Obs n Gynae

Question 1

define preterm labour

Answer 1

<37 weeks gestation

Question 2

define prolonged labour

Answer 2

no definite time period

cervical dilatation <2 cm in 4 hours during active labour

Question 3

describe the first stage of labour

Answer 3

onset to contractions to full dilatation

early latent phase = cervix becomes effaced, shortens and dilates up to 4 cm

active phase = 4 cm cervical dilatation to full dilatation (10 cm)

Question 4

describe the 2nd stage of labour

Answer 4

full dilatation to delivery of fetus

passive stage = full dilatation prior to or in absence of persistent involuntary expulsive contractions

active stage = when baby is visible OR persistent involuntary expulsive contractions/active maternal effort with a finding of full dilatation

Question 5

describe the 3rd stage of labour

Answer 5

delivery of fetus to delivery of placenta and membranes

Question 6

how long can the 3rd stage of labour last

Answer 6

usually 5-10 minutes after delivery

> 30 minutes = abnormal

Question 7

how long does labour normally last

Answer 7

first labour = average 8 hours

subsequent labours = average 5 hours

Question 8

when is delay in labour diagnosed

Answer 8

nulliparous: active second stage has reached 2 hours
multiparous: active second stage has reached 1 hour

Question 9

what is the difference between physiological and active management of the 3rd stage of labour

Answer 9

physiological: uterotonic drugs (oxytocin) are not used, cord not clamped until pulsations have ceased, placenta is delivered by maternal effort

active management: use of oxytocin before cord stops pulsating, bladder catheterisation, deferred clamping and cutting of the cord, controlled cord traction after signs of separation of the placenta

Question 10

what are the signs that indicate separation of the placenta and membranes

Answer 10

uterus contracts, hardens and rises

umbilical cord lengthens permanently

gush of blood variable in amount

placenta and membranes appear at introitus

Question 11

when should you change from physiological to active management of 3rd stage of labour

Answer 11

excessive bleeding or haemorrhage

failure to deliver placenta within 1 hour

patient’s desire to shorten 3rd stage

Question 12

what are clinical signs of onset of labour

Answer 12

regular, painful contractions which increase in frequency and duration and produce progressive cervical dilatation

passage of blood-stained mucus from the cervix is associated with onset of labour nut not an indicator

rupture of membranes not always at start of labour

Question 13

what is the definition of prelabour rupture of membranes

Answer 13

> 4 hours between rupture of membranes and onset of painful contractions

can be preterm or term

Question 14

what are Braxton hicks contractions

Answer 14

non-labour contractions towards the end of gestation

Question 15

which hormones are involved the initiation of labour

Answer 15

decreased progesterone

increased oestrogen and prostaglandin

oxytocin promotes PG release and initiates/sustains contractions

Question 16

what are special features of uterine myocytes

Answer 16

contract and shorten, and return to precontraction length

contain ion channels that influence the influx of calcium ions into the myocytes and promote contraction of myometrial cells

affected directly by hormones such as relaxin, activin A (cAMP)

Question 17

describe changes in the cervix leading up to labour

Answer 17

contains myocytes and fibroblasts

towards terms, there is a decrease in collagen (becomes softer and stretchy)

increased hyaluronic acid reduces the affinity of fibronectin for collagen and affinity of hyaluronic acid for water causes cervix to soften and stretch

Question 18

what are the cardinal movements of labour

Answer 18

engagement
descent 
flexion 
internal rotation 
extension
external rotation 
expulsion

Question 19

describe engagement (1st cardinal movement)

Answer 19

passage of widest diameter of the presenting part to a level below the plane of the pelvic inlet

engagement is measured in fifths (proportion of fatal head that is unpalpable)

Question 20

describe descent (2nd cardinal movement)

Answer 20

downward movement of the presenting part through the pelvis

Question 21

describe flexion (3rd cardinal movement)

Answer 21

flexion of the fatal head occurs passively as the head descends due to the shape of the bony pelvis and resistance by soft tissues

Question 22

describe internal rotation (4th cardinal movement)

Answer 22

rotation of the presenting part from its original position (usually transverse with regard to the birth canal) to the anterior position as it passes through the pelvis

Question 23

describe extension (5th cardinal movement)

Answer 23

occurs once the fetus has reached the introitus, and the base of occiput is in contact to the inferior margin of the pubic symphysis

Question 24

describe external rotation/restitution (6th cardinal movement)

Answer 24

return of the fetal head to the correct anatomical position in relation to the fatal torso and shoulders

Question 25

describe expulsion (7th cardinal movement)

Answer 25

delivery of rest of fetal body

Question 26

what are causes of abnormal labour

Answer 26

``` malpresentation malposition too early (preterm <37 weeks) too late (post-term >42 weeks) too painful too quick (<2 hours) too long (failure to progress, obstruction) fetal distress ```

Question 27

what is malpresentation

Answer 27

non-vertex presentation vertex is bounded by the anterior and posterior fontanelles and the parietal eminences involves breech presentation, transverse, shoulder/arm, face or brow presentation

Question 28

what is malposition (labour)

Answer 28

occipitoposterior or occipitotransverse

Question 29

what are the main causes of failure to progress

Answer 29

powers: inadequate contractions either in strength or frequency passages: trauma, shape, cephalopelvic disproportion passenger: big baby, malposition causing a relative cephalopelvic disproportion

Question 30

what are potential complications of obstructed labour

Answer 30

``` sepsis: ascending genitourinary tract infection postpartum haemorrhage fistula formation fetal asphyxiation neonatal sepsis uterine rupture obstructed acute kidney injury ```

Question 31

how is progress in labour assessed how often should it be performed

Answer 31

vaginal examination every 4 hours cervical dilatation descent of presenting part signs of obstruction (moulding, caput, anuria, haematuria, vulval oedema

Question 32

what are the three main types of forceps

Answer 32

outlet forceps mid-cavity/low-cavity forceps rotational forceps

Question 33

indications for outlet forceps

Answer 33

fetal scalp is visible without separating the labia the fatal skull has reached the pelvic floor sagittal suture is in the AP diameter or right or left occiput anterior or posterior position (not >45 degrees) fatal head is at or on perineum can be used for lift-out deliveries at c-section

Question 34

indications of mid/low-cavity. forceps

Answer 34

when fatal head is 1/5 palpable abdominally leading point of the skull is above station +2 but not above the ischial spines rotation of <45 degrees

Question 35

indications for rotational forceps

Answer 35

should be performed in theatre with effective regional anaesthesia

Question 36

what are the indications for FORCEPS

Answer 36

fully dilated (10 cm) occipitoposterior position ruptured membranes cephalic presentation engaged presenting part (fetal head must not be palpable abdominally and must be below the ischial spines) pain relief sphincter (bladder) empty (catheterisation) standard indications: failure to progress in 2nd stage, fatal distress, maternal exhaustion

Question 37

what are the advantages of operative vaginal delivery over C-section

Answer 37

80% will have a spontaneous vertex delivery subsequently reduced analgesic requirements shorter hospital stay and quicker recovery less physical restrictions on bonding with the baby

Question 38

what are the advantages of c-section compared to operative vaginal delivery

Answer 38

avoids tears to perineum and therefore problems with long term urinary and faecal incontinence no injury to cervix or high vaginal areas less change of neonatal trauma

Question 39

what are disadvantages of operative vaginal delivery compared to c-section

Answer 39

neonatal trauma urinary symptoms if retention occurred around the time of delivery high risk of postpartum haemorrhage shoulder dystocia as the traction applied cases head to deflex and shoulders to abduct, widening their diameter

Question 40

what types of neonatal trauma can occur as a result of operative vaginal delivery

Answer 40

intracranial haemorrhage skull fracture jaundice due to cephalohaematoma and caput succedaneum (ventouse) facial nerve palsy forceps leave mark on face brachial plexus injury

Question 41

disadvantages of c-section compared to operative vaginal delivery

Answer 41

``` haemorrhage/infection visceral injury VTE longer hospital stay risk of uterine rupture in future labours and placenta accreta in future pregnancy greater maternal mortality transient tachypnoea of newborn ```

Question 42

advantages and disadvantages of ventouse delivery

Answer 42

less perineal trauma but more likely to fail than forceps more likely to cause cephalohaematoma, chignon (swelling on baby's heads) and retinal haemorrhage

Question 43

contraindications to ventouse delivery

Answer 43

``` prematurity <34 weeks face presentation suspected fatal bleeding disorder eg haemophilia fetal predisposition to fracture maternal HIV or HepC ```

Question 44

describe caput succedaneum in terms of onset, pathology, site, associated features and management

Answer 44

onset: present at birth pathology: due to pressure of the presenting part against the cervix site: tissue swelling that forms over the vertex and crosses suture lines features: prolonged labour; soft puffy swelling; skin over swelling may look bruised; often with moulding management: conservative, resolves in days

Question 45

describe cephalohaematoma in terms of onset, pathology, site, associated features and management

Answer 45

onset: several hours after birth pathology: subperiosteal haemorrhage due to prolonged second stage or instrumental delivery site: forms below the first layer of periosteum, limited by suture lines features: jaundice in newborn; often following operative delivery; swelling is firm with distinct margins; no skin discolouration; increases in size 12-24 hours after birth management: conservative unless hyperbilirubinaemia in neonate, resolves over months

Question 46

what is a chignon

Answer 46

temporary swelling after a ventouse suction cap has been used 2 hours - 2 weeks

Question 47

describe subgleal haemorrhage in terms of onset, pathology, site, associated features and management

Answer 47

onset: at delivery and may progress rapidly pathology: severing of the emissary veins that are located between the dural sinuses that cover the skull and scalp site: forms above the periosteum, between the skull and the scalp aponeurosis; crosses the suture lines and covers a greater area than cephalohaematoma features: delay in recognition may lead to neonatal encephalopathy, seizures, death; diffuse ill-defined swelling may shift when palpated and shift with reposition of the head; forceps/ventouse deliveries management: resus and blood transfusions, assess for coagulopathies

Question 48

what are the main diagnostic features of amniotic fluid embolism

Answer 48

occurs during or within 30 minutes of labour | respiratory distress, hypoxia, hypotension

Question 49

after 30 minutes of physiological management of 3rd stage of labour and placenta still hasn't been delivered abs are stable and blood loss is minimal - what is the next best step

Answer 49

observe for 30 mins with IM syntocinon and breastfeeding can wait up to 30 minutes total for physiological management of 3rd stage of labour give syntocinon IM rather than In infusion breastfeeding will stimulate spontaneous expulsion

Question 50

29 yo primiparous women in prolonged labour following induction at 41 wks 6 cm dilated, fatal head is 1 cm above ischial spines fetal heart rate is progressively dropping, <100 bpm, not recovered for more than 3 minutes management?

Answer 50

category 1 C-section fetal HR <100 bpm is a worrying sign not fully dilated to instrumental delivery in theatre may not be advised

Question 51

when is terbutaline given?

Answer 51

given in premature labour to reduce contractions

Question 52

which of the following is not an indication for induction of labour? ``` prolonged pregnancy diabetes in pregnancy macrosomia pre-eclampsia at term IUGR ```

Answer 52

macrosomia

Question 53

a baby born 4 hrs ago by forceps has a swelling in the parietal region which does not cross suture lines what is it

Answer 53

cephalohaematoma

Question 54

31 yo due to have induction of labour at 38 wks due to cholestasis of pregnancy bishop's score of 1 calculated with the station at -1 but her cervix is closed and firm treatment?

Answer 54

vaginal prostaglandins (PGE2) PGs will ripen the cervix and cause a dilation allowing ARM to occur later

Question 55

what is syntometrine used for?

Answer 55

management of postpartum haemorrhage

Question 56

38 yo prim at 39+3 presents in spontaneous labour she has only dilated 3 cm in last 6 hrs she is now 6 cm dilated, CTG shows no fatal distress, uterine contractions are palpable but irregular and not very strong management?

Answer 56

vaginal examination followed by amniotomy and reassess after PV exam to assess dilatation, position and presentation of fetus membranes are intact, so amniotomy is performed to accelerate progress of labour CTG monitoring continued

Question 57

what is the average rate of dilation in a primiparous woman

Answer 57

1 cm per hour

Question 58

indications for induction of labour

Answer 58

``` prolonged pregnancy (>42 weeks) pre-eclampsia placental insufficiency and IUGR antepartum haemorrhage (includes abruption) Rh immunisation diabetes mellitus chronic renal disease ```

Question 59

what does the bishop score measure

Answer 59

assessment of the cervix to predict outcome following induction ``` dilatation effacement station cervical consistency cervix position ```

Question 60

a bishop score of ____ is strongly predictive of labour following induction

Answer 60

``` >6 = labour follows induction <5 = needs cervical ripening ```

Question 61

what are the criteria of the Bishop's score

Answer 61

dilatation: 0, 1-2, 3-4, 5+ effacement (?%): 0-30, 40-50, 60-70, 80-100 station: -3, -2, -1, >0 cervical consistency: firm, medium or soft cervix position: posterior, middle, anterior all criteria start at a score of 0 and up to a max of 3

Question 62

what are mechanisms of induction of labour

Answer 62

``` stripping of membranes artificial rupture of membranes medical induction following amniotomy medical induction and cervical ripening mechanical cervical ripening ```

Question 63

stripping of the membranes | requirements and hazards/precautions

Answer 63

requirements aseptic conditions: finger is inserted into cervix and the fetal membranes are separated from the lower segment hazards/precautions: if 7 people have sweeps, only 1 will labour in 48 hours

Question 64

artificial rupture of membranes (amniotomy) | requirements and hazards/precautions

Answer 64

requirements: aseptic conditions to prevent infection cervix should be soft, effaced and at least 2 cm dilated head should be engaged in pelvis and should be presenting by the vertex hazards/precautions: cord prolapse, vasa praevia )make sure to assess the fetal membranes and make sure there are no pulsating vessels present before amniotomy) need to monitor fetal heart rate on CTG

Question 65

medical induction following amniotomy using synthetic oxytocin infusion (syntocinon) requirements and hazards/precautions

Answer 65

requirements: aseptic conditions to prevent infection cervix should be soft, effaced and at least 2 cm dilated head should be engaged in pelvis and should be presenting by the vertex hazards/precautions: uterine hyperstimulation (>5 contractions in 10 minutes); reduces uterine blood flow and results in fetal asphyxia discontinue infusion if excessive uterine activity or signs of pathological fetal heart rate of concern can cause uterine rupture, particularly if there is a uterine scar

Question 66

medical induction of labour and cervical ripening by administration of PGE2 requirements and hazards/precautions

Answer 66

requirements: method of choice when the membranes are intact or where the cervix is unsuitable for surgical induction oral route: causes nausea and vomiting and not commonly used pessaries: most commonly used; 3 mg doses if no response repeat after 6 hours hazards/precautions: PG contraindicated if previous uterine scar (risk of hyper stimulation and uterine rupture) if hyperstimulation, remove pessary and use a bolus of short acting tocolytic eg terbutaline

Question 67

what is mechanical cervical ripening

Answer 67

insertion of balloon catheter through the cervix which is used to distend the cervical canal over a 12 hour period and then removed to allow amniotomy

Question 68

what is measure on a cartogram

Answer 68

``` fetal heart rate cervical dilatation duration of labour colour of liquor frequency and duration of contraction caput and moulding station/descent of the head maternal heart rate, BP and temperature ```

Question 69

how is descent of fetal head/station measured

Answer 69

assessing the level of the presenting part in cm above or below the ischial spine and marked as +1/2/3 if below the spines and _1/2/3 if above the spines

Question 70

pros and cons of narcotic analgesia in labour

Answer 70

pros: suitable for women who can't have regional analgesia eg women on anticonvulsants remifentanil is ultra-short acting and is superior to pethidine cons: maternal: nausea and vomting (give anti-emetic too) fetal: respiratory depression

Question 71

pros and cons of inhalation analgesia (gas and air)

Answer 71

pros: easy to administer short-acting cons: may cause nausea sometimes inadequate as labour progresses

Question 72

contraindication to regional anaesthesia

Answer 72

``` maternal refusal coagpulopathy local or systemic infection uncorrected hypovolaemia inadequate or inexperiences staff/facilities ```

Question 73

pros and cons of epidural anaesthesia

Answer 73

pros: complete pain relief in majority can be commenced at any time and does not increase risk of C-section can be controlled by patient can be topped up to allow operative deliveries ``` cons: may reduce desire to bear down in second stage of labour due to lack of sensation at the perineum and reduced uterine activity increased risk of a assisted delivery causes abnormal fetal HR hypotension accidental dural puncture postural headache high block which may cause resp depression in mother atonic bladder ```

Question 74

describe how an epidural anaesthetic works

Answer 74

fine catheter placed into lumbar epidural space (L3-4) and a local anaesthetic agent such as bupivacaine is injected adding an opioid to the local anaesthetic reduces dose requirements to spare motor function of the lower limbs and reduced complications eg hypotension and abnormal fetal HR

Question 75

describe a pudendal nerve block

Answer 75

injection of local anaesthetic around the pudendal nerve at the level of the ischial spine

Question 76

pros and cons of pudendal nerve block

Answer 76

pros: used in operative vaginal delivery cons: risk of haemorrhage from pudendal artery risk of lignocaine toxicity if inadvertent intravascular injection can be ineffective

Question 77

describe a spinal anaesthetic

Answer 77

catheter is placed at L3-4 and inserted into the subarachnoid space where anaesthetic agent is injected

Question 78

pros and cons of spinal anaesthesia

Answer 78

pros: commonly used for operative delivery cons: not used in pain control because of superior safety of epidural and its ability to top up with doses or as continuous infusion to get pain relief over a long period of time

Question 79

maternal indication for continuous electronic fetal monitoring

Answer 79

gestation <37 weeks or >42 weeks induced labour administration of oxytocin ante/intrapartum haemorrhage maternal illness pre-eclampsia previous uterine scar (C-section or myomectomy) contractions >5 in 10 mins or lasting >90 seconds during/following insertion of epidural block maternal request

Question 80

fetal indication for continuous electronic fetal monitoring

Answer 80

abnormal doppler artery velocimetry known or suspected IUGR oligohydramnios or polyhydramnios malpresentation meconium stained liquor multiple pregnancy suspected small for gestational age or macrosomia reduced fetal movements in the last 24 hours reported by mother two vessel cord prolonged ROM >24 hours unless delivery imminent rise in baseline, repeated decelerations or slow to recover decelerations or overshoots fetal structural abnormalities

Question 81

which mnemonic is useful while interpreting CTGs and what does it stand for

Answer 81

DR BRAVADO Define Risk: why are they on CTG (pre-eclampsia, antepartum haemorrhage, maternal obesity, DM, HTN etc) Contractions: normal = 3-5 contractions/10 minutes Baseline RAte: fetal HR 110-160 bpm Variability: good 5-25 bpm, reduced <5 bpm, Accelerations: rise in fetal HR of at least 15 bpm for 15 seconds (fetal movement), occur with contractions, at least 2 every 15 mins Decelerations: reductions of 15 bpm for 15 secs, generally abnormal, early or late in relation to contractions (late decelerations are worse) Overall impression: reassuring or not, BE AWARE of terminal bradycardia (<100 bpm for 10 mins) and terminal decelerations (HR drops and doesn't recover for 3 mins)

Question 82

describe a normal CTG in terms of baseline, variability and decelerations

Answer 82

baseline: 100-160 variability: 5 or more accelerations decelerations: none of early

Question 83

describe a non-reassuring/suspicious CTG in terms of baseline, variability and decelerations

Answer 83

baseline: 161-180 variability: <5 accelerations for 30-90 minutes decelerations: variable decelerations dropping <60 bpm, recovering in <60 secs, present for over 90 minutes, occurring with >50% of contractions OR variable decelerations dropping >60 bpm, recovers in >60 secs, present for up to 30 minutes, occurring with >50% of contractions OR late decelerations present up to 30 minutes, occurring with 50% of contractions

Question 84

describe an abnormal/pathological CTG in terms of baseline, variability and decelerations

Answer 84

baseline: >180 or <100 bpm, sinusoidal pattern variability: <5 for >90 minutes decelerations: non-reassuring variable decelerations still observed 30 mins after conservative management OR late decelerations present over 30 mins, do not improve with conservative measures, with >50% of contractions OR bradycardia or single prolonged deceleration lasting >3 mins

Question 85

definition and management of normal CTG

Answer 85

baseline, variability and decelerations all normal Continue CTG and normal care

Question 86

definition and management of non-reassuring CTG

Answer 86

1 non-reassuring features and 2 normal features inform senior, move to left lateral position, encourage fluids (IV or oral), stop oxytocin, consider tocolysis

Question 87

definition and management of abnormal CTG

Answer 87

1 abnormal feature or 2 non-reassuring features inform senior, start conservative measures, offer fetal blood sampling exclude factors indicating need for immediate delivery (cord prolapse, uterine rupture, hyperstimulation, abruption) treat dehydration, hyperstimulation, hypotension and change position

Question 88

definition and management of pathological CTG

Answer 88

bradycardia or a single prolonged deceleration with baseline <100 bpm for >3 minutes inform senior, start conservative measures, make preparations for urgent birth (c-section)

Question 89

early decelerations | definition, cause and management

Answer 89

drop in fetal HR of >15 bpm for >15 min that occurs at the beginning of the contraction with the lowest point occurring at the peak of the contraction and recovery when contraction stops often due to head compression during a contraction and increased vagal tone, occurs in late first and second stage of labour physiological management

Question 90

late decelerations | definition, cause and management

Answer 90

occurs well after contraction is established and does not return to normal baseline rate until at least 20 seconds after contraction is completed due to placental insufficiency and may indicate fetal hypoxia (maternal hypotension, pre-eclampsia, uterine hyperstimulation) call senior help, get fetal blood sample to check for hypoxia, may need to expedite delivery

Question 91

reduced variability | definition and cause

Answer 91

variability of <5 bpm for >40 minutes OR more than 25 bpm 15-25 minutes fetal sleeping (<40 mins), fetal acidosis and hypoxia, fetal tachycardia, drugs, prematurity, congenital heart problems

Question 92

variable decelerations | definition, cause and management

Answer 92

vary in timing and amplitude and may not have a relationship to uterine contractions cord compression change position of mother, increase monitoring

Question 93

what makes a variably deceleration more concerning

Answer 93

shoulders of deceleration are accelerations before and after a deceleration: indicate the fetus is not yet hypoxic and is adapting to the reduced blood flow variable decelerations without shoulders suggest that the fetus is hypoxic

Question 94

``` sinusoidal pattern (CTG) definition, cause and management ```

Answer 94

smooth irregular wave-like pattern, no beat-to-beat variability, stable baseline of 120-160 bpm severe fetal hypoxia, fetal anaemia, fetal/maternal haemoarhage urgent C-section

Question 95

how often is fetal heart rate monitored in the first and second stage of labour

Answer 95

1st stage: every 15 mins for a period of 1 minute soon after a contraction 2nd stage: every 5 mins or after every other contraction for 1 minute

Question 96

how is a fetal blood sample taken

Answer 96

amnioscope used to obtain blood from fetal scalp | cervix must be at least 3 cm dilated to allow insertion

Question 97

what is the normal fetal pH

Answer 97

7.25-7.35

Question 98

what does management of fatal distress involve

Answer 98

changing maternal position maternal assessment (pulse, BP, abdomen palpation, PV) IV fluids stopping contraction (stop/reduce syntocinon or start terbutaline) scalp stimulation during PV (should have an acceleration) fetal blood sampling operative delivery

Question 99

what is maternal collapse

Answer 99

acute event involving the cardiorespiratory systems and/or brain resulting in reduced or absent conscious level

Question 100

what are the 4H's of maternal collapse

Answer 100

hypovolaemia: bleeding, relative hypovolaemia of dense spinal block, septic or neurogenic shock hypoxia: peripartum cardiomyopathy, MI, aortic dissection, large vessel aneurysms hypo/hypoerkalaemia (and other electrolytes) hypothermia

Question 101

what are the 4T's of maternal collapse

Answer 101

thromboembolism: amniotic fluid embolism, PE, air embolus, MI toxicity: local anaesthetic magnesium tension pneumothorax tamponade (cardiac)

Question 102

how does amniotic fluid embolism cause maternal collapse

Answer 102

amniotic fluid enters the maternal circulation and triggers a syndrome similar to anaphylaxis and septic shock

Question 103

if the woman survives the amniotic fluid embolism what is she at risk of developing

Answer 103

disseminated intravascular coagulopathy

Question 104

which dietary supplements are recommended during gestation

Answer 104

folic acid 400 mcg from before conception to 12 weeks (reduce neural tube defects) up to 5 mg if DM, anti-epileptics, BMI >30, previous neural tube dect 10 mg vitamin D, through pregnancy + breastfeeding 250-300 extra calories

Question 105

what is the guidance for smoking and drinking during pregnancy

Answer 105

drinking: no safe limit (risk of fetal alcohol syndrome) smoking: avoid, increased risk of miscarriage, low birth weight, prematurity

Question 106

side effects of cocaine, amphetamines and ecstasy in pregnancy

Answer 106

maternal: hypersensitive disorders including pre-eclampsia, placental abrupt, death via stroke and arrhythmias fetal: prematurity, neonatal abstinence syndrome, teratogenicity, IUGR, preterm labour, miscarriage, developmental delay, sudden infant death syndrome, withdrawal

Question 107

side effects of opiates in pregnancy

Answer 107

risk of neonatal abstinence syndrome, IUGR, SIDS, stillbirth, maternal deaths

Question 108

side effects of cannabis in pregnancy

Answer 108

cognitive defects, miscarriage, fetal growth restrictions

Question 109

side effects of nicotine in pregnancy

Answer 109

increased risk of miscarriage increased risk of preterm labour and IUGR increased risk of still birth, SIDS

Question 110

side effects of alcohol in pregnancy

Answer 110

fetal alcohol syndrome (smooth philtre, thin vermillion, small palpebral fissures) IUGR and postnatal restricted growth learning difficulties risk of miscarriage withdrawal Wernicke's encephalopathy and Korsakoff's syndrome microcephaly

Question 111

how is substance abuse managed in pregnancy

Answer 111

consider methadone programme (avoid chaotic lifestyle) child protection and social work referral smear history (put measures in place to ensure the woman gets involved with a screening programme) breastfeeding education (HIV+ should bottle feed) labour plan regarding analgesia and labour ward delivery early IV access postnatal contraception plan (ASAP)

Question 112

when does a booking visit take place and what does it consist of

Answer 112

10-12 weeks by community midwife History: medical, drug, social and family, LMP, planned pregnancy, ethnicity of parents obstetric history: previous pregnancy, mode of delivery, previous miscarriages/terminations Ix: mother's blood group, Hb levels, haemoglobinopathies, blood borne infections (HIV/AIDs, syphilis, hep B/C)

Question 113

when does the anomaly scan take place and which conditions does it screen for

Answer 113

18-20+6 weeks anencephaly, open Spina Bifida, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious cardiac anomalies, bilateral renal genesis, skeletal dysplasia, trisomy 18/13

Question 114

when is the first stage of Down's syndrome testing and what does it consist of

Answer 114

11-13+6 weeks combined test = blood test and US US: nuchal translucency >3.5 mm bloods: serum PAPP-A, AFP, beta-hCG (down's = low PAPP-A and aFP, high beta-hCG)

Question 115

what is the 2nd stage of Down's syndrome testing andwhe does it take place

Answer 115

15-16 weeks quadruple test = blood test checking aFP, inhibin, estriol and total hCG

Question 116

how many routine midwife appointments with nulliparous and multiparous women have during pregnancy

Answer 116

nulli: 10 multi: 7

Question 117

women with pre-existing diabetes or gestational diabetes are offered extra monitoring during pregnancy - why?

Answer 117

monitor fetal growth and amniotic fluid volume increased risk of stillbirth, congenital malformation and polyhydramnios

Question 118

how does exposure to Rh antigen expose future pregnancies to risk of haemolytic disease on newborn

Answer 118

when mothers are first exposed to the RH antigen, they form IgM antibodies that are too big to cross the placenta and harm the current fetus in futur pregnancies when the mother is exposed to the same antigen from the foetus's red cells, the body forms IgG antibodies which are smaller and can cross the placenta to harm the fetus

Question 119

how does anti-D work?

Answer 119

removed the rhesus positive blood cells from mother's circulation before antibodies are formed

Question 120

who is anti-D given to

Answer 120

Rh negative mothers who have been exposed to a sensitising event should be given within 72 hours of the event prophylactic anti-D given at 28 weeks to cover silent sensitising events, regardless of other sensitising events

Question 121

what is a sensitising event (in the context of anti-D)

Answer 121

``` placental abruption any abdominal trauma amniocentesis or CVS external cephalic version IU surgery/transfusion fetal death vaginal bleeding from 12 weeks surgical management of miscarriage at <12 weeks evacuation of retained products of conception and molar pregnancy termination of pregnancy ectopic pregnancy delivery (baby is Rh+) ```

Question 122

what should always be undertaken before vaginal examination

Answer 122

abdominal examination

Question 123

what equipment is needed to perform a bimanual examination

Answer 123

``` apron alcohol hand rub sterile gloves lubricant eg aqua gel towel or sheet to cover the woman inco pad ```

Question 124

PV examination: inspection

Answer 124

inspect the clitoris (size, trauma, ulcers) external urethral meatus (discharge, prolapse) and 2 para urethral glands at the 3 and 9 o'clock position remnants of the hymenal ring vaginal canal (mucosa for colour, texture and rugosity) vaginal discharge (colour, texture and odour) older women: ask to cough to demonstrate urinary incontinence or utero-vaginal prolapse

Question 125

what do you assess the cervix for in PV examination

Answer 125

cervical os: open/closed length of cervix directed posteriorly (anteverted) or anteriorly consistency (usually firm when normal but hard in fibrosis/cancer and soft in pregnancy) cervical excitation tenderness: gently move the cervix from side to side simultaneously assessing the patient's face to ascertain if painful (positive in PID or ectopic pregnancy)

Question 126

how to assess the uterus in bimanual examination

Answer 126

vaginal fingers are pushed on or behind the cervix to elevate the uterus upwards and towards the anterior abdominal wall and the left hand is placed suprapubically to palpate the uterus between the two hands size, shape, consistency, position, tenderness, mobility

Question 127

how to assess the adnexa in bimanual examination

Answer 127

vaginal fingers are moved to one of the lateral fornices with the abdominal hand moving into the corresponding iliac fossa presence of ovary/Fallopian tube, adnexal masses, size, shape, tenderness

Question 128

what is shoulder dystocia

Answer 128

when the baby's head has been born but one of the shoulders becomes tuck behind the mother's pubic bone, delaying the birth of the baby's body

Question 129

how to manage shoulder dystocia (emergency situation)

Answer 129

stop pushing reposition into all fours position to increase pelvic diameter OR lie the woman on her back with her legs pushed outwards and up towards her chest (McRoberts manoeuvre) ideally have two helpers to abduct each knee to the woman's chest press on the abdomen just above the pubic bone in an attempt to dislodge the fetal shoulder

Question 130

what is the definition of post part haemorrhage

Answer 130

loss of >500 ml of blood from the genital tract within 24 hours of the birth of a baby

Question 131

indications for examination of pregnant abdomen

Answer 131

at each antenatal assessment from 24 wks to assess growth prior to auscultation fo fetal heart and use of CTG (to work out where to listen) prior to vaginal examination during labour

Question 132

which gestational ages are associate with the following fundal heights: pubic symphysis umbilicus xiphoid process of the sternum

Answer 132

pubic symphysis: 12 weeks umbilicus: 20 weeks xiphoid process: 36 weeks

Question 133

what is the relationship between the SFH and gestational age

Answer 133

gestational age +/- 2 cm

Question 134

where should you place the stethoscope to listen to the fetal heart rate

Answer 134

between the shoulders

Question 135

``` which swabs are used for; trichomonas vaginalis bacterial vaginosis chlamydia gonorrhoea ```

Answer 135

TV and BV: blue swab, vaginal chlam and gon: orange swab, vulvovaginal

Question 136

management of miscarriage

Answer 136

expectant: up to 14 days medical: misoprostol surgical: evacuation of uterus (manual vacuum or electric vacuum)

Question 137

when to give anti-D in case of miscarriage

Answer 137

Rh negative AND >12 weeks or <12 weeks and surgical management

Question 138

where is most common site of ectopic pregnancy

Answer 138

tubes

Question 139

risk factors for ectopics

Answer 139

smoking, PID, previous ectopic, previous tubal surgery

Question 140

investigation of suspected ectopic pregnancy

Answer 140

check HCG 48 hours apart if stable or cannot see pregnancy (PUL) if >63% rise, likely IUP and offer USS (if HCG >1500) if >50% drop, likely a failing pregnancy and check urine pregnancy test in 14 days

Question 141

when is expectant management of ectopic appropriate

Answer 141

HCG <1500 and dropping no significant pain empty uterus mass <35 mm and no FH (unruptured)

Question 142

medical management of ectopic | when/what

Answer 142

best if HCG <3000 but up to 5000 methotrexate

Question 143

side effects of methotrexate management of ectopic

Answer 143

bloating and flatulence transient elevation of LFTs stomatitis

Question 144

presentation of molar pregnancy

Answer 144

irregular bleeding hyperemesis hyperthyroidism

Question 145

what is a complete molar pregnancy

Answer 145

duplication of haploid sperm following fertilisation of an empty ovum no fetal tissue USS snowstorm appearance/IU cystic mass

Question 146

management of complete molar pregnancy

Answer 146

surgical evacuation | 15% chance of chemo

Question 147

what are the risks of molar pregnancy

Answer 147

becomes invasive and potentially cancer-y

Question 148

what is a partial molar pregnancy

Answer 148

triploid = 2 sets of paternal genes and 1 set of maternal | might be fetal tissue

Question 149

management of partial molar pregnancy

Answer 149

medical management if large fetal tissue or surgical 0.5% chance of chemo

Question 150

what is the guidance for future pregnancies after molar pregnancy

Answer 150

no pregnancy for 6 months | or 1 year if chemo

Question 151

fibroids are most common in pre- or post menopausal women

Answer 151

pre menopausal IU masses in post-menopausal women are cancer until proven otherwise

Question 152

symptoms of fibroids

Answer 152

``` none (50% incidental finding) HMB dysmenorrhoea pressure effects (frequency, hydronephrosis if compress ureters) infertility ```

Question 153

what further medical complications can be caused by fibroids

Answer 153

anaemia if heavy bleeding degeneration (pain) torsion if pedunculated infection

Question 154

management of fibroids <3 cm

Answer 154

``` Mirena 1st line tranexamic acid and NSAIDs other contraception (COCP, POP) if submucosal can have transcervical resection endometrial ablation hysterectomy ```

Question 155

management of fibroids >3 cm

Answer 155

``` tranexamic acid and NSAIDs Mirena coil/COCP/POP uterine artery embolisation myomectomy hysterectomy GnRH analogues (switch off hormone production from ovaries, 3 months pre-op) ```

Question 156

tumour marker of ovarian cancer

Answer 156

Ca125

Question 157

what is a complex ovarian cyst

Answer 157

multiloculated has solid parts in it in any way suspicious of cancer

Question 158

what is an RMI (risk of malignancy index) in ovarian cancer

Answer 158

USS features x menopausal status x ca123 <200 low risk (repeat in USS 3 months or benign surgery) >200 refer to gynae onc MDT and CT chest abdo pelvis

Question 159

who is offered cervical screening

Answer 159

25-64 year olds

Question 160

what is tested in cervical screening

Answer 160

HPV if negative - recall in 5 years if positive do cytology cytology if negative HPV in 12 months if positive colposcopy

Question 161

when would you diagnose someone with the menopause

Answer 161

cessation of menstruation for >1 year

Question 162

risks of HRT

Answer 162

VTE: increased with oral, no increase with transdermal stroke: increased with oral, not with transdermal CVS: if <60 no increase BrCa: increased, no increase if oestrogen only osteoporosis: reduced risk

Question 163

when to give combined or oestrogen only HRT

Answer 163

if no uterus = oestrogen only if uterus = combined (oestrogen and progesterone)

Question 164

what are the two main diagnostic tests available to high risk pregnancies

Answer 164

chorionic villous sampling and amniocentesis

Question 165

what is NIPT

Answer 165

non-invasive prenatal testing analyses cell-free DNA in the mother's blood from the fetus better sensitivity and specificity than 1st trimester DS screening

Question 166

risk factors for multiple pregnancy

Answer 166

``` assisted conception eg clomid, IVF ethnicity (African) family history on maternal side increased maternal age increased parity tall women > short women ```

Question 167

define zygosity and chorionicity

Answer 167

monozygotic: splitting of a single fertilised egg dizygotic: fertilisation of 2 ova by 2 sperm dichorionic: 2 placentas, always dichorionic diamniotic monochorionic: 1 placenta, may be mono- or diamniotic

Question 168

how is chorionicity determined

Answer 168

USS, at booking scan DCDA: lambda sign MCDA: T-sign

Question 169

how does management differ between DC and MC twins

Answer 169

MC twins need 2 weekly USS to pick up early signs of Twin-Twin transfusion syndrome

Question 170

signs and symptoms of multiple pregnancy

Answer 170

exaggerated pregnancy symptoms (eg hyperemesis gravid arum) high AFP large for dates uterus multiple fetal poles

Question 171

fetal complications of multiple pregnancy

Answer 171

``` congenital anomalies IU death (single and both) preterm birth growth restriction (equal, discordant) cerebral palsy TTTS (monochorionic pregnancies) ```

Question 172

maternal complications of multiple pregnancy

Answer 172

``` hyperemesis gravidarum anaemia pre-eclampsia GDM antepartum haemorrhage (abruption, praaevia) preterm labour c-section ```

Question 173

describe antenatal management of multiple pregnancy

Answer 173

consultant led care antenatal clinic every 2 weeks if MC and 4 weeks if DC iron and folic acid supplements low dose aspirin to prevent HTN USS from 16th week with deep vertical pool, bladder and umbilical artery assessment anomaly scan 18-20 weeks

Question 174

what is TTS

Answer 174

disproportionate blood supply to foetuses in MC pregnancies one twin has reduced blood supply leading to decreased urine output, anaemia and oligohydramnios while the other twin has increased urinary output, polyhydramnios, polycythaemia and eventually heart failure

Question 175

management of TTS

Answer 175

fetoscopic laser ablation before 26 weeks | after 26 weeks amnioreduction/septostomy and aim to deliver at 34-36 weeks

Question 176

timing of delivery in DCDA and MCDA twins

Answer 176

DCDA 37-38 weeks | MCDA 36+0 with steroids

Question 177

mode of delivery of multiple pregnancies

Answer 177

triplets c-section MCMA: c-section one cephalic twin: aim for vaginal but may need to with to CS

Question 178

labour management of multiple pregnancy

Answer 178

epidural to facilitate operative delivery continuous use of CTG for both syntocinon after twin 1 to maintain contractions USS to confirm presentation intertwine delivery time <30 mins

Question 179

what are the different types of breech presentation

Answer 179

complete breech: legs folded with the leet level with the bottom footling breech: on or both feet point down so will emerge first frank breech: feet are up at the baby's head so bottom emerges first

Question 180

what is external cephalic version

Answer 180

attempting to manually turn the fetus into a cephalic presentation 50% successful

Question 181

what is prolonged pregnancy

Answer 181

>42 weeks

Question 182

risks of prolonged pregnancy

Answer 182

stillbrith meconium aspiration respiratory distress

Question 183

when should induction be offered in prolonged pregnancy

Answer 183

21-42 weeks

Question 184

role of USS in early pregnancy

Answer 184

``` assessment of viability IU or ectopic date pregnancy using CR L determine chorionicity off Down syndrome screening ```

Question 185

role of USS in 2nd trim

Answer 185

fetal anomaly scans placental site screen maternal uterine artery resistance

Question 186

role of USS in 3rd trim

Answer 186

monitor fetal growth (abdominal circumference, head circumference, femur length - calculate EFW) fetal hypoxia anaemia

Question 187

how can USS assess for fetal anaemia/hypoxia

Answer 187

umbilical artery increases its resistance in fetal hypoxia and middle cerebral artery decreases resistance MCA shows increased peak systolic volume in anaemia

Question 188

how many USS does an uncomplicated pregnancy get

Answer 188

2: booking and anomaly scan

Question 189

risk factors for maternal morbidity and mortality

Answer 189

``` black/asian ethnicity age >40 deprivation VTE mental health issues ```

Question 190

define still birth

Answer 190

baby born with no signs of life at or after 28 weeks gestation

Question 191

major causes of stillbirth

Answer 191

``` labour complications post-term pregnancy maternal infections eg malaria, HIV maternal disorders eg DM, HTN fetal growth restriction congenital abnormalities ```

Question 192

what are the features of gestational HTN

Answer 192

develops after 20 weeks gestation, no proteinuria or oedema systolic >140 or diastolic >90 or increase above booking readings of >30 or >15

Question 193

what ar the features of pre-eclampsia

Answer 193

after 20 weeks gestation, HTN with proteinuria (>0.3 g/24 hours)

Question 194

complications of pre-eclampsia

Answer 194

``` fetal prematurity and IUGR eclampsia haemorrhage due to placental abruption cardiac failure stroke VTE DIC and HELLP pulmonary oedema multi-organ failure ```

Question 195

investigations for PET

Answer 195

BP urinalysis (protein) Hb, PLT, U&Es, coag screen, rate

Question 196

management of pre-existing HTN

Answer 196

switch from ACEI (teratogenic) to labetalol, nifedipine, methyldopa consider patient's allergies and PMH

Question 197

management of pregnancy induced HTN (if <20 weeks)

Answer 197

labetalol nifedipine methyldopa hydralazine

Question 198

management of PET >20 weeks

Answer 198

labetalol, nifedipine, methyldopa, hydralazine IV MgSulphate definitive treatment is delivery of baby steroids if early delivery

Question 199

secondary preventions in women with history of PET or risk factors for PET

Answer 199

low dose aspirin started at 12 weeks increased surveillance for signs and symptoms of PET regular growth scans

Question 200

risk factors for GDM

Answer 200

``` previous GDM obesity BMI >30 Fix of a first degree relative with GDM ethnicity (SE asian, Middle Eastern, black Caribbean) previous big baby ```

Question 201

signs of GDM

Answer 201

polyhydramnios | glycosuria

Question 202

complications of GDM

Answer 202

overgrowth of insulin sensitive tissues and macrosomia shoulder dystocia and vaginal trauma assisted delivery/c-section hyperaemic state in utero (risk of stillbirth) short term metabolic complications (fetal hypoglycaemia post-delivery) long term risk of obesity, insulin resistance and diabetes in baby

Question 203

complications of pre-exisiting diabetes in pregnancy

Answer 203

``` congenital anomalies (increased risk of NTD and cardiac anomalies) miscarriage (<24 weeks) IU death (>24 weeks) ```

Question 204

pre-pregnancy counselling in T1DM or T2DM

Answer 204

``` HbA1c monitoring: aim for 48 avoid pregnancy if >86 stop embryopathic medication determine micro-microvascular complications high dose folic acid low dose aspirin from 12 weeks ```

Question 205

when to deliver in GDM

Answer 205

metformin: 39-40 weeks diet controlled: 40-41 insulin: 38 weeks

Question 206

describe screening and diagnosis of GDM

Answer 206

assess risk factors at booking previous gestational diabetes blood glucose monitoring and OGTT in 1st trim (if normal repeat at 24-28 weeks) fasting: >5.1 2 hour: >8.5

Question 207

blood sugar targets in pregnancy

Answer 207

fasting: 3.5 - 5.5 | 1 hours post-meal: <7.8

Question 208

which medications can be used to control GDM if diet and exercise fail

Answer 208

metformin | insulin

Question 209

postnatal care in GDM

Answer 209

increased risk of T2DM fasting BG measured 6-8 weeks if results suggest T2DM, OGTT at 6 weeks annual screening for diabetes by GP

Question 210

aetiology of PROM

Answer 210

infection cervical incompetence over-distension of uterus vascular causes eg placental abruption

Question 211

risk factors for PROM

Answer 211

``` previous pre-term labour multiple pregnancy smoking uterine anomalies parity ethnicity poor socioeconomic status drugs (esp cocaine) ```

Question 212

what are the complications of PROM

Answer 212

neonatal mortality and morbidity (prematurity, sepsis, pulmonary hypoplasia) chorioamnionitis

Question 213

how to diagnose PPROM

Answer 213

maternal history followed by sterile speculum examination (pooling of blood in posterior vaginal fornix) USS: oligohydramnios avoid digital vaginal examination due to risk of infection, unless suspicion woman may be in labour

Question 214

management of PROM

Answer 214

monitor for signs of chorioamnionitis (maternal pyrexia, tachycardia, leucocytosis, uterine tenderness, discharge, fetal tachycardia) Abx to prevent ascending infection (erythromycin) tocolytics (nifedipine if 26-33+6) maternal steroids magnesium sulphate

Question 215

causes of fetal anaemia

Answer 215

``` Rh antibodies parvovirus CMV syphilis toxoplasmosis Hb-opathies feto-maternal haemorrhage MC tiwn complications ```

Question 216

what is hydrops fetalis

Answer 216

abnormal accumulation of fluid in 2 r more compartments and manifests as ascites, plural effusion, skin oedema, pericardial effusion

Question 217

causes of APH

Answer 217

``` placenta praaevia placental abruption local causes (cervical ectropion, polyps, infection, cervical cancer) vasa praevia uterine rupture indeterminate preterm labour ```

Question 218

how can blood loss by quantified in APH

Answer 218

spotting: staining, streaking or blood spotting noted on underwear or sanitary pad minor haemorrhage: <500 ml that has settles major: 500-1000 ml with no signs of shock massive: >1000 ml and/or signs of shock

Question 219

define placenta praaevia

Answer 219

placenta covering or within 2 cm of the cervical os

Question 220

investigation of placenta praaevia

Answer 220

if early scan (anomaly scan) shows low-lying placenta, another scan is done at 32 weeks to check if the placenta has moved if unclear offer transvaginal scan

Question 221

presentation of placenta praaevia

Answer 221

bright red painless bleeding

Question 222

risk factors of placenta praaevia

Answer 222

age previous c-section previous praaevia

Question 223

define placental abruption

Answer 223

separation of a normally implanted placenta either partially or totally before the birth of the fetus

Question 224

consequences of placental abruption

Answer 224

IU death and fetal hypoxia primary post part haemorrhage risks of massive bleeding (DIC, low BP, multi-organ failure, risk of death)

Question 225

risk factors for placental abruption

Answer 225

``` PET/HTN trauma smoking, cocaine, amphetamine medical thrombophilia, renal disease or diabetes polyhydramnios abnormal placenta previous abruption multiple pregnancy, PROM ```

Question 226

symptoms of placental abruption

Answer 226

``` severe, continuous abdominal pain backache with posterior placenta bleeding (concealed) preterm labour maternal collapse ```

Question 227

signs of placental abruption

Answer 227

unwell distressed patient signs may be inconsistent with revealed blood uterus large for dates or normal uterine tenderness woody, hard uterus fetal parts difficult to identify may be in preterm labour with heavy show fetal heart rate may be absent or bradycardia CTG shows irritable uterus

Question 228

management of placental abruption

Answer 228

resuscitate mother urgent c-section and replacing blood products fetal resuscitation if needed manage complications: anti-D

Question 229

define vasa praevia

Answer 229

fetal blood vessels I the membranes overlying close to the internal cervical os

Question 230

presentation of vasa praaevia

Answer 230

membranes are ruptured followed by small amount of dark vaginal bleeding and acute fetal bradycardia and decelerations

Question 231

how to prevent vasa praaevia

Answer 231

always feel for pulsations or any cord-like structures before performing amniotomy check fetal head is presenting and engaged before inducing labour or ARM

Question 232

what are the types of vasa praaevia

Answer 232

type 1: vessel connected to velamentous umbilical cord | type 2: when it connect to the placenta with a succenturiate or accessory lobe

Question 233

risk factors for vasa praaevia

Answer 233

placental abnormalities (bilobed, succinturiate lobes) low lying placenta in 2nd trim multiple pregnancy IVF

Question 234

management of vasa praaevia

Answer 234

antenatal diagnosis: steroids at 32 weeks inpatient management if risks of preterm birth (32-34 weeks) elective c-section before labour (34-36 weeks) diagnosed during labour: emergency c-section, might need blood transfusion for baby

Question 235

presentation of uterine rupture

Answer 235

acute constant abdominal pain even when the uterus is relaxed which may be referred to the shoulder tip sudden collapse fetal parts easily palpable as may be in abdominal cavity

Question 236

maternal chicken pox infection in last 4 weeks of pregnancy

Answer 236

avoid planned pregnancy for 7 days to allow transfer of maternal Ig

Question 237

pregnancy woman who has never had chicken pox is in contact with chicken pox

Answer 237

blood test to check IgG antibodies to varicella zoster will confirm immunity if not immune offer varicella zoster Ig as post-exposure prophylaxis (effective within 10 days)

Question 238

effects on fetus of CMV infection in pregnancy

Answer 238

hearing loss visual impairment or blindness mild to severe LD epilepsy

Question 239

clinical features of congenital CMV

Answer 239

``` jaundice petechial rash hepatosplenomegaly microcephaly SGA ```

Question 240

how long is a person with parvovirus infectious for

Answer 240

1 day after rash develops

Question 241

parvovirus B19 in fetus causes

Answer 241

severe anaemia, heart failure, hydrops fetalis

Question 242

symptoms of congenital rubella

Answer 242

sensorineural learning loss congenital heart disease (PDA) ocular abnormalities (congenital glaucoma, cataracts)

Question 243

HIV viral load

Answer 243

<50 copies/ml

Question 244

babys born the HIV positive mothers receive what postnatal

Answer 244

testing at birth and at regular intervals up to 2 yo

Question 245

should HIV positive women pbreast feed?

Answer 245

formula is safest way to feed baby safe to breast feed if: undetectable viral load and mother is taking ART exclusive breastfeeding for first 6 months and not mixing formulas or cow's milk avoid breastfeeding at high risk times eg mastitis, cracked nipples, detectable viral load, D+V in mother or baby

Question 246

diagnosis f DVT

Answer 246

swelling oedema leg pain or discomfort increased leg temperature

Question 247

testing for DVT in peurperium

Answer 247

compression duplex US if normal but high suspicion repeat in one week to exclude an extending thrombosis and give therapeutic dose of LMWH consider MRI venography if iliac vein thrombosis suspected

Question 248

symptoms and signs of PE

Answer 248

``` dyspnoea chest pain faintness collapse haemoptysis raised JVP focal signs in chest symptoms and signs of DVT ```

Question 249

diagnosis of PE

Answer 249

CTPA or V/Q scan

Question 250

management of PE

Answer 250

heparins

Question 251

risk factors for preterm birth

Answer 251

``` previous preterm labour multiple pregnancy uterine anomalies age parity (mulligan's- or grand) ethnicity poor socio-economic status smoking drugs (cocaine) Low BMI (<20) ```

Question 252

what is SGA

Answer 252

estimated fetal weight or abdominal circumference below the 10 decile in both population and customised gentiles

Question 253

what is LGA

Answer 253

>90th centile | SFH >2cm for gestational age

Question 254

causes of LGA

Answer 254

polyhydramnios multiple pregnancy macrosomia due to GDM wrong dates in late bookers

Question 255

what is polyhydramios

Answer 255

excess of amniotic fluid with AFI >25 cm or deepest vertical pool >8 cm

Question 256

risks associated with LGA

Answer 256

clinician and maternal concern shoulder dystocia PPH

Question 257

symptoms and signs of polyhydramnios

Answer 257

``` abdominal discomfort PROM preterm labour cord prolapse large for dates malpresentation shiny, tense abdomen inability to feel fatal parts ```

Question 258

innervation of detrusor muscle

Answer 258

parasympathetic nerves derived from the pelvic splanchnic S2-4

Question 259

innervation of urethral smooth muscle

Answer 259

sympathetic nerves from spinal cord at T10-L2 | descend to bladder and urethra via the hypogastric nerves

Question 260

innervation of the striated urethral sphincter and pelvic floor (levator ani) muscles

Answer 260

pudendal nerve S2-4

Question 261

describe the three levels of support the pelvic floor gives the vagina

Answer 261

cervix and upper vagina supported by uterosacral, transverse cervical and pubocervical ligaments middle vagina supported by pelvic fascia lower vagina supported by levator ani muscles and perineal body

Question 262

contents of deep perineal pouch in females

Answer 262

``` part of urethra vagina clitoral neuromuscular bundle extensions of ischioanal fat pads smooth muscle external urethral sphincter and compressor urethrae ```

Question 263

contents of deep perineal pouch in males

Answer 263

``` part of urethra bulbourethral glands neuromuscular bundle of penis extension of sischioanal fat pads smooth muscle external urethral sphincter and compressor urethrae ```

Question 264

contents of superficial perineal pouch (female)

Answer 264

``` clitoris and crura bulbs of vestibule bulbospongiosus ischiocavernosus vestibular glands superficial transverse perineal muscle internal pudendal vessels internal pudendal nerve ```

Question 265

contents of superficial perineal pouch (male)

Answer 265

``` bulb of penis and crura bulbospongiosus ischiocavernosus internal pudendal vessels pudendal nerve superficial transverse perineal muscle ```

Question 266

causes of pelvic floor weakness

Answer 266

increased intra-abdominal pressure: obesity, chronic cough, occupational or recreational exercise, constipation, intra-abdominal mass pelvic floor muscle trauma and denervation: obstetric trauma, pelvic fracture or surgery, congenital connective tissue disorder: age related, oestrogen deficiency, congenital or acquired connective tissue disorder, drug related (steroids)

Question 267

common features of stress incontinence

Answer 267

after childbirth, pelvic surgery and oestrogen deficiency | triggers: coughing, sneezing, exercise

Question 268

investigations for stress incontinence

Answer 268

exclude UTI frequency/volume charts (normal frequency and bladder capacity) urodynamic studies

Question 269

management of stress incontinence

Answer 269

lifestyle: weight loss, smoking cessation, avoid constipation, avoid heavy lifting, caffeine reduction conservative: pelvic floor exercises for 3 months, use of pads medical: duloxetine (not first line) surgical: bulking agents, autologous rectus fascial sling, colposuspension, artificial urinary sphincters

Question 270

side effects of duloxetine for stress incontinence

Answer 270

``` difficulty sleeping headache dizziness blurred vision change in bowel habit nausea and vomiting dry mouth sweating decreased appetite weight loss decreased libido ```

Question 271

features of urge incontinence

Answer 271

triggers: hearing running water, cold weather larger volumes that SUI "I have to go immediately"

Question 272

investigations of urge incontinence

Answer 272

frequency/volume charts (increased frequency) | urodynamic testing shows over-activity of detrusor muscle

Question 273

management of urge incontinence

Answer 273

lifestyle: decrease fluid intake, minimus caffeine and alcohol, use of pads bladder retraining medical: tolterodine/solifenacin (oxybutynin not recommended due to cognitive impairment), mirabegron, topical oestrogen, desmopressin in nocturia surgery: botox, percutaneous sacral nerve stimulation, augmentation cystoplasty

Question 274

causes of overflow incontinence

Answer 274

inactive detrusor muscle: neurological conditions (eg MS) involuntary bladder spasms: CV disease, diabetes cystocele or uterine prolapse

Question 275

investigation of overflow incontinence

Answer 275

frequency/volume charts | urodynamic testing shows inactivity of detrusor muscle

Question 276

management of overflow incontinence

Answer 276

treat the cause

Question 277

what are the stages of prolapses

Answer 277

stage 1: mild protrusion on examination (-1 cm) stage 2: prolapse present at introitus (-1 to +1 cm) stage 3: beyond +1 cm from the introitus stage 4: prodicentia (complete inversion)

Question 278

risk factors for prolapse

Answer 278

``` increasing age (40% post menopausal) multiparity vaginal deliveries obesity Spina Bifida ```

Question 279

clinical signs of prolapse

Answer 279

sensation of pressure, heaviness, bearing down | urinary incontinence, frequency, urgency

Question 280

management of prolapse

Answer 280

if mild and asymptomatic may not need treatment lifestyle: weight loss, avoid constipation, smoking cessation, avoid heavy lifting, caffeine reduction pelvic floor training: kegels, pilates, supervised PFE with physio ring pessary surgery

Question 281

surgical options for prolapse

Answer 281

cystocele/cystourethrocele: anterior colporrhaphy uterine prolapse: hysterectomy, sacrohysteropexy, Sacrospinous fixation (sutured placed in Sacrospinous ligament medial to ischial spine to fix prolapse in place) rectocele: posterior colporrhapy

Question 282

symptoms of UTI

Answer 282

``` dysuria increased frequency/urgency cloudy/offensive urine lower abdo pain fever/malaise delirium in elderly ```

Question 283

management of UTI in in non-pregnant women

Answer 283

urine culture if >65 yo or haematuria | trimethoprim or nitrofurantoin for 3 days

Question 284

management of symptomatic UTI in pregnancy

Answer 284

urine culture nitrofurantoin in 1st and 2nd trim trimethoprim in 3rd trim

Question 285

management of symptomatic UTI in pregnancy

Answer 285

urine culture should be done at 1st antenatal visit high risk of preogressing to acute pyelonephritis immediate course of nitrofurantoin (avoid near term), amoxicillin or cefalexin for 7 days urine culture after treatment for test of cure

Question 286

briefly describe the processes of fertilisation and implantation

Answer 286

at ovulation the egg is released into the fallopian tube where it is normally fertilised cells divide and progress to a morula, then blastocyst as it travels along tube to uterus blastocyst implants into uterine lining during days 5-8 the inner cells develop into the embryo and the outer cells invade the endometrium to become the placenta

Question 287

what are the four outcomes of fertilisation

Answer 287

normal pregnancy: normal embryo in normal locations miscarriage: normal/abnormal embryo in normal location ectopic: normal embryo in abnormal location molar: abnormal embryo in normal location

Question 288

how do HCG values change during a normal pregnancy

Answer 288

should double every 48 hours in a normal pregnancy

Question 289

when does HCG level reach peak

Answer 289

12-14 weeks | N+V normally reduce after this time

Question 290

what is the effect of human placental lactogen | when does it start to be released

Answer 290

growth-hormone like effects and decreases insulin resistance in the mother also involved in breast development (tenderness) week 5

Question 291

what are common non-hormonal changes in pregnancy

Answer 291

increased cardiac output due to increased blood volume (raised HR, ECG changes, functional murmurs) increased plasma volume causes decreased Hb by dilution

Question 292

what is implantation bleeding | how does it present and when

Answer 292

occurs when the fertilised egg implants into the uterine wall normally about 10 days after ovulation generally light brown and limited (earlier and lighter than a period)

Question 293

what is a subchorionic haematoma | what are its symptoms

Answer 293

collection of blood between the chorion and uterine wall symptoms vary by size but include bleeding, cramping and threatened miscarriage large haematomas may lead to miscarriage, infection or irritability

Question 294

what type is present in the two parts of the cervix

Answer 294

ectocervix: tough, squamous epithelium endocervix: columnar epithelium

Question 295

how does pregnancy affect the location of the transitional zone of the cervix what can occur as a result

Answer 295

location of transitional zone changes as a physiological response to pregnancy exposes the endocevical (columnar) epithelium to the external environment of the vagina can cause erosion (ectropion) which may bleed

Question 296

what are causes of bleeding in early pregnancy

Answer 296

``` implantation bleeding polyps cervical erosion infection (STI, herpes, bacterial infection) suchorionic haematoma malignancy miscarriage ```

Question 297

someone presenting with bleeding in early pregnancy may be experiencing non-PV bleeding what other sources of bleeding should be considered?

Answer 297

haematuria: UTI, kidney stones, malignancy PR bleeding: haemorrhoids, anal fissures, gastroenteritis, IDB, malignancy

Question 298

miscarriage can occur up to ______ weeks gestation

Answer 298

23+6

Question 299

what is a threatened miscarriage

Answer 299

risk to the pregnancy bleeding +/- cramping cervical os is closed

Question 300

USS signs of threatened miscarriage

Answer 300

intrauterine pregnancy | foetal pole is present and if measures >7 mm a foetal heart should be present

Question 301

what is an inevitable miscarriage

Answer 301

symptoms consistent with miscarriage and the pregnancy can't be saved open os, possibly products of conception at the os

Question 302

USS signs of inevitable miscarriage

Answer 302

may show viable pregnancy | products that are in the process of expulsion

Question 303

what is an incomplete miscarriage

Answer 303

some products have passed, but there are some products remaining in the uterus

Question 304

what is a septic miscarriage

Answer 304

infection alongside incomplete or complete miscarriage

Question 305

symptoms of septic miscarriage

Answer 305

fevers, riggers, uterine tenderness, bleeding, offensive discharge and pain

Question 306

recurrent miscarriage is defined as

Answer 306

3 or more consecutive pregnancy losses

Question 307

what is a missed miscarriage

Answer 307

no symptoms or a history of threatened miscarriage but on USS there is no viable pregnancy

Question 308

what are USS signs of early foetal demise

Answer 308

pregnancy in situ that has mean sac diameter of >25 mm and/or a foetal pole >7 mm but no heart beat

Question 309

causes of miscarriage - embryo - maternal factors - uterine factors - immunologic - infections - iatrogenic

Answer 309

embryo: chromosomal abnormalities maternal factors: PCOS, uncontrolled DM, increasing age, heavy smoking, alcohol/drugs (cocaine), severe HTN, obesity immunologic: APS infections: CMV, rubella, toxoplasmosis, listeria iatrogenic: CVS or amnio

Question 310

which antibodies are associated with APS what effect do they have on pregnancy

Answer 310

lupus anticoagulant anticardiolipin antibodies anti-B2 glycoprotein-1 inhibiting trophoblastic function and differentiation create localised inflammatory response at maternal-foetal interface cause thrombosis of uteroplacental vasculature

Question 311

what is cervical shock and how does it present

Answer 311

occurs during incomplete miscarriage where the products are sitting in the cervix cramps, severe abdo pain, N+V, sweating, fainting, bradycardia, hypotension

Question 312

why might IV fluids not correct hypotension in cervical shock

Answer 312

due to vagal stimulation of the products sitting in the cervix

Question 313

management of cervical shock

Answer 313

remove products from cervix | can be done with a speculum and sponge forceps

Question 314

presentation of ectopic pregnancy

Answer 314

``` localised pelvic pain light PV bleeding shoulder tip pain SOB dizziness passage of tissue rectal pressure or pain on defecation ```

Question 315

signs of Coptic pregnancy

Answer 315

pallor, haemodynamic instability peritonism, guarding, general abdominal or pelvic tenderness, adnexal tenderness cervical motion tenderness, abdominal distension, enlarged uterus

Question 316

presentation of molar pregnancy

Answer 316

``` hyperemesis funds large for dates varied bleeding grape-like tissue SOB ```

Question 317

assessment of woman presenting with suspected miscarriage

Answer 317

asses haemodynamic stability FBC, G&S, Rh status serum HCG (should halve every 48 hours)

Question 318

investigations for ectopic pregnancy

Answer 318

FBC, G&S, HCG and TVUSS suboptimal HCG (doesn't double every 48 hours) empty uterus on TVUSS or presence of pseudo sac free fluid in pouch of Douglas = suspect ruptured ectopic

Question 319

signs of molar pregnancy

Answer 319

raised levels of HCG typical snowstorm appearance on USS with or without fetus

Question 320

management of miscarriage

Answer 320

threatened: watchful waiting missed/incomplete and stable : conservative, medical or surgical management missed/incomplete and unstable: ABCDE, resus, surgical management normally safest option

Question 321

what are the surgical options for miscarriage

Answer 321

surgical evacuation under GA | manual vacuum aspiration under local anaesthetic

Question 322

advice for women with recurrent miscarriage/APS

Answer 322

low dose aspirin and daily fragmin injection for future pregnancies

Question 323

when is surgical management indicated in ectopic pregnancy

Answer 323

significant pain adnexal mass >35 mm visible heart beat on USS

Question 324

conservative management of ectopic

Answer 324

patients asked to return for serum HCG measurements on days 2, 4 and 7 after original test if they fall by at least 15% from previous value they can be repeated weekly until a negative (<20 IU/L) is obtained

Question 325

medical management of ectopic

Answer 325

single of 2 separate doses of methotrexate and continued HCG monitoring

Question 326

surgical management of ectopic

Answer 326

laparoscopic salpingotomy or salpingectomy

Question 327

management of molar pregnancy

Answer 327

surgery | send tissue for histological examination

Question 328

what is hyperemsis gravid arum

Answer 328

vomiting that is excessive, prolonged and begins to alter the woman's quality of life

Question 329

consequences of unmanaged hyperemesis gravid arum

Answer 329

dehydration, ketosis, electrolyte and nutritional imbalance, weight loss, altered liver function

Question 330

other causes of excessive vomiting in pregnancy

Answer 330

``` UTI gastritis peptic ulcer viral hepatitis pancreatitis ```

Question 331

management of hyperemesis gravid arum

Answer 331

IV fluids and electrolytes anti-emetic (PO or IV) first line is cyclising or prochlorperazine nutritional supplements: thiamine, pabrinex (Vit B/C) if severe NG/TPN ranitidine/omeprazole for reflux steroids if super bad consider thromboprophylaxis

Question 332

``` define the following: menorrhagia metrorrhagia polymenorrhoea polymenorrhagia menometrorrhagia amenorrhoea oligomenorrhoea ```

Answer 332

menorrhagia: prolonged and increased bleeding (heavy menstrual bleeding) metrorrhagia: regular Intermenstrual bleeding polymenorrhoea: menses occurring at <21 day interval polymenorrhagia: increased and frequent cycle menometrorrhagia: prolonged menses and Intermenstrual bleeding amenorrhoea: absence of menstruation >6 months oligomenorrhoea: menses with interval >35 days OR presence of <5 menstrual cycles in a year

Question 333

assessment of menorrhagia

Answer 333

thorough history general exam for signs of anaemia abdominal and pelvic examination smears and swabs if necessary

Question 334

what is dysfunctional uterine bleeding

Answer 334

menorrhagia in the absence of other pathology | a diagnosis of exclusion, found in 50% of women with abnormal uterine bleeding

Question 335

what are the two types of DUB and what are their characteristics

Answer 335

``` anovulatory: 85% of DUB occurs at extremes of reproductive life irregular cycle more common in obese women ``` ovulatory: more common in 35-45 yo regular heavy periods due to inadequate progesterone production by corpus luteum

Question 336

investigations for DUB

Answer 336

FBC TFTs (hypothyroid features) coagulation screen (very heavy bleeding or signs of bleeding tendency) TVUSS (endometrial thickness, fibroids, other masses) endometrial sampling (pipette biopsies, hysteroscopy, D&C) smear (if due - opportunistic, not a test for DUB) refer to colposcopy if abnormal cervix

Question 337

what are options for medical management of DUB

Answer 337

progestogen releasing IUCD (Mirena): 1st line treatment, may cause breakthrough bleeding for 3-9 months after insertion COCP: compliance issues, check UKMEC for contraindications antifibrinolytics (tranexamic acid): during menstruation, if contraception not wanted NSAIDs (mefenamic acid): during menstruation, CI in duodenal ulcers or severe asthma oral progestogens (norethisterone, medrocyprogesterone) GnRH analogues: act on pituitary to stop oestrogen production resulting in amenorrhoea, can cause osteoporosis danazol: synthetic androgen that acts on HPO axis

Question 338

surgical management of DUB

Answer 338

endometrial resection/ablation hysterectomy

Question 339

disadvantages of surgical management of DUB

Answer 339

anaesthetic risks loss of fertility in hysterectomy complications in future pregnancy after ablation (placenta accreta)

Question 340

causes of intermenstrual bleeding

Answer 340

``` cervical ectropion PID and STI endometrial or cervical polyps cervical cancer endometrial cancer undiagnosed pregnancy/complications of Hyatidiform molar disease ```

Question 341

psychological and physical manifestations of PMS

Answer 341

psych: depression, irritability and emotional lability phys: fluid retention, weight gain, breast tenderness

Question 342

diagnosis of PMS

Answer 342

menstrual diary of symptoms for at least 2 cycles

Question 343

management of PMS

Answer 343

severe symptoms: SSRIs daily or during luteal phase of cycle and CBT mild: lifestyle eg stress reduction, alcohol and caffeine reduction, exercise medical: COCP, transdermal oestrogen, short-term GnRH hysterectomy with bilateral salpingo-oophorectomy as last resort (trial of GnRH before surgery)

Question 344

how do GnRH analogues work to reduce PMS, improve endometrisos and shrink fibroids give some examples

Answer 344

if GnRH receptors are constantly simulated, they are desensitised, reducing GnRH release and thus reducing LH and SH release Buserelin and goserelin

Question 345

causes of postcoital bleeding

Answer 345

``` cervical ectropion cervical carcinoma trauma Atrophic vaginitis cervicitis due to STI polyps idiopathic ```

Question 346

what do the NICE guidelines say about post menopausal bleeding

Answer 346

women over the age of 55 with PMB should be investigated within 2 weeks by USS for endometrial cancer

Question 347

causes of PMB

Answer 347

``` Atrophic vaginitis (most common and benign) endometrial polyps endometrial hyperplasia endometrial carcinoma cervical carcinoma ovarian cancer (esp theca cell tumours) vaginal cancer (rare) ```

Question 348

investigations of PMB

Answer 348

USS (transvaginal > abdominal): endometrial thickens >4 mm, further investigation needed (5 mm cut off if taking HRT) if taking tamoxifen, endometrium will be thickened, irregular and cystic so do hysteroscopy and biopsy instead further imaging: CT/MRI

Question 349

management of PMB

Answer 349

Atrophic vaginitis: topical oestrogen and vaginal lubricants, HRT endometrial hyperplasia: D&C, progestogen treatment, Mirena IUS, oral progestogens endometrial cancer: refer to oncology cervical cancer: refer to oncology

Question 350

what are the Rotterdam criteria

Answer 350

used to diagnose PCOS, presence of two of the following: clinical or biochemical evidence of hyperandorgenism (hirsutism, acne, hah free testosterone, low sex hormone binding globulin, high free androgen index) polycystic ovaries on USS (ovarian volume >10 cm^3, at least 12 follicles in one ovary measuring 2-9 mm diameter) oligo/amenorrhoea

Question 351

features of PCOS

Answer 351

obesity/overweight hypertension acanthosis nigricans (thickening and pigmentation of skin of neck, axillae, skin folds) acne and hirsutism alopecia insulin resistance, diabetes, lipid abnormalities irregular periods

Question 352

why are people with PCOS at higher risk of endometrial hyperplasia/carcinoma

Answer 352

oligo/amenorrhoea in presence of pre-menopausal levels of oestrogen

Question 353

hormonal changes in PCOS

Answer 353

increase in LH:FSH ratio, LH levels very high and FSH low/nomral

Question 354

management of PCOS

Answer 354

dependent on how patient presents and what their main concern is optimise BMI endometrial protection with hormonal contraception

Question 355

management of infertility in PCOS

Answer 355

weight loss 5-10% indicated before ovulation treatment if BMI >30 first line: clomifene add metformin (improve glucose tolerance, decreases androgen levels and improves ovulation) ovarian drilling gonadotrophin injunctions IVF as last resort

Question 356

what is clomifene how does it work what are its side effects

Answer 356

selective oestrgoen receptor modulator block oestrogen negative feedback on hypothalamus resulting in more pulsatile GnRH secretion and therefore FSH and LH side effects: hot flushes, sweating, increased risk of multiple pregnancy, ovarian cancer (long term use)

Question 357

what is ovarian drilling

Answer 357

use in women who fail to conceive on clomifene diathermy to destroy ovarian storm which reduces androgen-secreting tissue leading to restoration of normal LH:FSH ratio and a fall in androgens

Question 358

how can acne be managed in PCOS

Answer 358

co-cyrprindol (Dianette): effective against acne and hirsutism, contains anti-androgen which block action of androgens on pilosebaceous glands COCP: improves hyperandrogenism and gives withdrawal bleed (endometrial protection), inferior to co-cyrprindol

Question 359

management of amenorrhoea in COCP

Answer 359

COCP: withdrawal bleed | cyclical medrocyprogesterone or Mirena coil can reduce risk of endometrial hyperplasia

Question 360

what is the difference between primary and secondary dysmenorrhea

Answer 360

primary: no underlying pelvic pathology - pain starts just before or within hours of period starting - suprapubic cramping, may radiate to back or down thigh secondary: due to underlying pathology - starts 3-4 days before period

Question 361

causes of secondary dysmenorrhoea

Answer 361

``` endometriosis adenomyosis (endometrium between muscle layers of the uterus) PID intrauterine devices (copper cold) fibroids ```

Question 362

clinical features and examination findings of primary dysmenorrhoea

Answer 362

features: pain precedes and accompanies menstruation onset with or shortly after menarche examination: normal exam ind investigations

Question 363

clinical features and examination findings of endometriosis

Answer 363

features: associated with heavy periods and dyspareunia examination: uterosacral modularity and/or tenderness fixed retroverted uterus

Question 364

clinical features and examination findings of adenomyosis

Answer 364

features: associated with prolonged, heavy periods examination: bulky uterus

Question 365

clinical features and examination findings of fibroids

Answer 365

features: menstrual pain pressure effects on the adjacent organs fibroid red degeneration during pregnancy examination: pelvic mass

Question 366

clinical features and examination findings of chronic PID

Answer 366

features: history of STI pain not limited to menstruation examination: mucopurulent discharge cervicitis findings suggesting Fitz-Curtis-Hugh syndrome on laparoscopy

Question 367

what is fitz-curtis-hugh syndrome

Answer 367

inflammation of the peritoneum and tissues surrounding liver complication of PID leads to formation of adhesions in the abdomen

Question 368

investigations for dysmenorrhea

Answer 368

``` high vaginal and endocervical swabs (PID, clam or gon) pelvic USS (endometriomas, adenomyosis, fibroids) diagnostic laparoscopy (endometriosis, other investigations normal) ```

Question 369

management of dysmenorrhoea

Answer 369

NSAIDs: menfanamic acid, ibuprofen COCP Mirena GnRH analogues

Question 370

what are the two types of amenorrhage

Answer 370

primary: failure of mestruation by 16 yo secondary: absence of menstruation for at least 6 months in female with history of regular cyclic bleeding

Question 371

causes of primary amenorrhoea

Answer 371

genital tract abnormalities: imperforate hymen, vaginal agenesis, cervical stenosis (amenorrhoea + secondary sexual characteristics) mullerian agenesis (absent mullerian ducts --> absent uterus) premature ovarian failure/insufficiency genetic causes (turner's, androgen insensitivity) hypothalamic disorders (kallmans) iatrogenic autoimmune endocrine causes (hypothyroid, constitutional delay, congenital hyperplasia, PCOS) pituitary disorders

Question 372

what is premature ovarian failure/insufficiency

Answer 372

cessation of periods <40 yo | can be due to chemo, radiotherapy, turner's, autoimmune causes

Question 373

causes f secondary amenorrhoea

Answer 373

physiological (excessive exercise, weight loss, stress) autoimmune pituitary (Sheehan, hyperprolactinaemia, haemochromatosis) iatrogenic endocrine (hypo/hypoerthyroid, PCOS) uterine problems (endometrial atrophy, cervical stenosis, Ashermann's) pregnancy/lactation

Question 374

what is Ashermann's syndrome

Answer 374

acquired condition that occurs when adhesions form inside the uterus often secondary to endometrial surgery or infection it prevents menstruation, reduces fertility and can cause placental abnormalities

Question 375

management/investigation of amenorrhea

Answer 375

thorough history general exam: BMI, secondary sexual characteristics, signs of endocrine disorders visual fields if possible pituitary examination of external genitalia pregnancy test essential

Question 376

what causes the menopause

Answer 376

loss of ovarian follicular activity leading to a fall in oestradiol levels below that needed for endometrial stimulation

Question 377

how to confirm premature menopause

Answer 377

<45 yo | 2 measurements at least 2 weeks apart

Question 378

physical effects of the menopause

Answer 378

vasomotor symptoms eg hot flushes and night sweats joint aches and pains dry and itchy skin hair changes vaginal dryness and soreness (dyspareunia) recurrent UTI, urgency urogenital prolapse osteoporosis increasing risk of fractures CVD dementia

Question 379

psychological effects of menopause

Answer 379

labile mood, anxiety, tearfulness loss of concentration, poor memory loss of libido

Question 380

what type of HRT is best suited for women with personal or family history of VTE or liver problems

Answer 380

oestrogen patches | skip first pas metabolism so less likely to affect liver or production of clotting factors

Question 381

what different cycles of HRT are available | who are they most appropriate for

Answer 381

continuous combined: menopausal, taken every day cyclical combined: perimenopausal, oestradiol everyday and progestogen on last 14 days

Question 382

what can be used to treat reduced libido in menopause

Answer 382

testosterone

Question 383

what are non-hormonal treatment options for menopause

Answer 383

SSRIs eg fluoxetine | CBT

Question 384

how long should contraception be continued after menopause

Answer 384

2 years after LMP of <50 | 1 year if >50

Question 385

side effects of NRT

Answer 385

oestrogen: breast enlargement, leg cramps, dyspepsia, fluid retention, nausea, headaches progestogen: fluid retention, breast tenderness, headaches, mood swings, acne, depression, irritability, constipation, increased appetite

Question 386

risks of HRT

Answer 386

breast cancer VTE (PE and stroke) endometrial cancer

Question 387

absolute contraindications for HRT

Answer 387

``` suspected pregnancy breast cancer endometrial cancer active liver disease uncontrolled HTN known VTE known thrombophilia otosclerosis ```

Question 388

relative contradictions for HRT

Answer 388

``` investigated abnormal bleeding large uterine fibroids past history of benign breast disease unconfirmed personal history or strong FH of VTE chronic stable liver disease migraine with aura ```

Question 389

presentation of lichen sclerosis

Answer 389

``` pruritus and skin irritation of vulva hypo pigmented skin atrophy (shiny appearance) hair loss white polygonal papule that coalesce to form plaques figure 8 pattern ```

Question 390

complications of untreated lichen sclerosis

Answer 390

``` persistent inflammation and healing scar formation atrophy and fusion of labia stenosis of introitus difficulties in defecation vulvar intraepithelial neoplasia ```

Question 391

management of lichen sclerosis

Answer 391

3 months of high dose steroids eg dermovate 2nd line topical calcineurin inhibitors eg tacrolimus, imiquimod (immunosuppressant to reduce inflammation) if treatment resistant, biopsy to rule out malignancy

Question 392

what is Paget's disease of the vulva

Answer 392

uncommon intraepithelial adenocarcinoma itching, pain, irritation, hyperpigmentation or leukoplakia

Question 393

management of Paget's disease of the vulva

Answer 393

often a sign of malignancy elsewhere | full work up

Question 394

describe normal, physiological changes to discharge

Answer 394

during more fertile days: thin and clear non-fertile days: thicker, hostile to sperm

Question 395

which bacteria are important in the maintenance of vaginal pH

Answer 395

lactobacilli

Question 396

what are risk factors for pelvic infection

Answer 396

``` age <25 years multiple sexual partners unprotected sex recent insertion of IUD recent change in sexual partner ```

Question 397

symptoms of pelvic infection

Answer 397

``` lower abdominal pain fever abnormal vaginal bleeding offensive vaginal discharge dysuria or menstrual irregularities ```

Question 398

examination signs of pelvic infection

Answer 398

cervical motion tenderness | adnexal tenderness

Question 399

management f pelvic infection

Answer 399

acutely unwell: sepsis 6 partner notification oral ofloxacin and oral metronidazole OR IM ceftriaxone and oral doxy and met

Question 400

which populations are functional cysts, germ cell tumour and benign epithelial tumours most common in

Answer 400

functional: young women or reproductive age germ cell: young women benign intraepithelial: older women

Question 401

what are concerning features of an ovarian cyst

Answer 401

thick wall septa | solid and cystic components

Question 402

recommended investigation for complex ovarian cysts

Answer 402

Inhibin, b-HCG, CA125

Question 403

features of functional ovarian cysts

Answer 403

simple, uniloculated cysts >3 cm | regress after several menstrual cycles

Question 404

what causes functional ovarian cysts

Answer 404

non-rupture of dominant follicle or failure of stress of a non-dominant follicle

Question 405

features of benign germ cell tumours

Answer 405

often lined with epithelial tissue, may contain hair, teeth often very big so at risk of torsion

Question 406

types of benign epithelial ovarian tumours

Answer 406

serous cystadenomas mutinous cyst adenomas

Question 407

gynae causes of acute abdo pain

Answer 407

``` ectopic pregnancy ovarian torsion ovarian cyst rupture or haemorrhage PID tubo-ovarina abscess endometriosis fibroids miscarriage mittelschmirz ```

Question 408

signs/symptoms, diagnosis and management of uterine fibroids

Answer 408

S&S: asymptomatic, menorrhagia and dysmenorrhoea, lower abdo pain during menstruation, sub fertility, pressure symptoms Dx: TVUSS management: Mirena, myomectomy, hysterectomy, short-term GnRH analogues, uterine artery embolisation

Question 409

signs/symptoms, diagnosis and management of endometriosis

Answer 409

S&S: dysmenorrhoea, deep dyspareunia, sub fertility, non-gynae signs (dysuria, urgency, dyschezia) Dx: often via laparoscopy, tender modularity on posterior fornix management: NSAIDs/paracetamol (symptomatic relief), COCP or progestogens, surgery (excisions of lesions)

Question 410

signs/symptoms, diagnosis and management of ovarian torsion

Answer 410

S&S: sudden onset deep colicky pain, vomiting, distress, adnexal tenderness/acute abdomen Dx: USS will show classical whirlpool sign management: laparoscopy to untwist ovary and remove cyst oophorectomy if necrotic

Question 411

signs/symptoms, diagnosis and management of PID

Answer 411

S&S: vaginal discharge, bilateral lower abdo pain Dx: FBC, high vaginal or endocervical swab may need pelvic imaging if doesn't respond to Abx or pelvic mass management: Abx, drainage of pelvic abscess

Question 412

signs/symptoms, diagnosis and management of mittelschmerz

Answer 412

S&S: mid cycle pain often Dx: exclusion of other things management: simple analgesia and reassurance

Question 413

how long does the puerperium normally last

Answer 413

6 weeks

Question 414

describe the changes in vaginal discharge in the first 3 weeks postpartum

Answer 414

3-4 days after birth - fresh red discharge - rubra 4-14 days after birth - brownish-red, watery - serosa 10-20 days after birth - yellow - alba

Question 415

what changes occur in the uterus postpartum

Answer 415

endometrial lining regenerates by day 7 funds of uterus returns to physiological position by 2 weeks uterine weight decreases to 5% of pregnancy weight

Question 416

what is colostrum

Answer 416

thick, yellowish substance produced by mammary tissue first milk a baby is fed contains more protein and vitamins that normal milk essential for immunological protection to the newborn

Question 417

what initiates lactiation

Answer 417

expulsion of the placenta decrease in oestrogen and progesterone levels high levels of oestrogen and progesterone during pregnancy prevent release of prolactin (it is still produced but not released) drop in oestrogen and progesterone so prolactin is released

Question 418

how is prolactin production maintained during breastfeeding

Answer 418

positive feedback from the infant suckling

Question 419

what is the let-down reflex

Answer 419

oxytocin stimulates myoepithelial cells surrounding breast alveoli to contract and squeeze milk out of breast triggered by suckling

Question 420

what is the WHO guidance related to breastfeeding

Answer 420

exclusive breastfeeding for 6 months | then up to 2 years along with introduction of solid foods

Question 421

what to ask if patient presents saying she has 'insufficient milk' when trying to breastfeed

Answer 421

any pain while breastfeeding or skin changes to nipples is baby irritable after a feed ask to assess technique

Question 422

risk factors for lactational nastitis

Answer 422

improper breastfeeding technique (trauma to breast, milk stasis and ineffective milk release --> harbours bacteria) smoking foreign body (breast implant or piercing)

Question 423

what are the main features of a focussed history of mastitis

Answer 423

MAIDS Milk stasis (decreased milk output) Abscess (tender lump) Inflammation (warmth, pain, swelling, firmness, erythema) Discharge Systemic symptoms (fever, malaise, myalgia)

Question 424

what is duct ectasia

Answer 424

blocked duct

Question 425

management of mastitis

Answer 425

fluclox 500 mg orally every 6 hours or co-amoxiclav 625 mg every 8 hours for 7 days breastfeeding should continue, use breast pump for infected breast if preferred

Question 426

management of breast abscess

Answer 426

USS and aspiration for culture

Question 427

# define PPH primary and secondary? minor and major?

Answer 427

PPH = blood loss =/>500 ml after the birth of the baby ``` primary = within 24 hours of delivery secondary = 24 hours - 6 weeks post delivery ``` ``` minor = 500-1000 ml major = >1000 ml or signs of cardiovascular collapse ```

Question 428

what are the 4 main causes of PPH

Answer 428

4T's tone: uterine atony trauma: vaginal tear, cervical laceration, rupture tissue: retained products of conception, placenta throbbing: coagulopathy

Question 429

antenatal risks for PPH

Answer 429

``` placental problems (praaevia, accreta) Hx of retained placenta, c-section, PPH multiple pregnancy polyhydramnios obesity fetal macrosomia ```

Question 430

intrapartum risk factors for PPH

Answer 430

``` operative vaginal delivery syntocinon/syntometrine use retained placenta c-section labour >12 hours perineal tear/episiotomy ```

Question 431

ABCDE management of PPH

Answer 431

oxygen via non-rebreather mask at 15 l/min IV access (grey/orange cannula) bloods: G&S, FBC, coagulation screen, fibrinogen, U&Es, LFTs, lactate cross-match 6 units of packed red cells check vitals every 15 mins determine cause of bleeding (4Ts) massive haemorrhage protocol tranexamic acid 0.5-1 g IV to stop bleeding

Question 432

how to stop the bleeding in PPH (non-surgical)

Answer 432

tone/tissue: uterine massage using bimanual compression administer IV syntocinon insert urinary catheter to minimise bladder pressure on uterus ergometrine, carboprost, misoprostol thrombin: expel clots manually trauma: repair trauma

Question 433

surgical management of PPH

Answer 433

examine under anaesthetic (trauma, RPOC, rupture) balloon insertion to put pressure on bleeding vessels arterial embolisation B-lynch sutures uterine artery/internal iliac ligation hysterectomy (last resort)

Question 434

fluid replacement in PPH

Answer 434

2 large bore IV access rapid fluid resus: warmed crystalloid (eg hartmann's), 0.9% saline blood transfusion early (O- if life-threatening) in DIC/coagulopathy give FFP, cryoprecipitate, platelets use blood warmer

Question 435

classifcation of perineal tears

Answer 435

1st degree: involving skin only 2nd degree: involving skin and levator ani (usually needs stitches) 3rd/4th degree: extend to anal sphincter muscle (may stretch pudendal nerve --> faecal incontinence)

Question 436

what is an episiotomy

Answer 436

surgical cut made by medical professional with patient's consent

Question 437

psychiatric red flags in postnatal period

Answer 437

recent significant chage in mental state or emergence of new symptoms new thoughts or acts of violent self-harm new and persistent expression of incompetency as a mother or estrangement from their baby

Question 438

when to consider admission to a mother and baby unit

Answer 438

``` a rapidly changing mental state suicidal ideation pervasive guilt or hopelessness beliefs of inadequacy as a mother evidence of psychosis ```

Question 439

who is most at risk of postnatal mental health problems

Answer 439

``` young, single domestic issues lack of support substance abuse unplanned/unwanted pregnancy pre-existing mental health problems ```

Question 440

when to refer a new mother to psychiatry

Answer 440

``` severe anxiety/depression Hx of BPSD or schizophrenia Hx of puerperal psychosis current psychosis developed mental illness in later stages of pregnancy/peurperium FHx of significant mental illness ```

Question 441

features of baby blues

Answer 441

brief period of emotional instability where more become tearful, irritable, anxious and confused arises day 3 postnatally and continues for about a week

Question 442

features of puerperal psychosis

Answer 442

sleep disturbance, confusion, irrational ideas, mania, delusions, hallucination presents 2 weeks postnatally emergency admission to mother and baby unit

Question 443

when does postnatal depression present and how long does it last

Answer 443

2-6 weeks postnatally can last weeks/months or even up to a year or more

Question 444

how long do the following fetal circulatory adaptions take to close up ``` foramen ovale ductus arteriosus umbilical arteries umbilical vein ductus venosus ```

Answer 444

``` foramen ovale: minutes ductus arteriosus: hours umbilical arteries: hours umbilical vein: days ductus venosus: days ```

Question 445

what are the parts of the APGAR score

Answer 445

appearance: blue/pale; blue extremities; no cyanosis pulse: absent; <100; >100 grimace: no response; grimace/feeble cry when stimulated; cry or motor response activity: none; some flexion; flexed limbs that resist extension respiration: absent; weak/irregular gasping; strong cry

Question 446

how often is the APGAR performed

Answer 446

60 seconds after delivery | 5 mins after

Question 447

which conditions are tested for on heelprick test

Answer 447

``` PKU CF congenital hypothyroidism MCADD sickle cell disorder maple syrup urine disease isovaleric acidaemia glutamic aciduria type 1 homocystinuria ```

Question 448

what is PKU

Answer 448

excess phenylalanine in the blood usually from an inherited deficiency of the enzyme that converts it to tyrosine

Question 449

what is CF

Answer 449

inherited mutation of the genes encoding the CFTR protein responsible for producing bodily secretions causing them to become thick and sticky

Question 450

what is congenital hypothyroidism

Answer 450

congenital thyroxine deficiency as a result of poorly developed/absent thyroid

Question 451

what is MCADD

Answer 451

inherited deficiency of an enzyme responsible for breaking down fats to make energy

Question 452

what is maple syrup urine disease

Answer 452

deficiency of an enzyme needed to break down amino acids in food and milk, including breast milk

Question 453

what is isovaleric acidaemia

Answer 453

deficiency of an enzyme needed to break down leucine in milk to isovaleric acid causing harmful build up of acid in blood and urine

Question 454

what is glutaric aciduria type 1

Answer 454

deficiency of an enzyme needed to break down glutamic acid from food and milk, high levels of glutamic acid exists in the blood as a result and causes illness

Question 455

what is homocystinuria

Answer 455

lack of CBS enzyme, resulting in a build up of homocysteine and methionine

Question 456

when is heel prick testing done | what is the latest time?

Answer 456

ideally 5 days after birth | can do it up to 1st birthday, apart from CF which must be done before 8 weeks

Question 457

what is the most common uterine malignancy

Answer 457

endometrial adenocarcinoma

Question 458

risk factors for endometrial cancer

Answer 458

high levels of oestrogen: PCOS, late menopause, nulliparity, obesity, unopposed oestrogen HRT, tamoxifen, carbohydrate intolerance, oestrogen secreting tumours

Question 459

presenting symptoms of endometrial cancer

Answer 459

abnormal uterine bleeding - any PMB or irregular bleeding in premenopausal women >40 should be investigated vaginal discharge (blood, watery, purulent) pain (normally related to mets)

Question 460

what are the 4 main investigations of endometrial cancer

Answer 460

TVUSS: measures endometrial thickness (>4 mm is concerning) endometrial biopsy: histological analysis D&C: scrape away endometrium under GA hysteroscopy: biopsy/curretage can also be performed

Question 461

histological signs of endometrial hyperplasia

Answer 461

increased gland-to-stromal ratio

Question 462

treatment of endometria lhyperplasia

Answer 462

progestogens in young women (Mirena) | if atypical --> hysterectomy

Question 463

what is the common pattern of spread of endometrial carcinoma

Answer 463

direct spread to myometrium and cervix | haematogenous or lymphatic spread can occur

Question 464

what are the two types of endometrial cancer

Answer 464

type I: endometrioid - more common, shortly after menopause - oestrogen dependent type II: serous and clear cell - older women, poorer prognosis, more aggressive - not related to oestrogen - spreads along Fallopian tubes and peritoneal surfaces so may present with extrauterine disease

Question 465

precursor lesions of endometrial cancer

Answer 465

endometrioid: atypical endometrial hyperplasia serous/clear cell: serous endometrial intraepithelial carcinoma

Question 466

how is endometrial cancer staged

Answer 466

I A/B: confined to uterus, >50% myometrial invasion II: cervical stromal invasion, not beyond uterus III A/B/C: tumour invades serosa or adnexa; vaginal or parametrical involvement; node involvement (pelvic/para-aortic) IV A/B: bladder or bowel invasion; distance mets

Question 467

grading of endometrial tumours

Answer 467

1: 5% or less solid growth 2: 6-50% solid growth 3: >50% solid growth

Question 468

management of endometrial cancer

Answer 468

surgery: hysterectomy and bilateral salpino-oophorectomy +/-lymphadenectomy radiotherapy or high dose progestogens if not suitable for surgery chemo if widespread disease

Question 469

smooth muscle tumours in the myometrium

Answer 469

leiomyoma aka fibroids leiomyosarcoma: rare, poor prognosis

Question 470

risk factors for ovarian cancer

Answer 470

increased number of ovulation genetic predisposition Lynch syndrome/BRCA endometriosis

Question 471

what is the most common ovarian cancer

Answer 471

serous epithelial

Question 472

precursors for serous ovarian cancer

Answer 472

high grade: serous tubal intraepithelial carcinoma low grade: serous borderline tumour

Question 473

types of epithelial ovarian cancer

Answer 473

``` serous mucinous endometrioid clear cell Brenner ```

Question 474

types of stromal tumours

Answer 474

granulose cell tumours thecoma/fibroma sertoli/leydig cell tumours

Question 475

types of germ cell ovarian tumours

Answer 475

teratoma dysgerminoma yolk sac tumour choriocarcinoma

Question 476

which primary cancers often metastasise to the ovaries

Answer 476

endometrial cancer breast cancer pancreatic GI

Question 477

presentation of ovarian cancer

Answer 477

often present late with non-specific symptoms | abdominal distension, GI symptoms

Question 478

what is the risk of malignancy index

Answer 478

used to separate benign and malignancy lesions RMI = USS score x menopausal score x CA125 level >200 cancer likely

Question 479

what USS features are suspicious of ovarian cancer | how are they scored on the RMI

Answer 479

``` complex mass with solid + cystic area mulitloculated thick separations associated ascites bilateral disease high doppler flow in solid areas ``` no features = 0 1 feature = 1 2+ features = 3

Question 480

which other markers may be raised in ovarian cancer

Answer 480

Carcino-embryonic antigen: particularly mutinous tumours serum hCG AFP

Question 481

staging of ovarian cancer

Answer 481

I A/B/C: one ovary/both ovaries/on surface of ovary II A/B: spread to Fallopian tube/bowel or bladder III A/B/C: microscopic cancer in peritoneum/cancer <2 cm in peritoneum/lymph node involvement

Question 482

what are the precursor lesions of cervical cancer

Answer 482

squamous: cervical intraepithelial neoplasia adenocarcinoma: cervical glandular intraepithelial neoplasia

Question 483

what is the classification of CIN

Answer 483

CIN I: abnormal cells in basal third of epithelium CIN II: abnormal cells in middle third CIN II: abnormal cells in full thickness

Question 484

which types of CIN need treatment | what is done

Answer 484

CIN II/III need treatment large loop excision of transformational zone (LLETZ) thermocoagulation

Question 485

presentation of cervical cancer

Answer 485

``` post-coital bleeding intermenstrual bleeding menorrhagia pelvic pain offensive vaginal discharge ``` advanced: backache, leg pain, haematuria, weight loss, anaemia, bowel habit changes

Question 486

common chemotherapy drugs in cervical cancer

Answer 486

cisplatin | carboplatin/paclitaxel

Question 487

inter-pregnancy interval of <12 moths is associated with which outcomes

Answer 487

increased risk of preterm labour, fetal growth restriction, stillbirth and perinatal mortality

Question 488

when should sex be avoided if using the fertility awareness-based method of contraception

Answer 488

7 days prior to ovulation and 2 days after sperm can survive in genital tract for up to 7 days ovum can survive up to 2 days after ovulation

Question 489

when does ovulation normally occur

Answer 489

10-16 days before the start of the next cycle

Question 490

what are different methods of fertility-awareness contraception

Answer 490

temperature measuring: increase in temp for 3 days in a row indicate fertility has decreased cervical mucous: moist, sticky, white and creamy mucous indicates start of fertile period, watery/clear indicates peak fertility mobile apps can be used to track symptoms

Question 491

pros and cons of fertility awareness

Answer 491

pros: no side effects, acceptable to all faiths and cultures, avoids hormones, increased awareness of cycle cons: higher rate of failure, user-dependent, restricts timing of intercourse, menstrual cycle can change or become irregular, requires constant monitoring, medication can interrupt cervical mucous, not suitable following pregnancy or if irregular cycle

Question 492

pros and cons of male condom

Answer 492

pros: protection against STI, no hormones cons: failure rate high with typical use, user dependent, not suitable with oil-based lubricants

Question 493

how to use contraceptive diaphragm

Answer 493

reusable circular dome inserted into vagina before sex must be used with spermicide leave in place for 6 hours after sex

Question 494

disadvantages of diaphragm

Answer 494

lack of spontaneity user dependent no protection against STIs increased risk of cystitis need refitted if gain/lose >3 kg, deliver baby/miscarriage/abortion latex and spermicide can cause irritation

Question 495

does COCP provide contraceptive protection immediately

Answer 495

if taken in the first 5 days of cycle then YES if taken after 5 days then NO, needs to be taken for 1 week if started by day 21 post partum then immediately effective

Question 496

missed pill rules COCP

Answer 496

1 pill missed: take last pill, even if two pills are taken that day no additional contraception 2 pills missed: take last pill missed but omit any other previous pills missed use condoms for 7 days - if pill missed in week 1, consider emergency contraception if UPSI in pill-free interval or in week 2 - if pill missed in week 2 no EC needed - if pill missed in week 3, current pack should be finishedand new pack started immediately

Question 497

pros and cons of COCP

Answer 497

pros: improves painful/heavy bleeding, endometriosis symptoms and PMS reversible effects upon stopping reduced risk of ovarian, endometrial and colorectal Ca cons: taken around same time every day interactions with other medicines increased risk of cervical and breast Ca increased risk of VTE, stroke, IHD (risk factors) hormonal side effects irregular bleeding

Question 498

relative contraindications to COCP | disadvantages outweigh the advantages (UKMEC 3)

Answer 498

``` >35 yo and smoking <15 cigarettes/day BMI >35 FHx of VTE in family member <45 controlled HTN immobility cancer mutations eg BRCA gallbladder or liver disese complicated DM ```

Question 499

absolute contraindications for COCP | should be avoided (UKMEC 4)

Answer 499

>35 and smoking >15 cigarettes/day migraine with aura PMHx of VTE, thrombogenic mutation, stroke, IHD uncontrolled HTN current breast cancer major surgery with prolonged immobilisation

Question 500

how to use transdermal contractpive patch

Answer 500

wear for 7 days change on the 8th wear for 3 weeks then a patch-free week if patch removed for >48 hours additional contraception for 7 days

Question 501

how to use combined vaginal ring

Answer 501

have in vagina for 3 weeks, remove for 1 week, new ring if out of vagina >3 hours in weeks 1/2 additional protection for 7 days new ring no later than 7 days after last one removed

Question 502

how is the contraception injection given

Answer 502

every 13 weeks depoprovera IM sayana press SC (self-administered)

Question 503

pros and cons of contraceptive injection

Answer 503

``` pros: long-acting and less user dependent no oestrogen can lead to amenorrhoea useful in HMB, dysmenorrhoea, endometriosis ``` cons: non-reversible once injected delayed retrun to fertility (up to 12 months) irregular bleeding common in first 3 months potential for weight gain long term use associated with osteoporosis

Question 504

missed pill rules for POP

Answer 504

pill taken <12 hours later than usual time, take pill as normal >12 hours, take missed pill ASAP and continue with rest of pack - use condoms until pill has been taken for 48 hours older POPs have 3 hours window

Question 505

pros and cons of POPs

Answer 505

pros: few contraindications immediately reversible cons: irregular bleeding D&V (assume missed pill) liver enzyme inducers may reduce effectiveness CI if PMHx of Br Ca or active liver disease

Question 506

pros and cons of implant

Answer 506

``` pros: most effective form of contraception non-user decedent can be used if not suitable for oestrogen safe in breastfeeding and postpartum reduce painful/heavy bleeding ``` cons: irregular bleeding common in first 6/12 headache, ausea, breast pain, skin changes efficacy reduced by enzyme inducing drugs (AEDs, rifampicin) CI in current Br Ca and active liver disease

Question 507

risks of IUS

Answer 507

uterine perforation in 2/1000 increased risk of ectopic pregnancy compared to other contracptive but not compared to no contraception small risk of PID in first 20 days 1/20 risk expulsion in first 3 months

Question 508

different types of IUS

Answer 508

Mirena: 52 mg LNG, 5 years, HMB etc, HRT kyleena: 19.5 mg LNG, 5 years, smaller so less side effects, not for HMB or HRT jaydess: 13.5 mg LNG, 3 years, more irregular bleeding

Question 509

when should dose of LNG EC be doubled

Answer 509

BMI >26 over 70 kg taking enzyme inducing drugs

Question 510

how does LNG EC work

Answer 510

delays/prevent ovulation and reduced successful implantation must be taken within 72 hours

Question 511

how does Uliprsital EC work

Answer 511

delays/inhibts ovulation taken within 120 hours of UPSI

Question 512

when is breastfeeding a suitable contraceptive

Answer 512

exlcusive breastfeeding up to 6 months no periods

Question 513

which types of contraception are safe in postnatal periods

Answer 513

implant and POP can be used anytime after birth depo safe anytime if not breastfededing IUS/IUD can be inserted with 48 hours of SVD or wait at least 4 weeks delay CHC for at least 3 weeks due to risk of VTE

Question 514

when is abortion permitted after 24 weeks

Answer 514

woman's life is in danger severe foetal abnormality woman at grave risk of physical or mental injury

Question 515

how is medical abortion carried out

Answer 515

mifepristone (antoprogesterone) 48 hours laters misoprostol (prostaglandin) <10 weeks: at home 10+1 - 23+6 wks: admission to hospital or clinic advised, multiple doses of misoprostol may be required (5 doses in 24 hours)

Question 516

risks of medical abortion

Answer 516

heavy and prolonged bleeding, may need transfusion incomplete ro failed procedure pain infection risks increase with increased age

Question 517

how does surgical abortion take place

Answer 517

misoprostol to soften and dilate cervix vacuum aspiration up to 14 weeks; dilation and evacuation >14 weeks (not in Scotland) local/regional/general anaesthetic or conscious sedation

Question 518

post abortion management

Answer 518

if uncomplicated can go home same day, accompanied if under anaesthesia contraception discussed (can be given same day) anti-D if >9+6 weeks and Rh -ve

Question 519

function of sertoli cells

Answer 519

blood-testes barrier: protect sperm from antibodies, maintain fluid composition of testes provide nutrient destroy defective sperm secrete seminiferous tubule fluid, androgen binding globulin, Inhibin hormone and activin hormone

Question 520

what is the function of the substance secreted by the Sertoli cells

Answer 520

seminiferous tubule fluid: essential for carrying spermatozoa to epididymis androgen binding globulin: binds testosterone, for sperm production Inhibin/activin: regulation of FSH secretion and control of spermatogenesis

Question 521

where does spermatogenesis take place | where does it go after

Answer 521

seminiferous tubules rete testes epididymis (storage and maturation)

Question 522

briefly describe the HPG axis in males

Answer 522

GnRH released in bursts from hypothalamus every 2-3 hours anterior pituitary releases LH and FSH LH stimulates testosterone secretion from leydig cells testosterone and FSH surges stimulate spermatogensis in seminiferous tubules inhibin from Sertoli cells decreases FSH secretion and testosterone decreases GnRH secretion

Question 523

what is capacitation

Answer 523

biochemical and electrical events that allow the sperm to penetrate the cell layer surrounding the oocyte sperms's tail movement increases in speed and strength to propel it forwards

Question 524

common causes of obstructive male infertility endocrinological features

Answer 524

``` cystic fibrosis (obstructed or absent vas) vasectomy ``` normal LH, FSH and testosterone

Question 525

common non-obstructive causes of male infertility

Answer 525

``` cryptorchidism klinefelter's syndrome (47 XXY) microdeletions of Y chromosome robertsonian translocation infection (mumps, STI) endocrine (pituitary tumours, hypothalamus disorders, thyroid, DM, DAH) testicular tumours ```

Question 526

what is globozoospermia

Answer 526

rounded head, no acrosome | can't fuse with zone pellucida

Question 527

hypothalamic causes of anovulatory infertility

Answer 527

anoerixa, bulimia, excessive exercise Low FSH, LH and estradiol

Question 528

pituitary causes of anovulatroy infertility

Answer 528

hyperprolactinaemia Sheehan's syndrome pituitary adenomas

Question 529

ovarian causes of anovulatory infertility

Answer 529

PCOS | premature ovarian failure

Question 530

causes of ovulatroy infertility

Answer 530

infection (PID, transperitoneal spread etc) endometriosis salpingitis isthmicya nodosa: nodular scarring of Fallopian tube uterine polyps/fibroids

Question 531

important parts of infertility history

Answer 531

duration of infertility primary or seconda frequency of sexual activity history of sexual function libido females: previous pregnancies, full obestetric Hx, menstrual history both: general health, medical/surgical Hx, medications

Question 532

normal testicular volume

Answer 532

12-25 mls

Question 533

how to ensure good quality semen anaylsis

Answer 533

``` assessed quickly after production (<1 hour ideally) kept at body temperature patient in good health avoid ejaculation for 72 hours prior avoid caffeine/alcohol ```

Question 534

investgiation oftubal patency

Answer 534

laparoscopy | hysterosalpingogram

Question 535

endocrine tests for males and females with infertility

Answer 535

male: LH and FSH, prolactin, TSH female: LH and FSH, oestradiol, mid-luteal progesterone, free androgen index, testosterone and SHBG, prolactin, TSH

Question 536

what is IUI | what are the indications

Answer 536

intrauterine insemination directly putting sperm inside the uterus healthy sperm, ovulation is occuring and no tubal disease sexual dysfunction, female same-sex with donor sperm, male same-sex with surrogate

Question 537

what IVF | what are the indication

Answer 537

In-vitro fertilisation fertilising egg outside of body unexplained infertility, pelvic disease, anovulatory infertility

Question 538

what is ICSI | what are the indictions

Answer 538

intra-cystoplasmic sperm injection sperm injected directly in cytoplasm of oocyte severe male factor infertility, previous failed IVF, pre-implantation genetic diagnosis

Question 539

how to harvest eggos

Answer 539

down regulation: synthetic GnRH used to shut down menstrual cycle, allows cycles to be scheduled ovarian stimulation: gonadotrophin hormone injection to to stimulate relase of eggs oocytes collection: under USS guidance, needle is inserted transvaginally and ovarian follicle aspirate

Question 540

at what stage are embryos transferred for IVF/ICSI

Answer 540

day five normally (blastocyst stage