1
Q
What positions can the uterus lie? What proportions lie in each position?
A
Up towards abdo wall (anteverted) 80%
Back into pelvis (retroverted) 20%
2
Q
Which cell type lines the uterus?
A
Glandular epithelium (endometrium)
3
Q
Which ligament is lateral to the uterus?
A
broad ligament
4
Q
Uterine blood supply
A
Uterine arteries (cross ureters) Ovarian arteries (anastamose at cornu)
5
Q
What do fibroids arise from? What’s another name for fibroids?
A
Myometrium
Leiomyomata (benign tumours)
6
Q
Incidence of fibroids
A
20% of white and around 50% of black women
7
Q
Risk factors for fibroids
A
- Older women (peri-menopausal)
- Afro-Caribbean
- Family history
Protective:
- Parous women
- women who have taken COCP or injectable progestogens
8
Q
Symptoms of fibroids
A
- 50% none
- menorrhagia 30%
- erratic/bleeding (IMB)
- pressure effects (urinary symptoms)
- subfertility if tubal ostia are blocked or submucous fibroids prevent implantation
- lower abdominal pain: cramping pains, often during menstruation or if tortion or degeneration
9
Q
Complications of fibroids
A
- tortion of pedunculated fibroid
- degenerations (red (partic in pregnancy), hyaline/cystic, calcification in postmenopausal)
- malignancy 0.1% leiomyosarcoma
10
Q
Investigations for fibroids
A
- FBC (low from blood loss but can be high as fibroids can secrete EPO)
- hysteroscopy (to assess uterine cavity distortion especially if fertility an issue)
- TVUS
- MRI or laparoscopy if diagnosis unsure
11
Q
Complications of fibroids during pregnancy
A
- premature labour
- malpresentations
- transverse lie
- obstructed labour
- PPH
- red degeneration
- pedunculated fibroids may tort postpartum
Don not remove during c-section as can cause heavy bleeding
12
Q
What are fibroids dependent on?
A
Oestrogen
13
Q
Management for fibroids
A
Observe or
Conservative (medical)
- symptomatic management with a levonorgestrel-releasing intrauterine system is recommended by CKS first-line
- other options include tranexamic acid, combined oral contraceptive pill, NSAIDs
- GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment. side effects limit use to 6 months
Surgical:
- myomectomy (if medical treatment has failed or want to preserve fertility). Do open as laproscopic is harder to excise. 2-3 months of GnRH analogues shrink fibroid and reduce vascularity.
- hysterectomy. 2-3 months of GnRH agonist allows less invasive operation
- hysteroscopic transcervical resection of fibroid (TCRF). If fibroid is a polyp or small (up to 3cm) submucous if causing menstrual/fertility problems. Pretreatment with GnRH agonist for 1-2 months first shrink fibroid
- hysterscopic endometrial ablation. safety and efficacy not determined
- uterine artery embolization (UAE). 80% success rate
14
Q
How do you reduce blood loss during a myomectomy?
A
Peroperative injection of vasopressin directly into the myometrium
15
Q
Indications for c-section post myomectomy
A
- endometrial cavity opened during procedure
- multiple or large fibroids
Reason is that there is an increase risk of uterine rupture during labour
16
Q
What normally happens to BP during pregnancy?
A
- falls to a minimum level in 2nd trimester (approx 30/15 mmHg) due to reduced vascular resistance
- happens to both normotensive and hypertensive mums
- rises to normal by term
17
Q
What happens to protein excretion during pregnancy?
A
Rises but shouldn’t go beyond 0.3g/24 hours
18
Q
What’s PIH?
A
Pregnancy induced hypertension
BP above 140/90 mmHg after 20 weeks
19
Q
Features of pre-eclampsia
A
- BP above 140/90 mmHg
- Proteinuria (>0.3 g/24h)
- second half of pregnancy
often with oedema
20
Q
What is pre-existing or chronic hypertension?
A
BP more than 140/90 mmHG before pregnancy or before 20 weeks
21
Q
If a woman has hypretension what is the additional risk of pre-eclampsia?
A
6 times
22
Q
Causative organ of pre-eclampsia
A
Placenta disease
Cured by delivery
23
Q
Pathogenesis of pre-eclampsia
A
Stage 1
- incomplete trophoblastic invasion (normally trophoblast invades spiral arteries and causes vasodilation of vessel walls) and acute artherosis (spiral arterioles may contain atheromatous lesions)->
- reduced spiral artery flow ->
- reduced uteroplacental blood flow (causes an abnormal uterine artery waveform) ->
- exaggerated inflammatory response ->
Stage 2
- endothelial cell damage ->:
- increased vascular permeability (oedema and proteinuria)
- vasoconstriction (hypertension, eclampsia, liver damage)
- clotting abnormality
24
Q
What proportion of women get pre-eclampsia?
A
- 6% of nulliparous women
- less common in multiparous women unless other risk factors
- 15% recurrence rate (upto 50% if there has been severe pre-eclampsia before 28 weeks)
25
What are the classifications for mild, moderate and severe hypertension?
Mild 140/90-149/99 mmHg
Moderate 150-100-159/109 mmHg
Severe 160/110:+ mmHg
26
What are the classifications of pre-eclampsia?
```
Mild= proteinuria and mild/moderate hypertension
Moderate= Proteinuria and severe hypertension with no maternal complications
Severe= proteinuria and any hypertension <34 weeks or with maternal complications
```
27
What are the risk factors for pre-eclampsia?
High risk factors
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
Moderate risk factors
- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- body mass index (BMI) of 35 kg/m² or more at first visit
- family history of pre-eclampsia
- multiple pregnancy
28
Features of HELLP syndrome
Haemolysis
(dark urine, raised lactic dehydrogenase, anaemia)
Elevated liver enzymes
(epigastric pain, liver failure, abnormal clotting)
Low platelets
(normally self-limiting)
29
What sign is suggestive of impending complications of pre-eclampsia?
epigastric tenderness
30
Complications of pre-eclampsia
Maternal (can cause maternal death)
- eclampsia
- cerebrovascular accident
- HELLP
- DIC
- liver failure
- renal failure
- pulmonary oedema
Fetal (can cause fetal death)
- IUGR
- preterm birth
- placental abruption
- hypoxia
31
Clinical features of pre-eclampsia
- usually asymptomatic
- occipital headache
- drowsiness
- visual disturbances
- nausea/vomiting
- epigastric pain
32
Pre-eclampsia accounts for what proportion of still births and preterm deliveries?
5% of still-births
| 10% preterm deliveries
33
Investigations for pre-eclampsia
Dipstick urinalysis.
If positive:
- infection is excluded by urine culture
- protein quantified (used to do 2 hour urine collection. now use protein: creatinine ratio)
34
What should you do to monitor pre-eclampsia?
Maternal complications:
- uric acid
- high Hb
- platelet count
- LFT (inc ALT suggests impending HELLP)
- creatinine (renal failure)
Fetal complications:
- US to estimate fetal weight and growth
- Umbilical artery doppler and CTG if abnormal
35
Screening and prevention of pre-eclampsia
Uterine artery doppler scan at 23 weeks gestation but low sensitivity
Now integration of following gives higher sensitivity
- UAD at 11-13+6 weeks (time of nuchal scan)
- other risk factors such as BP, biochemical markers
Prevention
Aspirin 75 mg from <16 weeks if pregnancy at risk
36
Management of pre-eclampsia
1. When to investigate?
2. When do you admit?
3. When do you give antihypertensives?
4. When do you give steroids?
5. When do you deliver?
6. When do you give magnesium sulphate?
7. What do you do postnatally?
1. BP > 140/90 mmHg
2. Confirmed pre-eclampsia or BP 160/110+ mmHg, proteinuria 2+ (if 1+ review 2 days later)
3. BP reaches 150/100 mmHg, urgently is 160/110 mmHg
4. Moderate/severe at <34 weeks to promote fetal pulmonary maturity
5. mild by 37 weeks, moderate-severe by 34-36 weeks or whatever the gestation if there are maternal complications
6. Eclampsia or to prevent it. Always deliver
7. Watch BP, urine output, blood tests (FBC, U&E, LFTs), ensure adequate follow up
37
How are patients with new hypertension monitored?
Assessed in day assessment unit. BP rechecked and investigations done.
Patients without proteinuria and with mild or moderate hypertension are usually managed as out-patients.
BP and urinalysis are repeated 2x weekly and US is performed every 2-4 weeks unless suggestive of fetal compromise
38
What do you use to treat hypertension in pre-eclampsia?
- oral nefedipine for initial control
| - IV laetalol as second line
39
How would you deliver a baby if required for pre-eclampsia?
- before 34 weeks caesarean section
- after 34 weeks can induce with prostaglandins
- epidural analgesia helps reduce BP
- fetus monitored using CTG
- antihypertensives used in labour
- if maternal BP above 160/110 mother should not push as increases risk of cerebral haemorrhage
- oxytocin rather than ergometrine is used for the 3rd stage as ergometrine can inc BP
40
How would you check for a phaeochromocytoma?
24 hour urine collection of vanillylmandelic acid (VMA)
41
Features of severe pre-eclampsia
- hypertension: typically > 170/110 mmHg and proteinuria - proteinuria: dipstick ++/+++
- headache
- visual disturbance
- papilloedema
- RUQ/epigastric pain
- hyperreflexia
- platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
42
A young woman of 28 weeks gestation presents to the emergency department with painless vaginal bleeding, she appears well and is haemodynamically stable.
Which investigation is most likely to help confirm the diagnosis?
Diagnosis of placenta praevia is with abdominal US with colour flow doppler.
Transvaginal ultrasound scans be safely performed at 20 weeks, in addition to the abdominal ultrasound scan to help improve the accuracy of localisation and RCOG guidelines state that they should be used to confirm the diagnosis of placenta praevia.
43
What is placenta praevia?
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment
44
What should you do if you detect a low lying placenta at 16-20 week scan?
- rescan at 34 weeks
- no need to limit activity or intercourse unless they bleed
- if still present at 34 weeks and grade I/II then scan every 2 weeks
- if high presenting part or abnormal lie at 37 weeks then Caesarean section should be performed
45
How do you treat placenta praevia with bleeding?
- admit
- treat shock
- cross match blood
- final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery
46
What causes maternal death with placenta praevia?
PPH
47
What causes rubella/german measles?
togavirus
48
What is the incubation period and infectious period of rubella?
incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
49
What's the risk of damage to baby from rubella?
- in first 8-10 weeks risk of damage to fetus is as high as 90%
- damage is rare after 16 weeks
50
What are the features of congenital rubella syndrome?
- congenital cataracts
- 'salt and pepper' chorioretinitis
- microphthalmia
- sensorineural deafness
- congenital heart disease (e.g. patent ductus arteriosus)
- hepatosplenomegaly
- purpuric skin lesions
- cerebral palsy
- growth retardation
51
What's the risk to fetus of parvovirus B19?
30% risk of transplacental infection, with a 5-10% risk of fetal loss
52
A woman who is 39 weeks pregnant has come in to hospital in labour. The midwife notices she has a temperature of 38.5ºC, and so suggests that the woman should get some antibiotic treatment. The woman has no drug allergies, and has has a normal and uneventful pregnancy so far. Which antibiotic should the woman get as Group B Streptococcus prophylaxis?
Benzylpenicillin
Vancomycin should be used if there is a known severe penicillin allergy.
53
Which antibiotic is given to women with PPROM?
Erythromycin
54
What's PPROM?
preterm premature rupture of membranes
55
What does the down syndrome screening programme involve?
The combined test is recommended at 10-14 weeks gestation. It involves an ultrasound scan for nuchal translucency and a blood test for levels of Beta-human chorionic gonadotrophin (beta-hCG) and pregnancy associated plasma protein A (PAPP-A). In pregnancies with Down Syndrome, PAPP-A is low and beta-hCG raised.
If the window for the combined test was missed, at 14-20 gestation, the triple* or quadruple** test will be offered. This involves a 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.
*alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
BOA
**alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A
I BOA
56
What do UKMEC 1-4 mean?
```
UK Medical Eligibility Criteria
1 Always usable
2 Broadly usable
3 Caution/counsel
4 Do no use
```
57
What are the safe or restricted drugs for women taking phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine?
UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS
58
What are the safe or restricted drugs for women taking lamotrigine?
UKMEC 3: the COCP
| UKMEC 1: POP, implant, Depo-Provera, IUD, IUS
59
Which drugs are potent EIDs and require longer periods of using barrier contraception after stopping (8 weeks)?
rifampicin and rifabutin
60
How do you manage urinary incontinence?
Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant:
- bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
- bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in 'frail older women'
If stress incontinence is predominant:
- pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
- surgical procedures: e.g. retropubic mid-urethral tape procedures
61
Incidence of urinary incontinence
4-5%
62
What are the risk factors for urinary incontinence?
- advancing age
- previous pregnancy and childbirth
- high body mass index
- hysterectomy
- family history
63
What are the classifications of urinary incontinence?
- overactive bladder (OAB)/urge incontinence: due to detrusor over activity
- stress incontinence: leaking small amounts when coughing or laughing
- mixed incontinence: both urge and stress
- overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
64
How do you investigate bladder incontinence?
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises)
- urine dipstick and culture
65
What do parity and gravidity mean?
the number of times a female is or has been pregnant (gravidity) and carried the pregnancies to a viable gestational age, beyond 24 weeks (parity)
66
How do you calculate the estimated date of delivery (EDD)?
Nagle's rule
LMP - 3 months + 1 yr 7 days
Adjust if cycle is longer than 28 days
67
What are the physiological CV changes that occur during pregnancy?
- SV up 30%, HR up 15% and cardiac output up 40%
- systolic BP is unaltered
- diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
- enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins
68
What are the physiological respiratory changes that occur during pregnancy?
- Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre)
- Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm
- BMR up 15% - this may be due to increased thyroxine and adrenocortical hormones - women may hence find warm conditions uncomfortable
69
What are the physiological blood changes that occur during pregnancy?
- Maternal blood volume up 30%, mostly in 2nd half - red cells up 20% but plasma up 50% Hb falls
- Low grade increase in coagulant activity
- rise in fibrinogen and Factors VII, VIII, X
- fibrinolytic activity is decreased - returns to normal after delivery (placental suppression?)
- prepares the mother for placental delivery
- leads to increased risk of thromboembolism
- Platelet count falls
- WCC & ESR rise
70
What are the physiological urinary changes that occur during pregnancy?
- blood flow increase by 30%
- GFR increases by 30-60%
- Salt and water reabsorption is increased by elevated sex steroid levels
- urinary protein losses increase
71
What are the physiological biochemical changes that occur during pregnancy?
- Calcium requirements increase during pregnancy
- especially during 3rd trimester + continues into lactation
- calcium is transported actively across the placenta
- serum levels of calcium and phosphate actually fall (with fall in protein)
- ionised levels of calcium remain stable
- Gut absorption of calcium increases substantially - due to increased 1,25 dihydroxy vitamin D
72
What are the physiological liver changes that occur during pregnancy?
- Unlike renal and uterine blood flow, hepatic blood flow doesn't change
- ALP raised 50%
- Albumin levels fall
73
What are the physiological changes that occur in the uterus during pregnancy?
- 100g → 1100g
- hyperplasia → hypertrophy later
- increase in cervical ectropion & discharge
- Braxton-Hicks: non-painful 'practice contractions' late in pregnancy (>30 wks)
- retroversion may lead to retention (12-16 wks), usually self corrects
74
What proportion of threatened miscarriages will go onto miscarry?
25%
75
What are the categories of miscarriage? How do you identify them?
Threatened miscarriage
- painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
- the bleeding is often less than menstruation
- cervical os is closed
- complicates up to 25% of all pregnancies
Missed (delayed) miscarriage
- 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'
Inevitable miscarriage
- heavy bleeding with clots and pain
- cervical os is open
Incomplete miscarriage
- not all products of conception have been expelled
- pain and vaginal bleeding
- cervical os is open
76
What factors help determine a miscarriage?
Ultrasound scan to determine:
- if there is still a fetal heart beat
- the size of the uterus
Examination to determine:
- whether the cervical os is opened or closed.
77
A 42-year-old female has just delivered her second and final child at 41 weeks gestation. She has currently been in the third stage of labour for 64 minutes. She has so far lost 2800ml of blood. Her previous baby was delivered by elective caesarean-section. Her only past medical history is pelvic inflammatory disease.
Due to her risk factors, an antenatal ultrasound was performed and confirmed the underlying diagnosis. Unfortunately, the results of this scan had not been seen by the delivery team until now.
What is the most definitive treatment of the underlying problem?
Hysterectomy is the recommended treatment for delayed placental delivery in patients with placenta accreta. The hysterectomy is done with the placenta left in-situ because the attempts to actively remove the placenta can cause significant haemorrhage.
78
What is placenta accreta?
Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.
79
Risk factors for placenta accreta?
- previous caesarean section
| - placenta praevia
80
If a woman has a tubal ectopic when would you offer a salpingotomy or salpingectomy
- patient failed to respond to medical treatment (methotrexate) for ectopic pregnancy
- based on the NICE guidelines, salpingectomy is offered to women who has a tubal ectopic unless they have other risk factors for infertility eg. Contra lateral tube damage. Otherwise, salpingotomy is offered as an alternative.
81
What proportion of salpingotomy patients require further treatment?
1 in 5
This treatment may include methotrexate and/or a salpingectomy.
82
When is a fetus considered macrosomic? What are the potential problems?
> 4kg
Shoulder dystocia
Baby: Erb's Palsy- damage to upper brachial plexus
Mother: PPH, perineal tears
83
Risk factors for shoulder dystocia
- fetal macrosomia
- high maternal body mass index
- diabetes mellitus
- prolonged labour
84
How do you manage shoulder dystocia?
- call for help
- McRoberts' manoeuvre should be performed
- An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.
- Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.
- Oxytocin administration is not indicated in shoulder dystocia.
85
What is McRobert's manoeuvre?
Flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen. This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
86
When is VBAC contraindicated?
- previous classical caesarean scars
- previous episodes of uterine rupture
- patients with other contraindications to vaginal birth (e.g. placenta praevia)
87
What are the main types of caesarean section?
- lower segment caesarean section: now comprises 99% of cases
- classic caesarean section: longitudinal incision in the upper segment of the uterus
88
Indications for caesarean section
Absolute indications:
- absolute CPD
- placenta praevia grades 3/4
- uncorrectable fetal lie
- previous vertical caesarean section
- severe antenatal compromise
Relative indications
- breech presentation
- twins
- pre-eclampsia
- post-maturity
- severe IUGR
- fetal distress in labour/prolapsed cord
- failure of labour to progress
- malpresentations: brow
- placental abruption: only if fetal distress; if dead deliver vaginally
- vaginal infection e.g. active herpes
- cervical cancer (disseminates cancer cells)
89
Risks of caesarean section
```
'Serious'
Maternal:
- emergency hysterectomy
- need for further surgery at a later date, including curettage (retained placental tissue)
- admission to intensive care unit
- thromboembolic disease
- bladder injury
- ureteric injury
- death (1 in 12,000)
```
Future pregnancies:
- increased risk of uterine rupture during subsequent pregnancies/deliveries
- increased risk of antepartum stillbirth
- increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
'Frequent'
Maternal:
- persistent wound and abdominal discomfort in the first few months after surgery
- increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
- readmission to hospital
- haemorrhage
- infection (wound, endometritis, UTI)
Fetal:
- lacerations, one to two babies in every 100
90
Features of cervical cancer
- may be detected during routine cervical cancer screening
- abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
- vaginal discharge
91
What are the types and proportion of cervical cancer?
- squamous cell cancer (80%)
| - adenocarcinoma (20%)
92
Risk factors for cervical cancer?
- Human papilloma virus (HPV), particularly serotypes 16,18 & 33
- smoking
- human immunodeficiency virus
- early first intercourse, many sexual partners
- high parity
- lower socioeconomic status
- combined oral contraceptive pill (debated)
93
Mechanism of HPV causing cervical cancer
- HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
- E6 inhibits the p53 tumour suppressor gene
- E7 inhibits RB suppressor gene
94
Which agent is used after the birth to facilitate delivery of the placenta and to prevent postpartum haemorrhage?
oxytocin/ergometrine
95
When is Prostaglandin E2 used
to initiate labour
96
Give 2 examples of tocolytics
Indomethacin and salbutamol
97
When is Mifepristone used? What kind of drug is it?
medical abortions
| anti progesterone
98
What is CPD?
Cephalopelvic disproportion
99
What is cord prolapse? Incidence? Consequence
Cord prolapse involves 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.
100
Risk factors for cord prolapse
- multiparity
- cephalopelvic disproportion
- prematurity
- polyhydramnios
- placenta praevia
- abnormal presentations e.g. Breech, transverse lie
- twin pregnancy
- long umbilical cord
- high fetal station
101
When do the majority of cord prolapses occur?
at artificial rupture of the membranes
102
Management of cord prolapse
- 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 caesarian 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 caesarian sections being used in breech presentations.
103
The COCP reduces the chance of which cancer?
Ovarian
Endometrial
Bowel
104
What are the advantages and disadvantages of taking the COCP?
Advantages of combined oral contraceptive pill
- highly effective (failure rate < 1 per 100 woman years)
- doesn't interfere with sex
- contraceptive effects reversible upon stopping
- usually makes periods regular, lighter and less painful
- reduced risk of ovarian, endometrial and colorectal cancer
- may protect against pelvic inflammatory disease
- may reduce ovarian cysts, benign breast disease, acne vulgaris
Disadvantages of combined oral contraceptive pill
- people may forget to take it
- offers no protection against sexually transmitted infections
- increased risk of venous thromboembolic disease
- increased risk of breast and cervical cancer
- increased risk of stroke and ischaemic heart disease (especially in smokers)
- temporary side-effects such as headache, nausea, breast tenderness may be seen
105
You are an FY-1 doctor working on a gynaecology ward. One of your patients has just been diagnosed with atypical endometrial hyperplasia. She is post-menopausal and otherwise fit and well. What is the ideal management of this condition?
A total hysterectomy with bilateral salpingo-oophorectomy, in addition, is advisable for all postmenopausal women with atypical endometrial hyperplasia, due to the risk of malignant progression
106
What are the types of endometrial hyperplasia and how do you manage it?
Types
- simple
- complex
- simple atypical
- complex atypical
Management
- simple endometrial hyperplasia without atypia: high dose progestogens with repeat sampling in 3-4 months. The levonorgestrel intra-uterine system may be used
- atypia: hysterectomy is usually advised
107
Do women who have gone through menopause require contraception?
Yes
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.
108
What type of contraceptive would you give post-menopause?
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.
109
Average age of menopause in UK
51
110
Which conditions should pregnant women be offered screening for?
```
Anaemia
Bacteriuria
Blood group, Rhesus status and anti-red cell antibodies
Down's syndrome
Fetal anomalies
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Rubella immunity
Syphilis
```
The following should be offered depending on the history:
```
Placenta praevia
Psychiatric illness
Sickle cell disease
Tay-Sachs disease
Thalassaemia
```
111
For which conditions should pregnant women not be offered screening
```
Bacterial vaginosis
Chlamydia
Cytomegalovirus
Fragile X
Hepatitis C
Group B Streptococcus
Toxoplasmosis
```
