GY Management new

. A 33-year-old nulliparous woman is 29 weeks pregnant. She was referred to the rapid access breast clinic for investigation of a solitary breast lump. Sadly, a biopsy of this lump revealed a carcinoma. After much counselling from the oncologists and her obstetricians a decision is reached on her further treatment. What option below may be available to her?

2. A 38-year-old woman with type 2 diabetes attends the maternal medicine clinic. She has a body mass index (BMI) of 48 and is currently controlling her sugars with insulin. You have a long discussion about her weight .What should not be routinely offered to this woman?

3. A 30-year-old nulliparous woman is 29 weeks pregnant. She presented to hospital with a history of a minor, unprovoked painless vaginal bleed of about a teaspoonful. Her anomaly scan at 20 weeks showed a low-lying placenta. Her fetus is moving well and continuous cardiotocography (CTG) is reassuring. What is the most appropriate management?

4. A 28-year-old pregnant woman attends accident and emergency with a history of clear vaginal loss. She is 18 weeks pregnant and so far has had no problems. Her past medical history includes a large cone biopsy of the cervix and she is allergic to penicillin. She is worried because the fluid continues to come and there is now some blood. On examination it is apparent that her membranes have rupture What is the most appropriate initial management?

5. A 32-year-old woman in her second pregnancy presents at 36 weeks gestation with a history of a passing gush of blood stained fluid from the vagina an hour ago, followed by a constant trickle since. The admitting obstetrician reviews her history and weekly antenatal ultrasound scans have shown a placenta praevia. What is the most appropriate management? She has a firm, posterior cervix and has not been experiencing any contractions?

6. A 30-year-old woman attends the antenatal clinic asking to be sterilized at the time of her elective caesarean. She is 34 weeks into her second pregnancy having had her first child 2 years ago via an emergency caesarean section. She is not sure that she wants any more children. Furthermore, she does not wish to try for a vaginal birth.She has tried the contraceptive pill in the past but does not like the side effects. You talk to her about other options, including the sterilization she is requesting. What is the best management option for this woman?

7. A 41-year-old multipara attends the antenatal clinic at 36 weeks gestation complaining oflower abdominal cramps and fatigue when mobilizing.Clinical examination is unremarkable save for a grade I pansystolic murmur, loudest over the fourth intercostal space in the midaxillary line. What is the most appropriate management?

8. A 32-year-old HIV positive woman who booked for antenatal care at 28 weeks gestation arrives on the delivery suite at 37 weeks with painful regular contractions and a cervix dilated to 4 em. Ultrasonography confirms a breech singleton pregnancy with a reactive fetal heart rat What is the most appropriate management option?

9. A 41-year-old multiparous woman attends accident and emergency at 32 weeks gestation complaining of sudden onset shortness of breath. A CTPA demonstrates a large saddle embolus. What is the most appropriate treatment regimen?

10. A 42-year-old para 4 with a dichorionic-diamniotic (DCDA) twin pregnancy at 31 weeks gestation presents to hospital with a painful per virginal bleed of 400 mL. The bleeding seems to be slowing. She is cardiovascularly stable, although having abdominal pains every 10 minutes. There is still a small active bleed on speculum and the cervix appears close Both fetuses have reactive CTGs. She has had no problems antenatally and her 28-week ultrasound revealed both placentas to be well away from the cervix.What is your preferred management plan?

11. You are the FYI covering the antenatal war A 27-year-old nulliparous woman who is 36 weeks and 5 days pregnant has been admitted to your ward with suspected pre-eclampsia The emergency buzzer goes off in her room. You are the first to attend and find your patient flat on the bed having a generalized seizure what do you do?

12. A 19-year-old woman in her first pregnancy is admitted to the labour ward with a 4-hour history of lower abdominal pain -she is 22 weeks pregnant. She has not had any vaginal bleeding but describes a possible history of rupture of her membranes. Her past medical history includes an appendectomy and a large cone biopsy of her cervix. On examination she has palpable lower abdominal tenderness, her cervix is 2 em dilated, she has an offensive vaginal discharge and her temperature is 38.9° Her white cell count is 19.0 * 109/L and her C-reactive protein is 188 mg!L. There are no signs of cardiovascular compromise. How would you manage this woman?

13. A 24-year-old multiparous woman is 23 weeks pregnant. She has not had chicken pox before. She goes to a collect her 3-year-old son from a birthday party and comes into contact with a child with an infective chicken pox infection. She is naturally very anxious. What is the best course of management?

14. A 24-year-old type 1diabetic woman has just had her first baby delivered by caesarean section at 35 weeks due to fetal macrosomia and poor blood sugar control. The operation is straightforward with no complications. She has an insulin sliding scale running when you review her on the ward 12hours postoperatively. She has begun to eat and drink. How would you manage her insulin requirements?

15. A 24-year-old woman in her first pregnancy has a significantly raised glucose tolerance test at 28 weeks gestation: 4.6 fasting 12.1 at one hour 9.1 at 2 hours (J.Lmol/L). She is given the diagnosis of GDM. You are asked to counsel her about the effects of gestational diabetes on pregnancy. Which of the following is not an additional effect of having GDM?

16. A 51-year-old woman in her 12th week of an assisted-conception triplet pregnancy presents to accident and emergency with severe nausea and vomiting. She has mild lower abdominal and back pains. Urine dipstick shows blood -ve, protein -ve, ketones ++++, glucose +. What is the most appropriate management plan?

17. A 31-year-old woman is seen in the termination of pregnancy (TOP) clinic requesting a termination. She is 5 weeks pregnant in her first pregnancy. She is otherwise well but does have some lower abdominal pain on the right hand side. On examination her abdomen is soft and non-tender. An ultrasound reveals a small sac in the uterus which might be a pseudosac. What would be your next management step?

18. A 28-year-old woman with a history of pelvic inflammatory disease is 6 weeks into her third pregnancy. She previously had two terminations. She presents with lower abdominal pain and per virginal bleeding. Her beta hCG is 1650 miU/mL, progesterone 11nmol/1. An ultrasound reveals a small mass in her left fallopian tube with no intrauterine pregnancy seen. There is no free fluid in the Pouch of Douglas. She is diagnosed with an ectopic pregnancy and is clinically stable but scared of surgery. How would you manage this case?

19. A 24-year-old woman attends her GP complaining of deep dyspareunia and post-coital bleeding. She has crampy lower abdominal pain. Of note, she has been treated in the past for gonorrhoea on more than one occasion. On speculum examination there is no visible discharge, but the cervix bleeds easily on contact. What is the most appropriate management?

20. A 24-year-old woman who is 9 weeks pregnant is brought to accident and emergency by ambulance with left iliac fossa pain and a small vaginal bleed. An abdominal ultrasound scan performed at the bedside demonstrates a corneal pregnancy and free fluid in the pelvis. Her observations are: pulse 119 bpm, blood pressure 74/40 mmHg, respiratory rate 24/minute. What is the most appropriate definitive management?

21. A 32-year-old woman with paranoid schizophrenia is admitted for antenatal assessment at 36 weeks' gestation with twins.Her pregnancy is complicated by intrauterine growth restriction and impaired placental flow. She has had no psychotic symptoms in this pregnancy .Her obstetricians recommend an early caesarean section and argue it is in the best interests of the mother and her babies and to prevent further fetal insult. She has repeatedly said that despite the significant risks, which she understands, she refuses caesarean delivery. What is the most appropriate action?

22. A 16-year-old Muslim woman attends accident and emergency department with her father. She complains of a 1-day history of left iliac fossa pain and mild vaginal spotting. A urinary beta hCG test is positive. As part of your assessment the patient consents to a vaginal examination. She insists you do not tell her father that she is pregnant, and you consider her to be competent in her judgement. Her father becomes angry and says you must not perform a vaginal examination. How should you proceed?

23. A 32-year-old woman is rushed to accident and emergency as the viction of a high speed vehicle collision. She is 35 weeks pregnant and unconscious.There is evidence of blunt abdominal trauma and she is showing signs of grade 3 hypovolaemic shock. The consultant obstetrician on call immediately attends the resus call and recommends immediate perimortem caesarean delivery in a resuscitative effort to improve the management of her shock. Her husband has been brought into resus by the police, and insists that she would refuse caesarean section under any circumstances. What is the most appropriate management?

24. A 59-year-old woman has been admitted for a hysterectomy for endometrial cancer. She has not yet given her consent and the rest of the team is in theatre. You have performed a hysterectomy before so feel confident in taking her through what will happen and the risks involve The General Medical Council (GMC) says that you should tailor your discussion to all of the options except which of the following?

25. A 15-year-old girl attends the gynaecology clinic with her boyfriend, also 15, requesting the morning after pill 4 months after being circumcised during a family trip to Somali She understands your advice and the implications of her decisions to engage in sexual activity, is using condoms regularly and refuses to inform her parents.What is the most appropriate management?

26. A 34-year-old woman with long-standing menorrhagia attends accident and emergency having fainted at home. She is on the third day of her period, which has been unusually heavy this month. She insists she cannot be pregnant as she has not had sexual intercourse for a year.She is haemodynamically stable. A point-of care test venous full blood count in the emergency department shows: Hb 5.2 gldL, WCC 8.9 .109/L, Hct 0.41% L, MCV 80 fL. What should the initial management be?

27. A 66-year-old post-menopausal woman is referred to you urgently by her general practioner (GP). She had been complaining of some lower abdominal pain. An ultrasound arranged by the GP shows a 4 em simple left ovarian cyst. A CA 125 comes back as 29 U/ml (normal 0-35 U/ml). What is the most appropriate management?

28. A 79-year-old woman attends your clinic with some vaginal bleeding. Her last period was 16 years ago. She has had two children both via caesarean section, has a normal smear history and is currently sexually active.On examination the vagina appears mildly atrophic with some raw areas near the cervix. What is the most important next step in her management?

29. At laparoscopy a 21-year-old woman is found to have severe endometriosis. There are multiple adhesions and both ovaries are adherent to the pelvic side wall.The sigmoid colon is adherent to a large rectovaginal nodule. The nodule is excised and the bowel and ovaries free Which of the following medications would be appropriate to help treat her endometriosis?

30. A 54-year-old woman comes to your clinic complaing of hot flushes and night sweats that are unbearable .Her last mentrual period was 14 months ago.She has had a levonorgestrel releasing intrauterine system (Mirena) in situ for 2 years as treatment for extremely heavy periods. What treatment would you consider for her symptoms?

31. A 41-year-old mother of two presents to the GP with long-standin g heavy menstrual bleedin g which has become worse over the past year.She is otherwise well and has no significant medical history.She requests treatment to alleviate the impact of her heavy bleeding on her sociallif Pelvic examination reveals a normal sized uterus. What is the most appropriate first line treatment?

32. A 42-year-old woman is seen in the gynaecology clinic. She has been suffering from severe premenstrual symptoms all her life. They have now significantly affected her relationship and her husband is filing for divorce. She comes to your clinic in tears regarding the future of her children. She demands a hysterectomy and bilateral salpingoophrectomy. After taking her history you talk about other less radical treatments.Which management option is inappropriate?

33. A 22-year-old woman is seen in accident and emergency with lower abdominal pain and some vaginal discharge. She has had PID once in the past and was treated for it. She is otherwise well. Her temperature is 36.9°c, pulse 90, blood pressure 105/66 mmHg. She is passing good volumes of urine. On clinical examination she has diffuse lower abdominal tenderness. There are no signs of peritonism on examing her abdomen. On vaginal examination she has adnexal tenderness and an offensive discharge. Her CRP is 28 mg!L and her white blood count is 12.2 x109/L. Her pregnancy test is negative. She is reviewed by your senior and is diagnosed with PI What would be an appropriate antibiotic regime?

34. A 24-year-old woman is in her first pregnancy. She has no significant medical history. She is 40 weeks and 2 days pregnant and has been contracting for 4 days. She is not coping with the pain. She has been given intramuscular pethidine. On examination she is found to be 4 em dilated (fetus in the occipito-posterior position) having been the same 4 hours previously. What analgesia would you recommend?

35. A 36-year-old woman is 41 weeks pregnant and is established in spontaneous labour. She is contracting three times every 10 minutes and has ruptured her membranes. She is draining significant meconium stained liquor. Her cervix is 7 em dilate Her midwife has started continuous electronic fetal monitoring using a cardiotocograph (CTG). The baseline rate has been 155, with variability of 2 beats per minute, for the past 60 minutes. There are no accelerations and no decelerations. What is the most appropriate management?

36. A multiparous woman is admitted to the labour ward with regular painful contractions. On examination she is 9 em dilated with intact membranes and is coping well with labour pains. Forty minutes later her membranes rupture while she is being examined and you see the umbilical cord hanging from her vagina. You inform the woman what has happened. She is now fully dilated, the fetal position is Direct occipitoanterior, and the presenting part is below the ischial spines. What do you do next?

37. A 34-year-old para 0 has been admitted for a post-dates induction of labour at 42 weeks. She has received 4 mg PGE2 (prostaglandin) vaginally. After 72 hours her cervix is 5 em dilate Four hours later she is still 5 em dilate On abdominal examination the fetus appears to be a normal size. The fetal head position is left occipito-transverse, and the station is -1. There is no moulding but a mild caput. She is contracting two times in every 10 minutes and has an epidural in situ. You are asked to review and make a management plan. What would be the most appropriate plan?

38. A 29-year-old woman comes to the labour ward complaining that her baby has not been moving for 72 hours. She is 36 weeks pregnant. Otherwise her pregnancy has been complicated with gestational diabetes for which she is taking insulin. On examination you fail to pick up the fetal heart. You confirm the diagnosis of an intrauterine death. The scan shows no liquor and the baby is transvers After a long discussion you explain that she unfortunately needs to deliver her baby. What is the best way for her to deliver her baby?

39. A 24-year-old woman with gestational diabetes has been progressing normally through an uncomplicated labour. The midwife delivers the head but it retracts and does not descend any further. What should the midwife do next?

40. A 29-year-old multiparous woman is in established labour contracting strongly. She is 4 em dilated and had been having regular painful contractions for 6 hours before they stopped abruptly, heralded by a sudden onset of severe, continuous lower abdominal pain. The fetal heart trace is difficult to identify, and the tocometer does not register a signal. What is the most appropriate management?

41. A 23-yea r-old woman is in her first labour. Her cervix is 6 em dilated and she is in distress. She is asking for an epidural. Before you call the anaesthetist you check her history.Which of the following would be an absolute contraindication to an epidural?

42. The obstetric team is alerted to a blue-light trauma call expected in accident and emergency. A 28-year-old woman who is 37 weeks pregnant has been involved in a high-speed road traffic collision. On arrival, where the obstetric team is on standby, her Glasgow Coma Scale score is 5 and she has a tachycardic hypotension. What is the most appropriate management sequence?

43. A 31-year-old undergoes a planned caesarean section for a breech presentation. After delivery of her healthy baby there is difficulty in delivering the placenta , as it is adhered to the uterus. She has lost 5 L of blood as a result of the placenta accrete. The placenta has been removed but she is still bleeding and is cardiovascularly unstable despite blood product replacement .What would be the most management to definitively arrest haemorrhage?

44. An 18-year-old woman has been successfully delivered of a healthy female infant by elective caesarean section for maternal request.Estimated blood loss was 1120 mL. Forty minutes after return to the recovery area, she has a brisk vaginal bleed of around a litre. Her pulse rate is 120 bpm and blood pressure is 95/55 mmHg. What should the immediate management process be?

45. An 89-year-old woman attends the gynaecology clinic with a long history of a dragging sensation in the vagina.Apart from severe aortic stenosis, she has no significant medical history. She leaks fluid when she sneezes or coughs. On examination with a Sims' speculum in the left lateral position, a grade 1uterine prolapse is seen, with an additional cystocoele.What is the most appropriate management?

46. A 46-year-old woman presents to your clinic with a 6-year history of Incontinence. She has had four children by vaginal deliveries, has a body mass index (BMI) of 35 kglm2 and suffers from hayfever. Initial examination reveals a very small cystocele. A mid-stream urine culture is negative and urodynamic studies show a weakened urethral sphincter. What is the most appropriate first line management?

47. A 25-year-old woman attends accident and emergency with an exquisitely sore, large swelling of her vagina which she noticed only a couple of days before. It has steadily got much bigger. On examination there is a soft fluctuant mass on the right labia minora which is very tender.What is the most appropriate management?

48. A 49-year-old woman presents to a private clinic expressing her desire to become pregnant. She has no past medical history. Initial investigations show that she still has ovarian function, is ovulating and is having regular periods. An ultrasound of her pelvis shows no structural abnormality and an hysterosalpingography demonstrates patent fallopian tubes. Analysis of her partner's semen is normal. Which would not be an appropriate first line management option?

49. A 42-year-old woman presents to the urogynaecology clinic with a 3-year history of urge incontinence.She has features of an overactive bladder and is desperate to start treatment for her problem as it is affecting her quality of life. She opts for medical treatment. What is the most appropriate first line pharmacological therapeutic?

50. A 16-year-old girl presents to your surgery with a history of unprotected sexual intercourse (UPSI) 70 hours ago. Her last menstrual period was 8 days ago.Her only past medical history of note is that of epilepsy which is well controlled by carbamazepine. She is worried about becoming pregnant, does not want her mother to find out and is in a hurry to get home before suspicions are raise Which of the following options are available to her?

51. A 28-year-old woman attends her GP clinic for routine cervical screening. Liquid based cytology (LBC) shows mild dyskaryosis. A repeat sample again shows mild dyskaryosis. What is the most appropriate management?

52. A 26-year-old undergoes potassium-titanyl -phosphate (KTP) laser laparoscopic excision of endometriosis. Her postoperative haemoglobin is 8.1 g!dL.Six hours postoperatively she complains of increased umbilical swelling, abdominal pain and shortness of breath and she appears pal A repeat full blood count now shows a haemoglobin count of 6.5 g!dL. What are the most appropriate steps you should take next?

53. A 54-year-old woman presents to her GP with a 1-year history of bloating, early satiety and occasional crampy pelvic pain. She was diagnosed a year ago with irritable bowel syndrome (IBS). A serum CA 125 is 62 IU/mL (normal range <36 IU/mL).What is the most appropriate management?

54. A 61-year-old woman has recently been diagnosed with a stage 1a endometrial carcinoma.She has had four children, she has mild utero-vaginal prolapse and she has never been operated on. She needs to have surgery.You see her in clinic and talk about the different operations available to her. Which is the most appropriate operation?

55. A 65-year-old woman is referred by her GP to the gynaecology clinic with increasing bloating and a raised CA 125level. ACT scan shows an irregular, enlarged left ovary and several well- circumscribed nodular lesions in the liver and on the omentum which are highly suspicious for metastatic ovarian cancer. What is the most appropriate treatment regimen?

56. A 28-year-old woman attends accident and emergency unable to walk because she is so faint. She has had heavy vaginal bleeding for 4 hours since she engaged in sexual intercourse with a new partner, which she described as 'rough and very painful'. She is still bleeding and cannot tolerate vaginal examination due to the pain. A point-of-care haemoglobin estimation is 6.4 gldL and she is haemodynamically unstable. What is the most appropriate management?

57. A 64-year-old woman with asthma is admitted to the ward prior to an elective vaginal hysterectomy for symptomatic uterine prolapse. Her medications include Seretide (fluticasone/salmeterol500/50) four times daily and oral prednisolone 20 mg twice daily. What is the most important peri-operative consideration?

58. A 46-year-old woman is returned to the ward from the recovery room following a routine vaginal hysterectomy for heavy period s and prolapse. The estimated blood loss at operation was 200 mL. Two hours later the ward sister becomes concerned that her urine output is low and calls the doctor.Her observations show: pulse 115 bpm, BP 90/62 mmHg, temperature 37.1o What are the most appropriate next steps in her management?

59. A 20-year-old female attends clinic requesting advice on appropriate contraception. She has a steady relationship and has no desire to start a family. There are no risk factors for venous thrombosis in her family history and she drinks approximately 12 units of alcohol each week. Apart from acne, she is otherwise fit and well. She has a body mass index of 35.5 kg/m2 and a blood pressure of 122/70 mmHg. Which of the following contraceptives would be most appropriate for this patient?

60. A 14-year-old girl presents to her health care provider informing him that she has missed two periods and that she has a pregnancy test confirming that she is pregnant. She has a boyfriend who is 15 and has been having protected sex with condoms for six months. She wants a termination but does not want to involve her parents at all. She is counselled regarding abortion and what it entails and is also asked to involve her parents, but she flatly refuses, indicating that she will otherwise get an abortion elsewhere. She understands the risks of having an abortion. What is the most appropriate action for this patient?

61. A 27-year-old female presents with a three hour history of vaginal bleeding, abdominal pain and right shoulder tip pain. Her past history includes pelvic inflammatory disease (PID), a miscarriage and two terminations. A urine pregnancy test is positive. From the following, which is the most appropriate next step of management?

62. A 51-year-old woman attends her GP concerned about her risk of osteoporosis. She had a hysterectomy and oophorectomy because of uterine fibroids one year ago, followed by mild hot flushes which have since resolve Recently her mother broke her hip at the age of 72, and the patient is worried about the possibility of fracture. She asks about medications for osteoporosis. Her body mass index is 17.3 kg/m2 and the subsequent T score is <-2.5. She received Depo­ Provera from the age of 39 to 45, during which time she was amenorrhoea. Breast examination and the remainder of the physical examination are normal. Which of the following would you recommend to her?

63. A 22-year-old nulliparous female, who is not sexually active, seeks treatment for menorrhagia and primary dysmenorrhoea, but she does not want a contraceptive treatment. Which of the following is the most appropriate choice, initially?

64. A 36-year-old overweight woman presents with irregular heavy bleeding. Her endometrial biopsy reveals cystic hyperplasia but no atypia. Which of the following would be the most appropriate treatment for this woman?

65. A 25-year-old woman who has three children and has recently undergone a second termination of pregnancy presents with menorrhagia and seeks appropriate contraceptive advice. Which of the following would be the most appropriate agent for this patient?

66. A 35-year-old female presents with menorrhagia that has not responded to treatment with non­ steroidal anti-inflammatory drugs. One year ago she underwent sterilisation. Which of the following would be the most appropriate treatment for her?

67. A 25-year-old woman is admitted on the medical intak She is 10 weeks post-partum and has been generally unwell for two weeks with malaise sweats and anxiety. On examination she is haemodynamicall y stable, and clinically euthyroid. TFTs show the following: Free T4: 33pmol/L (9-23); Free T3: 8 nmol/L (3.5-6); TSH <0.02mUIL (0.5-5). What is the appropriate management ?