Women's Health Flashcards
When can pts restart their pill after taking levonorgestrel?
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception
How does imperforate hymen present?
At puberty, girls usually do not have any problems from an imperforate hymen until they start their period. The imperforate hymen blocks the blood from flowing out. As the blood backs up the vagina, it causes: Mass or fullness in the lower part of the belly (from the buildup of blood that can’t come out)
When is the POP effective?
2/7 after taking, unless taken on first day of period
How do we treat eclampsia?
Mag Sulph first line
Levonorgestrel must be taken within x hours of UPSI
Levonorgestrel must be taken within 72 hours of UPSI
How frequent is cervical cancer screening?
Cervical cancer screening
25-49 years: 3-yearly
50-64 years: 5-yearly
What should we do with chickenpox exposure in pregnancy?
first step is to check varicella zoster immunoglobulins (unless had before/had vaccine). If -ve, antivirals are given 7-14/7 afterwards
What is the gold standard ix for endometriosis? First line?
Laparotomy
1st line = TVUS
Which medicine for nausea can causes EPSEs?
Metoclopramide is an option for nausea and vomiting in pregnancy, but it should not be used for more than 5 days due to the risk of extrapyramidal effects
What are EPSEs?
tremor
How can we treat vasomotor symptoms like flushing in the menopause?
SSRI e.g. fluoxetine
Why does the Mirena lead to light bleeding/amenorrhoea?
This is because the Mirena intrauterine system (IUS) releases a small amount of the hormone levonorgestrel into the uterus. This hormone has multiple effects, one of which is to thin the lining of the uterus which reduces menstrual flow and can lead to amenorrhoea in some women. Initially, this may cause irregular spotting or light bleeding but over time (usually within 3-6 months), periods tend to become lighter and less painful, and some women stop having periods altogether.
What is chorioamnionitis?
Chorioamnionitis is an infection of the amniotic fluid and fetal membranes, usually caused by ascending bacterial infection from the vagina and cervix.
How does chorioamnionitis present?
The patient’s presentation with PPROM, abdominal pain, uterine contractions, ‘flu-like symptoms’, fever, and foul-smelling discharge are all characteristic features of chorioamnionitis.
How does candida present?
The patient’s symptoms of a curd-like white vaginal discharge and pain during sexual intercourse are indicative of candidal vulvovaginitis, commonly caused by Candida albicans. This condition is characterised by pruritus, dyspareunia (painful sexual intercourse), and a thick, white ‘cottage cheese’ like discharge.
When do we test for coagulation disorders with heavy menstrual bleeding?
Testing for coagulation disorders (for example, von Willebrand’s disease) should be considered in women who have had heavy menstrual bleeding since menarche and have personal or family history suggesting a coagulation disorder.
When are we concerned about BP in pregnancy?
Above 160.80mmHg and proteinuria
What is the most common inherited bleeding disorder?
Von Willebrand’s Disease
How do we investigate for VWD?
prolonged bleeding time
APTT may be prolonged
factor VIII levels may be moderately reduced
defective platelet aggregation with ristocetin
How do we manage urge incontinence if bladder training is unsuccessful?
Muscarinic antagonist e.g. Tolterodine = ‘told her to hold it in!’
Others include oxybutynin and solifenacin
When do you feel a firm, woody uterus?
Placental abruption
What is Sheehan’s syndrome?
Sheehan’s syndrome (otherwise known as postpartum hypopituitarism) is a reduction in the function of the pituitary gland following ischaemic necrosis due to hypovolaemic shock following birth.
How does hypopituitarism present?
Amenorrhoea, problems with milk production and hypothyroidism
How must we manage a pt with placenta praevia who has just gone into labour in the community?
If a woman with known placenta praevia goes into labour (with or without bleeding), an emergency caesarean section should be performed
How does the COCP impact breast milk production?
Significantly reduces it, so is contraindicated in breast feeding mothers
When must levonorgestrel be taken?
Within 72H of UPSI
What conditions is premature menopause associated with?
Premature menopause is associated with increased all cause mortality including increased risk of osteoporosis and cardiovascular disease
When do women need contraception post-partum?
21 days
What abx prophylaxis do we give in PPROM?
10 days erythromycin should be given to all women with PPROM
How does ectopic pregnancy present?
amenorrhoea, abdominal pain and vaginal bleeding in combination with shoulder tip pain suggesting peritoneal bleeding
What is HELPP syndrome?
HELLP syndrome is a severe form of pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).
How do we treat atrophic vaginitis?
Treatment is with vaginal lubricants and moisturisers, if these do not help then topical oestrogen cream can be used.
How does atrophic vaginitis present?
Atrophic vaginitis often occurs in women who are post-menopausal women. It presents with vaginal dryness, dyspareunia and occasional spotting. On examination the vagina may appear pale and dry.
Give a RF for cervical cancer
Human papillomavirus infection (particularly 16,18 & 33) is by far the most important risk factor
Give the main adverse effect of the nexplanon implant.
Irregular menstrual bleeding. The Nexplanon implant, which contains the progestin etonogestrel, mainly functions by inhibiting ovulation. However, it also alters the endometrium and cervical mucus, which can lead to changes in menstrual bleeding patterns. According to UK guidelines, up to 1 in 5 women may experience amenorrhoea after a year of use, while others may have frequent or prolonged bleeding.
Where do you see cervical exitation?
Cervical excitation is found in both pelvic inflammatory disease and ectopic pregnancy.
How do we suppress lactation?
Cabergoline - dopamine receptor agonist which inhibits prolactin production causing suppression of lactation
How do we reduce occurrence of pre-eclampsia in women at high risk of developing it?
There is A level data showing that low-dose aspirin started at 12-14 weeks’ gestation is more effective than placebo at reducing occurrence of pre-eclampsia in women at high risk, reducing perinatal mortality and reducing the risk of babies being born small for gestational age
What is placenta praevia?
Placenta praevia refers to a pathological positioning of the placenta in the lower segment of the uterus, either wholly or partly. If the placenta overlies the internal cervical os then this is classed as ‘major praevia’, whereas in ‘minor’ or ‘partial’ praevia it does not. Bleeding from the placenta can occur spontaneously, as a result of trauma, or at the onset of labour as the cervix opens.
What is used first-line for infertility for a pt with PCOS?
Infertility in PCOS - clomifene is typically used first-line
What is Asherman’s syndrome?
Asherman’s syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.
When can the copper IUD be given as contraception?
The copper intrauterine device can be inserted for emergency contraception within 5 days after the first unprotected sexual intercourse in a cycle, or within 5 days of the earliest estimated date of ovulation, whichever is later
What is a molar pregnancy?
Molar pregnancy is a form of gestational trophoblastic disease. In a normal pregnancy, half of the chromosomes come from the father and half come from the mother. Molar pregnancies may be partial or complete.
What is the difference between a complete and incomplete hydatidiform mole.
A complete hydatidiform mole has a 46 XX or 46 XY karyotype with all of the genetic material deriving from the father. This is most commonly due to abnormal fertilisation of an empty ovum. A partial hydatidiform mole has a karyotype of 69 XXX or 69 XXY and contains both maternal and paternal chromosomes.
How do we manage uterine atony?
Bimanual uterine compression
IV oxytocin
IM carboprost
What is the most common cause of early onset sepsis in the neonate?
The most likely pathogen is Group B Strep which is a common commensal of the female genital tract.
What are the most common causes of late onset sepsis in the neonate?
Late-onset sepsis normally occurs due to hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.
When can we use instrumental delivery?
When the cervix is fully dilated
How do we manage stress incontinence in pts who don’t respond to pelvic floor muscle exercises.
Duloxetine may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention
What antibiotic is ceftriaxone? Can it be given with breast feeding?
Ceftriaxone is a third-generation cephalosporin antibiotic which is considered safe for use in breastfeeding mothers according to the British National Formulary (BNF). It has a low oral bioavailability, and therefore minimal amounts would be absorbed by the infant through breast milk.
Can we give Mirena as emergency contraception?
No
Give the RFs for placental abruption
Risk factors for ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
What does unopposed oestrogen increase the risk of?
Endometrial ca
When can oestrogen not be given by itself as HRT?
If the woman has a womb
What does progesterone in HRT increase the risk of?
Breast ca, VTE
What is the most common cause of post-coital bleeding
Cervical ectropion
How do we treat infertility in PCOS?
Clomifene first line, metformin second line
When can Down’s screening be performed?
Down’s syndrome screening including the nuchal scan is done at 11-13+6 weeks
If the patient requests the screening later in the pregnancy, either the triple or quadruple test should be offered between 15 and 20 weeks.
Give a disadvantage of using depo-provera.
Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions**
The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning.
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
When is ECV offered?
ECV should be offered from 36 weeks if the baby is still breech.
If the lady was multiparous ECV would be offered from 37 weeks.
What is dilation and curettage used for?
This procedure involves dilating the cervix and scraping or suctioning tissue from the lining of the uterus. It’s typically used to diagnose or treat conditions such as heavy bleeding or to clear the uterine lining after a miscarriage or abortion
What are sometimes referred to as chocolate cysts because of their external appearance?
Endometriotic cyst
Which is the most common ovarian cancer?
Serous carcinoma
What are follicular cysts?
Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
How do we treat nausea in hyperemesis gravidarum?
Cyclizine is correct. This patient has a likely diagnosis of hyperemesis gravidarum given the presentation of nausea and vomiting in association with pregnancy. The recommended initial anti-emetic agent of choice is an antihistamine such as cyclizine.
Why do we take a serum progesterone?
Serum progesterone is taken to confirm ovulation in patients who are struggling to conceive.
When do we take a serum progesterone level?
It should be taken 7 days before the next expected period to coincide with ovulation. For a typical 28 day cycle, this is done on day 21.
What is first-line in primary dysmenorrhoea?
NSAIDs such as mefenamic acid and ibuprofen are effective in up to 80% of women. They work by inhibiting prostaglandin production
combined oral contraceptive pills are used second line
Give three causes of secondary dysmenorrhoea
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids
What is oligohydramnios?
In oligohydramnios there is reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
What makes up the amniotic fluid?
Foetal urine
When do we offer the MMR vaccine in pregnancy?
If a pregnant woman is not immune to rubella, she should be offered the MMR vaccination in the post-natal period
What does the COCP protect against?
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
cOc - prOtective against Ovarian and endOmetrial cancer.
Why do we give aspirin in pts with diabetes in pregnancy?
Patients with diabetes (type 1 and 2) should take aspirin 75mg daily from 12 weeks gestation to reduce the risk of pre-eclampsia. They are also at higher risk of neural tube defects, therefore should take the higher dose of folic acid, 5mg daily, whilst trying to conceive until 12 weeks gestation. Pregnant women who have risk factors such as this should be referred at booking to Consultant lead antenatal care.
What is mefenamic acid?
NSAIDs such as mefenamic acid are the first line treatment for primary dysmenorrhoea
When is VBAC contraindicated?
Planned vaginal birth after caesarean (VBAC) is contraindicated in patients with previous vertical (classical) caesarean scars, previous episodes of uterine rupture and patients with other contraindications to vaginal birth (e.g. placenta praevia). Women with two or more previous caesarean sections may be offered VBAC.
What is seen on the combined test in Down’s syndrome?
In Down’s the papa leaves (the others are high)
Thickened nuchal translucency, increased B-HCG, reduced PAPP-A
What is the first-line mx of shoulder dystocia?
Shoulder dystocia: McRoberts manoeuvre (hyperflexion of the maternal legs) is the first management approach, then episiotomy if unsuccessful
How does nexplanon prevent pregnancy/
Inhibition of ovulation. Nexplanon, also known as the etonogestrel contraceptive implant, primarily works by inhibiting ovulation. The progestogen component in Nexplanon suppresses the mid-cycle surge in luteinising hormone (LH), preventing the release of an egg from the ovaries. This is its primary method of contraception.
How do we treat large uterine fibroids in infertility
The only effective treatment for large fibroids causing problems with fertility is myomectomy if the woman wishes to conceive in the future
What increases the risk of ovarian cancer?
risk factors relate to increased number of ovulations
Why do we give GnRH agonists with fibroids?
For patients with uterine fibroids, GnRH agonists e.g. leuprolide may reduce the size of the fibroid but are typically useful for short-term treatment
When can we give the EllaOne emergency pill?
Levonelle is most effective if taken within 72 hours of unprotected intercourse (it may be used until 96 hours but its effectiveness decreases over time) and can be used more than once during a menstrual cycle. ellaOne (ulipristal acetate) is effective if taken within 120 hours of unprotected intercourse. Previously it was advised that ulipristal could only be used once during a menstrual cycle. However, this guidance has now changed. Please see the link for more details.
The copper intrauterine device would be a viable alternative but did not appear on the list of options.
How do we manage mothers at higher risk of GBS?
Maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease
Can you give COCP to smokers?
Combined oral contraceptive pills (COCPs) are contraindicated in women over 35 years old who smoke more than 15 cigarettes per day due to the significantly increased risk of cardiovascular events, such as myocardial infarction and stroke.
What is a monochorionic twin pregnancy?
In a monochorionic twin pregnancy the two fetuses share a single placenta, meaning that blood can flow between the twins.
What is TTTS?
Twin-to-twin transfusion syndrome
In TTTS, one fetus, the ‘donor’ receives a lesser share of the placenta’s blood flow than the other twin, the ‘recipient’. This is due to abnormalities in the network of placental blood vessels. The recipient may become fluid-overloaded whilst the donor can become anaemic. One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems.
How do you manage PPROM in a 30w mother?
This woman is only 32 weeks gestation and it could be that she is going into labour with the rupture of the membranes. You therefore want to admit her and treat her with steroids to promote lung maturation of the baby. Because of the risk of sepsis and post-natal infection you would want to treat with antibiotics, currently erythromycin is recommended, but always consult your hospital guidelines. If a swab isolated Group B streptococcus you would treat with penicillin and clindamycin, but again, consult your hospital guidelines. If the woman does not progress to labour, she may be able to be managed at home and advised to take her temperature every 4-8 hours and to return to the hospital if she spikes a temperature. You should consider delivery at 34 weeks where the risks of infection may outweigh the risk of prematurity now you have allowed the lungs to mature.
Why do we give folic acid to 12w of pregnancy?
Neural tube defects tend to arise within the time-frame of the folic acid prescription, i.e. 12 weeks. Hence no need for folate after 12 weeks.
Meanwhile, vitamin D is for the whole pregnancy.
When would you consider gonadal dysgenesis?
Raised FSH/LH in primary amenorrhoea
What is Kallman syndrome?
Kallmann syndrome is a congenital form of hypogonadotropic hypogonadism, caused by an abnormally functioning hypothalamus. Patients with Kallmann syndrome may present similarly to the above case, but blood results would show low GnRH, FSH, and LH. Exam questions also often mention an absence of the sense of smell, which can be seen in Kallmann syndrome.
What is the SSRI of choice in pregnant women
Sertraline or paroxetine
How do we treat gestational diabetes if diet/metformin hasn’t been sufficient?
In gestational diabetes, if blood glucose targets are not met with diet/metformin then insulin should be added
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation. Dx?
Trichomonas vaginalis
A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram-negative diplococcus. Dx? Tx?
Gonorrhoea
IM ceftriaxone
How do we manage contraceptive patch delays?
If the contraceptive patch change is delayed greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days
What are the fasted GDD diagnostic thresholds?
GDD diagnostic thresholds fasted/2hr are 5678
How does congenital rubella syndrome present?
The neonate has congenital rubella syndrome with the classic triad of sensorineural deafness, eye abnormalities and congenital heart disease. The foetus is particularly at risk if the maternal primary infection occurs in the first trimester of pregnancy.
How do we manage premature labour?
This woman is now in premature labour, although at 3cm dilated it is still in an early stage. Therefore, it may be stopped by administering tocolytic medication. In case the labour continues and delivery is required, steroids are given as a pre-emptively to help the foetal lungs mature.
What is the Mirena IUS?
Levonorgestrel
What is Erb’s palsy?
Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’.
How would we advise HIV +ve pts when it comes to breastfeeding?
Contraindicated - formula feed only
Why do we give aspirin in pre-eclampsia?
Increase placental blood flow
What is clomifene used for?
induce ovulation in a number of conditions
Which contraceptive is contraindicated in wheelchair users?
COCP - increased VTE risk
What is second line in htn in pregnancy?
Nifedipine
How long is the nexplanon (etonogestrel) implant effective for?
3years
What is the Coombs test used for?
Direct Coombs: Is a investigation used to look for autoimmune haemolytic anaemia,
Indirect: Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.
Which drugs should be avoided in breastfeeding?
B - benzodiazepam, Bromocriptine
I - Iodine
L - Lithium, Laxatives
E- ergotamine
C- Carbimazole, Chloramphenicol
T- Tetracycline
H- Hormones (sex)
R- Radioisotopes
What causes ovulation?
LH surge
Which cyst iIf ruptures may cause pseudomyxoma peritonei?
Mucinous cystadenoma
What is the most common type of epithelial cell tumour?
Serous cystadenoma
When is ulipristal contraindicated?
Severe asthma i.e. controlled with oral steroids, you should be cautious due to the anti-glucocorticoid effect of ulipristal acetate.
How does the POP work?
Thickens cervical mucous
How does the COCP work?
Inhibits ovulation
How does desogestrel work?
The only POP to inhibit ovulation
At which point in the menstrual cycle do progesterone levels peak?
Luteal phase
When do we give anti-D in rhesus negative women?
anti-D at 28 + 34 weeks
When do we do the anomaly scan?
18 - 20+6 weeks
When do we do the booking visit?
8-12 weeks
When is the injection effective?
7 days
What is the Edinburgh scale used for?
The Edinburgh Scale is a screening tool for postnatal depression
How do we manage ectopic pregnancy?
Expectant management and monitoring is incorrect. This would be an appropriate option if the size of the ectopic pregnancy was less than 35 mm, the beta-hCG levels were less than 1000 IU/L, no foetal heartbeat was present, and the patient was asymptomatic
Methotrexate and monitoring is incorrect. This would be appropriate if the patient had no significant pain, the size of the ectopic pregnancy was <35 mm, the beta-hCG was less than 1500 IU/L, and no foetal heartbeat was present.
Ectopic pregnancy requiring surgical management: salpingectomy is first-line (rather than salpingotomy) for women with no other risk factors for infertility
Where do you see the whirlpool sign?
Ovarian torsion
Can we give the COCP to a breast-feeding mother?
Breast feeding < 6 weeks postpartum is UKMEC category 4 where as after this time it is UKMEC category 2
What is a second degree tear?
injury to the perineal muscle, but not involving the anal sphincter
require suturing on the ward by a suitably experienced midwife or clinician
What is a fourth degree tear?
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
require repair in theatre by a suitably trained clinician
When can the COCP be continued to?
Can be continued to 50 years Switch to non-hormonal or progestogen-only method
When can the injection be contoniued to?
Can be continued to 50 years Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method
How do we manage Implant, POP, IUS beyond 50y?
Continue
If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
Which HRT doesn’t increase the risk of VTE?
Transdermal HRT does not appear to increase the risk of VTE (vs. oral)
Which contraception is associated with weight gain?
Depo-provera
How do we manage a second positive HPV smear?
Cervical cancer screening: if 1st repeat smear at 12 months is still hrHPV +ve → repeat smear 12 months later (i.e. at 24 months)
Third one –> colposcopy
What does intrahepatic cholestasis of pregnancy present? What does it increase the risk of?
This patient is likely to be suffering from intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis). Patient’s typically present in the third trimester with intense itching that is generally worst on the palms of the hands and soles of the feet. It is not associated with a rash. Intrahepatic cholestasis of pregnancy increases the risk of stillbirth.
Offer delivery at 37-38w
How do we manage one missed pill in COCP?
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
How do we manage two missed pills in COCP?
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily. The women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: ‘This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed’
How do we manage two missed pills in week one of COCP?
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
How do we manage two missed pills in week two of COCP?
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception
How do we manage two missed pills in week three of COCP?
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
Which drugs should be avoided in breastfeeding?
B- bromocryptine, benzodiazepine
R- Radioactive drugs, rizatriptan
E- ergometer
A- aspirin, amiodaron, alcohol,
S- sulphinamide, sulphonylurea
T- tetracycline,( iso)tritinoin
First-line antibiotic tx for UTI in non-pregnant women?
In the UK, the first-line antibiotic treatment for UTIs in non-pregnant women is trimethoprim, as per NICE guidelines. Trimethoprim is safe to use in breastfeeding women, which makes it suitable for this patient.
How do we manage hyperglycaemia in pregnancy?
Offer diet and lifestyle changes UNLESS the patient would be diabetic even if NOT pregnant (i.e. Fasting Glucose >7.0 as in normal diabetes) in which case treat with Insulin.
If there is no improvement (or improvement is not to an adequate level) within 1-2 weeks, the patient should be started on metformin. If metformin is inadequate, the patient will then be started on insulin too.
If this patient had initial fasting plasma glucose of 7 mmol/L or more, insulin should be started. The vignette shows a patient with initial fasting glucose lower than this (6.8 mmol/L), however, if her blood glucose is not controlled by diet or metformin, she will need insulin.
When does the POP offer immediate protection?
If taken within five days of the cycle
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
When is contraception needed after the menopause?
Need for contraception after the menopause
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
When do we offer amniocentesis?
This is usually performed between weeks 15-20 due to its risks being higher if done earlier; therefore, it would be less appropriate to offer at this point. The patient also prefers any testing that carries the least risks to her and her baby, therefore making NIPT more appropriate.
Women who have a ‘higher chance’ combined or quadruple tests result are offered what if they don’t want an invasive test?
Offer non-invasive prenatal screening testing is correct. Given that this patient would like a test that carries the least risk of harm to her and her baby, NIPT would be the best option and is often preferred due to its extremely high sensitivity and specificity and non-invasive nature, as it requires a blood test and does not involve any needles inserted into the uterus.
What do we use citalopram for in the menopause?
Citalopram is a selective serotonin reuptake inhibitor (SSRI) that has been shown to be effective in reducing the frequency and severity of hot flushes and night sweats in menopausal women who do not wish to take hormone replacement therapy (HRT). The use of SSRIs for this indication is supported by UK guidelines.
What is tibolone?
Tibolone is a synthetic steroid hormone with estrogenic, progestogenic, and weak androgenic properties. It can be used as an alternative to HRT for the treatment of menopausal symptoms. However, since the patient specifically mentioned that she does not want HRT due to her sister’s history of breast cancer, Tibolone would not be an appropriate choice.
Which strains of HPV are most likely to cause cervical cancer?
Only high-risk HPV types are screened for as part of the national cervical screening programme. Types 16 and 18 cause more than 4 out of 5 cervical cancers in the UK. Types 31, 33, 45, 52 and 58 cause an additional 15% of cervical cancers. Types 6 and 11 are low-risk types that commonly cause benign genital warts. While they are not included in screening, both HPV types 6 and 11 are covered by the Gardasil vaccine.
Which medications do we recommend pts who are hoping to conceive?
Folic acid 400mcg OD and vitamin D 10mcg OD
How do we manage methotrexate in pts hoping to conceive?
Methotrexate: must be stopped at least 6 months before conception in both men and women
How does androgen insensitivity syndrome present?
Primary amenorrhoea, little or no axillary and pubic hair, elevated testosterone → androgen insensitivity syndrome
Patients with Turner’s syndrome have hypogonadism due to their ovaries failing to produce sex hormones including oestrogen.
What is Meig’s syndrome?
Meigs’ syndrome is a benign ovarian tumour (usually a fibroma) associated with ascites and pleural effusion
What is the Most common benign ovarian tumour in women under the age of 25 years?
Dermoid cyst (teratoma)
also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
most common benign ovarian tumour in woman under the age of 30 years
median age of diagnosis is 30 years old
bilateral in 10-20%
usually asymptomatic. Torsion is more likely than with other ovarian tumours
What is the The most common cause of ovarian enlargement in women of a reproductive age?
Follicular cysts
commonest type of ovarian cyst
due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
commonly regress after several menstrual cycles
What is corpus luteum cyst and how does it present?
Corpus luteum cyst
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
How are people with HIV followed-up as part of the cervical screening program?
Women who are HIV positive are at an increased risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer due to a decreased immune response and decreased clearance of the human papilloma virus. (1) HIV positive women who have low-grade lesions (CIN1) do not clear these lesions and these can progress to high-grade CIN or cervical cancer. Even those women who are effectively treated with antiretrovirals have a high risk of abnormal cytology and an increased risk of false-negative cytology. (1)
Women with HIV should be offered cervical cytology at diagnosis.. Cervical cytology should then be offered annually for screening.
How does body temperature change during ovulation?
Oestrogen is a thermoregulator, which is why you get hot flushes in menopause due to oestrogen insufficiency. So once ovulation occurs oestrogen temporarily plummits resulting in an increase in body temp.
Why is aspirin avoided in breastfeeding?
Aspirin must be avoided in breastfeeding due to a possible risk of Reye’s syndrome; regular use of high doses could impair platelet function and produce hypoprothrombinaemia in infants if neonatal vitamin K stores are low.
What dose of aspirin can be given in acute migraine?
Acute migraine
for aspirin
By mouth
Adult
900 mg for 1 dose, to be taken as soon as migraine symptoms develop.
When do we refer no foetal movements?
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
Why must we be careful prescribing alpha blockers with stress incontinence?
Alpha blockers such as doxazosin can worsen symptoms of stress incontinence by relaxing the bladder outlet and urethra
A 48-year-old woman visits her general practitioner with a 6-week history of unbearable hot flushes and vaginal dryness. She suspects that she is going through menopause. Her past medical history includes hypothyroidism and psoriasis. She takes regular levothyroxine and has the Mirena intrauterine system in situ.
What is the most appropriate additional treatment to initiate for this patient?
Estradiol - The Mirena intrauterine system is licensed for use as the progesterone component of HRT for 4 years
How does oral levonorgestrel and ulipristal work?
Inhibits ovulation
Which contraceptive can reduce bone mineral density?
Depo-provera injection
Is sodium valproate safe in breastfeeding?
Yes - only present in trace amounts
How do we screen for ovarian cancer?
We don’t
A 30-year-old para 1+0 has presented at term in labour. On vaginal examination, the occiput can be palpated posteriorly (near the sacrum). Which of these is correct regarding your further management of these patients?
The foetal head may rotate spontaneously to an OA position
What causes over 50% of umbilical cord prolapses?
Artificial amniotomy
Around 50% of cord prolapse occurs after artificial rupture of membranes
What is the Kleihauer test?
A Kleihauer test is a test for FMH (fetomaternal haemorrhage) which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.
When do we do the first screen for anaemia and atypical red cell alloantibodies?
8 - 12 weeks
When do we do the Early scan to confirm dates?
10 - 13+6 weeks
What dose of folic acid do we give in the first trimester?
For most pregnant patients, 400mcg daily in the first 12 weeks of pregnancy should prove sufficient. However, patients with a BMI of more than 30 kg/m² should be provided with 5mg daily for the first 12 weeks of pregnancy.
What are the classical signs of primary infection with varicella zoster in pregnancy?
I remembered this as Varicella? Barely see her!
Limb hypoplasia and microcephaly - smaller limbs and head which you can’t see as well as normal sized :D
What is OHSS?
Ovarian hyperstimulation syndrome (OHSS) is a complication that can occur in women undergoing in vitro fertilisation (IVF). It results from an excessive response to taking the medicines (gonadotropins) to stimulate the development of eggs in the ovaries.
Which type of condom are an alternative to latex ones?
Polyurethane condoms are a latex free alternative used in latex allergies
When is the Second screen for anaemia and atypical red cell alloantibodies?
28wks
When do we do a Urine culture to detect asymptomatic bacteriuria?
8-12wks
Which one of the following is most associated with smoking during pregnancy?
Pre-eclampsia
Increased risk of pre-term labour
Post-natal restricted growth
Microcephaly
Increased risk of pre-term labour
Smoking during pregnancy significantly increases the risk of pre-term labour. This is due to various harmful substances in cigarettes, including nicotine and carbon monoxide, which can cross the placenta and interfere with the baby’s oxygen supply. This can lead to a variety of complications, including premature birth.
Paradoxically, smoking has been found in some studies to be associated with a reduced risk of pre-eclampsia although it’s still detrimental for both mother and child for other reasons.
An actively breast-feeding mother comes into the GP surgery complaining of a sore nipple, and presence of a white discharge from the nipple. You suspect that she has a candidal infection. What treatment and advice should be given?
In order to fully treat the infection both the mother and child should be treated, usually with miconazole cream applied to the nipple post feed and the oral mucosa of the infant. Breast feeding should be continued during treatment.
Miconazole for mother: applied after each feed
Nystatin for oral mucosa of baby
How would we monitor a pt who has just been given first line tx for seizure in eclampsia?
Magnesium sulphate - monitor reflexes + respiratory rate
At which point in the cycle would we give the IUD rather than hormonal alternatives?
The copper IUD is the most appropriate option here, due to the likelihood that ovulation has already occurred (estimated as day 14, whereas now on day 17). It can be inserted as effective emergency contraception up to 5 days past the most likely ovulation date (typically day 14). The copper IUD is considered the single most effective form of emergency contraception, and should be offered to all patients unless contraindicated, particularly in cases where ovulation may have already occurred.
While the episode of UPSI took place only 48 hours ago and so falls within the window of use for both levonorgestrel and ulipristal, both hormonal contraceptives act primarily by inhibiting ovulation. Given that there’s a good chance ovulation has already occurred in this case, they will be less effective than the copper IUD.
When is the earliest an anomaly scan can be done?
18-20+6wks
How do we manage missed pill with traditional POPs?
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed
How do we manage missed pill with Cerazette (desogestrel)?
POP
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below
What do we do if action is required with a missed POP pill?
Take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
A 38-year-old woman and her partner come to the GP surgery after failing to conceive their first child. After what period of time of regular sexual intercourse should you begin to investigate?
6m (over 35)
1 year if under 35
How do we manage chickenpox with visible rash in pregnancy?
Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash
VZIG has no therapeutic benefit once the rash has started.
How do we manage combined oral contraceptive pill prior to surgery?
Oestrogen-containing contraceptives should preferably be discontinued 4 weeks before major elective surgery and all surgery to the legs or surgery which involves prolonged immobilisation of a lower limb. A progestogen-only contraceptive may be offered as an alternative and the oestrogen-containing contraceptive restarted after mobilisation.
Which ethnicity is associated with a higher prevalence of gestational diabetes?
Women of Afro-Caribbean origin are at an increased risk
4cm simple ovarian cyst noted on left ovary. Mx?
Repeat US in 12/52 - will likely have resolved by then
How does Progestogen-only pill (excluding desogestrel) work?
Thickens cervical mucous
How does Intrauterine system (levonorgestrel) work?
Prevents endometrial proliferation
How do we induce labour after sweep of the membranes is unsuccessful?
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
When do we start folic acid supplementation?
Preferably prior to conception
A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception?
Seven days
Which anti-epileptics can be given when breast feeding
Almost all - possible exception of the barbiturates
WHat is a third degree tear?
injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
require repair in theatre by a suitably trained clinician
