Volume 18 Issue 4 - October 2016 Flashcards
You are performing a caesarean section (CS) on a 29-year-old primigravida at 38 weeks of gestation because the fetus is large for gestational age and the woman has poorly controlled diabetes. When is the bladder most likely to be injured during this procedure?
During closure of the second layer During entry into the peritoneal entry During its dissection from the lower uterine segment When closing the visceral peritoneum When securing the angles
During entry into the peritoneal entry
In primary CS, most bladder injuries occur during peritoneal entry, while in repeat CS most occur during dissection of the bladder from the lower uterine section (i.e. raising the bladder flap).
A 30-year-old had an emergency caesarean section in the second stage for a persistent bradycardia 6 days ago. She now presents with progressive abdominal distension, which was initially painless but has become increasingly painful. The pain is localised mainly to the right side. She is tachycardiac on examination and also pyrexial. What is the most likely diagnosis?
Bowel obstruction from adhesions Bowel perforation Faeculent peritonitis Infected haematoma Ogilvie syndrome
Ogilvie syndrome
The classic presentation of Ogilvie syndrome is progressive abdominal distension, which may initially be painless and associated with varying degrees of constipation. As the caecum becomes more dilated, the pain worsens, localising to the right-hand side, and is associated with tachycardia. Eventually there is caecal ischaemia, perforation and peritonitis.
A 30-year-old woman presents 7 days after an emergency caesarean section with abdominal pain and a fever of 37.7°C . This isassociated with nausea, vomiting and mild abdominal distension. She is started on antibiotics and sent home but 3 days later she re-presents with no improvements in her symptoms and features of paralytic ileus. She is examined and found to have a tube-like mass in her abdomen on deep palpation. A request is made for an ultrasound scan of the abdomen and pelvis. What is the most likely cause of this woman’s symptoms?
Infected haematoma Postpartum ovarian vein thrombosis (POVT) Pyelonephritis Torted ovarian cyst Tubo-ovarian abscess
Postpartum ovarian vein thrombosis (POVT)
POVT presents with abdominal pain, pyrexia, nausea, vomiting, malaise and ileus with the fever persisting despite antibiotics. On deep palpation there is typically a mass in the adnexa that represents the thrombosed vein surrounded by an inflammatory mass – this is found in approximately 50% of cases. Most cases present within 10 days postnatally and the palpated mass is typically tube-like. Differential diagnoses include appendicitis, peritonitis, adnexal torsion, tubo-ovarian disease, infected haematoma and pyelonephritis.
A 26-year-old woman was seen 7 days after a ventouse delivery for maternal exhaustion in the second stage with a fever, nausea, vomiting and abdominal pain. When examined she had a temperature of 38°C, mild abdominal distension, an abdominal mass on deep palpation on the right adnexum and absent bowel sounds. An ultrasound scan of the abdomen and pelvis showed features consistent with an ovarian vein thrombosis. What treatment should this patient be offered?
Intravenous antibiotics for 7−10 days and fully anticoagulated with fragmin or unfractionated heparin and then continue with warfarin for 3−6 months
Intravenous antibiotics for 7−10 days and intravenous heparin followed by warfarin for 3−6 months
Intravenous heparin followed by warfarin for 3−6 months
Intravenous heparin for 3−6 months
Intravenous heparin for 4−5 days followed by subcutaneous heparin for 3−6 months
Intravenous antibiotics for 7−10 days and fully anticoagulated with fragmin or unfractionated heparin and then continue with warfarin for 3−6 months
The recommended management of POVT is a combination of intravenous antibiotics and heparin. The antibiotics should be administered for 7−10 days and the recommendation is to continue with this until 48 hours after leukocytosis has resolved. A combination of piperacillin/tazobactam or carbapenem plus clindamycin provides a broad coverage in cases of suspected sepsis. The recommended anticoagulation should follow the standards in haematology as recommended, which is 3−6 months.
A girl of 7 years has been diagnosed with leukaemia and is offered chemotherapy. Which anticancer agent has been most definitely associated with gonadotoxicity in girls?
Alkylating agents Antibiotics Antimetabolites Nitrosuria Vinca alkaloids
Alkylating agents
Chemotherapy may damage the ovaries through depletion of follicles, thus ovarian function and reserve and may result in premature ovarian failure. The effects of chemotherapy on the ovary are related to cumulative dose, the specific agent used, length of treatment and older age at treatment. Alkylating agents are the main chemotherapeutic are associated with gonadotoxicity. Most girls, however, retain or recover ovarian function if they are treated with low-risk chemotherapy.
You are seeing a 24-year-old woman who received chemotherapy for cancer as a child with doxorubicin, an anthracycline antibiotic, for prepregnancy counselling. What screening should she have prior to becoming pregnant?
Echocardiography or cardiac MRI
Follicular phase follicle-stimulating hormone and luteinising hormone
Liver function test
Pulmonary function test (lung function test)
Renal function test
Echocardiography or cardiac MRI
In women previously treated with anthracycline antibiotics (such as doxorubicin and daunorubicin) for childhood cancer, pregnancy has been shown to precipitate cardiac decompensation. These agents are known to cause ventricular dysfunction, cardiomyopathy and congestive heart failure. These effects can be asymptomatic in up to 60% of patients and therefore, are present for the first time during pregnancy. It is advisable that baseline echocardiography or cardiac MRI is performed prior to pregnancy in women with previous exposure to anthracycline antibiotics.
A 30-year-old primigravida at 14 weeks of gestation was seen 2 days ago with myalgia, rhinitis and a mild temperature. She was investigated and found to have an infection with cytomegalovirus (CMV). Assuming that this is a primary infection, what would be the estimated risk of vertical transmission in this pregnancy?
Up to 10% Up to 25% Up to 40% Up to 50% Up to 75%
Up to 50%
Following infection in a woman who was previously seronegative, the child transmission rate is estimated to vary from 14.2−52.4%.
A diagnosis of cytomegalovirus (CMV) infection has been made on a 20-year-old primigravida at 16 weeks of gestation. She would like to know whether her baby is infected or not. What investigation will you offer her?
Amniocentesis 7 weeks after the infection
Amniocentesis for viral particles as soon as possible
Fetal blood sample for immunoglobulin M (IgM)
MRI for typical features on imaging
Ultrasound on typical features
Amniocentesis 7 weeks after the infection
Amniocentesis should be performed at least 7 weeks after the presumed time of maternal infection and after 21 weeks of gestation. This interval allows for the maturation of the fetal genitourinary system and excretion of the replicating virus in the urine. If performed too early a false-negative result will be obtained. A blood sample is unreliable as the baby does not produce IgM until much later in pregnancy.
A 33-year-old woman had an induced vaginal delivery at 36 weeks of gestation. The pregnancy was induced on account of severe intrahepatic cholestasis of pregnancy. What recurrence rate will you give this women assuming that the diagnosis is confirmed by a return to normal of her bile acids after delivery?
>50% >60% >70% >80% >90%
> 90%
Intrahepatic cholestasis of pregnancy has a very high recurrence rate. It has been estimated to recur in over 90% of subsequent pregnancies.
A 27-year-old woman was diagnosed with intrahepatic cholestasis at 32 weeks of gestation. She had an induced vaginal delivery at 37 weeks of gestation. What plan with regard to monitoring will you recommend for her now?
Liver function and bile acid levels 7 days postpartum
Liver function and bile acid levels 10 days postpartum
Liver function and bile acid levels 21 days postpartum
Liver function and bile acid levels 28 days postpartum
Liver function and bile acid levels 42 days postpartum
Liver function and bile acid levels 42 days postpartum
All women with intrahepatic cholestasis should have their liver function and serum bile acid levels checked at 6 weeks postpartum to ensure resolution. If the liver transaminases or serum bile acids remain elevated at the postnatal check, alternative causes for hepatic dysfunction should be sought and referral to a hepatologist should be considered.
Which are the most pathogenic human papillomavirus (HPV) subtypes that are responsible for most cancers?
12 and 16 14 and 15 16 and 18 31 and 33 36 and 45
16 and 18
Subtypes 16 and 18 (HPV-16 and HPV-18) have been found to be the most pathogenic of the high-risk HPV subtypes. Indeed, together they account for 70−80% of cervical cancers, 40−50% of vulval and oropharyngeal cancers and 70−80% of anal cancers in women.
A 30-year-old had a routine recall cervical smear, which was reported as high-grade dyskaryosis. She attends for a colposcopy and a large loop excision of the transformation zone is performed. What follow-up should be arranged for her?
Cervical cytology alone at 6 months
Cervical cytology and colposcopy at 6 months
Cervical cytology and if negative, HPV test at 6 months
Cervical cytology at 6 and 12 months and then yearly for 9 years
Cervical cytology, colposcopy and, if negative, HPV test at 6 months
Cervical cytology and if negative, HPV test at 6 months
- Following treatment for abnormal cervical cytology that is high-grade moderate-to-severe dyskaryosis, a follow-up at 6 months for repeat cytology and HPV t
- If cytology is negative or borderline/low-grade and HPV negative, for routine 3-yearly recall cytology.
- If HPV positive, or high-grade moderate/severe dyskaryosis, referral to colposcopy.
- HPV test inadequate and cytology is low grade, refer to colposcopy
- but if it is borderline, repeat at 3 months.
A 25-year-old woman who had Hodgkin’s lymphoma as a child treated with chemotherapy only. With respect to her cancer treatment she is at a slightly increased risk of which pregnancy complication?
Congenital malformations Miscarriage Preterm delivery Small-for-gestational-age fetus Stillbirth
Preterm delivery
Women who are survivors of childhood cancer and are embarking on pregnancy should be advised about the slightly increased risk of preterm birth. They can be reassured that the risk of congenital malformations is not greater than in the general population. However, for those women with a history of abdomino-pelvic radiation, or who have developed secondary medical conditions, there may be an increased risk of miscarriage, stillbirths and small for gestational age. For these women, growth scans may be appropriate.
