Obstetrics

Question 1

ddx UTI

Answer 1

Vagina OPIUM

• vaginitis/osis
• > candida
• > trichomoniasis
• > bacterial vaginosis
• overactive bladder
• PID
• interstitial cystitis
• urethritis
• malignancy
• > urothelial

Question 2

investigations UTI

Answer 2

FBC
-raised WCC
EUC
-eGFR

urinalysis

• dipstick
• > leuks and nitrites
• > haematuria
• microscopy
• > follow up for haematuria -> haem or RCCs?
• > diagnostic = 100 CFU/mL of typical organism
• culture
• > growth >10^5 CFU/mL
• > gram stain
• > sensitivity

consider

• CT KUB
• > protracted illness, treatment resistance, upper tract signs
• renal ultrasound
• > hydronephrosis
• > stones
• > scarring
• cystoscopy
• > suspicion of lower tract pathology

Question 3

cervical screening

Answer 3

Demographic

• asymptomatic
• women over 25 (up to 75)
• every 5 years

Test

• cervical cell HPV testing (DNA PCR)
• partial genotyping (16/18)

Pathway

• positive result = liquid based cytology
• positive HPV with 16/18 -> colposcopy
• positive HPV not 16/18 -> triaged by LBC results
• > negative/pLSIL/LSIL = repeat HPV test 12 months
• > pHSIL/HSIL = colposcopy
• all adeno referred for colposcopy

Question 4

ddx PID

Answer 4

CATNAPEER

• cystitis
• tubo-ovarian abscess
• torsion (ovarian)
• nephrolithiasis
• appendicits
• pyelonephritis
• ectopic
• endometriosis
• ovarian cyst rupture

Discharge

• vaginosis
• trichimoniasis
• candidiasis

Question 5

Pelvic organ supports

Answer 5

Support provided by interaction between muscles of pelvic floor and connective tissue attachment to bony pelvis

a system of three integrated levels of support was described by DeLancey

Level 1

• uterosacral + cardinal ligaments
• suspends uterus plus upper vagina to sacran and pelvic side wall

Level 2
attachments along the length of vagina to
-superior fascia of levator ani
-tendinous arch

Level 3 
support of distal third of vagina by 
-perineal body
-superficial and deep transverse perineal muscles
-perineal membrane
-bulbospongiosis

Question 6

pelvic organ prolapse types

Answer 6

anterior compartment

• hernia of anterior wall
• associated with descent of bladder (cystocele)

posterior compartment

• hernia of posterior wall
• associated with descent of rectum (rectocele)

enterocele
-hernia of intestines through vaginal wall

apical compartment prolapse
-descent of apex of vagina/cervix/uterus into lower vagina

Question 7

PID risk factors

Answer 7

age <25
sexually active (unprotected, during menses)
multiple sex partners
sex partner with STI
previous STI/PID
instrumentation/IUD (briefly increased risk)

Question 8

types of hysterectomies

Answer 8

vaginal

• preferred method
• faster return to activities/shorter hospital stay
• faster surgery

laparoscopic

• second option
• longer surgery time
• increased risk of damage to urinary tract
• compared with abdominal
• > faster
• > shorter hospital stay
• > fewer infections

single port and robot assisted laparoscopy
-neither have improved outcome over conventional laparoscopy and are technically difficult

abdominal
-default when laparoscopy is insufficient

Variations

• supracerivcal (subtotal) hysterectomy
• > no difference in major outcomes (eg. continence or sexual function)
• > continued need for cancer screening, cyclic bleeding
• may include oophorectomy and salpingectomy depending on indication

Question 9

complications hysterectomies

Answer 9

haemorrhage

Structures

• ureters
• bladder
• bowel
• femoral nerve (placement of retractors lateral to psoas)

UTI

Urinary incontinence

Pelvic organ fistulae

Pelvic organ prolapse

• risk is controversial
• loss or damage to level 1 supports
• prophylactic apical suspension is recommended

Question 10

stages of labour

Answer 10

Stage 1

• start
• > contracts every 3-5mins every hour
• end
• > full (10cm) cervical dilation
• process
• > stretching cervix stimulates posterior pituitary
• > release of oxytocin causes contraction
• > contractions release prostaglandins from placenta
• > prostaglandins strengthen contractions
• > contractions stimulate stretch cervix
• substage
• > latent = slow progress until approx 5-6cm
• > active = more rapid effacement
• > inflection point less clear in nullips
• median progression time
• > approx 1.5hrs/cm until inflection
• > approx 0.5hrs/cm after inflection
• 95th centile progression time
• > approx 6hrs for 4-5cm
• > approx 3hrs for 5-6cm
• > approx 1.5hrs/cm after inflection

Stage 2

• start
• > complete dilatation
• end
• > delivery
• process
• >

Stage 3

• start
• > fetal expulsion
• end
• > placental expulsion
• process
• >