O&G Flashcards
(302 cards)
1
Q
What markers are screened for in the combined test?
A
PAPP-A
beta-hCG
Nuchal translucency (NT)
*performed from 10-13 weeks
2
Q
What markers are screened for in the quadruple test?
A
Unconjugated oestradiol
Total hCG
AFP
Inhibin A
3
Q
Can you use chemotherapy to treat cancer in pregnant patients?
A
Yes, although it may be teratogenic in the first trimester, it may be used in the 2nd and 3rd trimesters. Ideally, birth should be 2-3 weeks after the most recent chemotherapy session to allow for bone marrow regeneration.
*Tamoxifen is not safe in pregnancy and breastfeeding. Radiotherapy is contraindicated in pregnancy unless it is a life-saving option
4
Q
What is routinely offered to pregnant obese women?
A
Mechanical and pharmaceutical thromboprophylaxis
Vitamin D 10mg OD
Obstetric anaesthetist review
Active management of 3rd stage labour (syntometrine and controlled cord traction) due to higher risk of PPH
GDM assessment
5
Q
What are risk factors for 2nd trimester miscarriage?
A
Uterine septum
Incompetent cervix (including previous procedures like cone biopsy)
Autoimmune diseases (like SLE or scleroderma)
Chromosomal abnormalities of fetus
6
Q
Which investigation is the most useful for ruling out a pulmonary embolism in pregnancy?
A
Women presenting with symptoms and signs of an acute PE should have an electrocardiogram (ECG) and a chest X-ray (CXR) performed.
In women with suspected PE who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue.
When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA should be performed in preference to a V/Q scan.
*D-dimers are naturally raised in the first trimester of pregnancy + are only of predictive value and not diagnostic
7
Q
What is the management of PPROM (pre-term pre-labour rupture of membranes)?
A
Aim is to deliver by 37+0 weeks as early delivery is associated with improved outcomes
Give 10-day course of erythromycin prophylaxis or until in established labour (whichever is sooner)
Offer steroids for fetal lung maturation if under 34 weeks
Consider magnesium sulphate (usually if under 30 weeks and in labour and a planned birth within 24 hours)
8
Q
What physiological changes in pregnancy do you see?
A
Marked increase in fibrinogen, factor VII, factor X and factor XII throughout pregnancy
Stroke volume increases from the first trimester and is over 30% higher than the non-pregnant state by the third trimester
Haemodilution caused by a relative increase in plasma volume compared to the red cell mass reduces the Hb concentration
Thrombocytopenia
NOTE: You also get a physiological murmur (soft systolic flow frequently audible on auscultation of the praecordium due to dilatation across the tricuspid valve causing mild regurgitant flow)
9
Q
What do you want to do in HIV+ve pregnant lady?
A
Avoid vertical transmission to reduce morbidity (one procedure is to wash the baby shortly after delivery)
You also avoid interventions which increase the risk of maternal/fetal blood transfusion such as amniocentesis, fetal blood sampling or forceps delivery
10
Q
What anticoagulants can be given in pregnancy?
A
Warfarin should be avoided due to its teratogenic effects. This is most prominent in the first trimester and is associated with fetal warfarin syndrome (nasal hypoplasia, vertebral calcinosis and brachydactyly). Warfarin effects in the second and third trimester are reduced but it can still cause cerebral malformations and ophthalmic disorders.
Heparin and DOACs are both indicated for treatment of PE but there is only evidence of heparin hence it is preferred
11
Q
How do you acutely manage a seizing pregnant patient?
A
Call for help –> ABC –> left lateral tilt –> protect airway –> prepare magnesium sulphate
*Tilting on the left will relieve any aortocaval compression and stop the woman chocking if she vomits
*Magnesium sulphate is used for a cerebral membrane stabiliser
*You need to prioritise the pregnant lady first so make sure she is fine before monitoring the fetus
12
Q
How to prevent vertical transmission of HSV in pregnancy?
A
If HSV is present at the time of delivery or within 6 weeks of the due date, a caesarean is the safest mode of delivery. If the patient labours within 6 weeks, then she should consider a caesarean section.
If the patient refuses to have a CS, IV aciclovir during labour and close liaison with the neonatologist is recommended.
*Neonatal HSV can cause encephalitis, hepatitis and disseminated skin lesions.
13
Q
When is ECV offered?
A
From 36 weeks in nulliparous women and from 37 weeks in multiparous women
*You would offer tocolytics (to relax the uterus) and CTG (monitor fetus)
14
Q
Examples of absolute contraindincations for ECV
A
Multiple pregnancy
Major uterine abnormality (i.e. bicornuate uterus)
Anterpartum haemorrhage within 7 days
Rupture of membranes
15
Q
Examples of relative contraindications for ECV
A
Small for gestational age with abnormal Doppler scan
Pre-eclampsia
Scarred uterus
Oligohydramnios
16
Q
What is SLE and what are its risks in pregnancy?
A
SLE is a systemic connective tissue disorder that is more common in black African and black Caribbean women - it may manifest as arthritis, renal impairment, neurological involvement, haematological complications, serositis, pericardtitis. Pregnancy increases the likelihood of a flare by 40-60%
SLE in pregnancy creates an increased risk of spontaneous miscarriage, fetal death, pre-eclampsia, preterm delivery and fetal growth restriction
17
Q
How does Listeria monocytogenes affect pregnancy?
A
It can cause listeriosis, and pregnant women are at risk due to being immunocompromised.
It is a food-borne infection and can be present in unpasteurised cheese and pâté.
It can cause a 2nd trimester loss, early meconium and preterm labour.
18
Q
What is pruritic urticarial papules and plaques of pregnancy (PUPP)?
A
It is a benign itchy, raised rash caused by an immune response to connective tissue damage from stretching of the skin in the abdomen. It is most commen in first pregnancies.
The rash starts in the anbdomen in stretch marks (with peri-umbilical sparing) and then moves around the body.
It normally occurs after 34 weeks and disappears after birth
19
Q
Is sodium valproate absolutely contraindicated in pregnancy?
A
No, it is recommended to be avoided due to its high risks of congenital malformations.
However if it is the only anti-convulsant that works for a patient, they should continue it, even though there may be risks to the fetus.
20
Q
What is the diagnosis criteria for gestational diabetes?
A
75g 2-hour oral glucose tolerance test (OGTT) for women with risk factors at 24-28 weeks. If they previously had gestational diabetes, offer the OGTT as soon as possible after booking, and a second OGTT at 24-28 weeks if the results for the first one was normal
DIagnose gestational diabetes if:
a fasting plasma glucose level of 5.6 mmol/litre or above or
a 2‑hour plasma glucose level of 7.8 mmol/litre or above.
21
Q
What are the target blood glucose levels for pregnant women?
A
Fasting: 5.3 mmol/litre
and
1 hour after meals: 7.8 mmol/litre or
2 hours after meals: 6.4 mmol/litre.
*pregnant women with diabetes who are taking insulin to maintain their capillary plasma glucose level above 4 mmol/litre
22
Q
Complications of gestational diabetes mellitus
A
Women who develop GDM have a 35-60% chance of developing T2DM over the next 10-15 years
Shoulder dystocia with macrosomic fetus
Stillbirth
Neonatal hypoglycaemia
Pre-eclampsia
23
Q
How do you manage a pregnant lady with HIV?
A
Aim to reduce risk of vertical transmission from motjher to fetus. The mother needs to aim for a viral load of under 50 copies/ml.
o ART: all women should be offered ART regardless of whether they were previously taking it
o Delivery: vaginal delivery is recommended if viral load <50/mL at 36 weeks, otherwise C-section
o Neonatal ART: zidovudine (oral or IV) is usually administered orally to the neonate if maternal viral load is <50/mL; otherwise, triple ART should be used. Continue therapy for 2-4 weeks
o Breastfeeding: all women in the UK should be advised NOT to breastfeed
24
Q
What is a missed miscarriage?
A
The loss of pregnancy without the passage of products of conception or bleeding.
*Not when “you didn’t know what happened”
25
What are pseudosacs?
They may be confused with an early gestational sac but they represent decidualised reactive tissue. They can be a sign of an ectopic pregnancy, so it is important to rule them out.
26
What are risk factors for ectopic pregnancies?
Previous ectopic pregnancy
Previous tubal surgery
Intrauterine device/system
Pelvic Inflammatory disease
IVF
27
How do you differentiate an ovarian torsion from a ruptured ovarian cyst?
The type of pain is different:
Although both present with a suddent onset abdominal pain, the ovarian torsion will not improve with simple analgesia. The cyst rupture pain may be reduced by simple analgesia and may decrease gradually as the peritoneal lining (which initially caused pain from irritation by the leaking fluid/blood of the cyst) absorbs the intraperitoneal free fluid.
*Both are different to a rupture ectopic pregnancy which will present with significant tachycardic hypotension
28
What are the risks of commencing HRT?
Increased risk of heart disease in women who start HRT 10 years after menopause
There is a slight increase in the risk of stroke
There is an increased risk of breast cancer
There is a slight increased risk of ovarian cancer
There is an increased risk of VTEs
There is an increased risk of endometrial cancer in oestrogen-only HRT if the woman still has a uterus
29
What is a theca lutein cyst?
It is an ovarian cyst made of multiple luteinised follicular cells and is most common when the ovary is exposed to raised levels of beta hCG (as seen in multiple pregnancy).
30
What are the risks of a caesarean section (important to know for elective purposes)?
You are twice as likely to have a stillbirth in a subsequent pregnancy
There is an increased risk of placenta praevia in future pregnancies
1-2% of babies will suffer lacerations
The risk of infection is 6%
The risk of bladder damage is 1 in 1000
*Other risks include venous thromboembolism (4–16 in 10000), significant haemorrhage (≈five in 100) and the need for hysterectomy (eight in 1000). The risk of death for caesarean section is around one in 12000.
31
What is vaginismus?
The inability to engage in penetrative sex due to involuntary spasm of the pubococcygeus muscle
32
What are long-term consequences of PCOS?
Endometrial hyperplasia (treat with progestogens and a withdrawal bleed should be induced every 3-4 months)
Sleep apnoea
Diabetes
Acne (due to hyperandrogenism)
Infertility or difficulties conceiving
33
Which of the following is not true?
1. The risk of VTE is highest in the first year of taking HRT
2. Thrombophilia screen should be carried out prior to starting HRT
3. There is no evidence of a continuing VTE risk after stopping HRT
4. Personal history of VTE is a contraindication to oral HRT
5. If a woman develops any VTE whilst on HRT, it should be stopped immediately
Thrombophilia screen should be carried out prior to starting HRT.
It is a very costly test - could consider if there is a family history of VTE
34
How do you manage ovarian cysts?
A risk of malignancy index (RMI) can be calculated using the CA 125 value, the characteristics of the cyst on ultrasound and the menopausal status. The features of concern on ultrasound are bilateral cysts, multiloculated cysts, solid components, ascites and metastases. RMI <50 has a 3 per cent chance of cancer. RMI between 50 and 250 has a 20 per cent chance of cancer and an RMI >250 has a 75 per cent chance of cancer. If the cyst is simple and less than 5 cm in diameter with a CA 125 <30U/ml then conservative management (D) would be appropriate with 4-monthly scans and CA 125 levels for 1 year.
*You can consider a laparoscopic cystectomy to aspirate the cyst contents and excising the cyst capsule (to prevent recurrence) if other management fails and if the patient was sufficiently symptomatic
35
What should you do before prescribing oestrogens?
You should ultrasound the pelvis and ensure that the endometrial thickness is <4mm. This is really important if there is postmenopausal bleeding as you want to exclude endometrial cancer (but also cervical cancer)
36
What is triptorelin?
Gonadotropin-releasing hormone agonist that creates a temporary artificial menopause by reducing FSH and LH levels. This is a great option to cope with severe endometriosis for up to 6 months - any more and there is a risk of loss of bone density.
This is a great option before considering a laparoscopy to clear the disease
37
What is the function of progesterone?
It is released by the corpus luteum following ovulation and its main function is to enhance endometrial receptivity (in the event that an embryo should need to implant).
Progestogenic effects include:
* increase in respiratory rate
* increase in sodium excretion
* reduced bowel motility
* increase in body temperature
38
What is the function of oestrogen?
Oestrogen plays a role in ovulation as well as causing the proliferation of the endometrium.
Oestrogenic effects include:
* Increased uterine growth
* Increased fat deposition
* Increased bone resorption
* Endometrial growth stimulation
39
What is premenstrual syndrome?
A condition that is associated with distressing physical, behavioural and psychological symptoms in the absence of organic or underlying psychiatric disease - this recurs regularly during the luteal phase of each menstrual cycle and disappears/regresses by the end of menstruation.
First line measures include: SSRIs, vitamin B6, improved diet and physical exercise, CBT and trial of Yasmin or Cilest COCP.
Other complementary treatments (with no evidence) can be used such as St. John's Wort, Ginkgo Biloba and Evening Primrose Oil
40
What is the first-line treatment of pelvic inflammatory disease?
**Ceftriaxone 1 g as a single intramuscular (IM) dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days.**
OR
Oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days. Levofloxacin (500 mg once daily for 14 days) may be used as a more convenient alternative to ofloxacin.
OR
Oral moxifloxacin 400mg once daily for 14 days - use this one if initial test for *Mycoplasma genitalium* is positive
41
What is an episiotomy and which structures does it cut through?
It is a procedure where you cut structures in the vulval area (around 45º from the midline) to create extra space for the delivery of the fetal head.
It cuts through the:
* bulbospongiosus muscle - inserts into the fascia of the corpus cavernosa and originates from the perineal body
* Superficial trasverse perineii (STP) - goes from the ischial ramus and tuberosity to the perineal body
* Vaginal mucosa
* Perineal membrane - has two parts (dorsal and ventral). The ventral part consists of the urethra and surrounding structures. The dorsal part consists of the attachment of the lateral wall of the vaginal and perineal body to the ischiopubic rami
42
How do the following conditions cause an increase risk to the fetus if a fetal blood sample (FBS) is performed?
HIV
Hepatitis C
Maternal immune thrombocytopenia
Factor IX deficiency
HIV and Hepatitis C are blood-borne viruses and invasive tests such as FBS can increase the risk of vertical transmission
Factor IX is haemophilia B and this should be avoided as there is a risk the fetus may be affected
In maternal immune thrombocytopenia there is a risk the fetus may have a low platelet count
43
What is the sensitivity and specificity of CTG monitoring?
High sensitivity, low specificity
Its purpose was to reduce the number of babies born with fetal acidosis and poor APGAR scores. It is quite sensitive and will pick up if a fetus becomes acidotic through suspicious/pathological changes. However it is not very specific with 50% of babies delivered due to a pathological CTG having normal blood gases
44
How do you deliver a transverse lie fetus?
You can try performing ECV and if that doesn't work then you will have to opt for caesarean delivery as IOL in a transverse lie increases the risk of uterine rupture
45
What are the signs of uterine rupture and how do you proceed?
Significant fetal heart rate abnormality and the CTG will not register any contractions
A ‘crash’ caesarean delivery is normally performed with subsequent repair, if possible, of the uterus, although a caesarean hysterectomy is sometimes necessary.
46
What are contraindications to epidural anaesthesia?
Absolute:
* Patient refusal
* Allergies to anaesthetic agents
* Systemic infection
* Skin infection over the intended epidural site
* Bleeding disorders
* Platelet count <80,000/ml
* Uncontrolled hypotension (epidural causes peripheral vasolidation and worsens this)
Relative:
* Hypertroiphic obstructive cardiomyopathy
* Aortical stenosis
* Mitral stenosis
47
Where does a pudendal nerve block happen?
The pudendal nerve is a sensory and motor nerve arising from the sacral plexus and forms from the ventral spinal nerve roots S2-S4. The pudendal nerve passes through the greater sciatic foramen, traversing through the sacrospinous and sacrotuberous ligaments. It then re-enters the perineum through the lesser sciatic foramen along with the internal pudendal artery and vein.
A pudendal nerve block (transvaginal approach) aims to block the nerve as it enters the lesser sciatic foramen, 1 cm inferior and medial relative to the attachment of the sacrospinous ligament to the ischial spine.
48
How does disseminated intravascular coagulation (DIC) present?
PT (high or low)
aPTT (high or low)
Bleeding time (high or low)
Platelets (high or low)
Active haemorrhage (yes or no)
PT - high
aPTT - high
Bleeding time - high
Platelets - low
Active haemorrhage - yes
49
What is a B-Lynch suture?
It is an external uterine suture that helps with uterine contractions in PPH
50
How does an intrauterine balloon help with PPH?
It provides internal uterine tamponade against any bleeding vessels
51
How does internal artery ligation help with PPH?
It prevents blood flow down to the uterine artery, hence reducing the blood volume reaching the uterus
52
What is peri-partum cardiomyopathy?
It develops in the last month of pregnancy and up to 5 months post-partum, causing the woman's heart to become enlarged and weakened.
Risk factors include multiple pregnancies, hypertension in pregnancy and advances maternal age.
It presents as SOB, tachycardia, tachypnoea and signs of congestive cardiac failure. X-ray findings will show cardiomegaly and pulmonary oedema.
It is rare but has a mortality rate of 9-15%
53
Which of the following does not occur in fetal circulation?
* Right ventricular output increases
* Decrease in venous return
* Closure of foramen ovale
* Pulmonary artery vasoconstriction
* Closure of ductus arteriosus
**Pulmonary artery vasoconstriction**
Occlusion of umbilical vessels --> reduces venous return to the right heart --> reduced right arterial pressure and hence closure of foramen ovale.
As fetus starts to breath --> pulmonary pressure lowers and right ventricular output increases (accomodated by vasodilation of the pulmonary arteries).
Increased flow through pulmonary system --> increased venous return of the left side of the heart --> increased pressure on the left side --> closure of ductus arteriosus due to rising oxygen levels
54
How does Sheehan's syndrome present?
It can present as absence of lactation and periods, fatigue and less commonly diabetes insipidus. If long-standing this can further cause SIADH.
It is due to a PPH significant enough to cause hypovolaemia - this alongisde hypotension can cause reduced blood flow to the anterior pituitary (which is hyperplastic during pregnancy) and cause severe necrosis or infarction.
Treatment is hormone replacement
55
How does toxoplasmosis infection in pregnancy present?
It can be caused by *Toxoplasma gondii* and this is contracted from undercooked meat and cat faeces.
It can cause chorioretinitis, macro- or micro-cephaly, convulsions and long-term neurodevelopmental delay.
Initial infections in the mother is usually mild and she may often not be aware of it.
56
How does a patient with an imperforate hymen present?
Primary amenorrhoea but with pubertal features (suggesting hypothalamic-pituitary axis is intact).
On speculum examination there will be accumulation of blood inside the vagina (haematocolpos) - can present as intermittent bloating.
57
What are risk factors of molar pregnancies?
Extremes of ages
Previous molar pregnancy
Race (SE Asia)
58
How do molar pregnancies present?
Unusual/heavy bleeding (beyond 6 weeks of pregnancy) with a pregnancy that is large for dates.
Ovaries are also enlarged due to the size of theca lutein cysts
59
What are Bartholin's glands and how are Bartholin's abscesses treated?
They are paired glands (approx 0.5cm in diameter) and commonly found at the 4- and 8-o'clock positions in the labia minora.
They are normally non-palpable and they secrete vaginal lubricant into the vestibule via the Bartholin's ducts during sexual arousal. However if these ducts become blocked, an abscess of the gland can develop.
Treatment is usually with marsupialisation - opening the abscess and suturing its lining to the outside to create a permanent opening, thereby reducing recurrence.
Oral antibiotics can be used post-surgery
60
What is clomiphene?
It is a selective oestrogen receptor modulator which through inhibition of negative feedback on the hypothalamus, increases the production of gonadotrophins. This then induces ovulation.
61
What are the risks of IVF?
* Increased risk of ectopic pregnancies
* Increased risk of fetal congenital abnormalities
* Increased chance of multiple pregnancies (twins, triplets)
* Increased risk of SGA babies (in singleton pregnancies) and low birth weight
* Increased risk of pregnancy-induced hypertension (especially if egg was donated)
62
What needs to be discussed prior to surgical termination of pregnancy (STOP)?
Antibiotic prophylaxis or screening for chlamydia
Offer post-termination contraception
Explain the risks - bleeding, infection, failure of procedure, need to repeat procedure and perforation of uterus
63
What are risk factors for cervical cancer?
Smoking
HIV (due to immunocompromised status)
Early first intercourse
Multiple sexual partners - further associations with COCP and multiparity (not causal factors but associative factors with increased sexual activity)
64
What is a vesico-vaginal fistula?
Common fistula between the bladder and the vagina caused by obstructed labour (most common cause worldwide). The fetal head sits adjacent to the bladder and overtime, this can cause the tissues to become necrotic and breakdown, eventually forming a fistula. However the most common cause in resource-rich countries is pelvic surgery.
A simple test for this in clinic is passing a catheter and filling the bladder with methylene blue dye. Then you would perform a speculum examination to see if there is dye in the vagina.
2nd line investigations would be an examination under anaesthesia and cystoscopy
65
What are first line linvestigations for subfertility (female)?
Day 1-3 LH and FSH
Mid-luteal phase progesterone (day 21)
*These would provide an indication as to whether the woman is ovulating or not.
Further investigations would include an USS to look at the size of the uterus and to detect the presence of any fibroids/polyps. An hysterosalpingogram (HSG) would be useful to assess tubal patency.
66
What are the normal ranges for sperm analysis?
* Average ejacualte volume is 1.5-6ml
* Sperm count should be 15 million/ml
* pH should be between 7.2 and 8.0
* >4% of sample should have normal morphology
* 50% of the sperm should have normal motility
*Male factor subfertility is the cause of 25-40% of subfertile couples
67
How does ovarian hyperstimulation syndrome (OHSS) present?
Presents with abdominal pain, distension and swelling, nausea and vomiting, SOB, oedema/ascities.
Blood will become haemoconcentrated with hypoproteinaemia and ascities - which can lead to a pleural effusion
Ovaries will be enlarged on USS and in severe cases >12cm. Due to haemoconcentration, patients are at an increased risk of VTE so will require decompression stockings and prophylactic anticoagulants. The hypoproteinaemia (low albumin) can also lead to decreased intravascular plasma and eventually hypercoagulability.
If the OHSS is severe there may be problems perfusing the kidneys well if much of the intravascular volume is being drawn into the third space by the decrease in oncotic pressure in the blood vessels. This may lead to oliguria. Fluid balance and management is key to these patients.
68
What organisms can cause bacterial vaginosis?
* *Gardnerella* species
* *Mobiluncus*
* *Bacteroides*
* *Mycoplasma*
Due to an imbalance of the naturally occuring flora in the vagina so it presents with an off-white offensive discharge with a fishy smell. Swabs can show clue cells and a loss of vaginal acidity.
69
What are the bony landmarks of the pelvic outlet?
Pubic arch (inferior margin of the pubic symphysis)
Ischial tuberosities (left and right, aka ischial spines)
Tip of the coccyx
70
What are the landmarks of the pelvic inlet?
The promontory of the sacrum
The arcuate line of the ilium
The iliopubic eminence
71
What is a Wertheim's hysterectomy?
Also known as a radical hysterectomy
Operation for cervical cancer - involves removing the uterus, upper 1/3 of the vagina and all the parametrium
*Wertheim's hysterectomy + some bowel resection = pelvic exenteration
72
Endometrial cancer staging
I-A tumour confined to the uterus, no or <1⁄2 myometrial invasion
I-B tumour confined to the uterus, >1⁄2 myometrial invasion
II cervical stromal the invasion, but not beyond the uterus
III-A tumour invades the serosa or adnexa
III-B vaginal and/or parametrial involvement
III-C1 pelvic lymph node involvement
III-C2 para-aortic lymph node involvement, with or without pelvic node involvement
IV-A tumour invasion bladder and/or bowel mucosa (D)
IV-B distant metastases including abdominal metastases and/or inguinal lymph nodes
73
How do you diagnose and manage ovarian cancers?
You need a histological diagnosis at operation (even if imaging is already pointing to the whereabouts/spread of the cancer)
A staging laparotomy establishes the type and extent of the primary cancer and allows optimal cytoreduction (or ‘debulking surgery’) where as much of the disease as possible is removed at operation.
Even in advanced cancers, the preferred treatment for all women who are fit for operation is optimal cytoreductive surgery. Chemotherapy may also be indicated since ovarian cancers are highly sensitive to platinum based agents and the vinca alkaloids.
74
What is Meig's syndrome?
Triad of:
* Right-sided pleural effusion
* Ascites
* benign overian fibroma
75
What are patients on long-term steroids prior to surgery at risk of?
Patients on >10mg predisolone/day (or equivalent) for 3 months or more will require steroid supplementation due to secondary corticosteroid insufficiency. Patients on <10mg predisolone will still have a normal HPA response.
For major gynaecological surgery, such as vaginal hysterectomy, 50mg of hydrocortisone 8-hourly from induction is the standard practice, and may be stopped after 2 or 3 days, or when normal gut function returns and the patient can resume oral steroids. This is alongside 50mg IV hydrocortisone at the induction of anaesthesia.
76
Questions 2, 12, 13, 16, 20 of section 8 are on female pelvic anatomy
read if want
77
What can cause chest pain in a patient with ischaemic heart disease?
Anaemia - the myocardium will be deprived of oxygen so chest pain can develop even thought it may not be significant enough to cause an actual infarction
78
How do you calculate the risk of malignancy index score (RMI)?
You need to use the CA-125 score, the characteristics of the cyst on USS and the menopause status.
You give 0, 1 or 3 points to USS characteristics:
* Presence of bilateral cysts
* Multiloculated cysts
* Cysts with solid components
* Ascites
* Metastases
You then do the following calculation:
USS points x CA-125 x 3 (if post-menopausal)
RMI <50 has a 3 per cent chance of cancer. RMI between 50 and 250 has a 20 per cent chance of cancer and an RMI >250 has a 75 per cent chance of cancer.
79
What is important to consider in intermenstrual bleeding?
It is important to take pelvic swabs as pelvic infections are very common causes of new-onset intermenstrual bleeding
80
Which of the following is not at risk when inserting a lateral port in a laparoscopy?
* Superficial epigastric artery
* External iliac vein
* Iliohypogastric nerve
* Superior epigastric artery
* Ilioinguinal nerve
Superior epigastric artery
81
What do women with heart valvular problems require in an instrumental delivery?
Intra-partum prophylactic antibiotics due to infection-prone procedure
82
What is the role of prostaglandins and collagenase in the cervix during pregnancy?
Prostaglandins remodel the cercix
Collagenase aids in cervical softening
Both prepare the cervix for labour
83
What does maternal cortisol do?
Regulates uterine blood flow through effects on vascular endothelium and smooth muscle
84
What is the vessel that carries oxygenated blood from the placenta and in adult life forms part of the falciform ligament?
Umbilical vein
85
What are the trimesters in pregnancy?
1st: 1 to 12 weeks
2nd: 13 to 27 weeks
3rd: 28 to 40+ weeks
86
At how many weeks is a baby considered at term
37 weeks
87
What does baseline variability on a CTG demonstrate?
Reflection of the normal fetal autonomic nervous system
88
What is a biophysical profile?
It is an assessment of fetal breathing, gross body movements, fetal tone, reactive fetal heart rate and amniotic fluid.
This is usually done after 28 weeks on USS
89
What can be used to date pregnancies when booked between 14 and 20 weeks?
Head circumference
90
What is cordocentesis?
It is a relatively unusual procedure but can be performed where a fetal blood sample is required - i.e. to determine platelet count in suspected alloimmune thrombocytopaenia
91
Why do women need to be admitted to hospital at term if the fetal lie is unstable?
When the fetal lie is unstable, the longitudinal axis of the baby relative to the mother still fluctuares at term - this increases the risk of cord prolapse if the membranes rupture
92
What risks do monozygotic twin pregnancies carry?
Death or handicap of the co-twin in 25% of cases
93
How often should USS surveillance for monozygotic twins in the 3rd trimester be carried out?
Fortnightly
94
What is multi-fetal reduction?
The reduction of the number of fetuses in multiple pregnancies (>2) in order to improve the survival of the fetuses and reduce the possibility of preterm birth
95
What is an US measurement of the cervical length used for?
It is helpful in predicting preterm labour in multiple pregnancies
96
Why is intrauterine bleeding linked to reccurent episodes of threatened miscarriage in early pregnancy?
Blood is irritant to the uterus
97
What is cervical cerclage?
Surgical procedure to place a stitch/suture around the cervix.
It is done to prevent premature delivery or miscarriage in at risk women due to cervical insufficiency/weakness
It is contraindicated in the presence of vaginal bleeding, contractions or infection
98
What is the nitrazine test?
It tests for the alkaline pH of amniotic fluid to check if there has been rupture of membranes or not
It has a high negative predictive value
99
What is the Jarish-Herxheimer reaction?
It is a temporary reaction with an increased released of pro-inflammatory cytokines usually within the first 24h of syphilis treatment.
Symtpoms include:
* Fever
* Chills
* Headache
* Muscle aches
* Flushing of the skin
* Rapid heart rate
* Low blood pressure
* Sweating
* Increased breathing rate
100
Name the mechanisms of labour
Engagement
Descent
Flexion
Internal rotation
Extension
Restitution
External rotation
Delivery of the shoulders and fetal body
*Chapter 14 ten teachers
101
What is effacement?
It is a process where the cervix shortens in length and becomes included into the lower segment of the uterus
It can start weeks before the onset of labour but will complete by the end of the latent phase
102
How long should a third stage of labour last?
<30 mins
103
How long should an active 2nd stage of labour last?
<2 hours in primiparous
<1 in women with previous vaginal delivery
104
What is uterine inversion?
It is a rare complication of the 3rd stage of labour. It is caused by excessive traction on the umbilical cord prior to placental separation
105
Klumpke's vs Erb's palsy?
Klumpke's palsy, also known as "claw hand," is a rare condition that results from damage to the lower brachial plexus, affecting the nerves that control the muscles of the forearm and hand. This can cause weakness or paralysis of the hand and fingers, with the fingers appearing curved or claw-like.
Erb's palsy, on the other hand, is a more common condition that occurs when the upper brachial plexus is injured, affecting the nerves that control the shoulder, upper arm, and elbow. This can cause weakness or paralysis of the affected arm, with the arm appearing to be held at the side and rotated inward.
106
Management for primary dysmenorrhoea?
First line: NSAIDS like mefenamic acid or ibuprofen - inhibit prostaglandin production
2nd line: COCP
107
Placental abruption management
**Fetus alive and < 36 weeks**
* Fetal distress: immediate caesarean
* No fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
**Fetus alive and > 36 weeks**
* Fetal distress: immediate caesarean
* No fetal distress: deliver vaginally
**Fetus dead**
* Induce vaginal delivery
108
Placental abruption complications
Maternal:
* Shock
* DIC
* Renal failure
* PPH
Fetal:
* IUGR
* Hypoxia
* Death
109
Delivery with HIV positive women
Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
A zidovudine infusion should be started four hours before beginning the caesarean section
110
What do medical terminations of pregnancy involve (<9 weeks)?
Usually given mifepristone (oral) followed by at least one dose of prostaglandins (usually vaginal misoprostol)
111
What is the treatment for hyperemesis gravidarum?
1st line - cyclizine or promethazine
2nd line - ondansetron or metoclopramide
3rd line - steroids (hydrocortisone)
Alternative therapy - ginger tablets + P6 acupressure
*Metoclopramide is 2nd line due to chance for extra-pyramidal symptoms (EPS)
*Ondansetron is 2nd line due to increased risk of cleft lip/palate when taken in 1st trimester
*
Complications include: VTE, depression, anaemia, dehydration, electrolye imbalances - give KCl and vitamin B1
112
What is tubal microsurgery?
Surgical treatment of subfertility which involces tubal catheterisation or cannulation to resolve proximal tubal obstructions
113
What are contraindications to methyldopa?
Psychiatric history - anxiety, depression
Liver disease
MAOI use
Severe aortic stenosis
114
What are contraindications to labetolol?
Asthma or severe COPD
Cardiogenic Shock
Heart block or bradycardia
Severe liver disease
MAOI use
115
What is a side effect of hydralazine?
Causes a sudden and profound drop in blood pressure so patients may require pre-emptive administration of fluids
116
Neonatal varicella vs congenital varicella
Neonatal varicella does not have any teratogenic effects but it can cause extensive cutaneous involvement, pneumonitis and encephalitis.
You administer VZIG if birth occurs within 7 days of onset of chickenpox in the mother + monitor for signs of infection until 28 days post-delivery.
If neonatal varicella is contracted, treat with aciclovir
117
What are characteristics of congenital varicella?
Cutaneous scarring
Eye defects
Limb hypoplasia
Neurological abnormalities
118
What does a mid-luteal progesterone indicate?
It implies ovulation has taken place - after ovulation, the corpus luteum produces progesterone resulting in a high concentration of progesterone during the luteal phase
119
What is anti-mullerian hormone (AMH)?
It is important in regulating the development of follicles and is only present in the ovary until menopause - useful biomarker for ovarian reserve and helps predicts the outcome of assisted reproduction
120
How does genital herpes present?
Caused by HSV virus
Around 2-12 days post-exposure, patients will get painful, red lumps which turin into blisters within 24 hours. The blisters break and leave shallow, painful ulcers that take 2-4 weeks to heal after the initial infection
Other symptoms - dysuria and systemic (fever, malaise, headaches)
121
What is the main difference between vasa praevia and placenta praevia?
Vasa praevia will have an associated pathological CTG trace - despite both causing painless vaginal bleeding
122
What is the management for endometrial hyperplasia without atypia?
*Low risk
Continuous progestogens (IUS) for a minimum of 6 months
TVUSS with biopsies every 6 months
Adress reversible causes - obesity, T2DM
123
What is the management for endometrial hyperplasia with atypia?
*High risk
No preservation of fertility - total hysterectomy
Preservation of fertility - progestogens and endometrial surveillance with biopsies every 3 months
124
Risk factors for PID
<25 years
Multiple sexual partners
Previous STI or PID
Use of IUD
125
When do you remove the IUD in a patient wirth suspected PID?
If the initial course of abx (ceftriaxone, doxycycline and metronidazole) has not improved symptoms within 72hrs
126
What is the classical triad of congenital toxoplasmosis?
Intracranial calcifications
Hydrocephalus
Chorioretinitis
127
What is vacuum aspiration and when can it be performed?
Surgical TOP: dilation of cervic and using a vacuum suction to evacuate the uterine cavity
Can be performed up to 14 weeks' gestation
128
What is dilation and evacuation and when can it be performed?
Greater cervical dilatation than vacuum aspiration to enable the removal of large foetal parts - contents of the uterus are evacuated using aspiration and forceps. This is followed by an USS to confirm complete evacuation
Done in gestations 14-24 weeks
129
Why are NSAIDS contra-indicated in pregnancies?
Associated with an increased risk of miscarriage
>30weeks - there is a risk of premature closure of ductus aeteriosus, persistent pulmonary hypertension of the newborn and oligohydramnios
130
What can codein use in pregnancy cause?
Especially in the third trimester, it can cause neonatal withdrawal syndrome and neonatal respiratory distress
131
In women taking anticoagulants in pregnancy, what should you recommend for delivery?
Stop injections when they go into labour
or
Take last dose at least 24hrs before planned delivery
132
What is the physiological process in a cervical ectropion?
Glandular columnar epithelium (usually present on the endocervic) extends into the ectocervix (which usually consists of stratified squamous epithelium)
This occurs due to increased oestrogen exposure - pregnancy, puberty and COCP
133
What caution is needed when administering carboprost in a PPH?
It is a prostaglandin F2alpha analogue and you need to be careful in asthatic patients as it can precipitate bronchoconstriction
134
What is the most preferred treatment for symptomatic Bartholin's cysts?
Marsupialisation
Can also consider balloon catheter insertion (Words catheter)
*Always remember to give prophylactic Abx
135
What are 2nd and 3rd line treatments for symptomatic Bartholin's cysts?
2nd line = surgical excision of the gland - reserved for recurrent cysts/abscesses
3rd line = silver nitrate cauterisation, alcohol sclerotherapy or laser ablation
136
What is the definition of recurrent miscarriages and what are common causes?
Loss of 3 or more consecutive pregnancies before 24 weeks' gestation
Main causes: antiphospholipid syndrome, uterine anomalies, thrombophilia, balanced translocations within the genomes of the expecting parents
137
What is the treatment of candida infection of the nipples in breastfeeding woman?
Mother: topical miconazole
Baby: oral nystatin
138
What are granulosa cell tumours?
Rare type of ovarian cancer with peak incidence in pre-pubertal girls and post-menopausal women. They are malignant but slow growing.
They are oestrogen secreting and inhibit (which can be used as a tumour marker for recurrence). They contain call-exner bodies which are eosinophilic fluid-filled spaces found between granulosa cells
Symptoms include: post-menopausal bleeding, precocious puberty in young girls, and an increased risk of endometrial cancer due to endometrial hyperplasia
139
What can you give GDM patients if they don't tolerate metformin?
Glibenclamide (sulphonylurea)
*Side effects of metofmrin include: decreased appetite, diarrhoea, abdominal pain
140
What forms part of the initial investigations for inability to conceive?
Mid-luteal progesterone, semen analysis, chalmydia screen
141
What is a normal range of amniotic fluid index (AFI)?
Normal range for AFI varies with gestational age
An AFI between 5 and 25 cm is considered normal between 20 and 35 weeks (after which the amniotic fluid volume decreases)
142
What are causes of polyhydramnios?
Increased foetal urine production:
* Maternal cardiac or renal disease
* Maternal diabetes mellitus
* Multiple pregnancy
* Hydrops fetalis
* Foetal anaemia
Inability of the foetus to swallow or absorb amniotic fluid:
* Neurological/muscular abnormality - myotonic dystrophy, anencephaly
* GI obstruction - duodenal atresia, cleft palate
* Chromosomal abnormalities - Down's
Idiopathic in 30-50% of cases
143
What are risks of polyhydramnios?
Preterm delivery
Cord prolapse
PLacental abruption
Malpresentation
144
What are causes of oligohydramnios?
Leakage of amniotic fluid:
* Rupture of membranes
Reduced foetal urine production:
* Post-dates pregnancy
* Renal tract malformations or renal failure
* Foetal urinary obstruction e.g. posterior urethral valve
* IUGR
Other:
* Pre-eclampsia - placental insufficiency
* NSAID use
145
What are risks of oligohydramnios?
Stillbirth
Limb contractures
Incomplete lung maturation
146
What are risks factors of cord prolapse?
Preterm labour
Foetal malpresentation
Polyhydramnios
Low birth weight
Artificial rupture of membranes
147
What should you do in a cord prolapse?
Elevate the presenting part manually or by filling the bladder (minimise handling cord to prevent vasospasm)
Adopt maternal knee-to-chest or left lateral lie
Deliver the baby
148
Indications of planned caesarean section
* Singleton breech with contraindicated or unsuccessful ECV
* Multiple pregnancy if first twin is not cephalic at the time of planned birth
* Placenta praevia that is partly or completely covering the internal cervical os
* Morbidly adherent placenta
* HIV+ve not on ART or if viral load >400 copies/ml
* Co-infection with HCV and HIV
* Primay genital HSV in the 3rd trimester
* Classical caesarean section scar
149
What are the different types of caesarean sections?
Lower uterine segment (most common) - transverse incision superior to the edge of the bladder
Classical segment - longitudinal midline incision (rarely performed now due to risk of haemorrhage and uterine rupture)
Vertical incision
150
Why does lochia bleeding become heavier when breasfeeding is occuring?
Stimulation of the neuroendocrine reflex arc causes the uterus to contract - can be accompanied by crampy period-like pain
151
Examples of antimuscarinic drugs used in urge incontinence?
Tolterodine
Darifenancin
Oxybutynin
152
What is mirabegron and when is it used?
It is a beta3-agonist used for the treatment of urge incontinence - if antimuscarinics have not worked or if a patient is at risk of falls
153
What are the requirements of Neville Barnes forceps?
FORCEPS:
Fully dilated
Occipito-anterior position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (empty bladder)
*As seen, you can only use these in an OA position - if rotation is required, then consider ventouse or Kielland forceps (those these have a higher risk of perineal tears and need for episiotomy)
154
ITP management in pregnancy
Treat with steroids as autoantibodies can cross the placenta and cause neonatal thrombocytopaenia - increases risk of intracranial haemorrhage
If there is no response to steroids or platelet count still very low, then consider IVIG
155
What should you do in a pregnancy of unknown location (PUL)?
Take two serum beta-hCG measurements 48 hours apart. If it increases by over 63% after 48hrs then this is likely an intrauterine pregnancy. If it decreases by over 50% in 48hrs then this is likely a miscarriage. Though it it is between a 63% increase and 50% decrease, consider an ectopic pregnancy
*If initial bhCG is >1500IU/L then consider an ectopic pregnancy as this should be visible on a scan
156
What happens in colposcopy and LLETZ?
Colposcopy involves a speculum inserted inside the vagina and the use of a colposcope (specialised microscope) to allow direct visualisation of the cervix.
5% acetic acid (turns dysplastic areas white) and Lugol's iodine (turns normal epithelium brown) are applied.
If there are any abnormal cells, LLETZ can be done which involves the excision of abnormal cells using a heated wire under local anaesthetic - this is sent for histology
If no abnormal cells are detected, a punch biopsy can be done and sent for histology
157
What are the different types of female genital mutilation?
Type 1 (clitoridectomy): Partial or total removal of the clitoris and/or prepuce (skin covering the clitoris)
Type 2 (excision): Partial or total removal of the clitoris and the labia minor with or without excision of the labia majora
Type 3 (infibulation): Narrowing of the vaginal orifice (introitus) with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora, with or without excision of the clitoris
Type 4: All other harmful procedures to the female genitalia for non-medical purposes, including pricking, piercing, incising and cauterisation
158
What is the USS schedule for twin pregnancies?
Monochorionic - Every two weeks from 16 weeks (due to increased risk of TTTS)
Dichorionic - Every two weeks from 20 wekks
159
How does a vesicovaginal fistula present?
Continuous involuntary discharge of urine through the vagina - can also present with some degree of stress incontinence.
Causes:
Acquired - obstructed labour, malignancy, gynaecological surgery, radiotherapy, trauma
Congenital - urogenital malformations
160
What are the shapes of the anterior and posterior fontanelles?
Anterior: diamond-shaped depression
Posterior: Y-shaped depression
161
Which patients require intrapartum antibiotics?
Confirmed preterm labour
Pyrexial (38 or more)
GBS detected on swab in antenatal period
GBS detected in UTI in antenatal period
Previous baby with GBS infection (early or late)
*GBS on swab does not require immediate treatment, only intrapartum antibiotics - however for GBS UTI, both are required
162
What are procedural (neuromodulation) treatments for urge incontinence?
1st line - Botilinum toxin type A injection. This is done cystoscopically into the detrusor muscle which blocks neuromuscular transmission causing a temporary paralysis. Patients require self-catheterisation as there is a risk of temporary urinary retention
2nd line - percutaneous sacral nerve stimulation. This involves implanting an electrical pulse generator into the button to provide continuous stimulation to the S3 nerve root, suppressing detrusor activity
163
What surgical treatments are available if patients with urge incontinence have not responded to neuromodulation?
Augmentation cystoplasty - increase bladder size by adding tissue from the intestinal tract
Urinary diversion - redirect flow of urine trough an opening in the abdomen
164
Pathophysiology of amniotic fluid embolism
Exposure to foetal antigens during delivery triggers an inflammatory cascade which results in organ damage and activation of the coagulation cascade - results in DIC
Presentation is a triad of acute hypoxia, hypotension and coagulopathy
Respiratory failure with cyanosis and pulmonary oedema can develop and patients can go into cardiac arrest
165
Risk factors for amniotic fluid embolism
Caesarean delivery
Advanced maternal age
Multiple pregnancy
Antepartum haemorrhage
Induction of labour
Placental abruption
Uretotonics
166
What is another description for strawberry cervix in trichomonas vaginalis?
Punctate haemorrhages of the cervix
167
How is trichomonas vaginalis diagnosed?
Wet mount microscopy - flagellate protozoon with a characteristic 'pear' shape
168
What is the regimen of antenatal corticosteroids?
IM betamethasone 12mg, 2 doses given 24 hours apart (total 24mg in 48hrs)
or
IM dexamethasone 6mg, 4 doses given 12 hours apart (total 24mg in 48hrs)
169
What is the magnesium sulphate dose in eclampsia?
4g loading dose given over 5-15 minutes followed by 1g/hour for 24 hours after seizure or delivery (whichever one is later)
170
What is important to look out for in magnesium sulphate overdose?
Respiratory rate + cardia arrhythmias + loss of deep tendon reflexes (patellar)
171
How should you treat magnesium toxicity?
Stop infusion
10ml 10% calcium gluconate over 10 minutes
172
How is asherman's syndrome diagnosed?
Hysteroscopy (gold standard)
History will be extensive for gynaecological surgeries
173
When do you give treatment for acute HSV infection in pregnancy?
If in 1st or 2nd trimester - oral aciclovir from 36 weeks to delivery
If 3rd trimester, oral aciclovir immediately until deliver
*Neonatal IV aciclovir if signs of skin, eye, mouth disease or CNS involvement
174
What type of delivery is indicated in HSV infection?
1st episode ≥6 weeks prior to EDD: spontaneous vaginal delivery
1st episode ≤6 weeks prior to EDD: C-section
*However if a woman chooses vaginal delivery, ROM and invasive procedures are contraindicated and IV aciclovir should be given to the mother and neonate
175
Polymorphic Eruption of Pregnancy vs Prurigo of Pregnancy
Polymorphic Eruption of Pregnancy = pruritic urticarial papules and plaques of pregnancy (PUPPP)
PUPPP has raised itchy red patches/papules that merge together to form larger areas of involvement. Starts in the abdomen and spreads, usually wit umbilical sparring
Prurigo of Pregnancy has small itchy bumps/nodules that are often excoriated. These are commonly found in extensor surfaces of the arm and shoulders
176
What are last (extreme) measures in shoulder dystocia?
Symphysiotomy - dividing the mother's pubic symphysis
Cleidotomy - diving the foetal clavicles
Zavenelli manouevre - pushing foetal head back into the vagina for a c-section
177
What are predisposing factors of pelvic organ prolapse?
Childbirth
Old age
Obesity
Long-term constipation
Heavy lifting
178
What are the four main types of pelvic organ prolapse?
Cystocele - anterior vaginal wall prolapse involving the bladder. This can be associated with urethral prolapse (cystouretrocele)
Uterine prolapse - prolapse of the uterus, cervix and upper vagina
Enterocele - prolapse of the upper posterior vaginal wall, involving loops of bowel
Rectocele - prolapse of the lower posterior vaginal wall, involving the rectum
179
What are the degrees of severity of urogenital prolapse?
First degree - the lowest part of the prolapse descends halfway down the vaginal axis to the introitus
Second degree - lowest part of the prolapse extends to the level of the introitus and protrudes trough the introitus on straining
Third degree - lowest part of the prolapse extends through the introitus and lies outside the vagina
Procidentia - severe third degree prolapse were the uterus lies entirely outside the vagina and is associated with complications such as ulceration
180
What is the initial management of a symptomatic pelvic organ prolapse
Start with lifestyle modifications (and only this if asymptomatic)
Add on 16 weeks of pelvic floor muscle training and a vaginal pessary (to be changed every 6 months)
Provide oestrogen to reduce risk of vaginal erosion or if there are signs of vaginal atrophy
181
What days to zygotes divide to produce the different types of twin pregnancies?
DCDA - within 3 days of fertilisation (or from 2 separate zygotes initially)
MCDA - day 4 to 8 post-fertilisation
MCMA - after day 8 post-fertilisation
182
What is the Amsel criteria?
Used to diagnose bacterial vaginosis:
*Thin, white, homogenous vaginal discharge
*Clue cells on microscopy
*Vaginal pH >4.5
*Fishy odour when potassium hydroxide is added to the vaginal fluid
3/4 is diagnostic
183
What is the treatment for BV and what is an alternative?
PO metronidazole for 5-7 days
If not tolerated, clindamycin PV cream
184
What does the triple swab test include?
Two endocervical swabs (one NAAT and one charcoal) and one high vaginal
Swab 1 (NAAT endocervical/vulvovaginal) - chlamydia and gonorrhoea
Swab 2 (endocervical with charcoal) - gonorrhoea MC&S but only done is NAAT is positive
Swab 3 (high vaginal with charcoal) - BV, TV, candida, GBS (fungal and bacterial infections) MC&S
*Alternatively swabs 1 and 2 can be combined by taking a (2-in-1 NAAT testing swab
185
What should you do for a patient that is on warfarin and requires anticoagulation during pregnancy (i.e. mechanical valves)?
Switch them to LMWHs ideally before conception
186
What is an endometrioma?
Ovarian cyst formed by endometrial tissue which has a characteristic echogenic 'ground glass' appearance on TVUSS. It causes deep dyspareunia and dysmenorrhoea with raised CA125
187
What are the different types of ovarian cysts?
Functional:
*Follicular
*Corpus luteal
*Theca lutein
Benign germ cell:
*Dermoid
Benign epithelial:
*Serous cystadenoma
*Mucinous cystadenoma
*Brenner tumour
188
Cyclical vs continuous HRT
Cyclical HRT involves an oestrogen every day for 1-3 months and a progestogen for the last 14 days to precipitate a bleed
Continuous HRT involves an oestrogen and progestogen every day
*Continuous is for women who are post-menopausal (absence of periods for 1 year) whilst cyclical is perimenopausal
189
What should all babies of HIV+ve women receive?
4-6 week course of zidovudine (oral ART) starting within 4 hours of birth
They should also be tested for HIV by PCR at birth, on discharge, at 6 weeks and 12 weeks
190
Causes of secondary PPH
Endometritis (most common)
Retained products of conception
Local trauma (perineal tears)
Coagulopaty
191
Causes of primary PPH
Uterine atony (most common)
Uterine rupture
Coagulopathy
Retained products of conception
192
Where should medical TOPs >12weeks be conducted?
In clinic due to increased risk of bleeding and requirement of multiple doses of misoprostol
193
Mechanism of action of:
Mifepristone
Misoprostol
Methotrexate
Mifepristone - blocks progesterone so cannot maintain pregnancy
Misoprostol - synthetic prostaglandin that induces uterine contractions and expels the contents
Methotrexate - folic acid antagonist and affects the rapid growth of cells, including embryonic cells
194
What are the main tumour groups of the ovaries?
Epithelial tumours:
* Serous cystadenoma or adenocarcinoma
* Endometrioid carcinoma
* Clear cell carcinoma
* Mucinous cystadenoma or adenocarcinoma
* Brenner tumours
Germ cell tumours:
* Teratoma/dermoid cyst
* Yolk sac tumours
* Dysgerminoma (female equivalent of seminoma)
Sex cord tumours:
* Granulosa cell tumours
* Thecomas
* Fibromas (Meig's syndrome)
195
How long is clomiphene used for and what risk is it associated with?
Up to 6 months in PCOS
It is associated with risk of multiple pregnancy and ovarian hyper stimulation syndrome
196
What surgical procedure can be used in PCOS to help with fertility?
Laparoscopic ovarian drilling - breaking down parts of the ovarian stroma with hope that it induces ovulations
*If this doesn't work then IVF can be considered
197
What should you warn women about the MMR vaccine?
They should avoid getting pregnant for 1 month after receiving the vaccine.
Alternatively, if they are pregnant, they should avoid taking the MMR vaccine due to it being a live vaccine with risks of congenital rubella infection
198
How do you classify perineal tears.
1st degree: Superficial damage with no muscle involvement
2nd degree: Injury to the perineal muscle not involving the anal sphincter
3rd degree: Injury to the perineum and anal sphincter complex
3a - <50% of the external anal sphincter (EAS)
3b - >50% of the EAS
3c - Internal anal sphincter (IAS) torn
4th degree: Injury to the perineum involving the anal sphincter complex (EAS and IAS) and the rectal mucosa
199
What is the most useful surgical procedure for a cystourethrocele?
Anterior repair - pushes bladder back into its original anatomical location and supports the tissue between the anterior wall of the vagina and the bladder
200
What pelvic prolapse is a posterior repair usually done for?
Rectocele
201
What are side effects of the copper IUD?
In the first 3-6 months, periods may be heavier, longer and more painful
Risk of uterine perforation
Risk of infection
Risk of ectopic pregnancy
202
What are causes of pruritus vulvae (itchy vulva)?
Non-neoplastic:
*Lichen vulval dermatoses - lichen sclerosis, vulval dermatitis, lichen plants, vulval psoriasis
*Infection - candidiasis, trichomoniasis, threadworms
*Menopause - atrophic vaginitis
Neoplastic:
*Vulval intraepithelial neoplasia (VIN)
*Vulval carcinoma
203
What is lichen sclerosus?
Chronic condition of unknown aetiology seen commonly in post-menopausal women. It tends to affects the genital and perianal areas.
Presentation: crinkled and thickened patches of skin involving the clitoral hood, labia minors and perianal skin BUT NO INVOLVEMENT OF THE VAGINAL MUCOSA.
Symptoms: itchiness, soreness, dysuria and dyspareunia
Treatment: topical steroids
*Risks development into VIN and vulval carcinoma
204
What is the role of ulipristal acetate in fibroids?
It is a progesterone antagonist that can be used in lieu of goserelin (GnRH analogue) to shrink the fibroids before surgery. Alternatively, it can also be used intermittently in women not eligible for surgery.
It needs to be given with caution as it can cause liver damage, so regular LFT monitoring is needed
205
What is endometrial ablation?
It is a procedure that involves destroying the lining of the uterus with a heated wire. Although effective in treating heavy menstrual bleeding, it has an increased risk of miscarriage and ectopic pregnancy
206
What are major risk factors for pre-eclampsia?
Chronic kidney disease
Hypertensive disease during a previous pregnancy
Autoimmune diseases (e.g. SLE)
Diabetes mellitus
Chronic hypertension
*These patients require 150mg of aspirin from 12 weeks gestation until delivery
207
What are moderate risk factors for pre-eclampsia?
Primiparity
Advanced maternal age (>40yrs)
Pregnancy interval of >10yrs
BMI >35kg/mg2 at booking visit
FHx of pre-eclampsia
Multiple pregnancy
*If 2 or more are present, provide 150mg of aspirin from 12 weeks until delivery
208
How is premature ovarian failure diagnosed?
2 FSH measurements >30U/L taken 4-6 weeks apart
209
How do the following haematological markers change in pregnancy?
Hb
MCV
Plasma volume
Neutrophils
Platelets
Fibrinogen, Factor VIII and vWF
Protein S
Hb - low
MCV - raised
Plasma volume - raised
Neutrophils - raised
Platelets - low
Fibrinogen, Factor VIII and vWF - raised
Protein S - low
210
How do the following respiratory markers change in pregnancy?
Tidal volume
Respiratory rate
Oxygen consumption
Tidal volume - raised
Respiratory rate - same
Oxygen consumption - raised
211
How do the following cardiovascular markers change in pregnancy?
HR
Stroke volume
HR - raised
SV - raised
212
How does the following renal markers change in pregnancy?
GFR
GFR - raised
213
How do the following gastrointestinal markers change in pregnancy?
Intestinal tone and motility
Lower oesophageal sphincter tone
Gallbladder contractions
Intestinal tone and motility - decreased
Lower oesophageal sphincter tone - decreased
Gallbladder contractions - decreased
214
When can the levonorgestrel IUS be inserted post-partum?
Within 48 hours of delivery or after 4 weeks
215
When can you start progesterone contraceptives post-partum?
At any point but if started after 21 days, they should use barrier contraception for 2 days
216
Why is endometrial hyperplasia linked to PCOS?
Anovulation means there is persistently elevated levels of oestrogen which promotes endometrial proliferation and subsequently can lead to endometrial hyperplasia and cancer. PCOS patients are recommended to take the COCP with a withdrawal bleed every 4-6 months
217
What is pelvic girdle pain?
Also known as symphysis pubis dysfunction - common MSK condition in pregnancy due to excessive movement of the pubic symphysis as the cartilage becomes relaxed under the influence of various pregnancy hormones.
It presents with pain and tenderness over the pubic symphysis, which can spread to the back, thighs and perineum. The pain can be worse on walking or climbing stairs, with an occasional click/grinding sound from the pelvis.
Treatment: analgesia and physiotherapy
218
When are resus negative women routinely offered anti-D prophylaxis?
Single dose (1500 IU) at 28 weeks
Two doses (500 IU) at 28 and 34 weeks
219
When should a Kleihauer test be performed?
After any sensitising event after 20 weeks
220
What is the treatment for molar pregnancies?
Suction curettage to promptly evacuate the contents of the uterus (ERPC - evacuation of retained products of conception)
Monitor bHCG levels and consider methotrexate if it is rising/stagnant
221
How does thyroid function change in pregnancy?
Fall in TSH and rise in T4 in first trimester (due to similarities of bHCG)
Fall in T4 later in gestation
222
What are the 3 stages of post-partum thyroiditis and how do you treat it?
Thyrotoxicosis —> hypothyroidism —> euthyroid
Thyrotoxicosis (propranolol)
Hypothyroidism (levothyroxine)
223
Absolute contraindications for VBAC
Previous uterine rupture
Classical caesarean scar
Factors unrelated to previous caesareans i.e placenta praevia
224
How do you treat uterine hyperstimulation?
If caused by prostaglandins - tocolytics like terbutaline
If caused by syntocinon - reduce or stop the infusion
225
How do you manage a cerebral venous sinus thrombosis (post-partum)?
MRI is the gold standard investigation, however, in most acute situations a CT head is performed initially due to ease of access and to rule out other causes (e.g. intracranial bleeds).
IV heparin infusion is the first-line management option after which catheter-guided local thrombolysis can be performed. Patients usually require 3-6 months of anticoagulation following initial treatment.
226
What is a pulsatility index (PI)?
It is an index calculated by comparing the systolic and diastolic pressures of the umbilical arteries
High PI = reduced blood flow to the fetus
*In the MCA you can sometimes see a reduced PI and this is suggestive of improved blood flow to the foetal brain (the ‘brain sparing effect’) - seen in asymmetrical IUGR
227
What is the management of lichen sclerosus?
1st line (3 months): clobetasol propionate (strong steroid ointments)
2nd line: tacrolimus (topical calcineurin inhibitor) + biopsy (as steroid-resistant)
228
Relative contraindications for VBAC
2 or more previous C-sections
The need for induction of labour
Previous labour outcome suggestive of cephalopelvic disproportion
229
Is multiple pregnancy a contraindication for VBAC?
No, studies have shown no increased risk of VBAC complication post-delivery - just ensure that normal vaginal delivery is indicated in that multiple pregnancy
230
What manouvre can you use in a vaginal delivery of the 2nd baby (breech) in a multiple pregnancy?
Internal podalic version
231
What should you do in suspected maternal Parvovirus B19 infection?
Serology of maternal IgM to confirm infection (consider PCR amsniocentesis to check for foetal infection)
Foetal USS with doppler of MCA fortnightly until delivery to detect foetal anaemia
*Foetal aplastic crisis can occur with foetal hydrops so continous monitoring is needed
232
What is hypothyroidism associated with in pregnancy?
Developmental delay and pregnancy loss if sub-optimally replaced
There is also an increased risk of pre-eclampsia particularly if anti-thyroid abs are present. However unless a diagnosis of pre-eclampsia is made, hypothyroid women do not routinely receive prophylactic aspirin
233
What are common organisms that cause sepsis in the puerperium?
GAS (strep pyogenes) - most common
E. coli
Step pneumoniae
Staph aureus
meticillin-resistant S. aureus (MRSA)
Clostridium septicum
Morganella morganii
234
What measurement is associated with an elevated nuchal translucency?
>6mm
235
WHat is the most common ground of the Abortion Act under which terminations of pregnancy are carried out in the UK?
Ground C: That the pregnancy has not exceeded its 24th week and that continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.
236
What is an important examination to do when assessing a perineal tear?
The anal sphincter is involved in 3rd and 4th degree tears and, hence, is these types of tear are associated with an increased risk of faecal incontinence --> perform a digital rectal examination (DRE) to assess the extent of involvement of the anal canal.
237
What medication is given to PCOS patients to improve fertility?
PCOS is associated with irregular ovulation so clomiphene, a selective oestrogen modulator, is given to induce ovulation. It is most effective when given between day 2 and 6 of the cycle.
However, in oligomenorrhoeic patients, it is hard to tell when their next period will be and their endometrial lining can be thickened but inhospitable for implantation.
Therefore, a progestogen (medroxyprogesterone acetate) is given for 10 days after which a withdrawal bleed is precipitated. The clomiphene is usually started on day 2 of the period and continued for 5 days. On day 21, serum progesterone can be measured to check whether ovulation has occurred.
The cycle can be repeated a maximum of 6 times before the risk of ovarian cancer is deemed to be unacceptably high.
238
What stains are used in colposcopy and what do they indicate?
Acetic acid: "egg-white" (aceto-white) indicates the presence of abnormal nuclear:protein ratio within cells
Lugol's iodine: iodine binds to glycogen (which is present in normal cells), resulting in a chemical reaction that turns cells brown. However, abnormal cells lack glycogen, so these cells remain yellow.
239
In which situations can prophylactic vaginal progesterone (16-24w) and/or cervical cerclage be offered to women?
If cervical length <25mm AND:
* History of PTL (<34w GA)
* History of >16w GA miscarriage
* History of PPROM
* Cervical trauma
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What extra-vulval/perianal sign of luchen planus is there?
Wikham striae in the oral mucosa - "cobweb-like" white markings
241
What are the different types of colposcopy referral?
* Urgent – 2 weeks (Atypical glandular cells, borderline changes in glandular cells, High grade favours Moderate or Severe Dyskaryosis, Severe? Invasive, suspicious cervix)
* Soon – 4 weeks (non-urgent clinical indication)
* Routine – 6 weeks (HPV + and borderline neoplastic changes or low grade Dyskaryosis - mild)
242
What is the treatment for UTI in pregnancy?
7 day course of nitrofurantoin.
If symptoms don't improve after 48hrs, consider amoxicillin or cephalexin
243
What are the different types of vasa praevia?
Type 1: velamentous cord insertion in a single or bilobed placenta
Type 2: foetal vessels running between lobes of a placenta with **one or more accessory lobes**
244
What is seen on a CTG in vasa praevia?
Decelerations, bradycardia, sinusoidal trace
*Treat with Cat 1 C-section due to risk fo exsanguination
245
What is the definition of reduced fetal movements?
Defined primarily by the maternal perception of reduced movements. After beginning to detect foetal movements between 16 and 24 weeks’ gestation, pregnant women should be encouraged to become familiar with the pattern of their baby’s movements.
Anything that notably deviates from their usual pattern of foetal movements is considered reduced foetal movements and should warrant review at maternity triage.
246
What urine protein:creatinine ratio (PCR) in the context of high blood pressure is suggestive of pre-eclampsia?
PCR > 30 mg/mmol
247
When do you prescibe abx in mastitis?
Encourage continuation of milk expression and if symptoms are still present over 24hours despite adequate milk expression, consider oral abx (flucloxacillin)
248
What type of insulin is required during labour?
Patients with a background of type 1 or type 2 diabetes mellitus on insulin will require a variable-rate insulin infusion (sliding scale) during labour.
Aim to maintainblood glucose concentration within 4-7 mmol/L.
249
What are risk factors of placental abruption?
* Hypertension
* Polyhydramnios
* Abdominal trauma
* Smoking and cocaine
* Previous APH
* PPROM
250
What is a presentation of ovarian torsion on USS?
Enlarged ovary
Thickened fallopian tube
"Whirlpool" sign
251
What is the first line treatment of Asherman's syndrome?
Hysteroscopy with adhesiolysis
+
PO oestrogens to induce endometrial proliferation
252
In which patients should you avoid giving anti-muscarinics for urge incontinence?
Those with closed angle glaucoma
And those at risk of falls
253
When would you choose tolterodine over oxybutynin?
Oxybutynin is not recommended in frail, elderly patients as it can worsen cognitive impairment
*If they are at risk of falls, give them alpah3 mirabegron instead!
254
What are the three commonly cited theories for endometriosis?
1. Retrograde flow of products of menstruation
2. Metaplastic transformation of stem cells (Mullerian duct)
3. Lymphatic transportation of endometrial tissue to foreign sites
255
What are the causes of vulvar carcinoma?
HPV-related: HPV 16 and 18 infection in women of reproductive age with multiple sexual partners and early coitarche
non-HPV-related: women >70yo with long-standing lichen sclerosus
256
What is the triad of antiphospholipid syndrome?
Triad:
Venous thromboembolism
Thrombocytopaenia
Recurrent miscarriage
257
What autoantibodies is antiphospholipid syndrome associated with?
Anti-β2 glycoprotein I antibodies
Lupus anticoagulant
Anticardiolipin antibodies
258
What are the criteria for expectant management of an ectopic pregnancy?
Are clinically stable and pain free
Have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan
Have serum hCG levels of 1,000 IU/L or less and*
Are able to return for follow-up
*Consider expectant mx if: have serum hCG levels above 1,000 IU/L and below 1,500 IU/L
259
How do you carry out expectant management of ectopic pregnancy
Repeat hCG levels on days 2, 4 and 7 after the original test and:
If hCG levels drop by 15% or more from the previous value on days 2, 4 and 7, then repeat weekly until a negative result (less than 20 IU/L) is obtained
or
If hCG levels do not fall by 15%, stay the same or rise from the previous value, review the woman's clinical condition and seek senior advice to help decide further management
260
What are the criteria for medical management (methotrexate) of an ectopic pregnancy?
Have no significant pain
Have an unruptured tubal ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat
Have a serum hCG level less than 1,500 IU/litre*
Do not have an intrauterine pregnancy (as confirmed on an ultrasound scan)
Are able to return for follow-up
*If serum hCG is at least 1,500 IU/litre and less than 5,000 IU/litre and the woman fits all the criteria above, offer either methotrexate or surgical management
261
When should you offer surgery as a first-line treatment of ectopic pregnancy?
Women who are unable to return for follow-up after methotrexate treatment or who have any of the following:
* an ectopic pregnancy and significant pain
* an ectopic pregnancy with an adnexal mass of 35 mm or larger
* an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan
* an ectopic pregnancy and a serum hCG level of 5,000 IU/litre or more.
262
Risk factors for uterine rupture?
Previous C-section, especially if classical scar
Previous uterine surgery (e.g. myomectomy)
Multiple pregnancy
Induction of labour with agents that increase uterine contractions (e.g. syntocinon)
263
What glycosuria result should be offered OGTT test?
2+ on one occasion
or
1+ on two or more occasions
264
What are common analgesics used in the 1st stage of labour?
Paracetamol
Co-dydramol
Pethidine
265
What does active management of third stage of labour involve?
Uterotonic agent
Early cord clamping
Controlled cord traction
266
How many months should you wait to conceive again after having methotrexate?
3 months
267
A woman is having a repeat USS at 32 weeks gestation for a previously low-lying placenta. The USS shows the placenta is clear of the cervical os and an additional succenturiate lobe is seen. Which condition needs to be excluded in the USS?
a. Cervical shortening
b. Fetal growth restriction
c. Placenta praevia
d. Vasa praevia
e. Velamentous cord insertion
Vasa praevia
268
29 y/o woman with past history of cocaine and cannabis use denies using for the past 3 years. Which additional test should be done for this patient at booking?
a. Hair toxicology screen
b. Hepatitis C
c. Hepatitis E
d. Serum toxicology screen
e. Urine toxicology screen
Hepatitis C
269
32 y/o woman has diagnostic laparoscopy to investigate pelvic pain, and has a catheter inserted in recovery for urinary retention. The catheter is removed the next morning. When can she be safely discharged home?
a. When she has voided more than 200ml
b. Straight away with advice to return if she has problems voiding
c. When her post-void residual volume is 0ml
d. When her post-void residual volume is 100ml
e. When her post-void residual volume is 300ml
When her post-void residual volume is 100ml
Post-unrination residuals should be checked immediately after birthing women/people have voided with a bladder scan. If urine volume is 250mls to 400mls and post urination residuals are <150mls, then Reassurance and discharge can be offered.
270
When should you report FGM to the police?
If the patient is under 18.
If they are over 18 but had it done under 18, you would refer them to the FGM clinc
271
19 y/o woman attends GP for contraception review. She started Microgynon-30 14 months ago and reports a recent migraine without aura which lasted 2 days (which she has never experienced before). She is currently a smoker but has no other CVS disease or VTE risk factors. Her temperature is 36.5, HR 70, BP 115/63, RR 14, O2 sats 97% on room air, and her BMI is 21. What is the most appropriate next step in management?
a. Continue Microgynon-30 and offer smoking cessation
b. Continue Microgynon-30 and start Sumitriptan
c. Stop Microgynon-30 and offer Microgynon-20
d. Stop Microgynon-30 and offer progesterone-only contraception
e. Stop Microgynon-30 and start NuvaRing
Stop Microgynon-30 and offer progesterone-only contraception
She has UKMEC risks for the use of COCP hence you would move her to a POP
272
What complication of normal delivery is increased by a water birth
Infection
273
32 y/o with mild asthma has unexplained intra-uterine death at 37 weeks gestation. She is induced and has epidural analgesia and a spontaneous vaginal delivery. She is very distressed and would like to go home. What should be given to prevent her from expressing breast milk in this scenario?
Cabergoline - dopamine agonist that can suppress lactation. It inhibits the production of prolactin, a hormone involved in milk production.
274
A low risk woman would like to have epidural anaesthesia but is concerned about the risks. What is the risk of permanent paralysis (give as 1:X)
1:100,000
275
When is it inappropriate to use ultrasound appearances of the ovaries to make a diagnosis of PCOS?
In adolescents due to high likelihood of increased follicles
276
What is a pregnant woman with cystic fibrosis, most at risk of developing?
Gestational diabetes mellitus
277
What is the difference in the presentation of atrophic vaginitis vs lichen sclerosus?
Atrophic vaginitis:
* Vulvovaginal dryness
* Loss of vaginal elasticity
* Thinning of vulval skin/loss of minora
* Decreased vaginal diameter
Lichen sclerosus:
* White vulvar plaques/loss of minora
* Vulvar dryness --> intense pruritis
* Perianal "figure of 8"
* Spares vagina
* Dyspareunia (due to tightened skin)
* Dysuria (due to tightened skin)
278
Treatment for atrophic vaginitis?
Topical vaginal oestrogen or HRT
279
What should you do if a woman presents with normal blood pressure but 2+ protein on urine dip?
Arrange secondary care assessment even if there is evidence of possible UTI
280
What is used in IV rehydration of hyperemesis gravidarum?
Normal saline with added potassium
281
What is pemphigus gestationis?
Development of itchy, blistering skin lesions that typically start in the second or third trimester of pregnancy but can also occur shortly after delivery.
The lesions are often widespread and can affect the abdomen, trunk, extremities, and mucous membranes. The blisters are typically large, tense, and filled with clear or yellow fluid. When the blisters rupture, they leave behind erosions or shallow ulcers.
282
What is the chance of T2DM after having had GDM in pregnancy?
50%
283
What is the LH:FSH index in PCOS?
>1:1 (so around 2:1 to 3:1)
284
What is the investigation of choice for premenstrual syndrome?
Symptom diary over 2 cycles
285
What is the preferred mode of delivery for women who have experienced a 3rd or 4th degree perineal tear?
Need to counsel on the mode of delivery. Only perform future episiotomy is absolutely necessary - no need for prophylactic episiotomy
In women who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should be counselled regarding the option of elective caesarean birth.
286
What feral consequence does maternal T1DM increase the risk of?
Neural tube defects (uncontrolled glucose is teratogenic)
287
When is oxytocin given for active management of 3rd stage of labour?
After the delivery of the baby's shoulder
288
What is absolutely contraindicated in pregnant women with HIV?
Foetal blood sampling (even if viral load is undetectable)
289
What are you measuring at booking for hepatitis B?
The hepatitis B test detects for a protein on the surface of the virus called hepatitis B surface antigen (HbsAg)
290
When should you check your IUS/IUD string?
Once a month ideally after each period as the cervix head is the lowest then
291
Where are ectopic pregnancies more likely to occur?
Which part of the tube is more likely to rupture?
Ampulla
Isthmus
292
What can irregular and unpredictable bleeding within the first few years of menarche be suggestive of?
Anovulatory dysfunctional uterine bleeding due to an immature HPG axis. This means there is not enough gonadotropins and LH to induce an ovulation. Hence, oestrogen is not suppressed and causes endometrial hyperplasia with patchy bleeding
293
Which group of patients are at risk of developing thyroid disorders in pregnancy?
Current thyroid disease
Previous thyroid disease
Family history of thyroid disease in a first-degree relative
Autoimmune conditions such as coeliac disease
Type 1 and type 2 diabetes mellitus, as well as gestational diabetes.
294
What is ovarian stromal hyperthecosis?
Ovarian stromal hyperthecosis is characterised by hyperplasia of the ovarian stroma and clusters of luteinising cells distributed throughout the ovarian stroma.
There is increased androstenedione and testosterone secretion with subsequent hirsutism and virilism. Conversion of androgen to estrogen in the peripheral adipose tissue brings about a hyperoestrogenic state (especially in the obese patients). This may result in endometrial hyperplasia and abnormal uterine bleeding due to unopposed estrogen action.
In premenopausal women, the treatment is the same as for polycystic ovary syndrome, lifestyle measures and the combined oral contraceptive pill. For post-menopausal women, the preferred treatment is bilateral oophorectomy.
295
What fetal syndrome is phenytoin and carbamazepine use in pregnancy associated with?
Fetal hydantoin syndrome:
Intrauterine growth restriction
Microcephaly
Cleft lip/palate
Intellectual disability
Hypoplastic fingernails
Distal limb deformities
Developmental delay
296
When is the anomaly scan carried out?
Between 18+0 and 20+6 weeks
297
What are the main sites of haematopoiesis in an embryo/fetus?
< 8 weeks: yolk sac
8weeks to 20 weeks: liver
>20 weeks: bone marrow
298
Where gynaecological cancers metastasise to the para-aortic lymph nodes?
Ovarian and endometrial
299
Which lymph nodes do cervical cancers metastasise to?
Lymph nodes along the iliac arteries
300
When should GDM women give birth?
Offer induction of labour between 37+0 and 38+6 weeks.
Delivery should be no later than 40+6 weeks
301
When is fluoxetine contradindicated for vasomotor symptoms of menopause?
When a woman is simultaneously taking tamoxifen as fluoxetine can reduce its efficacy.
302
When are pregnant patients with pre-existing diabetes offered retinal scans?
At booking and at 28 weeks
