O&G

Question 1

What does a CTG measure and how?

Answer 1

• Foetal HR using ultrasound

- Uterine contractions by measuring the tension of the maternal abdominal wall

Question 2

CTG mnemonic - DR C BRAVADO

Answer 2

DR – Determine Risk
C – Contractions
BR – Baseline rate
A – Accelerations
V – Variability
D – Decelerations 
O – Overall assessment

Question 3

Why is an abnormal antenatal CTG more worrying than an abnormal labour CTG?

Answer 3

In the antenatal period, the baby is not in a stressful situation, so abnormality will indicate that it is compromised for other reasons

(however, abnormal labouring CTG also needs action)

Question 4

Why is interpretation of CTG important?

Answer 4

Misinterpretation of the CTG can lead to hypoxia and irreversible brain damage

Question 5

CTG - Define Risk

Answer 5

Pregnancies can be considered high risk due to:

1. Maternal illness – gestational diabetes, hypertension, asthma
2. Obstetric Complications – multiple gestation, post-date gestation, Previous CS, IUGR, PROM, congenital malformations, oxytocin induction/augmentation of labour, pre-eclampsia.
3. Other risk factors – absence of prenatal care, smoking, drug abuse.

Question 6

CTG - Contractions

Answer 6

Record the number of contractions present in a 10-minute period

Assess contractions for the following:

1. Duration: How long do the contractions last?
2. Intensity: How strong are the contractions (assessed using palpation)?

Question 7

CTG - Baseline Rate

Answer 7

= the mean level of the FHR when this is stable

Normal range = 110 – 160 bpm

Gestational appropriateness – the baseline rate lowers as foetal age advances and the nervous system matures.

Identify foetal tachycardia or bradycardia

Question 8

What is considered foetal tachycardia?

What are the causes?

Answer 8

= a baseline heart rate greater than 160 bpm

Causes of foetal tachycardia include:
•	Maternal tachycardia, dehydration and pyrexia – always suspect intrauterine infection.
•	Foetal hypoxia
•	Chorioamnionitis
•	Hyperthyroidism
•	Foetal or maternal anaemia
•	Foetal tachyarrhythmia

Question 9

What is considered foetal bradycardia?

When is this normal?

What are more worrying causes?

Answer 9

= a baseline heart rate of less than 110 bpm

It is common to have a baseline heart rate of between 100-120 bpm in the following situations:

• Postdate gestation
• Occiput posterior or transverse presentations

Severe prolonged bradycardia (more than 3 minutes) indicates severe hypoxia.

Causes of prolonged severe bradycardia include:

• Prolonged cord compression
• Cord prolapse
• Epidural and spinal anaesthesia
• Maternal seizures
• Rapid foetal descent

Question 10

What should be done if severe foetal bradycardia >3 mins?

Answer 10

emergency buzzer, requires immediate actions and preparation for delivery to prevent irreversible damage from hypoxia.

Question 11

CTG - accelerations

Answer 11

An abrupt baseline rate increase of 15 beats or more, for 15 secs or more

The presence of 2 or more in a 20-minute period is reassuring

Accelerations occurring alongside uterine contractions is a sign of a healthy foetus.

Accelerations are absent when foetus is sleeping, in chronic hypoxia, drugs and infection

Question 12

CTG - variations

Answer 12

Bandwidth variation of the baselines – excluding accelerations and decelerations

• Normal – 5-25 bpm (reassuring)
• Reduced – <5 bpm (non-reassuring)
• Saltatory (Increased) – >25 bpm – (non-reassuring)

Question 13

Causes of reduced variability on CTG

Answer 13

• Foetal sleeping (most common cause) – this should last no longer than 40 minutes
• Foetal acidosis (due to hypoxia) – more likely if late decelerations are also present
• Foetal tachycardia
• Drugs – opiates, benzodiazepines, methyldopa and magnesium sulphate
• Prematurity – variability is reduced at earlier gestation (<28 weeks)
• Congenital heart abnormalities

Question 14

CTG - decelerations

Answer 14

= an abrupt decrease in the baseline foetal heart rate of greater than 15 bpm for greater than 15 seconds

Can be classified as early, variable or late

Question 15

Early decelerations on CTG

Answer 15

“Baroreceptor Decelerations”

Start when the uterine contraction begins and recover when uterine contraction stops.

Due to increased foetal intracranial pressure causing increased vagal tone.

These are PHYSIOLOGICAL, not pathological.

Question 16

Variable decelerations on CTG

Answer 16

= fall in baseline FHR with a variable recovery phase

Variable in their duration and may not have any relationship to uterine contractions

Most often seen during labour and in patients with reduced amniotic fluid volume

Usually caused by umbilical cord compression

Any accelerations before and after a variable deceleration are known as the SHOULDERS of deceleration.
=> Their presence indicates the foetus is not yet hypoxic and is adapting to the reduced blood flow

Question 17

Late decelerations on CTG

Answer 17

“Chemoreceptor Decelerations”

Begin at the peak of the uterine contraction and recover after the contraction ends.

Indicates there is insufficient blood flow to the uterus and placenta – causing foetal hypoxia and acidosis.

Question 18

When is a deceleration of FHR considered prolonged?

Answer 18

= a deceleration that lasts more than 2 minutes.

If it lasts between 2-3 minutes, it is classed as non-reassuring.

If it lasts longer than 3 minutes, it is immediately classed as abnormal

Question 19

Sinusoidal CTG pattern

Answer 19

smooth, regular, wave-like pattern

rare, but very concerning

associated with high rates of foetal morbidity and mortality

usually indicates one or more of the following:

• Severe foetal hypoxia
• Severe foetal anaemia
• Foetal/maternal haemorrhage

Question 20

CTG - Overall impression

Answer 20

is the overall impression either reassuring, suspicious or abnormal?

Question 21

What generates the CTG FHR features

Answer 21

1. Autonomic Nervous System – involuntary
   - Generates a baseline
   - Interplay between sympathetic and parasympathetic nervous systems generates variability.
2. Somatic Nervous System – voluntary
   - Transient activity causes changes to HR
   - Generates accelerations.

Question 22

Decelerations in antenatal CTG

Answer 22

reflect hypoxic insult – always abnormal in antenatal CTG

• Poor placental perfusion
• Maternal complications
• Acute events – abruption/cord prolapse

Question 23

What is the rough total weight gained in pregnancy?

Answer 23

= ~12 kg.

Most of this in the last 20 weeks

Question 24

What contributes to weight gain in pregnancy?

Answer 24

• Foetus ~3.5kg,
• Placenta ~600g,
• Uterus ~900g,
• Breasts ~400g,
• Blood ~1.2kg,
• Fat ~2.5kg,
• Extracellular fluid ~2.6kg

Question 25

Physiological changes in pregnancy - the uterus

Answer 25

Undergoes Hypertrophy and Hyperplasia => 50 Grams to 950 Grams Distension after 20th week => Leaves pelvis and enters abdominal cavity. => Abdominal content is displaced => After 38th week fundus descends to prepare for delivery. Vessels undergo Hypertrophy and coiling

Question 26

Physiological changes in pregnancy - cervix and vagina

Answer 26

Softening of cervix Cervical mucous plug => Acts as a “seal” for the uterus – protect from ascending infection Vagina: - Mucosa thickens - Increased vaginal discharge - Increased blood supply - Becomes more elastic in 2nd trimester Increased infections – e.g. Candidiasis

Question 27

Physiological changes in pregnancy - CV changes

Answer 27

Increased blood volume Physiological anaemia – RBCs diluted due to the increase in plasma volume (no change in MCV) Heart rate increases (normally not beyond 100bpm) Increased cardiac output = increased HR x increased SV Decrease in Systemic Vascular Resistance - Vasodilatory effect of progesterone - 10-15mmHg decrease in both SBP and DBP initially - Tends to return to baseline in the 2nd half of pregnancy

Question 28

What % increase in maternal blood volume is there when pregnancy reaches term?

Answer 28

~45-50% increase at term | Plasma increase of 50% and RBC 30%

Question 29

How much as cardiac output increased by the time a pregnancy reaches term?

Answer 29

CO = 30-50% above baseline by term

Question 30

Normal CVS Signs in Pregnancy

Answer 30

``` Tachycardia, collapsing pulse Distended neck veins, JVP is normal Oedema Displaced, diffuse apex beat Loud S1 and S3 Systolic ejection murmurs Ectopics (Atrial and Ventricular) ```

Question 31

Abnormal CVS Signs in Pregnancy

Answer 31

``` Apex displaced by 2 cm Diastolic murmurs Pan-systolic murmurs Ejection systolic murmurs that are grade 2/6 or greater Raised JVP ```

Question 32

Physiological changes in pregnancy - haematological changes

Answer 32

Mild pro-thrombotic state created – less chance of bleeding during birth, but increased chance of VTE

Question 33

Physiological changes in pregnancy - respiratory changes

Answer 33

Increased AP and transverse diameters of thoracic cage Upward displaced diaphragm (due to enlarging uterus) Progesterone causes bronchodilation Increased oxygen demand (due to increased maternal metabolism and foetal demands) Decrease in: - Residual Volume - Total lung capacity Increase in: - RR (by 1-2 breaths, tachypnoea is a red flag in pregnancy) - Tidal Volume Slight decrease in PaCO2, increase in PaO2, slight change in pH (respiratory alkalosis)

Question 34

Why is there a change in PaCO2/PaO2 in pregnancy?

Answer 34

This facilitates the transfer of oxygen from mother to foetus and the transfers of carbon dioxide from foetus to mother.

Question 35

Physiological changes in pregnancy - renal changes

Answer 35

Increased renal blood flow by 75% Increased GFR Physiological hydronephrosis and hydroureteronephrosis => Predisposes to infection Physiological proteinuria and oedema Renin, EP and 1,25 DHCC increase In the third trimester when the foetus starts to engage in the pelvis, there is an increased frequency of urination and there can be incontinence.

Question 36

What happens as a result of increased glomerular filtration which occurs in pregnancy?

Answer 36

=> Increased creatinine clearance, protein/albumin excretion, and urinary glucose excretion => Serum creatinine and albumin levels fall => Proteinuria

Question 37

Physiological changes in pregnancy - GI changes

Answer 37

Progesterone causes smooth muscle relaxation which slows down GI motility and decreases lower oesophageal sphincter (LES) tone. => Constipation and Reflux. Nausea and vomiting (“morning sickness”) Haemorrhoids

Question 38

Physiological changes in pregnancy - Thyroid changes

Answer 38

Beta-HCG causes thyroid stimulation, due to its structural similarity with TSH. => Causes a decrease in serum TSH in 1st trimester. Increased renal clearance and foetal uptake induce a relative deficiency in circulating iodide. Increased thyroid-binding globulin (TBG) Increased total T4 and T3 (but normal Free T4 & Free T3)

Question 39

Importance of maternal thyroid function in pregnancy

Answer 39

The foetal thyroid begins concentrating iodine and synthesizing thyroid hormones after 12 weeks of gestation => Before this time any thyroid hormones are supplied by maternal reserves, in order to promote the physiological foetal brain development.

Question 40

Physiological changes in pregnancy - Adrenal changes

Answer 40

Increase in: - Corticosteroid-binding globulin, Total and Free cortisol - Renin, Angiotensin II, and Aldosterone No change in: - Catecholamine levels - Normal diurnal variation of ACTH

Question 41

Physiological changes in pregnancy - Pituitary changes

Answer 41

Increase in: - Gland volume - Prolactin Levels - Placental GH and Human placental lactogen (hPL) Undetectable LH and FSH

Question 42

Physiological changes in pregnancy - changes in calcium metabolism

Answer 42

Increased placental flux of Ca2+ to meet foetal requirements Increased Ca2+ absorption from gut Increased DHCC and PTH

Question 43

Physiological changes in pregnancy - skin changes

Answer 43

General darkening and glowing Breast enlargement and preparation for lactation Montgomery tubercles => Sebaceous (oil) glands that appear as small bumps around the dark area of the nipple. Increased areola pigmentation Spider naevi Chloasma of pregnancy Linea Nigra Striae Gravidarum

Question 44

what is Chloasma of pregnancy ?

Answer 44

= Hypermelanosis of sun-exposed areas

Question 45

What is linea nigra?

Answer 45

Linear hyperpigmentation that commonly appears on the abdomen Attributed to increased melanocyte-stimulating hormone made by the placenta

Question 46

What are the "3 P's" of normal delivery?

Answer 46

1. Passage (pelvis of the mother) must be adequate in terms of size and shape 2. Powers (contractions) should be regular and strong 3. Passenger (foetus) should be in the correct position, well flexed and not too large in relation to the maternal pelvis.

Question 47

How does the pelvic width vary?

Answer 47

Pelvic inlet = widest in its transverse direction. Mid-cavity = circular Pelvic outlet = widest in the antero-posterior direction

Question 48

Importance of the pubic arch in obstetrics

Answer 48

important to measure as if it is too narrow then vaginal delivery will be difficult/impossible.

Question 49

Importance of the sacral promontory in obstetrics

Answer 49

Measuring the distance between this and the pubic symphysis is known as the obstetric conjugate and should be ~10cm

Question 50

Importance of the ischial spine in obstetrics

Answer 50

used as a reference point to determine the station of the foetal head (or presenting part)

Question 51

Foetal skull - anterior fontanelle

Answer 51

* Diamond shaped. * Bound by the frontal and parietal bones. * The frontal, coronal and sagittal sutures come together at this fontanelle. * The anterior fontanelle is the anterior boundary of the vertex of the foetal skull.

Question 52

Foetal skull - posterior fontanelle

Answer 52

* Triangular in shape. * Bound by the occipital and parietal bones. * The sagittal and lambdoidal sutures come together at this fontanelle. * It is the posterior landmark for the vertex of the foetal skull

Question 53

What is caput? | What might this indicate?

Answer 53

swelling on the scalp of foetus may suggest labour is obstructed

Question 54

What is moulding? | What might this indicate?

Answer 54

crossing of the foetal parietal bones may suggest labour is obstructed

Question 55

Occiput presentation of foetal head

Answer 55

classified according to the position of the occitput in relation to the maternal pelvis – e.g. occipto-anterior, occipito-transverse

Question 56

What part of the foetal skull most commonly presents?

Answer 56

the vertex

Question 57

Brow presentation of foetal head

Answer 57

on VE - can very easily feel the orbital ridges above the foetal eyes. This presentation cannot deliver vaginally unless the foetus extends its head to become a face presentation or flexes to become a vertex presentation

Question 58

Face presentation of foetal head

Answer 58

the position is classified according to the position of the chin (mentum) in relation to the maternal pelvis e.g. mento-anterior, mento-posterior

Question 59

What is the most favourable position of the foetal head for delivery?

Answer 59

Occipitoanterior = most favourable You can deliver in the occipitoposterior position, but this is more difficult as the diameter of the head in this position is larger.

Question 60

What are the signs of labour?

Answer 60

CONTRACTIONS Regular, painful uterine contractions – every 2-3 mins, lasting 45-60 seconds. RUPTURED MEMBRANES SROM = spontaneous rupture of membranes DILATED CERVIX identified on vaginal examination

Question 61

Reasons for admission when labour is starting

Answer 61

* Established labour (regular contractions) * ROM * Bleeding * Green discharge * Mother feels unwell * Foetal movements stop * Strong urge to push

Question 62

Reasons for staying at home until labour is fully established

Answer 62

to reduce iatrogenic risk/unnecessary interventions

Question 63

What are the stages of labour

Answer 63

Latent phase - dilatation <4cm 1st stage - from established labour to full dilatation 2nd stage - from full dilatation to delivery of the baby 3rd stage - from delivery of baby to separation and delivery of placenta and membranes

Question 64

What happens in the latent phase of labour?

Answer 64

Irregular contractions Can be short lasting and not as painful Cervical change, with dilatation <4cm May stop and start, can last for a number of days

Question 65

What happens in the 1st stage of labour? What is the expected progress?

Answer 65

Regular, painful contractions (3-4 every 10 mins) Cervical dilatation 4cm => 10cm Expected progress – 0.5cm (Primips) or 1cm (Multips) cervical dilatation per hour.

Question 66

What happens in the 2nd stage of labour? How long does it last?

Answer 66

Passive = no pushing, to allow further descent of the head. Active = pushing No longer than 2 hours (primips) or 1 hour (multips) active second stage.

Question 67

What happens in the 3rd stage of labour? How long does it last?

Answer 67

Delivery of placenta (meanwhile: cord clamping, skin to skin, neonatal vitamin K, early feeding). - Physiological = no drugs - Active = IM syntometrine (oxytocin analogue) to induce placental separation. Normally ~15 mins (no longer than 60 mins if physiological, or 30 minutes if active = retained placenta).

Question 68

How is cervical dilatation monitored in labour? What is the expected progression of dilatation?

Answer 68

regular vaginal examination every 4 hours (up to 7cm, more frequently after 7cm) to ensure adequate progress. Progress should be at least: - 0.5cm per hour for primps - 1cm per hour for multips

Question 69

Maternal monitoring in labour

Answer 69

Low-risk pregnancy – suitable for midwifery-led care. High-risk pregnancy – requires consultant-led care All women will have regular observations in labour (every 4 hours) – BP, RR, temperature, urine output

Question 70

Foetal monitoring in labour

Answer 70

FHR is recorded every 15 minutes as part of the basic observations, and also monitored after contractions => If low-risk, offer intermittent auscultation of the foetal heart => If high-risk, offer continuous cardiotocograph (CTG). => Foetal scalp electrode if needed Liquor colour – check for meconium

Question 71

What factors put the foetus at high risk and CTG should be offered?

Answer 71

``` Foetal growth restriction, Reduced movements, Maternal medical conditions, Smoking, etc. ```

Question 72

What factors might lead to a CTG being started later in labour?

Answer 72

abnormal FHR, labour >5 hours, high risk labour, meconium

Question 73

What factors when monitoring the foetus in labour might indicate the need for emergency C-section?

Answer 73

Bradycardia >3mins = C-section pH <7.20 or BE

Question 74

Process of normal birth

Answer 74

Head free in maternal abdomen before engagement. Foetal head flexes and contractions allow descent of foetus. As the head descends it will undergo INTERNAL ROTATION to occipitoanterior (OA). As the foetal head is delivered though the pelvic outlet, it will undergo extension. Once the head has delivered, the foetus undergoes restitution (EXTERNAL ROTATION) where the head realigns with the body. Delivery of anterior shoulder, followed by posterior shoulder and the rest of the baby with the next contraction.

Question 75

What pain relief options are there in labour?

Answer 75

Entonox (gas and air) TENS Systemic opioids (Morphine/pethidine) - Given IM by midwife/doctor - Mild analgesia, fairly rapid onset Epidural (fentanyl and bupivacaine)

Question 76

What are the side effects of systemic opioids in labour?

Answer 76

N&V, sedation, crosses placenta (respiratory depression in baby)

Question 77

Where is an epidural injected? | What does this achieve?

Answer 77

Injected by anaesthetist into epidural space between L3 and L4. Achieves complete sensory (except pressure) & partial motor blockade from injection site downwards

Question 78

What problems are associated with an epidural?

Answer 78

* Hypotension * Itching/toxicity * Urinary retention (due to reduced sensation) * Poor mobility * CSF tap (if inserted too far), causes headache * Complete spinal analgesia * Reduced ability to push.

Question 79

What are indications for an epidural?

Answer 79

* Long labour * Twins * Pre-eclampsia (reduces BP) * For instrumental delivery/C-section

Question 80

What are contraindications for an epidural?

Answer 80

* Sepsis * Coagulopathy * Spinal abnormalities/neurological disease

Question 81

Bishop's score

Answer 81

indicates likelihood of IOL success - High score – cervix favourable, associated with an easier/shorter induction - Low score – cervix unfavourable, takes longer and more likely to fail. May end in LSCS

Question 82

Indications for induction of labour

Answer 82

``` Term +10 Multiples Pre-eclampsia Diabetes/GDM IUGR PROM = prelabour term ROM ```

Question 83

Methods of induction of labour

Answer 83

Membrane Sweep – use fingers to separate membranes from cervix/uteris Prostaglandin E2 gel (Propess) – into posterior vaginal fornix. Amniotomy (+ oxytocin if no induction after 2 hours) Oxytocin (following amniotomy OR if membranes are already ruptured)

Question 84

Complications of IOL

Answer 84

- Slow labour (insufficient uterine activity) - Cord prolapse - Infection - Postpartum haemorrhage

Question 85

Contraindications to IOL

Answer 85

- Abnormal lie - Placenta Praevia - Pelvic obstruction - Previous C-section(s)

Question 86

What can cause poor progress in labour?

Answer 86

``` POWER Dehydration/ketosis Maternal exhaustion Epidural/other medication Overactive uterus ``` ``` PASSENGER Twins (or more) Abnormal presentation (breech/brow) Abnormal position (OP/OT) Macrosomia ``` PASSAGE Size & shape of pelvis Pelvis deformities Cervical abnormalities

Question 87

What is the most common cause of slow progress in labour?

Answer 87

Insufficient uterine activity

Question 88

Augmentation in Labour

Answer 88

If dilation <1cm/hour in active phase: 1. Amniotomy (AROM) using amniohook. 2. Oxytocin Drip 3. C-section – if failed to reach 10cm after 12 hours. If pushing for >1 hour (multips) or >2 hours (primips) and delivery not imminent: 1. Assisted Vaginal Delivery 2. C-section – after 2 failed attempts of assisted delivery.

Question 89

Indications for assisted vaginal delivery

Answer 89

* Prolonged second stage * Acute bradycardia at full dilatation * Pathological CTG at full dilatation

Question 90

What are the pre-requisites for an assisted vaginal delivery?

Answer 90

* Fully dilated * >34 weeks * Cephalic presentation * Head below the ischial spines * Maternal consent gained * Adequate analgesia (epidural, spinal or pudendal nerve block) * Usually requires episiotomy

Question 91

Types of assisted vaginal delivery

Answer 91

NON-ROTATIONAL - if head in OA position => Neville barnes forceps => Ventouse ROTATIONAL - not in OA position =>Ventouse => Manual rotation (using the hand of the assistant) followed by forceps

Question 92

Complications of C-section delivery | how are these managed?

Answer 92

* Haemorrhage – G&S, XM, transfusion ready * Infection – prophylactic Abx * VTE – Prophylactic thrombolysis + TED stockings * Post-op pain and immobility * Damage to visceral organs/foetus * Cannot drive for 4-6 weeks * Future problems due to adhesions and scarring – risk of placenta previa/uterine rupture

Question 93

Elective C-Section - when? - why?

Answer 93

Usually done at ~39 weeks Indications: breech, placenta previa, severe IUGR, multiples, diabetes, severe pre-eclampsia

Question 94

Indications for emergency C-section

Answer 94

failure to progress in labour, | foetal distress

Question 95

Benefits of C-section

Answer 95

Lowers risk of scar rupture if previous C-section Lowers risk of perineal trauma Lowers risk of HIE Can plan delivery date

Question 96

Disadvantages of C-section

Answer 96

Longer recovery Increased risk of bleeding and infection Increased chance will need C-Section in future.

Question 97

Benefits of VBAC

Answer 97

* Quicker recovery * No anaesthetic risk * Reduced risk of bleeding, infection, VTE * Increased chance of normal vaginal delivery in future pregnancies.

Question 98

Risks of VBAC

Answer 98

* Rupture of previous uterine scar – needs emergency C-section * Increased risk of perianal trauma

Question 99

Problems with repeat C-section

Answer 99

* Increased complications with adhesions | * Increased risk of placenta previa in future pregnancies

Question 100

Management of VBAC

Answer 100

• Consultant-led care ``` • Hospital delivery with: Continuous CTG monitoring Maternal Obs IV access & FBC Pool birth not recommended (but can be discussed with consultant) ``` • Avoid IOL due to increased chance of scar rupture

Question 101

Presentation of foetus

Answer 101

= part of foetus occupying lower section of uterus. - Cephalic - Breech

Question 102

Lie of foetus

Answer 102

= relationship of foetus to long axis of uterus - Longitudinal - Transverse Unstable lie = continually changing position

Question 103

Causes of Abnormal Lie

Answer 103

Preterm labour Increased room to turn - Polyhydramnios, high parity (stretched uterus) Decreased room to turn - Uterine/foetal abnormalities, multiple pregnancy, oligohydramnios Prevention of engagement - Placenta praevia, pelvic tumour Foetal abnormalities - IUGR/macrosomia, short cord, hydrocephaly

Question 104

Management of abnormal lie

Answer 104

< 36 weeks - no action needed (may spontaneously turn) >37 weeks – admission and USS to exclude polyhydramnios/ placenta praevia (External Cephalic Version between 36-38 weeks if expert) Continued abnormal lie to 41 weeks/labour – C-section

Question 105

Risk factors for breech presentation

Answer 105

- Previous breech presentation - Pre-term labour/prematurity - RFs for abnormal lie

Question 106

Complications of breech presentation

Answer 106

- Foetal structural/neurological abnormalities - Cord prolapse - Late detection of trapped head => foetal hypoxia and death

Question 107

Management of breech presentation

Answer 107

1. External Cephalic Version (ECV): attempt after 37 weeks, 50% successful 2. Elective C-Section: advised if ECV failed or contra-indicated. 3. Vaginal Breech Birth: if patient chooses over C-section => Increased risk of foetal compromise and cord prolapse

Question 108

External Cephalic Version

Answer 108

No analgesia, but uterine relaxant (tocolytic) USS-guided manipulation of foetus with hands on abdomen CTG-monitoring and Anti-D given immediately after

Question 109

Contraindications to external cephalic version

Answer 109

``` multiple pregnancy, foetal distress, recent APH/active PV bleed, ruptured membranes, uterine abnormality ```

Question 110

Risks of external cephalic version

Answer 110

bleed, foetal distress, uterine rupture, placental abruption

Question 111

What is Shoulder Dystocia?

Answer 111

When normal downwards traction fails to deliver the shoulders after the head => anterior shoulder caught on pubic symphysis

Question 112

Risk factors for shoulder dystocia

Answer 112

``` LARGE baby (>4kg) Previous shoulder dystocia High maternal BMI Maternal diabetes IOL/instrumental delivery ```

Question 113

Complications of shoulder dystocia

Answer 113

Baby – brain damage, damaged brachial plexus (Erb’s Palsy) Mum – perineal injury, uterine rupture, PPH

Question 114

Management of shoulder dystocia

Answer 114

= RAPID SKILLED INTERVENTION 1. McRobert’s Manoeuvre – hyperextend legs + suprapubic pressure 2. Wood’s Screw manoeuvre – manual internal rotation of shoulders (need episiotomy) 3. Grasp posterior arm – gently pull down and rotate body as it follows 4. Last resorts – symphysiotomy, Zavanelli manoeuvre, C-section (often too late for this)

Question 115

SOAPS skilled intervention in obstetrics

Answer 115

* Senior Midwife * Obstetrician * Anaesthetist * Paediatrician * Scribe

Question 116

Cord prolapse

Answer 116

When the cord descends below the presenting part Felt on VE/pathological CTG signs

Question 117

Risk factors for cord prolapse

Answer 117

* Preterm labour/low birth weight * Breech/OP/abnormal lie * Multiples (2nd twin) * Polyhydramnios * Multiparous

Question 118

Complications of cord prolapse

Answer 118

cord compression/spasm => foetal hypoxia

Question 119

Management of cord prolapse

Answer 119

GET HELP (SOAPS) + Prepare for C-section 1. Stop cord compression 2. If cord is outside, keep warm and moist but do not force back inside 3. Delivery – keep patient on all 4s while prepare for safest delivery => C-section usually, but sometimes instrumental.

Question 120

Uterine Rupture

Answer 120

De novo tear OR opening of previous scar

Question 121

What predisposes to uterine rupture?

Answer 121

- Scarred uterus - Neglected obstructed labour - Congenital uterine abnormalities

Question 122

Management of uterine rupture

Answer 122

1. Maternal resuscitation – IV fluids and blood | 2. If blood loss too fast – urgent laparotomy to deliver foetus and repair/remove uterus

Question 123

Amniotic Fluid Embolism

Answer 123

Liqour enters maternal circulation, causing anaphylaxis

Question 124

Risk factors for amniotic fluid embolism

Answer 124

Polyhydramnios Very strong contractions Typically occurs at ROM, C-section or TOP

Question 125

Complications of amniotic fluid embolism

Answer 125

- Dyspnoea, hypoxia, hypotension - Seizures, cardiac arrest, acute heart failure - DIC, pulmonary oedema, respiratory distress All above can cause death

Question 126

Management of amniotic fluid embolism

Answer 126

Maternal resuscitation – IV fluids, O2, blood and FFP for transfusion

Question 127

Incidence of twin/triplet pregnancies

Answer 127

Twins – 1/80 pregnancies Triplets – 1/1000 pregnancies

Question 128

Risk factors for multiple pregnancy

Answer 128

Fertility treatments/ovarian hyperstimulation Increasing maternal age Higher parity Genetics

Question 129

How are Dizygotic Twins formed? | How common is this form?

Answer 129

fertilisation of 2 different oocytes by 2 different sperm 80% of twins

Question 130

How are monozygotic Twins formed? | How common is this form?

Answer 130

miotic division of a single oocyte (varies depending on when division occurs) 20% of twins

Question 131

Different types of monozygotic twin

Answer 131

Dichorionic Diamniotic (DC/DA) = 2 placentas, 2 amnions Monochorionic Diamniotic (MC/DA) = 1 placenta, 2 amnions Monochorionic Monoamniotic (MC/MA) = 1 placenta, 1 amnion Incomplete division – conjoined twins

Question 132

Twin USS - Lambda-sign

Answer 132

= triangular appearance to chorion insinuating between the layers of the inter twin membrane Strongly suggests a dichorionic twin pregnancy

Question 133

Twin USS - T-sign

Answer 133

= absence of lambda-sign suggests monochorionic twin pregnancy

Question 134

Maternal complications of multiple pregnancy

Answer 134

Gestational diabetes, pre-eclampsia, anaemia = more common Spontaneous miscarriage Preterm labour Malpresentation of a baby at labour Prolonged labour APH/PPH

Question 135

Foetal complications of multiple pregnancy

Answer 135

``` Increased mortality/stillbirth Increased chance of handicap Congenital abnormalities (more common in MC twins) IUGR (usually one twin is smaller) IUFD of one foetus ```

Question 136

What are some specific complications of Monochorionicity?

Answer 136

``` Twin-twin transfusion syndrome (TTTS) Twin Reversed Arterial Perfusion (TRAP) Selective Foetal Growth Restriction Co-twin Death Monoamniotic Twin entangled cords ```

Question 137

What is twin-twin transfusion syndrome (TTTS)? What are the outcomes?

Answer 137

Occurs in MCDA only. Unequal blood distribution through anastomoses in placenta => Donor twin – volume depletion, anaemia, IUGR, oligohydramnios => Recipient twin – volume overload, polycythaemia, cardiac failure, polyhydramnios Outcomes: - Severe pre-term delivery - IUFD

Question 138

what is Twin Reversed Arterial Perfusion (TRAP) ?

Answer 138

Foetal blood systems connected One twin (pump) = normal Other twin (acardiac) = abnormal/missing heart and upper limbs

Question 139

Selective Foetal Growth Restriction of twins

Answer 139

Due to superficial artery-artery anastomoses Intermittently absent or reversed blood flow to 1 twin Can cause sudden IUFD

Question 140

Co-twin Death

Answer 140

Death of one twin causes acute transfusion of blood Results in hypovolaemia => death/neurological damage in surviving twin

Question 141

Antenatal management of multiple pregnancy

Answer 141

= Consultant-led as high-risk. - Early USS to determine chorionicity - Regular USS checks for IUGR - Selective Reduction - Birth plan/method of delivery discussed - Education patient on signs of preterm labour and complications

Question 142

Selective reduction in multiple pregnancy

Answer 142

Discussed at 12 weeks if triplets or more. Reduces chance of preterm delivery and associated foetal death/handicap Intra-cardiac injection of potassium chloride to leave behind only 2 foetuses

Question 143

How often are USS checks for twins to check for IUGR?

Answer 143

DC twins – every 4 weeks from 28/40 | MC twins – every 2 weeks from 12/40

Question 144

Delivery management of multiple pregnancy

Answer 144

Timing: => DC twins = 37 weeks => MC twins = 36 weeks Hospital delivery => Consultant, 2x midwives (1 senior), paediatrician Continuous CTG Epidural recommended Mode of delivery!

Question 145

Mode of delivery of twins

Answer 145

C-section commonly used for any multiple pregnancies (vaginal delivery has more risk for 2nd twin). NVD = only viable if 1st twin is cephalic presentation Foetal distress – speed delivery with ventouse or breech extraction. After 1st twin is born, check lie of 2nd twin (2nd baby may need C-section) Active 3rd Stage due to high risk of PPH

Question 146

What are absolute indications for C-section in multiple pregnancy?

Answer 146

* Malpresentation of 1st twin * Hx of antepartum complications * Triplets or more

Question 147

When is the antenatal booking visit?

Answer 147

As early as possible in the pregnancy (before 10 weeks)

Question 148

What happens at the antenatal booking visit?

Answer 148

Risk assessment Full Hx taken from the patient by the midwife Relevant examinations Routine investigations Discuss screening and give information Arrange Dating Scan

Question 149

What points are important in the booking visit history?

Answer 149

Past obstetric Hx/disorders Gynaecological Hx – e.g. recurrent miscarriage, uterine surgery Medical conditions increasing the risk of problems (including psychiatric disorders) DHx – stop if contraindicated in pregnancy, vits/folate SHx – smoking, alcohol, illicit drugs, housing/support, safe at home?

Question 150

What examinations are relevant at the booking visit?

Answer 150

BMI (low or high?) BP Urine dip (glucose, protein, leucocytes, nitrites)

Question 151

Dating Scan

Answer 151

Between 11-13 +6weeks Check gestation, detect multiple pregnancies Screen for trisomies (13, 18, 21)

Question 152

What routine investigations are done at the booking visit?

Answer 152

Blood screen – FBC, blood group & Anti-D antibodies, glucose tolerance, syphilis, rubella immunity, HIV & Hep B, Hb electrophoresis. Other tests – infection screening (e.g. chlamydia), urinalysis, urine MC&S

Question 153

When do the regular antenatal visits occur?

Answer 153

16-28 weeks – monthly 28-36 weeks – fortnightly 36 weeks onwards – weekly

Question 154

What occurs at the regular antenatal visits?

Answer 154

History: - Brief review - Physical and mental health check up - Foetal movements Examination: - BP & urinalysis - Pregnant abdo exam – FHR, lie and presentation - Symphysio-fundal Height

Question 155

What occurs at the 28-week antenatal visit?

Answer 155

BP + urine dip SFH measured FBC & antibodies checked OGTT if indicated (e.g. raised BMI, glycosuria) Anti-D given if rhesus negative

Question 156

What occurs at the 34, 36, 38, 40 Weeks antenatal visits?

Answer 156

BP + urine dip SFH measured Foetal lie and presentation checked Info given on birth plan and labour Info give on caring for newborn, etc. USS – Presentation and Placental location

Question 157

What occurs at the 41-week antenatal visit?

Answer 157

``` Offer membrane sweep Discuss IOL (offered at 42 weeks) ```

Question 158

Antenatal lifestyle advice

Answer 158

Well-balanced diet, approx.. 2500 kcal. Avoid unpasteurised milk, soft cheese etc. (risk of salmonella, listeria, toxoplasmosis) ``` Avoid alcohol (especially in first 12 weeks) Avoid smoking ``` Exercise – avoid contact sports but swimming, etc. is advised.

Question 159

Antenatal medication advice

Answer 159

Avoid in first trimester if possible Folic acid supplementation – 400mcg/day until week 12 VitD supplementation – 10mcg/day if BMI >30 / low sun exposure Iron supplementation – if anaemic Vaccines – flu and whooping cough

Question 160

When is 5mg folate indicated in pregnancy?

Answer 160

* Epilepsy * Diabetes * BMI >30 * Hx of baby with spina bifida

Question 161

When do the routine antenatal USS scans occur?

Answer 161

12 weeks – dating (gestation and nuchal translucency) 20 weeks – foetal anomaly scan (+36/38 weeks if low lying placenta at 20 week scan)

Question 162

Why and when do the antenatal serial growth scans occur?

Answer 162

Take place if high risk 4 weekly from 28 weeks – (28, 32, 36 weeks) 2 weekly if monochorionic twins

Question 163

When can Rhesus sensitisation of Rh -ve mother occur ?

Answer 163

Rh -ve mother and Rh +ve foetus can cause the mother to develop IgG antibodies against foetal RBCs Can occur after previous birth, amniocentesis, APH/vaginal bleeds, miscarriage, TOP, ectopic, trauma (e.g. fall)

Question 164

How can Rhesus sensitisation be prevented?

Answer 164

Give Anti-D at 28-weeks +/- within 72 hours of sensitisation event

Question 165

Risks of alcohol in pregnancy

Answer 165

* Miscarriage * Reduced birth weight/IUGR * Intellectual impairment * Foetal alcohol syndrome

Question 166

Foetal alcohol syndrome

Answer 166

Small head/eyes, saddle nose, thin lips, Cerebral palsy, Learning difficulties, Behaviour/attention problems, Hearing/vision problems, Cardiac defects

Question 167

Risks of Smoking in pregnancy

Answer 167

* Low birth weight/foetal growth restriction * Preterm delivery * Miscarriage/stillbirth

Question 168

Risks of illicit drugs in pregnancy

Answer 168

* Low birth weight/foetal growth restriction * Preterm delivery * Cardiac defects (ecstasy) * Sudden infant death syndrome * Neonatal withdrawal syndrome (especially opiates and BZDs)

Question 169

Antenatal blood screening

Answer 169

Blood group and Rhesus Status Antibodies Haemoglobinopathies => Thalassaemia => Sickle cell (depending on ethnic background) Anaemia

Question 170

Antenatal infection screening

Answer 170

Rubella immunity Syphilis HIV Hepatitis B

Question 171

Foetal congenital abnormalities - screening tests

Answer 171

Blood tests - AFP, b-hCG, PAPP-A, oestriol. USS: - Combined test – nuchal translucency, blood hCG and PAPP-A - Triple test (>14 weeks) – AFP, b-hCG, oestriol - Foetal anomaly scan at 20 weeks

Question 172

Foetal congenital abnormalities - what might raised AFP indicate?

Answer 172

NTDs Abdominal Wall defects Multiple pregancy

Question 173

Foetal congenital abnormalities - what might low AFP indicate?

Answer 173

Down's (trisomy 21) Edward's (trisomy 18) Maternal DM

Question 174

What might a large nuchal translucency indicate?

Answer 174

= larger risk of structural abnormalities

Question 175

Foetal congenital abnormalities - non-invasive diagnostic tests

Answer 175

Foetal MRI – diagnose intracranial lesions 3D/4D USS – better visualisation of abnormality Pre-implantation genetic diagnosis (if IVF)

Question 176

Foetal congenital abnormalities - invasive diagnostic tests

Answer 176

Amniocentesis | Chorionic Villus Sampling

Question 177

Amniocentesis - process and risks

Answer 177

* 1% risk of miscarriage * Removal of amniotic fluid via fine-gauge needle and USS * Safest after 15 weeks’ gestation * Diagnosis of chromosomal abnormalities, infection, inherited disease

Question 178

Chorionic Villus Sampling

Answer 178

* 1-2% risk of miscarriage * Take sample of placental cells via fine gauge needle. * Done between 11-13 weeks’ gestation (early enough for TOP) * Diagnosis of chromosomal abnormalities, inherited disease.

Question 179

What is the risk of invasive tests for congenital abnormalities?

Answer 179

miscarriage, rhesus sensitisation, infection, foetal trauma

Question 180

What are some chromosomal abnormalities which can be detected ?

Answer 180

``` Down's syndrome (Trisomy 21) Edward's Syndrome (Trisomy 18) Patau Syndrome (Trisomy 13) Klinefelter's Syndrome Turner's Syndrome ```

Question 181

Foetal Hydrops

Answer 181

excess fluid in 2 or more areas; (including ascites, pleural effusion, pericardial effusion, and skin oedema) can result from rhesus antibodies, chromosomal/structural abnormalities, anaemia

Question 182

Obstetric Haemorrhage - minor blood loss

Answer 182

500 - 1000 mL

Question 183

Obstetric Haemorrhage - major blood loss

Answer 183

>1000 mL

Question 184

What is antepartum haemorrhage?

Answer 184

= bleeding from the genital tract after 24 weeks gestation until labour.

Question 185

Causes of APH

Answer 185

COMMON Undetermined Placental abruption Placenta praevia RARER Genital tract pathology Uterine rupture Vasa praevia

Question 186

What is placenta praevia?

Answer 186

When the placenta is totally or partially inserted in the lower uterine segment (<2cm from internal cervical os): => Minor – placenta not covering os => Major – placenta partially/fully covering os

Question 187

Risk factors for placenta praevia

Answer 187

``` Twins High parity Increased maternal age (>40) Scarred uterus – previous C-section/surgery, previous placenta praevia Smoking ```

Question 188

Placenta accreta

Answer 188

= when the placenta attaches itself too deeply and too firmly into the uterus

Question 189

Placenta increta

Answer 189

placenta accreta, where the placenta attaches itself even more deeply into the muscle wall of uterus

Question 190

Placenta percreta

Answer 190

= when the placenta attaches itself and grows through the uterus, sometimes extending to nearby organs, such as the bladder

Question 191

Stage I placenta praevia

Answer 191

Placenta reaches lower segment but not the internal Os

Question 192

Stage II placenta praevia

Answer 192

Placenta reaches internal os, but does not cover it

Question 193

Stage III placenta praevia

Answer 193

Placenta covers the os before dilatation, but not when dilated

Question 194

Stage IV placenta praevia

Answer 194

Placenta completely covers the os, even when dilated

Question 195

Symptoms of placenta praevia

Answer 195

Intermittent, PAINLESS bleeds (increasing in frequency and intensity) Abnormal foetal presentation – e.g. breech, transverse lie, foetal head not engaged

Question 196

What is a cause of PAINLESS bleeding during pregnancy?

Answer 196

placenta praevia

Question 197

What should you not do to examine suspected placenta praevia?

Answer 197

AVOID VAGINAL EXAMINATION – can provoke massive bleed

Question 198

Placenta praevia - investigations

Answer 198

TV USS to diagnose

Question 199

Management of placenta praevia

Answer 199

Presentation without bleeding (asymptomatic) – delivery between 36-37 weeks. Presentation with bleeding – ADMIT and consider late preterm delivery Delivery: => Elective CS (earlier if severe bleeding) => If placenta accreta/percreta – Rusch balloon compression/total hysterectomy after C-section to decrease bleeding.

Question 200

Placental Abruption

Answer 200

= part or all of the placenta separates from the uterine wall before delivery of the foetus. ~1% of pregnancies

Question 201

Risk factors for placental abruption

Answer 201

``` Hx of placental abruption Pre-eclampsia/pre-existing HTN IUGR Multiple pregnancy High parity Autoimmune Smoking/cocaine use ```

Question 202

Symptoms of placental abruption

Answer 202

PAINFUL, dark bleeds (amount does not equal severity) Tender, contracting uterus If severe – “woody-hard” uterus, hypotension, tachycardia Decreased foetal movements Signs of hypovolaemic shock

Question 203

Concealed placental abruption

Answer 203

Pain without any bleeding

Question 204

What is a cause of PAINFUL bleeding during pregnancy?

Answer 204

Placental abruption

Question 205

Management of APH

Answer 205

ADMIT - FBC, clotting screen, XM (4-6 units), U&Es, Kleihauer test (if mum Rh -ve) - Hx, including SHx to rule out domestic abuse. - A-E Assessment (including urine dipstick) - Abdominal examination - Speculum/vaginal examination – assess amount of bleeding, cervical appearance Stabilise the mum before assessing the foetus. => CTG for foetal wellbeing Anticipate PPH => Prepare for active 3rd stage to reduce risk

Question 206

Management of Placental Abruption

Answer 206

No foetal distress, >36 weeks – IOL with amniotomy No foetal distress, <36 weeks – monitor on antenatal ward, steroids if <34 weeks. Foetal distress = urgent C-section => Intra-operative/PP haemorrhage common

Question 207

Vasa Praevia

Answer 207

When foetal blood vessels run in the membranes in front of the presenting part, near the cervix. When the membranes rupture, the foetal vessels do too, leading to a massive foetal bleed.

Question 208

Symptoms of vasa praevia

Answer 208

Moderate, PAINLESS vaginal bleed when/after membranes rupture (amniotomy or spontaneous) Severe foetal distress

Question 209

Management of vasa praevia

Answer 209

Urgent C-section (usually too slow to save foetus)

Question 210

Uterine Rupture as a cause of APH

Answer 210

Occasionally rupture occurs before labour in women with scarred/congenitally abnormal uterus. ``` => Signs of hypovolaemia => Sudden onset abdo pain => High foetal presenting part => Uterine contractions may cease => Bleeding (can be concealed) => Haematuria (scar can involve the bladder) => Pathological CTG ``` = obstetric emergency

Question 211

APH - Bleeding of Gynaecological Origin

Answer 211

* Cervical carcinoma – suspect if small recurrent/post-coital bleeding * Cervical polyps * Ectropions * Vaginal lacerations

Question 212

Primary PPH

Answer 212

= Loss of >500mL blood within 24 hours of delivery | or >1000mL after C-section

Question 213

What are the 4T's as causes of PPH?

Answer 213

TONE – uterine atony (90% of PPH) TRAUMA – vaginal/cervical tears, episiotomy TISSUE – retained placenta, retained blood clots, placenta accreta THROMBIN (coagulopathies) – congenital disorders, anticoagulation, DIC, pre-eclampsia

Question 214

What are the risk factors for uterine atony?

Answer 214

``` prolonged labour, grand multiparity, fibroids, overdistension (multiples, polyhydramnios), muscle relaxants ```

Question 215

Prevention of PPH

Answer 215

Identify high-risk women in antenatal visits Active management of 3rd stage of labour – Syntometrine for placental delivery

Question 216

Management of primary PPH

Answer 216

1. GET SENIOR HELP (obstetric emergency) 2. Resuscitation – O2, XM and FBC => Transfuse blood as soon as possible (activate obstetric major haemorrhage call) => Catheter to monitor input and output 3. Identify cause – abdo palpation, VE, examine placenta, USS 4. Treat cause: - Retained placenta – remove manually if bleeding/not delivered in 60 minutes - Uterine atony – IV oxytocin/ergometrine to contract uterus; PGF2A if persists - Persistent haemorrhage – surgery

Question 217

Secondary PPH

Answer 217

= Excessive blood loss between 24 hours and 12 weeks after delivery. Caused by endometritis +/- retained placental fragments. Sometimes can be due to poor healing of a perineal tear

Question 218

What is the agent of choice in managing PPH?

Answer 218

Syntometrine/Syntocinon => 5 unit slow IV bolus => Sustained effect use with 40u infusion (in 500ml saline)

Question 219

Side effects of syntometrine

Answer 219

Vasodilation (hypotension) and reflex tachycardia

Question 220

Use of Ergometrine in PPH

Answer 220

125mcg-500mcg IV or IM SEs – Nausea and vomiting, HTN, coronary spasm, ischaemic pain Contraindicated in hypertensive patients

Question 221

Surgical management of PPH

Answer 221

Treat cause and early transfer to theatre if needed. No statistical difference among the outcomes of the various available surgical methods - Uterine balloon tamponade - Compression sutures - Arterial ligation - Aortic clamping - Hysterectomy/Subtotal hysterectomy

Question 222

Transexamic acid in PPH

Answer 222

Effective anti-fibrinolytic; Consider in cases where blood loss is major and ongoing

Question 223

The HPG-axis

Answer 223

Hypothalamus secretes GnRH GnRH promotes the release of LH and FSH from the anterior pituitary. LH and FSH travel in the bloodstream to the ovaries. When LH and FSH bind to the ovaries they stimulate the production of oestrogen and inhibin Increasing levels of oestrogen, progesterone and inhibin have a negative feedback effect on the pituitary and hypothalamus

Question 224

What is the role of progesterone in the menstrual cycle?

Answer 224

Progesterone stimulates the endometrium to become receptive to the implantation of a fertilised ovum ALSO: - negative feedback causing decreased LH and FSH (both needed to maintain the corpus luteum) - an increase in the woman’s basal body temperature

Question 225

What is the role of LH in the menstrual cycle?

Answer 225

causes the Graafian follicle to change into the corpus luteum, which begins to produce progesterone

Question 226

What is the role of FSH in the menstrual cycle?

Answer 226

Stimulates the development of ovarian follicles at the begining of the menstrual cycle The follicle most sensitive to FSH becomes the dominant Graafian follicle

Question 227

How does pregnancy cause the cessation of menstruation?

Answer 227

If a woman becomes pregnant oestrogen and progesterone levels cause GnRH, FSH and LH to remain inhibited, thereby causing menstruation to cease

Question 228

What are the phases of the menstrual cycle?

Answer 228

``` Follicular Phase (day 0-14) Ovulation (day 14) Luteal Phase (day 15-28) ```

Question 229

Which follicle becomes the dominant one?

Answer 229

The one with the most FSH-receptors - becomes the most sensitive to FSH When inhibin reduces release of FSH, the other follicles die (leaving just the dominant one)

Question 230

What is the role of oestrogen in the menstrual cycle?

Answer 230

The Graafian follicle secretes increasing amounts of oestrogen to cause: - endometrial thickening - thinning of the cervical mucus to allow easier passage of sperm - INHIBITION of LH production by the pituitary gland Eventually oestrogen surpasses threshold level and STIMULATES LH production, resulting in a spike in LH levels around day 12

Question 231

LH surge

Answer 231

~ day 12 of cycle oestrogen surpasses threshold level and stimulates LH production high amounts of LH cause the membrane of the Graafian follicle to become thinner. Within 24-48 hours of the LH surge, the follicle ruptures releasing a secondary oocyte The mature ovum is then released into the peritoneal space and is taken into the fallopian tube via fimbriae (finger-like projections)

Question 232

Luteal Phase - no fertilisation

Answer 232

After ovulation, LH and FSH stimulate the remaining Graafian follicle to develop into the corpus luteum. corpus luteum then begins to produce the hormone progesterone As the levels of FSH and LH fall, the corpus luteum degenerates. Degeneration of the corpus luteum results in loss of progesterone production. The subsequent falling level of progesterone triggers menstruation and the entire cycle begins again

Question 233

Luteal Phase - fertilisation

Answer 233

If an ovum is fertilised it produces hCG which is similar in function to LH. hCG prevents degeneration of the corpus luteum (resulting in the continued production of progesterone). Continued production of progesterone prevents menstruation. The placenta eventually takes over the role of the corpus luteum (from 8 weeks gestation).

Question 234

Two layers of endometrium

Answer 234

Functional layer: this grows thicker in response to oestrogen and is shed during menstruation Basal layer: this forms the foundation from which the functional layer develops (i.e. it is not shed)

Question 235

Phases of uterine cycle

Answer 235

Proliferative Phase Secretory Phase Menstrual Phase

Question 236

Phases of uterine cycle - Proliferative

Answer 236

Driven by the endometrium being exposed to increasing levels of oestrogen Oestrogen stimulates repair and growth of the functional endometrial layer allowing recovery from the recent menstruation (increasing endometrial thickness, vascularity and the number of secretory glands).

Question 237

Phases of uterine cycle - Secretory

Answer 237

Begins once ovulation has occurred. This phase is driven by progesterone Results in the secretion of various substances by the endometrial glands, making the uterus a more welcoming environment for an embryo to implant.

Question 238

Phases of uterine cycle - Menstrual

Answer 238

the corpus luteum degenerates (if no implantation occurs). The loss of the corpus luteum results in decreased progesterone production. The decreasing levels of progesterone cause the spiral arteries in the functional endometrium to contract. The loss of blood supply causes the functional endometrium to become ischaemic and necrotic. As a result, the functional endometrium is shed and exits through the vagina as menstruation.

Question 239

Group I ovulation disorders

Answer 239

hypogonadotropic, hypogonadal anovulation ~10% of ovulation disorders - Hypothalamic/pituitary failure. - Low gonadotrophins and oestrogen deficiency - E.g. brain surgery, eating disorders/reduced calories.

Question 240

Group II ovulation disorders

Answer 240

normal gonadotrophins, normal oestrogen, problem within the ovary causing anovulation ~85% of women with ovulation disorders Dysfunction of the hypothalamic-pituitary-ovarian axis.

Question 241

Group III ovulation disorders

Answer 241

hypergonadotrophic, hypo-oestrogenic anovulation ~5% of ovulation disorders Caused by ovarian failure

Question 242

Parameters of “normal” menstrual cycle

Answer 242

24-38 days cycle length ≤ 7-9 days difference between shortest to longest cycles ≤ 8 days of bleeding blood loss that does not interfere with a woman’s physical, social, emotional and/or quality of life.

Question 243

Abnormal uterine bleeding

Answer 243

Absent/infrequent/frequent periods Irregular cycle lengths IMB, PCB, prolonged duration of bleeding Heavy or light bleeding (subjective)

Question 244

Heavy Menstrual Bleeding

Answer 244

= excessive menstrual blood loss (MBL) that interferes with the physical, social, emotional and/or material quality of life. objective criteria of blood loss of >80 mL/cycle

Question 245

Intermenstrual bleeding (IMB)

Answer 245

Bleeding between clearly defined cyclic and predictable menses

Question 246

Postmenopausal bleeding (PMB)

Answer 246

Genital tract bleeding that recurs in a menopausal woman at least one year after cessation of cycles = RED FLAG

Question 247

Postcoital bleeding (PCB)

Answer 247

Non-menstrual genital tract bleeding immediately (or shortly after) intercourse

Question 248

Chronic AUB

Answer 248

AUB has been present for the majority of the past 6 months

Question 249

Acute AUB

Answer 249

Excessive AUB bleeding that requires immediate intervention to prevent further blood loss.

Question 250

Amenorrhoea

Answer 250

Absence of uterine bleeding

Question 251

How should Abnormal uterine bleeding (AUB) be described?

Answer 251

* regularity should be specified as irregular, regular or absent * frequency should be specified as frequent, normal or infrequent * duration should be specified as prolonged, normal or shortened * volume should be specified as heavy, normal or light

Question 252

Assessment of AUB

Answer 252

1. Exclude pregnancy. 2. Gynaecological history and examination. => Amount and timing of bleeding. => Signs of anaemia, palpation of masses, pelvic tenderness 3. Establish if chronic AUB (>6 months) or acute AUB (urgent intervention required). 4. Use history to screen for coagulopathy. 5. Investigations: => Full blood count (FBC), cervical smear, pelvic infection swabs and pelvic ultrasound (and coagulation screen if indicated). => TV USS – exclude masses/detect polyps 6. Referral to secondary care if malignancy is suspected.

Question 253

Coagulopathy Screen for AUB

Answer 253

Structured history – positive screen if: *  Excessive menstrual bleeding since menarche, or *  One of the following: - Postpartum haemorrhage, - Surgery-related bleeding, - Bleeding associated with dental work • Two or more of the following: - Bruising greater than 5 cm once or twice/month, - Epistaxis once or twice/month, - Frequent gum bleeding, - Family history of bleeding symptoms

Question 254

Gynaecological Red Flags

Answer 254

Suspected gynaecological cancer: - Post-coital bleeding - Post-menopausal bleeding - Inter-menstrual bleeding - Pelvic mass - Cervix lesion

Question 255

Causes of heavy menstrual bleeding (PALM-COEIN):

Answer 255

``` 1. Structural: • Polyp (AUB-P) • Adenomyosis (AUB-A) • Leiomyoma (AUB-L) • Malignancy and Hyperplasia (AUB-M) ``` ``` 2. Non-structural: • Coagulopathy (AUB-C) • Ovulatory dysfunction (AUB-O) • Endometrial (AUB-E) • Iatrogenic (AUB-I) • Not yet classified (AUB-N) ```

Question 256

Iatrogenic causes of AUB

Answer 256

exogenous sex steroid administration (combined oral contraceptives, progestins, tamoxifen), intrauterine contraceptive device, traumatic uterine perforation

Question 257

Coagulopathy as cause of AUB

Answer 257

thrombocytopenia, von Willebrand's disease, leukaemia, warfarin

Question 258

Ovulatory dysfunction as cause of AUB

Answer 258

``` PCOS, Congenital adrenal hyperplasia, Hypothyroidism, Cushing's disease, Hyperprolactinaemia ```

Question 259

Treatment of HMB - first steps

Answer 259

All medical! 1st line - IUS 2nd line tranexamic acid/NSAIDs/COCP 3rd line - progesterones/GnRH

Question 260

Why is IUS used first-line for treating HMB?

Answer 260

High rate of reducing HMB generates more quality-adjusted life years than other medical treatments (tranexamic acid, NSAIDs, COCP) and at a lower cost

Question 261

Treatment of HMB - further steps

Answer 261

Hysteroscopic/laparoscopic Myomectomy Endometrial ablation Resection of endometrium Abdominal myomectomy Hysterectomy

Question 262

How does the Mirena-IUS work?

Answer 262

Intrauterine dose of 20 microgram/24 hours with little systemic absorption. Inhibits endometrial proliferation, thickens cervical mucus and suppresses ovulation

Question 263

What is the mirena-IUS licensed for?

Answer 263

Contraception, HMB, progesterone component of HRT

Question 264

What are the requirements to be eligible for endometrial ablation?

Answer 264

Uterine cavity >10 cm length No large fibroids/polyps distorting the cavity No previous endometrial ablation No active infective process Myometrium is at least 10 mm if using the microwave ablation Family is complete!

Question 265

Why must the family be complete if a woman undergoes endometrial ablation?

Answer 265

Low chance of success of achieving pregnancy If pregnancy achieved, high chance of miscarriage/infiltrating placenta.

Question 266

Indications for hysterectomy for HMB

Answer 266

* Other treatment options have failed or are inappropriate * Women have completed their families * There is a wish for amenorrhoea * Women (who have been fully counselled) request it or other forms of further treatment are contraindicated.

Question 267

Types of hysterectomy

Answer 267

1. Abdominal hysterectomy (AH) 2. Vaginal hysterectomy (VH) 3. Laparoscopic-assisted vaginal hysterectomy (LAVH). 4. Total laparoscopic hysterectomy (TLH) 5. Subtotal hysterectomy (STH)

Question 268

Causes of IMB

Answer 268

1. Ovarian: 1-2% ovulation spotting, oestrogen secreting tumours 2. Uterine: iatrogenic (contraception), infection, structural benign or malignant 3. Cervical: iatrogenic (examination, smear), infective, structural benign or malignant 4. Vaginal: infective, structural benign or malignant

Question 269

Management of IMB

Answer 269

Medical: - IUS/COCP - Progesterones - HRT (if irregular bleeding during menopause) Surgical – same as for HMB, but ablation is less effective.

Question 270

Dysmenorrhoea

Answer 270

= painful periods High prostaglandin levels cause painful uterine contractions and ischaemia classified as primary or secondary

Question 271

Primary dysmenorrhoea

Answer 271

Occurs with the start of menstruation No organic cause Tx: NSAIDs, COCP

Question 272

Secondary dysmenorrhoea

Answer 272

Precedes and relieved by menstruation Caused by pelvic pathology => fibroids, adenomyosis, endometriosis, PID, malignancy Ix – pelvic USS, hysteroscopy Tx depends on cause

Question 273

Post-coital bleeding

Answer 273

= Vaginal bleeding after intercourse that is not menstrual loss. Always abnormal (unless 1st intercourse) ALWAYS exclude cervical cancer

Question 274

Causes of post-coital bleeding

Answer 274

Cervical carcinoma – MUST EXCLUDE => Cervical inspection and smear. => If no obvious cause, colposcopy to exclude malignancy. Cervical ectropions/eversion Benign cervical polyps

Question 275

Hypertension at booking visit

Answer 275

NOT pre-eclampsia => Essential or secondary HTN Need: • Careful history & physical examination • U&Es • Urine microscopy/renal USS/urinary catecholamines

Question 276

When does pre-eclampsia occur?

Answer 276

After 20 week's gestation

Question 277

What is pre-eclampsia?

Answer 277

= an endothelial cell disorder involving an excessive inflammatory response to pregnancy it is CAUSED by pregnancy and CURED by delivery (of the placenta)

Question 278

What are the features of pre-eclampsia?

Answer 278

Hypertension Proteinuria Oedema Multiorgan involvement Foetal compromise Significant maternal morbidity

Question 279

What are risk factors for pre-eclampsia?

Answer 279

* Extremes of reproductive age * Socio-economic status * Ethnic groups * Genetic factors * Multiple pregnancy * Primigravida * Assisted conception * Previous pre-eclampsia * Obesity * Chronic renal disease * Chronic hypertension * DM * Connective tissue diseases * Certain thrombophilias

Question 280

Pathophysiology of pre-eclampsia

Answer 280

1. Abnormal Placentation 2. Endothelial Cell Dysfunction 3. Organ Hypoperfusion 4. Plasma Volume Loss

Question 281

Pre-Eclampsia - abnormal placentation

Answer 281

* Failure of invasion of trophoblast cells * Maternal spiral arteries continue to have thick muscular walls * Reduced maternal perfusion of placenta and possible vasospasm * Placental damage leading to increased apoptosis (cell death) * Release of circulating factors or placental syncytial fragments

Question 282

Pre-Eclampsia - Endothelial Cell Dysfunction

Answer 282

* Tissue oedema (increased endothelial cell permeability) * Hypertension (altered production of vasodilator substances) * Clotting dysfunction (abnormal production of procoagulants by endothelial cells)

Question 283

Pre-Eclampsia - Organ Hypoperfusion

Answer 283

* Due to chronic/acute vasoconstriction | * Underperfusion/focal ischaemia in kidneys, liver, brain

Question 284

Pre-Eclampsia - Plasma Volume Loss

Answer 284

* Intravascular compartment becomes constricted and underfilled. * May be considerable tissue oedema * Low intravascular volume contributes to poor organ perfusion (including of the fetoplacental unit)

Question 285

Foetal complications of pre-eclampsia

Answer 285

``` IUGR Intrauterine hypoxia Prematurity Increased risk of placental abruption Stillbirth/intrauterine death HTN/IHD/metabolic disease later in life ```

Question 286

Maternal complications of pre-eclampsia

Answer 286

Eclampsia - Grand mal seizures due to cerebral vasospasm ``` Cerebrovascular Haemorrhage Retinal detachment DIC Thromboelbolism Renal failure Pulmonary oedema HELLP Syndrome (liver failure) ```

Question 287

HELLP syndrome

Answer 287

H - Haemolysis (low grade, rarely enough to cause severe anaemia) EL - Elevated liver enzymes (transaminases, lactate dehydrogenases, bilirubin) LP – Low platelets

Question 288

What is used for treatment of eclamptic seizures?

Answer 288

Mg Sulphate

Question 289

Umbilical artery - absent end diastolic flow

Answer 289

can be normal in early pregnancy (up to 16 weeks) mid to late pregnancy it usually occurs as a result of placental insufficiency

Question 290

Umbilical artery - reduced end diastolic flow

Answer 290

Indicates significant increase in resistance to blood flow within the placenta Associated with significant perinatal mortality

Question 291

Indications for delivery in Pre-eclampsia

Answer 291

Hypertension remaining uncontrolled despite maximal antihypertensives Eclampsia Renal, hepatic or coagulation impairment Pulmonary oedema Foetal distress Milder pre-eclampsia at term

Question 292

Which antihypertensive medications are used in pregnancy?

Answer 292

``` Labetalol Nifedipine Methyldopa Prazosin/Doxazocin Atenolol ``` Hydralazine in emergencies

Question 293

Which antihypertensive medications are avoided in pregnancy?

Answer 293

ACEis and diuretics

Question 294

Involution of the Uterus

Answer 294

= Return of the uterus to pre-pregnant size Normally firm and in midline Fundus at the level of the umbilicus post-partum Day 1 Descends one finger breadth (1 cm) a day for 10 days

Question 295

What are possible post-partum problems?

Answer 295

``` PPH (primary or secondary) Haematoma Infection VTE Mood disturbance ```

Question 296

Symptoms of post-partum haematoma

Answer 296

``` Severe pain Mass felt on vaginal examination Flank pain Abdominal distension Shock ```

Question 297

Management of post-partum haematoma

Answer 297

Conservative (if small) Surgery – incision and drainage Vaginal pack Catheter

Question 298

Puerperal infection

Answer 298

= infection of the genital tract that occurs at any time between the onset of rupture of the membranes or labour and the 42nd day post-partum (or post-termination).

Question 299

Predisposing factors for puerperal infection

Answer 299

``` Poor nutrition Low socio-economic group Hx of infections Anaemia Immunodeficiency ``` ``` Prolonged labour PROM Poor aseptic technique Birth trauma / Episiotomy Multiple VEs C-section ``` Manual removal of placenta Haemorrhage Retained products

Question 300

Endometritis

Answer 300

= infection of the uterus (endometrium, myometrium, or parametrium) Ascends from lower genital tract usually occurs within 10 days of delivery/miscarriage/termination

Question 301

Risk factors for post-partum endometritis?

Answer 301

Most important factor is mode of delivery => 1-3 % risk after NVD, 15-40% after Caesarean section Also: PROM, multiple vaginal examinations, UTI, GBS carrier, DM, poor nutrition, poor health, catheterisation

Question 302

Signs and symptoms of endometritis

Answer 302

Fever, abdominal pain, offensive discharge Pyrexia, tachycardia, lower abdominal tenderness, offensive discharge, uterine and adnexal tenderness

Question 303

Endometritis - investigations

Answer 303

Bloods – FBC, CRP, (+/- U&E, coagulation) Cultures – bloods, swabs (+/- MSU)

Question 304

Endometritis - management

Answer 304

Antibiotics (broad spectrum) Analgesia Drain any collection Consider Sepsis 6 bundle (blood cultures, IV Abx, fluid, serum lactate, oxygen, catheter)

Question 305

What is mastitis? | When does it develop post-partum?

Answer 305

= Infection of breast tissue Develops after breast milk is established, 2-4 weeks postpartum

Question 306

Causes of mastitis

Answer 306

``` Bacteria enters through cracks in nipple Milk stasis Poor hand washing Breast not dry or wet breast pad Incorrect placement of baby causes sore nipples ```

Question 307

Risk factors for mastitis

Answer 307

ineffective or infrequent breast feeding or milk stasis from engorgement, skipping a breast

Question 308

What are common pathogens causing mastitis?

Answer 308

E. Coli or Staph. aureus

Question 309

Signs and symptoms of mastitis

Answer 309

Fever, chills, malaise, painful, warm, red area of breast

Question 310

Management of mastitis

Answer 310

Supportive bra Breast feed frequently Warm compress before feeding Cold packs between feedings Analgesia Antibiotics (flucloxacillin or erythromycin) Increase fluids Drain any abscess

Question 311

Post-partum UTI

Answer 311

Bladder hypotonia post-delivery and residual urine and reflux leads to increased risk of UTI Most commonly caused by E. coli

Question 312

Risk factors for post-partum UTI

Answer 312

Frequent VE, catheterisation, birth trauma

Question 313

Sites of Post-partum Wound Infection

Answer 313

Incision (Caesarean), | Perineum (episiotomy or laceration)

Question 314

Signs and symptoms of wound infection

Answer 314

Erythema, bruising, oedema, purulent drainage, wound edges not approximated, pain, tenderness, pyrexia and signs of sepsis

Question 315

Management of wound infection

Answer 315

``` Wound and blood cultures Sutures/staple removal Antibiotics (broad spectrum) Analgesics Wound dressing (involve specialists) Drain purulent material Surgery ``` Sepsis bundle if necessary

Question 316

Causes of VTE in pregnancy?

Answer 316

Hypercoagulability of blood (↑ factor VIII, IX, X thrombin),(↓ fibrinolytic activity protein S) Venous stasis Endothelial injury

Question 317

Prevention of VTE

Answer 317

``` Avoid dehydration Avoid trauma to legs (lithotomy) Early postpartum mobilisation Leg exercises to support venous return Avoid smoking TED stockings ``` Prophylactic anticoagulants RCOG VTE assessment tool

Question 318

what is a Positive Homan’s sign ? | What might it indicate?

Answer 318

pain in the calf is produced by passive dorsiflexion of the foot indicates possible DVT

Question 319

Diagnosis of DVT

Answer 319

Doppler USS

Question 320

Treatment of CVT

Answer 320

LMWH (start before diagnosis confirmed) (+/- warfarin in the post-natal period). => Duration: 3 months Elevate leg and TEDS

Question 321

Symptoms/signs of PE

Answer 321

* Sudden, sharp, pleuritic chest pain * Shortness of breath/tachypnoea * Cough/Haemoptysis * Tachycardia * Sweating * Pyrexia * Hypotension/Collapse

Question 322

Investigations for suspected PE

Answer 322

* Blood gases: hypoxia * CXR * ECG * V/Q scan * CTPA * Leg Doppler if symptomatic

Question 323

Management of PE

Answer 323

= MEDICAL EMERGENCY * Anticoagulation (LMWH) prior to confirming diagnosis * Analgesia * Oxygen * (Thrombolysis / Embolectomy) Any woman with VTE in pregnancy/puerperium will require AN and PN thromboprophylaxis in subsequent pregnancies.

Question 324

Baby blues

Answer 324

~70% of women (very common) Occurs a few days after birth (day 3-4 PN), but self-limiting (days, up to 2 weeks) Transient feelings of tearfulness, fatigue, anxiety and irritability; Mild depression with interspersed happier feelings No association with previous psychiatric history.

Question 325

Postnatal Depression - onset

Answer 325

Onset between birth and 1 year post-natal Highest risk in first 3 months

Question 326

how common is Postnatal Depression?

Answer 326

Common – 10-15% of women

Question 327

Risk factors for post-natal depression

Answer 327

• Primiparity * Personal history of depression or substance misuse. * Depression during pregnancy * Family history of depression * Lack of support/ single parent * Marital or financial stress * Birth complications * Pre-term birth

Question 328

DDx for post-natal depression

Answer 328

puerperal psychosis, postpartum thyroiditis, anaemia

Question 329

Treatment of post-natal depression

Answer 329

Medication – SSRI Counselling/cognitive therapy Support groups

Question 330

How common is Puerperal Psychosis? | When does it normally occur?

Answer 330

Less common: 0.1 - 0.2% of births Usually occurs 3-6 weeks after delivery (up to 1 year)

Question 331

Who is at highest risk of puerperal psychosis?

Answer 331

People with: * bipolar disorder, * previous puerperal psychosis * schizo-affective disorder

Question 332

Symptoms of puerperal psychosis

Answer 332

Symptoms of depression In addition, there can be: - Agitation - Restlessness - Obsessive thoughts about baby - Rapid mood swings (mimic bipolar) - Delusions/ Hallucinations - Paranoia - Suicidal or homicidal thoughts

Question 333

Treatment of puerperal psychosis

Answer 333

= Medical emergency (suicide/infanticide risk) Hospitalisation (psychiatric mother and baby unit: voluntary or under MHA) Antipsychotic medication Psychotherapy

Question 334

Hormonal control of spermatogenesis

Answer 334

LH causes testosterone production in Leydig cells Testosterone and FSH control synthesis and transport of sperm in Sertoli cells

Question 335

Definition of infertility

Answer 335

= the inability to conceive after 1-year unprotected vaginal sexual intercourse, without any known cause of subfertility in a woman of reproductive age.

Question 336

How many couples will conceive within 1 year of trying?

Answer 336

~80%

Question 337

What is the impact of infertility?

Answer 337

``` Sense of failure Marital disharmony Psychological illness Financial implications – IVF treatment Anxieties – can continue during pregnancy, if it is achieved. ```

Question 338

Potential Causes of Subfertility

Answer 338

1. Unexplained => A large proportion occur due to defective implantation. 2. Male factors 3. Ovulation dysfunction 4. Tubal damage 5. Endometriosis 6. Coital problems 7. Cervical factor

Question 339

What are the possible causes of male infertility?

Answer 339

Primary Testicular Failure Hypogonadotrophic (Secondary Testicular Failure) Androgen Resistance (Testicular Feminisation) Genital Tract Obstruction - CF, absence of vas deferens, chlamydia/gonnorhoea ``` Immotile Sperm Problem with Coitus Uncertain Aetiology Systemic Illness Lifestyle Factors ```

Question 340

What are lifestyle factors that can affect fertility?

Answer 340

Drugs/ toxins – Therapeutic, occupational, recreational ``` Smoking Alcohol intake Caffeine Weight Stress/sleep dysfunction ```

Question 341

How can sleep disturbances/stress affect male fertility?

Answer 341

Testosterone secretion follows a diurnal pattern and increased with REM sleep.

Question 342

What are causes of Primary Testicular Failure?

Answer 342

Congenital - e.g. Klinefelter's Acquired - e.g. Mumps orchitis, testicular torsion, trauma, inguinal/scrotal surgery, radiotherapy

Question 343

Causes of Secondary Testicular Failure?

Answer 343

Idiopathic Acquired - e.g. cranial space occupying lesions, trauma, meningitis

Question 344

What are causes of female infertility?

Answer 344

``` Anovulation Thyroid Dysfunction Tubal Damage Uterine Problems Cervical Problems ``` ``` Increasing age Lifestyle factors Implantation defects Embryo development issues Metabolic disorders, immunological and genetic factors ```

Question 345

Causes of anovulation

Answer 345

1. PCOS 2. Hyperprolactinaemia 3. Hypothalamic Hypogonadism 4. Premature ovarian failure

Question 346

Sx of PCOS

Answer 346

infertility, oligomenorrhoea, hirsutism

Question 347

Risk factors for PCOS

Answer 347

genetics, high BMI, T2DM

Question 348

what occurs in Hypothalamic Hypogonadism in women? What causes it?

Answer 348

Decreased GnRH release = decreased LH/FSH and oestrogen. Causes – anorexia nervosa/reduced BMI, athletes, stress, Kallman Syndrome

Question 349

Kallmann syndrome

Answer 349

lack of production of certain hormones that direct sexual development Causes delayed or absent puberty and an impaired sense of smell

Question 350

How does hyperprolactinaemia cause anovulation?

Answer 350

Increased prolactin causes decreased release of GnRH

Question 351

What can cause tubal damage?

Answer 351

1. Infection - PID, STIs 2. Endometriosis 3. Previous Pelvic Surgery

Question 352

What uterine problems can affect fertility?

Answer 352

Submucous fibroids Intrauterine adhesions Polyps Anatomical abnormalities

Question 353

What Cervical Problems can affect fertility?

Answer 353

Cervical mucous hostility/anti-sperm antibodies => Kills sperm Loop excision of TZ of cervix. => No mucous for sperm to travel in

Question 354

What investigations are done for male infertility?

Answer 354

Semen Analysis Sperm DNA Fragmentation Test Blood tests – FSH, LH, TSH, testosterone, prolactin Testicular examination Genetic – Karyotype, CF screening

Question 355

How is semen analysis performed?

Answer 355

Sample produced by masturbation after 2-7 days abstinence Analysed within 1-2 hours, repeat abnormal results in 12 weeks Values measured = Volume, Total sperm, Sperm conc., Total motility, Morphology, Vitality, pH

Question 356

What is the normal volume of ejaculate?

Answer 356

>1.5 mL

Question 357

What is a normal sperm count?

Answer 357

>15 million/mL

Question 358

Azoospermia

Answer 358

= no sperm in ejaculate

Question 359

Oligospermia

Answer 359

= low sperm count in ejaculate | <15 million/mL, severe if <5 million/mL

Question 360

Asthenospermia

Answer 360

= sperm count where motility is poor.

Question 361

What investigations are done for female infertility?

Answer 361

``` Rubella Status Cervical swabs Follicular Phase Hormone Profile Endocrine Profile (if indicated) Ovulation Detection Tests of tubal latency USS scan of anatomy ```

Question 362

Follicular Phase Hormone Profile

Answer 362

Day 1-5 if regular periods, any time if irregular/absent Measure FSH, LH, oestradiol

Question 363

Follicular phase - FSH levels

Answer 363

* FSH raised in ovarian failure * FSH low in hypothalamic failure * FSH normal in PCOS

Question 364

Ovulation Detection

Answer 364

Luteal progesterone => day 21 should be mid-luteal increase (if 28-day cycle) USS ovulation tracking to detect follicle size/rupture Basal Body temperature

Question 365

Management of male infertility

Answer 365

Lifestyle changes: - Reduce or stop smoking/alcohol/drug exposure - Weight management - Testicles below body temperature (loose clothing/cooling methods). Hormonal – gonadotrophins Varicocoele – surgery Intrauterine Insemination with donor/husband semen Assisted contraception techniques

Question 366

Management of female infertility

Answer 366

General Measures: - Folic acid/Vitamin D - Diet and weight advice - Reduce or stop smoking/alcohol/drug exposure - Cervical smear Ovulation Induction Assisted contraception techniques

Question 367

What is the 1st line for Ovulation Induction? How does it work?

Answer 367

Clomifene - used for ~6-9 cycles Acts to decrease oestrogen levels, so the brain releases more GnRH => More FSH, LH for follicle development.

Question 368

What are other mechanisms (apart from clomifene) to induce ovulation ?

Answer 368

Gonadotrophins Metformin (insulin sensitisation in PCOS, often used combined with clomifene) Letrozole (aromatase inhibitor) Laparoscopic ovarian drilling Dopamine agonists (for hyperprolactinaemia)

Question 369

Risks of ovulation induction

Answer 369

If >1 follicle develops, there is risk of multiple pregnancies Ovarian Hyperstimulation syndrome (OHSS)

Question 370

what is Ovarian Hyperstimulation syndrome (OHSS)?

Answer 370

Exposure of hyperstimulated ovaries to hCG leads to the production of pro-inflammatory mediators increased vascular permeability leads to loss of fluid into the third space Sx – abdominal discomfort/pain (+/- oedema, ascites, SoB, hypovolaemia) RFs - gonadotrophins, IVF, <35yo, PCOS Management is supportive treatment

Question 371

Indications for assisted conception:

Answer 371

* All other methods have failed * Male factor subfertility * Unexplained subfertility >2 years * Endometriosis/tubal blockage * Genetic disorders

Question 372

Intrauterine Insemination

Answer 372

15-20% success Insert sperm into uterus (often following ovarian stimulation) Cheaper than IVF but need patent fallopian tubes Useful if cervical factors/endometriosis

Question 373

In Vitro fertilisation

Answer 373

35% success per cycle (10% if >40 years old) Consider after 2 years of trying to conceive Sperm and oocyte mixed in petri dish Needs normal oocyte production (not possible in ovarian failure) Pre-implantation genetic diagnosis if >37yo mother/high risk of genetic conditions

Question 374

Steps of IVF

Answer 374

1. Follicular development 2. Ovulation induction 3. Egg collection (transvaginal aspiration with USS guidance) 4. Fertilisation and transfer

Question 375

Risks of IVF

Answer 375

``` haemorrhage on egg collection, failure, multiple pregnancy, OHSS, ectopic pregnancy ```

Question 376

Why is cardiac disease a major cause of maternal mortality during pregnancy? what are important symptoms?

Answer 376

a damaged heart copes less well with the increased demand during pregnancy. It is often difficult to differentiate pathological cardiac symptoms from physiological ones in pregnancy => Persistent tachycardia and orthopnoea are important and should be fully investigated

Question 377

When does maternal cardiac disease cause the most problems in pregnancy?

Answer 377

>28 weeks OR During labour: 1. 1st stage – sympathetic response to pain and anxiety, supine position. 2. 2nd stage – BP increases with pushing, venous return decreases with pushing. 3. 3rd stage – up to 1L of blood returns to circulation

Question 378

Management of pregnancy with maternal cardiac disease

Answer 378

Consultant-led care Treat conditions before pregnancy if possible. Review medications and stop contraindicated drugs (e.g. warfarin, ACEI) Regular checks – BP, anaemia, foetal abnormalities

Question 379

Management of labour/birth with maternal cardiac disease

Answer 379

- CTG monitoring - Epidural (Pain control and reduces maternal tachycardia) - Position – avoid supine - Vaginal birth is recommended, unless obstetric indications for C-section (Less rapid haemodynamic changes) - Depending on severity, pushing (active 2nd stage) may be avoided and forceps/ventouse used to facilitate delivery.

Question 380

Problems associated with epilepsy in pregnancy

Answer 380

Seizure control is decreased (especially in labour or when sleep deprived) Morning sickness can affect medication Seizures can be associated with foetal hypoxia. Recurrent tonic-clonic seizures can cause IUGR There is increased risk of NTDs and also congenital heart defects, urinary tract/skeletal abnormalities and cleft palate due to medication

Question 381

Antenatal management of epilepsy in pregnancy

Answer 381

Consultant-led care Seizure control (aim for seizure free) => As few drugs as possible, at the lowest dose. => Involve the neurology team – DO NOT change drugs without their advice. => Sodium valproate is contraindicated unless no alternative therapies. => Safest drugs – carbamazepine, lamotrigine Folic acid supplementation – 5mg OD pre-conception Vitamin K supplementation – 10mg OD from 36 weeks Offer high resolution USS for anomalies (18-20 weeks) and serial growth scans

Question 382

Intrapartum management of epilepsy in pregnancy

Answer 382

Hospital delivery Continue AEDs during labour Appropriate care/analgesia to minimise risk factors for seizures (such as insomnia, stress and dehydration). => But avoid pethidine, as it increases seizure frequency.

Question 383

Postnatal management of epilepsy in pregnancy

Answer 383

Continue AEDs (may require dose adjustment) Support to minimise triggers for seizures (sleep deprivation, stress, pain) Safety strategies for minimising risk to baby during seizures Contraception – will depend on which AEDs the patient is taking.

Question 384

Obesity - maternal risks

Answer 384

``` Thromboembolism Pre-eclampsia GDM C-section PPH Wound infection Epidural failure/aspiration during GA Difficult IV access ```

Question 385

Obesity - foetal risks

Answer 385

``` Congenital abnormalities Increased mortality Miscarriage/stillbirth NTDs Macrosomia (causing shoulder dystocia) ```

Question 386

Antenatal management of maternal obesity

Answer 386

Lifestyle advice – diet, exercise, weight loss Consultant-led care 5mg folic acid and VitD Thromboprophylaxis Monitor for GDM and HTN => OGTT at 28 weeks => Serial growth scans

Question 387

Intrapartum/Postnatal management of maternal obesity

Answer 387

``` IOL if large baby Continuous CTG in labour May need to use FSE if difficult contact with CTG Thromboprophylaxis Active management of 3rd stage ```

Question 388

Glycaemic changes in pregnancy

Answer 388

1. Increased peripheral resistance to insulin due to hormones => Higher post-prandial glucose => Resistance increases with gestation. 2. Transplacental glucose transport to the foetus – lowers fasting glucose. => Reflects maternal levels (hyperglycaemia means more transported to foetus)

Question 389

Complications of Hyperglycaemia in Pregnancy

Answer 389

= Related to glucose levels, so usually less severe in GDM. ``` MATERNAL: Hypoglycaemia/ketoacidosis Infection Pre-eclampsia Deterioration of pre-existing disease (e.g. retinopathy/nephropathy) ``` ``` FOETAL: Hypoglycaemia Respiratory distress syndrome Congenital abnormalities (glucose = teratogenic) IUGR/IUFD Macrosomia Polyhydramnios Preterm labour Stillbirth Birth complications ```

Question 390

How can maternal hyperglycaemia cause foetal macrosomia?

Answer 390

High maternal blood glucose crosses the placenta and stimulates foetal insulin production, which acts as a growth promotor (bone, muscle, adipose).

Question 391

Management of pre-existing DM in pregnancy

Answer 391

Pre-pregnancy: - Optimise glycaemic control - Folic acid 5mg OD During pregnancy: - Increase insulin dose to maintain normoglycaemia - Aspirin 75mg daily to reduce pre-eclampsia risk - Regular BM, HbA1c, BP and renal monitoring. - Regular foetal monitoring (20-week USS and regular growth scans) Delivery by 39 weeks.

Question 392

What is GDM? What causes it?

Answer 392

= Glucose intolerance first diagnosed in pregnancy (may or may not resolve after). occurs if pancreatic beta-cells are unable to produce sufficient insulin to counteract the normal glycaemic changes in pregnancy

Question 393

Risk factors for GDM

Answer 393

``` PMHx/FHx of GDM 1st degree relative with DM BMI >30 Ethnicity (Black Caribbean, south Asian) Previous large foetus (>4.5kg) Previous unexplained stillbirth ```

Question 394

Screening for GDM

Answer 394

Booking appointment – screen for risk factors 28 weeks if RFs (or ASAP if previous GDM/DM) – OGTT OGTT any time if detect pregnancy risk factors (polyhydramnios, persistent glucosuria)

Question 395

Antenatal Management of GDM

Answer 395

1. Lifestyle advice – diet and exercise 2. Oral agents – e.g. metformin 3. Insulin 4. 75mg aspirin (prophylaxis for pre-eclampsia) 5. Folic acid 5mg 6. Regular foetal growth scans 7. Further Ix: - HbA1c (rule out T2DM) - Abdominal palpation (SFH, lie, pain) - USS & foetal artery dopplers

Question 396

Post-partum management of GDM

Answer 396

Educate on increased lifetime risk of DM Educate on increased recurrence of GDM Carefully monitor foetus for 24 hours

Question 397

What is menopause?

Answer 397

= the permanent cessation of menstruation due to loss of ovarian activity after the natural depletion of oocytes

Question 398

Perimenopause

Answer 398

= from first onset of symptoms to 12 months after last menstrual period.

Question 399

Post-menopause

Answer 399

= the period after 12 months since last menstrual period

Question 400

What is the average age of menopause? | When is menopause considered premature?

Answer 400

= 51 years = menopause before 40 years old

Question 401

How is menopause diagnosed?

Answer 401

If healthy and >45, diagnosis is based on vasomotor symptoms and irregular periods. If <45, then blood tests to measure FSH are required for diagnosis.

Question 402

Symptoms of menopause

Answer 402

Vasomotor symptoms – hot flushes and night sweats Urinary problems – frequency, urgency, nocturia, incontinence, infection. Vaginal atrophy – dyspareunia, itching, burning, dryness Loss of libido Psychological symptoms (e.g. anxiety/depression, reduced concentration, mood swings, forgetfulness) Risk of CVD Risk of osteoporosis (fractures)

Question 403

Menopause - what investigations may be needed?

Answer 403

1. Check ovarian reserve - FSH levels 2. Rule out other causes of symptoms (TSH, catecholamines) 3. DEXA scan to check for osteoporosis/fracture risk 4. Investigations to check suitability for HRT

Question 404

What will FSH levels be during the menopause?

Answer 404

raised due to loss of -ve feedback from oestrogen

Question 405

What is a pre-requisite for oestrogen-only HRT for the menopause?

Answer 405

Patient must not have a uterus (risk of endometrial ca)

Question 406

Menopause - Benefits of HRT

Answer 406

Treats vasomotor, vaginal and urinary symptoms Reduces risk of osteoporosis and fractures Reduces risk of colorectal cancer Prevents dementia and preserve cognition

Question 407

Menopause - Risks of HRT

Answer 407

Oestrogen only – endometrial cancer Combination – breast cancer Increased risk of VTE/CVA Increased risk of gallbladder disease

Question 408

Side effects of HRT

Answer 408

``` Headaches, nausea, Mood swings, Abnormal PV bleeds, Fluid retention, breast tenderness, Dyspepsia. ```

Question 409

How long is HRT provided for the menopause?

Answer 409

5 years at the lowest effective dose, and then review the risk vs. benefit.

Question 410

What type of HRT regime is used for perimenopausal women?

Answer 410

CYCLICAL combined HRT = daily oestrogen and 14 days of progesterone (either monthly or 3-monthly, to induce bleed).

Question 411

What type of HRT regime is used for postmenopausal women?

Answer 411

CONTINUOUS combined HRT = daily oestrogen and progesterone (amenorrhoea)

Question 412

What non-HRT options are available for managing symptoms of menopause?

Answer 412

Lifestyle measures – meditation, stop smoking, reduce alcohol intake, exercise. Hot flushes/night sweats – SSRIs, clonidine Vaginal atrophy – lubricants, creams, moisturisers Osteoporosis – lifestyle factors, bisphosphonates, calcium/vitD, raloxifene, denosumab

Question 413

What is a normal Symphysial Fundal Height ?

Answer 413

Normal = gestation +/- 2cm | Not usually measured before ~20 weeks

Question 414

What may make SFH inaccurate?

Answer 414

BMI >35 Large fibroids Polyhydramnios

Question 415

what should women be offered if foetal AC or EFW is <10th centile, or there is evidence of reduced growth velocity?

Answer 415

women should be offered serial assessment of fetal size and umbilical artery Doppler

Question 416

Symmetrical SGA

Answer 416

= small HC and AC, occurs from early pregnancy ~20% of SGA cases

Question 417

Asymmetrical SGA

Answer 417

= normal HC, small AC occurs later in pregnancy ~80% of SGA cases

Question 418

Small for gestational age (SGA)

Answer 418

= a statistical observation Definitions vary – generally foetus <10th centile for gestational age (WHO)

Question 419

When can SGA be normal?

Answer 419

Can be constitutionally small – no pathology is present. => Contributing factors include ethnicity, sex, and parental height.

Question 420

Foetal Growth Restriction (FGR)

Answer 420

= Failure of foetus to reach its genetic growth potential – due to a pathological process. Growth velocity slows down or stops because of inadequate nutrition supply and utilisation and/or oxygenation

Question 421

Causes of FGR - placenta-mediated

Answer 421

- Utero-placental insufficency | - Pre-eclampsia

Question 422

Causes of FGR - non-placenta mediated

Answer 422

- Chromosomal abnormality - Congenital anomaly - An error in metabolism - Foetal infection – varicella, CMV, rubella, syphylis, toxoplasmosis, (malaria) Maternal factors: - Nutrition - Smoking, Alcohol - Drugs – cocaine, heroin, beta-blockers. - Maternal disease

Question 423

What determines how many growth scans a woman will have during pregnancy?

Answer 423

Women with 1 major risk factor – serial growth scans Women with ≥3 minor risk factors – uterine artery doppler at 20-24 weeks to decide if additional scans warranted and how frequently

Question 424

Prevention of FGR

Answer 424

Aspirin (small effect - increase placental blood flow) Stop smoking

Question 425

Management of FGR

Answer 425

Optimal surveillance method and frequency: - Foetal biometry and amniotic fluid volume - Umbilical artery Doppler +/- regional Dopplers - Foetal medicine surveillance may be recommended Timing of delivery = dependent on doppler results. - Caesarean if abnormal umbilical Doppler (AEDF/REDF) - Steroids to promote lung development if pre-term delivery. - Continuous monitoring in labour - Neonatologist at delivery

Question 426

Foetal Macrosomia

Answer 426

(also LGA) = EBW >90th centile for gestational age = Birth weight > 4000g or 4500g

Question 427

Risk factors for foetal macrosomia

Answer 427

Previous macrosomia ``` Foetal sex (male) Genetic factors - taller, heavier patients tend to have larger babies ``` Maternal diabetes / Obesity Excessive maternal weight gain Post-dates pregnancy Multiparity Congenital anomalies (hydrops) Genetic disorders (e.g. Beckwith-Wiedermann)

Question 428

What labour/post-partum complications can occur due to macrosomia?

Answer 428

- Prolonged first stage of labour => need for augmentation - Prolonged second stage of labour => need for instrumental delivery - Shoulder dystocia and birth trauma (nerve damage, fractures, birth asphyxia) - Emergency caesarean section - Perineal trauma - Post-partum haemorrhage - Neonatal hypoglycaemia

Question 429

What are the available options for unwanted pregnancy?

Answer 429

* Continuation of pregnancy * Continuation and offer for adoption/fostering * Termination of pregnancy (not available in all countries!)

Question 430

Grounds for termination of pregnancy?

Answer 430

A. The continuation of pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated. B. The termination is necessary to prevent grave permanent injury to the physical/mental health of the pregnant woman. C. The pregnancy has not exceeded its 24th week and the continuation of pregnancy would involve risk greater than if the pregnancy were terminated to the physical/mental health of the pregnant woman. D. The pregnancy has not exceeded its 24th week and that the continuation of pregnancy would involve risk greater than if the pregnancy was terminated to the physical/mental health of any existing children or the family of the pregnant woman. E. There is substantial risk that if the child were born it would suffer from such physical/mental abnormalities as to be seriously disabled.

Question 431

What is the most common ground for terminating a pregnancy?

Answer 431

C is the most common ground for termination, followed by E.

Question 432

ToP in under 16s

Answer 432

Explain limits of confidentiality – assess Gillick Competency/Fraser Guidelines Safeguarding assessment Explore support available <13s unable to consent to sex = MUST refer to social care

Question 433

Referral to TOP

Answer 433

1. Self-referral by contacting an abortion provider directly 2. GP referral to an abortion service 3. Sexual health clinic can redirect to abortion provider

Question 434

Medical TOP - drugs used

Answer 434

1. Mifepristone (Antiprogesterone) • Dose = 200mg orally • Interrupts the pregnancy by encouraging placental detachment. • Induces cervical ripening and uterine contractions 2. Misoprostol (Prostaglandin): • 24-48 hours after Mifepristone. • 1st Dose = 800mcg vaginally (can be done at home) • 2nd dose = 400mcg vaginally/orally after 4 hours. • Repeated dosage used 3 hourly for late MTOP • Uterotonic effects cause softening of the cervix and contraction of the uterus, causing expulsion of the products of conception.

Question 435

Timings of MTOP

Answer 435

Early MTOP = before 10 weeks. Late MTOP = after 14 weeks (Between 10-14 weeks, surgical TOP is required) If >22 weeks, inject foetal heart/umbilical cord with KCl to prevent live birth.

Question 436

Contraindications to MTOP

Answer 436

- Pulmonary HTN - Oral Steroid use - Bleeding disorder/anticoagulant use - Renal insufficiency - Severe asthma - Previous CVA - Breastfeeding - Anaemia

Question 437

Surgical TOP

Answer 437

Give pre-op Abx to cover against chlamydia and anaerobes. Tends not to be used before 10 weeks (medical methods used). Misoprostol can be given for cervical ripening before surgical TOP. - 7-13 weeks – suction curettage TOP (under GA or LA) - >13 weeks – surgical TOP by dilatation and evacuation.

Question 438

Side effects of TOP

Answer 438

* Dizziness, hot flushes * Diarrhoea and nausea * Period-like cramping * Vaginal bleeding

Question 439

Complications of MTOP

Answer 439

- Haemorrhage - Infection (10%) - Failure (1%)

Question 440

Complications of surgical TOP

Answer 440

- Haemorrhage - Infection (10%) - Uterine perforation - Cervical trauma - Risk of preterm delivery - Failure (0.2%)

Question 441

What is the impact of abortion on future pregnancies ?

Answer 441

Abortion does not affect future fertility

Question 442

Post-termination care

Answer 442

Analgesia and 24-hour support helpline. Anti-D immunoglobulin to all non-sensitised Rh-negative women ABX prophylaxis Follow up after MTOP – rule out ongoing pregnancy/ectopic. => low sensitivity pregnancy test 2-3 weeks after medical TOP.

Question 443

TOP and retained products of conception

Answer 443

Hx of prolonged bleeding and pain Bulky, soft uterus with open cervical os = clinical diagnosis USS to r/o live pregnancy Pregnancy test can remain positive for up to 6 weeks and is not diagnostic. Managed expectantly, medically or surgically

Question 444

What are forms of LARC?

Answer 444

Implant IUS IUD Injection

Question 445

What is the main action of the Progestogen Releasing Implant

Answer 445

Mainly prevents ovulation Also thickens mucous and thins endometrium

Question 446

Implant - insertion

Answer 446

Time to effect = 7 days (use barrier contraception for 7 days). Inserted sub-dermally, over the triceps muscle (under local anaesthetic)

Question 447

How long is the contraceptive implant licensed for?

Answer 447

3 years

Question 448

Implant - Cautions/Contraindications

Answer 448

current breast cancer, past breast cancer, CV event while using method, liver conditions.

Question 449

Implant - Advantages

Answer 449

Immediate return to fertility on removal | Compliance not an issue

Question 450

Implant - Side effects

Answer 450

Hormonal related – irregular bleeding/amenorrhoea, headaches, mood, breast tenderness Procedural risks – bruising, infection at site, etc

Question 451

Copper IUD - mechanism of action

Answer 451

Acts by blocking fertilisation (toxic to sperm). | As emergency contraception, it prevents implantation

Question 452

What must be excluded before insertion of IUD/IUS?

Answer 452

MUST exclude pregnancy | also STI

Question 453

IUD - advantages

Answer 453

- Time to effect = instant (immediate protection). - Unaffected by D&V - Rapid return to fertility

Question 454

IUD - contraindications/cautions

Answer 454

- Unexplained HMB - Previous ectopic - Gestational trophoblastic disease - Cervical/endometrial cancer. - Active/recent pelvic infection

Question 455

IUD - side effects

Answer 455

- Periods may be heavier, longer and more painful (but usually settles) - Risks associated with insertion – pain, bleeding, infection - Perforation of uterus - Can fall out (counsel to check threads after every period). - Ectopic pregnancy

Question 456

IUS - mode of action

Answer 456

prevents fertilisation and implantation

Question 457

How long does an IUD or IUS take to work?

Answer 457

IUD - instant effect IUS - 7 days to effect

Question 458

IUS - advantages

Answer 458

- Lighter, less painful periods (Mirena is only IUD licenced for HMB) - Less hormonal SEs as actions more localised - Unaffected by D&V - Rapid return to fertility.

Question 459

IUS - contraindications/cautions

Answer 459

The same as IUD, but also breast cancer

Question 460

IUS - side effects/risks

Answer 460

- Irregular bleeding for 3-6 months - Hormonal-related effects – headaches, mood changes, breast changes. - Procedural risks - Perforation - Can fall out - Ectopic pregnancy

Question 461

Contraceptive injection - Mode of action

Answer 461

Prevents ovulation, also thickens mucous and thins endometrium

Question 462

Contraceptive injection - length to effect

Answer 462

7 days to take effect

Question 463

Why is the typical use failure rate for the contraceptive injection higher than other LARCs?

Answer 463

6% with typical use, 0.2% with perfect use Relies on coming back for the injection every 12 weeks.

Question 464

Contraceptive injection - contraindications/cautions

Answer 464

Current breast cancer, osteoporosis risk, obesity

Question 465

Contraceptive injection - advantages

Answer 465

- May have less painful, lighter periods. | - Unaffected by D&V

Question 466

Contraceptive injection - side effects/risks

Answer 466

- Delay in return to fertility - Reversible effect on bone density ``` Also: Hormonal side effects Weight gain Irregular bleeding/amenorrhoea Cannot be removed ```

Question 467

COC - mechanism of action

Answer 467

Mainly inhibit ovulation, | Also thickens cervical mucous, thins endometrium

Question 468

How is the COC taken?

Answer 468

3 weeks on and 1 week off, or back-to-back.

Question 469

Effectiveness of COC?

Answer 469

- Perfect use – failure rate 0.3% - Typical use – failure rate 8% Time to effect = 7 days

Question 470

COC - advantages

Answer 470

- Lighter and less painful periods. - Protective against endometrial, ovarian and bowel cancers. - Protective against fibroids, ovarian cysts, endometriosis

Question 471

COC - side effects/risks

Answer 471

- Nausea, headaches, dizziness - Decreased libido - Breast tenderness - VTE, MI/CVD, CVA, migraine - HTN - Breast/cervical cancer

Question 472

COCP - contraindications/cautions

Answer 472

- VTE, CVA, IHD - Migraine with aura - Breast/endometrial cancer - BMI >40 - Pregnancy - >40 years old (>35 if smoker)

Question 473

COC - missed pills

Answer 473

- If D&V within 2 hours of taking the pill, take another. | - >2 missed pills = 7 days condom use

Question 474

POP - mechanism of action

Answer 474

inhibit ovulation, thickens cervical mucous, thins endometrium

Question 475

POP - time to effect

Answer 475

48 hours to take effect

Question 476

When can the POP be started after delivery?

Answer 476

immediately after

Question 477

POP - advantages

Answer 477

- Can be used when COCP is contraindicated. - Periods may be less painful - Not affected by broad spectrum Abx

Question 478

POP - contraindications/cautions

Answer 478

Current breast cancer | considered safest method of contraception

Question 479

POP - side effects

Answer 479

- Irregular menstrual bleeding - Breast tenderness - Acne - Mood changes, decreased libido - Ovarian cysts

Question 480

Contraception - barrier methods

Answer 480

Mechanism of action = prevent sperm from entering the cervix. Only method provide STI protection. High failure rate (12-18%)

Question 481

What are the options for emergency contraception?

Answer 481

1. Emergency IUD 2. Emergency Pill with Ulipristal Acetate (EllaOne) 3. Emergency Pill with Levonorgestrel (Levonelle)

Question 482

Emergency IUD

Answer 482

Insert before implantation occurs! (e.g. up to 5 days after unprotected sex or ovulation day) 99% efficacy Can be used as contraception going forward (immediate protection)

Question 483

Emergency Contraception - EllaOne

Answer 483

= 30 mg ulipristal acetate. Within 5 days of UPSI (but it is better to take is ASAP) 95% efficacy Progesterone receptor modulator => Interacts with progesterone (e.g. POP) ``` Cautions/CIs: • Previous ectopic • Severe malabsorption • Hepatic impairment • CYP450 inducing drugs • Progesterone (e.g. POP) ```

Question 484

Emergency Contraception - Levonelle

Answer 484

= Levonorgestrel 1500 mcg (synthetic progesterone) Can be used within 3 days of UPSI (but better to take it ASAP). 90% efficacy ``` Cautions/CIs: • Previous ectopic • Pregnancy • Severe malabsorption • Hepatic impairment ``` If BMI >26 / taking CYP450 inducing drugs Levonelle may not work - need double dose

Question 485

Which emergency contraception may not work if BMI is too high?

Answer 485

Levonelle

Question 486

Which emergency contraception may not work if the patient is taking the COC/POP for contraception normally?

Answer 486

EllaOne

Question 487

Side effects of the morning after pills

Answer 487

- N&V - Headaches - Skin changes - Menstrual cycle irregularities, next period earlier/later than expected

Question 488

Safety netting for morning after pills

Answer 488

- If vomit within 3 hours, take another - Take a pregnancy test in 3 weeks to ensure it worked - Wait 7 days before restarting COC/POP

Question 489

What are other factors to consider when providing Emergency Contraception?

Answer 489

Consensual intercourse/domestic violence STI risk – assessment and screening Ensure they are not already pregnant before offering EC Starting long-term contraception as well => Cannot quick-start hormonal contraception with EllaOne as progesterone decreases it efficacy

Question 490

What are some benign conditions of the vulva?

Answer 490

``` Bartholin’s Cyst Sebaceous Cyst Vulval Haematoma Lipoma/Fibroma/Myoma Condylomata Acuminata (genital warts) Simple Mesonephric (Gartner’s) or Paramesonephric Cysts Lichen Sclerosus Hypertrophic Vulval Dystrophy Vulval Intraepithelial Neoplasia ```

Question 491

Bartholin’s Gland

Answer 491

Situated within the vestibule, just lateral to the introitus Normally function to secrete a lubricating fluid.

Question 492

Bartholin’s Cyst

Answer 492

Occurs when the duct of the gland becomes obstructed: Palpable swelling (+/- pain)

Question 493

Bartholin’s Abscess

Answer 493

occurs when a Bartholin's cyst becomes infected => Extreme pain, lymphadenopathy, erythema => In rare cases causes systemic upset.

Question 494

Management of Bartholin’s Abscess/Cyst

Answer 494

- Incision and drainage under local anaesthetic - Abx for abscess - Surgery may be required in recurrent cases.

Question 495

Sebaceous Cyst of vulva

Answer 495

Infected sebaceous gland in the hair-bearing vulval skin. Presents with a lump/swelling (+/- pain) May require removal

Question 496

What is Vulval Haematoma? How is it managed?

Answer 496

A result of direct violence/trauma – common in childbirth Treated by incision and drainage

Question 497

Simple Mesonephric (Gartner’s) or Paramesonephric Cysts

Answer 497

Represent embryologic remnants of the caudal end of the mesonephric (Wolffian) duct

Question 498

What is Lichen Sclerosis ? How is it managed?

Answer 498

= an inflammatory skin condition which typically affects the genital and anal areas of the body. more common in women (particularly post-menopausal) Can lead to malignant changes (5% develop squamous cell carcinoma) Treatment – symptom control with emollients and topical steroid

Question 499

Clinical features of lichen sclerosis

Answer 499

- Leucoplakia (thin, shiny and white skin) and inflamed/red - Shrinkage and loss of labia minora - Itching and/or pain (potentially after urination/sexual intercourse) - Adhesions – can fuse labia together

Question 500

Hypertrophic Vulval Dystrophy

Answer 500

= Squamous cell hyperplasia Causes raised, thickened lesions (white/grey or red, depending on inflammation) Histologically appears as dystrophy with no atypia Treatment = topical steroids

Question 501

Vulval Intraepithelial Neoplasia - presentation and risk factors

Answer 501

a pre-cancerous condition Often asymptomatic, but there can be pruritis, pain, palpable lesions RFs - HPV, HSV-2, smoking, immunosuppression, chronic vulvar irritation, lichen sclerosis

Question 502

What accounts for the majority of vulval malignancies?

Answer 502

Squamous cell carcinoma (90%) | 2nd most common = melanoma

Question 503

What is the single most prognostic marker for vulval cancers?

Answer 503

lymph node status also depends on lesion size and histological grade

Question 504

Risk factors for vulval malignancy

Answer 504

``` HPV, VIN, CIN, Lichen sclerosus, Squamous hyperplasia, Immunodeficiency/immunosuppression, Hx genital warts, Hx cervical/vaginal cancer Smoking, alcohol ```

Question 505

Vulval malignancy - clinical presentation

Answer 505

* Lump +/- lymphadenopathy * Itching * Vulval pain * Pain/dysuria

Question 506

Vulval malignancy - diagnosis

Answer 506

ANY vulval lesion warrants biopsy

Question 507

Vulval malignancy - Treatment

Answer 507

- Wide local excision (stage Ia) - Radical local excision plus ipsilateral groin node dissection (stage Ib and II) - Radical vulvectomy - Surgery + radiotherapy and chemotherapy

Question 508

Bartholin Gland Carcinoma - diagnosis

Answer 508

rare; often mistaken for benign cysts or abscesses Honan’s criteria: - The tumour is in the correct anatomical position - The tumour is located deep in the labium majus - Overlying skin is intact - Some recognisable normal gland present

Question 509

Bartholin Gland Carcinoma - Mx

Answer 509

Radical vulvectomy with bilateral groin and pelvic LN dissection If it involves adjacent structures, post-op radiation and chemotherapy.

Question 510

What are some benign cervical conditions?

Answer 510

- Cervical ectopy/ectropion - Acute/chronic cervicitis - Cervical polyps - Nabothian Follicles

Question 511

Cervical Ectopy

Answer 511

= when the columnar epithelium of the endocervix is visible as a red area around the os on the surface of the cervix - Due to eversion - A normal finding in young women. - Can cause vaginal discharge/PCB

Question 512

Cervical Ectropion

Answer 512

= a more irregular redness, resulting in minor lacerations during childbirth. - Can cause vaginal discharge/PCB - Can be treated by cryotherapy, without anaesthetic.

Question 513

Cervical Polyps

Answer 513

= Benign tumours of endocervical epithelium. Most common in women >40 May be asymptomatic or may cause IMB/PCB Small polyps are avulsed without anaesthetic

Question 514

what is Acute Cervicitis?

Answer 514

= acute ulceration and infection of cervix Rare; often results from STD occasionally found in severe degrees of prolapse when the cervix protrudes or is held back with a pessary.

Question 515

What is chronic cervicitis? How can it be managed?

Answer 515

= chronic inflammation and infection, often of an ectopy/ectropion. Common cause of vaginal discharge May cause “inflammatory smears” Cryotherapy +/- Abx (depending on culture)

Question 516

Nabothian Follicles

Answer 516

Squamous metaplasia can lead to obstruction of cervical glands and retention cysts form (Nabothian follicles/cysts). Linked to chronic cervicitis

Question 517

Why is cervical cancer considered preventable?

Answer 517

Long pre-invasive state Cervical cytology screening programme Treatment of pre-invasive lesions is effective

Question 518

Risk factors for cervical cancer

Answer 518

age group 30-34 years = highest incidence * Early sexual debut and increased number of sexual partners * Parity * Smoking * Immunosuppression/deficiency

Question 519

Protective factors against cervical cancer

Answer 519

HPV vaccination before sexual activity Barrier contraception

Question 520

HPV

Answer 520

HPV = circular, double-stranded DNA virus 80% of people will get HPV in their lifetime More than 200 serotypes of HPV in total Strongly associated with cervical cancer (Oncogenic HPV DNA is detected in >99% of cervical cancers)

Question 521

How does HPV cause cervical cancer?

Answer 521

Infection of the cell with HPV results in the loss of important cell control mechanisms and the cell is more susceptible to malignant changes.

Question 522

Cervical Intraepithelial Neoplasia

Answer 522

Grade depends on amount of dyskaryosis (abnormal nuclei). - CIN I – atypical cells in 1/3 epithelium - CIN II – atypical cells in 2/3 epithelium - CIN III – atypical cells throughout There is gradual progression from low-grade to high-grade without treatment.

Question 523

Epithelium of the cervix

Answer 523

1. The upper cervix (endocervix) is lined by a simple columnar epithelium that contains mucous-secreting cells. 2. In contrast, the lower cervix (ectocervix) is lined by a stratified squamous epithelium. 3. The transition zone between these two epithelia (the external os) is an area of metaplasia where the columnar epithelium has been replaced by squamous.

Question 524

NHS cervical screening programme

Answer 524

Aim is to detect presence of HPV in the cervix Starts at 25 years, then (if normal) every 3 years until age 49, then every 5 years until 64. If HPV is found, the sample is then checked for abnormal cytology => If liquid cytology is normal, repeat screening in 12 months. => If liquid cytology is abnormal, then colposcopy is done to get a biopsy for histology.

Question 525

Management of CIN

Answer 525

CIN I – Punch biopsy and repeat screening in 12 months CIN II/III – Large Loop Excision of the Transformation Zone (LLETZ)

Question 526

What happens in a LLETZ procedure? What are the complications/risks?

Answer 526

= Excision of abnormal cells under LA (with diathermy to stop bleeding vessels) Complications/risks: - Post-op haemorrhage - Cervical stenosis - Small increased risk of preterm labour and PROM

Question 527

Counselling post-LLETZ

Answer 527

Avoid tampons/intercourse/baths/swimming for 4 weeks. One LLETZ treatment does not reduce fertility May have some bleeding/brown discharge.

Question 528

Cervical Glandular Abnormalities

Answer 528

Difficult to distinguish from severe dyskaryosis High incidence of malignancy and high-grade lesions => Warrants early referral for biopsy

Question 529

Types of Cervical Malignancy

Answer 529

1. Squamous cell carcinoma (90%) 2. Adenocarcinoma (10%) 3. Other rarer types (melanoma, sarcoma, metastatic cancer, neuroendocrine cancer)

Question 530

Cervical Malignancy - presentation

Answer 530

Abnormal vaginal bleeding – PCB/PMB/IMB Vaginal discharge Pelvic pain OE - abnormal appearance and feel of the cervix

Question 531

Staging of Cervical Cancer

Answer 531

I – Confined to cervix II – Beyond cervix (but not lateral pelvic wall or lower 1/3 of vagina) III – Pelvic wall / lower 1/3 of vagina IV – Beyond true pelvis/bladder/rectum/distal mets

Question 532

Cervical cancer - diagnosis and management

Answer 532

Diagnosis = via cervical biopsy. Radiological staging = MRI, CXR, CT scan IA – cone biopsy (preserves fertility) IB/IIA – radical hysterectomy / trachelectomy IIB + (or +ve lymph nodes) – radical hysterectomy, pelvic lymphadenectomy, chemoradiotherapy

Question 533

Gynae cancers - palliative care

Answer 533

1. Pain control 2. N&V – antiemetics 3. Heavy vaginal bleeding – high dose progesterones/radiotherapy 4. Ascites/bowel obstruction – paracentesis, antiemetics, laxatives, antispasmodics

Question 534

Benign conditions of the uterus

Answer 534

``` Fibroids Adenomyosis Polyps Endometriosis Haematometra Endometrial Hyperplasia ```

Question 535

what is Haematometra?

Answer 535

= menstrual blood accumulating in the uterus because of outflow obstruction.

Question 536

what is Endometrial Hyperplasia? what is the main cause?

Answer 536

= Overflow of the glandular epithelium of the endometrial lining. Usually occurs when a patient is exposed to UNOPPOSED OESTROGEN Benign, but likelihood of malignancy increases in complex hyperplasia with atypia.

Question 537

What are fibroids? Who is more at risk?

Answer 537

Benign tumours of the uterine cavity (myometrial origin) Vary in size and location (intramural, subserosal or submucosal) More common in peri-menopausal women, afro-caribbean women, people with FHx of fibroids

Question 538

What is the difference between uterine fibroids and polyps?

Answer 538

Fibroids = myometrial origin Polyps = endometrial origin

Question 539

Growth of fibroids

Answer 539

Growth is oestrogen and probably progesterone dependent - Increases in pregnancy and with combined contraceptives. - Slow/calcify after menopause (but HRT may maintain growth)

Question 540

Fibroids - clinical presentation

Answer 540

~50% are asymptomatic and discovered only on pelvic/abdo examination or scan. Sx: HMB (30%), IMB, dysmenorrhoea, urinary frequency/urinary retention, subfertility

Question 541

Fibroids - investigation

Answer 541

- History and examination – palpable, solid mass in pelvis/abdo - TV USS – shows mass continuous with uterus - MRI/laparoscopy – distinguish from ovarian mass and adenomyosis - Hysteroscopy – assess uterine distortion - Bloods – Hb may be low if HMB, or high if fibroid secretes EPO.

Question 542

Fibroids - management

Answer 542

If Asymptomatic – no treatment needed Medical: preserves fertility • GnRH and add-back HRT – temporary shrinkage • Often used for 2-3 months pre-surgery Surgical • Myomectomy (if want to preserve fertility). • Hysterectomy = most effective, but loss of fertility. • Uterine artery embolization

Question 543

Complications of fibroids

Answer 543

Torsion Degenerations: • RED – painful, haemorrhage, necrosis • HYALINE/CYSTIC – liquified and soft • CALCIFICATION – post-menopausal Small risk of malignancy – leiomyosarcoma (0.1%)

Question 544

What is adenomyosis?

Answer 544

= presence of endometrium with its underlying stroma within the myometrium.

Question 545

Adenomyosis - clinical presentation

Answer 545

- Sx may be absent - Painful, regular HMB is common - OE – uterus is mildly enlarged and tender

Question 546

Adenomyosis - management

Answer 546

IUS/COCP +/- NSAIDs to manage HMB/dysmenorrhoea Often an indication for hysterectomy

Question 547

What are uterine polyps? Who is more at risk?

Answer 547

= small, benign tumours of the uterine cavity (endometrial origin) RFs - women age 40-50 years, high oestrogen (e.g. tamoxifen)

Question 548

Uterine polyps - clinical presentation and investigations

Answer 548

HMB, IMB May prolapse through cervix TV USS Hysteroscopy

Question 549

Uterine polyps - management

Answer 549

Hysteroscopic resection with diathermy Avulsion (twist and tear off polyp with forceps)

Question 550

what is Endometriosis? Where does it occur? What does it result in?

Answer 550

= endometrial tissue growth outside of the uterus. Can occur anywhere in the pelvis => Most common = uterosacral ligaments & on/behind ovaries Results in inflammation, progressive fibrosis, and adhesions.

Question 551

Where is the most common location for endometriosis tissue?

Answer 551

uterosacral ligaments & on/behind ovaries

Question 552

Risk factors for endometriosis

Answer 552

Oestrogen dependent – regresses after menopause Risk factors: - 30-45 years - Nulliparous - Genetics

Question 553

Endometriosis - symptoms

Answer 553

- May be asymptomatic if mild - Chronic pelvic pain (often cyclical, or can be constant) - Dysmenorrhoea before menstruation (peaks day 1) - Deep dyspareunia - Pain on passing stools (dyschezia) - Subfertility – ovarian problems, adhesions, tubal problems, peritoneal factors, endometrial factors.

Question 554

Endometriosis - signs

Answer 554

- Retro-uterine/adnexal tenderness and/or thickening - Uterus may be retroverted and immobile - Nodule of endometrial tissue may be palpable on VE

Question 555

Endometriosis - complications

Answer 555

Chocolate cyst (endometrioma) – accumulated, dark brown blood in ovaries Frozen pelvis – pelvic organs immobile due to adhesions (very severe cases)

Question 556

Chocolate cyst

Answer 556

= endometrioma accumulated, dark brown blood in ovaries occurs in endometriosis

Question 557

Endometriosis - investigations

Answer 557

- History and physical examination - Laparoscopy +/- biopsy gives definitive diagnosis - MRI – to r/o adenomyosis - Barium studies – to assess ureteric, bladder, bowel involvement.

Question 558

Endometriosis - management

Answer 558

No treatment if asymptomatic Medical (no improvement in fertility): - Analgesia - Back-to-back COCP/POP/GnRH/IUS Surgical (may improve fertility): - Laparoscopic ablation of lesions - Adhesiolysis - Drainage/removal of chocolate cysts - TAHBSO

Question 559

How common is Endometrial Cancer? | What is the most common type?

Answer 559

= 4th commonest female cancer (after breast, lung and bowel). incidence is increasing uncommon before age 40 Adenocarcinoma (columnar endometrial glands) account for 90%.

Question 560

What % of PMB patients will have endometrial cancer?

Answer 560

~10% but 90% of endometrial cancer cases present with PMB

Question 561

Risk factors for endometrial cancer

Answer 561

Main cause = exposure to UNOPPOSED oestrogens. Risk Factors: - Early menarche (< age 12) - Late menopause (> age 52) - Infertility or nulliparity - Obesity / Diabetes - Treatment with tamoxifen for breast cancer - Oestrogen replacement therapy after menopause - Age >40 - Caucasian women - FHx endometrial cancer or HNPCC - PMHx of breast/ovarian cancer - Prior radiation therapy for pelvic cancer

Question 562

What factors reduce the risk of getting endometrial cancer?

Answer 562

- COCP – 50% reduction rate (but actual reduction is small because uncommon in women of child-bearing age). - Tobacco smoking (smokers have lower levels of oestrogen and lower rate of obesity) - Avoid weight gain

Question 563

Endometrial cancer - presentation

Answer 563

Non-menstrual bleeding/discharge (especially PMB)

Question 564

Endometrial cancer - Diagnosis and Staging

Answer 564

TV USS Pelvic examination Endometrial biopsy Hysteroscopy – staging MRI/CXR – assess spread

Question 565

Endometrial cancer - stages

Answer 565

Pre-malignant = atypical hyperplasia. I. Confined to uterine body II. Involves cervix III. Involvement of serosa, tubes/ovaries, vagina, parametrium, pelvic and paraaortic nodes. IV. Bladder/bowel mucosa, distant mets

Question 566

Endometrial cancer - management

Answer 566

Stage 1 – TAH BSO (+ post-op radiotherapy if high risk LN involvement) Stage >1 – debulking surgery/radiotherapy.

Question 567

Endometrial cancer - prognosis

Answer 567

Poor prognosis in advanced disease. High recurrence rates 40% end up with chest mets

Question 568

Ovary - anatomy

Answer 568

Outer cortex – germinal epithelium. Inner medulla – connective tissue and blood vessels. Cortex – follicles: - Granulosa cells – secrete oestrogen - Theca cells – also secrete oestrogen

Question 569

Benign ovarian tumours

Answer 569

- 2 types – physiological and pathological - May arise from any ovarian tissue. - Most are cystic (fluid-filled), a few are solid.

Question 570

What are physiological ovarian cysts?

Answer 570

Follicular Cyst | Luteal Cyst

Question 571

physiological ovarian cysts - follicular

Answer 571

- Lined by oestrogen producing granulosa cells | - Can secrete oestrogen – cause menstrual disturbances and endometrial hyperplasia

Question 572

physiological ovarian cysts - luteal

Answer 572

- Formed when corpus luteum does not regress | - Occurs on days 20-26 of cycle

Question 573

What type of pathological ovarian cysts are more common in older or younger women?

Answer 573

Coelomic epithelium = more common in older women Germ cell = more common in younger women

Question 574

dermoid cyst/cystic teratoma

Answer 574

Derived from pluripotent germ cells. Contain hair/skin/teeth Asymptomatic. Malignant form = solid teratoma

Question 575

Serous cystadenoma

Answer 575

= Most common ovarian cyst ``` Thin, serous fluid content Epithelial lining (cuboidal/columnar) ```

Question 576

Mucinous cystadenoma

Answer 576

Contain mucin Can become enormous (cause pressure Sx on bladder and bowel) Can rupture 5% become malignant

Question 577

Ovarian cyst - Brenner cell tumour

Answer 577

Secrete oestrogen Presents with asymptomatic vaginal bleeding.

Question 578

Meig’s syndrome

Answer 578

= ovarian Fibroma + pleural effusion + ascites

Question 579

Presentation of Benign Ovarian Cysts

Answer 579

Asymptomatic Abdo/pelvic mass Pressure Sx Pain (variable) Cyst Accidents - Ruptur - Torsion

Question 580

Ovarian cyst - investigation

Answer 580

- Abdominal and pelvic exam – adnexal mass - USS - Tumour markers – Ca-125, beta-hCG, LDH, AFP, inhibin - CT scan - MRI

Question 581

Ovarian cyst - management

Answer 581

Spontaneous resolution = most common - Conservative/monitoring by scan +/- analgesia - Laparoscopy – if cysts persist/presents acutely - Ovarian cystectomy/oophorectomy - Laparotomy +/- salpingo-oophorectomy +/- TAHBSO

Question 582

How common is ovarian cancer? What is the most common type?

Answer 582

30% of ovarian masses after menopause will be malignant 90% are epithelial carcinomas => of which 75% serous and 25% mucinous => In women <30, germ cell tumours are the most common

Question 583

Ovarian cancer - risk factors

Answer 583

* Increased ovulation * Low parity/nulliparous * Early menarche * Late menopause * FHx BRCA1 and/or 2 * FHx HNPCC

Question 584

what are some factors which protect against ovarian cancer?

Answer 584

Anything which decreases ovulation: => OCP, lactation, pregnancies

Question 585

Ovarian cancer - signs and symptoms

Answer 585

• Most women are asymptomatic. • Symptoms are often vague and non-specific – bloating, abdominal discomfort, pressure, nausea. => Similar to IBS Sx!! * Mass, genital prolapse, ascites. * Late – secondaries.

Question 586

Ovarian cancer - diagnosis

Answer 586

A high index of suspicion. USS abdo/pelvis Ca-125 => if under 40 years, assess AFP, beta-hCG and LDH in case germ cell tumour. CT abdo/pelvis to assess spread

Question 587

Ovarian cancer - staging

Answer 587

I. One/both ovaries only II. Pelvic extension III. Extra-pelvic extension IV. Distant metastases

Question 588

Ovarian cancer - management

Answer 588

Staging laparotomy and optimal debulking. Aim to leave no macroscopic disease after surgery. Stage 1c and above – LN dissection and post-op chemo. If advanced/unfit for surgery – palliative care.

Question 589

What is a pelvic organ prolapse? | What is the cause?

Answer 589

= protrusion of pelvic organs into vaginal canal Caused by weakness of the surrounding structures

Question 590

Types of pelvic organ prolapse

Answer 590

1. Apical – uterus, cervix and upper vagina. 2. Anterior vaginal wall: - Cystocoele (bladder) - Urethrocoele (urethra) - Cysto-urethrocoele 3. Posterior vaginal wall: - Rectocoele (rectum) - Enterocoele (pouch of douglas)

Question 591

Prolapse - risk factors

Answer 591

- Vaginal Delivery/pregnancy – large baby, long labour, instrumental - Weakness of pelvic floor – inherited disease of collagen (e.g. Ehler’s Danlos), post-menopause, perineal damage, neuropathy/nerve damage - Chronic increased intra-abdominal pressure – obesity, chronic cough/constipation, heaving lifting, pelvic mass - Iatrogenic – pelvic surgery

Question 592

Prolapse - presentation

Answer 592

- Lump/bulge/dragging sensation – worse at the end of the day/when standing - Vaginal irritation/dryness/ulcers - Need to push vagina back after straining - Problems with sexual intercourse - Bladder symptoms – frequency, urgency, voiding difficulties, recurrent cystitis. - Bowel problems – obstruction of defecation, constipation, incomplete bowel emptying, faecal incontinence.

Question 593

What factors may be important to ask in a Hx for someone with suspected prolapse?

Answer 593

- Any urinary/bowel symptoms? - Sexually active? Gynae Hx - Pre-/postmenopausal, contraception Obstetric Hx PMHx - chronic cough, obesity DHx

Question 594

Prolapse - investigations

Answer 594

Abdo examination – pelvic mass? Pelvic examination – bimanual, speculum, vaginal mucosa (Pelvic USS) – may be done to r/o pelvic mass or to investigate any PMB

Question 595

Stages of uterine prolapse

Answer 595

Stage I – the uterus is in the upper half of the vagina. Stage II – the uterus has descended nearly to the opening of the vagina. Stage III – the uterus protrudes out of the vagina. Stage IV – the uterus is completely out of the vagina.

Question 596

Prolapse - management

Answer 596

CONSERVATIVE - Lifestyle changes – weight loss, stop smoking - Pessary (changed every 6-9 months) - Pelvic floor exercises. SURGICAL: Fixation/ repair/ hysterectomy.

Question 597

What does urinary continence rely on?

Answer 597

Bladder compliance Efficient urethral sphincter Efficient urethral support by pelvic floor and transmission of abdominal pressure. Leakproof mucosal seal

Question 598

What are the types of incontinence? | Which is the most common?

Answer 598

Stress incontinence (most common) Overflow Incontinence Urge Incontinence

Question 599

What causes Stress Incontinence?

Answer 599

Caused by relaxed pelvic floor or increased abdominal pressure, often multifactorial: - Pregnancy, obesity, age - Vaginal delivery (long labour, forceps) - Prolapse, hysterectomy - Muscular diseases

Question 600

Stress incontinence - presentation

Answer 600

Hx of leakage on exertion (e.g. cough/sneeze) because increased IAP causes bladder pressure > urethral pressure

Question 601

What causes overflow Incontinence?

Answer 601

Obstruction – pelvic surgery/strictures, BPH/prostate tumour, bladder calculi. Detrusor failure – neurological, medication, DM.

Question 602

Overflow incontinence - presentation

Answer 602

Hx of leakage on exertion or continuous flow/dribble Occurs due to bladder distension

Question 603

What causes urge incontinence?

Answer 603

Causes: - Idiopathic - Detrusor overactivity/overactive bladder – spinal cord injury/MS - Previous pelvic surgery

Question 604

Urge incontinence - presentation

Answer 604

Hx of urgency, frequency, nocturia (+/- stress incontinence). Because detrusor contraction causes bladder pressure > urethral pressure.

Question 605

What DHx might be particularly relevant in an incontinence history?

Answer 605

Diuretics, anticholinergics, anxiolytics/sedatives Also: alcohol and caffeine intake

Question 606

Examination of Incontinence

Answer 606

General – is the patient fit for surgery? BMI Abdominal exam – palpable mass/bladder? Neurological exam Pelvic exam: - Bimanual – assess pelvic floor tone - Speculum - Vaginal mucosa – atrophy?

Question 607

Incontinence - investigations

Answer 607

Urine dip - infection/DM? Urinary diary Post-micturition USS CT urogram Cystoscopy Cystometry (bladder pressure studies)

Question 608

How is cystometry performed?

Answer 608

Bladder pressure measured via catheter, | Abdominal pressure measured via rectum

Question 609

Stress incontinence - management

Answer 609

Lifestyle – Weight loss, Pelvic floor exercises Medical – duloxetine (SNRI for increased sphincter activity), injectable bulking agents Surgical – colposuspension

Question 610

Urge/overactive bladder incontinence - management

Answer 610

Lifestyle – decrease fluids and caffeince, medication review, bladder retraining Medical – anticholinergics (to decrease detrusor activity), botulinum toxin A (to block neuromuscular transmission), intravaginal oestrogens.

Question 611

What anticholinergics are used in incontinence? What are side effects if these drugs?

Answer 611

e.g. oxybutynin, tolterodine, solifenacin Side effects – dry mouth, constipation, blurred vision, cognitive dysfunction, CV effects

Question 612

Overflow incontinence - management

Answer 612

Intermittent self-catheterisation Treat underlying cause (e.g. BPH)

Question 613

What is required for consent to be valid?

Answer 613

Patient must: 1. Be competent to make a particular decision 2. Have received sufficient information to make the decision 3. Not be acting under duress, coercion or deceit.

Question 614

What are the four parts to consent process?

Answer 614

1. Understanding 2. Retaining 3. Deciding / weighing 4. Communicating

Question 615

Gillick Competence

Answer 615

minors of any age who are able to understand what is proposed and have sufficient discretion to be able to make a wise choice in their best interests, are competent to consent for medical treatment.

Question 616

Fraser Guidelines

Answer 616

Apply specifically to sexual health and contraception 1. The young person cannot be be persuaded to inform their parents or carers that they are seeking this advice or treatment (or to allow the practitioner to inform their parents or carers). 2. The young person understands the advice being given. 3. The young person's physical or mental health or both are likely to suffer unless they receive the advice or treatment 4. It is in the young person's best interests to receive the advice, treatment or both without their parents' or carers' consent. 5. The young person is very likely to continue having sex with or without contraceptive treatment.

Question 617

What counts as domestic abuse?

Answer 617

= any incident / pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members, regardless of gender or sexuality.

Question 618

Disclosing cases of domestic abuse

Answer 618

The doctor cannot inform the police about cases of marital violence unless specific consent is obtained from the patient. However, cases of DA can be shared without consent if it protects a child or public interest.

Question 619

How does HIV infect cells? | What does this lead to?

Answer 619

HIV is a retrovirus, infecting lymphocytes with CD4 receptors. The virus binds to the CD4 receptor and enters the cell. It uses enzymes and the host DNA to make copies of itself and the CD4 cell gets destroyed in the process. 10 billion new HIV virions can be produced per day, with up to 2 billion CD4 cells killed each day. The decline in CD4 cells leads to immunosuppression.

Question 620

Stages of HIV infection

Answer 620

1. Acute HIV infection syndrome => patient is non-specifically virally unwell => viral load high; no anti-HIV antibodies 2. Stable, asymptomatic phase => viral load low; anti-HIV antibodies; stable CD4. 3. Symptomatic => signs of damaged immune system => Low CD4, any viral load

Question 621

How long can the stable, asymptomatic phase of HIV last?

Answer 621

can last ~5-10 years for an average patient

Question 622

HIV - monitoring disease

Answer 622

CD4 Count – a measure of immune function • Predicts risk of opportunistic infection • Normal range = 600-1200 • <200 = risk of opportunistic infection Viral Load – a measure of viral replication • Predicts rate of disease progression • Aim for <50 copies/mL on treatment

Question 623

At what CD4 count is opportunistic infection more likely?

Answer 623

CD4 <200

Question 624

What is the aim for HIV viral load on treatment?

Answer 624

<50 copies/mL

Question 625

HIV Transmission

Answer 625

Sexual transmission => Anal > vaginal > oral IV drug use Contaminated blood products Vertical transmission => Mother to child

Question 626

Why is testing for HIV important?

Answer 626

* Long asymptomatic stage of HIV infection – increased risk of transmission * Treatment is very effective – near-normal life expectancy if treated early. * Late diagnosis after the immune system is damaged leads to poorer prognosis

Question 627

What is considered a late HIV diagnosis?

Answer 627

CD4 count <350 when diagnosed.

Question 628

What is the most important predictor of morbidity and mortality in HIV?

Answer 628

CD4 count

Question 629

HIV testing - consent

Answer 629

Consent is required before a HIV test. Very few scenarios where it is appropriate to test for HIV without someone’s consent.

Question 630

In what scenario is there universal offer for HIV testing

Answer 630

in specific clinical settings or with clinical indicator conditions. => Antenatal clinics, drug dependency programmes, TB services, blood-borne viruses, lymphoma, etc.

Question 631

In what scenario is there universal HIV testing in GP practices?

Answer 631

Universal testing of GP registrants/acute admissions in high prevalence areas (>2 per 1000 population). Regardless of symptoms and actual/perceived risk factors.

Question 632

In what scenario is there targeted HIV testing offered?

Answer 632

based on demographics - people with potential risk factors => Regardless of symptoms

Question 633

In what medical conditions is an HIV test indicated?

Answer 633

Anyone with one of the AIDs defining indicator conditions

Question 634

HIV - 4th Generation test

Answer 634

Combined antibody and P24 antigen (part of the virus). => Window period of 6.5 weeks (45 days) – where someone has HIV but the test cannot detect it. All positive tests confirmed with 2nd sample!

Question 635

HIV - Point-of-care tests (POCTs)

Answer 635

4th generation POCTs Drop of blood on test, wait 15 minutes. => Control result +/- positive HIV result. All positive tests confirmed with 2nd sample!

Question 636

HIV test result discussion

Answer 636

For most people – text message suggesting result is negative => Consider “window period” and re-test => Discuss ways of reducing risk Face-to-face discussion if positive result or if negative but vulnerable/high risk/ difficulties understanding.

Question 637

When is HIV treatment offered?

Answer 637

Anti-retroviral treatment is recommended for anyone with HIV When CD4 count <200, prophylaxis against PCP (usually co-trimoxazole) is recommended.

Question 638

90-90-90 UNAIDS target

Answer 638

90% with HIV are aware of HIV status. 90% of these people are on treatment 90% of those on treatment have an undetectable viral load.

Question 639

what does Undetectable = untransmissible mean?

Answer 639

a person living with HIV who has an undetectable viral load does not transmit the virus to their partners.

Question 640

Principles of HIV anti-retroviral therapy

Answer 640

A combination therapy to control the virus and minimise the chance of resistance. => Use of 2 or 3 drugs Choose drugs that target at least 2 different stages of virus life cycle Aim to maximise compliance - as few tablets as possible!

Question 641

HIV therapy and drug interactions

Answer 641

Many of the antiretrovirals have quite significant drug interactions

Question 642

HIV therapy side effects

Answer 642

- GI upset – nausea, diarrhoea - Rashes and allergies - Renal toxicity - Liver toxicity - Reduced bone mineral density - Lipodystrophy and weight gain - Increased cardiovascular risk/ blood pressure/ lipids/ blood sugars - Peripheral neuropathy

Question 643

HIV contact tracing

Answer 643

Aim = to break the chain of transmission by identifying those who may be at risk of an infection For HIV, ideally all partners since the last negative test should be contacted.

Question 644

HIV Prevention

Answer 644

Sexual Transmission - Condoms - PEP and PrEP - Treatment as prevention (TasP) – undetectable = untransmissible IVDU - Needle exchanges Vertical Transmission - Appropriate ante- and post-natal care. - If viral load is undetectable then vaginal delivery is possible! - PEP for baby Blood products - Screening for HIV in blood products

Question 645

Access to the genitourinary medicine service

Answer 645

GUM = branch of medical science concerned with diseases of the genital and urinary tract. - Open access – no referral required. - Strictly confidential – discrete building, separate patient records, etc.

Question 646

Aims of GUM service

Answer 646

- Immediate diagnosis - Effective, free treatment - Partner notification - Information/Sexual health education

Question 647

Who is at risk of STIs?

Answer 647

Everyone! Rates are higher in younger population (<25 years) and in MSM

Question 648

Management of ?STI

Answer 648

History Establish the diagnosis - Examination - Investigations Treatment - On the day where possible, stat doses Counselling, education, health promotion Partner notification

Question 649

?STI - History

Answer 649

Symptoms PMHx - Including past STIs DHx, allergies Women – menstrual cycle, obstetric Hx, contraception, cervical cytology, HPV vaccine. SHx – recreational drugs, alcohol, smoking, domestic violence, chemsex Sexual Hx BBV risk assessment

Question 650

What is chemsex?

Answer 650

Use of drugs in a sexualised context, leading to more sexually disinhibited behaviour

Question 651

STI Sx - Male

Answer 651

``` Discharge Dysuria Urinary frequency/haematuria Testicular pain/swelling Rashes/ulcers/lumps Rectal symptoms in MSM -- Asymptomatic screening STI contact ```

Question 652

STI Sx - Female

Answer 652

``` Unusual discharge Dysuria/Urinary frequency/haematuria Itching/soreness Pelvic/lower abdominal pain Dyspareunia (superficial/deep) Rashes/ulcers/lumps IMB and PCB -- Asymptomatic screening STI contact ```

Question 653

What is the most prevalent bacterial STI in the UK?

Answer 653

chlamydia

Question 654

Chlamydia trachomatis

Answer 654

Intracellular gram-negative bacteria Infects columnar and transitional epithelium Can infect the cervix, urethra, rectum, conjunctivae and pharynx. Sexual transmission (vaginal, anal, oral sex) is most common route of infection, but vertical transmission is also possible.

Question 655

RFs for chlamydia infection

Answer 655

* Condomless sex * New partner within the last year * Age <25

Question 656

Chlamydia - presentation

Answer 656

Often asymptomatic (especially pharyngeal and rectal infections) ``` Women: • Increased discharge (watery/milky) • AUB • Cervicitis • Dysuria ``` Men: • Dysuria • Urethral discharge

Question 657

Chlamydia - complications

Answer 657

PID (chronic pelvic pain, subfertility) Increased risk of ectopic pregnancy, Reiter’s Syndrome, Neonatal conjunctivitis.

Question 658

Reiter's Syndrome

Answer 658

= urethritis, conjunctivitis, arthritis.

Question 659

Chlamydia - diagnosis

Answer 659

Men – first catch urine (FCU) for NAAT analysis. | Women – endocervical/vaginal swab for microscopy.

Question 660

Chlamydia - management

Answer 660

- Doxycycline PO 7 days o.d. | - OR azithromycin PO stat dose.

Question 661

Neisseria gonorrhoea

Answer 661

gram-negative intracellular diplococcus Infects the mucous membranes of the urethra, endocervix, rectum, pharynx and conjunctiva. Transmission occurs by direct transmission from one infected mucous membrane to another – primarily through sexual contact, but vertical transmission also occurs.

Question 662

Gonorrhoea - presentation

Answer 662

Often asymptomatic White/yellow discharge (M&F) Urethritis Bartholinitis Cervicitis

Question 663

Super-gonorrhoea

Answer 663

multi-drug resistant gonorrhoea

Question 664

Gonorrhoea - complications

Answer 664

bacteraemia, acute septic arthritis, PID, neonatal conjunctivitis.

Question 665

Gonorrhoea - diagnosis

Answer 665

Men – FCU for NAAT analysis Women – endocervical swab for microscopy (looking for gram -ve diplococcus). !!Culture to check ABX sensitivities!!

Question 666

Gonorrhoea - management

Answer 666

Treatment = IM ceftriaxone. Alternative = ciprofloxacin, but resistance is common.

Question 667

trichomonas vaginalis

Answer 667

a flagellated protozoan Can be found in the vagina, paraurethral glands, sub-preputial sac and penile lesions. Main transmission is through vaginal intercourse.

Question 668

Trichomoniasis - RFs

Answer 668

>90% of diagnoses in women | => Rates are highest in women of black ethnicity.

Question 669

Trichomoniasis - Presentation

Answer 669

May be asymptomatic Vaginal discharge - Vary in colour and texture - Grey/green/yellow - Offensive smell Vulval itching or pain Dysuria (M&F)

Question 670

Trichomoniasis - Complications

Answer 670

preterm/LBW child, post-partum sepsis, HIV transmission.

Question 671

Trichomoniasis - Diagnosis

Answer 671

High vaginal swab | Wet film microscopy

Question 672

Trichomoniasis - Management

Answer 672

Treatment = metronidazole PO stat dose.

Question 673

treponema pallidum

Answer 673

a spirochete bacterium, causing syphilis infection Transmitted by sexual contact, vertical transmission from mother to child or transmission by infected blood products.

Question 674

Early syphilis

Answer 674

= when the person has been infected within the last 2 years. It can be asymptomatic (early latent) or symptomatic (primary or secondary).

Question 675

Late syphilis

Answer 675

= when the person has been infected for >2 years. It can be asymptomatic (late latent) or symptomatic (tertiary).

Question 676

Syphilis - RFs

Answer 676

MSM

Question 677

Syphilis - Presentation

Answer 677

Primary syphilis – chancre (painless genital/mouth ulcer). Secondary syphilis: - Fever, myalgia, headache, lethargy, malaise, anorexia. - Rash (soles/palms) - Warty genital and peri-oral growths (condylomata lata) - Multi-organ problems Tertiary Syphilis: - CV system – aortic regurgitation - Skin/bony swellings (gummata) - Neurological – Dementia, Tabes dorsalis

Question 678

Syphilis - diagnosis

Answer 678

Serological tests.

Question 679

Syphilis - management

Answer 679

Treatment – IM/IV penicillin. 10-14 days PO doxycycline if penicillin allergic.

Question 680

What causes genital warts?

Answer 680

HPV type 6 and 11 cause most genital warts (responsible for >75% of warts but are low-risk strains). Transmitted by skin-to-skin contact (usually sexual)

Question 681

Do condoms reduce the risk of transmission of genital warts?

Answer 681

condoms reduce the risk of transmission by ~30-60%.

Question 682

Genital warts - presentation

Answer 682

Multiple warts - Varied appearance, - External or internal - Flesh-coloured or pigmented

Question 683

Genital warts - diagnosis

Answer 683

Diagnosed on inspection.

Question 684

Genital warts - management

Answer 684

Topical podophyllin/imiquimod cream Cryotherapy Prevention – HPV vaccination

Question 685

What causes genital herpes?

Answer 685

Caused by HSV 1 and 2 Transmitted by skin-to-skin contact (vaginal/anal/oral sex or genital-to-genital contact). Can be transmitted when individuals have no symptoms (asymptomatic shedding).

Question 686

Genital herpes - presentation

Answer 686

Can be asymptomatic (1/3 develop symptoms). Multiple, small, painful vesicles. Dysuria and itchy genitals Malaise, fever, headache Local lymphadenopathy.

Question 687

Genital herpes - complications

Answer 687

secondary bacterial infection, acute urinary retention, neonatal herpes (high mortality). Can lie dormant in dorsal root and reactivate at a later time

Question 688

Genital herpes - diagnosis

Answer 688

Diagnosed by inspection and PCR of viral swabs.

Question 689

Genital herpes - management

Answer 689

Treated with acyclovir.

Question 690

What is Bacterial Vaginosis?

Answer 690

this is NOT an STI. Caused by a disturbance in the normal vaginal bacteria – makes the vagina slightly less acidic than normal and this encourages the growth of anaerobic bacteria and fewer normal lactobacilli.

Question 691

BV - presentation

Answer 691

grey/white discharge with fishy odour

Question 692

BV - complications

Answer 692

preterm labour

Question 693

BV - diagnosis

Answer 693

high vaginal swab, raised pH, “clue cells” on microscopy

Question 694

BV - management

Answer 694

Metonidazole 400 mg twice a day for 5-7 days. OR topical metronidazole gel for 7 days Or topical/PO clindamycin

Question 695

What is candidiasis/thrush?

Answer 695

This is NOT an STI. Caused by candida albicans

Question 696

Candidiasis - RFs

Answer 696

immunocompromise, diabetes, pregnancy, ABX use

Question 697

Candidiasis - presentation

Answer 697

``` often asymptomatic, “cottage-cheese” discharge, vulval itching, dyspareunia, dysuria. ```

Question 698

Candidiasis - diagnosis

Answer 698

high vaginal swab for culture

Question 699

Candidiasis - management

Answer 699

antifungal pessary/cream (clotrimazole) or oral fluconazole (NOT if pregnant).

Question 700

What is the window period for STI testing?

Answer 700

= the time from infection to the time detectable by testing. Gonorrhoea and chlamydia – 2 weeks Blood-borne viruses – 6 weeks.

Question 701

Menstrual Hx

Answer 701

Duration of bleeding and length of cycle Frequency/regularity of periods Volume of bleeding: - Heavier than normal? - Soaking through pads? - Impacting day to day life? Menarche Contraception

Question 702

Gynae Hx

Answer 702

Previous gynae problems? Previous gynae surgery? Cervical screening: - Confirm date of last smear test - Confirm HPV vaccination status Contraception Menstrual Hx

Question 703

Obstetric Hx

Answer 703

Gravidity and Parity Outcome of pregnancies Gather key details about the patient’s current pregnancy (if relevant) - Gestation - Sx associated with pregnancy (e.g. N&V, back pain) - Complications - Recent scan results

Question 704

Sexual History

Answer 704

Last sexual contact: - Timing – when? - Consensual? - Regular sexual partner or casual? - Clarify the sex and country of origin of the partner - Clarify the type of sex involved (Vaginal/anal/oral) - Contraception (Barrier and other forms) Ask about other sexual partners in the last 3 months.

Question 705

BBV risk assessment

Answer 705

"Have you ever had a partner who is known to be HIV positive?" "Have you ever had sex with a bisexual man/engaged in male homosexual activity?" "Have you ever had sex with someone abroad, or who was born in a different country?" "Have you ever injected drugs?" "Are you aware of any of your previous partners having ever injected drugs?" "Have you ever paid someone for sex, or been paid for sex?"

Question 706

What extra components are there in an O&G history?

Answer 706

* Menstrual History * Obstetric History * Contraception * Date of last cervical smear +/- Sexual History

Question 707

Gravidity

Answer 707

= number of times a woman is/had been pregnant (regardless of pregnancy outcome).

Question 708

Parity

Answer 708

= number of pregnancies reaching a viable gestational age [24 weeks] (including live and stillbirths)

Question 709

When should you start asking about foetal movements?

Answer 709

After 20 weeks

Question 710

What is the definition of chronic pelvic pain?

Answer 710

= intermittent or constant pain in lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.

Question 711

Chronic pelvic pain - Cyclical pain

Answer 711

Related to reproductive system (endometriosis/ adenomyosis) | Respond to ovarian suppression

Question 712

Chronic pelvic pain - Non-cyclical pain

Answer 712

- Adhesions - PID - Malignancy - GI/urological/neurological/MSK

Question 713

Chronic Pelvic Pain - Diagnosis

Answer 713

History Examination - BMI - Abdominal exam - Vaginal exam - Triple swabs for infection screening Investigations - Transvaginal USS - MRI - Laparoscopy = GOLD-STANDARD but 2nd line

Question 714

Chronic Pelvic Pain - Management

Answer 714

Therapeutic options depend on diagnosis: - Appropriate analgesia - IBS – trial of antispasmodics/diet - Cyclical pain – Trial with COCP/ GnRH analogue for 3-6 months - Psychological – counselling and psychotherapy - Referral to pain management team/pelvic pain clinic/other specialities

Question 715

Pelvic Inflammatory Disease

Answer 715

= infection of the cervix, uterus, tubes and contiguous structures.

Question 716

Causes of PID

Answer 716

Usually caused by ascending bacteria from sexually transmitted infection. Uterine instrumentation or retained products of conception are non-sexually transmitted causes.

Question 717

PID - Presentation

Answer 717

Often asymptomatic until complications present. * BILATERAL lower abdo pain * Abnormal PV bleeding/discharge * N&V * Deep Dyspareunia • RUQ pain (Fitz Hugh Curtis Syndrome – perihepatic irritation).

Question 718

PID - Diagnosis

Answer 718

OE: • Pyrexia, Tachycardia • Abdominal rigidity/peritonism • Tender uterus and bilateral adnexae, cervical excitation Ix: • Pregnancy test – r/o ectopic • WCC and CRP – raised • Blood cultures if pyrexial • Endocervical swabs – gonorrhoea and chlamydia • Pelvic USS – r/o abscess/ovarian cyst • Laparoscopy + fimbrial biopsy & culture = GOLD STANDARD

Question 719

PID - Management

Answer 719

• Analgesia • ABX => IM Ceftriaxone + PO doxycycline + PO metronidazole (empirical) Review at 24 hours If septic – admission and sepsis 6 and senior review

Question 720

PID - Complications

Answer 720

Abscess/Pyosalpinx Tubal obstruction/subfertility Chronic pelvic infection/pain 6x increased risk of ectopic pregnancy

Question 721

Important points for early pregnancy scanning

Answer 721

We do not expect to see anything meaningful on a scan until 6 weeks of pregnancy Interpreting scan results in the context of the patient’s history, examination findings and blood results is vital.

Question 722

Definition of miscarriage

Answer 722

when the foetus dies or delivers dead before 24 weeks. Usually occurs before 12 weeks.

Question 723

How common is miscarriage? What is the most common cause?

Answer 723

Occurs in ~15% of pregnancies Cause is significant chromosomal abnormality in ~60% of cases.

Question 724

Miscarriage - Sx

Answer 724

- Lower abdominal pain (crampy, “period-like”) | - Vaginal bleeding (often before pain)

Question 725

Miscarriage - Investigations

Answer 725

Speculum – open os suggestive of miscarriage. TV USS – shows if foetus is intrauterine/viable or any retained products of conception. 48-hour serum hCG – rise >66% in viable pregnancies, low in miscarriage. Check FBC, Rhesus Status, G&S CRP – often raised in miscarriage

Question 726

crown-rump Length (CRL) <7.2mm on 1st scan

Answer 726

this could either be a very early pregnancy OR a miscarriage. => Re-scan in 7-10 days.

Question 727

CRL >7.2mm and no cardiac activity on 1st scan

Answer 727

miscarriage is diagnosed (at this size a heartbeat should be present).

Question 728

Threatened miscarriage

Answer 728

Os Closed, Uterus normal for date Foetus still alive (only 25% miscarry)

Question 729

Inevitable miscarriage

Answer 729

Os Open Pain, heavy bleeding Foetus may/may not be alive

Question 730

Incomplete miscarriage

Answer 730

Os open USS – some RPOC Pain, bleeding Some foetal parts passed

Question 731

Complete miscarriage

Answer 731

Os closed USS – no RPOC Slowed bleeding ALL foetal parts passed

Question 732

Missed Miscarriage

Answer 732

Os closed Uterus small for date May be asymptomatic Often found on routine scan where no FHR is detected

Question 733

Septic miscarriage

Answer 733

Uterine tenderness Endometritis Pain Offensive vaginal loss +/- fever

Question 734

management of miscarriage

Answer 734

Anti-D prophylaxis needs to be given if Rh -ve and pregnancy >12 weeks’ gestation, as miscarriage is a sensitising event. 1. Conservative/Expectant – wait to see if the miscarriage occurs naturally (~80% success) 2. Medical: 3. Surgical Inevitable, incomplete, and missed miscarriages can be managed with all 3 options. Septic miscarriage is managed with antibiotics and surgical management

Question 735

Miscarriage - conservative management

Answer 735

Review after 14 days. No bleeding/pain – pregnancy test at 3 weeks to confirm miscarriage. Still bleeding/pain – consider medical/surgical management.

Question 736

Miscarriage - medical management

Answer 736

PO/PV misoprostol and mifepristone Also analgesia and anti-emetics PRN Pregnancy test at 3 weeks to confirm miscarriage Risks – bleeding, infection, failure

Question 737

Miscarriage - surgical management

Answer 737

Vacuum aspiration and histological examination to exclude molar pregnancy Complications - infection, partial removal of endometrium, perforation/scarring of uterus (causing Asherman’s Syndrome)

Question 738

What is considered recurrent Miscarriage?

Answer 738

3 or more miscarriages in succession – affects ~1% of couples.

Question 739

Causes of recurrent miscarriage

Answer 739

- Antiphospholipid antibodies - Chromosomal defects - Uterine abnormalities – e.g. LLETZ, fibroids - Hormonal – e.g. thyroid problems, uncontrolled diabetes. - Other – obesity, smoking, PCOS, higher maternal age

Question 740

Ectopic pregnancy

Answer 740

= a pregnancy that is growing anywhere outside the uterus. Most common location is the fallopian tubes/ampulla.

Question 741

ectopic pregnancy - Risk factors

Answer 741

= anything that can scar the tubes: * Advanced maternal age * Previous ectopic pregnancy * IVF pregnancy * PMHx chlamydia/pelvic infection/PID * Previous abdo/tubal surgery * Use of POP or IUD

Question 742

Ectopic pregnancy - presentation

Answer 742

Can be variable/vague/asymptomatic Lower abdominal pain Rebound tenderness Uterine and adnexal tenderness Abnormal vaginal bleeding Signs of intraperitoneal blood loss Amenorrhoea 4-10 weeks Uterus small for date and closed cervical os.

Question 743

What can be signs of intraperitoneal blood loss

Answer 743

- Dizziness - Shoulder-tip pain (referred) - Syncope/collapse

Question 744

Ectopic pregnancy - Investigations

Answer 744

In a woman of child-bearing age, abdominal pain and abnormal PV bleed = ectopic until proven otherwise => MUST do a urine pregnancy test! 1. Urine hCG pregnancy test (+ve in ectopic) 2. TV USS 3. Serum beta-hCG to distinguish early and ectopic pregnancies 4. Laparoscopy => Most sensitive, but invasive – rarely used.

Question 745

How to differentiate early pregnancy and ectopic pregnancy with serum beta-hCG?

Answer 745

Early pregnancy – increase by >60% in 48 hours. Ectopic – slower increase or decrease. If already >1000 IU/mL, you would see the pregnancy in the uterus unless it was ectopic.

Question 746

Ectopic pregnancy - management

Answer 746

1. Admit to hospital – A-E assessment, IV access, X-match, Anti-D if Rh -ve. 2. Medical = methotrexate (if small, un-ruptured) 3. Surgical 4. Counselling

Question 747

What are the requirements of an ectopic pregnancy to be suitable for medical management? How is medical management done?

Answer 747

if unruptured, no cardiac activity and hCG <3000 IU/mL Single dose methotrexate (15% need 2nd dose, 10% need surgical escalation) Followed by serial hCG level monitoring.

Question 748

Surgical management of ectopic pregnancy

Answer 748

Laparoscopic salpingectomy (tube removal) Consider salpingostomy (remove ectopic and leave tube) if other tube is damaged, for future conception.

Question 749

Counselling for ectopic pregnancy

Answer 749

Explain the need for serial hCG levels to confirm removal of ectopic. Make aware of warning signs of rupture – severe abdo pain, pale/clammy, tachycardic, LOC/collapse. Information about increased risk of ectopic (but reassure that many go on to have successful pregnancy in the future). Emotional support/counselling.

Question 750

Definition of Hyperemesis Gravidarum

Answer 750

Severe N&V in pregnancy that leads to: - Dehydration - Electrolyte disturbances - Weight loss - Ketosis

Question 751

Hyperemesis Gravidarum - presentation

Answer 751

Excessive vomiting Symptoms suggestive of dehydration (e.g. oliguria and syncopal episodes)

Question 752

Hyperemesis Gravidarum - risk factors

Answer 752

- Multiparous - Multiple pregnancy - Molar pregnancy

Question 753

Hyperemesis Gravidarum - DDx

Answer 753

- UTI - Gastroenteritis - Trophoblastic Disease

Question 754

Hyperemesis Gravidarum - Investigations

Answer 754

BP and Pulse – ?hypovolaemia Urine dip: => Ketonuria suggests dehydration/starvation => (r/o UTI) FBC, U&E, LFT Calcium => r/o hypercalcaemia (can cause vomiting) Pelvic USS => Check viability of pregnancy => Check for situations where hyperemesis is more likely.

Question 755

Hyperemesis Gravidarum - Management

Answer 755

Dehydration: => IV fluids (Hartmann’s/saline) N&V: => Antiemetics – promethazine, cyclizine, metoclopramide, ondansetron (IV/IM/SL if oral intake not tolerated) Close monitoring – BP, pulse, renal function

Question 756

What is Gestational Trophoblastic Disease?

Answer 756

Occurs when the trophoblastic tissue of the blastocyst proliferates more aggressively than normal. 1. HYDATIDIFORM MOLE 2. INVASIVE MOLE 3. CHORIOCARCINOMA

Question 757

Gestational Trophoblastic Disease - Hydatidiform Mole

Answer 757

localised and non-invasive proliferation. Complete: • Sperm fertilises the empty oocyte = mitosis of 46XX tissue • No foetal tissue and no foetal RBCs Partial: • Two sperms fertilise the oocyte = forms triploid zygote 69XXX/XXY/XYY • Viable evidence of foetus (but abnormal)

Question 758

Gestational Trophoblastic Disease - Invasive Mole

Answer 758

invasion localised to within the uterus

Question 759

Gestational Trophoblastic Disease - choriocarcinoma

Answer 759

invasion followed by metaplasia outside of the uterus

Question 760

Gestational Trophoblastic Neoplasia

Answer 760

= malignant transformation of the trophoblastic tissue. Diagnosed when persistently elevated hCG/persistent vaginal bleeding/blood-borne metastases resulting from persistence of any of the above.

Question 761

Risk factors for Gestational Trophoblastic Disease

Answer 761

- Asian ethnicity - Extremes of maternal age - Previous molar pregnancy - Familial/sporadic clusters of biparental complete hydatidiform mole.

Question 762

Gestational Trophoblastic Disease - Presentation

Answer 762

- Vaginal bleeding in early pregnancy (non-specific sign) - Severe vomiting/Hyperemesis - Uterus large for date - Early onset pre-eclampsia / hyperthyroidism

Question 763

Gestational Trophoblastic Disease - Investigation

Answer 763

Serum hCG – very high USS – characteristic “snowstorm” appearance Histology = diagnostic

Question 764

Gestational Trophoblastic Disease/Neoplasia - Management

Answer 764

Gold standard management = surgical evacuation of the uterus. => The resulting products of conception should be analysed in the laboratory to confirm the diagnosis. => Anti-D prophylaxis recommended Serial hCG levels – if remain persistent or rising, this suggests malignancy. Management of GTN: => Chemotherapy. => Only 3 specialist centres in the UK deal with these

Question 765

Prevention of infection in pregnancy

Answer 765

- Seasonal vaccination against influenza (and Covid) - Vaccination against rubella - Avoidance of individuals with chickenpox - Avoidance of foods that may harbour Listeria – e.g. soft cheeses Routine Antenatal Screening - Syphilis, HepB, HIV

Question 766

Pyrexia in pregnancy

Answer 766

Can be normal => pregnancy results in a progressive and significant increase in endogenous heat production. Antipyretics in a febrile pregnant woman are important to help prevent intrauterine hyperthermia and possible foetal damage

Question 767

Most common organisms causing maternal sepsis in pregnancy

Answer 767

Group A Strep and E. coli

Question 768

Maternal Sepsis - Presentation

Answer 768

Symptoms can be non-specific – diagnosis is very challenging * D&V, * Fever (but may be absent or even low in some cases) * Abdominal pain, * Tachycardia, Tachypnoea * Confusion • Offensive vaginal discharge/Productive cough/ Urinary symptoms/ rash

Question 769

Maternal Sepsis - management

Answer 769

1. Urgent and repeated microbial specimens => BLOOD CULTURES => Consider sputum sample, throat swab, MSU, wound swab, etc. 2. Appropriate IV antibiotic therapy. => Parenteral broad-spectrum immediately (within 1 hour), without waiting for microbiology results. 3. Fluid balance - input/output 4. Oxygen if needed 5. Serum lactate should be measured => Also FBC, U&E, ABG 6. Relevant imaging to confirm source of infection.

Question 770

Chorioamnionitis

Answer 770

= inflammation of the amniochorionic membranes of the placenta (typically in response to microbial infection). Usually polymicrobial cause

Question 771

what is the greatest risk factor for developing Chorioamnionitis?

Answer 771

preterm pre-labour rupture of membranes

Question 772

Chorioamnionitis - diagnosis

Answer 772

- Maternal pyrexia - Maternal tachycardia - Uterine tenderness - Offensive vaginal discharge - Foetal tachycardia

Question 773

Chorioamnionitis - management

Answer 773

Augment delivery if not already in established labour. Broad spectrum IV antibiotics Antipyretics and keep well-hydrated Send FBC, blood cultures, low vaginal swab and MSU for analysis.

Question 774

TORCH infections

Answer 774

toxoplasmosis, rubella, CMV, HSV

Question 775

How is congenital syphilis prevented in a syphilis sero-positive pregnant mother?

Answer 775

pregnant woman treated with penicillin

Question 776

Management of Chlamydia infection in pregnancy

Answer 776

Antibiotic Tx is necessary to prevent vertical transmission to the neonate Azithromycin / Erythromycin / Amoxicillin Test of cure (TOC) is recommended in pregnancy – 3 weeks following the completion of Abx treatment

Question 777

Which chalmydia Tx should be avoided in pregnancy?

Answer 777

Doxycycline and ofloxacin are contraindicated in pregnancy

Question 778

Implications of rubella infection on pregnancy

Answer 778

If rubella infection occurs in the first 16 weeks, implications are substantial. => cardiac defects, IUGR, eye defects, liver/bowel/spleen abnormalities If 16-20 weeks, implications are deafness only

Question 779

What cardiac defects can be caused by Congenital rubella syndrome?

Answer 779

Pulmonary artery stenosis | Patent ductus arteriosus

Question 780

Maternal Parvovirus infection

Answer 780

Main effect = foetal anaemia Infection in the first 20 weeks can lead to intrauterine death and hydrops fetalis

Question 781

Congenital CMV

Answer 781

= most common congenital infection Microcephaly, IUGR, hepatosplenomegaly, ascites, jaundice, seizures

Question 782

What happens if maternal infection with varicella zoster occurs at term?

Answer 782

Elective delivery should normally be avoided until 5-7 days after the onset of maternal rash to allow the passive transfer of antibodies from mother to child

Question 783

Effects of sodium valproate on foetus

Answer 783

``` Birth defects (10% of babies exposed) => Spina bifida, facial and skull malformations, limb/cardiac/renal and urogenital malformations ``` Developmental defects (30-40% of babies exposed)

Question 784

Sodium valproate and pregnancy

Answer 784

Causes birth/developmental defects Valproate MUST NOT be used in any woman/girl able to have children, unless she has a pregnancy prevention programme in place.

Question 785

Indications for 5mg daily folic acid

Answer 785

5mg folic acid daily is required if the patient or partner: 1. Had an NTD 2. Had a previous baby with NTD 3. Have FHx of NTD 4. Have diabetes

Question 786

Normal folic acid dose

Answer 786

Standard dose = 400mcg Folic Acid daily pre-pregnancy and for first trimester

Question 787

Placental transfer of drugs

Answer 787

Nearly all drugs, except those with a very high molecular weight (e.g. insulin and heparin) cross the placenta to the foetus Lipid-soluble un-ionised drugs cross the placenta more rapidly Highly protein-bound drugs cross the placenta to a lesser extent

Question 788

What factors affect the degree of harm to the foetus by maternal medications?

Answer 788

The effect of drug exposure depends on: 1. Timing of exposure 2. Dosage and duration 3. Genetic susceptibility 4. An element of chance

Question 789

Timing of drug exposure - Pre-embryonic period

Answer 789

Until 14 days post-conception “All or nothing” => Damage to all/most cells => death => Damage to only a few cells => normal development

Question 790

Timing of drug exposure - Embryonic period

Answer 790

Week 3-8 Most important phase for teratogenicity Major organ systems forming

Question 791

Timing of drug exposure - Foetal period

Answer 791

(week 9 onwards): Baby less susceptible to toxic insults Although some organs (cerebellum and urogenital structures) are still developing.

Question 792

Lower risk drugs in pregnancy

Answer 792

``` Antacids Paracetamol Penicillins, Cephalosporins Laxatives Inhaled asthma medications ``` (Generally considered okay to prescribe if needed)

Question 793

High risk drugs in pregnancy

Answer 793

``` ACEi Phenytoin/Sodium Valproate Lithium Isotretinoin/retinoids Alcohol Misoprostol Warfarin ``` (AVOID!)

Question 794

1st line anti-emetics in pregnancy

Answer 794

Cyclizine, | Promethazine

Question 795

Foetal defects caused by lithium

Answer 795

Cardiovascular Defects (Ebstein’s anomaly of the triscuspid valve)

Question 796

drugs that inhibit/reduce breastmilk production

Answer 796

Bromocriptine, diuretics, anabolic steroids Regular moderate/heavy alcohol consumption

Question 797

High risk drugs in breastfeeding

Answer 797

``` Ciclosporin Lithium Ecstasy / other illicit drugs Amiodarone Alcohol Tetracyclines Quinolones ```

Question 798

How can gestational diabetes be diagnosed?

Answer 798

=> '5678' Fasting glucose is >/= 5.6 mmol/L, or 2-hour glucose level of >/= 7.8 mmol/L

Question 799

Whirlpool Sign

Answer 799

Twisting of the structure on USS / CT | Indicates ovarian torsion

Question 800

NICE guidelines - indications for measuring Ca-125

Answer 800

CA125 should be performed if a woman (especially if aged 50 years old or over) has any of the following symptoms on a regular basis: Abdominal distension or 'bloating' Early satiety or loss of appetite Pelvic or abdominal pain Increased urinary urgency and/or frequency

Question 801

Pregnancy and the MMR vaccine

Answer 801

MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant Women should avoid becoming pregnant for 28 days after receipt of MMR vaccine

Question 802

C-section categories

Answer 802

CAT 1 An immediate threat to the life of the mother or baby Delivery of the baby should occur within 30 minutes of making the decision CAT2 Maternal/foetal compromise which is not immediately life-threatening Delivery of the baby should occur within 75 minutes of making the decision CAT3 Delivery is required, but mother and baby are stable CAT4 Elective C-section

Question 803

Indications for Category 1 C-section

Answer 803

Examples indications include: ``` Suspected uterine rupture, Major placental abruption, Cord prolapse, Foetal hypoxia Persistent fetal bradycardia ```