Women's Health

Question 1

What is Hyperprolactinaemia?

Answer 1

Hyperprolactinaemia occurs as the release of prolactin from the anterior lobe of the pituitary is under dominant-negative control through the release of dopamine from the hypothalumus. A reduction in the activity of dopamine in the pituitary will lead to an excess release of prolactin

Question 2

How does hyperprolactinaemia present?

Answer 2

• Reduced libido
• Galactorrhoea
• Amenorrhoea

Question 3

What can cause hyperprolactinaemia?

Answer 3

Second-generation (atypical) anti-psychotics, specifically dopamine antagonists have a strong association with HPL. Risperidone has the highest prevalence

Clozapine another 2nd generation dopamine antagonist does cause an elevation in prolactin levels but it is very low and unlikely to cause symptomatic hyperprolactinaemia

Question 4

What is Secondary amenorrhoea?

Answer 4

Secondary amenorrhoea is the absence of menstruation for 6 months or longer in a women with a previously present menstrual cycle

Question 5

What are the causes of Secondary Amenorrhoea?

Answer 5

• Pregnancy (most common causes) and breastfeeding
• Menopause
• Intrauterine adhesions causing outflow obstructions (Asherman’s Syndrome)
• PCOS
• Drug-Induced amenorrhoea (oral contraceptive)
• Physical stress, excess exercise and weight loss
• Pituitary gland pathology e.g Sheehan Syndrome or Hyperprolactinaemia
• Hypothyroidism or Hyperthyroidism

Question 6

What population is COCP recommended for?

Answer 6

• Healthy non-smokers up to the age of 50
• Patients with heavy or painful periods

COCP can improve ACNE, it can reduce risk of ovarian, uterus and colon cancer alongside reducing risk of fibroids, ovarian cysts and non-cancerous breast disease

Question 7

When is Foetal blood sampling indicated?

Answer 7

Foetal blood sampling is indicated when there is a suspicious cardiotocograph. It is used during labour to confirm whether there is foetal hypoxia

The procedure involves making a small incision of the foetal scalp trans-vaginally. Blood is then collected and analysed for acidaemia

Question 8

What are the contraindications for FBS?

Answer 8

You should not take a foetal blood sample during or immediately after a prolonged deceleration

Question 9

How do you interpret FBS?

Answer 9

Can use either pH or Lactate

• pH
  
  • normal: 7.25 or above
  • borderline 7.21 to 7.24
  • abnormal 7.2 or below
• Lactate
  
  • normal: 4.1mmol/l or below
  • borderline: 4.2 to 4.8mmol/l
  • abnormal: 4.9mmol/l or above

Interpret the FBS taking into account - previous pH/lactate measurements as well as the clinical features of the woman and baby i.e rate of progress in labour

Question 10

What do you do if foetal blood sample results are abnormal?

Answer 10

• Inform senior obstetrician and the neonatal team
• Talk to the woman and her birth companion about what is happening and take her preferences into account
• Expedite the birth (i.e caesarean section)

Question 11

What do you do if FBS is borderline or normal?

Answer 11

If borderline and there are no accelerations in response to the foetal scalp stimulation, consider second sample no more than 30 minutes later if still indicated by CTG

If normal and there are no accelerations in response to foteal scalp stimulation, consider second sample no more than 1 hour later if still indicated by CTG

Question 12

What is shoulder dystocia?

Answer 12

Shoulder dystocia is a specific type of obstructed labour, where following the delivery of the foetal head, the anterior shoulder becomes impacted behind the maternal pubic symphysis

Question 13

What are the risk factors for shoulder dystocia?

Answer 13

• Maternal gestational diabetes
• Macrosomia (birthweight >4kg)
• Advanced maternal age
• Maternal short stature or small pelvis
• Maternal obesity
• Post-dates pregnancy

Question 14

What observations indicate shoulder dystocia?

Answer 14

• Difficult delivery of the foetal face or chin
• Retraction of the foetal head (turtle-neck sign)
• Failure of restitution (remains in the occipital-anterior position after delivery by extension and therefore does not ‘turn to look to the side’)
• Failure of descent of the foetal shoulders following delivery of the head

Question 15

What is the management of shoulder dystocia?

Answer 15

• Immediately call for help
• Do not apply fundal pressure as this may lead to uterine rupture
• Discourage maternal pushing as this may exacerbate shoulder impaction
• First line procedure is McRobert’s Manouvre
  
  • Hyperflexion and abduction of the mother’s legs tightly to the abdomen - may be accompanied with applied suprapubic pressure
• Routine traction (same as in normal delivery) should be applied in an axial direction to asssess whether the shoulders have been released

Question 16

What is the management of Shoulder Dystocia if McRobert’s Manoeuvre fails?

Answer 16

• if McRoberts manoeuvre and suprapubic pressure fails - the attempt the following:
  
  • All-fours position
  • Internal Rotational manoeuvres - Woods’ screw manoeuvre (anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back) - Rubin manoeuvre II (rotation of the anterior shoulder towards the foetal chest)
• If both first and second line manouvres have failed - consider the following (note that the risk of morbidity and mortality as well as success rates are unknown:
  
  • Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
  • Zavanelli manoeuvre (replacement of the head into the canal and then subsequent delivery by caesarean)

Episiotomy will not relieve shoulder dystocia as it is a bony obstruction but it may be indicated to allow space for internal rotational manoeuvres

Question 17

What is the management of Shoulder dystocia after delivery?

Answer 17

• Mother should be examined and monitored for postpartum haemorrhage, severe perineal tears and other genital tract trauma
• The baby should also be examined by a neonatologist for injury including brachial plexus injury, hypoxic brain damage, humeral or clavicular fractures

Question 18

What are the risk factors for Breast cancer

Answer 18

• Increased hormone exposure
  
  • Early menarche or late menopause
  • Nulliparity or late first pregnancy
  • Oral contraceptics or HRT
• Susceptibility gene mutations (most commonly BRCA1/BRCA2)
• Advancing age
• Caucasian ethnicity
• Obesity and lack of physical activity
• Alcohol and tobacco use
• Past history of breast cancer
• Previous radiotherapy treatment

Question 19

How is breast cancer screening done?

Answer 19

3 yearly mammograms (x-ray) in the caudal-cranial and mediolateral oblique views for all women between 50-70

Question 20

What are the risks and benefits of breast cancer screening?

Answer 20

Benefits:

• Early detection of cancers
• Approximately 20% reduction in relative risk of death from breast cancer
• Can provide peace of mind

Risks:

• Mammograms are painful and can be felt to be undignified
• Screening is not 100% sensitive and some cancers are missed
• False positive results can be emotionally distressing for patients

Question 21

What are the indications for urgent referral to Breast assessment clinic?

Answer 21

Patients should be referred along the urgent cancer referral pathway for breast cancer if:

• They are >30 with an unexplained breast mass (regardless of whether there is pain present or not)
• They are >50 or older presenting with nipple discharge, retraction or other concerning symptoms
• Consider referral if there are skin changes suggestive of breast cancer or the patient is 30 years or older with an unexplained mass in the axilla

Non-urgent referral for patients under 30 years old with an unexplained breast mass

Question 22

What are the histological subtypes of breast cancer?

Answer 22

• Ductal carcinoma
• Lobular carcinoma
• Medullary carcinoma
• Phyllodes tumour

Question 23

What are the features of Ductal Carcinomas?

Answer 23

• Most common form of breast tumour (75%)
• Abnormal proliferation of ductal cells
• Grade is higher as the ductal cells lose their acinar structure and their nuclei become abnormally large
• If the basement membrane is not breached then it is considered ductal carcinoma in situ (DCIS)

Question 24

What are the features of Lobular Carcinoma?

Answer 24

• Makes up about 15% of breast cancers
• More likely to be bilateral and multi-centric
• Abnormal proliferation of lobular cells which arrange themselves in single rows - The cells are often small, bland, and uniform
• Due to the sparse distrubition of tumour cells, they’re frequency impalpable or not appreciable as a discrete lump
• If basement membrane not breached then it is considered lobular carcinoma in situ - these are frequently multifocal and impalpable

Question 25

What are the features of medullary carcinoma?

Answer 25

• More common in younger patients and those with BRCA1 mutations
• Composed of solid sheets of anaplastic cells with large pleomorphic nuclei, prominent nucleoli and frequent mitoses
• There is also significant lymphocytic infiltration surrounding the tumour
• Often has a better prognosis than ductal tumours

Question 26

What are the features of Phyllodes tumours?

Answer 26

• Rare (1% of breast tumours)
• Composed of epithelial and stromal tissue which grows in a leaf like pattern
• Other forms of breast tumour include mucinous, tubular, papillary and lymphoma

Question 27

What are the most common genes associated with familial breast cancer?

Answer 27

BRCA1:

• Found on Ch17
• Autosomal dominant inheritence
• lifetime risk of 65-85%
• associated with 40% risk of ovarian cancer as well as increased pancreatic, colon and prostate cancer
• More likely to give rise to high grade triple negative cancers

BRCA2:

• Found on CH13
• Autosomal dominant inheritence
• Life time risk of breast cancer 40-85%
• 15% lifetime risk of ovarian cancer
• more likely to give rise to oestrogen and progesterone receptor positive tumours
• increased risk of prostate, pancreas, biliary tract and stomach cancers

Question 28

What is the referral criteria for Familial Breast Cancer?

Answer 28

One of the following for genetic screening of healthy patient:

• One first degree relative with breast cancer diagnosed before 40 years old
• Any male first degree relative with breast cancer (any age)
• One first degree relative with bilateral breast cancer, the first of which was diagnosed <50 years old
• Two first degree, or one first and one second degree relative with breast cancer at any age
• one first/second degree relative with breast cancer and another first/second degree relative with Ovarian cancer (any age)
• Three first/second degree relatives with breast cancer (any age

Question 29

What are the hormonal receptors in Breast cancer?

Answer 29

• Oestrogen (ER)
• Progesterone (PR)
• HER2 (human epidermal growth factor receptor type 2)

Absence of ER or PR is poor prognostic factor

Being triple negative is associated with younger age of diagnosis and worse overall survival

Question 30

What is the management of ER positive Tumours?

Answer 30

Treat with Tamoxifen (oestrogen receptor antagonist) if premenopausal or Anastrozole (aromatase inhibitor) if post menopausal

Question 31

What is the management of HER2 positive Tumours?

Answer 31

Treat with Trastuzumab (a.k.a Herceptin) - a monoclonal antibody against the extracellular domain of the HER2 receptor

Question 32

What are components of the triple assessment for breast cancer?

Answer 32

Used to investigate women with suspected breast cancer

• Clinical examination (of the breast and surrounding lymph nodes)
• Radiological examination commonly mammography but can also involve breast ultrasound and MRI scanning
• Biopsy (typically core needle biopsy or fine needle aspirate - if the lesion is large or the there is suspicion of malignancy then core needle biopsy will be chosen over fine needle aspirate as it can provide histological info as well as cytological

Question 33

How do we stage breast cancer?

Answer 33

Breast cancer staging uses the TNM staging system

• T - Tumour described the size of the tumour which may be assessed using imaging and histological biopsy of the lesion
• N - Node described spread to the lymph nodes. Evaluation of this component may include investigation such as clinical examination, sentinel lymph node biopsy or axillary lymph node dissection
• M - Metastasis describes the spread to other parts of the body

Question 34

What is the surgical management of Breast Cancer?

Answer 34

• Can be Wide local excision (WLE) or Mastectomy - WLE is considered for smaller, solitary lesions which are peripherally located. It depends on there being enough breast left behind to close the wound with acceptable cosmetic results
• Sentinal node biopsies are generally performed for all invasive cnacers
• Axillary node clearance may be necessary if there are positive nodes
• BReast reconstruction can occur at the time of mastectomy or at a later date

Question 35

What are the possible other or adjunctive therapies for Breast Cancer?

Answer 35

• Radiotherapy - almost all patients with WLE should be offered adjuvant radiotherapy to reduce recurrence - should be offered to mastectomy patients with higher cancer states (T3 or 4 or positive nodes)
• Chemotherapy - Recommended for hormon receptor negative and HER2 over-expressing patients - sometimes given as neoadjuvant to downstage tumours before surgery
• Biological therapy - Trastuzumab for HER2 positive, can also be given to downstage tumour
• Bisphosphonates - can reduce occurance in node positive cancers

Question 36

What are the indications for the hormonal drugs given in Breast cancer?

Answer 36

• Tamoxifen - a pro-drug that is metabolised into active components which are competitive oestrogen receptor antagonist - current advise is to take this for 5 years following surgical treatment of oestrogen receptor positive breast cancer for pre-menopausal women
• Letrozole/anastrozole - aromatse inhibitors which prevent synthesis of oestrogen - taken for 5 years after surgical treatment
• Trustuzamab - given every 3 weeks for a year

Question 37

What is a Breast Cyst?

Answer 37

Breast Cyst - common in women from age 35 to menopause - overgrowth of glandular and connective tissue in fibrocycstic disease blocks breast ducts leading to filling of the lobules with fluid and distnetion

Question 38

What is Fibroadenoma?

Answer 38

Fibroadenoma: highly mobile, ecapsulated breast masses that arise from breast lobule stroma - common in younger women and may be described as breast mouse due to its mobile and smooth appreance

Question 39

What is Mastitis?

Answer 39

Mastitis - infection of the breast - commonly caused by bacteria entering the duct through a break in the nipple of the skin - associated with puerperal period and smoking - presents as redness of breast, mastalgia, malaise and fever

Question 40

What is Intraductal papilloma?

Answer 40

A benign papillary tumour which commonly presents as bloody discharge from the nipple. There is no palpable mass

Question 41

What is a radial scar?

Answer 41

Benign sclerosing breast lesion which presents as a stellate pattern of central scarring surrounded by proliferting glandular tissue on mammogram

Question 42

What is Fat Necrosis?

Answer 42

It is an inflammatory reaction to adipose tissue damage. It may present with a painless breast mass, skin thickening or seen on mammography. Common causes include physical trauma to the breast, radiotherapy and breast surgery

Question 43

What is Fribrocystic breast disease/fibroadenosis?

Answer 43

It is inflammation, fibrosis, cyst formation or adenosis of the breast which is thought to be caused by an exaggerated response to body hormones

Question 44

What is Mammary duct ectasia?

Answer 44

It is a palpable, peri-areolar breast mass caused by inflammation and dilation of the large breast ducts. It commonly presents with thick white nipple discharge. It may mimic the appearance of cancer on mammaography

Question 45

What are the signs of a left sided brain metastasis?

Answer 45

Often presents with evidence of right sided upper motor neuron lesion

Dysphasia is often found in left sided metastasis as majority of patietns are left hemisphere dominant

Question 46

When is the average age of menopause?

Answer 46

Average age of menopause is around 51 years old and most people experience menopause between the ages of 45 and 55

Question 47

When should Wide Local Excision be pursued over Mastectomy?

Answer 47

If the lesion is:

• Solitary
• Peripheral
• Ductal carcinoma in situ
• Less than 4cm
• Small lesion relative to a larger breast

Question 48

What investigation is best for Determining M in TNM staging?

Answer 48

• PET scans can be used to detect metastases in a patient with a diagnosis of cancer - works on the principle that cancer cells are more metabolically active than normal cells

Question 49

What information does core needle biopsy provide?

Answer 49

Minimally invasive - gives histological analysis and is the method of choice for breast lesions

Question 50

What is Trastuzumab related cardiotoxicity?

Answer 50

Side effect of Trastuzumab is cardiotoxicity resulting in heart failure

Leading to symptoms of Shortness of breath on exertion, peripheral oedema, ascites and paroxysmal nocturnal dyspnoea

Question 51

When do you use Ultrasound for initial imaging investigation?

Answer 51

Patients <40 have denser breast tissue which makes assessment with mammography difficult. Therefore ultrasound if the patient is <35 years old and there is an actual lump to assess. Otherwise is it used in everyone under 40 if they are asymptomatic

Question 52

What are the complications of Breast Surgery?

Answer 52

Can be broken down into anaesthetic, surgical and axillary node clearance related injuries:

• Anaesthetic
  
  • Stroke
  • Venothromboembolism
  • Myocardial infarction
  • Aspiration
• Surgical
  
  • Pain
  • Bleeding
  • Infection
  • Seroma
  • Displeasure with cosmetic outcome
• Axillary node clearance related injury
  
  • Lymphoedema
  • Damage to brachial plexus cords or nerves
  • Axillary artery/vein injury

Question 53

What is Cyclical mastalgia?

Answer 53

Cyclical mastalgia is breast tenderness which comes and goes with the montly menstrual cycle

Question 54

What are the clinical features of Cyclical mastalgia?

Answer 54

• Often associated with premenstrual syndrome
• Commonly may start a few days before the start of the period and subsiding by the end of the period

Question 55

What is the pathophysiology of Cyclical mastalgia?

Answer 55

• Thought to be associated with changes to hormone levels during the menstrual cycle
• Cyclical breast pain may also be associated with fibrocystic changes to the breast presenting as breast lumpiness or duct ectasia

Question 56

What are the risk factors of cyclical mastalgia?

Answer 56

Cyclical mastalgia is much more common in peri- and pre-menopausal women than postmenopausal

Question 57

What is Fat necrosis of the breast?

Answer 57

Fat necrosis is a benign pathology of the breast which is more common in obese patients

Question 58

What are the clinical features of Fat necrosis of the breast?

Answer 58

• Can vary from a firm, round lump to a hard, irregular lump
• Usually found following trauma to the breast
• Overlying skin inflammation/bruising

Question 59

How do you assess and manage Fat necrosis of the breast?

Answer 59

Assessment should be triple assessment to rule out cancer - Intervention is not generally required

Question 60

What are Fibroadenomas of the breast?

Answer 60

Fibroadenomas are benign tumours of fibrous and epithelial tissue which arise from lobules

Question 61

What are the clinical features of Fibroadenomas?

Answer 61

Common features are:

• Young age of presentation (peaking in early 20s)
• Firm, non-tender mass
• Rounded with smooth edges
• Highly mobile
• Normally don’t grow beyond 3cm

Question 62

What are the investigations and management of Fibroadenomas of the breast?

Answer 62

Though they are benign, patients should undergo triple assessment in order to rule out more sinister pathology

Management should be surgical excision but may also regress after menopause if conservatively managed

Question 63

What is Fibrocycstic disease of the breast?

Answer 63

Fibrocystic disease is the most common benign disease of the breast

It occurs most commonly in the 20-50 year old age group

Caused by the cumulative effect of cyclical hormones such as oestrogen and progesterone (among others) which leads to chronic changes in the breast including multiple small cysts and proliferative changes

Question 64

What are the clinical features of Fibrocystic disease of the breast?

Answer 64

• Bilateral lumpy breasts - more commonly in upper outer quadrant
• Breast Pain
• Symptoms which worsen with the menstrual cycle - normally peaking 1 week before menstruation

Question 65

What is the management of Fibrocystic disease of the breast?

Answer 65

Treatment is essentially supportive althought there is some question as to whether oral contraceptives or hormone replacement therapy may work

Most cases will resolve after menopause

Question 66

What is a Lactational Breast Acscess?

Answer 66

Infectious Mastitis may lead to an accumulation of pus in an area of the breast, which can lead to the development of a lactational breast abscess

The most common causative agent is Staphylococcus aureus which enters via a crack in the nipple skin or through a milk duct

Question 67

What are the clinical features of Lactational Breast Abscess?

Answer 67

• Fevers or Rigors
• Malaise
• Pain and erythema over an area of the breast
• There may be a fluctuant mass present but this is not always palpable

Question 68

What is the management of Lactational Breast Abscess?

Answer 68

Incision and drainage or needle aspiration (with or without diagnostic ultrasound)

Question 69

What is a Malignant Phyllodes tumour?

Answer 69

Phyllodes tumour is a breast cancer of fibroepithelial origin (epithelial and interlobular stromal components) which commonly presents in older women in their 40s and 50s

Question 70

What are the clinical features of malignant phyllodes tumour?

Answer 70

• Commonly present with a smooth, hard, palpable breast mass which may sometimes be seen as a smooth bulge under the skin of the breast
• In advanced cancer they may present with an ulcer on the breast
• Can be aggressive and can grow quickly to a very large size (although they rarely metastasise)

Question 71

How is a diagnosis of Malignant phyllodes tumour made?

Answer 71

May be difficult to diagnose as they often present similarly to fibroadenoma (benign breast condition - though these typically present in younger women and are not fast-growing)

Question 72

What are the investigations of malignant phyllodes tumour?

Answer 72

• On Mammography, a phyllodes tumour may appear as a round breast lesion with well-defined edges
• Biopsy of the tumour will help distinguish between benign and malignant phyllodes tumour

Question 73

What is Mastitis?

Answer 73

Mastitis is inflammation of the breast - if it is associated with lactation in postpartum women, it is known as puerperal mastitis

Smoking is a strong risk factor for periductal mastitis

Question 74

How is a diagnosis of Mastitis made?

Answer 74

Diagnosis is usually made on a clinical basis:

• Localised symptoms include a painful, tender, red and hot breast
• Systemic symptoms include fever, rigors, myalgia, fatigue, nausea and headache
• Normally unilateral and presents 1 week post-partum
• In puerperal mastitis, there may be development of a breast abscess which presents as a fluctuant, tender mass with overlying erythema - also associated with periductal fistula

Question 75

What are the features of a breast abscess?

Answer 75

In some cases of mastitis, there may be development of a breast abscess which presents as a fluctuant tender mass with overlying erythema

Ultrasound can reveal a collection of pus

Early referral to secondary care is required for a suspected abscess

Question 76

What is the management of Mastitis?

Answer 76

Reassure lactating women that they can continue to breastfeed

advise on methods to improve milk removal e.g. manual expression

Analgesia

If first line options fail, consider a course of flucloxacillin or erythromycin accoring to local guidelines

Consider surgical management if a rbeast abscess develops (will often require concomitant IV antibiotics)

Question 77

What is Twin to Twin transfusion syndrome?

Answer 77

TTTS is a serious condition that can occur in 10-15% of twins sharing one placenta (identical)

Is often caused by anastomoses of umbilical vessels between the two foetuses in the placenta of monochorionic twins

Question 78

What are the risks of TTTS?

Answer 78

Both Foetuses are at risk of developing heart failure and hydrops. The donor suffers high output cardiac failure as a consequence of severe anaemia and the reciepient suffers fluid overload

Question 79

What is the management of TTTS?

Answer 79

TTTS has a high mortality rate for both twins, with the donor more likely to survive. Treatment is now available at specialist centres and is by laster transection of the problem vessels in-utero

Question 80

What is the legal categorisation of termination of pregnancy?

Answer 80

There are 4 categories for requesting TOP:

• A - the pregnancy has not exceeded its 24th week and that the continuation of pregnancy would involve risk, greater than if the pregnancy were terminated of injury to the physical or mental health of the pregnant woman or any existing children of her family
• B - that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
• C - that the continuation of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated
• D - that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

Question 81

What is the management of TOP

Answer 81

Termination can be medical or surgical

Medical:

• Medical management is through the use of Misoprostol (a prostaglandin analogue) which causes smooth muscle contractions of the myometrium resulting in the expulsion of uterine contents
• Surgical management is through suction termination or Dilatation and evacuation/curettage ‘D&C’

Question 82

What is Paget’s disease of the nipple?

Answer 82

Paget’s disease of the breast is a rare condition of the nipple which is associated with underlying cancer

Question 83

What are the clinical features of Paget’s disease of the nipple?

Answer 83

Features commonly affect the nipple first before spreading to the areola and the rest of the breast

Features include:

• Eczema-like rash on the skin of the nipple and areola. This may be itchy, red, crusty, and inflamed.
• Nipple discharge which may be bloody
• Burning sensation, increased sensitivity or pain
• Nipple changes such as nipple retraction or inverted
• In some cases there may be a palpable breast lump
• There may be a skin ulcer which does not heal

Question 84

What is Post-coital bleeding?

Answer 84

Post-Coital bleeding is defined as vaginal bleeding after sexual intercourse - Almost always abnormal except after first intercourse

Question 85

What are the differentials for post-coital bleeding?

Answer 85

• Cervical ectropion
• Endocervical and cervical polyps
• Cervical cancer
• Sexually transmitted infection
• Atrophic vaginitis

Question 86

What are the features of cervical ectropion?

Answer 86

Often asymptomatic but may present with post-coital bleeding or vaginal discharge

Irritated closed cervix

Question 87

What are the features of Endocervical and cervical polyps?

Answer 87

• Often asymptomatic but may present with abnormal vaginal bleeding such as post-coital bleeding
• Additionally inter-menstrual bleeding or menorrhagia
• They can be diagnosed by speculum examination

Question 88

What are the features of Cervical cancer?

Answer 88

• Can cause post-coital bleeding as well as bleeding at other times such as spontaneously or after micturition (urinating)
• Other signs are urinary symptoms and vaginal discomfort

Question 89

Which STIs can cause post-coital bleeding?

Answer 89

Gonorrhoea and Chlymdia can cause post coital bleeding - discharge is also common and can also occur in cervical ectropion

If there is also dysuria, then it is more suggestive of a STI rather than cervical ectropion

Question 90

What is Atrophic vaginitis?

Answer 90

Atrophic vaginitis is the most common cause of bledding in post-menopausal women as the vaginal mucosa becomes drier and thinner → can then lead to bleeding espeically when there is contact on the mucosa such as during intercourse

Question 91

What is Pre-eclampsia?

Answer 91

Pre-eclampsia is a placental condition affecting pregnant women commonly from around 20 weeks of gestation

Question 92

What are the clinical features of pre-eclampsia?

Answer 92

Characterised by hypertension and proteinuria

Other signs include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia

Question 93

What is the suspected mechanism of pre-eclampsia?

Answer 93

May be related to dysfunctional trophoblast invasion of the spiral arterioles leading to decreased uteroplacental blood flow and resultant endothelial cell damage

Question 94

What are the risk factors for pre-eclampsia?

Answer 94

• Nulliparity
• Previous history or family history of pre-eclampsia
• Increasing maternal age
• Existing disease (hypertension, diabetes, renal disease, autoimmune disease)
• Obesity
• Multiple pregnancy
• Maternal complications
• Eclampsia (seizures due to cerebrovascular vasospasm)
• Organ failure
• Disseminated Intravascular coagulation
• HELLP syndrome (the presence of haemolysis, elevated liver enzymes and low platelets)

Question 95

What are the foetal complications for Pre-eclampsia?

Answer 95

• Intrauterine growth restriction
• Pre-term delivery
• Placental abruption
• Neonatal hypoxia

Question 96

What is the management of pre-eclampsia?

Answer 96

Management involves anti-hypertensive treatment (although delivery of the placenta is the only true curative treatment). Labetalol is the recommended first-line antihypertensive agent. Magnesium sulphate can be used for prevention and treatment of eclamptic seizures

Question 97

What is normal variant penile skin conditions?

Answer 97

• Normal variants affecting the glans and prepuce include pearly penile papules and angiokeratomas

Question 98

What are penile inflammatory skin conditions?

Answer 98

Inflammatory skin conditions include eczema, psoriasis, lichen planus, lichen sclerosus and Zoon’s balanitis

Question 99

What is Erythroplasia of Queyrat?

Answer 99

This is squamous cell carcinoma in situ that affects the penis and should be referred immediately in the primary care setting

This is more likely to affect older patients, and presents with a red, well circumscribed and painless lesion on the prepuce or the glans

Question 100

What medication suppresses lactation?

Answer 100

Cabergoline - it is a dopamine receptor agonist which inhibits prolactin production leading to a suppression of lactation

Question 101

What are the contraindications to breastfeeding?

Answer 101

• Galactosaemia (inability to break down the sugar in milk) is an absolute contraindication and can have a devastating impact on long term health and wellbeing of child
• Infants of mothers with TB infection
• Infants of mothers with uncontrolled/unmonitored HIV
• Infants of mother who are taking medications which may be harmful e.g amiodarone

Question 102

Can paracetamol be used in pregnancy?

Answer 102

Paracetamol can be used safely in pregnancy but NSAIDS are generally avoided in obstetrics - it does cross the placenta but does not cause teratogenic effects -

Question 103

What is used for Obstetric analgesia?

Answer 103

Follows a similar pain ladder to the non-pregnant population

• Non-pharmacological methods
  
  • Exercise/movement
  • Heat e.g warm bath, heat pack
  • TENs stimulation
  • Acupuncture
  • Hypnosis
  • Massage
• Nitrous Oxide (Entonox or ‘gas and air’)
• Simple analgesia
  
  • e.g paracetamol
• Opiate analgesia
  
  • Oral codeine phosphate
  • IV/IM Diamorphine
• Epidural analgesia
• Pudendal nerve block

Question 104

What are possible Post-partum contraceptions?

Answer 104

Contraception is not required in the first three weeks after childbirth

Most contraceptive methods can be started immediately postpartum, except the combined hormonal contraceptive (this is due to the fact that oestrogen in CHC is associated with greater risk of venous thromboembolism)

Contraceptives include:

• Intrauterine contraceptives - can be inserted at the time of delivery or up to 48 hours after uncomplicated vaginal delivery or caesarean - after 48 hours, insertion should be postponed 28 days postpartum
  
  • Copper intrauterine device (Cu-IUD)
  • Levonorgestrel-releasing intrauterine system (LNG-IUS)
• Progesterone injection, implant or only pill (can be started at anytime after delivery)
• Lactational amenorrhoea - can be used as effective contraception if woman is fully breastfeeding, amenorrhoeic and less than 6 months postpartum
• CHC including pill, patches and vaginal rings - should not be started in the first three weeks postpartum - after this, carry out risk assessment for venous thromboembolism. COCP should not be prescribed to women with other risk factors for VTE within the first 6 weeks postpartum

Question 105

What is Lichen Sclerosus?

Answer 105

Lichen sclerosus is an inflammatory skin condition which typically affects the genital and anal areas of the body. Much more common in women than men

Subtype of Lichen sclerosus is vulvar lichen sclerosus which affects the inner vulva

Question 106

What are the clinical features of Lichen sclerosus?

Answer 106

It appears as white patches, which may scar - these patches may be symptomatic, causing itch and sometimes pain (white discoloration and thickening of the labial folds with areas of scarring are noted.)

Pain may occur when the area is irritated during urination or during sexual intercourse

Question 107

What is the management of Lichen Sclerosus?

Answer 107

• Topical steroids - Use potent topical steroids
• Avoidance of soaps of the affected areas
• Emollients to relieve dryness and itching

Question 108

What is inversion of the Uterus?

Answer 108

It is a rare medical emergency in which the corpus (upper part of uterus) turns inside out and protrudes into the vagina

Immediate replacement of the uterus is the best first step as the greater the delay in attempting this, the likelihood the manoeuvre will fail (i.e replaced the fundus/corpus through the cervix with the palm of your hand)

General resus measures should be taken and tocolytic drugs can be used to aid replacement of the uterus if a first attempt fails

Question 109

How do you work out Due date?

Answer 109

Use Naegele’s rule to calculate estimated date of deliverly

Calculation is to add 1 year and seven days to the first day of the last menstrual cycle and subtract three months

Not accurate in women with irrefular or long cycles or those who had recently been using the combined Oral contraceptive pill

THIS IS AN ESTIMATE

Question 110

What is Gestational Diabetes?

Answer 110

Gestational diabetes is a state of insulin resistance induced by metabolic strain of pregnancy

Hyperglycaemia in pregnancy occurs in up to 5% of women and is associated with later risk of T2 DM in up to 50% of women over the next 5-10 years

It carries significant risk of morbidity and mortality as well as high risk of having macrosomic baby (weighing over 4kg) (this can lead to increased risk of shoulder dystocia)

Usually diagnosed based on an oral glucose tolerance test at 24-28 weeks gestation

Question 111

When should patients with gestational diabetes give birth?

Answer 111

Women with gestational diabetes should give birth no later than 40+6 weeks of gestation - at this point elective induction or caesarean section will be performed

Delivery between 37 weeks should be considered in the case of any metabolic, maternal or foetal complications (i.e. like gestational diabetes)

Question 112

What are the risk factors for Gestational Diabetes?

Answer 112

High risk groups for developing GDM from ethnicties with a high prevelance of T2 DM - Middle eastern, south asian, afro-caribbean

Previous GDM is a risk factor as is large previous babies>4.5kg, previous stillbirth or perinatal death, maternal obesity (BMI>30) and a family history of diabetes in first degree relatives

Question 113

What are the complications of Gestational Diabetes?

Answer 113

Raised blood glucose levels in pregnancy are associated with:

• Congenital malformations
• Large baby size
• Obstetric complications with increased rates of miscarriage and stillbirth

Question 114

What is the management of Gestational Diabetes?

Answer 114

• Treatment is with a low GI (glycaemic index) plus Metformin and insulin if required
• The risk of future type 2 diabetes can be addressed with diet, lifestyle and metformin therapy
• GDM usually tenxs to disappear as soon as the placenta is delivered

Question 115

What is the mechanism for an Intra-uterine device?

Answer 115

The intra-uterine device works due to the toxic effect of the copper to both egg and sperm. It prevents implantation

Question 116

What are the contraindications to an Intra-uterine device?

Answer 116

An active pelvic infection (i.e PID) or a distorted uterus is an absolute contraindication to IUD

Women with a repeated history of STI are not suitable for the device also

Contraindications also include unexplained bleeding and an abnormal cervix

Question 117

What are the features of the IUD?

Answer 117

• Device can stay in for up to 10 years, when removed returns to normal
• If fitted after 40, the device can stay in place until the menopause - women need to be taught how to check whether their device is in the right place

Question 118

What are the features of IUD as emergency contraception?

Answer 118

Intra-uterine device is the most effective form of emergency contraception - it prevents implantation and can be used 120 hours after Unprotected sex or after the earliest expected date of ovulation

Not reccommended to be used before 28 days post partum

Some women may experience spotting and period type pains. Women should visit their doctor 3-4 weeks later to check they are not pregnant and discuss future contraception and evalute whether they would like the IUD as a form of contraception for the long term

Question 119

What is Iron Deficiency anaemia?

Answer 119

Iron deficiency anaemia is caused by increased loss of iron, reduced intake or malabsoprtion

Possible causes include:

• Increased loss: Menorrhagia, GI bleeding, hookworm
• Reduced Intake: Poor diet
• Malabsorption: E.g coeliac disease and Inflammatory bowel disease

Question 120

What are the clinical features of Iron defiency anaemia?

Answer 120

• Lethargy
• Tiredeness
• Weakness
• Jaundice
• Heavy periods
• Change in bowel habit

Question 121

How is a diagnosis of Iron Deficiency Anaemia made?

Answer 121

Diagnosis may be suspected on presentation of classical symptoms and the presence of hypochromic, microcytic red cells

Further tests may be performed to confirm diagnosis - Total iron binding capacity (TIBC) and ferritin measurements - TIBC will be high as the body mobilises available iron stores due to iron deficiency - Ferritin will be low as available iron stores in the body are mobilised to counteract the iron deficiency

Question 122

What is the treatment of Iron deficiency anaemia?

Answer 122

Treatment depends on cause

Unexplained iron deficiency may require urgent investigation to rule out a new diagnosis of cancer

Iron deficiency itself can be treated with ferrous sulphate

For iron deficiency anaemia - if patient is asymptomatic, she can be given oral iron (oral Ferrous fumarate 200mg TDS - if patient can’t tolerate oral Iron, give IV Iron (IV ferric carboxymaltose 1000mg - Ferrinject)

Question 123

What are the neurological differentials in HIV?

Answer 123

• Stroke
• Meningitis - the most likely meningitis in a HIV patient is cryptocococcal meningitis which is the most likely diagnosis in a HIV patients with raised opening pressure on lumbar puncture
• Toxoplasmosis - has high opening pressure and fever
• Primary CNS lymphoma
• Progressive multifocal leucoencephalopathy
• CMV encephalitis
• HIV associated neurocognitive disorder

Question 124

Why are pregnant women more likely to develop aspiration pneumonia?

Answer 124

• Increased intragastric pressure due to the gravid uterus
• Relaxed gastro-oesophageal sphincter due to increased circulating progesterone levels
• Delayed gastric emptying
• Vigorous abdominal palpation or disturbance during examination, labour or Caesarean section

Question 125

Why are Protein pump inhibitors given to women undergoing caesarean section?

Answer 125

• PPI inhibit gastric acid secretion and are routinely given before caesarean sections to reduce the maternal gastric volume and acidity → reducing the risk of aspiration of gastric contents during surgery and subsequent aspiration penumonitis
• Most caesareans are under regional anaesthesia, occasionally general needed and thus prophylactic PPIs should be taken before the procedure
• Omeprazole is PPI that can be given before caesarean section

Question 126

What are baby blues

Answer 126

Postpartum blues describe transient lability in mood from around 3 days after birth usually resolving at day 10

Characterised by irraitability, anxiety about parenting skills and tearfullness

Management is supportive and involves reassuring mothers that this happens to around 50% of women - 10% do however develop postnatal depression so screening reccommended at 4-6 weeks and 3-4 months postnatally

Question 127

When does the second stage of labour begin?

Answer 127

2nd stage begins with complete cervical dilation and ends with delivery of the foetus

The steps of the second stage of labour:

• Foetus head is felxed and descends and engages into pelvis
• Foetus internally rotates to face towards the maternal back
• Foetal head extends to deliver the head
• Foetus externally rotates (restitution) after delivery of the head so that shoulder are now in the AP position
• The anterior shoulder is delivered first and then the rest of the foetus is expelled

Common sign of second stage of labour is maternal desire to push - second stage can last from 20 minutes to 2 hours

A prolonged 2nd stage is defined as:

• In Nulliparous women > 3 hours with epidural or >2 hours without
• In multiparous women >2 hours with epidural or >1 hour without

Management of the prolonged 2nd stage is an indication for instrumental delivery if possible - caesarean section in the second stage is associated with increased maternal morbidity

Question 128

What is Bacterial Vaginosis?

Answer 128

Bacterial Vaginosis is a bacterial overgrowth, leading to vaginal discharge with an associated fishy odour. It is associated with UPSI and menstruation

Miscarraige is a risk associated with bacterial vaginosis - generally during mid-trimester

Question 129

What is the diagnostic criteria for Bacterial Vaginosis?

Answer 129

The Amstel criteria are used to diagnose bacterial vaginosis - 3 out of 4 features are needed to confer a diagnosis:

• Vaginal pH >4.5
• Homogenous grey discharge
• Whiff test - 10% potassium hydroxide produces fishy odour
• Clue cells present on wet mount (microscopy)

Question 130

What is the management of Bacterial Vaginosis?

Answer 130

The treatment of choice is Metronidazole or Clindamycin - In pregnancy, treatment is Metronidazole

Question 131

What is Vasa Praevia?

Answer 131

Vasa Praevia is a condition in Obstetrics where the foetal vessels run near to or across the internal cervical OS (opening in the cervix at each end of the endocervical canal)

The foetal vessels are likely to rupture in Vasa praevia during rupture of membranes, as the vessels are unsupported by the umbilical cord or placental tissue. This can lead to foetal haemorrhage and foetal death

Question 132

What are the clinical features of Vasa Praevia?

Answer 132

There is a classic triad of:

• Painless vaginal bleeding
• Rupture of membranes
• Foetal Bradycardia (or resulting foetal death)

Question 133

What is the diagnosis of Vasa Praevia?

Answer 133

Diagnosis of Vasa Praevia is usually made with trans-vaginal ultrasonography and most cases can now be diagnosed antenatally.

Prior to the routine use of ultrasound this condition was usually only diagnosed until after delivery, when haemorrhage has led to foetal death

Question 134

What is management of Vasa Praevia?

Answer 134

Management is with elective caesarean section prior to rupture of membranes. This can be difficult to predict and so is usually arranged at 35-36 weeks gestation - if mother does rupture her membranes or go into labour then emergency caesarean section should be carried out immediately

Question 135

What is Ovarian Cancer

Answer 135

Ovarian cancer is a leading cause of gynaecological cancer in the UK. Its high mortality is linked to the fact that symptoms are often vague until relatively advanced

Differentials include other causes of abdominal discomfort such as gastrointestinal condition (e.g IBS). Other causes of masses include fibroids, ovarian cysts and other cancers (e.g bladder, endometrial)

Question 136

What are the types of Ovarian Cancer?

Answer 136

• Germ Cell tumours
  
  • Originate from the germ cells in the embryonic gonad
  • These tumours typically grow rapidly and spread predominantly via the lymphatic route
  • Most commonly arise in young women which is atypical for most cases of ovarian cancer
  • Tumour markers include alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG)
• Sex cord stromal tumours
  
  • Originate from connective tissue
  • They are rare, making up less than 5% of all ovarian tumours
  • They are malignant tumours but are much less aggressive than epithelial tumours
  • Additionally ovarian cancer can be secondary to another cancer elsewhere, which has metastasised to the ovary e.g a Krukenberg tumours (signet ring subtype of tumour) typically gastriointestinal in origin which has metastasised to the ovary

Question 137

What are the risk factors and protective factors of Ovarian cancer?

Answer 137

Risk factors include:

• Older age
• Smoking
• Great number of ovulations (early menarche, late menopause)
• Obesity
• HRT
• BRCA1,BRCA2

Protective factors include:

• Parity
• Breastfeeding
• Early menopause
• COCP

Question 138

What is the urgent referral criteria for ovarian cancer?

Answer 138

Urgently refer any women with ascites and/or an unexplained pelvic/abdominal mass

Tests should be considered in patients over 50 with:

• Abdominal distention
• Early satiety
• Pelvic/abdominal pain
• Urinary frequency/urgency

Question 139

What are the investigation for Ovarian Cancer?

Answer 139

Initial tests should include:

• CA-125
• Pelvic and abdominal ultrasound

^These can be used to calculate the risk malignancy index so stratify the likelihood of cancer - Ultrasound score (0-3 depending on the number of abnormalities) x menopausal score (1 for pre, 3 for post) x ca-125 level

Further tests include:

• CT scans for staging
• AFP and beta-hCG for younger women who may have germ cell cancers
• Laparotomy for tissue biopsy

Question 140

What is the management of Ovarian cancer?

Answer 140

Management depends on the stage of the cancer and the patient’s fitness for treatment - options include:

• Surgery
  
  • If early surgery can include removal of the uterus, ovaries, fallopian tubes and infracolic omentectomy
  • In advanced disease debulking surgery can be performed
• Chemotherapy
  
  • Adjuvant chemotherapy should be given to the patient in an ideal world
  • Intraperitoneal chemotherapy may be performed at the time of operation
  • Biological therapies are being trialled

Question 141

What are Fibroids?

Answer 141

Fibroids are benign smooth muscle tumours of the myometrium of the uterus - they are highly vascular and often heavy bleeding

Uterine fibroids are the most common benign uterine tumours in women and are the leading reason for hysterectomy - incidence increases with age until the menopause - symptomatic fibroids are low in women younger than 30 years old - occur in 20-50% of women older than 30 - peak incidence is in women in their 40s

Differential include other causes of menorrhagia (bleeding >7 days) and dysmenorrhoea such as endometrial polyps or endometriosis

Question 142

What is the presentation of fibroids?

Answer 142

• Fibroids are often asymptomatic
• When symptoms occur, they usually involve menstrual dysfunction, in the form of menorrhagia and dysmenorrhoea
• If large enough, fibroid may distort the uterine cavity to such extent they interfere with fertility
• If large fibroids may be palpable on abdominal examination as a suprapubic mass. Pelvic examination may reveal an irregularly enlarge uterus

Question 143

What are the investigations for Fibroids?

Answer 143

• Trans-vaginal ultrasound - used to assess the size and location of the fibroids
• MRI is used if ultrasound is not detailed enough to assess the fibroid for surgery
• If there is any doubt over a diagnosis a biopsy may be taken to differentiate the fibroid from other differentials such as endometrial cancer

Question 144

What is the treatment for fibroids?

Answer 144

If asymptomatic, do not require treatment

Treatment can be tailored to the symptoms which the woman is experiencing

• If abnormal bleeding and under 3cm in size with no uterine distortion can be targeted with medical options:
  
  • NSAIDs
  • Anti-fibrinolytics
  • CHC
  • Levonorgestrel-releaseing intrauterine system (Mirena)
    
    • The Mirena is often used first line, however the other treatments may be selected depending on the patient’s wishes to remain fertile, any contraindications, or patient preference

When the symptoms are due to the mass effect of the fibroid (e.g pressure on the bladder), there are several surgical options:

• Myomectomy involves removing the fibroid from the uterine wall, is generally fertility-sparing
• Ablation involves using a laser or radiofrequency (generates heat) to induce necrosis of the fibroaid and so the dead vessels no longer bleed
• Uterine artery embolisation may provide a targeted degeneration of the fibroid. this may also preserve fertility
• Hysterectomy involves removing the uterus. it is obviously exteremly effective but will not perserve fertility

Question 145

How do you manage Hepatitis B in pregnant patient?

Answer 145

If patient positive for both Hbs and Hbe antigens, there is an increased risk of vertical transmission at delivery - Using both HBV igG and a HBV vaccine within 24 hours of delivery reduces the risk of foetus contracting HBV at birth to 5%

Question 146

What is Endometriosis?

Answer 146

Endometriosis is a condition where endometrial tissue grows outside the uterine cavity

Question 147

What is the presentation of Endometriosis?

Answer 147

• Dysmenorrhoea - main differentials other than endometriosis are primary dysmenorrhoea, uterine conditions (e.g fibroids, adenomyosis), adhesions, and PID
• Dyspareunia
• Sub fertility
• Rarely, the endometrial tissue can grow outside the female reproductive system, such as in the bowel leading to cyclical rectal bleeding
• Pelvic examination may reveal tender, nodular masses on the ovaries or the ligaments surrounding the uterus

Question 148

What are the investigations for Endometriosis?

Answer 148

• Trans-vaginal ultrasound is often normal, in some cases it may identify an ovarian endometrioma, which is a cyst made of endometrial tissue in the ovary
• Gold standard is diagnostic laparoscopy - however it does carry a small risk of complications so it is not first line

Question 149

What is the surgical and medical mangement of Endometriosis?

Answer 149

• Medical management:
  
  • depends on symptoms and severity
  • for pain, when only mild, simple analgesia such as paracetamol or NSAIDs may be all that is needed
  • if this is insufficent, creating artificial menopause is used though - COCP, medroxyprogesterone acetate, gonadotrophin-releasing hormone agonists
• Surgical management
  
  • Diathermy of lesions
  • Ovarian cystectomy (for endometriomas)
  • Adhesiolysis
  • Biliaterla oophorectomy (sometimers with hysterctomy)

For managing infertility, menstrual suppression would be unsuitable and so ablation or surgery is more appropriate

Question 150

What is Candidiasis?

Answer 150

Cadidiasis is most commonly caused by Candida Albicans (85-90% of cases)

Associated with pregnancy, antibiotic use and immunosuppresion. The method of transmission is generally non-sexual

Question 151

What are the symptoms of Candidiasis?

Answer 151

In women - itching, white curdy discharge, sour milk odour, dysuria, superficial dyspareunia

on examination in women - redness, fissuring, swelling, intertrigo, thick white discharge

In men - soreness, pruritis, redness

on examination in men - dry, dull, red glazed plaques and papules

Question 152

What are the investigations for Vulvovaginal Candidiasis?

Answer 152

Investigations are not routinely recommended if history indicates acute uncomplicated vulvovaginal candidiasis.

Consider the need for investigation to confirm the diagnosis and/or exclude an alteranative diagnosis

Investigations may include microscopy where the presence of blastospores, pseudohyphae and neutrophils is indicative of Candida infection species.

Culture is recommended for recurrent vulvovaginal candidiasis.

Question 153

What is the managment of Candidiasis?

Answer 153

Managed with antifungal treatment:

• Oral (-azoles) e.g. fluconazole, itraconazole
• Intravaginal e.g. clotrimazole pessary
• Vulval e.g. topical clotrimazole cream

Common regimes:

• Fluconazole oral capsule 150mg as a single dose, generally first line reccomended treatment unless patient factor’s contraindicate use of oral agents, or the patient prefers topical treatment.
• Clotrimazole intravaginal pessary 500mg as a single dose
• Clotrimazole intravaginal vaginal cream (10%) 5g as a single dose
• Clotrimazole intravaginal pessary 200mg at night for 3 consecutive nights

The above regimes can be supplemented with topical -azole therapy if vulval symptoms.

The choice of treatment and formulation will depend on factors such as contraindications, drug history and the person’s preference.

Oral therapies must be avoided in pregnancy, risk of pregnancy and breastfeeding.

Intravaginal and topical treatments can damage latex condoms and diaphragms

Question 154

What is Trichomoniasis?

Answer 154

Trichomonas is caused by Trichomonas Vaginalis, a flagellated protozoan. Transmision is usually sexual with an incubation period of around 7 days

Question 155

What are the symptoms of Trichomoniasis?

Answer 155

• In women - can be asymptomatic, but classically profuse, frothy, yellow vaginal discharge. There can also be vulval irritation and dyspareunia present
• In men - can cause non gonococcal urethritis, can be asymptomatic

Question 156

What are the signs of Tichomoniasis on examination?

Answer 156

Commonly normal

Strawberry cervix is a rare sign

Question 157

How is diagnosis of Trichomoniasis made?

Answer 157

Direct microscopy and culture

Question 158

What is the treatment for Trichomoniasis?

Answer 158

• Treatment is Metronidazole (PO state or BD for 7 days), follow up in one week, screen sexual contacts

Question 159

What is Chlamydia?

Answer 159

Caused by Chlamydia trachomatis (an obligate intracellular bacterium) responsible for the infection of 1/10 women in the uk

Incubation is less than 4 weeks for men

Question 160

What are the symptoms of Chlamydia?

Answer 160

Asymptomatic infections are common

In men - most common symptoms in men are urethral discharge and dysuria

In women - main symptoms are dysuria, inter menstrual bleeding and vaginal discharge

Neonates with chlamydia can be affected with pneumonia and conjunctivitis

Question 161

How is the diagnosis of Chlamydia made?

Answer 161

Diagnosis in women is made by collecting endocervical swab and analysing using the NAAT test, the current investigation of choice

In males, urine and urethral swabs can be collected and analysed in a similar manner

Question 162

What is the treatment for Chlamydia?

Answer 162

Treatment is either by using Doxycycline BD for 7 days or Azithromycin 1g single dose. There is no need for a test of cure

Question 163

What is Gonorrhoea?

Answer 163

Neisseria Gonorrhoeae is a gram-negative diplococcus

Diagnosis is made by microscopy and successful culture

Question 164

What are the symptoms of Neisseria Gonorrhoeae?

Answer 164

In men - Asymptomatic, discharge, dysuria, tender inguinal nodes

In women - discharge, dysuria, abnormal bleeding

Examination may show discharge from the OS, skene’s gland or Bartholin’s gland

There can also be extra-genital complications, including pharyngitis, rectal pain and discharge and disseminated infection

Question 165

What is the current treatment of Gonorrhoea?

Answer 165

• Current guidance recommends treatment with both Ceftriaxone and azithromycin to cover possible chlamydia co-infection. Test of cure is recommended

Question 166

What is the management of Vulvovagal candidiasis?

Answer 166

Managed with antifungal treatment - obviously choices will depend on factors such as contraindications and cautions, licenced age and indication for the product and the person’s preference

For most women, prescribe an initial course of intravaginal antifungal cream or pessary (clotrimazole, econazole, miconazole, or fenticonazole) or an oral antifungal (fluconazole or itraconazole)

For women aged 60 years and older, oral antifungals may be more acceptable than intravaginal antifungals because of the ease of administration

For breastfeeding women, prescribe an initial course of intravaginal clotrimazole or miconazole, or oral fluconazole ( if the intravaginal antifungal is unacceptable to the woman)

Question 167

What is the management of HIV in pregnancy?

Answer 167

Patient should take multiple ART medications, should not breastfeed and that their child should have zidovudine therapy from birth

If patient elects for caesarean, risk of vertical transmission is 2% - but patient can have vaginal delivery if they are taking multiple antiretrovirals and have a viral load of <50 copies/ml

Question 168

What is polyhydramnios?

Answer 168

Polyhydramnios is the presence of too much amniotic fluid in the uterus

Presents with a uterus that feels tense or large for the date it is

May be difficult to feel the foetal parts on palpation of the abdomen. In many cases there is no identifiable cause

Question 169

What are the possible causes of polyhydramnios?

Answer 169

Can be due to excessive productions of amniotic fluid or insufficient removal of amniotic fluid

Excess production can be due to increased foetal urination:

• Maternal diabetes mellitus
• Foetal renal disorders
• Foetal anaemia
• Twin-to-twin transfusion syndrome

Insufficient removal can be due to reduced foetal swallowing:

• Oesophageal or duodenal atresia
• Diaphragmatic hernia
• Anencephaly
• Chromosomal disorders

Question 170

What are the complications of Polyhydramnios?

Answer 170

Can be either maternal and foetal

Maternal complication:

• Maternal respiratory compromise due to increased pressure on the diaphragm
• Increased risk of UTI due to increased pressure on the urinary system
• Worsening of other symptoms associated with pregnancy such as Gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks
• Increased incidence of c-section
• Increased risk of amniotic fluid embolism (this is rare)

Foetal complications:

• Pre-term labour and delivery
• Premature rupture of membranes
• Placental abruption
• Malpresentation of the foetus (the foetus has more space to “move” within the uterus
• Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Question 171

What is the management of polyhydroaminos?

Answer 171

Treatment includes treatment of any underlying causes (e.g in maternal diabetes) and amnio-reduction in severe cases

Question 172

When is the first dose of Rhesus D immunisation given to pregnant women?

Answer 172

Rhesus D isoimmunisation takes place when RHD- women comes into contact with blood of RHD+ foetus (the anti d antibodies can cross placenta and cause the foetal immune system to attack and destroy its own RBC leading ot haemolytic disease of the newborn)

at 28 weeks, the first dose of anti-D prophylaxis is given to rhesus negative women

Question 173

What booking appointments are made for pregnant women?

Answer 173

8-12 weeks - First booking visit should be performed - blood test

11-13 + 6 weeks - the timeframe for down’s syndrome screening including nuchal scan

16 weeks - results of blood released - also if women has Hb <11g/dl then iron supplemntation should be considered

18-20 + 6 weeks - anomaly exam should be preformed

Question 174

What are Aids- defining malignancies?

Answer 174

Kaposi’s sarcoma

High grade B cell non-hodgkin’s lymphoma

Invasive cervical cancer - greatest risk if less than 200 CD4+ cells - treated as normal just a more advanced presentaiton

if primary CNS found - commence cART and whole brain irradiation

HIV related hodgkin’s lymphoma and HIV related anal cancer are non AIDS defining malignancies

Question 175

What is the first line management in the active management of the third stage of Labour?

Answer 175

Intramuscular Oxytocin (10IU) given as first line - preferred over Syntometrine which is associated with greater side effects

Question 176

What is the third stage of labour?

Answer 176

The third stage of labour begins at delivery of the foetus and ends with delivery of the placenta and foetal membranes

Generally lasts 30 minutes to an hour when allowed to occur naturally or 5-10 minutes with administration of oxytocin

Question 177

What are the signs of the third stage of labour?

Answer 177

Signs of placental separation and imminent placental delivery

• Gush of blood
• Lengthening of the umbilical cord
• Ascension of the uterus in the abdomen

Question 178

What is the management of the third stage of labour?

Answer 178

Delivery of placenta is commonly managed manually by controlled cord traction - must be gentle or else there is increased risk of causing complications such as uterine inversion and postpartum haemorrhage

Question 179

What is Ovarian Hyperstimulation syndrome?

Answer 179

Ovarian hyperstimulation syndrome is complication of iatrogenic induction of ovulation

FSH used in IVF leads to many follicles maturing and enlarging - once ovulation occurs each becomes corpus luteum → excessive production of oestrogen, progesterone and local cytokines (Vascular endothelial growth factor)

Question 180

What is the presentation of Ovarian Hyperstimulation syndrome?

Answer 180

• Ovaries may enlarge to such an extent that they put pressone on surrounding structures causing bloating and abdominal discomfort
• The VEGF causes blood vessels to leak leading to fluid retention in the form of:
  
  • Oedema
  • Pleural effusion
  • Ascites
  • Weight gain

Question 181

What are the investigations for Ovarian Hyperstimulation syndrome?

Answer 181

• Routine bloods - haemoconcentration and organ dysfunction
• Chest X-ray for pleural effusion

Question 182

What is the management of Ovarian Hyperstimulation syndrome?

Answer 182

Management largely supportive. The degree of intervention depends on the severity and can range from simple analgesia to ITU admission

Question 183

Why is Epilepsy a concern in pregnancy?

Answer 183

• The physiological changes during pregnancy can lower the seizure threshold and increase the frequency of fits - prolonged fits are dangerous as they can increase the risk of foetal hypoxia
• Maternal use of anti-epileptics increase the risk to the foetus of congential abnormalities such as neural tube defects
• Balance must be found between risk of seizure to mother and risk of CongA in foetus - generally risk to the mother and foetus of stopping anti-epileptics takes priority over the risk of foetal abnormality

Question 184

What is the management of epilepsy in pre-pregnancy?

Answer 184

• Neurological review should be sought - lowest effective dose of medication should be used
• Carbamazepine and Iamotrigine are the safest anti-epileptics - Sodium valproate should be avoided in pregnancy as it carries the highest risk of CongA
• If history of epilepsy but no high risk of unprovoked seizure, can be managed as low risk pregnancy - if no fits have occurred for at least 2 years, consider stopping all medications
• Drug compliance must be emphasised and women should be advised to continue medication through pregnancy
• All need to take 5mg/day of folic acid pre-conceptually until at least end of the first trimester → minimises the risk of neural tube defects and folate deficiency

Question 185

What is the Antenatal management of Epilepsy?

Answer 185

• All preggos should be under joint medical and obstetric care
• Plasma anti-epileptic dug levels should be monitored regularly as levels are likely to decrease with increasing plasma volume
• Foetus should be monitored reguarly for abnromalities with serial growth and anomaly scans
• Anti-epileptic regimes may inhibit foetal clotting factor production so vitamin K therapy should be given at 36 weeks gestation
• Reassurance that most will have uncomplicated surgery
• If seizure occurs during labour, terminated as quickly as possible with benzos in order to avoid maternal + foetal hypoxia
• if no history of epilepsy but has a seizure than guidelines for eclampsia should be triggered until definitive neurological diagnosis can be made

Question 186

What is postnatal management of epilepsy?

Answer 186

Generally safe to take anti-epileptics whilst breastfeeding

The dose should be reviewed after delivery to prevent postpartum toxicity as plasma levels return to normal

Question 187

What bacteria is associated with early onset neonatal infections?

Answer 187

Listeria Monocytogenes - Gram positive rod organism

Group B streptococcus - Gram positive coccus

Escherichia Coli - Gram negative baccillus

Question 188

What is the causitive agent in Group B stroptococcus infections?

Answer 188

Streptrococcus agalactiae - gram positive coccus - some pregnant women are symptomatic carries, during delivery baby may be infected with GBS and can present as neonatal sepsis, pneumonia, and meningitis - 25% of women are suspected to be carriers

Question 189

What are the risk factors for GBS infection?

Answer 189

• Positive GBS culture in current or previous pregnancy
• Previous birth resulting in neonatal GBS infection
• Pre-term Labour
• Prolonged rupture of membranes
• Intra-partum fever >38 degrees celsius
• Chorioamnionitis (infection of the membranes that surround the feotus and the amniotic fluid)

Question 190

Is routine screening for GBS carried out in the Uk?

Answer 190

No - because colonisation status can change throughout pregnancy

Question 191

What is the management of a GBS infection?

Answer 191

Intra-partum antibiotic prophylaxis is the most effective method of preventing GBS infection in the newborn - if penicillin allergy, should give vancomycin

Antibiotics (commonly a peniciilin) given IV during labour and delivery if risk factors for GBS infection are present -

Question 192

What is Genital prolapse?

Answer 192

Genital or pelvic organ prolapse is the descent of pelvic structures from their normal anatomical location towards or through the vaginal opening

Question 193

What are the types of Anterior Vaginal Wall prolapse?

Answer 193

Cystocele - prolapse of bladder (may lead to stress incontinence i.e leaking urine when coughing or sneezing)

Urethrocele - prolapse of urethra

Cystourethrocele - both bladder and urethra

Question 194

What are the types of Posterior Vaginal Wall prolapse?

Answer 194

Enterocele - small intestine

Rectocele - rectum

Question 195

What are the types of Apical Vaginal Wall prolapse?

Answer 195

Uterineprolapse - uterus

Vaginal vault prolapse - roof of vagina (common after hysterectomy)

Question 196

What is the Bishop score used for?

Answer 196

Used to assess whether a patient is likely be a good candidate for an induction of labour - a score of 9 or more means that the patient is likely to achieve for induction

Can be broken down into 5 sections:

• Position of the cervix
• Length of the cervix (effacement)
• Consistency of the cervix
• Dilation of the cervix
• Foetal station (distance in cm in relation to the ischial spines)
• Pregnancy can enlarge dainty stomachs

There are certain modifiers that can be added or subtracted

1 point added for - presence of pre-eclampsia - each previous vaginal delivery

1 point subtracted for - post dates pregnancy - no previous vaginal deliveries - premature pre-term rupture of membranes

Question 197

If Bishop’s Score is low, what is the appropriate course of action for women in labour?

Answer 197

Administer Prostaglandin E2 PV - can encourage cervical ripening and increase likelihood of vaginal delivery

Question 198

What is Placental Abruption?

Answer 198

Placental abruption occurs when the placental prematurely separated from the wall of the uterus - can present with dark red vaginal blood with hard tender abdomen and pain that feels like continuous contractions

Immediate investigations can involve either dopplar or CTG and ultrasound to view the uterus and look for evidence of placental abruption

Ongoing management would be dependent on the conditions of the patient - if bleeding heavy, urgent caesarean section would be considered

Question 199

What is antepartum haemorrhage?

Answer 199

Antepartum haemorrhage is vaginal bleeding occurring between 24 weeks of pregnancy and birth

Question 200

What are the differentials for antepartum haemorrhage?

Answer 200

• Placental abruption
• Placenta praevia - occurs when part of the placenta overlaps or covers the cervical Os - often leads to painless bleeding which is usually bright in colour and abdomen is soft and non-tender
• Vasa praevia
• Malignancy or trauma of the genital tract
• Infection of the genital tract
• Uterine rupture - usually occurs during labour and is rare
• inherited bleeding disorder
• Gestational trophoblastic disease
• Cervical ectropian

Question 201

What is the management of Antepartum haemorrhage?

Answer 201

• First step is always to assess haemodynamic status - if compromised due to major haemorrhage, resus should be commenced - if not, thorough history, abdominal exam and speculum exam should be performed
• Digital vaginal exam should be avoided if chance of placenta praevia
• In almost all circumstances, women with antepartum haemorrhage should be admitted to hospital for observation
• Haemorrhage may be concealed and thus the degree of blood loss visible per vaginum may be disproprtionate to actual blood loss volume
• Iv access should be obtained and then the following should be obtained:
  
  • Group and save, crossmatch
  • FBC
  • Coagulation screen
  • U+E
  • LFTs
  • Kleihauer test should be taken in RHD- women to determine the dose of anti-D immunoglobulin required

Ultrasound may be required to exclude placenta praevia and CTG should be used to assess and monitor foetus

If risk of preterm birth and woman is between 24-34 weeks of gestation, antenatl corticosteroids should be offered to aid foetal lung maturation

Question 202

What is the gold standard diagnostic test for HIV?

Answer 202

Gold standard is HIV antibody (point of care test that is used commonly and detects antibody associated with HIV about 21-25 days after infection) and HIV antigen test (detects the p24 antigen and can be detected 6 days earlier than antibodies)

Window period (time between transmission and and detection in blood ) is about 4 weeks for the HIV antibody + antigen test - current practise to test at 4 weeks and at 3 months regardless of the calculated window period

Proviral DNA testing is used in cases of suspected HIV in babies - used as the mother’s antibodies remain in serum for 18 months

Question 203

What are the features of hypothyroidism?

Answer 203

• Peripheral features - Dry thick skin, Brittle hair, scanty secondary sexual hair
• Head and neck features - Macroglossia (enlargement of tongue), puffy face, loss of lateral third of eyebrow, Goitre (depending on cause)
• Cardiac features - Bradycardia, cardiomegaly
• Neurological features - Carpal tunnel syndrome, slow relaxing reflexes, cerebellar ataxia, peripheral neuropathy

Question 204

What are the causes of hypothyroidism?

Answer 204

• Autoimmune causes - Hashimotos’s thyroiditis (90-95% have anti-TPO, 35-60% have anti-thyroglobulin, 10% have Anti-TSH receptor (blocking) - Atrophic thyroiditis - autoimmune polyendocrine syndromes
• Iatrogenic causes - Surgical - Radioablation - Radiation
• Congenital causes - Thyroid aplasia - Pendred syndrome (defect in thyroxine synthesis)
• Iodine deficiency/Excess related causes - Infiltrative - Sarcoid - Haemochromatosis
• Primary autoimmune Hypothyroidism - Hashimoto’s thyroiditis - Atrophic thyroiditis - Autoimmune polyendrocrine syndromes

Question 205

What is the management of Hypothyroidism?

Answer 205

Levothyroxine is the first line to replace thyroxine (in pregnant women you should increase dose by 25mcg and repeat thyroid test in 4 weeks even if patient is euthyroid because there is a physiological increase of serum free thyroxine until the 12th week as foetus is dependent on mothers thyroxine, this is not seen in hypothyroid patients so you should mimic it with medication)

Risks include osteoporosis and cardiac arrythmias

Following stabilisation of dose, TSH should be checked annually

Question 206

What is the management of pregnancy at 41 weeks?

Answer 206

Risk of complications, especially past 42 weeks

At 41 weeks, a membrane sweep should be offered to the mother. This procedure involves the midwife or doctor inserting a finger into the cervical opening and “sweeping” to separate the amniotic membranes from the cervix.

This separation causes release of prostaglandins which may stimulate spontaneous labour.

If membrane sweep is unsuccessful, an induction of labour is offered. Induction of labour involves the administration of prostaglandins to stimulate contractions.

If induction of labour is refused, expectant management involving regular foetal monitoring is required.

Question 207

What are Perineal Tears?

Answer 207

Perineal tears are the most common maternal obstetric injuries and can be classified into four categories

Question 208

What are the degrees of perineal tears?

Answer 208

1. First degree tear
   
   • Tear limited to the superficial perineal skin or vaginal mucosa only
2. Second degree tear
   
   • Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)
3. Third degree tear
   
   • 3a: less than 50% of the thickness of the external anal sphincter is torn
   • 3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
   • 3c: external and internal anal sphincters are torn, but anal mucosa is intact
4. Fourth degree tear
   
   • Perineal skin, muscle, anal sphincter and anal mucosa are torn

Question 209

What is the management of Perineal tears?

Answer 209

Management of a perineal tear depends on the degree of severity and classification of the tear, thus full assessment of the extent of the trauma is required before any intervention.

1st degree - First degree tears with minimal blood loss may not require suturing as they are superficial with no muscle involvement and are likely to heal quickly.

2nd degree - Second degree tears will require suturing as they involve perineal muscle. This may be carried out by an experienced midwife.

3rd and 4th degree - Third and fourth degree tears require surgical repair by an experienced clinician and should take place in an operating theatre under regional or general anaesthetic.

Broad-spectrum antibiotics and laxatives should be given post-operatively.

Although some bleeding is expected with a tear, any excessive bleeding from the genital tract should prompt further investigation.

Question 210

What is HELLP Syndrome?

Answer 210

HELLP syndrome is the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP).

HELLP syndrome often manifests during the third trimester and is part of a spectrum of hypertensive disorders of pregnancy including preeclampsia.

Question 211

What are the clinical features and complications of HELLP syndrome?

Answer 211

Symptoms include:

• Headache
• Nausea and/or vomiting
• Epigastric pain
• Right upper quadrant abdominal pain due to liver distention
• Blurred vision
• Peripheral oedema

Maternal Complications

Maternal complications include:

• Organ failure
• Placental abruption
• Disseminated intravascular coagulopathy (DIC).

Foetal Complications

Foetal complications include:

• Intrauterine growth restriction
• Preterm delivery
• Neonatal hypoxia

Question 212

What is the management of HELLP Syndrome?

Answer 212

Usually the definitive treatment is delivery of the baby. Some mothers may also require blood transfusions or steroids during the pregnancy.

Question 213

What is the management of HELLP Syndrome?

Answer 213

Usually the definitive treatment is delivery of the baby. Some mothers may also require blood transfusions or steroids during the pregnancy.

Question 214

What is the treatment of gestational hypertension?

Answer 214

In women with gestational hypertension (hypertension with onset after 20 weeks gestation and no proteinuria) above 150/100mmHg the first line management is oral labetalol.

If there is only mild hypertension (140/90 to 149/99mmHg) during pregnancy then regular blood pressure monitoring should be carried out and no treatment is recommended.

If labetalol is not tolerated then alternative medications which can be used include methyldopa and nifedipine.

For all women, regular blood pressure monitoring and urinalysis should be carried out.

Question 215

What is Uterine Atony?

Answer 215

The failure for the uterus to contract after delivery, otherwise known as uterine atony, is the most common cause of postpartum haemorrhage. A major risk factor for uterine atony is uterine over-distension, as seen in multiple pregnancy. The soft and high position of the uterus is also an indication that there is atony. It is important to recognise that this woman is at risk of haemorrhagic shock and thus requires immediate intervention

Question 216

What is pregnancy of unknown origins?

Answer 216

A pregnancy of unknown origin is diagnosed when a woman has a positive pregnancy test, but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal ultrasound.

This can be due to three reasons:

• An early viable or failing intrauterine pregnancy
• A complete miscarriage
• An ectopic pregnancy

Question 217

What are the investigations for pregnancy of unknown origins?

Answer 217

• Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.
  
  • If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage
  • If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy
  • A normal increase in B-hCG suggests the foetus is growing normally, but does not exclude an ectopic pregnancy
• A transvaginal ultrasound may help to identify the location of the pregnancy, but in the early days of gestation the foetus may be too small to be accurately identified by ultrasound. In this instance it may be best to repeat the scan at a later date.

Question 218

What is Rhesus isoimmunisation?

Answer 218

The D antigen is found on red blood cells and is an important antigen in the rhesus factor system.

Rhesus isoimmunisation can occur when a rhesus negative mother has a baby which is rhesus positive. If any foetal red blood cells enter the maternal circulation, the mother will form anti-D antibodies against them.

The maternal anti-D antibodies can cross the placenta in subsequent pregnancies and cause Rhesus haemolytic disease if the future baby is rhesus positive.

Question 219

What are sensitisation events?

Answer 219

“Sensitisation” events are events which cause foetal blood to cross the placenta into the maternal circulation and thus these are indications for anti-D prophylaxis.

Examples of sensitisation events include:

• Antepartum haemorrhage
• Placental abruption
• Abdominal trauma
• External cephalic version
• Invasive uterine procedures such as amniocentesis and chorionic villus sampling
• Rhesus positive blood transfusion to a rhesus negative woman
• Intrauterine death, miscarriage or termination
• Ectopic pregnancy
• Delivery (normal, instrumental or caesarean section)

Question 220

What is the management for the RH-D negative mother?

Answer 220

Presence of anti-D antibodies can result in incompatibility and haemolysis in future pregnancies. To attenuate this risk, anti-D antibodies are given to patients who have experienced a sensitising event. Anti-D is also given to all non-sensitised Rhesus negative mothers at 28 weeks. Note that anti-D has no effect once sensitisation has already occurred (it is prophylactic only).

Question 221

What is the definition miscarriage?

Answer 221

Miscarriage is defined as the loss of a pregnancy prior to 24 weeks gestation. Just over 10% of recognised pregnancies end in miscarriage, although the total number of miscarriages is higher as many occur without the woman realising she is pregnant.

Question 222

What are the types of miscarriage?

Answer 222

Threatened miscarriage

This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the “threat” of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine.

Inevitable miscarriage

There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.

Complete miscarriage

There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.

Missed miscarriage

The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is ‘missed’ as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.

Incomplete Miscarriage

Incomplete miscarriage presents with bleeding per vagina with clots and pain. Cervical os is open as passage of products of conception is still underway

Question 223

What is recurrent miscarriage?

Answer 223

Recurrent miscarriage is defined as the loss of 3 or more consecutive pregnancies.

Question 224

What is the management of recurrent miscarriage?

Answer 224

The management is tailored to the contributing pathology:

Genetic disorder - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm

Uterine structural abnormality - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment

Cervical incompetence - regular ultrasound monitoring of the cervix. May use cervical cerclage

Polycystic ovary syndrome - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective

Antiphospholipid syndrome - heparin or low-dose aspirin

Thrombophilia - heparin may increase the live birth rate

Diabetes - improve glycaemic control

Question 225

What is Chorioamnionitis?

Answer 225

Chorioamnionitis is an infection of the membranes in the uterus.

Typical symptoms are of a fever, abdominal pain, offensive vaginal discharge and evidence of preterm rupture of membranes.

Typical signs are of maternal and foetal tachycardia, pyrexia and uterine tenderness.

Rupture of membranes can lead to chorioamnionitis, particular risk in pre-term pre-labour rupture

Question 226

What is the management of chorioamnionitis?

Answer 226

Chorioamnionitis is an indication for admission and delivery.

Women with chorioamnionitis require intravenous broad spectrum antibiotic therapy as part of the sepsis six protocol.

Question 227

What are the indications for induction of labour?

Answer 227

• Post-dates i.e. >41 weeks gestation
• Preterm prelabour rupture of membranes
• Intrauterine foetal death
• Abnormal CTG
• Maternal conditions such as pre-eclampsia, diabetes, cholestasis

Question 228

What are the contraindications for induction of labour?

Answer 228

• Previous classical/vertical incision during caesarean section
• Multiple lower uterine segment caesarean sections
• Transmissible infections e.g. herpes simplex
• Placenta praevia
• Malpresentations
• Severe foetal compromise
• Cord prolapse
• Vasa previa

Question 229

What are the methods of induction of labour?

Answer 229

• Membrane sweep - inserting a gloved finger into the external os and separating the membranes from the cervix
• Vaginal prostaglandins (PGE2)
• Amniotomy - artificial rupture of membranes
• Balloon catheter

Question 230

What is placenta praevia?

Answer 230

Placenta praevia (PP) is defined as the placenta overlying the cervical os.

The classical clinical presentation of placenta praevia is bright red vaginal bleeding which is painless. Placenta praevia should be suspected if there is vaginal bleeding which occurs after 24 weeks of pregnancy.

Note that malpresentation of the foetus may be found on examination as a result of the abnormal placental position and in some cases mothers may present with signs of shock if there is severe blood loss.

Question 231

What are the investigations for placenta praevia?

Answer 231

• If there is painless bleeding after 13 weeks or previous history of uterine incision, then transvaginal ultrasound should be used to exclude placenta praevia
• A further ultrasound should be carried out at 37 weeks to reassess the placental position
• Note that currently in the UK there is no routine screening for placenta praevia in low risk pregnancies.

Question 232

What is the management of placenta praevia?

Answer 232

Bleeding with unknown placental position:

• ABC approach, resuscitation and stabilisation
• If stable, perform urgent ultrasound
• If the bleeding is not controlled, immediate caesarean section required

Bleeding with known placenta praevia:

• ABC approach, resuscitation and stabilisation. If stabilisation is not achieved, send for emergency caesarean Section.
• Corticosteroids should be considered if between 24-34 weeks gestation and there is risk of preterm labour

In labour: caesarean section

Placenta praevia with no bleeding and not in labour:

• Monitor with ultrasound scans
• Give advice about pelvic rest (no penetrative sexual intercourse) and advise to go to hospital if there is significant vaginal bleeding

At term:

• If there is any degree of placental overlap at 35 weeks, aim for an elective caesarean section at 37-38 weeks gestation. Urgent C-section if she goes in to labour (due to risk of significant bleeding)
• When the placental edge is greater than 20mm from the internal cervical os, women can be offered a trial of labour (if no bleeding and with careful intrapartum monitoring). If significant haemorrhage or foetal distress develops during trialled vaginal delivery, immediately take to theatre for caesarean section.

Question 233

What are the clinical features of congenital VZV syndrome?

Answer 233

If a non-immune woman contracts VZV during the first trimester of pregnancy it has teratogenic effects and can cause congenital varicella syndrome.

Features of congenital varicella syndrome include:

• Low birth weight
• Limb hypoplasia (underdevelopment)
• Skin scarring
• Microcephaly
• Eye defects
• Learning disability

Question 234

What is the management of VZV infection?

Answer 234

If a non-immune pregnant woman comes into contact with someone infected with varicella zoster, immunoglobulin can be given as prophylaxis.

Acyclovir is used as treatment if the maternal infection occurs. This should be given within 24 hours of the onset of the rash.

The neonate should be monitored and given IV acyclovir following delivery.

Question 235

What defect does sodium valproate exposure cause in neonates?

Answer 235

Valproate exposure in the first trimester is associated with the highest risk of major congenital malformations.

These include neural tube defects, cardiovascular anomalies, genital abnormalities, skeletal abnormalities and developmental delay. AEDs such as Valproate, Phenytoin and Carbamazapine are known to be associated with the risk of development of neural tube defects

Question 236

What is Hyperemesis gravidarum?

Answer 236

Hyperemesis gravidarum is severe vomiting with onset before 20 weeks of gestation.

It is severe enough to require admission to hospital and is a diagnosis of exclusion.

Differentials for severe vomiting during pregnancy:

• Infections such as gastroenteritis, urinary tract infection, hepatitis and meningitis
• Gastrointestinal problems: Appendicitis, cholecystitis, bowel obstruction
• Metabolic conditions: Diabetic ketoacidosis, thyrotoxicosis
• Drug toxicity
• Molar pregnancy (abnormally high levels of beta-hCG due to gestational trophoblastic disease can cause severe nausea and vomiting)

Question 237

What is the management of hyperemesis gravidarum?

Answer 237

Management of hyperemesis gravidarum is generally supportive and should include the following:

• Fluid replacement therapy
• Potassium chloride as excessive vomiting usually causes hypokalaemia
• Anti-emetic medications such as cyclizine (first line), metoclopramide or prochlorperazine. Ondansetron or domperidone may be used in severe cases.
• Thiamine and folic acid to prevent development of Wernicke’s encephalopathy
• Antacids to relieve epigastric pain
• Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration.

Question 238

What is the management of hyperemesis gravidarum?

Answer 238

Management of hyperemesis gravidarum is generally supportive and should include the following:

• Fluid replacement therapy
• Potassium chloride as excessive vomiting usually causes hypokalaemia
• Anti-emetic medications such as cyclizine (first line), metoclopramide or prochlorperazine. Ondansetron or domperidone may be used in severe cases.
• Thiamine and folic acid to prevent development of Wernicke’s encephalopathy
• Antacids to relieve epigastric pain
• Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration.

Question 239

What is the management of Lichen Sclerosus?

Answer 239

• Topical steroids
• Avoidance of soaps of the affected areas
• Emollients to relieve dryness and itching

Question 240

What is the management of Lichen Sclerosus?

Answer 240

• Topical steroids
• Avoidance of soaps of the affected areas
• Emollients to relieve dryness and itching

Question 241

What is the management of Lichen Sclerosus?

Answer 241

• Topical steroids
• Avoidance of soaps of the affected areas
• Emollients to relieve dryness and itching

Question 242

What is Listriosis?

Answer 242

Listeriosis is the condition caused by the pathogen listeria monocytogenes.

Listeria monocytogenes can be contracted from contaminated foods (commonly unpasteurised dairy products and soft cheeses).

When a pregnant mother is infected, the bacterium may be transmitted through the placenta or during delivery and cause in utero infection of the foetus

Pregnant women should be advised to avoid potentially contaminated food products and if there is unexplained febrile illness or suspicion of infection cultures for listeria should be carried out.

Question 243

What are the clinical features of listeriosis?

Answer 243

Presentation is usually that of neonatal sepsis, meningitis, or respiratory distress due to aspiration of infected amniotic fluid. Manifestation of the infection may be early onset or late onset.

Infection can also lead to chorioamnionitis, premature labour and stillbirth.

Management includes antibiotic treatment (ampicillin) and an aminoglycoside

Question 244

What is obstetric cholestasis?

Answer 244

Obstetric cholestasis (also known as intra-hepatic cholestasis of pregnancy) is a condition which commonly develops after 24 weeks of pregnancy. It involves the build up of bile acids.

Question 245

What are the clinical features of cholestasis?

Answer 245

Features of obstetric cholestasis include:

• Pruritus which is commonly worse on the hands and feet and can be severe in nature. It is not accompanied by a rash, but may have excoriation marks from itching.
• Fatigue or malaise
• Nausea and loss of appetite
• Rarely there may be mild maternal jaundice (dark urine, pale stools)
• Abdominal pain which is typically in the right upper quadrant

Question 246

What is the management of obstetric cholestasis?

Answer 246

Treatment is with chlorphenamine to reduce itch, vitamin K to reduce risk of haemorrhage and scheduling of early delivery to avoid prolonged risk of spontaneous intrauterine death.

Ursodeoxycholic Acid (UDCA) can reduce serum bile acids and relieve pruritus; it is used on an off-licence basis.

Question 247

What is the medical management of ectopic pregnancy?

Answer 247

• Medical management involves a one-off dose of methotrexate
• There are strict criteria for methotrexate treatment, such as low HCG level, ability to attend follow up, adherence to avoiding pregnancy for a period following treatment
• If the initial dose of methotrexate has failed to treat the ectopic, a second dose of methotrexate or surgical management may be indicated

Question 248

What is the surgical management of ectopic pregnancy?

Answer 248

• Surgical management is recommended if the patient would be unable to attend follow-up, if the ectopic is advanced or if the patient is haemodynamically unstable. An advanced ectopic is suspected if any of the following are present:
  
  1. The patient is in a significant amount of pain
  2. There is an adnexal mass of size ≥35mm
  3. B-hCG levels are ≥5000IU/L
  4. Ultrasound identifies a foetal heartbeat
• Surgical management is often in the form of a salpingectomy where the fallopian tube containing the ectopic is removed. In cases where the ectopic is in a woman with only one functioning fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed
• Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are performed to exclude any trophoblastic tissue still within the fallopian tube

Question 249

What is the surgical management of ectopic pregnancy?

Answer 249

• Surgical management is recommended if the patient would be unable to attend follow-up, if the ectopic is advanced or if the patient is haemodynamically unstable. An advanced ectopic is suspected if any of the following are present:
  
  1. The patient is in a significant amount of pain
  2. There is an adnexal mass of size ≥35mm
  3. B-hCG levels are ≥5000IU/L
  4. Ultrasound identifies a foetal heartbeat
• Surgical management is often in the form of a salpingectomy where the fallopian tube containing the ectopic is removed. In cases where the ectopic is in a woman with only one functioning fallopian tube, and they wish to remain fertile, a salpingotomy may be done where only the ectopic is removed
• Salpingotomy carries the risk that not all the tissue may have been removed and so serial serum B-hCG measurements are performed to exclude any trophoblastic tissue still within the fallopian tube

Question 250

What are the clinical features of ectopic pregnancy?

Answer 250

• Pelvic pain, which may be unilateral to the side of the ectopic
• Shoulder tip pain - If the ectopic bleeds, the blood can irritate the diaphragm causing shoulder tip pain
• Abnormal vaginal bleeding e.g. missed period or intermenstrual bleeding
• Haemodynamic instability caused by blood loss if the ectopic ruptures
• Abdominal examination may reveal unilateral tenderness
• Cervical tenderness (chandelier sign) on bimanual examination

Miscarriage is the main differential. Both can present with pain and vaginal bleeding. In an ectopic pregnancy the pain is often the first and dominant symptom, and if vaginal bleeding does occur it is minor in comparison to a miscarriage.

Question 251

What is fibrocycstic disease of the breast?

Answer 251

• Fibrocystic disease is the most common benign breast disease
• It occurs most commonly in the 20-50 year old age group
• It is caused by the cumulative effect of cyclical hormones such as oestrogen and progesterone (among many others) which leads to chronic changes in the breast including multiple small cysts and proliferative changes.

Question 252

What are the clinical features of fibrocystic disease of the breast?

Answer 252

Features include:

• Bilateral “lumpy” breasts – most commonly in upper outer quadrant
• Breast pain
• Symptoms which worsen with the menstrual cycle – normally peaking 1 week before menstruation

Question 253

What is the management of fibrocystic disease of the breast?

Answer 253

• Treatment is supportive, recommending a soft but well-fitting bra, alongside analgesia
• Most cases will resolve after menopause.

Question 254

What is oligohydramnios?

Answer 254

Oligohydramnios is the presence of a lower than normal volume of amniotic fluid in the uterus.

Causes of oligohydramnios:

• Uteroplacental insufficiency leading to intrauterine growth restriction. This may be due to maternal disease such hypertension or pre-eclampsia, maternal smoking and placental abruption.
• Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). Examples include renal agenesis, polycystic kidneys or urethral obstruction.
• Premature rupture of membranes
• Post-term gestation
• Chromosomal anomalies
• Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)

Complications of oligohydramnios are related to reduced “space” surrounding the foetus and that reduced amniotic fluid for foetal lung growth and development.

Complications due to space limitation and subsequent foetal compression include clubbed feet, facial deformity and congenital hip dysplasia.

Underdevelopment of the lung due to lack of amniotic fluid can result in pulmonary hypoplasia in the foetus. A combination of the above features is commonly known as Potter syndrome.

Question 255

What are the complications of breast surgery?

Answer 255

Anaesthetic

• Stroke
• Venous thromboembolism
• Myocardial infarction
• Aspiration

Surgical

• Pain
• Bleeding
• Infection
• Seroma
• Displeasure with cosmetic outcome

Axillary node clearance related injury

• Lymphoedema
• Damage to brachial plexus
• Axillary artery/vein injury