PassMed wrong answers Flashcards

Question

What are the missed pill rules if more than one is missed during the pill free interval or at the start of a cycle?

Answer 1

If you miss more than one pill during the pill-free interval or at the start of a cycle, then you are at risk of becoming pregnant. 'the woman should use condoms or abstain from sex until she has taken pills for 7 days in a row'. The use of emergency contraception is also recommended if there was an episode of unprotected sexual intercourse (UPSI) during the pill-free interval or week 1 of the cycle, as in this case. The additional recommendation would be to advise the patient to take the most recent missed pill and continue subsequent pills as normal.

Answer 2

take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day no additional contraceptive protection needed

Answer 3

1. take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day 2. the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed' - if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 - if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception - if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 4

- all pregnant women are offered screening for hepatitis B - babies born to mothers who are chronically infected with hepatitis B or to mothers who've had acute hepatitis B during pregnancy (hepatitis B surface antigen positive or high risk of HepB) should receive a complete course of vaccination (1 soon after birth, 2 at 1-2 months and 3 at 6 months) + hepatitis B immunoglobulin - hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 5

new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: -proteinuria -other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Answer 6

THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Answer 7

Causes of folic acid deficiency: -phenytoin -methotrexate -pregnancy -alcohol excess Consequences of folic acid deficiency: -macrocytic, megaloblastic anaemia -neural tube defects

Answer 8

1. all women should take 400mcg of folic acid until the 12th week of pregnancy 2. women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy -women are considered higher risk if any of the following apply: *either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD *the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. *the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Answer 9

Risks to the mother - 5 times greater risk of pneumonitis Fetal varicella syndrome (FVS) - risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation - studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks - features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities Other risks to the fetus - shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester - severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 10

Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP) - if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies 1. if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible *RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure 2. if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 AFTER exposure

Answer 11

- if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought - there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy - consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash - if the woman is < 20 weeks the aciclovir should be 'considered with caution'

Answer 12

If the fasting glucose is <7mmol/L If diet and exercise have failed to control glucose levels after 1-2 weeks

Answer 13

- women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs - women with any of the other risk factors should be offered an OGTT at 24-28 weeks Risk factors are: - BMI of > 30 kg/m² - previous macrosomic baby weighing 4.5 kg or above - previous gestational diabetes - first-degree relative with diabetes - family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 14

- If glucose targets are not met with diet/exercise and metformin -If at time of diagnosis the fasting glucose level is > = 7mmol/L - If fasting glucose is between 6-6.9nmol/L and there is evidence of complications such as macrosomia or hydramnios Short-acting insulin is used

Answer 15

Glibemclamide

Answer 16

Fasting - 5.3nmol/L 1 hr after meals - 7.8nmol/L 2 hrs after meals - 6.4nmol/L

Answer 17

systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Answer 18

Oral labetalol first line Oral nifedipine (if asthmatic) and hydralazine

Answer 19

- should be given once a decision to deliver has been made - in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour - urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment - respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression - treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 20

48 hours (unless commenced up to and including day 5 of the menstrual cycle, in which case the cover is immediate and when switching from COCP if continued directly from the end of a pill packet)

Answer 21

- if < 3 hours* late: continue as normal - if > 3 hours*: take the missed pill as soon as possible, continue with the rest of the pack, extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours - diarrhoea and vomiting: continue taking POP but assume pills have been missed (except for Cerazette (desogestrel) where a 12 hour period is allowed)

Answer 22

Laparoscopy

Answer 23

1. Does not require contraception - either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period - if no improvement then try other drug whilst awaiting referral 2. Requires contraception, options include - intrauterine system (Mirena) should be considered first-line - combined oral contraceptive pill - long-acting progestogens Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Answer 24

1. Fetus alive and < 36 weeks fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation 2. Fetus alive and > 36 weeks fetal distress: immediate caesarean no fetal distress: deliver vaginally 3. Fetus dead induce vaginal delivery

Answer 25

1. Maternal - shock - DIC - renal failure - PPH 2. Fetal - IUGR - hypoxia - death

Answer 26

- induction of labour at 37-38 weeks is common practice but may not be evidence based - ursodeoxycholic acid - again widely used but evidence base not clear - vitamin K supplementation

Answer 27

Folic acid is converted to tetrahydrofolate (THF) THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA

Answer 28

Causes of folic acid deficiency: - phenytoin - methotrexate - pregnancy - alcohol excess Consequences of folic acid deficiency: - macrocytic, megaloblastic anaemia - neural tube defects

Answer 29

1. all women should take 400mcg of folic acid until the 12th week of pregnancy 2. women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy women are considered higher risk if any of the following apply: - either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD - the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. - the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).

Answer 30

LOW AFP LOW oestriol LOW beta-hCG NORMAL inhibin A

Answer 31

Isolated HIGH AFP Normal oestriol, hCG and inhibin A

Answer 32

- prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery - prelabour premature rupture of the membranes, where labour does not start - maternal medical problems *diabetic mother > 38 weeks *pre-eclampsia *obstetric cholestasis - intrauterine fetal death

Answer 33

The Bishop score is used to help assess whether induction of labour will be required. It has the following components: 1. Cervical position Posterior = 0 Intermediate = 1 Anterior =2 2. Cervical consistency Firm = 0 Intermediate = 1 Soft = 2 3. Cervical effacement 0-30% = 0 40-50% = 1 60-70% = 2 80% = 3 4. Cervical dilation <1 cm = 0 1-2 cm = 1 3-4 cm = 2 >5 cm = 3 4. Fetal station -3 = 0 -2 = 1 -1, 0 = 2 +1,+2 = 3 Interpretation *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' - there is a high chance of spontaneous labour, or response to interventions made to induce labour

Answer 34

1. membrane sweep - involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua - can be done by a midwife at the antenatal clinic. Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit - membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction - prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping 2. vaginal prostaglandin E2 (PGE2) - also known as dinoprostone 3. oral prostaglandin E1 - also known as misoprostol 4. maternal oxytocin infusion 5. amniotomy ('breaking of waters') 6. cervical ripening balloon *passed through the endocervical canal and gently inflated to dilate the cervix

Answer 35

1. if the Bishop score is ≤ 6 - vaginal prostaglandins or oral misoprostol - mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean (Reassess cervix at 6 hours before considering oxytocin) 2. if the Bishop score is > 6 - amniotomy and an intravenous oxytocin infusion (do not use amniotomy alone, and oxytocin can increase pain felt from contractions so additional analgesia is recommended)

Answer 36

Uterine hyperstimulation - the main complication of induction of labour - refers to prolonged and frequent uterine contractions - sometimes called tachysystole potential consequences: *intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia *uterine rupture (rare) management - removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started - consider tocolysis

Answer 37

Benzylpenicillin

Answer 38

- prematurity - prolonged rupture of the membranes - previous sibling GBS infection (women who've had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive) - maternal pyrexia e.g. secondary to chorioamnionitis

Answer 39

50% These women should be offered testing in late pregnancy (35-37 weeks or 3-5 weeks before the anticipated delivery date)

Answer 40

- All women with a previous baby with early or late onset GBS disease - All women in preterm labour regardless of GBS status - Women with pyrexia during labour

Answer 41

Size <35mm Unruptured Asymptomatic No fetal heartbeat hCG < 1,000IU/L Compatible if another intrauterine pregnancy Monitor over 48 hours and if bhCG levels rise again or symptoms manifest then intervention is performed

Answer 42

Size <35mm Unruptured No significant pain No fetal heartbeat hCG < 1,500IU/L Not suitable if another intrauterine pregnancy Involved giving Methotrexate and can only be done if the patient is willing to attend follow-up

Answer 43

Size >35mm Can be ruptured Pain Visible fetal heartbeat hCG < 5,000IU/L Compatible with another intrauterine pregnancy Surgical management can involve salpingectomy or salpingotomy - Salpingectomy is first-line for women with no other risk factors for infertility - Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage *around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)

Answer 44

1. Management of stage IA tumours - Gold standard of treatment is hysterectomy +/- lymph node clearance - Nodal clearance for A2 tumours - For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed *Close follow-up of these patients is advised - For A2 tumours, node evaluation must be performed - Radical trachelectomy is also an option for A2 2. Management of stage IB tumours - For B1 tumours: radiotherapy with concurrent chemotherapy is advised - Radiotherapy may either be bachytherapy or external beam radiotherapy - Cisplatin is the commonly used chemotherapeutic agent - For B2 tumours: radical hysterectomy with pelvic lymph node dissection 3. Management of stage II and III tumours - Radiation with concurrent chemotherapy - See above for choice of chemotherapy and radiotherapy - If hydronephrosis, nephrostomy should be considered 4. Management of stage IV tumours - Radiation and/or chemotherapy is the treatment of choice - Palliative chemotherapy may be best option for stage IVB Management of recurrent disease - Primary surgical treatment: offer chemoradiation or radiotherapy - Primary radiation treatment: offer surgical therapy

Answer 45

FIGO Stage IA - Confined to cervix, only visible by microscopy and less than 7 mm wide: A1 = < 3 mm deep A2 = 3-5 mm deep IB - Confined to cervix, clinically visible or larger than 7 mm wide: B1 = < 4 cm diameter B2 = > 4 cm diameter II - Extension of tumour beyond cervix but not to the pelvic wall A = upper two thirds of vagina B = parametrial involvement III - Extension of tumour beyond the cervix and to the pelvic wall A = lower third of vagina B = pelvic side wall NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III IV - Extension of tumour beyond the pelvis or involvement of bladder or rectum A = involvement of bladder or rectum B = involvement of distant sites outside the pelvis

Answer 46

Complications of surgery - Standard complications (e.g. bleeding, damage to local structures, infection, anaesthetic risk) - Cone biopsies and radical trachelectomy may increase risk of preterm birth in future pregnancies - Radical hysterectomy may result in a ureteral fistula Complications of radiotherapy - Short-term: diarrhoea, vaginal bleeding, radiation burns, pain on micturition, tiredness/weakness - Long-term: ovarian failure, fibrosis of bowel/skin/bladder/vagina, lymphoedema

Answer 47

Clinically a high vaginal swab is NOT routinely indicated if the clinical features are consistent with candidiasis

Answer 48

- NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected - women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Answer 49

All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway - first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value - hysteroscopy with endometrial biopsy

Answer 50

- exclude pregnancy with urinary or serum bHCG - full blood count, urea & electrolytes, coeliac screen, thyroid function tests - gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure), raised if gonadal dysgenesis (e.g. Turner's syndrome) - prolactin - androgen levels: raised levels may be seen in PCOS - oestradiol

Answer 51

Clotrimazole pessary Rather than Oral fluconazole as oral antifungals are contraindicated as they may be associated with congenital abnormalities.

Answer 52

Chlamydia trachomatis

Answer 53

Continue breastfeeding + analgesia and warm compresses

Answer 54

Those with clinically palpable lymphadenopathy Those with axillary node biopsies showing proven lymph node metastases NOT indicated when biopsy shows isolated tumour cells or micrometastases (risks associated with surgery including lymphoedema and functional arm impairment outweigh the benefits of treatment)

Answer 55

chronic pelvic pain secondary dysmenorrhoea: pain often starts days before bleeding deep dyspareunia subfertility non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Answer 56

GnRH agonists

Answer 57

From 36 weeks in nulliparous women From 37 weeks in multiparous women

Answer 58

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who've had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

Answer 59

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above severe hypertension 160/110 mmHg or above oxytocin use the presence of significant meconium fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014

Answer 60

Sertraline or paroxetine

Answer 61

Weight reduction Clomifene Metformin can also be used, particularly in patients who are obese Gonadotrophins

Answer 62

Mifepristone (anti-progestogen) followed by prostaglandins eg misoprostol 48 hours later to stimulate uterine contractions

Answer 63

Due to increased VTE risk postpartum

Answer 64

Down's Congenital heart defects Abdominal wall defects

Answer 65

Over 45 and not had a period in the last 12 months

Answer 66

1. first degree - superficial damage with no muscle involvement - do not require any repair 2. second degree - injury to the perineal muscle, but not involving the anal sphincter - require suturing on the ward by a suitably experienced midwife or clinician 3. third degree - injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS) 3a: less than 50% of EAS thickness torn 3b: more than 50% of EAS thickness torn 3c: IAS torn require repair in theatre by a suitably trained clinician 4. fourth degree injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa require repair in theatre by a suitably trained clinician

Answer 67

Increases peripheral insulin sensitivity to reduce changes in the hypothalamic pituitary ovarian axis

Answer 68

1. If past 28 weeks gestation: - Initially, handheld Doppler should be used to confirm fetal heartbeat. - If no fetal heartbeat detectable, immediate ultrasound should be offered. - If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. - If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement 2. If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat. 3. If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used. 4. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Answer 69

Edinburgh postnatal depression scale (EPDS) score of more than 13 suggests a 'depressive illness of varying severity' less, suggests their symptoms are less severe and more likely to be temporary.

Answer 70

1. pelvic floor muscle training NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months 2. surgical procedures: e.g. retropubic mid-urethral tape procedures 3. duloxetine may be offered to women if they decline surgical procedures - a combined noradrenaline and serotonin reuptake inhibitor - mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

Answer 71

Within 75 minutes

Answer 72

repeat the sample in 3 months if two consecutive inadequate samples then → colposcopy

Answer 73

Delayed puberty with short stature - Turner's syndrome - Prader-Willi syndrome - Noonan's syndrome Delayed puberty with normal stature - polycystic ovarian syndrome - androgen insensitivity - Kallman's syndrome - Klinefelter's syndrome

Answer 74

Adverse effects - menstrual disturbance: vaginal bleeding, amenorrhoea - hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects - venous thromboembolism - endometrial cancer

Answer 75

- osteoporosis: NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer - hot flushes - arthralgia, myalgia - insomnia

Answer 76

Aspirin 75mg Started from 12 weeks.

Answer 77

Oxybutynin/tolterodine/darifenacin should be avoided as they are antimuscarinics Mirabegron (beta 3 agonist) can be used if there is concern about anticholinergic side effects

Answer 78

Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic. Alternative techniques include cryotherapy.

Answer 79

Isthmus least able to expand to accommodate the growing embryo/fetus and is therefore most prone to rupture

Answer 80

Paget's disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).

Answer 81

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration. This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.

Answer 82

Refer: - aged 30 and over and have an unexplained breast lump with or without pain or - aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern Consider: - with skin changes that suggest breast cancer or - aged 30 and over with an unexplained lump in the axilla

Answer 83

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Answer 84

0.9% saline with potassium: Saline infusion is needed to replenish the lost intravascular volume. Adding potassium is essential as hypokalemia is common with hyperemesis gravidarum. It is worth knowing that women with hyperemesis gravidarum should have renal function and electrolytes, urine ketones and ultrasound (excluding multiple or molar pregnancies). As thiamine deficiency is common in patients with hyperemesis gravidarum; fluids containing dextrose should not be given as dextrose increases the body’s need for thiamine which might precipitate Wernicke encephalopathy.

Answer 85

- increased levels of beta-hCG *multiple pregnancies *trophoblastic disease - nulliparity - obesity - family or personal history of NVP Smoking is associated with a decreased incidence of hyperemesis.

Answer 86

- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics - Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics - A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection) Also recommend having a lower threshold for admission to hospital if the woman has a co-existing condition (for example diabetes) that may be adversely affected by nausea and vomiting.

Answer 87

1. 5% pre-pregnancy weight loss 2. dehydration 3. electrolyte imbalance

Answer 88

1. simple measures - rest and avoid triggers e.g. odours - bland, plain food, particularly in the morning - ginger - P6 (wrist) acupressure 2. first-line medications CKS - antihistamines: oral cyclizine or promethazine - phenothiazines: oral prochlorperazine or chlorpromazine 3. second-line medications - oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. The MHRA advise that if ondansetron is used then these risks should be discussed with the pregnant woman - oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects eg tremor. It should therefore not be used for more than 5 days 4. admission may be needed for IV hydration - normal saline with added potassium is used to rehydrate

Answer 89

- acute kidney injury - Wernicke's encephalopathy - oesophagitis, Mallory-Weiss tear - venous thromboembolism fetal outcome CKS - studies generally show little evidence of adverse outcomes for birth weight/other markers for mild-moderate symptoms - severe NVP resulting in multiple admissions and failure to 'catch-up' weight gain may be linked to a small increase in preterm birth and low birth weight

Answer 90

- the BNF advises treating 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection' - the first-line antibiotic is oral flucloxacillin for 10-14 days - reflects the fact that the most common organism causing infective mastitis is Staphylococcus aureus - breastfeeding or expressing should continue during antibiotic treatment.

Answer 91

Vulval intraepithelial neoplasia (VIN) is a pre-cancerous skin lesion of the vulva, and may result in squamous skin cancer if untreated. The average of an affected women is around 50 years Risk factors - human papilloma virus 16 & 18 - smoking - herpes simplex virus 2 - lichen planus Features - itching, burning - raised, well defined skin lesions

Answer 92

Wild local excision: - Solitary lesion - Peripheral tumour - Small lesion in large breast - DCIS < 4cm Mastectomy: - Multifocal tumour - Central tumour - Large lesion in small breast - DCIS > 4cm

Answer 93

1. Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. 2. For women who've had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

Answer 94

Cytotoxic therapy may be used either prior to surgery ('neoadjuvanant' chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.

Answer 95

- bimanual uterine compression to manually stimulate contraction - intravenous oxytocin and/or ergometrine (no ergometrine in hx of hypertension) - intramuscular carboprost (unless hx of asthma) - intramyometrial carboprost - rectal misoprostol - surgical intervention such as balloon tamponade *don't give carboprost in history of asthma

Answer 96

Mammary duct ectasia: - Dilatation breast ducts. - Most common in menopausal women - Discharge typically thick and green in colour - Most common in smokers Intraductal papilloma: - Commoner in younger patients - May cause blood stained discharge - There is usually no palpable lump

Answer 97

Lactational amenorrhoea is a reliable method of contraception if the following criteria are fulfilled: - baby under 6 months; - exclusively breastfeeding; - amenorrhoea, and - gaps between feeds do not exceed 4 hours in the day or 6 hours at night.

Answer 98

- uterine malformations, fibroids - placenta praevia - polyhydramnios or oligohydramnios - fetal abnormality (e.g. CNS malformation, chromosomal disorders) - prematurity (due to increased incidence earlier in gestation)

Answer 99

- where caesarean delivery is required - antepartum haemorrhage within the last 7 days - abnormal cardiotocography - major uterine anomaly - ruptured membranes - multiple pregnancy

Answer 100

Urine pregnancy test often remains positive for up to 4 weeks following termination. A positive test beyond 4 weeks indicates incomplete abortion or persistent trophoblast

Answer 101

NICE guidelines suggest that a woman who has been called for routine screening wait until 12 weeks post-partum for her cervical smear. If a smear has been abnormal in the past and a woman becomes pregnant then specialist advice should be sought. If a previous smear has been abnormal, a cervical smear can be performed mid-trimester as long as there is not a contra-indication, such as a low lying placenta.

Answer 102

Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.

Answer 103

Monitor reflexes (toxicity is indicated by loss of deep tendon reflexes), respiratory rate, oxygen sats and urine output (respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression)

Answer 104

25-49 = Every 3 years 50-64 = Every 5 years

Answer 105

Around 50% of cord prolapses occur at artificial rupture of the membranes. Risk factors for cord prolapse include: - prematurity - multiparity - polyhydramnios - twin pregnancy - cephalopelvic disproportion - abnormal presentations e.g. Breech, transverse lie

Answer 106

A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts. A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin. - Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. - If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal. The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include: - Age > 35 - Body mass index > 30 - Parity > 3 - Smoker - Gross varicose veins - Current pre-eclampsia - Immobility - Family history of unprovoked VTE - Low risk thrombophilia - Multiple pregnancy - IVF pregnancy If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.

Answer 107

Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy.

Answer 108

Benzylpenicillin

Answer 109

GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density they act to overstimulate GnRH production resulting in exhaustion of the GnRH axis and reduced oestrogen and progesterone concentration. Because they decrease serum oestrogen they have an increased risk of resulting in loss of bone mineral density when used for a long period hence are only used for a short time. Other side effects include menopausal symptoms such as hot flashes and vaginal dryness.

Answer 110

5 days Ulipristal may reduce the effectiveness of hormonal contraception.

Answer 111

In patients with severe asthma breastfeeding should be delayed for one week after taking ulipristal.

Answer 112

Increased AFP - Neural tube defects (meningocele, myelomeningocele and anencephaly) - Abdominal wall defects (omphalocele and gastroschisis) - Multiple pregnancy Decreased AFP - Down's syndrome - Trisomy 18 - Maternal diabetes mellitus - Maternal obesity

Answer 113

A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen); P for Polyhydramnios; T for Twins or multiple gestation; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 114

Some situations are better managed with medically or surgically. NICE list the following: 1. increased risk of haemorrhage - she is in the late first trimester - if she has coagulopathies or is unable to have a blood transfusion 2. previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) 3. evidence of infection

Answer 115

Risk malignancy index (RMI) prognosis in ovarian cancer is based on US findings, menopausal status and CA125 levels

Answer 116

Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Answer 117

Human chorionic gonadotrophin (HCG) is secreted by the syncytiotrophoblast into the maternal bloodstream, where is acts to maintain the production of progesterone by the corpus luteum in early pregnancy. It is later produced by the placental trophoblast. HCG can be detected in the maternal blood as early as day 8 after conception.

Answer 118

A non-lactational mastitis. Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav

Answer 119

The Pearl Index is the most common technique used to describe the efficacy of a method of contraception. The Pearl Index describes the number of pregnancies that would be seen if one hundred women were to use the contraceptive method in question for one year. Eg, Assuming the Pearl Index is 0.2 and the medication is adhered to perfectly, we would expect to see 0.2 pregnancies for every hundred women using the pill for one year - or 2 for every thousand.

Answer 120

In patients with breast cancer undergoing breast conserving surgery with adjuvant radiotherapy if, at sentinel node biopsy, less than 3 involved nodes are found then no further management of the axilla is required Otherwise, dissection is indicated

Answer 121

Normal = <115 First trimester < 110 g/L Second/third trimester < 105 g/L Postpartum < 100 g/L

Answer 122

Myomectomy

Answer 123

Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. It typically presents with nipple retraction and occasionally nipple discharge or a peri-areolar lump. Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).

Answer 124

Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (for example, with renal impairment or recurrent VTE)

Answer 125

options include local or oral treatment NICE Clinical Knowledge Summaries recommends: - oral fluconazole 150 mg as a single dose first-line - clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated - If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Answer 126

1. increased risk of breast cancer - increased by the addition of a progestogen - the increased risk relates to the duration of use - the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT 2. increased risk of endometrial cancer - oestrogen by itself should not be given as HRT to women with a womb - reduced by the addition of a progestogen but not eliminated completely - the BNF states that the additional risk is eliminated if a progestogen is given continuously 3. increased risk of venous thromboembolism - increased by the addition of a progestogen - transdermal HRT does not appear to increase the risk of VTE - NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal) 4. increased risk of stroke 5. increased risk of ischaemic heart disease if taken more than 10 years after menopause

Answer 127

The three features of Meig's syndrome are: - a benign ovarian tumour - ascites - pleural effusion It is a rare condition usually occurring in woman over the age of 40 years and the ovarian tumour is generally a fibroma. It is managed by the surgical removal of the tumour, however the ascites and pleural effusion may need to be drained first to allow symptomatic relief and improve pulmonary function before the anaesthetic. It has excellent prognosis due to the benign nature of the tumour.

Answer 128

The onset of menopausal symptoms and elevated gonadotrophin levels (FSH > 25 IU/L on two occasions more than 4 weeks apart) before the age of 40 years

Answer 129

- hypertensive disease in a previous pregnancy - chronic kidney disease - autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome - type 1 or type 2 diabetes - chronic hypertension

Answer 130

- first pregnancy - age 40 years or older - pregnancy interval of more than 10 years - body mass index (BMI) of 35 kg/m² or more at first visit - family history of pre-eclampsia - multiple pregnancy

Answer 131

Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer Types - simple - complex - simple atypical - complex atypical Features abnormal vaginal bleeding e.g. intermenstrual Management - simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used - atypia: hysterectomy is usually advised in premenopausal women, and Hysterectomy with bilateral salpingo-oophorectomy is the recommended management for postmenopausal women due to increased risk of ovarian malignancy if bilateral salpingo-oophorectomy is not performed.

Answer 132

Mid cycle pain is very common and is due to the small amount of fluid released during ovulation Often sharp onset. Little systemic disturbance. May have recurrent episodes. Usually settles over 24-48 hours. Full blood count- usually normal Ultrasound- may show small quantity of free fluid

Answer 133

Normal endometrial thickness in premenopausal women: - During menstruation: 2-4mm - Early proliferative phase (day 6-14): 5-7mm - Late proliferative: up to 11 mm - Secretory phase: 7-16 mm

Answer 134

For a diagnosis of PCOS to be made, 2 out of 3 of the following must be present: 1. Infrequent or no ovulation (usually manifested as infrequent or no menstruation). 2. Clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne or elevated levels of total or free testosterone). 3. Polycystic ovaries on ultrasound scan.

Answer 135

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

Answer 136

pelvic ultrasound, FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG)

Answer 137

Avoid alcohol throughout pregnancy. According to the NICE guidelines, it is recommended that women who are pregnant or planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage. However, if they choose to drink, to minimise the risk to the baby, they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk. The safest approach is not drinking alcohol at all during pregnancy.

Answer 138

In women with PCOS, intervals between menstruation of more than 3 months (or fewer than 4 per year) increase the risk of endometrial hyperplasia and carcinoma. Therefore inducing a withdrawal bleed every 3-4 months or preventing proliferation of the endometrium is recommended. This can be achieved with a cyclical oral progestogen (e.g. medroxyprogesterone) for at least 12 days a month, a combined oral contraceptive (COC), or levonorgestrel-releasing intrauterine system (LNG-IUS).

Answer 139

Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium. An ultrasound is indicated if lochia persists beyond 6 weeks

Answer 140

Risk in first 8-10 weeks risk of damage to fetus is as high as 90% damage is rare after 16 weeks

Answer 141

Diagnosis - suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary - IgM antibodies are raised in women recently exposed to the virus - it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss Management - suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit - since 2016, rubella immunity is no longer routinely checked at the booking visit - if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella - non-immune mothers should be offered the MMR vaccination in the post-natal period - MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

Answer 142

Ovarian torison

Answer 143

- Develop from a whole lobule - Mobile, firm, smooth breast lump - a 'breast mouse' - 12% of all breast masses - Over a 2 year period up to 30% will get smaller - No increase in risk of malignancy - If >3cm surgical excision is usual

Answer 144

- increased mortality depends on the gestation - respiratory distress syndrome - intraventricular haemorrhage - necrotizing enterocolitis - chronic lung disease, hypothermia, feeding problems, infection, jaundice - retinopathy of prematurity *important cause of visual impairment in babies born before 32 weeks gestation *the cause is not fully understood and multivariate. One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization) *screening is done in at-risk groups - hearing problems

Answer 145

intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola

Answer 146

Local areas of epithelial proliferation in large mammary ducts Hyperplastic lesions rather than malignant or premalignant May present with blood stained discharge

Answer 147

1. Physiological cysts (functional cysts) - Follicular cysts commonest type of ovarian cyst due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle commonly regress after several menstrual cycles - Corpus luteum cyst during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst more likely to present with intraperitoneal bleeding than follicular cysts 2. Benign germ cell tumours - Dermoid cyst also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth most common benign ovarian tumour in woman under the age of 30 years median age of diagnosis is 30 years old bilateral in 10-20% usually asymptomatic. Torsion is more likely than with other ovarian tumours 3. Benign epithelial tumours - Arise from the ovarian surface epithelium - Serous cystadenoma the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) bilateral in around 20% - Mucinous cystadenoma second most common benign epithelial tumour they are typically large and may become massive if ruptures may cause pseudomyxoma peritonei

Answer 148

Most common in middle-aged women 'Lumpy' breasts which may be painful. Symptoms may worsen prior to menstruation

Answer 149

1. Expectant management First-line and involves waiting for 7-14 days for the miscarriage to complete spontaneously If expectant management is unsuccessful then medical or surgical management may be offered Some situations are better managed with medically or surgically. NICE list the following: - increased risk of haemorrhage - she is in the late first trimester - if she has coagulopathies or is unable to have a blood transfusion - previous adverse and/or traumatic experience associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) evidence of infection 2. Medical management: - Vaginal misoprostol Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue The addition of oral mifepristone is not currently recommended by NICE in contrast to US guidelines Advise them to contact the doctor if the bleeding hasn't started in 24 hours. Should be given with antiemetics and pain relief 3. Surgical management The two main options are vacuum aspiration (suction curettage) or surgical management in theatre Vacuum aspiration is done under local anaesthetic as an outpatient Surgical management is done in theatre under general anaesthetic.

Answer 150

Low AFP Low Oestriol Low hCG Normal Inhibin A

Answer 151

A breast cyst

Answer 152

The NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are 'encouraged to make their own appointments'.

Answer 153

- bladder diaries should be completed for a minimum of 3 days - vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) - urine dipstick and culture - urodynamic studies

Answer 154

If low-lying placenta at the 20-week scan: - rescan at 32 weeks - no need to limit activity or intercourse unless they bleed - if still present at 32 weeks and grade I/II then 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 then a trial of vaginal delivery may be offered - if a woman with known placenta praevia goes into labour prior to the elective caesarean section an emergency caesarean section should be performed due to the risk of post-partum haemorrhage

Answer 155

cystocele/cystourethrocele: anterior colporrhaphy, colposuspension uterine prolapse: hysterectomy, sacrohysteropexy rectocele: posterior colporrhaphy Vault prolapse: Sacrocolpoplexy

Answer 156

Streptococcus agalactiae

Answer 157

- diabetes mellitus - drugs: antibiotics, steroids - pregnancy - immunosuppression: HIV

Answer 158

- Testosterone therapy does not provide protection against pregnancy and if the patient becomes pregnant, testosterone therapy is contraindicated as can have teratogenic effects. - Regimes containing oestrogen are not recommended in patients undergoing testosterone therapy as can antagonize the effect of testosterone therapy. - Progesterone only contraceptives are not considered to have any detrimental effect on testosterone therapy and the intrauterine system and injections may also suspend menstruation. - Non-hormonal intrauterine devices do not interact with hormonal regimes but can exacerbate menstrual bleeding, which may be unacceptable to patients.

Answer 159

1. Vasomotor symptoms fluoxetine, citalopram or venlafaxine 2. Vaginal dryness vaginal lubricant or moisturiser 3. Psychological symptoms self-help groups, cognitive behaviour therapy or antidepressants 4. Urogenital symptoms if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Answer 160

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery. Causes: - endometritis: most common cause - urinary tract infection - wound infections (perineal tears + caesarean section) - mastitis - venous thromboembolism Management - if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 161

The 'snowstorm' sign on ultrasound of axillary lymph nodes indicates extracapsular breast implant rupture. It is due to leakage of the silicone, which then drains via the lymphatic system, giving the 'snowstorm appearance' both in the breast and the lymph nodes.

Answer 162

The ampulla

Answer 163

Fetal fibronectin (fFN) is a protein that is released from the gestational sac. Having a high level has been shown to be related with early labour, and depending on the level different probabilities can be calculated for labour within one week, two weeks etc. Having a high level however does not mean that early labour is definite, some women will go to term even with a raised fFN

Answer 164

Autosomal dominant. Majority of cases people are heterozygotes.

Answer 165

A complete hydatidiform mole (all genetic material comes from the father) Features are: - vaginal bleeding - uterus size greater than expected for gestational age -abnormally high serum hCG - ultrasound: 'snow storm' appearance of mixed echogenicity

Answer 166

- excess oestrogen *nulliparity *early menarche *late menopause *unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously - metabolic syndrome *obesity *diabetes mellitus *polycystic ovarian syndrome - tamoxifen - hereditary non-polyposis colorectal carcinoma

Answer 167

Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women) Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases) Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive

Answer 168

1. Exercise and weight loss Typically this is the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered 2. Letrozole According to UptoDate, this is now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction Side effects: fatigue (20%), dizziness (10%) 3. Clomiphene citrate While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead Mechanism of action: clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%) 4. Gonadotropin therapy This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development

Answer 169

- Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly - In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including: *Hypovolaemic shock *Acute renal failure *Venous or arterial thromboembolism This is a rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction Depending on the severity, the management includes: - Fluid and electrolyte replacement - Anti-coagulation therapy - Abdominal ascitic paracentesis - Pregnancy termination to prevent further hormonal imbalances

Answer 170

The Wood's screw manoeuvre describes the action of putting a hand in the vagina and rotating the foetus 180 degrees in attempt to 'dislodge' the anterior shoulder from the symphysis pubis.

Answer 171

press on the posterior shoulder to allow the anterior shoulder extra room

Answer 172

- Skin - Superficial fascia - Deep fascia - Anterior rectus sheath - Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) - Transversalis fascia - Extraperitoneal connective tissue - Peritoneum - Uterus

Answer 173

1. Baseline bradycardia Heart rate < 100 /min - Increased fetal vagal tone, maternal beta-blocker use 2. Baseline tachycardia Heart rate > 160 /min - Maternal pyrexia, chorioamnionitis, hypoxia, prematurity 3. Loss of baseline variability < 5 beats / min Prematurity, hypoxia 4. Early deceleration Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction - Usually an innocuous feature and indicates head compression 5. Late deceleration Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction - Indicates fetal distress e.g. asphyxia or placental insufficiency 6. Variable decelerations Independent of contractions - May indicate cord compression

Answer 174

In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile. Causes - premature rupture of membranes - Potter sequence: bilateral renal agenesis + pulmonary hypoplasia - intrauterine growth restriction - post-term gestation - pre-eclampsia

Answer 175

There are a number of factors to consider for women with epilepsy: - the effect of the contraceptive on the effectiveness of the anti-epileptic medication - the effect of the anti-epileptic on the effectiveness of the contraceptive - the potential teratogenic effects of the anti-epileptic if the woman becomes pregnant For women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine: UKMEC 3: the COCP and POP UKMEC 2: implant UKMEC 1: Depo-Provera, IUD, IUS For lamotrigine: UKMEC 3: the COCP UKMEC 1: POP, implant, Depo-Provera, IUD, IUS If a COCP is chosen then it should contain a minimum of 30 µg of ethinylestradiol.

Answer 176

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below. - The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum. - Symptoms include: chills, shivering, sweating, anxiety and coughing. - Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction. There may be a sudden collapse.

Answer 177

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

Answer 178

Contraceptives - time until effective (if not first day period): instant: IUD 2 days: POP 7 days: COC, injection, implant, IUS

Answer 179

Effects on bone mineral density

Answer 180

Ondansetron during pregnancy is associated with a small increased risk of cleft palate/lip - the MHRA advise that these risks need to be discussed with the pregnant woman before use

Answer 181

1. Factors which reduce vertical transmission (from 25-30% to 2%) maternal antiretroviral therapy mode of delivery (caesarean section) neonatal antiretroviral therapy infant feeding (bottle feeding) 2. Screening NICE guidelines recommend offering HIV screening to all pregnant women 3. Antiretroviral therapy all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously 4. Mode of delivery - vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended - a zidovudine infusion should be started four hours before beginning the caesarean section 5. Neonatal antiretroviral therapy: zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks. 6. Infant feeding in the UK all women should be advised not to breast feed

Answer 182

Fetus alive and < 36 weeks fetal distress: immediate caesarean no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks fetal distress: immediate caesarean no fetal distress: deliver vaginally Fetus dead induce vaginal delivery

Answer 183

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year compliance with previous treatment should be checked confirm the diagnosis of candidiasis - high vaginal swab for microscopy and culture - consider a blood glucose test to exclude diabetes exclude differential diagnoses such as lichen sclerosus consider the use of an induction-maintenance regime - induction: oral fluconazole every 3 days for 3 doses - maintenance: oral fluconazole weekly for 6 months

Answer 184

- all pregnant women are offered screening for hepatitis B - babies born to mothers who are chronically infected with hepatitis B or to mothers who've had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin (studies are currently evaluating the role of oral antiviral treatment (e.g. Lamivudine) in the latter part of pregnancy) - there is little evidence to suggest caesarean section reduces vertical transmission rates - hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)

Answer 185

hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years) it should be noted that HRT does not provide contraception, in case spontaneous ovarian activity resumes

Answer 186

Erb's palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the 'waiter's tip'. Klumpke's palsy occurs due to damage of the lower brachial plexus and commonly affects the nerves innervating the muscles of the hand.

Answer 187

NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief if analgesia doesn't help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include: GnRH analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels drug therapy unfortunately does not seem to have a significant impact on fertility rates surgery this may be an option for women who have not responded to conventional medical treatment for women who are trying to conceive, NICE recommend laparoscopic excision or ablation of endometriosis plus adhesiolysis as this has been shown to improve the chances of conception. Ovarian cystectomy (for endometriomas) is also recommended