238 Module 17 429. Answer B Hysteroscopy and targeted biopsy Explanation All abnormal bleeding or spotting should be investigated, but pipelle endometrial biopsy rarely provides useful diagnostic information in women treated with tamoxifen; therefore, symptomatic women with a thickened endometrium should be investigated with a hysteroscopy and targeted biopsy. This is primarily because of tamoxifen-induced subepithelial stromal hypertrophy. Reference Otify M, Fuller J, Ross J, Shaikh H, Johns J. Endometrial pathology in the postmenopausal woman – an evidence based approach to management. The Obstetrician & Gynaecologist 2015;17:29–38. 430. Answer B 7% Explanation It is estimated that each year of using the COCP brings an approximate 7% reduction in risk of ovarian cancer. Reference Louis LS, Saso S, Ghaem-Maghami S, Abdalla H, Smith JR. The relationship between infertility treatment and cancer including gynaecological cancers. The Obstetrician & Gynaecologist 2013;15:177–83. 431. Answer A 0–20 years Explanation MOGCTs occur most commonly in the first two decades of life, but can appear at any age, with 82.3% of all MOGCTs occurring between the ages of 14 and 54 years. Reference RCOG. Management of female malignant ovarian germ cell tumours. RCOG Scientific Impact Paper No. 52. November 2016. 432. Answer A Laparotomy, unilateral oophorectomy, omental biopsy and selective removal of lymph nodes Explanation Surgery, when appropriate, should comprise unilateral oophorectomy, peritoneal washing, omental biopsy and selective removal of enlarged lymph nodes. Biopsy of a normal contralateral ovary is not indicated. Surgery should be by an open procedure to enable removal of the affected ovary with its tumour intact rather than broken or ruptured. Reference RCOG. Management of female malignant ovarian germ cell tumours. RCOG Scientific Impact Paper No. 52. November 2016. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Gynaecological oncology 239 433. Answer E Dysgerminoma and immature teratoma Explanation Approximately one-third of such cases are dysgerminomas, one-third are immature teratomas, and one-third include embryonal tumours, endodermal sinus tumours, choriocarcinoma and mixed-cell types. Reference RCOG. Management of female malignant ovarian germ cell tumours. RCOG Scientific Impact Paper No. 52. November 2016. 434. Answer B Family history of ovarian cancer Explanation The strongest known risk factor is a family history of the disease, which is present in about 10–15% of women with ovarian cancer. Reference Gaughan EMG, Walsh TA. Risk-reducing surgery for women at high risk of epithelial ovarian cancer. The Obstetrician & Gynaecologist 2014;16:185–91. 435. Answer E No screening recommended Explanation Screening for ovarian cancer with CA125 or ultrasound is not recommended for premenopausal and postmenopausal women without a family history of ovarian cancer. The predictive value of either test alone (<3%) yields an unacceptably high rate of false-positive results and attendant morbidity and costs. Reference Gaughan EMG, Walsh TA. Risk-reducing surgery for women at high risk of epithelial ovarian cancer. The Obstetrician & Gynaecologist 2014;16:185–91. 436. Answer B 2% Explanation It is important to remember that risk-reducing bilateral salpingo-oophorectomy is not completely protective and BRCA carriers still have a risk of developing primary peritoneal cancer (approximately 2% risk). Reference Gaughan EMG, Walsh TA. Risk-reducing surgery for women at high risk of epithelial ovarian cancer. The Obstetrician & Gynaecologist 2014;16:185–91. 437. Answer D 7 years Explanation Seven years is believed to be the minimum time span between infection by HPV and the development of a premalignant lesion with true malignant potential. Reference Aref-Adib M, Freeman-Wang T. Cervical cancer prevention and screening: the role of human papillomavirus testing. The Obstetrician & Gynaecologist 2016;18:251–63. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
240 Module 17 438. Answer B Postoperatively as an adjuvant therapy Explanation In endometrial cancer, the principal role of radiotherapy is as an adjuvant treatment postoperatively, and the past decade has seen this refined with far greater use of vagina brachytherapy and a marked reduction in the use of external beam radiotherapy. Reference Reed NS, Sadozye AH. Update on radiotherapy in gynaecological malignancies. The Obstetrician & Gynaecologist 2017;19:29–36. 439. Answer D Cobalt and iridium Explanation Over the decades, gynaecological brachytherapy has evolved from radium to caesium to modern-day cobalt and iridium sources. Reference Reed NS, Sadozye AH. Update on radiotherapy in gynaecological malignancies. The Obstetrician & Gynaecologist 2017;19:29–36. 440. Answer C Epithelial cancer Explanation While bowel obstruction is a rare presentation in women with gynaecological cancers, it is most commonly associated with ovarian cancer, the main subtype of which is epithelial ovarian cancer. Reference Kolomainen DF, Riley J, Wood J, Barton DPJ. Surgical management of bowel obstruction in gynaecological cancer. The Obstetrician & Gynaecologist 2017;19:63–70. EMQs 441. Answer C I C1 This is stage I C1 according to the International Federation of Gynecology and Obstetrics (FIGO) ovarian cancer staging classification (2014). 442. Answer I III B This is stage III B according to the FIGO staging of cervical carcinomas classification (2006). 443. Answer M IVB This is stage IV B according to the FIGO vulval cancer staging classification (2014). mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Gynaecological oncology 241 444. Answer I Inhibin Explanation Inhibin supresses follicle-stimulating hormone (FSH) production and secretion by the anterior pituitary. Inhibin has been used as a tumour marker for granulosa cell tumours. 445. Answer L Oestriol Explanation The key here is to read the question properly. Although most people will answer G, hCG is not a steroid – it is a glycoprotein. Oestriol is a steroid that is produced by the placenta, and is one of the components of serum screening. 446. Answer J Lactate dehydrogenase (LDH) Explanation LDH is found throughout the body, and levels are elevated in a number of cancers. From a gynaecological perspective, it has been used as a tumour marker in ovarian dysgerminoma. Reference Sanusi FA, Carter P, Barton DPJ. Non-epithelial ovarian cancers. The Obstetrician & Gynaecologist 2000;2:37–9. 447. Answer H Repeat cervical cytology in 3 months’ time 448. Answer G Refer to colposcopy 449. Answer G Refer to colposcopy 450. Answer E Perform human papillomavirus (HPV) test of cure Explanation See Figure 5 in the reference article. Reference Aref-Adib M, Freeman-Wang T. Cervical cancer prevention and screening: the role of human papillomavirus testing. The Obstetrician & Gynaecologist 2016;18:251–63. 451. Answer C 25–29 years The incidence rates for cervical cancer in the UK for 2012–14 were highest in people aged 25–29 years. 452. Answer M 75–79 years The incidence rates for ovarian cancer in the UK for 2012–14 were highest in females aged 75–79 years. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
242 Module 17 453. Answer L 70–74 years The incidence rates for uterine cancer in the UK for 2012–14 were highest in females aged 70–74 years. Reference See the Cancer Research UK website at www.cancerresearchuk.org (accessed 25 July 2018). 454. Answer G 55% The 5-year survival rates for stage 1 to stage 4 cervical cancer are 95.9%, 54.4%, 37.9% and 5.3%, respectively. For all stages taken together, the overall 5-year survival rate is 69.9%. Where the stage is not known, the 5-year survival rate is 31.6%. 455. Answer L 95% The 5-year survival rates for stage 1 to stage 4 uterine (endometrial ) cancer are 95.3%, 77%, 39% and 13.6%,respectively. For all stages taken together, the overall 5-year survival rate is 84.4%. Where the stage is not known, the 5-year survival rate is 54.4%. 456. Answer E 20% The 5-year survival rates for stage 1 to stage 4 ovarian cancer are 90%, 42.8%, 18.6% and 3.5%, respectively. For all stages taken together, the overall 5-year survival rate is 39.3%. Where the stage is not known, the 5-year survival rate is 12.5%. Reference See the Cancer Research UK website at www.cancerresearchuk.org (accessed 25 July 2018). 457. Answer A Arrange follow-up scan in 6 months’ time Explanation Asymptomatic, simple, unilateral, unilocular ovarian cysts of <5 cm in diameter have a low risk of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months. It is reasonable to discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal serum CA125, taking into consideration the woman’s wishes and surgical fitness. 458. Answer E Full staging laparotomy Explanation RMI is calculated as: U × M × CA125 (see question 301 for details). This woman’s RMI is 3 × 3 × 100 = 900. All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by an RMI of ≥200, CT findings, clinical assessment or findings at laparoscopy, require a full laparotomy and staging procedure. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Gynaecological oncology 243 459. Answer H Laparoscopic bilateral salpingo-oophorectomy Explanation This woman’s RMI is 1 × 3 × 40 = 120 (see question 301 for details). Women with an RMI of <200 (i.e. at low risk of malignancy) are suitable for laparoscopic management. Laparoscopic management of ovarian cysts in postmenopausal women should comprise bilateral salpingo-oophorectomy rather than cystectomy. 460. Answer R Ultrasound-guided cyst drainage Explanation This woman’s RMI is 1 × 3 × 2 = 6 (see question 301 for details). This is very unlikely to be a malignant cyst, but the woman is symptomatic. She is frail with co-morbidities. Aspiration has no role in the management of asymptomatic ovarian cysts in postmenopausal women. An exception exists for those symptomatic women who are medically unfit to undergo surgery or further intervention. In these women, aspiration will provide relief of their symptoms, albeit temporarily. Reference RCOG. The management of ovarian cysts in postmenopausal women. RCOG GTG No. 34. July 2016. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
244 Module SBAs 461. A 55-year-old woman attends the urogynaecology clinic with urinary incontinence associated with urgency. A urine dipstick is negative. A diagnosis of urgency urinary incontinence is made. What would be considered the first-line treatment? A. Bladder training B. Botulinum toxin A C. Mirabegron D. Oxybutynin E. Pelvic floor muscle training 462. A 60-year-old woman attends the urogynaecology clinic with urinary incontinence associated with coughing and sneezing. A urine dipstick is negative. A diagnosis of stress urinary incontinence is made. What would be considered the first-line treatment? A. Bladder training B. Desmopressin C. Duloxetine D. Systemic hormone replacement therapy (HRT) E. Supervised pelvic floor muscle training 463. What proportion of women who use vaginal pessaries to manage pelvic organ prolapse will report satisfaction in symptom relief? A. 47% B. 58% C. 69% D. 80% E. 92% Urogynaecology and pelvic floor problems mebooksfree.net 18 mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 245 464. The incidence of asymptomatic bacteriuria in pregnancy is 2–5%. If untreated, what proportion of cases will proceed to lower urinary tract infection (UTI)? A. 20% B. 40% C. 60% D. 80% E. 90% 465. Which aetiological factor is associated with the greatest increase in risk of developing pelvic organ prolapse? A. Age B. Connective tissue disorders C. Menopausal status D. Parity E. Weight 466. By what factor are obese women at increased risk of anal incontinence compared with non-obese women? A. 2-fold B. 3-fold C. 4-fold D. 6-fold E. 8-fold 467. Which antimuscarinic drug used in the management of an overactive bladder should be avoided in frail older women? A. Darifenacin B. Desmopressin C. Mirabegron D. Oxybutynin E. Tolterodine 468. What is the mode of action of duloxetine? A. M3 receptor antagonist B. Monoamine oxidase inhibitor C. α2 -Receptor agonist D. β3 -Receptor agonist E. Serotonin–noradrenaline uptake inhibitor mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
246 Module 18 469. A woman is seen on the postoperative ward round following the insertion of a transobturator tape for the treatment of stress urinary incontinence. Within what timeframe should she be offered a follow-up appointment with a vaginal examination to exclude erosion? A. Within 1 month B. Within 2 months C. Within 3 months D. Within 6 months E. Within 12 months 470. Which derangement of acid–base balance is associated with augmentation cystoplasty for the treatment of an overactive bladder? A. Metabolic acidosis B. Metabolic alkalosis C. No derangement D. Respiratory acidosis E. Respiratory alkalosis 471. What is the mode of action of darifenacin? A. M3 receptor antagonist B. Monoamine oxidase inhibitor C. α2 -Receptor agonist D. β3 -Receptor agonist E. Serotonin–noradrenaline uptake inhibitor 472. Following a vaginal hysterectomy, it is noted that the vaginal vault is at the level of the introitus. What further surgical procedure would be advised? A. Anterior repair B. McCall culdoplasty C. Moschcowitz procedure D. Sacrocolpopexy E. Sacrospinous fixation 473. Which invasive treatment for an overactive bladder is suitable for women who are unable to perform clean intermittent catheterisation? A. Augmentation cystoplasty B. Botulinum toxin A C. Detrusor myomectomy D. Percutaneous sacral nerve stimulation E. Transobturator tape mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 247 474. In the pelvic organs prolapse quantification (POP-Q) examination, what is the description of Aa? A. Anterior vaginal wall at the level of the hymen B. Anterior vaginal wall 1 cm proximal to the hymen C. Anterior vaginal wall 2 cm proximal to the hymen D. Anterior vaginal wall 3 cm proximal to the hymen E. Anterior wall 4 cm proximal to the hymen 475. Colpocleisis is a safe and effective procedure that can be considered for frail women and/or women who do not wish to retain sexual function. What proportion of cases of colpocleisis that are performed would be considered successful? A. 17% B. 37% C. 57% D. 77% E. 97% 476. What factor is most likely to aggravate the pain in patients with bladder pain syndrome? A. Coffee B. Constrictive clothing C. Sexual intercourse D. Spicy foods E. Stress 477. What proportion of patients with bladder pain syndrome will get relief of symptoms from voiding? A. 17–28% B. 31–42% C. 44–56% D. 57–73% E. 78–92% 478. What is the most common problem for a woman following cystoscopy? A. Bladder perforation requiring catheterisation B. Mild burning or bleeding during micturition C. Significant haematuria requiring clot evacuation D. UTI E. Urinary retention requiring catheterisation mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
248 Module 18 479. What is the only true contraindication to cystoscopy? A. Congenital urinary tract anomalies B. Untreated UTI C. Urethral stricture D. Vesicovaginal fistula E. Visible haematuria 480. What is the risk of developing a pelvic abscess following a vaginal hysterectomy for uterovaginal prolapse? A. 1 in 1000 women B. 2 in 1000 women C. 3 in 1000 women D. 4 in 1000 women E. 5 in 1000 women mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 249 EMQs Options for questions 481–483 A Abdominal X-ray B Bladder scan C Complete a bladder diary D CT of pelvis E Cystoscopy F Digital assessment of pelvic floor contraction G Filling and voiding cystometry H MRI of pelvis I No investigation required J Pad testing K Pelvic ultrasound scan L Perform a quality-of-life assessment M Repeat midstream urine N Ultrasound scan of renal tract O Urinary catheterisation P Urine dipstick test Q Video urodynamics For each of the following clinical scenarios, what is the most appropriate investigation that needs to be performed before any therapy is commenced? Each option may be used once, more than once or not at all. 481. A 40-year-old woman attends the gynaecology clinic with a history of leakage of urine on coughing or sneezing following the birth of her last child 2 years ago. A urine dipstick is negative. A decision is made to commence a course of supervised pelvic floor muscle training. 482. A 55-year-old woman who previously had insertion of a tension-free vaginal tape for the treatment of stress incontinence attends with new symptoms of urinary leakage with physical exertion or coughing. She is requesting further surgery. 483. A 60-year-old woman has an initial appointment at the gynaecology clinic. Her presenting symptoms are urinary leakage, urgency and nocturia. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
250 Module 18 Options for questions 484–486 A Botulinum toxin A B Botulinum toxin B C Darifenacin D Desmopressin E Dimethyl sulfoxide F Duloxetine G Flavoxate H Imipramine I Mirabegron J Oestriol cream K Oxybutynin L Propantheline M Propiverine N Solifenacin O Tibolone P Tolterodine Q Transdermal oestrogen R Trospium For each of the following clinical scenarios, choose the single most appropriate pharmacological therapy from the list above. Each option may be used once, more than once or not at all. 484. A 60-year-old woman returns to the urogynaecology clinic for a review. She initially presented with symptoms of urinary leakage and urgency. She has completed a course of bladder training with no effect. She has myasthenia gravis but is otherwise well. 485. A 55-year-old woman initially presented with urinary leakage on coughing and sneezing. She completed a course of pelvic floor muscle training with little effect. She wishes to avoid surgical intervention. 486. A 62-year-old woman who is otherwise fit and well presents with urgency, urinary leakage and nocturia. The urgency and leakage are improved with transdermal oxybutynin, but the nocturia remains troublesome with her needing to go to the toilet four or five times per night. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 251 Options for questions 487–489 A Berger’s disease (IgA nephropathy) B Bladder calculus C Bladder endometriosis D Cystocele E Foreign body F Haemophilia A G Idiopathic haematuria H Paroxysmal nocturnal haemoglobinuria I Polycystic kidney disease J Poststreptococcal glomerulonephritis K Renal calculus L Sickle-cell disease M Transitional cell carcinoma N Urethrocele O Urinary tract infection (UTI) P Von Willebrand’s disease For each of the following clinical scenarios, choose the single most likely cause of haematuria. Each option may be used once, more than once or not at all. 487. A 25-year-old woman presents to her GP with urinary frequency and dysuria. Her urine dipstick results are: Leucocytes + Nitrites + Blood +++ Protein + Ketones − Glucose − 488. Two days after an upper respiratory tract infection, a 20-year-old woman presents to her GP with episodes of frank haematuria. Renal function tests are normal. 489. A 45-year-old woman presents with acute loin pain and haematuria. She is found to be hypertensive with abnormal renal function tests. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
252 Module 18 Options for questions 490–492 A Anterior and posterior colporrhaphy B Anterior colporrhaphy C Artificial urinary sphincter D Augmentation cystoplasty E Colpocleisis F Fenton’s procedure G Intramural bulking agents H Laparoscopic colposuspension I Marshall–Marchetti–Krantz procedure J Open colposuspension K Posterior colporrhaphy L Tension-free vaginal tape M Transobturator tape N Urinary diversion O Vaginal hysterectomy For each of the following clinical scenarios, choose the single most appropriate surgical intervention from the list of options above. Each option may be used once, more than once or not at all. 490. A woman attends the urogynaecology clinic with symptoms of stress incontinence that have not responded to conservative measures. She is keen for surgical intervention but wishes to avoid synthetic meshes and tapes as she has read adverse reports in the media. 491. A 45-year-old woman presents with urinary frequency and urgency and a diagnosis of idiopathic detrusor overactivity is made. This has not responded to conservative measures and she is ready to proceed with surgical intervention. 492. A 90-year-old woman with hypertension and type 2 diabetes presents with worsening uterovaginal prolapse that is not being controlled with shelf pessaries. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 253 Options for questions 493 and 494 A Atrophic vaginitis B Bladder calculus C Bladder diverticulum D Bladder endometriosis E Bladder pain syndrome F Fibromyalgia G Pelvic inflammatory disease (PID) H Peritoneal adhesions I Sjögren’s syndrome J Systemic lupus erythematosus K Transitional cell carcinoma L Urethral diverticulum M Urinary tract infection (UTI) N Vesicovaginal fistula For each of the following clinical scenarios, choose the single most likely diagnosis from the list of options above. Each option may be used once, more than once or not at all. 493. A 40-year-old woman with no significant past medical history presents with a 10-month history of pelvic pain mainly located to the suprapubic area. She has urinary urgency and frequency but no leakage. The symptoms persist through her cycle. She suffers with constipation but not diarrhoea. 494. A 48-year-old woman presents to clinic with complex symptoms. She has urinary urgency and frequency but also dysuria and postmicturition dribble. A full gynaecological history also reveals dyspareunia. An initial pelvic examination is unremarkable. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
254 Module 18 Options for questions 495–497 A Arrange CT of kidneys, ureters and bladder (CT KUB) B Arrange MRI scan C Complete bladder diary D Consider antibiotics while awaiting midstream urine culture results E Measure postvoid residual volume by bladder scan F Measure postvoid residual volume by catheterisation G Perform cystoscopy H Perform digital pelvic examination I Perform pad test J Perform urodynamic testing K Prescribe antibiotics while awaiting midstream urine culture results L Refer to urologist M Send urine for culture and sensitivity From the list of management options above, choose the single most appropriate management for each of the following clinical scenarios. Each option may be used once, more than once or not at all. 495. A woman attends a general gynaecology clinic and has routine urinalysis by dipstick. She has no symptoms, but the urine tests positive for both leucocytes and nitrites. 496. A woman is referred to a urogynaecologist with recurrent UTIs. A urine dipstick in the clinic is negative. 497. A 53-year-old woman is referred to the urogynaecology clinic with urinary incontinence. She has routine urine dipstick testing and is found to have microscopic haematuria. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 255 Options for questions 498–500 A Bulbospongiosus muscle B Conjoint longitudinal coat C External anal sphincter D Iliococcygeus E Internal anal sphincter F Ischial tuberosities G Ischiocavernosus muscle H Ischiococcygeus muscle I Ischiopubic rami J Levator ani K Levator hiatus L Puborectalis muscle M Pubovaginalis muscle N Sacrotuberous ligaments O Superficial transverse perineal muscles From the list of options above, choose the single most appropriate anatomical structure from the list of descriptions below. Each option may be used once, more than once or not at all. 498. The most caudal component of the levator ani complex. 499. The structure separating the external and internal anal sphincters. 500. The structure accounting for the majority of the resting anal pressure. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
256 Module 18 Answers SBAs 461. Answer A Bladder training Explanation Offer bladder training lasting for a minimum of 6 weeks as the first-line treatment to women with urgency or mixed urinary incontinence. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG 171). September 2013. 462. Answer E Supervised pelvic floor muscle training Explanation Offer a trial of supervised pelvic floor muscle training of at least 3 months’ duration as the first-line treatment to women with stress or mixed urinary incontinence. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG 171). September 2013. 463. Answer E 92% Explanation Women have used mechanical devices to reduce pelvic organ prolapse since ancient times, and the use of vaginal pessaries remains a simple and satisfactory treatment. One study of 100 women using this method showed a 92% satisfaction rate in terms of prolapse symptoms. Reference Jefferis H, Jackson SR, Price N. Management of uterine prolapse: is hysterectomy necessary? The Obstetrician & Gynaecologist 2016;18:17–23. 464. Answer A 20% Explanation The incidence of asymptomatic bacteriuria during pregnancy is 2–5%, and if not treated, up to 20% of women will develop a lower UTI. Reference Asali F, Mahfouz I, Phillips C. The management of urogynaecological problems in pregnancy and the early postpartum period. The Obstetrician & Gynaecologist 2012;14:153–8. 465. Answer D Parity Explanation Parity is associated with the greatest increase in risk of developing pelvic organ prolapse. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 257 Reference Asali F, Mahfouz I, Phillips C. The management of urogynaecological problems in pregnancy and the early postpartum period. The Obstetrician & Gynaecologist 2012;14:153–8. 466. Answer A 2-fold Explanation Obesity appears to confer a 4-fold and 2-fold increased risk of urinary and anal incontinence, respectively. Reference Jain P, Parsons M. The effects of obesity on the pelvic floor. The Obstetrician & Gynaecologist 2011;13:133–42. 467. Answer D Oxybutynin Explanation Do not offer oxybutynin (immediate release) to frail older women. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 468. Answer E Serotonin–noradrenaline uptake inhibitor Explanation Duloxetine is a combined serotonin and noradrenaline reuptake inhibitor. Adverse effects are largely related to increases in levels of noradrenaline and serotonin, and include gastrointestinal disturbances, dry mouth, headache, decreased libido and anorgasmia. Reference Orme S, Ramsay I. Duloxetine: the long awaited drug treatment for stress urinary incontinence. The Obstetrician & Gynaecologist 2005;7:117–19. 469. Answer D Within 6 months Explanation Offer a follow-up appointment (including a vaginal examination to exclude erosion) within 6 months to all women who have had continence surgery. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 470. Answer A Metabolic acidosis Explanation Before augmentation cystoplasty, preoperative counselling for the woman or her carer should include the common and serious complications: bowel disturbance, metabolic acidosis, mucus production and/or retention in the bladder, UTI and urinary retention. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
258 Module 18 Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 471. Answer A M3 receptor antagonist Explanation See Table 1 in the reference article. Reference Abboudi H, Fynes MM, Doumouchtsis SK. Contemporary therapy for the overactive bladder. The Obstetrician & Gynaecologist 2011;13:98–106. 472. Answer E Sacrospinous fixation Explanation Sacrospinous fixation is recommended if the vaginal vault is at the introitus at the end of a vaginal hysterectomy procedure. Reference RCOG/BSUG. Post-hysterectomy vaginal vault prolapse. RCOG GTG No. 46. July 2015. 473. Answer D Percutaneous sacral nerve stimulation Explanation Offer percutaneous sacral nerve stimulation to women after a multidisciplinary team review if: • Their overactive bladder has not responded to conservative management including drugs and • They are unable to perform clean intermittent catheterisation. Start treatment with botulinum toxin A only if the woman has been trained in clean intermittent catheterisation and has performed the technique successfully. Restrict augmentation cystoplasty for the management of idiopathic detrusor overactivity to women whose condition has not responded to conservative management and who are willing and able to self-catheterise. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 474. Answer D Anterior vaginal wall 3 cm proximal to the hymen Explanation See Appendix 1 in the reference article. Reference RCOG/BSUG. Post-hysterectomy vaginal vault prolapse. RCOG GTG No. 46. July 2015. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 259 475. Answer E 97% Explanation Colpocleisis has a short operating time and a low incidence of complications. One published study included 33 women and a second included 92 women. Success rates of ≥97% have been reported. Reference RCOG/BSUG. Post-hysterectomy vaginal vault prolapse. RCOG GTG No. 46. July 2015. 476. Answer E Stress Explanation A study of 565 patients with bladder pain syndrome was used to identify factors that can aggravate and alleviate this condition. Pain was found to be aggravated by stress (61%), sexual intercourse (50%), constrictive clothing (49%), acidic beverages (54%), coffee (51%) and spicy foods (46%). Reference RCOG. Management of bladder pain syndrome. RCOG GTG No. 70. December 2016. 477. Answer D 57–73% Explanation In a study of 565 patients with bladder pain syndrome, voiding was found to relieve the pain in 57–73% of patients. Reference RCOG. Management of bladder pain syndrome. RCOG GTG No. 70. December 2016. 478. Answer B Mild burning or bleeding during micturition Explanation The risks associated with cystoscopy in women are as follows: Common risks (>1 in 10): • Mild burning or bleeding on passing urine for a short period after the operation • Biopsy of abnormal areas in bladder. Occasional risks (between 1 in 10 and 1 in 50): • Infection of the bladder requiring antibiotics. Rare risks (<1 in 50): • Temporary insertion of a catheter • Delayed bleeding requiring removal of clots or further surgery • Injury to the urethra causing delayed scar formation • Very rarely, perforation of the bladder requiring a temporary catheter or open surgical repair. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
260 Module 18 Reference Lyttle M, Fowler G. Cystoscopy for the gynaecologist: how to do a cystoscopy. The Obstetrician & Gynaecologist 2017;19:236–40. 479. Answer B Untreated UTI Explanation The only true contraindication to cystoscopy is an untreated UTI, as outlined in the British Association of Urological Surgeons (BAUS) guidelines. Reference Lyttle M, Fowler G. Cystoscopy for the gynaecologist: how to do a cystoscopy. The Obstetrician & Gynaecologist 2017;19:236–40. 480. Answer C 3 in 1000 women Explanation The risk of a pelvic abscess is 3 in every 1000 women (uncommon). Reference RCOG. Vaginal surgery for prolapse. RCOG Consent Advice No. 5. October 2009. EMQs 481. Answer F Digital assessment of pelvic floor contraction Explanation Undertake routine digital assessment to confirm pelvic floor muscle contraction before the use of supervised pelvic floor muscle training for the treatment of urinary incontinence. 482. Answer G Filling and voiding cystometry Explanation After undertaking a detailed clinical history and examination, perform multichannel filling and voiding cystometry before surgery in women who have had previous surgery for stress incontinence. 483. Answer P Urine dipstick test Explanation Undertake a urine dipstick test in all women presenting with urinary incontinence to detect the presence of blood, glucose, protein, leucocytes and nitrites in the urine. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 261 484. Answer I Mirabegron Explanation Mirabegron is recommended as an option for treating the symptoms of an overactive bladder only for people in whom antimuscarinic drugs are contraindicated or clinically ineffective, or have unacceptable side effects. Myasthenia gravis is a contraindication to antimuscarinics. Reference NICE. Mirabegron for treating symptoms of overactive bladder. NICE Technology Appraisal Guidance (TA290). June 2013. 485. Answer F Duloxetine Explanation Do not routinely offer duloxetine as a second-line treatment for women with stress urinary incontinence, although it may be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. If duloxetine is prescribed, counsel women about its adverse effects. 486. Answer D Desmopressin Explanation The use of desmopressin may be considered specifically to reduce nocturia in women with urinary incontinence or an overactive bladder who find it a troublesome symptom. Use particular caution in women with cystic fibrosis and avoid in those >65 years with cardiovascular disease or hypertension. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 487. Answer O Urinary tract infection (UTI) Explanation Urinary frequency or dysuria suggests a UTI, which is the most common cause of haematuria in young women. 488. Answer A Berger’s disease (IgA nephropathy) Explanation IgA nephropathy is the most common glomerulonephritis worldwide and tends to present in young adults within a few days of an upper respiratory tract infection. Poststreptococcal glomerulonephritis would tend to present much later. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
262 Module 18 489. Answer I Polycystic kidney disease Explanation Autosomal-dominant polycystic kidney disease is the most common inherited kidney disorder. Renal dysfunction may not present until after 40 years of age but is often associated with hypertension. A renal calculus may give similar symptoms but would not be associated with hypertension and abnormal renal function tests. Reference Price N, Jackson S. Urogynaecology for the MRCOG and Beyond. 2nd edn. Cambridge: Cambridge University Press, 2012. 490. Answer J Open colposuspension Explanation If conservative management for stress urinary incontinence has failed, offer one of the following: • A synthetic midurethral tape • Open colposuspension • An autologous rectus fascial sling. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 491. Answer D Augmentation cystoplasty Explanation Restrict augmentation cystoplasty for the management of idiopathic detrusor overactivity to women whose condition has not responded to conservative management and who are willing and able to self-catheterise. Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 492. Answer E Colpocleisis Explanation Colpocleisis is often reserved for elderly patients, in particular those with comorbidities that may render them unsuitable for the longer operating times and more invasive procedures associated with reconstructive surgery. Reference Jefferis H, Jackson SR, Price N. Management of uterine prolapse: is hysterectomy necessary? The Obstetrician & Gynaecologist 2016;18:17–23. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Urogynaecology and pelvic floor problems 263 493. Answer E Bladder pain syndrome Explanation The widespread definition for bladder pain syndrome is that proposed by the European Society for the Study of BPS (ESSIC) in 2008 as ‘pelvic pain, pressure or discomfort perceived to be related to the bladder, lasting at least 6 months, and accompanied by at least one other urinary symptom, for example persistent urge to void or frequency, in the absence of other identifiable causes’. Reference RCOG. Management of bladder pain syndrome. RCOG GTG No. 70. December 2016. 494. Answer L Urethral diverticulum Explanation A urethral diverticulum may present with multiple symptoms. The historical classical triad of dysuria, postvoid dribbling and dyspareunia is only seen in a minority of patients. Lower urinary tract symptoms, namely frequency and urgency, are present in 40–100% of cases. Reference Archer R, Blackman J, Stott M, Barrington J. Urethral diverticulum. The Obstetrician & Gynaecologist 2015;17:125–9. 495. Answer M Send urine for culture and sensitivity Explanation If women do not have symptoms of a UTI but their urine tests positive for both leucocytes and nitrites, do not offer antibiotics without the results of a midstream urine culture. 496. Answer E Measure postvoid residual volume by bladder scan Explanation Measure the postvoid residual volume by a bladder scan or catheterisation in women with symptoms suggestive of voiding dysfunction or recurrent UTIs. A bladder scan is used in preference to catheterisation on the grounds of acceptability and a lower incidence of adverse events. 497. Answer L Refer to urologist Explanation Urgently refer women with urinary incontinence who have any of the following: • Microscopic haematuria in women aged ≥50 years • Visible haematuria • Recurrent or persisting UTI associated with haematuria in women aged ≥40 years • A suspected malignant mass arising from the urinary tract. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
264 Module 18 Reference NICE. Urinary incontinence in women: management. NICE Clinical Guideline (CG171). September 2013. 498. Answer L Puborectalis muscle Explanation The puborectalis muscle is the most caudal component of the levator ani complex and is situated cephalad to the deep component of the external anal sphincter, from which it is almost inseparable. 499. Answer B Conjoint longitudinal coat Explanation The anal sphincter complex consists of the external and internal anal sphincters separated by the conjoint longitudinal coat. 500. Answer E Internal anal sphincter Explanation The internal anal sphincter is innervated by the sympathetic (L5) and parasympathetic (S2–S4) nerves and accounts for 50–85% of the resting anal pressure. Reference Lone F, Sultan A, Thakar R. Obstetric pelvic floor and anal sphincter injuries. The Obstetrician & Gynaecologist 2012;14:257–66. mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
265 Index abdominal pain, 66, 162, 168, 181, 194 abdominal pregnancy, 214, 222 abortion. See termination of pregnancy Abortion Act 1967, 18 ACE inhibitors, 79 aciclovir, 110, 207 acid–base balance, 34, 210 augmentation cystoplasty, 246 acute kidney injury, 96 acute renal failure, 144 adenomyosis, 155, 184 adnexal cyst, 61 adnexal mass, 215 air travel, and thromboprophylaxis, 107, 120 alanine transaminase (ALT), 113 alcohol cirrhosis and, 119 in pregnancy, 57 α-fetoprotein (AFP), 104, 119 amenorrhoea, 156, 162 aminosalicylates, 109 amniocentesis, gestational age and, 56 amnioreduction, 74 amniotic fluid embolism, 99 amniotomy, 128, 131 amylase, 113 anabolic steroid abuse, 197 anaemia, 71, 89 anal incontinence, 245 anal sphincter complex, 264 anal sphincter injury, obstetric, 142 analgesia and OHSS, 185 in labour, 126–27 regional, 111, 129 androgens, 177 aneuploidy screening, 60, 80 angiotensin-receptor blockers (ARBs), 79 anorectal mucosa repair, 23 antenatal care, 52–72, See also early pregnancy care FGM and, 55, 66 frequency of monitoring, 64 haematological problems, 71 infections and, 69 multiple pregnancy and, 65 scan investigations/actions, 62 severe hypertension, 67 thrombosis and embolism monitoring, 63 antepartum haemorrhage, 55, 71 anterior vaginal wall, 258 antibiotics intrapartum prophylaxis, 59, 77, 82 MRSA, 2, 5 perineal tear, 44 postpartum problems, 148 prophylactic, 2, 4, 6 anticoagulants, 83, 84 anti-D immunoglobulin, 58 anti-D prophylaxis, 212 anti-epileptics, 93, 100 antihypertensives, 58, 98, 114 anti-K antibody, 58 anti-Müllerian hormone (AMH) level, 187, 197 antimuscarinics, 245, 261 antiretrovirals, 102 antithrombin deficiency, 107, 121 anti-Xa activity, peak, 95 anxiety, 126 postpartum, 149 anxiety disorder, 54 appendicitis, laparoscopy, 43 appraisal, 12 artesunate, 110 aspiration pneumonia, 146 aspirin, 111 low dose, 115 asthma, 67, 144 atosiban, 124 atrophic vaginitis, 159, 160 audit cycle, 15, 20 augmentation cystoplasty, 246, 258, 262 auscultation of the fetal heart, 53 autosomal dominant, 89 autosomal resessive, 89 azithromycin, 207 azoospermia, 187, 191, 198 bacterial vaginosis, 180, 207 bacteriuria, 245 balanced chromosomal translocation, 212 bariatric surgery, 22 obstetric complications and, 56 basal FSH test, 193 benign tumours, most common, 158 benzodiazepines, 100 Berger’s disease, 261 β-HCG test, 209, 215 β-lactamase, extended spectrum, 148 β-thalassaemia, 71, 94 bilateral oophorectomy, 166, 182, 230 bilateral salpingooophorectomy, 31, 229, 243 bilirubin, 113 biological syndrome, 154 bipolar disorder, 95, 146, 149, 163 bladder injuries, 21 caesarean section, 39, 43 laparoscopy, 42 repairs, 31 bladder management, postpartum, 30 bladder pain syndrome, 247, 263 bladder scan, 263 bladder training, 250, 256 blood loss, caesarean section, 140 blood transfusion intraoperative, 44 posthaemorrhage, 39 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
266 Index body mass index (BMI) >30 anal incontinence and, 245 antenatal care and, 52 cirrhosis and, 119 endometrial biopsy, 155 endometrial polyps, 157 glucose tolerance test, 101 heavy menstrual bleeding, 164, 165 hormone replacement therapy, 208 postpartum headache, 147 proportion of women, 22 subfertility problems, 188, 196 thromboprophylaxis and, 95, 107 body weight, LMWH and, 95 borderline personality disorder, 154 botulinum toxin A, 258 bowel obstruction, 229 brachial plexus injury, 140 brachytherapy, 229 BRCA gene mutation, 229 breast cancer, 52, 91, 227 breastfeeding, type 2 diabetics, 101, 117 breech birth emergency caesarean section, 134 perinatal mortality, 134 buzz groups, 13 CA125. See serum CA125 caesarean scar pregnancy, 214 caesarean section bladder injuries, 21, 39, 43 breech birth and, 134 category 2, 133 emergency hysterectomy and, 48 lactate levels and, 129 postoperative infections, 32 stage three of labour, 134 stage two of labour, 134 vaginal birth after, 135 Caldicott guardian, 20 candidiasis, vulvovaginal, 207 carbamazepine, 94, 110 carboplatin, 236 cardiac arrest, 99 cardiac disease, 19, 91 atosiban and, 124 cardiotocography (CTG) antenatal care, 73 categorisation of traces, 127 computerised, 75 difficulty in interpreting, 136 failure to recognise abnormal, 128 in labour, 123 suspicious trace, 133 catheter size, 22 catheterisation, 246, 263 ceftriaxone, 207 cell-free fetal DNA, 60 cervical bleeding, 25 cervical cancer, 230 age ranges, 233 squamous cell, 229 stage 2, 234 cervical dilation, 131 cervical polyps, 175 cervical pregnancy, 217, 222, 224 cervical screening, 232 Charrière (Ch) gauge, 22 chemotherapy, 108, 225 Chlamydia, 181, 214 Chlamydia trachomatis, 201 chloroquine, 110 chlorothiazide, 79 choriocarcinoma, 223 chorionicity, 65 chromosomal abnormality, screening, 58 chronic hypertension, 53, 98 chronic pelvic pain, 158, 168, 172 surgical management, 44, 45 cleft lip, 100 clindamycin, 110, 153, 207 clinical governance, 14–20 clinical skills, 1–6 clinical trial, phases of, 15 clomifene, 189 clomifene citrate, 189, 196 Clostridium difficile, 44 cobalt isotopes, 240 cognitive behavioural therapy (CBT), 73 coincidental death, 115, 116 colpocleisis, 51, 247, 262 colposcopy, 232 colposuspension, 51, 262 combined hormonal contraception, 206 combined oral contraceptive pill (COCP), 145, 174, 181 ovarian cancer and, 227 combined screening test, 80 complete molar pregnancy, 212, 216 complete septation, 237 complex ovarian cyst, 237 compression duplex ultrasound, 84 computerised CTG (cCTG), 75 congenital malformations anti-epileptics and, 93, 100 antihypertensives and, 58 fusion in the female genital tract, 160 consent. See informed consent conservative management gestational hypertension, 84 intramural fibroids, 193 twin pregnancy, 74 contraception. See also combined oral contraceptive pill (COCP); family planning emergency, 199 perimenopausal woman, 200 copper intrauterine contraceptive devices (IUCDs), 111, 144, 205 coroners, 20 corticosteroids, 110 crown–rump length, 72 ultrasound and, 85 cryoprecipitate, 151 CT, 237 CT pulmonary angiogram (CTPA), 83 CTG. See cardiotocography (CTG) cyclical pelvic pain, 175 cyst drainage, ultrasoundguided, 243 cystic fibrosis, 261 cystometry, filling and voiding, 260 cystoscopy contraindications, 248 risks of, 247 cytomegalovirus, 88 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Index 267 danazol, 181 darifenacin, 246 death classification of, 99, 146 maternal. See maternal death perinatal, 134 death rates, extreme preterm births, 59 decelerations, CTG trace, 127, 132 deep dyspareunia, 172 deep vein thrombosis (DVT), 63, 84 in pregnancy, 95 deinfibulation, 66, 75, 86 delayed cord clamping, 133 delivery, management of, 133–39 depression postnatal, 145, 149, 154 postpartum, 146 dermoid cyst, 82, 169 desmopressin, 261 desquamation of palms and soles, 77 diabetes gestational, 101, 117, 138 type 1, 96, 97 type 2, 93, 101 diabetic ketoacidosis (DKA), 96, 97 diamorphine, 111, 132 dichorionic diamniotic (DCDA) twin pregnancy, 65 direct death, 115, 152 DNA pox virus, 204 domestic violence, 61, 99 donor insemination with ovulation induction, 195 Down’s syndrome, 57 genetics and, 88 drospirenone, 180 Duchenne muscular dystrophy, 89 duloxetine, 245, 261 dura mater puncture, 124, 152 dural puncture headache, 152 dyschezia, 190 dysgerminomas, 231, 239 dyskaryosis, 232 dysmenorrhoea, 164, 172, 179, 190 dyspareunia, 163, 172, 253 dysuria, 202, 253 early-onset group B streptococcus (GBS) disease, 77 early pregnancy care, 209–17, See also antenatal care eclampsia antenatal care, 67, 86 postpartum problems, 146 seizures and, 118 ectopic pregnancy abdominal, 214, 222 cervical, 217, 222, 224 following IVF treatment, 214 interstitial, 209 management of, 215 salpingotomy after, 42 tubal, 209, 222 Eisenmenger’s syndrome, 91 electrolyte replacement therapy, 1, 5 emergency contraception, 199 emergency hysterectomy, 42 enalapril, 98, 114 endometrial ablation, 159 second generation, 179 endometrial biopsy, 160, 161, 171 endometrial cancer. See uterine (endometrial) cancer endometrial hyperplasia without atypia, 155, 160, 161 endometrial polyps, 157, 175 endometrial scratch, 186 endometriosis, 158, 181 peritoneal, 156 rectal, 190, 197 subfertility and, 196, 190–91 endometritis, 37 atrophic, 160 enhanced recovery planning, 30 Enterobacteriaceae, 27 enterocele, 51 Entonox, 111 epidurals, dura mater puncture, 124, 152 epigastric pain, 104 epilepsy anti-epileptics, 93, 100 maternal death, 99 opiates and, 94 pain relief in labour, 126 postnatal contraception, 94 episiotomy repair, 144 epithelial ovarian cancer, 240 exercise in pregnancy, 52 exogenous oestrogens, 176 expertise, determinants of, 7 extended-spectrum β-lactamase (ESBL), 148 facial hair, excessive, 170 faecal urgency, 44 fallopian tube function, 184 family history, ovarian cancer, 239 Family Origin Questionnaire, 80 family planning postnatal, and epilepsy, 94 postpartum, 144, 145, 200 female genital mutilation (FGM), 2, 5 antenatal care and, 55, 66 femoral neuropathy, 26, 38 fenoprofen, 150 ferritin levels, 71, 89 fetal abnormality, termination of pregnancy and, 61 fetal blood sampling (FBS), 123, 124 fetal heart rate variation, 75 fetal heartbeat, absence of, 210, 215, 218 fetal movements, reduced, 55, 60 fibrinogen concentrate, 151 fibrinogen levels, 145 fibroid uterus, 41 fibronectin test, 142 Filshie clip, 3, 6 fishbowls, 13 fluconazole, 207 folic acid, 92 forceps delivery, 135 bladder management, 30 Kielland, 142 fosphenytoin, 116 French gauge (Fg), 22 frequently occurring risk, 34 full blood count (FBC), 179 fusion in the female genital tract, 160 genital herpes, 93, 207 gentamicin, 148 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
268 Index germ cells, in testes, 191, 198 gestational age, 72 amniocentesis and, 56 cell-free fetal DNA, 60 magnesium sulfate and, 122 multiple pregnancy and, 65 small for, 69, 76 gestational diabetes, 101, 117, 138 gestational trophoblastic disease, 212 glibenclamide, 117 glucose monitoring, 93 plasma glucose levels, 93, 101, 117 glucose tolerance test, 101 glycine overload, 37 GnRH analogues, 158, 174, 180, 181 gonadotropins, 196 gonococcal infection, 207 gonorrhoea, 181 Graves’ disease, 113 ground E abortions, 82 group A Streptococcus, 148 group B Streptococcus (GBS), 57, 59, 82 early-onset disease, 77 growth scan, 62 gynaecological oncology, 225–43 5-year survival rates, 234 age ranges, 233 cervical screening, 232 stage of disease, 230 tumour markers, 231 gynaecological problems, 155–70 gynaecomastia, 191, 198 haematuria, 254, 261 haemoglobinopathy screening, 59 haemophilia, 88 haemorrhage antepartum, 55, 71 cystic mass, 216 postpartum, 145 requiring blood transfusion, 39 Hartmann’s solution, 1, 5 Hasson (open) technique, 24 headaches postdural puncture, 124 postpartum, 147 heavy menstrual bleeding, 155, 156, 160 management of, 31, 160, 164 tests taken, 165–66 HELLP syndrome acute kidney injury and, 96 thrombotic thrombocytopenic purpura (TTP) and, 118 hepatic haemangioma, 118 hepatitis B, 104, 119 screening for, 59 hepatitis C, 119 hepatocellular carcinoma, 119 hepatosplenomegaly, 69 HIV infection, in pregnancy, 102 hormone replacement therapy (HRT), 200, 203 hot flushes, 156 human epidermal growth factor receptor 2 (HER2), 91 Human Fertilisation and Embryology Authority (HFEA), 194 human papillomavirus (HPV), 229, 232, 237 Huntington’s disease, 89 hydatidiform mole, 223 hydralazine, 87 hydronephrosis, unilateral, 230 hydrosalpinges, 185 hyperandrogenism, 170, 187 hyperemesis, 216 hyperemesis gravidarum, 96, 211, 219 thyroid function tests, 211 hypertension antihypertensives, 58, 98, 114 chronic, 53, 98 gestational, 115 postpartum treatment, 144 severe gestational, 64, 67, 84 treatment of, 151 hyperthyroidism, 96, 183 hypoactive sexual desire disorder (HSDD), 199 hysterectomy, 14, 155 arterial blood gas levels, 35 emergency, 42 endometrial hyperplasia, 176 enhanced recovery planning, 30 laparoscopic assisted vaginal, 47 most common serious risk, 39 perioperative complications, 41 postoperative complications, 31 serious complications from, 22 vaginal, 246, 248 vaginal vault prolapse post, 46 hysterosalpingogram (HSG), 187 hysteroscopy, 238 arterial blood gas levels, 35 heavy menstrual bleeding, 180 pain relief after, 23 uterus perforation, 41 ibuprofen, 194 ICSI with donated eggs, 195 idiopathic detrusor overactivity, 252, 262 IgA nephropathy, 261 immature teratomas, 239 indirect death, 115, 116 indomethacin, 150 induction of labour and antibiotic prophylaxis, 81 and maternal age, 123 management of, 53 vaginal examination, 77 vaginal PGE2, 128 infections. See also urinary tract infections (UTIs) antenatal care and, 69 pelvic, 202 postoperative, 32 surgical site, 22 wound, 37 inflammatory bowel disease, 92 information technology (IT), 14–20 informed consent obtaining, 18 presence of students, 14 process of, 3 inguinal lymphadenitis, 202 inhibin, 241 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Index 269 insulin, 117 insulin-like growth factorbinding protein-1, 141 intermenstrual bleeding, 165 intermittent auscultation, 141 interstitial ectopic pregnancy, 209 intra-abdominal pressure, laparoscopy, 43 intrahepatic cholestasis of pregnancy, 96 intramural fibroids, 184 intravenous fluid therapy, 23 maintenance volume, 24 intravenous rehydration, 211 in vitro fertilisation (IVF) ectopic pregnancy following, 214 hydrosalpinges prior to, 185 maternal age and, 187 OHSS and, 185 recurrent implantation failure, 186 vasa praevia and, 56 iridium isotopes, 240 iron supplements, 71, 89 irritable bowel syndrome, 181 jaundice, 69 K antigen, 79 karyotype 23,X, 223 karyotype 46,XX, 162, 223 karyotype 46,XY, 178 karyotype 69,XXY, 223 karyotypes, 216 karyotyping of products of conception, 221 ketoacidosis, 96, 97 kidney injury, acute, 96 Kielland forceps (KF), 142 Klinefelter’s syndrome, 198 knowledge importance of, 11 retention of, 8 Krukenberg tumours, 236 labetalol, 64, 67, 98, 115, 136, 150 labour, management of, 122–27, See also antenatal care, See also caesarean section, See also preterm labour, See also induction of labour pain relief, 126–27 lactate, 123, 124 lactate dehydrogenase (LDH), 228, 241 lactational amenorrhoea method (LAM), 200 lamotrigine, 110 laparoscopic-assisted vaginal hysterectomy (LAVH), 47 laparoscopic ovarian cystectomy, 42 laparoscopy actions/manoeuvres at incision, 45 appendicitis, 43 bladder injuries, 31, 42 chronic pelvic pain, 44, 45 conversion to minilaparotomy, 41 depth below indented umbilicus, 24 entry-related injuries, 29 Hasson technique, 24 incision location, 45 oophorectomy. See oophorectomy ovarian drilling, 196 risks of, 3, 6 salpingectomy, 195 salpingotomy, 222 laparotomy, 181 full-staging, 242 mini, 41 ovarian tumours, 238 laser ablation, 74 late death, 116 learning methods, 8 leg, pain and swelling, 63 levonorgestrel, 199 levonorgestrel-releasing intrauterine system (LNG-IUS), 111, 155, 156, 160, 164, 171, 174, 177 lichen planus, 156, 178, 237 lichen sclerosus, 178, 237 lichen simplex, 178 lichenification, 163, 178 liquor volume, 62 assessment, 73 lithium treatment, 95 litigation obstetric claims, 122 shoulder dystocia, 134 liver cirrhosis, 119 liver function tests (LFTs), 96, 104 liver, lesions of the, 104 losartan, 98 low-molecular-weight heparin (LMWH), 63, 95, 111, 120 lower urinary tract infection, 245 lymph nodes, 225, 230 M3 receptor antagonist, 258 magnesium sulfate, 67, 86, 122, 142 malaria, 92 malaria prophylaxis, 54 malignancy index (RMI) score, 157, 226, 242 malignant ovarian germ cell tumours (MOGCTs), 227, 228 malposition, reversion to, 137 malpresentation at term spinal cord injuries and, 73 manual rotation of fetal head, 143 maternal age induction of labour and, 123 IVF treatment, 187 miscarriage and, 217 reproductive outcome and, 192 maternal death causes of, 16, 99 classification, 146 congenital heart disease, 108 definitions of, 115 reporting, 20 types of, 99 maternal medicine, 91–108 maturation arrest, 187, 195, 198 Mayer–Rokitansky–Kuster– Hauser syndrome (MRKH), 177 MBRRACE report 2016, 16 McCall culdoplasty, 51 mebeverine, 181 medroxyprogesterone acetate (MPA), 111, 177 mefenamic acid, 164, 179 meiosis, in the testes, 184 membrane sweeps, 56, 122 menstruation. See heavy menstrual bleeding mental health services, perinatal, 152 meropenem, 153 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
270 Index mesalazine, 109 metabolic acidosis, 257 metabolic alkalosis, 219 metformin, 35, 40, 101, 117, 196 methicillin-resistant Staphylococcus aureus (MRSA), 2, 5, 148 methotrexate, 222 methyldopa, 53, 98, 114, 145 microcephaly, 69 micronised progesterone, 180 midurethral tape procedure, 30 migraine, 153 Miller’s pyramid, 7 mini-laparotomy, 41 mirabegron, 261 miscarriage diagnosis of, 218 fetal heart activity, 210 gestational trophoblastic disease, 212 maternal age and, 217 missed, 218 recurrent, 137, 211, 212, 213 molar pregnancy, 212, 216 molluscum contagiosum, 208 monochorionic diamniotic (MCDA) twin pregnancy, 54, 55, 65 antenatal care, 58 morphine, 2, 5 mortality. See death moxifloxacin, 207 MRI, 74, 87 myasthenia gravis, 250, 261 myomectomy, 41, 193 naproxen, 150 National Health Service Litigation Authority (NHSLA), 122 nausea, 194 nausea and vomiting, 1 acid–base balance, 210 hyperemesis gravidarum, 211 intravenous rehydration, 211 peak of, 210 severity of, 210 NCEPOD categories, 14 nephrotoxicity, 109 nerve damage, postoperative, 33 neurodevelopmental disability, 81 neuroprotection, 142 magnesium sulfate for, 128 nifedipine, 142, 150 nitrous oxide, 123 nocturia, 250, 261 non-epileptic seizure disorder, 118 non-steroidal antiinflammatory drugs (NSAIDs), 28, 144, 179, 194 normal saline, 219 norpethidine, 111, 132 nuchal fold measurement, 53 nuchal translucency measurements, 80 nucleic acid amplification test (NAAT), 206 obesity. See body mass index (BMI) >30 Objective Structured Assessment of Technical Skills (OSAT), 8 obstetric anal sphincter injury (OASIS), 142 oestrogen, transdermal, 166, 208 oestriol, 159, 241 oestrogen receptor, 91 oestrogens, exogenous, 176 oestrone, 173 ofloxacin, 207 oligohydramnios, 75 omental biopsy, 238 oncology, gynaecological. See gynaecological oncology oophorectomy bilateral, 166, 182, 230 bilateral salpingo-, 31, 229, 243 unilateral, 182, 238 open abdominal sacrocolpopexy, 48 opiates, 194, See also morphine epilepsy and, 94 orchidopexy, 188, 196 ovarian cancer, 225, 226, 230 age ranges, 233 bowel obstruction and, 229 combined oral contraceptive pill and, 227 germ cell tumours, 227, 228 risk factors, 228 screening, 228 stage 3, 234 ovarian cystectomy, 42, 181 ovarian cysts, 155, 169, 182 complex, 237 malignancy, 226 management options, 234–43 persistent, 230 surgery, 41 ultrasound parameters, 157 ovarian drilling, 196 ovarian dysgerminoma, 231 ovarian hyperstimulation syndrome (OHSS), 185 analgesia and, 185 IVF and, 185 ovarian hyperthecosis, 182 ovarian reserve, 192 overactive bladder, 245 treatment of, 246 oxybutynin, 250, 257 oxygen saturation, 126, 132 oxytocin, 128, 129, 131, 139, 140, 143 oxytocin/ergometrine, 143 paclitaxel, 236 Palmer’s point, 50 paracetamol, 194 paranoia, 149 paraplegia, and pregnancy, 54 partial molar pregnancy, 216 partial moles, triploid, 217, 223 partner abuse, 99 during pregnancy, 61 pelvic abscess, 248 pelvic floor muscle training, 249, 250, 256 pelvic infection, 202 pelvic organ prolapse aetiological risk factors, 245 vaginal pessaries, 244 pelvic pain chronic. See chronic pelvic pain cyclical, 175 subfertility and, 189, 190 urinary urgency and, 253 pelvic ultrasound, 179 pemphigoid gestationis, 109 Pendleton’s rules, 9, 12 percutaneous sacral nerve stimulation, 258 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Index 271 perinatal mental health services, 152 perinatal mortality, 134 perineal tear, repair of, 44 peritoneal cancer, 229 peritoneal endometriosis, 156 peritoneal washing, 230, 238 permethrin, 204 peroneal neuropathy, 39 petechial rash, 69 pethidine, 111, 132 pH, fetal scalp blood, 124 phenytoin, 116 placenta delivery of, 150 manual removal of, 139 retained, 133 placenta praevia, 87 emergency hysterectomy and, 48 plasma glucose levels, 93, 101, 117 Plasmodium vivax, 92 pneumococcal vaccine, 92 pneumonia, aspiration, 146 polycystic kidney disease, 262 polycystic ovarian syndrome (PCOS), 35, 182, 195 polycystic ovaries, 188 polydioxanone (PDS), 21, 28 polyglactin (Vicryl), 28 polymorphic eruption of pregnancy, 109 postablation tubal sterilisation syndrome (PATSS), 175 postdural puncture headache, 152 postmenopausal women bleeding, 160, 161 cervical and endometrial polyps, 159 ovarian cysts, 155, 226 postnatal depression, 145, 149, 154 postoperative care, 30–40 postpartum depression, 146 postpartum haemorrhage, 145 postpartum problems, 144–49 postpartum psychosis, 144 post-thrombotic syndrome (PTS), 95 post-traumatic stress disorder (PTSD), and pregnancy, 54 postvoid residual volume, 263 potassium chloride, 1, 5, 219 preconception counselling, 52 pre-eclampsia acute kidney injury and, 113 antenatal care, 67, 87 management of delivery, 136 postpartum problems, 144 tests at diagnosis, 84 TTP and, 118 women at high risk, 115 pregnancy. See also antenatal care; early pregnancy care; labour, management of; twin pregnancy alcohol during, 57 bacteriuria in, 245 caesarean scar, 214 dating scan, 52 DVT in, 95 ectopic. See ectopic pregnancy exercise during, 52 glucose monitoring in, 93 HIV infection management, 102 intrahepatic cholestasis of, 96 molar, 212, 216 partner abuse during, 61 spinal cord injuries and, 54 spontaneous intrauterine, 193 termination of. See termination of pregnancy pregnancy-unique quantification of emesis (PUQE), 219 premature ovarian insufficiency, 156 premenstrual syndrome, 158, 166 preterm labour delayed cord clamping, 133 disabilities and, 59 magnesium sulfate and, 122 management of, 129 multiple pregnancies, 60 poor prognosis following, 137 survival rates, 59 thyroid disease and, 93 preterm prelabour rupture of membranes (PPROM), 57, 93 preterm rupture of membranes management of delivery, 136, 141 primaquine, 110 primary metabolic acidosis with respiratory compensation, 40 primary metabolic alkalosis with respiratory compensation, 40 primary respiratory acidosis, 39 primary respiratory alkalosis, 39 primiparity, and postpartum psychosis, 150 procidentia, 46 progesterone micronised, 180 serum, 196 progesterone-receptor modulator-associated endometrial changes (PAEC), 157 progestogen-only implant, 206 progestogens, 159, 174, 177 proteinuria screening, 60, 84 prothrombin gene mutation, 95 pruritus, 202 psychosexual disorders, 205 psychosis postpartum, 144 puerperal, 154 pubococcygeus spasm, 205 puborectalis, 264 pudendal neuropathy, 38 puerperal psychosis, 154 pulmonary atelectasis, 38 pulmonary embolism (PE), 83, 84 pyelonephritis, 148, 153 pyrexia, 32 quadruple test, 80 quality assessment criteria, 9, 12 quality of life, 165, 176 quinine, 110 quinolones, 207 radioactive iodine, 183 radiotherapy, 108, 229 rectal endometriosis, 190, 197 rectal examination, 197 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
272 Index regional analgesia, 111, 129 rehydration, intravenous, 211 remifentanyl, 132 renal failure, acute, 144 rescue cervical cerclage, 142 research, 14–20 respiratory depression, 132 reversible cerebral vasoconstriction syndrome (RCVS), 153 Rhodes index, 219 rifampicin, 113 right ventricular dysfunction, 108 risk of malignancy index (RMI), 157, 226, 242 risks of an operation, 34 rubella, 88 sacrocolpopexy, 48, 51 sacrospinous fixation, 51, 258 saline, 114, 219 salpingectomy, 48, 195 salpingo-oophorectomy, bilateral, 31, 229, 243 salpingotomy, 42, 215, 222 Sarcoptes scabiei, 208 SBAR format, 7 schizophrenia, 95, 146, 149, 163 seizures. See also epilepsy causes of, 103 self-harm, 149, 154 sensitivity of an assay, 78 serious risk, 34 serotonin–noradrenaline uptake inhibitor, 257 serum AMH, 197 serum CA125, 158, 171, 174, 230, 235 tumour marker, 226, 236 serum FSH, 156, 162, 178, 187 serum ketones, 97 serum LH levels, 197 serum progesterone, 196 sexual and reproductive health, 199–204 shoulder dystocia, 134 sickle cell disease, 80, 92 sitagliptin, 101 small for gestational age (SGA), 76 infections and, 69 small group teaching, 10 smoking, 107, 126, 202 snowball groups, 13 sodium chloride, 28 sodium valproate, 116 Solomon technique, 74 somatic subtype, 154 speculum examination, PPROM, 77 spermatids, 194 spermatogonia, 194 spina bifida, 100 spinal anaesthesia, 2 spinal cord injuries, and pregnancy, 54 splenectomy, 94 spontaneous intrauterine pregnancy, 193 spontaneous rupture of membranes, 59, 102, 125 squamous cell carcinoma cervical, 229 vulval, 225, 227 staphylococcal toxic shock, 56 sterilisation, postablation tubal, 159 steroids, 110, 231 abuse of, 197 prophylactic, 137 stockings, anti-embolic, 120 Streptococcus. See group A Streptococcus; group B Streptococcus (GBS) stress urinary incontinence, 30, 244, 246, 249, 250, 252 postoperative symptomatic, 46, 51 stress, and bladder pain syndrome, 259 subfertility, 183–91 endometriosis and, 196, 190–91 investigation options, 189 male factors causing, 185 treatment options, 188 unexplained, 183, 193, 196 subgaleal haematoma, 137 suicide, 19, 154 sulfasalazine, 92 surgery breast cancer, 108 core skills, 21–29 ovarian cancer, 236 ovarian tumours, 228 procedures, 41–47 surgical evacuation, 216 surgical evacuation of the uterus, 35, 44, 212 suture materials, 23 absorbable, 21 Swyer syndrome, 178 Syntocinon, 133, 143 Syntometrine, 143 tachycardia, 63 tremor, 130 tamoxifen, 52, 108, 227 targeted biopsy, 238 teaching and assessment, 7–10 teicoplanin, 153 TENS, 111 termination of pregnancy congenital heart disease, 108 fetal abnormality and, 61 ground E abortions, 82 testes, end product of meiosis, 184 testicular failure, 183 testosterone, 161, 208 tetralogy of Fallot, 91 thalassaemia, 71, 89, 94 thrombophilia, test for, 121, 221 thromboprophylaxis, 94, 95, 107–8 thrombotic thrombocytopenic purpura (TTP), 118 thyroid disease, 93, 96, 183 thyroid function tests, 211 thyrotoxicosis, 220 tocolytics, 137, 142 toxic shock syndrome, 56, 148 tranexamic acid, 164, 179 transcervical resection of the endometrium (TCRE), 31 transdermal continuous combined HRT, 208 transdermal oestrogen, 166, 208 transforming growth factor-β (TGF-β), 231 transobturator tape, 246 transvaginal ultrasound, 87, 129 early pregnancy, 209 ectopic pregnancy, 222 endometriosis, 197 miscarriage, 210, 218 tubal ectopic pregnancy, 218 transverse vaginal septum, 157, 177 trastuzumab, 108 tremor tachycardia, 130 Trendelenburg position, 50 Trichomonas vaginalis, 200, 208 trichomoniasis, 181 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net
Index 273 triplet pregnancy, 65 trisomy 21, 88 trophoblastic disease, 212 tubal ectopic pregnancy, 209, 222 tumour markers, 226, 228, 231 twin pregnancy DCDA, 65 delivery, 138 MCDA, 54, 55, 58, 65 preterm delivery, 60 thromboprophylaxis, 107 ultrasound scanning and, 65 twin-to-twin transfusion syndrome (TTTS), 54 type 1 diabetes, 96, 97 type 2 diabetes, 93, 101 UK Medical Eligibility Criteria for Contraceptive Use (UKMEC), 199 ulipristal acetate, 157 ultrasound adenomyosis, 184 compression duplex, 84 crown–rump length and, 85 cyst drainage, 243 intramural fibroids, 184 multiple pregnancy and, 65 OHSS, 185 ovarian cysts, 157, 171 pelvic, 179 transvaginal. See transvaginal ultrasound umbilical adhesions, 50 umbilical artery absent or reversed end-diastolic velocity (AREDV), 75 umbilical artery Doppler, 62 umbilical hernias, 44 umbilical port, 47 unilateral oophorectomy, 182, 238 ureteric injuries, 21 urethral diverticulum, 263 urgency urinary incontinence, 244, 249, 250, 252, 253 urinary catheter size, 22 urinary incontinence obesity and, 257 stress. See stress urinary incontinence with urgency, 244, 249, 250, 252, 253 urinary tract infections (UTIs), 251, 254 lower, 245 untreated, 260 urine dipstick test, 260 urogynaecology, 244–55 ursodeoxycholic acid (UDCA), 96 urticaria, 92 uterine (endometrial) cancer, 236 age ranges, 233 radiotherapy, 229 stage 1, 234 uterine fibroids, 23, 157 uterine hyperstimulation, 128 uterine leiomyoma, 174 uterine perforation, 41 uterine septum, 175 uterotonic agents, 134, 138–39 uterovaginal prolapse, 248, 252 vagina, short, blind ending, 162 vaginal birth after a caesarean (VBAC), 135 vaginal bleeding, 23, 209, 215, 221, 227 vaginal breech birth, 134 vaginal discharge, 167, 202 vaginal hysterectomy, 246 laparoscopic assisted, 47 pelvic abscess after, 248 vaginal pessaries, 244, 252 vaginal prostaglandin (PGE2), 128 vaginal spotting, 175 vaginal tape, 249 vaginal vault bleeding, 25 vaginal vault level, 246 vaginal vault prolapse, 42, 46 posthysterectomy, 46 vaginismus, 199 vaginitis, atrophic, 159, 160 valaciclovir, 207 vancomycin, 153 vasa praevia, IVF treatment and, 56 vasectomy, 164 failures from, 3, 6 venous thromboembolism (VTE), 95, 107, 121 postdelivery, 145 postpartum family planning, 151 ventilation/perfusion (V/Q) scan, 83 ventouse, 142 Veress needle, 45, 50 vesicovaginal fistula, 37 viral load, 117 vitamin A, 59 vitamin D, 53 voiding, and bladder pain syndrome, 259 vulval biopsy, 178 vulval cancer, 230 vulval intraepithelial neoplasia (VIN), 227 vulval lichen planus, 156 vulval squamous cell carcinoma, 225, 227 weight loss, subfertility problems, 196 workplace-based assessment, 7, 8 World Health Organization (WHO), classification of death, 99 wound infections, 37 X-linked recessive, 88, 89 zidovudine, 102 Zika virus, 88 mebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netmebooksfree.net mebooksfree.net mebooksfree.netfree.net free.net free.net