Obstetrics and Gynaecology

Question 1

Define stress incontinence

Answer 1

Involuntary leakage of urine on effort or exertion, or on sneezing/coughing

Question 2

Risk factors for stress incontinence?

Answer 2

Increasing age, pregnancy and vaginal delivery, obesity, constipation, prolapse, hysterectomy, menopause and decreased oestrogen, family history, smoking, drugs eg ACEi

Question 3

How to assess pelvic muscle tone?

Answer 3

Digitally

Use modified oxford grading system (0-5, rates strength of contraction)

Question 4

What can you do initially to manage stress incontinence?

Answer 4

Lifestyle advice: decrease caffeine, weight loss if bmi ove 30, advice on fluid intake, smoking cessation, pelvic floor muscle training

3 months pelvic floor training then duloxetine/surgery consideration

Question 5

What can be done in secondary care for stress incontinence?

Answer 5

Colposuspension, autologous rectus fascial sling, retro pubic mid-urethral mesh sling, intramural urethral bulking agents

Surgery is first line in secondary care. Can offer duloxetine as 2nd line

Question 6

Describe an overactive bladder presentation

Answer 6

Urinary urgency associated with increased frequency and nocturia
Can be wet (incontinent) or dry (no incontinence)

Question 7

Pathophysiology of overactive bladder?

Answer 7

Involuntary contractions of detrusor muscle during filling phase of micturition

Question 8

Aetiology of overactive bladder?

Answer 8

Most=idiopathic

Can be a/w PD, MS, injury to pelvic/spinal nerves, drugs eg diuretics/antidepressants/hrt

Question 9

How to manage overactive bladder initially?

Answer 9

Exclude/manage treatable causes
Lifestyle advice
Bladder training for at least 6 weeks
Then add in antimuscarinic eg oxybutynin/tolterodine/darifenacin
Mirabegron is another option (beta 3 adrenergic receptor agonist- relaxes sm and increases bladder capacity)

Question 10

Secondary care options for overactive bladder?

Answer 10

Botulinum toxin type a injection into bladder wall
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion

Question 11

Pathophysiology of uterovaginal prolapse

Answer 11

Pelvic floor muscles and ligaments stretch and weaken over time and can no longer support the uterus. The uterus slips down into or protrudes out of the vagina

Question 12

Presentation of uterovaginal prolapse?

Answer 12

Tends to affect postmenopausal women who have had at least one vaginal delivery

Mild=normally asx
Mod-severe= heaviness/pulling in pelvis, tissue protruding from vagina, urinary sxs, trouble with bowel movements, feeling like they’re sitting on a small ball, sexual concerns

Symptoms tend to be worse later on in the day

Question 13

Causes of weakened pelvic floor muscles?

Answer 13

Pregnancy, difficult labour, large baby, overweight, lower oestrogen after menopause, chronic constipation, chronic cough, repeated heavy lifting

Question 14

Management of uterovaginal prolapse?

Answer 14

Self care measures, pessary, surgery (repair of tissues or hysterectomy). Kegel exercises very important

Question 15

Difference between rectocele and cystocele?

Answer 15

Rectocele=posterior vaginal prolapse

Cystocele=anterior vaginal prolapse

Question 16

Potential presentations of rectocele?

Answer 16

Small ones may be asx
Bulge of tissue, difficulty having bowel movement, sensation of rectal pressure or fullness, feeling of incomplete emptying, sexual concerns

Question 17

Causes of rectocele?

Answer 17

Chronic constipation, chronic cough, repeated heavy lifting, overweight, more vaginal deliveries

Question 18

management of rectocele?

Answer 18

Self care measures eg Kegel exercises
Pessary
Surgical repair may be considered (mesh patch inserted)

Question 19

Pathophysiology of cystocele?

Answer 19

Bladder drops from normal position and pushes on wall in vagina- pelvic floor weakened or too much pressure on pelvic floor

Question 20

Management of cystocele?

Answer 20

Mild cases typically are watch and wait
Pelvic floor muscle exercises
Pessary
May consider surgery

Question 21

Types of female genital tract fistulae?

Answer 21

Vesicovaginal (bladder fistula, most common)
Uterovaginal
Urethrovaginal
Rectovaginal
Colovaginal
Enterovaginal (small intestine and vagina)

Question 22

Why do fistulae develop?

Answer 22

Due to injury, surgery, infectoin or radiation treatment

Can occur as a result of prolonged childbirth

Question 23

What are potential problems with vesicovaginal or rectovaginal fistulae?

Answer 23

Uncontrolled urinary or faecal incontinence or leakage out of the vagina

Question 24

Treatment of genital tract fistulae?

Answer 24

surgery

Question 25

Describe a fibroid

Answer 25

Most common benign tumour in women | Smooth muscle cells and fibroblasts accumulate to form a hard, round, whorled tumour in the myometrium

Question 26

When do you get fibroids and why?

Answer 26

Develop during reproductive age as maintained by oestrogen and progestogen

Question 27

Types of fibroid?

Answer 27

Subserosal (outer serosal surface of uterus and extend into peritoneal cavity, commonly asx) Intramural (don't extend into uterine/peritoneal cavities, may cause menorrhagia and dysmenorrhoea) Submucosal (inner mucosal surface, extend into uterine cavity, cause significant menorrhagia, dysmenorrhoea and reduced fertility) NB/ subserosal and submucosal may become pedunculated

Question 28

Risk factors for fibroids? | What reduces risk?

Answer 28

RF: increasing age, early puberty, obesity, family history, black Reduced risk: pregnancy and number of pregnancies

Question 29

Complications of fibroids?

Answer 29

Abnormal uterine bleeding, compression or adjacent organs, infertility, pregnancy problems, torsion of pedunculated fibroid, red degeneration of fibroid (during 1st and 2nd trimester, fever, pain and vomiting)

Question 30

Presentation of fibroids?

Answer 30

Menorrhagia, pelvic pain, abdo distension, pelvic pressure/discomfort, urinary symptoms, subfertility, non-specific bowel problems

Question 31

Management of fibroids?

Answer 31

Doesn't require management in most cases If fibroid under 3cm: mirena coil is first line, if unsuitable can use tranexamic acid. NB/ can also use COCP but contraindicated when surgery might be involved. Endometrial ablation can he used. As can uterine artery embolisation Myomectomy or hysterectomy If surgery: GnRH agonists (eg goserelin acetate) used before surgery to reduce size of fibroid and make them less likely to bleed.

Question 32

Types of ovarian cysts?

Answer 32

``` Functional cysts (most common) Dermoid (teratomas- form from embryonic cells and can contain tissue eg hair/skin/teeth) Cystadenomas (on surface of ovary) Endometriomas ```

Question 33

Complications of ovarian cysts?

Answer 33

``` Dermoid cysts and cystadenomas can grow large and move ovary therefore increasing chance of ovarian torsion Also rupture (severe pain and bleeding) ```

Question 34

What investigations for ovarian cysts?

Answer 34

``` Pelvic exam Pregnancy test (+=?corpus luteum cyst) Pelvic USS Laparoscopy CA125 blood test (?malignancy) ```

Question 35

Management of ovarian cysts?

Answer 35

Watchful waiting, oral contraceptives, surgery

Question 36

What are functional cysts? What are the two types?

Answer 36

Cysts as a result of the menstrual cycle, when normal follicle continues to grow. Rarely painful, usually harmless and self limiting for 2-3 cycles Follicular cyst and corpus luteum cyst (when follicle doesn't rupture/release its egg or fluid accumulates inside follicle= corpus luteum grows into cyst)

Question 37

Age distribution of ovarian torsion?

Answer 37

Bimodal : | 15-30 and postmenopausal

Question 38

Causes of ovarian torsion?

Answer 38

``` Hypermobility of ovary Adnexal mass (most lesions=dermoid cysts or paraovarian cysts) ``` Younger= developmental abnormalities Adults=ovarian tumours, polycystic ovaries, adhesions

Question 39

Presentation of ovarian torsion?

Answer 39

severe non specific lower abdo/pelvic pain (intermittent or sustained) Nausea and vomiting Adnexal tenderness Commonly have increased WCC

Question 40

Management of ?ovarian torsion?

Answer 40

Urgent USS Urgent surgery to prevent ovarian necrosis Most ovaries non-salvageable: salpingo-oophorectomy If non-infarcted= surgical untwisting

Question 41

What is lichen sclerosus?

Answer 41

Common chronic skin disorder- most often affects genital and perianal areas Most common in women over 50 Thought to be autoimmune

Question 42

Presentation of lichen sclerosus?

Answer 42

Crinkled/thickened white patches of skin that tend to scar Vulval lichen sclerosus= primarily non hair bearing inner areas, localised or diffuse, never involves vaginal mucosa, can be v itchy and sore

Question 43

Complications of lichen sclerosus?

Answer 43

Infections (thrush, herpes, S. aureus) | Increased risk of SCC

Question 44

Management of lichen sclerosus?

Answer 44

Lifestyle measures eg wash gently, non soap cleanser, loose clothing Topical steroid ointment eg clobetasol propionate 0.05% Other topical tx= oestrogen cream, calcineurin inhibitor eg tacrolimus ointment

Question 45

What are the types of cervical cancer?

Answer 45

``` SCC (70-80%) Cervical adenocarcinoma (up to 10%) ```

Question 46

What virus is associated with cervical cancer? Which subtypes specifically?

Answer 46

``` Human papillomavirus (HPV) esp HPV16 and HPV18 ```

Question 47

What increases risk of HPV causing cervical cancer?

Answer 47

Co-infection with other STIs, smoking, high parity, young age at first pregnancy, FH, oral contraceptive pill for over 5 years, immunocompromised

Question 48

What increases risk of contracting HPV?

Answer 48

Increased number of sexual partners, no condom use, age at first sexual intercourse

Question 49

Presentation of cervical cancer?

Answer 49

Asx, non specific sxs; Intermenstrual/postcoital/postmenopausal bleeding, blood-stained vaginal discharge, mucoid/purulent discharge, pelvic pain/dyspareunia

Question 50

What things are in place to help prevent cervical cancer?

Answer 50

HPV vaccination at age 12-13 for girls | Cervical cancer screening: every 3 years after 24/25

Question 51

Describe the stages of cervical cancer?

Answer 51

I (carcinoma restricted to cervix- either microscopic (1A1 and 1A2) or clinically visible (1B1 and 1B2)) II (beyond uterus but not into pelvic wall or into lower third of vagina) III (onto pelvic sidewall, lower third of vagina) IV (beyond true pelvis either adjacent organs or distant organs)

Question 52

What is cervical intraepithelial neoplasia/CIN?

Answer 52

Pre-invasive cancer

Question 53

Management of cervical cancer?

Answer 53

Conservative Hysterectomy, lymphadenectomy Chemoradiation (over 4cm) Manage complications

Question 54

How does endometrial cancer present?

Answer 54

``` Postmenopausal= vaginal bleeding and visible haematuria Pre-menopausal= abnormal bleeding ```

Question 55

RFs for endometrial cancer?

Answer 55

Increasing age, unopposed oestrogne after menopause (not kept in balance by progestogen), overweight/obese (oestrogen produced in fatty tissue), nulliparous, on tamoxifen, high levels of insulin, PCOS, endometrial hyperplasia

Question 56

What type are most endometrial cancers?

Answer 56

Adenocarcinoma

Question 57

How to investigate ?endometrial cancer? What would treatment consist of?

Answer 57

Transvaginal USS then hysteroscopy and biopsy then staging with CXR/MRI/CT/bloods etc Mx=hysterectomy, remove ovaries and fallopian tubes, may need radio/chemotherapy

Question 58

Presentation of ovarian cancer?

Answer 58

IBS like symptoms- constantly bloated, abdominal distension, pelvic/abdo discomfort, early satiety/loss of appetite, urinary frequency/urgency Also: indigestion, nausea, dyspareunia, bowel habit change, back pain, tiredness, unintentional weight loss

Question 59

RFs for ovarian cancer?

Answer 59

Increasing age, FH, BRCA1/2, HRT, endometriosis, obesity, smoking, asbestos exposure

Question 60

Investigations for ?ovarian cancer? Management?

Answer 60

CA125 (blood test) USS CT/Xray/needle biopsy/laparoscopy Mx= surgery and chemo

Question 61

Describe staging of ovarian cancer?

Answer 61

``` i= ovary(ies) ii= into pelvis/womb iii= into peritoneum, bowel surface or lymph glands iv= distant organs ```

Question 62

Presentation of vulval cancer?

Answer 62

Mostly in over 65s, rare Persistent itch, pain/soreness/tenderness, bleeding, open sore, dysuria, mole on vulva Most often affects inner edge of labia majora or labia minora

Question 63

RFs for vulval cancer?

Answer 63

Increasing age, vulval intraepithelial neoplasia, HPV infection, lichen sclerosus, smoking, previous radiotherapy

Question 64

What type of cancer is vaginal cancer?

Answer 64

``` SCC mostly (90%) 10% are adenocarcinomas ```

Question 65

Presentation of vaginal cancer?

Answer 65

Very rare! | Asx, abnormal bleeding, abnormal discharge, dyspareunia, lump/growth, persistent vaginal itch

Question 66

What is a hydatidiform mole? Two types-describe

Answer 66

Molar pregnancy- abnormal growth of trophoblasts ``` Complete= no formation of foetal tissue, placenta is abnormal and swollen Partial= maybe normal placental tissue, maybe formation of foetus (miscarried) ```

Question 67

Presentation of hydatidiform mole?

Answer 67

Dark brown-bright red vaginal bleeding during 1st trimester, severe N/V, sometimes passage of grape-like cysts, pelvic pressure or pain

Question 68

Pathophysiology of hydatidiform mole?

Answer 68

Egg fertilised by 1 or 2 sperm | Maternal chromosomes lost/inactivated (complete) or father provides 2 sets with mum's 1 (partial)

Question 69

Complications of hydatidiform mole?

Answer 69

Molar tissue may remain and continue to grow= gestational trophoblastic neoplasia (GTN) High level of HCG May develop cancerous form= choriocarcinoma

Question 70

Investigating hydatidiform mole? | Management?

Answer 70

``` Ix= HCG, USS, other bloods Mx= non viable pregnancy will either miscarry of need surgery ```

Question 71

Different management options for prolapse?

Answer 71

Pelvic floor muscle training, vaginal oestrogen, vaginal pessaries, pelvic floor repair, hysterectomy, sacroplexy or sacrospinous fixation (mesh and tape)

Question 72

What is endometriosis?

Answer 72

Endometrial tissue grows outside of the uterus- commonly involves ovaries, fallopian tube and tissue lining pelvis This tissue thickens, breaks down and bleeds but there is no way for the tissue to exit the body and so is trapped Tissue becomes irritated and can form scar tissue and adhesions If ovaries involved, cysts/endometriomas may form

Question 73

Presentation of endometriosis?

Answer 73

``` Chronic pelvic pain often a/w periods Dysmenorrhoea Dyspareunia Pain on bowel movements or urination Excessive bleeding Infertility ```

Question 74

How to diagnose endometriosis?

Answer 74

Pelvic exam, USS, MRI can point towards diagnose | Only way to formally diagnose= laparoscopy

Question 75

How to manage endometriosis?

Answer 75

Simple analgesia= NSAIDs and tranexamic acid Ovulation suppression (tricyclic COCP, Mirena coil, GnRH analogues) Laser/diathermy ablation Radical hysterectomy and oophorectomy

Question 76

What increases marker CA125?

Answer 76

NOT vulval Only one used in ovarian cancer Also: adenomyosis, ascites, endometriosis, menstruation, breast cancer, ovarian cancer, ovarian torsion, endometrial cancer, liver disease, metastatic lung cancer

Question 77

What is adenomyosis?

Answer 77

Uterine condition of ectopic endometrial tissue in the myometrium

Question 78

RFs for adenomyosis?

Answer 78

High oestrogen exposure eg short menstrual cycles and early menarche, or treated with tamoxifen

Question 79

Presentation of adenomyosis?

Answer 79

Most commonly asx and multiparous women of reproductive age | Potential sxs= dysmenorrhoea, menorrhagia, dyspareunia, chronic pelvic pain, menometrorrhagia

Question 80

What are the 3 types of adenomyosis?

Answer 80

Diffuse, focal, cystic

Question 81

What investigations for adenomyosis? | Management?

Answer 81

1st line=Uss, gold= pelvic MRI Mx: similar to endometriois- GnRH agonist, hysterectomy

Question 82

Define dysfunctional endometrial bleeding?

Answer 82

Abnormal uterine bleeding in absence of recognisable pelvic pathology, general medical disease or pregnancy Mainly caused by imbalance in sex hormones Abnormal may= intermenstrual, heavy, clots, bleeding>7 days, short or long cycles, spotting

Question 83

When do you see lots of dysfunctional endometrial bleeding?

Answer 83

Early on in puberty

Question 84

how to manage dysfunctional endometrial bleeding?

Answer 84

Oral contraceptives, or other hormonal contraceptives. Mostly a temporary condition- manage any anaemia

Question 85

How is androgen insensitivity syndrome inherited?

Answer 85

X linked recessive

Question 86

How does androgen insensitivity syndrome present?

Answer 86

Complete or partial where partial has more ambiguous px eg micropenis or clitoromegaly/hypospadias etc External female phenotype, genotype is male Undescended testes, female external genitalia, breast tissue, absence of internal female genitalia, lack of pubic hair/facial hair, taller than female average Infertile and increased risk of testicular cancer Primary amenorrhoea

Question 87

What can be seen in the bloods of someone with androgen insensitivity syndrome?

Answer 87

Increased LH Normal/raised FSH Increased oestrogen Normal/raised testosterone

Question 88

How to manage androgen insensitivity syndrome?

Answer 88

Bilateral orchidectomy, oestrogen therapy, vaginal dilators/surgery to create adequate vaginal length Raised as girls/women generally

Question 89

Incidence of premature menopause

Answer 89

1 in 100 (occurring in under 40s)

Question 90

Common menopause symptoms?

Answer 90

Hot flushes, night sweats, vaginal dryness, difficulty sleeping, low mood or anxiety, reduced libido, memory and concentration problems

Question 91

What gonadotrophin is higher in menopause?

Answer 91

FSH

Question 92

how to manage menopause?

Answer 92

HRT, simple measures for sweats/flushes, CBT, antidepressants, testosterone gel (libido), vaginal oestrogen, calcium/vit d/bisphosphonates (osteoporosis risk)

Question 93

What is atrophic vaginitis? | When does it occur?

Answer 93

Thinning, drying and inflammation of vaginal walls due to decreased oestrogen Occurs: perimenopause, menopause, surgical menopause, during breast feeding, contraceptive pills, pelvic radiation, chemo, breast cancer hormonal treatment

Question 94

Describe GSM (genitourinary syndrome of menopause)

Answer 94

Dryness, burning, discharge, itching, burning/urinary/frequency, recurrent UTIs, incontinence, postcoital bleeding, dyspareunia, decreased vaginal lubrication during intercourse, shortening and tightening of vagina

Question 95

Management of atrophic vaginitis?

Answer 95

Vaginal moisturisers, water-based lubricant, topical oestrogen, vaginal dilators, topical lidocaine, regular intercourse

Question 96

Precocious and late menarche?

Answer 96

Precocious=under 9 | Late= over 15 years

Question 97

Describe physiology of menarche

Answer 97

Pulsatile GnRH from hypothalamus stimulates pituitary production of FSH and LH. This increases ovarian production of oestrogens (oestradiol and androgens). Oestradiol causes maturation of ovarian follicles Increased oestrogen causes uterine endometrial proliferation and eventually an LH surge, causing ovulation or rupture of dominant ovarian follicle Progesterone (adrenal cortex and ovaries) causes thickening of endometrium

Question 98

Presentation of endometrial polyps?

Answer 98

Irregular menstrual bleeding, intermenstrual bleeding, menorrhagia, bleeding after menopause, infertility

Question 99

RFs for endometrial polyps?

Answer 99

Oestrogen dependent: peri/postmenopausal, hypertension, obesity, tamoxifen

Question 100

How to investigate and manage endometrial polyps?

Answer 100

Ix: transvaginal USS, hysteroscopy, endometrial biopsy Mx: watchful waiting, short term meds (progestins and GnRH agonists), surgical removal

Question 101

Most common location for ectopic pregnancy?

Answer 101

Fallopian tube (tubal pregnancy)

Question 102

RFs for ectopic pregnancy?

Answer 102

Previous ectopic pregnancy, inflammation or infection (STIs), fertility treatments, tubal surgery, birth control (IUD and tubal ligation/tubes tied), smoking

Question 103

Presentation of ectopic pregnancy?

Answer 103

Positive pregnancy test, early presentation pregnancy (missed period, breast tenderness, nausea), light vaginal bleeding and pelvic pain NB/ if blood leaks from fallopian tube may feel shoulder pain or urge to have bowel movement Rupture if continued growth- shock and life threatening

Question 104

How to manage an ectopic pregnancy?

Answer 104

Methotrexate injection for early ectopic without unstabke bleeding Laparoscopy- salpingostomy/salpingectomy (ectopic/ectopic and tube removed) Emergency surgery

Question 105

Incidence of polycystic ovaries and polycystic ovary syndrom?

Answer 105

Polycystic ovaries= up to 33% of women of reproductive age | PCOS= 5-15% of women of reproductive age

Question 106

Pathophysiology of PCOS?

Answer 106

``` Excess androgens (ovary theca cells- due to hyperinsulinaemia or increased LH) and insulin resistance > hyperinsulinaemia > increased androgens and decreased SHBG (sex hormone binding globulin) in liver, increased LH due to increased production (anterior pituitary) and increased oestrogen in some women (causing hyperplastic endometrium) ```

Question 107

Presentation of PCOS?

Answer 107

Peripubertal -mid 20s Oligomenorrhoea (under 9 periods/year), infertility/subfertility, acne and hirsutism, alopecia, obesity/difficulty losing weight, psych symptoms, sleep apnoea, may have acanthosis nigricans

Question 108

Criteria for PCOS? describe

Answer 108

Rotterdam criteria- need at least 2: Polycystic ovaries, oligo-ovulation/anovulation, clinical and/or biochemical signs of hyperandrogenism

Question 109

Investigating PCOS?

Answer 109

Testosterone (normal or high), SHBG (normal or low), LH (high), USS, fasting glucose/oral glucose tolerance test

Question 110

Management of PCOS?

Answer 110

MDT management, advise on cardiac risks | Weight control and exercise, COC pills or IUS, metformin can be used

Question 111

Complications of PCOS?

Answer 111

Infertility, endometrial hyperplasia/cancer, CVD, T2DM, sleep apnoea

Question 112

Abnormal formations of uterus ?

Answer 112

Due to incomplete fusion of mullerian or paramesonephric ducts: Complete failure (double vagina, cervix and uterus) Some fusion (single vagina and cervix, double single horned uteruses partially fused) Septate uterus (midline septum) Arcuate Unicornuate

Question 113

Abnormal formations of vagina?

Answer 113

Vaginal agenesis, vaginal atresia, mullerian aplasia, transverse vaginal septa

Question 114

Turner syndrome genotype?

Answer 114

45X

Question 115

What is Asherman syndrome? | How to manage?

Answer 115

Formation of intrauterine adhesions; usually due to injury to endometrium Tendency to develop them after pregnancy Mx; lysis of adhesions via hysteroscopy

Question 116

Presentation of asherman syndrome?

Answer 116

Infertility, loss of pregnancy, menstrual abnormalities, abdominal pain

Question 117

How might prolactinoma present?

Answer 117

Galactorrhoea, amenorrhoea/oligomenorrhoea, anovulatory cycles, infertility, hirsutism, decreased libido

Question 118

How to manage prolactinoma?

Answer 118

Dopamine agonists eg cabergoline Surgery Oestrogen contraception

Question 119

What can cause pelvic inflammatory disease?

Answer 119

STIs esp gonorrhoea and chlamydia | Mycoplasmas, flora, strep, TB

Question 120

Presentation of pelvic inflammatory disease?

Answer 120

Bilateral lower abdominal pain, deep dyspareunia, abnormal bleeding, purulent discharge, may have fever, may have N/V, urinary symptoms, proctitis and adnexal mass

Question 121

Investigating PID?

Answer 121

STI swabs, pregnancy test, laparoscopy (single best diagnostic test), exclusions eg UTI

Question 122

How to manage PID?

Answer 122

Analgesia Abx immediately before swab results- IM ceftriaxone 500mg stat then doxycyline 100mg bd and metronidazole 400mg bd for 14 days Partner notification and treatment

Question 123

Recent coil insertion but got PID?

Answer 123

If coil recently inserted can leave in, but if no response to abx in 48-72 hour, remove and prescribe any emergency contraceptives if needed

Question 124

Complications of PID?

Answer 124

Infertility, ectopic pregnancy, chronic pelvic pain, perihepatitis, tubo-ovarian abscess, reactive arthritis, preterm delivery, vertical transmission

Question 125

How many stages of labour are there?

Answer 125

3

Question 126

describe the 1st stage of labour

Answer 126

Cervix dilation. Early labour: -Latent phase- cervix starts to soften, irregular contractions=hours-days -Established labour- cervix dilated to 4cm and regular contractions -Established labour- dilation 6-10cm

Question 127

How can you speed up labour?

Answer 127

ARM=artificial rupture of the membranes | or oxytocin drip

Question 128

Describe the 2nd stage of labour

Answer 128

Full cervix dilation up to birth aka the pushing stage

Question 129

How long does 2nd stage of labour generally take in primiparous women? Multiparous women?

Answer 129

``` Primi= less than 3 hours Multi= less than 2 hours ```

Question 130

Describe the 3rd stage of labour

Answer 130

Delivery of placenta

Question 131

Two ways of 3rd stage of labour happening?

Answer 131

Active=oxytocin IM injection or Physiological= natural where the cord isn't cut until it's stopped pulsing, can take about an hour

Question 132

Pros and cons of active 3rd stage of labour?

Answer 132

``` Pros= much faster delivery of placenta and lowers risk of postpartum haemorrhage Cons= increased risk of nausea and can make afterpains worse ```

Question 133

What counts as premature labour?

Answer 133

Regular contractions resulting in dilation of cervix after week 20 and before week 37 of pregnancy

Question 134

Presentation of premature labour?

Answer 134

Contractions, constant low dull back ache, pelvic pressure, mild cramps, spotting or light bleeding, rupture of membranes, change in vaginal discharge

Question 135

Potential risk factors for premature labour?

Answer 135

Multiple pregnancy, previous preterms, shortened cervix, cigarettes, drugs, infections, chronic conditions, stress, polyhydramnios, foetal birth defect, age of mother

Question 136

How to try to prevent premature labour?

Answer 136

Regular prenatal care, healthy diet, avoid risky substances, pregnancy spacing, cautious with IVF/how many embryos

Question 137

How should you manage premature labour?

Answer 137

If unwell, speed up delivery with oxytocin/induction/C-section If over 34 weeks, then let labour progress naturally Corticosteroids if between 23 and 34 weeks if risk of delivery in next week Tocolytics can be used for around 48 hours to buy time for course of steroids/transfer time Magnesium sulfate venous infusion to reduce risk of cerebral palsy for under 34 weeks

Question 138

What to give if in labour before 34 weeks gestation?

Answer 138

Magnesium sulfate, steroids | Tocolytics if need to buy time (about 48 hours)

Question 139

Define premature rupture of membranes (prom)?

Answer 139

Rupture of foetal membranes at least one hour prior to the onset of labour in over 37 weeks gestation pregnancies

Question 140

How common is premature rupture of membranes?

Answer 140

10-15% term pregnancies

Question 141

Define preterm premature rupture of membranes (p-prom)

Answer 141

rupture of membranes at least one hour prior to onset of labour in under 37 weeks of gestation pregnancies

Question 142

Incidence of preterm premature rupture of membranes

Answer 142

Associated with 40% preterm deliveries

Question 143

What comprises foetal membranes?

Answer 143

chorion and amnion

Question 144

What can cause premature rupture of membranes?

Answer 144

Early activation of normal physiological processes (enzymes) Infection (inflammatory markers weaken the membranes) Genetic predisposition

Question 145

Risk factors for premature rupture of membranes?

Answer 145

Smoking, previous PROM, vaginal bleeding, lower genital tract infection, invasive procedures eg amniocentesis, polyhydramnios, multiple pregnancy, cervical insufficiency

Question 146

Presentation of premature rupture of membranes?

Answer 146

"broken waters"- painless popping sensation then gush of watery fluid or non specific eg gradual leakage

Question 147

Management of suspected premature rupture of membranes?

Answer 147

Speculum exam- pooling in posterior vaginal fornix (need to lie down for at least 30 mins to see this) Avoid digital vaginal examination until active labour High vaginal swab- if GBS then start clindamycin/penicillin during labour

Question 148

Complications of premature rupture of membranes?

Answer 148

Chorioamnionitis, oligohydramnios, neonatal death, placental abruption, umbilical cord prolapse

Question 149

Commonest associations with placental insufficiency and low birthweight?

Answer 149

DM, htn, clotting disorders, anaemia, medications especially blood thinners, smoking, drug abuse especially cocaine/heroin/methamphetamine, placental poor attachment or placental abruption

Question 150

Risk of placental insufficiency - to mum? - to baby?

Answer 150

``` Mum= preeclampsia, placental abruption, preterm labour and delivery Baby= greater risk of o2 deprivation, hypothermia, hypoglycaemia, hypocalcaemia, polycythaemia, premature, c-section, stillbirth, death ```

Question 151

What is a miscarriage? | 2 types?

Answer 151

Loss of pregnancy before 24 weeks gestation Early miscarriage= more common- 1st trimester (before 12-13 weeks) Late miscarriage=13-24 weeks

Question 152

How common is miscarriage?

Answer 152

Very! 20-25% of pregnancies

Question 153

Risk factors for miscarriage?

Answer 153

Over 30, previous miscarriage, obesity, chromosomal abnormalities, smoking, uterine anomalies, previous uterine surgery, anti-phospholipid syndrome, coagulopathies

Question 154

Presentation of suspected miscarriage?

Answer 154

Vaginal bleeding, cramping pain, incidental finding on USS | Positive pregnancy test and bleeding +/- pain

Question 155

Investigations for suspected miscarrage?

Answer 155

Transvaginal USS is 1st line | Serum b-HCG if us not available

Question 156

Management of miscarriage?

Answer 156

If late miscarriage- need anti- D prophylaxis if rh neg Conservative/expectant=allow to pass naturally Medical=vaginal misoprostol (prostaglandin analogue- stimulates cervical ripening and contractions) Surgery= manual vacuum aspiration if early miscarriage or for evacuation of retained products of conception

Question 157

Classification of miscarriages?

Answer 157

Threatened, inevitable, missed, incomplete, complete, septic

Question 158

Describe a threatened miscarriage

Answer 158

Mild bleeding +/- pain, cervix close - still a viable pregnancy

Question 159

Describe an inevitable miscarriage

Answer 159

Heavy bleeding, clots, pain, cervix open- internal cervical os opened Foetus viable or non viable

Question 160

Describe a missed miscarriage

Answer 160

Asx or hx of threatened miscarriage, ongoing discharge, small for dates uterus

Question 161

Describe an incomplete miscarriage

Answer 161

Products of conception partially expelled, sxs of missed miscarriage or bleeding/clots

Question 162

Describe a septic miscarriage

Answer 162

Infected POC: fever, rigors, uterine tenderness, bleeding/discharge, pain

Question 163

Define recurrent miscarriage

Answer 163

At least 3 consecutive pregnancies with miscarriage

Question 164

What is gestational diabetes?

Answer 164

Any degree of glucose intolerance with onset of first recognition during pregnancy

Question 165

Why does gestational diabetes occur?

Answer 165

Progressive insulin resistance in pregnancy and insulin requirements rise by 30% during pregnancy A borderline pancreatic reserve is unable to respond to higher requirements and causes transient hyperglycaemia (insulin resistance falls after pregnancy)

Question 166

RFs for gestational diabetes?

Answer 166

BMI over 30, asian, previous gestational dm, 1st degree relative with dm, PCOS, previous macrosomic baby (pver 4.5kg)

Question 167

How would gestational diabetes present? What investigation

Answer 167

Px= asx or DM sxs eg polyuria/dipsia and fatigue | Ix=OGTT

Question 168

How to manage gestational diabetes?

Answer 168

Lifestyle advice, capillary glucose measurements qds, may need metformin (glibenclamide 2nd line) or insulin Deliver at 37-38 weeks if on treatment Stop treatment immediately after delivery then 6-13 weeks later do a fasting glucose test to confirm transience

Question 169

Foetal complications of gestational diabetes

Answer 169

Macrosomia, organomegaly, erythropoiesis, polyhydramnios, increased rate of pre-term delivery Neonatal hypoglycaemia

Question 170

Pathophysiology of pre-eclampsia

Answer 170

Incomplete remodelling of spiral arteries causes a high resistance low flow uteroplacental circulation (the constrictive muscular walls are maintained) Increased BP, hypoxia and oxidative stress leads to inadequate uteroplacental perfusion causing a systemic inflammatory response and endothelial cell dysfunction

Question 171

Risk factors for pre-eclampsia? 3 moderate and 3 high

Answer 171

``` Moderate= nuliparity, over 39 years, BMI at least 35, FH, pregnancy interval over 10 years, multiple pregnancy High= chronic htn, htn/pre-eclampsia/eclampsia in previous pregnancy, CKD, DM, autoimmune diseases ```

Question 172

How to do and who to consider prophylaxis for pre-eclampsia?

Answer 172

75mg aspirin/day from 12 weeks to birth | In women with at least 1 high or at least 2 moderate risk factors

Question 173

Pre-eclampsia potential features

Answer 173

hypertension (2 occasions at least 4 hours apart, over 140/90) significant proteinuria over 20 weeks gestation

Question 174

How does pre-eclampsia present?

Answer 174

Asx, frontal headaches, visual disturbance, epigastric pain, hyperreflexia, sudden onset non-dependent oedema

Question 175

Classification of pre-eclampsia

Answer 175

Mild= 140/90-149/99 Mod=150/100-159/109 Severe= at least 160/110 and proteinuria or at least 140/90+sxs+proteinuria

Question 176

Does pre-eclampsia resolve?

Answer 176

Yes, following placental delivery

Question 177

Management of pre-eclampsia?

Answer 177

Monitoring, VTE prevention, antihypertensives= labetalol (1st line), also nifedipine/methyldopa, delivery! After delivery, monitor BP for 2 days then once every 3-5 days

Question 178

Maternal complications of pre-eclampsia?

Answer 178

HELLP syndrome (haemolysis, elevated liver enzymes, low plateletes), eclampsia, aki, dic, ards, htn, stroke, death

Question 179

What is eclampsia?

Answer 179

Pre-eclampsia and convulsions | Obstetric emergency

Question 180

Presentation of eclampsia?

Answer 180

Most seizures occur in postnatal period New onset tonic clonic type seizure, lasting about 60-75 seconds with variable post ictal period S+Ss relating to end organ dysfunction

Question 181

Foetal complications of eclampsia?

Answer 181

Intrauterine growth restriction, prematurity, IRDS, foetal death, placental abruption

Question 182

How to manage eclampsia?

Answer 182

Resuscitation Seizure cessation with magnesium sulfate BP control with labetalol and hydralazine Prompt delivery via C section after mother stabilised Postpartum and postnatal monitoring and follow up

Question 183

Why might people with essential hypertension prior to pregnancy not need treatment during their pregnancy?

Answer 183

Physiological drop in BP during pregnancy, so may even get hypotension, or sustain BP below 110/70

Question 184

What is target BP during pregnancy?

Answer 184

Less than 135/85

Question 185

How to manage essential hypertension during pregnancy?

Answer 185

Stop ACEi/ARB and start labetalol (1st line) Nifedipine (2nd line), methyldopa (3rd line) From 12 weeks onwards 75-150mg aspirin daily

Question 186

What is placenta praevia? 2 types?

Answer 186

Placenta fully or partially attached to lower uterine segment Minor= low placenta, but doesn't cover internal cervical os Major= placenta lies over internal cervical os

Question 187

RFs for placenta praevia?

Answer 187

Previous C-section (higher risk with greater number), high parity, age over 40, multiple pregnancy, PMH, endometritis

Question 188

How does placenta praevia present?

Answer 188

Painless vaginal bleeding

Question 189

Causes of antenatal haemorrhage?

Answer 189

Placental abruption, placenta praevia, vasa praevia, uterine rupture, local genital causes

Question 190

How to manage placenta praevia?

Answer 190

ABCDE If incidental finding at 20 week scan; minor= repeat scan at 36 weeks, major=repeat scan at 32 weeks C-section=safest mode of delivery (38 weeks for major) Anti-D within 72 hours of onset of bleeding to Rh neg mother

Question 191

What is placenta accreta?

Answer 191

Placenta grows too deeply into uterine wall and part/all of placenta remains attached after childbirth- can cause severe haemorrhage

Question 192

What is placenta percreta?

Answer 192

Placenta grows through the uterine wall

Question 193

RFs for placenta accreta?

Answer 193

Previous C section, low placental position, maternal age, increased number if pregnancies

Question 194

Management of placenta accreta?

Answer 194

Confirm on MRI | C-section at 36 weeks and hysterectomy (helps to prevent haemorrhage if there's an attempt to separate placenta)

Question 195

What is placenta increta?

Answer 195

Placenta invades into muscles of uterus (form of placenta accreta)

Question 196

What is placental abruption? Why does it occur?

Answer 196

Part/all of placenta separates from uterine wall prematurely (cause of antenatal haemorrhage) Due to rupture of maternal vessels within basal layer of endometrium- blood accumulates and splits the placental attachment

Question 197

2 types of placental abruption?

Answer 197

Revealed- blood drains through the cervix | Concealed- bleeding remains within uterus causing a retroplacental clot

Question 198

RFs for placental abruption?

Answer 198

PMH (most predictive factor), pre-eclampsia/htn, abnormal lie of baby, polyhydramnios, abdo trauma, smoking, drugs, bleeding in 1st trimester, thrombophilia, multiple pregnancy

Question 199

Presentation of placental abruption?

Answer 199

Painful bleeding

Question 200

Management of placental abruption?

Answer 200

ABCDE Emergency delivery due to maternal and/or foetal compromise Induction of labour Conservative Anti-D if applicable within 72 hours of bleeding onset

Question 201

How to reduce the risk of a retained placenta?

Answer 201

Use active management in third stage of labour with syntocinon

Question 202

Presentation of retained placenta?

Answer 202

Fever, badly smelling discharge, heavy bleeding, pain

Question 203

Management of retained placenta?

Answer 203

Empty bladder/change position Pull on umbilical cord Surgery to scrape it away

Question 204

What is uterine rupture? Two types

Answer 204

Obstetric emergency: Full thickness disruption of uterine muscle and overlying serosa, typically during labour, can extend to affect bladder or broad ligament Incomplete= intact peritoneum over uterus, uterine contents remain in uterus Complete= torn peritoneum, uterine contents can escape into peritoneal cavity

Question 205

RFs for uterine rupture?

Answer 205

Previous C-section/uterine surgery, induction, obstruction of labour, multiple pregnancy, multiparity

Question 206

Presentation of uterine rupture?

Answer 206

Non specific | Sudden, severe abdo pain persisting between contractions, may have vaginal bleeding

Question 207

Management of uterine rupture?

Answer 207

ABCDE Emergency C section and uterus repair or hysterectomy (decision-incision interval should be less than 30 mins)

Question 208

What is cervical show?

Answer 208

Small amount of bleeding from vagina caused by rupture of small blood vessels in cervix due to contractions- slow cervical dilatation Part of labour

Question 209

What is vasa praevia?

Answer 209

Foetal blood vessels run near/over internal cervical os- likely to rupture in active labour as unprotected by placental tissue or wharton's jelly of umbilical cord

Question 210

How does vasa praevia present?

Answer 210

Vaginal bleeding (fresh red blood), rupture of membranes and foetal compromise

Question 211

How to manage vasa praevia?

Answer 211

Emergency C sections | Improved mortality rates if picked up on USS and using a planned C section

Question 212

What differentiates antepartum haemorrhage from miscarriage?

Answer 212

Timing Miscarriage= before 24 weeks Antepartum haemorrhage= bleeding from birth canal after 24th week of pregnancy until second stage of labour complete

Question 213

Causes of antepartum haemorrhage?

Answer 213

Major ones= placenta praevia and placental abruption | Also= local causes (infection, trauma, tumours), vasa praevia, uterine rupture, inherited bleeding problems

Question 214

How to differentiate placenta praevia from placental abruption clinically?

Answer 214

Both=bleeding Pain=abruption Painless=praevia

Question 215

What volume of blood for minor antepartum haemorrhage?

Answer 215

Blood loss less than 50ml and stopped

Question 216

What constitutes major anterpartum haemorrhage?

Answer 216

50-1000ml blood loss with no signs of shocks

Question 217

What constitutes massive antepartum haemorrhage?

Answer 217

Over 1000ml blood loss and/or signs of shock

Question 218

Management of antepartum haemorrhage?

Answer 218

ABCDE DO NOT attempt vaginal examination Consider delivery Urgent USS, foetal monitoring (CTG), anti-D if indicated

Question 219

Minor and major primary post partum haemorrhages?

Answer 219

``` Minor= 500-1000ml within 24 hours Major= over 1000ml within 24 hours delivery or signs of shock ```

Question 220

Two broad groups of causes of post partum haemorrhage?

Answer 220

Primary and secondary

Question 221

Primary causes of post partum haemorrhage?

Answer 221

Four Ts= tone (uterine atony, distended bladder), trauma, tissue (retained placenta or clots), thrombin (coagulopathy) Most common=uterine atony then retained placenta

Question 222

Secondary causes of post partum haemorrhage?

Answer 222

infection (endometritis) or retained products of conception, subinvolution of placental implantation site, pseudoaneurysms, AV malformation

Question 223

How to manage post partum haemorrhage?

Answer 223

``` Resuscitation 2 14/16 G cannulas Crystalloid infusion for minor Blood transfusion for major Catheterise Cross match or O neg If uterine atony is cause- fundal rub, bimanual uterine compression to stimulate contraction, oxytocin, ergometrine, carboprost, misoprostol If medical management not working then surgery Antibiotics for endometritis ```

Question 224

What is sheehan's syndrome?

Answer 224

In women who lose life threatening amount of blood in childbirth or have severely low BP, causes hypoxia which causes pituitary gland damage and subsequent HYPOPITUITARISM

Question 225

How does sheehan's syndrome present?

Answer 225

Presents slowly over months/years, but may also have inability to breastfeed S+Ss: a/oligomenorrhoea, slowed mental function, weight gain, hypothyroid, low bp, low glucose, fatigue, irregular HR, breast shrinkage

Question 226

Complications of sheehan's syndrome?

Answer 226

Adrenal crisis, hypotension, unintended wt loss, menstrual irregularities

Question 227

Management of sheehan's syndrome?

Answer 227

Lifelong hormone replacement eg corticosteroids, levothyroxine, oestrogen, GH

Question 228

When do baby blues occur?

Answer 228

During first week after childbirth, last for only a few days

Question 229

Timing of post-partum depression?

Answer 229

Depressive episode within first 12 months postpartum. Peak incidence during first 2 months

Question 230

Presentation of post partum depression?

Answer 230

Similar to symptoms of regular depression, negative cognitions about motherhood, anxiety surrounding baby

Question 231

Management of post partum depression?

Answer 231

Social support and psychological therapies | If not breastfeeding can use SSRI as usual, if breastfeeding need to weigh up risk benefit ratio with patient

Question 232

Timing of puerperal psychosis?

Answer 232

Can develop rapidly over a few hours and starts within days-weeks of delivery

Question 233

Who is puerperal psychosis more common in?

Answer 233

Those with bipolar affective disorder or other psychotic illness history. Those with previous postpartum psychosis have 50% chance of recurrence in next pregnancy FH links NB/ can develop in women with no past psychiatric history too

Question 234

How to manage puerperal psychosis?

Answer 234

Most nee to be treated under MHA | Antipsychotic and/or mood stabiliser

Question 235

Prognosis of puerperal psychosis?

Answer 235

Good! Most take 6-12 months to recover fully Earlier diagnosis and intervention improves prognosis further

Question 236

Causes of puerperal infection?

Answer 236

Most= staph and strep | Highest risk in non-scheduled C section

Question 237

What is the leading cause of maternal mortality

Answer 237

VTE in pregnancy (about 1/3 of maternal deaths)

Question 238

Why is there increased risk of VTE in pregnancy?

Answer 238

Changes in protein levels in clotting cascade- increased fibrinogen and decreased protein S Changed more pronounced as pregnancy progresses (highest risk is post partum)

Question 239

RFs for VTE in pregnancy?

Answer 239

Pre-existing RFs: thrombophilia, medical co-morbidities, age over 35, BMI over 30, parity over 3, smoking, varicose veins, paraplegia Obstetric RFs: multiple pregnancy, pre-eclampsia, c-section, prolonged labour, stillbirth, preterm, PPH

Question 240

What investigations for VTE in pregnancy?

Answer 240

Bloods, compression duplex USS, ECG, CXR then CTPA or V/Q scan NB/ d-dimer raised anyway in pregnancy so don't test this

Question 241

Management of VTE in pregnancy?

Answer 241

LMWH throughout pregnancy until 6-12 weeks post partum DON'T use warfarin as teratogenic Prophylaxis if at least 4 RFs during assessment with LMWH

Question 242

How would amniotic fluid embolism present?

Answer 242

Acutely- hypoxia, resp arrest, hypotension, foetal distress, seizures, shock, confusion, cardiac arrest, DIC

Question 243

How is a definitive diagnosis of amniotic fluid embolism made?

Answer 243

On post mortem- foetal squamous cells and debris in pulmonary vasculature

Question 244

Levels of Hb for anaemia diagnosis in different trimesters?

Answer 244

First: Hb<110g/L Second/third: Hb<105g/L Postpartum: Hb<100g/L

Question 245

Why is anaemia likely in pregnancy?

Answer 245

In pregnancy, plasma volume and RBC mass increase but plasma volume increases disproportionately, so there is a haemodilution effect

Question 246

When do you screen for anaemia in pregnancy?

Answer 246

Screen at booking visit and at 28 weeks | Need to add in 20-28 week screen for multiple pregnancies

Question 247

Management of anaemia in pregnancy?

Answer 247

Trial of oral iron (1st line management and diagnostic test) | or folate supplementation

Question 248

When does rhesus disease of the newborn occur and why?

Answer 248

In rhesus negative mums with rhesus positive foetuses Mum is sensitised to rh positive blood and then produces antibodies which will come into effect on second exposure Antibodies cross the placenta and attack the foetal RBCs

Question 249

How will rhesus disease of the newborn/haemolytic disease of foetus and newborn present?

Answer 249

Haemolytic anaemia, jaundice, may have hypotonia, lack of energy Symptoms may not develop until a few months of age

Question 250

What tests can be used to determine if there will be haemolytic disease of foetus?

Answer 250

``` Kleihauer test (see if foetal blood in maternal circulation) Rosette test (incubate rh neg maternal sample with anti-Rh) ```

Question 251

How to prevent/decrease risk of haemolytic disease of newborn?

Answer 251

Anti-D to mum and monitoring

Question 252

UTI in pregnancy, which abx?

Answer 252

Nitrofurantoin is 1st line, but should be avoided at term: 100mg bd 1/52 2nd line= amoxicillin 500mg tds 1/52 or cefalexin 500mg bd 1/52

Question 253

What percentage of pregnant women carry GBS?

Answer 253

25%

Question 254

What can GBS cause? Name of pathogen

Answer 254

S. agalactiae | Can cause GBS disease of newborn, chorioamnioitis, endometritis

Question 255

How does chorioamniotis present?

Answer 255

Fevers, lower abdo tenderness, foul discharge, tachycardia

Question 256

How does endometritis present?

Answer 256

Fevers, lower abdo pain, intermenstrual bleeding, foul discharge

Question 257

How will a neonatal GBS infection present?

Answer 257

Pyrexia, cyanosis, resp difficulties, floppiness

Question 258

How to prevent poor outcomes in GBS positive women?

Answer 258

IV penicillins throughout labour in women (if GBS positive, UTI by GBS, previous baby with GBS, pyrexia during labour, premature, rupture membranes over 18 hours)

Question 259

When is management for GBS not indicated?

Answer 259

Elective C-section- as no rupture of membranes

Question 260

What are the risks of having a gonorrhoea infection during pregnancy?

Answer 260

Perinatal mortality, spontaneous abortion, premature labour, early foetal membrane rupture, vertical transmission causing conjunctivitis in foetus- which if untreated can cause long term blindness and damage

Question 261

What is cephalopelvic disproportion?

Answer 261

Mismatch between size of foetal head and maternal pelvis causing a difficulty in safe passage through the birth canal

Question 262

How to classify cephalopelvic disproportion? Examples for each

Answer 262

``` Absolute CPD=true obstruction- permanent/maternal factors (contracted pelvis, pelvic exostoses, spondylolisthesis, tumours) or temporary/foetal factors (hydrocephalus, macrosomia) Relative CPD (brow/face presentations, occipitoposterior positions, deflexed head) ```

Question 263

Most common cause of cephalopelvic disproportion?

Answer 263

Contracted pelvis with average sized infant

Question 264

Management of cephalopelvic disproportion?

Answer 264

Depends when discovered May have planned C section May trial a vaginal delivery

Question 265

What can cause a hypoactive uterus/uterine inertia?

Answer 265

Premature labour, multiple pregnancy: over distension, psychology, contracted pelvis/malpresentation/deflexed head, full bladder, loaded rectum, hypertensive, anaemia/chronic illness, uterine fibroid Primary or secondary inertia (after a period of good contraction)

Question 266

Complications of uterine inertia?

Answer 266

Prolonged labour, distress, increased risk of infection, PPH

Question 267

Management of uterine inertia?

Answer 267

Empty bladder and bowels, oxytocin, may need C section, can use instrumental delivery if head low enough

Question 268

Define obstructed labour?

Answer 268

Labour dystocia- baby doesn't exit pelvis due to being physically blocked despite the uterus contracting normally

Question 269

Causes of obstructed labour?

Answer 269

cephalopelvic disproportion due to small pelvis/large baby/foetal malpresentation/tight perineum/abnormalities

Question 270

Complications of obstructed labour?

Answer 270

Foetal anoxia, pressure necrosis, foetal death, vesicovaginal fistula

Question 271

Management of obstructed labour?

Answer 271

Prevention is key! | Mode of delivery chosen on a case by case basis- episiotomy, ventouse, forceps, symphysiotomy, C section

Question 272

How can shoulder dystocia occur?

Answer 272

After delivery of head, anterior shoulder becomes impacted on maternal pubic symphysis (more common) or posterior shoulder impacted on sacral promontory

Question 273

RFs for shoulder dystocia?

Answer 273

Pre-labour RFs: previous event, macrosomia, diabetes, BMI over 30, induction of labour Intrapartum RFs: prolonged 1st stage of labour, secondary arrest, prolonged 2nd stage, augmentation with oxytocin, assisted vaginal delivery

Question 274

Ultimate complication of shoulder dystocia? | Other complications

Answer 274

Delay in delivery of foetal shoulders causes hypoxia (proportional to time delay) Others=tears (3rd and 4th degree), PPH, foetal fracture, brachial plexus injury

Question 275

Signs of shoulder dystocia?

Answer 275

``` Failure of restitution (foetus doesn't turn to look to the side) Turtle neck (head retracts back into pelvis and neck no longer visible) ```

Question 276

Management of shoulder dystocia?

Answer 276

Stop pushing Avoid downwards traction on foetal head (risk of brachial plexus injury) Consider episiotomy Use manoeuvres: McRoberts (hyperflex maternal hips and stop pushing, 90% success rate), suprapubic pressure (sustained or rocking fashion to apply pressure behind anterior shoulder) Other 2nd line manoeuvres= internal rotation or posterior arm

Question 277

What is cord prolapse and types of it?

Answer 277

Umbilical cord descends through cervix with/before presenting part of foetus Occult (incomplete-with foetus but not beyond) Overt (complete-lower than presenting part in pelvis)

Question 278

Why does a prolapsed cord cause foetal hypoxia?

Answer 278

Occlusion of umbilical cord and arterial vasospasm due to cold exposure

Question 279

RFs for cord prolapse?

Answer 279

Breech presentation, unstable lie, artificial rupture of membranes, polyhydramnios, prematurity, PROM, long cord, multiple pregnancy

Question 280

How to manage cord prolapse?

Answer 280

Avoid handling of cord to reduce vasospasm, manually elevate the presenting part, encourage into left lateral position, consider tocolysis (stop contraction), emergency C-section/quickest mode of delivery

Question 281

What is lie of foetus? What are potential lies of the foetus? what's normal?

Answer 281

Lie=relationship between long axis of foetus and mother Longitudinal, transverse, oblique Longitudinal is lie if the right way up!

Question 282

What is presentation of the foetus? What types?

Answer 282

``` Presentation= foetal part that first enters the maternal pelvis Cephalic vertex (most common and safest), breech, shoulder, face, brow ```

Question 283

What is foetal position? What types?

Answer 283

Position of foetal head as it exits birth canal | Occipito-anterior (ideal), occipito-posterior or occipito-transverse

Question 284

How to manage abnormal foetal lie?

Answer 284

External cephalic version (ECV) between 36 and 38 weeks to manipulate foetus to a cephalic presentation through maternal abdomen

Question 285

Who can't you do ECV in?

Answer 285

Recent APH, ruptured membranes, uterine abnormalities, previous C section

Question 286

How to manage abnormal foetal position?

Answer 286

90% of malpositions spontaneously rotate as labour progresses If not, rotation and operative vaginal delivery or C section

Question 287

How to manage malpresentations?

Answer 287

Brow or shoulder- need C section | Face : if chin anterior can have normal labour, but likely to be prolonged, if chin posterior need C section

Question 288

Types of breech presentation?

Answer 288

Complete (flexed, cross legged appearance) Frank (extended- flexed at hip and extended at knee)- most common Footling (extended at knees)

Question 289

Management of breech presentation?

Answer 289

About 28% babies breech at 28 weeks but only 3% at term, use USS to confirm diagnosis ECV, if unsuccessful then C-section (vaginal breech birth can be attempted but requires specific manoeuvres)

Question 290

Complications of breech presentation?

Answer 290

Cord prolapse, foetal head entrapment, prem rupture of membranes, birth asphyxia, intracranial haemorrhage

Question 291

Types of instrumental delivery/operative vaginal delivery?

Answer 291

Forceps | Ventouse (silastic cup for occipito-anterior or kiwi cup for any position)

Question 292

Indications for instrumental delivery?

Answer 292

Inadequate progress, maternal exhaustion, maternal conditions where prolonged exertion should be limited, suspected foetal compromise, any clinical concerns

Question 293

When should you stop using instrumental delivery?

Answer 293

After 3 contractions and pulls with any instruments with no reasonable progress, should abandon attempt

Question 294

Pros and cons of ventouse?

Answer 294

Lower success rate, increased foetal injury eg retinal haemorrhage, must be over 34 weeks to attempt Lower incidence of maternal injuries, less pain

Question 295

Pros and cons of forceps?

Answer 295

Higher success rate, no maternal effort required | Higher rate of tears

Question 296

Contraindications to instrumental delivery?

Answer 296

Incomplete dilation, true CPD, breech/face/brow presentation, can't be under 34 weeks for ventouse

Question 297

Potential complications of instrumental delivery?

Answer 297

Jaundice, lacerations, haematoma, facial nerve damage, fractures, tears, VTE, incontinence, PPH, shoulder dystocia, infection

Question 298

What is polyhydramnios?

Answer 298

Amniotic fluid above 95th centile for gestational age

Question 299

Causes of polyhydramnios?

Answer 299

Idiopathic in 50-60% Other cases= foetal swallow prevention, duodenal atresia, anaemia, foetal hydrops, twin-twin transfusion syndrome, increased lung secretions, genetic abnormalities, maternal diabetes, maternal lithium ingestion, macrosomia, some TORCH infections

Question 300

How to diagnose polyhydramnios or oligohydramnios?

Answer 300

On USS using either amniotic fluid index or maximum pool depth

Question 301

Management of polyhydramnios?

Answer 301

Most don't need management, good prognosis | May consider amnioreduction or indomethacin (enhances water retention)

Question 302

What is oligohydramnios?

Answer 302

Low level of amniotic fluid, less than the 5th centile for gestational age

Question 303

What causes oligohydramnios?

Answer 303

Anything that reduces production of urine, blocks output from foetus, or ruptures the membranes Main causes= preterm premature rupture of membranes, placental insufficiency, renal agenesis (Potter's syndrome), non functioning foetal kidneys, obstructive uropathy, genetic/chromosomal anomalies, viral infections

Question 304

What test to do if considering ruptured membranes as the cause of oligohydramnios?

Answer 304

IGFBP-1 in vagina (bedside test)

Question 305

How to manage oligohydramnios?

Answer 305

Manage underlying cause Ruptured membranes- labour likely to commence within 24-48 hours, consider induction, need steroids and abx Placental insufficiency- likely to be delivered before 36/37 weeks

Question 306

Prognosis of oligohydramnios in 2nd trimester?

Answer 306

Poor | Decreased amniotic fluid means decreased foetal movements, which causes muscle contractures

Question 307

Pathophysiology of pubic symphysial dysfunction?

Answer 307

Physiological pelvic ligament relaxation and increased joint mobility in pregnancy causes discomfort and pain in pelvic area, may radiate to upper thighs and perineum Joint sufficiently relaxed to allow instability in pelvic girdle- excessive movement of pubic symphysis in anterior or lateral direction

Question 308

What other factors apart from pregnancy itself can contribute to pubic symphysial dysfunction?

Answer 308

Strenuous work during pregnancy, weight gain, multiparity, increasing age, history of difficult deliveries

Question 309

Presentation of pubic symphysial dysfunction?

Answer 309

PAIN- variable, usually relieved by rest, disappears commonly after giving birth LOCOMOTOR difficulties- walking, stairs, chairs, weight bearing activities, turning in bed, standing on one leg

Question 310

How to manage pubic symphysial dysfunction?

Answer 310

Analgesia (paracetamol) then after delivery can use NSAIDs | Weight-bearing aids, physio and exercise

Question 311

Most common cause of intrauterine growth restriction? Consequences of IUGR?

Answer 311

Placental insufficiency | Consequences: lack of oxygen at birth, premature labour, hypoglycaemia, hypocalcaemia, stillbirth, increased RBC

Question 312

When is booking appointment and what happens there?

Answer 312

8-12 weeks | Provide info, decide care plan, BP, BMI, urine, identify any risks, screen for vulnerabilities

Question 313

When do multiparous women have appointments in antenatal schedule?

Answer 313

GP contact, 8-12 week booking and 8-14 week dating scan | 16 weeks, 20 week anomaly scan, 28 weeks, 34 weeks, 36 weeks, 38 weeks

Question 314

What extra appointments do nulliparous women get in antenatal schedule?

Answer 314

25 weeks, 31 weeks, 40 weeks

Question 315

What sorts of things are done in antenatal schedule?

Answer 315

(Sickle cell/thalassaemia screening offered before 10 weeks) BP, urine, screening, measure uterus, care plan, any anti-D injections, information giving, checking position of foetus, ECV if required

Question 316

What may be discussed at 41 week appointment?

Answer 316

Offer a membrane sweep, discuss induction

Question 317

What is looked at in the 20 week/anomaly scan?

Answer 317

Looks at bones, heart, brain, spinal cord, face, kidneys, abdomen and can determine sex

Question 318

What 11 conditions does the 20 week scan look for?

Answer 318

Anencephaly, open spina bifida, cleft lip, diaphragmatic hernia, gastroschisis, exophthalmos, serious cardiac abnormalities, bilateral renal agenesis, lethal skeletal dysplasia, Edward's syndrome (trisomy 18), Patau's syndrome (trisomy 13)

Question 319

How are the trisomies screened for?

Answer 319

Combined test (USS and blood test) then nuchal translucency measurement at 12 week scan For trisomy 21, can do quadruple blood screening test iif combined not done- done at 14-20 weeks

Question 320

At what point is routine anti-D prophylaxis given?

Answer 320

28 and 34 weeks

Question 321

Different types of breast cancer?

Answer 321

Ductal carcinoma in situ, invasive lobular carcinoma, angiosarcoma, inflammatory breast cancer, lobular carcinoma in situ, male breast cancer, Paget's disease of the breast, recurrent breast cancer

Question 322

How will breast cancer present?

Answer 322

Lump/thickening, change in size/shape/appearance, skin changes, newly inverted nipple, peeling/scaling/crusting of areola or breast, redness or pitting

Question 323

RFs for breast cancer?

Answer 323

BRCA1/2, female, increasing age, history of breast condition, previous breast cancer, family history, genes, radiation exposure, obesity, puberty under 12, menopause over 55, first child at older age, nulliparous, postmenopausal HRT, alcohol

Question 324

What is involved in triple assessment of breast cancer?

Answer 324

Breast examination Mammogram/USS Biopsy

Question 325

How is breast cancer managed?

Answer 325

Depends on stage and prognosis Surgery (lumpectomy, mastectomy, sentinel node biopsy, axillary LN dissection, prophylactic mastectomy) Radiation, chemo, hormone therapy

Question 326

What hormone therapies may be used in breast cancer?

Answer 326

Selective oestrogen receptor modulators/SERMs eg tamoxifen Aromatase inhibitors eg anastrozole Surgery/medication to suppress ovaries

Question 327

When is breast screening undertaken?

Answer 327

Every 3 years between 50 and 70 years

Question 328

When are implants allowed on the NHS?

Answer 328

Severe asymmetry or amastia

Question 329

2 types of breast implants with pros/cons

Answer 329

Silicone- most common, less likely to rupture, more natural, can spread into breast and cause lumps Saline- more likely to fold/rupture/go down over time, but will be absorbed safely into the body

Question 330

What is the earliest form of breast cancer?

Answer 330

In situ carcinoma- abnormal cells inside milk duct

Question 331

Presentation of paget's disease of the nipple

Answer 331

Flaky/scaly nipple, crusting/oozing/hardened skin, itch, erythema, tingling/burning sensation, inverted/flattened nipple, lump Usually unilateral

Question 332

3 common benign breast lumps?

Answer 332

Breast abscess, cysts, fibroadenoma (most common)

Question 333

Two kinds of breast abscess?

Answer 333

Lactational-peripheral region of breast, commonly upper and outer quadrant Non lactational-central/subareolar or lower quadrants

Question 334

Risk factors for breast abscess?

Answer 334

Previous mastitis, immunosuppressed, S. aureus carriage, poor hygiene

Question 335

How will breast abscesses present?

Answer 335

Recent history mastitis or previous abscess, fever, general malaise, painful swollen lump, inflammatory signs Lump may be fluctuant with skin discolouration

Question 336

How to manage breast abscess?

Answer 336

Diagnose by USS. | Drainage then culture fluid to guide abx choice, advise lactating women to continue breastfeeding

Question 337

How do breast cysts present?

Answer 337

Smooth and mobile, round/oval lump May have nipple discharge (clear/yellow/brown) Pain/tenderness over area Increased size/tenderness just before period Symptoms improve after period

Question 338

Do breast cysts require treatment?

Answer 338

Generally no

Question 339

Different types of fibroadenoma?

Answer 339

Simple, complex, juvenile, giant (over 2 inches), phyllodes tumour (risk of becoming malignant)

Question 340

How does a fibroadenoma present?

Answer 340

Most often in 15-35 year olds Round, distinct smooth borders, easily moved, firm or rubbery, painless lump Lumps can become bigger during pregnancy/use of hormone therapy, might shrink after menopause

Question 341

What swabs in double swab? Triple swab?

Answer 341

``` Double= NAAT then high vaginal charcoal media Triple= NAAT, then high vaginal charcoal media and endocervical charcoal media swab ```

Question 342

What does NAAT swab detect for? Where to swab?

Answer 342

Swab endocervical or vulvovaginal | Detects chlamydia and gonorrhoea

Question 343

What does a charcoal media swab detect? Where to swab?

Answer 343

High vaginal swab | Detects BV, trichomonas vaginalis, candida, GBS

Question 344

RFs for vulvovaginal candidiasis?

Answer 344

Pregnancy, diabetes, broad spectrum abx, corticosteroids, immunocompromised

Question 345

How does thrush present?

Answer 345

Pruritus vulvae, discharge (white, curd like, non offensive), dysuria (superficial), erythema and swelling of vulva, satellite lesions (red, pustular with superficial white/creamy pseudomembranous plaques that can be scraped off)

Question 346

How to manage thrush?

Answer 346

No need to investigate if uncomplicated Initial pessary antifungal eg clotrimazole (pregnancy= only option, don't use oral) Consider oral antifungal eg fluconazole Topicla imidazole in conjunction to address vulval symptoms If symptoms persisting over 7-14 days, need to review If recurrent/ complicated- need vaginal smear and microscopy

Question 347

Organism causing chlamydia? Incubation period?

Answer 347

Chlamydia trachomatis (bacterium). 7-21 days incubation

Question 348

Presentation of chlamydia?

Answer 348

70% women asymptomatic, 50% men asx Dysuria, abnormal discharge, intermenstrual/postcoital bleeding, dyspareunia, lower abdo pain, cervicitis +/- contact bleeding, mucopurulent endocervical discharge, pelvic tenderness, cervical excitation

Question 349

Investigations for chlamydia?

Answer 349

National screening for sexually active under 25s | Vulvovaginal swab then for NAAT (endocervical swab or 1st urine catch are 2nd line alternatives)

Question 350

How to manage chlamydia?

Answer 350

Doxycyline orally 100mg bd for 1 week or stat azithromycin 1g Avoid sex until treatment completed, partner tracing

Question 351

How does bacterial vaginosis present?

Answer 351

50% asx, offensive fishy smelling discharge, not usually associated with irritation Thin, white grey discharge. Increased vaginal pH

Question 352

Pathophysiology of BV?

Answer 352

some disturbance in natural vaginal flora, causes a decrease in lactobacilli. This increases the pH and allows a polymicrobial infection- especially Gardnerella vaginalis, anaerobes and mycoplasma

Question 353

RFs for BV?

Answer 353

sex, IUD, receptive oral sex, STI present, douching, recent abx, smoking, black

Question 354

Investigating for BV?

Answer 354

High vaginal smear and microscopy Can do vaginal pH over 4.5 Can do KOH whiff test (alkali added causing strong fishy odour)

Question 355

Management for BV?

Answer 355

oral metronidazole 400mg bd for 5-7 days or stat 2g | Can use topical gel

Question 356

What causes trichomoniasis?

Answer 356

Curable STI by protozoan Trichomonas vaginalis

Question 357

Presentation of trichomoniasis?

Answer 357

Commonly asx, offensive vaginal odour, abnormal discharge (yellow-green), vulval irritation, dyspareunia, dysuria, vulvitis, strawberry cervix

Question 358

Management of trichomoniasis?

Answer 358

Metronidazole- 2g stat or 400-500mg bd for 5-7days Partner trace (preceding 4 weeks) Abstain from sex until treatment completed

Question 359

Cause of gonorrhoea?

Answer 359

Neisseria gonorrhoea (bacteria)

Question 360

Presentation of gonorrhoea?

Answer 360

Around 50% asx, sxs occru 2-5 days after infection, altered/increased discharge (thin, watery, green or yellow), dysuria, dyspareunia, lower abdo pain, rarely causes unexpected bleeding Often co-exists with chlamydia infection

Question 361

Management of gonorrhoea?

Answer 361

IM ceftriaxone 1g and partner notification

Question 362

Which herpes causes what?

Answer 362

``` HSV-1= genital herpes and cold sores HSV-2= genital herpes ```

Question 363

How will a primary HSV infection present?

Answer 363

Small red blisters- very painful and can form open sores, discharge, flu like symptoms, itchy genitals After 20 days lesions crust and heal

Question 364

How will secondary HSV infections present?

Answer 364

Recurrent outbreaks (shorter and less severe over time), burning and itching, red blisters

Question 365

How long do cold sores last?

Answer 365

7-10 days

Question 366

How to investigate and manage HSV infection?

Answer 366

``` Ix= swab open sore and send for PCR Mx= aciclovir and full STI screen ```

Question 367

What causes syphilis?

Answer 367

STI caused by spirochete gram negative bacteria Treponema pallidum

Question 368

Presentation of primary syphilis?

Answer 368

Bacteria divide forming infectious hard ulcer= chancre forming after 2-3 weeks Papule>chancre (painless) Heal within 3-10 weeks, can persist during secondary syphilis NB/ if chancre left untreated, systemic damage via obliterating arteritis causes ischaemia and symptoms

Question 369

How does secondary syphilis present?

Answer 369

``` 3 months post initial infection Skin rash (hands and feet), fever, malaise, arthralgia, wt loss, headaches, condylomata lata, painless lymphadenopathy, silver mucous membrane lesion ```

Question 370

How does tertiary syphilis present?

Answer 370

Gummatous (non infectious, various tissues) Neurosyphilis (tabes dorsalis, dementia, meningovascular complications, argyll robertson pupil) Cardiovascular (aortic regurgitation, angina, calcification of ascending aorta)

Question 371

How to investigate syphilis?

Answer 371

Dark ground microscopy, PCR, serology, LP (?neuro)

Question 372

How to manage syphilis?

Answer 372

Penicillin (benzathine)

Question 373

What may happen 24 hours after treatment of syphilis?

Answer 373

Jarisch Herxheimer reaction- flu like illness | Needs follow up serology

Question 374

What causes genital warts?

Answer 374

``` Human papillomavirus (mainly HPV 6 and 11) Needs skin-skin contact ```

Question 375

How to manage genital warts?

Answer 375

May not need tx Topical tx eg podophyllotoxin/imiquimod Physical ablation (excision, cryotherapy, electrosurgery, laser surgery) Vaccination!

Question 376

Describe progression of HIV to AIDS

Answer 376

Single stranded RNA retrovirus uses CD4 cells Seroconversion (producing anti-HIV abs), flu like illness with decreasing CD4 levels- highly infectious Latent phase- decreasing Cd4 and increasing viral load May be asx latent phase initially, then late latent= infectious Over 10 years or so, becomes AIDS when CD4 is under 200

Question 377

What investigations for HIV/AIDS?

Answer 377

4th generation tests- HIV antibodies and p24 antigen

Question 378

How to manage HIV?

Answer 378

HAART reduces viral load to undectable (=untransmissable) levels, but not a cure- atripla, eviplera etc PEP if within 72 hours of contact and taken for a month (truvada and raltegravir)

Question 379

Pregnant woman with HIV- what to do and what does t reduce risk of transmission to?

Answer 379

Antenatal HAART, avoid breastfeeding, neonate PEP | Reduced risk from over 25% to less than 1%

Question 380

4 phases of sexual arousal?

Answer 380

Excitement, plateau, orgasmic, resolution

Question 381

What happens in excitement phase in men?

Answer 381

Psychogenic or somatogenic stimuli Sacral parasympathetic Arteriolar vasodilation in corpora cavernosa, penile filling (latency) and penile tumescence (erection)

Question 382

What happens in plateau phase in men?

Answer 382

Sacrospinous reflex Contraction of ischiocavernosus, venous engorgement and decreased arterial inflow, testes engorged and elevated Secretion from accessory glands (5% ejaculate), lubricates distal urethra and neutralises acidic urine Increased HR and BP

Question 383

What happens in orgasmic phase in men?

Answer 383

``` Emission= thoracolumbar sympathetic reflex- contraction of smooth muscle, internal and external urethral sphincters contract, semen pools in urethral bulb (mixing of ejaculate contents) Ejaculation= spinal reflex (l1, l2), contraction of glands and ducts and urethral sphincter, filling internal urethra stimulates pudendal nerve- contracts genital organs and expels semen ```

Question 384

What happens in resolution phase in men?

Answer 384

Thoracolumbar sympathetic- contraction of arteriolar smooth muscle, increased venous return, causes dehumescence flaccidity and refractory period

Question 385

Nervous system control of female 4 phases of sexual arousal?

Answer 385

``` Excitement= sacral parasympathetic Plateau= sacrospinous reflex Orgasmic= thoracolumbar sympathetic reflex and spinal reflex Resolution= thoracolumbar sympathetic ```

Question 386

Describe excitement phase in women?

Answer 386

Vasocongestion, vaginal lubrication, clitoris engorges, uterus elevates, increased muscle tone/HR/BP, inner 2/3 of vagina lengthens and expands

Question 387

Describe plateau phase in women?

Answer 387

Increased tone/HR/BP, labia minora deepends in colour, clitoris withdraws under hood, bartholin glands secretion to lubricate vestibule, uterus completely elevated and orgasmic platform forms in lower 1/3 of vagina

Question 388

Describe orgasmic phase in women?

Answer 388

Orgasmic platform contracts rhythmically 3-15 times, uterus and sphincter contracts

Question 389

Describe resolution phase in women?

Answer 389

Clitoris descends, labia return to normal size and colour, uterus descends, vagina shortens and narrows, no refractory period

Question 390

What happens to aid the sperm to reach the ampulla for fertilisation?

Answer 390

Oxytocin stimulates uterus to contract aiding travel Sperm undergoes capacitation- tail movement changes from beat like action to thrashing whip like action, also removal of protein coat of sperm exposes the acrosome enzymes which allows penetration of zona pellucida

Question 391

Physiology of sperm fertilising the ovum

Answer 391

After capacitation, zona pellucida 3 (ZP3) proteins interact with sperm and allow calcium to enter spermatozoa, causing increased cAMP Acrosome swells, outer membrane fuses with sperm plasma membrane- releases enzymes Inner cell membrane of acrosome exposed, ZP2 glycoprotein holds sperm near egg Proteolytic enzymes penetrate ZP and sperm and oocyte membranes fuse and calcium enters cells stopping them moving

Question 392

What prevents polyspermy?

Answer 392

Calcium enters, egg cell membrane depolarises (primary block preventing polyspermy) Cortical reaction where granules in egg release contents into ZP (secondary block to polyspermy) Final meiotic division (polar body released)

Question 393

How does the placenta form?

Answer 393

Formed form outer trophoblast cells Day 9- lacunae/spaces form within syncytiotrophoblast and this erodes maternal tissues allowing maternal blood from uterine spiral arteries to enter the lacunar network Cytotrophoblast forms primary chorionic villi which penetrate and expand into syncytiotrophoblast, by 3rd week secondary chorionic villi form Villi expand into branching villi to form surface area for exchange

Question 394

How does the placenta change throughout trimesters?

Answer 394

First= thick placental barrier | By full term= increased surface area but barrier much thinner and cytotrophoblast layer is lost from first trimester

Question 395

What is the placenta covered by on maternal and foetal side?

Answer 395

``` Maternal= decidua basalis Foetal= chorionic plate ```

Question 396

at 4/5th month, what happens to placenta?

Answer 396

Decidua form decidual septa- divides placenta into cotyledons, where each receives blood supply from 80-100 spiral arteries

Question 397

What does the placenta like by full term?

Answer 397

Discoid, 15-25 cm diameter, 3cm thick, weighs about 500g | Maternal side has about 15-20 bulging areas

Question 398

What score can be used to judge likelihood of woman entering labour soon?

Answer 398

Bishop scoring

Question 399

What factors are considered in bishop scoring?

Answer 399

Dilation, effacement (how thin cervix is), consistency (should be a soft cervix), position (cervix should move forward with head), foetal station (how far up baby's head is)

Question 400

What different bishop scores mean?

Answer 400

Over 8= spontaneous labour about to start soon 6 or 7= unlikely to start soon, induction of labour could go either way Under 5= unlikely and induction probably won't work

Question 401

What is a partogram?

Answer 401

Document used to monitor labour Records maternal obs, foetal HR, amniotic fluid, contraction frequency and strength, position, cervicograph, any oxytocin administration, urine, all vaginal examinations

Question 402

What does cardiotocography measure?

Answer 402

Foetal HR and contractions

Question 403

How can CTG be performed?

Answer 403

External maternal elastic belt | Can insert vaginal electrode for FHR

Question 404

Indications for CTG?

Answer 404

Premature/smaller than expected, htn, fever, infection, fresh blood passed in labour, multiple pregnancy, passed meconium, premature rupture of membranes, unusual foetal position, labour sped up or epidural needed

Question 405

What are foetal scalp samples?

Answer 405

Used during labour to confirm foetal oxygenation Create shallow cut by a transvaginally inserted blood lancet Tests pH and lactate as acidosis a/w hypoxia

Question 406

When would you do a foetal scalp sample?

Answer 406

If CTG suggested pathology

Question 407

Indications for amniocentesis?

Answer 407

Genetic testing eg trisomy 21 Foetal lung testing- if mature enough for birth (32-39 weeks) Diagnosis of foetal infection Evaluate severity of anaemia in babies with Rh sensitisation Polyhydramnios treatment Paternity testing

Question 408

When is genetic amniocentesis performed?

Answer 408

Between 15-20 weeks

Question 409

Risks of amniocentesis?

Answer 409

Leaking amniotic fluid, miscarriage, needle injury, Rh sensitisation, infection, infection transmission

Question 410

When is chorionic villus sampling done?

Answer 410

Usually between 11-14 weeks, but can be done as early as 10 weeks

Question 411

What can chorionic villus sampling not detect?

Answer 411

Neural tube defects (but genetic amniocentesis can)

Question 412

Cons of chorionic villus sampling?

Answer 412

Risks of miscarriage, rh sensitisation and uterine infection Sometimes results are unclear and may need amniocentesis as well Rare chance of false positive

Question 413

What is viability re ejaculate, and the usual number?

Answer 413

What percentage of live sperm are in a semen sample | Should be at least 58%

Question 414

Examples of fertility medications?

Answer 414

Clomifene (encourages ovulation in women who ovulate irregularly) Tamoxifen (alternative to clomifene) Metformin (if has PCOS) Gonadotrophins GnRH and dopamine agonists (encourgae ovulation)

Question 415

Options for assisted conception?

Answer 415

``` Fertility medications Fertility surgery (fallopian tubes if blocked or scarred, laparoscopy for endometriosis) Intrauterine/artificial insemination In vitro fertilisation Donation (egg or sperm) ```

Question 416

Causes of male infertility?

Answer 416

Low sperm production, abnormal sperm function, blockages Medical eg varicocele, infection, retrograde ejaculation, antibodies, tumours, undescended testes, hormones, tubule defects, chromosome, sex problems, Coeliac, medications, prior surgery Environmental eg industrial chemicals, heavy metal, radiation, overheated testes Lifesyle eg drug abuse (anabolic steroids, cocaine, weed), alcohol, smoking, obesity

Question 417

What is the apgar score?

Answer 417

Describes condition of newborn infant immediately after birth done at 1 minute and 5 minutes Activity (tone), pulse, grimace (reflex irritability), appearance (colour), respiratory

Question 418

What apgar score means hypoxia-ischaemia is unlikely?

Answer 418

Over 7 at 5 minutes

Question 419

2 types of HRT? 2 regimes?

Answer 419

Combined or oestrogen only (for hysterectomy patients) | Regimes= cyclical or continuous

Question 420

SEs of HRT?

Answer 420

Oestrogen and progestogen related= bloating, breast tenderness, nausea, cramps, headaches, vaginal bleeding Progestogen related= mood swings, depression, acne, abdo pain, back pain

Question 421

What defines heavy menstrual bleeding?

Answer 421

Subjectively (what the woman deems) heavy

Question 422

Causes of menorrhagia?

Answer 422

Most due to a combination of coagulopathy, ovulatory and endometrial dysfunction Pathological causes=uterine fibroids (20-30%), polyps (5-10%), endometriosis 40-60% women= dysfunctional uterine bleeding

Question 423

NICE investigation for menorrhagia?

Answer 423

FBC +/- haematinics, coagulation, TFT, TVUS, hysteroscopy +/- endometrial biopsy

Question 424

Management options for menorrhagia/abnormal uterine bleeding?

Answer 424

``` 1= IUS (Mirena) 2= antifibrinolytics eg transexamic acid 3= NSAIDs eg mefenamic acid 4= progestogens eg medroxyprogesterone acetate or northesisterone 5= COCP 6= POP 7= danazol 8= reassurance 9= endometrial ablation 10= hysterectomy 11= uterine artery embolisation 12= myomectomy/resection fibroids ```

Question 425

Example of antifibrinolytic and administration? how does it work?

Answer 425

Transexamic acid 1g TDS for up to 4 days Inhibits tissue plasminogen activator

Question 426

How does mefenamic acid work? administration?

Answer 426

inhibits COX and blocks PGE2 receptors 500mg tds until bleeding stops/reduces

Question 427

When are progestogens least effective in AUB? When must you use them? How long to take them for? 2 examples?

Answer 427

Least effective if in luteal phase. Should use from day 5-25. Take for minimum 3 months Medroxyprogesterone acetate and northesisterone

Question 428

How does danazol work?

Answer 428

Inhibits sex steroid production and blocks receptors

Question 429

Indications for endometrial ablation?

Answer 429

HMB, not expecting amenorrhoea, normal endometrium, uterus under 12 weeks size, completed family

Question 430

Contraindications to endometrial ablation?

Answer 430

Malignancy, acute PID, desire for future pregnancy, excessive uterine cavity length

Question 431

Which options for AUB are fertility sparing?

Answer 431

Uterine artery embolisation and myomectomy/resection of fibroid

Question 432

What time period= puerperium?

Answer 432

From delivery of placenta to 6 weeks following the birth

Question 433

During involution of uterus and genital tract in puerperium, what different lochia are shed?

Answer 433

Lochia rubra (day 0-4), lochia serosa (day 4-10), lochia alba (day 10-28)

Question 434

Describe prolactin response in breast feeding?

Answer 434

Baby suckles, sensory impulses from nipple to brain, prolactin from anterior pituitary via bloodstream to breasts, makes lactocytes produce milk More secreted at night, suppresses ovulation, level peaks after feed (to produce milk for next feed)

Question 435

Describe oxytocin reflex in breast feeding?

Answer 435

Baby suckles, sensory impulse from nipple to brain, oxytocin released from posterior pituitary, causes myoepithelial cells to contract and expel milk Helped by sight, sound and smell of baby, hindered by anxiety/stress/pain

Question 436

Benefits of breastfeeding?

Answer 436

Decreases GI disease, resp disease, otitis media and NEC in baby Lactoferrin: regulated iron absorption and delivery, boosts immune system

Question 437

How does post dural puncture headache present?

Answer 437

Headache worse on sitting/standing, starts 1-7 days after spinal/epidural. Neck stiffness, photophobia

Question 438

RFs for urinary retention in puerperium?

Answer 438

Epidural analgesia, prolonged 2nd stage of labour, forceps/ventouse, extensive perineal lacerations, poor labour bladder care

Question 439

What is obstetric cholestasis?

Answer 439

Itching with no rash, abnormal liver function (increased AST, ALT and bile acid), resolves after delivery

Question 440

How to manage obstetric cholestasis?

Answer 440

Urseodeoxycholic acid

Question 441

Anti-thyroid drug to use in pregnancy?

Answer 441

Propylthiouracil

Question 442

When would you offer sickle cell and thalassaemia screening?

Answer 442

By 8-10 weeks in all pregnant women | Unbooked women in labour

Question 443

When are babies to hepatitis B woman vaccinated?

Answer 443

Within 24 hours of birth 4,8,12 and 16 weeks Then at 12 months

Question 444

When is the combined test offered?

Answer 444

11+2 to 14+1 weeks

Question 445

What is involved in the combined test?

Answer 445

Uses maternal age, crown rump, nuchal translucency, 2 biochem markers= PAPP-A and free BHCG

Question 446

What can combined test screen for?

Answer 446

2 risk results produced 1 for T21 1 for T18/T13

Question 447

What is quadruple testing for? When to offer?

Answer 447

T21 | 14+2 to 20+0 weeks or when head circumference is 101-172mm

Question 448

What is involved in quadruple testing?

Answer 448

Alpha fetoprotein, total BHCG, oestriol and inhibin A

Question 449

When is the early pregnancy scan done, what for?

Answer 449

10-14 weeks | For dating and confirming viability, can form part of combined test

Question 450

When is foetal anomaly screening done?

Answer 450

18-20 week

Question 451

What does the foetal anomaly screening scan look for?

Answer 451

Open spina bifida, anencephaly, cleft lip, diaphragmatic hernia, gastroschisis, exomphalos, serious cardiac abnormalities, bilateral renal agenesis, lethal skeletal dsyplasia, trisomy 13+18

Question 452

When might transdermal patch HRT be used?

Answer 452

Gastric upset eg Crohns, need for steady absorption (eg migraines), perceived increased risk of VTE, older women, medical conditions eg htn, patient choice

Question 453

How to diagnose premature ovarian insufficiency?

Answer 453

In under 40 | FSH over 25 IU/L in 2 samples 4 weeks apart and 4 months of amenorrhoea

Question 454

How fertile are you generally around menopause?

Answer 454

For 2yrs if menopause under 50 years | For 1 year if menopause over 50 years

Question 455

Contraindications to HRT?

Answer 455

Undiagnosed abnormal PV loss, breast lump, acute liver disease

Question 456

When should you use HRT with caution?

Answer 456

Fibroids, uncontrolled BP, migraine, epilepsy, endometriosis, FH VTE, over 60s

Question 457

Genes associated with breast cancer?

Answer 457

BRCA1/2, Tp53, PTEN, STKII, CDHI

Question 458

How to investigate a breast presentation?

Answer 458

Triple assessment: clinical exam, imaging, biopsy. | Everything scored 1-5.

Question 459

What is the nottingham prognostic index used for? | Formula?

Answer 459

Prognosis of breast cancer if no treatment other than surgery used Grade (1-3) x nodes (1-3) + 0.2(size cm) Score 2-7 with 7 being worst prognosis

Question 460

Receptors used in prognosis and treatment in breast cancer?

Answer 460

ER (positive= good) PgR (positive=good) Her2 (positive=bad) Ki67 (positive=bad)

Question 461

Endocrine treatment options for breast cancer?

Answer 461

Direct oestrogen receptor inhibitor (pre menopausal)= tamoxifen Aromatase inhibitors (stops androgen conversion to oestrogen) (post menopausal)= anastrazole, letrozole

Question 462

Adjuvants for breast cancer therapy?

Answer 462

Chemo, endocrine, trastuzumab/herceptin and pertuzumab (for Her2 +ve), radio, bisphophonates (decrease mets)

Question 463

What is non cyclical breast pain usually due to`?

Answer 463

Pulled pectoral or serratus muscle | RARELY due to cancer

Question 464

When can you carry out termination of pregnancy?

Answer 464

Before 24 weeks After 24 weeks if risk to life of baby or if to prevent grave permanent injury to maternal physical/mental health, or if continuation of pregnancy would involve risks to life of pregnant woman 2 consultants need to sign

Question 465

Female genital mutilation type 1?

Answer 465

Clitoridectomy (partial or total)

Question 466

FGM type II?

Answer 466

Excision: clitoris and labia minora (partial or total)

Question 467

FGM type III?

Answer 467

Infibulation: narrowing of vaginal orifice with creation of a covering seal +/- clitoral excision

Question 468

FGM type IV?

Answer 468

All other harmful procedures including pricking, piercing, incising, scraping and cauterisation

Question 469

UK law on FGM?

Answer 469

Offence to perform, assist in carrying out, assist non UK person to carry out FGM outside of UK on UK national or permanent UK resident

Question 470

Hormones involved in labour?

Answer 470

Prostaglandins, oxytocin, oestrogen (surge at labour to inhibit progesterone to prepare smooth muscle), beta endorphins (natural pain relief), adrenaline (released as birth is imminent), prolactin

Question 471

What is the most common pelvis type in females? other types?

Answer 471

Gynaecoid most common others= platypelloid, android, anthropoid

Question 472

Mechanism of labour?

Answer 472

Descent, flexion of neck, internal rotation, extension, external rotation (naturally aligns head with shoulders), delivery of body (anterior then posterior shoulder)

Question 473

How much amniotic fluid at term?

Answer 473

500-800mls

Question 474

What is the term used for when foetus born in intact amniotic sac?

Answer 474

en caul

Question 475

Why do we allow at least 1 minute before clamping the umbilical cord?

Answer 475

Allows time to transfuse blood to baby (can received up to 214g of blood), allows baby transition time to extra uterine life, increases rbcs/iron/stem cells, decreased need for inotropic support

Question 476

Analgesia options in labour?

Answer 476

Holistic and non invasive eg aromatherapy, water immersion, massage, TENS Etonox (gas and air), paracetamol and codeine Opioids: diamorphine, pethidine, remifentanyl Epidural (mix of bupivacaine and fentanyl)

Question 477

2 planes for mammogram?

Answer 477

Craniocaudal (horizontal plates)- for medial breast and deeper parts Medio-lateral oblique- good for axillary tail and lateral breast

Question 478

How much does breast cancer screening reduce mortality?

Answer 478

Between 16 and 29%

Question 479

Main two types of invasive breast cancer?

Answer 479

ductal (70%) | lobular (10%)- harder to feel, more diffuse, more prone to be bilateral

Question 480

On breast screening, what are ductal carcinomas in situ and how do they look on mammogram?

Answer 480

Pre-malignant, not yet able to invade basement membrane so can't metastasise Appear as microcalcifications generally

Question 481

Fluid and renal physiological changes in pregnancy?

Answer 481

Increased total plasma volume (30-50%) Favour sodium retention and increase potassium absorption Increased extracellular fluid; dilution effects Decreased plasma osmolality without diuresis, decreased plasma oncotic pressure Increase kidney size (20%) Dilation of renal system, decreased ureteral tone Increased renal blood flow, increased GFR Increased renin-angiotensin II

Question 482

CV physiological changes in pregnancy?

Answer 482

Peripheral vasodilation early on, increased SV, HR, and CO BP changes biphasic: early on drop in BP, increase in late pregnancy Dilution anaemia, increased polymorphs Hypercoagulable

Question 483

Resp physiological changes in pregnancy?

Answer 483

Diaphragmatic elevation Increased maternal oxygen consumption TLC, FRC, VC and ERV+IRV reduced Increased TV increases minute volume Maternal RBCs have increased 2,3 diphosphogylcerate (DPG)- allows o2 release at same po2

Question 484

GI physiological changes in pregnancy?

Answer 484

Progesterone induced generalised smooth muscle relaxation decreased CCK and decreased gallbladder motility Increased gut transit time

Question 485

Metabolic physiological changes in pregnancy?

Answer 485

``` Weight gain (mean around 12.5kg) Early= maternal glycogen synthesis and fat deposition, late= maternal insulin resistance ```

Question 486

Which pessary will still allow sexual intercourse?

Answer 486

Ring

Question 487

Different types of hypertension to experience in pregnancy?

Answer 487

Gestational hypertension Pre-eclampsia, eclampsia Chronic hypertension Pre-eclampsia superimposed upon chronic hypertension

Question 488

What defines gestational hypertension?

Answer 488

New hypertension after 20 weeks gestation Systolic over 140 and or diastolic over 90mmHg No or little proteinuria

Question 489

What counts as chronic hypertension with superimposed pre-eclampsia?

Answer 489

New onset proteinuria after 20weeks or before if there's a sudden increase in proteinuria/BP, thrombocytopenia or abnormal AST/ALT

Question 490

What protein:creatinine ratio can be seen in pre-eclampsia?

Answer 490

Over 30mg/mmol

Question 491

What warrants severe pre-eclampsia?

Answer 491

``` BP over 160 systolic or 110 diastolic Proteinuria over 5g or +++ on dipstick Oliguria under 400ml in 24 hours CNS signs Pulmonary oedema Epigastric/RUQ pain Impaired LFTs Thrombocytopenia IUGR Oligohydramnios ```

Question 492

Definitive cure for pre-eclampsia?

Answer 492

Delivery of placenta

Question 493

Low birth weight? Very low birth weight? Extremely low birth weight?

Answer 493

Low= under 2500g Very low= under 1500g Extremely low= under 1000g

Question 494

Primary prevention methods for preventing preterm birth?

Answer 494

Smoking cessation, STI prevention, prevent multiple pregnancy (IVF caution), variable work schedules, physical and sexual activity advice, cervical assessment at 20-26 weeks

Question 495

Secondary prevention methods for preventing preterm birth?

Answer 495

Transvaginal cervical ultrasound, qualitative foetal fibronectin test Screen high risk asymptomatic women Manage women with threatened preterm labour with a cervix under 3cm dilated- administer progesterone (pessary), cervical cerclage can be used

Question 496

How can you manage a woman with threatened preterm birth?

Answer 496

Intravaginal progesterone first line | Cervical cerclage can be used

Question 497

Tertiary prevention methods for preventing preterm birth?

Answer 497

Prompt diagnosis, tocolysis and antibiotics, corticosteroids

Question 498

What is foetal fibronectin? significance of it?

Answer 498

Extracellular matrix protein found in choriodecidual interface Abnormal finding in cervicovaginal fluid after 20 weeks so may indicate disruption of attachment of membranes to decidua Reappears close to term as labour approaches

Question 499

What test to look for foetal fibronectin/ FDC-6? downfalls?

Answer 499

ELISA | NB/ false positives eg cervical manipulation, sexual intercourse, lubricants, bleeding

Question 500

How far away must placenta be from internal cervical os to be considered normal?

Answer 500

At least 20mm

Question 501

General management for any worrying APH?

Answer 501

``` ABCDE 2 14/16 G cannulas IV fluids (crystalloid) Cross match 6 units Inform senior colleagues and paediatrics Examination (avoid digital exam) Foetal monitoring +/- delivery Steroids if under 34 weeks ```

Question 502

Complications of antepartum haemorrhage?

Answer 502

Premature labour/delivery, blood transfusion, acute tubular necrosis (+/- renal failure), DIC, PPH, ITU admission, ARDS (secondary to transfusion), foetal morbidity and mortality

Question 503

Uterotonic options?

Answer 503

Oxytocine, ergometrine, carboprost, misoprostol, tranexamic acid

Question 504

Sepsis 6?

Answer 504

Give three, take three oxygen, IV abx, IV fluids Blood cultures, bloods (hb/lactate/glucose), measure hourly urine output

Question 505

Describe the follicular phase of the menstrual cycle?

Answer 505

Low oestrogen and progesterone Increasing levels of FSH Developing follicles release oestrogen This inhibits FSH and leads to one dominant follicle Oestrogen levels rise high enough to induce positive feedback on pituitary (not negative) LH surge= ovulation

Question 506

Describe the luteal phase of the menstrual cycle?

Answer 506

Follicle forms corpus luteum which secretes progesterone Progesterone peaks 7 days after ovulation and unless maintained by the pregnancy, corpus luteum regresses to corpus albicans Falling progesterone induces menstruation

Question 507

When does progesterone level peak in menstrual cycle?

Answer 507

7 days after ovulation eg day 21 in 28 day cycle eg day 28 in 35 day cycle

Question 508

How many days from ovulation to menstruation?

Answer 508

14 days

Question 509

What maintains the corpus luteum in pregnancy?

Answer 509

HCG secreted by synctiotrophoblast (similar to FSH and LH) | Continues to secrete progesterone until the placenta takes over at about 12 weeks

Question 510

How does the COCP work?

Answer 510

provides a constant level of oestrogen and progestogen, causes negative feedback on FSH and LH This prevents development of follicles and stops the LH surge so no ovulation!

Question 511

In fertility investigations, when to check baseline FSH and LH?

Answer 511

Day 2-5

Question 512

What happens in the menstrual phase of the menstrual cycle?

Answer 512

Falling levels of progesterone cause shedding of the endometrium; spasm of spiral arterioles, ischaemic necrosis and generalised inflammation

Question 513

What happens in the proliferative phase of the menstrual cycle?

Answer 513

Endometrium grows under the influence of oestrogen. Early development of glands and spiral arterioles

Question 514

What happens in the secretory phase of the menstrual cycle?

Answer 514

After ovulation, progesterone dominates Development of complex glands, increase in spiral arterioles, endometrial cells produce and store glycogen Endometrium stops growing so much but prepares for implantation

Question 515

Why do obese people produce more oestrogen?

Answer 515

Increased aromatase

Question 516

How do progestogen contraceptives work?

Answer 516

Maintain the thin uterine lining and inhibit action of oestrogen- stops menstruation by avoiding the drop in progesterone before menstruation

Question 517

What is cervical motion tenderness or cervical excitation seen in?

Answer 517

PID and ectopic pregnancy

Question 518

What is pelvic congestion syndrome?

Answer 518

Incompetence of pelvic vein valves, typically occurring after pregnancy Causes constant dull lower abdo ache which is worse after standing/exercise

Question 519

How to investigate pelvic congestion syndrome? How to manage?

Answer 519

Transvaginal duplex USS or MRI venogram | Mx= analgesia, or non invasive transcatheter vein embolisation

Question 520

What is sampson's theory?

Answer 520

Retrograde menstruation contributing to endometriosis