Women's & Reproductive Health Flashcards
1
Q
What are the diagnostic criteria for gestational diabetes?
A
Either:
- Fasting plasma glucose of 5.6 mmol/litre or above; or
- 2-hour plasma glucose of 7.8 mmol/litre or above
2
Q
What are the recommended target plasma glucose levels for gestational diabetes?
A
- 5.3 mmol/litre for fasting
- 7.8 mmol/litre 1 hour after meals
- 6.4 mmol/litre for 2 hours after meals
Target HbA1C < 48 mmol/mol (6.5%), albeit in pregnancy it is not as useful in monitoring control.
3
Q
What are the diagnostic criteria for hyperemesis gravidarum?
A
Diagnostic triad:
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
4
Q
What is the differential diagnosis for vaginal discharge?
A
Infective
- Sexually transmitted: trichomonas, chlamydia, gonorrhea
- Non-sexually transmitted: candida, bacterial vaginosis
Physiological
- Pregnancy
- Ovulation
Cervical ectropion
5
Q
What are the clinical and diagnostic features of bacterial vaginosis?
A
- 50% asymptomatic
- Thin, grey discharge with strong fishy odour
- Doesn’t usually cause soreness or itching
- Vaginal PH of > 4.5
- Clue cells on microscopy
6
Q
How do you manage bacterial vaginosis?
A
Asymptomatic and not pregnant: treatment not required
Symptomatic or pregnant: oral metronidazole twice a day for 5 to 7 days
General advice:
- Avoid douching and other products targetting BV
- Avoid perfumed soaps, shower gels, and shampoo
7
Q
Why should all pregnant women be treated for BV?
A
BV in pregnancy is associated with:
- Late miscarriage
- Preterm birth
- Premature rupture of membranes
- Postpartum endometriosis
8
Q
What are the causes of postpartum haemorrhage?
A
The four Ts:
Tone
Tissue
Trauma - genital tract injury
Thrombin - coagulation abnormalities
9
Q
Risk factors for postpartum haemorrhage?
A
Tone
- Polyhydramnios, multiple gestation, macrosomnia, fibroids, placenta praevia, uterine abnormalities, prolonged labour, prolonged rupture of membranes
Trauma - genital tract injury
- Operative delivery, previous uterine surgery, implementation (e.g forceps delivery).
Thrombin - coagulation abnormalities
- History of PPH, haemophilia A, Von Willebrand’s disease, idiopathic thrombocytopenic purpura, HELLP, gestational thrombocytopenia, DIC
10
Q
How do you manage a major obstetric haemorrhage?
A
Call for help!
Resuscitation
- Airway
- Breathing - oxygen mask (15L)
- Circulation
- Bed head down
- x2 wide-bore IV cannulae
- FBC, coagulation, U&Es, LFTs, cross-match (4 units)
- IV fluids (Hartmann’s or saline)
- Consider blood transfusion (O RhD-negative or group-specific blood)
- Consider blood products (FFP, PLT, factor VII)
- Foley catheter (to empty bladder and monitor fluid output)
Medical treatment
- Bimanual compression
- Oxytocin 5 iu, slow IV
- Ergometrine o.5 mg, slow IV
- Oxytocin infusion (40 iu in 500 ml)
- Carboprost 0.25 mg IM every 15 min up to 8 times
- Misoprostol 800 micrograms subligually
- Consider tranexamic acid 1 g IV
Theatre
- Intrauterine balloon tamponade
- Brace suture
- Consider stepwise uterine devascularisation (requires interventional radiologist)
- Bilateral internal artery ligation
- Hysterectomy
11
Q
What are the risks of being overweight or obese in pregnancy?
A
Risks to mother
- Miscarriage
- Gestational diabetes
- Gestational hypertension and pre-eclampsia
- Venous thromboembolism (DVT and PE)
- Macrosomia and shoulder dystocia
- Post-partum haemorrhage
- Instrumental delivery or emergency caesarean section
Risks to baby
- Prematurity
- Stillbirth
- Birth injury
- Congenital abnormality
12
Q
Who is at risk of gestational diabetes?
A
Women who:
- are overweight or obese
- have had gestational diabetes before (80% recurrence rate)
- have had a very large baby in a previous pregnancy (4.5kg/10lb or over)
- have first degree relative with diabetes
- are from a South Asian, Black or African Caribbean or Middle Eastern background
13
Q
Summarise the antenatal care for uncomplicated primiparous and multiparous women.
A
Booking appointment (ideally by 10 weeks)
16 weeks - review screening tests
18 - 20 weeks - anomoly scan
- 25 weeks - (nulliparous woman)
28 weeks - offer second screening for Hb and antibodies, gestational diabetes and anti-D if Rh neg
- 31 weeks (nulliparous woman)
34 weeks - offer a second dose of ani-D if Rh neg
36 weeks - check position of baby, offer ECV if breech
38 weeks
- 40 weeks (nulliparous woman)
41 weeks - membrane sweep, offer IOL
At each appointment, measure blood pressure, test urine for proteinuria, and measure and plot symphysis-fundal height.
14
Q
When do we screen for Down’s syndrome?
What are the screening tests?
A
Ideally by the end of the first trimester (13 weeks 6 days)
The combined test
- Nuchal translucency
- Beta-human chorionic gonadotrophin
- Pregnancy-associated plasma protein-A
- Between 11 weeks and 13 weeks 6 days
The triple or quadruple test
- Beta-human chorionic gonadotrophin
- Alpha-fetoprotein
- Oestriol (E3)
- Inhibin A
- Between 14 weeks and 20 weeks
NB. The presence of an increased nuchal fold (6 mm or above) or two or more soft markers should prompt the offer of a referral to a fetal medicine specialist.
15
Q
What two diagnostic tests are offered following a higher-chance result for Down’s syndrome?
A
- Amniocentesis
- Chorionic villus sampling
This will tell you for certain whether or not the baby has Down’s, Edwards’ or Patau’s syndrome.
16
Q
What are the risk factors for pre-eclampsia?
A
- Age 40 years or older
- Nulliparity
- Pregnancy interval of more than 10 years
- Family history of pre-eclampsia
- Previous history of pre-eclampsia
- BMI 30 kg/m2 or above
- Pre-existing hypertension
- Pre-existing renal disease
- Multiple pregnancy
- Diabetes
17
Q
What are the symptoms of pre-eclampsia?
A
- Severe headache
- Problems with vision, such as blurring or flashing before the eyes
- Severe pain just below the ribs
- Vomiting
- Sudden swelling of the face, hands or feet
18
Q
What are the diagnostic criteria for pre-eclampsia?
A
- Blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two separate readings taken at least four to six hours apart after 20 weeks gestation
(In a woman with essential hypertension beginning before 20 weeks gestational age: an increase in systolic blood pressure of ≥30mmHg or an increase in diastolic blood pressure of ≥15mmHg)
- Proteinuria ≥ 300 mg or more of protein in a 24-hour urine sample or a SPOT urinary protein to creatinine ratio ≥ 0.3 or a urine dipstick reading of 1+ or greater
19
Q
How can women prevent pre-eclampsia?
A
Take low-dose aspirin
20
Q
How do you manage pre-eclampsia?
A
Definitive treatment is delivery
- Expectant management to expedited delivery by induction of labour or caesarian section
In severe hypertension, reduce blood pressure
- Labetolol, Methyldopa and Nifedipine
In severe pre-eclampsia, prevent eclampsia
- Magnesium sulphate
21
Q
What is the screening pathway for placenta praevia?
A
Most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born.
Only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 32 weeks.
If the transabdominal scan is unclear, a transvaginal scan should be offered.
22
Q
Which infections are routinely screened for in pregnancy?
A
- Hepatitis B virus
- HIV
- Rubella
- Syphilis
23
Q
Which haemoglobinopathies are routinely screened for in pregnancy?
A
Sickle cell diseases
Thalassaemias
24
Q
When is routine antenatal anti-D prophylaxis (RAADP) given?
A
One or two doses at 28 weeks +/- 34 weeks
25
What is the purpose of a booking appointment?
**Determine whether** **pregnancy** **is** **high** **or low risk**
Measure blood pressure
Calculate BMI
Test urine for proteinuria
Risk factors for pre-eclampsia
Risk factors for gestational diabetes
Offer blood tests (blood group, rhesus D status, anaemia, haemoglobinopathies, red-cell alloantibodies, infections)
Offer screening for asymptomatic bacteriuria
Offer screening for Down's syndrome
Offer early ultrasound scan for gestational age assessment and structural anomalies
Identify women who have had FGM
Inform women younger than 25 years about National Chlamydia Screening Programme
26
What nutritional advice should be offered to pregnant women?
* Take folic acid supplements before conception and throughout first 12 weeks (400 microgram per day)
* Take vitamin D supplements during pregnancy and breastfeeding (10 micrograms per day)
* Do not take iron supplements
* Don't eat liver (excess vitamin A)
* Avoid raw or partially cooked eggs (salmonella)
* Avoid all types of pâté, soft blue-veined cheeses such as danish blue, gorgonzola and roquefort (listeria)
* Do not eat raw or undercooked meat (toxoplasmosis)
* Don't have more than 200 mg of caffeine a day (one mug of instant coffee: 100mg; one mug of filter coffee: 140mg, one mug of tea: 75mg)
27
What are the effects of caffeine in pregnancy?
High levels of caffeine can result in babies having a **low** **birthweight**, which can increase the risk of health problems in later life, and can cause **miscarriage**.
28
What are the risks of smoking during pregnancy?
Increased risk of:
* Stillbirth
* Prematurity
* Small for gestational age baby
* More prone to infection
* Sudden infant death syndrome
* Child asthma
29
When does the embryonic period and fetal period start and end?
Embryonic period: 2 to 8 weeks
Fetal period: 9 to 40 weeks
30
What is labetalol and when is it contraindicated?
Alpha- and beta-adrenergic receptor blocker
Asthma and pheochromocytoma
31
Which three drugs are recommended in the treatment of hypertension during pregnancy?
1. Labetalol
2. Nifedipine
3. Methyldopa
32
Which antibiotics should be avoided during pregnancy?
Sulphonamides
Quinolones
Aminoglycosides
Tetracyclines
33
Which drugs can be used to treat a UTI during pregnancy?
Nitrofuantoin
Trimethoprim
Penicillins (amoxycillin; coamoxyclav)
Cephalosporins (cefalexin)
34
When should nitrofurantoin be avoided and why?
Avoid at term
Haemolytic anaemia in the neonate
35
When should trimethoprim be avoided and why?
First trimester
Folate antagonist associated with structural defects
36
Which antibiotic is associated with cholestatic jaundice?
Coamoxyclav
37
What are the indications for a higher dose of folic acid (5 mg) until 12 weeks of pregnancy?
* Diabetes
* Epilepsy
* BMI of 30 or above
* Coeliac disease
* Thalassaemia trait
* Family history of neural tube defect
* Previous pregnancy affected by neural tube defect
* Mother or father has a neural tube defect
38
What factors affect drug levels in pregnancy?
Physiological
* Increased blood volume (50% by 34 weeks)
* Increased clearance (GFR 50% by 24 weeks)
* Increased hepatic metabolism
* Vomiting
* Decreased absorption
Non-physiological
* Decreased compliance (fear of teratogenesis)
* Fear of prescribing
39
What is Becotide, Serevent, and Ventolin?
Asthma medication
* Becotide: Beclomethasone
* Serevent: Salmeterol
* Ventolin: Salbutamal
40
Which asthma medication should not be started during pregnancy?
Leukotriene receptor antagonists
| (Montelukast and Zafirlukast)
41
What is meant by teratogenic and fetotoxic drugs?
**Teratogenic drugs**
* Increase the risk of structural abnormalities
* Occurs in the first trimester
* Greatest risk from 3 to 8 weeks after conception (5 to 10 weeks’ gestation)
**Fetotoxic**
* A substance that increases the risk of functional damage
* Occurs later in pregnancy
42
What is the risk of major malformation in the general population?
2%
43
NSAIDs are teratogenic. What two functional abnormalities are they associated with?
1. Fetal renal dysfunction in the second and third trimester
2. Premature closure of the ductus arteriosus in the third trimester
44
What are the main principles of prescribing in pregnancy?
* Medication should only be used if the expected benefits (usually to the mother) are greater than the potential adverse effects (usually to the fetus).
* Try to avoid first trimester use
* Use drugs that have been used extensively in pregnancy
* Use the minimum dose required
* Absence of data does not imply safety
45
What are the key medication considerations for pregnant women with epilepsy?
* If seizure-free for many years, consider dose reduction or withdrawal
* Monotherapy is less teratogenic than polytherapy
* Avoid sodium valproate
* Consider a pre-emptive increase in lamotrigine dose in the second trimester
* Start 5mg folic acid
## Footnote
*Compared to valproate, lamotrigine has a lower risk of congenital malformations (2-3% vs 5-11%)*
46
What are the key medication considerations for pregnant women with depression?
If mild to moderate depression:
* Consider gradual withdrawal of antidepressant
* Switch to psychological therapy (e.g. CBT) alone, if possible
If severe depression:
* Consider switching to psychological therapy
* Consider combining drug treatment with psychological therapy
* If medication required,
* SSRIs (Fluoxetine; Citalopram; Sertraline)
* Tricyclic antidepressants (Amitriptyline)
47
What are the key medication considerations for pregnant women with thyroid disease?
Hypothyroidism
* Most women will require an increase in their thyroxine
* Adequate intake of iodine is also important
Hyperthyroidism
* Avoid radioisotopes
* Propylthiouracil is preferred to carbimazole
48
Which drugs should **not** be used to treat hypertension during pregnancy and why?
ACE inhibitors
They are both teratogenic and fetotoxic
49
What is the mortality rate of pancreatitis in pregnancy?
Almost 40%
## Footnote
*Always consider this diagnosis in any woman with unexplained abdominal pain.*
50
What is the frequency (%) of the different types of diabetes in pregnancy?
Gestational: **87.5%**
Type I: **7.5%**
Type II: **5%**
51
What is Pederson’s hypothesis?
* Fetal hyperglycaemia results from maternal hyperglycaemia stimulating fetal pancreatic β-cell hypertrophy
* This results in inappropriate release of insulin
* Fetal insulin acts as a growth promoting hormone
## Footnote
*Maternal insulin does not cross the placenta. Glucose crosses the placenta via facilitated diffusion.*
52
What are the potential complications resulting from fetal hyperinsulinaemia?
**Macrosomnia**: traumatic delivery; Erbs palsy
**Organomegaly**: neonatal *hypoglycaemia*
**Increased erythropoiesis**: neonatal polycythaemia
**Decreased surfactant production**: hyaline membrane disease
53
What are the effects of diabetes on pregnancy?
Increased risk of:
* Congenital malformations
* Miscarriage
* Macrosomia (IOL, difficult birth, caesarian section)
* Baby developing obesity or diabetes later in life
* Pre-eclampsia
* UTI/pyelonephritis
* Diabetic ketoacidosis (50% fetal mortality)
* Vaginal candidiasis
54
What are the effects of pregnancy on type I and II diabetes?
* Need for greater doses of insulin
* Worsening of renal disease
* Worsening of retinopathy
* Risk of hypoglycaemia
* Risk of aspiration/Mendelson syndrome if general anaesthetic
55
What is MODY?
**Maturity onset** **diabetes of the young**
Several hereditary forms of diabetes mellitus caused by mutations in an autosomal dominant gene
56
What is LADA?
**Latent autoimmune diabetes of** **adult**
Type I DM with slower progression to insulin dependence
57
Who do we offer the OGTT to and when?
All women who have a risk factor for gestational diabetes
Women with persistent glycosuria, macrosomia, polyhydramnios
Usually offered at 28 weeks, unless previous GDM then 16 to 18 weeks
58
What postpartum care is required for GDM, Type I DM, Type II DM, and neonate?
**GDM**: Insulin not required following delivery of the placenta; offer fasting glucose 6 weeks after birth; annual HbA1c (*increased risk of Type II DM up to 50% by 10 years*)
**Type I**: Insulin 2/3 pre-pregnancy dose
**Type II**: Continue metformin
**Neonate**: Breastfeed within 30 mins and frequent intervals (2-3 hr); monitor blood glucose for at least 24 hours
59
What is Couvade syndrome?
A condition in which a partner experiences some of the same symptoms and behavious as the expectant mother.
For example, minor weight gain, sleep disturbance, morning nausea, and postpartum depression.
60
What is pseudocyesis?
A condition in which the sign and symptoms associated with pregnancy are present when the person is not actually pregnant.
For example, amenorrhoea, morning sickness, and tender breasts.
61
What is tokophobia?
Fear of giving birth
62
How do the following cardiovascular variables change in pregnancy?
Cardiac output
Stroke volume
Heart rate
Blood pressure
Oncotic pressure
**Cardiac output**: increases; 40%
**Stroke volume**: increases
**Heart rate**: increases; 10-120 bpm
**Blood pressure**: decreases in 1st and 2nd trimester; increases in 3rd
**Oncotic pressure**: decreases; 10-15%
63
What is ovarian hyperstimulation syndrome?
A potentially serious complication of fertility treatment, particularly of IVF
64
What are the symptoms of ovarian hyperstimulation syndrome?
Symptoms range from mild to severe:
* **Mild**: mild ascites, discomfort and nausea
* **Moderate**: the ascites is worse, causing abdominal pain and vomiting
* **Severe**: extreme thirst and dehydration, leading to haemoconcentration, thrombosis, distension, oliguria, pleural effusion, and respiratory distress.
65
What is the most common location for a DVT in pregnancy?
Ilio-femoral region
66
Should you do a D dimer test for a pregnant woman with suspected VTE?
**No**
Useless in pregnancy as false positives are high
67
Which imaging modalities should be used to diagnose VTE in pregnancy?
* Doppler ultrasound
* Chest X-ray
* VQ scan if no chest pathology and normal chest X-ray
* CTPA if concomitant chest pathology and abnormal chest X-ray
* Lower radiation dose to fetus but increased lifetime risk of breast cancer (13.6%)
68
How does pregnancy effect asthma?
**Rule of thirds**
1/3 will get worse
1/3 will stay the same
1/3 will get better
69
What are the high-risk and low-risk thrombophilias?
**High-risk thrombophilia**
* Antithrombin deficiency
* Protein C deficiency
* Proten S deficiency
* Compound or homozygous for low-risk thrombophilias
**Low-risk thrombophilia**
* Heterozygous factor V Leiden
* Heterozygous prothrombin G20210A mutation
70
Why should carbimazole not be used to treat hyperthyroidism during pregnancy?
It is associated with aplasia cutis in the fetus
71
What is the treatment for hyperthyroidism during pregnancy?
**Propylthiouracil**
It is not first choice outside of pregnancy as it may cause liver impairment
72
What are the causes of transverse lie and breech presentation?
* Uterine abnormalities, e.g. fibroids
* Abnormal baby
* Polyhydramnios
* Oligohydramnios
* Twins
* Lax uterus (multiparous)
* Placenta praevia
* Preterm labour
* Pelvic mass
73
Define early miscarriage.
Loss of pregnancy before 12 weeks gestation
74
Define late miscarriage.
Loss of pregnancy between 12 and 24 weeks gestation
75
What is loss of pregnancy called after 24 weeks?
Stillbirth
76
What is cervical shock?
Vasovagal syncope produced by stimulation of the cervical canal during dilatation. Rapid, spontaneous recovery usually follows.
77
What are the three management options for miscarriage?
What are the pros and cons of each option?
1. Expectant management
* Pros: avoids hospital and general anaesthetic
* Cons: unpredicatable bleed; bleeding may last up to 3 weeks; passing the fetus can be distressing; it may not be successful (50%)
2. Medical management (misoprostol vaginal pessaries)
* Pros: 85% successful; predictable bleed
* Cons: may cause diarrhoea, nausea, and vomiting; bleeding may last up to 3 weeks; passing the fetus can be distressing
3. Surgical management (evacuation with misoprostol vaginal pessaries)
* Pros: 95% successful; controlled; less pain and bleeding
* Cons: anaesthetic risks; surgical risks (i.e. infection, heavy bleeding, and damage to the uterus)
78
What does the follow-up appointment involve after a miscarriage?
Two to three weeks after:
* Pregnancy test, if positive...
* Ultrasound scan
* Anti-D prophylaxis if RhD negative
79
What is the most common cause of spontaneous recurrent miscarriage?
Antiphospholipid syndrome (15%)
80
Define ectopic pregnancy.
The implantation and development of a pregnancy in any site outside of the uterine cavity.
81
What is the most common location of an ectopic pregnancy?
Ampulla segment of the fallopian tube (70%)
82
What is a heterotopic pregnancy?
The coexistence of an intrauterine pregnancy and an ectopic pregnancy
83
Which sexually-transmitted infection is strongly linked to the rise in ectopic pregnancies?
Chlamydia trachomatis
84
What is pregnancy of unknown location (PUL)?
PUL means that you have a positive pregnancy test but there is no identified pregnancy on an ultrasound scan
85
What are three reasons for pregnancy of unknown location?
1. you may have a very early pregnancy within the uterus that is too small to be seen on a scan
2. you may have miscarried; your pregnancy test can remain positive for up to 2–3 weeks following a miscarriage
3. you may have an ectopic pregnancy
86
What are the symptoms associated with an ectopic pregnancy?
* Lower abdominal pain
* Vaginal bleeding
* Shoulder tip pain
* Diarrhoea
* Dyschezia (pain on opening your bowels)
* Collapse
## Footnote
*May be asymptomatic.*
87
When are most ectopic pregnancies diagnosed?
Between 6 and 10 weeks gestation
88
In regard to the pregnancy hormone βhCG, what does 'doubling time' refer to?
With an intrauterine pregnancy, the hormone level rises by 63% every 48 hours
89
How is an ectopic pregnancy diagnosed?
* Consultation and examination
* Urine pregnancy test
* Ultrasound scan
* Blood test (βhCG test every few days to look for a change)
* Laparoscopy (only if the diagnosis is still unclear)
90
What are the treatment options for tubal ectopic pregnancy?
What is the criteria for each treatment option?
1. Expectant management
* asymptomatic
* low serum βhCG and declining
* size \< 30mm
* no free fluid in pelvis (unruptured)
* no fetal heartbeat
* coexisting intrauterine pregnancy
* available for close monitoring of βhCG levels until \<20iu/L
2. Medical management
* IM methotrexate injection
* no significant pain
* low serum βhCG, ideally \< 1500iu/L but can be up to 5000iu/L
* size \< 35mm
* no free fluid in pelvis (unruptured)
* no fetal heartbeat
* no coexisting intrauterine pregnancy
* willing to attend for follow-up
3. Surgical management
* salpingectomy or salpingostomy
* significant pain or haemodynamically unstable
* high serum βhCG \> 5000iu/L
* size \> 35mm
* free fluid in pelvis (ruptured)
* fetal heartbeat visible
* coexisting intrauterine pregnancy
* unable to attend for follow-up
91
What are the risks of salpingostomy?
* Greater risk of future ectopic pregnancies
* 8% risk of persistent trophoblastic tissue
92
Do rhesus D-negative women with an ectopic pregnancy require anti-D immunoglobulin?
**Yes**, if they have surgical removal of an ectopic pregnancy, or where bleeding is repeated, heavy or associated with abdominal pain
93
What are the clinical features of gestational trophoblastic disease?
* Vaginal bleeding
* Hyperemesis
* Large for dates uterus
* Early failed pregnancy
* Hyperthyroidism\*
* Early pre-eclampsia
* Abdominal distension due to theca lutein cysts
## Footnote
*\*hCG can mimic thyroid-stimulating hormone*
94
What investigations would you do to confirm gestational trophoblastic disease and what results would you expect?
**Blood test**: markedly elevated serum hCG
**Ultrasound scan**: 'snowstorm' appearance
95
Gestational trophoblastic disease is a term used for a group of rare pregnancy-related tumours. What are the different types?
Benign/pre-malignant tumour
* Hydatidiform mole
Malignant tumours
* Invasive mole (local invasion)
* Choriocarcinoma (metastasis)
* Placental site trophoblastic tumour (presents years later)
96
Hydatidiform mole can be subdivided into *complete* and *partial* mole. What is the difference and how do they commonly arise?
**Complete mole**: diploid tissue; no evidence of a fetus
* Entirely paternal origin; usually single sperm fertilises an empty oocyte and undergoes mitosis; typically 46XX
**Partial mole**: triploid tissue; variable evidence of a fetus
* Usually two sperm fertilise a haploid oocyte; typically 69XXY
97
How do you manage a molar pregnancy?
* **Complete mole**: suction curettage (ERPC). Anti-D prophylaxis is not required.
* **Partial mole**: suction curettage (ERPC), unless size of the fetal parts deters this and then medical evacuation can be used but avoid where possible (potential risk of increasing trophoblastic embolisation by inducing uterine contractions). Anti-D prophylaxis is required.
* Serial blood or urine hCG levels taken thereafter
* Register with supraregional centre who guide follow-up
* Avoid pregnancy until after completion of suveillance period
98
Where is human chorionic gonadotropin produced?
The human placenta by the syncytiotrophoblast
99
What is the role of human chorionic gonadotropin?
It promotes the maintenance of the corpus luteum during the beginning of pregnancy. This allows the corpus luteum to secrete the hormone progesterone during the first trimester.
100
What is the role of progesterone?
Progesterone:
* Enriches the uterus with a thick lining of blood vessels and capillaries so that it can sustain the growing fetus (secretory stage)
* Decreases uterine contractility
* Inhibits lactation
101
What level of progesterone suggests an intrauterine pregnancy?
**\> 60 nmol/l**
\<20 nmol/l = non-viable pregnancy
102
What is the Bishop score used for?
To help assess whether induction of labour will be required.
103
What Bishop score indicates that labour is unlikely to start without induction?
\< 5
104
What Bishop score indicates that labour will most likely commence spontaneously?
\> 9
105
What is the most dangerous location of an ectopic pregnancy and why?
**Isthmus of the fallopian tube**
Increased risk of rupture
106
How do you treat mastitis in a breastfeeding woman?
If systemically unwell, infected nipple fissure, symptoms don't improve after 12-24 hours despite effective milk removal and/or breast milk culture positive:
* **Flucloxacillin for 10 to 14 days**
* Breastfeeding is safe to continue
Otherwise:
* Continue breastfeeding
* Use simple analgesia
* Use warm compresses
107
It is safe for a woman with hepatitis B to breastfeed her child?
Yes
108
How do you treat a Bartholin's cyst?
Marsupialisation procedure
109
What are the risk factors for endometrial cancer?
* Obesity
* Nulliparity
* Early menarche
* Late menopause
* Diabetes mellitus
* Tamoxifen
* Polycystic ovarian syndrome
110
How is premature ovarian failure defined?
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years
111
What are the three components of the risk malignancy index (RMI)?
1. CA125 levels\*
2. Menopausal status
3. Ultrasound score
## Footnote
*\*If 35 IU/mL or greater then an urgent ultrasound scan of the abdomen and pelvis should be ordered*
112
Which ovarian tumour is associated with the development of endometrial hyperplasia?
Granulosa cell tumour
113
How does Trichomonas vaginalis present?
Frothy yellow vaginal discharge
May also have a 'strawberry' cervix
114
How do you treat Trichomonas vaginalis?
Oral metronidazole
115
How does Bacterial vaginosis present?
Offensive fishy smelling vaginal discharge
Not associated with soreness, itching, or irritation
Many women (approx 50%) are asymptomatic
116
How do you manage Bacterial vaginosis?
If symptomatic and/or pregnant:
* Oral metronidazole
General advice:
* Avoid vaginal douching
* Avoid overwashing
* Avoid perfumed soap, shower gel, shampoo etc
117
How does vulvovaginal candidiasis present?
Cream 'cottage cheese'-like vaginal discharge
Vulval itch and soreness
Superficial dyspareunia
118
How do you treat vulvovaginal candidiasis?
If not pregnant:
* Clotrimazole pessary or vaginal cream; or
* Fluconazole orally
If pregnant: topical imidazoles only
General Advice:
* Vulval moisturisers
* Avoid tight-fitting synthetic clothing
* Avoid irritants e.g. perfumed products
119
What are the most common causes of vaginal discharge?
* Physiological
* Candida
* Trichomonas vaginalis
* Bacterial vaginosis
120
What type of bacteria is Neisseria gonorrhoeae?
Gram-negative diplococcus
121
How does gonorrhoea present?
Mucopurulent yellow-green urethral discharge
122
How do you treat gonorrhoea?
Ceftriaxone 500mg IM as a single dose with azithromycin 1g oral as a single dose
## Footnote
*Patients should be advised to abstain from sexual intercourse until they and their partner(s) have completed treatment; if azithromycin is used, this will be 7 days after treatment was given.*
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What are the potential complications of disseminated gonorrhoea infection?
* Pelvic inflammatory disease
* Epididymo-orchitis
* Infective arthritis and tenosynovitis
* Distal skin lesions
* Conjunctivitis
124
What are the potential complications of a chlamydia infection?
* Pelvic inflammatory disease
* Infertility
* Peri-hepatitis
* Chronic pelvic pain
* Reactive arthritis
* Neonatal infection
125
How does chlamydia present?
* Majority of women are asymptomatic
* Men may present with mild urethral discharge and/or dysuria
126
How do you treat chlamydia?
* Doxycycline 100mg bd for 7 days (contraindicated in pregnancy); or
* Azithromycin 1g orally as a single dose, followed by 500mg once daily for 2 days
127
What are the symptoms of endometriosis?
* Chronic pelvic pain
* Dysmenorrhoea
* Deep dyspareunia
* Subfertility
* Urinary symptoms e.g. dysuria, urgency, haematuria
* Dyschezia
128
When should women who have been treated for cervical intraepithelial neoplasia be next offered cervical screening?
**At 6 months**
Perform HPV test of cure
129
What are the risk factors for hyperemesis gravidarum?
* Multiple pregnancies
* Trophoblastic disease
* Hyperthyroidism
* Nulliparity
* Obesity
130
Which lifestyle choice is associated with a decreased incidence of hyperemesis?
Smoking
131
What is the initial management of nausea and vomiting of pregnancy and hyperemesis gravidarum?
**Antiemetics**
Anti-histamines (H1 receptor antagonists) such as Cyclizine
132
Define premature ovarian failure.
The onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
133
Name three UKMEC 3 and UKMEC 4 conditions for the combined oral contraceptive pill.
UKMEC 3
* more than 35 years old and smoking less than 15 cigarettes/day
* BMI \> 35
* family history of thromboembolic disease in first degree relatives \< 45 years
* controlled hypertension
* immobility e.g. wheelchair use
* carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
UKMEC 4
* more than 35 years old and smoking more than 15 cigarettes/day
* migraine with aura
* history of thromboembolic disease or thrombogenic mutation
* history of stroke or ischaemic heart disease
* breast feeding \< 6 weeks post-partum
* uncontrolled hypertension
* current breast cancer
* major surgery with prolonged immobilisation
134
What should you do if you are asked to come for a routine smear test while you are pregnant?
Delay the appointment until 3 months after your baby is born
135
What should you do if you are pregnant and are called for a repeat smear after a previous abnormality?
You should go for the smear.
## Footnote
*The best time to have it done is between 3 and 6 months of pregnancy.*
136
What is the average menstrual cycle length?
23 - 35 days
137
What is the first-line treatment for heavy menstrual bleeding?
Levonorgestrel-releasing intrauterine system
138
If a woman with heavy menstrual bleeding declines an LNG-IUS or it is not suitable, what other options should you consider?
Non-hormonal:
* tranexamic acid
* NSAIDs (non-steroidal anti-inflammatory drugs)
Hormonal:
* combined hormonal contraception
* cyclical oral progestogens
139
Is the haemoglobin concentration going to be high or low in women with symptomatic fibroids?
Trick question!
It may be low due to heavy menstrual bleeding
It may be high as fibroids secrete erythropoietin
140
What is Meig's syndrome?
Clinical triad:
1. Ovarian mass, usually fibroma
2. Ascites
3. Plural effusion
141
What are the two types of vulval intraepithelial neoplasia (VIN) and how do they differ?
Usual type VIN:
* Associated with HPV, CIN, smoking and immunosuppression
* Multifocal
* Linked to warty or basaloid squamous cell carcinoma
Differentiated type VIN:
* Associated with lichen sclerosis
* Unifocal ulcer or plaque
* Linked to keratinising squamous cell carcinoma
142
What are the Rotterdam criteria?
**The criteria required to make a diagnosis of** **polycystic** **ovarian syndrome**
2 of 3 required:
* morphology on ultrasound
* irregular periods \>35 days apart
* clinical or biochemical hirsutism
143
How do you treat syphilis?
Parenteral penicillin
144
How can women avoid vertical transmission of HIV?
* Elective caesarean section
* Anti-retroviral therapy
* Avoid breastfeeding
145
Treatment for acute pelvic inflammatory disease?
* Analgesia
* IM Ceftriaxone
* Metronidazole and doxycycline
146
Bacterium responsible for puerperal sepsis?
**Group A streptococcus**
Chorioamnionitis may ensue
147
Bacterium responsible for neonatal sepsis?
**Group B streptococcus**
148
