HARD SAQs Flashcards

Question

options for treatment of IDA

Answer 1

History o Exclude pvb o Fhx/personal hx o Previous treatments trialled and response o Allergies o Review diet and intake o Exclude hyperemesis sx o PMedhx: coeliac/absorption issues o Psurghx: bariatric surgery Examination o Signs of anaemia: conjunctival pallor, HR Ix o Exclude concurrent thalassemia or alternative cause, iron levels Management o depends on gestation, previous response, symptoms, allergies - do nothing - diet - PO iron with vitamin C  Instructions: do not take with milk products, mindful of constipation (advise to take 2-3L water, fibre in diet, fibre supplements, over the counter apperients eg Movicol and lactulose as required)  Advantages: cheap, non invasive, can continue postpartum, minimal risks and side effects, simple, does not require hospital, accessible  Disadvantage: takes a longer time to increase stores – not ideal if 38 weeks pregnant and about to have a LSCS etc , may not be absorbed well during pregnancy with increased progesterone, side effects – nausea, constipation, requires adherence, limited efficacy – may be insufficient - IV iron infusion  Instruction: done as inpatient, must meet criteria at hospital – Hb <103, ferritin <30  meets criteria  Advantages: minimally invasive – requires IVC, covered by medicare, less constipating, more rapid correction therefore can be used closer to due date, better tolerated, effective even with absorption issues, only 1-2 doses, can be used for those with poor response or unable to tolerate PO iron  Risks: anaphylaxis, staining, cost, requires hospital admission, access, time consuming - pRBC  instructions: done as inpatient, rapid reversal  advantages: rapid  risks: antibodies, costly to healthcare system, access, availability, anaphylactoid reactions, transfusion reactions, antibodies

Answer 2

Establish whether immediate birth in singleton pregnancies with ROM close to term reduces neonatal infection without increasing other morbidity

Answer 3

multi-centre multinational RCT, large sample size good generalisability randomised to expectant management vs induction of labour when PPROM K34-36+6 * primary outcome: neonatal sepsis * secondary: neonatal composite – sepsis, NICU + maternal composite: APH, PPH, sepsis, intrapartum fever, IV ABX, MOD outcomes immediate management group  increased respiratory distress  increased mechanical ventilation  more time in SCN expectant  increased APH + PPH  increased intrapartum fever  increased PP abx use  longer hospital stay  reduced rates of CS no difference in  neonatal sepsis  composite of neonatal outcomes

Answer 4

GBS E coli enterococcus STI: mycoplasma, chlamydia, gonorrhea gardnerella ureaplasma polymicrobia rare: candida, GAS

Answer 5

Maternal o Fever o IV abx o Endometritis o Sepsis o Prolonged hospital admission o Morbidity related to sepsis o PPH o RDS o Death Fetal o Death o Cerebral palsy o Hypoxia o Pneumonia o Sepsis o Prolonged admission o NICU o I/V o Antibiotic exposure o Pneumonia o Menigitis

Answer 6

* Maternal: APLS, PET, bariatric surgery, chronic conditions eg CKD, DM, hx of SGA/IUFD/PTB/placental dysfunction, substances eg smoking, methamphetamines, IVF, AMA * Fetal: chromosomal abnormalities, infection eg CMV or syphilis, echogenic bowel * Placental: low PAPP-A, multiple pregnancy, uterine anomaly, single uterine artery

Answer 7

When AEDF or REDF in UA – monitor every 2-3 days unless delivery indicated K26 – 31+6: deliver if DV a wave at or below baseline K32-33+6: delivery if UA-REDF >K34: delivery if UA – AEDF K36-37: delivery if UA-PI >95th or AC/EFW <3% K38-39: deliver if signs fo cerebral redistribution or any other features of FGR any gestation: maternal indication, BPP, CTG

Answer 8

T - tolerance A - asked to stop and got annoyed at the person C - cut down - attempt to cut down E - eye opener

Answer 9

Hx Exam Investigations o BBV o Antenatal screening o Growth and wellbeing o UDS with consent Aims of admission o Link into services – drug and alcohol, MDT including SW + high risk obstetrics o Maternal health o Fetal wellbeing o Establish continuity of care and rapport for ongoing cares o Safety – exclude BBV, IPV, mental health, harms Management o Patient centred approach o Identify patient goals o MDT o Assistance from CL psychiatry if concurrent mental health disorder and drug and alcohol services to switch to methadone/ long acting injectable buprenorphine program o Manage acute withdrawal – benzos, antiemetics, hydration o Methadone is to be continued throughout pregnancy o Link into services for long term  Social work – stable housing, supports,  Drug and alcohol services o High risk clinic – SB, IUGR, SGA o Counselling re risks of substance o Screen for harms – ensure no physical harm from substance use including screening for BBV and antibodies o Growth and wellbeing – potential harm to fetus including LBW o Advice paeds – baby at risk of withdrawal when born o Child safety: unborn child at risk alert to be placed o Breastfeeding plan  Yes  NAS scoring  Safety plan re pumping  Increased pain/lack of sleep – laise with MDT - ?increased dose  7 day admission for scoring  Risks PND  Contraception  Constipation due to opioids o Anasthetics for pain plan post MOD

Answer 10

patient centred approach shared decision making determine patient goals, ideas, concerns and expectations review previous notes - determine incision type - determine length of time since previous CS - exclude contraindications to VBAC eg angle extension, T/J incision, classical incision, praaevia, PAS - indication for previous CS: FTP, breech, FD pre pregnancy weight discuss risks and benefits of both determine future pregnancy plans and motivations review Obs and medical hx consider VBAC calculator management plan VBAC vs CS discuss Intrapartum management explain additional risks of CS in labour

Answer 11

VBAC o Birth trauma – shoulder dystocia, fractures o Increased stillbirth – more to do with the timing of delivery o Intrapartum fetal death or neonatal death o Ris of HIE o Increased risk of perinatal mortality CS o Lower initiation of BF o Fetal injury – often superficial laceration o Increased risk of TTN, surfactant deficiency and pulmonary hypertension – although after K40 there is no difference in incidence

Answer 12

VBAC o 20-40% Risk of emergency CS with higher morbidity associated o Uterine rupture  1:7 severe neonatal and maternal morbidirty associated o OASI o ~40% risk of instrumental CS o Longer recovery o Higher VTE o Recommendation for repeat CS in future pregnancies with additional morbidity associated o Increased risk of PAS o Surgical complications – bleeding, infection, damage to other strucures, hysterectomy o Increased risk of complication in future pregnancies

Answer 13

* CTG abnormality * Loss of station/presenting part * PVB * Consistent pain at incision – pain in between tightenings * Haemodynamic instability * Chest pain, shortness of breath, shoulder tip pain * Cessation or alteration of contractions * Change in abdominal contour

Answer 14

* Patient centred care to facilitate shared decision making * If confirm that patient is in spontaneous labour recommend admission * Introduce self to patient, confirm desires for VBAC vs CS o Review on arrival o TOLAC – high risk o Review and assess desire to continue, dsicuss epidural * Notify SMO and anasthetics, paeds  high risk patient * 1:1 midwifery care * IVC + Bloods  access if emergency + potential to cross match blood if required * CTG  allow for fetal monitoring, if fetal distress if a potential early indicator of uterine rupture, consider FSE if abdominal monitoring not adequate provided no contraindications * VE within 1 hour of presentation then 4 hourly VEs until 7cm then 2 hourly  ensure appropriate diltation o Highest risk of rupture is intrapartum o Labour dystocia can be sign of rupture * Risk of PPH, placenta related complications * Clear fluid intake rather then full diet – high risk of section, risk of aspiration * Anasthetic review and consideration of epidural * Psychosocial support

Answer 15

* No menarche over 15-16yo * No menarche within 3 years of breast development (thelarche) * No breast development by 13yo * No menarche by 14 if hirsutism

Answer 16

* Hypogonadotrophic hypogonadism – HPO axis dysfunction/ central cause - Stress - Anorexia - Exercise - Kallman’s - Pituitary - constitutional - hyperPRL - CNS tumour - chronic illness * Hypergonadotrophic hypogonadism – gonadal dysfunction o Turners o POF o Swyers o Galactosemia o Chemo/radiation * Obstruction o Imperforate hymen * Absent uterus o MRKH o CAIS * Pregnancy

Answer 17

Urine: HCG  exclude pregnancy Bloods o Hormone profile: FSH, LH, estradiol, testosterone ==> determine whether a hypogonadoatrophic vs hyper and the functional production by the ovary o PRL – exclude a hyperprolactinoma o TFT – exclude endocrine cause o HCG – exclude pregnancy o PCOS bloods – consideration if features on hx – DHEAS, SHBG, FAI o Karyotype - determine genetic karyotype o Fragile x premutation screening o CAH – 17 OHP , 21-OH Imaging o USS pelvis – determine if uturus present, exclude mullerian anomalies o Bone density o XR bone wrist – determine bone age Special: GnRH test

Answer 18

--> HEADS establish a therapeutic relationship --> goals, Ideas, concerns and expectation Biological o Osteoporosis prevention – requirement for oestrogen for bone health and prevention of fractures, important time in life to lay down bone density o Cardioprotective effects of oestrogen o Physical transition to full reproductive maturation o Fertility o Removal of streak gonads due to malignancy risk Psychological o Gender identity o Body image o Sexual health – dilators, estrogen replacement, physio Social o Feeling isolated, support groups

Answer 19

bleeding that deviates from the normal menstrual patterns in terms of frequency, duration and volume

Answer 20

Pipelle o Easy, acceptable, accessible o Lower cost, low risk of perforation o Samples ~50% of endometrium o Limited if polyp or focal lesion o Will miss 2% of endometrial hyperplasia o PPV >99% o Sensitivity 70-80% some pathology HD+C o Increased risks – GA, perforation o Visualise entire endometrium o Better to target focal lesion or polyp o Higher diagnostic accuracy o More likely to up stage (40% of endometrial hyperplasia have concurrent endometrial cancer) o ~90% sensitivity when combined with diagnostic procedure o Diagnostic and therapeutic o Visualisation o Perf, infection, cost o More invasive but accepted

Answer 21

Benign proliferative phase endometrium suggests an oestrogen dominant environment  suggestive that she is in the ovulatory functional cause of AUB This could represent PCOS, thyroid or pituitary/hypothalamus Could also represent iatrogenic with exogenous oestrogen and with no opposing

Answer 22

Minimally invasive first or second generation Endometrium destroyed to basal layer Pre op sampling recommended [x] Needs contraception o Mirena improves efficacy o Bilateral salpingectomy – 10% risk post ablation of tubal sterilisation syndrome, increased surgical risks and operating time 20% failure, 40% amenorrhea, 40% reduction Risks of pregnancy: IUGR< uterine rupture PTB, miscarriage, ectopic, abnormal placentation Contraindications: endometrial hyperplasia or cancer Caution: lynch, risk factors for endometrial hyperplasia/cancer, requirement for sampling Factors associated with failure: large cavity, adenomyosis, previous CS, retro/ante flexed, SM fibroid >3cm

Answer 23

* Figure 8 distribution * Loss of labial architecture – loss of distinction between labia, narrowing of introitus * Fissures * Excoriation * White lichenoid plaques * Vulval atrophy and thinning * Vaginal mucosa spared

Answer 24

* Hyperkeratosis and atrophy of epidermis * Hylanisation of dermis * Lymphcytic invasion of basal layer * Loss of rete ridge

Answer 25

Internal (from internal iliac) and external femoral) pudenal artery

Answer 26

* Anterior: ilioinguinal, genital branch of genitofemoral * Posterior: pudenal, posterior cutaneous nerve of the tight * Clitoris + vestibule – PSNS – cavernous

Answer 27

Consent o Capacity o Not under duress/voluntary o Understanding o Retention of information, about to relay consent o Current Risks o Increased surgical time o Increased risk of complications eg bleeding, damage to other structures o May not be able to compelte salpingectomy if scarring or adhesions  3 previous CS o Very small risk of failure and if does conceive then risk of ectopic o Difficulty of reversal o Increased risk of POI Benefits o Risk reduction for ovarian cancer o Already having operation so does not require additional operation o Minimal risk of surgical complications Alternatives o Mirena – reduces HMB and dysmenorrhea o POP if breastfeeding o Vasectomy – LA, less risk, not intraabdominal Describe procedure o Aim to perform complete salpingectomy – meaning remove entire tube  Ovarian cancer, histo o If unable to do complete salpingectomy  still aim to remove fimbrial end, interrupt/diathermy/tie o Shared decision making regarding Post operative recovery Wait time for surgery, alternative reliable contraception while waiting

Answer 28

* Amenorrhea * <6/12 postpartum * Continuous breastfeeding not interrupted, no longer break then 4 hours (means baby does not sleep through), no solids added into diet, not pumping

Answer 29

Identify injury Call for help – O+G SMO, urology o If large defect, multiple defects, close to trigome or other complication – urology consult Notify anasthetics + OT staff o Different tray, equipment o Increased time o Disposition to change to inpatient Evaluate injury --> ? need to convert to open * If small defect  consider repair or IDC for 5-7 days * If 1-2cm – slingle layer closure with 3-0 vicryl continuous * >2cm – two layer closure with 3-0 vicryl, second layer does not involve mucosa – aiming water tight therefore check with cystoscopy Check with cystoscopy at end – other injuries, ureteric jets IDC in situ for 14 days – voiding cystogram prior to IDC removal then TOV Cystoscopy Complete operation vs abandon for just repair Risk management Documentation Debrief

Answer 30

PARTIAL genetics - triploid - 2x sperm or 1x sperm that divides - single ovum - contains maternal genetics therefore p57 histo - some fetal maternal - tissue, vessels - focal - less florid hydropic villi - focal/minimal throphoblastic proliferation - p57 positive COMPLETE genetics - diploid - 2x sperm or 1x sperm that divides in empty ovum histo - diffuse hydropic villi - trophoblastic proliferation - atypia - no p57

Answer 31

* Age >40 * Antecent pregnancy * Time since incident pregnancy * Mets – number * Mets – sites * Size of tumour * Previous methotrexate / failed chemo * Baseline HCG >100,000

Answer 32

2x Cochrane reduction in CP RR 0.71 NNT = ~60 reduction in CP and death RR 0.87 reduction in IVH reduction in gross motor dysfunction RR 0.61 reduction in neurodevelopment outcomes increased maternal side effects no significant paediatric mortality or other neurological impairments in the first few years need to assess outcomes in older children

Answer 33

nausea vomiting flushing feeling generally unwell CTG changes

Answer 34

3.8 - 5.0 - side effects, flushing, nausea, generally unwell, warmth, slurring >5: loss of deep tendon reflexes >6: resp depression >6.3: resp arrest >12 cardiac arrest other signs - BP <15mmhg under baseline - UO <100ml/4 hours

Answer 35

10% calcium gluconate in 10mL slow IV stop infusion MET - O2 ECG Bloods

Answer 36

alpha thalassemia is an autosomal recessive disease with a complex inheritance pattern gene on chr 16 mother could be alpha0 and therefore could have mild anaemia baby - 2x defective genes (50%): alpha thal triat --> generally normal Hb, sometimes anaemia and reduced MCV but no real implications - no defective genes --> 25% - 3x defective genes-: HbH - moderate to severe microcytic anaemia, 70% iron overload complications, severe haemolytic anaemia (tetramer of beta globulin HbH) - 4x defective genes: Hb Barts - tetramer of gamma globulin - severe anaemia --> hydrops --> death

Answer 37

determine type of thalassemia - perform Hb electrophoresis - consider molecular testing to termite if alpha treat - location of defective genes (cis or trans), has implications for inheritance arrange partner testing - electrophoresis - if carrier or has disease refer to genetics pre conception - reduced fertility - counselling, testing --> genetic referral - chelation is contraindicated in pregnancy - screen and optimise - DM, thyroid, cardiac, liver - no parenteral iron --> overload - PO iron and folate antenatal - MDT - baseline Ix: FBC, electrophoresis, iron studies, B12, folate, BBV - screen: TFT and GTT - refer to cardiologist: ECG, ECHO, cardiac MRI - liver USS: cholestasis, cirrhosis - bone density and vitamin D - IV iron avoided - worsens overload - PO iron and foliate +/- pRBC - baby --> screening to determine what genetic make up is - early USS, tertiary morph, serial growth

Answer 38

low fetal fraction - small placenta --> miscarriage, incorrect dates, fetal chromosomal anomaly/trisomy obesity faulty assay LBWH metformin placental mosaicism exercising just pior haemoglobinopathies

Answer 39

RANZCOG does not recommend universal genetic carrier screening but does recommend 3 specific genes that are high incidence in australian/nz population limited clinical utility - targeted for those at high risk - high number of population carries a recessive gene --> high anxiety if screen positive but unlikely to have partner have same - may not change medical management or outcome - low carrier rates psychological and ethical concerns - anxiety - confusion - medical insurance resource and cost - healthcare resources are finite - cost effectiveness - access - exacerbate disparities variations of unknown significance high at this stage therefore may screen positive but don't know what it means in practice lack of consensus of what to include counselling prior to test

Answer 40

antenatal - perineal massage overall reduction in trauma requiring suturing NNTB = 15, less likely to have episiotomy but no difference in incidence of tears (level 1) - engagement with pelvic floor physiology about relaxation of pelvic floor - combination reduction in OASI - case selective - elective vs for selective women eg previous OASI - level 3 Intrapartum - Intrapartum perineal massage - birthing position (all 4x kneeling, lateral or standing) - warm compresses RR 0.48 (level 1) - selective episiotomy eg for instrumentals (level 1) - perineal protection techniques level 3 - use of perineal care bundle - reduction in OASI reduce risk factors: no excessive GWG, screen GDM, identify LGA

Answer 41

- Intrapartum perineal massage - warm compresses RR 0.48 (level 1) - selective episiotomy eg for instrumentals (level 1) --> reduction in OASI with VAB 16% and with FAB 24% --> correct technique at 60degrees with contraction from midline at crowning - perineal protection techniques level 3 - use of perineal care bundle - reduction in OASI

Answer 42

shared decision making risk of recurrence 4-8% Hx exam no high level evidence for recommendation for optimal MOD - consider: extent of previous injury, functional status, extent of anatomical and functional defects + anal manometry - risks vs ebnefits - in asx women SVB following OASI does not increase risk of subsequent sx but those with anal incontience likely to worsen sx - australian linkage study OASI in P1 --> no more likely to have another severe tear in subsequent then women who did not stress issues at start if another insult then risk of anal incontnence long term indications to offer cs - current sx of anal incontinence - psychological or sexual dusfunction - previous 4th (no hard and fast) - more then 1 OASI - endoanal defect evidence on USS - low anorectal manometric pressures - maternal request no role for prophylactic episiotomy

Answer 43

A - apperients A - analgesia A - Abx B - bladder - IDC P - physio + psychosocial supports F - follow up (debrief and 6/52 for symptoms) and red flags (higher incidence of wound infection and breakdown) risk managements

Answer 44

Identification - PR recommended, explain reasoning behind performing, consent - 2 clinicians reviewing perineum - increased detection explain diagnosis to patient shared decision making, written consent note risk of PPH and management required repair - transfer to OT (lighting, positioning, equipment) - IV Abx (evidence that cef reduces post op infection) - senior involvement - analgesia/epidural/spinal GA - prep - betadine - EUA with assessment of trauma confirm degree - mobilisation of external anal sphincter and identification - visualisation, may be retracted - protection of sterile field - sutures (3-0 PDS for internal sphincter and external sphincter but 3-0 vicryl for anal mucosa) --> overlapping - no difference in perineal pain, dyspareunia, flatus incontinence at 3 years but improved faecal urgency and anal incontiencence at 1 year - perineal body and muscles 2/0 vicryl rapide - continuous interrupted - paraurethral or paraclitoral may consider 3-0 - avoid figure of 8 sutures - tissue ischema - bury knots beneath perineal muscles to reduce migration, cut short - PR confirm no sutures where should not be (fistula risk) - confirm haemostats post operative plan

Answer 45

short term - perineal pain, oedema, brusiing - urinary retention - infection - wound breakdown - incontinence/defecation issues long term - fistula - dyspareunia - incontience - psychosexual / psychological - chronic perineal pain

Answer 46

maternal: asian, nullip, previous OASI baby: LGA >4000g, OP labour: prolonged second stage, instrumental, shoulder dystocia, midline episiotomy

Answer 47

FGM is the non medically indicated alteration of external female genitals - partial or full removal of the external genitalia or other injury to female genitals for non medical benefit 0.4% Australian population type 3 = reduction in the Introits/vaginal orifce (+/- urethral meatus) with creation of covering seal by cutting and apposing labia majora +/- minora +/- removal of clitoris and prepuce

Answer 48

sensitive trauma informed culturally appropriate +/- interpreter written consent risks of FGM: obstructed labour, CS, PPH, OASI risks of FGM outside of labour: dyspareunia, UTI, poor CST uptake de-infibulation = a minor surgical procedure carried out by a trained medical professional to re open the vaginal Introits for FGM - midline incision across the scar that covers the vaginal Introits until the external urethral meatus and eventually clitoris are visible - cut edges are sutured apart to allow Introits to stay open aim for antenatal ideally second trimester (as reduces risk of UTI/infection and therefore PTB/PPTOM) explain risks of procedure explain benefits of procedure can be done Intrapartum must discuss anatomical and physiological changes that would happen after procedure eg altered urination, increased vaginal discharge, change in labial/vulval appearance, sexual experience discuss post op cares ensure aware reinfibulation is illegal in australia

Answer 49

can still be offered - reduces CS and PPH risk culturally sensitive, trauma informed, MDT autonomy, respect higher risk of PPH, obstructed labour and CS discuss risks of FGM and labour - recommence IVC + G/H - routine episiotomy not recommended but may be indicated due to scarring and lack of skin elasticity - difficult examinations, IDC insertion, Intrapartum procedures - increased risk of CS and PPH - FGM is not an indication for CS aim to deinfibulate in first stage of labour with consent and analgesia eg epidural document skilled accoucheur +/- interpreter postpartum - monitor perineal swelling and urinary obstruction - recommend delaying intercourse until wounds healed - reinfibuation is illegal - 6/52 PP follow up

Answer 50

why: take hx, family hx including partners Who: anyone when: >K10 what: screening test, cfDNA written information principles of consent risks: VUS, sensitivity, specificity on extended, implications of management, costs benefits: very good for T21/18/13 alternatives addition of USS

Answer 51

sensitivity 97% specificity 95-99%

Answer 52

CTPA - more likely to give answer - sensitivity for central pe - higher radiation to breasts V/Q - lower radiation to breasts - higher childhood malignancy (low) - hard when abnormalities on CXR

Answer 53

allows ve reduces risk of emergency trauma or in labour deinfibulation reduces prolonged, obstructed labour, CS reduces PPH 1. obstructed labour 2. prevent CS 3. PPH prevent haematocolpos UTI dyspareunia reducing scarring at Introits -

Answer 54

Copper IUD - MOA: impact on sperm, foreign body - hostile environment preventing fertilisation and implantation - within 5 days - failure <1% Ulipristal - delays ovulation - 120 hours - failure 1.4% levongestrel 75mg - impacted by BMI >30 2 doses - 72 hours (24hours 90%, <50% over 48 hours) to be taken as soon as possible - failure ~2.2%

Answer 55

HCG bloods - FBC - serum HCG swabs - STI - HVS - co test imaging - USS pelvis consider colp

Answer 56

pre operative - identify those at risk: post menopausal women, extremes of age - vaginal oestrogen pre procedure can then be given misoprostol - review imaging intra op - VE ensure flexion - hydrodilatation - keep bladder full - keep midline - USS guided - reverse dilatation

Answer 57

carboplatin - ear/renal/bone marrow placlitexal - neurotoxic 80% success

Answer 58

Fhx estrogen exposure increasing

Answer 59

less heparin incited thrombocytopenia and oestroporosis injection rather then infusion at home easy accessible acceotable SE: rash, discomfort at injection site

Answer 60

mesh exposure higher combined re operation rates increased bladder injury SUIT increased rates of prolapse at other vaginal sites chronic pain

Answer 61

highest success rate 76-100% gold standard most durable using type 1 mesh/grafts increased bleeding, post op pain, hospital stay, recovery increased risk of visceral injury - cystotomy 3%, enterotomy 1.6% involves mesh and exposure of mesh risks

Answer 62

explain diagnosis - chronic likely autoimmune condition - not due to poor vulval hygiene vulval hygiene - cotton undies - air out when possible - no tight clothes - no soaps or cleaning products - no douching - avoid triggers medical management - high potency steroids (ointment) clobetasol or diprosone - can add in vaginal oestrogen - second line: topical taco or intralesion steroid injection follow up - review in 6 weeks for symptoms - review 6 monthly to ensure no concerning features of progression to dVIN

Answer 63

midline important anatomy involved wide spread extensive multifocal previous surgery or radiation recurrent failed first treatment

Answer 64

timing, no distress, nullip reduces requirement for instrumental delivery and reduces need for rotational instrumentals OP position increases risk of failed instrumental, OASI and fetal injury analgesia - minimal discomfort no signs of obstruction shared decision making

Answer 65

assessment - adequate contractions - no signs of obstruction - abdo palpa for size of foetus and <1/5 palpable abdominally - fetal and maternal wellbeing - vertex - dilation - membranes ruptured - ve: at spines or lower, exact position determined, <2+ caput and moulding, pelvis deemed adequate indications for AVB - maternal exhaution - fetal distress - prolonged second stage - contraindications to prolonged second stage of valsalva preparation - explain indication, alterantives - consent - analgesia - empty bladder - aseptic alternatives - if no fetal or maternal concerns could allow further time to descent and rotation - risks of maternal exhaustion and fetal distress - CS discuss risks/benefits of AVB - risks- maternal (OASI, PPH, failure, conversion to LSCS), fetal (injury) - benefits: achieve SVB, if distress then timely delivery - prepare for emergencies - SD and PPH preparation of staff - experienced operator and supervioion - bed, lighting, positioning - equipment - back up plan - anticipate copletcations - paeds

Answer 66

maternal: BMI >30, short stature fetal: EFW >4kg or clinically big, OP, head circumference >95% Exam: mid cavity or >1/5 palpable abdominally

Answer 67

fetal bleeding disorder predisposition to fracture where maternal consent refused fetal station >spines >1/5 head palpable abdominally VAB: face or

Answer 68

pattern of behaviour in any relationship that is used to gain or maintain power/control over an intimate partner physical, financial, coercive, emotional

Answer 69

CS LLP anterior AMA multiparty previous uterine surgery

Answer 70

antenatal - optimise Hb - further imaging - MDT referral - discuss management options - recommend CS hysterectomy - timing of delivery K34-36+6 depending on guideline delivery - risks: massive obstetric haemorrhage, damage to lower genital tract, GA - tertiary unit - MDT - cell saver - 2x IVC/art line - cross match and blood bank available - lithotomy with graduated drapes to assess vaginal bleeding - ICU post op surgery - experienced operator - VML or extended transverdse - total hysterectomy + BS aimed for - baby delivered through incision away from placenta and closed - no prophylactic oxytocin but given TXA - proceed to hysterectomy post op - ICU - drain - watch for intraabdo bleeding - average EBL 3L - replacement - observe for complications eg fluid overload, renal/liver failure, infection, unrecognised injury, pulmonary oedema, DIC, Sheehan syndrome - BF - psych - VTEp - GOPD 6/52

Answer 71

CAIS: 26XY, testosterone increased MRKH: 46XX, female range testosterone

Answer 72

vault haematoma infection granulation tissue vault dehiscence trauma

Answer 73

1. HPV infection - microabrasions --> infect epithelial cells, replicates within cells, does not cause inflammation therefore evade 2. APC - dendritic and langerhan cells pick up HPV --> travel to LN and present to naive T cells via MHC molecules 3. T cell activation - CD4 helper T cells are activated - B cells - HPV specific antibodies - CD8 cytotoxic T cells - recognise and kill HPV affected cells MHC 1 4. B cells - differentiate into plasma cells secrete Ab to neutralise free virus particles 5. memory formation

Answer 74

E1+E2 binds to epithelial cells takes over host machinery E6 --> p53 E7 --> pRB tumour suppressor cells --> controls repplication new virus particles assembled in upper layers of epithelium and virus is released when epithelium sheds restricted to the cervical epithelium with no viraemia

Answer 75

glands and supporting structure of endometrium found in crypts in myometrium therefore tissue breast down each menstrual cycle causing painful and heavy periods increased blood supply and surface area increased inflammatory response and increased PG bulky due to myometrial hyperplasia - structural distortion

Answer 76

asymmetrical uterine cavity thickening anterior or posterior myometrial wall thicker myometrial texture heterogenecity small myometrial hypo echoic cysts enlarged uterus globally striated projections from endometrium to myometrium ill-defined border heterogenous myometrium diffuse vascular colour

Answer 77

Mirena - decidualisation of endometrium - reduces HMB 90% at 12 months TXA + NSAID - reduce 60%

Answer 78

future fertility distorted uterine cavity high risk for endometrial cancer Fhx Lynch endometrial hyerplasia or cancer tamoxifen high risk failure: adenomyosis, grandmultiparity, large cavity size, previous CS

Answer 79

PG - MOA: direct stimulation of myometrial contractions, biophysical changes - CI: PVB, contracting, abnormal CTG, previous uterine scar - pro: reduced induction time, increased rates of SVB at 24 hours, increased successful IOL - con: hysterstimulation, uterine rupture, abruption, CTG abnormalities Balloon - MOA: mechanical dictation and effacement, can cause release of PG - CI: PVB, abnormal CTG, high head caution, PPROM - Pro: easily removed - con: malpresentation, PVB

Answer 80

pneumonia sepsis meningitis incidence 0.4 per 1000 (reduced significantly since additional of antibiotics as Abu reduce transmission by 80%) mortality in term 1-3%, 20-30% in preterm (previously as high as 55% for both)

Answer 81

meningitis sepsis

Answer 82

febrile ROM >18 hours previous baby affected EOGBS screening urine pregnancy - urine, swab

Answer 83

transient bacteria - over treatment of some who test positive ~20% - undertrement of those who are negative at time of swab - aiming for 3-5 weeks prior - 40% population has cost effectiveness low rates of EOGBS importance of sticking to a protocol 40% have no risk factors

Answer 84

vaginal 1-2cm and perianal or anorectal 1cm - increased detection by 25% document allergy as high resistance rates and need sensitivities if penicillin allergy document GBS screning media rich sent to lab immediately, if not processed immediately then kept according to protocol in appropriate conditions before digit exam or lubricants timing around delivery 3-5 weeks prior

Answer 85

ranzcog guidelines recommend Ill at K34 if GBS positive - local guideliens re antibiotics and gestation - reduces risk of EOGBS with mortality rate 20-30% - higher risk of NICU/SCN, RDS - steroid loading - monitor for signs of infection

Answer 86

Mum - probably fewer CS - little or no difference in AVB - little or no difference to perineal trauma, PPH, breastfeeding at discharge - no increase in maternal morbidity, mortality or infection Bub - lower NICU admission - lower RDS, O2 requirements, IVH - lower stillbirths - reduced perinatal deaths but NNTB = 554 - higher Apgar scores - no difference HIE or neonatal trauma

Answer 87

less likely to receive oxytocin more likely to require Abx or CS

Answer 88

macrosomia 7x previous shoulder dystocia 7x DM or GDM - 2-4x

Answer 89

straightens the lumbosacral curve, rotates the maternal pelvis towards the mothers head and increased the relative AP diameter of the pelvic inlet --> facilitates descent of posterior shoulder below sacral promontory and by flexing the fetal shoulder towards the anterior shoulder dislodges reduces angle of inclination of pelvis - plane of pelvic inlet is brought perpendicular to expulsion forces gentle traction no pushing

Answer 90

pressure on fetal back in downward and lateral direction just above pubic symphsis reduce the fetal bisacromial diameter and rotates the anterior shoulder into wider oblique pelvic diameter

Answer 91

C5.6 excessive traction on neck --> shoulder under pubic bone --> stretches on C5/6 excessive downward traction rocking, lateral or rapidly applied traction posterior axillary sling

Answer 92

klumpsie flail arm, horners HIE encephalopathy fractures CP

Answer 93

age obesity Fhx medical: chronic HTN, renal dx, DM, APLS multiple pregnancy smoking IVF

Answer 94

abruption stroke eclampsia fetal compomise multi organ disease HELLP

Answer 95

reduces PET 18% reduces PTB 9% reduces NND 14% reduces SGA 16%

Answer 96

NMDA receptor antagonists --> stabilises neurons contraindications: renal disease, hepatic disease, MG, anaphylaxis

Answer 97

maternal: AMA, BMI >30, DM, HTN fetal: >K41, malpresentation, macrosomia labour: induction previous: >1CS, CS for dystocia

Answer 98

maternal - uterine rupture 1:200: haemorrhage, hysterectomy, emergency OT - CS in labour (20-40% chance): increased risk of complications eg wound infection, endometritis, bladder or ureteric injury, injury to baby, pain, pph - risks of vaginal delivery: OASI, PPH, instrumental (40%) fetal - if rupture: risk of morbidity and mortality 1:7, HIE, death - if vaginal delivery: SD, birth trauma, increased stillbirth, increased Intrapartum death or NND, increased perinatal mortality, HIE

Answer 99

maternal - 60-80% success - less maternal morbidity for this and future pregnancies - avoid major surgery and need for repeat CS - early mobilisation - shorter admission - reduced VTE - higher satisfaction - faster recovery fetal - improved gut microbiome ?reduce allergies - reduce transient resp morbidity - increased fetal/maternal bonding --> BF

Answer 100

peak incidence 4-5cm, 18% second stage, 8% after delivery vaginal bleeding constant pain haemodynamic instability cessation or alteration of uterine contractivility loss of station or presenting part change in abdo contour chest pain/syncope/SOB tenderness over wound CTG

Answer 101

10-20% of untreated 6-21% if perforated appneidicitis

Answer 102

pre op - more difficult diagnosis - limited imaging intra op - more difficult entry given gravid uterus - more difficult operation given gravid uterus - risk of injury to gravid uterus with port placement - anaesthetic risk: more difficult intubation given oedema, reflux and relaxation of lower oesophageal sphincter, increased risk of miscarriage - positioning - left lateral tilt 15-30 degrees post op - lower birth weight, low Apgar, PTB - longer admission NND - VTE prophylaxis

Answer 103

empathies expressed validate experience trauma informed, respectful, kind, recognise grief confirm diagnosis and pmedhx confirm suitability for expectant - lives close to hospital, can follow red flag advice, haemodynamically stable, no bleeding disorders explain 3 options: expectant, medical and surgical discuss benefits and risks of each expectant: often miscarriage occurs spontaneously with onset of period like cramping, vagnal bleeding and passage of tissue success rates of expectant - 80% incomplete at D14 - 60% of missed at D14 - success rate lower if prolonged loss without exposure - failure up to 50% benefits - avoid surgery and medications contraindications: GTD, haemodynamic instability, IUD, increased haemorrhage risk, infection risks: unpredictable, more days bleeding, higher rates of hospital admission and surgery unplanned red flag advice follow up - no limit on how long before call failed - success reduces with time - recommend NSAID and paracetamol for pain - HCG at D1 and 8 --> repeat USS if drop <90% patient choice, shared decision makings espect autonomy bereavement services EPS follow up psychological suoports written information

Answer 104

ranzcog recommendation higher rates of expulsion within 3 days 84% vs 67% reduces need for subsequent surgical management no difference in adverse events

Answer 105

200mg MOA: synthetic steroid and competitive progesterone receptor antagonist - binds competitively to progestin receptor - stops pregnancy growing - causes the developing placenta and embryo to detach from uterine linign - softens and dilates the cervix - increased uterine contractility - sensitises the myometrium to PG induces contractions

Answer 106

synthetic PG E1 analogue - induces contractions of smooth muscle in myometrium - relaxes cervix

Answer 107

C - clinical effectiveness A - audits/research R - risk management E - education

Answer 108

excessive menstrual blood loss that interferes with a woman's social, physical, emotional and material QoL

Answer 109

heavy menstrual bleeding since menarche one of the following: PPH, surgical related bleeding, bleeding with dental work 2 or more of the following: bruising 1-2x per month, epistaxis 1-2x per month, frequent gum bleeding, Fix

Answer 110

suspected fibroid or polyp persistent IMB or irregular bleeding RF for cancer unsuccessful treatment

Answer 111

hyper stimulated ovaries proinflammatory cyctokines release of vasoactive products eg VEGF increased vascular permeability and endothelial dysfunction leak fluid from vascular space into third space which depletes the vascular volume

Answer 112

PCOS young age low BMI increased AMH increased antral follicle count >17 eggs collected HCG type of induction and trigger

Answer 113

vte RDS renal failure cerebral oedema torsion ileus ascites pericardial and pleural effusions

Answer 114

torsion bulky ovaries bleeding infection

Answer 115

Maternal increased - CS - AVB - anxiety/frutsration - OASI - PPH - infection - labour dystocia - gestational HTN FETAL - increased perinatal death (K42 2x, K43 6x) - macrosomia + SD - birth trauma - MAS - neonatal acidemia - neonatal encephalopathy, CP, reduce IQ - post maturity syndrome - increased NICU

Answer 116

reduces PND (IOL K41 NNTB 554) reduces stillbirths reduces CS RR 0.9 reduced NICU RR 0.88 reduces APGARs <7 at 5 mins (likely) no difference: AVB, perineal trauma, PPH, BF, neonatal encephalopathy

Answer 117

#accurate dating - reduces 50% of pregnancies reaching K42 #S+S - NNT = 8 IOL - reduced CS, PND. HTN

Answer 118

failed hyperstimulation increased intervention cord prolapse uterine rupture PPH

Answer 119

reduced chorio (maternal) RR 0.49 reduced definitive/probably early neonatal sepsis RR 0.73 reduced CS RR 0.84 reduced neonate receiving IV abx RR 0.61 reduced NICU/SCN RR 0.75

Answer 120

Hannah et al 1996 RCT N=5000 singleton confirmed ROM - IOL oxytocin/ IOL PG then oxytocin/ expectant results - no difference in neonatal infection or CS - oxytocin: reduced chorio, PP fever, neonatal abx/NICU, increased maternal satisfaction

Answer 121

1. NON INVASIVE FLOWOMETRY - sit on toilet and pass urine - voiding function - ?detrusor/obstruction - volume measured 2. FILLING CYSTOMETRY - catheter placed in bladder - PVR measured (MCS sent) - detrusor activity + ability to completely void (Retention/overflow) - rectal catheter placed - abdo pressure - bladder - rectal = vesicle pressure (detrusor) - bladder filled (?detrusor activate during filling - OAB) - compliance and capacity 3. PRESSURE FLOW STudy - asked to void bladder pressure and flow of urine measured - "leak point pressure pressure bladder needs to push out urine 4. URETHRAL PRESSURE PROFILE - catheter removed asked to cough, urethra compliance, pressure, competence - SUI due to intrinsic sphincter dysfunction 5. ELCTROMYOGRAM - perineal muscles

Answer 122

DDx - high block (tingling in arms C8 (diaphragm C4/5) - LA toxicity (CNS often precedes cardiac) - in advertant spinal Management - Met call - SMO involvement ICU, medical team, pads, call second on call anasthetics - DRsABC - O2 on - turn off epidural - sit patient up - check bromage and block - repeat BP - if still low then IVF bolus, consider meteraminol - CEFM - prepare for resp arrest: notify OT chance of emergency CS, intubation, call appropriate team - if thought to be LA toxicity - intralipid

Answer 123

fetal: anomalies, EFW/AC, dopplers, exact position, hyperextension of neck AFI placental: location, cord maternal: congenital uterine anomalies, fibroids

Answer 124

Explain what it is - turning baby through abdomen provide written information discuss options: SVB, ECV, CS exclude contraindications - USS prior - consider obstetric hx - maternal wishes and consent - MARCH discuss risks and benefits - 40% success nullips, 60% multi RISKS - 1:5000 stillbirth - 1:1200 abruption - <1:200 CS - 4.3% risk of minor complication eg APH, transient CTG changes, ROM - failure - turns back - pain/discomfort BENEFITS - aims to avoid CS timing: K35 setting: explain what happens next - if successful - if unsuccessful Rh status use of tocolysis - exclude CI: cardiac disease, arrhythmia, untreated thyrotoxicosis - SE: tachy, tremor, flushing, nausea, increased BSL, pulmonary oedema, VF, SVT, ventricular ectopics - most common tachy, tremor, flushing empty bladder recomentm position

Answer 125

no difference in maternal outcomes between planned CS and planned SVB planned CS reduced fetal morbidity and mortality - reduced perinatal mortality and serious morbidity in planned CS 1.6% vs 5% (sub) - perinatal death 0.3% vs 1.3% (SVB) - serious neonatal morbidity including brith trauma, seizures, encephalitis, NICU, I/V, low APGAR 1.4% vs 3.8% no difference between groups at 2years

Answer 126

Pmedhx: DM, immunosuppression, anaemia no vaccinations Shx: smoking, BMI, GAS in close contact Obshx: prolonged ROM, retained product, GBS, CS

Answer 127

benzylpenicillin 1.6g Q4H or 2.4g if in ICU + clindamycin 600mg TDS OR Cefazoline 2g Q8H + clindamycin 600mg TDS OR severe penicillin allergy Vancomycin + clinda IF severe or toxic shock then add IVIG 2mg/kg within 72 hours

Answer 128

o UAPI >95th, indicates abnormal increased resistance at placental vasculature to the fetus o Good predictor of fetal wellbeing o Cochrane review 2017 – use of UAPO leads to fewer obstetric interventions and decreases perinatal mortality o Result helps guide ongoing monitoring required and timing of delivery

Answer 129

Maternal: - age - bmi - nulliparity - IVF - pmedhx (SLE, APLS, DM, CKD, HTN) - uterine anomalies - smoking/substance use - fibroids - low SES - ATSI fetal - chromosomal - infections placenta - velamentous cord - placental insufficiency

Answer 130

generally considered safe excessive or inappropriate use carries theoretical risks thermal effects (heating) --> USS waves cause tissue to absorb energy --> heat --> prolonged exposure can raise temperature mechanic effects - cavitation doppler use in early pregnancy - heating ALARA principles as long as reasonably achievable - minimise USS energy while still obtaining the necessary diagnostic information - justification - only perform when medically indicated - optimisation - lowest possible USS output - pain, fain, time, pulse repetition frequency - dose limitation - time, power, mode - machine settings - adjust gain, focus and frequency of power

Answer 131

M - Multiple pregnancy A - abnormal CTG R - ROM C - contraindications to SVB H - haemorrhage - ash in last 7 days caution - sga with abnormal dopplers - pet - oligo - major fetal anomalies - major uterine anomalies

Answer 132

suspension of the vaginal apex to the anterior longitudinal ligament of the sacrum using a graft, with possible incorporation of the graft into the fibromuscular layer of the anterior and/or posterior vaginal wall Compared with sacrospinous ligament suspension, sacrocolpopexy has a higher anatomical success rate, less stress urinary incontinence, and less postoperative dyspareunia, but has greater surgical morbidit Sacrocolpopexy, using type 1 synthetic mesh, is a recommended treatment of post-hysterectomy vaginal vault prolapse, and is especially important for women suffering from severe prolapse or recurrent prolapse following previous surger

Answer 133

1. state emergency - send for help - obstetric SMO - alert anaesthetic - may need to give GTN --> PPH - paeds - resus 2. GTN - smooth muscle relaxation - allowing for easier manoeuvring of baby and release of head - preparation for PPH 3. extension of incision - T or J - more space to perform and release of head 4. manoeuvres - continuous pressure on flexed head to prevent hyperextension of neck - MSC - prevents hyperextension of head, fingers on malaria eminences and occiput to cause flexion of neck and easier delivery - burns Marshall - feet to assistant at 90 degrees and delivery of head 5. more advanced - forceps of after coming head - pipers, flexion of head 6. debriefing, documenting, review of case personally, M+M

Answer 134

artery - away from feta heart to placenta with deoxygenated blood - high resistance vein - from placenta to foetus with oxygenated blood - low resistance uterine artery doppler therefore measures placental resistance and is a sign of placental insufficiency

Answer 135

MOA: aromatise inhibitor used for ovulation induction indications - PCOS - higher live birth rates, pregnancy rates and similar amounts of multiple pregnancies/losses are climb - unexplained infertility with IUI - breast cancers dose: 2.5 - 7.5mg OD for 5 days D2-5 of cycle monitoring - USS pelvis - D6-12 to track every second day, ensure no follicle >20mm, no more then 3 follicles (Abort cycle), determine timing of intercourse - Estradiol - LH - D21 progesterone confirm ovulation success rates - induces ovulation 60-80% - pre cycle pregnancy rate 15-25% (40-60% within 5 cycles) - if using for unexplained infertility then success 10-20%

Answer 136

# development of follicles pre work up - semen [x] - tubes [x] - genetic carrier screening/fhx [x] - pre conception [x] - lifestyle [x] 1. CONTROLLED OVULATION STIMULATION - GnRH agonist - D20 previous cycle to D10 current cycle to down regulate activiaty of pituitary for controlled ovarian stimulation - gonadotropin (recombinant FSH) - D1 used for control over ovarian stimulation and development of follicles - GnRH antagonist - D6 used to prevent premature ovulation - prevent LH surge # follicular growth monitored by USS D8 + D10 and estradiol levels - TRIGGER with agonist or HCG D10 - induced final follicular maturation and ovulation moving eggs into meiosis 2 2. OOCYTE RETRIVAL - retrieved from follicle before ovulation by USS guided TV aspiration of follicular fluid - 36-38h after trigger - oocytes placed in culture medium and incubated 3. FERTILISATION - sperm introduced D0 - can use ICSI if male sperm a concern - pre testing 4. EMBRYO TRANSFER - transferred into uterus D3-5 post retrieval - success rate - fresh 35-60% vs frozen 25-40% 5. LUTEAL PHASE SUPPORT - progesterone

Answer 137

#increased sensitivity to progestins/hormonal fluctuations - influence CNS functioning/neurotransmitters #serotinergic system dysfunction - reduced sertonergic activity in luteal phase #brain derived neurotropic factor increased

Answer 138

#Hypogonadoatrophic Hypogonadism (Central) - constitutional - anorexia, exercise, stress - increased PRL - chronic illness - CNS - kallman #hypergonadotrophic hypogonadism (gonad failure) --> karyotype needed - turners 45Xo - POI 46 XX (genetic, autoimmune, metabolic) - sayers 46XY - chemo/rad - galactosemia #structural (normal boobs) --> USS pelvis uterus present: mullerian anomalies eg imperforate hymen uterus not present: CAIS (increased T, 46XY) or MRKH (N T 46XX) other - PCOS - Kleinfelter - pregnant - causes of hyperandrogegism eg CAH

Answer 139

reduced vaccination reduced health literacy reduces access living rural/remote areas reduced services increased smoking and lifestyle factors distrust in system duration of exposure to HPV immunocompromised states eg DM

Answer 140

recurrence 1:70 does not make subsequent pregnancy high risk - does need early USS K5-6 placenta for histo HCG at 6 weeks PP

Answer 141

referral to GTD centre discuss results with patient - explain what it is - what implications it has - what the risks are - SPIKES - sensitive psych, social work, bereavement supports EPS follow up red flag advice: PVB, resp sx, neuro sx contraception - COCP, mirena is not suitable due to risk of perforation - explain importance of not falling pregnant in this time weekly HCG - weekly until negative for 3 weeks in a row, once negative then can do monthly for 6 months - if increases by 10% over 2 weeks or plateaus 10% over 3 weeks then concerns for GTN

Answer 142

USUAL PRECONCEPTION - genetic screening/Fhx - vaccinations [x] - lifestyle [x] - stop smoking, alcohol, reduce caffeine [x] - pre pregnancy examination - heart, BP, weight, CST [x] - screen psych and IPV [x] - supplementation - increased in epilepsy - counselling re perinatal infections and how to prevent - pmedhx [x] - optimise SPECIFIC TO EPILEPSY - refer to MDT - high risk pregnancy - preconception optimisation - medication review: lamotrigine lower risk, risks

Answer 143

NTD 1-3.8% CHD high risk of psychomotor and neurodevelopment outcomes eg ASH, ADHD, low IQ dysmorphic facial features - V shaped eyebrows, low set ears, broad nasal bridge, irregular teeth, hypoplasic nails, hyperplasia of mid face

Answer 144

Intrapartum - MDT - care plan - during day - 1:1care, delivery in hospital - CTG - MOD/IOL obs driven - 1-2% have seizure in labour, 1-2% have seizure in first 24 hours --> lowered seizure threshold, reduced gastric emptying - continue regular AED - early epidural considered - anaesthetic input, reduce stress, rest and pain but ?lower threshold - if seizure and not self limiting --> left lateral tilt, maintain airway, oxygen IV Lora - could consider long acting Benz but high risk of neonatal resp depression - seizure in labour --> maternal hypoxia --> fetal hypoxia + acidosis due to uterine hypertonic Postpartum - IM IVt K to baby - BF [x] - consideration of AED after, return to pre dosing - PND - contraception - copper IUD if interaction

Answer 145

C3 deposition in the basement membrane

Answer 146

autoimmune ?related to exposure to fetal antigens binding of circulating complement fixing IgG antibodies to protein - bulls pemphigoid antigen 2 in BM --> skin triggers immune response

Answer 147

INTERNAL - smooth muscle - shiny, pale, white - starts 1-2cm above anal verge - longitudinal - under external - involuntary control --> if damaged results in passive soiling (70% of faecal and flatus continence) EXTERNAL - striated muscle - horizontal - bulk - voluntary control --> urge incontience, squeeze pressure (30% of faecal and flatus continence)

Answer 148

erythromycin - prolonged latency of pregnancy - reduced primary outcome (reduced positive blood cultures, oxygen dependence at 28 days, surfactant use, cerebral abnormalities on USS) >>> reduces resp complications, composite neonatal morbidity and mortality, increased length of pregnancy

Answer 149

risk factors such as obesity, genetics lead to #increased GnRH pulsation + metabolic syndrome - increased LH>FSH ealse - increased SHBG + increased peripheral oestrogen + increased androgen enzymes + increased insulin like growth factor #androgen excess - arrest f follicles --> anovulation --> no CL --> no progesterone --> no feedback into cycle

Answer 150

lymphedema wound breakdown infection haemaotoma VTE neuropathy cellulitis recurrence neuovascular injury

Answer 151

failure to map learning curve pain on injection false positive

Answer 152

linear tubular structure over internal os or within 2 cm attached to inner perimeter of the fetal membranes colour and pulse wave doppler through structure differential diagnoses excluded - does not float away, confirmed not maternal vessels 100% sensitive and 99.8% specific

Answer 153

undiagnosed vasa pare via had very high fetal mortality rates ~60% with poor outcomes for survivors - low pH, low APGARs, high need for pRBC - foetus exsanguination with ROM or labour as well as hypoxic injury with cord compression allows earlier CS and timed steroid loading allow for admission in case of PROm, PTL, PVB to expidite delivery

Answer 154

CP gross motor dysfunction seizures hypoglycemia intellectual impairment visual or auditory impairment neurodevelopment outcomes unaffected delayed mile stones autonomic dysfunction language delays learning impairments

Answer 155

bladder - IDC - insufflation - careful handling bowel - trendelenberg - insufflation - visualisation of instruments at all time - do not rest on bowel - minimise traffic and crossing of instruments inferior epigastric artery - awareness of anatomy - locate, illuminate - port placement technique - insufflation 20-25mmH, insertion under vision, careful not to track, >5cm from midline

Answer 156

malpresentation - septum, difficult to foetus to turn, increased transverse #abnormal placentation eg praevia - abnormal endometrial lining recurrent pregnancy loss - failed implantation #ectopic in horn - abnormal tubal morphology #labour dystocia and CS - inordinate contractions #PPH - retained placenta, poor tone

Answer 157

septic shock not improving pregnant patient preference malpositioned due to be expired TOA

Answer 158

source control - copious pelvic irrigation and wash out pelvic infection systematic inspection of pelvic cavity for other potential causes eg appendix, diverticulitis drain to facilitate drainage faster recovery drainage of abscess do if no clinical improvement 48-72h TOA >7cm or ruptured TOA

Answer 159

risk to other twin - 10-25% death - 25-40% risk of neurological insult secondary to hypertension and exsanguination of surviving twin into dead twin fetoplacental circulation through anastomoses do not deliver immediately unless death of other twin during USS or on a CTG it could be considered with expert input when adding up risks of prematurity longer interval between delivery improved outcomes fetal MRI head to exclude neurological insult ~4 weeks following

Answer 160

WHO time out IV abx correct clinicians present eg PAG IDC prep drape position imaging prior Hymenectomy - cruciate incision or U shaped using sharp dissection - avoid urethra - drainage of haematocolpos - approximate hymenal edges to - vestibule/mucosal edges reapproximated - absorbable suture - consider electrocautery post op - IDC - topical e 6/52 - nothing in vagina 6 weeks

Answer 161

CAH Sertoli cell tumour PCOS Cushings Hyper/hypothyroidism Hyperprolactinoma

Answer 162

SHORT TERM - perforation --> visceral injury - cervical trauma - thermal injury to adjacent tissue - failure to open device and activate - failed fun coverage - uterine necrosis - endometritis - anaesthetic complications LONG TERM - post ablation/sterilisation syndrome - unsuccessful treatment - failed contraception resulting in pregnancy --> miscarriage, PTB, PAS, uterine rupture, hysterectomy - failed or difficult endometrial sampling - cervical stenosis - haematometra

Answer 163

whorl pool sign arterial/venous blood supply oedematous, round overies string of pearls ovarian mass probe tenderness ovary pulled midline pelvic free fluid limitations: poor sensitivity, specificity, TA views limited, signs non specific, access, training, machine, interpreting, not a radiological diagnosis

Answer 164

loss of clear zone - muometrial plane under the placenta myometrial thinning <1mm abnormal placental lacunae + vessels - large irregular often containing turbulent flow bladder wall interruption - loss or interruption of bright bladder wall placental budge - deviation of uterine serosa focal expohytic mass - placenta through serosa briding vessels - placenta to bladder uterovasical/subplacental hypervascularity

Answer 165

direct surgical scar: CS, D+C MROP, Sherman, endometrial resection, myometectomy non surgical: IVF, UAE, chemo/rad, MROP, endoemtitis, previous accreta uterine anomalies

Answer 166

# spiral arteries do not undergo the normal vascular remodelling to become high capacitance and low resistance vessels due to abnormal trophoblast infiltration FIRST HALF OF PREGNANCY: diffuse vascular endothelial dysfunction and abnormal placentation --> placental ischemia #spiral arteries do not undergo normal vascular remodelling to become high capacitance low resistance vessels due to abnormal trophoblast invasion #uteroplacental ischemia SECOND HALF: maternal inflammatory response #endothelial cell activation --> increased capillary permeability, prothrombotic factors and platelet activation and vascular tone #microvascular damage and dysfunction --> HTN, proteinuria, hepatic dysfunction #increased sFLT --> antagonise and therefore reduce VEGF and PlGF --> systemic endothelial dysfunction

Answer 167

sexual contact with infectious syphilis case ATSI and in outbreak area substance use women whose partner is MSM high risk sexual activity late booking

Answer 168

sterilisation OR 9 previous ectopic OR 8 previous tubal surgery OR 4 documented tubal pathology OR 3 PID OR 3 previous miscarriage OR 3 IUD >2years OR 3 AMA OR 3 infertility OR 2 smoker Or 1.5

Answer 169

1. beginning below the incision, the needle pierces the lower uterine segment to enter the uterine cavity 2. needle exists the cavity abouve the incision. the suture then loops up and around the funds to the posterior uterine surface 3. the needle pierces the posterior uterine wall to re enter the uterine cavity. the suture then transverses to the opposite side within the cavity 4. the needle exists the uterine cavity through the posterior uterine wall. from the back of the uterus the suture loops up and around the fundus to the front of the uterus 5. the needle pierces the myometrium above the incision to re enter the uterine cavity 6. the needle exists below the incision and the sutures at point 1 and 6 are tied 7. the hysterectomy incision is then closed in the usual fashion

Answer 170

1. round ligament is clamped, ligated and transected bilaterally - anterior leaf is used to incise downward to meet the former bladder flap 2. posterior leaf of the broad adjacent to the uterus is perforated just beneath the Fallopian tube, utero-ovarian ligaments and ovarian vessels 3. uteroovarian ligament and Fallopian tube are clamped and cut. lateral pedicle is double tied - medial clamp is left in place and removed with entire specimen 4. posterior leaflet of broad is divided inferiorly toward uterosacral ligament 5. bladder and attached peritoneal flap are further deflected and dissected - special care to avoid ureters here 6. uterine vessels are clamped, once divided the lateral vascular pedicle is double ligated to ensure haemostasis 7. cardinal ligaments are clamped, incised and ligated 8. curved clamp is placed across the lateral vaginal fornix below the level of the cervix and tissue inside medially to point of the clamp 9. transfixing stitch is placed on each side to close the lateral vaginal cuff. interrupted pitches may be need to close the midline gap

Answer 171

TTTS - placentas have predominance of unidirectional artery to vein anastomoses --> haemodynamic imbalance within circulation of twins - adversely affecting - fetoplacental perfusion (inequalities territories) - fetal renal function (discordant RAAS activation) TOPS 10% - large central artery to vein anastomoses - classical > donor, oligo, FGR, UA PI doppler > recipient: poly, cardiac dysfunction, cardiac failure, DV wave doppler - midtriemster (rare over >26) - fetoscopic laser if donor anaemia: MCA PSV >1.5 > recipient: polycythemia selective growth restriction 15% - uneven distribution of placenta, influenced by degree and type of vascular anastomoses, differing placental territories - EFW <10 or discordance >25% --> dopplers - can happen in DCDA too - cord abnormalities, differing growth potential, poor placentation, aneuploidy, congenital anomalies TRAP - twin reversed arterial perfusion sequence - cardiac twin - large artery to artery placental shunt intrauterine fetal death - more likely in MCDA - if 1 dies then 10-25% risk of death and 25-40% risk of ischemic cerebral lesion - secondary to hypotension and exsanguination of surviving twin into hypotensive dead twin fetoplacental circulation twin to placental anastomoses - DCDA 3% death, 2% neuro sx

Answer 172

not MCMA >k32 uncomplicated no contraindication to SVB presenting twin cephalic no significant growth discordance note 1/3 emLSCS epidurals increase success specific risks - malposition - increased CS - acute TTTS - IVP - PPH

Answer 173

1. significant discordance AFI - donor: oligo - recipient: poly - bladder seen - normal dopplers - 90% survival 2. cannot see bladder in donor - donor: oligo - recipient: poly - survival 88% 3. dopplers - donor: UA PI - recipient: DV - survival 67% 4. recipient - hydrops - survival 50% 5. death 20% survivors severely handicapped and 40% of those have CP before intervention stage 3 or higher 70-100% death now with intervention 76% survival

Answer 174

1. dono MoM >1.5 recipient <1.0 2. donor MoM >1.7, recipient <0.8 3. stage 1 or 3 + cardiac compromise in donor 4. donor: hydrops 5. death of 1 or both

Answer 175

5-10% mortality in first 3 months 35-50% chance of neuro sequelae from microcephaly including 10% seizures, 10-20% chorioretinitis, 70% developmental delay 25-50% chance of sensorineural hearing loss with progression expected in 1/2

Answer 176

neuro: microcephaly, ventriculomegaly, cerebral calcifications abdo: abdo calcifications, hypo echoic bowel, HSM hydrops: ascites, judrp[s AFI: oligo/poly FGR

Answer 177

5% sensorineural hearing loss with progression in half 2% choriretinitis

Answer 178

FGR microcephaly intracranial calcifications chorioretinitis mental and morta rtardation haemolytic anaemia thrombocytopenia jaundice HSM sensorineural deficits

Answer 179

clinician education patient education written information to be given out wash hands after touching nappies, wiping bottoms, wiping noses/secretions from babies/toddlers do not share food, drinks, utensils do not put dummy or toothbrush in mouth do not kiss on lips wash hands with soap and water clean toys and bench spaces

Answer 180

baby - examination - investigations urine/saliva PCR within 21 days, bloods, USS head - treatment - optical review - hearing review - long term follow up: eyes, ears, paeds until 6yo mum - contraception as highest risk first 12 months following primary - risk in future pregnancy of reactivation or re infection - BF safe

Answer 181

baby - reduced PND (NNTB 554) - reduces stillbirth - reduces NICU - reduces low APGARs mum - reduces CS - reduces maternal HTN little to no difference, AVB, PPH, BF, perineal trauma, NE

Answer 182

BEP bleomycin - lung toxicity etoposide - N/V, fatigue, bone marrow, alopecia cisplatin - ear/renal/bone, peripheral neuropathy increased POI 90% success rate if recurrence lethal

Answer 183

urinary urgency accompanied by frequency and nocturne with or without urgency urinary incotnence in absence of UTI or other pathologies urgency = desire to avoid that is difficult to defer

Answer 184

GALACTORRHEA # increased PRL from anterior pituitary --> direct stimulation of mammary glands to produce milk OLIGOMENORRHEA # PRL --> HPO axis --> reduce GnRH --> reduce LH and FSH --> reduce follicular development, ovulation and oestrogen production --> no CL therefore no P --> endometrial shedding becomes irregular

Answer 185

antipsychotics eg haloperidol antiemetics eg metoclopromide opioids SSRI - escitalopram cART antihypertensives eg methyldopa

Answer 186

D2: LH, FSH, E D21 progesterone free T, FAI, SBHG, DHEAS TFT AMH PRL fastring glucose, lipids USS pelvis

Answer 187

CAH cushings adrenal tumour androgen secreting ovarian tumour exogenous androgen ovarian hyperthecosis severe insulin resistance Paraneoplastic production of acth eg small cell lung cancer Ix - bloods: LH, FSH, E, T, DHEA, DHEAS, 17 OHP, androstenedione, 11 deoxycortisol, - imaging: USS pelvis, MRI, ct chest - special: ACTH, dexamethasone suppression test, 24h urine cortisol - tumour markers: inhibin, afp, ca125

Answer 188

Hormonal- T, LH, FSH #determine if primary or secondary hypogonadotroism or partial androgen insensitivity - really reduce LH - exogenous androgen - reduce T, increased LH/FSH: kleinfelter - normal T/LH, increased FSH: micro Y deletion - increased T/LH, N FSH - androgen insensitivity - all normal - obstruction Genetic/karyotyping - CFTR, kleinfelter scrotal/testicular USS: obstruction PRL +/- MRI brain TFT repeat semen/post urination

Answer 189

CUT - sinusoidal continuous wave form with low amplitude --> rapid rise in temp --> rapid expansion of intracellular fluid and cell explosion - no contact: vaporisation 100degrees - contact: desiccation or coaptation COAG - interrupted, intermittent wave form with high amplitude - current delivered 6% of the time but increased voltage --> slow rise in temp - no contact: fulguration 200 degrees - contact: desiccation or coaptation

Answer 190

INADVERANT ACTIVATION: foot pedal, noise, plastic holder, in view LATERAL SPREAD: reduced prolonged activation, low power, proximity RESIDUAL HEAT: avoid touching after activating COAPTATION COUPLING: avoid hybrid cannulas, reduce power DIRECT COUPLING: do not touch instruments, reduce traffic INSULATION FAILURE: avoid re usable, inspect, AEM technology ALTERNATIVE PATH: AEM RETURN ELECTRODE BURN

Answer 191

general: APGAR <7 at 5 mins with no asphyxia, AVB later: HD instability, poor activity, paler, anaemia, coagulopathy, acidosis, death Localised - vague generalised scalp swelling and laxity - fluctuant old death pouch - fluid thrill - bLottable lesion that crosses suture lines - gravity dependent fluid shift - pitting oedema

Answer 192

epicranial aponeurosis - sheet of fibrous tissue that covers the entire cranial vault extending from orbital ridges to nape of neck and lateral to ears separation of epicranial aponeurosis from periosteum creates a large potential space due to rupture of emissary veins (connections between dural sinuses and scalp veins)

Answer 193

CAPUT - pressure on head during labour - serosanginous extra-aponeurotic collection extend over midline and sutures CAPHALOHAEMATOMA - occurs when friction forces generated during birth in bleeding between periosteum and underlying skin - does not cross suture lines SGH - results from bleeding into large potential space between epicranial aponeurosis and periosteum from bleeding emissary veins (connections between dural sinuses and scalp veins) - fluctuant, ill defined, crepitus, fluid thrill

Answer 194

SERM antagonistic effect on oestrogen receptors in the hypothalamus - withdrawing any negative feedback on the hypothalamus --> increased pulsatility of GnRH --> increased gonadotropins SE: hot flushes, vaginal dryness, mood changes, nausea, pelvic pain, visual disturbances, OHSS, multiples

Answer 195

atrophy 60% polyp 2-12% exogenous oestrogen 15-25% endometrial hyperplasia 10% malignancy 5% other: infection, trauma, iatrogenic, fibroids

Answer 196

immediate: bleeding, damage to surrounding structures Short term - secondary bleed - infection - malodorous discharge - pain long term - altered apperance - cervical stenosis - menstrual sx, dysmenorrhea, haematometra - TZ no longer visible - difficult colp - cervical incompetence - PTB

Answer 197

histo p16 "block type", high N:C ratio, hyper chromic SURFACE CONTOUR - visible/rolled edges - peeling epithelium - ulcerated - fungating VASCULAR - tree link branching - coarse punctation/mosaicism ACW - dull oyster gray - rigid, rapid - sharp border TOPOGRAPHY - well defined - linear - sharp margins - cuffed cripts - ridge sign - extends to endocervical canal IODINE STAINING - negative/no staining

Answer 198

perineal body part of levator ani: Pubococygeus, iliococcygeus, puborectalis, coccygeus superficial and deep transverse perineal bulbospongiosum at crowning using mediolateral incision at minimum 60 degrees from fourchete

Answer 199

Expectant - 80% incomplete by D14 - 60% missed by D14 - up to 50% failure medical - 80% but in shorter time - wife 16% failure - mife + miso 67 --> 84% expulsion - Zhang 84% by D8 miso (71% D3) - safe no difference in haemorrhage, endometritis, fever, hospital admission, acceptability Surgical - 95-99% success - failure 3% Zhang

Answer 200

perf 1:200-400 infection <1% RPOC 3-5% bleeding 2/52 10% pRBC 0-3:1000 intrauterine adhesions 10-21%??? cervical injury 1% PGE - binds smooth muscle contractions and softens cervix - reduces complications related to cervical lacerations and false passages, not perforation - reduces OT time - increase SE

Answer 201

MOA: folic acid antagonist - folic acid is essential in rapid cell division and growth therefore interferes with DNA synthesis in rapidly dividing cells SE: GI upset (abdo pain, N/V/D), photosensitivity, oral ulcers, alopecia monitoring - HCG D1, 4, 7 - drop >15% D4 to 7, HCG weekly until negative - no drop give second dose - check D14 - avoid pregnancy 3-6/12, Nsaids, etoh, sex - 90% success if HCG <1000

Answer 202

ovarian hyperstimulation release of pro inflammatory cytokines and VEGF endothelial dysfunction increased vascular permeability fluid leakage into interstitial space third spacing oedema (ascites, pleural effusions) + intravascular hypovolaemia (hypotension, increased Hct, vte)

Answer 203

starts early gestation 13 - severe N/V unable to eat/drink normally strong limitations on ADL

Answer 204

MUST - APLS - anticardiolipin (>99% titre), lupus anticoagulant (positive at all) +/- beta 2 glycoprotein (high titre) - 3D USS pelvis - TFT + TPO consider - hx and shared decision making - POC for karyotype - parental karyotype - ANA - PRL/PCOS - HyCoSy/HSG - semen analysis for sperm DNA fragmentation

Answer 205

- Meningocele – budging of neural tube often at sacrum - Obliteration of cisterna magna - Lemon sign - fontal bone scalloping - Banana sign – cerebellum - Neural arch is U Shaped +/- associated bulding meningocele (thin walled cyst)

Answer 206

ethics power size protocols primary/secondary outcomes risks/benefits change in practice supported in Cochrane

Answer 207

MATERNAL - Pruritis - GDM 3x increased - PET 10x increased - long term: chronic liver disease, gallstones, liver//biliary tree cancer, DM, thyroid disease, psoriasis, corns FETAL - stillbirth - mec - iatrogenic and idiopathic ptb - RDS - no long term studies

Answer 208

Power: inadequate contractions Passenger: macrosomia, flexed, asynclitism, fetal anomaly Pelvis: certain pelvic formations are more predisposed to OP positioning eg android or anthropoid, CPD, soft tissue obstruction eg bladder Other: epidural, positioning lack of movement

Answer 209

maternal - BMI >30 - poor maternal effort - short stature fetal - macrosomia, HC >95% - OP - deflexed, asynclitic - >1/5 palpable abdominally, not below spines - caput >2+

Answer 210

Multi centre randomised control trial Analysed on intention to treat Aim: investigate the impact of planned vaginal delivery vs planned CS for term breech on perinatal mortality and morbidity Results - Reduction in perinatal morbidity and mortality with planned CS compared to planned SVB (1.6% vs 5%) RR 0.33 NNT = 14 - Reduction in perinatal mortality 0.3% vs 1.3% - Reduction in perinatal serous morbidity eg NICU, apgars, acidosis, ventilation 1.4% vs ~4% - No difference in maternal morbidity or mortality o Difference between high and low income countries – more prounced in high income (PMR) Strengths: large study, powered for results, multi centre international – generalisable, clear statistical difference, clear primary outcome, good protocol for management Weaknesses: no USS compulsory – exclusion for planned breech eg LGA, position other then frank or complete etc not done, not all breech babies were breech at time of delivery, had to self nominate to be a breech expert - ?variable skill levels between institutions , optional CTG, randomised in labour, no labour management

Answer 211

functional change - altered tubes and endometrial environment / function - disordered tube motility and myometrial contractions impair gamete transport and embryo implantation - aberrent gene expression and down regulation of progesterone R may impact on endometrial receptivity pelvic environment/autoimmune dysregulation - increased inflammatory cytokines, growth and angiogenic factors that may disturb sperm activity, egg activity, fertilisation and embryo transfer anatomical distortion - adhesions ovarian research - reduced endometriosis treatment - inherently contraceptives pain - impact normal sexual function

Answer 212

CVS - gestation: K 11-13+6 - risks: limb reduction, mosaicism, miscarriage 1:100 Amnio - gestation: >15 - risks: direct fetal injury, miscarriage 1:200 general: ROM, failed result, alloimmunisation, infection, BBV

Answer 213

Referral to genetic counselling with MDT approach Sent POC for confirmation microarray and karyotyping Bereavement support Explain that this is not something that can be altered by behavioural management etc Explain what an autosomal recessive condition is and how happens Provide information Referral into high risk obstetric clinic and MFM for counselling Confirmation of parental carrier status IVF with pre implantation genetic testing Donation of gamete or embryo (given autosomal recessive could be donation of either ovum or sperm) Natural conception with amnio or CVS then termination if positive Natural conception with no action and confirmation on delivery Adoption Surrogacy would only work with donation of embryo, sperm or ovum as autosomal recessive No future children

Answer 214

universal cervical length screening – provides ability to intervene if cervix length <25mm, evidence to support that progesterone reduces PTB and complications of such #addressing risk factors eg smoking – smoking cessation, screening for smoking, referral to QUIT line, often highly motivated population #screening for asymptomatic bacteremia or UTI – treatment reduces PTB rates # weight loss prior to conception # continuity of care # identification of those who already had PTB and appropriate management, screen for infections, screen cervix length, continuity of care model in dedicated preterm birth clinics, progesterone # avoid iatrogenic PTB

Answer 215

Antenatal corticosteroids is supported with Cochrane evidence and numerous RCTs – level 1 evidence PND RR 0.85 NND RR 0,78 RDS RR 0.71 Likely reduction in IVH ~RR 0.56 Likely reduction in NEC Likely reduction in poor neurodevelopmental outcomes

Answer 216

Ensure that patient if safe to do so is transferred to a tertiary unit with baby in utero because this improves outcomes Given under K30 then would provide with mgso4 - Cochrane evidence to support reduction in cerebal palsy 50% reduction diagnoses NNT 60, reduction in cerebral palsy or death NNTB 56, likely reduction in IVH, older Cochrane would also support reduction in gross motor dysfunction - Would give 4g loading over 10 minutes with CTG monitoring then 1g/hr following, aiming at least 4hours prior but ideally 24 hours - Exclude contraindications eg myasthenia gravis, - Suitable for multiple pregnancies - Continuous CTG monitoring - MOA: NMDA receptor antagonist  reduces calcium release, provides neuronal stability, reduces cytokines and injury Tocolysis - Could consider tocolysis in this instance to delay for steroid loading - Allows for benefits of steroids - Nifedipine – CCB – smooth muscle relaxant - CI: APH, chorio - Dosing: - Duration: 48hours Antibiotics - ORACLE 2 would suggest that antibiotics for threatened preterm birth are contraindicated - Antibiotics for imminent preterm birth are recommended for GBS coverage as well as other bacteria, reduces sepsis and EOGBS - If this woman was contracting regularly despite tocolysis, dilated >3cm or progressing then would commence IV abx at dosage of 3g benzylpen  4h 1.8g - Best if >2 hours prior to delivery - Baby likely to be given IV abx as well after delivery

Answer 217

Individual:hand hygiene, sterile gloves, 5 steps of hand hygiene, vaccination #Preconception: optimization of medical conditions, education re hand hygiene, vaccinations eg MMR, education re CMV, toxo prevention #Antenatal: regular urine screening for asx bacteria and treatment, infulenza and covid vacciantions, education antenatal re early presentation, recognition of sepsis by team Hospital: hot water, sterile equipment, prompt, maternal early warning scores, vaccination programs for staff, isolation rooms Policy: protocols eg sepsis 6, IV abx prophylaxis – AVB, CS, Somanz guidelines eg sofa scores, sepsis 6 – broad spectrum abx

Answer 218

general antibiotic coverage depends on local hospital guidelines but recommend broad coverage including gentamycin 5mg/kg one off dose (can be considered at 24 hours for a second dose but risk of ototoxicity), metronidazole 500mg BD IV, ampicillin or amoxicillin 2g Q4-6H if concerned that there is a GAS then start with broad spectrum + clindamycin 600mg IV TDS until confirmation then can step down to benzylpenicillin 1.8g Q4-6H + clindamycin 600mg IV Q8H (inhibits and reduces the release of toxins)

Answer 219

Power: inadequate contractions Passenger: macrosomia, deflexed, asynclitism, fetal anomaly Pelvis: certain pelvic formations are more predisposed to OP positioning eg android or anthropoid (contracted pelvis), CPD, soft tissue obstruction eg bladder, fibroids Other: epidural, positioning lack of movement, dehydration

Answer 220

patient - Abdo examination: <1/5 palpable abdominally, - VE: membranes broken, fully dilated, known position in pelvis – below spines, known position of head, <2+ moulding/caput, descent with pushing - Confirmation of position on USS - Adequate contractions - Exclude signs of obstruction: haematuria, irreducible moulding - Confirm indication: maternal exhaustion, fetal distress, prolonged second stage contraindications to second stage or Valsalva - Exclude contraindications to instrumental: fetal – bleeding disorder, predisposition to fracture, spines or >1/5 palpable abdominally #consent - Risks: injury to baby – SGH, fracture, birth trauma, injury to mum – OASI, incontinence, risk of failure – conversion to forceps (increased poor maternal and fetal outcomes) or CS - Benefits: shorten time to delivery - Indications as above - Written consent could be considered - Include episiotomy as part of consent – strong recommendation for, reduction in OASI with vacuum 16%, FAB 24% - IDC removed/in out done/bladder empty - Lithotomy - Correct instruments - Good lighting - Aseptic technique #positioning/preparation - Supervision/appropriate experience level - Preempt complicaitons – consider whether there is fast availability to recourse to CS if required, perform in OT vs on birthsuite - Paeds present, prepare for resus - PPH preempted - Shoulde rdystocia pre empted

Answer 221

Subgaleal haemorrhage is a potentially life threatening complication of delivery and associated with vacuum deliveries (1:300 chance). It is where there is bleeding into a potential space between the epicranial aponeurosis and the periosteum with rupture of emissary vessels. Patient selection eg poor maternal effort (excessive force may have been used), fetal predisposition to bleeding Use as per manufacturer instructions – 600-800mmHg pressure Vacuum position: at flexion point, midline on sagittal suture 3cm from posterior fontenalle and 6cm from anterior, avoiding asynclitic placement increases risk Only pull with maternal effort in smooth motion (avoid rocking and irregular pulling) When to abandon procedure: >2 pop offs, >20 minutes, head not on perineum with 3 pulls, not delivered within 6 pulls Experience, workshops, clinical skill development, appropriate supervision

Answer 222

Forceps: increased success RR 0.5, increased OASI RR 1.5 and maternal trauma RR 1.8, reduced fetal injury Vacuum: reduces success, reduces maternal injury, increased subgaleal, retinal haemorrhage Depends on circumstances eg fetal bradycardia, poor maternal effort, dense epidural, maternal wishes, caput that increases risk of vacuum failure, clinician experience and preference Overall: VAB reduced risk to mum, with low risks to baby and no contraindications to VAB No difference in PPH, APGAR or pH

Answer 223

Rh negative or kell negative (antibody negative) mums  when these mums are exposed to a fetus (or blood products) that has antibodies they create initially IgM which cannot cross placenta so often does not affect the first pregnancy. These mothers then develop IgG which can cross the placenta in subsequent pregnancies. When IgG crosses the placenta it attacks and sequesters fetal RBC for destruction leading to anaemia. With anaemia there is a reduction in RBC and therefore there is extramedullary haematopoisis often from the liver  reduced oncotic pressure reduced cardiac output  hydrops  death If kell there is also destruction of the erythropoetic progenitor cells leading to more profound complications at much lower titres and more unpredictable. Immune destruction of erythropoitic cells. Neonates with HDFN develop jaundice and hyperbilirubinaemia. If the hyperbilirubinaemia overwhelms processes of its removal there can be damage of the basal ganglia leading to kernicteris. The complications are kernicterus, sensorineal hearing loss and death. These babies frequently need hydration and pRBC for replacement. Requirements: fetal Ag present Circumstances: blood transfusion, sensitization events – 1st, 2nd, 3rd, pp

Answer 224

#confirm at blood group and ab status - Provide Anti d cross matching for blood groups – blood bank may need time to match and therefore in cases of emergency may be difficult to administer correct blood but default should be o neg (she would be fine with this) and kell neg (fine) and therefore shouldn’t have reaction. If planned for delivery then would be best to cross match as a default for her. #high risk pregnancy – 2x antibodies  will need titres from first trimester likely weekly but if kell titre returns positive (1:4) then immediate referral to MFM, would need weekly USS for MCA PSV and hydrops from K16 with referral to MFM for serial titres and USS

Answer 225

other causes of deranged LFT/itch in pregnancy o Dermatoses: PUPPS, atopic erupton, phemphogoid o Other: jaundice, AFLP, hepatitis, PET/HELLP, obstructive eg cholecystitis/choledocholithias - no longer a diagnosis of exclusion but would recommend screening alternative causes if red flags - red flags: commences 4x upper limit normal, signs of liver failure - infectious screen: Hep A/B/C, EBV, CMV - structural/obstructive: liver USS – cholecystitis - autoimmune: anti smooth muscle antibiotics, anti liver-kidney ab, ANA

Answer 226

#Counselling with patient regarding risks Fetal risks: stillbirth, PTB, meconium, RDS  no monitoring prevents these Maternal risks: GDM, PET, pruritis, long term risks #Timing of delivery – risk of stillbirth No other ways to change outcome Supportive management #Avoid itching: emollients, avoid heat, cut nails short, pine tarsal #Antihistamines #Ursodeoxycholic acid: Ptiches trial and Cochrane: do not reduces perinatal outcomes, statisifically significant reduction in itch but not clinically significant, no alternative medication Follow up: Weekly review for bloods, Given BA >110 would perform coags --> ensure that normal --> if abnormal give IV Vit K and then repeat weekly and before delivery #High risk GDM and PET – monitor #No role for routine USS or CTG but red flag advice re DFM and presenting if concerns, low threshold to perform # No impact on MOD – obstetric indications #Given BA >100 – very severe ICP --> Delivery around K36, could be considered earlier if previous IUFD at earlier gestation due to ICP # Risk of idiopathic PTB – red flag advice #Paeds consult given likely to have a PTB Postnatal o Discuss risk of recurrence high 60-70% o Can have COCP but needs to wait until LFT normal, recheck LFT 3/12 after commencing, risk of itch o Repeat bloods at 6 weeks to ensure normalized, if not referral to hepatology o Cease urso at delivery o No impact on BF o Not a RF for VTE #Avoid medications that can worsen LFTs

Answer 227

Immediate risks: bleeding, damage to other structures Short term: pain, abnormal discharge, bleeding, infection Long term: - Gynae: cervical stenosis – haematometra, dyspareunia, dysmenorrhea; difficulty with future examinations and assessments – cannot see TZ, insufficient sample/incomplete excision with positive margins needing further surgery - Obs: cervical incompetnence – preterm birth, cervical stenosis obstructed labour

Answer 228

Colp at 6 months + Annual screening for 12 months for 3-5 years (clear margins) Positive margins – repeat cone following MDT Consideration of HPV vaccination – improved coverage for other strains

Answer 229

Precocious puberty is defined as puberty (breast development and menarche in females) before the age of 8 (or 9 in males) development of physical characteristics associated with puberty - onset <8 - menarche <9 Incidence: 4-5%

Answer 230

Central (gonadotrophic dependent) - early activation of the HPO axis --> pulsatile GnRH secretion --> increased gonadotrophin --> increase sex steroid production = 80% (general normal reproductive life, no association with POI) - Idiopathic - CNS tumour - CNS malformation – hydrocephalus - CNS inflammation/meningitis ==> GnRH stimulation test --> increase LH following test = central (reduced LH/FSH but increase E = peripheral) ==> treatment: GnRH agonist until appropriate age Periperhal (gonadotrophic independent) = lack of GnRH pulsatile release and reduced gonadotrophin (increased E from peripheral source) (often do not have pubic hair as adrenal testosterone is not increased, E dominant) - Adrenal: CAH - replace steroids, 21-OHP deficient, reduced BP/BSL, adrenal crisis, FTT, hyperpigmentation, virilisation - Ovarian: granulosa cell tumour (60%), thecal cell tumour, malignant teratoma - McCune Albright syndrome - spironolactone, cafe au late spots - Exogenous oestrogen

Answer 231

basic: height, weight, growth charts bloods - baseline hormones: , LH, FSH, Estradiol, testosterone, FAI - adrenal: 21 OHP, DHEA, DHEAS, SHBG - endocrine causes: TFT, PRL, IGF-1 - if ovarian mass: AFP + HCG - GnRH stimulation: central vs peripheral imaging - bone age XR - USS pelvis + renal - uterine maturity, ovaries, tumours - MRI/CT head

Answer 232

MDT approach – PAG, endocrinology, psychology, GP Explain diagnosis – early puberty and exposure to sex hormones Discuss implications – growth, prolonged oestrogen exposure Discuss importrance of psychology – some evidence to suggest hthat those exposed prematurely to sex hormones have negative impacts eg body image, sexualization Treatment may depend on cause - Ovarian tumour: remove, potential for chemo, referral to GONC - Adrenal tumour: referral for expert management - CNS tumour: referral for expert management - CAH: replace steroids - McCune Allbright: spironolactone Hormone therapy - Hormone suppression required – GnRH suppression to stop or reverse changes important for bone maturation - Add back hormones when appropriate age to trigger menarche

Answer 233

respect of autonomy - Recommend confirmation of IUP prior, exclusion of STI and discussion around contraception medical terminations - generally mifepristone + misoprostol - mifepristone MOA: progesterone receptor antagonist  primes the uterus for misoprostol, increased oxytocin receptors, detaches pregnancy from wall, stops pregnancy growing, cervical priming - misoprostol: PGF1 causes uterine contractions and cervical dilatation and opening to expel product - benefits: similar rates of bleeding, infection, no general anasthetic or surgical complication risk, can be done at home - risks: increased emergency surgeries, increased unplanned hospital admissions, increased retained products - Zhang et al: acceptable, would recommend to others, expulsion rate ~80% - Expulsion rate increased by mifepristone - Faster then expectant management - In Australia done up to 63 days at home and >63 days within a hospital - Exclude contraindications to medications as well as lack of supports or access to emergency care Surgical - Suction D+C or manual vacuum aspiration - Can be done under general, sedation or local depending on hospital, team and patient preference - Risks: general anasthetic, surgical – perforation, asherman, retained product, cervical laceration - Benefits: faster, overall less time bleeding, generally avoids unplanned surgery and repeat surgeries - D+E >K14 based on clinican experience

Answer 234

Immediately: do not remove suction, turn suction off Notify OT and anasthetics that likely complication, requirement for additional equipment and set up and change of disposition will require admission Call to SMO and ask to attend immediately Conversion to laparoscopy - Primary survey of pelvis and abdomen, Survey of perforation and damage - Remove the suction device - Oversaw perforation - May require general surgery to walk bowel or urology if bladder injury - Iv abx - Photos Documentation - Post operative plan: admit, analgesia - Sent product for histo to confirm POC - Open disclosure including implications for future pregnancies recommend against labouring on uterus - Risk management - Review of own practice - Notify medicolegal insurance

Answer 235

- confirm ovulation: D2 LH, FSH, E, D21 progesterone - exclude endocrine conditions: TFT, PRL, HbA1c - AMH - PCOS sx: T, SHBG, DHEA, DHEAS - USS pelvis: antral follicle count, structure - check tubal patency: HyCoSy, HSG - antenatal bloods + genetic carrier screening

Answer 236

Clomid: SERM Letrozole: aromatase inhibitor Reduce E  Increase GnRH Both increase FSH to increase follicular recruitment - why is letrozole better improved pregnancy rates including live birth rate, reduced multiple pregnancy, OHSS, miscarriage theoretic risk of BOT with clomid and less so with letrozole 25% of people don’t respond to clomid

Answer 237

failed first line management if undergoing laparoscopy if all other pathologies excluded second line * Laparoscopy * Typical protocol * 3-6 punctures bilaterally * 40W coag for 4 seconds * Second-line treatment after failed ovulation induction * Compared with GH ovulation induction * Similar efficacy, fewer multiple pregnancies or OHSS * Likely reduces ovarian production of androgens and proteins which leads to endogenous increase in gonadotrophins * Ovulation occurs in 80% (30-90%) * The normalization of ovulatory function continued for many years in the majority of patients following ovarian drilling

Answer 238

Hysterectomy - MOA: - Risks: prolonged operation, recovery, pain, risk of surgical complication, excludes fertility - Benefits: definitive, histo, risk reduction of BS can be done, no risk of endometrial cancer Endometrial ablation - Burns lining at decidua reducing flow, often combined with mirena - Risks: less likely to work in the setting of adenomyosis, perforation, thermal damage to other structures, is not definitive, high percentage require additional procedure, needs contraception - Benefit: day procedure, fast recovery, reduction in HMB Uterine artery embolization - Mechanism: causes obstruction of uterine artery resulting in ischemia - Risks: immediate – vasovagal, reaction to contrast, short term – post ablation syndrome, infection, bleeding, pain, vte, long term – repeat procedure, necrosis, more likely to fail with adenomyosis - Benefits: day procedure,

Answer 239

dysmenorrhea dyspareunia infertility pelvic pain hmb less common - bowel sx- dyschezia - fatigue - back pain - sleep disturbance - headache - urinary sx - allergies

Answer 240

reduced pelvic organ mobility pelvic organ enlargement posterior vaginal wall nodularity pelvic + vaginal tenderness visible vaginal endometriosis lesion

Answer 241

#abnormal remodelling spiral arteries - do not become high capacitance and low resistance vessels - defective trophoblast differentiation - placental hypo perfusion, hypoxia, ischemia release of pro-inflammatory cytokines #endothelial dysfunction - increased permeability, increased pro-thrombotic factors, increased vascular tone

Answer 242

#Discussion of recurrence risk and provide written evidence at time of first pregnancy #preconception optimisation exclusion of essential HTN medication review weight management exercise and diet #first trimester - discussion of LDA 150mg and calcium 1g for prophylaxis - reduction in PET by up to 60% with NNT = 60, commence prior to K16 and continue until K34 - risk screening: bloods, Hx, BP in first trimester - ranzcog PET screening recommend: clinical hx and BP at minimum + uss uterine artery pulsatility index and maternal serum biochemical markers (Papp-a + PIGF) - risk factors: pet, ghtn, twins, pre existing DM, chronic renal disease, autoimmune (moderate - AMA, BMI, Fhx, nullip, art, IPI >10yrs) - baseline PET screen SECOND trimester onwards K20-24 UA PI Increased surveillance and high risk clinic – BP and urine checked each visit, growth and wellbeing USS High risk obs for continuity of care Safety netting

Answer 243

HELLP eclampsia persistently elevated HTN despite management signs of fetal compromise signs of abruption APO >K37 persistent neuro sx or signs progressively worsening liver or renal failure

Answer 244

#increased risk of - chronic HTN - cardiac disease - vascular disease - stroke - chronic renal impairment - diabetes - annual check ups for BP and metabolic screening #discuss risk of recurrence - recommend LDA

Answer 245

skin to skin golden hour early breastfeeding targeted breast feeding support antenatal expressing

Answer 246

Lactogenesis I – 1st + 2nd trimester * Oestrogen o Results in ductal expansion o Deepening of the pigment of the alveolar o Increase in number of lactophins in hypothalamus * Progesterone o Results in alveolar and lobule development * Prolactin o Increased allows for increase in enzymes that would produce milk * High oestrogen and progesterone inhibit prolactin and thus the production of milk * Relaxin – helps expansion of mammary tissue Lactogenesis II – third trimester onwards * Reduction in oestrogen and progesterone remove the inhibition of prolactin * Prolactin  milk production * Oxytocin  milk reflex with contraction of the myoepithelial cells (letdown reflex)

Answer 247

Baby * Bonding * Reduction in GI/ear/renal/resp infections in first few months – passive immunity passage of IgA * Reduction in metabolic syndrome, T2DM and obesity * Reduced SIDs * Reduced NEC * Note: not vitamin D and therefore some countries where less sun exposure babies will be supplemented Mother * Reduced premenopausal breast cancer * Reduced ovarian cancer * Increased weight loss * Cost reduction * Bonding * Reduction in T2DM

Answer 248

fetal: MTCT, congenital syphilis, PTB, miscarriage, FGR, IUFD, NND mother: progression of disease, tertiary/neurosyphilis

Answer 249

<20 risk of spontaneous bleeding, below 50 requires treatment if something is about to happen to mum eg amnio/cvs, labour, high risk PPH 70-80 anasthetics may decline to perform regional anasthetic due to risks of haematoma > benefits <100: increased PPH

Answer 250

* Maternal plateltts do not correlate to baby’s platelets --> Could consider CS if <50 * <1% risk of IVH * Risk exists once in labour: No FBS, FBS, AVB mid cavity, VAB * Bloods o Cord blood: FBC o Capillary blood at birth and repeated 7/7 * Treatment IVIG * Do not test in utero  cordocentesis 2% fetal loss

Answer 251

Experienced MDT including anasthetics  consideration of use of rotem 1 unit pRBC :1 FFP --> once 8 pRBC give 1 unit plt if fibrinogen <2.5 give cry prevent hypothermia, acidosis and hypocalcemia (lethal triad) avoid dilution coagulopathy - limit crystalloid use, ensure plasma and plt given early with pRBC monitor and correct coagulopathy stop the bleeding step-down and deactivate continuous reassessment

Answer 252

Large multi national multi centre RCT Reduced death from bleeding if given within 3 hours Reduced laparotomy to control bleeding Increased brace sutures No difference in hysterectomy Low resource countries where hysterectomy where most used modality to use pph due to lack of blood and product available, lack of cold chain Thus woman – high resource world many steps prior

Answer 253

Reduces risk of RDS and TTN/NICU or SCN admission At K37 1:10, K38 1:20, K39 1:100 similar to vaginal delivery background rates Campaign regarding every week counts and avoiding iatrogenic early term deliveries – increasing evidence about neurodevelopmental outcomes improved when delivered K39 - 40

Answer 254

pre operative optimisation - medical conditions - stop clexane and aspirin - timing of medication documented fasting rules consider pre surgical scrub group and hold, FBC, IVC resources: NICU, cell saver, team, pre op planning

Answer 255

Hypogonadotrophic hypogonadism o Stress, exercise, eating disorder o Prolactin o Kallman o Constitutional o CNS tumour o Chronic illness Hypergonadoatrophic hypogonadism o Turners o POI - Genetic: turners, fragile X - Autoimmune: TFT, DM, type 1 and 2 polyglandular - Metabolic: galactosemia - Secondary: iatrogenic, chemo/rad, infections, toxins o Swyers Obstructive: imperforate hymen Absent uterus o CAIS 46XY o MRKH 46XX Physiological: pregnancy other: CAH, kleinfelter

Answer 256

Bedside: Urine HCG – immediately exclude pregnancy Bloods o Hormone profile: LH, FSH, oestradiol, T, FAI – confirm HPO axis o PCOS bloods: DHEAS, SHBG o HCG o Endocrine: PRL, TFT o Adrenal: 17-OHP o Karyotype - POI o Fragile X premutation carrier screening Imaging o USS pelvis: confirm uterus, exclude ovarian masses, exclude mullerian anomaly o XR bone age o Dexa scan once confirmed Special: GnRH test

Answer 257

CAIS 5 alpha reductase deficiency Swyers

Answer 258

XY fetus --> male pattern development with SRY gene --> normal testicular development and AMH present therefore regression of mullein duct BUT lack ability to respond to androgens due to defective androgen receptor --> female external genitalia and CNS #XY female # no mullein structures, no uterus #normal external genitalia - female #viariable extent of vaginal hypoplasia #absent/spares pubic and axillary air #normal breast development - peripheral conversion of androgen to oestrogen #intra abdo testes --> increased T, 5% malignancy risk

Answer 259

#gonadal tumours - remove 5% risk of malignancy infertility sexual dysfunction - short vagina psych/gender osteoporosis

Answer 260

Partnership – rapport, ICE, safety screening, culturally safe, non judgemental Privacy Pronouns Partners – number, genders, risk factors Practices/preferences – anal Presenting complaint/symptoms Protection + BBV screening Past hx – previous STI Prevention of pregnancy – contraception, pregnant in past Pap smears

Answer 261

Benign tumour of smooth muscle and fibroblasts in the myometrium which is derived from a single cell that has undergone genetic mutations with angiogenic growth factors increased.

Answer 262

AUB * HMB * Increased surface area * Altered endometrium above fibroid * Increased angiogenic growth factors * Abnormal vasculature and altered haemostasis Mass effects * Very large subserosal fibroid that could place pressure on surrounding organs o Bladder: urgency, frequency***, retention, recurrent UTI o Bowel: urgency, frequency, pressure, dyschezia o Uterus: dyspareunia * Sensation of mass Pain * Altered contractility * Increased bleeding  cltos  prostaglandin * Degeneration Infertility and pregnancy complications * Altered cavity: impaired implantation and increased miscarriage * Altered endometrium over fibroid: IUGR * Altered contractility: PPH, MROP, CS, labour dystocia * Altered anatomy: malpresentation, increased surgical complicaitons

Answer 263

* Urine HCG * Bloods: D2 LH, FSH, estradiol, D21 progesterone (confirmation of ovulation), if PCOS sx SHBG, DHEAS, DHEA, FAI, T; PRL, AMH, TFT, HbA1c, if recurrent miscarriage APLS bloods * USS pelvis * Tubal patency: HSG, HyCoSy, dye studies * Semen analysis and consideration of anti sperm DNA * Antenatal bloods

Answer 264

* Altered cavity: impaired implantation and increased miscarriage * Altered endometrium over fibroid: IUGR * Altered contractility: PPH, MROP, CS, labour dystocia, PTB * Altered anatomy: malpresentation, increased surgical complicaitons * Pain: red degeneration

Answer 265

Young age <30 Low BMI <18 High AMH High antral follicle count High number of eggs collected >17 HCG – pregnant, fresh transfer, used for trigger or luteal support Methods of triggering PCOS

Answer 266

Assessment: urine output – oliguria/anuria, tense ascites Bloods * FBC: Hct 0.45 (severe)  0.55 critical, WCC >25 * CRP * UEC: K>5, Na <135, albumin <35 o Osmolality o Check Cr as risk of AKI * HCG level would be important as can risk stratify whether course is going to be protracted and potentially become worse before it gets better USS * Ovarian size >10-12cm * Exclude torsion * Exclude TOA * Exclude IUP and ectopic * Ascites Consider: CXR, CTPA, VBG, ABG, d-dimer, ECG

Answer 267

Management * Admit patient * Explain OHSS * Explain risks: AKI, VTE, worsening of symptoms, ARDS, cerebral oedema, ovarian torsion, ileus * Supportive cares o Fluid balance - May require albumin for fluid resuscitation but careful with guidance of ICU/medics given patient is third spacing - IDC o Daily abdo girth and weight o Analgesia, avoid NSAIDs risk of AKI o Antiemetics o Daily examination and bloods o If tense ascites +/- AKI consideration of paracentesis o Consideration of drainage of pleural effusions if required o VTE prophylaxis: clexane and TEDS o Daily examination: resp, abdo, calves o Daily bloods o Electrolyte correction o Cardiac monitoring if severe shifts * Disposition depends on a number of factors including stability, some patients are managed in ICU * OT if concerns for torsion * Rehabilitation: physio * Psychosocial supports * If pregnant: may offer termination if significant deterioration in maternal health, if continues pregnancy – high risk pregnancy, offer USS and serial HCG to confirm IUP vs ectopic, referral to MFM – risk of PET

Answer 268

When younger patient and distortion of anatomy would not be acceptable or high risk of psychosexual impacts of surgical management High risk area eg clitoris Field effect – multifocal, multiple small lesions Biopsy and histo confirmed no stromal invasion Poor surgical candidate No previous surgery These options to not provide histology

Answer 269

Short term risks: haematoma, infection, wound breakdown, pain, lymphocele Long term: lymphedema 20-60%, neuropathy, scarring, recurrence, cellulitis, lymphadenitis, ulcer formation, delayed recovery, VTE

Answer 270

reduced OT time, less invasive, reduce ST and LT implications, reduced complications

Answer 271

* Solid * >4 papillary projections * Large size * Complex * Thick septations * Ascites * Peritoneal nodules * Bilaterality * Vascular * Adhesions * Omental caking

Answer 272

* carboplatin (renal/oto/bone marrow) and paclitaxel (peripheral neuropathy) – serous or mucinous epithelial - 80% success * BEP – germ cell (lung toxicity) – 90% success

Answer 273

criteria based on TV USS !!! - CRL >7mm with no FHR - MSD >25mm with no fetal pole - absence of embryo with heart breast >2 weeks after USS that showed GS without YS - absence of embryo with FHR >11 days after USS that showed GS with YS - previous USS that demonstrated fetus with FHR and subsequent that does not 100% specificity and positive predictive value accounts for quality of monographer and radiologist, variations in USS and patient factors like obesity, uterine fibroids and uterine position

Answer 274

often miscarriage occurs spontaneously with onset of period like cramping, vaginal bleeding and passage of tissue success rate - 80% of incomplete in 14 days - 60% of missed in 14 days - success rate less if prolonged loss without expulsion benefits - may avoid surgery and anaesthesia - similar success to medical for incomplete Risks - unpredictable - more days of bleeding and greater amount then surgical - higher rates of unplanned hospital admissions and surgery - risk of DIC is approx 10% at 4 weeks - infection risk increases as time progresses follow up - no limit on how long before called failed - recommend NSAID and paracetamol for pain and safety netting to present to ED if severe pain or soaking >1 pad on 2 consecutive hours - HCG D1 + D8 --> repeat USS if drop <90% - if convincing hx of passage of tissue when woman can perform urine HCG at 3-6 weeks to ensure negative

Answer 275

regimen success rate - ~80% but achieved within shorter timeframe 24-48h - use of mifepristone increases success rate - more effective for missed miscarriage than expectant management - if incomplete, no difference between medical and expectant management for rates of completion and need for surgery - success rate less if prolonged loss without expulsion benefits - may avoid surgery and anaesthetise - can be done at home - decreases time to expulsion - increases rate of complete expulsion risks - SE - higher risk of failure compared to surgery - higher rate of unplanned hospital admissions and surgery - 2% risk of bleeding requiring transfussion - 8-9% risk of RPOC requiring evacuation follow up - analgesia - safety netting - HCG D1 + D9 --> repeat uss if not dropped 90% - if convincing hx of passage urine HCG 3-6 weeks post

Answer 276

suction dilation or manual vacuum aspiration success - 99% - cervical priming reduces need for mechanical dilation and decrease OT time benefits - avoids pain and bleeding - fastest - reduced rate of unplanned admissions and emergency surgery - appropriate for those unsuitable for other management - GTD, infection, excessive bleeding, HD instability - appropriate for those at increased risk of haemorrhage or reduced ability to tolerate ir eg bleeding dyscrasia, inability to have blood transfusion, cardiopulmonary disease, anti coagulated risks - overall 6% risk - perf 1:200 - RPOC with repeat D+C 4% - cervical trauma 3% - intrauterine adhesions - AFE follow up - history confirms products

Answer 277

* Ranzcog signs and symptoms of ectopic can be diagnosed with o Gestational sac in adnexa with FP/FHR/CRL or with gestational sac in adnexa alone (bagel sign) or inhomogenous mass in adnexa “blob sign” o Separate from CL * Empty uterus * Free fluid in POD

Answer 278

Discriminatory zone: the HCG level which you would expect to see an IUP. In Australia 2000 is used as see 91% of IUP at this level. At 3510 see 99%. This can be impacted by sonographer, USS machine, patient factors – BMI, fibroids, uterine position, declining TV USS

Answer 279

defect with backboard/stability of structures/atrophy  instrincic sphincter dysfunction, urethral hypermobility

Answer 280

PTB, IUFD, FGR, misarriage

Answer 281

* Ideally 2 consultants present for MDT decision to be made * Conversion to GA * Replacement of product, keep warm, ensure no electrolyte disturbances * Next of kin notified * Broad ligament: ligated and divided, anterior leaflet of broad opened down to bladder reflection. Bilateral * Clamps placed on the utero-ovarian ligament and fallopian tube – ligated and divided. Medial clamp left on and not removed * Posterior leaflet divided down to uterosacral * Bladder dissected down * Uterine artery ligated, divided and tied * Cardinal ligaments dissected posteriorly * Curved clamp used to get under cervix, cut * Vaginal cuff created and closed * Post operative o ICU vs HDU o VTEp o Recheck bloods o Return of normostasis o IDC out early, mobilisation o Eat and drink o Debrief o Additional GOPD debrief o Psychosocial o Lactation support o Bereavement support if required o M+M o Monitor PND o Letter to GP, give copy to patient

Answer 282

* Mechanism: hyperinsulinaemia  hyperinsulinaemia in the fetus  increases growth and abdominal circumference * Immediate: shoulder dystocia, birth injury – hypoxia, brachial plexus injury, fractures, higher risk of AVB – SGH, low APGAR * Short term: hypoglycemia, NICU admission, RDS, TTN, jaundice * Long term: metabolic syndrome, obesity, T2DM, complications of birth trauma eg CP, HIE Maternal complications: OASI, infection, CS , PPH

Answer 283

* Recommendations prior to ensure no macrosomia: universal screening of GDM, treatment of GDM including low glycemic diet, exercise, induction of labour, prevention of excesive gestational weight gain, in those who are obese consideration of bariatric surgery prior to pregnancy

Answer 284

o Maternal: hospitalisation, ICU, death, complications – RDS, pneumonia, sepsis o Fetal: teratogenic effect of fever during first trimester – increased NTD, increased miscarriages, IUFD, PTB, LBW, abruption (increased cytokines) o Incidence: 1-2% of pregnancies  if not vaccinated then 1:2 go to hospital with 10% mortality in pregnancy, 10% ICU vasopressor or resp support o Vaccinated reduces 80%, ED presentation 60% reduction,

Answer 285

distended soft cervix engorged dilated pelvic vessels friable oedematous tissue large bulky uterus potentially unstable patient

Answer 286

reduced EBL and pRBC faster reduced intra/postop complications

Answer 287

Short term: haemorrhage, pain, infection, heamatoma, trauma LT: increased UTI, dysmenorrhea, dyspareunia, itch, reduced lubrication obs complications: PPH, CS, obstructed labour, Oasi, episiotomy discuss risks and benefits: anatomical, cosmetic and physiological changes - increased micturition, vaginal discharge, appearance discussed illegal to reinfundibulate

Answer 288

extra dose of MTX

HARD SAQs Flashcards

(315 cards)