Womens (Obs/breast)

Question 1

What are benign nipple changes?

Answer 1

Slit like retraction Retraction that is easily everted

Question 2

Suspicious or clinically abnormal nipple changes?

Answer 2

Colour change Fixed whole nipple inversion Ulceration or eczematous like changes

Question 3

Nipple discharge - suspicious for malignancy

Answer 3

Unilateral Bloody Serous from a single duct Spontaneous Over 60 years

Question 4

Should you perform Discharge cytology?

Answer 4

No. High specifity but low sensitivity

Question 5

Whats the management of Bilateral discharge only on expression (not spontaneous) No discrete lesion No blood

Answer 5

Cease expression Mammogram if due Review in 2-3 months

Question 6

First visit - antenatal history questions?

Answer 6

Menstrual history - regularity of cycle, contraception used

medical history - including depression, DM, thyroid disease and thombosis

Vaccinations and current meds

PRevious obstetric hx

FHx of birth defects and DM

Diet, exercise, smoking, DM, ETOH, HTN,

Social support

Domestic violence

Question 7

Examination in initial Antenatal visit

Answer 7

BMI
CV - record heart sounds, BP in every visit

Abdomen, Respiratory

Thyroid

Breast

Bedside - Urine pregnancy test

urine dipstick - if positive for protein send for ACR

Question 8

Essential screening tests in pregnancy

Answer 8

Urine dipstick for protein (Send for ACR if greater than plus one)

Urine MCS for asymptomatic bacteriuria

FBE +/- electrophoresis if appropriate

HIV test

Hep B test

Syphillis serology

Rubella serology

VZV serology if no definitive hx of chicken pox

Question 9

Routine tests to add on to antenatal screening in certain circumstances

Answer 9

Dating scan if unsure of dates

Consider OGTT early

1st Trim screening should be discussed on first visit in all pregs

TSH - not routinely recommended

UEC

LFT

Iron Studies

B12 - if bariatric surg is done

HB electrophoresis in certain ethnic groups

VITAMIN D in all without exposure to sun or BMI over 30

If cervical screening test is due during preg - do on first visit

HCV serology if risk factors

If less than 25 year consider urine for chlamydia and gonorrhea PCR

Question 10

Who should be routinely tested for thalassemia with Hb electrophoresis?

Answer 10

Southern European, ATSI NT/WA, Indian subcontinent, Central and SE Asian, Carribean, South AMerican, Pac Islander, Maori, Middle Eastern, African, Chinese

• check couple for carrier status - prior to preg or during first trimester

Check FBE, Fe studies, HB Electrophoresis and DNA studies.

If MCV less than 80 and MCH less than 27 check partner

Question 12

Which blood tests should be performed at 1st antenatal visit and then at 28 weeks?

Answer 12

Vit D at 28 if BMI over 30

Syphillis repeat at 28 if ATSI

FBE first visit and then at 28 weeks

Question 13

Which immunisations are required in pregnancy?

Answer 13

1. Boostrix - for pertussis and tetanus
2. Influenza vaccine
3. Pneumococcal for smokers or known RF’s

Question 14

What health advice would you give at the first antenatal visit?

Answer 14

Advice about maternal weight gain - limitations and targets

Smoking cessation - first line counselling with quitline referral. Second line nicotine replacement Rx.

Exercise 30/mins per day 5 days a week - non contact (Risk of placental abruption)

Avoid cats, soil

avoid soft cheese and pre packed salads,

Avoid high Hg fish

Supplements: All women 400mcg folate and 150micrograms iodine

5mg in folate in high risk

Vitamin D and calcium if deficient

Screening for Downs offered to every woman - combined screening and NIPT

Question 15

How frequently should a pregnant woman be seen in clinic?

Answer 15

First visit before 10 weeks.

Once every 4 weeks till 28 weeks

Once every 2 weeks till 36 weeks

weekly thereafter

Question 17

Is domestic abuse an issue in pregnancy?

Answer 17

Yes. Consider in women who miss antenatal appointments.

strongest RF for ATSI women being a victim of violence is alcohol use.

Question 18

What are the causes of aneamia in pregnancy?

Answer 18

b12/folate

Thalassemia

haemolytic anaemia (eg with preeclampsia)

Anemia of chronic disease,

Fe Deficiency - reduced intake (Vegetarians), GI bleeding (eg helmnithic infection), Reduced absorption (Eg chrons in terminal ileum)

Question 19

If Blood group scrrening of pregnant mother comes back as positive eg RH pos, what’s your approach

Answer 19

Check ab status of father - to determine likelihood of child

Risk of haemolytic disease of the new born.

Liaise with obstetrician

Monitor antibody titres 4 weekly till 32 weeks

then 2 weekly

(anti c, d and k)

Question 20

What specific causes of back pain in pregnancy must be considered?

Answer 20

1. Posterior placental abruption - check BP and pulse for circulatory collapse and abdomen for tense/woody uterus (constantly contracted) - note there may be no PV bleeding if blood is concealed.
2. Pyelonephritis - chack flank pain
3. Pubic symphisis diastasis
4. Transient osteoporosis of hip = conservative mx
5. Transient osteonecrosis of hip - dx on mri - treatment osteotomy, grafts
6. Pubic girdle pain.

Question 21

How would you identify pubic girdle pain (pubic symphisis dysfunction)

Answer 21

Dx in 2/3 of back pain in preg

Sx - pain classically at night, worse with rolling over, getting out of car, going up stairs.

o/e waddling gait

Positive trendelenburg

FABER test positive (flex, abduct, ext rot) - pain in SIJ

Mx - keep knees together

rest

avoid heavy lifting

exercise - keep knees together whilst increasing core strength eg swimming

Regular PCM for pain (not nsaid)

Question 22

What is diastasis symphisis pubis? How is it treated?

Answer 22

separation of normally joined pubic bones. nO fracture

Presents with pain, swelling, patients legs involuntarily move apart

Conservative Mx - pelvic brace or belt coupled with muscle strengthening to stabalise pelvis

simple analgesia

Question 23

WHat happens to oestrogen, progesterone and prolactin in pregnancy?

Answer 23

Increase

Question 24

when does nausea and vomiting usually begin and end in preg

Answer 24

6 to 14 weeks (usually improves around end of first trimester)

Question 25

When can vomiting in pregnancy be worse? red flags

Answer 25

Worse in multiple pregs and molar preg. (Early preg vomiting) Persistent vomiting that begins after 9 weeks - specialist referral - can be infection (Eg pyelo) or metabolic causes. Severe vomiting starting LATE in preg - can indicate preeclampsia or acute fatty liver disease of preg

Question 26

Dietary and lifestyle modifications for management of vomiting in pregnancy?

Answer 26

Eating small, frequent, high carb, low fat meals changing to a multivitamin without iron maintain adequate hydration with cold drinks or ice chips as tolerated snacking on high protein food between meals eating crackers or plain biscuits before getting out of bed in the morning avoid spicy foods and strong odours treat reflux if present Ginger can be helpful for some patients

Question 27

Antiemetics for vomiting in preg

Answer 27

Trial non drug treatments for one week then: 12.5 mg mane and midday 25mg nocte AND Doxylamine 25mg nocte. If not improving add Metoclopramide 10mg TDS prn If cannot tolerate oral Add metoclopramide 10mg IM TDS prn or prochlorperazine 12.5mg IM TDS prn

Question 28

Important things to consider if a woman has a history of exposure to Varicella?

Answer 28

Was the patient infective at that stage? Does the mother have immunity? Is the exposure significant? (Face to face exposure for five mins or living with a person with chicken pox in the same house) **IF patient is IgG negative and significant exposure:** _Immunoglobulin should be given within 96 hrs / 4 days_

Question 29

Do immunoglobulins give complete protection to a mother who has been exposed to VZV?

Answer 29

NO. If rash develops, give acyclovir.

Question 30

What are symptoms of congenital varicella syndrome?

Answer 30

Distal limb hypoplasia with clubbed feet Eye - cataracts, chorioretinitis, optic atrophy Prematurity Low birth weight Cortical atrophy Intellectual disability Early death

Question 31

When is VZV infective?

Answer 31

2 days before lesions appear and as long as lesions are active. Cease to be infective when lesions crust over.

Question 32

Risks and problems associated with obesity in preg for the fetus/neonate?

Answer 32

Fetal/Neonatal: Congenital malformations - NTDefects, congenital heart disease, cleft lip and palate Shoulder dystocia Suboptimal electronic fetal monitoring Increased admission to NICUs Increased rates of still birth and neonatal death Metabolic disorders such as diabetes/HTN in early adulthood

Question 33

Risks and problems associated with obesity in pregnancy for the mother?

Answer 33

**1. Throughout preg** - VTE, maternal mortality and depression 2**. Antenatal** Increased infections, Preeclampsia, OSA 3. **Labour and birth** Preterm birth Failed induction of labour Obstructed labour 4**.Surgical and anaesthetic** Increased risk of aspiration **5. Postnatal** Reduced breastfeeding rates

Question 34

Which nutritional supplements if any should be advised for an obese woman (over 30 BMI) during preg

Answer 34

1. , High dose folic acid - 5mg -start one month prior to conception and continue till end of first trimester 2. Check Vit D and supplement If Greater than 50 nmol/l - 400iu (preg vitamin dose) 30-50 - 1000iu less than 30 - 2000IU daily 3. 150 micrograms iodine recommended for all preg women

Question 35

What special testing should be perfomred on obese women? Special advice?

Answer 35

OGTT in 1st trimester MUST have dating ultrasound (as ovulation not reliable) Advise to limit weight gain in pregnancy (dont advise to lose weight in preg) - to 5-9kilos if BMI is over 30.

Question 36

Likely causes of perineal pain post a normal vaginal delivery?

Answer 36

1. Poor healing of an episiotomy or vaginal tear (+/\_ infection) 2. New STI 3. Reactivation of previous genital herpes 4. Referred pain 5. Bartholins abcess 6. Trauma 7. Unexplained pelvic pain can be due to intimate partner violence

Question 37

What examination findings would you look for in a woman with perineal pain post vaginal delivery?

Answer 37

Palpate abdomen - if you can feel uterus consider RPOC or endometritis if tender.

Question 38

4-6 weeks postpartum check up - What would you discuss with mother

Answer 38

Mum: Vaginal discharge (Lochia) - ceased? Healing of perineum (if vaginal delivery) Bowel or bladder probs? Breastfeeding? Issues? Check abdomen (uterus should be impalpable) and Caesarean wound if present Has intercourse resumed ? Any problems or concerns? Discuss contraceptive options DIscuss Postnatal exercises Discuss diet, rest, personal care Check Psychologial health, Consider Edinburgh Depression score Consider pelvic examination, check perineum and pelvic floor strenght Cervical screening test (if due) R/V antenatal screening tests for f/u action (Eg rubella booster) Further f/u if necessary

Question 39

4-6 weeks postpartum check up - what checks would you do on baby?

Answer 39

Measure weight, height and head circumference Routine examination - check for red reflex, hips, heart sounds, testes in boys Check growth and feeding Complete childhood health record Discuss immunisation schedule with parents

Question 40

What is an ectopic pregnancy and where do they occur?

Answer 40

An extrauterine pregnancy Most occur in fallopian tube (96%) Other possible sites - cervical, interstitial, hysterotomy (Caesaran) scar, ovarian or abdominal IN rare cases - multiple gestation can be heterotopic - one intrauterine and one extrauterine

Question 41

When do ectopic pregs usually present?

Answer 41

Usually 5-6 weeks gestation Before 8 weeks .

Question 42

What are the symptoms of ectopic pregnancy?

Answer 42

Usually signs of preg like breast tenderness and nausea are ABSENT Sometimes cramping iliac fossa pain for a few days Usually presents with ABDO PAIN Vaginal bleeding in 90% - dark colour 10% - none 50% urine pregnancy test negative (high suspicion send to Ed)

Question 43

What are the risk factors for ectopic pregnancy?

Answer 43

High Risk PREVIOUS ECTOPIC - sterilisation Tubal pathology Previous tubal surgery IUD - past use, current use, levonorgestrel IUD IVF

Question 44

Examination findings in ectopic pregnancy?

Answer 44

1. Examine for circulatory stability, PR, BP, RR 2. Examine the abdomen - Uterine size - in case of wrong date, and tenderness 3. Speculum examination - Os closed or open? Plus blood in vagina 4. Bimanual examination - cervical tenderness, adnexal tenderness, and masses, uterine size ALL patients should have a urinary BHCG - but its negative in 50% of ectopics so high suspicious --\> ED If Adnexal mass or tenderness --\> ED If circulatory collapes --\> ED If U/s suggests ectopic --\> ED

Question 45

What are the essential investigations for a patient with ?ECTOPIC pregnancy

Answer 45

SERUM QUANTITATIVE BETA HCG - measure serially every two to three days Blood group and antibody Pelvic Ultrasound - Transvaginal ultrasound

Question 46

How is the diagnosis of ectopic pregnancy made?

Answer 46

A clinical diagnosis made based upon Serial HCG readings and TVUS findings. Diagnostic criteria depend upon relationship to the HCG discriminatory zone. Serum HCG level above which a gestational sac should be visualised on TVUS.

Question 47

Complications of Ectopic pregnancy

Answer 47

1. Rupture of the structure in which the ectopic has been implanted. 2. Circulatory collapse. 3. Sepsis.

Question 48

What is the management of an ectopic pregnancy?

Answer 48

Watchful waiting - monitor serial hcgs and u/s Medical - methotrexate injection into the sac Surgery - laporoscopic removal/laporotomy if rupture

Question 49

What is the post management obstetric prospects in a woman with ectopic pregnancy?

Answer 49

A successful pregnancy - 60- 65% Subsequent risk of ectopic - 10-15%

Question 50

Causes of thrombocytopenia in pregnancy?

Answer 50

Preexisting - ITP gestational thrombocytopenia - around 80% HELP syndrome/preeclampsia Acute fatty liver of pregnancy

Question 51

What is gestational thrombocytopenia

Answer 51

Happens in mid 2nd to 3rd trimester - dx of exclusion No impact on baby and returns back to normal after preg

Question 52

What are the parameters for intervention in thrombocytopaenia in pregnancy?

Answer 52

As long as over 50 - no intervention needed - can do vaginal birth or LSCS (lower segment CS) In order for epidural - platelets need to be above 90