ObGyn Flashcards

Question

Depot medroxyprogesterone acetate (DMPA) (Depo-Provera®) - overview

Answer 1

It is usually initiated within 5 days of beginning of normal menses, immediately post-partum in breastfeeding and non-breastfeeding women It is a particularly good choice in women in whom an oestrogen-containing contraceptive is either contraindicated or causes additional health concerns. It works by inhibiting follicular development and preventing ovulation primarily. The progestogen decreases the pulse frequency of GnRH release by the hypothalamus which decreases the release of FSH and LH by the anterior pituitary. Decreased levels of FSH inhibit follicular development preventing an increase in oestrogen levels. Progestogen negative feedback and the lack of oestrogen positive feedback on LH release prevent a LH surge thus preventing ovulation. A secondary mechanism of action is inhibition of sperm penetration by changes in the cervical mucus. Inhibition of ovarian function causes the endometrium to become thin and atrophic therefore theoretically also preventing implantation. With correct use, the probability of pregnancy in the first year is <1% whereas with typical use, it is 6%.

Answer 2

Are based on the principle that the vaginal epithelium can absorb steroids and steroids in turn can be released from a silicone elastomer into the vagina at a constant rate. Avoiding gastrointestinal absorption and hepatic first pass metabolism allows use of lower hormone does to achieve contraceptive effects. With perfect use, the failure rate is 0.3% while with typical use, it is 9%.

Answer 3

50 YO After -> increased risk of CV disease, breast and cervix cancer, VTE

Answer 4

Fibroids are a benign tumour of the myometrium. They are currently the most common benign tumour in females and close to half of all women over 40 years of age will have at least one fibroid. It's the most common cause of hysterechtomy The cause is unknown In a very small percentage (0.1-.0.5%) fibroids can transform into a malignant tumour.

Answer 5

Nulliparity (never having given birth) Being overweight or obese. Polycystic ovarian syndrome Family history African

Answer 6

Pelvic or TV ultrasound - most useful Histeroscopy - best way to diagnose MRI - most accurate (when that are multiple or cancer is suspected)

Answer 7

If asymptomatic, nothing is needed IUD Mirena (not if nulliparous) Fibroids will recur in up to 60% of women after a laparotomy and in up to 25% after a laparoscopic surgery.

Answer 8

Hyperthyroidism - less periods Hypothyroidism - more periods

Answer 9

Swelling and inflammation of the connective tissue in pelvic ligaments due to hormone influencie. Causes Pain NOT related to periods

Answer 10

Shift from anovulatory to ovulatory periods due to higher sensitivity to prostaglandines

Answer 11

Menstrual blood loss (MBL) exceeding 80mL An average of 35 mL of menstrual blood is lost during a menstrual period. !!! Is the most frequent cause of iron deficiency anaemia in Australian women !!!

Answer 12

In women aged over 45, Intermenstrual bleeding or persisting menorrhagia despite medical therapy If abnormality is detected on US or endometrial thickness exceeds 12 mm

Answer 13

First line: - Non-steroidal anti-inflammatory drugs (NSAIDs) - Tranexamic acid (^^^^ risk of VTE) - Combined oral contraceptive pill: choice in patients with anovulatory menorrhagia, as it lowers the risk of endometrial cancer. - Oral progestogens - Levonorgestrel Intrauterine System (LNG-IUS): Around 30% of women are amenorrhoeic after 12 months. Second line: - Danazol - has virilising effects - Surgical: in patients who have failed medical therapy and completed their family. - Endometrial ablation - Hysterectomy

Answer 14

Increased prostaglandin F2a (PGF2a), which stimulates uterine contractions. Blood flow is reduced causing ischaemia. The production of PGF2a requires progesterone, which explains the association between dysmenorrhoea and ovulatory cycles. Primary dysmenorrhoea affects 71.7% of Australian women, with 15.0% of women experiencing severe pain.

Answer 15

Less than 30 years of age, Having a low body mass index, Menarche at less than 12 years of age, Longer and heavier menstrual periods, smoking, Alcohol, history of sexual abuse, sterilisation, suspected pelvic inflammatory disease psychological symptoms

Answer 16

Primary dysmenorrhoea can be diagnosed on the basis of history and examination but Endometriosis and pelvic inflammatory disease should be excluded. Investigations include high vaginal and endocervical swabs to exclude pelvic inflammatory disease and transvaginal pelvic ultrasound scans to identify endometriomas or adenomyosis. Laparoscopy is the gold standard for the evaluation of dysmenorrhoea. It is performed in suspected endometriosis, or when previous investigations have been normal.

Answer 17

Lifestyle & Alternative Treatments - Low-fat, vegetarian diets and heat in the form of topical abdominal patches have been shown to improve dysmenorrhoea. Also Vitamin B1, magnesium and Chinese herbal medicine Medical NSAIDs - first-line treatment. Should be given two days before menstruation and taken for the first three days of menstruation. Suggested doses include mefanamic acid 500mg orally, three times daily or ibuprofen 200 to 400mg orally, 3 times daily. COCP - induce anovulation and reduce endometrial prostaglandin production Levonorgestrel-releasing intrauterine system - stimulating endometrial atrophy.

Answer 18

Vaginal bleeding occurring 12 months after the last period. 10% of all patients presenting with PMB will have endometrial carcinoma Other causes include atrophic vaginitis, endometrial hyperplasia, endometrial polyps, and uterine fibroids. Irregular vaginal bleeding is common in the first six to twelve months of starting HRT, but PMB persisting one year after HRT initiation requires further investigation.

Answer 19

PMB is endometrial cancer until proven otherwise. The first-line investigation is transvaginal ultrasound assessing endometrial thickness. Endometrial thickness exceeding 5 mm warrants endometrial biopsy Biopsy is also indicated in patients with persistent PMB despite normal ultrasound findings. Tamoxifen causes irregular, cystic thickening of the endometrium. As such, patients with PMB on tamoxifen should proceed straight to hysteroscopy and endometrial biopsy.

Answer 20

Atrophic vaginitis - Local vaginal oestrogen Cervical polyps - Resection under speculum examination Endometrial polyps - Hysteroscopic resection Endometrial hyperplasia - Progestins (e.g. oral or LNG-IUS) or hysterectomy Endometrial cancer - Appropriate treatment is dependent on the stage and grade of endometrial cancer

Answer 21

During the menopausal transition, the number of ovarian follicles decline. The remaining ovarian follicles are less responsive to FSH levels and ovarian inhibin production subsequently falls. With the loss of negative feedback from the ovary, FSH levels rise. Despite stimulation from FSH, the declining supply of functioning ovarian follicles cause oestrogen levels to further decrease. Anovulatory cycles become increasingly frequent. With each subsequent menstrual cycle, fewer ovarian follicles are recruited until eventually no follicles are recruited at all. FSH and LH remain persistently elevated while oestradiol levels stabilize, falling below 20 pg/mL.

Answer 22

Clinical and retrospective But, FSH levels above 40 mIU/mL are also diagnostic of menopause.

Answer 23

Lifestyle modification: - Smoking cessation to reduce exacerbation of vasomotor symptoms. - LIfestyle changes include stress management, regular exercise and weight optimization. - Vasomotor triggers, such as caffeine, alcohol, hot drinks and spicy food, should be avoided. Hormonal Therapies - HRT should only be reserved for very symptomatic patients. - Avoid HRT in patients with a history of breast cancer, venous or arterial thromboembolic disease, pre-existing cardiovascular and cerebrovascular disease and uncontrolled hypertension. Synthetic steroid Tibolone is a synthetic steroid. It has oestrogenic, progestogenic and weak androgenic effects and can be used for vasomotor and urogenital symptoms, but is less effective when compared to combined HRT. It offers bone protection but may increase the risk of recurrent breast cancer and stroke. Selective serotonin and noradrenaline reuptake inhibitors Venlafaxine (SNRI) and paroxetine (SSRI) are considered the most effective SSRIs for vasomotor symptoms. !! Paroxetine should be avoided if taking Tamoxifen for breast cancer Relief of Urogenital Symptoms Local vaginal oestrogen is the treatment of choice for women with vaginal symptoms only. Progestogens are usually not required, but are recommended if the dose of oestradiol is over 0.5mg daily due to possible systemic absorption.

Answer 24

It is recommended that the lowest dose of HRT that allows adequate symptom control should be prescribed for the minimum duration. Most guidelines advise 4 to 5 years for duration of HRT use. Women should be reviewed every 6 to 12 months for follow-up of symptoms and need for continuing HRT. Transdermal therapy may be preferred in patients with limited oral absorption or with risk factors for thromboembolic disease. Oestrogen-only preparations may be used in women after hysterectomy - doesn't enhance breast cancer risk if used only UP TO SEVEN YEARS Progesterone is required in women with an intact uterus to reduce the risk of endometrial hyperplasia and cancer. Avoid IF: history of breast cancer, venous or arterial thromboembolic disease, pre-existing cardiovascular and cerebrovascular disease and uncontrolled hypertension.

Answer 25

Smoking Advances age of menopause by 2 years Nulliparity Pelvic surgery, radiation and chemotherapy Leads to artificial menopause. Family history of early menopause Ethnicity Black and Hispanic women undergo menopause around 2 years earlier than their Caucasian counterparts Lower educational attainment Being separated, widowed or divorced Being unemployed History of heart disease

Answer 26

Family history – there is a 3 to 4 fold increase in developing breast cancer in women who have a first degree relative with a history of breast cancer. BRCA 1 gene mutation found on chromosome 17 is found in families with early onset breast cancer and ovarian cancer. BRCA 2 gene mutation on chromosome 13 is also associated Early menarche and late menopause Nulliparity and late age of first pregnancy The highest risk group in this regard are found in women who have their first child after 35.

Answer 27

- Unpasteurised dairy products, soft cheese (Risk of Listeria- foetal mortality- 30-50%) - Raw meat ( risk of toxoplasma ) - Mantain good exercise routine and avoid SAD (alcohol) - Reduce caffiene intake (IUGR) up to 2 cups of tea / 1cup coffee per day is permissible. - Ensure rubella and chicken pox immunity- - check for rubella antibodies. If IgG negative (< 10IU/L) give 1 dose MMR + or- varicella vaccine and Advice not to become pregnant at least for 1 mnth preferably for 3 months. Test for seroconversion after 3 mths.

Answer 28

5 Folic acid 0.5 mg/day 3 months before and 3 months after pregnancy. High dose of 5 mg/day if on enzyme inducing medications like antiepileptics, in history of neural tube defects, family H/O neural tube defects and also in women with DM, coeliac disease and sickle cell anaemia. Folic acid decreases incidence of neural tube defects and spina bifida in baby.

Answer 29

Detected by blood test about 11 days after conception and 12- 14 days by urine test. Doubles every48- 72 hours, reaches peak in 8-11 weeks, then declines and levels off for rest of pregnancy. HCG level above 25mIU/ml is considered positive for pregnancy.

Answer 30

Confirm pregnancy by period history and urine/blood Beta HCG. Book into hospital/ OP department Complete O&G history- previous pregnancies/ miscarriages. Medical/surgical history, family history, social history, medications/ allergy. Establish EDC- by obstetric calendar- from first day of last period subtract 3 from months and add 7 to days. Naegele’s rule- add 7 days and 9 months. If patient not quite sure of her LMP, do U/S at 8weeks to determine EDC ( dating scan) Offer Down’s syndrome screening.

Answer 31

by obstetric calendar- from first day of last period subtract 3 from months and add 7 to days. Naegele’s rule- add 7 days and 9 months.

Answer 32

Blood tests- FBE( Hb),UCE, Blood group and Rh, coagulation profile, Vit D, antibodies for rubella, chicken pox. STI screen-HepB, Hep C, HIV, syphilis with patient’s consent. Urine microscopy/ C&S. PAP smear- if not taken during last 2 years. Safe up to 20 weeks but some recommend up to 24wks.

Answer 33

U/S at 18- 20 and 32 weeks. (first = 8w if patients doesn't remember last menses) Diabetic testing at 26/ 28 weeks. GBS testing at 36 weeks. First trimester screening tests for Down syndrome (9-12 weeks): - Ultrasonography for nuchal translucency (>0.5mm) - Maternal serum biomarkers: Increased free beta hCG with decreased pregnancy-associated plasma protein

Answer 34

Average 12. First trimester- 8-10 weeks. Up to 28 weeks- every 4-6 weeks. Up to 36 weeks- every 2 weeks Up to delivery- every week.

Answer 35

During each visit: - Record weight, BP. - Fundal height - if corresponds to gestational age +/- 2cm. Up to umbilicus in 20-22 weeks and xiphi sternum in 36-38wks. If greater think about wrong dates, poly hydramnios, multiple gestation, hydatidiform mole, big baby( DM), birth defects. If less, wrong dates, oligo hydramnios, IUGR, birth defects. - Foetal heart - 120-160 beats/min. Usually with hand held Doppler. If altered, CTG ( cardiotocographic monitoring) - Presentation - usually cephalic/vertex. Breech is the most common abnormal presentation. Face and brow are other abnormal presentations. - Normal lie is longitudinal. Other lies- transverse and oblique. Malpositions - Abnormal positions of vertex relative to maternal pelvis. Normal position is left occipitoanterior. - Occipito posterior( commonest abnormal position). occipito transverse.

Answer 36

Eat most- cereals and bread, fruits and vegetables. Eat moderate- diary products, meat and fish. Eat least- sugar and refined carbs, polyunsaturated fats. Could gain around 12 kg during pregnancy. If healthy diet, no need for iron, calcium supplements. Only folic acid and iodine. >>>>According to NHMRC, all women considering pregnancy, pregnant and breast feeding should take 150 micrograms/ day of iodine. Iodine deficiency leads to defects in the brain, nervous system of the fetus and a reduced IQ in infants. Dietary sources- fortified bread, dairy products and seafood except seaweed. Requirement of iodine during pregnancy- 220 micrograms/day. Requirement during breast feeding- 270 micrograms/day. If patient is vegan, give folic acid, iron and iodine as supplements. SAD Avoid SAD during pregnancy. No safe limit for drinking during pregnancy. Effects of alcohol in pregnancy. 1 Miscarriage. 2 Premature birth. 3 Fetal alcohol syndrome- 2 in 1000 live births. Due to teratogenic effects of alcohol.

Answer 37

If patient is vegan, give folic acid, iron and iodine as supplements. Requirement of iodine during pregnancy- 220 micrograms/day. Requirement during breast feeding- 270 micrograms/day.

Answer 38

Microcephaly. Facial defects- narrow forehead, short palpebral fissures, upturned nose, low set ears, long, smooth philtrum, thin upper lip, micrognathia. Congenital heart disease. Skeletal abnormalities. Central nervous system dysfunction and mental retardation. Markedly underweight till puberty. Hyperactivity.

Answer 39

1 Ectopics. 2 Miscarriage. 3 Placenta praevia. 4 Abruptio placentae. 5 Low birth weight. 6 Premature labour. 7 SIDS.

Answer 40

1 Decreased breast milk. 2 Decreased Vit C in breast milk. Effect of smoking in the later life of child. 1 Asthma. 2 Obesity. Quitting of smoking- First and foremost, behavioural therapies. Then if necessary, NRT (Nicotine replacement therapy)

Answer 41

2nd trimester Unadvised during 3rd OFF after 36w

Answer 42

Weight gain 1st trimester- 1-2 kg. 2nd trimester and 3rd up to 36 weeks- 500gm/week. Then levels off after 36 weeks.

Answer 43

First in primi- 17- 20 wks. In multi- 16-18 weeks. Ideally it should be 10 or more per day.

Answer 44

Incidence in normal pregnancy- 10%. Total incidence is around 25%. Causes of normal light vaginal bleeding in early pregnancy Hormonal - could trigger bleeding at the time of periods.( break through bleeding) Embryo embedding into uterus.(implantation bleeding) Cervical irritation- due to softening of cervix. OTHER CAUSES: Polyps. Fibroids. Clotting disorders

Answer 45

- 3 consecutive pregnancy losses prior to 20 weeks. - Incidence- 1-2%. - Causes: Chromosomal abnormalities.- first trimester Immunologic- antiphospholipid antibody syndrome. Anatomical- uterine abnormalities, cervical incompetence. Endocrine- DM, thyroid. Haematologic- Thrombophilia. Infections.

Answer 46

Causes First trimester- chromosomal abnormalities, APAS. Second trimester- cervical incompetence, uncontrolled DM, infections. TYPES Missed abortion - Pregnancy lost but retained. Non viable retained intrauterine pregnancy. Features - amenorrhea + non progressive pregnancy. Threatened abortion Symptoms - Minimal bleeding P/V + Minimal cramps. Examination - Cervical os closed. Pregnancy corresponds to gestational age. 50% might stop bleeding and have normal pregnancy. Inevitable abortion Symptoms - severe bleeding PV+ severe abdominal cramps. Examination - Cervical os open. Products at lower uterine segment. Uterine size less. Incomplete abortion Symptoms - severe bleeding PV+ abdominal cramps+passage of POC. Examination - Cervical os open. Tissues protruding through os. Uterine size less. Complete abortion Symptoms - bleeding PV+ abdominal cramps+ all POC lost. So later bleeding subsides. Examination - Cervical os closed. Uterus empty. ADMINISTER ANTI D GLOBULIN IF PATIENT IS Rh NEGETIVE after doing an indirect Coombs test and if it is negative. Risk of recurrence- 1% Risk in general population- 10- 20%.

Answer 47

In threatened- limit activities, admit and observe till bleeding stops. Rest not found to be very effective. U/s after 1 week. Try to remove POC by sponge forceps in incomplete abortion. Medical- by misoprostol (PGE1 analogue) orally/ vaginally. Brings cervical softening and induces uterine contractions. Usually before 9 weeks. Surgical- dialatation and evacuation

Answer 48

Implantation of blastocyst at sites other than endometrium. Incidence - 1-2% Sites- 1 Fallopian tube- most common site 2 Uterine cornua. 3 Ovary 4 Cervix 5 Abdominal/ pelvic cavity. Most common part of tube for ectopics- ampulla. Most common part of tube prone for early rupture- isthmus.

Answer 49

Tubal abnormalities - previous ectopic ( 10-25% chance of recurrence), H/O PID, tubal surgeries including ligation. IUCD/ IUS. Pregnancy due to GIFT, ZIFT. Smoking. Prior induced abortion.

Answer 50

Urine pregnancy test- NEGATIVE in minority, weakly positive or positive. Serum beta HCG estimation- shows decreased rise in Beta HCG levels. Trans vaginal Ultrasound- Most important tool to diagnose ectopics. Around 5-6weeks. Becomes positive only when Beta HCG level reaches 1500-1800 mIU/ml. Findings in U/S- Empty uterus. Adnexal mass. Fluid in the POD. Laparoscopy- criterion standard for diagnosis.

Answer 51

Classic triad Abdominal pain.( most common) Amenorrhea. Vaginal bleeding.( prune juice bleeding. Absent in 10-15%) PRE RUPTURE SYMPTOMS Cramping pain in one or more iliac fossa radiating to rectum,(lavatory sign) vagina or leg. Vaginal bleeding. RUPTURED ECTOPIC Generalised, excruciating abdominal pain, shoulder pain. Features of shock.

Answer 52

Medical - Methotrexate - for unruptured. DOSE - Single (50mg/m2) or multiple I/M injections or under ultrasonic guidance through hysteroscopy directly into sac. Considered more in ectopics in cervix, ovary and interstitial or cornual part of tube. Action - interferes with DNA synthesis and disrupts cell multiplication. Pre requesits - haemodynamically stable, no severe/ persisting abdominal pain, normal LFT and RFT. Beta HCG <5000, no foetal cardiac activity. CONTRAINDICATIONS Absolute - Intrauterine pregnancy, sensitivity to methotrexate, immunodeficiency ,tubal rupture, breast feeding, liver/renal dysfunction, haematologic variations. Relative - Beta HCG >5000, foetal cardiac activity, ectopic sac greater than 3.5- 4 cm in size, significant free fluid in the POD.

Answer 53

LAP with linear salpingostomy- especially for ampullary ectopics. LAP with salpingectomy- damaged tubes, previous ectopic in the same tube, family completed. LAP and segmental resection followed by delayed microsurgical re anastomosis.

Answer 54

1 Serial Beta HCG estimation after 1 week until level is 0. If decreasing- treatment effective. If remaining same- consider another injection of methotrexate. If increasing- surgery. COC until BHCG normalizes!!!

Answer 55

Also called vesicular mole. Incidence - 1:1200. Gestational trophoblastic disease. Abnormal placental development. Types - Complete moles - has no foetal tissue. When a sperm fertilises an empty egg. Partial mole - some foetal tissue is present. When 2 sperms fertilise 1 normal ovum. Invasive mole - when it invades the uterus. Are not malignant. Chorio carcinoma - when they turn cancerous

Answer 56

Cause Exact cause unknown. Diet deficient in carotene and animal fat may be a risk factor. Risk of recurrence- 1-2%. Clinical presentation Vaginal bleeding- most common. Associated passage of vesicles/ grape like material. Hyperemesis- due to high levels of beta HCG. Exaggerated pregnancy symptoms. Hyperthyroidism- due to stimulation of thyroid by high levels of Beta HCG. Hypertension. Asymptamatic.– diagnosed by U/S. Examination. Uterus large for dates.

Answer 57

Beta HCG- Very high. May be greater than 100,000mIU/mL. FBE- anaemia. Coagulation profile- coagulopathy. LFT. RFT. TFT. S. inhibin and S.activin- higher. Pelvic U/S- Is the criterion standard. Shows snow storm appearance due to hydropic chorionic villi.

Answer 58

DRABCDE and stabilise patient if in shock. SURGERY- Dialatation, suction evacuation and curettage. I/V oxytocin after dialatation of cervix, at the initiation of suction and continued post op to reduce bleeding. Follow up Prophylactic chemotherapy not recommended. Serial beta HCG estimation weekly until 0, then monthly for 12 months. Pregnancy to be avoided for 1yr after Beta HCG becomes normal. Contraception during follow up period- any contraceptive method - AT LEAST 1 YEAR AVOIDING PREGNANCY If beta HCG levels plateau/rise, it could be an invasive mole or chorio carcinoma.

Answer 59

Risk factors Age greater than 40 . Complete mole. Beta HCG above 100,000 IU/l. Theca lutein cysts greater than 6 cm. SITES OF METASTASIS Lung- most common site. Brain, liver, vagina. Treatment Chemo therapy- methotrexate with folic acid. Follow up.

Answer 60

Severe nausea, vomiting, dehydration, electrolyte disturbance and weight loss during pregnancy. Commonest symptom is severe, constant nausea. Subsides by 12 weeks. Hyperemesis in normal pregnancy. Hormonal- due to beta HCG and oestrogen. Mechanical- due to decreased gastric peristalsis and emptying. Emotional. Causes Normal pregnancy- 10%. Mole Multiple pregnancy. Urinary infection.

Answer 61

Investigations Urine analysis- M/ C&S and also for ketones. 2 Blood - U&E, S.creatinine. 3 LFT. 4 U/S - exclude v.mole, multiple pregnancy. Treatment Admit if electrolyte disturbances. Bed rest. Nil orally. Start I/V infusion- 0.9% NaCl or Hartmann’s. Nasogastric feeding. Antiemetic medications- metoclopramide 10mg I/v then 10mg tds. Vitamins- Pyridoxine 25mg 1tab tds. Decreases nausea. Small, frequent meals.

Answer 62

Symptoms Pain especially at night, tingling and numbness in the thumb, index finger, middle finger and radial half of ring finger. Cause Due to fluid retention caused by hormones. Usually goes away after delivery. Treatment General measures- Rest, limit activities with affected hand, Ice application. Splint or brace to maintain wrist in neutral position. Surgery of volar carpal ligament is the last resort.

Answer 63

Around 5-6w If sack absent in uterus, consider echtopic

Answer 64

1.8 - 2.0 cm when about to burst

Answer 65

Probably malignant. Mostly if containing solid elements. Bening cyst are unilocular, thin walled

Answer 66

Uturine rupture Previous C-section is a risk factor

Answer 67

Mitral valve stenosis The pregnancy-induced increase in blood volume, cardiac output, and tachycardia can increase the trans-mitral pressure gradient and cause pulmonary oedema in women with mitral stenosis. Pregnancy associated with long-standing mitral stenosis may result in pulmonary hypertension. Pregnant women with mitral stenosis are at increased risk for the development of atrial fibrillation and other tachyarrhythmias.

Answer 68

Sudden abdominal pain followed by the cessation of contractions, the termination of the urge to push, and vaginal bleeding. Abdominal examination shows no fetal heart activity, and signs of a fluid collection like the fluid thrill and shifting dullness are present. This fluid is blood, and it usually enters into the peritoneum after the rupture of the uterus. Vaginal examination in such patients reveals a range of cervical dilatation with evidence of cephalopelvic disproportion. The most common site of spontaneous uterine rupture is the anterior lower transverse segment. Patient with tachycardia and hypotension is in shock due to blood loss and requires urgent resuscitation.

Answer 69

Bloody lochia can persist for up to 2 weeks without indicating an underlying pathology; however, if bleeding continues beyond 2 weeks, it may indicate placental site subinvolution, retention of small placental fragments, or both. At this point, appropriate diagnostic and therapeutic measures should be initiated. The physician should first estimate the blood loss and then perform a pelvic examination in search of uterine subinvolution or tenderness. Excessive bleeding or tenderness should lead the physician to suspect retained placental fragments or endometritis.

Answer 70

The fetal heart tones are audible in most patients at 10 weeks. If no fetal heart tones are audible by Doppler auscultation and the patient is 10 weeks or more, an ultrasound of the pregnancy should be ordered.

Answer 71

Oligohydramnios is associated with an increased risk for fetal or neonatal death, which may be related to the underlying cause of the reduced amniotic fluid volume or due to sequelae of the reduced amniotic fluid volume. The volume of amniotic fluid reflects the balance between fluid production and movement of fluid out of the amniotic sac. The most common mechanisms for development of oligohydramnios are fetal oliguria/anuria and fluid loss due to rupture of membranes. A reduction in the egress of lung fluid and increased swallowing do not play major roles. Idiopathic cases (ie, idiopathic oligohydramnios) may be due to alterations in the expression of water pores (aquaporin 1, aquaporin 3) in fetal membranes and placenta. Causes of oligohydramnios Maternal Medical or obstetric conditions associated with uteroplacental insufficiency (eg, preeclampsia, chronic hypertension, collagen vascular disease, nephropathy, thrombophilia) Medications (eg, angiotensin converting enzyme inhibitors, prostaglandin synthetase inhibitors, trastuzumab) Placental Abruption Twin to twin transfusion (ie, twin polyhydramnios-oligohydramnios sequence) Placental thrombosis or infarction Fetal Chromosomal abnormalities Congenital abnormalities, especially those associated with impaired urine production Growth restriction Demise Postterm pregnancy Ruptured fetal membranes Infection Idiopathic First trimester — The etiology of first trimester oligohydramnios is often unclear. Reduced amniotic fluid prior to 10 weeks of gestation is rare because gestational sac fluid is primarily derived from the fetal surface of the placenta, transamniotic flow from the maternal compartment, and secretions from the surface of the body of the embryo. Second trimester — By the beginning of the second trimester, fetal urine begins to enter the amniotic sac, and the fetus begins to swallow amniotic fluid. Therefore, disorders related to the fetal renal/urinary system begin to play a prominent role in the etiology of oligohydramnios. These anomalies include intrinsic renal disorders (eg, cystic renal disease) and obstructive lesions of the lower urinary tract (eg, posterior urethral valves, urethral atresia). Maternal and placental factors, as well as rupture of the fetal membranes (traumatic or nontraumatic), are also common causes of oligohydramnios in the second trimester Third trimester — Oligohydramnios first diagnosed in the third trimester is often associated with PPROM or with uteroplacental insufficiency due to conditions such as preeclampsia or other maternal vascular diseases. Oligohydramnios frequently accompanies fetal growth restriction related to uteroplacental insufficiency. Fetal anomalies and abruptio placentae also play a role at this gestational age. Amniotic fluid volume normally decreases postterm, so oligohydramnios may develop in these pregnancies. In addition, many cases of third trimester oligohydramnios are idiopathic. (Refer to individual topic reviews on these subjects). There may be an association between pregnancy during the summer season and oligohydramnios, likely related to suboptimal maternal hydration in hot weather. Maternal TORCH (toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus) and parvovirus B19 infections that infect the fetus may be associated with second- or third-trimester oligohydramnios, often in association with other evidence of fetal infection

Answer 72

A voiding diary to classify predominant type of urinary incontinence (eg, stress, urgency) and to determine optimal treatment. All patients with mixed incontinence generally require bladder training with lifestyle changes (eg, weight loss, smoking cessation, decreased alcohol and caffeine intake) and pelvic floor muscle exercises (eg, Kegels). Patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery, depending on predominant type: In patients with urgency-predominant incontinence, oral antimuscarinics and timed voiding (eg, urinating on a fixed schedule, rather than based on a sense of urgency) are used . In patients with stress-predominant incontinence due to weakened pelvic floor muscles (eg, cystocele), surgery with a midurethral sling is performed

Answer 73

Spinal epidural abscess Epidemiology Staphylococcus aureus (65%) Immunosuppression (HIV, diabetes mellitus, alcohol use, old age) Inoculating sources Distant infection (eg, cellulitis, joint/bone) Spinal procedure (eg, epidural catheter) Injection drug use Manifestations Classic triad Fever (~50%) Focal/severe back pain Neurologic findings (eg, motor/sensory change, bowel/bladder dysfunction, paralysis) Diagnosis ↑ ESR Blood & aspirate cultures MRI of the spine Treatment Broad-spectrum antibiotics (eg, vancomycin plus ceftriaxone) Emergency aspiration/surgical decompression Lumbar back pain, low-grade fever, and lower-extremity neurologic symptoms (eg, weakness, tingling, numbness), raises strong suspicion for spinal epidural abscess. Most cases arise via hematogenous spread of a distant infection, contiguous spread from an adjacent infection (eg, vertebral osteomyelitis), or following direct inoculation during spinal/epidural anesthesia. The epidural space is a vertical, contiguous area that contains fat, arteries, and a venous plexus; infections tend to affect multiple spinal levels and cause progressive neurologic impairment due to direct spinal cord compression, thrombophlebitis of the draining venous plexus, and/or interruption of the arterial blood supply. Although patients classically have the triad of fever, spinal pain, and neurologic symptoms, all 3 are present in a minority of cases. Most patients have fever, malaise, and neurologic symptoms that typically progress in the following fashion (due to worsening spinal cord compression): Focal back pain → Nerve root pain (eg, shooting, electric-shock sensation) → Motor weakness, sensory changes, bowel/bladder dysregulation → Paralysis Early diagnosis is crucial to prevent paralysis and death; MRI of the affected spinal area

Answer 74

Measures the amount of fetal blood mixed into maternal circulation following trauma, which helps guide anti-D immunoglobulin dosing in Rh-negative patients (ie, to prevent Rh-alloimmunization). Rh-positive patients are not at risk for Rh-alloimmunization, and testing does not change management.

Answer 75

Abruptio placentae (ie, placental abruption). Due to the volume of blood supplied to the uterus, abruptio placentae can cause hypovolemic shock from hemorrhage (ie, hemorrhagic shock), as seen in this patient with hypotension, tachycardia, and cool extremities. Management of the trauma patient with hemorrhagic shock requires rapid resuscitation with replacement of intravascular volume, transitioning from crystalloid to blood products as soon as possible. In addition, pregnant patients are placed in a left lateral decubitus position (if the spine is stable) to displace the uterus off the aortocaval vessels and maximize cardiac output. If hemorrhage or hemodynamic instability continues despite initial resuscitation efforts, massive transfusion protocol (MTP) should be activated. MTP is the administration of packed red blood cells, platelets, and fresh frozen plasma in a 1:1:1 ratio to avoid coagulopathy from dilution of platelets and clotting factors. Emergency cesarean delivery after maternal trauma may be indicated for imminent fetal compromise

Answer 76

Hyponatremia Oxytocin, commonly used for induction of labor and postpartum hemorrhage management, has a similar structure to antidiuretic hormone (vasopressin); therefore, elevated levels can stimulate the renal collecting ducts to increase free water absorption. This leads to acute hyponatremia, decreased serum osmolality, and increased free water movement into the brain cells with resultant cerebral edema and seizure. >>The risk of this rare but life-threatening side effect is increased with excessive or prolonged oxytocin administration, as seen in this patient who had a 48-hour oxytocin infusion followed by a bolus. Management of oxytocin-induced hyponatremia includes cessation of oxytocin infusion and gradual administration of hypertonic saline (eg, 3% saline) in symptomatic patients (eg, seizures) to raise serum osmolality and reverse cerebral edema.

Answer 77

CMV(a DNA virus) is the most common cause of intrauterine infection and the most common viral cause of birth defects. Primary infection of the mother is often asymptomatic but may present as flue-like symptoms. Up to 50% of pregnant women are CMV lgG seropositive. Vertical transmission from mother to fetus occurs mainly during the viremia of a primary infection. However, since the result of primary infection is predisposition to a residual life -long latency. fetal infection can occur with reactivation as well. Transplacental fetal infection is 50% with primary infection, regardless of the gestational age but less than 1% with reactivation of a latent infection. The infected newborn will be symptomatic in 10 % of cases, but of these 10% almost 90% carry a risk of sequelae including: Microcephaly Ascites Hydrops fetalis Oligo or polyhydramnios Hepatomegaly Pseudomeconium ileus Hydrocephalus (ventricular dilation) Intrauterine growth restriction(IUGR) Pleural or pericardial effusions lntracranial calcification Abdominal calcification Hearing loss Serologic testing for cytomegalovirus is recommended for the following women in pregnancy: History suggestive of CMV illness Exposure to known CMV infected individual or blood product lmmunocompromised Abnormalities on routine antenatal ultrasound (usually at 18 weeks) The serology results are interpreted as follows: A patient with positive lgG but negative lgM has a had past exposure Changing from an lgG-negative to an lgG-positive state (seroconversion) or a significant rise in lgG indicates a recent primary CMV infection If the patient has a positive lgM with or without a positive lgG, the result is equivocal and the test should be repeated in 2-4 The reasons for this include: lgM can remain positive for over one year after an acute infection; therefore, presence of CMV lgM is not helpful for timing of the onset of infection lgM is only positive in only 75-90% of women with acute infection lgM can revert from negative to positive in women with CMV reactivation or reinfection with a different strain NOTE– Interpretation of CMV lgM results in pregnancy requires specialist opinion. Fetal diagnosis is best achieved by a combination of fetal ultrasound, amniocentesis+/- fetal serology; however, the definite diagnosis of fetal infection is by amniocentesis and PCR or the amniotic fluid for CMV. It should be born in mind that positive results do not predict any degree of fetal damage. Since this woman is 16 weeks pregnant. amniocentesis for definite diagnosis is the most appropriate option. Amniocentesis is performed in the rather small window of 15-18 (up to 20) weeks. However, repeating the test in 2-4 weeks was the most appropriate option if it was an option.

Answer 78

Fetal diagnosis is best achieved by a combination of fetal ultrasound, amniocentesis+/- fetal serology; however, the definite diagnosis of fetal infection is by amniocentesis and PCR or the amniotic fluid for CMV. It should be born in mind that positive results do not predict any degree of fetal damage. Since this woman is 16 weeks pregnant. amniocentesis for definite diagnosis is the most appropriate option. Amniocentesis is performed in the rather small window of 15-18 (up to 20) weeks. However, repeating the test in 2-4 weeks was the most appropriate option if it was an option.

Answer 79

Fetal demise Listeria monocytogenes is a common foodborne infection due to consumption of contaminated food (eg, unpasteurized milk, deli meats) and typically causes a self-limited gastroenteritis. During pregnancy, L monocytogenes can cause transplacental fetal infection and possible intrauterine fetal demise. Infection acquired in early pregnancy (eg, first and second trimesters) typically results in granulomatosis infantiseptica (ie, disseminated abscesses/granulomas) and possible intrauterine fetal demise. Infection in the third trimester may be less severe and present as fetal distress, preterm delivery, or early-onset neonatal sepsis.

Answer 80

36-37 weeks If spontaneous version to cephalic presentation has not occurred consider following steps: -External cephalic version. -If external cephalic version is unsuccessful, consider Cesarean section or vaginal delivery at 38-39 weeks of gestation.

Answer 81

Types of breech presentation include: -Frank breech: The fetal hips are flexed, and the knees extended (pike position). -Complete breech: The fetus seems to be sitting with hips and knees flexed. -Footling breech: One or both legs are completely extended and present before the buttocks. -Kneeling breech: The baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees Fetal position is a transverse lie if the fetal long axis is oblique or perpendicular rather than parallel to the maternal long axis. Shoulder-first presentation requires cesarian delivery unless the fetus is the 2nd twin.

Answer 82

Swelling and inflammation of connective tissues in ligaments in pelvis due to hormones Pain NOT RELATED to periods

Answer 83

Hypothyroidism - Heavier and more periods Hyperthyroidism - Less periods

Answer 84

Higher sensitivity to prostaglandins and excessive production. Normal during the change from anovulatory to ovulatory cycles

Answer 85

For ovulation induction in PCOs

Answer 86

Menstrual pain associated with ovular cycles without any pathologic findings. The pain usually commences within 1–2 years after the menarche and becomes less severe with age. Due to excessive local prostaglandin release. Features: Low midline abdominal pain Pain radiates to back or thighs Usually lasts 24 hours but may persist for 2–3 days May be associated with nausea and vomiting, headache, syncope or flushing No abnormal findings on examination

Answer 87

Promote a healthy lifestyle: regular exercise avoid smoking and excessive alcohol Yoga, hot water bottles Medications: Simple analgesics NSAIDs Vitamin B1 (Thiamine) COCs Progesterone

Answer 88

After 35y with +15 cigarretes/day or aura present

Answer 89

Stop OCP for 1 month and reassess

Answer 90

The woman reviews and records six cycle lengths and then selects the shortest and longest cycles. Ovulation always occurs 14 days before the period – length of luteal phase is always constant. Subtract 14 from longest and shortest cycles to find out range of ovulation. Subtract 6 from earliest ovulation – reflecting sperm survival Add 2 to the latest ovulation – reflecting ovum survival

Answer 91

At the time of ovulation serum progesterone levels start to rise à elevation in temperature rise of 0.3 – 0.4C after ovulation (compared to BBT of six previous days) Elevation remains until commencement of periods OK to commence sexual activity when temperature has been elevated for two days.

Answer 92

Common, safe procedure Laparoscopically (unless at time of caesarean section) Clips (Filshie), rings (Falope) Potentially reversible method – 50% success rate of reversal

Answer 93

Important to confirm the absence of spermatozoa in ejaculate 2-3 months after procedure – do not cease other contraceptive measures before It takes 12-15 ejaculates to clear all sperm from tubes proximal to surgical division Reversal successful in 80% of patients 1:500-1000 chance of recanalisation (vas deferns re-joins)

Answer 94

Provide: good cycle control effective contraception least side effects using pill at lowest dose As early as: in adolescents once menstruation has commenced Counsel about save sex & STDs!! ADOLESCENTS = PILL + CONDOMS Can be used safely up to 50 years of age (then, rises risk of breast and cervix cancer, cardiovascular disease) Start on first day of menses Cover starts from day one of cycle

Answer 95

COC combinations: (all + Progesterone) Low dose - 20mcg, Regular 30, 35 mcg, High dose 50 mcg FIRST CHOICE: 30 mcg ethinyloestradial (EO) with levenogestrel LNG or norethisterone NET– High dose (50 mcg oestrogen) should be reserved for the following Break through bleeding on low dose COCs Control of menorrhagia Concomitant use of enzyme-inducing drugs Low dose pill failure !!!! Decision with the specialist!!!!

Answer 96

Breakthrough bleeding in first 2-3 months is common If persists start on COC with 50mcg EO Periods tend to become shorter, lighter Drug interactions affecting efficacy Antacids, vit C, anitbiotics, (esp rifampicin), anticonvulsants (except sodium valporate) Warfarin, oral hypoglycaemics, Diarrhoea and vomiting (if vomiting within 2h of taking a pill, take additional active pill) Yearly GP follow up! Check BP Pap smear yearly Common side effects get better with time >>>> Mandatory to prescribe BetaHCG even if sexually absent. + Thrombophilia screening

Answer 97

Absolute contraindications < 6 wks postpartum smoker over the age of 35 (>15 cigarettes per day) hypertension (systolic > 160mmHg or diastolic > 100mmHg) current of past histroy of venous thromboembolism (VTE) ischemic heart disease history of cerebrovascular accident complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis) migraine headache with focal neurological symptoms breast cancer (current) diabetes with retinopathy/nephropathy/neuropathy severe cirrhosis liver tumour (adenoma or hepatoma) OR disease Polycythaemia Oestrogen-dependent tumours (e.g. breast) Relative contraindications smoker over the age of 35 (< 15 cigarettes per day) adequately controlled hypertension hypertension (systolic 140 - 159mmHg or diastolic 90 - 99mmHg) migrain headache over the age of 35 currently symptomatic gallbladder disease mild cirrhosis history of combined OCP-related cholestasis users of medications that may interfere with OCP metabolism severe depression

Answer 98

In general: take missed pill ASAP and then resume usual pill taking schedule If missed pill in week three – no pill-free interval, start new pack If forgot to take pill >12h, take ASAP, resume usual schedule PLUS use condoms Condoms/abstinence for 7 days if Two for twenty – two or more 20 mcg pills are missed Three for thirty – three or more of 30 mcg pills are missed (take most recent pill asap, continue taking remaining pills, use condoms until pill is taken for 7 consecutive days)

Answer 99

Acne Amenorrhoea Breakthrough bleeding Breast problems: fullness/tenderness Depression Dysmenorrhoea / menorrhagia Libido loss Headache Nausea/vomiting Weight gain

Answer 100

Possible effect (not absolutely proven) and possibly very low risk: cervix (take regular smears at yearly intervals) breast Protective effect: endometrial, colon epithelial ovarian No effect: melanoma choriocarcinoma prolactinomas

Answer 101

Progesterone only pill “Mini-pill” Must be taken same time each day Low compliance – shortens cycle Indicated: lactation, >45, smokers >45, DM, migraine, well controlled HTN

Answer 102

Depo-Provera – IM injectable contraceptive Effective for 14 weeks (give every 12 weeks in first 5 days of menstrual cycle) SE: 70% amenorrhoea, excessive weight gain, breast tenderness, depression, delay in return to fertility (average 6 months) Only use < 2 years, not recommended under 18 yrs old, preferably 25 yrs and older Implanon – Sub cutaneous implant releases progesterone. Not for use in obese patients.

Answer 103

CI: pregnancy, active PID, undiagnosed abnormal genital tract bleeding, previous ectopic pregnancy, severe uterine cavity distortion If pregnancy occurs high risk of ectopic, 50% increased risk of abortion and intra-uterine sepsis. Early removal of IUCD essential SE: extrusion, perforation, translocation, bleeding (spotting in first 2-3 months normal), back pain Bioactive substance Copper – affect sperm motility and transport 6 – 10 years Bioactive substance progesteron (Mirena) 5 years

Answer 104

Yuzpe method High dose COC (50 mcg EO + 250 mcg LNG e.g. Nordiol) Two pills initially then repeated 12h later Postinor-2 (Plan B) 2x 750 mcg levenogestrel tablets taken 12 hours apart Use limited to first 72 hours

Answer 105

Leiomyomas

Answer 106

Higher risk Early first period (menarche) Obesity (BMI 30.0 or higher) A family history of fibroids Never having given birth Age (risk increases in your late reproductive years) Having polycystic ovary syndrome (PCOS) High blood pressure (hypertension) Lower risk Having more than two children Having had a multiple birth Use of Depo-Provera (a contraceptive) Use of the oral contraceptive pill

Answer 107

heavy or prolonged periods period pain anaemia or iron deficiency (due to heavy periods), and you may feel: tired dizzy frequent passing of urine a pressure sensation on the bladder, bowel or back and/or feeling of incomplete emptying of bladder or bowel lower back pain swelling in the abdomen painful sex (dyspareunia) Bleeding in between periods is not common but can sometimes happen. In rare instances, a fibroid may become cancerous and this is called a sarcoma.

Answer 108

Single, small : Medical (Mefenemic acid, tranexamic acid, GnRH analogues, OCPs, mirena, iron ) Gonadotropin-releasing hormone (GnRH) agonists are the most effective medical therapy for uterine myomas. These drugs work by initially increasing the release of gonadotropins, followed by desensitisation and downregulation to a hypogonadotropic, hypogonadal state that clinically resembles menopause. Most women will develop amenorrhea, improvement in anaemia, and a significant reduction (35 to 60%) in uterine size within 3 months of initiating this therapy. Multiple/large: Surgical (myomectomy, hysterectomy, uterine artery embolization) The only surgical procedure that preserves fertility and effectively ameliorates fibroid-related symptoms is myomectomy. If heavy menstrual bleeding has not settled after 6 months of pharmacotherapy, refer for specialist assessment and consideration of surgical options such as uterine artery embolisation, myomectomy, hysteroscopic resection of fibroids or polyps, or hysterectomy. Early referral (before 6 months) in heavy menstrual bleeding is indicated for:concurrent severe dysmenorrhoea at baselineconcurrent dysmenorrhoea that does not settle after 3 months of pharmacotherapyindividuals who wish to conceive

Answer 109

Benign cystic teratoma, dermoid cyst - most common benign complex ovarian tumor in young women Follicular cyst - simple, never have calcifications. Mucinous cystadenoma - benign epithelial ovarian tumor, frequently multiloculated, but never has calcifications. Serous cystadenoma - unilocular, no calcifications.

Answer 110

Blood serum FSH and oestradiol levels High FSH and Low oestradiol. The dx doesn't depend on progesterone

Answer 111

Endometrial cancer (until proven otherwise) Induction of follicular activity - due to high FSH levels, a remained follicle could respond and start producing estrogen Cervical cancer Women taking HRT >> THINK OF CANCER!!! IF JUST BLEEDING, without other signs of hormone correlation, like breast enlargement/tenderness,

Answer 112

Anatomical and functional changes in the genitourinary tissues Loss of labial and vulval fullness Contraction of labia majora and clitoral hood Narrowing and stenosis of the introitus Loss of hymenal remnants or reduced elasticity Vaginal shortening and narrowing Prolapse Pelvic floor weakening Vaginal epithelium dry and thin with petechiae Loss of superficial cells and increase in parabasal cells Loss of vaginal rugae Inflamed vaginal tissues Alkaline pH changes the vaginal microbiome with loss of Lactobacilli (vaginal pH >4.5) Persistent or recurrent discharge with odour (not Candida in postmenopause) Urethral meatal prominence and prolapse with thinning of the urethral epithelium Touch perception altered either hypersensitive or decreased feeling Loss of clitoral stimulation

Answer 113

Semen analysis

Answer 114

The follicle-stimulating hormone (FSH) assay. If high levels of FSH are found, most of the ovulation-induction therapies are ineffective, although rarely a spontaneous pregnancy does occur rarely. If the FSH level is normal, ovulation-induction therapy is usually effective with correction of thyroid function being necessary if the thyroid function is not normal, with dopamine agonist therapy being indicated if the prolactin level is elevated Clomiphene (SERM) or gonadotrophin therapy being employed where the luteinising and oestradiol levels are low, normal or minimally elevated.

Answer 115

Reduced sperm production: congenital cryptorchidism (maldescent) inflammation (e.g. mumps orchitis) Antispermatogenic agents: chemotherapy drugs irradiation heat idiopathic Klinefelter syndrome (46 XXY) sperm autoimmunity Hypothalamic pituitary disease: hypogonadotropic disorder Disorders of coitus: erectile dysfunction psychosexual ejaculatory failure retrograde ejaculation: genitourinary surgery autonomic disorders (e.g. diabetes) congenital abnormalities Ductal obstruction

Answer 116

First-line Semen analysis Basal body temperature chart and cervical mucus diary Serum progesterone (mid-luteal-day21) in female Transvaginal ultrasound Rubella immune status (female)

Answer 117

Better to treat both partners together. Marital counselling Educate regarding fertile period basal body temperature method, cervical mucous method the chance of fertilisation is best during days 10–16 of a 28-day cycle Further treatment depends on cause. Anovulation - Ovulation induction drugs such as clomiphene, bromocriptine, gonadotrophins or GnRH. PCOS- Life style modifications, Metformin, ovulation inducing drugs, surgery. Fibroids- Surgery. Endometriosis- Surgery Male problems—little can be done (including testosterone and vitamins) to enhance semen quality. Corticosteroids may help if sperm antibodies are present Severe tubal disease, Unexplained subfertility—use IVF and embryo transfer (IVF-ET). “Test-tube baby” depends on the woman's age and the couple's attitudes. Intracytoplasmic sperm injection (ICSI) into the oocyte. Artificial insemination. Donor insemination. Surrogacy Adoption/Foster care

Answer 118

Menorrhagia= heavy menstrual flow (>80mls/L) Metrorrhagia= intermenstrual bleeding Hypomenorrhoea= light flow Oligomenorrhoea=irregular & light periods Metromenorrhagia=irregular & heavy periods Dysmenorrhoea=excessive pain during periods

Answer 119

IUCD OCP induced(breakthrough bleeding) Can be related to sexual activity Uterine/ cervical pathology (esp cancers)

Answer 120

Cervical causes are the most important Cervical polyp Cervical erosion/ectropion Cervical cancer Cervicitis Atrophic vaginitis Endometrial pathology to be considered

Answer 121

Single layer of columnar cells of endocervix has extended onto ectocervix à exposed to trauma during coitus Common in women on OCP and postpartum Can be left untreated if tolerable discharge or moderate PCB (post-coital bleeding) IUCD should be removed Causative pill should be changed to one with higher oestrogen dose Treatment: Eradication of cervical lesion by cautery under anaesthesia Healing of lesion within 4 weeks

Answer 122

In a 45-year-old woman is likely to be due to a disorder of ovulation, most likely that of anovulatory cycles, especially as the cycles have become Irregular. Endometrial carcinoma is an uncommon cause of menorrhagia and usually causes postmenopausal bleeding. Fibroids, endometrial polyps and adenomyosis can certainly cause menorrhagia, although the cycles are usually regular and a dramatic change from normal cycles six months previously would be unusual. The uterus is usually enlarged if fibroids or adenomyosis are the cause of the menorrhagia

Answer 123

excessive bleeding, whether heavy, prolonged or frequent, of uterine origin, which is not associated with recognisable pelvic disease, complications of pregnancy or systemic disease’. It is a diagnosis of exclusion. Heavy bleeding caused by: Excessive local production of prostaglandins in endometrium -> Prostaglandin inhibitors (NSAIDs) Excessive local fibrinolysis of clots -> Antifibrinolytic agents (Tranexamic acid) Hormonal dysfunction -> COC, POP, IUD Most cases are associated with anovulatory bleeding (90%) Normally, the production of progesterone in the latter 2 weeks of the cycle balances out the regenerative effects of estrogen, halting further endometrial growth. In anovulation, level of estrogen does not decline and progesterone is not secreted to balance out the effects of estrogen. Endometrial growth does not stop and the endometrial tissue accumulates and thickens, resulting in abnormally heavy bleeding. Also, without progesterone, the endometrium lacks structural support and sloughs off irregularly, causing heavy and/or irregular periods. Ovulatory DUB is less common than anovulatory DUB, and the bleeding, though abnormally heavy, is usually regular. Ovulatory DUB may be due to abnormalities in the 2-week luteal phase of menstruation that occurs just before bleeding begins. Can also result from an atrophic endometrium that can result from a high progesterone to estrogen ratio, may occur in women who take progesterone-only contraceptives. A lack of cell-building estrogen causes the endometrium to slough off and bleed. Ovulatory: Regular cycles, more in 30s, 40s. Anovulatory: Irregular cycles, more in 12-16 yrs, 45-55 yrs. Histological changes on endometrial samples: Cystic glandular hyperplasia (in pre menopausal) Atypical endometrial hyperplasia (in post menopausal)

Answer 124

Medications 1st line: Mefenamic acid, NSAIDs (naproxen, ibuprofen) before the start till end of periods 2nd line: Tranexamic acid (Day 1-4) 3rd line: Oral hormone therapy ( Combined or Progesterone only pills) 5th line: IUDs

Answer 125

Painful periods/ coitus , infertility, haematuria, backache, haemoptysis. O/E: large tender uterus, nodularity in pouch of Douglas, uterosacral ligament Inv: USG(initial), laparoscopy(diagnostic/gold standard) Management: Medical - GnRH agonists (downregulation of Gnrh activity inducing a pseudomenopause) - MAX 6 MONTHS; Oral Contraceptive Pills (Decidualization of endometrium leading to atrophy), danazol (multiple effects causing high androgen low oestrogen enviroment and inhibiting endometrial growth) - MAX 6 MONTHS!!! POPs (Decidualization of endometrium leading to atrophy); Surgical- Depending on age, symptoms, family planning laser or microsurgery can be attempted.

Answer 126

Itching, bloody/mucoid discharge On/Examination: inflammation, discharge Caused by lack of oestrogen. Common in: Post menopausal women Post partum/ breast feeding Anorexic patients Athletes Pre menarche girls

Answer 127

Most common is Chlamydia then E.coli. Chlamydia, gonorrhea E coli, bacteroides fragilis Actinomycosis (IUCD) Inv: Bloods, cultures Swabs Urine PCR (initial) USG Acute: Fever Lower abdominal pain, Premenstrual pain, Irregular/regular heavy periods, Vaginal discharge Positive cervical motion tenderness test Ttx: azithromycin plus metronidazole.

Answer 128

History of IUCD, D&C, ruptured appendix, pelvic infection, STIs… Premenstrual pain, Irregular/regular heavy periods, vaginal discharge, infertility, dyspareunia, painful and frequent urination.

Answer 129

Actinomycosis (IUCD)

Answer 130

Management Azithromycin + metronidazole ( mil to mod) Cefotaxime + doxycycline + metronidazole IV ( severe) Amoxy + metronidazole (actinomyces)

Answer 131

Cystocele-upper anterior vaginal wall; rectocele-lower posterior, enterocele-upper posterior (pouch of Douglas). lower anterior - Urethral displacement

Answer 132

A. Stress incontinence B. Urge incontinence C. Overflow D. Neurologic bladder dysfunction E. Psychogenic incontinence A menopause, multiparty, pelvic relaxation. B- over active bladder -detrusor instability, sudden urge to urinate. C- bladder over distended chronically, abdo fullness, random dribbling. D- can be hyper or hypotonic.

Answer 133

Imperforate hymen leading to vagina beeing pooled with menstrual blood

Answer 134

Elevated above 150 mg/l

Answer 135

Ashermans Syndrome

Answer 136

Pregnancy test (1st) FBE, iron TFTs Coagulation screen Antibody screen USG (TV) Hysteroscopy & D&C/endometrial sampling (gold standard for uterine bleeding) Laparoscopy ( gold standard for endometriosis)

Answer 137

Absence of periods for 3 months after regular periods and 6 months if infrequent periods. Causes: Pregnancy. Premature ovarian failure. Post pill amenorrhoea. PCOS. Thyroid. Hyperprolactinemia. Exercise induced. Eating disorders. Stress induced. Asherman’s syndrome. Other medical illness- DM/ renal. Medications.

Answer 138

Policystic ovaries Syndrome

Answer 139

Diagnostic criteria for Rotterdam diagnosis of polycystic ovary syndrome Two of the following three criteria are required: oligo/anovulation hyperandrogenism clinical (hirsutism or less commonly male pattern alopecia) or biochemical (raised free testosterone) polycystic ovaries on ultrasound (10 small antral follicles are seen in each ovary) Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia oligo/anovulation is usually seen in women with menstrual cycles greater than 35 days apart or, conversely, with short cycles of less than 21 days. It is important to remember that even women with regular cycles may be anovulatory. For these women a measure of luteal progesterone (day 21 in a 28 day cycle) will determine ovulatory status hyperandrogenism. Hirsutism is difficult to assess as most women treat this so it is not obvious on examination. Hyperandrogenaemia is best measured with free testosterone; either calculated free testosterone, free androgen index (FAI) or bioavailable testosterone. Most laboratories will offer at least one of these. Hormonal contraceptive use will affect free testosterone measures. If appropriate, assess after 3 months cessation; alternative contraception should be discussed for this time. If free testosterone is significantly raised or there is evidence of rapid virilisation, further investigations are required to exclude late onset congenital adrenal hyperplasia and virilising tumours polycystic ovaries on ultrasound are diagnosed when 10 small antral follicles are seen in each ovary.

Answer 140

Hirsutism and male pattern balding consistent with hyperandrogenism Irregular or absent menstrual cycles Subfertility or infertility Psychological symptoms – anxiety, depression, psychosexual dysfunction, eating disorders Metabolic features – obesity, dyslipidaemia, diabetes

Answer 141

Oligomenorrhoea/amenorrhoea Lifestyle change (5–10% weight loss + structured exercise) Combined oral contraceptive pill (low oestrogen doses, eg. 20 µg may have less impact on insulin resistance)13 Cyclic progestins (eg. 10 mg medroxyprogesterone acetate 10–14 days every 2–3 months) Metformin (improves ovulation and menstrual cyclicity)

Answer 142

Hirsutism cosmetic therapy is first line (laser is recommended) Eflornithine cream can be added and may induce a more rapid response Pharmacological therapy Consider if there is patient concern or if cosmetic treatment is ineffective/inaccessible/unaffordable Should be trialled for at least 6 months before making changes in dose or medication Primary therapy is the COCP (monitor glucose tolerance in those at risk of diabetes) Anti-androgen monotherapy (eg. aldactone or cyproterone acetate)used with adequate contraception Combination therapy – if 36 months of COCP is ineffective, add anti-androgen to COCP (daily spironolactone >50 mg twice daily or cyproterone acetate 25 mg/day, days 1–10 of COCP)

Answer 143

Advise smoking cessation, optimal weight, exercise and folate supplementation Advise regarding the age-related decline in fertility to allow optimal timing of family planning Infertility therapies may include clomiphene, metformin, gonadotrophins, surgery and in vitro fertilisation Cardiometabolic risk Lifestyle change with a >5% weight loss in those who are overweight reduces diabetes risk by ~50–60% in high risk groups11 Metformin* reduces the risk of diabetes by ~50% in adherent high risk groups * Metformin and the COCP are not currently approved for use to manage PCOS by many regulatory bodies. The COCP is indicated for contraception and metformin for diabetes. However, their use is supported by evidence and is recommended by international and national specialist societies and is evidence based

Answer 144

often are used in an attempt to arrest labour or premature contractions.

Answer 145

120-160 bpm

Answer 146

Baseline FHR over 10 minutes Normal FHR- 120 to 160/ minute Variability Variation of FHR from one beat to next Normal- 6 to 25 beats per minute Accelerations Rise in FHR from baseline Seen as peaks Normal is 2 or more/ 15 minutes

Answer 147

3 types Early-starting with uterine contraction and finishing when contraction finishes. Normal physiological Variable- no connection with uterine contractions. Denotes umbilical cord compression Late- starts at peak of contraction and finishes with contraction. Denotes decreased uteroplacental blood flow

Answer 148

CVS- 9-11 weeks. CVS higher miscarriage rate. Recommended for women who are genetic carriers of the diseases. Amniocentesis- 16 weeks.

Answer 149

At 16-18 gestation. Low – down Syndrome, trisomy 18, wrong dates. High- neural tube defects ( anencephaly, spina bifida), multiple gestation.

Answer 150

Fetus swallow amniotic fluid but can not excrete it. The end result of the OLIGOHYDRAMNIOS is hypoplastic lungs, neonatal respiratory distress,

Answer 151

Amoxicillin Rapid progression to pyelonephritis due to gravid uterus compressing the ureters and progesterone relaxing effect on ureters. Untreated bacteriuria in pregnancy is associated with a 20 to 30% increased risk of developing pyelonephritis in later pregnancy. Untreated bacteriuria may be associated with preterm birth and low birth weight. Antibiotic treatment of asymptomatic bacteriuria reduces the risk of symptomatic urinary tract infection (UTI) during pregnancy.

Answer 152

Screen for asymptomatic bacteriuria during pregnancy by obtaining a urine sample for culture and susceptibility testing at 12 to 16 weeks gestation (or at the first antenatal visit, if this occurs later). Confirm asymptomatic bacteriuria with a second urine culture. Confirm the infection has resolved by repeating urine culture 1 to 2 weeks after treatment is completed. Streptococcus agalactiae (group B streptococcus [GBS]) is detected in urine at any stage of pregnancy, intrapartum prophylaxis for GBS is usually indicated

Answer 153

Choose treatment for recurrent bacteriuria based on the results of culture and susceptibility testing Consider giving antibiotic prophylaxis to pregnant women with recurrent bacteriuria or bacteriuria and risk factors for pyelonephritis (eg immune compromise, diabetes, neurogenic bladder). Use: 1 cefalexin 250 mg orally, at night for the remainder of the pregnancy OR 2 nitrofurantoin 50 mg orally, at night for the remainder of the pregnancy

Answer 154

Avoid using nitrofurantoin close to delivery (after 37 weeks' gestation, or sooner if early delivery is planned) because of the possible increased risk of neonatal jaundice and haemolytic anaemia.

Answer 155

A choriocarcinoma and molar pregnancy in general may occur after any pregnancy. 50%-complete mole, but others occur after miscarriage (25%), term delivery ( 20%) or ectopic pregnancy (5%). Hydatiform mole- benign, Malignant trophoblastic disease. Ix: Uterus larger than dates, Fetal heart sounds can not be heard, US appearance, High b-HCG. TTx: Evacuation by Suction Curette. FOLLOW UP : b-HCG every 7-10 days, complete disappearance takes 12-14 weeks. When b-HCG normal for 6 consecutive months-discontinue. TTx: Malignant is treated with chemotherapy- methotrexate.

Answer 156

Hegar’s sign- softness and compressibility of the low uterine segment. Chadwick’s- dark discoloration of the vulva.

Answer 157

Intravenous salbutamol can be used as a second line tocolytic (to reduce uterine contractions) in certain circumstances. The use of salbutamol is contraindicated in following situations: – Hyperthyroidism. – Fetal cardiac disease. – Maternal cardiac disease. – Insulin-dependent diabetes mellitus. Salbutamol is often associated with following side effects: – Hyperglycemia. – Hypokalemia. – The maternal tachycardia. – Pulmonary oedema. – Hypotension. – Tremors.

Answer 158

-Premature birth, -Placental abruption (double the risk for smokers who consume more than 20 cigarettes a day). -Spontaneous abortion. -Low birth weight. -Stillbirth. -Placenta praevia.

Answer 159

Is usually caused by cyclical hormonal changes and is common in females between 35 to 50 years of age. As conservative management including reduced caffeine intake, use of analgesics and vitamin B complex especially B1 and B6 Danazol is an androgen that is effective in relieving breast pain in more than 90 percent of cases with minimal side effects. Tamoxifen can be used in severe mastalgia, but it causes more severe adverse effects including DVT and endometrial cancer so not preferred. Bromocriptine has been proven to improve breast pain in many women but is not as effective as danazol. Oral contraceptive pills are considered as one of the causes of mastalgia so they are better avoided in that case.

Answer 160

From 28 weeks (3rd trimester)

Answer 161

Contraindicated or are better avoided before conception and during pregnancy. These drugs include: Angiotensin converting enzyme (ACE) inhibitors eg. ramipril, captopril Angiotensin receptor blockers (ARBs) g. losartan, irbesartan Diuretics Calcium channel blockers Most beta blockers Methyldopa is the first-line antihypertensive agent during pregnancy for controlling mild to mode rate hypertension during pregnancy. Beta blockers can cause fetal bradycardia and with long-term use result in growth restriction. Labetolol is an exception and can be used in hypertensive emergencies. Angiotensin receptor blockers and ACE inhibitors both are teratogenic in first trimester. In the second and third trimesters they can result in fetal renal dysfunction, oligohydramnios and skull hypoplasia. Hydralazine can be safely used for treatment of hypertensive emergencies during pregnancy. Otherwise,methyldopa remains the choice. Other anithypertensive medications: Diuretics – Diuretics can cause fetal electrolyte disturbances and reduction in maternal blood volume. This can consequently lead to restricted fetal growth. Calcium channel blockers (CCBs)- with the exception o f nifedipine, CCBs should be avoided in pregnancy due to risk of maternal hypotension and fetal hypoxia. Nifedipine is commonly used as first-line tocolytic agent. but is not used as an anti hypertensive medication during pregnancy.

Answer 162

When approaching a woman who wishes to become pregnant while on antiepileptic drugs, two major groups of epilepsies should be distinguished because they typically respond differently to different drugs. Partial epilepsies respond to most antiepileptic drugs, but for idiopathic generalized epilepsies, especially juvenile myoclonic epilepsy, seizure can be controlled with a reasonably low dose of sodium valproate. Although lamotrigine may be helpful, it is not as effective as sodium valproate and sometimes worsens the myoclonic seizures of juvenile myoclonic epilepsy. Therefore, substitution of sodium valproate with lamotrigine is not the right choice. Topiramate and levetiracetam may be effective in idiopathic generalized epilepsies, while carbamazepine, phenytoin and gabapentin may worsen some seizure types, especially myoclonic and absence seizures. For some women with idiopathic generalized epilepsies, there may be no effective alternative to sodium valproate. Cessation of sodium valproate is associated with recurrence and not advisable. On the other hand, sodium valproate has the highest teratogenicity potential compared with other antiepileptic medications. The Australian Pregnancy Register has reported the risk to be as high as 16% for the first trimester. Sodium valproate should therefore be avoided in women of reproductive age. If a patient is willing to become pregnant, she should be fully informed of the risk of teratogenicity, but the decision should be left to her. If she decides to accept the risks and pregnancy is unavoidable, the lowest effective dose should be used. If sodium valproate dose has been reduced to a minimum during pregnancy, the prepartum effective dose may need to be re-established before the onset of labor. This is a time of increased seizure risk, especially in patients with idiopathic generalized epilepsy who are very sensitive to sleep deprivation.

Answer 163

Cervical carcinoma

Answer 164

– Oral contraceptive pills for more than 5 years – Smoking – Immunosuppression – Persistence infection of high risk human papilloma virus infection. Sexual activity is an average risk factor for developing cervical carcinoma

Answer 165

Anti-histaminics (Doxylamine, Cyclizine, prochlorperazine, promethazine, diphenhydramine)

Answer 166

screening at 35-37 weeks gestation for rectovaginal GBS colonisation via a combined low vaginal and anorectal swab. Adequate intrapartum chemoprophylaxis is defined receipt of ß lactam (penicillin, amoxicillin or cefazolin) antibiotics for more than 4 hours before birth. Provide intrapartum antibiotics for women with: – A positive culture. – A previous infant with GBS disease regardless of present culture. – Symptomatic or asymptomatic GBS bacteriuria of any count in current pregnancy Clinical risk factors for early onset of group B streptococcus sepsis include: – Spontaneous onset of labour at less than 37 weeks gestation. – Rupture of the membranes more than 18 hours. – Maternal fever above 38°C. – A previous infant with early onset GBS sepsis. – GBS bacteriuria during the current pregnancy. – Known carriage of GBS in the current pregnancy. – Clinical diagnosis of chorioamnionitis. For elective caesarian section before the onset of labour, no additional prophylaxis is recommended, irrespective of GBS carriage

Answer 167

HPV types 16, 18, and 31

Answer 168

HPV types 6 and 11

Answer 169

history of previous cesarean section

Answer 170

If delivery prior to 34 w

Answer 171

– Weight more than 90 kg. – Age more than 45. – Early menarche. – Late menopause. Also, nulliparous women are at higher risk of developing endometrial cancer than multiparous.History of infertility and previous tamoxifen use also increases the risk of endometrial cancer.

Answer 172

Simple unilateral, unilocular ovarian cysts of <5 cm and low risk of malignancy (normal Ca125) can be managed conservatively as the RMI would be zero and 50% of these will resolve spontaneously in 3 months. Cysts of 2–5 cm should be rescanned in 3–4 months. Women with a moderate-to-high risk RMI should be referred to a gynaecologist or gynaecological oncologist for consideration of surgical management. In addition, any woman who does not meet the criteria for conservative management should be offered surgical management. If malignancy is suspected, an oophorectomy is recommended rather than a cystectomy. This allows removal of the cyst intact and prevention of spillage into the peritoneal cavity. A bilateral oophorectomy may be offered for postmenopausal women because the contralateral ovary may also be affected; however, there are no studies that have assessed malignancy after unilateral versus bilateral oophorectomy.

Answer 173

Nipple discharge, as a sign, may have a variety of underlying causes. Some of these causes are as follows: Bloody nipple discharge – bloody discharge from nipple is usually caused by benign duct papilloma, but breast neoplasm including breast duct carcinoma and Paget disease of the breast should always be excluded Serous, green, yellow-brown discharge – it is usually due to benign fibrocystic changes Toothpaste {worm)-like discharge – it is characteristic of mammary duct

Answer 174

Higher risk - HPV 16/18 positive - non–16/18 positive with any of the following: possible high grade cytology high-grade squamous lesion (HSIL) cancer glandular abnormality. Refer immediately to a specialist for further investigation. Some colposcopy clinics are currently experiencing high demand and long waiting lists. If you are concerned about your patient being delayed, contact the specialist or clinic your patient has been referred to.

Answer 175

Intermediate risk HPV non-16/18 positive (with negative or low-grade cytology): Follow up HPV test at 12 months where possible. A delay of 3 to 6 months may be acceptable. We discourage delays of more than 6 months. Follow up HPV test – HPV non 16/18 (possible high grade cytology or high-grade squamous lesion (HSIL): Treated as Higher risk. Refer immediately to a specialist for further investigation. Follow up HPV test – HPV non-16/18 positive (with negative or low-grade cytology): If your patient is: 2 or more years overdue for screening at the time of the initial screen identifies as Aboriginal or Torres Strait Islander aged 50 years or older. They may be at increased risk and should be referred immediately to a specialist for further investigation. 2nd Follow up HPV test – HPV detected Treated as Higher risk: Refer immediately to a specialist for further investigation.

Answer 176

Patients may initially present with nausea, flushing, and hyporeflexia due to magnesium inhibition of presynaptic acetylcholine release (ie, neuromuscular inhibition). Further toxicity is uncommon in patients with normal renal function, but those with decreased urine output, such as this patient, are at a higher risk due to decreased urinary excretion of magnesium. Therefore, magnesium toxicity can progress to cause further muscle weakness, loss of deep tendon reflexes (ie, areflexia), and respiratory depression (eg, drowsiness, respirations of 10/min). At severely high serum magnesium levels, patients are at risk for respiratory paralysis and cardiac arrhythmias. Because of these life-threatening risks, patients treated with magnesium sulfate require close monitoring. Patients with signs of toxicity require a serum magnesium level and immediate cessation of magnesium sulfate. In addition, patients are administered calcium gluconate, which reverses neuromuscular paralysis, stabilizes cardiac membranes, and prevents cardiac arrest.

Answer 177

– Combined oral contraceptives. – Depo Medroxyprogesterone acetate-injectable. – Vaginal ring containing estrogen and progesterone. All of these three can lead to increased cardiovascular risk and so should be avoided in the women over 50 years of age. For the women over 50 years of age, following is the list of suitable contraceptives: – Progesterone only pill. – Contraceptive implant (Implanon). -Intrauterine contraceptive devices (Mirena or copper). – Tubal ligation

Answer 178

uterosacral ligament These ligaments are the round ligament, uterosacral ligaments, broad ligament and the ovarian ligament.

Answer 179

After 20 weeks gestation, fundal height in centimeters should directly correlate to gestational age in weeks with a small variation (eg, ±2-3 cm)

Answer 180

A diagnosis of GDM can be made with an elevated 75g 1-hour GTT (eg, ≥ 10.0 mmol/L) or 2-hour GTT (≥8.5 mmol/L)

Answer 181

– Evidence of serious, sustained fetal compromise. – Risk of fetal bleeding disorders (e.g. fetal thrombocytopenia, haemophilia). – Non-vertex presentation. – Maternal infection* (e.g. HIV, hepatitis B, hepatitis C, active primary herpes and suspected fetal sepsis). *Group B Streptococcus carrier status does not preclude FBS.

Answer 182

The clinical features of endometritis include: -Lower abdominal pain and uterine tenderness, followed by fever most commonly within the first 24 to 72 hours postpartum. -Chills, headache, malaise, and anorexia are common. -The diagnosis of postpartum endometritis is clinical and primarily based upon the presence of a postpartum illness that cannot be attributed to another aetiology after a thorough history and physical examination between day 2 to day 10 postpartum.

Answer 183

The most appropriate treatment is intravenous antibiotics within the first hour of presentation. The first-line choice of antibiotics is intravenous Piperacillin/Tazobactam 4.5 gram three times a day. If the patient is allergic to penicillin (non-anaphylactic, no angioedema), intravenous cefuroxime 1.5 gram three times a day along with intravenous Metronidazole 500mg three times a day. In severe penicillin allergy ( anaphylactic reaction or angioedema), then Clindamycin and gentamicin can be used as an alternative. The dose of clindamycin is usually 900mg three times a day and gentamicin as per local hospital protocol

Answer 184

Ovarian torsion is a gynecologic emergency and conservative management has no place in the treatment decision of suspected torsion even if pain improves in the ED. Failure to surgically correct this entity may result in ischemia and subsequent necrosis of the involved ovary. Therefore, the mainstay of therapy is laparoscopy or laparotomy.

Answer 185

The primary diagnostic steps in the workup of the infertile couple include (1) documentation of ovulation by measurement of basal body temperature (BBT) or mid–luteal phase serum progesterone; (2) semen analysis; (3) postcoital test; (4) hysterosalpingogram; and (5) endometrial biopsy. Women should record their BBT for evidence of ovulation. In addition, serial serum progesterone levels may be helpful to confirm ovulation. Serum progesterone values should be obtained 7 days after ovulation and may also be helpful in evaluating inadequate luteal phase. An endometrial biopsy may also provide valuable information regarding the status of the luteal phase. The biopsy is obtained 12 days after the thermogenic shift, or 2 to 3 days before the expected onset of menses, on about day 26 of a 28-day cycle. A postcoital test is an in vivo test that evaluates the interaction of sperm and cervical mucus. It is performed during the periovulatory period up to 12 hours after coitus. The cervical mucus is obtained, and its quantity and quality as well as its interaction with the sperm are evaluated. The hysterosalpingogram is performed in the mid–follicular phase in order to evaluate the fallopian tubes and the contour of the uterine cavity; it should not be done while the patient is menstruating or after ovulation has occurred. Although gonadotropin levels are not routinely evaluated, they should be obtained in the early follicular phase when testing is indicated (eg, in cases where there is a history of oligo-ovulation).

Answer 186

The maternal vitamin D deficiency in pregnancy is associated with: – Hypocalcemia in newborn. – Rickets later in life. – Defective tooth enamel. – Small for gestational due to effect on skeletal growth – Fetal convulsions or seizures due to hypocalcemia

Answer 187

Progestogen-only methods are contraindicated in suspected pregnancy, breast cancer and undiagnosed vaginal bleeding. For all progestogen-only methods, with the possible exception of DMPA, drug interactions are likely with many anticonvulsants, rifampicin, spironolactone and griseofulvin

Answer 188

If VZV IgG antibodies are absent, then she would need Varicella Zoster Immunoglobulins within ten days since the exposure to shingles.

Answer 189

Krukenberg tumors are typically bilateral, solid masses of the ovary that nearly always represent metastases from another organ, usually the stomach or large intestine. They contain large numbers of signet ring adenocarcinoma cells within a cellular hyperplastic but nonneoplastic ovarian stroma.

Answer 190

SCREENING TESTS At present there are two recommended sets of antenatal screening tests for Down syndrome: First trimester screening tests for Down syndrome (9-12 weeks): Ultrasonography for nuchal translucency (>0.5mm) Maternal serum biomarkers: Increased free beta hCG with decreased pregnancy-associated plasma protein = PAPP-A Second trimester screening tests for Down syndrome (15-18 weeks): Triple marker screening tests: Free beta hCG Increased Alpha-fetoproteln(AFP) Decreased Unconjugated estriol Decreased - Sensitivity 65-70% Quadruple marker screening test: Free beta hCG Increased Alpha-fetoprotein(AFP) Decrease, Unconjguated estriol Decrease lnhibin A level Increased Sensitivity 70-75% DIAGNOSTIC TESTS Chorionic villous sampling – performed at 12- 14 weeks of pregnancy and carries a 1:100 risk of pregnancy loss Amniocentesis – performed at 15-18 weeks of pregnancy and carries a 1:200 risk pregnancy loss

Answer 191

Placenta accreta Definition Morbidly adherent placental attachment to the myometrium Risk factors Placenta previa + prior uterine surgery (eg, cesarean delivery, D&C, myomectomy) Clinical features Prenatal diagnosis: US with placenta previa, numerous placental lacunae, myometrial thinning Postpartum diagnosis: adherent placenta, postpartum hemorrhage Management Electtive Cesarean hysterectomy with placenta in situ or emergency hysterectomy if needed after delievery if undiagnosed during pregnancy

Answer 192

Choriocarcinoma is a metastatic form of gestational trophoblastic neoplasia that may occur after a hydatidiform mole, normal pregnancy, or spontaneous abortion. The lungs are the most frequent site of metastasis. Choriocarcinoma should be suspected in postpartum women with an enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, and multiple infiltrates on chest x-ray. Diagnosis is confirmed by an elevated β-hCG level. Treatment with chemotherapy (methotrexate)

Answer 193

Monochorionic twins are at risk for twin-twin transfusion syndrome (TTTS), a complication that can result in heart failure and fetal/neonatal mortality in both twins. In TTTS, unbalanced arteriovenous anastomoses are present between the shared placental vessels that supply the twins. Because of these anastomoses, blood from the placental arteries (high resistance/pressure) of one twin (donor) is shunted into the placental veins (low resistance/pressure) of the other twin (recipient). The shunting of blood away from the donor twin causes anemia that leads to renal failure, oligohydramnios, low-output heart failure, and fetal growth restriction. In contrast, the shunting of blood toward the recipient twin causes polycythemia, which leads to polyhydramnios, cardiomegaly, high-output heart failure, and hydrops fetalis. Both twins are at risk for intrauterine and neonatal death. Mild TTTS is expectantly managed with serial ultrasounds to evaluate for worsening clinical features. Moderate-to-severe cases are treated with laser coagulation of the placental anastomoses.

Answer 194

Twin gestations are at increased risk for many pregnancy complications. This risk is further stratified based on the chorionicity (number of placentas) and amnionicity (number of amniotic sacs) of the gestation. This patient has monochorionic diamniotic twins (1 placenta, 2 amniotic sacs) based on 2 embryos, a single placenta, and a thin intertwin membrane (composed of 2 amniotic sacs) that meets the placenta at a 90-degree angle (“T sign”). In patients who appear to have a single placenta, the base shape of the intertwin membrane distinguishes between a monochorionic (“T sign”) and fused dichorionic (“lambda sign” or twin peak sign) gestation.

Answer 195

Colon Cancer Osteoporosis

Answer 196

Condoms 🌟: Can be used immediately; avoid spermicide gels. Minipill (POP - Progestin-Only Pill) 💊: Can be started in breastfeeding women but recommended after 3-4 weeks. Etonorgestrel implant (Implanon®) 💪: Can be inserted from 6 weeks postpartum after excluding pregnancy. Progesterone intramuscular injection (e.g., Depo-Provera®) 💉: Recommended after 6 weeks postpartum but can be used earlier if necessary. Mirena® (Levonorgestrel) IUD or Copper Intrauterine Devices (Cu-IUD) 🩸: Should be delayed until 4 weeks postpartum unless inserted within 48 hours. Mirena® effective within 7 days; Cu-IUDs effective immediately.

Answer 197

Lactational Amenorrhea Method (LAM) 🤱: A contraceptive method during breastfeeding. Criteria for LAM Effectiveness: Woman remains amenorrheic 🩸. Less than 6 months since giving birth 📆. Baby is fully breastfed (or breastfed with very infrequent supplements) 🍼. Ovulation may occur in the absence of menstruation if not meeting LAM criteria ❌.

Answer 198

Enzyme-Inducing Drugs 💊: Reduce plasma levels of progesterone and estrogen, affecting contraceptive efficacy. Affected Contraception Methods: Combined oral contraceptive pills (COCs) 🚫. Progestin-only pills (POPs) 🚫. Progestin implants (Implanon®) 🚫. Exceptions 🛡️: Mirena® and Depo Provera® not affected by enzyme-inducing drugs.

Answer 199

Recommended Contraception Options 🩺: Progestin-only injectable (e.g., Depo Provera®). Copper-bearing intrauterine devices (Cu-IUDs) 🩸. Levonorgestrel-containing intrauterine system (LNG-IUS) 🪙. Short-Term Enzyme-Inducing Drug Use and POP/Implant 🚑: Additional contraception (e.g., condoms) should be used during enzyme-inducing drug use and 28 days after stopping treatment. Option to switch to DMPA injection during short-term enzyme-inducing drug use. Increased COC Dose 📈: COC users with enzyme-inducing drugs may increase COC dose (≥50mcg ethinyl estradiol) with extended/tricycling regimen. Rifampicin and Rifabutin 🚫: Advising to increase COC dose is inappropriate; an alternative method is needed.

Answer 200

Bacterial Vaginosis (BV) Diagnosis: BV is suspected in the presence of 'fishy-smelling' thin white vaginal discharge 🐟. Diagnostic Criteria (Amsel’s criteria) include: Clue cells on microscopy 👀. Vaginal pH > 4.5 📊. Positive whiff test: Addition of potassium hydroxide to the discharge results in a fishy odor 👃. Bacterial Vaginosis (BV) Treatment: First-line: 7 days of oral metronidazole (400 mg twice daily) or, Second-line: Vaginal clindamycin (1 g at night) 🌙. Cure rates range from 70-90%, but recurrence occurs in over 50% of patients within 6 months of treatment ♻️. Australian national guidelines recommend oral clindamycin or metronidazole for 7 days as preferred treatments (category A and B2) 🇦🇺.

Answer 201

Postpartum GDM Management: Less than 10% of women with GDM remain hyperglycemic after delivery. Ongoing care from a diabetes or medical clinic in collaboration with the general practitioner is required. Recommendations: Check a random blood glucose level the day after delivery 🩸. Perform a 4-point blood glucose level (BGL) measurement on the day prior to discharge, including fasting and two hours post meals for three meals 📊. Cease blood glucose monitoring if BGL is within the normal range. If BGL is elevated (above 10 mmol/L), contact the medical registrar or diabetes educator; after-hours contacts are justified if BGLs are considerably elevated ☎️. Schedule a follow-up oral glucose tolerance test (75 gr) at 6-12 weeks postpartum for women who had GDM, and repeat every 1-2 years thereafter. Provide lifestyle counseling. A summary letter is given to the woman's GP for follow-up care 📝.

Answer 202

Effects of Warfarin Exposure During Pregnancy: Warfarin crosses the placenta and should be avoided throughout pregnancy, especially in the first and third trimesters. Warfarin exposure at 6-12 weeks' gestation results in fetal warfarin syndrome, which includes: Characteristic nasal hypoplasia 👃. Short fingers with hypoplastic nails 🖐️. Calcified epiphyses, specifically chondrodysplasia punctata (visible as stippling of epiphyses on X-ray) 🦴. Intellectual disability 🧠. Low birth weight 👶. The risk of fetal warfarin syndrome in babies of women who require warfarin throughout pregnancy is approximately 5%, and these effects are dose-dependent. Later exposure (after 12 weeks) is associated with central nervous system anomalies like microcephaly, hydrocephalus, agenesis of the corpus callosum, Dandy-Walker malformation, and mental retardation. Eye anomalies can occur, including optic atrophy, microphthalmia, and Peter anomaly. Blindness may be seen in newborns exposed to warfarin in all three trimesters. Perinatal intracranial and other major bleeding can also occur in neonates exposed to warfarin.

Answer 203

Round Ligament Pain: Round ligament pain is a normal finding during pregnancy. It commonly occurs during the second trimester. Symptoms include sharp, often unilateral or bilateral pain in the iliac fossa (lower abdomen) that may radiate to the groin. The pain is sudden-onset, sharp, and spastic, typically lasting for a few seconds. It can be aggravated by activities such as standing, getting off chairs, sneezing, laughing, or rolling in bed. Sudden changes in body position can trigger the pain. Management: Rest and avoiding sudden changes in body position are key to managing round ligament pain during pregnancy. No specific medical interventions are usually required for this condition.

Answer 204

LSIL (CIN 1): Women with low-grade cytologic lesions should be managed similarly to non-pregnant women. Repeat smear after 12 months if previous cervical screening is normal in the past 2-3 years. Refer to a specialist for colposcopy if no recent normal screening. HSIL (CIN 2,3): High-grade squamous intraepithelial lesion (HSIL) (CIN 2,3) requires referral for colposcopy. Colposcopy is safe during pregnancy but may be more challenging. Biopsy may be deferred if invasive cancer is excluded by an experienced colposcopist. Review at 20-24 weeks with cytology and colposcopy if HSIL is diagnosed. Invasive carcinoma: Immediate delivery and treatment if fetal lungs are mature. Initiate therapy if the pregnancy is previable and the patient opts not to continue. Consider disease stage, trimester, and patient preferences for other cases.

Answer 205

If fetal lungs are mature or near maturity, prefer immediate delivery and treatment. Administer antenatal corticosteroid therapy if needed. For previable pregnancies and patient choice not to continue, initiate maternal therapy. Decisions on timing depend on disease stage, trimester, and patient preferences.

Answer 206

Onset of HG is typically at 5-6 weeks of gestation, peaking at 9 weeks and abating by 16-20 weeks (🤰🤢). Symptoms may persist until the third trimester in 15-20% of women and until delivery in 5% (📆). Diagnosis of HG is mainly clinical; investigations are needed to assess the patient's status and exclude other causes (🩺🔍). Initial evaluation includes weight, vital signs, orthostatic blood pressure, serum electrolytes, urine ketones, specific gravity, and urine microscopy and culture (⚖️🩸🧪). Attending to hydration and electrolytes is crucial before further investigations (💧⚡). Obstetric transvaginal ultrasound (option A) checks for trophoblastic disease or multiple gestation (🩺👶). Stool exam and culture (option C) may be considered for suspected gastroenteritis (🩸🦠). Quantitative serum beta HCG (β-HCG) (option D) is less useful for dating errors (📏). Abdominal ultrasound (option E) is inferior to transvaginal ultrasound for female reproductive organs (🩺🔍).

Answer 207

MSAF occurs in 10-15% of labors 🩸 Rare before 30 weeks gestation 📆 Incidence increases with longer gestations (mature fetus) 📈 Approximately 20% of term newborns have MSAF 🤰👶 An intrapartum risk factor for the fetus' well-being 🚼 Indication for continuous cardiotocography (CTG) monitoring 📉📈

Answer 208

Baseline fetal heart rate (FHR) 110-160 bpm ❤️ Variability of FHR 6-25 bpm 📈 Absence of decelerations or presence of early decelerations ⏬ Significance of accelerations unclear 🤔 Allows normal labor progression 🏃‍♀️🤰

Answer 209

Baseline FHR between 100-109 bpm or 161-170 bpm 📉📈 Reduced FHR variability (3-5 bpm for >40 minutes) 📊 Variable decelerations without complicating features 🔄 Absence of accelerations not considered abnormal 🤷‍♀️

Answer 210

Baseline FHR <100 bpm or >170 bpm 📉📈 Absent or <3 bpm FHR variability 📊 Prolonged (>3 minutes), late, or complicated variable decelerations ⏳⏰ Two or more features from non-reassuring CTG present 📉🔄 Requires investigation and potential reversal of causes 🏥🔄

Answer 211

Used to assess fetal well-being during non-reassuring or abnormal CTG 🩸👶 Contraindications: Serious fetal compromise Prolonged deceleration Mobile presenting part Unknown presentation Face presentation Undilated cervix (<3 cm) Active second stage of labor Fetal hereditary bleeding disorders Maternal infection Prematurity (<34 weeks) 🚫🩸🤚

Answer 212

First-line: NSAIDs (inhibit prostaglandin synthesis) 💊🚫 Second-line: Oral contraceptive pills (OCPs) (suppress ovulation, reduce prostaglandin levels) 🆗🩸 If either treatment fails after 2-3 menstrual cycles, consider the other modality 🔄🆗 Combined therapy with hormonal contraceptives and NSAIDs may be effective 🩸💊

Answer 213

Consider secondary dysmenorrhea if treatment fails despite NSAIDs and OCPs 🚫💊 Re-evaluate for possible underlying causes such as endometriosis, leiomyomas, or polyps 🏥🔍 First-line: Abdominal and transvaginal ultrasonography (inexpensive, effective, readily available) 📊🔍 Transvaginal ultrasound preferred if possible for higher accuracy 📏🔍 Transabdominal ultrasound can be used if transvaginal is not possible, e.g., in virgin girls 🧍‍♀️📏 Dilation and curettage or laparoscopy might be indicated later if initial evaluation points towards a specific pathology 🩸🏥

Answer 214

Positive IgM indicates acute infection 🧪 Negative IgG suggests early infection without seroconversion 🩸 Conservative management for symptoms and complications 🤒🩺 Notify cases of measles to public health units 📢 Priority in contact tracing for infants, immunocompromised individuals, and pregnant women 👶🦠🤰

Answer 215

Measles control relies on early diagnosis, notification, and contact tracing 🦠📢 Contacts defined as those sharing the same enclosed air space 🏢🌬️ Prioritize contact tracing in specific settings: Household and communal facilities Educational settings with shared classrooms Shared waiting areas and healthcare facilities Work settings with shared work areas 🏠🏫🏥💼

Answer 216

MMR vaccine used for prevention and post-exposure prophylaxis, not after contracting measles 🚫💉 Contraindicated during pregnancy 🤰 Serologic testing of the fetus not useful due to maternal antibodies crossing the placenta 🩸👶 NHIG used for post-exposure prophylaxis in cases with MMR contraindications 🩸🚫 Repeating measles-specific serologic tests not necessary for established measles diagnosis 🧪🚫

Answer 217

PPROM defined as rupture of membranes before 37 + 0 weeks 🩸👶 Classic presentation: sudden gush of watery fluid or continuous leakage 🌊 Presence of liquor flow from cervical os or pooling in vaginal fornix is pathognomonic 🏊‍♀️

Answer 218

Risks include preterm labor, cord prolapse, placental abruption, chorioamnionitis, fetal pulmonary hypoplasia, limb positioning defects, perinatal mortality 🚑💔

Answer 219

Diagnosis via history, physical exam, fetal monitoring, and speculum vaginal exam 📝🔍 Obtain high and low vaginal swabs and perform nitrazine test 🩸🧫 Consider ultrasound for amniotic fluid volume and fetal well-being 📏🤰 Management includes maternal corticosteroids, antibiotics, and tocolytics if indicated 🚼💉🦠 Transfer to tertiary care facility if necessary 🏥

Answer 220

Indicated between 23+0d and 34+6d weeks if preterm labor a concern 🤰📆 Given if preterm birth planned/expected within 7 days 🚼⏰ Regimens: IM betamethasone (11.4 mg x 2 doses, 24 hrs apart) or IM dexamethasone (12 mg x 2 doses, 24 hrs apart) 📅💉

Answer 221

Antibiotics reduce maternal/fetal infection and delay preterm labor 🦠🚼 Prophylactic choice: erythromycin for 10 days intravenously 🩸💊

Answer 222

Chorioamnionitis feared complication of PPROM 🦠 Clinical diagnosis includes maternal fever and other signs 🌡️ Chorioamnionitis an absolute contraindication to tocolysis 🚫🦠 PPROM in absence of intrauterine infection relatively contraindicated for tocolysis due to difficulty in excluding infections 🤷‍♀️💊

Answer 223

First steps: Reverse potential causes of decelerations 🔄 Maternal hypotension Cord prolapse or compression Uterine hypertonia Scar dehiscence Placental abruption Rapid fetal descent Management of prolonged decelerations or bradycardia includes: Repositioning the woman (e.g., lateral position) Checking maternal blood pressure and IV fluids for hypotension Discontinuing or decreasing oxytocin infusion Differentiating maternal pulse rate from FHR Vaginal exam if indicated for cord prolapse or cervical dilatation Consider fetal scalp electrode Assess abdominal tone for uterine hypertonia Prepare for assisted delivery (vacuum/forceps) or emergency cesarean section if bradycardia persists 🚼🩺💉

Answer 224

Cessation of oxytocin (cyntocinon) infusion is the immediate step 🚫 Check maternal blood pressure for hypotension, and administer IV fluids if needed 💉 Continue CTG monitoring for fetal assessment and response to treatment 📈

Answer 225

Assisted vaginal delivery using forceps or vacuum (options A and B) or emergent cesarean delivery (option E) 🩺🔪 Consider after attempting conservative interventions for prolonged decelerations 🚼🩺

Answer 226

Young women (<25 years) Women older than 25 years with a new partner Women older than 25 year with two or more partners in the last year Women older than 25 years whose regular partner has multiple partner

Answer 227

Apart from routine trauma workup necessary for non-pregnant patients, a minimum 24-hour period of monitoring is recommended for all pregnant women who have sustained trauma if any of the following is present: Regular uterine contractions Vaginal bleeding A non-reassuring fetal heart rate tracing Abdominal/uterine pain Significant trauma to the abdomen

Answer 228

Non-Pharmacological Treatment: Age < 35 Years, BMI > 25: For women in this category with no other suspected cause of infertility, an intensive lifestyle program addressing weight loss is recommended without pharmacological treatment for the first 6 months. Small amounts of weight loss (~5%) may restore menstrual cycle regularity and ovulation, providing benefit even if pharmacological intervention is subsequently required. 🏃‍♀️🥦💪

Answer 229

Pharmacological Treatment: First-Line: If pharmacological treatment is necessary, the first-line option is clomiphene citrate, which has a pregnancy rate of 30-50% after six ovulatory cycles. 💊🤞 BMI < 30-32 kg/m²: For women with a BMI below this range, metformin may have similar efficacy to clomiphene citrate and is the first-line treatment (with or without clomiphene citrate) if there is concomitant impaired glucose tolerance. 📊🥄 Second-Line: If clomiphene citrate, metformin, or their combination is unsuccessful in achieving pregnancy, gonadotropins are the next pharmacological options. 🩸💉 Third-Line: Laparoscopy with ovarian surgery/drilling (LOS) is an appropriate second-line treatment if clomiphene citrate with metformin has failed. The pregnancy rate with LOS is as effective as 3-6 cycles of gonadotropin ovulation induction. 🪄🔍 In Vitro Fertilization (IVF) or Intra-Cytoplasmic Sperm Injection (ICSI): If all previous treatments are unsuccessful or if other factors contribute to infertility, such as endometriosis or male factors, IVF or ICSI is recommended. 👶🧬

Answer 230

suspected subarachnoid hemorrhage (SAH The clinical presentation suggests SAH, which can be a rare complication of pregnancy. To confirm the diagnosis, a non-contrast CT scan of the brain is the preferred initial step. Although CT scanning exposes the fetus to radiation, its benefits usually outweigh the risks, especially when appropriate measures are taken to shield the uterus. CT is more sensitive than MRI in detecting blood and is the primary investigation for intracranial hemorrhage. If the CT scan is inconclusive, lumbar puncture should be considered and performed within 12 hours of symptom onset. 🤰🧠🏥

Answer 231

urner syndrome is characterized by a 45-XO karyotype. Clinical features of Turner syndrome include short stature, a webbed neck, puffy hands and feet, coarctation of the aorta, cardiac abnormalities, high-arched palate, and absent secondary sexual characteristics when puberty is expected. In Turner syndrome, the ovaries consist of small amounts of connective tissue and few or no follicles (streak gonads), while the external genitalia, vagina, uterus, and Fallopian tubes are anatomically normal but fail to function when estrogen-induced maturity should occur. Older adolescents and adults with Turner syndrome often experience issues related to puberty, fertility, and short stature. Adrenarche, the beginning of pubic hair growth, may occur, but it does not indicate that puberty will progress normally. Breast development is usually absent when ovarian failure occurs before puberty, but pubic hair growth can be normal in some cases. Approximately 30% of girls with Turner syndrome have some spontaneous pubertal development, but the condition should be suspected in individuals with primary or secondary amenorrhea and in adult women with unexplained infertility, particularly those with short stature. 🧬🩸🩺👧

Answer 232

Fibrocystic breast changes are characterized by heterogeneous breast tissue, consisting of glands, stroma, and ducts, leading to nonfocal chest pain in women. [Heterogeneous breast tissue 📊, Glands, stroma, ducts, Nonfocal chest pain 💔] Breast tissue proliferation in fibrocystic changes varies with hormonal fluctuations, such as estrogen and progesterone, during the menstrual cycle. [Hormonal fluctuations 🔄, Estrogen, Progesterone] Pre-menopausal and reproductive-age women often experience diffusely nodular breasts and breast pain, typically premenstrual in nature. [Nodular breasts 🤰, Premenstrual breast pain 💢] Management involves reassurance, and symptomatic relief options include nonsteroidal anti-inflammatory drugs (NSAIDs) and/or oral contraceptives. [Reassurance 🤝, NSAIDs 💊, Oral contraceptives 🌡️]

Answer 233

Fetal bradycardia is considered abnormal when it's <100 bpm for more than five minutes or <80 bpm for more than three minutes. 🩺👶💓

Answer 234

Immediate management includes identifying any reversible cause and taking appropriate actions such as maternal repositioning, correcting maternal hypotension, rehydration with intravenous fluids, cessation of oxytocin, tocolysis for excessive uterine activity, and initiating or maintaining continuous cardiotocography (CTG). 🩺👩‍⚕️🚼

Answer 235

All pregnant women need rubella serological testing (IgM/IgG), regardless of history. Immunity = IgG ≥10 IU/ml. After exposure to rubella, the next best step for a pregnant woman is rubella serology testing, with one exception - if the IgG level is equal to or greater than 10 IU/ml during the current pregnancy, the patient can be reassured without further testing. 🩺🤰🧪🔍 IgG testing at the first prenatal visit. IgG ≥10 IU/ml = minimal reinfection risk. If IgG ≤15, administer post-delivery vaccination. 🩺🤰🧪💉

Answer 236

After maternal infection confirmation, antenatal testing should occur at least 6 weeks post-infection, preferably after the 20th week of gestation. If maternal infection happens in the first trimester, it's associated with a high risk of fetal infection and anomalies, making termination of pregnancy a recommended option. Testing should include Rubella PCR, rubella culture, and fetal IgM following chorionic villus sampling (CVS), amniocentesis, or cordocentesis. 🩺🤰🦠🔬

Answer 237

HPV test with partial genotyping every 5 years. 💡 Commence screening at age 25. 💡 Exit test between 70 and 74 years old. 💡 HPV test at any age for cervical cancer symptoms, even with regular screening. 💡

Answer 238

Cervical Screening Test replaces the Pap test. 💡 It detects HPV infection, a common cause of most cervical cancers. 💡 It can identify various HPV types, including high-risk HPV 16 and 18. 💡

Answer 239

Symptomatic patients need diagnostic testing, not screening. 💡 Diagnostic testing includes a co-test and gynecological assessment. 💡 The co-test checks for HPV and liquid-based cytology in a single sample, simultaneously. 💡

Answer 240

If breech persists after 36-37 weeks, try external cephalic version (ECV). 🔄 ECV can be attempted from 36 weeks for nulliparous women and 37 weeks for multiparous women. ⏳ If ECV fails, consider elective caesarean section or vaginal delivery (if no contraindication) after 38.5 weeks. 📅

Answer 241

Pregnancy leads to a hypercoagulable state. 🤰 This results from decreased anticoagulation (proteins C and S) and increased pro-coagulation (factor V and VII) activity. 🩸💉

Answer 242

Pregnant patients with DVT are typically treated with therapeutic doses of low-molecular-weight heparin (LMWH) for 6 months for DVT above the knee and 3 months for DVT below the knee. 🤰💉 Prophylactic LMWH is administered until delivery, and anticoagulation is continued for an additional 6 weeks postpartum. Warfarin may be used after delivery. 🩺📆 LMWH should be switched to unfractionated heparin four weeks before the due date if neuraxial anesthesia is planned to reduce the risk of spinal hematoma. 🚼🩹

Answer 243

For patients experiencing bothersome fluid retention and weight gain as side effects of combined oral contraceptive pills (COCPs), preparations containing drospirenone (Yaz®, Yasmin®) may be suitable. Drospirenone has anti-mineralocorticoid activity, reducing fluid retention and possibly leading to slight weight loss. 🚫💧🏋️‍♀ If a patient is suspected to have polycystic ovarian syndrome (PCOS), a contraceptive containing cyproterone acetate is preferable. 🧬💊

Answer 244

Candidates for fetal fibronectin (fFN) testing should meet the following criteria: Intact fetal membranes 🚼 Cervical dilation less than 3 cm 📏 Gestational age between 22+0d and 34+6d weeks 🗓️ The absence of fetal fibronectin (fFN) in cervical secretions is a very useful negative predictor of imminent birth (negative predictive value for birth within 7 days 97-98%). This means that with a negative test, preterm labor is unlikely, but a positive test does not guarantee that preterm labor will occur 📊📉

Answer 245

Cervical length screening is required at least twice between 14-24 weeks gestation in the following situations to predict preterm labor: Prior preterm birth less than 34 weeks gestation 🤰 Previous cervical cone biopsy 🩺 Women with suspected cervical incompetency 📏 Multiple pregnancies 🍼

Answer 246

fFN is not useful for the prediction of preterm labor if performed earlier than 22 weeks of gestation 📆

Answer 247

- HPV non 16 or 19: repeat