Selected Notes obgyn 1

Question 1

How can urinary incontinece be characterised?

Answer 1

1. Overactive bladder/urge incontinence<br></br>2. Stress incontinence<br></br>3. Mixed incontinence<br></br>4. Overflow incontince<br></br>5. Functional incontinence

Question 2

How is urinary incontinence investigated?

Answer 2

1. Physical exam-in some cases to rule out pelvic organ prolapse and ability to contract pelvic floor muscles<br></br>2. Bladder diary-minimum of 3 days<br></br>3. Urinalysis-rule out infection<br></br>4. Urodynamic studies-cystometry and cystogram

Question 3

Describe the management of stress incontinence

Answer 3

Conservative: avoid caffeine and fizzy drinks and excessive fluid intake<br></br>-Pelvic floor exercises<br></br>Medical: Duloxetine-ONLY if conservative doesn’t work and patients doesn’t want surgery<br></br>Surgical: GS: Mid urethral slings<br></br>Other surgeries: Incontinence pessaries, bulking agents, colposuscpension and fascial slings 

Question 4

In the gold standard surgical management of stress incontinence, mid-urethral slings {{c1::compress the urethra against a supportive layer}} and assist in the {{c2::closure of the urethra}} during {{c3::increased intra-abdominal pressures}}

Question 5

In the surgical management of stress incontinence, {{c1::colposuspension and fascial slings}} involve <span>s</span>{{c2::uspending the anterior vaginal wall}} <span>to the </span>{{c3::iliopectineal ligament of Cooper}}

Question 6

Describe the general conservative management of incontinence

Answer 6

Lifestyle advice: avoid caffeine and fizzy drinks, avoid excessive fluid intake<br></br>Pelvic floor exercises

Question 7

Describe the medical management of urge incontinence

Answer 7

Anticholinergics(antimuscarinics): inhibit the parasympathetic action of the detrusor muscle<br></br>-Oxybutinin, tolterodine, etc<br></br><br></br>

Question 8

Describe the symptoms of a genital prolapse

Answer 8

<ul><li>Pelvic discomfort or a sensation of 'heaviness'</li><li>Visible protrusion of tissue from the vagina</li><li>Urinary symptoms such as incontinence, recurrent urinary tract infections or difficulties voiding</li><li>Defecatory symptoms, including constipation or incomplete bowel emptying</li><li>Sexual dysfunction</li></ul>

Question 9

Describe the management of a gential prolapse

Answer 9

If asymptomatic and mild: no treatment <br></br>Conservative: Weight loss, smoking cessation, avoid heavy lifting, pelvic floor exercises<br></br>Ring pessary<br></br>Surgery

Question 10

Describe the surgical management for a cystocele

Answer 10

Anterior colporrhaphy, colposuspension

Question 11

Describe the symptoms of a vaginal fistula

Answer 11

Incontinence-especailly if vesicovaginal(bladder and vagina)<br></br>Also: diarrhoea, nausea, vomiting, weight loss<br></br>

Question 12

How is a vaginal fistula diagnosed?

Answer 12

Pelvic exam<br></br>Cystoscopy and urodynamic studies<br></br>Imagin<br></br>

Question 13

Describe the management of vaginal fistulas

Answer 13

Conservative: catheterisation, antibiotics to prevent/treat infection<br></br>Surgical: fistula repair, tissue grafts<br></br>

Question 14

Describe the aetiology of uterine fibroids

Answer 14

Unknown<br></br>Genetic, hormonal and environmental factors<br></br>

Question 15

How can uterine fibroids cause polycythaemia?

Answer 15

Secondary to autonomous production of erythropoeitin

Question 16

How are uterine fibroids diagnosed

Answer 16

<ul><li>Trans-vaginal ultrasound: Used to assess the size and location of the fibroids</li><li>MRI: Used if ultrasound does not provide enough detail to assess the fibroid for surgery</li><li>Biopsy: May be taken if there is any doubt over the diagnosis to differentiate the fibroid from other conditions such as endometrial cancer</li></ul>

Question 17

Describe the management of <b>asymptomatic</b> fibroids

Answer 17

No treatment, just review to monitor growth and size

Question 18

Describe the management of menorrhagia secondary to fibroids

Answer 18

Levonorgestrel intrauterine system (LNG-IUS)-Mirena coil first line<br></br>Mefenamic and TXA<br></br>COCP and oral/injectable progesterone

Question 19

How does red degeneration of fibroids present?

Answer 19

-Severe abdominal pain<br></br>-Low grade fever<br></br>-Tachycardia<br></br>-Vomiting

Question 20

How is red degeneration of fibroids managed?

Answer 20

Supportive: rest, fluids and analgesia

Question 21

Describe the aetiology of ovarian cysts

Answer 21

<span>Hormonal imbalances, endometriosis, pregnancy and pelvic infections.</span>

Question 22

Describe some symptoms of an ovarian cyst

Answer 22

-Asymptomatic<br></br>-Acute unilateral pain<br></br>Bloating/fullness in the abdomen<br></br>-Intra-peritoneal haemorrhage with haemodynamic compromise<br></br>

Question 23

Describe the management of a simpole ovarian cyst in premenopausal women

Answer 23

<5cm: often resolve within 3 cycles<br></br>5-7cm: gynae referral and yearly US<br></br>>7cm: consider MRI or surgical evaluation-difficult to characterise with US

Question 24

Describe the management of ovarian cysts in postmenopausal women

Answer 24

Post-menopausal->concerning for malignancy<br></br>Check Ca125 and referall to gynaecology<br></br>High Ca125: 2 week cancer list<br></br>Normal Ca125: if simple cyst and <5cm: mUS every 4-6 months

Question 25

How are persistent or enlarging ovarian cysts treated?

Answer 25

Surgical intervention-laparoscopy-> ovarian cystectomy, sometimes with affected oophorectomy

Question 26

How can benign ovarian cysts becharacterised?

Answer 26

1. Physiological/functional cysts
2. Benign germ cell tumours
3. Benign epithelial tumours
4. Benign sex cord stromal tumours

Question 27

Follicluar cysts represent {{c1::the developing follice.}} When these {{c1::fail to rupture and release the egg,}} the cyst can persist. Typically on US they have {{c1::thin walls and no internal structures}}

Question 28

Corpus luteum cysts occur when the corpus luteum fails to break down and instead {{c1::fills with fluid.}} They may cause symptoms such as {{c1::pelvic discomfort, pain or delayed menstruation.}} They are often seen in {{c1::early pregnancy.}} 

Question 29

An endometrioma is a lump of {{c1::endometrial tissue}} within the ovary, occurring in patients with {{c1::endometriosis.}} They can cause {{c1::pain}} and disrupt {{c1::ovulation.}}

Question 30

Dermoid cysts/germ cell tumours are {{c1::benign ovarian teratoma}}s-> come from {{c1::germ cells}}. Can contain tissue types like {{c1::skin, teeth hair and bone.}} . {{c1::Torsion}} is more likely than with other ovarian tumours

Question 31

Describe the pathophysiolgy of an ovarian torsion

Answer 31

Twisting of the adnexa and blood supply to the ovary leads to ischaemia. If the torsion persists, necrosis will occur, and the function of that ovary will be lost.

Question 32

Describe the presentation of a patient with ovarian torsion

Answer 32

• Sudden onset severe unilateral pelvic pain
• Pain is constant and gets progressively worse
• Associated with nausea and vomiting

Pain can also come and go if ovary twists and untwists intermittently 

Question 33

How is ovarian torsion diagnosed?

Answer 33

1st line: Pelvic US(transvaginal ideally, transabdominal as backup)->'whirlpool sign' free fluid in pelvis and oedema or ovary
Doppler-> reduced blood flow
Definitive-> laparoscopic surgery

Question 34

Describe the management of ovarian torsion

Answer 34

• Urgent admission and gynae involvemebt
• Laparoscopic surgery to:

1. Untwist the ovary and fix it in place(de-torsion)
2. Remove the affected ovary (oophorectomy)

Laparotomy may be needed if large ovarian mass or malignancy is suspected

Question 35

Describe the aetiology of lichen sclerosus

Answer 35

Thought to be autoimmune reaction-associated with T1DM
Also genetics and hormonal factors

Question 36

Describe a typical presentation of a patient with lichen sclerosus

Answer 36

45-60yr old woman
Vulval itching
Soreness/pain
Skin tightness

• Painful sex (superficial dyspareunia)
• Erosions
• Fissures

Koebner phenomenon

Question 37

Describe the appearance of lichen sclerosus

Answer 37

• “Porcelain-white” in colour
• Shiny
• Tight
• Thin
• Slightly raised
• There may be papules or plaques

Question 38

How is lichen sclerosus diagnosed?

Answer 38

• Mostly clinical
• Skin biopsy can be used to confirm the diagnosis-usually done if atypical features are present(e.g. doesn't respond to treatment, clinical suspicion of cancer etc)
• Blood tests to check for potential autoimmune conditions

Question 39

Describe the management of lichen sclerosus

Answer 39

• Topical corticosteroids(dermovate) to reduce inflammation and itching
• Avoidance of soap in affected areas to prevent further irritation
• Emollients to relieve dryness and soothe itching

Question 40

Cervical cancer:
2 main tumour suppressor genes: {{c1::P53 and pRb}}
HPV produces 2 main proteins: {{c2::E6 and E7}}

E6 protein inhibits {{c2::p53}} and E7 inhibits {{c2::pRb}}

Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.

Question 41

At what age are children vaccinated against HPV?

Answer 41

age 12-13 yrs

Question 42

Describe the signs and symptoms of cervical cancer

Answer 42

• Most commonly picked up on screening incidentally
• Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding)
• Vaginal discharge
• Pelvic pain
• Dyspareunia (pain or discomfort with sex)
• Urinary/boewl habit change
• Abnormal white/red patches on cervix
• Mass on PR exam

Question 43

How is cervical cancer investigated and diagnosed?

Answer 43

-If symptoms-> speculum exam and smear test
If abnormal appearance of cervice-> urgen cancer referral for colposcopy

Question 44

How is the cervical intraepithelial neoplasia determined?

Answer 44

Colposcopy NOT screening

Question 45

Grades of cervical intraepithelial neoplasia:

• CIN I: {{c1::mild}} dysplasia, affecting {{c1::1/3 t}}he thickness of the {{c1::epithelial layer,}} likely to r{{c1::eturn to normal}} without treatment
• CIN II: {{c2::moderate}} dysplasia, affecting {{c2::2/3}} the thickness of the {{c2::epithelial layer}}, l{{c2::ikely to progress to cancer}} if untreated
• CIN III: {{c2::severe}} dysplasia, {{c2::very likely to progress}} to cancer if untreated

Question 46

Cervical cancer screening:
Offered to all women between ages {{c1::25-64 years}}

• 25-49yrs: {{c2::3}} yearly screening
• 50-64yrs: {{c3::5}} yearly screening

Cannot be offered to women over {{c4::64 years}}

Question 47

Describe the results obtained from cervical cancer screening cytology

Answer 47

• Inadequate
• Normal
• Borderline changes
• Low-grade dyskaryosis
• High-grade dyskaryosis (moderate)
• High-grade dyskaryosis (severe)
• Possible invasive squamous cell carcinoma
• Possible glandular neoplasia

 

Question 48

A cone biopsy is a treatment for {{c1::cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer. }}It involves a general anaesthetic. The surgeon removes a cone-shaped piece of the cervix using a {{c1::scalpel.}} This sample is sent for histology to assess for {{c1::malignancy.}}

Question 49

Bevacizumab (Avastin) targets{{c1:: vascular endothelial growth factor A (VEGF-A),}} which is responsible for {{c2::the development of new blood vessels.}} Therefore, it {{c3::reduces the development of new blood vessels}}. 

Question 50

Endometrial cancer is a malignancy that originates from the {{c1::endometrium}}-the {{c1::inner}} lining of the uterus

Question 51

Endometrial cancer:
All women {{c1::>=55yrs}} presenting with {{c1::postmenopausal bleeding}} should be referred using the suspected cancer pathway

Question 52

How is endometrial cancer investigated?

Answer 52

• first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
• hysteroscopy with endometrial biopsy

Question 53

How is endometrial cancer managed?

Answer 53

Surgery: hysterecotmy with bilateral alpingo-oophorectomy-can be curative if limited
Radio/chemotherapy
Progesterone therapy sometimes used in frail elderly women not suitable for surgery

Question 54

Describe the outcomes of endometrial hyperplasia

Answer 54

1. Most return to normal
2, <5% become cancer

Question 55

How is endometrial hyperplasia treated?

Answer 55

1. Intrauterine system(mirena coil)
2. Continuous oral progesterones(levonorgestrel)

Question 56

How does adipose tissue result in increased oestrogen levels?

Answer 56

• Contains aromatase->converts androgens.
• More adipose tissue->more androgens converted to oestrogen

Question 57

How common is ovarian cancer?

Answer 57

5th most common malignancy in femals

Question 58

Epithelial ovarian tumours are partically {{c1::cystic}} so can contain {{c1::fluid}}

Question 59

How do germ cell ovarian tumours typically spread?

Answer 59

Via lymphatics

Question 60

Describe the presentation of ovarian cancer

Answer 60

• Typicall present layte-non-specific symptoms
• Abdominal pain
• Bloating
• Ealry satiety
• Urinary frequency or change in bowel habits

Later stages:

• Ascites(vascular growth factors increasing vessel permeability)
• Pelvic, back and abdominal pain
• Palpable pelvic or abdominal mass

Question 61

How is CA125 used to guide further investigations when investigting a patient for possible ovarian cancer?

Answer 61

• Raised CA125(>=35IU/mL)-> urgent US of abdomen and pelvis

Question 62

How is ovarian cancer treated?

Answer 62

Surgery:

• If early disease-remove uterus, fallopian tubes, ovaries and infracolic omentectomy
• Advanced-debulking surgery

Adjuvant/intraperitoneal chemotherapy

Biologics

Question 63

Describe the prognosis of ovarian cancer

Answer 63

80% have advanced disease at presentation
All stage 5 year survival is 46%

Question 64

An ovarian mass may press on the {{c1::obturator}} nerve and cause referred {{c2::hip or groin}} pain. 

Question 65

How common is vulval cancer?

Answer 65

Rare-4% of gynae cancers

Question 66

At what age are the majority of vulval cancers diagnosed?

Answer 66

>60 years

Question 67

Describe the clinical features of a patient with vulval cancer

Answer 67

• Lump on labia majora
• Inguinal lymphadenopathy
• Itching/discomfort in vulval area
• Non healing ulcer
• Changes in skin colour/thickening of vulva
• Bleeding/discharge not related to the menstrual cycle

Question 68

How is vulval cancer managed?

Answer 68

Surgery

• Radical/wide local excision
• Radical vulvectomy for multi-focal disease
• Reconstructive surgery
• Radioterhapy.chemo

Question 69

A molar pregnancy, also known as a {{c1::hydatidiform mole}}, forms part of a spectrum of disorders known as {{c2::gestational trophoblastic disease}}. It is characterized by an imbalance in the {{c3::number of chromosomes}} originating from the mother and father during conception.

Question 70

How can molar pregnancies be characterised?

Answer 70

• Complete
• Partial

Question 71

Describe the presentation of a patient with a hydatidiform mole

Answer 71

• Vaginal bleeding
• Enlargement of uterus beyond the expected size for gestational age
• Nausea and hyperemesis gravidarum
• Thyrotoxicosis

Question 72

How can a molar pregnancy cause enlargement of the uterus?

Answer 72

Excessive growth of trophoblasts and retained blood

Question 73

How can a molar pregnancy cause thryotoxicosis?

Answer 73

HCG closely related to TSH so able to activate receptors

Question 74

How is a molar pregnancy diagnosed?

Answer 74

B-HCG->higher than normal 
Trans-vaginal US->'snowstorm' appearance, low resistance of blood vessel flow and absence of a foetus

Question 75

How are molar pregnancies managed?

Answer 75

• Immediate referral to a specialist centre for treatment is necessary to reduce the risk of potential complications such as choriocarcinoma or invasion.
• As molar pregnancies are not viable, they are managed with suction curettage to remove them from the uterus.
• When fertility preservation is not a concern, a hysterectomy may be performed.
• Surveillance is recommended, including:
  • Bimonthly serum and urine hCG testing until levels are normal.
  • In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance.
  • In a complete mole, monthly repeat hCG samples are sent for at least 6 months.

Question 76

How common is endometriosis?

Answer 76

Common-10% of women in reproductive years

Question 77

Describe the symptoms of endometriosis

Answer 77

• Chronic pelvic pain
• Dysmenorrhoea
• Dyspareunia
• Subfertility
• Non-gynaecological-> dysuria, urgency, haematuria
• Cyclical rectal bleeding, if endometrium-like tissue grows outside the female reproductive system

Question 78

Describe the medical management of endometriosis

Answer 78

• Analgesia->paracetemol/NSAIDs
• Hormonal therapies-> COCP, medroxyprogesterone acetate, Gonadotrophin releasing hormone agonists

Question 79

Describe the surgical management of endometriosis

Answer 79

• Diathermy of lesions
• Ovarian cystectomy(for endometriomas)
• Adhesiolysis
• Bilateral oophorectomy(sometimes hysterectomy)

Question 80

How do patients with adenomyosis typically present?

Answer 80

• Asymptomatic
• Dysmenorrhoea
• Menorrhagia
• Dyspareunia
• Infertility or pregnancy-related complications

Question 81

Describe the management of adenomyosis

Answer 81

Symptomatic: TXA/mefenamic acid

1. Mirena coil(first line)
2. COCP
3. Cyclical oral progesterones

GnRH agonists

Uterine artery embolisation

Hysterecomy-definitive treatment

Question 82

How is andorgen insensitivity syndrome diagnosed?

Answer 82

• Buccal smear or chromosomal analysis to reveal 46XY genotype
• After puberty: hormonal tests

Question 83

Describe the presentation of a patient with atrophic vaginitis

Answer 83

• Vaginal dryness and discharge
• Dyspareunia
• Occasional spotting
• Loss of pubic hair
• Urinary symptoms like dysuria and recurrent UTI

Question 84

Describe the management of atrophic vaginitis

Answer 84

• Hormonal treatment:
  • Systemic hormone-replacement therapy (oral or transdermal)
  • Topical oestrogen preparations
• Non-hormonal treatments:
  • Lubricants, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia
  • Moisturisers, which should be used regularly
• Transvaginal laser therapy, although not currently recommended due to lack of evidence

Question 85

Describe the management of a miscarriage

Answer 85

• Conservative: Allow POC to pass naturally-> repeat scan/pregnancy test
• Medical: vaginal misoprostol
• Surgical

Question 86

How does vaginal misoprostol work as medical management for a msicarriage?

Answer 86

• Stimulates cervical ripening and myometrial contractions

Question 87

Describe the features of a threatened pregnancy

Answer 87

• Painless vaignal bleeding <24 weeks(usually 6-9 weeks)
• Bleeding but often less than menstruation
• Cervical os closed

Question 88

How is a threatened pregnancy treated?

Answer 88

• Reassurance
• If heavy: admit and observe
• If >12 weeks, and rhesus negative: Anti D

Question 89

Describe the features of an inevitable pregnancy

Answer 89

• Heavy bleeding
• Clots
• Pain
• Cervical os open

Question 90

How is an inevitable miscarriage treated?

Answer 90

• Reassurance, if heavy bleeding then admit and observe
• If >12 weeks and rhesus negative : Anti D
• Likely to proceed to a complete/incomplete miscarriage

Question 91

Describe the features of a missed/delayed pregnancy

Answer 91

• Gestational sac containing a dead fetus <2 weeks without symptoms of expulsion
• Cervical os closed
• Asymptomatic, light bleeding, discharge, pregnancy symptoms which disappear

Question 92

How is a missed/delayed miscarriage treated?

Answer 92

• Reassurance, if heavy bleeding admit for observation
• Low success rate

Question 93

Describe the features of an incomplete miscarriage

Answer 93

• POC partly expelled
• Symptom of bleeding.clots
• Cervical os open

Question 94

How might a patient with a complete miscarriage present?

Answer 94

• History of bleeding
• Clots
• POC
• Pain
• Symptoms settled

Question 95

How are patients with complete miscarriages managed?

Answer 95

• Discharged to GP

Question 96

Describe the symptoms of a septic miscarriage

Answer 96

• Infected POC
• Rigors
• Fever
• Bleeding
• Leukocytosis
• Increased CRP

Question 97

How is a septic miscarriage treated?

Answer 97

• IV antibiotics and fluids
• Medical/surgical treatment

Question 98

Describe the symptoms of a patient with an ectopic pregnancy

Answer 98

• Pelvic pain: can be unilateral
• Shoulder tip pain-irritation of diaphragm by intra-abdominal bleeding
• Vaginal discharge/bleeding-decidua breaking down

Question 99

Describe the conservative management of an ectopic pregnancy

Answer 99

• Close follow up and repeat B-HCG's
• Not usually done

Question 100

Describe the medical management of an ecoptic pregnancy

Answer 100

• IM methotrexate
• Regular B-HCG checks : >15% decline by day 4/5 or repeat methotrexate

Question 101

How does methotrexate work as treatment in a patient with an ectopic pregnancy?

Answer 101

• Disrupts folate dependent cell division

Question 102

Describe the surgical management of an ectopic pregnancy

Answer 102

1. Tubal ectopics: laparoscopic salpingectomy (remove ectopic and tube)
2. If only one tube left: salpingotomy (cut in fallopian tube and remove ectopic)

B-HCG follow up until <5iU(negative)-> check for residual trophoblast

Question 103

How does amniotic fluid normally change throughout pregnancy?

Answer 103

• Volune increases until 33 weeks
• Platueaus at 33-38 weeks
• Decreases at term to reach 500ml

Question 104

Describe the normal physiological cycle of amniotic fluid

Answer 104

Fetus breathes and swallows fluid, processed and voided through the bladder

• Predominantly fetal urine output with some fetal secretions and placenta

Question 105

How does placental insufficiency cause oligohydramnios?

Answer 105

• Blood flows to brain instead of kidneys so there is a lower fetal urine output

Question 106

How do patients with oligohydramnios present?

Answer 106

Potter's syndrome:

1. Fetal compression: clubbed feet, facial deformity, congenital hip dysplasia
2. Lack of amniotic fluid: pulmonary hypoplasia in fetus

Question 107

Describe the management of oligohydramnios

Answer 107

• Treat underlying cause and optimise gestation of delivery
• Maternal rehydration to increase amniotic fluid volume if mild
• Amnioinfusion: saline into amniotic fluid to increase volume
• Deliver: may be induced-C-section

Question 108

Describe the prognosis of patients with oligohydramnios

Answer 108

If 2nd trimester: poor prognosis

• If premature delivery and pulmonary hypoplasia: respiratory distress at birth
• PLacental insufficiency: higher rate of preterm deliveries

Question 109

Aetiology of polyhdramnios:

• 50-60% of cases: {{c1::idiopathic}}
  

Excess production due to {{c2::increased fetal urination:}}

• {{c2::
• Maternal diabetes
• Fetal anaemia
• Fetal renal disorders
• Twin to twin transfusion syndrome
}}

Insufficient removal due to {{c3::decreased fetal swallowing:}}

• {{c3::
• Oesophageal duodenal atresia
• Diaphragmatic hernia
• Anencephaly
• Chromosomal disorders
}}

Question 110

How is polyhdramnios diagnosed?

Answer 110

• USS
• Measure amniotic lfuid: AFI/MPD

Question 111

How fast does cervical dilation typicaly progress?

Answer 111

• Primiparous: 1cm every 2 hours
• Multiparous: 1cm every hour

Question 112

Describe the physiology of the first stage of labour

Answer 112

• Hormones(mostly prostaglandinds and oxytocin) stimulate regular uterine contractions
• That and pressure from presenting part of foetus-> progressive dilation of the cervix

Question 113

Describe the signs and symptoms of the first stage of labour

Answer 113

• Regular, painful contractions
• Progressive cervical dilation
• Passage of blood stainf mucus-'show'
• Rupture of membranes
• Descent of foetal head into pelvis

Question 114

How is the first stage of labour managed?

Answer 114

• Pain relief-> epidural analgesia, nitrous oxide, opioids
• Encourage mobility and changes in position to facilitate labour progression
• Ensure hydration and nutritional supprot
• Regular monitoring

Question 115

How is the second stage of labour managed?

Answer 115

• Instrumental delivery
• C-section

Question 116

How long does the third stage of labour usually last?

Answer 116

• Natural: 30-60 minutes
• With oxytocin: 5-10 minutes

Question 117

How is the 3rd stage of labour managed?

Answer 117

• Controlled cord traction-> gently to avoid uterine inversion/PPH
• If retained placenta: manual removal or curettage may be necessary

Question 118

How is labour induction carried out?

Answer 118

• Membrane sweep: insert finger into extenral os and separate membranes from cervix
• Vaginal prostalgandins: Used to ripen cervix and induce contractions
• Amniotony: artificial rupture of membranes
• Ballon catheter: mechanically dilates cervix

Question 119

Describe the aetiology of pre-term labour

Answer 119

• Overstretching of uterus: multiple pregnancy, polyhydramnios
• Foetal risk complications: pre-eclampsia, placental abruption
• Uterus/cervical problems: fibroids, malformations
• Infections: chorioamnionitis, sepsis, group B strep etc
• Maternal co-morbidity: htn, diabetes etc

Question 120

How might patients with pre term labour present?

Answer 120

• Regular uterine contractsion/changes in cervical effacement or dilation/rupturing of membranes before onset of contractions

Question 121

How is pre term labour managed?

Answer 121

• Corticosteroids: betamethasone/dex to assist foetal lung maturation
• IV abx if increased risk of infection(penicillin)
• Tocolytic agents may be used(nifedipine), risk of side effects

Question 122

How is menopause diagnosed?

Answer 122

• Clinically: absence of menarche for 12 months in someone >45(generally>45)
• If <40: test FSH etc

Question 123

Describe the management of menopause

Answer 123

Conservative: 

• Lifestyle: regular exercise, weight loss, good sleep

Medical:

• HRT
• SSRI's
• Vaginal lubricants/moisturisers
• Clonidine for vasomotor

Question 124

In terms of time frames, when can HRT be given?

Answer 124

• Cyclically: perimenopausal women still having periods
• Continuously: Post menopausal not having periods

Question 125

How is HRT given cyclically?

Answer 125

• Monthly: oestrogen every day of months and progesterone for last 14 days
• Every 3 months: Oestrogen very day for 3 months and progesterone for the last 14 days

Question 126

How can menopause result in dyspareunia?

Answer 126

• Vaginal dryness from reduced oestrogen

Question 127

How can menopause result in urinary incontinence?

Answer 127

• Caused by epithelial thinning as a result of decline in oestrogen

Question 128

Describe the feedback systems that control the menstrual cycle

Answer 128

• Moderate oestrogen levels-> negative feedback on HPG
• High oestrogen with no progesterone-> positive feedback on HPG
• Oestrogen +progesterone-> negative feedback on HPG
• Inhibin selectively inhibits FSH at anterior pituitary

Question 129

How much blood is usually lost during menses?

Answer 129

• 10-80ml

Question 130

Describe the epidemiology of PCOS

Answer 130

• Common
• Affects up to 1/4 of women during reproductive years

Question 131

Describe the aetiology of PCOS

Answer 131

• Hormonal imblanaces-unknown?
• Hyperandrogenism
• Insulin resistance
• Elevated levels of LH
• Raised oestrogen

Question 132

Describe the symptoms of PCOS

Answer 132

• Oligomenorrhoea
• Subfertility
• Acne
• Hirsutism
• Obesity
• Mood changes: depression, anxiety
• Male pattern baldness
• Acanthosis nigracans-> secondary to insulin resistance

Question 133

Describe the rotterdam diagnositc criteria

Answer 133

>=2 of:

• Polycystic ovaries(>12 cysts on imaging or ovarian volume >10cubic cm)
• Oligo/an ovulation
• Clinical or biochemical features of hyperandrogenism

Question 134

How is PCOS managed?

Answer 134

Conservative:

• Weight loss, exercise, educate on risks of diabetes.cvr.endometrial cancer

Medical for those not planning pregnancy:

• Co-cyprindrol
• COCP
• Metformin

Medical for those wanting to conceive:

• Clomiphene-induces ovulation 
• Metformin
• Gonadotrophins-induce ovulation

Surgical for those wanting to conceive:

• Ovarian drilling: laparoscopic-damages hormone producing cells of ovary

Question 135

How can endometrial curettage result in Asherman's syndrome

Answer 135

• Damages basal layer of endometrium-> heals abnormally creating adhesions connecting areas of the uterus that aren't normally connected
• Adhesions can bind uterine walls together or might seal the endocervix shut

Question 136

How do adhesions cause problems in Asherman's syndrome?

Answer 136

• Can cause physical obstruction and distort pelvic organs-> menstrual abnormalities, infertility and recurrent miscarriages

Question 137

How might patient with Asherman's syndrome present?

Answer 137

• Secondary amenorrhoea(absent periods)
• Significantly lighter periods
• Dysmenorrhoea
• Infertility

Question 138

How is Asherman's syndrome diagnosed?

Answer 138

• Hysteroscopy: GS-can also treat adhesions
• Hysterosalpingography
• Sonohysterography
• MRI

Question 139

How is Asherman's syndrome treated?

Answer 139

• Dissect adhesions during hysteroscopy

Question 140

How are congenital uterine abnormalities diagnosed?

Answer 140

• USS
• Hysterosapingography
• MRI-considered best

Question 141

How are congenital uterine abnormailites managed?

Answer 141

• Surgical intervention

Question 142

Give some examples of congenital uterine malformations

Answer 142

• Complete failure of duct fusion: double vagina, double cervix, double uterus
• Septate uterus
• arcuate uterus
• 
  

Question 143

Give some examples of congenital vaginal abnormalities

Answer 143

• Vaginal agenesis
• Vaginal atresia
• Mullerian aplasia-normal external genitalia but absense of vagina
• transverese vaginal septa

Question 144

How might abnormalities of the hymen present?

Answer 144

• Obstruciton of menstrual flow after puberty

Question 145

Descriebe the pathogenesis of polyps

Answer 145

• Involves oestrogen-> stimulates endometrial growth
• Can arise from hyperplasia of basal layer of endometrium

Question 146

How are endometrial polyps diagnosed?

Answer 146

• Speculum exam
• USS

Question 147

How are endometrial polyps managed?

Answer 147

• ASX in premenopausal: monitor
• Symptomatic/postmenopausal/atypical: removed via hysteroscopic polypectomy
• Histology of removed polyp to exclude malignancy

Question 148

Describe the presentation of a patient with PID

Answer 148

• Bilateral abdominal pain
• Vaginal discharge
• Post-coital bleeding
• Adnexal tenderness
• Cervical motion tenderness
• Fever
• Dysuria and menstrual irregularitis

Question 149

How is Fitz Hugh Curtis syndrome diagnosed and treated?

Answer 149

• Normal LFTs
• US rule out stones
• Definitive dx: laparoscopy
• Tx: abx

Question 150

How is PID managed?

Answer 150

• IM ceftriaxone+14 days oral doxycycline+metronidazole
• 2nd line: oral ofloxacin+oral metronidazole
• Consider removal of IUD
• Avoid unprotected sexual intercourse

Question 151

Describe the epidemiology of urinary tract stones

Answer 151

• Common
• M>F
• <65 yrs
• Can be both renal and ureteric

Question 152

Describe the aetiology of renal stones

Answer 152

• Calcium oxalate-mc
• Calcium phosphate
• Cystine
• Uric acid
• Struvite
• Indinavir

Question 153

How might patient with urinary tract calculi present?

Answer 153

• Severe intermittent loin pain that can radiate ot the groin
• Restlessness
• Haematuria
• N+V
• Sedoncary infection of stone-> fever/sepsis

Question 154

How are renal stones managed?

Answer 154

• Analgesia
• Wait if <5mm
• Medical expulsive therapy
• Extracorporeal shockwave lithotripsy
• Uteroscopy-pregnanyt women
• Prevention

Question 155

How can pituitary adenomas be classified?

Answer 155

• Size -micro(<1cm) or macro(>1cm)
• Hormonal status (secretory vs non secretory)

Question 156

Describe the symptoms of a prolactinoma in men

Answer 156

Macroadenomas:

• Headache
• Visual disturbance-bitemporal hemianopia
• Hypopituitarism signs and sx

Excess prolactin:

• Impotence
• Loss of libido
• Galactorrhoea

Question 157

Describe the symptoms of prolacitnomas in women

Answer 157

Macroadenomas:

• Headache
• Visual disturbance-bitemporal hemianopia
• Hypopituitarism signs and sx

Excess prolactin:

• Amenorrhoea
• Infertility
• Galactorrhoea
• Osteoporosis

Question 158

How is a prolactinoma diagnosed?

Answer 158

• MRI head

Question 159

How are prolactinomas treated?

Answer 159

• Dopamine agonists: cabergoline, bromocriptine(inhibits release of prolactin)
• Trans-sphenoidal surgery: those who can't toelrate therapy

Question 160

Describe the surface anatomy of the breast

Answer 160

• Lateral border of sternum at mid axillary line
• 2nd and 6th costal cartilages
• Superficial to pectoralis major and serratu anterior muscles

Circular body

Axillary tail

Question 161

Describe the mammary glands with regards to breast anatomy

Answer 161

• Modified sweat glands-> ducts and secretory lobules
• Each lobule consists of many alveoli drained by a lactiferous duct

Question 162

Describe the connective tissue stroma with regards to breast anatomy

Answer 162

• Fibrous and fatty component
• Fibrous stroma condenses to form suspensory ligaments
• Attach and secure breast to dermis and underlying pectoral fascia
• Separate secretory lobules of breast

Question 163

Describe the pectoral fascia with regards to breast anatomy

Answer 163

• Flat sheet of connective tissue associated with pec major
• Retromammaroy space-> layer of loose conective tissue between breast and pectoral fascia(used in reconstruction)

Question 164

Describe the medial vasculature of the breast

Answer 164

• Internal thoracic(mammary) artery-> branch of subclavian

Question 165

Describe the lateral vasculature of the breast

Answer 165

• Lateral thoracic and thoracocromial branches-> axillary
• Lateral mammary branches-> posterior intercostal arteries
• Mammary branch-> anterior intercostal artery

Question 166

How does lymphatic drainage link into the presentation of patiens with breast cancer

Answer 166

• Blockages of lymphatic drainage-> lymph builds up in SC tissues-> nipple deviation and retraction, peau d'orange
• Metastasis can occur through lymph nodes-> axillary mx, then can spread to liver, bones and ovary

Question 167

Describe the nerve supply of the breast

Answer 167

• Anterior and lateral cutaneous branches of 4th-6th IC nerves(autonomic and sensory nerve fibres)

Question 168

Describe the epidemiology of fibroadenomas

Answer 168

• Young women-early 20s

Question 169

Describe the presentation of a patient with a fibroadenoma

Answer 169

• Firm, non-tender breast mass
• Rounded and smooth edges
• Highly mobile on palpation-'rubbery' 
• <3cm in diameter(mc 2.5cm)
• Usually slow growing and solitary

Question 170

Describe the management of fibroadenomas

Answer 170

• Conservative: Leave, usually regress naturally post menopause
• Surgical excision: considered if large, growing, causing significant symptoms or diagnostic uncertainty

Question 171

Describe the epidemiology of fibrocystic breast disease

Answer 171

• Most common benign breast condition
• 20-50 years

Question 172

Describe the aetiology of fibrocystic breast disease

Answer 172

• Cumulative effect of cyclical hormone
• Mostly oestrogen and progesterone-> multiple cysts and proliferative changes

Question 173

Describe the presentation of a patient with fibrocystic breast disease

Answer 173

• Bilateral 'lumpy' breasts, most commonly in upper outer quadrant
• Breast pain
• Sx worsen with menstrual cycle and peak 1 week before menstruation

Question 174

Describe the management of fibrocystic breast disease

Answer 174

• Encourage use of soft, well-fitting bra
• Analgesia for pain relief
• Most resolve after menopause

Question 175

Describe the eppidemiology of breast cancer

Answer 175

• Commonest cancer in UK in women
• 2nd most common cause of cancer deaths

Question 176

Describe the pathophysiology of breast cancer

Answer 176

• Genetic mutations and damaged cellular signalling-> generation of malignant cells-> metastasise

Question 177

Describe how breast cancer cells metastasize

Answer 177

1. Invasion through basement membrane
2. Intravasation(entry into circulation)
3. Circulation
4. Extravasation
5. Colonisation

Question 178

Describe the features of ductal carcinoma in situ

Answer 178

• From epithelial cells
• Confined to ducts

Question 179

Describe the features of lobular carcinoma in situ

Answer 179

• Arise from epithelial cells
• Neoplastic cell proliferation

Question 180

Describe the features of invasive ductal carcinoma

Answer 180

• Neoplastic proliferation of epithelial cells-> ductal basement membrane-> fatty tissue

Question 181

Describe the features of medullary carcinoma

Answer 181

• Younger people
• Higher grade than invasive ductal carcinoma

Question 182

Describe some signs and symptoms of breast cancer

Answer 182

• Unexplained breast/axillary mass in those >30 years
• Nipple discharge
• Nipple retraction
• Skin changes-p'eau d'orange
• Metastatic features: weight loss, bone pain, SOB

Question 183

How is breast cancer diagnosed?

Answer 183

1st line: imaging

• >30yrs and clinical suspicion: mammogram
• <30yrs: USS
• US of axilla

2nd line: biopsy

• Fine needle aspiration and cytology

Others:

• Oestrogen/progesterone receptor testing, HER2 receptor testing
• CT if metastatic disease suspected

Question 184

Breast cancer staging:

• 1A: {{c1::<2cm, isolated to breast}}
  
• 1B: {{c2::<2cm, minor axillary LN spread}}
• 2A: {{c3::<2cm, spread to 1-3 ipsilateral lymph nodes}}
• 2B: {{c4::2-5cm, minor axillary node spread/>5cm with no nodal spread/2-5cm with 103 ipsilateral LN spread}}
• 3A: {{c5::4-9 ipsilateral nodes/>5cm with 1-3 ipsilateral nodes}}
• 3B: {{c6::Spread to skin/chest wall}}
• 3C{{c7::: >10 axillary nodoes/supraclavicular/parasternal/axillary spread}}
• 4: {{c8::metastatic spread to other organs}}

Question 185

How can bisphosphonates be used in the treatment of breast cancer?

Answer 185

• Can help reduce recurrence in node-positive cancers

Question 186

Aetiology of benign breast disease:

• Fibroadenomas: {{c1::overgrowth of glandular and connective tissue resulting in blocked breast ducts and subsequent fluid accumulation}}
• Mastitis: bacterial infection-> {{c2::breaks in skin around nipple}}
• Intraductal papilloma: {{c3::benign tumour of breast ducts}}
• Radial scar: {{c4::benign sclerosing breast lesion}}
• Fat necrosis: {{c5::response to adipose tissue damage}}
• Fibroycstic breast disease: {{c6::increased hormonal response resulting in inflammation and fibrosis}}
• Mammary duct ectasia: {{c7::inflammation and dilation of large bresat ducts}}

Question 187

Describe the general management of benign breast disease

Answer 187

• Reassurance: often only need monitoring
• Antibiotics: for infections like mastitis
• Analgesics
• Surgery: e.g. large fibroadenomas, persistent cysts, symptomatic intraductal papillomas

Question 188

Describe the epidemiology of Paget's disease of the nipple

Answer 188

• Rare: <5% of all breast cancer patients
• Most common in postmenopausal women

Question 189

Describe the aetiology of Paget's disease of the nipple

Answer 189

2 theories:

• Epidermotrophic: underlying breasst cancer cells migrate to the nipple
• Intraepidermal origin: originates in nipple itself

Question 190

Describe the signs and symptoms of a patient with Paget's disease of the nipple

Answer 190

• Eczema like rash on skin of nipple/areola(often crusty, red, inflamed, itchy)
• Bloody nipple discharge
• Non-healing skin ulcer
• Changes to nipple-> retraction/inversion
• Pain
• Breast lump

Question 191

How is Paget's disease of the nipple diagnosed?

Answer 191

• Mammography/US
• Punch biopsy of affected skin, nipple discharge cytology
• MRI for stagin in uncertain cases

Question 192

How is Paget's disease of the nipple different to eczema of the nipple?

Answer 192

• Paget's involves the nipple primarily and only latterly spreads to the areolar(opposite way around in eczema)

Question 193

How is Paget's disease of the nipple treated?

Answer 193

• Depends on underlying lesin
• Simple mastectomy: remove entire breast and nipple and areeola
• Modified radical mastectomy: remove some axillarry lymph nodes 
• Lumpectomy
• Chemo, radiation, hormonal

Question 194

Describe the latent phase of labour

Answer 194

• Contractions(may be irregular)
• Mucoid plug
• Cervix beginning to efface and dilate(0-4cm)
• Can last up to 2-3 days

Question 195

Describe the features of contractions

Answer 195

• Starts in the fundus(pacemaker)
• Retraction/shortenng of muscle fibres
• Build in aplitude as labour progresses
• Fetus forced down causing pressure on the cervix

Question 196

Describe the features of a gynaecoid pelvis

Answer 196

• Inlet is slightly transverse oval
• Sacrum wide with average concavitiy and inclination
• Side walls straight with blunt ischial spines
• Wide suprapubic arch

Question 197

How might midwives help with the delivery of the body stage of labour?

Answer 197

• Gentle downward traction to assist with delivery of shoulder below suprapubic arch
• Gentle upwads traction to assist delivery of posterior shoulder

Question 198

Describe the anatomy of the placenta and how it is connected to the fetus

Answer 198

• Lobes which attach to the uterine wall
• Connected to fetus via umbilical cord whcih has 2 arteries and a vein

Question 199

How is a ventouse used?

Answer 199

• Cup is applied with centre over flexion point on fetal skull
• During uterine contractons, traction applied perpendicular to cup

Question 200

At what age gestation is non invasive prenatal testing available?

Answer 200

• From 10 weeks

Question 201

At what week gestation is CVS offered for?

Answer 201

• 11-14 weeks gestation

Question 202

How many weeks gestatin would amniocentesis be performed?

Answer 202

• >15 weeks

Question 203

Describe the epidemiology of mastitis

Answer 203

• Postpartum: 10-20% prevalence
• Usually in first 6 weeks post birth
• Increased risk in 1st time mothers and previous hx of mastitis

Question 204

Describe the aetiology if mastitis

Answer 204

• Milk stasis-> inflammatory response and potential secondary infection
• Cracked/sore nipples-> S.aureus-> infective mastitis

Question 205

Describe the presentation of mastitis

Answer 205

• Localised: painful, red, tender, hot breast
• Systemic: fever, rigors, myalgia, fatigue nausea and headache
• Usually unilateral-presents 1st week post partum

Question 206

How is mastitis diagnosed?

Answer 206

• Mostly clinical
• US to ID if suspicion of abscess-> done in secondary care

Question 207

How is mastitis managed?

Answer 207

• Reassure lactating women they can continue to breastfeed
• Advice on methods to faciliate milk expression
• Analgesia
• Oral/IV abx, surgery if abscess

Question 208

Describe the aetiology of a breast abscess

Answer 208

• S.aureus mc through crack in nipple/through milk duct
• Accumulation of milk, trauma to nipple skin from incorrect latch/pump

Question 209

Describe the presentation of a patient with a breast abscess

Answer 209

• Fever/rigors
• Malaise
• Pain and erythema over an area of the breast
• Possible presence of a fluctuant mass-> might not be palpable
• Hisotry of recent/ongoing mastitis

Question 210

How is a breast abscess diagnosed/investigated?

Answer 210

• Breast USS-> visualise abscess and guide drainage
• Diagnostic needle aspiration-> culture organism and evacuation

Question 211

How is a breast abscess managed?

Answer 211

• Incision and drainage/needle aspiration(with/out US guidance)
• Abx therapy targeted towards most likely causative organism

Question 212

Describe the epidemiology of bacterial vaginosis?

Answer 212

• Mc cause of abnormal dishcarge in women of childbearing age
• More common in sexually active women but not an STI

Question 213

Describe the pathophysiology of bacterial vaginosis

Answer 213

• Disturbance of normal vaginal flora-> decrease in number of lactobacilli bacteria

Question 214

How is bacterial vaginosis managed in pregnanct/lactating women?

Answer 214

• Screening done antenatally and quick treatment if needed
• Lower doses of metronidazole in lactating women

Question 215

Describe the epidemiology of vulvovaginal candidiasis

Answer 215

• Highlyy prevalent: 20% of women/yr
• Most women will experience it at some point in their lifetime

Question 216

Describe the aetiology of vulvovaginal candidiasis

Answer 216

• Candida albicans-> replicated by budding
• Opportunistic infection vs hypersensitivity reaction

Question 217

Describe the symptoms of vulvovaginal candidiasis

Answer 217

• Pruritus vulvae
• Vaginal discharge-white, curd like
• Dysuria

Question 218

How is vulvovaginal candidiasis diagnosed/inveestigated?

Answer 218

• Usually history/clinical
• Vaginal smear and mc+s-> blastospores, pseudohyphae and neutrophils

Question 219

Describe the management of vulvovaginal candidiasis

Answer 219

• Intravaginal antifungal-> clotrimazole pessary
• Oral antifungal-> fluconazole
• Vulva/topical steroid-> topical imidazole

Question 220

How is vulvovaginal candidiasis treated in pregnancy?

Answer 220

• DO NOT use oral antifungals
• Advise care with intravaginal treatment applicator
• Saftynetting if not resolved in 7-14 days

Question 221

Describe the epidemiology of chlamydia

Answer 221

• Most common STD in UK
• Highest prevalence in 15-24 yr olds

Question 222

How is chlamydia transmitted?

Answer 222

• Via unprotected vaginal, oral, anal sex
• Skin to skin contact of genitals
• Vertical(mother to baby during delivery)

Question 223

Describe the signs and symptoms of chlamydia in men

Answer 223

• Often asymptomatic: incubation period 7-21 days
• Urethritis: dysuria, urethral discharge
• Epididymo-orchitis: testicular pain
• Epididymal tenderness
• Mucopurulent discharge

Question 224

Describe the signs and symptoms of chlamydia in women

Answer 224

• Asymptomatic often: incubation period 7-21 days
• Dysuria
• Discharge
• Intermenstrual bleeding
• Pain/tenderness

Question 225

Describe the signs and symptoms of chlamydia in neonates

Answer 225

• Pneumonia
• Conjunctivitis

Question 226

How is chlamydia diagnosed?

Answer 226

• Women: vulvovaginal swab
• Men: first catch urine sample

Analyze using nucelic acid amplification tests

Question 227

Describe the management of chalmydia in non-pregnant people

Answer 227

• Doxycycline: 100mg twice daily for 7 days

Question 228

Describe the management of chlamydia in pregnant women

Answer 228

• Azithromycin/erythromycin

Question 229

Describe the management of neonates with chlamydia

Answer 229

• Oral erythromycin

Question 230

 Describe the epidemiology of gonorrhoea

Answer 230

• 2nd most common STI after chlamydia
• increased prevalence in 15-24yrs
• Hihger prevalence in MSM

Question 231

How is gonorrhoea transmitted?

Answer 231

• Unrpotected vaginal/oral/anal sex
• Vertical transmission

Question 232

Describe the aetiology and pathology of gonorrhoea

Answer 232

• Gram negative diplococcus neisseria gonorrhoea
• Causes acute inflammation-> uterus, urethra, cervix, fallopian tube, ovaries, rectum, testicles, eyes, throat

Question 233

How do patients with gonorrhoea present?

Answer 233

• Males: urethral discharge, dysuria
• Women: discharge, dysuria, dyspareunia, pain
• Dishcarge tends to be thin, watery green/yellow
• Asymptomoatic especially when rectal/pharyngeal infection

Question 234

How is gonorrhoea diagnosed?

Answer 234

• Females: endocervical/vaginal/urethral swab
• Males: first pass urine(NAAT), urethral/meatal swab

Microsopcy, culture and NAAT

Question 235

How is gonorrhoea treated?

Answer 235

• Singled soe 1g IM ceftriaxone
• Screen/treat other infections
• test of cure recommended

Question 236

Describe the symptoms of disseminated gonococcall infection

Answer 236

• Tenosynovitis
• Migratory polyarthritis
• Dermatitis

Question 237

How is gonorrhoea treated in pregnancy?

Answer 237

• Prophylactic abx+tx in pregnancy-> ceftriaxone

Question 238

How are neonates with gonorrhoea managed?

Answer 238

• Urgent referral and treatment
• Long term damage and blindness

Question 239

Describe the epidemiology of genital herpes

Answer 239

• Very common
• 15-24yrs

Question 240

Describe the pathophysiology of genital herpes

Answer 240

• After infecting surface-> travels up to meet nearest ganglion and stays there until reactivated

Question 241

Describe the presentation of a patient with a primary genital herpes infection

Answer 241

• Asymptomatic
• Small, painful red blisters around genitals, can form open sores
• Vaginal/penile discharge, dysuria, urinary retention
• Flu like sx-> fever ,muscle aches, malaise, headaches
• After 20 days: lesions crust and heal-> end of viral shedding

Question 242

Describe the presentation of a patient with an outbreak of a genital herpes infection

Answer 242

• Usually shorter and less severe than initial infection
• Burning, itching, painful red blisters

Question 243

How is genital herpes diagnosed?

Answer 243

• Clinical hz and exam
• Swab from abse of ulcer-> NAAT

Question 244

Describe the management of genital herpes

Answer 244

• Primary infection: aciclovir 400mgTD 5 days
• Recurrent outbreaks: OTC analgesia, ice, topical lidocaine
• Regular episodes: episodic aciclovir tx when sx begin

Question 245

Describe the management of herpes in pregnancy

Answer 245

• Low risk of transmission with vaginal birth
• Referral to GUM clinic and treat with aiclovir if 1st time HSV infection
• If contracted in last trimester: antibodies not developed-> C-section

Question 246

Describe the features/management of neonatal herpes

Answer 246

• Skin/eyes/mouth herpes(SEM)-antiviral tx
• Disseminated herpes(DIS)-internal organs
• CNS herpes-> encphalitis

DIS and CNS herpes associated with increased mortality

Question 247

Describe the aetiology of genital warts

Answer 247

• 90% HPV 6/11-low risk, not associated with cancer

Question 248

How do patients with genital warts typically present?

Answer 248

• Asx
• Painless warts of scrotum, penis, vagina, cervix, perianal skin, anus
• Warts can be keratinised(hard) or non-keratinised(soft)
• Extra-genital lesions: oral cavity, larynx, nasal cavity, conjunctivae

Question 249

How are genital warts diagnosed/

Answer 249

• Usually from clinical exam/hx
• Proctoscopy/vaginal speculum exam to check for internal warts
• Biopsy for atypical lesions/suspected intraepithelial neoplastic lesions

Question 250

Describe the management of genital wwarts

Answer 250

Tx not always needed, can resolve spontaneously

Topical:

• Podophyllotoxin: antiviral to destroy clusters(BD 3 days then 4 days rest)
• Imiquimod: immune response modifier for larger keratinised warts(3 times/week)

Physical:

• Cryotherapy
• Surgical excision
• Elecrto/laser-surgery

Question 251

How does pregnancy impact genital warts?

Answer 251

• No risk to babies but maternal warts can multiply/enlarge during pregnancy

Question 252

Describe the pathophysiology behind the HIV infection

Answer 252

1. Penetrates host CDD4 cell and empties its contents. Single strands of viral RNA converted to double stranded DNA by reverse transcriptase and combined host DNA using integrase
2. Infected cell divides, viral DNA read-> creates viral protein chains and immature virus pushes out of cell, retaining some membranes
3. Virus matures when protease cuts viral protein chains and assemble to create a working virus, destroying a host cell

Question 253

How do CD4 levels change over the course of the HIV infection?

Answer 253

• Seroconversion(producing anti-HIV antiibodies during primary infection)-> flu-like sx-> decrease in CD4 levels due to initial rapid replication-> extremely infectious
• Latent phase: months-yrs: initiay asx but increased susceptibility to infections

Question 254

How is HIV transmitted?

Answer 254

• Unprotected sexual intercourse
• Sharing needles
• Medical procedures
• Vertical transmission

Question 255

Describe the symptoms of the seroconversion stage of HIV

Answer 255

• 2-6 weeks post exposure
• Fever
• Muscle aches
• Malaise
• Lymphadenopathy
• Maculoapular rash
• Pharyngitis

Question 256

Describe the symptoms of the symptomatic stage of HIV

Answer 256

• Weight loss
• High temperature
• Diarrhoea
• Frequent opportunistic infections

Question 257

Describe the symptoms of the AIDS defining illness stage

Answer 257

• Advanced stage: immune system significantly weakened
• Deveopment of AIDS defining illnesses/infections/malignancies

Question 258

How is HIV diagnosed?

Answer 258

4th generation tests:

• ELISA-> test for serum/salivary HIV antibodies and p24 antigen
• Reliable results 4-6 weeks post exposure

Contact tracing

Question 259

Describe the management of HIV

Answer 259

HAART: highly active antiretroviral therapy
>=3 drugs: usually 2 nRTIs and 1 PI/NNRTI-> Decreases viral replication and reduces risk of viral resistance emerging

Question 260

Describe the features of NNRTI's

Answer 260

• non-nucleoside reverse transcriptase inhibitors
• E.g. nevirapine
• SE: P450 enzyme interaction, rashes

Question 261

Describe the features of protease inhibitors

Answer 261

• E.g. indinavir, nelfanivir
• SE: diabetes, hyperlipidaemia, central obesity, P450 enzyme inhibitirion

Question 262

Describe the features of integrase inhibitors

Answer 262

• E.g. raltegravir, elvitegravir
• Block the action of integrase(viral enzyme that inserts the viral genome into the DNA of the host cell)

Question 263

How is HIV managed in pregnancy and why?

Answer 263

• Can be transmitted in utero, at delivery and through breast-feeding
• Risk reduction strategies(separate flashcard)
• C-section non longer recommended if undetectable viral load

Question 264

How is the risk of HIV transmission in pregnant women minimised?

Answer 264

• Anttenatal antiretroviral therapy during pregnancy and delivery
• Avoidance of breastfeeding
• Neonatal post-exposure prophylaxis

Question 265

How do patients with a threatened miscarriage present?

Answer 265

• Painless vaginal bleeding <24 weeks(usually 6-9 weeks)
• Bleeding often less than menstruation

Question 266

How can the aetiology of polyhydramnios be classified?

Answer 266

• Idiopathic
• Excess production due to increased fetal urination
• Insufficient removal due to decreased fetal swallowing

Question 267

How might a patient with polyhydramnios present?

Answer 267

• Uterus feels tense/large for dates
• Difficult to feel fetal parts on abdominal palpation

Question 268

How is polyhydramnios managed?

Answer 268

• Usually no intervention needed
• Treat underlying cause
• Severe only: amnioreduction
• Indomethacin

Question 269

How is indomethacin useful for treating polyhydramnios?

Answer 269

• Enhances water retention and decreases fetal urine output

Question 270

How is prolonged pregnancy managed?

Answer 270

1. Membrane sweeps-40 wks nulliparous, 41 wks in parous
2. Induction of labour-41/42 weeks gestation

If 2 declined: twice weekly CTG moniotring and US with amniotic fluid measurement to predict fetal distress. Might need C-section

Question 271

How do patients with placenta praevia present?

Answer 271

• Painless bright red vaginal bleeding after 24 weeks
• Sometimes pain if in labour
• Can present with signs of shock if severe blood loss
• Malpresentation of fetus due to abnormal placental position

Question 272

Describe the management of acute presentation of placenta praevia

Answer 272

• ABCDE approach
• If bleeding not controlled/in labour: C-section
• Anti-D within 72 hours of bleeding onset if rhesus D negative

Question 273

How is placenta praevia managed if found in a 20 week scan

Answer 273

• Placenta praevia minor: rpt scan at 36 weeks-likely to move
• Major: rpt at 32 weeks and plan for delivery-> usually elective c-section
• Advice about pelvic rest: no penetrative sexual intercourse and go hospital if major bleeding

Question 274

Describe the pathophysiology of placental abruption

Answer 274

• Rupture of maternal vessels in basal layer of endometrium-> blood gathers and splits placental attachment from basal layer
• Detached portion unable to funciton-> rapid fetal compromise

Question 275

How might patients with placental abruption present?

Answer 275

• Painful vaginal bleeding
• If in labour: may have pain between contractions
• Abdominal pain: often sudden and severe
• Hypovolaemic shock disproportionate to amount of vaginal bleeding visible

Question 276

How is placental abruption managed?

Answer 276

• ABCDE resus including anti D if rh D negative
• Tx dependednt on health of fetus
• Emergency delivery: usually C section, even if in-utero death
• Induction of labour at term to avoid further bleeding if haemodynamically stable

Question 277

Describe the natural progressin of most breech babies

Answer 277

• 20% breech at 28weeks
• Most revert to cephalic presentation spontaneously witih onlly 3% still breech at term

Question 278

How is breeech presentation diagnosed?

Answer 278

Clinical:

• Head felt in upper uteris, buttocks and elgs in pelvis
• Fetal heart auscultates higher on maternal abdomen on US
• 20% not diagnosed until labour

Question 279

How might breech presentatin present at labour?

Answer 279

• Fetal distress-> meconium stained liquor
• Vaginal exam: sacrum/foot felt through cervical opening

Question 280

Describe the management of breech presentation

Answer 280

• External cephalic version: offered at 37 weeks to primiparous women
• C-section
• Vaginal breech birth

Question 281

How is abnormal fetal lie/malpresentation/malrotation diagnosed?

Answer 281

• Abdominal exam
• Confirm with US-> also ID predisposing abnormalities

Question 282

Describe the management of normal fetal lie

Answer 282

• External cephalic version(ECV)-> 36-38 weeks gestation

Question 283

Describe the management of malpresentation

Answer 283

• Breech: ECV before labour, vaginal birth, C section
• Brow: c-section
• Shoulder: c -section
• Face: chin posterior: c section, chin anterior: attempt normal labour

Question 284

Describe the management of malposition

Answer 284

• 90% spontaneously rotate during labour
• If not: operative vaginal delivery/C-section

Question 285

Describe the pathophysiology of pre-eclampsia

Answer 285

• High resistance, low flow uteroplacental circulation develops as constrictive muscular walls of spiral arterioles are maintained
• Increase in BP, hypoxia-> systemic inflammatory response

Question 286

Describe the symptoms of pre-eclampsia

Answer 286

• Headaches
• visual changes
• Epigastric pain
• Sudden onset non-dependent oedema
• Hyper-reflexia

Question 287

Describe the management of pre-eclampsia

Answer 287

• Serial monitoring: BP, urinalysis, fetal growth scans, CTG
• VTW-LMWH
• Anti-hypertensives-labetalol, nifedipine, methyldopa
• Delivery(give IM steroids if <35 weeks)
• Post-natal: monitor for 24 hours post partum and BP for 5 days

Question 288

Descrbe the split of eclamptic seizures in the post natal, antepartumand intrapartum periods

Answer 288

Post-natal: mc-44%
Antepartum: 38%
Intrapartum: 18%

Question 289

Describe the symptoms of eclampsia

Answer 289

• New onset tonic clonic seizure in presence of pre-eclampsia
• Lasts 60-75 secs then post-ictal phase
• May cause fetal distress and bradycardia

Question 290

Describe the management of eclampsia

Answer 290

Rescuscitation

• ABCDE approach
• Pt lie in left lateral position and secure airway and O2 therapy

Seizure control:

• Magensium sulphate
• Monitor for signs of magensium poisoning

BP control:

• IV labetalol and hydralazine

Delivery of baby and placenta:

• Usually C-section

Monitoring:

• Fluid balance: prevent pulmonary oedema and AKI
• Monitor platelets, transaminases and creatinine

Question 291

How long should a magnesium suflate drip be continued for after an eclamptic seizure?

Answer 291

• 48 hours after last seizure

Question 292

How is trichomoniasis transmitted?

Answer 292

• Predominanly sexual

Question 293

Describe the epidemiology of trichomoniasis

Answer 293

• Mc non-viral STI globally

Question 294

Describe the signs and symptoms of trichomoniasis in women

Answer 294

• Profuse, frothy, yellow vaginal discharge
• Vulvovaginitis
• Dyspareunia
• Starwberry cervix-may be seen
• pH>4.5
• Asx

Question 295

Describe the signs and symptoms of trichomoniasis in men

Answer 295

• Usually asymptomatic
• Non-gonococcal urethritis

Question 296

How is trichomoniasis diagnosed?

Answer 296

• Direct microscopy and culture of the causative organism-> motile trophozoites
• pH>4.5
• Test for other STIs

Question 297

How is trichomoniasis treated?

Answer 297

• Oral metronidazole for 5-7 days or single dose of 2g orally
• Abstain from sex for a week
• Screen for others
• Contact tracing

Question 298

Describe the epidemiology of chancroid

Answer 298

• Global incidence decreasing
• Mc in tropical areas and greenland

Question 299

Describe the symptoms of chancroid

Answer 299

• Painful genital ulcers which may bleed on contact-ulcers are sharply defined, ragged, undermined border
• Painful inguinal lymphadenopathy
• Sx 4-10 days after bacterium exposure

Question 300

How is chancroid diagnosed?

Answer 300

• Usually clinical

Can culture and use PCR

Question 301

How is chancroid treated?

Answer 301

• Antibiotics: ceftriaxone/azithromycin/ciprfloxacin
• Analgesics 
• Incision/drainage of buboes

Question 302

Describe the presentatin of a patient with lymphogranuloma venereum

Answer 302

• Stage 1: small painless pustule which later forms an ulcer
• Stage 2: painful ingional lymohadenopathy-may from fistulaitng buboes
• Stage 3: proctocolitis(can include rectal pain and discharge)

Question 303

How is lymphogranuloma venereum diagnosed?

Answer 303

• PCR from swab of genital ulcer

Question 304

How is lymphogranuloma venereum managed?

Answer 304

• oral doxycuclin 100mg twice daily for 21 days
• Can also use: tetracycline, erythromycin

Question 305

How is lymphogranuloma venereum different to 'normal' chalmydia?

Answer 305

• Normal chalmydia: urethritis and PID: Chlamydia trachomatis serovars D-> K
• lymphogranuloma venereum: serovards L1, L2, L3
  

Question 306

Describe the aetiology of balanitis

Answer 306

• Mc: infective: bacterial and candidal
• Autoimmune causes

Question 307

How is balanitis investigated/diagnosed?

Answer 307

• Usually clinical-hx and exam
• Swab for mc+s/PCR-> bacteria or candida albicans
• If doubt/extensive skin changes: biopsy

Question 308

Describe the general treatment of balanitis

Answer 308

• Gentle saline washes
• Wash properly under foreskin
• 1%hydrocortisone for a short period
• Treat underlying cause

Question 309

How is balanitis due to dermatitis treated?

Answer 309

• Mild potency steroid- hydocortisone

Question 310

How is balanitis due to lichen sclerosus treated?

Answer 310

• High potency topical steroids
• Clobetasol
• Circumcision can help

Question 311

How is balanitis due to candidiasis treated?

Answer 311

• Topical clotrimazole for 2 weeks

Question 312

How is syphilis transmitted?

Answer 312

• Direct contact with shyphilis sores or rash during vaginal,  anal or oral sex
• Vertical: mother to child

Question 313

Describe the features of primary syphilis?

Answer 313

• Chancre-painless ulcer at the site of sexual contact
• Local non-tender lymphadenopathy
• Often not seen in women(lesion can be on the cervix)

Question 314

Describe the lesion associated with the primary syphilis infection

Answer 314

• Painless
• Round, indurated base
• Heals spontaneously within 3-8 eeks

Question 315

Describe the features of secondary syphilis

Answer 315

• Systemic: fevers, malaise etc
• Rash on trunks, palsm and sores
• buccal 'snail track' ulcers
• Condylomata lata ( painless warty lesions on genitalia)#

Question 316

Describe the features of tertiary syphilis

Answer 316

• Gummas(granulomatous lesions of skin and bones)
• Ascending aortic aneurysms
• neurological: demenita, paresis, tabes dorsalis, argyll-robertson pupil)

Question 317

Describe the features of congenital syphilis

Answer 317

• Presents shortly after birth or later in infancy
• Rash: palms/soles, mucous patches/leisons in motuh/nose/genitals
• Feever
• Blunted upper incisor teeth(Hutchinson's teeth), 'mulberry' molars
• Rhagaades( linear scars at angle of mouth)
• Keratitis
• Saber shins
• Saddle nose
• Neruological; seizures, developmental delay

Question 318

How can serological tests for syphilis be divided?

Answer 318

• Non-treponemal tests
• Treponemal specific tests

Question 319

Describe the features of non-treponemal tests for syphilis

Answer 319

• Not-specific for syphilis: false positives
• Based on reactivity of serum from infected patients to a cardiolipin cholesterol-lecithin antigen
• Negative after treatment

Question 320

Describe the features of treponemal specific tests?

Answer 320

• More complex and expensive but sspecific for syphilis
• Qualitative

Question 321

Describe the treatment pf syphilis

Answer 321

• IM benzathine penzylpenicillin
• Tertiary/late latent: longer course of IM penicillin G
• Neurosyphilis: IV penicillin G for 10-14 days

Backup for penicillin allergy: doxycycline

Question 322

How might patients with intraductal papilloma present?

Answer 322

• Bloody discharge from the nipple
• With/without a palpable mass
• May have breast tenderness

Question 323

How are intraductal papillomas treated?

Answer 323

• Severe cases might need surgery

Question 324

How can breast cysts be classified?

Answer 324

• Microcysts: seen on imaging but too small to be felt
• Macrocysts: 1-2cm: large enough to be felt

Question 325

How might patients with mammary duct ectasia present?

Answer 325

• Tender lump arounf areola +/- thick green nipple discharge
• If ruptures: local inflammation-> 'plasma cell mastitis'

Question 326

Describe the treatment for mammary duct ectasia

Answer 326

• Surgical intervention may be needed if symptomatic

Question 327

Describe the epidemiology of HELLP syndrome

Answer 327

• Rare
• Significant cause of maternal and perinatal morbidity/mortality

Question 328

Describe the aetiology of HELLP syndrome

Answer 328

• Unknown
• Related to abnormal placentation, endothelial cell injury and generalized inflammatory response

Question 329

Describe the presentation of patients with HELLP syndrome

Answer 329

• N+V
• RUQ pain-> liver distention
• Lethargy
• Headahces
• Blurred vision
• Peripheral oedema

Question 330

Describe the maangement of HELLP syndrome

Answer 330

• Definitive: deliver baby
• Steroids: accelerate fetal lung maturation
• Blood transfusions to manage anaemia and thrombocytopenia

Question 331

Describe the epidemiology of cord prolapse

Answer 331

• Relatively rare
• Higher risk in breech presentations and multiple pregnancies

Question 332

Describe the pathology of cord prolapse

Answer 332

• Usually membrane rupture-> amniotic fluid egress-> descent of umbilical cord
• Cord compression-> against maternal soft tissues or bony pelvis-> fetal hypooxia

Question 333

How might patients with cord prolapse present?

Answer 333

• Abnormal fetal heart rate: mc -> varibable/prolonged decelerations
• Palpable umbilical cord
• Sudden onset of sympotms post rupture of membranes
• Patient reported sensation

Question 334

How is a cord prolapse investigates/diagnosed?

Answer 334

• Clinical
• USS
• Cardiotocoography(CTG)
• Speculum exam

Question 335

How is cord prolapse managed?

Answer 335

• Immediate delivery of fetus-> instrumental or C section 
• 'knees chest' position to reeduce pressure on cord
• Avoid exposure and handling of cord, reducing into vagina
• Use of tocolytics like terbutaline to stop uterine contractions

Question 336

Describe the pathophysiology of vasa praevia

Answer 336

• Abnormal placental development
• Fetal membrane development: persistence of membranous vessels
• Fetal vessel vulnerability: prone to rupture

Question 337

How can vasa praevia be classified?

Answer 337

• Type 1 and Type 2
• Ramified or funic

Question 338

Describe the signs and symptoms of vasa praevia

Answer 338

• Painless vaginal bleesin
• Rupture of membranes
• Fetal bradycardia/resulting fetal death

Also:

• Foetal anaemia

Question 339

How is vasa praevia diagnosed?

Answer 339

• Transabdominal/TV USS-most cases now diagnosed antenatally

Can use MRI and prenatal testing

Question 340

How is vasa praevia managed?

Answer 340

• Elective C-section prior to rupture of membranes: 35-36 weeks gestation
• Emergency C-section of premature labour or membranes rupture
• Prompt neonatal resus

Question 341

Describe the epidemiology of peruperal psychosis

Answer 341

• Rare: 11-2/1000 childbirths

Question 342

Describe the aetiology of peurperal psychosis

Answer 342

• Unknown
• Hormonal changes post childbirth
• Genetics
• Psychosocial stressors
• Sleep deprivation

Question 343

Describe the signs and symptoms of peurperal psychosis

Answer 343

• Paranoia
• Delusions: Capgras
• Hallucinations-command 
• Manic episodes
• Depressive episodes
• Confusion

Question 344

How is peurperal psychosis diagnosed?

Answer 344

• Clinical
• Thorough psych evaluation
• Rule out: thyroid disorders, sepsis etc

Question 345

Describe the management of peurperal psychosis

Answer 345

• Admit to mother/baby mental health unit: especially if Capgras/command hallucinations
• Antipsychotics: olanzapine and quetipaine
• Mood stabilisers in some cases
• CBT

Question 346

Describe the epidemiology of postpartum depression

Answer 346

• Prevalent: 10-20% of mothers

Question 347

Describe the aetiology of postpartum depression

Answer 347

• Multifactorial
• Biological: hormones, melatonin, cortisol, inflammatory processes, genetics
• Psychological 
• Social

Question 348

Describe the signs and symptoms of postpartum depression

Answer 348

• Persistents low mood and anhedonia
• Low energy
• Sleep issues-important to distinguish between abby's fault and depression
• Poor appetite
• Concerns relating to bonding with baby, caring for baby etc

Question 349

How is baby blues different to postpartum depression?

Answer 349

• MIlder: mood swings, irritability, anxiety and tearfullness
• Sx present within first 2 weeks after birth and resolve spontaneously

Question 350

How is postpartum depression diagnosed?

Answer 350

• Clinical
• Edinburgh postnatal depression scale
• Rule out risk of psychosis-risk assessment really important

Physical exam: anaemia, hypothyroidism to rule out organic causes

Question 351

Describe the management of postpartum depression

Answer 351

• Self-help, CBT, ITP(interpersonal therapy)
• Antidepressants(SSRIs)
• Severe: admission to mother baby mental health unit

Question 352

How is baby blues managed?

Answer 352

• Reassurance and support
• Regular health visitor checks to check in with mother

Question 353

Define pre-term labour

Answer 353

• Onset of regular uterine contractions accompanied by cervical changes occuring before 37 weeks gestation

Question 354

Define pre-term birth

Answer 354

• Delivery of a baby 20-37 weeks gestation

Question 355

Define premature rupture of membranes

Answer 355

• Rupture of membranes at least one hour before onset of contracitons

Question 356

Define prolonged premature rupture of membranes

Answer 356

• Rupture of membranes over 24 hours before onset of labour

Question 357

Define pre-term premature rupture of membranes

Answer 357

• Early rupture of the membranes before 37 weeks gestation

Question 358

Describe the epidemiology of preterm prelabour rupture of the membranees

Answer 358

• Occurs in around 2% of all pregnancies
• Associated with 40% of preterm delvieries

Question 359

How is PPROM diagnosed?

Answer 359

• Sterile speculum exam: look for pooling of amniotic fluid in posterior vaginal vault
• Avoid digital exam: risk of infection
• If no pooling: test fluid for placental alpha microglobulin protein(PAMG-1) or insulin like growth factor binding protein 1
• USS-oligohydramnios

Question 360

How is PPROM managed?

Answer 360

• Admission
• Regular observations to check for chorioamnionitis
• Oral erythromycin for 10 days
• Antenatal corticosteroids: reduce risk of respiratory distress syndrome
• Delivery should be considered at 34 weeks gestation

Question 361

Describe the aetiology of postpartum haemorrhage

Answer 361

4T's:

• Tone: mc: uterine atony(failure of uterus to contract after delivery)
• Trauma
• Tissue(retained placenta etc)
• Thrombin(clotting/bleeding disorder)

Question 362

Describe the initial management of PPH

Answer 362

• Life threatening emergency: ABCDE approach
• 2 14 gauge large bore peripheral cannulas
• Lie flat
• Bloods including grooup and save
• Commence warm crystalloid infusion

Question 363

Describe the mechancial strategies that can be used to manage postpartum haemorrhage

Answer 363

• Palpate uterine fundus and rub it to stimulate contractions
• Catheterisation to prevent bladder distention and monitor urine output

Question 364

Describe the medical management of postpartum haemorrhage

Answer 364

• IV oxytocin: slow IV injection then infusion 
• ergometrine slow IV(unless hx of htn)
• carboprost IM(unless hx of asthma)
• sublingual misprostol

Question 365

Describe the surgical management of postpartum haemorrhage

Answer 365

If medical options fail to control bleeding:

• Intrauterine balloon tamponde-if uterine atony as cause
• B-lynch suture, ligation of uterine/internal iliac arteries
• If severe: hysterectomy as life-saving procedure

Question 366

How is secondary postpartum haemorrhage managed?

Answer 366

• Depends on underlying cause
• Abx for infection
• Surgical evacuation for retained products of conception

Question 367

Describe the pathophysiology of rhesus negative pregnancy

Answer 367

• 15% of mothers rhesus negative
• If rh negative mother delivers a rh positive child, a leak of fetal red blood cells can occur
• Causes anti D-IgG antibodies to form in mother
• Maternal anti-D antibodies can cross placenta in subsequent pregnancies and cause rhesus haemolytic disease if baby is rhesus positive
• Can also occur in first pregnancy due to leaks

Question 368

Give some examples of sensitisation events in rhesus negative pregnancies

Answer 368

• Anteepartum haemorrhage
• Placental abruption
• Abdo trauma
• ECV
• Miscarriage if gestation > 12 weeks
• Termination of pregnancy
• Delivery of rh positive infant
• Ectopic pregnancy
• Amniocentesis, CVS, fetal blood sampling

Question 369

How is rhesus heamolytic disease prevented and screened for?

Answer 369

• Test for D antibodies in all rhesus negative mothers at booking
• Anti-D given to non-sensitised rh negative mothers at 28 and 34 weeks-prophylaxis(once sensitisation occurs can't be undone)

Question 370

How is rhesus negative pregnancy managed?

Answer 370

• Screening/prevention strategies
• Give Anti-D immunoglobulin as soon as possible but always within 72 hours when a sensitisation even occurs

Question 371

Describe the medical management of termination of pregnancy

Answer 371

• Mifepristone(first orally) then misoprostol 24-48 hours after
• Misoprostol can be repeated 3 hourly(max 5) until expulsion
• Takes time: hours to days
• Pregnancy test required in 2 weeks: multi-level pregnancy test-measures level of HCG not just positive or negative

Question 372

How is trichomoniasis vaginalis managed in pregnancy?

Answer 372

• Same: oral metronidazole 400-500mg twicce a day for 5-7 days
• High dose not recommended in pregnancy/breastfeeding(no 2g single dose)

Question 373

Describe the symptoms of uterine rupture

Answer 373

• Sudden severe abdominal pain which persists between contractions
• Shoulder tip pain-diaphragmatic irritation)
• Vaginal bleeding

Question 374

Describe the signs of a uterine rupture

Answer 374

• O/E: regression of presenting part
• Abdominal palpation: scar tenderness and palpable fetal parts
• Fetal monitoring: fetal distress/absent heart sounds
• Significant haemorrhage: signs of shock: tachycardia, hypotension

Question 375

Describe the management of a uterine rupture

Answer 375

• ABCDE appproach
• C-section
• Uterus either repaired or removed
• Decision-incision interval should be under 30 minutes

Question 376

Define gestational diabetes

Answer 376

• Glucose intolerance on OGTT with:
• Fasting blood glucose >=5.6mmol/L
• 2 hour plasma glucose levels >=7.8mmol/L

Question 377

Describe the epidemiology of gestational diabetes

Answer 377

• 5% of pregnancies
• 2nd most common medical disorder complicating pregnancies

Question 378

How might patients with gestational diabetes present?

Answer 378

• Often asx
• Polyuria
• Thirst
• Fatigue

Question 379

How is gestational diabetes diagnosed?

Answer 379

• OGTT: fasting >=5.6, 2 hour: >=7.8-REMEMBER 5,6,7,8
• HbA1c: distinguish between gestational and pre-existing diabetes early on
• Urinalysis: check for glycosuria

Question 380

Describe the management of gestational diabetes

Answer 380

• Fasting glucose <7mmol/L: lifestyle : diet and exercise. Give it 1-2 weeks then metformin if targets not met, then insulin added
• >=7mmol/L: start insulin (short acting not long acting)
• 6-6.9mmmol/L + complications like macrosomia or hydramnios: offer insulin
• Glibenclamide only for women who can't use metormin/doesn't work and decline insulin

Question 381

Describe the management of pre-existing diabetes in pregnancy

Answer 381

• Weight loss if BMI >27
• Stop oral hypoglycaemimcs except metformin and start insulin
• Folic acid 5mg/day until 12 weeks 
• Detailed anomaly scan at 20 weeks including 4 chamber view of heart and outflow tracts
• Tight glycaemic control reduces complication rates
• Treat retinopathy: can worsen in pegnancy

Question 382

Describe the normal changes in blood pressure in pregnancy

Answer 382

• Usually falls in the 1st trimester and continues to fall until 20-24 weeks
• After this: BP usually increases to pre-pregnancy levels by term

Question 383

How should pregnant patients with hypertension be classified?

Answer 383

• Pre-existing hypertension
• Pregnancy induced hypertension/gestational hypertension
• Pre-eclampsia

Question 384

Describe the management of pre-existing hypertension in pregnancy

Answer 384

• STOP ACE inhibitor or angiotensin 2 receptor
• SWAP for alternative: labetalol whilst waiting specialist review
• Nifedipine if asthmatic

Question 385

Describe the features of pregnancy induced hypertension

Answer 385

• Hypertension occuring in the 2nd half of pregnancy(after 20 weeks)
• No proteinuria, no oedema
• 5-7% of pregnancies

Question 386

Describe the management of pregnancy induced hypertension

Answer 386

• Oral labetalol/nifedipine/hydralazine
• Typically resolves within 1 month after birth 

Question 387

Describe the features of pre-eclampsia

Answer 387

• Pregnancy induced hypertension associated wwith proteinuria(>0.3g/24hrs)
• Oedema may occur but less commonly used now as a criteria
• 5% of pregnancies

Question 388

Describe the epidemiology of Group B strep infection

Answer 388

• Mc asx commensal bacterium in GI and GU tracts
• 25% of pregnant women estimated to be carriers
• Can cause severe illness to mother and infant during transmission during delivery

Question 389

How might Group B strep infection be investigated?

Answer 389

• No current routine screening test for pregnant women as colonisation status can change through pregnancy
• GBS culture may be done in certain cirumstances

Question 390

How is Group B strep infection managed?

Answer 390

• Intrapartum antibiotic prophylaxis-benzylpenicillin
• Abx IV during labour and delivery

Question 391

Describe the management of obesity in pregnancy

Answer 391

• 5mg folic acid not 400mcg
• Screening for gestational diaebetes with OGTT at 24-28 weeks
• BMI >=35: Birth in consultant led obstetric clinic
• BMI>=40: Antenatal coonsultation with ostetric anaesthetist and plan made in advance

Question 392

How is cephalopelvic disproportion managed?

Answer 392

• Trial of labour
• Intrumental vaginal delivery-may need episiotomy
• C-section

Question 393

How is prolonged labour managed?

Answer 393

• ID causes and evaluate progress of labour

Medical:

• Artificial rupture of membranes
• IV oxytpcin to augemnt contractions
• Pian management: epidural, nitrous oxide etc

Surgical:

• Operative delivery
• C-section

Postpartum:

• Monitor closely for infection
• Active management of 3rd stage of labour: uterotonic agents
• Ensure adequate analgesia

Question 394

Describe the clinical features of obstetric cholestasis

Answer 394

• Pruritus: intense-typically worst in palms, soles, abdomen
• Jaundice: dark urine and pale stools in about 20% of patients
• General fatigue and malaise
• GI sx: nausea and appetite loss
• RUQ abdominal pain
• Raised bilirubing in >90% of acses

Question 395

How is obstetric cholestasis managed?

Answer 395

• Chlorphenamine and emollients to reduce itching
• Induction of labour at 37-38 weeks
• Ursodeoxycholic acid
• Vitamin K supplementation-> minimise risk of bleeding

Question 396

Describe the prognosis of obstetric cholestasis

Answer 396

• Hihg recurrence: 45-90% in subseqquent pregnancies

Question 397

Describe the aetiology of chorioamnionitis

Answer 397

• Bacteria ascending from vagina into uterus
• Mc: Group B strep, E.coli and anaerobic bacteria

Question 398

How is chorioamnionitis diagnosed?

Answer 398

• Usually clinical
• Blood tests and cultures ot confirm and ID causative organism

Question 399

How is chorioamnionitis managed?

Answer 399

• IV broad sectrum abx: sepsis 6 protocol
• Monitoring of fetus and mother for complications
• Early delivery might be needed-C section

Question 400

Describe the management of FGM in the UK

Answer 400

• Illegal in UK-immediate child protection referrral if child at risk
• Anterior episiotomy during second stage of labour under local anaesthetic or regional block
• Deinfibulation surgery: important to protect urethra

Question 401

Describe the clinical features of shoulder dystocia

Answer 401

• Difficult delivery of fetal face/chin
• Retraction of fetal head-turtle neck sign
• Failure of restitution
• Failure of descent of fetal shoulders following delivery of head

Question 402

Describe the management of shoulder dystocia

Answer 402

• Immediately call for senior help
• Do not apply fundal pressure-can lead to uterne rupture
• McRoberts maneouevre
• All fours position
• Internal rotational manoeuvers
• Episiotomy-won't remove bony obstruction but will allow space for internal manoeuvers
• Cleidotomy/symphysiotomy: not 1st line-associated with significant maternal morbidity]
• Zavanelli manoeuvre-also dangerous

Question 403

Define anaemia in pregnancy

Answer 403

Hb:

• 1st trimester: <110g/L
• 2/3 triester: <105g/L
• Postpartum: <100g/L

Question 404

Describe some clinical features of anaemia

Answer 404

• Asx
• Dizziness, fatigue, dyspnoea: normal pregnancy
• Pallor
• Koilonychia
• Angular cheilitis

Question 405

How is anaemia diagnosed/investigated in pregnancy?

Answer 405

• FBC
• Folate to check for folate deficiency
• Check for beta thalassaemia and sickle cell

Question 406

Describe the risk of congenital rubella syndrome?

Answer 406

• Risk high as 90% in first 8-10 weeks
• Damage rare after 16 weeks

Question 407

Describe the epidemiology of congenital rubella syndrome

Answer 407

• Rare now due to MMR vaccine

Question 408

How is rubella transmitted ot the fetus in congenital rubella syndrome?

Answer 408

• Virus can cross the placenta and affect the developing fetus

Question 409

How is congenital rubella syndrome diagnosed?

Answer 409

• Serology to confirm rubella infection-IgM raised in women recently exposed to virus
• Audiology tests for hearing impairment
• Opthalmology for eye abnormalities
• Echos for congenital heart defects

Question 410

How is congenital rubella syndrome managed?

Answer 410

• During pregnancy: discuss with local health protection unit
• Advised to keep away from people who might have rubella
• Offer MMR vaccine in post natal period
• Neonates: primarily supprotive and symptomatic-monitor progress and manage long-term complications

Question 411

How can perineal tears be classified?

Answer 411

• 1st, 2nd, 3rd, 4th degree 

Question 412

Describe the features of a first degree perineal tear

Answer 412

• Superficial damage with no muscle involvement
• Do not require any repair

Question 413

Describe the features of a second degree perineal tear

Answer 413

• Injury to perineal muscle but not involving the anal sphincter
• Require suturing on ward by suitably experienced midwife or clinician

Question 414

Describe the features of a third degree perineal tear

Answer 414

• Injury to perineum involving the anal sphincter complex(external anal sphincter(EAS) and internal anal sphincter(IAS)
• 3a: < 50% EAS thickness torn
• 3b: >50% EAS thickness torn
• 3c: IAS torn
• Require repair in theatre by suitably trained clinician

Question 415

Describe the features of a fourth degree perineal tear

Answer 415

• INjury to perineum involving the anal sphincter complex(EAS and IAS) and rectal mucosa
• Require repair in theatre by suitably trained clinician

Question 416

Describe the management of perineal tearss

Answer 416

• 1st degree: no repair
• 2nd: suturing
• 3rd/4th: surgical repair under regional or general anaesthetic
• Broad spectrum abx and laxatives given post surgery

Question 417

Describe the epidemiology of amniotic fluid embolism

Answer 417

• Rare but significant cause of maternal morbidity and mortality

Question 418

Describe the aetiology of an amniotic fluid embolism

Answer 418

• Not known fully
• Amniotic fluid can enter maternal circulation and form embolism-> block circulation like a blood clot especially in lung
• Fluid also triggers inflammatory response within mother's immune system-> DIC

Question 419

Describe the signs and symptoms of an amniotic fluid embolism

Answer 419

• Tachypnoea
• Tachycardia
• Hypotension
• Hypoxia
• DIC
• Cyanosis and MI
• Chills, shivering, sweating, anxiety and coughing

Question 420

How is an amniotic fluid embolism diagnosed?

Answer 420

• Clinical
• Exclude other causes-no definitive diagnostic test

Question 421

Describe the management of an amniotic fluid embolism

Answer 421

• Immediate transfer to ICU, MDT care
• Oxygen, fluid resus
• Correction of any coagulopathy
• FFP if prolonged PT
• Cryoprecipitate for low fibrinogen
• Platelet transfusion for low platelets

Question 422

Describe the management of hyperemesis gravidarum

Answer 422

Simple:

• Rest and avoid trigggers
• Bland, plain food, ginger
• P6(wrist) acupressure

1st line meds:

• antihistamines: oral cyclyzine/promethazine
• phenothiazines: oral prochlorperazine or chlorppromazine

2nd line:

• Oral odansetron
• Oral metoclopramide/domperidone-5 DAYS MAX

• Thiamine and folic acid supplementation
• Atacids
• Thromboembolic stockings and LMWH -dehydration 

• 
  

Question 423

How is hyperemesis gravidarum managed in hospital?

Answer 423

• Normal saline with added potassium for rehydation
• Antiemetics

Question 424

Describe the management of hypothyroidism in pregnancy

Answer 424

• Levothyroxine: usual dose increased by 25-50mcg due to increased metabolic demand

Question 425

Describe the aetiology of acute fatty liver of pregnancy

Answer 425

• LCHAS mutation-> accumulation of fatty acid metabolites in placenta-> shunted into maternal circulation and accumulate in maternal liver

Question 426

How is acute fatty liver of pregnancy investigated/diagnosed?

Answer 426

Raised:

• AST/ALT
• Bilirubin
• Creatinine
• Ammonia
• Lactate
• Serum uric acid

Leukocytosis, low-normal platelets, normocytic normochromic anaemia

Coagulopathy: prolonged PT, hypofibrinogenaemia and elevated D dimer

Question 427

Describe the management of acute fatty liver of pregnancy

Answer 427

• Curative: delivery of the fetus
• Maternal stabilisation: correct hypoglycaemia, coagulopathy and hypertension
• After delivery: cloese monitoring-if ongoing deteriorattion in liver function post birth-transfer to liver transplant facility

Question 428

Describe the management of the thyrotoxic phase of postpartum thyroidits

Answer 428

• Propanolol for sx control
• Not usually treated with anti-thyroid drugs as thhryroid not overactive

Question 429

Describe the treatment of the hypothyroid phase of postpartum thyroidits

Answer 429

• Usually treated with thyroxine

Question 430

Describe the presentation of a patient with obstructed labour

Answer 430

• Widest diameter of fetal sckull remains stationary above the pelvic brim
• Prolionged labour: >12 hours
• Premature rupture of membranes
• Mother has abnormal vital signs
• Bandls' ring
• Foul smelling meconium from mother's vagina
• Oedema of fulva/cervix
• Caput
• Malpresentation/malposition of fetus
• Poor cervical effaceemnt

Assess using vaginal exam

Question 431

Describe the management of obstructed labour

Answer 431

• Saline for dehydration
• catheter to drain bladder
• May need C section or instrumental delivery

Question 432

Describe the epidemiology of intrauterine growth restriction

Answer 432

• 3-7% of newborns
• Increased prevalence in low/middle income countries-> maternal malnutrition and infection

Question 433

Describe the signs and symptoms of intrauterine growth restriction

Answer 433

• Decreased fetal movement
• Abnormal fundal height for gestational age
• Complications like pre-eclampsia and stillbirh

Question 434

How is intrauterine growth restriction managed?

Answer 434

• Close monitoring of fetal growth and wellbeing
• Management of maternal conditions contributing
• Consideration for early delivery if fetus is in distress/conditions worsens

Question 435

Describe the aetiology of ovarian hyperstimulation syndrome

Answer 435

• Excessive response to hormones-> multiple follicles mature and enlarge-> all transform into corpus luteum-> overproduction of oestrogen, progesterone and local cytokines, especially vascular endothelial growth factor-> increased membrane permeability and loss of fluid from intravascular compartment

Question 436

Describe the signs and symptoms of ovarian hyperstimulation syndrome

Answer 436

• Bloating
• Abdo pain
• Oedema
• Pleural efffusions
• Ascites
• Weight gain

Question 437

How is ovarian hyperstimulation syndrome diagnosed?

Answer 437

• Routine bloods: evaluate haemoconcentration and detect potential organ dysfunction
• CXR: ID pleural effusion

Question 438

Describe the management of ovarian hyperstimulation syndrome

Answer 438

• Supportive-tailored to severity of condition
• Simple analgesia for discomfort
• Might need ICU and close monitoring if severe

Question 439

Describe the features of fetal varicella syndrome

Answer 439

• Skin scarring
• Eye defects: microphthalmia
• Limb hypoplasia
• Microcephaly
• Learning difficulties

Question 440

Describe the management of chickenpox exposure in pregnancy

Answer 440

• If doubt about previous infection: check blood urgently for varicella antibodies
• Oral aciclovir now first choice for post exposure prophylaxis(used to be VZIG)-should be given day 7-14 after exposure not immediately

Question 441

Describe the management of chickenpox in pregnancy

Answer 441

• Seek specialist advice
• Oraal aciclovir if >=20 weeks and presents within 24hrs of rash onset
• If <20 weeks: aciclovir 'considered with caution

Question 442

Describe the pathophysiology of placental insufficiency?

Answer 442

• Placental vascular remodeling is affected-> placental functioning progressively deteriorates. This process affects the placental blood flow, leading to fetal hypoxemia, or low levels of oxygen in the blood, and restriction of fetal growth. 

Question 443

How might placental insufficiency present?

Answer 443

• Usually no observable sx
• Decreased fetal movemennt
• Intrauterine growth restriction
• Prematurity
• Stillbirth

Question 444

How is placental insufficiency diagnosed/investigated?

Answer 444

• Doppler USS: evaluate fetal and placental circulations-> regulare screening
• MRI if inconclusive

Question 445

Describe the management of placental insufficiency

Answer 445

• <34 weeks: delay delivery: low dose aspirin, vitamin C and E, heparin
• >34 weeks: prompt delivery

Question 446

How is a pregnant women at high risk of VTE treated?

Answer 446

• LMWH throughout antenatal period and input from experts

Question 447

If a pregnant woman has 3 risk factors for VTE how should this be managed?

Answer 447

• LMWH from 28 weeks and continued nutil 6 weeks postnatal

Question 448

If a diagnosis of DVT is made shortly beefore delivery in a pregnant woman, how long should treatment be continued for?

Answer 448

• At least 3 months

Question 449

How can twin pregnancies be classified?

Answer 449

• Zygosity
• Chorionicity
• Amnionicity

Question 450

How can monozygotic twwins be further classified?

Answer 450

• Dichorionic + daimniotic: 2 different sacs
• Monochorionic + diamniotic: same outer sac, two inner sacs
• Monochorionic + monoamniotic: same sacs

Question 451

Describe the epidemiology of twins

Answer 451

• 2/3: dizygotic
• 1/3: monozygotic

^When conceived naturally

Question 452

Describe the management of twins

Answer 452

• Rest
• USS for diagnosis and monthly checks
• Additional iron and folate
• More antenatal care( weeekly when >30 weeks)
• Precautions at labour(2 obstetricians present)
• 75% of twins deliver by 38 twins, if longer, most twins are induced at 38-40 weeks

Question 453

Describe the aetiology of twin-to-twin transfusion syndrome

Answer 453

• Precipitated by anastamoses of umbilical vessels betwween 2 fetuses in the placenta of monochorionic twins

Question 454

How is twin-to-twin transfusion syndrome diagnosed?

Answer 454

• Monochorionic twins: regular USS to monitor
• Observe fluid levels in each amniotic sac, measure size of twins and assess blood flow in umbilical cord and placenta

Question 455

Describe the management of twin-to-twin transfusion syndrome

Answer 455

• Laser transection of problematic vessels in utero-can increase survival rate, high mortlaity for both twins without tx

Question 456

Describe the symptoms of UTI in pregnancy

Answer 456

• Frequent urination
• Dysuria
• Lower abdo pain
• Fever
• Haematuria

Question 457

Describe the management of asymptomatic bacteriuria in pregnancy

Answer 457

• Nitrofurantoin and cefalexin mc used
• Ig Group B strep ID d: intrapartum prophylactic abx to reduce risk of transmission 

Question 458

Describe the treatment for a UTI in pregnant women

Answer 458

1. nitrofurantoin for 7 days(avoid at term)
2. Amoxicillin/cefelexin

Question 459

Describe the symptoms of puerperal infection

Answer 459

• Fever
• Abdo pain
• Tahycardia
• Abnormal discharge
• Foul smellinf lochia(postpartum bleeding)
• Tenderness/pain in pelvi area
• Sepsis signs: hypotension, tachypnoea etc

Question 460

Describe the maangement of puerperal infection

Answer 460

• Abx-broad spectrum initially: ceftriaxone and metronidazole
• Fluids
• Analgesia
• Prevention: good hygiene practices during childbirth and postpartum care
• Close monitoring
• Drainage od abscesses if needed

Question 461

Describe LH and FSH in Turners

Answer 461

• Raised LH
• Raised FSH

Question 462

Describe LH and FSH in Kallman's

Answer 462

• Low LH
• Low FSH

Question 463

Describe the general function of blood hormones

Answer 463

• Oestrogen: sex development-females
• Progesterone: uterine development
• Testosterone: sex development males
• FSH and LH: ovarian funcitonality

Question 464

Describe the management of primary amenorrhoea

Answer 464

• Primary hypo: COCP
• Primary hyper: GnRH analogue

Question 465

Descrieb the management of secondnary amenorrhoea

Answer 465

• Lifestyle: stress/weight managemenet
• Treat underlying cause
• Surgical: tumour/cyst removal

Question 466

For how long/how frequently do a couple need to be having unrpotected sexual intercourse to be cnsidered infertile?

Answer 466

• 2 years despite sex 3-4 times/wweek

Question 467

How can causes of infertility be classified?

Answer 467

• Genetics
• Ovulation/endocrine
• Tubal abnormalities
• Uterine abnormalities
• Endometriosis
• Cervical abnormalities
• Testricular disorders
• Ejaculatory disorders

Question 468

Give some ovulation/endocrine disorders that can cause infertility

Answer 468

• PCOS
• Pituitary tumours
• Sheehan's syndrome
• Hyperprolactinaemia
• Cushing's
• Premature ovarian failure

Question 469

Give some tubal abnormalities that can cause infertility

Answer 469

• Congenital anatomical abnormalities
• Adhesions
• Can be secondary to PID(-> gonorrhoea, chlamydia)

Question 470

Give some uterine abnormalities that can cause infertility

Answer 470

• Bicronate uterus
• Fibroids
• Asherman's syndrome

Question 471

How is infertility investigated in women?

Answer 471

Bedside:

• Thorough hx including PMH, sexual history and past pregnancies
• Speculujm and bimaual exam-e.g. fibroids
• STI screen

Bloods:

• Serum progesterone testing
• Prolactin
• LH/FSH
• Anti-mullerian hormone
• TFTs

Imaging:

• TV USS
• Hysterosalpingography
• Laparoscopy and dye

Question 472

How is infertility investigated in men?

Answer 472

Bedside:

• Thorough hx including PMH, sexual history past children
• Testicular exam: e.g. varicocele
• Semen analysis: evaluate sperm count, motility and morphology

Bloods:

• Serum testosterone
• LH/FSH
• TFTs

Question 473

Describe the conservative management of infertility

Answer 473

• Folic acid
• Weight loss: BMI 20-25
• Smoking cessation and alcohol advice
• Stres reduction strategies
• Advice sexual intercourse every 2-3 days