Anti D 20w Every 1ml =

20w 👉 500 IU Every 1ml = 125 ml

Sba Flashcards by Siba Kherbek

Anti D
* < 20w
* > 20w
* Every 1ml =

< 20w👉 250 IU
> 20w 👉 500 IU
Every 1ml = 125 ml

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What is the time intervals between anti D shots ?
If the patient is at high risk for antenatal bleeding+ RH - , when to do kleinhouer test ?

6w
Every 2 weeks

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A 36-year-old woman with known hypothyroidism has been taking
levothyroxine 100 micrograms once a day. Her most recent thyroid function
tests performed 3 months ago were normal with a thyrotropin (TSH) of
2.5 mU/L. She has come to the early pregnancy unit with abdominal pain and
a positive pregnancy test. Transvaginal ultrasound confirmed an intrauterine
pregnancy.
How would you advise with regards to her levothyroxine dosage?

Increase dose to 125 micrograms per day
* the dose should be increased initially by 25 micrograms daily once pregnancy is confirmed

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How to monitor Thyroid function tests in pregnancy?

every 4–6 weeks to maintain optimal serum TSH levels :
(2.5 mU/L in the first trimester and 3 mU/L in the second and third trimesters).
Once optimized, thyroid function tests need to be performed once in each trimester

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A 25-year-old woman known to have hyperthyroidism is going for radioactive
iodine therapy. She has been trying to conceive for the last 6 months.
How long should she avoid pregnancy after this treatment?

6 months

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A 28-year-old para 1 woman at 40 weeks’ gestation delivered a baby with a
skin condition, diagnosed as ‘Aplasia cutis congenita’. She is known to have
hyperthyroidism secondary to Grave disease and has been on anti-thyroid
medication throughout the pregnancy.
Which one of the medications below is known to cause the above
condition?
a. Carbimazole
b. Hydrouracil
c. Levothyroxine
d. Methythiouracil
e. Propylthiouracil

Carbimazole
& methimazole & misoprostol : rare, reversible and benign condition is characterised by skin defects mostly on the scalp.

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What is the preferred agent among anti-thyroid medication in the pregnancy ?

Propylthiouracil
* carbimazole and methimazole
are not contraindicated in pregnancy and need not be changed in women stable on
these medications pre-pregnancy, as ( ‘aplasia cutis congenita’ ) is very rare.

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Which one of the immunosuppressant drugs would be contraindicated in
pregnancy?
a. Azathioprine
b. Cyclosporine
c. Hydroxychloroquine
d. Sirolimus
e. Tacrolimus

Sirolimus
& mycophenolate mofetil
* other cytotoxic agents like cyclophosphamide and chlorambucil are teratogenic and should be
avoided in pregnancy

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What is the recurrence rate of pyelonephritis during the pregnancy?

20%
* regular screening should be offered for asymptomatic bacteriuria for the remainder of the pregnancy

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When to offer ultrasound of the urinary tract after an Acute pyelonephritis is diagnosed in pregnancy?

If there is no improvement within 48–72 hours of starting broad spectrum intravenous antibiotics

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What is the recommended time interval for conception after
1- an allograft transplantation?
2- breast Cancer?
3- gastric operations ?
4- tracheotomy?
5- radioactive iodine?
6- methotrexate?
7- tamoxifen ?

1- 24 months
* serum creatinine preferably below 125 micromol/L
2- breast Cancer: 2years
3- gastric operations : 1 year
4- tracheotomy : 6 months
5- radioactive iodine : 6 months
6- methotrexate 3 months
7- tamoxifen : months

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What is the incidence of Acute pyelonephritis in pregnancy?

1-2%

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Which one of the following statements is true about pemphigoid
gestationis?
a. Associated with other autoimmune diseases
b. Most common dermatosis of pregnancy
c. Not associated with any adverse effect on mother or foetus
d. Rash usually begins in the abdomen with periumbilical sparing
e. Recurrence in subsequent pregnancies is rare

Associated with other autoimmune diseases ( particularly Graves disease)
* rare : occurring in 1:1700 to 1:50 000 pregnancies
* There is an association with foetal growth restriction
* The rash usually begins on the abdomen around the umbilicus, but with mucosal sparing.
* Recurrence may occur in subsequent pregnancies with earlier onset and increasing severity, and also with menstrual cycles and oral contraception.
* Exacerbations and remissions are characteristic, with a postpartum flare occurring in about 75% of women.

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A 30-year-old primigravida at 35 weeks’ gestation with monochorionic
diamniotic pregnancy presents with intense itching and rash on the abdomen.
On examination there were erythematous papules and plaques in the striae
gravidarum with umbilical sparing.
The most likely diagnosis is which one of the following?
a. Pemphigoid gestationis
b. Polymorphic eruption of pregnancy
c. Atopic eruption of pregnancy
d. Prurigo of pregnancy
e. Pruritic folliculitis of pregnancy

Polymorphic eruption of pregnancy

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Polymorphic eruption of pregnancy
Incidence?
Risk factors?
Presentation?
Adverse effects?
Recurrence?

Incidence 1 / 200
Risk factors : multiple pregnancy + nullipara
Presentation : third trimester or immediately postpartum ( umbilical sparing)
Adverse effects : none
Recurrence : rare

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A 34-year-old woman at 36 weeks’ gestation was admitted with feeling
unwell, vomiting and right-sided upper abdominal pain. On examination
she was tender in the right upper quadrant with BP 140/90 mmHg, pulse
90 bpm, temperature 37.6°C and protein 1+ in the urine. Her Hb was 128 g/L,
platelets 160, white blood cell (WBC) count was elevated at 18, liver function
was deranged with hyperbilirubinaemia and moderately raised alanine
aminotransferase (ALT) and aspartate aminotransferase (AST). She was
hypoglycaemic and clotting was mildly deranged with prolonged prothrombin
time (PT) and activated partial thromboplastin time (aPTT). Renal function
and liver scan were normal.
What is the most likely diagnosis?
a. HELLP syndrome
b. Pre-eclampsia
c. Cholecystitis
d. Acute fatty liver of pregnancy
e. Hepatic rupture

Acute fatty liver of pregnancy
(hypoglycaemic + hyperbilirubinaemia + gradual onset of nonspecific symptoms + normal plt count)

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hellp syndrome VS acute fatty liver of pregnancy :
Parity?
Juandice ?
Ammonia?
Encephalopathy?
Platelets?
PT / PTT ?
Fibrinogen?
Glucose?

Parity / AFLP : nullipara+ twins
Juandice AFLP
Ammonia AFLP
Encephalopathy AFLP
Platelets / both more common in HELLP
PT / PTT / AFLP : prolonged
Fibrinogen / AFLP : low
Glucose / AFLP : low

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A 38-year-old primigravida at 36 weeks’ gestation with dichorionic diamniotic
twin pregnancy was diagnosed with acute fatty liver of pregnancy. She was
stabilised and delivered by caesarean section.
What is the risk of recurrence in subsequent pregnancies?

25 %

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A 26-year-old, nulliparous woman at 33 weeks’ gestation presented with severe
generalised itching that was worse at night and also present on the palms and
soles. She was diagnosed to have intrahepatic cholestasis of pregnancy (IHCP)
and was started on ursodeoxycholic acid and chlorpheniramine.
Which one of the statements is true with regards to counselling women with
IHCP?
a. Ursodeoxycholic acid (UDCA) treatment improves foetal outcomes in
women with IHCP
b. There is good evidence that foetal risk is related to the maternal serum bile
acid levels
c. Liver function tests should be monitored twice weekly after the diagnosis of
IHCP
d. Risk of recurrence in subsequent pregnancies is about 90%
e. Hormone replacement therapy should be avoided

Risk of recurrence in subsequent pregnancies is about 90%
* oestrogen-containing oral contraceptives should be avoided, but hormone
replacement therapy should not be omitted

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Recurrence:
HELLP / AFLP / IHCP ?

HELLP 5%
AFLP 25%
IHCP 90%

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A 28-year-old nulliparous woman with sickle cell disease (SCD) attends
the preconception clinic for advice as she wishes to start her family. Her
husband’s haemoglobinopathy screen was normal, HbAA. You have reviewed
her vaccination history and noted that she had haemophilus influenza type B
conjugated meningococcal C vaccine, pneumococcal vaccine and hepatitis B
vaccines previously (5 years ago) and influenza vaccine 8 months ago.as
Which one of the vaccines would you recommend her to have
preconceptually?

pneumococcal vaccine ( should be given every 5 years )
* haemophilus influenza type b , conjugated meningococcal C vaccine ,Hepatitis B vaccine as a single dose

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A 30-year-old nulliparous woman with sickle cell disease (SCD) attends your
clinic for preconception advice. You have requested the following tests to
assess for the chronic disease complications prior to stopping contraception.
Which one of these screening tests is not indicated yearly?
a. Pulmonary function tests
b. Renal function tests
c. Liver function tests
d. Retinal screening
e. Red cell antibody screening

Red cell antibody screening
( not yearly, maybe more often )
* Pulmonary function tests👉 Screening for pulmonary hypertension with echocardiography
* Renal function tests 👉 Blood pressure and urinalysis ( to identify proteinuria )
* Liver function tests 👉 deranged hepatic function
* Retinal screening 👉 Proliferative retinopathy ( especially patients with HbSC )
+ Screening for iron overload

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A 25-year-old woman with transfusion-dependent beta thalassaemia has been
trying to conceive and undergoing ovulation induction.
Which one of the statements is true with regards to young women with beta
thalassemia major?
a. Diabetes is the most common endocrine complication
b. Hyperthyroidism is a known complication
c. Desferrioxamine can be safely used throughout pregnancy
d. Pneumococcal vaccine should be given annually
e. Cardiac failure is the primary cause of death in more than 50% cases

Cardiac failure is the primary cause of death in more than 50% cases
* hypogonadotrophic hypogonadism is the most common endocrine complication
Diabetes is the second , hypothyroidism is the third.
* Desferrioxamine during ovulation induction. It should be avoided in the first trimester
( Safe > 20w)

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A 26-year-old nulliparous woman at 36 weeks’ gestation was diagnosed as
having idiopathic immune thrombocytopenia (ITP). Her recent platelet count
was 70 × 109
/L.
Which one of the following statements is true?
a. Should be treated with immunosuppressants
b. Regional anaesthesia is contraindicated
c. Instrumental delivery is contraindicated
d. Deliver by caesarean section at 37 weeks
e. Neonatal thrombocytopenia occurs in 25% cases

Regional anaesthesia is contraindicated ( if platelet counts are < 80 × 109/L.)
* very low counts or significant bleeding risk may prompt treatment
with corticosteroids or IV immunoglobulins or immunosuppressants.
* Ventouse delivery is best avoided /but Forceps can be used judiciously .
* Neonatal thrombocytopenia occurs in 10 % cases

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A 28-year-old para 1 woman with systemic lupus erythematosus (SLE) presents for a growth scan at 28 weeks’ gestation. Foetal heart (FH) rate was 80–90 beats per minute and a foetal echocardiogram confirmed a seconddegree congenital heart block (CHB). Which one of the following autoantibodies is associated with CHB in women with SLE? a. Anti-nuclear antibodies (ANA) b. Anti-double-stranded DNA antibodies (anti-dsDNA) c. Anti-Smith antibodies (anti-Sm antibody) d. Anti-Ro antibodies e. Anti-phospholipid antibodies (aPL)

Anti-Ro antibodies * In babies with Ro/La-positive mothers, the risk of transient neonatal cutaneous lupus is about 5% and the risk of CHB is about 2%

A 28-year-old nulliparous woman with anti-phospholipid syndrome (APS) and a previous venous thromboembolism (VTE) while on oral contraceptive pills is planning to conceive and seeks your advice. Which one of the options is the most appropriate with regards to her thromboprophylaxis in pregnancy? a. Higher dose of low molecular weight heparin (LMWH) antenatally and for 6 weeks postpartum b. LMWH antenatally and for 6 weeks postpartum c. LMWH from 28 weeks onwards and for 6 weeks postpartum d. LMWH postpartum for 10 days e. No need for thromboprophylaxis

Higher dose of low molecular weight heparin (LMWH) antenatally and for 6 weeks postpartum * higher dose : VTE associated with either antithrombin deficiency or APS or with recurrent VTE (who will often be on long-term oral anticoagulation).

A nulliparous woman had a thrombophilia screen requested by her GP because of the family history of VTE in her mother and sister. Which one of the thrombophilia defects is associated with the highest risk of VTE in pregnancy? a. Heterozygosity for factor V Leiden b. Prothrombin gene deficiency c. Homozygous factor V Leiden d. Protein C deficiency e. Antithrombin deficiency

Antithrombin deficiency * (antithrombin, protein C and protein S) : naturally anticoagulants : are of greater significant * higher risk of pregnancy-related VTE in women who : are antithrombin deficient or who are homozygous for factor V Leiden, the prothrombin gene mutation or are compound heterozygotes for factor V Leiden and the prothrombin gene mutation.

25-year-old nulliparous woman with type 1 diabetes on insulin attends her first diabetic/antenatal clinic at 10 weeks’ gestation. You have discussed diet, exercise, blood glucose monitoring and target blood glucose levels. Which one of the options is correct with regards to her capillary plasma glucose target levels? a. Fasting glucose 5–7 mmol/L b. Pre-meal glucose 4–7 mmol/L c. Fasting glucose below 5.8 mmol/L d. One-hour post-meal 7.8 mmol/L e. Two-hour post-meal 7.8 mmol/L

One-hour post-meal 7.8 mmol/L * target : Fasting: 5.3 mmol/L 1 hour after meals: 7.8 mmol/L 2 hours after meals: 6.4 mmol/L. * For Dx: FBS ≥ 5.6 mmol/L 2h post meal ≥ 7.8 mmol/L * Target intrapartum: 4-7 mmol/L

A 30-year-old nulliparous woman with poorly controlled type 1 diabetes attends a preconception clinic for advice. You have reviewed her recent HbA1c test results. At what HbA1c level should you strongly advise her not to get pregnant? a. Above 48 mmol/mol = 6.5% b. Above 58 mmol/mol c. Above 66 mmol/mol d. Above 76 mmol/mol e. Above 86 mmol/mol

Above 86 mmol/mol = 10%

A 30-year-old para 1 woman with a body mass index (BMI) of 38 and family history of diabetes attends antenatal clinic at 28 weeks’ gestation. She was diagnosed with gestational diabetes 2 days ago when her glucose tolerance test was abnormal with a fasting glucose of 7.0 mmol/L and a 2-hour plasma glucose of 8.9 mmol/L. What is the most appropriate intervention in managing her gestational diabetes? a. Trial of changes in diet and exercise b. Diet + exercise + metformin c. Diet + exercise + glibenclamide d. Diet + exercise + insulin ± metformin e. Diet + exercise + insulin ± glibenclamide

Diet + exercise + insulin ± metformin * Offer immediate treatment with insulin ; fasting plasma glucose level of 7.0 mmol/L or above. * Offer a trial of changes in diet and exercise to women with gestational diabetes who have a fasting plasma glucose level below 7 mmol/L at diagnosis. * Offer metformin to women with gestational diabetes if blood glucose targets are not met within 1–2 weeks using changes in diet and exercise.

Anti-D prophylaxis should be administered in which one of the options, if she had the following blood products transfused? a. RhD-positive FFP b. RhD-positive cryoprecipitate c. RhD-positive platelets d. RhD-negative packed RBC e. Reinfusion of the salvaged red cells

RhD-positive platelets * No anti-D prophylaxis is required if an RhD-negative woman receives RhDpositive FFP or cryoprecipitate * A dose of 250 IU anti-D immunoglobulin is sufficient to cover five adult therapeutic doses of platelets given within a 6-week period

A 20-year-old, nulliparous woman at 12 weeks’ gestation attends her antenatal booking appointment. Which one of the following questionnaires was recommended to assess the mental health and well-being of the woman? a. Depression identification questions b. Three-item Generalised Anxiety Disorder scale (GAD-3) c. Edinburgh Postnatal Depression Scale (EPDS) d. Patient Health Questionnaire (PHQ-9) e. Nine-item Generalised Anxiety Disorder scale (GAD-9)

Depression identification questions ( the past month) Or 2-item Generalised Anxiety Disorder scale (GAD-2) ( the past 2 weeks) * responds positively to either of the depression identification questions, consider using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) for full assessment * woman scores 3 or more on GAD-2 scale, consider using GAD-7 scale for further assessment.

A 28-year-old para 1 woman with history of bipolar disorder and previous postpartum psychosis attends her antenatal clinic appointment at 14 weeks’ gestation. What is her risk of developing postpartum psychosis?

1:2

A 28-year-old nulliparous woman was diagnosed with an early stage breast cancer at 12 weeks of pregnancy. Her case was reviewed by the multidisciplinary team. What is likely to be their recommendation? a. Advise termination of pregnancy prior to surgical treatment b. Proceed with the surgical treatment c. Postpone surgical treatment until the second trimester d. Postpone surgical treatment until the third trimester e. Postpone surgical treatment until delivery

Proceed with the surgical treatment * Systemic chemotherapy is contraindicated in the first trimester because of a high rate of foetal abnormality, but is safe from the second trimester * Tamoxifen and trastuzumab are contraindicated in pregnanc

A 28-year-old teacher was given varicella-zoster immunoglobulin G (VZIG) after a significant exposure to chickenpox at 24 weeks’ gestation, as she was found to be seronegative on her booking bloods. How long should she be considered potentially infectious after exposure to chickenpox?

8–28 days

A para 2, HIV-positive woman with low viral load and two previous normal vaginal deliveries was planning to have a vaginal delivery. She attends antenatal clinic at 28 weeks’ gestation and says that she had a recurrence of genital herpes 2 weeks ago, which has now resolved. From what gestation would you advise her to take prophylactic daily suppressive acyclovir to reduce the risk of HIV transmission to the foetus?

32 weeks onwards ( acyclovir 400 mg three times daily )

A para 1 woman at 33 weeks’ gestation presents with preterm premature rupture of membranes (PPROM). She had a recurrence of genital herpes 3 days ago. On examination PPROM was confirmed, and the genital lesions are healing. What is the most appropriate management option? a. Steroids + erythromycin + oral acyclovir + delivery by caesarean section at 34 weeks b. Steroids + erythromycin + intravenous acyclovir + delivery by caesarean section at 34 weeks c. Steroids + erythromycin + oral acyclovir + consider induction of labour at 34 weeks d. Steroids + erythromycin + intravenous acyclovir + consider induction of labour at 34 weeks e. Steroids + erythromycin + oral acyclovir + delivery by caesarean section after completion of the two steroid injections

Steroids + erythromycin + oral acyclovir + consider induction of labour at 34 weeks * Primary: Steroids + erythromycin + IV acyclovir + delivery by caesarean section after completion of the two steroid injections

Which one of the risk factors has the most predictive value for abruption in this pregnancy? a. Advanced maternal age b. Multiparity c. Pre-eclampsia d. Foetal growth restriction e. Abruption in previous pregnancy

Abruption in previous pregnancy

A 38-year-old para 3 woman with three previous caesarean sections has attended her first antenatal clinic appointment. What is her risk for placenta praevia in comparison to women with no previous caesarean sections? a. More than 5 times b. More than 10 times c. More than 15 times d. More than 20 times e. More than 25 times

More than 20 times * The odds ratio for placenta praevia in women with one previous caesarean section is 2.2, two previous caesarean sections is 4.1 and three previous caesarean sections is 22.4.

A gravida 4 para 2 woman attends at 32 weeks’ gestation with history of ruptured membranes. She had cervical cerclage placed at 13 weeks’ gestation because of two previous preterm deliveries and one second trimester loss. She is well in herself with no signs of infection, not contracting, CTG is normal and PPROM is confirmed on examination. Scan confirmed normal growth, liquor and Doppler. Which one of the statements is true with regards to the timing of suture removal?

Give steroids and consider delayed suture removal for 48 hours

A nulliparous woman was referred to the day assessment unit after an incidental finding of a cervical length of 18 mm with funnelling at 23 weeks’ gestation by the sonographer. On speculum examination, no bulging membranes were seen. She had no previous cervical trauma or preterm deliveries. What is the most appropriate step?

Offer prophylactic vaginal progesterone * No history of preterm birth or midtrimster loss + cervical length< 25 mm * If there is a history 👉 Offer( recommended ) a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage to women * Consider: prophylactic cervical cerclage in whom cervical length of less than 25 mm and who have either: had preterm prelabour rupture of membranes (P-PROM) in a previous pregnancy or a history of cervical trauma

Which one of the options represents the incidence of idiopathic polyhydramnios?

50%–60%

What is the definition of polyhydramnios?

AFI > 25 or DVP > 8 cm Mild 25-30 Moderate 30-35 Severe> 35

amniotic fluid index of 29 cm. Which one of the statements is appropriate with regards her management? a. Offer amniodrainage to avoid preterm birth b. Commence indomethacin until delivery c. Deliver by caesarean section at 39 weeks d. Recommend induction of labour at 40 weeks e. Thorough neonatal survey should be performed

Thorough neonatal survey should be performed ( check patency of upper gastrointestinal tract with nasogastric tube) * Perform serial scans and cervical length • No benefit from induction of labour (IOL) * indomethacin is contraindicated

A 30-year-old nulliparous woman with a monochorionic diamniotic (MCDA) pregnancy was diagnosed to have twin-to-twin transfusion syndrome (TTTS) at 18 weeks’ gestation. There was significant discrepancy in the amniotic fluid volume with a maximum vertical pool of 1.8 cm in twin A and polyhydramnios with maximum vertical pool of 10 cm in twin B. Both the bladders are seen and the Doppler studies are normal. Which one of the options below represents the TTTS staging based on the Quintero classification system?

Stage 1

You are seeing a 32-year-old para 2 woman at 16 weeks’ gestation in the antenatal clinic. She had two previous normal vaginal deliveries, but sustained a third-degree tear during her second delivery. She is asymptomatic and is anxious about the risk of recurrence in this pregnancy. What is her risk of sustaining another third- or fourth-degree tear in this pregnancy? a. 1%–3% b. 5%–7% c. 10%–12% d. 15%–17% e. 20%–22%

5%–7%

A 36-year-old para 3 woman attends day assessment unit after a growth scan for large for gestational age at 28 weeks’ gestation. She had three previous normal vaginal deliveries and was low risk at booking. She declined first trimester screening, but had normal dating and anomaly scans. Growth scan showed polyhydramnios, small for gestation foetus with a double bubble sign, and she was referred to the foetal medicine unit by the sonographers. Which one of the aneuploidies is the foetus more likely to have? a. Down syndrome b. Edwards syndrome c. Klinefelter syndrome d. Patau syndrome e. Turner syndrome

Down syndrome in 50% of the cases * Down syndrome has double bubble in 40% of the foetuses)

A healthy 36-year-old primiparous woman attended her dating scan at 12 weeks’ gestation and was found to have a nuchal translucency (NT) of 4.5 mm. She is awaiting her first trimester screening results. What is the most appropriate immediate action in this case with an increased NT? a. Amniocentesis b. Chorionic villus sampling c. Ultrasound by a foetal medicine specialist d. Foetal echocardiography e. Non-invasive prenatal test

Ultrasound by a foetal medicine specialist * Non-invasive prenatal testing and invasive testing may not be required if the first trimester screening is low

What is The prevalence of chromosomal defects with abnormal NT thickness?

50% have trisomy 21 25% have trisomy 18 or 13 10% have Turner syndrome 5% have triploidy 10% have other chromosomal defects.

on the first trimester screening her pregnancy-associated plasma protein A (PAPP-A) was low at 0.33 MoMs (multiples of the median) and the free b-hCG was high at 2.4 MoMs. Which one of the aneuploidies is more likely than the others with these free b-hCG and PAPP-A levels? a. Trisomy 21 b. Trisomy 18 c. Trisomy 13 d. Triploidy e. Turner syndrome

Trisomy 21

You are seeing a 30-year-old nulliparous woman in the antenatal clinic at 12 weeks’ gestation with a family history of Duchenne muscular dystrophy. She is a known carrier and keen to know the likelihood of her children being affected. What is the likelihood of her children being affected? a. One in two chances of being affected b. One in four chances of being affected c. One in two chances of her sons being affected d. One in four chances of her sons being affected e. All daughters are affected

One in two chances of her sons being affected ( is an X-linked recessive )

X linked conditions ( What is the likelihood of her children being affected?)

F A H D * F : Fragile X * A: Androgen insensitivity syndrome * H : hemophilia * D : Duchenne

Which one of the following is most appropriate in woman with a recent primary maternal CMV infection? a. Presence of IgM antibodies in the maternal serum indicates a recent primary infection b. Risk of transmission is higher if CMV infection is acquired in the first trimester c. High avidity of IgG antibodies is suggestive of a primary CMV infection d. Primary maternal infection is associated with a 30%–40% risk of intrauterine transmission and foetal infection e. Foetal infection is diagnosed when there are ultrasound markers of infection

Primary maternal infection is associated with a 30%–40% risk of intrauterine transmission and foetal infection * Diagnosis based on seroconversion in pregnancy ( appearance of IgG who were previously seronegative or on detection of specific IgM and IgG antibodies in association with low IgG avidity). * Risk of transmission is higher if CMV infection is acquired in the 3rd trimester ( but less severe) * diagnosis: amniocentesis performed at least 7 weeks after the presumed maternal infection and after 21 weeks of gestation.( Unlike varecella ultrasound after 5 w)

31 w ,The scan today confirmed foetal growth below the third centile with normal amniotic fluid index but abnormal umbilical artery Doppler with intermittent absent end diastolic flow. Middle cerebral artery and ductus venous Doppler scans are normal with no evidence of foetal redistribution. What are the most appropriate recommended mode and timing of delivery? a. Caesarean section by 32 weeks b. Caesarean section by 34 weeks c. Induction of labour at 32 weeks d. Induction of labour at 34 weeks e. Induction of labour at 36 weeks

Caesarean section by 32 weeks * In the SGA foetus with umbilical artery AREDV delivery by caesarean section is recommended * If ductus venous Doppler scan is abnormal 👉 CS immediately

36 weeks’ Small for gestational age foetus was diagnosed at 34 weeks’ gestation normal amniotic fluid and positive end diastolic flow on umbilical artery Doppler, but with pulsatility index (PI) along the 95th centile. Middle cerebral artery Doppler scans are normal. What are the most appropriate recommended mode and timing of delivery? a. Caesarean section at 37 weeks b. Caesarean section at 39 weeks c. Induction of labour at 37 weeks d. Induction of labour at 39 weeks e. Induction of labour when Doppler scans show absent or reverse end diastolic flow

Induction of labour at 37 weeks * In the SGA foetus with normal umbilical artery Doppler or with abnormal umbilical artery PI but end-diastolic velocities present, induction of labour can be offered but rates of emergency caesarean section are increased and continuous foetal heart rate monitoring is recommended * In the SGA foetus detected after 32 weeks of gestation with an abnormal umbilical artery Doppler, delivery no later than 37 weeks of gestation is recommended.

Which one of the following statements is correct with regards to mastitis? a. Group A streptococcus is the most common causative organism b. Mastitis may occur in the absence of bacterial infection c. Breastfeeding should be discontinued from the affected breast d. Mastitis commonly occurs in the lower left quadrant of the breast e. Ultrasound should be performed in all cases routinely

Mastitis may occur in the absence of bacterial infection * Staphylococcus aureus is the most common causative agent. * Mastitis commonly occurs in the upper outer quadrant of the breast * flucloxacillin or erythromycin (if allergic to penicillin) should be administered { amoxam500 1×3}.

A 20-year-old, para 1 woman was brought in to the hospital 2 weeks after delivery as she has been tearful, irritable, with lack of interest in herself and her baby. She has not been eating or sleeping well, feels life is not worth living and has expressed thoughts of self-harming. What is the most appropriate immediate course of action? a. Admit to postnatal ward for observation b. Start antidepressant medication c. Refer to perinatal mental health team for follow-up d. Ensure urgent assessment by the perinatal mental health team e. Admit to mother and baby unit immediately

Ensure urgent assessment by the perinatal mental health team

Which one of the antidepressant medication is safer during breastfeeding? a. Doxepin b. Fluoxetine c. Citalopram d. Escitalopram e. Sertraline

Sertraline * fluoxetine, citalopram and escitalopram should be avoided if possible.

A nulliparous woman had a precipitous, spontaneous vaginal delivery and sustained a third-degree tear. Which one of the NSAIDs has the best safety profile? a. Ibuprofen b. Diclofenac c. Naproxen d. Meloxicam e. Fenoprofen

Ibuprofen

A para 2 woman with a body mass index (BMI) of 40, two previous caesarean sections and history of deep vein thrombosis at 33 weeks’ gestation has taken her last dose of low molecular weight heparin (LMWH) at 6 a.m. the day before. Her elective caesarean section at 39 weeks was uncomplicated under combined spinal epidural (CSE) anaesthesia at 9 a.m., and the epidural catheter was removed at the end of surgery a few minutes ago, at 10 a.m. After what time can she have her LMWH injection?

2 p.m * LMWH should not be given for 4 hours after the use of spinal anaesthesia or after the epidural catheter has been removed * the epidural catheter should not be removed within 12 hours of the most recent injection.

You have just delivered a 33-weeks preterm baby by caesarean section in good condition. Both mother and baby are stable. Which one of the statements is most appropriate with regards to the timing of cord clamping?

Wait at least 30 seconds, but no longer than 3 minutes

A 30-year-old para 1 woman with gestational diabetes had a normal vaginal delivery. She has stopped her metformin and insulin after birth. At discharge, you have counselled her about the risk of developing diabetes and discussed lifestyle changes. Which one of the tests would you advise her to do postnatally? a. Fasting blood glucose at 6–13 weeks b. Fasting blood glucose after 13 weeks c. Oral glucose tolerance test at 6–13 weeks d. Oral glucose tolerance test after 13 weeks e. Oral glucose tolerance test after 24 weeks

Fasting blood glucose at 6–13 weeks ( 6 w postnatal check) * up to 50% of women diagnosed with gestational diabetes develop type 2 diabetes within 5 years of the birth * Do not routinely offer a 75 g 2-hour oral glucose tolerance test (OGTT).

Which one of the following techniques is the most appropriate in the repair of a fourth-degree tear? a. Interrupted sutures only to repair anorectal mucosa b. Overlapping method to repair internal anal sphincter c. Figure-of-eight sutures to repair the anal sphincter complex d. End-to-end method to repair the partial thickness external anal sphincter tear e. Overlap method to repair the partial thickness external anal sphincter tear

End-to-end method to repair the partial thickness external anal sphincter tear * Figure-of-eight sutures should be avoided during the repair of (OASIS). * internal anal sphincter (IAS)👉 interrupted or mattress sutures without any attempt to overlap the IAS. * full-thickness external anal sphincter (EAS)👉 either an overlapping or an end-to-end. * partial-thickness (all 3a and some 3b) 👉 an end-to-end technique should be used.

A 30-year-old nulliparous woman in a prolonged second stage of labour was delivered in theatre with ventouse. The baby was reviewed by the neonatal team, and there was a large well-defined swelling over the parietal bone of the foetal head with clear margins. Which one of the following conditions is the most likely diagnosis for this swelling? a. Caput succedaneum b. Cephalhaematoma c. Chignon d. Subaponeurotic haemorrhage e. Subgaleal haemorrhage

Cephalhaematoma : subperiosteal collection of blood between the periosteum and the skull due to rupture of blood vessels and may be associated with skull fracture. It is well defined, with clear delineation of the suture lines. It is most commonly parietal. * Chignon is a temporary swelling on the baby’s head at the ventouse cup application site.

A 42-year-old para 3 woman with three previous normal vaginal deliveries and postpartum haemorrhage after her last delivery was induced at 39 weeks’ gestation due to severe pre-eclampsia. She had an instrumental delivery for prolonged second stage and has consented for the active third-stage management. What is the most appropriate immediate drug of choice? a. Syntocinon 10 IU intramuscularly (IM) b. Syntocinon 40 IU IV infusion c. Syntocinon 5 IU intramuscularly d. Syntometrine intramuscularly e. Misoprostol 1000 micrograms rectally

Syntocinon 10 IU intramuscularly (IM) : with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is clamped and cu

You were asked to attend to a para 3 woman, who had a normal vaginal delivery 45 minutes ago in the midwifery-led birth unit and was transferred to the adjacent labour ward for retained placenta. She has moderate per vaginal bleeding, but is haemodynamically stable. IV access was secured and bloods were sent by the midwife. What is your most appropriate immediate course of action? a. Intra-umbilical vein injection of Syntocinon 10 units b. Intramuscular injection of Syntocinon 10 units c. Intravenous (IV) infusion of Syntocinon 40 units d. Transfer to theatre for assessment under anaesthesia e. Vaginal examination for assessment of the placenta

Vaginal examination for assessment of the placenta * then arrange to Transfer to theatre for assessment under anaesthesia * Give IV oxytocic agents if bleeding is excessive and the placenta retained. * Do not use umbilical vein agents or IV oxytocic agents routinely to deliver a retained placenta.

Active management of the third stage of labour reduces the risk of PPH by what proportion? a. 20% b. 30% c. 40% d. 50% e. 60%

60% 👉 Prophylactic oxytocics should be offered routinely in the management of the third stage of labour in all women , as they reduce the risk of PPH by about 60%.

A 12-year-old girl was brought in to the hospital with severe lower abdominal pain and was diagnosed to have hematometrocolpos after examination and investigations. Surgical management with hymenotomy and drainage was recommended the same day by the consultant on call, who gave a clear explanation of the procedure, reasons, implications and risks. The young girl instantly declined as she was too scared of the operation, but later agreed after her mother and stepfather calmed her down. From which one of the following options is it most appropriate for you to obtain consent? a. Consent from the patient alone b. Consent from the mother alone c. Consent from the patient and mother d. Consent from the patient and stepfather e. Consent from both parents

Consent from the patient and mother

A 15-year-old girl accompanied by her friend presents to the emergency gynaecology unit with crampy lower abdominal pain and vaginal bleeding. Her observations were stable. Her last menstrual period was 7 weeks ago and the urine pregnancy test was positive. Ultrasound performed showed missed miscarriage. After discussing the options, she opted for surgical management of miscarriage and requests you to keep this confidential as her parents are not aware. a. You can proceed with the girl’s consent, as the mother’s consent is not necessary b. Mother’s consent is necessary and you encourage her to inform her mother c. Mother’s consent is necessary and you would like to inform with the patient’s consent d. You can proceed with the girl’s consent, but you need to inform social services e. You can proceed with the girl’s consent after obtaining a second consultant approval

You can proceed with the girl’s consent, as the mother’s consent is not necessary * In cases of termination of pregnancy or issuing contraceptive medication for a girl under 16 years, the clinician should not contact the parents of the child unless the child agrees the clinician can do this.

Which one of the following statements is correct in assessing statistical correlations? a. Correlation coefficient tests the association between two variables b. It is a measure of the curvilinear association between the variables c. If Pearson’s r is 0, there is a negative correlation d. Pearson’s correlation depends on all the data of the observations being normal distributed e. A statistically significant association between two variables means it is causal

Correlation coefficient tests the association between two variables

What is the diameter of the presenting part in * Brow presentation * Flexed vertex presentation * Partially deflexed vertex presentation * Deflexed vertex presentation * Face presentation

* Brow presentation 👉 Mento-vertical = 13 cm * Flexed vertex presentation 👉 Suboccipito-bregmatic = 9,5 cm * Partially deflexed vertex presentation👉 Suboccipito-frontal = 10,5 cm * Deflexed vertex presentation 👉 Occipito-frontal = 11,5 * Face presentation 👉 Submento-bregmatic = 9,5 cm

Which is more appropriate for care of the women labouring in water : Temperature of the water should not be more than .......C and should be checked ....

Temperature of the water should not be more than 37.5°C and should be checked hourly

Which one of the following statements is correct with regards to the postures in labour? a. Upright position in labour is associated with reduction in blood loss at delivery b. Upright position in labour has no effect on instrumental delivery rates c. Upright position in labour has shown a reduction in the duration of labour d. Use of birthing balls in labour have no effect on caesarean section rates e. Use of birthing balls in labour have been shown to reduce pain by up to 15%

Upright position in labour has shown a reduction in the duration of labour ( first & second stage) * Increase the blood loss * Reduction in pain by 30 - 40 % * reduction in caesarean sections, instrumental delivery rates and episiotomies

Which one of the following statements is true with regards to the opioid analgesics? a. Pethidine intramuscular injection is a better analgesic than diamorphine injection b. Diamorphine injection has shown to reduce the duration of labour c. Remifentanil patient-controlled analgesia (PCA) is superior to epidural analgesia d. Remifentanil PCA is contraindicated if pethidine was given previously within 6 hours e. Remifentanil PCA needs continuous monitoring of maternal oxygen saturations

Remifentanil PCA needs continuous monitoring of maternal oxygen saturations * diamorphine is a better analgesic than pethidine but associated with prolonged delivery. * (PCA) is not superior to epidural analgesia. * PCA is contraindicated if pethidine or diamorphine was given previously within 4 hours.

What is the recommended drug of choice for the treatment of local anaesthetic toxicity? a. Intralipid 10% intravenous bolus at 1 mL/kg over 1 minute b. Intralipid 10% intravenous bolus at 1.5 mL/kg over 1 minute c. Intralipid 20% intravenous bolus at 1 mL/kg over 1 minute d. Intralipid 20% intravenous bolus at 1.5 mL/kg over 1 minute e. Intralipid 20% intravenous bolus at 1.5 mL/kg over 2 minutes

Intralipid 20% intravenous bolus at 1.5 mL/kg over 1 minute

Which one of the following would be most appropriate in preventing the obstetric anal sphincter injuries (OASIS)? a. Cold compression during the second stage reduces the risk of OASIS b. Mediolateral episiotomy that is 45° away from the midline when perineum is distended c. Mediolateral episiotomy that is 60° away from the midline when perineum is distended d. Perineal protection at crowning e. Perineal massage throughout the antenatal period

Perineal protection at crowning * the protective effect of episiotomy is conflicting ( where episiotomy is indicated, the mediolateral with angle is 60° away from the midline when the perineum is distended).

What is the risk of umbilical cord prolapse in breech presentation?

1% * The overall incidence 0.1-0.6% in all presentations.

A woman in spontaneous labour at term , Abdominal examination reveals that the head is not palpable per abdomen. She presents a fully dilated cervix, absent membranes, with a left occipitoanterior position with the vertex at +1 station. You have decided to proceed with an operative vaginal delivery with the woman’s consent. Which one of the operative vaginal deliveries would you be performing at this stage? a. High-cavity delivery b. Mid-cavity delivery c. Low-cavity delivery d. Inlet delivery e. Outlet delivery

Mid-cavity delivery * High cavity 👉 the leading point of the foetal skull is above the ischial spines with more than two-fifths head palpable per abdomen. * Mid-cavity 👉 0 to +2 with one-fifth or less head palpable per abdomen * Low cavity 👉 at or lower than the +2 station * Outlet delivery 👉 foetal skull has reached the pelvic floor and the foetal scalp is visible without parting the labia. Sagittal suture is in the anterior-posterior diameter or right or left occiput anterior or posterior position (rotation does not exceed 45°).

A 20-year-old nulliparous woman at 26 weeks and 4 days of gestation attends triage with a history of spotting per vaginam. On speculum examination, the cervical os was open with bulging membranes in the vagina, but there were no signs of vaginal bleeding. Your neonatal unit is full and you are arranging an in utero transfer. What is the most appropriate initial management? a. Betamethasone injection b. Betamethasone injection and atosiban c. Betamethasone injection and oral nifedipine d. Betamethasone injection, atosiban and MgSO4 e. Betamethasone injection, oral nifedipine and MgSO4

Betamethasone injection and oral nifedipine

A 38-year old para 1 woman at 40 weeks’ gestation attends triage with a 2-hour history of spontaneous rupture of membranes (SROM). She had a previous caesarean section 3 years ago for failure to progress at 5 cm dilation and is keen to have vaginal birth after caesarean (VBAC). She is having irregular contractions, one in 10–15 minutes lasting 20 seconds. SROM was confirmed and the cervix was noted to be fully effaced and 1 cm dilated. CTG was normal at admission. What is the most appropriate plan? a. Await events b. Perform continuous electronic foetal monitoring c. Commence Syntocinon infusion d. Reassess in 4 hours and then start Syntocinon if no progress e. Reassess in 6 hours and then start Syntocinon if no progress

Await events ( she isn't in established labour) * In established VBAC labour should receive: continuous electronic foetal monitoring & (no less than 4-hourly) assessment of their progress in labour

You were asked to see a 29-year-old nulliparous woman in the active second stage of labour, pushing for about an hour and exhausted, asking for a caesarean section. She was induced at 38 weeks for type 1 diabetes and suspected macrosomia. She is contracting 4 in 10 minutes and the CTG is normal. Per abdomen, 0/5th head was palpable and you have confirmed full dilatation, absent membranes, right occipito-posterior (ROP) position with the vertex at spines and descent to +1 during pushing. What is the most appropriate management plan? a. Allow another 30 minutes for pushing b. Commence Syntocinon augmentation c. Instrumental delivery in room d. Trial of instrumental delivery in theatre e. Caesarean section

Trial of instrumental delivery in theatre * She has risks of failure of instrumental delivery: Suspected Big baby+ occipito-posterior position+ mid-cavity delivery

A 36-year-old para 1 woman with a previous caesarean section for failure to progress at 7 cm was admitted at 40 + 10 weeks’ gestation for induction of labour. Which one of the statements is most appropriate with regards to her risks with induction of labour in comparison with the spontaneous VBAC labour? a. Risk of uterine scar rupture is 1.5-fold increased b. Risk of uterine scar rupture is two- to threefold increased c. Risk of uterine scar rupture is fivefold increased d. Risk of emergency caesarean section is fivefold increased e. Risk of emergency caesarean section is two- to threefold increased

Risk of uterine scar rupture is two- to threefold increased & 1,5 fold increased risk of CS .

A nulliparous woman had a trial of instrumental delivery in theatre for failure to progress in the second stage of labour. She sustained a fourth-degree tear with 1 cm of the anal mucosa torn during the forceps delivery. Which one of the suture materials should be used to repair the anorectal mucosa? a. 2-0 Polyglactin (Vicryl) b. 3-0 Polyglactin (Vicryl) c. 2-0 Vicryl Rapide d. 3-0 Vicryl Rapide e. 3-0 Polydioxanone (PDS)

3-0 Polyglactin (Vicryl) * The deep layers of the vagina and the perineal body are reapproximated with figure-of-eight sutures of 2-0 Monocryl. * vaginal epithelium and perineal epithelium are repaired with a single, running, intracutaneous 3-0 Monocryl. * The IAS is repaired via end-to-end anastomosis using a simple running stitch of 3-0 or 4-0 PDS.

You performed forceps delivery in one of the labour ward rooms for prolonged second stage of labour and maternal exhaustion. You have diagnosed shoulder dystocia, delivered the baby in good condition with simple maneuvers. Later during the parent debriefing, you were asked about the risk of recurrence in the future. What is her risk of shoulder dystocia in future pregnancies? a. Same risk as the general population b. Five times higher than the general population c. Ten times higher than the general population d. Fifteen times higher than the general population e. Twenty times higher than the general population

Ten times higher than the general population

You were asked by the midwife to assess the presenting part in a para 2 woman in spontaneous labour at term after SROM at 8 cm cervical dilation. She is low risk, contracting 3–4 in 10 minutes and the CTG is normal. You have confirmed that she is now fully dilated with a mento-anterior face presentation at spines. What is the most appropriate management? a. Caesarean section b. Start active pushing c. Start Syntocinon augmentation d. Transfer to theatre for delivery e. Allow an hour for passive second stage

Allow an hour for passive second stage * CS is recommended for the mento-posterior face presentation. * this presentation itself is not an indication for delivery in theatre.

A nulliparous woman at 40 + 2 gestation was admitted in spontaneous labour and progressed satisfactorily to full dilatation 2 hours ago. On reassessment there is no change in the descent with the vertex at −1 station, the position is occipitoanterior with absent membranes, no caput or moulding. Epidural is effective, contractions are three in 10 minutes and the CTG is normal. What is the most appropriate management? a. Caesarean section b. Trial of instrumental delivery in theatre c. Commence Syntocinon augmentation d. Commence active second stage of labour now e. Allow another hour for passive second stage of labour

Commence Syntocinon augmentation ( no progress/change in the descent of the presenting part during the last 2 hours) * Oxytocin is advised if 1-contractions are inadequate or 2-if there is a delay secondary to malposition or 3- if there is little or no descent of the head.

A 30-year-old para 1 woman with an uncomplicated dichorionic diamniotic (DCDA) pregnancy goes into spontaneous labour at 36 weeks and delivers the first twin with cephalic presentation. The second twin is in breech presentation with good descent during contractions. The CTG is normal with four to five contractions in 10 minutes and the epidural is effective. SROM occurred with cord prolapse and the feet at the introitus. What is the most appropriate management? a. Transfer to theatre for caesarean section b. Deliver by breech extraction c. Conduct an assisted breech delivery d. Await events for spontaneous breech delivery e. Replace the cord and deliver breech by hands-off technique

Deliver by breech extraction

You have just performed a trial of forceps in theatre and diagnosed shoulder dystocia. She has an effective epidural and had episiotomy at forceps delivery. Your team arrived for help; McRoberts manoeuvre and suprapubic pressure were not successful. What is the most appropriate next manoeuvre in this scenario? a. Internal manoeuvres b. Delivery of posterior arm c. Internal rotational manoeuvres d. Internal manoeuvres or all-fours position e. All-fours position

Internal manoeuvres * Internal manoeuvres or ‘all-fours’ position should be used if McRoberts manoeuvre and suprapubic pressure fail. As the epidural is effective in this case, internal manoeuvres would be more appropriate than the all-fours position

A 38-year-old, para 3 woman with gestational diabetes and pre-eclampsia was induced at 38 weeks’ gestation for polyhydramnios and a big baby. She progressed well in labour and is pushing with signs of imminent delivery. She has consented for active management of the third stage of labour. What one of these is recommended for administration in the immediate postpartum? a. Syntocinon 5 IU intramuscular b. Syntocinon 10 IU intramuscular c. Syntometrine Intramuscular d. Ergometrine 0.5 mg intramuscular e. Syntocinon infusion

Syntocinon 10 IU intramuscular

A 60-year-old woman is referred to the rapid access 2 week wait clinic with vulval itching and soreness. Vulval examination reveals small ivory-coloured slightly raised areas which join to form white patches in a figure-of-eight distribution. Vaginal introitus is narrowed with atrophy of the labia minora. Vulval mapping biopsies reveal lichen sclerosus. Her associated risks include all of the following except which one condition? a. Increased risk of a personal history of autoimmune disorders b. Increased risk of a family history of autoimmune disorders c. An associated thyroid disorder d. An associated pernicious anaemia e. Vesiculobullous autoimmune disease of anogenital site

Vesiculobullous autoimmune disease of anogenital site * personal history of autoimmune disorders 40% * family history of autoimmune disorders 30%

What is the incidence of lichen sclerosus ?

1/1000 1/30 in postmenopausal women

What is the incidence of lichen sclerosus ?

1/1000 1/30 in postmenopausal women

What is the risk of cancer developing in lichen sclerosus ?

2-4 % SCC

What is the treatment of lichen sclerosus ?

Clobetasol 0.05% Once daily for 1 month Then alternate days for 1 month Then twice weekly for 1 month Then once a week for 1 month * The relapse rate is 84% within 4 years. 👉 In 4%–10% symptoms will not improve 👌 second-line treatment : topical tacrolimus.

A 40-year-old woman presents with severe vulval pruritus. Vulvoscopy reveals acetowhite areas following application of acetic acid. Vulval mapping biopsy reveals usual type (human papilloma virus [HPV] related) of VIN. She can be treated with which one of the following methods? a. Radical vulvectomy b. Simple vulvectomy c. Therapeutic human papilloma virus vaccine d. Interferon therapy e. Local surgical excision

Local surgical excision * The risk of recurrence with excision is same as vulvectomy.

What are the 2 types of VIN ? What is the risk of progression into cancer?

(1) usual type which is associated with HPV (2) differentiated type which occurs in the background of LS. Both types of VIN can progress to develop into cancer (the risk of progression is 40%–60%)

What are the Differences between usual type and differentiated type of VIN according to : * Age * Associated disease * Appearance * Treatment

* Age : classical type ( 30-50y) Differentiated type ( 60-80y) * Associated disease: classical type ( Bowen disease SCC Insitu ) Differentiated type ( LS) * Appearance : classical type ( univocal ) Differentiated type ( multifocal : warty or basaloid) * Treatment classical : type & Differentiated type : surgical excision ( The risk of recurrence with excision is same as vulvectomy ) and it's better than ablation.

What are the non surgical treatments used to treat VIN ?

1- imiquimod cream ( used to treat warts) 2- laser ablation ( failure rate 40%) * insufficient evidence to suggest the use of interferons and therapeutic HPV vaccine.

How to follow up patients with VIN after surgical excision?

Annually by vulvoscopy & colposcopy

A 24-year-old woman presents to her GP with abdominal pain. Clinical examination reveals a large abdomino-pelvic mass. She is referred to a rapid access 2-week wait clinic. Following investigations, computed tomography (CT) scan reveals left-sided solid ovarian mass with raised serum lactate dehydrogenase (LDH) enzyme levels. She undergoes fertility sparing surgery and the histology reveals nests of tumour cells (vesicular cells with clear cytoplasm and central nuclei) separated by fibrous stroma infiltrated with T lymphocytes. Which is the most likely type of ovarian tumour in her case? a. Brenner tumour b. Immature teratoma c. Endodermal sinus tumour d. Dysgerminoma e. Embryonal carcinoma

Dysgerminoma * raised serum lactate dehydrogenase+ (LDH) enzyme levels + PLAP ( placental like alkaline phosphatase) * histology: fibrous stroma infiltrated with T lymphocytes ( fried egg appearance)

A 48-year-old is referred to rapid access clinic with postmenopausal bleeding. Her ultrasound shows endometrial thickness of 5.1 mm. She gives family history of endometrial cancer in the mother (died at the age of 44 years), her brother died of bowel cancer at the age of 44 years and her sister died of ovarian cancer at the age of 46 years. She is anxious that she has a genetic history and worried that she has inherited some genetic condition. The patient is at increased risk of which one of the following? a. Breast cancer b. Bowel cancer c. Cervical cancer d. Endometrial cancer e. Ovarian cancer

Endometrial cancer

Lynch syndrome ( HNPCC) - HEREDITARY NONPOLYPOSIS COLORECTAL CANCER * HEREDITARY * Chance of passing the gene mutation to their children * Components

* HEREDITARY : autosomal dominant * Chance of passing the gene mutation to their children : 50% * Components : NONPOLYPOSIS COLORECTAL CANCER 80% Endometrial cancer 60% Ovarian cancer 12% - early stage ( unlike BRCA- related)

. A 70-year-old woman , Her main symptom is vulval itching and soreness. Vulval examination reveals erythematous vulva with excoriation and lichenification. Vulval biopsy shows large pleomorphic cells with amphophilic, granular cytoplasm and prominent nucleus and mainly located in the lower portion of the epidermis. Occasional signet cells were seen. The cells stained positive with mucicarmine and PAS. Immunohistochemical studies showed positivity with EMA, CAM 5.2, CK7 and GCDFP-15. The doctor recommends vulval excision. What is the most likely diagnosis in her case? a. Plasma cell vulvitis b. Vulval Crohn disease c. Malignant melanoma d. Bowen disease e. Extramammary Paget disease

Extramammary Paget disease ( erythematous , well delineated, and measure around several centimeters) * Usually associated with underlying adenocarcinoma ( 10-30%) * appearance of a signet ring * The cells stained positive with mucicarmine and PAS.

30-year-old woman has a current smear reported as mild dyskaryosis. A high-risk HPV test on the liquid-based cytology (LBC) sample is positive. Colposcopy reveals CIN2 and therefore a large loop excision of transformation zone (LLETZ) is performed. The next management step in her case is which one of the following? a. HPV testing in 6 months b. Cytology follow-up at 12 months with colposcopy c. Cytology follow-up at 6 months d. Cytology follow-up at 6 months with HPV testing e. Cytology follow-up at 12 months with HPV testing

Cytology follow-up at 6 months with HPV testing

A 40-year-old woman para 2 presents with bloating and abdominal swelling. Her mother died of ovarian cancer and her sister died of breast cancer at the ages of 50 and 40, respectively. A genetic screening test reveals that she is carrier of BRCA1 gene. Her management include the following except for which of the following? a. Risk-reducing bilateral salpingo-oophorectomy (RRBSO) b. Risk-reducing breast surgery (bilateral mastectomy) c. Screening for ovarian cancer d. Breast screening e. Counselling regarding 1%–6% risk of primary peritoneal cancer even after oophorectomy

Screening for ovarian cancer ( there is no screening for ovarian Cancer) *Who carry BRCA1 and therefore RRBSO is recommended between 35 and 40 years of age * Who carry BRCA2 RRBSO can be delayed until 45 years of age

A CT scan (chest, abdomen and pelvis) reveals a large abdominal mass possibly filled with mucin. The findings are suggestive of mucinous carcinoma. She undergoes staging laparotomy which reveals pre-operative rupture of the cyst with ascites and mucinous substance filling the abdomen. The histology is reported as mucinous carcinoma of the left ovary with rupture of cyst. What is the International Federation of Gynecology and Obstetrics (FIGO) stage in her case? a. IB b. IC1 c. IC2 d. IC3 e. IIA

IC2

She undergoes total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO). The final histology reveals Grade 1 endometrioid carcinoma with less than half myometrial invasion and involvement of cervical glands. What is the FIGO stage in her case? a. IA b. IB c. II d. IIIA e. IIIB

IA * Endocervical gland involvement only is no longer stage II but will be stage I.

55y + for PMB. An ultrasound scan reveals thickened endometrium and a solid ovarian mass on the left side. An endometrial Pipelle biopsy shows grade 1 endometrioid carcinoma. She undergoes TAH+BSO. Her Ca125 (150 units/mL) and inhibin B levels (100 ng/L) are elevated. She undergoes staging laparotomy (TAH+BSO, omentectomy, peritoneal biopsies and peritoneal washings and look around inside the abdomen). What would be the likely histological diagnosis of ovarian mass in her case? a. Polyembryoma b. Granulose cell tumour c. Sertoli-stromal cell tumour d. Gynandroblastoma e. Serous cystadenocarcinoma

Granulose cell tumour * Age of presentation 52y * Associated with endometrial hyperplasia 40% * Associated with endometrial carcinoma 10% * Inhibin B levels (Alfa-subunit more specific) are measured at follow-up

A 20-year-old woman presents to GP with abdominal distension. She is referred to rapid access clinic (gynaecological oncology). Her Ca125 is 100, CEA, AFP, ß-HCG, LDH are normal. CT scan reveals a large solid mass arising from the left ovary with normal right ovary. She undergoes staging laparotomy with fertility preservation. The histology reveals immature grade 2 neural tissue. What is the histological diagnosis in this case? a. Struma ovarii b. Mature teratoma c. Glioblastoma d. Neuroblastoma e. Immature teratoma

Immature teratoma ( immature grade 2 neural tissue.) * Malignant+ almost always unilateral * Treatment: surgery+ chemotherapy ( not sensitive to radiotherapy) * Prognosis in children depends on the presence of yolk sac components)

A patient is noted to have symmetrical bilateral ovarian tumours which are removed. The histopathology report reveals tumour cells show signet ring morphology and raise the possibility that these represent metastasis rather than primary ovarian malignancy. Which is the most likely primary site? a. Cervix b. Thymus c. Pancreas d. Stomach e. Thyroid

Stomach * cells show signet ring ( also in extramammelary Paget disease)

74y + Examination reveals a 2 cm mass on the right labia away from the midline. A biopsy of the lesion from the margin of the tumour reveals squamous cell carcinoma with depth of invasion <1 mm. The MRI of the pelvis reveals the same vulva mass with no other abnormality. Her case is subsequently discussed in the multidisciplinary team meeting. The management of this patient involves which one of the following? a. Radical vulvectomy b. Radical vulvectomy with bilateral groin lymphadenectomy c. Radical vulvectomy with groin lymphadenectomy on the same side d. Wide local excision of vulval lesion e. Wide local excision of vulval lesion with groin lymphadenectomy on the same side

Wide local excision of vulval lesion * IA 👉 no lymphadenectomy ( risk of node involvement< 1%) * Bilateral groin node dissection should be performed in women with midline tumours or those involving the clitoris.

A 25-year-old woman is 14 weeks’ pregnant. She has a moderate dyskaryosis in the cervical smear and is referred to the colposcopic clinic. How would you manage her? a. Colposcopy and LLETZ b. Colposcopy to rule out invasive disease and follow-up in colposcopy clinic at 3 months post-delivery c. Colposcopy and wedge biopsy of cervix d. No need for colposcopy during pregnancy as it is difficult to interpret findings on cervix e. Discharge the patient to GP if colposcopy is normal

Colposcopy to rule out invasive disease and follow-up in colposcopy clinic at 3 months post-delivery

62-year-old woman presents with one episode of postmenopausal bleeding. Ultrasound scan shows endometrial thickness (ET) of 4 mm and bilateral ovarian cyst 7 × 8 × 9 cm each. They are multilocular and partly solid, partly cystic with thick walls. CA-125 is 30. What is the recommended management in her case? a. Manage locally in gynaecological oncology unit with laparotomy and oophorectomy b. Manage locally in gynaecological oncology unit with laparotomy and pelvic clearance c. Refer her to cancer centre for further management d. Conservative treatment e. Manage in gynaecological oncology centre with laparoscopic oophorectomy

Refer her to cancer centre for further management * RMI = 3 ×3×30 = 270 > 200 👉 risk of malignancy> 70%

To calculate RMI , what is the ultrasound score?

U = 1 for ultrasound score of 1 U= 3 for ultrasound score of (2-5) One point for each: multilocular cyst; evidence of solid areas; evidence of metastases; presence of ascites; and bilateral lesions.

Which of these instruments is used to identify and release the ureter in the ureteric tunnel in radical hysterectomy? a. Gullums b. Zaplins c. Rogers d. Roberts e. Lahey

Lahey

A 28-year-old woman is referred for colposcopy with abnormal smear reported as severe dyskaryosis. Colposcopy reveals a high-grade lesion. She subsequently undergoes LLETZ procedure under general anaesthesia in view of anxiety. The final histology reveals cervical cancer (microinvasion <3 mm depth of invasion and horizontal spread of <7 mm). The margins of LLETZ reveal cervical intra-epithelial neoplasia 3 (CIN3). What should be her subsequent management? a. Follow-up for colposcopy and smear with HPV testing b. Repeat LLETZ c. Radical hysterectomy d. Simple hysterectomy e. Laparoscopic pelvic lymphadenectomy

IA1 Repeat LLETZ If < 50 y Or follow up if > 50y

A 40-year-old woman is referred to gynaecology clinic with large fibroids. Three are subserosal (5 × 6 cm, 6 × 5, 8 × 4 cm) and two are intramural (10 × 12 cm). Which one of the following would be a contraindication for uterine artery embolisation (UAE) in her case? a. Adenomyosis b. Menorrhagia c. Asymptomatic fibroids d. Presence of intrauterine copper device (IUCD) e. Woman who is a Jehovah’s Witness

Asymptomatic fibroids

UTERINE ARTERY EMBOLISATION (UAE) may cause ovarian failure in ..........?

1-2% * And small proportion of patients need hysterectomy following UAE

The woman declines surgery but is willing to have UAE for uterin fibroids Which statement is false regarding counselling of this patient? a. 1%–2% will have early ovarian failure b. May need further treatment in the form of hysterectomy in 2.9% of women c. 40%–70% reduction in the fibroid volume d. Risk of post-embolisation syndrome e. 98% of the patients will be symptom free following UAE

98% of the patients will be symptom free following UAE * At 1 year 80-90% of the patients will be asymptomatic

What are the risks of uterin artery embolization?

HARDI Hysterectomy ( emergency) 1% Amenorrhea 5% Recurrence 10-25% Discharge ( vaginal) 25% Infertility

What is the percentage of fibroid size reduction after UAE?

40-70%

A 30-year-old woman presents to GP with increase in growth of hair on the chin, chest and back which she noticed for the last 3 months. She also gives history of deepening of voice and frontal hair loss. Vulval examination reveals clitoromegaly. Which one of the following tests differentiates androgen-producing adrenal tumour from ovarian tumour? a. Increased free serum testosterone levels b. Increased serum dehydroepiandrosterone (DHEA) levels c. Increased serum dehydroepiandrosterone sulphate (DHEAS) levels d. Decreased serum sex hormone binding globulin (SHBG) levels e. Increased serum 17-hydroxyprogesterone levels

Increased serum dehydroepiandrosterone sulphate (DHEAS) levels * normal DHEAS with increased testosterone of more than 8.7 nmol/L (two to three times the normal value) is highly suggestive of an ovarian androgen-secreting tumour. * Both testosterone and DHEAS will be increased in adrenal tumours (DHEAS exclusively produced in the adrenal gland).

What are the Pathophysiology of hirsutism due to Increased exposure to androgen ?

✅ Increased production : Tumours Cushing syndrome Hyperinsulinaemia Increased (LH) levels ✅ Alterations in binding globulins (SHBG): Hyperinsulinaemia Liver disease Hyperprolactinemia Hypothyroidism

What are the Investigations during assessment of hirsutism ?

• Testosterone • DHEAS (exclusively produced in the adrenal gland) • (OGTT) – insulin resistance (seen in PCOS) • 17-Hydroxyprogesterone (rule out congenital adrenal hyperplasia) • 24-Hour urinary cortisol levels, early morning serum cortisol before 9 a.m. and dexamethasone suppression test (rule out Cushing syndrome) • Transvaginal scan (TVS) • Abdominal scan to rule any adrenal mass

A 30-year-old woman presents to GP with severe cyclical mastalgia. GP prescribes her Danazol 200 mg once daily for 3 months and arranges a follow-up after 3 months. When counselling this woman one should explain the following except that it a. Can cause osteoporosis with long-term use b. Can cause irreversible changes in voice c. Can cause virilisation of the female fetus if she gets pregnant d. Can cause oily skin and acne e. Should be avoided during pregnancy

Can cause osteoporosis with long-term use ( unlike (GNRH) analogues ) * It can also cause adverse blood lipid profile * One should use reliable contraception while using danazol as it can cause virilization of the female fetus if the woman gets pregnant * is not recommended to be used for more than 6 months.

One of the following is a recognised cause of gynaecomastia: a. Charcot-Marie-Tooth syndrome b. Down syndrome c. Klinefelter syndrome d. Lynch syndrome e. Turner syndrome

Klinefelter syndrome

A drug is a recognised cause of gynaecomastia:

Spironolactone (anti-androgen)

The causes of gynaecomastia include ..?

Idiopathic 58% Hypogonadism 25% Liver disease Hyperprolctinemia Hyperthyroidism

Patient has an abnormal cervical smear and biopsy results are reported as high-grade cervical glandular intraepithelial neoplasia (CGIN). This patient is at increased risk of a. Endometrial carcinoma b. Adenocarcinoma of cervix c. Serous ovarian carcinoma d. Endometrioid endometrial carcinoma e. Cervical sarcoma

Adenocarcinoma of cervix

of cytological abnormalities of the cervix, what is the percentage of Glandular abnormalities CGIN ?

0.05% (1 in 2,000) * coexists with cervical intraepithelial lesions (squamous) in 50% of cases

What is the management of CGIN ?

urgent colposcopy referral within 2 weeks ✅ If the margins of the first cone biopsy are not clear, it is reasonable to offer a repeat cone biopsy in order to exclude invasion and obtain negative margins. ✅A hysterectomy (preferably vaginally) should be offered if she has completed her family or does not wish to conceive in the future. ✅Close surveillance for 10 years of conservatively treated women should consist of cytology (with endocervical brush) and may be best managed in colposcopy clinic.

65-year-old, nulliparous woman presents to A&E with shortness of breath and cough. She is admitted under the acute medical team. Chest X-ray confirmed a right-sided pleural effusion. No malignant cells identified in the pleural aspirate. There was a large, firm abdominal mass palpated on examination of the abdomen with ascites. What is the most likely explanation for this presentation? a. Sheehan syndrome b. Meigs syndrome c. Atypical Meigs syndrome d. Neuroendocrine carcinoma e. Kikuchi disease

Meigs syndrome : ascites+ pleural effusion ( right sided) + ovarian fibroma .( Usually> 40y) Pseudo- Meigs syndrome : ascites+ pleural effusion ( right sided) + benign ovarian tumor other than fibromas ( mature teratoma...) Atypical Meigs syndrome : without ascites

LAPAROSCOPIC SURGERY: CONSENTING AND RISKS OF SURGERY The following risks are appropriate to discuss during consenting with this woman except a. The overall risk of serious complications is 2/1000 women. b. The risk of death is 100/100,000 because of complications. c. It may not be possible to enter the abdominal cavity. d. It may not be possible to complete the procedure laparoscopically due to extensive adhesions. e. Wound bruising may occur around the port sites

The risk of death is 100/100,000 because of complications. It is 8 / 100,000 ( and is not routinely discussed by doctors during consent.)

9. A 70-year-old woman with history of vaginal prolapse is referred to the gynaecology clinic by GP. Pelvic examination reveals procidentia. General examination reveals clear fluid-filled dome-shaped firm blisters on the arm, legs and bilateral groin. Her previous clinic letter reveals that she has been on long-term steroids for this condition. You see scarring of the previous blisters on the arm and legs. Previous biopsy and immunofluorescence studies show antibody deposits at dermo-epidermal junction. What is the most likely diagnosis of the skin condition in her case? a. Pemphigus vulgaris b. Bullous pemphigoid c. Psoriasis d. Erythema multiforme e. Dermatitis herpetiformis

Bullous pemphigoid

The following risks have been reported regarding administration of Intralipid other than a. Hypercoagulation b. Severe sepsis c. Disseminated intravascular coagulation (DIC) d. Allergic reaction e. Fetal teratogenicity

Allergic reaction

Intralipid use has been reported to be of benefit in one of the following conditions: a. Assisted conception b. Recurrent miscarriage c. Disseminated intravascular coagulation d. Local anaesthetic toxicity e. Anaphylaxis to intravenous iron

Local anaesthetic toxicity

She wishes to have endometrial ablation for treatment ( she suffers menorrhagia, dysmenorrhoea and past history of premenstrual syndrome. ) All the statements regarding her counselling this woman are true except a. Subsequent pregnancy should be avoided. b. Further contraception will be necessary c. Dysmenorrhoea will be relieved. d. Premenstrual syndrome will not be relieved. e. Approximately 20% will have no benefit with endometrial ablation

Dysmenorrhoea will be relieved

A 42-year-old woman with abnormal vaginal bleeding has an endometrial Pipelle biopsy. The histology shows endometrial hyperplasia. To treat her appropriately the following need to be determined except for a. The type of hyperplasia b. Malignant potential c. Fertility wishes d. Sources of any exogenous (e.g. tamoxifen) and endogenous (ovarian tumour) oestrogen e. Ethnic origin

Ethnic origin

What is the risk of endometrial hyperplasia with Atypia of progression to cancer?

8% in 4 years 12% in 9 years 27% in 19 years 🌟 Associated with carcinoma in situ in up to 43% of women undergoing hysterectomy

A 44-year-old woman is referred to a menopausal clinic with severe vasomotor symptoms and low mood. She has a history of oestrogen-receptor-positive and progesterone-receptor-negative breast cancer which was treated with wide local excision and radiotherapy. She is currently on tamoxifen. What would you prescribe to treat her menopausal symptoms? a. Selective serotonin reuptake inhibitors (SSRIs) b. Conjugated equine oestrogens c. Oestrogen and PG d. Topical vaginal oestrogen e. Clonidine

Clonidine SSRIs paroxetine and fluoxetine should not be offered to women with breast cancer who are taking tamoxifen. (The liver uses the cytochrome P450 enzymes to metabolise many drugs)

38-year-old woman is referred to gynaecology clinic by GP. She gives history of amenorrhoea for the past 6 months. She has two children delivered by caesarean section and regular periods prior to this. Her urine pregnancy test is negative. Her mother had premature menopause at the age of 30. The diagnosis in her case is based on a. Single elevated follicle-stimulating hormone (FSH) levels on blood test b. Elevated anti-müllerian hormone levels and inhibin A levels on blood test c. Elevated inhibin A levels on blood test d. Elevated FSH levels on two blood samples taken 4–6 weeks apart e. Single elevated FSH levels and anti-müllerian hormone levels on blood test

Elevated FSH levels on two blood samples taken 4–6 weeks apart

Which of the following is not an absolute contraindication for uterine artery embolisation? a. Asymptomatic fibroids in women <40 years of age b. Infection of the genital tract 3 weeks ago c. Pedunculated fibroid d. Sixteen weeks’ pregnancy e. Where a patient would refuse a hysterectomy under any circumstances due to social or cultural reasons even after appropriate counselling

Pedunculated fibroid

She delivered 20 days ago , She is hoping that lactation amenorrhoea method (LAM) will prevent her getting pregnant. Which one of the following will not increase the risk of her getting pregnant? a. Stopping the night feeds b. Supplementary feeding c. Increase in breastfeeding frequency d. Use of pacifiers e. Return of menstruation

Increase in breastfeeding frequency

Is LACTATION AMENORRHOEA METHOD (LAM) effective in preventing pregnancy.?

98% effective if : they are <6 months postpartum, amenorrhoeic and fully breastfeeding

When is it allowed to use COC for contraception in non breastfeeding women? & Breastfeeding women?

From day 21 for non breastfeeding women 6 months postpartum in breastfeeding women

When to start a hormonal method for contraception postpartum?

On or before day 21 If after day 21 should advise that she avoids sex or uses additional contraception for the first 7 days of use (2 days for the POP), unless fully meeting LAM criteria

When women can start progesterone only injection method postpartum?

Non breastfeeding 👉 any time Breastfeeding 👉 should not start it before day 21

When women can start progesterone only pills method postpartum?

Any time in breastfeeding & non breastfeeding

When IUD ( copper or LNG ) can be inserted after delivery?

Within 48 h Or until day 28 : Women should avoid sex or use additional contraception for 7 days after insertion unless fully meeting LAM criteria

Concerning the use of contraception methods in women with cardiac disease, which one of the following is a correct statement? a. Prophylactic antibiotics are recommended during insertion or removal of intrauterine contraception in women with an increased risk of infective endocarditis b. In women on warfarin therapy the risk of bleeding complication is very high during insertion of a progestogen-only implant and therefore its use should be restricted in these women c. The intrauterine device should be fitted in the hospital setting if the risk of vasovagal reaction is particularly high d. A causal association has been demonstrated between progestogen-only contraceptive and venous thromboembolism e. The cardiologist should always be involved in deciding whether to use an intrauterine contraceptive device

The intrauterine device should be fitted in the hospital setting if the risk of vasovagal reaction is particularly high * In women on warfarin therapy the risk of bleeding complications is small during insertion of a progestogen-only implant

A 28-year-old woman attends a family planning clinic for contraception advice. She has tested positive for BRCA1 gene. She has blood pressure (BP) of 140/92 at her last visit with GP. The following are true regarding contraceptive use for her except which one? a. She can be advised that there may be an additional risk of breast cancer with COC use b. She can be advised that there is a reduction in the risk of colorectal cancer with COC use c. In view of her being a BRCA1 gene carrier, her risk of ovarian cancer increases by 30% with COC use d. She can be advised that COC use provides a protective effect against endometrial cancer that continues for 15 years or more after stopping COC e. Hypertension may increase the risk of stroke and myocardial infarction (MI) in those using COC

In view of her being a BRCA1 gene carrier, her risk of ovarian cancer increases by 30% with COC use * this risk can be reduced by 60% by using COC pills.

What is the relationship between COC and benign breast diseases ?

there may be a reduction in the incidence of benign breast disease with CHC use ❎ But : there may be a small additional risk of breast cancer with CHC use, which reduces to no risk 10 years after stopping CHC use.

One of the following conditions does not fall into UKMEC (UK Medical Eligibility Criteria for Contraceptive Use) category 1 for using levonorgestrel intrauterine system (LNG-IUS) a. Infections including past pelvic inflammatory disease (PID) with subsequent pregnancy b. Schistosomiasis (with fibrosis of the liver) c. Non-pelvic tuberculosis or malaria d. Infections including past PID without subsequent pregnancy e. Superficial venous thrombosis (varicose veins or superficial thrombophlebitis)

Infections including past PID without subsequent pregnancy

What are the conditions that fall into UKMEC for Cu-IUD and the LNG-IUS: UKMEC category 2 ?

1- Past PID without subsequent pregnancy 2- Continuation if : current PID or purulent cervicitis 3- HIV, using highly active antiretroviral therapy [HAART]) or with current infection (excluding HIV and hepatitis) or vaginitis (Trichomonas vaginalis or bacterial vaginosis) . 4- Continuation in women with cervical cancer awaiting treatment or with endometrial or ovarian cancer

Which one of the following conditions falls into UKMEC category 3 for using a LNG-IUS? a. Complicated valvular and congenital heart disease b. Women with known pelvic tuberculosis c. Severe dysmenorrhoea d. Past history of breast cancer with no recurrence in the last 5 years e. Undiagnosed breast mass or carriers of gene mutations (e.g. BRCA1)

Past history of breast cancer with no recurrence in the last 5 years * • Continuation of LNG-IUS if a new diagnosis of ischaemic heart disease is made • If new symptoms of migraine with aura occur at any age • Active viral hepatitis • Cirrhosis or liver tumours (benign or malignant)

A 26-year-old woman para 1 chooses to have a LNG-IUS as a method of contraception. She has been using other forms of contraception. In which of the following scenarios mentioned below will this woman need the use of extra protection (condoms or abstinence) for 7 days after insertion? a. If the woman is within <12 weeks since last progestogen-only injection b. If the woman is within 3 years of insertion of a subdermal implant c. If the woman is no later than day 1 of the hormone-free interval for pills or patch d. If the woman is within 7 days post-abortion or miscarriage e. If the woman is partially breastfeeding, amenorrhoeic and less than 3 months’ postpartum

. If the woman is partially breastfeeding, amenorrhoeic and less than 3 months’ postpartum

A 20-year-old woman was brought to A&E with a history of sexual assault 4 days ago. The perpetrator had forced her to have vaginal intercourse (used condom) and also performed digital anal penetration. You are the doctor in A&E who is now collecting the samples for forensic medical examination. All the following samples are indicated for forensic medical examination except which one? a. Low vaginal swab b. Vulval swab c. Peri-anal swab d. High vaginal swab e. Anal canal swab

Anal canal swab

Gonorrhoea most commonly causes the following except for which one? a. Urethritis b. Proctitis c. Conjunctivitis d. Pharyngitis e. Endocarditis

Endocarditis

What is the incubation period of gonorrhoea ? What is the percentage of asymptomatic patients?

incubation period : 3-5 days asymptomatic patients : 50%

The following facts about chlamydia are true except for which one? a. It is the most common sexually transmitted infection (STI) in the United Kingdom b. 3%–7% of sexually active women under 24 years of age have this condition c. 70% of women can be asymptomatic d. Abnormal menstrual bleeding is not a symptom e. If untreated, it can cause sexually acquired reactive arthritis (SARA)

Abnormal menstrual bleeding is not a symptom

What is the most common sexually transmitted infection (STI) in the United Kingdom ?

chlamydia * 3%–7% of sexually active women under 24 years of age have this condition

Chlamydia is the most common STI in the United Kingdom. With regards to chlamydia pelvic infection, the following facts are true except for which one? a. It is effectively treated with doxycycline b. PID occurs in 10%–15% of untreated women attending GUM with chlamydia c. It is treated with erythromycin if diagnosed during pregnancy d. Eradication should be checked 4–6 weeks after treatment e. Barrier contraception helps to prevent re-infection

Eradication should be checked 4–6 weeks after treatment ( 3 months)

Chlamydia : How to make a diagnosis? Treatment? Complications if not treated?

✅ How to make a diagnosis : endocervical swab for NAAT + screening for STDs ✅ Treatment: Doxycycline 100 ( 1×2) for 14 days Or azythromycin 1g single dose In pregnancy: erythromycin ✅ If left untreated: PID 10-20% + infertility 5-18% + ectopic pregnancy+ perihepatitis+ chronic pelvic pain+ SARA ( sexually acquired reactive arthritis )

Chlamydia : How to make a diagnosis? Treatment? Complications if not treated?

If Chlamydia is detected prior to TOP and not treated what proportion of these women will develop postabortal pelvic infection ?

20%–25%

A 28-year-old woman attends antenatal clinic at 29 weeks of gestation. She recently had visited a sexual health clinic for investigation of her painless vulval ulcer and inguinal lymphadenopathy. What treatment would be appropriate for her from the following options? a. Benzathine penicillin G single dose as first-line therapy b. Azithromycin single dose as first-line therapy c. Two doses of benzathine penicillin G to be given 1 week apart d. Benzathine penicillin G three weekly doses as first-line therapy e. Tetracycline 100 mg three times a day for 14 days

Two doses of benzathine penicillin G to be given 1 week apart ⚡ Early syphilis : First and second trimesters: give benzathine penicillin G, single dose. In third trimester, a second dose of benzathine penicillin G to be given 1 week after the first. Ceftriaxone 500 mg IM ×10 days added to alternatives.

A 29-year-old woman attends antenatal clinic at 28 weeks of gestation. She gives a history of syphilis 2 years ago. She has recently been diagnosed with late syphilis and now advised to have a cerebrospinal fluid (CSF) examination test. The indications for CSF examination include all of the following except for which one? a. Ophthalmic signs and symptoms b. Syphilis treatment failure c. Neurological signs and symptoms d. Cardiovascular signs and symptoms e. HIV infection with late latent syphilis

Cardiovascular signs and symptoms

A 25-year-old woman presents to A&E with painful vulva. Examination reveals multiple ulcers (around the fourchette) with ragged undermined edges with necrotic base and purulent exudate. There was contact bleeding. Also noted were enlarged tender left inguinal lymph modes. The like diagnosis in her case is which of the following? a. Lymphogranuloma venerum b. Syphillis gummata c. Chancroid d. Donovanosis e. Type 2 herpes simplex infection

Chancroid

Chancroid Cause ? Induction period? Diagnosis? Treatment?

Caused by : haemophilus ducreyi Incubation period: 3-10 days Diagnosis: culture from the painful ulcer base Treatment: 1- azythromycin 1g 2 - ciprofloxacin 500 mg 3- ceftriaxon 250 mg IM ✅ Treatment in pregnancy: erythromycin 500 / 4 times a day for 7 days Or ceftriaxon 250 mg IM / single dose

What is the adverse antenatal outcomes of chancroid?

No adverse effects

A 23-year-old woman presents to the sexual health clinic with warty lesions on her vulva. Examination reveals warts on the vulva and the lower part of vagina but not obstructing the vagina. She is currently 16 weeks by dates and is booked for an anomaly scan at 20 weeks. How would you treat her at this stage? a. Podophylline b. Trichloroacetic acid c. 5-Fluorouracil d. Excision of all lesions under general anaesthesia e. Interferons

Trichloroacetic acid * or imiquimod

What are the treatment options of anogenital warts?

Podophyllin 👉 skin Trichloroacetic acid ( TCA) 👉 vaginal & cervical Imiquimod 👉 suitable for keratinized & non- keratinized warts

A 66-year-old woman is referred to the vulval clinic as a 2-week wait. She is para 2 with premature menopause. She has been taking hormone replacement therapy (HRT) for the last 27 years. She gives history of vulval itching, soreness and superficial dyspareunia. Clinical examination reveals erythematous changes within the vulval skin with fissuring, excoriation and oedema. Satellite lesions are seen on the inner thigh and lower abdomen. A probable diagnosis in her case is which of the following? a. Lichen sclerosis b. Lichen planus c. Candidiasis d. Donovanosis e. Lichen simplex

Candidiasis

When to offer Induction and maintenance therapy Management of vulvovaginal candidiasis?

If it is complicated : 1- Severe symptoms 2- Pregnancy 3- Recurrent vulvovaginal candidiasis (more than four symptomatic attacks per year). 4- Non-albicans species 5- Abnormal host (e.g. hyper-oestrogenic state, diabetes mellitus, immunosuppression)

A 35-year-old woman presented with a frothy vaginal discharge that is fishy in odour. On speculum examination, the cervix was red, punctate and inflamed. The wet mount shows the mobile organism. What is a likely diagnosis in her case? a. Trichomoniasis b. Candidiasis c. Bacterial vaginosis d. Chlamydia e. Donovanosis

Trichomoniasis * ‘strawberry cervix’ with its characteristic vascular pattern is only present in 2% of cases * Diagnosis rests on direct observation of the organism on a wet smear (mobile trichomonads are visible on the slide).

A woman who is 14 weeks pregnant presents with a thin vaginal discharge and fishy odour. She gives history of this getting worse before her periods and with sexual intercourse. On examination, the vulva and vagina looked normal and not inflamed. The diagnosis in her case is which of the following? a. Tricomoniasis b. Candidiasis c. Bacterial vaginosis d. Chlamydia e. Donovanosis

Bacterial vaginosis ( getting worse before her periods and with sexual intercourse.)

How to make a diagnosis of bacterial vaginosis ?

Diagnosis is made if >20% of cells are clue cells (and two of the following three criteria are met). • Discharge is thin and homogeneous. • Sample smells fishy when mixed with potassium hydroxide (whiff test). • Vaginal pH is >4.5.

20-year-old woman attends the sexual health clinic with symptoms of frothy, yellow vaginal discharge and associated lower abdominal pain. The organism can be seen when a drop of saline is added to the vaginal discharge placed on the slide. What is the most likely diagnosis? a. Chlamydia b. Trichomonas vaginalis c. Gonorrhoea d. Candida albicans e. Syphilis

Trichomonas vaginalis

A 16-year-old woman attends the sexual health clinic with a complaint of thin homogenous vaginal discharge for 2 weeks. A vaginal wet mount smear shows clue cells. What is the most likely diagnosis? a. Treponema pallidum b. ß-Haemolytic streptococci c. Gardnerella vaginalis d. Herpes simplex e. Donovanosis

Gardnerella vaginalis

For her future pregnancies pre-implantation genetic testing can be offered to detect the following, except which one condition? a. Cystic fibrosis b. Foetal sex c. Duchenne muscular dystrophy d. Spinal muscular atrophy type 1 ( Werdnig-Hoffman) e. Down syndrome

Duchenne muscular dystrophy

. Karyotyping report following amniocentesis is reported as 47XX,+21. The associated risks to the foetus include all except which one of the following? a. Hirschsprung disease b. Congenital heart disease c. Acute leukaemia d. Low IQ of 25–50 e. Spina bifida

Spina bifida

Down syndrome (trisomy 21). This is a condition which results from.... Incidence?

non-disjunction (95% of cases) or chromosomal translocation (5% of cases). Incidence: 1/700 live births

What is the quadruple test ? When is it performed?

between 16 and 18 weeks • AFP – produced by the baby • ß-hCG – produced in the placenta • Unconjugated oestriol (uE3) – produced in the foetus and placenta • Inhibin A – released by the placenta

When Low levels of maternal serum AFP is seen?

• Trisomy 21 • Trisomy 18 • Diabetes mellitus in mother

When High levels of maternal serum AFP is seen ?

• Anencephaly • Spina bifida • Duodenal atresia • Abdominal wall defects (exomphalos) • Tetralogy of Fallot • Intrauterine death of foetus • Multiple gestation

Which one of the following is not associated with Down syndrome? a. Clinodactyly of the little finger (fifth finger) b. Congenital deafness c. Non-disjunction d. Single palmar crease e. Atrial septal defect

Congenital deafness

What is the risk of miscarriage after CVS & amniocentesis?

CVS 2% Amniocentesis 0.5%

What would be the genetic complement and parental origin of the complete molar pregnancy? a. Haploid: two paternal sets b. Diploid: two paternal sets c. Triploid: paternal and maternal d. Tetraploid: two paternal and two maternal set e. Diploid: one maternal and one paternal set

Diploid: two paternal sets * 80% single sperm fertilises an empty egg followed by a duplication of all of the chromosomes. * 20% an empty egg is fertilised by two sperms

Genetic syndromes are associated with different gene mutations. The following are correctly matched except which one? a. Cowden syndrome: Germline PTEN mutations b. Hereditary breast and ovarian cancer BRCA1/BRCA2 c. Lynch syndrome: MSH6 d. Li-Fraumeni syndrome: Germline TP53 mutations e. Peutz-Jeghers syndrome: PMS2

Peutz-Jeghers syndrome: PMS2 ( STK11)

. What is the most likely chromosomal abnormality responsible for truncus arteriosus? a. Trisomy 13 b. Trisomy 21 c. Chromosome 22q11 deletions d. 46 XXY syndrome e. Trisomy 18

Chromosome 22q11 deletions ( in 40-50% of the cases)

What are the features of Chromosome 22q11 deletions (DiGeorge Syndrome). ?

1- cardiac abnormality especially tetralogy of Fallot + TRUNCUS ARTERIOSUS 2- cleft palate 3- thymic aplasia 4- hypoparathyroidism + hypocalcemia 5- learning disability

A 29-year-old woman is planning to conceive. Her brother is diagnosed with haemophilia A. The following offspring in her family are at risk of developing haemophilia in the scenarios described below except for which one? a. A female child whose mother is a carrier and has an affected father with haemophilia b. A male child of a healthy female silently carrying the faulty gene c. A male child whose father has the deficient gene d. A female child with Turner syndrome whose mother is carrying the deficient gene e. A male child with an affected cousin on his mother’s side

male child whose father has the deficient gene

Which one of the following statements is true regarding foetal isoimmune erythroblastic anaemia? a. Mirror syndrome is associated with maternal anaemia b. Doppler artery waveforms in the uterine artery predict foetal anaemia c. Anti-D levels are considered significant only above 60 IU/mL d. Repeated amniocentesis does not help in reliable monitoring of anti-Kell disease e. Middle cerebral artery Doppler waveforms accurately predict foetal anaemia

Middle cerebral artery Doppler waveforms accurately predict foetal anaemia * The mirror syndrome is seen in hydrops fetalis, when the mother develops pre-eclampsia and the severity of her condition ‘mirrors’ that of the foetus. * Anti-D levels are considered significant only above 4 IU/ml ( anti C above 7,5 IU/ml ) * Clinically significant antibodies should be monitored by titration testing every 2 to 4 weeks.

Triploidy can be associated with the following features except for which one? a. Partial hydatidiform mole b. Severe intrauterine growth restriction c. First-trimester spontaneous abortions d. Three sets of diploid chromosomes e. Fertilisation of diploid sperm

Three sets of diploid chromosomes

The following conditions are transmitted as autosomal dominant except for which one? a. Hereditary spherocytosis b. Von Hippel-Lindau syndrome c. Tuberous sclerosis d. Xeroderma pigmentosum e. Neurofibromatosis (von Recklinghausen disease)

Xeroderma pigmentosum

The following conditions except one manifest only when the individual is homozygous for the mutant allele. Which one is the exception? a. Galactosaemia b. G6PD deficiency c. Glycogen storage diseases d. Homocystinuria e. Marfan syndrome

Marfan syndrome

The following genetic conditions except one, only manifest when an individual is homozygous and heterozygous for the mutant allele. Which condition is the exception? a. Adult polycystic kidney disease b. Familial adenomatous polyposis coli c. Fanconi anaemia d. Gilbert syndrome e. Huntington chorea

Fanconi anaemia

What is the song about autosomal dominant disorders?

Von , Von , APK ,, Rb , MEN Tubes & spheres & Huntington Marfan , Ehler's Dan NF 1&2 don't FAP too much ✅ Von Willebrand's disease Von Hippel-Lindau disease Adult polycystic kidney disease Retinoblastoma Multiple endocrine neoplasia Tuberose sclerosis Hereditary spherocytosis Huntington chorea Marfan syndrome Ehlers-Danlos syndrome Neurofibromatosis types 1 and 2 Familial adenomatous polyposis

What is the song of X linked recessive disorders?

The itsy bitsy Hunter's, name was Lesch Fabry He shot the Meinke, WASP , and G6PD Up came Bruton, what a Duchenn guy A & B are X linked , don't forget DI ✅ Hunter's disease Lesch Nyhan syndrome Fabry disease Meinke disease Wiskott Aldrich's syndrome G6PD Bruton's Agammaglobulinemia Duchenne's muscular dystrophy Hemophilia A Hemophilia B Diabetes insipidus

The following can cause azoospermia except one condition. Which one is the exception? a. Cystic fibrosis carrier b. Kallmann syndrome c. Testosterone therapy d. Klinefelter syndrome e. Down syndrome

Down syndrome

Which one of the following is a recognised indication for ovum donation treatment in her case? a. Turner syndrome b. Kallmann syndrome c. Androgen-insensitivity syndrome d. Rokitansky syndrome e. Congenital adrenal hyperplasia

Turner syndrome

What percentage of women are affected by Premature ovarian failure ? chance of spontaneous pregnancy/year. ?

1% before the age of'40 5% before the age of 45 Sporadically 1%

Which of the following is not a risk factor for having a twin pregnancy? a. IVF b. Older age c. Personal history of monochorionic twins d. Maternal family history of dizygotic twins e. Japanese origi

Personal history of monochorionic twins

cycle of IVF treatment. Which of the following will not reduce the success rate of IVF pregnancy? a. Rising age b. Previous unsuccessful IVF cycle c. Body mass index (BMI) 35 d. Consumption of less than one unit of alcohol twice a week e. Smoking

Consumption of less than one unit of alcohol twice a week ✅Consumption of less than one unit of alcohol per a day

Which one of the following parameters is an abnormal result? a. Percentage of abnormal form: 85% b. Progressive motility: 35% c. pH: 7.12 d. Total sperm number: 40 million e. Semen volume: 2 mL

pH: 7.12 ✅ • Semen volume: 1.5 mL or more • pH: 7.2 or more • Sperm concentration: 15 million spermatozoa per millilitre or more • Total sperm number: 39 million spermatozoa per ejaculate or more • Total motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility • Vitality: 58% or more live spermatozoa • Sperm morphology (percentage of normal forms): 4% or more

Which one of the following results indicates a higher response to gonadotrophin stimulation? a. Oestradiol level 266 IU/L b. FSH 9 IU/L for a high response c. Anti-müllerian hormone of 25.5 pmol/L d. Ovarian volume of 15 cc e. Total antral follicle count of 4

Anti-müllerian hormone of 25.5 pmol/L ❎ low response : Total antral follicle count of ≤4 Anti-müllerian hormone of ≤5.4 pmol/L FSH >8.9 IU/L ✅ high response : Total antral follicle count of > 16 Anti-müllerian hormone of ≥25 pmol/L FSH < 4 IU/L

A 30-year-old Asian woman is referred to the fertility clinic. She has been trying to conceive for the last 14 months. Her recent HyCoSy scan reveals a normal uterine cavity and tubes. A day 21 serum progesterone level is reported to be 31 ng/mL. Her husband’s semen analysis results are reported as follows: Percentage of abnormal form: 85% Progressive motility: 35% pH: 7.22 Total sperm number: 40 million Semen volume: 2 mL How should she be managed regarding her subfertility? a. IVF with intra-cytoplasmic sperm injection (ICSI) b. Clomiphene citrate for three cycles followed by IUI c. Clomiphene citrate and IUI d. Advise regular unprotected intercourse at least three times a week e. Clomiphene citrate for six cycles followed by IUI

Advise regular unprotected intercourse at least three times a week

A 38-year-old Asian woman has been referred to the infertility clinic. She has been trying to conceive for the last 2 years with her menstrual cycles every 6 weeks. Her ultrasound scan shows two small intramural fibroids and two large subserosal fibroids and polycystic ovaries. Her husband’s semen analysis is normal. A recent HyCoSy scan of the uterine cavity and tubes is normal. Her serum progesterone level is reported to be 20 ng/mL. She smokes five cigarettes per day and her BMI is 35. She has one child from her previous partner. She wants to discuss her current options for IVF treatment. What would be the next course of management in her case? a. Laparoscopic myomectomy b. Clomiphene citrate for six cycles c. Clomiphene citrate for six cycles with IUI after three cycles d. Lifestyle modifications and advise weight loss e. Offer IVF as she has been trying for 2 years

Lifestyle modifications and advise weight loss BMI should be< 30

A 20-year-old woman presents to the early pregnancy assessment unit with abdominal pain. An ultrasound scan reveals left tubal ectopic pregnancy of 3.5 × 3 cm. She undergoes laparoscopy and the findings are as follows: Left tubal unruptured ectopic pregnancy of 3 cm with normal right fallopian tube. Minimal endometriosis in the pouch of Douglas with extensive bowel adhesions on the right side due to previous appendisectomy. Uterus is bulky but normal. How should she be managed? a. Left salpingostomy with treatment of endometriosis b. Left salpingectomy with adhesiolysis c. Left salpingostomy with adhesiolysis and treatment of endometriosis d. Left salpingectomy e. Abandon laparoscopy and treat with medical management (methotrexate)

Left salpingectomy * in the presence of contralateral tubal disease and the desire for future fertility. The woman should be warned about the risk of persistent trophoblast and the 20% risk of ectopic pregnancy with salpingostomy * risk of recurrence in future pregnancies (10%)

A clinical diagnosis of suspected ovarian torsion is made as there is marked tenderness as well as guarding on abdominal palpation. An ultrasound scan reveals a large ovarian dermoid cyst on the left side (9 × 7 × 8 cm) with absent blood flow. Bloods reveal leucocytosis and raised C-reactive protein. A laparotomy is performed in view of clinical suspicions of ovarian torsion. Intra-operative findings reveal the following: • Normal right ovary • Torsion of ovarian pedicle × 3 loops (left ovary) • Left ovary appears non-viable • Normal fallopian tubes and uterus • Normal rest of pelvis and abdomen with no ascites Her surgical management includes which one of the following? a. Left salpingo-oophorectomy b. Left salpingectomy and left ovarian cystectomy c. Left ovarian cystectomy d. Left-sided oophorectomy e. Left-sided oophorectomy and peritoneal washings

Left-sided oophorectomy and peritoneal washings

She is pushed to theatre for crash caesarean section. What is her risk of bladder injury? a. 4–6/10,000 b. 1/1000 c. 3/1000 d. 5/1000 e. 1–2/100

1/1000

What are her chances of death if she has a planned cesarean section at 39 weeks of gestation? a. 15/100,000 b. 13/100,000 c. 11/100,000 d. 5/100,000 e. 1/100,000

13/100,000

A 15-year-old girl presents to the early assessment unit at 9 weeks of gestation with mild vaginal bleeding. An ultrasound scan reveals a missed miscarriage. The on-call doctor discusses pros and cons of medical versus surgical management with her. This girl prefers surgical management. What would be her risk of uterine perforation? a. Up to 2/1000 b. Up to 4/1000 c. Up to 5/1000 d. Up to 3/100 e. Up to 1/100

Up to 5/1000

She was taken to theatre for diagnostic laparoscopy. A Veress needle was inserted for gas insufflation. What is the recommended pressure for port insertion? a. 10 mm of Hg b. 15 mm of Hg c. 20 mm of Hg d. 25 mm of Hg e. 30 mm of Hg

20 mm of Hg

She was taken to theatre for diagnostic laparoscopy. She had one suprapubic 7 mm port, one 10 mm umbilical port and one lateral 7 mm port on the left side and one lateral 5 mm port on the right side. Which of the following port sites rectus sheath should be closed with Vicryl 1? a. All port sites b. 7 mm lateral port, 7 mm suprapubic port and 10 mm umbilical port c. 7 mm suprapubic port and 10 mm umbilical port d. 7 mm lateral port and 5 mm lateral port e. Only 10 mm umbilical port

7 mm suprapubic port and 10 mm umbilical port ( midline incisions)

A 56-year-old woman has a staging laparotomy for stage 3 ovarian cancer. The following measures improve the best possible outcome with regards to abdominal incisions except for one. Which statement is the exception? a. Making a transverse suprapubic skin incision has cosmetic advantages compared with longitudinal incisions but may not allow adequate access b. A subcuticular suture also improves the cosmetic appearance and enhances postoperative comfort c. Longitudinal incisions (particularly midline) are more likely to be complicated by the development of wound dehiscence and incisional hernia d. Mass closure of longitudinal incisions reduces the risk of complete abdominal wound dehiscence and incisional hernia e. Closure of peritoneal surfaces decreases the risk of intestinal obstruction resulting from adhesions

Closure of peritoneal surfaces decreases the risk of intestinal obstruction resulting from adhesions (✅ increase)

Which of the following statements is incorrect regarding the degree of perineal tears? a. First degree – injury to the perineum involving just the skin b. First degree – injury to the perineum involving both skin and the transverse perineal muscle c. Second degree – injury to the perineum not involving the anal sphincter d. Third degree – injury to the perineum involving the anal sphincter complex e. Fourth degree – injury to the perineum involving the rectal mucosa

First degree – injury to the perineum involving both skin and the transverse perineal muscle

She has tried Mirena but this has not reduced her bleeding. She undergoes a NovaSure endometrial ablation. Which one of the following expectations might not be met? a. Dysmenorrhoea might not be relieved b. Premenstrual syndrome might not be relieved c. Subsequent pregnancy is not contraindicated d. Successful reduction in bleeding occurred in 98% of the patients by 12 months e. Subsequent contraception will not be required

Successful reduction in bleeding occurred in 98% of the patients by 12 months ( 40-50%)

A 48-year-old woman undergoes laparoscopic hysterectomy and bilateral salpingo-oophorectomy, pelvic lymphadenectomy, peritoneal washings and bowel adhesiolysis for International Federation of Gynecology and Obstetrics (FIGO) stage Ib, high-grade serous endometrial cancer. Her blood loss was 1000 mL. A peritoneal pelvic drain is inserted. Her observations are stable and she is apyrexial. Her abdominal drain is straw-coloured fluid and is 500 mL on day 2. Her haemoglobin (HB) is 9 gm% and serum creatinine is 75. Drain fluid creatinine is reported as 90. What is the diagnosis in her case? a. Urinoma b. Ureteric injury c. Ascites d. Lymphocele e. Pelvic collection

Lymphocele

Which of the following is not a sign or symptom of urinary tract injury in her case? a. Persistent loin pain b. Poor urine output in the presence of normal postoperative observations – urine leaking into peritoneal cavity c. Anuria d. Urine draining vaginally e. Persistent very heavily bloodstained urine postoperatively with later leakage of fluid into the vagina f. Only straw colour fluid in the peritoneal drain

Only straw colour fluid in the peritoneal drain

You are suspecting a ureteric injury or occlusion. What is most important investigation that would help in making a diagnosis of ureteric injury or occlusion? a. Computed tomography (CT) scan pelvis with contrast b. Magnetic resonance imaging (MRI) scan pelvis with contrast c. Intravenous urogram d. Positron emission tomography (PET) scan of kidney, ureter and bladder e. Cystoscopy and methylene blue test

Intravenous urogram

While dissecting the pelvic side wall, the consultant notices right ureteric injury close to the bladder edge. The urologist on call has been called for opinion and repair. What would be recommended management for her surgically? a. Right ureter repair and ureteric stenting b. End-to-end anastomosis of the ureter and ureteric stenting c. Stenting of the ureter d. Foley catheter for 2 weeks and stenting of the ureter e. Ureteric re-implantation into the bladder using a psoas hitch to relieve tension of the repair

Ureteric re-implantation into the bladder using a psoas hitch to relieve tension of the repair

A 44-year-old woman undergoes laparoscopic subtotal hysterectomy for fibroids with a blood loss of 500 mL. On day 2 (36 hours post-operation) she develops abdominal pain and looks pale. Her haemoglobin (HB) is reported as 7.8 gm% (pre-operative HB: 13 gm%). She is clinically stable and apyrexial with good urine output. She herself is an A&E nurse and is asking for blood transfusion. You are the registrar on call and have been asked to review this woman and make a plan of management. What should be her immediate management? a. Laparotomy and drainage of pelvic haematoma b. Intravenous cannulas, blood transfusion ×2 units, antibiotics, withhold Clexane, close monitoring and repeat HB after transfusion c. Drainage of vault haematoma through the vault d. Image-guided (CT scan) drainage of haematoma through abdominal drain e. Laparoscopic drainage of the haematoma

Intravenous cannulas, blood transfusion ×2 units, antibiotics, withhold Clexane, close monitoring and repeat HB after transfusion