Women's Health

Question 1

Name 3 hormones that are important in pregnancy.

Answer 1

Main hormones:

hCG.
Progestins.
Oestrogens.
Other hormones:

hPL.
Prolactin.
Oxytocin.

Question 2

Where is hCG produced?

Answer 2

The trophoblast.

Question 3

Give 2 functions of hCG.

Answer 3

1. It signals the presence of the blastocyst.
2. It prevents the corpus luteum from dying - luteal regression.

Question 4

Where are progestins produced?

Answer 4

Initially from the corpus luteum and then from the placenta from week 7.

Question 5

Give 3 functions of progestins.

Answer 5

1. Prepares the endometrium for implantation.
2. Promotes myometrial quiescence.
3. Increases maternal ventilation.

Question 6

How do progestins prepare the endometrium for implantation?

Answer 6

Progestins stimulate the proliferation of cells, vascularisation and the differentiation of endometrial stroma.

Question 7

Where are oestrogens produced?

Answer 7

Initially in the ovary and then from a combination of fetal and maternal sources.

Question 8

Give 2 functions of oestrogens in pregnancy.

Answer 8

1. Promotes a change in the CV system.
2. Alters carbohydrate metabolism.

Question 9

What is the main oestrogen in pregnancy?

Answer 9

E3 - it indicates fetal well-being.

Question 10

What is the role of E2 in pregnancy?

Answer 10

E2 is responsible for proliferation of the endometrial epithelium. It also facilitates progesterone action.

Question 11

What is the role of human placental lactogen (hPL)?

Answer 11

1. Mobilises glucose from fat.
2. Acts as an insulin antagonist.
3. Converts mammary glands into milk secreting tissues.

Question 12

What is the role of prolactin?

Answer 12

Prolactin is responsible for milk production.

Question 13

What is the role of oxytocin?

Answer 13

Oxytocin is responsible for milk secretion and uterine contractions.

Question 14

Where is prolactin produced?

Answer 14

In the anterior pituitary gland.

Question 15

Where is oxytocin produced?

Answer 15

In the posterior pituitary gland.

Question 16

Where are FSH and LH produced?

Answer 16

In the anterior pituitary gland.

Question 17

What hormone does the hypothalamus release that acts on the anterior pituitary gland and stimulates the production of FSH and LH?

Answer 17

GnRH.

Question 18

What cells in the ovaries does FSH act on?

Answer 18

Granulosa cells -> oestrogen production.

Question 19

What cells in the ovaries does LH act on?

Answer 19

Theca cells -> androgen production.

Question 20

What hormone is released from the hypothalamus that acts on the anterior pituitary to inhibit prolactin release?

Answer 20

Dopamine.

Question 21

What is the principle foetal nutrient?

Answer 21

Glucose.

Question 22

Can the foetus produce any of its own glucose?

Answer 22

No, gluconeogenic enzymes are inactived in the foetus and so all its glucose has to come from its mother.

Question 23

In early pregnancy, is plasma glucose high or low?

Answer 23

Plasma glucose is lower because glucose is being stored.

Question 24

Why is plasma glucose lower in early pregnancy?

Answer 24

Because the mother is storing glucose.

Question 25

In late pregnancy, is plasma glucose high or low?

Answer 25

Plasma glucose is higher. This is due to maternal insulin resistance and glucose sparing for the foetus.

Question 26

Why is plasma glucose higher in late pregnancy?

Answer 26

1. Because of increasing maternal insulin resistance. 2. Glucose sparing for the foetus.

Question 27

What are the consequences of maternal insulin resistance?

Answer 27

Maternal insulin resistance -> gestational diabetes -> increased risk of macrosomia and shoulder dystocia.

Question 28

Why is the immune response suppressed in a pregnant lady?

Answer 28

It prevents foetal rejection.

Question 29

Give 4 ways in which foetal rejection is prevented in a pregnant lady.

Answer 29

1. A TH2 bias is observed. 2. Syncytiotrophoblast has no self:non-self markers and so doesn’t stimulate an immune response. 3. Extra-villous trophoblast cells have modified markers. 4.The overall immune response is suppressed.

Question 30

In a normal pregnancy, a TH2 bias is observed, this helps prevent foetal rejection. Give 3 potential consequences if there is not a TH2 bias.

Answer 30

Pre-eclampsia. IUGR. Miscarriage.

Question 31

How does the endometrial epithelium become adhesive to the blastocyst?

Answer 31

The blastocyst and endometrium communicate via the release of hormones -> ‘sticky endometrium’.

Question 32

When in a woman’s cycle does the endometrium become sticky?

Answer 32

This usually happens between days 20-24. This is called the window of implantation and outside of this time implantation will not occur.

Question 33

What reaction occurs when a blastocyst implants into the endometrium?

Answer 33

A primary decidual reaction occurs.

Question 34

What part of the blastocyst facilitates placental formation?

Answer 34

The cytotrophoblast.

Question 35

Placenta formation: What does the cytotrophoblast go on to form?

Answer 35

Anchoring villi -> extra villous trophoblast. Floating villi are also involved

Question 36

What can trigger the differentiation of anchoring villi into extra-villous trophoblast?

Answer 36

Hypoxia

Question 37

What is the role of extra villous trophoblast (EVT) cells?

Answer 37

EVT invade and remodel spiral arteries. This leads to more hypoxia and so more EVT; a positive feedback effect is observed.

Question 38

Why do EVT cells invade and remodel spiral arteries?

Answer 38

To allow for optimum nutrient delivery for the baby.

Question 39

Give 3 potential consequences of poor endovascular remodelling.

Answer 39

Pre-eclampsia. IUGR. Pre-term birth.

Question 40

Where should normal placenta invade into?

Answer 40

The decidua

Question 41

What is placental accreta?

Answer 41

When the placenta invades into the superficial myometrium.

Question 42

What is placental increta?

Answer 42

When the placenta invades into the deeper myometrium.

Question 43

What is placental percreta?

Answer 43

Invasion of the placenta into nearby organs e.g. the bladder.

Question 44

What are the potential consequences, if left untreated, of a rhesus negative mother having a rhesus positive foetus?

Answer 44

There is a risk of RBC lysis -> foetal anaemia and death.

Question 45

Describe the pathophysiology of rhesus disease.

Answer 45

1. Foetal Rh+ RBC’s leak through the placenta and interact with the mother’s blood -> IgM reaction -> sensitisation. 2. IgM can’t cross the placenta and so there is no RBC lysis but memory B cells are created. 3. On a subsequent pregnancy, IgG may cross the placenta and cause foetal RBC lysis.

Question 46

What is the only antibody that can cross the placenta?

Answer 46

IgG

Question 47

How can foetal RBC lysis be prevented in rhesus negative mothers?

Answer 47

Anti-D prophylaxis can be given. This destroys Rh+ IgG and so no RBC are attacked.

Question 48

What is quiescence?

Answer 48

When the myometrium is inactive, there are no contractions.

Question 49

Describe the physiology behind quiescence?

Answer 49

Increased cAMP -> K+ extrusion -> myocyte hyperpolarisation -> muscle fibres are unable to contract. There is also phosphorylation of intracellular proteins -> actin-myosin ATPase is inactivated -> smooth muscle relaxation.

Question 50

Give 2 theories behind the induction of labour

Answer 50

1. Placental clock theory. 2. Signals from the baby.

Question 51

Induction of labour: describe the placental clock theory.

Answer 51

Increased release of CRH from the placenta -> foetal ACTH release -> release of oestrogens, formation of myometrial gap junctions -> regular and co-ordinated uterine contractions.

Question 52

Induction of labour: describe the theory that suggests that there are signals from the baby.

Answer 52

Increased ACTH or increased foetal surfactant proteins activate amniotic fluid macrophages. These migrate to the uterine wall, there is up-regulation of inflammatory gene expression which stimulates labour.

Question 53

Describe the 3 stages of parturition.

Answer 53

1. Dilation - cervical remodelling and uterine contractions. 2. Expulsion - full dilation to delivery of infant. 3. Placental delivery.

Question 54

Parturition: do progesterone levels fall when the cervix dilates and remodels?

Answer 54

Progesterone levels don’t fall but it becomes ineffective -> contractions.

Question 55

Parturition: what happens in the expulsion phase that triggers myometrial contractions?

Answer 55

Oxytocin release -> increased intracellular Ca2+ -> myometrial contractions.

Question 56

Why can nifedipine be used to inhibit premature contractions?

Answer 56

Nifedipine is a CCB and so can block the rise of intracellular calcium therefore inhibiting muscle contraction.

Question 57

Name 2 drugs that can inhibit uterine contractions.

Answer 57

1. Nifedipine - CCB. 2. Atosiban - oxytocin antagonist.

Question 58

Name an oxytocin analogue that can induce labour.

Answer 58

Syntocinon.

Question 59

Define: pelvic organ prolapse

Answer 59

Descent of the pelvic organs into the vagina uterine prolapse = uterus Vault prolapse = women who have a hysterectomy so vagina descends Rectocele = rectum due to defect in peoterior vaginal wall cystocele = bladder due to defect in anterior vaginal wall

Question 60

What are the risk factors for prolapse?

Answer 60

- multiple vaginal deliveries - instrumental, prolonged or traumatic delivery - Advanced age and postmenopause status - Obesity - Chronic respiratory disease causing coughing - Chronic constipation causing straining

Question 61

Presentation: prolapse

Answer 61

- A feeling of “something coming down” in the vagina - A dragging or heavy sensation in the pelvis - Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention - Bowel symptoms, such as constipation, incontinence and urgency - Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Question 62

What are the grades of uterine prolapse?

Answer 62

Pelvic organ prolapse quantification (POP-Q) Grade 0: Normal Grade 1: The lowest part is more than 1cm above the introitus (external opening of vagina) Grade 2: The lowest part is within 1cm of the introitus (above or below) Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended Grade 4: Full descent with eversion of the vagina

Question 63

Management: Prolapse

Answer 63

1. conservative - pelvic floor exercises - weight loss - treat stress incontinence symptoms - vaginal oestrogen cream 2. Vaginal pessary - inserted into vagina to give more support 3. Surgery - repair anterior or posterior walls - sacro spinous fixation = stick top of vagina to ligament - sarocolpopexy = mesh in abdomen - Hysterectomy

Question 64

What are the types of urinary incontinence?

Answer 64

1. Stress = weakness of the pelvic floor and sphincter muscles 2. Urge = overactivity of the detrusor muscle of the bladder 3. Mixed 4. Overflow = due to chronic urinary retention due to an obstruction to the outflow of urine

Question 65

What are the risk factors for urinary incontinence?

Answer 65

Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia

Question 66

Presentation: stress incontinence

Answer 66

involuntary leakage - cough - laughing - lifting - exercise - movement - intercourse - walking/running downhill (sphincter weakness)

Question 67

Presentation: urgency incontinence

Answer 67

Overactive bladder Urgency incontinence Frequency Nocturia Nocturnal enuresis ‘Key in the door’ ‘Handwash’ Intercourse

Question 69

Investigations: urinary incontinence

Answer 69

1. bladder diary 2. urine dipstick testing 3. post-void residual bladder volume 4. urodynamic testing - measure detrusor muscle contraction - measure flow rate - measure pressure in bladder vs pressure in vagina/anus to calculate detrusor activity

Question 70

What is the innervation of the detrusor muscle?

Answer 70

detrusor muscle - smooth muscle, transitional epithelium sacral parasympathetic (para pee) S2-4 = cause bladder wall to contract and sphincter to relax neurotransmitter = acetylcholine Receptors = muscarinic M2 + M3 Antagonists = atropine (oxybutynin, tolterodine)

Question 71

Management: stress incontinence

Answer 71

Lifestyle - Avoiding caffeine, diuretics and overfilling of the bladder - smoking cessation - Avoid excessive or restricted fluid intake - Weight loss (if appropriate) - Supervised pelvic floor exercises for at least three months before considering surgery Containment - bladder bypass (catheters) - leakage barrier (pads + pants) - vaginal support (pessaries) - skin care (barrier creams - Surgery - Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Question 72

What are the mechanisms of mirabegnon?

Answer 72

Beta-3 adrenergic receptor agonist Relaxes smooth muscle detrusor Increases bladder capacity

Question 73

Define: urinary tract calculi

Answer 73

Hard lumps of minerals that can from inside the bladder when its not completely empty of urine e.g. due to enlarged prostate gland

Question 74

Presentation: urinary tract calculi

Answer 74

- lower abdominal pain - pain or difficulty peeing - peeing more frequently - cloudy or dark coloured urine - blood

Question 75

MAnagement: urinary tract calculi

Answer 75

Surgery - cystolitholapaxy = cystoscope camera tube inserted and stones crushed

Question 76

What are the most common types of uterine abnormalities?

Answer 76

Incomplete fusion of mullein or paramesonephric ducts - lead to double vagina, cervix, uterus - uterus with midline septum - double single-horned uteruses

Question 77

Investigations: uterine abnormalities

Answer 77

- ultrasound - hysterosalpingography - MRI scan

Question 78

Complications of uterine abnormalities?

Answer 78

- dysmenorrhoea - haematometra - pregnancy + labour complications - fertility usually unaffected - congenital renal abnormalities

Question 79

Management: uterine abnormalities

Answer 79

- surgery = if affects viable pregnancy - uterine reconstruction

Question 80

What types of vaginal abnormalities occur?

Answer 80

1. Vaginal agenesis: absent uterus but ovaries present. 2. Vaginal atresia: The lower portion of the vagina consists of fibrous tissue with a well-differentiated uterus. 3. Müllerian aplasia: Nearly all of the vagina and most of the uterus are absent. 4. Transverse vaginal septa: Can be present as single or multiple in the upper or lower segments and may be patent or perforated; can be the cause of haematometra or other fluid collections. 5. Longitudinal vaginal septa anomalies: The urethra can open into the vaginal wall or the vagina can open into a persistent urogenital sinus.

Question 81

Define: androgen insensitivity syndrome

Answer 81

Condition where the cells are unable to respond to androgen hormones due to a lack of androgen receptors - x- linked recessive - mutation in androgen receptor gene - extra androgens converted to oestrogen

Question 82

Pathophysiology: androgen insensitivity syndrome

Answer 82

- genetically male with XY - but female phenotype externally - extra androgens converted to oestrogen - patients have testes in abdomen or inguinal canal and absence of uterus, upper vagina, cervix, ovaries - due to testes producing anti-mullerian hormone

Question 83

Presentation: androgen insensitivity syndrome

Answer 83

- lack of pubic + facial hair - inguinal hernias at infancy containing testes - primary amenorrhoea - raised LH - normal or raised FSH - normal or raised testosterone levels (for a male) - raised oestrogen ( for a male)

Question 84

Management: androgen insensitivity syndrome

Answer 84

1. bilateral orchidectomy (removal of testes to avoid testicular tumour) 2. oestrogen therapy 3. vaginal dilators or vaginal surgery (to create an adequate vaginal length)

Question 85

Define: menarche

Answer 85

First menstrual cycle ages 11-15

Question 86

What hormone changes occur in puberty?

Answer 86

1. Hypothalamus releases Gonadotropin releasing hormone GnRH in a pulsatile manner 2. stimulates release of LH and FSH from anterior pituitary gland (rise in FSH stimulates an increase in oestrogen synthesis + oogenesis + sperm production) 3. FSH + LH act on gonads to stimulate synthesis of sex steroid hormones (oestrogen/progesterone and testosterone)

Question 87

What are the physical changes in females in puberty?

Answer 87

1. Thelarche = breast development aged 9-10 2. Pubarche = growth of public hair 3. Menarche = first period

Question 88

What are the physical changes in males in puberty?

Answer 88

1. genital changes = increased testicular size - Increased LH stimulates testosterone synthesis by Leydig cells - Increased FSH stimulates sperm production by Sertoli cells - scrotal skin becomes thinner and darker - ejaculation then occurs - penis then grows in length then width 2. pubarche = growth of pubic hair 3. Growth spurt -rise in GH and IGF-1 - larynx and vocal cords enlarge

Question 89

What are the stages of menopause?

Answer 89

Premature menopause = before age of 40 yrs Perimenopause = time around the menopause and 12 months after last period Menopause = point at which menstruation stops Postmenopause = period from 12 months after the final menstrual period

Question 90

What happens to hormones during menopause?

Answer 90

Lack of ovarian follicular function - Oestrogen low - progesterone low - LH + FSH high (lack of feedback from oestrogen)

Question 91

What is the process that starts menopause?

Answer 91

1. reduced development of ovarian follicles 2. reduced production of oestrogen 3. Absence of negative feedback from oestrogen 4. LH and FSH increase

Question 92

What are some perimenopausal symptoms?

Answer 92

- Hot flushes - Emotional lability or low mood - Premenstrual syndrome - Irregular periods - Joint pains - Heavier or lighter periods - Vaginal dryness and atrophy - Reduced libido

Question 93

What does a lack of oestrogen increase the risk of?

Answer 93

Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence

Question 94

What is contraception advice for menopausal women?

Answer 94

Still need to use contraception until: - 2 yrs after last period in women <50 yrs - 1 yrs after last period in women >50 yrs

Question 95

Management: perimenopausal symptoms

Answer 95

- No treatment - Hormone replacement therapy (HRT) - Tibolone = synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) - Clonidine = agonists of alpha-adrenergic and imidazoline receptors - Cognitive behavioural therapy (CBT) - SSRI antidepressants = fluoxetine or citalopram - Testosterone can be used to treat reduced libido (usually as a gel or cream) - Vaginal oestrogen cream or tablets = help with vaginal dryness and atrophy (can be used alongside systemic HRT) - Vaginal moisturisers = Sylk, Replens and YES

Question 96

Define: adenomyosis

Answer 96

Endometrial tissue inside the myometrium (muscle layer of uterus) - usually later in life after several pregnancies

Question 97

Presentation: adenomyosis

Answer 97

1. Painful periods (dysmenorrhoea) 2. Heavy periods (menorrhagia) 3. Pain during intercourse (dyspareunia) - infertility or pregnancy complications

Question 98

Investigations: adenomyosis

Answer 98

1. transvaginal USS 2. transabdominal USS 3. MRI gold standard diagnosis = Hysterectomy with histology

Question 99

Management: adenomyosis

Answer 99

Contraception wanted/acceptable 1. Mirena coil 2. combined oral contraceptive pill 3. cyclical oral progesterones No contraception 1. tranexamic acid = when no associated pain, reduced bleeding 2. Mefenamic acid = reduced pain + bleeding - GnHR analogues induce menopause like state - endometrial ablation - uterine artery embolisation - hysterectomy

Question 100

What is the effect of adenomyosis on pregnancy?

Answer 100

Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage

Question 101

Define: Asherman's syndrome

Answer 101

Adhesions form within the uterus following damage to the uterus - Occurs after pregnancy related dilatation + curettage procedure (remove tissue left behind) - uterine surgery - pelvic infections

Question 102

Presentation: Asherman's syndrome

Answer 102

- Secondary amenorrhoea (absent periods) - Significantly lighter periods - Dysmenorrhoea (painful periods) May present with infertility

Question 103

Investigations: Asherman's syndrome

Answer 103

- Gold standard = Hysteroscopy (can involved dissection + treatment) - Hysterosalpingography = contrast injected into uterus + imaged with x-rays - Sonohysterography = uterus filled with fluid + pelvic USS performed - MRI scan

Question 104

Management: Asherman's syndrome

Answer 104

Hysteroscopy - dissect adhesions

Question 105

Define: Lichen Sclerosis

Answer 105

Chronic inflammatory skin condition - commonly affects labia, perineum, and perianal skin in women - men = foreskin and glans of penis - autoimmune conditions

Question 106

Presentation: lichen sclerosis

Answer 106

- patches of shiny, porcelain white skin - itching - soreness + pain - skin tightness - painful sex - erosions - fissures - papules or plaques - slightly raised Koebner phenomenon = symptoms made worse by friction to skin

Question 107

Management: lichen sclerosis

Answer 107

1. potent topical steroids = clobetasol propionate (long term use) 2. Emollients

Question 108

What are the complications of lichen sclerosis?

Answer 108

Squamous cell carcinoma of the vulva - pain + discomfort - sexual dysfunction - bleeding - narrowing of the vagina or urethral openings

Question 109

Define: Atrophic vaginitis

Answer 109

Dryness and atrophy of the vaginal mucosa related to a lack of oestrogen - occurs in women entering menopause - oestrogen causes epithelial to be thicker, more elastic and produce secretions

Question 110

Presentation: Atrophic vaginitis

Answer 110

Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation Signs - pale mucosa - thin skin - reduced skin folds - erythema + inflammation - dryness - sparse pubic hair

Question 111

MAnagement: Atrophic vaginitis

Answer 111

1. vaginal lubricants = Sylk, Replens, YES 2. Topical oestrogen - estriol cream, pessaries, tablets, ring (SE = breast cancer, angina, venous thromboembolism)

Question 112

Define: Vulval cancer

Answer 112

90 % = squamous cell carcinoma less likely = malignant melanomas

Question 113

What are the risk factors for vulval cancer?

Answer 113

Advanced age (particularly over 75 years) Immunosuppression Human papillomavirus (HPV) infection Lichen sclerosus

Question 114

Define: vulval intraepithelial neoplasia

Answer 114

Premalignant condition affecting the squamous epithelium of the skin - watch + wait - wide local excision - imiquimod cream - laser ablation

Question 115

Presentation: vulval cream

Answer 115

Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin Labia majora = irregular mass, fungating lesion

Question 116

Management: vulval cancer

Answer 116

1. 2 week wait urgency cancer referral 2. Biopsy of lesion 3. Sentinel node biopsy = demonstrate lymph node spread FIGO 4.wide local excision to remove cancer 5. groin lymph node dissection 5. chemo + radiotherapy

Question 117

What is the cell type and cause of cervical cancer?

Answer 117

80% squamous cell carcinoma Then adenocarcinoma Cause = human papilloma virus (STI) - p53 and pRb are tumour suppressor genes - HPV produces E6 and E7 that inhibit these tumour suppressor genes

Question 118

What are the risk factors for cervical cancer?

Answer 118

Increased risk of HPV - early sexual activity - multiple sexual partners - not using condoms Non-engagement with cervical screening - smoking - HIV - COCO pill - increased number of full term pregnancies - family history

Question 119

Presentation: cervical cancer

Answer 119

- Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) - Vaginal discharge - Pelvic pain - Dyspareunia (pain or discomfort with sex) - ulceration - bleeding - visible tumour

Question 120

Investigations: cervical cancer

Answer 120

Smear test: - cervical smear test every 3 years aged 25-49 then every 5 yrs - test involves collecting cells from the cervix using a small brush Colposcopy - inserting a speculum to magnify cervix - stains (acetic acid + iodine solution) used to differentiate abnormal areas Large loop excision of the transformation zone - loop of wire with electrical current to remove abnormal epithelial tissue on the cervix Cone biopsy - cone shaped piece of cervix removed using a scalpel - sent for histology

Question 121

What is the staging for obs+gynae cancers?

Answer 121

The International Federation of Gynaecology and Obstetrics (FIGO) Stage 1: Confined to the cervix Stage 2: Invades the uterus or upper 2/3 of the vagina Stage 3: Invades the pelvic wall or lower 1/3 of the vagina Stage 4: Invades the bladder, rectum or beyond the pelvis

Question 122

Management: cervical cancer

Answer 122

Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy Stage 2B – 4A: Chemotherapy and radiotherapy Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care Pelvic exenteration = advancesd, removes most of pelvic organs

Question 123

What strains does the HPV vaccine protect against and what would these strains cause otherwise?

Answer 123

Given to girls and boys before becoming sexually active Gardasil vaccine strains 6 &11 =genital warts strains 16 & 18 = cervical cancer

Question 124

What is human papilloma virus?

Answer 124

DNA virus - can infect all types of squamous epithelium - high risk types = 16 + 18 - low risk types = 6 +11 > cause genital warts

Question 125

Presentation: HPV

Answer 125

presence of new lumps/growths in the anogenital area - cauliflower like growths - flat, plaques - pigmented - generally IP between 3-8 weeks local irritation bleeding discomfort/itching

Question 126

Management: HPV

Answer 126

Physical ablation - excision - cryotherapy - electrosurgery - laser treatment Topical applications - Podophyllotoxin (Warticon® and Condyline®) - Imiquimod 5% cream - Catephen® 10% ointment - TCA 80-90% (specialist clinic setting only)

Question 127

What is the most likely type of endometrial cancer?

Answer 127

Adenocarcinoma oestrogen dependent cancer = oestrogen stimulates the growth of endometrial cancer cells

Question 128

Define: endometrial hyperplasia

Answer 128

precancerous condition involving thickening of the endometrium (less than 5% become endometrial cancer) worrying types - hyperplasia without atypia - atypical hyperplasia

Question 129

Treatment: endometrial hyperplasia

Answer 129

Using progesterones - intrauterine system e.g. mirena coil - continuous oral progesterones

Question 130

What are the risk factors for endometrial cancer?

Answer 130

Unoppoed oestrogen = oestrogen without progesterone (as stimulates the endometrial cells) - Increased age - Earlier onset of menstruation - Late menopause - Oestrogen only hormone replacement therapy - No or fewer pregnancies - Obesity = adipose tissue is a source of oestrogen - Polycystic ovarian syndrome = increased exposure to unopposed oestrogen due to lack of ovulation (less progesterone released) - Tamoxifen = oestrogenic effect in endometrium

Question 131

What are protective factors against endometrial cancer?

Answer 131

(most increase progesterone) Combined contraceptive pill Mirena coil Increased pregnancies Cigarette smoking = anti-oestrogenic, oestrogen metabolised differently, smokers thinner

Question 132

Presentation: endometrial cancer

Answer 132

1. postmenopausal bleeding Postcoital bleeding Intermenstrual bleeding Unusually heavy menstrual bleeding Abnormal vaginal discharge Haematuria Anaemia Raised platelet count

Question 133

What is the referral criteria for endometrial cancer?

Answer 133

2-week-wait urgent cancer referral: 1. Postmenopausal bleeding (more than 12 months after the last menstrual period) NICE also recommends referral for a transvaginal ultrasound in women over 55 years with: 1. Unexplained vaginal discharge 2. Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Question 134

Investigations: endometrial cancer

Answer 134

- transvaginal USS for endometrial thickness (normal <4mm post menopause) - Pipelle biopsy = highly sensitive, sample from uterus - Hysteroscopy with endometrial biopsy

Question 135

Management: endometrial cancer

Answer 135

Stage 1 + 2: Total abdominal hysterectomy with bilateral salpingo-oophorectomy (uterus, cervix, adnexa) Other: - radical hysterectomy - radiotherapy - chemotherapy - progesterones hormone treatment

Question 136

What are the types of ovarian cancer?

Answer 136

1. epithelial cell tumours MC 2. Dermoid cysts/ germ cell tumours - benign ovarian tumours - associated with ovarian torsion - germ cells may cause raised a-FP and hCG 3. Sex cord stromal tumours - benign or malignant 4. Metastasis - Krukenberg tumour = metastasis form GI tract cancer

Question 137

What are the risk factors for ovarian cancer?

Answer 137

Age (peaks age 60) BRCA1 and BRCA2 genes (consider the family history) Increased number of ovulations Obesity Smoking Recurrent use of clomifene ( factors that increase number of ovulations, increase risk of ovarian cancer e.g. late menopause, early onset periods, no pregnancies)

Question 138

Presentation: ovarian cancer

Answer 138

Can present with non-specific symptoms Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites

Question 139

What is the referral criteria for ovarian cancer?

Answer 139

2 week wait - ascites - pelvic mass - abdominal mass

Question 140

Investigations: ovarian cancer

Answer 140

1. CA125 blood test (>35 is significant) 2. pelvic USS 3. CT scan 4. histology using CT guided biopsy 5. Paracentesis for ascitic fluid women under 40 with complex ovarian masss check - alpha fetoprotein (a-FP) - human chorionic gonadotropin (HCG)

Question 141

What are the causes of raised CA125?

Answer 141

Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Question 142

Management: ovarian cancer

Answer 142

specialist gynaecologist oncology MDT - surgery - chemotherapy

Question 143

Define: dysfunctional uterine bleeding

Answer 143

Abnormal uterine bleeding in the absence of organic disease - usually presents with menorrhagia (heavy) without any cause

Question 144

What are the causes of menorrhagia?

Answer 144

- Dysfunctional uterine bleeding (no identifiable cause) - Extremes of reproductive age - Fibroids - Endometriosis and adenomyosis - Pelvic inflammatory disease (infection) - Contraceptives, particularly the copper coil - Anticoagulant medications - Bleeding disorders (e.g. Von Willebrand disease) - Endocrine disorders (diabetes and hypothyroidism) - Connective tissue disorders - Endometrial hyperplasia or cancer - Polycystic ovarian syndrome

Question 145

What are the structural and non-structural differential diagnoses of menorrhagia?

Answer 145

Structural = PALM - Polyp adenomyosis - Leiomyoma (fibroids) - Malignancy and hyperplasia Non-structural = COEIN - Coagulopathy Ovulatory dysfunction - Endometrial - Iatrogenic - Not yet classified

Question 146

What are the key questions in menorrhagia history?

Answer 146

Age at menarche Cycle length, days menstruating and variation Intermenstrual bleeding and post coital bleeding Contraceptive history Sexual history Possibility of pregnancy Plans for future pregnancies Cervical screening history Migraines with or without aura (for the pill) Past medical history and past drug history Smoking and alcohol history Family history

Question 147

What are the red flags for bleeding?

Answer 147

- post menopausal bleeding - bleeding during pregnancy - pelvic mass - haemodynamically unstable - USS findings of thickness of endometrium (>12mm pre menopausal and >5mm peri-menopausal)

Question 148

Investigations: Menorrhagia

Answer 148

1. pelvic examination with a speculum and bimanual 2. FBC = iron deficiency anaemia 3. outpatient hysteroscopy = submucosal fibroids, endometrial pathology, persistent intermenstrual bleeding 4. Pelvic + transvaginal USS = fibroids, adenomyosis Swabs coagulation screen ferritin thyroids function tests

Question 149

Management: menorrhagia

Answer 149

Exclude pathology No contraception - tranexamic acid = reduce bleeding - mefenamic acid = reduce bleeding + pain Contraception 1. mirena coil 2. Combined oral contraceptive pill 3. Cyclical oral progesterones Final: Endometrial ablation + hysterectomy

Question 150

What are the terms used for variations in menstrual bleeding?

Answer 150

Irregular = metrorrhagia absent = amenorrhea frequent = polymenorrhea infrequent = oligomenorrhoea heavy = menorrhagia Painful periods = dysmenorrhoea

Question 151

Define: endometriosis

Answer 151

ectopic endometrial tissue outside the uterus a lump of endometrial tissue outside uterus = endometrioma

Question 152

What is the cause of endometriosis?

Answer 152

No clear cause just a few theories 1. Retrograde menstruation = during menstruation endometrial lining flows backwards through the Fallopian tubes and seeds itself around the pelvis 2. embryonic cells meant to become endometrial tissue remain outside uterus 3. spread of cells through lymphatic system 4. metaplasia = cells outside uterus change

Question 153

What is the pathophysiology of the symptoms of endometriosis?

Answer 153

Main symptom = pelvic pain 1. endometrial tissue outside uterus still responds to hormones and bleeds in menstruation 2. causing inflammation + irritation of tissue around the bleeding 3. deposits in bladder or bowel can lead to blood in urine or stools 4. can lead to adhesions = due to scar tissue from inflammation

Question 154

Presentation: endometriosis

Answer 154

- Cyclical abdominal or pelvic pain (pain only during menstruating) - Deep dyspareunia (pain on deep sexual intercourse) - Dysmenorrhoea (painful periods) - Infertility - Cyclical bleeding from other sites, such as haematuria - associated with IBS (follow ROME criteria to ensure endometriosis instead of IBS) examination : - Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix - A fixed cervix on bimanual examination - Tenderness in the vagina, cervix and adnexa

Question 155

Investigations: endometriosis

Answer 155

1. Examination 2. pelvic USS 3. Laparoscopic surgery (gold standard) = can remove deposits

Question 156

Management: Endometriosis

Answer 156

1. analgesia 2. hormonal management = combined pill, POP pill, implant, coil, injections - Zolendax (triggers menopause) (can stop ovulation + reduce endometrial thickening) (if pain goes away with these then can diagnose with endometriosis) 3. surgical - laparoscopic surgery (50% see nothing) - hysterectomy

Question 157

Define: fibroids

Answer 157

Benign tumours of the smooth muscle of the uterus also known as Uterine leiomyomas Oestrogen sensitive

Question 158

What are the types of fibroids?

Answer 158

- intramural = within the myometrium - subserosal = just below the outer layer of the uterus, fill abdominal cavity - submucosal = just below the lining of the uterus (endometrium) - pedunculated = means on a stalk

Question 159

Presentation: fibroids

Answer 159

Often asymptomatic - Heavy menstrual bleeding (menorrhagia) MC - Prolonged menstruation, >7 days - Abdominal pain = worse during menstruation - Bloating or feeling full in the abdomen - Urinary or bowel symptoms due to pelvic pressure or fullness - Deep dyspareunia (pain during intercourse) - Reduced fertility

Question 160

Investigations: fibroids

Answer 160

1. Hysteroscopy = for submucosal fibroids with menorrhagia 2. pelvic USS = larger fibroids 3. MRI scan = before surgery

Question 161

Management: Fibroids

Answer 161

Fibroids <3cm 1. Mirena coil 2. symptomatic management with NSAIDs + tranexamic acid 3. combined pill 4. Cyclical oral progesterones 5. Surgical = endometrial ablation, resection, hysterectomy Fibroids >3cm 1. refer to gynaecologist 2. Symptomatic management = NSAIDs and tranexamic acid 3. Mirena coil – depending on the size and shape of the fibroids and uterus 4. Combined oral contraceptive 5. Cyclical oral progestogens 6. Surgical - uterine artery embolisation - Myomectomy - Hysterectomy

Question 162

Define: Ovarian cyst

Answer 162

A fluid filled sac - premenopausal = usually benign, fluctuate with hormones - post menopausal = concern for malignancy

Question 163

What does a diagnosis of PCOS require?

Answer 163

Two of: - Anovulation - Hyperandrogenism - Polycystic ovaries on USS

Question 164

Presentation: ovarian cysts

Answer 164

Most are asymptomatic Pelvic pain Bloating Fullness in the abdomen A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

Question 165

What are the types of functional cysts?

Answer 165

1. Follicular cysts = represent the follicle, persist after egg is released, usually disappear after a few menstrual cycles 2. Corpus luteum cysts - occur when corpus luteum fails to break down + instead fills with fluid - often seen in early pregnancy

Question 166

Investigations: ovarian cysts

Answer 166

premenopausal with cyst < 5cm on USS no further investigations needed 1. USS 2. Bloods = CA125, LDH, a-FP, HCG

Question 167

Management: ovarian cysts

Answer 167

1. rule out ovarian cancer 2. dermoid cysts = refer to gynaecologist 3. simple ovarian cysts in premenopausal women <5cm = no follow up 5-7 cm = routine referral to gynaecologist + yearly USS >7cm = MRI scan, surgical evaluation 4. Postmenopausal women - CA125 bloods, refer to gynaecologist (ovaries not functioning so shouldn't develop cysts) - Then CT scan 5. surgery - ovarian cystectomy - oophorectomy (never drain as will refill)

Question 168

What is a cyst accident?

Answer 168

- includes rupture, haemorrhage and torsion - cyst rupture + haemorrhage occurs with functional cysts and are generally self-limiting - laparoscopy = required if diagnosis uncertain or patient haemodynamically unstable

Question 169

Define: Meig's syndrome

Answer 169

Triad of : 1. Ovarian fibroma (a type of benign ovarian tumour) 2. Pleural effusion 3. Ascites Usually in older women Removal of tumour = complete resolution

Question 170

Define: ovarian torsion

Answer 170

Ovary twists in reaction to the surrounding connective tissue, Fallopian tube and blood supply - usually due to an ovarian mass > 5cm - more likely with benign tumours and in pregnancy

Question 171

Presentation: ovarian torsion

Answer 171

Sudden onset severe unilateral pelvic pain - constant - gets progressively worse - nausea and vomiting - often non-specific (can assume its appendicitis) examination - localised tenderness - palpable mass Seen in women of reproductive age and can occur in pregnancy

Question 172

Investigations: ovarian torsion

Answer 172

1. pelvic USS = whirlpool sign, free fluid in pelvis, and oedema of the ovary 2. Laparoscopic surgery = definitive diagnosis

Question 173

Management: ovarian torsion

Answer 173

1. emergency admission 2. laparoscopic surgery - un-twist ovary and fix it in place (detorsion) - remove affected ovary (oophorectomy)

Question 174

Define: Pelvic inflammatory disease

Answer 174

Inflammation and infection of the organs of the pelvis caused by infection spreading up through the cervix Endometritis = inflammation of the endometrium Salpingitis = fallopian tubes Oophoritis = ovaries Parametritis = parametrium, (connective tissue around the uterus) Peritonitis = peritoneal membrane

Question 175

What are the causes of pelvic inflammatory disease?

Answer 175

Usually STI - Chlamydia trachomatis MC - Neisseria gonorrhoeae (tends to produce more severe PID) - Mycoplasma genitalium other: - gardnerella vaginalis - haemophilus influenzae - E.coli

Question 176

What are the risk factors for inflammatory pelvic disease?

Answer 176

Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous pelvic inflammatory disease Intrauterine device (e.g. copper coil)

Question 177

Presentation: pelvic inflammatory disease

Answer 177

Pelvic or lower abdominal pain Abnormal vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria (usually young person) Examination findings may reveal: Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge

Question 178

Investigations: pelvic inflammatory disease

Answer 178

1. check for STIs - NAAT swabs - HIV test - syphilis test 2. high vaginal swab = send to lab 3. pregnancy test = exclude ectopic pregnancy 4. inflammatory markers = ESR + CRP raised

Question 179

Management: pelvic inflammatory disease

Answer 179

1. antibiotics - 14 days course - single IM ceftriaxone - plus PO doxycycline + metronidazole avoid sexual intercourse until patient and partner completed treatment

Question 180

Define: Fitz-Hugh-Curtis syndrome

Answer 180

Complication of pelvic inflammatory disease - inflammation and infection of the liver capsule - leads to adhesions between liver and peritoneum - bacteria may spread from pelvis via cavity, lymphatic system or blood Presentation - RUQ pain referred to right shoulder tip Laparoscopy Adhesiolysis = to treat adhesions

Question 181

Define: Polycystic ovarian syndrome

Answer 181

common condition causing metabolic and reproductive problems in women - multiple ovarian cysts - infertility - oligomenorrhoea (irregular infrequent) - hyperandrogegism - insulin resistance

Question 182

What is the Rotterdam criteria?

Answer 182

2 are required to diagnose PCOS: 1. oligoovulation or an ovulation (irregular or absent periods) 2. hyperandrogegism (hirsutism and acne) 3. Polycystic ovaries on USS

Question 183

Presentation: PCOS

Answer 183

Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern

Question 184

What are some complications of PCOS?

Answer 184

- Insulin resistance and diabetes = high levels of insulin increase androgens released + halt development of follicles in ovaries - Acanthosis nigricans = thickened, rough skin - Cardiovascular disease - Hypercholesterolaemia - Endometrial hyperplasia and cancer - Obstructive sleep apnoea - Depression and anxiety - Sexual problems

Question 185

Investigations: PCOS

Answer 185

1. Blood tests: - Raised Testosterone - Sex hormone-binding globulin - Raised LH - FSH = high LH to FSH ratio - Prolactin (may be mildly elevated in PCOS) - Thyroid-stimulating hormone - raised insulin - normal/raised oestrogen 2.- Pelvic USS - transvaginal USS - gold standard 3. Oral glucose tolerance test

Question 186

What diagnostic criteria is used for PCOS in USS?

Answer 186

String of pearls appearance Either: - 12 or more developing follicles in one ovary - ovarian volume > 10cm3

Question 187

Management: PCOS

Answer 187

1. reduce risks associated with obesity, type 2 diabetes, hypercholersterolaemia and cardiovascular disease 2. manage risk of endometrial cancer - mirena coil - induce a withdrawal bleed with COCP or cyclical progesterones 3. manage infertility 4. manage hirsutism - Co-cyprindiol (Dianette) COCP 5. Manage acne - COCP - topical adapalene (retinoid)

Question 188

What is the perinatal mental health period?

Answer 188

- preconception - during pregnancy - mental health for the first 12 months after birth

Question 189

What are the different stage of poor mental health in postpartum?

Answer 189

Baby blues = majority of women in 1st week (10 days) Postnatal depression = 1in10, peak around 3 months after birth Puerperal psychosis = 1in1000, few weeks after birth

Question 190

What is the puerperium?

Answer 190

it is defined as the 6 week period immediately after the birth - mother's body physiological returns to pre-pregnancy state

Question 191

What family history do you ask for in a postnatal mental health risk assessment?

Answer 191

- schizophrenia - bipolar

Question 192

What are the red flags signs for perinatal mental health?

Answer 192

Suicidal ideation Feelings of incompetence as a parent Estrangement from child Hallucinations

Question 193

Presentation: Baby blues

Answer 193

Mood swings Low mood Anxiety Irritability Tearfulness Baby blues may be the result of a combination of: Significant hormonal changes Recovery from birth Fatigue and sleep deprivation The responsibility of caring for the neonate Establishing feeding All the other changes and events around this time

Question 194

Presentation: Postnatal depression

Answer 194

Triad: 1. low mood 2. anhedonia (lack of pleasure in activities) 3. low energy

Question 195

What screening tool is used for postnatal depression?

Answer 195

Edinburgh scale Patient health Questionnaire-9

Question 196

Management: postnatal depression

Answer 196

Mild cases = additional support, self-help, GP Moderate = antidepressants SSRI + CBT Severe = specialist psychiatry services, mother + baby unit

Question 197

What are the features of pathological anxiety in perinatal period?

Answer 197

chronic excessive worry (not situational) Hyperarousal

Question 198

Investigations: Perinatal anxiety

Answer 198

Screening: Generalised Anxiety Disorder-2 Diagnosis: GAD-7

Question 199

What are common anxiety disorders during perinatal period?

Answer 199

Generalised anxiety PTSD - flashbacks Obsessive compulsive disorder - Intrusive thoughts, ideas or images which a woman finds distressing Tocophobia - Morbid dread and fear of childbirth, Primary/secondary

Question 200

Management: Anxiety

Answer 200

MDT Behavioural Medication - Anti-depressants Benzodiazepines - Associated with cleft palate, neonatal withdrawal syndrome & floppy baby syndrome - Short term management of symptoms - Lowest dose possible for shortest time possible - Avoid in third trimester

Question 201

Presentation: Puerperal psychosis

Answer 201

Insomnia, tearful and agitated at first Delusions Hallucinations Depression Mania Confusion Thought disorder most present within in first 3 months

Question 202

Management: Puerperal psychosis

Answer 202

emergency 1. Admission to the mother and baby unit (need bonding to continue, baby is protective factor) 2. Cognitive behavioural therapy 3. Medications (antidepressants, antipsychotics (not teratogenic) or mood stabilisers) 4. Electroconvulsive therapy (ECT)

Question 203

What are the associated risks of antipsychotics in pregnancy?

Answer 203

Used: olanzapine = increased risk of weight gain, gestational diabetes NOT USED Lithium = cardiac abnormalities Sodium valproate = neural tube defects

Question 204

Define: ectopic pregnancy

Answer 204

A pregnancy that is implanted outside the uterus - MC in the Fallopian tube - Also in ovary, cervix, abdomen

Question 205

What are the risk factors for an ectopic pregnancy?

Answer 205

Previous ectopic pregnancy Previous pelvic inflammatory disease Previous surgery to the fallopian tubes Intrauterine devices (coils) Older age Smoking

Question 206

Presentation: Ectopic Pregnancy

Answer 206

6- 8 weeks pregnant - Missed period - Constant lower abdominal pain in the right or left iliac fossa - Vaginal bleeding - Lower abdominal or pelvic tenderness - Cervical motion tenderness (pain when moving the cervix during a bimanual examination) - dizziness or syncope - shoulder tip pain (peritonitis - phrenic nerve)

Question 207

What are the USS findings in an ectopic pregnancy?

Answer 207

Transvaginal USS - gestational sac containing a yolk sac or fetal pole may be seen in a Fallopian tube - empty gestational sac - tubal ectopic = moves separately to the ovary - empty uterus - fluid in the uterus = pseudogestational sac with BHCG >1500

Question 208

What is a pregnancy of unknown location and how to investigate?

Answer 208

Positive pregnancy test but no evidence of pregnancy on USS Track HCG: 1. rise >63% = intrauterine pregnancy 2. rise of <63% after 48 hrs/ stays the same = ectopic pregnancy 3. a fall >50% = miscarriage

Question 209

What is the MC location of an ectopic pregnancy?

Answer 209

1. Tubal ectopic in ampulla - diagnosed by USS = adnexal mass that moves separately to the ovary - 20% of cases a pseudo sac seen within the uterine cavity - free fluid may be seen but no diagnostic - serum b-hCG should be performed

Question 210

Management: Ectopic pregnancy

Answer 210

Perform pregnancy test in all women with abdominal or pelvic pain caused by ectopic pregnancy --> referred to early pregnancy assessment unit ectopic pregnancy must be terminated, it is not viable. Terminating options: 1. expectant management (awaiting natural termination = needs no heart beat, HCG<1500, no significant pain) 2. Medical management (methotrexate) 3. Surgical management (salpingectomy (remove affected Fallopian tube) or salpingotomy (cut made in tube and ectopic pregnancy removed))

Question 211

When is conservative management allowed in ectopic pregnancy?

Answer 211

1. patient must be clinically stable and pain free 2. have a tubal ectopic pregnancy <35mm with no visible heartbeat 3. serum hCG <1000 4. patient is able to return for follow up repeat hCG on day 2,4 and

Question 212

When is medical management allowed for ectopic pregnancy termination?

Answer 212

Systemic methotrexate 1. have no significant pain and be clinically well 2. enraptured tubal ectopic with an adnexal mass <35mm with no visible FH 3. Serum hCG <1500 4. Do not have an intrauterine pregnancy 5. Can return for follow up

Question 213

How is methotrexate used in pregnancy termination?

Answer 213

Methotrexate is highly teratogenic - IM injection into a buttock - halts progress of pregnancy - advise not to get pregnant for 3 months after bhCG monitored on day 4 + 7 and then weekly until hCG is negative

Question 214

What are the contraindications of methotrexate?

Answer 214

- thrombocytopenia - hepatic or renal dysfunction - immunocompromised - breastfeeding - peptic ulcer disease

Question 215

When is surgical management advised for ectopic pregnancy?

Answer 215

First line in women who: - have significant pain - adnexal mass >35mm - live ectopic - HCG >5000 - signs of rupture - haemodynamic instability

Question 216

What are the options for surgical management in ectopic pregnancy?

Answer 216

- laparoscopically preferred 1. first line = salpingectomy (remove affected Fallopian tube) 2. Salpingotomy - make incision in tube and remove ectopic pregnancy

Question 217

Define: miscarriage types

Answer 217

Early miscarriage = 12 weeks gestation late miscarriage = 12-24 weeks gestation

Question 218

What is a missed, threatened, inevitable, and anembryonic miscarriage?

Answer 218

Missed miscarriage – the fetus is no longer alive, but no symptoms have occurred Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive Inevitable miscarriage – vaginal bleeding with an open cervix Anembryonic pregnancy – a gestational sac is present but contains no embryo

Question 219

What is a complete miscarriage?

Answer 219

Complete miscarriage – a full miscarriage has occurred, - and there are no products of conception left in the uterus - USS will show empty uterus - present following an episode of PV bleeding require bHCG follow up (still might be positive initially so need to come back)

Question 220

What is an incomplete miscarriage?

Answer 220

Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage - USS = see mixed echoes within the uterine cavity - in previous IUP seen, require bHCG monitoring to ensure failing IUP <35 mm = expectant, medical or surgical management under LA >35 mm = surgical or medical management in hospital

Question 221

What is a delayed miscarriage?

Answer 221

No symptoms - diagnosed on transvaginal scan or booking scan at 12 weeks (strict criteria so don't miss just early pregnancy) 1. requires visualisation of a gestation sac, yolk sac and foetal pole with a CRL >7mm with no foetal heart activity 2. confirmed by 2nd sonographer 3. if any doubt organised an USS in 1 week

Question 222

What is the management for delayed miscarriage?

Answer 222

CRL <22mm = expectant, medical or surgical CRL <54mm = medical or surgical CRL >54mm = medical treatment consider signs/ symptoms of infection

Question 223

What are the USS findings in a miscarriage?

Answer 223

Transvaginal USS 1. mean gestational sac diameter <25mm 2. fetal pole and crown rump length <7mm 3. no fetal heartbeat

Question 224

Management: miscarriage

Answer 224

less <6 weeks - expectant management = wait for miscarriage - repeat urine pregnancy test after 7-10 days more than 6 weeks 1. early pregnancy assessment service 2. USS = confirm location + viability - no fetal heartbeat (visible if CRL >7mm) - fetal pol should be visible of mean gestational sac diameter >25mm 3. expectant management = 1-2 weeks to allow for miscarriage 4. medical management - misoprostol = prostaglandin analogue (softens the cervix + stimulate contraction) 5. Surgical management = manual/electric vacuum aspiration - prostaglandins - anti-rhesus D prophylaxis

Question 225

What are the legal requirements for termination of pregnancy?

Answer 225

Abortion is legal till 24 weeks - if continuing the pregnancy involves greater risk to the physical or mental of the women or existing children - 2 registered practitioners must sign - must be carried out by a registered medical practitioner in an NHS hospital or approved premise

Question 226

What is involved in a medical abortion?

Answer 226

1. Mifepristone = anti-progesterone (halts pregnancy + relax cervix) 2. Misoprostol = prostaglandin analogue 1-2 days later (softens cervix, stimulates contractions)

Question 227

What are the options for a surgical abortion?

Answer 227

Before surgery = cervical priming - soften + dilate cervix - misoprostol, mifepristone or osmotic dilators 1. cervical dilatation + suction of the contents of the uterus (up to 14 weeks) 2. cervical dilatation + evacuation using forceps (14-24 weeks)

Question 228

What is involved in post-abortion care?

Answer 228

- symptoms = vaginal bleeding, abdo cramp up to 2 weeks - urine pregnancy test = 3 weeks - contraception discussed - support + counselling offered

Question 229

What are the types of multiple pregnancies?

Answer 229

Monozygotic: identical twins (from a single zygote) Dizygotic: non-identical (from two differe=nt zygotes) Monoamniotic: single amniotic sac Diamniotic: two separate amniotic sacs Monochorionic: share a single placenta Dichorionic: two separate placentas

Question 230

How is a multiple pregnancy diagnosed and the type?

Answer 230

USS 1. Dichorionic diamniotic twins = membrane between the twins, with a lambda sign or twin peak sign 2. Monochorionic diamniotic twins = membrane between the twins, with a T sign 3. Monochorionic monoamniotic twins = no membrane separating the twins lambda sign or twin peak sign = triangular appearance where the membrane between the twins meets the chorion T sign = where membrane between twins meets the chorion, single placenta

Question 231

Define: twin-twin transfusion syndrome

Answer 231

- foetuses share a placenta - one fetus (recipient) receives the majority of the blood from the placenta + other (donor) is starved - recipient = fluid overload, heart failure, polyhydramnios - donor = growth restriction, anaemia, oligohydramnios (laser treatment can destroy connection)

Question 232

Define: twin anaemia polycythaemia sequence

Answer 232

one twin becomes anemic whilst the other develops polycythaemia (raised Hb)

Question 233

What antenatal care is given to women with a multiple pregnancy?

Answer 233

Anaemia, FBC checked - booking clinic - 20 weeks - 28 weeks Additional scans for fatal growth, unequal growth - 2 weekly sans from 16 weeks for monochorionic twins - 4 weekly scan from 20 weeks for dichorionic twins

Question 234

What different delivery options are there for multiple pregnancies?

Answer 234

Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks. Diamniotic twins (aim to deliver between 37 and 37 + 6 weeks): - Vaginal delivery = first baby has a cephalic presentation (head first) - Caesarean section = may be required for the second baby after successful birth of the first baby - Elective caesarean = is advised when the presenting twin is not cephalic presentation

Question 235

What are the types of diabetes in pregnancy?

Answer 235

Pre-existing - type 1 - type 2 - cystic fibres related - MODY - rare Gestational diabetes - true - pre-existing diabetes presenting for the first time

Question 237

Define: gestational diabetes

Answer 237

Diabetes triggered by pregnancy - reduced insulin sensitivity during pregnancy that resolves after birth

Question 238

What are the risk factors for gestational diabetes?

Answer 238

1. Previous gestational diabetes 2. Previous macrosomic baby (≥ 4.5kg) 3. BMI > 30 4. Ethnic origin (black 5. Caribbean, Middle Eastern and South Asian) 5. Family history of diabetes (first-degree relative

Question 239

What is the investigation for gestational diabetes?

Answer 239

Oral glucose tolerance test 1. blood sugar measured (fasting) 2. then drink 75g glucose drink 3. blood sugar measure 2 hours later fasting = <5.6 mol/l at 2 hours = <7.8 mol/l 5- 6- 7- 8

Question 240

What signs would result in investigations for gestational diabetes?

Answer 240

1. Large for dates foetus (macrosomia - big babies) >9. 5 lbs at birth 2. Polyhydramnios = increased amniotic fluid 3. Glucose on urine dipstick

Question 241

Management: Gestational diabetes

Answer 241

1. fasting glucose <5.3mmol/l 1 hour post meal <7.8 - trial of diet and exercise for 1-2 weeks - metformin OR fasting glucose >7mmol/l - immediately start insulin +/- metformin OR fasting glucose above 6mmol/l + macrosomia - start insulin +/- metformin 2. Insulin (if targets still not met) 3. Glibenclamide (Sulfonylureas) - option for women who decline insulin or cannot tolerate metformin

Question 242

What is the importance of identifying GDM?

Answer 242

- fetal macrosomia - increased risk of developing type 2 diabetes - some will have diabetes pre-dating the pregnancy - neonatal hypoglycaemia - perinatal mortality - should dystocia - birth related trauma

Question 243

What is the protocol for pregnancy with pre-existing diabetes?

Answer 243

Before pregnant: - 5mg folic acid until 12 weeks gestation Pregnancy: - early dating and viability scan 7-9 weeks - Aim for same targets - use only insulin and metformin - retinopathy screening at 28 weeks - aspirin once daily from 12 weeks until delivery (reduce risk of pre-eclampsia) - USS fetal growth scans at 28, 32, 36 weeks Labour: - advise planned delivery between 37-38 +6 weeks - a sliding scale insulin regime = dextrose and insulin infusion titrate to blood sugar levels

Question 244

What is postnatal protocol for diabetes?

Answer 244

Gestational - should resolve immediately after birth - fasting glucose tested at 6 weeks - advice on healthy lifestyle, contraception - HbA1c at 13 weeks: 39-47 = high risk. >48 = type 2 diabetes - annual HbA1c Pre-existing - lower their insulin doses - insulin sensitivity will increase after birth and with breastfeeding

Question 245

What are babies of mothers with pre-existing diabetes at risk of?

Answer 245

- neonatal hypoglycaemia - polycythaemia (raised Hb) - jaundice - congenital heart disease - cardiomyopathy - fetal macrosomia - respiratory distress syndrome

Question 246

What are the effects of pregnancy on diabetes?

Answer 246

- increased insulin dose requirement - diabetic nephropathy may worsen - risk of progression/development of retinopathy due to rapid improvement in glycemic control - hypoglycaemia with relative hypo unawareness - diabetic ketoacidosis

Question 247

What is advised for the care of neonate from a diabetic mother?

Answer 247

Women with diabetes should feed their babies as soon as possible after birth (within 30 minutes) – reduce hypoglycaemia Blood glucose testing routinely at 2 to 4 hours after birth in babies of women with diabetes Minimum 24-hour hospital stay

Question 248

What hypertension medication should be stooped in pregnancy?

Answer 248

Cause congenital abnormalities - ACE inhibitors e.g. ramipril - Angiotensin receptor blockers e.g. losartan - Thiazide and thiazide like diuretics e.g. indapamide

Question 249

Define: gestational hypertension

Answer 249

Hypertension occurring after 20 weeks gestation, without proteinuria

Question 250

Define: Pre-eclampsia

Answer 250

Pregnancy induced hypertension associated with organ damage, and PROTEINURIA - after 20 weeks --> when spiral arteritis of placenta form abnormally - leading to high vascular resistance 1. hypertension >90/140 2. significant proteinuria >300mg in 24 hrs 3. >20 weeks gestation (can occur in postpartum)

Question 251

What is the pathophysiology of pre-eclampsia?

Answer 251

1. when the blastocyst implants on the endometrium - outer most layer called syncytiotrophoblast grows into endometrium 2. chorionic villi form containing metal blood vessels 3. trophoblast invasion of endometrium send signals to spiral arteries to reduce vascular resistance 4. blood flow increases to these arteries and eventually they break down, leaving pools of blood called lacunae (20 weeks) 5. maternal blood flows from uterine arteries into lacunae then back into uterine veins 6. If lacunae formed inadequately --> high vascular resistance in spiral arteries + poor perfusion of placenta 7. causes oxidative stress in placenta. releases inflammatory chemicals into systemic circulation -> systemic inflammation + impaired endothelial function

Question 252

What are the risk factors for pre-eclampsia?

Answer 252

High-risk factors are: Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease Moderate-risk factors are: Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia

Question 253

What prophylaxis is given to high risk women for pre-eclampsia?

Answer 253

aspirin from 12 weeks - if have one high risk factor or more than one moderate risk factor

Question 254

What are the symptoms of severe pre-eclampsia?

Answer 254

Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (this is due to liver swelling) Oedema Reduced urine output Brisk reflexes + clonus Papilloedema Abnormal liver enzymes

Question 255

How to diagnose pre-eclampsia?

Answer 255

Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: - Proteinuria (1+ or more on urine dipstick) - Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) - Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies) Proteinuria can be quantified using: Urine protein:creatinine ratio (above 30mg/mmol is significant) Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Question 256

Management: pre-eclampsia

Answer 256

- aspirin prophylaxis from 12 weeks - monitor BP - regular urine dipstick for proteinuria Medical management of pre-eclampsia is with: 1. Labetolol = first-line as an antihypertensive 2. Nifedipine = (modified-release) is commonly used second-line (and if asthma contraindicates labetalol) 3. Methyldopa = third-line (needs to be stopped within two days of birth) - Intravenous hydralazine = may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia - IV magnesium sulphate = is given during labour and in the 24 hours afterwards to prevent seizures - Fluid restriction = is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload (cerebral oedema)

Question 257

What is the management of pre-eclampsia post birth?

Answer 257

BP monitored closely 1. Enalapril (1st line) 2. Nifedipine or amlodipine 3. Labetolol or atenolol

Question 258

Define: Eclampsia

Answer 258

Occurrence of one or more seizure in a woman with pre-eclampsia - seizure in a pregnant woman are always eclampsia until proven otherwise - increased risk in 24hrs after delivery

Question 259

Management: eclampsia

Answer 259

1. IV magnesium sulphate - over 5 mins - followed by an infusion of 1g/hour maintained for 24 hrs 2. stabilise mum first and then deliver baby (if give pregnant lady anaesthetic = cause cerebral haemorrhage)

Question 260

What can IV magnesium sulphate for eclampsia cause and treatment?

Answer 260

Respiratory depression - calcium gluconate

Question 261

What is the HELLP syndrome?

Answer 261

Combination of features that occur as complications of pre-eclampsia + eclampsia 1. Haemolysis 2. Elevated Liver enzymes 3. Low Platelets

Question 262

What causes anaemia during pregnancy?

Answer 262

1. Plasma volume increase 2. reduction in the haemoglobin concentration 3. blood is diluted due to the higher plasma volume

Question 263

Presentation: Anaemia in pregnancy

Answer 263

Often anaemia in pregnancy is asymptomatic. Women may have: Shortness of breath Fatigue Dizziness Pallor

Question 264

Investigations: anaemia in pregnancy

Answer 264

Booking bloods >110 g/l 28 weeks gestation >105 g/l Postpartum >100 g/l low MCV = iron deficiency normal MCV = physiological anaemia due to increased plasma volume high MCV = B12 or folate deficiency Women are screened at the booking clinic for thalassaemia and sickle cell disease

Question 265

Management: anaemia in pregnancy

Answer 265

1. Iron replacement e.g. ferrous sulphate 2. B12 deficiency: - IM hydroxocobalamin injections - Oral cyanocobalamin tablets 3. Folate deficiency - all women = 400mcg folic acid per day - deficiency = 5mg folic acid daily

Question 266

Why is VTE a risk in pregnancy?

Answer 266

thrombosis occurs as a result of stagnation of blood and hyper-coagulable states, such as pregnancy PE is a significant cause of death in obstetrics - highest in postpartum

Question 267

What are the risk factors for VTE in pregnancy?

Answer 267

Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy

Question 268

What is the protocol for VTE prophylaxis in pregnancy?

Answer 268

1st trimester = 4 or more risk factors at 28 weeks = if 3 risk factors

Question 269

Presentation: VTE in pregnancy

Answer 269

Unilateral Calf or leg swelling Dilated superficial veins Tenderness to the calf (particularly over the deep veins) Oedema Colour changes to the leg

Question 270

Investigations: VTE in pregnancy

Answer 270

1. Doppler USS (well's score not validated for pregnant women and pregnancy raises D-dimer naturally anyway) PE 1. CXR 2. ECG 3. CT pulmonary angiogram CTPA

Question 271

Management: VTE in pregnancy

Answer 271

Prophylaxis - Low molecular weight heparin e.g. Enoxaparin, Dalteparin, tinzaparin Temporarily stopped in labour and then carried on 6 weeks postnatally (risk is higher in first 3 weeks postpartum) PE 1. in fractionated heparin 2. thrombolysis 3. surgical embolectomy

Question 272

What are the complications of chickenpox in pregnancy?

Answer 272

- More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis - Fetal varicella syndrome - Severe neonatal varicella infection (if infected around delivery)

Question 273

How to check exposure to chickenpox in pregnancy?

Answer 273

- previously had chickenpox = they are safe - Not sure about their immunity = test the VZV IgG levels. If positive, they are safe. - Not immune = they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.

Question 274

Management: chickenpox in pregnancy

Answer 274

1. oral aciclovir - if present within 24hrs and >20 weeks gestation

Question 275

Define: congenital varicella sundrome

Answer 275

occurs when infection occurs in first 28 weeks of gestation Features: - Fetal growth restriction - Microcephaly, hydrocephalus and learning disability - Scars and significant skin changes located in specific dermatomes - Limb hypoplasia (underdeveloped limbs) - Cataracts and inflammation in the eye (chorioretinitis)

Question 276

What is the risk of UTI in pregnancy?

Answer 276

Pregnant women are at higher risk of developing UTIs Tested routinely for asymptomatic bacteriuria (bacteria present in urine)

Question 277

Presentation: UTI + pyelonephritis in pregnancy

Answer 277

Lower urinary tract infections present with: Dysuria (pain, stinging or burning when passing urine) Suprapubic pain or discomfort Increased frequency of urination Urgency Incontinence Haematuria Pyelonephritis presents with: Fever (more prominent than in lower urinary tract infections) Loin, suprapubic or back pain (this may be bilateral or unilateral) Looking and feeling generally unwell Vomiting Loss of appetite Haematuria Renal angle tenderness on examination

Question 278

Management: UTI in pregnancy

Answer 278

7 day course 1. nitrofurantoin (avoid in 3rd trimester) 2. Amoxicillin 3. Cefalexin

Question 279

Define: Oligohydramnios

Answer 279

Abnormally low volume of amniotic fluid surrounding the foetus during pregnancy

Question 280

What are the causes of Oligohydramnios?

Answer 280

Increase fluid loss or decreased fluid production - rupture of membranes - Fetal growth restriction - Maternal medical comorbidities (e.g. hypertension) - Placental abnormalities (e.g. abruption) - Fetal urinary tract anomalies (e.g. renal agenesis, posterior urethral valves) - Maternal drug use (e.g. NSAIDs, ACE inhibitors) - Post-term pregnancy

Question 281

Investigation: Oligohydaminos

Answer 281

USS - no symptoms at all - clear or light pink fluid leaking from vagina --> rupture of membranes Examination - fetal parts easier to feel - uterus may appear small for dates - sterile speculum examination Fluid analysis - ferrying test = cervical secretions, when dry should form a fern like pattern of crystals - Amnisure = vaginal swab to screen for presence of placental alpha micro globulin-1 (high conc normally in amniotic fluid) - Actim-PROM = swab that screens for insulin like growth factor binding protein-1 (high conc normally found in amniotic fluid)

Question 282

What is the diagnosis measurement of oligiohydramnios?

Answer 282

Amniotic fluid index <5cm Maximum vertical pocket < 2cm

Question 283

Management: oligohydramnios

Answer 283

1. Monitoring - serial fetal testing 2. Intervention - therapeutic amino-fusion, saline or Ringer's lactate is infused into the amniotic cavity 3. time of delivery - induced labour 36-38 weeks

Question 284

What are some complications of oligohydramnios?

Answer 284

- Pulmonary hypoplasia - limb deformities = due to fetal compression - porters labour - umbilical cord compression - meconium aspiration - caesarean delivery - non-reassuring fetal CTG traces

Question 285

Define: polyhydramnios

Answer 285

Abnormally large level of amniotic fluid during pregnancy - above 95th centime for gestational age

Question 286

How should amniotic fluid vary during pregnancy?

Answer 286

- Steadily increased until 33 weeks gestation - plateaus from 33-38 weeks and then declines - volume at term = 500ml - mainly comprised of fetal urine output - small bits of placenta and fetal secretions - foetus breathes and swallows amniotic fluid and then voided by the bladder

Question 287

What are the causes of polyhydramnios?

Answer 287

- condition that prevents the foetus from swallowing - duodenal atresia 'double bubble' - anaemia - fetal hydrops - twin to twin transfusion syndrome - increased lung secretions - maternal diabetes - maternal ingestion of lithium --> fetal diabetes insipidus - macrosomia - larger baby, more urine - infection

Question 288

Investigation: polyhydramnios

Answer 288

1. palpate uterus - feel tense 2. USS - assess fetal size, measure fluid volume 3. maternal glucose tolerance test = maternal diabetes 4. karyotyping - structural abnormalities 5. TORCH infections = Toxicoplasmosis, Rubella, Cytomegalovirus, HSV

Question 289

Management: Polyhydramnios

Answer 289

- no medical intervention usually required - Amnioreduction = if symptoms, associated with infection + placental abruption - Indomethacin = NSAID, enhance water retention, thus reduces fetal urine output - nasogastric tube = passed through baby to check for tracheoesophageal or oesophageal fistula

Question 290

What is the prognosis for polyhydramnios?

Answer 290

Usually good complication - postpartum haemorrhage = uterus has to contract further to achieve haemostasis - cord prolapse - malpresentation e.g. transverse lie, breech presentation

Question 291

Define: breech presentation + types

Answer 291

legs and bottom of foetus present first Complete = legs are fully flexed at hips and knees Incomplete = one leg flexed at the hip and extended at the knee Extended = 'frank breech', both legs flexed at the hip and extended at the knee Footling = foot is presenting through the cervix with leg extended

Question 292

Management: breech birth

Answer 292

- turn spontaneously = babies before 36 weeks - external cephalic version = used at 37 weeks - can decide between vaginal birth or elective Caesarean section

Question 293

What is external cephalic version?

Answer 293

Technique used to turn a foetus from the breech position to a cephalic position using pressure on pregnant abdomen 1. tocolysis = relax uterus 2. subcutaneous terbutaline = beta agonist, reduces contractility of the myometrium Rhesus-D negative women require anti-D prophylaxis when ECV performed

Question 294

define: stillbirth

Answer 294

birth of a dead foetus after 24 weeks gestation - intrauterine fetal death

Question 295

What are the causes of stillbirth?

Answer 295

Unexplained (around 50%) Pre-eclampsia Placental abruption Vasa praevia Cord prolapse or wrapped around the fetal neck Obstetric cholestasis Diabetes Thyroid disease Infections, such as rubella, parvovirus and listeria Genetic abnormalities or congenital malformations

Question 296

What increases the risk of stillbirth?

Answer 296

Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back (as opposed to either side)

Question 297

What prevention is taken to reduce likelihood of stillbirth?

Answer 297

- risk assessment for baby small for gestational age or fetal growth restriction - serial growth scans to monitor fetal growth

Question 298

Management: stillbirth

Answer 298

1. USS - confirm fetal heartbeat 2. Rhesus D neg women require anti-D prophylaxis 3. Vaginal birth (first line) - induction of labour - or expectant management awaiting natural labour 4. Dopamine agonists = suppress lactation after stillbirth 5. testing post birth with parental consent

Question 299

Define: cephalopelvic disproportion

Answer 299

Baby's head doesn't fit through the opening of your pelvis - large babies - out of position at birth canal - shape of pelvis

Question 300

Management: cephalopelvic disproportion

Answer 300

1. vacuum extraction or forceps 2. Caesarean section

Question 301

What are complications of cephalopelvic disproportion?

Answer 301

- baby's shoulders might get stuck - require emergency c-section - vaginal tears - postpartum haemorrhage

Question 302

Define: uterine rupture

Answer 302

complication of labour = Muscle layer of the uterus ruptures - incomplete rupture or uterine dehiscence = uterine serosa surrounding the uterus remains intact - complete rupture = serosa ruptures along with the myometrium, contents of uterus released into peritoneal cavity

Question 303

What are the risk factors for uterine rupture?

Answer 303

Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Question 304

Presentation: uterine rupture

Answer 304

Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Question 305

Management: uterine rupture

Answer 305

- obstetric emergency - resuscitation + transfusion may be required - emergency Caesarean section required to remove the baby, stop any bleeding and repair or remove uterus

Question 306

What the different types of ruptures of membranes?

Answer 306

- Rupture of membranes = amniotic sac ruptured Spontaneous rupture of membranes (SROM): The amniotic sac has ruptured spontaneously. Prelabour rupture of membranes (PROM): The amniotic sac has ruptured before the onset of labour. Preterm prelabour rupture of membranes (P‑PROM): The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm). Prolonged rupture of membranes (also PROM): The amniotic sac ruptures more than 18 hours before delivery.

Question 307

What are the levels of prematurity?

Answer 307

prematurity = before 37 weeks <28 weeks = extreme preterm 28-32 weeks = very preterm 32-37 weeks = moderate to late preterm

Question 308

What are the 4 phases of cervical remodelling?

Answer 308

Softening = from early pregnancy Ripening = weakness Dilation = opening Repair = after delivery

Question 309

What are the causes of preterm labour?

Answer 309

1. Infection MC = from vagina, transplacental infection, peritoneal cavity, invasive procedures 2. Placenta ischaemia = reduced blood flow to placenta 3. uterine over distension = due to uterine abnormalities, polyhydramnios, multiple pregnancy 4. Cervical weakness - primary cervical disease = congenital disorder. surgical trauma, interrupted structural integrity - secondary cervical insufficiency = 50% associated with infection

Question 310

What screening is done for preterm labour?

Answer 310

High risk - previous preterm birth (biggest RF) - previous cevical cerclage - multiple pregnancy - previous cervical treatment - intrauterine adhesions - uterine anomalies - previous Caesarean section at full dilatation High risk women then have cervical length measured - using transvaginal USS - cervical length <25mm between 16-24 weeks is associated with an increased risk of preterm birth

Question 311

What prophylaxis can be given for preterm labour?

Answer 311

1. Vaginal progesterone gel or pessary = maintains pregnancy + prevent labour by decreasing activity of myometrium - for those with previous preterm labour or short cervix 2. cervical cerclage = putting stitch in cervix to add support and keep it closed, removed when in labour - inserted around 11-14 weeks with history of 3 or more previous preterm birth - short cervix - or dilated preterm cervix

Question 312

Presentation: preterm labour

Answer 312

Abdominal pain Vaginal/pelvic pressure Increased vaginal discharge, bleeding, watery loss Gastrointestinal disturbance Urinary symptoms Signs - uterine contractions - vulval changes = oedema, labial parting - cervical changes - liquor draining - CTG changes - maternal composition

Question 313

Assessment of someone in preterm labour

Answer 313

Uterine activity and cervical dilatation prior to 37 weeks If uncertainty e.g. uterine activity without cervical dilatation: < 30 weeks: Treat as threatened preterm labour >30 weeks: Fetal fibronectin Cervical length (<15mm higher chance) QUIPP app

Question 314

Management: preterm rupture of membranes

Answer 314

1. prophylactic antibiotics = prevent development of chorioamnionitis 2. induction of labour = from 34 weeks

Question 315

Investigation: preterm labour with intact membranes

Answer 315

Regular painful contraction + cervical dilatation, without rupture of amniotic sac - speculum exam - fatal fibronectin = glue between chorion and uterus, found in vagina during labour

Question 316

Management: preterm labour with intact membranes

Answer 316

1. Fetal monitoring (CTG or intermittent auscultation) 2. Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour (given at slow release so mothers BP doesn't drop drastically) 3. Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality - 2 IM injections 24 hrs apart - beneficial if baby is born 24-48hrs after 2nd dose given 4. IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain - prevents cerebral palsy 5. Antibiotics - in labour to reduce risk of sepsis and cerebral palsy. - ideally given 4hrs before baby is born

Question 317

Non- pharmacological Management: of preterm babies

Answer 317

1. Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth 2. thermoregulation - keep baby especially preterm babies warm 3. Maternal early breast milk - use for mouth care - introduce baby to mothers microbiome - ask mother to start expressing some milk if know baby is going to be preterm

Question 318

Define: cord prolapse

Answer 318

When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes

Question 319

How to diagnose cord prolapse?

Answer 319

suspected where there are signs of fatal distress on the CTG - diagnosed by vaginal examination or speculum exam

Question 320

Management: cord prolapse

Answer 320

1. emergency caesarean section - reduce risk of cord compression + hypoxia to baby - cord should have minimal handling (cause vasospasm) 2. woman lies in left lateral position (pillow under hip) or knee chest position (on all fours) - to reduce compression on cord 3. Tocolytic medication = used to minimise contractions whilst waiting for delivery by caesarean section

Question 321

Define: instrumental delivery

Answer 321

refers to a vaginal delivery assisted by either a ventouse suction cup or forceps

Question 322

What are the indications for a instrumental delivery?

Answer 322

Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions (increased risk after epidural)

Question 323

What are the risks of a instrumental delivery?

Answer 323

Having an instrumental delivery increases the risk to the mother of: Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve) The key risks to remember to the baby are: Cephalohaematoma with ventouse Facial nerve palsy with forceps

Question 324

What is a molar pregnancy?

Answer 324

- type of gestational trophoblastic disease (can develop in to gestational cancer) 2 types: 1. complete mole = single sperm fertilising an egg which has lost its DNA (2-4% of developing into cancer) 2. Partial = father supplies 2 sets of chromosome, but mothers chromosomes are also present (e.g. 2 sperm fertilising an egg so 3 sets of chromosomes)

Question 325

Investigation: molar pregnancy

Answer 325

- diagnosed on USS = visualisation of an irregular echo bright area containing multiple cysts (bunch of grapes or snowstorm appearance)

Question 326

Management: molar pregnancy

Answer 326

- only surgical = evacuation of contents of the uterus - increased risk of bleeding - send POC for urgent histology - may need chemo if metastasise

Question 327

What is antepartum haemorrhage?

Answer 327

- bleeding from anywhere within the genital tract after the 24th week of pregnancy - occurs in 3-5 % pregnancies

Question 328

What are the causes of antepartum haemorrhage?

Answer 328

Identifiable causes: Low Lying placenta / placenta praevia. = implanted into lower segment Vasa praevia Minor/Major abruption Infection

Question 329

Management: low lying placenta

Answer 329

major - covering/reaching OS minor - in lower segment/encroaching diagnosed at 20 week anomaly USS Management: - Advise to present if pain / bleeding - Advise to avoid sexual intercourse - If recurrent bleeds may require admission until delivery and ensuring has cross-match in date - Remember to give anti-D if Rh negative - Elective LSCS around 37/40

Question 330

Management: bleeding placenta praevia

Answer 330

- placenta covering os - ABCDE - if major bleed: two 14/16 G cannulas, IV fluids, X match 6 units, inform senior team and pads ASAP - examination abdominal, vaginal, USS - fetal monitoring - steroids if <34 weeks gestation

Question 331

What is vasa praevia?

Answer 331

Fetal vessels coursing through the membranes over the internal cervical os and below the fetal presenting part, unprotected by placental tissue or the umbilical cord - no major maternal risk, but major fetal risk - membrane rupture leads to major fetal haemorrhage - CTG abnormalities

Question 332

Define: morbidly adherent placenta or placenta accreta spectrum

Answer 332

placenta penetrates through the decides basalts and through the myometrium

Question 333

What are the types of placenta acreta?

Answer 333

1. Superficial placenta accreta = is where the placenta implants in the surface of the myometrium, but not beyond 2. Placenta increta = is where the placenta attaches deeply into the myometrium 3. Placenta percreta = is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Question 334

What are the risk factors for placenta accreta spectrum?

Answer 334

Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Question 335

Presentation: placenta accreta spectrum

Answer 335

- no symptoms - diagnosed on antenatal USS - or at birth when difficult to deliver placenta = postpartum haemorrhage

Question 336

Management: placenta accreta spectrum

Answer 336

1. 20 w scan watch for anterior LLP is previous CS = loss of definition between wall of uterus and abnormal vasculature 2. arrange elective CS at 36-37 weeks 3. - may need hysterectomy, cell salvage - blood transfusion - intensive care for mother and baby - uterine preserving surgery - expectant management = leaving placenta in place to be reabsorbed over time

Question 337

Define: placental abruption

Answer 337

- premature separation of the placenta from the uterine wall - concealed or revealed haemorrhage

Question 338

Presentation: placental abruption

Answer 338

- woody hard abdomen - Sudden onset severe abdominal pain that is continuous - Vaginal bleeding (antepartum haemorrhage) - Shock (hypotension and tachycardia) - Abnormalities on the CTG indicating fetal distress

Question 339

What are the risk factors for placental abruption?

Answer 339

- Advanced maternal age - previous placental abruption - smoker - cocaine use - multiple pregnancy - multigravida - trauma - pre-eclampsia - fetal growth restriction

Question 340

What is the severity of antepartum haemorrhage?

Answer 340

The RCOG guideline (2011) defines the severity of antepartum haemorrhage as: Spotting: spots of blood noticed on underwear Minor haemorrhage: less than 50ml blood loss Major haemorrhage: 50 – 1000ml blood loss Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

Question 341

What are the 2 types of placental abruption?

Answer 341

1. concealed = cervical os remained closed, bleeding occurs within uterine cavity 2. revealed = blood loss is observed via the vagina

Question 342

Management: placental abruption

Answer 342

1. Urgent involvement of a senior obstetrician, midwife and anaesthetist 2 x grey cannula Bloods include FBC, UE, LFT and coagulation studies Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring of the fetus Close monitoring of the mother 2. emergency s-section - risk of postpartum haemorrhage

Question 343

What is the likelihood of sepsis on pregnancy?

Answer 343

- sepsis is the leading cause of maternal death in the UK - advise all women to be immunised for seasonal flu and COVID

Question 344

What are the risk factors for sepsis in pregnancy?

Answer 344

Obesity Diabetes Impaired immunity / immunosuppressant medication Anaemia Vaginal discharge History of pelvic infection History of group B Strep infection Amniocentesis and other invasive procedures Cervical cerclage Prolonged spontaneous rupture of membranes Group A Strep infection in close contacts / family members

Question 345

Management: sepsis

Answer 345

Timely recognition – be alert to signs/MEOWS First hour SEPSIS SIX BUNDLE 1) O2 as required to achieve SpO2 over 94% 2) Take blood cultures  3) Commence IV antibiotics 4) Commence IV fluid resuscitation 5) Take blood for Hb, lactate (+glucose) 6) Measure hourly urine output Ongoing multidisciplinary care: obstetrician, anaesthetist, critical care, microbiologist, etc

Question 346

Define: shoulder dystocia

Answer 346

failure for the anterior shoulder to pass under the symphysis pubis after delivery of the foetal head

Question 347

what are the risk factors for shoulder dystocia?

Answer 347

Macrosomia (most cases occur in normally grown babies) Maternal diabetes Previous shoulder dystocia Disproportion between mother and fetus Postmaturity and induction of labour Maternal obesity Prolonged 1st or 2nd stage of labour Instrumental delivery

Question 348

Management: shoulder dystocia

Answer 348

H – Call for help (emergency buzzer) E – Evaluate for episiotomy L – Legs in McRoberts P – Suprapubic pressure E – Enter pelvis  R – Rotational manoeuvres R – Remove posterior arm (R – Replace head and deliver by LSCS -Zavanelli)

Question 349

What are shoulder dystocia complications?

Answer 349

Maternal   PPH  Extensive vaginal tear (3rd and 4th degree)  Psychological Neonatal   Hypoxia  Fits  Cerebral palsy  Injury to brachial plexus

Question 350

What are the types of post partum haemorrhage?

Answer 350

Primary - Within 24 hours of delivery, blood loss > 500mls Secondary After 24 hours and up to 12 weeks post delivery Minor (500 -1000 mls) Major (> 1000 mls)

Question 351

What are the causes of post patrol haemorrhage?

Answer 351

The four ‘T’s - Tissue: ensure placenta complete (MROP) - Tone: ensure uterus contracted (uterotonics) - Trauma: look for tears (repair) - Thrombin: check clotting (transfusion RPC/ CP/ FFP)

Question 352

What are the risk factors for postpartum haemorrhage?

Answer 352

Big baby Nulliparity and grand multiparity Multiple pregnancy Precipitate or prolonged labour Maternal pyrexia Operative delivery Shoulder dystocia Previous PPH

Question 353

Investigations + management: secondary PPH

Answer 353

If haemodynamically unstable, resuscitate using an A to E approach ● Assess blood loss and full examination ● Send swabs - high vaginal swab (HVS) and endocervical swab ● Pelvic ultrasound ● Manage according to likely cause ○ Antibiotics ○ Uterotonics if required (syntocinon) ○ Surgical measures if excessive or continuing bleeding

Question 354

What are the causes of secondary PPH?

Answer 354

* Endometritis (uterine infection) ● Retained placental fragments / tissue ● Abnormal involution of placental site ● Arteriovenous malformations

Question 355

What are the different hormonal contraceptions?

Answer 355

All release progesterone - combined pill - progesterone pill - implant - mirena coil - injection

Question 356

How often do smear tests occur?

Answer 356

25-64 yrs 25-50 yrs Every 3 years 50-64 yrs Every 5 years

Question 357

What is gravidity and parity?

Answer 357

gravidity - total number of pregnancies including current pregnancies (gravida only if currently pregnant) parity - total number of deliveries after 24 weeks (is about past pregnancies, doesn't matter if it was twins, stillbirth etc.) Gravidity will always be higher as you are counting the current pregnancy

Question 358

How do you signify a pregnancy that has not gone beyond 24 weeks?

Answer 358

+1 e.g. P4 +1

Question 359

What pregnancy appointment are routine?

Answer 359

12 week booking clinic - USS - bloods for conditions - dating scan - sex 20 weeks - USS - position in uterus - placental localisation - foetal anatomy 37 weeks - bloods - check baby

Question 360

What are the different trimesters?

Answer 360

first trimester = till 12 weeks second trimester = 12-28 weeks full term = 37 weeks (till 42 weeks) complete term = 40 weeks

Question 361

When should induction of labour be offered?

Answer 361

from 41 weeks if have not spontaneously gone into labour

Question 362

What are the stages of labour?

Answer 362

1. Latent phase - contractions (may be irregular) - mucoid plugs ('show') - cervix is beginning to efface and dilate - last up to 2-3 days 2. first stage - stronger uterine contractions - cervix is continuing to efface and dilate up to 10cm 3. second stage - from full dilatation to the birth of the foetus 4. third stage - from the birth of the foetus to the expulsion of the placenta

Question 363

What is the role of oxytocin in labour?

Answer 363

A surge in oxytocin levels at the onset of labour will contract the uterus

Question 364

What is the role of prostaglandins in labour?

Answer 364

To aid with cervical ripening

Question 365

What is the role of prolactin?

Answer 365

to begin the process of milk production in the mammary glands

Question 366

What is the role of oestrogen in labour?

Answer 366

surges at the onset of labour to inhibit progesterone to prepare the smooth muscles for labour

Question 367

What is the role of beta-endorphins?

Answer 367

natural pain relief in labour

Question 368

What is the role of adrenaline in labour?

Answer 368

released as birth is imminent to give the woman the energy to give birth

Question 369

Where do contractions occur and what is happening?

Answer 369

- Starts in the fundus (pacemaker) - Retraction/shortening of muscle fibres - Build in amplitude as labour progresses - Fetus forced down causing pressure on cervix

Question 370

What is effacement?

Answer 370

Cervical effacement (also called cervical ripening) refers to a thinning of the cervix. - Prior to effacement, the cervix is like a long bottleneck, usually up to 4cm in length. - Throughout pregnancy, the cervix is tightly closed and protected by a plug of mucus. - in labour cervix shortens - midwives do a sweep of the cervix to release the bodies natural hormones

Question 371

What is the most common type of female pelvis?

Answer 371

Gynaecoid MC - The inlet is slightly transverse oval Sacrum is wide with average concavity and inclination Side walls are straight with blunt ischial spines Wide subpubic arch

Question 372

What are the steps in the foetal journey of birth?

Answer 372

1. Descent 2. Flexion 3. Internal rotation 4. Extension 5. Restitution - baby turns to allow shoulders to get out 6. External rotation 7. Delivery of body

Question 373

What happens in descent?

Answer 373

The fetus descends into the pelvis This can occur from 37 weeks gestation onwards, and may not occur until established labour. It is encouraged by: - Increased abdominal muscle tone - Increased frequency and strength of contractions

Question 374

What happens in flexion step of labour?

Answer 374

1. as fetus descends through the pelvis, uterine contractions exerts pressure down the fetal spine towards the occiput, forcing the occiput to come into contact with the pelvic floor. 2. When this occurs, the fetal neck flexes allowing the circumference of the fetal head to reduce. 3. In this position, the fetal skull has a smaller diameter which assists passage through the pelvis.

Question 375

What occurs during the internal rotations step of labour?

Answer 375

1. With each maternal contraction, the fetal head pushes down on the pelvic floor. 2. Following each contraction, a rebound effect supports a small degree of rotation. 3. Regular contractions eventually lead to the fetal head completing the 90-degree turn.

Question 376

What occurs during there extension step of labour?

Answer 376

1. The foetal occiput slips beneath the suprapubic arch allowing the head to extend. 2. The fetal head is now born and will be facing the maternal back with its occiput anterior.

Question 377

What occurs during the restitution/external rotation step of the labour?

Answer 377

1. the shoulders at the point of the head being delivered are only just reaching the pelvic floor they are often still negotiating the pelvic outlet and the fetus may naturally align its head with the shoulders. 2. visually you may see the head externally rotate to face the right or left medial thigh of the mother

Question 378

What occurs in the delivery step of labour?

Answer 378

1. Gentle downward traction may be conducted by the midwife to assist with the delivery of the shoulder below the suprapubic arch. 2. This then may be followed by gentle upwards traction assisting the delivery of the posterior shoulder.

Question 379

Define: En cal

Answer 379

when a baby is born within the amniotic sac

Question 380

What is delayed cord clamping and benefits?

Answer 380

- Delayed cord clamping is the practice in which the umbilical cord is not immediately clamped and cut at the point of birth, but allowed at least 1 minute to transfuse blood to the baby. - The baby could receive up to 214g of blood if this is facilitated. Associated benefits: - Allows the baby time to transition to extra-uterine life - Increase in red blood cells, iron and stem cells (this can aid with growth and development up to 6 months old) - Reduced need for inotropic support

Question 381

What is the placenta?

Answer 381

- temporary organ during pregnancy = made up of lobes attached to the uterine wall - connected t the foetus via the umbilical cord which ahas 2 arteries and one vein - produced hormones that assist with fetal growth In - oxygen and nutrients - (alcohol + nicotine) - maternal antibodies out - waste products e.g. CO2 - passed back to maternal blood stream for disposal

Question 382

What are the 2 membranes of the placenta?

Answer 382

amnion = bag around baby chorion = membrane around placenta

Question 383

What are the options for birth positions?

Answer 383

1. immersion in water - reduced pain - analgesia aspects - promotes calmness - hands off approach 2. upright birth - increases diameter the pelvic inlet - less risk of compressing mothers aorta - encourages stronger and longer contractions - gravity

Question 384

What holistic non invasive analgesia can be used in birth?

Answer 384

Water immersion (birthing pool or bath) Aromatherepy Massage Hypnobirthing TENS machine Entonox (gas and air) paracetamol codeine

Question 385

What opioid options are there in labour?

Answer 385

Diamorphine Pethidine Remifentanyl

Question 386

How does epidural work? pros and cons?

Answer 386

- Epidural analgesia is a mixture of bupivacaine and fentanyl - Epidural catheter is inserted by an anaesthetist, and drugs are administered through this via a pump. pros: Total pain relief in 90% of cases Effect will last until the baby is born Cons: Reduced mobility Can take up to an hour to take effect Will need a urinary catheter Can slow down labour if not established

Question 387

What asymptomatic screening is offered for females and heterosexual males?

Answer 387

Female Self taken Vulvo-vaginal swab for Gonorrhoea/Chlamydia NAAT (Nucleic Acid Amplification Test) Bld for STS + HIV Heterosexual male First void urine for Chlamydia/Gonorrhoea NAAT Bld test for STS + HIV

Question 388

What asymptomatic screening is offered to gay men?

Answer 388

MSM (Men who have Sex with Men): First void urine for Chlamydia/Gonorrhoea NAAT Pharyngeal swab for Chlamydia/Gonorrhoea NAAT (may be self taken) Rectal swab for Chlamydia/Gonorrhoea NAAT (may be self taken) Bld for STS, HIV, Hep B (& Hep C if indicated

Question 389

What symptoms would a female with an STI present with?

Answer 389

Vaginal discharge Vulval discomfort/soreness, itching or pain Superficial dyspaerunia Pelvic pain/deep dyspaeruniaVulval lumps Vulval ulcers Inter-menstrual bleeding Post-coital bleeding

Question 390

What is the symptomatic presentation for men with STIs?

Answer 390

Pain/burning during micturition Pain/discomfort in the urethra Urethral discharge Genital ulcers, sores, or blisters Genital lumps Rash on penis or genital area Testicular pain/swelling

Question 391

Who is screened for hepatitis B?

Answer 391

Men who have Sex with Men (MSM) Commercial Sex Workers (CSW) and their sexual partners IVDUs (current or past), and their sexual partners People from high risk areas and their sexual partners Africa, Asia, Eastern Europe Aim to vaccinate them if non-immune

Question 392

What treatment is offered to partners?

Answer 392

Central activity in GUM Necessary to prevent re-infection of index patient To identify & treat asymptomatic infected individuals as a public health measure Role of Health advisers Importance of confidentiality in maintaining patient trust

Question 393

Define: PEP and PREP

Answer 393

PEP = post exposure prophylaxis (antiretorviral) PREP = pre exposure prophylaxis (given in anticipation of exposure to HIV)

Question 394

What are the options for inducing labour?

Answer 394

1. membrane sweep = involves inserting a finger into the cervix to stimulate the cervix 2. vaginal prostaglandin E2 = inserting gel, tablet, or pessary into the vagina, stimulating the cervix 3. cervical ripening balloon = silicon balloon inserted into cervix + gently inflated to dilate the cervix 4. artificial rupture of membranes = oxytocin infusion 5. oral mifepristone + misoprostol = used when intrauterine fetal death has occurred

Question 395

What monitoring is used during induction of labour?

Answer 395

1. Cardiotocography (CTG) = to assess fetal heart rate and uterine contractions before and during induction of labour 2. Bishop score

Question 396

What scoring system is used to determine whether to induce labour?

Answer 396

Bishop Score Fetal station (scored 0 – 3) Cervical position (scored 0 – 2) Cervical dilatation (scored 0 – 3) Cervical effacement (scored 0 – 3) Cervical consistency (scored 0 – 2)

Question 397

Define: uterine hyperstimulation

Answer 397

- main complication of induction of labour with vaginal prostaglandins - contractions are prolonged and frequent causing fetal distress and compromise Criteria 1. Individual uterine contractions lasting more than 2 minutes in duration 2. More than five uterine contractions every 10 minutes

Question 398

Management: uterine hyperstimulation

Answer 398

- removing the vaginal prostaglandins or stopping the oxytocin infusion - tocolysis with terbutaline

Question 399

What are the complications of uterine hyper stimulation?

Answer 399

- fetal compromise with hypoxia and acidosis - emergency Caesarean section - uterine rupture

Question 400

What are the 3 things progress in labour is influenced by?

Answer 400

1. power = uterine contractions 2. passenger = size, presentation, and position of the baby 3. passage = the shape and size fo the pelvis and soft tissue

Question 401

What is the criteria for delay in the 1st stage of labour?

Answer 401

Less than 2cm of cervical dilatation in 4 hours Slowing of progress in a multiparous women

Question 402

Management: failure to progress

Answer 402

Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes Oxytocin infusion Instrumental delivery Caesarean section

Question 403

When are perineal tears more common?

Answer 403

First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries

Question 404

What is the classification for perineal tears?

Answer 404

1. First-degree – vaginal mucosa torn 2. Second-degree – perineal muscles torn 3. Third-degree – including the anal sphincter: - 3a = <50% of external anal sphincter affected - 3b = >50% of external anal sphincter affected - 3c = external and internal anal sphincter affected 4. Fourth-degree – rectal mucosa torn

Question 405

Management: perineal tears

Answer 405

1st degree - no sutures 2nd degree + = sutures 3rd + 4th degree = repairing in theatre Additional measures are taken to reduce the risk of complications: - Broad-spectrum antibiotics = to reduce the risk of infection - Laxatives = to reduce the risk of constipation and wound dehiscence - Physiotherapy = to reduce the risk and severity of incontinence - Followup = to monitor for longstanding complications

Question 407

What is an episiotomy?

Answer 407

when the obstetrician or midwife cuts the perineum before the baby is delivered - cut made diagonally from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter = mediolateral episiotomy

Question 408

What physiological changes occur in pregnancy?

Answer 408

Hormones Increase production of: - ACTH = increase cortisol + aldosterone lead to improvement in most autoimmune conditions and more susceptible to diabetes and infections - prolactin - melanocyte = increase pigmentation - T3 + T4 - Progesterone + oestrogen = vaginal hypertrophy Cardiovascular: - increased blood volume, plasma volume, cardiac output - decreased peripheral vascular resistance, blood pressure respiratory - increased tidal volume and respiratory rate Renal - increased blood flow to kidneys, GFR, aldosterone (increase salt + water retention), protein excretion Blood - increased WBC, Esr, ALP, RBC (so higher iron, folate and B12 requirements)

Question 409

What are the implications of STIs for pregnancy?

Answer 409

Implications for management of pregnancy: - HIV - Viral load, compliance with medication - Vertical transmission of all infections - Associations with miscarriage, fetal growth restriction, preterm birth and neonatal sepsis Doxycycline = contraindicated in pregnancy

Question 410

What emergency contraception options are there?

Answer 410

1. levonorgestrel (progesterone only pill) = 72 hrs 2. copper IUD = up till 5 days 3. ulipristal acetate (selective progesterone receptor modulator) = 120 hrs

Question 411

Define: vaginismus

Answer 411

Involuntary spasming of vaginal muscles

Question 412

Define: vulvodynia

Answer 412

unnatural pain response when anything touches the vulva

Question 413

What are indications for mammography?

Answer 413

- Clinically suspicious lump in patients > 40 years * Breast cancer where mammography not previously performed [any age] * Residual lump after cyst aspiration * Single duct blood stained nipple discharge * Nipple skin change * Triennial mammograms between ages 47 and 73 as part of the National Breast Screening Programme. - breast cancer - increased familial risk aged 40-50 yrs

Question 414

What are contraindications to mammography?

Answer 414

- breast pain without a lump * symmetrical thickening * before commencing HRT * women under 40 years unless diagnosed with previous breast cancer.

Question 415

Investigations: breast lumps

Answer 415

Clinical examination < 24 yrs = USS 25-39 yrs = USS + histology or cytology >40 yrs = mammography + USS and either histology or cytology

Question 416

Presentation: lumps in breast cancer

Answer 416

- Lumps that are hard, irregular, painless or fixed in place - Lumps may be tethered to the skin or the chest wall - Nipple retraction - nipple discharge - Skin dimpling or oedema (peau d’orange) - lymphadenopathy

Question 417

When is the 2 week referral recommended for breast cancer?

Answer 417

- unexplained breast lump in patients > 30 years - unilateral nipple changes in patients >50 yrs - unexplained lump in axilla in patients > 30 yrs - skin changes suggestive of breast cancer

Question 418

What is the triple assessment?

Answer 418

Done for every woman with a complaint of breast lumps 1. History + examination 2. Imaging - mammogram (over 40yrs) or MRI (any age) 3. biopsy

Question 419

Why is a mammogram better than a USS?

Answer 419

Looks at the whole breast compares both breasts USS - just looks at the focal abnormality (used in women <49 yrs as breast tissue is to dense for a mammogram - glandular and cancerous tissue both appear white on scan)

Question 420

What criteria defined breast cysts as non-cancerous?

Answer 420

when fluid is aspirated: - the fluid is not blood stained - there is no residual lump - the cyst does not continually refill

Question 421

When is chemo used in breast cancer before surgery?

Answer 421

First test for receptors (oestrogen, progesterone, HER2) chemo effective for: - HER 2 positive - Triple negative (as won't respond to hormones) - inflammatory breast cancer - a large cancer also can shrink tumour so breast conservation surgery can happen Converts inoperable to operable disease in the breast or axilla

Question 422

When is chemo used for breast cancer after surgery?

Answer 422

- cancer cells found in lymph nodes - cancer cells don't have hormone receptors - breast cancer cell are high grade >3 - small HER2 positive breast cancer

Question 423

What is done for young women having chemo for breast cancer?

Answer 423

Egg collection and embryo freezing - check for gene testing

Question 424

How does lymph node assessment work for breast cancer?

Answer 424

- assess to see if cancer has spread to lymph nodes - USS of axilla and guided biopsy sentinel lymph node biopsy - performed during breast surgery - an isotope contrast and blue dye are injected into the tumour area - lymph nodes can then be removed or biopsied

Question 425

What are the types of breast cancer receptors?

Answer 425

1. Oestrogen receptors (ER) 2. Progesterone receptors (PR) 3. Human epidermal growth factor (HER2) Triple-negative breast cancer = is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Question 426

Where can breast cancer metastasis to?

Answer 426

Lungs Liver Bones Brain 2Ls and 2 Bs but it can spread practically everywhere

Question 427

What are the surgery options for breast cancer?

Answer 427

tumour removal: 1. lumpectomies (if less than <20% of breast tissue needs to be removed) 2. mastectomy (multiple tumours, big tumours, when radiotherapy is contraindicated (for previous breast cancer or for lymphoma), advanced disease, patient choice) Similar survival rates Axillary clearance - removal of axillary lymph nodes

Question 428

What is a complication of lymph node clearance?

Answer 428

chronic lymphoedema - buildup of fluid in an arm

Question 429

What is the management for chronic lymphedema?

Answer 429

Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) Compression bandages Specific lymphoedema exercises to improve lymph drainage Weight loss if overweight Good skin care

Question 430

What are non-surgical management options for breast cancer?

Answer 430

1. radiotherapy - used in patients after breast conserving surgery to reduce risk of recurrence 2. chemo - neoadjuvant = shrink tumour before surgery - adjuvant = given after surgery to reduce recurrence - treatment 3. hormones - Tamoxifen = premenopausal women (blocks oestrogen receptors in ER positive cancers) - aromatase inhibitors = postmenopausal women, block the creation of oestrogen in fat tissue

Question 431

What hormonal treatment is used used for HER2 receptors?

Answer 431

1. Trastuzumab (Herceptin) = monoclonal antibody that targets HER2 receptor 2. Pertuzumab (perjeta) = monoclonal antibody targets HER2 receptors 3. Neratinib (nerlynx) = tyrosine kinase inhibitor, reducing the growth of breast cancers

Question 432

What is the difference between grade and stage in cancers?

Answer 432

Grade = how different the cells look down the microscope from the original cell Stage = how advanced and spread the cancer is

Question 433

Define: fibroadenoma

Answer 433

common benign tumours of stromal/epithelial breast duct tissue - common in younger women aged 20-40 yrs - respond to female hormones so often regress in menopause

Question 434

Presentation: fibroadenomas

Answer 434

- painless - Smooth - Round - Well circumscribed (well-defined borders) - Firm - Mobile (moves freely under the skin and above the chest wall) - Usually up to 3cm diameter

Question 435

Define: fibrocystic breast changes

Answer 435

- generalised lumpiness to the breast - normal variation - fluctuate with menstrual cycle - great pain or tenderness - fluctuation of breast size

Question 436

Management: fibrocystic breast changes

Answer 436

- Wearing a supportive bra - Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen - Avoiding caffeine is commonly recommended - Applying heat to the area - Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 437

Presentation: breast cysts

Answer 437

Benign, individual, fluid filled lumps - smooth - well circumscribed mobile - possibly fluctuate - ages 30-50 yrs

Question 438

Investigations: breast cysts

Answer 438

- imaging - aspiration or excision (aspiration can resolve pain)

Question 439

Define: fat necrosis

Answer 439

Benign lump formed by localised degeneration and scarring of fat tissue in the breast - associated with an oil cysts containing liquid fat

Question 440

presentation: fat necrosis

Answer 440

Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue (MC by trauma, radiotherapy or surgery) Painless Firm Irregular Fixed in local structures There may be skin dimpling or nipple inversion

Question 441

Management: fat necrosis

Answer 441

- USS - Mammogram similar appearance to breast cancer - histology = fine needle aspiration or core biopsy (helps exclude breast cancer)

Question 442

Define: Lipoma

Answer 442

benign tumours of fat adipose tissue - can occur anywhere in the body - soft - painless - mobile - do not cause skin changes treated conservatively but can be surgically removed

Question 443

Define: Galactocele

Answer 443

Occur in lactating women, often after stopping breastfeeding - breast milk filled cysts (lactiferous duct is blocked) - firm - mobile - painless - usually beneath the areola usually resolve without treatment

Question 444

Define: Phyllodes tumour

Answer 444

Rare tumours of connective tissue of the breast - ages 40-50 yrs - large and fast growing - can be benign or malignant and metastasis - surgical removal, - chemo

Question 445

What are the risk factors for breast cancer?

Answer 445

Female (99% of breast cancers) Increased oestrogen exposure (earlier onset of periods and later menopause) More dense breast tissue (more glandular tissue) Obesity Smoking Drinking Having less children and older Family history (first-degree relatives) Combined contraceptive pill (increase slightly but decreases after having stopped for 10 yrs) HRT

Question 446

What are the types of breast cancer?

Answer 446

1. ductal carcinoma in situ 2. lobular carcinoma in situ 3. Invasive ductal or carcinoma 4. Invasive lobular carcinomas 5. inflammatory breast cancer 6. Paget's disease of the nipple

Question 447

Presentation: ductal carcinoma in situ

Answer 447

- Pre-cancerous or cancerous epithelial cells of the breast ducts - Localised to a single area - Often picked up by mammogram screening - Potential to spread locally over years - Potential to become an invasive breast cancer (around 30%) - usually complete mastectomy - Good prognosis if full excised and adjuvant treatment is used

Question 448

What are the features of lobular carcinoma in situ?

Answer 448

- A pre-cancerous condition occurring typically in pre-menopausal women - Usually asymptomatic and undetectable on a mammogram - Usually diagnosed incidentally on a breast biopsy - Represents an increased risk of invasive breast cancer in the future (around 30%) - Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)

Question 449

What are the features of Paget's disease of the nipple?

Answer 449

- Looks like eczema of the nipple/areolar - Erythematous, scaly rash - Indicates breast cancer involving the nipple - May represent DCIS or invasive breast cancer - Requires biopsy, staging and treatment, as with any other invasive breast cancer

Question 450

What is peau d'orange?

Answer 450

Orange bumpy discolouring of the breast - usually signified in inflammatory breast cancer - start with chemotherapy (to kill cancer in lymphatics) - and then operate very bad prognosis

Question 450

age

Question 451

What are the guidelines for breast screening?

Answer 451

women ages 50 to 70 = every 3 years MRI screening for BRCA gee carriers from aged 30 yrs

Question 452

What is the guidelines for breast screening for people with familial risk?

Answer 452

- A first-degree relative with breast cancer under 40 years - A first-degree male relative with breast cancer - A first-degree relative with bilateral breast cancer, first diagnosed under 50 years - Two first-degree relatives with breast cancer

Question 453

Define + types: breast abscess

Answer 453

collection of pus within an area of the breast usually caused by a bacterial infection 1. lactational abscess - associated with breastfeeding - Mastitis can lead to abscess 2. non-lactational abscess - unrelated to breastfeeding

Question 454

What are the most common causative bacterial of breast abscesses?

Answer 454

1. Staphylococcus aureus (the most common) 2. Streptococcal species 3. Enterococcal species 4. Anaerobic bacteria (such as 5. Bacteroides species and anaerobic streptococci)

Question 455

Presentation: breast abscess

Answer 455

Mastitis with infection in the breast tissue presents with breast changes of: Acute onset Nipple changes Purulent nipple discharge (pus from the nipple) Tender fluctuant lump Localised pain Tenderness Warmth Erythema (redness) Hardening of the skin or breast tissue Swelling

Question 456

Management: breast abscess

Answer 456

lactational mastitis - continued breastfeeding - expressing milk - breast massage - heat packs - warm showers - simple analgesia - antibiotics = flucloxacillin non-lactational mastitis - analgesia - antibiotics - treatment of underlying cause e.g. eczema, candidly infection breast abscess - antibiotics - USS - drainage = needle aspiration - microscopy, culture and sensitivities of fluid

Question 457

define: intra ductal papilloma

Answer 457

wart lesion that grows within one of the ducts in the breast - result of proliferation of epithelial cells - benign tumours - can be associated with atypical hyperplasia or breast cancer

Question 458

presentation: papilloma

Answer 458

often asymptomatic - accidentally picked up on mammograms present with: - Nipple discharge (clear or blood-stained) - Tenderness or pain - A palpable lump

Question 459

Diagnosis: papilloma

Answer 459

Patients require triple assessment with: 1. Clinical assessment (history and examination) 2. Imaging (ultrasound, mammography and MRI) 3. Histology (usually by core biopsy or vacuum-assisted biopsy) ductography = inject contrast into abnormal duct and perform mammograms to visualise duct (papilloma an area that doesn't fill with contrast)

Question 460

Management: papilloma

Answer 460

Complete surgical excision - tissue then examined for atypical hyperplasia or cancer

Question 461

Define: ductal ectasia /

Answer 461

Benign breast condition - as menopause approaches women's nipples shorten and widen - fluid can collect in the widened ducts

Question 462

Presentation: duct ectasia

Answer 462

- Discharge from the nipple – usually thick but sometimes watery and may be brown, green or bloodstained - Breast pain = not common - A lump felt behind the nipple – this could mean the tissue behind the nipple has become infected or scarred - The nipple can be red or tender - The nipple is pulled inwards (inverted) – this could be because the ducts have shortened MC in middle aged women

Question 463

How do you diagnose duct ectasia?

Answer 463

- breast examination - mammogram - USS - core biopsy of breast - fine needle aspiration

Question 464

Management: duct ectasia

Answer 464

- most don't need treatment (normal part of ageing) - analgesia for pain - if infected = antibiotics - surgery if discharge continues = remove affected ducts

Question 465

What are the causes of small for gestational age?

Answer 465

1. Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart 2. Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR) - placental mediated growth restriction e.g. smoking, alcohol, malnutrition, anaemia, infection - non-placental mediated growth restriction e.g. genetic/structural abnormalities, fetal infection, errors of metabolism

Question 466

What are the complications of SGA?

Answer 466

Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia long term risk of: Cardiovascular disease, particularly hypertension Type 2 diabetes Obesity Mood and behavioural problems

Question 467

What are risk factors for SGA?

Answer 467

Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome

Question 468

Management: small for gestational age

Answer 468

1. identifying those at risk 2. aspirin = if at risk of pre-eclampsia 3. treat modifiable risk factors = stop smoking 4. serial growth scan 5. early delivery where growth is static - blood pressure + urine dipstick - uterine artery doppler scanning - detailed fetal anatomy scan - karyotyping - test for infections

Question 469

Define + causes: macrosomia

Answer 469

Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby

Question 470

What are the risks of macrosomia?

Answer 470

The risks to the mother include: Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare) The risks to the baby include: Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) Neonatal hypoglycaemia Obesity in childhood and later life Type 2 diabetes in adulthood

Question 471

Management: Macrosomia

Answer 471

- Ultrasound to exclude polyhydramnios and estimate the fetal weight - Oral glucose tolerance test for gestational diabetes can still have vaginal delivery = just higher risk for shoulder dystocia

Question 472

What are the different symptoms for ovarian, endometrial, cervical, vaginal and vulva cancer?

Answer 472

cervical - smears pick up HPV Endometrial - post-menopausal bleed - haematuria visible - thrombocytosis - vaginal discharge unexplained Ovarian - appetite loss or early satiety - abdominal distension - ascites - abdominal/pelvic mass - abdominal/pelvic pain - IBS symptoms - change in bowel habit - fatigue - urinary urgency - weight loss - serum CA125 results Vaginal - mass in or at entrance to the vagina Vulva - vulval bleeding - vulval lump or ulceration

Question 473

What are the gynaecologist tumour markers?

Answer 473

- CA 125 (only use for post-menopausal) - beta-HCG (high when not pregnant) - alpha fetoprotein - Inhibin (normally produced by ovarian granuloma cells - ovarian tumours) - carcinoembryonic antigen CEA

Question 474

What is included under the 2 week wait criteria?

Answer 474

- post-menopausal bleeding Transvaginal USS for women over 55 yrs with: - unexplained vaginal discharge - visible haematuria plus raised platelets, anaemia or elevated glucose levels

Question 475

Define: chronic pelvic pain

Answer 475

intermittent or constant pain in the pelvic area for at least 6 months - not exclusively related to menstruation, intercourse or pregnancy

Question 476

Which swab is used for each infection?

Answer 476

High vaginal swabs = candida, bacterial vaginosis, trichomonad Endocervical = Gonorrhoea, chlamydia Cervical smear = HPV

Question 477

Define: obstetric cholestasis

Answer 477

Inactivity of the bile acids from the liver, so bile acids build up in the blood

Question 478

Presentation: obstetric cholestasis

Answer 478

Typically presents after 28 weeks - itching = esp palms of hands and feet - fatigue - dark urine - pale, greasy stools - jaundice NO RASH

Question 479

Investigations: Obstetric cholestasis

Answer 479

Liver function test and bile acids checked - abnormal ALT, AST, and GGT ( normal for ALP to increase in pregnancy, placenta produces ALP) - raised bile acids rule out other causes: - gallstones - acute fatty liver - autoimmune hepatitis - viral hepatitis

Question 480

Management: obstetric cholestasis

Answer 480

1. Ursodeoxycholic acid Itching - emollients - antihistamines 2. Increased risk of stillbirth so planned induction 37-38 weeks

Question 481

What is the testing for fetal Down syndrome?

Answer 481

1. nuchal translucency; 2. serum testing to measure levels of β-human chorionic gonadotropin (β-hCG) 3. pregnancy-associated plasma protein A (PAPP-A). can also assess for Edward's (trisomy 18) and Patau (trisomy 13) syndromes.

Question 482

What is the preconception advice?

Answer 482

- advise regular sex every 2 to 3 days - folic acid 0.4 mg - aim for BMI 19-30 - smoking/drinking advice (women no drinking but men within health guidelines) - smear - rubella - aware of environmental/occupational exposure

Question 483

What reproductive disorders are associated with obesity?

Answer 483

- PCOS - lower ART success - miscarriage - infertility - obstetric complications

Question 484

Investigations: infertility

Answer 484

1. ovulation/ovarian function/ovarian reserve - check mid-luteal progesterone (<16 anov, 16-30 equivocal, >30 ovular) = 7 days prior to next period - FSH ( day 2) - astral follicle count - antimullerian hormone (<5.4 low response, >25 high response) (last 3 mainly for IVF treatment) 2. semen quality - count, motility, morphology, total - repeat if abnormal (could be due to illness/ bad day = need 2 abnormal to diagnose semen problem) - further test if count <5m/ml (endocrine, karyotype, Cystic fibrosis screen) - testicular biopsy = can then freeze sperm 3 tubal patency - Low risk = hysterosalpingogram (HSG) - high risk = laparoscopy + dye

Question 485

IVF process

Answer 485

1. ovarian stimulation + monitoring (2 weeks) 2. egg collection (sedation) 3. insemination/ICSI 4. fertilisation check ( day1) 5. embryo culture (2-5 days) 6. embryo transfer +/- cryopreservation 7. luteal support (2 weeks - progesterone) 8. pregnancy test

Question 486

Management: male infertility

Answer 486

Mild - intrauterine insemination ? - environment/ lifestyle = occupation, smoking, alcohol, diet, weight Moderate - IVF severe - IVF with intracytoplasmic sperm injection into the egg Azoospermia - surgical sperm removal - donor insemination surgery - correction of epidermal block - vasectomy reversal - varicocele - no benefit Hormonal - hypogonadotrophic hypogonadism = gonadotrophins - hyperprolactinaemia = bromocriptin with sexual dysfunction

Question 487

Management: anovulation

Answer 487

Group 1 = low FSH/LH/E2 - Give FSH + LH - GnRH pump - normalise weight = either too low or high (may need to reduce exercise) Adenoma = bromocriptine Sheehan's = FSH + LH Group 2 = PCOS - normal FSH, USS, androgens - Treatment = ovulation induction e.g. clomifene (or tamoxifen) (have the eggs just need help releasing them) - If resistant after 6 cycles = gonadotrophin + then laparoscopic ovarian drilling Group 3 = premature/menopause - High FSH - treatment = donor egg

Question 488

Management: tubal disorders

Answer 488

1. Tubal Surgery (Laparotomy or Laparoscopy) Adhesiolysis - 40% Salpingostomy - 30% Proximal anastamosis - 30% Reversal of sterilisation - 60-80% 2. Tubal catheterisation Selective Salpingography - 21% Hysteroscopic - 49% 3. In vitro Fertilisation (IVF) – 30-40%

Question 489

What is the criteria for early infertility referral?

Answer 489

Female: Age > 35 Menstrual disorder Previous abdominal / pelvic surgery Previous PID / STD Abnormal pelvic examination Male: Previous genital pathology Previous urogenital surgery Previous STD Systemic Illness Abnormal genital examination

Question 490

Define + presentation: chorioamnionitis

Answer 490

Chorioamnionitis is a clinical diagnosis and is suggested by uterine tenderness and foul-smelling discharge. - maternal fever, - tachycardia - neutrophilia

Question 491

What is a risk factor for chorioamnionitis?

Answer 491

Premature rupture of membranes

Question 492

Management: chorioamniotitis

Answer 492

- delivery of baby - IV antibiotics

Answer 493

liquor = the fluid that surrounds baby Lochia = normal shedding of the decidua discharge/bleeding following delivery fundus = top of uterus Decidua = part of the endometrium that allows implantation of blastocyst

Question 494

How does the size of the uterus change after birth?

Answer 494

1. immediately following delivery, uterus contracts fully two level of umbilicus 2. fundal height then decreases by 1cm/day 3. returns to pre-pregnancy size at 6 weeks muscle layer reduces to normal thickness through ischaemia, autolysis and phagocytosis decidua is shed as lochia

Question 495

What are the types of lochia?

Answer 495

LOCHIA RUBRA Day 0-4 ● Blood ● Cervical discharge ● Decidua ● Fetal membrane ● Vernix ● Meconium LOCHIA SEROSA Day 4-10 ● Cervical mucus ● Exudate ● Fetal membrane ● Micro-organisms ● White blood cells LOCHIA ALBA Day 10-28 ● Cholesterol ● Epithelial cells ● Fat ● Micro-organisms ● Mucus ● Leukocytes

Question 496

How does prolactin response when breastfeeding?

Answer 496

Prolactin response ○ Stimulated through sensation of suckling ○ Hypothalamus disinhibits production of prolactin by anterior pituitary ○ Through bloodstream to breast to stimulate milk production

Question 497

How does oxytocin respond in breastfeeding?

Answer 497

Oxytocin ○ Stimulated through sensation of suckling as well as sight/sound/smell of baby ○ Hypothalamus stimulates oxytocin secretion by posterior pituitary ○ Through bloodstream to stimulate myoepithelial cell contraction leading to milk ejection

Question 498

What is the benefit of breastfeeding for the baby?

Answer 498

Improved bonding Reduced incidence of respiratory and gastrointestinal disease, otitis media and necrotising enterocolitis (NEC) Presence of lactoferrin: ○ Highest in colostrum ○ Improves iron absorption ○ Protects against infections ○ Involved in bone marrow function ○ Boosts immune system functioning

Question 499

What hormones decrease after birth?

Answer 499

HCG Progesterone oestrogen Human placental lactogen

Question 500

which hormones increase after delivery?

Answer 500

progesterone oxytocin

Question 501

What is in colostrum?

Answer 501

High in protein Contains IgA and immunoglobulins higher in glucose

Question 502

What are the red flags of sepsis?

Answer 502

RR>25 >2 lactate systolic bP <90 HR >130 purpuric rash supplemental O2 requirement V or less on AVPU

Question 503

What is the sepsis 6?

Answer 503

Give 3 and take 3 Give - fluids - antibiotics - oxygen Take - blood cultures - lactate - fluid balance

Question 504

Presentation: post dural puncture headache

Answer 504

Headache worse with sitting/standing ○ Onset 1-7 days post spinal/epidural ○ Neck stiffness ○ Photosensitivity

Question 505

Management: post dural puncture headache

Answer 505

* Lying flat ○ Caffeine / fluids ○ Simple analgesia ○ Epidural blood patch if severe

Question 506

Define: postpartum urinary retention

Answer 506

the inability to completely micturate, requiring urinary catheterisation >12h after giving birth OR not to void spontaneously within 6 hours of vaginal delivery

Question 507

What are the causes of postpartum urinary retention?

Answer 507

* Common due to engorgement / trauma to the genital tract following delivery ● Can be related to spinal / epidural anaesthesia

Question 508

define: maternal death

Answer 508

death of a patient while pregnant or within 42 days of termination of pregnancy, from any cause related to of aggravated by pregnancy or its management

Question 509

What non-pharmacological pain relief is provided in labour?

Answer 509

Water - may help relaxation TENS - gentle electric current passes through pads on their back - can control strength - reduces backache in early labour Alternative therapies - acupuncture - acupressure - hypnotherapy

Question 510

What pharmacological pain relief is offered in labour?

Answer 510

Etonox - nitrous oxide and oxygen - spaced out, nauseate, tiring, mouth dry - don't use when pushing Diamorphine - IM/SC injection - takes about 30 mins to work, lasts a few hours - casue baby to sleep, slow to breathe - mother - sickness, sleepiness PCIA - remifentanil - press a button with every contraction - baby = slow to breathe - mum = sickness, sleepiness, slow breathing, O2 via nasal cannula

Question 511

Where is the anaesthetic injected into with a epidural and spinal block?

Answer 511

Epidural = epidural space Spinal = subarachnoid space

Question 512

What are the different Caesarean section categories?

Answer 512

Cat 1 Delivery within 30 minutes Cat 2 Delivery within 75 minutes Cat 3 Delivery within 24 hours Cat 4 Elective

Question 514

What are the causes of vaginitis?

Answer 514

Non-infectious - allergic reactions - normal physiological variation - atrophic vagintiis lichen sclerosis Infectious - genital herpes - chlamydia - gonorrhoea - trichomonad - candidia - bacterial vaginosis

Question 515

What are the risks of IVF?

Answer 515

Multiple Pregnancy Miscarriage Ectopic Fetal abnormality? Ovarian Hyperstimulation Syndrome (OHSS) 1-5% (lower @JW) Egg Collection (1:2000) Longer term - ? Ovarian Ca

Question 516

Presentation: vaginitis

Answer 516

- vaginal discharge - vulval itching - vulval irritation - vaginal odour

Question 517

When is IVF offered?

Answer 517

Treat after 2 years infertility women< 40 yrs - 3 full cycles - stop once age = 40 women 40-42 - 1 full cycle (if no previous IVF, no low ovarian reserve) - cancelled cycles don't count (unless low ovarian reserve) - private cycles count against total

Question 518

Presentation: bacterial vaginosis

Answer 518

MC cause of abnormal discharge - pH of vaginal fluid increased >4.5 - offensive fishy smelling discharge - white or grey discharge - no itching, soreness or irritation

Question 519

What are the risk factors for bacterial vaginosis?

Answer 519

Vaginal douching Receptive cunnilingus Black race Recent change of sex partner Smoking Presence of an STI e.g. chlamydia or herpes

Question 520

Investigation: bacterial vaginosis

Answer 520

gram staining - clue cells Nugant score

Question 521

Management: bacterial vaginosis

Answer 521

Metronidazole 400mg twice daily for 5-7 days or intravaginal gel

Question 522

Presentation: trichomonas vaginalis

Answer 522

- vaginal discharge = frothy yellow/ green - vulval itching - dysuria - offensive odour (+/-) low abdo pain (+/-) vulval ulceration.

Question 523

What are the complications of trichomonad vaginalis?

Answer 523

- preterm delivery and low birth weight in pregnancy - May predispose to maternal postpartum sepsis - May enhance HIV transmission

Question 524

Investigations: trichomonas vaginalis

Answer 524

- swab taken from posterior fornix - nucleic acid amplification tests if available

Question 525

Management: trichomonas vaginalis

Answer 525

General Advice Full explanation of diagnosis with written information. Screening for other STIs Recommended regimes Metronidazole 400-500mg twice daily for 5-7 days  Alternative regimens Tinidazole 2g orally in a single dose  (partners should be treated)

Question 526

Define: vulvovaginal candidiasis

Answer 526

acute inflammatory dermatitis of the vulva and vagina - caused by mucosal invasion of commensal yeast species = Candida albicans

Question 527

Presentation: candida

Answer 527

Vulval itch Vulval soreness Vaginal discharge = white, cottage cheese Superficial dyspareunia External dysuria excoriation satellite lesions

Question 528

Investigations: candida

Answer 528

vaginal swab from anterior fornix - gram or wet film examination - direct plating to solid fungal media

Question 529

Management: un complicated candidiasis

Answer 529

general advice: - Vulval moisturises as soap substitute - avoid tight fitting synthetic clothing - avoid irritants Medical - Clotrimazole Pessary - Clotrimazole Vaginal cream (10%) - Fenticonazole Pessary - Isoconazole Vaginal tablet  - Miconazole Ovule - Miconazole Pessary - Nystatin Vaginal cream - Nystatin Pessary

Question 530

Management: complicated candidiasis

Answer 530

Severe symptoms (a subjective assessment) Pregnancy Recurrent vulvovaginal candidiasis (more than 4 attacks per year) Non-albicans species Abnormal host (e.g. hyperoestrogenic state, diabetes mellitus, immunosuppression) treatment - fluconazole 150mg repeated after 3 days

Question 531

What are the features of mycoplasma genitalium?

Answer 531

majority asymptomatic - urethritis - urethral disachrge - dysurai - penile irritation - urethral discomfort - sexually acquired reactive arthritis - PID - pre-term delivery - post-coital bleeding

Question 532

Investigations: mycoplasma genitalium

Answer 532

Males - first void urine Females - vulvovaginal swab (viral swab) test any partners that the patient is planning to have sex with again

Question 533

Treatment: mycoplasma genitalium

Answer 533

non-complicated infection 1. doxycycline 100mg BD 7 days followed by azithromycin 2. Moxifloxacin 400mg OD 10 days Complicated - moxifloxacin 400mg OD 14 days

Question 534

Define: gonorrhoea

Answer 534

Gram negative diplococcus bacteria - it infects mucous membranes with a columnar epithelium - spreads via contact with mucous secretions

Question 535

What is the presentation for gonorrhoea?

Answer 535

odourless purulent discharge = green or yellow dysuria pelvic pain or testicular pain for men

Question 536

Management: Gonorrhoea

Answer 536

1. Nucleic acid amplification testing = detect RNA or DNA present 2. Single dose of IM ceftriaxone (sensitivities not known) Single dose of oral ciprofloxacin (sensitivities KNOWN)

Question 537

What is disseminated goncoccal infection?

Answer 537

A complication of untreated gonococcal infection, where the bacteria spreads to the skin and joints. It causes: Various non-specific skin lesions Polyarthralgia (joint aches and pains) Migratory polyarthritis (arthritis that moves between joints) Tenosynovitis Systemic symptoms such as fever and fatigue

Question 538

Define: chlamydia

Answer 538

Chlamydia trachomatis = gram negative bacteria causes STI

Question 539

What is the presentation for chlamydia?

Answer 539

In women that are sexually active: Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria) men that are sexually active and present with: Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis

Question 540

Investigations: chlamydia

Answer 540

Nucleic acid amplification tests (NAAT) - swab checking the DNA/RNA of organism - swab endocervical, vulvovaginal and then urine

Question 541

Management: chlamydia

Answer 541

1. Doxycycline 100mg twice a day for 7 days abstain from sex for 7 days inform all partners + refer for testing advice on future prevention

Question 542

What are some consequences of chlamydia?

Answer 542

Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis

Question 543

What is SARA?

Answer 543

Sexually acquired reactive arthritis - seronegative spondyloarthropathies - sterile inflammation of the synovial membranes, fascia, and tendons triggered by an infection at a distal site Causes: chlamydia gonorrhoea mycoplasma genitalium

Question 544

Define = causes: syphillis

Answer 544

STI caused by Treponema palladium - sex - vertical transmission - IV drugs - blood transfusion

Question 545

Presentation: syphilis

Answer 545

Primary - painless genital ulcer = chancre - local lymphadenopathy Secondary - maculopapular rash - wart lesions - fever - alopecia - oral lesions Tertiary - gummatous lesions - aortic aneurysms - neurosyphilis Neurosyphilis - headache - altered behaviour - dementia - paralysis

Question 546

Management: syphilis

Answer 546

Antibody testing = PCR or dark field microscopy IM benzathine benzylpenicillin