Sba 2 Flashcards
(196 cards)
1
Q
WHO) defines indirect maternal death as that
resulting from:
A
Previous existing disease or developed during the pregnancy and not the result
of direct obstetric causes but aggravated by the physiological effects of
pregnancy.
2
Q
What is the definition of Direct maternal deaths ?
A
those that result from interventions, omissions or incorrect treatment.
3
Q
What is the definition of Late maternal deaths ?
A
those occurring between 42 days and 1 year postpartum
4
Q
What is the leading cause of late maternal death ?
A
Malignancy 23 %
Second cause: Psychiatric causes
5
Q
What is the leading cause of indirect maternal death ?
A
Cardiac disease
6
Q
What was the percentage of maternal deaths due to ectopic pregnancy?
A
4.8%
7
Q
What was the percentage of maternal deaths due to ectopic pregnancy?
A
4.8%
8
Q
With regard to the MBRRACE-UK report:
Which statement is true regarding the trends in incidence of direct maternal deaths?
A
Direct maternal deaths have fallen every year since 2004.
9
Q
A 33-year-old woman who is 33 weeks pregnant was involved in a road traffic
accident. She is cardiovascularly stable, her blood clotting profile is normal and there
is no fetal distress but she has a pelvic fracture and needs a Caesarean section in the
operating theatre.
Why is regional anaesthesia preferable over general anaesthesia?
A
Lower risk of maternal hypoxaemic events.
10
Q
What is your explanation for the most likely cause of maternal deaths secondary to
anaesthesia?
A
Failure to secure adequate airway with general anaesthesia.
11
Q
What is the rate of amniotic fluid embolism?
A
0.68/100 000.
12
Q
Which obstetric intervention is most strongly associated with amniotic fluid embolism?
A
Induction of labour
13
Q
A pregnant woman sees her general practitioner with a sore throat and palpable
lymph nodes in her neck. One day later she attends the emergency department with
severe diarrhoea and vomiting and feeling very unwell. While there she becomes
hypotensive, tachycardic and then collapses.
What is the most likely diagnosis?
A
Group A streptococcal sepsis.
* ( which often presents with
a sore throat/urinary tract infection.)
14
Q
You are asked to review a severely ill woman who is 35 weeks pregnant. Her pulse is
102 bpm. You suspect systemic inflammatory response (SIRS).
What other finding is the most strongly associated diagnostic feature?
A
New onset confusion or altered mental state.
* Other criteria for SIRS:
1- temperature
<36 C or >38.3C
2- respiratory rate
>20/min
3- blood glucose over 7.7 mmol/L in the absence of known diabetes,
4- white cell count >12x109
/L or <4x109
/L.
15
Q
A woman with a BMI of 37 kg/m2 and asthma had an elective Caesarean section for
breech at term with blood loss of 1300 ml. She was discharged home three days later.
One week later, she became acutely short of breath and collapsed.
What is the most likely diagnosis?
A
Pulmonary embolism
* Risk factors : include elevated BMI, operative delivery,
postpartum haemorrhage, postsurgical immobility
16
Q
You are called urgently to see a collapsed woman in room 4 on the labour ward. She
has just had a prolonged labour and instrumental delivery. The midwife says the
woman complained of slight headache, became short of breath and then said she had
chest pain before she collapsed.
Which of these symptoms is not suggestive of a pulmonary embolism?
A. Chest pain.
B. Dizziness.
C. Headache.
D. Sudden onset breathlessness.
E. Tachycardia.
A
Headache
17
Q
A fit, 39-year-old, 18-week pregnant woman presented with non-specific abdominal
pain, left-sided leg pain and oedema to the emergency department following a recent
safari holiday in Africa. Doppler ultrasound scan of the leg is normal.
What is the most likely diagnosis?
A
Deep vein thrombosis.
* Deep vein thrombosis cannot be excluded by the presence of a negative
Doppler scan if strong clinical suspicion remains.
* If the D-dimer test is negative, it rules out the possibility of deep venous
thrombosis in up to 97% of cases.
18
Q
What is the leading cause of maternal mortality worldwide?
A
Haemorrhage
19
Q
Haemoglobin levels are tested in the UK at booking. If the level is below the normal
range, the woman should be investigated further.
The abnormal range is less than:
A
110 g/L
20
Q
A woman has a postpartum haemorrhage following a forceps delivery. Uterotonics
(syntocinon, intramuscular syntometrine and oral misoprostol) have been used but
uterine atony remains. An intrauterine balloon tamponade is inserted but the postpartum haemorrhage continues. The estimated blood loss is 2100 ml.
What is the next management step?
A
Laparotomy
* ( After Laparotomy Transfusion )
21
Q
A 31-year-old woman who is 33 weeks pregnant presented with acute weight loss and
fatigue in pregnancy. A malignancy is suspected but the primary is not identified. A
category 3 Caesarean section for maternal deterioration is performed. The placenta is
sent for histology as it looks and feels abnormal.
Which malignancy is most likely to show metastatic involvement of the placenta?
A
Malignant melanoma.
22
Q
In the 2016 report, case notes were available for in-depth review of the care offered in
183 deaths.
What is the percentage of women in whom improvements to care may have made a
difference to the outcome?
A
42%
23
Q
You are following up a 22-week pregnant woman in the antenatal clinic. Her epileptic
fits are well controlled on medications.
What is the most common cause of maternal death secondary to epilepsy?
A
Sudden unexpected death in pregnancy (SUDEP).
24
Q
Women who are victims of domestic abuse are more likely to suffer obstetric
complications. Which one of the following is not associated with domestic violence?
A
Pregnancy-induced hypertension
25
A general practitioner calls you about a postnatal woman who delivered two weeks
previously. He thinks she should be admitted to a mother-and-baby psychiatric unit
and gives you a full history.
Which of these reasons is not an indication for admission?
A. Beliefs of inadequacy as a mother.
B. Evidence of psychosis.
C. Persistent insomnia over three nights.
D. Pervasive guilt or hopelessness.
E. Suicidal ideation.
Persistent insomnia over three nights.
26
What is the most common respiratory cause of maternal death in the UK in the three
MBRRACE-UK reports?
Asthma
27
You are reviewing a woman who is 16 weeks pregnant and has asthma. Her antenatal
care has been uneventful to date but she had an exacerbation of her asthma with the
recent cold weather, which has now improved.
What is your immediate advice?
Ensure she has the seasonal influenza vaccin
28
You are reviewing a 23-year-old pregnant woman with long-standing type 1
diabetes in the combined pregnancy diabetic clinic. She has good control of her blood
sugar levels.
Which of these complications most increases her risk of dying during this pregnancy?
Hypoglycaemia
29
What is the most common cardiac cause of late maternal death in the UK in the latest
MBRRACE-UK report?
Sudden arrhythmic cardiac deaths with a morphologically normal heart.
30
A previously well 37-year-old patient with a metal mitral valve who is anticoagulated, presents at 15 weeks’ gestation on a cold day with an acute onset cough
and frothy pink sputum. She becomes more short of breath and deteriorates very
rapidly and has a cardiac arrest.
At postmortem, what is the most likely cause of death?
Heart failure
31
A previously well 26-year-old UK-born woman presents to her antenatal clinic at 18
weeks’ gestation with a history of palpitations in recent weeks.
What is the most likely diagnosis?
Ectopic cardiac beats.
32
A 31-year-old smoker with no medical history comes for booking in the antenatal
clinic and a systolic murmur is heard.
What is the most likely diagnosis?
Flow murmur of pregnancy
33
A 34-year-old woman who books in her pregnancy gives a history of her mother
dying of a heart attack at 39 years old and her maternal grandfather dying of a heart
attack at 38 years old. Her 27-year-old brother recently had a cardiac arrest while
playing football, but survived after resuscitation. , what is the most likely diagnosis?
Inherited cardiomyopathy
34
What is the difference in death rates reported in the UK confidential enquiry into
maternal deaths for the years 2011–2013 compared to the previous 2010–2012 report?
There was a reduction from 10.12 to 9.02 deaths per 100 000 maternities
35
In the 2012–2014 confidential enquiry report, what was the rate of the most common
cause of death?
Cardiac disease at a rate of 2.18/100 000 maternities
36
A 33-year-old woman comes to the antenatal booking clinic. She is 14 weeks pregnant.
On checking on her mental health, you find she had a previous mental health
problem. She has improved and is not currently under any treatment.
What is the highest risk time for a recurrent episode?
In the immediate postpartum period
37
The midwife in the postnatal ward calls you to review a woman who is doubtful
about her competence as a mother and is not sure she will be able to look after her
baby. She has no history of any past illnesses or any special medications.
How will you deal with the situation?
Arrange for urgent senior psychiatric assessment
38
A woman who came from a country in the developing world had just had an
emergency Caesarean section for failure to progress. She was not sure if she had a
past varicella zoster virus (VZV) infection. She has been tested and found to be nonimmune. She requests postpartum vaccination.
What is your advice for breastfeeding?
It is safe to breastfeed
* studies have not detected the varicella zoster virus (VZV)
vaccine in breast milk.
* women should be advised to avoid pregnancy for
four weeks.
39
A woman who is 26 weeks pregnant is referred by the general practitioner because of
recent contact with a friend with chickenpox (varicella zoster). On testing, she is not
immune to the infection.
What is your immediate plan of care?
Offer one single dose of varicella zoster immunoglobulin (VZIG) as soon as
possible.
* within 7
–10
days of exposure.
The duration of protection is three weeks. If there is a second exposure after
three weeks, repeat VZIG prophylaxis is recommended
40
Fetal varicella zoster syndrome
(FVS) is more likely to occur if infection is contracted ...
After 28 w of Pregnancy
41
The general practitioner phones you about a woman who is 24 weeks pregnant and
has developed mild signs and symptoms of chickenpox in the last 24 hours. He wants
to know what treatment he should offer her.
What advice will you give him?
Offer her oral administration of 800 mg acyclovir five times a day for seven days
42
What is the risk of varicella infection of the newborn if Maternal infection occurred in the last four weeks of pregnancy ?
up to 50% of babies are infected and
approximately 23% develop clinical varicella)
* a planned delivery should normally be avoided for at least seven
days after the onset of the maternal rash
43
A woman who is 22 weeks pregnant is seen in the antenatal clinic. Her hepatitisscreening test shows IgM antibody to the hepatitis B core antigen (HBcAg ).
What is your diagnosis?
Acute hepatitis B infection
* Acute infection is characterized by the presence of HBsAg and anti-HBcAg)
* Chronic infection is characterized by IgG levels and the persistence of HBsAg
without the antibody (anti-HBsAg).
44
Which lab test indicates recovery and
immunity from hepatitis B infection or is an indication of successful vaccination ?
The presence of anti-HBsAg of
>10–12 mIU/mL
45
NICE guidelines Antiviral Prophylaxis in Pregnant Women advise offering tenofovir
disoproxil fumarate (TDF) to hepatitis B-infected pregnant women, to reduce motherto-child vertical transmission (MTCT).
At what gestational age should you advise starting this treatment?
Start treatment from 28 weeks and continue until four to 12 weeks postpartum.
46
A hepatitis B-positive woman has just been delivered. The midwife tells you the
woman wants to discuss breastfeeding.
How will you counsel her?
Breastfeeding is not contraindicated unless she is on antiviral therapy.
47
An unbooked mother comes into early labour. On reviewing her notes, she was not
screened for hepatitis B infection.
What is your advice for the immediate follow-up for the baby?
The mother should be tested and if found to be HBsAg positive, the child should
receive vaccination within 24 hours.
* also have HBIG to offer a passive immunization, within 24 hours of birth.
*
This post-exposure prophylaxis (PEP) programme can prevent up to 90% of
vertical transmission.
48
A woman who is 35 weeks pregnant is diagnosed with primary genital herpes. She
received acyclovir treatment but was reluctant to accept Caesarean section delivery.
What are the risks of the baby developing neonatal herpes if she has a vaginal
delivery?
41%
49
A woman who is 35 weeks pregnant is complaining of painful vulval blisters. She was
diagnosed with genital herpes when she was 25 weeks pregnant and received acyclovir treatment. She is not keen on Caesarean section delivery.
What is your first line of investigation to help her decide the mode of delivery?
🌸 Test her for type-specific HSV-IgG antibodies to HSV-1 and HSV-2
* Type-specific HSV antibody testing (IgG) will help
distinguish between primary and recurrent .
The presence of antibodies of the same type as the HSV isolated from genital swabs would confirm
this episode to be a recurrence rather than a primary infection.
🤭 Recurrent genital herpes in the third trimester is not an indication for CS .
50
For women who are diagnosed with suspected genital herpes in the primary care or
obstetric services, what audit should you perform to ensure correct management?
Percentage of women referred to a genitourinary medicine specialist.
51
What is the percentage of all HIV-positive women in the UK, who are identified
because of antenatal screening in their current pregnancy?
16%
52
A woman who is 13 weeks pregnant has screened positive to HIV infection. During
counselling, you felt it was important to explain the declining rate of mother-to-child
transmission (MTCT) because of interventions.
What is the current rate of MTCT of HIV infection?
<0.5%
Antiretroviral therapy, appropriate management of delivery and the avoidance
of breastfeeding can reduce the risk of MTCT from 15%–25% to 1% or less.
53
A woman who is 26 weeks pregnant, and who has multiple sexual partners, is seen in
the antenatal clinic. She had screened negative for HIV infection at her 13-week
booking visit.
How would you re-counsel her to reduce possible MTCT?
Offer a repeat HIV screening
54
A woman who is 14 weeks pregnant has screened positive for HIV infection. She
agrees to start combined antiretroviral therapy (cART).
When would you test her viral load in order to monitor her adherence to treatment?
Two to four weeks after commencing cART, at the second and third trimester, at
36 weeks, and at delivery.
* if the woman has not achieved a plasma viral load of
<50 copies/mL at 36 weeks,
she should be referred to a virologist.
55
A woman who is 11 weeks pregnant has screened positive for HIV infection.
How would you counsel her about her options for the best time to start cART?
She should start treatment immediately
56
A full-term primigravida pregnant woman presented in established labour at 6-cm
dilatation. Her previous screening showed she is HIV screen positive but did not have
any treatment.
What is your immediate management?
Start oral combined antiretroviral therapy.
* Zidovudine infusion for the duration of labour in addition to cART will add
further protection but alone is not the first-line management as it does not
reduce MTCT significantly.
57
An HIV screen-positive pregnant woman at 36 weeks is reviewed at the antenatal
clinic. She was on cART and her viral load is <50 HIV-RNA copies/mL.
Justify your plan for her delivery.
There is no need for planned elective Caesarean section (PLCS) as she has a very
low risk of MTCT.
* In women on cART with a plasma viral load
<50 HIV-RNA copies/mL, the
MTCT rates are reduced
(<0.5%) irrespective of the mode of delivery. { recommending planned vaginal delivery }
58
An HIV screen-positive pregnant woman at 36 weeks is reviewed at the antenatal
clinic. Where the viral load is
400 HIV-RNA copies/mL , Justify your plan for her delivery.
PLCS is
recommended
surgery should be
undertaken at between 38 and 39 weeks’ gestation
59
An HIV screen-positive pregnant woman and PLCS is indicated , when to perform the surgery?
1- only for obstetric indications, and the plasma viral
load is
<50 copies/mL, surgery should be undertaken between 39 and
40 weeks.
2- if the viral load is
400 HIV-RNA copies/mL , surgery should be
undertaken at between 38 and 39 weeks’ gestation
60
A 30-year-old woman has just come back from a tour of Brazil. She is 29 weeks
pregnant. She has complained of a low-grade fever, and a maculopapular rash.
What is your next course of action?
Request serum transcription polymerase chain reaction (RT-PCR).
(RT-PCR is the main diagnostic test. It detects the viral RNA, to identify the type
of virus infection)
61
A 30-year-old woman has just come back from a tour of Brazil. She is 29 weeks
pregnant. She has complained of a low-grade fever, and a maculopapular rash.
After doing RT-PCR to identify the type
of virus infection(ZIKV or the dengue fever viru).
What is the management?
Currently there is neither any specific antiviral treatment nor any vaccination
for either the ZIKV or the dengue fever virus.
62
A woman who is 12 weeks pregnant has a serum screening test showing a Venereal
Disease Research Laboratory/rapid-plasma-reagin (VDRL/RPR) titre of >16.
This result indicates she has:
Active syphilis infection
( It disappears in an adequately treated person after
about three years )
(VDRL/RPR) : Non-treponemal
63
What is the difference between :
(VDRL/RPR) antibody test Non-treponemal & (FTA-ABS) treponemal antibody ?
1- (VDRL/RPR) antibody test Non-treponemal ; indicate Active syphilis infection
It disappears in an adequately treated person after
about three years .
2- (FTA-ABS) treponemal antibody ; does not differentiate between acute and old, chronic
infection , lasts for life .
64
How to confirm the diagnosis in syphilitic infections ?
by dark ground microscopy to look for the syphilis
Treponema pallidum
in a sample of fluid or tissue from an open sore.
65
How to assess the Response to treatment in syphilitic infections ?
four-fold or greater titre decrease in the
VDRL/RPR within 3-6 months after treatment.
66
A woman who is 14 weeks pregnant comes to the antenatal booking clinic after she
has been diagnosed with a primary syphilis infection.
What will you tell her about the risk of transfer of the disease to her baby?
Around 40%–50%.
67
A woman who is 33 weeks pregnant is diagnosed with a syphilis infection.
What is your first-line treatment option?
A single dose of benzathine benzyl penicillin G 2.4 MU followed by a second
dose after one week.
* All babies should be evaluated at birth and treated with penicillin
68
What is the Alternative second line therapy for syphilis infection.
?
1- Oral amoxicillin 500 mg six hourly plus oral probenecid 500 mg six hourly for
14 days.
2- Intramuscular ceftriaxone 500 mg for 10 days
3- Oral erythromycin 500 mg six hourly for 14 days
4- Oral azithromycin 500 mg daily for 10 days
69
What is the incidence of early onset neonatal group B-streptococcal (EOGBS) disease
in the UK?
0.5/1000 live births.
70
On reviewing the notes of a woman who is 16 weeks pregnant, you notice she was a
GBS carrier diagnosed from a vaginal swab in her previous pregnancy.
What treatment options would you recommend?
There is no need for current or intrapartum treatment
71
A woman who is 27 weeks pregnant complains of dysuria and loin pains. Urine
cultures indicated GBS growth greater than 105 CFU (colony-forming units)/mL. She
received the appropriate treatment.
What is your further management?
She should receive IAP.
72
A woman who is 22 weeks pregnant has a vaginal swab because of symptomatic
vaginal discharge. The swab shows heavy growth of GBS. She has received the
appropriate treatment.
What is your further management?
She should receive IAP.
73
What is the Recommended IAP treatment regimens ?
1- IV benzylpenicillin 3 g be given as soon as possible after the onset of
labour and 1.5 g four hourly until delivery .
2- Clindamycin 900 mg IV / eight hourly to those
allergic to benzylpenicillin.
3- An alternative agent vancomycin
74
A woman who is 22 weeks pregnant comes to the emergency department complaining of flu-like symptoms. She is pyrexial with no other clinical signs.
What is the most relevant information in her history that makes you suspect malaria
infection?
Travel to an endemic area.
75
A woman who is 16 weeks pregnant is referred by the general practitioner because of
pyrexia and flu-like symptoms. You noticed a yellowish tinge to her conjunctiva; she
says she has been to sub-Saharan Africa. You suspected malaria infection.
How will you confirm the diagnosis?
🌼Microscopic examination of blood films for parasites
( is the gold standard for a
definite diagnosis of malaria infection )
* has the advantage of quantifying the number of infected red
blood cells (parasitaemia) and of confirming the infecting species and the stage
of the parasites
76
A woman who is 11 weeks pregnant is admitted with uncomplicated Plasmodium
falciparum malaria infection.
What management options would you offer?
Start oral quinine 600 mg eight hourly and oral clindamycin 450 mg eight hourly
for 7 days.
1- Hospitalization improves compliance
2- There has not been any evidence of congenital defects in babies born to
mothers who received antimalarial treatment even in first trimester.
77
A woman who is 17 weeks pregnant comes for advice, as she has to travel to Nigeria.
She is worried about malaria infection.
What chemoprophylaxis medication would you prescribe?
Mefloquine
- it is highly effective against drug-resistant
P. falciparum
- no association for mefloquine with
stillbirths or miscarriages in the second and third trimesters.
78
A woman who is 13 weeks pregnant comes to see you at the early pregnancy
assessment unit. She works at a childcare facility and has heard that contact with
children is a common cause for cytomegalovirus (CMV) infection.
How will you counsel her about prevention
Follow the advice about hygienic measures to prevent infection
79
A woman who is 16 weeks pregnant has a urine culture showing an Escherichia coli
bacteria concentration of 105 CFU/mL. She is completely asymptomatic and was
reluctant to receive antibiotic treatment.
What will you say to her?
Antibiotic treatment is effective in reducing the risk of renal complications
( comparing single-dose versus a four- to seven-day course
of antibiotic treatment for ASB did not show a difference in the prevention of
preterm birth or pyelonephritis between the two regimens)
80
The general practitioner calls you to ask about the best test to confirm asymptomatic
bacteruria (ASB) in an asymptomatic 14-week pregnant woman who had a previous
urinary tract infection preceding this pregnancy.
What is the most reliable test?
Urine culture ( not Urine microscopy. )
81
A woman who is 16 weeks pregnant presents at the booking clinic complaining of
dysuria, frequency, urgency and suprapubic pain. She also noticed her urine is
slightly blood stained. On examination, you observed a urethral discharge. Urine
culture did not show significant bacteriuria.
What is the most likely diagnosis?
Gonococcal urethritis.
82
A woman who is 30 weeks pregnant has a recurrent urinary tract infection (UTI).
What would you recommend for prevention of recurrence until the end of pregnancy?
A daily suppressive dose of 250 mg cephalexin
- Nitrofurantoin should not be given after 36 weeks
- There is no evidence to
support trimethoprim use for treatment of UTI infection.
83
A 32-year-old woman who is 17 weeks pregnant complains of recent polyarthralgia,
affecting the hands, wrists, ankles and knees. On history taking, she admits to being in
recent contact with a child who developed a non-vesicular rash.
What is your provisional diagnosis?
Human parvovirus infection
* Arthropathy is the most common symptom (80%) of parvovirus B19 infection
in adults.
In children : facial rash (Erythema infectiosum,
slapped cheek or ‘fifth disease’
84
A woman who is 32 weeks pregnant had a proven B19 infection and has developed
fetal hydrops at 36 weeks.
What is your management?
Administer steroids for lung maturity and deliver
( No need for measuring MCA-PSV )
85
A woman who is 26 weeks pregnant with confirmed B19 infection and non-immune
hydrops fetalis (NIHF) is being followed up for any further developments in the fetus.
The MCA-PSV is >1.5 MoM.
What is your management?
Arrange for cordocentesis and intrauterine blood transfusion (IUT)
( A fetal blood sample should be taken during IUT to perform a measurement of :
B19V DNA, haemoglobin, platelet and reticulocyte counts )
86
A woman who is 15 weeks pregnant gives a history of recent contact with an infected
child. Her blood test was negative for both IgM and IgG rubella antibodies.
What advice will you offer?
Further serum test required one month after contact
(PCR is a specific 24-hour test result. It will definitely exclude a rubella infection )
87
A woman who is 25 weeks pregnant is referred by her general practitioner with a
confirmed measles infection. She has already been given human normal immunoglobulin (HNIG) post-exposure prophylaxis.
What are your plans for the rest of her antenatal care and management?
She should carry on with her usual antenatal care
* There is no treatment for measles, and it does not cause congenital anomalies.
There is no need for any extra antenatal-specific measures. There is no need to
expose her to the risks of amniocentesis
88
How to distinguish in symptoms between rubella (German measles) & measles ?
1- rubella (German measles) : the rash pink or light red, spotted, and lasts up
to three days. It begins on the face and then spreads downwards
- swollen lymph
nodes and joint swelling
2- measles : full-body red or reddish-brown bumpy rash,
which lasts for several days.
-
cough, runny nose and high fever.
89
A 19-year-old books her pregnancy at 18 weeks’ gestation. Her anomaly ultrasound
scan is normal. She has attended maternity triage on five occasions in the last six
weeks complaining of abdominal pain. On each occasion, she was discharged home
with analgesia. She presents to maternity triage at 28 weeks’ gestation complaining of
abdominal pain. Examination is unremarkable and all investigations are normal.
Which of the following management options is the most appropriate?
Refer to the safeguarding team
-( book late + have
repeated attendances with no clear diagnosis)
90
What proportion of women experience domestic abuse in pregnancy?
25 %
91
A 33-year-old woman attends the gynaecology outpatient clinic with a six-month
history of pelvic pain and dyspareunia. She reports having had chlamydia in the past.
On examination you notice bruises of various colours on the medial aspect of her thighs.
What is the most appropriate next step?
Ask about domestic abuse
( Before Check her clotting profile.
or Refer for psychosexual counselling or Take triple swabs )
92
A 25-year-old woman attends the antenatal clinic, with her partner, at 32 weeks’
gestation. She appears anxious and makes very little eye contact. You notice her
partner gives you her maternity book and he is answering the majority of the
questions on her behalf.
What is the most appropriate next management step?
Speak to the woman on her own
93
A 32-year-old hedge fund manager is admitted at 34 weeks’ gestation with signs
suggestive of a placental abruption. A few hours following admission, she has a
spontaneous vaginal delivery of an 1100 g female infant.
What is the most likely cause of her preterm delivery?
A. Alcohol abuse.
B. Amphetamine use.
C. Benzodiazepine use.
D. Cannabis use.
E. Cocaine use.
Cocaine use.
94
An unemployed 22-year-old has a spontaneous vaginal delivery of a male infant at 38
weeks’ gestation. She is breastfeeding; however, the baby is not gaining weight. The
health visitor notices that the baby has a thin upper lip and small palpebral fissures.
What is the most likely diagnosis?
Fetal alcohol syndrome
* microcephaly, intrauterine growth restriction, failure to thrive, characteristic facial
abnormalities such as short palpebral fissures and a short upturned nose
95
A 19-year-old has a Caesarean section for failure to progress at 37 weeks’ gestation. It
was noted previously that it was difficult to secure intravenous access, because her veins are difficult to cannulate. While she was in recovery, her baby started to have
seizures and was taken to the neonatal unit.
What is the most likely cause for the neonatal seizures?
Neonatal abstinence syndrome.
* seizures, poor feeding, high-pitched shrill cry, irregular sleep patterns, respiratory distress.
96
An 18-year-old books her pregnancy at 26 weeks’ gestation. She is a smoker and lives
in a hostel. At her first ultrasound scan, the fetus is found to have gastroschisis and a
cleft lip and palate.
What is the most likely cause of these fetal abnormalities?
Amphetamine use.
97
35-year-old woman books her pregnancy at 11 weeks’ gestation. She had a forceps
delivery two years previously and developed postpartum psychosis on day 3 postpartum. She has been discharged from the community mental health team and is not
currently on any psychiatric medication.
What is her risk of developing postpartum psychosis in this pregnancy?
50%
should review all women with
a history of postpartum psychosis prior to discharge from hospital
98
What are the Risk factors for developing postpartum psychosis ? What is the incidence?
1
–2/1000 births
Risk factors : a previous episode
of postpartum psychosis (~50%)
bipolar disorder (at least 25%)
schizoaffective
disorder
discontinuation of mood stabilizer
family history of bipolar disorder
mother or sister who has had postpartum psychosis
primiparity
sleep deprivation
shorter gestation period
99
A 27-year-old woman is brought in to the maternity triage on day 5 postpartum by
her husband. She is visibly detached and unkempt. She claims that her baby is not
hers and refuses to look at the baby.
What is the most appropriate next management step?
Admit to a mother-and-baby unit.
( Not 🚫 general psychiatric ward )
100
35-year-old woman attends the antenatal clinic at 30 weeks’ gestation. She reports
feeling anxious about the pregnancy and is especially anxious about contracting an
infection. She is washing her hands multiple times a day and has stopped using public
transport. What is the most appropriate initial treatment?
Cognitive behavioural therapy
The
first-line
treatment for mild to moderate anxiety disorders
101
From the MBRRACE-UK report published in 2015, almost a quarter of women who
died between six weeks and one year after pregnancy died of mental health-related
causes.
Of those women who committed suicide, what was the most common method
of death?
Hanging
102
A 14-year-old girl comes to the labour ward in early labour at 2 am. She is 38 weeks
pregnant with a single viable fetus. She had regular uneventful antenatal care. Her
serial growth scans are all normal. She had stopped smoking during this pregnancy
and her sexually transmitted disease screening is negative.
What would you recommend in her delivery?
Routine care of labour
* They need postpartum extra care of
support
103
A 15-year-old girl comes to the antenatal clinic. She is 11 weeks pregnant. She comes
from a broken family. She claims it was an unintended pregnancy; she does not want
to terminate the pregnancy but is not sure what to do with the child when it is born.
What options will you offer her?
She can offer the child for adoption
104
You work as an ST 5 in an inner city hospital. You are asked to discuss the high
incidence of teenage pregnancy with the local school administration to see how it may
be possible to prevent and reduce teenage pregnancy.
What is the primary prevention management that you may propose?
Advise arrangement of a series of presentations for sexual education of the
school girls
105
You are working as a year ST 5 in an inner city hospital. You are asked to propose an
effective family planning method for the teenage girls.
What will you propose?
Etonogestrel-releasing implant and the condom
106
A 23-year-old woman is using male and female barrier contraception to prevent
sexually transmitted infections (STIs). She wants to know if there is further protection
if a spermicide is included.
What will you tell her regarding spermicidal creams and STIs?
Does not offer added protection
107
A 26-year-old woman consults you. She was at a hen party and may have had
unprotected sex. She wants to make sure she did not acquire any sexually transmitted
infections. She wants to know when she should be tested.
What will you tell her?
After two weeks.
* (STI) screening tests are those for chlamydia,
gonorrhoea, syphilis and HIV
* Individuals at a specific risk of HIV infections should have a repeat test at four
weeks and 12 months from exposure
108
A 39-year-old woman consults you about the risk of venous thrombosis if she uses a
combined hormonal contraceptive. She shows you a brand, which contains 35 μg
ethinylestradiol and levonorgestrel norethisterone progestogen.
How will you counsel her?
Her current pill has the lowest risk of blood clotting.
* The risk of venous thromboembolis (VTE) is influenced by progestogen type;
- lowest risk : levonorgestrel, norethisterone or norgestimate (5–7/10 000 women)
- highest risk : drospirenone, desogestrel or gestodene (9–12/10 000
women)
109
How much the risk of VTE with use of combined hormonal
contraceptives Compared to non-users ?
approximately doubled but the absolute risk is still very low ( 10 / 10 000 )
110
Give Examples of progestogens according to their classified ‘generation’ ?
First generation: norethisterone acetate.
Second generation: levonorgestrel.
Third generation: desogestrel, gestodene, norgestimate.
Fourth generation: drospirenone, dienogest, nomegestrol acetate
111
A 36-year-old woman consults you about her contraception. She is seeking a method
with the lowest risk of thrombosis. She has a family history of venous thromboembolism (VTE) in a first-degree relative aged under 45 years. She is not keen on any
intrauterine devices.
How will you counsel her?
It is safe to use any progestogen-only method.
112
She is seeking a method
with the lowest risk of thrombosis. She has a family history of venous thromboembolism (VTE) in a first-degree relative , How will you counsel her about thrombophilia screen ?
A thrombophilia screen is not recommended routinely for women considering
hormonal contraception
113
She is seeking a method with the lowest risk of thrombosis. She has a family history of venous thromboembolism (VTE) in a first-degree relative , what category the combined oral contraceptive is ?
category 3
(the risk outweighs the advantage)
114
For women on anticoagulation what category is COC & POP ?
The combined oral contraception is category 4 (unacceptable risk).
Progestogen-only methods are category 2 (the benefits outweigh the risk)
115
A woman who weighs 100 kg wants to start the combined transdermal patch (CTP)
for contraception.
What is your advice?
Efficacy may be decreased because of her weight; she should use additional
precautions or an alternative method should be advised.
* in women
weighing ≥ 90 kg
116
A 28-year-old woman consults you about combined hormonal contraception (CHC).
Her mother died of breast cancer at the age of 55 years. She is healthy but has a
problem with painful periods.
What will you tell her?
She is at no risk and it will help her period pains
1- no increased risk of
breast cancer in women with a family history.
2- long-term protection
against ovarian cancer
117
A 28-year-old woman consults you about combined hormonal contraception (CHC).
Her mother died of breast cancer at the age of 55 years. She is healthy but has a
problem with painful periods.
Under what UKMEC category she is?
category 1
118
What are the Non-contraceptive benefits of CHC ( combined hormonal contraceptive ) ?
Improves and treats menstrual disorders (irregular periods, dysmenorrhea,
premenstrual tension syndrome and menorrhagia).
Reduces the risk of ovarian, endometrial and colorectal cancer.
May improve acne and improve bone health.
119
On a Saturday morning, an 18-year-old girl who is on an enzyme-inducing drug
comes to the accident and emergency department requesting advice as she had
unprotected sexual intercourse . She did not accept your advice for an intrauterine device (IUD)
fitting.
What alternatives can you offer her?
Offer a single 3 mg dose of levonorgestel (LNG) (two Levonelle®
tablets).
* Enzyme-inducing drugs have the potential to decrease the contraceptive effinacy of levonelle
* The clinical effectiveness unit does not advise the use of the progesterone
receptor modulator ulipristal acetate (UPA) (ellaOne®) for women on
enzyme-inducing drugs.
120
A 17-year-old girl comes to the accident and emergency department. She had unprotected intercourse four days previously. She was not very keen on an intrauterine
device (IUD).
What other alternatives do you wish to offer?
Single dose of 30 mg micronized ulipristal acetate (ellaOne®)
* is the only licenced oral emergency contraception that can be used
between 72 and 120 hours after unprotected intercourse.
121
A 35-year-old woman comes for a suitable family planning method. She is obese (BMI
35 kg/m2
), with a family history of endometrial cancer.
What are her options?
Either the copper intrauterine device (IUD) or the levonorgestrel (LNG) IUD is a
suitable option
* Both copper and LNG IUDs have a protective effect against endometrial cancer
122
An 18-year-old woman asks about contraception. She has acne and complains of
heavy bleeding.
How will you help her to choose?
She can use a product with cyproterone acetate (CPA/EE).
123
The general practitioner calls you to ask about one of his patients who is on
progesterone-only contraception. She will be started on an enzyme-inducing drug.
He says this new medication is expected to be taken long term.
What will you tell him?
She should change to another long-term reversible contraceptive.
( No 🚫 doubling the dose.OR changing to another progestogen OR COC )
124
A woman with sickle cell disease is seeking a long-acting reversible contraception
method. She is asking if there is any method that may also help reduce her risk of
sickle cell crisis and pain.
What well you tell her?
🌟🌟 The long-acting injectable contraceptive may help reduce her crisis pain.
125
A woman with systemic lupus erythematosus comes to see you regarding safer
contraception. From her notes, you see she has positive antiphospholipid antibodies.
According to the UK medical eligibility criteria (UKMEC), which contraceptive would
you offer?
The copper intrauterine device.
* CHC is category 4
* progesterone implant & pills & injection are category 3
126
A healthy 47-year-old woman comes for contraception counselling. She was under the
impression that the combined hormonal contraception (CHC) method is contraindicated at her age.
How will you counsel her?
Age alone is not a contraindication to any method.
127
What are the Risk factors to screening for sexually transmitted infections (STIs)
before IUD applications ?
being sexually active and aged <25 years
having had a
new sexual partner in the last three months
having had more than one sexual
partner in the last year
having a regular sexual partner who has other sexual
partners
having a history of STIs or attending as a previous contact of STI,
alcohol/substance abuse.
128
A healthy 33-year-old woman is on the combined hormonal contraceptive (CHC). She
is involved in a road traffic accident and requires surgery with prolonged immobilization. The orthopaedic surgeon is asking for advice , Based on our knowledge of the UKMEC, what is your advice?
She fulfills medical eligibility criteria 4.
* She has to stop it
129
A 33-year-old woman is on the levonorgestrel intrauterine system. She has recently
suffered from a cerebral transient ischaemic attack. She is now improving. The
general practitioner asks for your advice as she still requires effective
contraception.
What will you tell him?
Discontinue the method and offer a more suitable option
* the method has become a category 3 & should be offered a category 1 contraception (barrier or a
copper intrauterine device)
130
A 28-year-old woman who is on the combined hormonal contraceptive comes to see
you because she has recently developed migraine without aura. She has thus far been
happy with her current method of contraception.
What is your contraceptive advice?
She should discontinue, as the method is now category 3
* An increased risk of both ischaemic stroke and ischaemic heart disease have
been reported in women with headache who take the combined oral
contraceptive
131
You are counselling a 30-year-old woman with hypertrophic cardiomyopathy
regarding contraception. You explain that according to UKMEC, intrauterine (IUD)
contraception is her best option.
What is your advice for prophylactic antibiotics?
😏 There is no need to administer prophylactic antibiotics.
Cardiomyopathy increases the risk of bacterial endocarditis. However, there is insufficient evidence that the administration of prophylactic antibiotics reduces
the incidence of infective endocarditis
132
Your consultant has successfully carried out a hysteroscopic tubal occlusion
(Essure ESS305 microinsert. © Bayer). You are asked to review the patient before
discharge.What is the most important advice to give the patient prior to discharge?
🌼 She should use a reliable method of contraception for three months and until
proper placement of the device is confirmed.
* An X-ray after three months is required to confirm the proper placement of the
device.
133
A seven-year-old girl is brought to the clinic because she has been having regular
monthly bleeds for the last four months. You suspect gonadotropin-dependent precocious puberty. What is the gold standard to confirm your diagnosis?
Luteinizing hormone (LH) peak after gonadotropin-releasing hormone (GnRH)
stimulation.
* test included measuring LH and FSH levels 30
–60 min after
stimulation with GnRH at 100 mcg or with a GnRH analogue
134
A family history of precocious puberty was found in .......of cases ?
25%
helps to decrease the likelihood of an organic
cause
135
A six-year-old girl is referred to the clinic because she showed signs of precocious
puberty (thelarchy, adrenarchy and menarche). She was otherwise healthy and
asymptomatic.
What is the incidence of this condition in girls?
1 in 5000–10 000
136
A 12-year-old girl is referred because she has had regular vaginal bleeding for the last
four months, although her breasts had not developed beyond a small breast bud and
she had no visible pubic hair. She is otherwise asymptomatic with a normal growth
velocity. The most likely diagnosis is:
A normal variant
137
What are the stages of Marshall and Tanner
2 ( the variations in the pattern of pubertal changes in
girls) ?
stage 1 : prepubertal
stage 2 : small
amounts of pubic and axillary hair + early development of subareolar breast bud
stage 3 : increased amount of dark pubic hair and of axillary hair
stage 4 : adult pubic hair
stage 5 : pubic hair with extension to the upper thigh + full-contour
adult breast size
138
A five-year-old girl presents with a history of accelerated growth, menarche and signs
of sexual development. Examination revealed light to dark brown spots, predominantly noticeable on one side of the body without crossing the midline.
What is your differential diagnosis?
McCune–Albright syndrome.
139
What is the classic triad of McCune-Albright syndrome?
1- precocious puberty ( gonadotropin-independent )
2- café-au-lait spots ( unilateral)
3- polyostotic fibrous dysplasia (abnormal growth of two or more bones )
140
What is the treatment options in McCune–Albright syndrome ?
Oestrogen receptor antagonist ( raloxifene and tamoxifen )
binds to oestrogen receptors and inhibits the
action of oestrogen
* moderately effective in decreasing vaginal bleeding and rates of
skeletal maturation
141
A five-year-old girl is referred because of Tanner classification stage 3 breast development, pubic hair growth and irregular uterine bleeding. She also complained of the
occasional right-sided abdominal pain.
Based on her history, what is your first line of investigation?
Pelvic ultrasound
oestrogen-secreting tumours of
the ovary
142
What is The most likely oestrogen-secreting tumour of
the ovary in a case of precocious pseudopuberty ?
granulosa cell tumour (GCT)
* oestradiol
levels often exceed 100 pg/mL
143
What are the most common causes of precocious pseudopuberty ?
1- congenital adrenal
hyperplasia (CAH)
2- human chorionic gonadotropin (hCG)-secreting tumours,
3- tumours of the adrenal gland, ovary or testis
4- McCune–Albright syndrome
(MAS)
5- aromatase excess syndromes
6-- iatrogenic pseudopuberty due to
exposure to exogenous oestrogens
144
A mother presents with her seven-year-old daughter. The girl has developed noticeable pubic and axillary hair growth. The daughter is otherwise asymptomatic with no
history of vaginal bleeding. On examination, pubic hair was easily noticeable, but the
area covered is smaller than in most adults without spread to the medial side of the
thighs. Her breasts had not developed beyond a small bud. Physical examination did
not reveal any abnormality with a normal linear growth pattern.
What is your provisional diagnosis?
Physiological premature adrenarchy
145
What is the percentage of the girls had adult secondary
sexual characteristics before they began to menstruate ?
10 %
146
six and a half-year-old child. The child has had an
advanced growth spurt with thelarchy and adrenarchy to Tanner classification stage
4, and with regular uterine bleeding for the last five months. Her bone age report
showed she is three years more advanced than her chronological age. A pelvic
ultrasound showed a pear-shaped uterus and with a 4 mm endometrial thickening and normal ovaries.What is your diagnosis?
Central precocious puberty (CPP)
147
A 6-year-old girl presents to the outpatient clinic with a diagnosis of central precocious puberty. Her bone age/height ratio was less than 1.2.
What management do you offer her to attain a normal adult height?
No pharmacotherapy is required
148
A 6-year-old girl presents to the outpatient clinic with a diagnosis of central precocious puberty. Her bone age/height ratio was more than 1.2.
What management do you offer her to attain a normal adult height?
GnRH agonists
The mean duration of treatment is between three and
five years
treatment is safe for the reproductive system, bone mineral
density and BMI and helps to achieve the target height
149
A 6-year-old girl comes with her mother because she has been bleeding vaginally for
the last week.
What is the most common cause of this complaint?
Vulvovaginitis
* Sexual abuse is not found to be a common contributing factor for the development of vulvovaginitis
150
During your labour ward on call, the midwife asks you to see a newborn baby; she is
unable to assign the sex of the baby because of abnormal-looking external genitals. On
examination, you realized the baby has ambiguous genitalia.
What is the incidence of ambiguous genitalia and uncertain sex?
1 in 4500 newborn babies
151
You delivered a baby with complete fusion of the labioscrotal folds, absent scrotal
gonads and clitoromegaly. You provisionally diagnosed congenital adrenal hyperplasia (CAH).
When do you expect to observe clinical signs of a salt-losing form of the disease?
Between the fourth and the 14th day.
152
What type of inheritance is Congenital adrenal hyperplasia (CAH) ?
autosomal recessive
153
What hormonal changes occur in congenital adrenal hyperplasia?
Decrease cortisol + decrease aldosterone + androgen excess
causes increased sodium loss and potassium retention while excess androgen causes the different androgenic effects.
154
What are the signs and symptoms of the the non-classical mild or late form of Congenital adrenal hyperplasia (CAH) ?
usually appear
after
five years of age.
Androgen excess causes premature development of
pubic and axillary hair, accelerated growth but with short final height (because
of early epiphyseal fusion).
155
You are asked by the midwife to review a baby she has just delivered because she was
not able to identify the sex of the baby. Your examination reveals ambiguous
genitalia.
What is your first urgent investigation?
Blood karyotyping.
It should be carried out in day 1
A full karyotype is still required to confirm or exclude mosaicism
156
A 14-week pregnant woman attends your antenatal clinic. She is worried because she
has a relative who delivered an ambiguous genitalia child. She is wondering if there
are any NHS screening tests carried out at delivery to make an early diagnosis.
What will you tell her about the current recommendations in the UK Screening Policy
for Congenital Adrenal Hyperplasia (CAH)?
The current UK National Screening Committee (UKNSC) does not recommend
screening for CAH as part of the newborn bloodspot screening programme.
* the screening tests are
less likely to identify mild conditions of the disorder in preterm babies.
157
A mother brings her five-year-old girl to the clinic. She noticed early excess pubic and
body hair with clitoromegaly. She also noticed that her girl is taller than her peers.
You suspect a mild non-classical form of CAH.
What is the most sensitive investigation to diagnose mild forms of CAH?
👋 Adrenocorticotrophic hormone (ACTH)-stimulation test
* Basal plasma 17-OHPG
is the primary test, but it is not sensitive enough in mild forms of CAH
* CAH
is considered if basal 17-OHPG levels are elevated and/or ACTH-stimulated
17-OHPG is >260 ng/dL (7.87 nmol/L) above the basal level
158
The parents of a baby girl with ambiguous genitalia are requesting your advice for
immediate cosmetic surgery to correct her ambiguous genitalia.
You counsel them that it should be carried out:
In the neonatal period, if there is an imminent threat to the child’s health
* e.g. creating a
new urinary opening or removing malignant tissue
* Surgery is more effective if it is delayed until after puberty
159
The general practitioner calls you to ask about the best test to measure the adequacy
of glucocorticoid treatment for a two-year-old baby with CAH.
What will you tell him?
🌟 Measure 17-hydroxyprogesterone (17-OHP), androstenedione and testosterone
every 3 months
( assess the glucocorticoid treatment )
* Electrolytes and plasma renin assess the mineralocorticoid treatment
160
A fifteen and a half-year-old girl presents to the outpatient department complaining
of absent menstruation. On examination, she has well-developed breasts but no pubic
or axillary hair. Ultrasound reveals absent ovaries, no uterus and no upper vagina.
What is your provisional diagnosis?
Complete androgen insensitivity syndrome
161
What type of inheritance is In androgen insensitivity syndrome (AIS) ?
X-linked disease with variable defects in virilization of a 46,XY
individual
162
How is Mild androgen insensitivity syndrome
(MAIS) appear?
A person's genitals appear male, but they're usually infertile
163
A twenty-eight-year-old woman who has just delivered a baby with complete andro-
gen insensitivity (AIS) comes to ask you about her risk in a future pregnancy of
having a child with the same condition.
You tell her that there is:
A 50% likelihood of an affected male offspring and a healthy female carrier
164
The mother of a three-year-old child with complete androgen insensitivity syndrome
and undescended gonads comes to the clinic asking about removal of the undes-
cended testicles. She has heard there is a risk that they would become malignant.
How will you counsel her with regard to timing of orchiectomy?
Suggest removal before puberty if the undescended testes are physically or aesthetically uncomfortable and/or if inguinal herniorrhaphy is necessary
* otherwise: experts recommend removal after puberty
165
Why do experts recommend removal of the undescended tests in patients with complete androgen insensitivity after puberty?
Early removal before puberty will expose the patient to lack of oestrogen with
less feminization, risk of osteoporosis and delayed puberty.
* If the gonads are removed before puberty, oestrogen administration is required.
166
What is The gonadal malignancy risk of undescended testes in patients with complete androgen insensitivity?
(5%) seldom occurs before puberty
167
A mother of a three-year-old child with incomplete androgen sensitivity syndrome
brings the child to the clinic. She asks about the best time for cosmetic vaginal surgery.
On examination, you notice mild clitoromegaly, some fusion of the labia and undes-
cended testes.
How will you counsel her?
Surgery should be carried out at puberty.
168
A mother of a three-year-old child with incomplete androgen sensitivity syndrome
brings the child to the clinic. She asks about the best time for cosmetic vaginal surgery.
On examination, you notice mild clitoromegaly, some fusion of the labia and undes-
cended testes.
How will you counsel her?
Surgery should be carried out at puberty.
169
A 15-year-old girl is referred by her general practitioner because she has not yet
menstruated. The general practitioner’s letter states that she has been diagnosed as
Turner syndrome.
What is the percentage of this condition in the female population at birth?
1 in 2500–1 in 3000.
170
How Turner syndrome babies look like?
babies are born with swelling of the hands and feet, redundant nuchal skin with a webbed neck, a broad chest, a low hairline and low-set ears.
171
A 36-year-old Hispanic woman who previously had a child affected by Turner
syndrome consults you because she is considering another pregnancy. She is worried
about recurrence of this condition.
What advice will you give her regarding the inheritance of Turner syndrome?
Turner syndrome is usually not passed from mother to child.
* The risk of recurrence is not
increased for subsequent pregnancies
172
39-year-old woman came to see you when she was 13 weeks pregnant. The triple
screening test showed abnormal levels of human chorionic gonadotropin, unconjugated oestriol and alpha-fetoprotein. The ultrasound scan showed severe lymph
oedema, a cystic hygroma and a horse shoe kidney.
Based on these findings, what is your provisional diagnosis?
Turner syndrome
* Turner syndrome is suspected when there is elevation of the triple test
* together with ultrasound signs of generalized oedema and renal tract
abnormalities.
173
A woman brings in her 10-year-old-girl complaining of short stature. A standard
karyotyping has confirmed your clinical diagnoses of Turner syndrome.
What management options will you offer?
Recombinant growth hormone. ( for short stature )
* growth hormone to achieve a
normal
final height, oestrogen to prevent oesteoporoses and induce regular
menstruation, and progesterone to protect against endometrial hyperplasia
and uterine adenocarcinoma.
174
A 21-year-old woman comes to the accident and emergency unit complaining
of bilateral lower abdominal pain and fever. On examination, her temperature is
38.2 C with bilateral adnexal tenderness.
What is your first line of investigation?
Pregnancy test.
175
A 21-year-old woman comes to the outpatient clinic requesting testing for gonorrhoea
as she read a poster about gonorrhoea infection. She has had three sexual partners in
the last year but uses condoms for contraception.
What tests should you offer her?
A. Gonorrhoea only.
B. Gonorrhoea and chlamydia.
C. Gonorrhoea, chlamydia, HIV and syphilis.
D. Gonorrhoea, chlamydia, HIV and human papilloma virus (HPV).
E. Gonorrhoea, chlamydia, HIV and hepatitis C virus (HCV).
Gonorrhoea, chlamydia, HIV and syphilis.
176
A 23-year-old woman presents complaining of vaginal discharge. She has had recurrent episodes of vulvovaginal candidiasis. You prescribe an induction and maintenance regimen for six months. She is worried about use of contraception as she had a
copper intrauterine device (IUD) inserted two months earlier.
What advice would you offer her?
A. Should remove the IUD.
B. Should remove the copper IUD and insert the Mirena coil.
C. Switch to a suitable oral contraceptive.
D. Should continue with this method.
E. Use the condom as an additional method to prevent recurrence of infection
Should continue with this method.
177
A 23-year-old woman presents complaining of vaginal discharge. She has had recurrent episodes of bacterial vaginosis (BV) infection . She is worried about use of contraception as she had a
copper intrauterine device (IUD) inserted two months earlier.What advice would you offer her?
Copper-bearing IUD should be changed
178
For recurrent VVC ( vulvovaginal candidiasis) what is the
first-line regimen.?
For recurrent VVC, oral
fluconazole (150 mg or 200 mg dose) weekly for six
months
179
A 21-year-old woman comes to the genitourinary medicine clinic complaining of
vaginal discharge. Vaginal high-swab results show that she has bacterial vaginosis.
She asks you about treatment of her sexual partner.
Which infection needs treatment of an asymptomatic sexual partner?
A. Bacterial vaginosis.
B. Candidiasis.
C. Human papilloma virus.
D. Herpes simplex virus.
E. Trichomonas vaginalis.
Trichomonas vaginalis.
* should be offered a full sexual health screen and should be treated for TV
irrespective of the results of their tests.
* In the management of BV, testing and treatment of male sexual partners is not
indicated
180
What are the Symptoms of PID ?
lower abdominal pain that is typically bilateral
deep
dyspareunia
abnormal vaginal bleeding (post-coital, intermenstrual and/or
menorrhagia) and/or abnormal vaginal or cervical discharge that is often
purulent.
181
What are the Signs of PID ?
lower abdominal pain
adnexal tenderness
cervical motion tenderness on bimanual vaginal examination
fever
(>38 C).
182
What is the recommended therapy for PID ?
Empirical antibiotic IV therapy is recommended for patients with :
more severe clinical
disease : e.g. pyrexia >38 C, clinical signs of a tubo-ovarian abscess, signs of
pelvic peritonitis.
* Ceftriaxone 1 g IV every 24 hours PLUS. Doxycycline at 100 mg PO or IV every 12 hours PLUS. Metronidazole at 500 mg PO or IV every 12 hours
183
A 26-year-old woman comes to the accident and emergency unit complaining of
abnormal vaginal bleeding, including post-coital and intermenstrual bleeding and
menorrhagia. Her temperature is 38 C. On bimanual vaginal examination, there is
adnexal tenderness and cervical motion tenderness. A pregnancy test is negative. You
diagnosed a pelvic inflammatory disease (PID). The patient tells you that she has been
abroad and had unprotected sex.
What is the recommended regimen for this patient?
Azithromycin 1 g per week orally for two weeks plus ceftriaxone 500 mg intramuscular stat dose.
( Her temperature is 38 C not more )
* Quinolones should also be avoided as
first-line empirical treatment
( quinolone resistance )
184
A 25-year-old woman comes to the outpatient clinic for follow-up after a diagnosis of
PID three weeks previously. Results of swabs were negative for chlamydia and
gonorrhoea. You explained the significance of PID and its sequelae. She stated that
the symptoms resolved and she had her antibiotics regularly.
What else should you check at this visit?
Screening and treatment of sexual contacts
185
What is the Review schedule for patients with PID ?
1- Review at 72 hours to check for substantial improvement in clinical symptoms
and signs
2- Further review two to four weeks after therapy to ensure
compliance with oral antibiotics, adequate clinical response, screening
and treatment of sexual contacts and repeat pregnancy test, if clinically
indicated.
186
When to Repeat testing for gonorrhoea or chlamydia in patients with PID after intiating treatment?
if there are persisting symptoms, poor compliance with antibiotics or if tracing of sexual contacts indicate the possibility of persisting or
recurrent infection
187
A 24-year-old woman comes to the genitourinary medicine clinic complaining of
small multiple groups of painful vulval ulcers. On examination, the base of the ulcer
was erythematous and inguinal lymph nodes were painful.
What is the most likely diagnosis?
Herpes simplex virus (HSV).
188
A 24-year-old woman comes to the genitourinary medicine clinic complaining of
multiple painful ulcers on the vulval area. On examination, the ulcers are sharply
circumscribed with a yellow exudate in the base. There are also painful inguinal
lymph nodes on the left side.
What is the most likely causative organism?
Haemophilus ducreyi. ( Gram-negative streptobacillus )
* Chancroid : painful, sharply circumscribed , not indurated but the base may have a grey or
yellow exudate and multiple ulcers . adenopathy, often painful, usually unilateral .
189
During diagnostic laparoscopy on a 28-year-old female for chronic pelvic pain, you
noticed inflammation of the liver capsule and adjacent peritoneum.
What is the most likely causative organism?
Chlamydia trachomatis.
* The Fitz
–Hugh–Curtis syndrome : right upper quadrant pain associated with peri-hepatitis .
190
A young woman presents to the genitourinary medicine clinic. After a swab was taken
from the endocervix, microscopic examination reveals a Gram-positive diplococcus.
What organism looks like this under a microscope?
Neisseria gonorrhoea.
* Less than 50% of women are symptomatic
191
A 20-year-old pregnant woman presented to the genitourinary medicine clinic with
anogenital warts. She is diagnosed with human papillomavirus (HPV) infection-type
11.
What are her treatment options?
❄️ Cryotherapy
* trichloracetic acid (TCA)& imiquimod can be used safely
* podophylline : is unsafe during pregnancy.
192
What is the treatment options for vaginal and cervical warts ?
trichloracetic acid (TCA)
193
A 20-year-old pregnant woman presented to the genitourinary medicine clinic two
weeks previously and was found to have a chlamydia infection. She received azithromycin 1 g as a single dose. You arranged for contact tracing.
What is the next step?
A. Follow-up after six months.
B. Full STI screen.
C. Nothing to be done.
D. Test of cure during this visit.
E. Test of cure after five weeks.
💯 Full STI screen.( (hepatitis B, syphilis and HIV) )
* You should wait for six weeks with azithromycin treatment for a test-of-cure as
NAAT can give false-positive results for up to five weeks following successful
treatment.
194
What is{ test-of-cure} (NAAT) ?
* is a highly sensitive molecular technique to detect a virus or a bacterium
* It has the ability to detect the infectious agent during the incubation
period.
* Results can be ready in three days.
* is not recommended unless the patient is pregnant, has been non-compliant to treatment or been re-exposed.
* You should wait for six weeks for a test-of-cure to be done after treatment.
195
You made a diagnosis of moderate PID in a young 24-year-old woman who presented
to the accident and emergency unit with lower abdominal pain and pyrexia. You
prescribe a combination of a single intramuscular injection of cefoxitin and oral
doxycycline and antipyretics. She is worried about her future fertility as a result of
her PID.
Where is she best treated to preserve her fertility?
A. As an inpatient.
B. As an outpatient.
C. In the accident and emergency unit until her temperature normalizes.
D. In a fever hospital.
E. In an isolation ward.
As an outpatient.
196
When Admission for parenteral therapy, observation, further investigation and/or
possible surgical intervention should be considered in patients with PID ?
1- surgical emergency cannot be excluded .
2- lack of response to oral therapy .
3- clinically severe disease .
4- presence of a tubo-ovarian abscess .
5- intolerance to
oral therapy.
