Womens Health (Joe) Flashcards

Question

What are some possible complications of Pelvic Organ Prolapse Surgery?

Answer 1

* Pain, bleeding, infection, DVT and risk of anaesthetic * Damage to the bladder or bowel * Recurrence of the prolapse * Altered experience of sex

Answer 2

Involuntary passage of urine

Answer 3

A chronic condition that results rom hyperactivity of the **detrusor muscle**. This is primarily characterised by **urinary urgency and urge incontinence**

Answer 4

* **Urinary Urgency** * **Urge Incontinence** * Frequency * Nocturia

Answer 5

* Typical description is of suddenly feeling the urge to pass urine, having to rush to the bathroom and not arriving before urination occurs. * Women with urge incontinence are very conscious about always having access to a toilet, and may avoid activities or places where they may not have easy access. * This can have a significant impact on their quality of life, and stop them doing work and leisure activities.

Answer 6

* **Urinary tract infections:** Characterised by dysuria, urgency, frequency, suprapubic pain and haematuria. * **Bladder stones:** Symptoms include lower abdominal pain, dysuria, intermittent stream, and blood in the urine. * **Interstitial cystitis:** Presents with symptoms such as chronic pelvic pain, a persistent, urgent need to urinate, and frequent urination. * **Diabetic neuropathy:** Can cause bladder dysfunction, resulting in symptoms like frequent urination and incontinence.

Answer 7

* **Urinalysis and culture:** To rule out infection * **Frequency/volume chart:** To assess the severity of the condition * **Urodynamics:** To evaluate bladder muscle function

Answer 8

**First Line: For at least 6 weeks:** * **Bladder retraining:** Which aims to increase the interval between voids, and suppress the urinary urge * **Behavioural modifications:** Such as reducing oral fluid intake, and avoiding caffeine and alcohol **Second Line:** * **Anticholinergic drugs:** Like oxybutynin, Tolterodine and solifenacin * **Mirabegron:** An alternative to anticholinergics * **Vaginal oestrogens:** Used if urogenital atrophy is a likely contributory factor **Invasive options when medical treatments fail** * **Botulism toxin:** Used specifically for refractory cases

Answer 9

* Oxybutynin * Tolterodine * Solifenacin

Answer 10

* Dry mouth and eyes * Urinary Retention * Constipation * Postural Hypotension * Cognitive decline and memory problems * Worsening of Dementia

Answer 11

A beta 3 agonist that stimulates the sympathetic nervous system causing relaxation of the bladder.

Answer 12

**Uncontrolled Hypertension.** * Since it stimulates the sympathetic nervous system it can lead to a raised blood pressure and can result in a hypertensive crisis! * Can also increase the risk of stroke and TIA

Answer 13

* **Botulinum toxin type A** injection into the bladder wall * **Percutaneous sacral nerve stimulation** involves implanting a device in the back that stimulates the sacral nerves * **Augmentation cystoplasty** involves using bowel tissue to enlarge the bladder * **Urinary diversion** involves redirecting urinary flow to a urostomy on the abdomen

Answer 14

The loss of control of urination leading to involuntary passage of urine

Answer 15

* Impulses from the cerebral cortex are transmitted to the pontine continence centre. * The **pontine continence centre** sends signals to sympathetic nuclei within **T10-L2** sympathetic ganglia, which then sends further signals to the detrusor and internal urethral sphincter muscles via the sympathetic hypogastric nerve, stimulating: * Relaxation of the detrusor muscle. * Contraction of the internal urethral sphincter. * Somatic innervation of the external urethral sphincter also contributes to continence during bladder filling

Answer 16

* Afferent signals from the distended bladder ascend via the **spinal cord to the pontine micturition centre** and the cerebral cortex (conscious urge to pass urine). * **Efferent parasympathetic** signals to the detrusor cause it to contract, transmitted via **S2-4 pelvic splanchnic nerve.** * **Inhibition of Onuf’s nucleus** (due to pontine micturition centre activity) reduces sympathetic storage-promoting activity. * Conscious relaxation of external urethral sphincter via somatic pudendal nerve fibres allows passage of urine.

Answer 17

Sympathetic - T10-L2 hypogastric - detrusor relaxation, IUS closing * Parasympathetic - S2-4 pelvic splanchnic - detrusor contraction, IUS opening * Somatic afferent - S2-4 pudendal - sensation of bladder fullness * Somatic efferent - S2-3 pudendal - closes / opens EUS.

Answer 18

1. Reflexive contraction of the pelvic floor muscles elevates the IUS. 2. Augmentation of pelvic floor muscle closure by suspensory ligaments. 3. Urethrovaginal sphincter and compressor urethrae muscle contraction assists with urethral closure

Answer 19

* Stress incontinence * Urge incontinence * Overflow incontinence * Functional incontinence * Mixed incontinence

Answer 20

Caused by **Overactivity of the detrusor muscle.** This is also known as overactive bladder syndrome

Answer 21

Leaking of urine when intra-abdominal pressure is raised that puts pressure on the bladder. The pressure overcomes the mechanisms to maintain continence. **This occurs due to weakness of the pelvic floor and sphincter muscles**

Answer 22

* Childbirth (Especially vaginal) * Hysterectomy

Answer 23

**Anything that can increase abdominal pressure sufficiently** * Coughing * Laughing * Sneezing * Exercising

Answer 24

**Lifestyle Advice:** * Avoid caffeine, fizzy and sugary drinks * Avoid excessive fluid intake * Pelvic floor exercises (8x contractions x3 per day) **Medical Management:** * **Duloxetine** (only recommended if conservative management fails and the patient is not a surgical candidate) **Surgical Management:** * Pessaries * **Bulking agents** placed at the bladder neck * **Colposuspension and fascial slings** * **Mid urethral slings

Answer 25

**Mid-urethral slings** is the gold standard surgical treatment of stress incontinence. It compresses the urethra against a supportive layer and assists in closing the urethra.

Answer 26

Individual has the urge to pass urine but for whatever reason they are unable to access the necessary facilities and are aw a result incontinent.

Answer 27

* Sedating Medications * Alcohol * Dementias

Answer 28

Occurs when small amounts of urine leak without warning. This may happen when the pressure within the bladder overcomes the pressures of the outlet structure and thus urine leaks

Answer 29

* Underactivity of the detrusor muscle **such as from neurological damage** * Urinary outlet pressures are too high **Such as in constipation or prostatism** * Chronic urinary retention due to an obstruction. * Anti-cholinergic medications.

Answer 30

A combination of urge incontinence and stress incontinence. It is crucial to identify which of the 2 is having the more significant impact and address this first.

Answer 31

**First Line:** * **Medical history and Assessment** * **Physical Examination** * **Bladder Diary:** tracking fluid intake, episodes of urination and incontinence **over at least 3 days** * **Urinalysis and Urine-Dip stick:** To look for infection or other pathology **Second Line:** * **Urinary Stress Tests:** Cough stress test, empty supine stress test * **Cystometry and Cystogram:** Bladder scan to assess for bladder pressures when voiding or fistulas * **Urodynamics**

Answer 32

**Differentiate between Stress or Urge:** * Urinary leakage with coughing, laughing or sneezing (**Stress**) * Urinary leakage due to sudden urge to pass with loss of control (**Urge**) **Assess for Modifiable lifestyle factors:** * Caffeine consumption * Alcohol consumption * Medications (anticholinergics) * BMI **Assess the Severity:** * Frequency of urination * Frequency of incontinence * night-time urination * Use of pads and changes of clothing.

Answer 33

**Assessment of Pelvic Tone:** 0: No contraction 1: Faint contraction 2: Weak contraction 3: Moderate contraction with some resistance 4: Good contraction with resistance 5: Strong contraction, a firm squeeze and drawing inwards **Also examine for** * Pelvic organ prolapse * Atrophic vaginitis * Urethral diverticulum * Pelvic masses * urinary incontinence (asking the patient to cough)

Answer 34

* Patients with Urge incontinence **not responding to first line medical treatments** * Difficulties urinating * Urinary retention * Previous surgery in and around the pelvis * Unclear diagnosis

Answer 35

* Patients should stop taking anticholinergic and bladder related medications for **5 days before** testing. * A catheter is inserted into the bladder and the rectum and they measure the pressures for comparison. The bladder is filled with liquid and different measurements are taken.

Answer 36

* **Cystometry** measures the detrusor muscle contraction and pressure * **Uroflowmetry** measures the flow rate * **Leak Point Pressure** is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence. * **Poist-void residual bladder volume** tests for incomplete emptying of the bladder * **Video urodynamic testing** involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

Answer 37

Urinary tract stones or Urolithiasis refer to solid concretions or crystal aggregations formed in the urinary system from substances present in the urine

Answer 38

A condition characterised by severe pain caused by the presence of a stone in the urinary tract

Answer 39

* Common condition affecting 2-3% of western population * More common in males * More common in people **younger than 65**

Answer 40

**Calcium oxalate stones:** * Represent **85% of stones**. They are radiopaque, formed in variable urine pH, and majorly linked to **hypercalciuria**. **Calcium phosphate stones:** * Account for **10% of stones**. They are radiopaque and linked to **renal tubular acidosis type 1 & 3,** leading to increased urine pH and supersaturation of calcium and phosphate in the urine. **Cystine stones:** * Make up **1% of stones**. Characterised by a semi-opaque "ground glass" appearance, they result from inherited recessive inborn errors of metabolism causing disruption in cystine transport and decreased absorption from the renal tubule. **Uric acid stones:** * Comprise **5-10 of stones.** They are radiolucent, formed due to acid produced from **purine metabolism and precipitate when urinary pH is low.** They can be linked to diseases causing extensive tissue breakdown. **Struvite stones:** * Account for **2-20% of stones**. They are radiopaque and formed from magnesium, ammonium, and phosphate, often **associated with chronic UTIs from urease producing bacteria like ureaplasma, proteus.** **Indinavir stones:** * Associated with the antiretroviral protease inhibitor Indinavir** used in HIV treatment. It can crystallize in renal tubules and result in renal stones. These stones are radiolucent on CTKUB.

Answer 41

**Hypercalcaemia/Hypercalciuria** Patients may present with symptoms of hypercalcaemia (**renal stones, painful bones, abdominal groans and psychiatric moans**) **3 Main causes of Hypercalcaemia:** * Calcium supplementation * Hyperparathyroidism * Cancer (Myeloma, Breast, Lung)

Answer 42

**Modifiable risk factors include:** * Obesity * Dehydration * Diet rich in oxalate-rich foods like fruits, nuts, and cocoa **Non-modifiable risk factors include:** * Previous stone disease * Anatomical abnormalities of the collecting system * Family history **Underlying medical conditions, such as:** * Hyperparathyroidism * Renal tubular acidosis * Myeloproliferative disorders * All chronic diarrhoeal conditions

Answer 43

Where the stone forms in the shape of the renal pelvis giving it a similar appearance to the antlers of a deer stag. Often associated with **Struvite stones**

Answer 44

* Unilateral ** Colicky loin to groin pain** that can be excruciating (“worse than childbirth”) * Haematuria * Nausea or vomiting * Reduced urine output * Symptoms of sepsis (Fever), if infection is present

Answer 45

* **Pyelonephritis:** Presents with fever, flank pain, and urinary symptoms such as frequency, urgency, and dysuria. * **Appendicitis:** Presents with right lower quadrant pain, nausea, vomiting, and possibly fever. * **Diverticulitis:** Presents with left lower quadrant pain, fever, nausea, vomiting, and changes in bowel habits. * **Ovarian torsion:** Presents with acute lower abdominal pain, nausea, vomiting, and sometimes fever. * **Ectopic pregnancy:** Presents with lower abdominal pain, vaginal bleeding, and a positive pregnancy test. * **Abdominal aortic aneurysm:** Presents with central abdominal pain, pulsatile/expansile abdominal aorta and if ruptured, haemodynamic instability.

Answer 46

**Bedside investigations:** * Urinalysis to detect haematuria * Urine MC+S as there may be a co-existing infection/precipitant. * Observations to look for any signs of sepsis **Blood tests:** * Full Blood Count to detect any inflammatory response * Urea and Electrolytes to assess any impairment in renal function. * Calcium & Uric acid to identify underlying metabolic conditions predisposing to stone formation. **Radiological investigations:** * A **non-contrast helical CT KUB, the gold standard for identifying renal calculi.** * An x-ray for managing renal colic if there's a confirmed stone on CT KUB, **necessary for the use of extracorporeal shockwave lithotripsy.**

Answer 47

**Non-contrast CT Kidney, Ureter and Bladder (CTKUB)** is both the **initial** and **Gold standard investigation** * NICE recommend a CT within **24 hours** of presentation

Answer 48

* **Analgesia:** NSAIDs such as **IM Diclofenac** * **Anti-emetics:** Metoclopramide, Cyclizine * **Antibiotics:** If infection is present * **Medical Expulsive Therapy:** Uses Tamsulosin to help passage of distal ureter stones < 5mm * **Watchful Waiting:** If stones are less than **5mm** * **Surgical Intervention:** required in larger stones **10mm** or more or ones that do not pass spontaneously. Also required if there is complete obstruction or infection.

Answer 49

**Stones < 2cm** * Extracorporeal shockwave lithotripsy (ESWL): shock waves fragment the stone to then be passed * **Ureteroscopy:** Treatment of choice for middle or distal ureteric stones and for **Pregnant women** **Stones > 2cm** * **Percutaneous nephrolithotomy:** for large stones or complex calculi like staghorn or cysteine. * **Open Stone surgery:** when other options have failed.

Answer 50

* **Significant risk of recurrent episodes** * Obstructive infection * Sepsis * Renal Failure

Answer 51

* Increase oral fluid intake (2.5 – 3 litres per day) * Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones) * Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation) * Reduce dietary salt intake (less than 6g per day) * Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)

Answer 52

Infrequent/irregular menstrual periods (fewer than 6-8 per year)

Answer 53

Absence of a menstrual period **Primary:** absence of a period at age 15 in the presence of normal secondary sexual characteristics **or** at age 13 with no secondary sexual characteristics **Secondary:** Absence of a period for 3 consecutive cycles in a women with a previously established menstrual cycle

Answer 54

* Constitutional delay (Familial) * Imperforate hymen * **Endocrinological:** Hypo-hyperthyroidism, Hyperprolactinaemia, Cushing's Syndrome * **Androgen Insensitivity Syndrome** * Turners syndrome

Answer 55

* **Pregnancy** (most common cause) * Breastfeeding * Menopause * Intrauterine adhesions leading to outflow tract obstruction **(Asherman's syndrome)** * Polycystic ovary syndrome (PCOS) * Drug-induced amenorrhoea (e.g. contraceptive use) * **Functional Hypothalamic Amenorrhoea:** Physical stress, excess exercise, and weight loss * **Pituitary gland pathology:** such as Sheehan syndrome or hyperprolactinaemia * **Hypothyroidism or hyperthyroidism**

Answer 56

An **X-linked Recessive** genetic condition where cells are unable to respond to androgen hormones due to **a lack of androgen receptors** This results in **Genetic Males** with a **Female Phenotype**

Answer 57

* Mutation in Androgen receptor gene on the *X chromosome** results in cells becoming unable to respond to androgens. * Excess androgens are converted to Oestrogen resulting in **female secondary sexual characteristics** (Previously known as **Testicular feminisation syndrome**) * Males are genetically XY with a female phenotype

Answer 58

* Female External Genitalia and Breast Development * Testes located within the abdomen or inguinal canal. * Absence of Female internal organs (Uterus, upper vagina, cervix, fallopian tubes and ovaries) due to the **testes producing anti-Mullerian hormone**. * Patients are taller than female average, with a lack of pubic hair, facial hair and male type muscle bulk.

Answer 59

High risk of Testicular cancer unless the testes are removed

Answer 60

* **Often presents in infancy** with **Inguinal hernias containing testes** * May present at puberty with **Primary Amenorrhoea**

Answer 61

**Hormonal Tests:** To assess levels of FSH, LH and Oestradiol **Genetic Testing:** Identify chromosomal or genetic abnormalities **Imaging:** To identify structural abnormalities

Answer 62

* Raised LH * Normal or raised FSH * Normal or Raised Testosterone levels (For a male) * Raised Oestrogen levels (For a male)

Answer 63

**Depends on the underlying cause** * **Hormone replacement therapy:** For hormonal imbalances * **Surgery:** For structural abnormalities * **Psychological support:** For conditions related to stress or eating disorders * **Lifestyle modifications:** For issues related to excessive exercise or low body weight * **Monitoring and regular follow-ups:** To assess effectiveness of treatment and adjust as necessary

Answer 64

MDT Specialist Coordination: Paediatrics, Gynaecology, Urology, Endocrinology, Clinical Psychology * **Bilateral Orchiectomy:** To avoid testicular tumours * **Oestrogen Therapy** * **Vaginal Dilators or Vaginal Surgery:** To create and adequate length vagina **Generally patients are raised as female but this is tailored to the individual**

Answer 65

They develop from the **paramesonephric ducts** (**Mullerian ducts**)

Answer 66

The testes in a male foetus produce Anti-Mullerian hormone which suppresses the growth of the paramesonephric ducts and so they do not form.

Answer 67

* Bicornuate Uterus * Uterus Agenesis * Imperforate Hymen * Transverse vaginal Septae * Vaginal Hypoplasia and Agenesis

Answer 68

* Uterus has 2 horns giving it a heart shaped appearance. * This can be associated with adverse pregnancy outcomes however successful pregnancies are generally expected.

Answer 69

* Miscarriage * Premature Birth * Malpresentation

Answer 70

Where the hymen at the entrance of the vagina is fully formed without an opening.

Answer 71

* May be discovered when the girl starts to menstruate, and the menses are sealed in the vagina. * This causes cyclical pelvic pain and cramping that would ordinarily be associated with menstruation, but without any vaginal bleeding.

Answer 72

* Diagnosed during a **clinical examination** * Treatment is a **Surgical incision** to create an opening in the hymen.

Answer 73

* If not treated then **retrograde menstruation** could occur leading to **endometriosis** * Amenorrhoea

Answer 74

Caused by an error in development, where a septum (wall) forms transversely across the vagina. This septum can either be perforate (with a hole) or imperforate (completely sealed).

Answer 75

* **Perforate Septae:** Girls will menstruate but can have difficulty with intercourse or tampon use * **Imperforate Septae:** Presents similarly to an Imperforate Hymen

Answer 76

* Infertility * Pregnancy related complications * **Vaginal Stenosis** * **Recurrence of the Septae**

Answer 77

* Diagnosis is by **Examination, Ultrasound or MRI** * Treatment with with **Surgical Correction**

Answer 78

**Hypoplasia:** An Abnormally small vagina **Agenesis:** An absent vagina These occur due to failure of the Mullerian ducts to properly develop and are often associated with an absent uterus and cervix

Answer 79

The Mullerian Ducts fail to develop but not due to Anti-Mullerian Hormone. Therefore patients do not have Testes (like in AIS) but **do have Ovaries**

Answer 80

* **Vaginal Dilator** over a prolonged period of time to create and adequate vaginal size * **Vaginal Surgery** may be necessary

Answer 81

The first occurrence of Menstruation

Answer 82

Mean age 13 11-15 usually.

Answer 83

This term describes the permanent cessation of menstruation, characterised by **at least 12 months of amenorrhoea** in otherwise healthy women over the age of 45 who are not using hormonal contraception.

Answer 84

Between the ages of 45-55 with the average age being around 51-52 years old.

Answer 85

* The time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. * Perimenopause **includes the time leading up to the last menstrual period, and the 12 months afterwards.** * This is typically in women older than 45 years.

Answer 86

The period from 12 months after the final menstrual period

Answer 87

Menopause before the age of 40 years old. It is the result of premature ovarian insufficiency

Answer 88

Caused by ovarian failure which leads to oestrogen deficiency

Answer 89

* Decline in the development of Ovarian follicles * Without the follicles there is reduced production of oestrogen * Oestrogen has a negative feedback effect on the pituitary * As oestrogen levels fall in the perimenopause period, this negative feedback is lost * Increasing levels of LH and FSH * Failing follicular development means ovulation does not occur * This results in irregular menstrual cycles. * Without Oestrogen the endometrium does not develop eventually leading to a lack of menstruation (amenorrhoea)

Answer 90

Lower levels of Oestrogen

Answer 91

**Vasomotor Symptoms:** * Hot flushes * Night sweats * Irregular periods, Heavy or lighter periods * Joint Pains **Sexual Dysfunction:** * Vaginal dryness and atrophy * Reduced libido * Problems with Orgasm * Dyspareunia **Psychological Symptoms:** * Depression * Anxiety * Mood Swings, Low mood and emotional lability * Lethargy * Reduced Concentration

Answer 92

**Reduced oestrogen increases the risk of certain conditions:** * Cardiovascular disease and stroke * Osteoporosis due to increased bone turn over since normal oestrogen levels inhibit osteoclast activity * Pelvic Organ Prolapse * Urinary Incontinence

Answer 93

* **Thyroid disease:** symptoms can include hot flushes, sweating, palpitations, and changes in menstrual cycle * **Depression:** exhibits mood swings, lethargy, reduced concentration * **Premature ovarian insufficiency:** can cause hot flushes, night sweats, vaginal dryness, and reduced libido

Answer 94

**Diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms without performing any investigations** NICE Guidelines (2015) recommend FSH Blood test to help with Diagnosis: * **Women under 40 years** with suspected premature menopause * **Women aged 40-45** with menopausal symptoms or a change in menstrual cycle * Elevated FSH level **(>30 IU/L)** may predict impending menopause after several months of amenorrhoea

Answer 95

**Two years** after the last menstrual period in women **under 50** **One year** after the last menstrual period in women **over 50**

Answer 96

Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms. This can make diagnosing menopause in women on hormonal contraception more difficult.

Answer 97

Barrier methods Mirena or copper coil Progesterone only pill Progesterone implant Progesterone depot injection (under 45 years) Sterilisation

Answer 98

**Weight Gain and Reduce bone mineral density (osteoporosis)** This is why this form of contraception is unsuitable for women **Over 45 years old**

Answer 99

**Vasomotor symptoms likely resolve after 2-5 years without treatment** **Management of Symptoms depends on severity, personal circumstances and response to treatment** **First Line: Lifestyle Measures** * Regular Exercise * Weight Loss (as necessary) * Avoidance of triggers (Smoking, alcohol, spicy food) **Second line: Hormone replacement therapy (HRT)** * **Tibolone**, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) * **Clonidine**, which act as agonists of alpha-adrenergic and imidazoline receptors * **Cognitive behavioural therapy (CBT)** * **SSRI antidepressants**, such as fluoxetine or citalopram * **Testosterone** can be used to treat reduced libido (usually as a gel or cream) * **Vaginal oestrogen** cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) * **Vaginal moisturisers**, such as Sylk, Replens and YES

Answer 100

**Oestrogens:** Overcome oestrogen deficiency **Progesterone's:** Required for endometrial protection from unopposed systemic oestrogens * HRT can be given cyclically (for perimenopause) or continuously (for post menopause)

Answer 101

**Benefits** * Relief of Vasomotor symptoms * Relief of urogenital symptoms * Reduced risk of Osteoporosis **Risks** * Increased risk of Breast Cancer * Increased risk of Endometrial Cancer (**if given oestrogen alone**) * Increased risk of VTE

Answer 102

* History of breast cancer, any oestrogen-dependent cancer, current undiagnosed PV bleeding, current endometrial hyperplasia. * History of idiopathic VTE (if not anticoagulated). * Thromboembolic disease e.g. MI, angina * Liver disease. * Inherited thrombophilia. * Pregnancy.

Answer 103

Refers to a condition where **endometrial tissue** is inside the **myometrium** (muscle layer of the uterus)

Answer 104

* More common in **later reproductive years** * More common in those **who have had several pregnancies (Multiparous)** * Occurs in around 10% of women * May occur alone or alongside endometriosis or fibroids

Answer 105

**Not fully Understood** * Multiple factors involved including **Sex hormones, trauma and inflammation** * Condition is hormone dependent

Answer 106

* Painful periods (dysmenorrhoea) * Heavy periods (menorrhagia) * Pain during intercourse (dyspareunia) * Infertility or pregnancy related complications * **1/3 of patients are asymptomatic**

Answer 107

**First Line:** * Transvaginal Ultrasound of the pelvis * MRI and Transabdominal ultrasound are alternatives if transvaginal is unsuitable **Gold Standard:** * Histological examination of the uterus after a hysterectomy * Not usually a suitable way of establishing the diagnosis for obvious reasons

Answer 108

**Depends on symptoms, age and plans for pregnancy** **Women does NOT want contraception** * **Tranexamic Acid** when there is no pain associated (antifibrinolytic) * **Mefenamic Acid** when there is pain associated (NSAID) **Women DOES want Contraception:** * **Mirena coil** - First Line * Combined Oral Contraceptive Pill (COCP) * Cyclical oral progestogens **Other options considered by specialist** * GnRH analogues to induce menopause like state * Endometrial ablation * Uterine artery embolisation * Hysterectomy

Answer 109

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

Answer 110

Where adhesions form within the uterus (intrauterine adhesions) following damage to the uterus that lead to outflow tract obstruction.

Answer 111

**Anything that creates scar tissue within the uterus causing adhesions that are normally not connected** * Pregnancy related **dilateion and Curettage procedure** * Treatment of retained productions of conception (removing placental tissue left behind after birth) * Uterine surgery (myomectomy) * Pelvic infection (endometritis)

Answer 112

* Damage to the uterus causing scar tissue formation and subsequent adhesions. * Adhesions form **Physical Obstructions** and distort the pelvic organs * Leads to **menstruation abnormalities, infertility, recurrent miscarriages**

Answer 113

**Presents following recent dilatation and curettage, uterine surgery or endometritis with:** * **Secondary amenorrhoea** * Significantly lighter periods * Dysmenorrhoea * Infertility **Incidentally found adhesions that are asymptomatic are not classed as Asherman's Syndrome**

Answer 114

**History of uterine surgery** **Hysteroscopy** is **Gold Standard investigation** and can involve dissection and treatment of adhesions. **Others:** * Hysterosalpingography when contrast is injected into the uterus and imaged with X-rays * Sonohysterography uterus is filled with fluid and pelvic USS is performed * MRI Scan

Answer 115

* Dissecting the adhesions during hysteroscopy. * Reoccurrence of the adhesions after treatment is common

Answer 116

The **primary symptom of secondary amenorrhoea is the absence of menstrual periods for six months or longer.** Additional symptoms, depending on the underlying cause, may include: * **Pregnancy symptoms:** nausea, breast tenderness, increased urination, food cravings or aversions * **Menopause symptoms:** hot flashes, night sweats, sleep problems, mood changes * **Symptoms of PCOS:** acne, weight gain, hirsutism (excessive body hair), thinning hair * **Symptoms of pituitary gland issues:** headaches, vision problems, unexplained weight gain or loss

Answer 117

* Pregnancy test * **Hormone level checks:** including FSH, LH, TSH, prolactin, and testosterone * **Ultrasound** or other imaging studies, to identify potential structural abnormalities * Hysteroscopy, in cases where intrauterine adhesions are suspected

Answer 118

**Management of secondary amenorrhoea is determined by the underlying cause:** * **Pregnancy:** regular prenatal care * **Menopause:** hormone replacement therapy (HRT) if symptoms are troublesome * **PCOS:** lifestyle changes, hormonal contraceptives, and potentially metformin * **Asherman's syndrome:** surgical removal of adhesions and hormone therapy * **Drug-induced amenorrhoea:** discontinuing the offending drug if possible and safe to do so * **Conditions related to physical stress, weight loss, or excessive exercise:** lifestyle modifications and nutritional counselling.

Answer 119

A chronic inflammatory skin condition that presents with patches of **Porcelain-white** skin. It typically affects the genital and anal regions of the body: **labia, perineum, perianal skin, foreskin and glans penis**

Answer 120

* Typically affects women * Can affect men * Considered to be an **autoimmune condition** and therefore is associated with **T1DM, Alopecia, hypothyroid and vitiligo**

Answer 121

The cause of lichen sclerosus is currently unknown, but it is likely multifactorial. Potential contributing factors could include **autoimmune condition**, genetic predisposition, and hormonal factors. Some studies suggest a possible link with previous skin damage or trauma.

Answer 122

Lichen refers to a **flat eruption that spreads**. *It is important not to get lichen sclerosus confused with lichen simplex or lichen planus.

Answer 123

Chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin.

Answer 124

An autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

Answer 125

**Woman aged 45 – 60 years complaining of vulval itching and skin changes in the vulva. ** The condition may be **asymptomatic**, or present with **several symptoms:** * Itching * Soreness and pain possibly worse at night * Skin tightness * Painful sex (superficial dyspareunia) * Erosions * Fissures

Answer 126

When signs and symptoms are made worse by friction to the skin. This **occurs with Lichen Sclerosus**

Answer 127

Changes affect the labia, perianal and perineal skin. There can be associated fissures, cracks, erosions or haemorrhages under the skin. The affected skin appears: * **“Porcelain-white” in colour** * Shiny * Tight * Thin * Slightly raised * There may be papules or plaques

Answer 128

* **Lichen planus:** Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin. * **Psoriasis:** Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back. * **Vitiligo:** Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.

Answer 129

**Primarily Clinical Diagnosis based on characteristic appearance of skin lesions** * Skin biopsy may be performed to confirm diagnosis * Blood tests may rule out other potential autoimmune conditions

Answer 130

**Lichen Sclerosus cannot be cured but symptoms are controlled and should be followed up every 3-6 months** **First Line** * **Potent Topical Steroids: Clobetasol propionate 0.05% (dermovate)** * Steroids used long term to control symptoms * Once daily for 4 weeks. Then gradually reduce frequency every 4 weeks to alternate days then twice weekly. * Daily steroids when condition flares * **Emollients** should be used regularly both with steroids and as part of maintenance * Avoidance of soaps in affected areas to prevent further irritation.

Answer 131

* **5% risk of developing squamous cell carcinoma of the vulva** * Pain and discomfort * Sexual dysfunction * Bleeding * Narrowing of the vaginal or urethral openings

Answer 132

**vulvovaginal atrophy** is inflammation and thinning of the genital tissues, dryness and atrophy of the vaginal mucosa due to **reduced oestrogen levels**

Answer 133

**Decrease in oestrogen levels** most commonly due to **menopause**

Answer 134

**Presents in post-menopausal women with:** * Itching and dryness * Loss of pubic hair * Dyspareunia (discomfort or pain during sex) * Post coital Bleeding due to localised inflammation * **recurrent UTIs or Stress incontinence** * Pelvic organ prolapse may also occur.

Answer 135

* Postmenopausal bleeding:** malignancy, endometrial hyperplasia * **For genital itching/discharge:** sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes * **For narrowed introitus:** female genital mutilation * **For urinary symptoms:** urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis * **For dyspareunia:** malignancy, vaginismus

Answer 136

* **Clinical examination,** including speculum examination if tolerated, to look for vaginal signs of atrophy * Transvaginal ultrasound and endometrial biopsy, **if necessary**, to exclude endometrial cancer * **An infection screen** if itching or discharge is present * A biopsy of any abnormal skin lesions, if needed

Answer 137

* Pale mucosa * Thin skin * Reduced skin folds * Erythema and inflammation * Dryness * Sparse pubic hair

Answer 138

**Hormonal treatment:** * **Topical oestrogen preparations:** * Estriol cream * Estriol pessaries * Estradiol Tablets * Estradiol ring **Non-hormonal treatments:** * **Lubricants such as Sylk, Replens, YES:**, which provide short-term improvement to vaginal dryness, alleviating symptoms such as dyspareunia * **Moisturisers**, which should be used regularly

Answer 139

* Breast Cancer * Angina * Venous Thromboembolism

Answer 140

Malignant growth that primarily affects the skin of the vulva (the external part of the female genitalia). It can be host to various types of Skin cancers however **Squamous Cell Carcinoma** is the most prevalent.

Answer 141

* Rare gynaecological cancer accounting for 4% * Most commonly found in older women >60 (but can occur at any age) * **90% are Squamous Cell Carcinomas**

Answer 142

* Advanced age (particularly over 75 years) * Immunosuppression * Human papillomavirus (HPV) infection * **Lichen sclerosus** Around 5% of women with lichen sclerosus get vulval cancer.

Answer 143

* Squamous Cell Carcinoma (**90%**) * Malignant Melanomas * Basal Cell Carcinoma

Answer 144

* A lump, which may be associated with lymphadenopathy of the groin * Itching or discomfort in the vulval area * A non-healing ulcer * Vulval pain * Changes in the skin of the vulva, such as thickening or changes in color * Bleeding or discharge not related to the menstrual cycle

Answer 145

**Labia Majora**

Answer 146

* **Vulval intraepithelial neoplasia:** This precancerous condition can cause itching, burning, skin changes, and discomfort. * **Lichen sclerosus:** This condition can cause itching, pain, and white patches on the vulva. * **Bartholin's cyst:** This may present as a lump or swelling on the vulva, and can cause discomfort or pain.

Answer 147

**Physical Examination** Suspected vulval cancer should be referred on a **2-week-wait urgent cancer referral.** **Establishing the diagnosis and staging involves:** * **Biopsy of the lesion** * Sentinel node biopsy to demonstrate lymph node spread * Further imaging for staging (e.g. CT abdomen and pelvis)

Answer 148

**International Federation of Gynaecology and Obstetrics (FIGO)** Management of Vulval Cancer depends on the stage

Answer 149

**Depends on the Stage** * Wide local excision to remove the cancer * Groin lymph node dissection * Chemotherapy * Radiotherapy

Answer 150

* VIN is a **premalignant** condition affecting the squamous epithelium of the skin. * VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia)

Answer 151

* **High grade squamous intraepithelial lesion:** A type of VIN associated with **HPV infection** that occurs in younger women aged 35-50 years. * **Differentiated VIN:** Type of VIN associated with **lichen Sclerosus** and typically occurs in older women aged 50-60 years.

Answer 152

* Watch and wait with close follow-up * Wide local excision (surgery) to remove the lesion * Imiquimod cream * Laser ablation

Answer 153

Malignant proliferation of the cells of the Cervix (the lower part of the uterus that connects to the vagina)

Answer 154

* **3rd most common cancer worldwide and 4th biggest cause of cancer death** * Strongly associated with **Human papilloma virus (HPV)**

Answer 155

* Squamous Cell Carcinoma (**80%**) * Adenocarcinoma (**10-20%**) * Very rarely, **Small cell Cancer**

Answer 156

**HPV 16 and 18 infection (accounts for 70% of cases)** **Non Engagement with Cervical Screening** **Activities that increase risk of catching HPV** * Early sexual activity * Increased number of sexual partners * Sexual partners who have had more partners * Not using condoms **Other risk factors:** * Smoking * Immunosuppression (e.g. HIV or organ transplants) * Combined Contraceptive pill use for >5 years * Family History * Increased number of **full term pregnancies** * Exposure to **Diethylstilboestrol** previously used to prevent miscarriages

Answer 157

* HPV is a **Sexually Transmitted Infection** of the virus that is associated with **anal, vulval, vaginal, penile, mouth and throat cancers** * There are over 100 strains but the**HPV 16 and 18** are responsible for 70% of cervical cancers * HPV Infection spontaneously resolves **within 2 years in 90%** of women. At this point the risk returns to baseline.

Answer 158

Current NHS vaccine is **Gardasil** protecting against **HPV 6, 11, 16, 18, 31, 33, 45, 52, 58** * **HPV 6 and 11** cause **Genital Warts** * **HPV 16 and 18** cause **Cervical Cancer (plus others)** * Girls and boys are given the HPV vaccine around age **12-13 years old**

Answer 159

* HPV produces two proteins (**E6 and E6**) that inhibit **tumour suppressor genes**. * **E6** inhibits **p53** * **E7** inhibits **pRb** * These cause dysregulated cell cycle regulation leading to the formation of a **pre-malignant monoclonal cell population** * This cell population is **cervical intraepithelial neoplasia (CIN)** which subsequently mutates further to become an invasive carcinoma

Answer 160

What is Cervical Intraepithelial Neoplasia (CIN) is a grading system for the level of **dysplasia and premalignant change in the cells of the cervix** CIN is diagnosed at **Colposcopy (not with cervical screening)**

Answer 161

* **CIN I:** mild dysplasia, affecting **1/3 the thickness** of the epithelial layer, likely to return to normal without treatment * **CIN II:** moderate dysplasia, affecting **2/3 the thickness** of the epithelial layer, likely to progress to cancer if untreated * **CIN III:** severe dysplasia, very likely to progress to cancer if untreated **CIN III is sometimes called cervical carcinoma in situ.**

Answer 162

Most cases are picked up **asymptomatically** during cervical screening or smears. * When symptoms are present these are often non-specific and so an examination of the cervix is required to exclude cancer

Answer 163

* Vaginal discharge * Abnormal Vaginal Bleeding (e.g. postcoital or with micturition or defaecation) * Dyspareunia * Vaginal discomfort * Urinary or bowel habit change * Suprapubic pain * Abnormal white/red patches on the cervix. * Pelvic bulkiness on PV examination * Mass felt on PR examination

Answer 164

* **Vaginitis:** itching, burning, pain, and abnormal discharge * **Cervicitis:** abnormal discharge, pelvic pain, and postcoital bleeding * **Endometrial cancer:** abnormal vaginal bleeding, pelvic pain, and unintentional weight loss * **Cervical polyps:** abnormal vaginal bleeding, discharge, and pain during intercourse

Answer 165

* **Clinical History prompting Cervix examination with Speculum** +/- Swabs to exclude infection **If there is an abnormal appearance of the cervix suggestive of cancer:** * First line investigation is an **Urgent cancer referral for Colposcopy** for visualisation and biopsy of the cervix. * HPV testing * CT Chest, Abdomen and Pelvis is used for Cancer Staging

Answer 166

* Involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. * Stains such as **Acetic acid and Iodine solution** are used to identify abnormal areas * A Punch biopsy or LLETZ Biopsy can be performed to get a tissue sample

Answer 167

**Acetic Acid Stain:** * Abnormal cells appear white (**Acetowhite**) **Schiller's Iodine Test:** * Stains **healthy cells** of the cervix a **brown colour**. * **Abnormal** areas/cells will **not stain**

Answer 168

* Ulceration * Bleeding * Inflammation * Visible tumour

Answer 169

* Abnormal vascularity * White change with Acetic Acid * Exophytic Lesions

Answer 170

**FIGO system** **Stage 1:** Confined to cervix **Stage 2:** Extending into the uterus or upper 2/3 of the vagina **Stage 3:** Extending into lower third of the vagina or pelvic wall **Stage 4:** Spread beyond true pelvis or bladder / rectum involvement

Answer 171

**Depends on the Stage** **CIN and Early Stage 1A:** * **Cone Biopsy** * Large Loop Excision of the Transformation Zone (LLETZ) **Stage 1B - 2A** * **Fertility Preserved: Radical Trachelectomy** which is removal of the cervix, upper vagina and pelvic lymph nodes * **Fertility not Preserved: Hysterectomy and Lymphadenectomy +/- Chemo/radiotherapy** **Stage 2B-4A:** * Chemotherapy and Radiotherapy + **Bevacizumab (Avastin)** * **Werthelm's Hysterectomy (radical):** Is removal of the uterus, primary tumour, pelvic lymph nodes and upper 1/3 of the vagina used in **invasive, infiltrating early metastatic cancer** **Stage 4b:** * Management is a combination of **Surgery, Radiotherapy, Chemotherapy and Palliative Care**

Answer 172

5 year survival drops significantly with an advanced stage. * Stage 1a: **98% 5 year survival** * Stage 4: **15% 5 year survival**

Answer 173

* **Monoclonal antibody** used in combination with other chemotherapies in the treatment of Metastatic or Recurrent Cancers. * It is a **Vascular Endothelial Growth Factor A Inhibitor (VEGF-A)** to reduce the development of new blood vessels from the cancer.

Answer 174

* A cone biopsy is a treatment for cervical intraepithelial neoplasia (CIN) and very early-stage cervical cancer. * It involves a **general anaesthetic**. * The surgeon removes a cone-shaped piece of the cervix using a scalpel. * This sample is sent for histology to assess for malignancy

Answer 175

* Pain * Bleeding * Infection * Scar formation with stenosis of the cervix * Increased risk of miscarriage and premature labour

Answer 176

Also called a Loop Biopsy * Involves a **Local Anaesthetic** * Often performed during a **Colposcopy procedure** * Involves a wire loop with electrical current (diathermy) to remove the abnormal epithelial tissue on the cervix. * Electrical current cauterises the tissue and stops bleeding

Answer 177

* Bleeding and Abnormal discharge can occur for several weeks following a LLETZ procedure * Intercourse and tampon use after the procedure should be avoided to reduce infection * May increase the risk of **Preterm labour**

Answer 178

* For all Women and People (Transmen) with a cervix between the age of **25-64 years** * Cervical sample is taken and tested for **High -risk HPV viruses (hrHPV)**

Answer 179

* **3 yearly** for women aged **25-49** * **5 yearly** for women aged **50-64**

Answer 180

Aims to pick up precancerous changes in epithelial cells of the cervix. * Involves a **smear test** performed by a qualified practice nurse * Test consists of a **Speculum examination** and collection of cells from the cervix using a small brush. * The samples are initially tested for **high-risk HPV** before examination. * The cells are then examined under a microscopy using **liquid based cytology (LCB)** for **precancerous changes (dyskaryosis)** **If the HPV is negative then the cells are not examined**

Answer 181

**Smear Test for hrHPV:** * **Positive:** further testing is indicated with LBC * **Negative:** Return to normal recall (age based intervals) **1st Positive hrHPV:** * Use LBC to detect cellular atypia * **Cytology Positive:** Colposcopy is indicated * **Cytology Inadequate:** Cytology is repeated in **3 months** * Repeat cytology inadequate - refer for colposcopy * If Colposcopy is normal - test hrHPV in **12 months** * **Cytology Negative:** Perform 2nd hrHPV test in **12 months** **2nd hrHPV:** * **Negative:** return to normal recall * **Positive:** Offer 3rd hrHPV test in a further **12 months** (24 months after first positive test) **3rd hr HPV:** * **Negative:** Return to normal Recall * **Positive:** Refer to Colposcopy

Answer 182

* Inadequate * Normal * Borderline changes * Low-grade dyskaryosis * High-grade dyskaryosis (moderate) * High-grade dyskaryosis (severe) * Possible invasive squamous cell carcinoma * Possible glandular neoplasia * Infections such as bacterial vaginosis, candidiasis, trichomoniasis

Answer 183

* Women with HIV are screened annually * Women over 65 may request a smear if they have not had one since aged 50 * Women with previous CIN may require additional tests (e.g. test of cure after treatment) * Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant) * Pregnant women due a routine smear should wait until 12 weeks post-partum

Answer 184

Clinical condition defined as Heavy menstrual bleeding (excessive blood loss) during a menstrual period to the extent that it is affecting a woman's quality of life

Answer 185

* Average menstruation women lose 40ml of blood * Excessive menstrual blood loss involves **more than 80ml loss** **Volume of blood loss is rarely measured in practice**

Answer 186

* Common gynaecological complaint * 50% of cases **no underlying pathology is found** and the condition is called **Dysfunctional Uterine/endometrial bleeding**

Answer 187

Menorrhagia (heavy menstrual periods) where there is no underlying pathology identified

Answer 188

**Local:** * **Dysfunctional Uterine Bleeding** * Fibroids * Adenomyosis * Endometrial polyps * Endometriosis * Pelvic inflammatory disease * PCOS * Contraceptives such as copper coil * Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding) **Systemic:** * Bleeding disorders * Hypothyroidism * Liver and kidney disease * Obesity

Answer 189

**Heavy or prolonged menstrual bleeding** **Other features:** (Due to Iron deficiency Anaemia) * Fatigue * Weakness * Shortness of Breath

Answer 190

Differentials that include abnormal uterine bleeding: * **Fibroids:** Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination. * **Adenomyosis:** Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse. * **Endometrial polyps:** Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding. * **Endometrial cancer:** Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.

Answer 191

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

Answer 192

* **FBC + Iron studies:** to look for iron deficiency anaemia * **Pelvic examination with a speculum:** Should be performed unless there is a straightforward history without other risk factors or symptoms or they are young and not sexually active **Imaging Studies if Indicated:** * Hysteroscopy (outpatient) * Pelvic and Transvaginal Ultrasound **Additional Tests based on features:** * **Swabs** if there is evidence of infection (e.g. abnormal discharge or suggestive sexual history) * **Coagulation screen** if there is a family history of clotting disorders (e.g. Von Willebrand disease) or periods have been heavy since menarche * **Ferritin** if they are clinically anaemic * **Thyroid function tests** if there are additional features of hypothyroidism

Answer 193

* Suspected submucosal fibroids * Suspected endometrial pathology, such as endometrial hyperplasia or cancer * Persistent intermenstrual bleeding

Answer 194

* Possible large fibroids (palpable pelvic mass) * Possible adenomyosis (associated pelvic pain or tenderness on examination) * Examination is difficult to interpret (e.g. obesity) * Hysteroscopy is declined

Answer 195

**Exclude underlying pathology/Treat pathology first** **Women does NOT want Contraception:** * **Tranexamic acid** when no associated pain (antifibrinolytic – reduces bleeding) * **Mefenamic acid** when there is associated pain (NSAID – reduces bleeding and pain) **Women DOES want Contraception:** * **Mirena coil** (first line) * Combined oral contraceptive pill * Progesterone only contraception can be tried **Medical management Failed:** * **Hysterectomy** * **Endometrial Ablation** **Referral to Secondary Care:** * If treatment is unsuccessful * Symptoms are Severe * Large fibroids (>3cm)

Answer 196

Malignant proliferation that originals from the endometrium (the inner lining of the uterus) It is an Oestrogen Depending cancer meaning that oestrogen stimulates the growth of Endometrial cancer cells

Answer 197

* 6th Most commonly diagnosed cancer in women * 15th most common cancer * 80% of cases are **adenocarcinoma**

Answer 198

a **precancerous condition** that involves thickening of the endometrium * The risk factors, presentation, investigations are similar to Endometrial cancer * Most cases of Endometrial Hyperplasia will return to normal over time and **<5%** become endometrial cancer.

Answer 199

* Hyperplasia without **atypia** * **Atypical** Hyperplasia

Answer 200

**Without Atypical Cells:** * Reversal of risk factors: Weight loss, stopping HRT * Intrauterine System (IUS/Mirena coil) * Continuous Oral Progestogens (Medroxyprogesterone) **With Atypical Cells:** * Total Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO)

Answer 201

Anything that causes increased Exposure to **Unopposed Oestrogen** (Oestrogen without progesterone): * Increased Age * Nulliparity (never given birth or carried child) * Obesity * Diabetes * Early menarche * Late menopause * Polycystic ovary syndrome * Oestrogen-only hormone replacement therapy * Tamoxifen

Answer 202

Polycystic ovarian syndrome leads to increased exposure to unopposed oestrogen due to a lack of ovulation. Usually, when ovulation occurs, a corpus luteum is formed in the ovaries from the ruptured follicle that released the egg. It is this corpus luteum that produces progesterone, providing endometrial protection during the luteal phase of the menstrual cycle (the second half of the menstrual cycle). Women with polycystic ovarian syndrome are less likely to ovulate and form a corpus luteum. Without developing a corpus luteum during the menstrual cycle, progesterone is not produced, and the endometrial lining has more exposure to unopposed oestrogen

Answer 203

One of: * Combined Contraceptive Pill * Intrauterine System (Mirena coil) * Cyclical Progestogens

Answer 204

Obesity is a crucial risk factor because adipose tissue (fat) is a source of oestrogen. Adipose tissue is the primary source of oestrogen in postmenopausal women. Adipose tissue contains aromatase, which is an enzyme that converts androgens such as testosterone into oestrogen This extra Oestrogen is **unopposed** in women that are not ovulating (PCOS/post-menopause)

Answer 205

Tamoxifen has an anti-oestrogenic effect on breast tissue however it has an **oestrogenic effect** on the endometrium increasing the risk of endometrial cancer.

Answer 206

* Combined Contraceptive Pill * Mirena Coil * Increased Pregnancies * Cigarette Smoking

Answer 207

**Features vary but commonly include:** * **Postmenopausal Bleeding** * Postcoital bleeding * Intermenstrual bleeding * Unusually heavy menstrual bleeding * Abnormal vaginal discharge * Dyspareunia * Abdominal discomfort or bloating * Weight Loss * Haematuria * Anaemia * Raised platelet count

Answer 208

**This is endometrial cancer until proven otherwise** Other key risk factors include **obesity and diabetes**

Answer 209

* **Uterine fibroids:** Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation. * **Endometrial polyps:** Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause. * **Cervical cancer:** Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.

Answer 210

**Guidelines for a 2 week wait urgent Endometrial cancer referral:** * **Postmenopausal Bleeding** more than 12 months after the last menstrual period. NICE also recommends referral for **Transvaginal Ultrasound in women Over 55 years with:** * Unexplained vaginal discharge * Visible haematuria **Plus** raised platelets, anaemia, or elevated glucose levels

Answer 211

* First Line: **Transvaginal Ultrasound:** for endometrial thickness (normal is **less than 4mm post menopause**) * Second Line: Endometrial Biopsy * **Pipelle Biopsy:** highly sensitive for endometrial cancer * **Hysteroscopy** with endometrial biopsy

Answer 212

**FIGO System:** **Stage 1:** Confined to the uterus **Stage 2:** Invades the cervix **Stage 3:** Invades the ovaries, fallopian tubes, vagina or lymph nodes **Stage 4:** Invades bladder, rectum or beyond the pelvis

Answer 213

* **Progesterone:** May be used as a hormonal treatment to slow the progression of the cancer **Stage 1 and 2 Endometrial Cancer:** * **Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy (TAH and BSO):** Removal of uterus, cervix and adnexa **Later stages spread outside of the uterus:** * Combination of Hysterectomy, Radiotherapy, Chemotherapy

Answer 214

A gynaecological condition where ectopic endometrium-like tissue (Glands and stroma) , which typically lines the uterus, proliferates outside the uterine cavity. **Endometrioma:** A lump of endometrial tissue outside the uterus **Chocolate Cysts:** Endometriomas in ovaries **Adenomyosis:** Endometrial tissue within the myometrium of the uterus

Answer 215

*Approximately estimated to affect 10% of women in their reproductive years

Answer 216

**No clear cause** but several theories: * **Genetic component:** Though no specific genes are identified * **Retrograde menstruation** * **Coelomic metaplasia:** Cells outside of the uterus somehow change via metaplasia into endometrial cells * **Lymphatic or vascular dissemination of endometrial cells:** Cells spread similarly to cancer

Answer 217

* **Cyclical abdominal or pelvic pain** * **Dysmenorrhoea** * Dyspareunia * Sub/infertility * Cyclical bleeding from other sites (eg. rectal bleeding o haematuria) * Urinary and bowel symptoms * Palpable mass on examination (endometriomas) * Fixed retroverted uterus

Answer 218

Chronic and cyclical pelvic/abdominal pain occurs due to the ectopic endometrial tissue responding to hormones in the same way normal endometrial tissue does. Therefore during menstruation, the ectopic endometrial tissue spreads and bleeds in new cavities in the body. This causes both a cyclical burning, dull pain but also can lead to inflammation and cause further discomfort. The inflammation may lead to adhesions developing due to damage and scar tissue. This can also lead to chronic non-cyclical pain that is sharp or stabbing. Adhesions may also contribute to reduced fertilities due to blocking the release of eggs or kinking fallopian tubes and obstructing the route to the uterus.

Answer 219

* **Primary dysmenorrhoea:** characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology. * **Uterine conditions (e.g. fibroids, adenomyosis):** these can cause heavy menstrual bleeding and pelvic discomfort. * **Adhesions:** pelvic pain and possible bowel obstruction. * **Pelvic inflammatory disease (PID):** presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.

Answer 220

**Clinical Examination:** May identify endometriomas or deep nodules. **Transvaginal/Pelvic Ultrasound scan:** Often unremarkable however they may reveal large endometriomas or chocolate cysts **Referral to gynaecology for ultrasound or Laparoscopy:** Patients with severe persistent or recurrent symptoms of endometriosis should be referred. **Laparoscopic Surgery (Gold Standard):** Definitive diagnosis is established with a biopsy of lesion during Laparoscopy. Surgeons may also remove deposits of endometriosis to potentially improve symptoms.

Answer 221

**Laparoscopic Surgery** This however comes with risks of complications such as bowel perforation and therefore **is not the first line initial investigation**

Answer 222

**Initial management involves:** * Establishing a diagnosis * Providing a clear explanation * Listening to the patient, establishing their ideas, concerns and expectations and building a partnership * **First Line:** Analgesia as required for pain (**NSAIDs and paracetamol**) **Hormonal management options can be tried before establishing a definitive diagnosis with laparoscopy:** * **First line:** Combined oral contractive pill, which can be used back to back without a pill-free period if helpful * Progesterone only pill * Medroxyprogesterone acetate injection (e.g. Depo-Provera) * Nexplanon implant * Mirena coil * **Second Line:** GnRH agonists (Goserelin (Zoladex) or Leuprorelin (prostap)) **Surgical management options:** * Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) * Bilateral oophorectomy +/-Hysterectomy **Laparoscopic treatment may improve fertility. Hormonal therapies may improve symptoms but not fertility.**

Answer 223

Benign smooth muscle tumours (uterine leiomyomas) originating from the myometrium of the uterus.

Answer 224

* Most prevalent benign uterine tumour in women * Leading cause for Hysterectomy * Very common affecting **40-60% of women in later reproductive years** * More common in black women

Answer 225

**Unknown but thought to be related to hormonal and environmental factors** **Oestrogen sensitive** meaning they grow in response to oestrogen

Answer 226

* **Intramural** means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. * **Subserosal** means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. * **Submucosal** means just below the lining of the uterus (the endometrium). * **Pedunculated** means on a stalk.

Answer 227

**Often Asymptomatic** **Symptoms:** * **Heavy menstrual bleeding (menorrhagia) is the most frequent presenting symptom * Prolonged menstruation, lasting more than 7 days * Abdominal pain, worse during menstruation * Bloating or feeling full in the abdomen * Urinary or bowel symptoms due to pelvic pressure or fullness * Deep dyspareunia (pain during intercourse) * Reduced fertility * Palpable mass on abdominal or pelvic exam

Answer 228

**Other causes of Menorrhagia and Dysmenorrhoea:** * **Endometrial polyps:** Present with irregular menstrual bleeding and spotting * **Endometriosis:** Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility

Answer 229

**First Line:** * Transvaginal/Pelvic/Abdominal Ultrasound scan * Hysteroscopy is initial investigation for submucosal fibroids presenting with menorrhagia **Second Line:** * MRI scan if ultrasound does not provide enough detail before considering surgical options

Answer 230

**For fibroids less than 3 cm, the medical management is the same as with heavy menstrual bleeding:** * **Mirena coil (1st line)** – fibroids must be less than 3cm with no distortion of the uterus * **Symptomatic management with NSAIDs and tranexamic acid** * Combined oral contraceptive * Cyclical oral progestogens **Surgical options for managing smaller fibroids with heavy menstrual bleeding are:** * Endometrial ablation * Resection of submucosal fibroids during hysteroscopy * Hysterectomy **For fibroids more than 3 cm, women need referral to gynaecology for investigation and management. Medical management options are:** * **Symptomatic management with NSAIDs and tranexamic acid** * Combined oral contraceptive * Cyclical oral progestogens * **GnRH Agonists (Goserelin) may be used to shrink fibroids before surgery** **Surgical options for larger fibroids are:** * Uterine artery embolisation * Myomectomy * Hysterectomy

Answer 231

* Heavy menstrual bleeding, often with iron deficiency anaemia * Reduced fertility * Pregnancy complications, such as miscarriages, premature labour and obstructive delivery * Constipation * Urinary outflow obstruction and urinary tract infections * **Red degeneration** of the fibroid * **Torsion** of the fibroid, usually affecting pedunculated fibroids * **Malignant change** to a leiomyosarcoma is very rare (<1%)

Answer 232

Red degeneration refers to ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. Red degeneration is more likely to occur in larger fibroids (above 5 cm) during the second and third trimester of pregnancy.

Answer 233

* **Severe abdominal pain** * Low grade fever * Tachycardia * Vomiting

Answer 234

**Supportive management** * Rest * Fluids * Analgesia

Answer 235

Look out for the pregnant woman with a history of fibroids presenting with severe abdominal pain and a low-grade fever in your exams. The diagnosis is likely to be red degeneration.

Answer 236

A type of tumour that grows like a pregnancy inside the uterus. This is known as a **Molar Pregnancy** It forms part of a spectrum of disorders known as **gestational trophoblastic disease**

Answer 237

**Complete Mole:** * Occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). * These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole (46YY)????. * No foetal material will form. **Partial Mole:** * Occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. * The new cell now has three sets of chromosomes (it is a haploid cell). * The cell divides and multiplies into a tumour called a partial mole. * In a partial mole, some foetal material may form.

Answer 238

Women at highest risk of developing a molar pregnancy are at the extreme ends of the fertility age range, specifically those under 16 years of age and over 45 years of age.

Answer 239

* Vaginal bleeding * More severe morning sickness * Hyperemesis gravidarum * Thyrotoxicosis (due to hCG being closely related to TSH and therefore able to activate its receptors) * Enlargement of the uterus beyond the expected size for gestational age, due to excessive growth of trophoblasts and retained blood.

Answer 240

* **Ectopic pregnancy:** Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea. * **Miscarriage:** Symptoms include vaginal bleeding, abdominal pain, and passage of tissue. * **Normal pregnancy:** Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.

Answer 241

**Molar pregnancy behaves like a normal pregnancy** However some indications include: * **B-hCG** Levels are often significantly higher than normally expected * **Transvaginal Ultrasound:** May show a **snowstorm appearance of pregnancy**, low resistance of blood vessel flow and absence of a foetus * Histology may be used to confirm after mole evacuation

Answer 242

**Immediate referral to a specialist centre for treatment** * **Evacuation of the uterus** to remove the mole (using suction curettage) which is sent for **histological examination** * Hysterectomy is a possibility if fertility preservation is not a concern * **Systemic Chemotherapy:** may be required if the mole has **metastasised**

Answer 243

* Bimonthly serum and urine hCG testing until levels are normal. * In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance. * In the case of a complete mole, monthly repeat hCG samples are sent for at least 6 months.

Answer 244

Pituitary tumours characterized by excessive production of prolactin (leading to hyperprolactinaemia), a hormone that plays a crucial role in lactation.

Answer 245

* The most common hormone-secreting tumours originating in the pituitary gland. * Can affect people of any age but more commonly diagnosed in adults

Answer 246

Multiple Endocrine Neoplasia (MEN) Type I

Answer 247

Microprolactinomas – smaller than 10 mm Macroprolactinomas – larger than 10 mm

Answer 248

**Both Genders:** * Reduced Libido * Headaches * Visual Field Defects (bitemporal hemianopia) **Women:** * Oligomenorrhoea/Amenorrhoea * Galactorrhoea (breast milk production outside of pregnancy or breastfeeding) * Infertility * Vaginal dryness **Men:** * Erectile dysfunction * Reduced facial hair growth * Gynaecomastia

Answer 249

* **Pregnancy Test:** Essential in women with childbearing potential presenting with breast milk production * **Blood Tests:** Serum Prolactin, U&Es, LFTs, TFTs * **MRI** scan is investigation of choice for diagnosing pituitary tumours

Answer 250

**Pharmacological:** * **Dopamine Agonists** (e.g. Cabergoline or Bromocriptine): These drugs reduce serum prolactin levels, alleviate galactorrhea, and restore gonadal function. * **Trans-sphenoidal Surgical Resection** is indicated when medical treatment fails to manage the tumour effectively. **Definitive treatment** * **Radiotherapy:** Reserved for cases where other treatments are unsuccessful.

Answer 251

* Hormonal imbalances * Recurrence of the tumour * Risks associated with surgical and radiation interventions

Answer 252

Malignant proliferation originating from various cell types within the ovary

Answer 253

* Epithelial Cell Tumours * Dermoid Cysts/ Germ Cell Tumours * Sex Cord-Stromal tumours

Answer 254

* Originate from the **epithelium which lines the fimbria of the fallopian tubes or the ovaries** * Epithelial tumours are partially cystic, and the cysts can contain fluid * The initial metastatic spread typically involves the **peritoneal cavity**, with seeding particularly affecting the bladder, paracolic gutters and the diaphragm * **Around 90% of ovarian cancers are epithelial ovarian tumours.**

Answer 255

* Serous tumours (the most common) * Endometrioid carcinomas * Clear cell tumours * Mucinous tumours * Undifferentiated tumours

Answer 256

* Originate from the germ cells in the embryonic gonad (**Teratomas**) * May contain various tissue types such as **Skin, teeth, bone and hair** * These tumours typically grow rapidly and spread predominantly via the lymphatic route * Germ cell tumours **most commonly arise in young women**, which is atypical for most cases of ovarian cancer * Tumour markers include **alpha-fetoprotein and sometimes beta human chorionic gonadotrophin (B-HCG)**.

Answer 257

* Originate from connective tissue (stroma) or Sex Cords (Embryonic structures associated with the follicles) * They are **rare, making up less than 5%** of all ovarian tumours. They can be benign or malignant tumours, but are **much less aggressive** than epithelial tumours

Answer 258

**Ovarian Tumours may be due to metastasis from a cancer elsewhere in the body** * A **Krukenberg tumour** refers to a metastasis in the ovary, **usually from a gastrointestinal tract cancer, particularly the stomach.** * Krukenberg tumours have **characteristic “signet-ring” cells** on histology, which look like signet rings on under a microscopy.

Answer 259

**Occurs via Trans coelomic routes** (Across a body cavity) and thus can spread to the liver, bowel and associated mesentery

Answer 260

* Advanced age (peak age 60 years) * Smoking * Increased number of ovulations (early menarche, late menopause, no pregnancies) * Genetic predisposition **(BRCA 1 and 2 genes and family history)** * Obesity * Hormone replacement therapy (HRT) * Recurrent use of **clomiphene** (fertility drug)

Answer 261

**Factors that reduce lifetime ovulations** * Childbearing (parity) * Breastfeeding * Early Menopause * Combined oral contraceptive pill

Answer 262

** Often present late in disease progression with Non-specific symptoms** * Abdominal bloating/discomfort * Early satiety (feeling full after eating) and Loss of appetite * Pelvic, back or abdominal pain * Urinary symptoms (frequency / urgency) * Weight loss * Abdominal or pelvic mass * Ascites (due to VEGF increasing vessel permeability)

Answer 263

An Ovarian mass may press on the **obturator nerve** causing referred hip or groin pain.

Answer 264

* **Gastrointestinal conditions (e.g., irritable bowel syndrome):** Characterised by abdominal pain, bloating, and changes in bowel habits * **Fibroids:** May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation * **Ovarian cysts:** Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating * **Other cancers (e.g., bladder, endometrial):** May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms

Answer 265

**Direct Urgent 2-Week-Wait Referral** * Ascites * Pelvic Mass * Abdominal Mass **Carry out further Investigations before referral Starting with CA125 blood test** * New symptoms of IBS/change in bowel habit * Abdominal Bloating * Early Satiety * Pelvic Pain * Urinary frequency or urgency * Weight loss

Answer 266

**Initial Investigations:** * **CA125 Blood Test:** (> 35IU/ml is significant) * **Pelvic and Abdominal Ultrasound Scan** **Risk of Malignancy Index (RMI): Estimates risk of ovarian mass being malignant** * Menopausal Status * Ultrasound findings * CA125 Level **Further Investigations in Secondary Care:** * **CT Scan:** for Staging * **Histology:** via CT guided biopsy, laparoscopy or laparotomy * **Paracentesis:** Ascitic tap used to look for cancer cells **Women Under 40 years with complex ovarian mass:** * AFP and hCG tumour markers for possible **Germ cell tumour**

Answer 267

CA125 is a **tumour marker for epithelial cell ovarian cancer**. It is not very specific, and there are many non-malignant causes of a raised CA125: * Endometriosis * Fibroids * Adenomyosis * Pelvic infection * Liver disease * Pregnancy

Answer 268

FIGO System: **Stage 1: Confined to Ovary:** * IA: Limited to one ovary, Capsule intact * IB: Limited to both ovaries, Capsule intact * IC: Limited to one or both ovaries, Capsule intact **Stage 2: Spread past the ovary but inside the pelvis:** * IIA: Extension to uterus or fallopian tubes, No malignant cells in ascites/washings * IIB: Extension to other pelvic tissues, No malignant cells in ascites/washings * IIC: Pelvic Extension (IIA/IIB) with malignant cells in ascites/washings **Stage 3: Spread past the pelvis but inside abdomen:** * IIIA: Microscopic peritoneal mets beyond pelvis * IIIB: Macroscopic peritoneal mets beyond pelvis < 2cm * IIIC: Peritoneal mets beyond pelvis > 2cm and/or regional lymph node mets **Stage 4: Spread outside the abdomen (distant metastasis):** * Tumour is involving one or both ovaries with distant metastasis

Answer 269

**Managed by specialist gynaecology oncology MDT** **Surgery:** Radical Hysterectomy, BSO, Infracolic omentectomy are options if early stage **Chemotherapy:** Used an adjuvant to surgery. **Bevacizumab (anti-VEGF) may also be used

Answer 270

Fluid filled sac that develops within or on the surface of an ovary They can range in size and occur as a normal part of the menstrual cycle or as a result of an underlying condition.

Answer 271

* Very common in premenopausal women with most women experiencing at least one * Cysts in postmenopausal women are more concerning for malignancy and need further investigation * Majority of cysts in premenopausal women are **benign**

Answer 272

Can be caused by a variety of factors, including: * Hormonal imbalances * Endometriosis, * Pregnancy * Pelvic infection

Answer 273

Patients with multiple ovarian cysts may have a **String of pearls appearance to the ovaries** **This is not PCOS unless they have other features of the condition**

Answer 274

**Most ovarian cysts are Asymptomatic** May Cause: * Pelvic pain (often acute unilateral pain) * Bloating * Fullness in the abdomen * Palpable pelvic mass * **Intra-peritoneal haemorrhage with haemodynamic compromise**

Answer 275

**Functional Cysts:** * Follicular Cysts: Most common and harmless. they form due to failure to the follicle failing to rupture and release an egg. * Corpus Luteum Cysts: Occur when the corpus luteum fails to break down and fills with fluid. Often seen in early pregnancy **Non-Functional Cysts:** * Serous Cystadenoma: Benign tumours of the epithelial cells * Mucinous Cystadenoma: Can become huge * Endometrioma: occurs with endometriosis * Malignant cysts: Dermoid/ Sex cord/Stromal

Answer 276

* **Ovarian torsion:* Characterised by sudden, severe pain, often accompanied by nausea and vomiting. * **Ectopic pregnancy:** Symptoms include abdominal pain, amenorrhea, and vaginal bleeding. * **Appendicitis:** Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.

Answer 277

**Detailed History and Examination:** to establish for features that may suggest malignancy **Pregnancy test:** Exclude ectopic pregnancy **Ultrasound Scan** if less than 5cm in premenopausal women then no further investigation needed. ** Tumour Markers:** CA125, AFP, LDH, B-hCG

Answer 278

* Abdominal bloating * Reduce appetite * Early satiety * Weight loss * Urinary symptoms * Pain * Ascites * Lymphadenopathy

Answer 279

Estimates the risk of an ovarian mass being malignant, taking account of three things: * Menopausal status * Ultrasound findings * CA125 level

Answer 280

**Conservative:** * Monitoring and Pain management (analgesia) * Surgical intervention may be required

Answer 281

* Torsion * Haemorrhage into the cyst * Rupture, with bleeding into the peritoneum

Answer 282

Triad of: * Ovarian fibroma (benign ovarian tumour) * Pleura effusion * Ascites **Treatment is removal of the tumour**

Answer 283

A condition where the ovary twists in relation to the surrounding connective tissue, the fallopian tube (Adnexa) and blood supply. **Adnexal torsion:** when the fallopian tube is involved

Answer 284

* Usually due to an **ovarian mass** (often > 5cm) such as a cyst or tumour. * Can occur with normal ovaries in girls **before menarche** when girls have a longer **infundibulopelvic ligaments**

Answer 285

* Ovarian mass: present in around 90% of cases of torsion * Being of a reproductive age * Pregnancy * Ovarian hyperstimulation syndrome

Answer 286

* Ovary twists around the adnexa and blood supply * Leads to ischaemia of the Ovary * If torsion persists then necrosis will occur and the function of the ovary will be lost * Ovarian torsion is **an emergency** where treatment delay can have significant consequences

Answer 287

* **Sudden onset severe unilateral pelvic pain** * Constant getting progressively worse * Associated with **Nausea and Vomiting** * Localised tenderness * May have a palpable mass * Vaginal examination may show adnexial tightness

Answer 288

**Pelvic Ultrasound** initial investigation of choice * Transvaginal is Ideal but Transabdominal can be used if transvaginal is not possible. * May show **"Whirlpool sign of free fluid"** in the pelvis and **Oedema** of the ovary **Laparoscopic Surgery is definitive diagnostic investigation**

Answer 289

* Patients need emergency admission under gynaecology for urgent investigation and management. * Depending on the duration and severity of the illness they require laparoscopic surgery to either: * **Un-twist** the ovary and fix it in place (detorsion) * **Remove** the affected ovary (oophorectomy)

Answer 290

* Delayed treatment can lead to loss of function of that ovary * If necrotic ovary is not removed it may lead to infection, abscess formation and sepsis

Answer 291

PCOS is a heterogeneous condition within the endocrine system, with its onset commonly observed at puberty. The disorder is characterised by **hyperandrogenism (manifesting as oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.**

Answer 292

* **Anovulation:** refers to the absence of ovulation * **Oligoovulation:** refers to irregular, infrequent ovulation * **Amenorrhoea:** refers to the absence of menstrual periods * **Oligomenorrhoea:** refers to irregular, infrequent menstrual periods * **Androgens:** are male sex hormones, such as testosterone * **Hyperandrogenism:** refers to the effects of high levels of androgens * **Hirsutism:** refers to the growth of thick dark hair, often in a male pattern, for example, male pattern facial hair * **Insulin Resistance:** refers to a lack of response to the hormone insulin, resulting in high blood sugar levels

Answer 293

* Prevalent condition affecting up to 1/3 of women during their reproductive years

Answer 294

**Complex and Multifactorial (still unclear)** * Hormone imbalances, low oestrogen, high androgens and high insulin (with insulin resistance) leads to increased circulating androgens

Answer 295

**Rotterdam Criteria: requires at least 2 out of 3 key features:** * Oligoovulation or Anovulation * Hyperandrogenism (hirsutism and acne) * Polycystic Ovaries on Ultrasound (> 12 cysts on imaging or ovarian volume > 10 cm3) **Having only one feature such as multiple ovarian cysts does not qualify for diagnosis of PCOS**

Answer 296

* **Oligomenorrhoea or amenorrhoea** * Sub/Infertility * Obesity (in about 70% of patients with PCOS) * **Hirsutism** * Acne * Mood changes including Anxiety and depression * Hair loss in a male pattern

Answer 297

* Insulin resistance and diabetes * Acanthosis nigricans * Cardiovascular disease * Hypercholesterolaemia * Endometrial hyperplasia and cancer * Obstructive sleep apnoea * Depression and anxiety * Sexual problems

Answer 298

* **Menopause:** characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems. * **Congenital adrenal hyperplasia (CAH):** presenting with signs of androgen excess like hirsutism, acne, and irregular periods. * **Hyperprolactinaemia:** symptoms include irregular periods, galactorrhoea, and infertility. * **Androgen-secreting tumours:** may cause virilisation, amenorrhoea, and hirsutism. * **Cushing's syndrome:** characterised by weight gain, purple stretch marks, and easy bruising.

Answer 299

* Medications, such as phenytoin, ciclosporin, corticosteroids, testosterone and anabolic steroids * Ovarian or adrenal tumours that secrete androgens * Cushing’s syndrome * Congenital adrenal hyperplasia

Answer 300

When someone is resistant to insulin, their pancreas has to produce more insulin to get a response from the cells of the body. Insulin **promotes the release of androgens from the ovaries and adrenal glands.** Therefore, **higher levels of insulin result in higher levels of androgens** (such as testosterone). Insulin also **suppresses sex hormone-binding globulin (SHBG)** production by the liver. SHBG normally binds to androgens and suppresses their function. **Reduced SHBG further promotes hyperandrogenism in women with PCOS.** The **high insulin levels contribute to halting the development of the follicles** in the ovaries This leads to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan). **Diet, exercise and weight loss help reduce insulin resistance.**

Answer 301

**Blood Tests:** * **LH:** Raised * **LH:FSH Ratio** increased >2 aids in differentiating from menopause (ratio is normal) * Testosterone: Raised * Insulin resistance (Fasting and OGTT) * Oestrogen Levels: Normal or Raised * TFTs: Exclude thyroid dysfunction * 17 Hydroxyprogesterone: Exclude CAH * Prolactin levels: Exclude hyperprolactinaemia * 24 Hour urinary cortisol: Exclude Cushing's **Imaging: Pelvic Ultrasound** * **Transvaginal Ultrasound** is Gold Standard * **String of Pearls Appearance** * 12 or more developing follicles in one ovary * Ovarian Volume > 10 cm3

Answer 302

**Endometrial Cancer** Within the syndrome of PCOS it has multiple risk factors for Endometrial cancer including: * Obesity * Diabetes * Insulin Resistance * Amenorrhoea

Answer 303

**General Advice:** * Education and reduction of increased risks of CVD, DM, Endometrial cancer, Obesity * **Weight Loss**, * Calorie controlled diet, * **Exercise**, * Smoking cessation, * Antihypertensives (if required), * Statins (if QRISK >10%) **Management if Fertility is NOT Desired:** * **First Line:** COCP + Weight Loss * **Second Line: (if prolonged amenorrhea):** * Cyclical Progesterone (taken for 14 days every 3 months) * Transvaginal USS to assess endometrial thickness **Management if Fertility IS Desired:** * **First Line:** Weight Loss Plus: * Clomiphene OR Letrozole (aromatase inhibitor) * **Second Line:** Metformin

Answer 304

* Weight loss * **Mirena coil** * **Inducing a withdrawal bleed** at least every 3-4 months using: * Cyclical Progestogens (medroxyprogesterone acetate 10mg OD for 14 days) * COCP

Answer 305

Weight loss is the initial step for improving fertility Other options: * Clomiphene - induces ovulation * Laparoscopic Ovarian Drilling * IVF

Answer 306

Weight loss may improve the symptoms of Hirsutism * **Co-cyprindiol (Dianette)** is a COCP liscenced for hirsutism and acne with anti-androgenic effects Others: * Topical Eflornithine * Electrolysis * Laser hair removal

Answer 307

Combined Oral Contraceptive Pill (COCP) is First line (**Co-cprindiol**). Other treatments: * Topical Adapalene (retinoid) * Topical Antibiotics (clindamycin + Benzoyl peroxide) * Topical Azelaic acid 20% * Oral Tetracycline antibiotics (lymecycline)

Answer 308

Significantly increased risk of **Venous Thromboembolism** * This contraindicated in increased risk of clots * Medication usually stopped after 3 months of use.

Answer 309

Inflammation and infection of the organs of the pelvis, caused by infection spreading up the vagina through the cervix and into the upper genital tract. **It is a significant cause of tubular infertility and chronic pelvic pain**

Answer 310

* **Endometritis:** is inflammation of the endometrium * **Salpingitis:** is inflammation of the fallopian tubes * **Oophoritis:** is inflammation of the ovaries * **Parametritis:** is inflammation of the parametrium, which is the connective tissue around the uterus * **Peritonitis:** is inflammation of the peritoneal membrane

Answer 311

**Most commonly via Sexually Transmitted Pelvic Infections:** * Neisseria gonorrhoeae (produces more severe PID) * Chlamydia trachomatis * Mycoplasma genitalium **Less commonly via non-sexually transmitted infections:** * Gardnerella vaginalis (associated with bacterial vaginosis) * Haemophilus influenzae * Escherichia coli

Answer 312

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

Answer 313

**Women may present with symptoms of:** * Pelvic or lower abdominal pain * Abnormal vaginal discharge * Abnormal bleeding (intermenstrual or postcoital) * Pain during sex (dyspareunia) * Fever * Dysuria **Examination findings may reveal:** * Pelvic tenderness * Cervical motion tenderness (cervical excitation) * Inflamed cervix (cervicitis) * Purulent discharge

Answer 314

* **Appendicitis:** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting. * **Ectopic Pregnancy:** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor. * **Endometriosis:** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation. * **Ovarian Cyst:** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination. * **Urinary Tract Infection:** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.

Answer 315

**Pelvic Examination** **Swabs for causative organisms:** * NAAT swabs for gonorrhoea and chlamydia * NAAT swabs for Mycoplasma genitalium (if available) * HIV Test * Syphilis test **Blood Tests:** Inflammatory markers (CRP/ESR) can help support diagnosis **Pregnancy test:** To exclude ectopic pregnancy **Transvaginal Ultrasound** May be used

Answer 316

**Combination Antibiotics** * **Ceftriaxone** IM 1g Single dose (Cover for gonorrhoea) * **Doxycycline** 100mg BD for 2/52 (cover for chlamydia and Mycoplasma) * **Metronidazole** 400mg BD for 2/52 ( Cover for Gardnerella) **Alternative regime is Ofloxacin + Metronidazole** **Analgesia may be required** **Contact Tracing**

Answer 317

* Chronic pelvic pain (in around 40% of cases) * Infertility (approximately 15%) * Ectopic pregnancy (about 1%) * Sepsis * Abscess * **Fitz-Hugh-Curtis Syndrome** (about 10%)

Answer 318

Complication of PID where adhesions form between the liver capsule and the peritoneum causing inflammation and infection of the **liver capsule (Glisson's capsule)** This results in **right upper quadrant pain** in about **10% of patients**

Answer 319

Investigations include abdominal ultrasound to exclude stones. laparoscopy to diagnose, visualise and treat adhesions by **Adhesiolysis**

Answer 320

A transient mood disorder that typically manifests around **three days after childbirth**. It is characterized by irritability, anxiety about parenting skills, and tearfulness. The condition **typically resolves within two weeks** without medical intervention.

Answer 321

* Very common affecting up to 80% of women after childbirth * More commonly affects **first time mothers** * 10% of these women may develop a more severe form: **Postnatal Depression**

Answer 322

**not fully understood** * Likely due to hormonal changes that occur after childbirth including a rapid drop in oestrogen and progesterone. * Fatigue/sleep deprivation, physical discomfort after delivery and stress/challenges of caring for a new baby likely also contribute

Answer 323

**Presents within the first week after childbirth** * Mood swings * Low mood * Anxiety (about parenting) * Irritability * Tearfulness

Answer 324

**Postpartum blues should be differentiated from other postnatal mood disorders such as postnatal depression and postpartum psychosis. The primary distinguishing symptoms are:** * **Postnatal depression:** Persistent feelings of sadness, anxiety, or emptiness; difficulty bonding with the baby; severe mood swings; trouble eating, sleeping, or concentrating; and thoughts of harming oneself or the baby. * **Postpartum psychosis:** Severe confusion and disorientation, hallucinations and delusions, paranoia, and attempts to harm oneself or the baby.

Answer 325

**Clinical Diagnosis** * Routine screening at medical appointments is recommended by NICE to identify the approximately 10% of women who may develop postnatal depression following postpartum blues. * Use of tools such as the **Edinburgh Postnatal Depression Scale**

Answer 326

**Supportive measures and reassurance (that the condition is common)** * Symptoms are usually mild and only last **a few days**. * Baby blues tend to **resolve within two weeks of delivery without any treatment being required** * Mothers should be encouraged to seek help if they have symptoms persisting beyond 2 weeks

Answer 327

It's a significant mood disorder that can **develop at any time up to one year after the birth of a baby.** This condition represents a considerable aspect of maternal mental health and extends beyond the common "baby blues". Typically presenting with **persistent depressive symptoms** that may interfere with daily functioning and parenting.

Answer 328

* Affects approximated 10-20% of mothers within 1 year of childbirth * Rates vary depending on population, geographic location, socioeconomic status (low), History of mental health and lack of social support * Typically women are affected **around 3 months after birth**

Answer 329

Development of postpartum depression is multifactorial with a combination of **Biological, Psychological, and Social factors all contributing.**

Answer 330

* Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones. * Alterations in melatonin and cortisol rhythms and immune-inflammatory processes * Genetic predispositions

Answer 331

* A history of mood or anxiety disorders * Previous episodes of postpartum depression * Certain personality traits such as neuroticism * Psychological stress from the transition to parenthood * Unrealistic expectations of motherhood

Answer 332

* Lack of social support * Relationship issues, * Life stressors * Low socioeconomic status

Answer 333

**Classic triad of:** * **Low Mood** * **Anhedonia:** reduced enjoyment or interest in activities. * **Lowering of energy levels.** **Others:** * Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby) * Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.

Answer 334

**Baby blues** Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously. **Postpartum Psychosis** **Adjustment disorders** These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression. **Generalized Anxiety Disorder (GAD)**

Answer 335

**Edinburgh Postnatal Depression Scale (EPDS)** assess how the mother has felt over the past week with 30 questions. A cut-off score of **over 10 is used as a positive result.**

Answer 336

**First-line treatments**: * Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT). **Pharmacological treatments** * Antidepressants (**SSRIs**) considered in high risk cases **In severe cases** admission to a mother and baby inpatient mental health unit might also be necessary.

Answer 337

**SSRIs** such as: * Paroxetine * Sertraline **Due to their safety profile in breastfeeding

Answer 338

**Also known as Puerperal Psychosis** It's a serious psychiatric disorder that typically develops within the first two weeks following childbirth. It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.

Answer 339

**unknown** but thought to be a combination of: * Genetic susceptibility * Hormonal Changes * Psychosocial stressors * Prior history of **severe mental illness significantly increases the risk**

Answer 340

* **Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder** * Family history of postpartum psychosis * Previous episode of postpartum psychosis

Answer 341

* Paranoia * Delusions (including Capgras Delusions) * Hallucinations * Manic episodes * Depressive episodes * Confusion

Answer 342

Postpartum depression with psychotic features

Answer 343

Diagnosis is **predominantly clinical**, based on the presenting signs and symptoms. It requires a thorough psychiatric evaluation. Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.

Answer 344

**Women with Postpartum Psychosis need urgent assessment and input from specialist mental health services** * Admission to **mother and baby unit** * Cognitive behavioural Therapy * May require pharmacotherapy with: * Antidepressant medications * Antipsychotic medications * Mood stabilisers in some instances Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby's role or identity).

Answer 345

The mother's breastfeeding status and the potential for the transfer of drugs to the nursing infant.

Answer 346

The mother and baby unit is a specialist unit for pregnant women and women that have given birth in the past 12 months. They are designed so that the mother and baby can remain together and continue to bond. Mothers are supported to continue caring for their baby while they get specialist treatment.

Answer 347

Women with existing mental health concerns before or during pregnancy are referred to **perinatal mental health services**. Advice and input from specialists can help manage decisions around ongoing medications such as **SSRIs, antipsychotics and lithium during pregnancy. They also ensure that mothers are closely followed up after giving birth so management can be put in place early should these conditions occur.

Answer 348

**Neonatal abstinence syndrome/neonatal adaptation syndrome** * Presents in first few days after birth * Symptoms include irritability and poor feeding * Neonates are monitored for this after delivery * Treatment is supportive management

Answer 349

**Gynaecological Emergency** Where a fertilised egg or embryo implants and begins to grow **Outside of the uterine cavity**. Most common site is the **fallopian tube**

Answer 350

* **Fallopian tube (most common (97%))** * Ovary * Cervix * Abdomen

Answer 351

* Previous ectopic pregnancy * Previous pelvic inflammatory disease or Salpingitis (tubal inflammation) * Previous surgery to the pelvis (Especially the fallopian tubes) * Intrauterine devices in situ (coils) * Endometriosis * Older age * Smoking

Answer 352

* Fertilisation of the oocyte **typically takes place in the ampulla of the fallopian tube**; the conceptus must then travel into the endometrial cavity. * This occurs due to tubal peristalsis alongside ciliary motion and tubal fluid flow. * Any **dysfunction in the tubal peristalsis** above due to e.g. tubal surgery, salpingitis, PID can prevent the conceptus from implanting in the correct place. * A pregnancy that implants in the fallopian tube will **grow and eventually lead to rupture and catastrophic bleeding.** * **Most tubal ectopics implant in the ampulla (widest point)**.

Answer 353

Around **6-8 weeks gestation**

Answer 354

* **Pelvic or abdominal pain** Often unilateral to the side of the ectopic (RIF/LIF) * Abnormal vaginal bleeding: **missed period or intermenstrual bleeding** * Cervical motion tenderness (**Chandeller sign**) where pain occurs when moving the cervix during a bimanual examination * **Haemodynamic instability** caused by blood loss if the ectopic ruptures * Dizziness or Syncope (due to blood loss) * Shoulder tip pain (blood irritating the diaphragm causing referred pain)

Answer 355

* Miscarriage * Appendicitis * Ovarian Torsion

Answer 356

**Any female of childbearing age presenting with abdominal pain should be offered a UPT (urine pregnancy test) to exclude ectopic pregnancy** * Urine Pregnancy Test (First Line) * **Transvaginal Ultrasound Scan** is investigation of choice to locate the pregnancy * Serial serum B-hCG if no pregnancy found of USS.

Answer 357

* A mass representing a tubal ectopic pregnancy **moves separately to the ovary**. * It may appear similar to the corpus luteum however this **will move with the ovary** **Other features indicative:** * An empty uterus * Fluid in the uterus (may be mistaken as a gestational sac)

Answer 358

**women with pelvic pain/tenderness and a positive pregnancy test need to be referred to an Early Pregnancy Assessment Unit (EPAU)** **All ectopic pregnancies need to be terminated (they are not viable)** **Options for terminating an Ectopic Pregnancy:** * Expectant management (awaiting natural termination) * Medical Management (methotrexate) * Surgical management (Salpingectomy or Salpingotomy)

Answer 359

**Criteria:** * Follow up needs to be possible to ensure successful termination * The ectopic needs to be unruptured * Adnexal mass < 35mm * No visible heartbeat * No significant pain * HCG level < 1500 IU / l **Women with Expectant management need careful follow up with close monitoring of hCG levels and quick/easy access to services if their condition changes**

Answer 360

**Criteria: Injection of Methotrexate** * Follow up needs to be possible to ensure successful termination * The ectopic needs to be unruptured * Adnexal mass < 35mm * No visible heartbeat * No significant pain * **HCG level < 5000 IU / l** * **Confirmed absence of intrauterine pregnancy on ultrasound** **Methotrexate is highly teratogenic** and is given as an **IM Injection** to halt the progress of pregnancy and results in spontaneous termination Women treated with Methotrexate are advised to **not get pregnant for 3 months following treatment** as the harmful effects of methotrexate may last this long

Answer 361

* Measure beta-hCG on days 0, 2, 4, and 7 * If drop of more than 15% from previous measurement, repeat weekly until beta-hCG is less than 20IU/L. * If not, refer for further management.

Answer 362

* Vaginal Bleeding * Nausea and Vomiting * Abdominal Pain * Stomatitis (inflammation of the mouth)

Answer 363

**Anyone that does not meet the criteria for expectant or medical management requires surgical** ** Criteria for Surgical:** * Patient is **haemodynamically unstable** * Pain * Adnexal mass > 35mm * Visible heartbeat * HCG Levels > 5000 IU/l **Surgical Options:** * Laparoscopic salpingectomy (**first line treatment for ectopic pregnancy**) * Laparoscopic salpingotomy (used in women at increased risk of infertility due to damage to other fallopian tube) **Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of ectopic pregnancy**

Answer 364

Increased risk of failure to remove the ectopic pregnancy with salpingotomy compared to salpingectomy. * 1 in 5 women having salpingotomy may need **further treatment with methotrexate or salpingectomy**

Answer 365

Diagnosed when a woman has a positive pregnancy test, but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal ultrasound.

Answer 366

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

Answer 367

**Early viable or failing intrauterine pregnancy** * Signs and symptoms: Mild cramping, spotting or delayed menstruation. **Complete miscarriage** * Signs and symptoms: Severe abdominal pain, heavy bleeding, passage of tissue or clot-like material. **Ectopic pregnancy** * Signs and symptoms: Sharp or stabbing pain in the abdomen, light vaginal bleeding, dizziness or fainting.

Answer 368

**Serum hCG is tracked over time to monitor Pregnancy of Unknown Origin/Location** **Serum hCG level is repeated after 48 hours to measure change from baseline** **Monitoring the clinical signs and symptoms is more important than tracking the hCG level, and any change in symptoms needs careful assessment.** **The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy.** **Rise of more than 63%:** * After 48 hours likely indicates an Intrauterine pregnancy. * Repeat Ultrasound scan after **1-2 weeks** to confirm intrauterine pregnancy * Pregnancy should be visible on USS once hCG > 1500 IU/ L **Rise of Less than 63%** * May indicate an Ectopic pregnancy. This patient needs close monitoring and review **Fall of More than 50%** * Likely to indicate a miscarriage * Urine pregnancy test should be performed after 2 weeks (confirms miscarriage is complete)

Answer 369

Miscarriage is defined as the spontaneous loss/termination of a pregnancy prior to 24 weeks gestation. **Early Miscarriage:** Before 12 weeks gestation **Later Miscarriage:** Between 12 and 24 weeks gestation

Answer 370

* 10% of recognised pregnancies end in miscarriage. * Number is likely higher as many occur without the women realising she in pregnant

Answer 371

the foetus is no longer alive, but no symptoms have occurred and thus the miscarriage is often missed as the mother did not know that something was wrong.

Answer 372

vaginal bleeding with a closed cervix and a foetus that is alive

Answer 373

vaginal bleeding with an open cervix. Due to the cervix being open the miscarriage is inevitable.

Answer 374

retained products of conception remain in the uterus after the miscarriage

Answer 375

A full miscarriage has occurred, and there are no products of conception left in the uterus

Answer 376

a gestational sac is present but contains no embryo

Answer 377

**Often Idiopathic** **Foetal Pathology:** * Genetic disorder * Abnormal development * Placental failure **Maternal Pathology:** * Uterine abnormality (Bicornuate uterus, Cervical insufficiency) * Cervical incompetence * Polycystic ovary syndrome * Poorly controlled diabetes * Poorly controlled thyroid disease * Anti-phospholipid syndrome, Factor V Leiden * Infections: Toxoplasmosis, Syphilis

Answer 378

* Increased Maternal Age * Previous Miscarriage

Answer 379

**May be Asymptomatic** * Vaginal Bleeding * Pelvic Pain - Often reported to be worse than the pain of a usual period * Vaginal tissue loss

Answer 380

Main other differential for vaginal bleeding before 24 weeks gestation is an **Ectopic Pregnancy** * Both can present with pain and vaginal bleeding * Pain is often **the first symptom in an ectopic** * Vaginal bleeding is usually **larger in miscarriage**

Answer 381

**Transvaginal Ultrasound Scan: Investigation of choice** **Viability of Pregnancy features:** * Mean Gestational Sac Diameter * Foetal pole and crown-rump length * Foetal Heart Beat

Answer 382

* A foetal pole is expected once the mean gestational sac diameter is 25mm or more. * When there is a mean gestational sac diameter of **25mm or more, without a foetal pole**, the scan is repeated after one week before confirming an anembryonic pregnancy.

Answer 383

* A foetal heartbeat is expected once the **crown-rump length is 7mm or more.** * When the crown-rump length **is less than 7mm, without a foetal heartbeat,** the scan is repeated after at least one week to ensure a heartbeat develops * When there is a crown-rump length **of 7mm or more, without a foetal heartbeat**, the scan is repeated after one week before confirming a non-viable pregnancy. Pregnancy is considered viable when there is a foetal heart beat

Answer 384

Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be **managed expectantly** * Provided they have no pain and no other complications or risk factors (e.g. previous ectopic).

Answer 385

Expectant management before 6 weeks gestation involves: * Awaiting the miscarriage without investigations or treatment. * An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen. * A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. * When bleeding continues, or pain occurs, referral and further investigation is indicated.

Answer 386

**NICE 2019 suggests referral to an early pregnancy assessment service (EPAU) for women with a positive pregnancy test (more than 6 weeks’ gestation) and bleeding.** **Expectant Management: Watch and Wait** * First line for women without risk factors for heavy bleeding or infection * 1-2 weeks are given to allow the miscarriage to occur spontaneously * repeat UPT preformed **3 weeks after bleeding and pain settle to confirm miscarriage is complete** * Persistent or worsening bleeding require further assessment **Medical Management: Mifepristone followed by Misoprostol 48 hours later** * Mifepristone is an anti-progesterone that sensitises the myometrium to prostaglandins and induces breakdown of decidua basalis * Misoprostol is a prostaglandin analogue that soften the cervix and stimulates uterine contractions. * Can be a vaginal suppository or Oral dose **Surgical Management: Third line:** * Surgical Options Include: * **Manual Vacuum aspiration:** under local anaesthetic as outpatient * **Electric vacuum aspiration:** under general anaesthetic * Prostaglandins (misoprostol) are given before surgical management to soften the cervix. * Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage

Answer 387

* Heavier bleeding * Pain * Vomiting * Diarrhoea

Answer 388

An incomplete miscarriage occurs when retained products of conception (foetal or placental tissue) remain in the uterus after the miscarriage. **Retained products create a risk of infection.** **Options for an Incomplete Miscarriage:** * Medical management (misoprostol) * Surgical management (evacuation of retained products of conception)

Answer 389

Defined as the loss of 3 or more consecutive pregnancies.

Answer 390

* **Blood tests:** antiphospholipid antibodies, thrombophilia screen * **Cytogenetic analysis of products of conception:** if abnormal then the parents should be karyotyped * **Pelvic ultrasound:** to identify uterine abnormalities.

Answer 391

**The management is tailored to the contributing pathology:** **Genetic disorder** - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm **Uterine structural abnormality** - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment **Cervical incompetence** - regular ultrasound monitoring of the cervix. May use cervical cerclage **Polycystic ovary syndrome** - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective **Antiphospholipid syndrome** - heparin or low-dose aspirin **Thrombophilia** - heparin may increase the live birth rate **Diabetes** - improve glycaemic control

Answer 392

A termination of pregnancy (TOP) that is an elective procedure to end a pregnancy governed by the **1967 Abortion Act**

Answer 393

* Pregnancy has not exceeded 24 weeks gestation * **Continuing the pregnancy involves greater risk to the physical or mental health of:** * The woman * Existing children of the family The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.

Answer 394

* Continuing the pregnancy is likely to risk the life of the woman * Terminating the pregnancy will prevent **“grave permanent injury”** to the physical or mental health of the woman * There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Answer 395

* Two registered medical practitioners must sign to agree abortion is indicated * It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

Answer 396

* Abortion services can be accessed by self-referral or by GP, GUM or family planning clinic referral. * Doctors who object to abortions should pass on to another doctor able to make a referral * **Marie Stopes UK** is a charity that provides abortion services * Women should be offered counselling and information to help decision making from a trained practitioner * **Informed consent is essential**

Answer 397

A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments: * Mifepristone (anti-progestogen) * Misoprostol (prostaglandin analogue) 1 – 2 day later **Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.**

Answer 398

Surgical abortion can be performed, depending on preference and gestational age, under: Local anaesthetic (+/-plus sedation) or General anaesthetic * Prior to surgical abortion, **medications are used for cervical priming.** This involves softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators. **Surgical Options:** * Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks) * Cervical dilatation and evacuation using forceps (between 14 and 24 weeks) **Rhesus negative women having a surgical TOP should have anti-D prophylaxis.**

Answer 399

* Inform women they may experience vaginal bleeding and abdominal cramps intermittently for up to 2 weeks post procedure * UPT is performed 3 weeks after abortion to confirm completion * Support and counselling is offered

Answer 400

* Bleeding * Pain * Infection * Failure of the abortion (pregnancy continues) * Damage to the cervix, uterus or other structures * Psychological stress

Answer 401

Diabetes that is triggered by pregnancy due to **reduced insulin sensitivity** during pregnancy and resolves after birth.

Answer 402

* Approximately 5% of pregnancies are affected by GDM. * Women diagnosed with GDM have an increased risk of developing T2DM * Up to a 50% chance of developing T2DM within 5-10 years postpartum

Answer 403

* Ethnic backgrounds with a high prevalence of type 2 diabetes (e.g., Middle Eastern, South Asian, and Afro-Caribbean) * Prior history of GDM * Prior delivery of macrosomic babies (>4.5kg) * History of stillbirth or perinatal death * Maternal obesity (BMI>30) * Diabetes in first-degree relatives

Answer 404

* In normal pregnancy, local and placental hormones stimulate peripheral insulin resistance - the purpose of this is to spare glucose for delivery to the developing foetus. * This is accompanied by lipolysis and gluconeogenesis, further increasing free fatty acid and glucose levels. * Hypertrophy and hyperplasia of pancreatic beta-cells occurs to protect maternal glucose homeostasis. * Failure of this protective mechanism due to beta-cell dysfunction, in combination with insulin resistance, leads to GDM.

Answer 405

**Often no noticeable symptoms** * Thirst * Polyuria * Fatigue

Answer 406

* **Type 1 or Type 2 Diabetes Mellitus:** Generally presents with symptoms outside of pregnancy, including potential weight loss * **Other forms of gestational hyperglycaemia:** These can be identified through early pregnancy HbA1c testing

Answer 407

* Women with **any** risk factor should be screened for GDM at 24-28 weeks gestation * Women with **glycosuria** detected at a routine antenatal scan should be screened at any time during their pregnancy

Answer 408

**Oral Glucose Tolerance Test (OGTT):** Used in patients with **risk factors** for gestational diabetes or when there are features suggestive of GDM. **OGTT performed in the morning after fasting. Patient drinks 75g glucose drink and then blood sugar level is measured before and at 2 hours after.** **Gestational Diabetes:** * Fasting: **> 5.6 mmol/l** * At 2 hours: **> 7.8 mmol/l** (remember for GDM cut off is 5-6-7-8)

Answer 409

Patients with GDM need careful explanation about the condition and learn how to monitor and tract blood sugar **First Line:** * Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin if targets are not met. **Second Line:** * Fasting glucose above 7 mmol/l: start **insulin** ± metformin * Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin * Glibenclamide (a Sulfonylurea) Can be used if Insulin or Metformin are not tolerated **Postpartum management includes glucose testing to ensure resolution of GDM** **Women with GDM must also have 4 weekly USS to tract foetal growth at 28, 32 and 36 weeks**

Answer 410

4-weekly scans at: **28, 32 and 36 weeks** to monitor foetal growth

Answer 411

NICE 2015 Targets: * Fasting: 5.3 mmol/l * 1 hour post-meal: 7.8 mmol/l * 2 hours post-meal: 6.4 mmol/l * Avoiding levels of 4 mmol/l or below

Answer 412

* Pre-eclampsia * Developing T2DM (50% increased risk) * Increased risk of cardiovascular disease

Answer 413

**Key Complications:** * **Macrosomia leading to shoulder dystocia** * **Neonatal hypoglycaemia** **Others:** * Childhood Obesity (2x background risk) * Increased risk of Metabolic syndrome + associated complications * Polycythaemia (raised haemoglobin) * Jaundice (raised bilirubin) * Congenital heart disease * Cardiomyopathy

Answer 414

Babies born to mothers with GDM need close monitoring for neonatal hypoglycaemia with regular blood glucose checks and frequent feeds. * Maintain blood glucose **> 2mmol/l** * If it falls below this they may need **IV Dextrose of nasogastric feeding**

Answer 415

**Prior to conception** * Aim for good glucose control * **Take 5mg folic acid from preconception until 12 weeks gestation**

Answer 416

**Both type I and type II diabetes should aim for the same target insulin levels as with gestational diabetes** NICE 2015 Targets: * Fasting: 5.3 mmol/l * 1 hour post-meal: 7.8 mmol/l * 2 hours post-meal: 6.4 mmol/l * Avoiding levels of 4 mmol/l or below

Answer 417

Metformin and Insulin. **Other oral diabetic medications should be stopped**

Answer 418

**Diabetic Retinopathy:** referral to ophthalmologist for diabetic retinopathy screening * Retinopathy Screening should be performed **shortly after Dating/Booking scan (11 and 14 weeks) and at 28 weeks gestation** * Pre-existing diabetes and pregnancy carries a risk of rapid progression of retinopathy

Answer 419

**Pre-existing Diabetes:** * Planned delivery between **37 and 38+6 weeks** **Gestational Diabetes:** * Women can give birth up to 40+6 weeks

Answer 420

**Sliding-scale insulin regime** considered during labour for women with T1DM. May also be considered for women with **poorly controlled** blood sugars with GDM or T2DM.

Answer 421

Refers to a pregnancy with **more than one foetus**

Answer 422

identical twins (from a single zygote)

Answer 423

non-identical (from two different zygotes)

Answer 424

Single amniotic sac

Answer 425

Two separate amniotic sacs

Answer 426

Share a single placenta

Answer 427

Two separate placentas

Answer 428

**Diamniotic, Dichorionic** Twin pregnancies as each foetus has their own nutrient supply.

Answer 429

**Usually diagnosed on the "booking/dating" ultrasound scan**

Answer 430

* **Dichorionic diamniotic** twins have a membrane between the twins, with a **lambda sign or twin peak sign** * **Monochorionic diamniotic** twins have a membrane between the twins, with a **T sign** * **Monochorionic monoamniotic** twins have no membrane separating the twins

Answer 431

* Anaemia * Polyhydramnios * Hypertension * Malpresentation * Spontaneous preterm birth * Instrumental delivery or caesarean * Postpartum haemorrhage

Answer 432

* Miscarriage * Stillbirth * Foetal growth restriction * Prematurity * **Twin-twin transfusion syndrome** * **Twin anaemia polycythaemia sequence** * Congenital abnormalities

Answer 433

Twin-twin transfusion syndrome occurs when the foetuses share a placenta. **It is called foeto-foetal transfusion syndrome in pregnancies with more than two foetuses.** When there is a connection between the blood supplies of the two foetuses, one foetus (the recipient) may receive the majority of the blood from the placenta, while the other foetus (the donor) is starved of blood. * The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. * The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the foetuses. **Women with Twin-Twin transfusion syndrome need to be referred to a tertiary specialist foetal medicine centre**

Answer 434

Twin anaemia polycythaemia sequence is similar to twin-twin transfusion syndrome, but less acute. One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).

Answer 435

**Women with multiple pregnancies require additional monitoring for anaemia, with a full blood count at:** * Booking clinic * 20 weeks gestation * 28 weeks gestation **Additional ultrasound scans are required in multiple pregnancy to monitor for foetal growth restriction, unequal growth and twin-twin transfusion syndrome:** * 2 weekly scans from 16 weeks for monochorionic twins * 4 weekly scans from 20 weeks for dichorionic twins

Answer 436

32 and 33+6 weeks

Answer 437

36 and 36+6 weeks

Answer 438

37 and 37 +6 weeks

Answer 439

Before 35 +6 weeks

Answer 440

Require **elective caesarean section between 32 and 33 +6 weeks**

Answer 441

**Aim to deliver between 37 and 37 +6 weeks** * **Vaginal delivery** is possible when the first baby has a cephalic presentation (head first) * **Caesarean section** may be required for the second baby after successful birth of the first baby * **Elective caesarean** is advised when the presenting twin is not cephalic presentation

Answer 442

Anaemia is defined as a low concentration of haemoglobin. In pregnancy, the **plasma volume increases** and thus there is a reduction in the concentration of haemoglobin leading to anaemia. It is important to optimise the treatment of anaemia in pregnancy so that the woman has reasonable reserves in cases there is significant blood loss during delivery

Answer 443

**Often asymptomatic** May present as: * Shortness of breath * Fatigue * Dizziness * Pallor

Answer 444

**Booking/dating Bloods:** > 110 g/l **28 Weeks Gestation:** > 105 g/l **Post-partum:** > 100 g/l **Women are also offered Haemoglobinopathy screening at the booking clinic for Thalassaemia and Sickle Cell Disease**

Answer 445

**Low MCV** Indicates Iron Deficiency Anaemia **Normal MCV:** Indicates a physiological anaemia due to increased plasma volume of pregnancy **Raised MCV:** Indicates B12 or Folate Deficiency

Answer 446

**Depends on the cause:** **Iron:** * Women with anaemia in pregnancy are started on iron replacement: **Ferrous sulphate 200mg 3x daily** * Women who are not anaemic but have low ferritin may also be started on supplementary iron. **B12:** * The increased plasma volume and B12 requirements often result in a low B12 in pregnancy. Women with low B12 should be tested for pernicious anaemia (checking for intrinsic factor antibodies). * **IM Hydroxocobalamin injections or Oral Cyanocobalamin Tables** **Folate:** * All women should already be taking folic acid **400mcg OD** * Women with folate deficiency are started on **folic acid 5mg daily**

Answer 447

Spina bifida is a neural tube defect characterised by incomplete development of the spinal column, resulting in herniation of the spinal cord.

Answer 448

* Incomplete fusion of the vertebrae, but with no herniation of the spinal cord * May be visible only as a small tuft of hair overlying the site

Answer 449

* Incomplete fusion of the vertebrae, with herniation of a meningeal sac containing CSF * Visible prominence at the site, but usually covered by skin

Answer 450

* Incomplete fusion of the vertebrae with herniation of herniation of a meningeal sac containing CSF and spinal cord. * Usually accompanied by other defects such as hydrocephaly or Chiari malformation * Visible prominence at the site, with exposed meninges

Answer 451

**All pregnant women, and those trying to conceive are recommended to take folic acid as this has been shown to decrease the risk of neural tube defects** * **400 micrograms/day from 3 months prior to conception, until 12 weeks gestation** * In women at **higher risk** (e.g. those with a child affected by a neural tube defect, or those on certain medications) are recommended a **higher dose of 5mg/day**

Answer 452

Usually diagnosed on prenatal scans

Answer 453

**Neurological:** * Motor deficits * Sensory deficits * Neurogenic bladder or bowel * Hydrocephalus * Seizures **Musculoskeletal:** * Increased risk of hip subluxation * Scoliosis * Contractures

Answer 454

* Primary neurosurgical repair * Orthopaedic surgery

Answer 455

High blood pressure that **exists before pregnancy or is diagnosed before 20 weeks gestation** and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.

Answer 456

When there is an onset of high blood pressure that occurs **after 20 weeks gestation without the presence of proteinuria**

Answer 457

Multifactorial, often involving genetic predisposition, lifestyle factors, and physiological changes during pregnancy.

Answer 458

**Asymptomatic** * May have headaches and blurred vision

Answer 459

* **Preeclampsia:** Characterized by high blood pressure and damage to another organ system, most often the liver and kidneys, after 20 weeks of gestation. * **Chronic Kidney Disease:** Typically presents with proteinuria, haematuria, and a rise in serum creatinine.

Answer 460

Gestational Hypertension must be **new onset after 20 weeks gestation WITHOUT proteinuria** * **Blood pressure Monitoring** * **Urinalysis:** To exclude proteinuria and subsequently Pre-eclampsia

Answer 461

* Discontinuation of some anti-hypertensive medications (**ACEis and ARBs**) to switch to pregnancy safe options. * **Regular Blood Pressure Monitoring** * **Regular Urinalysis at least weekly** * Monitoring Foetal growth by serial growth scans * PlGF testing on one occasion **Blood pressure control:** * **Gestational Hypertension > 150/100mmHg: Oral Labetalol** * Treating to aim for BP < 135/85mmHg * Admission for women with a BP above 160/110 mmHg * Gestational Hypertension (mild) of: 140/90 to 149/99mmHg: **No treatment other than regular monitoring** * Alternatives if Labetalol is not tolerated: **2nd Line:** Nifedipine. **3rd Line:** Methyldopa

Answer 462

Pre-eclampsia refers to **new high blood pressure (hypertension)** in pregnancy with **end-organ dysfunction, notably with proteinuria** (protein in the urine). It occurs **after 20 weeks gestation**

Answer 463

When **seizures** occur as a result of Pre-eclampsia due to **cerebral vasospasm**

Answer 464

* Significant cause of **maternal and foetal morbidity and mortality** * Occurs after **20 weeks gestation**

Answer 465

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

Answer 466

* Blastocyst implants on the endometrium and the outer layer (Syncitiotrophoblast) grows into the endometrium to form chorionic villi. * Trophoblast invasion into the endometrium sends signals to the **spiral arteries** to **reduce their vascular resistance** making them more fragile and enabling **lacunae** to form. (Lacunae typically form around **20 weeks gestation**) * If this process becomes defective, the formation of the lacunae is inadequate and the women can develop Pre-eclampsia. * **High vascular resistance in the spiral arteries leads to poor perfusion of the placenta** * This causes **oxidative stress** in the placenta leading to the release of inflammatory chemicals into systemic circulation. * This leads to **systemic inflammation and impaired endothelial cell function** resulting in the symptoms and complications of Pre-eclampsia

Answer 467

**Classical Triad:** * **Hypertension** * **Proteinuria** * **Peripheral Oedema** **Symptoms:** * Severe Headaches (potentially due to cerebral oedema) * Visual Disturbance (due to retinal artery vasospasm) * Epigastric pain (due to reduced blood flow to the liver causing injury and swelling of liver and capsule) * Drowsiness * Nausea and vomiting * Hyperreflexia

Answer 468

**Hypertension** * Oxidative stress on the placenta causes the release of **pro inflammatory cytokines** * These entre the mothers circulation and cause **endothelial cell dysfunction** * This results in **vasoconstriction and salt retention (at the kidneys)** leading to hypertension **Proteinuria** * **Local vasospasm and hypertension** will result in reduced blood flow to the kidneys. * The systemic inflammatory response may also lead to **glomerular changes and disruption of the basement membrane and podocytes** * This results in the leakage of proteins out the kidneys causing **proteinuria** **Peripheral Oedema** * Endothelial injury increases **vascular permeability** enabling water to leak out of blood vessels and into the surrounding tissues * Furthermore, the proteinuria leads to low protein concentrations within blood vessels reducing **the oncotic pressure** and hence leads to further water loss into tissues * This results in **generalised oedema** that is commonly seen in the **Legs, face and hands**. * Pulmonary oedema (causing cough and SOB) as well as cerebral oedema (causing headaches, confusion and **seizures**)

Answer 469

* **Eclampsia** (seizures due to cerebrovascular vasospasm) * Organ failure * Disseminated intravascular coagulation (DIC) * **HELLP syndrome** (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))

Answer 470

* **Intrauterine growth restriction (IUGR)** * Pre-term delivery * **Placental abruption** * Neonatal hypoxia

Answer 471

**Blood Pressure Monitoring** * Systolic BP > 140mmHg * Diastolic BP > 90mmHg * **Severe Pre-eclampsia:** Systolic >160mmHg and Diastolic >110mmHg **Urinalysis:** * Proteinuria **1+ or more** on urine dipstick * **Urine protein:creatinine ratio** > 30mg/mmol is significant * **Urine albumin:creatinine ratio** > 8mg/mmol is significant **Blood Tests:** * U&E, FBC, LFTs (To assess kidney function, liver function and clotting status)

Answer 472

NICE guidelines 2019 state diagnosis can be made with: * Hypertension (systolic >140mmHg/Diastolic >90mmHg) **PLUS any of:** * Proteinuria (1+ or more on urine dipstick) * Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) * Placental dysfunction (e.g. foetal growth restriction or abnormal Doppler studies) **NICE Guidelines 2019 and Placental Growth Factor (PlGF):** * Recommend testing on one occasion during pregnancy in women suspected to have Pre-eclampsia between **20 and 35 weeks gestation to rule out pre-eclampsia** * **sFLT:PlGF ratio >85 is diagnostic**

Answer 473

* Scoring systems are used to determine whether to admit the woman (**fullPIERS or PREP‑S**) * Blood pressure is monitored closely (**at least every 48 hours**) * Ultrasound monitoring of the foetus, amniotic fluid and dopplers is performed two weekly **Urine dipstick testing is not routinely necessary (the diagnosis is already made)** **Medical Management:** * **Labetolol** is first-line as an antihypertensive * **Nifedipine** (modified-release) is commonly used second-line * **Methyldopa** is used third-line (needs to be stopped within two days of birth) * **Intravenous hydralazine** may be used as an antihypertensive in **critical care in severe pre-eclampsia or eclampsia** * **IV magnesium sulphate** is given **during labour and in the 24 hours afterwards** to prevent seizures * **Fluid restriction** is used during **labour in severe pre-eclampsia or eclampsia,** to avoid fluid overload

Answer 474

Consider early delivery at **37 weeks** if blood pressure cannot be controlled or complications occur. **Corticosteroids** should be given to the women having a premature birth **to help the foetal lungs mature**

Answer 475

Delivery of the foetus and placenta

Answer 476

Similar to Pre-eclampsia with additional **IV Magnesium Sulphate** to manage the seizures

Answer 477

Combination of features that occur as a complication of Pre-eclampsia and Eclampsia: **H**aemolysis **E**levated **L**iver enzymes **L**ow **P**latelets

Answer 478

* HELLP syndrome is relatively rare, affecting approximately 0.5-0.9% of all pregnancies. * Occurs in 10-20% of women with **severe pre-eclampsia or eclampsia** * However, it is a significant cause of maternal and perinatal morbidity and mortality.

Answer 479

* Reduced perfusion of the placenta and thus oxidative stress releasing inflammatory cytokines. * Hypertension and endothelial damage reduces blood flow to the liver causing injury and swelling. This results in **elevation of liver enzymes** and stretches the liver capsule causing **RUQ and epigastric pain** * Endothelial cell injury leads to formation of thrombi in vasculature **using up platelets making their numbers low** * Thrombi can act as blocks for RBCs which crash into them causing them to become damaged and **haemolyse**

Answer 480

Headache Nausea and/or vomiting Epigastric pain Right upper quadrant abdominal pain due to liver distension Blurred vision Peripheral Oedema

Answer 481

* Full blood count to assess for low platelet count and evidence of haemolysis * Liver function tests to assess for elevated liver enzymes * Coagulation studies to evaluate for disseminated intravascular coagulation * Ultrasound scans to assess for liver abnormalities and placental abruption

Answer 482

**Delivery of the baby and placenta** * Mothers may also require **blood transfusions** to manage anaemia and thrombocytopenia

Answer 483

Obstetric cholestasis, also known as **intra-hepatic cholestasis of pregnancy**, is a pregnancy-related hepatobiliary disorder that **typically manifests after the 24th week of gestation.** The condition is characterised by impaired bile flow leading to the accumulation of bile acids.

Answer 484

* Relatively common complication of pregnancy occuring in 1% * Develops later in pregnancy **(Typically after 24-28 weeks)** * More common in **South Asian Ethnicity**

Answer 485

Multifactorial: * Hormonal Factors such as Increased oestrogen and Progesterone * Genetic factors * Environmental triggers

Answer 486

* In obstetric cholestasis, the outflow of bile acids is reduced, causing them to build up in the blood * Bile salts are deposited into various tissues such as the skin and placenta * **Skin deposition** leads to pruritus (itching) * **Placental deposition** causes raised foetal bile acid levels causing deterioration potentially due to arrhythmia, cardiomyopathy or placental vasoconstriction **Obstetric cholestasis is associated with an increased risk of stillbirth.**

Answer 487

* **Pruritus:** This is often severe and typically more intense on the hands and feet. **It is not associated with a rash**, although excoriation marks from scratching may be present. * **General discomfort:** Patients may experience fatigue or malaise. * **Jaundice:** Mild maternal jaundice characterised by dark urine and pale stools may occasionally occur. * **Gastrointestinal symptoms:** Nausea and loss of appetite are common. * **Abdominal pain:** Pain is typically localised in the right upper quadrant.

Answer 488

* Polymorphic eruption of pregnancy * Pemphigoid gestationis.

Answer 489

* Gallstones * Acute fatty liver * Autoimmune hepatitis * Viral hepatitis

Answer 490

* **Serum Bile Acids:** Raised above 19 micromol/l * **LFTs:** Mainly ALT, AST and GGT **ALP typically rises in pregnancy due to it being produced by the placenta.

Answer 491

**First Line:** * **Emollients:** soothe the skin * **Antihistamines: Chlorphenamine** to alleviate itching and aid in sleeping **Second Line:** * **Ursodeoxycholic acid:** Improves LFTs, bile acids and symptoms

Answer 492

The Bartholin’s glands are a pair glands located either side of the posterior part of the vaginal introitus (the vaginal opening). They are usually pea-sized and not palpable. They produce mucus to help with vaginal lubrication.

Answer 493

This occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin's gland.

Answer 494

This occurs when a cyst becomes infected, resulting in extreme pain, lymphadenopathy, erythema, and in rare cases, systemic upset.

Answer 495

The primary cause of Bartholin's gland cysts and abscesses is the blockage of the gland's duct. This blockage can be due to thick mucus, inflammation, trauma, or in rare cases, malignancy. Abscesses are typically caused by infection of a cyst, often with normal vaginal flora or sexually transmitted bacteria.

Answer 496

**Bartholin's gland cyst:** * Palpable swelling and pain at the site of the Bartholin's gland. **Bartholin's gland abscess:** * Extreme pain * lymphadenopathy * erythema, * rare cases, systemic upset such as fever and malaise.

Answer 497

* **Vaginal cysts:** Typically asymptomatic but can cause discomfort during sex or when sitting. * **Skene's duct cysts:** Located on either side of the urethra, can cause discomfort during sex or urination. * **Vulvar cancer:** Can present with a vulvar lump, itching, pain, or abnormal bleeding.

Answer 498

**Physical examination:** To assess the size, location, and nature (cystic or solid) of the swelling. **Ultrasound:** To confirm the diagnosis and rule out other potential causes of vulvar swelling. **Biopsy:** In postmenopausal women or in cases where malignancy is suspected. **Culture:** In cases of abscess to identify the causative organism.

Answer 499

**Cysts:** * Good hygiene and warm compresses * Incision and Drainage is typically avoided due to likelihood of reoccurrence **Abscess:** * Antibiotics * **Surgical intervention may be required:** * **Word Catheter:** requires local anaesthetic * **Marsupialisation:** requires general anaesthetic

Answer 500

Also known as **Cot death** is the sudden unexplained death of an infant. It usually occurs within the first **six months of life**

Answer 501

* Prematurity * Low birth weight * Smoking during pregnancy * Male baby (slightly increased risk)

Answer 502

* Put the baby on their back when not directly supervised * Keep their head uncovered * Place their feet at the foot of the bed to prevent them sliding down and under the blanket * Keep the cot clear of lots of toys and blankets * Maintain a comfortable room temperature (16 – 20 ºC) * Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes). * Avoid co-sleeping, particularly on a sofa or chair * If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers

Answer 503

* **Lullaby Trust** is a charity to help support families affected. * Bereavement services and counselling should also be available. * **Care of Next Infant (CONI) Team** supports parents with their next infant after SIDS including extra support and home visits and resuscitation training

Answer 504

**Follicular/Proliferative Phase** Days 1-14 **Luteal/Secretory Phase** Days 15-28

Answer 505

* Increased frequency of pulsatile GnRH secretion leads to an increase in LH, and an initial increase in FSH. * Oestrogen rises gradually as granulosa cells convert thecal androgens under the influence of FSH. Progesterone levels remain low after loss of corpus luteum. Moderate levels of oestrogen exert negative feedback on FSH secretion. * **Days 1-5:** Progesterone withdrawal due to degeneration of corpus luteum leads to sloughing of the stratum functionalis (a menstrual bleed). * **Days 6-14:** The endometrium undergoes its proliferative phase due to rising oestrogen levels. * Meanwhile, 15-20 early antral (tertiary) follicles undergo development. At approximately **day 7, a single dominant follicle is selected.** * It is thought that this occurs because rising oestrogen levels lower FSH levels through negative feedback - the dominant follicle is the one that can cope with lower FSH. * **Day 13** - Rising oestrogen levels reach a ‘tipping point’, at which their negative feedback on LH secretion is reversed - the LH surge occurs, stimulating the oocyte to complete meiosis I and form a single Graafian follicle. * **Day 14** - Ovulation - The secondary oocyte erupts from its follicle, carried by antral fluid.

Answer 506

* **Day 15** - the granulosa cells of the ruptured follicle become luteinised, forming the progesterone-secreting corpus luteum. * The corpus luteum’s progesterone acts upon the endometrium to cause it to enter its secretory phase - amongst other things, it secretes glycogen and mucous. * **Progesterone levels peak 7 days before** the next menstrual bleed - 7 days before CL completely degenerates. * High levels of progesterone increase the volume and viscosity of cervical secretions; this begins the formation of the protective operculum. * **After 10 days, if no conceptus has implanted**, the corpus luteum spontaneously regresses. This leads to diminishing progesterone levels: * Without progesterone’s negative feedback on the hypothalamus, GnRH release frequency increases and facilitates a rise in gonadotrophins. * Progesterone withdrawal also stimulates the stratum functionalis of the secretory endometrium to be shed. * As FSH and LH levels rise, and the menstrual bleed begins, the cycle restarts on Day 1.

Answer 507

* Copper intrauterine device (Cu-IUD) * **Barrier methods** e.g. male condom, female condom, diaphragm/cervical cap * **Surgical methods** e.g. tubal ligation, vasectomy * Lactational amenorrhoea * Fertility awareness methods (FAM)

Answer 508

* Combined Hormonal Contraception (CHC) * Combined Oral Contraceptive Pill (COCP) * Progesterone Only Pill (POP/Mini-pill) * Levonorgestrel Intrauterine System (LNG-IUS commonly known as **Mirena**) * Contraceptive Injection (Depo-Provera) * Contraceptive Implant

Answer 509

* Levonorgestrel Pill * Ulipristal Acetate Pill (**EllaOne**) * Copper Intrauterine Device (Cu-IUD)

Answer 510

**Mechanism:** Copper ions prevent fertilisation by immobilising sperm and inactivating lytic enzymes required for the acrosome reaction **Efficacy:** 0.8% experience unintended pregnancy after 1 year **Advantages:** * Effective immediately on insertion (can be used in emergency). * No hormonal side effects. * High Efficacy **Absolute Contraindications:** * PID * Gonorrhoea/Chlamydia * Unexplained vaginal bleeding/endometrial cancer * postpartum/postabortion septicaemia * Gestational trophoblastic disease * Purulent cervicitis, Pelvic TB **Side Effects:** * Breakthrough bleeding. * Increased duration or heaviness of periods **Other:** * Classified as **Long-acting reversible contraceptive (LARC)** * Left in situ for **5 years** * Most effective form of emergency contraception. * The Cu-IUD is licensed for insertion 5 days post-ovulation.

Answer 511

**Mechanism:** Progestogen and Oestradiol components exert negative feedback on hypothalamus and pituitary respectively reducing LH and FSH release and thus ovulation is suppressed **Efficacy:** 0.03% failure rate if used perfectly but human error is important taking average unwanted pregnancy to 9% **Advantages:** * Rapidly reversible if unintended side effects * Regulars and tends to lighten periods **Absolute Contraindications:** * <6 weeks postpartum in breastfeeding women * Aged 35, smoking >15 cigarettes per day * Stage 2 hypertension (160/100) * History of VTE * Disease: Breast cancer, inherited thrombophilia e.g. Factor V Leiden, cardiomyopathy, cirrhosis, vascular disease, SLE, positive antiphospholipid antibodies. * Migraine with aura **Side Effects:** * Headache * Mood disturbance * Breakthrough bleeding

Answer 512

**Mechanism:** Progestogen exerts negative feedback on hypothalamus, reducing GnRH release frequency and therefore suppressing secretion of LH and FSH. This suppresses follicle development, the LH surge, and ovulation **Efficacy:** 9% experience unintended pregnancy after 1 year. **Advantages:** * Rapidly reversible * Far fewer absolute contraindications than the combined pill **Absolute Contraindications:** * Breast Cancer **Side Effects:** * Breakthrough Bleeding **Other:** * Effective after 2 days of administration

Answer 513

**Mechanism:** Thinning of endometrium by downregulation of endometrial oestrogen receptors; this prevents implantation. Does not inhibit ovulation. **Efficacy:** 0.2% unintended pregnancy after 1 year **Advantages:** * Extremely high efficacy * Can be left in situ for 3-5 years * Lightens periods * Systemic absorption is minimal, reducing systemic hormonal side effects **Absolute Contraindications:** * PID * Gonorrhoea or chlamydia * Unexplained vaginal bleeding / endometrial cancer * Postpartum / post-abortion septicaemia * Gestational trophoblastic disease * Purulent cervicitis, pelvic TB **Side Effects:** * Irregular Menstrual Bleeding

Answer 514

**Mechanism:** Progestogen exerts negative feedback on hypothalamus, reducing GnRH release frequency and therefore suppressing secretion of LH and FSH. This suppresses follicle development, the LH surge, and ovulation **Efficacy:** 6% experience unintended pregnancy after 1 year. **Advantages:** * Long acting - Requires injection every **13 weeks** **Absolute Contraindications:** * Breast Cancer **Side Effects:** * Amenorrhoea

Answer 515

**Mechanism:** Progestogen exerts negative feedback on hypothalamus, reducing GnRH release frequency and therefore suppressing secretion of LH and FSH. This suppresses follicle development, the LH surge, and ovulation **Efficacy:** 0.05% experience unintended pregnancy after 1 year **Advantages:** * Most effective contraception available. * Active for 3 years before replacement is required. **Absolute Contraindications:** * Breast Cancer **Side Effects:** * Irregular Menstrual Bleeding

Answer 516

**Mechanism:** * Exogenous progestogen, exerts negative feedback on hypothalamus to prevent the LH surge and delay ovulation in event of unprotected sexual intercourse (UPSI) * Can delay ovulation by 5 days (the viable lifespan of ejaculated sperm). * Not effective in the late luteal phase, in which case ulipristal acetate is required. **Efficacy:** * Effective up to **72 hours post UPSI** * Not effective if taken after ovulation has occurred

Answer 517

**Mechanism:** Selective progesterone receptor modulator, inhibits ovulation (possibly by blocking hypothalamic progesterone receptors, which studies suggest play a role in producing the LH surge) **Efficacy:** * Effective up to **120 hours post UPSI** * Can delay ovulation even if LH surge has started * Remains effective in **late follicular phase** * Not effective if taken after ovulation

Answer 518

* Offer most effective method (Cu-IUD) first line; * Can be taken either within 120 hours of first UPSI or within 120 hours of calculated date of ovulation; whichever is later. * If Cu-IUD not acceptable / appropriate, offer oral emergency contraception; * If within 72 hours of UPSI - offer LNG or UPA. * If 72-120 hours post-UPSI - offer UPA.

Answer 519

Fusion of haploid sperm and oocyte, typically occurring in the ampulla of the fallopian tube.

Answer 520

**1. Capacitation** - final stage of sperm maturation - involves exposure of receptor sites involved in zona pellucida penetration. **2. Acrosome reaction** - loss of the acrosome cap on the head of the sperm cell leads to release of lytic enzymes, which allows the sperm to penetrate the zona pellucida. **3. Adhesion and entry** - cell membranes of sperm and egg fuse, and the head of the sperm if phagocytosed - it then breaks down to release the sperm nucleus. **4. Cortical reaction** - modification of the zona pellucida to prevent polyspermy, induced by membrane fusion and mediated by cortical granules **5. Meiosis II** - the oocyte completes meiosis II (which until this point is arrested in metaphase II) to give the second polar body. **6. Syngamy** - the male and female pronuclei replicate DNA and shed their nuclear membranes as they move toward one another, before aligning at a common metaphase plate and undergoing mitosis

Answer 521

* **Day 6-7:** implantation of blastocyst into endometrium * **Week 3:** gastrulation - formation of trilaminar disc (endoderm, mesoderm, ectoderm) from the primitive streak * **Week 3-8:** beginning of development of organ systems * **Week 4:** neurulation - development of neural tube from the ectoderm * **Week 23:** generally considered to be the threshold of viability.

Answer 522

**Exchange:** * **gaseous:** Oxygen moves readily from maternal to foetal haemoglobin (HbF) due to HbF’s higher affinity. CO2 diffuses from foetal to maternal blood down the concentration gradient * **Nutritional:** Glucose moves from maternal to foetal circulation via facilitated diffusion; both amino acids and free fatty acids also cross from mother to foetus, the former through active transport. **Endocrine:** * **Human Chorionic Gonadotrophin (hCG)** Produced by trophoblast cells - maintains the corpus luteum to allow for sufficient progesterone production until the placenta takes over * **Human Placental Lactogen (hPL):** Increases maternal free fatty acid and insulin levels, as well as inducing maternal insulin resistance. * **Progesterone:** Inhibits uterine contractility and thickens endometrium * **Oestrogen:** Stimulates myometrial growth, oxytocin receptor synthesis and pregnancy related breast changes

Answer 523

**Cardiovascular:** * TPR decreases * Cardiac output increases by 45% **Haematological:** * Red cell mass increases * Physiological anaemia due to an increase in plasma volume diluting the conc of Hb * Decreased platelet count * Clotting factors VII, VIII, IX, X increase leading to a **hypercoagulable state** **Renal:** * Increased renal blood flow and GFR * Low serum urea and creatinine due to raised GFR **Respiratory:** * Lung volume increases * Minute ventilation and oxygen consumption in crease by 50% and 30% respectively **Breasts:** * Ductal proliferation * Prolactin stimulates milk production from alveolar cells * Alveoli grow **Gastrointestinal:** * Gastric emptying is slowed and bowel motility is decreased (Gastric reflux and constipation) **Skin:** * Increased pigmentation of face and areola * Linea nigra * Stria gravidarum **Endocrine:** * Oestrogen and progesterone rise throughout pregnancy

Answer 524

**8 routine for parous women and 11 for nulliparous women** (Women who haven't given birth to a live baby.) Also possibility of a **41 week appointment** if women has not yet delivered Nulliparous women have an additional 3 at: **25 weeks, 31 weeks and 40 weeks**

Answer 525

**Before 10+0 weeks: Booking Visit** * Heigh and weight measurement * Screening offered * BP and urinalysis * Assess for risk of **GDM, Pre-eclampsia, FGR, VTE, FGM * Offer vaccines (influenza (any time) and pertussis (16-30 weeks) **11+2 to 14+1 weeks: Dating Scan** * Estimate gestational age * Assess for Multiple Pregnancy * Foetal anomaly screening **16 Weeks:** Blood pressure and urinalysis **18+0 to 20+6 weeks: Anomaly scan** * Detailed scan to assess for anatomical anomalies (anencephaly, meningocele, exomphalos) * Assess position of the Placenta (low lying, Praevia) * Foetal movements typically felt at this point **25 weeks:** BP and urinalysis + Symphyseal-fundal height (SFH) **28 weeks:** * Height, Weight, BP, Urinalysis and SFH * Anti-D prophylaxis (first dose) for Rhesus negative women **31 Weeks:** BP, Urinalysis and SFH **34 Weeks:** * BP, Urinalysis and SFH * Anti-D prophylaxis (second dose) for Rhesus negative women **36 Weeks:** * BP, urinalysis and SFH * Palpate abdomen to assess for breech presentation **38 Weeks:** * BP, Urinalysis and SFH * Discuss possibility of prolonged pregnancy and its management **40 Weeks:** BP, urinalysis and SFH **41 Weeks:** * BP, urinalysis and SFH * Sweep offered to induce labour

Answer 526

**All offered at the Booking visit** * Infectious Disease * Sickle Cell and Thalassaemia * Foetal Anomaly

Answer 527

* **HIV:** 25% risk of MTC transmission if untreated * **Syphilis:** Risk of miscarriage, stillbirth, congenital syphilis * **Hepatitis B:** 70-90% risk of MTC transmission if HBeAg positive

Answer 528

**Trisomy's 21 (Down's), 18 (Edwards') and 13 (Patau's)** All Screened for at the booking visit with the **combined Test:** * Maternal age * b-hCG, PAPP-A (pregnancy associated Plasma Protein) * USS (11+2-14+1) - Nuchal translucency (NT) and Crown-rump Length (CRL) * CRL must be 45-84mm to be eligible for combined test * Too low then wait and Too high offer Quadruple test If the mother is late-booking (>14+0) then the **quadruple test is used for T21:** * Maternal age, b-hCG, AFP, inhibin A and Unconjugated Oestriol **If high Chance of Anomaly (> 1/150) there are 3 options: * No further testing * Non-invasive prenatal testing (NIPT) - Placental cell free DNA * Prenatal diagnosis (PND) - Chorionic villus sampling (11-14 weeks), Amniocentesis (15+ weeks)

Answer 529

**Trisomy 21 (Down's):** high b-hCG, Low PAPP-A, High NT (>3.5mm) (Quadruple test: Low AFP, high Inhibin-A, Low Unc Oestriol) **Trisomy 18 (Edwards'):** Low b-hCG, Low PAPP-A, High NT **Trisomy 13 (Patau's):** Low b-hCG, Low PAPP-A, High NT

Answer 530

Normally occur between **37 and 42 weeks gestation**

Answer 531

* **First stage** – from the onset of labour (true contractions) until 10cm cervical dilatation * **Second stage** – from 10cm cervical dilatation until delivery of the baby * **Third stage** – from delivery of the baby until delivery of the placenta

Answer 532

The first stage of labour is defined as the period that starts with regular uterine contractions and ends when the cervix is fully dilated to 10cm. This stage can be further divided into: ** Latent Phase:** from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. **Active Phase:** from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions **Transition Phase:** from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Answer 533

The first stage of labour is initiated by a complex interplay of hormonal signals, primarily involving prostaglandins and oxytocin, which stimulate regular uterine contractions. These contractions, in combination with the pressure exerted by the presenting part of the foetus, lead to progressive dilation of the cervix.

Answer 534

* Occasional irregular contractions of the uterus. * They are usually felt during the second and third trimester. * Women can experience temporary and irregular tightening or mild cramping in the abdomen. * These are not true contractions, and they do not indicate the onset of labour. * They do not progress or become regular. * Staying hydrated and relaxing can help reduce Braxton-Hicks contractions.

Answer 535

* Show (mucus plug from the cervix) * Rupture of membranes * Regular, painful contractions * Dilating cervix on examination **Latent First stage:** is when there are both * Painful contractions * Changes to the cervix with effacement and dilation up to 4cm **Established first stage of labour:** is when there are both * Regular painful contractions * Dilation of the cervix from 4cm onwards

Answer 536

The second stage of labour is defined as the period beginning with complete cervical dilation and ending with the delivery of the foetus. **There are 7 Stages:** 1. **Descent:** the baby’s head (providing it is in cephalic presentation) descends deeper into the pelvis until it is no longer palpable on abdominal examination. 2. **Flexion:** the baby’s head flexes (chin to chest) to give the narrowest (suboccipitobregmatic) diameter. 3. **Internal rotation:** baby’s occiput rotates anteriorly from the lateral position to give the normal occipito-anterior position. 4. **Extension:** baby’s occiput contacts the maternal pubic rami - it then extends and crowns 5. **Restitution:** baby’s occiput re-aligns with its shoulders, which lie in between the anterior-posterior and lateral positions 6. **External rotation:** baby’s shoulders rotate into anterior-posterior position (i.e. perpendicular to mother’s). At this point, the baby’s head is delivered - it is aligned with its shoulders, so the face looks laterally at the mother’s thigh. 7. **Delivery of shoulders:** the anterior shoulder is delivered first from beneath the pubic ramus; the head is then gently lifted anteriorly to deliver the posterior shoulder. The rest of the baby’s body rapidly follows.

Answer 537

The period beginning at the delivery of the foetus and ending with the delivery of the placenta and foetal membranes. * This stage **generally occurs within 30 minutes of delivery of the baby.** * **Physiological Management:** * This stage generally lasts within 30 minutes to an hour when allowed to occur naturally * **Active Management:** It may take as long as 5-10 minutes with **administration of IM oxytocin**

Answer 538

**Routinely offered to all women to reduce the risk of postpartum haemorrhage** Initiated if: * Haemorrhage * More than a 60 minute delay in the delivery of the placenta (Prolonged third stage)

Answer 539

The medically initiated process of starting labour artificially. It is performed under specific circumstances to ensure the safety of the mother and the child.

Answer 540

* Post-dates/Prolonged pregnancy (>41 weeks gestation) * Preterm prelabour rupture of membranes (offered at 37+0) * Intrauterine foetal death (IUFD) * Abnormal CTG * Maternal request * Maternal conditions such as pre-eclampsia, diabetes, cholestasis

Answer 541

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

Answer 542

**Bishop Scoring System:** Score from 0-13 * Foetal station (scored 0 – 3) * Cervical position (scored 0 – 2) * Cervical dilatation (scored 0 – 3) * Cervical effacement (scored 0 – 3) * Cervical consistency (scored 0 – 2) **A score of 8 or more predicts a successful induction of labour** **A score below this suggests cervical ripening may be required to prepare the cervix**

Answer 543

**Membrane Sweep** * Inserting a finger into the cervix to stimulate the cervix and begin the labour process * Labour should follow **within 48 hours if successful** * Is used from **40 weeks gestation** to attempt to initiate labour in women over their EDD (estimated delivery date) **Vaginal Prostaglandin E2 (Dinoprostone)** * Insert a Gel, Tablet or Pessary into the vagina to **slowly release local prostaglandins over 24 hours.** to stimulate labour onset. * Usually performed when there is a **Bishop Score < 6** **Amniotomy (Artificial Rupture of Membranes)** * May be done with/without **oxytocin infusion** * Only used where Vaginal Prostaglandins are not tolerated/successful * Used when the **Bishop Score > 6**

Answer 544

* Further vaginal prostaglandins * Artificial rupture of membranes and oxytocin infusion * Cervical ripening balloon (CRB) * Elective caesarean section

Answer 545

**Uterine Hyperstimulation:** This is where the contraction of the uterus is prolonged and frequent, causing foetal distress and compromise. 2 Criteria for Uterine Hyperstimulation: * Individual uterine contractions lasting more than 2 minutes in duration * More than five uterine contractions every 10 minutes

Answer 546

* Foetal compromise, with hypoxia and acidosis * Emergency caesarean section * Uterine rupture

Answer 547

* Removing the vaginal prostaglandins, or stopping the oxytocin infusion * Tocolysis with terbutaline

Answer 548

* Take a history, Assess for risk factors and assess for pain * Pules, BP, Resp Rate, Urinalysis * Abdominal palpation to determine Lie, presentation, engagement and contraction strength * Vaginal examination to determine station, position, cervical effacement and dilation, presence or absence of membranes and caput or cranial moulding.

Answer 549

**Partogram** * **Progress:** Cervical dilation, descent, contractions (frequency and duration) * **Foetal wellbeing:** Heart rate, Amniotic fluid (liquor) * **Maternal wellbeing:** Pulse, BP, Temp, Urinalysis

Answer 550

**Low risk deliveries:** Intermittent Auscultation with a **Doppler Probe** **High risk Deliveries:** **Cardiotocograph (CTG)**

Answer 551

Used to measure the foetal heart rate and the contractions of the uterus. CTG Readouts are interpreted as: **Normal:** No non-reassuring features **Suspicious:** One non-reassuring feature **Pathological:** Two non-reassuring features **OR** one abnormal feature **Need for urgent Intervention:** Acute bradycardia or prolonged deceleration of more than 3 minutes

Answer 552

* **Contractions** – the number of uterine contractions per 10 minutes * **Baseline rate** – the baseline foetal heart rate * **Variability** – how the foetal heart rate varies up and down around the baseline * **Accelerations** – periods where the foetal heart rate spikes * **Decelerations** – periods where the foetal heart rate drops

Answer 553

**Baseline Heart Rate:** 110-160bpm **Decelerations (Drops of 15 bpm for 15s):** Absent **Accelerations (increases of 15 bpm for 15s):** Present **Baseline variability:** 5-25bpm

Answer 554

**Baseline Rate:** 100-109 / +20 from start of labour **Decelerations:** * Repetitive Variable for < 30 mins * Variable for < 30 mins * Repetitive late for 30 mins **Accelerations:** Absent **Baseline Variability:** <5 for 30-50 mins / >25 for <10mins

Answer 555

**Baseline Rate:** <100/ >60 **Decelerations:** * Repetitive variable with concerning characteristics >30 mins * Repetitive late > 30mins * 3 minutes of Bradycardia **Accelerations:** Absent **Baseline Variability:** <5 for 50 mins / >25for >10mins / sinusoidal pattern

Answer 556

**Severe Foetal Compromise** Usually associated with severe foetal anaemia caused by **vasa praevia with foetal haemorrhage**

Answer 557

**Rule of 3s:** * **3 Minutes:** Call for help * **6 Minutes:** Move to theatre * **9 Minutes:** Prepare for delivery * **12 Minutes:** Deliver the baby (**by 15 Minutes**)

Answer 558

**DR** – **D**efine **R**isk (define the risk based on the individual woman and pregnancy before assessing the CTG) **C** – **C**ontractions **BRa** – **B**aseline **R**ate **V**– **V**ariability **A** – **A**ccelerations **D** – **D**ecelerations **O** – **O**verall impression (given an overall impression of the CTG and clinical picture)

Answer 559

* Understanding what to expect * Having good support * Being in a relaxed environment * Changing position to stay comfortable * Controlled breathing and relaxation techniques * Water births may help some women * TENS machines may be useful in the early stages of labour

Answer 560

**Simple Analgesia:** Paracetamol or Codeine (NSAIDS are avoided) **Gas and Air (Entonox):** 50% nitrous oxide and 50% oxygen used during contractions for short term pain relief **IM Opiates (Pethidine, Diamorphine):** Opioid medications given by IM injection **Patient Controlled Analgesia:** PCA using IV remifentanil

Answer 561

**Epidural** Local anaesthetic medications ((Levobupivacaine or bupivacaine combined with fentanyl injected into the epidural space at L3-4.

Answer 562

* Headache after insertion * Hypotension * Motor weakness in the legs * Nerve damage * Prolonged second stage * Increased probability of instrumental delivery

Answer 563

Women unable to straight leg raise is concerning. Suggests that the catheter for an epidural is incorrectly sited in the **subarachnoid space (within the spinal cord)**