Obs and Gynae

Question 1

Name 3 hormones that are important in pregnancy

Answer 1

1. hCG
2. Progestins
3. Oestrogens
   - hPL, Prolactin, Oxytocin also important

Question 2

Where is hCG produced?

Answer 2

The trophoblast

Question 3

Give 2 functions of hCG

Answer 3

1. It signals the presence of the blastocyst

2. It prevents the corpus luteum from dying (luteal regression)

Question 4

Where are progestins produced?

Answer 4

Initially from the corpus luteum and then from the placenta from week 7

Question 5

Give 3 functions fo progestins

Answer 5

1. Prepares the endometrium for implantation
2. Promotes myometrial quiescence
3. Increases maternal ventilation

Question 6

How do progestins prepare the endometrium for implantation?

Answer 6

Stimulate the proliferation of cells, vascularisation and the differentiation of endometrial stroma

Question 7

Where are oestrogen produced?

Answer 7

Initially in the ovary and then from a combination of fetal and maternal sources

Question 8

Give 2 functions of oestrogens in pregnancy

Answer 8

1. Promotes uterine blood flow, myocetrial growth and cervical softening
2. Increases sensitivity and expression of myocetrial oxytocin receptors
3. Increases water renovation and protein synthesis
4. Increases breast and nipple growth
5. Promotes a change in the cardiovascular system

Question 9

What is the main oestrogen in pregnancy?

Answer 9

E3 = indicates fetal wellbeing

Question 10

What is the role of E2 in pregnancy?

Answer 10

Responsible for proliferation of the endometrial epithelium and it also facilitates progesterone action

Question 11

What is the role of human placental lactose (hPL)?

Answer 11

1. Mobilises glucose from fat
2. Acts as an insulin antagonist
3. Converts mammary glands into milk secreting tissues

Question 12

Where is prolactin produced?

Answer 12

Anterior pituitary gland

Question 13

What is the role of prolactin?

Answer 13

Responsible for milk production

Question 14

Where is oxytocin produced?

Answer 14

Posterior pituitary gland

Question 15

What is the role of oxytocin?

Answer 15

Responsible for uterine contractions and milk secretion

Question 16

Where are FSH and LH produced?

Answer 16

Anterior pituitary gland

Question 17

What is the main basis of the HPG axis?

Answer 17

Hypothalamus releases GnRH that acts on the anterior pituitary gland
Anterior pituitary release FSH and LH that act on the ovaries
Ovaries produce oestrogens and androgens

Question 18

What cells in the ovaries does FSH act on?

Answer 18

Granuloma cells –> oestrogen production

Question 19

What cells in the ovaries does LH act on?

Answer 19

Theca cells –> androgen production

Question 20

What hormone inhibits prolactin release?

Answer 20

Dopamine (released from hypothalamus to act on anterior pituitary)

Question 21

Are the changes that occur during pregnancy pathological or physiological?

Answer 21

Physiological changes occur in pregnancy –> resetting of normal physiological values

Question 22

Give 2 characteristics of maternal physiological changes

Answer 22

1. Anticipatory –> precede fetal demands and growth
2. In excess of fetal requirements
3. Dynamic –> inter-trimester variation
4. All enhance placental exchange of nutrients and waste

Question 23

What happens to maternal renal function in pregnancy?

Answer 23

• Kidneys increase in size (20%)
• Increase in renal blood flow –> increase in GFR (–> decreased plasma urea and creatinine)
• Increased creatinine clearance, glycosuria, aminoaciduria
• Increased UTI risk (progesterone reduced smooth muscle tone –> urinary statis)

Question 24

What happens to maternal cardiac output in pregnancy?

Answer 24

Cardiac output, HR and stroke volume increase by 30-50%

Question 25

How does maternal BP change throughout pregnancy?

Answer 25

Biphasic changes - 16-20 weeks = decrease in peripheral resistance --> decrease in systolic and diastolic pressure - Late pregnancy = increase in BP

Question 26

Why does dilution anaemia occur in pregnancy?

Answer 26

Increase in ECF volume causes dilution effects There is an increase in RBC numbers but RBC concentration decreases per unit volume due to increased plasma volume level (by 50% by term) Decreased haemoglobin and haematocrit levels

Question 27

What happens to white blood cells during pregnancy?

Answer 27

Increase in white cells (polymorphonuclear leukocytes) | NO dilution effect seen

Question 28

Why does thromboembolism risk increase during pregnancy?

Answer 28

Blood becomes hypercoagulable - Increase in plasma fibrinogen - Increase in clotting factors (VII, VIII, X) - Increase in plasminogen activator inhibitor

Question 29

How does maternal respiratory function change in pregnancy?

Answer 29

- Increase in maternal oxygen consumption (15-20%) - Increase in tidal volume --> increases minute volume - Decrease in total lung volume

Question 30

Why does maternal PCO2 decrease in pregnancy?

Answer 30

Decreases from 4.7kPa to 4.0kPa Creates much steeper gradient helping the fetal gas exchange State of compensated respiratory alkalosis Increase in maternal DPG --> promotes O2 release at low maternal Hb saturations seen in placenta

Question 31

What GI and Liver changes occur in pregnancy?

Answer 31

- Delayed gastric emptying - Cardiac sphincter relaxation --> heart burn - Increased gut transit time - Reduced CCK secretion - Reduced gall bladder motility --> obstetric cholestasis and increased risk of gallstones

Question 32

What is the principle fetal nutrient?

Answer 32

Glucose

Question 33

Can the foetus produce any of its own glucose?

Answer 33

No, gluconeogenic enzymes are inactivated int he foetus and so all its glucose has to come from its mother The foetus also has no mechanism to limit uptake of glucose so will always take up glucose even if excessive

Question 34

In early pregnancy, is maternal plasma glucose high or low?

Answer 34

Plasma glucose is low as it is being stored (glycogen) and deposited (as fat)

Question 35

In late pregnancy, is maternal plasma glucose high or low?

Answer 35

Plasma glucose is higher, due to maternal insulin resistance and glucose sparing for the foetus

Question 36

What are the consequences of maternal insulin resistance?

Answer 36

Maternal insulin resistance --> gestational diabetes --> increased risk of macrosomia and shoulder dystocia

Question 37

Why is the immune response suppressed in a pregnant last?

Answer 37

Prevention of foetal rejection

Question 38

Give 4 ways in which foetal rejection is prevented in a pregnant lady?

Answer 38

1. A TH2 bias is observed 2. Syncytiotrophoblast has self:no-self markers so doesn't stimulate an immune response 3. Extra-villous trophoblast cells have modified markers 4. Overall immune response is suppressed

Question 39

Give 3 potential complications if there is not a TH2 bias in pregnancy

Answer 39

1. Pre-eclampsia 2. IUGR 3. Miscarriage

Question 40

How does the endometrium epithelium become adhesive to the blastocyst?

Answer 40

The blastocyst and endometrium communicate via the release of hormones --> 'sticky endometrium'

Question 41

When is a women's cycle does the endometrium become 'sticky'?

Answer 41

Between 20-24 days = window of implantation

Question 42

What reaction occurs when a blastocyst implants into the endometrium?

Answer 42

Primary decidual reaction

Question 43

What part of the blastocyst facilitates placental formation?

Answer 43

The cytotrophoblast

Question 44

What does the cut-trophoblast go onto form?

Answer 44

Anchoring villi --> extra villous trophoblast

Question 45

What can trigger differentiation fo anchoring villi into extra-villous trophoblast?

Answer 45

Hypoxia

Question 46

What is the role of extra-villous trophoblast (EVT) cells?

Answer 46

EVT invade and remodel spiral arteries (become wide bore, low resistance) Leads to more hypoxia so more EVT = positive feedback

Question 47

Why do EVT cells invade and remodel spiral arteries?

Answer 47

To allow for optimum nutrient delivery and blood supply for the baby

Question 48

Give 3 potential consequences of poor end-vascular remodelling

Answer 48

1. Pre-eclampsia 2. Preterm birth 3. IUGR Due to reduced acquisition of maternal blood supply for baby

Question 49

What happens to the cervix during pregnancy?

Answer 49

``` Cervix increases in softness and vascularity with increase gestation Blue tinge (oestrogen mediated) = Chadwick's sign ```

Question 50

Define Screening

Answer 50

Process of identifying apparently healthy individuals who may have an increased risk of developing a disease

Question 51

What are the Wilson and Jugner screening criteria?

Answer 51

1. The condition should be a serious health problem 2. The natural history of the condition should be understood 3. There should be a detectable early stage 4. There should be a treatment available 5. Facilities for diagnosis and treatment should be available 6. There should be a suitable test 7. The test should be acceptable to the population 8. There should be an agreed policy on whom to treat 9. The cost of testing should be balanced against the benefits 10. Screening should be a continuous process not just a one off

Question 52

When would a woman have her booking appointment and what is the purpose of it?

Answer 52

Before 12 weeks, often 10 weeks - Obstetric history and examination - BMI, BP, urine dip, Hb - Check for HIV, Hep B, Syphilis, Rubella - General healthy lifestyle advice - Screen for complications

Question 53

When should the dating US be done?

Answer 53

Preferably between 11 to 13+6 weeks - Dates pregnancy, confirms viability, singleton/multiple and picks up any gross structural abnormalities - Screening occurs --> Crown-rump length (CRL) and Nuchal Translucency (NT) - Blood test --> including BhCG, PAPPA, infection, rhesus status

Question 54

What diseases are screening for in the foetal anomaly screening test?

Answer 54

1. Down's (T21) 2. Edward's (T18) --> LBW, small head/mouth/jaw, low set ears, cleft palate, exomphalos 3. Patau's (T13) --> cleft lip/palate, microcephaly ,ear malformations, rocker-bottom feet

Question 55

What fetal screening tests can be done?

Answer 55

- Combined Test = first trimester (11+2 to 14+1 weeks) --> maternal age, US CRL and NT, blood sample (PAPP-A and free beta hCG) - Quadruple Test = second trimester (14+0 to 20+0 weeks) --> Blood test (AFP, total beta hCG, oestriol, inhibin A)

Question 56

Why is the quadruple test sometimes done?

Answer 56

If combined screening is not possible --> if late booking or NT not obtained ONLY A MARKER OF DOWNS

Question 57

When is the anomaly US done?

Answer 57

18+0 to 20+6 weeks | Detects major structural abnormalities

Question 58

What is the threshold for further testing following a fetal anomaly screening test?

Answer 58

If the risk is >1 in 150 then further testing will be done --> chorionic villous sample (CVS - at 10 weeks) or amniocentesis (at 15 weeks) (NIPT available privately)

Question 59

What diseases are being screened for in the antenatal infectious diseases screening test?

Answer 59

1. HIV --> treat mum and reduce transmission to baby 2. Hep B --> see if mum is infected 3. Syphilis --> treat mum to prevent congenital syphillis or possible loss of baby

Question 60

What is the inheritance pattern of sickle cell and thalassaemia?

Answer 60

Autosomal recessive

Question 61

Name 3 neonatal screening programmes

Answer 61

1. Newborn blood spot 2. Hearing test 3. Newborn and 6-8 weeks physical examination

Question 62

What is the neonatal newborn blood spot screening test?

Answer 62

Screens for 9 conditions by a heel prick blood test at days 5-8 1. Sickle cell disease (can also identify beta thalassaemia major and carriers of sickle cell) 2. Cystic fibrosis 3. Congenital hyperthyroidism 4. Phenylketonuria 5. Medium chain acyl-CoA dehydrogenase deficiency (MCADD) 6. Maple syrup urine disease 7. Isovaleric acidaemia 8. Glutaric aciduria type 1 9. Homocystinuria

Question 63

When is the neonatal hearing test done?

Answer 63

Within 4 weeks | - Looking for a response in the cochlea

Question 64

When are the newborn physical examinations done?

Answer 64

Within 72 hours of birth and repeated at 6-8 weeks by a GP

Question 65

Give 4 things that a newborn physical examination is looking for

Answer 65

1. Eye problems 2. Heart defects 3. Hip dysplasia 4. Undescended testes

Question 66

Name 3 risk factors that require serial scans from 28 weeks

Answer 66

1. Previous SGA baby 2. LGA baby 3. Polyhydramnios/oligohydramnios 4. Smokers 5. BMI >35 Serial scans = US every 3 weeks

Question 67

Name 3 disorders that are exacerbated by pregnancy

Answer 67

1. HTN 2. Renal disease 3. Cardiac Disease (e.g. mitral stenosis) 4. Endocrine disease

Question 68

Name 3 disorders that are specific to pregnancy

Answer 68

1. Gestational Diabetes 2. Pre-eclampsia 3. Obstetric cholestasis 4. Acute fatty liver in pregnancy

Question 69

How can pregnancy affect anaemia?

Answer 69

2 fold increase in iron requirements and 10 fold increase in folate requirements IDA = ferrous sulphate Folate deficiency = folic acid Multivitamins can be taken --> contain iron and folate Anaemia is associated with low birthweight and preterm delivery

Question 70

How is asthma affected in pregnancy?

Answer 70

Affected by physiological changes Main exacerbation risk in 3rd trimester Most medications are safe in pregnancy --> SABA, ICS, LABA, theophylline, leukotriene antagonists Make sure to avoid ibuprofen and BB in labour

Question 71

If a mother has a cardiac condition when can the baby be screened?

Answer 71

20 week ECHO

Question 72

What are low risk cardiac conditions in pregnancy?

Answer 72

``` Mitral incompetence Aortic incompetence ASD VSD PDA ```

Question 73

What are high risk cardiac conditions in pregnancy?

Answer 73

``` Aortic stenosis Coarctations of aorta Prosthetic valves Pulmonary HTN Marfan's with aortic root dilation - Pregnancy often discouraged in these patients ```

Question 74

What inheritance pattern is associated with obstetric cholestasis?

Answer 74

Autosomal dominant

Question 75

What symptoms does obstetric cholestasis often present with?

Answer 75

Itching --> often hands and feet and at night | Can have anorexia, malaise, epigastric discomfort, steatorrhoea, dark urine

Question 76

What might you see on the blood results of a patient with obstetric cholestasis?

Answer 76

Raised AST, ALT and bile acid

Question 77

What does obstetric cholestasis increase in the risk of?

Answer 77

Premature and Still birth

Question 78

How is obstetric cholestasis managed?

Answer 78

LFTs weekly Ursodeoxycholic acid --> improves liver function and itching Vitamin K

Question 79

What risks are associated with hyperthyroidism in pregnancy?

Answer 79

Maternal risk = thyroid crisis with cardiac failure m | Fetal risk = thyrotoxicosis due to transfer of thyroid stimulating antibodies (usually resolves after 6 months)

Question 80

What hyperthyroidism controlling drug is preferred in pregnancy?

Answer 80

Propylthiouracil (PTU) preferred over carbimazole as less teratogenic

Question 81

What risks are associated with untreated hypothyroidism in pregnancy?

Answer 81

Early fetal loss and impaired neurodevelopment Higher dose of thyroxine often needed during pregnancy, especially in first trimester (T4 needed for fetal brain development <12 weeks)

Question 82

What diabetic medications can be used during pregnancy?

Answer 82

Insulin and metformin are safe All other oral hypoglycaemics are contraindicated ACEi and statins also contraindicated

Question 83

Name 3 maternal complications due to diabetes

Answer 83

1. DKA 2. Pre-eclampsia 3. Progression of retinopathy (screened twice at least throughout pregnancy) 4. Hypoglycaemia

Question 84

Name 3 possible fetal complications due to maternal diabetes

Answer 84

1. Miscarriage 2. Stillbirth 3. Premature labour 4. Macrosomia --> shoulder dystocia 5. Neonatal hypoglycaemia, hypocalcaemia, polycythaemia 6. Polyhydramnios 7. Respiratory distress 8. Fetal abnormalities

Question 85

What happens in women with gestational diabetes when extra glucose crosses the placenta?

Answer 85

Insulin, GF and GH's are produced --> foetal growth is stimulated and fat and glycogen are deposited

Question 86

How is gestational diabetes diagnosed?

Answer 86

``` Oral Glucose Tolerance Test at 28 weeks 75mg glucose given - Fasting plasma glucose >5.6 OR - >7.8 after 2 hours ```

Question 87

How is gestational diabetes managed?

Answer 87

Diet and exercise = first line Metformin = 2nd line Insulin = 3rd line OGTT 6 weeks postpartum to ensure it has resolved after medications have been stopped following delivery

Question 88

How can epilepsy in pregnancy be managed?

Answer 88

- Preconception counselling - Manage triggers and control seizures - Medications often teratogenic --> sodium valporate (swap to lamotrigine) - Alpha fetoprotein, anomaly scan, fetal ECHO (22-24 weeks) - High dose folic acid throughout (before conception if possible) - Vitamin K from 36 weeks

Question 89

Name 3 possible fetal complications due to being on sodium valproate during pregnancy

Answer 89

1. Nueral tube defects 2. ASD 3. Cleft palate 4. Hypospadias 5. Learning difficulties and autism

Question 90

Define Chronic HTN

Answer 90

HTN diagnosed before pregnancy or before the 20th week of gestation and nor resolved postpartum

Question 91

Define Gestational HTN (Pregnancy Induced HTN)

Answer 91

New HTN after 20 weeks gestations which resolves after birth NO proteinuria >140/90

Question 92

Define Pre-eclampsia

Answer 92

New HTN after 20 weeks with proteinuria (>0.3g protein/24hours)

Question 93

What is eclampsia?

Answer 93

Preeclampsia (gestational HTN + proteinuria) and generalised tonic clonic seizures

Question 94

Describe the pathophysiology behind pre-eclampsia

Answer 94

Spiral arteries do not remodel --> arteries are tight leading to increased resistance in the placenta --> placental ischaemia --> RAAS activated --> poor renal perfusion, HTN, proteinuria and oedema --> pre-eclampsia

Question 95

Give 4 risk factors for developing preeclampsia

Answer 95

1. Previous pre-eclampsia 2. Age >40 or teenage 3. Primipatiry 4. Multiple pregnancy 5. Long birth interval (>10 years) 6. Existing medical conditions --> HTN, renal disease, Dm, antiphospholipid anitbodies

Question 96

Give 3 signs of pre-eclampsia that are detected at the kidneys

Answer 96

1. GFR and renal blood flow decrease 2. Raised uric acid 3. Proteinuria

Question 97

Give 3 symptoms of pre-eclampsia

Answer 97

1. Visual disturbances 2. Headaches 3. Epigastric pain 4. Weight gain 5. Vomiting

Question 98

Give 3 signs of pre-eclampsia

Answer 98

1. HTN 2. Proteinuria 3. Retinal Vasospasm 4. RUQ tenderness 5. Ankle clonus or brisk reflexes 6. Oedema

Question 99

How is preeclampsia classified?

Answer 99

``` Mild, moderate, severe - Severe = severe HTN (>160/110) and/or symptoms and/or biochemical and/or haematological impairment OR Early = <34 weeks Late = >34 weeks ```

Question 100

Management of preeclampsia

Answer 100

- Restrict activity and regular BP, urine and biochemistry checks - Labetalol (not in asthmatics) +/- nifedipine - IV MGSO4 (neuroprotection) = reduces frequency of eclampsia - DELIVERY = CURE

Question 101

Give 3 indications for delivery in preeclampsia

Answer 101

1. Gestational age >38 weeks 2. Platelet count <100,000 cells/mm3 3. Progressive deterioration in liver and renal function 4. Suspected placental abruption 5. Persistent severe headaches, visual changes, N+V, epigastric pain 6. HELLP syndrome or eclampsia 7. Severe fetal growth restriction 8. Oligohydramnios

Question 102

Give 3 possible maternal complications due to pre-eclampsia

Answer 102

1. Eclampsia 2. CVA 3. HELLP (Haemolysis, elevated liver enzymes, low platelets) 4. Liver failure 5. Renal failure 6. DIC 7. Pulmonary oedema

Question 103

Give 3 possible fetal complications due to pre-eclampsia

Answer 103

1. IUGR 2. Preterm brith 3. Placental abruption 4. Hypoxia

Question 104

When and why is aspirin prescribed in pregnancy?

Answer 104

150mg from 12 weeks OD if 1 high risk factor or 2 moderate risk factors Moderate Risk Factors - 1st pregnancy - >40 y/o - Pregnancy interval >10 years - BMI >35 (at first visit) - FHx of preeclampsia - Multiple pregnancy High Risk Factors - Hypertensive disease in previous pregnancy - CKD - AI (like SLE or antiphospholipid syndrome) - Type 1 or 2 diabetes - Chronic HTN

Question 105

Give 2 signs of polyhydraminos

Answer 105

1. Increased abdominal size that is out of proportion for weight and gestation (increased SFH) 2. AFI >20 on USS 3. Maternal dyspnoea and faint foetal heart sounds

Question 106

Give 3 causes of polyhydramnios

Answer 106

1. Maternal diabetes 2. Fetal abnormalities (duodenal atresia) 3. Multiple pregnancy

Question 107

Give 3 potential consequences of polyhydramnios

Answer 107

1. Cord prolapse 2. PPH 3. Preterm labour 4. IUGR

Question 108

Describe the 3 stages of labour

Answer 108

Stage 1 = Cervical remodelling, dilation and uterine contractions Stage 2 = Full dilation to delivery of foetus Stage 3 = Placental delivery

Question 109

Describe the 3 stages of labour

Answer 109

Stage 1 = Cervical remodelling, dilation and uterine contractions Stage 2 = Full dilation to delivery of foetus - can have a passive hour once fully dilated = contractions slow down Stage 3 = Placental delivery

Question 110

What are the 2 phases of Stage 1 labour?

Answer 110

Latent phase = irregular contractions that vary in length and strength, cervix begins to dilate and efface up to 4cm (hours) Active phase = established labour, stronger and more regular contractions, cervix becomes fully effaced and dilates up to 10cm (primi woman = 0.5cm/hour)

Question 111

What causes myometrial contractions?

Answer 111

Oxytocin release --> increased intracellular Ca2+ --> myometrial contractions

Question 112

Name an oxytocin analogue that can induce labour

Answer 112

Syntocin

Question 113

Name 2 drugs that can inhibit uterine contractions

Answer 113

1. Nifedipine (CCB) | 2. Atosiban (oxytocin antagonist)

Question 114

Why can nifedipine inhibit uterine contractions?

Answer 114

It is a CCB so blocks rise of intracellular calcium --> inhibiting muscle contraction

Question 115

Define Lie in terms of the foetus during pregnancy

Answer 115

Relationship between the longitudinal axis of the uterus and longitudinal axis of the foetus Can be longitudinal, transverse or oblique lie

Question 116

Define Presentation in terms of the foetus during pregnancy

Answer 116

Anatomical part of the foetus which presents itself first though the birth canal

Question 117

Define Position in terms of the foetus during pregnancy

Answer 117

relationship between a defined area of the presenting part (the denominator) and the mothers pelvis - Occiput = denominator in a fully flexed head - Chin = denominator in fully extended head (face presentation) - Brow = denominator in partially extended head (brow presentation) - Sacrum = denominator in breech presentation

Question 118

Define Attitude in terms of the foetus during pregnancy

Answer 118

Relationship of the fetal head and limbs to the fetal trunk --> flexed or extended

Question 119

What are the 3 key participants in labour?

Answer 119

1. Passage = maternal boney pelvis and soft tissues 2. Passenger = fetus --> size, presentation, postion, anomalies 3. Power = uterine contractions and maternal effort

Question 120

What is cervical ripening?

Answer 120

Increased softening, distensibility, effacement and dilatation of the cervix and occur prior to the onset of labour and in the latent phase Primiparous = process completed before first active stage of labour Multiparous - can take place at the same time as dilation

Question 121

Explain moulding

Answer 121

Overlapping of fetal skull bones during labour to help reduce the size of the head

Question 122

Briefly describe the mechanism of labour

Answer 122

1. Engagement and descent 2. Flexion 3. Internal rotation = fetal head turns 90 degrees 4. Extension = head extends once occiput beneath suprapubic arch 5. Restitution = align head with shoulders 6. External/lateral rotation 7. Delivery of body

Question 123

Briefly describe the mechanism of labour

Answer 123

1. Engagement and descent 2. Flexion 3. Internal rotation = fetal head turns 90 degrees 4. Extension = head extends once occiput beneath suprapubic arch 5. Restitution/external/lateral rotation = align head with shoulders 6. Delivery of body

Question 124

Why is there often delayed cord clamping?

Answer 124

Allows baby to transition Increase in RBC, iron and stem cells Reduces the need for inotropic support

Question 125

What are the 2 membranes associated with the placenta?

Answer 125

1. Amnion = bag around baby 2. Chorion = membranes around the placenta Need to examine placenta and membranes after to ensure they are intact --> left in can cause severe PPH

Question 126

When is there shared antenatal care between the hospital and the community?

Answer 126

High risk women - Underlying medical conditions --> HTN, DM, epilepsy, RA, asthma, ITP - Complications in previous pregnancy --> Previous CS/preeclampsia/PPH/SGA/preterm/3rd/4th degree tear - Complications in current pregnancy --> preeclampsia, breech, GDM, multiple, PP - Issues with women herself --> high/low BMI, smoking, alcohol, drugs, old/young

Question 127

How are babies monitored antenatally?

Answer 127

1. USS 2. Intermittent auscultation --> with handheld doppler or pinned stethoscope (listen to fetal heart) 3. CTG

Question 128

What fetal measurements are taken antenatally on US?

Answer 128

Growth/estimated fetal weight measurements - Abdominal circumference - Head circumference - Femur length Liquor volume (amniotic fluid index) Umbilical artery dopplers (pulsatility index)

Question 129

Give 2 methods used for monitoring the fetal heart rate

Answer 129

1. Intermittent auscultation --> low risk | 2. Continuous monitoring, cardiotocgraphy (CTG) --> high risk patients

Question 130

During labour when should intermittent auscultations be performed?

Answer 130

Every 15 minutes in the 1st stage | Immediately after a contraction for at least 1 minute or every 5 minutes in 2nd stage

Question 131

Give 2 disadvantages of intermittent auscultation

Answer 131

1. Variability and decelerations can't be detected 2. Long term monitoring is not possible 3. Quality of FHR can be affected by maternal HR and movement

Question 132

Give 2 advantages of continuous monitoring of the FHR

Answer 132

1. Gives lots of information --> variability, accelerations, decelerations 2. Long term monitoring possible 3. Monitors FHR and uterine contractions

Question 133

CTG: what is a normal baseline HR?

Answer 133

110-160 bpm

Question 134

CTG: what is a non-reassuring baseline HR?

Answer 134

100-109 bpm

Question 135

CTG: what is an abnormal baseline HR?

Answer 135

<100bpm or >180 bpm

Question 136

CTG: what is normal variability

Answer 136

5-25 bpm

Question 137

CTG: what is non-reassuring variability?

Answer 137

<5 for 40-90 minutes

Question 138

CTG: what is abnormal variability?

Answer 138

<5 for >90 minutes

Question 139

CTG: what is an acceleration?

Answer 139

An increase in the baseline HR by 10-15 bpm | Presence of accelerations is reassuring

Question 140

CTG: what is a deceleration?

Answer 140

A decrease in the baseline HR by 10-15bpm | Presence of decelerations are non-reassuring

Question 141

CTG: What are early decelerations?

Answer 141

Decelerations seen just before a uterine contraction | They may be due to fetal head compression

Question 142

CTG: What are late decelerations?

Answer 142

Decelerations seen just after uterine contraction They may be due to placental insufficiency/hypoxia They are more concerning than early decelerations

Question 143

CTG: What are variable decelerations?

Answer 143

Mixture of early and late decelerations | Can often be cord compression

Question 144

CTG: how would you determine if a CTG was overall normal, suspicious or abnormal?

Answer 144

- Normal = everything is normal and accelerations are present - Suspicious = one non-reassuring feature - Abnormal = >2 non-reassuring features and/or >1 abnormal feature

Question 145

How do you define a normal CTG?

Answer 145

1. Baseline HR = 110-160 bpm 2. Variability >5 3. Accelerations present 4. No decelerations

Question 146

What is the gold standard method for direct FHR monitoring?

Answer 146

Scalp ECG

Question 147

Give a disadvantage of a scrap ECG for monitoring the HFR

Answer 147

1. Invasive 2. Membranes need to be broken and cervix >2cm 3. Risk of scalp injury and perinatal infection

Question 148

When is a fetal blood sample taken?

Answer 148

If there is a pathological CTG but don't want to get baby out straight away (e.g. contracting >4 in 10)

Question 149

How do you interest FBS samples?

Answer 149

Look at pH or lactate Normal pH = >7.25 Borderline pH = 7.21-7.24 --> repeat after 30 minutes Abnormal pH = <7.2 --> consider C section

Question 150

How do you interpret FBS samples?

Answer 150

Look at pH or lactate Normal pH = >7.25 Borderline pH = 7.21-7.24 --> repeat after 30 minutes Abnormal pH = <7.2 --> consider C section

Question 151

Define prematurity

Answer 151

Babies born alive between 24 and 36+6 weeks

Question 152

What is preterm labour?

Answer 152

Persistent uterine activity AND change in cervical dilatation and/or effacement before 37 weeks

Question 153

What organs are most likely to be affected in babies that are premature?

Answer 153

Lungs and the brain

Question 154

Name 3 things that can be given to a premature baby to increase survival rates

Answer 154

1. Antenatal steroids 2. Artificial surfactant 3. Ventilation 4. Nutrition 5. Antibiotics

Question 155

How is preterm delivery classified?

Answer 155

Spontaneous (70%) --> preterm labour, PPROM, cervical weakness, amnionitis Induced --> medical/obstetric disorder

Question 156

Give 5 risk factors for having a preterm baby

Answer 156

1. Previous preterm birth 2. Previous late miscarriage 3. APH or other vaginal bleeding 4. Multiple pregnancy 5. Ethnic group 6. Genital infections 7. Medical conditions --> HTN, renal disease 8. Cervical surgery/weakness 9. Lower socioeconomic status

Question 157

How can preterm birth be prevented?

Answer 157

Progesterone suppositories --> from early pregnancy for those at high risk Cervical cerclage --> sutures in cervix to keep it closed Screen for STIs and UTIs Manage medical disease

Question 158

How is preterm birth managed?

Answer 158

``` Steroids Tocolysis (nifedipine or oxytocin receptor antagonist - atosiban) = prevent labour and delivery MgSO4 = neuroprotective if given <34 weeks ```

Question 159

What is preterm prelabour rupture of membranes (PPROM) commonly associated with?

Answer 159

Chorioamnionitis = bacterial infection that occurs before or during labour

Question 160

How do you manage PPROM?

Answer 160

If evidence of chorioamnionitis = steroids, deliver whatever the gestation, broad spectrum Abx If NO evidence of chorioamnionitis = admit, steroids, Abx

Question 161

Define small for gestational age (SGA)

Answer 161

Estimated fetal birth weight (EFW) or abdominal circumference (AC) <10th centime on a customised growth chart Severe SGA = <3rd centile

Question 162

Define low birth weight (LBW)

Answer 162

Infant with birth weight <2500g

Question 163

Define fetal growth restriction

Answer 163

Failure of the ferrous to achieve its predetermined growth potential

Question 164

Give 5 potential causes of FGR

Answer 164

1. Poor nutrition and diet 2. Alcohol, smoking, drug use 3. Gestational Diabetes 4. HTN and preeclampsia 5. Placental insufficiency 6. Multiple pregnancy 7. Structural or chromosomal abnormalities 8. Poor weight gain during pregnancy

Question 165

Briefly describe why FGR often occurs

Answer 165

Trophoblasts don't invade the placental vessels as normal so respond to vasopressors --> restricting nutrients to baby and restricting growth

Question 166

What investigations might you so if you are concerned about FGR?

Answer 166

Clinical Examination including SFH USS --> HC, AC, FL, liquor volume - Serial scans from 28 weeks if SGA Umbilical artery doppler

Question 167

What happens if an umbilical artery doppler is abnormal?

Answer 167

Measure pulsatility index (resistance index) - Raised --> Monitor - Intermittent absent --> delivery within 24 hours - Absent --> Consider stat delivery - Reversed --> deliver stat

Question 168

Describe the types of FGR

Answer 168

``` Symmetrical = head size and AC reduced in parallel Asymmetrical = Abdominal circumference reduced, head circumference normal ```

Question 169

Name 2 possible causes of symmetrical FGR

Answer 169

1. Congenital/chromosomal abnormalities 2. Intrauterine infections 3. Environmental factors

Question 170

Name 2 possible causes of asymmetrical FGR

Answer 170

Often due to later onset pathology 1. Pre-eclampsia 2. Idiopathic 3. Essential HTN 4. Smoking

Question 171

How do you manage early onset FGR (<32 weeks)?

Answer 171

Or symmetric FGR at any gestation - USS to exclude fetal structural abnormality - Karyotyping of foetus - Investigate for viral infection - Corticosteroids - Intensive and repeated fetal monitoring

Question 172

How do you manage late onset FGR (>32 weeks)?

Answer 172

- Corticosteroids - Increased fetal surveillance - Possible delivery

Question 173

Give 2 possible short term complications of FGR

Answer 173

1. Premature birth 2. Hypoxic brain injury 3. Need for respiratory support

Question 174

Give 2 possible long term complications of FGR

Answer 174

Increased risk of developing 1. Coronary heart disease 2. HTN 3. T2DM 4. Hyperlipidaemia

Question 175

Define large for gestational age (LGA)

Answer 175

Estimated birth weight >90th centile as plotted on customised growth chart

Question 176

Define fetal macrosomia

Answer 176

Birth weight >4000g | - Often associated with those with diabetic mothers

Question 177

Briefly describe why macrosomia occurs

Answer 177

Glucose not taken up by mum due to insulin resistance --> excessive glucose in blood --> crosses placenta to baby --> baby takes up excessive amounts of glucose --> stimulates babies’ pancreas to produce higher amount of insulin (anabolic hormone) --> increase in size and build-up of fat

Question 178

How can is fetal macrosomia managed?

Answer 178

Identification with SFH and USS Rule out diabetes or treat if present Plan delivery

Question 179

Give 3 possible complications of fetal macrosomia

Answer 179

1. Shoulder dystocia 2. Instrumental delivery 3. C section 4. PPH 5. 3rd degree perineal tears 6. Neonatal hypoglycaemia --> need early feeding

Question 180

Give 2 theories behind the induction of labour

Answer 180

1. Placental clock theory --> increased CRH release form placenta --> fetal ACTH please --> release of oestrogen, formation fo myocetrial cap junction --> contractions 2. Signals from the baby --> increased ACTh or increase fetal surfactant proteins activate amniotic fluid macrophages --> migrate to uterine wall, upregulartion fo inflammatory gene expression stimulating labour

Question 181

Give 3 indications for artificial induction of labour

Answer 181

1. Post Maturity (T+10) 2. Pre-eclampsia 3. Diabetes 4. Growth restriction 5. Reduced fetal movements 6. PPROM 7. In-utero death

Question 182

How can labour be induced?

Answer 182

1. Membrane sweep (natural induction) --> to see if waters can be broken (in woman at term) 2. Balloon catheter --> to help ARM to become possible 3. Prostin (prostaglandin E2) pessaries --> cervical priming - Syntocin can help stimulate contractions once membranes have been ruptured

Question 183

Give 3 non-pharmacological therapies that can be used to help manage labour pain

Answer 183

1. Trained support 2. Acupuncture 3. Hypnotherapy 4. Massage 5. Hydrotherapy

Question 184

Give 3 pharmacological therapies that can be used to help manage labour pain

Answer 184

1. Gas and air = entonox 2. Paracetamol 3. Codeine 4. Opioids --> pethidine, diamorphine 5. Epidural 6. Spinal anaesthesia

Question 185

Give 2 advantages to entonox

Answer 185

1. Rapid onset 2. Minimal side effects 3. Self limiting

Question 186

Give 3 potential side effects of opioids

Answer 186

1. Sedation 2. Respiratory depression 3. Nausea and committing 4. They cross the placenta (as lipid soluble)

Question 187

Give 3 indications for an epidural

Answer 187

1. Maternal request 2. Augmented labour 3. Twins 4. Existing co-morbidities

Question 188

What anaesthetic can be given as an epidural?

Answer 188

Bupivacaine

Question 189

How does bupivacaine work as an epidural?

Answer 189

Blocks sodium channels

Question 190

Why is an epidural useful if a woman needs to go for an emergency C section?

Answer 190

It can be topped up

Question 191

Where is spinal anaesthesia injected into and at what level?

Answer 191

The CSF | No higher than L2 or L3 (pudendal nerve S2-4 is main nerve involved in labour)

Question 192

What is used in a spinal anaesthetic in labour?

Answer 192

Bupivacaine AND fentanyl/diamorphine

Question 193

Give 3 contraindications for regional anaesthetics (epidural or spinal)

Answer 193

1. Maternal refusal 2. Local infection 3. Allergy Relative CIs 4. Hypovolaemia 5. Systemic infection 6. Coagulopathy/thormbocytopenia

Question 194

Give 2 advantages of using regional anaesthetic when performing a C-section

Answer 194

1. Safer 2. Can see baby immediately 3. Partner can be present

Question 195

Give 2 disadvantages of using regional anaesthetic when performing a C-section

Answer 195

1. Can cause hypotension 2. Can cause headaches 3. Patient may experience discomfort from pressure sensations 4. Failure

Question 196

Why would general anaesthetic be given for performing a C-section?

Answer 196

- If there is an imminent threat to mother and/or foetus - Coagulopathy - Contraindication of local anaesthetic - Maternal preference

Question 197

Name 4 maternal obstetric emergencies

Answer 197

1. Antepartum haemorrhage (APH) 2. Postpartum haemorrhage (PPH) 3. Venous thromboembolism 4. Pre-eclampsia 5. Amniotic Fluid Embolism

Question 198

Define antepartum haemorrhage

Answer 198

Bleeding from anywhere in the genital tract after 24 weeks of pregnancy until delivery

Question 199

Give 3 causes of APH

Answer 199

1. Placenta praevia/LLP 2. Placenta accreta and placenta percreta 3. Placental abruption 4. Vasa praevia 5. Uterine rupture

Question 200

Give 3 potential complications of APH

Answer 200

1. Premature labour 2. Need for blood transfusion 3. Actor tubular necrosis (+/- renal failure) 4. DIC 5. PPH

Question 201

What is placenta praaevia?

Answer 201

Any part of the placenta that has implanted into the lower segment of the uterus - Major = covering/reaching the os - Minor = in lower segment/encroaching

Question 202

Give 2 risk factors for placenta praevia

Answer 202

1. Previous CS 2. Smoking 3. Assisted reproduction

Question 203

When might placenta praevia be detected?

Answer 203

20 week anomaly scan = placenta must be <20mm from the cervical os - It can move repeat scan at 32 (major) or 36 (minor) weeks

Question 204

What is the classical presentation of placenta praevia?

Answer 204

Intermittent PAINLESS bleeding --> increases in frequency intensity

Question 205

How is placenta praevia managed?

Answer 205

1. If mum is rhesus negative then anti-D 2. Steroids if <35+6 weeks 3. Placenta >20mm from os for vaginal delivery, <20mm from os = elective C-section at 38 weeks

Question 206

What is placenta accreta?

Answer 206

Placenta is embedded into the uterine wall

Question 207

What is placenta percreta?

Answer 207

Placenta is embedded through the uterine wall into the surroundings

Question 208

Define placental abruption

Answer 208

Premature separation of the placenta from the uterine wall | - Can be concealed or revealed

Question 209

Give 3 risk factors for placental abruption

Answer 209

1. Previous placental abruption 2. IUGR 3. Preeclampsia 4. Smoking, cocaine 5. Truma --> RTA, domestic abuse 6. Multiple pregnancy

Question 210

What is the classical presentation of placental abruption?

Answer 210

Sudden onset, constant and severe abdominal pain Bleeding (but can be concealed) O/E = tense, woody-hard tender uterus Fetal distress and maternal shock --> shock doesn't match blood loss observed Coagulation failure

Question 211

How is placental abruption managed?

Answer 211

Fetal CTG, FBC, coagulation screen, cross match, U+Es Steroids, anti D if rhesus negative, fluids Urgent C-section if fetal distress Amniotomy and induction fi >37 weeks

Question 212

Give 2 potential consequences of placental abruption

Answer 212

1. Fetal distres 2. Maternal shock --> doesn't match blood loss observed 3. Coagulation failure

Question 213

What is vasa praevia?

Answer 213

Fetal vessels run through the membranes and below the fetal presenting part

Question 214

What are the possible consequences of vasa praevia?

Answer 214

Painless and moderate bleeding WHEN MEMBRANES RUPTURE | Can lead led to major fetal haemorrhage

Question 215

What is the main cause of uterine rupture?

Answer 215

Rupture of caesarean section scar (70%)

Question 216

Name 2 possible signs of uterine rupture

Answer 216

- Pain and tenderness over the uterus - Maternal tachycardia - Sudden maternal shock - Cessation of contractions - Disappearance of presenting part from pelvis

Question 217

How do you manage uterine rupture?

Answer 217

``` Laparotomy and deliver baby by C-section High flow O2 and IV fluid Small rupture = possible repair Cervix or vagina involved = hysterectomy Abx post surgery ```

Question 218

Define primary Postpartum Haemorrhage (PPH)

Answer 218

>500ml blood loss within 24 hours of delivery

Question 219

Define Secondary PPH

Answer 219

>500ml blood loss between 24 hours and 12 weeks post delivery

Question 220

What is minor PPH?

Answer 220

<1500mls and no lineal signs of shock

Question 221

What is a major PPH?

Answer 221

>1500mls and continuing bleeding or clinical shock

Question 222

What can cause PPH?

Answer 222

The 4 T's - Tone --> is the uterus contracted? (atonic uterus) - Trauma --> tears, episiotomy, rupture - Tissue --> any retained placental tissue/is the placenta complete? - Thrombin --> check clotting

Question 223

Give 5 risk factors for PPH

Answer 223

1. Large baby 2. Nulliparity and grand multiparty 3. Multiple pregnancy 4. Precipitate or prolonged labour 5. Previous PPH 6. Operative delivery

Question 224

How might you manage a PPH?

Answer 224

Atonic uterus = ergometrine and oxytocin Retained tissue --> removal of placenta or retained tissue Laparotomy --> stop bleeding, oversewing or insertion of Rusch ballon, compression, internal iliac or uterine artery ligation, uterine artery embolisation, total/subtotal hysterectomy

Question 225

Give 5 risk factors for a VTE in pregnancy

Answer 225

1. Increasing gestational age 2. Obesity (BMI >30) 3. Smoking 4. C-section 5. FHx 6. Immobility 7. Multiple pregnancy 8. Previous VTE 9. Thrombophilia 10. Medical co-morbidities 11. Parity 3 or more

Question 226

When is a woman at the greatest risk of VTE?

Answer 226

Greatest just after giving birth, postpartum period

Question 227

What medication can be given to reduce a woman's risk of VTE?

Answer 227

LMWH (Dalteparin) | TED stockings

Question 228

When is VTE prophylaxis given?

Answer 228

Antenatally - From 1st trimester is TRAF >4 - From 28 weeks if TRAF 3 Postnatally - If antennal prophylaxis = continue for 6 weeks - 10 days if TRAF >2, 6 weeks if additional risk factors

Question 229

Describe the pathophysiology of rhesus disease

Answer 229

1. Fetal Rh+ RBCs leak through the placenta and interact with the mothers blood --> IgM reaction --> sensitisation 2. IgM can't cross the placenta so there is no RBC lysis but memory B cells are created 3. On a subsequent pregnancy, IgG may cross the placenta and cause fetal RBC lysis

Question 230

What are the potential consequences, if left intreated, of a rhesus negative mother having a rhesus positive fetus?

Answer 230

Risk of RBC lysis --> fetal anaemia and death

Question 231

What is the only antibody that can cross the placenta?

Answer 231

IgG

Question 232

How can fetal RBC lysis be prevented in rhesus negative mothers?

Answer 232

Anti-D prophylaxis given - Destroys Rh+ IgG and so no RBC are attacked - Given at 28 weeks and 72 hours after sensitising event

Question 233

Name 3 events during pregnancy when sensitisation of rhesus disease may occur

Answer 233

1. Miscarriage 2. Abortion 3. Amniocentesis 4. Placental abruption 5. During delivery

Question 234

When can Anti-D not be used?

Answer 234

If the mum has already produced Anti-D antibodies

Question 235

What is Amniotic Fluid embolism?

Answer 235

When liquor enters maternal circulation causing anaphylaxis and sudden dyspnoea

Question 236

Name 3 fetal emergencies

Answer 236

1. Fetal distres 2. Cord prolapse 3. Shoulder dystocia

Question 237

What is cord prolapse?

Answer 237

When the cord is presenting before the baby after rupturing of the membranes

Question 238

Give a potential consequence of cord prolapse

Answer 238

Vasospasm --> hypoxia --> fetal morbidity and mortality

Question 239

Give 4 risk factors for cord prolapse

Answer 239

1. Premature ROM 2. Polyhydramnios 3. Long umbilical cord 4. Fetal malpresentaiton 5. Multiparity 6. Multiple pregnancy

Question 240

How can cord prolapse be managed?

Answer 240

1. Infused fluid into bladder via catheter (elevated presenting part of cord) 2. Trendelenburg position (feet higher than head) 3. Constant monitoring 4. Transfer to theatre for delivery

Question 241

WHat is shoulder dystocia?

Answer 241

Failure for the anterior shoulder to pass under the symphysis pubis after delivery of the fetal head

Question 242

Give 3 risk factors for shoulder dystocia

Answer 242

1. Macrosomia 2. Maternal Diabetes 3. Previous shoulder dystocia 4. Post maturity 5. Prolonged labour 6. Obesity

Question 243

How should should shoulder dystocia be managed?

Answer 243

``` HELPERR H = call for Help E = evaluate for Episiotomy L = Legs in McRoberts (hyperflexed at hips with thigh abducted and eternal rotated) P = suprapubic Pressure E = Enter pelvis R = Rotational manoeuvres R = Remove posterior arm ```

Question 244

Give 3 potential maternal complications of shoulder dystocia

Answer 244

1. Vaginal tear 2. PPH 3. PTSD 4. Bladder/uterine rupture

Question 245

Give 3 potential fetal complications of shoulder dystocia

Answer 245

1. Hypoxia 2. Cerebral palsy 3. Brachial plexus injury (Erb's palsy) 4. Fractured humerus or clavicle

Question 246

Define puerperium

Answer 246

The period from placental delivery to 6 weeks after birth (postnatal period)

Question 247

Name 3 features of puerperium

Answer 247

1. Return to pre-pregnancy state 2. Initiation/suppression fo lactation 3. Transition to parenthood

Question 248

Give 2 endocrine changes that occur during puerperium

Answer 248

1. Reduced placental hormones (BhCG, progesterone, oestrogen) 2. Increase in prolactin (for lactation)

Question 249

Give 3 physiological changes that occur during the puerperium

Answer 249

1. Involution of the uterus 2. Decidua sheds as lochia 3. Lactation

Question 250

Describe the physiology behind the involution fo the uterus in puerperium

Answer 250

There is muscle ischaemia, autolysis and phagocytosis --> involution the uterus

Question 251

The decider sheds as lochia, what are the 3 stages of the process called?

Answer 251

1. Lochia rubra (days 0-4) 2. Lochia serosa (days 4-10) 3. Lochia alba (days 10-28)

Question 252

What is the name of the breast milk that is produced at birth?

Answer 252

Colostrum

Question 253

What does colostrum contain?

Answer 253

- Protein rich - VItamin A - NaCl - Growth factors (stimulate development of infant gut) - Antibodies (passive immunity) - Lactoferrin (antimicrobial)

Question 254

Describe the physiology of lacation

Answer 254

Baby suckles --> sensory impulses from nipple to brain --> prolactin secreted from anterior pituitary --> milk produced my lactocytes --> oxytocin released from posterior pituitary --. my-epithelial contraction --> milk ejection

Question 255

Name 3 minor things woman are at risk of during puerperium

Answer 255

1. Infection 2. PPH 3. Fatigue 4. Anaemia 5. Backache 6. Haemorrhoids/constipation

Question 256

Name 3 major things woman are at risk of during puerperium

Answer 256

1. Sepsis 2. Severe haemorrhage 3. Pre-eclampsia 4. VTE 5. Prolapse 6. Incontinence 7. Depression 8. Post dural puncture headache

Question 257

Name 3 members of a postnatal MDT

Answer 257

1. Midwives 2. Breastfeeding support workers 3. Doulas 4. Nurses If complex --> obstetricians and paediatricians too

Question 258

Define sepsis

Answer 258

Infection +systemic manifestations of infection - Severe sepsis = sepsis + sepsis induced oran dysfunction or tissue hypoperfusion - Septic shock = prestige of hypoperfusion despite adequate fluid replacement therapy

Question 259

Give 3 risk factors for sepsis in pregnancy

Answer 259

1. Obesity 2. Diametes 3. Anaemia 4. Amniocentesis/invasive procedures 5. Prolonged SROM 6. Vaginal trauma/CS

Question 260

What can cause sepsis in pregnancy?

Answer 260

1. Endometriosis 2. Skin and soft tissue infections 3. UTI 4. Chorioamnionitis 5. Pneumonia 6. Gastroenteritis 7. Pharyngitis

Question 261

What are the main symptoms/signs of sepsis in pregnancy?

Answer 261

3T's white with sugar - Temperature = <36 or >38 - Tachycardia = >90 bpm - Tachypnoea = >20 bpm - WCC = >12 or <4 x10^9 - Hyperglycaemia = >7.7 mmol

Question 262

What is the management of sepsis?

Answer 262

Sepsis 6 = BUFALO - Blood cultures + FBC, U&E, clotting, glucose, CRP, ABG - Urine output - Fluid resuscitation - Antibiotics (broad spec) - Lactate (>2 = sign of organ failure) - Oxygen (high flow)

Question 263

Describe the physiology of a post dural puncture headache

Answer 263

Accidental dural puncture --> CSF leakage and decreased pressure in fluid around the brain

Question 264

Give 3 symptoms of a post dural puncture headache

Answer 264

1. Headache is worse on sitting/standing 2. Neck stiffness 3. Photophobia

Question 265

How would you treat a post dural puncture headache?

Answer 265

1. Lying flat 2. Analgesia 3. IV fluids 4. Epidural blood patch

Question 266

Define postnatal urinary retention

Answer 266

Abrupt onset of aching or aches inability to completely micturate, requiring urinary catheterisation, over 12 hours after giving birth OR Not voiding spontaneously within 6 hours of vaginal delivery

Question 267

Give 3 risk factors for urinary retention postnatally

Answer 267

1. Epidural analgesia 2. Prolonged 2nd stage of labour 3. Forceps/Ventouse delivery

Question 268

Give 3 red flag signs that a mother may be developing mental health problems postnatally

Answer 268

1. Recent significant change in mental state 2. Thoughts or act of self harm 3. Estrangement form the infant

Question 269

Give 3 symptoms of postnatal depression

Answer 269

1. Depression 2. Irritable 3. Tired 4. Sleepless 5. Appetite change 6. Anxious 7. Negative thoughts Psychosis = depression, mania, psychosis

Question 270

Give 2 risk factors for postpartum psychosis

Answer 270

1. FHx of mental health disorders, particularly postpartum psychosis 2. Diagnosis of bipolar disorder 3. Traumatic birth or pregnancy

Question 271

Name 2 risk factors for postpartum PTSD

Answer 271

1. Perceived lack of care 2. Poor communication 3. Perceived unsafe care 4. Perceived focus on outcome over experience of the mother

Question 272

Name how postpartum PTSD can present

Answer 272

- Anger - Low mood - Self-blame - Isolation - Intrusive and distressing flashbacks

Question 273

Name 2 possible consequences of postpartum PTSD

Answer 273

1. Women may delay or avoid future pregnancies 2. Request C section to avoid vaginal delivery 3. Avoidance of intimate physical relationships 4. Impact on breastfeeding

Question 274

Define maternal death

Answer 274

Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes

Question 275

What is a direct maternal death?

Answer 275

Death relating from obstetric complications of pregnancy, labour or puerperium (haemorrhage, genital sepsis, suicide)

Question 276

What is indirect maternal death?

Answer 276

Death resulting from pre-existing disease/disease that developed in pregnancy but not a direct result of obstetric causes (cardiac disease, malignancies)

Question 277

What are the 3 most common causes of maternal death?

Answer 277

1. VTE 2. Haemorrhage 3. Pre-eclampsia Suicide = leading cause of direct deaths occurring 6 weeks to 1 year after the end of pregnancy

Question 278

Why can ovarian cysts cause pain?

Answer 278

- Haemorrhage into cyst with sudden increase in size/rupture into the peritoneal cavity with spillage of blood - Twist so blood supply is reduced, can be intermittent as it untwist (can stop hurting if necrotic)

Question 279

How can you treat ovarian cysts?

Answer 279

- Remove ovary (reduces fertility and may have cyst on other ovary) - Remove cyst --> laparotomy or laparoscopy

Question 280

Define miscarriage

Answer 280

The loss of a pregnancy before 24 weeks gestation

Question 281

In approximately what percentage of pregnancies does miscarriage occur?

Answer 281

20%

Question 282

What is a threatened miscarriage?

Answer 282

When a lady experiences bleeding +/- abdominal pain but the cervical os is closed

Question 283

What is an inevitable miscarriage?

Answer 283

What a lady experiences heavy bleeding, clots, pain and the cervical os is open

Question 284

Define complete miscarriage

Answer 284

When all products of conception leave the body

Question 285

Define incomplete miscarriage

Answer 285

Bleeding +/- pain with a possible open cervix | - some products of conception remain in the uterus

Question 286

Define recurrent miscarriage

Answer 286

>3 consecutive miscarriages

Question 287

Give 4 potential causes of miscarriage

Answer 287

1. Abnormal fetal development 2. Uterine abnormality 3. Incompetent cervix 4. Placental failure 5. Multiple pregnancy

Question 288

Give 3 risk factors for miscarriage

Answer 288

1. Age >30 2. Smoking 3. Excessive alcohol consumption 4. Uterine surgery 5. Poorly controlled diabetes

Question 289

What investigations might you do to determine whether someone has had a miscarriage?

Answer 289

Transvaginal USS | Serum hCG

Question 290

Describe the management of a miscarriage

Answer 290

1. Expectant (natural) --> no heavy bleeding or early gestation (<8 weeks) 2. Medical 3. Surgical --> manual vacuum aspiration

Question 291

What is medical management of a miscarriage?

Answer 291

Mifepristone (anti progesterone) followed 36-48 hours by misoprostol (synthetic prostaglandin) - only misoprostol if <12 weeks

Question 292

What is an ectopic pregnancy?

Answer 292

Implantation of a concepts outside the uterine cavity

Question 293

What is the most common site of an ectopic pregnancy?

Answer 293

Fallopian tube = 90-95%

Question 294

Give 3 risk factors for an ectopic pregnancy

Answer 294

1. History of infertility or assisted conception (IVF) 2. History of PID 3. Endometriosis 4. Pelvic or tubal surgery 5. Previous ectopic 6. IUCD in situ 7. Smoking

Question 295

What are the signs/symptoms of an ectopic pregnancy?

Answer 295

``` Often asymptomatic Amenorrhoea Lower abdominal pain (in women of reproductive age = ectopic until ruled out) Vaginal bleeding D+V, dizziness, shoulder tip pain ```

Question 296

What investigations might you do to confirm an ectopic pregnancy?

Answer 296

TVS/USS --> establish location Serum progesterone Serum hCG --> associated with lower levels (repeat 48 hours after) Laparoscopy

Question 297

How is an ectopic pregnancy managed?

Answer 297

- Expectant management used under strict criteria --> strict follow up - Medical management of IM methotrexate --> ensure liver and renal function satisfactory - Surgical if criteria aren't met ---> laparoscopy preferred to laparotomy

Question 298

What is gestational trophoblastic disease (GTD)?

Answer 298

GTD describes a group of pregnancy related tumours - These tumour can be pre-malignant and often benign (molar pregnancies) or malignant (choriocarcinoma and invasive mole)

Question 299

What is a molar pregnancy?

Answer 299

A type of GTD - Occurs when there is an abnormality in chromosomal number during fertilisation - Non-viable fertilised egg implants and fails to come to term - Grows into a mass in the uterus

Question 300

Describe a partial molar pregnancy

Answer 300

Where an ovum is fertilised by two sperm --> produces cells with 69 chromosomes (triploidy)

Question 301

Describe a complete molar pregnancy

Answer 301

Where one ovum without any chromosomes is fertilised by 1 sperm which duplicates - There are 46 chromosomes all of paternal origin

Question 302

Give 3 risk factors for GTD

Answer 302

1. Maternal age <16 or >45 2. Multiple pregnancy 3. Previous GTD 4. OCP

Question 303

Give 3 symptoms of molar pregnancies

Answer 303

1. Vaginal bleeding in early pregnancy 2. Abdominal pain in early pregnancy 3. Hyperemesis and hyperthyroidism in late pregnancy due to high levels of BhCG

Question 304

What investigations might you do in someone to determine if they have GTD?

Answer 304

URine and blood BhCG --> very high | USS --> compete mole = snow storm appearance

Question 305

What is the treatment for molar pregnancies?

Answer 305

Suction curettage | Chemotherapy

Question 306

What is hyperemesis gravidarum?

Answer 306

Excessive vomiting associated with dehydration and ketosis in pregnancy - Tends to settle by 15 weeks gestation but ca continue into 2nd and 3rd trimesters

Question 307

Which placental hormone is associated with hyperemesis gravidarum?

Answer 307

BhCG --> very high levels (like multiple pregnancies)

Question 308

How is hyperemesis gravidarum managed?

Answer 308

Rehydrate with IV fluids Vitamins, frequent small meals Antiemetics

Question 309

What forms of contraception can be given anytime after brith?

Answer 309

- Contraceptive implant - Contraceptive injection (depot provera) - Progesterone only pill (POP) - Male condoms - Female condoms - Natural family planning and lactational amenorrhoea

Question 310

What forms of contraception can be given 3 weeks after birth?

Answer 310

- COCP - Contraceptive patch - Contraceptive ring If not breastfeeding and no medical risks/exclusion criteria 6 weeks if breast feeding or VTE risk factors

Question 311

What forms of contraception can be given 4 weeks after birth?

Answer 311

- IUD - IUS If not fitted in the first 24 hours post delivery

Question 312

How does POP work as a contraceptive?

Answer 312

It thickens cervical mucus to prevent sperm penetration and suppresses (thins) the endometrium

Question 313

Give 2 advantages of the POP as a contraceptive?

Answer 313

1. Prevents oestrogen side effects (breast tenderness) | 2. Suitable for smokers, those with obesity, those at increased risk of VTE

Question 314

Give 3 disadvantages of the POP as a contraceptive?

Answer 314

1. Less effective than the COCP 2. Increased risk of ectopic pregnancy 3. Disrupts menstrual pattern --> amenorrhoea, infrequent bleeding, spotting, prolonged bleeding 4. Functional ovarian cyst may develop

Question 315

How long does the contraceptive implant last?

Answer 315

3 years | - Progesterone only so works similarly to POP

Question 316

How often do you need to get the contraceptive injection?

Answer 316

IM injection every 12 weeks | - Progesterone only so acts similarly to POP

Question 317

How long does lactational amenorrhoea act as a contraceptive for following pregnancy?

Answer 317

Until menses return | - Less effective if don't exclusively breastfed

Question 318

How does the COCP work as a contraceptive?

Answer 318

Prevents ovulation, suppressed LH and FSH, thickens cervical mucus and thins the endometrium

Question 319

Give 5 advantages of the COCP as a contraceptive

Answer 319

1. Reversible 2. Reliable 3. Regular cycle 4. Reduces menorrhagia 5. Helps with acne 6. Reduces post-menopausal symptoms

Question 320

Give 3 disadvantages to the COCP as a contraceptive

Answer 320

1. No protection against STIs 2. Headaches/migraines 3. Breakthrough bleeding for first 3-6 months 4. Increased risk of breast and cervical cancer 5. Increased increase of VTE, MI and ischaemic stroke

Question 321

What is the IUD and how long does it last?

Answer 321

Copper coil --> causes foreign body reaction within uterus preventing implantation and sperm transport Lasts 5-10 years

Question 322

Give 2 advantages of the IUD

Answer 322

1. Non hormonal 2. Lasts 5-10 years 3. Effective immediately 4. Effective as emergency contraception

Question 323

Give 2 disadvantages of the IUD

Answer 323

1. May cause menstrual irregularities, spotting, IMB 2. Menorrhagia, dysmenorrhoea 3. Increased risk of PID in first 20 days of insertion (STI screen prior) 4. Risk of ectopic pregnancy 5. Perforation at insertion

Question 324

What is an IUS and how long does it last?

Answer 324

Mirena coil = hormonal Causes endometrial atrophy, thickens cervical mucus, may suppress ovulation Lasts 5 years

Question 325

Give 3 side effects of an IUS

Answer 325

1. Acne 2. Brest tenderness and pain 3. Headache 4. Change to menstruation --> irregular, prolonged or frequent bleeding for 3-6 months after insertion 5. Risk of ectopic pregnancy

Question 326

What type of drug group particularly needs to be thought of when prescribing hormonal contraception?

Answer 326

Anti-epileptic drugs

Question 327

What are the Fraser guidelines?

Answer 327

A doctor can proceed to give contraceptive advice and treatment to someone <16 provided they are satisfied in the following criteria 1. The patient will understand the advice 2. The doctor cannot persuade the patient to inform their parents 3. The patient is very likely to continue having sexual intercourse with or without contraception 4. If the patient does not receive contraceptive advice their physical/mental health will suffer 5. It is in the patients best interests to receive contraceptive advice and treatment without parental consent

Question 328

Define menstruation and the menstrual cycle

Answer 328

Menstruation = Monthly bleeding from female reproductive tract induced by cyclical hormonal changes Cycle = Interval between 1st day of last period and 1st day of next Average cycle = 28 days

Question 329

Name the phases of the menstrual cycle

Answer 329

Follicular phase Ovulation = day 14 Luteal/Secretory Phase Post luteal = implantation or no implantation

Question 330

What happens in the follicular phase of the menstrual cycle?

Answer 330

Low oestrogen and progesterone stimulates GnRH from hypothalamus GnRH stimulates anterior pituitary to release FSH and LH FSH --> proliferation of granulosa follicular cells LH --> proliferation of granulosa cells in follicles Oestrogen released from granulosa cells --> stimulates endometrium growth At low levels oestrogen inhibits release of FSH and LH from anterior pituitary Inhibin released from granulosa cells --> inhibits anterior pituitary

Question 331

What happens during ovulation in the menstrual cycle?

Answer 331

Oestrogen production reaches threshold = no longer negative feedback LH surge causes weakening in follicle wall = mature ovum released Ovulation occurs 36 hours after LH surge (+ve feedback)

Question 332

What happens in the luteal/secretory phase of the menstrual cycle?

Answer 332

FSH and LH cause follicle to degrade into corpus luteum Corpus luteum produces high amounts of progesterone and some oestrogen Progesterone stimulates endometrium growth --> ready for blastocyst Corpus luteum suppresses FSH and LH production from anterior pituitary

Question 333

What happens in the post luteal phase of the menstrual cycle?

Answer 333

Implantation = embryo produces beta human chorionic gonadotrophin hormone which preserves corpus luteum and endometrium No implantation = low FSH and LH levels cause corpus luteum atrophy which stops progesterone production and menstruation occurs

Question 334

Which hormone is responsible for thickening the endometrium?

Answer 334

Oestrogen

Question 335

Which hormone is responsible for thinning the endometrium?

Answer 335

Progesterone

Question 336

A surge in which hormone leads to ovulation?

Answer 336

LH

Question 337

Approximately how much blood is lost in menstruation?

Answer 337

60-80ml

Question 338

Define menorrhagia

Answer 338

Heavy menstrual bleeding that occurs at expected intervals of the menstrual cycle that interferes with the physical, emotional and social QOL

Question 339

Define Abnormal uterine bleeding

Answer 339

Any menstrual bleeding from the uterus that is either abnormal in volume, regularity, timing or is non-menstrual (PCB, IMB, PMB)

Question 340

Give 3 causes of menorrhagia

Answer 340

1. Fibroids 2. Uterine polyps 3. Endometriosis/adenomyosis 4. Hypothyroidism 5. Infection 6. Ovulatory problems --> PCOS, perimenopause 7. Malignancy or hyperplasia 8. Coagulopathy

Question 341

Give 5 questions that you should ask when taking history from a lady who is presenting with menorrhagia

Answer 341

1. How much blood? 2. How many pads? Flooding? 3. Clots? 4. Duration of bleeding? 5. Pain? --> when this occurs during cycle? 6. Impact on ADLs and QOL? 7. Any associated symptoms --> thyroid? clotting? drugs (warfarin)?

Question 342

What investigations might you do on a woman presenting with menorrhagia?

Answer 342

1. FBC, B12/folate/iron, TSH, STI screen 2. Smear if due 3. TVS 4. Endometrial biopsy if >45 and IMB or unresponsive to treatment

Question 343

Describe the management of menorrhagia

Answer 343

1. Minera 2. Anti-fibrinolytics --> tranexamic acid 3. NSAIDs --> mefenamic acid 4. Progesterones --> depo-provera injection or oral (noresthisterone) 5. COCP 6. Endometrial ablation 7. Myomectomy = resection of fibroids 8. Uterine artery embolisation 9. Hysterectomy

Question 344

Define primary amenorrhoea

Answer 344

No menses by the age of 16 in the presence of secondary sexual characteristics or by 14 in girls with no secondary sexual characteristics

Question 345

Define secondary amenorrhoea

Answer 345

Cessation of menses for 6 months in women with previously normal and regular menses, or for 12 months in women with previous oligomenorrhoea

Question 346

Give 3 hypothalamic causes of amenorrhoea

Answer 346

1. Functional disorders --> eating disorder, stress, excessive exercise 2. Non-functional --> SOL, surgery, radiotherapy, Kallman's syndrome (primary GnRH deficiency 3. Reduced GnRH

Question 347

Give 3 pituitary causes of amenorrhoea

Answer 347

1. Prolactinoma 2. Other pituitary tumours --> acromegaly, Cushing's 3. Sheehan's syndrome (infarction fo pituitary often due to PPH) 4. Surgery

Question 348

Give 3 ovarian causes of amenorrhoea

Answer 348

1. PCOS 2. Primary Ovarian Failure 3. Turner's syndrome (45X)

Question 349

Give 2 uterine/genital outflow obstruction causes of amenorrhoea

Answer 349

1. Imperforate hymen 2. Transverse vaginal septum 3. Cervical stenosis 4. Mullerian agenesis

Question 350

Give 3 physiological causes of amenorrhoea

Answer 350

1. Pregnancy 2. Lactation 3. Menopause

Question 351

Give 3 important questions to ask in a amenorrhoea history

Answer 351

1. Sexual history 2. Galactorrhoea or androgenic symptoms (weight gain, hirsutism) 3. Menopausal symptoms 4. Previous genital tract surgery --> IUD, LLETZ 5. Issue with eating/excessive exercise 6. Drug use --> especially dopamine antagonist (psych) 7. Fhx

Question 352

Give 3 important tings to look for in an amenorrhoea examination

Answer 352

1. BMI 2. Secondary sexual characteristics 3. Stigmata of endocrinopathies or Turner's 4. Evidence of virillisation --> deep voice, male pattern balding, cliteromegaly 5. Abdominal masses 6. Imperforate hymen, blind ended vaginal septum, absence of cervix or uterus

Question 353

What investigations should be done in a woman complaining of amenorrhoea?

Answer 353

- Pregnancy test - FSH/LH - Testosterone and sex hormone binding globulin - Prolactin - TFTs - Pelvic USS - Karyotype

Question 354

Amenorrhoea: what part of the hypothalamic gonadal axis would be affected if FSH/LH levels came back abnormal?

Answer 354

Could indicate a pituitary problem

Question 355

Amenorrhoea: what part of the hypothalamic gonadal axis would be affected if GnRH levels came back abnormal?

Answer 355

Could indicate a hypothalamic problem

Question 356

Name 3 possible complications of amenorrhoea

Answer 356

1. Osteoporosis 2. Infertility 3. CVD 4. Psychological distress 5. PCOS --> DM, CVD, endometrial hyperplasia 6. Gonadal tumours in presence of Y chromosome

Question 357

What is androgen insensitivity syndrome?

Answer 357

When a person is genetically male but phenotypically female. They have intra-abdominal gonads and their cells don't respond to male hormones e.g. androgens

Question 358

Define Oligomenorrhoea

Answer 358

Menses occurring more than 35 days apart

Question 359

Define primary and secondary dysmenorrhoea

Answer 359

``` Primary = painful menses with no obvious organic cause Secondary = painful menses due to underlying condition ```

Question 360

Define chronic pelvic pain

Answer 360

Lower abdominal pain for >6 months that does not occur exclusively with menstruation, intercourse or pregnancy

Question 361

Define acute pelvic pain

Answer 361

Sudden, unexpected pain for <6 months

Question 362

Name 3 pregnancy related causes of acute pelvic pain

Answer 362

1. Ectopic pregnancy 2. Miscarriage 3. Ovarian cyst rupture/haemorrhage/torsion

Question 363

Name 3 gynaecological causes of acute pelvic pain

Answer 363

1. PID 2. Abscess 3. Ovarian cyst rupture/haemorrhage/torsion

Question 364

Name 3 gastrointestinal causes of acute pelvic pain

Answer 364

1. Appendicitis 2. Constipation 3. Bowel obstruction 4. Peritonitis

Question 365

Name 3 Genito-urinary causes of acute pelvic pain

Answer 365

1. UTI 2. Renal stones 3. Urinary retention

Question 366

Name 2 MSK causes of acute pelvic pain

Answer 366

1. Disc prolapse | 2. Nerve entrapment

Question 367

Name 3 gynaecological causes of chronic pelvic pain

Answer 367

1. Endometriosis/adenomyosis 2. Fibroids 3. Adhesions 4. PID 5. Ovarian cysts 6. Prolapse

Question 368

Name 3 gastrointestinal causes of chronic pelvic pain

Answer 368

1. IBS 2. Constipation 3. Inflammatory bowel

Question 369

Name a genito-urinary cause of chronic pelvic pain

Answer 369

Interstitial cystitis

Question 370

Name MSK causes of chronic pelvic pain

Answer 370

1. Nerve entrapment | 2. Referred MSK pain

Question 371

What investigations might you do on a patient presenting with pelvic pain?

Answer 371

1. Urinalysis, MSU, pregnancy test, bloods 2. Pelvic USS -> fibroids, ovarian cysts, endometriosis 3. Laparoscopy -> endometriosis, adhesions 4. Hysteroscopy -> fibroids 5. MRI -> adhesions, adenomyosis, fibroids 6. STI screen

Question 372

If pain fluctuates with the menstrual cycle what is the diagnosis likely to be?

Answer 372

Endometriosis or Adenomyosis

Question 373

What is endometriosis?

Answer 373

A chronic oestrogen dependent disease where there is growth of endometrial tissue outside the endometrial cavity

Question 374

Why does endometriosis tend to get better after menopause?

Answer 374

Endometriosis relies on oestrogen so when oestrogen levels fall after menopause, symptoms of endometriosis tend to improve

Question 375

In what group of people is endometriosis most common?

Answer 375

Young, nulliparous women (25-35)

Question 376

Describe the aetiology of endometriosis

Answer 376

The cause of endometriosis is thought to be due to retrograde menstruation and a genetic component Lymphatic spread may also be responsible

Question 377

What anatomical areas are most likely to be affected by endometriosis?

Answer 377

The pouch of Douglas and the uterosacral ligaments

Question 378

Give 5 risk factors for developing endometriosis

Answer 378

1. Early menarche 2. Late menopause 3. Delayed childbearing 4. Short cycles 5. Obstruction to vaginal flow 6. Genetic predisposition

Question 379

Give 2 factors that are protective against endometriosis

Answer 379

1. COCP | 2. Multiparity

Question 380

Give 5 symptoms of endometriosis

Answer 380

1. Cyclical pain --> dysmenorrhoea and dyspareunia 2. Bleeding 3. Lump 4. Dysuria 5. Dyschezia (pain on defecation) 6. Infertility 7. Haematuria, rectal bleeding, or bleeding form umbilicus during menstruation (severe) 8. Endometrioma = endometriosis in ovary (cyst) that bleeds into ovary during menstruation

Question 381

What investigations might you do in a woman with suspected endometriosis?

Answer 381

1. Digital examination 2. TVS 3. Diagnostic laparoscopy 4. Hysteroscopy

Question 382

What is the gold standard investigating for diagnosing endometriosis?

Answer 382

Diagnostic laparoscopy

Question 383

What grading classification is used in endometriosis ?

Answer 383

AFS classification

Question 384

What non specific protein marker might be raised in a woman with endometriosis?

Answer 384

CA125 - Non-specific --> raised in anything that irritates with peritoneum - Often raised in ovarian cancer

Question 385

What medications can be given to treat endometriosis?

Answer 385

``` Abolish cyclicity - OCP - GnRH agonists +/- HRT Thin endometrium - POP/Depot provera - Mirena ```

Question 386

Give 3 advantages of using the OCP to treat endometriosis

Answer 386

1. Cheap 2. Effective 3. Minimal side effects 4. Predictable an reliable Often 3 packs taken back to back (try-phasing) then a bleed then 3 packs etc.

Question 387

How to GnRH agonists work in treating endometriosis?

Answer 387

GnRH is normally released in a pulsatile way, GnRH agonists are given continuously in order to stop ovulation and triggers an 'artificial menopause' (this is reversible) GnRH agonist -> huge release of FSH/LH -> down-regulation of FSH/LH -> no oestrogen release

Question 388

Give 3 side effects of GnRH agonist being used to treat endometriosis

Answer 388

1. Osteoporosis 2. Hot flushes 3. Mood swings

Question 389

How can GnRH agonist side effects be prevented in the treatment of endometriosis?

Answer 389

HRT 'add back' therapy --> small dose of oestrogen prescribed alongside GnRH agonist

Question 390

What is the surgical treatment for endometriosis?

Answer 390

1. Laparoscopy with ablation or excision 2. Hysterectomy with bilateral salpingo-oophrectomy - Only if completed family

Question 391

What is adenomyosis?

Answer 391

Invasion of endometrial tissues into the myometrium

Question 392

Give 3 risk factors for adenomyosis?

Answer 392

1. Multiparity 2. Uterine surgery 3. Previous C section

Question 393

Describe the epidemiology of adenomyosis and compare it to that of endometriosis

Answer 393

``` Adenomyosis = older, multiparous women Endometriosis = younger, nulliparous women ```

Question 394

Give 3 symptoms fo adenomyosis

Answer 394

1. Menorrhagia 2. Dysmenorrhoea 3. Dyspareunia Pain is typically cyclical

Question 395

What investigations might you do for suspected adenomyosis?

Answer 395

1. TSH 2. TVS 3. MRI Adenomyosis is difficult to diagnose with imaging, histology at hysterectomy is definitive

Question 396

What is the treatment for adenomyosis?

Answer 396

Analgesia --> NSAIDs, TXA Ovulation suppression --> tricyclic COCP, minera coil, GnRH analgoues Surgery = hysterectomy and oophorectomy --> CURE

Question 397

What are fibroids?

Answer 397

Benign smooth muscle tumours of the uterine myometrium (leiomyomas)

Question 398

What hormone is thought to stimulate fibroid development?

Answer 398

Oestrogen

Question 399

How are fibroids classified?

Answer 399

According to their position in the uterine wall - Intramural - Submucosal - Subserosal

Question 400

What type of fibroids are most common?

Answer 400

Intramural = fibroids to the myometrium

Question 401

Describe the location of submucosal fibroids

Answer 401

Fibroids growing into the uterine cavity

Question 402

Describe the location of subserosal fibroids

Answer 402

Fibroids growing outwards from the outwards

Question 403

Give 4 risk factors for the development of fibroids

Answer 403

1. Obesity 2. Early menarche 3. FHx 4. Increasing age (during reproductive ages) 5. Low parity

Question 404

Give 4 symptoms of fibroids

Answer 404

1. Pain 2. Infertility/sub-fertility 3. Menorrhagia 4. Pressure symptoms --> urinary frequency (if on bladder) 5. Iron deficiency anaemia 6. IMB

Question 405

What investigations might you do to determine if a patient has fibroids?

Answer 405

1. TVS 2. Hysteroscopy 3. MRI 4. Diagnostic laparoscopy

Question 406

What treatments can you have for fibroids?

Answer 406

1. Conservative --> watch and wait 2. Medical - NSAIDS +/- TXA - hormonal therapy (COCP, Mirena, GnRH agonists) 3. Surgical --> hysteroscopic resection, myomectomy, hysterectomy

Question 407

What is the gold standard treatment for uterine fibroids?

Answer 407

Hysterectomy | - If patient if young and wants children = myomectomy

Question 408

Give 3 differentials for uterine fibroids

Answer 408

1. Endometrial polyps 2. Cancer 3, Endometriosis/adenomyosis 4. Chronic PID

Question 409

What are endometrial polyps?

Answer 409

Overgrowth of glandular tissue within lining of the womb (as extension of endometrium)

Question 410

Who is most likely to get endometrial polyps?

Answer 410

Women aged 40-50 when oestrogen is high | - Also seen in post menopausal women on tamoxifen

Question 411

What is Pelvic Inflammatory Disease (PID)?

Answer 411

Inflammation of the upper genital tract (cervix, uterus, Fallopian tubes)

Question 412

What can cause PID?

Answer 412

Infection --> gonorrhoea, chlamydia that ascends from the endocervix

Question 413

What are the risk factors for PID?

Answer 413

1. Young age 2. Multiple sexual partners 3. Not using barrier contraception 4. Surgical TOP 5. IUCD (especially inserted within the last 20 days) 6. Previous STIs

Question 414

Give 3 symptoms of PID

Answer 414

1. Bilateral lower abdominal pain (can be chronic) 2. Deep dyspareunia 3. Abnormal vaginal bleeding --> PCB, IMB, menorrhagia 4. Purulent vaginal or cervical discharge 5. Asymptomatic --> present with subfertility or menstrual problems

Question 415

Give 2 signs of PID

Answer 415

1. Lower abdominal tenderness (usually bilateral) 2. Cervical motion tenderness and adnexal tenderens = cervical excitation (on bimanual exam) 3. Fever >38 (can be pyrexial)

Question 416

What investigations might you do in someone with suspected PID

Answer 416

Bloods --> FBC, WCC, CRP, ESR, cultures HSV and endocervical swabs Pelvic Us --> exclude abscess or ovarian cyst Diagnostic laparoscopy

Question 417

Describe the treatment of PID

Answer 417

IM ceftriaxone 500mg followed by PO doxycycline 100mg BD and PO metronidazole 400mg BD for 14 days

Question 418

Name 2 possible complications of PID

Answer 418

1. Abscess 2. Pyosalpinx (obstructed and dilated Fallopian tubes by pus) 3. Subfertility 4. Ectopic pregnancy

Question 419

What is the role of p53?

Answer 419

p53 = tumour supressor gene | - Transcription factor that regulates cell division and death

Question 420

What is the role of Rb?

Answer 420

Rb = tumour supressor gene | - Alters the activity fo transcription factors and so controls cell division

Question 421

If there is a mutation in either p53 or Rb what might happen?

Answer 421

Uncontrolled cell growth may occur --> cancer

Question 422

What are the roles of oncogenes?

Answer 422

Oncogenes stimulate excessive cell growth and cell division --> cancer development

Question 423

Give an example of an oncogene

Answer 423

HER-2

Question 424

What is the most common type of gynaecological cancer?

Answer 424

Endometrial cancer

Question 425

What is the pathophysiology behind endometrial cancer?

Answer 425

Unopposed oestrogen leads to endometrial hyperplasia and so increased risk of endometrial adenocarcinoma

Question 426

Give 5 risk factors for developing endometrial cancer

Answer 426

1. Obesity = unopposed oestrogen 2. Diabetes 3. Nulliparity 4. Late menopause and early menarche 5. HRT (oestrogen only) m 6. Pelvic irradiation 7. Tamoxifen 8. PCOS 9. Genetic --> HNPCC

Question 427

What is the most common type of endometrial cancer?

Answer 427

Endometrial adenocarcinoma

Question 428

What is the red flag symptom for endometrial cancer?

Answer 428

Post menopausal bleeding | - Any PMB at all = 2WW

Question 429

What investigations might you do if you suspect that a woman may have endometrial cancer?

Answer 429

- Pelvic and abdominal examination - TVS = measure endometrial thickness - Endometrial biopsy - Hysteroscopy

Question 430

How thick should the endometrium be, postmenopausally?

Answer 430

<4mm | - If >4mm = endometrial biopsy

Question 431

What type of staging is used for endometrial cancer?

Answer 431

FIGO staging - Stage 1 = confined to endometrium in the womb - Stage 2 = limited to uterine body and cervix - Stage 3 = extension to uterine serosa, peritoneal cavity +/- lymph nodes - Stage 4 = extension beyond true pelvis and/or involvement of bladder/bowel mucosa

Question 432

Describe the treatment for endometrial cancer

Answer 432

1. Hysterectomy +/- pelvic lymph node removal | 2. Adjuvant radiotherapy (vault brachytherapy) and progesterone therapy

Question 433

Define adenocarcinoma

Answer 433

A malignant tumour of glandular epithelium

Question 434

Why is the incidence of cervical cancer decreasing?

Answer 434

1. Screening = cervical smears | 2. HPV vaccines

Question 435

Name 2 oncoproteins associated with HPV

Answer 435

1. E6 = blocks p53 | 2. E7 = blocks Rb

Question 436

Which oncoprotein blocks p53?

Answer 436

E6

Question 437

Which oncoprotein blocks Rb?

Answer 437

E7

Question 438

Give 5 risk factors for HPV and so cervical cancer

Answer 438

1. Early age intercourse (<16) 2. Multiple sexual partners 3. STIs 4. Smoking 5. Multiparity 6. OCP 7. Persistent high risk HPV infection

Question 439

What is the most common type of cervical cancer?

Answer 439

Squamous (90%)

Question 440

What type of staging is used for cervical cancer?

Answer 440

FIGO staging

Question 441

What is the red flag symptom for cervical cancer?

Answer 441

Post coital bleeding | - Usually asymptomatic and found on cervical smear

Question 442

What investigations might you do in a patient who you suspect has cervical cancer?

Answer 442

1. Vaginal and bimanual examination 2. Coloposcopy 3. Biopsy 4. HPV testing

Question 443

Describe the treatment for cervical cancer

Answer 443

1. Local excision or total abdominal hysterectomy (<2cm) 2. Radical hysterectomy with pelvic lymphadenectomy (>2cm) 3. Radiotherapy, chemotherapy, palliative care (>4cm)

Question 444

What must you consider when treating cervical cancer?

Answer 444

Fertility --> does the patent want children in the future?

Question 445

Give 3 potential risks of performing a radical hysterectomy

Answer 445

1. Bowel problems 2. Sexual problems 3. Bladder problems 4. Lymphoedema

Question 446

When does cervical screening occur?

Answer 446

Smear tests from 25-50 every 3 years and every 5 years between 50-64

Question 447

When would someone be referred to colposcopy following a smear?

Answer 447

- Moderate/severe dyskaryosis - HPV +ve with any abnormal cells - HPV +ve with normal cells for 2 years in a row - GP unable to obtain smear

Question 448

What is done in coloposcopy for cervical cancer screening?

Answer 448

Magnified visualisation of the transformation zone - Acetic acid = turns abnormal cells white - Lugol's iodine = turns normal cells 'chocolate' coloured Biopsy taken if abnormal cells seen

Question 449

What is the treatment for HPV?

Answer 449

Is just HPV and no abnormal cells then there is NO treatment - Often own immune system eradicates it - Stopping smoking can help eradicate HPV

Question 450

What is the treatment for CIN?

Answer 450

- Low grade (CIN1) = spontaneously regressed in 50-60% cases within 2 years --> conservative monitoring (LLETZ if persistent) - High grade (CIN II or III) --> LLETZ = removal of abnormal tissue under local - CGIN (cervicl glandular intraepithelial neoplasia) LLETZ or cone biopsy

Question 451

What is the most common type of vulval cancer

Answer 451

Squamous

Question 452

Describe the aetiology of vuluval cancer

Answer 452

Vulval intraepithelial neoplasia (VIN - skin disease) --> Abnormal cells develop in the surface layers of the skin covering the vulva - It is not vulval cancer but may turn into cancer = pre-malignant - Usual type is associated with HPV infection

Question 453

Give 3 symptoms of vulval cancer

Answer 453

1. Itching 2. Soreness 3. Lump 4. Bleeding 5. Pain on micturition

Question 454

What investigations would you do for suspected vulval cancer?

Answer 454

Vulval biopsy --> histology

Question 455

Describe the treatment for vulval cancer

Answer 455

- Surgery --> WLE or radical +- lymphadenectomy - Radiotherapy - Chemotherapy

Question 456

What is the most common type of ovarian cancer?

Answer 456

Epithelial (85%) | - Also sex cord and germ cell

Question 457

Describe the epidemiology of ovarian cancer

Answer 457

More common in women >50, postmenopausal | Often with late presentation

Question 458

Give 3 risk factors for ovarian cancer

Answer 458

1. Early menarche 2. Late menopause 3. Nulliparity 4. Hysterectomy 5. Gene mutation --> BRCA 1/2, HNPCC

Question 459

Give 4 symptoms of ovarian cancer

Answer 459

1. Bloating/IBS like symptoms 2. Abdominal pain 3. Change in bowel habit 4. Urinary frequency 5. Bowel obstruction 6. Abnormal vaginal bleeding - Can often be asymptomatic

Question 460

What investigations might you do for someone with suspected ovarian cancer?

Answer 460

- CA125 - USS - CT - Biopsy - CXR --> mets

Question 461

What classification if used to stage ovarian cancer?

Answer 461

FIGO

Question 462

How is ovarian cancer treated?

Answer 462

- Prophylactic surgery for those with identified BRCA mutation = BSO - Laparotomy and chemotherapy

Question 463

What types of vaginal cancers can occur?

Answer 463

- Mostly metastases from other gynaecological cancer - Most common primary vaginal cancer = squamous cell (commonly HPV related) - Vaginal clear cell adenocarcinoma (young women associated with diethylstilbestrol exposure in utero before 18 weeks gestation)

Question 464

How do you treat a Bartholin's cyst?

Answer 464

Blocked Bartholin duct in lower 1/3 of labia major | - Incision and marsupialisation

Question 465

What HPV are genital warts associated with?

Answer 465

HPV 6 and 11 | - Both covered in HPV vaccine with 16 and 18 (cancer)

Question 466

What is Paget's disease of the vulva?

Answer 466

Non mammary adenocarcinoma in situ | - Surgical excise and exclude underlying malignancy

Question 467

When would you refer a couple for infertility invetgtiatlons?

Answer 467

Failure to conceive after 1 year of trying

Question 468

What would make you consider early referral or investigating infertility?

Answer 468

Is the woman is >35, has a menstrual disorder, previous surgery or previous PID/STI and/or if the man has genital pathology, previous STI, systemic illness or an abnormal genital examination

Question 469

What pre-conception advice would you give to a couple?

Answer 469

1. Intercourse 2/3 times a week 2. Folic acid 3. Up to date smears 4. Smoking cessation and reduce alcohol intake 5. Manage comorbidities 6. Ensure healthy weight

Question 470

Name 3 reproductive disorders that are associated with obesity

Answer 470

1. PCOS 2. Miscarriage 3. Infertility 4. Obstetric complications

Question 471

Give 5 causes of infertility

Answer 471

1. Male factors (30%) 2. Unexplained (25%) 3. Ovulatory (25%) 4. Tubal (20%) 5. Uterine/peritoneal (10%) - Combined male and female factors

Question 472

What 3 things are investigated in initial infertility tests?

Answer 472

1 . Ovulation/ovarian function 2. Semen quality 3. Tubal patency

Question 473

What infertility investigations would the GP do?

Answer 473

1. Hormone profile 2. TFT's and prolactin 3. Rubella and chalmydia screen 4. Smear 5. Semen analysis

Question 474

Infertility investigations: how can you check ovulation?

Answer 474

Measure mid-luteal progesterone --> around 21 days | - >30 mol/L = ovulation

Question 475

Infertility investigations: what hormone levels are looked at in order to test ovarian reserve?

Answer 475

1. FSH 2. Anitmullerian Hormone (AMH) 3. Antral follicle count (AFC)

Question 476

What does a sperm count need to be for further tests to be done?

Answer 476

<5m/ml | - Further tests --> endocrine, karyotyping (Klinefelter's), CF screen, testicular biopsy, imaging

Question 477

Infertility investigations: how can tubal patency be investigated?

Answer 477

1. Hysterosalpingography (HSG) 2. HyCoSy (Hysteroslapingo-contrast-sonograph) = US test with galactose-containing contrast medium 3. Laparoscopy and dye (under GA)

Question 478

How can infertility be managed if there is a mild male abnormality?

Answer 478

Intrauterine insemination

Question 479

How can infertility be managed if there is a moderate male abnormality?

Answer 479

IVF

Question 480

How can infertility be managed if there is a severe male abnormality?

Answer 480

Intracytoplasmic sperm injection

Question 481

How can infertility be managed is azoospermia is the cause?

Answer 481

1. Surgical sperm recovery | 2. Donor insemination

Question 482

Infertility: Give 3 risk factors for anovulation

Answer 482

1. Stress 2. Low weight 3. Excessive exercise 4. Kallmann's and Turner's syndrome

Question 483

Give 3 causes of anovulation

Answer 483

1. Hypothalamic problems --> low FSH/LH/E2 levels 2. Pituitary problems = adenoma, Sheehans, thyroid/adrenal 3. Ovarian problems --> PCOS, Menopause

Question 484

What is the Rotterdam diagnostic criteria for PCOS?

Answer 484

1. Anovulation/oligo/amenorrhoea 2. Polycystic ovaries seen on imaging 3. Increased androgens --> clinically (hirsutism/acne) or biochemical (raised testosterone) 2/3 = diagnosis

Question 485

How can PCOS be treated?

Answer 485

1. Encourage weight loss 2. COCP if not wanting to get pregnant 3. Symptomatic treatment of acne and hirsutism 4. Clomifene/tamoxifen (antioestrogene) 5. + Metformin 6. Gonadotrophin or pulsatile GnRH (if clomifene resistant) 7. Ovarian drilling

Question 486

How does clomifene work in the treatment of PCOS?

Answer 486

Antioestrogen --> leads to increased production of LH/FSH so more follicle stimulation Can treat menstrual disturbance and has a good pregnancy rate

Question 487

Give 3 causes of tubal disease

Answer 487

1. Infections --> chlamydia, gonorrhoea 2. Endometriosis 3. Iatrogenic --> adhesions, sterilisation

Question 488

How can you treat tubal disease?

Answer 488

Laparoscopic tubal surgery --> adhesiolysis, salpingostomy, proximal anastomosis, reversal of sterilisation Tubal catheterisation IVF

Question 489

Briefly describe the process fo IVF

Answer 489

Ovulation stimulation --> egg collection --> insemination --> fertilisation check --> embryo culture --> embryo transfer --> luteal support

Question 490

Why is only 1 egg transferred in IVF?

Answer 490

To avoid multiple pregnancy

Question 491

Give 4 risks associated with IVF

Answer 491

1. Multiple pregnancy 2. Miscarriage 3. Ectopic pregnancy 4. Fetal abnormality

Question 492

Give 4 factors that can affect the likelihood of IVF being successful

Answer 492

1. Increased age --> reduces egg quality 2. Successive cycles/longer duration infertility 3. Obesity 4. Environmental factors --> smoking, alcohol, caffeine 5. Maternal medical problems

Question 493

Give 3 uterine abnormalities that can affect fertility

Answer 493

1. Endometrial polyps 2. Fibroids --> especially submucous 3. Adhesions

Question 494

Define menopause

Answer 494

The cessation of menstruation normally around 51 years old - Diagnosed retrospectively after 12 months of amenorrhoea or 12 months after the onset of symptoms if the patient has had a hysterectomy (straight away if BSO too)

Question 495

Define peri-menopause

Answer 495

The period leading up to menopause | Characterised by irregular periods and symptoms --> hot flushes, mood swings, urogenital atrophy

Question 496

A depletion in what hormone is thought to trigger the symptoms of menopause?

Answer 496

A reduction in oestrogen

Question 497

Give 2 vasomotor symptoms of the menopause

Answer 497

1. Hot flushes 2. Night sweats Can impact on sleep, mood and QOL

Question 498

Give 4 generalised symptoms of menopause

Answer 498

1. Mood change/irritability 2. Loss of memory/concentration 3. Headaches 4. Joint and muscle pain 5. Dry, itchy skin

Question 499

Give 3 local effects of menopause

Answer 499

Urogenital atrophy 1. Vaginal dryness 2. Dyspareunia 3. Recurrent UTIs 4. PMB

Question 500

Give 3 possible long term impacts of menopause

Answer 500

1. Osteoporosis 2. CV disease 3. Dementia

Question 501

Describe how menopause can be managed in a symptomatic patient

Answer 501

1. holistic approach, lifestyle advice, reduce modifiable RFs 2. HRT, vaginal oestrogens 3. Non-hormonal options (clonidine) 4. Non-pharmaceutical (CBT)

Question 502

Give 3 advantages of HRT being used to treat the menopause

Answer 502

1. Relief of symptoms 2. BMD protection 3. Prevents long term morbidity

Question 503

Give 3 disadvantages of HRT being used to treat menopause

Answer 503

1. Increased risk of breast cancer 2. Increased VTE risk with oral HRT 3. Increased CVD risk

Question 504

What hormone should be given to women with a uterus who are prescribed HRT?

Answer 504

Progesterone - Protects the endometrium from the stimulatory effects of unopposed oestrogen - No need in those who have had a hysterectomy

Question 505

How can progesterone be prescribed alongside HRT?

Answer 505

Used for 12-14 days every 4 weeks = sequential --> bleeds OR Continuous combined, everyday --> no bleeding

Question 506

When might transdermal HRT be indicated?

Answer 506

1. Women with gastric problems (Crohn's) 2. Migraines/epilepsy suffered 3. High risk VTE 4. Older women 5. Medical conditions --> HTN 6. Patient choice

Question 507

Give 3 possible side effects of systemic HRT

Answer 507

Fluid retention, breast tenderness, headaches Oestrogen --> bloating, leg cramps, nausea Progesterone --> migraine, mood swings, depression, acne, backache Combined HRT --> irregular breakthrough bleeding Weight gain

Question 508

Give 3 possible non-hormonal treatments for menopause

Answer 508

1. Alpha adrenergic receptor agonist = Clonidine --> for vasomotor symptoms 2. Low dose SSRI = fluoxetine, citalopram, sertraline --> for vasomotor symptoms 3. Anti-epileptics = gabapentin 4. Bisphosphonates --> prevention and treatment of osteoporosis 5. Non oestrogen vaginal lubricants

Question 509

Define premature menopause

Answer 509

Menopause before the age of 40

Question 510

What is premature ovarian failure?

Answer 510

Primary ovarian insufficiency before the age of 40 with associated menopausal symptoms such as night sweats

Question 511

What can cause premature ovarian failure?

Answer 511

1. Idiopathic 2. Chromosomal abnormalities 3. Enzyme deficiencies 4. Autoimmune disease 5. Iatrogenic --> bilateral oophorectomy, surgical menopause, hysterectomy, chemo/radiotherapy

Question 512

What does premature ovarian failure usually present with?

Answer 512

Secondary amenorrhoea or oligomenorrhoea | Often coexisting disease --> hypothyroid, Addisons, DM, chromosomal abnoramlities

Question 513

What would hormone profile tests show in women with premature ovarian failure?

Answer 513

Low oestrogen and high FSH

Question 514

What is the diagnostic criteria for premature ovarian failure?

Answer 514

1. FSH >25IU/L --> 2 samples 4 weeks apart AND 2. 4 months of amenorrhoea

Question 515

Describe the treatment for premature ovarian failure

Answer 515

Oestrogen replacement --> HRT or continuous COCP - Until average age of menopause - Donor eggs for fertility

Question 516

If a woman goes through the menopause <50 for how many years is she still fertile for?

Answer 516

2 years

Question 517

If a woman goes through the menopause >50 for how many years is she still fertile for?

Answer 517

1 year

Question 518

Give 3 contraindications for HRT

Answer 518

1. Undiagnosed abnormal PV bleeding 2. Breast lump 3. Acute liver disease

Question 519

Define FGM

Answer 519

All procedures involving damaging or removing external female genitalia for non-medical reasons

Question 520

Give 3 possible gynaecological problems of FGM

Answer 520

1. Dysparenuia 2. Sexual dysfunction with anorgasmia 3. Chronic pain 4. Dysmenorrhoea 5. Urinary outflow obstruction/recurrent UTI 6. PTSD

Question 521

Give 3 possible obstetric problems of FGM

Answer 521

1. Problems with conception and labour 2. Increased likelihood of C section 3. Increased likelihood of PPH 4. Increased likelihood os severe vaginal lacerations

Question 522

Describe a first degree vaginal tear

Answer 522

First degree = tear within vaginal mucosa only

Question 523

Describe a second degree vaginal tear

Answer 523

Second degree = tear into sub-cutaneous tissue

Question 524

Describe a third degree vaginal tear

Answer 524

Third degree = laceration extends into external anal sphincter

Question 525

Describe a fourth degree vaginal tear

Answer 525

Fourth degree = Laceration extends through external anal sphincter into rectal mucosa

Question 526

Give 3 risk factors for vaginal tears

Answer 526

1. Primigravida 2. Macrosomia and shoulder dystocia 3. Forceps delivery 4. FGM

Question 527

What laters of the tri-laminar disc forms the male and female genitalia?

Answer 527

Intermediate mesoderm

Question 528

What does the mullerian duct form?

Answer 528

1. Fallopian tubes 2. Uterus 3. Cervix 4. Proximal 1/3 of vagina

Question 529

What does the cloaca divide into?

Answer 529

1. Anorectal canal | 2. Urogenital sinus

Question 530

From what artery are the ovarian arteries branch off?

Answer 530

The abdominal aorta

Question 531

Where do the L and R ovarian veins drain?

Answer 531

L ovarian vein --> L renal vein | R ovarian vein --> IVS

Question 532

Describe the hypothalamic gonadal axis

Answer 532

Hypothalamus --> GnRH --> anterior pituitary --> FSH/LH --> Granulosa and Theca cells --> androgens and oestrogen

Question 533

Define precocious puberty

Answer 533

The onset of secondary sexual characteristics before 8 years old (girls) or 9 years old (boys)

Question 534

Name 3 possible causes of precocious puberty

Answer 534

Gonadotropin dependent --> maturation of entire HPG axis 1. CNS abnormalities --> trauma, pituitary tumours, hydrocephalus 2. Cerebral palsy Gonadotropin independent 3. Primary hypothyroidism 4. CAH 5. Tumour of adrenals or ovaries

Question 535

Define delayed puberty

Answer 535

Delay in onset of development of secondary sexual characteristics

Question 536

Name 3 possible causes of delayed puberty

Answer 536

1. Constitutional delay 2. Chronic systemic disease 3. Weight loss, excessive exercise 4. Hypogonadotropic hypogonadism 5. Pituitary tumours 6. Ovarian failure --> Turner's, Swyer syndrome

Question 537

What disease must you rule out in girls with delayed puberty and short stature?

Answer 537

Turner's syndrome

Question 538

Give 4 differentials for a breast lump

Answer 538

1. Breast carcinoma 2. Fibroadenoma 3. Breast abscess 4. Breast cyst

Question 539

Why is the incidence of breast cancer thought to be increasing?

Answer 539

1. Western lifestyle 2. Screening 3. Increasing life expectancy

Question 540

Who is offered breast screening?

Answer 540

All women aged 50-71 every 3 years BRCA carries High risk young women = MRI screening

Question 541

What happens at breast screening?

Answer 541

Mammogram = 2 X-rays taken of each breast from different angles

Question 542

What percentage of women who have a mammogram will be called back for more tests?

Answer 542

Roughly 5% recalled --> US, biopsy | 1/4 will have cancer

Question 543

Name 3 reasons why a women maybe be recalled after a mammogram

Answer 543

1. MAss 2. Microcalcification 3. Asymmetric density 4. Enlarged axillary lymph nodes 5. Clinical recall = women says she has a lump 6. Technical recall = not good enough image

Question 544

Name 3 modifiable risk factors for breast cancer

Answer 544

1. Alcohol intake 2. Obesity 3. Use of HRT/OCP

Question 545

Name 3 non-modifiable risk factors for breast cancer

Answer 545

1. Early menarche and late menopause 2. Breast denisty 3. Genetics --> BRCA 1/2 4. Not breast feeding 5. Early parity and nulliparity

Question 546

Approximately what percentage of breast cancers are ductal and what percentage are lobular?

Answer 546

- Ductal = 70% | - Lobular = 10%

Question 547

Give 4 signs that you may find on clinical examination that are suggestive of breast cancer

Answer 547

1. Palpable lump --> irregular, hard, fixed, painless 2. Discharge from nipple 3. Nipple inversion 4. Skin changes --> peau d'orange, skin tethering

Question 548

Breast cancer: what is the triple assessment?

Answer 548

1. Clinical examination 2. Mammogram 3. Core Needle biopsy

Question 549

What is the first line investigation for younger vs older women with a lump in their breast

Answer 549

``` Younger women (<35) = USS--> more dense/glandular tissue Older women (>35) = Mammogram --> less dense/fatty breasts - Breast black and lump white on mammogram ```

Question 550

Breast cancer: is a P1/2 lump that is described as soft, mobile and regular likely to be benign or malignant?

Answer 550

Benign | - E.g. fibroadenoma

Question 551

Breast cancer: is a P4/5 lump that is described as hard, fixed and irregular likely to be benign or malignant?

Answer 551

Malignant

Question 552

How is breast cancer staged?

Answer 552

Stage 1 = confined to breast Stage 2 = growth confined to breast, mobile lymph nodes in ipsilateral axilla Stage 3 = locally advanced --> tumour fixed to muscle, ipsilateral lymph nodes matted and may be fixed, skin involvement larger than tumour Stage 4 = metastatic --> complete fixation of tumour to chest wall, distant metastases

Question 553

How can breast cancer be treated?

Answer 553

1. Conservative surgery (WLE/lumpectomy) + radiotherapy 2. Mastectomy + radiotherapy 3. Mastectomy + reconstruction + radiotherapy 4. Axillary lymph node removal --> limited removal or clearance

Question 554

Why might a mastectomy be indicated as opposed to a lumpectomy in someone with breast cancer?

Answer 554

1. If the tumour is large relative to size of breast 2. If there are multiple tumours 3. Patient preference

Question 555

What should you do to ensure that breast cancer hasn't spread to the axillary lymph nodes?

Answer 555

A sentinel node biopsy

Question 556

Name 2 adjuvant treatments that can be given to women with oestrogen receptor +ve cancer

Answer 556

1. Tamoxifen (premenopausal) | 2. Aromatase inhibitors (post menopausal)

Question 557

Why might a woman with breast cancer have chemotherapy?

Answer 557

If she has a very aggressive cancer or to shrink a tumour prior to surgery ER -ve, Her2 +ve, high grade, node +ve

Question 558

What adjuvant treatment can be given to Her-2 receptor +ve breast cancer patients

Answer 558

Trastuzumab | +/- Pertuzumab

Question 559

When are bisphosphonates given in women with breast cancer?

Answer 559

Given to post menopausal women with ER +ve disease

Question 560

Define incontinence

Answer 560

Involuntary leakage of urine

Question 561

What is the functional bladder capacity?

Answer 561

400ml

Question 562

Describe the epithelium of the detrusor muscle

Answer 562

Smooth muscle with transitional epithelium

Question 563

Describe the innervation of the detrusor muscle

Answer 563

Sacral parasympathetic innervation

Question 564

What is OAB?

Answer 564

Overactive Bladder | - Involuntary detrusor contractions --> urgency

Question 565

Give 3 symptoms of OAB

Answer 565

1. Urgency 2. Frequency 3. Nocturia 4. 'Key in the door' urgency

Question 566

What is stress incontinence?

Answer 566

Leakage of urine due to a weak sphincter | - Any increase in intra-abdominal pressure results in leakage of urine = coughing, laughing, exercise

Question 567

If a patient has a good bladder capacity and small volume leakage would this be more in keeping with a diagnosis of OAB or stress incontinence?

Answer 567

Stress incontinence

Question 568

What investigations might you do in a patient complaining of incontinence?

Answer 568

1. Bladder diary (frequency/volume chart) 2. Urinalysis (particularly for nitrates and leukocytes) 3. Residual urine measurement --> catheter or USS 4. ePAQ

Question 569

What investigations might you do in a patient complaining of incontinence?

Answer 569

1. Bladder diary (frequency/volume chart) 2. Urinalysis (particularly for nitrates and leukocytes) 3. Residual urine measurement --> catheter or USS 4. ePAQ 5. Urodynamics/cystometry 6. Contract bladder scan

Question 570

What is an ePAQ for investigating incontinence?

Answer 570

A questionnaire regarding urinary, bowel, vaginal and sexual symptoms

Question 571

Describe the non-pharmacological treatments for managing stress incontinence

Answer 571

1. Lifestyle changes --> weight loss, stop smoking, reduce caffeine, avoid straining 2. Physiotherapy --> pelvic floor exercises

Question 572

How do pelvic floor exercises work in treating someone with stress incontinence?

Answer 572

Pelvic floor muscle contraction --> urethra compression --> increased urethral pressure --> reduced leakage - Vaginal cones can also be used

Question 573

What pharmacological option can be offered to someone with stress incontinence?

Answer 573

Duloxetine (SNRI)

Question 574

What surgical options can be offered to someone with stress incontinence?

Answer 574

1. Sling 2. Colposuspension = restores pressure to urethra and supports the urethra by elevating vagina with stutters wither side of bladder neck

Question 575

Describe the non pharmacological treatments for managing OAB

Answer 575

1. lifestyle changes --> weight loss, stop smoking, reduce caffeine, avoid straining 2. Bladder drill 3. Pads

Question 576

Name 3 drugs that can used to treat OAB

Answer 576

1. Oxybutynin 2. Mirabegron = B3 adrenergic receptor agonist 3. Botulinum Toxin

Question 577

How does Oxybutynin work in treating OAB?

Answer 577

Anticholinergic = M2/3 receptor antagonist | - Reduces detrusor muscle innervation and so its activity

Question 578

Give 3 potential side effects of Oxybutynin

Answer 578

1. Dry mouth 2. Constipation 3. blurred vision 4. Cognitive impairment

Question 579

How does Mirabegron work in treating OAB?

Answer 579

B3 adrenergic receptor agonist | - Relaxes smooth muscle detrusor and increases bladder capacity

Question 580

How does Botulinum toxin work in treating OAB?

Answer 580

Blocks ACh release and so reduced detrusor muscle contraction

Question 581

Name 2 possible surgeries that can help treat OAB

Answer 581

1. Neuromodulation and sacral nerve stimulation 2. Augmentation ileocystoplasty 3. Bypass

Question 582

Describe the physiology of micturition

Answer 582

The bladder fills and stretch receptors are stimulated. Afferent impulses stimulate the parasympathetic action of detrusor muscle; it contracts. The urethral sphincters relax; this is mediated by inhibition of the neurones to them. The PAG is stimulated.

Question 583

Is the detrusor muscle relaxed or contracted during storage?

Answer 583

Relaxed | - Sphincter contracted

Question 584

Is the detrusor muscle relaxed or contracted during voiding?

Answer 584

Contracted | - Sphincter relaxed

Question 585

Define prolapse

Answer 585

Protrusion of the uterus and/or vagina beyond normal anatomical confines

Question 586

Define Urethrocele

Answer 586

Prolapse of lower anterior vaginal wall, involving the urethra only

Question 587

Define Cystocoele

Answer 587

Prolapse of the upper anterior vaginal wall, involving the bladder

Question 588

Define Apical (uterine) prolapse

Answer 588

Prolapse of uterus, cervix and upper vagina

Question 589

Define Enterocoele

Answer 589

Prolapse of the upper posterior wall of the vagina

Question 590

Define Rectocele

Answer 590

Prolapse of the lower posterior wall of vagina, involving the anterior wall of the rectum

Question 591

Name 3 possible causes of prolapse

Answer 591

1. Vaginal delivery and pregnancy 2. Menopause 3. Congenital collagen deficiency 4. Chronic elevated abdominal pressure 5. Pelvic surgery

Question 592

Give 3 symptoms of prolapse

Answer 592

1. Dragging sensation 2. Lump 3. dyspareunia 4. Urgency, frequency, dysuria 5. Constipation

Question 593

Give 3 symptoms of prolapse

Answer 593

1. Dragging sensation 2. Lump and pain 3. Dyspareunia 4. Urgency, frequency, dysuria 5. Constipation

Question 594

How is a prolapse graded?

Answer 594

1st degree = mild --> halfway down (>1cm above hymen) 2nd degree = moderate --> visible at entrance but not out (within 1cm proximal or distal to plan of hymen) 3rd degree = severe --> comes out of vagina (>1cm below plane of hymen but protrude no further than 2cm less than the total length of the vagina) 4th degree = everything out (complete eversion of the vagina)

Question 595

Describe the management for a patient with prolapse

Answer 595

1. Reassurance 2. Symptom management --> pelvic floor exercises, physic 3. Vaginal pessaries --> ring, shelf, Gellhorn 4. Surgery --> sacrospinous fixation, sacrocolpopexy, hysterectomy

Question 596

Give 5 questions that are important to ask when taking a sexual health history?

Answer 596

1. When was last intercourse? 2. Regular or casual partners? 3. Male or female partners? 4. Contraceptive use? 5. Type of intercourse? 6. How many partners in the last 3 months and 12 months?

Question 597

Give 3 risk factors for STIs

Answer 597

1. Multiples partners 2. Concurrent partners 3. No barrier protection 4. STI in partner 5. Other STI 6. Younger age (<25y/o) 7. Involvement in the sex industry

Question 598

What STI investigations might you do in a asymptomatic woman?

Answer 598

- Vulvo-vaginal swab for NAAT --> gonorrhoea, chlamydia | - Blood sample --> syphilis and HIV

Question 599

What STI investigations might you do in a asymptomatic heterosexual male?

Answer 599

- First void urine NAAT --> gonorrhoea, chlamydia | - Blood test --> syphilis, HIV

Question 600

What STI investigations might you do in a asymptomatic MSM?

Answer 600

- First void urine NAAT --> chlamydia, gonorrhoea - Pharyngeal swab NAAT --> gonorrhoea, chlamydia - Rectal swab NAAT --> chlamydia, gonorrhoea - Blood test --> syphilis, HIV, Hep B (and C if indicated)

Question 601

Give 5 symptoms of STIs that are seen in women

Answer 601

1. Abnormal discharge 2. Itching 3. Soreness 4. Ulcers and lumps 5. PCB or IMB 6. Dyspareunia

Question 602

Give 5 symptoms of STIs that are seen in men

Answer 602

1. Pain/burning on micturition 2. Urethral pain 3. Urethral discharge 4. Ulcers and bilsters 5. Rash 6. Testicular pain or swelling

Question 603

What STI investigations might you do in a symptomatic woman?

Answer 603

- Vulvovaginal swab NAAT --> gonorrhoea, chlamydia - High vaginal swab --> bacterial vaginosis, trichomonad vaginalis, candida - Cervical swab - Dipstick urinalysis - Blood test --> syphilis, HIV

Question 604

What STI investigations might you do in a symptomatic heterosexual male?

Answer 604

- Urethral swab - First void urine NAAT --> gonorrhoea, chlamydia - Urinalysis - Blood test --> syphilis, HIV

Question 605

What STI investigations might you do in a symptomatic MSM?

Answer 605

- Tests for heterosexual male + - Urethral and rectal slides - Urethral, rectal and pharyngeal culture plates

Question 606

Why is contact tracing important with regard to STIs?

Answer 606

1. Prevents re-infection 2. Break the chain of infection 3. Allows treatment of asymptomatic individuals

Question 607

Who is more likely to get chlamydia?

Answer 607

Women aged 16-20 y/o

Question 608

Give 3 symptoms and 3 signs of chlamydia

Answer 608

``` Symptoms 1. Asymptomatic = 70% 2. Dysuria 3. Vaginal discharge (pale, thick) 4. Irregular bleeding --> IMB, PCB Signs 1. Pelvic/abdominal tenderness 2. Cervical motion tenderness 3. Inflamed cervix (Cervicitis) 4. Purulent discharge ```

Question 609

What is the treatment for chlamydia?

Answer 609

Azithromycin single dose or doxycycline BD for 7 days - Erythromycin BD 10-14 days In PREGNANCY - Contact tracing

Question 610

Give 3 possible complications of chlamydia

Answer 610

1. PID 2. Perihepatitis 3. Reiter's syndrome (reactive arthritis) 4. Tubal infertility 5. Ectopic pregnancy - During pregnancy = preterm ROM and delivery, neonatal conjunctivitis or pneumonia

Question 611

Name 3 symptoms of primary Herpes Simplex Virus

Answer 611

1. Prodrome --> tingling/itching 2. Flu like illness +/- inguinal lymphadenopathy 3. Vulvitis and pain 4. Vesicles - Recurrent attacks triggered by stress, sex, menstruation

Question 612

What investigations would you do for HSV?

Answer 612

- Clinical - PCR of vesicular fluid = gold standard - Culture of vesicular fluid

Question 613

What is the treatment for HSV?

Answer 613

Symptomatic --> analgesia, saline bathing, topic anaesthetic Oral acyclovir 5/day for 5/7

Question 614

Give 2 possible complications of HSV

Answer 614

1. Meningitis 2. Sacral radiculopathy 3. Transverse myelitis 4. Disseminated infection

Question 615

Who is more likely to have gonorrhoea?

Answer 615

Men aged 25-30 y/o

Question 616

Name 3 possible symptoms of gonorrhoea

Answer 616

1. Asymptomatic 2. Discharge = odourless, purulent, can be green/yellow 3. Lower abdominal pain 4. IMB or PCB

Question 617

What is the treatment for gonorrhoea?

Answer 617

Ceftriaxone IM stat + azithromycin stat | Contact tracing

Question 618

Name 3 possible complications of gonorrhoea

Answer 618

1. PID 2. Bartholin's or Skene's abscess 3. Disseminated gonorrhoea --> fever, pustular rash, migratory polyarthralgia, septic arthritis 4. Tubal infertility 5. Ectopic pregnancy In PREGNANCY = preterm ROM and delivery, chorioamnionitis, ophthalmia neonatarum (baby)

Question 619

What is Primary syphilis?

Answer 619

- 10 to 90 days post infection - Painless, genital ulcer (chancre) - Inguinal lymphadenopathy

Question 620

What is Secondary syphilis?

Answer 620

- Within first 2 years of infection - Generalised polymorphic rash affecting palms and soles - Generalised lymphadenopathy - Genital condyloma lata - Anterior uveitis

Question 621

What is Tertiary syphilis?

Answer 621

- Can take 40+ years to develop - Neurosyphilis = tabes dorsalis and dementia - Cardiovascular syphilis = affects aortic root - Gummata = inflammatory plaques or nodules

Question 622

How do you diagnose Syphilis?

Answer 622

TTPA | Primary lesion smear --> spirochaetes on dark field microscopy

Question 623

How do you treat Syphilis?

Answer 623

Benzathine benzylpenicillin single IM dose (used in pregnancy) - Doxycycline BD for 14 days (CI in pregnancy) - Erythromycin QDS for 14 days (used in pregnancy) - Longer in tertiary syphilis - Contract tracing

Question 624

Name 3 possible symptoms of Trichomonas

Answer 624

1. Asymptomatic 2. Frothy, greenish, offensive smelling vaginal discharge 3. Vulval itching and soreness 4. Dysuria

Question 625

How do you treat Trichomonas?

Answer 625

Metronidazole 2g oral single dose | Contact tracing

Question 626

What subtypes of HPV are associated with CIN and cervical neoplasia?

Answer 626

Subtypes 16 and 18

Question 627

What subtypes of HPV are associated with genital warts?

Answer 627

Subtypes 6 and 11

Question 628

How can genital warts be treated?

Answer 628

Cryotherapy, trichloroacetic acid, electrosurgery/scissors excision/curettage/laser OR home therapy (podophyllotoxin cream/solution or imiquimod cream)

Question 629

How are some types of subtypes of HPV prevented?

Answer 629

HPV Vaccination at 12/13 y/o against subtypes 6, 11, 16 and 18

Question 630

How is bacterial vaginosis diagnosed?

Answer 630

Amsel criteria = 3/4 required 1. Homogenous profuse grey-white discharge 2. Increased vaginal pH >5.5 3. Characteristic fishy smell 4. 'Clue cells' on microscopy

Question 631

How is bacterial vaginosis treated?

Answer 631

- Can resolve spontaneously - Metronidazole 2g single dose or 400mg orally BD for 5 days - Clindamycin 2% cream vaginally at night for 7 days

Question 632

Name 3 risk factors for candidiasis (thrush)

Answer 632

1. Immunosuppression 2. Abx 3. Pregnancy 4. DM 5. Anaemia

Question 633

Give 3 symptoms of thrush

Answer 633

1. Thick, curd like white vaginal discharge 2. Vulval itching and soreness 3. Dysuria 4. Superficial dyspareunia

Question 634

How do you treat thrush?

Answer 634

ONLY if symptomatic - Fluconazole sing dose (CI in pregnancy) - Clotrimazole 500mg pessary +/- topical clotrimazole cream

Question 635

What shoudl a doctor tell a patient in order for the patient to give fully informed consent?

Answer 635

1. Nature of the procedure 2. About any reasonable alternative 3. Relevant risks, benefits and uncertainties 4. The patients understanding should be assessed

Question 636

What 4 questions can be asked to assess mental capacity?

Answer 636

1. Does the patient understand the information? 2. can the patient retain the information 3. Can they use the information to weigh up options and make a decision? 4. Can they communicate their decision?

Question 637

Until what week can a lady legally have an abortion?

Answer 637

Legal int he UK up to 24 weeks (1967) | - Illegal after that unless there is a substantial risk to the woman's life or fetal abnormalities

Question 638

Give 4 risks associated with amniocentesis

Answer 638

1. Miscarriage 2. Infection 3. Trauma 4. Bleeding 5. Sensitisation reaction 6. Preterm labour

Question 639

What is Sheehan's syndrome?

Answer 639

Pituitary infarction/necrosis following PPH | - Can lead to reduced TSH, ACH, FSH/LH and so hypothyroidism and genital atrophy