Selected Notes obgyn 2

Question 1

What group is urinary incontinence most common in?

Answer 1

Elederly females

Question 2

Name some risk factors for developing urinary incontinence

Answer 2

Advancing age<br></br>Previous pregnancy/childbirth<br></br>High BMI<br></br>Hysterectomy<br></br>Family history

Question 3

Name the reversible causes of urinary incontinence

Answer 3

DIAPPERS<br></br>D-delirium<br></br>I-Infection<br></br>A-atrophic vaginitis or urethritis<br></br>P-Pharmaceuticals-meds)<br></br>P-Psychiatric disorders<br></br>E-Endocrine disorders-diabetes etc<br></br>R-Restricted mobility<br></br>S-Stool impaction

Question 4

What causes urge incontinence?

Answer 4

Detrusor overactivity

Question 5

What is functional incontinence?

Answer 5

Comorbid physical conditions impair the patient’s ability to get to a bathroom in time<br></br>Causes: dementia, medications, injury/illness causing impaired mobility

Question 6

What is a cystometry?

Answer 6

Investigation to measure bladder pressure whilst voiding

Question 7

What is a cystogram?

Answer 7

Contrast instilled into the bladder and a radiological image is obtained to see if the contrast travels anywhere else 

Question 8

In the surgical management of stress incontinence, {{c1::colposuspension and fascial slings}} involve <span>s</span>{{c2::uspending the anterior vaginal wall}} <span>to the </span>{{c3::iliopectineal ligament of Cooper}}

Question 9

What are the surgical management options for treating urge incontinence?

Answer 9

Bladder instillation->botox injection to paralyse detrusor muscle<br></br>Sacral neuromodulation->only int mtertiary centres where all other treatments have failed

Question 10

What causes overflow incontinence?

Answer 10

Either:<br></br>1. Underactivity of the detrusor muscle e.g. from neurological damage OR<br></br>2. Urinary outlet pressures are too high e.g. constipation or prostatism

Question 11

What is a genital or pelvic organ prolapse?

Answer 11

Descent of one or more pelvic structures from their normal anatomical position moving towards or through the vaginal opening

Question 12

Name some risk factors for developing a genital prolapse

Answer 12

-Vaginal childbirth, especially with traumatic or complicated deliveries<br></br>-Increasing age<br></br>-Menopause<br></br>-Hysterectomy<br></br>-Obesity<br></br>-Chronic cough<br></br>-Heavy lifting<br></br>-Connective tissue disorders<br></br>-Spina bifida

Question 13

What are the types of anterior vaginal wall prolapse?

Answer 13

Cystocele-bladder<br></br>Urethrocele-urethra<br></br>Cystourethrocele-both bladder and urethra

Question 14

What is a cystocele? What condition can it lead to?

Answer 14

<ul><li>Bladder prolapse</li></ul>

Sterss incontinence<br></br>

Question 15

Name the posterior wall prolapses

Answer 15

Enterocele-small intestine<br></br>Rectocele-rectum

Question 16

Name the atypical vaginal wall prolapses?

Answer 16

Uterine prolapse-uterus<br></br>Vaginal vault prolapse-roof of the vagina

Question 17

What are some differential diagnoses for a uterogential prolapse?

Answer 17

<ul><li>Gynecologic malignancy: associated with abnormal vaginal bleeding, weight loss, and pelvic pain</li><li>Cervicitis: characterized by vaginal discharge, bleeding, and pelvic pain</li><li>Urethral diverticulum: presents with dysuria, recurrent UTIs, and a palpable anterior vaginal mass</li></ul>

Question 18

Name some investigations to diagnose a genital prolapse

Answer 18

-Pelvic exam<br></br>Imaging if compolx or required for surgical planning<br></br>Urodynamic studies if co-existing urinary symptoms

Question 19

What is a vaginal fistula?

Answer 19

Unusual opening that connects your vagina to another organ<br></br>Can link vagina to bladder, ureters, urethra, rectum, intestines

Question 20

Name some of the causes of a vaginal fistula?

Answer 20

Childbirth<br></br>Abdominal surgery<br></br>Pelvic, cervical or colon cancer<br></br>Radiation teatment<br></br>Bowel disease-Crohn’s or diverticulitis<br></br>Infection

Question 21

Name some complications of a vaginal fistula

Answer 21

Vaginal/urinary tract infections that keep returning<br></br>Stool or gas that leaks through the vagina<br></br>Irritated/swollen skin around vagina/anus<br></br>Abscesses<br></br>

Question 22

What are fibroids?

Answer 22

Benign smooth muscle tumours <span>originating from the myometrium of the uterus.</span>

Question 23

Uterine fibroids develop in response to {{c1::oestrogen}}. The incidence increases with age until {{c1::menopause}}

Question 24

In which group of people are uterine fibroids most common?

Answer 24

More common in Afro-Caribbean women

Question 25

The growth of fiborids is promoted by {{c1::oestrogen and progesterone.}} Fibroids contain more oestrogen and progesterone than {{c1::normal uterine muscle cells}}

Question 26

Name some symptoms of uterine fibroids

Answer 26

-Asymptomatic
-Menorrhagia and dysmenorrhoea-.can cause iron deficiency anaemia
-Bloating
-Lower abdominal pain, cramps
-Urinary symptoms
-Subfertility
Rare: polycythaemia

Question 27

Name some differential diagnoses for uterine fibroids

Answer 27

• Endometrial polyps: Present with irregular menstrual bleeding and spotting
• Endometriosis: Characterized by dysmenorrhoea, deep dyspareunia, chronic pelvic pain, and infertility

Question 28

Name some complications of uterine fibroids

Answer 28

-Subfertility
-Iron deficiency anaemia
-Red degeneration-> haemorrhage into tumour-> commonly occurs during pregnancy

Question 29

What are the types of uterine fibroids?

Answer 29

1. Intramural
2. Subserosal
3. Submucosal
4. Pedunculated

Question 30

Intramural fibroids grow {{c1::within the myometrium}}. As they grow they {{c1::distort the uterus}}

Question 31

Subserosal fibroids develop {{c1::just below the outer layer}} of the uterus. They grow outwards and can become very large filling the {{c1::abdominal cavity}}

Question 32

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Answer 32

Types of fibroids ## Footnote

Question 33

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Answer 33

Types of fibroids ## Footnote

Question 34

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Answer 34

Types of fibroids ## Footnote

Question 35

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Answer 35

Types of fibroids ## Footnote

Question 36

Red degeneration of fibroids refers to i{{c1::schaemia, infarction and necrosis}} of the fibroid due to disrupted blood supply. It is more likely to occur in larger fibroids during the {{c1::2nd and 3rd}} trimester of pergnancy. It may occur as the {{c1::fibroid rapidly enlarges during pregnancy,}} outrgrowing its blood supply and becoming ischamic or due to{{c1:: kinking in the blood vessels}} as the uterus changes shape and expands during pregnancy.

Question 37

What is an ovarian cyst?

Answer 37

Fluid filled sac that develops within or on the surface of an ovary.

Question 38

What are some differential diagnoses for ovarian cysts?

Answer 38

• Ovarian torsion: Characterised by sudden, severe pain, often accompanied by nausea and vomiting.
• Ectopic pregnancy: Symptoms include abdominal pain, amenorrhea, and vaginal bleeding.
• Appendicitis: Presents with abdominal pain that begins near the navel and then moves lower and to the right, loss of appetite, nausea, and vomiting.

Question 39

What investigations are done into a suspected ovarian cyst?

Answer 39

Pregnancy test to exclude ectopic
Diagnostgic laparoscopy-> especially if haemodynamically unstable
Ultrasound
Bloods: 

• Ca125: tumour marker for ovarian cancer
• LDH, aFP, HCG to assess for germ cfell tumour

Question 40

What are the main possible complications of an ovarian cyst?

Answer 40

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

Question 41

What are the types of physiological/functional cysts?

Answer 41

1. Follicular cysts
2. Corpus luteum cysts

Question 42

Serous cystadenoma are {{c1::benign}} tumours of the {{c1::epithelial cells}}

Question 43

Mucinour cystadenomas mare also {{c1::benign tumours of the epithelial cells}} but these can {{c1::become huge,}} taking up lots of space in the pelvis and abdomen.

Question 44

Sex cord stromal tumours are rare tumours, that can be {{c1::benign or malignant.}} They arise from the {{c1::stroma (connective tissue)}} or {{c2::sex cords (embryonic structures associated with the follicles).}} There are several types, including {{c2::Sertoli–Leydig cell tumours and granulosa cell tumours}}.

Question 45

Name some risk factors for ovarian malignancy

Answer 45

• Age
• Postmenopause
• Increased number of ovulations
• Obesity
• Hormone replacement therapy
• Smoking
• Breastfeeding (protective)
• Family history and BRCA1 and BRCA2 genes

Question 46

Name some protective factors for ovarian cancer

Answer 46

• Anything that will reduce the number of ovulations:
• Later onset of periods (menarche)
• Early menopause
• Any pregnancies
• Use of the combined contraceptive pill

 

Question 47

Name some non-malignant causes of a raiserd CA125

Answer 47

• Endometriosis
• Fibroids
• Adenomyosis
• Pelvic infection
• Liver disease
• Pregnancy

Question 48

In women under 40 with a complex ovarian mass what tests should be done?

Answer 48

Tumour markers for a possibole germ cell tumour:

• Lactate dehydrogenase (LDH)
• Alpha-fetoprotein (α-FP)
• Human chorionic gonadotropin (HCG)

Question 49

Ovarian torsion is usually due to an {{c1::ovarian mass}} larger than {{c1::5cm.}} It is more likely to occur with {{c1::benign t}}umours. Also more likely to occur during {{c1::pregnancy}}

Question 50

Name some risk factors for developing ovarian torsion?

Answer 50

Ovarian mass
Being of reproductive age
Pregnancy
Ovarian hyperstimulation syndrome

Question 51

Name some complications of an ovarian torsion

Answer 51

Fertility not typically affected as other ovary can compensate
If only functioning ovary removed-> infertility and menopause

If necrotic ovary not removed:

• Infection
• Abscess
• Sepsis

If it ruptures-> peritonitis and adhesions

Question 52

What is lichen sclerosus?

Answer 52

Inflammatory dermatological condition

Question 53

What is Koebner phenomenon?

Answer 53

When the signs and symptoms worsen with friction to the skin

Question 54

Name a few things that cane make lichen sclerosus worse

Answer 54

Friction to the skin
Tight underwear
Sex
Urinary incontinence
Scratching the affected area

Question 55

Name some differential diagnoses for lichen sclerosus

Answer 55

• Lichen planus: Characterized by purplish, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.
• Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.
• Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.

Question 56

Name some complications of lichen sclerosus

Answer 56

• 5% risk of developing squamous cell carcinoma of the vulva
• Pain and discomfort
• Sexual dysfunction
• Bleeding
• Narrowing of vaginal/urethral openings

Question 57

Name some risk factors for developing cervical cancer

Answer 57

• HPV 16 and 18 infection or anything that increases the risk of this (early sexual activity, not suing condoms, increased number of sexual partners)
• Smoking
• Immunosuppression
• Non engagementwith cervical screening
• Using COCP for >5yrs

Question 58

Name some differential diagnoses of cervical cancer

Answer 58

• Vaginitis: itching, burning, pain, and abnormal discharge
• Cervicitis: abnormal discharge, pelvic pain, and postcoital bleeding
• Endometrial cancer: abnormal vaginal bleeding, pelvic pain, and unintentional weight loss
• Cervical polyps: abnormal vaginal bleeding, discharge, and pain during intercourse

Question 59

What characteristics of a cervix would be worrying and prompt an urgen colposcopy?

Answer 59

Ulceration
Inflammation
Bleeding
Visible tumour

Question 60

What does cervical screening involve?

Answer 60

• Speculum exam
• Collection of cells from the cervix
• Cells examined for precancerous changes(dyskaryosis)
• Transporting the cells: liquid based cytology

Question 61

Name some exceptions to the usual cervical screening programme

Answer 61

• Women with HIV are screened annually
• Women over 65 may request a smear if they have not had one since aged 50
• Women with previous CIN may require additional tests (e.g. test of cure after treatment)
• Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
• Pregnant women due a routine smear should wait until 12 weeks post-partum

Question 62

Name 3 infections that can be identified from smear testing for cervical cancer

Answer 62

• Bacterial vaginosis
• Candidiasis
• Trichomoniasis

Question 63

Management of smear results:

• Inadequate sample – {{c1::repeat the smear after at least three months}}
• HPV negative – {{c2::continue routine screening}}
• HPV positive with normal cytology – {{c3::repeat the HPV test after 12 months}}
• HPV positive with abnormal cytology – {{c4::refer for colposcopy}}

Question 64

What is a colposcopy?

Answer 64

Inserting a speculum and using a colposcope to magnify the cervix.
Allows epithelial lining of cervix to be examined

Question 65

Tests used in a colposcopy:

1. Acetic acid causes abnormal cells to appear {{c1::white.}} This appearance is described as acetowhite. This occurs in cells with an increased {{c1::nuclear to cytoplasmic ratio (more nuclear material),}} such as {{c1::cervical intraepithelial neoplasia and cervical cancer }}cells.
2. Schiller’s iodine test involves using an {{c1::iodine solution }}to stain the cells of the cervix. Iodine will stain {{c1::healthy cells a brown colour.}} Abnormal areas {{c1::will not stain.}}
3. A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.

Question 66

Large Loop Excision of the Transformation Zone (LLETZ)

A large loop excision of the transformation zone (LLETZ) procedure is also called a {{c1::loop biopsy.}} It can be performed with a {{c1::local anaesthetic d}}uring a {{c1::colposcopy procedure.}} It involves using a loop of wire with electrical current (diathermy) to {{c1::remove abnormal epithelial tissue on the cervix.}} The electrical current cauterises the tissue and stops bleeding.

{{c1::Bleeding and abnormal discharge}} can occur for several weeks following a LLETZ procedure. This varies between women. {{c1::Intercourse and tampon use should be avoided}} after the procedure to reduce the risk of infection. Depending on the depth of the tissue removed from the cervix, the procedure may increase the risk of {{c1::preterm labour.}}

 

Question 67

What are the main risks associated with a cone biopsy?

Answer 67

• Pain
• Bleeding
• Infection
• Scar formation with stenosis of the cervix
• Increased risk of miscarriage and premature labour

Question 68

Staging of cervical cancer

The{{c1:: International Federation of Gynaecology and Obstetrics (FIGO)}} staging system is used to stage cervical cancer:

• Stage 1: {{c2::Confined to the cervix}}
• Stage 2: {{c3::Invades the uterus or upper 2/3 of the vagina}}
• Stage 3: {{c4::Invades the pelvic wall or lower 1/3 of the vagina}}
• Stage 4: {{c5::Invades the bladder, rectum or beyond the pelvis}}

Question 69

Management of cervical cancer

• Cervical intraepithelial neoplasia and early-stage 1A: {{c1::LLETZ or cone biopsy}}
• Stage 1B – 2A: {{c2::Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy}}
• Stage 2B – 4A: {{c3::Chemotherapy and radiotherapy}}
• Stage 4B: M{{c4::anagement may involve a combination of surgery, radiotherapy, chemotherapy and palliative care}}

Question 70

What do HPV strains 6 and 11 cause?

Answer 70

Genital warts

Question 71

Name some risk factors for developing endometrial cancer

Answer 71

• Nulliparity
• Obesity
• Early menarche
• Late menopause
• Polycystic ovary syndrome
• Oestrogen-only hormone replacement therapy
• Tamoxifen

Question 72

Name some protective factors against endometrial cancer

Answer 72

• multiparity
• combined oral contraceptive pill
• smoking (the reasons for this are unclear)

Question 73

Name some symptoms of endometrial cancer

Answer 73

• Postmenopausal bleeding(usually slight and intermittent then becomes heavier)
• Abnormal vaginal bleeding, such as intermenstrual bleeding
• Dyspareunia
• Pelvic pain-uncommon apart from in later stages
• Abdominal discomfort or bloating
• Weight loss
• Anaemia

Question 74

Name some differentials for endometrial cancer

Answer 74

• Uterine fibroids: Characterised by heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation.
• Endometrial polyps: Symptoms may include irregular menstrual bleeding, bleeding between menstrual periods, excessively heavy menstrual periods, and vaginal bleeding after menopause.
• Cervical cancer: Signs can include abnormal vaginal bleeding, postmenopausal bleeding, and pelvic pain.

Question 75

What is endometrial hyperplasia?

Answer 75

Precancerous thickening of the endometrium

Question 76

What are the 2 types of endometrial hyperplasia

Answer 76

• Hyperplasia without atypia
• Atypical hyperplasia

Question 77

Type 2 diabetes may increase the risk of endometrial cancer due to the increased production of{{c1:: insulin. }} which may stimulate the endometrial cells and increase the risk of endometrial hyperplasia and cancer. 

Question 78

Tamoxifen has an {{c1::anti-oestrogenic effec}}t on breast tissue, but an {{c1::oestrogenic}} effect on the endometrium. This {{c1::increase}} the risk of endometrial cancer.

Question 79

What are the NICE suspected cancer referral guidelines concerning endometrial cancer?

Answer 79

Urgent 2 week wait: women with postmenopausal bleeding

Transvaginal US in women >55yrs with:

• Unexplained vaginal discharge
• Visible haematuria+raised platelets, anaemia or elevated glucose levels

Question 80

The {{c1::International Federation of Gynaecology and Obstetrics (FIGO)}} staging system is used to stage endometrial cancer:

• Stage 1: {{c2::Confined to the uterus}}
• Stage 2: {{c3::Invades the cervix}}
• Stage 3: {{c4::Invades the ovaries, fallopian tubes, vagina or lymph nodes}}
• Stage 4: {{c5::Invades bladder, rectum or beyond the pelvis}}

Question 81

What are the different types of ovarian cancers?

Answer 81

1. Epithelial 
2. Germ cell
3. Sex cord

Question 82

What group of people do ovarian germ cell tumours typically arise from?

Answer 82

Young women-> atypical for most cases of ovarian cancer

Question 83

What are the tumour markers for ovarian germ cell tumours?

Answer 83

Alpha fetoprotein and B-HCG

Question 84

What is a Krukenbery tumour?

Answer 84

'Signet ring' sub-type of tumour typically GI in origin whcih has metastasised to the ovary

Question 85

Name some risk factors for developing ovarian cancer

Answer 85

• Advanced age
• Smoking
• Increased numbr of ovulations(early menarche, late menopause)
• Obesity
• HRT
• Genetics: BRCA1&2

Question 86

Name some protective factors against ovarian cancer

Answer 86

• Childbearong
• Breastfeeding
• Early menopause
• Use of COCP

Question 87

Name some differentials for developing ovarian cancer

Answer 87

• Gastrointestinal conditions (e.g., irritable bowel syndrome): Characterised by abdominal pain, bloating, and changes in bowel habits
• Fibroids: May cause heavy menstrual bleeding, pelvic pressure or pain, frequent urination, and constipation
• Ovarian cysts: Can cause pelvic pain, fullness or heaviness in the abdomen, and bloating
• Other cancers (e.g., bladder, endometrial): May present with symptoms such as abnormal bleeding, pelvic pain, and urinary symptoms

Question 88

What investigations are done to diagnose ovarian cancer?

Answer 88

1. CA125 blood test
2. Pelvic and abdominal US scan
3. CT scans for staging
4. AFP and B-HCG in younger women-germ cell tumours
5. Laparotomy for tissue biopsy

Question 89

Name some conditions aside from ovarian cancer that can raise the CA125 level

Answer 89

• Endometriosis
• Menstruation
• Benign ovarian cysts

Question 90

• Ovarian cancer staging:
• Stage I ({{c1::limited to the ovaries):}}
• Stage II {{c2::involving one or both ovaries with pelvic extension and/or implants:}}
• Stage III {{c3::involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis:}}
• Stage IV ovarian cancer is {{c4::tumour involving one or both ovaries with distant metastasis.}}

Question 91

What are the NICE suspected cancer guidelines relating to ovarian cancer?

Answer 91

2 week wait if:

• Ascites
• Pelvic mass
• Abdominal mass

Further investigations includng CA125 if:

• New symptoms of IBS/change in bowel habit
• Abdominal bloating
• Early satiety
• Pelvic pain
• Urinary frequency/urgency
• Weight loss

Question 92

What does the risk of malignancy index relating to ovarian cancer take into account?

Answer 92

Estimates the risk of an ovarian mass being malignant

• Menopausal status
• Ultrasound findings
• CA125 level

Question 93

Name some risk factors for developing vulval cancer

Answer 93

• Advancing age
• HPV infeciton
• Vulval intraepithelial neoplasia(VIN)
• Immunosuppression
• Lichen sclerosus

Question 94

Name some differential diagnoses for vulval cancer

Answer 94

• Vulval intraepithelial neoplasia: This precancerous condition can cause itching, burning, skin changes, and discomfort.
• Lichen sclerosus: This condition can cause itching, pain, and white patches on the vulva.
• Bartholin's cyst: This may present as a lump or swelling on the vulva, and can cause discomfort or pain.

Question 95

What investigations might be done to diagnose vulval cancer?

Answer 95

• Torough exam of vulva
• Biopsy
• Imaging/blood tests to a\ssess extent of disease and staging

Question 96

What are the treatment options for VIN

Answer 96

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

Question 97

What age group(s) are most at risk of developing a molar pregnancy?

Answer 97

Extreme ends of the fertility age range: 

• <16yrs
• >45yrs

Question 98

What is a complete molar pregnancy?

Answer 98

• Formation from a single sperm and empty egg with no genetic material
• Sperm replicates to provide a normal number of chromosomes-all paternal origin
• No foetal tissue, only proligeration of swollen chorionic villi

Question 99

What is a partial molar paregnancy?

Answer 99

• Formed from 2 sperm and a normal egg
• Both paternal and maternal genetic materials present
• Variable evidence of foetal parts

Question 100

Name some differential diagnoses for a molar pregnancy

Answer 100

• Ectopic pregnancy: Symptoms include lower abdominal pain, vaginal bleeding, and amenorrhea.
• Miscarriage: Symptoms include vaginal bleeding, abdominal pain, and passage of tissue.
• Normal pregnancy: Typically characterized by a positive pregnancy test, absence of menstruation, and possible morning sickness.

Question 101

Name 2 complications of molar pregnancies

Answer 101

Choriocarcinoma
Mole can metastasise-> patient may require systemic chemotherapy

Question 102

What is endometriosis?

Answer 102

Growth of ectopic endometrial tissue outside of the uterine cavity

Question 103

Name some theories thought to explain the cause of endometriosis

Answer 103

• Retrograde menstruation
• Coelomic metaplasia
• Lymphatic/vascular dissemination of endometrial cells

Question 104

Name some differential diagnoses for endometriosis

Answer 104

• Primary dysmenorrhoea: characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.
• Uterine conditions (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort.
• Adhesions: pelvic pain and possible bowel obstruction.
• Pelvic inflammatory disease (PID): presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.

Question 105

What investigations are used to diagnose endometriosis?

Answer 105

• Transvaginal US-> Often normal but may ID an ovarian endometrioma
• GS: Diagnositc laparoscopy

Question 106

Name a complication of endometriosis

Answer 106

• Infertility
• Poor quality of life due to chronic pain

Question 107

The {{c1::American Society of Reproductive Medicine (ASRM)}} has a staging system for endometriosis.

• Stage 1: {{c2::Small superficial lesions}}
• Stage 2: {{c3::Mild, but deeper lesions than stage 1}}
• Stage 3: {{c4::Deeper lesions, with lesions on the ovaries and mild adhesions}}
• Stage 4: {{c5::Deep and large lesions affecting the ovaries with extensive adhesions}}

Question 108

What is adenomyosis?

Answer 108

Presence of endometrial tissue within the myometrium

Question 109

In which group of people is adenomyosis most common in?

Answer 109

Multiparous women towards the end of their reproductive years

Question 110

What conditions can adenomyosis occur with?

Answer 110

• Endometriosis
• Fibroids

Question 111

What investigations are done to diagnose adenomyosis?

Answer 111

1st line: transvaginal US of pelvis
If unsuitable: MRI and transabdominal US
GS: Histological exam of the uterus after a hysterectomy(mostly unsuitable)

Question 112

What complications relating to pregnancy can adenomyosis cause?

Answer 112

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

Question 113

What is atrophic vaginitis?

Answer 113

Inflammation and thinning of the geniatl tissues due to a decrease in oestrogen levels

Question 114

What causes atophic vaginitis?

Answer 114

Decline in oestrogen levels, typically post-menopause

Question 115

On examination, what might you find in a patient with atrophic vaginitis?

Answer 115

Pale and dry vagina

• Loss of pubic hair
• Thinning of vaginal mucosa
• Narrowed introitus
• Loss of vaginal rugae

Question 116

Name some differentials for atrophic vaginitis

Answer 116

• For postmenopausal bleeding: malignancy, endometrial hyperplasia
• For genital itching/discharge: sexually transmitted infection, vulvovaginal candidiasis, skin conditions such as lichen sclerosis, lichen planus, diabetes
• For narrowed introitus: female genital mutilation
• For urinary symptoms: urinary tract infection, bladder dysfunction, pelvic floor disfunction, cystitis
• For dyspareunia: malignancy, vaginismus

Question 117

What investigations should be done in a patient presenting with likely atrophic vaginitis?

Answer 117

• Clinical examination, including speculum examination if tolerated, to look for vaginal signs of atrophy
• Transvaginal ultrasound and endometrial biopsy, if necessary, to exclude endometrial cancer
• An infection screen if itching or discharge is present
• A biopsy of any abnormal skin lesions, if needed

Question 118

What is a miscarriage?

Answer 118

Loss of pregnancy <24 weeks gestation

Question 119

Name some risk factors for having a miscarriage

Answer 119

• Maternal age >30
• Previous miscarriage
• Obesity
• Smoking
• APS
• Uterina abnormalities
• Coagulopathies
• Previous uterine surgeries
• Chromosomal abnormalities

Question 120

Name some symptoms of a miscarriage

Answer 120

• Often found incidentally on US
• Vaginal bleeding->clots/conception products
• If lots of bleeding: signs of haemodynamic instability: pallor, dizziness, SOB
• Suprapubic, cramping pain

Question 121

Signs a patient is having a miscarriage:

• Haemodynamic instability: {{c1::tachycardia, hypotension, tachypnoea}}
  
• Abdominal exam: {{c2::distended, local areas of tenderness}}
• Speculum exam: {{c3::diameter of cervical os, products of conception, bleeding}}
• Bimanual exam: {{c4::uterine tenderness, adnexal masses/collections}}

Question 122

Name some differentials for a miscarriage

Answer 122

• Ectopic pregnancy
• Hydatidiform mole
• Cervical/uterine cancer

Question 123

What blood might be done in a patient suspected of having a miscarriage?

Answer 123

b-HCG-important to also assess the possibility of an ectopic pregnancy

Question 124

What are the different kinds of miscarriage?

Answer 124

• Threatened
• Inevitable
• Missed/delayed
• Incomplete
• Complete
• Septic

Question 125

What is an ectopic pregnancy?

Answer 125

• Embryo implants and beigns to grow outside fo the uterine cavity, usually in the fallopian tuubes

Question 126

Name some of the causes/risk factors for having an ectopic pregnancy

Answer 126

• Pelvic inflammatory disease
• Endometriosis
• Genital infections
• Previous ectopic pregnancies
• Having an IUD/coil in situ
• Assissted reproduciton like IVF

Question 127

Name some differentials for an ectopic pregnancy

Answer 127

• Miscarriage
• UTI
• Appendicitis
• Diverticulitis
• PID
• Ovarian accident

Question 128

What investigations should be done in a patient with a suspected ectopic pregnancy?

Answer 128

1. B-HCG-POSITIVE
2. Pelvic US
3. Transvaginal US

Can't find evidence of pregnancy on any scans

• Serum B-HCG

Question 129

Serum B-HCG in suspected ectopic pregnancy:

• Initial >1500iU: {{c1::ectopic-diagnostic laparoscopy}}
• Initial <1500iU {{c2::and stable: repeat in 48 hours}}

Question 130

Using B-HCG monitoring how can you tell if a patient is having a miscarriage or has a viable pregnancy?

Answer 130

• Viable pregnancy: will double every 48 hours
• Miscarriage: halves every 48 hours

Question 131

What complications can arise from an ectopic pregnancy

Answer 131

• Fallopian tube rupture-> hypovolaemic shock->organ failure-> death

Question 132

Name some causes of oligohydramnios

Answer 132

• Pre-term rupture of membranea
• Non-functional kidneys
• Renal agenesis(Potter's)
• Obstructive uropathy
• Placental insufficiency
• Chromosomal abnormalities
• Viral infections

Question 133

What are the most common causes of oligohydramnios?

Answer 133

• Pre-term rupture of membranes
• Placental insufficiency 

Question 134

What causes symptoms in patients with oligohydramnios?

Answer 134

• Decreased space around fetus
• Lack of amniotic fluid for fetal growth and development

Question 135

What investigations are typically done to diagnose oligohydramnios?

Answer 135

USS:

• Reduced amniotic fluid index
• Reduced max pool depth(MPD) or single deepest pocket(SDP)

To ID underlying cause:

• Meernal bloods
• Karyotyping

If membrane rup[ture suspecteD:

• IGFBP-1 or PAMG-1(usually in amniotic fluid)

Question 136

What is important to remember if delivering a baby early via C-section due to oligohydramnios?

Answer 136

Give a course of steroids for fetal lung development and antibtiotics to lower risk of infection

Question 137

What complications can arise from oligohydramnios and why?

Answer 137

• Amniotic fluid allows fetus to move in utero
• No fluid-> no exercise-> muscle contracures-> disability after birth

Question 138

What investigations might be done in a patient with polyhydramnios?

Answer 138

USS-diagnostic
To look for cause:

• Maternal glucose tolerance test
• Fetal anaemia
• Karyotyping
• Fetal anatomy for structural cause
• Viral screen(TORCH)

Question 139

Viral screen: TORCH

• T{{c1::oxoplasmosis}}
  
• P{{c2::arvovirus}}
• R{{c3::ubella}}
• C{{c4::MV}}
• H{{c5::epatitis}}

Question 140

What are the 2 stages of labour?

Answer 140

• Latent phase: 0-3cm cervical dilation
• Active phase: 3-10cm cervical dilation

Question 141

Name some differentials for the first stage of labour

Answer 141

• Braxton Hicks
• Preterm labour

Question 142

What investigations might be done if a woman is in the first stage of labour?

Answer 142

• Regular assessment of maternal and foetal vital signs
• Frequent exam to determine cervical dilation and effacement
• Palpation to assess position and descent of foetus

Question 143

Name some signs and symptoms of the second stage of labour

Answer 143

• Foetal head flexion, descent and ngagement into the pelvis
• Foetal internal rotation to face maternal back
• Foetal head extension to deliver head
• Foetal external rotation after delivery of head, positioning of shoulders in AP position
• Delivery of anterior shoulder first then rest of foetus
• Maternal desure to push

Question 144

Name some signs indicative of the 3rd stage of labour

Answer 144

• Gush of blood from vagina
• Lengthening of umbilical cord
• Ascension of uterus in abdomen

Question 145

Name some indications for inducing labour

Answer 145

• Post dates: >41 weeks gestation
• Preterm prelabour rupture of membranes
• Intrauterine foetal death
• Abnormal CTG
• Maternal conditions like pre-eclampsia, diabetes, cholestasis

Question 146

Name some contrainidctaions for inducing labour

Answer 146

• Previous classica/vertical incision during C-section
• Multiple lower uterine segment C-sections
• Transmissable infections 
• Placenta praevia
• Malpresentations
• Severe fetal compromise
• Cord prolapse
• Vasa previa

Question 147

What investigations might be carried out prior to starting inductino of labour?

Answer 147

• US: confirm gestational age, foetal position and placental location
• Bloods: Check mother's health status-pre-eclampsia/diabetes

Question 148

Name some differentials for pre-term labour

Answer 148

• Braxton Hicks
• UTI
• Placental abruption
• Uterine rupture

Question 149

What investigations might be done in a patient presentign with pre term labour

Answer 149

• Foetal fibroenctin tes(fFN)- assesss risk of pre term elivery after onset of pre-term labour

Question 150

What age does menopause usually happen?

Answer 150

• 45-55
• Average in UK: 52yrs

Question 151

Name some symptoms of menopause

Answer 151

• Vasomotor: hot flushes, night sweats
• Sexual dysfunction: vaginal dryness, reduced libido, problems with orgasm
• Psychological: depression, anxiety, brain fog

Question 152

Name some differentials for menopause

Answer 152

• Hyperthyroidism
• Depression
• premature ovarian insufficiency

Question 153

What are the types of HRT

Answer 153

• Oestrogens-can be oral, transdermal or topical
• Progestogens-oral, transdermal, intrauterine

Question 154

Name some benefits of HRT

Answer 154

• Relief of vasomotor sx
• Relief of urogential sc
• Reduced risk of osteoporosis

Question 155

Name some things HRT can increase the risk of?

Answer 155

• Breast cancer
• Endometrial cancer(especially if given alone)
• VTE

Question 156

Name some contraindications for prescribing HRT

Answer 156

• Breast cancer
• Oestrogen dependednt cancer
• Vaginal bleeding of unknown cause
• Pregnancy
• Untreated endometrial hyperplasia
• VTE
• Liver disease with abnormal LFTs

Question 157

Name some complications of menopause

Answer 157

• Osteoporosis
• Cardiovascular disease
• Dyspareunia
• Urinary incontinence

Question 158

What does GnRH do for the menstrual cycle?

Answer 158

• Released from the hypothalamus and stimulates LH and FSH release from anterior pituitary

Question 159

What are the phases of the ovarian cycle?

Answer 159

• Follicular 
• Ovulation
• Luteal

Question 160

What happens during the follicular phase of the ovarian cycle?

Answer 160

• Follicles begin to mature and prepare to release an oocyte

At the start: low ovarian hormoen profuction: little negative feedback at HPG axis so increase in FSH and LH

Only 1 follicle can reach maturity, other follicles form polar bodies

Oestrogen becomes high enough to initiate positive feedback, increases everything, especially LH but increased inhibin means FSH doesn't surge(inhibin selectively inhibits FSH)

Granulosa cells express LH receptors

Question 161

What happens during the ovulaton stage of the ovarian cycle

Answer 161

• Response to LH surge: follicle ruptures and oocyte assissted to fallopiani tube by fimbria-> viable for fertilisaton for 24 hours
• After ovulation, follicel remains luteinised, secreting oestrogen and progesterone

Question 162

What happens in the luteal phase of the ovarian cycle?

Answer 162

• In absence of fertilisation: corpus luteum regresses after 14 days, fall in hormones relieving negative feedback

Question 163

What happens to the corpus luteum if fertilisation occurs?

Answer 163

• HCG is produced exerting a leuteningin effect to maintain the corpus luteum

Question 164

What are the stages of the uterine cycle?

Answer 164

• Proliferative 
• Secretory
• Menses

Question 165

What happens in the proliferative phase of the uterine cycle?

Answer 165

• Runs alongside follicular phase
• Prepares reproductive tract for fertilisation and implantation
• Oestrogen initiates fallopian tube formation-> endometrium thickening-> increased growth and motility o fmyometrium and productive of thin alkaline cervical mucus

Question 166

What happens during the secretory phase of the uterine cycle?

Answer 166

• Runs alongside luteal phase
• Progesterone stimulates thickening of endometrium into glandular secretory form, thickening of myometrium, reduction of motility in myometrium, thick acidic cervical mucus production(prevent polyspermy)

Question 167

What are the main hormones involved in:
a)proliferative phase
b)secretory phase?

Answer 167

a)oestrogen
b)progesterone

Question 168

Name some differentials for PCOS

Answer 168

• Menopause
• Congenital adrenal hyperplasia
• Hyperprolactinaemia
• Androgen secreting tumour
• Cushing's

Question 169

What investigations might be done to diagnose PCOS?

Answer 169

• Bedside: clinical exam to look for features of hyperandrogenism/insulin resistance
• Bloods: LH:FSH ratio, total testosterone, fasting/oral glucose tolerance, TFT, prolactin, cortisol
• Imaging: transabdominal/transvaginal USS

Question 170

What diagnostic criteria is used for PCOS?

Answer 170

• Rotterdam diagnostic criteria

Question 171

Name some complications of PCOS

Answer 171

• Infertility
• Metabolic syndrome and dyslipidaemia
• T2DM
• CVD
• Hypertension
• Obstructive sleep apnoea

Question 172

What is Asherman's syndrome?

Answer 172

• Adhesions(synechiae) form within uterus following damage to the uterus

Question 173

Name some common causes of Asherman's syndrome

Answer 173

• Pregnancy related dilatation and curettage procedure
• Post uterine surgery
• Pelvic infections

Question 174

Name some complications of Asherman's syndrome

Answer 174

• Menstruation abnormalities
• Infertility
• Recurrent miscarriages

Question 175

What are congenital malformations of the female genital tract?

Answer 175

• Deviations form normal anatomy resulting from embryonic maldevelopment of Mullerian or paramesonephric ducts

Question 176

What are the most common types of congenital uterine abnormalities caused by?

Answer 176

• Incomplete fusion of mullerian or paramesonephric ducts

Question 177

Name some complications of congenital uteirne abnormalities

Answer 177

• Dysmenorrhoea
• Haematoemtra
• Complicaitons during pregnancy and labour
• Congenital renal abnormalities often co-exist

Question 178

What are endometrial polyps?

Answer 178

• Benign growths of endometrial lining of the uterus, consisting of glandular epithelium, stroma and blood vessels

Question 179

What age groups are endometrial polyps found in?

Answer 179

• Reproductive age women
• Can occur post menopausal

Question 180

Name some risk factors for polyps

Answer 180

• Obesity
• Htn
• Tamoxifen
• HRT

Question 181

Name some differentials for a polyp

Answer 181

• Fibroid
• Adenomyoma
• Endometrial carcinoma
• Gestation trophoblastic disease

Question 182

Name some complications fo endometrial polyps

Answer 182

• Small percentage may have atypical hyperplasia/endometrial carcinoma
• Anaemia due to chronic blood loss in those with heavy menstrual bleeding

Question 183

Name the causative organisms of PID

Answer 183

• Chlamydia trachomatis-most common cause
• Gonnorhoea
• Mycoplasma genitalium
• Mycoplasma hominis
• Sometiems no pathogen isolates

Question 184

What is Fitz Hugh Curtis syndrome?

Answer 184

• Adhesions form between anterior liver capsule and anterior wall/diaphragm in context of PIC

Question 185

Name some differential diagnoses for PID

Answer 185

• Appendicitis
• Ectopic
• Endometriosis
• Ovarian cyst
• UTI

Question 186

What investigations are used to diagnose PID

Answer 186

• Pregnancy test to exclude ectopic
• Swabs for gonorrhoea and chlamydia or urine NAAT 
• Bimanual exam: cervical motion tenderness

Bloods: FBC+WCC+CRP

Imaging: TV USS

Question 187

Name some complications of PID

Answer 187

• Chornic pelvic pain-tubal damage from inflammation
• Infertility
• Ectopic pregnancy
• Fitz-High Curtis syndrome

Question 188

What condition might Fitz Hugh Curtis syndrome be confused with?

Answer 188

• Cholecystitis

Question 189

Name some risk factors for developing renal stones

Answer 189

• Obesity
• Dehydration
• Diet rich in oxalate foods like fruit, nuts, cocoa
• Previous stones
• Anatomical abnormalities
• FHx

Question 190

Name some differentials for urinary tract calculi

Answer 190

• Pyelonephritis
• Appendicits
• Diverticulitis
• Ovarian torsion
• Ectopic pregnancy
• AAA

Question 191

What investigaitons might be done to diagnose renal stones?

Answer 191

• Urinalysis
• Uirne mc+s
• Observations to check for sepsis
• FBC, UE, calcium and uric acid
• GS: non contrast helical CT KUB
• 
  

Question 192

What is a prolactinoma?

Answer 192

• Benign tumour of the pituitary gland-secretes excessive prolactin

Question 193

What does the aerola contain and how do they change during pregnancy?

Answer 193

• Contain sebaceous glands
• Enlarge during pregnancy and secrete an oily substance that acts as a protective lubricant

Question 194

What are the 3 main parts that make up the anatomical structure of the breast

Answer 194

• Mammary glands
• Connective tissue stroma
• Pectoral fascia

Question 195

What are the groups of lymph nodes that receive lymph from breast tissues?

Answer 195

• Axillary nodes(75%)
• Parasternal nodes(20%)
• Posterior intercosta nodes(5%)

Question 196

What is a fibroadenoma?

Answer 196

• Benign tumour consisting of a mixture of fibrous and epithelial tissue

Question 197

Name some differentials for fibroadenomas

Answer 197

• Breast cyst
• Invasive breast cancer
• Intraductal papilloma
• Lipoma

Question 198

What investigations might be done in a patient presenting with a likely fibroadenoma?

Answer 198

Triple assessment:

• Clinical exam
• Imaging: US/Mammogram
• Needle biopsy-fine needle aspiration/core biopsy

Question 199

What is fibrocytic breast disease?

Answer 199

• Benign condition-> presence of fibrous tissue and cysts in the breast
• Considered a variation of normal breast tissue

Question 200

Name some differentials for fibrocystic breast disease

Answer 200

• Breast cancer
• Cysts
• Fibroadenoma
• Mastitis/abscess

Question 201

What investigations might be used to diagnose fibrocystic breast disease

Answer 201

• Clinical exam
• Mammogram and US
• Biopsy: exclude malignancy if suspicious findings

Question 202

What genetic mutations are implicated in breast cancer?

Answer 202

• BRCA1/2

Question 203

Name some risk factors for developing breast cancer

Answer 203

High hormone exposure:

• Endogenous oestrogen: early menarche, nulliparity, late menopause
• Exogenous oestrogen and progestin: COCP, HRT

Inherited gene mutations: BRCA1/2

Increasing age

F history/personal history of breast cancer

Alcohol/tobacco use

Question 204

What are the subtypes of breast cancer?

Answer 204

Pre-invasive:

• Ductal carcinoma in situ
• Lobular carcinomaa in situ

Invasive:

• Invasive ductal carcinoma
• Invasive lobular carcinoma
• Medullary carcinoma

Others:

• Inflammatory
• Mucinous
• Tubular
• HER2 positive breast cancer
• Triple negative breast cancer

Question 205

Name some differentials for breast cancer

Answer 205

• Fibroadenoma
• Cysts
• Mastitis
• Lipoma

Question 206

Name 2 methods for staging breast cancer

Answer 206

• TNM staging(tumour node metastasis)
• Stage 1A/B/2A/B/ETC

Question 207

What are some methods used to treat breast cancer?

Answer 207

• Surgery
• Radiotherapy
• Hormone therapy
• Biological therapy
• Chemotherapy

Question 208

What are some features that wwould favour a mastectomy instead of awide local excision?

Answer 208

• Multifocal tumour rather than solitary lesion
• Central tumour rather than peripheral
• Large lesion in small breast rather than small lesion in large breast
• DCIS >4CM rather than <4cm

Question 209

Name a biological therapy that might be used in breast cancer treatment and when it might be used?

Answer 209

• Trastuzumab(Herceptin)-used in HER2 positive tumours
• Can't be used in patients with heart disorders

Question 210

Name some examples of hormonal therapies that might be used in patients with breast cancer

Answer 210

• Tamoxifen: pre/peri menopausal women
• Anastrozole: aromatose inhibitors: post-menopausal women

Question 211

Name some side effects of tamoxifen

Answer 211

• Increased risk of endometrial cancer
• VTE
• Menopausal symptoms

Question 212

Symptoms of benign breast disease

• Fibroadenoma: {{c1::highly mobile, encapsulated breast masses}}
  
• Mastitis: {{c2::breast redness, mastalgia, malaise, fever}}
• Intraductal papilloma: {{c3::bloody discharge from nipple, no mass}}
• Radial scar: {{c4::mammogram-stellite pattern-central scanning and glandular tissue}}
• Fat necrosis: {{c5::painless breast mass, skin thickening}}
• Fibrocystic breast disease: {{c6::breast lumps, pain, tenderness}}
• Mammry duct ectasia: {{c7::palpable peri-areolar breast mass, nipple discharge}}

Question 213

Name some differentials for Paget's disease of the nipple

Answer 213

• Atopic dermatitis/contact dermatitis/psoriasis
• Intraductal papilloma
• Mastitis/abscess

Question 214

What is cervical effecement?

Answer 214

• Also called cervical ripening
• Thinning of the cervix
• Before: shaped like a bottleneck and up to 4cm
• Through pregnancy: cervix tightly closed and protected by mucus plug

Question 215

What are the 7 mechanisms of labour?

Answer 215

• Descent
• Flexion
• Internal rotation
• Extension
• Restitution
• External rotation
• Delivery of body

Question 216

What happens during the 'descent' stage of labour?

Answer 216

• Fetus descends into pelvis

Question 217

What encourages the 'descent' stage of labour?

Answer 217

• Increased abdominal muscle tone
• Increased frequency and strength of contractions

Question 218

What happens during the 'flexion' stage of labour?

Answer 218

• Fetus descends through pelvis-> uterine contractions exert pressure down fetal spine towards occiput forcing the occiput to come into contact with pelvic floor
• Fetal neck flexes allowing the circumference of the head to reduce-easier to pass through pelvis
• 
  

Question 219

What happens during the internal rotation stage of labour?

Answer 219

• With each contraction, fetal head is pushed onto pelvic floor, supporting a small degree of rotation
• Regular contractions eventually lead to head completing 90 degree turn

Question 220

What happens during the 'extension' phase of labour?

Answer 220

• Fetal occiput slips beneath suprapubic arch allowing the head to extend-fetal head born and usually facing maternal back

Question 221

What happens during the 'restitution/external rotation' stage of labour?

Answer 221

• fetus naturally aligns head with shoulders
• Visually head may be seen to externally rotate face to right or left

Question 222

What is delayed cord clamping?

Answer 222

• Umbilical cord not immediately clamped and cut at point of birth but allowed >1 minute to transfuse blood to baby
• Baby can receive up to 214g of blood 

Question 223

Name some benefits of delayed cord clamping

Answer 223

• Allows baby time to transition to extra-uterine life
• Increase in RBC, irone and stem cells
• Reduced need for inotropic support

Question 224

What are some benefits of an upright birth?

Answer 224

• Increases diameter of pelvic inlet
• Less risk of compressing mother's aorta
• Encourages stronger and longer contractions
• Gravity

Question 225

What are the advantages of using entotox as pain relief in labour?

Answer 225

• Fast actnig-20-30 seconds
• Can eb used alongside analgesia
• Does not require further fetal monitoring

Question 226

What is an epidural?

Answer 226

• Mix of bupivacaine and fentanyl
• Epidural catheter inserted by anaesthetist and drugs administered through pump

Question 227

Name some pros and cons of using an epidural

Answer 227

Pros:

• Total pain relief in 90% of cases
• Effect will last until baby is born

Cons:

• Reduced mobility
• Cant take up to an hour to take effect
• Will need urinary catheter
• Can slow donw labour if not already established

Question 228

What is an operative vaginal delivery?

Answer 228

• Use of an instrument to aid delivery of the fetus

Question 229

What are the 2 main instruments used in operative deliveries?

Answer 229

• Ventouse
• Forceps

Question 230

What are ventouse deliveries associated with?

Answer 230

• Lower success rate
• Less maternal perineal injuries
• Less pain
• More cephalhaematoma
• More subgaleal haematoma
• More fetal retinal haemorrhage

Question 231

What are forceps and how are they used for delivery?

Answer 231

• Double bladed instruments
• Inserted into pelvis, applied round sides of fetal head with blades locked together
• Gentle traction applied during uterine contractions

Question 232

What are forceps associated with?

Answer 232

• Higher rate of 3rd/4th degree tears
• Less often used to rotate
• Doesn't require maternal effort

Question 233

Name some indications for performing an assisted vaginal delivery

Answer 233

Maternal:

• Maternal exhaustion
• Maternal medical conditions that mean active pushing should be avoided(intracranial pathologies, severe heart disease/htn)

Fetal:

• Suspected fetal compromise in 2nd stage of labour0CTG monitoring/abnormal fetal blood sample
• Cinical concerns like significant antepartum haemorrhage

Question 234

Name some absolute contraindications to an instrumental delivery

Answer 234

• Unengaged fetal head
• Incompletely dilated cervix
• True cephalo pelvic disproportion
• Breech and face presentation
• Preterm gestation(<34 weeks)

Question 235

What are the pre-requisites for intstrumental delivery?

Answer 235

• Fully dilated
• Ruptured membranes
• Cephalic presentation
• Defined fetal position
• Fetal head at least at level of ischial spines and no more than 1/5 palpable per abdomen
• Empty bladder
• Adequate pain relief
• Adequate maternal pelvis

Question 236

Name some fetal complications from an instrumental deliver

Answer 236

• Neonatal jaundice
• Scalp lacerations
• Cephalohaematoma
• Subgaleal haematoma
• Retinal heamorrhage
• Skull fractures

Question 237

Name some maternal complications of instrumental deliveries

Answer 237

• Vaginal tears: 3rd/4th degree
• VTE
• Incontinence
• PPH
• Shoulder dystocia
• Infection

Question 238

Results of quadruple test indicative of higher Down's risk

• AFP: {{c1::Low}}
  
• hCG: {{c2::high}}
• Inhibin A: {{c3::high}}
• Unconjugated oestriol: {{c4::low}}

Question 239

What are the 2 types of invasive prenatal diagnostic testing?

Answer 239

• Chorionic villus testing(CVS)
• Amniocentesis

Question 240

What is CVS?

Answer 240

• US guided smapling of placental tissue by insterting a fine needle through abdomen and into uterus
• Rules out mosaicism-if positive will need amniocentesis

Question 241

What is amniocentesis?

Answer 241

• US guided insertion of fine needle through abdomen into uterus to take a sample of amniotic fluid-contains abby's cells so is a true reflection of baby's DNA

Question 242

Name some risks of invasive prenatal testing

Answer 242

• Miscarriage
• Infection

Question 243

What does the anomaly scan screen for?

Answer 243

• 11 physical confitions
• Some associated with Down's-congenital heart disease, abdominal wall defects

Question 244

Name some risk factors for mastitis

Answer 244

• Poor breastfeeding technique
• Nipple damage
• Maternal stress
• Previous hx of mastitis

Question 245

Name some differentials for mastitis

Answer 245

• Breast abscess
• Breast cancer
• Breast engorgement-> bilateral, ssociated with milk stasis and tense breasts

Question 246

Name a complication of mastitis

Answer 246

• Breast abscess

Question 247

What is a breast abscess?

Answer 247

• Accumulation of pus within an area of breast tissue, often a complication of infectious mastitis

Question 248

What is bacterial vaginosis?

Answer 248

• Bacterial imblaance of the vagina cuased by an overgrowth of anaerobic bacteria and loss of lactobacilli

Question 249

What are the features of lactobacilli bacteria?

Answer 249

• Rod-shaped
• Produce hydrogen peroxide-> keeps vaginal pH >4.5 which inhibits growth of other organisms

Question 250

Name some risk factors for bacterial vagnosis

Answer 250

• Sexual activity
• Receptive oral sex
• Presence of an STI
• Smoking
• Recent antibiotic use
• Ethnicity(higher in black women)
• Vaginal douching/use of scented soaps/vaginal deoderants

Question 251

Name some differentials for bacterial vaginosis

Answer 251

• Vulvovaginal candidiasis
• Trichomonas vaginalis infection
• Chlamydia/gonorrhoea
• Atrophic vaginitis

Question 252

What investigations are done to diagnose bacterial vaginosis?

Answer 252

Ansel criteria: 3/4 of:

• pH>4.5
• grey/milky discharge
• clue cells on wet mount(vaginal epithelial cells studded with gram variable coccobacilli)
• KOH whiff test

Microscopy: high vaginal smear: clue cells, decreased lactobacilli and no pus cells

Question 253

Name some complications for bacterial vaginosis

Answer 253

• Pregnancy related-> premature birth, miscarriage, chorioamnionitis risks

Question 254

Name some risk factors for vulvovaginal candidiasis

Answer 254

• Pregnancy
• Diabetes
• Antibiotic use
• Corticosteroid use/immunosuppression

Question 255

Name some signs of vulvovaginal candidiasis

Answer 255

• Erythema/swelling of vulva
• Discharge
• Satellite lesions-red, pustular lesions with superficial white/creamy pseudomembranous plaques

Question 256

What is chlamydia?

Answer 256

• STD caused by obligate intracellular bacteria chlamydia trachomatis

Question 257

What are the different serotypes of chlamydia and what infections do they cause?

Answer 257

• A-C: Ocular infection: chlamydial conjunctivitis
• D-K: classical GU infection
• L1-L3: Lymphogrannuloma venereum(LGV), MSM, proctitis

Question 258

What group of people is L1-L3 chalmydial infections found in most commonly?

Answer 258

• MSM

Question 259

Name some risk factors for chlamydia

Answer 259

• <25yrs
• Recent change in sexual partner/infected partner
• Co-infection with other STIs
• Non-barrier contraception

Question 260

What does chlamydia in rpegnancy increase the risk of?

Answer 260

• Low birth weight
• Miscarriage

Question 261

What contact tracing should be done in patient with chlamydia?

Answer 261

• Men with urethral sx: all partners 4 weeks prior to sx onset
• asx men and women: last 6 months r most recent partner

Question 262

Name some complicatons of chlamydia

Answer 262

• Reactive arthritis
• Infertility
• Epididymitis
• PID
• Endometritis
• Increased incidence of ectopics
• Perihepatitis

Question 263

Name some risk facotrs for gonorrhoea

Answer 263

• <225yrs
• MSM
• High density urban areas
• Previous gonorrhoea infections
• Multiple sexual partners

Question 264

Name some complications of gonorrhoea

Answer 264

• PID
• Epididdymo-orchitis.prostatitis
• Dissminated gonococcal infection

Question 265

Name some complications of disseminated gonococcal infection

Answer 265

• Septic arthriits: mc cause of septic arthritis in young people
• Endocarditis
• Perihepatitis

Fitz-Hugh-Curtis syndrome

Question 266

What is gonorrhoea in pregnancy associated with?

Answer 266

• Perinatal mortality
• Spontaneous abortion
• Premature labour
• fetal membrane rupture
• Vertical transmission-> gonococcal conjunctivitis

Question 267

What are gential herpes?

Answer 267

• Infectious disease that causes painful sores/ulceers on the genitals
• HSV1/2

Question 268

What does HSV1 cause?

Answer 268

• Oral/genital herpes-coldsores

Question 269

What does HSV2 cause?

Answer 269

• Anogenital herpes

Question 270

Name some risk factors for developing gential herpes

Answer 270

• Multiple sexual partners
• Oral sex with partner with cold sores

Question 271

What are genital warts?

Answer 271

• Benign epithelial/mucosal outgrowths caused by HPV

Question 272

Name some risk factors for developing genital warts

Answer 272

• Early age at 1st sex
• Multiple partnes
• Smoking
• Immunosuppression
• Diabetes-> persistence of warts

Question 273

Name some differentials for genital warts

Answer 273

• Molluscum contagiosum
• Condyloma lata(secondary syphilis)
• Genital herpes
• Skin tags

Question 274

What is a risk of gential warts in pregnancy?

Answer 274

• Very low risk of transmission during birth-can cause respiraotry papillomatosis

Question 275

What is HIV?

Answer 275

• Single stranded RNA retrovirus that infects and replicates in CD4(T helper) cells

Question 276

Name some risk factors for developing HIV

Answer 276

• MSM
• IVDU
• High prevalence areas
• Other STDs, breaks in skin

Question 277

What are the different stages of HIV infection?

Answer 277

1. Seroconversion illness
2. Symptomatic HIV
3. AIDS defining illness

Question 278

Name some AIDS defining illnesses/infections/malignancies

Answer 278

• Pneumocystis jiroveci
• Non-Hodgkin's lymphoma
• TB

Question 279

What are NRTI's? 

Answer 279

• nuceloside analogue reverse transcriptase inhibitors
• E.g. zidovudine, abacavir etc
• General SE: peripheral neuropathy

Question 280

Is the cervical os open or closed in a threatened miscarriage?

Answer 280

• Closed

Question 281

What are the surgical options for miscarriage management?

Answer 281

• <12 weeks: manual vacuum aspiration
• >12 weeks: evacuation of retained products of conception(ERPC)

Question 282

Name some causes of polyhydramnios

Answer 282

Idiopathic: 50-60% of cases

Excess production due to increased fetal urination:

• Maternal diabetes mellitus
• Fetal renal disorders
• Fetal anaemia
• Twin to twin transfusion syndrome

Insufficiency removal due to decreased fetal swallowing:

• Oeosphageal.duodenal atresia
• Diaphragmatic disorders
• Anencephaly
• Chromosomal disorders

Question 283

What are some risks of amnioreduction in patients with polyhydramnios?

Answer 283

• Infection
• Placental abruption-> sudden increase in intrauterine pressure

Question 284

What are the risks of indomethacin for polyhydramnios?

Answer 284

• Associated with premature closure of ductus arteriosus(<32 weeks only)

Question 285

Name some complications of polyhydramnios

Answer 285

• Higher incidence of preterm labour
• Malpresentation-fetus has more space to move within uterus
• Higher risk fo cord prolapse
• postpartum haemorrhage

Question 286

What is a prolonged pregnancy?

Answer 286

• 5-10% of pregnancies that persist after 42 weeks gestation

Question 287

Name some risk factors for a prolonged pregnancy

Answer 287

• Nulliparity
• Maternal age >40yrs
• Previous prolonged pregnancy/fhx
• High BMI

Question 288

Name some symptoms patient with a prolonged pregnancy might experience

Answer 288

• Static growth/macrosomia
• Oligohydramnios
• Decreased fetal movements
• Presence of meconium
• Dry/flaky skin with reduced vernix

Question 289

What investigations might be done in a patient with a prolonged pregnancy?

Answer 289

• Datig between 11+0 and 13+6 wk gestation during 1st triemster scan
• US scanning to check growth and liquor volume-> poor prognostic value in determining placental functino and predicting fetal distress 

Question 290

What are the 2 main types of placenta praevia?

Answer 290

• Minor placenta praevia: placenta is low but not coverig cervical s
• Major placenta praevia: placenta lies over internal cervical os

Question 291

What are the risks associated with placenta praevia?

Answer 291

• Defective attachment to uterine wall-> increased risk of haemorrhage
• Bleeding can be spontaneous or from mild trauma
• Placenta can be damaged as fetus moves into lower uterine segment

Question 292

Name some risk factors for placenta praevia

Answer 292

• High parity
• Age >40yrs
• Previous hx
• Hx of endometritis
• Curettage to endometrium post miscarriage

Question 293

What investigations might be done for a patient with suspected placenta praevia?

Answer 293

• TV USS-> short distance between lower edge of placenta and internal os
• Further USS at 37 weeks to reassess placental position
• Kleihour testl if RH negative doe anti D for feto-maternal haemorrhage
• >26 weeks: CTG to assess fetal wellbeing

Question 294

What are the 2 kinds of placental abruption

Answer 294

1. Revealed: bleeding tracks down and drains through cervix-> vaginal bleeding
2. Concealed: Bleeding stays in uterus and forms clot retroplacentally-> not visible-> can cause systemic shock

Question 295

Name some risk factors for placental abruption

Answer 295

ABRUPTION

• Abruption previously
• B: BP-hypertension/pre-eclampsia
• R: ruptured membranes-preamture/prolonged
• Uterine injury
• Polyhydramnios
• Twins/multiple gestation
• Infection-chorioamnionitis
• Older age: >35yrs
• Narcotic use +smoking

Question 296

Name some differentials for placental abruption

Answer 296

• Placenta praevia
• Vasa praevia
• Marginal placental bleeed
• Uterine rupture
• Local genital causes

Question 297

What investigations might be used in a patient with suspected placental abruption?

Answer 297

• CTG
• US-retroplacental haematoma-> poor negative preedictive value(shouldn't be used to exclude abruption)

Question 298

What are the different kinds of breech presentation?

Answer 298

• Complete(flexed)-cross legged
• Frank(extended): legs flexed at hip and extended at knees-mc
• Footling: Atl eeast one leg extended at hip so foot is presenting part

Question 299

Name some risk factors for breech presentation

Answer 299

Uterine:

• Multiparity
• Fibroids
• Placenta praevia
• Uterine malformations

Fetal:

• Prematurity
• Macrosomia
• Polyhydramnios
• Twins

Question 300

Name some differentials for breech presentation

Answer 300

• Oblique lie
• Transverse lie
• Unstable lie(position changes)

Question 301

Name some complications of external cephalic version

Answer 301

• Transient/persistent heart rate abnormalities
• Placental abruption

Question 302

Name some specific manouvers used during a vaginal breech birth

Answer 302

• Flexing fetal knees
• Lovsett's manoeuver(rotate body and deliver shoulders)
• Mauriceau-Smellie-Veit(MSV) manoeuver

If fails: forceps

'hands off': no tractions: fetal head would extend and get trapped

Question 303

Name some complications of a breech presentation

Answer 303

• Cord prolapse
• Fetal head entrapment
• Birth asphyxia-> usually secondary from delay in delivery
• Premature rupture of membranes
• Intracranial haemorrhage-> rapid head compression during delivery
• Developmental dysplasia of the hip

Question 304

What are the different kinds of fetal lies

Answer 304

• Longitudinal
• Transverse 
• Oblique

Question 305

What are the different kinds of fetal presentation?

Answer 305

• Cephalic-mc and safest
• Shoulder
• face
• brow
• breech

Question 306

What are the different kinds of fetal position?

Answer 306

• Occipito-anterior: mc and ideal
• Occipito posterior
• Occipito transverse

Question 307

Name some risk factors for abnormal fetal lie/malpresentation/rotation

Answer 307

• Prematurity
• Multiple pregnancy
• Fetal abnormalities
• Placenta praevia
• Primiparity
• Uterine abnormalities(fibroids, partial septate uterus)

Question 308

Name some contraindications for external cephalic version

Answer 308

• Recent APH
• Rutpured membranes
• Uterine abnormaliites
• Prior C section

Question 309

Name some moderate risk factors for pre-eclampsia

Answer 309

• Nulliparity
• >40yrs
• High BMI
• Multiple pregnancy

Question 310

Name some high risk factors for pre-eclampsia

Answer 310

• Chronic hypertension
• Previous eclampsia/pre-eclampsia
• Diabetes
• CKD
• AI diseases: SLE, APS

Question 311

Name some differentials for pre-eclampsia

Answer 311

• Essential hypertension
• Pregnancy induced hypertension
• Eclampsia

Question 312

What investigations might be done in a patient with suspected pre-eclampsia?

Answer 312

• BP and proteinuria measurements
• FBC: low Hb, low platelets
• U&Es: high urea, high creatinine, low urine output
• LFTs: high ALT, high AST

Question 313

Name some maternal complications of pre-eclampsia

Answer 313

• Eclampsia
• Organ failure
• DIC
• HELLP syndrome

Question 314

Name some fetal complications of pre-eclampsia

Answer 314

• Intrauterine growth restriction
• Pre-term delivery
• Placental abruption
• Neonatal hypoxia

Question 315

What is eclampsia?

Answer 315

• Occurence of one or more seizure in a pre-eclamptic women in the absence of another cause

Question 316

What investigations might be done in a patient with eclampsia?

Answer 316

• Exclude other reversible causes of seizure and assess for complications: blood glucose, neuro workup
• Abdo USS-> rule out placental abruption

Question 317

Name some signs of magnesium sulfate toxicity

Answer 317

• Hypo-reflexia
• Respiratory distress

Question 318

What are the risks of BP treatment for a patient with eclampsia

Answer 318

• If drop in BP is too rapid-> fetal HR abnormalities-> continuous CTG monitoring

Question 319

Name some differentials for eclampsia

Answer 319

• Hypoglycaemia
• Stroke
• Head trauma
• Pre-existing epilepsy
• Meningitis
• Medication induced

Question 320

Name some differentials for trichomoniasis

Answer 320

• Bacterial vaginosis
• Candidiasis
• Gonorrhoea
• Chlamydia

Question 321

Name some complications in females of trichomoniasis

Answer 321

• Perinatal complications
• HIV transmission
• PID
• Bacterial vaginosis
• Cervical cancer risk
• Infertility

Question 322

Name some complications in males of trichomoniasis

Answer 322

• Prostatitis
• HIV transmission
• Prostate cancer risk
• Infertility

Question 323

What is chancroid?

Answer 323

• STI of the genital skin

Question 324

What causes chancroid?

Answer 324

• Gram negative bacillus haemophilius ducreyi

Question 325

Name some risk factors for chancroid

Answer 325

• Tropical areas
• Poor living conditions
• Lack of public health infrastructure

Question 326

Name some differentials for chancroid

Answer 326

• HSV
• Syphilis
• Lymphogranuloma venereum

Question 327

Name some risk factors for lymphogranuloma venereum

Answer 327

• MSM
• Tropics
• Developed countries: concurrent HIV infection more common

Question 328

Name some differentials for lymphogranuloma venereum?

Answer 328

• Primary syphilis
• HSV
• Chancroid

Question 329

What is balanitis?

Answer 329

• Inflammation of the glans penis
• Balanoposthitis: extends to underside of foreskin

Question 330

Name some causes of balanitis

Answer 330

• Candidiasis
• Dermatits
• Bacterial-mc Staph spp
• Anaerobic
• Lichen planus
• Lichen sclerosus

Question 331

What are the different stages of syphilis?

Answer 331

• Primary
• Secondary
• Tertiary

Question 332

Name some differentials for syphilis

Answer 332

Primary:

• Herpes
• Lymphgranuloma venereum
• Malignancy

Secondary:

• HIV
• Mono
• Malignancy

Tertiary:

• Dementia
• Psych conditions
• Chronic granulomatous lesions

Question 333

Name some causes of a false positive non-treponemal test for syphilis

Answer 333

• Pregnancy
• SLE
• APS
• TB
• Leprosy
• Malaria
• HIV

Question 334

What conclusion could be drawn from a positive non-treponemal test and positive treponemal test for syphilis?

Answer 334

• Consistent with active syphilis infection

Question 335

What conclusion could be drawn from a positive non-treponemal test and negative treponemal test for syphilis?

Answer 335

• False positive syphilis result

Question 336

What conclusion could be drawn from a negative non-treponemal test and positive treponemal test for syphilis?

Answer 336

• Successfully treated syphilis

Question 337

What is a Jarisch-Herxheimer reaction?

Answer 337

• May occur on treatment initiation for syphilis
• Rash, fever, tachycardia after 1st dose NO wheeze/hypotension
• Due to release of endotoxins following bacterial death
• Tx: reassuring and antipyretics

Question 338

Name some complications of syphilis

Answer 338

• Neurosyphilis: general paresis, tabes dorsalis, meningitis, ocular/auditory abnormalities
• CVR: aortic aneurysm, regurg, angina, heart failure
• Gummatous syphilis: granulomatous lesions affecting skin and bone
• HIV transmission facilitation

Question 339

Name some complications of syphilis in pregnancy

Answer 339

• Hydrops
• Preterm labour
• Low birth weight
• Fetal loss
• Congeital syphilis of the newborn

Question 340

What is intraductal papilloma?

Answer 340

• Benign tumour: local areas of epithelial proliferation in large mammary ducts
• Hyperplastic lesions rather than malignant

Question 341

What is a breast cyst?

Answer 341

• Benign fluid-filled sacs inside the breast

Question 342

What groups of people are more likely to get breast cysts?

Answer 342

• Women before menopause: <50yrs
• Post menopausal women on HRT

Question 343

What is HELLP syndrome?

Answer 343

• Complication of pregnancy characterised by hemolysis(H), elevated liver enzymes(EL) and low platelets(LP)

Question 344

What can HELLP syndrome follow on from?

Answer 344

• Severe pre-eclampsia: 10-20% of patients go on to get HELLP
• Considered separate disorder

Question 345

Name some differentials for HELLP syndrome

Answer 345

• Acute fatty liver of pregnancy
• ITP
• TTP

Question 346

Name somme investigations for HELLP syndrome

Answer 346

• FBC: low platelets, hemolysis
• LFTs: elevated liver enzymes
• Coags: assess for DIC
• US: liver abnormlities and placental abruption

Question 347

Name some maternal complications of HELLP syndrome

Answer 347

• Organ failure
• Placental abruption
• DIC

Question 348

Name some fetal complications of HELLP syndrome

Answer 348

• Intrauterine growth restriction
• Preterm delivery
• Neonatal hypoxia

Question 349

What is cord prolapse?

Answer 349

• Umbilical cord descends through the cervix into the vagina before the presenting part of the feotus

Question 350

Name some risk factors associated with cord prolapse

Answer 350

• Abnormal lie: breech, transverse
• Multiple pregnancy
• Polyhydramnios
• High fetal head at deliveery
• Multiparity
• Low birth weight
• Prematurity
• Premature rupture of membranes

Question 351

Name some differentials for cord prolapse

Answer 351

• Cord presentation
• Funic presentation
• Vaginal bleeding or unkown origin

Question 352

Name some risk factors for vasa praevia

Answer 352

• Multiparity
• Previous C sectionn
• IVF
• Velamentous cord insertion-BIG one

Question 353

Name some differentials for vasa praevia

Answer 353

• Placenta praevia-no change in fetal hr unless maternal haemorrhage
• Placental abruption
• Premature rupture of membranes

Question 354

Name some complications of vasa praevia

Answer 354

• Fetal exsanguination: rupture or unprotected vessels
• Hypoxic ischaemic encephalopathy
• Preterm labour
• Intrauterine growth restriction-> compromised placental perfusion

Question 355

Name some risk factors for peruperal psychosis

Answer 355

• Hx of schizophrenia
• Hx of bipolar affective disorder
• FHx/hx of postpartum psychosis

Question 356

Name a differential for peurperal psychosis

Answer 356

• Postpartum depression
• Baby blues

Question 357

Name 2 antipsychotics that are safe for use in breastfeeding

Answer 357

• olanzapine
• quetiapine

Question 358

Name some risk factors for postpartum depression

Answer 358

• Low socioeconomic status
• History of mental health disorders
• Lack of social support

Question 359

Name some differentials for postpartum depression

Answer 359

• Baby blues
• Postpartum psychosis
• Adjustment disorders
• GAD

Question 360

Name some fetal complications of PPROM

Answer 360

• Prematurity
• Infection
• Pulmonary hyoplasia

Question 361

Name a maternal complication of PPROM

Answer 361

• Chorioamnionitis

Question 362

Name some risk factors for primary postpartum haemorrhage

Answer 362

• Previous PPH
• Prolonged labour
• Pre-eclampsia
• Increase maternal age
• Polyhydramnios
• Emergency C-section
• Plaacenta praevia/accreta
• BMI>35
• Instrumental delivery and episiotomy

Question 363

What investigations might be done in a patient with postpartum haemorrhage

Answer 363

• Bloods for group/save and crossmatch
• Consider FFP if clotting abnormalities
• Secondary: US looking for retained products of conception
• Endocervical/high vaginal swabs-infection

Question 364

What health professionals are needed for a termination of pregnancy?

Answer 364

• 2 registered medical practitioners mmust sign legal document(only one needed in emergency)
• Must be performed by a registered medical practitioner and done in an NHS hospital or licensed premise

Question 365

What advice is there regarding anti D and termination of pregnancy?

Answer 365

• Anti-D prophylaxis should be given to women who are rhesus D negative and having an abortion after 10 weeks gestation

Question 366

Name some side effects/complications of medical termination of pregnancy

Answer 366

• Severe nausea
• Cramps
• Diarrhoea
• Vaginal bleeeding
• Incomplete termination of pregnancy-> must be maanaged surgically

Question 367

Name some side effects/complications of surgical termination of pregnancy

Answer 367

• Retained products of conception
• Haemorrhage
• Infection
• Perforation

Question 368

Name some risks of trichomoniasis vaginalis in pregnancy

Answer 368

• Premature births
• Low birth weight
• Maternal postpartum sepsis

Question 369

What is a uterine rupture?

Answer 369

• Full-thickness disruption of the uterine muscle and overlying serosa
• Can extend to affect bladder and broad ligament

Question 370

What are the 2 main types of uterine rupture?

Answer 370

• Incomplete: peritoneum overlying uterus is intact-uterine contents remain inside
• Compleete: peritoneum is torn and uterine contents can escape into peritoneal cavity

Question 371

Name some risk factors for uterine rupture

Answer 371

• Previous C-section(especially classical/vertical incision)
• Previous uterine surgery
• Induction(esp prostaglandins or augmentation of labour)
• Obstruction of labour
• Multiple pregnancy
• Multiparity

Question 372

Name some differentials for a uterine rupture

Answer 372

• Placental abruption
• Placenta praevia
• Vasa praevia

Question 373

What investigations might be done for a patient with a suspected uterine rupture

Answer 373

• USS: abnormal fetal lie/presentation, haemoperitoneum and absent uterine wall
• CTG: ;changes in fetal heart rate patern and prolonged fetal bradycardia: early indicators for uterine rupture

Question 374

Name some causes of folic acid deficiency

Answer 374

• Phenytoin
• Methotrexate
• Pregnancy
• Alcohol excess

Question 375

Name some connsequences of folic acid deficiency

Answer 375

• Macrocytic, megaloblastic anaemia
• Neural tube defects

Question 376

What advice should be given around pregnancy and folic acid?

Answer 376

• All women should take 400mcg folic acid until 12th week of pregnancy
• Women at higher risk of children with neural tube defects should take 5mg folic acid from before conception to 12th week

Question 377

Name some risk factors for developing gestational diabetea

Answer 377

• BMI>30kg/m2
• Previous macrosomic baby weighing >=4.5kg
• Previous gestational diabetes
• 1st degree relatives with diabetes
• Ethnic backgrounds with high prevalence of diabetes(middle easterm south asian, afro-caribbean)
• Hx of stilllbirth/perinatal death

Question 378

Name some fetal complications of gestational diabetes

Answer 378

• Macrosomia(birtthweight >4kg)-> shoulder dystocia, birth injuries and C section
• Sacral agenesis 
• Pre-term delivery and neonatal respiratory distress syndrome
• Neonatal hypoglycaemia
• Increased risk of T2DM later in life

Question 379

Name some maternal complications of gestational diabetes

Answer 379

• Increased risk of hypertension and pre-eclampsia
• Increased risk of T2DM and gestational diabetes in subsequent pregnancies

Question 380

What is hypertension defined as in pregnancy?

Answer 380

• Systolic >140mmHg or diastolic >90mmHg OR
• Increase above booking readings of >30 systolic or >15 diastolic

Question 381

What are women with pregnancy induced hypertension more at risk of later in life?

Answer 381

• Future pre-eclampsia
• Future hypertension

Question 382

Name some risk factors for Group B strep infection

Answer 382

• Prematurity
• Prolonged rupture of membranes
• Previous sibling GBS infection
• Maternal pyrexia (e.g. secondary to chorioamnionitis)

Question 383

Name some clinical features of Group B strep infection in the newborn

Answer 383

• Sepsis
• Pneumonia
• Meningitis

Question 384

Name some maternal risks of obesity in pregnancy

Answer 384

• Miscarriage
• VTE
• Gestational diabetes
• Pre-eclampsia
• Postpartum haemorrhage
• Wound infections
• Higher C section rate

Question 385

Name some fetal risks of maternal obesity in pregnancy

Answer 385

• Congenital abnormality
• Prematurity
• Macrosomia
• Stillbirth
• Increased risk of developing obesity and metabolic disorders in childhood
• Neonatal death

Question 386

What is cephalopelvic disproportion?

Answer 386

• Mismatch between size of fetal head and maternal pelvis causing difficulty in the safe passage of the fetus through the birth canal

Question 387

Name some causes of absolute cephalopelvic disproportion

Answer 387

Maternal:

• Contracted pelvis
• Spondylolisthesis

Fetal:

• Hydrocephalus
• Macrosomia

Question 388

Name some causative factors for prolonged labour

Answer 388

• Cephalopelvic disproportion
• Insufficient uterine contractions
• Fetal malpresentation
• Macrosomia
• Anomalies in birth canal

Question 389

Name some complications of prolonged labour

Answer 389

• Maternal exhaustion
• Post partum haemorrhage
• Post partum infection
• Fetal distress: hypoxia or acidosis

Question 390

Name some differentials for obstetric cholestasis

Answer 390

• Prurigo of pregnancy
• Pruritus gravidarum
• Other hepatobiliary dirsorders

Question 391

What investigations might be done for obstetric cholestasis

Answer 391

• LFT's-. raissed bilirubin
• Bile acid measurements
• Fetal monitoring may be required  due ot risk of spontaneous intrauterine death

Question 392

What is chorioamnionitis?

Answer 392

• Bacterial infection that affects the amniotic sac and amniotic fluid within the uterus
• Life threatening emergency to both mother and fetus

Question 393

What is a major risk factor for chorioamnionitis?

Answer 393

• Preterm premature rupture of membranes: expose normally sterile environment of uterus to pathogens

Question 394

Name some signs and symptoms of chorioamnionitis

Answer 394

• Fever
• Abdo pain
• Offensive vaginal discharge
• Evidence of preterm rupture of memebranes
• Maternal and fetal tachycardia
• Pyrexia
• Uterine tenderness

Question 395

Name some differentials for chorioamnionitis

Answer 395

• UTI
• Appendicitis
• Placental abruption

Question 396

What is female genital multilation?

Answer 396

• Harful practice of injuring or cutting the female genitalia for non-medical reasons

Question 397

Name some risk factors for shoulder dystocia

Answer 397

• Maternal gestational diabetes
• Macrosomia
• Birthweight >4kg
• Advanced maternal age
• Maternal short stature/small pelvis
• Maternal obesity
• Post-dates pregnancy/prolonged labour

Question 398

Name some internal rotational manoeuvres used in shoulder dystocia management

Answer 398

• Woods' screw: anterior shoulder pushed towards fetal chest and posterior shoulder pushed towards fetal back
• Rubin 2: rotate anerior shoulder towards fetal chest

Question 399

What is celidotomy?

Answer 399

• Division of fetal clavicle

Question 400

Name some maternal complications of shoulder dystocia

Answer 400

• PPH
• Perineal tears
• Genital tract trauma

Question 401

Name some fetal complications of shoulder dystocia

Answer 401

• brachial plexus injury
• Neonatal death
• Hypoxic brain damage
• Humeral/clavicle fractures

Question 402

Name some risk factors for anaemia in pregnancy

Answer 402

• Haemoglopinathies: thalassaemia/sickle cell disease
• Increasing maternal age
• Low socioeconomic staus
• Poor diet
• Anaemia during previous pregnancy

Question 403

Name some differentials for congenital rubella syndrome

Answer 403

• Toxoplasmosis
• CMV
• HSV
• Syphillis
• VZV

Question 404

Name some risk factors for perineal tears

Answer 404

• Primigravida
• Large babies
• Precipitant labour
• Shoulder dystocia
• Forceps delivery

Question 405

What is an amniotic fluid embolism?

Answer 405

• Life threatening condition that occurs when amniotic fluid or other debris enters the maternal circulation

Question 406

Name some differentials for an amniotic fluid embolism

Answer 406

• Septic shock
• Anaphylactic shock
• PE
• Hypovolaemia shock

Question 407

What is hyperemesis gravidarum?

Answer 407

• Severe nausea and vomiting commencing before the 20th week gestation
• Different to 'morning sickness' -more severe

Question 408

What is hyperemesis gravidarum thought to be related to?

Answer 408

• Raised B hCG levels

Question 409

Name some risk factors for hyperemesis gravidarum

Answer 409

• Increased levels of B-hCG-multiple pregnancies, trophoblastic disease
• Nulliparity
• Obesity
• Personal/family hx of hyperemesis gravidarum

Question 410

Name a protective factor for hyperemesis gravidarum

Answer 410

• Smoking

Question 411

What criteria should be met for a diagnosis of hyperemesis gravidarum?

Answer 411

1. 5% pre-pregnancy weight loss
2. Dehydration
3. Electrolyte imbalance

Question 412

Name some differentials for hyperemesis gravidarum

Answer 412

• Infections: gastroenteritis, UTI, hepatitis, meningitis
• GI: appendicitis, cholecystitis, bowel obstruction
• Metabolic: DKA, thyrotoxicosis
• Drug toxicity
• Molar rpegnancy

Question 413

What is a risk of odansetron use in pregnancy?

Answer 413

• In first trimester: increased risk of cleft lip/palate

Question 414

Name some complications of hyperemesis gravidarum

Answer 414

• AKI
• Wernicke's encephalopathy
• Oesophagitis
• Mallory-Weiss tear
• VTE

Question 415

What is acute fatty liver of pregnancy?

Answer 415

• Severe, rare, liver disease related to pregnancy which can result in hepatic failure and results in immediate medical and obstetric intervention

Question 416

Name some risk factors for acute fatty liver of pregnancy

Answer 416

• Fetal homozygous mutation for long chain 3 hydroxyl CoA dehydrogenase
• Multiple pregnancies
• Male fetuses

Question 417

Name some signs and symptoms of acute fatty liver of pregnancy

Answer 417

• N+V
• Headache
• Anorexia
• Abdo pain
• Can rapidly progress to liver failure: HE, jaundice, hypoglycaemia and coagulopathy

Question 418

What criteria can be used to diagnose acute fatty liver of pregnancy

Answer 418

• Swansea criteria

Question 419

What are the best predictors for the need for liver transplantation or risk of maternal death in acute fatty liver of pregnancy

Answer 419

• Elevated lactate levels+hepatic encephalopathy

Question 420

What are the 3 stages of postpartum thyroiditis?

Answer 420

1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thryoid function(high recurrence rate in future pregnancies)

Question 421

What antibodies are found in postpartum thyroidits?

Answer 421

• Thyroid peroxidase antibodies in 90%

Question 422

Name some risk factors for VTE that might suggest the need for postnatal thromboprophylaxis

Answer 422

>=4:

• Previous VTE
• Thrombophilia
• Medical comorbidities(cancer, heart failure, systemic inflammatory conditions)
• Age >35yrs
• Parity >3
• BMI>30
• Smoking
• Multiple pregnancy
• Pre-eclampsia
• C-section
• Prolonged labour
• Obstructed delivery
• Preterm birth
• Stillbirth
• Postpartum haemorrhage >1000mL
• Other surgical prcedure carried out
• Immobility
• Systemic infection

Question 423

Name some causes of obstructed labour

Answer 423

• Head: large fetal head/cephalopelvic disproportion, hydrocephalus
• Presentation: brow, face, shoulder, persistent malposition
• Twin pregnancy: locked/conjoined twins
• Bony pelvis: contracted(malposition), deformed(trauma, polio)
• Soft tissue: tumour in pelvis, viral infection from uterus/abdomen, scars(FGM)

Question 424

Name some complications from an obstructed labour

Answer 424

• Fistula-mc
• PPH
• Sepsis
• Paralytic ileus
• noenatal sepsis
• Asphyxia of the baby
• Facila injury of the baby

Question 425

What is intrauterine growth restriction?

Answer 425

• Fetus is unable to reach its genetically determined potential size

Question 426

Name some maternal causes of intrauterine growth restriction

Answer 426

• Maternal BMI and nutritional status
• Co-morbidities: diabetes, anaemia, htn, infeciton, sickle cell, CVR/renal disease, coelia
• Cigarette smoking, alchol and substance abuse
• Structural uterine malformations

Question 427

Name dome fetal causes of intrauterine growth restriction

Answer 427

• Chromosomal defects
• Multiple pregnancy
• Vertically transmitted infection(CMV, rubella, toxoplasmosis)

Question 428

Name some placental causes of intrauterine growth restriction

Answer 428

• Utero-placental insufficiency
• Pre-eclampsia

Question 429

Name some differentials for intrauterine growth restriction

Answer 429

• Normal physiological variation
• Constitutional smallness-> small for gestational age but healthy
• Chromosomal abnormalities

Question 430

What investigations might be done for intrauterine growth restriction?

Answer 430

• USS: fetal biometry, amniotic fluid volume, placental appearance
• Doppler studies: blood flow in umbilical artery, middle cerebral and ductus venosus
• Biophysical profile to assess fetal wellbeing

Question 431

What are the risks to the baby if exposed to VZV in pregnancy?

Answer 431

• Fetal varicella syndrome
• Shingles in infancy
• Severe neonatal varicella

Question 432

Name some risk factors for placental insufficiency

Answer 432

• Maternal hypertensive disorders
• Smoking, alcohol consumption and drug use
• Primiparity
• Advanced maternal age
• Use of antiepileptics/antineoplastics

Question 433

What factor would make a pregnant woman immediately high risk for VTE?

Answer 433

• Prevous VTE history

Question 434

What are monozygotic twins?

Answer 434

• Identical-fertilisation of one egg and one sperm

Question 435

What are dizygotic twins? Describe the features

Answer 435

• Non-identical
• Fertilisation of 2 different eggs with 2 different sperms
• All will be dichorionic and diamnotic(2 outer separate sacs and inner sacs) and separate placentas

Question 436

Name some complications associated with monoamniotic monozygotic twins

Answer 436

• Increased spontaenous miscarriage
• Increased malformations, IUGR, prematurity
• Twin to twin transfusion syndrome

Question 437

Name some predisposing factors for dizygotic twins

Answer 437

• Previous twins
• Fhx
• Increasing maternal age
• Multigravida
• Induced ovulation and IVF
• Race(Afro-Caribbean)

Question 438

Name some antenatal complications of monozygotic twins

Answer 438

• Polyhydramnnios
• Pregnancy induced hypertension
• Anaemia
• Antepartum haemorrhage

Question 439

Name some fetal omplications of monozygotic twins

Answer 439

• Perinatal mortality (twins x5, triplets x 10)
• Prematurity
• Light for date babies
• Malformation(x3)

Question 440

Name some labour complications of monozygotic twins

Answer 440

• Increased PPH risk(x2)
• Malpresentation
• Cord prolapse, entanglement

Question 441

Name some differentials for twin-to-twin transfusion syndrome

Answer 441

• Anaemia
• Cardiac failure
• Hydrops fetalis

Question 442

What is asymptomatic bacteriuria

Answer 442

• Positive urine culture without UTI sx

Question 443

What is a puerperal infection?

Answer 443

• Occurs when bacteria infect the uterus and surrounding areas after birth

Question 444

What are the types of puerperal infections?

Answer 444

• Endometritis-uterine lining
• Myometritis: uterine muscle
• Parametritis(aka pelvic cellulitis): supportive tissue around uterus

Question 445

Name some complications of puerperal infection

Answer 445

• Sepsis-> organ failure and shock
• Increased risk of infertility/ectopic pregnancy

Question 446

What is constitutional delay?

Answer 446

• Delay in puberty and growth with no medical cause-do reach normal height
• Check fhx for delay in puberty

Question 447

Name some causes of primary amenorrhoea

Answer 447

• Primary hypergonadotropism: Turners
• Primary hypogonadotropism: Kallmann's
  
• Androgen insensitivity syndrome
• Imperforated hymen

Question 448

What investigations might be done to investigate primary amenorrrhoea

Answer 448

• Urine BHcg
• HbA1c
• Blood hormones: oestrogen, progesterone, testosterone, FSH ad LH
• Prolactin, thyroid function, IGF1, estradiol

Question 449

Name some causes of secondary amenorrhoea

Answer 449

• Sheehan's
• Asherman's
• Breastfeeding
• Contraceptives
• Stress/exercise induced
• PCOS
• Ovvarian failure

Question 450

What is Ashermann's syndrome?

Answer 450

• Intrauterine adhesions formed typically as a result of surgery/infeciton and trauma to uterus

Question 451

What investigations might be done for secondary amenorrhoea?

Answer 451

• Pregnancy test
• Bloods including hormones
• USS/MRI
• Endometrial biospy

Question 452

Name some causes of menorrhagia

Answer 452

• Idiopathic
• Fibroids
• Adenomyosis
• Polyps
• Endometriosis
• IUD coontraception
• Bleedig disorders

Question 453

What is infertility?

Answer 453

• Diminished ability of a coupe to conceive a child
• Can be from a definable cause: ovulatory, tubal or sperm problems or
• Unexplained failure to conceive over a two year period despite regule(3-4 times/week) unprotected sexual intercourse

Question 454

Name some factors affecting natural fertility

Answer 454

• Increasing age
• Obesity
• Smoking
• Tight fitting underwear
• Excessive alchohol consumption
• Anabolic steroid use
• Illicit drug use

Question 455

Name some genetic causes of infertility

Answer 455

• Turner's(XO)
• Kleinfelter's(XXY)

Question 456

Name some cervical abnormalities that can cause infertility

Answer 456

Cervical damage after biopsy/LLETZ procedure

Question 457

Name some testicular disorders that can result in infertility

Answer 457

• Cryptochordism
• Varcicele
• Testicular cancer
• Congenital testicular defects

Question 458

Name some ejaculatory disorders that can cause infertility

Answer 458

• Obstruction of ejaculatory system
• Retrograde ejaculation

Question 459

What does anti-mullerian hormone show?

Answer 459

• Measure of ovarian reserve

Question 460

In what condition might you find a 'woody' uterus?

Answer 460

• Placental abruption