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  • Question 1 - A 20-year-old woman who is 8 weeks into her first pregnancy presents with...

    Incorrect

    • A 20-year-old woman who is 8 weeks into her first pregnancy presents with vaginal bleeding and is seen in the early pregnancy assessment unit. The ultrasound scan confirms a viable intrauterine pregnancy, but the high vaginal swab has isolated group B streptococcus (GBS). What is the appropriate management for her?

      Your Answer: Intrapartum oral benzylpenicillin only

      Correct Answer: Intrapartum intravenous benzylpenicillin only

      Explanation:

      GBS is a type of bacteria commonly found in the vagina of many women. While it is generally harmless, it can cause serious infections in newborns, leading to significant health problems and even death.

      If GBS is detected during pregnancy, it does not require immediate treatment as it will not reduce the likelihood of transmission to the baby during delivery. However, intravenous benzylpenicillin or clindamycin is necessary during labor to reduce the risk of transmission. This applies to GBS found in vaginal swabs and urine, and appropriate antibiotics are required for GBS urinary tract infections during pregnancy.

      There is currently no screening program for GBS in the UK, and vaginal swabs should only be taken when clinically necessary. Women who have had a previous baby infected with GBS are offered intrapartum intravenous benzylpenicillin in future pregnancies.

      (Source – RCOG guidelines, GBS in pregnancy).

      Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of 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, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 2 - A 28-year-old female patient contacts her GP seeking guidance on folic acid supplements....

    Correct

    • A 28-year-old female patient contacts her GP seeking guidance on folic acid supplements. She and her partner are attempting to conceive, and she has never been pregnant before. She is in good health overall, with a history of asthma that she manages with a salbutamol inhaler as needed. Her BMI is 31 kg/m2, and she has no notable family medical history. What recommendations should she receive?

      Your Answer: 5mg folic acid from now until the 12th week of pregnancy

      Explanation:

      Pregnant women with obesity (BMI >30 kg/m2) are recommended to take a high dose of 5mg folic acid from before conception until the 12th week of pregnancy. This is because obesity puts them at a higher risk of neural tube defects. The suggestion of taking 400 micrograms would be for women who are not at a higher risk. Therefore, the other answers provided are incorrect.

      Folic Acid: Importance, Deficiency, and Prevention

      Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

      To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

      In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 3 - A 35 year-old woman has been diagnosed with fibroids and has been attempting...

    Incorrect

    • A 35 year-old woman has been diagnosed with fibroids and has been attempting to conceive for 2 years. She has been undergoing evaluation at the sub-fertility clinic and all tests have come back normal except for the presence of three uterine fibroids, which are asymptomatic. Her partner's semen analysis showed no abnormalities.
      What are the most suitable treatment options in this scenario?

      Your Answer: Ulipristal acetate

      Correct Answer: Myomectomy

      Explanation:

      If a woman with large fibroids is experiencing fertility issues, the most effective treatment option that also preserves her ability to conceive in the future is myomectomy. However, depending on the specifics of the procedure, the woman may need to consider delivery options, such as a caesarean section, due to the risk of uterine rupture.

      While GnRH agonists can shrink fibroids and make them easier to remove surgically, they also temporarily turn off the ovaries, inhibiting ovulation and making pregnancy impossible during treatment. Additionally, fibroids tend to regrow after treatment is stopped. However, when combined with myomectomy, GnRH agonists can be a suitable treatment option.

      Endometrial ablation, on the other hand, destroys the endometrial lining, making it impossible for an embryo to implant. Uterine artery embolisation is also not recommended for women trying to conceive, as it significantly reduces blood supply to the uterus, making it impossible for a fetus to implant and grow.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are thought 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.

      Diagnosis is usually made through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is recommended. Menorrhagia secondary to fibroids can be managed with various treatments, including the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, and hormonal therapies.

      Medical treatment to shrink or remove fibroids may include GnRH agonists or ulipristal acetate, although the latter is not currently recommended due to concerns about liver toxicity. Surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, but complications such as subfertility and iron-deficiency anaemia can occur. Red degeneration, which is haemorrhage into the tumour, is a common complication during pregnancy.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 4 - A 25-year-old woman visits the GUM clinic at 18 weeks gestation. Her partner...

    Incorrect

    • A 25-year-old woman visits the GUM clinic at 18 weeks gestation. Her partner has tested positive for Chlamydia and she needs treatment as a contact. The doctor prescribes a single dose of azithromycin 1g and screens her for infection. When is it appropriate to conduct a test of cure (TOC)?

      Your Answer: 4 weeks

      Correct Answer: 6 weeks

      Explanation:

      For symptomatic men with Chlamydia, it is recommended to notify all sexual partners from the 4 weeks prior to the onset of symptoms. As for women and asymptomatic men, all sexual partners from the last 6 months or the most recent partner should be notified. Pregnant women should undergo a test of cure (TOC) 6 weeks after infection, according to BASHH guidelines. Performing a TOC earlier than 6 weeks may result in a false positive due to the presence of nonviable Chlamydia DNA on the NAAT. However, uncomplicated Chlamydia infection in men and non-pregnant women does not require a routine TOC.

      Chlamydia is a common sexually transmitted infection caused by Chlamydia trachomatis. It is prevalent in the UK, with approximately 1 in 10 young women affected. The incubation period is around 7-21 days, but many cases are asymptomatic. Symptoms in women include cervicitis, discharge, and bleeding, while men may experience urethral discharge and dysuria. Complications can include epididymitis, pelvic inflammatory disease, and infertility.

      Traditional cell culture is no longer widely used for diagnosis, with nuclear acid amplification tests (NAATs) being the preferred method. Testing can be done using urine, vulvovaginal swab, or cervical swab. Screening is recommended for sexually active individuals aged 15-24 years, and opportunistic testing is common.

      Doxycycline is the first-line treatment for Chlamydia, with azithromycin as an alternative if doxycycline is contraindicated or not tolerated. Pregnant women may be treated with azithromycin, erythromycin, or amoxicillin. Patients diagnosed with Chlamydia should be offered partner notification services, with all contacts since the onset of symptoms or within the last six months being notified and offered treatment.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 5 - A 21-year-old woman begins taking Microgynon 30 on the 8th day of her...

    Incorrect

    • A 21-year-old woman begins taking Microgynon 30 on the 8th day of her menstrual cycle. When will it become a dependable form of birth control?

      Your Answer: Until first day of next period

      Correct Answer: 7 days

      Explanation:

      Contraceptives – Time to become effective (if not used on the first day of period):
      Immediate: IUD
      2 days: Progestin-only pill (POP)
      7 days: Combined oral contraceptive (COC), injection, implant, intrauterine system (IUS)

      Counselling for Women Considering the Combined Oral Contraceptive Pill

      Women who are considering taking the combined oral contraceptive pill (COC) should receive counselling on the potential harms and benefits of the pill. The COC is highly effective if taken correctly, with a success rate of over 99%. However, there is a small risk of blood clots, heart attacks, and strokes, as well as an increased risk of breast and cervical cancer.

      In addition to discussing the potential risks and benefits, women should also receive advice on how to take the pill. If the COC is started within the first 5 days of the menstrual cycle, there is no need for additional contraception. However, if it is started at any other point in the cycle, alternative contraception should be used for the first 7 days. Women should take the pill at the same time every day and should be aware that intercourse during the pill-free period is only safe if the next pack is started on time.

      There have been recent changes to the guidelines for taking the COC. While it was previously recommended to take the pill for 21 days and then stop for 7 days to mimic menstruation, it is now recommended to discuss tailored regimes with women. This is because there is no medical benefit to having a withdrawal bleed, and options include never having a pill-free interval or taking three 21-day packs back-to-back before having a 4 or 7 day break.

      Women should also be informed of situations where the efficacy of the pill may be reduced, such as vomiting within 2 hours of taking the pill, medication that induces diarrhoea or vomiting, or taking liver enzyme-inducing drugs. It is also important to discuss sexually transmitted infections and precautions that should be taken with enzyme-inducing antibiotics such as rifampicin.

      Overall, counselling for women considering the COC should cover a range of topics to ensure that they are fully informed and able to make an informed decision about their contraceptive options.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 6 - A 16-year-old girl presents with heavy menstrual bleeding since her first period at...

    Correct

    • A 16-year-old girl presents with heavy menstrual bleeding since her first period at age 13. She has a history of frequent nosebleeds in childhood. After a normal physical exam and ultrasound, what is the most crucial next step?

      Your Answer: Blood test for coagulation disorder

      Explanation:

      Women who have experienced heavy menstrual bleeding since their first period and have indications of a coagulation disorder in their personal or family medical history should undergo testing for such disorders, including von Willebrand’s disease. This recommendation is made by NICE CG44.

      Understanding Menorrhagia: Causes and Definition

      Menorrhagia is a condition characterized by heavy menstrual bleeding. While it was previously defined as total blood loss exceeding 80 ml per menstrual cycle, the assessment and management of the condition now focuses on the woman’s perception of excessive bleeding and its impact on her quality of life. Dysfunctional uterine bleeding, which occurs in the absence of underlying pathology, is the most common cause of menorrhagia, accounting for about half of all cases. Anovulatory cycles, uterine fibroids, hypothyroidism, pelvic inflammatory disease, and bleeding disorders such as von Willebrand disease are other potential causes of menorrhagia. It is important to note that the use of intrauterine devices, specifically copper coils, may also contribute to heavy menstrual bleeding. However, the intrauterine system (Mirena) is a treatment option for menorrhagia.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 7 - A 35-year-old female patient complains of a malodorous vaginal discharge that appears white....

    Incorrect

    • A 35-year-old female patient complains of a malodorous vaginal discharge that appears white. She denies any associated dyspareunia or itch. The clinician suspects bacterial vaginosis. Which organism is most likely responsible for this presentation?

      Your Answer: Trichomonas

      Correct Answer: Gardnerella

      Explanation:

      Bacterial vaginosis is a condition characterized by the excessive growth of mainly bacteria.

      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 regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 8 - A 17-year-old girl with a history of acne is interested in starting a...

    Correct

    • A 17-year-old girl with a history of acne is interested in starting a combined oral contraceptive pill (COC). She has been taking doxycycline for the past 2 months. What advice should be given?

      Your Answer: She can start using a COC with usual advice

      Explanation:

      If the COC is not started on the first day of the next period, it is important to follow the standard guidelines and use condoms for 7 days.

      Special Situations for Combined Oral Contraceptive Pill

      Concurrent antibiotic use has been a concern for many years in the UK, as doctors have advised that it may interfere with the effectiveness of the combined oral contraceptive pill. 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 to abandon the extra precautions previously advised during antibiotic treatment and for 7 days afterwards. The latest edition of the British National Formulary (BNF) has also been updated to reflect this guidance, although precautions should still be taken with enzyme-inducing antibiotics such as rifampicin.

      When it comes to switching combined oral contraceptive pills, the BNF and Faculty of Sexual & Reproductive Healthcare (FSRH) appear to give contradictory advice. The FSRH’s Combined Oral Contraception guidelines state that the pill-free interval does not need to be omitted, while the BNF advises missing the pill-free interval if the progesterone changes. Given this uncertainty, it is best to follow the BNF’s advice.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 9 - A 26-year-old female patient visits your clinic complaining of vaginal discharge. She reports...

    Correct

    • A 26-year-old female patient visits your clinic complaining of vaginal discharge. She reports a strong odour but no itching, dysuria, dyspareunia, or post-coital bleeding. During the examination, you observe a watery discharge with an odour, but no erythema on the labia. The cervix appears healthy, and there is no cervical excitation. What is the probable diagnosis?

      Your Answer: Bacterial vaginosis

      Explanation:

      To determine the cause of the watery vaginal discharge in this patient, further information about her sexual history would be necessary. However, based on the appearance of her cervix, a diagnosis of Gonorrhoea is unlikely. Gonorrhoea typically presents with a green and purulent discharge, and is not often associated with an odour. Similarly, Chlamydia would likely cause more problems with the cervix and a more mucopurulent discharge. Herpes simplex does not typically cause vaginal discharge, but instead presents with ulcers or tingling sensations around the vulva. Thrush, or candidiasis, would likely cause more itching and have a thicker, cottage cheese-like consistency. Bacterial vaginosis is the most likely diagnosis, as it often presents with a fishy odour and a thin, watery discharge that may be green or white. It can be asymptomatic and does not typically cause irritation or soreness. Diagnosis can be confirmed with a vaginal pH > 4.5 and the presence of clue cells on microscopy. These findings are in line with BASHH guidelines.

      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 regimes. Clue cells, which are vaginal epithelial cells covered with bacteria, can be seen on microscopy in women with BV.

    • This question is part of the following fields:

      • Reproductive Medicine
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  • Question 10 - A 40-year-old woman presents to her General Practitioner for investigation as she and...

    Incorrect

    • A 40-year-old woman presents to her General Practitioner for investigation as she and her male partner have not become pregnant after 24 months of trying to conceive. Her female partner has also had normal investigations and on examination, she has a small uncomplicated left-sided inguinal hernia. She takes fluoxetine for depression and occasionally uses acetaminophen for back pain but is not on any other medications. Her male partner's sperm count is normal.
      What would be the next most appropriate step in managing this couple’s inability to conceive?

      Your Answer: Refer to general surgery for hernia repair

      Correct Answer: Refer to secondary care fertility services

      Explanation:

      Recommendations for a Couple Struggling with Infertility

      When a couple is struggling to conceive, there are several recommendations that healthcare providers may suggest. Firstly, if the couple has been trying to conceive for a year without success, they should be referred to fertility services. However, if there is an underlying reason for conception difficulties, earlier investigation may be necessary. In cases where the male partner is taking non-steroidal anti-inflammatory drugs, there is no impact on his ability to conceive. A hernia repair is not indicated to improve the couple’s chances of conception. Watching and waiting is not appropriate, and referral to fertility services is recommended. Finally, while sertraline and other SSRIs are not teratogenic, they can cause sexual dysfunction, which should be explored with the patient.

    • This question is part of the following fields:

      • Reproductive Medicine
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SESSION STATS - PERFORMANCE PER SPECIALTY

Reproductive Medicine (4/10) 40%
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