148
Q: What are the management options for adenomyosis?
A: Symptomatic treatment, tranexamic acid for menorrhagia, GnRH agonists, uterine artery embolisation, and hysterectomy (considered the 'definitive' treatment).
149
Q: What is primary amenorrhoea?
A: Primary amenorrhoea is the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics, or by 13 years of age in girls with no secondary sexual characteristics.
150
Q: What is secondary amenorrhoea?
A: Secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea.
151
Q: What are some causes of primary amenorrhoea?
A: Gonadal dysgenesis (e.g., Turner's syndrome), testicular feminisation, congenital malformations of the genital tract, functional hypothalamic amenorrhoea (e.g., secondary to anorexia), congenital adrenal hyperplasia, and imperforate hymen.
152
Q: What are some causes of secondary amenorrhoea?
A: Hypothalamic amenorrhoea (e.g., secondary to stress or excessive exercise), polycystic ovarian syndrome (PCOS), hyperprolactinaemia, premature ovarian failure, thyrotoxicosis, Sheehan's syndrome, and Asherman's syndrome (intrauterine adhesions).
153
Q: What initial investigations should be done for amenorrhoea?
A: Exclude pregnancy with urinary or serum bHCG, full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, androgen levels, and oestradiol.
154
Q: What does low gonadotrophin levels indicate in amenorrhoea?
A: Low gonadotrophin levels suggest a hypothalamic cause.
155
Q: What does raised gonadotrophin levels indicate in amenorrhoea?
A: Raised gonadotrophin levels suggest an ovarian problem, such as premature ovarian failure.
156
Q: How is primary amenorrhoea managed?
A: Investigate and treat any underlying cause, and hormone replacement therapy may be beneficial for conditions like primary ovarian insufficiency due to gonadal dysgenesis (e.g., Turner's syndrome).
157
Q: How is secondary amenorrhoea managed?
A: Exclude pregnancy, lactation, and menopause (in women 40 years or older), and treat the underlying cause.
158
Q: What is Androgen Insensitivity Syndrome (AIS)?
A: Androgen Insensitivity Syndrome is an X-linked recessive condition due to end-organ resistance to testosterone, causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is also known as testicular feminisation syndrome.
159
Q: What are the features of Androgen Insensitivity Syndrome?
A: Primary amenorrhoea, little or no axillary and pubic hair, undescended testes causing groin swellings, and breast development due to the conversion of testosterone to oestradiol.
160
Q: How is Androgen Insensitivity Syndrome diagnosed?
A: Diagnosis is made through a buccal smear or chromosomal analysis revealing a 46XY genotype, and after puberty, testosterone concentrations are in the high-normal to slightly elevated range for postpubertal boys.
161
Q: What is the management for Androgen Insensitivity Syndrome?
A: Management includes counselling to raise the child as female, bilateral orchidectomy due to the increased risk of testicular cancer from undescended testes, and oestrogen therapy.
162
Q: What is atrophic vaginitis?
A: Atrophic vaginitis is a condition that often occurs in post-menopausal women, characterized by vaginal dryness, dyspareunia (painful intercourse), and occasional spotting. On examination, the vagina may appear pale and dry.
163
Q: How is atrophic vaginitis treated?
A: Treatment for atrophic vaginitis includes vaginal lubricants and moisturisers. If these do not provide relief, topical oestrogen cream can be used.
164
Q: What are the main differential diagnoses for bleeding in the first trimester?
A: The main differential diagnoses for bleeding in the first trimester are miscarriage, ectopic pregnancy (which is potentially life-threatening), implantation bleeding (diagnosis of exclusion), and miscellaneous conditions such as cervical ectropion, vaginitis, trauma, and polyps.
165
Q: What are the worrying symptoms suggesting an ectopic pregnancy?
A: Worrying symptoms for an ectopic pregnancy include pain and abdominal tenderness, pelvic tenderness, and cervical motion tenderness. Women with a positive pregnancy test and any of these symptoms should be referred to an early pregnancy assessment service.
166
Q: How should a pregnancy > 6 weeks gestation with bleeding be managed?
A: If the pregnancy is > 6 weeks gestation (or of uncertain gestation) and there is bleeding, the woman should be referred to an early pregnancy assessment service. A transvaginal ultrasound is the most important investigation to determine the location of the pregnancy and whether there is a fetal pole and heartbeat.
167
Q: How should a pregnancy < 6 weeks gestation with bleeding but no pain be managed?
A: If the pregnancy is < 6 weeks gestation with bleeding but no pain or risk factors for ectopic pregnancy, women can be managed expectantly. They should be advised to return if bleeding continues or pain develops, repeat a urine pregnancy test after 7-10 days, and return if it is positive. A negative pregnancy test indicates that the pregnancy has miscarried.
168
Q: What is the most common type of cervical cancer?
A: The most common type of cervical cancer is squamous cell carcinoma, which accounts for 80% of cases. Adenocarcinoma makes up 20% of cases.
169
Q: What are the common features of cervical cancer?
A: Common features of cervical cancer include abnormal vaginal bleeding (postcoital, intermenstrual, or postmenopausal bleeding) and vaginal discharge. It may also be detected during routine cervical cancer screening.
170
Q: What is the most important risk factor for cervical cancer?
A: The most important risk factor for cervical cancer is infection with human papillomavirus (HPV), particularly serotypes 16, 18, and 33.
171
Q: What are other risk factors for cervical cancer?
A: Other risk factors include smoking, human immunodeficiency virus (HIV), early first intercourse, multiple sexual partners, high parity, lower socioeconomic status, and the use of the combined oral contraceptive pill.
172
Q: What is the main aim of cervical cancer screening?
A: The main aim of cervical cancer screening is to detect pre-malignant changes, rather than to detect cancer itself.
173
Q: How has the cervical cancer screening program evolved?
A: The cervical cancer screening program evolved from examining smears for dyskaryosis (which may indicate cervical intraepithelial neoplasia) to introducing HPV testing. HPV testing allows further risk-stratification, where HPV-negative results are treated as normal.
174
Q: What is the current cervical cancer screening system in the UK?
A: The UK now uses an HPV-first system, where a sample is first tested for high-risk HPV strains, and cytological examination is only performed if the HPV test is positive.
175
Q: Who is eligible for cervical cancer screening in the UK and how often is it done?
Cervical screening is offered to all women aged 25-64:
Ages 25-49: every 3 years
Ages 50-64: every 5 years
Screening is not offered to women over 64.
176
Q: When should cervical screening be delayed during pregnancy?
A: Cervical screening during pregnancy is usually delayed until 3 months postpartum unless the screening was missed or there were previous abnormal smears.
177
Q: How are negative hrHPV results managed?
A: For negative hrHPV results, individuals are returned to the normal recall schedule unless they are on the test of cure (TOC) pathway or are being followed up for incompletely excised CIN, CGIN, SMILE, or cervical cancer.
178
Q: What happens if hrHPV is positive?
A: If hrHPV is positive, the sample is examined cytologically. If the cytology is abnormal, colposcopy is performed. If the cytology is normal, the test is repeated in 12 months.
179
Q: What is the management for normal cytology with positive hrHPV?
A: If the cytology is normal but hrHPV is positive, the test is repeated in 12 months. If hrHPV is negative at 12 months, the patient returns to normal recall. If hrHPV is still positive, the test is repeated again at 24 months. If hrHPV is negative at 24 months, the patient returns to normal recall; if still positive, colposcopy is performed.
180
Q: What happens if the sample is inadequate?
A: If the sample is inadequate, it should be repeated in 3 months. If two consecutive samples are inadequate, colposcopy should be performed.
181
Q: What is the first step in managing patients previously treated for CIN?
A: The first step is inviting individuals who have been treated for CIN1, CIN2, or CIN3 for a test of cure with a repeat cervical sample in the community, 6 months after treatment.
182
Q: What is the most common treatment for CIN?
A: The most common treatment for CIN is Large Loop Excision of the Transformation Zone (LLETZ). Alternative techniques include cryotherapy.
183
Q: How is the management of cervical cancer determined?
A: The management of cervical cancer is determined by the FIGO staging and the patient's wishes regarding fertility preservation.
184
Q: What is cervical ectropion?
A: Cervical ectropion occurs when elevated oestrogen levels cause a larger area of columnar epithelium to be present on the ectocervix, where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. It is common during the ovulatory phase, pregnancy, and with combined oral contraceptive pill use.
185
Q: What are the features of cervical ectropion?
A: The features of cervical ectropion include vaginal discharge and post-coital bleeding.
186
Q: How is cervical ectropion treated?
A: Ablative treatments, such as cold coagulation, are used only for troublesome symptoms.
187
Q: What are the features of a complete hydatidiform mole?
A: The features of a complete hydatidiform mole include vaginal bleeding, an abnormally large uterus for the gestational age, very high serum hCG levels, and a "snow storm" appearance of mixed echogenicity on ultrasound.
188
Q: What are the causes of delayed puberty with short stature?
A: The causes of delayed puberty with short stature include Turner's syndrome, Prader-Willi syndrome, and Noonan's syndrome.
189
Q: What are the causes of delayed puberty with normal stature?
A: The causes of delayed puberty with normal stature include polycystic ovarian syndrome (PCOS), androgen insensitivity, Kallmann's syndrome, and Klinefelter's syndrome.
190
Q: What is primary dysmenorrhoea and its management?
A: Primary dysmenorrhoea occurs without underlying pelvic pathology, affecting up to 50% of menstruating women. It typically starts 1-2 years after menarche and is thought to be caused by excessive prostaglandin production. Management includes NSAIDs (e.g., mefenamic acid, ibuprofen), which inhibit prostaglandin production, and combined oral contraceptives as a second-line treatment.
191
Q: What is secondary dysmenorrhoea and its causes?
A: Secondary dysmenorrhoea develops many years after menarche and is caused by underlying conditions. It usually starts 3-4 days before the period. Causes include endometriosis, adenomyosis, pelvic inflammatory disease, intrauterine devices (except Mirena), and fibroids.
192
Q: What is the management for secondary dysmenorrhoea?
A: NICE recommends referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
193
Q: What are the typical features of ectopic pregnancy?
A: Ectopic pregnancy presents with a history of 6-8 weeks of amenorrhoea, lower abdominal pain (due to tubal spasm), and vaginal bleeding (usually darker and less than a normal period). Additional symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Pregnancy symptoms like breast tenderness may also be reported.
194
Q: What are the examination findings in ectopic pregnancy?
A: Examination may reveal abdominal tenderness, cervical excitation (cervical motion tenderness), and an adnexal mass. However, NICE advises against examining for an adnexal mass due to the risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is recommended.
195
Q: How can ectopic pregnancy be diagnosed in the case of pregnancy of unknown location?
A: Serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy in cases of pregnancy of unknown location.
196
Q: What are the risk factors for ectopic pregnancy?
A: Risk factors include anything that slows the ovum's passage to the uterus, such as damage to the tubes (e.g., from pelvic inflammatory disease or surgery), previous ectopic pregnancies, endometriosis, intrauterine contraceptive devices (IUCD), progesterone-only pill use, and in vitro fertilization (IVF), with 3% of IVF pregnancies being ectopic.
197
Q: What is the investigation of choice for ectopic pregnancy?
A: The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.
198
Q: What are the three management options for ectopic pregnancy, and when are they used?
Expectant management: Used if the ectopic is <35mm, unruptured, asymptomatic, with no fetal heartbeat, hCG <1,000 IU/L, and compatible with another intrauterine pregnancy. It involves monitoring the patient over 48 hours to check for changes in symptoms or hCG levels.
Medical management: Used for unruptured ectopics <35mm, with no significant pain, no fetal heartbeat, hCG <1,500 IU/L, and compatible with another intrauterine pregnancy. Methotrexate is used if the patient is willing to attend follow-up.
Surgical management: Indicated for ectopics >35mm, or if the ectopic is ruptured, with pain, visible fetal heartbeat, or hCG >5,000 IU/L. This can involve salpingectomy (first-line for women without infertility risk) or salpingotomy (considered for women with infertility risk factors).
199
Q: What is the most common location for ectopic pregnancy?
A: 97% of ectopic pregnancies are tubal, with most occurring in the ampulla. The isthmus is more dangerous if affected.
200
Q: What is the main aetiology of endometrial cancer?
A: The main aetiology of endometrial cancer is excess oestrogen, which can arise from factors such as nulliparity, early menarche, late menopause, unopposed oestrogen, obesity, diabetes mellitus, and polycystic ovarian syndrome. Additionally, tamoxifen use and hereditary non-polyposis colorectal carcinoma can increase the risk.
201
Q: What are the common symptoms of endometrial cancer?
A: The classic symptom of endometrial cancer is postmenopausal bleeding, which typically starts as slight and intermittent before becoming heavier. Premenopausal women may experience menorrhagia or intermenstrual bleeding. Pain is uncommon but may indicate more advanced disease, and vaginal discharge is unusual.
202
Q: How is endometrial cancer investigated?
A: The first-line investigation for endometrial cancer is transvaginal ultrasound. A normal endometrial thickness (< 4 mm) has a high negative predictive value. If further investigation is required, hysteroscopy with endometrial biopsy is performed.
203
Q: What is the main treatment for endometrial cancer?
A: The main treatment for endometrial cancer is surgery. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is used for localized disease, while patients with high-risk disease may receive postoperative radiotherapy. Progestogen therapy may be used in frail elderly women not suitable for surgery.
204
Q: What is endometrial hyperplasia?
A: Endometrial hyperplasia is an abnormal proliferation of the endometrium that occurs beyond the normal proliferation seen during the menstrual cycle. A minority of cases may progress to endometrial cancer.
205
Q: What are the common features of endometrial hyperplasia?
A: The most common feature of endometrial hyperplasia is abnormal vaginal bleeding, such as intermenstrual bleeding.
206
Q: How is endometrial hyperplasia managed?
Simple endometrial hyperplasia without atypia: High-dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may also be used.
Atypical hyperplasia: Hysterectomy is usually advised.
207
Q: What is endometriosis?
A: Endometriosis is a common condition where ectopic endometrial tissue grows outside of the uterine cavity. It affects around 10% of women of reproductive age.
208
Q: What are the clinical features of endometriosis?
Chronic pelvic pain
Secondary dysmenorrhoea (pain before bleeding)
Deep dyspareunia (pain during intercourse)
Subfertility
Non-gynaecological symptoms such as urinary symptoms (dysuria, urgency, haematuria) and dyschezia (painful bowel movements)
On pelvic examination, there may be reduced organ mobility, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions.
209
Q: What is the gold-standard investigation for endometriosis?
A: Laparoscopy is the gold-standard investigation for endometriosis.
210
Q: What is the management of endometriosis?
First-line treatment: NSAIDs and/or paracetamol for symptomatic relief.
Hormonal treatments: Combined oral contraceptive pill or progestogens (e.g., medroxyprogesterone acetate) if analgesia is ineffective.
Secondary care: For patients whose symptoms persist or for those prioritizing fertility, treatment options include:
GnRH analogues (induce a pseudomenopause with low estrogen)
Surgery: Laparoscopic excision or ablation of endometriosis and adhesiolysis, which can improve fertility. Ovarian cystectomy may be considered for endometriomas.
211
Q: What is female genital mutilation (FGM)?
A: Female genital mutilation (FGM) refers to procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.
212
Q: What are the WHO classifications of FGM?
Type 1: Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
Type 2: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
Type 3: Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, with or without excision of the clitoris (infibulation).
Type 4: All other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization.
213
Q: What is fibroid degeneration and how does it occur?
A: Fibroid degeneration occurs when uterine fibroids, which are sensitive to oestrogen, outgrow their blood supply. This can result in red or "carneous" degeneration.
214
Q: What are the symptoms of fibroid degeneration?
A: Symptoms typically include low-grade fever, pain, and vomiting.
215
Q: How is fibroid degeneration managed?
A: Management is usually conservative with rest and analgesia. The condition typically resolves within 4-7 days.
216
Q: What are the differential diagnoses for abdominal pain in females?
Mittelschmerz: Mid-cycle pain with a sharp onset, usually without systemic disturbance. Diagnosed via full blood count and ultrasound. Treated conservatively.
Endometriosis: Associated with menstrual irregularity, infertility, pain, and deep dyspareunia. Diagnosed with ultrasound and laparoscopy. Treated medically, with surgery for complex cases.
Ovarian torsion: Sudden onset of colicky abdominal pain, vomiting, and adnexal tenderness. Diagnosed via ultrasound and treated with laparoscopy.
Ectopic gestation: Symptoms of pregnancy without intrauterine pregnancy, presenting with abdominal pain and circulatory collapse in some cases. Diagnosed with ultrasound and beta HCG levels. Treated with laparoscopy or laparotomy if unstable, often with salpingectomy.
Pelvic inflammatory disease: Bilateral lower abdominal pain, vaginal discharge, dysuria, and fever. Diagnosed with full blood count, vaginal swabs, and amylase levels. Treated medically.
217
Q: How is heavy menstrual bleeding (menorrhagia) defined?
A: Menorrhagia is defined based on the woman’s perception of excessive bleeding, as quantifying blood loss is difficult. Previously, it was defined as blood loss >80 ml per menses.
218
Q: What is the first step in investigating heavy menstrual bleeding?
A: The first step is to perform a full blood count in all women presenting with heavy menstrual bleeding.
219
Q: When should a transvaginal ultrasound be arranged for heavy menstrual bleeding?
A: A transvaginal ultrasound should be arranged if symptoms suggest a structural or histological abnormality, such as intermenstrual or postcoital bleeding, pelvic pain, or abnormal pelvic exam findings.
220
Q: What is the treatment for heavy menstrual bleeding in women who do not require contraception?
A: In women who do not require contraception, either mefenamic acid 500 mg tds or tranexamic acid 1 g tds is recommended. Both are started on the first day of the period.
221
Q: What is the treatment for heavy menstrual bleeding in women who require contraception?
A: In women who need contraception, the first-line option is an intrauterine system (Mirena). Other options include the combined oral contraceptive pill and long-acting progestogens.
222
Q: What are common side effects of hormone replacement therapy (HRT)?
A: Common side effects of HRT include nausea, breast tenderness, fluid retention, and weight gain.
223
Q: What is a potential complication of HRT related to breast cancer?
A: HRT can increase the risk of breast cancer, especially with the addition of a progestogen. The relative risk in the Women's Health Initiative (WHI) study was 1.26 at 5 years. The risk declines after stopping HRT and returns to baseline within 5 years.
224
Q: How does HRT affect the risk of endometrial cancer?
A: Oestrogen alone increases the risk of endometrial cancer in women with a uterus. This risk is reduced but not eliminated by the addition of a progestogen. The risk is said to be eliminated if a progestogen is given continuously.
225
Q: How does HRT affect the risk of venous thromboembolism (VTE)?
A: HRT increases the risk of VTE, especially with the addition of a progestogen. Transdermal HRT does not appear to increase the risk of VTE. Women at high risk for VTE should be referred to haematology before starting HRT.
226
Q: How does HRT affect the risk of stroke and heart disease?
A: HRT increases the risk of stroke and ischaemic heart disease, particularly if started more than 10 years after menopause.
227
Q: What is hyperemesis gravidarum, and how does it relate to nausea and vomiting in pregnancy (NVP)?
A: Hyperemesis gravidarum is an extreme form of nausea and vomiting during pregnancy, occurring in around 1% of pregnancies. It is related to elevated beta-hCG levels and is most common between 8 and 12 weeks but can persist up to 20 weeks.
228
Q: What are the risk factors for hyperemesis gravidarum?
A: Risk factors include increased levels of beta-hCG, multiple pregnancies, trophoblastic disease, nulliparity, obesity, and a personal or family history of NVP. Smoking is associated with a decreased incidence of hyperemesis.
229
Q: What are the referral criteria for nausea and vomiting in pregnancy (NVP)?
A: Admission is considered for continued nausea and vomiting unable to keep liquids down, ketonuria, weight loss (>5% of body weight), or a co-existing condition like diabetes that may be adversely affected. A lower threshold for admission is recommended for women with a co-existing condition.
230
Q: What is the diagnostic triad for hyperemesis gravidarum according to the RCOG?
A: The diagnostic triad includes 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance.
231
Q: What medications are used to manage hyperemesis gravidarum?
A: First-line medications include oral cyclizine or promethazine, prochlorperazine or chlorpromazine, and a combination of doxylamine/pyridoxine. Second-line options are oral ondansetron, metoclopramide, or domperidone, with caution due to side effects. IV hydration may be needed in severe cases.
232
Q: What complications can arise from hyperemesis gravidarum?
A: Complications include dehydration, weight loss, electrolyte imbalances, acute kidney injury, Wernicke's encephalopathy, oesophagitis, Mallory-Weiss tear, and venous thromboembolism.
233
Q: What are the common long-term complications of vaginal hysterectomy with an antero-posterior repair?
A: Common long-term complications include enterocoele and vaginal vault prolapse.
234
Q: What is a potential acute complication following hysterectomy?
A: Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.
235
Q: What are the common causes of infertility?
A: Common causes include male factor (30%), unexplained (20%), ovulation failure (20%), tubal damage (15%), and other causes (15%).
236
Q: What is the purpose of serum progesterone testing in infertility investigations?
A: Serum progesterone is tested 7 days prior to the expected next period (typically on day 21 of a 28-day cycle) to assess ovulation.
237
Q: How should serum progesterone levels be interpreted?
< 16 nmol/l: Repeat test, if consistently low refer to specialist.
16 - 30 nmol/l: Repeat test.
30 nmol/l: Indicates ovulation.
238
Q: What are key counselling points for infertility management?
A: Key points include taking folic acid, maintaining a BMI between 20-25, having regular sexual intercourse every 2 to 3 days, and offering smoking and drinking advice.
239
Q: At what age does the average woman in the UK go through menopause?
A: The average woman in the UK goes through menopause at 51 years old.
240
Q: What are the three main categories for managing menopause?
Lifestyle modifications
Hormone replacement therapy (HRT)
Non-hormone replacement therapy
241
Q: What lifestyle modifications can help manage menopause symptoms?
Hot flushes: Regular exercise, weight loss, and stress reduction
Sleep disturbance: Avoiding late evening exercise and maintaining good sleep hygiene
Mood: Sleep, regular exercise, and relaxation
Cognitive symptoms: Regular exercise and good sleep hygiene
242
Q: What are the contraindications for hormone replacement therapy (HRT)?
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
243
Q: What type of HRT should be used in women with a uterus?
A: In women with a uterus, combined HRT (oestrogen and progestogen) should be used, either orally or transdermally, to reduce the risk of endometrial cancer.
244
Q: What type of HRT should be used in women without a uterus?
A: In women without a uterus, oestrogen alone (either orally or in a transdermal patch) can be used.
245
Q: What are some risks associated with HRT?
Venous thromboembolism: Slight increase with all forms of oral HRT; no increased risk with transdermal HRT
Stroke: Slight increase with oral oestrogen HRT
Coronary heart disease: Slight increase with combined HRT
Breast cancer: Increased risk with all combined HRT, but no increased risk of dying from breast cancer
Ovarian cancer: Increased risk with all HRT
246
Q: What are the non-HRT treatments for menopause?
Vasomotor symptoms: Fluoxetine, citalopram, or venlafaxine
Vaginal dryness: Vaginal lubricant or moisturiser
Psychological symptoms: Self-help groups, cognitive behavioural therapy (CBT), or antidepressants
Urogenital symptoms: Vaginal oestrogen can be prescribed for urogenital atrophy, and moisturisers or lubricants can also be used.
247
Q: When should a woman be referred to secondary care for menopause management?
A: Referral to secondary care is necessary if treatment has been ineffective, if there are ongoing side effects, or if there is unexplained bleeding.
248
Q: What changes in periods may occur during menopause?
Change in the length of menstrual cycles
Dysfunctional uterine bleeding
249
Q: What are vasomotor symptoms and how common are they?
A: Vasomotor symptoms, affecting around 80% of women, include hot flushes and night sweats, and they may continue for up to 5 years.
250
Q: What are the urogenital changes that occur in menopause?
A: Urogenital changes, affecting around 35% of women, include vaginal dryness, atrophy, and urinary frequency.
251
Q: What psychological symptoms can be seen during menopause?
A: Psychological symptoms can include anxiety and depression (seen in around 10% of women) and short-term memory impairment.
252
Q: What are the longer-term complications of menopause?
Osteoporosis
Increased risk of ischaemic heart disease
253
Q: What is dysfunctional uterine bleeding?
A: Dysfunctional uterine bleeding refers to menorrhagia in the absence of underlying pathology and accounts for approximately half of the cases.
254
Q: What are common causes of menorrhagia?
Dysfunctional uterine bleeding
Anovulatory cycles (more common at the extremes of a woman's reproductive life)
Uterine fibroids
Hypothyroidism
Intrauterine devices (copper coils)
Pelvic inflammatory disease
Bleeding disorders (e.g., von Willebrand disease)
255
Q: How does the intrauterine system (Mirena) relate to menorrhagia?
A: The intrauterine system (Mirena) is used to treat menorrhagia, unlike normal copper coils, which can be a cause.
256
Q: What is a threatened miscarriage, and when does it typically occur?
A: A threatened miscarriage is painless vaginal bleeding occurring before 24 weeks, typically between 6-9 weeks. The bleeding is often less than menstruation, and the cervical os remains closed. It complicates up to 25% of pregnancies.
257
Q: What is a missed (delayed) miscarriage, and how is it diagnosed?
A: A missed (delayed) miscarriage occurs when a gestational sac contains a dead fetus before 20 weeks without symptoms of expulsion. The mother may have light vaginal bleeding/discharge, and pregnancy symptoms disappear, but pain is not usually present. The cervical os is closed, and when the gestational sac is >25mm with no visible embryo/fetus, it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy.'
258
Q: What is an inevitable miscarriage, and what are the features?
A: An inevitable miscarriage involves heavy bleeding with clots and pain, and the cervical os is open.
259
Q: What characterizes an incomplete miscarriage?
A: An incomplete miscarriage occurs when not all products of conception have been expelled. It involves pain and vaginal bleeding, with the cervical os being open.
260
Q: What are the common causes of early miscarriage?
A: Chromosomal abnormalities account for about 50% of early miscarriages.
261
Q: What are some risk factors for miscarriage?
A: Risk factors include advanced maternal age (especially women over 35), a history of previous miscarriages, previous large cervical cone biopsy, lifestyle factors such as smoking, alcohol consumption, and obesity, and medical conditions such as uncontrolled diabetes and thyroid disorders.
262
Q: What is recurrent miscarriage, and how common is it?
A: Recurrent miscarriage is defined as three or more consecutive miscarriages, affecting about 1% of couples.
263
Q: What is expectant management for miscarriage?
A: Expectant management involves waiting for a spontaneous miscarriage to occur, typically for 7-14 days. If it is unsuccessful, medical or surgical management may be considered.
264
Q: What situations may require medical or surgical management for miscarriage?
A: These situations include increased risk of hemorrhage, late first trimester miscarriage, coagulopathies or inability to have a blood transfusion, previous adverse pregnancy experiences, and evidence of infection.
265
Q: How is medical management of miscarriage performed for missed miscarriage?
A: Medical management involves administering oral mifepristone, followed 48 hours later by misoprostol to induce uterine contractions and expel products of conception.
266
Q: How is medical management of incomplete miscarriage performed?
A: A single dose of misoprostol (vaginal, oral, or sublingual) is given, and antiemetics and pain relief should be offered. A pregnancy test should be performed 3 weeks later.
267
Q: What are the surgical options for miscarriage management?
A: The two main surgical options are vacuum aspiration (suction curettage) under local anesthetic as an outpatient or surgical management in theatre under general anesthetic, previously referred to as evacuation of retained products of conception.
268
Q: What is the most common type of ovarian cancer?
A: Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas.
269
Q: What are some key risk factors for ovarian cancer?
A: Key risk factors include family history with mutations in BRCA1 or BRCA2 genes, and many ovulations (e.g. early menarche, late menopause, nulliparity).
270
Q: What are common clinical features of ovarian cancer?
A: Common symptoms include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms (e.g. urgency), early satiety, and diarrhea.
271
Q: What is the first investigation recommended for suspected ovarian cancer?
A: A CA125 test is done initially to assess for ovarian cancer. If the level is 35 IU/mL or greater, an urgent ultrasound scan of the abdomen and pelvis should be ordered.
272
Q: What is the role of ultrasound in ovarian cancer diagnosis?
A: Ultrasound is used to further investigate after an elevated CA125 test result.
273
Q: How is ovarian cancer typically managed?
A: Management typically involves a combination of surgery and platinum-based chemotherapy.
274
Q: What is a complex ovarian cyst, and how should it be managed?
A: A complex ovarian cyst is multi-loculated and should be biopsied to exclude malignancy.
275
Q: What are follicular cysts?
A: Follicular cysts are the most common type of ovarian cyst, caused by the non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle. They typically regress after several menstrual cycles.
276
Q: What is a corpus luteum cyst?
A: A corpus luteum cyst forms when the corpus luteum fails to break down after ovulation, filling with blood or fluid. It is more likely to cause intraperitoneal bleeding than follicular cysts.
277
Q: What is a dermoid cyst?
A: A dermoid cyst (mature cystic teratoma) is a benign germ cell tumor, often containing skin appendages, hair, and teeth. It is the most common benign ovarian tumor in women under 30, with a median age of diagnosis at 30. It may cause torsion more frequently than other ovarian tumors.
278
Q: What is a serous cystadenoma?
A: A serous cystadenoma is the most common benign epithelial ovarian tumor, resembling serous carcinoma, the most common type of ovarian cancer. It is bilateral in about 20% of cases.
279
Q: What is a mucinous cystadenoma?
A: A mucinous cystadenoma is the second most common benign epithelial ovarian tumor. These cysts are typically large and may become massive. If ruptured, they may cause pseudomyxoma peritonei.
280
Q: What is the initial imaging modality for suspected ovarian cysts/tumors?
A: The initial imaging modality is ultrasound.
281
Q: What is the management approach for premenopausal women with ovarian cysts?
A: For younger women (especially those under 35 years), a conservative approach may be taken if the cyst is small (e.g., <5 cm) and classified as 'simple,' as malignancy is less common. A repeat ultrasound should be arranged for 8-12 weeks, and referral should be considered if the cyst persists.
282
Q: What is the management approach for postmenopausal women with ovarian cysts?
A: Any postmenopausal woman with an ovarian cyst, regardless of its nature or size, should be referred to gynaecology for assessment, as physiological cysts are unlikely at this stage.
283
Q: What is ovarian hyperstimulation syndrome (OHSS)?
A: Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of infertility treatment, where high levels of oestrogens, progesterone, and vasoactive substances like vascular endothelial growth factor (VEGF) lead to increased membrane permeability and fluid loss from the intravascular compartment.
284
Q: What treatments are most commonly associated with OHSS?
A: OHSS is more likely to occur following gonadotropin or hCG treatment and is rarely seen with clomifene therapy. Up to one-third of women undergoing IVF may experience a mild form of OHSS.
285
Q: What is the RCOG classification for OHSS?
Mild: Abdominal pain, abdominal bloating.
Moderate: Includes symptoms from mild, plus nausea and vomiting, ultrasound evidence of ascites.
Severe: Includes symptoms from moderate, plus clinical evidence of ascites, oliguria, haematocrit > 45%, hypoproteinaemia.
Critical: Includes symptoms from severe, plus thromboembolism, acute respiratory distress syndrome, anuria, and tense ascites.
286
Q: What is ovarian torsion?
A: Ovarian torsion is the partial or complete twisting of the ovary on its supporting ligaments, which may compromise the blood supply. If the fallopian tube is also involved, it is referred to as adnexal torsion.
287
Q: What are the risk factors for ovarian torsion?
Ovarian mass (present in around 90% of cases)
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome
288
Q: What are the features of ovarian torsion?
Sudden onset of deep-seated, colicky abdominal pain
Associated vomiting and distress
Fever (in a minority, possibly due to adnexal necrosis)
Adnexal tenderness on vaginal examination
289
Q: How is ovarian torsion diagnosed?
Ultrasound may show free fluid or a whirlpool sign
Laparoscopy is usually both diagnostic and therapeutic
290
Q: What are the three main categories of anovulation?
Class 1: Hypogonadotropic hypogonadal anovulation (e.g., hypothalamic amenorrhoea)
Class 2: Normogonadotropic normoestrogenic anovulation (e.g., polycystic ovary syndrome)
Class 3: Hypergonadotropic hypoestrogenic anovulation (e.g., premature ovarian insufficiency)
291
Q: What are the forms of ovulation induction?
Exercise and weight loss: First-line for women with polycystic ovarian syndrome (PCOS), especially if overweight or obese.
Letrozole: First-line medical therapy for PCOS, promoting follicular development with a higher rate of mono-follicular development than clomiphene.
Clomiphene citrate: A selective estrogen receptor modulator used for ovulation induction, especially in women with PCOS, but with higher side effects than letrozole.
Gonadotropin therapy: Used for women with hypogonadotropic hypogonadism (Class 1 anovulation), and for other cases if other treatments fail.
292
Q: What is ovarian hyperstimulation syndrome (OHSS) and how is it managed?
A: OHSS is a potential side effect of ovulation induction, characterized by ovarian enlargement and fluid shift, which can lead to life-threatening complications like hypovolaemic shock and acute renal failure. Management includes fluid and electrolyte replacement, anticoagulation therapy, abdominal ascitic paracentesis, and pregnancy termination if necessary.
293
Q: What is pelvic inflammatory disease (PID)?
A: PID is an infection and inflammation of the female pelvic organs, including the uterus, fallopian tubes, ovaries, and surrounding peritoneum. It typically results from an ascending infection originating from the endocervix.
294
Q: What are the common causative organisms of PID?
Chlamydia trachomatis (most common)
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
295
Q: What are the key features of PID?
Lower abdominal pain
Fever
Deep dyspareunia
Dysuria and menstrual irregularities
Vaginal or cervical discharge
Cervical excitation
296
Q: What investigations are needed for PID?
Pregnancy test to exclude ectopic pregnancy
High vaginal swab (often negative)
Screen for Chlamydia and Gonorrhoea
297
Q: How is PID managed?
First-line treatment: Stat IM ceftriaxone + 14 days of oral doxycycline + oral metronidazole
Second-line treatment: Oral ofloxacin + oral metronidazole
Consider removing intrauterine contraceptive devices in more severe cases for better short-term clinical outcomes.
298
Q: What are the complications of PID?
Perihepatitis (Fitz-Hugh Curtis Syndrome): Right upper quadrant pain, which may be confused with cholecystitis.
Infertility: 10-20% risk after a single episode of PID.
Chronic pelvic pain
Ectopic pregnancy
299
Q: What is the most common cause of pelvic pain in women?
A: The most common cause of pelvic pain in women is primary dysmenorrhoea.
300
Q: What is mittelschmerz?
A: Mittelschmerz is transient pelvic pain that occurs in the middle of the menstrual cycle, usually due to ovulation.
301
Q: What are the characteristics of acute pelvic pain conditions?
Ectopic pregnancy: Lower abdominal pain after 6-8 weeks of amenorrhoea, vaginal bleeding, shoulder tip pain, cervical excitation.
Urinary tract infection (UTI): Dysuria, frequency, suprapubic burning from cystitis.
Appendicitis: Central abdominal pain moving to the right iliac fossa, anorexia, tachycardia, low-grade fever, tenderness in RIF, Rovsing's sign (more pain in RIF than LIF).
Pelvic inflammatory disease (PID): Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria, menstrual irregularities, cervical excitation.
Ovarian torsion: Sudden onset unilateral lower abdominal pain, often after exercise, nausea, vomiting, unilateral tender adnexal mass.
Miscarriage: Vaginal bleeding and crampy lower abdominal pain after amenorrhoea.
302
Q: What are the characteristics of chronic pelvic pain conditions?
Endometriosis: Chronic pelvic pain, dysmenorrhoea starting days before bleeding, deep dyspareunia, subfertility.
Irritable bowel syndrome: Abdominal pain, bloating, changes in bowel habits, lethargy, nausea, backache, bladder symptoms.
Ovarian cyst: Unilateral dull ache, intermittent or during intercourse, torsion or rupture causing severe pain, large cysts causing abdominal swelling or pressure on the bladder.
Urogenital prolapse: Sensation of pressure or heaviness, urinary symptoms like incontinence, frequency, urgency, common in older women.
303
Q: What is polycystic ovary syndrome (PCOS)?
A: PCOS is a complex condition of ovarian dysfunction affecting 5-20% of women of reproductive age, often associated with hyperinsulinaemia, high levels of luteinizing hormone (LH), and overlap with metabolic syndrome.
304
Q: What are the features of PCOS?
Subfertility and infertility
Menstrual disturbances (oligomenorrhoea and amenorrhoea)
Hirsutism and acne due to hyperandrogenism
Obesity
Acanthosis nigricans due to insulin resistance
305
Q: What are the investigations for PCOS?
Pelvic ultrasound: Multiple cysts on the ovaries
Blood tests: FSH, LH, prolactin, TSH, testosterone, SHBG
Raised LH:FSH ratio (formerly a classical feature, but not useful for diagnosis)
Prolactin may be normal or mildly elevated
Testosterone may be normal or mildly elevated (consider other causes if markedly raised)
SHBG is normal to low in women with PCOS
Check for impaired glucose tolerance
306
Q: What are the Rotterdam criteria for diagnosing PCOS?
A diagnosis of PCOS can be made if at least two of the following three criteria are present:
Infrequent or no ovulation (manifested as infrequent or no menstruation)
Clinical and/or biochemical signs of hyperandrogenism (e.g., hirsutism, acne, elevated testosterone)
Polycystic ovaries on ultrasound (≥ 12 follicles (2-9 mm in diameter) in one or both ovaries and/or ovarian volume > 10 cm³)
307
Q: What is postcoital bleeding?
A: Postcoital bleeding refers to vaginal bleeding that occurs after sexual intercourse.
308
Q: What are the causes of postcoital bleeding?
In around 50% of cases, no identifiable pathology is found
Cervical ectropion: Most common identifiable cause, occurring in about 33% of cases; more common in women on the combined oral contraceptive pill
Cervicitis: Often secondary to infections such as Chlamydia
Cervical cancer
Polyps
Trauma
309
Q: What is postmenopausal bleeding?
A: Postmenopausal bleeding refers to vaginal bleeding occurring after 12 months of amenorrhoea in women who have reached menopause.
310
Q: What are the causes of postmenopausal bleeding?
Vaginal atrophy: Most common cause due to thinning, drying, and inflammation of the vaginal walls from decreased oestrogen after menopause
Hormone replacement therapy (HRT): Can cause periods or spotting; endometrial hyperplasia may occur with long-term oestrogen therapy
Endometrial hyperplasia: Abnormal thickening of the endometrium, which can precede endometrial cancer
Endometrial cancer: Present in about 10% of cases; requires urgent exclusion
Cervical cancer: Must be ruled out, especially if there is a history of inadequate cervical screening
Ovarian cancer: Particularly oestrogen-secreting tumours (e.g., theca cell) can cause bleeding
Vaginal cancer: Rare, but can also cause postmenopausal bleeding
Other causes: Trauma, vulval cancer, bleeding disorders
311
Q: What investigations should be performed for postmenopausal bleeding?
A: According to NICE guidelines, women over 55 with postmenopausal bleeding should undergo an ultrasound within two weeks to exclude endometrial cancer. A transvaginal ultrasound is typically used to assess endometrial lining thickness. An acceptable thickness is <5mm; however, if clinical suspicion is high, further testing is warranted.
312
Q: What is the treatment for postmenopausal bleeding based on the cause?
Vaginal atrophy: Topical oestrogens, lubrication, and HRT
HRT-related bleeding: Different HRT preparations may be tried
Endometrial hyperplasia: Dilatation and curettage to remove excess endometrial tissue
313
Q: What are the minor symptoms of pregnancy?
Nausea/vomiting
Tiredness
Musculoskeletal pains
314
Q: What is premature ovarian insufficiency, and what are its causes?
Premature ovarian insufficiency is the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40. Causes include:
Idiopathic (most common)
Bilateral oophorectomy
Hysterectomy with ovarian preservation
Radiotherapy
Chemotherapy
Infection (e.g., mumps)
Autoimmune disorders
Resistant ovary syndrome (due to FSH receptor abnormalities)
315
Q: What are the features of premature ovarian insufficiency?
Climacteric symptoms (hot flushes, night sweats)
Infertility
Secondary amenorrhoea
Raised FSH and LH levels (e.g., FSH > 30 IU/L)
Low oestradiol levels (e.g., < 100 pmol/l)
316
Q: How is premature ovarian insufficiency managed?
Hormone replacement therapy (HRT) or a combined oral contraceptive pill until the average menopause age (51 years).
HRT does not provide contraception if spontaneous ovarian activity resumes.
317
Q: What is Premenstrual Syndrome (PMS)?
A: PMS refers to emotional and physical symptoms that women may experience during the luteal phase of the menstrual cycle, occurring only in ovulatory cycles.
318
Q: When does PMS occur?
A: PMS only occurs in the presence of ovulatory menstrual cycles, not before puberty, during pregnancy, or after menopause.
319
Q: What are common emotional symptoms of PMS?
A: Anxiety, stress, fatigue, and mood swings.
320
Q: What are common physical symptoms of PMS?
A: Bloating and breast pain.
321
Q: How are mild symptoms of PMS managed?
A: With lifestyle advice including sleep, exercise, smoking cessation, alcohol reduction, and regular, small, balanced meals rich in complex carbohydrates.
322
Q: What treatment is recommended for moderate PMS symptoms?
A: A new-generation combined oral contraceptive pill (COCP), such as Yasmin (drospirenone 3 mg and ethinylestradiol 0.030 mg).
323
Q: What treatment may benefit women with severe PMS symptoms?
A: A selective serotonin reuptake inhibitor (SSRI), taken continuously or during the luteal phase (days 15-28 of the menstrual cycle).
324
Q: How common is vaginal itching, also known as pruritus vulvae?
A: Vaginal itching is common, with 1 in 10 women seeking help at some point.
325
Q: How does pruritus vulvae differ from pruritus ani?
A: Unlike pruritus ani, pruritus vulvae usually has an underlying cause.
326
Q: What is the most common cause of pruritus vulvae?
A: Irritant contact dermatitis, such as from latex condoms or lubricants.
327
Q: Name some other causes of pruritus vulvae.
A: Atopic dermatitis, seborrhoeic dermatitis, lichen planus, lichen sclerosus, and psoriasis (seen in about a third of psoriasis patients).
328
Q: What hygiene advice should be given to women with pruritus vulvae?
A: Take showers instead of baths, clean the vulval area with an emollient like Epaderm or Diprobase, and clean only once a day to avoid aggravating symptoms.
329
Q: What is the general treatment for most underlying conditions causing pruritus vulvae?
A: Topical steroids are effective for most conditions.
330
Q: What treatment may be tried if seborrhoeic dermatitis is suspected in pruritus vulvae?
A: A combined steroid-antifungal cream.
331
Q: How is recurrent miscarriage defined?
A: Recurrent miscarriage is defined as 3 or more consecutive spontaneous abortions.
332
Q: What are the causes of recurrent miscarriage?
Antiphospholipid syndrome
Endocrine disorders: Poorly controlled diabetes mellitus, thyroid disorders, polycystic ovarian syndrome (PCOS)
Uterine abnormality: E.g., uterine septum
Parental chromosomal abnormalities
Smoking
333
Q: What are the abstinence requirements for semen analysis?
A: Semen analysis should be performed after a minimum of 3 days and a maximum of 5 days of abstinence.
334
Q: How quickly should a semen sample be delivered to the lab?
A: The sample needs to be delivered to the lab within 1 hour.
335
Q: What act governs abortion laws in the UK, and what was its major amendment?
A: The 1967 Abortion Act governs abortion laws, amended in 1990 to reduce the upper gestation limit from 28 weeks to 24 weeks (with some exceptions).
336
Q: How many registered medical practitioners must sign the legal document for an abortion?
A: Two registered medical practitioners must sign, except in an emergency when only one is required.
337
Q: When should anti-D prophylaxis be given during an abortion?
A: Anti-D prophylaxis should be given to Rhesus D-negative women undergoing an abortion after 10+0 weeks' gestation.
338
Q: What medications are used for a medical abortion, and how do they work?
A: Mifepristone (anti-progestogen) is followed 48 hours later by prostaglandins (e.g., misoprostol) to stimulate uterine contractions, mimicking a miscarriage.
339
Q: What is required two weeks after a medical abortion to confirm completion?
A: A multi-level pregnancy test that measures hCG levels.
340
Q: What are the surgical options for abortion?
Manual vacuum aspiration (MVA)
Electric vacuum aspiration (EVA)
Dilatation and evacuation (D&E)
Cervical priming with misoprostol ± mifepristone is done before procedures.
341
Q: When can an intrauterine contraceptive be inserted after an abortion?
A: Immediately after evacuation of the uterine cavity following a surgical abortion.
342
Q: Up to what gestation should women be offered a choice between medical or surgical abortion according to NICE?
A: Up to and including 23+6 weeks' gestation.
343
Q: Under what circumstances can the 24-week gestation limit for abortion be exceeded?
To save the life of the woman.
Evidence of extreme fetal abnormality.
Risk of serious physical or mental injury to the woman.
344
Q: What are the four legal grounds for abortion under the 1967 Abortion Act?
Risk to the woman's physical or mental health or her family's well-being if the pregnancy continues.
Prevention of grave permanent injury to the woman’s health.
Risk to the woman’s life if the pregnancy continues.
Substantial risk of the child being born with severe physical or mental abnormalities.
345
Q: What are the risk factors for urinary incontinence?
Advancing age
Previous pregnancy and childbirth
High body mass index
Hysterectomy
Family history
346
Q: What is overactive bladder (OAB)/urge incontinence?
A: A type of UI caused by detrusor overactivity, where the urge to urinate is quickly followed by uncontrollable leakage, ranging from a few drops to complete bladder emptying.
347
Q: What is stress incontinence?
A: Leakage of small amounts of urine during activities that increase abdominal pressure, such as coughing or laughing.
348
Q: What is mixed incontinence?
A: A combination of both urge and stress incontinence.
349
Q: What is overflow incontinence?
A: UI caused by bladder outlet obstruction, such as prostate enlargement, leading to incomplete bladder emptying.
350
Q: What is functional incontinence?
A: UI caused by physical or cognitive conditions, such as dementia or decreased mobility, that impair the ability to reach the bathroom in time.
351
Q: What initial investigations are recommended for urinary incontinence?
Bladder diaries (minimum of 3 days)
Vaginal examination to exclude pelvic organ prolapse and assess pelvic floor muscle function
Urine dipstick and culture
Urodynamic studies
352
Q: What is the first-line treatment for urge incontinence?
A: Bladder retraining for at least 6 weeks and antimuscarinics such as oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily).
353
Q: When is mirabegron used for urge incontinence?
A: In frail elderly patients when there is concern about anticholinergic side effects.
354
Q: What surgical options are available for stress incontinence?
A: Retropubic mid-urethral tape procedures.
355
Q: What medication can be offered for stress incontinence if surgery is declined?
A: Duloxetine, a combined noradrenaline and serotonin reuptake inhibitor.
356
Q: What is urogenital prolapse?
A: Urogenital prolapse is the descent of one of the pelvic organs, resulting in protrusion on the vaginal walls. It affects around 40% of postmenopausal women.
357
Q: What are the types of urogenital prolapse?
Cystocele
Cystourethrocele
Rectocele
Uterine prolapse
Less common: Urethrocele, Enterocele (herniation of the pouch of Douglas with small intestine into the vagina)
358
Q: What are the risk factors for urogenital prolapse?
Increasing age
Multiparity and vaginal deliveries
Obesity
Spina bifida
359
Q: What are the common presentations of urogenital prolapse?
Sensation of pressure, heaviness, or "bearing-down"
Urinary symptoms: incontinence, frequency, urgency
360
Q: When is no treatment needed for urogenital prolapse?
A: No treatment is needed if the prolapse is asymptomatic and mild.
361
Q: What are the conservative management options for urogenital prolapse?
Weight loss
Pelvic floor muscle exercises
Use of a ring pessary
362
Q: What are the surgical options for cystocele/cystourethrocele?
Anterior colporrhaphy
Colposuspension
363
Q: What are the surgical options for uterine prolapse?
Hysterectomy
Sacrohysteropexy
364
Q: What is the surgical option for rectocele?
A: Posterior colporrhaphy.
365
Q: What are uterine fibroids?
A: Uterine fibroids are benign smooth muscle tumors of the uterus, occurring in around 20% of white women and 50% of black women in their later reproductive years.
366
Q: What are the features of uterine fibroids?
May be asymptomatic
Menorrhagia, which can lead to iron-deficiency anemia
Bulk-related symptoms: lower abdominal pain, bloating, urinary frequency (with larger fibroids)
Subfertility
Rare: polycythemia secondary to autonomous erythropoietin production
367
Q: What is the diagnostic investigation for uterine fibroids?
A: Transvaginal ultrasound.
368
Q: What is the management for asymptomatic fibroids?
A: Periodic review to monitor size and growth; no treatment is typically required.
369
Q: How is menorrhagia secondary to fibroids managed?
Levonorgestrel intrauterine system (LNG-IUS) (if no distortion of the uterine cavity)
NSAIDs (e.g., mefenamic acid)
Tranexamic acid
Combined oral contraceptive pill
Oral or injectable progestogen
370
Q: What medical treatments are used to shrink fibroids?
GnRH agonists: Effective for short-term treatment but have side effects (e.g., menopausal symptoms, loss of bone density)
Ulipristal acetate: Previously used but not currently recommended due to liver toxicity concerns
371
Q: What surgical options are available for fibroids?
Myomectomy (abdominal, laparoscopic, or hysteroscopic)
Hysteroscopic endometrial ablation
Hysterectomy
Uterine artery embolization
372
Q: What happens to fibroids after menopause?
A: Fibroids generally regress after menopause.
373
Q: What is red degeneration, and when does it commonly occur?
A: Red degeneration is hemorrhage into the fibroid tumor, commonly occurring during pregnancy.
374
Q: What is vaginal candidiasis, and what causes it?
A: Vaginal candidiasis, or thrush, is a common condition caused by Candida species, with around 80% of cases due to Candida albicans and the remaining 20% caused by other Candida species.
375
What are features of vaginal candidiasis
'Cottage cheese' non-offensive discharge
Vulvitis: Superficial dyspareunia (pain during sex), dysuria (painful urination)
Itch
Vulval erythema, fissuring, and satellite lesions
376
Q: Is a high vaginal swab routinely indicated for vaginal candidiasis?
A: No, a high vaginal swab is not routinely needed if clinical features are consistent with candidiasis.
377
Q: What are the first-line treatments for vaginal candidiasis?
Oral fluconazole 150 mg as a single dose
Clotrimazole 500 mg intravaginal pessary as a single dose (if oral treatment is contraindicated)
378
Q: What should be added if there are vulval symptoms in vaginal candidiasis?
A: Consider adding a topical imidazole in addition to an oral or intravaginal antifungal.
379
Q: What treatment options are safe for pregnant women with vaginal candidiasis?
A: Only local treatments (e.g., cream or pessaries) are recommended; oral treatments are contraindicated.
380
Q: How is recurrent vaginal candidiasis defined, and how is it managed?
Recurrent vaginal candidiasis is defined as 4 or more episodes per year. Management includes:
Checking compliance with previous treatment
Confirming the diagnosis with a high vaginal swab for microscopy and culture
Excluding diabetes with a blood glucose test
Considering differential diagnoses such as lichen sclerosus
Induction-maintenance regime:
Induction: Oral fluconazole every 3 days for 3 doses
Maintenance: Oral fluconazole weekly for 6 months
381
Q: What are the common causes of vaginal discharge?
Physiological
Candida
Trichomonas vaginalis
Bacterial vaginosis
382
Q: What are the less common causes of vaginal discharge?
Gonorrhoea
Chlamydia (rarely presents as discharge)
Ectropion
Foreign body
Cervical cancer
383
Q: What are the key features of vaginal discharge caused by Candida?
'Cottage cheese' discharge
Vulvitis
Itch
384
Q: What are the key features of vaginal discharge caused by Trichomonas vaginalis?
Offensive, yellow/green, frothy discharge
Vulvovaginitis
Strawberry cervix
385
Q: What are the key features of vaginal discharge caused by bacterial vaginosis?
Offensive, thin, white/grey, 'fishy' discharge
386
Q: What is the most common type of vulval cancer?
A: Around 80% of vulval cancers are squamous cell carcinomas.
387
Q: What are the risk factors for vulval carcinoma?
Human papilloma virus (HPV) infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
388
Q: What are the common features of vulval carcinoma?
Lump or ulcer on the labia majora
Inguinal lymphadenopathy
May be associated with itching or irritation
389
Q: What is vulval intraepithelial neoplasia (VIN)?
A: VIN is a pre-cancerous skin lesion of the vulva that may lead to squamous skin cancer if untreated. The average age of an affected woman is around 50 years.
390
Q: What are the risk factors for vulval intraepithelial neoplasia (VIN)?
Human papilloma virus (HPV) 16 & 18
Smoking
Herpes simplex virus 2
Lichen sclerosus
391
Q: What are the common features of vulval intraepithelial neoplasia (VIN)?
Itching, burning
Raised, well-defined skin lesions
392
Q: How is vulval intraepithelial neoplasia (VIN) diagnosed?
Biopsy: Punch biopsy or excisional biopsy for histological diagnosis
HPV Testing: PCR or in situ hybridization for high-risk HPV DNA
393
Q: What are the treatment options for vulval intraepithelial neoplasia (VIN)?
Topical therapies:
Imiquimod (immune response modifier)
5-Fluorouracil (topical chemotherapeutic agent)
Surgical interventions:
Wide local excision, laser ablation, partial vulvectomy (for extensive disease)
394
Q: How is vulval intraepithelial neoplasia (VIN) monitored after treatment?
A: Regular monitoring with repeat colposcopy and biopsy if recurrence or progression is suspected.
395
Q: What is the most important cause of abdominal pain to exclude in early pregnancy?
A: Ectopic pregnancy is the most important cause to exclude. It occurs in 0.5% of pregnancies and is often associated with risk factors such as tubal damage, previous ectopic pregnancy, and IVF.
396
Q: What are the typical symptoms of ectopic pregnancy?
Lower abdominal pain (usually unilateral)
Vaginal bleeding (typically dark brown and less than a normal period)
History of recent amenorrhoea (usually 6-8 weeks)
Peritoneal bleeding can cause shoulder tip pain and pain on defecation/urination
397
Q: What are the different types of miscarriage and their features?
Threatened miscarriage: Painless vaginal bleeding before 24 weeks, cervical os closed, occurs at 6-9 weeks.
Missed (delayed) miscarriage: No expulsion of the dead fetus, symptoms of pregnancy disappear, gestational sac >25mm without embryonic/fetal part.
Inevitable miscarriage: Cervical os open, heavy bleeding with clots and pain.
Incomplete miscarriage: Not all products of conception expelled.
398
Q: What are the causes of abdominal pain in late pregnancy?
Labour: Regular abdominal tightening, painful in later stages.
Placental abruption: Separation of placenta from uterine wall, causing maternal haemorrhage, pain, tense uterus, and fetal heart distress.
Symphysis pubis dysfunction: Pain over the pubic symphysis, waddling gait, radiation to the groins.
Pre-eclampsia/HELLP syndrome: Epigastric or RUQ pain associated with hypertension, proteinuria, hemolysis, elevated liver enzymes, and low platelet count.
Uterine rupture: Typically occurs during labour, with shock, abdominal pain, and vaginal bleeding, especially in women with previous C-sections.
399
Q: What are the causes of abdominal pain at any point during pregnancy?
Appendicitis: Occurs in 1:1,000-2:1,000 pregnancies, with pain location changing based on gestation.
Urinary tract infection (UTI): Affects 1 in 25 women in pregnancy, associated with an increased risk of pre-term delivery and IUGR.
400
Q: What are the causes of increased AFP?
Neural tube defects (meningocele, myelomeningocele, anencephaly)
Abdominal wall defects (omphalocele, gastroschisis)
Multiple pregnancy
Maternal diabetes mellitus
401
Q: What are the causes of decreased AFP?
Down's syndrome
Trisomy 18
402
Q: What is Amniotic Fluid Embolism?
A: Amniotic fluid embolism occurs when fetal cells or amniotic fluid enter the mother's bloodstream, triggering a reaction that results in various symptoms.
403
Q: What are the known risk factors for Amniotic Fluid Embolism?
A: Maternal age and induction of labour have been consistently associated with Amniotic Fluid Embolism, though the exact cause remains unclear.
404
Q: When do most cases of Amniotic Fluid Embolism occur, and what are the symptoms?
A: Most cases occur during labour, caesarean section, or immediately after delivery. Symptoms include chills, shivering, sweating, anxiety, and coughing.
405
Q: What signs are indicative of Amniotic Fluid Embolism?
A: Signs include cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia, and myocardial infarction.
406
Q: What is the management approach for Amniotic Fluid Embolism?
A: Management is predominantly supportive and requires a multidisciplinary team in a critical care unit.
407
Q: What is the recommended dosage of folic acid for pregnant women, and when should it be taken?
A: Folic acid 400mcg should be taken from before conception until 12 weeks to reduce the risk of neural tube defects. Higher doses may be required for women taking antiepileptics.
408
Q: What should pregnant women avoid in terms of vitamin A intake?
A: Pregnant women should avoid vitamin A supplementation above 700 micrograms. Liver, which is high in vitamin A, should also be avoided.
409
Q: What vitamin D supplementation is recommended for pregnant women?
A: Pregnant women should take a daily supplement of 10 micrograms of vitamin D, as found in the Healthy Start multivitamin supplement.
410
Q: What are the risks of smoking during pregnancy?
A: Smoking during pregnancy increases the risk of low birth weight and preterm birth. Nicotine replacement therapy (NRT) may be used if the woman has already stopped smoking, but varenicline and bupropion should not be used during pregnancy.
411
Q: What is the guidance on air travel during pregnancy?
A: Women over 37 weeks with a singleton pregnancy and no additional risk factors should avoid air travel. Women with uncomplicated multiple pregnancies should avoid air travel after 32 weeks. Wearing compression stockings helps reduce the risk of venous thromboembolism.
412
Q: What is the first-line pharmacological treatment for nausea and vomiting in pregnancy according to NICE and BNF?
A: Antihistamines, with promethazine suggested as first-line treatment.
413
Q: At what gestational age should the booking visit occur, and what does it include?
A: The booking visit should occur between 8 and 12 weeks (ideally < 10 weeks). It includes general information, blood pressure (BP), urine dipstick, BMI check, booking bloods/urine (e.g., FBC, blood group, rhesus status, hepatitis B, syphilis, HIV test), and urine culture.
414
Q: When is the early scan to confirm dates and exclude multiple pregnancy typically done?
A: Between 10 and 13+6 weeks.
415
Q: What screening is offered at 11 - 13+6 weeks of pregnancy?
A: Down's syndrome screening, including a nuchal scan.
416
Q: What is checked during the 16-week visit?
A: BP, urine dipstick, and information on anomaly and blood results. If hemoglobin (Hb) < 11 g/dL, iron is considered.
417
Q: When is the anomaly scan done during pregnancy?
A: Between 18 and 20+6 weeks.
418
Q: At 25 weeks, what additional measurements and checks are done?
A: Routine care (BP, urine dipstick, symphysis-fundal height [SFH] for primigravida), and iron is considered if Hb < 10.5 g/dL.
419
Q: When is the first dose of anti-D prophylaxis administered to rhesus negative women?
A: At 28 weeks.
420
Q: What care is provided during the 34-week visit?
A: Routine care (BP, urine dipstick, SFH), second dose of anti-D prophylaxis to rhesus negative women, and information on labor and birth plan.
421
Q: When should the external cephalic version be offered, and at which visit?
A: At 36 weeks if indicated.
422
Q: What is discussed during the 40-week visit (only if primip)?
A: Routine care and discussion about options for prolonged pregnancy.
423
Q: What happens at the 41-week visit?
A: Routine care and discussion of labor plans and the possibility of induction.
424
Q: What is the definition of antepartum haemorrhage?
A: Antepartum haemorrhage is defined as bleeding from the genital tract after 24 weeks of pregnancy, prior to delivery of the fetus.
425
Q: What are the key features of placental abruption?
Shock out of keeping with visible loss
Constant pain
Tender, tense uterus
Normal lie and presentation
Absent/distressed fetal heart
Coagulation problems
Beware of pre-eclampsia, DIC, anuria
426
Q: What are the key features of placenta praevia?
Shock in proportion to visible loss
No pain
Uterus not tender
Lie and presentation may be abnormal
Fetal heart usually normal
Coagulation problems rare
Small bleeds before large
427
Q: What is the recommendation for vaginal examination in suspected antepartum haemorrhage?
A: Vaginal examination should not be performed in primary care for suspected antepartum haemorrhage, as women with placenta praevia may haemorrhage.
428
Q: What are the major causes of bleeding during the 1st trimester of pregnancy?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
429
Q: What are the major causes of bleeding during the 2nd trimester of pregnancy?
Spontaneous abortion
Hydatidiform mole
Placental abruption
Bloody show
430
Q: What are the major causes of bleeding during the 3rd trimester of pregnancy?
Placental abruption
Placenta praevia
Vasa praevia
431
Q: What is the key feature of a threatened miscarriage?
A: Painless vaginal bleeding typically around 6-9 weeks.
432
Q: What is the key feature of a missed (delayed) miscarriage?
A: Light vaginal bleeding with the disappearance of symptoms of pregnancy.
433
Q: What is the key feature of an inevitable miscarriage?
A: Heavy bleeding and crampy, lower abdominal pain (incomplete), or little bleeding (complete).
434
Q: What are the key features of ectopic pregnancy?
History of 6-8 weeks amenorrhoea
Lower abdominal pain (usually unilateral)
Vaginal bleeding later
Shoulder tip pain and cervical excitation may be present
435
Q: What are the key features of hydatidiform mole?
Bleeding in first or early second trimester
Associated with exaggerated symptoms of pregnancy (e.g., hyperemesis)
Uterus may be large for dates
Serum hCG is very high
436
Q: What are the key features of placental abruption?
Constant lower abdominal pain
Shock more than expected by visible blood loss
Tender, tense uterus with normal lie and presentation
Fetal heart may be distressed
437
Q: What are the key features of placenta praevia?
Vaginal bleeding with no pain
Non-tender uterus
Lie and presentation may be abnormal
438
Q: What are the key features of vasa praevia?
Rupture of membranes followed immediately by vaginal bleeding
Fetal bradycardia is classically seen
439
Q: What is a common cause of nipple pain during breastfeeding?
A: A poor latch can cause nipple pain during breastfeeding.
440
Q: What is a blocked duct ('milk bleb') and how should it be managed?
A: A blocked duct causes nipple pain when breastfeeding. Breastfeeding should continue, and advice should be sought about positioning. Breast massage may also help.
441
Q: How is nipple candidiasis treated in breastfeeding mothers and infants?
A: Miconazole cream should be used for the mother, and nystatin suspension should be used for the baby.
442
Q: What is mastitis, and when should it be treated?
A: Mastitis is inflammation of the breast tissue, affecting about 1 in 10 breastfeeding women. It should be treated if the mother is systemically unwell, if a nipple fissure is present, or if symptoms do not improve after 12-24 hours of effective milk removal. The first-line antibiotic is flucloxacillin for 10-14 days.
443
Q: What complications can arise from untreated mastitis?
A: Untreated mastitis can lead to the development of a breast abscess, which usually requires incision and drainage.
444
Q: What is breast engorgement, and how should it be managed?
A: Breast engorgement causes pain or discomfort, typically worse before a feed. It usually occurs in the first few days after birth and affects both breasts. Milk flow may be impaired, and the infant may have difficulty attaching. Hand expression of milk can help relieve discomfort. Fever usually resolves within 24 hours.
445
Q: What is Raynaud's disease of the nipple, and how is it treated?
A: Raynaud's disease of the nipple causes intermittent nipple pain during and after feeding, with blanching, cyanosis, and erythema. Treatment includes minimizing exposure to cold, using heat packs after breastfeeding, avoiding caffeine, and stopping smoking. If symptoms persist, a trial of oral nifedipine may be considered.
446
Q: What should be done if a breastfed baby loses more than 10% of their birth weight in the first week?
A: The baby should be examined for underlying issues, and breastfeeding problems should be considered. NICE recommends expert review (e.g., midwife-led breastfeeding clinics) and monitoring of weight until it is satisfactory.
447
Q: What is a contraindication for breastfeeding in infants?
A: Galactosaemia is a contraindication for breastfeeding.
448
Q: Which antibiotics are safe for breastfeeding mothers?
A: Safe antibiotics for breastfeeding mothers include penicillins, cephalosporins, and trimethoprim.
449
Q: Which drugs are safe for breastfeeding mothers with endocrine issues?
A: Glucocorticoids (avoid high doses) and levothyroxine are safe for breastfeeding mothers.
450
Q: Which epilepsy drugs are safe for breastfeeding mothers?
A: Sodium valproate and carbamazepine are safe for breastfeeding mothers.
451
Q: Which psychiatric drugs are safe for breastfeeding mothers?
A: Tricyclic antidepressants and antipsychotics are safe for breastfeeding mothers (except clozapine, which should be avoided).
452
Q: Which drugs should be avoided during breastfeeding?
A: Drugs to avoid include ciprofloxacin, tetracycline, chloramphenicol, sulphonamides, lithium, benzodiazepines, aspirin, carbimazole, methotrexate, sulfonylureas, cytotoxic drugs, and amiodarone.
453
Q: Can a breastfeeding mother take warfarin or heparin?
A: Yes, warfarin and heparin are safe for breastfeeding mothers.
454
Q: What are the techniques to suppress lactation?
Stop the lactation reflex (i.e., stop suckling or expressing milk).
Supportive measures such as wearing a well-supported bra and using analgesia.
If needed, cabergoline is the medication of choice for suppressing lactation.
455
Q: What are the indications for a caesarean section?
Absolute indications: Cephalopelvic disproportion, placenta praevia (grades 3/4).
Relative indications: Pre-eclampsia, post-maturity, intrauterine growth restriction (IUGR), fetal distress, failure of labor progression, malpresentations (e.g., brow).
Other: Placental abruption (only if fetal distress), active herpes, cervical cancer
456
Q: What are the categories of caesarean section urgency?
Category 1: Immediate threat to mother or baby (e.g., uterine rupture, cord prolapse). Delivery within 30 minutes.
Category 2: Maternal/fetal compromise but not life-threatening. Delivery within 75 minutes.
Category 3: Delivery required, mother and baby stable.
Category 4: Elective caesarean.
457
Q: What are some serious risks associated with caesarean sections?
Emergency hysterectomy
Need for further surgery (e.g., curettage)
ICU admission
Thromboembolic disease
Bladder and ureteric injury
Death (1 in 12,000 cases)
458
Q: What are some frequent risks associated with caesarean sections?
Persistent wound and abdominal discomfort
Increased risk of repeat caesarean section in future pregnancies
Readmission to hospital
Haemorrhage
Infection (e.g., wound, endometritis, UTI)
459
Q: What are the fetal risks associated with caesarean sections?
Lacerations (1 to 2 babies in every 100)
460
Q: What are the risks for future pregnancies after a caesarean section?
Increased risk of uterine rupture
Increased risk of antepartum stillbirth
Increased risk of placenta praevia and placenta accreta
461
Q: What is vaginal birth after caesarean (VBAC) and its success rate?
VBAC is an option for women with a single previous caesarean at >= 37 weeks gestation.
Success rate: 70-75% for vaginal delivery.
Contraindications: Previous uterine rupture or classical caesarean scar.
462
Q: What is a breech presentation, and how common is it at term?
A breech presentation occurs when the caudal end of the fetus occupies the lower segment.
Around 25% of pregnancies at 28 weeks are breech, but only 3% are breech near term.
463
Q: What are the different types of breech presentation?
Frank breech: Hips flexed and knees fully extended (most common).
Footling breech: One or both feet come first, with the bottom at a higher position (rare, higher perinatal morbidity).
464
Q: What are the risk factors for breech presentation?
Uterine malformations, fibroids
Placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormalities (e.g., CNS malformation, chromosomal disorders)
Prematurity (increased incidence earlier in gestation)
465
Q: What is the management for breech presentation at <36 weeks?
Many fetuses will turn spontaneously.
If still breech at 36 weeks, NICE recommends external cephalic version (ECV), with a success rate of around 60%.
466
Q: What is the recommended timing for offering ECV to nulliparous and multiparous women?
ECV should be offered from 36 weeks in nulliparous women.
ECV should be offered from 37 weeks in multiparous women.
467
Q: What are the delivery options if the baby is still breech after 36/37 weeks?
Planned caesarean section or vaginal delivery.
468
Q: What are the absolute contraindications to External Cephalic Version (ECV)?
Caesarean delivery required
Antepartum haemorrhage within the last 7 days
Abnormal cardiotocography
Major uterine anomaly
Ruptured membranes
Multiple pregnancy
469
Q: What is the normal fetal heart rate range?
The normal fetal heart rate varies between 100-160 beats per minute.
470
Q: What causes baseline bradycardia in CTG?
Heart rate < 100 beats per minute.
Causes: Increased fetal vagal tone, maternal beta-blocker use.
471
Q: What causes baseline tachycardia in CTG?
Heart rate > 160 beats per minute.
Causes: Maternal pyrexia, chorioamnionitis, hypoxia, prematurity.
472
Q: What causes loss of baseline variability in CTG?
Variability < 5 beats per minute.
Causes: Prematurity, hypoxia.
473
Q: What do early decelerations indicate on CTG?
Early deceleration: Deceleration of the heart rate that starts with a contraction and returns to normal after the contraction.
It usually indicates head compression and is an innocuous feature.
474
Q: What do late decelerations indicate on CTG?
Late deceleration: Deceleration that lags the onset of the contraction and doesn't return to normal until after 30 seconds post-contraction.
It indicates fetal distress, e.g., asphyxia or placental insufficiency.
475
Q: What do variable decelerations indicate on CTG?
Variable decelerations are independent of contractions.
They may indicate cord compression.
476
Q: What is fetal varicella syndrome (FVS) and when does it occur?
FVS occurs when a mother is infected with varicella before 20 weeks gestation.
The risk is around 1%.
Features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly, and learning disabilities.
477
Q: What are the risks to the fetus from maternal chickenpox exposure after 20 weeks gestation?
Shingles in infancy: 1-2% risk if exposure occurs in the second or third trimester.
Severe neonatal varicella: If the mother develops a rash between 5 days before and 2 days after birth, there is a risk of neonatal varicella, which may be fatal to the newborn in around 20% of cases.
478
Q: How is post-exposure prophylaxis (PEP) for chickenpox managed in pregnancy?
If there's doubt about prior chickenpox, maternal blood should be checked for varicella antibodies.
Due to VZIG shortage, oral aciclovir or valaciclovir is now the first choice for PEP, given between day 7 and day 14 after exposure.
479
Q: How should chickenpox in pregnancy be managed if the mother develops a rash?
Specialist advice should be sought.
If the woman is ≥ 20 weeks, oral aciclovir should be given within 24 hours of rash onset.
If < 20 weeks, aciclovir should be considered with caution.
480
Q: What is the main risk factor for chorioamnionitis?
The major risk factor is preterm premature rupture of membranes (PPROM), which exposes the normally sterile environment of the uterus to potential pathogens.
Chorioamnionitis can also occur when the membranes are still intact.
481
Q: What is the initial treatment for chorioamnionitis?
The mainstay of treatment includes prompt delivery of the fetus, often via cesarean section if necessary, and administration of intravenous antibiotics.
482
Q: What is the standard test for antenatal screening for Down's syndrome?
The combined test is now standard, performed between 11-13+6 weeks of pregnancy.
It includes nuchal translucency measurement, serum B-HCG, and pregnancy-associated plasma protein A (PAPP-A).
483
Q: What are the typical results of the combined test for Down's syndrome?
Down's syndrome is suggested by:
↑ HCG
↓ PAPP-A
Thickened nuchal translucency.
Trisomy 18 (Edwards syndrome) and trisomy 13 (Patau syndrome) give similar results but with lower HCG.
484
Q: What test is offered between 15-20 weeks if antenatal care is booked later in pregnancy?
The quadruple test, which includes:
Alpha-fetoprotein
Unconjugated oestriol
Human chorionic gonadotrophin (HCG)
Inhibin A.
485
Q: How do the results of the quadruple test correlate with various conditions?
Down's syndrome: ↓ Alpha-fetoprotein, ↓ Unconjugated oestriol, ↑ HCG, ↑ Inhibin A
Edward's syndrome: ↓ All markers except Inhibin A (which remains unchanged)
Neural tube defects: ↑ Alpha-fetoprotein, others unchanged
486
Q: When is NIPT typically offered, and how is it performed?
NIPT is offered if a woman has a "higher chance" result from the combined or quadruple test.
NIPT can be performed from 10 weeks gestation and involves analyzing small DNA fragments from the mother’s blood.
487
Q: What is eclampsia?
Eclampsia is the development of seizures in association with pre-eclampsia.
Pre-eclampsia is defined as pregnancy-induced hypertension, proteinuria, and symptoms occurring after 20 weeks gestation.
488
Q: What is the role of magnesium sulphate in eclampsia treatment?
Magnesium sulphate is used to prevent seizures in patients with severe pre-eclampsia and to treat seizures once they develop.
489
Q: What is the recommended dosing for magnesium sulphate in eclampsia?
IV bolus of 4g over 5-10 minutes, followed by an infusion of 1g/hour.
Treatment continues for 24 hours after the last seizure or delivery.
490
Q: What should be monitored during magnesium sulphate treatment in eclampsia?
Urine output, reflexes, respiratory rate, and oxygen saturations should be monitored.
Respiratory depression can occur.
491
Q: How should magnesium sulphate-induced respiratory depression be managed?
The first-line treatment for magnesium sulphate-induced respiratory depression is calcium gluconate.
492
Q: What is an important aspect of managing severe pre-eclampsia/eclampsia regarding fluid management?
Fluid restriction is crucial to avoid the potentially serious consequences of fluid overload.
493
Q: What should women planning pregnancy with epilepsy be advised to take before pregnancy?
Folic acid 5mg per day to minimize the risk of neural tube defects.
494
Q: Which antiepileptic drugs are associated with teratogenic effects?
Sodium valproate: associated with neural tube defects.
Carbamazepine: considered the least teratogenic of older antiepileptics.
Phenytoin: associated with cleft palate.
Lamotrigine: studies suggest a low rate of congenital malformations.
495
Q: What special consideration is needed for women taking phenytoin during pregnancy?
They should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn.
496
Q: What are some common causes of folic acid deficiency?
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
497
Q: What are the consequences of folic acid deficiency?
Macrocytic, megaloblastic anaemia
Neural tube defects (NTDs)
498
Q: How can neural tube defects (NTDs) be prevented during pregnancy?
All women should take 400mcg of folic acid until the 12th week of pregnancy.
Women at higher risk should take 5mg of folic acid from before conception until the 12th week of pregnancy.
499
Q: Who is considered at higher risk for conceiving a child with a neural tube defect?
Either partner has a NTD, a previous pregnancy affected by a NTD, or a family history of NTDs.
The woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
The woman is obese (BMI ≥ 30 kg/m²).
500
Q: What are the indications for using forceps in delivery?
Fetal distress in the second stage of labour
Maternal distress in the second stage of labour
Failure to progress in the second stage of labour
Control of head in breech delivery
501
Q: What is a galactocele, and how is it different from an abscess?
A galactocele occurs in women who have recently stopped breastfeeding, due to the occlusion of a lactiferous duct.
It results in a cystic lesion caused by the build-up of milk.
Unlike an abscess, a galactocele is usually painless, with no local or systemic signs of infection.
502
Q: What are the risk factors for gestational diabetes?
BMI > 30 kg/m²
Previous macrosomic baby (weighing 4.5 kg or above)
Previous gestational diabetes
First-degree relative with diabetes
Family origin with high diabetes prevalence (e.g., South Asian, black Caribbean, Middle Eastern)
503
Q: How is gestational diabetes diagnosed?
The oral glucose tolerance test (OGTT) is the test of choice.
Gestational diabetes is diagnosed if:
Fasting glucose >= 5.6 mmol/L
2-hour glucose >= 7.8 mmol/L
504
Q: How should gestational diabetes be managed?
Women should be seen in a joint diabetes and antenatal clinic within a week.
Self-monitoring of blood glucose should be taught.
Diet and exercise advice should be given.
If fasting glucose < 7 mmol/L, trial diet and exercise first.
If glucose targets are not met, metformin should be started.
If still not controlled, insulin should be added.
505
Q: What are the target glucose levels for pregnant women with diabetes (gestational or pre-existing)?
Fasting: 5.3 mmol/L
1 hour after meals: 7.8 mmol/L
2 hours after meals: 6.4 mmol/L
506
Q: What is gestational thrombocytopenia and how does it affect pregnancy?
Gestational thrombocytopenia is a common condition in pregnancy characterized by mild platelet reduction due to a combination of dilution, decreased production, and increased destruction.
It results from the increased workload of the maternal spleen leading to mild sequestration of platelets.
507
Q: How is immune thrombocytopenia (ITP) different from gestational thrombocytopenia?
ITP is an autoimmune condition typically presenting with acute purpuric episodes, often seen in children but may have a chronic relapsing course in women.
Unlike gestational thrombocytopenia, ITP involves maternal antibodies that may cross the placenta, potentially affecting the neonate.
508
Q: How can gestational thrombocytopenia be differentiated from immune thrombocytopenia (ITP)?
The differentiation often relies on a careful history.
Gestational thrombocytopenia typically has a gradual decrease in platelets as pregnancy progresses, though this is not a reliable sign.
In severe cases, if the platelet count becomes dangerously low, steroids are used, and ITP is assumed.
Serum antiplatelet antibodies may be tested to confirm ITP.
509
Q: How does immune thrombocytopenia (ITP) affect the neonate?
Maternal antibodies in ITP can cross the placenta and cause thrombocytopenia in the newborn.
Depending on the severity, platelet transfusions may be needed for the newborn.
510
Q: What are gestational trophoblastic disorders?
Complete hydatidiform mole
Partial hydatidiform mole
Choriocarcinoma
511
Q: What is a complete hydatidiform mole?
A benign tumour of trophoblastic material caused when an empty egg is fertilized by a single sperm, which then duplicates its DNA.
All 46 chromosomes are of paternal origin.
512
Q: What are the key features of a complete hydatidiform mole?
Bleeding in the first or early second trimester
Exaggerated pregnancy symptoms (e.g., hyperemesis)
Uterus large for dates
Very high serum levels of human chorionic gonadotropin (hCG)
Hypertension and hyperthyroidism (hCG can mimic TSH)
513
Q: How is a complete hydatidiform mole managed?
Urgent referral to a specialist centre for evacuation of the uterus
Effective contraception recommended to avoid pregnancy for the next 12 months
2-3% risk of developing choriocarcinoma
514
Q: What is a partial hydatidiform mole?
Occurs when a normal haploid egg is fertilized by two sperms, or by one sperm with duplication of paternal chromosomes.
The DNA is both maternal and paternal in origin, usually triploid (e.g., 69 XXX or 69 XXY).
Fetal parts may be present.
515
Q: What are the risk factors for GBS infection in the neonate?
Prematurity
Prolonged rupture of membranes
Previous sibling with GBS infection
Maternal pyrexia (e.g., due to chorioamnionitis)
516
Q: When should intrapartum antibiotic prophylaxis (IAP) be offered to pregnant women?
Women with a previous baby with early- or late-onset GBS disease.
Women in preterm labor, regardless of GBS status.
Women with a pyrexia during labor (>38ºC).
517
Q: What is the antibiotic of choice for GBS prophylaxis?
Benzylpenicillin is the preferred antibiotic for GBS prophylaxis during labor.
518
Q: What does HELLP stand for?
Hemolysis
Elevated Liver enzymes
Low Platelet count
519
Q: What are the common features of HELLP syndrome?
Nausea and vomiting
Right upper quadrant pain
Lethargy
520
Q: How is HELLP syndrome diagnosed?
Blood tests showing:
Hemolysis
Elevated liver enzymes
Low platelet count
521
Q: What is the primary treatment for HELLP syndrome?
Delivery of the baby is the main treatment for HELLP syndrome.
522
Q: How are pregnant women screened for hepatitis B?
All pregnant women are offered screening for hepatitis B.
523
Q: What should babies born to mothers with chronic hepatitis B or acute hepatitis B during pregnancy receive?
A complete course of hepatitis B vaccination
Hepatitis B immunoglobulin
524
Q: What are the factors that reduce vertical transmission of HIV (from 25-30% to 2%)?
Maternal antiretroviral therapy
Mode of delivery (caesarean section)
Neonatal antiretroviral therapy
Infant feeding (bottle feeding)
525
Q: What does the NICE guideline recommend regarding HIV screening in pregnancy?
HIV screening should be offered to all pregnant women.
526
Q: Should pregnant women with HIV be offered antiretroviral therapy?
Yes, all pregnant women should be offered antiretroviral therapy, regardless of whether they were taking it previously.
527
Q: What is the recommended mode of delivery for HIV-positive women?
Vaginal delivery is recommended if the viral load is less than 50 copies/ml at 36 weeks.
Caesarean section is recommended if the viral load is higher than 50 copies/ml.
Zidovudine infusion should be started four hours before caesarean section.
528
Q: What is the recommended neonatal antiretroviral therapy?
Zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml.
If the viral load is higher, triple ART should be used.
Therapy should be continued for 4-6 weeks.
529
Q: What is the advice on infant feeding for HIV-positive women in the UK?
All women should be advised not to breastfeed.
530
Q: How does the level of human chorionic gonadotropin (hCG) change in the early stages of pregnancy?
hCG levels double approximately every 48 hours in the first few weeks of pregnancy.
531
Q: How does blood pressure typically change during a normal pregnancy?
Blood pressure usually falls in the first trimester (especially the diastolic) and continues to fall until 20-24 weeks.
After 20-24 weeks, blood pressure usually increases to pre-pregnancy levels by term.
532
Q: What is the definition of hypertension in pregnancy?
Hypertension in pregnancy is defined as:
Systolic blood pressure > 140 mmHg
Diastolic blood pressure > 90 mmHg
Or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic.
533
Q: What should women at high risk of developing pre-eclampsia take during pregnancy?
Women at high risk of developing pre-eclampsia should take aspirin 75 mg daily from 12 weeks until the birth of the baby.
534
Q: What are the three categories of hypertension in pregnancy?
Pre-existing Hypertension
Pregnancy-induced Hypertension (PIH)
Pre-eclampsia
535
Q: What is the difference between pre-existing hypertension and pregnancy-induced hypertension (PIH)?
Pre-existing Hypertension: A history of hypertension before pregnancy or elevated blood pressure > 140/90 mmHg before 20 weeks gestation.
PIH: Hypertension occurring in the second half of pregnancy (after 20 weeks) with no proteinuria or oedema.
536
Q: What is the management for pregnancy-induced hypertension (PIH)?
Oral labetalol is the first-line treatment according to NICE guidelines (2010).
Oral nifedipine and hydralazine are alternatives (e.g., if asthmatic).
537
Q: What should be done for a pregnant woman taking an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension?
These medications should be stopped immediately, and alternative antihypertensives, such as labetalol, should be started while awaiting specialist review.
538
Q: What are common indications for induction of labour?
Prolonged pregnancy (e.g., 1-2 weeks after the estimated date of delivery)
Pre-labour premature rupture of membranes (PROM)
Maternal medical problems (e.g., diabetic mother > 38 weeks, pre-eclampsia, obstetric cholestasis)
Intrauterine fetal death
539
Q: What is the Bishop score used for?
The Bishop score is used to assess whether induction of labour is necessary and to evaluate how "favourable" the cervix is for induction. It includes components such as cervical position, consistency, effacement, dilation, and fetal station.
540
Q: What does a Bishop score of <5 and ≥8 indicate?
A score of <5 indicates that labour is unlikely to start without induction.
A score of ≥8 indicates that the cervix is "ripe" or favourable, with a high chance of spontaneous labour or response to induction.
541
Q: What are the possible methods for induction of labour?
Membrane sweep
Vaginal prostaglandin E2 (dinoprostone)
Oral prostaglandin E1 (misoprostol)
Maternal oxytocin infusion
Amniotomy (breaking of waters)
Cervical ripening balloon
542
Q: What are the NICE guidelines for induction based on the Bishop score?
Bishop score ≤ 6: Vaginal prostaglandins or oral misoprostol; mechanical methods (e.g., balloon catheter) if at higher risk of hyperstimulation or previous caesarean.
Bishop score > 6: Amniotomy and intravenous oxytocin infusion.
543
Q: What is uterine hyperstimulation, and what are its potential consequences?
Uterine hyperstimulation refers to prolonged and frequent uterine contractions, sometimes called tachysystole.
Potential consequences include intermittent interruption of blood flow to the placenta, which may lead to fetal hypoxemia and acidemia, and rarely, uterine rupture.
544
Q: How should uterine hyperstimulation be managed?
Stop vaginal prostaglandins if possible and discontinue the oxytocin infusion if started.
Consider tocolysis (use of medications to relax the uterus).
545
Q: What is intrahepatic cholestasis of pregnancy?
Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, affects around 1% of pregnancies in the UK and is associated with an increased risk of premature birth.
546
Q: What are the common features of intrahepatic cholestasis of pregnancy?
Intense pruritus, often worse on the palms, soles, and abdomen.
Jaundice occurs in around 20% of patients.
Raised bilirubin levels are seen in more than 90% of cases.
547
Q: What is the management for intrahepatic cholestasis of pregnancy?
Induction of labour at 37-38 weeks, though this may not always be evidence-based.
Ursodeoxycholic acid is commonly used, though its evidence base is unclear.
Vitamin K supplementation is also used.
548
Q: What are the signs of labour?
Regular and painful uterine contractions
A show (shedding of the mucous plug)
Rupture of the membranes (not always)
Shortening and dilation of the cervix
549
Q: What are the stages of labour?
Stage 1: From the onset of true labour to when the cervix is fully dilated.
Stage 2: From full dilation to delivery of the fetus.
Stage 3: From delivery of the fetus to when the placenta and membranes have been completely delivered.
550
Q: What is the monitoring process during labour?
Fetal heart rate (FHR) is monitored every 15 minutes (or continuously via CTG).
Contractions are assessed every 30 minutes.
Maternal pulse rate is assessed every 60 minutes.
Maternal BP and temperature are checked every 4 hours.
Vaginal examination (VE) is offered every 4 hours to check progression.
Maternal urine should be checked for ketones and protein every 4 hours.
551
Q: How long does Stage 1 labour typically last in a primigravida?
Stage 1 in a primigravida typically lasts 10-16 hours.
552
Q: What are the two phases of Stage 1 labour?
Latent phase: 0-3 cm dilation, normally takes 6 hours.
Active phase: 3-10 cm dilation, normally progresses at a rate of 1 cm per hour.
553
Q: In which position does the baby's head enter the pelvis, and what position does it normally deliver in?
The head enters the pelvis in an occipito-lateral position.
The head normally delivers in an occipito-anterior position.
554
Q: What is Stage 2 of labour?
Stage 2 of labour is from full dilation to the delivery of the fetus.
555
Q: What is the difference between 'passive second stage' and 'active second stage'?
Passive second stage: Refers to the second stage without maternal pushing (normal).
Active second stage: Refers to the active process of maternal pushing.
556
Q: How painful is Stage 2 of labour compared to Stage 1?
Stage 2 is less painful than Stage 1 because pushing masks the pain.
557
Q: How long does Stage 2 of labour typically last?
Stage 2 lasts approximately 1 hour.
558
Q: What should be considered if Stage 2 lasts longer than 1 hour?
If Stage 2 lasts longer than 1 hour (can be longer if epidural), consider:
Ventouse extraction
Forceps delivery
Caesarean section
559
Q: What is a common fetal sign associated with Stage 2 of labour?
Transient fetal bradycardia is commonly associated with Stage 2 of labour.
560
Q: What is lochia?
Lochia is the vaginal discharge containing blood, mucus, and uterine tissue that may continue for up to 6 weeks after childbirth.
561
Q: How long can lochia last after childbirth?
Lochia can last up to 6 weeks after childbirth.
562
Q: What is oligohydramnios?
Oligohydramnios refers to reduced amniotic fluid in the uterus. Definitions include less than 500ml at 32-36 weeks or an amniotic fluid index (AFI) < 5th percentile.
563
Q: What are the causes of oligohydramnios?
Premature rupture of membranes
Potter sequence:
Bilateral renal agenesis and pulmonary hypoplasia
Intrauterine growth restriction (IUGR)
Post-term gestation
Pre-eclampsia
564
Q: What is the classification of perineal tears according to RCOG guidelines?
First degree: Superficial damage, no muscle involvement, no repair needed.
Second degree: Injury to the perineal muscle, no anal sphincter involvement, requires suturing by an experienced clinician.
Third degree: Injury involving the anal sphincter complex (EAS and IAS):
3a: <50% of EAS thickness torn
3b: >50% of EAS thickness torn
3c: IAS torn
Requires repair in theatre.
Fourth degree: Injury involving the anal sphincter complex and rectal mucosa, requires repair in theatre.
565
Q: What are the risk factors for perineal tears?
Primigravida
Large babies
Precipitous labour
Shoulder dystocia
Forceps delivery
566
Q: What are the different types of placenta accreta?
Accreta: Chorionic villi attach to the myometrium.
Increta: Chorionic villi invade into the myometrium.
Percreta: Chorionic villi invade through the perimetrium.
567
Q: What are the risk factors for placenta accreta?
Previous caesarean section
Placenta praevia
568
Q: What is placenta praevia?
A: Placenta praevia refers to a placenta lying wholly or partly in the lower uterine segment, which may obstruct the birth canal.
569
Q: What are the associated factors of placenta praevia?
Multiparity
Multiple pregnancy
Previous caesarean section, as embryos are more likely to implant on a lower segment scar.
570
Q: What are the clinical features of placenta praevia?
Shock in proportion to visible blood loss
No pain
Uterus not tender
Abnormal lie and presentation
Fetal heart usually normal
Coagulation problems are rare
Small bleeds may precede large bleeds
571
Q: How is placenta praevia diagnosed?
Digital vaginal examination should not be performed before an ultrasound, as it may provoke a severe hemorrhage.
Transvaginal ultrasound is recommended for accurate placental localization and is considered safe.
572
Q: What are the classical grading of placenta praevia?
Grade I: Placenta reaches lower segment but not the internal os.
Grade II: Placenta reaches internal os but doesn't cover it.
Grade III: Placenta covers internal os before dilation but not during dilation.
Grade IV (major): Placenta completely covers the internal os.
573
Q: What is the management approach for a low-lying placenta at the 20-week scan?
Rescan at 32 weeks.
No need to limit activity or intercourse unless bleeding occurs.
If still present at 32 weeks and grade I/II, scan every 2 weeks.
Final ultrasound at 36-37 weeks to determine the method of delivery.
Elective caesarean section for grades III/IV between 37-38 weeks.
If grade I, a trial of vaginal delivery may be offered.
574
Q: What should be done if a woman with known placenta praevia goes into labour prior to the elective caesarean section?
A: An emergency caesarean section should be performed due to the risk of post-partum hemorrhage.
575
Q: What is the management for placenta praevia with bleeding?
Admit the woman.
Follow the ABC approach to stabilize.
If not able to stabilize, perform an emergency caesarean section.
If in labour or term is reached, perform an emergency caesarean section.
576
Q: What is placental abruption?
A: Placental abruption refers to the separation of a normally sited placenta from the uterine wall, resulting in maternal hemorrhage into the intervening space.
577
Q: What are the associated factors for placental abruption?
Proteinuric hypertension
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age
578
Q: What are the clinical features of placental abruption?
Shock out of keeping with visible loss
Constant pain
Tender, tense uterus
Normal lie and presentation
Absent or distressed fetal heart
Coagulation problems
Watch for pre-eclampsia, DIC, anuria.
579
Q: What is the management for placental abruption if the fetus is alive and < 36 weeks?
Fetal distress: Immediate caesarean section.
No fetal distress: Observe closely, administer steroids, avoid tocolysis, and the threshold to deliver depends on gestational age.
580
Q: What is the management for placental abruption if the fetus is alive and > 36 weeks?
Fetal distress: Immediate caesarean section.
No fetal distress: Vaginal delivery.
581
Q: What is the management if the fetus is dead in the case of placental abruption?
A: Induce vaginal delivery.
582
Q: What are the maternal complications of placental abruption?
Shock
Disseminated intravascular coagulation (DIC)
Renal failure
Postpartum hemorrhage (PPH)
583
Q: What are the fetal complications of placental abruption?
Intrauterine growth restriction (IUGR)
Hypoxia
Death
584
Q: What is the definition of a post-term pregnancy according to the World Health Organization (WHO)?
A: A pregnancy that extends to or beyond 42 weeks.
585
Q: What are the neonatal complications associated with post-term pregnancy?
Reduced placental perfusion
Oligohydramnios (low amniotic fluid)
586
Q: What are the maternal complications associated with post-term pregnancy?
Increased rates of intervention, including forceps and caesarean section
Increased rates of labour induction
587
Q: What defines Postpartum Haemorrhage (PPH)?
A: Blood loss of > 500 ml after a vaginal delivery. It can be primary (within 24 hours) or secondary (between 24 hours and 12 weeks).
588
Q: What are the 4 Ts of primary postpartum haemorrhage (PPH)?
Tone (uterine atony): The vast majority of cases
Trauma: e.g., perineal tear
Tissue: Retained placenta
Thrombin: Clotting or bleeding disorder
589
Q: What are the risk factors for primary postpartum haemorrhage (PPH)?
Previous PPH
Prolonged labour
Pre-eclampsia
Increased maternal age
Polyhydramnios
Emergency caesarean section
Placenta praevia, placenta accreta
Macrosomia
Nulliparity (modern studies suggest this as a risk factor)
590
Q: What is the initial management for primary postpartum haemorrhage (PPH)?
Immediate involvement of senior staff
ABC approach
Two peripheral cannulae (14 gauge)
Lie the woman flat
Blood tests (group and save)
Commence warmed crystalloid infusion
591
Q: What are the mechanical interventions for primary postpartum haemorrhage (PPH)?
Palpate and rub the uterine fundus to stimulate contractions
Catheterisation to prevent bladder distension and monitor urine output
592
Q: What are the medical treatments for primary postpartum haemorrhage (PPH)?
IV oxytocin (slow injection followed by infusion)
Ergometrine (slow IV or IM)
Carboprost IM (unless history of asthma)
Misoprostol sublingual
Tranexamic acid (emerging role)
593
Q: What are the surgical interventions for primary postpartum haemorrhage (PPH) if medical options fail?
Intrauterine balloon tamponade (first-line for uterine atony)
B-Lynch suture
Ligation of uterine arteries or internal iliac arteries
Hysterectomy (if severe, uncontrolled bleeding)
594
Q: What defines secondary postpartum haemorrhage?
A: Occurs between 24 hours and 12 weeks post-delivery, typically due to retained placental tissue or endometritis.
595
Q: What does a score of > 13 on the Edinburgh Postnatal Depression Scale indicate?
A: A score > 13 indicates a depressive illness of varying severity.
596
Q: What is the Baby Blues?
Seen in 60-70% of women, typically 3-7 days after birth
More common in first-time mothers (primips)
Symptoms: Anxiety, tearfulness, irritability
Reassurance and support are important for management
597
Q: What is Postnatal Depression?
Affects around 10% of women, typically starting within a month and peaking at 3 months
Symptoms are similar to depression seen in other circumstances
Cognitive Behavioral Therapy (CBT) may be beneficial
Certain SSRIs like sertraline and paroxetine may be used if symptoms are severe
598
Q: What is Puerperal Psychosis?
Affects approximately 0.2% of women
Onset usually within 2-3 weeks after birth
Features include severe mood swings (similar to bipolar disorder) and disordered perceptions (e.g., auditory hallucinations)
Hospital admission is usually required, ideally in a Mother & Baby Unit
599
Q: What medications may be used for Postnatal Depression if symptoms are severe?
Cognitive Behavioral Therapy (CBT)
Certain SSRIs, such as sertraline and paroxetine (low milk/plasma ratio)
Fluoxetine should be avoided due to its long half-life
600
Q: What are the three stages of postpartum thyroiditis?
Thyrotoxicosis
Hypothyroidism
Normal thyroid function (but high recurrence rate in future pregnancies)
601
Q: What percentage of patients with postpartum thyroiditis have thyroid peroxidase antibodies?
A: 90%
602
Q: What is the typical treatment for symptom control during the thyrotoxic phase of postpartum thyroiditis?
A: Propranolol
603
Q: Why are anti-thyroid drugs not usually used in the thyrotoxic phase of postpartum thyroiditis?
A: Because the thyroid is not overactive.
604
Q: What is the treatment for the hypothyroid phase of postpartum thyroiditis?
A: Thyroxine
605
Q: What is the classical triad of pre-eclampsia?
New-onset hypertension
Proteinuria
Oedema
606
Q: What is the formal definition of pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
Proteinuria
Other organ involvement (e.g. renal insufficiency, liver, neurological, haematological, uteroplacental dysfunction)
607
Q: What are some potential consequences of pre-eclampsia?
Eclampsia
Neurological complications (altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata)
Fetal complications (intrauterine growth retardation, prematurity)
Liver involvement (elevated transaminases)
Haemorrhage (placental abruption, intra-abdominal, intra-cerebral)
Cardiac failure
608
Q: What are the features of severe pre-eclampsia?
Hypertension: > 160/110 mmHg
Proteinuria: Dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100 * 10⁶/l
Abnormal liver enzymes or HELLP syndrome
609
Q: What are some high-risk factors for pre-eclampsia?
Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease (e.g. systemic lupus erythematosus, antiphospholipid syndrome)
Type 1 or type 2 diabetes
Chronic hypertension
610
Q: What are some moderate-risk factors for pre-eclampsia?
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
BMI of 35 kg/m² or more at first visit
Family history of pre-eclampsia
Multiple pregnancy
611
Q: What is the recommended aspirin dosage for reducing hypertensive risk in pregnancy?
A: 75-150 mg daily from 12 weeks gestation until birth for women with:
≥ 1 high risk factor
≥ 2 moderate risk factors
612
Q: What is the first-line treatment for pre-eclampsia according to the 2010 NICE guidelines?
A: Oral labetalol. Other options include nifedipine (e.g. for asthmatics) and hydralazine.
613
Q: What is the most important and definitive management step for pre-eclampsia?
A: Delivery of the baby. The timing depends on the clinical scenario.
614
Q: What is the recommended initial assessment for pre-eclampsia?
A: Emergency secondary care assessment for any woman suspected of having pre-eclampsia. Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed.
615
Q: When are pregnant women screened for anaemia?
A: At the booking visit (usually 8-10 weeks) and at 28 weeks.
616
Q: What are the NICE cut-off values for determining when a woman should receive oral iron therapy during pregnancy?
First trimester: < 110 g/L
Second/third trimester: < 105 g/L
Postpartum: < 100 g/L
617
Q: What is the recommended treatment for anaemia in pregnancy?
A: Oral ferrous sulfate or ferrous fumarate.
618
Q: How long should iron therapy be continued after correcting iron deficiency in pregnancy?
A: For 3 months to allow iron stores to be replenished.
619
Q: What investigation should be performed when deep vein thrombosis (DVT) is suspected in pregnancy?
A: Compression duplex ultrasound.
620
Q: What investigations should be performed when pulmonary embolism (PE) is suspected in pregnancy?
ECG
Chest x-ray (in all patients)
Compression duplex ultrasound (if signs of DVT are also present)
621
Q: What should be done if compression duplex ultrasound confirms the presence of DVT in a patient with suspected PE?
A: No further investigation is necessary, and treatment for VTE (venous thromboembolism) should continue.
622
Q: What are the risks associated with CTPA and V/Q scanning in pregnancy?
CTPA slightly increases the lifetime risk of maternal breast cancer (up to 13.6%) due to radiation sensitivity of breast tissue during pregnancy.
V/Q scanning carries a slightly increased risk of childhood cancer compared to CTPA (1/50,000 vs. <1/1,000,000).
623
Q: Why is D-dimer of limited use in the investigation of thromboembolism during pregnancy?
A: Because D-dimer levels are often raised during pregnancy.
624
Q: What is intrahepatic cholestasis of pregnancy, and when does it typically occur?
A: Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs in around 1% of pregnancies and is generally seen in the third trimester. It is the most common liver disease of pregnancy.
625
Q: What are the features of intrahepatic cholestasis of pregnancy?
Pruritus, often in the palms and soles
No rash (though skin changes may occur due to scratching)
Raised bilirubin
626
Q: What is the management for intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid for symptomatic relief
Weekly liver function tests
Induction at 37 weeks
627
Q: What are the complications of intrahepatic cholestasis of pregnancy?
A: An increased rate of stillbirth. It is generally not associated with increased maternal morbidity.
628
Q: What is acute fatty liver of pregnancy, and when does it typically occur?
A: Acute fatty liver of pregnancy is a rare complication that may occur in the third trimester or the period immediately following delivery.
629
Q: What are the features of acute fatty liver of pregnancy?
Abdominal pain
Nausea & vomiting
Headache
Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia
630
Q: What is typically elevated in the investigations for acute fatty liver of pregnancy?
A: ALT is typically elevated (e.g., 500 u/l).
631
Q: What is the management for acute fatty liver of pregnancy?
A: Supportive care, with delivery being the definitive management once stabilised.
632
Q: Which conditions may be exacerbated during pregnancy, leading to jaundice?
A: Gilbert's syndrome and Dubin-Johnson syndrome may be exacerbated during pregnancy.
633
Q: What is the definition of obesity in pregnancy?
A: Obesity is usually defined as a body mass index (BMI) ≥ 30 kg/m² at the first antenatal visit.
634
Q: What are some maternal risks associated with obesity during pregnancy?
Miscarriage
Venous thromboembolism
Gestational diabetes
Pre-eclampsia
Dysfunctional labour, induced labour
Postpartum haemorrhage
Wound infections
Higher caesarean section rate
635
Q: What are some fetal risks associated with maternal obesity during pregnancy?
Congenital anomaly
Prematurity
Macrosomia
Stillbirth
Increased risk of developing obesity and metabolic disorders in childhood
Neonatal death
636
Q: What is the recommended dosage of folic acid for obese women during pregnancy?
A: Obese women should take 5 mg of folic acid, rather than the usual 400 mcg.
637
Q: What screening is recommended for obese women during pregnancy?
A: All obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks.
638
Q: How does the cardiovascular system change during pregnancy?
Stroke volume (SV) increases by 30%
Heart rate (HR) increases by 15%
Cardiac output increases by 40%
Systolic blood pressure (BP) is unaltered
Diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
The enlarged uterus may interfere with venous return, leading to ankle oedema, supine hypotension, and varicose veins
639
Q: What respiratory changes occur during pregnancy?
Pulmonary ventilation increases by 40%, with tidal volume rising from 500 to 700 ml (due to progesterone effect)
Oxygen requirements increase by 20%, but over-breathing can lead to a fall in pCO2, causing a sense of dyspnoea
Basal metabolic rate (BMR) increases by 15% due to increased thyroxine and adrenocortical hormones, making women feel uncomfortable in warm conditions
640
Q: How does pregnancy affect blood volume and blood components?
Maternal blood volume increases by 30%, mostly in the second half of pregnancy
Red blood cells increase by 20%, but plasma volume increases by 50%, causing a drop in hemoglobin (Hb)
Coagulant activity rises (fibrinogen, Factors VII, VIII, X)
Fibrinolytic activity is decreased, returning to normal after delivery
Platelet count falls
White cell count (WCC) and erythrocyte sedimentation rate (ESR) rise
641
Q: What changes occur in the urinary system during pregnancy?
Blood flow increases by 30%
Glomerular filtration rate (GFR) increases by 30-60%
Salt and water reabsorption increases due to elevated sex steroid levels
Urinary protein losses increase
Trace glycosuria is common due to increased GFR and reduced tubular reabsorption of glucose
642
Q: What are the biochemical changes in pregnancy related to calcium?
Calcium requirements increase, especially during the 3rd trimester and lactation
Calcium is actively transported across the placenta
Serum calcium and phosphate levels fall (with a fall in protein)
Ionised calcium levels remain stable
Gut absorption of calcium increases substantially due to increased 1,25 dihydroxy vitamin D
643
Q: How does pregnancy affect liver function?
Hepatic blood flow does not change
Alkaline phosphatase (ALP) is raised by 50%
Albumin levels fall
644
Q: What are the risks associated with prematurity?
A: Risks of prematurity include increased mortality, respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis, chronic lung disease, hypothermia, feeding problems, infection, jaundice, and retinopathy of prematurity (a leading cause of visual impairment in babies born before 32 weeks). Over-oxygenation during ventilation may contribute to retinal neovascularization. Additionally, hearing problems may occur.
645
Q: What are the complications of preterm prelabour rupture of membranes (PPROM)?
A: Fetal complications include prematurity, infection, and pulmonary hypoplasia. Maternal complications include chorioamnionitis.
646
Q: How is PPROM confirmed?
A: A sterile speculum examination should be performed to look for pooling of amniotic fluid in the posterior vaginal vault. If not observed, fluid testing for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein-1 can be done. Ultrasound may also show oligohydramnios.
647
Q: What is the management for PPROM?
A: Management includes admission, regular observations for chorioamnionitis, oral erythromycin for 10 days, antenatal corticosteroids to reduce respiratory distress syndrome, and delivery consideration at 34 weeks gestation.
648
Q: What is puerperal pyrexia?
A: Puerperal pyrexia is defined as a temperature >38ºC in the first 14 days following delivery.
649
Q: What are the causes of puerperal pyrexia?
A: Causes include endometritis (most common), urinary tract infection, wound infections (perineal tears and caesarean section), mastitis, and venous thromboembolism.
650
Q: How is puerperal pyrexia managed?
A: If endometritis is suspected, the patient should be referred to the hospital for intravenous antibiotics (clindamycin and gentamicin) until afebrile for more than 24 hours.
651
Q: What can reduced fetal movements indicate?
A: Reduced fetal movements can indicate fetal distress due to chronic hypoxia and may reflect placental insufficiency, fetal growth restriction, and increased risk of stillbirth.
652
Q: What is the RCOG threshold for reduced fetal movements?
A: Less than 10 movements in 2 hours (after 28 weeks gestation) is an indication for further assessment.
653
Q: How can Rhesus sensitization be prevented?
A: Anti-D immunoglobulin is given to non-sensitized Rh-negative mothers at 28 weeks and optionally at 34 weeks. Anti-D acts as prophylaxis and cannot reverse sensitization once it has occurred.
654
Q: How are reduced fetal movements investigated after 28 weeks?
A: Confirm fetal heartbeat using a handheld Doppler. If a heartbeat is detected, perform a CTG for at least 20 minutes. If concerns persist, conduct an urgent ultrasound within 24 hours.
655
Q: When should anti-D immunoglobulin be administered?
Anti-D should be given within 72 hours in situations including:
Delivery of a Rh-positive infant
Termination of pregnancy
Miscarriage >12 weeks
Ectopic pregnancy (if surgically managed)
External cephalic version
Antepartum haemorrhage
Amniocentesis, CVS, fetal blood sampling
Abdominal trauma
656
Q: What tests are performed at delivery for Rh-negative mothers?
Cord blood tests include:
FBC
Blood group
Direct Coombs test (detects antibodies on fetal RBCs)
A Kleihauer test can be done to detect fetal red cells in maternal circulation.
657
Q: What are the clinical features of an affected fetus in Rhesus disease?
Features include:
Hydrops fetalis (oedema, hepatosplenomegaly)
Anaemia
Jaundice
Heart failure
Kernicterus
658
Q: How is a fetus affected by Rhesus disease treated?
A: Treatment includes intrauterine transfusions and UV phototherapy after birth to manage jaundice.
659
Q: What causes rubella and how is it transmitted?
A: Rubella, or German measles, is caused by the togavirus. It is transmitted through respiratory droplets and has an incubation period of 14-21 days. Individuals are infectious from 7 days before symptoms to 4 days after the rash appears.
660
Q: What is the risk of congenital rubella syndrome in pregnancy?
A: The risk of fetal damage is up to 90% if contracted within the first 8-10 weeks of pregnancy but is rare after 16 weeks.
661
Q: What are the features of congenital rubella syndrome?
Sensorineural deafness
Congenital cataracts
Congenital heart disease (e.g., PDA)
Growth retardation
Hepatosplenomegaly
Purpuric skin lesions
'Salt and pepper' chorioretinitis
Microphthalmia
Cerebral palsy
662
Q: How is rubella diagnosed during pregnancy?
Raised rubella IgM antibodies
Parvovirus B19 serology (as it can mimic rubella)
Suspected cases should be reported to the Health Protection Unit (HPU).
663
Q: What is the management of rubella in pregnancy?
Discussing suspected cases with the local HPU
Advising non-immune pregnant women to avoid exposure
Offering MMR vaccination postpartum for non-immune mothers
Avoiding MMR vaccination during pregnancy
664
Q: What are key risk factors for shoulder dystocia?
Fetal macrosomia
Maternal diabetes mellitus
High maternal BMI
Prolonged labor
665
Q: How is shoulder dystocia managed?
Call for senior help immediately.
Perform McRoberts' manoeuvre (flexion and abduction of maternal hips).
Consider episiotomy for better access if internal manoeuvres are required.
666
Q: What complications can arise from shoulder dystocia?
Postpartum hemorrhage
Perineal tears
Fetal complications:
Brachial plexus injury
Neonatal death
667
Q: What is symphysis-fundal height (SFH)?
A: SFH is the measurement from the top of the pubic bone to the top of the uterus in centimeters.
668
Q: How does SFH correlate with gestational age?
A: After 20 weeks, SFH should match the gestational age in weeks ±2 cm. For example, at 24 weeks, a normal SFH would be 22 to 26 cm.
669
Q: What is transverse lie?
A: Transverse lie is an abnormal fetal presentation where the fetus's longitudinal axis is perpendicular to the uterus, with the fetal head and buttocks positioned laterally.
670
Q: What are the complications of transverse lie?
A: Complications include preterm rupture of membranes, cord prolapse, and compound presentations if vaginal delivery is attempted.
671
Q: How is transverse lie managed?
A: Before 36 weeks, no management is needed, as the fetus often moves into longitudinal lie. After 36 weeks, management options include external cephalic version (ECV) or elective cesarean section depending on factors like the patient's preference, the success of ECV, and maternal or fetal conditions.
672
Q: What are the risk factors for dizygotic twins?
A: Risk factors for dizygotic twins include previous twin pregnancies, family history, increasing maternal age, multigravida, induced ovulation, in-vitro fertilization (IVF), and certain races, e.g., Afro-Caribbean.
673
Q: What complications are associated with monoamniotic monozygotic twins?
A: These twins have increased risks of spontaneous miscarriage, perinatal mortality, malformations, intrauterine growth restriction (IUGR), prematurity, and twin-to-twin transfusion syndrome. The recipient twin is typically larger with polyhydramnios, and laser ablation of interconnecting vessels may be needed.
674
Q: What are the antenatal complications of twin pregnancies?
A: Antenatal complications include polyhydramnios, pregnancy-induced hypertension, anemia, and antepartum hemorrhage.
675
Q: What are the fetal complications of twin pregnancies?
A: Fetal complications include higher perinatal mortality (5 times higher for twins and 10 times higher for triplets), prematurity (mean gestation of 37 weeks for twins and 33 weeks for triplets), light-for-date babies, and increased malformations, particularly in monozygotic twins.
676
Q: What labor complications can occur in twin pregnancies?
A: Labor complications include an increased risk of postpartum hemorrhage (PPH), malpresentation, cord prolapse, and entanglement.
677
Q: How is a twin pregnancy managed?
A: Management includes rest, monthly ultrasound checks, additional iron and folate supplementation, more frequent antenatal visits (e.g., weekly after 30 weeks), and precautions during labor (e.g., two obstetricians present). Around 75% of twins deliver by 38 weeks, and if delivery is delayed, they are often induced between 38-40 weeks.
678
Q: When is a nuchal scan performed during pregnancy, and what are the causes of an increased nuchal translucency?
A: A nuchal scan is performed at 11-13 weeks of pregnancy. Causes of an increased nuchal translucency include Down's syndrome, congenital heart defects, and abdominal wall defects.
679
Q: What are the causes of hyperechogenic bowel in pregnancy?
A: Causes of hyperechogenic bowel include cystic fibrosis, Down's syndrome, and cytomegalovirus infection.
680
Q: What is umbilical cord prolapse, and what are the risk factors?
A: Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. Risk factors include prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations (e.g., breech, transverse lie). Around 50% of cord prolapses occur at artificial rupture of membranes.
681
Q: How is umbilical cord prolapse diagnosed and managed?
A: Umbilical cord prolapse is diagnosed when the fetal heart rate becomes abnormal, and the cord is palpable vaginally or visible beyond the introitus. Management involves pushing the presenting part back into the uterus to avoid compression, keeping the cord warm and moist if visible, and preparing for an immediate caesarean section. Tocolytics may be used, and retrofilling the bladder may help elevate the presenting part. Although caesarean section is the usual approach, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.
682
Q: What are the management strategies for women at risk of VTE during pregnancy?
A: Women with a previous VTE history are automatically considered high risk and require low molecular weight heparin throughout pregnancy. Women at intermediate risk should be considered for prophylactic low molecular weight heparin. If four or more risk factors are present, low molecular weight heparin should be started immediately and continued for six weeks postpartum. For women with three risk factors, it should start at 28 weeks and continue for six weeks postnatal.
683
Q: What is the treatment for VTE in pregnancy, and which medications are avoided?
A: Low molecular weight heparin is the treatment of choice for VTE prophylaxis during pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided due to potential risks to the fetus.
684
Q: What is the general management approach for polycystic ovarian syndrome (PCOS)?
A: General management involves weight reduction if appropriate. If contraception is needed, a combined oral contraceptive (COC) pill can help regulate menstrual cycles and induce monthly bleeding.
Cyclical oral progestogen/IUS can also be used
685
Q: How can hirsutism and acne be managed in PCOS?
A: Hirsutism and acne can be managed with a COC pill, particularly third-generation pills or co-cyprindiol, which have anti-androgen effects but may carry an increased risk of venous thromboembolism. If unresponsive, topical eflornithine or medications like spironolactone, flutamide, and finasteride may be used under specialist supervision.
686
Q: How is infertility managed in PCOS?
A: Management includes weight reduction if needed. Clomifene is commonly used to stimulate ovulation and is considered more effective than metformin, though metformin may be used alone or with clomifene, especially in obese patients. Gonadotrophins may also be considered.
687
What type of US is done for reduced foetal movements
trans abdominal US
688
What is Sheehans syndrome and what does it cause
Sheehan's syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan's syndrome is a lack of postpartum milk production and amenorrhoea following delivery. Diagnosis of Sheehan's is by inadequate prolactin and gonadotropin stimulation tests in patients with a history of severe PPH.
689
What is Ashermans syndrome and what is it associated with
Asherman's syndrome is seen as adhesions and fibrosis of the endometrial cavity most commonly associated with dilation and curettage procedures.
690
When should you be able to see foetal pole
by 9 weeks, by 5-6 weeks if using TVUS
691
What is recommended in the third stage of labour
Active management
692
What does active management in the third stage of labour include
Uterotonic drugs:
10 IU oxytocin by IM injection
Given after anterior shoulder is delivered
Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes
Controlled cord traction after signs of placental separation
693
Asymptomatic patient with BP 162/114 with no proteinuria management
admit and do obstetric assessment
694
When would ulipristal acetate and Levonorgestrel not work as emergency contraception
if ovulation has already occured
695
When cant you use IUD/IUS
presence of UTI
696
What hydration is needed for hyperemesis gravidarum
IV normal saline with potassium chloride
697
What are results for pataus syndrome in quadruple test
Alpha-fetoprotein (AFP) ↓
Unconjugated oestriol (uE3) ↓
Total human chorionic gonadotrophin (hCG) ↓
inhibin-A ↑
698
How often should HIV patients have cervical screening and what type
annual cytology
699
When should fetal movements be felt by
24 weeks
700
What is the most common complication of myomectomy
adhesions
701
What are the stages in ovarian cancer
Stage 1 (1 word) = ovary
Stage 2 (2 words) = ovary + pelvis
Stage 3 (3 words) = ovary + pelvis + abdomen
Stage 4 = distant metastasis
702
Features of lichen sclerosis
intense itching, especially worse at night, and presents with white, shiny patches, thinning of the vulvar skin, and areas of atrophy.
703
What does trace glucose in urine mean in pregnant women
nothing, happens due to increased GFR
704
How do you measure bilirubin if a neonate is < 24hrs old and >24 hours old
<24 serum within 2 hours
>24 transcutaneous bilirubinometer
705
If you are having surgery, what should you do regarding COCP usage
stop 4 weeks before, start 2 weeks after
706
If a foetus is small for dates ie SFH is less than expected, what do you do
do US to confirm
707
What is the long term side effect of GnRH agonists
loss of bone mineral density
708
What steroid do you give for <36 weeks PPROM
dexamethasone
709
710
