PBGYN

Question 1

Pregnancy: DVT/PE path

Answer 1

• ↑ in factors VII, VIII, X and fibrinogen
• ↓ in protein S
• Uterus presses on IVC causing venous stasis in legs

Question 2

Pregnancy: DVT/PE management

Answer 2

Management
* Warfarin is contraindicated
* S/C low-molecular weight heparin preferred to IV heparin (less bleeding and
thrombocytopenia)

Question 3

Pregnancy: DVT/PE invest

Answer 3

CXR ALL
The decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
* CTPA exposes the fetus to about 10-30% of the radiation dose of a V/Q scan
* V/Q scanning exposes the maternal breast tissue to less radiation than a CTPA

Question 4

Cholestasis in Pregnancy: features

Answer 4

Features:
* Seen across maternal ages and in both nulliparous and primiparous women
* More common in women with a history of cholestasis associated with OCP use and those who
have a family history of cholestasis in pregnancy.
* Itching is the commonest symptom of cholestasis of pregnancy
* Severe jaundice is uncommon.
* Both ALT and Alk P are ↑.

Question 5

Cholestasis in Pregnancy: Prognosis & Mangement:

Answer 5

Prognosis & Mangement:
* Long-term maternal outcome is good, although the risk of gallstones is ↑.
* The condition rapidly resolves after delivery of the child.
* Prior to delivery, antihistamines, benzodiazepines and ursodeoxycholic acid may all have a role
to play in symptom relief

Question 6

Peripartum Cardiomyopathy:

Answer 6

Peripartum Cardiomyopathy: is a dilated cardiomyopathy of uncertain aetiology occurring in the last month of pregnancy or within 6 months after delivery. Symptoms are the same as those of cardiac failure in non-pregnant patients.

Question 7

Peripartum Cardiomyopathy: Management:

Answer 7

• Same as for cardiac failure, although ACE inhibitors should be avoide
• Mainstay of medical treatment is digoxin and loop diuretics. If indicated nitrates and inotropic
  support with dobutamine should be used.
• Heparin (during pregnancy) or Warfarin (postpartum) for the hypercoagulopathy (caused by
  cardiomyopathy + peripartum)
• Salt or Na+ restriction
  Prognosis:
• 50% recover to normal
• Recurrence is high in further pregnancies
• If no recovery, heart transplantation is needed

Question 8

Polycystic ovarian syndrome (PCOS) features

Answer 8

Features
* Subfertility and infertility
* Menstrual disturbances: oligomenorrhea and amenorrhoea
* Hirsuitism, acne (due to hyperandrogenism)
* Obesity
* Acanthosis nigricans (due to insulin resistance)

Question 9

PCOS INVEST

Answer 9

Investigations
* Pelvic ultrasound
* FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a
‘classical’ feature but is no longer thought to be useful is diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
* Check for impaired glucose tolerance
Management:

Question 10

PCOS weight

Answer 10

Management:
General
* Weight reduction if appropriate
* If a women requires contraception then a combined oral contraceptive (COC) pill may help
regulate her cycle and induce a monthly bleed (see below)
Hirsuitism

Question 11

PCOS hirtuismm

Answer 11

• A COC pill may be used help manage hirsuitism. Possible options include a third generation
  COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action.
  Both of these types of COC may carry an ↑ risk of venous thromboembolism
• If doesn’t respond to COC then topical eflornithine may be tried
• Spironolactone, flutamide and finasteride may be used under specialist supervision

Question 12

PCOS infertility

Answer 12

nfertility
* Weight reduction if appropriate
* The management of infertility in patients with PCOS should be supervised by a specialist.
There is an ongoing debate as to whether metformin, clomifene or a combination should be
used to stimulate ovulation
* A 2007 trial published in the New England Journal of Medicine suggested clomifene was the
most effective treatment. There is a potential risk of multiple pregnancies with anti-estrogen*
therapies such as clomifene
* Metformin is also used, either combined with clomifene or alone, particularly in patients who
are obese
* Gonadotrophins

Question 13

Pelvic inflammatory disease (PID) cause

Answer 13

Causative organisms
* Chlamydia trachomatis - the most common cause
* Neisseria gonorrhoeae
* Mycoplasma genitalium
* Mycoplasma hominis

Question 14

Pelvic inflammatory disease (PID) fears

Answer 14

Features
* Lower abdominal pain
* Fever
* Deep dyspareunia
* Dysuria and menstrual irregularities may occur
* Vaginal or cervical discharge
* Cervical excitation Investigation
* Screen for Chlamydia and Gonorrhoea

Question 15

PID

Answer 15

Management
* Due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
* Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
* RCOG guidelines suggest intrauterine contraceptive devices may be kept in in mild cases
Complications
* Infertility - the risk may be as high as 10-20% after a single episode
* Chronic pelvic pain
* Ectopic pregnancy

Question 16

family history that suggests increased risk of breast cancer and indicates referral to a specialist breast clinic.

Answer 16

Mother or sister diagnosed with breast cancer before the age of 40 years
* Close relatives from the same side of the family diagnosed with breast cancer at least one must
be a mother, sister or daughter
* 3 close relatives diagnosed with breast cancer at any age

Question 17

NICE issued guidelines in 2004 that set out the criteria for a family history that suggests increased risk of breast cancer

Answer 17

• Mother or sister diagnosed with breast cancer before the age of 40 years
• Close relatives from the same side of the family diagnosed with breast cancer at least one must
  be a mother, sister or daughter
• 3 close relatives diagnosed with breast cancer at any age
  The Only MRCP Notes You’ll Ever Need
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• Father or brother diagnosed with breast cancer at any age
• Mother or sister with breast cancer in both breasts (the first cancer diagnosed before the age of
  50 years)
• 1 close relative with ovarian cancer and one with breast cancer, diagnosed at any age at least
  one must be a mother, sister or daughter.

Question 18

Ovarian cancer RF

Answer 18

Risk factors
* Family history: mutations of the BRCA1 or the BRCA2 gene
* Many ovulations: early menarche, late menopause, nulliparity
It is traditionally taught that infertility treatment ↑ the risk of ovarian cancer, as it ↑ the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill ↓ the risk (fewer ovulations) as does having many pregnancies.
Clinical features are notoriously vague
* Abdominal bloating
* Pelvic pain
* Urinary symptoms e.g. Urgency
* early satiety, bloating

Question 19

Cervical Cancer:
Risk Factors:

Answer 19

Cervical Cancer:
Risk Factors: (Christiana is a poor lady who smoked cigarettes and became prostitute at a young age)
* Christians (male non-circumcision)
* Low socioeconomic status
* Smoking
* Multiple partners
* Commencement of sexual intercourse and/or pregnancy at young age
* Human papillomavirus (HPV), of course the 1st risk factor

Question 20

Cervial cancer - Screening:

Answer 20

• Women are sent their first invitation for routine screening at 25 years age.
• Then invited for screening every three years until the age of 49 years.
• From 50 to 64 years they are invited for screening every five years.
• Women who have had treatment for abnormal cells on the cervix may need to have a screening
  test more often.
• After 65 years no need to have cervical screening unless they have had recent cervical changes,
  or for some reason they have not had a screening test since the age of 50 years.

Question 21

If the result shows mild cell changes or CIN1

Answer 21

repeat smear in 6 months. Sometimes these slightly abnormal cells can go back to normal by themselves.

Question 22

If the next smear is abnormal,

Answer 22

then referral is made for colposcopy.