Obstetrics and Gynaecology

Question 1

Most common symptom of chalmydia?

Answer 1

Asymptomatic

Question 2

Define stress incontinence

Answer 2

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

Question 3

Risk factors for stress incontinence?

Answer 3

Increasing age
Past pregnancy and vaginal delivery
Post menopausal
Decreased oestrogen
High BMI
Constipation,
Hysterectomy,
Prolapse
family history, smoking, drugs eg ACEi

Question 4

How to assess pelvic muscle tone?

Answer 4

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

Question 5

What can you do initially to manage stress incontinence?

Answer 5

1) Lifestyle advice: decrease caffeine, advice on fluid intake, smoking cessation, weight loss if BMI over 30
2) 3 months pelvic floor training
3) surgery/duloxetine if surgery undesired by woman or contraindicated

Question 6

What can be done in secondary care for stress incontinence?

Answer 6

Retro pubic mid-urethral sling
Autologous rectus fascial sling
Colposuspension
Intramural urethral bulking agents

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

Question 7

Describe an overactive bladder presentation

Answer 7

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

Question 8

Pathophysiology of overactive bladder?

Answer 8

Involuntary contractions of detrusor muscle during filling phase of micturition

Question 9

Aetiology of overactive bladder?

Answer 9

Most=idiopathic
Can be associated with injury to pelvic/spinal nerves, surgery, MS, drugs eg diuretics/antidepressants/hrt

Question 10

Mirabegron:

• use
• mechanism
• contraindication

Answer 10

• Overactive bladder if anticholinergics not suitable
• relaxes sm and increases bladder capacity
• uncontrolled bp

Question 11

How to manage overactive bladder initially?

Answer 11

1) Lifestyle advice
2) Bladder training for at least 6 weeks
3) Anticholingergic e.g. oxybutynin/tolterodine/darifenacin
4) Mirabegron is another option

Question 12

What are the side effects of anticholinergics?

Answer 12

Mad as a hatter - confused, COGNITIVE DECLINE
Hot as a beet - flushed skin
Hot as a dessert - high temp
Blind as a bat - dilated pupils
Dry as a bone - dry mouth+eyes, urinary retention, constipation

-anticholinergics are not suitable for patients with dementia

Question 13

Secondary care options for overactive bladder?

Answer 13

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

Question 14

Types of prolapse?

Answer 14

• Cystocele
• Uterovaginal
• Rectocele

Question 15

Pathophysiology of prolapse

Answer 15

Pelvic floor muscles and ligaments stretch and weaken over time and can no longer support the bladder/uterus/rectum so the organ slips down into and can protrude out of the vagina

Question 16

Difference between cystocele and rectocele?

Answer 16

Cystocele=anterior vaginal prolapse (bladder falls through)
Rectocele=posterior vaginal prolapse (rectum falls through

Question 17

Causes of prolapse/weakened pelvic floor muscles?

Answer 17

pregnancy

difficult labour

large baby

overweight

lower oestrogen after menopause

chronic constipation

chronic cough

repeated heavy lifting

Question 18

Presentation of prolapse?

Answer 18

Asymptomatic

Heaviness/pulling in pelvis

Feeling like sitting on a small ball

Urinary sx, Bowel sx, Sexual sx

Tissue protruding from vagina

Question 19

Is prolapse more common in pre or post menopausal women?

Answer 19

Postmenopausal women who have had at least one vaginal delivery

Question 20

Management of prolapse?

Answer 20

1. Lifestyle changes, pelvic floor exercises, oestrogen cream
2. Pessaries
3. Surgery: repair of tissues (sacroplexy, sacrospinous fixation) or hysterectomy

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

• injury
• surgery
• infection
• radiation treatment
• prolonged childbirth

Question 23

What are potential problems with vesicovaginal or rectovaginal fistulae?

Answer 23

• uncontrolled urinary or faecal incontinence
• 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** (uterine myoma)

Question 26

When do you get fibroids and why?

Answer 26

During reproductive age as maintained by oestrogen and progestogen

Question 27

Types of fibroid?

Answer 27

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

Question 28

Risk factors for fibroids? What reduces risk?

Answer 28

RF: early menarche, late menopause, increasing age, obesity, Afro-carrib, family history, Reduced risk: pregnancy and number of pregnancies

Question 29

How does red degeneration of fibroids present?

Answer 29

Pregnant woman with a history of fibroids presenting with severe abdominal pain, vomiting, low-grade fever and tachycardia.

Question 30

Presentation of fibroids?

Answer 30

* **Heavy menstrual bleeding** (menorrhagia) * Prolonged menstruation, lasting more than 7 days * Abdominal pain, worse during menstruation * Bloating or feeling full in the abdomen * Urinary or bowel symptoms due to pelvic pressure or fullness * Deep dyspareunia (pain during intercourse) * Reduced fertility

Question 31

Investigations for fibroids?

Answer 31

Hysteroscopy is the initial investigation for submucosal fibroids presenting with heavy menstrual bleeding. Pelvic ultrasound is the investigation of choice for larger fibroids.

Question 32

Management of fibroids?

Answer 32

1. No management/safety netting 2. If fibroid under 3cm: Mirena coil. Tranexamic acid 2nd line. Can also use COCP but contraindicated when surgery might be involved. 3. Surgery +GnRH agonist: endometrial ablation, uterine artery embolisation, myomectomy or hysterectomy. GnRH agonists (e.g. goserelin acetate) used before surgery to reduce size of fibroid and make them less likely to bleed.

Question 33

Complications of fibroids?

Answer 33

* menorrhagia with iron deficiency anemia * compression of adjacent organs - urinary obstruction, constipation * infertility * torsion * red degeneration of fibroid (during 1st and 2nd trimester, fever, pain and vomiting) * miscarriage

Question 34

Management of fibroids \>3cm?

Answer 34

Medical: * **Tranexamic acid/NSAIDS** * Mirena coil – depending on the size and shape of the fibroids and uterus * Combined oral contraceptive - unless surgery seems likely * Cyclical oral progestogens Surgical: * **Uterine artery embolisation** * Myomectomy * Hysterectomy

Question 35

Medical management of fibroids less than 3cm?

Answer 35

For fibroids **less than 3 cm**, the medical management is the same as with heavy menstrual bleeding: 1. **Mirena coil** 2. Tranexamic acid/NSAIDS 3. Combined oral contraceptive unless surgery is impending 4. Cyclical oral progestogens Surgical options if symptoms are severe: * **Endometrial ablation** * Resection of submucosal fibroids during hysteroscopy * Hysterectomy

Question 36

Difference between uterine fibroid and polyp?

Answer 36

Fibroid = benign tumour of fibrous muscle tissue Polyp = benign tumour of endometrial tissue

Question 37

Types of ovarian cysts?

Answer 37

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

Question 38

Complications of ovarian cysts?

Answer 38

* Ovarian torsion - dermoid cysts and cystadenomas can grow large and move ovary * Rupture (severe pain and bleeding) * Necrosis

Question 39

Investigations for ovarian cysts?

Answer 39

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

Question 40

Management of ovarian cysts?

Answer 40

Watchful waiting, oral contraceptives, surgery

Question 41

What are functional cysts? What are the two types?

Answer 41

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 42

Age distribution of ovarian torsion?

Answer 42

Bimodal : 15-30 and postmenopausal

Question 43

Causes of ovarian torsion?

Answer 43

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

Question 44

Presentation of ovarian torsion?

Answer 44

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

Question 45

Management of suspected ovarian torsion?

Answer 45

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

Question 46

What is lichen sclerosus?

Answer 46

* Chronic skin condition that presents with shiny, “porcelain-white” patches of skin. * Often affects genital and perianal areas. * Most common in women over 50 * Thought to be autoimmune, linked to type 1 diabetes, thyroid, alopecia, vitiligo.

Question 47

Presentation of lichen sclerosus?

Answer 47

* Porcelain-white patches of skin * Skin tightness * Soreness and pain * Painful sex (superficial dyspareunia) * Erosions * Fissures

Question 48

Complications of lichen sclerosus?

Answer 48

* Infections (thrush, herpes, S. aureus) * Increased risk of **squamous cell carcinoma (SCC)**

Question 49

Management of lichen sclerosus?

Answer 49

1. Lifestyle measures: wash gently, non soap cleanser, loose clothing 2. 2. Topical steroid ointment: **clobetasol propionate** 0.05% 3. Other topical tx= oestrogen cream, tacrolimus ointment

Question 50

What are tumour-suppressor genes?

Answer 50

* Genes that act as ‘braking signals’ during G1 phase of the cell cycle, to stop or slow the cycle before S phase. * If they are mutated, cells grow uncontrollably = cancer

Question 51

What are oncogenes?

Answer 51

Mutated genes whose presence can stimulate the development of cancer

Question 52

Most common gynae cancer a)worldwide b)in UK

Answer 52

a) Cervical b) Endometrial

Question 53

What are the types of cervical cancer?

Answer 53

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

Question 54

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

Answer 54

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

Question 55

What increases risk of HPV causing cervical cancer?

Answer 55

* Missed vaccination * Early age intercourse * STI co-infection Immunocompromised * Smoking * OCP usage \> 5yrs

Question 56

What increases risk of contracting HPV?

Answer 56

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

Question 57

Presentation of cervical cancer?

Answer 57

* Asx Intermenstrual/postcoital/postmenopausal bleeding * blood-stained vaginal discharge * mucoid/purulent discharge, pelvic pain/dyspareunia

Question 58

What things are in place to help prevent cervical cancer?

Answer 58

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

Question 59

Describe the stages of cervical cancer?

Answer 59

* Stage 1: Confined to the cervix * Stage 2: Invades the uterus or upper 2/3 of the vagina * Stage 3: Invades the pelvic wall or lower 1/3 of the vagina * Stage 4: Invades the bladder, rectum or beyond the pelvis

Question 60

What is cervical intraepithelial neoplasia/CIN?

Answer 60

* Grading system for the level of ***dysplasia*** (**premalignant change**) in the **cells** of the cervix. * CIN is diagnosed at ***colposcopy*** (not with cervical screening, thats diskaryosis - abnormal **karyo**/chromosomes/nucleus)

Question 61

Management of cervical cancer?

Answer 61

* Conservative * Stage 1: Hysterectomy/lymphadenectomy * Stage 2+: Radiotherapy, chemotherapy, palliative

Question 62

What percentage of endometrial cancer cases are preventable? a) 70.7% b) 85.1% c) 94.6% d) 99.8%

Answer 62

d) 99.8%

Question 63

Most common cancer in the UK?

Answer 63

Endometrial 9000 cases a year

Question 64

Red flag symptom for endometrial cancer?

Answer 64

Postmenopausal bleeding

Question 65

Presentation of endometrial cancer?

Answer 65

* **POST MENOPAUSAL BLEEDING** * Postcoital bleeding * Intermenstrual bleeding * Unusually heavy menstrual bleeding * Abnormal vaginal discharge * Haematuria * Anaemia * Raised platelet count

Question 66

RFs for endometrial cancer?

Answer 66

* **Unopposed oestrogen…** * Postmenopausal * PCOS * Obese (oestrogen produced in fatty tissue) * Nulliparous * Oestrogen only HRT * on tamoxifen * High insulin (diabetes,PCOS) * Lynch syndrome

Question 67

Protective factors for endometrial cancer?

Answer 67

* COCP * Mirena coil * Increased pregnancies * Cigarette smoking (anti-oestrogenic)

Question 68

What type are most endometrial cancers?

Answer 68

Adenocarcinoma (90%)

Question 69

How to investigate suspected endometrial cancer?

Answer 69

* **Transvaginal USS** for **endometrial thickness** (normal is \<4mm post-menopause) * **Pipelle biopsy** * **Hysteroscopy** with endometrial biopsy

Question 70

Management of endometrial cancer?

Answer 70

* hysterectomy +/- lymph nodes * radio/chemotherapy * progesterone therapy to slow progression

Question 71

Presentation of ovarian cancer?

Answer 71

* **IBS like symptoms** - constantly bloated, abdo distension, abdo discomfort, early satiety/loss of appetite * change in bowel habit * urinary frequency/urgency

Question 72

RFs for ovarian cancer?

Answer 72

* Age (peaks age 60) * BRCA1 and BRCA2 genes (consider the family history) * Increased number of ovulations - early onset periods, late menopause, no pregnancies, use of clomifene * Obesity * Smoking

Question 73

What type are most ovarian cancers?

Answer 73

Epithelial

Question 74

Investigations for suspected ovarian cancer? Management?

Answer 74

* CA125 blood test (\>35 IU/mL is significant) * USS Mx= surgery and chemo

Question 75

Describe staging of ovarian cancer?

Answer 75

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

Question 76

Presentation of vulval cancer?

Answer 76

* RARE! * Over 65s * itch * pain * bleeding * lump * dysuria

Question 77

Presentation of hydatidiform mole?

Answer 77

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

Question 78

RFs for vulval cancer?

Answer 78

* Increasing age * VIN * lichen sclerosis * smoking * previous radiotherapy

Question 79

What type of cancer is vulval cancer?

Answer 79

SCC - 90% 10% are adenocarcinomas

Question 80

What is gestational trophoblastic disease?

Answer 80

* A group of rare diseases in which abnormal trophoblast cells (tumours) grow inside the uterus after conception. * Premalignant: Hydatiform mole * Malignant: Invasive mole, choriocarcinoma

Question 81

What is a hydatidiform mole? Two types

Answer 81

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

Question 82

Pathophysiology of hydatidiform mole?

Answer 82

* Complete mole: No fetal material - enucleated egg is fertilised by 2 sperms, only paternal DNA is expressed * Partial: May contain fetal material - egg is fertilised by 2 sperms

Question 83

Complications of hydatidiform mole?

Answer 83

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

Question 84

Investigating hydatidiform mole? Management?

Answer 84

``` Ix= HCG, USS, histology, other bloods Mx= evacuation of uterus ```

Question 85

What is endometriosis?

Answer 85

* Endometrial tissue grows outside of the uterus - commonly involves ovaries, fallopian tube and pelvis lining * 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, can form scar tissue and adhesions * If ovaries involved, cysts/endometriomas may form

Question 86

What is Sampson's theory of endometriosis?

Answer 86

Retrograde menstruation contributing to endometriosis

Question 87

Presentation of endometriosis?

Answer 87

* Chronic pelvic pain often associated with periods * Dysmenorrhoea * Deep dyspareunia * Pain on bowel movements or urination * Excessive bleeding * Infertility

Question 88

How to diagnose endometriosis?

Answer 88

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

Question 89

How to manage endometriosis?

Answer 89

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

Question 90

What increases marker CA125?

Answer 90

Ovarian cancer Also: adenomyosis, ascites, endometriosis, menstruation, breast cancer, ovarian torsion, endometrial cancer, liver disease, metastatic lung cancer

Question 91

What is found in the functional layer of the endometrium?

Answer 91

Endometrial glands! Endometrium is glandular tissue that secretes glycogen etc. in secretory phase, in preparation for implantation of fertilised egg.

Question 92

What is adenomyosis?

Answer 92

Uterine condition of ectopic endometrial tissue (adeno) **in the myometrium**

Question 93

RFs for adenomyosis?

Answer 93

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

Question 94

Presentation of adenomyosis?

Answer 94

* Asx * multiparous women of reproductive age * Potential sxs= dysmenorrhoea, menorrhagia, dyspareunia, chronic pelvic pain

Question 95

What are the 3 types of adenomyosis?

Answer 95

Diffuse, focal, cystic

Question 96

Investigations for adenomyosis?

Answer 96

1. Transvaginal ultrasound 2. Transabdominal ultrasound, MRI

Question 97

Management of adenomyosis?

Answer 97

If contraception not wanted: * **Tranexamic acid** when there is no associated pain (antifibrinolytic – reduces bleeding) * **Mefenamic** acid when there is associated **pain** (NSAID – reduces bleeding and pain) If contraception is wanted or acceptable, same as endometriosis: 1. **Mirena coil (first line)** 2. Combined oral contraceptive pill 3. Cyclical oral progestogens

Question 98

Define dysfunctional endometrial bleeding?

Answer 98

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 99

When do you see lots of dysfunctional endometrial bleeding?

Answer 99

Early on in puberty

Question 100

how to manage dysfunctional endometrial bleeding?

Answer 100

* Oral contraceptives * Hormonal contraceptives. * Mostly a temporary condition- manage any anaemia

Question 101

How is androgen insensitivity syndrome inherited?

Answer 101

X linked recessive

Question 102

How does androgen insensitivity syndrome present?

Answer 102

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

Question 103

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

Answer 103

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

Question 104

How to manage androgen insensitivity syndrome?

Answer 104

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

Question 105

Incidence of premature menopause

Answer 105

1 in 100 (occurring in under 40s)

Question 106

Common menopause symptoms?

Answer 106

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

Question 107

What gonadotrophin is higher in menopause?

Answer 107

FSH

Question 108

how to manage menopause?

Answer 108

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

Question 109

What is atrophic vaginitis? When does it occur?

Answer 109

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 110

Describe GSM (genitourinary syndrome of menopause)

Answer 110

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

Question 111

Management of atrophic vaginitis?

Answer 111

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

Question 112

Precocious and late menarche?

Answer 112

Precocious=under 9 Late= over 15 years

Question 113

Describe physiology of menarche

Answer 113

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 114

Presentation of endometrial polyps?

Answer 114

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

Question 115

RFs for endometrial polyps?

Answer 115

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

Question 116

How to investigate and manage endometrial polyps?

Answer 116

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

Question 117

Most common location for ectopic pregnancy?

Answer 117

Fallopian tube (tubal pregnancy)

Question 118

RFs for ectopic pregnancy?

Answer 118

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

Question 119

Presentation of ectopic pregnancy?

Answer 119

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 120

How to manage an ectopic pregnancy?

Answer 120

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

Question 121

Incidence of polycystic ovaries and polycystic ovary syndrom?

Answer 121

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

Question 122

Pathophysiology of PCOS?

Answer 122

``` 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 123

Presentation of PCOS?

Answer 123

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 124

Criteria for PCOS? describe

Answer 124

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

Question 125

Investigating PCOS?

Answer 125

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

Question 126

Management of PCOS?

Answer 126

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

Question 127

Complications of PCOS?

Answer 127

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

Question 128

Abnormal formations of uterus ?

Answer 128

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 129

Abnormal formations of vagina?

Answer 129

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

Question 130

Turner syndrome genotype?

Answer 130

45X

Question 131

What is Asherman syndrome? How to manage?

Answer 131

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

Question 132

Presentation of asherman syndrome?

Answer 132

Infertility, loss of pregnancy, menstrual abnormalities, abdominal pain

Question 133

How might prolactinoma present?

Answer 133

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

Question 134

How to manage prolactinoma?

Answer 134

Dopamine agonists eg cabergoline Surgery Oestrogen contraception

Question 135

What can cause pelvic inflammatory disease?

Answer 135

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

Question 136

Presentation of pelvic inflammatory disease?

Answer 136

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

Question 137

Investigating PID?

Answer 137

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

Question 138

How to manage PID?

Answer 138

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 139

Recent coil insertion but got PID?

Answer 139

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 140

Complications of PID?

Answer 140

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

Question 141

How many stages of labour are there?

Answer 141

3

Question 142

describe the 1st stage of labour

Answer 142

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 143

How can you speed up labour?

Answer 143

ARM=artificial rupture of the membranes or oxytocin drip

Question 144

Describe the 2nd stage of labour

Answer 144

Full cervix dilation up to birth aka the pushing stage

Question 145

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

Answer 145

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

Question 146

Describe the 3rd stage of labour

Answer 146

Delivery of placenta

Question 147

Two ways of 3rd stage of labour happening?

Answer 147

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

Question 148

Pros and cons of active 3rd stage of labour?

Answer 148

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

Question 149

What counts as premature labour?

Answer 149

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

Question 150

Presentation of premature labour?

Answer 150

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

Question 151

Potential risk factors for premature labour?

Answer 151

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

Question 152

How to try to prevent premature labour?

Answer 152

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

Question 153

How should you manage premature labour?

Answer 153

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 154

What to give if in labour before 34 weeks gestation?

Answer 154

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

Question 155

Define premature rupture of membranes (prom)?

Answer 155

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

Question 156

How common is premature rupture of membranes?

Answer 156

10-15% term pregnancies

Question 157

Define preterm premature rupture of membranes (p-prom)

Answer 157

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

Question 158

Incidence of preterm premature rupture of membranes

Answer 158

Associated with 40% preterm deliveries

Question 159

What comprises foetal membranes?

Answer 159

chorion and amnion

Question 160

What can cause premature rupture of membranes?

Answer 160

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

Question 161

Risk factors for premature rupture of membranes?

Answer 161

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

Question 162

Presentation of premature rupture of membranes?

Answer 162

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

Question 163

Management of suspected premature rupture of membranes?

Answer 163

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 164

Complications of premature rupture of membranes?

Answer 164

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

Question 165

Commonest associations with placental insufficiency and low birthweight?

Answer 165

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

Question 166

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

Answer 166

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

Question 167

What is a miscarriage? 2 types?

Answer 167

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

Question 168

How common is miscarriage?

Answer 168

Very! 20-25% of pregnancies

Question 169

Risk factors for miscarriage?

Answer 169

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

Question 170

Presentation of suspected miscarriage?

Answer 170

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

Question 171

Investigations for suspected miscarrage?

Answer 171

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

Question 172

Management of miscarriage?

Answer 172

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 173

Classification of miscarriages?

Answer 173

Threatened, inevitable, missed, incomplete, complete, septic

Question 174

Describe a threatened miscarriage

Answer 174

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

Question 175

Describe an inevitable miscarriage

Answer 175

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

Question 176

Describe a missed miscarriage

Answer 176

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

Question 177

Describe an incomplete miscarriage

Answer 177

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

Question 178

Describe a septic miscarriage

Answer 178

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

Question 179

Define recurrent miscarriage

Answer 179

At least 3 consecutive pregnancies with miscarriage

Question 180

What is gestational diabetes?

Answer 180

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

Question 181

Why does gestational diabetes occur?

Answer 181

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 182

RFs for gestational diabetes?

Answer 182

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

Question 183

How would gestational diabetes present? What investigation

Answer 183

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

Question 184

How to manage gestational diabetes?

Answer 184

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 185

Foetal complications of gestational diabetes

Answer 185

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

Question 186

Pathophysiology of pre-eclampsia

Answer 186

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 187

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

Answer 187

``` 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 188

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

Answer 188

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

Question 189

Pre-eclampsia potential features

Answer 189

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

Question 190

How does pre-eclampsia present?

Answer 190

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

Question 191

Classification of pre-eclampsia

Answer 191

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 192

Does pre-eclampsia resolve?

Answer 192

Yes, following placental delivery

Question 193

Management of pre-eclampsia?

Answer 193

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 194

Maternal complications of pre-eclampsia?

Answer 194

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

Question 195

What is eclampsia?

Answer 195

Pre-eclampsia and convulsions Obstetric emergency

Question 196

Presentation of eclampsia?

Answer 196

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 197

Foetal complications of eclampsia?

Answer 197

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

Question 198

How to manage eclampsia?

Answer 198

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 199

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

Answer 199

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

Question 200

What is target BP during pregnancy?

Answer 200

Less than 135/85

Question 201

How to manage essential hypertension during pregnancy?

Answer 201

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

Question 202

Causes of antenatal haemorrhage?

Answer 202

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

Question 203

Management of APH?

Answer 203

- corticosteroids 24+0-36+6 weeks - active management of third stage of labour

Question 204

Should women with APH be hospitalised?

Answer 204

Women presenting with spotting who are no longer bleeding and where placenta praevia has been excluded can go home. All women with APH heavier than spotting and women with ongoing bleeding should remain in hospital at least until the bleeding has stopped.

Question 205

Complications of APH?

Answer 205

Maternal: Anaemia, infection, shock, consumptive coagulopathy, PPH Fetal: Hypoxia, SGA and FGR, prematurity, fetal death

Question 206

What is placenta praevia? 2 types?

Answer 206

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 207

RFs for placenta praevia?

Answer 207

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

Question 208

What examination should you NOT perform in suspected placenta praevia?

Answer 208

Digital vaginal exam

Question 209

How does placenta praevia present?

Answer 209

Painless vaginal bleeding

Question 210

How to manage placenta praevia?

Answer 210

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 211

What is placenta accreta?

Answer 211

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

Question 212

3 degrees of placenta accreta?

Answer 212

Accreta - placenta ATTACHES to the surface of the myometrium Increta - placenta INVADES deeply into the myometrium Percreta - placenta PERMEATES past the myometrium and perimetrium, potentially reaching other organs

Question 213

RFs for placenta accreta?

Answer 213

PMH Previous C section and other uterine surgery e.g. endometrial curretage due to miscarriage/abortion Low-lying placenta or placenta previa Maternal age, multigravida

Question 214

Management of placenta accreta?

Answer 214

Confirm on MRI C-section and hysterectomy (helps to prevent haemorrhage if there's an attempt to separate placenta) Deliver between 34-36+6 if complicated, 36-37 weeks if uncomplicated

Question 215

What is placenta increta?

Answer 215

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

Question 216

What is placental abruption? Why does it occur?

Answer 216

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 217

2 types of placental abruption?

Answer 217

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

Question 218

RFs for placental abruption?

Answer 218

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

Question 219

Presentation of placental abruption?

Answer 219

Painful bleeding

Question 220

Management of placental abruption?

Answer 220

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 221

How to reduce the risk of a retained placenta?

Answer 221

Use active management in third stage of labour with syntocinon

Question 222

Presentation of retained placenta?

Answer 222

Fever, badly smelling discharge, heavy bleeding, pain

Question 223

Management of retained placenta?

Answer 223

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

Question 224

What is uterine rupture? Two types

Answer 224

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 225

RFs for uterine rupture?

Answer 225

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

Question 226

Presentation of uterine rupture?

Answer 226

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

Question 227

Management of uterine rupture?

Answer 227

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

Question 228

What is cervical show?

Answer 228

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 229

What is vasa praevia?

Answer 229

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 230

How does vasa praevia present? (classic triad)

Answer 230

rupture of membranes painless vaginal bleeding fetal bradycardia

Question 231

How to manage vasa praevia?

Answer 231

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

Question 232

What differentiates antepartum haemorrhage from miscarriage?

Answer 232

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

Question 233

Causes of antepartum haemorrhage?

Answer 233

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

Question 234

How to differentiate placenta praevia from placental abruption clinically?

Answer 234

Both=bleeding Pain=abruption Painless=praevia

Question 235

What volume of blood for minor antepartum haemorrhage?

Answer 235

Blood loss less than 50ml and stopped

Question 236

What constitutes major anterpartum haemorrhage?

Answer 236

50-1000ml blood loss with no signs of shocks

Question 237

What constitutes massive antepartum haemorrhage?

Answer 237

Over 1000ml blood loss and/or signs of shock

Question 238

Management of antepartum haemorrhage?

Answer 238

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

Question 239

Minor and major primary post partum haemorrhages?

Answer 239

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

Question 240

Two broad groups of causes of post partum haemorrhage?

Answer 240

Primary and secondary

Question 241

Primary causes of post partum haemorrhage?

Answer 241

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

Question 242

Secondary causes of post partum haemorrhage?

Answer 242

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

Question 243

How to manage post partum haemorrhage?

Answer 243

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 244

What is sheehan's syndrome?

Answer 244

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 245

How does sheehan's syndrome present?

Answer 245

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 246

Complications of sheehan's syndrome?

Answer 246

Adrenal crisis, hypotension, unintended wt loss, menstrual irregularities

Question 247

Management of sheehan's syndrome?

Answer 247

Lifelong hormone replacement eg corticosteroids, levothyroxine, oestrogen, GH

Question 248

When do baby blues occur?

Answer 248

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

Question 249

Timing of post-partum depression?

Answer 249

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

Question 250

Presentation of post partum depression?

Answer 250

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

Question 251

Management of post partum depression?

Answer 251

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 252

Timing of puerperal psychosis?

Answer 252

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

Question 253

Who is puerperal psychosis more common in?

Answer 253

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 254

How to manage puerperal psychosis?

Answer 254

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

Question 255

Prognosis of puerperal psychosis?

Answer 255

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

Question 256

Causes of puerperal infection?

Answer 256

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

Question 257

What is the leading cause of maternal mortality

Answer 257

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

Question 258

Why is there increased risk of VTE in pregnancy?

Answer 258

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 259

RFs for VTE in pregnancy?

Answer 259

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 260

What investigations for VTE in pregnancy?

Answer 260

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 261

Management of VTE in pregnancy?

Answer 261

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 262

How would amniotic fluid embolism present?

Answer 262

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

Question 263

How is a definitive diagnosis of amniotic fluid embolism made?

Answer 263

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

Question 264

Levels of Hb for anaemia diagnosis in different trimesters?

Answer 264

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

Question 265

Why is anaemia likely in pregnancy?

Answer 265

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

Question 266

When do you screen for anaemia in pregnancy?

Answer 266

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

Question 267

Management of anaemia in pregnancy?

Answer 267

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

Question 268

When does rhesus disease of the newborn occur and why?

Answer 268

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 269

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

Answer 269

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

Question 270

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

Answer 270

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

Question 271

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

Answer 271

Anti-D to mum and monitoring

Question 272

UTI in pregnancy, which abx?

Answer 272

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 273

What percentage of pregnant women carry GBS?

Answer 273

25%

Question 274

What can GBS cause? Name of pathogen

Answer 274

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

Question 275

How does chorioamniotis present?

Answer 275

Fevers, lower abdo tenderness, foul discharge, tachycardia

Question 276

How does endometritis present?

Answer 276

Fevers, lower abdo pain, intermenstrual bleeding, foul discharge

Question 277

How will a neonatal GBS infection present?

Answer 277

Pyrexia, cyanosis, resp difficulties, floppiness

Question 278

How to prevent poor outcomes in GBS positive women?

Answer 278

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 279

When is management for GBS not indicated?

Answer 279

Elective C-section- as no rupture of membranes

Question 280

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

Answer 280

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 281

What is cephalopelvic disproportion?

Answer 281

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

Question 282

How to classify cephalopelvic disproportion? Examples for each

Answer 282

``` 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 283

Most common cause of cephalopelvic disproportion?

Answer 283

Contracted pelvis with average sized infant

Question 284

Management of cephalopelvic disproportion?

Answer 284

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

Question 285

What can cause a hypoactive uterus/uterine inertia?

Answer 285

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 286

Complications of uterine inertia?

Answer 286

Prolonged labour, distress, increased risk of infection, PPH

Question 287

Management of uterine inertia?

Answer 287

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

Question 288

Define obstructed labour?

Answer 288

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

Question 289

Causes of obstructed labour?

Answer 289

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

Question 290

Complications of obstructed labour?

Answer 290

Foetal anoxia, pressure necrosis, foetal death, vesicovaginal fistula

Question 291

Management of obstructed labour?

Answer 291

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

Question 292

How can shoulder dystocia occur?

Answer 292

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

Question 293

RFs for shoulder dystocia?

Answer 293

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 294

Ultimate complication of shoulder dystocia? Other complications

Answer 294

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 295

Signs of shoulder dystocia?

Answer 295

``` 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 296

Management of shoulder dystocia?

Answer 296

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 297

What is cord prolapse and types of it?

Answer 297

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 298

Why does a prolapsed cord cause foetal hypoxia?

Answer 298

Occlusion of umbilical cord and arterial vasospasm due to cold exposure

Question 299

RFs for cord prolapse?

Answer 299

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

Question 300

How to manage cord prolapse?

Answer 300

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 301

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

Answer 301

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

Question 302

What is presentation of the foetus? What types?

Answer 302

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

Question 303

What is foetal position? What types?

Answer 303

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

Question 304

How to manage abnormal foetal lie?

Answer 304

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

Question 305

Who can't you do ECV in?

Answer 305

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

Question 306

How to manage abnormal foetal position?

Answer 306

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

Question 307

How to manage malpresentations?

Answer 307

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 308

Types of breech presentation?

Answer 308

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

Question 309

Management of breech presentation?

Answer 309

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 310

Complications of breech presentation?

Answer 310

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

Question 311

Types of instrumental delivery/operative vaginal delivery?

Answer 311

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

Question 312

Indications for instrumental delivery?

Answer 312

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

Question 313

When should you stop using instrumental delivery?

Answer 313

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

Question 314

Pros and cons of ventouse?

Answer 314

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

Question 315

Pros and cons of forceps?

Answer 315

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

Question 316

Contraindications to instrumental delivery?

Answer 316

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

Question 317

Potential complications of instrumental delivery?

Answer 317

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

Question 318

What is polyhydramnios?

Answer 318

Amniotic fluid above 95th centile for gestational age

Question 319

Causes of polyhydramnios?

Answer 319

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 320

How to diagnose polyhydramnios or oligohydramnios?

Answer 320

On USS using either amniotic fluid index or maximum pool depth

Question 321

Management of polyhydramnios?

Answer 321

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

Question 322

What is oligohydramnios?

Answer 322

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

Question 323

What causes oligohydramnios?

Answer 323

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 324

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

Answer 324

IGFBP-1 in vagina (bedside test)

Question 325

How to manage oligohydramnios?

Answer 325

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 326

Prognosis of oligohydramnios in 2nd trimester?

Answer 326

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

Question 327

Pathophysiology of pubic symphysial dysfunction?

Answer 327

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 328

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

Answer 328

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

Question 329

Presentation of pubic symphysial dysfunction?

Answer 329

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 330

How to manage pubic symphysial dysfunction?

Answer 330

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

Question 331

When do multiparous women have appointments in antenatal schedule?

Answer 331

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 332

What extra appointments do nulliparous women get in antenatal schedule?

Answer 332

25 weeks, 31 weeks, 40 weeks

Question 333

What sorts of things are done in antenatal schedule?

Answer 333

(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 334

What may be discussed at 41 week appointment?

Answer 334

Offer a membrane sweep, discuss induction

Question 335

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

Answer 335

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

Question 336

What 11 conditions does the 20 week scan look for?

Answer 336

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 337

How are the trisomies screened for?

Answer 337

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 338

At what point is routine anti-D prophylaxis given?

Answer 338

28 and 34 weeks

Question 339

Different types of breast cancer?

Answer 339

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 340

How will breast cancer present?

Answer 340

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

Question 341

RFs for breast cancer?

Answer 341

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 342

What is involved in triple assessment of breast cancer?

Answer 342

Breast examination Mammogram/USS Biopsy

Question 343

How is breast cancer managed?

Answer 343

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

Question 344

What hormone therapies may be used in breast cancer?

Answer 344

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

Question 345

When is breast screening undertaken?

Answer 345

Every 3 years between 50 and 70 years

Question 346

When are implants allowed on the NHS?

Answer 346

Severe asymmetry or amastia

Question 347

2 types of breast implants with pros/cons

Answer 347

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 348

What is the earliest form of breast cancer?

Answer 348

In situ carcinoma- abnormal cells inside milk duct

Question 349

Presentation of paget's disease of the nipple

Answer 349

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

Question 350

3 common benign breast lumps?

Answer 350

Breast abscess, cysts, fibroadenoma (most common)

Question 351

Two kinds of breast abscess?

Answer 351

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

Question 352

Risk factors for breast abscess?

Answer 352

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

Question 353

How will breast abscesses present?

Answer 353

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

Question 354

How to manage breast abscess?

Answer 354

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

Question 355

How do breast cysts present?

Answer 355

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 356

Do breast cysts require treatment?

Answer 356

Generally no

Question 357

Different types of fibroadenoma?

Answer 357

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

Question 358

How does a fibroadenoma present?

Answer 358

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 359

What swabs in double swab? Triple swab?

Answer 359

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

Question 360

What does NAAT swab detect for? Where to swab?

Answer 360

Swab endocervical or vulvovaginal Detects chlamydia and gonorrhoea

Question 361

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

Answer 361

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

Question 362

RFs for vulvovaginal candidiasis?

Answer 362

Pregnancy, diabetes, broad spectrum abx, corticosteroids, immunocompromised

Question 363

How does thrush present?

Answer 363

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 364

How to manage thrush?

Answer 364

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 365

Organism causing chlamydia? Incubation period?

Answer 365

Chlamydia trachomatis (bacterium). 7-21 days incubation

Question 366

Presentation of chlamydia?

Answer 366

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 367

Investigations for chlamydia?

Answer 367

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

Question 368

How to manage chlamydia?

Answer 368

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

Question 369

How does bacterial vaginosis present?

Answer 369

50% asx, Discharge: Offensive, fishy smelling, white/grey, thin Not usually associated with irritation Vaginal pH more than 4.5

Question 370

Pathophysiology of BV?

Answer 370

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 371

RFs for BV?

Answer 371

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

Question 372

Investigating for BV?

Answer 372

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

Question 373

Management for BV?

Answer 373

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

Question 374

What causes trichomoniasis?

Answer 374

Curable STI by protozoan Trichomonas vaginalis

Question 375

Presentation of trichomoniasis?

Answer 375

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

Question 376

Management of trichomoniasis?

Answer 376

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

Question 377

Cause of gonorrhoea?

Answer 377

``` Neisseria gonorrhoea (bacteria) -gram negative diplococci ```

Question 378

Presentation of gonorrhoea?

Answer 378

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 379

Management of gonorrhoea?

Answer 379

IM ceftriaxone 1g and partner notification

Question 380

Which herpes causes what?

Answer 380

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

Question 381

How will a primary HSV infection present?

Answer 381

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

Question 382

How will secondary HSV infections present?

Answer 382

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

Question 383

How long do cold sores last?

Answer 383

7-10 days

Question 384

How to investigate and manage HSV infection?

Answer 384

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

Question 385

What causes syphilis?

Answer 385

STI caused by spirochete gram negative bacteria Treponema pallidum

Question 386

Presentation of primary syphilis?

Answer 386

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 387

How does secondary syphilis present?

Answer 387

``` 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 388

How does tertiary syphilis present?

Answer 388

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

Question 389

How to investigate syphilis?

Answer 389

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

Question 390

How to manage syphilis?

Answer 390

Penicillin (benzathine)

Question 391

What may happen 24 hours after treatment of syphilis?

Answer 391

Jarisch Herxheimer reaction- flu like illness Needs follow up serology

Question 392

What causes genital warts?

Answer 392

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

Question 393

How to manage genital warts?

Answer 393

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

Question 394

Describe progression of HIV to AIDS

Answer 394

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 395

What investigations for HIV/AIDS?

Answer 395

4th generation tests- HIV antibodies and p24 antigen

Question 396

How to manage HIV?

Answer 396

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 397

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

Answer 397

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

Question 398

4 phases of sexual arousal?

Answer 398

Excitement, plateau, orgasmic, resolution

Question 399

What happens in excitement phase in men?

Answer 399

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

Question 400

What happens in plateau phase in men?

Answer 400

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 401

What happens in orgasmic phase in men?

Answer 401

``` 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 402

What happens in resolution phase in men?

Answer 402

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

Question 403

Nervous system control of female 4 phases of sexual arousal?

Answer 403

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

Question 404

Describe excitement phase in women?

Answer 404

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

Question 405

Describe plateau phase in women?

Answer 405

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 406

Describe orgasmic phase in women?

Answer 406

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

Question 407

Describe resolution phase in women?

Answer 407

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

Question 408

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

Answer 408

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 409

Physiology of sperm fertilising the ovum

Answer 409

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 410

What prevents polyspermy?

Answer 410

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 411

How does the placenta form?

Answer 411

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 412

How does the placenta change throughout trimesters?

Answer 412

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

Question 413

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

Answer 413

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

Question 414

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

Answer 414

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

Question 415

What does the placenta like by full term?

Answer 415

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

Question 416

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

Answer 416

Bishop scoring

Question 417

What factors are considered in bishop scoring?

Answer 417

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 418

What different bishop scores mean?

Answer 418

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 419

What is a partogram?

Answer 419

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 420

What does cardiotocography measure?

Answer 420

Foetal HR and contractions

Question 421

How can CTG be performed?

Answer 421

External maternal elastic belt Can insert vaginal electrode for FHR

Question 422

Indications for CTG?

Answer 422

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 423

What are foetal scalp samples?

Answer 423

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 424

When would you do a foetal scalp sample?

Answer 424

If CTG suggested pathology

Question 425

Indications for amniocentesis?

Answer 425

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 426

When is genetic amniocentesis performed?

Answer 426

Between 15-20 weeks

Question 427

Risks of amniocentesis?

Answer 427

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

Question 428

When is chorionic villus sampling done?

Answer 428

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

Question 429

What can chorionic villus sampling not detect?

Answer 429

Neural tube defects (but genetic amniocentesis can)

Question 430

Cons of chorionic villus sampling?

Answer 430

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

Question 431

What is viability re ejaculate, and the usual number?

Answer 431

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

Question 432

Examples of fertility medications?

Answer 432

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

Question 433

Options for assisted conception?

Answer 433

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

Question 434

Causes of male infertility?

Answer 434

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 435

What is the apgar score?

Answer 435

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 436

What apgar score means hypoxia-ischaemia is unlikely?

Answer 436

Over 7 at 5 minutes

Question 437

2 types of HRT? 2 regimes?

Answer 437

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

Question 438

SEs of HRT?

Answer 438

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

Question 439

What defines heavy menstrual bleeding?

Answer 439

Subjectively (what the woman deems) heavy

Question 440

Causes of menorrhagia?

Answer 440

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 441

NICE investigation for menorrhagia?

Answer 441

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

Question 442

Management options for menorrhagia/abnormal uterine bleeding?

Answer 442

``` 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 443

Example of antifibrinolytic and administration? how does it work?

Answer 443

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

Question 444

How does mefenamic acid work? administration?

Answer 444

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

Question 445

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

Answer 445

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

Question 446

How does danazol work?

Answer 446

Inhibits sex steroid production and blocks receptors

Question 447

Indications for endometrial ablation?

Answer 447

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

Question 448

Contraindications to endometrial ablation?

Answer 448

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

Question 449

Which options for AUB are fertility sparing?

Answer 449

Uterine artery embolisation and myomectomy/resection of fibroid

Question 450

What time period= puerperium?

Answer 450

From delivery of placenta to 6 weeks following the birth

Question 451

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

Answer 451

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

Question 452

Describe prolactin response in breast feeding?

Answer 452

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 453

Describe oxytocin reflex in breast feeding?

Answer 453

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 454

Benefits of breastfeeding?

Answer 454

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

Question 455

How does post dural puncture headache present?

Answer 455

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

Question 456

RFs for urinary retention in puerperium?

Answer 456

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

Question 457

What is obstetric cholestasis?

Answer 457

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

Question 458

How to manage obstetric cholestasis?

Answer 458

Urseodeoxycholic acid

Question 459

Anti-thyroid drug to use in pregnancy?

Answer 459

Propylthiouracil

Question 460

When would you offer sickle cell and thalassaemia screening?

Answer 460

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

Question 461

When are babies to hepatitis B woman vaccinated?

Answer 461

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

Question 462

When is the combined test offered?

Answer 462

11+2 to 14+1 weeks

Question 463

What is involved in the combined test?

Answer 463

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

Question 464

What can combined test screen for?

Answer 464

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

Question 465

What is quadruple testing for? When to offer?

Answer 465

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

Question 466

What is involved in quadruple testing?

Answer 466

Alpha fetoprotein, total BHCG, oestriol and inhibin A

Question 467

When is the early pregnancy scan done, what for?

Answer 467

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

Question 468

When is foetal anomaly screening done?

Answer 468

18-20 week

Question 469

What does the foetal anomaly screening scan look for?

Answer 469

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

Question 470

When might transdermal patch HRT be used?

Answer 470

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

Question 471

How to diagnose premature ovarian insufficiency?

Answer 471

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

Question 472

How fertile are you generally around menopause?

Answer 472

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

Question 473

Contraindications to HRT?

Answer 473

Undiagnosed abnormal PV loss, breast lump, acute liver disease

Question 474

When should you use HRT with caution?

Answer 474

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

Question 475

Genes associated with breast cancer?

Answer 475

BRCA1/2, Tp53, PTEN, STKII, CDHI

Question 476

How to investigate a breast presentation?

Answer 476

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

Question 477

What is the nottingham prognostic index used for? Formula?

Answer 477

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 478

Receptors used in prognosis and treatment in breast cancer?

Answer 478

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

Question 479

Endocrine treatment options for breast cancer?

Answer 479

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

Question 480

Adjuvants for breast cancer therapy?

Answer 480

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

Question 481

What is non cyclical breast pain usually due to`?

Answer 481

Pulled pectoral or serratus muscle RARELY due to cancer

Question 482

When can you carry out termination of pregnancy?

Answer 482

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 483

Female genital mutilation type 1?

Answer 483

Clitoridectomy (partial or total)

Question 484

FGM type II?

Answer 484

Excision: clitoris and labia minora (partial or total)

Question 485

FGM type III?

Answer 485

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

Question 486

FGM type IV?

Answer 486

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

Question 487

Difference between a uterine fibroid and a poylp?

Answer 487

Fibroid = benign tumour of fibrous muscle tissue Polyp = benign tumour of endometrial tissue

Question 488

UK law on FGM?

Answer 488

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 489

Hormones involved in labour?

Answer 489

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 490

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

Answer 490

Gynaecoid most common others= platypelloid, android, anthropoid

Question 491

Mechanism of labour?

Answer 491

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

Question 492

How much amniotic fluid at term?

Answer 492

500-800mls

Question 493

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

Answer 493

en caul

Question 494

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

Answer 494

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 495

Analgesia options in labour?

Answer 495

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 496

2 planes for mammogram?

Answer 496

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

Question 497

How much does breast cancer screening reduce mortality?

Answer 497

Between 16 and 29%

Question 498

Main two types of invasive breast cancer?

Answer 498

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

Question 499

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

Answer 499

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

Question 500

Fluid and renal physiological changes in pregnancy?

Answer 500

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 501

CV physiological changes in pregnancy?

Answer 501

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 502

Resp physiological changes in pregnancy?

Answer 502

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 503

GI physiological changes in pregnancy?

Answer 503

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

Question 504

Metabolic physiological changes in pregnancy?

Answer 504

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

Question 505

Which pessary will still allow sexual intercourse?

Answer 505

Ring

Question 506

Different types of hypertension to experience in pregnancy?

Answer 506

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

Question 507

What defines gestational hypertension?

Answer 507

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

Question 508

What counts as chronic hypertension with superimposed pre-eclampsia?

Answer 508

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

Question 509

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

Answer 509

Over 30mg/mmol

Question 510

What warrants severe pre-eclampsia?

Answer 510

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 511

Definitive cure for pre-eclampsia?

Answer 511

Delivery of placenta

Question 512

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

Answer 512

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

Question 513

Primary prevention methods for preventing preterm birth?

Answer 513

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

Question 514

Secondary prevention methods for preventing preterm birth?

Answer 514

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 515

How can you manage a woman with threatened preterm birth?

Answer 515

Intravaginal progesterone first line Cervical cerclage can be used

Question 516

Tertiary prevention methods for preventing preterm birth?

Answer 516

Prompt diagnosis, tocolysis and antibiotics, corticosteroids

Question 517

What is foetal fibronectin? significance of it?

Answer 517

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 518

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

Answer 518

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

Question 519

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

Answer 519

At least 20mm

Question 520

General management for any worrying APH?

Answer 520

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 521

Complications of antepartum haemorrhage?

Answer 521

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

Question 522

Uterotonic options?

Answer 522

Oxytocine, ergometrine, carboprost, misoprostol, tranexamic acid

Question 523

Sepsis 6?

Answer 523

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

Question 524

Describe the follicular phase of the menstrual cycle?

Answer 524

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 525

Describe the luteal phase of the menstrual cycle?

Answer 525

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 526

When does progesterone level peak in menstrual cycle?

Answer 526

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

Question 527

How many days from ovulation to menstruation?

Answer 527

14 days

Question 528

What maintains the corpus luteum in pregnancy?

Answer 528

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

Question 529

How does the COCP work?

Answer 529

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 530

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

Answer 530

Day 2-5

Question 531

What happens in the menstrual phase of the menstrual cycle?

Answer 531

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

Question 532

What happens in the proliferative phase of the menstrual cycle?

Answer 532

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

Question 533

What happens in the secretory phase of the menstrual cycle?

Answer 533

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 534

Why do obese people produce more oestrogen?

Answer 534

Increased aromatase

Question 535

How do progestogen contraceptives work?

Answer 535

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

Question 536

What is cervical motion tenderness or cervical excitation seen in?

Answer 536

PID and ectopic pregnancy

Question 537

What is pelvic congestion syndrome?

Answer 537

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

Question 538

How to investigate pelvic congestion syndrome? How to manage?

Answer 538

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

Question 539

How common is failure to conceive after 1 year?

Answer 539

15-25% of couples will not have conceived after 1 year.

Question 540

Common causes of infertility?

Answer 540

Male 30% Ovulatory 25% Tubal 20% Uterine/peritoneal 10% unexplained - 25%

Question 541

Criteria for early referral regarding infertility?

Answer 541

* female age \>35 * known or suspected problem

Question 542

Criteria for early referral regarding infertility?

Answer 542

* female age \>35 * known or suspected problem e.g. menstrual disorder * previous abdo/pelvic surgery * previous PID/STD

Question 543

What preconception advice is given to couples trying to conceive?

Answer 543

* Intercourse – 2-3 x week * Folic acid – 0.4mg (5mg high risk) * Smear * Rubella * Smoking – cessation services * Pre-existing medical conditions * Drug history (prescribed / recreational) * Environmental / occupational exposure * Alcohol (women none * **Weight** (BMI 19 – 30)

Question 544

Primary care investigations for infertility?

Answer 544

- Hormone profile (D2 FSH, D21 Prog) - TFT, Prolactin if indicated - Rubella - Smear - Swabs - Semen analysis

Question 545

Investigations for female infertility?

Answer 545

* mid-luteal progesterone (ovulation) * ovarian reserve testing (ovulation) * Tubal/uterus patency

Question 546

Mid-luteal progesterone values? (anovular, ovular)

Answer 546

\<16 anov 16-30 equivocal \>30 ovular

Question 547

How is tubal/uterine patency investigated in infertility?

Answer 547

Hysterosalpingogram (HSG) Laparoscopy + dye = when pathology suspected e.g. PID, pain, previous surgery

Question 548

Grouping of ovulation disorders? (WHO groups 1-3, other)

Answer 548

_Group 1: Hypogonadotropic (10%)_ * **↓hypo**FSH/LH, **↓hypo**E2 * hypothalamic-pituitary problem: decreased secretion or pituitary unresponsiveness * ammenorrhea (stress, weight loss, exercise), Sheehan's syndrome, tumours _Group 2: Normogonadotrophic (85%)_ * normal FSH/LH, normal E2 * pituitary-ovaries problem * PCOS, hyperprolactinaemic ammenorrhea (prolactin inhibits gonadotropins) _Group 3: Hypergonadotrophic (5%)_ * **↑hyper**FSH/LH, **↓hypo**E2 * premature ovarian failure Other: thyroid, adrenal

Question 549

Treatment of ovulation disorders (WHO groups 1-3)?

Answer 549

Group 1 (hypogonadotropic): FSH+LH, GnRH pump, normalise weight Group 2 (normogonadotropic): Induce ovulation with clomifene Groupo 3: (hypergonadotropic): Donor egg

Question 550

Infertility treatment in group 2 ovulation disorders/PCOS?

Answer 550

1. Normalise weight 2. Clomifene/tamoxifen): * Up to 6 cycles * Stop after 12 mo (increased ovarian cancer risk) * Monitor (Progesterone & USS) * Inform of multiple preg rate (6-8%) 3.Metformin may help if clomifene resistant Further tx: ovarian drilling GnRh ovulation induction

Question 551

Causes of tubal disease infertility?

Answer 551

* Infections: Chlamydia, Gonorrhoea * Endometriosis * Surgical:Adhesions, Sterilisation

Question 552

Treatment for endometriosis infertility?

Answer 552

* Laparoscopic ablation * Laparoscopic cystectomy for endometriomas

Question 553

Treatment of unexplained infertility?

Answer 553

IVF

Question 554

Risks of IVF?

Answer 554

* Multiple Pregnancy * Miscarriage * Ectopic * Fetal abnormality

Question 555

What should happen to baby's heart during and after contractions?

Answer 555

* Decrease during contraction * Increased after contraction * If no increase after contraction, problem

Question 556

How common is stillbirth in the UK?

Answer 556

* 5/1000 live births * one of the highest rates in the developed world

Question 557

Indications for a high risk pregnancy (obstetrician lead rather than midwifery lead)?

Answer 557

* **Underlying medical conditions:** Hypertension, Diabetes, Epilepsy, Rheumatoid arthritis, Asthma, most medical conditions * **Issues with woman:** high/low BMI, smoking/alcohol/drugs, old/young * **Complications in previous pregnancy**: c-section, traumatic delivery, 3^rd/4^th degree tear, pre-eclampsia, preterm birth * **Complications in current pregnancy**: multiple pregnancy, breech presentation, pre-eclampsia, gestational diabetes

Question 558

If a pregnancy is classified as high risk, what does this mean for fetal monitoring?

Answer 558

High risk pregnancies need continuous monitoring with CTG. (Low risk pregnancies will have intermittent auscultation with pinnard stethoscope or handheld doppler.)

Question 559

Normal range for CTGs? * baseline * variability * accels/decels Conditions for a CTG to be classed as normal?

Answer 559

* baseline: 110-160bpm * variability: \>5bpm * accels: present * decels: early - all 4 features need to be within range for CTG to be reassuring - CTG can be suspicious (1 non-reassuring feature) or pathological (2 non-reassuring features/1 abnormal feature)

Question 560

Tools available for continuous monitoring of fetal heart rate?

Answer 560

* CTG (doppler ultrasound) * Fetal scalp electrocardiogram/ecg - used only in labour * Abdominal fetal ECG - not widely available

Question 561

What is cardiotocography (CTG?)

Answer 561

Doppler ultrasound used to measure fetal heart rate (FHR).

Question 562

Frothy discharge indicates?

Answer 562

Trichomonas vaginalis

Question 563

Strawberry cervix indicates?

Answer 563

Trichomonas vaginalis

Question 564

Mirabegron: * use * mechanism * contraindication

Answer 564

* Overactive bladder if anticholinergics not suitable * relaxes sm and increases bladder capacity * uncontrolled bp

Question 565

What causes the symptoms seen in menopause?

Answer 565

Decreasing **oestrogen** levels lead to: Short term * vasomotor: hot flushes, night sweats * general: mood change, irritability, loss of memory/concentration, headaches, dry/itchy skin Medium term * urogenital atrophy: dyspareunia, reucurrent UTIs, PMB Long term osteoporosis CVD and dementia if early menopause

Question 566

How does the risk of breast cancer change when on HRT containing * oestrogen * oestrogen+progesterone?

Answer 566

Oestrogen: little or no change Oestrogen + Progesterone: increased risk depends on duration of treatment and decreases once treatment stops

Question 567

A woman who is on HRT for menopausal symptoms has just been diagnosed with breast cancer. What must you do?

Answer 567

Discontinue HRT immediately.

Question 568

How do oral and transdermal HRT affect risk of VTE?

Answer 568

oral HRT: significantly increased transdermal: no change

Question 569

How do oral and transdermal HRT affect risk of stroke?

Answer 569

oral: slightly increased transdermal: no change

Question 570

How does HRT affect risk of CVD?

Answer 570

* HRT does not increase cardiovascular risk when started in women \< 60 years * The presence of cardiovascular risk factors is not a CI to HRT as long as they are optimally managed

Question 571

For a woman with a uterus you have to give oestrogen+progesterone, but for a woman with no uterus you can give unopposed oestrogen. Why?

Answer 571

Oestrogen causes proliferation of endometrium. In a woman with a uterus, unopposed oestrogen could lead to endometrial hyperplasia\>\>neoplasia\>\>cancer, so we give progesterone to counteract this. In a woman with no uterus;no endometrium, there is no risk of this so can give unopposed oestrogen.

Question 572

HRT regime options?

Answer 572

Oestrogen: oral, gel, patch, vaginal lubricant (for atrophy symptoms) + Progesterone: continuous (Mirena coil, tibolone) or sequential

Question 573

What are the pros and cons of taking continuous combined HRT vs sequential HRT?

Answer 573

Continuous combined: 1/50 risk of breast cancer but no bleeds Sequential: 1/70 risk but bleeds

Question 574

When should transdermal oestrogen be prescribed for HRT instead of oral?

Answer 574

* Gastric upset eg Crohns * Increased risk of VTE including * CVD risk factors: hypertension, BMI\>30 * Need for steady absorption eg migraine/epilepsy * Concomitant hepatic enzyme-inducing drug treatment (for example carbamazepine). * Lactose sensitivity * Patient choice

Question 575

How long can the Mirena IUS be used for in * contraception * HRT?

Answer 575

* Contraception: 5 yrs * HRT: 4 yrs

Question 576

HRT contraindications and cautions?

Answer 576

Cautions * Current, past, or suspected breast cancer * Undiagnosed vaginal bleeding * VTE * arterial thromboembolic disease e.g. angina or myocardial infarct * Active liver disease with abnormal liver function tests. * Pregnancy. * Thrombophilic disorder * **caution** * Diabetes mellitus (increased risk of heart disease). * Factors predisposing to venous thromboembolism. * History of endometrial hyperplasia. * Migraine and migraine-like headaches.

Question 577

Non-hormal HRT options?

Answer 577

Alpha adrenergic receptor agonist–Clonidine SSRI–Fluoxetine–Paroxetine–Citalopram–Sertraline– SSRI-SNRI–Venlafaxine Anti-epileptics–Gabapentin

Question 578

Which non-hormonal HRT options are contraindicated in women on tamoxifen for breast cancer?

Answer 578

SSRIs: fluoxetine and paroxetine

Question 579

What are the long-term complications of early menopause and what does this mean for management?

Answer 579

Early osteoporosis Early CVD Early cognitive decline (dementia) This means women with early menopause should be on HRT.

Question 580

Do women who have undergone early menopause need to be on contraception?

Answer 580

Yes Fertile for 2 years if menopause \<50 years Fertile for 1 year of menopause \>50 years