Specialties - O&G Flashcards

Question

A 28 year old woman attends an appointment with her doctor to talk about getting pregnant. She is a known epileptic who has been well-controlled on sodium valproate for the last 5 years (i.e. since diagnosis). She wants to know how pregnancy will affect her condition, and what changes in her management may be needed. What should the doctor tell her? A. She will need to take the standard 400mcg dose of folic acid B. Her medication dose will need to be increased, and then decreased shortly after birth C. She will probably experience an increase in seizure activity during pregnancy, but this can be mitigated by drug dosage changes and monitoring D. Sodium valproate given at the lowest therapeutic dose has no association with birth defects E. She is at no more increased risk of psychiatric issues during pregnancy than a non-epileptic person

Answer 1

B. Her medication dose will need to be increased, and then decreased shortly after birth 'A' is wrong because women with epilepsy are recommended to take the higher 5mg dose of folic acid, as there is some evidence it reduces the incidence of congenital malformation in children of woman taking anti-epileptic drugs (AEDs). 'B' is correct because there is increased renal and hepatic clearance of drugs during pregnancy which, in addition to the haemodilution, necessitates a higher dose of AEDs. However these changes rapidly reverse post-partum, and so any epileptic woman whose AED dose was increased during pregnancy should be reviewed within 10 days post-partum to adjust the dose. 'C' is incorrect because most women will not experience seizure deterioration during pregnancy. Overall about 1/3 of epileptic women experience a deterioration during pregnancy, and the best predictor for this is their seizure activity immediately prior to pregnancy - if their epilepsy is well-controlled, they are unlikely to have seizures while pregnant. Epileptic women are particularly vulnerable to seizures during delivery and immediately post-partum, mostly due to the exhaustion and dehydration that accompanies that period. 'D' sodium valproate is associated with neural tube defects. There are conflicting opinions as to whether carbamazepine causes neural tube defects depending on who you ask. Lamotrigine is generally considered safe during pregnancy. 'E' is incorrect as both certain varieties of epilepsy and certain AEDs carry an increased risk of depression. This means that epileptic mothers are more at risk from depression during and immediately after pregnancy, and should be made aware so they can monitor any symptoms that arise and seek help. NB: Babies born to mothers taking AEDs particularly need their vitamin K injection if the AED is enzyme inducing

Answer 2

C. Give I.V. lorazepam, consider I.V. phenytoin and tocolytics if seizures and uterine hypertony persist The acute management of a seizure in a pregnant woman is very similar to that of a non-pregnant person having an epileptic seizure. First line management is to give I.V. lorazepam, which is usually achievable as women in labour should already have at least one cannula in situ. Diazepam can be given I.V. as an alternative. If there is no I.V. access, then rectal diazepam or buccal midazolam can be given, so 'D' and 'E' are good second line options. If seizures are not controlled by initial steps, I.V. phenytoin or fosphenytoin is given. I.V. Hartmann's and supplementary oxygen (A) may well be needed depending on oxygen saturations and hydration status/ blood pressure, but are not the best option here. Tocolytics may be used for a seizure during labour, but only if there is persistent uterine hypertonus due to the seizure and you become concerned for the fetal wellbeing. The CTG should be continuously monitored, and the decision to expedite delivery should be considered.

Answer 3

B. Unconjugated oestradiol, hCG, AFP and inhibin A Down’s syndrome screening is offered to all pregnant women in the UK. She is 42 which gives you an age related risk of one in 55 of having a child with Down’s syndrome. Early in the second trimester the combined test is offered. This includes an ultrasound scan of the fetal neck looking at the nuchal translucency (NT) and two blood tests – PAPP-A and beta hCG. This can be reliably performed from 10 to 13 weeks. Ideally, an integrated test using the combined test and the quadruple test can be used to create a Down’s risk. As she has missed the chance to have an NT, she would only be offered the quadruple test, which is unconjugated oestradiol, total hCG, AFP and inhibin A – Answer (B). The downside of the quadruple test is that it has a 4.4 per cent false-positive rate compared with 2.2 per cent for the combined test and only 1 per cent for the integrated test. In the event of a high risk result, this woman would be offered an amniocentesis to exclude Down’s syndrome and other chromosome abnormalities. NB: This question is reproduced from '450 SBAs in Clinical Pathology'

Answer 4

E. Counsel the woman that the fetus is alive, but there is a 1 in 4 risk of miscarriage This is most likely a threatened miscarriage, in which there is bleeding but the os is closed and the fetus is still alive; it carries a 25% of actual miscarriage. Because the fetus is still alive, the USS should show a fetal pole and cardiac activity (detectable on USS from 5-6 weeks onwards). 'A' would imply a missed miscarriage - the fetus has died some time prior but the products of conception have not been passed so the mother is unaware. Later in pregnancy, this may be evident as the uterus will be smaller than expected. 'B' implies a septic miscarriage, as these are signs of infection, though there is nothing here to suggest this would be the case. 'C' is referring to the lower levels of beta-hCG seen in ectopic pregnancy. Ectopic pregnancy is a very important differential to exclude, but occurs in ~1% of pregnancies making miscarriage more likely Molar pregnancy (D) is a possible differential, but occurs in 0.1% of pregnancies, whereas miscarriage occurs in ~20% of clinical pregnancies, especially in the first trimester, making 'E' a more likely finding.

Answer 5

B. Assess her hydration status, weigh her, and take bloods Hyperemesis gravidarum can be diagnosed when there is persistent nausea and vomiting in pregnancy (NVP) with the triad of >5% weight loss, electrolyte imbalance, and dehydration. It usually follows the same pattern as regular morning sickness in that it begins around 4 weeks and usually disappears by 14-20 weeks. UTI, multiple pregnancy, and molar pregnancy can all cause hyperemesis gravidarum, and so should be routinely excluded.

Answer 6

E. Her failure to progress in a previous labour, combined with her never having given birth vaginally, reduces the likelihood of vaginal birth Vaginal birth after a previous C-section (VBAC) is complex, and each mother must be assessed individually on their suitability for vaginal birth. A successful VBAC carries the lowest risk of all options, but a failed VBAC with emergency C-section carries the highest, therefore the risks need to be appropriately weighed. Advise her there is a 75% chance of success, but that attempting and failing vaginal birth to then perform an emergency C-section is the riskiest option. There is also an increased (~0.5%) risk of uterine rupture at the site of the C-section scar, which would necessitate a hysterectomy and would probably result in significant haemorrhage. The best indicator of a successful VBAC is a previous vaginal birth, especially a previous VBAC which makes the odds of another successful VBAC 85-90%.

Answer 7

Monitor pulse, RR, and blood pressure, and test the patellar tendon reflex This should be done at least once every 4 hours

Answer 8

C. Admit the woman, give a 10 day course of erythromycin, offer steroids, and employ a watchful waiting approach In a woman presenting with rupture of the membranes between 24+0 and 36+6 weeks, a speculum exam should be performed. If the speculum exam is not clear (does not show pooled liquor) then an IGFBP‐1 or PAMG‐1 test is a sensitive and specific marker to aid diagnosis. If PPROM is confirmed, the patient should be admitted for at least 48 hours as in >50% of cases preterm labour follows PPROM within 48 hours. Patients with no contraindications should be offered expectant management until 37 weeks with frequent clinical assessment. Infection often co-exists with PPROM and may be either the result or the cause: the earlier the gestation, the more likely the infection is to have caused PPROM. Infection is an important complication and should be assessed using a combination of maternal history, maternal abdominal exam, CTG monitoring, bloods including a CRP and WCC, and potentially a high vaginal swab (though none of these should be used in isolation). Any woman presenting with PPROM should be given a course of antibiotics for 10 days or until she is in established labour – whichever comes first. Erythromycin is the first-line antibiotic. Co-amoxiclav is contraindicated as it raises the risk of necrotising enterocolitis in the newborn. A. This patient requires admission and the measurement of amniotic fluid volume in the context of PPROM using ultrasound is not recommended or supported by evidence. B. This would be a good answer if the speculum examination were less conclusive, but is unnecessary here. D. There is no reason to induce labour here E. There is no indication for continuous CTG monitoring and this woman should not be discharged home given the risk she will deliver soon. NB: "established labour" refers to the second part of the first stage of labour: when the cervix dilates from 4cm to 10cm.

Answer 9

B. Do nothing for the moment but offer the woman a follow-up scan at 32 weeks 5% of pregnancies feature a low-lying placenta at 20 weeks, but only 10% of these are still low-lying at term. This is because the lower segment of the uterus expands later than the upper segment, so low-lying placenta usually 'move up' after 20 weeks. It is important to determine whether this position will persist, so the mother should be invited for a TVUSS at 32 weeks, and then again at 36 weeks if it is still low-lying. If the placenta is lying directly over the internal cervical os, then it is praevia. If the placenta does not cover the os but is within 20mm, then it is low-lying (this distinction is used because of the difference in risks during delivery). Cervical length should also be assessed at 32 weeks, as this indicates risk of preterm labour and massive haemorrhage during C-section. She should be counselled that if the placenta is low-lying or praevia, that vaginal birth may be inadvisable or impossible depending on the placenta's position. She should also be told to attend hospital urgently if she experiences abdominal pain, contractions, or vaginal bleeding. She should be counselled on the risk of massive haemorrhage with delivery, and should be consented to receive blood products and potentially a hysterectomy in the worst case scenario.

Answer 10

A. Perform a TVUSS to measure cervical length In a woman presenting with potential preterm labour, the stage of pregnancy has a small effect on how you diagnose her: if she is less than 30 weeks pregnant and the history and exam suggest preterm labour, then proceed to treatment. If she is 30 weeks pregnant or more, then a TVUSS can be used to assess cervical length: a length of 15mm or less is diagnostic of preterm labour. If TVUSS is contraindicated or unacceptable, then fetal fibronectin can be used instead, but guidelines specifically state not to use the two together. If the cervix were dilated and it was clear she was in labour, this step would be unneccessary. Once preterm labour is diagnosed, tocolysis can be attempted to stop the labour. First line is nifedipine (CCB) but oxytocin receptor antagonists (e.g. atosiban) can be used if nifedipine is contraindicated. Magnesium sulphate is given I.V. to the mother for neuroprotection of the preterm baby, and corticosteroids should be given to help mature the preterm baby's lungs. 'D' and 'E' are therefore both correct treatment options once preterm labour is diagnosed, but are not the best next step. 'B' is wrong as there are no indications for C-section, and 'C' is unnecessary as there are no contraindications to TVUSS, and there is no need to use the two diagnostic methods together.

Answer 11

C. Elevated AST and ALT Though thrombocytopenia and anaemia are components of HELLP syndrome, they are also both physiological features of pregnancy. In this scenario - assuming no prior results are available for comparison - AST and ALT are more useful because they are a component of HELLP syndrome not physiologically raised in pregnancy. ALP is physiologically raised in pregnancy, and CRP is a very general measure of inflammation.

Answer 12

D. Thrombocytopenia Thrombocytopenia of the mother (gestational thrombocytopenia) is normal and is thought to occur due to increased consumption rather than a dilutional effect. This is because it manifests late in the pregnancy, unlike the dilutional anaemia.

Answer 13

Oligohydramnios: A. COX inhibitors F. IUGR G. Posterior urethral valves ``` Polyhydramnios: B. Fetal renal disease (e.g. Bartter syndrome) C. Tracheoesophageal fistula D. Gestational diabetes E. Anencephaly H. Down syndrome ```

Answer 14

Glycosuria generally occurs around a serum concentration of 11mmol/L in non-pregnant patients, but will often occur at a lower threshold in pregnancy

Answer 15

C. Diabetics are monitored regularly for preeclampsia, but not routinely given prophylaxis Pre-existing diabetics are at high risk of developing preeclampsia during pregnancy, and so should be given 75-150mg aspirin ODS from 12 weeks till the end of their pregnancy. Management of diabetics during pregnancy is complex, with myraid potential complications. Established diabetics face more complications than gestational diabetics, with type I and II faring similarly. Maternal complications include: increased birth trauma and delivery complications (due to macrosomia); increased insulin requirement; hypoglycaemia (from attempts to control tightly); UTIs, wound infection, and endometritis; preeclampsia; worsening of pre-existing ischaemic heart disease; and worsening of diabetic retinopathy. Management of these patients begins pre-conceptually, where the patient is advised to closely monitor their blood glucose levels. Diabetic prospective mothers are advised to take the higher dose of folic acid (5mg instead of 400mcg) for 3 months before conception up until week 12 of pregnancy; this is because of the increased risk of neural tube defects (there is also increased risk of cardiac defects). Retinal function, renal function, signs of preeclampsia, and fetal growth must all be monitored during pregnancy. Labour is more likely to be complicated, so problems like increased birth trauma and shoulder dystocia should be planned for. Post-partum the baby is particularly vulnerable to hypoglycaemia which must be monitored for. Finally, it is important to note that the mother's insulin requirement will rapidly return towards pre-pregnancy after delivery, and failure to attenuate insulin doses may lead to hypoglycaemia. Gestational diabetes in diabetes presenting during pregnancy in susceptible women, due to changes in metabolism. It account for ~90% of diabetes in pregnancy, increase the risk of developing type II diabetes later, and is associated with conditions impairing glucose tolerance e.g. PCOS. An OGTT is performed between 24-28 weeks to assess for gestational diabetes, or earlier (shortly after the booking appointment) if the woman has developed it before. NB: glycosuria in pregnancy is a less significant finding than normal because a pregnant woman's kidneys have a lower threshold for excreting glucose (normal being serum concentration of 11mmol/L)

Answer 16

A. Systemic chemotherapy is safe from the second trimester onwards 'B' is not true, for though 24 weeks is the general limit for TOP, it may be carried out at any time if there are risks to the mother's health. 'C' is untrue, though the prognosis of breast cancer is worse in the cohort of pregnant women overall. However this is because pregnant women obviously make up the younger demographic of women with breast cancer, and it is this demographic who are more likely to develop aggressive cancers that do not respond to hormonal treatments. 'D' is incorrect as both tamoxifen and Herceptin are contraindicated during pregnancy and breastfeeding. 'E' is wrong because radiotherapy is only used if absolutely necessary e.g. to preserve the spinal cord if it is being compressed.

Answer 17

C. Previous vaginal birth NB: this is reproduced from a set of practice SBAs for the MRCOG exam

Answer 18

B. The woman should wait 3 weeks before attempting any significant activity It is recommended to wait 4-6 weeks before attempting significant physical activity after an OASI.

Answer 19

B. Bipolar affective disorder NB: this is reproduced from a set of practice SBAs for the MRCOG exam

Answer 20

C. Serum hCG (human chorionic gonadotrophin) measurement in 48 hours This is a pregnancy of unknown location (PUL). Ultrasound findings suggest a pseudosac, as a true gestational sac would be eccentrically located and have a double decidual sac sign (two concentric rings surrounding an anechoic sac). The visualisation of the yolk sac is the critical landmark of the gestational sac. Performing serial serum hCG measurements is the next most appropriate step to guide further management. NB: this is reproduced from a set of practice SBAs for the MRCOG exam

Answer 21

A. Measure LFTs weekly until delivery, and then again post-partum 'C' is correct in that cholestasis of pregnancy is caused by a reaction in susceptible women to increased levels of circulating oestrogen. However it is by no means ultimately harmless, and carries an increased risk of premature birth and meconium passage. 'B' would be appropriate for atopic dermatitis, and may provide some relief here, but is not the best option. 'D' and 'E' are incorrect because CTG, USS, and bile acids serum concentration are not useful in predicting fetal morbidity and mortality, so there is no use in performing them any more regularly than you would for an uncomplicated pregnancy. NB: there is a common perception that cholestasis of pregnancy increases the risk of stillbirth, but this is not well supported by evidence, and if it exists is thought to be a very slight increased risk

Answer 22

E. The frequency of uterine contractions External transducer CTG traces are considered to only be accurate in assessing the frequency of uterine contractions. The duration and intensity should be assessed by palpating the uterus.

Answer 23

D. Give 15L oxygen, give warmed I.V. Hartmann's, then take blood for clotting, fbc, U&Es, and cross-match for 6 units Green Top Guideline on PPH: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14178

Answer 24

A. Ask her to come back for another scan in a week's time The guidelines for determining whether there is a viable intrauterine pregnancy using TVUSS are as follows: If there is a fetal heartbeat, there is a viable pregnancy If there is no heartbeat but there is a fetal pole, measure it Whether the pole is above or below 7mm, you will likely re-scan in a minimum of 7 days If there is no pole, measure the gestational sac diameter Whether the sac diameter is above or below 25mm, you will likely re-scan in a minimum of 7 days

Answer 25

C. Separation of the placenta from the endometrium, and bleeding into the space between them This is a history of a concealed placental abruption: the placenta detaches from the endometrium and begins to bleed into the space between them. The blood does not exit the uterus until the bleeding becomes very severe, so a concealed abruption does not present with bleeding. This occurs in around 20% of abruptions, so the absence of bleeding in abdominal pain in pregnancy is not considered reassuring. The clues in the history are the tense woody abdomen, the haemodynamic instability, and the pain, along with the CTG suggestive of fetal distress/hypoxia (reduced variability, late declerations). Given the severity of the abruption, this woman would need a C-section, despite the age of the fetus.

Answer 26

B. Prescribe tranexamic acid and mefenamic acid Tranexamic acid antagonises lysine binding sites on plasminogen, reducing conversion to plasmin and so preventing fibrinolysis. Mefenamic acid is a COX inhibitor that is particularly useful in reducing menstrual pain. When used together they provide synergistic relief from both heavy bleeding and pain, and so are a good option in this patient. 'A' is the NICE-recommended first line treatment and is effective at reducing heavy bleeding. However, for the first 6 months a Mirena coil causes constant light bleeding. If the patient can weather this period, then they will get occasional light periods (~1/3 have no periods at all) but in this patient the initial 6 month period is likely to prompt them to either refuse or remove the coil after a few months. The Mirena coil lasts 5 years before it has to be replaced (the copper IUD lasts 10). 'C' would be a good step, but the patient is not reporting the symptoms of anaemia, so it isn't the most pressing concern and the pain and bleeding is affecting her life more. 'D' is not a particularly strong option because it seems likely she has tried over the counter medication before, and it will not address the bleeding issue, which she is most concerned about. 'E' would be a reasonable option were it not for the significant FMHx of VTE.

Answer 27

A. There is a 15% chance of recurrence after a LLETZ The LLETZ is an effective procedure, and is successful in over 95% of cases: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2000.tb11623.x

Answer 28

E. It usually presents in women >50 CIN is most common in women in their late 20s/ early 30s, and is associated with HPV infection in 99.7% of cases - infection with HPV is generally considered to be a prerequisite. The transformation zone of the cervix (where squamous epithelium gives way to columnar) is particularly vulnerable to HPV infection, hence it is also more vulnerable to cervical cancer. CIN is a major cause of death worldwide, but less so in the Western world because of vaccination against HPV. The two main vaccines are Cervarix (bivalent protection against serotypes 16 and 18) and Gardasil (quadravalent protection against 6, 11, 16, 18). CIN 3 refers to malignancy that occupies >2/3 of the epithelial thickness of the cervix, but has not breached the basement membrane. Progression to full carcinoma (invasion of the basement membrane) is a very slow process and may take decades (one study found the medium progression time to be over 20 years - see below). CIN may recur after treatment, but equally there is a trend in young women to develop dysplastic lesions which then spontaneously remit as the immune system brings them under control. Link to CIN 3 - cancer progression study: https://academic.oup.com/aje/article/178/7/1161/211254 NB: This question is taken from a Capsule case

Answer 29

E. Ovarian cancer typically metastasises to the peritoneum and para-aortic nodes 'C' is unlikely to be true without a stronger family history, as the majority of women with ovarian cancer have no known risk factors, and genetics are thought to play a part in only 1% of cases. Where there is a genetic basis, it is the strongest risk factor, but the presence of such a risk factor is uncommon. 'A' is untrue - taking oral contraceptives has actually been shown to reduce the risk of ovarian cancer, and an important analysis of 45 studies in the Lancet suggested the pill has actually prevented hundreds of thousands of cases (https://www.thelancet.com/article/S0140-6736(08)60167-1/fulltext). 'B' is false: having children reduces the risk of multiple cancers, including breast and ovarian. 'D' is also false: ovarian cancer is typically caught late due to its subtle and non-specific presentation. This leads to a higher mortality rate than comparable cancers e.g. endometrial or cervical.

Answer 30

1. Frothy yellow/ green discharge, vulvovaginitis, strawberry cervix - A. Trichomonas vaginalis 2. Vaginal discharge, cervical excitation, abdominal pain, deep dyspareunia - C. Pelvic inflammatory disease 3. Vulval pruritis, superficial dyspareunia, cottage cheese discharge - D. Thrush 4. Thin grey/ white discharge with a strong fishy smell, clue cells are seen on microscopy, alkaline vaginal environment - B. Bacterial vaginosis

Answer 31

D. Assess risk factors for stillbirth and IUGR, then use a handheld doppler to look for a fetal heartbeat The first step when assessing a woman with reduced fetal movements (RFM) is to exclude fetal death. This is done by finding the fetal heartbeat with a handheld doppler. Once this is done, there should be a general assessment including palpation of the abdomen (to assess size as IUGR is associated with RFM) and a CTG trace to assess fetal wellbeing. If no abnormalities are detected, the mother should be reassured that 70% of pregnancies featuring one episode of RFM feature no complications. She should be asked to return if it happens again or if she experiences any other symptoms. She should not be asked to keep a formal record of the number of kicks, as this is not a useful indicator of fetal health, and increases maternal anxiety by making the mother fixate on the number of kicks.

Answer 32

E. ECV has a better chance of success in multips, but increases the risk of instrumental delivery or C-section compared to natural cephalic presentation 'A' is incorrect, as there is only a 0.5% risk of complications necessitating an emergency C-section. 'B' is incorrect, as she should be given tocolytics (e.g. ritodrine?) to increase the chance of success, and may be offered analgesia if they cannot tolerate the procedure without it. 'C' is only slightly wrong - there is a 50-50 chance of success, but it is true that few babies revert to breech after a successful attempt. The chance of success is around 60% in multips and 40% in primips, so overall is considered to be 50% though individual factors affect this considerably. 'D' is wrong - it is uncomfortable and may well be painful, so 'D' is misleading. There is no absolute consensus on ECV contraindications, but the following are usually considered: multiple pregnancy, Rh isoimmunisation, APH within the last week, abnormal fetal monitoring, and rupture of membranes

Answer 33

C. Amniotic fluid embolism Amniotic fluid embolism is a rare complication of pregnancy, usually occurring during labour, where amniotic fluid enters the maternal circulation causing an anaphylactoid reaction and rapid circulatory collapse. This classically occurs when the membranes rupture, and though it is rare (~1 in 50,000 pregnancies) it is so lethal that it is still a significant cause of maternal mortality and morbidity. The first sign of amniotic fluid embolism is usually symptoms of hypotension and circulatory collapse with rapid acute heart failure, quickly followed by pulmonary oedema, ARDS, and DIC. The speed of deterioration along with the bilateral crackles on auscultation make this most likely to be an amniotic fluid embolism, though 'A', 'B', 'D', and 'E' are important differentials.

Answer 34

A. Take her pill now then take the next one at the usual time, and use condoms till she has been taking the POP for 48 hours Micronor is a brand of progesterone-only pill (POP) that must be taken in the same 3 hour window every day. POPs are taken continuously and do not have a week off (so 'E' is wrong). 'B' would be true for the COCP when missing one pill does not matter, but for the POP barrier contraception should be used until there is 48 hours worth of coverage. 'C' is incorrect because there is nothing to suggest emergency contraception is necessary here. 'D' would be correct if she were taking Cerazette which has a 12 hour window in which to take it, but Micronor only has a 3 hour window so she has missed the pill. 'E' is incorrect because there is no such break with the POP.

Answer 35

B. Offer insertion of the copper IUD The copper IUD is effective up to 5 days after either sexual intercourse, or the day of ovulation (whichever is latest). The copper IUD is the most effective form of emergency contraception and prevents implantation of the embryo (making it ethically dicey for some people). Though an excellent form of emergency contraception, the copper coil is not ideal as a LARC because it makes womens' periods heavier and more painful. NB: If the woman is having regular menstrual cycles, the day of ovulation will reliably be 14 days from the first day of menstruation.

Answer 36

E. Tell her to take the COCP as normal, offer emergency contraception, and advise her to use barrier contraception for 7 days Missing one COCP dose is not concerning, the patient should be advised to take the missed pill immediately and then take the pill as they would normally, even if that means taking two pills in one day. If two pills have been missed (at least 48 hours since the last pill) then the next step depends on which pill was missed. If the missed pill was in the first week, then the woman will need to use barrier contraception for a week and take emergency contraception if she has had unprotected sex in the preceding 7 days. If the missed pills were in the 2nd or 3rd week there is less concern: barrier contraception may be used if the woman is worried, but emergency contraception won't be necessary as long as the rest of the cycle has been taken correctly.

Answer 37

A. Is the most effective form of contraception listed (according to Pearl index) - 8. Progestogen implant B. Prevents implantation of the embryo as emergency contraception - 4. Copper coil C. Carries a risk of osteoporosis - 7. Depo-provera (progesterone depot injection) D. Carries the highest risk of VTE - 2. COCP E. Lasts for 5 years before it must be replaced - 3. Mirena coil F. A progesterone receptor modulator that may be given as a tablet up to 5 days after unprotected sex as emergency contraception - 6. Ulipristal G. Is taken continuously with no breaks - 1. Mini-pill H. The active ingredient of the Mirena coil which may also be used for emergency contraception - 5. Levonorgesterel

Answer 38

B. The annual risk of VTE in COCP use is ~0.05-0.1% The annual risk of VTE in COCP use according to the European Medicines Agency is 5-12 per 10,000. In the non-COCP population this risk is 2 per 10,000. The COCP is generally accepted to increase VTE risk 3-3.5 fold, but the absolute increase in risk is only 0.08%. 'A' is incorrect because the COCP is relatively contraindicated in migraine without aura, and is absolutely contraindicated in patients who have had migraines with aura due to an increased risk of stroke. 'C' is false, though the standard advice has always been to have a week off, there is not benefit to this unless the woman wants to keep track of her periods to reassure her she is not pregnant. 'D' is nearly correct, but the COCP is absolutely contraindicated in women over 35 who are smoking more than 15 per day. 'E' is wrong because the COCP is absolutely contraindicated for the first 6 weeks post-partum in breastfeeding mothers as it interferes with breastfeeding.

Answer 39

D. Measure her serum Ca125 level This history could well be describing IBS, however new onset IBS in a woman of this age is rare, and all presentations of IBS-like symptoms in this demographic should be investigated for ovarian cancer. Ideally the GP would take a history focusing on the risk factors for ovarian cancer (nulliparity, family history, BMI, PMHx e.g. endometriosis etc.). However that is not an option here, and the next thing that should be done is a serum Ca-125 measurement. If the level is 35 IU/mL, the woman should be referred for an USS of her abdomen and pelvis. If a mass is found she is then referred to a specialist, if not she may require other investigations or be asked to monitor her symptoms and return if they worsen. If the Ca-125 and USS suggest ovarian cancer, the disease should be staged in secondary care with a CTAP (CT abdo pelvis) with added chest CT if clinically indicated. Histology or cytology should then be used for tissue diagnosis.

Answer 40

D. Cystourethrocoele

Answer 41

C. Measure day 21 progesterone and day 2 LH and FSH Mid luteal progesterone should be measured to confirm ovulation, though this will be challenging in this patient due to the irregular cycle. In this case the irregular cycle is the indication for measuring gondadotropins. Other tests would also probably be carried out (e.g. hysterosalpingiogram, AMH, antral follicle count), but the ones described here are those specifically indicated by the menstrual irregularity.

Answer 42

C. She will not fall pregnant within the first 21 days, then afterwards should use contraception, but not the COCP Women will not fall pregnant within the first 21 days post-partum, but afterwards will need to use contraception. This should be planned for before birth, and can be initiated soon after birth; an IUD can be inserted within 48 hours post-partum, though outside of this window the woman will have to wait 4 weeks (hence 'D' is almost right but not quite). 'A' is wrong because not only can a woman fall pregnant within the 6 weeks post-partum, she should not take the COCP as it interferes with milk production and so may cause problems with breastfeeding. 'B' is wrong because there is a 21 day 'safe period'. 'E' is wrong.

Answer 43

D. Perform an episiotomy and attempt internal rotational manoeuvres (Wood's) Shoulder dystocia is when the baby's shoulders become stuck after delivery of the head. It is an obstetric emergency and in these cases there is only minutes in which to act to deliver the baby before brain damage occurs. There is no agreed-upon time limit before brain damage in dystocia, though limiting the time to 5 minutes or less carries a very low risk of hypoxic encephalopathy. There are known risk factors for dystocia including macrosomia, maternal diabetes and obesity, previous dystocia in labour, and induction/ augmentation of labour but there is no good way to predict dystocia and most cases are considered unpredictable. If the baby is delivered in a way that puts excess traction on the neck, they are at risk of brachial plexus injury, specifically Erb's palsy (C5, C6 nerve root injury). If the baby is not delivered rapidly they are at risk of brain damage. Upon suspicion of shoulder dystocia the midwife or doctor should immediately call for help and position the mother lying flat near the edge of the bed. They then implement McRobert's manoeuvre and apply suprapubic pressure which resolves the dystocia in 90% of cases. If this fails the patient will need an episiotomy to allow a hand into the vagina to attempt an internal rotation manoeuvre (Wood's screw manoeuvre) and to deliver the posterior arm. If all these fail they may be repeated with the woman on all fours, or the consultant obstetrician may decide on a symphysiotomy (division of the maternal pubic symphysis), cleidotomy (division of the baby's clavicle), or Zavanelli manoeuvre (pushing the baby back up through the birth canal, then immediately performing a Caesarean section) See appendix 2: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf

Answer 44

D. Move her into the left lateral position and stop the oxytocin infusion, examine the abdomen, vagina, and check her observations Fetal distress usually refers to signs of fetal hypoxia +/- acidosis, of which late declarations is one. In this case it seems likely that the induction of labour with oxytocin has lead to over-stimulation of the uterus which has caused the fetal hypoxia. Over-stimulation is defined as having a series of contractions each lasting 2 minutes or more, or having 5 or more contractions in 10 minutes. The most obvious step is to stop the oxytocin infusion, and turning the mother into the left lateral position to relieve pressure on the maternal inferior vena cava and aorta. After that the abdomen and vagina should be examined to look for cord prolapse, presence of liquor, and to examine the tonicity of the uterus. Maternal observations are also important as maternal hypotension an compromise fetal blood supply. Fetal blood sampling may be used to assess the well-being of the child, and a pH of less than 7.2 is often used as the cutoff for expediting delivery urgently (though Impey suggests this is unnecessarily conservative).

Answer 45

C. Refer her for serial uterine artery Doppler scans and USS for fetal size from 26-28 weeks onwards The chronic renal impairment and smoking of 11 or more cigarettes per day gives this woman a high risk of having a small for gestational age (SGA) baby. There is no way to boost the growth of an SGA baby other than by minimising risk factors, and the only initial management is to monitor the pregnancy. If there are one or more major risk factors, the mother should be sent for serial assessment of fetal size on USS and uterine artery Doppler scans beginning at 26-28 weeks. If there are 3 or more minor risk factors, the mother should be sent for a uterine artery Doppler at 20-24 weeks. If the 20-24 week Doppler is abnormal, the woman should be referred for serial assessment of fetal size on USS and uterine artery Doppler scans beginning at 26-28 weeks. Depending on the results of the Doppler scans and the growth of the baby, the obstetrician may recommend delivering the baby early especially if there is static growth. In this case the mother would require steroids to mature the baby's lungs, and there should be adequate planning for complications depending on the gestational age of the baby when it is delivered. The RCOG guidelines are very helpful for this area, and there is an investigation flowchart and table of risk factor sin the appendix: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_31.pdf

Answer 46

E. An oestrogen-only patch would not increase her risk of VTE Menopause has two main functions: control of menopausal symptoms, and improving long-term health. The former reason is the most common indication, as the symptoms of insomnia, hot flushes, irritability/ mood swings, reduced libido, and vaginal dryness can be very distressing. HRT can be taken in many different preparations, and may consist of oestrogen alone, or there may be progesterone added. The decision to add a progestogen rests on whether the woman still has a womb, as unopposed oestrogen therapy increases the risk of endometrial cancer. However if the woman does not have a womb, lone oestrogen is the preferred choice, because progestogens increase the risk of breast cancer, whereas lone oestrogen therapy has little or no effect on breast cancer risk, hence 'A' is wrong. 'B' is incorrect because not only are testosterone levels over 100 times higher in pre-menopausal women than oestrogen levels, but testosterone supplementation can be helpful in restoring libido. 'C' is correct in that her risk of osteoporosis will increase, but vitamin D supplementation will do nothing to prevent this; don't confuse osteoporosis with osteomalacia. 'D' is true in that it would help her vaginal dryness, but a vaginal preparation will not improve her libido or her hot flushes. Vaginal oestrogen's major advantage is its lack of systemic side-effects, and it does not increase the risk of cancer or VTE. However this lack of systemic effect also means it will not improve symptoms of the menopause outside of the vagina. HRT patches (E) are a way of taking HRT without any increased risk of VTE, whilst still addressing the symptoms of menopause. More information on HRT: https://www.nice.org.uk/guidance/ng23/ifp/chapter/Benefits-and-risks-of-HRT

Answer 47

B. BMI <20 All pregnant women should be screened for risk factors for a small for gestational age (SGA) baby at their booking appointment (8-10 weeks). There are many risk factors which have been divided into major and minor by RCOG depending on the odds ratio with respect to having an SGA baby based on a meta analysis study.

Answer 48

C. Mid Operative delivery is indicated to shorten the second stage of labour in a mother at risk of complications, to resolve fetal distress, or to deliver a baby where progress of labour has halted. Operative delivery should only be used if the fetal head is 1/5 or less palpable, and the leading part of the head has at least reached the ischial spines. This of course means that operative delivery is only possible once the cervix is fully dilated and the baby has descended into the pelvis. Operative vaginal deliveries are classified as below: Outlet: Fetal scalp visible without separating the labia Fetal skull has reached the pelvic floor Fetal head is at or on the perineum Low: Leading point of the skull (not caput) is at station plus 2 cm or more and not on the pelvic floor Mid: Fetal head is no more than 1/5th palpable per abdomen Leading point of the skull is above station plus 2 cm but not above the ischial spines High: Not included in the classification as operative vaginal delivery is not recommended in this situation where the head is 2/5th or more palpable abdominally and the presenting part is above the level of the ischial spines GTG 26 on operative delivery: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_26.pdf

Answer 49

E. 250 IU anti-D prophylaxis Sensitising event under 12 weeks = no action needed Special sensitising event* under 12 weeks = min. 250 IU Sensitising events 12-20 weeks = min. 250 IU Sensitising events 20+ weeks = min. 500 IU + FMH test** (includes labour***) Routinely give 1 dose (1500 IU) at 28 weeks or 2 doses (min. 500 IU each) at 28 and 34 weeks * Special sensitising events are molar pregnancy, ectopic pregnancy, termination of pregnancy, or uterine bleeding that is heavy, repeated, or painful * *Feto-maternal haemorrhage test is also known as a Kleihauer–Betke test and is used to quantify the amount of fetal haemoglobin that enters the mother's bloodstream * **Anti-D prophylaxis after birth is based on typing of baby's cord blood NB: This is obviously only necessary in a Rh- non-sensitised woman, and a woman's blood type will be tested for at her booking appointment (before 10 weeks) Guidelines: https://onlinelibrary.wiley.com/doi/full/10.1111/tme.12091

Answer 50

C. Take an MSU, perform a urine dipstick, and prescribe Nitrofurantoin 100mg BDS for 7 days Management of a UTI in pregnancy is similar to management in a non-pregnant woman. Nitrofurantoin is first line and safe to give in pregnancy, though NICE recommends it is avoided near term. Second line is Amoxicillin (depending on culture sensitivities) or Cefalexin. If the patient shows signs of systemic illness or more severe pain in their side, they may need to attend secondary care and be treated for pyelonephritis.

Answer 51

E. Offer a choice of laparoscopy or a single I.M. dose of 5mg/m^2 methotrexate Though this woman has been diagnosed with an ectopic pregnancy - a very serious and potentially dangerous condition - she is currently asymptomatic and haemodynamically stable. A more acute picture would necessitate emergency surgical management, but this picture means that treatment does not need to be rushed and does not necessarily need to be surgical. In these cases beta hCG is used to guide treatment: <1000 IU/L: expectant management <1500 IU/L: patient's choice between methotrextate and expectant management 1500-5000 IU/L: patient's choice between methotrexate and surgery >5000 IU/L: surgery NB: The ectopic pregnancy must not be larger than 35mm, there must be no visible heartbeat, and no pain or haemodynamic instability, otherwise surgery is indicated 'A' would only be appropriate for a beta-hCG of less than 1500 IU/L, though it is correct in that beta-hCG must be re-measured on day 2, 4, and 7. If the value drops by 15% by day 7, then monitoring is continued until it is less than 20IU/L. If the value does not drop by 15% by day 7, then senior advice is sought.

Answer 52

E. Caesarean section Seeing as the fetal head is more than 1/5 palpable, this baby is not suitable for operative delivery. At 3/5 palpable this baby's head is not even engaged in the pelvis, which in combination with failure to progress means this woman will need a C-section.

Answer 53

D. Urgent 2 week suspected cancer referral Post-menopausal bleeding should essentially always trigger an urgent referral because of the risk of endometrial cancer.

Answer 54

A. If she opts for a planned C-section, that will not increase the risk of complications of vaginal birth in a subsequent pregnancy https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.14465

Answer 55

C. When the widest diameter of the presenting part passes through the pelvic inlet Engagement usually happens at 34-35 weeks and refers to when the widest point of the presenting part passes the pelvic inlet. At this point the head will be a maximum of 2/5 palpable by definition, and generally the vertex will be level with the ischial spines, though obviously this depends on the size of the baby and the mother's pelvis.

Answer 56

B. Take a history to assess for psychiatric issues, but reassure her this is very likely 'baby blues' which happens in half of all women after childbirth and will soon pass The 'baby blues' affect 50% of all women during the first week after childbirth and only persist a few days. It causes low mood, irritability, anxiety, and labile mood. Whilst guilt is not a classic feature, it is understandable why this mother feels guilty that she feels this way when societal expectations tell her she should be ecstatic. Postnatal depression in 10%, 70% risk of depression in later life.

Answer 57

``` A. Fluid retention - progesterone B. Osteoporosis - progesterone (specifically depot-Provera) C. Reduced libido - progesterone D. Hypertension - oestrogen E. Headaches - oestrogen ```

Answer 58

D. A woman with blood pressure of 165/110 All other options are rated '3' by UKMEC i.e. the risks most likely outweigh the benefits, but hypertension of over 160/100 is '4' i.e. absolutely contraindicated. Other absolute contraindications include: Vascular disease Previous or current VTE Migraine with aura Being within the puerperium and breastfeeding Being within the first 3 weeks of the puerperium and having risk factors (e.g. obesity, PPH, pre-eclampsia, smoking) Being over 35 and smoking 15 or more cigarettes per day

Answer 59

A. Acute fatty liver of pregnancy This is a history of acute fatty liver of pregnancy - a 1 in 20,000 condition that usually affects women late in the third trimester. Its pathogenesis is not well understood, but is thought to be linked to an underlying mitochondrial disorder affecting fatty acid oxidation. Fat builds up in the liver causing dysfunction which leads to jaundice (decreased bilirubin clearance, DIC, hypoglycaemia, and metabolic acidosis (reduced lactate clearance). Classic features include epigastric pain, vomiting, and excessive thirst. This is a difficult pathology to separate from the preeclampsia - eclampsia - HELLP conditions and is theorised to be on the same spectrum.

Answer 60

E. Evaluate lifestyle factors e.g. BMI, caffeine intake, and fluid intake Lifestyle factors have a significant impact on many diseases, including incontinence. There isn't much point treating the patient for incontinence if the issue could be solved by altering fluid or caffeine intake. It should also be noted that BMI can contribute to stress incontinence, and if a woman has a BMI >30, she should be advised to lose weight. If lifestyle modifications fail, behavioural therapy (bladder training) or physiotherapy (pelvic floor training) can be used as first line interventions depending on whether the incontinence is stress, urgency, or mixed (physio for stress, bladder training for urge, either for mixed). Medications may prove useful in patients with urge incontinence, but only after more conservative measures, and only for urge incontinence which is not described here.

Answer 61

E. Immediately reduce their insulin and monitor their blood glucose to establish the most appropriate dose Insulin requirements for diabetics rapidly return to normal post-partum, so their insulin should be immediately reduced to avoid hypoglycaemia. Any medications discontinued for safety reasons pre-conception should still be avoided in a woman who is breastfeeding.

Answer 62

C. Call for help, secure the woman's airway, listen for breathing and move her into the left lateral position Management of acute collapse of a pregnant woman is similar to that for a non-pregnant adult, though in pregnant women it is particularly important to protect the airway as there is a greater chance of regurgitation and aspiration. Furthermore the woman should be moved into a left lateral tilt to relieve pressure from the gravid uterus on the Vena Cava and Aorta. See appendix II: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_56.pdf

Answer 63

A. Insert two wide bore cannulas, give fluid resuscitation, take bloods, attach a CTG probe and expedite delivery This is a history of placental abruption, albeit concealed one. 1 in 5 abruptions are concealed (no vaginal bleeding) so vaginal bleeding should not be relied upon to spot this diagnosis. The key to this history is the acute onset of severe abdominal pain in a pregnant woman, which should always make you consider abruption. In this case there are two risk factors: advanced maternal age and a multiple pregnancy, though as many as 70% of cases will occur in supposedly low-risk pregnancies, hence 'D' is wrong and dangerous. 'B' is the general management of an acute abdomen which is a differential here, but not the foremost. 'C' would be a good option if the mother was stable but doctor suspected there was a high chance of premature birth. However in this case the mother is haemodynamically compromised, so delivery must be expedited (this is usually through C-section). 'E' includes two important steps in a woman presenting with ante-partum haemorrhage where the placenta position is unknown, but the USS would not come before CTG monitoring to establish the health of the baby, and is not appropriate in an emergency such as this. APH guidelines: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_63.pdf

Answer 64

C. Admit her, take baseline bloods, give subcutaneous Clexane, arrange an ECG and CXR For a pregnant woman presenting with a clinically suspected PE, the first steps are clinical assessment, baseline bloods to determine whether LMWH dose needs adjustment, give LMWH, and perform an ECG and CXR. The CXR then guides treatment: if it is abnormal then a CTPA is indicated, but if it is normal then a V/Q scan is preferred. CTPA is not contra-indicated in pregnancy, and the decision whether to use a V/Q scan or CTPA is an individual one influenced by equipment availability, maternal age and PMHx/ FMHx, and clinical factors. The main concern with a CTPA is irradiation of a young woman's breasts and the subsequent risk of breast cancer. CTPA is actually believed to expose the fetus to less radiation than a V/Q scan, and the increase in risk of breast cancer is very small, but must still be considered. If a woman presents with a suspected DVT +/- signs of a PE, a compression Duplex USS is performed, and if this is positive no further investigation is needed and they are treated with LMWH. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37b.pdf

Answer 65

D. A fasting blood glucose of 5.6 or more, or an OGTT of 7.8 or more Gestational diabetes is screened for with an oral glucose tolerance test (OGTT) between 24-28 weeks in those who are identified as at risk in their booking appointment. Risk factors include: Asian, Afro-Caribbean, or Middle Eastern race; BMI over 30; previous macrosomic baby; or FMHx of type II diabetes. Previous pregnancy with gestational diabetes is obviously a big risk factor, and these women are screened much earlier, shortly after their booking test. It is worth noting that neither random blood glucose nor HbA1c is used to diagnose gestational diabetes, though HbA1c is used to monitor it. Management of diabetics during pregnancy is complex, with myraid potential complications. Established diabetics face more complications than gestational diabetics, with type I and II faring similarly. Maternal complications include: increased birth trauma and delivery complications (due to macrosomia); increased insulin requirement; hypoglycaemia (from attempts to control tightly); UTIs, wound infection, and endometritis; preeclampsia; worsening of pre-existing ischaemic heart disease; and worsening of diabetic retinopathy. Management of these patients begins pre-conceptually, where the patient is advised to closely monitor their blood glucose levels. Diabetic prospective mothers are advised to take the higher dose of folic acid (5mg instead of 400mcg) for 3 months before conception up until week 12 of pregnancy; this is because of the increased risk of neural tube defects (there is also increased risk of cardiac defects). Pre-existing diabetics are at high risk of developing preeclampsia during pregnancy, and so should be given 75-150mg aspirin ODS from 12 weeks till the end of their pregnancy. Retinal function, renal function, signs of preeclampsia, and fetal growth must all be monitored during pregnancy. Labour is more likely to be complicated, so problems like increased birth trauma and shoulder dystocia should be planned for. Post-partum the baby is particularly vulnerable to hypoglycaemia which must be monitored for. Finally, it is important to note that the mother's insulin requirement will rapidly return towards pre-pregnancy after delivery, and failure to attenuate insulin doses may lead to maternal hypoglycaemia. Gestational diabetes in diabetes presenting during pregnancy in susceptible women, due to changes in metabolism. It account for ~90% of diabetes in pregnancy, increase the risk of developing type II diabetes later, and is associated with conditions impairing glucose tolerance e.g. PCOS. An OGTT is performed between 24-28 weeks to assess for gestational diabetes, or earlier (shortly after the booking appointment) if the woman has developed it before. NB: glycosuria in pregnancy is a less significant finding than normal because a pregnant woman's kidneys have a lower threshold for excreting glucose (normal being serum concentration of 11mmol/L)

Answer 66

B. It is safe for her to stop using contraception For menopausal women it is recommended to use contraception for 24 months after the last period in under 50's, and for 12 months in women aged 50 or over.

Answer 67

B. Perform a pregnancy test and give her antibiotics if she is deemed competent, and tell her they'll need to contact the safeguarding lead and social services/ the police Contrary to popular belief, you do not always have to disclose sexual activity in a child under 13 to the police. However you should automatically disclose it unless there is a very good reason not to, and it should at least be discussed with a safeguarding lead and documented. In this case there is no good reason not to report this relationship, so it should be discussed with a safeguarding lead, then the police and social services should be involved. With regards to the pregnancy test and giving antibiotics, the girl can consent if deemed Gillick competent. If the girl is not competent, treatment may still proceed based on her best interests as determined by a doctor. GMC guidelines on consent and sexual activity in children: https: //www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/0-18-years/making-decisions#paragraph-24 https: //www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/0-18-years/sexual-activity

Answer 68

A. Mifepristone followed by Misoprostol The choice between medical and surgical management of a TOP is mostly up to the patient, though they are generally used at different stages in pregnancy. Mifepristone and Misoprostol can be used in any termination before 24 weeks. Vacuum aspiration may be used up to 16 weeks, but does not require general anaesthesia. Dilatation and evacuation is appropriate for pregnancies of >14 weeks gestation. 24 weeks gestational age is the legal cutoff for abortions generally, but they may be performed all the way up to term if: The mother's life is at risk Continuing the pregnancy poses a serious risk to the mother's physical or mental health There is a substantial risk of the baby being handicapped In such cases the fetus is injected with KCl (potassium chloride).

Answer 69

C. Beta-hCG Unconjugated oestriol, hCG, AFP and Inhibin A are the four hormones used in the 'quadruple test' for Down syndrome. The quad test is used if the mother misses the 11-14 week window for the standard Down syndrome screening, or if nuchal translucency cannot be measured. Unconjugated oestriol and AFP are decreased in a Down syndrome pregnancy, but Inhibin A and beta-hCG which are raised.

Answer 70

Skin - subcutaneous tissues (Camper's and Scarper's) - rectus sheath - rectus abdominis - parietal peritoneum - vesicouterine peritoneum - uterus

Answer 71

A. Trans-vaginal USS This is a case history of a molar pregnancy - a subset of gestational trophoblastic disease where the proliferating cells are abnormal and become invasive rather than developing into a viable pregnancy. This results either from a sperm fertilising an empty ovum (no chromosomes - complete mole) or from two sperm fertilising one ovum (partial mole). In both cases the resulting tissue can never become a viable pregnancy and must be removed before it invades and metastasises. It can only be definitively diagnosed by analysing histology, but suggestive features within the history are: nausea and vomiting, irregular vaginal bleeding, and an abnormally large uterus. The classic finding on USS is of a 'snowstorm appearance', and b-hCG can be useful as it is often much higher in molar pregnancy than normal. Management is with suction and curettage of the pregnancy, or evacuation if needed. The tissue is sent to histology to confirm the diagnosis, and anti-D prophylaxis is given in Rh- women as this is a potentially sensitising event.

Answer 72

B. Ursodeoxycholic acid Emollients and antihistamines (chlorphenamine) may help a little: emollients will help moisturise damaged skin and the antihistamines will cause sedation and aid sleep. However the only effective agent for symptom control is ursodeoxycholic acid (UDCA). There is insufficient evidence on S-adenosyl methionine for its use, and colestyramine may improve pruritis but is poorly tolerated.

Answer 73

E. Reassure her and send her home This is describing Braxton-Hicks contractions, involuntary movements of the uterine smooth muscle that do not signal the onset of labour. They are generally mild and more uncomfortable than painful, and are completely normal in the second/ third trimester.

Answer 74

E. She will require Clexane from the start of her pregnancy till 6 weeks post-partum A previous VTE that is unrelated to major surgery is a massive risk factor and so this woman will need anticoagulation throughout pregnancy and the puerperium. The decision on whether to anticoagulate a pregnant women, and for how long, is based on the presence of risk factors identified antenatally: Previous VTE without major surgery - definitely anticoagulate full pregnancy and puerperium Intermediate risk factor (e.g. cancer, thrombophilia) -probably anticoagulate full pregnancy and puerperium 4 minor risk factors - probably anticoagulate full pregnancy and puerperium 3 minor risk factors - anticoagulate from 28 weeks 2 minor risk factors - anticoagulate for the first 10 days post-partum NB: There is also a 'very high risk' category for people with a previous VTE on a background of thrombophilic disease, or whilst on anticoagulants. These patients get high dose LMWH.

Answer 75

A. At least 10 days post-partum, but not during the pregnancy This woman has 2 minor risk factors for VTE, therefore it is not recommended to anticoagulate her during her pregnancy. However the puerperium carries the highest risk of VTE of any time during pregnancy, especially just after birth. Therefore this woman will need Clexane for at least the first 10 days after birth.

Answer 76

B. Give a vaginal prostaglandin This woman's Bishop score indicates labour is unlikely to start spontaneously, and that the cervix is not 'ripe'. Vaginal prostaglandin given as either a tablet or a gel is the recommended way to induce labour after trying a membrane sweep. Amniotomy with an oxytocin infusion (Syntocinon) can be used once the cervix is more favourable, but is not the standard method recommended for induction. Ergometrine is not used until the fetus has been delivered because it causes the arteries supplying the uterus to constrict to limit post-partum haemorrhage - if this were done before the baby were born it would restrict their blood supply.

Answer 77

C. Give nifedipine, dexamethasone, and magnesium In cases of preterm labour, the goal of tocolytics is not generally to stop labour totally, but to delay it enough to allow corticosteroids to take effect and mature the baby's lungs.

Answer 78

C. Stop taking it 4 weeks before the surgery, then resume 2 weeks after The COCP should be discontinued 4 weeks before major or immobilising surgery, and resumed 2 weeks after. In the meantime the mini POP or barrier contraception should be used.

Answer 79

A. Semen analysis, mid-luteal progesterone, AMH, hysterosalpingiography

Answer 80

C. Ovarian torsion Ovarian torsion occurs when the ovary twists around the suspensory ligament and occludes its blood supply. This presents similarly to appendicitis, though perhaps more rapidly, but the 'whirlpool sign' on USS differentiates it as ovarian torsion.

Answer 81

D. Red degeneration of fibroids Fibroids respond to hormones and so in pregnancy they sometimes enlarge (around 1/3 of fibroids enlarge in pregnancy). Red degeneration is where a fibroid enlarges to the point it occludes or outgrows its blood supply. This causes severe abdominal pain, nausea, and vomiting. Management is conservative and supportive.

Answer 82

1. The most common ovarian cyst in young women - C. Follicular cyst 2. The most common benign ovarian tumour in young women, features Rokitansky's nodule - D. Mature teratoma 3. Also known as 'chocolate cysts' - B. Endometrioma 4. Seen during pregnancy as they grow in response to beta-hCG - E. Theca lutein cyst 5. Particularly associated with haemorrhage - A. Corpus luteum cyst

Answer 83

C. It can be diagnosed on an USS Endometrial hyperplasia requires a biopsy for diagnosis. It is key to differentiate typical from atypical endometrial hyperplasia: typical hyperplasia would probably self-resolve and is very conservatively managed, whereas atypical hyperplasia requires a full hysterectomy and bilateral salpingo-oopherectomy (the latter depends on age). This is because atypical hyperplasia has a significant risk of progressing to malignancy. 'D' is true because tamoxifen use is associated with endometrial hyperplasia.

Answer 84

D. Cervical ectropion Cervical ectropion is a common and benign condition (particularly associated with COCP use and pregnancy) where columnar epithelium develops on the vaginal section of the cervix. This epithelium is more delicate than the usual stratified squamous epithelium, and so can be damaged during sex leading to post-coital bleeding. This may also cause an increase in clear vaginal discharge, as columnar epithelium secretes mucous. Cervical cancer is an important differential to rule out in this woman, especially as she is in the peak age category. However as she is fully vaccinated cervical cancer is unlikely, because this would have included an HPV vaccine.

Answer 85

E. Metformin may be used +/- insulin

Answer 86

D. Prescribe mefanemic acid The first line treatment for dysmenorrhea is NSAIDs, and mefanemic acid is well know for being effective in reducing period pain. The Mirena coil may well be effective and can be used for dysmenorrhea as an alternative first line option, but would be an issue in this patient given her reluctance to even have a vaginal exam. Similarly the COCP can be used as an alternative first line treatment, but given this child doesn't need contraception, it is better to give an NSAID as there are fewer side-effects. A TENS machine may be tried in some cases but is not a standard treatment. Lastly, telling a patient to use OTC analgesia in cases where the pain has been present for some time isn't a good option as they have probably already tried it.

Answer 87

E. 7 days The copper IUD is immediately effective, the POP mini-pill is effective after 48 hours, but generally speaking other hormonal contraception will not provide protection till 7 days after initiation (including COCP, Mirena, depot, and the implant).

Answer 88

D. Fluoxetine A trial of an SSRI can be used to help with vasomotor symptoms in women who don't want to use HRT or can't.

Answer 89

C. Prescribe Nitrofurantoin B.D.S. for 7 days Even if it is asymptomatic, bacteriuria in pregnancy is a risk factor for pyelonephritis, stillbirth, and IUGR, and so should be treated. Trimethoprim is contraindicated in the first trimester because it is an anti-folate drug which would cause birth defects.

Answer 90

B. Intrapartum infusions of Zidovudine are recommended for all HIV positive women Intrapartum infusions of Zidovudine may be recommended depending on the woman's viral load, but are unnecessary if the load is <50, and may not be necessary even if it is a little over. 'A' is true - the British HIV Association recommend that breastfeeding should be avoided, though the risk in a mother with well-controlled HIV is very small. 'C' is also correct - all babies born to HIV+ mothers should receive at least 2 weeks of Zidovudine therapy even if the mother's viral load is undetectable. 'D' is correct - if a mother has rupture of the membranes with a viral load >400, the risk of transmission to the fetus is too high and she should have an immediate C-section. 'E' is also true because in a woman with viral load <50 there is no contraindication to vaginal birth, and if it is between 50-399 then it's a grey area. BHIVA guidelines: https://www.bhiva.org/file/5bfd30be95deb/BHIVA-guidelines-for-the-management-of-HIV-in-pregnancy.pdf

Answer 91

C. 400 mcg Folate, Vitamin D

Answer 92

A. Thiamine Women with nausea and vomiting of pregnancy (N&VP) or hyperemesis gravidarum are at increased risk of developing Wernicke's encephalopathy. Not only do they have an increased demand by virtue of being pregnant, but if the vomiting becomes severe they become malnourished and deficient in thiamine. Administration of I.V. dextrose and parenteral nutrition is part of the treatment for severe N&VP, but will also precipitate Wernicke's encephalopathy in a woman who is thiamine deficient. Hence thiamine must be supplemented before starting I.V. dextrose or nutrition, and must be given with all infusions of dextrose or nutrition thereafter.

Answer 93

D. Perform an OGTT as soon as is feasible

Answer 94

1. A smear shows moderate dyskaryosis - B. Refer for urgent colposcopy 2. A smear shows borderline dyskaryosis - G. Perform HPV testing 3. A smear shows HPV negative mild dyskaryosis - A. Perform a smear in 3 years 4. A 6 month pregnant woman is due for a smear - D. Perform a smear in 6 months 5. 3 samples in a row come back inadequate - C. Refer for colposcopy

Answer 95

D. Pelvic inflammatory disease Cervical excitation is also known as cervical motion tenderness and is characterised by intense pain on palpation of the cervix. Classically there are two main things that cause cervical excitation: pelvic inflammatory disease (PID), and ectopic pregnancy. The negative pregnancy test excludes an ectopic, making this PID. In reality there are other things that may cause cervical excitation, but PID and ectopic pregnancy are the main differentials. You would also expect to see fever, perhaps tachycardia, and discharge on a vaginal exam (possibly with a history of unsafe success) but these have been omitted from this question to make cervical excitation the focus.

Answer 96

C. Measure day 30 progesterone Though the length of menstrual cycles varies, the luteal phase is kept relatively constant, therefore if a patient has regular cycles they will reliably ovulate 7 days before the end of their cycle - in this case day 30.

Answer 97

C. I.V. Magnesium sulphate Seizures in eclampsia are both prevented and managed with Magnesium sulphate, instead of with I.V. Midazolam as in normal seizures.

Answer 98

E. Myomectomy Myomectomy is the only option for fibroid treatment that will preserve fertility. Other options will either damage/ remove the endometrium, or shutdown the HPG axis making the woman infertile. Uterine artery embolisation is an option for fibroid treatment but its effect on pregnancy is unclear so myomectomy is used.

Answer 99

D. If a woman is still having periods The purpose of cyclical HRT is to still have periods, allowing the woman to keep track of her progression through the menopause. Periods are triggered not by withdrawal of a medication, but by addition: oestrogen is taken continuously and a progestogen is added for 14 days. The progestogen triggers a period and can be added either once or month or once every 3 months (the latter is usually for women having irregular periods). NB: You use cyclical HRT till a woman is officially post-menopausal (12 months of amenorrhea)

Answer 100

B. Imperforate hymen

Answer 101

D. Liver Cream cheese is a red herring, it is pasteurised so it is safe. Most foods that are advised against in pregnancy carry an infection risk, and so are safe if thoroughly cooked or pasteurised. However liver is dangerous because it is so high in Vitamin A which is a teratogenic.

Answer 102

E. Post-partum haemorrhage All the mentioned complications are risk factors for post-partum haemorrhage - defined as more than 500ml loss of blood from the genital tract within 24 hours of the birth of a baby.

Answer 103

B. Elevate the presenting part towards the uterus, get the patient on all fours, take her to theatre for emergency C-section A cord prolapse is an obstetric emergency, as compression of the cord can cause fetal hypoxia and death. The most important initial intervention is to relieve pressure from the baby on the cord by pushing the presenting part back towards the uterus, and to put the woman on all fours. She should then be taken to theatre for C-section in most cases, though instrumental delivery may sometimes be appropriate (but not here as it is too early). Tocolytics (e.g. Terbutaline) are also be given. NB: It is important to not try and push the cord back into the uterus as this may result in further compression. NB: The amniotomy (assisted rupture of membranes) is significant here because it is associated with cord prolapse

Answer 104

B. Counsel her that she is miscarrying and discuss expectant management This is a history of an inevitable miscarriage, as the cervical os is open and there is no cardiac activity. The first line management for miscarriage is expectant which may last 7-14 days. However the woman's choice is very important, and medical management in hospital involving vaginal Misoprostol to pass the products of conception may be used instead.

Answer 105

A. Offer intra-partum antibiotics If a mother has had a child with early onset (within 24 hours of birth) GBS infection before, then she should be offered intra-partum antibiotics (IPA) in subsequent pregnancies. This is done regardless of the results of GBS testing. If a woman has GBS bacteriuria then she should be offered IPA. If a woman has a UTI with GBS, she should be treated at the time of diagnosis, and also offered IPA.

Answer 106

D. Offer a GBS swab at 35 weeks This woman has a ~50% chance of GBS colonisation in a subsequent pregnancy, and so should be offered a swab for GBS. Whilst a woman may choose intra-partum antibiotics (IAP) without testing, a swab should at least be offered. Swabs are done between 35-37 weeks, or 3-5 weeks before expected delivery if the baby is expected earlier. It is worth noting that a positive swab is not a very useful result, as it indicates a chance of 1 in 400 of early-onset GBS disease of the newborn. However a negative swab makes this risk 1 in 5000 so it is a useful test for ruling out the need for intra-partum antibiotics, but not so much for ruling them in. If a woman has GBS bacteriuria then she should be offered IPA. If a woman has a UTI with GBS, she should be treated at the time of diagnosis, and also offered IPA.

Answer 107

E. 37 weeks As she is a multip, she is offered ECV at 37 weeks, as opposed to a primip who would be offered it at 36 weeks. This is because multips have a higher chance of their baby spontaneously moving out of breech, so ECV is delayed by one week for them.

Answer 108

1. COCP - C. Inhibits ovulation 2. IUS - D. Thickens cervical mucous and thins the endometrium 3. IUD as emergency contraception - B. Inhibits implantation 4. IUD as regular contraception - A. Inhibits fertilisation by impairing sperm 5. The progesterone implant - C. Inhibits ovulation NB: The POP mini-pill was excluded here because its effects vary with preparation and are more complex

Answer 109

E. TVUSS In ante-partum haemorrhage it is most important to ensure the health of mother and baby first. After that it is important to establish the placental location, which is done using TVUSS. A CTG is not listed here as an option but is also an important test, arguably more important as fetal well-being should be established as a priority.

Answer 110

C. Reassure her this is normal Lochia refers to the bloody discharge after pregnancy and normally lasts 6-8 weeks, though generally should not be blood stained after 4 weeks. There are no signs of infection or retained products in this woman, so this is not worrying and she should be reassured that this is normal.

Answer 111

A. Advise that she takes a pregnancy test, prescribe the COCP A woman is naturally protected against pregnancy for the first 3 weeks post-partum, but not afterwards. This woman will therefore need a pregnancy test. Whilst the COCP is absolutely contraindicated (UKMEC 4) for breastfeeding mothers within the puerperium, it is generally accepted that the benefits outweigh the risks (UKMEC 2) after the first 6 weeks post-partum. NB: This question is modified from a PassMed question

Answer 112

B. Retained products of conception A soft or 'boggy' uterus shortly after birth indicates uterine atony or retained products of conception. This may cause either primary (within 24 hours) or secondary (24 hours - 12 weeks) post-partum haemorrhage. In this case there are clearly signs of infection which points to retained products of conception that have now become infected causing endometritis. This woman would require examination + ERPC under anaesthesia.

Answer 113

A. BMI, blood pressure, urine dip, blood test for infections, blood test for thalassaemia

Answer 114

E. MRI This is a history of adenomyosis - essentially endometriosis ocurring within the myometrium. It causes uterine tenderness and enlargement, as well as heavy and painful periods. USS can be helpful, but this condition can only be definitely diagnosed on MRI. There is a variety of treatments including: the IUS, mefanemic acid and tranexamic acid to control the pain and bleeding, and hysterectomy as the most comprehensive management.

Answer 115

E. Switch Ramipril for Labetalol and give aspirin from 12 weeks gestation Ramipril is an ACE inhibitor, a class of drugs which is teratogenic in pregnancy. Accordingly it should be swapped with Labetalol which is the first line anti-hypertensive in pregnancy. Nifedipine is given if Labetalol is unsuitable, and Methyldopa is the third-line treatment. Chronic hypertension is a high risk factor for preeclampsia development, so 75-150 mg aspirin is given from 12 weeks.

Answer 116

B. Salpingectomy Repeating the b-hCG measurement may be useful when considering expectant management, but that is not an option here because the tubal pregnancy is >35mm and has a heartbeat. The size of the mass and presence of a heartbeat also excluded medical management. A salpingectomy is usually preferred to ensure none of the ectopic pregnancy is left behind, and would usually be performed unless the other Fallopian tube is impaired. Beta hCG may be used to guide treatment: <1000 IU/L: expectant management <1500 IU/L: patient's choice between methotrextate and expectant management 1500-5000 IU/L: patient's choice between methotrexate and surgery >5000 IU/L: surgery NB: The ectopic pregnancy must not be larger than 35mm, there must be no visible heartbeat, and no pain or haemodynamic instability, otherwise surgery is indicated

Answer 117

C. Chronic hypertension The reason this is chronic hypertension and not gestational hypertension, is because gestational hypertension is defined as now-onset hypertension after 20 weeks. By definition, this cannot be gestational hypertension and must have been long-standing. There is nothing in the history to suggest renal disease, or proteinuria indicating preeclampsia. NB: This is modified from a PassMed question

Answer 118

A. Tell her to take the pill now, and reassure her no further action is needed Desogestrel POPs such as Cerazette can be taken within a 12 hour window, which this girl has not actually missed. If she had missed a POP, then she would need to take the missed pill as soon as she remembered, then take the rest of the pills normally (even if that means having 2 in 1 day). Barrier contraception should be used until 48 hours after re-starting the pill, and emergency contraception should be offered if there is unprotected sex before that time.

Answer 119

B. Give Varicella-Zoster immunoglobulin Children infected with VZV are most infectious before the typical chickenpox rash develops. Accordingly this woman needs immunoglobulin prophylaxis because there is a risk of congenital Varicella syndrome (though it is very small). Measuring IgM would be unhelpful because that would only be positive once an infection has developed, and the goal is to prevent that from occurring. Furthermore she says she did not have the infection as a child, though if there were any uncertainty this could be checked by measuring VZV IgG. Oral aciclovir is not generally indicated unless the woman develops the chickenpox rash, though this is contentious as some hospitals will give prophylactic aciclovir to exposed women. I.V. aciclovir is reserved for severe ZVZ infection, e.g. pneumonitis which is a significant complication in adults.

Answer 120

It depends on whether the mother breastfeeds, as high prolactin causes amenorrhea. If the mother doesn't breastfeed they may return as early as 5-6 weeks post-partum.

Answer 121

A. Trial oral iron tablets and reassess her in 2 weeks According to RCOG, a normocytic or microcytic anaemia in pregnancy is managed with a 2 week trial of oral iron supplementation, before any investigations are done. This is not a normal finding in pregnancy, there may be an anaemia but the haemoglobin shouldn't be below 110 in the first trimester, 105 in the second, and 100 in the third.

Answer 122

Ovulatory dysfunction Clinical or biochemical evidence of hyperandrogenism Polycystic ovaries Two of these 3 criteria must be fulfilled for a diagnosis; these are known as the Rotterdam criteria

Answer 123

E. Caesarean section delivery C-section delivery greatly increases the risk of endometritis: the incidence after normal delivery is 1-3%, whereas the incidence after C-section is between 15-40%.

Answer 124

B. 3a RCOG grades tears as follows: First-degree tear: Injury to perineal skin and/or vaginal mucosa. Second-degree tear: Injury to perineum involving perineal muscles but not involving the anal sphincter. Third-degree tear: Injury to perineum involving the anal sphincter complex: Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn. Grade 3b tear: More than 50% of EAS thickness torn. Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn. Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa

Answer 125

E. 4 RCOG grades tears as follows: First-degree tear: Injury to perineal skin and/or vaginal mucosa. Second-degree tear: Injury to perineum involving perineal muscles but not involving the anal sphincter. Third-degree tear: Injury to perineum involving the anal sphincter complex: Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn. Grade 3b tear: More than 50% of EAS thickness torn. Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn. Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anorectal mucosa

Answer 126

1. Trichomonas vaginalis - B. Oral Metronidazole 2. Chlamydia trachomatis - C. Doxycycline 3. Neisseria gonorrhea - D. Oral Azithromycin and intramuscular Ceftriaxone 4. Bacterial vaginosis - B. Oral Metronidazole 5. Candida albicans - A. Topical Clotrimazole

Answer 127

D. Vaginal sacrospinous hysteropexy with sutures There are two surgical options listed by NICE for rectifying uterine prolapse that allow women to have children afterwards: vaginal sacrospinous hysteropexy with sutures, and sacro-hysteropexy with mesh. If the woman does not wish to have more children, then a Manchester repair or hysterectomy +/- sacrospinous fixation may also be appropriate. NICE specifically states that surgery to treat incontinence should not be performed prophylactically. NICE guidelines on prolapse and incontinence: https://www.nice.org.uk/guidance/ng123/chapter/Recommendations#surgical-management-of-pelvic-organ-prolapse

Answer 128

C. Depo-Provera Depo-Provera is the progesterone depot injection and has some significant side-effects not seen with other methods of contraception, including weight gain and osteoporosis.

Answer 129

Urine dipstick to rule out UTI which can cause temporary incontinence

Answer 130

C. Vaginal Misoprostol The first-line management of miscarriage according to NICE is expectant: tell them to go home and return for assessment in 7-14 days. However there are several indications for active medical management: Previous traumatic/ adverse outcome of pregnancy (APH, miscarriage) High risk of haemorrhage (e.g. coagulopathy, late first trimester) High susceptibility to consequences of infection (e.g. coagulopathy, unable to receive blood transfusion) Evidence of infection Preference of the patient Medical management is vaginal (or oral) Misoprostol to stimulate the passage of the products of conception. Surgical management - if required - consists of manual vacuum aspiration under local anaesthetic, or surgical evacuation under general anaesthetic. NB: Women with a miscarriage should be told to take a pregnancy test 3 weeks after their management has concluded to exclude molar or ectopic pregnancy

Answer 131

B. Transverse head position upon engagement in the pelvis The fetal head enters the pelvis transversely because the widest diameter of the pelvic inlet is transverse. Once engaged, the baby rotates, usually to the Occiput anterior (OA) position. It sometimes rotates to the Occiput posterior position which makes for a trickier delivery (though most spontaneously revert to OA). A 3/5 abdominally palpable head is by definition not engaged in the pelvis. A brow presentation occurs when the fetal neck is extended instead of flexed (a vertex presentation is normal and less complicated). Primip women should dilate at a rate of ~1cm/hour once at 4cm, and multips at 2cm per hour (this will vary, but should certainly be greater than 1cm/4 hours). Lastly, the baby should present head first (cephalic) not rear first (breech).

Answer 132

D. Asherman's syndrome Asherman's syndrome is the presence of intra-uterine adhesions. These adhesions can prevent the passage of blood during the menstrual cycle, and impair fertility. It is classically caused by excessive curettage at a TOP or ERPC, though may also be caused by irradiation, myomectomy, schistosomiasis, or tuberculous endometritis.

Answer 133

D. Antiphospholipid antibodies, pelvic USS, thrombophilia screen, cytogenetic analysis on products of conception https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_17.pdf

Answer 134

1. Within 120 hours of sex - B. Ullipristal acetate 2. Within 120 hours of sex or ovulation (whichever is latest) - C. Copper IUD 3. Within 72 hours of sex - A. Levonorgesterel

Answer 135

D. Ruptured ovarian cyst This is a tricky question, and multiple options given here would need to be ruled out. However the sudden onset pain during intercourse is classic for a rupture ovarian cyst, and the fact that this woman is generally well makes a more catastrophic diagnosis like ruptured ectopic or appendicitis less likely.

Answer 136

The Lambda sign | The 'T' sign

Answer 137

B. Prescribe the COCP The COCP is effective at regulating menstruation and the symptoms of PCOS. Diet and exercise modifications to reduce weight would not be helpful here as the woman is of a normal BMI. Letrozole, clomiphene, and metformin are helpful for fertility in patients with PCOS, but there is no indication that pregnancy is a priority for this patient.

Answer 138

A. Contact the police to make a report This is a very straightforward case because doctors are legally compelled to inform the police if they become aware of female genital mutilation of a child. It is important to remember that this does not apply to adults, who may still need medical attention and support, but there is no legal duty to inform the police and social services.

Answer 139

B. Pelvic inflammatory disease Peri-hepatic adhesions are considered relatively specific to PID and are caused by a complication known as Fitz-Hugh-Curtis syndrome. This is an inflammation of the liver capsule arising in a case of PID which causes the formation of peri-hepatic adhesions.

Answer 140

C. A minimum 6 week course of bladder training This is a history of urge incontinence - also called overactive bladder - which is caused by detrusor muscle overactivity. The first line management of this condition, in conjunction with lifestyle modification (e.g. decreasing caffeine intake), is a course of bladder training.

Answer 141

1. Fibroma - C. Most common growth associated with Meig's syndrome 2. Serous cystadenoma - A. Most common ovarian tumour 3. Dermoid cyst - B. May have a range of mature cell types within the growth

Answer 142

C. Fibroma This is a description of Meig's syndrome - a fibroma with associated ascites and pleural effusion. It is not well understood why the effusion and ascites occurs secondary to the fibroma. This may be caused by a range of tumours, but classically and most commonly by fibromas.

Answer 143

B. Admit her to hospital This woman is presenting with an exacerbation of nausea and vomiting of pregnancy (NVP) and possible hyperemesis gravidarum. There are several criteria for admission to hospital: NVP that persists and prevents the patient from keeping oral anti-emetics down NVP causing weight loss >5 % or ketonuria despite oral anti-emetics Confirmed or suspected co-morbidity This patient will therefore need admitting to hospital. Many of the steps mentioned in the other options will be required, but the important point is that she be admitted.

Answer 144

A. The Mirena coil It is fair to infer from the lack of PMHx that this woman has not had a hysterectomy, in which case her oestrogen preparation will need a progestogen adding to prevent endometrial proliferation and malignancy. The Mirena coil is used for this purpose, and provides a progestogen locally where it is needed. Depo-provera would not be recommended because of the risk of osteoporosis linked to it. The Mini-pill is not recommended for the progestogen component of HRT because of an absence of data for its efficacy. Fluoxetine can be used to relieve some symptoms of the menopause but does not replace a progestogen. NB: This is modified from a PassMed question

Answer 145

D. HPV 6 and 11 HPV subtypes 16 and 18 are the most high risk for cervical cancer; 6 and 11 are not associated with cancer but are responsible for the majority of HPV genital warts. All the other factors increase the risk of cervical cancer, though infection with HPV 16 and 18 is by far the biggest risk factor.

Answer 146

C. Vasa praevia The classic triad of vasa praevia is rupture of membranes, painless vaginal bleeding, and fetal bradycardia or death. Vasa praevia is a condition where the fetal blood vessels run over or near the internal cervical os. When the membranes rupture, these vessels rupture too and may cause rapid exsanguination and death of the fetus, though with no effect on the health of the mother.

Answer 147

D. 6 months For a cervical intraepithelial neoplasia (essentially pre-cervical cancer) that has been removed, there should be a cervical swab 6 months later for a 'test of cure".

Answer 148

A. 2 Here is a simplified version of the FIGO staging of cervical cancer (each stage has several subdivisions but these are omitted): 1 - Limited to the cervix (NB: extension into the body of the uterus is disregarded) 2 - Spreads into the upper 2/3 of the vagina and the connective tissue around the uterus 3 - Spreads into the lower 1/3 of the vagina and/or involves the pelvic wall and/or causes hydronephrosis or a non-functional kidney and/or involves the para-aortic/ pelvic lymph nodes 4 - Spreads beyond the true pelvis to the mucosa of the bladder and rectum, or to distant sites

Answer 149

Oxytocin (Syntocinon)

Answer 150

E. Preeclampsia in a previous pregnancy Preeclampsia in a previous pregnancy is a strong risk factor for it occurring again, but folic acid supplementation has been shown to not affect this risk, therefore these women should take the standard 400mcg dose. Diabetes of any type is linked to an increased risk of neural tube defects, though the risk is lower the better controlled it is. A BMI of over 30 is also linked to neural tube defects. Anti-retroviral and anti-epileptic drugs are both linked with neural tube defects.

Answer 151

A. Bartholin's cyst This is a cyst forming in one of Bartholin's glands - glands either side of the vaginal introitus that secrete lubrication. Blockage of the duct can cause a cyst to form. which may become infected and form an abscess. Small asymptomatic cysts may be left alone, but will require antibiotics and marsupialisation if they become infected and problematic.

Answer 152

Investigation: Assess pelvic floor muscles, perform urine dipstick, bladder diary Non-surgical: Pelvic floor exercises Surgical: Colposuspension or autologous rectal fascial sling

Answer 153

C. Caesarean section Her membranes have ruptured so ECV cannot be attempted. The baby cannot be vaginally delivered fro a transverse position, so a C-section is needed.

Answer 154

Investigation: Perform urine dipstick, bladder diary, sometimes urodynamic studies* Non-surgical: Bladder training, anti-cholinergic medication Surgical: Botulinim type A injection, percutaneous sacral nerve stimulation * can be used to diagnose urge incontinence

Answer 155

1st: NSAIDs or hormonal contraception (COCP, POP, depot, implant, IUS) 2nd: A combination of the two

Answer 156

1st: A Levonorgesterel IUS (e.g. the Mirena coil) 2nd: Oral contraception (COCP, cyclic oral progestogen), or Tranexamic acid, or an NSAID

Answer 157

E. Advise her to continue breastfeeding from both breasts, use OTC analgesia, prescribe oral flucloxacillin It is important in cases of mastitis for the mother to continue to breastfeed or manually express her milk, as milk stasis is a causative factor. Over the counter (OTC) analgesia is advised, and antibiotics should be given in cases where: symptoms persist for 12-24 hours, there is an infected nipple fissure, or a breast milk culture is positive.

Answer 158

Within the first 5 days of a woman's cycle | If inserted afterwards, it will take 7 days to become effective

Answer 159

B. Advise the woman on what to do if she develops symptoms, and perform two beta-hCG measurements 48 hours apart This is a pregnancy of unknown location (PUL), and so two sets of beta-hCG measurements 48 hours apart are taken in order to guide management. If the levels rise by >63% in that time, it is very likely there is a viable intrauterine pregnancy. These women should be offered another TVUSS in 7-14 days. If the levels fall by >50% in that time the pregnancy is unlikely continue, and the woman should be asked to take a pregnancy test in 14 days. If there is an intermediate result, the woman should be referred for clinical assessment within 24 hours. NB: It is important to inform women of the symptoms of an ectopic pregnancy so they know to come to hospital if they develop.

Answer 160

E. A Pipelle biopsy In a post-menopausal woman presenting with vaginal bleeding, it is important to perform a trans-vaginal USS to measure the endometrial thickness. If it is above 4mm, that is suggestive of endometrial cancer, so a Pipelle (aspiration) biopsy is needed.

Answer 161

B. Lactational amenorrhea method It sounds surprising, but if a woman is breastfeeding her child exclusively, the prolactin produced will act as contraception. This will only work for the first 6 months, and only as long as the mother feeds the baby often and does not use formula top ups. Assuming perfect use, this method is ~98% effective. As for the other methods: Hysterectomy is a bit radical, especially considering she has only had one child and may want more Insertion of either the IUS or IUD should be done within 48 hours of birth, or at 4 weeks The COCP is absolutely contraindicated for the first 4 weeks post-partum in breastfeeding women https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-1---postpartum-family-planning.pdf

Answer 162

1. A woman who is currently 18 weeks pregnant, with two previous first trimester miscarriages, and one live baby - g4p1+2 2. A woman who is not pregnant, but has had one stillbirth - g1p1 3. A woman who recently gave birth to a baby, and has previously had a miscarriage, and an ectopic pregnancy that was managed with salpingectomy at 7 weeks - g3p1+2 Gravidity and parity can be confusing, so here is a summary: Gravidity is the total number of pregnancies, regardless of outcome; this includes current pregnancies. Twins or multiple count as 1. Parity is the number of pregnancies carried to the limit of viability (24 weeks). There is no consensus on whether twins are counted as 1 or 2 for parity, and the course lead (big up Roshni Patel) has said that accordingly she will not examine this debated section. Pregnancies not carried to 24 weeks (miscarriage, ectopic, TOP) are sometimes added after the parity number (GxPx+y) though this is not always consistent Stillbirth counts as surviving to 24 weeks and so counts for parity This website has a good summary: https://teachmeobgyn.com/history-taking-examinations/history-taking/obstetric/#:~:text=Gravidity%20and%20Parity,%2B0%20in%20the%20UK). NB: This has been examined before and you should work on being confident calculating it

Answer 163

1. LMP: 9th January 2020 - Due date: 16th October 2020 2. LMP: 8th March 2020 - Due date: 15th December 2020 3. LMP 28th October 2020 - Due date: 4th August 2021 ``` Naegele's rule is: Take the *first day* of the last menstrual period Add 1 year Subtract 3 months Add 7 days ``` NB: This has been examined before

Answer 164

A. Take blood for a group and antibody screen, then give 500IU anti-D prophylaxis, and perform a Kleihauer test This is a case of a potentially sensitising event after 20 weeks: in any such case it is necessary to screen for anti-D antibodies (to see if the mother has been sensitised) and give anti-D prophylaxis. A Kleihauer test - a way to quantify feto-maternal haemorrhage (FMH) - should also be performed, This quantifies maternal haemorrhage The standard dose of 500IU will be given as a minimum within 72 hours of a potentially sensitising event, but more may be required depending on the result of the Kleuhauer test.

Answer 165

D. The baby should receive prophylactic Varicella-Zoster immunoglobulin The risk of maternal - baby transmission of VZV is considered to be significant if the mother is infected within 4 weeks before, or 1 week after, birth. Serious infection is more likely if the mother is infected within one week either side of birth. Accordingly, this child should receive VZIG prophylaxis to prevent development of serious disease. Testing the mother for IgM antibodies will be of limited use, the history shows fairly clearly that she is infected and the antibody test won't add any information. Testing the baby for IgG antibodies would not be helpful because they will form after IgM antibodies to fight the infection, but the goal is to prevent infection taking hold. I.V. aciclovir would probably only be given if severe disease developed.

Answer 166

A) The pregnancy has not exceeded 24 weeks, and to continue would risk injury to the physical or mental wellbeing of the woman or her existing children B) Abortion is necessary to prevent serious permanent injury to mother's physical or mental health C) Continuing the pregnancy would risk the mother's life more than terminating it D) The baby would be severely handicapped

Answer 167

A) The pregnancy has not exceeded 24 weeks, and to continue would risk injury to the physical or mental wellbeing of the woman or her existing children 97% of abortions are carried out under this sub-section

Answer 168

MCMA: 32 to 33+6 weeks MCDA: 36 to 36+6 weeks DCDA: 37 to 37+6 weeks

Answer 169

C. Whooping cough and influenza

Answer 170

D. Admit her for I.V. Ceftriaxone and Erythromycin This is a history of pelvic inflammatory disease in a pregnant woman. PID may be caused by a range or organisms including Chlamydia trachomatis and Neisseria gonorrhoeae, and it is important to treat it as the complications can be severe (notably infertility). There are two factors that require this woman to be admitted for treatment: she is pregnant, and she has been experiencing nausea and vomiting which may make it difficult to take oral antibiotics. Between the two choices of I.V. antibiotic regimes given here, Ciprofloxacin and Doxycycline are wrong because they are both avoided in pregnancy. NB: Cervical excitation is a useful sign of PID, but may also indicate ectopic pregnancy, so it is important to rule out an ectopic in cases of PID Link to PID guidelines: https://www.bashh.org/documents/3572.pdf

Answer 171

Starts week 4-6 | Ends week 16-20

Answer 172

A. No treatment is needed, repeat the smear after 12 months CIN2 and above is generally treated with a LLETZ, but CIN1 is just monitored as it may spontaneously resolve and will not progress quickly.

Answer 173

D. Refer for outpatient Pipelle biopsy This woman has a history that is suspicious for endometrial cancer, and her endometrial thickness is >4mm which supports this suspicion. She needs an endometrial biopsy which is done as an outpatient if possible. A hysteroscopy and biopsy is used if the woman finds the outpatient procedure intolerable, if she has cervical stenosis, or if the outpatient sample is inadequate. Imaging (CT and MRI) would be used to stage disease if endometrial cancer was confirmed. Ca-125 is measured in primary care to assess for the presence of ovarian cancer.

Answer 174

A. Ectopic pregnancy This is supposed to be a slightly unusual history of ectopic pregnancy because of the GI symptoms - however these are common in ectopic pregnancy and shouldn't distract from the other clear features. The abdominal pain, spotting, and cervical motion tenderness are all features of ectopic pregnancy. PID is also a good differential in this scenario, but the presence of bowel symptoms is consistent with ectopic pregnancy, not PID.

Answer 175

Stage 1-2: Total abdominal hysterectomy + bilateral salpingo-oopherectomy Stage 2+: Radical hysterectomy (means cervix is taken too) Adjuvant chemotherapy and radiotherapy may be used for higher risk disease

Answer 176

This is a bit of a trick question but important: it shouldn't. Preventers and relievers should be taken as normal during pregnancy, especially as asthma may well worsen during pregnancy.

Specialties - O&G Flashcards

A few of these questions are taken from '450 SBAs in Clinical Specialities' which is an amazing resource. Those questions have an acknowledgement in the answer