Obs and gyn Flashcards

Question

COCP postpartum

Answer 1

- absolute contraindication UKMEC 4 if breastfeeding <6 weeks postpartum - UKMEC 2 - if breastfeeding 6 weeks - 6 months - Do not use in first 21 days due to venous thromboembolism risk - after day 21 additional contraception should be used for the first 7 days - COCP may reduce breast milk production in lactating women

Answer 2

- can be inserted within 48 hours of childbirth or after 4 weeks

Answer 3

98% effective providing woman is fully breastfeeding (no supplementary feeds), amenorrheic, and less than 6 months postpartum

Answer 4

Less than 12 months between childbirth and conceiving is associated with increased risk of preterm birth, low birth weight, and small for gestational age babies

Answer 5

Pregnancy outside of the uterine cavity

Answer 6

1. Smoking 2. History PID 3. In-vitro fertilisation 4. Gynecologic surgery 5. Current IUD 6. Tubal Ligation 7. Previous ectopic pregnancy

Answer 7

- Varies based on health 1. If hemodynamically unstable - SURGERY 2. Haemodynamically stable (vital signs normal) - no hypertension or tachycardia A. Serial HCG testing (levels should double every 2 days in a normal early pregnancy) ``` B. TV USS Intrauterine pregnancy (visible by weeks 5-6) and excess fluid ```

Answer 8

Indicated if: 1. Hemodynamically stable 2. Diagnosed early 3. HCG declining Perform serial HCG measurements and no additional tings

Answer 9

Methotrexate

Answer 10

Salpingotomy = the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure Salpingectomy - which the affected Fallopian tube is removed,

Answer 11

1. Levonorgestrel 2. Ulipristal 3. Copper IUD

Answer 12

mode of action not fully understood - acts both to stop ovulation and inhibit implantation should be taken as soon as possible - efficacy decreases with time must be taken within 72 hours of unprotected sexual intercourse (UPSI)* single dose of levonorgestrel 1.5mg (a progesterone) the dose should be doubled for those with a BMI >26 or weight over 70kg 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 3 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception

Answer 13

a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Answer 14

a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are must be inserted within 5 days of UPSI, or if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date may inhibit fertilisation or implantation prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection is 99% effective regardless of where it is used in the cycle may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Answer 15

Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage. Risk factors previous caesarean section placenta praevia Strictly speaking, there are 3 different types of placenta accreta, depending on the degree of invasion although this is quite small print: accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis increta: chorionic villi invade into the myometrium percreta: chorionic villi invade through the perimetrium

Answer 16

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Answer 17

gonadal dysgenesis (e.g. Turner's syndrome) - the most common causes testicular feminisation congenital malformations of the genital tract functional hypothalamic amenorrhoea (e.g. secondary to anorexia) congenital adrenal hyperplasia imperforate hymen

Answer 18

hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis* Sheehan's syndrome Asherman's syndrome (intrauterine adhesions)

Answer 19

Key points two registered medical practitioners must sign a legal document (in an emergency only one is needed) only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

Answer 20

less than 9 weeks: mifepristone (an anti-progestogen, often referred to as RU486) followed 48 hours later by prostaglandins to stimulate uterine contractions less than 13 weeks: surgical dilation and suction of uterine contents more than 15 weeks: surgical dilation and evacuation of uterine contents or late medical abortion (induces 'mini-labour')

Answer 21

Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

Answer 22

Oral mifepristone, followed by vaginal misoprostol. Mifepristone is a progestogen antagonist that is used to ripen the cervix for medical termination of pregnancy and sensitise the myometrium to prostaglandin analogues. Misoprostol is a uterotonic prostaglandin analogue that initiates expulsion of pregnancy tissue, given 48 hours after mifepristone. Misoprostol may have to be given multiple times to ensure adequate expulsion of pregnancy tissue from the uterus. Mifepristone is only licensed for oral use in medical termination of pregnancy, while misoprostol may be given orally, sublingually, or vaginally.

Answer 23

- New-onset hypertension of >140/90 mmHg after 20 weeks and 1 of the following - Proteinuria - Other organ involvement (e.g. renal insufficiency (creatinine > or = 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction)

Answer 24

eclampsia other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata fetal complications intrauterine growth retardation prematurity liver involvement (elevated transaminases) haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure

Answer 25

hypertension: typically > 160/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 26

Women with the following should take aspirin 75-150 mg daily from 12 weeks gestation until the birth ≥ 1 high risk factors ≥ 2 moderate factors High risk: - hypertensive disease in a previous pregnancy - chronic kidney disease - autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome - type 1 or type 2 diabetes - chronic hypertension Moderate risk: - first pregnancy - age 40 years or older - pregnancy interval of more than 10 years - body mass index (BMI) of 35 kg/m² or more at first visit - family history of pre-eclampsia multiple pregnancy

Answer 27

Initial assessment - NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected - Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed Further management - oral labetalol is now first-line following the 2010 NICE guidelines. - Nifedipine (e.g. if asthmatic) and hydralazine may also be used Delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 28

Group B Streptococcus (GBS) is the most common cause of early-onset severe infection in the neonatal period. It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as 'carriers' of GBS. Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.

Answer 29

prematurity prolonged rupture of the membranes previous sibling GBS infection maternal pyrexia e.g. secondary to chorioamnionitis

Answer 30

The Royal College of Obstetricians and Gynaecologists (RCOG) published guidelines on GBS in 2017. The main points are as follows: universal screening for GBS should not be offered to all women the guidelines also state a maternal request is not an indication for screening women who've had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date IAP should be offered to women with a previous baby with early- or late-onset GBS disease IAP should be offered to women in preterm labour regardless of their GBS status women with a pyrexia during labour (>38ºC) should also be given IAP benzylpenicillin is the antibiotic of choice for GBS prophylaxis

Answer 31

Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years. Associations more common in Afro-Caribbean women rare before puberty, develop in response to oestrogen

Answer 32

may be asymptomatic menorrhagia may result in iron-deficiency anaemia lower abdominal pain: cramping pains, often during menstruation bloating urinary symptoms, e.g. frequency, may occur with larger fibroids subfertility rare features: polycythaemia secondary to autonomous production of erythropoietin

Answer 33

Transvaginal USS

Answer 34

Asymptomatic fibroids no treatment is needed other than periodic review to monitor size and growth Management of menorrhagia secondary to fibroids levonorgestrel intrauterine system (LNG-IUS) useful if the woman also requires contraception cannot be used if there is distortion of the uterine cavity NSAIDs e.g. mefenamic acid tranexamic acid combined oral contraceptive pill oral progestogen injectable progestogen Treatment to shrink/remove fibroids medical GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment ulipristal acetate has been in the past but not currently due to concerns about rare but serious liver toxicity surgical myomectomy: this may be performed abdominally, laparoscopically or hysteroscopically hysteroscopic endometrial ablation hysterectomy uterine artery embolization

Answer 35

Involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.

Answer 36

nausea breast tenderness fluid retention and weight gain

Answer 37

increased risk of breast cancer increased by the addition of a progestogen in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer the increased risk relates to the duration of use the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT increased risk of endometrial cancer oestrogen by itself should not be given as HRT to women with a womb reduced by the addition of a progestogen but not eliminated completely the BNF states that the additional risk is eliminated if a progestogen is given continuously increased risk of venous thromboembolism increased by the addition of a progestogen transdermal HRT does not appear to increase the risk of VTE NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal) increased risk of stroke increased risk of ischaemic heart disease if taken more than 10 years after menopause

Answer 38

Depo Provera is the main injectable contraceptive used in the UK*. It contains medroxyprogesterone acetate 150mg. It is given via in intramuscular injection every 12 weeks. It can however be given up to 14 weeks after the last dose without the need for extra precautions** The main method of action is by inhibiting ovulation. Secondary effects include cervical mucus thickening and endometrial thinning. Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months) Adverse effects irregular bleeding weight gain may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable not quickly reversible and fertility may return after a varying time Contraindications breast cancer: current breast cancer is UKMEC 4, past breast cancer is UKMEC 3

Answer 39

Urinary incontinence (UI) is a common problem, affecting around 4-5% of the population. It is more common in elderly females. ``` Risk factors advancing age previous pregnancy and childbirth high body mass index hysterectomy family history ```

Answer 40

- Frequency and urgency | - due to detrusor overactivity

Answer 41

- leaking small amounts when coughing or laughing

Answer 42

Both urge and stress

Answer 43

due to bladder outlet obstruction, e.g. due to prostate enlargement

Answer 44

comorbid physical conditions impair the patient’s ability to get to a bathroom in time causes include dementia, sedating medication and injury/illness resulting in decreased ambulation

Answer 45

bladder diaries should be completed for a minimum of 3 days vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) urine dipstick and culture urodynamic studies

Answer 46

bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: antimuscarinics are first-line NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation) Immediate release oxybutynin should, however, be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

Answer 47

pelvic floor muscle training NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months surgical procedures: e.g. retropubic mid-urethral tape procedures duloxetine may be offered to women if they decline surgical procedures a combined noradrenaline and serotonin reuptake inhibitor mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced

Answer 48

ABRUPTION A - Abruption previously B - Blood pressure (hypertension or pre-eclempsia) R- Ruptured membranes, either premature or prolonged U for Uterine injury (Trauma to abdomen) P for Polyhydramnios T for Twins or multiple pregnancies I for Infection (to uterus, especially chorioamionitis) O for old age (35 and older) N for Narcotic us (smoking, cocaine, amphetamines)

Answer 49

Common causes: - physiological - Candida - Trichomonas vaginalis - bacterial vaginosis Less common causes: - Gonorrhea - Chlamydia - ectropion - foreign body - cervical cancer

Answer 50

Trichomonas vaginalis

Answer 51

Bacterial vaginosis

Answer 52

'You can provide contraceptive, abortion and STI advice and treatment, without parental knowledge or consent, to young people under 16 provided that: They understand all aspects of the advice and its implications You cannot persuade the young person to tell their parents or to allow you to tell them In relation to contraception and STIs, the young person is very likely to have sex with or without such treatment Their physical or mental health is likely to suffer unless they receive such advice or treatment, and It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent You should keep consultations confidential even if you decide not to provide advice or treatment (for example, if your patient does not understand your advice or the implications of treatment).' In this question, the young girl fulfils the Frazer guidelines, thus you should prescribe her the pill. So answers 2, 3 and 5 are clearly wrong. This leaves us with answer 1 and 4.In answer 4 this involves breaking confidentiality, which the GMC guidelines states we should not do. This leaves us with the correct answer - 1.

Answer 53

Occurs in the last 4 weeks of pregnancy Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.

Answer 54

Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours. Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Answer 55

Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year. ``` Other than age, risk factors include: Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus ``` Features lump or ulcer on the labia majora inguinal lymphadenopathy may be associated with itching, irritation

Answer 56

Placenta abruption presents with painful vaginal bleeding whereas placenta praevia is usually painless A woody, hard uterus may be palpable in placenta abruptio - this is because retroplacental blood tracks into the myometrium. The fetal heart is often absent and the woman may be shocked. Resuscitation is vital in these cases and the baby will need urgent delivery when stable. There is an increased risk of postpartum haemorrhage.

Answer 57

protective against ovarian and endometrial cancer | increased risk of breast and cervical cancer

Answer 58

Shoulder dystocia is a complication of vaginal cephalic delivery. It entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered. It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis. Shoulder dystocia is a cause of both maternal and fetal morbidity. ``` Key risk factors fetal macrosomia (hence association with maternal diabetes mellitus) high maternal body mass index diabetes mellitus prolonged labour ```

Answer 59

Senior help should be called as soon as shoulder dystocia is identified and McRoberts' manoeuvre should be performed: this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery. An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options. Oxytocin administration is not indicated in shoulder dystocia.

Answer 60

mode of action not fully understood - acts both to stop ovulation and inhibit implantation should be taken as soon as possible - efficacy decreases with time must be taken within 72 hours of unprotected sexual intercourse (UPSI)* single dose of levonorgestrel 1.5mg (a progesterone) the dose should be doubled for those with a BMI >26 or weight over 70kg 84% effective is used within 72 hours of UPSI levonorgestrel is safe and well-tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1% if vomiting occurs within 3 hours then the dose should be repeated can be used more than once in a menstrual cycle if clinically indicated hormonal contraception can be started immediately after using levornogestrel (Levonelle) for emergency contraception

Answer 61

a selective progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation 30mg oral dose taken as soon as possible, no later than 120 hours after intercourse concomitant use with levonorgestrel is not recommended Ulipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods should be used during this period caution should be exercised in patients with severe asthma repeated dosing within the same menstrual cycle was previously not recommended - however, this has now changed and ulipristal can be used more than once in the same cycle breastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Answer 62

a copper IUD is the most effective method of emergency contraception and should be offered to all women if they meet the criteria if the criteria for insertion of a copper IUD are not met or is not acceptable to the woman, oral emergency contraception should be considered in practice the vast majority of women choose oral emergency contraception, but it is important to offer the choice to all women given how effective copper IUDs are must be inserted within 5 days of UPSI, or if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date may inhibit fertilisation or implantation prophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infection is 99% effective regardless of where it is used in the cycle may be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Answer 63

Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) affects around 1% of pregnancies in the UK. It is associated with an increased risk of premature birth. Features pruritus - may be intense - typical worse palms, soles and abdomen clinically detectable jaundice occurs in around 20% of patients raised bilirubin is seen in > 90% of cases Management induction of labour at 37-38 weeks is common practice but may not be evidence based ursodeoxycholic acid - again widely used but evidence base not clear vitamin K supplementation Recurrence of intrahepatic cholestasis of pregnancy is 45-90% in subsequent pregnancies.

Answer 64

Features vaginal bleeding uterus size greater than expected for gestational age abnormally high serum hCG ultrasound: 'snow storm' appearance of mixed echogenicity

Answer 65

foetus is asleep. However, if the decreased variability lasts for more than 40 minutes, we start to worry. Other causes of decreased variability in foetal heart rate on CTG are due to maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol), foetal acidosis (usually due to hypoxia), prematurity (< 28 weeks, which is not the case here), foetal tachycardia (> 140 bpm, again not the case here) and congenital heart abnormalities.

Answer 66

FHR monitored every 15min (or continuously via CTG) Contractions assessed every 30min Maternal pulse rate assessed every 60min Maternal BP and temp should be checked every 4 hours VE should be offered every 4 hours to check progression of labour Maternal urine should be checked for ketones and protein every 4 hours

Answer 67

Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following: should be given once a decision to deliver has been made in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum) Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload

Answer 68

Vaginal candidiasis ('thrush') is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species. ``` The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop: diabetes mellitus drugs: antibiotics, steroids pregnancy immunosuppression: HIV ```

Answer 69

Features 'cottage cheese', non-offensive discharge vulvitis: superficial dyspareunia, dysuria itch vulval erythema, fissuring, satellite lesions may be seen

Answer 70

Management options include local or oral treatment local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat) oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Answer 71

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year compliance with previous treatment should be checked confirm the diagnosis of candidiasis high vaginal swab for microscopy and culture consider a blood glucose test to exclude diabetes exclude differential diagnoses such as lichen sclerosus consider the use of an induction-maintenance regime induction: oral fluconazole every 3 days for 3 doses maintenance: oral fluconazole weekly for 6 months

Answer 72

should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.

Answer 73

Indications prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery prelabour premature rupture of the membranes, where labour does not start diabetic mother > 38 weeks pre-eclampsia rhesus incompatibility

Answer 74

is classically seen in post-menopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection

Answer 75

``` obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma ```

Answer 76

postmenopausal bleeding is the classic symptom premenopausal women may have a change intermenstrual bleeding pain and discharge are unusual features

Answer 77

Indications: Low b HCG, no symptoms, tubal ectopic pregnancy measuring less than 35 mm with no heartbeat

Answer 78

The National Institute for Health and Care Excellence (NICE) states that if a woman has a small (<35mm) unruptured ectopic pregnancy with no visible heartbeat, a serum B-hCG level of <1500 IU/L, no intrauterine pregnancy and no pain, then first line treatment should be with methotrexate as long as the patient is willing to attend for follow-up.

Answer 79

antimetabolite chemotherapeutic drug. It interferes with DNA synthesis and disrupts cell multiplication thus preventing the pregnancy from developing.

Answer 80

laparoscopic salpingectomy (or salpingotomy where there is risk of infertility). This should be offered where the ectopic is larger than 35mm, is causing severe pain or if the B-hCG level is >1500. There is a risk of infertility if a problem arises with the remaining Fallopian tube in the future.

Answer 81

First trimester <110 g/L Second/third <105 g/L Postpartum <100 g/L Management: oral ferrous sulfate or ferrous fumarate treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished

Answer 82

New-onset blood pressure of >140/90 mmHg after 20 weeks of pregnancy, AND 1 of the following: - proteinuria - organ involvement (renal insufficiency (creatinine >90 umol/L), liver, neurological, haematological, uteroplacental dysfunction)

Answer 83

eclampsia other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata fetal complications intrauterine growth retardation prematurity liver involvement (elevated transaminases) haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure

Answer 84

hypertension: typically > 160/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 85

hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension

Answer 86

``` first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy ```

Answer 87

women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth ≥ 1 high risk factors ≥ 2 moderate factors

Answer 88

NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Answer 89

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Answer 90

the combined test is now standard nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A) these tests should be done between 11 - 13+6 weeks Down's syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower if women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks triple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A

Answer 91

A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnancies along with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system around 15% of mothers are rhesus negative (Rh -ve) if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur this causes anti-D IgG antibodies to form in mother in later pregnancies these can cross placenta and cause haemolysis in fetus this can also occur in the first pregnancy due to leaks

Answer 92

test for D antibodies in all Rh -ve mothers at booking NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks the evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors' anti-D is prophylaxis - once sensitization has occurred it is irreversible if event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present

Answer 93

Ovarian cancer is the fifth most common malignancy in females. The peak age of incidence is 60 years and it generally carries a poor prognosis due to late diagnosis. Pathophysiology around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas interestingly, it is now increasingly recognised that the distal end of the fallopian tube is often the site of origin of many 'ovarian' cancers Risk factors family history: mutations of the BRCA1 or the BRCA2 gene many ovulations*: early menarche, late menopause, nulliparity ``` Clinical features are notoriously vague abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea ``` Investigations CA125 NICE recommends a CA125 test is done initially. Endometriosis, menstruation, benign ovarian cysts and other conditions may also raise the CA125 level if the CA125 is raised (35 IU/mL or greater) then an urgent ultrasound scan of the abdomen and pelvis should be ordered a CA125 should not be used for screening for ovarian cancer in asymptomatic women ultrasound Diagnosis is difficult and usually involves diagnostic laparotomy Management usually a combination of surgery and platinum-based chemotherapy Prognosis 80% of women have advanced disease at presentation the all stage 5-year survival is 46% *It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. Recent evidence however suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

Answer 94

1. US findings 2. Menopausal status 3. CA125 levels

Answer 95

If 1 pill is missed (at any time in the cycle) take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day no additional contraceptive protection needed f 2 or more pills missed take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed' if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception* if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval *theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off

Answer 96

Cholestasis of pregnancy - severe pruritis Acute fatty liver of pregnancy has predominantly non-specific symptoms (e.g. malaise, fatigue, nausea).

Answer 97

- generally seen in third trimester - most common liver disease in pregnancy - Features: Pruritus, no rash, raised bilirubin

Answer 98

- ursodeoxycholic acid - LFT monitoring weekly - Women typically induced at 37 weeks - Increased rate of stillbirth

Answer 99

Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery. ``` Features abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia ``` ALT is typically elevated to 500 u/l

Answer 100

- support care | - once stabilised delivery is the definitive management

Answer 101

Haemolysis Elevated Liver enzymes Low Platelets

Answer 102

Conservative: Asymptomatic - no treament needed - perioidc review to monitor size and growth Managemet of menorrhagia secondary to fibroids: - levonorgestrel intrauterine system (LNG-IUS) (useful if women also requires contraception - cannot be used if distortion in uterine cavity) - NSAIDS (mefenamic acid) - tranexamic acid - COCP - Oral progesterone - Injectable progesterone Treatment to shrink fibroids: - Medical GnRH agonists to reduce the size of the fibroids shrt-term ``` - Surgical Myomectomy Hysteroscopic endometrial ablation Hysterectomy Uterine artery embolisation ```

Answer 103

Fibroids generally regress after the menopause. Some of the complications such as subfertility and iron-deficiency anaemia have been mentioned previously. Other complications red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Answer 104

Features vaginal bleeding uterus size greater than expected for gestational age abnormally high serum hCG ultrasound: 'snow storm' appearance of mixed echogenicity

Answer 105

The following results would be expected in a trisomy 21 (Down's syndrome) pregnancy: Low alpha fetoprotein (AFP) Low oestriol High human chorionic gonadotrophin beta-subunit (-HCG) Low pregnancy-associated plasma protein A (PAPP-A) Thickened nuchal translucency

Answer 106

surface derived tumours germ cell tumours sex cord-stromal tumours metastasis

Answer 107

These account for around 65% of ovarian tumours, including the greatest number of malignant tumours. Serous cystadenoma

Answer 108

- involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms. Side-effects nausea breast tenderness fluid retention and weight gain

Answer 109

Potential complications increased risk of breast cancer increased by the addition of a progestogen in the Women's Health Initiative (WHI) study there was a relative risk of 1.26 at 5 years of developing breast cancer the increased risk relates to the duration of use the risk of breast cancer begins to decline when HRT is stopped and by 5 years it reaches the same level as in women who have never taken HRT increased risk of endometrial cancer oestrogen by itself should not be given as HRT to women with a womb reduced by the addition of a progestogen but not eliminated completely the BNF states that the additional risk is eliminated if a progestogen is given continuously increased risk of venous thromboembolism increased by the addition of a progestogen transdermal HRT does not appear to increase the risk of VTE NICE state women requesting HRT who are at high risk for VTE should be referred to haematology before starting any treatment (even transdermal) increased risk of stroke increased risk of ischaemic heart disease if taken more than 10 years after menopause

Answer 110

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Answer 111

gonadal dysgenesis (e.g. Turner's syndrome) - the most common causes testicular feminisation congenital malformations of the genital tract functional hypothalamic amenorrhoea (e.g. secondary to anorexia) congenital adrenal hyperplasia imperforate hymen

Answer 112

hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis* Sheehan's syndrome Asherman's syndrome (intrauterine adhesions)

Answer 113

Initial investigations exclude pregnancy with urinary or serum bHCG full blood count, urea & electrolytes, coeliac screen, thyroid function tests gonadotrophins low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) raised if gonadal dysgenesis (e.g. Turner's syndrome) prolactin androgen levels raised levels may be seen in PCOS oestradiol Management primary amenorrhoea: investigate and treat any underlying cause with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner's syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC) secondary amenorrhoea exclude pregnancy, lactation, and menopause (in women 40 years of age or older) treat the underlying cause *hypothyroidism may also cause amenorrhoea

Answer 114

Asherman's syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.

Answer 115

Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock. ``` Features may include: agalactorrhoea amenorrhoea symptoms of hypothyroidism symptoms of hypoadrenalism ```

Answer 116

For many women, the cause of irregular or absent menstruation is functional hypothalamic amenorrhea (FHA). FHA is a hormonal imbalance related to stress, exercising too much or consuming too few calories (like with an eating disorder).

Answer 117

Congenital adrenal hyperplasia (CAH) refers to a group of genetic disorders that affect the adrenal glands, a pair of walnut-sized organs above the kidneys. The adrenal glands produce important hormones, including: Cortisol, which regulates the body's response to illness or stress.

Answer 118

Polycystic ovarian syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age. Management is complicated and problem based partly because the aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.

Answer 119

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix The term cervical erosion is used less commonly now This may result in the following features vaginal discharge post-coital bleeding

Answer 120

The incidence of multiple pregnancies is as follows twins: 1/105 triplets: 1/10,000 Twins may be dizygotic (non-identical, develop from two separate ova that were fertilized at the same time) or monozygotic (identical, develop from a single ovum which has divided to form two embryos). Around 80% of twins are dizygotic Monoamniotic monozygotic twins are associated with: increased spontaneous miscarriage, perinatal mortality rate increased malformations, IUGR, prematurity twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels) The rate of monozygotic twins is fairly constant. The incidence of dizygotic twins is increasing mainly due to infertility treatment. Predisposing factors for dizygotic twins include: previous twins family history increasing maternal age multigravida induced ovulation and in-vitro fertilisation race e.g. Afro-Caribbean ``` Antenatal complications polyhydramnios pregnancy induced hypertension anaemia antepartum haemorrhage ``` Fetal complications - perinatal mortality (twins * 5, triplets * 10) prematurity (mean twins = 37 weeks, triplets = 33) light-for date babies malformation (*3, especially monozygotic) Labour complications PPH increased (*2) malpresentation cord prolapse, entanglement Management rest ultrasound for diagnosis + monthly checks additional iron + folate more antenatal care (e.g. weekly > 30 weeks) precautions at labour (e.g. 2 obstetricians present) 75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks

Answer 121

Premature ovarian failure can be diagnosed in women less than 40 years of age with menopausal like symptoms and increased levels of FSH measured twice with at least a month between measurements. There are numerous causes, it can be inherited such as in cases of fragile X syndrome or acquired for example from radiation exposure. In premature ovarian failure, the pituitary responds to low levels of oestrogen by increasing the production of gonadotropins in an attempt to stimulate the production of oestradiol in the ovary but fails to do so. Caroline's case does not display these features.

Answer 122

Pregnancy is a risk factor for developing venous thromboembolism (VTE). By assessing a womans individual risk during pregnancy then appropriate prophylactic measures can be initiated. A risk assessment should be completed at booking and on any subsequent hospital admission. A woman with a previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts. A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin. ``` The assessment at booking should include risk factors that increase the womans likelihood of developing VTE. These risk factors include: Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy ``` Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal. If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy. Direct Oral Anticoagulants (DOACs) and warfarin should be avoided in pregnancy.

Answer 123

Whilst the majority of women experience nausea (previously termed 'morning sickness') during the early stages of pregnancy it can become problematic in a minority of cases. The Royal College of Obstetricians and Gynaecologists (RCOG) now use the term 'nausea and vomiting of pregnancy' (NVP) to describe troublesome symptoms, with hyperemesis gravidarum being the extreme form of this condition. It occurs in around 1% of pregnancies and is thought to be related to raised beta hCG levels. Hyperemesis gravidarum is most common between 8 and 12 weeks but may persist up to 20 weeks*. ``` Associations multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity ``` Smoking is associated with a decreased incidence of hyperemesis.

Answer 124

Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

Answer 125

- sudden onset unilateral pelvic pain precipitated by intercourse or strenuous activity

Answer 126

Generally women can feel their babies move around 18-20 weeks, but this can be earlier especially in multiparous women. Reduced fetal movements can be a worrying sign of fetal distress and hypoxia. While singular episodes can often be harmless, they can also be an indication of stillbirths and restricted growth. Absent movements is very concerning and requires further investigation. The 24 week cut off is set by the Royal College of Obstetricians and Gynaecologists (RCOG).

Answer 127

Fetal movements are usually based solely on maternal perception, though it can also be objectively assessed using handheld Doppler or ultrasonography. As per RCOG Green-top guidelines, investigations are dependent of gestation at onset of RFM. If past 28 weeks gestation: Initially, handheld Doppler should be used to confirm fetal heartbeat. If no fetal heartbeat detectable, immediate ultrasound should be offered. If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used. Ultrasound assessment should include abdominal circumference or estimated fetal weight (to exclude SGA), and amniotic fluid volume measurement If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat. If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used. If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit. If RFM are recurrent, further investigations are also required to consider structural or genetic fetal abnormalities.

Answer 128

UNOPPOSED OESTROGEN INCREASES RISK OF ENDOMETRIAL CANCER

Answer 129

``` Pregnant women with GDM should be advised to maintain their CBGs below the following target levels: fasting: 5.3mmol/L AND 1 hour postprandial: 7.8 mmol/L or 2 hours postprandial: 6.4 mmol/L ``` If these targets are not met with diet, exercise and metformin, then insulin should be offered as add-on therapy.

Answer 130

The advice from the Faculty of Sexual and Reproductive Healthcare (FSRH) has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol If 1 pill is missed (at any time in the cycle) take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day no additional contraceptive protection needed If 2 or more pills missed take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day the women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed' if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1 if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception* if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 131

The bleeding associated with placenta praevia is painless and usually bright red. Meanwhile the bleeding associated with placental abruption is associated with pain and is usually dark red. The pattern of previous bleeding also favours placenta praevia. Though vasa praevia can also present with painless vaginal bleeding other expected features would include fetal bradycardia and membrane rupture.

Answer 132

Haemolysis, elevated liver enzymes and low platelets

Answer 133

Around 80% of vulval cancers are squamous cell carcinomas. Most cases occur in women over the age of 65 years. Vulval cancer is relatively rare with only around 1,200 cases diagnosed in the UK each year. ``` Other than age, risk factors include: Human papilloma virus (HPV) infection Vulval intraepithelial neoplasia (VIN) Immunosuppression Lichen sclerosus ``` Features lump or ulcer on the labia majora inguinal lymphadenopathy may be associated with itching, irritation

Answer 134

The history of tearing pain and haemodynamic compromise in a women of child bearing years should prompt a diagnosis of ectopic pregnancy.

Answer 135

Tamoxifen Endometrial hyperplasia develops due to the presence of unopposed oestrogen. Oestrogen stimulates endometrial growth while progesterone stimulates shedding of this tissue. Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.

Answer 136

Endometrial hyperplasia may be defined as an abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer ``` Types simple complex simple atypical complex atypical ``` Features abnormal vaginal bleeding e.g. intermenstrual Management simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used atypia: hysterectomy is usually advised

Answer 137

Common long term complications of vaginal hysterectomy with antero-posterior repair include enterocoele and vaginal vault prolapse. Urinary retention may occur acutely following hysterectomy, but it is not usually a chronic complication.

Answer 138

increased risk of breast and cervical cancer | protective against ovarian and endometrial cancer

Answer 139

Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours. Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Answer 140

Follicular cysts commonest type of ovarian cyst due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle commonly regress after several menstrual cycles Corpus luteum cyst during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst more likely to present with intraperitoneal bleeding than follicular cysts

Answer 141

Dermoid cyst also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth most common benign ovarian tumour in woman under the age of 30 years median age of diagnosis is 30 years old bilateral in 10-20% usually asymptomatic. Torsion is more likely than with other ovarian tumours

Answer 142

Arise from the ovarian surface epithelium Serous cystadenoma the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) bilateral in around 20% Mucinous cystadenoma second most common benign epithelial tumour they are typically large and may become massive if ruptures may cause pseudomyxoma peritonei

Answer 143

Transdermal HRT does not appear to increase the risk of VTE (vs. oral)

Answer 144

``` The following drugs should be avoided: antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone ```

Answer 145

Ovulation disorders are the cause of infertility in approximately one-quarter of couples who have difficulty conceiving naturally, and whilst ovulation may occur sometimes, natural spontaneous conception is usually unlikely. Therefore, for these couples, ovulation induction is often required and will typically depend on the cause of anovulation in the first place.

Answer 146

The early follicular phase requires an increase in gonadotropin-releasing hormone (GnRH) pulse frequency which increases the release of follicle-stimulating hormone (FSH) and luteinising hormone (LH), to allow for stimulation and development of multiple ovarian follicles, and usually only one of which will become the dominant ovulatory follicle in that menstrual cycle. In the mid-follicular phase, FSH gradually stimulates estradiol production, following which estradiol itself produces a negative feedback loop on the hypothalamus and pituitary gland to suppress FSH and LH concentrations. In the luteal phase, there is a unique switch from negative to positive feedback of estradiol, resulting in a surge of LH secretion and this leads to subsequent follicular rupture and ovulation.

Answer 147

``` Before understanding the process of ovulation induction, it is paramount to understand the main causes of ovulatory dysfunction first There are three main categories of anovulation: Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women) Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases) Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive ```

Answer 148

It is ideal to start with the least invasive and simplest management option first, and work the way up to more complicated and intensive treatment For most women, it is the goal to induce mono-follicular development and subsequent ovulation as opposed to multi-follicular development, and this is to ultimately lead to a singleton pregnancy, which tends to be far lower risk and therefore preferable

Answer 149

Exercise and weight loss Typically this is the first-line treatment for patients with polycystic ovarian syndrome, as ovulation can spontaneously return with even a modest 5% weight loss Therefore, particularly for overweight or obese women with polycystic ovarian syndrome, this should be trialled solely first, and then artificial ovulation induction be considered Letrozole According to UptoDate, this is now considered the first-line medical therapy for patients with PCOS, due to the reduced risk of adverse effects on endometrial and cervical mucous compared to clomiphene citrate Mechanism of action: letrozole is an aromatase inhibitor, reducing the negative feedback caused by estrogens to the pituitary gland, therefore increasing the amount of follicle-stimulating hormone (FSH) production and promoting follicular development The rate of mono-follicular development is much higher with letrozole use compared to clomiphene, which is a key goal in ovulation induction Side effects: fatigue (20%), dizziness (10%) Clomiphene citrate While most women with PCOS will respond to clomiphene treatment and ovulate (80% of women), the rates of live birth are higher with letrozole therapy, hence why it has become a first-line treatment instead Mechanism of action: clomiphene is a selective estrogen receptor modulator (also known as SERMs), which acts primarily at the hypothalamus, blocking the negative feedback effect of estrogens. This subsequently leads to an increase in gonadotropin-releasing hormone (GnRH) pulse frequency and therefore FSH and LH production, stimulating ovarian follicular development Side effects: hot flushes (30%), abdominal distention and pain (5%), nausea and vomiting (2%) ``` Gonadotropin therapy This tends to be the treatment used mostly for women with class 1 ovulatory dysfunction, notably women with hypogonadotropic hypogonadism For women with PCOS, this tends to be only considered after attempt with other treatments has been unsuccessful, usually after weight loss, letrozole and clomiphene trial This is because the risk of multi-follicular development and subsequent multiple pregnancy is much higher, as well as increased risk of ovarian hyperstimulation syndrome Mechanism of action: pulsatile GnRH therapy involves administration of GnRH via an intravenous (or less frequently, subcutaneous) infusion pump, leading to endogenous production of FSH and LH and subsequent follicular development ```

Answer 150

Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction, and unfortunately can be life-threatening if not identified and managed promptly In OHSS, ovarian enlargement with multiple cystic spaces form, and an increase in the permeability of capillaries leads to a fluid shift from the intravascular to the extra-vascular space, which has the potential to result in multiple life-threatening complications including: Hypovolaemic shock Acute renal failure Venous or arterial thromboembolism This is a rare side effect which varies in severity, with the risk of severe OHSS occurring in less than 1% of all women undergoing ovarian induction Depending on the severity, the management includes: Fluid and electrolyte replacement Anti-coagulation therapy Abdominal ascitic paracentesis Pregnancy termination to prevent further hormonal imbalances

Answer 151

Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery. ``` Causes: endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism ``` Management if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 152

Combined oral contraceptive pill increased risk of breast and cervical cancer protective against ovarian and endometrial cancer

Answer 153

``` Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus ```

Obs and gyn Flashcards

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