Hormone replacement therapy like oestrogen and progestogen patches are indicated here as she is having menopausal symptoms. This systemic treatment can also alleviate symptoms of vaginal dryness.

A vaginal oestrogen cream or pessary would be appropriate if the patient only had symptoms of vaginal dryness without the other symptoms of menopause like hot flushes. In such cases, there is no need for a systemic treatment as topical treatment can alleviate symptoms.

Current evidence suggests that the use of HRT is not associated with an increase in blood pressure and therefore HRT is not contraindicated in women with hypertension as long as the blood pressure can be controlled by antihypertensive medication.

It is good practice to monitor the patient’s blood pressure 2 to 3 times in the first 6 months and then 6 monthly.

Current indications for the use of HRT are :

• Vasomotor symptoms such as flushing, including sleep, mood disturbance, and headaches.

• For women with early menopause, they should be treated with HRT until the age of natural menopause (around 51 years). The most important reason for HRT in this group is preventing the development of osteoporosis.

• For those women under 60 years who are at risk of an osteoporotic fracture in whom non-estrogen treatments are unsuitable it is especially important to note that other indications such as the reversal of vaginal atrophy should be treated with topical oestrogens.

Products of conception still present in the uterus define incomplete miscarriage. Some products of conception have been expelled but some remain thus giving the diagnosis of incomplete miscarriage.

There is usually pain and vaginal bleeding and the cervical os is open.

A summary of types of miscarriages that are commonly asked in the exam :

Threatened miscarriage -  Vaginal bleeding + fetal heart seen. The cervical os is closed.

Missed miscarriage (delayed miscarriage)  -  Dead fetus before 20 weeks without the symptoms of expulsion. May or may not have vaginal bleeding. The cervical os is closed.

Inevitable miscarriage- Cervical os opened and bleeding.

Incomplete miscarriage - Not all products of conception have been expelled

Complete miscarriage - Everything has been expelled.

Secondary PPH is characterized by abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally. It is most commonly caused by endometritis.

Investigations should include :

• High vaginal swab

• Blood including FBC and CRP

• Consider a transvaginal ultrasound to assess for retained products if there is no improvement.

Co-amoxiclav is the first-line antibiotic for endometritis. It is safe for breastfeeding.

This is the common presentation of urge incontinence.

Types of urinary incontinence:

Urge incontinence / overactive bladder (OAB) is due to detrusor overactivity. A common complaint is “When I have to go to the toilet, I really have to go” or “I have the desire to pass urine, and sometimes urine leaks before I have time to get to the toilet”.

Stress incontinence leaks small amounts of urine when coughing or laughing. Usually with a history of many vaginal deliveries as this would weaken the pelvic floor muscles.

Mixed incontinence: Mix of both urge and stress incontinence.

Overflow incontinence: Involuntary release of urine from an overfull urinary bladder, often in the absence of any urge to urinate. It occurs in people who have a blockage of the bladder outlet (benign prostatic hyperplasia, prostate cancer, or narrowing of the urethra), or when the muscle that expels urine from the bladder is too weak to empty the bladder normally.

Urethrovaginal fistula : Opening between vagina and urethra. A common complaint is “There is continual leakage of urine from my vagina” or “My vagina has a foul smell”.

MANAGEMENT OF URINARY INCONTINENCE:

The management of incontinence depends on whether urge or stress urinary incontinence is predominant.

For stress incontinence:

1. Pelvic floor exercise is the initial treatment of choice. NICE recommends that at least eight contractions be performed three times a day for a minimum of three months.

2. Surgical procedures e.g., retropubic mid-urethral tape procedures may be required.

3. Duloxetine is used for those who are not surgical candidates.

For urge incontinence :

1. Bladder retraining (minimum of six weeks). The idea is to increase the intervals between voiding gradually

2. Bladder stabilizing drugs: antimuscarinic agents are first-line. NICE recommends oxybutynin, tolterodine, or darifenacin. Immediate release oxybutynin should however, be avoided in frail older women.

Polycystic ovary syndrome (PCOS) would fit the best among the answers.

Cushing’s would be a consideration here as it can sometimes cause amenorrhoea too.

POLYCYSTIC OVARIAN SYNDROME (PCOS) is a complex endocrine disorder with clinical features that include hirsutism and acne (due to excess androgens), oligomenorrhoea or amenorrhoea, and multiple cysts in the ovary.

Symptoms:

• Oligomenorrhoea or amenorrhoea

• Hirsutism

• Alopecia

• Obesity

• Acne

• Subfertility

Diagnosis :

Rotterdam consensus criteria : Two out of three of the following criteria are diagnostic of the condition.

1. Ultrasound polycystic ovaries (either 12 or more follicles or increased ovarian volume)

2. Oligo-ovulation or anovulation

3. Clinical and/or biochemical signs of hyperandrogenism. Around 20% of women have an appearance suggestive of polycystic ovaries on ultrasound but unless they fulfill the criteria of PCOS, they should not be treated.

Biochemical abnormalities :

• Hyperadrenogenism. Biochemical hyperandrogenism is considered an elevated free androgen index (FAI) of more than 5.

• Hyperinsulinemia

• Increase in serum LH

General management - Weight loss

Management of menstrual irregularities -

• Weight loss

• Combined oral contraceptive pills, cyclical progestogen, or levonorgestrel intrauterine system.

Management of infertility :

• Weight loss alone may achieve spontaneous ovulation

• Clomifene Citrate

• If clomifene citrate fails, add on metformin or gonadotrophins or Laparoscopic ovarian drilling.

Note regarding metformin:

• The RCOG published an opinion paper and concluded that on current evidence metformin is not a first-line treatment of choice in the management of PCOS.

• Metformin is however still used, either combined with clomifene or alone, particularly in patients who are obese.

• The rationale behind metformin use is that it improves insulin sensitivity and reduces hyperinsulinemia.

This lady is suffering from stress incontinence as evidenced by small amounts of urine leakage when she sneezes or coughs.

The best management would be pelvic floor exercises.

.Tension-free vaginal tape operation should only be considered after trying conservative methods for the treatment of stress incontinence.

Bladder drill (retraining) is a method used for detrusor instability and not stress incontinence. Ring pessary is of no use here as there is no cystocele.

Loss of weight, and reducing caffeine are other lifestyle modifications that could be effective but were not given in this question.

A tubo-ovarian abscess is an advanced complication of acute salpingitis, known clinically as pelvic inflammatory disease.

Ultrasonography should be done in very ill patients in whom tubo-ovarian abscess is suspected. A high vaginal swab or endocervical swab can take days to return with results.

As this is an A&E case, an ultrasound would be more appropriate as this would lead to a diagnosis.

Causes for PPH may be considered to relate to one or more of ‘the four Ts’:

• Tone (abnormalities of uterine conception)

• Tissue (retained products of conception)

• Trauma (of the genital tract)

• Thrombin (abnormalities of coagulation) 

The most common cause of primary PPH is uterine atony and in this case, since the uterus is felt to be above the uterus and relaxed, a uterine massage would be the most appropriate next step.

Following potentially sensitizing events which include giving birth, anti-D immunoglobulins should be administered as soon as possible and always within 72 hours of the sensitizing event.

.If exceptionally this deadline has not been met and 72 hours have passed, you can still administer anti-D immunoglobulins for up to 10 days as there may still be some protection offered during this time.

RHESUS NEGATIVE PREGNANCY :

A basic understanding of the pathophysiology is essential to understand Rhesus-negative pregnancies. If a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur which causes anti-D IgG antibodies to form in the mother. In future pregnancies, these antibodies can cross the placenta and cause haemolysis in the fetus.

Prevention of Rh sensitization-

• Test for anti-D antibodies in all Rh -ve mothers at booking.

• If Rh –ve and not previously sensitised, guidelines (2008) advises giving anti-D at 28 and 34 weeks gestation.

• Anti-D is for prophylaxis only–Remember once sensitization has occurred it is irreversible and Anti-D administration would be pointless Anti-rhesus (anti-D) immunoglobulin is given intramuscularly. It neutralizes any Rhesus D-positive antigens that have entered the mother’s blood. If the antigens have been neutralized, there will be no reason for a mother to develop immunity and produce antibodies. She would remain non-sensitised.

Anti-D immunoglobulin should be given as soon as possible (but always within 72hours) in the following situations:

• Delivery of a Rh +ve infant, whether live or stillborn.

• Any termination of pregnancy or evacuation of retained products of conception (ERPC) after miscarriage.

• Miscarriage if gestation is > 12 weeks.

• Ectopic pregnancy.

• Blunt abdominal trauma.

• External cephalic version.

• Antepartum haemorrhage, any vaginal bleeding over 12 weeks gestation.

• Amniocentesis, chorionic villus sampling, fetal blood sampling.

Affected fetus : If unborn - Oedematous (Hydrops fetalis, as liver devoted to RBC production thus albumin falls), Foetal heart failure.

Treatment involves intrauterine blood transfusion :

• If born - Jaundice (due to build-up of excessive bilirubin from RBC breakdown), Anaemia, Hepatosplenomegaly.

• Treatment involves UV phototherapy, blood transfusion, and exchange transfusion.

Combined hormonal contraception (CHC): Despite the 'pill' previously being considered a risk factor for fibroid growth, CHC is helpful if the patient requires contraception, although it is not as effective as a levonorgestrel-releasing intrauterine system.

Thus, the intrauterine system would be the answer here.

The intrauterine system (IUS) reduces the uterine size in women with fibroids. If this lady here had presented with asymptomatic fibroids and was not looking for contraception, expectant management would be a valid answer especially if she was peri-menopausal.

CONTRACEPTION CLINCHERS : Choosing the correct contraceptive for the correct situation is something a lot of doctors have problems with. Here are some useful contraception/abnormal uterine bleeding clinchers for the exam.

Young woman, not sexually active (don’t require contraception)

• Menorrhagia only – Tranexamic acid

• Menorrhagia with dysmenorrhoea – Mefenamic acid

• Menorrhagia / dysmenorrhoea/metrorrhagia (irregular menses) - COCP Sexually active woman (require contraception).

• Menorrhagia / dysmenorrhoea or those suffering from fibroids (which do not distort the uterine cavity) – IUS Mirena (first-line).

These questions will also mention possible contraindications for COCP like obesity/smoking/history of thromboembolism etc.

• Women with sickle cell disease and menorrhagia – Depo-provera IM

Emergency contraception • Within 72 hours of unprotected sex

• Within 120 hours of unprotected sex – IUCD 

FIBROID MANAGEMENT-

If Asymptomatic

• Follow up annually to monitor size and growth unless rapid growth or reason to suspect pelvic malignancy in which case further investigations are warranted with menorrhagia.

• Levonorgestrel-releasing intrauterine system (LNG-IUS) – provided uterine fibroid is not distorting the uterine cavity.

• Tranexamic acid, NSAIDs or COCP

• Norethisterone as a temporary measure With severe menorrhagia and fibroid more than 3 cm • Ulipristal acetate up to 4 courses. Each course is up to 3 months. Usually used in pre-operative treatment.

Surgical management-

• Hysterectomy – The most successful treatment

• Myomectomy

• Uterine artery embolization

• Endometrial ablation – only for fibroids less than 3 cm in diameter.

Both myomectomy and uterine artery embolization can be performed in patients who would like to preserve their fertility with myomectomy usually being the preferred option in these cases especially if treatment of infertility is required. Myomectomy has been shown to increase pregnancy rates compared with uterine artery embolization.

Other medical management :

• Gonadotropin-releasing hormone (GnRH) agonists. Reduces the size of fibroids and is used before surgery to reduce perioperative blood loss. Surgery must take place as uterine fibroids would return to pretreatment size if GnRH agonist treatment is stopped.

The key to answering this is knowing when a diagnostic laparoscopy is required for endometriosis. In practice, we would offer a trial of hormonal treatment for a period of 3 to 6 months before having a diagnostic laparoscopy. This is due to the risk of laparoscopic surgery with the additional fact that even with a laparoscopic ablation of endometrial tissue the relapse of symptoms occurs in 40 to 45% of women with up to 30% of women being readmitted for surgery within 5 years.

ENDOMETRIOSIS :

Endometriosis is the presence of endometrial-like tissue outside the uterine cavity. It is oestrogen dependent, and therefore mostly affects women during their reproductive years. If the ectopic endometrial tissue is within the myometrium itself it is called adenomyosis. Up to 10-12% of women have a degree of endometriosis.

Clinical features :

• Chronic pelvic pain (cyclic or constant)
• Dysmenorrhoea - pain often starts days before bleeding
• Deep dyspareunia (indicates possible involvement of uterosacral ligaments)
• Subfertility

INVESTIGATIONS :

• Laparoscopy is the gold-standard investigation
• Transvaginal ultrasound scanning appears to be a useful test, both to make and exclude the diagnosis of an ovarian endometrioma.

Management :

• NSAIDs to treat pain
• Combined oral contraceptive pill (other hormonal drugs can be used too)
• Levonorgestrel intrauterine system

Note: Drug therapy unfortunately does not seem to have a significant impact on fertility rates. Laparoscopic excision and ablation of endometrioid lesions help reduce endometriosis-associated pain. Laparoscopic excision and ablation of endometriotic ovarian cysts may improve fertility.

There are two possibilities here. Endometriosis and pelvic congestion syndrome. Given that endometriosis is much more common than pelvic congestion syndrome, endometriosis is the answer.

A take-home point here is a normal ultrasound pelvis does not exclude endometriosis.

Endometriosis presents exactly the way they describe this question with chronic pelvic pain, dysmenorrhoea, and dyspareunia.

Pelvic ultrasound scans are usually normal. In pelvic venous congestion, there are dilated veins believed to cause a cyclical dragging pain. It is worse premenstrually and after prolonged periods of standing and walking.

Dyspareunia is also often present. Given there is no history of standing here, pick endometriosis. It is also by far more a common diagnosis when it comes to chronic pelvic pain.

Laparoscopic tubal occlusion using Filshie clips to mechanically occlude the fallopian tubes is now the laparoscopic method of choice.

The risk of pregnancy after sterilization by tubal ligation is about 1:200, meaning that 1 in every 200 women who undergo sterilization may get pregnant at some point after sterilization.

No action is needed. The latest recommendations are that no additional contraceptive precautions are required when combined oral contraceptives are used with anti bacterials that do not induce liver enzymes unless diarrhoea or vomiting occurs.

ORAL CONTRACEPTION INTERACTION AND HEPATIC ENZYME INDUCERS : Hepatic enzyme inducers can decrease the effectiveness of the combined oral contraceptive pill and progesterone-only pill when taken at normal doses.

The two most commonly used oral contraception interactions with hepatic enzyme inducers are:

1. Rifampicin

2. Anticonvulsants (such as phenytoin, carbamazepine, phenobarbitone) : Women starting enzyme-inducing drugs should be advised to use a reliable contraceptive method that is unaffected by enzyme inducers. In general, depo-provera, copper intrauterine devices or the levonorgestrel containing intrauterine system (LNG-IUS) are the safest to use. 

A good GP would discuss the use of additional barrier methods, having progesterone-only injections, insertion of intrauterine devices, or use of an increasing dose of oestrogen. 

Multiple sexual partners are a risk factor for Pelvic inflammatory disease. Women of her age group (<25 years old) are at greater risk for pelvic inflammatory disease as they are more sexually active during this period.

Other options are less likely because:

Although chronic pelvic pain, deep dyspareunia, and menstrual irregularities could be seen in endometriosis, it is unlikely the given choice here as the history of multiple sexual partners and cervical excitation does not match this answer. This pain is non cyclical which also suggests PID rather than endometriosis.

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease (PID). Usually presents with an acute onset of the right upper quadrant (RUQ) abdominal pain aggravated by breathing, or coughing. This pain may be referred to the right shoulder.

Cervicitis usually presents with discharge.

Do not get confused between cervicitis and PID. Infection at the cervix can eventually ascend to cause PID. But if the infection is purely at the cervix, they will not present with menstrual irregularities and lower abdominal pain as the infection has not ascended to involve the uterus, fallopian tubes, and ovaries.

Asherman syndrome are adhesions of the endometrium often associated with dilation and curettage of the intrauterine cavity. It results in infertility. Often, they experience menstrual irregularities. But in this question, there is no relevant past medical history meaning she did not have any dilation and curettage thus this option is very unlikely.

PELVIC INFLAMMATORY DISEASE :

Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries, and the surrounding peritoneum.

Most commonly caused by ascending infection from the endocervix.

Causative organisms :

• Chlamydia trachomatis - The most common cause

• Neisseria gonorrhoeae

Risk factors for PID :

• Age <25

• Previous STIs

• New sexual partner / multiple sexual partners

• Uterine instrumentation such as surgical termination of pregnancy

• Intrauterine contraceptive devices

• Post-partum endometritis

Features :

• Lower abdominal pain

• Fever

• Deep dyspareunia

• Dysuria and menstrual irregularities may occur

• Vaginal or cervical discharge

• Cervical excitation

• Abnormal vaginal bleeding (intermenstrual, postcoital)

Investigation :

• Screen for Chlamydia and Gonorrhoea

Management :

There are many combinations of antibiotics to treat PID. This is one of the combination examples for the treatment of PID.

Outpatients: Ceftriaxone 500 mg as a single intramuscular dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily, both for 14 days.

Note the differences between acute PID and just cervicitis.

If just cervicitis (Chlamydia)

• Azithromycin 1g single dose (OR doxycycline 100mg bd for 7 days); both have similar efficacy of more than 95%.

If just cervicitis (Neisseria gonorrhoeae)

• Azithromycin 1g PO and ceftriaxone 500mg IM.

RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in.

Complications :

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

• Chronic pelvic pain

• Ectopic pregnancy

Bacterial vaginosis and Trichomonas vaginalis can give foul-smelling discharge.

In bacterial vaginosis, the vaginal discharge is grey-white and has a “fishy” smell.

In trichomonas vaginalis, it can be greenish and frothy along with vulvovaginitis i.e. strawberry cervix.

The discharge of Chlamydia and Gonorrhea is not usually foul-smelling.

Since Trichomoniasis is not present among the available choices, Gardnerella is the answer.

Bacterial vaginosis (BV) is caused by an overgrowth of mixed anaerobes, such as Gardnerella vaginalis, which replace the usually dominant vaginal lactobacilli resulting in a raised vaginal pH. It is the commonest cause of abnormal vaginal discharge in women of childbearing age. Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.

Features :

• Vaginal discharge: 'fishy', offensive 

• Asymptomatic in 50% 

• Homogenous grey-white discharge

• Characteristic fishy smell

• ‘Clue cells’ present on microscopy

• Vaginal pH > 5.5

Management- May resolve spontaneously and if successfully treated has a high recurrence rate.

However, most women prefer it to be treated.

• Metronidazole 400mg orally bd for 5 days or metronidazole 2g (single dose) OR

• Clindamycin 2% cream vaginally at night for 7 days.

No guideline says any of the above medications should be started as an adjuvant to her regime. However, given the choices provided, bisphosphonates are probably the best choice as it is shown in some studies to reduce the risk of bone metastasis in breast cancers.

Constipation can be improved by increasing fluid intake, eating high-fiber foods, and exercising, all of which this patient has already done. When conservative management has been attempted and is unsuccessful, laxatives should be tried.

Lactulose, which is not known to be harmful in pregnancy is usually used as first-line for pregnant women as it is a very well-tolerated medication.

Senna which is a stimulant laxative is also very effective however they do cause more abdominal discomfort compared to bulk-forming laxatives like lactulose.

If senna is used, it should only be used for short periods.

Not all questions are straightforward in exams. You will come across somewhere you feel the information is missing like this one. The options of incorrect dates and molar pregnancy come close. It is important to that that the question states the uterus extends up to 16 weeks gestation.

It can therefore be inferred that the pregnancy is either large for dates with a uterine fibroid or molar pregnancy alternatively an incorrect menstrual period date is also a possibility.

If this patient had uterine fibroids, it would NOT explain the excessive morning sickness. If this patient had an incorrect menstrual period date and was 16 weeks gestation, it would NOT explain the reason hyperemesis started so late in pregnancy. Symptoms of hyperemesis would have occurred several weeks ago as hyperemesis symptoms begin 6 to 8 weeks and peak at 12 weeks. The patient is presenting with features of molar pregnancy which are uterus large for dates, first trimester bleeding, and hyperemesis.

This is a presentation that is also similar to multiple pregnancies like twin pregnancies as they are also at increased risk of bleeding, hyperemesis, and have a uterus that is larger for dates. However, in multiple pregnancies, the uterus is seen to be larger in the second trimester rather than the first. Also, multiple pregnancies are not an option given here. Hyperemesis gravidarum is not completely incorrect as this patient also has a diagnosis of hyperemesis gravidarum as she has been seen to be vomiting for the past two weeks. However, the most likely diagnosis given the whole clinical picture is still molar pregnancy.

Gestational trophoblastic disease (GTD) covers a spectrum of diseases caused by overgrowth of the placenta.

It ranges from molar pregnancies to malignant conditions such as choriocarcinoma.

If there is any evidence of persistence of GTD the condition is referred to as gestational trophoblastic neoplasia (GTN).

Features:

• Hyperemesis  due to excessive amounts of human chorionic gonadotropin (hCG)

• Irregular first-trimester vaginal bleeding

• Uterus large for dates

• Vaginal passage of vesicles containing products of conception

• Serum hCG is excessively high with complete moles, but levels may be within the normal range for partial moles.

Ultrasound findings of a complete mole : ‘Snowstorm’ appearance of mixed echogenicity, representing hydropic villi and intrauterine haemorrhage , Large theca lutein cysts.

Management of Hydatidiform mole:

• Surgical evacuation (Suction curettage)

 Note that histological examination of products of conception is essential to confirm the diagnosis.

• Two-weekly serum and urine samples until hCG concentrations are normal. Women should be advised not to conceive until their hCG level has been normal for 6 months. Barrier contraception should be used until serum hCG is normal (oral contraception may also be used after molar evacuation before hCG returns to normal)

Management of gestational trophoblastic neoplasia (GTN) : This is unlikely to be asked in detail in EXAM due to the complexity of management. But you do need to know it involves chemotherapy. If chemotherapy is started, women should wait a year from the completion of their treatment before trying to conceive.

It is important to remember that you should never prescribe any pain-relief other than paracetamol to a pregnant woman. Paracetamol has a good safety profile with pregnant women when compared to all the other analgesics.

There are cases where stronger pain relief is needed, but usually, consultants would be involved in the management.

For EXAM, whenever you see a pregnant lady with any sort of pain(whether it is from osteoarthritis, back pain, headaches, or a sprained ankle), never give any analgesia except for paracetamol.

This is a typical case of stress incontinence. To understand it further, first, we need to understand what urinary incontinence is. Incontinence is the involuntary leakage of urine.

Stress incontinence is a leak of small amounts of urine when coughing or laughing. This is due to an increase in intra-abdominal pressure. Usually with a history of many vaginal deliveries as this would weaken the pelvic floor muscles.

The next management here would be pelvic floor exercises. Loss of weight and reducing caffeine are other lifestyle modifications that could be effective but were not given in this question.

The diagnosis here is ectopic pregnancy. The first clue here is the gestational age 8 weeks. Ectopic pregnancies would usually present around 6-8 weeks from the start of the last period as it is then that they are large enough to stretch the fallopian tubes thus causing pain.

The stretching of the fallopian tubes is also the reason why they may sometimes experience cervical motion tenderness on a vaginal examination. The second clue here is the unilateral abdominal pain.

This gives us a clue that the pathology is towards one side rather than in the middle. The remaining choices are far less likely to be the correct answer.

In the past, fibroids could be the cause of an inconclusive scan as they may obstruct the view of the gestational sac.

However, with the modern transvaginal scan, this is no longer the case. And thus ectopic pregnancies are a more likely diagnosis here.

Complete miscarriage - This is when all products of conception have been expelled. This is unlikely the case as she has only suffered mild vaginal bleeding (vaginal spotting).

Threatened miscarriage - Presents with vaginal bleeding + fetal heart is seen. A diagnosis of threatened miscarriage cannot be made without seeing a viable fetus on an ultrasound scan.

Incomplete miscarriage - Not all products of conception have been expelled. This means that products of conception would still be visible on an ultrasound scan.

ECTOPIC PREGNANCY: Defined by the implantation of a fertilized ovum outside the uterus.

Clinical features :

• Lower abdominal pain: typically the first symptom.

• Vaginal bleeding: usually less than a normal period.

• History of recent amenorrhoea: typically 6-8 weeks from the start of the last period.

• Peritoneal bleeding can cause shoulder tip pain.

Any woman of childbearing age who attends A&E with abdominal pain MUST have a urine pregnancy test performed. Ruptured ectopic pregnancies are life-threatening. Do not miss a diagnosis of an ectopic by forgetting to do a urine pregnancy test.

Examination findings :

• Abdominal tenderness

• Cervical excitation (also known as cervical motion tenderness)

• Adnexal mass may be noticed – rarely seen.

Always observe the blood pressure of the patient as a significant drop of blood pressure in a suspected ectopic needs to be quickly escalated.

Management:

• If haemodynamically stable - Laparoscopic salpingectomy or salpingostomy

• If haemodynamically unstable- Laparotomy (open salpingectomy or salpingostomy)

METHOTREXATE would be the first line for an ectopic pregnancy, if the patient was not in significant pain however it can only be used if it contains all the criteria below

• Not in significant pain

• Haemodynamically stable

• Adnexal mass smaller than 35 mm with no fetal heart visible

• No intrauterine pregnancy

• Serum hCG less than 5000 IU/liter (ideally less than 1500 IU/liter)

• Able to return for follow-up.

HELLP syndrome : This is a serious complication regarded by most as a variant of severe pre-eclampsia which manifests with haemolysis (H), elevated liver enzymes (EL), and low platelets(LP).

Liver enzymes usually increase and platelets decrease before haemolysis occurs. The syndrome is usually self-limiting, but permanent liver or renal damage may occur. Note that eclampsia may co-exist.

Signs and Symptoms:

• Epigastric or RUQ pain and tenderness

• Nausea and vomiting

• Urine is ‘tea-colored’ due to hemolysis.

• Increased BP and other features of pre-eclampsia

Management :

• Delivery

• Supportive and as for eclampsia (magnesium sulfate (MgSO 4 ) is indicated)

• Although platelet levels may be very low, platelet infusions are only required if bleeding, or for surgery and <40

DIFFERENTIATING AFLP FROM HELLP - Acute fatty liver of pregnancy vs Haemolysis, Elevated Liver enzymes, Low Platelets syndrome. It is unlikely that you would need to know all the different features of HELLP and AFLP for the level of the exam as even senior medical and obstetric teams often have difficulty telling them apart in a clinical setting, however, this table is inserted for those who would like to understand how to differentiate them for your clinical knowledge.

Painless vaginal bleeding without abdominal pain should raise suspicion of placenta praevia.In many countries, it is common to have an ultrasound scan during the first trimester and again around 20 weeks for an anomaly scan in which the sonographer would formally report the position of the placenta.

In this case, she did not have previous scans so she may very well have a low-lying placenta. The painless bleeding seen in the placenta praevia may occur without warning or after intercourse. This is one reason obstetricians advise women with placenta praevia not to have intercourse.

From her observations, one can see that it is maternal blood that is being lost which is consistent with placenta praevia. If this was the case of vasa praevia, it would be fetal blood that would be lost and maternal observations would remain normal.

Placental abruption presents with sudden onset abdominal pain +/- vaginal bleeding. It is also commonly associated with CTG abnormalities.

Placenta accreta is less common than placenta praevia and is seen commonly in the presence of a uterine scar which allows the placenta to attach to the myometrium.

PLACENTA PRAEVIA:

Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment. This is common early in the pregnancy but is most often not associated with bleeding. The key clinical feature is painless bleeding after 24 weeks of gestation.

Risk factors :

• Previous placenta praevia

• Multiple pregnancies

Symptoms :

- Vaginal bleed

- Uterus not tender

- Lie and presentation may be abnormal

- Fetal heart is usually normal. The painless late-pregnancy bleeding may occur during rest or activity, suddenly and without warning. It may be preceded by trauma, coitus, or pelvic examination. A digital vaginal examination should NOT be performed. However, a speculum or a transvaginal probe can safely be used in placenta praevia.

Diagnosis- This is based on the presence of painless late-trimester vaginal bleeding with an obstetric ultrasound showing placental implantation over the lower uterine segment. A transvaginal ultrasound is preferred over abdominal ultrasound for the detection of placenta praevia.

To answer this question accurately, it is essential to know about the management of lost intrauterine device threads.How do we manage lost intrauterine device threads

1. Exclude pregnancy by performing a urine pregnancy test.

2. Request a pelvic ultrasound to look for the IUCD

3. If the IUCD is not found on ultrasound, request an abdominal X-ray

Emergency contraception is incorrect as there is no evidence of recent sexual intercourse in the stem. Remember, one needs to know the timing of sexual intercourse to know which emergency contraception to use.

For example, levonorgestrel can be used for up to 72 hours whereas ulipristal acetate and copper intrauterine device can be used for up to 5 days. We are not sure if the coil is in place. There is no evidence of sexual intercourse.

A hysteroscopy may be used to remove an IUCD from within the uterine cavity provided it is proven to be there. An X-ray of the abdomen would be best to determine if the IUCD is in the abdomen. This can occur when the IUCD perforates through the uterus during insertion or finds a way to migrate to the abdominal cavity when initially inserted intrauterine.

If the IUCD is found outside the uterus but inside the abdominal cavity, a laparoscopy can be done to retrieve it.

MANAGEMENT OF LOST INTRAUTERINE DEVICE THREADS : If speculum examination reveals no IUD thread -

• Take a menstrual and sexual history, excluding pregnancy. Provide alternative contraception and/or post-coital contraception if indicated by history. If a woman is pregnant refer to the Early Pregnancy Unit for rapid access to ultrasound scans. The viability of pregnancy, site, and gestation will need to be determined. If the ultrasound scan reports the device is correctly located in the uterus, leave the IUD in situ until it is due to be removed. If an IUD is not seen in the uterus, order a plain abdominal X-ray.

• If an abdominal X-ray shows the IUD is in the abdominal cavity, this may require laparoscopic removal If an X-ray shows IUD is not located, this implies that the IUD has fallen out and a replacement of the IUD can be offered.

Please see Q-16

In this scenario, this patient needs a contraceptive method that will solve her excessive menstrual bleeding and which will cater to her specific needs. The levonorgestrel-releasing intrauterine system (Mirena) is the best option for this patient. The levonorgestrel-releasing intrauterine system (Mirena) is the best option for this patient to treat her heavy menstrual periods and to relieve her dysmenorrhoea.

It has been shown to reduce the severity of dysmenorrhoea even though it doesn’t affect or regulate the release of the female hormones that govern ovulation. According to guidelines, if a uterine fibroid is less than 3 cm by 3 cm in size and is not distorting the uterine cavity, medical treatments that can be considered are the intrauterine system, tranexamic acid, and the combined oral contraceptive pill.

We cannot offer the combined oral contraceptive pill in this patient as COCPs are contraindicated in patients with a history of venous thromboembolism. In the exam, if no contraindications exist for choosing the levonorgestrel-releasing intrauterine system, then choose that as an answer. 

Maternal tachycardia, tenderness suprapubically, and purulent vaginal discharge with a history of ruptured membranes points toward chorioamnionitis.

PROM is a major risk factor for ascending infections causing chorioamnionitis. Maternal tachycardia often precedes pyrexia hence the normal temperature given in this stem. There is no indication of miscarriage here which is characterized by vaginal blood loss.

CHORIOAMNIONITIS : Chorioamnionitis is an acute inflammation of the fetal amnion and chorion membranes, typically due to ascending bacterial infection from the vagina into the uterus in the setting of membrane rupture in pregnancy.

Features suggestive of chorioamnionitis :

• Fever

• Abdominal pain, including contractions

• Maternal pyrexia and tachycardia (tachycardia)

• Uterine tenderness

• Fetal tachycardia

• Foul odour of amniotic fluid

• Speculum: offensive vaginal discharge - yellowish brown

Risk factors :

• Prolonged labour

• Internal monitoring of labour

• Multiple vaginal exams

• Meconium-stained amniotic fluid

She has been diagnosed with antiphospholipid syndrome in the past. This puts her at risk for blood clots and she would eventually need heparin. Heparin and aspirin also reduce the risk of miscarriages in patients with diagnosed antiphospholipid syndrome.

Guidelines give clear recommendations for the use of prophylactic cerclage and prophylactic vaginal progesterone. They should be offered to women if she has a history of spontaneous preterm birth or mid-trimester loss between 16 weeks and 34 weeks of gestation AND in whom a transvaginal ultrasound scan has been carried out between 16 to 24 weeks of pregnancy that reveals a cervical length of less than 25 mm.

Prophylactic cervical cerclage can also be considered in women with cervical length less than 25 mm who have a history of cervical trauma like a LLETZ procedure. This patient had 3 early miscarriages and thus there is no indication of a cervical cerclage or progesterone pessaries.

CERVICAL CERCLAGE : Cervical weakness is a recognized cause of second-trimester miscarriage. The diagnosis is essentially a clinical one and based on a history of second-trimester miscarriage preceded by spontaneous rupture of membranes or painless cervical dilatation. Cervical cerclage does come with risks which are related to the surgery.

Risks include infections and rupture of the membranes. The criteria is a strict and complicated one thus it is unlikely to be a correct answer during EXAM. Nonetheless, if they do give a history of painless dilatation during previous miscarriages, cervical cerclage could be the option.

ANTIPHOSPHOLIPID SYNDROME : Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. Antiphospholipid syndrome refers to the association between antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies, and anti-B2 glycoprotein-I antibodies) and adverse pregnancy outcomes or vascular thrombosis.

All women with recurrent first-trimester miscarriages and all women with one or more second-trimester miscarriages should be screened before pregnancy for antiphospholipid antibodies. Note the term recurrent miscarriage refers to the loss of three or more consecutive pregnancies.

If diagnosed with antiphospholipid syndrome, pregnant women can be treated with aspirin 75 mg plus heparin as this is seen to lower the risk of further miscarriage. Corticosteroids have no role in improving the live birth rate of women with recurrent miscarriages associated with antiphospholipid antibodies.

Day 21 progesterone which is the mid-luteal progesterone level is used to assess ovulation. If this is low, it may need repeating, as ovulation does not occur every month.

FSH and LH should be measured if there is menstrual irregularity :

High levels may suggest poor ovarian function.

A comparatively high LH level relative to FSH level can occur in PCOS.

In reality, we would obtain FSH, LH, and mid-luteal progesterone levels.

But for examination, always pick mid-luteal progesterone levels as the answer when it comes to infertility investigations.

Basal body temperature charts are not recommended to predict ovulation, as they are unreliable.

Causes of female infertility :

• Unexplained

• Ovulation failure

• Tubal damage

• Note that a history of pelvic inflammatory disease is highly suggestive of damage to tubes basic investigations.

• Serum progesterone 7 days prior to the expected next period. Meaning day 21 of a 28-day cycle. However, this day will need to be adjusted for different lengths cycle.

•This is also termed the “Mid-luteal progesterone level “

• It is done to assess ovulation. If low, it may need repeating, as ovulation does not occur every month.

Uterine rupture is the complete separation of the wall of the pregnant uterus with or without expulsion of the fetus that endangers the life of the mother the fetus, or both. This usually occurs during labour but has been reported antenatally.

Signs and symptoms:

• Tenderness over sites of previous uterine scars

• Fetal parts may be easily palpable

• Fetus not palpable on vaginal examination

• Vaginal bleeding may be evident

• Signs of maternal shock may be present. CTG may show fetal distress and change in apparent uterine activity (contractions may seem to disappear on the tocograph).

The most common risk factors are:

• Previous C-section or other uterine surgeries

• Excessive oxytocin stimulation

• Failure to recognize obstructed labour.

Diagnosis : Confirmation of the diagnosis is made by surgical exploration of the uterus and identifying the tear.

Management :

• Urgent laparotomy to deliver the fetus and repair the uterus.

Among the options levonorgestrel intra-uterine system (Mirena coil) is the best treatment to reduce menorrhagia. It is currently the first-line treatment for menorrhagia. Combined oral contraceptive pills can do the job as well but she has already stated that she would want a long-term treatment with minimal side effects.

Thus the levonorgestrelintra-uterine system would be the most appropriate. Copper intrauterine contraceptive devices and progestogen implants are more prone to have irregular heavy bleedings compared to levonorgestrel intra-uterine system(Mirena coil). Endometrial ablation does affect fertility and is not an appropriate management for a woman who may still want children in the future.

MENORRHAGIA MEDICAL MANAGEMENT : Guidelines has suggested that this medical management of heavy menstrual bleeding should be considered in the following order:

1. Levonorgestrel-releasing intrauterine system.

2. Tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives.

3. Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle, or injected long-acting progestogens. This should be taken into account if contraception is desired. If contraception is desired, then preference would go towards the intrauterine system (Mirena) followed by COCP and injected long-acting progestogens.

Important combinations  :

• A combination of tranexamic acid and a nonsteroidal anti-inflammatory drug (NSAID) can be used if the patient has both menstrual bleeding and dysmenorrhoea

• A combination of NSAID and COCP can be used if dysmenorrhoea is problematic

• Do NOT combine tranexamic acid with a COCP or Mirena coil For heavy menstrual bleeding that needs stopping rapidly:

• Oral norethisterone 5 mg three times daily for 10 days In secondary care,

Treatment includes:

• Gonadotrophin-releasing hormone (GnRH) agonists.

The management of menorrhagia and fibroids overlap considerably. So it is always wise to go through these two topics together.

The question here describes the signs and symptoms of polycystic ovarian syndrome (PCOS). The scenario of acne on her face points towards an excess of androgens (hirsutism, alopecia, and acne are all manifestations of hyperandrogenism). Not to mention that her initial complaint was infertility which is one of the diagnostic criteria for PCOS.

The dark pigmentation on her neck is called acanthosis nigricans which is characterized by brown to black hyperpigmentation of the skin found in body folds, such as the axilla, nape of the neck, and groin. It is a marker of insulin resistance.

Weight loss is the most appropriate answer as part of INITIAL management. Clomifene citrate is an option together with weight loss however it is advisable to encourage weight loss first. In practice, we would advise patients to lose weight while getting blood tests done to confirm anovulation.

Some clinicians would start them on metformin right away on their first visit. This is a debatable action but since metformin was not given in the options, we shall not discuss it here. Just note that metformin is currently unlicensed for use in PCOS and so women would need to be counseled carefully before initiating therapy.

Laparoscopic drilling is a treatment for infertility for PCOS but is not the first line. COCP is a treatment for PCOS to regulate irregular periods but it is not for treatment of infertility.

Spironolactone (an antiandrogen) is used by endocrinologists to help with the effects of hirsutism. But again, this will not help with infertility.

The key word here is primary amenorrhoea. This means that she has never had her menses before. The only possibility among the options given that could cause primary amenorrhoea is haematometra. Primary amenorrhoea and cyclical pain indicate haematometra. Haematometra is an accumulation of blood within the uterus.

One of the causes of haematometra that is associated with primary amenorrhoea is an imperforate hymen or a transverse vaginal septum. In an imperforate hymen, one might have a bluish bulging membrane visible at the introitus.

A transverse vaginal septum may present with a possible abdominal mass.

Transvaginal ultrasound is a good step to locate if the intrauterine device is still intrauterine, displaced, or fallen out. It is unlikely that it has perforated the uterus as if, the patient would be presenting with an acute abdomen.

Transvaginal ultrasound has better image quality when looking at the uterus compared to a transabdominal ultrasound.

An X-ray is capable of seeing the intrauterine device as well but it is reserved for more acute presentations like suspected perforation or when the IUD is not seen on an ultrasound scan.

Combined oral contraceptives are not completely wrong as if there was a delay in obtaining the ultrasound scan, it may be necessary to start the woman on a form of contraception until the ultrasound scan can be performed. The choice of your answer depends on how the question is phrased. If the last line of the question asks “What is the most appropriate NEXT step” or “What is the most appropriate IMMEDIATE action”, prescribing a form of contraception would be your best pick.

The possible diagnosis here is a pelvic abscess or tubo-ovarian abscess which are complications of PID. A high vaginal swab or endocervical swab can take days to return with results.

As this is an A&E case, an ultrasound would be more appropriate as this would lead to a diagnosis. Ultrasound scan is the diagnostic imaging method of choice for acute pelvic pain in gynaecology.

It can easily diagnose sequelae of PID (including pyosalpinx and tubo ovarian abscess). Laparoscopy would be the next step after finding a mass on ultrasound. Urine culture has no part in the diagnosis of pelvic abscess.

The results that show inflammatory changes are nonspecific. These findings are difficult to interpret. It may be nonsignificant or it may also represent genital infections like candida amongst others.

Inflammation is usually not a worrying sign unless it is severe in which case we may consider a more serious sexually transmitted infection. It is good practice to repeat the smear in 6 months to ensure that the inflammation has resolved.

The values of anaemia differ in pregnancy as compared to a non pregnant women.

Anemia in pregnancy as the following values Hb levels of:

<11.0g/dl in the first trimester

<10.5 g/dl in the second and third trimesters <10.0 g/dl in the postpartum period.

Since her Hb level is above 10.5g/dL, she does not need iron tablets.

This is one of the questions that differ in terms of how you answer in exam and how you would act in real life.

Again, it depends on hospital guidelines. 

Serum and urine samples of hCG concentrations are extremely important. In hydatidiform moles, hCG levels are likely to be raised excessively (especially in incomplete moles). Management would involve surgical evacuation, after which the hCG levels are expected to return to a normal, non-pregnant level.

We would like the hCG to go down towards a normal level but If it plateaued or if hCG levels rise after evacuation, chemotherapy is indicated.

This is the reason it is so important not to get pregnant during the time that hCG levels are decreasing if one were to get pregnant, hCG levels would increase again, and we would not know if it is due to the hydatidiform mole or the new pregnancy.

Any pregnant woman with symptoms and/or signs suggestive of venous thromboembolism should have objective testing performed expeditiously and treatment with low-molecular-weight heparin (LMWH) given until the diagnosis is excluded by objective testing unless treatment is strongly contraindicated.

The guidance on termination of pregnancy in patients who are under 16 is clear. In summary, female patients under the age of 16 do not need parental consent to request a termination of pregnancy using either medical or surgical methods if:

• The patient understands all aspects of the procedure

•The patient’s physical or mental health is likely to suffer unless they receive a termination The consent of a young patient with Gillick competence and full mental capacity overrides parental refusal. Consent from the partner is not required. The decision to involve the partner is up to the patient as the partner has no legal right to be informed or consulted.

According to guidelines, one-third of women with ectopic pregnancies do have prior risk factors that predispose them to having an ectopic pregnancy. However, few risk factors are recognized only in around 25% of patients who are diagnosed with ectopic pregnancy.

Pelvic inflammatory disease is the most common cause of ectopic pregnancy. It may cause complete obstruction of the fallopian tube or it can even delay the transport of the embryo so that implantation occurs in the tube.

Predisposing factors for ectopic pregnancy include:

• Previous tubal pregnancy

• Previous induced abortion

• Pelvic inflammatory disease

• Previous ectopic pregnancy

• IUCD – (relative risk) conception rarely occurs with an intrauterine device in place but around half of such pregnancies conceived are thought to be ectopic

• Tubal ligation

This question by the examiners is written purely to test your knowledge of absolute and relative risk. You would need to know a little about the background of intrauterine systems. The absolute risk of ectopic pregnancy with the mirena coil is decreased but the relative risk is increased.

This means that if you were to become pregnant while on the Mirena coil, the risk of it being ectopic is higher as compared to if you were to become pregnant while you were not on the Mirena coil.

The risk of ectopic pregnancy when using IUDs is lower than when using no contraception.

If a woman becomes pregnant with the IUD in situ, the risk of ectopic pregnancy is about 1 in 20.

With constant abdominal pain and PV bleeding, placental abruption is one of our differences. The first and most important step is to put on a cardiotocograph (CTG).

If there is fetal distress seen on the CTG, the woman may be rushed for an emergency C-section. As abruption is a clinical diagnosis, an ultrasound would have little value.

A CTG is extremely important as a first step to monitoring the fetus.

An ultrasound would be a good step to perform to rule out placenta praevia if the CTG is found to be reassuring.

A group and save is also important as she is having PV bleeding, but the importance of monitoring the fetus comes above having a group and save as most maternity units will have O-type blood stored in the fridge.

Fever, maternal tachycardia, tenderness suprapubically, and purulent vaginal discharge with a history of ruptured membranes points towards chorioamnionitis. The blood tests also show an inflammatory response with a high CRP and high white cell count. There is no indication of miscarriage here which is characterized by vaginal blood loss. Although endometritis is a possibility, this is a more common complication in the postpartum period.

It is clear here that she has an ectopic pregnancy. As she is haemodynamically stable, a laparoscopic approach to the surgical management of tubal pregnancy is warranted. Laparotomy would be the choice if the patient is haemodynamically unstable. The reason for this is laparotomy is quicker than a laparoscopy. Methotrexate would be the first line for an ectopic pregnancy if she was not in significant pain.

Please see Q-31

This is likely her menstrual cycles returning. Menstrual cycles could return as early as 21 days postpartum in a woman who is not breastfeeding. The fear here is missing a secondary postpartum haemorrhage associated with endometritis or placental tissue remaining in the uterus.

However, if there was an infection, the question writers would normally provide additional hints such as fever, offensive-smelling lochia, or feeling unwell. That being said, in a well patient like the above, it would be reasonable to just reassure.

There may also be retained pieces of the placenta after 4 weeks, however, with a small amount of bleed and normal observations, it is unlikely that any obstetrician would order a pelvic ultrasound.

A pelvic ultrasound would be ordered if the patient was haemodynamically unstable or if there were signs of an infection. 

POST PILL AMENORRHOEA : Post-pill amenorrhoea occurs when stopping oral contraceptives does not lead to a resumption of a normal menstrual cycle. It is described as the loss of menstrual periods for at least 6 months after stopping birth control pills. Post-pill amenorrhea is believed to be due to suppression of the pituitary gland by birth control pills.

Investigations are usually needed if menstrual cycles do not resume after 3 months of postpill.

It may be that the cause of amenorrhoea started whilst taking the contraceptives which induced an artificial cycle, masking the issue until they were stopped.

• Ultrasonography will reveal ovaries with no signs of developing follicles and ovulation even after having stopped the pills for 6 months

• Blood tests showing a low level of FSH, LH, and oestrogen are usually sufficient to confirm the diagnosis.

Treatment :

• The first line of treatment in case of post-pill amenorrhea is waiting for a spontaneous remission of the amenorrhea and a spontaneous occurrence of periods.

• The time limit is usually six months. But if the woman is anxious to get her period, active treatment may be started after waiting for only three months. The standard treatment of post-pill amenorrhea is by stimulating the pituitary to produce FSH and LH. This is done by the drug clomiphene citrate.

AMENORRHOEA : is the absence of menstruation. Pathological amenorrhoea is the failure to menstruate for at least 6 months.

Amenorrhoea can be divided into:

• Primary amenorrhoea – lack of menstruation before age 16 years or 14 in the absence of secondary characteristics

• Secondary amenorrhoea – cessation of menstrual cycles following established cycles.

Aetiology :

• Hypothalamic amenorrhoea - Most common. Usually due to low BMI or excessive exercise.

• Polycystic ovarian syndrome (PCOS)

• Hyperprolactinaemia

• Premature ovarian failure - Raised FSH levels

• Anatomical problems - Usually results in primary amenorrhoea. Vaginal examinations to rule out imperforate hymen is important. Pelvic ultrasound is also useful to determine the pelvic anatomy (Mullerian agenesis). Anatomical problems can also cause secondary amenorrhoea (Asherman’s syndrome).

• Thyroid problems - Both hyperthyroidism and hypothyroidism can cause amenorrhoea. Don’t forget pregnancy as a cause of amenorrhoea (Specific to look for in the stems)

• Short stature – may indicate Turner syndrome

• Hirsutism, acne (androgen excess) – May indicate PCOS or hyperprolactinemia

• Menopausal symptoms in women before age 40 – May indicate premature ovarian failure

• Eating disorder – May indicate anorexia nervosa

• Galactorrhoea – May indicate hyperprolactinemia.

Labour may be divided into three stages :

• Stage 1: from the onset of true labour to when the cervix is fully dilated. It is divided into a latent and an active phase. The latent phase begins with the onset of regular contractions and ends with the acceleration of cervical dilation. Active phase begins with cervical dilation acceleration, usually at 3-4 cm of dilation, ending with complete cervical dilation.

. • 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.

Signs of labor include :

• Regular and painful uterine contractions

• A show (shedding of mucous plug)

• Rupture of the membranes (not always)

• Shortening and dilation of the cervix.

A transvaginal ultrasound is most specific to identify the viability of the fetus.

The following are routine blood tests performed at the booking :

• Blood Group and antibodies

• Rhesus status

• Haemoglobinopathies

• Syphilis

• Hepatitis B status

• HIV

• Full blood count looking for anaemia

• Rubella susceptibility

The likely diagnosis here is ovarian torsion. Although ovarian torsion cannot be diagnosed clinically as it is often diagnosed in theatre during a laparoscopy, the question writers want you to consider ovarian torsion as part of your differential diagnosis as it is one of the important gynaecologic emergencies.

It is quite rare and only accounts for about 3% of gynaecologic emergencies however it is important to consider it especially given that this patient has a tender mobile mass at the right iliac fossa.

In clinical practice, appendicitis would also be part of your differential. If there was a history of an ovarian mass or if an ultrasound pelvis was done which found an ovarian mass, then the surgeons would refer her to the gynaecology team to rule out an ovarian torsion.

Ovarian torsion presents with sudden onset of sharp, unilateral lower abdominal pain often with nausea and vomiting. In the reproductive years, regular growth of large corpus luteal cysts is a risk factor for rotation.

Any enlargement of the ovary is a risk factor for ovarian torsion. The definitive diagnosis is often made in the theatre as ovarian torsion is difficult to diagnose accurately and an operation is often performed before the diagnosis is made.

Pregnant woman and recent use of antibiotics predisposes her to higher risk of developing vaginal candidiasis. She was likely prescribed a broad-spectrum antibiotic which has destroyed the normal flora leading to the development of vaginal thrush.

It is well known that broad-spectrum antibiotics destroy healthy bacteria and disrupt the vagina’s normal flora which can predispose women to develop either vaginal candidiasis due to the change of the natural balance of bacteria in the vagina.

Why pick candidiasis and not Gardnerella While both may be good answers, candidiasis is more likely a better answer as broad-spectrum antibiotics that inhibit lactobacilli also inhibit Gardnerella which makes it less likely to trigger bacterial vaginosis.

The idea here is to think of endometrial cancer. Any woman who has postmenopausal bleeding should have a transvaginal ultrasound to determine the endometrial thickness. If the endometrium is thick, a hysteroscopy with endometrial biopsy would be arranged.

A cervical smear is offered every 5 years if in the age group of 50 to 64 years old. Thus, having a cervical smear that was normal 3 years ago is a usual phenomenon. A repeat cervical smear is not necessary. 

ENDOMETRIAL CANCER : Endometrial cancer is classically seen in post-menopausal women.

Classically, endometrial cancer presents as postmenopausal bleeding (PMB), and, although this is not the only cause, it must be excluded.

Risk factors for endometrial cancer:

• Obesity

• Nulliparity

• Early menarche

• Late menopause

• Unopposed oestrogen.

The addition of a progestogen to oestrogen reduces the risk (e.g. In HRT). Additional risk is eliminated if the progestogen is given continuously.

• Diabetes mellitus

• Tamoxifen

• Polycystic ovarian syndrome

Features in exam, they will always present with postmenopausal bleeding.

Investigation :

• First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value.

• Hysteroscopy with endometrial biopsy gives the definitive diagnosis.

Management Is beyond the scope of exam. 

The diagnosis of premature ovarian failure usually needs two raised levels of FSH(more than 40 IU/L) taken at least four weeks apart. In this question, since she is amenorrheic with raised FSH and LH and a normal prolactin level, the most likely diagnosis would be premature ovarian failure. Women with premature ovarian failure also have low estradiol (usually < 50 pmol/l).

PREMATURE OVARIAN FAILURE : Premature ovarian failure (Premature ovarian insufficiency) is defined as the onset of menopausal symptoms and elevated gonadotropin levels before the age of 40 years.

Causes :

• Idiopathic - the most common cause

• Chemotherapy (this can be temporary, as recovery of ovarian function can occur, especially in younger women)

• Radiation

• Autoimmune disease

• Bilateral oophorectomy or surgical menopause

Presentation :

1. The most common presentation is amenorrhoea or oligomenorrhoea (which may not necessarily be accompanied by hot flushes)

2. Infertility

3. Other features are similar to those of the normal climacteric symptoms:

• Hot flashes

• Night sweats

• Irritability

• Poor concentration

• Decreased sex drive

• Dyspareunia

• Vaginal dryness Tests: FSH levels: FSH test should be undertaken in women aged under 40 years in whom menopause is suspected.

• Two raised levels (more than 40 IU/L) taken at least four weeks apart are diagnostic. Serum follicle-stimulating hormone (FSH) measurement alone can be used to diagnose the disease. The anterior pituitary secretes FSH and LH at high levels due to the dysfunction of the ovaries and consequent low estrogen levels.

Management:

• Hormone replacement therapy (HRT) until at least the average age of the menopause (51 years).

• The term early menopause is used for those women who go through their menopause between 40-45 years. Do NOT use premature menopause and premature ovarian failure interchangeably.

• Premature ovarian failure is sometimes referred to as premature menopause, but the two conditions aren't the same. Women with premature ovarian failure may have irregular or occasional periods for years and may even become pregnant. Women with premature menopause stop having periods and can't become pregnant.

There is always concern about women with sickle cell disease using hormonal medications as there is the fear that their blood vessels would be blocked by blood clots.

The first step towards picking an answer here is using UKMEC as a guide :

: • Sickle cell disease is considered UKMEC 2 for copper IUD as there are concerns of increased risk of blood loss with its use.

• Sickle cell disease women may use progestogen-only implants, depot medroxyprogesterone acetate (DMPA) or progestogen-only pill (POP) as evidence concludes that these do not have adverse effects on hematological parameters (UKMEC 1)

• Mirena coil (IUS) is also considered UKMEC 1 and is generally associated with reduced blood loss. As COCP and IUD are UKMEC 2, they are not going to be the right options when there are better alternatives (UKMEC 1).

So why pick DMPA over POP or IUS in this question?

Depot medroxyprogesterone acetate (DMPA) is a long-acting injectable contraceptive that may reduce menstrual bleeding or cause amenorrhoea with the additional benefits that it is preferred in women with sickle cell disease because it reduces the frequency and severity of painful crises.

Remember this note:

Whilst all three (POP, IUS, and DMPA) are completely safe to use in patients with sickle cell disease, evidence shows that DMPA reduces the severity of sickle crisis pain.

A family history of ovarian cancer is an important risk factor. Women with a first-degree relative with ovarian cancer have 3-4 times the risk of developing the disease.

However, only 10% of cases arise in women with a positive family history. Smoking is a risk factor but it is not as important as family history.

It is estimated that 2% of cases may be caused by smoking. HRT increases the risk of developing ovarian cancer but only slightly and it is only seen in patients using HRT for more than five years. About 1% of cases may be linked with taking HRT.

Ovarian Cancer Risk factors :

• Family history: mutations of the BRCA1 or the BRCA2 gene

• Many ovulations: early menarche, late menopause, nulliparity

• Age incidence increases with age

Protective factors against ovarian cancer:

• COCP

• Pregnancy

The ideal contraception for her would be an etonogestrel implant like NexplBatman. Mirena and Depo-Provera would not be ideal as it is considered UKMEC 2 under 20 years of age whereas POP, COCP, and implants are UKMEC 1 and are recommended as first-line for young women. She has mild learning difficulties and being a teenager she is likely to forget to take regular pills. 

It is very unlikely for eclamptic fits to occur with no history of proteinuria or high blood pressure in the past. But given that she is pregnant and just delivered, it is the most likely given the options. Eclampsia does occur in the postpartum period as well as antenatally.

This is why it is common practice to keep patients with severe pre-eclampsia in the hospital for the next few days post-delivery even though the delivery was uncomplicated.

The most common cause of postpartum haemorrhage is uterine atony however this is not the case here as the uterus is well contracted. The risk factors point towards genital tract trauma. Asian ethnicity, nulliparous, diabetic, and big baby were thrown in these are risk factors for a 3rd and 4th-degree perineal tear which can be the sole cause of the PPH.

Causes for PPH may be considered to relate to one or more of ‘the four Ts’:

• Tone (abnormalities of uterine contraction)

• Tissue (retained products of conception)

• Trauma (of the genital tract)

• Thrombin (abnormalities of coagulation).

The most common cause of primary PPH is uterine atony.

However, clinical examination must be undertaken to exclude other or additional causes:

• Retained products (placenta, membranes, clots)

• Vaginal/cervical lacerations or haematoma

• Ruptured uterus

• Broad ligament haematoma

• Extragenital bleeding (for example, subcapsular liver rupture)

• Uterine inversion

The term for the head retracting is called the “turtle sign”. It is seen in shoulder dystocia. At this stage, the first step is to call for help then evaluate for episiotomy and start McRoberts maneuver. There is no need for an episiotomy prior to McRoberts maneuver but it is advisable to perform an episiotomy before any enter rotation maneuvers.

This creates more room for the obstetrician to use his fingers and hands to perform rotation maneuvers. Remember: Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder. The diabetes thrown into this stem is just to highlight that she has risk factors for shoulder dystocia.

RISK FACTORS FOR SHOULDER DYSTOCIA :

The key risk factors to remember for shoulder dystocia can be divided into two categories:

Pre-labour risk factors -

• Fetal macrosomia > 4.5 kg

• Maternal BMI > 30 kg/m2

• Diabetes mellitus

• Previous shoulder dystocia

• Induction of labour

Intrapartum risk factors -

• Prolonged labour

• Oxytocin augmentation

• Assisted vaginal delivery

 • Episiotomy

It is worth remembering that maternal age is a risk factor for placental abruption and those over 35 years are at greater risk. In this stem, an age of 42 was used. Although trauma may elicit placenta abruption, the majority of abruptions do not have a background history of injury to the abdomen. Back pain can be a presentation of placenta abruption if the placenta is located posteriorly. This needs to be dealt with rather urgently with an emergency caesarean section as fetal distress is often followed by fetal death in abruptions.

PLACENTAL ABRUPTION : Placental abruption is the premature separation of a normally placed placenta resulting in maternal bleedinghemorrhagic behind the placenta or loss through the cervix.

The cause is not known but associated factors include:

• Pre-eclampsia

• Multipolarity

• Trauma

• Maternal age

• Cocaine • Smoking

Clinical features :

- Abdominal pain is constant

• Very tender and tense uterus (woody hard)

• Bleeding, which may be accompanied by pain

• Fetal distress or fetal death

• Maternal signs of hypovolemic shock if bleeding is severe. Severe abruption can result in haemorrhagic shock with acute tubular necrosis from profound hypotension. Disseminated intravascular coagulation can result from the release of tissue thromboplastin into the circulation from the disrupted placenta. One should not look at the extent of vaginal loss as an indicator of the severity of abruption ahemorrhagethe haemorrhage may be much much greater (it is just concealed behind the placenta)

Management :

• Resuscitation and delivery if presence of fetal distress or maternal compromise.

A complete miscarriage is a spontaneous abortion with the expulsion of the entire fetus through the cervix. Pain and uterine contractions cease after the fetus has been expelled. An ultrasound scan would show an empty uterus.

This patient needs to be admitted for antibiotics. An outpatient therapy has already failed. She has signs and symptoms of pelvic inflammatory disease. She has a high temperature and tachycardia. One of the more common inpatient regimens for pelvic inflammatory disease is IVceftriaxone 2g daily plus IV doxycycline 100mg twice daily (oral doxycycline may be used if tolerated) followed by oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily for a total of 14 days.

Intravenous therapy should be continued until 24 hours after clinical improvement and then switched to oral.

Although it’s stated that we use intravenous doxycycline as part of the antibiotic regimen, this is usually not the case as Intravenous doxycycline is not currently licensed. Whilst taking triple swabs is appropriate, we should not wait for results before commencing antibiotics.

Antibiotics should be commenced immediately to avoid complications such as tubo-ovarian abscess or tubal damage leading to infertility. Once culture and sensitivity results are available, a change of antibiotics may be required. The change usually involves ofloxacin as gonorrhoea is increasingly resistant to fluoroquinolone.

OPTIONS FOR MANAGEMENT OF PID :

• IM ceftriaxone stat plus oral doxycycline and oral metronidazole for 14 days; or

• Ofloxacin and metronidazole orally for 14 days Inpatient management of PID

• IV ceftriaxone and IV doxycycline followed by oral doxycycline and oral metronidazole for 14 days; or

• IV ofloxacin and IV metronidazole for a total of 14 days.

Please see Q-4

Tamoxifen is a risk factor for endometrial carcinoma. Tamoxifen is a Selective estrogen receptor modulator (SERM) used in the treatment of breast cancer. Even though it acts as an antagonist in breast tissue, it acts as an antagonist in the endometrium thus there is an increased risk of endometrial cancer.

There is also an Increased risk of thromboembolism. One benefit of tamoxifen is that it prevents bone loss by acting as an estrogen receptor agonist.

A hysterosalpingography is a type of radiographic evaluation that looks at the uterus and fallopian tubes predominantly as part of investigation for infertility. It uses a contrast material that is injected into the cervical canal that appears on real-time X-ray(fluoroscopy) to visualize the fallopian tubes to determine if the tubes are partially fully blocked.

If the fallopian tubes are patent, the contrast medium will fill the tubes and spill out into the abdominal cavity. Complications associated with a hysterosalpingogram include the possibility of an allergic reaction to the dye or infection (endometritis or salpingitis), which are common. Uterine perforation or fallopian tube perforation like in this stem are also possible complications, but these are very rare.

If a perforation were to occur, the patient may have bleeding intraabdominal and an ultrasound scan would be a good start to evaluate the severity of the bleeding.

The picture given in this stem with a low BP, rapid heart rate, abdominal rigidity, and absent rash does point towards a likely intra-abdominal bleed. In a real clinical setting, a laparoscopy or laparotomy would be a more suitable option as she is clinically unstable.

As these options are not provided, ultrasound would be the next best investigation.

Cervicitis management If just cervicitis (Chlamydia)

• Azithromycin 1g single dose (OR doxycycline 100mg bd for 7 days) (both have similar efficacy of more than 95%). The guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7-day course of doxycycline If just cervicitis (Neisseria gonorrhoeae)

• Azithromycin 1g PO and ceftriaxone 500mg IM. It is important to note the differences between acute PID and just cervicitis as the management is different. 

Serum and urine samples of hCG concentrations are extremely important. In hydatidiform moles, hCG levels are likely to be raised excessively (especially in incomplete moles). Management would involve surgical evacuation, after which the hCG levels are expected to return to a normal, non-pregnant level. We would like the hCG to go down towards a normal level but If it plateaued or if hCG levels rise after evacuation, chemotherapy is indicated.

This is the reason it is so important not to get pregnant during the time that hCG levels are decreasing if one were to get pregnant, hCG levels would increase again and we would not know if it is due to the hydatidiform mole or the new pregnancy.

The best advice to give is to use barrier contraception until serum hCG is normal and follow-up is complete. Fortunately, women who have a molar pregnancy are enrolled in a national follow-up program where they can have repeated hCG measurements. For example, follow-up for molar pregnancies.

The previous guidance for oral contraception use was to use only once hCG levels have normalized.

However, the advice is now changing and the latest advice is that oral contraception has no role in increasing the risk of invasive mole or choriocarcinoma from developing hence oral contraception may be used after molar evacuation, before hCG returns to normal values. 

Serum progesterone (Mid-luteal cycle progesterone) is tested one week before a menstrual period is expected. For example, on day 21 of a 28-day menstrual cycle.

In this case, since she has regular 32-day menstrual cycles, the serum progesterone should be taken on day 25 (32 days - 7 days = day 25). A serum progesterone of more than 30 nmol/L is consistent with ovulation and no further biochemical assessment is required.

As part of the management of infertility, FSH and LH are usually taken in clinics.

However in this context, since her menses are regular, it is less important. It is usually measured if there is menstrual irregularity to help exclude conditions like premature ovarian insufficiency (LH and FSH both raised), polycystic ovarian syndrome (LH: FSH ratio increased), and hypogonadotropic hypogonadism (LH and FSH reduced). 

Please see Q-65

This woman has developed anti-D immunoglobulins (Rhesus isoimmunisation) as a result of recurrent antepartum haemorrhages in a previous pregnancy. The fetus is at risk of these antibodies crossing the placenta, leading to fetal anaemia and hydrops fetalis. Assessing the fetal middle cerebral artery on ultrasound allows estimation of fetal haemoglobin concentrations and therefore the severity of fetal anaemia.

This is usually performed in rhesus-negative women following rhesus is immunized in a previous pregnancy.

Fetal cord blood sampling is an option to directly quantify fetal haemoglobin concentration but is only indicated if the peak systolic velocity (PSV) of the middle cerebral artery (MCA) is abnormal.

A Kleihauer-Betke test is used to confirm and quantify a maternal-fetal haemorrhage in the prevention of Rhesus isoimmunization. It has no role in women who are already sensitized.

One of the many causes of dyspareunia is atrophic vaginitis (vaginal atrophy). Oestrogen deficiency after menopause causes atrophic changes within the urogenital tract and is associated with urinary symptoms, such as frequency, urgency, nocturia, incontinence, and recurrent infection.

These symptoms may coexist with those of vaginal atrophy, including dyspareunia, itching, burning, and dryness. Intravaginal oestrogens are the treatment choice for vaginal atrophy.

Alongside helping with the vaginal dryness, it can help with symptoms of urgency, urge incontinence, frequency, and nocturia. Note as the symptoms are local (in the vagina), you would not prescribe a systemic hormone like oral oestrogen or HRT. 

Salpingitis, endometriosis, ovarian torsions, and ovarian tumours are not associated with amenorrhoea. Patients' pelvic pain and vaginal bleeding with peritonism and cervical excitation point towards ectopic pregnancy.

The key to choosing the correct answer here is to take into account firstly the fact that this woman has fibroids which are distorting her uterine cavity and the fact that any type of pill is not an option. Depo-Provera, even though a viable option, isn’t the correct option for this stem.

Depo-Provera has a dosing interval of 13-16 weeks which is a pretty long time, but out of all the options is not the longest time.

An Intra-Uterine System (Mirena) which is the favorite of is not the choice here because insertion of an intra-uterine device would be difficult due to the fibroid uterus that is distorting the uterine cavity.

The use of an intra-uterine system (Mirena) is contraindicated in women with congenital or acquired uterine anomalies, including fibroids if they distort the uterine cavity.

In fact and in clinical practice, having a large fibroid that distorts the uterine cavity is NOT a contraindication for insertion of a Mirena coil. Gynaecologist still use mirena coils for patients with large fibroids that distort the cavity.

While it is true that the risk of expulsion of a Mirena coil is greater if the fibroid is large, there is no reason why it cannot first be tried. However, for the exam, since the prescribing leaflet does mention that it is contraindicated if fibroids distort the uterine cavity, please do not choose the Mirena coil as the answer. NexplBatman is the only contraceptive implant.

NexplBatman is a 4 cm flexible rod containing 68 mg etonogestrel (a progestogen) which is released slowly into the systemic circulation following subdermal insertion in the upper arm. It must be removed after three years when it can be replaced immediately.

Progestogen-only subdermal implants (POSDIs) such as NexplBatman are suitable for:

• Those who want a reliable but reversible form of contraception that does not require daily vigilance or action at the time of intercourse.

• Women who have contra-indications to oestrogen therapy. 

Hormone replacement therapy is an important part of management for women with premature ovarian failure to reduce the risk of osteoporosis, and cardiovascular disease and maintain sexual health and quality of life. This should be continued until the average age of menopause which is 51.

Irregular bleeding whilst taking hormonal contraception is a common problem. A small percentage of women may also experience breakthrough bleeding or spotting however, the bleeding usually settles with time, and it is therefore recommended that women preserve for three months before considering changing their method of contraception.

Labetalol is the most studied antihypertensive in pregnancy with the safest profile. Although this woman has pre-eclampsia and would benefit from magnesium sulphate to prevent seizures, you must first stabilize her blood pressure to prevent intracerebral bleeding.

According to current guidelines IV magnesium sulphate is administered for:

• Women in a critical care setting who have severe hypertension or severe preeclampsia who have or previously had an eclamptic fit.

• Women with severe preeclampsia who are in a critical care setting if birth is planned within 24 hours.

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

Risk factors :

• Pre-existing hypertensive disease in pregnancy

• Type 1 or 2 diabetes

• Chronic kidney disease

• Chronic hypertension

• Autoimmune disease (e.g. systemic lupus erythematosus or antiphospholipid syndrome)

• > 40 years old or teenager

• Family history (mother or sister)

• Obesity

• Multiple pregnancy

• Pregnancy interval more than 10 years

Symptoms :

• Headache

• Visual disturbance (flashing lights)

• Epigastric or right upper quadrant (RUQ) pain

• Rapid oedema (especially on the face)

Note: Symptoms usually occur only with severe disease

Signs :

• Hypertension (>140/90; severe if >/=160/110)

• Proteinuria (>300 mg in 24 hours)

• Hyperreflexia

Management :

• Guidelines recommend treating blood pressure > 150/100 mmHg although many clinicians have a lower threshold.

• Oral labetalol is now first-line following the 2010 guidelines. Nifedipine and hydralazine would also be an option has them in the question.

• Cure is delivery of placenta. Thus the definitive management is to deliver the baby. Unfortunately this needs to be balanced out with gestation as we would not want to deliver a baby too prematurely.

Endometrial hyperplasia is a premalignant condition, that can predispose to, or be associated with, endometrial carcinoma. It is characterized by the overgrowth of endometrial cells and is caused by excess unopposed oestrogens, either endogenous or exogenous, similar to endometrial cancer, with which it shares a common aetiology.

Presentation :

• Usually presents clinically as abnormal vaginal bleeding (intermenstrual, polymenorrhoea or postmenopausal)

• It is most commonly diagnosed in women over 40 years old with irregular menstruations or in those with post-menopausal bleeding.

Investigation:

• Transvaginal ultrasound (TVUS) is an appropriate first-line procedure. In general, the thicker the endometrium seen on ultrasound, the higher the likelihood of important pathology, ie endometrial cancer, being present.

• Endometrial sampling or formal endometrial curettage is necessary for diagnosis.

Management of endometrial hyperplasia (no atypia) : It largely depends on the age of the patient, histology, symptoms, and desire for retaining fertility.

Both continuous oral progestogens and levonorgestrel-releasing intrauterine systems are effective in achieving regression of endometrial hyperplasia without atypia. However, the Royal College of Obstetrics and Gynaecology states that levonorgestrel-releasing intrauterine system should be the first-line medical treatment because compared with oral progestogens it has a higher disease regression rate with a more favorable bleeding profile and it is associated with fewer adverse effects.

She is classified as a person with a new onset of hypertension (mild pre-eclampsia in this case since there is proteinuria). In pregnancy, we treat this very seriously. She should be asked to see the obstetric team on the same day for further assessment, blood test and to further quantify protein in the urine.

If her blood test comes back at an acceptable level and she is asymptomatic, she would be advised to take blood pressure measurements at least four times a day at home and to come back if the blood pressure is higher than 150/100 as this figure is the cut off where we would start antihypertensive treatment (usually oral labetalol if in an outpatient setting).

Uterine Atony is the most common cause of excessive postpartum bleeding.

Risk Factors for uterine atony include:

• Rapid or protracted labour (most common)

• Chorioamnionitis

• Overdistended uterus  e.g. Macrosomic baby

Clinical Findings : A soft uterus is palpable above the umbilicus.

Management : Uterine massage and uterotonic agents ( e.g., oxytocin)

The possible diagnosis here is a pelvic abscess or tubo-ovarian abscess which are complications of PID. A high vaginal swab or endocervical swab can take days to return with results. As this is an A&E case, an ultrasound would be more appropriate as this would lead to a diagnosis.

Ultrasound scan is the diagnostic imaging method of choice for acute pelvic pain in gynaecology. It can easily diagnose sequelae of PID (including pyosalpinx and tuboovarianabscess). Note that even if no PID history was given in this question, an ultrasound scan would still be the most appropriate as it would rule out ovarian cysts or adnexal torsion.

Women of her age group (< 25 years old) are at greater risk for pelvic inflammatory disease as they are more sexually active during this period. An endocervical swab is the first test to do to help diagnose PID.

Condoms reduce the risk of HPV infections and hence reduce the risk of developing cervical cancer.

Please see Q- 50

There are two vaccines that are specifically recommended for pregnant women: the flu (influenza) vaccine and whooping cough (pertussis) vaccine. For whooping cough, the best time to get vaccinated is between 20 weeks and 32 weeks gestation.

This maximizes protection for the baby through antibody transfer.

Note that there is no whooping cough-only (pertussis) vaccine. The vaccine is usually combined with polio, diphtheria, and tetanus.

Please see Q-16

The absence of a fetal heart seen on an ultrasound suggests intrauterine death which could be a complication of most of the given options however the presentation of bleeding and constant abdominal pain indicates placental abruption.

There are no signs and features suggestive of preeclampsia.

Cocaine use in pregnancy is one of the risk factors for placental abruption.

A point worth remembering as it is commonly asked. It is extremely rare for a primigravid woman to have a ruptured uterus in the absence of any previous uterine scar. The stem would usually include past histories of caesarean sections or myomectomies for the question writers would want you to pick uterine rupture as the answer.

Please see Q-58

Iron deficiency anaemia is very common in pregnancy. The values of anaemia differ in pregnancy as compared to a nonpregnant woman .

Anaemia in pregnancy is defined as the following values Hb levels of: <11.0g/dl in the first trimester <10.5 g/dl in the second and third trimesters <10.0 g/dl in the postpartum period.

Since her Hb level is below 10 g/dL, she should be on oral iron.

Please see Q-16

It is important to note that missed miscarriage may present with heavy vaginal bleeding or none at all. But if there is no fetal heart seen, at this stage of pregnancy, it is a missed miscarriage.

Note that in normal pregnancy the fetal heart is seen usually at 6 weeks. So you should not be diagnosing a missed miscarriage if a 4-week pregnant lady has no fetal heartbeat seen on a transvaginal ultrasound.

There are more specific ultrasound criteria to diagnose missed miscarriage but are beyond what will be asked in the exam.

There is no screening test needed for cervical ectropion as cervical ectropion is not linked to the development of cervical cancer or any other condition that causes cancer. Treatment can be offered if the cervical ectropion is causing problems such as bleeding or pain during or after sex.

However, in this case, the cervix is not bleeding on touch thus no treatment is needed.

.Remember: An asymptomatic cervical ectropion should be left alone.

Cervical ectropion : This occurs when the columnar epithelium of the endocervix is displayed beyond the os. The stratified squamous epithelium that normally lines the vaginal part of the cervix (ectocervix) is replaced by columnar epithelium, which has migrated from the endocervix.

• The cervix enlarges under the influence of oestrogen and as a result, the endocervical canal is everted. Exposure to high levels of oestrogen usually occurs at certain times (e.g. puberty, in pregnancy or women on COCP).

• It is seen on examination as a red ring around the os and is so common as to be regarded as normal.

• It is generally an asymptomatic condition but patients occasionally present with bleeding or excessive discharge.

• The discharge if present is usually clear, watery in consistency and without odour.

• Once a normal cervical smear has been confirmed, it is actively managed only if there are symptoms.

• After stopping any oestrogen-containing contraceptive, treatment options include diathermy or cryotherapy.

CERVICAL ECTROPION : Cervical ectropion occurs when the columnar epithelium of the endocervix is displayed beyond the cervical os.

The stratified squamous epithelium that usually lines the vaginal part of the cervix (ectocervix) is replaced by columnar epithelium, which has migrated from the endocervix. Cervical ectropion – red ring around the os. The cervix enlarges under the influence of estrogen, and as a result, extends the endocervical canal. Exposure to high levels of oestrogen usually is seen in pregnant women on COCP.

It is usually asymptomatic however women occasionally present with post-coital bleeding or excessive non-purulent discharge.It is managed if symptoms are bothersome. Treatments include cautery with silver nitrate, diathermy, and cryotherapy.

That being said, it is essential to obtain a cervical smear and ensure it is normal prior to any treatments.

The incubation period between exposure and the first skin lesions is around 10 to 14 days but can be as long as 21 days. She was only exposed 8 days ago. The best management here is to administer varicella-zoster immunoglobulin (VZIG) as it is effective when administered up to 10 days after contact. Chickenpox exposure in pregnancy. Chickenpox is caused by primary infection with varicella-zoster virus.

Shingles are the reactivation of dormant viruses in dorsal root ganglion. In pregnancy, there is a risk to the mother and also the fetus, a syndrome now termed fetal varicella syndrome.

Fetal varicella syndrome (FVS) :

• Features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly, and learning disabilities. Other risks to the fetus shingles in infancy: 1-2% risk if maternal exposure in the second or third-trimester severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases.

 Management of chickenpox exposure :

Exam usually would test your knowledge on 3 of these scenarios:

1. Who gets checked for Varicella antibodies?

If the woman’s immunity to chickenpox is unknown and if there is any doubt about previous infection, or if there is no previous history of chickenpox or shingles, serum should be tested for VZV IgG.

This can usually be performed within 24–48 hours and often within a few hours if the laboratory can access serum stored from an antenatal booking blood sample. At least 80% of women tested will have VZV IgG and can be reassured.

2. Who gets VZIG?

If the pregnant woman is not immune to VZV and has had significant exposure, she should be offered VZIG as soon as possible. VZIG is effective when given up to 10 days after contact.

Note: If the immune status of the woman is unknown, the administration of VZIG can be delayed until serology results are available.

Note: VZIG has no therapeutic benefit once chickenpox has developed and should therefore not be used in pregnant women who have developed a chickenpox rash.

3. Who gets oral aciclovir?

Oral aciclovir should be prescribed for pregnant women with chickenpox if they present within 24 hours of the onset of the rash and if they are 20+ weeks of gestation or beyond.

In summary:

1. Pregnant exposed to chicken pox - Check women’s immunity (previous infection, varicella antibodies)

2. Not immune - Administer VZIG

3. If develop chicken pox rash - Administer oral aciclovir.

It is clear here that she has an ectopic pregnancy. Laparotomy would be the choice here as she is haemodynamically unstable. An open approach is quicker than a laparoscopic approach.

If she was haemodynamically stable, a laparoscopic approach to the surgical management of tubal pregnancy would be preferred as this has less post-surgical complications and reduced length of hospital stay.

Please see Q-2

This lady has pre-eclampsia. The first clue in this question stems from her age.

One of the risk factors of preeclampsia is an age over 40 or a teenager. Extremes of both ages. Headaches, epigastric pain, and flashing lights are all symptoms of preeclampsia and are confirmed by having protein in the urine with a BP > 140/90.

The first thing to do here is to lower the blood pressure.

Management of pregnancy with pre-eclampsia for moderate hypertension (150/100 to 159/109 mmHg) starts with oral labetalol as first-line treatment. Magnesium sulphate is important here as well however labetalol oral should be given first.

Remember, the question is asking for the most appropriate INITIAL management. Magnesium sulphate takes a while to prepare. It is an intravenous medication and usually needs consultant approval and also cardiac monitoring when giving the intravenous MgS04.

Oral labetalol does not require any of those and it is part of management as she is hypertensive in this stem.

When is magnesium sulphate the answer?

According to current guidelines IV magnesium sulphate is administered for:

• Women in a critical care setting who have severe hypertension or severe pre-eclampsia who have or previously had an eclamptic fit.

OR women with severe pre-eclampsia who are in a critical care setting if birth is planned within 24 hours.

Hospitals have their local guidelines and many do not follow the above guidance.

The diagnosis here is antiphospholipid syndrome in which case aspirin plus heparin is indicated. As there is no option for both aspirin and heparin, pick aspirin.

Intrauterine contraceptive devices are a risk factor for pelvic inflammatory disease. Women of her age group (<25 years old) are at greater risk for pelvic inflammatory disease as they are more sexually active during this period. Other options are less likely because: Endometriosis, adenomyosis, and fibroids. Are less likely as an intrauterine system is likely to benefit symptoms and not worsen them.

Asherman syndrome are adhesions of the endometrium often associated with dilation and curettage of the intrauterine cavity. It results in infertility. Often, they experience menstrual irregularities.

But in this question, there is no relevant past medical history meaning she did not have any dilation and curettage thus this option is improbable.

A previous caesarean is not a contraindication for a levonorgestrel intra-uterine system. Among the options, the levonorgestrel intra-uterine system (Mirena coil) is the best treatment to reduce menorrhagia. It is currently the first-line treatment for menorrhagia.

Copper intrauterine contraceptive devices and ImplBatman are more prone to irregular heavy bleedings compared to levonorgestrel intra-uterine system (Mirena coil).

Painless vaginal bleeding is consistent with placenta praevia. Placental abruption is associated with abdominal pain. Placenta accreta and vasa praevia are less common than placenta praevia. There is no indication that she is in labour.

The average age for menopause is 51. For this question, we must go back to the definitions of menopause and perimenopause.

Menopause is the permanent cessation of menstruation. It is recognized to have occurred after 12 consecutive months of amenorrhoea for which no other obvious pathological or physiological cause is present. Peri-menopause includes the period beginning with the first clinical, biological, and endocrinological features of the approaching menopause, such as vasomotor symptoms and menstrual irregularity. As the above question presents irregular menstruation and absent menstruation for a period of 12 months, perimenopause is the correct answer.

SYMPTOMS OF MENOPAUSE: The experience of each woman varies widely -

• Some may be asymptomatic

• Some may experience symptoms while menstruating

• Some may not experience symptoms until a year or more after their last period.

Symptoms of menopause include:

• Hot flushes and night sweats (80% of women) – these are the hallmark symptoms.

• Sleep disturbance

• Menstrual irregularities

• Vaginal dryness

• Loss of libido

• Urinary problems which include recurrent lower urinary tract infections & urinary incontinence.

A thick-walled cystic structure containing homogeneous ground-glass echos are ultrasound findings of an endometrioma. Ovarian endometriomas are ovarian cysts lined by endometriotic tissue.

Remember that the ground-glass appearance often describes the cyst fluid in an ovarian endometrioma. The cyst fluid is usually a thick chocolate coloured fluid which differentiates it from a simple haemorrhagic cyst.

The ultrasound findings of the bilateral cystic masses represent the large theca lutein cysts. Uterus large for dates and vaginal bleeding are typical features of hydatidiform mole.

Another term worth remembering for complete molar pregnancies is the “Snowstorm” appearance of mixed echogenicity which represents hydropic villi and intrauterine haemorrhage.

A transverse lie at 37 weeks in a primigravid woman is the first clue that there is a mass in the way. In this case, it is the placenta. Painless vaginal bleeding is consistent with placenta praevia. Transvaginal ultrasounds are preferred for the diagnosis of placenta praevia although abdominal ultrasound scans may also be used.

Dysmenorrhoea is very common among this age group. Mefenamic acid is usually the first tried management as the pain during periods may sometimes lessen over the next couple of months to years.

Dysmenorrhoea can be divided into two:

• Primary dysmenorrhoea: the pain has no obvious cause.

• Secondary dysmenorrhoea: the pain is due to an underlying condition.

Primary dysmenorrhoea Management:

• NSAIDs such as mefenamic acid with each period is usually the first treatment.

• Combined oral contraceptive pills are used second line if the only symptom is pain.

• Mirena IUS demonstrates benefit

Secondary dysmenorrhoea common aetiology :

• Endometriosis

• Adenomyosis

• PID

• Management - Treat the underlying condition.

OPTIONS FOR MANAGEMENT OF PID :

• IM ceftriaxone stat plus oral doxycycline and oral metronidazole for 14 days OR

• Ofloxacin and metronidazole orally for 14 days Inpatient management of PID

• IV ceftriaxone and IV doxycycline followed by oral doxycycline and oral metronidazole for 14 days OR

• IV ofloxacin and IV metronidazole for a total of 14 days.

The values of anaemia differ in pregnancy as compared to a non-pregnant woman.

Anaemia in pregnancy is defined as the following values - Hb levels of: <11.0g/dl in the first trimester <10.5 g/dl in the second and third trimesters <10.0 g/dl in the postpartum period. Since her Hb level is below 10.5g/dL, she does need iron tablets.

Advise women who are at high risk of having a child with neural tube defects to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect. This can be started even before conception.

Women who are at high risk include:

• Diabetes

• Receiving antiepileptic medication

• Previous pregnancy with neural tube defects

• Sickle-cell disease (folic acid given throughout pregnancy)

• Thalassaemia or thalassaemia trait (folic acid given throughout pregnancy)

In addition, guidelines also recommends using 5 mg/day of folic acid for those who have:

• BMI more than 30 kg/m2

• Family history of an NTD If the woman has a low risk of conceiving a child with neural tube defects, then she should be advised to take a smaller dose of folic acid (400 mcg/day) until 12 weeks of gestation.

There is no screening test needed for cervical ectropion as cervical ectropion is not linked to the development of cervical cancer or any other condition that causes cancer.

Treatment can be offered if the cervical ectropion is causing problems such as bleeding or pain during or after sex. However, in this case, the cervix is not bleeding on touch thus no treatment is needed.

Bacterial vaginosis and Trichomonas vaginalis can give foul-smelling discharge. Bacterial vaginosis which is mostly caused by an overgrowth of Gardnerela vaginalis causes vaginal discharge which is gre-white and has a “fishy” smell.

The characteristic “fishy smell” is a clincher and one should pick Bacterial vaginosis (Gardnerella vaginalis) as the answer. In trichomonas vaginalis, it can be greenish and frothy along with vulvovaginitis i.e. strawberry cervix.

The discharge of Chlamydia and Gonorrhea is not usually foul-smelling. Candida albicans (vaginal candidiasis) has a white, ‘cheesy’ discharge. The discharge is non-offensive.

To understand failure rates of contraception, one would need to understand the Pearl index. The Pearl index is defined as the number of pregnancies occurring per 100 women years (a woman year is defined as 13 menstrual cycles).

For example, if the Pearl index is 2 for contraception X, this means that if 100 women use contraception X for 1 year, 2 of the 100 women would end up pregnant in that year. 

Levonorgestrel intra-uterine system (Mirena) is the first-line pharmaceutical treatment for menorrhagia. Smoking is not a contraindication for use for the Mirena coil.

This is a very straightforward question. Her symptoms and signs all point towards pelvic inflammatory disease (PID). A raised WBC and CRP is also consistent with PID.

Please see Q-69

In pelvic venous congestion, there are dilated pelvic veins believed to cause a cyclical dragging pain. It is worse premenstrually and after prolonged periods of standing and walking. Dyspareunia is also often present.

Non-organic dyspareunia + with symptoms similar to premenstrual syndrome + aggravated by standing = Pelvic congestion syndrome.

Pelvic congestion syndrome is a chronic medical condition in women caused by varicose veins in the lower abdomen.

The condition causes chronic pain, often manifesting as a constant dull ache, which can be aggravated by standing. It is a diagnosis of exclusion where other organic causes of dyspareunia have been excluded.

It may present as pain during intercourse that may be deep within the vagina with symptoms similar to premenstrual syndrome. It is caused by the accumulation of blood during arousal without the occurrence of orgasm. Achieving orgasm (by intercourse, masturbation, or use of a vibrator) may help to alleviate this congestion.

Prolonged rupture of membranes (PROM) is a risk factor for chorioamnionitis. Although endometritis is a possibility, this is a more common complication in the postpartum period.

Please see Q-94

Topical oestrogen is advisable as first-line for women with vaginal atrophy. A vaginal oestrogen cream or pessary would be appropriate here since the patient only had symptoms of vaginal dryness without the other symptoms of menopause like hot flushes.

If she had vasomotor symptoms such as flushing, including sleep, mood disturbance, and headaches, then a systemic hormone replacement therapy like the oestrogen plus progestogen patch would be a better pick.

Eclampsia is defined as the occurrence of a tonic-clonic seizure in association with a diagnosis of pre-eclampsia. Eclampsia is an obstetric emergency. Every hospital should have an eclampsia protocol and eclampsia box with all the drugs for treatment.

Prevention and control of seizures:

• Magnesium sulfate should be considered when there is concern about the risk of eclampsia. It is used to prevent seizures as well as control it. • To control a seizure, a loading dose of 4 g MgSO4 in 100 ml 0.9% normal saline is given by infusion pump over 5-10 minutes. This is followed by a further infusion of 1 g/hour maintained for 24 hours after the last seizure.

• Recurrent seizures should be treated with either a further bolus of 2 g of magnesium sulfate or an increase in the infusion rate to 1.5 g or 2.0 g/hour.

Explained already.

It is clear here that she has an ectopic pregnancy. The be more specific, this is a presentation of an unruptured ectopic pregnancy. The fact that there are no signs of peritonism, no shoulder tip pain or per vaginal bleeding and observations are normal means that a ruptured ectopic is unlikely.

As she is haemodynamically stable with severe right abdominal pain, a laparoscopic approach to the surgical management of tubal pregnancy is warranted however we would need to obtain a serum beta-hCG test first.

With the results of the serum beta hCG, we would be able to plan the next step in management. If the serum beta-hCG was less than 1500 IU/litre and the patient is clinically stable with pain resolving, then we would prefer expectant management where we would just observe.

The reason behind this is that one cannot be sure of the diagnosis of an ectopic pregnancy when the serum beta-hCG is less than 1500 IU/litre as it could very well be an intrauterine pregnancy that is just too small to see on a scan at the moment. If a beta-hCG was more than 1500 IU/litre, we would expect to see a gestational sac in the uterus.

Meaning if the beta-hCG was more than 1500 IU/litre and nothing can be found in the uterus on transvaginal ultrasound, the diagnosis of an ectopic can be certain.

Laparotomy would be the choice if the patient is haemodynamically unstable. The reason for this is laparotomy is quicker than a laparoscopy. Culdocentesis was previously used to diagnose a ruptured ectopic pregnancy by the presence of free fluid in the pouch of Douglas. However, ultrasonography is noninvasive and has largely replaced culdocentesis where available.

Intrauterine system and progestogen-only implants are not suitable for use in this woman as she would like to become pregnant in 6 months. She is afraid of needles, thus contraceptive injections such as the Depo-Provera injections are not suitable. Combined oral contraceptives should not be used in any woman less than 6 weeks postpartum.

In breastfeeding women, COCP is considered UKMEC 4 if less than 6 weeks postpartum and UKMEC 2 if between 6 weeks to 6 months postpartum. In a nonbreastfeeding woman, it is considered UKMEC 3 if less than 3 weeks postpartum and UKMEC 2 between 3 to 6 weeks postpartum.

For ease, just remember that the safest time to prescribe COCP postpartum is after 6 weeks for nonbreastfeeding mothers and after 6 months for breastfeeding mothers. There is no evidence that progestogen-only pills affect breast milk or infant growth and thus this can be started at any time.

Ideally, we should delay starting POP until 21 days postpartum as there is no use starting it before and she would not require contraception during that time.

POSTPARTUM CONTRACEPTION : Menstrual periods usually return 5 to 6 weeks after birth if the mother is not breastfeeding. If the mother is breastfeeding, the menstrual cycle usually returns once the breastfeeding is less often. It is important to remember that, women can become pregnant BEFORE their periods return because ovulation occurs prior to menstrual bleeds.

For women who are not breastfeeding, it is reasonable to start using contraception from 3 weeks (21 days) after birth. Remember, no contraception is needed until 21 days postpartum.

Summary of postpartum contraception :

• Breastfeeding mothers – COCP after 6 months

• Nonbreastfeeding mothers – COCP after 6 weeks

• In both cases, during the period before they can start using COCP, they can use condoms or progesterone-only preparations.

Women should be advised that although contraception is not required in the first 21 days after childbirth, POP can be safely initiated immediately. There is usually no need for any contraception use until day 21 postpartum as ovulation can only take place on day 28 and sperms can only survive 7 days.

• IUS/IUCD unless fitted within 48 hours of birth, delay until after 28 days postpartum (delay until 28 days as if inserted before may risk uterine perforation)

The likely diagnosis here is cervicitis caused by either chlamydia or Neisseria gonorrhoeae. The endocervix is the principal site to be tested. Swabs of the endocervix can be taken during a speculum examination or indirectly by a vulvovaginal swab. These samples are suitable to be sent for nucleic acid amplification tests (NAATs), cultures, or microscopy. A high vaginal swab (HVS) is only worthwhile where there are recurrent symptoms, treatment failure, or in pregnancy, postpartum, post-abortion, or post-instrumentation.

Cervical cytology is a useful tool to screen for cervical cancers however it is a screening tool for asymptomatic patients. There is no role for cervical smears for symptomatic patients. Furthermore, cervical screening starts at age 25. Cervical cancer is extremely rare under 25 years of age.

CERVICITIS (CHLAMYDIA AND NEISSERIA GONORRHOEAE) DIAGNOSIS

• Usually asymptomatic

• Can present with vaginal discharge, low abdominal pain, intermenstrual bleeding, or postcoital bleeding.

Diagnosis :

• Endocervical or vulvovaginal swab with NAAT, culture, or microscopy. Screening asymptomatic heterosexual patients for gonorrhoea involves using NAAT. A first-pass urine is collected for males and a vulvovaginal swab (which may be self-taken) is collected for females.

If NAAT results show positive for gonorrhoea, a culture needs to be sent prior to starting antibiotics if possible. This is to test for susceptibility and resistant strains.

Diagnosis in detail :

• Endocervical swab in transport medium (charcoal preferably) is to diagnose gonorrhoea.

• Endocervical swab for a chlamydia nucleic acid amplification test (NAAT) is to diagnose chlamydia.

• If examination is declined, a self-taken vulvovaginal swab for C. trachomatis and N. gonorrhoeae for NAAT may be an option and is more sensitive in women than urine testing.

This woman is trying to conceive. The only option to preserve fertility here is a myomectomy.Endometrial ablation is a very good option to decrease menorrhagia however the procedure involves using electrical currents or heated water to destroy the endometrium which could result in infertility.

This procedure is therefore NOT recommended for women who still want children. It is also important to note that endometrial ablation is not used in patients with large fibroids. It is primarily used in patients with heavy menstrualbleeding due to endometrial hyperplasia without fibroids, but it can also be used to treat small submucosal fibroids.

Uterine artery embolization (UAE) is an alternative procedure to a hysterectomy or myomectomy for treating fibroids. It is performed by a radiologist and involves embolizing the uterine arteries to shrink the fibroids.

It is recommended for women with large fibroids however it is not recommended if the woman is trying to conceive as it reduces blood to the uterus significantly.The levonorgestrel intrauterine system (LNG-IUS) is a small, plastic, t-shaped device placed in your uterus that slowly releases progestogen. It also acts as a contraceptive and thus should not be used for a woman trying to conceive. GnRH analogues essentially shrink the fibroids however they would grow back once the medication is stopped. Its primary use is so that it is easier to remove the fibroids during surgery. As GnRH analogues inhibit ovulation, it would prevent pregnancy from occurring. This would be a suitable option given that it was combined with a myomectomy.

It is also important to note that if she does decide to go for a myomectomy, she would need to be counseled on the risk of uterine rupture in the future if she becomes pregnant, especially during labour. Her obstetrician would need to weigh the risks and benefits of normal delivery and consider a cesarean section due to the risk of a uterine rupture.

FIBROID LOCATIONS :

Submucosal fibroids - Are located beneath the endometrium and bulge into the uterine cavity

Intramural fibroids - Are located within the muscular uterine wall

Most common type of fibroid : Subserosal fibroids - Located on the external surface of the uterus and projected to the outside of the uterus.

This lady has pre-eclampsia and now has RUQ pain. This could be a potential HELLP syndrome. A liver function test would help us with the diagnosis.

This is a case of hyperemesis gravidarum.

Intravenous fluids are the most important part of management to ensure that the patient is not dehydrated. As this has already been given and dehydration managed, intravenous antiemetics is the next best answer since only intramuscular cyclizine has been given.

Regular antiemetics such as promethazine or cyclizine are often tried first in many early pregnancy units. If this fails, prochlorperazine intramuscularly or orally can be added on. If the patient continues to vomit, intravenous metoclopramide or ondansetron can be used on top of the already prescribed regular antiemetics. Advice such as to eat little and often should be given.

Thiamine is also used in hyperemesis gravidarum and should ideally be given to all women admitted with prolonged vomiting. This is to prevent Wernicke’s encephalopathy which is due to vitamin B1 (thiamine) deficiency. However, the importance of thiamine in an acutely vomiting woman is less compared to having intravenous antiemetics.

HYPEREMESIS GRAVIDARUM : Nausea and vomiting are common in early pregnancy. When it is severe or prolonged it is called hyperemesis gravidarum.

Symptoms usually begin between 6-8 weeks; peaks at 12 weeks and usually resolve by 20 weeks.

Symptoms :

• Nausea

• Vomiting

• Food and fluid intolerance

• Lethargy

Signs -

• Ketonuria

• Weight loss > 5%

• Tachycardia

• Signs of dehydration: Decreased skin turgor , Prolonged capillary refill, Sunken eyes

Management :

• IV fluids : If potassium is found to be low i.e. < 3.5 mmol, sodium chloride 0.9% with 20:40 mmol/litre potassium chloride (KCl) is usually added.

• Antiemetics : 1st line- Promethazine, Cyclizine, Prochlorperazine, Chlorpromazine. 2nd line - Metoclopramide & Ondansetron. 3rd line - Corticosteroids.

Please see Q-121

Antepartum haemorrhage is seen here. Two of the most common causes are placental abruption and placenta praevia. Other causes include local causes like bleeding from the vulva, vagina, or cervix (cervical polyp or cervical carcinoma).

It is not uncommon to fail to identify a cause for APH (over 30% of APH are of unknown origin). The most important investigation is an ultrasound. This helps us rule out causes such as placenta praevia if the placenta is seen to be high.

Usually, pregnant women would have had a scan at 20 weeks which would show the location of the placenta. Note that placenta praevia is usually painless bleeding.

Placenta abruption is a clinical diagnosis and should be considered if the pain is continuous. The abdominal pain usually has a sudden onset. Vasa praevia would also be in the differential as it is another cause of painless bleeding vaginally.

Kleihauer is an important test to perform for any woman with a significant antepartum haemorrhage who is rhesus negative. It is a blood test used to measure the amount of fetal haemoglobin transferred from a fetus to a mother’s bloodstream.

Note however that this question is asking about investigations that would lead to a diagnosis. The Kleihauer test will not provide any input for a differential.

It is merely a test to determine the required dose of anti-D immunoglobulins to inhibit the formation of Rh antibodies in a Rh-negative mother to prevent Rh disease in future pregnancies with a Rhesus-positive fetus.

It is worth mentioning that if the question was asking for the SINGLE best action and a CTG was within one of the options, that would usually be the best action.

The reason behind this is placenta abruption is part of the differential and if the CTG shows fetal distress, the baby would need to be delivered immediately. There is no time to wait around for an ultrasound. with a Rhesus-positive fetus.

Before you go any further, remember that progesterone should be taken 7 days prior to her menstrual bleeding. This woman has a 35-day menstrual cycle. For her hormone levels to be accurately interpreted, we would need to take a blood sample from her on day 28 of her menstrual cycle.

This is equivalent to day 21 of a standard 28-day menstrual cycle.

To get the best day to measure progesterone levels you take (total length of the cycle) – 7 days. For example, in this patient, it would be 35 (her total cycle length) – 7 days = 28.

The progesterone levels are low because it is not taken on the appropriate day.

Premature ovarian failure would have persistently elevated FSH and LH levels. Polycystic ovary syndrome would usually have elevated levels of LH.

The idea here is to think of endometrial cancer. Any woman who has postmenopausal bleeding should have a transvaginal ultrasound to determine the endometrial thickness. If the endometrium is thick, a hysteroscopy with endometrial biopsy would be arranged.

The hormone replacement therapy in this scenario has no relevance as HRT (progesterone and oestrogen) is not a risk factor for endometrial cancer.

Only unopposed oestrogen would be a risk factor for endometrial cancer.

A cervical smear is offered every 5 years if in the age group of 50 to 64 years old. Thus, having a cervical smear that was normal 3 years ago is a usual phenomenon. A repeat cervical smear is not necessary. 

There is an obvious delay in the first stage of labour since there has been no cervical change over the last 4 hours. Amniotomy, oxytocin infusion and reassessment in 2 hours should always be considered in nulliparous women.

Since her waters have already been broken. It would be appropriate to start oxytocin (syntocinon).

Some causes of poor progress in the 1st stage :

• Inefficient uterine activity ( power - commonest cause)

• Malposition, malpresentation, or large baby (passenger)

• Inadequate pelvis (passage). Oxytocin will increase the frequency and strength of her contractions.

Please see Q-69

The woman needs to be investigated for premature ovarian failure. That is done by having two raised FSH levels taken 4 weeks apart.

The diagnosis of premature ovarian failure usually needs two raised levels of FSH (more than 40 IU/L) taken at least four weeks apart.

In this question, since she is amenorrhoeic with raised FSH and LH and a normal prolactin level, the most likely diagnosis would be premature ovarian failure. Women with premature ovarian failure also have low estradiol (usually < 50 pmol/L).

Increased LDH levels suggest haemolysis. The decreased haemoglobin level, elevated liver enzymes, and low platelets give rise to the diagnosis of HELLP syndrome. This is supported by the fact that she has a high BP and epigastric pain that is associated with nausea and vomiting.

HELLP syndrome: This is a serious complication regarded by most as a variant of severe pre-eclampsia which manifests with haemolysis (H), elevated liver enzymes (EL), and low platelets (LP).

Liver enzymes usually increase and platelets decrease before haemolysis occurs. The syndrome is usually self-limiting, but permanent liver or renal damage may occur. Note that eclampsia may co-exist.

Signs and Symptoms:

• Epigastric or RUQ pain and tenderness

• Nausea and vomiting

• Urine is ‘tea-coloured’ due to haemolysis.

• Increased BP and other features of pre-eclampsia

Management :

• Delivery

• Supportive and as for eclampsia (magnesium sulfate (MgSO 4 ) is indicated)

• Although platelet levels may be very low, platelet infusions are only required if bleeding, or for surgery and <40.

One must remember that uterine fibroids are more commonly found in Afro-Caribbean women. Menorrhagia and a uterus of 14 weeks in size are highly suggestive of a fibroid. A transvaginal ultrasound scan should be performed to assess the fibroid.

A normal LH, FSH, oestradiol, and prolactin rule out polycystic ovary syndrome (PCOS). In PCOS there would be an increased LH, increased FSH, and normal oestradiol. The LH: FSH ratio is usually 2:1 or 3:1.

In premature ovarian failure, LH and FSH are raised. Turner syndrome and absent ovary would have blood with low estradiol, high FSH, and LH. Thus, the only answer possible here would be an absent uterus.

The most likely diagnosis here is Polycystic ovarian syndrome (PCOS).

Elevated insulin levels, elevated LH levels, and moderately elevated testosterone levels can be seen in PCOS. The scenario of acne on her face points towards an excess of androgens (Hirsutism, alopecia, and acne are all manifestations of hyperandrogenism). And not to mention that her initial complaint was infertility which is one of the diagnostic criterion for PCOS.

The dark pigmentation on her neck is called acanthosis nigricans which is characterized by brown to black hyperpigmentation of the skin found in body folds, such as the axilla, nape of the neck, and groin is a marker of insulin resistance.

Ultrasound pelvis is the most appropriate as seeing 12 or more follicles on the ovaries can help make the diagnosis.

This is a very uncommon presentation of endometriosis. Note that in some patients with endometriosis, along with the typical symptoms of endometriosis such as dysmenorrhoea and dyspareunia, they have increased urinary frequency, urgency, and painful voiding.

Symptoms such as dysuria may be due to the involvement of the bladder, peritoneum, or invasion of the bladder.

Sacral backache with menses is due to the growth and bleeding of the ectopic endometrium. These cyclic symptoms usually precede menses (24 to 48 hours) and continue throughout and after the flow. Dyschezia refers to pain on defaecation. It is a symptom of endometriosis and is seen when there are endometriotic lesions in the Pouch of Douglas or the recto-vaginal septum.

The blood results of increased levels of FSH on two separate occasions with prolonged amenorrhoea suggest premature ovarian failure.

Polycystic ovarian syndrome (PCOS) is incorrect as raised FSH makes PCOS unlikely. She also has no features of hyperandrogenism. Early menopause is used for those women who go through their menopause between 40-45 years.

This lady is having a seizure but at the same time, she is experiencing signs and symptoms of magnesium sulphate toxicity.

Magnesium sulphate toxicity is characterized by confusion, loss of reflexes (deep tendon reflexes), respiratory depression, and hypotension. In obstetric women with magnesium sulphate toxicity, the following needs to be performed:

If only loss of patellar reflex or a respiratory rate less than 10 breaths/minute:

1. Stop magnesium sulphate maintenance infusion

2. Send magnesium sulphate levels to the laboratory urgently

3. Consider administration of intravenous calcium gluconate 1 g (10 ml) over 10 minutes if there is concern over respiratory depression. Calcium gluconate is the antidote.

4. Withhold further magnesium sulphate until patellar reflexes return or blood magnesium sulphate level known.

If cardiorespiratory arrest (due to magnesium sulphate toxicity) :

1. Crash call

2. Position woman in the left lateral tilt position and initiate CPR

3. Stop magnesium sulphate maintenance infusion

4. Administer intravenous calcium gluconate 1 g (10 ml) over 10 minutes. Calcium gluconate is the antidote.

5. Intubate immediately and manage with assisted ventilation until the resumption of spontaneous respirations

6. Send magnesium sulphate levels to the laboratory urgently In general, we do not use diazepam or phenytoin as an alternative to magnesium sulphate in women with eclampsia. However, since she is still having a fit, and magnesium sulphate toxicity is suspected, we are not able to use magnesium sulphate and thus diazepam would be the option here.

Note however, that we would only use it as a single dose since prolonged use of diazepam is associated with an increase in maternal death. If there were no features of magnesium sulphate toxicity in this question, recurrent seizures are treated with either a further bolus of 2 g magnesium sulphate or an increase in the infusion rate to 1.5 g or 2.0 g/hour.

The fetus should be continuously monitored with CTG.

The woman in this stem is 38 weeks pregnant, and so plans for delivery should be made once stabilized but there is no particular hurry, and a delay of several hours to make sure the correct care is in hand is acceptable assuming that there is no acute fetal concern such as fetal bradycardia.

Serum FSH/LH would be useful. Serum follicle-stimulating hormone (FSH) measurement alone can be used to diagnose premature ovarian failure.

There are a few points worth remembering when it comes to questions on combined oral contraceptive pills.

Combined oral contraceptive pills are UNLIKELY to be the appropriate choice of contraception in the following scenarios in the exam.

• History of VTE or family history of VTE

• Migraine with aura

• BMI more than 30 kg/m2.

• Smoker or ex-smoker

• History of Breast cancer - It is alright to use COCP in patients with a family history of breast cancer as long as the patient does not have a history of breast cancer and is not a carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)

• Hypertension (even if adequately controlled)

Mnemonic: "Vitamins Make Boys Sleep Better Hours"

This patient may just be having signs and symptoms of perimenopause. If so, we could easily just do nothing and have no investigations performed. As this is not an option given, the next best option would be to arrange a transvaginal ultrasound scan.

Transvaginal ultrasounds are useful as an initial investigation for irregular heavy vaginal bleeding even in the perimenopausal period with its primary use to look at endometrial thickness as a thick endometrium would prompt a referral for a hysteroscopy and endometrial biopsy to exclude endometrial cancer.

The reason we say that she is perimenopausal and not menopausal is because perimenopause includes the period beginning the first clinical, biological, and endocrinological features of the approaching menopause, such as vasomotor symptoms and menstrual irregularity whereas menopause is defined as 1 year of amenorrhoea after the age of 50 years old (alternatively 2 years of amenorrhoea after the age of 45). Fibroids may also be a cause of irregular heavy bleeding, but at this age group, it has less of an impact as fibroids tend to decrease in size once reaching perimenopause and menopause. This is because of the decrease in oestrogen and progesterone which are hormones involved in stimulating the growth of the fibroids.

The confusion that people have with this question is that they are looking for a test that is used to diagnose menopause. A key point worth remembering from guidelines in 2015 is that the diagnosis of menopause in healthy women above the age of 45 years should be based on symptoms and menopausal patterns and thus we should NOT routinely check FSH.

FSH levels tend to fluctuate in the perimenopausal period and so are unhelpful in diagnosing menopause in women above the age of 45. When is FSH useful? It is useful in the diagnosis of premature ovarian failure or early menopause (< 45 y).

Two FSH levels would be required and they are taken 4 to 8 weeks apart. FSH also has its use in decisions regarding stopping contraception however it is unlikely to be raised. Serum estradiol and progesterone are not helpful and it is not recommended by NICE in diagnosing menopause.

The key point to remember in this question: A transvaginal ultrasound scan may be considered for women with atypical symptoms of menopause which would involve heavy irregular bleeding.

This is a classic presentation of ovarian cancer.

Concerns should be raised with any pelvic mass that is identified after menopause. Ovaries in the postmenopausal age group should be atrophic, and anytime they are enlarged, the suspicion of ovarian cancer arises.

The term “nulliparous” was thrown into the question to help guide you toward the suspicion of ovarian cancer as nulliparity is a risk factor.

In a woman of this age with persistent symptoms of abdominal discomfort and bloating it is essential to consider the possibility of ovarian cancer. Due to the nonspecific nature of symptoms of this disease, you should have a low threshold for initiating investigations. Serum CA125 is a tumour marker that is used in the investigation of possible ovarian cancer, though it is not 100% sensitive or specific for this disease. 

Guidelines state that serum CA 125 should be performed if a woman

- Especially if aged 50 years old or over

- Has any of the following symptoms regularly

• Abdominal distension or 'bloating'

• Early satiety or loss of appetite

• Pelvic or abdominal pain

• Increased urinary urgency and/or frequency.

All women with recurrent first-trimester miscarriages and all women with one or more second-trimester miscarriages should be screened before pregnancy for antiphospholipid antibodies.

Parental peripheral blood karyotyping of both partners should be performed in couples with recurrent miscarriages where testing of products of conception reports an unbalanced structural chromosomal abnormality.

But in this case, cytogenetic analysis performed on products of conception shows no abnormalities thus there is no need for parental karyotyping. There is currently no satisfactory objective test that can identify women with cervical weakness in the non-pregnant state.

Hence, the option for transvaginal ultrasound for cervical length is incorrect.

Serum follicle-stimulating hormone (FSH) measurement alone can be used to diagnose premature ovarian failure Note that Anti-Mullerian hormone can also be used to help diagnose premature ovarian failure as it is a measure of reduced ovarian reserve. However, it is usually only undertaken if there is diagnostic uncertainty.

Although retained products of conception may be an option. Endometritis fits more perfectly with the scenario given the fever, the history of an emergency C-section, prolonged labour, and the foul discharge.

Uterine infection (endometritis) Is the most common cause of postpartum fever.

Predisposing factors :

• Emergency caesarean section

• Prelabour rupture of membranes

• Prolonged labour

• Multiple pelvic examinations.

• Internal fetal monitoring - use of scalp electrodes/ intrauterine

Signs and symptoms :

• Fever usually in proportion to the extent of infection.

• Foul smelling, profuse, and bloody discharge.

• Tender bulky uterus on abdominal examination

Management :

• Antibiotics

Stress incontinence is a leak of small amounts of urine when coughing or laughing. Usually with a history of many vaginal deliveries as this would weaken the pelvic floor muscles. The next management here would be surgical. A tension-free vaginal tape would be appropriate.

The other options are less likely the correct answer: Bladder training is used for women with urgency or mixed urinary incontinence. It is not used for stress incontinence.

Oestrogens do not offer systemic hormone replacement therapy for the treatment of urinary incontinence Intermittent urethral catheters. This is primarily for people with urinary retention rather than stress incontinence Antimuscarinic medications are used to treat overactive bladder and not stress incontinence.

The likely diagnosis here is endometriosis. A laparoscopy would be the gold standard to diagnose it. A laparoscopy would also be able to identify any other pathologies that may be causing the chronic pelvic pain such as adhesions. Serum CA125 may be seen elevated with endometriosis, however, there is no evidence that it is a useful screening test for this endometriosis. Ultrasound pelvis may help detect ovarian endometriosis but is unable to detect peritoneal disease.

Remember, pelvic ultrasound scans are likely to be normal but are still requested in some cases to help to diagnose an ovarian endometrioma (cyst) associated with endometriosis.

NICE clearly states that pelvic MRI should NOT be performed as a primary investigation to diagnose endometriosis.

An MRI can be considered before operative laparoscopy in women with suspected deep endometriosis involving bowel, bladder, or ureter which is not the case here.

A hysteroscopy has no value in diagnosing endometriosis as the presence of endometrial-like tissue is outside of the uterine cavity.

This question describes Tubo-ovarian abscess which is a complication of PID. The ultrasound findings of a tubo-ovarian abscess usually show a multilocular complex adnexal mass with debris, septations, and irregular thick walls.

Endometriosis : Does not present as a mass in the US.

Ovarian cancer : Unlikely as she is very young and she has signs of an infection.

Ectopic pregnancy : Unlikely as urine BHC is negative and signs and symptoms point towards PID.

Dermoid cyst : Typically an ovarian dermoid is seen as a cystic adnexal mass with some mural components. Most lesions are unilocular.

Hormone replacement therapy like oestrogen and progestogen patches are indicated here as she is having menopausal symptoms. This systemic treatment can also alleviate symptoms of vaginal dryness and symptoms of urinary frequency. A vaginal oestrogen cream or pessary would be appropriate if the patient only had symptoms of vaginal dryness without the other symptoms of menopause like hot flushes. In such cases, there is no need for a systemic treatment as topical treatment can alleviate symptoms.

The history of a myocardial infarction is irrelevant. The relation between HRT and cardiovascular disease is controversial. The National Institute for Health and Care Excellence (NICE) states that HRT does not increase cardiovascular risk when started in women aged under 60 years and does not affect the risk of dying from cardiovascular disease and hence the presence of cardiovascular risk factors is NOT a contraindication to HRT.

Please see Q- 69

Lichen sclerosus is a chronic inflammatory dermatosis that usually affects the skin of the anogenital region in women. It presents with general itching and is seen as white atrophic plaques. It occurs in little girls or middle-aged women. It is thought to have an autoimmune mechanism in the pathogenesis. The main complaint is itching which is worse at night.

Dyspareunia and pain may be seen in cases of erosions or fissures. Topical steroids are used as part of the management. Follow-up is important and is recommended at three and six months, to ensure responses to treatment. This is because long-standing, untreated cases show a 4% incidence of malignant change (association with development of squamous cell carcinoma of the vulva).

The possible diagnosis here is a pelvic abscess or tubo-ovarian abscess which are complications of PID. A high vaginal swab or endocervical swab can take days to return with results.

As this is an A&E case, an ultrasound would be more appropriate as this would lead to a diagnosis. Ultrasound scan is the diagnostic imaging method of choice for acute pelvic pain in gynaecology.

It can easily diagnose sequelae of PID (including pyosalpinx and tuba ovarian abscess). Laparoscopy would be the next step after finding a mass on ultrasound. Abdominal X-ray has no part in the diagnosis of a pelvic abscess.

The mother did not receive any Anti-D injections in her previous pregnancy. The stem is trying to tell you that she was immunized during her last pregnancy when delivered a Rhesus (+ve) baby. This woman now has antibodies against fetal RBC.

They attack fetal red blood cells causing a bilirubin build up leading to jaundice. Other common causes of jaundice which present within 24 hours of birth are ABO incompatibility, G6PD, and sepsis. However, the stem does not provide any information that would point you to pick any of them.

Abruption of the placenta can still occur despite no evidence of vaginal bleeding. This type of abruption is called concealed abruption and it occurs in less than 20% of all placental abruptions.

Although the clinical scenario here looks like placenta abruption, one important diagnosis that we need to rule out as well as a placenta praevia for which initial the investigation of choice is an ultrasound. An ultrasound cannot exclude placental abruption, which is a clinical diagnosis. Placenta praevia usually presents with a painless vaginal bleed however the abdominal pain in this stem could very well be mild contraction pains.

With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin however this should not be done in an acute setting as the first investigation. A Kleihauer-Betke test can wait.

It is worth mentioning that if the question was asking for the best action and a CTG was within one of the options, that would usually be the best action. The reason behind this is placenta abruption is part of the differential and if the CTG shows fetal distress, the baby would need to be delivered immediately. There is no time to wait around for an ultrasound. Speculum examination is important to exclude a cervical cause of bleeding such as chlamydia but ideally, this should be done after the ultrasound scan rules out placenta praevia.

Combined oral contraceptive pills suppress the production of gonadotrophins and are thought to reduce menstrual blood loss by up to 50%. It can improve dysmenorrhoea, lighten periods, regulate the cycle, and improve premenstrual symptoms, COCP is very useful in adolescence. Also, note that tranexamic acid is also effective. Although the levonorgestrel intra-uterine system is the first line for menorrhagia, it is difficult to fit in a nulliparous woman as her cervix has not yet been dilated before.

However, there has been more and more research regarding the use of levonorgestrel intrauterine systems in nulliparous women and some clinicians would prefer levonorgestrel intra-uterine system to combined oral contraceptives. They argue that the levonorgestrel intra-uterine systems such as Jaydess may be fitted more easily, as the frame is smaller and narrower compared to the Mirena IUS.

In this situation, she is not sexually active so preference should go towards combined oral contraception to control the bleeding as a girl her age might feel uncomfortable with a speculum examination. NSAIDS such as mefenamic acid may decrease menstrual blood loss by up to 20–30% and also significant decreases in dysmenorrhoea.

But it will not regulate her periods whereas COCP will regulate an irregular cycle.

NICE has suggested that this medical management of heavy menstrual bleeding should be considered in the following order:

1. Levonorgestrel-releasing hormone

2. Tranexamic acid or non-steroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives

3. Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle or infected long-acting progestogens

There are certain situations where one might choose a different order.

The summary to answering these types of questions is as below:

• Dysmenorrhoea in a young girl – Mefenamic acid

• Dysmenorrhoea, menorrhagia, and irregular menstrual cycles in a young girl – COCP

• Dysmenorrhoea, menorrhagia, and irregular menstrual cycles in sexually active women (or para 1 or more) – Levonorgestrel intra-uterine system.

Please see Q-121

Advise women with diabetes who are planning to become pregnant to take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.

Intravenous magnesium sulphate is the most important initial management. Fetal CTG is also needed, but MgSO4 comes first. Delivery should follow after stabilizing the mother.

Tamoxifen is a risk factor for endometrial carcinoma. So vaginal bleeding will be of concern for us.

The diagnosis of premature ovarian failure usually needs two raised levels of FSH (more than 40 IU/L) taken at least four weeks apart.

In this question, since she is amenorrheic with raised FSH and LH and a normal prolactin level, the most likely diagnosis would be premature ovarian failure.

Women with premature ovarian failure also have low estradiol (usually < 50 pmol/l).

Obese, amenorrhoea, and hirsutism are consistent with Polycystic ovary syndrome (PCOS). She has high LH, normal FSH, and slightly high prolactin levels.

These are not diagnostic for PCOS but among the choices given, the lab results reflect PCOS. Serum LH levels are elevated in approximately 40% of women with PCOS, owing to increased production (increased amplitude and frequency of LH pulses). Prolactin may be mildly elevated in PCOS.

It has been described by some authors that women with polycystic ovary syndrome (PCOS) may have elevated levels of prolactin. However, a diagnostic criterion is to rule out other possible causes, including hyperprolactinemia.

This is because high prolactin levels have many of the same symptoms as PCOS and need to be ruled out to be certain of a PCOS diagnosis.

The definitions for hypertensive disease in pregnancy are important. Pre-eclampsia is where a 20 weeks of gestation woman has a blood pressure more than 140/90 mmHG and proteinuria (> 0.3 g/24 hours).

Labetalol is the most studied antihypertensive in pregnancy with the safest profile.

Pregnancy Induced Hypertension :

The general management for gestational hypertension can be summarized below -

Degree of hypertension: Mild hypertension (140/90 to 149/99 mmHg) - No Treatment.

Moderate hypertension (150/100 to 159/109 mmHg) - With oral labetalol as first-line treatment to keep

• Diastolic blood pressure between 80-100 mmHg

• Systolic blood pressure less than 150 mmHg

Severe hypertension (160/110 mmHg or higher) - Admit to hospital.

Treat with oral labetalol as first-line treatment to keep.

• Diastolic blood pressure between 80-100 mmHg

• Systolic blood pressure less than 150 mmHg.

Commonly used medicines in pregnancy are methyldopa and nifedipine.

The first step is understanding that the screening result of mild dyskaryosis would follow samples being sent for HPV testing. If mild dyskaryosis is present but there is an absence of HPV testing, then this case should be referred to colposcopy. This means that if HPV testing was part of the options, that would be a better answer compared to colposcopy.

The second step is understanding what a colposcopy includes.

A colposcopy involves visualising the cervix using a microscope. A speculum is used to open the vagina and the cervix is stained with acetic acid in the area of the transformation zone (TZ) to identify the site, grade, and shape of any abnormal area of cells.

Iodine is then gently applied to the rest of the cervix to identify the complete area of abnormality.

A small biopsy is usually taken to be sent to the laboratory. When an area of abnormality extends into the cervical canal beyond the area that can be seen with the colposcope, a cone biopsy is indicated. We need a colposcopy first before we can be certain if a cone biopsy is required, hence the option for cone biopsy is incorrect.

Large loop excision of the transformation zone (LLETZ) takes place at the end of colposcopy if abnormality is obvious on colposcopy or for women who have had a positive biopsy result. Therefore if the option for colposcopy is present, that would take priority over the option for LLETZ since the question is asking for “the next step in action”.

Endocervical swabs have no value in the management of cervical screening tests. Endocervical swabs are used to diagnose chlamydia or gonorrhoea.

SUMMARY OF MANAGEMENT OF CERVICAL SCREENING TEST RESULTS :

Negative – Recall for screening as appropriate for a negative result Inflammatory.

– Repeat cervical swab in 6 months, consider taking swabs for infection if severe inflammation

Inadequate – Repeat sample

– If results are still persistently inadequate, assess using colposcopy

Borderline – Perform HPV testing on these samples – If HPV positive, refer for colposcopy.

Mild dyskaryosis – Perform HPV testing on these samples – If HPV positive, refer for colposcopy.

Note: If mild dyskaryosis and absence of HPV testing or HPV results are unreliable or inadequate, refer for colposcopy.

Moderate dyskaryosis or Severe dyskaryosis – Refer for urgent colposcopy for suspected cancer (two-week wait).

The idea here is to think of endometrial cancer. Any woman who has postmenopausal bleeding should have a transvaginal ultrasound to determine the endometrial thickness.

If the endometrium is thick, hysteroscopy with endometrial biopsy would be arranged. The hormone replacement therapy in this scenario has no relevance as HRT (progesterone and oestrogen) is not a risk factor for endometrial cancer.

Only unopposed oestrogen would be a risk factor for endometrial cancer.

A cervical smear is offered every 5 years if in the age group of 50 to 64 years old. Thus, having a cervical smear that was normal 3 years ago is a usual phenomenon. A repeat cervical smear is not necessary.

This is a case of hyperemesis gravidarum. Intravenous fluids is the most important part of management to ensure that the patient is not dehydrated. As this has already been given and dehydration managed, intravenous antiemetics is the next best answer since only intramuscular cyclizine has been given. Regular antiemetics such as promethazine or cyclizine are often tried first in many early pregnancy units.

If this fails, prochlorperazine intramuscularly or orally can be added on. If the patient continues to vomit, intravenous metoclopramide or ondansetron can be used on top of the already prescribed regular antiemetics. Advice such as eat little and often should be given.

Thiamine is also used in hyperemesis gravidarum and should ideally be given to all women admitted with prolonged vomiting.

This is to prevent Wernicke’s encephalopathy which is due to vitamin B1 (thiamine) deficiency.

However, the importance of thiamine in an acutely vomiting woman is less compared to having intravenous antiemetics. Intravenous corticosteroids is NOT the answer here.

Corticosteroids may be used for intractable cases of severe hyperemesis gravidarum in secondary care but this is usually a consultant decision and all other measures such as intravenous antiemetics have been taken to attempt to manage the patient's vomiting.

Non-organic dyspareunia + with symptoms similar to premenstrual syndrome + aggravated by standing = Pelvic congestion syndrome

Abdominal myomectomy is the most appropriate in this situation. As the fibroids are seen to be subserosal and intramural, an abdominal incision would give us access to these fibroids. A vaginal approach using a hysteroscopy would be a choice for submucosal fibroids but not for intramural and subserosal fibroids.

Myomectomy and uterine artery embolization are both uterine-sparing surgeries and can both preserve her fertility but myomectomies are usually the better choice. If myomectomy has failed, uterine artery embolization may be attempted. Generally, women with fibroids causing infertility are offered myomectomies. The other options given will affect the patient's fertility.