Obstetrics & gynaecology Flashcards

Question

What are some differentials for excessive, discoloured or foul-smelling discharge?

Answer 1

Bacterial vaginosis Candidiasis (thrush) Chlamydia Gonorrhoea Trichomonas vaginalis Foreign body Cervical ectropion Polyps Malignancy Pregnancy Ovulation (cyclical) Hormonal contraception

Answer 2

Irritants such as soaps, detergents and barrier contraception Atrophic vaginitis Infections such as candidiasis (thrush) and pubic lice Skin conditions such as eczema Vulval malignancy Pregnancy-related vaginal discharge Urinary or faecal incontinence Stress

Answer 3

Not starting menstruation: By 13 years when there is no other evidence of pubertal development By 15 years of age where there are other signs of puberty, such as breast bud development

Answer 4

deficiency of LH and FSH

Answer 5

lack of response to LH and FSH by the gonads (the testes and ovaries)

Answer 6

Hypopituitarism Damage to the hypothalamus or pituitary, for example, by radiotherapy or surgery for cancer Significant chronic conditions can temporarily delay puberty (e.g. cystic fibrosis or inflammatory bowel disease) Excessive exercise or dieting Constitutional delay in growth and development Endocrine disorders such as growth hormone deficiency, hypothyroidism, Cushing’s or hyperprolactinaemia Kallman syndrome

Answer 7

Previous damage to the gonads (e.g. torsion, cancer or infections such as mumps) Congenital absence of the ovaries Turner’s syndrome (XO)

Answer 8

genetic condition causing hypogonadotrophic hypogonadism, with failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia)

Answer 9

congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone, and overproduction of androgens from birth Autosomal recessive

Answer 10

tissues are unable to respond to androgen hormones (e.g. testosterone), so typical male sexual characteristics do not develop. It results in a female phenotype

Answer 11

Imperforate hymen Transverse vaginal septae Vaginal agenesis Absent uterus Female genital mutilation

Answer 12

Full blood count and ferritin for anaemia U&E for chronic kidney disease Anti-TTG or anti-EMA antibodies for coeliac disease

Answer 13

FSH and LH will be low in hypogonadotropic hypogonadism and high in hypergonadotropic hypogonadism Thyroid function tests Insulin-like growth factor I is used as a screening test for GH deficiency Prolactin is raised in hyperprolactinaemia Testosterone is raised in polycystic ovarian syndrome, androgen insensitivity syndrome and congenital adrenal hyperplasia

Answer 14

Xray of the wrist to assess bone age and inform a diagnosis of constitutional delay Pelvic ultrasound to assess the ovaries and other pelvic organs MRI of the brain to look for pituitary pathology and assess the olfactory bulbs in possible Kallman syndrome

Answer 15

no menstruation for more than three months after previous regular menstrual periods

Answer 16

Dopamine agonists such as bromocriptine or cabergoline

Answer 17

Detailed history and examination to assess for potential causes Hormonal blood tests Ultrasound of the pelvis to diagnose polycystic ovarian syndrome

Answer 18

High LH, or LH:FSH ratio raised testosterone

Answer 19

adequate vitD and calcium COCP or HRT

Answer 20

psychological, emotional and physical symptoms that occur during the luteal phase of the menstrual cycle, particularly in the days prior to the onset of menstruation

Answer 21

Low mood Anxiety Mood swings Irritability Bloating Fatigue Headaches Breast pain Reduced confidence Cognitive impairment Clumsiness Reduced libido

Answer 22

General healthy lifestyle changes, such as improving diet, exercise, alcohol, smoking, stress and sleep Combined contraceptive pill (COCP) RCOG recommends COCPs containing drospirenone first line (i.e. Yasmin). Drospironone as some antimineralocortioid effects, similar to spironolactone. Continuous use of the pill, as opposed to cyclical use, may be more effective. SSRI antidepressants Cognitive behavioural therapy (CBT)

Answer 23

Pelvic examination with a speculum and bimanual Full blood count, coag screen, ferritin Outpatient hysteroscopy Pelvic and transvaginal ultrasound

Answer 24

Tranexamic acid when no associated pain (antifibrinolytic – reduces bleeding) Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Answer 25

Mirena coil (first line) Combined oral contraceptive pill Cyclical oral progestogens, such as norethisterone 5mg three times daily from day 5 – 26 (although this is associated with progestogenic side effects and an increased risk of venous thromboembolism)

Answer 26

endometrial ablation and hysterectomy

Answer 27

Intramural means within the myometrium (the muscle of the uterus). As they grow, they change the shape and distort the uterus. Subserosal means just below the outer layer of the uterus. These fibroids grow outwards and can become very large, filling the abdominal cavity. Submucosal means just below the lining of the uterus (the endometrium). Pedunculated means on a stalk.

Answer 28

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

Answer 29

palpable pelvic mass or an enlarged firm non-tender uterus

Answer 30

Hysteroscopy pelvic ultrasound MRI

Answer 31

referral to gynaecology Symptomatic management with NSAIDs and tranexamic acid Mirena coil – depending on the size and shape of the fibroids and uterus Combined oral contraceptive Cyclical oral progestogens Surgical options for larger fibroids are: Uterine artery embolisation Myomectomy Hysterectomy GnRH agonists, such as goserelin (Zoladex) or leuprorelin (Prostap), may be used to reduce the size of fibroids before surgery.

Answer 32

Heavy menstrual bleeding, often with iron deficiency anaemia Reduced fertility Pregnancy complications, such as miscarriages, premature labour and obstructive delivery Constipation Urinary outflow obstruction and urinary tract infections Red degeneration of the fibroid Torsion of the fibroid, usually affecting pedunculated fibroids Malignant change to a leiomyosarcoma is very rare (<1%)

Answer 33

ischaemia, infarction and necrosis of the fibroid due to disrupted blood supply. presents with severe abdominal pain, low-grade fever, tachycardia and often vomiting. Management is supportive, with rest, fluids and analgesia common in pregnancy

Answer 34

condition where there is ectopic endometrial tissue outside the uterus

Answer 35

Endometriomas in the ovaries

Answer 36

Cyclical abdominal or pelvic pain Deep dyspareunia (pain on deep sexual intercourse) Dysmenorrhoea (painful periods) Infertility Cyclical bleeding from other sites, such as haematuria

Answer 37

Endometrial tissue visible in the vagina on speculum examination, particularly in the posterior fornix A fixed cervix on bimanual examination Tenderness in the vagina, cervix and adnexa

Answer 38

Pelvic ultrasound Laparoscopic surgery = gold standard

Answer 39

American Society of Reproductive Medicine (ASRM)

Answer 40

Combined oral contractive pill, which can be used back to back without a pill-free period if helpful Progesterone only pill Medroxyprogesterone acetate injection (e.g. Depo-Provera) Nexplanon implant Mirena coil GnRH agonists

Answer 41

Laparoscopic surgery to excise or ablate the endometrial tissue and remove adhesions (adhesiolysis) Hysterectomy

Answer 42

endometrial tissue inside the myometrium (muscle layer of the uterus)

Answer 43

Painful periods (dysmenorrhoea) Heavy periods (menorrhagia) Pain during intercourse (dyspareunia)

Answer 44

1st line = transvaginal ultrasound MRI/transabdominal ultrasound Gold = histology following hysterectomy

Answer 45

Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage

Answer 46

after a woman has had no periods for 12 months

Answer 47

describes the period from 12 months after the final menstrual period onwards.

Answer 48

time around the menopause, where the woman may be experiencing vasomotor symptoms and irregular periods. Perimenopause includes the time leading up to the last menstrual period, and the 12 months afterwards

Answer 49

menopause before the age of 40 years. It is the result of premature ovarian insufficiency.

Answer 50

Oestrogen and progesterone levels are low LH and FSH levels are high, in response to an absence of negative feedback from oestrogen

Answer 51

decline in development of follicles -> reduced production of oestrogen -> no negative feedback -> increased LH and FSH

Answer 52

Hot flushes Emotional lability or low mood Premenstrual syndrome Irregular periods Joint pains Heavier or lighter periods Vaginal dryness and atrophy Reduced libido

Answer 53

Cardiovascular disease and stroke Osteoporosis Pelvic organ prolapse Urinary incontinence

Answer 54

Women under 40 years with suspected premature menopause Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 55

Two years after the last menstrual period in women under 50 One year after the last menstrual period in women over 50

Answer 56

No treatment Hormone replacement therapy (HRT) Tibolone, a synthetic steroid hormone that acts as continuous combined HRT (only after 12 months of amenorrhoea) Clonidine, which act as agonists of alpha-adrenergic and imidazoline receptors Cognitive behavioural therapy (CBT) SSRI antidepressants Testosterone can be used to treat reduced libido (usually as a gel or cream) Vaginal oestrogen cream or tablets, to help with vaginal dryness and atrophy (can be used alongside systemic HRT) Vaginal moisturisers

Answer 57

Idiopathic (the cause is unknown in more than 50% of cases) Iatrogenic, due to interventions such as chemotherapy, radiotherapy or surgery (i.e. oophorectomy) Autoimmune, possibly associated with coeliac disease, adrenal insufficiency, type 1 diabetes or thyroid disease Genetic, with a positive family history or conditions such as Turner’s syndrome Infections such as mumps, tuberculosis or cytomegalovirus

Answer 58

Traditional hormone replacement therapy Combined oral contraceptive pill

Answer 59

breast cancer (particularly combined HRT) endometrial cancer Increased risk of venous thromboembolism (2 – 3 times the background risk) stroke and coronary artery disease with long term use in older women

Answer 60

The risk of endometrial cancer is greatly reduced by adding progesterone in women with a uterus The risk of VTE is reduced by using patches rather than pills

Answer 61

Undiagnosed abnormal bleeding Endometrial hyperplasia or cancer Breast cancer Uncontrolled hypertension Venous thromboembolism Liver disease Active angina or myocardial infarction Pregnancy

Answer 62

Take a full history to ensure there are no contraindications Take a family history to assess the risk of oestrogen dependent cancers (e.g. breast cancer) and VTE Check the body mass index (BMI) and blood pressure Ensure cervical and breast screening is up to date Encourage lifestyle changes that are likely to improve symptoms and reduce risks

Answer 63

progesterone needed for endometrial protection

Answer 64

Perimenopausal: give cyclical combined HRT Postmenopausal (more than 12 months since last period): give continuous combined HRT

Answer 65

Oestrogenic side effects: Nausea and bloating Breast swelling Breast tenderness Headaches Leg cramps Progestogenic side effects: Mood swings Bloating Fluid retention Weight gain Acne and greasy skin

Answer 66

Rotterdam Criteria diagnosis requires at least two of the three key features

Answer 67

Oligoovulation or anovulation, presenting with irregular or absent menstrual periods Hyperandrogenism, characterised by hirsutism and acne Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

Answer 68

Oligomenorrhoea or amenorrhoea Infertility Obesity (in about 70% of patients with PCOS) Hirsutism Acne Hair loss in a male pattern

Answer 69

PCOS Medications Ovarian or adrenal tumours that secrete androgens Cushing’s syndrome Congenital adrenal hyperplasia

Answer 70

Diet, exercise and weight loss

Answer 71

Testosterone Sex hormone-binding globulin Luteinizing hormone Follicle-stimulating hormone Prolactin (may be mildly elevated in PCOS) Thyroid-stimulating hormone

Answer 72

Raised luteinising hormone Raised LH to FSH ratio (high LH compared with FSH) Raised testosterone Raised insulin Normal or raised oestrogen levels

Answer 73

12 or more developing follicles in one ovary Ovarian volume of more than 10cm3

Answer 74

Mirena coil for continuous endometrial protection Inducing a withdrawal bleed at least every 3 – 4 months with either: Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) Combined oral contraceptive pill

Answer 75

Weight loss Clomifene Laparoscopic ovarian drilling In vitro fertilisation (IVF)

Answer 76

Co-cyprindiol (Dianette) is a combined oral contraceptive pill Topical eflornithine

Answer 77

combined oral contraceptive pill

Answer 78

string of pearls

Answer 79

Pelvic pain Bloating Fullness in the abdomen A palpable pelvic mass (particularly with very large cysts such as mucinous cystadenomas)

Answer 80

Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Answer 81

estimates the risk of an ovarian mass being malignant, taking account of three things: Menopausal status Ultrasound findings CA125 level

Answer 82

Torsion Haemorrhage into the cyst Rupture, with bleeding into the peritoneum

Answer 83

Ovarian fibroma (a type of benign ovarian tumour) Pleural effusion Ascites

Answer 84

ovarian mass larger than 5cm, such as a cyst or a tumour

Answer 85

sudden onset severe unilateral pelvic pain. The pain is constant, gets progressively worse and is associated with nausea and vomiting

Answer 86

localised tenderness may be a palpable mass

Answer 87

Pelvic ultrasound (ideally transvaginal) will show whirlpool sign - free fluid and oedema or the ovary

Answer 88

laparoscopic surgery

Answer 89

laparoscopic surgery to either: Un-twist the ovary and fix it in place (detorsion) Remove the affected ovary (oophorectomy)

Answer 90

adhesions (sometimes called synechiae) form within the uterus, following damage to the uterus

Answer 91

dilation and curettage uterine surgery severe pelvic infection

Answer 92

Secondary amenorrhoea (absent periods) Significantly lighter periods Dysmenorrhoea (painful periods) It may also present with infertility.

Answer 93

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions Hysterosalpingography, where contrast is injected into the uterus and imaged with xrays Sonohysterography, where the uterus is filled with fluid and a pelvic ultrasound is performed MRI scan

Answer 94

dissecting the adhesions during hysteroscopy

Answer 95

columnar epithelium of the endocervix (the canal of the cervix) has extended out to the ectocervix (the outer area of the cervix).

Answer 96

younger women COCP pregnancy

Answer 97

increased vaginal discharge vaginal bleeding (postcoital) dyspareunia (pain during sex).

Answer 98

well-demarcated border between the redder, velvety columnar epithelium extending from the os (opening), and the pale pink squamous epithelium of the ectocervix. This border is the transformation zone

Answer 99

no treatment if not causing problems if problematic bleeding - cauterisation with silver nitrate or cold coagulation during colposcopy

Answer 100

fluid-filled cysts often seen on the surface of the cervix

Answer 101

uterus itself descends into the vagina

Answer 102

women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina

Answer 103

defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina

Answer 104

Constipation and faecal loading, urinary retention

Answer 105

defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.

Answer 106

Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age and postmenopause status Obesity Chronic respiratory disease causing coughing Chronic constipation causing straining

Answer 107

A feeling of “something coming down” in the vagina A dragging or heavy sensation in the pelvis Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention Bowel symptoms, such as constipation, incontinence and urgency Sexual dysfunction, such as pain, altered sensation and reduced enjoyment

Answer 108

pelvic organ prolapse quantification (POP-Q) system: Grade 0: Normal Grade 1: The lowest part is more than 1cm above the introitus Grade 2: The lowest part is within 1cm of the introitus (above or below) Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended Grade 4: Full descent with eversion of the vagina A prolapse extending beyond the introitus can be referred to as uterine procidentia.

Answer 109

Physiotherapy (pelvic floor exercises) Weight loss Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations Vaginal oestrogen cream

Answer 110

Conservative management Vaginal pessary Surgery

Answer 111

ring shelf/gellhorn cube donut hodge

Answer 112

Pain, bleeding, infection, DVT and risk of anaesthetic Damage to the bladder or bowel Recurrence of the prolapse Altered experience of sex

Answer 113

urge stress

Answer 114

overactivity of the detrusor muscle of the bladder

Answer 115

weakness of the pelvic floor and sphincter muscles

Answer 116

chronic urinary retention due to an obstruction to the outflow of urine

Answer 117

Increased age Postmenopausal status Increase BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neurological conditions, such as multiple sclerosis Cognitive impairment and dementia

Answer 118

Caffeine consumption Alcohol consumption Medications Body mass index (BMI)

Answer 119

modified Oxford grading system

Answer 120

bladder diary urine dipstick post-void residual bladder volume Urodynamic testing

Answer 121

Avoiding caffeine, diuretics and overfilling of the bladder Avoid excessive or restricted fluid intake Weight loss (if appropriate) Supervised pelvic floor exercises for at least three months before considering surgery Surgery Duloxetine is an SNRI antidepressant used second line where surgery is less preferred

Answer 122

Tension-free vaginal tape autologous sling procedures colposuspension intermural urethral bulking

Answer 123

Bladder retraining (gradually increasing the time between voiding) for at least six weeks is first-line Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin Mirabegron is an alternative to anticholinergic medications Invasive procedures where medical treatment fails

Answer 124

uncontrolled hypertension

Answer 125

Botulinum toxin type A injection into the bladder wall Percutaneous sacral nerve stimulation Augmentation cystoplasty urinary diversion

Answer 126

dryness and atrophy of the vaginal mucosa related to a lack of oestrogen

Answer 127

Itching Dryness Dyspareunia (discomfort or pain during sex) Bleeding due to localised inflammation

Answer 128

vaginal lubricants topical oestrogen e.g. cream, pessary

Answer 129

Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair

Answer 130

labia, perineum, perianal skin

Answer 131

chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin

Answer 132

Itching Soreness and pain possibly worse at night Skin tightness Painful sex (superficial dyspareunia) Erosions Fissures

Answer 133

“Porcelain-white” in colour Shiny Tight Thin Slightly raised There may be papules or plaques

Answer 134

potent topical steroids e.g. dermovate Emollients

Answer 135

SCC of vulva Pain and discomfort Sexual dysfunction Bleeding Narrowing of the vaginal or urethral openings

Answer 136

Type 1: Removal of part or all of the clitoris. Type 2: Removal of part or all of the clitoris and labia minora. The labia majora may also be removed. Type 3: Narrowing or closing the vaginal orifice (infibulation). Type 4: All other unnecessary procedures to the female genitalia.

Answer 137

Pain Bleeding Infection Swelling Urinary retention Urethral damage and incontinence

Answer 138

Vaginal infections, such as bacterial vaginosis Pelvic infections Urinary tract infections Dysmenorrhea (painful menstruation) Sexual dysfunction and dyspareunia (painful sex) Infertility and pregnancy-related complications Significant psychological issues and depression Reduced engagement with healthcare and screening

Answer 139

paramesonephric ducts (Mullerian ducts)

Answer 140

Miscarriage Premature birth Malpresentation

Answer 141

X-linked recessive

Answer 142

inguinal hernias containing testes in infancy primary amenorrhoea

Answer 143

Raised LH Normal or raised FSH Normal or raised testosterone levels (for a male) Raised oestrogen levels (for a male)

Answer 144

XY female phenotype

Answer 145

Bilateral orchidectomy (removal of the testes) to avoid testicular tumours Oestrogen therapy Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length

Answer 146

squamous cell carcinoma

Answer 147

human papilloma virus

Answer 148

type 16 and 18

Answer 149

Early sexual activity Increased number of sexual partners Sexual partners who have had more partners Not using condoms

Answer 150

non-engagement with cervical screening Smoking HIV COCP Increases number of full term pregnancies family history exposure to diethylbestrol

Answer 151

Abnormal vaginal bleeding (intermenstrual, postcoital or post-menopausal bleeding) Vaginal discharge Pelvic pain Dyspareunia (pain or discomfort with sex)

Answer 152

Ulceration Inflammation Bleeding Visible tumour

Answer 153

CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated CIN III: severe dysplasia, very likely to progress to cancer if untreated

Answer 154

women (and transgender men that still have a cervix): Every three years aged 25 – 49 Every five years aged 50 – 64

Answer 155

Inadequate sample – repeat the smear after at least three months HPV negative – continue routine screening HPV positive with normal cytology – repeat the HPV test after 12 months HPV positive with abnormal cytology – refer for colposcopy

Answer 156

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

Answer 157

Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy Stage 2B – 4A: Chemotherapy and radiotherapy Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

Answer 158

adenocarcinoma

Answer 159

precancerous condition involving thickening of the endometrium

Answer 160

Intrauterine system (e.g. Mirena coil) Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)

Answer 161

Increased age Earlier onset of menstruation Late menopause Oestrogen only hormone replacement therapy No or fewer pregnancies Obesity Polycystic ovarian syndrome Tamoxifen Type 2 diabetes Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome

Answer 162

Combined contraceptive pill Mirena coil Increased pregnancies Cigarette smoking

Answer 163

postmenopausal bleeding

Answer 164

Postcoital bleeding Intermenstrual bleeding Unusually heavy menstrual bleeding Abnormal vaginal discharge Haematuria Anaemia Raised platelet count

Answer 165

Transvaginal ultrasound for endometrial thickness Pipelle biopsy Hysteroscopy

Answer 166

Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 167

total abdominal hysterectomy with bilateral salpingo-oophorectomy

Answer 168

Epithelial cell (most common) dermoid cysts/germ cell tumours sex cord-stromal tumours

Answer 169

metastasis in the ovary, usually from a gastrointestinal tract cancer "signet-ring” cells on histology

Answer 170

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

Answer 171

Combined contraceptive pill Breastfeeding Pregnancy

Answer 172

Abdominal bloating Early satiety (feeling full after eating) Loss of appetite Pelvic pain Urinary symptoms (frequency / urgency) Weight loss Abdominal or pelvic mass Ascites

Answer 173

CA125 blood test (>35 IU/mL is significant) Pelvic ultrasound

Answer 174

Menopausal status Ultrasound findings CA125 level

Answer 175

Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)

Answer 176

Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Answer 177

Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Answer 178

combination of surgery and chemotherapy

Answer 179

squamous cell carcinomas

Answer 180

Advanced age (particularly over 75 years) Immunosuppression Human papillomavirus (HPV) infection Lichen sclerosus

Answer 181

Watch and wait with close followup Wide local excision (surgery) to remove the lesion Imiquimod cream Laser ablation

Answer 182

Vulval lump Ulceration Bleeding Pain Itching Lymphadenopathy in the groin Vulval cancer most frequently affects the labia majora, giving an appearance of: Irregular mass Fungating lesion Ulceration Bleeding

Answer 183

Wide local excision to remove the cancer Groin lymph node dissection Chemotherapy Radiotherapy

Answer 184

loss of the lactobacilli “friendly bacteria” in the vagina - the pH rises. This more alkaline environment enables anaerobic bacteria to multiply

Answer 185

Gardnerella vaginalis (most common) Mycoplasma hominis Prevotella species

Answer 186

Multiple sexual partners Excessive vaginal cleaning Recent antibiotics Smoking Copper coil

Answer 187

fishy-smelling watery grey or white vaginal discharge

Answer 188

Vaginal pH >4.5 vaginal swab for microscopy (clue cells)

Answer 189

Metronidazole

Answer 190

Miscarriage Preterm delivery Premature rupture of membranes Chorioamnionitis Low birth weight Postpartum endometritis

Answer 191

Candida albicans

Answer 192

Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) Poorly controlled diabetes Immunosuppression (e.g. using corticosteroids) Broad-spectrum antibiotics

Answer 193

Thick, white discharge that does not typically smell Vulval and vaginal itching, irritation or discomfort

Answer 194

charcoal swab with microscopy

Answer 195

A single dose of intravaginal clotrimazole cream (5g of 10% cream) at night A single dose of clotrimazole pessary (500mg) at night Three doses of clotrimazole pessaries (200mg) over three nights A single dose of fluconazole (150mg)

Answer 196

Bacterial vaginosis Candidiasis Gonorrhoeae (specifically endocervical swab) Trichomonas vaginalis (specifically a swab from the posterior fornix) Other bacteria, such as group B streptococcus (GBS)

Answer 197

Chlamydia and gonorrhoea

Answer 198

Abnormal vaginal discharge Pelvic pain Abnormal vaginal bleeding (intermenstrual or postcoital) Painful sex (dyspareunia) Painful urination (dysuria)

Answer 199

Urethral discharge or discomfort Painful urination (dysuria) Epididymo-orchitis Reactive arthritis

Answer 200

Pelvic or abdominal tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge

Answer 201

doxycycline 100mg twice a day for 7 days

Answer 202

Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis

Answer 203

Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis Neonatal infection (conjunctivitis and pneumonia)

Answer 204

condition affecting the lymphoid tissue around the site of infection with chlamydia

Answer 205

gram-negative diplococcus

Answer 206

Odourless purulent discharge, possibly green or yellow Dysuria Pelvic pain

Answer 207

Odourless purulent discharge, possibly green or yellow Dysuria Testicular pain or swelling (epididymo-orchitis)

Answer 208

Nucleic acid amplification testing (NAAT)

Answer 209

IM ceftriaxone 1g oral ciprofloxacin 500mg if sensitivities known

Answer 210

Pelvic inflammatory disease Chronic pelvic pain Infertility Epididymo-orchitis (men) Prostatitis (men) Conjunctivitis Urethral strictures Disseminated gonococcal infection Skin lesions Fitz-Hugh-Curtis syndrome Septic arthritis Endocarditis

Answer 211

Various non-specific skin lesions Polyarthralgia (joint aches and pains) Migratory polyarthritis (arthritis that moves between joints) Tenosynovitis Systemic symptoms such as fever and fatigue

Answer 212

Urethritis Epididymitis Cervicitis Endometritis Pelvic inflammatory disease Reactive arthritis Preterm delivery in pregnancy Tubal infertility

Answer 213

nucleic acid amplification tests (NAAT)

Answer 214

Doxycycline 100mg twice daily for 7 days then; Azithromycin 1g stat then 500mg once a day for 2 days

Answer 215

Neisseria gonorrhoeae tends to produce more severe PID Chlamydia trachomatis Mycoplasma genitalium

Answer 216

Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous pelvic inflammatory disease Intrauterine device (e.g. copper coil)

Answer 217

Pelvic or lower abdominal pain Abnormal vaginal discharge Abnormal bleeding (intermenstrual or postcoital) Pain during sex (dyspareunia) Fever Dysuria

Answer 218

Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge

Answer 219

A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea) Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium) Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)

Answer 220

Sepsis Abscess Infertility Chronic pelvic pain Ectopic pregnancy Fitz-Hugh-Curtis syndrome

Answer 221

complication of PID, inflammation and infection of liver capsule leading to adhesions between liver and peritoneum, right upper quadrant pain

Answer 222

Vaginal discharge Itching Dysuria (painful urination) Dyspareunia (painful sex) Balanitis (inflammation to the glans penis)

Answer 223

frothy yellow-green discharge (may be fishy) strawberry cervix

Answer 224

charcoal swab for microscopy

Answer 225

metronidazole

Answer 226

Ulcers or blistering lesions affecting the genital area Neuropathic type pain (tingling, burning or shooting) Flu-like symptoms (e.g. fatigue and headaches) Dysuria (painful urination) Inguinal lymphadenopathy

Answer 227

viral PCR swab from lesion

Answer 228

Unprotected anal, vaginal or oral sexual activity Mother to child at any stage of pregnancy, birth or breastfeeding (called vertical transmission) Mucous membrane, blood or open wound exposure to infected blood or bodily fluids (e.g., sharing needles, needle-stick injuries or blood splashed in an eye)

Answer 229

Kaposi’s sarcoma Pneumocystis jirovecii pneumonia (PCP) Cytomegalovirus infection Candidiasis (oesophageal or bronchial) Lymphomas Tuberculosis

Answer 230

CD4 count HIV RNA indicates viral load

Answer 231

antiretroviral therapy

Answer 232

Prophylactic co-trimoxazole

Answer 233

IV zidovudine

Answer 234

Treponema pallidum

Answer 235

Primary syphilis involves a painless ulcer called a chancre at the original site of infection (usually on the genitals). Secondary syphilis involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the latent stage. Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards. Tertiary syphilis can occur many years after the initial infection and affect many organs of the body, particularly with the development of gummas and cardiovascular and neurological complications. Neurosyphilis occurs if the infection involves the central nervous system

Answer 236

A painless genital ulcer (chancre). This tends to resolve over 3 – 8 weeks. Local lymphadenopathy

Answer 237

Maculopapular rash Condylomata lata (grey wart-like lesions around the genitals and anus) Low-grade fever Lymphadenopathy Alopecia (localised hair loss) Oral lesions

Answer 238

Gummatous lesions (gummas are granulomatous lesions that can affect the skin, organs and bones) Aortic aneurysms Neurosyphilis

Answer 239

Headache Altered behaviour Dementia Tabes dorsalis (demyelination affecting the spinal cord posterior columns) Ocular syphilis (affecting the eyes) Paralysis Sensory impairment

Answer 240

Antibody testing

Answer 241

Dark field microscopy Polymerase chain reaction (PCR)

Answer 242

rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL)

Answer 243

single deep intramuscular dose of benzathine benzylpenicillin

Answer 244

UKMEC 1: No restriction in use (minimal risk) UKMEC 2: Benefits generally outweigh the risks UKMEC 3: Risks generally outweigh the benefits UKMEC 4: Unacceptable risk (typically this means the method is contraindicated)

Answer 245

Copper coil

Answer 246

98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic

Answer 247

either within 48 hours of birth or more than 4 weeks after birth

Answer 248

should be avoided in breastfeeding (UKMEC 4 before 6 weeks postpartum, UKMEC 2 after 6 weeks)

Answer 249

Preventing ovulation (this is the primary mechanism of action) Progesterone thickens the cervical mucus Progesterone inhibits proliferation of the endometrium, reducing the chance of successful implantation

Answer 250

Yasmin and other COCPs containing drospirenone

Answer 251

Dianette and other COCPs containing cyproterone acetate (i.e. co-cyprindiol)

Answer 252

Unscheduled bleeding is common in the first three months and should then settle with time Breast pain and tenderness Mood changes and depression Headaches Hypertension Venous thromboembolism Small increased risk of breast and cervical cancer, returning to normal ten years after stopping Small increased risk of myocardial infarction and stroke

Answer 253

endometrial ovarian colon

Answer 254

Uncontrolled hypertension (particularly ≥160 / ≥100) Migraine with aura (risk of stroke) History of VTE Aged over 35 and smoking more than 15 cigarettes per day Major surgery with prolonged immobility Vascular disease or stroke Ischaemic heart disease, cardiomyopathy or atrial fibrillation Liver cirrhosis and liver tumours Systemic lupus erythematosus (SLE) and antiphospholipid syndrome

Answer 255

Take the most recent missed pill as soon as possible Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.

Answer 256

active breast cancer

Answer 257

The traditional progestogen-only pill cannot be delayed by more than 3 hours. Taking the pill more than 3 hours late is considered a “missed pill”. The desogestrel-only pill can be taken up to 12 hours late and still be effective. Taking the pill more than 12 hours late is considered a “missed pill”

Answer 258

unscheduled bleeding breast tenderness headaches acne

Answer 259

if they have had sex since missing the pill or within 48 hours of restarting the regular pills

Answer 260

Weight gain Acne Reduced libido Mood changes Headaches Flushes Hair loss (alopecia) Skin reactions at injection sites Osteoporosis Irregular bleeding

Answer 261

Copper coil (Cu-IUD): contains copper and creates a hostile environment for pregnancy Levonorgestrel intrauterine system (LNG-IUS): contains progestogen that is slowly released into the uterus

Answer 262

Pelvic inflammatory disease or infection Immunosuppression Pregnancy Unexplained bleeding Pelvic cancer Uterine cavity distortion (e.g. by fibroids)

Answer 263

Expulsion Pregnancy Uterine perforation

Answer 264

Levonorgestrel should be taken within 72 hours of UPSI Ulipristal should be taken within 120 hours of UPSI Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation

Answer 265

1.5mg as a single dose 3mg as a single dose in women above 70kg or BMI above 26

Answer 266

N+V Spotting and changes to the next menstrual period Diarrhoea Breast tenderness Dizziness Depressed mood

Answer 267

5 days Extra contraception (ie. condoms) is required for the first 7 days of the combined pill or the first 2 days of the progestogen-only pill.

Answer 268

Breastfeeding should be avoided for 1 week after taking ulipristal (milk should be expressed and discarded) Ulipristal should be avoided in patients with severe asthma

Answer 269

Vas deferens

Answer 270

over 12 months 6 months if woman over 35

Answer 271

Sperm problems (30%) Ovulation problems (25%) Tubal problems (15%) Uterine problems (10%) Unexplained (20%)

Answer 272

The woman should be taking 400mcg folic acid daily Aim for a healthy BMI Avoid smoking and drinking excessive alcohol Reduce stress as this may negatively affect libido and the relationship Aim for intercourse every 2 – 3 days Avoid timing intercourse

Answer 273

Body mass index (BMI) Chlamydia screening Semen analysis Female hormonal testing Rubella immunity in the mother

Answer 274

weight loss Clomifene Letrozole Gonadotrophins Ovarian drilling Metformin

Answer 275

Hot baths Tight underwear Smoking Alcohol Raised BMI Caffeine

Answer 276

Suppressing the natural menstrual cycle Ovarian stimulation Oocyte collection Insemination / intracytoplasmic sperm injection (ICSI) Embryo culture Embryo transfer

Answer 277

Failure Multiple pregnancy Ectopic pregnancy Ovarian hyperstimulation syndrome

Answer 278

Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)

Answer 279

Previous ectopic pregnancy Previous pelvic inflammatory disease Previous surgery to the fallopian tubes Intrauterine devices (coils) Older age Smoking

Answer 280

Missed period Constant lower abdominal pain in the right or left iliac fossa Vaginal bleeding Lower abdominal or pelvic tenderness Cervical motion tenderness dizziness/syncope shoulder tip pain

Answer 281

transvaginal ultrasound

Answer 282

Expectant management (awaiting natural termination) Medical management (methotrexate) Surgical management (salpingectomy or salpingotomy)

Answer 283

Follow up needs to be possible to ensure successful termination The ectopic needs to be unruptured Adnexal mass < 35mm No visible heartbeat No significant pain HCG level < 1500 IU / l

Answer 284

Pain Adnexal mass > 35mm Visible heartbeat HCG levels > 5000 IU / l

Answer 285

Laparoscopic salpingectomy

Answer 286

Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation.

Answer 287

vaginal bleeding with a closed cervix and a fetus that is alive

Answer 288

vaginal bleeding with an open cervix

Answer 289

retained products of conception remain in the uterus after the miscarriage

Answer 290

transvaginal ultrasound scan

Answer 291

expectantly repeat pregnancy test after 7-10d

Answer 292

Misoprostol (prostaglandin analogue)

Answer 293

Manual vacuum aspiration Electric vacuum aspiration misoprostol given before

Answer 294

three or more consecutive miscarriages

Answer 295

Idiopathic (particularly in older women) Antiphospholipid syndrome Hereditary thrombophilias Uterine abnormalities Genetic factors in parents (e.g. balanced translocations in parental chromosomes) Chronic histiocytic intervillositis Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)

Answer 296

Low dose aspirin Low molecular weight heparin (LMWH)

Answer 297

Continuing the pregnancy is likely to risk the life of the woman Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Answer 298

Two registered medical practitioners must sign to agree abortion is indicated It must be carried out by a registered medical practitioner in an NHS hospital or approved premise

Answer 299

Mifepristone (anti-progestogen) Misoprostol (prostaglandin analogue) 1 – 2 day later

Answer 300

Bleeding Pain Infection Failure of the abortion (pregnancy continues) Damage to the cervix, uterus or other structures

Answer 301

More than 5 % weight loss compared with before pregnancy Dehydration Electrolyte imbalance

Answer 302

Prochlorperazine Cyclizine Ondansetron Metoclopramide

Answer 303

Unable to tolerate oral antiemetics or keep down any fluids More than 5 % weight loss compared with pre-pregnancy Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant) Other medical conditions need treating that required admission

Answer 304

IV or IM antiemetics IV fluids (normal saline with added potassium chloride) Daily monitoring of U&Es while having IV therapy Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome) Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission

Answer 305

two sperm cells fertilise an ovum that contains no genetic material

Answer 306

two sperm cells fertilise a normal ovum

Answer 307

More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

Answer 308

snowstorm appearance

Answer 309

The first trimester is from the start of pregnancy until 12 weeks gestation. The second trimester is from 13 weeks until 26 weeks gestation. The third trimester is from 27 weeks gestation until birth.

Answer 310

20 weeks gestation

Answer 311

between 10 and 13+6

Answer 312

between 18 and 20+6

Answer 313

between 24 – 28 weeks

Answer 314

28 and 34 weeks

Answer 315

Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter

Answer 316

Take folic acid 400mcg from before pregnancy to 12 weeks Take vitamin D supplement (10 mcg or 400 IU daily) Avoid vitamin A supplements and eating liver or pate Don’t drink alcohol Don’t smoke Avoid unpasteurised dairy or blue cheese (risk of listeriosis) Avoid undercooked or raw poultry (risk of salmonella) Continue moderate exercise but avoid contact sports Sex is safe Flying increases the risk of venous thromboembolism (VTE) Place car seatbelts above and below the bump (not across it)

Answer 317

Miscarriage Small for dates Preterm delivery Fetal alcohol syndrome

Answer 318

Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye to the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy

Answer 319

Fetal growth restriction (FGR) Miscarriage Stillbirth Preterm labour and delivery Placental abruption Cleft lip or palate Sudden infant death syndrome (SIDS)

Answer 320

37 weeks in a single pregnancy 32 weeks in a twin pregnancy

Answer 321

Blood group, antibodies and rhesus D status Full blood count for anaemia Screening for thalassaemia (all women) and sickle cell disease HIV, HepB, Syphilis

Answer 322

Weight, height and BMI Urine for protein and bacteria Blood pressure Discuss female genital mutilation Discuss domestic violence

Answer 323

NSAIDs beta-blockers (except labetalol) ACEi/ARBs Opiates Warfarin Sodium valproate Lithium SSRIs (balance risk and benefit) Isotretinoin

Answer 324

Congenital deafness Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability

Answer 325

Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures

Answer 326

Intracranial calcification Hydrocephalus Chorioretinitis (inflammation of the choroid and retina in the eye)

Answer 327

Miscarriage or fetal death Severe fetal anaemia Hydrops fetalis (fetal heart failure) Maternal pre-eclampsia-like syndrome

Answer 328

checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.

Answer 329

fetus that measures below the 10th centile for their gestational age

Answer 330

Constitutionally small Fetal growth restriction e.g. pre-eclampsia, smoking, alcohol, anaemia, malnutrition, infection, genetic abnormalities, structural abnormalities, fetal infection, errors of metabolism

Answer 331

Reduced amniotic fluid volume Abnormal Doppler studies Reduced fetal movements Abnormal CTGs

Answer 332

Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia

Answer 333

Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome

Answer 334

symphysis fundal height (SFH)

Answer 335

Blood pressure and urine dipstick for pre-eclampsia Uterine artery doppler scanning Detailed fetal anatomy scan by fetal medicine Karyotyping for chromosomal abnormalities Testing for infections

Answer 336

growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results)

Answer 337

Newborn is more than 4.5kg at birth During pregnancy, an estimated fetal weight above the 90th centile

Answer 338

Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby

Answer 339

Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare)

Answer 340

Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) Neonatal hypoglycaemia Obesity in childhood and later life Type 2 diabetes in adulthood

Answer 341

Ultrasound to exclude polyhydramnios and estimate the fetal weight Oral glucose tolerance test for gestational diabetes

Answer 342

diamniotic, dichorionic

Answer 343

membrane between the twins, with a lambda sign or twin peak sign

Answer 344

membrane between the twins, with a T sign

Answer 345

Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage

Answer 346

Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities

Answer 347

one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios

Answer 348

32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins Before 35 + 6 weeks for triplets

Answer 349

7 days nitrofurantoin (avoid in 3rd trimester) Amoxicillin (only after sensitivities are known)

Answer 350

risk of neonatal haemolysis

Answer 351

Booking clinic 28 weeks gestation

Answer 352

Smoking Parity ≥ 3 Age > 35 years BMI > 30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy

Answer 353

28 weeks if there are three risk factors First trimester if there are four or more of these risk factors

Answer 354

low molecular weight heparin (LMWH) e.g. enoxaparin

Answer 355

Hypertension Proteinuria Oedema

Answer 356

after 20 weeks

Answer 357

high vascular resistance in the spiral arteries and poor perfusion of the placenta causes oxidative stress leading to systemic inflammation and impaired endothelial function

Answer 358

Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease

Answer 359

Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia

Answer 360

aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors

Answer 361

Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (this is due to liver swelling) Oedema Reduced urine output Brisk reflexes

Answer 362

Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Answer 363

Labetolol is first-line as an antihypertensive Nifedipine (modified-release) second-line Methyldopa third-line (needs to be stopped within two days of birth) Intravenous hydralazine in critical care in severe pre-eclampsia or eclampsia IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Answer 364

IV magnesium sulphate

Answer 365

complication of pre-eclampsia and eclampsia Haemolysis Elevated Liver enzymes Low Platelets

Answer 366

large for dates fetus, macrosomia shoulder dystocia developing type 2 diabetes

Answer 367

oral glucose tolerance test at 24 – 28 weeks gestation.

Answer 368

Previous gestational diabetes Previous macrosomic baby (≥ 4.5kg) BMI > 30 Ethnic origin (black Caribbean, Middle Eastern and South Asian) Family history of diabetes

Answer 369

Fasting: < 5.6 mmol/l At 2 hours: < 7.8 mmol/l

Answer 370

trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

Answer 371

start insulin ± metformin

Answer 372

start insulin ± metformin

Answer 373

Fasting: 5.3 mmol/l 1 hour post-meal: 7.8 mmol/l 2 hours post-meal: 6.4 mmol/l Avoiding levels of 4 mmol/l or below

Answer 374

Neonatal hypoglycaemia Polycythaemia (raised haemoglobin) Jaundice (raised bilirubin) Congenital heart disease Cardiomyopathy

Answer 375

stillbirth

Answer 376

pruritis (mainly palms and soles) fatigue dark urine pale, greasy stools jaundice

Answer 377

Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis

Answer 378

Abnormal liver function tests (LFTs), mainly ALT, AST and GGT Raised bile acids

Answer 379

pruritis = emollients, antihistamines e.g. chlorphenamine water soluble vitamin K if PT deranged

Answer 380

long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus

Answer 381

General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia (lack of appetite) Ascites

Answer 382

elevated liver enzymes (ALT and AST).

Answer 383

obstetric emergency and requires prompt admission and delivery of the baby

Answer 384

polymorphic eruption of pregnancy Atopic eruption of pregnancy Melasma Pyogenic granuloma Pemphigoid Gestationis

Answer 385

placenta is within 20mm of the internal cervical os

Answer 386

when the placenta is over the internal cervical os

Answer 387

Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth

Answer 388

Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os Partial praevia, or grade III – the placenta is partially covering the internal cervical os Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

Answer 389

Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)

Answer 390

20-week anomaly scan

Answer 391

repeat transvaginal USS at 32 and 36w Corticosteroids between 34-35+6w planned delivery considered between 36-37w

Answer 392

haemorrhage

Answer 393

fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os

Answer 394

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 395

Low lying placenta IVF pregnancy Multiple pregnancy

Answer 396

Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation

Answer 397

when the placenta separates from the wall of the uterus during pregnancy

Answer 398

Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (consider domestic violence) Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or amphetamine use

Answer 399

Sudden onset severe abdominal pain that is continuous Vaginal bleeding (antepartum haemorrhage) Shock (hypotension and tachycardia) Abnormalities on the CTG indicating fetal distress Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Answer 400

Urgent involvement of a senior obstetrician, midwife and anaesthetist 2 x grey cannula Bloods include FBC, UE, LFT and coagulation studies Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring of the fetus Close monitoring of the mother

Answer 401

Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond Placenta increta is where the placenta attaches deeply into the myometrium Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 402

Previous placenta accreta Previous endometrial curettage procedures (e.g. for miscarriage or abortion) Previous caesarean section Multigravida Increased maternal age Low-lying placenta or placenta praevia

Answer 403

postpartum haemorrhage

Answer 404

antenatally by ultrasound

Answer 405

Hysterectomy with the placenta remaining in the uterus (recommended) Uterus preserving surgery, with resection of part of the myometrium along with the placenta Expectant management, leaving the placenta in place to be reabsorbed over time

Answer 406

between 35 to 36 + 6 weeks gestation

Answer 407

Complete breech, where the legs are fully flexed at the hips and knees Incomplete breech, with one leg flexed at the hip and extended at the knee Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee Footling breech, with a foot is presenting through the cervix with the leg extended

Answer 408

After 36 weeks for nulliparous women (women that have not previously given birth) After 37 weeks in women that have given birth previously

Answer 409

tocolysis to relax the uterus e.g. subcutaneous terbutaline anti-D if needed

Answer 410

birth of a dead fetus after 24 weeks gestation

Answer 411

Unexplained (around 50%) Pre-eclampsia Placental abruption Vasa praevia Cord prolapse or wrapped around the fetal neck Obstetric cholestasis Diabetes Thyroid disease Infections, such as rubella, parvovirus and listeria Genetic abnormalities or congenital malformations

Answer 412

Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back

Answer 413

Reduced fetal movements Abdominal pain Vaginal bleeding

Answer 414

Ultrasound scan to visualise the fetal heartbeat

Answer 415

vaginal birth

Answer 416

Dopamine agonists (e.g. cabergoline)

Answer 417

Genetic testing of the fetus and placenta Postmortem examination of the fetus (including xrays) Testing for maternal and fetal infection Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Answer 418

Obstetric haemorrhage Pulmonary embolism Sepsis leading to metabolic acidosis and septic shock

Answer 419

Ectopic pregnancy Placental abruption Placenta praevia Placenta accreta Uterine rupture

Answer 420

place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava

Answer 421

after 20 weeks

Answer 422

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta Early intubation to protect the airway Early supplementary oxygen Aggressive fluid resuscitation (caution in pre-eclampsia) Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

Answer 423

There is no response after 4 minutes to CPR performed correctly CPR continues for more than 4 minutes in a woman more than 20 weeks gestation

Answer 424

between 37 and 42 weeks gestation

Answer 425

First stage – from the onset of labour (true contractions) until 10cm cervical dilatation Second stage – from 10cm cervical dilatation until delivery of the baby Third stage – from delivery of the baby until delivery of the placenta

Answer 426

Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions. Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions. Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.

Answer 427

Show (mucus plug from the cervix) Rupture of membranes Regular, painful contractions Dilating cervix on examination

Answer 428

Painful contractions Changes to the cervix, with effacement and dilation up to 4cm

Answer 429

Regular, painful contractions Dilatation of the cervix from 4cm onwards

Answer 430

amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).

Answer 431

The amniotic sac ruptures more than 18 hours before delivery

Answer 432

birth before 37 weeks gestation

Answer 433

below 23 weeks gestation

Answer 434

Under 28 weeks: extreme preterm 28 – 32 weeks: very preterm 32 – 37 weeks: moderate to late preterm

Answer 435

Vaginal progesterone Cervical cerclage

Answer 436

cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy)

Answer 437

speculum examination revealing pooling of amniotic fluid in the vagina.

Answer 438

Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes Placental alpha-microglobin-1 (PAMG-1)

Answer 439

Prophylactic antibiotics Induction of labour may be offered from 34 weeks to initiate the onset of labour

Answer 440

Fetal monitoring (CTG or intermittent auscultation) Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth

Answer 441

Reduced respiratory rate Reduced blood pressure Absent reflexes

Answer 442

between 41 and 42 weeks gestation Prelabour rupture of membranes Fetal growth restriction Pre-eclampsia Obstetric cholestasis Existing diabetes Intrauterine fetal death

Answer 443

scoring system used to determine whether to induce labour

Answer 444

Fetal station (scored 0 – 3) Cervical position (scored 0 – 2) Cervical dilatation (scored 0 – 3) Cervical effacement (scored 0 – 3) Cervical consistency (scored 0 – 2)

Answer 445

predicts a successful induction of labour

Answer 446

Membrane sweep Vaginal prostaglandin E2 (dinoprostone) Cervical ripening balloon artificial rupture of membranes with an oxytocin infusion

Answer 447

Oral mifepristone (anti-progesterone) plus misoprostol

Answer 448

Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour Bishop score before and during induction of labour to monitor the progress

Answer 449

Uterine hyperstimulation

Answer 450

Individual uterine contractions lasting more than 2 minutes in duration More than five uterine contractions every 10 minutes

Answer 451

Fetal compromise, with hypoxia and acidosis Emergency caesarean section Uterine rupture

Answer 452

Removing the vaginal prostaglandins, or stopping the oxytocin infusion Tocolysis with terbutaline

Answer 453

Sepsis Maternal tachycardia (> 120) Significant meconium Pre-eclampsia (particularly blood pressure > 160 / 110) Fresh antepartum haemorrhage Delay in labour Use of oxytocin Disproportionate maternal pain

Answer 454

Contractions – the number of uterine contractions per 10 minutes Baseline rate – the baseline fetal heart rate Variability – how the fetal heart rate varies up and down around the baseline Accelerations – periods where the fetal heart rate spikes Decelerations – periods where the fetal heart rate drops

Answer 455

110 – 160

Answer 456

fetal heart rate drops in response to hypoxia

Answer 457

Early decelerations Late decelerations Variable decelerations Prolonged decelerations

Answer 458

early decelerations

Answer 459

3 minutes – call for help 6 minutes – move to theatre 9 minutes – prepare for delivery 12 minutes – deliver the baby (by 15 minutes)

Answer 460

DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG) C – Contractions BRa – Baseline Rate V – Variability A – Accelerations D – Decelerations O – Overall impression (given an overall impression of the CTG and clinical picture)

Answer 461

stimulates the ripening of the cervix and contractions of the uterus during labour and delivery. It also plays a role in lactation during breastfeeding

Answer 462

Induce labour Progress labour Improve the frequency and strength of uterine contractions Prevent or treat postpartum haemorrhage

Answer 463

Power (uterine contractions) Passenger (size, presentation and position of the baby) Passage (the shape and size of the pelvis and soft tissues)

Answer 464

Less than 2cm of cervical dilatation in 4 hours Slowing of progress in a multiparous women

Answer 465

Cervical dilatation (measured by a 4-hourly vaginal examination) Descent of the fetal head (in relation to the ischial spines) Maternal pulse, blood pressure, temperature and urine output Fetal heart rate Frequency of contractions Status of the membranes, presence of liquor and whether the liquor is stained by blood or meconium Drugs and fluids that have been given

Answer 466

2 hours in a nulliparous woman 1 hour in a multiparous woman

Answer 467

More than 30 minutes with active management More than 60 minutes with physiological management

Answer 468

intramuscular oxytocin and controlled cord traction

Answer 469

Amniotomy (artificial rupture of membranes) for women with intact membranes Oxytocin infusion Instrumental delivery Caesarean section

Answer 470

paracetamol in early labour Gas and Air (Entonox) IM Pethidine or Diamorphine Patient controlled IV remifentanil Epidural

Answer 471

Headache after insertion Hypotension Motor weakness in the legs Nerve damage Prolonged second stage Increased probability of instrumental delivery

Answer 472

when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes

Answer 473

fetus is in an abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique)

Answer 474

Emergency caesarean section left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), and tocolysis whilst waiting

Answer 475

when the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.

Answer 476

macrosomia secondary to gestational diabetes

Answer 477

failure of restitution turtle-neck sign

Answer 478

Episiotomy McRoberts manoeuvre Pressure to the anterior shoulder Rubins manoeuvre Wood's screw manoeuvre Zavanelli manoeuvre

Answer 479

Fetal hypoxia (and subsequent cerebral palsy) Brachial plexus injury and Erb’s palsy Perineal tears Postpartum haemorrhage

Answer 480

co-amoxiclav

Answer 481

Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions

Answer 482

Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve)

Answer 483

Cephalohaematoma with ventouse Facial nerve palsy with forceps

Answer 484

Subgaleal haemorrhage (most dangerous) Intracranial haemorrhage Skull fracture Spinal cord injury

Answer 485

weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.

Answer 486

weakness of hip adduction and rotation, and numbness of the medial thigh.

Answer 487

First births (nulliparity) Large babies (over 4kg) Shoulder dystocia Asian ethnicity Occipito-posterior position Instrumental deliveries

Answer 488

First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin Second-degree – including the perineal muscles, but not affecting the anal sphincter Third-degree – including the anal sphincter, but not affecting the rectal mucosa Fourth-degree – including the rectal mucosa

Answer 489

3A – less than 50% of the external anal sphincter affected 3B – more than 50% of the external anal sphincter affected 3C – external and internal anal sphincter affected

Answer 490

Broad-spectrum antibiotics to reduce the risk of infection Laxatives to reduce the risk of constipation and wound dehiscence Physiotherapy to reduce the risk and severity of incontinence Follow up to monitor for longstanding complications

Answer 491

Pain Infection Bleeding Wound dehiscence or wound breakdown

Answer 492

Urinary incontinence Anal incontinence and altered bowel habit (third and fourth-degree tears) Fistula between the vagina and bowel (rare) Sexual dysfunction and dyspareunia (painful sex) Psychological and mental health consequences

Answer 493

mediolateral

Answer 494

Minor PPH – under 1000ml blood loss Major PPH – over 1000ml blood loss

Answer 495

Moderate PPH – 1000 – 2000ml blood loss Severe PPH – over 2000ml blood loss

Answer 496

Primary PPH: bleeding within 24 hours of birth Secondary PPH: from 24 hours to 12 weeks after birth

Answer 497

T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder)

Answer 498

Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in the second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery General anaesthesia Episiotomy or perineal tear

Answer 499

Treating anaemia during the antenatal period Giving birth with an empty bladder (a full bladder reduces uterine contraction) Active management of the third stage (with intramuscular oxytocin in the third stage) Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Answer 500

Resuscitation with an ABCDE approach Lie the woman flat, keep her warm and communicate with her and the partner Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 501

Rubbing the uterus Catheterisation

Answer 502

Oxytocin (slow injection followed by continuous infusion) Ergometrine (contraindicated in hypertension) Carboprost Misoprostol (sublingual) Tranexamic acid (intravenous)

Answer 503

retained products of conception (RPOC) or infection (i.e. endometritis).

Answer 504

Intrauterine balloon tamponade B-Lynch suture Uterine artery ligation hysterectomy

Answer 505

Previous caesarean Symptomatic after a previous significant perineal tear Placenta praevia Vasa praevia Breech presentation Multiple pregnancy Uncontrolled HIV infection Cervical cancer

Answer 506

Category 1: There is an immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes. Category 2: There is not an imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby. Decision to delivery time is 75 minutes. Category 3: Delivery is required, but mother and baby are stable. Category 4: This is an elective caesarean, as described above.

Answer 507

Skin Subcutaneous tissue Fascia / rectus sheath Rectus abdominis muscles Peritoneum Vesicouterine peritoneum Uterus (perimetrium, myometrium and endometrium) Amniotic sac

Answer 508

H2 receptor antagonists (e.g. ranitidine) or proton pump inhibitors (e.g. omeprazole) before the procedure Prophylactic antibiotics during the procedure to reduce the risk of infection Oxytocin during the procedure to reduce the risk of postpartum haemorrhage Venous thromboembolism (VTE) prophylaxis with low molecular weight heparin

Answer 509

Previous uterine rupture Classical caesarean scar (a vertical incision) Other usual contraindications to vaginal delivery (e.g. placenta praevia)

Answer 510

Chorioamnionitis Urinary tract infections

Answer 511

Abdominal pain Uterine tenderness Vaginal discharge

Answer 512

Increasing maternal age Induction of labour Caesarean section Multiple pregnancy

Answer 513

Shortness of breath Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest

Answer 514

Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions

Answer 515

Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse

Answer 516

Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy)

Answer 517

fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out.

Answer 518

large postpartum haemorrhage. There may be maternal shock or collapse.

Answer 519

Johnson manoeuvre Hydrostatic methods Surgery

Answer 520

Analgesia as required Help establishing breast or bottle-feeding Venous thromboembolism risk assessment Monitoring for postpartum haemorrhage Monitoring for sepsis Monitoring blood pressure (after pre-eclampsia) Monitoring recovery after a caesarean or perineal tear Full blood count check (after bleeding, caesarean or antenatal anaemia) Anti-D for rhesus D negative women (depending on the baby’s blood group) Routine baby check

Answer 521

General wellbeing Mood and depression Bleeding and menstruation Scar healing after episiotomy or caesarean Contraception Breastfeeding Fasting blood glucose (after gestational diabetes) Blood pressure (after hypertension or pre-eclampsia) Urine dipstick for protein (after pre-eclampsia)

Answer 522

should settle within six weeks

Answer 523

Breastfeeding releases oxytocin, which can cause the uterus contract

Answer 524

3 weeks onwards

Answer 525

21 days after giving birth

Answer 526

Foul-smelling discharge or lochia Bleeding that gets heavier or does not improve with time Lower abdominal or pelvic pain Fever Sepsis

Answer 527

Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors) Urine culture and sensitivities

Answer 528

Placenta accreta

Answer 529

Vaginal bleeding that gets heavier or does not improve with time Abnormal vaginal discharge Lower abdominal or pelvic pain Fever (if infection occurs)

Answer 530

Ultrasound

Answer 531

dilatation and curettage

Answer 532

adhesions (sometimes called synechiae) form within the uterus

Answer 533

Hb under 100 g/l – start oral iron (e.g. ferrous sulfate) Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject) Hb under 70 g/l – blood transfusion in addition to oral iron

Answer 534

Mood swings Low mood Anxiety Irritability Tearfulness (usually in 1st week)

Answer 535

Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Fever

Answer 536

1st: continued breastfeeding, heat packs, analgesia 2nd: Flucloxacillin

Answer 537

Sore nipples bilaterally, particularly after feeding Nipple tenderness and itching Cracked, flaky or shiny areola Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Answer 538

Topical miconazole 2% after each breastfeed Treatment for the baby (e.g. miconazole gel or nystatin)

Answer 539

changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both.

Answer 540

Thyrotoxicosis (usually in the first three months) Hypothyroid (usually from 3 – 6 months) Thyroid function gradually returns to normal (usually within one year)

Answer 541

complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland

Answer 542

anterior pituitary gland

Answer 543

Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Luteinising hormone (LH) Growth hormone (GH) Prolactin

Answer 544

Reduced lactation (lack of prolactin) Amenorrhea (lack of LH and FSH) Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH) Hypothyroidism with low thyroid hormones (lack of TSH)

Answer 545

Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause) Hydrocortisone for adrenal insufficiency Levothyroxine for hypothyroidism Growth hormone

Obstetrics & gynaecology Flashcards

(591 cards)