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Obstetrics and Gynaecology Tutorial • Some short answer questions and LOTS of MCQs. Trying to cover as much content as possible • NICE guidelines and RCOG green top guidelines are recommended Picture 1 Question 1: What is the name of this instrument? Question 2: What is it used for? Picture 2 Question 1: What is the name of this instrument? Question 2: Name a surgical alternative to its use Picture 3 Question 1: What is the name of this instrument? Question 2: What is it used for? Question 3: What are the complications of the procedure? Cervical Screening Guidelines HPV testing is done BEFORE cytology • HPV –ve = routine recall – Aged 25-49yr = 3yr; Aged 50-64yr = 5yr • +ve HPV alone = 1yr recall – If still +ve at 24mo --> colposcopy • Inadequate = 3/12 recall – If 2x --> colposcopy • Abnormal = colposcopy Indications for colposcopy https://gpnotebook.com/en-gb/simplepage.cfm?ID=x20201118134945110617&linkID=81354&cook=noQ Regardingcervicalscreening,whichof the followingisfalse? Picture 4 What does this ovary removed from a 32 year old female show? What is the likely cause? Case 1 Jane, a 26-year-old female, presented to the GUM clinic following 1/52 Hx of odourless, thick, white discharge and dyspareunia. She has a regular partner , a student from Nigeria currently studying in the UK. They do not use barrier contraception. Jane also admits to taking her oral contraceptive pill “less than reliably”. Case 1 – Question 1 • Q: Which of the following tests is least appropriate to offer Jane at her appointment? • A) Chlamydia swab • B) Gonorrhoea swab • C) Blood test for HIV and syphilis • D) Cervical smear • E) Pregnancy test Case 1 – Question 2 • Q: All of the following are considered risk factors for contracting HIV except for: • A) IVDU • B) Having a sexual partner from the African continent • C) Women who have sex with women • D) Being paid/paying for sex • E) Receiving a blood transfusion in a foreign country Case 1 – Question 3 Jane, a 26-year-old female, presented to the GUM clinic following 1/52 Hx of odourless, thick, white discharge and dyspareunia. You perform a speculum examination, carry out the appropriate swabs and prepare a wetmount slide which shows the following under microscopy: Case 1 – Question 3 • Q: What does the slide suggest is the causative organism of Jane’s symptoms? • A) Gardnerella vaginalis • B) Candida albicans • C) Lactobacillus • D) Trichomonas vaginalis • E) Peptostreptococcus Choose the single best contraceptive method for a 45 year old woman with a BMI of 40, smoker, with multiple fibroids, who is in a stable relationship whose family is complete, and who has had a peritonitis secondary to appendicitis in the past? • A) COCP • B) Laparoscopic clip sterilisation • C) Mirena • D) POP • E) Hysteroscopic sterilisation A 45-year-old woman presents to her GP . She is keen to commence some form of contraception. She has recently been diagnosed with osteoporosis. She is a non-smoker and non-drinker. The following are all suitable forms of contraception except: • A) POP • B) COCP • C) Diaphragm • D) Medroxyprogesterone IM • E) Implant deviceA 52-year-old woman presents to surgery seeking advice regarding contraception. She has recently started in a new relationship but is unsure if she requires contraception as she thinks she may be going through menopause. She is experiencing hot flushes and her last period was 7 months ago. What is the most appropriate advice? A) She no longer requires contraception B) Contraception is needed until 12 months after her last period C) Contraception is needed until 18 months after her last period D) Contraception is needed until 24 months after her last period E) Contraception is needed until 36 months after her last period Your friend takes the COCP (Microgynon). She is worried because she has forgotten to take three pills in the second week of her current pack, and has been having regular unprotected sex with her male partner. She has taken the rest of her pills correctly this month. What is the best advice for her? • A) Take three pills just to be sure • B) Take the most recent missed pill as soon as possible and get emergency contraception • C) Take the most recent missed pill as soon as possible. Finish the pack and have usual 7-day break. • D) Stop taking COCP for rest of month, use barrier contraception and start again next month • D) Abstain from sex until 7 consecutive pills have been taken Useful links: Contraception • https://geekymedics.com/tag/contraception/ • https://srh.org/mecwheel/ WHO medical eligibility for contraception (App available also) Case 2 – Question 1 Emily presents to your gynaecology clinic with a one-year history of menorrhagia and worsening dysmenorrhoea. She is using 15 sanitary towels a day and regularly experiences flooding. She and her partner are currently trying to conceive. • Q: What is the primary differential diagnosis? • A) Endometriosis • B) Uterine fibroids • C) Ovarian cysts • D) Myometriosis • E) Pelvic inflammatory disease Case 2 – Question 2 Emily consents to an abdominal and pelvic examination, both of which are normal. • Q: What is the most appropriate investigation following examination? • A) Blood test for Ca125 • B) Hysteroscopy • C) Transvaginal US • D) Diagnostic laparoscopy • E) Cervical smear Case 2 – Question 3 A hysteroscopy is performed and shows a uterine fibroid of 2cm. • Q: Which of the following would be best indicated as a first line treatment for Emily? • A) Tranexamic acid • B) Norethisterone • C) Ulipristal acetate • D) COCP • E) Uterine artery embolisation A 67 year old female presents with a grade 2 uterovaginal prolapse, on examination you would expect the prolapse to be: • A) Visible only on speculum examination • B) Visible on straining, >1cm above the opening of the vagina • C) Between 1cm above and below the opening of the vagina • D) Extends ≥1cm below the opening of the vagina but without complete vaginal eversion • E) Vagina completely everted Grade of prolapse – International Continence Society (ICS) Pelvic Organ Prolapse scoring system Grade 0: No descent of pelvic organs during straining Grade 1: Leading surface of prolapse does not descend below 1cm above opening of the vagina Grade 2: Leading surface of prolapse is ≤1cm from the opening of the vagina Grade 3: Leading edge of the prolapse extends >1cm below opening of the vagina but not fully Grade 4: Vagina completely everted Regarding cervical screening, which of the following are false? • A) In Scotland women between age 25 and 49 are screened 3-yearly • B) Women between age 50 and 64 are screened 5- yearly • C) Smear is best taken at the end of the menstrual cycle • D) Screening process is non-diagnostic for cancer • E) In the UK, non-sexually-active women are invited for cervical screening The leuteal/secretory phase is during day: • A) Days 1-14 • B) Days 4-8 • C) Days 14-28 • D) Days 5-13 • E) Days 2-12 When should serum progesterone be measured in a woman to confirm ovulation? • A)Day 14 in a 28 day cycle • B) Day 18 in a 32 day cycle • C) Day 21 in a 32 day cycle • D) Day 25 in a 32 day cycle The hormone best used as a measurement of ovarian reserve is: • A) FSH • B) Oestradiol • C) LH • D) Inhibin • E) AMH The following are all likely investigative findings in PCOS except: • A) Raised testosterone • B) Decreased SHBG • C) Raised FSH • D) Raised LH • E) Normal TFTs A 34 year old presents complaining of amenorrhea following a dilatation and curettage 4 months ago, she is otherwise well, which of the following would be the most likely diagnosis? A) Turners syndrome B) Pelvic inflammatory disease C) Anorexia nervosa D) Ashermans Syndrome E) Kallmans syndrome Which of the following is false regarding side effects of hormone replacement in menopause? A) Patients are at an increased risk of venous thromboembolic disease B) Patients are at an increased risk of endometrial cancer C) Patients can often complain of breast tenderness D) Patients are at an increased risk of breast cancer E) Patients are at an increased risk of cervical cancer A 35 year old woman who is undergoing her 1 IVF cycle presents with abdominal pain. Which one of the following would be least consistent with a diagnosis of ovarian hyperstimulation syndrome (OHSS)? • A) Thromboembolism • B) Jaundice • C) Clinical evidence of ascites • D) Oliguria • E) Vomiting Main IVF Criteria NHS Lothian • Co-habiting in stable relationship min 2 years • One partner has no living biological children • Female BMI 18.5 - <30 • Both non smokers and nicotine free for at least 3 months before referral + continue so throughout treatment • No alcohol prior to or during treatment IVF NHS Lothian Number of Cycles (General) • Up to two cycles of IVF/ICSI may be undertaken • New treatment cycles must be initiated by date of female partners 40 birthday • All subsequent frozen embryo transfers st completed before 41 • No individual can access more cycles, even if in new relationship There are exceptions to age but these are the main key points Picture 5 What’s abnormal here? Teratoma of the left ovary Regarding prenatal diagnosis, which of the following is false: • A) Chorionic villus sampling is usually performed between 11+0 to 13+6 • B) Amniocentesis carries a miscarriage risk of around 1% • amniocentesis women are given anti-D following • sampling is less than amniocentesislowing chorionic villus • pregnancyPP-A suggests potential Down syndrome What is the recommended dose of preconceptual folic acid? • A) 0.25mg • B) 0.4mg • C) 1mg • D) 5g • E) 2.5mg Case 3 – Question 1 Stacey, a para 1+2 (previous child was a spontaneous vertex delivery) presents to her antenatal clinic at week 34 of her pregnancy. She has had an US which shows that the presentation of her baby is currently breech. • Q: What would be the most appropriate next step in Stacey’s management? • A) External cephalic version should be offered to try and turn the baby • B) A watch and wait approach. Rescan in two weeks • C) List for a C-section immediately • D) Do nothing. There is no increased risk in vaginal delivery of a breech baby • E) Delivery the baby now in a controlled setting with an obstetrician on handExtended (Frank) Flexed (complete) Footling Case 3 – Question 2 • Q: Which of the following is not a risk factor for breech presentation? • A) Uterine fibroids • B) Placenta previa • C) Maternal obesity • D) Polyhydramnios • E) Twins Case 3 – Question 3 • Q: Which of the following is not a complication associated with breech delivery? • A) Shoulder dystocia • B) Cord prolapse • C) Cerebral palsy • D) Hypoxic ischaemic encephalopathy • E) Hyperextension of the head Case 4 – Question 1 A young woman undergoes diagnostic laparoscopy for pelvic pain. Case 4 – Question 1 What is the most likely diagnosis? A) Ectopic pregnancy B) Endometriosis C) PID D) Metastatic disease E) Uterine rupture Case 5 – Question 1 A 21-year old woman attends gynae triage with lower abdominal pain, and PV bleeding. A pregnancy test is positive. O/E there is cervical excitation and cervical os mass (2.5cm) and free fluid. Beta hCG is 2200. What is the most likely diagnosis? A) Threatened miscarriage B) Pelvic inflammatory disease C) Ruptured appendix D) Incomplete miscarriage E) Ectopic pregnancy Case 5 – Question 2 Which of the following is true regarding management of ectopic pregnancy? • A) Ectopic pregnancy cannot be managed conservatively • B) Women must use reliable contraception for 3 months after medical management • C) Women with a plateauing hCG should be treated medically • D) Laparoscopy is the method of choice in haemodynamically unstable patient • E) All patients require anti-D regardless of their Rhesus status Case 6 – Question 1 24 year old female presenting with 4 months of amenorrhoea followed by PV bleed. What is the most likely diagnosis? Complete hyatidiform mole Case 6 – Question 2 Which one of the following features is least consistent with a diagnosis of a hyatidiform mole? • A) Hyperemesis • B) Crampy lower abdominal pains • C) Uterus large for dates • D)Symptoms of thyrotoxicosis • E) High serum levels of hCG Case 6 – Question 3 Which one of the following statements regarding gestational trophoblastic disorders is incorrect? • A) In a complete hyatidiform mole all 46 chromosomes are of paternal origin • B) Very high serum levels of hCG are seen • C) Symptoms of hyperthyroidism may be seen with a complete hyatidiform mole • D) <1% of women with complete hyatidiform mole go on to develop choriocarcinoma • E) Effective contraception is recommended to avoid pregnancy in the next 12 monthsThis baby was born at 39w+4d. What condition was the mother likely to have ? GDM/DMWhich of the following is not a risk factor for shoulder dystocia? • A) Previous Hx of shoulder dystocia • B) Post-term pregnancy • C) Diabetes mellitus • D) Instrumental vaginal delivery • E) Excess maternal alcohol consumption during pregnancy Shoulder Dystocia - Management • H Call for HELP! • Evaluate for episiotomy • Legs into McRoberts • Pressure (suprapubic) • Enter pelvis for internal manoeuvres • Release of posterior arm by flexing elbow • Roll over to all fours Causes of PPH Primary PPH – the Four Ts • Tone = atonic uterus • Trauma • Tissue = retained products of conception • Thrombin = coagulopathy Secondary PPH • Infection (associated with retained POC)Which drug should not be used during PPH if patient is has a Hx of HTN? • A) Any antibiotic • B) Labetolol • C) Ergometrine • D) Syntocinon • E) MorphineWhat is this pruritic rash that began in the abdominal striae before spreading to the arms and thighs? Pruritic Urticarial Papules and Plaques of Pregnancy/ Polymorphic eruption of pregnancy A baby is born to a mother who is known to have chronic hepatitis B. The mother’s latest results show her to be +ve for HBsAg and HBeAg. What is the most appropriate strategy for reducing the vertical transmission rate? • A) Give the newborn hep B vaccine + hep B immunoglobulin • B) Give the newborn hep B vaccine • C) Give the newborn hep B immunoglobulin • D) Give the mother IV zidovudine during labour • shortly before birth + the newborn hep B vaccine A 28-year-old woman 27 weeks into her 1 pregnancy presents with PV bleed. Which one of the following features would point towards a diagnosis of placenta praevia rather than placenta abruption? • A) Tender, tense uterus • B) Normal lie and presentation • C) No pain • D) Distressed foetal heart rate • E) Shock out of keeping with visible blood loss Placenta Praevia • Associations: APH, PPH, pre-term delivery, etc • Do not VE until placenta location is known A 32 year old woman presents to A&E following an episode of heavy vaginal bleeding. She is currently 29 weeks pregnant. She complains of severe abdominal pain. Obs: BP 90/50mmHg, HR 140bpm. She is pale and clammy to touch. What is the next most appropriate step in management? • A) Vaginal swab • B) Abdo USS • C) CTG • D) AXR • E) IV access and urgent fluid resuscitation The following are all true with regards to labour except: • A) Labour typically occurs between the 37 andh 42 week of pregnancy • B) The 2 stage of labour is associated with dilatation of the cervix • C) The 3 stage of labour is the interval between delivery of the foetus to delivery of the placenta • D) The cervix is drawn up into the lower uterine segment • E) It is associated with the passage of a mucus plugWhich of the following is not a component of the Bishop’s score? • A) Station of the foetal head • B) Position of the foetal head • C) Cervical dilatation • D) Length of the cervix • E) Consistency of the cervix Which maternal condition is a contraindication for epidural analgesia? • A) Placental praevia • B) Multiple sclerosis • C) Epilepsy • D) Thrombocytopenia • E) Obstetric cholestasisWhich of the following is a contraindication for ventouse delivery? • A) Twins • B) OP position • C) Previous C-section • D) 39 weeks gestation • E) Presenting part -2 to spines A new mother 4 weeks post-partum has developed a warm, red tender patch on the right breast just lateral to the areola, which has been getting worse for the past 3 days and feeding is now painful. On examination, she has mastitis of the right breast with no obvious abscess. What is the most appropriate management? • A) Co-amoxiclav, continue breast feeding • B) Flucloxacillin, continue breast feeding • C) Flucloxacillin, stop breast feeding • D) Co-amoxiclav, stop breast feeding • E) Metronidazole, continue breast feeding The following are all true with regards to foetal heart rate except: • A) Tachycardia is >160bpm • B) Bradycardia is <80bpm • C) Early decelerations occur with the onset of a contraction • D) Tachycardia may be due to hypoxia • E) Bradycardia may be due to hypoxia What is indicated by the CTG? A) Variable decelerations B) Normal CTG C) Early decelerations D) Reduced Variability E) Sinusoidal pattern https://geekymedics.com/how- Dr C BRAV ADO • Dr = Define risk (High or Low) • Contractions (Present or absent) • Bra = Baseline rate (110-160bpm) • Variability (Normal 5-25 bpm) • Accelerations (increase in baseline FHR >15bpm for >15 secs) • Decelerations (Early, late, variable, prolonged) • Overall impression (Reassuring, suspicious, abnormal)