Revise Notes Obg Flashcards

Question

1) Cervical cancer screening Offered to all women aged 24.5-64 25-49 screened every 3 years 50-64 every 5 years Screened through cervical smear Smear sent for HPV test

Answer 1

If positive -> cytological examination and cytology-> if abnormal-> colposcopy Treat if cancer or rescreen at 1/3/5 years / repeat colposcopy depending on results Poorest uptake in highest risk patients (low socio-economic background and high sexual activity)

Answer 2

Screening involves mammography MRI can be used for young women at high risk due to family history Separate high risk surveillance screening for those with known BRCA/TP53 mutations or strong family history Breast cancer incidence has increased since screening due to high levels of detection of ductal carcinoma in-situ (DCIS)- treated as cancer but may not ever invade surrounding tissue Screening Outcomes If a breast cancer screening test is abnormal, the patient will undergo triple assessment of the breast If triple assessment is normal, the patient will return to the normal screening programme If cancer is detected (including DCIS) it will be treated There is a 10% false negative rate

Answer 3

Colonoscopy: Clear- return to screening Cancer- treat Polyp- removed and analysed and risk stratified: Low risk- continue FOBT screening Medium risk- Colonoscopy every 3 years High risk- Colonoscopy in 12 months then 3 yearly 0.1% samples= cancer- majority confined to bowel 0.5%= polyps

Answer 4

High risk groups: First degree relative bowel cancer < 50 Familial adenomatous polyposis (FAP) Hereditary non-polyposis colorectal cancer (HNPCC) Inflammatory bowel disease (IBD) Acromegaly

Answer 5

. Diagnosis Threshold: An aortic diameter ≥3 cm confirms an AAA. Monitoring: Small AAA (3.0–4.4 cm): Annual ultrasound surveillance. Medium AAA (4.5–5.4 cm): Surveillance every 3 months. Large AAA (≥5.5 cm): Consideration for elective surgery due to increased rupture risk. Elective Surgical Management: Surgery is recommended for large AAAs (≥5.5 cm) or if the aneurysm grows ≥1 cm per year. Options include open surgical repair or endovascular aneurysm repair (EVAR), with choice depending on patient suitability and risk assessment.

Answer 6

Renal: Adult polycystic kidney disease: Regular US kidneys for relatives of patients Diabetes (known diabetics): Diabetic foot disease: annual screening Diabetic retinopathy: annual screening Genetic screening examples: Cystic fibrosis: CFTR gene mutation Haemochromatosis: HFE gene mutations

Answer 7

Screening Programmes Cancer Screening Programme Target Population Screening Test Frequency Purpose Breast Cancer Screening Women aged 43-73 Mammography Every 3 years Early detection of breast cancer including DCIS Cervical Cancer Screening Women aged 25-64 Cervical smear Every 3-5 years Detection of abnormal cervical cells Bowel Cancer Screening Men and women aged 60-74 Faecal occult blood test (FOBT) Every 2 years Detection of blood in stool Summary of UK National Cancer Screening Programme Sensitivity and Specificity Cancer Screening Programme Sensitivity Specificity Breast Cancer Screening Approx. 80% Approx. 90% Cervical Cancer Screening Approx. 80-90% Approx. 90-95% Bowel Cancer Screening Approx. 60-70% Approx. 90%

Answer 8

Risk Factors Risk factors for TTN include: Caesarean section Prematurity (especially late preterm, 34-37 weeks) Rapid labor and delivery Investigations Chest X-ray - hyperinflation, fluid in the fissures, and occasional pleural effusions. Management TTN is usually self-limiting. Management focuses on supportive care: Oxygen therapy to maintain adequate oxygen saturation Nasal CPAP (Continuous Positive Airway Pressure) in severe cases TTN typically resolves within 72 hours, with most infants recovering fully without long-term complications.

Answer 9

Risk Factors Maternal diabetes Foetal macrosomia Maternal obesity Prolonged second stage of labor History of shoulder dystocia Instrumental delivery (use of forceps or vacuum) Clinical features Difficulty in delivering the foetal shoulders after the head has been delivered . "Turtle sign": the foetal head retracts against the perineum after it has emerged. Management Manoeuvres including McRoberts Manoeuvre Hyperflex the mother’s legs tightly to her abdomen to flatten the sacrum and rotate the symphysis pubis. RCOG: “McRobert’s is a simple, rapid and effective intervention and should be performed first” Other manoeuvres include : Rubin’s Manoeuver: Apply pressure on the accessible shoulder to push it towards the chest. Wood's Screw Maneuver: Rotate the posterior shoulder to release the impacted anterior shoulder. Delivery of Posterior Arm: Insert a hand into the vagina, locate the posterior arm, and gently pull it out. Gaskin Manoeuver: Position the mother on all fours to widen the pelvis. Suprapubic pressure should be applied Episiotomy can be required Prevention: Optimal management of gestational diabetes Consider elective cesarean delivery in cases of suspected foetal macrosomia or prior shoulder dystocia

Answer 10

Complications For the baby: Brachial plexus injury Fractures (clavicle, humerus) Hypoxia, or death. For the mother: Postpartum haemorrhage Perineal tears Uterine rupture.

Answer 11

Diagnosis Diagnosis involves clinical suspicion based on history of significant postpartum haemorrhage and symptoms. Hormonal assays confirm pituitary hormone deficiencies. Management Hormone replacement therapy (e.g., corticosteroids, levothyroxine, oestrogen/progesterone replacement) tailored to specific deficiencies. Regular monitoring and adjustment of replacement therapy optimise patient outcomes.

Answer 12

Clinical Features Commonly presents in 2nd trimester - most common in weeks 12-22. Sharp, stabbing pain, exacerbated by movements such as standing up/coughing etc. Most commonly felt in groin/lower abdomen (more common in right groin) or bilaterally. Management Conservative - rest, avoidance of sudden movements, simple analgesia, maternity support belts, stretching.

Answer 13

Often triggered by pregnancy due to increased laxity of ligaments Clinical features: Pain over the pubic symphysis which radiates into the groins, a ‘waddling’ gait

Answer 14

Management Treatment depends on gestational age, infection status, and foetal condition: Antibiotic Therapy: Administered to prolong pregnancy and prevent infection. Prophylactic erythromycin 250mg QDS to prevent infective chorioamnionitis Corticosteroids: To enhance foetal lung maturity if the gestational age is 24-34 weeks. Two x 12-mg doses of IM betamethasone 24 hours apart or.. Four x 6-mg doses of IM dexamethasone every 12 hours Expectant management vs Delivery: Expectant Management: In the absence of infection and with stable conditions, close monitoring in a hospital setting. Delivery: Indicated if there are signs of infection, foetal distress, or if the pregnancy reaches 34-37 weeks depending on the clinical scenario. Complications Chorioamnionitis Neonatal sepsis Umbilical cord prolapse Preterm birth with associated neonatal morbidity and mortality.

Answer 15

Management The usual A-E management, resuscitation with packed red cells, FFP etc. Mechanical management - ‘massaging’ the uterus (to stimulate contraction and increase tone) Medical management: IV oxytocin - strengthens/improves uterine contractions/tone IV ergometrine - stimulates uterine and vascular smooth muscle contraction CI: HTN IM carboprost - PG analogue - stimulates contraction of uterus, improving tone Caution: Asthma Sublingual misoprostol - PG analogue Tranexamic acid Surgical - IU balloon tamponade, hysterectomy

Answer 16

Placenta Accreta Can be a cause of significant PPH Pathology: Implantation of the placenta beyond the endometrium, and into the myometrium resulting in great difficulty separating the placenta during delivery --> PPH RFs: history of c-section, increasing maternal age Diagnosis: TVUS during antenatal care Management: Planned c-section with antenatal steroids, with subsequent uterus preserving surgery or hysterectomy (safest)

Answer 17

Investigations US to r/o retained products, swabs Management Antibiotics for endometritis or surgical removal of retained products

Answer 18

Examination findings Bimanual exam - adnexal tenderness, cervical excitation/motion tenderness SIRS, pyrexia Investigations Clinical assessment Pregnancy test Test for causative organisms - CT/NG/MG (Nb. negative tests do not exclude PID) Bloods - elevated inflammatory markers The absence of endocervical/vaginal pus cells has a negative predictive value of 95% (but poor PPV), so is useful to r/o PID

Answer 19

Management BASHH recommend a low threshold for empiric treatment due to (i) lack of definitive diagnostic criteria and (ii) risk of long-term sequelae with delayed treatment (ectopic/infertility). Outpatient antibiotic regimens IM ceftriaxone 1g stat + PO doxycycline 100mg BD + PO metronidazole 400mg BD for 14 days PO ofloxacin + metronidazole for 14 days PO moxifloxacin for 14 days Inpatient antibiotic regimens IV ceftriaxone + IV doxycycline (followed by PO metronidazole + doxycycline) IV clindamycin + IV gentamicin (followed by PO clindamycin + metronidazole)

Answer 20

Clinical features Sudden onset pelvic pain Unilateral, affecting the LIF/RIF. Sudden onset, severe pain which worsens progressively as ischaemic time increases May be intermittent pain if the ovary intermittently untwists and retwists Nausea and vomiting Examination findings: There may be a palpable adnexal mass in the affected iliac fossa. Abdominal tenderness with guarding in the LIF/RIF. Investigations Urgent transvaginal ultrasound (TVUS) is the primary imaging modality. The "whirlpool sign" indicates the twisting of the vascular ovarian pedicle, which is highly suggestive of torsion.

Answer 21

Management Surgical intervention Emergency surgery is required to detorse the ovary and restore blood flow. Laparoscopy is typically the preferred approach Oophorectomy may be necessary if the ovary is non-viable due to necrosis or if there is an associated mass or tumour Prompt recognition and surgical management of ovarian torsion are crucial to preserve ovarian function and prevent complications such as necrosis and subsequent infertility.

Answer 22

Assessment/Investigations If ascites/mass present - refer via a 2 week wait (suspected cancer pathway) If examination is NAD - carry out assessment in primary care - 1st step: measure CA125 level If CA125 is high (>35) - arrange urgent US abdomen/pelvis If US suggests ovarian cancer, refer urgently to gynaecology for further investigation. Management: Surgery is mainstay References and Further Reading

Answer 23

Complications of obesity in pregnancy : To mother: Pre-eclampsia Gestational diabetes VTE/PE Postpartum haemorrhage Requirement for induction of labour / C-section Mental health issues- anxiety/depression To fetus: Congenital anomalies Fetal macrosomia Stillbirth/neonatal death More difficult to initiate and maintain breastfeeding

Answer 24

Management 💕Ante-natal: Encourage to optimise weight before pregnancy Screen for gestational diabetes If BMI > 30: 5mg folic acid at least 1 month before conception and continue during first trimester If BMI > 35: Consider aspirin 150mg OD from 12 weeks gestation until birth to reduce risk of pre-eclampsia No weight loss drugs are recommended during pregnancy 💕Intra-partum management: VTE prophylaxis Early anesthetic review 💕Post-partum: Weight management Breastfeeding support MDT planning for future pregnancies

Answer 25

❤️Expectant management (as above) is 1st line for incomplete/missed miscarriage, UNLESS any of the following risk factors are present (in which case, medical/surgical mx should be considered): 💕High risk of haemorrhage - e.g. late first trimester, coagulopathy 💕Previous adverse outcome - miscarriage, stillbirth, antepartum haemorrhage 💕Evidence of infection If bleeding and pain settle, this suggests a completed miscarriage, and the woman should repeat the urine pregnancy test up to 3 weeks. ❤️Medical Management Indication: Symptoms > 14 days OR not appropriate for expectant management (RFs above) 1st line - vaginal/PO misoprostol (stimulates uterine expulsion) ❤️Surgical Management Indication: Ongoing symptoms, or retained products of conception despite PO/vaginal misoprostol Options include: 💕Manual vacuum under local anaesthetic 💕Surgical management under general anaesthetic (GA) 💕Nb. Anti-D Ig must be offered to all Rh -ve women who have surgical management of miscarriage.

Answer 26

Threatened miscarriage - symptoms (bleeding), but closed cervical os with viable pregnancy, foetal heartbeat present etc. Management: Vaginal progesterone (400mg BD) - continue until 16 completed weeks of pregnancy - may reduce risk of miscarriage If bleeding worsens, lasts > 14 days - repeat assessment.

Answer 27

If > 6 weeks - refer to EPAU TVUS to confirm location/viability of pregnancy, and rule out ectopic pregnancy (laparoscopy if suspected) If the pregnancy remains viable, treat as a threatened miscarriage The pregnancy can then be managed with either: Expectant management Medical management Surgical management

Answer 28

Expectant management - allow natural course of miscarriage, and repeat urine pregnancy test in 7-10 days If negative - confirms miscarriage If positive / ongoing bleeding or worsening symptoms - refer to EPAU

Answer 29

Clinical features History of pregnancy OR amenorrhoea/breast tenderness etc. PV Bleeding Lower abdominal pain - often cramping, may radiate into back Investigations Investigation of choice - transvaginal ultrasound Features include absence of foetal heartbeat, or abnormal development (e.g. absent foetal pole)

Answer 30

Investigations Initial investigations Bloods - FBC (?IDA), coagulation screen (?VWD), TFTs HVS/Cervical swab if symptoms of infection Further investigations If symptoms/signs suggest probable underlying pelvic pathology arrange further investigations: Suspected fibroids (palpable uterus/pelvic mass) - pelvic ultrasound Suspected endometrial pathology/submucosal fibroids - hysteroscopy Suspected adenomyosis (dysmenorrhoea, bulky tender uterus) - TVUS

Answer 31

Management For the following patients Menorrhagia with no identified pathology (previous termed dysfunctional uterine bleeding) Fibroids < 3cm Adenomysosis 1st line: Levonorgestrel intrauterine system (LNG-IUS) Prevents endometrial proliferation 2nd line: If LNG-IUS unsuitable or declined - consider pharmacological treatment: Non-hormonal - either TXA or NSAID (mefenamic acid) Hormonal - COCP/cyclical progestogen For patients with fibroids >3cm Refer to gynaecology - consideration of surgical mx (e.g. myomectomy), uterine artery embolisation, as well as above treatment options.

Answer 32

Examination findings An enlarged, firm, irregular uterus (not tender on palpation) An irregular abdominal mass Management Menorrhagia - As per above notes (>3cm - gynae, < 3cm - LNG-IUS) Subfertility/pressure symptoms - refer to gynae Complications: Red degeneration of Fibroids Definition: Ischaemia and subsequent necrosis of a fibroid, which commonly occurs during the second or third trimester of pregnancy, due to disruption of the fibroids blood supply Clinical features: Severe, acute abdominal pain, N&V, low fever - in a pregnant woman with a history of fibroids.

Answer 33

Clinical Features A change in menstrual cycle in the perimenopause - e.g. lengthening or shortening of the cycle length Vasomotor symptoms Hot flushes Night sweats Mood disorders Mood swings, anxiety, irritability or low mood Genitourinary syndrome of menopause: Oestrogen deficiency in post-menopausal women causes atrophy of the vaginal lining. Clinical features: vaginal irritation and soreness, commonly worsened by sex Post-coital bleeding - trauma to fragile vaginal skin. Vaginal dryness, itching or discomfort Associated dyspareunia On examination: smooth, pale, dry vaginal walls with contact bleeding. Reduced libido

Answer 34

Hormonal 1st Line: Low dose vaginal oestrogen (can also be added to systemic HRT if severe symptom) 2nd line: Trial oral ospemifene (SERM) if mod-severe symptoms. Non-hormonal Vaginal moisturisers

Answer 35

Vasomotor symptoms SSRI or SNRI - fluoxetine, citalopram, paroxetine, venlafaxine Clonidine (alpha-2 R agonist - also used in rosacea) Gabapentin CBT Mood disorders Antidepressant treatment

Answer 36

Contraception Inform women that they may remain fertile for up to 2 years after their last menstrual cycle if < 50 years of age (or 1 year if > 50 years of age) and so should continue to use contraception during this… period. Progestogen only contraception can be used alongside cyclical HRT Combined hormonal contraception (e.g.COCP) can be used as an alternative to HRT in women who are < 50 years of age, for the relief of menopausal symptoms (but should switch to progestogen-only contraception once > 50yrs)

Answer 37

For COMBINED HRT - Timing of LMP Perimenopausal - periods ongoing or stopped < 1 year ago - Sequential (cyclical) combined HRT Oestrogen is taken every day, and the progesterone is taken for aprox. half of the month Results in a monthly withdrawal bleed Post-menopausal - LMP was > 1 year ago - Continuous combined HRT Continuous = oestrogen and progesterone are taken together every day Continuous is preferred - advantage is NO withdrawal bleeding

Answer 38

Routes Systemic oestrogen can be taken orally or transdermally (patch, gel, spray) Importanlty, transdermal oestrogen is NOT associated with increased risk of VTE (PO oestrogen only!) Contraindications to HRT (1) Breast/Endometrial Cancer (2) Clots (3) Liver disease (4) Pregnancy History of breast cancer or endometrial cancer By the same logic - undiagnosed breast lump/ PV bleeding/untreated endometrial hyperplasia History of VTE (PE/DVT), thromboembolic disease (angina/MI) or thrombophilic disorder Active liver disease Pregnancy

Answer 39

Non-hormonal alternatives Vasomotor symptoms SSRI or SNRI - fluoxetine, citalopram, paroxetine, venlafaxine Clonidine (alpha-2 R agonist - also used in rosacea) Gabapentin CBT Mood disorders Antidepressant treatment

Answer 40

Management Surgical Resection of the ovarian fibroma leads to resolution of ascites and pleural effusion.

Answer 41

Management Send urine MCS 1st line: Nitrofurantoin (avoid at term) 100mg BD for 7 days (if eGFR > 45) 2nd line: Amoxicillin 500mg TDS 7 days, cefalexin 500mg BD 7 days Trimethoprim is contraindicated (folate antagonist) Note - A repeat urine culture should be performed after completion of antibiotic treatment in pregnancy, as a test of cure.

Answer 42

Causes of infertility Disorders of ovulation The most common cause of infertility in women Causes include: ❤️Hypogonadotropic hypogonadism - usually present with primary or secondary amenorrhoea Stress/exercise/eating disorder induced hypothalamic amenorrhoea Kallman syndrome (clue: anosmia) ❤️Hypothalamic-pituitary-ovarian axis disorders - often present with oligo-/amenorrhea PCOS Hyperprolactinaemic amenorrhea (prolactinoma, drug-induced etc.) ❤️Ovarian failure Suggested by high levels of gonadotrophins (LH/FSH) and low levels of oestrogen ❤️Other: Endocrine (thyroid dysfunction, Cushing’s syndrome, CAH), chronic disease

Answer 43

Investigations Investigations should begin after 1 year of failure to conceive for couples who are having regular UPSI every 2-3 days. Consider earlier investigation if: Woman is age > 36 years - begin investigations after 6 months of trying History of oligo-/amenorrhoea History of PID/STI/medical history that might affect fertility in male/female

Answer 44

Investigations - Female patient ❤️Mid-luteal phase progesterone - Send for all women! Confirms ovulation Should be taken 7 days before the expected period For a 35 day cycle - measure on day 28 For a 28 day cycle - measure on day 21 ❤️Consider the following Gonadotropins (FSH/LH - usually on D2-D4 of cycle) Low in hypogonadotrophic hypogonadmis (hypothalamic amenorrhoea - XS exercise/weight loss/ED) High in ovarian failure Prolactin, TFTs STI screen ❤️Investigations in secondary care may include: Tubal patency test If no history of comorbidities which may affect tubal patency (PID/endometriosis) - HYSTEROSALPINGOGRAPHY If there is a history - diagnostic laparoscopy and dye - assess tubes and pelvis simultaneously

Answer 45

Initial investigations - Male patient Semen analysis Consider STI screen Management options.. Medical - clomifene, gonadotrophins Surgical management - e.g. if tubal abnormalities/endometriosis Assisted conception - IUI/IVF/ICSI etc.

Answer 46

Placental Abruption Pathophysiology The separation of part, or all of the placenta from the wall of the uterus during pregnancy with resultant antepartum haemorrhage. Bleeding can be: Revealed - Blood tracks down genital tract - visible APH Concealed - Cervical os remains closed, bleeding remains in uterine cavity- presenting with abdominal pain and shock Risk factors History of P. abruption, pre-eclampsia, multiple pregnancy, increasing age, smoking

Answer 47

Investigations Diagnosis is clinical, though US can be used to diagnose placenta praevia CTG monitoring should be performed Management Maternal resuscitation and blood transfusion is required Foetal management: If there is foetal distress, urgent c-section should be considered If no foetal distress and > 37 weeks gestation - induction of labour < 37 weeks gestation - admit, give steroids if required for foetal lung maturation

Answer 48

Management Monitoring: If PP or LLP is identified at the routine foetal anomaly scan (20 weeks), a follow up TVUS is recommended at 32 weeks to diagnose persistent LLP /PP. If there is evidence of persistent LLP or PP, an additional TVUS should be performed at 36 weeks as this will inform the most appropriate mode of delivery Corticosteroids are given to aid fetal lung maturation, due to the increased risk of prematurity Patients with PP require planned c-section at 36-37 weeks to reduce the risk of severe bleeding.

Answer 49

Management Planned, c-section at 34-36 weeks (to avoid spontaneous rupture of membranes) Corticosteroids for foetal lung maturation

Answer 50

Investigations Hysteroscopy - the gold standard Management Surgical dissection of adhesions during hysteroscopy, often combined with placement of intrauterine devices or barriers to prevent adhesion reformation.

Answer 51

Risk factors Postmenopausal women due to oestrogen deficiency Premenopausal women during breastfeeding Patients undergoing chemotherapy or hormonal therapy History Vaginal dryness, itching, burning Dyspareunia (painful intercourse) Occasional spotting Urinary symptoms such as frequency or urgency Examination Findings Vaginal mucosa appears pale, dry, and atrophic May have petechiae or ulceration Investigations Clinical diagnosis Vaginal pH may be elevated (>5) Hormonal assays may be indicated in certain cases to evaluate oestrogen levels. Management 1st line- Vaginal moisturizers, and lubricants 2nd line- Topical oestrogen therapy (cream, ring, or tablet) Complications Recurrent urinary tract infections Vaginal or urethral prolapse Sexual dysfunction

Answer 52

Clinical Features Asymptomatic swelling - Small cysts may be asymptomatic and discovered incidentally . Classically a unilateral swelling at 4 / 8 o’clock, on the inferior labia majora, which protrudes medially Pain - Larger cysts can cause significant pain, especially during walking, sitting, or sexual intercourse. Dyspareunia: Painful intercourse due to the cyst's location near the vaginal opening. Bartholin's abscess - present with erythema, marked tenderness and sometimes fever.

Answer 53

Management Conservative management may be considered if asymptomatic. Medical Management: Antibiotics - if evidence of infected cysts / abscesses. Surgical Management: Incision and Drainage: For symptomatic or infected cysts/abscesses. Word Catheter: Inserted after drainage to allow continued drainage and prevent recurrence. Marsupialisation: Creation of a permanent opening to prevent future cyst formation, typically reserved for recurrent cases.

Answer 54

Cephalohaematoma Pathophysiology: Caused by rupture of blood vessels crossing the periosteum due to trauma during delivery, leading to blood accumulation. Clinical Features: Collection of blood between the periosteum and skull bone Does NOT cross suture lines Typically appears hours to days after birth Firm, well-defined edges Takes weeks to months to resolve Key Points Caput succedaneum is soft and crosses sutures, while cephalohaematoma is firm and does not cross sutures. Caput resolves quickly, whereas cephalohaematoma takes longer and may lead to complications like jaundice or infection.

Answer 55

Other, rare types of breast cancer include Paget’s disease of the nipple Erythematous, dry, scaly ulceration of the skin around the nipple. Sore, itchy. Significance: Paget’s is usually associated with an underlying breast malignancy (in situ or invasive). Inflammatory breast cancer Rare and aggressive breast malignancy which results from lymphatic obstruction by malignant cells. The breast becomes painful, erythematous and oedematous.

Answer 56

Clinical Features Breast lump A painless breast lump is the most common presenting complaint On examination, malignant lumps may feel hard or ‘gritty’, with irregular margins. Due to their invasive nature they may also be fixed to the chest wall or tethered to surrounding tissue. Axillary lymphadenopathy Nipple changes Paget’s disease - erythematous, ulcerated skin around nipple Change in shape, colour Irritation or bleeding Discharge and retraction Skin changes Dimpling, puckering of skin Peau d’orange

Answer 57

Management Patients may be managed with a combination of chemotherapy (neoadjuvant or adjuvant), radiotherapy, and surgery (wide local excision, mastectomy) with sentinel node sampling to identify lymph node involvement. Pharmacological treatments include Anti-oestrogen therapy - to reduce oestrogen dependent tumour growth Tamoxifen - ER blocker - used in premenopausal women with ER+ BC SEs: Flushes, VTE risk, menstrual cycle disturbance Typically continued for up to 5 years post-excision Aromatase inhibitors (anastrozole, letrozole etc) - used in postmenopausal women with ER+ BC (blocks the conversion of androgens into oestrogen). Biological treatments Herceptin (trastuzumab) - monoclonal antibody used in HER2+ BC.

Answer 58

The NHS Breast Screening Program Women aged 50-70 years 3-yearly routine breast screening which uses mammography to detect breast cancer Differential diagnosis 💕Breast cyst Smooth, fluid-filled lump, may be painful Size varies throughout menstrual cycle 💕Fibroadenoma Common in young patients (20-30) Discrete, rubbery, firm and non tender Highly mobile, so sometimes referred to as “breast mouse” ❤️Fat necrosis A fibrotic lump which occurs following trauma to the breast More common in obese women 💕Breast abscess A painful, inflamed lump with systemic upset such as fever, malaise, SIRS Commonly occurs during breastfeeding Examination - erythematous, warm and tender to touch 💕Cyclical breast pain Hormone related breast pain - presents with pain which starts within 2 weeks of menstruation, gradually increases and then improves once period begins Pain is usually bilateral Management - simple analgesia (paracetamol +/- ibuprofen)

Answer 59

Management Management depends on factors including gestational age, type of breech, and maternal preference. Breech at < 36 weeks gestation: Often resolves spontaneously due to the space available in the uterus. Therefore, no intervention is typically recommended at this stage. Breech at > 36 weeks in nulliparous women or > 37 weeks in multiparous women: External cephalic version (ECV) is offered to attempt to turn the foetus to a cephalic (head-first) position. ECV involves applying gentle pressure on the pregnant abdomen to manually rotate the foetus. The success rate is approximately 60%. Failed ECV: If ECV is unsuccessful, a decision needs to be made between attempting a vaginal delivery (which is generally safer for the mother) or opting for a planned caesarean section (which is generally safer for the baby in breech presentations). Anti-D prophylaxis: If the mother is rhesus-negative and undergoes ECV, it is considered an indication for anti-D prophylaxis to prevent rhesus isoimmunisation, where maternal antibodies attack foetal red blood cells. This is a standard practice to prevent sensitisation in subsequent pregnancies. Complications Complications of breech delivery include foetal head entrapment, umbilical cord prolapse, birth trauma (such as brachial plexus injury), and perinatal asphyxia

Answer 60

Screening program Inclusion: Women aged 25-64 years Cervical smear every 3 years from ages 25-49 Cervical smear every 5 years from ages 50-64 Unscheduled cervical screening: Not recommended if the previous smear test is up to date. Women with new symptoms should be referred to gynaecology. If a cervical smear is postponed due to pregnancy it should be performed 12 weeks after delivery. Referral Refer any women with clinical features suggestive of cervical cancer (as above) using a 2 week wait referral via a suspected cancer pathway, for urgent colposcopy/specialist assessment, regardless of previous screening results.

Answer 61

Congenital rubella syndrome Sensorineural hearing loss Cataracts, chorioretinitis (with “salt and pepper” retinal appearance) Congenital heart disease - Patent ductus arteriosus CNS - microcephaly Hepatosplenomegaly Blue muffin rash Assessment and Management Contact health protection team immediately, notifiable disease IgG -ve women should keep take precautions to avoid exposure, offer vaccine post-natal IgM +ve confirms recent exposure If rubella confirmed, refer to O&G If 8-10 weeks gestation, 90% risk of CRS, and no effective treatments If > 20 weeks - reassure

Answer 62

Care for pregnant women who develop chickenpox: 1st Line: Prescribe oral aciclovir if presenting within 24 hours of rash onset if 20+0 weeks of gestation or beyond (should also be "considered" if < 20 weeks gestation) Aciclovir/valaciclovir can be used in pregnancy, based on evidence and consultation, despite not being licensed for this use, in patients best interest. Severe chickenpox - Intravenous aciclovir recommended for all severe cases. VZIG NOT beneficial once chickenpox rash develops. Referral and follow-up: Refer to a foetal medicine specialist at 16–20 weeks or 5 weeks post-infection for detailed ultrasound. Discuss risks/benefits of amniocentesis for detecting varicella DNA via PCR, with awareness of predictive limitations. Avoid amniocentesis until after skin lesions heal.

Answer 63

Congenital toxoplasmosis Clinical Features Chorioretinitis Hydrocephalus Intracranial calcification

Answer 64

Congenital cytomegalovirus Clinical features Growth restriction Microcephaly and learning disability Sensorineural hearing loss Loss of vision Seizures

Answer 65

Bishop Score The Bishop score can be used to predict whether IOL will be successful. It assesses cervical readiness for labour induction based on cervical dilation, effacement, station, consistency, and position. A score of 6 or less indicates an unfavourable cervix, whereas a score higher than 6 suggests a favourable cervix for induction. Strategies for Induction of Labour 💕Membrane Sweep: Inserting a finger into the cervix to separate the amniotic membranes from the lower uterine segment. Stimulates prostaglandin release, which can initiate labour within 48 hours. 💕Dinoprostone (Prostaglandin E2) Indicated in women with an unfavourable cervix (Bishop Score ≤6). Administered as vaginal gel, tablet, or slow-release pessary to soften the cervix. 💕Amniotomy (Artificial Rupture of Membranes - ARM) followed by IV Oxytocin Infusion Recommended for women with a favourable cervix (Bishop Score >6). 💕ARM involves deliberate breaking of the amniotic sac followed by IV oxytocin infusion to stimulate uterine contractions. ❤️Complications Potential complications include Uterine hyperstimulation Foetal distress Increased risk of instrumental delivery or caesarean section.

Answer 66

Urgency incontinence A sudden sense of the need to pass urine, followed by incontinence Usually idiopathic - part of OAB syndrome, characterised by the presence of urgency, frequency, nocturia (which occur due to involuntary detrusor muscle contractions) Management Step 1: Bladder training (minimum 6 weeks) Step 2: If ongoing symptoms, consider either: Antimuscarinic (oxybutynin, tolterodine, darifenacin) Avoid oxybutynin in older women at risk of deterioration of mental or physical health - high risk adverse effects and cognitive impairment Mirabegron (beta-3 agonist) - if antimuscarinic is contraindicated

Answer 67

Mixed incontinence A combination of stress and urgency incontinence Management: follow above management for the most pressing symptom (i.e. stress vs urgency) Overflow incontinence Urinary retention occurs due to bladder outflow obstruction (BOO) or detrusor muscle dysfunction, which is followed by involuntary ‘overflow’ leakage. Management: Refer to specialist

Answer 68

Levothyroxine Levothyroxine is safe in pregnancy and breastfeeding patients Pregnant patients often require significantly increased doses of levothyroxine Current guidance states that in a woman with known stable hypothyroidism who becomes pregnant, immediately increase the levothyroxine dose (an increase of 30-50% is commonly required) Typically, increase the dose of levothyroxine by least 25–50 micrograms levothyroxine (depending on dose the woman is currently taking). For example, for a woman with stable hypothyroidism on 125 mcg of levothyroxine OD, who becomes newly pregnant, increase the dose to 175 mcg levothyroxine OD To avoid delay, increase the dose before checking TFTs If there is uncertainty about what dose to prescribe, seek specialist advice promptly to avoid delay.

Answer 69

Classification of Hypertension Patients with hypertension should be categorised into: (1) Pre-existing hypertension A previous diagnosis of hypertension OR Hypertension is diagnosed before 20 weeks gestation (2) Pregnancy Induced Hypertension Hypertension diagnosed after 20 weeks gestation Usually resolves following delivery, increased future risk of pre-eclampsia ( 3) Pre-eclampsia Hypertension AND Proteinuria (>0.3g/24hrs) Patients may develop oedema

Answer 70

❤️High risk Prescribe all patients with high risk aspirin 75-150 mg OD from 12 weeks until birth Hypertension in a previous pregnancy Pre-existing diagnosis of hypertension Background of autoimmune disease including SLE & antiphospholipid syndrome Chronic kidney disease (CKD) Diabetes (T1 & T2) ❤️Moderate risk Prescribe patients with 2 of the following RFs aspirin as above. 1st pregnancy Age > 40 Pregnancy interval longer than 10 yrs BMI > 35 FHx of pre-eclampsia Multiple pregnancy

Answer 71

Complications of Pre-eclampsia Foetal: Prematurity, IUGR, Placental abruption Maternal: Heart failure, Haemorrhage – abdominal or cerebral, Multi-organ failure, Eclampsia Severe Pre-eclampsia Pre-eclampsia is diagnosed in the presence of hypertension AND PROTEINURIA (>0.3g/24hrs). Associated with high risk of eclampsia. Pre-eclampsia is classified as severe in the presence of any of the following: Severe hypertension – BP >170/110 (systolic or diastolic) Significant proteinuria – dipstick ++ or +++ Clinical features Headache RUQ or epigastric pain Visual disturbance Hyperreflexia Papilloedema Bloods: Platelets < 100 Deranged LFTs HELLP syndrome

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Eclampsia Eclampsia is defined as seizures developing in the context of pre-eclampsia Management: magnesium sulfate - 4g bolus, followed by 1g/hour infusion HELLP Syndrome A complication defined by: Haemolytic anaemia Elevated Liver enzymes Low Platelets

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Management 1st Line: Promethazine Cyclizine Prochlorperazine Alternatives: Metoclopramide, ondansetron. Additional Measures: Hydration: Oral or IV fluids to correct dehydration and electrolyte imbalances. Nutritional Support: Thiamine/Pabrinex

Answer 74

Hydrops Fetalis Overview Hydrops fetalis is a serious foetal condition characterised by abnormal fluid accumulation in two or more foetal compartments, including ascites, pleural effusion, pericardial effusion, and subcutaneous edema. It is an end-stage manifestation of various underlying conditions, leading to severe foetal anaemia, heart failure, and hypoxia. Hydrops is classified into: Immune hydrops – Due to Rhesus (Rh) incompatibility and other alloimmune hemolytic diseases. Non-immune hydrops (NIHF) – Accounts for >85% of cases, caused by a variety of genetic, hematologic, cardiac, infectious, and metabolic conditions. Key learning: 1. Most hydrops is non-immune (>85%) – Think thalassemia, parvovirus, cardiac causes first. 2. Look for clues – Ethnicity, maternal infection, family history, previous losses. 3. MCA Doppler is key to detecting foetal anaemia early. 4. Intrauterine transfusion is lifesaving in severe foetal anaemia. 5. Rh disease is preventable – Always give anti-D immunoglobulin to Rh-negative mothers.

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Causes 1. Immune Causes (Alloimmune Haemolysis) Rh incompatibility – Most common immune cause. Clue: Rh-negative mother, second pregnancy, no anti-D prophylaxis. Mechanism: Maternal anti-D antibodies attack foetal Rh-positive red blood cells, causing severe foetal anaemia and resultant hydrops. 2. Non-Immune Causes (Most Common) Hematologic Causes Alpha Thalassemia (Hb Barts Hydrops Fetalis) Clue: Southeast Asian descent, recurrent early hydrops, no alloimmunisation. Mechanism: Absence of functional alpha-globin chains causes severe fetal anemia, hypoxia, and heart failure. Cardiac Causes Congenital Heart Disease Clue: Foetal bradycardia/tachycardia, abnormal echocardiogram. Parvovirus B19 Infection Clue: Contact with a child with “slapped cheek” rash. Mechanism: Virus destroys foetal erythroid precursors, leading to aplastic anaemia and hydrops. Other Infectious Causes (TORCH Infections) Cytomegalovirus (CMV), Toxoplasmosis, Syphilis, Herpes, Rubella Clue: Maternal history of flu-like symptoms, hepatosplenomegaly, intracranial calcifications. Chromosomal & Genetic Causes Turner Syndrome (45,X) & Noonan Syndrome Mechanism: Lymphatic dysplasia leads to fluid accumulation.

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Management Positive GBS Culture: For any patient with positive GBS in urine/swabs (or previous babies affected by GBS), IV antibiotics should be administered during labor to reduce vertical transmission risk. Antibiotics should be administered as soon as labour begins or membranes rupture, and continued every 4 hours until delivery. Benzylpenicillin is typically 1st line. Asymptomatic Bacteriuria (>10^5): Pregnant women with GBS bacteriuria (>10^5) should receive antibiotic treatment (usually PO amoxicillin) at the time of diagnosis, as well as IV antibiotics during labour (as above) References

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Investigations Ultrasound: Characteristic features of molar pregnancy, include the "snowstorm" or "bunch of grapes" appearance (numerous small cystic spaces within the uterus). Elevated serum beta-hCG - often significantly higher than normal pregnancy levels. Histopathology: Confirmation of diagnosis through examination of tissue obtained from dilation and curettage (D&C) or biopsy, revealing hydropic villi with trophoblastic hyperplasia. Management Treatments include evacuation of the molar pregnancy, followed by monitoring serum beta-hCG levels until normalisation. Chemotherapy is tailored based on risk for invasive mole or choriocarcinoma. Surgical resection may be necessary for placental site trophoblastic tumour. Regular follow-up with beta-hCG monitoring and imaging detects recurrence/metastasis.

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Management Early diagnosis and referral for developmental support (e.g., speech therapy, special education) Multidisciplinary approach for managing cognitive, behavioural , and physical complications Preventative: Public health measures to educate on the dangers of alcohol consumption during pregnancy

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Venous Thromboembolism Pregnancy is a hypercoagulable state which results in an increased risk of DVT/PE. Pathophysiology: Increased clotting factors 7, 8, 10 + fibrinogen, decreased protein S levels, increased venous stasis due to uterine compression of the IVC. Investigations + Management Do NOT check D-dimer- raised in pregnancy. Investigating suspected DVT 1st Line: compression duplex US of affected leg Investigating suspected PE If patient also has symptoms of a DVT, perform duplex US first If positive, treat and most patients will not require CTPA or V/Q If no symptoms of DVT, but suspected PE consider CTPA or V/Q after discussion with patient. CTPA – increased risk of breast cancer (approx. 10% increase) V/Q – increased risk of childhood cancer

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Management of Hypothyroidism in pregnancy Monitoring: Check TSH levels every trimester and at 6-8 weeks post-partum Management: During pregnancy, patients can require a significant increase in levothyroxine dose - typically 50%

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Management: No treatments have been shown to reduce adverse perinatal outcomes or bile acid levels. Ursodeoxycholic acid should not be routinely offered for preventing adverse outcomes. Treatment for maternal itching is limited in efficacy - emolients, chlorphenamine may help References: RCOG. Intrahepatic cholestasis of pregnancy (Green-top Guideline No. 43). August 2022. Available at URL: https://obgyn.onlinelibrary.wi...

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Clinical Features: Abdominal pain Nausea & vomiting Jaundice Ascites (note HELLP syndrome is more likely if there is thrombocytopenia) Bloods: Hepatitis - ALT often > 500 Management: Delivery

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Rashes in Pregnancy Polymorphic Eruption of Pregnancy Clinical features An intensely itchy rash which usually begins in the third trimester The rash usually begins on the abdomen (particularly within the abdominal striae) as small, pink papules, often with surrounding pallor. Later the papules coalesce to form urticarial/erythematous plaques Later may spread across the trunk and proximal limbs Resolves following delivery Management Symptomatic relief with antihistamines, topical corticosteroids (or oral if very severe)

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Clinical features Timing: 2nd or 3rd trimesters Intensely itchy, urticarial rash which begins as red bumps, classically around the umbilicus. The rash later spreads acoss the abdomen, and may spread across the trunk, buttocks and limbs. After a few weeks, the lesions develop into tense, fluid-filled blisters Management Topical corticosteroids in mild disease, systemic if severe disease

Answer 85

NICE advises to offer whichever method of contraception is preferred by the woman, unless CId. Adverse Effects Levonorgestrel IUS 1/20 risk of expulsion Hormonal side effects - acne, breast tenderness, mood changes Pelvic pain, cramping Irregular periods/Amenorrhoea - periods become irregular, or stop altogether Copper IUD Expulsion 1/20 Pelvic pain, cramping Bleeding - Menorrhagia, intermenstrual bleeding and dysmenorrhoea Progestogen-only implant (e.g. Nexplanon subdermal implant) Unscheduled bleeding, irregular, heavy Reduced efficacy with enzyme inducers

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Intrauterine device - contraindications Both the Cu-IUD and LNG-IUS are contraindicated in the following: Unexplained vaginal bleeding Current pelvic inflammatory disease or STI (chlamydia/ gonorrhoea) Postpartum sepsis Unexplained PV bleeding UKMEC 4 - Cu-IUD, LNG-IUS UKMEC 3 - progestogen only implant, progestogen-only injectable

Answer 87

Liver enzyme inducers and drug interactions Inducers Inducers can interact with, and reduce the efficacy of hormonal contraception Offer LARCs which are unaffected (CU-IUD, LNG-IUS, Depo injection) Inducers include (PCBRAS) Phenytoin Carbamazepine Barbiturates Rifampicin Alcohol (chronic xs) and Antiretrovirals (-avirs and NNRTIs) Sulphonylureas, St John’s Wort Drug interactions Note - Lamotrigine is NOT an inducer BUT may interact with POP/CHC - avoid CHC (reduces lamotrigine efficacy - inc. seizure risk), POP inc. lamotrigine levels increasing adverse effects etc.

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A missed pill is defined as any pill > 3 hours late (if missed by < 3hrs, take as normal) Exceptions - desogestrel POP = 12 hours, Drospirenone POP = 24 hours Advice: Take missed pill now Use additional precautions for the next 48 hours Emergency contraception is needed if they have had sex since missing the pill OR within 48 hours of restarting the regular pills Nb. Irregular periods are the most common side effect of POP

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Vomiting and diarrhoea Vomit within 3 hours - take another pill V&D for > 24hrs Follow missed pill rules (counting each day of V&D as 1 missed pill) Avoid sex or use barrier during illness and 7 days after

Answer 90

Dysmenorrhoea Background Dysmenorrhoea - menstruation related abdominal pain Primary dysmenorrhoea Dysmenorrhoea in the absence of underlying pelvic pathology, usually in young women Suggested by History of dysmenorrhoea beginning approx. 6 months after commencing menarche Cramping lower abdominal pain which starts just before menstruation and lasts for 2-3 days Secondary dysmenorrhoea Dysmenorrhoea secondary to underlying pelvic pathology. Causes include: endometriosis, adenomyosis, pelvic inflammatory disease, fibroids Suggested by: Painful periods - which were previously not painful, or different pain Irregular pain history - often starting 3 or 4 days before menstruation, or continuing after. Other gynaecological symptoms are present - vaginal discharge/bleeding, dyspareunia, menorrhagia

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Step 1 1st Line: NSAID (ibuprofen, naproxen, mefenamic acid) Add paracetamol if required, or prescribe PCM alone if NSAID not tolerated/CI Alternative - If does not want to conceive - trial a hormonal contraceptive for 3-6 months(e.g. COCP) Step 2 Combination of NSAID (or paracetamol) + COCP The management of secondary dysmenorrhoea depends on the cause (see other notes on endometriosis/fibroids/PID)

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Clinical features Secondary dysmenorrhoea Chronic pelvic pain Deep dyspareunia Sub/infertility Bowel symptoms - e.g. pain on defecation Investigations Diagnosis - can only be confirmed by laparoscopic visualisation of the pelvis (findings include blood filled, ‘chocolate cysts’ - endometriomas) Other invx: TVUS, TAUS Management Refer for specialist assessment Endometriosis pain management Consider a trial of paracetamol and/or NSAID Offer hormonal treatment - COCP or POP, implant, mirena, depot Secondary care management includes surgery

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Adenomyosis Pathophysiology Extension of endometrial tissue into the uterine myometrium Clinical features Menorrhagia Irregular periods Dysmenorrhoea Diagnosis MRI imaging - an enlarged uterus, with thickened myometrium

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Investigations Transvaginal ultrasound is the diagnostic investigation of choice for EP. Beta-HCG levels should be obtained to guide management. Management Management options include watchful waiting, medical mx or surgical intervention Expectant management Uncommon, but an option if clinically stable and pain free, and hcg < 1500 Medical management Criteria: No significant pain, unruptured and no h/d compromise Serum hcg is < 1500 and adnexal mass is < 35mm Able to return for follow up 1st line: Methotrexate Nb. Patient must wait 3 months before trying to conceive again due to teratogenic effects

Answer 95

Surgical management Salpingectomy or salpingotomy - laparoscopic approach preferred Indications: Not able to return for follow up Significant pain Adnexal mass > 35mm Foetal heartbeat is present Serum hCG > 5000 Options: If the contralateral tube is healthy - salpingectomy should be performed If there is a history of factors associated with reduced fertility (prev. Ectopic, PID, abdo surgery, tubal damage) - salpingotomy should be considered All rhesus negative women who undergo surgical management require anti-D immunoglobulin If the hcg is 1500-5000, a choice between medical or surgical management can be offered, as long as the mass is < 35mm, and no significant pain/h/d instability.

Answer 96

Endometrial Cancer Background A common, oestrogen-dependent malignancy, which is preceded by endometrial hyperplasia, which subsequently progresses to malignancy. Any post-menopausal bleeding should be considered endometrial ca. until proven otherwise. Clinical features - Red flags & Referrals Post-menopausal bleeding is defined by NICE as unexplained PV bleeding > 12 months after menstrual cessation due to the menopause. Post-menopausal bleeding in women > 55 years- Refer as 2 week wait (via suspected cancer pathway) If < 55 years “consider a 2WW referral as above” Consider a direct access US scan for the assessment of endometrial cancer in any woman who is aged 55 or over with: Unexplained vaginal discharge and. 1st presentation of this OR thrombocytosis OR report haematuria Visible haematuria and.. Anaemic OR thrombocytosis OR hyperglycaemic

Answer 97

Oral ulipristal acetate - 30mg once only (ellaOne) Mechanism of action: Progesterone receptor modulator Suppresses the LH surge responsible for ovulation, therefore inhibiting/delaying ovulation Timing: Within 120 hours/ 5 days UPSI Not suitable if: using liver enzyme-inducing drugs (PCBRASS) Oral levonorgestrel (progestogen) - 1.5mg once only Mechanism of action: Prevents/delays follicular rupture, disrupting luteal function, and inhibiting ovulation Timing: Within 72 hours/ 3 days UPSI Note - can be used up to 96 hrs but efficacy decreases with time, so UA is preferred If on enzyme inducer, offer Cu-IUD as LNG effectiveness can be reduced. If Cu-IUD is not appropriate, a double dose of LNG (3mg) can be considered but women should be informed that the effectiveness of this regimen is unknown. Oral EC and Vomiting Both UA and Levonorgestrel can cause vomiting If a woman vomits within 3 hours of taking UA/levonorgestrel, a repeated dose is required Choosing which method of EC 1st line: Copper-IUD The most effective Offer to all women 2nd line: If criteria for insertion of Cu-IUD are not met, it is contraindicated (e.g. PID/STI etc) or if the woman does not want the Cu-IUD, offer oral EC. If > 72 hours - choose ulipristal acetate (ellaOne) - can be used up to 120 hours If on a liver-inducing drug (PCBRAS) Avoid ulipristal acetate Consider levonorgestrel double dose (if Cu_IUD cannot be offered) References FSRH Guideline: Emergency contraception [March 2017, amended July 2023]. Available at URL: https://www.fsrh.org/Common/Up...