PassMed wrong answers

Question 1

What is postpartum thyroiditis? How is it managed?

Answer 1

The immune system attacks the thyroid within around 6 months of giving birth. This causes a temporary rise in thyroid hormone levels and symptoms of hyperthyroidism.

Three stages
1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function (but high recurrence rate in future pregnancies)

Thyroid peroxidase antibodies are found in 90% of patients

Management
1. Thyrotoxic phase:
Propranolol is typically used for symptom control.
Not usually treated with anti-thyroid drugs as the thyroid is not overactive. (Mild, temporary rise in thyroid hormones levels and function returns to normal after 12 months after childbirth so carbimazole not needed as a self-solving condition)
2. Hypothyroid phase
usually treated with thyroxine

Question 2

What are the signs of a thyroid storm and how is it treated?

Answer 2

Thyroid storm is the complication of thyrotoxicosis.
Additional features to support a thyroid storm would include a fever >38.5ºC, confusion and agitation, nausea and vomiting, and hypertension.

Dexamethasone is given. This would be co-prescribed with thioamides, such as methimazole, IV fluids, and propranolol.

Question 3

What is the first line treatment for hyperthyroidism during pregnancy?

Answer 3

Propylthiouracil
It is usually first-line during pregnancy because carbimazole has teratogenic properties.

Question 4

How should reduced fetal movements be investigated?

Answer 4

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

If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.

If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.

If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Question 5

What might reduced fetal movements suggest?

Answer 5

Reduced fetal movements can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.

Question 6

What is the normal timeline of fetal movements?

Answer 6

The first onset of recognised fetal movements is known as quickening. This usually occurs between 18-20 weeks gestation, and increase until 32 weeks gestation at which point the frequency of movement tends to plateau. Multiparous women will usually experience fetal movements sooner, from 16-18 weeks gestation. Towards the end of pregnancy, fetal movements should not reduce.

Expectant mothers will usually quickly recognise a pattern to these movements. The nature of the movements themselves can be very variable. There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment.

Question 7

What are the risk factors for reduced fetal movements?

Answer 7

Risk factors for reduced fetal movements
1. Posture: There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
2. Distraction:
Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
3. Placental position:
Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
4. Medication: Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
5. Fetal position: Anterior fetal position means movements are less noticeable
6. Body habitus: Obese patients are less likely to feel prominent fetal movements
7. Amniotic fluid volume: Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
8. Fetal size: Up to 29% of women presenting with RFM have a SGA fetus

Question 8

Which conditions are associated with raised or lowered alpha-fetoprotein levels?

Answer 8

AFP is a protein produced by the fetal liver and yolk sac. In a normal pregnancy, AFP levels in maternal blood start to rise early in gestation and peak at around 32 weeks.

Raised in neural tubes defects (meningocele and anencephaly), abdominal wall defects (omphalocele and gastroschisis) and multiple pregnancy

Decreased in Down’s syndrome

Question 9

What are the UKMEC 3 conditions for avoiding the COCP?

Answer 9

1. more than 35 years old and smoking less than 15 cigarettes/day
2. BMI > 35 kg/m^2*
3. family history of thromboembolic disease in first degree relatives < 45 years
4. controlled hypertension
5. immobility e.g. wheel chair use
6. carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
7. current gallbladder disease

Question 10

What are the UKMEC 4 conditions for avoiding the COCP?

Answer 10

1. more than 35 years old and smoking more than 15 cigarettes/day
2. migraine with aura
3. history of thromboembolic disease or thrombogenic mutation
4. history of stroke or ischaemic heart disease
5. breast feeding < 6 weeks post-partum
6. uncontrolled hypertension
7. current breast cancer
8. major surgery with prolonged immobilisation
9. positive antiphospholipid antibodies (e.g. in SLE)

Question 11

What are the two forms of hormonal emergency contraception and up to how long after UPSI can they be taken?

Answer 11

1. Levonorgestrel
   - acts both to stop ovulation and inhibit implantation
   - should be taken as soon as possible - efficacy decreases with time
   - must be taken within 72 hours of UPSI
   - single dose of levonorgestrel 1.5mg
   - the dose should be doubled for those with a BMI >26 or weight over 70kg
   - 84% effective is used within 72 hours of UPSI
   - Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
   if vomiting occurs within 3 hours then the dose should be repeated
   - can be used more than once in a menstrual cycle if clinically indicated
   hormonal
   - contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception
2. Ulipristal
   - a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation
   - 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
   concomitant use with levonorgestrel is not recommended
   - Ulipristal may reduce the effectiveness of hormonal contraception.
   - Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period
   - caution should be exercised in patients with severe asthma
   - repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle
   - breastfeeding should be delayed for one week after taking ulipristal.

Question 12

What are the criteria for using the copper coil as emergency contraception?

Answer 12

• must be inserted within 5 days of UPSI, or
• if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
• may inhibit fertilisation or implantation
• prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection
• is 99% effective regardless of where it is used in the cycle
  may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

A copper coil is contraindicated in patients with an active STI or pelvic inflammatory disease. This would otherwise be the first-line option if the patient did not have a suspected STI.

Question 13

What is normal weight loss after birth?

Answer 13

Weight loss of between 7-10% in the few days after birth is normal and most babies will return to their birth weight within the first 2 weeks of life

Question 14

What are some potential ‘minor’ breastfeeding problems?

Answer 14

‘Minor’ breastfeeding problems
1. frequent feeding in a breastfed infant is not alone a sign of low milk supply
2. nipple pain: may be caused by a poor latch
3. blocked duct (‘milk bleb’): causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
4. nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby

Question 15

How is mastitis due to breastfeeding managed?

Answer 15

Mastitis affects around 1 in 10 breastfeeding women. The BNF advises to treat ‘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 flucloxacillin for 10-14 days. Breastfeeding or expressing should continue during treatment.

If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.

Question 16

How can raynaud’s disease of the nipple be treated?

Answer 16

In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.

Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

Question 17

How is obstetric cholestasis managed?

Answer 17

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

Question 18

What are the contraindications to breastfeeding (/which drugs and conditions are contraindicated in breastfeeding)?

Answer 18

1. antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
2. psychiatric drugs: lithium, benzodiazepines, clozapine
3. aspirin
4. carbimazole
5. methotrexate
6. sulfonylureas
7. cytotoxic drugs
8. amiodarone
9. galactosaemia
10. viral infections - this is controversial with respect to HIV in the developing world. This is because there is such an increased infant mortality and morbidity associated with bottle feeding that some doctors think the benefits outweigh the risk of HIV transmission

Question 19

What is a typical quadruple test result that indicates Down’s syndrome?

Answer 19

↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A

People who receive an increased risk result from their screening test are offered non-invasive prenatal testing (NIPT), amniocentesis, or chorionic villous sampling to confirm the diagnosis.

Question 20

When are Down’s syndrome tests undertaken?

Answer 20

the combined test is now standard
- these tests should be done between 11 - 13+6 weeks
- nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
- Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
- trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the hCG tends to lower

quadruple test
- if women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks
quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A

Question 21

NIPT

Answer 21

analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
cffDNA derives from placental cells and is usually identical to fetal DNA
analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation

Question 22

What should be monitored during treatment of eclampsia?

Answer 22

• 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)

Question 23

What are the UKMEC3 and 4 contraindications to the depo injection (medroxyprogesterone acetate)?

Answer 23

3 = past breast cancer
4 = current breast cancer

Question 24

What are the 3 types of placenta accreta?

Answer 24

1. accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
2. increta: chorionic villi invade into the myometrium
3. percreta: chorionic villi invade through the perimetrium

Question 25

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 25

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.

Question 26

What are the missed pill rules if one pill is missed at any time in the cycle?

Answer 26

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

Question 27

What are the missed pill rules when 2 or more pills are missed for: week 1, week 2 and week 3?

Answer 27

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

Question 28

How are babies born to mothers with hepatitis B (chronic or acute) treated?

Answer 28

• 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)

Question 29

What is the formal definition of pre-eclampsia?

Answer 29

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

Question 30

What is the function of folic acid?

Answer 30

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

Question 31

What are the causes and consequences of folic acid deficiency?

Answer 31

Causes of folic acid deficiency:
-phenytoin
-methotrexate
-pregnancy
-alcohol excess

Consequences of folic acid deficiency:
-macrocytic, megaloblastic anaemia
-neural tube defects

Question 32

How are neural tube defects prevented during pregnancy?

Answer 32

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).

Question 33

What are the risks to the mother and fetus in chicken pox exposure during pregnancy?

Answer 33

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

Question 34

How is maternal EXPOSURE to chickenpox managed?

Answer 34

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

Question 35

How is chickenpox in pregnancy managed?

Answer 35

• 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’

Question 36

When is metformin indicated in gestational diabetes?

Answer 36

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

Question 37

When is OGTT offered ?

Answer 37

• 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)

Question 38

When is insulin indicated in gestational diabetes?

Answer 38

• 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

Question 39

What is used in women who cannot tolerate metformin or need but decline insulin?

Answer 39

Glibemclamide

Question 40

What are the glucose targets for self-monitoring of blood glucose in diabetes in pregnant women?

Answer 40

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

Question 41

How is hypertension in pregnancy defined?

Answer 41

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

Question 42

What are the appropriate treatments for hypertension in pregnancy?

Answer 42

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

Question 43

When is magnesium sulphate given in patients with pre-eclampsia?

Answer 43

• 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)

Question 44

How long does the progestogen-only-pill take to become effective?

Answer 44

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)

Question 45

When is a POP missed and what are the rules?

Answer 45

• 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)

Question 46

What is the gold standard investigation for endometriosis?

Answer 46

Laparoscopy

Question 47

How is heavy menstrual bleeding managed?

Answer 47

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.

Question 48

How is placental abruption managed?

Answer 48

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

Question 49

What are the complications of placental abruption?

Answer 49

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

Question 50

How is obstetric cholestasis managed?

Answer 50

• 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

Question 51

How long is Mirena licensed for?

Answer 51

5 years

Question 52

What is the mechanism of folic acid?

Answer 52

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

Question 53

What are the causes and consequences of folic acid?

Answer 53

Causes of folic acid deficiency:
- phenytoin
- methotrexate
- pregnancy
- alcohol excess

Consequences of folic acid deficiency:
- macrocytic, megaloblastic anaemia
- neural tube defects

Question 54

What doses of folic acid are given to patient groups in pregnancy?

Answer 54

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).

Question 55

What are the findings on quadruple test that may suggest Edward’s (Trisomy 18) syndrome?

Answer 55

LOW AFP
LOW oestriol
LOW beta-hCG
NORMAL inhibin A

Question 56

What are the findings on quadruple test that may suggest neural tube defect?

Answer 56

Isolated HIGH AFP
Normal oestriol, hCG and inhibin A

Question 57

When is induction of labour indicated?

Answer 57

• 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

Question 58

What is the Bishop score?

Answer 58

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
5. 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

Question 59

What are the different methods of induction of labour?

Answer 59

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

Question 60

Which induction methods should be used based on Bishop scores?

Answer 60

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)

Question 61

What is the main complication of induction of labour and how is it managed?

Answer 61

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

Question 62

Which antibiotic is used for group B streptococcus prophylaxis intrapartum?

Answer 62

Benzylpenicillin

Question 63

What are the risk factors for Group B streptococcus infection?

Answer 63

• 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

Question 64

What is the risk of GBS infection when GBS was detected in a previous pregnancy?

Answer 64

50%

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

Question 65

When is intrapartum antibiotic prophylaxis for GBS indicated?

Answer 65

• 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

Question 66

What are the criteria for expectant management of ectopic pregnancy?

Answer 66

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

Question 67

What are the criteria for medical management of ectopic pregnancy?

Answer 67

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

Question 68

What are the criteria for surgical management of ectopic pregnancy?

Answer 68

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)

Question 69

How is cervical cancer managed?

Answer 69

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

Question 70

How is cervical cancer staged?

Answer 70

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

Question 71

What are the complications of cervical cancer treatment?

Answer 71

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

Question 72

How is vaginal candidiasis diagnosed?

Answer 72

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

Question 73

How is pre-eclampsia INITIALLY managed?

Answer 73

• 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

Question 74

How is suspected endometrial cancer investigated?

Answer 74

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

Question 75

How is amenorrhoea investigated?

Answer 75

• 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

Question 76

Which treatment should be used for vaginal candidiasis in pregnant women?

Answer 76

Clotrimazole pessary

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

Question 77

What is the most common cause of PID?

Answer 77

Chlamydia trachomatis

Question 78

What is the first line management for mastitis?

Answer 78

Continue breastfeeding
+ analgesia and warm compresses

Question 79

When is axillary node clearance indicated in breast cancer?

Answer 79

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)

Question 80

Clinical features of endometriosis

Answer 80

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

Question 81

How can uterine fibroids be treated to reduce the size before removal?

Answer 81

GnRH agonists

Question 82

When is external cephalic version done?

Answer 82

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

Question 83

When is breast radiotherapy offered?

Answer 83

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

Question 84

When is CTG monitoring indicated during labour?

Answer 84

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

Question 85

Which are the SSRIs of choice in breastfeeding women?

Answer 85

Sertraline or paroxetine

Question 86

How is infertility treated in PCOS?

Answer 86

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

Question 87

Which medications are used for a medical abortion?

Answer 87

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

Question 88

Why should the COCP not be used in the first 21 days postpartum?

Answer 88

Due to increased VTE risk postpartum

Question 89

What are the causes of increased nuchal translucency?

Answer 89

Down’s
Congenital heart defects
Abdominal wall defects

Question 90

When is a woman considered post-menopausal?

Answer 90

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

Question 91

How are perineal tears classified?

Answer 91

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

Question 92

What is the mechanism of action of metformin in PCOS?

Answer 92

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

Question 93

How are reduced fetal movements investigated?

Answer 93

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.

Question 94

What is the screening tool for postnatal depression?

Answer 94

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.

Question 95

How is stress incontinence managed?

Answer 95

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

Question 96

What is the time frame for delivery in a CAT2 section?

Answer 96

Within 75 minutes

Question 97

What should be done in the case of inadequate smear samples?

Answer 97

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

Question 98

\What are the causes of delayed puberty based on stature?

Answer 98

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

Question 99

What are the adverse effects of Tamoxifen?

Answer 99

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

Question 100

What are the side effects of aromatase inhibitors?

Answer 100

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

Question 101

Which drug should women who are at risk of developing pre-eclampsia take?

Answer 101

Aspirin 75mg

Started from 12 weeks.

Question 102

How is urge incontinence medically managed in frail older patients?

Answer 102

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

Question 103

How is cervical intraepithelial neoplasia treated?

Answer 103

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.

Question 104

When a rhesus negative women given their first anti-D prophylaxis during pregnancy?

Answer 104

28 weeks

Question 105

In ectopic pregnancy, which location is the most associated with an increased risk of rupture?

Answer 105

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

Question 106

How does Paget’s disease of the nipple differ from eczema of the nipple?

Answer 106

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).

Question 107

What can happen to fibroids during pregnancy?

Answer 107

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.

Question 108

What are the indications for 1. Referral or 2. Consideration of referral to 2week wait for breast cancer?

Answer 108

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

Question 109

when is non-urgent referral considered for breast lumps?

Answer 109

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

Question 110

Which fluids are given to women admitted with hyperemesis gravidarum?

Answer 110

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.

Question 111

What are the risk factors for hyperemesis gravidarum?

Answer 111

• 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.

Question 112

When is admission indicated in hyperemesis gravidarum?

Answer 112

• 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.

Question 113

What is the triad needed to diagnose hyperemesis gravidarum?

Answer 113

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

Question 114

How is hyperemesis gravidarum managed?

Answer 114

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

Question 115

What are the complications of hyperemesis gravidarum?

Answer 115

• 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

Question 116

When is medical management indicated in mastitis?

Answer 116

• 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.

Question 117

What is vulval intraepithelial neoplasia, what are the risk factors?

Answer 117

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

Question 118

When are mastectomy or wide local excision indicated?

Answer 118

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

Question 119

When is radiotherapy used in breast cancer?

Answer 119

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

Question 120

When is chemotherapy used in breast cancer?

Answer 120

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.

Question 121

What is the sequence of management in PPH (after stabilising)?

Answer 121

• 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

Question 122

What is the discharge like in mammary duct ectasia compared with intraductal papilloma?

Answer 122

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

Question 123

When is lactational amenorrhoea considered reliable?

Answer 123

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.

Question 124

What are the risk factors for breech presentation?

Answer 124

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

Question 125

What are the contraindications to external cephalic version?

Answer 125

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

Question 126

When can you expect pregnancy test to become negative following a termination?

Answer 126

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

Question 127

When should a smear take place if a woman is called while she is pregnant?

Answer 127

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.

Question 128

What should be given to pregnant women at risk of developing pre-eclampsia?

Answer 128

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

Question 129

What needs to be monitored when giving magnesium sulphate treatment?

Answer 129

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)

Question 130

How often is cervical screening done in women of varying ages?

Answer 130

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

Question 131

What is the most common cause of cord prolapse? What are other risk factors?

Answer 131

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

Question 132

When should women be given VTE prophylaxis in pregnancy?

Answer 132

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.

Question 133

Which drug is used in the treatment/prophylaxis of VTE in pregnancy?

Answer 133

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.

Question 134

Which antibiotic is used for group B streptococcus?

Answer 134

Benzylpenicillin

Question 135

What are the side effects of using GnRH agonists for shrinking uterine fibroids?

Answer 135

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.

Question 136

When can hormonal contraception be used after ellaone?

Answer 136

5 days

Ulipristal may reduce the effectiveness of hormonal contraception.

Question 137

When should ellaone be used with caution?

Answer 137

In patients with severe asthma

breastfeeding should be delayed for one week after taking ulipristal.

Question 138

What causes an increased or decreased AFP?

Answer 138

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

Question 139

What are the risk factors for placental abruption?

Answer 139

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)

Question 140

What are the contraindications to expectant management of a miscarriage?

Answer 140

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

Question 141

What 3 factors make up the risk malignancy index?

Answer 141

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

Question 142

What is a galactocele?

Answer 142

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.

Question 143

Where is hCG secreted by?

Answer 143

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.

Question 144

What is periductal mastitis and how is it managed?

Answer 144

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

Question 145

What is the Pearl index?

Answer 145

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.

Question 146

When is axillary node dissection indicated during breast conserving surgery?

Answer 146

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

Question 147

What are the Hb cut-offs for giving iron therapy in pregnant and postpartum women?

Answer 147

Normal = <115

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

Question 148

Which is the only effective therapy to treat fibroids causing problems with fertility?

Answer 148

Myomectomy

Question 149

What is duct ectasia and how is it managed?

Answer 149

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).

Question 150

How is LMWH monitored?

Answer 150

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)

Question 151

How is vaginal candidiasis treated?

Answer 151

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

Question 152

What are the potential complications of hormonal replacement therapy?

Answer 152

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

Question 153

What is Meig’s syndrome?

Answer 153

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.

Question 154

What is the definition of premature ovarian failure?

Answer 154

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

Question 155

What are the high risk factors fir pre-eclampsia (presence of 1 merits aspirin 75mg from 12 weeks)?

Answer 155

• 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

Question 156

What are the moderate risk factors for pre-eclampsia (presence of 2 merits aspirin 75mg from 12 weeks)?

Answer 156

• 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

Question 157

What bHCG level points towards an ectopic rather than miscarriage?

Answer 157

> 1,500

Question 158

What are the types of endometrial hyperplasia and how should it be managed?

Answer 158

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.

Question 159

What is Mittelschmerz?

Answer 159

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

Question 160

What is the normal endometrial thickness at different stages of the menstrual cycle?

Answer 160

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

Question 161

What are the diagnostic criteria for PCOS?

Answer 161

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.

Question 162

What is Sheehan’s syndrome?

Answer 162

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

Question 163

What investigations should be done in suspected PCOS?

Answer 163

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

Question 164

What is alcohol advice during pregnancy?

Answer 164

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.

Question 165

Why are withdrawal bleeds important in endometriosis?

Answer 165

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).

Question 166

After what period of time would continued lochia warrant further investigation with ultrasound?

Answer 166

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

Question 167

At what gestation is there risk of congenital rubella syndrome?

Answer 167

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

Question 168

How is rubella investigated and monitored in pregnancy?

Answer 168

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

Question 169

wot haz whirlpool sign?

Answer 169

Ovarian torison

Question 170

What are the features of breast fibroadenomas and how are they managed?

Answer 170

• 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

Question 171

What are the risks of prematurity for baby?

Answer 171

• 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

Question 172

What is paget’s disease of the breast?

Answer 172

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

Question 173

What is a duct papilloma?

Answer 173

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

Question 174

What are the 3 types (with 5 overall subtypes) of benign ovarian cysts?

Answer 174

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

Question 175

What is fibroadenosis?

Answer 175

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

Question 176

How are miscarriages managed?

Answer 176

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.

Question 177

What results of the quadruple test suggest edward’s or patau syndrome

Answer 177

Low AFP
Low Oestriol
Low hCG
Normal Inhibin A

Question 178

What does a halo sign on a mammogram suggest?

Answer 178

A breast cyst

Question 179

Who is breast cancer screening offered to and how often?

Answer 179

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’.

Question 180

How should urinary incontinence be initially investigated?

Answer 180

• 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

Question 181

What should happen if a low-lying placenta is found at the 20 week scan?

Answer 181

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

Question 182

What are the surgical options for pelvic organ prolapse?

Answer 182

cystocele/cystourethrocele: anterior colporrhaphy, colposuspension

uterine prolapse: hysterectomy, sacrohysteropexy

rectocele: posterior colporrhaphy

Vault prolapse: Sacrocolpoplexy

Question 183

Which bug is Group b streptococcus?

Answer 183

Streptococcus agalactiae

Question 184

Which factors make candidiasis more likely?

Answer 184

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

Question 185

Which contraception can be used in patients assigned female at birth with a uterus that are taking testosterone therapy?

Answer 185

• 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.

Question 186

Which non-hormonal medications can be used to manage menopausal symptoms?

Answer 186

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.

Question 187

What is puerperal pyrexia and how is it managed?

Answer 187

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)

Question 188

What does a ‘snowstorm’ sign on axillary lymph node ultrasound indicate?

Answer 188

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.

Question 189

Where is the most common location of ectopic pregnancies?

Answer 189

The ampulla

Question 190

What is fibronectin?

Answer 190

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

Question 191

What type of inheritance is the BRCA1 mutation?

Answer 191

Autosomal dominant.

Majority of cases people are heterozygotes.

Question 192

What is a snow-storm appearance of ultrasound scan?

Answer 192

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

Question 193

What are the risk factors for endometrial cancer?

Answer 193

• 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

Question 194

What are the 3 main categories of anovulation?

Answer 194

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

Question 195

What are the forms of ovarian induction?

Answer 195

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

Question 196

What is ovarian hyperstimulation syndrome?

Answer 196

• 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

Question 197

What is the wood screw’s manoeuvre for shoulder dystocia?

Answer 197

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.

Question 198

What is the Rubin’s manoeuvre for shoulder dystocia?

Answer 198

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

Question 199

Which layers are cut through during a lower segment C section?

Answer 199

• 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

Question 200

What are the 6 possible abnormalities on CTG and what are their causes?

Answer 200

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

Question 201

What are the causes of oligohydramnios?

Answer 201

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

Question 202

Which contraceptives can be used concurrently with antiepileptics?

Answer 202

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.

Question 203

What is an amniotic fluid embolism?

Answer 203

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.

Question 204

What are the rules for taking methotrexate during conception?

Answer 204

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

Question 205

What is the time until effectiveness if different contraceptives are not started on the first day of the period?

Answer 205

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

Question 206

Why is the depo not used in women over 50?

Answer 206

Effects on bone mineral density

Question 207

What is the potential risk of ondansetron use in pregnancy?

Answer 207

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

Question 208

What measures reduce vertical transmission of HIV from mother to baby?

Answer 208

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

Question 209

How is placental abruption managed based on gestation and fetus?

Answer 209

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

Question 210

How is recurrent vaginal candidiasis managed?

Answer 210

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

Question 211

What are the main considerations with hepatitis B and pregnancy?

Answer 211

• 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)

Question 212

How should premature ovarian insufficiency be managed?

Answer 212

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

Question 213

What are the presentations of the two potential brachial plexus injuries from shoulder dystocia?

Answer 213

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.

Question 214

How is endometriosis managed?

Answer 214

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