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Flashcards in O&G Deck (102):
1

Differential diagnosis for pain in early pregnancy

Ectopic
Miscarriage
OHSS

2

Differential for cycle independent pain

PID
Mass

3

Annual of prevalence of chronic pelvic pain in women 15-73

38/1000

4

Definition of primary amenorrhoea

Lack of menstruation by 16 in the presence of secondary sexual characteristics; by 14 in the absence of secondary characteristics.

5

Staging of OHSS

Mild - pain/bloating

Moderate - Mild + N+V + USS ascites

Severe - Clinical ascites, haematocrit >45%, hypoproteinaemia

Critical - VTE/ARDS/anuria/tense ascites

6

You are asked to see a 32 year old woman in the antenatal clinic after her routine dating scan. She is in her first pregnancy and her last menstrual period was 12 weeks ago. She felt very sick when she first got pregnant but more recently these symptoms have subsided. The ultrasonographer shows you the scan report which documents an intrauterine gestation sac measuring 30mm in diameter. A small fetal pole is seen measuring 10mm but no fetal heart was present. The patient does not report any vaginal bleeding.

A. Ovarian torsion
B. Heterotopic pregnancy
C. Threatened miscarriage
D. Inevitable miscarriage
E. Delayed miscarriage
F. Appendicitis
G. Ectopic pregnancy
H. Haemorrhagic corpus luteum
I. Pelvic inflammatory disease
J. Complete miscarriage

Delayed miscarriage

7

A 28 year old woman presents to the GP surgery with her baby, who is three weeks old. The delivery was by emergency caesarean section for failure to progress in labour. She was discharged on day three after the delivery. She had minimal bleeding for the first two weeks, but over the last few days, bleeding has increased. She is now passing clots vaginally and is feeling unwell. On palpation, the abdomen is tender suprapubically. Her temperature is 38ºC.

A. Endometritis
B. Urinary tract infection
C. Wound haematoma
D. Pulmonary embolism
E. Deep venous thromboembolism
F. Urinary retention
G. Incisional hernia
H. Retained products of conception
I. Wound infection
J. Atelectasis

Endometritis

8

You are called to see a 35 year old woman who is in labour. She was last examined 4 hours ago when the cervix was 6cm dilated. The cardiotogograph indicates a fetal heart rate of 70bpm for the last 10 minutes. There is meconium staining of the liquor. You perform a vaginal examination which shows the cervix to be 8cm dilated.

A.
Continue CTG and review later
B.
Perform fetal blood sample
C.
Increase syntocinon infusion
D.
Admit to antenatal ward for observation
E.
Start syntocinon infusion
F.
Cardiotocograph
G.
Complete partogram
H.
Perform caesarean section
I.
Speculum examination

Perform caesarean section

9

A 38 year old woman is being induced at 41+5 weeks’ gestation in her first pregnancy. She has had an uneventful pregnancy so far. She has been given 2 doses of prostaglandin by the midwives on the antenatal ward and had an amniotomy (artificial rupture of membranes) 4 hours ago. She is not contracting. The cardiotocograph is reassuring.

A.
Continue CTG and review later
B.
Perform fetal blood sample
C.
Increase syntocinon infusion
D.
Admit to antenatal ward for observation
E.
Start syntocinon infusion
F.
Cardiotocograph
G.
Complete partogram
H.
Perform caesarean section
I.
Speculum examination

Start syntocin infusion

10

At 10pm you are called to see a 25 year old woman who is in labour at 41 weeks’ gestation. At 6pm cervical assessment showed a dilatation of 6cm. The cardiotocograph shows the fetal heart rate to have a baseline of 150bpm, with reduced variability for 1 hour. There are also variable decelerations present for the last hour. Vaginal examination reveals the cervix to be 9cm dilated and the head is at the level of the ischial spines. The liquor is clear.

A.
Continue CTG and review later
B.
Perform fetal blood sample
C.
Increase syntocinon infusion
D.
Admit to antenatal ward for observation
E.
Start syntocinon infusion
F.
Cardiotocograph
G.
Complete partogram
H.
Perform caesarean section
I.
Speculum examination

Perform fetal blood sample.

11

A 33 year old nulliparous lady has a cervical smear performed in accordance with the NHS Cervical Screening Programme and it is reported as inadequate. Her previous cervical smears have always been normal and she has no gynaecological complaints. She uses the combined oral contraceptive pill for contraception. The correct management for this patient is.

1. She should be referred for colposcopy where she should be seen within 8 weeks
2. She should be advised to discontinue the combined oral contraceptive pill and have the smear repeated in 4 weeks time
3. She should be referred for colposcopy where she should be seen within 2 weeks
4. The smear should be repeated and she should be referred for colposcopy if 3 consecutive smears are reported as inadequate
5. The smear should be repeated and she should be referred for colposcopy if 2 consecutive smears are reported as inadequate

The smear should be repeated and she should be referred for colposcopy if 2 consecutive smears are reported as inadequate

12

A 24 year old primagravida has HIV antibody testing as part of her antenatal booking investigations at 15 weeks gestation. The test is positive. Which of the following statements regarding mother to child transmission of HIV is NOT true.

1. Exclusive formula feeding reduces transmission by half
2. All women, irrespective of their plasma viral load, should be advised to take antiretroviral therapy in pregnancy in order to reduce the risk of transmission
3. Without intervention transmission occurs in approximately 60% of cases
4. All neonates born to HIV-infected women should be given antiretroviral therapy to reduce the risk of transmission
5. Transmission most commonly occurs at the time of delivery

Without intervention transmission occurs in approximately 60% of cases

13

The number of weeks at which induction should be considered if maternal diabetic control has not been optimal.

A. 8
B. 40
C. 2
D. 36
E. 7
F. 38
G. 6
H. 3
I. 1
J. 34

38

14

For tight control a woman’s % HbA1c should be below this number.

A. 8
B. 40
C. 2
D. 36
E. 7
F. 38
G. 6
H. 3
I. 1
J. 34

7

15

A 26 year old primigravida is admitted to the delivery suite in spontaneous labour at term. She has no obstetric risk factors and undergoes epidural anaesthesia at 5cm dilatation. Full dilatation is confirmed at 21.30, where the baby is shown to be in the OP position, at ischial spines, with minimal caput/moulding. According to the RCOG guidelines, at what time may an assisted delivery be offered for delay in second stage?

a) at any time
b) 2230
c) 2330
d) 0030
e) 0130

0030.

This lady is nulliparous and one hour passive second stage should be recommended due to her epidural anaesthesia.
Delivery should then be expected within 2 hours of active 2nd stage.

16

Which of the following is an absolute contraindication to external cephalic version?

a) fetal abnormalities
b) maternal hypotension
c) oligohydramnios
d) 1 previous C-section
e) Transverse lie

C - oligohydramnios

Think of a vacuum-packed foetus. Lack of amniotic fluid means ECV won't work.

A,B & D are relative contraindications.
E is an indication.

17

Which is false in relation to medical terminology relating to miscarriage?

a) A complete miscarriage should have a closed cervix clinically and an empty uterus on USS.
b) A missed miscarriage should have a closed cervix with evidence of a fetal pole on USS and women may have slightly symptoms of pain/bleeding.
c) A threatened miscarriage should have a closed cervix and evidence of an intrauterine gestational sac on USS.
d) An incomplete miscarriage should have evidence of tissue/sac on USS with a possibly open cervix clinically.
e) An inevitable miscarriage should have a closed cervix clinically with evidence of an intrauterine gestation sac on USS.

E

An inevitable miscarriage will have an open cervical os.

18

Which is true regarding antepartum haemorrhage?

a) All women with APH should be admitted
b) Refers to bleeding from or into the genital tract from conception until the delivery of the baby
c) Steroids should be administered at

D

a - All women with APH heavier than spotting and women with ongoing bleeding should be admitted.

b - from 24/40 until delivery

c)

19

Which of the following regarding hCG if true?

a) It is detectable in maternal bloodstream at 3 days after fertilisation.
b) It is maintained by progesterone.
c) It is maintained by the corpus lute
d) It is secreted by syncytiotrophoblasts
e) It is secreted by the corpus luteum

D

hCG is secreted by the syncytiotrophoblast into the maternal bloodstream, where it acts to maintain the production of progesterone by the corpus lute in early pregnancy.
hCG can be detected in the maternal bloodstream as early as day 8 after conception.

20

Which of the following is true in relation to placenta praevia?

a) Can be diagnosed from 12/40 gestation.
b) Describes when the chorionic villi are seen at the interface with the myometrium
c) Describes when the chorionic villi invade the full thickness of the uterine wall
d) Describes when the placental cord overlies the cervical opening
e) Describes when the leading part of the placenta is within 5cm of the cervical os.

E

a - Lower segment develops at 28/40 and so before this point it is not possible to diagnose praevia as it describes a condition relating to the position of the placenta within the lower segment
b - placenta accreta
c - placenta percreta
d - vasa praevia

21

In relation to Termination of Pregnancy

a) Late TOP are usually performed surgically
b) It is more likely to have retained products following a surgical TOP than a medical TOP
c) Mifepristone is used in both medical and surgical TOPs
d) Misoprostol is used in both medical and surgical TOPs.
e) Potential complications of medical TOPS include future cervical incompetence.

D

a - Surgical TOPs from 7-13.6/40
b - mTOP > sTOP for risk of incomplete evacuation
c - Mifepristone is an anti-progesterogenic steroid that ripens the cervix. Used in mTOPs only.
e - Cervical incompetence is a complication of sTOPs not mTOPs.

22

Which of the following make up the standard bloods taken at a woman's first booking visit for pregnancy.

a) autoAbs, CMV, Hbopathies, Hepatitis, HIV, Rubella, syphilis, VZV
b) autoAbs, CMV, EBV, FBC, Hepatitis, HIV, Rubella, syphilis, VZV
c) autoAbs, FBC, Hbopathies, Hepatitis, HIV, Rubella, syphilis,
d) CMV, FBC, Hbopathies, Hepatitis, HIV, Rubella, VZV
e) FBC, Hepatitis, HIV, Rubella, syphilis,

C

VZV not included
CMV not included: although potentially fatal to the foetus there is no available treatment so no point screening.

23

Which of the following if false in relation to GDM?

a) Even if initial screening is negative, the OGTT should be done at 34/40 if there are concerns.
b) First line management is with diet and exercise alone.
c) Management aims include normoglycemia and avoidance of ketosis.
d) Risk factors include BMI >30, a previous baby weighing >4.5kg, and a 1st degree relative with DM.
e) The WHO recommend universal screening at 26-28 weeks.

E.

The WHO does not advocate universal screening but selective screening based on risk.

Post partum, patient treatment is stopped and glucose checked prior to discharge to ensure a return to normal and a 6 week follow up OGTT is organised.

NB. GDM has a 50% risk of developed T2DM within 25y

24

A 43 year old woman is admitted acutely at 33/40. She describes heavy PV blood loss and lower abdominal pains for the last 2 hours. The placenta is not low lying and she is RhD positive. Examination reveals a firm tender abdomen with palpable contractions 3-4:10, a moderate amount of active bleeding through the (closed) cervical os, and no evidence of UGI tract bleeding. CTG monitoring reveals a sinusoidal foetal heart rate pattern for 30 minutes, with no accelerations. What is the most appropriate management.

a) Induction of labour with prostaglandin pessary
b) Steroid administation - 2 does 24 hours apart
c) Steroid administration - 2 does 24 hours apart with tocolytic cover
d) Tocolysis
e) Urgent delivery by C-section.

E

This women has had a significant APH, likely due to placental abruption.
A sinusoidal CTG pattern is associated with severe foetal anaemia and therefore indicative of severe foetal compromise.
Urgent delivery is indicated for foetal wellbeing, with induction of labour being far long a process to undertake with the suspicion of foetal compromise.
Prior to delivery a singly dose of beclamethasone may give some benefit to foetal respiratory function,however the indication is too urgent to allow a full course to be given.
Tocolysis is contraindicated in the presence of APH.

25

Recommended induction of labour protocols do not include:

a) Amniotomy alone
b) Amniotomy and oxytocin
c) Oxytocin alone
d) Prostaglandins
e) 2 prostaglandin doses 6hr apart

A

ARM alone is not recommended for induction of labour. It can be used later in labour to help progression.

ARM + oxytocin has been shown to decrease the interval between induction and delivery.

Oxytocin should be started at a low dose and increased to induce optimal contractions.

Prostaglandins should be used in conjunction with CTG to confirm foetal wellbeing and detect hyper stimulation. IF no effect noted at 6hrs on VE, another dose may be administered.

26

The 4 common causes of PPH include all except:

a) Tears
b) Thrombosis
c) Tissue
d) Tone
e) Underlying haemostasis defects.

B

4 common causes of PPH as 4 Ts

Tone - uterine atony where it fails to contract post-partum.
Trauma - include tears from vaginal delivery
Tissue - retained products.
Thrombin - underlying coagulation defects or acquired defects (drugs).

27

Which of the following is true with reference to PCOS?

a) An elevated LH:FSH ratio is needed for diagnosis.
b) It is related to type I DM
c) It can be diagnosed using the Rotterdam criteria
d) It is responsible for 50% of all cases of anovulatory sub fertility
e) USS evidence of polycystic ovaries is seen in 10% of women.

C

Rotterdram criteria requires the presence of 2 of the following in the absence of other disorders:
- irregular/absent ovulations (>42 day cycles)
- clinical/biochemical signs of hyperandrogenism
- polycystic ovaries on pelvic USS: >12 antral follicles on 1 ovary.
- Ovarian volume >10mls.

a - an elevated LH:FSH ratio is often seen but not needed for diagnosis.
b - related to T2DM
d - responsible for 80% of all cases of anovulatory sub fertility
e - USS evidence is seen in 20-30% of women.

28

Concerning cervical disorders, which of the following statements is true?

a) The most common histological subtype of cervical cancer is adenocarcinoma, which is derived from columnar epithelial cells.
b) The most common histological subtype of cervical cancer is adenocarcinoma, which is derived from squamous epithelial cells.
c) Smear tests are used to detect cervical intraepithelial neoplasia
d) All HPV subtypes cause cervical cancer
e) CIN has a characteristic white appearance when stained with 5% acetic acid (vinegar)

E

Acetic acid is used to visualise areas of CIN at colposcopy.

The most common histological subtype of cervical cancer is squamous cell carcinoma, which is derived from squamous epithelial cells.

Smear test are used to detect dyskariosis which is the cytological finding. CIN is a histological finding and therefore requires biopsy to look at the cellular architecture. CIN is grade I-III depending on what proportion of the epithelium is affected.

Of >40 genital mucosal HPV subtypes identified, approx 15 are known to be oncogenic.

29

Which of the following is not an ABSOLUTE contraindication to the combined OCP?

a) History of VTE in a 1st degree relative.
b) Smoker >35 yrs old and

a.

Absolute contraindication of COCP with regards to VTE are:
- Hx of DVT/PE, not on anticoagulation therapy and higher risk of recurrence
- Hx of oestrogen-associated DVT/PE
- Pregnancy-associated DVT/PE
- Idiopathic DVT/PE
- Known thrombophilia, including antiphospholipid syndrome
- active cancer (incl. within 6/12 of remission)
- active PE/DVT

30

Diagnostic criteria for anti-phospholipid syndrome

1 clinical feature
• ≥3 miscarriages
• mid-trimester fetal loss
• severe early-onset preeclampsia, IUGR or abruption
• A/V thrombosis

AND haematological feature
• 2 positive anticardiolipin Ab or lupus anticoagulant at least 6/52 apart.

31

Management of endometriosis

• Surgical
o Laparoscopic ablation or excision of endometriotic deposits
o Incision and drainage of cysts (‘chocolate cysts’)
• Medical
o COCP, GnRH analogues and IUS can limit endometriosis but ineffective vs endometriomas

32

A 42 year old woman and a 51 year old man have conceived their first child together with a gestation of 11 weeks. They are very concerned about the possibility of Down's syndrome. They would like a test that would give them the definitive diagnosis as to whether their baby has Down's syndrome, as they may consider terminating the pregnancy if an abnormality is found.

A amniocentesis
B CTG
C CVS
D FBS
E fetal echo
F fetal ECG
G fetal tissue sampling
H 1st trimester USS
I Nuchal translucency test
J 2nd trimester USS
K Serum 'triple test'
L Uterine artery Doppler USS

.

33

A 42 year old woman and a 51 year old man have conceived their first child together with a gestation of 11 weeks. They are very concerned about the possibility of Down's syndrome. They would like a test that would give them the definitive diagnosis as to whether their baby has Down's syndrome, as they may consider terminating the pregnancy if an abnormality is found.

A amniocentesis
B CTG
C CVS
D FBS
E fetal echo
F fetal ECG
G fetal tissue sampling
H 1st trimester USS
I Nuchal translucency test
J 2nd trimester USS
K Serum 'triple test'
L Uterine artery Doppler USS

Chorionic villus sampling.

CVS is a diagnostic test: it will give a definite answer rather than the 'risk' of a condition being present. A chorionic villus (placental) biopsy is taken either transabdominally or transcervically under US guidance, and the cells analysed.
It is performed between 11 and 14 weeks (which is why it is appropriate for the couple in this question) and therefore a decision regarding possible termination can be made as early as possible before a pregnancy becomes easily visible 'under the clothes'. It is not performed before 9-11 weeks, as there is a risk of foetal limb abnormalities.
The risk of miscarriage is around 2%. Results of CVS are ready in 48 hours. In a few cases, inconclusive results occur due to placental mosaicism; this would mean that amniocentesis would have to be performed later. There is also a possibility of maternal contamination, which would lead to false negative. Rhesus D-negative women must receive anti-D when undergoing CVS.

34

A 25 year old woman would like a non-invasive initial assessment for Down's syndrome and spina bifida. She is 16 weeks gestation.

A amniocentesis
B CTG
C CVS
D FBS
E fetal echo
F fetal ECG
G fetal tissue sampling
H 1st trimester USS
I Nuchal translucency test
J 2nd trimester USS
K Serum 'triple test'
L Uterine artery Doppler USS

.

35

A 25 year old woman would like a non-invasive initial assessment for Down's syndrome and spina bifida. She is 16 weeks gestation.

A amniocentesis
B CTG
C CVS
D FBS
E fetal echo
F fetal ECG
G fetal tissue sampling
H 1st trimester USS
I Nuchal translucency test
J 2nd trimester USS
K Serum 'triple test'
L Uterine artery Doppler USS

Serum 'triple test'

The triple test screens for Down's syndrome, and spina bifida. A number of serum markers are used in combination with the age of the mother and confirmed gestation of the pregnancy to give a 'risk' of Down's syndrome. The serum markers used are AFP, oestriol and BhCG, hence 'triple'. Triple testing is available from 14-20 weeks (optimal being 15-16) with results being ready in 2 weeks. A high BhCG, low AFP and low estriol are associated with Down's syndrome.
The false positive rate is around 5%. Increasing maternal age is the strongest risk factoring the incidence of Down's. A 'risk' of the foetus having Down's syndrome is presented to the parents with a counsellor present so that the appropriate course of action can be taken. A 'positive' result is said to be anything about a risk of 1 in 250. In these cases, amniocentesis or CVS is offered.
An incidental finding of raised AFP alone is associated with a break in the foetal skin, often indicating neural tube defects such as spina bifida and anencephaly. As there is a large overlap with the normal and abnormal levels of AFP, further testing (imaging) is needed to confirm a diagnosis of spina bifida.

36

On CTG tracing, a dip in the foetal heart rate of 20 bpm is seen. It starts at the same time as contractions and recovers to normal by the end of contraction.

A accelerations
B Baseline tachycardia
C early decelerations
D late decelerations
E normal baseline fetal heart rate
F normal variability
G pseudosinusoidal pattern
H reduced variability
I sinusoidal pattern
J sustained tachycardia
K variable decelerations

Early decelerations.

37

On CTG tracing, a dip in the foetal heart rate of 20 bpm is seen. It starts at the same time as contractions and recovers to normal by the end of contraction.

A accelerations
B Baseline tachycardia
C early decelerations
D late decelerations
E normal baseline fetal heart rate
F normal variability
G pseudosinusoidal pattern
H reduced variability
I sinusoidal pattern
J sustained tachycardia
K variable decelerations

Early decelerations.

38

This pattern is often seen in cord compression, particularly in oligohydramnios.

A accelerations
B Baseline tachycardia
C early decelerations
D late decelerations
E normal baseline fetal heart rate
F normal variability
G pseudosinusoidal pattern
H reduced variability
I sinusoidal pattern
J sustained tachycardia
K variable decelerations

Variable decelerations

39

On CTG tracing, a dip in the foetal heart rate of 20 bpm is seen. It starts at the same time as contractions and recovers to normal by the end of contraction.

A accelerations
B Baseline tachycardia
C early decelerations
D late decelerations
E normal baseline fetal heart rate
F normal variability
G pseudosinusoidal pattern
H reduced variability
I sinusoidal pattern
J sustained tachycardia
K variable decelerations

Early decelerations.

These occur with contractions and return to normal by the end of contraction. They are probably physiological and are thought to reflect increased vagal tone when foetal intracranial pressure increases during a contraction. They are uniform in depth, length and shape.

40

This pattern is often seen in cord compression, particularly in oligohydramnios.

A accelerations
B Baseline tachycardia
C early decelerations
D late decelerations
E normal baseline fetal heart rate
F normal variability
G pseudosinusoidal pattern
H reduced variability
I sinusoidal pattern
J sustained tachycardia
K variable decelerations

Variable decelerations

These vary in timing and shape in relation to uterine contraction. They suggest cord compression, especially in oligohydramnios. 'Shouldering' is a sign that the foetus is coping well with the compression: this is when there is a small acceleration before and after the decelerations. These may resolve if the mother's position is changed.

41

A 45 year old woman attends the GP with a persistent headache. She has recently finished a 10 year round-the-world expedition. On examination, you notice that her pupils are small, irregular and unequal in size. The light reflex is absent.

A bacterial vaginosis
B cervical Ca
C chancroid
D chlamydia
E EBV
F genital candidiasis
G genital herpes
H genital warts
I gonorrhoea
J granuloma inguinale (donovanosis)
K HIV
L Lymphogranuloma venereum
M molluscum contagiousum
N Phthiriasis
O Reiter's syndrome
P scabies
Q syphilis
R trichomoniasis

Syphilis

42

A 45 year old woman attends the GP with a persistent headache. She has recently finished a 10 year round-the-world expedition. On examination, you notice that her pupils are small, irregular and unequal in size. The light reflex is absent.

A bacterial vaginosis
B cervical Ca
C chancroid
D chlamydia
E EBV
F genital candidiasis
G genital herpes
H genital warts
I gonorrhoea
J granuloma inguinale (donovanosis)
K HIV
L Lymphogranuloma venereum
M molluscum contagiousum
N Phthiriasis
O Reiter's syndrome
P scabies
Q syphilis
R trichomoniasis

Syphilis

Syphilis is caused by Treponema pallidum and is spread by sexual contact (it is also acquired congenitally). There are many stages of syphilis infection.

Primary syphilis - this occurs 10-90 days post-infection. A dull red papule develops on the external genitalia and forms a single well-demarcated, painless ulcer associated with bilateral inguinal LN enlargement. This lesion heals within 8 weeks.

Secondary syphilis - this develops 7-10 weeks after primary infection and involves malaise, mild fever, headache, a pruritic skin rash, hoarseness, swollen LNs, pathcy or diffuse hair loss, bone pain and arthralgia.

Latent syphilis - here, there is no clinical evidence of disease, but it is till detectable by serological testing.

Gummatous syphilis - late stage of infection when the host resistance to the infection begins to fail. Areas of syphilitic granulation tissue develop on the scalp, upper aspect of the leg or sternoclavicular region. These so called 'gummatous' lesions are copper in colour. Granulaiton can also occur internally e.g. on heart valves and bone. At this stage, there is still a good response to treatment.

Neurosyphilis - this is where the disease is detectable in the CSF. Patients complain of headache, cranial nerve palsies, general paralysis of the insane (psychosis with muscular reflex abnormality, dementia and seizures), tabes dorsalis ( degeneration of the dorsal column of the spinal cord resulting in poor coordination), trophic ulcers, Charcot's joints, and Argyll Robertson pupils (bilateral small, irregular pupils that DO accommodate but DO NOT react to light).

43

Granuloma inguinale

Aka donovanosis. This is caused by Klebsiella granulomatis. A flat-topped papule develops on the genitalia days to months post-infection, and then degenerates into a painless ulcer. The ulcer spreads along skinfolds and heals with scarring.

44

A 45 year old woman attends the GP with a persistent headache. She has recently finished a 10 year round-the-world expedition. On examination, you notice that her pupils are small, irregular and unequal in size. The light reflex is absent.

A bacterial vaginosis
B cervical Ca
C chancroid
D chlamydia
E EBV
F genital candidiasis
G genital herpes
H genital warts
I gonorrhoea
J granuloma inguinale (donovanosis)
K HIV
L Lymphogranuloma venereum
M molluscum contagiousum
N Phthiriasis
O Reiter's syndrome
P scabies
Q syphilis
R trichomoniasis

Syphilis

Syphilis is caused by Treponema pallidum and is spread by sexual contact (it is also acquired congenitally). There are many stages of syphilis infection.

Primary syphilis - this occurs 10-90 days post-infection. A dull red papule develops on the external genitalia and forms a single well-demarcated, painless ulcer associated with bilateral inguinal LN enlargement. This lesion heals within 8 weeks.

Secondary syphilis - this develops 7-10 weeks after primary infection and involves malaise, mild fever, headache, a pruritic skin rash, hoarseness, swollen LNs, pathcy or diffuse hair loss, bone pain and arthralgia.

Latent syphilis - here, there is no clinical evidence of disease, but it is till detectable by serological testing.

Gummatous syphilis - late stage of infection when the host resistance to the infection begins to fail. Areas of syphilitic granulation tissue develop on the scalp, upper aspect of the leg or sternoclavicular region. These so called 'gummatous' lesions are copper in colour. Granulaiton can also occur internally e.g. on heart valves and bone. At this stage, there is still a good response to treatment.

Neurosyphilis - this is where the disease is detectable in the CSF. Patients complain of headache, cranial nerve palsies, general paralysis of the insane (psychosis with muscular reflex abnormality, dementia and seizures), tabes dorsalis ( degeneration of the dorsal column of the spinal cord resulting in poor coordination), trophic ulcers, Charcot's joints, and Argyll Robertson pupils (bilateral small, irregular pupils that DO accommodate but DO NOT react to light).

45

Phthiriasis

aka 'Crabs', pubic lice

These are caused by the crab-louse Phthirus pubis, which mainly lives in the thick hairs or the pubic and perianal areas. Most are transmitted by sexual contact, but any close contact with an infected person can transmit the crabs. Clinically, there is itching in the affected areas. The lice feed on blood and can leave spots on the skin (pediculosis pubis).

46

Lymphygranoloma venereum

LGV is an STI caused by serovars L1, L2 and L3 of Chlamydia trachomatis. It is mainly found in the tropics. Between 3-21 days after infection, 1/3 of people develop a small painless papule, which ulcerates and heals after days. The patients then develops lymphadenopathy, which is unilateral in 2/3 of cases. Inguinal abscesses (buboes) may form and develop a sinus. Acute ulcerative proctitis may develop when infection takes place via the rectal mucosa. Treatment is with appropriate antibiotics.

47

A 32 year old woman of 40+3 gestation attends the antenatal day unit with sudden-onset epigastric pain with nausea and vomiting. She is clinically jaundiced. Her biochemistry results show a raised bilirubin, abnormal liver enzymes, high uric acid and hypoglycaemia.

.

48

A 32 year old woman of 40+3 gestation attends the antenatal day unit with sudden-onset epigastric pain with nausea and vomiting. She is clinically jaundiced. Her biochemistry results show a raised bilirubin, abnormal liver enzymes, high uric acid and hypoglycaemia.

Acute fatty liver of pregnancy

This is rare and occurs in only 1 in 10,000-15,000 pregnancies in the 3rd trimester. It presents similarly to cholecystitis, with sudden onset epigastric abdo pain, anorexia, malaise, nausea, vomiting and diarrhoea, with the distinguishing features of jaundice, mild HTN, proteinuria and fulminant liver failure.
On biochemical testing, there is raised bilirubin with abnormal liver enzymes, leukocytosis, thrombocytopenia, hypoglycaemia and coagulation defects. Acute fatty liver of pregnancy is biochemically distinguisged from HELLP syndrome by the hypoglycaemia and high uric acid.
Diagnosis is clinical (CT or MRI may be useful), but a liver biopsy may be needed.
Managment is by correction of fluid balance, coagulation and electrolyte disturbance with hasty delivery. Women may need admission to a specialist liver unit or ICU.
Maternal mortality rate is 20%.

49

A 32 year old woman of 40+3 gestation attends the antenatal day unit with sudden-onset epigastric pain with nausea and vomiting. She is clinically jaundiced. Her biochemistry results show a raised bilirubin, abnormal liver enzymes, high uric acid and hypoglycaemia.

A acute fatty liver of pregnancy
B acute pyelonephritis
C Braxton-Hicks contractions
D cholecystitis
E chorioamnionitis
F HELLP syndrome
G labour
H obstetric cholestasis
I placental abruption
J Round ligament stretching
K symphysis pubis dysfunction
L UTI
M uterine rupture

Acute fatty liver of pregnancy

This is rare and occurs in only 1 in 10,000-15,000 pregnancies in the 3rd trimester. It presents similarly to cholecystitis, with sudden onset epigastric abdo pain, anorexia, malaise, nausea, vomiting and diarrhoea, with the distinguishing features of jaundice, mild HTN, proteinuria and fulminant liver failure.
On biochemical testing, there is raised bilirubin with abnormal liver enzymes, leukocytosis, thrombocytopenia, hypoglycaemia and coagulation defects. Acute fatty liver of pregnancy is biochemically distinguisged from HELLP syndrome by the hypoglycaemia and high uric acid.
Diagnosis is clinical (CT or MRI may be useful), but a liver biopsy may be needed.
Managment is by correction of fluid balance, coagulation and electrolyte disturbance with hasty delivery. Women may need admission to a specialist liver unit or ICU.
Maternal mortality rate is 20%.

50

On VE, the head is high. Anteriorly, the sagittal suture is palpable leading to the anterior fontanelle. The supraorbital ridges and bridge of the nose are also palpable.

A Brow
B Extended breech
C Face
D Flexed breech
E Footling breech
F Left OP
G Left OT
H OA
I OP

Brow

51

On VE, the head is high. Anteriorly, the sagittal suture is palpable leading to the anterior fontanelle. The supraorbital ridges and bridge of the nose are also palpable.

A Brow
B Extended breech
C Face
D Flexed breech
E Footling breech
F Left OP
G Left OT
H OA
I OP

Brow

52

On abdominal palpation, the lie feels longitudinal, although the back is not easily felt. The contour of the uterus is irregular. The head is 2/5 palpable and the fetal heart is difficult to locate. The anterior fontanelle is easily palpable on VE.

A Brow
B Extended breech
C Face
D Flexed breech
E Footling breech
F Left OP
G Left OT
H OA
I OP

OP

53

On VE, the head is high. Anteriorly, the sagittal suture is palpable leading to the anterior fontanelle. The supraorbital ridges and bridge of the nose are also palpable.

A Brow
B Extended breech
C Face
D Flexed breech
E Footling breech
F Left OP
G Left OT
H OA
I OP

Brow

This is the least common presentation, occurring in 1 in 2000 labours. For the brow to present, the neck is extended, which results in the largest diameter of the fetal head presenting. This is often too large to pass through the pelvis, and if it persists can cause delay in the 2nd stage of labour. Do not forget that the pelvic brim is widest in the transverse diameter, but the outlet is widest in the AP diameter, which requires the head to rotate.

54

A 51 year old woman presents to the GP with infrequent bleeding per vagina. ON further questioning, she admits to suffering from occasional hot flushes and night sweats. Her last menstrual period was 4 months ago.

A bisphosphonates
B Continuous combined HRT
C Cyclical combined HRT
D Not suitable for HRT
E Oestrogen cream/pessary
F Oestrogen-only HRT
G Specialist referral

Cyclical combined HRT

There are a huge number of HRT options available on the market. Overall, the minimum effective dose should be used for the shortest duration. For the purposes of treatment, women should be divided into those with a uterus and those who have had a hysterectomy.
In women with a uterus who have bled within the last year (perimenopausal), low dose cyclical combined HRT is recommended, which gives progesterone on the last 12/28 days. This results in post-progesterone withdrawal bleed, which protects the endometrium. Prolonged used of cylical HRT can increase the risk of endometrial Ca, so should be given for a maximum of 5 years. Higher doses are available for symptom control. Once the patient has been amenorrhoeic for 1 year or reaches the age 52 (whichever is sooner), she should be transferred to continuous combined therapy.

55

A B-agonist that is used to reduce uterine contractions.

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Ritodrine

56

A B-agonist that is used to reduce uterine contractions.

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Ritodrine

57

An oxytocin receptor antagonist licensed for tocolysis.

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Atosiban

58

A drug that is proven to reduce the risk of RDS following preterm labour

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Betamethasone

59

Clinical evidence recommends this to be used for infection prophylaxis in preterm rupture of membranes

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Erythromycin

60

Use of this drug in preterm labour is associated with NEC

Co-amoxiclav

61

A B-agonist that is used to reduce uterine contractions.

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Ritodrine

Tocolytics act by inhibiting smooth muscle contraction in the uterus in an attempt to delay labour. They must be used with caution in ruptured membranes. A variety of drugs has been used in clinical trials. Cases most likely to benefit are those that are very preterm, those requiring time for transfer to specialist units and those requiring time for corticosteroids. There is as yet no proven significant benefit of tocolytics on perinatal mortality.

62

An oxytocin receptor antagonist licensed for tocolysis.

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Atosiban

Atosiban is an oxytocin inhibitor that has been found to have some benefit in reducing delivery within a 48 hour period, and has a preferable side effect profile compared with ritodrine.

Nifedipine, a CCB that is often used as a tocolytic is easier and cheaper to administer that atosiban. It is, however, not yet licensed for use in the UK. Other tocolytics include MgSO4 and indometacin. Relative contraindications to tocolysis include rupture of membranes, fetal distress and intrauterine infection.

63

A drug that is proven to reduce the risk of RDS following preterm labour

A Atosiban
B Betamethasone
C Co-amoxiclav
D Erythromycin
E Gentamicin
F Indometacin
G Nifedipine
H Ritodrine

Betamethasone

Corticosteroids, such as betamethasone and dexamethasone, are indicated between 24-34 weeks' gestation in preterm labour in the absence of infection to promote pulmonary maturity and stimulate surfactant production. They have been proven to reduce the incidence of RDS, intraventricular haemhorrage and NEC in the premature infant. One commonly used dosing regimen is 2 IM injections of betamethasone 12 mg given 12h apart. The steroids take 24h to become effective. Delivery may then be delayed, by tocolysis, if necessary, to occur after 24h and within 7 days of treatment.

64

Use of this drug in preterm labour is associated with NEC

Co-amoxiclav

Antibiotics are indicated for infection prophylaxis in preterm rupture of membranes. Erythromycin is the antbiotic of choice following the diagnosis of PPROM. If GBS positive, penicllin is given in addition.

Co-amoxiclav is not recommended, as it has been associated with an increased incidence of fetal NEC.

65

Indications for a planned C-section

1. Singleton breech at term, after ECV has failed or contraindicated.
2. Twin pregnancy where the 1st baby is breech.

3. Placenta praevia

4. Maternal infection.
- maternal HIV not on HAART or with viral load >400 copies/ml
- primary genital HSV in 3rd trimester.

66

A sinusoidal trace on CTG

A smooth undulating sine-wave like baseline with no variability. The pattern lasts over 10 minutes with an amplitude of 5-15 bpm.

A sinusoidal pattern may be physiological or can represent fetal anaemia/hypoxia, but MUST be considered serious until proven otherwise.

Sinusoidal patterns should be distinguished from pseudosinusoidal traces which are a benign, uniformed, long-term pattern. They are less regular shape and amplitude when compared to sinusoidal traces.

67

Which one of the following factors increases your risk of developing ovarian cancer?

A early menopause
B late menarche
C multiparity
D nulliparity
E OCP

Nulliparity

Ovarian Ca is the most common gyne Ca in the UK and the 5th most common cancer in the UK overall, and the incidence is rising. It is seen mainly in the 5th-7th decades. It has a poor 5 year survival rate of only 25%. There is no pre-malignant phase so no screening test can be developed.

The more you ovulate the more you increase your risk of developing ovarian cancer. This is due to the repair of the ovarian epithelium required following each ovulation. Hence nulliparity, infertility, early menarche and late menopause increase your risk.
Whereas risk is lowered by the OCP, breastfeeding and pregnancy. Pelvic surgery decreases risk for reasons that are not fully understood.

The risk of ovarian cancer is slightly increased with a positive family history and this much more significant if there was early onset and more than 1 primary relative affected. Around 5-10% of ovarian cancers have a direct genetic link with the most significant being BRCA1 and BRCA2. Affected women have a liftetime risk of upto 50% of developing ovarian cancer, hence close monitoring is needed using CA125 and pelvic USS. Furthermore, a prophylactic bilateral oophorectomy may be considered by some once hte family is complete. Other linked cancers are breast, endometrial and colonic.

68

A 31 year old pregnant woman was involved in a minor RTA where she banged her abdomen on the steering wheel. Serious injury has been excluded but she is concerned about the baby. She has good fetal movements and has had no bleeding per vagina. The fetal heart is heard and is regular. She s 25 week gestation and is RhD negative. She has had no previous children.

A) Give antenatal anti-D prophylaxis 250iu
B) Give antenatal anti-D prophylaxis 500iu
C) Give postnatal anti-D
D) Give routine antenatal anti-D prophylaxis at 28 weeks
E) No action needed at present.

Give antenatal anti-D prophylaxis 500 iu

All women who are RhD negative are offered anti-D prophylaxis 500iu at 28 and 34 weeks regardless of sensitising events or previous administration of anti-D.

RhD -ve women are offered antenatal anti-D prophylaxis at the time of a possible sensitising event where fetal blood could enter the maternal circulation such as APH, closed abdominal injury, ECV, invasive prenatal diagnosis (amniocentesis, CVS, FBS), other intrauterine procedures (insertion of shunts, embryo reduction) or intrauterine death. The dose is 250iu before 20 weeks and 500 iu after 20 weeks gestation.

Postnatally, if an RhD -ve women has given birth to an RhD +ve baby, 500 iu anti-D prophylaxis should be offered. The anti-D Ig is given IM ASAP and ideally within 72h of the sensitising event, however, there is evidence that it still provides some protection if given within 10 days.

69

You examine a lady who has attended a labour ward for induction of labour at term +12 days. She has cephalic presentation with is 3/5 palpable. The cervix is not dilated at all, is 3cm long, of average consistence and is in a mid-position. The station is -2.

What is her Bishop score?

A 0
B 2
C 4
D 6
E 8

4

70

You examine a lady who has attended a labour ward for induction of labour at term +12 days. She has cephalic presentation with is 3/5 palpable. The cervix is not dilated at all, is 3cm long, of average consistence and is in a mid-position. The station is -2.

What is her Bishop score?

A 0
B 2
C 4
D 6
E 8

4

Dilation: 4 (3)
Consistency: Firm (0), Average (1), Soft (2)
Length: >4 (0), 2-4 (1), 1-2 (2), 9 labour is likely to progress

71

You examine a lady who has attended a labour ward for induction of labour at term +12 days. She has cephalic presentation with is 3/5 palpable. The cervix is not dilated at all, is 3cm long, of average consistence and is in a mid-position. The station is -2.

What is her Bishop score?

A 0
B 2
C 4
D 6
E 8

4

Dilation: 4 (3)

Consistency: Firm (0), Average (1), Soft (2)

Length: >4 (0), 2-4 (1), 1-2 (2), 9 labour is likely to progress.

72

A 23 year old woman with a positive pregnancy test complains of lower abdo cramping with what she describes as a period-type bleed at home. On abdominal palpation there is mild suprapubic discomfort. On speculum examination a small amount of blood is seen in the vagina and the cervical os is closed. Urine dipstick is unremarkable.

A Complete miscarriage
B Incomplete miscarriage
C Inevitable miscarriage
D Menstruation
E Threatened miscarriage

Threatened miscarriage

This scenario describes threatened miscarriage. There can be cramping lower abdo pain with vaginal bleeding. O/E the cervical is is closed. Only 25% of threatened miscarriages eventually miscarry. A scan should be arranged to investigate the bleeding and to confirm the viability of the pregnancy. This can be done in an EPAU.

An inevitable miscarriage will present with an open os. The fetus may still be aline but the miscarriage will occur due to dilation of the cervical os. An incomplete miscarriage is where some of the fetal material has been passed but some products of conception are retained in the uterus (visible on USS), the cervical os remains open until all products have passed (often with significant bleeding).
Complete miscarriage will have a closed os having passed all fetal tissue. Missed miscarriage is where the fetus dies in utero and the cervix stays closed and is only discovered on USS. There may or may not be bleeding.

73

A 42 year old woman was seen by the GP after she complained of fatigue, weight loss and more recently a change in bowel habit. O/E her abdomen was distended and the doctor elicited a positive fluid thrill test. She was urgently referred to the bowel surgeons; however, on CT bilateral ovarian cysts were seen. After referral to the gyne oncologists she had an operation and the histological findings were of psammoma bodies. Her diagnosis is the most common ovarian carcinoma.

A Clear cell tumour
B Endometrioid tumour
C Mucinous tumour
D Serous tumour
E Urothelial-like carcinoma

Serous tumour

74

A 42 year old woman was seen by the GP after she complained of fatigue, weight loss and more recently a change in bowel habit. O/E her abdomen was distended and the doctor elicited a positive fluid thrill test. She was urgently referred to the bowel surgeons; however, on CT bilateral ovarian cysts were seen. After referral to the gyne oncologists she had an operation and the histological findings were of psammoma bodies. Her diagnosis is the most common ovarian carcinoma.

A Clear cell tumour
B Endometrioid tumour
C Mucinous tumour
D Serous tumour
E Urothelial-like carcinoma

Serous tumour

Epithelial tumours are the most common of the ovarian tumours and are divided into serous, mucinous, endometrioid, clear cell and urothelial-like (Brenner) tumours.

Serous tumours comprise approx half of all ovarian Ca and are the most common ovarian neoplasm. They occur mainly in women of reproductive age. The benign form - serous cystadenomas - consts of unilocular cysts of variable sizes filled with straw-coloured fluid and 20% are bilateral. The malignant type - serous cystadenocarcinomas - consists of mixed solid areas with unilocular cysts. Histological findings are psammoma bodies which are concentric laminated calcified concretions. They are bilateral in 30-50% cases.

75

Most common cause of PPH

Atonic uterus

Accounts for 90% primary PPH

76

A 30 year old primigravid woman who is 34 weeks pregnant attends the antenatal clinic. She has persistent hypertension of 164/112 and some protein in her urine on dipstick. She has no visual disturbances, no epigastric pain and complains of mild headaches which are generally relieved by paracetamol. O/E her abdomen is soft and non-tender, she has mild pedal oedema, normal reflexes and one beat of clonus. Her bloods are all normal. She has asthma for which she uses a salbutamol inhaler when required.

Which antihypertensive?

A Furosemide
B Labetalol
C MgSO4
D Nifedipine
E Ramipril

Nifedipine

This lady has pre-eclampsia. Nifedipine is given orally. It is a CCB and vasodilator. SFx include flushing, headache and ankle swelling. This is the most suitable drug in this case.

Labetalol is the first drug of choice in pre-eclampsia it is not suitable in this case due to the history of asthma. Atenolol should be avoided due to the associated with fetal growth restriction.

Methyldopa is a good first line medication for essential HTN in pregnancy but is not used in pre-eclampsia as it is slow to act and may take several days to decrease the BP.

77

A 31 year old pregnant woman was involved in a minor RTA where she banged her abdomen on the steering wheel. Serious injury has been excluded but she is concerned about the baby. She has good fetal movements and has had no bleeding per vagina. The fetal heart is heard and is regular. She s 25 week gestation and is RhD negative. She has had no previous children.

A) Give antenatal anti-D prophylaxis 250iu
B) Give antenatal anti-D prophylaxis 500iu
C) Give postnatal anti-D
D) Give routine antenatal anti-D prophylaxis at 28 weeks
E) No action needed at present.

Give antenatal anti-D prophylaxis 500 iu

All women who are RhD negative are offered anti-D prophylaxis 500iu at 28 and 34 weeks regardless of sensitising events or previous administration of anti-D.

RhD -ve women are offered antenatal anti-D prophylaxis at the time of a possible sensitising event where fetal blood could enter the maternal circulation such as APH, closed abdominal injury, ECV, invasive prenatal diagnosis (amniocentesis, CVS, FBS), other intrauterine procedures (insertion of shunts, embryo reduction) or intrauterine death. The dose is 250iu before 20 weeks and 500 iu after 20 weeks gestation.

Postnatally, if an RhD -ve women has given birth to an RhD +ve baby, 500 iu anti-D prophylaxis should be offered. The anti-D Ig is given IM ASAP and ideally within 72h of the sensitising event, however, there is evidence that it still provides some protection if given within 10 days.

78

A 32 year pregnant woman attends the ED with history of PV bleeding. She says the bleeding is lighter than her normal period and has lasted for 2 days. She is 9 week gestation and this is her first pregnancy. She says she knows she is RhD negative as she gives blood regularly.

A) Give antenatal anti-D prophylaxis 250iu
B) Give antenatal anti-D prophylaxis 500iu
C) Give postnatal anti-D
D) Give routine antenatal anti-D prophylaxis at 28 weeks
E) No action needed at present.

No action needed at present.

79

A 29 year old woman who is 38+3 attends the antenatal clinic after being referred by the midwife smaller than her dates. The baby is on the 25th centrile for all measurements and there is a normal liquor volume. The placental site is fundal.

What emergency does this make her more risk of when she is in labour?

A Cord prolapse
B Fetal distress
C Stillbirth
D Uterine inversion
E Uterine rupture

Uterine inversion

80

A 32 year pregnant woman attends the ED with history of PV bleeding. She says the bleeding is lighter than her normal period and has lasted for 2 days. She is 9 week gestation and this is her first pregnancy. She says she knows she is RhD negative as she gives blood regularly.

A) Give antenatal anti-D prophylaxis 250iu
B) Give antenatal anti-D prophylaxis 500iu
C) Give postnatal anti-D
D) Give routine antenatal anti-D prophylaxis at 28 weeks
E) No action needed at present.

No action needed at present.

It sounds like this woman has had a threatened miscarriage. Only those women with PV bleeding after 12 weeks gestation require anti-D. As long as the bleeding is not heavy this woman could be sent home after arranging a pelvic scan to assess the bleeding and viability of the pregnancy.

The 12 week rule applies to all miscarriage unless uterine evacuation is required.

All unsensitised women who receive TOPs and ectopic pregnancies should receive anti-D prophylaxis regardless of gestational age/

81

A 29 year old woman who is 38+3 attends the antenatal clinic after being referred by the midwife smaller than her dates. The baby is on the 25th centrile for all measurements and there is a normal liquor volume. The placental site is fundal.

What emergency does this make her more risk of when she is in labour?

A Cord prolapse
B Fetal distress
C Stillbirth
D Uterine inversion
E Uterine rupture

Uterine inversion

A fundal placenta means there is an increased risk of uterine inversion, so it is particularly important not to attempt to remove the placenta before signs of placental separation have been seen (cord lengthening and a gush of dark blood). It is also important to only use CCT with counter-pressure on the uterus above the suprapubic region.

Other risk factors for uterine inversion are atony and previous uterine inversion.

82

A woman is in early labour. The CTG has been reactive with a baseline rate of 140, multiple accelerations, no decelerations and variability of 15-20. The trace 30 minutes later shows a baseline rate of 135, with no accelerations or decelerations and a variability of 5-7 beats.

A Maternal pyrexia
B Normal trace
C Pre-terminal trace
D Sleep pattern of foetus
E Thumb sucking of fetus

Sleep pattern of foetus.

83

Which of the following movement occurs during crowning of the head during labour?

A Effacement
B Extension
C External rotation
D Flexion
E Internal rotation

..

84

Which of the following movement occurs during crowning of the head during labour?

A Effacement
B Extension
C External rotation
D Flexion
E Internal rotation

Extension

85

A 28 year old woman attends labour ward for induction of labour at term + 12. She has some contraction pains but these are mild and she is not troubled by them. She has had an uncomplicated pregnancy and had 2 previous normal deliveries both of which needed inducing due to post-maturity. The CTG is normal. A scan is done which shows a transverse lie of the foetus. The cervix is 3cm dilated.

Next course of action?

A) ARM
B Emergency C-section
C Oxytocin
D Prostaglandin
E Semi-elective Caesarean section

Semi elective Caesarean section

This lady would not be suitable for a normal delivery as the baby is in a transverse position. She would therefore need a semi-elective C-section which would be classified as grade 3 on the RCOG guidelines.

Urgency of C-section is indicated as follows:
Grade 1 - immediate threat to life of the woman of foetus
Grade 2 - maternal or fetal compromise which is not immediately life-threatening.
Grade 3 - no maternal or foetal compromise but needs early delivery
Grade 4 - delivery timed to suit woman or staff.

This would not be a true Grade 4 as she has started to contract and the cervix is starting to dilate. It would not be grade 1 or 2 as there is no foetal or maternal compromise.

86

How long does it take for a single sperm to be created from start to finish?

A 12 hours
B 64 hours
C 12 days
D 64 days
E Varies from 12hours to 12 days

64 days

Spermatogenesis takes place when the adult male reaches puberty and occurs under the influence of testosterone. The whole process of spermatogenesis takes 64 days.
Primordial germ cells divide by mitosis and differentiate into spermatogonia, which lie immediately beneath the basement membrane of the seminiferous tubules.
As spermatogenesis progresses, the germ cells move from the basement membrane into the lumen of the of the seminiferous tubules.
Spermatogonia divide by mitosis and differentiate into primary spermatocytes.
Primary spermatocytes contain 46 double-structured chromosomes. These divide by meiosis. The primary spermatocytes intitially complete the first meiotic division to give secondary spermatocytes. Secondary spermatocytes therefore contain 23 double-structured chromosomes which complete second meiotic division to become spermatids.
Spermatids undergo spermiogenesis to give spermatozoa.

87

A 31 year old woman attends the GUM clinic saying she had unprotected sex with a new partner 3 weeks ago. She reports seeing a dull red spot on her labia which has now turned into a single, painless, well demarcated ulcer. she is otherwise well.

A Chancroid
B Granuloma inguinale
C HSV
D Lymphogranuloma venereum
E Syphilis

Syphilis

Treponema pallidum, which is spread by sex, is responsible for syphilis. Primary syphilis occurs 10-90 days after initial infection when a dull red papule appears on the site of inoculation. It ulcerates to give a single, painless well-demarcated ulcer known as a chancre (NOT chancroid). This heals to leave a thin scar within 8 weeks. Diagnosis is by dark field microscopy from the serum at the base of the chancre or direct immunofluorescence and serology. The patient can go on to develop secondary, latent, gummatous and neurosyphilis. Treatment is with penicillin.

Chancroid is caused by the Gram negative bacterium Haemophiuls ducreyi, and is found mostly in tropical countries. It is an ulcerative condition of the genitalia (single/multiple painful superficial ulcers) which develop within a week of exposure. Inflammation can leads to phimosis.

88

A 31 year old woman attends the GUM clinic saying she had unprotected sex with a new partner 3 weeks ago. She reports seeing a dull red spot on her labia which has now turned into a single, painless, well demarcated ulcer. she is otherwise well.

A Chancroid
B Granuloma inguinale
C HSV
D Lymphogranuloma venereum
E Syphilis

Syphilis

Treponema pallidum, which is spread by sex, is responsible for syphilis. Primary syphilis occurs 10-90 days after initial infection when a dull red papule appears on the site of inoculation. It ulcerates to give a single, painless well-demarcated ulcer known as a chancre (NOT chancroid). This heals to leave a thin scar within 8 weeks. Diagnosis is by dark field microscopy from the serum at the base of the chancre or direct immunofluorescence and serology. The patient can go on to develop secondary, latent, gummatous and neurosyphilis. Treatment is with penicillin.

Chancroid is caused by the Gram negative bacterium Haemophiuls ducreyi, and is found mostly in tropical countries. It is an ulcerative condition of the genitalia (single/multiple painful superficial ulcers) which develop within a week of exposure. Inflammation can leads to phimosis. Enlargement and suppuration of inguinal LNs may occur leading to a unilocular abscess (bubo) that can rupture to form a sinus. Diagnosis is by microscopy and culture. Treatment is with appropriate antibiotics.

Lymphogranuloma venereum = Chlamydia trachomatis manifestation.

Granuloma inguinale = Klebsiella granulomatis

89

Asthenospermia

Poor motility sperm, i.e. lack normal forward movement

90

Azoospermia

Complete absence of sperm such as testicular failure

91

Oligospermia

Reduced sperm count of normal appearance

92

Teratospermia

Morphologically defective, with abnormalities of head, mid piece or tail.

93

Leucospermia

Infection

Leucospermia and anti-sperm Abs can both be associated with agglutination and can affect sperm function.

94

Which of the following is the most common cause of secondary postpartum haemorrhage?

A Atonic uterus
B DIC
C Infection
D Perineal trauma
E Retained placental fragments

Infection

Infection is the most common cause of secondary PPH and can be due to retained products of conception such as placenta. The woman may complain of malodorous prolonged PV bleeding associated with fever and sweating. Examination reveals tenderness in the lower abdomen. A specula examination should be performed

95

Which of the following is the most common cause of secondary postpartum haemorrhage?

A Atonic uterus
B DIC
C Infection
D Perineal trauma
E Retained placental fragments

Infection

Infection is the most common cause of secondary PPH and can be due to retained products of conception such as placenta. The woman may complain of malodorous prolonged PV bleeding associated with fever and sweating. Examination reveals tenderness in the lower abdomen. A speculum examination should be performed and HVS taken. A full blood count is taken to look for anaemia and infection. Antibiotics (e.g. cefuroxime and metronidazole) are first line. f this does not settle the bleeding an USS can be done to rule out retained products of conception which may require surgical evacuation.

96

A 38 year old woman is asking about the COCP. She used to be on it prior to having a family is hoping to return to using it for contraception. She suffers from hypertension for which she takes ramipril. Her BMI is 28 and she is currently trying to lose weight.

Can you safely prescribe the COCP?

A No - combination of age and HTN
B No - combination of BMI and HTN
C No - high BMI alone
D No - taking ramipril alone
E Yes

No - combination of age and HTN

The combination fof age >35 and HTN is considered too much of a risk of arterial disease to safely prescribe the COCP.

97

A 16 year old girl attends her GP with complaints of heavy and painful periods. She is normally fit and well and is not sexually active. She needs first-line treatment for these complaints?

Most appropriate?

A Antifibrinolytics
B COCP
C GnRH analogues
D IUS
E Prostaglandin inhibitors

Prostaglandin inhibitors

This girl is suffering from menorrhagia and primary dysmenorrhea. The first line treatment is with NSAIDs e.g. mefenamic acid or ibuprofen. NSAIDs act as prostaglandin synthesis inhibitor to reduce pain and also reduce blood loss by unto 25%.

98

Which hormone promotes proliferation of glandular and stream elements of the endometrium?

A Activin
B FSH
C LH
D Oestradiol
E Progesterone

Oestradiol

99

Which hormone promotes proliferation of glandular and stream elements of the endometrium?

A Activin
B FSH
C LH
D Oestradiol
E Progesterone

Oestradiol

This is a steroid hormones and is mainly secreted by the ovary. Levels of oestrogen and progesterone are low during the initial stages of the follicular phase due to regression of the corpus luteum from the previous cycle.

The latter half of the follicular phase of menstrual cycle correlates to the proliferative phase of the endometrium. The high concentration of oestrogen seen at this time promotes rapid regeneration of the endometrium that has been shed during the recent menses. It stimulates proliferation of glandular and tremble elements of the endometrium to give tubular glands arranged in a regular pattern, parallel to each other with little section.

100

A 27 year old woman has an early pregnancy TVUS which shows an empty uterus with a BhCG result of 2365iu. She has no pain and is otherwise fit and well.

Most likely diagnosis?

A Early intrauterine pregnancy
B Ectopic pregnancy
C Inevitable miscarriage
D Missed miscarriage
E Threatened miscarriage

Ectopic

The most likely diagnosis is an ectopic pregnancy despite the patient having no pain, as with a BhCH result of 2365u a gestational sac should have been visualised if it were intrauterine. A laparascopy should be considered to look for an ectopic foetus. If the result of the BhCG had been lower than 1000iu and no gestational sac had been seen, the BhCG should be rechecked in 48 hours to assess whether it was doubling, reaching a plateau or falling.

101

What are the 3 main long term complications of pelvic inflammatory disease?

Chronic pelvic pain
Infertility
Ectopic pregnancy

102

What medication is useful in managing PCOS?

Cyproterone acetate containing COCP.

Cyproterone acetate is an anti-androgen with progestognenic activity.