Women's Health Flashcards
1
Q
What is uterine prolapse?
A
Loss of anatomical support for the uterus, typically surrounding the apex of the vagina.
2
Q
What is a cystocele?
A
Bladder prolapse
3
Q
What is a rectocele?
A
Prolapse of the rectum or large bowel
4
Q
What is an enterocele?
A
Prolapse of the small bowel
5
Q
What grading system is used for uterine prolapse?
A
POP-Q
- Grade 0 - Normal
- Grade 1 - Lowest part is <1cm above introitus
- Grade 2 - Lowest part is within 1cm above or below introitus
- Grade 3 - Lowest part is >1cm below introitus, but not fully descended
- Grade 4 - Full descent with eversion of the vagina
6
Q
What is the management for uterine prolapse?
A
Vaginal pessary
7
Q
What are the risk factors for urinary incontinence?
A
Advancing age
Previous pregnancy and childbirth
High BMI
Hysterectomy
Family history
8
Q
What are the difference types of urinary incontinence?
A
Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence
9
Q
What is urge incontinence and what it is caused by?
A
The urge to urinate quickly followed by an uncontrollable leakage ranging from a few drops to complete emptying.
Due to detrusor muscle overactivity.
10
Q
What is stress incontinence and what is it caused by?
A
Leaking small amounts when coughing or laughing, due to a high abdominal pressure
11
Q
The urge to urinate quickly followed by an uncontrollable leakage ranging from a few drops to complete emptying would be what type of incontinence?
A
Urge incontinence
12
Q
Urine leaking out when coughing or laughing, due to a high abdominal pressure would be what type of incontinence?
A
Stress incontinence
13
Q
What is mixed incontinence?
A
A mixture of both stress and urge incontinence
14
Q
What is overflow incontinence?
A
AKA neurogenic bladder - the bladder doesn’t empty completely which leads to an eventual leak e.g. prostate enlargement
15
Q
If the bladder doesn’t completely empty and causes an eventual leak, what type of incontinence is this?
A
Overflow incontinence - AKA neurogenic bladder
16
Q
What is the main cause of overflow incontinence?
A
Damage to the peripheral nerves or nerves of the brain and spinal cord
17
Q
What are the classic signs/symptoms of urge incontinence?
A
Frequent urination, especially at night
18
Q
Frequent urination, especially at night, would indicate what type of incontinence?
A
Urge incontinence
19
Q
What is functional incontinence?
A
Co-morbid physical conditions impair the patient’s ability to get to a bathroom in time
20
Q
What are some causes of functional incontinence?
A
Dementia
Sedating medication
Injury / illness resulting in decreased ambulation
21
Q
What are the classic signs/symptoms of overflow incontinence?
A
There is a weak or intermittent stream / hesitancy
22
Q
If there is a weak or intermittent stream / hesitancy when urinating, what type of incontinence is this?
A
Overflow incontinence
23
Q
What are the initial investigations for urinary incontinence?
A
Bladder diaries for a minimum of 3 days
Vaginal examination
Kegel exercises
Urine dipstick and culture
Urodynamic studies
24
Q
What is the first line intervention for urge incontinence?
A
Bladder retraining for 6 weeks minimum
25
What is the first line pharmacological agent for urge incontinence?
Oxybutynin (immediate release)
26
What class of drugs are used first line in urge incontinence?
Antimuscarinics (anticholinergics)
27
What is a contraindication of using oxybutynin for urge incontinence?
Frail elderly women due to an increased risk of falls
28
What is the second line pharmacological intervention for urge incontinence?
Tolterodine or Solifenacin
29
What is a contraindication for Tolterodine or Solifenacin for urge incontinence?
Closed-angle glaucoma
30
If a female patient is elderly with closed angle glaucoma, what is the pharmacological agent which can be given?
Mirabegron
31
What class of drug is Mirabegron?
A beta-3-agonist
32
What is the first line management for stress incontinence?
Pelvic floor retraining (Kegel exercises)
8 contractions performed 3 times per day for a minimum of 3 months
33
What is the second line management for stress incontinence?
Surgical procedures: e.g. retropubic mid-urethral tape procedures
34
What is the second line management for women for stress incontinence if they decline surgical procedures?
Duloxetine
35
What class of drug is Duloxetine?
A combined noradrenaline and serotonin reuptake inhibitor
36
What is the mechanism of action of Duloxetine?
Increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
37
What is the management for overflow incontinence?
Re-establish a clear pathway for urine flow e.g. catheterisation or medications like alpha blockers, which relax smooth muscle e.g. Tamsulosin
38
What are the most common type of renal stones?
80% of stones are composed of calcium oxalate or phosphate stones
39
What is the gold standard investigation for renal / urinary stones?
Non-contrast CT within 24 hours of presentation
40
What would the management be for renal stones that are less than less than 5mm?
Watchful waiting
41
In what case would you use watchful watching for the management of renal stones?
If they are less than 5mm
42
What would the management be for renal stones that are less than more than 10mm?
Surgical management
43
In what case would you use surgical intervention in the management of renal stones?
If they are more than 10mm.
44
What pharmacological agent may aid in the passage of renal stones?
Alpha blocker e.g. Tamsulosin
45
What is androgen insensitivity syndrome?
X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype.
46
What is the inheritance pattern of androgen insensitivity syndrome?
X-linked recessive
47
What are the classical signs/symptoms of androgen insensitivity syndrome?
Primary amenorrhoea with little or no axillary or public hair.
Undescended testes may be felt in the suprapubic region.
48
Primary amenorrhoea with little or no axillary or public hair. Alongside
undescended testes felt in the suprapubic region would indicate what?
Androgen insensitivity syndrome
49
What is the management for androgen insensitivity syndrome?
Raise the child as a female
Bilateral orchidectomy
Oestrogen therapy
50
Why is a bilateral orchidectomy performed in patients with androgen insensitivity syndrome?
There is an increased risk of testicular cancer due to undescended testes.
51
Define bicornate uterus?
A bicornuate uterus is where there are two “horns” to the uterus
Gives the uterus a heart-shaped appearance
52
What are some complications of bicornate uterus?
Miscarriage
Premature birth
Malpresentation
53
Define imperforate hymen?
This is where the hymen at the entrance of the vagina is fully formed without an opening
54
What is the management for imperforate hymen?
Diagnosed on clinical examination
Management is with surgical incision to create an opening in the hymen
55
What is the potential complication of an imperforate hymen?
Retrograde menstruation which could lead to endometriosis
56
Define transverse vaginal septae?
Where a septum (wall) forms transversely across the vagina
57
What are the investigations for transverse vaginal septea?
Clinical examination
Ultrasound
MRI
58
What are the main complications of transverse vaginal septae?
Infertility
Pregnancy-related conditions
59
Define vaginal hypoplasia?
Abnormally small vagina
60
Define vaginal agenesis?
An absent vagina
61
What is spared in vaginal agenesis and hypoplasia?
Ovaries are usually spared = normal female sex hormones
62
What is the management for vaginal hypoplasia and agenesis?
Vaginal dilator over a prolonged period to create an adequate vaginal size and alternative is vaginal surgery
63
What is menarche?
Menarche is the first menstrual cycle, or first menstrual bleeding, in female humans.
64
Define thelarche?
'Breast budding' - onset of secondary breast development
65
Define pubarche?
Development of pubic hair
66
What is the normal endometrial thickness in pre-menopausal women during menstruation?
2-4mm
67
What is the normal endometrial thickness in pre-menopausal women during the early proliferative phase (day 6-14)?
5-7mm
68
What is the normal endometrial thickness in pre-menopausal women during the late proliferative phase (day 14-18)?
Up to 11mm
69
What is the normal endometrial thickness in pre-menopausal women during the secretory phase (day 18-28)?
7-16mm
70
A endometrial thickness of 2-4mm would indicate a woman is in what part of their cycle?
Menstruation
71
A endometrial thickness of 5-7mm would indicate a woman is in what part of their cycle?
Early proliferative phase (day 6-14)
72
A endometrial thickness of up to 11mm would indicate a woman is in what part of their cycle?
Late proliferative phase (day 14-18)
73
A endometrial thickness of 7-16mm would indicate a woman is in what part of their cycle?
Secretory phase (day 18-28)
74
When can menopause be diagnosed?
Cessation of menses for at least 12 consecutive months
75
When does menopause usually occur in women, what is the average age?
40-60 years old. Average age is 51 years.
76
What is considered to be pre-menopausal?
Menopause before the age of 40 years.
77
When is contraception needed until after menopause?
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
78
What are some contraindications of HRT?
Current or past breast cancer.
Any oestrogen sensitive cancer.
Undiagnosed vaginal bleeding.
Untreated endometrial hyperplasia.
79
Unopposed oestrogen HRT can be given to women under what conditions?
If they do not have a uterus.
80
Combined HRT should be given to women who have what?
A uterus
81
What is a complication of oral HRT?
Increased risk of VTE, no increased risk with transdermal
82
Which two cancers are associated with an increased risk due to HRT use?
Ovarian and breast
83
What pharmacological agent can be given for women suffering from vasomotor symptoms (non-HRT)?
Fluoxetine
84
What is oestrogen HRT called when it is given in oral form?
Estradiol
85
What is progesterone HRT called when given in oral form?
Utrogestan (micronised progesterone)
86
Define adenomyosis?
Adenomyosis is characterised by the presence of endometrial tissue within the myometrium
87
What are the classical features of adenomyosis?
Dysmenorrhoea
Menorrhagia
Enlarged, boggy uterus
88
What is the first-line investigation for adenomyosis?
Transvaginal ultrasound
89
What is the management for adenomyosis?
Tranexamic acid to manage ammenhorea
GnRH agonists
Uterine artery embolisation
90
What is the definitive treatment for adenomyosis?
Hysterectomy
91
What is Asherman's syndrome?
Also referred to as intrauterine adhesions or intrauterine synechiae, occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix
92
How is Asherman's syndrome diagnosed?
Hysteroscopy - Gold standard
93
What is the management for Asherman's syndrome?
Dissection of adhesions during hysteroscopy
94
What would the classical signs/symptoms of lichen sclerosis be?
Intense itching, especially worse at night, and presents with white, shiny patches, thinning of the vulvar skin, and areas of atrophy.
95
What demographic is lichen sclerosus most common in?
Elderly females
96
What is the first line management for lichen sclerosus?
Gold standard - Clobetasol proprionate 0.05%
97
What is the second line management for lichen sclerosus?
Topical calcineurin inhibitors e.g. Tacrolimus 0.1%
Topical retinoids e.g. Tretinoin 0.025-0.1%
98
Why is there a need for follow up in patients with lichen sclerosus?
There is an increased risk of vulval cancer
99
What is the most common cause of vaginal itching?
Contact dermatitis
100
Define atrophic vaginitis?
Inflammation of the vagina due to changes in the composition of the vaginal micro-environment due to hormonal deficiency (oestrogen)
101
Atrophic vaginitis most commonly occurs in women at what stage in life?
Post-menopausal
102
What is the management of atrophic vaginitis?
Vaginal lubricants and moisturisers - if these do not help then topical oestrogen cream can be used.
103
What investigation should you always perform before a diagnosis of atrophic vaginitits?
Transvaginal ultrasound - endometrial cancer
104
What are the causes of infertility?
Male factor 30%
Unexplained 20%
Ovulation failure 20%
Tubal damage 15%
Other causes 15%
105
What is the investigation for infertility in males?
Semen analysis
106
What is the investigation for infertility in females?
Serum progesterone 7 days prior to expected next period.
Day 21 for 28 day period
107
How would you interpret a serum progesterone in females for infertility?
< 16 nmol/l - Repeat, if consistently low refer to specialist
16 - 30 nmol/l - Repeat
> 30 nmol/l - Confirms ovulation
108
What are the key counselling points for infertility?
Folic acid
Aim for BMI 20-25
Advise regular sexual intercourse every 2 to 3 days
Smoking/drinking advice
109
What is the most common type of vulval cancer?
Squamous cell carcinoma
110
What are the risk factors for vulval cancer?
Increased age
HPV infection
Vulval intraepithelial neoplasia (VIN)
Immunosuppression
Lichen sclerosus
111
What are the classical features of vulval cancer?
Lump or ulcer on the labia majora
Inguinal lymphadenopathy
May be associated with itching, irritation
112
What is the management of vulval cancer?
Wide local excision to remove the cancer
Chemotherapy - Erlotibib
113
What are the two types of cervical cancer?
Squamous cell cancer (80%)
Adenocarcinoma (20%)
114
What serotypes of HPV are associated with increased risk of cervical cancer?
16,18 & 33
115
What staging system is used for cervical cancer?
FIGO staging
116
What is stage IA cervical cancer classified as?
Confined to cervix, only visible by microscopy and less than 7 mm wide
117
What is stage IB cervical cancer classified as?
Confined to cervix, clinically visible or larger than 7 mm wide
118
What is stage II cervical cancer classified as?
Extension of tumour beyond cervix but not to the pelvic wall
119
What is stage III cervical cancer classified as?
Extension of tumour beyond the cervix and to the pelvic wall
A = lower third of vagina
B = pelvic side wall
120
What is stage VI cervical cancer classified as?
Extension of tumour beyond the pelvis or involvement of bladder or rectum
A = involvement of bladder or rectum
B = involvement of distant sites outside the pelvis
121
What is the gold standard treatment for stage IA cervical cancer?
Hysterectomy +/- lymph node clearance
122
What is the management option for patients with stage IA cervical cancer and wanting to preserve fertility?
Cone biopsy with negative margins
123
What are the management choices for stage II and above cervical cancer?
Chemotherapy - cisplatin
Radiotherapy
124
What type of cervical cancer is frequently not detected in cervical cancer screening?
Adenocarcinoma
125
At what age are women offered cervical smears?
All women between the ages of 25-64 years
126
At what ages is 3 yearly screening performed for cervical cancer screening?
25-49 years: 3-yearly screening
127
At what ages is 5 yearly screening performed for cervical cancer screening?
50-64 years: 5-yearly screening
128
Explain how cervical cancer screening works?
HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive
129
When is cervical cancer screening performed during pregnancy?
Usually delayed until 3 months post-partum unless missed screening or previously abnormal smears
130
What is the protocol of an inadequate sample is obtained during cervical cancer screening?
Repeat test in 3 months
131
What is the protocol in cervical cancer screening if there is a negative result for high-risk HPV?
Return to normal recall
132
What is the protocol in cervical cancer screening if there is a positive result for high-risk HPV?
Samples are examined cytologically
133
If cytological samples are normal following a positive high-risk HPV sample in cervical cancer screening, what is the protocol?
Test is repeated in 12 months
134
If cytological samples are normal following 2 x positive high-risk HPV sample after 12 months in cervical cancer screening, what is the protocol?
Test is repeated in 12 months
135
If cytological samples are normal following 3 x positive high-risk HPV sample after 12 months in cervical cancer screening, what is the protocol?
If positive after 24 months = Colposcopy
136
If cytological samples are abnormal following a positive high-risk HPV sample in cervical cancer screening, what is the protocol?
Colposcopy
137
When is the HPV vaccine offered in schools and to whom?
Boys and Girls at ages 12-13
138
What is the treatment for cervical intraepithelial neoplasia?
Large loop excision of transformation zone (LLETZ)
139
What should happen for all women > 55 years old who present with post-menopausal bleeding?
All women >= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway
140
What is the most common identifiable cause of postcoital bleeding?
Cervical ectropion
141
What is endometrial hyperplasia?
Defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle
142
What is the management for simple endometrial hyperplasia without atypia?
High dose progestogens with repeat sampling in 3-4 months
The levonorgestrel intra-uterine system may be used
143
What is the management for endometrial hyperplasia with atypia?
Hysterectomy is usually advised
144
What are the risk factors for endometrial cancer?
Nulliparity
More periods - early menarche, late Menopause
Unopposed oestrogen
Tamoxifen
HNPCC
145
What are some protective factors against endometrial cancer?
Multiparity
COCP
Smoking
146
What is the classic symptom of endometrial cancer?
Postmenopausal bleeding
147
What are some axillary features of endometrial cancer?
Pain (uncommon - signifies extensive disease)
Vaginal discharge - unusual
148
How may endometrial cancer present in premenopausal women?
Premenopausal women may develop menorrhagia or intramenstrual bleeding
pain is not common and typically signifies extensive disease
149
What is the first line investigation for endometrial cancer?
First-line investigation is trans-vaginal ultrasound
150
What is the management for endometrial cancer?
Surgery - total abdominal hysterectomy with bilateral salpingo-oophorectomy
High-risk - posteroperative radiotherapy
151
Define endometriosis?
Characterised by the growth of ectopic endometrial tissue outside of the uterine cavity
152
What are the features of endometriosis?
Chronic pelvic pain
Secondary dysmennhorea - starts before bleeding
Dysparenuria
153
What is the investigation of choice for endometriosis?
Laparoscopy is the gold-standard investigation
154
What is the first-line management for endometriosis?
NSAIDs and/or paracetamol
155
What is the second line management for endometriosis?
Combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate
GnRH analogues CAN be tried
156
What is the management for endometriosis for patient who are trying to conceive?
Laparoscopic excision or ablation of endometriosis plus adhesiolysis
157
What are uterine fibroids?
Fibroids are benign smooth muscle tumours of the uterus
158
What demographic are uterine fibroids most common in?
More common in Afro-Caribbean women
159
How are uterine fibroids diagnosed?
Transvaginal ultrasound
160
What is the management for asymptomatic uterine fibroids?
No treatment is needed other than periodic review to monitor size and growth
161
What are some management options of menorrhagia secondary to uterine fibroids?
Levonorgestrel intrauterine system (LNG-IUS)
NSAIDs e.g. mefenamic acid
Tranexamic acid
Combined oral contraceptive pill
Oral progestogen
Injectable progestogen
162
What are some management options for shrinking / removal of uterine fibroids?
GnRH analogues
Myomectomy
Endometrial ablation
Hysterectomy
163
Why are GnRH analogues only used short-term?
Due to side-effects such as menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
164
What is the most common cause of postmenopausal bleeding?
Vaginal atrophy
165
What is a hydatidiform mole?
Molar pregnancies (hydatidiform moles) are chromosomally abnormal pregnancies that have the potential to become malignant
166
What is a complete hydaitdiform mole?
Complete hydatidiform moles have a 46 XX or 46 XY karyotype that is derived entirely of paternal DNA.
167
What is an incomplete hydatidiform mole?
Partial hydatidiform moles contain a karyotype of either 69 XXX or 69 XXY, and contain both maternal and paternal genetic material
168
What are the classical features of complete hydatidiform mole?
Vaginal bleeding
Uterus size greater than expected for gestational age
169
What are the investigations for hydatidiform mole?
Pelvic ultrasound
Serum hCG - will be abnormally high
170
What would a complete hyaditidiform mole show on ultrasound?
'snow storm' appearance of mixed echogenicity
171
A 'snow storm' appearance of mixed echogenicity would indicate what?
Complete hyatidiform mole
172
What is the management for hydatidiform mole?
Evacuation of the uterus - referral to specialist care
Products of conception need to be sent for histological examination
173
What is recommended after pregnancy with a hydatidiform mole?
Effective contraception is recommended to avoid pregnancy in the next 12 months
174
What is a prolactinoma?
A type of pituitary adenoma, a benign tumour of the pituitary gland.
175
What are the size ranges for a pituitary micro- and macroadenoma?
Microadenoma is <1cm and a macroadenoma is >1cm
176
What is the management for a prolactinoma?
Dopamine agonists (e.g. cabergoline, bromocriptine) they inhibit the release of prolactin from the pituitary gland
177
What type of drugs are cabergoline and bromocriptine?
Dopamine agonists
178
What is the management for patients with a pituitary gland who cannot tolerate or fail therapy?
A trans-sphenoidal surgery
179
Why does ovarian cancer carry a poor prognosis?
Poor prognosis due to late diagnosis.
180
What are the risk factors for ovarian cancer?
BRCA1 and BRCA2
Many ovulations - early menarche, late menopause, nulliparity
181
What are the investigations for ovarian cancer?
CA125 - if above 35IU/mL then urgent ultrasound of abdomen and pelvis
182
How is ovarian cancer diagnosed?
Diagnostic laparotomy
183
What is the management for ovarian cancer?
Usually a combination of surgery and platinum-based chemotherapy
184
Define ovarian torsion?
Ovarian torsion may be defined as the partial or complete torsion of the ovary on it's supporting ligaments that may in turn compromise the blood supply
185
What are the classical features of ovarian torsion?
Sudden onset of deep-seated colicky abdominal pain
Associated with vomiting and distress
Adenexal tenderness
186
What will ovarian torsion show on ultrasound?
Whirlpool sign
187
What would whirlpool sign on an ultrasound be suggestive of?
Ovarian torsion
188
What is the management for ovarian torsion?
Laparoscopy is usually both diagnostic and therapeutic
189
Define pelvic inflammatory disease?
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum
190
What are the features of pelvic inflammatory disease?
Lower abdominal pain
Fever
Deep dyspareunia
Dysuria and menstrual irregularities may occur
Vaginal or cervical discharge
Cervical excitation
191
What are the causative organisms for PID?
Chlamydia trachomatis - most common
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
192
What are the investigations for pelvic inflammatory disease?
Pregnancy test - exclude ectopic pregnancy
High vaginal swab - often negative
Screen for Chlamydia and Gonorrhoea
193
What are the complications of pelvic inflammatory disease?
Perihepatitis (Fitz-Hugh Curtis Syndrome) - 10%
Infertility
Ectopic pregnancy
194
What is the first line management for PID?
Stat IM ceftriaxone +
14 days of oral doxycycline + oral metronidazole
195
What is the second line management for PID?
Oral ofloxacin + oral metronidazole
196
What are the features of PCOS?
Subfertility and infertility
Senstrual disturbances: oligomenorrhoea and amenorrhoea
Hirsutism, acne (due to hyperandrogenism)
Obesity
Acanthosis nigricans
197
What are the investigations for PCOS?
Pelvic ultrasound
Various bloods
Glucose tolerance test
198
What bloods should be checked in PCOS and what would they show?
LH:FSH will be raised
Prolactin - raised
Testosterone - Normal / mildy elevated
SHGB (sex hormone-binding globulin) normal
199
What is the Rotterdam criteria used for?
To confirm a diagnosis of PCOS.
200
What are the Rotterdam criteria?
Diagnosis can be made if 2/3:
Infrequent or no ovulation
Clinical / biochemical signs of hyperandrogenism
Polycystic ovaries on ultrasound (≥12) in one or both
201
What is the general management of PCOS?
Weight reduction if appropriate
COCP may help regulate cycle and induce bleed
202
What is the management for hirtuism and acne in PCOS?
COCP for hirtuism
Topical eflornithine may be used if above fails
203
Define fistula?
A fistula is a connection or hole that forms between two organs
204
Define vesicovaginal fistula?
Opening between the vagina and the bladder
205
Define rectovaginal fistula?
Opening between the vagina and rectum/lower part of the large intestine
206
Define colovaginal fistula?
Opening between the vagina and colon
207
Define enterovaginal fistula?
Opening between the vagina and small intestine
208
Define uterivaginal fistula?
Opening between the vagina and the tubes (ureters) that carry urine from your kidneys to your bladder
209
Define urethrovaginal fistula?
Opening between the vagina and urethra, a part of the bladder
210
What score is used to assess postpartum mental health problems in pregnancy?
The Edinburgh Postnatal Depression Scale may be used to screen for depression
211
What score in the Edinburgh Postnatal Depression Scale would indicate a 'depressive illness of varying severity'
Score of > 13
212
A score of > 13 in the the Edinburgh Postnatal Depression Scale would indicate what?
A 'depressive illness of varying severity'
213
When is 'baby-blues' most likely to occur?
Typically seen 3-7 days following birth
214
When is post-natal depression most likely to occur?
Most cases start within a month and typically peaks at 3 months
215
When is puerperal psychosis most likely to occur?
Onset usually within the first 2-3 weeks following birth
216
What is the management for 'baby blues'?
Reassurance and support, the health visitor has a key role
217
What is the management for postnatal depression?
Reassurance and support are important
CBT may be beneficial
Paroxetine SSRI may be used if severe
218
What is the management for puerperal psychosis?
Admission to hospital is usually required, ideally in a Mother & Baby Unit
219
Define ectopic pregnancy?
Implantation of a fertilised ovum outside the uterus results in an ectopic pregnancy
220
What are some risk factors for ectopic pregnancy?
Damage to tubes (PID, surgery)
Previous ectopic
Endometriosis
IUCD
Progesterone only pill
221
What are the signs / symptoms of an ectopic pregnancy?
6-8 weeks of amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later
222
6-8 weeks of amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later would indicate what?
Ectopic pregnancy
223
What signs / symptoms 'may' be present in an ectopic pregnancy?
Shoulder tip pain and cervical excitation
224
What is the primary investigation for a ectopic pregnancy?
Transvaginal ultrasound
225
What would the options be for an ectopic pregnancy with no foetal heartbeat?
Expectant or medical management.
226
What would the options be for an ectopic pregnancy with a a visible foetal heartbeat?
Surgical management.
227
What would the management be for an ectopic pregnancy with a hCG of <1000?
Expectant management
228
What would the management be for an ectopic pregnancy with a hCG of <1500?
Medical management. Can only be done so if the patient is willing to attend a follow up appointment.
229
What would the management be for an ectopic pregnancy with a hCG of >5000?
Surgical management
230
What would the hCG level need to be for expectant management to be commenced for an ectopic pregnancy?
hCG of <1000
231
What would the hCG level need to be for medical management to be commenced for an ectopic pregnancy?
hCG of <1500
232
What would the hCG level need to be for surgical management to be commenced for an ectopic pregnancy?
hCG of >5000?
233
What is the only intervention of choice for an ectopic pregnancy if there is a ruptured fallopian tube?
Surgical management (salplngotomy, salplngectomy)
234
When is a salpingotomy preferred over a salpingectomy?
Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage
Patients will also require methotrexate
235
Where do most ectopic pregnancies implant?
Tubal in the ampulla
236
What is the most dangerous type of ectopic pregnancy?
Isthmus
237
What is the classic feature of threatened miscarriage?
Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
Cervical os is closed
238
Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks would indicate what?
Threatened miscarriage
239
Define missed (delayed) miscarriage?
A gestational sac which contains a dead foetus before 20 weeks without the symptoms of expulsion
240
What would the symptoms of missed (delayed) miscarriage)?
May have light vaginal bleeding / discharge
Cervical os is closed
241
What are the classical features of inevitable miscarriage?
Heavy bleeding with clots and pain
Cervical os is open
242
What would heavy bleeding with clots and pain with an open cervical os indicate?
Inevitable miscarriage
243
Define incomplete miscarriage?
Not all products of conception have been expelled
244
What are the classical features of incomplete miscarriage?
Pain and vaginal bleeding
Cervical os open
245
Define chronicity?
The number of chorionic membranes, or outer membranes.
246
Define amnioticity?
The number of amnions, or inner membranes.
247
What would a lambda sign indicate on ultrasound?
This indicates dichorionic twins
248
What would a T sign indicate on ultrasound?
This indicates a monochorionic twin pregnancy
249
Define twin-twin transfusion syndrome?
One foetus become the recipient and receives the majority of the blood supply
One foetus becomes the donor and is starved of blood
250
What may occur to the recipient foetus in twin-twin transfusion syndrome?
Excess fluid causes fluid overload, heart failure and polyhydramnios
251
What may occur to the donor in twin-twin transfusion syndrome?
This causes growth restriction, anaemia and oligohydramnios
252
What is twin anaemia polycythaemia sequence?
Similar to twin-twin transfusion syndrome but less acute.
One twin becomes anaemia whilst the other develops polycythaemia
253
What is the current law for abortion based around?
1967 Abortion Act
In 1990 the act was amended, reducing the upper limit from 28 weeks gestation to 24 weeks
254
What must happen during a termination of pregnancy?
Two registered medical practitioners must sign a legal document (in an emergency only one is needed)
255
When should anti-D prophylaxis be given for termination of pregnancy?
Should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation
256
What are the medical options for termination of pregnancy?
Mifepristone (anti-oestrogen) followed 48-hours later by misoprostol (prostoglandins)
Pregnancy test required 2 weeks later to confirm loss (should detect hCG rather than just positive / negative)
257
When would a medical abortion usually occur?
Before 10 weeks gestation
258
What are the surgical options for termination of pregnancy?
Vacuum aspiration (MVA)
Electric vacuum aspiration (EVA)
Dilatation and evacuation (D&E)
259
What should also be given alongside surgical termination of pregnancy?
Cervical priming with misoprostol +/- mifepristone
260
What is the first line investigation for gestational diabetes?
Oral glucose tolerance test
261
At what weeks should an oral glucose tolerance test be performed for gestational diabetes?
Screening is offered at 24-28 weeks
262
At what weeks should an oral glucose tolerance test be performed for gestational diabetes if there are risk factors present?
Women who've previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.
263
What is the target blood glucose level for pregnant women (pre-existing and gestational diabetes) at fasting?
5.6 mmol/l
264
What is the target blood glucose level for pregnant women (pre-existing and gestational diabetes) 1 hour after meals?
7.8 mmol/l
265
What is the target blood glucose level for pregnant women (pre-existing and gestational diabetes) 2 hour after meals?
6.4 mmol/l
266
What is the management of pre-existing diabetes in pregnancy?
Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
267
What is the management of gestational diabetes with a fasting glucose of > 7 mmol/L?
Insulin ± metformin
268
What is the management of gestational diabetes with a fasting glucose of > 6 mmol/L with Macrosomia or Other Complications?
Insulin ± metformin
269
If the woman declines insulin therapy or cannot tolerate metformin what is second line for gestational diabetes?
Glibencalmide (sulfonylurea)
270
What is the management of gestational diabetes with a fasting glucose of <7mmol/L?
Trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
271
A diagnosis of gestational diabetes would be made with what levels of blood glucose following an oral glucose tolerance test?
Fasting glucose is >= 5.6 mmol/L, or
2-hour glucose level of >= 7.8 mmol/L
272
What type of insulin is gestational diabetes treated with and why?
Gestational diabetes is treated with short-acting, but not longer-acting SC insulin due to lower risk of hypoglycaemia, and better post meal blood glucose control
273
What risk factors will women be screened for during their booking appointment for gestational diabetes?
BMI above 30 kg/m²
Previous macrosomic baby weighing 4.5 kg or more
Previous gestational diabetes
Family history of diabetes (first-degree relative with diabetes)
An ethnicity with a high prevalence of diabetes
274
Define hypertension in pregnancy?
>140 / >90 mmHg
275
What is the target blood pressure for gestational hypertension?
<135 / 85 mmHg
276
What is the management for pre-existing hypertension in pregnancy?
Oral labetalol
ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately
277
What is the management for gestational hypertension?
Lebatalol
278
Define pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy
Pregnancy-induced hypertension AND
Proteinuria / oedema or other organ involvement
279
Define severe pre-eclampsia?
New onset hypertension: typically > 160/110 mmHg
Proteinuria: dipstick ++/+++
Oedema may be seen
280
What medication should be given to reduce the risk of developing pre-eclampsia?
Low dose aspirin (75-150mg) from 12 weeks gestation until birth
281
When would a woman with pre-eclampsia be admitted?
Blood pressure ≥ 160/110 mmHg are likely to be admitted
282
What is the first-line management of pre-eclampsia?
Oral labetalol
283
What is a contraindication to labetalol?
Asthma
284
What is the management of pre-eclampsia if the patient is asthmatic?
Nifedipine
285
Define eclampsia?
Development of seizures in association pre-eclampsia
286
What is the pharmacological management for eclampsia?
IV magnesium sulphate bolus - 4g over 5-10 minutes then 1g infusion over an hour
287
How long should treatment be for eclampsia?
24-hours after last seizure activity
288
What is a complication of magnesium sulphate, for eclampsia, and what is the management for this?
Magnesium sulphate induced respiratory depression
Calcium gluconate
289
What is the most common organism that causes UTI in pregnancy?
Escherichia coli
290
What organisms can cause UTI in pregnancy?
KEEPS
E. coli (60-82.5%)
Klebsicalla pneumonia (11%)
Proteus (5%)
Staphylococcus
Streptococcus
Enterococcus
291
What is the first-line management for LUTI in pregnancy?
Nitrofurantoin 100mg for 7 days
292
What is the second line management for LUTI in pregnancy?
Amoxicillin or Cefalexin
293
What is the management for UUTI in pregnancy?
Cefalexin PO 500mg for 7-10 days
IV if unable to take orally
294
What is the VTE prophylaxis of choice during pregnancy?
Low molecular weight heparin
295
When should VTE prophylaxis be given during pregnancy for those in which it is indicated?
From 28 weeks and continued until six weeks postnatal.
296
What is the causative organism of bacterial vaginosis?
Gardnerella vaginalis
297
What disease can gardnerella vaginalis cause?
Bacterial vaginosis
298
Describe the pathophysiology behind bacterial vaginosis?
An overgrowth of predominately anaerobic organisms leading to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.
299
What are the classical features of bacterial vaginosis?
Vaginal discharge: 'fishy', offensive
Asymptomatic in 50% of patients
300
What criteria is used for the diagnosis of bacterial vaginosis?
Amsel's criteria (3/4):
Thin, white homogenous discharge
Clue cells on microscopy: stippled vaginal epithelial cells
Vaginal pH > 4.5
Positive whiff test (addition of potassium hydroxide results in fishy odour)
301
What is the management of bacterial vaginosis in an asymptomatic patient?
If the woman is asymptomatic, treatment is not usually required
Exceptions include if the patient is undergoing termination of pregnancy
302
What is the first line management of bacterial vaginosis in a symptomatic patient?
Oral metronidazole for 5-7 days
Single oral dose of 2g may be used if adherence is an issue
303
What are the alternative management options for bacterial vaginosis?
Topical metronidazole or topical clindamycin
304
What medication for RA should be stopped when trying to conceive?
Methotrexate: must be stopped at least 6 months before conception in both men and women
305
What is the Bishop scoring system used for?
The Bishop score is used to help assess whether induction of labour will be required.
306
What points are given in the Bishop score for cervical position?
0 - Posterior
1 - Intermediate
2 - Anterior
307
What points are given in the Bishop score for cervical consistency?
0 - Firm
1 - Intermediate
2 - Soft
308
What points are given in the Bishop score for cervical effacement?
0 - 0-30%
1 - 40-50%
2 - 60-70%
3 - 80%
309
What points are given in the Bishop score for cervical dilation?
0 - <1 cm
1 - 1-2 cm
2 - 3-4 cm
3 - >5 cm
310
What points are given in the Bishop score for foetal station?
0 - -3
1 - -2
2 - -1,0
3 - +1,+2
311
What does a Bishop score of <5 indicate?
Indicates that labour is unlikely to start without induction
312
What does a Bishop score of ≥ 8 indicate?
That the cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour
313
What would the management be for a Bishop score of ≤ 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
314
What would the management be for a Bishop score of >6?
Amniotomy and an intravenous oxytocin infusion
315
What is the definition for the first stage of labour?
From the onset of true labour to when the cervix is fully dilated
316
What is the definition for the second stage of labour?
From full dilation to delivery of the foetus
317
What is the definition of the third stage of labour?
From delivery of foetus to when the placenta and membranes have been completely delivered
318
What is the active management choice for the third stage of labour? and what is the reason for this?
10 IU oxytocin by IM injection
Reduce the risk of PPH
319
Define post-partum haemorrhage?
Postpartum haemorrhage is defined as blood loss of 500 ml after a vaginal delivery
320
What are the causes of PPH?
4 T's
- Tone (uterine atony)
- Trauma
- Tissue (retained placenta)
- Thrombin (clotting / bleeding disorder)
321
What is the management for PPH secondary to uterine atony?
IV oxytocin (syntocinon)
IM ergometrine
IM carboprost
Misoprostol sublingual
322
What is the surgical management for PPH, secondary to uterine atony, if medical intervention fails?
Intrauterine balloon tamponade
B-lynch suture
323
What is a contraindication for administration of ergometrine for PPH?
Hx of hypertension and cardiac diseases
324
What is a contraindication for administration of carboprost for PPH?
Hx of asthma
325
What investigation should be performed if there is no amniotic fluid in the posterior vaginal vault following a speculum examination for PPROM?
Placental alpha microglobulin-1 protein (PAMG-1)
OR
Insulin-like growth factor binding protein-1
326
What is the medical management for PPROM?
- Oral erythromycin / 10 days
- Antenatal corticosteroids to reduce the risk of respiratory distress syndrome (IM dexamethasone)
327
When should delivery be considered for PPROM?
34 weeks gestation
328
What is the most common complication of shoulder dystocia?
Erb's palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia.
329
What is the most common pattern of shoulder placement due to a complication of 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'.
330
What is the management of shoulder dystocia?
McRoberts manoeuvre - supine with both hips fully flexed and extended
331
What is the management for intrahepatic cholestasis of pregnancy?
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
332
Define cephalopelvic disproportion?
Condition where the baby’s head or body is too large to fit through the mother’s pelvis.
333
What is the management for cephalopelvic disproportion?
Cesarean section
334
Define placenta accreta?
Describes the attachment of the placenta to the myometrium, due to a defective decidua basalis.
335
What is the main risk in placenta accreta?
Risk of postpartum haemorrhage.
336
Define placental incetra?
Chorionic villi invade into the myometrium
337
Define placenta percreta?
Chorionic villi invade through the perimetrium
338
Define placenta praevia?
Describes a placenta lying wholly or partly in the lower uterine segment
339
What are the signs / symptoms of placenta praevia?
Vaginal bleeding with no pain, the uterus will be non-tender but the presentation and lie may be abnormal.
340
Vaginal bleeding with no pain, a non-tender uterus but with presentation and lie abnormal would indicate what?
Placenta praevia.
341
What would a grade I placental praevia indicate anatomically?
Placenta reaches lower segment but not the internal os
342
What would a grade II placental praevia indicate anatomically?
Placenta reaches internal os but doesn't cover it
343
What would a grade III placental praevia indicate anatomically?
Placenta covers the internal os before dilation but not when dilated
344
What would a grade IV placental praevia indicate anatomically?
Placenta completely covers the internal os
345
When would the last ultrasound scan be performed in patients with placental praevia?
Final ultrasound at 36-37 weeks to determine the method of delivery
346
What would a grade I placenta praevia indicate for type of birth?
If grade I then a trial of vaginal delivery may be offered
347
What would a grade III-IV placenta praevia indicate for type of birth?
Elective caesarean section for grades III/IV between 37-38 weeks
348
If a woman with placenta praevia goes into labour prior to the 37-38 week scan what is the management?
Emergency caesarean section should be performed due to the risk of post-partum haemorrhage
349
Define placental abruption?
Describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
350
What are the signs / symptoms of placental abruption?
Constant lower abdominal pain. Woman may be more shocked than is expected by visible blood loss. Tender, tense uterus. Foetal heart may be distressed.
351
Constant lower abdominal pain. Woman may be more shocked than is expected by visible blood loss. Tender, tense uterus. Foetal heart may be distressed. Would indicate what?
Placental abruption
352
What is the management for placental abruption when the foetus is alive and <36 weeks and showing no signs of distress?
Admit and administer steroids
353
Define vasa praevia?
Vasa praevia describes a complication in which foetal blood vessels cross or run near the internal orifice of the uterus.
354
What are the signs / symptoms of vasa praevia?
Rupture of the membranes followed immediately by vaginal bleeding. Foetal bradycardia is classically seen.
355
Rupture of the membranes followed immediately by vaginal bleeding and foetal bradycardia would indicate what?
Vasa praevia.
356
Define oligohydramnios?
Reduced amniotic fluid
357
What are the causes of oligohydramnios?
PROM
Potter sequence
Intrauterine growth restriction
Post-term gestation
Pre-eclampsia
358
Define oligohydramnios?
Increased amniotic fluid
359
Define lie?
The relationship between the long axis of the foetus and the mother.
360
Define presentation?
The foetal part that first enters the maternal pelvis.
361
Define position?
The position of the fetal head as it exits the birth canal.
362
What is the management for abnormal foetal lie?
External Cephalic Version (ECV) - between 36 and 38 weeks gestation
363
When is ECV contraindicated?
Recent APH
Ruptured membranes
Uterine abnormalities
Previous C-section
364
What is the management for breech presentation?
Attempt ECV before labour, vaginal breech delivery or C-section
365
What is the management for brow presentation?
C-section is necessary
366
What is the management for shoulder presentation?
A C-section is necessary
367
What is the management for malposition?
90% of malpositions spontaneously rotate
Rotation can be attempted vaginally
Alternatively C-section can be performed
368
What is the biggest cause of cord prolapse?
Artificial amniotomy - around 50% of cord prolapses are due to this
369
What is the biggest risk factor when performing an artificial amniotomy?
Cord prolapse
370
Define rhesus disease of the newborn?
Rh incompatibility occurs in an Rh-negative mother carrying an Rh-positive fetus
371
What is the investigation for rhesus incompatibility?
Test for D antibodies in all Rh -ve mothers at booking
372
What is the management for rhesus incompatibility?
Anti-D immunoglobulin to to non-sensitised Rh -ve mothers at 28 and 34 weeks
373
What is HELPP syndrome?
Haemolysis, Elevated liver enzymes and Low platelets
374
What are the features of HELLP syndrome?
Nausea & vomiting
Right upper quadrant pain
Lethargy
375
What is the management for HELLP syndrome?
Delivery of the baby
376
What agent, usually used to treat hyperthyroidism, is contraindicated in pregnancy and why?
Carbimazole, may be associated with an increased risk of congenital abnormalities
377
What is the agent of choice for treatment of hyperthyroidism in pregnancy, what is it associated with?
Propylthiouracil, associated with an increased risk of severe hepatic injury
378
What is a category 1 caesarean section?
An immediate threat to the life of the mother or baby
Delivery of the baby should occur within 30 minutes of making the decision
379
What is a category 2 caesarean section?
Maternal or foetal compromise which is not immediately life-threatening
Delivery of the baby should occur within 75 minutes of making the decision
380
What is a category 3 caesarean section?
Delivery is required, but mother and baby are stable
381
What is a category 4 caesarean section?
Elective caesarean
382
What are some indications for a category 1 caesarean section?
Suspected uterine rupture
Major placental abruption
Cord prolapse
Foetal hypoxia
Persistent foetal bradycardia
383
Describe a fibroadenoma?
Mobile, firm breast lumps
384
What would a mobile, firm breast lump indicate?
Fibroadenoma
385
What is the management for fibroadenoma?
If >3cm surgical excision is usual
386
Describe a breast cyst?
Usually presents as a smooth discrete lump (may be fluctuant)
387
A smooth, discrete breast lump (may be fluctuant) would indicate what?
Breast cyst
388
What would you see on mammogram of breast cysts?
Halo sign
389
What would halo sign on mammogram indicate?
Breast cysts compress the underlying fat and produce a radiolucent area (halo sign)
390
What is the management for breast cysts?
Aspiration - if blood stained or persistently refill then biopsy and removal
391
Describe duct ectasia?
A harmless, age-related breast change which causes the milk duct under the nipple to become blocked or clogged with a thick, sticky substance.
392
In what demographic does fat necrosis usually occur?
Obese women with large breasts
Usually follows trauma
393
Define breast abscess?
A localised collection of pus within the breast.
Can be either lactational or non-lactational
394
Define mastitis?
Painful inflammatory condition of the breast
395
What is the first-line management for mastitis?
Continue breastfeeding
396
What is the management for mastitis that does not improve after effective milk removal?
Oral flucloxacillin 10-14 days
Breastfeeding or expressing should continue through Abx treatment
397
What is the most common causative organism of infective mastitis?
Staphylococcus aureus
398
Define fibroadenosis?
'Lumpy' breasts which may be painful.
Symptoms may worsen prior to menstruation
399
When should a patient definitely be referred using the suspected breast cancer pathway?
Aged 30 and over and have an unexplained breast lump with or without pain or
Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
400
When should a patient be considered for referral using the suspected breast cancer pathway?
Skin changes that suggest breast cancer or
Aged 30 and over with an unexplained lump in the axilla
401
When should a patient be put forward for non-urgent referral for breast changes?
Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.
402
What hormonal therapy should be offered to breast cancer patients who are oestrogen-receptor-positive and are post-menopausal?
Letrozole / Anastrozole
403
What biological therapy should be offered to breast cancer patients who are HER2 receptor positive? What is a contraindication of this therapy?
Trastuzumab (Herceptin)
cannot be used in patients with Hx of heart disorders
404
What hormonal therapy should be offered to breast cancer patients who are oestrogen-receptor-positive and are pre- or perimenopausal?
Tamoxifen
405
What is management recommended after a patient has undergone a wide-local excision for breast cancer?
Whole breast radiotherapy
406
When is FEC-D chemotherapy used for breast cancer?
FEC-D chemotherapy is used for breast cancer that is node +ve
407
When is FEC chemotherapy used for breast cancer?
Used for node -ve breast cancer that requires chemotherapy
408
What complication is associated with axillary node clearance?
Arm lymphedema and functional arm impairment
409
What age does the breast cancer screening programme start?
50-70 years old
After 70 years old patients are 'encouraged to make their own appointments'
410
How often are women screened for breast cancer under the breast cancer screening programme?
Women are offered a mammogram every 3 years.
411
What is the most common type of breast cancer?
Invasive ductal carcinoma (no special type)
412
What are the features of Paget's disease of the breast?
Erythematous rash and associated thickening of the nipple
413
An erythematous rash and associated thickening of the nipple would indicate what?
Paget's disease of the breast
414
What is the management for Paget's disease of the nipple?
Urgent referral to breast clinic
415
Define intraductal papilloma?
Benign tumour found within breast ducts. The abnormal proliferation of ductal epithelial cells causes growth.
416
What are the features of intraductal papilloma?
May present with blood stained discharge
417
What is the management of intraductal papilloma?
Surgical excision and complete removal of the tumour
418
What is a contraindication for injectable progesterone contraceptives?
Breast cancer
419
What is a contraindication for the combined oral contraceptive pill?
Smoking >15 cigarettes a day
Migraine with aura
420
The COCP increases risk of which cancers?
Breast and cervical
421
The COCP decreases risk of which cancers?
Endometrial and ovarian
422
What is a contraindication for the IUD and IUS?
Unexplained vaginal bleeding
423
When will the IUD be an effective method of contraception?
Instantly, even if not first day of period
424
When will the POP be an effective method of contraception?
In 2 days, if not on first day of period. If first day then instantly
425
When will the COC, injection, implant, IUS contraceptives be an effective method of contraception?
In 7 days, if not on the first day of period. If first day then instantly
426
By what inheritance pattern is the BRCA gene inherited?
Autosomal dominant
427
What would the imaging modality of choice be for a breast lump in an under-35-year-old patient?
Ultrasound
428
What would the imaging modality of choice be for a breast lump in an over-35-year-old patient?
Mammogram
