WOMENS HEALTH - SEXUAL HEALTH, BREAST AND EXTRA CONDITIONS

Question 1

CHLAMYDIA
What findings may there be on clinical examination in chlamydia?

Answer 1

• Pelvic/abdo tenderness
• Cervical excitation
• Cervicitis
• White/purulent discharge

Question 2

CHLAMYDIA
What are some generic complications of chlamydia?

Answer 2

• Reactive arthritis,
• epididymitis,
• PID,
• endometriosis,
• increased incidence of ectopic pregnancy,
• most common preventable cause of infertility

Question 3

CHLAMYDIA
How would you manage chlamydia?

Answer 3

• Test for other STIs, contraceptive advice, ?safeguarding if child.
• Doxycycline 100mg BD for 7d (C/I pregnancy or breastfeeding).
• 1g azithromycin stat dose in pregnancy (erythromycin or amoxicillin safe too)
• Referral to GUM for partner notification + contact tracing.

Question 4

GONORRHOEA
What are the local complications of gonorrhoea?

Answer 4

• Urethral strictures
• Epididymo-orchitis + salpingitis (can lead to infertility)

Question 5

GONORRHOEA
What are the systemic complications of gonorrhoea?

Answer 5

• PID
• Gonococcal arthritis (most common cause of septic arthritis in young adults)
• Disseminated gonococcal infection as triad (tenosynovitis, migratory polyarthritis, dermatitis lesions can be maculopapular or vesicular)

Question 6

BACTERIAL VAGINOSIS
What are the risk factors of bacterial vaginosis?

Answer 6

• Multiple sexual partners
• Excessive vaginal cleaning
• Recent Abx
• Smoking
• IUD

Question 7

BACTERIAL VAGINOSIS
What diagnostic criteria is used in BV?

Answer 7

Amsel’s (3/4)
- Thin, white discharge (can present asymptomatically)
- Vaginal pH using swab + pH paper >4.5
- Clue cells on cervical swab MC&S (endocervical or self-taken vaginal)
- Positive whiff test (add potassium hydroxide to get very strong fishy odour)

Question 8

TRICHOMONAS VAGINALIS
What causes TV?
What is the structure of this organism?

Answer 8

• Protozoan parasite, single-celled organism with flagella – trichomonas vaginalis
• 4 flagella at front, 1 on back making it highly motile, attach to tissues + cause damage

Question 9

TRICHOMONAS VAGINALIS
What is the clinical presentation of TV?

Answer 9

• PV discharge classically offensive, frothy + yellow/green.
• Vulvovaginitis, itching, dysuria + dyspareunia.
• May cause urethritis + balanitis in men

Question 10

TRICHOMONAS VAGINALIS
What might clinical examination of TV show?

Answer 10

• Speculum = strawberry cervix (colpitis macularis) due to cervicitis + tiny haemorrhages on surface of cervix due to infection

Question 11

TRICHOMONAS VAGINALIS
What investigations would you do for TV?

Answer 11

• Vaginal pH >4.5
• Charcoal swab for MC&S (HVS, urethral swab or first-catch urine).
• Microscopy shows motile trophozoites + wet microscopy shows polymorphonuclear leukocytes

Question 12

SYPHILIS
What is the clinical presentation of secondary syphilis?

Answer 12

• Systemic (low grade fever, lymphadenopathy).
• Maculopapular rash (trunk, soles + palms).
• Condylomata lata (grey wart-like lesions around genitals + anus).
• Alopecia
• Buccal ‘snail track ulcers’

Question 13

SYPHILIS
What is the clinical presentation of tertiary syphilis?

Answer 13

• Gummas (granulomatous lesions that can affect skin, organs + bones)
• Aortic aneurysms
• Neurosyphilis – tabes dorsalis (locomotor ataxia), paralysis, dementia,
• Argyll-Robertson (prositutes) pupil - accomodates but does not react

Question 14

SYPHILIS
What is an Argyll-Robertson pupil?

Answer 14

“Accommodates but does not react”
- Constricted pupil that accommodates when focusing on near object but does not react to light, often irregularly (small) shaped

Question 15

SYPHILIS
What investigations would you do for syphilis?

Answer 15

• Treponemal tests (enzyme immunoassay or haemagglutination assay)
• Samples from site of infection tested with dark field microscopy or PCR

Question 16

SYPHILIS
How would you manage syphilis?

Answer 16

• Specialist GUM (full STI screening, contact tracing, contraceptive information).
• Single dose IM benzathine benzylpenicillin or PO doxycycline if allergic

Question 17

SYPHILIS
What is a potential adverse effect of treating syphilis?

Answer 17

• Jarisch-Herxheimer reaction within a few hours of treatment
• Fever, rash + tachycardia thought to be due to release of endotoxins following bacterial death

Question 18

GENITAL HERPES
What other specific symptoms may be seen in genital herpes?

Answer 18

• Aphthous ulcers (small painful oral sores)
• Herpes keratitis (inflammation of the cornea = blue)
• Herpetic whitlow (painful skin lesion on finger/thumb)

Question 19

GENITAL HERPES
What is the management or primary genital herpes contracted before 28w gestation?

Answer 19

• Aciclovir during infection
• Prophylactic aciclovir from 36w gestation onwards to reduce risk of genital lesions during labour + delivery
• Asymptomatic at delivery can have vaginal if >6w from initial infection, if Sx then c-section

Question 20

GENITAL WARTS
What are the investigations for genital warts?

Answer 20

• Clinical diagnosis (may use magnifying glass or colposcope)
• Application of acetic acid/vinegar produces acetowhite changes of surface
• Biopsy if atypical

Question 21

GENITAL WARTS
How is genital warts managed?

Answer 21

• Prophylaxis with HPV vaccine for 12–13y (may be given to MSM, trans men/women + sex workers)
• Topical podophyllotoxin cream/lotion or cryotherapy.
• GUM contact tracing, contraceptive advice

Question 22

LICHEN SCLEROSUS
What phenomenon can occur in lichen sclerosus?

Answer 22

• Koebner phenomenon where signs + Sx worse with friction to skin
• Can be worse with tight, rubbing underwear, scratching + incontinence

Question 23

HIV
What is HIV?
What is the pathophysiology of HIV?

Answer 23

• RNA retrovirus that encodes reverse transcriptase
• Binds to GP120 envelope glycoprotein to CD4 receptors which migrate to lymphoid tissue where virus replicates + produces billions of new virions
• Reverse transcriptase makes single strand RNA > double stranded DNA + viral DNA is integrated to host cell’s DNA with enzyme integrase + core viral proteins synthesised + cleaved by viral protease
• These then released + in turn infect new CD4 cells

Question 24

HIV
What tests can be used to investigation HIV?

Answer 24

• Serum/salivary HIV enzyme-linked immunosorbent assay (ELISA)
• Rapid point of care screening blood test for HIV antibodies
• PCR testing

Question 25

HIV What are the considerations with HIV and pregnancy?

Answer 25

- Normal vaginal delivery if viral load <50 copies/ml - Consider c-section if >50, but mandatory in >400 - IV zidovudine 4h before c-section - Neonatal PO zidovudine if maternal viral load <50 if not triple ART both for 4–6w - No breastfeeding

Question 26

HIV What are the 4 main groups of HIV treatment?

Answer 26

- Nucleoside reverse transcriptase inhibitors (NRTIs) - Protease inhibitors (PIs) - Integrase inhibitors (IIs) - Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Question 27

GONORRHOEA What is the clinical presentation of gonorrhoea discharge?

Answer 27

Odourless purulent, can be green/yellow

Question 28

TRICHOMONAS VAGINALIS What can it increase the risk of?

Answer 28

Contracting HIV by damaging vaginal mucosa BV, cervical cancer, PID pregnancy-related complications.

Question 29

SYPHILIS What is the causative organism?

Answer 29

Treponema pallidum – spirochete (spiral-shaped) bacteria

Question 30

CANDIDIASIS What are some risk factors?

Answer 30

Increased oestrogen (pregnancy, during menstrual years) poorly controlled DM, immunosuppression, broad spectrum Abx

Question 31

CANDIDIASIS What treatment should be used in pregnancy?

Answer 31

Clotrimazole in pregnancy as fluconazole can cause congenital abnormalities

Question 32

BALANITIS what are the causes?

Answer 32

candidiasis dermatitis bacterial anaerobic lichen planus lichen sclerosis

Question 33

BALANITIS what are the acute causes?

Answer 33

candidiasis dermatitis bacterial anaerobic

Question 34

BALANITIS what is the treatment for bacterial infection?

Answer 34

flucloxacillin or clarithromycin if penicillin allergic

Question 35

BALANITIS what is the treatment for anaerobic balanitis?

Answer 35

saline washing oral metronidazole

Question 36

LYMPHOGRANULOMA VENEREUM what is it?

Answer 36

STI caused by serovars L1, L2 or L3 or chlamydia trachomatis

Question 37

LYMPHOGRANULOMA VENEREUM what are the clinical features?

Answer 37

Painless genital ulcer Appears 3-12 days after infection May not be noticeable e.g. if occurs inside the vagina Inguinal lymphadenopathy Proctitis, rectal pain, rectal discharge (in rectal infections) Systemic symptoms such as fever and malaise

Question 38

LYMPHOGRANULOMA VENEREUM what is the management?

Answer 38

Treatment is with antibiotics. Common regimes include: Oral doxycycline 100 mg twice daily for 21 days Oral tetracycline 2 g daily for 21 days Oral erythromycin 500 mg four times daily for 21 days

Question 39

CHANCROID what are the causes?

Answer 39

Haemophilus ducreyi Given its relatively high incidence in topical areas and Greenland, it is important to inquire in the history about recent travel.

Question 40

CHANCROID what are the clinical features?

Answer 40

A painful genital lesion which may bleed on contact Associated symptoms include painful lymphadenopathy

Question 41

CHANCROID what is the management?

Answer 41

The infection is treated using antibiotics (typically Ceftriaxone, Azithromycin or Ciprofloxacin)

Question 42

COCP What are the benefits of the COCP?

Answer 42

- Effective contraception, rapid return of fertility after stopping. - Improvement in PMS, menorrhagia + dysmenorrhoea (acne in some). - Reduced risk of endometrial, ovarian, colon cancer + benign ovarian cysts.

Question 43

COCP What are some side effects + risks with the COCP?

Answer 43

- Unscheduled bleeding common in first 3m. - Breast pain + tenderness. - Mood changes + depression. - Headaches, HTN, VTE. - Small raise in risk of breast + cervical cancer (risk normalises after 10y taking pill). - Small raise in risk of MI + stroke.

Question 44

COCP What are the UKMEC3 criteria for the COCP?

Answer 44

- >35 smoking <15/day. - BMI >35kg/m^2. - Controlled HTN. - VTE FHx in 1st degree relatives. - Immobility. - Known carrier of BRCA1/2.

Question 45

POP What is the main complaint/side effect of the POP? What are some other side effects of the POP?

Answer 45

- Unscheduled bleeding common in first 3m (if persists exclude other causes like STIs, pregnancy, cancer). - Changes to bleeding schedule one of primary adverse effects (40% regular bleeding, 40% irregular, prolonged or troublesome + 20% amenorrhoeic). - Breast tenderness, headaches + acne.

Question 46

POP What are some risks of the POP?

Answer 46

- Increased risk of ovarian cysts, small risk of ectopic pregnancy with traditional POP due to reduced ciliary action, minimal increased risk of breast cancer (returns to normal 10y after stopping).

Question 47

PROGESTERONE INJECTION What is the mechanism of action of the progesterone injection?

Answer 47

- Inhibits ovulation by inhibiting FSH secretion by the pituitary gland + prevents development of follicles in the ovary. - Thickens cervical mucus + alters endometrium to make it less favourable for implantation.

Question 48

PROGESTERONE INJECTION What are 3 unique side effects to the progesterone injection?

Answer 48

- Weight gain - Reduced BMD (oestrogen maintains BMD + mostly produced by follicles in ovaries) – Makes depot unsuitable for those >45 - Takes 12m for fertility to return after stopping

Question 49

PROGESTERONE INJECTION What are some general side effects of the progesterone injection?

Answer 49

- Acne. - Reduced libido. - Mood issues (depression). - Headaches. - Alopecia. - Skin reactions at injection sites. - Small rise in breast/cervical cancer risk.

Question 50

PROGESTERONE IMPLANT What is the mechanism of action for the progesterone implant?

Answer 50

- Inhibits ovulation. - Thickens cervical mucus. - Alters endometrium to make it less accepting to implantation.

Question 51

PROGESTERONE IMPLANT What are the side effects of the progesterone implant?

Answer 51

- Problematic bleeding (20% amenorrhoeic, 25% frequent/prolonged bleeding, 33% infrequent, rest normal, can use COCP for 3m if problematic bleeding + no C/Is). - Can worsen acne, no STI protection.

Question 52

PROGESTERONE IMPLANT What are the risks with the progesterone implant?

Answer 52

- Can be bent/fractured or impalpable/deeply implanted needing extra contraception until located (USS/XR), may need specialist removal. - Very rarely can enter vessels + migrate through body to lungs.

Question 53

COILS What are the contraindications to the coils?

Answer 53

- PID or infection, - immunosuppression, - pregnancy, - unexplained bleeding, - pelvic cancer, - uterine cavity distortion (fibroids).

Question 54

COILS What are the drawbacks of the IUD?

Answer 54

- Procedure with risks for insertion/removal. - Can cause HMB/IMB which often settles. - Some women have pelvic pain. - No STI protection. - Increased risk of ectopic pregnancies. - Occasionally falls out.

Question 55

COILS What is the mechanism of action for the IUS?

Answer 55

- Progesterone component thickens cervical mucus. - Alters endometrium making less hospitable + inhibits ovulation in small # of women.

Question 56

COILS What are the drawbacks of the IUS?

Answer 56

- Procedure with risks for insertion/removal. - Can cause spotting or irregular bleeding. - Some women experience pelvic pain. - No STI protection. - Increased risk of ectopic pregnancies. - Occasionally falls out. - Increased incidence of ovarian cysts. - Systemic absorption can lead to progesterone Sx (acne, headaches, breast tenderness).

Question 57

EMERGENCY CONTRACEPTION For the copper IUD, answer the following... i) effectiveness? ii) time frame? iii) mechanism? iv) extra notes?

Answer 57

i) 99% regardless of time in cycle ii) <120h of UPSI or 120h after earliest estimated date of ovulation iii) Toxic to sperm + ovum so inhibits fertilisation + implantation. iv) Keep in until at least next period

Question 58

EMERGENCY CONTRACEPTION For Ulipristal acetate, answer the following... i) dose? ii) effectiveness? iii) time frame? iv) mechanism? v) extra notes? vi) side effects?

Answer 58

i) Single 30mg dose ii) Second most effective but decreases with time iii) <120h iv) Selective progesterone receptor modulator that inhibits ovulation v) Vomiting within 3h then repeat dose vi) Spotting + changes to next menstrual period, abdo/pelvic/back pain, mood changes, headaches, dizziness, breast tenderness

Question 59

EMERGENCY CONTRACEPTION For Ulipristal acetate, what are the pros and cons?

Answer 59

Pros - More effective than levonorgestrel - Can be used >1 in one cycle Cons - Avoid breastfeeding for 1w (express but discard) - Avoid in severe asthma - Wait 5d before starting COCP or POP with 7 or 2d extra contraception needed

Question 60

EMERGENCY CONTRACEPTION For levonorgestrel, answer the following... i) dose? ii) effectiveness? iii) time frame? iv) mechanism? v) side effects?

Answer 60

i) Single 1.5mg dose (3mg if BMI >26kg/m^2) ii) Least effective of group 84% iii) <72h iv) Stops ovulation + inhibits implantation v) Spotting + changes to next menstrual period, diarrhoea, breast tenderness, dizziness, depressed mood

Question 61

EMERGENCY CONTRACEPTION For Levonorgestrel, what are the pros and cons?

Answer 61

Pros - Safe during breastfeeding (Avoid for 8h to avoid infant exposure though). - COCP/POP can start instantly but with extra contraception for 7/2d - Use more than once in a menstrual cycle Cons - Less effective

Question 62

FEMALE INFERTILITY What are some risk factors of infertility?

Answer 62

- Extremes of weight - Increasing age - Smoking - Alcohol/drug use

Question 63

ASSISTED CONCEPTION What is the clinical presentation of ovarian hyperstimulation syndrome?

Answer 63

- Mild = abdo pain + vomiting - Mod = N+V + ascites on USS - Severe = ascites, oliguria - Critical = anuria, VTE, ARDS

Question 64

ASSISTED CONCEPTION What are the risk factors for ovarian hyperstimulation syndrome?

Answer 64

- Younger age. - Lower BMI. - PCOS. - Higher antral follicle count.

Question 65

ASSISTED CONCEPTION What investigations would you do in ovarian hyperstimulation syndrome and what would they show? How could you identify someone at risk?

Answer 65

- Activation of RAAS > high renin - Haematocrit raised as less fluid in intravascular space - USS + serum oestrogen (high = risk) – monitor these to identify those at risk.

Question 66

ASSISTED CONCEPTION What is ovarian hyperstimulation syndrome? What is it associated with?

Answer 66

- Increased vascular endothelial growth factor (VEGF) from granulosa cells increases vascular permeability so fluid leaks from intravascular>extravascular space (oedema, ascites + hypovolaemia). - Gonadotrophins to mature follicles.

Question 67

BREAST CANCER What are the 2 main genes involved in breast cancer and how do they act?

Answer 67

- BRCA1 = mutation of C17, 60-80% lifetime risk, stronger incidence - BRCA2 = mutation of C13, 45% lifetime risk - Tumour suppression genes that act as inhibitors of cellular growth

Question 68

BREAST CANCER What are some other genetic mutations associated with breast cancer?

Answer 68

- TP53 (Li Fraumeni) - Peutz-Jeghers

Question 69

BREAST CANCER What tumour marker can be used to monitor response to breast cancer treatment and disease recurrence?

Answer 69

- CA 15-3

Question 70

BREAST CANCER Reconstruction surgery can either be primary (immediately) or delayed. What are the pros and cons of primary reconstruction?

Answer 70

- Increased skin preservation options, reduced psychological trauma - May delay chemo/radiotherapy if complications, radiotherapy may ruin results (fibrosis)

Question 71

BREAST CANCER Reconstruction surgery can either be primary (immediately) or delayed. What are the pros and cons of delayed reconstruction?

Answer 71

- Minimal risks of delay in adjuvant therapies, healthy tissue used to recreate breast - Limited skin preservation options, psychological impact (no breast)

Question 72

BREAST INFECTION What is the management of non-lactational mastitis?

Answer 72

- Same as lactational mastitis (flucloxacillin or erythromycin) but + metronidazole

Question 73

BREAST INFECTION What is the most common cause of mastitis? What is there a caution with?

Answer 73

- S. Aureus then anaerobes (esp. non-lactational) - Repeated incision in non-lactational abscess as can develop mammary fistula which is difficult to treat

Question 74

GYNAECOMASTIA What are some pathological causes of gynaecomastia?

Answer 74

- Drugs (spironolactone, oestrogen, anabolic steroids) - Marijuana - Liver failure - Testicular failure or tumour (Can produce beta-hCG)

Question 75

DUCT ECTASIA What is the management?

Answer 75

Expectant management If symptoms persist then operation to remove affected ducts may be offered

Question 76

BREAST CANCER what is tamoxifen?

Answer 76

tamoxifen inhibits the oestrogen receptor on breast cancer cells It increases survival by 15-25% in woman with ER+ cancer give for 10 years in higher risk women

Question 77

BREAST CANCER what are the complications of tamoxifen?

Answer 77

hot flushes nausea vaginal bleeding rarely thrombosis and endometrial cancer

Question 78

BREAST CANCER what are aromatase inhibitors?

Answer 78

letrozole Inhibit aromatase enzyme responsible for the conversion of androgens to oestogen in post-menopausal woman slightly better anticancer efficacy than tamoxifen

Question 79

BREAST CANCER what are the side effects of aromatase inhibitors?

Answer 79

hot flushes reduced bone density joint pains

Question 80

PAGET'S DISEASE OF THE NIPPLE what are the risk factors?

Answer 80

- old age - FHx of breast cancer - Previous breast cancer - overweight - excess alcohol - smoking - risk factors for breast cancer

Question 81

1* AMENORRHOEA What is primary amenorrhoea?

Answer 81

Absence of menstruation by – - 14y if no secondary sexual characteristics (more indicative of a chromosomal abnormality) - 16y with secondary sexual characteristics (breast buds)

Question 82

1* AMENORRHOEA What is the difference between hypogonadotrophic hypogonadism and hypergonadotrophic hypogonadism?

Answer 82

- Deficiency in gonadotrophins (LH + FSH) stimulating ovaries due to abnormal hypothalamus or pituitary means they do not respond by producing sex hormones (oestrogen) - Gonads fails to respond to stimulation of gonadotrophins meaning no negative feedback + increasing amounts of FSH/LH

Question 83

1* AMENORRHOEA What are some causes of hypogonadotrophic hypogonadism?

Answer 83

- Constitutional delay (temporary delay, no pathology, ?FHx) - Hypopituitarism - Kallmann's (failure to start puberty + anosmia) - Excessive exercise, dieting or stress causes hypothalamic failure - Endo = Cushing's, prolactinoma, thyroid - Damage (cancer, surgery)

Question 84

1* AMENORRHOEA What are some causes of hypergonadotrophic hypogonadism?

Answer 84

- Turner's syndrome XO - Congenital absence of ovaries - Previous damage to gonads (torsion, cancer, infections like mumps)

Question 85

1* AMENORRHOEA What are some other causes of primary amenorrhoea and how may they present?

Answer 85

- Congenital adrenal hyperplasia (tall, deep voice, facial hair) - Androgen insensitivity syndrome (46XY but female phenotype) - Congenital malformations of genital tract (if ovaries unaffected = secondary sexual characteristics but no menses) - Gonadal dysgenesis (no ovaries or uterus form)

Question 86

1* AMENORRHOEA What are some first line investigations for primary amenorrhoea?

Answer 86

- Examination = signs of puberty, PV exam, BMI, visual fields - FBC + ferritin (anaemia), U+E for CKD, anti-TTG for coeliac, urinary beta-hCG crucial

Question 87

1* AMENORRHOEA What hormonal blood tests would you do for primary amenorrhoea?

Answer 87

- FSH + LH (low or high) - TFTs, prolactin (if indicated) - Free androgens raised in PCOS, AIS + CAH - Insulin-like growth factor I used for screening for GH deficiency

Question 88

2* AMENORRHOEA What is secondary amenorrhoea? What is oligomenorrhoea?

Answer 88

- Previously normal menstruation ceases for >3m in a non-pregnancy woman - Where menses are >35d apart (up to 6m), can be ovarian normality but exclude PCOS

Question 89

2* AMENORRHOEA What are the causes of secondary amenorrhoea?

Answer 89

- Pregnancy (most common), breastfeeding, menopause (physiological) - Iatrogenic (contraception) - Hypothalamic/pituitary - Ovarian causes (PCOS, POI) - Thyroid, uterine pathology (Asherman's) - Excessive exercise, stress or eating disorders

Question 90

2* AMENORRHOEA What are the hypothalamic or pituitary causes of secondary amenorrhoea?

Answer 90

- Sheehan's syndrome = pituitary necrosis following PPH - Pituitary tumour like prolactinoma leading to hyperprolactinaemia which prevents GnRH - Trauma, radiotherapy or surgery

Question 91

2* AMENORRHOEA How does excessive stress or eating disorders cause secondary amenorrhoea?

Answer 91

- Hypothalamus reduces GnRH in times of stress > hypogonadotrophic hypogonadism to prevent pregnancy in adverse situations

Question 92

2* AMENORRHOEA What hormonal tests would you do in secondary amenorrhoea?

Answer 92

- Urine/blood beta-hCG - High FSH (POI) - Low FSH/LH (hypgonadotrophic hypogonadism) - High LH or LH:FSH ratio suggests PCOS - Free androgen raised in PCOS - Mid-luteal (day 21) progesterone to check ovulation happened - Prolactin + TFTs if indicated

Question 93

2* AMENORRHOEA What is the management of... i) hyperprolactinaemia? ii) hypothalamic failure?

Answer 93

i) Bromocriptine or cabergoline (dopamine agonists) ii) GnRH replacement

Question 94

POI What are some causes of POI?

Answer 94

- Majority idiopathic - Iatrogenic (chemo/radio, oophorectomy) - Autoimmune (coeliac, T1DM) - Genetic (FHx, Turner's) - Infections (mumps, TB, CMV)

Question 95

POI What are the complications of POI?

Answer 95

- Higher risk of conditions due to lack of oestrogen > CVD, stroke, osteoporosis, dementia + cognitive impairment + Parkinsonism

Question 96

FGM What is the WHO classification for the types of FGM?

Answer 96

- 1 = partial or total clitoridectomy - 2 = excision - 3 = infibulation - 4 = all other non-medical harmful procedures incl. pricking, piercing, incising

Question 97

MACROSOMIA What are the causes of macrosomia?

Answer 97

- Constitutionally large or familial (parental height + weight) - Maternal diabetes, previous macrosomia, obesity or rapid weight gain - Overdue - Male baby

Question 98

INFECTIONS + PREGNANCY What is Parvovirus? What are the adverse effects? What is the management?

Answer 98

- Parvovirus B19 can give viral Sx then 'slapped cheeks' (erythema infectiosum) - Worse <20w = suppresses foetal erythropoiesis causing anaemia + foetal hydrops, death, pre-eclampsia-like (mirror) syndrome in women - Maternal IgM + IgG, supportive, refer to foetal medicine to monitor

Question 99

INFECTIONS + PREGNANCY What is the management of HIV in pregnancy?

Answer 99

- Normal vaginal delivery if viral load <50 copies/ml if. not c-section (IV zidovudine 4h before) - Neonatal zidovudine PO if maternal viral load <50 if not triple ART, both for 4–6w - Breastfeeding C/I

Question 100

THYROID + PREGNANCY What is the management of hyperthyroidism in pregnancy?

Answer 100

- Propylthiouracil is choice in 1st trimester (associated with maternal hepatic injury) - Carbimazole C/I until 2nd trimester as causes foetal abnormalities - If mother has stimulating antibodies, monitor foetal growth with USS

Question 101

THYROID + PREGNANCY Is hypothyroidism in pregnancy common? What is the prognosis of untreated hypothyroidism in pregnancy? What is the management?

Answer 101

- Yes - Early foetal loss + congenital hypothyroidism leading to impaired neurodevelopment - Aim for adequate replacement with levothyroxine (safe), especially in 1st trimester

Question 102

THYROID + PREGNANCY What is post-partum thyroiditis?

Answer 102

3 stages – - Thyrotoxicosis (3m) - Hypothyroidism (3–6m) - Normal thyroid function Sx control of thyrotoxicosis, treat hypothyroidism with levothyroxine Just need TFTs to Dx if within 12m of giving birth + Sx

Question 103

PREMATURITY What is the prophylaxis for prematurity and how do they work?

Answer 103

- Progesterone gel or pessary decreases activity of myometrium + prevents cervix remodelling in preparation for delivery - Cervical cerclage = ≥1 sutures to strengthen + keep cervix closed - 'Rescue' cerclage to halt delivery

Question 104

PREMATURITY What are the indications for... i) progesterone prophylaxis? ii) cervical cerclage? iii) 'rescue' cerclage?

Answer 104

i) Cervical length <25mm on TVS at 16–24w ii) Cervical length <25mm on TVS at 16–24w, previous premature birth or cervical trauma (colposcopy, cone biopsy) iii) Cervical dilatation without ROM at 16–27+6 with no infection, bleeding or contractions

Question 105

PREMATURITY What is the acute management of prematurity?

Answer 105

- Senior obs + neonate input - Foetal monitoring (CTG) - Tocolytics - Corticosteroids - IV magnesium sulfate - Consider delayed cord clamping or cord milking (increases circulating blood volume + Hb in baby)

Question 106

AMNIOTIC EMBOLISM What are some risk factors for amniotic fluid embolism? Presentation?

Answer 106

- Increasing maternal age + ARM - Often around time of labour + delivery but can be postpartum - Sx = SOB, sweating, anxiety, seizures, haemorrhage - Signs = hypoxia, tachycardia + hypotension, may lead to cardiac arrest

Question 107

MATERNAL SEPSIS What are the investigations for maternal sepsis?

Answer 107

- Monitor Maternal Early Obstetric Warning Score (MEOWS) - Warning signs of sepsis (3Ts white with sugar)

Question 108

MATERNAL SEPSIS What are the warning signs of sepsis?

Answer 108

3Ts white with sugar – - Temp <36 or >38 - Tachycardia >90bpm - Tachypnoea >20bpm - WCC >12 or <4 - Hyperglycaemia >7.7mmol/L in absence of diabetes

Question 109

MATERNAL SEPSIS What are the SEPSIS 6 components?

Answer 109

BUFALO (3 in, 3 out) – - Blood cultures (out) - Urine output by catheter (hourly, out) - Fluids resus (IV, in) - Abx (IV broad-spec, in) - Lactate (ABG, out) - Oxygen (high flow SpO2 >94%, in)

Question 110

PUERPERIUM What are some drug contraindications in breastfeeding?

Answer 110

- Abx (ciprofloxacin, tetracyclines, chloramphenicol) - Psych drugs (lithium, BDZs) - Amiodarone, aspirin - Carbimazole, methotrexate - Sulfonylureas - Cytotoxic drugs

Question 111

PUERPERIUM What are the pros + cons of breast feeding?

Answer 111

- Readily available good nutrition, cheaper, contraceptive effect, decrease childhood infections (gastroenteritis), decrease in necrotising enterocolitis - Feed more often, uncomfortable + pain (mastitis)

Question 112

SHEEHAN'S SYNDROME What is Sheehan's syndrome?

Answer 112

- Drop in circulating blood volume leads to avascular necrosis of the pituitary gland - Ischaemia + infarction of anterior pituitary cells as supplied by hypothalamo-hypophysial portal system which is susceptible to rapid drops in BP after PPH

Question 113

SHEEHAN'S SYNDROME How does Sheehan's syndrome present? What is the management?

Answer 113

- Reduced lactation (lack of prolactin) - Amenorrhoea (lack of LH + FSH > HRT) - Hypothyroidism (lack of TSH > levothyroxine) - Adrenal insufficiency (lack of ACTH > hydrocortisone)

Question 114

NEWBORN SCREENING What is the process of the newborn blood spot conditions screen (Guthrie/heel-prick)?

Answer 114

- Screening on day 5–9 - Residual blood spots stored for 5 years (part of consent process) for research

Question 115

NEWBORN SCREENING What conditions does the newborn blood spot screen for?

Answer 115

3 genetic – - Sickle cell disease - Cystic fibrosis - Congenital hypothyroidism 6 inherited metabolic – - Phenylketonuria - Medium-chain acyl-CoA dehydrogenase deficiency - Maple syrup urine disease - Isovaleric acidaemia - Glutaric aciduria type 1 - Homocystinuria

Question 116

NEWBORN SCREENING What specifically is tested for in... i) cystic fibrosis? ii) congenital hypothyroidism? iii) phenylketonuria?

Answer 116

i) Immunoreactive trypsinogen ii) TSH iii) Phenylalanine

Question 117

PREGNANCY PHYSIOLOGY What hormones increase in regards to the anterior pituitary gland?

Answer 117

- ACTH = rise in steroid hormones (cortisol, aldosterone) = improves autoimmune conditions (RA) but susceptible to DM + infections - Prolactin = suppresses FSH + LH - Melanocyte stimulating hormone = increased skin pigmentation (linea nigra + melasma = brown pigmentation)

Question 118

PREGNANCY PHYSIOLOGY What other hormones rise in pregnancy?

Answer 118

- T3/T4 - HCG = doubles every 48h until plateau at 8–12w then gradual fall - Progesterone - Oestrogen

Question 119

PREGNANCY PHYSIOLOGY What changes occur to the uterus in pregnancy?

Answer 119

- Increase from 100g–1.1kg - Hyperplasia + hypertrophy of myometrium - Decidual spiral arteries remodelled for wide bore low resistance

Question 120

PREGNANCY PHYSIOLOGY What changes occur to the cervix in pregnancy?

Answer 120

- Increased oestrogen = ?cervical ectropion + increased discharge - Before delivery, prostaglandins break down collagen in cervix = dilate + efface - Chadwick's sign = early pooled deoxygenated blood > blue tinge

Question 121

PREGNANCY PHYSIOLOGY What changes occur to the vagina in pregnancy?

Answer 121

- Oestrogen > hypertrophy of vaginal muscles + increased PV discharge - Makes bacterial + candida infection more common

Question 122

PREGNANCY PHYSIOLOGY In terms of the cardiovascular system in pregnancy, what... i) increases? ii) decreases?

Answer 122

i) Blood volume, plasma volume, CO (as increased SV + HR) ii) Peripheral vascular resistance (can cause flushing + hot sweats) + BP in early-mid pregnancy but returns to normal by term

Question 123

PREGNANCY PHYSIOLOGY What CVS anatomical changes are there?

Answer 123

- Diaphragmatic elevation > heart displaced upwards/left so apex moved laterally - Increased ventricular muscle mass + increased LV/LA size - Altered QRS (LAD), ECG changes (inverted T waves) + flow (ES) murmurs

Question 124

PREGNANCY PHYSIOLOGY In terms of the respiratory system, what are the mechanical changes?

Answer 124

- Increased subcostal angle, pulmonary blood flow + tidal volume - Decreased vital capacity + functional residual capacity - Progesterone causes trachea-bronchial smooth muscle relaxation

Question 125

PREGNANCY PHYSIOLOGY In terms of the respiratory system, what are the biochemical changes?

Answer 125

- Increased oxygen consumption (20%) + RR - Compensated resp alkalosis may occur as increased pO2 + reduced pCO2 (facilitates foetal CO2 excretion), renal HCO3- excretion to prevent this - Increased 2,3 DPG to promote maternal Hb to release oxygen

Question 126

PREGNANCY PHYSIOLOGY In terms of the renal system, what... i) increases? ii) decreases?

Answer 126

i) Blood flow to kidneys (so GFR), aldosterone (Na + water reabsorption + Retention), protein excretion ii) Serum creatinine, urate + albumin

Question 127

PREGNANCY PHYSIOLOGY What can happen in terms of the urinary system? What is a consequence of this? What else contributes?

Answer 127

- Dilatation of ureters + collecting system > physiological hydronephrosis (more R) - Increased risk of UTIs - Decreased ureter tone/peristalsis = urinary stasis

Question 128

PREGNANCY PHYSIOLOGY What 4 forces/pressures govern fluid retention in pregnancy?

Answer 128

- Capillary (hydrostatic) pressure of blood in vessel = draws fluid OUT - Interstitial fluid colloid oncotic pressure of proteins in interstitial fluid = draws fluid OUT - Interstitial fluid pressure of tissues surrounding vessel = draws fluid IN - Plasma colloid oncotic pressure (albumin) = draws fluid IN

Question 129

PREGNANCY PHYSIOLOGY Why does pregnancy cause dilutional anaemia? What is the purpose of this?

Answer 129

- Increased RBC production = higher iron, folate + B12 requirements - Increased ECF + plasma volume MORE than RBC volume leading to lower red cell conc (haematocrit) + lower Hb conc - Facilitates placental perfusion

Question 130

PREGNANCY PHYSIOLOGY In terms of haematology in pregnancy, what... i) increases? ii) decreases?

Answer 130

i) WBCs, ESR, d-dimers, ALP ii) Platelets, albumin

Question 131

PREGNANCY PHYSIOLOGY What are the metabolic changes are there in pregnancy?

Answer 131

- Early = post-prandial glucose plasma peak lower due to fat deposition + glycogen storage - Late = higher for longer + maternal insulin resistance (via hPL) for foetal glucose sparing - Maternal insulin rises during most of pregnancy

Question 132

PREGNANCY PHYSIOLOGY What are the changes to the skin and hair in pregnancy?

Answer 132

- Linea nigra + melasma - Striae gravidarum - General pruritus (?OC) - Spider naevi + palmar erythema - PP hair loss normal, improves within 6m

Question 133

PREGNANCY PHYSIOLOGY What facilitates blastocyst implantation in pregnancy?

Answer 133

- Increased GFs, proteolytic enzymes + inflammatory mediators - Not rejected as change in self/non-self pattern recognition molecules (HLA + MHC proteins)

Question 134

PREGNANCY PHYSIOLOGY In pregnancy, what changes to the humoral and cell-mediated immunity?

Answer 134

- Humoral = unchanged, plenty of circulating Th2 cells to fight infections (antibodies) - Cell-mediated = reduced as progesterone down regulates production of Th1 cells (phagocytes, cytotoxic T lymphocytes)

Question 135

PREGNANCY PHYSIOLOGY What is the impact of dampening Th1 production? What are the implications?

Answer 135

- Shift to increased Th2 production (bias) to protect foetus - Pre-eclampsia, IUGR + miscarriage do not have a Th2 bias

Question 136

REPRODUCTION What are the different stages in follicular genesis and what stage in the cell cycle are they?

Answer 136

- Primordial follicles = diploid, arrested at prophase I - Primary follicle = diploid, undergoing meiosis I - Secondary follicle = haploid, once meiosis I complete - Antral (Graafian) follicle = haploid, frozen in metaphase II

Question 137

REPRODUCTION What happens when follicles reach the secondary follicle stage?

Answer 137

- Granulosa cells express FSH receptors = oestrogen production to grow - Theca cells express LH receptors = steroidogenesis

Question 138

REPRODUCTION What happens at ovulation?

Answer 138

- LH surge = smooth muscle of theca externa contracts - Follicle bursts + secretes enzymes puncturing hole in ovary - Fimbriae of fallopian tubes sweeps oocyte up, surrounded by zona pellucida - Leftover follicle > corpus luteum

Question 139

REPRODUCTION How does fertilisation occur?

Answer 139

- Sperm enters fallopian tube + attempts to penetrate through corona radiata + zona pellucida via acrosome reaction - Fusion of sperm + egg = zygote

Question 140

REPRODUCTION What happens immediately after fertilisation?

Answer 140

- Cell rapidly divides > mass of cells (morula) travels to uterus - Fluid filled cavity (blastocele) expands to form blastocyst (>80 cells) with outer layer (trophoblast) + inner layer (embryoblast)

Question 141

REPRODUCTION When does the blastocyst reach the uterus? What happens?

Answer 141

- 8–10d after ovulation - Trophoblast cells undergo adhesion to stroma of endometrium - Outer layer of trophoblast (syncytiotrophoblast) forms projections into the stroma

Question 142

REPRODUCTION Once the blastocyst has implanted, what happens to the stroma? What signifies blastocyst implantation?

Answer 142

- Cells of stroma convert into decidua to provide nutrients (decidual reaction) - Syncytiotrophoblast produces hCG to maintain corpus luteum

Question 143

REPRODUCTION When does the embryonic disc develop further? What does it develop into?

Answer 143

- 5w - Foetal pole with 3 layers = ectoderm (outer), mesoderm (mid), endoderm (inner)

Question 144

REPRODUCTION What tissues does the... i) ectoderm ii) mesoderm iii) endoderm produce?

Answer 144

i) Skin, hair, nails, teeth, CNS ii) Heart, muscle, bone, connective tissue, kidneys, blood iii) GI tract, lungs, liver, pancreas, thyroid, reproductive

Question 145

REPRODUCTION When do actual organs begin to develop?

Answer 145

- 6w foetal heart forms + starts to beat - 8w all major organs start development

Question 146

REPRODUCTION How does the placenta develop?

Answer 146

- Syncytiotrophoblast forms chorionic villi with foetal blood vessels - Those nearest connecting stalk most vascular, cells proliferate + become placenta at about 10w

Question 147

REPRODUCTION What role does the placenta play in immunity?

Answer 147

- IgG crosses placenta to give foetus immunity - Primary immune deficiency hypogammaglobulinaemia can occur in babies whose mothers did not have high enough IgG during pregnancy

Question 148

REPRODUCTION What are the main hormones produced by the placenta?

Answer 148

- hCG (maintain corpus luteum) - Oestrogen - Progesterone - Human placenta lactogen

Question 149

REPRODUCTION What is the role of oestrogen in pregnancy?

Answer 149

- Softening tissue > more flexible, allows muscles + ligaments of uterus and pelvis to expand + cervix become soft - Enlarges + prepares breasts + nipples for breast feeding - E3 declines with foetal distress, E2 increases endometrial progesterone receptors

Question 150

REPRODUCTION What is the role of progesterone in pregnancy?

Answer 150

- Produced by corpus luteum until 10w - Initially prepares endometrium for implantation by proliferation, vascularisation + decidual reaction - Later, maintains pregnancy by preventing contraction - Relaxation elsewhere > heartburn, constipation, hypotension

Question 151

REPRODUCTION What is the role of human placental lactogen in pregnancy?

Answer 151

- Diabetogenic as raises blood glucose levels to help increase nutrient supply + helps convert mammary glands into milk secreting tissue

Question 152

MENSTRUAL CYCLE what are the roles of FSH and LH?

Answer 152

FSH - enables production of oestrogen LH - enables production of progesterone

Question 153

MENSTRUAL CYCLE what are the stages of the ovarian cycle?

Answer 153

follicular phase luteal phase

Question 154

MENSTRUAL CYCLE what happens during the follicular phase?

Answer 154

- rising levels of FSH stimulates developing follicles to produce oestrogen - oestrogen inhibits FSH leading to one dominant follicle - follicle starts developing LH receptors - egg completes first meiotic division - oestrogen levels cause positive feedback leading to LH surge

Question 155

MENSTRUAL CYCLE what causes the LH surge at the end of the follicular phase?

Answer 155

oestrogen levels cause positive feedback leading to LH surge

Question 156

MENSTRUAL CYCLE what happens during the luteal phase?

Answer 156

- follicle becomes corpus luteum (lifespan of 14 days) - corpus luteum secretes progesterone which peaks 7 days after ovulation unless maintained by pregnancy - falling progesterone causes menstrual bleeding

Question 157

MENSTRUAL CYCLE What occurs during ovulation?

Answer 157

- Follicle (dominant) with most FSH receptors continues developing - Secretes further oestrogen which at a threshold causes spike in LH (+ slight rise in FSH) causing release of ovum on day 14

Question 158

MENSTRUAL CYCLE What happens if the egg is fertilised?

Answer 158

- Syncytiotrophoblast of embryo secretes human chorionic gonadotropin (hCG) which maintains corpus luteum

Question 159

MENSTRUAL CYCLE What happens if the egg is not fertilised?

Answer 159

- hCG absence > corpus luteum degenerates into corpus albicans - Fall in progesterone + oestrogen causes endometrium to breakdown + menstruation occurs - FSH + LH levels rise - Stromal cells of endometrium release prostaglandins to encourage endometrium breakdown + uterine contraction

Question 160

MENSTRUAL CYCLE What are the stages of the menstrual cycle?

Answer 160

- Menstruation (Days 1-5) - Proliferation (Days 6-14) - Ovulation (Day 14) - Secretion (Days 16-28)

Question 161

MENSTRUAL CYCLE What happens during the menstrual phase?

Answer 161

- falling levels of progesterone cause shedding of endometrium - spasm of spiral arteries - ischaemic necrosis - generalised inflammation

Question 162

MENSTRUAL CYCLE What happens in the proliferative phase?

Answer 162

- endometrium grows under influence of oestrogen - oestrogen causes hyperplasia of the endometrium - early development of glands and spiral arterioles

Question 163

MENSTRUAL CYCLE What happens in the early secretory phase of the menstrual cycle?

Answer 163

- after ovulation progesterone predominates - changes from focusing on growth to preparing for implantation - development of complex glands, increased spiral arterioles - endometrial cells produce and store glycogen

Question 164

MENSTRUAL CYCLE What happens in the late secretory phase of the menstrual cycle?

Answer 164

- Cervical mucus thickens + less hospitable for sperm - Decrease in oestrogen + progesterone > spiral arteries collapse + constrict + functional layer prepares to shred

Question 165

CONTRACPETION What is the method of action for COCP?

Answer 165

Inhibits ovulation

Question 166

CONTRACEPTION what is the method of action for POP (excluding desogestrel)?

Answer 166

Thickens cerivcal mucus

Question 167

CONTRACEPTION What is the method of action for desogestrel POP?

Answer 167

Primary = inhibits ovulation Also thickens cervical mucus

Question 168

CONTRACEPTION What is the method of action for injectable contraceptives (e.g. depo)?

Answer 168

Primary = inhibits ovulation Also thickens cervical mucus

Question 169

CONTRACEPTION What is the method of action for IUD?

Answer 169

Decreases sperm motility and survival

Question 170

CONTRACEPTION What is the method of action for IUS?

Answer 170

Primary = prevents endometrial proliferation Also thickens cervical mucus

Question 171

EMERGENCY CONTRACEPTION What is the method of action for levonogestrel?

Answer 171

Inhibits ovulation

Question 172

EMERGENCY CONTRACEPTION What is the method of action for ulipristal acetate?

Answer 172

Inhibits ovulation