Passmed O&g 1

Front 1

mgmt. of mastitis in breastfeeding women

Back 1

first simple analgesia and warm compresses (i.e. use hand or pump to express or remove milk)

next use Oral antibiotics if indicated by:

- infected nipple fissure

- symptoms not improving after 12-24hrs despite effective milk removal

- and or positive breast milk culture

next if you suspect breast abscess (i.e. palpable lump) refer to hospital

Front 2

what are the first line antibiotics for mastitis

Back 2

first line would be flucloxacillin for 10-14 days or erythromycin or clarithromycin if penicillin allergic.

Front 3

An 18-year old girl presents to her GP with discharge. She reports a new sexual partner with whom she is not using barrier protection. On examination thick cottage-cheese like discharged is visualised. She reports no other symptoms of note. What is the most likely diagnosis?

Back 3

Candida albicans causing vaginal candidiasis

Front 4

Cottage-cheese like vaginal discharge is almost pathognomonic of

Back 4

thrush aka vaginal candidiasis

Front 5

remember that 70% of chlamydia is asymptomatic in women, and the majority of gonorrhoea is also asymptomatic

Back 5

true

Front 6

vaginal candidiasis - is it common

Back 6

extremely common

Front 7

what are the predisposing factors to getting vaginal candidiasis

Back 7

diabetes mellitus

drugs: antibiotics, steroids

pregnancy

immunosuppression: HIV, iatrogenic

Front 8

features of vaginal candidiasis

Back 8

'cottage cheese', non-offensive discharge

vulvitis: dyspareunia, dysuria

itch

vulval erythema, fissuring, satellite lesions may be seen

Front 9

do you need to investigate for vaginal candidiasis if clinically suspected

Back 9

no, not routine

Front 10

treatment for vaginal candidiasis

Back 10

topical aka local clotrimazole pessary - only use topical in pregnancy

oral itraconzaole or fluconazole

Front 11

if someone gets recurrent vaginal candidiasis what should you do

Back 11

compliance with previous treatment should be checked

confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses such as lichen sclerosus

exclude predisposing factors (see above)

consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months

Front 12

whats Meigs syndrome

Back 12

a triad of ascites, pleural effusion and benign ovarian tumour

Front 13

Most common type of ovarian pathology associated with Meigs' syndrome

Back 13

fibroma

Front 14

Most common benign ovarian tumour in women under the age of 25 years

Back 14

dermoid cyst

which is a type of teratoma

Front 15

The most common cause of ovarian enlargement in women of a reproductive age

Back 15

follicular cyst

Front 16

ovarian cysts: types

Back 16

physiological cysts (aka functional cysts)

- follicular cysts (most common of physio cysts)

- corpus luteum cyst

benign germ cell tumours

- dermoid cyst

benign epithelial tumours (arise from ovarian surfarce epithelium)

- serous cystadenoma

- mucinous cystadenoma

Front 17

Benign ovarian cysts are extremely common. They may be divided into

Back 17

physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours

Front 18

Follicular cysts features

Back 18

commonest type of ovarian cyst

due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle

commonly regress after several menstrual cycles

Front 19

a chocolate cyst is caused by

Back 19

endometriosis

Front 20

Dermoid cyst features

Back 20

also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth

most common benign ovarian tumour in woman under the age of 30 years

median age of diagnosis is 30 years old

bilateral in 10-20%

usually asymptomatic. Torsion is more likely than with other ovarian tumours

Front 21

Serous cystadenoma features

Back 21

the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma)

bilateral in around 20%

Front 22

what are the screening tests in pregnancy for down syndrome

Back 22

at 10-14 weeks gestation

ultrasound scan for nuchal translucency and

blood test for bHCG and pregnancy associated plasma protein A (PAPP-A)

In pregnancies with Down Syndrome, PAPP-A is low and beta-hCG raised.

Front 23

If the window for the combined test for downs was missed, the next at 14-20 gestation, the quadruple test will be offered. This involves a

Back 23

blood test for levels of alfa-fetoprotein (AFP), unconjugated oestriol, beta-hCG and inhibin A.

In pregnancies with Down Syndrome, AFP and unconjugated oestriol are low and beta-hCG and inhibin A are raised.

Front 24

A 27-year-old woman presents complaining of heavy menstrual bleeding. She reports saturating her pads with blood regularly and frequently has to change them hourly. She is otherwise asymptomatic and has no desire to have children in the near future. Following a normal examination, what is the most appropriate management?

Back 24

Intrauterine system

Front 25

If there is no structural or histological abnormality causing the heavy menstrual bleeding, the intrauterine system is the first line treatment.

Back 25

true

Front 26

menorrhagia definition

Back 26

what woman considers to be excessive

Front 27

management of menorrhagia depends on whether woman needs

Back 27

contraception

Front 28

if a woman doesnt need contraception what is the management for menorrhagia

Back 28

either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds.

Both are started on the first day of the period

if no improvement then try other drug whilst awaiting referral

Front 29

if a woman does require contraception what is the management of menorrhagia

Back 29

intrauterine system (Mirena) should be considered first-line

combined oral contraceptive pill

long-acting progestogens

Front 30

Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.

Back 30

true

Front 31

what investigation should all woman get with menorrhagia

Back 31

Full blood count

Front 32

unsuccessfully trying to conceive for 4 months, management

Back 32

Address how the couple are having sexual intercourse and reassure the patient

Front 33

Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years

Back 33

true

Front 34

basic investigations for infertility

Back 34

semen analysis

serum progesterone 7 days prior to expected next period

Front 35

Key counselling points for infertility

Back 35

folic acid

aim for BMI 20-25

advise regular sexual intercourse every 2 to 3 days

smoking/drinking advice

Front 36

You receive the results of a 29-year-old female who has recently had a routine cervical smear. Her last smear 4 years ago was reported as normal. The results are reported as follows: Moderate dyskaryosis

What is the most appropriate management?

Offer HPV vaccineRepeat smear immediatelyRefer to a gynaecological oncologistRepeat smear in 3 monthsRefer to colposcopy

Back 36

Refer to colposcopy

Front 37

Cervical cancer screening: interpretation of results

Back 37

management of abnormal cervical smears (around 5% of all smears). Cervical intraepithelial neoplasia is abbreviated to CIN

Front 38

Moderate dyskaryosis

Back 38

Consistent with CIN II. Refer for colposcopy

Front 39

Severe dyskaryosis

Back 39

Consistent with CIN III. Refer for colposcopy

Front 40

Suspected invasive cancer

Back 40

Refer for urgent colposcopy (within 2 weeks)

Front 41

Inadequate

Back 41

Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy

Front 42

Borderline or mild dyskaryosis

Back 42

The original sample is tested for HPV*

if negative the patient goes back to routine recall

if positive the patient is referred for colposcopy

Front 43

A woman who is 20 weeks pregnant comes for her routine scan. She informs you that she has had a previous baby who has grown Group B streptococcus. What additional treatment will this mother require?

Back 43

Intrapartum antibiotics

Front 44

About 50% of babies born to women who carry Group B streptococcus will become carriers themselves but less than 1% will be ill themselves. The largest risk factor for a baby developing Group B streptococcus growth is

Back 44

the mother having a previous baby who has grown it - the risk is increased by a factor of 10.

Front 45

high risk woman who have Group B strep should be treated with

Back 45

intrapartum antibiotics

this reduces the risk of the baby developing Group B streptococcus.

no need for it before labour

vaginal or rectal swab will not change management as intrapartum antibiotics would still be recommended even if they were negative.

Front 46

Women who have known GBS carrier status prior to this pregnancy, but have not had a baby with a GBS pregnancy there is

Back 46

not a requirement for IV antibiotics during labour unless another risk factor is present.

Front 47

Risk factors for Group B Streptococcus (GBS) infection:

Back 47

prematurity

prolonged rupture of the membranes

previous sibling GBS infection

maternal pyrexia e.g. secondary to chorioamnionitis

Front 48

Women found to have GBS infection in the antenatal period should be treated with intravenous antibiotics during labour. This has been shown to reduce early-onset GBS disease in the neonate

Back 48

true

Front 49

A 28-year-old lady who is 9 weeks pregnant comes to see you for review of booking bloods. Her haemoglobin is 105 g/L and the mean cell volume (MCV) is 70 fL (normal range 77-95 fL).What is the most appropriate management?

Back 49

Oral iron tablets

Front 50

Anaemia in pregnancy is defined using different cut off values than in non-pregnant women and varies according to trimester. British Committee for Standards in Haematology (BCSH) guidance gives the following values:

Back 50

first trimester Hb less than 110 g/l

second/third trimester Hb less than 105 g/l

postpartum Hb less than 100 g/l

Front 51

Royal College of Obstetricians and Gynaecologists (RCOG) guidelines advise for normocytic or microcytic anaemia a trial of

Back 51

oral iron should be considered as the first step,

and further investigations only required if no rise in haemaglobin after 2 weeks

Parenteral iron is only indicated if oral iron is not tolerated, absorbed, patient is not compliant or they are near term and there is insufficient time for oral iron to be effective.

Front 52

A 23-year-old woman, gravidity 2 and parity 1, at 37 weeks gestation presents after fainting and has severe abdominal pain. Blood pressure = 92/58 mmHg and heart rate = 132/min. On examination she is cold and her fundal height is 37 cm; the cervical os is closed and there is no vaginal bleeding. Which is the most appropriate diagnosis?

Back 52

Placental abruption

Front 53

Placental abruption features

Back 53

Presents with sudden abdominal pain in the third trimester.

On examination the mother can be seen to be in extreme pain and cold to touch.

Bleeding is present in 80% of cases.

Absence of visible bleeding does not rule out this diagnosis.

Front 54

what are the risk factors for placental abruption

Back 54

maternal hypertension (common),

cocaine,

trauma,

uterine overdistension,

tobacco and

previous placental abruption.

Front 55

is placental abruption common

Back 55

occurs in approximately 1/200 pregnancies

Front 56

Clinical features of placental abruption

Back 56

shock out of keeping with visible loss

pain constant

tender, tense uterus

normal lie and presentation

fetal heart: absent/distressed

coagulation problems

beware pre-eclampsia, DIC, anuria

Front 57

placental abruption

can be associated with

Back 57

proteinuric hypertension

multiparity

maternal trauma

increasing maternal age

Front 58

What is the most common cause of pelvic inflammatory disease in the UK?

Back 58

Chlamydia trachomatis

Front 59

Pelvic inflammatory disease (PID) is a term used to describe

Back 59

infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum

Front 60

PID usually due to

Back 60

usually the result of ascending infection from the endocervix

Front 61

what are the causative agents in PID

Back 61

Chlamydia trachomatis - the most common cause

Neisseria gonorrhoeae

Mycoplasma genitalium

Mycoplasma hominis

Front 62

features of PID

Back 62

lower abdominal pain

fever

deep dyspareunia

dysuria and menstrual irregularities may occur

vaginal or cervical discharge

cervical excitation

Front 63

investigations for PID

Back 63

screen for chlamydia and gonorrhoea

Front 64

management of PID principle

Back 64

due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment

Front 65

PID treatment

Back 65

oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole

Front 66

PID complications

Back 66

infertility - the risk may be as high as 10-20% after a single episode

chronic pelvic pain

ectopic pregnancy

?fitz hugh curtis

Front 67

A 31-year-old woman attended her GP for a routine cervical smear. Several weeks later she was informed that her smear was abnormal but no further intervention was required. Which of the following describes her result?

Back 67

Mild dyskaryosis, HPV -ve

Front 68

The 2015 NICE guidelines on 'Cervical Screening' state that a woman with a normal smear should be returned to

Back 68

the routine screening programme (every 3-5 years, depending on her age), provided that she has no symptoms or signs suggestive of gynaecological cancer.

Front 69

If a cervical smear shows borderline or mild (low grade) dyskaryosis, then what should happen

Back 69

the laboratory will also test the cytology sample for human papillomavirus (HPV). If HPV is found, the woman will be referred for colposcopy within 8 weeks. If HPV is not found, the woman will be returned to the routine screening programme

Front 70

If a cervical smear shows moderate or severe (high grade) dyskaryosis, the woman will be referred for colposcopy within 4 weeks.

Back 70

true

Front 71

If a cervical smear shows suspected CGIN or invasive cancer, the woman will be referred for colposcopy within 2 weeks.

Back 71

true

Front 72

is if safe for asthmatic mothers to breastfeed while on steroids

Back 72

yes, only a small amount will get into the breastmilk

Front 73

Patients with acute severe asthma are stratified into moderate, severe or life-threatening

moderate

Back 73

PEFR 50-75% best or predicted

Speech normal

RR < 25 / min

Pulse < 110 bpm

Front 74

Patients with acute severe asthma are stratified into moderate, severe or life-threatening

severe

Back 74

PEFR 33 - 50% best or predicted

Can't complete sentences

RR > 25/min

Pulse > 110 bpm

Front 75

Patients with acute severe asthma are stratified into moderate, severe or life-threatening

life threatening

Back 75

PEFR < 33% best or predicted

Oxygen sats < 92%

Silent chest, cyanosis or feeble respiratory effort

Bradycardia, dysrhythmia or hypotension

Exhaustion, confusion or coma

Front 76

A 36-year-old multiparous woman is in advanced labour at 37 weeks gestation. An ultrasound confirms a breech presentation. She is fully dilated and has been pushing for an one and a half hours, however the buttocks are still not visible. How should this situation be managed?

Back 76

Caesarian section

Front 77

Due to the foetal presentation and station, vaginal delivery is likely to be difficult. Breech extraction is not recommended for singleton pregnancies and requires considerable skill. Therefore Caesarean section should be advised.

Back 77

true

Front 78

Risk factors for breech presentation

Back 78

uterine malformations, fibroids

placenta praevia

polyhydramnios or oligohydramnios

fetal abnormality (e.g. CNS malformation, chromosomal disorders)

prematurity (due to increased incidence earlier in gestation)

Front 79

whats the most common cause of breech presentation

Back 79

cord prolapse

Front 80

whats the management of breech presentation if less than 36 weeks

Back 80

many fetuses will urn spontaneously

Front 81

management of breech after 36 weeks

Back 81

external cephalic versin

success rate = 60%

Front 82

The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women

Back 82

true

Front 83

mgmt for breech

Back 83

<36 weeks - nothing

>36 weeks = external cephalic version

if ECV fails do C section or vaginal delivery

Front 84

breech information to help decision making - the RCOG recommend:

Back 84

'Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.

''Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.'

Front 85

A 28 -year-old is found to have an ectopic pregnancy at 10 weeks gestation. She undergoes surgical management of the ectopic with a salpingectomy. She is known to be rhesus negative. What is the recommendation with regard to anti-D?

Back 85

Anti-D should be given

Front 86

In surgical management of an ectopic pregnancy even in anti D negative mothers, what should they get

Back 86

Anti-D immunoglobulin should be administered

Anti-D is not required in circumstances where a medical management of the ectopic has been used, nor for treatment of pregnancy of unknown location..

Front 87

Coombs test

Back 87

Direct Coombs: Is a investigation used to look for autoimmune haemolytic anaemia,

Indirect: Used antenatally to detect antibodies in the maternal blood that can cross the placenta and result in haemolytic disease of the newborn.

Front 88

Rhesus negative pregnancy

Back 88

A basic understanding of the pathophysiology is essential to understand the management of Rhesus negative pregnanciesalong with the ABO system the Rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus systemaround 15% of mothers are rhesus negative (Rh -ve)if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occurthis causes anti-D IgG antibodies to form in motherin later pregnancies these can cross placenta and cause haemolysis in fetusthis can also occur in the first pregnancy due to leaksPreventiontest for D antibodies in all Rh -ve mothers at bookingNICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeksthe evidence base suggests that there is little difference in the efficacy of single-dose (at 28 weeks) and double-dose regimes (at 28 & 34 weeks). For this reason the RCOG in 2011 advised that either regime could be used 'depending on local factors'anti-D is prophylaxis - once sensitization has occurred it is irreversibleif event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs presentAnti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:delivery of a Rh +ve infant, whether live or stillbornany termination of pregnancymiscarriage if gestation is > 12 weeksectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)external cephalic versionantepartum haemorrhageamniocentesis, chorionic villus sampling, fetal blood samplingTestsall babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs testCoombs test: direct antiglobulin, will demonstrate antibodies on RBCs of babyKleihauer test: add acid to maternal blood, fetal cells are resistantAffected fetusoedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)jaundice, anaemia, hepatosplenomegalyheart failurekernicterustreatment: transfusions, UV phototherapy

Front 89

A 35-year-old woman presents as she has not had a period for six-months. Prior to this time she had a 28 day cycle with a five day bleed. Which one of the following investigations is least helpful initially?

Back 89

Serum progesterone

Front 90

Causes of primary amenorrhoea

Back 90

Turner's syndrome

testicular feminisation

congenital adrenal hyperplasia

congenital malformations of the genital tract

Front 91

primary amenorrhoea

Back 91

failure to start menses by the age of 16 years

Front 92

secondary amenorrhoea

Back 92

cessation of established, regular menstruation for 6 months or longer

Front 93

Causes of secondary amenorrhoea (after excluding pregnancy)

Back 93

hypothalamic amenorrhoea (e.g. Stress, excessive exercise)

polycystic ovarian syndrome (PCOS)

hyperprolactinaemia

premature ovarian failure

thyrotoxicosis*

Sheehan's syndrome

Asherman's syndrome (intrauterine adhesions)

Front 94

Initial investigations of amenorrhoea

Back 94

exclude pregnancy with urinary or serum bHCG

gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)

prolactin

androgen levels: raised levels may be seen in PCOS

oestradiol

thyroid function tests

Front 95

A 62-year-old woman presents with post-menopausal bleeding. Which one of the following is not a risk factor for endometrial cancer?

Back 95

Past history of combined oral contraceptive pill use

Front 96

The risk factors for endometrial cancer are as follows

Back 96

obesity

nulliparity

early menarche

late menopause

unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously

diabetes mellitus

tamoxifen

polycystic ovarian syndrome

Front 97

first line investigation for suspected endometrial cancer

Back 97

transvaginal ultrasound

next do hyseroscoy with endometrial biopsy

Front 98

Management of endometrial cancer

Back 98

localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy

progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Front 99

A 37 year old female presents to her GP complaining of dyspareunia, irregular menstrual cycles for 6 months until she recently missed 3 periods. She also complains of sudden hot flushes for the past 3 months. Her only history of note includes previous breast cancer for which she was on chemotherapy and radiation. Examination reveals no abnormalities and her pregnancy test is negative. What is the most likely diagnosis?

Back 99

Premature ovarian failure

Front 100

Premature ovarian failure (POM) is defined as

Back 100

the cessation of menses for 1 year before the age of 40.

Front 101

common symptoms associated with premature ovarian failure

Like early menopause

Back 101

hot flushes,

vaginal dryness,

vaginal atrophy,

sleep disturbance, and irritability.

Front 102

Strong risk factors for POM include

Back 102

a positive family history, exposure to chemotherapy / radiation and autoimmune disease.

Front 103

whats the commonest cause of premature ovarian failure

Back 103

idiopathic

other causes

chemotherapy

autoimmune

radiation

Front 104

A 34-year-old woman comes to see you because of painful and heavy periods. These started about a year ago and are associated with deep dyspareunia. She and her partner have been unable to conceive, and this is under investigation at the local hospital. What one investigation may be ordered which could definitively explain both these problems?

Back 104

Diagnostic laparoscopy

Front 105

whats the gold standard investigation for endometriosis

Back 105

laparoscopy

Front 106

management of endometriosis

medical management

Back 106

NSAIDs and other analgesia for symptomatic relief

combined oral contraceptive pill

progestogens e.g. medroxyprogesterone acetate

gonadotrophin-releasing hormone (GnRH) analogues - said to induce a 'pseudomenopause' due to the low oestrogen levels

intrauterine system (Mirena)

drug therapy unfortunately does not seem to have a significant impact on fertility rates

Front 107

surgical management of endometriosis

Back 107

some treatments such as laparoscopic excision and laser treatment of endometriotic ovarian cysts may improve fertility

Front 108

A 38-year-old woman with a 4.5cm fibroid has been listed for a myomectomy following a 5 month history of heavy menstrual bleeding, What drug should be prescribed to be taken whilst awaiting surgery?

Back 108

Gonadotrophin-releasing hormone analogue

Front 109

what can you give for fibroids before surgery to reduce its size

Back 109

gonadotrophin-releasing hormone analogue

Front 110

how do you diagnose fibroids

Back 110

transvaginal ultrasound

Front 111

management for fibroids

Back 111

symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line

other options include tranexamic acid, combined oral contraceptive pill etc

GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment

surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy

uterine artery embolization

Front 112

complications of fibroids

Back 112

red degeneration - haemorrhage into tumour - commonly occurs during pregnancy

Front 113

A woman who is 9 weeks pregnant presents with vaginal bleeding. The cervical os is closed. An ultrasound shows an intrauterine pregnancy with a fetal heart. She has been pregnant once before which resulted in a miscarriage

Back 113

Threatened miscarriage

The possibility of bleeding due to non-pregnancy causes (e.g. cervical ectropion) should also be considered

Front 114

A 22-year-old woman has a booking ultrasound scan. Her last menstrual period was 8 weeks ago. This shows an intrauterine sac with no fetal pole

Back 114

Missed miscarriage

Front 115

A woman who is 10 weeks pregnant presents with heavy vaginal bleeding and crampy lower abdominal pains. On examination some clots are seen around an open cervical os

Back 115

Inevitable miscarriage

Front 116

miscarriage types

Back 116

threatened

missed/delayed

inevitable

complete

Front 117

Threatened miscarriage

Back 117

painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeksthe bleeding is often less than menstruationcervical os is closedcomplicates up to 25% of all pregnancies

Front 118

Threatened miscarriage

Back 118

cervical os closed

some bleeding

usually at 6-9 weeks

Front 119

Missed (delayed) miscarriage

Back 119

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion

mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature

cervical os is closed

when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'

Front 120

missed aka delayed miscarriage

Back 120

sac still there but dead fetus

before 20 weeks

light bleed

cervical os closed

Front 121

Inevitable miscarriage

Back 121

heavy bleeding with clots and pain

cervical os open

Front 122

incomplete miscarriage

Back 122

not all products of conception have been expelled

pain and vaginal bleeding

cervical os is open

Front 123

Hydatidiform mole

Back 123

typically painless vaginal bleeding

Front 124

A 26-year-old woman who is 12 weeks pregnant presents with vaginal blood loss. Which one of the following features is least consistent with a diagnosis of a hydatidiform mole?

Back 124

Crampy lower abdominal pains

Front 125

Vaginal bleeding is typically painless with a hydatidiform mole. Symptoms of thyrotoxicosis may occur secondary to high levels of hCG, which may mimic thyroid stimulating hormone

Back 125

true

Front 126

Gestational trophoblastic disorders

Describes a spectrum of disorders originating from the placental trophoblast:

Back 126

complete hydatidiform mole

partial hydatidiform mole

choriocarcinoma

Front 127

Complete hydatidiform mole

Back 127

Benign tumour of trophoblastic material.

Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

Front 128

Complete hydatidiform mole features

Back 128

bleeding in first or early second trimester

exaggerated symptoms of pregnancy e.g. hyperemesis

uterus large for dates

very high serum levels of human chorionic gonadotropin (hCG)

hypertension and hyperthyroidism* may be seen

Front 129

Complete hydatidiform mole management

Back 129

urgent referral to specialist centre - evacuation of the uterus is performed

effective contraception is recommended to avoid pregnancy in the next 12 months

Front 130

Around 2-3% go on to develop choriocarcinoma in

Back 130

Complete hydatidiform mole

Front 131

partial mole

Back 131

In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

Front 132

Which one of the following features would point towards a diagnosis of placenta praevia rather than placenta abruption?

Back 132

no pain

Front 133

Antepartum haemorrhage is defined as

Back 133

bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

Front 134

Placental abruption features

Back 134

shock out of keeping with visible loss

pain constant

tender, tense uterus*

normal lie and presentation

fetal heart: absent/distressed

coagulation problems

beware pre-eclampsia, DIC, anuria

Front 135

Placenta praevia features

Back 135

shock in proportion to visible loss

no pain

uterus not tender*

lie and presentation may be abnormal

fetal heart usually normal

coagulation problems rare

small bleeds before large

Front 136

A 35 year-old lady presents to general practice with cyclical pelvic pain associated with dysmenorrhoea and dyspareunia. On examination she has a fixed, retroverted uterus. Which investigation is most useful diagnostically?

Back 136

Laparoscopy

dx endometriosis

Front 137

uterus positions

Back 137

Front 138

A 27-year-old woman with a BMI of 18 is referred to a fertility clinic after failing to become pregnant after 2 years of trying with her partner. Male factor infertility has been ruled out and you suspect the patient's low BMI may mean she is not ovulating. Which hormone could you measure on day 21 of her menstrual cycle to test for ovulation?

Back 138

Progesterone

Front 139

formation of corpus leutum

Back 139

Following ovulation, the hormones Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH) - produced in the anterior pituitary gland - cause the dominant follicle to transform into the corpus luteum. The corpus luteum produces a surge of progesterone which typically peaks on day 21 of the cycle. Measuring this can give information as to whether a woman has ovulated or not.

Front 140

effect of low BMI (i.e. skinny) on FSH and LH in females

Back 140

can cause hypogonadotrophic hypogonadism, where the anterior pituitary gland stops producing FSH and LH, thus meaning follicles do not develop sufficiently. Gaining weight should reverse the subfertility.

Front 141

You are reviewing the blood results for a pregnant woman. Which one of the following results would indicate the need for routine antenatal anti-D prophylaxis to be given at 28 weeks?

Back 141

Rhesus negative mothers who are not sensitised

Front 142

A neonate is born at 32 weeks gestation after prolonged premature rupture of membranes (PROM). Approximately 12 hours after birth the neonate presents with temperature instability, respiratory distress and lethargy. Sepsis is confirmed by blood cultures. What is the most likely infectious agent?

Back 142

Group B Streptococcus

Front 143

Sepsis in the neonate can broadly be divided into

Back 143

early-onset (<48 hours since birth) and

late-onset (>48 hours from birth).

Front 144

Early-onset sepsis is associated with

Back 144

acquisition of micro-organisms from the mothers birth canal

The most likely pathogen is Group B Strep which is a common commensal of the female genital tract.

Front 145

Late-onset sepsis normally occurs due to

Back 145

hospital acquired pathogens such as Staphylococcus epidermidis and Staphylococcus aureus.

Front 146

Risk factors for Group B Streptococcus (GBS) infection:

Back 146

prematurity

prolonged rupture of the membranes

previous sibling GBS infection

maternal pyrexia e.g. secondary to chorioamnionitis

Front 147

Which one of the following is the most common cause of recurrent first trimester spontaneous miscarriage?

Back 147

Antiphospholipid syndrome

Front 148

Antiphospholipid antibodies (aPL) are present in 15% of women with recurrent miscarriage, but in comparison, the prevalence of aPL in women with a low risk obstetric history is less than 2%

Back 148

true

Front 149

Recurrent miscarriage is defined as

Back 149

3 or more consecutive spontaneous abortions.

It occurs in around 1% of women

Front 150

Recurrent miscarriage causes

Back 150

antiphospholipid syndrome = most common

endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome

uterine abnormality: e.g. uterine septum

parental chromosomal abnormalities

smoking

Front 151

Which of these is correct in regards to the management of endometrial cancer?

Back 151

Most, 75%, patients present with stage 1 disease, and are therefore amenable to surgery alone

Front 152

some facts of endometrial cancer

Back 152

1: 75% of patients present with stage 1 disease, which is generally treated with a hysterectomy and bilateral salpingo-oophorectomy.

2: Endometrial biopsy is required for diagnosis.

3: Radiotherapy is used more often than chemotherapy, particularly in treating high-risk patients post-hysterectomy or in pelvic recurrence.

4. Routine lymphadenectomy is not usually beneficial.

5. Progestogens are now seldom used in treatment.

Front 153

when you think of risk factors for endometrial cancer think of things that increase

Back 153

estrogen

Front 154

A 26 year-old woman presents to her GP with a 3 month history of inter-menstrual bleeding and occasional post-coital bleeding. She is sexually active and takes Microgynon (a combined oral contraceptive pill). Her last cervical smear was normal. What is the most likely diagnosis?

Back 154

Cervical ectropion

Front 155

In a young woman taking COCP, cervical ectropions are a common finding in the context of post-coital bleeding.

Back 155

true

Front 156

Cervical ectropion pathophys

Back 156

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal. Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

Front 157

features of cervical ectropion

Back 157

vaginal discharge, can

post-coital bleeding

Front 158

define intermenstrual bleeding

Back 158

Intermenstrual bleeding (IMB) refers to vaginal bleeding (other than postcoital) at any time during the menstrual cycle other than during normal menstruation.

It can sometimes be difficult to differentiate true IMB bleeding from metrorrhagia (irregularly frequent periods).

Front 159

treatment for cervical ectropion

Back 159

Ablative treatment (for example 'cold coagulation') is only used for troublesome symptoms

Front 160

A 24-year-old female who is 10 weeks in to her first pregnancy presents for review. Her blood pressure today is 126/82 mmHg. What normally happens to blood pressure during pregnancy?

Back 160

Falls in first half of pregnancy before rising to pre-pregnancy levels before term

Front 161

A mother attends the GP with her 14-year-old daughter. She is concerned as her daughter has not yet started her periods although suffers cyclical pain. On examination the daughter looks well. What is the most likely diagnosis?

Back 161

Imperforate hymen

Front 162

Delayed puberty with short stature

Back 162

Turner's syndrome

Prader-Willi syndrome

Noonan's syndrome

Front 163

Delayed puberty with normal stature

Back 163

polycystic ovarian syndrome

androgen insensitivity

Kallman's syndrome

Klinefelter's syndrome

Front 164

Delayed puberty in deciding what the cause is first distinguish whether

Back 164

short stature or normal stature patient

Front 165

What is the main pathology in monochorionic twins, that ultrasound monitoring performed between 16 and 24 weeks gestation aims to detect?

Back 165

Twin-to-twin transfusion syndrome

after 24 weks, ultrasound is mainly aimed at detecting fetal growth restriction

Front 166

Twin-to-twin transfusion syndrome

Back 166

is a relatively common complication of monochorionic twin pregnancies

Front 167

Twin-to-twin transfusion syndrome info

Back 167

Twin-to-twin transfusion syndrome (TTTS) is a relatively common complication of monochorionic twin pregnancies. The two fetuses share a single placenta, meaning that blood can flow between the twins. In TTTS, one fetus, the 'donor' receives a lesser share of the placenta's blood flow than the other twin, the 'recipient'. This is due to abnormalities in the network of placental blood vessels. The recipient may become fluid-overloaded whilst the donor can become anaemic. One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems. In severe cases, TTTS can be fatal for one or both fetuses.

TTTS usually occurs in early or mid-pregnancy, thus ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition. After 24 weeks the main purpose of ultrasound examinations is to detect fetal growth restriction.

Front 168

Twins may be

Back 168

dizygotic or monozygotic

Front 169

whats a dizygotic twin

Back 169

non-identical, develop from two separate ova (EGG) that were fertilized at the same time

Front 170

whats a monozygotic twin

Back 170

identical, develop from a single ovum (EGG) which has divided to form two embryos

Front 171

most twins are

Back 171

Around 80% of twins are dizygotic

Front 172

Monoamniotic monozygotic twins are associated with:

Back 172

increased spontaneous miscarriage, perinatal mortality rate

increased malformations, IUGR, prematurity

twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)

Front 173

The rate of monozygotic twins is fairly constant. The incidence of dizygotic twins is increasing mainly due to infertility treatment. Predisposing factors for dizygotic twins include:

Back 173

previous twins

family history

increasing maternal age

multigravida

induced ovulation and in-vitro fertilisation

race e.g. Afro-Caribbean

Front 174

Antenatal complications

Back 174

polyhydramnios

pregnancy induced hypertension

anaemia

antepartum haemorrhage

Front 175

Fetal complications - perinatal mortality (twins * 5, triplets * 10)

Back 175

prematurity (mean twins = 37 weeks, triplets = 33)

light-for date babies

malformation (*3, especially monozygotic)

Front 176

Labour complications of twins

Back 176

PPH increased (x2)

malpresentation

cord prolapse, entanglement

Front 177

Management of twins

Back 177

rest

ultrasound for diagnosis + monthly checks

additional iron + folate

more antenatal care (e.g. weekly > 30 weeks)

precautions at labour (e.g. 2 obstetricians present)

75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks

Front 178

A woman who is 34 weeks pregnant is admitted to the obstetric ward. She has been monitored for the past few weeks due to pregnancy-induced hypertension but has now developed proteinuria. Her blood pressure is 162/94 mmHg. Which one of the following antihypertensives is it most appropriate to commence?

Back 178

Labetalol is first-line for pregnancy-induced hypertension

Front 179

magnesium sulphate is used in

Back 179

eclampsia - first line

torsades de pointes - first line

acute asthma

Front 180

A 31-year-old woman with a history of normal smear results has a routine smear. Select the most appropriate action based on the following smear results:

Back 180

Normal smear = Repeat smear in 3 years

Moderate dyskaryosis = Refer for colposcopy

Borderline dyskaryosis (HPV negative) = Repeat smear in 3 years

Front 181

A 28-year-old woman with polycystic ovarian syndrome consults you as she is having problems becoming pregnant. She has a past history of oligomenorrhea and has previously recently stopped taking a combined oral contraceptive pill. Despite stopping the pill 6 months ago she is still not having regular periods. Her body mass index is 28 kg/m^2. Apart from advising her to lose weight, which one of the following interventions is most effective in increasing her chances of conceiving?

Back 181

Clomifene

Front 182

Infertility in PCOS - clomifene is superior to metformin

Back 182

true

so lose weight and give clomifene to increase chance of conceiving

Front 183

difference between hirsuitism and hypertrichosis

Back 183

hirsuitism is androgen dependent

hypertrichosis is androgen independent

Front 184

A 19-year-old woman at ten weeks gestation presents to her general practitioner with intermittent vaginal bleeding over the previous month and hyperemesis. Obstetric examination reveals a non-tender, large-for-dates uterus. These symptoms are strongly suggestive of which condition?

Back 184

Molar pregnancy

Front 185

hydratidiform mole aka

Back 185

molar pregnancy

give the mole a hiding

Front 186

fibroid aka

Back 186

leiomyoma

leo likes frybread (fibroid)

Front 187

A 30-year-old woman presents with a white, malodorous vaginal discharge. There is no associated itch or dyspareunia. A diagnosis of bacterial vaginosis is suspected.Overgrowth of which one of the following organisms is most likely to cause this presentation?

Back 187

Gardnerella

Front 188

Bacterial vaginosis - overgrowth of predominately Gardnerella vaginalis

Back 188

true

Front 189

Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present

Back 189

thin, white homogenous discharge

clue cells on microscopy: stippled vaginal epithelial cells

vaginal pH > 4.5

positive whiff test (addition of potassium hydroxide results in fishy odour)

Front 190

BV management

Back 190

oral metronidazole

Front 191

A mother brings her 6 year-old son to clinic with a widespread rash. You diagnose chickenpox. You know his mother, who is also a patient at the practice, is currently 20 weeks pregnant with her second child. What action should you take, if any, regarding her exposure to chickenpox?

Back 191

Enquire as to her chickenpox history

Front 192

You should ask pregnant women exposed to chickenpox if they have had the infection before. If they say no or are unsure, varicella antibodies should be checked. If it is confirmed they are not immune, varicella immunoglobulin should be considered. It can be given at any point in pregnancy and is effective up to 10 days after exposure.

Back 192

true

Front 193

if a woman is pregnancy and had chicken exposure and its now day 12 post exposure would you give varicella immunoglobulin

Back 193

no

It can be given at any point in pregnancy and is effective up to 10 days after exposure.

Front 194

A 48-year-old female smoker attends the GP for information regarding contraception. Her last menstrual period was 9 months ago and she is convinced that she has 'gone through the menopause'. The most suitable form of contraception is:

Back 194

The intrauterine system (IUS)

Front 195

menopause

Back 195

The menopause is a retrospective diagnosis and is said to occurred 12 months after the last menstrual period. Women who menopause under the age of 50 require contraception for at least 2 years after their last menstrual period. Those over the age of 50 require only 1 year of contraception. In view of this, it would be inappropriate to say this lady does not require any contraception because she is protected. Similarly prescribing the COCP for only 12 months would be equally inappropriate. The fact that she is also a smoker would mean that the risks outweigh the benefits of the COCP as she is over the age of 35. Hormone replacement therapy should not be used solely as a form of contraception and barrier methods are less effective than the other types of contraception listed thus the most appropriate answer is the IUS. This will take the patient through the menopause and can be used for 7 years (off-licence) or 2 years after her last menstrual period.

Front 196

Diagnosis

Back 196

12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

Front 197

The average women in the UK goes through the menopause when she is 51 years old. The climacteric is the period prior to the menopause where women may experience symptoms, as ovarian function starts to fail

Back 197

It is recommend to use effective contraception until the diagnosis has been confirmed using the above criteria

Front 198

A 47 year old woman is admitted to the gynaecology ward after the discovery of an ovarian mass on an annual gynaecological checkup. On general examination she is found to have a distended abdomen, with possible ascites, and bilateral pleural effusions. Biopsy of the mass reveals a fibroma. Given the signs and symptoms, what is the diagnosis?

Back 198

Meig's syndrome

Front 199

Meig's syndrome:

TAP

Back 199

Benign ovarian tumour, ascites, and pleural effusion.

Front 200

Pleural effusion

Back 200

Exudate (> 30g/L protein)

Transudate (< 30g/L protein)

Front 201

Pleural effusion

Exudate (> 30g/L protein)

Back 201

Exudate (> 30g/L protein)

infection: pneumonia, TB, subphrenic abscess

connective tissue disease: RA, SLE

neoplasia: lung cancer, mesothelioma, metastases

pancreatitis

pulmonary embolism

Dressler's syndrome

yellow nail syndrome

Front 202

Pleural effusion

Transudate (< 30g/L protein)

Back 202

heart failure

hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)

hypothyroidism

Meigs' syndrome

Front 203

A 25-year-old woman who is 7 weeks into her pregnancy, presents to A&E with a one week history of severe vomitting. She feels tired and unwell. She has dry skin and complains of a headache. Her B-hCG is raised however the uterus is of normal size for date. What is the most likely diagnosis?

Back 203

Hyperemesis gravidarum

Front 204

The vomitting, dry skin, tiredness and raised B-hCG may point towards molar pregnancy but however her uterus is not large for dates which is a classic finding on US in molar pregnancy

Back 204

true

Front 205

vomitting, dry skin, tiredness and raised B-hCG may point towards molar pregnancy

Back 205

true

Front 206

Smoking is associated with a decreased incidence of hyperemesis

Back 206

true

Front 207

management for hyperemesis gravidarum

Back 207

antihistamines should be used first-line (BNF suggests promethazine as first-line)

ginger and P6 (wrist) acupressure: NICE Clinical Knowledge Summaries suggest these can be tried but there is little evidence of benefit

admission may be needed for IV hydration

Front 208

hyperemesis gravidarum associations

Back 208

multiple pregnancies

trophoblastic disease

hyperthyroidism

nulliparity

obesity

Front 209

Complications of hyperemesis gravidarum

Back 209

Wernicke's encephalopathy

Mallory-Weiss tear

central pontine myelinolysis

acute tubular necrosis

fetal: small for gestational age, pre-term birth

Front 210

You are called to see a 25-year-old 10 week pregnant lady in the Emergency Department complaining of abdominal pain and heavy vaginal bleeding. Her observations are normal and she is afebrile, on ultrasound a fetal heart rate is still present and the uterus is the size expected. On examination her cervical os is closed. How would you classify her miscarriage?

Back 210

Threatened

Front 211

the eyes are open

the I's are open for miscarriages

Back 211

Inevitable and Incomplete

cervical os is open

Front 212

Always remember to rule out an ectopic pregnancy in pregnant women presenting with pain and bleeding.

Back 212

true

Front 213

A woman who is 8 weeks pregnant presents with abdominal pain and vaginal bleeding. On examination she is tender in the right iliac fossa and suprapubic region. Speculum examination shows an open cervical os. Ultrasound confirms an intrauterine pregnancy.

Back 213

This lady is likely to be having an inevitable miscarriage.

Front 214

A woman who is 33 weeks pregnant presents with vaginal bleeding, which she describes as being like a period. She also has constant, lower abdominal pain. On assessment her blood pressure is 90/60 mmHg and pulse is 110/min

Back 214

Placental abruption

Front 215

A woman who is 22 weeks pregnant presents with abdominal pain on the right side of her abdomen. On examination she has abdominal tenderness on the right side and urine dipstick is normal. White blood cells are raised at 18.5 * 109/l

Back 215

Appendicitis

Front 216

Ectopic pregnancy risk factors

Back 216

damage to tubes (salpingitis, surgery)

previous ectopic

IVF (3% of pregnancies are ectopic)

Front 217

Ectopic pregnancy

Back 217

A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleedinglower abdominal pain:

typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm

vaginal bleeding: usually less than a normal period, may be dark brown in colour

history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion

peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination

Front 218

Abdominal pain in early pregnancy differentials

Back 218

ectopic pregnancy

miscarriage

Front 219

Abdominal pain in late pregnancy differentials

Back 219

normal labour

placental abruption

symphysis pubis dysfunctin

Preeclampsia/HELLP

uterine rupture

Front 220

Abdominal pain at any point in pregnancy

Back 220

appendicitis

UTI

Front 221

Symphysis pubis dysfunction

Back 221

Ligament laxity increases in response to hormonal changes of pregnancy

Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

Front 222

Pre-eclampsia/HELLP syndrome

Back 222

Associated with hypertension, proteinuria. Patients with HELLP also have haemolysis, elevated liver enzymes and a low platelet count.The pain is typically epigastric or in the RUQ

Front 223

Uterine rupture

Back 223

Ruptures usually occur during labour but occur in third trimester

Risk factors: previous caesarean section

Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree

Front 224

A 33-year-old woman visits her general practitioner complaining of inability to conceive after two years of trying with a regular partner. She has a body mass index of 28 kg/m² and an existing diagnosis of polycystic ovarian syndrome. Which of the following drugs is most likely to help restore normal ovulation in this case?

Back 224

Metformin

Front 225

PCOS management if trying to conceive

Back 225

first line if overweight/obese = lose weight

next clomifene

next metformin

Metformin has been shown to have a beneficial effect on ovulation and conception rates in patients with PCOS.

Front 226

What is the most common identifiable cause of postcoital bleeding?

Back 226

Cervical ectropion is the most common identifiable cause of postcoital bleeding

Front 227

Postcoital bleeding

Back 227

no identifiable pathology is found in around 50% of cases

cervical ectropion is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill

Front 228

Rhesus negative woman - anti-D at 28 + 34 weeks

Back 228

true

Front 229

A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:

shes rhesus D negative

Back 229

Give first dose of anti-D at 28 weeks

Front 230

Antenatal care: timetable

Back 230

review

Front 231

A 40-year-old woman returns to the GP to discuss her recent blood results. A CA 125 was measured after she reported persistent abdominal bloating and urinary urgency over the past 2 months. Her CA 125 level is reported as 15 IU/ml. Normal CA 125 <35 IU/mlWhich one of the following is the most appropriate next action?

Back 231

Assess for other cause of symptoms and advise to return if these become more frequent

Front 232

A 37 year old woman who is 32 weeks pregnant presents with malaise, headaches and vomiting. She is admitted to the obstetrics ward after a routine blood pressure measurement was 190/95mmHg. Examination reveals right upper quadrant abdominal pain and brisk tendon reflexes. The following blood tests are shown:Hb85 g/lWBC6 * 109/lPlatelets89 * 109/lBilirubin2.8 µmol/lALP215 u/lALT260 u/lγGT72 u/lLDH846 u/IA peripheral blood film is also taken which shows polychromasia and schistocytes.What is the most likely diagnosis?

Back 232

HELLP syndrome

Front 233

HELLP syndrome is a severe form of

Back 233

pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).

Front 234

HELLP syndrome is a severe form of pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A typical patient might present with

Back 234

malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.

Front 235

Dubin–Johnson syndrome

gilberts

Back 235

they conjugate together dubin and johnson

thus get high conjugated bilirubin

were as gilbert is just one so unconjugated thus high levels of unconjugated

Front 236

A 32-year-old woman presents at 34 weeks gestation in her first pregnancy. She was admitted with loss of conciousness following a 1 day period of severe abdominal pain, nausea, vomiting, and visual disturbance. She has a family history of epilepsy. On examination, hyperreflexia is noted. What is the most likely diagnosis?

Back 236

Eclampsia

Front 237

Other symptoms of pre-eclampsia include

Back 237

abdominal pain, nausea, vomiting and visual disturbance.

Front 238

Prolonged hyperemesis gravidarum can result in dehydration and metabolic abnormalities, which could result in seizures. However this would be less likely due to the 1 day history.

Back 238

true

Front 239

An ultrasound scan shows a well-circumscribed lesion and aspiration yields a white fluid. What is the likely diagnosis?

Back 239

Galactocele

Front 240

A 30-year-old woman at 32 weeks gestation presents to the Emergency Department with a small amount of painless vaginal bleeding that came on spontaneously. Obstetric examination finds a cephalic presentation with high presenting part. The uterus is non-tender. The cervical os is closed and the cervix appears normal. Which of the following diagnoses is most likely?

Back 240

Placenta praevia

Front 241

Placenta praevia Classical grading

Back 241

I - placenta reaches lower segment but not the internal os

II - placenta reaches internal os but doesn't cover it

III - placenta covers the internal os before dilation but not when dilated

IV - placenta completely covers the internal os

Front 242

You are the obstetrics FY2 doctor checking through the list of patients currently on the labour ward. Which one of the following findings in one of the patients would prompt you to start continuous CTG tracing while in labour?

Back 242

New onset vaginal bleed while in labour

Front 243

As per NICE guidelines; the following would warrant continuous CTG monitoring if any of the following are present or arise during labour;

Back 243

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above

severe hypertension 160/110 mmHg or above

oxytocin use

the presence of significant meconium

fresh vaginal bleeding that develops in labour - this was a new point added to the guidelines in 2014

Front 244

You are called to see a 32-year-old woman who has vaginal bleeding one hour post delivery. Formal measurement estimates the blood loss at 1200mls including liquor. Blood pressure is 98/52mmHg and heart rate 110bpm. Bleeding is ongoing. Which of the following options is most appropriate?

Back 244

IV access, crossmatch, commence crystalloid infusion

Front 245

The causes of PPH can be divided into four T's

Back 245

uterine Tone, Tissue, Trauma and Thrombin

Front 246

Post-partum haemorrhage (PPH) is defined as

Back 246

blood loss of > 500mls and may be primary or secondary

Front 247

Primary PPH

Back 247

occurs within 24 hours

affects around 5-7% of deliveries

most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors

Front 248

Risk factors for primary PPH include*:

Back 248

previous PPH

prolonged labour

pre-eclampsia

increased maternal age

polyhydramnios

emergency Caesarean section

placenta praevia

macrosomia

ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)

Front 249

Management of PPH

Back 249

ABCIV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms

IM carboprost

other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries

if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Front 250

Secondary PPH

Back 250

occurs between 24 hours - 12 weeks**

due to retained placental tissue or endometritis

Front 251

major post partum haemorrhage (PPH) due to an estimated blood loss of greater than 1000 mls

Back 251

true

Front 252

do you do a group and save in major PPH

Back 252

no

Front 253

do you use tranexamic acid in PPH

Back 253

NO

Front 254

do you do crossmatch in major PPH

Back 254

yes

Front 255

major PPH ED mgmt

Back 255

IV access, crossmatch, commence crystalloid infusion

Front 256

major PPH

Back 256

The causes of PPH can be divided into four T's (uterine Tone, Tissue, Trauma and Thrombin). In uterine atony bimanual uterine compression should be trialed first and a Foley catheter passed to ensure an empty bladder. Uterine balloon tamponade is a suitable first line surgical management, but pharmacological measures should be trialled first. These include a bolus of intravenous syntocinon (repeated if necessary), followed by ergometrine, syntocinon infusion and carboprost in turn.

A fluid challenge should be instituted in the first instance while blood products are awaited. The RCOG state that up to 3.5L of warmed crystalloid can be infused at an appropriate rate while waiting for blood products.

Front 257

Which of the following is the most commonly recognised risk of combined hormone replacement therapy (HRT)?

Back 257

Gallbladder disease

Front 258

Unopposed oestrogen increases the risk of endometrial cancer and remains elevated for 5 or more years after stopping therapy

Back 258

The risk is not eliminated completely with additional sequential progestogen

No increased risk has been found with continuous combined HRT

Front 259

Risk of ovarian cancer is higher the longer HRT is taken.

Back 259

But when the HRT is stopped, the risk goes back down to normal over a few years

Front 260

Venous thromboembolism risk is more than doubled with HRT but absolute risk remains small

Back 260

true

Front 261

Risk of breast cancer is increased as it simulated delaying menopause.

Back 261

Every year the menopause is naturally delayed, the risk increases by 2.8%

With HRT the risk is increased by 2.3% by year

Front 262

The risk of gallbladder disease is increased in women taking HRT - though this risk may be reduced with transdermal administration:

Back 262

true

Front 263

Hormone replacement therapy (HRT) may be used to replace decreasing oestrogen levels around the perimenopausal period

Back 263

true

Front 264

A 26-year-old woman presents to the sexual health clinic with a 2 week history of purulent vaginal discharge. Microscopy of an endocervical swab sample shows Gram-negative diplococci. Tests for other pathogens are negative. The patient has no comorbidities or allergies. Which of the following antibiotic choices is most appropriate?

Back 264

Azithromycin + ceftriaxone

Front 265

A hirsute 28-year-old lady attends the GP practice complaining that her periods are absent. Which one of these is part of the diagnostic criteria for polycystic ovarian syndrome (PCOS)?

Back 265

Oligomenorrhoea

Front 266

PCOS should be diagnosed if 2/3 of the following criteria are present:

Back 266

Infrequent or no ovulation (thus oligomenorrhoea is the correct answer in this scenario)

Clinical or biochemical signs of hyperandrogenism or elevated levels of total or free testosterone (no mention of 'low levels of oestrogen')

Polycystic ovaries on ultrasonography or increased ovarian volume

Front 267

hyperandrogenism in woman

Back 267

hirsutism, alopecia, acne vulgaris occurring after adolescence

Front 268

PCOS features

Back 268

subfertility and infertility

menstrual disturbances: oligomenorrhea and amenorrhoea

hirsutism, acne (due to hyperandrogenism)

obesity

acanthosis nigricans (due to insulin resistance)

Front 269

PCOS investigatins

Back 269

pelvic ultrasound

FSH, LH, prolactin, TSH, and testosterone

check for impaired glucose tolerance

Front 270

A 30-year-old para 1+0 has presented at term in labour. On vaginal examination, the occiput can be palpated posteriorly (near the sacrum). Which of these is correct regarding your further management of these patients?

Back 270

The fetal head may rotate spontaneously to an OA position

Front 271

2: Delivery is possible in the OP position, however labour is likely to be longer and more painful.

3: Augmentation should be used if progress is slow.

4: Kielland's forceps are associated with the most successful outcomes, however require particular expertise.

5: Generally, women will experience an earlier urge to push in OP than OA.

Back 271

true

Front 272

Labour may be divided in to three stages

Back 272

stage 1: from the onset of true labour to when the cervix is fully dilated

stage 2: from full dilation to delivery of the fetus

stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

Front 273

Stage 2 - from full dilation to delivery of the fetus

Back 273

'passive second stage' refers to the 2nd stage but in the absence of pushing (normal)

active second stage' refers to the active process of maternal pushing

less painful than 1st (pushing masks pain)

lasts approximately 1 hours

if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section

episiotomy may be necessary following crowning

associated with transient fetal bradycardia

Front 274

A 22 year old woman who was admitted 2 days ago to the obstetrics ward because of preterm premature rupture of membranes (PPROM) has started to complain of abdominal pain, uterine contractions and 'flu-like symptoms'. Her history reveals that she is currently 24 weeks pregnant and has not had any complications up until the current admission. On examination she looks unwell with a fever of 39 degrees. A gynaecological examination reveals a foul-smelling discharge originating from the cervix which is subsequently collected and sent for analysis. At this point, what is the most likely diagnosis?

Back 274

Chorioamnionitis

Front 275

Chorioamnionitis

Back 275

(which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

Front 276

A 34-year-old pregnant woman presents at 30 weeks gestation for a routine check. On examination she has a symphysis-fundal height of 25 cm. What is the next most important investigation to confirm the examination findings?

Back 276

Ultrasound

Front 277

The measurement of the symphysis-fundal height in centimetres should closely match the foetal gestational age in weeks within 1 or 2 cm from 20 weeks gestation.

Back 277

so if it shows small for dates

It is therefore important to perform an ultrasound to confirm whether or not the foetus is small for gestational age.

Front 278

Symphysis-fundal height

Back 278

The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres

It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm

Front 279

A 23-year-old woman who has been diagnosed with polycystic ovary syndrome (PCOS) is trying to become pregnant. She has already made any appropriate lifestyle changes and reduced her BMI to 25. However, she remains anovulatory. What is the most appropriate next step of treatment?

Back 279

Clomifene

Front 280

A 31-year-old woman presents for review. For the past few months she has been feeling generally tired and has not had a normal period for around 4 months. Prior to this she had a regular 30 day cycle. A pregnancy test is negative, pelvic examination is normal and routine bloods are ordered:FBCNormalU&ENormalTFTNormalFollicle-stimulating hormone41 iu/l ( < 35 iu/l)Luteinizing hormone33 mIU/l (< 20 mIU/l)Oestradiol70 pmol/l ( > 100 pmol/l)What is the most likely diagnosis?

Back 280

Premature ovarian failure

Front 281

Premature ovarian failure is defined as

Back 281

the onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years

Front 282

Premature ovarian failureFeatures are similar to those of the normal climacteric but the actual presenting problem may differ

Back 282

climacteric symptoms: hot flushes, night sweats

infertility

secondary amenorrhoea

raised FSH, LH levels

Front 283

A 28-year-old woman is 30 weeks into her first pregnancy. She is found to have a blood pressure of 162/110 mmHg and a urine dipstick shows protein +++. She also has marked oedema of her ankles but feels well in herself. What is the first line therapy to manage her high blood pressure?

Back 283

Labetalol

Front 284

This patient is suffering from pre-eclampsia. The National Institute for Health and Care Excellence state that women with severe hypertension in pregnancy (160/110mmHg or higher) should be treated with labetalol as first time treatment. Delivery should not be offered to women before 34 weeks unless:

Back 284

severe hypertension remains refractory to treatment

maternal or fetal indications develop as specified in the consultant plan

Front 285

Frusemide should not be used to treat hypertension in pregnancy because

Back 285

placental perfusion may be reduced and it crosses the placental barrier

Front 286

At 34 weeks delivery should be offered to women with pre-eclampsia once a course of corticosteroids has been completed.

Back 286

true

Front 287

A 33-year-old female presents with a vaginal discharge. Which one of the following features is not consistent with bacterial vaginosis?

Back 287

Strawberry cervix

Front 288

A strawberry cervix is associated with

Back 288

Trichomonas vaginalis

Front 289

You are called to see a 33-year-old patient complaining of vaginal bleeding 12 hours after a vaginal delivery. On arrival, she is alert, complaining of breathlessness and giddiness. Her blood pressure is 97/73 mmHg. She has no history of a bleeding disorder, and you are told she did not tear. She has a blue cannula in situ with nothing attached, and the midwife has bleeped the registrar on call. What is your immediate course of action?

Back 289

Insert a large bore cannula

Front 290

Cannula = Flow rate (mL/min)

Back 290

Blue (22G) = 31

Pink (20G) = 55

Green (18G) = 90

White (17G) = 135

Grey (16G) = 170

Orange (14G) = 265

Front 291

A pregnancy test performed in the department is positive and transvaginal ultrasound confirms a pregnancy in the adnexa with a fetal heart beat present. What is the most appropriate management in this case?

Back 291

Surgical management - salpingectomy or salpingotomy

Front 292

Which one of the following statements regarding endometrial cancer is incorrect?Has a poor prognosis

Back 292

Has a poor prognosis

Front 293

Endometrial cancer usually has a good prognosis

Back 293

true

Front 294

whats the first line investigation for endometrial cancer suspicion

Back 294

transvaginal ultrasound

Front 295

A 32 year old woman with gestational diabetes undergoes a difficult spontaneous vaginal delivery. During her strenuous efforts she unfortunately suffers a perineal tear. Examination reveals it involves structures from the vaginal mucosa to approximately 70% of the external anal sphincter.What degree of tear is this?

Back 295

3rd degree - subcategory B

Front 296

The RCOG has produced guidelines suggesting the following classification of perineal tears:

Back 296

first degree: superficial damage with no muscle involvement

second degree: injury to the perineal muscle, but not involving the anal sphincter

third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):

3a: less than 50% of EAS thickness torn

3b: more than 50% of EAS thickness torn

3c: IAS torn

fourth degree: injury to perineum involving the anal sphincter complex (EAS and

Front 297

Risk factors for perineal tears

Back 297

primigravida

large babies

precipitant labour

shoulder dystocia

forceps delivery

Front 298

A 20-year-old primiparous woman is in the final stages of delivery. The baby's leading shoulder becomes impacted behind her pelvis. The midwife rings the emergency call bell. What is the first step in management?

Back 298

Flex and abduct the hips as much as possible (McRobert's manoeuvre)

Front 299

McRobert's manoeuvre is the first recommended step in

Back 299

managing shoulder dystocia.

Front 300

McRobert's manoeuvre

Back 300

involves flexing the mother's hips towards her abdomen and abducting them outwards, usually with the help of two assistants. This movement tilts the pelvis upwards, moving the pubic symphysis in the same direction, which increases the functional dimensions of the pelvic outlet. This increases the space available for the anterior shoulder to be delivered, and is successful in the majority of cases of shoulder dystocia. It should be carried out before invasive, potentially damaging procedures.

Front 301

A pregnant woman at 11 weeks gestation has a miscarriage. Of these five factors, which one is most associated with miscarriage?

Back 301

Obesity

Front 302

Factors that are associated with an increased risk of miscarriage are:

Back 302

Increased maternal age

Smoking in pregnancy

Consuming alcohol

Recreational drug use

High caffeine intake

Obesity

Infections and food poisoning

Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes

Medicines, such as ibuprofen, methotrexate and retinoids

Unusual shape or structure of womb

Cervical incompetence

Front 303

Factors that have not been associated with an increased risk of miscarriage are:

Back 303

Heavy lifting

Bumping your tummy

Having sex

Air travel

Being stressed

Front 304

A 39-year-old female with a history of chronic pelvic pain is diagnosed with endometriosis. Which one of the following is not a recognised treatment for this condition?

Back 304

Dilation and curettage

Front 305

A pregnant woman is found to have tested positive syphilis during her routine booking visit bloods. She is currently 12 weeks pregnant. What is the most appropriate management?

Back 305

IM benzathine penicillin G

dont use doxycycline in pregnancy

Front 306

Syphilis: management

Back 306

benzylpenicillin

alternatives: doxycycline

the Jarisch-Herxheimer reaction is sometimes seen following treatment. Fever, rash, tachycardia after first dose of antibiotic. It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment.

Front 307

A 25-year-old woman presents for her first cervical smear. What is the most important aetiological factor causing cervical cancer?

Back 307

Human papilloma virus 16 & 18

Front 308

The incidence of cervical cancer peaks around the 6th decade. It may be divided into

Back 308

squamous cell cancer (80%)

adenocarcinoma (20%)

Front 309

features of cervical cancer

Back 309

may be detected during routine cervical cancer screening

abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding

vaginal discharge

Front 310

Mechanism of HPV causing cervical cancer

Back 310

HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively

E6 inhibits the p53 tumour suppressor gene

E7 inhibits RB suppressor gene

Front 311

A 50-year-old woman comes to see you in clinic complaining of hot flushes which are keeping her up at night. She is still having periods, although they are lighter and not every month. You counsel her about hormone replacement therapy (HRT) and she decides she would like to try it. She has not had a hysterectomy. Which of the following HRT regimes would be most appropriate?

Back 311

Systemic combined cyclical HRT

Front 312

In order to find the correct HRT regime, there are 3 main areas to address -

Back 312

whether there is a uterus or not, whether the patient is perimenopausal or menopausal and whether a systemic or local effect is required.

Front 313

This patient can be classed as perimenopausal as she is still having periods (menopause is defined as 12 months after the last menstrual period). Therefore the correct answer is: combined oestrogen and progestogen cyclical HRT.Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.

Back 313

true

Front 314

Cyclical HRT is recommended in perimenopausal women because it produces predictable withdrawal bleeding, whereas continuous regimens often cause unpredictable bleeding.

Back 314

true

Front 315

A 38-year-old patient who is undergoing in vitro fertilisation (IVF) for tubal disease presents 4 days after egg retrieval with abdominal discomfort, nausea and vomiting. She has a past medical history of well-controlled Crohn's disease and is currently taking azathioprine maintenance therapy. On examination her abdomen is visibly distended. The most likely diagnosis is:

Back 315

Ovarian hyperstimulation syndrome

Front 316

Ovarian hyperstimulation syndrome (OHSS) is a complication seen in some forms of

Back 316

infertility treatment

Front 317

Ovarian hyperstimulation syndrome (OHSS) pathphys

Back 317

It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment

Front 318

Ovarian hyperstimulation syndrome

Back 318

Whilst it is rarely seen with clomifene therapy is more likely to be seen following gonadotropin or hCG treatment. Up to one third of women who are having IVF may experience a mild form of OHSS

Front 319

A 17-year-old comes to your clinic, concerned that she has not yet started her periods although most of her friends have. She is 150 cm tall and 45 kg in weight. She reports the development of pubic hair since the age of 14 and has normal breast development. What management would you suggest?

Back 319

Refer to a gynaecologist

Front 320

A 35 year-old lady attends the GP practice complaining of heavy painless periods which are interrupting with her lifestyle and causing her distress at work. She is currently in the process of trying for a family. The most suitable option is:

Back 320

Tranexamic acid

Front 321

most suitable treatment for menorrhagia specific to this patient. This patient is in the process of trying to get pregnant thus ruling out

Back 321

contraceptive pill and the intrauterine system (IUS)

Front 322

Tranexamic acid moa

Back 322

a plasminogen activator inhibitor that acts as an anti-fibrinolytic to prevent heavy menstrual bleeding.

Front 323

menorrhagia management

Back 323

if want to get preg

mefenamic acid (if painful)

tranexamic acid (not painful)

if not want to get preg

IUS first line

COC

long acting P4

Front 324

A 17 year old girl presents with a history of amenorrhoea, having never started her period. On further questioning she has developed secondary sexual characteristics, such as growth of breast tissue and pubic hair. She also complains of pelvic pain and some bloating.Which of the following is likely to be the cause?

Back 324

Imperforate hymen

Front 325

A 40-year-old woman presents to her GP with a history of menorrhagia, she notes that more recently her periods last 10 days and are very heavy. In addition to this, she has no history of weight loss, her recent sexual health screen was negative and her examination findings are normal. She has two children and has completed her family. What is the first line treatment in this patient?

Back 325

Intrauterine system (Mirena coil)

Front 326

Mirena coil is first line management in women whom long term contraception with an intrauterine device is acceptable.

Back 326

true

Front 327

A 78 year old woman presents with post-menopausal bleeding. She has had multiple episodes over the past 8 months. She has to wear sanitary pads due to the bleeding, and says it can be quite heavy but denies any clots. She does not have any bowel or urinary symptoms. She denies weight loss and is otherwise well. She went through the menopause at the age of 49 years and took hormone replacement therapy to reduce symptoms of hot flushes and mood swings for 3 years. She has 1 child who was born by spontaneous vaginal delivery 50 years ago. There is no family history of any gynaecological problems. What is the most likely diagnosis?

Back 327

Endometrial cancer

Front 328

In women presenting with post menopausal bleeding (PMB), we must rule out endometrial cancer.

Back 328

A speculum examination should first be performed to look for any obvious abnormalities and ultimately endometrial biopsy and hysteroscopy should be carried out in women over 40 years of age in order to diagnose endometrial cancer.

Front 329

Cervical ectropion does present with bleeding, but is usually in younger patients.

Back 329

true

Front 330

Ovarian cancer usually presents with minimal symptoms and rarely PMB - more frequently patients will complain of

Back 330

bloating, abdominal pain, weight loss, urinary incontinence.

Front 331

Vaginal cancer usually presents with vaginal discharge

Back 331

true

Front 332

If ruptures may cause pseudomyxoma peritonei

Back 332

Mucinous cystadenoma

Front 333

The most common type of epithelial cell tumour

Back 333

Serous cystadenoma

Front 334

A 32 year-old lady has a diagnosis of fibroids and has been trying for a baby for 18 months. She has been under investigation at the sub-fertility clinic and no abnormality has been found except for three small submucosal fibroids, for which she does not have any symptoms. Her partner has had sperm analysis which found no abnormality. Which of the following treatments are most appropriate in this situation?

Back 334

Myomectomy

Front 335

myomectomy as a treatment for uterine fibroids can help to

Back 335

retain fertility

therefore if a patient wants to have kids then this is a good option

Front 336

how do GNRH agonists work in uterine fibroids

Back 336

GnRH agonists effectively turn off the ovaries, which causes the fibroids to shrink and therefore are easier to remove surgically. On stopping the medication, the fibroids grow back. As this treatment turns off the ovaries, it inhibits ovulation and therefore means that pregnancy is not possible during this time. As a treatment on its own, it would not be suitable in this case as it causes temporary infertility and fibroid regrowth on cessation. However, if combined with a myomectomy, it would provide a suitable treatment option.

Front 337

of the treatment options for uterine fibroids which helps to retain fertility

Back 337

myomectomy

Front 338

do GnRH agonists permanently turn of the ovaries so you dont ovulate

Back 338

no, only temporarily while you take it, you will start ovulating when you stop it

thus if you want to get pregnant immediately then don't use this option

Front 339

is endometrial ablation allow fertility in uterine fibroid management

Back 339

no, it destroys the endometrial lining thus no implantation

Front 340

uterine artery embolisation is a treatment option for uterine fibroids, but does it retain fertility

Back 340

no, it will decrease blood supply to the uterus significantly

thus fetus can't implant and grow

Front 341

does ulipistal acetate affect fertility in uterine fibroids

Back 341

yes

so if female wants to get pregnant don't give this

Front 342

ulipistal acetate features

Back 342

is a selective progesterone receptor modulator. It is used pre-operatively for women with fibroids as it has been proven to shrink them, thus making surgery easier. This medication affects fertility, thus is not suitable for women trying to get pregnant, unless (like GnRH agonists) it is used for a short period in combination with surgery.

Front 343

uterine fibroids aka fibroids are a

Back 343

benign smooth muscle tumours of the uterus

occur in later reproductive years

Front 344

features of fibroids

Back 344

may be asymptomatic

menorrhagia

lower abdominal pain: cramping pains, often during menstruation

bloating

urinary symptoms, e.g. frequency, may occur with larger fibroids

subfertility

Front 345

how are uterine fibroids diagnosed

Back 345

transvaginal ultrasound

Front 346

management of uterine fibroids

Back 346

symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line

other options include tranexamic acid, combined oral contraceptive pill etc

GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment

surgery is sometimes needed: myomectomy, hysterscopic endometrial ablation, hysterectomy

uterine artery embolization

Front 347

A 32-year-old women para 1+0 is 37+1 weeks pregnant and is being monitored and treated for pre-eclampsia. Her current treatment is with labetalol and her blood pressure has been well controlled. She attends the antenatal clinic complaining of a severe headache, one episode of vomiting, and blurred vision. Her blood pressure is currently 156/100 mmHg. On examination she has papilloedema. She is admitted to hospital. What is the appropriate management?

Back 347

IV magnesium sulphate and plan immediate delivery

Front 348

Can you give magnesium sulphate to treat and prophylactically and if your concerned about female developing eclampsia

Back 348

yes

Magnesium sulphate is used to treat women with severe hypertension or severe pre-eclampsia that have already had a seizure. IV magnesium sulphate should also be considered if birth is planned within 24 hours or if there is concern that a woman may develop eclampsia.

Front 349

what do you use to treat magnesium toxicity

Back 349

IV calcium gluconate

Front 350

NICE guidelines recommend delivery within 24-48 hours in those women who has pre-eclampsia with mild or moderate hypertension after 37 weeks

Back 350

true

Front 351

IV magnesium sulphate should also be considered if birth is planned within 24 hours or if there is concern that a woman may develop eclampsia.

Back 351

true

Front 352

preeclampsia facts

Back 352

Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific

Front 353

Pre-eclampsia is important as it predisposes to the following problems

Back 353

fetal: prematurity, intrauterine growth retardation

eclampsia

haemorrhage: placental abruption, intra-abdominal, intra-cerebral

cardiac failure

multi-organ failure

Front 354

Risk factors for preeclampsia

Back 354

> 40 years old

nulliparity (or new partner)

multiple pregnancy

body mass index > 30 kg/m^2

diabetes mellitus

pregnancy interval of more than 10 years

family history of pre-eclampsia

previous history of pre-eclampsia

pre-existing vascular disease such as hypertension or renal disease

Front 355

Features of severe pre-eclampsia

Back 355

hypertension: typically > 170/110 mmHg and proteinuria as above

proteinuria: dipstick ++/+++

headache

visual disturbance

papilloedema

RUQ/epigastric pain

hyperreflexia

platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Front 356

management of preeclampsia

Back 356

consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used

delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenarioNext question

Front 357

A 32-year-old woman is found having a seizure on the maternity ward. The midwife mentions she had been admitted to 'keep an eye on her blood pressure' and that she had recently been complaining of a severe headache. Her last blood pressure was 167/92mmHg and was taking Labetalol 200mg three times daily. There is no past medical history of note. Which of the following is most appropriate?

Back 357

Intravenous magnesium sulphate

Front 358

Management of eclampsia seizure

Back 358

Intravenous magnesium sulphate is the anticonvulsant of choice in this situation.

An ABC approach should be used initially and pregnant woman should be placed in the left lateral position. Once terminated, a magnesium infusion should be started and continued for 24 hours.

Pregnant woman should be resuscitated in a left lateral position. This is to prevent the pregnant uterus from compressing the inferior vena cava and reducing venous return to the heart

Front 359

Eclampsia may be defined as

Back 359

the development of seizures in association pre-eclampsia

Front 360

pre-eclampsia is defined as:

Back 360

condition seen after 20 weeks gestation

pregnancy-induced hypertension

proteinuria

Front 361

Magnesium sulphate is used to both

Back 361

prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop.

Front 362

Eclampsia

Guidelines on its use suggest the following:

Back 362

should be given once a decision to deliver has been made

in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour

urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment

treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Front 363

Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload

Back 363

true

Front 364

A pregnant woman at 9 weeks gestation attends the emergency department with abdominal pain, bleeding and passing large clots. She is having a miscarriage and the cervical os was open. An ultrasound shows products of conception in the womb and she is offered three different management options; medical, surgical or expectant. What sort of miscarriage has she had?

Back 364

Incomplete

Front 365

table of different types of miscarriages

Back 365

Front 366

A 30-year-old pregnant woman attends the Emergency Department complaining of shortness of breath. She is 36-weeks pregnant and has had no complications. Physical examination was unremarkable other than a rapid pulse of 110 bpm. A prominent central pulmonary artery was seen on CXR. Which of the following investigations should be ordered to provide a definite diagnosis of pulmonary embolism in this patient?

Back 366

Computed tomography pulmonary angiogram

Front 367

Pregnancy: DVT/PE investigation

Guidelines were updated in 2015 by the Royal College of Obstetricians. Key points include:

Back 367

ECG and chest x-ray should be performed in all patients

if CXR normal then do duplex doppler to try look for PE and prevent use of radiation

next do V/Q or CTPA

Front 368

Comparing CTPA to V/Q scanning in pregnancy

Back 368

CTPA slightly increases the lifetime risk of maternal breast cancer (increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation

V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA (1/280,000 versus less than 1/1,000,000)

Front 369

Comparing CTPA to V/Q scanning in pregnancy

Back 369

CTPA can increase lifetime risk of maternal breast cancer

V/Q scanning increase risk of childhood cancer

Front 370

D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.

Back 370

true

Front 371

A primigravid 43 year-old woman, who is at 27 weeks gestation, presents to the maternity unit with regular weak contractions. Examination reveals her cervix is 3 cm dilated and membranes are intact. What would be the most appropriate management?

Back 371

Admit and administer tocolytics and steroids

Front 372

A primigravid 43 year-old woman, who is at 27 weeks gestation, presents to the maternity unit with regular weak contractions. Examination reveals her cervix is 3 cm dilated and membranes are intact. What would be the most appropriate management?

Back 372

This woman is now in premature labour, although at 3cm dilated it is still in an early stage. Therefore, it may be stopped by administering tocolytic medication. In case the labour continues and delivery is required, steroids are given as a pre-emptively to help the foetal lungs mature. Antibiotics are not required as there is no indication of an infection. Syntocinon injection contains oxytocin which strengthens the contractions of the uterus!

Front 373

Risk of prematurity

Back 373

increased mortality depends on gestation

respiratory distress syndrome

intraventricular haemorrhage

necrotizing enterocolitis

chronic lung disease, hypothermia, feeding problems, infection, jaundice

retinopathy of newborn, hearing problems

Front 374

A 29-year-old woman who is known to have HIV visits her general practitioner (GP) to discuss becoming pregnant. At present she is not on any antiretroviral (ARV) medications because her CD4 count is sufficiently high and viral load low. What advice should the GP give her about what treatment she may need in pregnancy or post-partum?

Back 374

She will need to begin ARV treatment and may require a caesarean section

Front 375

Breastfeeding should be avoided as this increases the risk of viral transmission even when the mother is taking cART.

Back 375

true

Front 376

Although this woman's viral load is low at present she should begin

Back 376

combination antiretroviral therapy (cART) in early pregnancy to ensure that it remains as low as possible, minimising the risk of transmission to the fetus

Viral load is measured again in the third trimester and caesarean section at 38 weeks is recommended for women with HIV RNA levels > 1000 copies/ml at this time.

Front 377

Factors which reduce vertical transmission (from 25-30% to 2%)

Back 377

maternal antiretroviral therapy

mode of delivery (caesarean section)

neonatal antiretroviral therapy

infant feeding (bottle feeding)

Front 378

The aim of treating HIV positive women during pregnancy is to

Back 378

minimise harm to both the mother and fetus, and to reduce the chance of vertical transmission.

Front 379

Antiretroviral therapy

Back 379

all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously

if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation

Front 380

all HIV pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously

Back 380

true

if women are not currently taking antiretroviral therapy the RCOG recommend that it is commenced between 28 and 32 weeks of gestation and should be continued intrapartum. BHIVA recommend that antiretroviral therapy may be started at an earlier gestation depending upon the individual situation

Front 381

whats the mode of delivery for HIV pregnant mother

Back 381

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended

a zidovudine infusion should be started four hours before beginning the caesarean section

Front 382

Neonatal antiretroviral therapy after birth from HIV positive mother

Back 382

zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.

Front 383

A 35-year-old woman comes to see you, her GP, because she feels tearful and low since the birth of her son 1 month ago and she isn't sleeping well. She says she thinks the baby hates her and feels they aren't bonding, though she is still breast feeding. She has a good family network, including the baby's father and has never suffered with depression in the past. She does not feel suicidal and has not been abusing any substances, you do not feel the baby is at risk. What is the most appropriate management?

Back 383

Cognitive behavioural therapy (CBT)

Front 384

The National Institute for Health and Care Excellence recommends that for women without previous history of severe depression, the first line treatment for moderate to severe depression in pregnancy or the post-natal period should be

Back 384

a high intensity psychological intervention (such as CBT).

If this is refused, or symptoms do not improve, then an antidepressant should be used - SSRI or TCA

Mindfulness may be useful for women with persistent subclinical depressive symptoms.

You would only need to involve social services if you felt that someone in the household may be at risk.

Front 385

zopiclone should be avoided whilst breast feeding as it is present in breast milk.

Back 385

true

Front 386

Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis.

Back 386

true

Front 387

whats the screening tool for postnatal depression

Back 387

The Edinburgh Postnatal Depression Scale:

10-item questionnaire, with a maximum score of 30

indicates how the mother has felt over the previous week

score > 13 indicates a 'depressive illness of varying severity'

sensitivity and specificity > 90%

includes a question about self-harm

Front 388

baby blues

Back 388

Seen in around 60-70% of women

Typically seen 3-7 days following birth and is more common in primips

Mothers are characteristically anxious, tearful and irritable

Reassurance and support, the health visitor has a key role

Front 389

Postnatal depression

Back 389

Affects around 10% of women

Most cases start within a month and typically peaks at 3 months

Features are similar to depression seen in other circumstances

As with the baby blues reassurance and support are important

Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant

*paroxetine is recommended by SIGN because of the low milk/plasma ratio

**fluoxetine is best avoided due to a long half-life

Front 390

Puerperal psychosis

Back 390

Affects approximately 0.2% of women

Onset usually within the first 2-3 weeks following birth

Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Admission to hospital is usually required

There is around a 20% risk of recurrence following future pregnancies

Front 391

the three mental illnesses after pregnancy

Back 391

baby blues - days

puerperal psychosis - weeks

postnatal depression - month(s)

Front 392

A 3 week old boy presents with dehydration and 1 day history of vomiting. His mother is very worried and blames herself saying that she has done something wrong because this is her first child. She says he is always very hungry after feeding. On inspection, the vomit contains formula. On examination, the anterior fontanelle is sunken. The abdomen has peristaltic waves and a firm, mobile 2cm mass above the umbilicus. A nasogastric tube is placed. What is the next step?

Back 392

Correct hypokalaemic metabolic alkalosis

Front 393

treatment for pyloric stenosis with dehydration

Back 393

The treatment of dehydration is rehydration along with correction of hypokalaemia.

Front 394

A 24-year-old woman presents to her GP complaining of excess arm hair. She has olive skin and dark brown hair. She removes the hair by shaving it. Her menstrual cycle is 27-41 days long. What is the most likely diagnosis?

Back 394

Polycystic ovarian syndrome

Front 395

Hirsutism is a common feature of polycystic ovarian syndrome, where hair growth can occur in excess on the face and body.

Back 395

true

Front 396

ady's menstrual cycle varies between 27-41 days. A variation of 8 days of more is abnormal. Normal menstrual cycles are 24-35 days long.

Back 396

true

Front 397

A 23-year-old primigravida woman at 36 weeks gestation presents with mild irregular labor pains in the lower abdomen. On examination she has a firm, posterior, closed cervix. Fetal heart tones are heard. The pain stops during the consultation. What is the most appropriate next step?

Back 397

Reassure and discharge

Front 398

False Labor

Back 398

Occurs in the last 4 weeks of pregnancy

Presentation: contractions felt in the lower abdomen. The contractions are irregular and occur every 20 minutes. Progressive cervical changes are absent.

Front 399

Head enters pelvis in occipito-lateral position. The head normally delivers in an occipito-anterior position.

Back 399

true

Front 400

most pregnancy presentation is

Back 400

90% of babies are vertex

Front 401

An 18-year-old woman presents to her general practitioner seeking emergency contraception for an episode of unprotected sex that occurred 36 hours ago. She is on day 20 of her menstrual cycle. The GP notes that ellaOne (ulipristal acetate) was prescribed to this patient one week ago for a similar episode. Which of the following is a suitable method of emergency contraception in this case?

Back 401

Levonelle (levonorgestrel) pill

Front 402

emergency contraception include ellaOne (ulipristal acetate 30mg) and Levonelle (levonorgestrel 1.5mg)

Back 402

true

Front 403

Levonelle features

Back 403

Levonelle is effective if taken within 72 hours of unprotected intercourse (it may be used until 96 hours but its effectiveness decreases over time) and can be used more than once during a menstrual cycle

Front 404

ellaOne (ulipristal acetate) features

Back 404

ellaOne is effective if taken within 120 hours of unprotected intercourse, but can only be used once in a menstrual cycle.

Front 405

Emergency hormonal contraception

Back 405

Levonorgestrel

Ulipristal

Intrauterine device (IUD)

Front 406

Intrauterine device (IUD)

Back 406

must be inserted within 5 days of UPSI, orif a women presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation datemay inhibit fertilisation or implantationprophylactic antibiotics may be given if the patient is considered to be at high-risk of sexually transmitted infectionis 99% effective regardless of where it is used in the cyclemay be left in-situ to provide long-term contraception. If the client wishes for the IUD to be removed it should be at least kept in until the next period

Front 407

Ulipristal

Back 407

a progesterone receptor modulator currently marketed as EllaOne. The primary mode of action is thought to be inhibition of ovulation30mg oral dose taken as soon as possible, no later than 120 hours after intercourseconcomitant use with levonorgestrel is not recommendedUlipristal may reduce the effectiveness of hormonal contraception. Contraception with the pill, patch or ring should be started, or restarted, 5 days after having Ulipristal. Barrier methods should be used during this periodcaution should be exercised in patients with severe asthmarepeated dosing within the same menstrual cycle is not recommendedbreastfeeding should be delayed for one week after taking ulipristal. There are no such restrictions on the use of levonorgestrel

Front 408

Levonorgestrel

Back 408

should be taken as soon as possible - efficacy decreases with timemust be taken within 72 hrs of unprotected sexual intercourse (UPSI)*single dose of levonorgestrel 1.5mg (a progesterone)mode of action not fully understood - acts both to stop ovulation and inhibit implantation84% effective is used within 72 hours of UPSIlevonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%if vomiting occurs within 2 hours then the dose should be repeatedcan be used more than once in a menstrual cycle if clinically indicated

Front 409

You are the junior doctor on the labour ward, and are called to a 27-year-old's first delivery. She underwent spontaneous preterm rupture of membranes at 34 weeks, and now the umbilical cord is palpable vaginally above the level of the introitus. Which of these is correct regarding your management of this patient?

Back 409

The presenting part of the fetus may be pushed back into the uterus

Front 410

cord prolapse can lead to

Back 410

fetal hypoxia and death due to the cord being compressed or going into spasm.

Front 411

cord prolapse management

Back 411

1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery

2: The presenting part of the fetus may be pushed back into the uterus to avoid compression

3: The patient is advised to go onto all fours

4: The cord should not be pushed back into the uterus

5: Immediate Caesarean section is the delivery method of choice

Front 412

Cord prolapse involves

Back 412

the umbilical cord descending ahead of the presenting part of the fetus

This occurs in 1/500 deliveries.

Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia and eventually irreversible damage or death.

Front 413

risk factors for cord prolapse

Back 413

pre-term delivery,

breech presentation or abnormal lie,

polyhydramnios and

twin pregnancy

Front 414

The majority of cord prolapses occur at artificial rupture of the membranes.

Back 414

true

Front 415

Dx of cord prolapse

Back 415

The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus.

Front 416

For management of cord prolapse

Back 416

the presenting part of the fetus may be pushed back into the uterus to avoid compression. Tocolytics may be used. If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside. The patient is asked to go on 'all fours' until preparations for an immediate Caesarean section have been carried out. Although this is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low. If treated early, fetal mortality in cord prolapse is low. Incidence has been reduced by the increase in Caesarean sections being used in breech presentations.

Front 417

You have just assisted with the normal vaginal delivery of a baby girl, during the delivery there was a large amount of meconium. On observation of the baby just after the birth the presence of which of following would prompt you to get the baby seen by the neonatal team?

Back 417

Respiratory rate 75/minute

Front 418

APGAR

Back 418

Apearance as in colour

Pulse

Grimace aka reflex irritability - sneezes, coughs; grimace; nil

Activity aka muscle tone - active, limb flexion, flaccid

Respiratory effort/rate - strong, crying; weak, irregular; nil

Front 419

A woman who is 10 weeks pregnant presents to clinic with a pre-existing heart condition. Which of the following put her at the highest risk of complications?

Back 419

Eisenmenger's syndrome

has a maternal mortality ranging from 30% to 50%, with a 50% risk of foetal loss if the mother survives.

theres also a VTE risk

Front 420

PDA in preg

Back 420

PDA during pregnancy is not associated with additional maternal risk, provided the shunt is small to moderate and the pulmonary artery pressures are normal. Percutaneous closure is now considered first-line therapy, and it is reasonable to close even asymptomatic small PDAs. Following repair of more significant PDAs, women are at no additional risk for complications during pregnancy.

Front 421

VSDs in preg

Back 421

Isolated VSDs are well tolerated during pregnancy, provided it is not associated with pulmonary hypertension or eisenmenger's, and so considered a low-risk lesion

Front 422

Coarctation in preg

Back 422

Coarctation is well tolerated during pregnancy, although hypertension, heart failure, angina, and aortic dissection are possible complications. Coarctation can be associated with intracerebral aneurysms, which may rupture during pregnancy. It is therefore considered to be a moderate-risk lesion, even when repaired.

Front 423

chronic mitral regurg in preg

Back 423

In chronic mitral regurgitation, the physiologic reduction in SVR partially compensates for the additional volume overload generated by the regurgitant valve. Should heart failure occur, it can be treated safely with nitrates, hydralazine and dihydropyridine calcium channel-blocking agents. It is considered a low risk lesion, especially after repair.

Front 424

mgmt for heart failure in preg

Back 424

treated safely with nitrates, hydralazine and dihydropyridine calcium channel-blocking agents

Front 425

what's Eisenmenger's syndrome

Back 425

describes the reversal of a left-to-right shunt in a congenital heart defect due to pulmonary hypertension. = right to left shunt

This occurs when an uncorrected left-to-right leads to remodeling of the pulmonary microvasculature, eventually causing obstruction to pulmonary blood and pulmonary hypertension.

Front 426

Eisenmenger's syndrome is associated with

Back 426

VSD

ASD

PDA

Front 427

features of Eisenmenger's syndrome

Back 427

original murmur may disappear

cyanosis

clubbing

right ventricular failure

haemoptysis, embolism

Front 428

management of Eisenmenger's syndrome

Back 428

heart-lung transplantation is required

Front 429

A 29-year-old woman presents with right iliac fossa pain. She has a past medical history of an ectopic 8 months previously with right sided salpingectomy. She had an ultrasound scan 3 days previously which demonstrated a viable intrauterine pregnancy. Clinically she is Rovsing sign positive with raised inflammatory markers. What is the most likely diagnosis?

Back 429

Appendicitis

Front 430

can you visualise appendicitis on ultrasound

Back 430

no

Front 431

A 35-year-old female who is 34 weeks pregnant presents with a swollen, painful right calf. A deep vein thrombosis is confirmed on Doppler scan. What is the preferred anticoagulant?

Back 431

Subcutaneous low molecular weight heparin

Front 432

warfarin in preg

Back 432

Although teratogenic effects of warfarin are greater in the first trimester most clinicians would use low molecular weight heparin in this situation. Another factor to consider is the risk of peripartum haemorrhage and potential problems reversing the effects of warfarin if this occurred

Front 433

Pregnancy: DVT/PE

Back 433

pregnancy is a hypercoagulable state

majority occur in last trimester

Front 434

in preg when are you most hypercoagulable

Back 434

in the third trimester

Front 435

whats the pathophys for hypercoagulability in pregnancy

Back 435

increase in factors VII, VIII, X and fibrinogen

decrease in protein S

uterus presses on IVC causing venous stasis in legs

Front 436

whats the management for DVT/PE in pregnancy

Back 436

S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)

warfarin contraindicated

Front 437

why is subcutaneous LMWH preferred over IV heparin in pregnancy DVT/PE management

Back 437

less bleeding and thrombocytopenia

Front 438

A 29 year-old woman visits her general practitioner to discuss smoking cessation, having just discovered that she is ten weeks pregnant. She has tried to give up several times in the past using motivational interviewing sessions but was unsuccessful. She wants to know if there are any medications that might help her. Which of the following could be prescribed for this purpose?

Back 438

Nicotine replacement patch

dont give:

Varenicline

Chlordiazepoxide

Bupropion

Front 439

what do you give for smoking cessation in pregnancy in terms of medications

Back 439

Nicotine replacement patch

Front 440

Chlordiazepoxide is used in the treatment of alcohol withdrawal and has no role in smoking cessation.

Back 440

true

Front 441

Amitriptyline is used in the management of neuropathic pain, depressive illness and migraine prophylaxis, but not for smoking cessation.

Back 441

true

Front 442

mgmt of smoking cessation in preg

Back 442

first line: CBT, motivational interviewing or structured self help and support from smoking cessation services

NRT patches

Front 443

Which one of the following statements regarding cervical ectropion is incorrect?

Back 443

Is less common in women who use the combined oral contraceptive pill

Front 444

A 26-year-old woman was admitted at 34 weeks gestation with preterm labour. On examination she has a blood pressure of 175/105 mmHg. Urinalysis reveals 3+ proteinuria. She is commenced on magnesium sulphate and labetalol. She is now complaining of reduced foetal movements. A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute. What should be the next step in the management?

Back 444

Emergency caesarian section

Front 445

Cardiotocography

Back 445

Cardiotocography (CTG) records pressure changes in the uterus using internal or external pressure transducers

Front 446

Early deceleration

Back 446

Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction

Usually an innocuous feature and indicates head compression

Front 447

Late deceleration

Back 447

Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction

Indicates fetal distress e.g. asphyxia or placental insufficiency

Front 448

Variable decelerations

Back 448

Independent of contractions

May indicate cord compression

Front 449

Loss of baseline variability

Back 449

< 5 beats / min

Prematurity, hypoxia

Front 450

Baseline tachycardia

Back 450

Heart rate > 160 /min

Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

Front 451

Baseline bradycardia

Back 451

Heart rate < 100 /min

Increased fetal vagal tone, maternal beta-blocker use

Front 452

You receive the results of a 34-year-old female who has recently had a routine cervical smear. Her last smear 3 years ago was reported as normal. The results are reported as follows: Mild dyskaryosis

What is the most appropriate management?

Back 452

The sample will be tested for high-risk HPV subtypes

If there are high-risk HPV subtypes present the patient will be referred for coloposcopy. Otherwise they will go back to routine screening

Front 453

What happens if you do a smear and the result is Borderline or mild dyskaryosis

Back 453

The original sample is tested for HPV (high risk subtypes 16, 18 and 33)

if negative the patient goes back to routine recall

if positive the patient is referred for colposcopy

Front 454

What happens if you do a smear and the result is moderate or severe dyskaryosis

Back 454

refer to colposcopy

Front 455

what happens if you do a smear and the result is suspected invasive cancer

Back 455

Refer for urgent colposcopy (within 2 weeks)

Front 456

what happens if you do a smear and the result is inadequate

Back 456

Repeat smear - if persistent (3 inadequate samples), assessment by colposcopy

Front 457

A 36-year-old woman suffers from a major postpartum haemorrhage after delivering twins. The obstetric consultant examines her and suspects uterine atony to be the cause. The protocol for major PPH is initiated. Bimanual uterine compression fails to control the haemorrhage. Which drug is an appropriate next step in the management of uterine atony?

Back 457

Intravenous oxytocin

Front 458

In addition to the usual steps taken in an episode of PPH (including an ABC approach if the patient is unstable), the following management should be initiated in sequence:

Back 458

bimanual uterine compression to manually stimulate contraction

intravenous oxytocin and/or ergometrine

intramuscular carboprost

intramyometrial carboprost

rectal misoprostol

surgical intervention such as balloon tamponade

Front 459

Uterine atony is the most common cause of primary postpartum haemorrhage.

Back 459

true

It entails failure of the uterus to contract fully following the delivery of the placenta, which hinders the achievement of haemostasis

Front 460

does uterine atony occur during stage 2 of labour

Back 460

no, it occurs after delivery of the placenta

thus after stage 3

Front 461

Post-partum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary

Back 461

true

Front 462

A 33-year-old woman who is 35 weeks pregnant presents to the Emergency Department with severe continuous abdominal pain. She had some vaginal bleeding an hour ago but this has mostly stopped now, with only a small amount of bloody discharge remaining. She is pale and clammy and obstetric examination reveals a firm, woody uterus which is very tender. Her pulse is 102bpm and her blood pressure is 98/65 mmHg. What is the most likely diagnosis?

Back 462

Placental abruption

Front 463

A 26 year old woman is found to be hypertensive with a blood pressure of 155/110 mmHg during labour for her first baby at 39 weeks. Urinalysis shows +++ protein. Which of these is the most appropriate way to manage her hypertension?

Back 463

Administer intravenous labetalol with target diastolic blood pressure 80-100 mmHg

Front 464

in preeclampsia whats the target BP

Back 464

NICE recommend that blood pressure is targeted at systolic < 150 mmHg and diastolic 80-100 mmHg.

Front 465

Pre-existing hypertension

Back 465

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

nothing else just HTN

Front 466

Pregnancy-induced hypertension (PIH, also known as gestational hypertension)

Back 466

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)

resolves after pregnancy

Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life

Front 467

Preeclampsia

Back 467

HTN after 20 weeks with proteinuria

+/- edema now less commonly used as a criteria

Front 468

Which of the following is the greatest risk factor for hyperemesis gravidarum?

Back 468

Twin pregnancy

Front 469

A 20 year old woman presents to her GP complaining of painful periods. She currently uses an implant (Nexplanon) for contraception. What is the most suitable initial treatment?

Back 469

Mefenamic acid

Front 470

A 30-year-old woman, para 2+0, is in the second stage of labour and has just delivered the anterior shoulder. She has opted for active management during the third stage of her labour. She had mild gestational hypertension during pregnancy with a recent blood pressure recording of 142/91 mmHg. What drug should now be administered?

Back 470

Oxytocin

Guidelines suggest the use of 10 IU oxytocin by IM injection to reduce the risk of PPH and for active management of the third stage of labour. This is given after delivery of the anterior shoulder.

Front 471

Active management in the third stage is recommended to

Back 471

reduce post-partum haemorrhage (PPH) and the need for blood transfusion post delivery.

Active management lasts less than 30 minutes and involves the following:

Uterotonic drugs

Deferred clamping and cutting of cord, over 1 minute after delivery but less then 5 minutes

Controlled cord traction after signs of placental separation

Front 472

Also oxytocin causes less nausea and vomiting

Back 472

true

Front 473

Labour may be defined as

Back 473

the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part

Front 474

A woman who is 36 weeks pregnant is reviewed. This is her first pregnancy. Her baby is known to currently lie in a breech presentation. What is the most appropriate management?

Back 474

Refer for external cephalic version

Front 475

types of breech presentation

Back 475

frank breech

footling breech

A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity

Front 476

Management of breech presentation

Back 476

<36 weeks will turn spontaneously

at 36 weeks = do external cephalic version

if still in breech = C sxn or vaginal delivery

Front 477

Which of these is a possible indication for induction of labour?

Back 477

Uncomplicated pregnancy at 41 weeks gestation

Front 478

Bishops score is used to determine need for induction of labour

Back 478

Bishop's score is scored out of 10, and the higher the score the more favourable the cervix, or the more likely spontaneous birth will occur. A score <5 indicates labour is unlikely to start without induction.

Front 479

when should you induce labour according to the Bishop score

Back 479

<5 score

Front 480

women should be offered induction between 41-42 weeks of an uncomplicated pregnancy to avoid risks of prolonged pregnancy.

Back 480

true

Front 481

Induction is not recommended when the fetus is in breech position.

Back 481

true

Front 482

Induction is not recommended in FGR (fetal growth restriction).

Back 482

true

Front 483

Induction of labour describes a process where labour is started artificially. It happens in around 20% of pregnancies

Back 483

true

Front 484

indications for induction of labour

Back 484

prolonged pregnancy, e.g. > 12 days after estimated date of delivery

prelabour premature rupture of the membranes, where labour does not start

diabetic mother > 38 weeks

rhesus incompatibility

Front 485

methods to help induce labour

Back 485

membrane sweep

intravaginal prostaglandins

breaking of waters

oxytocin

Front 486

A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?

Back 486

Admit her for at least 48 hours and prescribe antibiotics (oral erythromycin) and steroids

Front 487

for PROM, You should consider delivery at 34 weeks where the risks of infection may outweigh the risk of prematurity now you have allowed the lungs to mature.

Back 487

true

Front 488

Group B streptococcus you would treat with

Back 488

penicillin and clindamycin

in preg