Obstetrics and Gynaecology Flashcards

Question

What are the symptoms of vulval cancer?

Answer 1

Suspicious symptoms include a vulval lump or ulcer with pain/itchiness which may make them struggle to sit down. Itchiness which is not responding to candesartan should be examined.

Answer 2

examination, biopsy and then a CT chest, abdomen, and pelvis

Answer 3

Treatment is with a wide local excision (+/- skin flap reconstruction), groin node dissection (sentinel or full clearance), chemotherapy to downstage a tumour or radiotherapy and as an alternative to surgery.

Answer 4

This is caused by chlamydia trachomatis and is the most common STI in the UK. It is highly infectious spreading to 75% of the partners of an infected individual. It can affect the male/female urethra, cervix, rectum, pharynx, and conjunctiva. It is often asymptomatic and diagnosed on routine screening.

Answer 5

Urethral discharge, dysuria, urethral discomfort, and testicular pain

Answer 6

Vaginal discharge, dysuria, lower abdominal pain, and dyspareunia

Answer 7

Rectal discharge, conjunctivitis and systemic illness

Answer 8

Complications include pelvic inflammatory disease, epididymo-orchitis, sexually acquired reactive arthritis (SARA is a triad of urethritis, conjunctivitis, and polyarthritis) and perihepatitis (Fitz-Hugh-Curtis Syndrome). There are increased rates of sub-fertility and ectopic pregnancy in women who have had complications from chlamydia.

Answer 9

Diagnosis is with vulvo-vaginal nucleic acid amplification swabs (NAAT) or a cervical NAAT, but this is less accurate and requires a physician to do it. In men, a first pass urine sample is sent for a NAAT test and extra genital sites such as the pharyngeal, rectal or conjunctival swabs can also be sent for NAAT. Chlamydia cannot be seen on a microscope, but pus cells may suggest infection (unspecific for chlamydia) therefore NAAT is the best test.

Answer 10

The management is doxycycline 100mg BD (twice a day) for 7 days. Second line is with azithromycin 1g stat followed by 500mg OD for 2 days (first line in pregnancy or breastfeeding). For under 25s repeat screening is offered at 12 weeks to check for re-infection. Partner notification should be provided by all asymptomatic males and all females for the last 6 months but only notify partners in the last month if the patient is a male with urethral symptoms.

Answer 11

There are three serovars of Chlamydia trachomatis: 1. A-C types cause trachoma (blindness) and usually found in tropical countries 2. D-K types cause chlamydia in the genital tract 3. L1-L3 cause LGV Classical LGV is endemic in parts of Africa, India, SE Asia, Caribbean, and C/S America. A new presentation of LGV re-emerged in MSM (men who have sex with men) in early 2000s and has spread across the UK, Europe, Australia, and the US.

Answer 12

Primary: small painless papules which are ulcerated Secondary: gross lymphadenopathy, buboes, necrosed to form abscesses Tertiary: Scaring, fibrosis, rectal strictures, and fistulae Primary rectal LGV presents with direct transmission to the rectal mucosa and therefore haemorrhagic proctitis which is often mistaken for IBD. Haemorrhagic proctitis is bleeding, pain, tenesmus and change in bowel habit.

Answer 13

Diagnosis is with a rectal NAAT for Chlamydia which needs LGV testing added on to the form. There should be a biopsy of lymph nodes and a culture of fluid from the bubo (75-85% sensitivity).

Answer 14

Management is with Doxycycline 100mg BD for 3/52. A test is cure is done and partner notification should be done for partners 4 weeks before becoming symptomatic or 3 months if they were asymptomatic.

Answer 15

This is caused by the gram-negative intracellular diplococci Neisseria Gonorrhoea. Symptoms are similar to chlamydia but the urethral and vaginal discharge teds to be more purulent. 90% of males will be symptomatic and symptoms occur within 2-5 days of infection. Resistance is a serious problem in gonorrhoea with 9.2% of cases resistant to azithromycin. Ceftriaxone resistance is very low but increased in strains with reduced sensitivity and resistance is on the rise.

Answer 16

Diagnosis is with microscopy which is less than 50% sensitive in women but 95% sensitive in men. NAAT has over 95% sensitivity so should be used for women. A culture should be performed for everyone with a positive NAAT and all contacts at all sites that they have sex. All tests are doubled checked for false positives. Triple site testing is offered to women and MSM. Women who do not have anal sex can also get gonorrhoea in the rectum.

Answer 17

Complications include PID, PO, SARA and disseminated gonococcal infection which presents as a rash with a polyarthritis. It is more common in women but is very rare.

Answer 18

Management is with: 1st line: Ceftriaxone 1g IM stat or ciprofloxacin 500mg PO if culture is sensitive 2nd line: Gentamicin 240mg IM stat and 2g azithromycin PO or cefixime 400mg PO and azithromycin 2g 3rd line: Spectinomycin 2g IM and azithromycin 2g PO or azithromycin 2g PO alone All patients should have a test of cure at 2 weeks. Partners of the patient 2 weeks before symptomatic males should be notified or 3 months for asymptomatic males and all females. Partners should only be treated empirically if they have had sex in the last 14 days, everyone else should be tested and then treated.

Answer 19

This is caused by Trepnonema pallidum (gram negative spirochaete). 75% of cases occur in MSM but rates are increasing in women and heterosexual men. There are also increasing rates of congenital syphilis which has a 40% mortality. The older the patient the worse the outcomes.

Answer 20

After an incubation of 21 days (range 9-80 days) there can develop a chancre (anogenital, single, painless, indurated lesion), moderate lymphadenopathy and ulcers which resolve over 3-8/52.

Answer 21

After an incubation of 3/12 there can develop a maculopapular rash over palms, soles and widespread over the rest of the body (75%), chondylomata lata (wart lesions which need penicillin), mucocutaneous lesions (6-30%), generalised lymphadenopathy (50-86%), sore throat, malaise, weight loss, fever, MSK and multi-system involvement. Tinnitus, ocular syphilis and strokes can occur at this stage.

Answer 22

1. Cardiovascular syphilis presents 10-30 years after infection and is symptomatic/complicated in 10%. In the ascending aorta there may be dilatation or aortic regurgitation. Rarely coronary ostial stenosis and saccular aneurysms can occur. 2. Granulomatous syphilis occurs between 2-15 years and present with granulomatous lesions with a central necrosis. 3. Neurological syphilis (neurosyphilis): This famously presents with the Argyle Robertson pupil which does not dilate to light but does dilate to accommodation. Argyle Robertson pupil presents in Tabes Dorsalis neurosyphilis (15-25 years) which also presents with lightening pains and sensory ataxia. General paresis neurosyphilis (10-25 years) causes progressive dementia with seizures. Finally, meningo-vascular neurosyphilis presents 2-7 years after exposure and usually affects younger patients. The MCA is affected which causes focal arteritis leading to ischaemic stroke, they may have a prodrome of headache, liable emotions and insomnia.

Answer 23

If a Chancre is present (primary or some secondary) then a dark ground microscopy (usually genital lesions only as other sites less accurate) or PCR swab-from the chancre and rash could be taken. Blood tests should always be repeated if negative and high suspicion. The serology is not particularly sensitive. Once there has been a positive syphilis test it will be positive for life.

Answer 24

Management should always be done by the GUM clinic because of the reaction called Jarisch Herxheimer reaction, partner notification and health advice. Prep and Pep may need to be considered. Primary/secondary/early latent: 2.4MU benzathine penicillin IM stat Late latent: 2.4MU benzathine IM stat weekly for 3 weeks Neurosyphilis: 1.8-2.4 MU procaine penicillin IM OD for 14 days with 500 mg QDS probenecid orally, and 40-60 mg Prednisolone given for 72 hours. Partner notification for primary is last 3 months, secondary is 2 years and tertiary is guided by previous serology and try and notify as many as possible. Serology should be repeated in 12 months to monitor.

Answer 25

This is the smallest known self-replicating bacteria. Lots of people carry it without symptoms. Symptoms are similar to chlamydia, and it is responsible for 30% of cases of non-specific urethritis. This is seen in men with clinical urethritis and pus cells (neutrophils) under the microscope. Once Chlamydia and Gonorrhoea are excluded, 30% of those remaining cases will be caused by mycoplasma genitalium. Indications for testing are NSU, PID, muco-purulent cervicitis, Epididymo-orchitis, sexually acquired proctitis or a current sexual partner has a positive case. Testing is with a NAAT test in the area the patient has sex in and rectal in needed. They should be tested for macrolide resistance genes (parC and 23s rRNA).

Answer 26

Uncomplicated: Doxycycline 100mg BD for 7 days followed by Azithromycin 1g stat and then 500mg OD for 2/7. This is in macrolide sensitive samples. Complicated infections are those which fail first line, presented with PID or epididymo orchitis. They should be treated with Moxifloxacin 400mg OD for 14/7 and test of cure at 5 weeks. Only current partners should be notified.

Answer 27

Type 1 is the most common cause of genital herpes whereas type 2 is more likely to cause recurrent symptoms. Initial episodes can be primary or non-primary. In primary cases there are no antibodies to either HSV1 or 2 whereas non-primary has prior antibodies to HSV1 or 2. Recurrent episodes are reactivations of a latent infection.

Answer 28

Symptoms include painful ulceration, dysuria, vaginal or urethral discharge (deep ulceration), prodrome of flu like illness, lymphadenopathy, mild fever, some are asymptomatic or have minor symptoms such as itching. Signs can include vesicles, ulcers (shallow based ulcers) and local lymphadenopathy. The first herpes episodes tends to be bilateral whereas recurrent episodes tend to be unilateral.

Answer 29

Causes of genital ulcers can include HSV, Behcet’s, drug reaction, VIN (Vulval intraepithelial metaplasia) carcinoma, lichen planus, lichen sclerosis, Steven Johnson’s syndrome, candidiasis, LGV, chancroid, syphilis and donovanosis.

Answer 30

Extra genital manifestations of herpes include meningitis, encephalitis, herpetic eye disease (dendritic ulcers) and skin lesions such as herpetic whitlow on the finger.

Answer 31

Complications of HSV include urinary retention, auto-inoculation, secondary bacterial infection of lesions, aseptic meningitis, herpes proctitis and neonatal herpes.

Answer 32

Diagnosis is with a viral PCR swab from skin lesions such as open ulcers or by popping a vesicle. Serology of type specific IgG and a culture may be required. IgG will be negative in early infection and there is often cross reactivity. IgG does not distinguish between oral or genital HSV and there is a poor predictive value in low prevalence populations.

Answer 33

Supportive: Salt bathing, local anaesthetic gels, urinate in warm water such as a shower or bath and take regular analgesia. Vaseline may be used as a barrier to protect the skin. Avoid sex when ulcers are present and counsel them on asymptomatic shedding. Pharmacological management must be started within 5 days of symptoms in order to be effective. Treatment is with acyclovir 400mg TDS (three times a day) for 5-10 days. Valciclovir or Famciclovir can be used as alternatives. Management of recurrences: Often this is only minor symptoms so supportive treatment is needed only. For frequent recurrences (>6 episodes per year) then suppressive treatment can be considered with acyclovir 400mg BD for 3-12 months. In pregnancy, women with HSV should inform their midwives so that they can be offered acyclovir from 36 weeks onwards to prevent neonatal herpes simplex. The risk if greatly increased with acquisition of HSV during pregnancy so these patients should be referred to the GUM clinic so that they can be offered suppression and caesarean section. Neonatal herpes has a very high mortality and morbidity. Serodiscordant relationships are where one partner has HSV and the other doesn’t. Counselling is offered in the GUM clinic and serology, or suppression can be considered in certain cases. Immunosuppressed patients will require long term suppression.

Answer 34

Low risk HPV types (6 and 11) cause benign warts and are spread by skin to skin contact and fomites. High risk types are 16, 18, 31, 33, and 35. They can cause VIN, AIN, PIN, VAIN, CIN and other malignancies. They are screened for on smears, biopsied and sent for histology

Answer 35

Management is with cryotherapy for benign warts, topical agents (imiquimod/podophyllotoxin), electro-cautery, surgery and some patients should be left alone as 30% disappear without treatment. Atypical lesions or lesions not responding to treatment should be biopsied.

Answer 36

Hepatitis A is spread by the faecal oral route, B by vertical transmission/parenteral/sexual and hepatitis C is transmitted by parenteral/sexual/vertical. Patients are seen in GUM and are screened or offer vaccination or referral to hepatology.

Answer 37

Hepatitis A is an RNA virus which can be transmitted by oral-anal sexual contact or digital rectal exposure. The incubation period is 15-45 days (28 average) and GUM screens all patients who are MSM or who have multiple partners, group sex, or having sex on premises (public places such as saunas).

Answer 38

50% of Hep A patients are asymptomatic. There is a prodrome of flu like illness for 3-10 days followed by an icteric stage with jaundice, itching and RUQ pain. 15% of symptomatic patients require hospital treatment and less than 1% will develop acute fulminant liver failure unless they are infected with another hepatitis or HIV.

Answer 39

Diagnosis is with IgM (positive 45-60 days) or IgG for hep A (positive lifelong or vaccination). Other tests include HIV, Hep B, C and E and Syphilis. LFTs and clotting should be checked as with all liver issues.

Answer 40

Management is supportive but consider hospitalisation if there is vomiting, dehydration or signs of decompensated liver disease. In GUM patients are screened and IVDU are screened. Vaccination is offered to HIV or other Hep infection patients. Patients will be monitored for infection and partner notification for partners 2 weeks before and one week after jaundice who should then be vaccinated. All acute hepatitis are notifiable diseases

Answer 41

Hepatitis B is a DNA virus which is transmitted in blood, sexual fluids and vertically. The incubation period is 40-160 days with a prevalence of 1% in the UK. GUM screens sex workers, IVDU, MSM, HIV, high endemic areas, sexual assault victims, needlestick injuries, partners of positive people, and children born to infected mothers.

Answer 42

10-50% of adults are asymptomatic. There are prodromal and icteric phases, but these may be prolonged. 1% will develop acute liver failure which may be more severe than seen in hep A. Chronic carriers may suffer from fatigue and develop signs of chronic liver disease.

Answer 43

Diagnosis is with: 1. HbsAg + (surface antigen) in hepatitis B infection 2. HbsAb + is either in naturally cleared infection or vaccination 3. HbeAg + (envelope antigen) when virus is replicating rapidly 4. Hbe-antibody to e antigen indicates the virus has stopped replicating as rapidly 5. HBV DNA indicates the viral load 6. HbcAg (core antigen) does not circulate in the blood so is not tested 7. HbcAb is IgM high in acute infection IgG is high in chronic or cleared infection Therefore Acute infection: HbsAg +, HbeAg +, HbcAb IgM +, HBV DNA + Chronic infection: HbsAg and HbcAb +, HBV DNA + and HbeAg may be positive Vaccination: HbsAB +ve only Cleared infection: HbcAb + only Chronic carrier state: HbsAg +, HbcAb + and HBV DNA negative

Answer 44

Management is with screening for hepatitis D, A, C, HIV, and syphilis. Refer to hepatology or infectious diseases. Treatment is based on the stage of infection and pattern of disease. Some will clear the infection so 6 months until treatment should be started. Some treatment options are Tenofovir, Entecavir and Peg interferon. GUM will also provide vaccination and partner notification.

Answer 45

Hepatitis C is an RNA virus with a 1% prevalence and the majority are asymptomatic. This is a curable infection and is transmitted parentally and rarely sexually/vertical. There is a long incubation period of 4-20 weeks and can be longer in HIV co-morbidities. GUM is involved because risks include Chemsex (recreational drug use), traumatic anal sex, fisting, group sex, sharing lubricant, sero-sorting and having a partner with HIV. Vertical transmission is higher if the mum also has HIV.

Answer 46

60% are asymptomatic, some experience serious fatigue which improves with treatment. Diagnosis is with bloods for Anti HCV and HCV RNA (viral load). Management is done by the regional MDT which involves directly acting

Answer 47

Absorption: Decreased gastric emptying, decreased small bowel motility, nausea, vomiting, and increased gastric pH Metabolism: Increased hepatic blood flow and increased rate of hepatic metabolism Distribution: Increased cardiac output, increased plasma volume, increased total body fat and water, and decreased plasma albumin Excretion: Increased glomerular blood flow, increased glomerular filtration rate, and thus enhanced clearance.

Answer 48

Pharmacology in pregnancy is complicated by research factors as pregnant women are excluded from clinical trials, most drugs are not tested for use in pregnancy and therefore there is limited guidance on dosing and efficacy in pregnancy. Animal studies cannot be trusted for human research. Spontaneous reporting of side effects is done through the yellow card scheme. There are also congenital malformation registries, pregnancy registries (epilepsy) and population registries (GPRD). These are observational methods. These fail to consider co-factors. Teratogenesis are fetal adverse effects arising from drug and chemical exposure. Congenital malformations occur in 2-3% of pregnancies and 1% of these are caused by drugs. The highest risk is during organogenesis (1st trimester), but there are also risks in growth and neurodevelopment in the 2nd and 3rd trimester. Exposure at term carries the highest risk of neonatal toxicity or withdrawal from drugs. In preconception, drugs can prevent implantation. Alcohol causes fetal growth restriction. In the 3rd trimester anticoagulation can increase the post-partum bleeding risk. Transmission of drugs in breastmilk should always be considered. Prescribing in pregnancy is about managing the risk of harm to the mother by not taking their medication and the risk to the neonate from teratogenesis.

Answer 49

Increased hepatic blood flow, increased cytochrome P450 enzymes and so increased hepatic metabolism. CYP3A4 is a P450 enzyme that is responsible for the metabolism of over 50% of all drugs. The activity of P450 enzymes can be increased or reduced by oestrogen.

Answer 50

Citalopram, amlodipine, diltiazem, methadone, midazolam, nifedipine, and oxycodone

Answer 51

Amitriptyline, codeine, fluoxetine, metoprolol, propranolol, venlafaxine, and haloperidol

Answer 52

All drugs should be avoided In the first trimester. All known teratogens should be avoided and any drug which has to be continued should be done so at the lowest effective dose. High dose folic acid supplementation should be advised and older drugs which are known to be safe in pregnancy should be first line options.

Answer 53

ACE inhibitors: Renal dysfunction and decreased skull ossification Aminoglycosides: Deafness and vestibular damage Cytotoxic drugs: Multiple defects and miscarriage Anti-thyroid drugs: Foetal goitre Carbamazepine: Neural tube defects Diethylstilboestrol: Vaginal carcinoma Lithium: CVS defects include ebstein's anomaly Phenytoin: Foetal hydantoin syndrome Retinoids: Craniofacial, cardiac and CNS defects Sodium valproate: Neural tube defects Warfarin: Foetal warfarin syndrome

Answer 54

Tetracyclines: Tooth discoloration Warfarin: Fetal intracranial hemorrhage Androgens: Masculinization of female feotus NSAIDs: Closure of fetal ductus arteriosus Opioids: Withdrawal effects in neonate Theophylline: Neonatal irritability SSRIs: Neonatal irritability

Answer 55

Antiepileptics: With reduced medication there are increased risks of mortality for the mother, as well as injury, SUDEP and placental abruption. Risks for the fetus from antiepileptics include hypoxia, fetal death, prematurity, and malformation. Children exposed to sodium valproate have a 10% increased risk of congenital malformation and there are longer term effects on neurodevelopmental delay and behaviour. AEDs that can be used are Lamotrigine and Levetiracetam.

Answer 56

Palliative neonatal referrals are made when there has been a diagnosis of a life-limiting/life-threatening illness made in the antenatal period. The foetus must be older than 23/40 weeks and thus classed as viable and the parents have decided to continue with the pregnancy.

Answer 57

A parallel birth plan encompasses normal discussion around a birth plan such as method, pain relief, birthplace and management but also include medical management after birth, religious beliefs, baby’s place of death if that happens and the role of the neonatal unit. Palliative, funeral, and post-mortem decisions. Organ donation can be considered. When the baby is born, they may be given end of life care or active treatment. Even if the baby is considered for active treatment the parallel plan remains in place just in case. Post bereavement care is also offered.

Answer 58

There should be screening for other STIs before commencing antibiotics so that a diagnosis can be made, and it is not compromised. Antibiotics should be started as a priority if PID is suspected and should not be delayed whilst awaiting an appointment or swab results. She should be counseled to avoid sexual intercourse until the improvement of symptoms and advised about barrier methods of contraception if this is unlikely or not possible. All partners of a woman in the last 6 months should be traced and managed appropriately.

Answer 59

Whilst awaiting the chlamydia and gonorrhoea results the patient should be offered empirical treatment of a broad-spectrum antibiotic such as doxycycline 100mg BDO for 1/52. If the results come back as positive then treat the partners as well. The patient should be advised to complete the course of antibiotics even if the swabs are negative because this will reduce the risks of long-term complications such as PID, infertility, ectopic pregnancy, and chronic pelvic pain. You should advise sexual abstinence until both partners have completed their antibiotics. You should advise that in future a barrier contraception method should be used as this greatly reduces the risk of re-infection and protect against STIs.

Answer 60

TOA: This is diagnosed with a mass on CT or laparoscopy. There will be persistent high temperature and infection markers. This should be treated with drainage of the abscess. Micro-organisms can include e coli, and actinomyces Israeli. PID: No presence of mass on CT. Infection markers will improve with antibiotics. This is seen in chlamydia and gonorrhea.

Answer 61

Follow the BASHH Guidelines for PID. This suggests IV Ceftriaxone 2g daily plus IV doxycycline 100mg BDO. IV therapy should be continued until 24 hours after clinical improvement and then switched to oral doxycycline 100mg BD and metronidazole 400mg BD for 2/52. Remember to include a STOP/Review date. Alternatives can include clindamycin, gentamicin, oflaxacin and ciprofloxacin. Warfarin interacts with antibiotics so this will require monitoring of the INR. Monitoring requirements include INR, infection markers and swab results to ensure antibiotics are working

Answer 62

Warfarin needs to be reversed. Pre-operatively the aim of under. if surgery can be delayed for 6-8 hours then use Vitamin K 5mg IV (phytomenadione). If the surgery cannot be delayed then anticoagulation can be reversed with pro-thrombin complex concentrate. This should be discussed with the haematologist.

Answer 63

She can have either oral or transdermal options and the drug will be estradiol or conjugated equine oestrogens. Tablets: Elleste Solo, Premarin, Progynova and Zumenon Transdermal patches: Evorel, Elleste Solo Mx, Estradot or Progynova TS Transdermal gel: Sandrena or Oestrogel In women with a uterus, Oestrogen only HRT can increase the risk of endometrial cancer which is reduced by the addition of progesterone. In women with a history of endometriosis, endometrial foci may remain despite hysterectomy and the addition of progesterone should be considered in these circumstances.

Answer 64

Women are considered potentially fertile for 2 years after their last menstrual period if under 50 and 1 year if over 50.

Answer 65

Tablets Advantages: Easy to take, convenient and variety of doses. Disadvantages: Cannot be used if VTE risk, migraines, stroke risk, GI disorders affecting absorption, and gallbladder disease Patches Advantages: Lower risk of N&V than other forms, lower VTE risk, less chance of causing migraines, easy to use, able to shower, swim and bathe. Disadvantages: If it begins to peel off it will become defective, can cause local irritation, increased absorption in hot climates, and plaster marks Gels Advantages: As per patches and dose can be easily adjusted Disadvantages: Only available as oestrogen and patients who need higher doses need to use vast quantities of gel.

Answer 66

A patient that is peri-menopausal so should be started on sequential therapy (cyclical combined HRT). Sequential therapy is where oestrogen and cyclical progesterone is used for at least 10-14 days within 28 days to mimic the cycle. The patient will still have a withdrawal bleed. This can be prescribed as Elleste duet, femoston, prempak C, evorel sequi or femSeven sequi. Other options include Mirena intrauterine system, medroxyprogesterone (provera) tablets, and Micronized progesterone (Utrogestan) capsules. If her symptoms were vaginal/bladder related due to urogenital atrophy only then treatment should be a topical vaginal oestrogen such as Estradiol (Vagifem or Estring) or Estriol (Ovestin cream, Imvaggis pessary or Blissel vaginal gel). Tablets and creams should be used nighly for 2 weeks and pessaries/gels for 3 weeks. The patient should then continue twice weekly as maintenance. This can be continued long-term

Answer 67

Continuous combined HRT regimens are indicated in patients who have not had a hysterectomy and are either post-menopausal (last period more than 12 months ago) or in patients once they reach the age of 54 or have been on HRT for 5 years. Continuous combined HRT is classed as ‘bleed-free’.

Answer 68

Over 5 years there is a higher risk of breast cancer with 5 years treatment with new HRT preparation. There is also a higher risk of VTE. All types of HRT can increase the risk of breast cancer after 1 year of use. The risk is higher for combined oestrogen-progesterone HRT (especially continuous preparations). The longer the duration the higher the risk. Vaginal preparations are considered low risk for breast cancer. Long term use of combined or oestrogen only HRT is associated with a small increased risk of ovarian cancer, and the risk reduces a few years after stopping HRT. The risk of VTE is increased when using these HRT types, especially in Y1. Risk is lower transdermally. They also slightly increase the risk of stroke.

Answer 69

Oestrogen related: Breast tenderness, bloating, nipple sensitivity, leg cramps, nausea, heartburn, headaches and fluid retention. These should settle within 3 months or dose may need to be lowered. Changing the type of oestrogen or administration may also help Progesterone related: Breast tenderness, fluid retention, headaches, mood swings, PMT-like symptoms, bloating, acne and greasy skin. This should be managed by changing the type of progesterone, reducing the dose if possible, changing the route, altering the duration and changing the regimen.

Answer 70

Start empirical treatment such as Nitrofurantoin MR 100mg BD for 3 days (if eGFR over 45) or trimethoprim 200mg BD for 3 days. Should also consider paracetamol and oral fluid. There is limited evidence for cranberry containing products.

Answer 71

A recurrent UTI is defined as 2 or more episodes of LUTI in the last 6 months or 3 episodes in 12 months.

Answer 72

1st line: Trimethoprim 100mg at night or nitrofurantoin 50-100mg at night 2nd line: Amoxicillin 250mg at night or cephalexin 125mg at night The risks of long-term antibiotics include antimicrobial resistance and increased risk of adverse effects. Therefore, it should only be used when essential. If the patient is started on trimethoprim, she needs to use adequate contraception. Trimethoprim is teratogenic in the first trimester. She should seek immediate advice if she becomes pregnant. Seek urgent attention if UTI symptoms develop and different antibiotics should be used from the prophylaxis if UTi develops.

Answer 73

Stress urinary incontinence: Involuntary leakage of on effort on exertion, or on sneezing or coughing Urgency urinary incontinence: Involuntary leakage accompanied by, or immediately preceded by, a sudden compelling desire to pass urine which is difficult to defer. UUI is part of a larger symptom complex known as overactive bladder syndrome (OAB). OAB is defined as urinary urgency, with or without incontinence, which is usually associated with increasing frequency and nocturia. Symptoms usually occur without a UTI or other pathology. Mixed urinary incontinence: This is both stress and urgency incontinence; involuntary leakage is associated with both urgency and physical stress (exertion/sneeze/coughing).

Answer 74

Mixed incontinence should be managed according to their most predominant type of urinary incontinence.

Answer 75

Stress incontinence should be managed with duloxetine trials (an SSRI). This should be started at 20mg BDO for 2 weeks and then increased to 40mg BDO. The patient should be reassessed after 2-4 weeks.

Answer 76

Lifestyle advice should include reducing caffeine intake, maintain balanced fluid intake, advise weight loss if needed and smoking cessation. Bladder training can be considered and pelvic floor exercises. After 2 months of no improvement of her UUI she should continue bladder training. Pharmacological treatment can include Oxybutynin immediate-release 5mg BD, Tolterodine immediate-release 2mg BD or darifenacin 7.5mg daily. Oxybutynin should not be used in the frail. Mirabegron may be used in patients for whom anti-muscarinic medications are contra-indicated. Treatment should be reviewed after 4 weeks. If effective it should be reviewed again in 12 weeks. Potential side effects of anti-muscarinic medications can include dry mouth, constipation, dizziness, drowsiness, headache, nausea, vomiting, dyspepsia, palpitations, tachycardia, urinary retention, skin reactions and flushing. Can’t think, see, spit, pee or poo or: Blind as a bat (mydriasis), dry as a bone (mouth, sweating and eyes), hot as a hare (increased body temperature), mad as a hatter (delirium) and red as a beet (flushing).

Answer 77

This is used to assess skull shape with sutures. It is also useful for brain structures such as the cavum septum pellucidum, lateral ventricles, choroid plexus, thalamus, and cerebellum.

Answer 78

- NHS fetal Anomaly Screening Programme (FASP) aims to ensure there is equal access to unform and quality assured screening across England and it is offered to all pregnant women (not mandatory). No screening test is mandatory and it should be noted that additional tests can increase the risk of miscarriage. - Dating scan should occur between 10-14 weeks. This encompasses the combined test for Trisomy 21 (11+2 to 14+1 weeks). There is also the CRL 45-84mm for combined screening. CRL is crown rump length. This also assesses multiple pregnancy. - Anomaly scan is undertaken between 18+0 to 20+6 weeks. This aims to identify abnormalities which indicate the baby may die shortly after birth. It also aims to identify conditions which may benefit from treatment before or after birth, plan delivery in an appropriate hospital/centre and there is no requirement to determine gender as very few disorders are related to gender.

Answer 79

2. Nuchal Translucency is the ultrasound appearance of a collection of fluid under the skin, behind the neck of the fetus, in the 1st trimester. Over >3.5mm is considered abnormal. Lower values will still contribute to risk as part of the combined screening test for T21. Associations with raised NT include aneuploidy, T21/18/13/Turner’s, congenital diaphragmatic hernia, abdominal wall defects (exomphalous), skeletal dysplasia, miscarriage, and normal outcome.

Answer 80

Congenital heart disease is the most common congenital abnormality affecting 0.5-1% of all live births. AVSD found on anomaly scan has a 50% chance of being Down’s syndrome. CMV and toxoplasmosis are risk factors for cardiac abnormalities. Warfarin, sodium valproate and methotrexate. Anti-lo/ra antibodies seen in Sjogrens is also a risk factor. Family history is an important risk factor.

Answer 81

The chromosomal abnormalities associated with an AVSD include Trisomy 21, Turner’s syndrome whereas Trisomy 13/18 are less common causes of AVSD. If AVSD is detected antenatally in about 50% of T21 children. Turner’s syndrome is more commonly associated with coarctation of the aorta.

Answer 82

Increased NT, increased nuchal fold, hypoplastic/absent nasal bone, ventriculomegaly, echogenic bowel, short femur and duodenal atresia. Cardiac abnormalities can include AVSD, VSD, ASD and tetralogy of fallot.

Answer 83

Increased NT, holoprosencephaly, ventriculomegaly, microcephaly, exomphalous, echogenic bowel, and intrauterine growth restriction. Cardiac abnormalities than can be seen include ASD, VSD, hypoplastic heart syndrome, and coarction of the aorta.

Answer 84

Increased NT, ventriculomegaly, cleft lip and palate, micrognathia, clenched hands, rocker-bottom feet, exomphalous, diaphragmatic hernia and intrauterine growth restriction. Cardiac abnormalities can include ASD, VSD tetralogy of fallot, and coarctation of the aorta.

Answer 85

Increased NT and hydrops (oedema in the fetus). Cardiac abnormalities include coarctation of the aorta and hypoplastic left heart syndrome.

Answer 86

Invasive tests to confirm T21 include: Both carry a miscarriage risk, failure to obtain a sample, fetal injury, maternal bowel injury, amniotic fluid leakage, chorioamnionitis, and discomfort. NIPT (non-invasive prenatal testing is not available on the NHS). Amniocentesis: Carried out from 15+0 under real time USS guidance but carries a 1/200 loss rate. Late amniocentesis may cause PPROM. There is a risk of infection and pain. Chorionic Villous Sampling: This can be carried out at 11+0 – 13+6 weeks but carries a 1-2% risk of miscarriage.

Answer 87

Psychological effects of these investigations can include heightened anxiety, uncertainty, stress, grief, and difficult decisions based on debatable information. To counteract this patient should be provided with multiple opportunities to ask questions, have information widely available and psychological support.

Answer 88

2-3% of pregnancies are affected by a single major structural anomaly. The frequency is higher closer to conception. Fetal structural abnormalities account for 10% of stillbirths and 25% of neonatal deaths. Advancing maternal age is a risk factor.

Answer 89

Concerning aspects of the history which suggest a higher chance of structural abnormality include the maternal age >40 and a previous pregnancy affected by a fetal chromosomal problem (T18) which increases the risk of recurrence by 1%. Maternal age over 40 increases the risk of aneuploidy as T21 risk 1:60 compared with 1:1100 for 25–29-year-olds.

Answer 90

The causes of ventriculomegaly (posterior horn of lateral ventricle 10mm or greater) include idiopathic/primary (majority), chromosomal abnormalities such as T21 (3-4%), and viral infections such as CMV and toxoplasmosis. Idiopathic may occur with other intracranial or CNS anomalies such as spina bifida. The majority of cases are isolated, arising during embryogenesis with obstruction of the flow of CSF through the ventricular system. Initially they should be offered a simple blood test for fetal viral infections such as CMV and toxoplasmosis and amniocentesis to assess for fetal chromosomes. Amniocentesis cannot detect single gene disorders and carriers a 1:200 risk of miscarriage.

Answer 91

Screening options include the combined test (measures PAPP-A, beta HCG, combined with maternal age and fetal nuchal translucency measurement), quadruple test (HCG, AFP, oestriol, inhibin A which is then combined with maternal age), and fetal structural anomalies can be detected with a detailed USS between 18+0 – 20+6. This is where the posterior horn of the lateral ventricle is measured and should be under 10mm. For the combined test, high risk is above 1/150. Quad only provides info for T21/18 whereas combined is T21/18/13. Other fetal imaging can include MRI of the fetal brain which can help to identify if the ventriculomegaly is isolated or is associated with other structural brain abnormalities. This is done after 30 weeks because fetus is less mobile so still image can be taken and the brain has developed more so the structures can be visualised clearly. This can then be used to counsel patients accurately about neurodevelopmental delays. Over 85% of babies with isolated mild and non-progressive ventriculomegaly have good outcomes. 1/3 of cases will have progressive severe dilatation which in some cases become severely dilated with hydrocephalus.

Answer 92

7Antenatal and postnatal considerations should include: Antenatal: Monitoring for progression of ventriculomegaly and size of fetal head, planning mode of delivery (usually vaginal but caesarean may be needed if fetal head too large) Postnatal: Neonatal assessment and USS imaging after birth, outpatient neurosurgical clinic review

Answer 93

Risk factors for multiple pregnancy include advanced maternal age (>35), previous multiple pregnancy, use of fertility enhancing treatments (clomid and IVF), and maternal family history of dizygotic twins.

Answer 94

Twin pregnancies can be differentiated into monozygotic and dizygotic pregnancies. Monozygotic (identical) twin pregnancies result from the division of the fertilised oocyte into two embryonic layers whereas dizygotic (fraternal) twin pregnancies arise from the fertilisation of two oocytes with two spermatozoa. Multiple pregnancies are classified based on how the amniotic sac and placenta are divided among the fetuses, as shown on USS. Chornionicity relates to placenta and amniocity relates to the amniotic sac. Dizygotic twin are almost exclusively dichorionic-diamniotic. Monozygotic twins have different types depending on when the division occurred.

Answer 95

These account for 1/3 of all twin pregnancies. Division of the fertilised oocyte into embryonic layers which are thus genetically identical. Choronicity and amniocity varies

Answer 96

These account for 2/3 of twin pregnancies and occur due to fertilization of two oocytes by two sperm. They are genetically different and always dichorionic diamniotic.

Answer 97

Dichorioic-diamniotic is where each baby has an amniotic sac and placenta Monochorionic-diamniotic is where the babies share the same placenta but have separate amniotic sacs Monochorionic-monoamniotic is where the wins share the placenta and amniotic sac Combined twins: The twins share an amniotic sac and placenta and are conjoined

Answer 98

Twins affect 1:80 pregnancies accounting for 2% of births. The prevalence of dizygotic twins varies across populations whereas monozygotic twins’ rates are stable worldwide at 3-5/1000.

Answer 99

Maternal complications of twins include anaemia, gestational hypertension, pre-eclampsia, gestational diabetes, preterm labour, past-partum haemorrhage due to atony and operative/instrumental delivery

Answer 100

6. Monochorionic twin pregnancy are specifically related to Twin To Twin Transfusion Syndrome, sFGR, twin anaemia-polycythaemia sequence (TAPs), twin reversed arterial perfusion (TRAP) sequence, and single intrauterine death. They have increased risk of pre-eclampsia, DVT, gestational hypertension, preterm labour, PPH, and hyperemesis (more bHCG). Monochorionic twins are seen fortnightly whereas dichorionic is seen monthly. TTTS occurs in monochorionic twin pregnancies. Blood flowing in a fixed direction from one twin to the other results in the transfer of blood from the donor twin to the recipient twin. This poses a risk for both fetuses. The recipient twin is at risk of polycythaemia or polyhydramnios in diamniotic pregnancies whereas the donor twin is at risk from anaemia, dehydration, growth retartdation, and oligohydramnios (is diamniotic pregnancies). TTTS complicates 10% of monochorionic pregnancies. sFGR (selective fetal growth restriction) is where one twin is normal and the other twin is growth restricted. Growth discordance between twins is over 25% and it complicates 10% of monochorionic pregnancies. Growth disconcordance is calcaluted as: Weight discordance = ((larger twin weight – smaller twin weight) / larger twin weight) x 100 TAPS (twin anaemia-polycythaemia sequence) is an atypical chronic form of TTTS caused by slow transfusion of RBCs through a very small placental AV anastomoses, resulting in anaemia of one twin and polycythaemia of the other. The amniotic fluid volumes will be normal. TRAP (Twin reversed arterial perfusion sequence) is where one twin has an absent or rudimentary heart which is perfused by its co-twin (pump twin and acardiac twin) via aberrant arterio-arterial anastomoses. The Acardiac twin is completely dependent on the circulatory support from the pump twin, and its upper body and head are often poorly developed or absent. As a result of the circulatory burden of supporting is acardiac twin the pump twin may develop heart failure, preterm birth, or death. This is seen in less than 1% of monochorionic pregnancies

Answer 101

The Quintero stages of TTTS: Stage 1: Oligohydramnios and polyhydramnios sequence and the bladder of the donor twin is visible. Dopplers in both twins is normal Stage 2: Oligohydramnios and polyhydramnios sequence but the bladder of the donor is not visible. Doppler is normal in both twins Stage 3: Oligohydramnios and polyhydramnios sequence but the bladder is not visualised and there are abnormal dopplers. Stage 4: One or both fetuses show signs of hydrops Stage 5: ONe or both fetuses have died

Answer 102

Hydrops fetalis is a condition in which large amounts of fluid builds up in the fetal organs and tissues causing odema. There is an 80% chance of demise if TTTS stage 2 is left untreated. In general there is a 50% chance of survival of both babies, 25% one baby and 25% no babies. This will vary by gestation of diagnosis and intervention.

Answer 103

Fetoscope laser ablation is a procedure in which a laser is inserted through a fetoscope to ablate superficial blood vessels on the surface of the placenta that cross the inter-twin membrane.

Answer 104

Before 20 weeks gestation, the max vertical amniotic fluid pockets for Oligohydramnios and Polyhydramnios are usually defined as <2cm and >8cm, respectively. After 20 weeks it becomes over 10cm.

Answer 105

Amnionicity and fetal presentation at the onset of labour affect the choice of delivery route in twin pregnancies. Vaginal delivery is possible for monochorionic diamniotic or dichorionic diamniotic twins in which the presenting twin is cephalic at the onset of labour if appropriate expertise in internal and external version and / or vaginal breech delivery is available. Caesarean delivery is preferred for all monoamniotic twins, diamniotic twins with a non-cephalic-presenting twin, and for pregnancies with standard obstetric indications for caesarean delivery (e.g. placenta praevia).

Answer 106

1. Ovulation should occur at day 21 in a regular 28 day cycle so can be measured with mid-luteal progesterone. 2. Ovarian reserve assessment is via Anti-mullerian hormone (AMH) and early follicular phase FSH/LH (day 2-4) 3. Tubal patency is assessed with a HyCoSy ultrasound scan and other options include a hysterosalpinogram (HSG) X-ray ad laproscopy with dye is the surgical option.

Answer 107

The types of subfertility include: Normospermia: Normal sperm quality Oligospermia: Reduced sperm count Astenospermia: Reduced sperm motility Teratospermia: Reduced sperm morphology Cryptospermia: Very low sperm count (under 2 million) Combination: Oligoteratoasthenospermia which is very low sperm count, reduced morphology and motility

Answer 108

The parameters recorded on a male semen analysis include the volume (>1.5ml), concentration (>15million/ml), motility excellent + sluggish (>32%), total sperm count (>39 million) and normal morphology (>4%).

Answer 109

Thorough history including childhood undescended testes, infection (mumps), surgery (hernia, varicocele, tumour, trauma or chemotherapy) and respiratory problems such as cystic fibrosis. The examination should include secondary sexual characteristics (consider Klinefelter’s), palpation, and full examination. Blood tests include FSH, LH, Testosterone, Prolactin, Oestradiol, TFTs, Karyotype (Y micro deletion) and cystic fibrosis markers. Radiology should only be a USS if there is undescended testes. Testicular sperm extraction and testing with TESE, micro TESE, PESA and MESA.

Answer 110

Low FSH/LH/Testosterone is seen in hypogonadotrophic hypogonadism Low FSH/LH and high testosterone is seen in anabolic steroid use High FSH/LH and low testosterone is seen in testicular failure

Answer 111

Treatment depends on the cause. Consider donor sperm or appropriate hormone replacement of FSH, LH or testosterone. Testicular sperm extraction and testing with TESE, micro TESE, PESA and MESA.

Answer 112

This may have been caused by lifestyle (sedentary, alcohol, and smoking), diet (higher oestrogen content and fast foods) and environmental causes (pesticides, fertilisers, and chemicals)

Answer 113

General medical history taking should be performed with attention to pregnancy history, duration of chlamydia, smoking, timed intercourse, factors influencing IVF, and the NHS funding criteria of age of the woman, BMI, smoking (both) and childlessness (both)

Answer 114

Investigations should include semen analysis for the male. For females an ovarian reserve assessment (AMH or FSH/LH), TFTs, prolactin, chlamydia, gonorrhoea urine and swabs. USS for pelvic anatomy and tubal patency can be assessed with a HyCoSy ultrasound or HSG x-ray.

Answer 115

The chances of conceiving after a period of unprotected sex if all tests come back as normal is 80% for one year and 90% for 2 years.

Answer 116

- Ovulation induction: Anovulation is treated with clomiphene citrate (anti-oestrogen) or letrozole (aromatase inhibitor). This does not increase the live birth rate of a normal woman but will increase multiple pregnancy rate so should be used only in anovulating women. - Artificial insemination/in utero insemination (IUI) Both of these options require patent fallopian tubes and healthy sperm. If there is hydrosalpinx on scan, then discuss tubal removal before IVF. There may be a role of STIs in tubal disease. - Medically assisted reproduction (MAR); artificial reproductive technology (ART); in vitro fertilisation (IVF); intracytoplasmic sperm injection (ICSI) if male factor

Answer 117

Women are born with all their eggs which get reabsorbed as they age. This causes reduced fertility and higher aneuploidy and thus miscarriage. Further, Down’s syndrome risk is age related so 1:1000 at age 30, 1:250 at 37, 1:100 at 40 and 1:30 at 45.

Answer 118

The man already having children has implications for the couple because some NHS trusts do not fund IVF for couples with pre-existing children of either parent. Childlessness is defined as Other considerations include the health economics of fertility funding and NHS 18-week referral to treatment targets (RTT)

Answer 119

Currently single females and same sex females are entitled to NHS funded fertility investigations. Male couples are not funded apart from general sperm testing.

Answer 120

PCOS can present with a history of hirsutism, irregular cycles, oily skin, and male pattern hair loss. On examination there may be increased body habitus, facial hair and chest hair growth.

Answer 121

Investigations should include anti-Mullerian hormone (raised over >40 in PCOS); early follicular phase gonadotrophins LH/FSH with ratio over 3:1; impaired glucose tolerance test; USS – Rotterdam criterion, ring of pearls (small follicles around periphery).

Answer 122

An increased BMI is relevant because Mersey NHS excludes women with a BMI of over 30 from treatment. Obesity is associated with reduced fertility treatment outcomes and obstetric complications. Until the intended mother loses enough weight they will not be funded. After that, anovulatory subfertility, due to oligomenorrhoea secondary to PCOS may be the cause of the subfertility. This means she would be funded for treatment. For borderline cases (35-day cycles), a trial of clomiphene citrate ovulation induction might be undertaken.

Answer 123

Initial management options can include donor sperm insemination as a first line option. If the couple pay for 6 rounds of this privately they will be deemed to have proven subfertility in a heterosexual couple and thus will be eligible for NHS funded treatment.

Answer 124

500ml with a normal input of 1.5-2L and output of 1-2.8 litres

Answer 125

Damage during childbirth, increased abdominal pressure (obesity/pregnancy), damage during hysterectomy, neurological conditions, connective tissue disorders such as Erlos Danlos syndrome and some medications.

Answer 126

Alcohol, caffeine, poor fluid intake, constipation, UTIs, tumours, neurological conditions (MS and Parkinson’s), and certain medications.

Answer 127

1. Storage/filling phase: The bladder is filled at a pre-determined rate and the patient is asked to describe sensations such as desire to void, urgency, bladder pain and the urodynamic bladder capacity is assessed. The patient is asked to cough every minute to check the lines in place and the presence of detrusor contractions. 2. Provocation: Leak with cough sitting and standing 3. Voiding phase: This starts when the patient is given permission to void and it provides information about flow rates and stream, complete/incomplete bladder emptying, and detrusor muscle pressure required to empty the bladder if the patient strains to void.

Answer 128

Conservative management: 3-month trial of pelvic floor exercises is 1st lne and should consist of 8 contractions 3x a day. Consider electrical stimulation if they cannot actively contract the muscles. Pharmacological management: Duloxetine is 2nd line management in women who do not want surgery or are unsuitable but they must be made aware of the side effects. Surgical management: Options include laparoscopic/burch colposuspension, autologous facial sling, TVT/TOT with a mesh and bulking agents such as Bulkamid. Colposuspension involves suspending the urethrovesical junction to the iliopectineal ligament which can be open or laparoscopic. Complications include bleeding, infection, injury, urinary retention, overactive bladder, posterior wall collapse and osteitis pubis.

Answer 129

First line treatment: Life-style changes with fluid intake and reduction of caffeine, alcohol and fizzy drinks. If over BMI 30 then advise to lose weight. Bladder retaining should be tried for 6 weeks and involves teaching deferring techniques to increase bladder capacity. Second line treatment: Anticholinergics or Mirabegron (B3 receptor agonist used when anticholinergics not tolerated). Lower doses should be used in the elderly and effects take around 4 weeks. Common side effects of anticholinergics include blurred vision, dry mouth, tachycardia, and constipation. They are contraindicated in acute angle glaucoma. Examples are oxybutynin, solifenacin, fesoteridine, and tolterodine. Third line treatment: Intravesical Botox lasts for 9 months, Posterior tibial nerve stimulation (PTNS) and sacral nerve stimulation.

Answer 130

Modified oxford grading for pelvic muscle strength: Grade 0: No discernible contraction Grade 1: Very weak contraction like a flicker Grade 2: Weak contraction Grade 3: Moderate contraction with some squeeze and lift ability Grade 4: Good contraction with squeeze and lift against resistance Grade 5: Strong contraction with squeeze and lift against strong resistance

Answer 131

Higher parity, vaginal childbirth, advancing age, increased BMI, hysterectomy, constipation, family history, connective tissue disorders, occupations with heavy lifting, and instrumental deliveries.

Answer 132

Cystocele: Prolapse of the anterior vaginal wall Urethrocele: Prolapse of the area below the urethra Rectocele: Prolapse of the lower posterior vaginal wall Enterocele: Prolapse of the upper posterior vaginal wall Uterine prolapse: Descent of the uterus down the vagina/outside the vagina Vault prolapse: Descent of the top of the vagina down the vagina/outside the vagina

Answer 133

Urinary incontinence affects 25-45% of women over the age of 40 with over 50% being due to stress urinary incontinence. It is a major cause of depression. Stress UI is caused by movement of the bladder neck inferiorly (such as in a prolapse) so that there is no longer abdominal pressure exerted on the urethra and sole control of urinary retention is therefore due to the sphincter. When there is raised intra-abdominal pressure, this can be enough to overcome the sphincter resistance and leakage of urine can occur.

Answer 134

Pelvic organ prolapse is present in over 50% of women 12 years after their first delivery. 24% will have POP protruded beyond the hymen. 80% of women with POP will also have SUI.

Answer 135

Frequency (8 times a day), nocturia (>1 per night), urgency, urge incontinence and nocturia.

Answer 136

Leaking with coughing, laughing or straining

Answer 137

involuntary loss of urine on effort or physical exertion, or on sneezing or coughing

Answer 138

Hesitancy and incomplete emptying

Answer 139

On examination there may be signs of vulval irritation/excoriation from urine or skin disorders, vaginal atrophy, cough leak test, and presence of pelvic organ prolapse, the strength of the pelvic floor should be assessed with squeeze test on DRE and vaginal examination to check for pelvic/adnexal masses.

Answer 140

The grade of any uterine prolapse is categorised as 1. Descent within the vagina 2. Descent to hymen 3. Descent beyond hymen 4. Uterus outside vagina (procidentia)

Answer 141

Investigations could include urine dipstick, post-micturition bladder scan to assess residual volume, bladder diary for minimum 3 days, consider cystoscopy, urodynamic testing, USS to exclude pelvic mass and proctogram/ARMS if bowel symptoms co-exist.

Answer 142

Bulking agents (Bulkamid) which has a 40-50% success rate but the least side effects of less voiding dysfunction, CISC and OAB and repeat injections. Colposuspension has an 80% success and can be done laparoscopically or with open surgery. Risks include voiding dysfunction, CISC, OAB, laparoscopic injury, posterior wall prolapse and pelvic pain. Autologous fascial sling has an 80% success rate and greatest longevity. However, this has the greatest risk of voiding dysfunction, CISC, OAB, wound hernia, and injury to pelvic organs TVT has a 70% success rate. There is a risk of bladder/urethral injury, OAB, mesh complications, voiding dysfunction and CISC

Answer 143

Investigations should include a urine dipstick (infection), flow study and post void residual scan and bladder diary to rule out nocturnal polyuria.

Answer 144

Surgical options include Pelvic floor repair and sacrospinous fixation or colpoclesis.

Answer 145

CIN 1: 1/3 thickness affected and can revert to normal in 10-23 months CIN 2: 2/3 thickness CIN 3: Full thickness Management of CIN 1 is cold coagulation and follow up according to NHS screening guidelines. LLETZ is large loop excision of transformation zone which is performed under LA to confirm diagnosis and treat.

Answer 146

SCC (85%), adenocarcinoma, malignant melanoma and sarcoma.

Answer 147

Management options are colposcopy, cystoscopy and sigmoidoscopy, investigations of FBC/U&Es/LFTs, MRI pelvis/CT abdomen chest, clinical staging with FIGO, cone biopsy, Wertheim’s hysterectomy and radiotherapy.

Answer 148

Symptoms include intermenstrual bleeding, post-coital bleeding, vaginal discharge, pelvic pain, abnormal looking cervix and pelvic vein thrombosis causing swollen leg.

Answer 149

Obesity, DM, HTN, unopposed oestrogen (HRT), family history of breast cancer, colorectal cancer (HNPCC) and endometrial cancer.

Answer 150

USS for endometrial thickness, hysteroscopy with dilation and curettage, MRI abdomen and pelvis, chest X-ray, FBC/U&Es/LFTs

Answer 151

Discuss in MDT, hysterectomy with bilateral salpingoopherectomy, FIGO staging after surgery, chemotherapy/radiotherapy, and hormonal therapy or palliation.

Answer 152

CA125 and CA19-9 but usually advanced stage when detected

Answer 153

Those with a family history such as BRCA are offered annual USS as there is a 5-10% increased risk. They may also go for prophylactic removal of the tubes and ovaries once their family is complete.

Answer 154

Types: 70% are epithelial, germ cell and sex chord stromal usually affect younger patients. Epithelial include serous, mucinous and endometrioid. Sex chord stroma are granulosa cell. Malignancy germ cell tumours are dysgerminoma and immature teratoma. Metastases are also possible

Answer 155

MDT discussion, hysterectomy and bilateraly salpingo-ophorectomy, and omentectomy, and then FIGO staging. Chemotherapy is with Carboplatin. Tumour markers can be used for monitoring. Palliative care is with drainage of ascites.

Answer 156

Women present with vulval itching/irritation, pain and bleeding. It can develop from lichen sclerosis, VIN, lichen planus and Paget’s disease. Lesions can be exophytic or ulcerative. It spreads locally and can embolise to the inguinal lymph nodes.

Answer 157

Treatment is with local excision in early disease with radiotherapy to protect sphincter function. Radical vulvectomy with inguinal node dissection is done for larger tumours.

Answer 158

Vaginal carcinoma is very rare and usually secondary to another malignancy elsewhere. Most are SCC and rarely adenocarcinoma. They are treated with chemotherapy and radiotherapy.

Answer 159

These are aggressive tumours arising from the myometrium of the uterus including leiomyosarcoma, endometrial stromal sarcoma, and mixed mullerian tumours. MRI and CT chest should be done and then surgical resection.

Answer 160

Fallopian tube cancers are extremely rare. 90% are papillary serous adenocarcinoma which arise from the endosalpinx and transition from benign to malignant tubal mucosa. The ovaries and endometrium will be normal or contain very small tumours. They present with vaginal bleeding, pain, and discharge. USS will show a tubal cystic mass which is diagnosed at laparotomy with FIGO staging. Management is with surgical TAH and BSO along with omentectomy and removal of lymph nodes. Chemotherapy as an adjunct.

Answer 161

1. Initial investigations should include urine dipstick, pregnancy test, FBC, U&Es, LFTs, calcium profile, amylase, CA125, US or CT and possibly an AXR.

Answer 162

Differentials can include germ cell ovarian tumours secreting HCG, molar pregnancies, fibroid uterus with red degeneration, or sarcoma in pregnancy. She needs investigations with cross-sectional imaging. This could include a MR Abdomen and Pelvis with DWI. A CT CAP would also be helpful to look for metastatic disease once pregnancy has been firmly excluded.

Answer 163

The routine cervical cancer screening programme first call is at 24.5 years. Screening is not recommended to under 25s. If HPV is negative then 3 year follow up until 49 and 5 year from 49-65. If the screen is positive, cytology will be assessed and a referral for a colposcopy is indicated if there is dyskaryosis. Women who have been vaccinated against HPV should still attend as vaccine does not cover all HPV subtypes. HPV 16 and 18 are responsible for 80% of cancers which have been successfully tackled with the vaccine. Genital warts have also fallen by 90% with HPV 6/11 dealt with.

Answer 164

RMI is calculated as menopausal status x USS score x Ca125. Any RMI greater than 250 is high risk of ovarian cancer so she is at high risk. She should be referred to a specialised gynaecological oncology centre.

Answer 165

Menarche typically occurs between 10-16, menopause around 51, and menstrual cycles lasts 28 days with ovulation 14 days before next period. Menses typically last between 3-5 days.

Answer 166

A fertility history should include pregnancy history, STIs, smoking, timed intercourse, occupation, diabetes, HTN and same sex couples. NHS funding criteria is based on the age of the woman, BMI, smoking (both), childlessness (both), and local NHS trust guidelines. Female Fertility Assessment: Measure mid luteal progesterone at day 21 if there is a regular 28-day cycle. Ovarian reserve assessment is with anti-Mullerian hormone (AMH) and early follicular phase FSH/LH (day 2-4). Tubal patency can be assessed with HyCoSy USS, Hysterosalpingogram X-ray or laparoscopy with dye.

Answer 167

This should always be seriously assessed and considered if it is HRT related. There should always be investigations. Rapid access clinic uses USS and endometrial assessment with a biopsy. The risk of endometrial cancer is the reason for 2WW as most are stage 1 which has a very high cure rate with hysterectomy.

Answer 168

The history should include drugs, health, medication, alcohol, STI history, safeguarding concerns, last sexual contact and type of sex, previous sexual partners, risk assessment for blood borne viruses, protection from STIs and prevention of pregnancy. Risk factors include sexual contact outside of Europe, IVDU and sex workers.

Answer 169

Clause A: The continuance of pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated Clause B: The termination is necessary to prevent grave permanent injury to the physical or mental health of the woman Clause C: The pregnancy has NOT exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman. This is used for 98% of terminations. Clause D: The pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing children of the family of the pregnant woman. Clause E: There is a substantial risk that if the child were born it would suffer from physical or mental abnormalities as to be seriously handicapped.

Answer 170

Menopause is a biological stage in a woman’s life when menstruation ceases permanently die to loss of ovarian follicular activity. It is usually diagnosed clinically after 12 months of amenorrhoea and usually occurs in the over 45s. The average age is 51. The menopause is caused by the loss of all the oocytes. During perimenopause the ovarian follicular activity begins to fall which causes oestrogen levels to decrease. This causes negative feedback to the pituitary gland causing FSH and LH to rise to try to stimulate the ovaries to produce oestrogen. With less oocytes the ovaries fail to respond so falling oestrogen levels begin to disrupt the menstrual cycle and cause menopausal symptoms. Oestrogen production becomes insufficient to stimulate the endometrium and amenorrhoea occurs. Cycles tend to become anovulatory and eventually follicular development stops. The menopausal pattern of low oestrogen and persistently high FSH/LH is established. The diagnosis of menopause is a clinical diagnosis. Perimenopause is diagnosed in over 45s with menopausal symptoms. Menopause is diagnosed in women aged 45+ who have not had a period for over 12 months and not using hormonal contraception and in women without a uterus with menopausal symptoms. FSH blood test is used to diagnose menopause only in women aged under 45. Two FSH blood tests 6 weeks apart and FSH over 30 on both tests means menopause. Oestrogen containing and high dose progesterone contraception can affect FSH tests so unable to test whilst taking these. Peri/menopause symptoms include irregular periods, hot flushes, night sweats, and palpitations caused by the pulsatile release of FSH. Psychological symptoms include fatigue, depression, reduced libido, insomnia, poor concentration, and short-term memory loss. MSK symptoms include osteoporosis, osteoarthritis, and sarcopenia (age-related muscle wasting). Urogenital complications include dyspareunia, vulval dryness, itching, urinary frequency, recurrent UTIs, incontinence/prolapse, and vaginal atrophy from reduced oestrogen. 75% of women will experience vasomotor symptoms and 25% of these are severely affected.

Answer 171

Perimenopause: This is menopausal transition in the months/years before the menopause when clinical features of approaching the menopause start due to falling oestrogen levels.

Answer 172

Premature menopause: Is also known as premature ovarian insufficiency or premature ovarian failure. This is defined as menopause occurring before 40. Loss of normal ovarian function (<40). Cessation of periods with elevated gonadotrophin levels and it occurs in 1/100. It is unexplained in most cases.

Answer 173

Menopause occurring between 40-45

Answer 174

Menopause increases the risk of heart disease, osteoporosis, stroke and urinary incontinence.

Answer 175

A woman is considered potentially fertile for 2 years after her last menstrual period if she is less than 50 and 1 year if she is over 50. HRT does not provide contraception so must be on additional contraception.

Answer 176

Causes can include genetic/chromosomal abnormalities, strong maternal family history, autoimmune disease, chemotherapy/surgery/radiotherapy, infections (mumps/malaria/shigella), and hysterectomy with preservation of the ovaries can disturb blood supply to ovarian tissue.

Answer 177

Based on combination of oligomenorrhoea/amenorrhoea of more than 4 months’ duration associated with elevated gonadotrophins (FSH >40 iu/L) on at least two occasions measured 4-6 weeks apart in women under the age of 40.

Answer 178

These women are at increased risk of cardiovascular disease, osteoporosis, and cognitive impairment. Lifestyle advice is with balanced diet, adequate calcium intake, vitamin D supplementation, exercise, smoking cessation, and avoidance of excessive alcohol intake. Hormone replacement is likely to lower the long-term risk of CVS disease, prevent osteoporosis, and have a beneficial effect on cognitive function. Assessment of bone mineral density should be considered at the time of diagnosis and advised to take hormone replacement and continue to do so until natural age of menopause unless there are contraindications. HET or the COCP can be used. HRT may be more beneficial in improving bone health and cardiovascular markers compared to the COCP. Other causes to consider in a patient presenting with cessation of periods under 40 are secondary amenorrhoea which is seen in PCOS, low BMI, rapid weight loss, excessive exercise, and hyperprolactinaemia. Sheehan’s syndrome (pituitary infarction due to prolonged, severe hypotension following major obstetric haemorrhage). Secondary amenorrhoea can also be caused by asherman’s syndrome (intrauterine adhesions following surgery or endometritis), cervical stenosis after cervical treatment or adrenal causes such as virilising adrenal tumours.

Answer 179

Non-pharmacological: 1. Lifestyle: sleeping in a cool room/lighter clothes/sleep hygiene 2. Regular exercise 3. Weight loss 4. CBT Pharmacological: 1. SSRI/SNRI – vasomotor symptoms and anxiety/depression 2. Vaginal lubrication 3. Clonidine – vasomotor symptoms but limited evidence 4. Gabapentin – hot flushes limited evidence 5. Complementary therapies are not recommended by nice but include Isoflavones (vasomotor symptoms and anxiety), black cohosh (vasomotor symptoms) and red clover (anxiety). HRT is Oestrogen +/- progesterone. Women with a uterus would be combined preparation (oestradiol plus progesterone). Women without a uterus would be given an oestrogen only preparation.

Answer 180

HRT can be given orally or transdermally (patch/gel). Progesterone can also be given locally to endometrium as IUS. Transdermal HRT may be appropriate if women prefers this route, there are GI side effects with oral, history or risk of VTE, taking a hepatic enzyme-inducing drug (carbimazole), bowel disorder that may affect treatment, or a history of migraine. HRT benefits include improval of symptoms, decreased risk of fragility fractures, decreased CHD risk, decreased Alzheimer’s risk, decreased risk of colorectal cancer and decreased risk of T2DM. Oestrogen only HRT has little or no increased risk for breast cancer. Combination HRT does increase the risk and this increases with duration of treatment and falls when stopped. Women should be counselled that other factors such as BMI ad alcohol can have a greater effect on risk than HRT. Women who are overweight or obese have a 6 times increased risk compared with HRT. HRT risks include endometrial cancer (reduced by addition of progesterone), VTE (only for oral preparation not transdermal), coronary heart disease (increased in over 60s or pre-existing CHD), and stroke risk is increased when oral HRT is started in women over 60s not transdermally.

Answer 181

HRT contraindications include current/past breast cancer, oestrogen sensitive cancer, undiagnosed vaginal bleeding, untreated endometrial hypoplasia, VTE (unless on anticoagulation), active or recent arterial TED (MI or angina), active liver disease with abnormal LFTs, but uncontrolled HTN is no longer a contraindication but is an indication for transdermal HRT. 160/95 is in the BNF as a reason to stop HRT.

Answer 182

In the UK, the age of consent is 16 but 1/3 of young people have had intercourse before 16. Under 13 is considered under the age to be able to legally consent and should be referred to the child protection services. The Fraser Guidelines: UPSSI - The young person understands the professional’s advice (U) - The young person cannot be persuaded to inform their parents (P) - The young person is likely to begin, or to continue having sexual intercourse with or without contraceptive treatment (S) - Unless the young person receives contraceptive treatment their physical or mental health are likely to suffer (S) - The young person’s best interests require them to receive contraceptive advice or treatment with or without parent consent. (I) It is important that the young person is made aware of confidentiality policies including when this would need to be breached. You should consider whether there have been exploitation/coercion, this should be routinely checked for between 13-16 years. 16–17-year-olds are protected by the sexual offenses act of 2003 that it should be considered sexual abuse if engaged in a relationship with a person in a position of trust, regardless of consent. During the consultation, consider whether they could be pregnant, consider drug interaction, inform about all methods of contraception, think about suitability and consider medical eligibility.

Answer 183

All young people attending for contraception should be informed about STIs and routes of transmission, that condoms and diaphragms offer protection against STIs including HIV and syphilis and how to use and access free condoms.

Answer 184

Options include the progesterone only subdermal implant, progesterone only injectables (POI), and intrauterine contraception (IUC) such as a IUS or IUD. These are the most reliable and cost effective contraception options.

Answer 185

The CU-IUD is the most effective method of emergency contraception and should be considered by all women who have unprotected sex and do not want to conceive. It is the only method of emergency contraception which is effective after ovulation. This can be inserted within 5 days after the first UPSI in a cycle or within 5 days of the earliest estimated date of ovulation, whichever is later. This provides immediately effective ongoing contraception and is not affected by BMI or other drugs. If there is a risk that there is already an implanted pregnancy then a CU-IUD should not be used. Oral emergency contraception should be offered ASAP after UPSI if a CU-IUD is not appropriate or accessible. It is unlikely to be effective if taken >120 hours after the last UPSI. This works by delaying ovulation and so the oral EC is not effective after ovulation. There are 2 options: Levonorgestrel or ulipristal acetate.

Answer 186

This is defined as bleeding from the uterus corpus that is abnormal in duration, volume, frequency, and/or regularity. It is very common and affects women of reproductive age.

Answer 187

The FIGO classification: Normal is defined as bleeding every 24-38 days, duration of bleeding of up to 8 days, regularity between 7-9 days, and normal flow Abnormal: is defined as bleeding <24 days or <38 days, for longer than 8 days, regularity over 8-10 days, and subjectively abnormal flow.

Answer 188

PALM COEIN: P – polyps A – Adenomyosis L - Leiomyoma M - Malignancy C – Coagulopathy O – Ovulatory E – Endometrial I – Iatrogenic (tamoxifen causes HMB) N – Not yet classified

Answer 189

Investigations should include high vaginal swab, endocervical swab, smear, urinalysis, pregnancy test, FBC, clotting, and hormone profile if suspecting an ovulatory cause such as PCOS (LH: FSH) and oestradiol for premature ovarian failure and thyroid function tests. Imaging is not required unless there is a bulky uterus but it is normal done with a USS for structural causes such as polyps and fibroids.

Answer 190

LING-UIS, tranexamic acid, norethisterone/medroxyprogesterone, NSAIDs, COCP, and POP

Answer 191

Surgical options are usually reserved for polyps. Hysteroscopy, endometrial ablation, uterine artery embolisation, myomectomy, and hysterectomy

Answer 192

This is defined as bleeding from the genital tract after 24 weeks gestation. There are many causes but the most serious are placenta praevia and placental abruption.

Answer 193

Placenta praevia is where the placenta partially or completely covers the opening of the cervix. This can be major or minor and presents with painless vaginal bleeding. Signs include a high presenting part, malpresentation and a soft uterus. TV USS should be done to confirm diagnosis. Investigations should include a G&S, cross match, U&Es, and kleihauer (if RhD negative). The patient may require hospital admission until delivery or emergency C-section.

Answer 194

Fetal assessment should escalate step wise from fetal movement assessment, fetal auscultation, CTG and then USS.

Answer 195

Placental abruption: This is where an abnormally sited placenta separates in part or completely from the uterus. This can be concealed, revealed or both. Symptoms are sudden onset severe abdominal pain and PV bleeding. Signs include a hard uterus, vaginal bleeding, fetal distress and maternal shock. Haemodynamic instability can develop can quickly and there is a risk of pre-term delivery, hypoxic ischaemic encephalopathy and intrauterine death. This is an obstetric emergency.

Answer 196

Risk factors include multiparous os, previous c-section, adhesions from previous surgery, history of placenta praevia, ART for fertility and multiple pregnancy.

Answer 197

Risk factors include placental abruption in a previous pregnancy, hypertension, HELLP, pre-eclampsia, trauma, smoking and cocaine.

Answer 198

Primary PPH is blood loss of 500 ml or more occurring from the genital tract within 24 hours of delivery. The cause should be identified and adjusted. This is known as the 4Ts: Tone, trauma, tissue, and thrombin: Tone: Uterine massage, bimanual compression, medical and then surgical management Trauma: Repair Tissue: Manual removal Thrombin: Haematology advice as this can be seen in HELLP syndrome and requires replacement of blood.

Answer 199

Secondary PPH is defined as excessive abnormal bleeding from the genital tract from 24 hours post-delivery to 6 weeks. This is more common in developing countries and is seen in endometritis, retained placenta and membranes or trauma.

Answer 200

Only high-risk women should have an intrapartum CTG such as those with abnormal intermittent auscultation, deranged maternal observations, sepsis, significant meconium, abdominal pain, APH, hypertonus, oxytocin use, confirmed delay in 1st/2nd stage, other medical conditions or pregnancy conditions or problems that arise during labour.

Answer 201

DR – Define risk (hypoxia, susceptibility to damage of the fetus to difficult labour) C – Contractions (frequency, and compare them to accelerations) BRA – Baseline Rate (average should be between 110-160) V – Variability (how much the line moves around the baseline rate) should be between 5-25 A – Accelerations (up for 15 beats for 15 seconds) These must be present antenatally but not during labour. D – Decelerations (down for 15 beats for 15 seconds) O – Opinions (Always write your conclusion) Normal CTG will have all features reassuring and CTG should be continued. Non-reassuring CTG: 1 non-reassuring feature and 2 reassuring features. If this occurs any underlying causes should be corrected such as hypotension or uterine hyperstimulation, perform a full set of maternal obs, start conservative measures such as changing position, inform obstetrician, document a plan for reviewing the whole clinical picture and the CTG, and discuss with patient and family.

Answer 202

When a CTG is pathological (1 abnormal feature OR 2 non-reassuring features) then acute events of cord prolapse, placental abruption and uterine rupture must always be ruled out as these are life-threatening. Correct any underlying causes such as hypotension or uterine hyperstimulation and start conservative measures. If abnormality persists, then consult obstetrician and senior midwife. Offer digit fetal scalp stimulation, consider fetal blood sampling, consider expediting birth, and take the woman’s preferences into account. Urgent investigation is required if there is acute bradycardia, or a single prolonged deceleration of more than 3 minutes. Urgently seek obstetric help and if there has been an acute event, expediate birth. Expediate birth if acute bradycardia occurs for more than 9 minutes. Take the woman’s preferences into account.

Answer 203

Early: uncommon repetitive deceleration caused by the head being squeezed. They are not late and not of concern. Variable: These can be typical or atypical. Typical is not worrying. Typical variable decelerations are V shaped, barocreptor related so less worrying as this is mechanical stress. Atypical are chemoreceptor, U shaped which indicates hypoxia. Late: Late decelerations tend to be chemoreceptor related, U shaped and more concerning.

Answer 204

e-PAQ is a quality-of-life assessment which should be done for illness affecting someone’s life. Bladder diary for volume and habits

Answer 205

The risk of stillbirth is increased with gestation over 41 weeks, BMI over 30, smoking, aged over 40, IVF, T1DM, previous stillbirth, multiple pregnancy, and intrauterine growth restriction. Inducing at 41 weeks reduces the risk of stillbirth as 42 weeks is proven to be significantly higher. IOL may also improve the sense that the woman is in control of the labour. Inducing halts maternal disease risk, prevents stillbirth and harm and is often a maternal wish. Risks of IOL include harm to mothers (CS, forceps, PPH, and prolonged labour), harm to baby (fetal hypoxia), cost to NHS and bad experiences. IOL may not be beneficial before 39 weeks because there are respiratory distress risks.

Answer 206

Fetal distress, maternal exhaustion, neurological (myasthenia) or cardiac comorbidities in the mother, and delay in 2nd stage of labour.

Answer 207

Episiotomy can cause a 3rd/4th degree tear and does not always work. There are also fetal risks such as swelling on the head and marks on the face. If it does not work an emergency C-section will be required.

Answer 208

Simpson-Braun forceps are the most common or a handheld suction cup is often used. When using forceps there must be adequate analgesia with a pudendal block or epidural. This is beneficial as it is less reliant on maternal effort but there is a need to do an episiotomy with all forceps to minimise Obstetric anal sphincter injury risk. Always check for vaginal trauma. This is the instrument of choice for preterm infants. In theatre it is useful for rotating the baby.

Answer 209

Ventouse is a suction cup that can be used with a pudendal block or local infiltration if necessary. This is more reliant on maternal effort than forceps. The positioning of the cup is very important and consider episiotomy in nulliparous women. It should not be used on babies under 34 weeks and be cautious with babies under 36 weeks due to bleeding risk. Warn the mother that there will be a swelling on babies head which will settle down quickly.

Answer 210

Fetal Biometry looks at the biparietal diameter and head circumference, abdominal circumference and femur length. These are used to calculate an estimated fetal weight. LGA is large for gestational age (>90th), SGA is small for gestational age (<10th) and fetal growth restriction is under 10th with abnormal doppler.

Answer 211

Polyhydramnios: Maximum Pool Depth (MPD) >10cm . This is seen in twin pregnancies, diabetes, gut atresia, infections (parvovirus B19, rubella and CMV) and rhesus disease. Oligohydramnios: MPD <2cm. This can be caused by placental abnormalities, post due date, dehydration, diabetes, hypertension/pre-eclampsia, PPROM, twin-to-twin transfusion syndrome and congenital abnormalities of the fetus renal tract. Anhydramnios: no measurable liquor. This is caused by bilateral renal agenesis or fetal renal failure and is 100% fatal unless treated.

Answer 212

Medical: Methotrexate provided the patient is stable, small, no free fluid on US and bhsc. Surgical: Salpingectomy

Answer 213

Management of miscarriage: This has to be diagnosed by USS Missed miscarriage: Conservative/medical (misoprostol)/surgical approach Incomplete miscarriage: As per above but higher success for conservative management Inevitable miscarriage should be managed by monitoring and stabilising the patient. If the bleeding does not settle, she would need surgical management.

Answer 214

There is increased renal blood flow during pregnancy with an increased GFR of around 50%. There is also a decreased in blood pressure and proteinuria increases (normal in pregnancy 300mg/24hr with a PCR under 30mg/mmol).

Answer 215

CKD reduces fertility and is proportionate creatinine. Proteinuria is associated with adverse outcomes with a PCR of over 100 increasing the risk of preterm delivery two-fold. Risks for the mother include thrombo-embolic disease, worsening renal function, HTN/pre-eclampsia, and for the baby there is an increased risk of intrauterine growth restriction and preterm delivery.

Answer 216

ACE inhibitors should be stopped when pregnancy is confirmed. Once pregnant these women are looked after by a joint obstetric and renal clinic with basline U&Es and urine PCT. eGFR is not validated in pregnancy and a drop in creatinine is a good prognostic sign. Drug level monitoring should be done if the patient is on tacrolimus. Safe alternatives to ACE inhibitors include labetalol, nifedipine, and methyldopa. Aspirin 150mg OD should be given as this is shown to reduce the risk of pre-eclampsia and LMWH should be given if there is significant proteinuria or lupus. There should be IOL at 38 weeks. There is a lower threshold for dialysis at urea over 20mmol/L. Post-partum breast feeding is okay. Monitor BP and restart ACE-I if appropriate.

Answer 217

Bacterial vaginosis: This presents with an offensive fishy vaginal discharge. This is the overgrowth if anaerobic organisms. It is seen in vaginal douching, change of partner, smokers and women who are black. A Clue Cell: This is a vaginal epithelial cell that when examined under a microscope is found to have a cluster of bacteria attached to it. If the normal bacteria (lactobacilli) are not there but there are many clue cells then the diagnosis is likely bacterial vaginosis. Treatment is to avoid vaginal douching and metronidazole 400 mg BDS for 5-7 days. Symptomatic pregnant women should be treated in the same way. Alcohol should be avoided with metronidazole. No partner notification is necessary as this is not an STI and no test of cure is required.

Answer 218

The full sexual health screen should include blood sample for HIV and syphilis and depending on the risk also test for Hep B and C. Dysuria should be tested with urinalysis. Leucocytes can be positive in an STI.

Answer 219

Gonorrhoea is a gram-negative diplococcus. This infects mucus membranes, incubates 2-5 days, and in men can be asymptomatic but most have urethral discharge. There may also be dysuria and increased frequency. Untreated gonorrhoea can cause prostatitis, epididymitis, acute urethritis, later urethral strictures, SARA, and disseminated gonococcal infection. Antibiotic sensitivity should be assessed via a culture plate before commencing treatment because there is a high risk of resistance. Treatment is with first line ceftriaxone 1g IM injection given with 1% lignocaine as per BASHH guidelines.

Answer 220

Non-gonococcal urethritis (non-specific urethritis) can be caused by chlamydia, mycoplasma genitalium, ureaplasma, trichomonas vaginalis, adenoviruses and HSV. If NSU is diagnosed then there should be a further NAAT for mycoplasma genitalia. The treatment for NSU is doxycycline 100 mg BD for 7 days.

Answer 221

The COCP contains progesterone and oestrogen which inhibits the ovulation process, thickens cervical mucus, and thins the lining of the endometrium. If used correctly it is over 99% effective in preventing pregnancy.

Answer 222

Every patient should have their BMI, BP and STI screen done for prescribing.

Answer 223

Monophasic COCP is 21 days of pills and then a 7-day break. This is the most commonly prescribed pill and there are the same number of hormones in all the tablets. Phasic 21-day pills are different pills in a pack containing different amounts of hormones. These have to be taken in the right order. Try to keep as close to the natural menstrual cycle. Every day (ED) pills) are 21 pills containing hormones and 7 break pills taken continuously over 28 days.

Answer 224

The other benefits of COCP include making bleeds regular, lighter and less painful, reduced risk of ovarian, uterine and colon cancer, reduced symptoms of PMS and can be used for acne. Disadvantages include temporary side effects such as headaches, nausea, breast tenderness, and mood swings. It can also increase BP, does not protect against STIs, there can be breakthrough bleeding and spotting, can interact with medications and has been linked to increased risk of VTE and breast cancer.

Answer 225

Category 1: A condition for which there is no restriction for the use of the method Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of the method requires expect clinical judgment and referral to a specialist contraceptive provider. Category 4: A condition which represents an unacceptable health risk if the method is used

Answer 226

UKMEC 3 or 4 is an absolute contraindication. Examples of UKMEC 4 are pregnancy, smoker aged over 35, BMI over 35, history of VTE, family history of VTE under 45, history of stroke of vascular disease, heart abnormality including hypertension, migraine with aura, history of breast cancer, gallbladder or liver disease and diabetes with complications or longer than 20 years.

Answer 227

This should be done in days 1-5 of the menstrual cycle and there is no need for further contraception. If it is started at any other time during the cycle then will need to take additional contraception for the first 7 days.

Answer 228

1. Miss 1 pill anytime should be taken asap even if this means 2 pills in one day and then continue as normal. No need for additional contraception. 2. Miss 2 pills in a pack then this becomes more complicated and depends on where in the cycle the pills were missed. 3. Diarrhoea and vomiting: If you vomit within 3 hours of taking the pill then take another one. You will need contraception until well again because the pill may not be absorbed properly. Post-partum should be considered for contraception from 21 days after delivery.

Answer 229

No contraception used, withdrawal method, barrier method has failed, failure of contraceptive pill or device, unprotected sex within 28 days of starting enzyme inducing drugs and/or 21 days post-partum if not breastfeeding. Always do a pregnancy test before staring EC and an STI screen. Ask about their menstrual cycle and where they are in it at the moment. Have they had the EC before and what type. Safeguard all patients.

Answer 230

The copper bearing intra-uterine device is always offered first. Copper is toxic to eggs and sperm and is effective immediately. It works by inhibiting fertilisation and preventing implantation. Needs to be inserted within 120 hours (5 days) of UPSI and within 5 days of expected date of ovulation. Need to do an STI screen before insertion. This is the most effective EC at 99%. Neither tablet is effective after ovulation but coil is. Advantages: Can be used as ongoing contraception and can be removed after use if used for EC. It is easily removed, and fertility is immediately restored. Disadvantages: Pain during fitting, uterine perforation risk, pelvic infection risk, HMB, and spontaneous expulsion.

Answer 231

Levonorgestrel (levonelle): This is progesterone pill with an unknown mechanism of action. It is thought to inhibit ovulation. It does not interfere with implantation. It should be used within 72 hours of UPSI or contraceptive failure and is taken as a single tablet of 1.5mg (doubled in obese). Repeated dose is required if vomiting within 3 hours. Not suitable for women taking drugs that induce liver enzymes. Ulipristal Acetate (EllaOne): This inhibits or delays ovulation. After LH levels have peaked and ovulation has occurred this is ineffective. It is taken as a single 30 mg tablet within 120 hours of UPSI or contraceptive failure. A repeated dose is required if vomited within 3 hours, not suitable for women taking liver enzyme inducing drugs, breastfeeding should be avoided for 1 week and not advised in poorly controlled asthma. All women who have had EC are advised to do a pregnancy test after 3 weeks of UPSI.

Obstetrics and Gynaecology Flashcards

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