try to solve

Anatomy:

(1) The main tissues which provide support to the uterus include:
T F	True False False True False	(a) uterosacral ligaments (b) perineal body (c) round ligament (d) cardinal ligaments (e) broad ligaments
The uterosacral and transverse cervical (cardinal) ligaments provide the main support for the uterus and although the other structures (round & broad) are named ligaments, they offer no support.

(2) Which of the following statements are TRUE:
T F	False True False True True	(a) Bartholins gland are found in the para-urethral area (b) The ampulla is the commonest site for ectopic pregnancies (c) The ureter enters the bladder ABOVE the uterine / cervical artery (d) After the menopause the ratio of uterus : cervix is 1 : 1 (e) FSH is raised above 30 iu after the menopause
The Bartholin's glands are situated on either side of the vaginal orifice deep to the posterior ends of the labia minora (ie not anteriorly). The ampulla is the widest and longest portion of the fallopian tube and is the commonest site for ectopic pregnancy implantation. If implantation occurs within the isthmus of the tube, this is the commonest site for rupture of the ectopic. The uterine/cervical artery enters the uterus at the level of the internal os just above the ureter (like a bridge over troubled water). This important anatomical feature highlights the need to stay as close to the uterus as possible when clamping the artery to avoid damaging the ureter during hysterectomy operations (1% risk). In the child, the cervix forms almost 2/3 of the total length of the corpus uterus. In the adult these proportions are reversed (i.e. 1:2) and in old age the uterus shrinks such that the ratio is approximately 1:1. After the menopause, although the oestradiol level may drop, this is not a consistent finding and should not be used to make the diagnosis. A FSH (Follicle Stimulating Hormone) level > 30 iu is however diagnostic.

Contraception:

(3) The combined oral contraceptive pill:
T F	False False False False True	(a) is taken continuously for 28 days (b) has a pearl index of 10 (c) can be used as a form of post-coital contraception (d) if a pill is forgotten (eg. 12 hours late), other contraception must be used for 7 days (e) can be used to reduce menorrhagia & dysmenorrhoea effectively
The combined oral contraceptive pill contains oestrogen and progesterone and is taken on a cyclical basis for 21 days out of 28 days each month. It can be used as first line treatment for patients with heavy (menorrhagia) or painful (dysmenorrhoea) periods, as long as there are no contraindications or at risk groups (eg smokers over 35). The Pearl index (number of pregnancies which occur in 100 women during a year of using a method of contraception) is a marker of the effectiveness of the method used. The combined pill has a pearl index of approximately 1 (cf. condoms 2-15, progesterone only pill 2-3). BNF 55 (March 2008): The critical time for loss of contraceptive is when a pill is ommitted at the beginning or end of a cycle. If a woman forgets to take a pill, it should be taken asap and the next one taken at the normal time (even if this means taking 2 pills together). A missed pill is one that is 24 hrs or more late. If a woman misses only one pill NO ADDITIONAL PRECAUTIONS ARE REQUIRED. If a woman misses 2 pills she is unprotected for 7 days and should use other forms of contraception (This answer was updated October 2008). Although in the past, a whole packet of progesterone only pills could be taken as a form of post-coital contraception, this is no longer required and the main method used is levonelle one-step. This can be used up to 72 hours post-coitus (i.e. NOT just the morning after) and has success rates approaching 95 %.

(4) The progesterone only pill (POP):
T F	True True True True False	(a) must be taken at the same time (within 3hrs) each day (b) if a pill is missed e.g. taken 15 hrs late, other contraception needs to be used for only 2 days (c) this pill is preferred to the combined oral contraceptive pill for use in smokers (d) can be used as a form of post-coital contraception (e) main contraceptive method is by stopping ovulation
The progesterone only pill (pop) must be taken at the same time every day, with a 3 hour window period and no breaks in the packets. Their main method of action is by thickening the cervical mucus, although ovulation is blocked in about 40% of cases. Theoretically the lack of cervical mucus occurs for only about 48 hrs after missing the pop. Some manufactures used to advise the use other precautions for 7 days after missing (ie. 3 hrs late) a pill, BUT NOW the BNF 55 p 433 (March 2008) and the faculty of Family planning recommend other precautions are only required for 2 days. Cerazette (Organon) is one of the newer types of pop, classified as an "oestrogen-free pill". Its manufacturers claim that it is 99% effective and works first line by blocking ovulation (and second line by thickening cervical mucus). Rather than having a 3 hr window period, Cerazette can be missed for up to 12 hours before other contraceptive precautions are required. In the past, a whole packet of progesterone only pills could be taken as a form of post-coital contraception. This is no longer required and the main method used is Levonelle one-step (Schering Health). This contains 1.5 mg levenogestrel and can be used up to 72 hours post-coitus (i.e. NOT just the morning after), and has success rates approaching 95%.

(5) The intra-uterine contraceptive device (IUCD):
T F	False False False False False	(a) increases your risk of ectopic pregnancy cf. general population (b) cannot be used for post-coital contaraception after 72 hrs (c) should be changed every 3 yrs (d) if lost, and an USS confirms it is not visible inside the uterus, the patient can be reassured and discharged (e) should never be used in women who have never been pregnant
It a common misunderstanding that the IUCD increases the risk of an ectopic pregnancy. Overall the Pearl index for the copper IUCD is between 4 (Nova T) and 1.5 (CuT380) with the Mirena IUCD approaching 0.1. This means that overall having a coil in place will markedly reduce the chances of a patient getting pregnant compared with those not using any contraception (about 80-90% over 1 year trying). Similarly the figure for the pregnancy being ectopic will be even lower. If a patient does get pregnant with a IUCD in place then it will most likely be intrauterine, although 30% may be ectopic (cf. 1% of pregnancies in general being ectopic). It can be used as a method of post-coital contraception up to 5 days after unprotected intercourse and has success rates approaching 95%. Most are changed every 5 years (some are licensed for 8-10 yrs e.g. T-Safe CU 380 A (FP) etc. ) and although it is not always easy, or advisable to insert IUCD's into nulliparous women, never use the term never (or always !) in medicine, especially in MCQ's. If a patient presents with a missing IUCD and the ultrasound fails to reveal its position within the uterus, an abdominal X-ray is required to exclude that the uterus has been perforated and the IUCD misplaced before the patient can be reassured and discharged.

(6) A female sterilization:
T F	False False False False True	(a) has a lower failure rate than a vasectomy (b) can never be reversed (c) has better success rate than a Mirena IUCD (Schering Health) (d) can only be carried out on multiparous women (e) can be done at any point during the patients cycle
The failure rate in a vasectomy is 1:2000 compared with the failure rate in a sterilization being 1:200 (NB cf. Mirena IUCD 1:1000). A failed sterilization is one of the commonest medico-legal cases in gynaecology and counselling the patient is as important as the procedure itself. It can be carried out at any time during a patient's cycle, but a patient must be warned of risks of a "luteal" phase pregnancy i.e. if they are mid-cycle, then there is a risk of the patient still becoming pregnant if the oocyte has already passed the portion of the fallopian tube being occluded. It is therefore important that ALL patients do have a pregnancy test before the procedure and are advised to continue with their current contraception till their next period. Although the operation can be carried out on nulliparous women, they must be 110% sure, and the operator must be happy that there are no psychological implications in the case and must not be pressurised into carrying out a procedure if they do not agree. If there is any doubt, a second opinion should be sought. Although it should be explained as a permanent procedure, it can be reversed (NOT on the NHS) and success rates range between 20-70% depending on who's doing it, how the initial procedure was done, how long ago it was and how old the patient is etc. With the advent of assisted reproduction (i.e. in vitro fertilisation), reversals are rarely sought.

Infertility:

(7) The following are useful investigations in the management of a subfertile couple:
T F	True False False False True	(a) Hysterosalpingogram (b) Rhesus blood group status of both partners (c) Day 25 progesterone level in the female with 28 day cycles (d) Chlamydia investigation of the male partner (e) Rubella status of the female
The main causes for subfertility include: anatomical (eg tubal blockage), ovulation problems, male factors, idiopathic and other factors (eg endometriosis). A hysterosalpingogram (HSG) is a useful test to be done to check tubal patency. This can be done in the out-patient department but the patient is exposed to X-rays. A HyCoSe test is a similar test but is done in the OPD under ultrasound control and therefore avoids exposure to radiation. A Laparoscopy & Dye test is an alternative for tubal assessment and allows a full view of the pelvis to exclude conditions such as endometriosis, pelvic inflammatory disease etc. but the patient does have to go through a general anaesthetic and the risks of key-hole surgery (e.g. bowel, bladder, blood vessel damage).

(8) On assessment of Semen Fluid Analysis:
T F	False True True False True	(a) Azoospermia indicates a sperm count more than 5 million/ml (b) Asthenozoospermia indicates abnormal motility (>60%) (c) Teratozoospermia indicates abnormal forms (>30%) (d) Only needs to be assessed if no female subfertility factors have been found (e) Abstinence should be maintained for 3 days prior to "production" of the sample
Subfertility may be primary, when the patient has never been pregnant, or secondary when the patient has had a previous pregnancy (this may have ended in a miscarriage, but the patient has conceived). Even if female factors have been found as a cause (e.g. ovulation problems, anatomical), the male partner must always be tested i.e.semen fluid analysis. The sample is analysed for the correct number, forms and motility of the sperms in addition to anti-sperm antibodies. A normal sperm count should be >20 million per ml. Oligospermia indicates a sperm count concentration less than this and azoospermia indicates a sperm count of 0. The patients are advised to abstain from sex for 3 days prior to the sample production and bring "it" in warm, although not too warm. (I once received a specimen report which read "lots of sperm, but they are all dead as the patient brought the sample in with a hot water bottle !!)

Early pregnancy bleeding:

(9) An ectopic pregnancy:
T F	True False True False False	(a) Occurs in about 1:100 spontaneous conceptions (b) Can only be treated surgically (c) May be suspected in the absence of symptoms when the uterus appears "empty" on a TV scan and a beta-HCG level is 2000 IU (d) Gives an increased risk of Hyperemisis Gravidarium (e) Pain always presents before the bleeding
A fertilised egg normally implants in the decidua of the uterus. Occasionally it can implant in another site and this is described as an ectopic pregnancy. Almost all cases occur in the fallopian tube and the ampulla is the most dilated portion and as a result the commonest site. Although some textbooks claim that pain presents before bleeding, this does not ALWAYS happen and the full case scenario and investigations need to be assessed as a whole. The vaginal bleeding may appear more minimal than occurs in a miscarriage, but the patients can be shocked with tachycardia, hypotension and blood in the abdomen. In the last confidential enquiry into maternal mortality (CEMACH, 2002), ectopic pregnancy still remains a major cause with 11 deaths and substandard care in a majority of them. They can be treated surgically, either laparoscopically or via a laparotomy), but this depends on the clinical findings and the skill of the operator. The tube may be cut: salpingectomy - removing the portion of the tube or salpingostomy - opening up the portion of the tube to remove the ectopic. As long as the other tube looks healthy, the recommended treatment is a laparoscopic salpingectomy. They can also be treated medically with methotrexate, or conservatively (i.e. sit and watch) in some extreme cases with a brave (?stupid) gynaecologist. Although no beta-HCG level is diagnostic of an ectopic, the suspicion may be raised in cases where a beta-HCG level is greater than 1500 IU and no intrauterine pregnancy is visible on a transvaginal scan. Alternatively, where the beta-HCG level doesn't double within 48 hours as it should in the case of an intra-uterine pregnancy. Although the ectopics themselves are rarely visible on ultrasound, "worring features" may include - "...nil in uterus and free fluid in pouch of douglas (i.e. blood)".

(10) In the presence of a positive pregnancy test and vaginal bleeding, the following are possible differential diagnoses if the CERVIX is closed:
T F	True False True False True	(a) ectopic pregnancy (b) incomplete miscarriage (c) threatened miscarriage (d) inevitable miscarriage (e) complete miscarriage
Although ultrasound machines are used commonly to determine the viability and site of a pregnancy, these terms are based on the clinical findings when examining a patient during early pregnancy. If the cervix is CLOSED and the patient has been bleeding, then she may be having a threatened miscarriage (i.e. pregnancy still on going) or she may have had a complete miscarriage. In an ectopic pregnancy scenario, the cervix will be closed and she may have marked cervical excitation (extreme discomfort on being examined). If the cervix is PATULOUS (OPEN) then a diagnosis of an incomplete miscarriage (i.e. products still inside the uterine cavity) or inevitable (although the pregnancy may still be within the uterus, it will inevitably come out). Twin pregnancies can sometimes make these clinical diagnoses more difficult and cases have occurred where one twin has been lost, the cervix has been open and then closes down spontaneously such that the other pregnancy remains on-going.

Gynaecological cancers:

(11) Which of the following statements with regards to endometrial, ovarian and cervical cancer are TRUE:
T F	True False False False True	(a) Ovarian cancer has the worst prognosis (b) Cervical cancer is best treated with chemotherapy (c) The number of cases of endometrial cancer has been reduced by good screening techniques (d) Ovarian dermoid cysts are often malignant (e) Cervical cancer is most commonly squamous
The overall prognosis from cases of ovarian cancer over 5 years is 30%. This compares to 55% for cervical cancer and 65% for endometrial cancer. Endometrial cancer has the best prognosis because patients often present with "post-menopausal bleeding" and seek advice from their GP at an early stage. Similarly the cervical screening regime in the UK picks up cases of cervical cancer at a pre-malignant stage and recognises those patients who will be at risk of cervical cancer. Unfortunately no accurate screening test exists for ovarian cancer and patients often present at a late stage (i.e. stage III-IV) which is difficult to treat. Cervical cancer and endometrial cancer are treated with surgery and or radiotherapy, dependent on the stage of the disease etc, and ovarian cancer is treated with surgery and or chemotherapy (e.g. taxol, cisplatin). Dermoid cysts of the ovary account for approximately 25% of ovarian neoplasms and are made from the primary germ layers: endoderm, ectoderm and mesoderm. As a result they can consist of hair, teeth, cartilage etc and only about 1% have a malignant potential.

(12) In Cervical cancer:
T F	True False False False False	(a) Human papilloma virus types 16, 18, 31,33 and 35 are associated with cervical cancer (b) Cervical cancer affects about 1000 women in the UK each year (c) Stage for stage, cervical cancer has a worse prognosis than endometrial cancer (d) all patients with Borderline nuclear abnormalities on their cervical smears should be referred directly for colposcopy (e) at colposcopy, citric acid allows clear demarcation of abnormal areas
Cervical cancer is most commonly squamous although glandular lesions are found in the older age group (40 yrs) and about 2800 cases happen in the UK each year (2002). The prognosis has improved over recent years because of the cervical screening picking up cases at a pre-malignant stage and the overall death rate is 1100 deaths in 2002 (cf. 1500 in 1993). Although the prognosis for cervical cancer is the same, stage for stage compared with endometrial cancer, because there are more cases of endometrial cancer which present at an earlier stage the overall prognosis for endometrial cancer is better (65% cf. 55% for cervical). Orange juice (citric acid) will be of no benefit in the colposcopy clinic! 5% acetic acid (dilute vinegar) is used and this shows up the abnormal cells with acetowhite changes. The abnormal cells have a high nuclear to cytoplasmic ratio, and thus contain a lot of protein. It is this protein which gives the acetowhite changes.

(13) In Endometrial cancer:
T F	True True False False True	(a) It often presents with postmenopausal bleeding (b) Women taking oestrogen only HRT are at increased risk (c) May be screened for using CA125 and TV scanning (d) commonly develops from leiomyomas (e) Polycystic ovarian disease is a recognised risk factor
Endometrial cancer often presents at an early stage, as soon as the cancer has invaded the endometrium (stage Ia). The peak incidence is at 61 yrs and over 75% occur in the postmenopausal age group. If women require HRT and they have a uterus in place then they must be given progesterone therapy as well as oestrogen. If they are on short term therapy, they can have a cyclical HRT (bleed every 21 days), but if they want to use it long term i.e. more than 1-2 yrs, and they are aware of the risks, e.g. breast cancer, DVT's etc, then they should be prescribed continuous combined preparations (e.g. kliovance) as long as no other contraindications exist. Those patients on continuous combined preparations have a lower risk of endometrial cancer compared with those on cyclical HRT. There is no screening test for endometrial cancer and although CA125 and ultrasound scans can help to detect ovarian cancer, they are of no use as screening tools for this condition at present. Leiomyomas (fibroids) are often benign and less than 0.2% will become malignant leiomyosarcomas. Most leiomyosarcomas arise de novo, are rapid growing and have a bad prognosis. Patients with polycystic ovaries are at higher risk of endometrial cancer and diabetes later on in life.

(14) In Ovarian cancer:
T F	False False True False False	(a) The commonest types of tumour arise from the "germ cell lines" (b) Often present in the premenopausal age group (c) The risk of developing ovarian cancer can be increased to 40% if > 2 first degree relatives have been affected (d) It is commonly treated with radiotherapy (e) It often presents at an early stage due to abdominal ascites
Over 70% of ovarian neoplasms develop from epithelial cell tumours (e.g. mucinous cystadenomas (commonest benign) or serous papilliferous (commonest malignant)). The remainder are germ cell tumours (e.g. dermoid cysts) or sex cord/gonadal stromal tumours (e.g. granulosa cell tumours). Most present in the post menopausal age group although the germ cell tumours may be seen in younger patients. The overall risk of ovarian cancer in women between 50-70 is 1:70. This increases to 5% in women who have 1 first degree relative with the disease, and 40% in women with 2 relatives. Although ascites can be recorded at any stage during the disease (e.g. Ic, IIc etc) this is often a late feature and patients commonly present with stage III or IV disease. If at all possible, debulking surgery is carried out and this may be followed by chemotherapy.

Pelvic pain:

(15) In patients with vaginal discharge:
T F	False False True False False	(a) Bacterial vaginosis is the commonest sexually transmitted infection in women (b) Trichomonas infections are treated with amoxycillin (c) Candidiais is not a sexually transmitted infection (d) Chlamydia can be tested for using a high vaginal swab (e) Gonorrhoea "crosses" the placenta
Bacterial vaginosis and thrush are not sexually transmitted infections. Trichomonas Vaginalis is a sexually transmitted infection and can be treated with metronidazole. As with all STD's it is important that contact tracing is carried out and the patients are encouraged to notify their partners. If this does not occur then the infections can return causing further pelvic pain and may result in subfertility later on due to tubular blockage. Chlamydia is the commonest sexually transmitted infection, and can affect 10% of the female population aged 20-25 yrs old. It grows in endocervical cells and can be tested on urine samples or endo cervical swabs, but not high vaginal swabs. It is treated with doxycycline (e.g.100mg bd 10 days) or azithromycin as a single dose (1g stat). Again, contact tracing is important. Gonorrhoea and chlamydia do not cross the placenta, but can result in neonatal conjunctivitis if the mother has it active at the time of vaginal delivery. This should be treated with antibiotics and is not a valid indication for a caesarean section.

Multiple pregnancy:

(16) In mothers carrying multiple pregnancies:
T F	False True False False False True	(a) The incidence of twins is approximately 1 : 802 (b) Monochorionic twins are at higher risk of complications than dichorionic twins (c) IVF has dramatically increased the incidence of monochorionic twins (d) Twin-Twin transfusion only affects dichorionic twins (e) Identical twins are more common in those with a family history (f) The incidence of hyperemisis gravidarium is increased
The incidence of multiple pregnancies has been increasing since the advent of assisted reproduction, but this involves dizygotic twins. In spontaneous conceptions the incidence has remained fairly stable. 1:80 pregnancies are twins, 1:802 (i.e.1:6400) are triplets and 1:803 (i.e.1:512000) are quadruplets. 70% of twins are dizygotic and all have 2 placentas (dichorionic) and 2 separate sacs (diamniotic). These result in non-identical twins and are the lowest risk type. Various risk factors for non-identical twins exist including race, increasing age, parity, family history and assisted conception techniques (e.g. clomiphene). Monozygotic twins only account for 30% of the twin population and result in identical twins. The number of placentas and sacs depends on the timing of cell division, but monochorionic twins are at risk of twin-twin transfusion. One twin can become hydropic (excess blood supply and oedema) and the other twin can become growth restricted. Similar to molar pregnancies, multiple pregnancies have excessively high levels of beta-HCG and this results in hyperemisis gravidarium - excess vomiting in early pregnancy.

Incontinence:

(17) With regards to urinary incontinence:
T F	False True False False False	(a) Genuine Stress Incontinence can be diagnosed on history alone (b) Detrusor instability can be treated with anticholinergic medication (c) Tension free vaginal tape (TVT) is an ideal treatment for detrusor instability (d) Urodynamics is only required if surgery fails (e) A TVT can only be done under general anaesthetic
Although a diagnosis of stress incontinence may be suggested by a history (ie. leakage of urine on coughing/laughing etc), the true diagnosis of Genuine Stress Incontinence (GSI) can only be made following urodynamics. This is a pre-requistite test required before embarking on any uro-gynaecology surgery. Tension free Vaginal Tape (TVT) is an improved procedure for GSI compared with the old Burch colposuspension. It can be done under local or spinal anaesthetic, and rather than the patients requiring an open abdominal wound the procedure can be done through small incisions, and the patients can often go home later on the same day or following day.

(18) Which of the following statements are TRUE:
T F	True False False	(a) A ring pessary should be changed every 4-6 months (b) Reduction in fluid intake is the ideal treatment for nocturia (c) A rectocele can be repaired by an anterior colporophy
For symptoms of prolapse, a ring pessary or shelf pessary may offer a conservative approach compared to surgery. They do however have to be changed in the out patient setting every 4-6 months as otherwise they can become embedded within the vaginal tissues and require removal under general anaesthetic. Although coffee and tea may be cut down in patients with urge incontinence, overall reduction in fluid intake can sometimes be dangerous, and have a detrimental effect on the patient's renal function. The normal fluid intake should be about 1.5 L/day. This can be assessed carefully using a diary. An anterior colporophy (anterior pelvic floor repair) is the surgical management for a cystocele and a posterior colporophy is the treatment for a rectocele.

Menopause:

(19) HRT offers protection against:
T F	False True True True False	(a) breast CA (b) osteoporosis (c) Alzheimer's (d) Colorectal CA (e) Cardiovascular disease
Advice on Hormone Replacement Therapy is changing continuously and it is often difficult for doctors (let alone patients and medical students !) to keep up to date with the current recommendations. The 2 major trials in recent years are the WHI (Women's Health Initiative), a randomised placebo-controlled trial in America, and the Million Women's Study (MWS), a large observational study carried out in the UK. Overall, the benefits of HRT include a reduction in menopausal symptoms and this is currently its main indication for use. Although it can reduce the risk of osteoporosis, this is second line treatment and should only be used after bisphosphonates, Selective Oestrogen Receptor Modulators etc. WHI also found that combined HRT (i.e. oestrogen & progesterone) also reduced the risk of colonic cancer. Various risks do exist however and these include breast cancer and venous thromboembolism. Although HRT was previously believed to offer cardioprotection, this was not found in these trials and it is felt that there is an increased risk of stroke and myocardial infarction in HRT users. Although HRT does increase the risk of dementia, a side arm of the trials showed a reduction in the incidence of Alzheimer's disease.

(20) Continuous combined HRT (e.g. Kliovance, Premique low dose):
T F	True False False True False	(a) is period free (b) contains progesterone alone (c) can be prescribed at any age (d) can be prescribed as tablets or patches (e) in tablet form is taken for 21 days followed by a 7 day break
Continuous combined HRT preparations contain oestrogen and progestogen throughout the whole cycle and are taken in 28 day packets with no break. Although they are described as period free, some patients may experience spotting, certainly during the initial months of use. They are licensed for women over the age of 54 and those who have been definitely menopausal for 12 months i.e. not those who are perimenopausal.

(21) Which of the following statements are true:
T F	False False	(a) Menopause can be diagnosed with a single oestradiol blood test (b) Following a hysterectomy, oestrogen should be withheld from the HRT preparations given to a patient
Oestradiol levels can vary considerably after the menopause and the best indicator of the menopause on a biochemical test is the FSH level (menopausal >30 iu). Oestrogen-only therapy is associated with an increased risk of endometrial hyperplasia and cancer. It should therefore only be prescribed to patients who have had a hysterectomy. Sequential HRT (oestrogen throughout with progesterone therapy towards the end of the month) can also increase the risk of endometrial cancer if it is used long term (i.e. 5 years or more) and patients who wish to stay on HRT long term are often advised to switch over to the continuous combined regimes (SEE ABOVE) which appear to offer no increased risk.

Pregnancy:

(22) Which of the following statements are true:
T F	True False False False False	(a) Pre-Eclampsia is more common in nulliparous than multiparous women (b) The commonest lie for a baby in a mother is occipito-anterior (c) Morphine offers the best pain relief in labour (d) The umbilical cord normally consists of 2 veins and 1 artery (e) Ventouse deliveries should only be carried out in theatre
The following definitions are useful: lie - longitudinal axis of baby in relation to longitudinal axis of mother e.g. longitudinal, oblique, transverse presentation - part of the fetus which is in or over the pelvic brim in relation to the cervix eg. cephalic, breech position - the relationship that some selected part (the denominator) of the fetus bears to the maternal pelvis e.g. occipitoanterior, occipitoposterior Thus the commonest lie of a baby is longitudinal, the commonest presentation is cephalic and the commonest position is occipito-anterior. An epidural gives the best pain relief during labour, but pethidine may be used and is less invasive. A normal umbilical cord consists of 1 vein (going into the baby from the placenta) and 2 arteries coming out. Ventouse deliveries can be carried out in the delivery room, but if there have been complications during the labour (e.g. prolonged labour, OP position etc) and the delivery may end in a caesarean, then the acoucher may decide it is safer to do a "trial of instrumental in theatre +/- caesarean section" rather than having a failed instrumental in the room.

(23) In the Confidential Enquiries into maternal and Child Health 2000-2002:
T F	False True False	(a) The commonest "direct" cause of maternal death was Pre-eclampsia (b) Overall commonest cause of maternal death was psychiatric (c) Care was deemed substandard in less than 10% of cases
The confidential enquires into maternal and child health (CEMACH) is a triennial report looking at the number of deaths related to pregnancy in the UK within the last 3 years. In the 2004 report (CEMACH 2000-02), although suicide and psychiatric problems have featured heavily in the "indirect" causes of death, the commonest "direct" cause of death is thrombosis and venous thromboembolism (VTE) (30 cases). This was followed by haemorrhage (17), early pregnancy deaths (15 including 11 ectopics) , pre-eclampsia/hypertension (14) and genital tract sepsis (11). Although VTE has led this table for a number of years, it is the first time for a few reports where PET and hypertension have not been ranked 2nd. Although the condition is called pre-eclampsia - only 6 of these 14 patients fitted i.e. eclampsia and 9 of the deaths were caused by intracranial bleeding. This highlights the fact that systolic hypertension is just as important as the diastolic blood pressure in these patients. When the committee reviewed the notes of the maternal deaths, they felt that substandard care was apparent in over 50% of cases and improvements may have resulted in a reduced number of deaths.

(24) During labour:
T F	False False False False	(a) Syntometrine should be given as soon as the babies head is crowning (b) Fundal pressure can assist in shoulder dystocia (c) Late decelerations are due to head compression in the 2nd stage of labour (d) A Neville Barnes forceps delivery can be done safely on a baby in OT position
Syntometrine (syntocinon & ergometrin) should only be given in an active 3rd stage after the baby's shoulders are delivered. If it is given before this and shoulder dystocia occurs, it will be very difficult to treat. When shoulder dystocia does occur and the babies anterior shoulder becomes impacted behind the pubis symphysis, fundal pressure will impact the baby's shoulder even more. Thus following - calling for help, McRoberts manouveur (flexing the patients hips to increase the pelvic capacity) and an episiotomy to increase the operators access, suprapubic pressure should be applied in a rocking CPR grip, to try to dislodge the babies shoulder. Lateral traction must be avoided as this can result in Erb's/Klumpe's palsy (and a law suit !). Early decelerations (peak at the same time as the contraction) are due to head compression and are a normal finding during labour, but late decelerations, where the deceleration occurs after the contraction can be a sign of fetal hypoxia and fetal distress. Other worrying features include reduced variability (<5> A Simpson's or Neville Barnes Forceps should only be used intentionally for a baby in Occipito Anterior position. This is the smallest diameter to come through the mother's cervix - suboccipito bregmatic diameter - 9.5 cm on the baby coming through a 10 cm hole. If the baby is in OT or OP position - occipito frontal diameter - 11cm (i.e. doesn't come through 10 cm hole easily), then ideally they should be rotated around prior to a vaginal delivery. This may be done manually, with a ventouse cup or with the Kiellands forceps (in the hands of an experienced operator only !). If forceps are applied unintentionally on a baby in OT position then it can result in fetal trauma and blade marks across the baby's face.

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Answers are:

1	The main tissues which provide support to the uterus include: (a) uterosacral ligaments - True (b) perineal body - False (c) round ligament - False (d) cardinal ligaments - True (e) broad ligaments - False The uterosacral and transverse cervical (cardinal) ligaments provide the main support for the uterus and although the other structures (round & broad) are named ligaments, they offer no support.
2	Which of the following statements are TRUE: (a) Bartholins gland are found in the para-urethral area - False (b) The ampulla is the commonest site for ectopic pregnancies - True (c) The ureter enters the bladder ABOVE the uterine / cervical artery - False (d) After the menopause the ratio of uterus : cervix is 1 : 1 - True (e) FSH is raised above 30 iu after the menopause - True The Bartholin's glands are situated on either side of the vaginal orifice deep to the posterior ends of the labia minora (ie not anteriorly). The ampulla is the widest and longest portion of the fallopian tube and is the commonest site for ectopic pregnancy implantation. If implantation occurs within the isthmus of the tube, this is the commonest site for rupture of the ectopic. The uterine/cervical artery enters the uterus at the level of the internal os just above the ureter (like a bridge over troubled water). This important anatomical feature highlights the need to stay as close to the uterus as possible when clamping the artery to avoid damaging the ureter during hysterectomy operations (1% risk). In the child, the cervix forms almost 2/3 of the total length of the corpus uterus. In the adult these proportions are reversed (i.e. 1:2) and in old age the uterus shrinks such that the ratio is approximately 1:1. After the menopause, although the oestradiol level may drop, this is not a consistent finding and should not be used to make the diagnosis. A FSH (Follicle Stimulating Hormone) level > 30 iu is however diagnostic.
3	The combined oral contraceptive pill: (a) is taken continuously for 28 days - False (b) has a pearl index of 10 - False (c) can be used as a form of post-coital contraception - False (d) if a pill is forgotten (>12hrs), other contraception must be used for 7 days - True (e) can be used to reduce menorrhagia & dysmenorrhoea effectively - True The combined oral contraceptive pill contains oestrogen and progesterone and is taken on a cyclical basis for 21 days out of 28 days each month. It can be used as first line treatment for patients with heavy (menorrhagia) or painful (dysmenorrhoea) periods, as long as there are no contraindications or at risk groups (eg smokers over 35). The Pearl index (number of pregnancies which occur in 100 women during a year of using a method of contraception) is a marker of the effectiveness of the method used. The combined pill has a pearl index of approximately 1 (cf. condoms 2-15, progesterone only pill 2-3). If a pill is missed by more than 12 hrs the patient is unprotected for 7 days and should use other contraceptive methods during this time. Even if the "missed pill" is towards the end of the packet (i.e. less than 7 days), other precautions should be used and the patient instructed to continue directly onto the next packet without a break. Although in the past, a whole packet of progesterone only pills could be taken as a form of post-coital contraception, this is no longer required and the main method used is levonelle one-step. This can be used up to 72 hours post-coitus (i.e. NOT just the morning after) and has success rates approaching 95%.
4	The progesterone only pill (POP): (a) must be taken at the same time (within 3hrs) each day - True (b) if a pill is missed e.g. taken 15 hrs late, other contraception needs to be used for only 5 days - False (c) this pill is preferred to the combined oral contraceptive pill for use in smokers - True (d) can be used as a form of post-coital contraception - True (e) main contraceptive method is by stopping ovulation - False The progesterone only pill (pop) must be taken at the same time every day, with a 3 hour window period and no breaks in the packets. Their main method of action is by thickening the cervical mucus, although ovulation is blocked in about 40% of cases. Theoretically the lack of cervical mucus occurs for only about 48 hrs after missing the pop, but the manufactures advise to use other precautions for 7 days after missing (i.e. 3 hrs late) a pill. Cerazette (Organon) is one of the newer types of pop, classified as an "oestrogen-free pill". Its manufacturers claim that it is 99% effective and works first line by blocking ovulation (and second line by thickening cervical mucus). Rather than having a 3 hr window period, Cerazette can be missed for up to 12 hours before other contraceptive precautions are required. In the past, a whole packet of progesterone only pills could be taken as a form of post-coital contraception. This is no longer required and the main method used is Levonelle one-step (Schering Health). This contains 1.5 mg levenogestrel and can be used up to 72 hours post-coitus (i.e. NOT just the morning after), and has success rates approaching 95%.
5	The intra-uterine contraceptive device (IUCD): (a) increases your risk of ectopic pregnancy cf. general population - False (b) cannot be used for post-coital contaraception after 72 hrs - False (c) should be changed every 3 yrs - False (d) if lost, and an USS confirms it is not visible inside the uterus, the patient can be reassured and discharged - False (e) should never be used in women who have never been pregnant - False It a common misunderstanding that the IUCD increases the risk of an ectopic pregnancy. Overall the Pearl index for the copper IUCD is between 4 (Nova T) and 1.5 (CuT380) with the Mirena IUCD approaching 0.1. This means that overall having a coil in place will markedly reduce the chances of a patient getting pregnant compared with those not using any contraception (about 80-90% over 1 year trying). Similarly the figure for the pregnancy being ectopic will be even lower. If a patient does get pregnant with a IUCD in place then it will most likely be intrauterine, although 30% may be ectopic (cf. 1% of pregnancies in general being ectopic). It can be used as a method of post-coital contraception up to 5 days after unprotected intercourse and has success rates approaching 95%. Most are changed every 5 years (some are licensed for 8-10 yrs e.g. T-Safe CU 380 A (FP) etc. ) and although it is not always easy, or advisable to insert IUCD's into nulliparous women, never use the term never (or always !) in medicine, especially in MCQ's. If a patient presents with a missing IUCD and the ultrasound fails to reveal its position within the uterus, an abdominal X-ray is required to exclude that the uterus has been perforated and the IUCD misplaced before the patient can be reassured and discharged.
6	A female sterilization: (a) has a lower failure rate than a vasectomy - False (b) can never be reversed - False (c) has better success rate than a Mirena IUCD (Schering Health) - False (d) can only be carried out on multiparous women - False (e) can be done at any point during the patients cycle - True The failure rate in a vasectomy is 1:2000 compared with the failure rate in a sterilization being 1:200 (NB cf. Mirena IUCD 1:1000). A failed sterilization is one of the commonest medico-legal cases in gynaecology and counselling the patient is as important as the procedure itself. It can be carried out at any time during a patient's cycle, but a patient must be warned of risks of a "luteal" phase pregnancy i.e. if they are mid-cycle, then there is a risk of the patient still becoming pregnant if the oocyte has already passed the portion of the fallopian tube being occluded. It is therefore important that ALL patients do have a pregnancy test before the procedure and are advised to continue with their current contraception till their next period. Although the operation can be carried out on nulliparous women, they must be 110% sure, and the operator must be happy that there are no psychological implications in the case and must not be pressurised into carrying out a procedure if they do not agree. If there is any doubt, a second opinion should be sought. Although it should be explained as a permanent procedure, it can be reversed (NOT on the NHS) and success rates range between 20-70% depending on who's doing it, how the initial procedure was done, how long ago it was and how old the patient is etc. With the advent of assisted reproduction (i.e. in vitro fertilisation), reversals are rarely sought.
7	The following are useful investigations in the management of a subfertile couple: (a) Hysterosalpingogram - True (b) Rhesus blood group status of both partners - False (c) Day 25 progesterone level in the female with 28 day cycles - False (d) Chlamydia investigation of the male partner - False (e) Rubella status of the female - True The main causes for subfertility include: anatomical (eg tubal blockage), ovulation problems, male factors, idiopathic and other factors (eg endometriosis). A hysterosalpingogram (HSG) is a useful test to be done to check tubal patency. This can be done in the out-patient department but the patient is exposed to X-rays. A HyCoSe test is a similar test but is done in the OPD under ultrasound control and therefore avoids exposure to radiation. A Laparoscopy & Dye test is an alternative for tubal assessment and allows a full view of the pelvis to exclude conditions such as endometriosis, pelvic inflammatory disease etc. but the patient does have to go through a general anaesthetic and the risks of key-hole surgery (e.g. bowel, bladder, blood vessel damage).
8	On assessment of Semen Fluid Analysis: (a) Azoospermia indicates a sperm count more than 5 million/ml - False (b) Asthenozoospermia indicates abnormal motility (>60%) - True (c) Teratozoospermia indicates abnormal forms (>30%) - True (d) Only needs to be assessed if no female subfertility factors have been found - False (e) Abstinence should be maintained for 3 days prior to "production" of the sample - True Subfertility may be primary, when the patient has never been pregnant, or secondary when the patient has had a previous pregnancy (this may have ended in a miscarriage, but the patient has conceived). Even if female factors have been found as a cause (e.g. ovulation problems, anatomical), the male partner must always be tested i.e.semen fluid analysis. The sample is analysed for the correct number, forms and motility of the sperms in addition to anti-sperm antibodies. A normal sperm count should be >20 million per ml. Oligospermia indicates a sperm count concentration less than this and azoospermia indicates a sperm count of 0. The patients are advised to abstain from sex for 3 days prior to the sample production and bring "it" in warm, although not too warm. (I once received a specimen report which read "lots of sperm, but they are all dead as the patient brought the sample in with a hot water bottle !!)
9	An ectopic pregnancy: (a) Occurs in about 1:100 spontaneous conceptions - True (b) Can only be treated surgically - False (c) May be suspected in the absence of symptoms when the uterus appears "empty" on a TV scan and a beta-HCG level is 2000 IU - True (d) Gives an increased risk of Hyperemisis Gravidarium - False (e) Pain always presents before the bleeding - False A fertilised egg normally implants in the decidua of the uterus. Occasionally it can implant in another site and this is described as an ectopic pregnancy. Almost all cases occur in the fallopian tube and the ampulla is the most dilated portion and as a result the commonest site. Although some textbooks claim that pain presents before bleeding, this does not ALWAYS happen and the full case scenario and investigations need to be assessed as a whole. The vaginal bleeding may appear more minimal than occurs in a miscarriage, but the patients can be shocked with tachycardia, hypotension and blood in the abdomen. In the last confidential enquiry into maternal mortality (CEMACH, 2002), ectopic pregnancy still remains a major cause with 11 deaths and substandard care in a majority of them. They can be treated surgically, either laparoscopically or via a laparotomy), but this depends on the clinical findings and the skill of the operator. The tube may be cut: salpingectomy - removing the portion of the tube or salpingostomy - opening up the portion of the tube to remove the ectopic. As long as the other tube looks healthy, the recommended treatment is a laparoscopic salpingectomy. They can also be treated medically with methotrexate, or conservatively (i.e. sit and watch) in some extreme cases with a brave (?stupid) gynaecologist. Although no beta-HCG level is diagnostic of an ectopic, the suspicion may be raised in cases where a beta-HCG level is greater than 1500 IU and no intrauterine pregnancy is visible on a transvaginal scan. Alternatively, where the beta-HCG level doesn't double within 48 hours as it should in the case of an intra-uterine pregnancy. Although the ectopics themselves are rarely visible on ultrasound, "worring features" may include - "...nil in uterus and free fluid in pouch of douglas (i.e. blood)".
10	In the presence of a positive pregnancy test and vaginal bleeding, the following are possible differential diagnoses if the CERVIX is closed: (a) ectopic pregnancy - True (b) incomplete miscarriage - False (c) threatened miscarriage - True (d) inevitable miscarriage - False (e) complete miscarriage - True Although ultrasound machines are used commonly to determine the viability and site of a pregnancy, these terms are based on the clinical findings when examining a patient during early pregnancy. If the cervix is CLOSED and the patient has been bleeding, then she may be having a threatened miscarriage (i.e. pregnancy still on going) or she may have had a complete miscarriage. In an ectopic pregnancy scenario, the cervix will be closed and she may have marked cervical excitation (extreme discomfort on being examined). If the cervix is PATULOUS (OPEN) then a diagnosis of an incomplete miscarriage (i.e. products still inside the uterine cavity) or inevitable (although the pregnancy may still be within the uterus, it will inevitably come out). Twin pregnancies can sometimes make these clinical diagnoses more difficult and cases have occurred where one twin has been lost, the cervix has been open and then closes down spontaneously such that the other pregnancy remains on-going.
11	Which of the following statements with regards to endometrial, ovarian and cervical cancer are TRUE: (a) Ovarian cancer has the worst prognosis - True (b) Cervical cancer is best treated with chemotherapy - False (c) The number of cases of endometrial cancer has been reduced by good screening techniques - False (d) Ovarian dermoid cysts are often malignant - False (e) Cervical cancer is most commonly squamous - True The overall prognosis from cases of ovarian cancer over 5 years is 30%. This compares to 55% for cervical cancer and 65% for endometrial cancer. Endometrial cancer has the best prognosis because patients often present with "post-menopausal bleeding" and seek advice from their GP at an early stage. Similarly the cervical screening regime in the UK picks up cases of cervical cancer at a pre-malignant stage and recognises those patients who will be at risk of cervical cancer. Unfortunately no accurate screening test exists for ovarian cancer and patients often present at a late stage (i.e. stage III-IV) which is difficult to treat. Cervical cancer and endometrial cancer are treated with surgery and or radiotherapy, dependent on the stage of the disease etc, and ovarian cancer is treated with surgery and or chemotherapy (e.g. taxol, cisplatin). Dermoid cysts of the ovary account for approximately 25% of ovarian neoplasms and are made from the primary germ layers: endoderm, ectoderm and mesoderm. As a result they can consist of hair, teeth, cartilage etc and only about 1% have a malignant potential.
12	In Cervical cancer: (a) Human papilloma virus types 16, 18, 31,33 and 35 are associated with cervical cancer - True (b) Cervical cancer affects about 1000 women in the UK each year - False (c) Stage for stage, cervical cancer has a worse prognosis than endometrial cancer - False (d) all patients with Borderline nuclear abnormalities on their cervical smears should be referred directly for colposcopy - False (e) at colposcopy, citric acid allows clear demarcation of abnormal areas - False Cervical cancer is most commonly squamous although glandular lesions are found in the older age group (40 yrs) and about 2800 cases happen in the UK each year (2002). The prognosis has improved over recent years because of the cervical screening picking up cases at a pre-malignant stage and the overall death rate is 1100 deaths in 2002 (cf. 1500 in 1993). Although the prognosis for cervical cancer is the same, stage for stage compared with endometrial cancer, because there are more cases of endometrial cancer which present at an earlier stage the overall prognosis for endometrial cancer is better (65% cf. 55% for cervical). Orange juice (citric acid) will be of no benefit in the colposcopy clinic! 5% acetic acid (dilute vinegar) is used and this shows up the abnormal cells with acetowhite changes. The abnormal cells have a high nuclear to cytoplasmic ratio, and thus contain a lot of protein. It is this protein which gives the acetowhite changes.
13	In Endometrial cancer: (a) It often presents with postmenopausal bleeding - True (b) Women taking oestrogen only HRT are at increased risk - True (c) May be screened for using CA125 and TV scanning - False (d) commonly develops from leiomyomas - False (e) Polycystic ovarian disease is a recognised risk factor - True Endometrial cancer often presents at an early stage, as soon as the cancer has invaded the endometrium (stage Ia). The peak incidence is at 61 yrs and over 75% occur in the postmenopausal age group. If women require HRT and they have a uterus in place then they must be given progesterone therapy as well as oestrogen. If they are on short term therapy, they can have a cyclical HRT (bleed every 21 days), but if they want to use it long term i.e. more than 1-2 yrs, and they are aware of the risks, e.g. breast cancer, DVT's etc, then they should be prescribed continuous combined preparations (e.g. kliovance) as long as no other contraindications exist. Those patients on continuous combined preparations have a lower risk of endometrial cancer compared with those on cyclical HRT. There is no screening test for endometrial cancer and although CA125 and ultrasound scans can help to detect ovarian cancer, they are of no use as screening tools for this condition at present. Leiomyomas (fibroids) are often benign and less than 0.2% will become malignant leiomyosarcomas. Most leiomyosarcomas arise de novo, are rapid growing and have a bad prognosis. Patients with polycystic ovaries are at higher risk of endometrial cancer and diabetes later on in life.
14	In Ovarian cancer: (a) The commonest types of tumour arise from the "germ cell lines" - False (b) Often present in the premenopausal age group - False (c) The risk of developing ovarian cancer can be increased to 40% if > 2 first degree relatives have been affected - True (d) It is commonly treated with radiotherapy - False (e) It often presents at an early stage due to abdominal ascites - False Over 70% of ovarian neoplasms develop from epithelial cell tumours (e.g. mucinous cystadenomas (commonest benign) or serous papilliferous (commonest malignant)). The remainder are germ cell tumours (e.g. dermoid cysts) or sex cord/gonadal stromal tumours (e.g. granulosa cell tumours). Most present in the post menopausal age group although the germ cell tumours may be seen in younger patients. The overall risk of ovarian cancer in women between 50-70 is 1:70. This increases to 5% in women who have 1 first degree relative with the disease, and 40% in women with 2 relatives. Although ascites can be recorded at any stage during the disease (e.g. Ic, IIc etc) this is often a late feature and patients commonly present with stage III or IV disease. If at all possible, debulking surgery is carried out and this may be followed by chemotherapy.
15	In patients with vaginal discharge: (a) Bacterial vaginosis is the commonest sexually transmitted infection in women - False (b) Trichomonas infections are treated with amoxycillin - False (c) Candidiais is not a sexually transmitted infection - True (d) Chlamydia can be tested for using a high vaginal swab - False (e) Gonorrhoea "crosses" the placenta - False Bacterial vaginosis and thrush are not sexually transmitted infections. Trichomonas Vaginalis is a sexually transmitted infection and can be treated with metronidazole. As with all STD's it is important that contact tracing is carried out and the patients are encouraged to notify their partners. If this does not occur then the infections can return causing further pelvic pain and may result in subfertility later on due to tubular blockage. Chlamydia is the commonest sexually transmitted infection, and can affect 10% of the female population aged 20-25 yrs old. It grows in endocervical cells and can be tested on urine samples or endo cervical swabs, but not high vaginal swabs. It is treated with doxycycline (e.g.100mg bd 10 days) or azithromycin as a single dose (1g stat). Again, contact tracing is important. Gonorrhoea and chlamydia do not cross the placenta, but can result in neonatal conjunctivitis if the mother has it active at the time of vaginal delivery. This should be treated with antibiotics and is not a valid indication for a caesarean section.
16	In mothers carrying multiple pregnancies: (a) The incidence of twins is approximately 1 : 802 - False (b) Monochorionic twins are at higher risk of complications than dichorionic twins - True (c) IVF has dramatically increased the incidence of monochorionic twins - False (d) Twin-Twin transfusion only affects dichorionic twins - False (e) Identical twins are more common in those with a family history - False (f) The incidence of hyperemisis gravidarium is increased - True The incidence of multiple pregnancies has been increasing since the advent of assisted reproduction, but this involves dizygotic twins. In spontaneous conceptions the incidence has remained fairly stable. 1:80 pregnancies are twins, 1:802 (i.e.1:6400) are triplets and 1:803 (i.e.1:512000) are quadruplets. 70% of twins are dizygotic and all have 2 placentas (dichorionic) and 2 separate sacs (diamniotic). These result in non-identical twins and are the lowest risk type. Various risk factors for non-identical twins exist including race, increasing age, parity, family history and assisted conception techniques (e.g. clomiphene). Monozygotic twins only account for 30% of the twin population and result in identical twins. The number of placentas and sacs depends on the timing of cell division, but monochorionic twins are at risk of twin-twin transfusion. One twin can become hydropic (excess blood supply and oedema) and the other twin can become growth restricted. Similar to molar pregnancies, multiple pregnancies have excessively high levels of beta-HCG and this results in hyperemisis gravidarium - excess vomiting in early pregnancy.
17	With regards to urinary incontinence: (a) Genuine Stress Incontinence can be diagnosed on history alone - False (b) Detrusor instability can be treated with anticholinergic medication - True (c) Tension free vaginal tape (TVT) is an ideal treatment for detrusor instability - False (d) Urodynamics is only required if surgery fails - False (e) A TVT can only be done under general anaesthetic - False Although a diagnosis of stress incontinence may be suggested by a history (ie. leakage of urine on coughing/laughing etc), the true diagnosis of Genuine Stress Incontinence (GSI) can only be made following urodynamics. This is a pre-requistite test required before embarking on any uro-gynaecology surgery. Tension free Vaginal Tape (TVT) is an improved procedure for GSI compared with the old Burch colposuspension. It can be done under local or spinal anaesthetic, and rather than the patients requiring an open abdominal wound the procedure can be done through small incisions, and the patients can often go home later on the same day or following day.
18	Which of the following statements are TRUE: (a) A ring pessary should be changed every 4-6 months - True (b) Reduction in fluid intake is the ideal treatment for nocturia - False (c) A rectocele can be repaired by an anterior colporophy - False For symptoms of prolapse, a ring pessary or shelf pessary may offer a conservative approach compared to surgery. They do however have to be changed in the out patient setting every 4-6 months as otherwise they can become embedded within the vaginal tissues and require removal under general anaesthetic. Although coffee and tea may be cut down in patients with urge incontinence, overall reduction in fluid intake can sometimes be dangerous, and have a detrimental effect on the patient's renal function. The normal fluid intake should be about 1.5 L/day. This can be assessed carefully using a diary. An anterior colporophy (anterior pelvic floor repair) is the surgical management for a cystocele and a posterior colporophy is the treatment for a rectocele.
19	HRT offers protection against: (a) breast CA - False (b) osteoporosis - True (c) Alzheimer's - True (d) Colorectal CA - True (e) Cardiovascular disease - False Advice on Hormone Replacement Therapy is changing continuously and it is often difficult for doctors (let alone patients and medical students !) to keep up to date with the current recommendations. The 2 major trials in recent years are the WHI (Women's Health Initiative), a randomised placebo-controlled trial in America, and the Million Women's Study (MWS), a large observational study carried out in the UK. Overall, the benefits of HRT include a reduction in menopausal symptoms and this is currently its main indication for use. Although it can reduce the risk of osteoporosis, this is second line treatment and should only be used after bisphosphonates, Selective Oestrogen Receptor Modulators etc. WHI also found that combined HRT (i.e. oestrogen & progesterone) also reduced the risk of colonic cancer. Various risks do exist however and these include breast cancer and venous thromboembolism. Although HRT was previously believed to offer cardioprotection, this was not found in these trials and it is felt that there is an increased risk of stroke and myocardial infarction in HRT users. Although HRT does increase the risk of dementia, a side arm of the trials showed a reduction in the incidence of Alzheimer's disease.
20	Continuous combined HRT (e.g. Kliovance, Premique low dose): (a) is period free - True (b) contains progesterone alone - False (c) can be prescribed at any age - False (d) can be prescribed as tablets or patches - True (e) in tablet form is taken for 21 days followed by a 7 day break - False Continuous combined HRT preparations contain oestrogen and progestogen throughout the whole cycle and are taken in 28 day packets with no break. Although they are described as period free, some patients may experience spotting, certainly during the initial months of use. They are licensed for women over the age of 54 and those who have been definitely menopausal for 12 months i.e. not those who are perimenopausal.
21	Which of the following statements are true: (a) Menopause can be diagnosed with a single oestradiol blood test - False (b) Following a hysterectomy, oestrogen should be withheld from the HRT preparations given to a patient - False Oestradiol levels can vary considerably after the menopause and the best indicator of the menopause on a biochemical test is the FSH level (menopausal >30 iu). Oestrogen-only therapy is associated with an increased risk of endometrial hyperplasia and cancer. It should therefore only be prescribed to patients who have had a hysterectomy. Sequential HRT (oestrogen throughout with progesterone therapy towards the end of the month) can also increase the risk of endometrial cancer if it is used long term (i.e. 5 years or more) and patients who wish to stay on HRT long term are often advised to switch over to the continuous combined regimes (SEE ABOVE) which appear to offer no increased risk.
22	Which of the following statements are true: (a) Pre-Eclampsia is more common in nulliparous than multiparous women - True (b) The commonest lie for a baby in a mother is occipito-anterior - False (c) Morphine offers the best pain relief in labour - False (d) The umbilical cord normally consists of 2 veins and 1 artery - False (e) Ventouse deliveries should only be carried out in theatre - False The following definitions are useful: lie - longitudinal axis of baby in relation to longitudinal axis of mother e.g. longitudinal, oblique, transverse presentation - part of the fetus which is in or over the pelvic brim in relation to the cervix eg. cephalic, breech position - the relationship that some selected part (the denominator) of the fetus bears to the maternal pelvis e.g. occipitoanterior, occipitoposterior Thus the commonest lie of a baby is longitudinal, the commonest presentation is cephalic and the commonest position is occipito-anterior. An epidural gives the best pain relief during labour, but pethidine may be used and is less invasive. A normal umbilical cord consists of 1 vein (going into the baby from the placenta) and 2 arteries coming out. Ventouse deliveries can be carried out in the delivery room, but if there have been complications during the labour (e.g. prolonged labour, OP position etc) and the delivery may end in a caesarean, then the acoucher may decide it is safer to do a "trial of instrumental in theatre +/- caesarean section" rather than having a failed instrumental in the room.
23	In the Confidential Enquiries into maternal and Child Health 2000-2002: (a) The commonest "direct" cause of maternal death was Pre-eclampsia - False (b) Overall commonest cause of maternal death was psychiatric - True (c) Care was deemed substandard in less than 10% of cases - False The confidential enquires into maternal and child health (CEMACH) is a triennial report looking at the number of deaths related to pregnancy in the UK within the last 3 years. In the 2004 report (CEMACH 2000-02), although suicide and psychiatric problems have featured heavily in the "indirect" causes of death, the commonest "direct" cause of death is thrombosis and venous thromboembolism (VTE) (30 cases). This was followed by haemorrhage (17), early pregnancy deaths (15 including 11 ectopics) , pre-eclampsia/hypertension (14) and genital tract sepsis (11). Although VTE has led this table for a number of years, it is the first time for a few reports where PET and hypertension have not been ranked 2nd. Although the condition is called pre-eclampsia - only 6 of these 14 patients fitted i.e. eclampsia and 9 of the deaths were caused by intracranial bleeding. This highlights the fact that systolic hypertension is just as important as the diastolic blood pressure in these patients. When the committee reviewed the notes of the maternal deaths, they felt that substandard care was apparent in over 50% of cases and improvements may have resulted in a reduced number of deaths.
24	During labour: (a) Syntometrine should be given as soon as the babies head is crowning - False (b) Fundal pressure can assist in shoulder dystocia - False (c) Late decelerations are due to head compression in the 2nd stage of labour - False (d) A Neville Barnes forceps delivery can be done safely on a baby in OT position - False Syntometrine (syntocinon & ergometrin) should only be given in an active 3rd stage after the baby's shoulders are delivered. If it is given before this and shoulder dystocia occurs, it will be very difficult to treat. When shoulder dystocia does occur and the babies anterior shoulder becomes impacted behind the pubis symphysis, fundal pressure will impact the baby's shoulder even more. Thus following - calling for help, McRoberts manouveur (flexing the patients hips to increase the pelvic capacity) and an episiotomy to increase the operators access, suprapubic pressure should be applied in a rocking CPR grip, to try to dislodge the babies shoulder. Lateral traction must be avoided as this can result in Erb's/Klumpe's palsy (and a law suit !). Early decelerations (peak at the same time as the contraction) are due to head compression and are a normal finding during labour, but late decelerations, where the deceleration occurs after the contraction can be a sign of fetal hypoxia and fetal distress. Other worrying features include reduced variability (<5> A Simpson's or Neville Barnes Forceps should only be used intentionally for a baby in Occipito Anterior position. This is the smallest diameter to come through the mother's cervix - suboccipito bregmatic diameter - 9.5 cm on the baby coming through a 10 cm hole. If the baby is in OT or OP position - occipito frontal diameter - 11cm (i.e. doesn't come through 10 cm hole easily), then ideally they should be rotated around prior to a vaginal delivery. This may be done manually, with a ventouse cup or with the Kiellands forceps (in the hands of an experienced operator only !). If forceps are applied unintentionally on a baby in OT position then it can result in fetal trauma and blade marks across the baby's face.