Final Obs

Question 1

Describe the management of fibroids [+]

Answer 1

Menorrhagia is the most common problem associated with fibroids and thus management focuses on the treatment of heavy periods:
- Levonorgestrel-releasing intrauterine system (Mirena) - 1st line
- COCP
- NSAIDS
- TXA

Surgical intervention:
- Endometrial ablation
- Myomectomy or hysterectomy
- Uterine artery embolisation (for large fiboids)

Question 2

Endometrial ablation can be used to destroy the endometrium.

Name a type of endometrial ablation that is most commonly used? [1]

Answer 2

Second generation, non-hysteroscopic techniques are used, such as balloon thermal ablation
- This involves inserting a specially designed balloon into the endometrial cavity and filling it with high-temperature fluid that burns the endometrial lining of the uterus.

Question 3

Describe the management of fibroid degeneration

Answer 3

The mainstay of treatment is conservative management. The patient will need to be assessed at a centre with obstetrics care

Patients should be reassured that fibroids usually regress during the puerperium owing to hormonal withdrawal.

Analgesia
- Acute painful episode usually resolves in 4-7 days
- Paracetamol
- NSAIDS should be used with caution to avoid fetal complications such as premature closure of the ductus arteriosus

In very rare cases, the decision may be made to remove fibroids in the first or second trimester of pregnancy:
- Fibroids causing intractable pain or a torted pedunculated fibroid are rare indications

Question 4

When would you refer fibroids on to further gynaecology appointments? [5]

Answer 4

Routine referral to Gynaecology:
* Palpable mass on initial examination,
* Fertility or pregnancy issues
* Painful sex, pelvic pain, constipation, frequency
* Fibroids which are palpable abdominally, or intracavity fibroids greater than 12 cm.
* Menorrhagia, symptomatic anaemia

Question 5

Describe the risk of fibroids in pregnancy:
during pregnancy [5]
during delivery [2]

Answer 5

During Pregnancy
* Increased rates of miscarriage and PTB
* Difficult to measure - growth scans
* Degeneration pain
* Malposition
* Growth restriction

Delivery and Post Partum
* If fibroid below presenting part of head, baby may not come vaginally
* Can make CS very difficult
* Risk of Post Partum Haemorrhage

Question 6

Describe what happens [1] & what tests [2] are performed when colposcopy occurs

Answer 6

Colposcopy is a procedure that allows optimal visualisation of the cervix.:
- As with the cervical smear a speculum is placed in the vaginal vault and the cervix identified.
- A colposcope (which remains external) is then used to offer a magnified view of the cervix

Tests:
- Schiller’s iodine test involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.
- Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite.
- A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.

Question 7

White cervical cells after staining in colposcopy would indicate which test has been performed? [1]

What would this indicate? [1]

Answer 7

Acetic acid causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.

Question 8

What staining has been used on this cervix? [1]

Answer 8

Question 9

Which test / stain has been performed? [1]
What does this indicate? [1]

Answer 9

Schiller’s (Lugol’s) iodine test involves the application of an iodine-based solution. As the iodine solution is glycophilic, normal glycogen containing squamous epithelium stains brown or black
- CIN and invasive cancer has little glycogen and does not stain. Columnar epithelium is also deficient in glycogen so does not stain.

Question 10

Describe the different stages of cervical cancer [4]

Answer 10

Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina but not lower 1/3 or vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis

Question 11

Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and early stage 1A is? [1]

Answer 11

Cervical intraepithelial neoplasia and early-stage 1A:
- LLETZ or cone biopsy

Question 12

Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 1B-2A is? [2]

Answer 12

Stage 1B – 2A:
- Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy

Question 13

Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 2B-4A ? [1]

Answer 13

Stage 2B – 4A:
- Chemotherapy and radiotherapy
- Radiotherapy may either be bachytherapy or external beam radiotherapy
- Cisplatin is the commonly used chemotherapeutic agent

Question 14

Management of cervical cancer depends on the stage and the individual situation. The usual treatments for CIN and stage 4B ? [1]

Answer 14

Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care

Question 15

Which MAB may be used in combination with some chemotherapies? [1]

What is its target? [1]

Answer 15

Bevacizumab (Avastin) is a monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer.

It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels. Therefore, it reduces the development of new blood vessels. You may also come across this medication as a treatment for wet age-related macular degeneration, where it is injected directly into the patient eye to stop new blood vessels forming on the retina.

Question 16

Describe complications that may arise due to cervical cancer to the urinary system [2] and bowel dysfunction [2]

Answer 16

Urinary Dysfunction: may arise from the local invasion of the tumour or as a consequence of treatment:
* Ureteral obstruction: Advanced cervical cancer can infiltrate the ureters, causing obstruction and hydronephrosis.
* Urinary incontinence and retention: Surgery and radiation therapy can damage nerves and muscles controlling urinary function, leading to urinary incontinence or retention.
* Vesicovaginal (bladder and vagina) fistula may occur

Cervical cancer and its treatments can also result in bowel dysfunction:
* Obstruction: Direct invasion of the tumour into the rectum, or radiation-induced fibrosis, can cause bowel obstruction.
* Radiation proctitis: Radiation therapy can induce inflammation and damage to the rectum, causing symptoms such as diarrhoea, urgency, and rectal bleeding.

Question 17

Lecture

Which structures are removed in a radical hysterectomy? [5]

Answer 17

removing the:
- uterus and supporting ligaments
- cervix
- upper vagina
- the pelvic lymph nodes
- sometimes the para-aortic lymph nodes.

Question 18

Incidence of recurren is 80% in 2 years for cervical cancer.

Where is most likey to reoccur? [3]

Answer 18

Vaginal cuff, pelvis, lymph nodes (paraaortic, supraclavicular), lungs

Question 19

Describe how you would treat cervical cancer in patients who have a recurrence, but who were initially been treated via:
- surgery [1]
- radiotherapy [1]

Answer 19

Pts previously treated with surgery: give Radiotherapy

Pts previously treated with radiotherapy – Pelvic exenteration for central pelvic recurrence - Removal, vagina, cervix and uterus
* Plus bladder - anterior exenteration
* Plus rectum - posterior exenteration
* Plus bladder and rectum - total exenteration

Question 20

Describe fertility sparing surgery used for cervical cancer

Answer 20

Radical Trachelectomy:
- removal of the cervix, the upper vagina and pelvic lymph nodes

For early stages only

Question 21

Describe the clinical features of ectopic pregnancies [+]

Answer 21

Female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

Constant lower abdominal pain:
- in the right or left iliac fossa
- often FIRST symptom
- pain is constant

Vaginal bleeding:
* usually less than a normal period
* may be dark brown in colour

Recent amenorrhoea
- if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion

Cervical motion tenderness (pain when moving the cervix during a bimanual examination)

Dizziness or syncope (blood loss)

Shoulder tip pain(peritonitis)

Question 22

Describe how you interpret serum bHCG levels with ectopic pregnancies [2]

Answer 22

If the initial β-HCG level is >1500 iU (discriminatory level)
- & there is no intrauterine pregnancy on transvaginal ultrasound –> consider ectopic pregnancy until proven otherwise

If the initial β-HCG level is < 1500 iU:
- and the patient is stable, a further blood test can be taken 48 hours later
- Viable pregnancy: HCG level would be expected to double every 48 hours.
- Miscarriage: HCG level would be expected to halve every 48 hours

Question 23

Describe the intermediate-term complications of an ectopic pregnancy [2]

Answer 23

Persistent trophoblastic tissue:
* Following treatment with methotrexate or surgical management, residual trophoblastic tissue may remain and continue to produce hCG.
* This can necessitate further medical or surgical intervention to ensure complete removal of the ectopic pregnancy
.
Infection:
- Post-surgical infection or an undiagnosed tubo-ovarian abscess may complicate ectopic pregnancy management, requiring antibiotic therapy or additional surgical procedures.

Question 24

What follow up management do all patients who require a salpignotomy require? [1] What other management needs to be considered post-ectopic pregnancy? [1]

Answer 24

Patients who have required salpingotomy require **weekly b-hCG measurements until negative**. Approximately 1 in 5 will need further treatment **Anti-D Rhesus Prophylaxis** - Rhesus D negative women may require anti-D rhesus prophylaxis if surgical management and/or repeated, heavy bleeding and/or pain

Question 25

Define the following terms: - hydatidiform mole - complete mole - partial mole

Answer 25

**A hydatidiform mole**: - is a type of **tumour** that **grows like a pregnancy inside the uterus**. This is called a molar pregnancy. There are **two types of molar pregnancy: a complete mole and a partial mole.** **A complete mole**: - occurs when **two sperm cells fertilise an ovum** that contains **no genetic material** (an “empty ovum”). - These **sperm** then **combine genetic material**, and the cells start to **divide** and grow into a tumour called a **complete** **mole** - **No fetal material will form.** **A partial mole**: - occurs when **two** **sperm** **cells** fertilise a **normal ovum** (containing genetic material) at the **same** **time**. - The new cell now has **three sets of chromosomes**. - The cell divides and multiplies into a tumour called a partial mole. - **In a partial mole, some fetal material may form.**

Question 26

Describe the managment of moderate - server HG

Answer 26

**IV Fluids** - NaCl or Hartmann’s [avoid glucose containing fluid as they precipitate Wernicke’s encephalopathy] +/- KCl as necessary. *** Anti-emetics IM or IV** * **Daily U&Es** * **Thiamine supplementation** to prevent Wernicke Korsakoff syndrome (Thiamine Hydrochloride 25-50mg PO TDS or thiamine 100mg infusion weekly) * **Ranitidine or Omeprazole** if acid reflux is a problem * **Laxatives as required** * **NBM** for **24hr** then introduce food as tolerated – enteral or parenteral nutrition maybe considered in refractory cases * **VTE prophylaxis** (TEDS and LMWH)

Question 27

How do you manage future pregnancies if they have previously had severe HG? [2]

Answer 27

Pre-emptive use of **doxylamine** and **pyridoxine** to **reduce** **severity** of **disease** (20/20 mg PO at night should be started when positive pregnancy test)

Question 28

Describe the presentation of: * complete miscarriage [1] * incomplete miscarriage [1]

Answer 28

**complete miscarriage:** - **Bleeding** **stops** and further treatment is not needed **incomplete** **miscarriage**: - **Placenta** is **not** fully **expelled** and **bleeding persists** - Surgical management needed

Question 29

Describe the presentation of: * missed miscarriage [2] * threatened miscarriage [2]

Answer 29

**Missed miscarriage:** - **no** **symptoms** have occurred - the **cervix** is **closed** **Threatened miscarriage:** - **Vaginal bleeding +/- pain** - **Closed cervical os** - **Viable** **pregnancy**

Question 30

Describe the presentation of: * inevitable miscarriage [2]

Answer 30

**Inevitable miscarriage**: - **vaginal** **bleeding** - **open cervical os** - Progresses to an incomplete or complete miscarriage

Question 31

Describe the clinical features of a miscarriage:

Answer 31

* **Vaginal bleeding** - brownish light spotting to heavy bright-red blood with clots; * **Lower abdominal cramping pain** * **Vaginal fluid discharge/tissue discharge** * **Loss of pregnancy symptoms** (eg. No more nausea/breast tenderness) * **Lower back pain** ## Footnote Should be suspected in all women with bleeding in early pregnancy

Question 32

How do you differentiate an ectopic pregnancy from a miscarriage? Similarities: [2] Differences [4]

Answer 32

**Ectopic pregnancy**: * **Similarities**: vaginal bleeding and lower abdominal pain * **Differences**: **pain** is usually **unilateral**, more **severe**, and **before** **bleeding** **presents**. The bleeding in an ectopic pregnancy also tends to be **darker and less heavy**. There is also **cervical excitation in ectopic pregnancy.**

Question 33

When would you repeat a scan with regards to the following on TVUS: [3] Mean gestational sac diameter Fetal pole and crown-rump length Fetal heartbeat

Answer 33

* When the **crown-rump length is less than 7mm**, **without** a **fetal** **heartbeat**, the scan is repeated after at least one week to ensure a heartbeat develops. * When there is a **crown-rump length of 7mm** or **more**, **without** a **fetal** **heartbeat**, the scan is **repeated after one week before confirming a non-viable pregnancy.** * A **fetal pole is expected** once the mean **gestational sac diameter is 25mm or more**. When there is a **mean gestational sac diameter of 25mm or more, without a fetal pole**, the scan is repeated after one week before confirming an **anembryonic pregnancy.**

Question 34

Describe the management of a miscarriage if its a < 6 weeks gestation [3]

Answer 34

**Less Than 6 Weeks Gestation**: - Women with a pregnancy less than 6 weeks’ gestation **presenting** with **bleeding** can be managed **expectantly** provided they have **no pain and no other complications or risk factors** (e.g. previous ectopic) - involves **awaiting** the **miscarriage** without **investigations or treatment** - **A repeat urine pregnancy test** is performed **after 7 – 10 days**, and if **negative**, a **miscarriage can be confirmed** ## Footnote **NB**: An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen.

Question 35

In which scenerios are miscarriages medically or surgically managed? [3]

Answer 35

**increased risk of haemorrhage** * she is in the **late first trimester** * if she has **coagulopathies** or is unable to have a blood transfusion **previous adverse and/or traumatic experience** **associated with pregnancy** (for example, stillbirth, miscarriage or antepartum haemorrhage) **evidence of infection**

Question 36

Describe the management of a missed miscarriage [2]

Answer 36

**1. oral mifepristone** **2. 48 hours later: misoprostol** (unless the gestational sac has already been passed) **3.** if bleeding has **not started within 48 hours** after **misoprostol** **treatment**, they should **contact their healthcare professional**

Question 37

Describe the medical management of incomplete miscarriage [2]

Answer 37

**a single dose of misoprostol** (vaginal, oral or sublingual) women should be offered **antiemetics and pain relief**

Question 38

Describe the medical management of a threatened miscarriage [4]

Answer 38

* If patient **stable**: **observe** symptoms * In women with a **previous miscarriage**, use of **vaginal micronized progesterone** (400mg twice daily) NICE 2021 * **Advise to return if symptoms worse**n or do not settle after **14** **days** * Analgesia, written information, contact details and safety netting advice should be given

Question 39

When is manual vacuum aspiration not indicated? [1]

Answer 39

After 10 weeks gestation

Question 40

Describe the management plan for reduced fetal movements if: - Past 28 weeks [3] - Between 24-28 weeks [1] - Below 24 weeks [1]

Answer 40

**If past 28 weeks gestation**: * Initially, **handheld Doppler** should be used to confirm fetal heartbeat. * If **no fetal heartbeat** detectable, immediate **ultrasound** should be offered. * If fetal heartbeat present, **CTG** should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise. * If **concern** **remains**, despite normal CTG, urgent (within 24 hours) **ultrasound can be used.** Ultrasound assessment should include **abdominal circumference or estimated fetal weight** (to exclude SGA), and a**mniotic fluid volume measurement** **If between 24 and 28 weeks gestation**: - a handheld **Doppler** should be used to confirm **presence of fetal heartbeat.** **If below 24 weeks gestation** - and fetal movements have previously been felt, a handheld Doppler should be used. ## Footnote If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.

Question 41

/ What are causes for reduced fetal movements [+]

Answer 41

**Intrauterine growth restriction** **Small for gestational age** **Placental insufficiency** **Oligohydramnios** **Threatened preterm labour** **Fetomaternal transfusion** **Intrauterine infections**

Question 42

When determining the type of twins using an ultrasound scan. Which findings regarding placentas and amniotic sacs would determine the type of twins occuring? [3]

Answer 42

**Dichorionic diamniotic twins** - have a **membrane** **between** the **twins**, with a **lambda sign or twin peak sign** **Monochorionic diamniotic twins** - have a **membrane** **between** the **twins, with a T sign** **Monochorionic monoamniotic** - twins have **no membrane separating the twins**

Question 43

What are the risks to the mother of twins? [+]

Answer 43

Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage

Question 44

Describe the risk to the fetusesus and neonates of being twins [+]

Answer 44

Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities

Question 45

Describe what is meant by twin-twin transfusion syndrome [+]

Answer 45

**Twin-twin transfusion** **syndrome** occurs when the **fetuses** **share a placenta** - When there is a **connection** between the **blood supplies of the two fetuses,** one fetus (the **recipient**) may **receive the majority of the blood** from the **placenta**, while the other **fetus** (the **donor**) is **starved of blood** - the recipient gets the **majority** of the blood, and can become **fluid** **overloaded**, with **heart failure and polyhydramnios** - The **donor** has **growth restriction, anaemia and oligohydramnios**

Question 46

When do additional US scans in multiple pregnancy? [2]

Answer 46

**2 weekly** scans from **16 weeks for monochorionic twins** **4 weekly scans** from **24 weeks for dichorionic twins**

Question 47

The three major causes of cardiac arrest in pregnancy to remember are [3]

Answer 47

**Obstetric haemorrhage** **Pulmonary embolism** **Sepsis** leading to **metabolic acidosis** and **septic** **shock**

Question 48

Obstetric haemorrhage is a major cause of severe hypovolaemia and cardiac arrest. What are the causes of massive obstetric haemorrhage? [5]

Answer 48

**Ectopic** **pregnancy** (early pregnancy) **Placental abruption** (including concealed haemorrhage) **Placenta praevia** **Placenta accreta** **Uterine rupture**

Question 49

When is immediate c-section performed for a pregnant women when CPR has been performed? [2]

Answer 49

* There is **no response** after **4 minutes to CPR** performed correctly * **CPR** continues for **more than 4** **minutes** in a woman **more than 20 weeks gestation**

Question 50

Describe how VTE prophylaxis used in pregnancy? [1]

Answer 50

All women recieve a risk assessment at booking clinic. If deemed high risk - recieve **LMWH prophylaxis** - e.g. **enoxaparin, dalteparin or tinzaparin** - Prophylaxis is started **as soon as possible** in **very high risk patients** and at **28 weeks in those at high risk** - Continues till **6 weeks post-natally**

Question 51

How do you calculate the dose of a LMWH for tx in pregnancy? [1] How do you manage VTE in pregnany? [1]

Answer 51

The dose is based on the **woman’s weight at the booking clinic**, or from **early pregnancy.** - LMWH should be start before the **dx for suspected DVT or PE** - When the diagnosis is confirmed, **LMWH** is continued for the **remained of pregnancy, plus six weeks postnatally,** or **three months in total** (whichever is longer)

Question 52

Which pathologies are specific to MC twins? [4]

Answer 52

* Twin to Twin Transfusion Syndrome (TTTS) * Selective Intrauterine Growth Restriction (s-IUGR) * Twin Anemia Polycythemia Sequence (TAPS) * Twin Reverse Arterial Perfusion (TRAP) sequence

Question 53

# Lecture: When should you deliver [3] DC twins MC twins Triplets

Answer 53

Intrapartum care of multiple pregnancy * **DC**: Delivery by **38 weeks** * **MC**: Delivery by **37 weeks** * **Triplets**: Delivery by **34 weeks**

Question 54

Describe the difference in egg / sperm etc in the different types of twins

Answer 54

Identical twins are always the same sex, so if your twins are identical, you'll have 2 girls or 2 boys.