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  • Question 1 - At what stage of the menstrual cycle do levels of progesterone reach their...

    Incorrect

    • At what stage of the menstrual cycle do levels of progesterone reach their highest point?

      Your Answer: Levels remain constant throughout cycle

      Correct Answer: Luteal phase

      Explanation:

      A fundamental comprehension of physiology is necessary to comprehend contraception, gynaecological disorders, and fertility issues, as progesterone is produced by the corpus luteum after ovulation, despite the AKT having limited inquiries about it.

      Phases of the Menstrual Cycle

      The menstrual cycle is a complex process that can be divided into four phases: menstruation, follicular phase, ovulation, and luteal phase. During the follicular phase, a number of follicles develop in the ovaries, with one follicle becoming dominant around the mid-follicular phase. At the same time, the endometrium undergoes proliferation. This phase is characterized by a rise in follicle-stimulating hormone (FSH), which results in the development of follicles that secrete oestradiol. When the egg has matured, it secretes enough oestradiol to trigger the acute release of luteinizing hormone (LH), which leads to ovulation.

      During the luteal phase, the corpus luteum secretes progesterone, which causes the endometrium to change to a secretory lining. If fertilization doesn’t occur, the corpus luteum will degenerate, and progesterone levels will fall. Oestradiol levels also rise again during the luteal phase. Cervical mucous thickens and forms a plug across the external os following menstruation. Just prior to ovulation, the mucous becomes clear, acellular, low viscosity, and stretchy. Under the influence of progesterone, it becomes thick, scant, and tacky. Basal body temperature falls prior to ovulation due to the influence of oestradiol and rises following ovulation in response to higher progesterone levels. Understanding the phases of the menstrual cycle is important for women’s health and fertility.

    • This question is part of the following fields:

      • Maternity And Reproductive Health
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  • Question 2 - A 35-year-old woman with a history of type 2 diabetes mellitus and obesity...

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    • A 35-year-old woman with a history of type 2 diabetes mellitus and obesity comes in for a visit after experiencing a late period. Upon taking a urinary hCG test, it comes back positive. She is currently taking the following medications:

      - Orlistat 120mg three times a day
      - Simvastatin 40 mg once a day
      - Aspirin 75 mg once a day
      - Metformin 1g twice a day
      - Paracetamol 1g four times a day
      - Aqueous cream as needed

      Which medication should be discontinued immediately?

      Your Answer: Metformin

      Correct Answer: Simvastatin

      Explanation:

      Prescribing Considerations for Pregnant Patients

      When it comes to prescribing medication for pregnant patients, it is important to exercise caution as very few drugs are known to be completely safe during pregnancy. Some countries have developed a grading system to help guide healthcare professionals in their decision-making process. It is important to note that the following drugs are known to be harmful and should be avoided: tetracyclines, aminoglycosides, sulphonamides and trimethoprim, quinolones, ACE inhibitors, angiotensin II receptor antagonists, statins, warfarin, sulfonylureas, retinoids (including topical), and cytotoxic agents.

      In addition, the majority of antiepileptics, including valproate, carbamazepine, and phenytoin, are potentially harmful. However, the decision to stop such treatments can be difficult as uncontrolled epilepsy poses its own risks. It is important for healthcare professionals to carefully weigh the potential risks and benefits of any medication before prescribing it to a pregnant patient.

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      • Maternity And Reproductive Health
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  • Question 3 - Linda is a 35-year-old woman who is 19 weeks pregnant. She presents to...

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    • Linda is a 35-year-old woman who is 19 weeks pregnant. She presents to the emergency department with a 2 day history of sharp abdominal pain. There is no vaginal bleeding. She also has a low grade fever of 37.8 ºC. Her pregnancy until now has been unremarkable.

      On examination, she is haemodynamically stable, but there is tenderness on palpation of the right lower quadrant of her abdomen. Fetal heart rate was normal. An ultrasound scan was performed which showed a singleton pregnancy, and multiple large fibroids in the uterus. The ovaries appear normal and there was no appendix inflammation.

      What is the most likely cause of Linda's symptoms?

      Your Answer: Appendicitis

      Correct Answer: Fibroid degeneration

      Explanation:

      During pregnancy, fibroid degeneration can occur and may cause symptoms such as low-grade fever, pain, and vomiting. If an ultrasound scan shows no signs of inflammation in the appendix, it is unlikely that the patient has appendicitis. Given the presence of fibroids in the uterus, the patient is at risk of experiencing fibroid degeneration, particularly red degeneration, which can cause fever, pain, and vomiting. The absence of vaginal bleeding makes it unlikely that the patient is experiencing a threatened miscarriage. Ovarian torsion typically presents with pain and vomiting, but it is usually associated with risk factors such as ovarian cysts or enlargement.

      Understanding Fibroid Degeneration

      Uterine fibroids are non-cancerous growths that can develop in the uterus. They are known to be sensitive to oestrogen and can grow during pregnancy. However, if the growth of the fibroids exceeds their blood supply, they can undergo a type of degeneration known as red or ‘carneous’ degeneration. This condition is characterized by symptoms such as low-grade fever, pain, and vomiting.

      Fortunately, fibroid degeneration can be managed conservatively with rest and analgesia. With proper care, the symptoms should resolve within 4-7 days. It is important to note that fibroid degeneration is a common occurrence and doesn’t necessarily indicate a serious underlying condition.

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  • Question 4 - A 25-year-old woman who is 16 weeks pregnant complains of a foul-smelling vaginal...

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    • A 25-year-old woman who is 16 weeks pregnant complains of a foul-smelling vaginal discharge. Apart from this, she has been in good health. Despite washing twice a day, the discharge has persisted and is causing her considerable embarrassment. Her partner is asymptomatic. What course of treatment would you suggest?

      Your Answer:

      Correct Answer: Metronidazole

      Explanation:

      Pregnant women with bacterial vaginosis can still use oral metronidazole as it has been found to be safe during pregnancy. Bacterial vaginosis can increase the risk of premature birth and miscarriage. There is no evidence of any harmful effects on the fetus during the first trimester of pregnancy. The guidelines suggest treating symptomatic patients at any stage of pregnancy. While both metronidazole and oral clindamycin can enter breast milk, breastfeeding women are advised to use clindamycin intravaginal gel.

      Bacterial vaginosis (BV) is a condition where there is an overgrowth of anaerobic organisms, particularly Gardnerella vaginalis, in the vagina. This leads to a decrease in the amount of lactobacilli, which produce lactic acid, resulting in an increase in vaginal pH. BV is not a sexually transmitted infection, but it is commonly seen in sexually active women. Symptoms include a fishy-smelling vaginal discharge, although some women may not experience any symptoms at all. Diagnosis is made using Amsel’s criteria, which includes the presence of thin, white discharge, clue cells on microscopy, a vaginal pH greater than 4.5, and a positive whiff test. Treatment involves oral metronidazole for 5-7 days, with a cure rate of 70-80%. However, relapse rates are high, with over 50% of women experiencing a recurrence within 3 months. Topical metronidazole or clindamycin may be used as alternatives.

      Bacterial vaginosis during pregnancy can increase the risk of preterm labor, low birth weight, chorioamnionitis, and late miscarriage. It was previously recommended to avoid oral metronidazole in the first trimester and use topical clindamycin instead. However, recent guidelines suggest that oral metronidazole can be used throughout pregnancy. The British National Formulary (BNF) still advises against using high-dose metronidazole regimens. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

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  • Question 5 - A 27-year-old lady calls for telephone advice. She is 20 days postpartum and...

    Incorrect

    • A 27-year-old lady calls for telephone advice. She is 20 days postpartum and had unprotected sexual intercourse 72 hours ago. She has no significant medical history and doesn't take any regular medication. She is bottle-feeding her baby. She is uncertain if there is a possibility of pregnancy and if emergency contraception is necessary.

      Which of the following would be the most suitable recommendation to provide in this situation?

      Your Answer:

      Correct Answer: Emergency contraception is advised and oral ulipristal acetate 30 mg is the only safe treatment option

      Explanation:

      Emergency Contraception Options After Childbirth

      Oral levonorgestrel 1.5 mg and ulipristal acetate 30 mg are safe to use 21 days after childbirth, while the copper intrauterine device can be used for emergency contraception from day 28 postpartum. Among the three options, the copper intrauterine device is the most effective, with a pregnancy rate of approximately 1 in 1000.

      It is important to note that the copper intrauterine device carries the same contraindications as when used for standard contraception. It can be retained until the next period then removed or kept in situ for ongoing long-term contraception. With these options available, women can make informed decisions about their reproductive health after childbirth.

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  • Question 6 - A 27-year-old Indian woman contacts her doctor for guidance. She is currently 12...

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    • A 27-year-old Indian woman contacts her doctor for guidance. She is currently 12 weeks pregnant and was in close proximity to her nephew who has been diagnosed with Chickenpox. The patient spent a few hours with her nephew and had physical contact such as hugging. The patient reports feeling fine and has no noticeable symptoms. She is unsure if she has had Chickenpox before.

      What is the best course of action in this scenario?

      Your Answer:

      Correct Answer: Check antibody levels

      Explanation:

      When a pregnant woman is exposed to Chickenpox, it can lead to serious complications for both her and the developing fetus. To prevent this, the first step is to check the woman’s immune status by testing for varicella antibodies. If she is found to be non-immune, she should receive varicella-zoster immune globulin (VZIG) as soon as possible for post-exposure prophylaxis (PEP).

      It is important to note that the management and organization of the blood test can be arranged by the GP, although the midwife should also be informed. If the woman is less than 20 weeks pregnant and non-immune, VZIG should be given immediately, but it may still be effective up to 10 days after exposure.

      For pregnant women who develop Chickenpox after 20 weeks of gestation, oral aciclovir or an equivalent antiviral should be started within 24 hours of rash onset. However, if the woman is less than 20 weeks pregnant, it is recommended to seek specialist advice.

      It is crucial to take action and not simply provide reassurance in cases where the woman is found to be non-immune to varicella, as both she and the fetus are at risk.

      Chickenpox Exposure in Pregnancy: Risks and Management

      Chickenpox is caused by the varicella-zoster virus and can pose risks to both the mother and fetus during pregnancy. The mother is at a five times greater risk of pneumonitis, while the fetus is at risk of developing fetal varicella syndrome (FVS) if the mother is exposed to Chickenpox before 20 weeks gestation. FVS can result in skin scarring, eye defects, limb hypoplasia, microcephaly, and learning disabilities. There is also a risk of shingles in infancy and severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth.

      To manage Chickenpox exposure in pregnancy, post-exposure prophylaxis (PEP) may be necessary. If the pregnant woman is not immune to varicella, VZIG or antivirals may be given within 10 days of exposure. Waiting until days 7-14 is recommended to reduce the risk of developing clinical varicella. However, the decision on choice of PEP for women exposed from 20 weeks of pregnancy should take into account patient and health professional preference as well as the ability to offer and provide PEP in a timely manner.

      If a pregnant woman develops Chickenpox, specialist advice should be sought. Oral aciclovir may be given if the pregnant woman is ≥ 20 weeks and presents within 24 hours of onset of the rash. However, caution should be exercised if the woman is < 20 weeks. Overall, managing Chickenpox exposure in pregnancy requires careful consideration of the risks and benefits to both the mother and fetus.

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  • Question 7 - You are reviewing the recent results for a 23-year-old patient in your general...

    Incorrect

    • You are reviewing the recent results for a 23-year-old patient in your general practice. A vaginal swab has come back positive for Chlamydia trachomatis. The patient has a history of asthma and is allergic to penicillin. She is currently 12 weeks pregnant. You have contacted the genitourinary clinic for contact tracing and treatment for her partner. What is the most suitable prescription for her treatment?

      Your Answer:

      Correct Answer: Erythromycin

      Explanation:

      In the case of treating Chlamydia during pregnancy, erythromycin would be the most appropriate option among the listed antibiotics. Amoxicillin, azithromycin, or erythromycin can be used to treat Chlamydia during pregnancy. However, since the patient is allergic to penicillin, amoxicillin is not suitable. Doxycycline, which is the first-line treatment for uncomplicated Chlamydia in non-pregnant individuals, is not recommended during pregnancy due to its teratogenic effects. Co-amoxiclav is also not appropriate for treating Chlamydia and is contraindicated in this patient due to their penicillin allergy.

      Chlamydia is the most common sexually transmitted infection in the UK caused by Chlamydia trachomatis. It is often asymptomatic but can cause cervicitis and dysuria in women and urethral discharge and dysuria in men. Complications include epididymitis, pelvic inflammatory disease, and infertility. Testing is done through nuclear acid amplification tests (NAATs) on urine or swab samples. Screening is recommended for sexually active individuals aged 15-24 years. Doxycycline is the first-line treatment, but azithromycin may be used if contraindicated. Partners should be notified and treated.

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  • Question 8 - What is true during menopause? ...

    Incorrect

    • What is true during menopause?

      Your Answer:

      Correct Answer: Phyto-oestrogens are as effective as HRT

      Explanation:

      Treatment Options for Menopausal Symptoms

      Systemic oestrogens remain the most effective treatment for hot flashes during menopause, according to available evidence. However, hormone profiling is only useful in uncertain cases, and clonidine effectiveness in treating hot flashes is not yet conclusive. Loss of libido is often caused by a decrease in circulating androgens, but tibolone has been shown to improve libido. On the other hand, counselling efficacy in treating menopausal symptoms is still uncertain, and phyto-oestrogens are no more effective than a placebo, according to BMJ Clinical Evidence. In summary, systemic oestrogens and tibolone are the most promising treatments for menopausal symptoms, while other options require further research.

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  • Question 9 - A 32-year-old man comes to your GP clinic seeking advice on infertility. He...

    Incorrect

    • A 32-year-old man comes to your GP clinic seeking advice on infertility. He and his partner have been attempting to conceive for 2 years. He is in good health and doesn't take any regular medications. He is a non-smoker and has a BMI of 24 kg/m2. There is no history of testicular torsion or sexually transmitted infections. His blood pressure and genital examination are normal. His partner has consulted her GP, who is arranging some blood tests for her.

      What investigations should be conducted for this man?

      Your Answer:

      Correct Answer: Semen sample and chlamydia testing

      Explanation:

      For men with infertility, NICE suggests that the first primary care investigations should include semen analysis and chlamydia screening using a first void urine sample. Additionally, a clinical examination should be conducted to check for any indications of hypogonadism, cryptorchidism, or scrotal masses. It is recommended that a semen sample be produced after abstaining for at least 2 days but no more than 7 days. However, NICE doesn’t recommend screening for antisperm antibodies.

      Understanding Infertility: Initial Investigations and Key Counselling Points

      Infertility is a common issue that affects approximately 1 in 7 couples. However, it is important to note that around 84% of couples who have regular sex will conceive within 1 year, and 92% within 2 years. The causes of infertility can vary, with male factor accounting for 30%, unexplained causes accounting for 20%, ovulation failure accounting for 20%, tubal damage accounting for 15%, and other causes accounting for the remaining 15%.

      To determine the cause of infertility, basic investigations are typically conducted. These include a semen analysis and a serum progesterone test, which is done 7 days prior to the expected next period. The interpretation of the serum progesterone level is as follows: if the level is less than 16 nmol/l, it should be repeated and if it consistently remains low, referral to a specialist is necessary. If the level is between 16-30 nmol/l, it should be repeated, and if it is greater than 30 nmol/l, it indicates ovulation.

      In addition to these investigations, there are key counselling points that should be addressed. These include advising the patient to take folic acid, aiming for a BMI between 20-25, and having regular sexual intercourse every 2 to 3 days. Patients should also be advised to quit smoking and limit alcohol consumption.

      By understanding the initial investigations and key counselling points for infertility, healthcare professionals can provide their patients with the necessary information and support to help them conceive.

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  • Question 10 - A 42-year-old multiparous lady has been referred for a 75 g 2-hour oral...

    Incorrect

    • A 42-year-old multiparous lady has been referred for a 75 g 2-hour oral glucose tolerance test by the midwife. She is 34 weeks pregnant on her 3rd pregnancy. Her urine tested 1+ to glucose on two occasions and her midwife arranged for her to undergo further testing.

      What is the threshold plasma glucose level for diagnosing gestational diabetes following a 75 g 2-hour oral glucose tolerance test?

      Your Answer:

      Correct Answer: 7.8

      Explanation:

      Diagnosis of Gestational Diabetes

      Gestational diabetes is a common condition that affects pregnant women. It is important to be familiar with the threshold levels of plasma glucose for diagnosing gestational diabetes using both a fasting and 75g 2-hour oral glucose tolerance test. The diagnosis of gestational diabetes is different from that of non-pregnant or male patients.

      To diagnose gestational diabetes, a woman should have either a fasting plasma glucose level of 5.6 mmol/litre or above or a 2-hour plasma glucose level of 7.8 mmol/litre or above. For non-pregnant or male patients, the figures are 7 mmol/l and 11.1 mmol/l.

      It is recommended that patients should be offered a 75 g 2-hour OGTT if they have risk factors for diabetes or if they had gestational diabetes in a previous pregnancy. In 2015, NICE offered new advice that glycosuria of 2+ or above on one occasion or of 1+ or above on two or more occasions detected by reagent strip testing during routine antenatal care may indicate undiagnosed gestational diabetes. If this is observed, further testing should be considered to exclude gestational diabetes.

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  • Question 11 - You are reviewing a 4-week old baby girl who is brought in by...

    Incorrect

    • You are reviewing a 4-week old baby girl who is brought in by her parents. Lily was born vaginally at term at the local hospital. She became unwell straight after birth and was treated for neonatal sepsis in the neonatal intensive care unit. Thankfully, she recovered well and was discharged after 7 days.

      What is the most common cause of sepsis in newborns?

      Your Answer:

      Correct Answer: Group B Streptococcus

      Explanation:

      Neonatal sepsis is primarily caused by GBS, with preterm and very low birthweight infants being at a higher risk. Coagulase-negative Staphylococci, Staphylococcus aureus, and Escherichia coli are also frequently identified as causative agents. Listeria monocytogenes and Streptococcus pneumoniae are also significant pathogens.

      Understanding Group B Streptococcus (GBS) Infection in Neonates

      Group B Streptococcus (GBS) is a common cause of severe infection in newborns during the early stages of life. It is estimated that 20-40% of mothers carry GBS in their bowel flora, making them potential carriers of the bacteria. Infants can be exposed to GBS during labor and delivery, which can lead to serious infections. Prematurity, prolonged rupture of the membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection.

      The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management. The guidelines state that universal screening for GBS should not be offered to all women, and a maternal request is not an indication for screening. Women who have had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%. They should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and then antibiotics if still positive. If women are to have swabs for GBS, this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date. IAP should be offered to women with a previous baby with early- or late-onset GBS disease, women in preterm labor regardless of their GBS status, and women with a pyrexia during labor (>38ºC). Benzylpenicillin is the antibiotic of choice for GBS prophylaxis.

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  • Question 12 - A 50-year-old lady presents to you seeking advice on how to manage her...

    Incorrect

    • A 50-year-old lady presents to you seeking advice on how to manage her possible menopause. Her periods have been light and infrequent for a few years and stopped about three months ago. She has no significant medical or surgical history. Her family history doesn't reveal any significant cardiovascular or thromboembolic disease, and she has never smoked. She has had two pregnancies, both resulting in healthy children. Currently, she feels well, and on further questioning, she reports experiencing mild flashes that are not bothersome. On examination, her blood pressure is 120/80, and her BMI is 23. What advice should you give her regarding her possible menopause?

      Your Answer:

      Correct Answer: She is probably post menopausal but she should continue to use contraception until 12 months have elapsed since her last period

      Explanation:

      Understanding Menopause and Hormone Replacement Therapy

      The menopause is a natural biological process that marks the end of a woman’s reproductive years. It is defined as the cessation of normal menstruation, which typically occurs around the age of 51 in the UK. However, the climacteric, a period of gradually declining ovarian function, can begin years before and last years after menopause itself. This perimenopausal period can be characterized by irregular periods and occasional menorrhagia.

      To be considered postmenopausal, a woman must have gone without menstruation for at least 12 months. However, it is important to note that a woman can still potentially become pregnant for up to two years after her last period if she is under 50, and one year if over 50. Therefore, contraception should be discussed with healthcare providers.

      While hormone replacement therapy (HRT) can be used to alleviate symptoms of hypo-oestrogenism, it is not always necessary or appropriate. Routine hormone testing is not recommended unless there is diagnostic doubt. Women who are considering HRT should discuss the potential risks and benefits with their healthcare provider, as well as any pre-existing medical conditions that may affect their suitability for treatment.

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  • Question 13 - A 32-year-old female presents to the clinic with a complaint of amenorrhea for...

    Incorrect

    • A 32-year-old female presents to the clinic with a complaint of amenorrhea for the past eight months. She reports weight gain and decreased libido during this time and has noticed milk production from her breasts. Her last sexual encounter was about seven months ago. On examination, vital signs are normal, and there are no abnormalities on abdominal examination. Galactorrhea is confirmed on expression. What is the probable underlying diagnosis?

      Your Answer:

      Correct Answer: Depression

      Explanation:

      Signs and Symptoms of Hyperprolactinaemia

      This patient is presenting with several signs and symptoms of hyperprolactinaemia, including weight gain, loss of libido, menstrual disturbance, and galactorrhoea. While conditions such as PCOS, depression, and Cushing’s can cause weight gain and menstrual changes, galactorrhoea is only associated with pregnancy, prolactinoma, certain medications, and hypothyroidism.

      It is important to note that the patient’s normal abdominal examination after ten months of amenorrhea, with her last sexual encounter occurring nine months prior, rules out pregnancy as a potential cause for her symptoms. Further investigation and testing may be necessary to determine the underlying cause of her hyperprolactinaemia.

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  • Question 14 - A 32-year-old woman contacts the clinic seeking guidance regarding her cervical screening invitation,...

    Incorrect

    • A 32-year-old woman contacts the clinic seeking guidance regarding her cervical screening invitation, which indicates that her cervical screening test is now due. She has consistently attended screening and has never received an abnormal result. She is presently 28 weeks pregnant, and there is no significant obstetric or gynaecological history. When should she schedule her cervical screening test?

      Your Answer:

      Correct Answer: 3 months following delivery

      Explanation:

      Cervical Screening During Pregnancy

      According to the latest guidelines from the NHS Cervical Screening Programme, it is not recommended for women to have cervical screening while pregnant. However, if a smear test is due during pregnancy, it is advised to wait approximately three months after delivery before having the test. This recommendation is particularly relevant for women with no history of abnormal smears. It is important to follow these guidelines to ensure accurate results and to avoid any potential harm to the developing fetus. Therefore, if you are pregnant and due for a smear test, it is best to wait until after delivery to schedule your appointment.

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  • Question 15 - A 35-year-old patient presents to you for pre-pregnancy counseling and inquires about folic...

    Incorrect

    • A 35-year-old patient presents to you for pre-pregnancy counseling and inquires about folic acid supplementation. The patient has a medical history of sickle cell disease and reports taking folic acid once a week. What recommendations would you make regarding the dose and duration of folic acid supplementation?

      Your Answer:

      Correct Answer: 5 mg daily, to be taken before conception and continued throughout pregnancy

      Explanation:

      Folic Acid Requirements for Women During Pregnancy

      Most women are advised to take 400 mcg of folic acid daily from before conception until week 12 of pregnancy. However, there are exceptions to this rule. Women who are at a higher risk of neural tube defects, such as those with a history of bearing children with NTDs, or women with diabetes or taking anticonvulsants, should take a higher dose of 5 mg daily from before conception until week 12 of pregnancy.

      Another group of women who require a higher dose of folic acid are those with sickle cell disease. They need to take 5 mg of folic acid daily throughout pregnancy, and even when not pregnant, they’ll usually be taking folic acid 5 mg every 1 to 7 days, depending on the severity of their disease. It’s important for women to consult with their healthcare provider to determine the appropriate dose of folic acid for their individual needs during pregnancy.

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  • Question 16 - A 25-year-old woman comes in seeking to switch from her current Microgynon 30...

    Incorrect

    • A 25-year-old woman comes in seeking to switch from her current Microgynon 30 COC to another option due to experiencing mood swings. The decision is made to start her on Marvelon. What guidance should be provided regarding transitioning to a new COC?

      Your Answer:

      Correct Answer: Finish the current pill packet and the start the new COC without a pill free interval

      Explanation:

      There is conflicting advice from the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) regarding the omission of the pill free interval. The FSRH’s Clinical Effectiveness Unit has stated that the pill free interval doesn’t need to be skipped, while the BNF recommends skipping it if there are changes in progesterone. As there is no clear consensus, it is advisable to follow the BNF’s recommendation.

      Special Situations for Combined Oral Contraceptive Pill

      Concurrent Antibiotic Use:
      In the UK, doctors have previously advised that taking antibiotics concurrently with the combined oral contraceptive pill may interfere with the enterohepatic circulation of oestrogen, making the pill ineffective. As a result, extra precautions were advised during antibiotic treatment and for seven days afterwards. However, this approach is not taken in the US or most of mainland Europe. In 2011, the Faculty of Sexual & Reproductive Healthcare updated their guidelines, abandoning the previous approach. The latest edition of the British National Formulary (BNF) has also been updated in line with this guidance. Precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

      Switching Combined Oral Contraceptive Pills:
      The BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice on switching combined oral contraceptive pills. The Clinical Effectiveness Unit of the FSRH has stated in the Combined Oral Contraception guidelines that the pill-free interval doesn’t need to be omitted. However, the BNF advises missing the pill-free interval if the progesterone changes. Given the uncertainty, it is best to follow the BNF.

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  • Question 17 - What is the accurate statement about the connection between IUDs and PID? ...

    Incorrect

    • What is the accurate statement about the connection between IUDs and PID?

      Your Answer:

      Correct Answer: Increased risk in first 20 days then returns to normal

      Explanation:

      New intrauterine contraceptive devices include the Jaydess® IUS and Kyleena® IUS. The Jaydess® IUS is licensed for 3 years and has a smaller frame, narrower inserter tube, and less levonorgestrel than the Mirena® coil. The Kyleena® IUS has 19.5mg LNG, is smaller than the Mirena®, and is licensed for 5 years. Both result in lower serum levels of LNG, but the rate of amenorrhoea is less with Kyleena® compared to Mirena®.

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  • Question 18 - A 27-year-old Caucasian woman who is 10 weeks pregnant visits her GP. This...

    Incorrect

    • A 27-year-old Caucasian woman who is 10 weeks pregnant visits her GP. This is her first pregnancy. Her BMI is 29 kg/m² and she has no significant medical history or family history. The birthweight of her siblings is unknown. As per the current NICE guidelines, what investigation should be arranged in primary care?

      Your Answer:

      Correct Answer: Arrange an Oral Glucose Tolerance Test (OGTT) at 24-28 weeks only

      Explanation:

      It is recommended that all women with a BMI greater than 30 undergo screening for gestational diabetes using an oral glucose tolerance test (OGTT) between 24-28 weeks of pregnancy. Additionally, women who have risk factors for gestational diabetes, such as a family history of diabetes, a previous large baby weighing 4.5 kg or more, or belonging to an ethnic group with a high prevalence of diabetes, should also be offered an OGTT during this time. If a woman has previously had gestational diabetes, she should be offered an OGTT as soon as possible after booking and again at 24-28 weeks if the first test is normal. Alternatively, early self-monitoring of blood glucose may be offered as an option.

      Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.

      To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.

      For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from preconception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.

      Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.

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  • Question 19 - A 19-year-old female seeks guidance as she has missed taking her Microgynon 30...

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    • A 19-year-old female seeks guidance as she has missed taking her Microgynon 30 pills during a weekend trip. She usually remembers to take her pill but has missed days 10, 11, and 12 of her packet, and it is now day 13. Despite taking the day 13 pill this morning, she is worried about the possibility of pregnancy as she had unprotected sex while away. What is the best course of action to take?

      Your Answer:

      Correct Answer: No action needed but use condoms for next 7 days

      Explanation:

      The patient is protected for the next 7 days as she had taken the pill for 7 days in a row previously. According to the FSRH guidelines, emergency contraception is not required after taking seven consecutive pills. However, the guidelines suggest using condoms for the next 7 days in this scenario. Please refer to the provided link for more information.

      The Faculty of Sexual and Reproductive Healthcare (FSRH) has updated their advice for women taking a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol. If one pill is missed at any time during the cycle, the woman should take the last pill, even if it means taking two pills in one day, and then continue taking pills daily, one each day. No additional contraceptive protection is needed. However, if two or more pills are missed, the woman should take the last pill, leave any earlier missed pills, and then continue taking pills daily, one each day. She should use condoms or abstain from sex until she has taken pills for seven days in a row. If pills are missed in week one, emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week one. If pills are missed in week two, after seven consecutive days of taking the COC, there is no need for emergency contraception. If pills are missed in week three, she should finish the pills in her current pack and start a new pack the next day, thus omitting the pill-free interval. Theoretically, women would be protected if they took the COC in a pattern of seven days on, seven days off.

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  • Question 20 - A 28-year-old woman presents to your clinic at 36 weeks of pregnancy with...

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    • A 28-year-old woman presents to your clinic at 36 weeks of pregnancy with complaints of severe itching all over her body that is causing her sleepless nights. She reports experiencing a mild stomach bug, which has resulted in abdominal pain and loss of appetite. During the examination, you notice excoriation marks due to her constant scratching. What would be the most suitable course of action to manage her condition?

      Your Answer:

      Correct Answer: Arrange a same-day obstetric referral

      Explanation:

      Obstetric cholestasis is the primary cause of itch during pregnancy that is not accompanied by a rash. To diagnose obstetric cholestasis, doctors should look for symptoms such as itchiness that begins in the third trimester, starts on the palms and soles before spreading upwards, worsens at night, and causes severe scratching that leads to excoriation marks. Additionally, patients may report anorexia, malaise, and abdominal pain, which are also associated with obstetric cholestasis.

      If a woman displays any of these symptoms, it is recommended that she be admitted to the hospital or referred to an obstetrician on the same day. In secondary care, liver function tests are conducted to confirm the diagnosis, and treatment may include ursodeoxycholic acid and sedating antihistamines.

      Jaundice During Pregnancy

      During pregnancy, jaundice can occur due to various reasons. One of the most common liver diseases during pregnancy is intrahepatic cholestasis of pregnancy, which affects around 1% of pregnancies and is usually seen in the third trimester. Symptoms include itching, especially in the palms and soles, and raised bilirubin levels. Ursodeoxycholic acid is used for symptomatic relief, and women are typically induced at 37 weeks. However, this condition can increase the risk of stillbirth.

      Acute fatty liver of pregnancy is a rare complication that can occur in the third trimester or immediately after delivery. Symptoms include abdominal pain, nausea, vomiting, headache, jaundice, and hypoglycemia. ALT levels are typically elevated. Supportive care is the initial management, and delivery is the definitive management once the patient is stabilized.

      Gilbert’s and Dubin-Johnson syndrome may also be exacerbated during pregnancy. Additionally, HELLP syndrome, which stands for Haemolysis, Elevated Liver enzymes, Low Platelets, can also cause jaundice during pregnancy. It is important to monitor liver function tests and seek medical attention if any symptoms of jaundice occur during pregnancy.

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  • Question 21 - A 25-year-old woman who is 14 weeks pregnant complains of painful urination and...

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    • A 25-year-old woman who is 14 weeks pregnant complains of painful urination and an itchy rash. During examination, a red, tender, vesicular rash is observed on her vulva. A urine dipstick reveals the presence of both white cells and blood. What is the most effective treatment?

      Your Answer:

      Correct Answer: Oral aciclovir

      Explanation:

      The use of gel can provide relief from symptoms. However, the main goal of treatment is to minimize the risk of transmission to the newborn during delivery. This risk is particularly high if the woman experiences primary genital herpes simplex during the last six weeks of pregnancy. In such cases, a caesarean section is the recommended method of delivery.

      The herpes simplex virus (HSV) comes in two strains: HSV-1 and HSV-2. It was once believed that HSV-1 caused cold sores and HSV-2 caused genital herpes, but there is now significant overlap between the two. Symptoms of a primary infection may include severe gingivostomatitis, while cold sores and painful genital ulceration are also common. Treatment options include oral aciclovir and chlorhexidine mouthwash for gingivostomatitis, topical aciclovir for cold sores (although the evidence for its effectiveness is limited), and oral aciclovir for genital herpes. Pregnant women with herpes should be treated with suppressive therapy, and those who experience a primary attack during pregnancy after 28 weeks gestation should have an elective caesarean section. The risk of transmission to the baby is low for women with recurrent herpes. Pap smear images can show the cytopathic effect of HSV, including multinucleation, marginated chromatin, and molding of the nuclei.

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  • Question 22 - A 32-year-old pregnant woman has been diagnosed with gestational diabetes at 35 weeks...

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    • A 32-year-old pregnant woman has been diagnosed with gestational diabetes at 35 weeks gestation and started on insulin therapy. She has not experienced any hypoglycaemic episodes since starting treatment. As her delivery is expected at around 40 weeks, she has been advised to consult her GP regarding driving. Currently, she holds a group 1 driving licence. What advice should be given to the patient regarding driving?

      Your Answer:

      Correct Answer: Doesn't need to inform the DVLA. However, should check blood glucose two hours before driving and every two hours during the journey

      Explanation:

      Patients on insulin are not always required to inform the DVLA, except for those on temporary treatment for less than three months or those with gestational diabetes who are taking insulin for less than three months after delivery. If a patient falls under these exceptions, they can continue driving but must follow the guidelines for insulin-taking patients, which include checking their blood glucose two hours before driving and every two hours during the journey. It is incorrect to assume that a patient can continue driving as normal without any stipulations, even if they do not need to inform the DVLA.

      DVLA Regulations for Drivers with Diabetes Mellitus

      The DVLA has recently changed its regulations for drivers with diabetes who use insulin. Previously, these individuals were not allowed to hold an HGV license. However, as of October 2011, the following standards must be met for all drivers using hypoglycemic inducing drugs, including sulfonylureas: no severe hypoglycemic events in the past 12 months, full hypoglycemic awareness, regular blood glucose monitoring at least twice daily and at times relevant to driving, an understanding of the risks of hypoglycemia, and no other complications of diabetes.

      For those on insulin who wish to apply for an HGV license, they must complete a VDIAB1I form. Group 1 drivers on insulin can still drive a car as long as they have hypoglycemic awareness, no more than one episode of hypoglycemia requiring assistance within the past 12 months, and no relevant visual impairment. Drivers on tablets or exenatide do not need to notify the DVLA, but if the tablets may induce hypoglycemia, there must not have been more than one episode requiring assistance within the past 12 months. Those who are diet-controlled alone do not need to inform the DVLA.

      To demonstrate adequate control, the Honorary Medical Advisory Panel on Diabetes Mellitus recommends that applicants use blood glucose meters with a memory function to measure and record blood glucose levels for at least three months prior to submitting their application. These regulations aim to ensure the safety of all drivers on the road.

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  • Question 23 - A 25-year-old female presents 16 weeks into her pregnancy with a vaginal discharge....

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    • A 25-year-old female presents 16 weeks into her pregnancy with a vaginal discharge. Further investigation confirms infection with Chlamydia trachomatis.

      Which of the following is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Erythromycin

      Explanation:

      Treatment of C. trachomatis Infection in Pregnancy

      C. trachomatis infection is becoming more common in the UK and can lead to adverse fetal outcomes such as spontaneous miscarriage, premature rupture of membranes, and intrauterine growth retardation. Therefore, treatment is advised ahead of test results if chlamydia is strongly suspected clinically. Current UK guidelines recommend three different options for pregnant patients: erythromycin, amoxicillin, and azithromycin. However, erythromycin is the most appropriate option as it is the recommended treatment by most guidelines. Doxycycline, co-trimoxazole, and metronidazole are not routinely used in the treatment of chlamydia during pregnancy. It is also important to note that pregnant patients should be tested for cure 5 weeks after completing treatment (or 6 weeks if azithromycin is used).

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  • Question 24 - Which one of the following statements regarding uterine fibroids is incorrect? ...

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    • Which one of the following statements regarding uterine fibroids is incorrect?

      Your Answer:

      Correct Answer: Undergo malignant change in 1 in 200 cases

      Explanation:

      Most pathologists hold the view that uterine leiomyosarcomas, which may appear as ‘fibroids’ at first, are most likely new growths rather than a conversion of pre-existing fibroids.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are believed to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility, but this is rare.

      Diagnosis is usually done through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is necessary. For menorrhagia, treatment options include the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, oral progestogen, and injectable progestogen. Medical treatment to shrink or remove fibroids includes GnRH agonists and ulipristal acetate, while surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, and complications such as subfertility and iron-deficiency anaemia have been mentioned previously. Another complication is red degeneration, which is haemorrhage into the tumour and commonly occurs during pregnancy. Understanding uterine fibroids is important for women’s health, and seeking medical attention is necessary if symptoms arise.

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  • Question 25 - A 19-year-old sexually active female who is on the combined oral contraceptive pill...

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    • A 19-year-old sexually active female who is on the combined oral contraceptive pill presents with breakthrough bleeding between her periods.

      She has been on the same pill for almost three years and noticed breakthrough bleeding for the first time two months ago. She denies post-coital bleeding. On further questioning she has not missed any pills and has had no recent illnesses or medical problems.

      What is the most probable reason for her breakthrough bleeding?

      Your Answer:

      Correct Answer: Chlamydia infection

      Explanation:

      Breakthrough Bleeding on Combined Oral Contraceptive

      In patients experiencing breakthrough bleeding while on the combined oral contraceptive, it is crucial to check their compliance and potential illness. However, if these factors are not the cause, breakthrough bleeding may indicate an alternative issue and prompt further investigation for gynaecological causes. This is especially true for patients who have been taking the pill for an extended period.

      To assess potential gynaecological causes, a pelvic examination and swabs are necessary. It is also important to ensure that the patient’s smear is up-to-date and to take one if overdue. While cervical cancer is rare in this age group, swabs should be taken to check for chlamydial cervicitis, the most common cause of breakthrough bleeding in young sexually active women.

      Additionally, it is crucial to consider the possibility of pregnancy and perform a pregnancy test. However, in cases where compliance and regular usage of the combined pill are confirmed, the likelihood of pregnancy is remote. Proper investigation and assessment can help identify the underlying cause of breakthrough bleeding and ensure appropriate treatment.

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  • Question 26 - Which of the following anti-epileptic medications poses the highest risk of neurodevelopmental delay...

    Incorrect

    • Which of the following anti-epileptic medications poses the highest risk of neurodevelopmental delay when taken by expectant mothers?

      Your Answer:

      Correct Answer: Sodium valproate

      Explanation:

      The use of sodium valproate in pregnant women poses a considerable threat of causing neurodevelopmental delay.

      Pregnancy and breastfeeding can be a concern for women with epilepsy. It is generally recommended that women continue taking their medication during pregnancy, as the risks of uncontrolled seizures outweigh the potential risks to the fetus. However, it is important to aim for monotherapy and to take folic acid before pregnancy to reduce the risk of neural tube defects. The use of antiepileptic medication during pregnancy can increase the risk of congenital defects, with sodium valproate being associated with neural tube defects, carbamazepine being considered the least teratogenic of the older antiepileptics, and phenytoin being associated with cleft palate. Lamotrigine may be a safer option, but the dose may need to be adjusted during pregnancy. Breastfeeding is generally safe for mothers taking antiepileptics, except for barbiturates. Women taking phenytoin should be given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn. It is important to seek specialist neurological or psychiatric advice before starting or continuing antiepileptic medication during pregnancy or in women of childbearing age. Recent evidence has shown a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate, leading to recommendations that it should not be used during pregnancy or in women of childbearing age unless absolutely necessary.

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  • Question 27 - A 28-year-old woman with a history of hypothyroidism and antiphospholipid syndrome is expecting...

    Incorrect

    • A 28-year-old woman with a history of hypothyroidism and antiphospholipid syndrome is expecting a baby. What should she avoid during pregnancy?

      Your Answer:

      Correct Answer: Warfarin

      Explanation:

      Pregnant women should not take warfarin and are typically prescribed low-molecular weight heparin instead throughout their pregnancy.

      Prescribing Considerations for Pregnant Patients

      When it comes to prescribing medication for pregnant patients, it is important to exercise caution as very few drugs are known to be completely safe during pregnancy. Some countries have developed a grading system to help guide healthcare professionals in their decision-making process. It is important to note that the following drugs are known to be harmful and should be avoided: tetracyclines, aminoglycosides, sulphonamides and trimethoprim, quinolones, ACE inhibitors, angiotensin II receptor antagonists, statins, warfarin, sulfonylureas, retinoids (including topical), and cytotoxic agents.

      In addition, the majority of antiepileptics, including valproate, carbamazepine, and phenytoin, are potentially harmful. However, the decision to stop such treatments can be difficult as uncontrolled epilepsy poses its own risks. It is important for healthcare professionals to carefully weigh the potential risks and benefits of any medication before prescribing it to a pregnant patient.

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  • Question 28 - A 25-year-old woman who is 36 weeks pregnant with her first child seeks...

    Incorrect

    • A 25-year-old woman who is 36 weeks pregnant with her first child seeks your advice on whether to breastfeed. She is facing pressure to return to work soon but is aware of the benefits of breastfeeding for both her and her baby's health.

      Which of the following conditions is known to have a lower incidence in breastfed infants?

      Your Answer:

      Correct Answer: Otitis media

      Explanation:

      Benefits of Breastfeeding

      Breastfeeding has been shown to have numerous benefits for both the mother and the baby. According to the National Institute for Health and Clinical Excellence (NICE) Promotion of breastfeeding initiation and duration (2006), breastfeeding can help reduce the incidence of various conditions.

      Studies have demonstrated that breastfeeding can reduce the risk of infantile gastroenteritis, urinary tract infections, atopic disease, juvenile insulin-dependent diabetes mellitus, respiratory infections, and otitis media. However, it is important to note that breastfeeding may not necessarily protect against other conditions such as ADHD, intussusception, or rickets.

      Overall, breastfeeding is a natural and effective way to promote the health and well-being of both the mother and the baby.

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  • Question 29 - A 27-year-old patient visits you on a Wednesday morning after having unprotected sex...

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    • A 27-year-old patient visits you on a Wednesday morning after having unprotected sex on Saturday. She is worried about the possibility of an unintended pregnancy and wants to know the most effective method to prevent it. Her last menstrual cycle was two weeks ago.

      What would be the best course of action?

      Your Answer:

      Correct Answer: Arrange for copper coil (IUD) insertion

      Explanation:

      For this patient who has had unprotected intercourse within the last 72 hours and is seeking the most effective form of emergency contraception, the recommended course of action is to arrange for a copper coil (IUD) insertion. The copper coil is highly effective in preventing pregnancy for up to five days (120 hours) after intercourse, whether or not ovulation has occurred, by preventing fertilization or implantation. If there are concerns about sexually transmitted infections, antibiotics can be given at the same time. It is important to note that the patient has not missed the window for emergency contraception, as both the copper coil and ulipristal acetate are licensed for use up to five days after intercourse, while levonorgestrel emergency contraception can be taken up to 72 hours after intercourse. However, given that the patient is presenting 72 hours after intercourse and may have already ovulated, levonorgestrel emergency contraception or ulipristal acetate may not be as effective as the copper coil and therefore the copper coil is the most appropriate choice.

      Emergency contraception is available in the UK through two methods: emergency hormonal contraception and intrauterine device (IUD). Emergency hormonal contraception includes two types of pills: levonorgestrel and ulipristal. Levonorgestrel works by stopping ovulation and inhibiting implantation, and should be taken as soon as possible after unprotected sexual intercourse (UPSI) for maximum efficacy. The single dose of levonorgestrel is 1.5mg, but should be doubled for those with a BMI over 26 or weight over 70kg. It is safe and well-tolerated, but may cause vomiting in around 1% of women. Ulipristal, on the other hand, is a selective progesterone receptor modulator that inhibits ovulation. It should be taken within 120 hours after intercourse, and may reduce the effectiveness of hormonal contraception. The most effective method of emergency contraception is the copper IUD, which may inhibit fertilization or implantation. It must be inserted within 5 days of UPSI, or up to 5 days after the likely ovulation date. Prophylactic antibiotics may be given if the patient is at high-risk of sexually transmitted infection. The IUD is 99% effective regardless of where it is used in the cycle, and may be left in-situ for long-term contraception.

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  • Question 30 - A 35-year-old woman presents with a one-week history of morning sickness. She is...

    Incorrect

    • A 35-year-old woman presents with a one-week history of morning sickness. She is 10 weeks pregnant. She can keep down oral fluid but has vomited twice in the previous 24 hours. There are no acid reflux symptoms, abdominal pain, vaginal bleeding or urinary symptoms.

      She takes folic acid and is not on any other medications.

      On examination, her temperature is 36.8ºC. Blood pressure is 100/60 mmHg and heart rate is 80/min. Her abdomen is soft and non-tender. Urine B-HCG is positive and urine dipstick shows 1+ ketone only. There is no weight loss.

      What is the most appropriate management option for this patient?

      Your Answer:

      Correct Answer: Commence on oral cyclizine

      Explanation:

      The first-line management for nausea and vomiting in pregnancy/hyperemesis gravidarum is antihistamines, specifically oral cyclizine. Second-line options include ondansetron and domperidone. Hospital admission may be necessary if the patient cannot tolerate oral antiemetics or fluids, symptoms are not controlled with primary care management, or hyperemesis gravidarum is suspected. There is no indication for oral omeprazole in this case as the patient has not reported any dyspeptic symptoms.

      Hyperemesis gravidarum is a severe form of nausea and vomiting that affects around 1% of pregnancies. It is usually experienced between 8 and 12 weeks of pregnancy but can persist up to 20 weeks. The condition is thought to be related to raised beta hCG levels and is more common in women who are obese, nulliparous, or have multiple pregnancies, trophoblastic disease, or hyperthyroidism. Smoking is associated with a decreased incidence of hyperemesis.

      The Royal College of Obstetricians and Gynaecologists recommend that a woman must have a 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance before a diagnosis of hyperemesis gravidarum can be made. Validated scoring systems such as the Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

      Management of hyperemesis gravidarum involves using antihistamines as a first-line treatment, with oral cyclizine or oral promethazine being recommended by Clinical Knowledge Summaries. Oral prochlorperazine is an alternative, while ondansetron and metoclopramide may be used as second-line treatments. Ginger and P6 (wrist) acupressure can be tried, but there is little evidence of benefit. Admission may be needed for IV hydration.

      Complications of hyperemesis gravidarum can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth restriction, preterm birth, and cleft lip/palate (if ondansetron is used during the first trimester). The NICE Clinical Knowledge Summaries recommend considering admission if a woman is unable to keep down liquids or oral antiemetics, has ketonuria and/or weight loss (greater than 5% of body weight), or has a confirmed or suspected comorbidity that may be adversely affected by nausea and vomiting.

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