Obs/ Gynae Flashcards

Question 1

Q

What happens to the total volume of the lungs in pregnancy?

Answer

A

Decreases

Question 2

Q

What happens to the tidal volume in pregnancy?

Answer

A

Increases

Question 3

Q

What is pelvic inflammatory disease?

Answer

A

Infection and inflammation of female pelvic organs- uterus, fallopian tubes, ovaries and the surrounding peritoneum

Question 4

Q

What organisms cause pelvic inflammatory disease?

Answer

A

Chlamydia trachomatis- most common
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

Question 5

Q

What are the features of pelvic inflammatory disease?

Answer

A

Lower abdominal pain
Fever
Deep dyspareunia
Dysuria and menstrual irregularities may occur
Vaginal or cervical discharge
Cervical excitation

Question 6

Q

What are the investigations for pelvic inflammatory disease?

Answer

A

Pregnancy test to exclude ectopic
High vaginal swab
Screen for chlamydia and gonorrhoea

Question 7

Q

Pelvic inflammatory disease management?

Answer

A

Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Removal IUD might give better short term outcomes

Question 8

Q

Pelvic inflammatory disease complications?

Answer

A

Perihepatitis
Infertility
Chronic pelvic pain
Ectopic pregnancy

Question 9

Q

What are the harms and benefits of the combined oral contraceptive pill?

Answer

A

99% effective if taken correctly
Small risk of blood clots
Very small heart attack/stroke risk
Increased risk breast and cervical cancer

Question 10

Q

When does the combined oral contraceptive pill become effective?

Answer

A

Within first 5 days of cycle no need for additional contraception. Any other point 7 days of alternative contraception.

Same time every day

Question 11

Q

What may reduce COCP efficacy?

Answer

A

Vomiting within 2 hours of taking pill
Medications that induce diarrhoea or vomiting may reduce effectiveness eg orlistat
Liver enzyme inducing drugs

Question 12

Q

Risk factors for ovarian cancer?

Answer

A

BRCA 1 or BRCA 2 mutations
Many ovulations- early menarche, late menopause, nulliparity

Question 13

Q

What are the clinical features of ovarian cancer?

Answer

A

Very vague

Abdominal distension and bloating
Abdominal and pelvic pain
Urinary symptoms- urgency
Early satiety
Diarrhoea

Question 14

Q

Ovarian cancer investigations?

Answer

A

CA125
If CA 125 raised then ultrasound of abdomen and pelvis
Diagnosis usually involves diagnositc laparotomy

Question 15

Q

Ovarian cancer management?

Answer

A

Surgery and chemotherapy

Question 16

Q

What are the features of placenta praevia?

Answer

A

Shock in proportion to visible loss
No pain
Uterus not tender
Lie and presentation my be abnormal
Fetal heart usually normal
Coagulation problems rare
Small bleeds before large

Question 17

Q

How to diagnose placenta praevia?

Answer

A

Digital vaginal examination should not be performed before USS as could cause bleeding

Often picked up on 20 week USS

Question 18

Q

Grading of placenta praevia?

Answer

A

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os

Question 19

Q

What are the barrier methods of contraception?

Question 20

Q

What are the daily methods of contraception?

Answer

A

Combined oral contraceptive pill

Progesterone only pill

Question 21

Q

What are the long-acting methods of reversible contraception (LARCs)

Answer

A

Implantable contraceptives

Injectable contraceptives

Intrauterine system (IUS)- progesterone releasing coil

Intrauterine device (IUD)- copper coil

Question 22

Q

How does the combined oral contraceptive pill work?

Answer

A

Inhibits ovulation

Increased risk of VTE
Increased risk of breast and cervical cancer

Question 23

Q

How does the progesterone only pill work?

Answer

A

Thickens cervical mucus

Irregular bleeding common side effect

Question 24

Q

How does the injectable contraceptive work?

Answer

A

(Medroxyprogesterone acetate)
Primary: inhibits ovulation
Also thickens cervical mucus

Lasts 12 weeks

Question 25

Q

How does the implantable contraceptive work?

Answer

A

Etonogestrel
Primary: Inhibits ovulation
Also thickens cervical mucus

Irregular bleeding
Lasts 3 years

Question 26

Q

How does the intrauterine contraceptive device work?

Answer

A

Decreases sperm motility and survival

Question 27

Q

How does the intrauterine system work?

Answer

A

(Levonorgestrel)
Primary: prevents endometrial proliferation
Also thickens cervical mucus

Irregular bleeding

Question 28

Q

What is desogestrel?

Answer

A

A type of progestogen-only pill that also inhibits ovulation

Question 29

Q

Features of cervical cancer?

Answer

A

May be detected during routine cervical cancer screening
Abnormal vaginal bleeding- postcoital, intermenstrual or postmenopausal
Vaginal discharge

Question 30

Q

Which types of HPV cause cervical cancer?

Answer

A

16, 18 and 33

Question 31

Q

What are some cervical cancer risk factors?

Answer

A

HPV 16, 18 and 33
Smoking
HIV
Early first intercourse, many sexual partners
High parity
Lower socioeconomic status
COCP

Question 32

Q

When is endometrial cancer usually seen?

Answer

A

Post menopause

Question 33

Q

What are the risk factors for endometrial cancers?

Answer

A

Excess oestrogen- nulliparity, early menarche, late menopause, unopposed oestrogen (HRT without progestogen)

Metabolic syndrome- obesity, diabetes, polycystic ovarian syndrome

Tamoxifen

Hereditary nonn-polyposis colorectal carcinoma

Question 34

Q

Protective factors against endometrial cancer?

Answer

A

Multiparity, COCP, smoking

Question 35

Q

Features of endometrial cancer?

Answer

A

Classic symptom- postmenopausal bleeding- slight before becoming heavier

Others-
Premenopausal women with menhorrhagia or intermenstrual bleeding
Pain uncommon
Vaginal discharge unusual

Question 36

Q

Endometrial cancer investigations?

Answer

A

Women older than 55 presenting with post menopausal bleeding reffered using cancer pathway

First line- trans vaginal ultrasound
Hysteroscopy with endometrial biopsy

Question 37

Q

Endometrial cancer management?

Answer

A

Surgery- total abdominal hysterectomy

High risk patients may have postoperative radiotherapy

Progestogen therapy in frail elderly women not suitable for surgery

Question 38

Q

What is placental abruption?

Answer

A

Seperation of normally sited placenta from uterine wall, causes maternal haemorrhage into intervening space

Question 39

Q

What are the factors associated with placental abruption?

Answer

A

Proteinuric hypertension
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age

Question 40

Q

What are the clinical features of placental abruption?

Answer

A

Shock out of keeping with visible loss
Pain constant
Tender, tense uterus
Normal lie and presentation
Fetal heart- absent/distressed
Coagulation problems
Beware pre-eclampsia, DIC, anuria

Question 41

Q

What happens with a negative hrHPV result?

Answer

A

Return to normal recall unless-
Test of cure pathway
Untreated CIN1 pathway
Follow up borderline changes in endocervical cells
Follow up incompletely excised cervical cancer

Question 42

Q

Positive hrHPV result?

Answer

A

Samples examined cytologically

If cytologically abnormal- colposcopy

If cytology normal- repeat test in 12 months

Question 43

Q

What are the different results from an abnormal colposcopy?

Answer

A

This includes the following results:
Borderline changes in squamous or endocervical cells.
Low-grade dyskaryosis.
High-grade dyskaryosis (moderate).
High-grade dyskaryosis (severe).
Invasive squamous cell carcinoma.
Glandular neoplasia

Question 44

Q

What are the options from a normal colposcopy?

Answer

A

Repeat after 12 months
If the repeat test is now hrHPV -ve → return to normal recall

If the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
If hrHPV -ve at 24 months → return to normal recall
if hrHPV +ve at 24 months → colposcopy

Question 45

Q

What to do with inadequate hrHPV?

Answer

A

Repeat within 3 months
If two consecutive inadequate- colposcopy

Question 46

Q

How often is Depo Provera given?

Answer

A

Via IM every 12 weeks

Question 47

Q

What are the adverse effects of the depo?

Answer

A

Irregular bleeding
Weight gain
Potential increase of osteoporosis- only use in adolescents if no other contraception is suitable
Not quickly reversed and fertility may return after varying time

Contraindications- breast cancer

Question 48

Q

What are the risk factors for urinary incontinence?

Answer

A

Advancing age
Previous pregnancy and childbirth
High BMI
Hysterectomy
Family history

Question 49

Q

What are the types of urinary incontinence?

Answer

A

Overactive bladder- detrusor overactivity
Stress incontinence- cough/laugh
Mixed incontinence- both urge and stress
Overflow incontinence- bladder outlet obstruction
Functional incontinence

Question 50

Q

Investigations for urinary incontinence?

Answer

A

Bladder diaries kept for minimum of 3 days
Vaginal examination
Urine dipstick and culture
Urodynamic studies

Question 51

Q

Management for urge incontinence?

Answer

A

Bladder retraining- lasts six weeks
Bladder stabilising drugs- antimuscarinics are first line- oxybutinin, tolterodine or darifenacin. No oxybutinin in frail old women
Mirabegron useful if concern over anticholinergic side effects in elderley patients

Question 52

Q

Management for stress incontinence?

Answer

A

Pelvic floor muscle training- at least 8 contractions performed 3 times a day for mimimum of 3 months
Surgical procedures
Duloxetine if decline surgery

Question 53

Q

What are the symptoms of the menopause?

Answer

A

Change in periods- length of menstrual cycles, dysfunctional uterine bleeding may occur

Vasomotor symptoms- hot flushes, night sweats- usually occur daily and may continue for 5 years

Urogenital changes- vaginal dryness and atrophy, urinary frequency

Psychological- anxiety and depression, short term memory impairment

Longer term complications- osteoporosis, increased risk of ischaemic heart disease

Question 54

Q

When should a urine culture to detect asymptomatic bacteriuria be carried out?

Answer

A

8-12 weeks (ideally < 10 weeks)

Question 55

Q

What should happen at 8 - 12 weeks (ideally < 10 weeks)?

Answer

A

Booking visit

General information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes

BP, urine dipstick, check BMI

Booking bloods/urine

FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
Hepatitis B, syphilis
HIV test is offered to all women
Urine culture to detect asymptomatic bacteriuria

Question 56

Q

10 - 13+6 weeks

Answer

A

Early scan to confirm dates, exclude multiple pregnancy

Question 57

Q

11 - 13+6 weeks

Answer

A

Down’s syndrome screening including nuchal scan

Question 58

Q

16 weeks

Answer

A

Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron

Routine care: BP and urine dipstick

Question 59

Q

18 - 20+6 weeks

Answer

A

Anomaly scan

Question 60

Q

25 weeks (only if primip)

Answer

A

Routine care: BP, urine dipstick, symphysis-fundal height (SFH)

Question 61

Q

28 weeks

Answer

A

Routine care: BP, urine dipstick, SFH

Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron

First dose of anti-D prophylaxis to rhesus negative women

Question 62

Q

31 weeks (only if primip)

Answer

A

Routine care as above

Question 63

Q

34 weeks

Answer

A

Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan

Question 64

Q

36 weeks

Answer

A

Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’

Answer 64

A

Routine care as above
Discussion about options for prolonged pregnancy

Answer 65

A

Routine care as above
Discuss labour plans and possibility of induction

Answer 66

A

COCP
Nexplanon (implantable contraceptive)
Intrauterine system (Mirena)
Depo provera (injectable contraceptive)

Answer 67

A

Progesterone only pill

Answer 68

A

Hypertension
Gestational diabetes

Answer 69

A

BMI of > 30 kg/m²

Previous macrosomic baby weighing 4.5 kg or above

Previous gestational diabetes

First-degree relative with diabetes

Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 70

A

Oral glucose tolerance test (OGTT)

Previous gestational diabetes: OGTT performed asap and at 24-28 weeks if first normal

Women with any other RFs offered at 24-28 weeks

Answer 71

A

Fasting glucose is >= 5.6 mmol/L

2-hour glucose is >= 7.8 mmol/L

Answer 72

A

Newly diagnosed seen in a joint diabetes and antenatal clinic within a week

Women taught about self monitoring blood glucose

Diet advice

If the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered

If glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started

If glucose targets are still not met insulin should be added to diet/exercise/metformin

Gestational diabetes is treated with short-acting, not long-acting, insulin

If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started

If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered

Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 73

A

Weight loss for women with BMI of > 27 kg/m^2

Stop oral hypoglycaemic agents, apart from metformin, and commence insulin

Folic acid 5 mg/day from pre-conception to 12 weeks gestation

Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts

Tight glycaemic control reduces complication rates

Treat retinopathy as can worsen during pregnancy

Answer 74

A

Fasting- 5.3 mmol/l

1 hour- 7.8 mmol/l

2 hour- 6.4 mmol/l

Answer 75

A

Extreme morning sickness

Answer 76

A

Between 8 and 12 weeks but may persist up to 20 weeks

Answer 77

A

Increased levels of beta-hCG eg ( multiple pregnancies, trophoblastic disease)

Nulliparity

Obesity

Family or personal history of NVP

Smoking associated decreased incidence of hypermesis

Answer 78

A

Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics

Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics

A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

Answer 79

A

5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance

Answer 80

A

Pregnancy-Unique Quantification of Emesis (PUQE)

Answer 81

A

Simple measures
Rest and avoid triggers e.g. odours
Bland, plain food, particularly in the morning
Ginger
P6 (wrist) acupressure

First-line medications
Antihistamines: oral cyclizine or promethazine
Phenothiazines: oral prochlorperazine or chlorpromazine

Second-line medications
Oral ondansetron
Oral metoclopramide or domperidone- metoclopramide may cause extrapyramidal side effects so not to be used for more than 5 days

Admission for IV hydration
Normal saline with added potassium used to rehydrate

Answer 82

A

Triad of- dehydration, weight loss, electrolyte imbalance

AKI

Wernicke’s encephalopathy

Oesophagitis, Mallory-Weiss tear

Venous thromboembolism

Fetal outcome- little adverse effect- maybe low birth weight, slight increase prem

Answer 83

A

Emergency hormonal contraception- levonorgestrel, ulipristal

Intrauterine device (IUD)

Answer 84

A

Levonorgestrel

Ulipristal

Answer 85

A

Taken as soon as possible- efficacy decreases with time

Must be taken within 72 hours of unprotected sexual intercourse (UPSI)

Single dose of 1.5mg should be doubled for those with BMI over 26 or weight over 70kg

If vomiting occurs within 3 hours dose should be repeated

Can be used more than once in a menstrual cycle if clinically indicated

Hormonal contraception can be started immediately after using levornogestrel

Answer 86

A

30mg dose take as soon as possible, no later than 120 hours after intercourse

Don’t use with levonorgestrel

Ulipristal may reduce the effectiveness of the hormonal contraceptive. Contraceptive with the pill, patch or ring should be started, or restarted, 5 days after having ulipristal. Barrier methods used during this time.

Caution exercised in patients with severe asthma

Ulipristal can be used more than once in the same cycle

Breastfeeding delayed one week after ulipristal, no restrictions with levonorgestrel

Answer 87

A

Copper IUD most effective method of emergency contraception and offered to all women if they meet criteria

Must be inserted within 5 days of UPSI

If more than 5 days, may be fitted up to 5 days after the likely ovulation date

Prophylactic antibiotics may be given if patient at high risk of STI

99% effective no matter where used in cycle

May be left in situ for long term contraception. If to be removed, kept until at least next period

Answer 88

A

A pregnancy test will be positive

Transvaginal ultrasound is the investigation of choice

Answer 89

A

Expectant management

Medical management- methotrexate- patient must attend follow up

Surgical management- salpingectomy or salpingotomy

Answer 90

A

Size <35mm

Unruptured

Asymptomatic

No fetal heartbeat

hCG <1000IU/L

Compatable with another intrauterine pregnancy

Involves closely monitoring patient over 48 hours and if B-hCG levels rise again or symptom manifest intervention performed

Answer 91

A

Size <35mm

Unruptured

No significant pain

No fetal heartbeat

hCG<1500 IU/L

Not suitable if intrauterine pregnancy

Medical management involves using methotrexate and only done if patient willing to attend follow up

Methotrexate is teratogenic no pregnacy 3 months after

Answer 92

A

Size >35mm

Can be ruptured

Pain

Visible fetal heartbeat

hCG >5000IU/L

Compatible with another intrauterine pregnancy

Surgical management can involve salpingectomy or salpingotomoy

Salpingectomy is the first-line for women with no other risk factors for infertility

Salpingotomy considered for women with risk factors for infertility such as contralateral tube damage-
Around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or salpingectomy)

Answer 93

A

New-onset hypertension

Proteinuria

Oedema

Answer 94

A

New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:

Proteinuria

Other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Answer 95

A

Eclampsia- also altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata

Fetal complications- Intrauterine growth retardation
Prematurity

Liver involvement- elevated transaminases

Haemorrhage- placental abbruption, intra-abdominal, intro-cerebral

Cardiac failure

Answer 96

A

Hypertension- typically >160/110 and proteinuria

Proteinuria: dipstick ++/+++

Headache

Visual disturbance

Papilloedema

RUQ/epigastric pain

Hyperreflexia

Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Answer 97

A

High risk factors

Hypertensive in previous pregnancy
CKD
Autoimmune disease
DM T1/T2
Chronic hypertension

Moderate risk factors

First pregnancy
Over 40
Pregnancy interval over 10 years
BMI 35 or more
FH pre eclampsia
Multiple pregnancy

Answer 98

A

Women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth

≥ 1 high risk factors
≥ 2 moderate factors

Answer 99

A

Emergency secondary care assessment for any woman with suspected pre-eclampsia

Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Answer 100

A

Oral labetalol first line. Nifedipine if asthmatic, hydralazine may also be used

Answer 101

A

Chronic pelvic pain

Secondary dysmenorrhoea- pain often starts days before bleeding

Deep dyspareunia

Subfertility

Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)

On pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Answer 102

A

Laparoscopy is gold standard

Answer 103

A

NSAIDs and/or paracetamol are first line

If analgesia doesn’t work then COCP or progestogens (medroxyprogesterone acetate)

If analgesia does not improve symptoms or fertility a priority refer to secondary care

Answer 104

A

GnRH analogues

Drug therapy has no significant impact on fertility rates

Surgery
If trying to conceive can use laparoscopic excision or ablation of endometriosis

Answer 105

A

After day 21

Answer 106

A

Progesterone only pill (POP)

Can start POP anytime postpartum

After day 21 additional contraception for first 2 days

Combined oral contraceptive pill (COCP)

Absolute contraindication if breastfeeding <6 weeks post partum

UKMEC 2 if 6 weeks-6 months postpartum and breastfeedng

Not used in the first 21 days due to increase VTE risk post partum

After day 21 additional contraception for first 7 days

IUD or IUS inserted within 48 hours of childbirth or after 4 weeks

Lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breast feeding, amenorrhoeic and < 6 months post-partum

Answer 107

A

Increased risk preterm birth, low birth weight and small for gestational age babies

Answer 108

A

Edinburgh postnatal depression scale

10-item questionnaire, with a maximum score of 30

Indicates how the mother has felt over the previous week

Score > 13 indicates a ‘depressive illness of varying severity’

Includes a question about self-harm

Answer 109

A

‘Baby-blues’

Postnatal depression

Puerperal psychosis

Answer 110

A

Typically 3-7 days after giving birth and more common in primips

Mothers are characteristically anxious, tearful and irritable

Reassurance and support

Answer 111

A

10% women

Most cases start within a month and peak at 3 months

Features similar to depression

Support and reassurance

CBT may be helpful

Sertraline and paroxetine may be beneficialif symptoms are severe

Answer 112

A

Onset 2-3 weeks after birth

Severe swings in mood (similar to bipolar) and disordered perception (auditory hallucinations)

Admission to hospital- ideally mother and baby unit

25-50% risk of recurrence following future pregnancies

Answer 113

A

Fetal varicella syndrome

Answer 114

A

5x risk pneumonitis

Answer 115

A

Skin scarring
Eye defects (microphthalmia)
Limb hypoplasia
Microcephaly
Learning disabilities

Other risks
Shingles in infacy
Severe neonatal varicella

Answer 116

A

If doubt about mother previously having chicken pox maternal blood should be checked for varicella antibodies

If the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible

VZIG effective up to 10 days after exposure

If the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure

Answer 117

A

Specialist advice

Risk of serious chicken pox infection (maternal), fetal varicella risk and the safety of aciclovir in pregnancy

Oral aciclovir given if pregnant woman is ≥ 20 weeks and presents within 24 hours of onset of the rash

If the woman is < 20 weeks the aciclovir should be ‘considered with caution’

Answer 118

A

UKMEC 1: a condition for which there is no restriction for the use of the contraceptive method

UKMEC 2: advantages generally outweigh the disadvantages

UKMEC 3: disadvantages generally outweigh the advantages

UKMEC 4: represents an unacceptable health risk

Answer 119

A

More than 35 years old and smoking less than 15 cigarettes/day

BMI > 35 kg/m^2*

Family history of thromboembolic disease in first degree relatives < 45 years

Controlled hypertension

Immobility e.g. wheel chair use

Carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)

Current gallbladder disease

Answer 120

A

More than 35 years old and smoking more than 15 cigarettes/day

Migraine with aura

History of thromboembolic disease or thrombogenic mutation

History of stroke or ischaemic heart disease

Breast feeding < 6 weeks post-partum

Uncontrolled hypertension

Current breast cancer

Major surgery with prolonged immobilisation

Positive antiphospholipid antibodies (e.g. in SLE)

Answer 121

A

Diabetes mellitus diagnosed > 20 years ago is classified as UKMEC 3 or 4 depending on severity

Answer 122

A

Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery and may be primary or secondary

Primary PPH occurs within 24 hours

Answer 123

A

4 Ts:
Tone (uterine atony): the vast majority of cases

Trauma (e.g. perineal tear)

Tissue (retained placenta)

Thrombin (e.g. clotting/bleeding disorder)

Answer 124

A

Previous PPH

Prolonged labour

Pre-eclampsia

Increased maternal age

Polyhydramnios

Emergency Caesarean section

Placenta praevia, placenta accreta

Macrosomia

Answer 125

A

PPH life threatening- senior members of staff involved immediately

ABC approach

Mechanical:
Palpate the uterine fundus and rub it to stimulate contractions
Catheterisation to prevent bladder distension and monitor urine outpur

Medical:
IV oxytocin (syntocinon): slow IV injection followed by an IV infusion
Ergometrine slow IV or IM (unless hypertension history)
Carboprost IM (unless history of asthma)
Misoprostol sublingual

Surgical:
Intrauterine balloon tamponade first line surgical management
B-lynch suture, ligation uterine arteries etc
If severe uncontrolled then hysterectomy sometimes performed

Answer 126

A

24 hours- 6 weeks due to retained placental tissue or endometritis

Answer 127

A

Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day

No additional contraceptive protection needed

Answer 128

A

Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day

The women should use condoms or abstain from sex until she has taken pills for 7 days in a row

If pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1

If pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception

If pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval

Answer 129

A

Hypertensive in previous pregnancy
CKD
Autoimmune disease
DM T1/T2
Chronic hypertension

Answer 130

A

First pregnancy
Over 40
Pregnancy interval over 10 years
BMI 35 or more
FH pre eclampsia
Multiple pregnancy

Answer 131

A

Input from expert

Add low molecular weight heparin

Answer 132

A

Hospitalisation, surgery, comorbidities or thrombophilia

Answer 133

A

Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy

4+ warrants immediate treatment with LMWH continued until 6 weeks postnatal

Answer 134

A

Direct oral anticoagulants (DOACs)

Warfarin

Answer 135

A

New onset hypertension diagnosed after 20 weeks without significant proteinuria

Answer 136

A

Mild 140-149 over 90-99
Moderate 150-159 over 100-109
Severe >160 over >110

Answer 137

A

Pre-existing HTN- over 140/90 before pregnancy or before 20 weeks, no proteinuria/oedema
If already on an ACE/ARB stop

Pregnancy induced HTN- occuring in second half of pregnancy (after 20 weeks), no proteinuria, no oedema, resolves following birth

Pre-eclampsia- pregnancy induced hypertension in association with proteiuria, oedema may occur

Answer 138

A

1st- Oral labetalol (not for asthmatics)
2nd- Oral nifeddipine

Answer 139

A

If less than 3 hours late
no action required, continue as normal

If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed

Answer 140

A

If less than 12 hours late
no action required, continue as normal

If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below

Answer 141

A

Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Answer 142

A

Two or more minor risk factors or one red flag antibiotic therapy with benzylpenicillin and gentamicin.

One minor risk observe for 24 hours

Red flags:
Suspected or confirmed infection in another baby in the case of a multiple pregnancy

Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis]

Respiratory distress starting more than 4 hours after birth

Seizures

Need for mechanical ventilation in a term baby

Signs of shock

Answer 143

A

Prematurity

Prolonged rupture of the membranes

Previous sibling GBS infection

Maternal pyrexia e.g. secondary to chorioamnionitis

Answer 144

A

Benzylpenicillin

Answer 145

A

Previous GBS in a pregnancy (or offer testing late in pregnancy and antibiotics if positive)

Women with a previous baby with early or late onset GBS disease

Preterm labour regardless of GBS status

Women with pyrexia of >38 during labour

Answer 146

A

Primigravida

Large babies

Precipitant labour

Shoulder dystocia

Forceps delivery

Answer 147

A

First degree- superficial no muscle involvement, do not require repair

Second degree- injury to perineal muscle but not involving anal sphincter, requires suturing

Third degree- injury to perineum involving anal sphincter complex, require repair in theatre

Fourth degree- injury to perineum involving anal sphincter complex and rectal mucosa, repair on theatre

Answer 148

A

May be asymptomatic

Menorrhagia

Bulk related symptoms- lower abdo pain, cramping, bloating, urinary symptoms

Subfertility

Rare features- polycythemia secondary to autonomous production of erythropietin

Answer 149

A

Transvaginal ultrasound

Answer 150

A

Asymptomatic- review periodically

Treatment to shrink:

Medical- GnRH agonists- use for short periods loss of bone density

Surgical:
Myomectomy- performed abdominally, laparoscopically or hysteroscopically

Hysteroscopic endometrial ablation

Polycythaemia due to autonomous production of erythropoietin

Answer 151

A

1st Levonorgestrel intrauterine system (LNG-IUS)

NSAIDs- mefeanamic acid

Tranexamic acid

COCP

Oral progestogen

Injectable progestogen

Answer 152

A

Thyrotoxicosis
Hypothyroidism
Normal thyroid function (but high recurrence rate in future pregnancies)

Thyroid peroxidase antibodies are found in 90% of patients

Answer 153

A

Thyrotoxic phase- propanolol for symptom control

Hypothyroid phase- treat with thyroxine

Answer 154

A

Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

Answer 155

A

Irregular vaginal bleeding is the most common

Answer 156

A

Up to and including day 5 immediate, otherwise 2 days and use condoms inbetween

If switching from COCP immediate protection if continued from end of pill packet

Answer 157

A

Galactosemia

Viral infections

Answer 158

A

The following drugs can be given to mothers who are breastfeeding:
Antibiotics: penicillins, cephalosporins, trimethoprim

Endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines

Psychiatric drugs: tricyclic antidepressants, antipsychotics**

Hypertension: beta-blockers, hydralazine

Anticoagulants: warfarin, heparin

Digoxin

Answer 159

A

The following drugs should be avoided:
Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

Psychiatric drugs: lithium, benzodiazepines

Aspirin

Carbimazole

Methotrexate

Sulfonylureas

Cytotoxic drugs

Amiodarone

Clozapine

Answer 160

A

Androgen insensitivity syndrome

Answer 161

A

Primary amenorrhoea

Little or no axillary and pubic hair

Undescended testes causing groin swellings

Breast development may occur as a result of the conversion of testosterone to oestradiol

Answer 162

A

US findings

Menopausal status

CA125 levels

Answer 163

A

Fetal macrosomia (association with maternal diabetes)

High maternal BMI

DM

Prolonged labour

Answer 164

A

Senior help called immediately

McRoberts manoeuvre should be perfromed- this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
this rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.

Answer 165

A

Potential complications include:
Maternal:
Postpartum haemorrhage
Perineal tears
Fetal:
Brachial plexus injury
Neonatal death

Answer 166

A

Sertraline

Answer 167

A

Nausea
Breast tenderness
Fluid retention and weight gain

Answer 168

A

Increased risk of breast cancer- increased by progesterone

Increased risk of endometrial cancer- oestrogen by itself not given to women with a womb- reduced by the addition of progesterone

Increased risk VTE- increased by addtion of progesterone, transdermal HRT does not increase VTE risk

Increased risk of stroke

Increased risk of ischaemic heart disease

Answer 169

A

If past 28 weeks-
1. Handheld doppler to confirm fetal heartbeat
2. If not detected immediate ultrasound offered
3. If present CTG used for at least 20 mins to monitor fetal HR

If fetal movements not felt by 24 weeks referral should be made

Answer 170

A

Phenytoin

Methotrexate

Pregnancy

Alcohol excess

Answer 171

A

Macrocytic, megaloblastic anaemia

Neural tube defects

Answer 172

A

All women should take 400mcg of folic acid until 12th week of pregnancy

Women at higher risk of NTD should take 5mg folic acid from before conception until 12th week of pregnancy

Answer 173

A

Either partner has a NTD, FH or previous prgnancy with NTD

Woman taking antiepileptic drugs, coeliac disease, DM or thalassaemia

Woman is obese 30 BMI or more

Answer 174

A

Development of seizures in association with pre-eclampsia

Answer 175

A

Magnesium sulphate

Answer 176

A

Urine output, reflexes, respiratory rate and oxygen saturations

Answer 177

A

Calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

Answer 178

A

Treatment should continue for 24 hours after last seizure of delivery

Answer 179

A

Fluid restriction to prevent fluid overload

Answer 180

A

In older women

Lump or ulcer on labia majora
Inguinal lymphadenopathy
May be associated with itching/irritation

Answer 181

A

Anything slowing ovum’s passage to the uterus:

Damage to tubes (pelvic inflammatory disease, surgery)
Previous ectopic
Endometriosis
IUCD
Progesterone only pill
IVF (3% of pregnancies are ectopic)

Answer 182

A

> 35mm

hCG over 5000IU/L

Answer 183

A

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction

Answer 184

A

During labour, after delivery in the immediate post partum or during caesarean insection

Answer 185

A

Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia and myocardial infarction.

Answer 186

A

Critical care unit

Answer 187

A

Uterine atony

Answer 188

A

Synthetic oxytocin

Answer 189

A

A benign ovarian tumour

Ascites

Pleural effusion

Answer 190

A

Surface derived tumours

Germ cell tumours

Sex cord-stromal tumours

Metastasis

Answer 191

A

Rescan at 32 weeks
No need to limit activity or intercourse unless they bleed
If still present at 32 weeks then scan every 2 weeks
Final ultrasound at 36-37 weeks to determine method of delivery- elective aesarean section for grades III/IV between 37-38 weeks, trial of vaginal may be offered if grade I
If know placenta praevia goes into labour prior to the electve caesarean secton emergency caesarean section should be performed due to PPH risk

Answer 192

A

Admit
ABC approach to stabilise woman
If not able to stabilise- emergency caesarean section
If in labour or term reached- emergency caesarean section

Answer 193

A

Transvaginal utrasound

Answer 194

A

Painless Praevia
Agony Abruption

Answer 195

A

Painless and bright red

Answer 196

A

Pain and dark red

Answer 197

A

Excessive pain during the menstrual period

Answer 198

A

No underlying pelvic pathology. Usually appears within 1-2 years of menarche.

Pain typically starts just before or within a few hours of period starting

Suprapubic cramping pains which may radiate to the back or down the thigh

Answer 199

A

1st- NSAIDs such as mefenamc acid and ibuprofen

2nd- COCP

Answer 200

A

Develops many years after the menarche. Is the result of underlying pathology. Pain usually starts 3-4 days before the onset period.

Causes incude:
Endometriosis
Adenomyosis
Pelvic inflammatory disease
Intrauterine devices (copper coil, inrauterine system (mirena) may help)
Fibroids

Answer 201

A

Refer to gynae

Depends on cause

Answer 202

A

High HCG

Low PAPP-A

Nuchal translucency- thickened

Answer 203

A

Between 11 weeks and the end of the 13th week

Answer 204

A

From the 15th week onwards

Answer 205

A

The combined test is now standard- tests should be done between 11-13+6 weeks
Combined is- nuchal translucency measurement, serum B-HCG and pregnancy-associated plasma protein A (PAPP-A)
Trisomy 18 and 13 give similar results to Down’s but HCG lower

Quadruple test

If women book later in pregnancy quadruple test should be offered between 15-20 weeks

Answer 206

A

Alpha-fetoprotein

Unconjugated oestriol

Human chorionic gonadotrophin

Inhibin A

Answer 207

A

Nuchal translucency measurement

Serum B-HCG

Pregnancy-associated plasma protein A (PAPP-A)

Answer 208

A

Alpha-fetoprotein- low

Unconjugated oestriol- low

HCG- high

Inhibin A- high

Answer 209

A

Both tests return a lower chance or higher chance result

Lower chance- 1 in 150 or more

High chance- 1 in 150 or less

Answer 210

A

If a woman has a higher chance result she will be offered a second screening test (NIPT) or a diagnostic test (amniocentesis or chorionic villus sampling (CVS). Given NIPT non-invasive and highly sensitive and specific this is preffered choice

Answer 211

A

Analyses small DNA fragments that circulate in the blood of a pregnant woman

cffDNA derives from placental cells

Analysis of cffDNA allows early detection chromosomal abnormalities

Sensitivity and specificity are very high for trisomy 21 (>99%)- similarly high for other chromosomal abnormalities

Answer 212

A

5mg folic acid instead of 400mcg

Answer 213

A

Thrush- very common 80% caused by Candida albicans

Answer 214

A

DM

Drugs- antibiotics, steroids

Pregnancy

Immunosuppression- HIV

Answer 215

A

Cottage cheese, non offensive discharge

Vulvitis- superficial dyspareunia, dysuria

Itch

Vulval erythema, fissuring, satellite lesions

Answer 216

A

High vaginal swab- not indicated if the clinical features consistent with candidiasis

Answer 217

A

Local or oral

1st- Oral fluconazole

Clotrimazole 500mg intravaginal pessary as single dose if oral therapy contraindicated

If there are vulval symptoms consider adding topical imidazole in addition to an oral or intravaginal antifungal

If pregnant only local treaments may be used

Answer 218

A

4 or more episodes per year

Compliance checked

Confirm candidiasis with high vaginal swab

Blood glucose to exclude diabetes

Consider induction maintinence regime-
Induction: Oral fluconazole every 3 days for 3 doses
Maintinence- oral fluconazole weekly for 6 months

Answer 219

A

Sudden onset unilateral lower abdominal pain. May coincide with exercise

N+V common

Unilateral, tender adnexal mass on examination

Answer 220

A

Adnexal torsion

Answer 221

A

RFs

Ovarian mass
Being reproductive age
Pregnancy
Ovarian hyperstimulation syndrome

Answer 222

A

Usually sudden onset of deep seated colicky abdominal pain

Vomiting and distress

Fever in minority

Vaginal examination shows adnexial tenderness

Ultrasound may show whirlpool sign

Laparoscopy both diagnostic and theraputic

Answer 223

A

Pelvic pain, fever, deep dyspareunia, vaginal discharge, dysuria and menstrual irregularities

Cervical excitation may be found on examination

Answer 224

A

Togavirus

Answer 225

A

Sensorineural deafness

Congenital cataracts
Congenital heart disease (e.g. patent ductus arteriosus)

Growth retardation

Hepatosplenomegaly

Purpuric skin lesions

‘salt and pepper’ chorioretinitis

Microphthalmia

Cerebral palsy

Answer 226

A

Suspected cases should be discussed immediately with the local Health Protection Unit

IgM antibodies raised in women recently exposed to the virus

Difficult to differentiate between rubella and parvovirus B19

Answer 227

A

Discuss with local Health Protection Unit

If a woman has no immunity advise to keep away from people who might have rubella

Non-immune mothers should be offered the MMR vaccination in the post-natal period- MMR should not be given to known pregnant mothers or ones trying to get pregnant

Answer 228

A

11-13+6 weeks

Answer 229

A

15-20 weeks

Answer 230

A

Irregular heavy bleeding

Answer 231

A

Levonorgestrel within 72 hours

Ulipristal within 120 hours

Answer 232

A

Administer tocolytics and steroids

Answer 233

A

Weight reduction

Metformin, clomifene or a combination should be used to stimulate ovulation

Clomifene 1st, metformin more used in overweight

Answer 234

A

Weight reduction

COC may help regulate cycle if contraception required

Answer 235

A

COC may help

2nd Eflornithine

Answer 236

A

The attachment of the placenta to the myometrium. Placenta does not properly seperate during labour higher risk of post partum haemorrhage

Answer 237

A

Accreta: chorionic villi attach to the myometrium

Increta: chorionic villi will invade into the myometrium

Percreta: chorionic villi will invade through the perimetrium

Answer 238

A

Most common liver disorder in pregnancy

Answer 239

A

Pruritis- often in palms and soles

Clinicallydetectable jaundice

Raised bilirubin

Answer 240

A

Ursodeoxycholic acid is used for symptomatic relief

Weekly liver function tests

Women are typically induced at 37 weeks

Answer 241

A

Abdominal pain

Nausea & vomiting

Headache

Jaundice

Hypoglycaemia

Severe disease may result in pre-eclampsia

Answer 242

A

ALT is typically elevated e.g. 500 u/l

Answer 243

A

Support care

Once stabilised- delivery

Answer 244

A

Transvaginal ultrasound

Answer 245

A

Heavy menstrual bleeding >80ml per menses

Answer 246

A

Full blood count

Transvaginal ultrasound scan if symptoms suggest structural or histological abnormality (intermenstrual or post coital bleeding, pelvic pain/pressure symptoms)

Answer 247

A

Either mefenamic acid (particularly with dysmenorrhoea) or tranexamic acid

Both started on first day of period

Answer 248

A

1st- intraterine system (Mirena)

2nd- COCP

3rd- long acting progestogens (depo provera)

Answer 249

A

Irregular, solid tumour

Ascites

At least 4 papillary structures

Strong blood flow

Answer 250

A

Follicular cysts- commonest type ovarian cyst

Corpus luteum cyst- more likely to intraperitoneal bleed than follicular

Answer 251

A

Low dose aspirin started at 12-14 weeks

Answer 252

A

In all cases as more effective especially if ovulation has just occured (14 days) as other two stop ovulation

Unless contraindicatted

Answer 253

A

Subfertility and infertility

Menstrual disturbances- oligomenorrhoea and amenorrhoea

Hirsutism, acne

Obesity

Acanthosis nigricans

Answer 254

A

Pelvic ultrasound- multiple cysts on the ovaries

Baseline investigations- FSH, LH, Prolactin, TSH, testosterone, sex hormone-binding globulin
Raised LH:FSH ratio
Prolactin normal to mildly elevated
Testosterone normal to mildly elevated
SHBG normal to low

Check impaired glucose tolerance

Answer 255

A

Rotterdam criteria- PCOS diagnosis made if 2 of the following 3 are present:

Infrequent/no ovulation

Clinical and biochemical signs of hyperandrogenism (hirsutism, acne or elevated levels of testosterone)

Polycystic ovaries on ultrasound scan

Answer 256

A

> 30 with dysmenorrhoea, menorrhagia and an enlarged boggy uterus

Answer 257

A

Endometrial tissue within the myometrium

More common in multiparous women towards the end of their reproductive years

Answer 258

A

Dysmenorrhoea

Menorrhagia

Enlarged, boggy uterus

Answer 259

A

1st- Transvaginal ultrasound

MRI is alternative

Answer 260

A

Symptomatic treatment- tranexamic acid to manage menorrhagia

GnRH agonists

Uterine artery embolisation

Hysterectomy- definitive treatment

Answer 261

A

210,000 mIU/ml

If higher suggests a molar pregnancy- complete hydatidiform mole

Answer 262

A

Vaginal bleeding

Uterus size greater than expected for gestational age

Abnormally high hCG

Ultrasound: Snow storm appearance of mixed echogenicity

Answer 263

A

Urine output, reflexes, respiratory rate and oxygen saturations

Answer 264

A

Between 25-64 years

25-49 years- 3-yearly

50-64 years- 5-yearly

Cervical screening not offered to patients over 64

Answer 265

A

Cervical screening in pregnancy delayed until 3 months post partum unless missed screening/previous abnormal smears

Women never sexually active before are low risk so may want to opt out

Answer 266

A

Complete hydatidiform mole

Partial hydatidiform mole

Choriocarcinoma

Answer 267

A

Bleeding in first or early second trimester

Exaggerated symptoms of pregnancy- hyperemesis

Uterus large for dates

Very high hCG

Hyertension and hyperthyroidism my be seem (hCG can mimick TSH)

Answer 268

A

Urgent referral to specialist centre- evacuation of uterus performed

Effective contraception recommended to avoid a pregnancy in the next 12 months

Answer 269

A

Waiting for spontaneous miscarrige

Wait 7-14 days for miscarrige to complete spontaneously

If expectant management unsuccessful then medical or surgical management offered

Situations where medical or surgical:
Increased risk of haemorrhage- late first trimester or coagulopathies

Previous adverse/ traumatic pregnancy- stillbirth, miscarrige, antepartum haemorrhage

Evidence of infection

Answer 270

A

Tablets to expedite the miscarrige

Vaginal misprostol- prostaglandin analogue

Contact doctor if bleeding not stopped within 24 hours

Given antiemetics and pain relief

Answer 271

A

Surgical procedure under local or general anaesthetic

Vacuum aspiration (suction curettage) or surgical management in theatre

Vacuum aspiration done under local anaesthetic as an out patient

Answer 272

A

anti-D prophylaxis

Answer 273

A

Mifepristone (anti-progestogen) followed 48 hours later by prostaglandins (e.g. misoprostol) to stimulate uterine contractions

Takes hours/days to complete

Pregnancy test required at 2 weeks to confirm the pregnancy has ended. Should detect the level of hCG (rather than positive or negative)- termed a multi level pregnancy test

Answer 274

A

Transcervical procedures- vacuum aspiration, electric vacuum aspiration and dilitation and evacuation

Following surgical abortion an intrauterine contraceptive can be inserted immediately after evacuation of the uterine cavity

Answer 275

A

Choice between medical and surgical offered up to and including 23+6 weeks gestation

After 9 weeks medical abortions less common- increased likelihood of products of conception seen and decreased success rate

Before 10 weeks medical abortions usually done at home

Answer 276

A

Stop immediately and give alternative antihypertensives (labetalol) while awaiting specialist review

Answer 277

A

systolic > 140 mmHg or diastolic > 90 mmHg

Increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Then catagorise into pre-existing, pregnancy induced or pre- eclampsia

Proteinuria/oedema

Answer 278

A

Hypoechoic masses

Answer 279

A

Snow-storm appearance

Answer 280

A

Large loop excision of the transformation zone (LLETZ)

Answer 281

A

It should be taken for the full duration of pregnancy

Answer 282

A

Either partner has NTD, previous pregnancy NTD or FH NTD

Woman taking antiepileptic drugs, has coeliac, diabetes or thalassemia

Obese 30+ BMI

Answer 283

A

4 3 2 1
4 blood (FBC, rhesus, blood group, alloantibodies)
3 virus (hepB, HIV, syphilis) rubella no more
2 UTI (dipstick, culture)
1 full physical examination (breast, BMI, BP)

Answer 284

A

Class 1 (hypogonadotropic hypogonadal anovulation) - notably hypothalamic amenorrhoea (5-10% of women)

Class 2 (normogonadotropic normoestrogenic anovulation) - polycystic ovary syndrome (80% of cases)

Class 3 (hypergonadotropic hypoestrogenic anovulation) - premature ovarian insufficiency (5-10% of cases). In this class, any attempts at ovulation induction are typically unsuccessful and therefore usually require in-vitro fertilisation (IVF) with donor oocytes to conceive

Answer 285

A

Exercise and weight loss

Letrozole

Clomiphene

Gonadotrphin therapy

Answer 286

A

Ovarian hyperstimulation syndrome (OHSS) is one of the potential side effects of ovulation induction

Hypovolaemic shock
Acute renal failure
Venous or arterial thromboembolism

Answer 287

A

Prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery

Prelabour premature rupture of the membranes, where labour does not start

Maternal medical problems:
diabetic mother > 38 weeks
pre-eclampsia
obstetric cholestasis

Intrauterine fetal death

Answer 288

A

Use to assess whether the induction of labour is required

Score of <5 indicates labour unlikely to start without an induction

Score of ≥ 8 indicates high chance of spontaneous labour

Answer 289

A

Look up table

Cervical postition
0- posterior
1- intermediate
2- anterior

Cervical consistency
0- firm
1- intermediate
2- soft

Cervical effacement
0- 0-30%
1- 40-50%
2- 60-70%
3- 80%

Cervical dilitation
0- <1 cm
1- 1-2 cm
2- 3-4 cm
3- >5 cm

Fetal station

0- -3
1- -2
2- -1, 0
3- +1,+2

Answer 290

A

Options-

1st- Membrane sweep

Vaginal prostoglandin E2 (PGE2)- dinoprostone

Oral prostoglandin E1- misoprostol

Maternal oxytocin

Amniotomy

Cervical ripening balloon

if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion

Answer 291

A

If the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol

Mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean

If the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion

Answer 292

A

Uterine hyperstimulation:
Prolonged and frequent uterine contractions
Fetal hypoxia
Uterine rupture

Management:
Removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
Consider tocolysis

Answer 293

A

It’s Not My Time

Indomethacin

Nifedipine

Magnesium sulphate

Terbutaune

Answer 294

A

Intense pain

Ruptured endometriosis, fluid in abdomen

Answer 295

A

Rock, Paper, Scissors –> Median, Radial, Ulnar

Answer 296

A

Fetus alive and under <36 weeks
Fetal distress: emergency caesarean
No fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and >36 weeks
Fetal distress: immediate caesarean
No foetal distress: deliver vaginally

Foetus dead- induce vaginal delivery

Answer 297

A

Pruritus - may be intense - typical worse palms, soles and abdomen

Clinically detectable jaundice occurs in around 20% of patients

Raised bilirubin is seen in > 90% of cases

Answer 298

A

Induction of labour at 37-38 weeks is common practice but may not be evidence based

Ursodeoxycholic acid

Vitamin K supplementation

Answer 299

A

MORE folic acid (5mg) for:

M- Metabolism diseases- Diabetes and Coeliac
O- Obesity (BMI >30)
R- Relative (Family or personal Hx of NTDs)
E- Epilepsy (on anti-epileptic meds)

(+Thalassaemia and Sickle Cell- less likely in exams)

Antipsychotics too

Answer 300

A

EdwardIAn- inhibin A stands out

Alpha fetoprotein- low
Unconjugated oestriol- low
hCG- low
Inhibin A- normal

Answer 301

A

Alpha fetoprotein- low
Unconjugated oestriol- low
hCG- high
Inhibin A- high

Answer 302

A

Alpha fetoprotein- High
Unconjugated oestriol- normal
hCG- normal
Inhibin A- normal

Answer 303

A

Anyone with risk factors for pre-eclampsia- 1 high risk or two moderate risks

High risk factors:
Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
Type 1 or type 2 diabetes
Chronic hypertension

Moderate risk factors:
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m² or more at first visit
Family history of pre-eclampsia
Multiple pregnancy

Answer 304

A

The umbilical cord descending before the presenting part of the uterus

Answer 305

A

Prematurity

Multiparity

Polyhydraminos

Twin pregnancy

Cephalopelvic disproportion

Abnormal presentation- breech, transverse lie

Answer 306

A

At artificial rupture of the membranes

Answer 307

A

Obstetric emergency

Presenting part of the fetus may be pushed back into the uterus to avoid compression

If cord past the level of introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm

Ask patient to go on all fours until immediate caesarian ready

Tocolytics may be used to reduce the uterine contractions

Retrofilling the bladder with 500-700ml of saline may be helpful

Instrumental vaginal possible if cervix fully dilated and head is low

Answer 308

A

Intrauterine device

Intrauterine system

Both last for 5 years

Answer 309

A

Implantable contraceptive

Contraindications- current breast cance- UKMEC 4

Answer 310

A

Similar to neuroleptic malignant sydrome

Answer 311

A

Miscarriage

Ectopic pregnancy

Implantation bleeding

Answer 312

A

Latest traditional can be- 3 hours

Latest desogestrel can be- 12 hours

Answer 313

A

Longitudinal lie

Transverse Lie

Oblique

Answer 314

A

Women who have had previous pregnancy most common

Fibroids and pelvic tumours

Twins or triplets

Prematurity

Polyhydraminos

Foetal abnormalities

Answer 315

A

Abnormal foetal lie detected during routine antenatal appointments

Abdominal examination

Ultrasound scan

Answer 316

A

Pre-term rupture membranes (PROM)

Cord-prolapse

Answer 317

A

Before 36 weeks none most resolve

After 36 weeks:

Active management- external cephalic version (ECV) of the foetus- can be late in pregnancy or early in labour- contraindications- maternal rupture in last 7 days, multiple pregnancy (except 2nd twin), major uterine abnormality.

Elective caesarean section

Answer 318

A

Copper intrauterine device

Answer 319

A

POP anytime- contraception used first two days

COCP- UKMEC 4 if less than 6 weeks post partum, UKMEC2 6 weeks to 6 months, not in first 21 days as VTE risk, after 21 days additional contraception for first 7 days

IUD or IUS can be used within 48 hours of childbirth or after 4 weeks

Lactationnal amenorrhoea method 98% effective if fully breastfeeding, amenorrhoeic and <6 months post partum

Answer 320

A

Give Pabrinex (B vitamins)

Wernicke’s encephalopathy can come from vomiting (hyperemesis gravidarum)

Answer 321

A

External cephalic version (ECV)

Answer 322

A

If less then 36 weeks reassureit might move round

If over 36 weeks give external cephalic version (ECV) a go

If it fails offer planned caesarean or vaginal delivery

Answer 323

A

Where caesarean delivery is required

Antepartum haemorrhage within the last 7 days

Abnormal cardiotocography

Major uterine anomaly

Ruptured membranes

Multiple pregnancy

Answer 324

A

Admit for IV saline with potassium replacement

Answer 325

A

Just vaginal misoprostol

Contact doctor if bleeding not stopped in 24 hours

Misoprostol expels products of contraception, don’t need mifepristone to end pregnancy as would be the case in an abortion

Answer 326

A

Vaccum aspiration

Surgical management

Answer 327

A

Menopausal symptoms and loss off mineral bone density

Used in fibroids

Answer 328

A

On Passmed

Answer 329

A

Stop lactation reflex- stop suckling

Supportive measures- well supported bra and analgesia

Cabergoline is the medication of choice

Answer 330

A

GnRH analogues to try and reduce the size of the fibroid (uterus) before surgery- particularly for hysterectomy

COCP not taken 4-6 weeks before surgery due to VTE risk

Answer 331

A

12 months since last period

Women under 50 who menopause require contraception for 2 years, over 50 only 1 year

Answer 332

A

If menopause happened over 50- 1 year

If menopause happened under 50- 2 years

Answer 333

A

Lower segment caesarean- now over 99% of cases

Classic caesarean- longitudinal incision

Answer 334

A

Absolute cephalopelvic disproportion

Placenta praevia grades 3/4

Pre-eclampsia

Post-maturity

IUGR

Fetal distress in labour/prolapsed cord

Failure of labour to progress

Malpresentations: brow

Placental abruption: only if fetal distress; if dead deliver vaginally

Vaginal infection e.g. active herpes

Cervical cancer (disseminates cancer cells)

Answer 335

A

Category 1- immediate threat to life of mother or baby- suspected uterine rupture, cord prolapse, foetal hypoxia, persistent fetal bradycardia- to be delivered within 30 mins

Category 2- Maternal or fetal compromise not immediately life threatening - delivery should occur within 75 minutes

Category 3- delivery required but mother and baby stable

Category 4- elective caesarean

Answer 336

A

Previous uterine rupture

Classical caesarean scar

Answer 337

A

Elevated prolactin 10-20 mins after episode can differentiate between general tonic clonic/partial and non-epileptic pseudo seizure

Serum prolactin raised in true seizures
Tongue biting in true seizures

Answer 338

A

Pelvic thrusting

Family member with epilepsy

Much more common in females

Crying after seizure

Don’t occur when alone

Gradual onset

Answer 339

A

pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don’t occur when alone
gradual onset

Answer 340

A

1st- NSAIDs such as mefenamic acid and ibuprofen

COCP is 2nd line

Answer 341

A

Ectocervix transformation. Caused by elevated levels of oestrogen (pregnancy. COCP, ovulatory phase)

Features:
Vaginal discharge
Post coital bleeding

Ablative treatment

Answer 342

A

Uterine fibroids are sensitive to oestrogen and can grow during pregnancy

If growth outstrips blood supply can undergo red degeneration

This presents with low grade fever, pain and vomiting

Conservative management- rest, analgesia- should resolve within 4-7 days

Answer 343

A

Surgery

Total abdominal hysterectomy with bilateral salpingo-oophorectomy

Patients with high risk disease may have post operative chemotherapy

Answer 344

A

Enterocele and vaginal vault prolapse

Urinary retention may occur acutely

Answer 345

A

All types of incontinence

Bladder diaries

Vaginal examination to exclude prelvic organ prolapse

Urine dipstick and culture

Urodynamic studies

Answer 346

A

Yes, can’t use with UKMEC 3COCP, POP UKMEC2 implant

Answer 347

A

Before 115

First trimester Hb less than 110 g/l

Second/third trimester Hb less than 105 g/l

Postpartum Hb less than 100 g/l

Normocytic or microcytic anaemia a trial of oral iron should be considered as the first step, and further investigations only required if no rise in haemaglobin after 2 weeks.

Answer 348

A

Normocytic or microcytic

Oral ferrous sulphate or ferrous fumarate

Treatment continued for 3 months after iron deficieny corrected to allow iron stores to be replenished

Answer 349

A

For 3/4 weeks

Do a pregnancy test with hCG level 2 weeks after the termination to confirm

Answer 350

A

Levornogestrel- imediately

Ulipristal- 5 days after taking- barrier methods used during this period
Ulipristal used with caution in asthmatics

Both can be used more than once in a menstrual cycle

Answer 351

A

<6 weeks- if no pain or risk factors then expectant management, return if bleeding develops, repeat pregany test in 7-10 days

> 6 weeks if bleeding refer to the early pregnancy assesment unit for a transvaginal ultrasound scan

Answer 352

A

IV normal saline with potassium chloride

Treat hypokalaemia

Answer 353

A

Bladder retraining

Answer 354

A

Syntocinon and ergometrine

Answer 355

A

Threatened-
Painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
The bleeding is often less than menstruation
Cervical os is closed

Missed-
A gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear.
Pain is not usually a feature
Cervical os is closed
When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

Inevitable-
Heavy bleeding with clots and pain
Cervical os is open

Incomplete-
Not all products of conception have been expelled
Pain and vaginal bleeding
Cervical os is open

Answer 356

A

Around 5 weeks of age

Answer 357

A

7 days before next period as that is when it is highest

Answer 358

A

Fetal distress- immediate caesarean

No fetal distress- observe closely, SteroidS, no tocolysis, threshold to deliver depends on gestation

Answer 359

A

Maternal antiretroviral therapy
Mode of delivery (caesarean section)
Neonatal antiretroviral therapy
Infant feeding (bottle feeding)

Offer HIV screening to everyone

Answer 360

A

Yes everyone with HIV

Answer 361

A

Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended

A zidovudine infusion should be started four hours before beginning the caesarean section

Answer 362

A

Zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks

Breast feeding not reccomended in UK

Answer 363

A

Cervical intraepithelial neoplasia

6 months for test of cure

Answer 364

A

Vaginal atrophy

(Can occur in women taking HRT)
(Can occur in endometrial hyperplasia?

Answer 365

A

Anyone with risk factors:

BMI of > 30 kg/m²

Previous macrosomic baby weighing 4.5 kg or above

Previous gestational diabetes

First-degree relative with diabetes

Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

Answer 366

A

Gastroschisis
Vaginal can be attempted
- without a peritoneal covering.
- lateral to the umbilical
Mx - surgical correction ASAP
- cover with sling-film(since no peritoneal covering)

Omphalocele
Caesarean indicated
- with peritoneal covering
- umbilical site
Mx - no need csling film BUT surgical treatment usually in staged (may take months) to allow lung adaptation

Answer 367

A

If 7 days missed consecutively- start again as new user

Answer 368

A

Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock

Amenorrhoea and symptoms of hypothyroidism

(Big cause is PPH)

Answer 369

A

May occur after dilitation and cutterage

Can prevent endometrium responding to oestrogen- could cause amenorrhoea

Answer 370

A

Primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics

Secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Answer 371

A

Hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)

Polycystic ovarian syndrome (PCOS)

Hyperprolactinaemia

Premature ovarian failure

Thyrotoxicosis*

Sheehan’s syndrome

Asherman’s syndrome (intrauterine adhesions)

Answer 372

A

Presents in women who have recently stopped breast feeding

Should be painless

Answer 373

A

Within the first or second trimester

Answer 374

A

RF is premature membrane rupture

Deliver foetus and IV antibiotics

Fever, tachycardia, neutrophilia, uterine tenderness and foul smelling discharge

Answer 375

A

Acronym for Haemolysis, Elevated Liver enzymes and Low Platelet count

Can develop in the late stages of pregnancy

Got a cross over with severe pre eclampsia

Answer 376

A

Nausea & vomiting
Right upper quadrant pain
Lethargy

Investigations: haemolysis, elevated liver enzymes, low platelets

Treatment: Delivery

Answer 377

A

Ursodeoxycholic acid is used for symptomatic relief

Weekly liver function tests

Women are typically
induced at 37 weeks

Answer 378

A

Raised LH:FSH ratio

Testosterone may be normal or mildly elevated

Sex hormone binding globulin (SHBG) is normal to low

Answer 379

A

All relatively deficient and breastmilk poor source- reduces the risk of haemorrhagic disease of the newborn

Either IM or orally

Answer 380

A

Emotional and physical symptoms women may experience before the luteal phase

Doesn’t occur pre puberty, in pregnancy or post menopause

Answer 381

A

Emotional symptoms include:
anxiety
stress
fatigue
mood swings

Physical symptoms:
bloating
breast pain

Answer 382

A

Mild symptoms- lifestyle advice- sleep, exercise, smoking, alcohol, small regular meals

Moderate symptoms- COCP

Severe symptoms- SSRIs

Answer 383

A

Hypothalamic hypogonadism

Answer 384

A

Temperature of > 38ºC in the first 14 days following deliver

Endometritis: most common cause

Urinary tract infection

Wound infections (perineal tears + caesarean section)

Mastitis

Venous thromboembolism

Management:
If endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)

Answer 385

A

Sacrocolpoplexy

Answer 386

A

Cystocele/cystourethrocele: anterior colporrhaphy, colposuspension

Uterine prolapse: hysterectomy,
sacrohysteropexy

Rectocele: posterior colporrhaphy

Answer 387

A

Abnormal proliferation of the endometrium- abnormal intermentrual bleeding- higher risk for endometrial cancer

Simple or atypical

Simple- high dose progestogens, levornogestrel system

Atypia- hysterectomy

Answer 388

A

Babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin

Hep B cannot be transmitted through breast feeding but HIV can

Answer 389

A

36 weeks in nulliparous

37 in multiparous

Answer 390

A

Onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40

Answer 391

A

Idiopathic

Bilateral oophorectomy

Radiotherapy

Chemotherapy

Infection

Autoimmune disorders

Answer 392

A

Similar to normal climacteric

Climacteric symptoms- hot flushes, night sweats
Infertility
Secondary amenorrhoea
Raised FSH, LH levels (elevated FSH from two samples taken 4-6 weeks apart)
Low oestradiol

Answer 393

A

HRT or COCP until average age of menopause (51)

Answer 394

A

The isthmus- most at risk of rupture

Most common in the ampulla

Answer 395

A

Expectant management of an ectopic pregnancy can only be performed for
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining

Answer 396

A

A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 397

A

Goserelin

Triptorelin

Answer 398

A

For the first 3 weeks, the patch is worn everyday and needs to be changed each week. During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed

Answer 399

A

If the patch change is delayed at the end of week 1 or week 2:
If the delay in changing the patch is less than 48 hours, it should be changed immediately and no further precautions are needed.

If the delay is greater than 48 hours, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.

If the patch removal is delayed at the end of week 3:

The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.

If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.

Answer 400

A

FBC

Ultrasound scan

Answer 401

A

Requires contraception:
Mirena coil- intrauterine system
COCP
Long-acting progestogens

Does not require contraception:
Mefenamic acid (helps with dysmenorrhoea)or tranexamic acid

Answer 402

A

HIV, syphillis, Hep B

Sickle cell, thalassemia

Answer 403

A

Rupture of the membranes followed by painless vaginal bleeding and foetal bradycardia

Answer 404

A

Respiratory rate and reflexes

(urine output, oxygen sats)

Answer 405

A

Increased risk of breast cancer- by addition of progestogen

Increased risk of endometrial cancer- oestrogen by itself not given to women with a womb

Increased risk of VTE- due to addition of progestogen- not the case for transdermal

Increased risk of stroke

Increased risk of ischaemic heart disease if taken 10 years after menopause

Answer 406

A

Both have bleeding

Vaginal atrophy- most common and assocaited with dryness and dyspareunia, post coital bleeding

Endometrial hyperplasia- associated with obesity, no pain or post coital bleeding

Answer 407

A

A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection

if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure®) or insulin-like growth factor binding protein‑1

Ultrasound may also be useful to show oligohydramnios

Answer 408

A

Admission

Regular observations to ensure chorioamnionitis is not developing

Oral erythromycin should be given for 10 days

Antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome

Delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses

Answer 409

A

bHCG- High
TSH- Low
Thyroxine- High

bHCG can stimulate the thyroid gland to produce thyroxine, negative feedback so TSH low

Answer 410

A

Mild symptoms- lifestyle advice- exercise, smoking, alcohol

Moderate symptoms- new-generation COCP (contains drospirenone)

Severe symptoms- SSRI

Answer 411

A

Women with previous GBS offered intrapartum antibiotic prophlaxis or testing late in pregnancy and then antibiotics

If woman has GBS requires intrapartum benzylpenicillin

Answer 412

A

Depo provera

Also delay in fertility returning of up to 1 year, increased risk osteoporosis and irregular bleeding

Answer 413

A

Amenorrhoea, climateric symptoms (hot flushes, night sweats), lost oestradiol, raised gonadotrophins

Answer 414

A

Flucloxacillin

Continue breastfeeding

Answer 415

A

BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Answer 416

A

In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy

Answer 417

A

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

Answer 418

A

Caesarean sections

Answer 419

A

Yes for up to 4 years

The patient can then just take oestradiol

Answer 420

A

Regular and painful uterine contractions

A show (shedding of mucous plug)

Rupture of the membranes (not always)

Shortening and dilation of the cervix

Answer 421

A

Labour may be divided in to three stages
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Answer 422

A

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

Answer 423

A

Stage 1 - from the onset of true labour to when the cervix is fully dilated. In a primigravida lasts typical 10-16 hours
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr

Also

Latent- 0-3cm
Active- 3-7cm
Transition- 7-10cm

Answer 424

A

Stage 2 - from full dilation to delivery of the fetus
‘passive second stage’ refers to the 2nd stage but in the absence of pushing (normal)
active second stage’ refers to the active process of maternal pushing
less painful than 1st (pushing masks pain)
lasts approximately 1 hours
if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section
episiotomy may be necessary following crowning
associated with transient fetal bradycardia

Answer 425

A

must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date

Likely ovulation date is normal length of period (take the shortest one) and subtract 14

Answer 426

A

William’s syndrome

Answer 427

A

Previous uterine rupture or classical caesarean scar

Answer 428

A

Paroxetine

Answer 429

A

Reduced urea, reduced creatinine, increased urinary protein loss

Answer 430

A

Refer to speacialist midwife led clinic

Answer 431

A

Intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Remove copper IUD

Answer 432

A

Mild- Lifestyle advice

Moderate- new generation COCP

Severe- SSRI

Answer 433

A

Endometrial

Answer 434

A

IgG- got antibodies

IgM- met someome with virus, immediate infection

Answer 435

A

4 weeks

Pregnancy test taken 2 weeks after

Answer 436

A

Over 4.5 kg

Answer 437

A

3 or more

Causes:
Antiphospholipid syndrome

Endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome

Uterine abnormality: e.g. uterine septum

Parental chromosomal abnormalities

Smoking

Answer 438

A

PCOS women

Abdominal pain/bloating
N+V
Oliguria
Ascites
Thromboembolism
Acute respiratory distress syndrome

Answer 439

A

Increased

Increased AFP
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

Decreased

Down’s syndrome
Trisomy 18
Maternal diabetes mellitus

Answer 440

A

15 if secondary sexual characteristics

13 with no secondary sexual characteristics

Answer 441

A

PElvic ultrasound

FSH, LH, TSH, testosterone, sex hormone-binding globulin (SHBG)

LH:FSH ratio raised
Prolactin normal or elevated
Testosterone normal or elevated
SHBG normal to low

Rotterdam criteria:

Infrequent/no ovulation

Clinical/biochemical hyperandrogenism

Polycystic ovaries on USS

Answer 442

A

Refferal using suspected cancer pathway

First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value

Hysteroscopy with endometrial biopsy

Answer 443

A

Admit for obersvation and give steroids

Answer 444

A

Streptococcus agalacticae

In chains

Answer 445

A

Vit A may be teratogenic- so avoid liver

Take folic acid and vit D

No drinking

No smoking

Answer 446

A

For stage IA
Most likely to preserve fertility- cone biopsy
Recommended for women who don’t want children- hysterectomy with lymph node clearance- gold standard

Later sage- radiotherapy and chemotherapy

Answer 447

A

The woman who gave birth, not the genetic parents

Answer 448

A

Croup- Autumn
Bronchiolitis- Winter

Answer 449

A

Neonatal resuscitation guidelines
Birth: Dry the baby, remove any wet towels and cover and start the clock or note the time.
Within 30 seconds: Assess tone, breathing and heart rate.
Within 60 seconds: If gasping or not breathing - open the airway and give 5 inflation breaths
Re-assess: If no increase in heart rate look for chest movement
If chest not moving: Recheck head position, consider 2-person airway control and other airway manoeuvres, repeat inflation breaths and look for a response.
If no increase in heart rate look for chest movement
When the chest is moving: If heart rate is not detectable or slow (< 60 min-1) - start chest compressions with 3 compressions to each breath.
Reassess heart rate every 30 seconds. If heart rate is not detectable or slow (<60 beats per minute) consider venous access and drugs

Answer 450

A

Usually mid cycle pain.
Often sharp onset.
Little systemic disturbance.
May have recurrent episodes.
Usually settles over 24-48 hours.

Answer 451

A

Fitz-Hugh-Curtis (PID complication)
it is characterised by right upper quadrant pain and may be confused with cholecystitis

Answer 452

A

PID or suspected STI

Answer 453

A

4 weeks before

Answer 454

A

Depo provera

Answer 455

A

Multiparous women towards the end of their reproductive years

dysmenorrhoea
menorrhagia
enlarged, boggy uterus

NICE recommend transvaginal ultrasound as the first-line investigation
MRI is an alternative

symptomatic treatment
tranexamic acid to manage menorrhagia
GnRH agonists
uterine artery embolisation
hysterectomy
considered the ‘definitive’ treatment

Answer 456

A

Maternal pyrexia

Maternal tachycardia

Foetal tacycardia

More likely in pre-term PROM

Answer 457

A

Oral contraceptives due to lack of efficacy

Answer 458

A

In 3 months

Should be performed after minimum of 3 days and max of 5 days of abstinence

Deliver to lab within an hour

Answer 459

A

Increased risk of haemorrhage
she is in the late first trimester
if she has coagulopathies or is unable to have a blood transfusion

Previous adverse and/or traumatic experience associated with
pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage)

Evidence of infection

Answer 460

A

Vacuum aspiration

Answer 461

A

Fibroid degeneration

Grow in pregnancy due to oestrogen

Enlarged uterus

Answer 462

A

Three stages:
1.Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function

Answer 463

A

First the embryo
Then the placental trophoblast

Main role is to prevent the disintergration of the corpus luteum

Answer 464

A

When you measure for ovulation

7 days before end of cycle

Answer 465

A

First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L

Treat with oral ferrous sulphate

Answer 466

A

Myomectomy

Answer 467

A

Breast cancer

Answer 468

A

ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen- C-section);
P for Polyhydramnios;
T for Twins or multiple gestation/multiparity;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 469

A

Immediately

After 4 weeks if breast feeding

Answer 470

A

Yes, if before it is pre existing hypertension

Answer 471

A

A micturating cystourethrogram

Answer 472

A

None it works straight away

Answer 473

A

Previous gestational diabetes- at booking and 24-28 weeks

Other risk factors- just 24-28 weeks

Answer 474

A

Causes:

Premature rupture of membranes

Potter sequence
bilateral renal agenesis + pulmonary hypoplasia

Intrauterine growth restriction

Post-term gestation

Pre-eclampsia

Answer 475

A

Stage 1 (1 word) = ovary
Stage 2 (2 words) = ovary + pelvis
Stage 3 (3 words) = ovary + pelvis + abdomen
Stage 4 = distant metastasis

Stage 1 Tumour confined to ovary
Stage 2 Tumour outside ovary but within pelvis
Stage 3 Tumour outside pelvic but within abdomen
Stage 4 Distant metastasis

Answer 476

A

Erb’s palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the ‘waiter’s tip’

Klumpke’s palsy occurs due to damage of the lower brachial plexus and commonly affects the nerves innervating the muscles of the hand

Answer 477

A

Aspirin from 12 weeks to all pregnant women who are at moderate or high risk of pre-eclampsia

Answer 478

A

2/3 on the Rotterdam scale:

oligomenorrhoea
clinical and/or biochemical signs of hyperandrogenism
polycystic ovaries on ultrasound

Answer 479

A

Management

Simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used

Atypia: hysterectomy is usually advised

Answer 480

A

High level related to early labour

Give steroids incase go into labour, monitor BMs if diabetic as can mess them up

Answer 481

A

Fluoxetine

Answer 482

A

Potentially sensitising events in pregnancy:
- Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)

Answer 483

A

Every year

Women who are HIV positive are at an increased risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer due to a decreased immune response and decreased clearance of the human papilloma virus

Answer 484

A

Until 24 hours after EITHER last seizure or delivery

Answer 485

A

Secondary amenorrhoea due to uterine adhesions following surgery or trauma from birth

Answer 486

A

The three features of Meig’s syndrome are:
a benign ovarian tumour
ascites
pleural effusion

Answer 487

A

Types
cystocele, cystourethrocele
rectocele
uterine prolapse
less common: urethrocele, enterocele (herniation of the pouch of Douglas, including small intestine, into the vagina)

Surgical options
cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
uterine prolapse: hysterectomy, sacrohysteropexy
rectocele: posterior colporrhaphy

Answer 488

A

VEAL CHOP

Variable decelerations –> Cord compression
Early decelerations –> Head compression
Accelerations –> Okay!
Late decelerations –> Placental Insufficiency

Answer 489

A

Only if amniotic sac not ruptured

Answer 490

A

Higher risk of screening cancers- cervical and breast

Lower risk of old age cancers- ovarian and endometrial

Answer 491

A

1st trimester- CHD

3rd trimester- persistant pulmonary hypertension of the newborn

Answer 492

A

Pelvic ultrasound

Answer 493

A

Up to 6 weeks

Answer 494

A

ABRUPTION:
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 495

A

Cause of oligohydraminos- renal agenesis and pulmonary hypoplasia

Answer 496

A

Yes, phenytoin reduces folate

Answer 497

A

Vesicovaginal fistula

Answer 498

A

Prolonged rupture of the membranes >24 hours

Answer 499

A

Same

On quadruple/combined similar to Down’s but hCG lower

Answer 500

A

Can breastfeed as doesn’t go into the milk

Babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin

Vaccine+HBIG within 12 hours of birth
Hep B vaccine 1-2 months then 6 months

Answer 501

A

FSH/LH- anterior pituitary

Oestrogen- ovaries

Proesterone- corpus luteum of ovary

Answer 502

A

Menstration

Follicular phase

Ovulatory phase

Luteal phase- last 14 days

FSH causes maturation of an egg

Oestrogen causes lining of uterus to grow

LH causes ovulation

Progesterone maintains the uterus lining, inhibits both LH and FSH

Answer 503

A

Clue cells

Answer 504

A

Trimethoprim tetarogenic

1st- nitrofurantoin (avoid near term)
2nd- amoxicillin

MEN- 7 days treatment

Women- 3 days

Answer 505

A

Calluses on knuckles or back of hand in bulimia

Answer 506

A

Face seizures at night

Centrotemporal spikes

Answer 507

A

Referral to gynae

Answer 508

A

NSAIDs/Paracetamol

COCP or progestogens

GnRH analogues

Surgery- ablation, laparoscopic excision

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Obs/ Gynae Flashcards

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