MRCOG Part 2 Mastery

This presentation is classic for HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe variant of pre-eclampsia.

• Key features supporting HELLP syndrome:
  • Elevated liver enzymes (ALT 120, AST 115 – normal <40 U/L)
  • Thrombocytopenia (platelets 85,000 – normal >150,000/μL)
  • Elevated LDH (450 U/L – suggests hemolysis)
  • Hypertension and proteinuria (pre-eclamptic features)
  • Right upper quadrant/epigastric pain
• Why other options are less likely:
  • Option A: Acute fatty liver typically presents later (>35 weeks) with more severe coagulopathy and hypoglycemia
  • Option C: Severe pre-eclampsia alone wouldn’t explain the liver enzyme elevation and thrombocytopenia
  • Option D: Acute cholecystitis would show different pain pattern and wouldn’t cause thrombocytopenia
  • Option E: Hyperemesis gravidarum occurs in early pregnancy, not at 36 weeks

In a woman over 45 years with heavy menstrual bleeding and thickened endometrium, endometrial sampling is essential to exclude malignancy before considering treatment options.

• Key clinical features requiring investigation:
  • Age >45 years (increased risk of endometrial cancer)
  • Heavy menstrual bleeding with recent onset/change
  • Thickened endometrium (15mm – abnormal for reproductive age)
  • Need to exclude endometrial hyperplasia or carcinoma
• NICE guidance: Endometrial biopsy should be performed in women >45 years with heavy menstrual bleeding, particularly with thickened endometrium on ultrasound
• Why other options are premature:
  • Options A, C, D, E: All are potential treatments but inappropriate until malignancy is excluded
  • Histological diagnosis must precede treatment planning

Recurrent late decelerations indicate uteroplacental insufficiency and fetal hypoxia. Immediate intrauterine resuscitation should be attempted first.

• Late decelerations significance:
  • Indicate uteroplacental insufficiency
  • Gradual decrease in FHR beginning after contraction peak
  • Return to baseline after contraction ends
  • Associated with fetal hypoxia and acidosis
• Immediate intrauterine resuscitation measures:
  • Change maternal position (left lateral to improve venous return)
  • Administer high-flow oxygen
  • Increase IV fluids if hypotensive
  • Discontinue oxytocin if running
• Why other options are inappropriate initially:
  • Option A: Inappropriate to wait with pathological FHR pattern
  • Option B: Too precipitous – attempt resuscitation first
  • Option D: Cervix not fully dilated, head not engaged
  • Option E: May delay necessary intervention

The constellation of symptoms and the specific demographic (pre-pubertal black girl) strongly point towards urethral mucosal prolapse.

• Option A: Correct. Urethral mucosal prolapse is a condition where the urethral mucosa protrudes through the external urethral meatus. It is most common in pre-pubertal black girls and post-menopausal women. The typical presentation includes vaginal bleeding (often mistaken for menstrual bleeding), dysuria, urinary frequency, and a visible, often doughnut-shaped, reddish-purple mass at the introitus. The symptoms of superficial dyspareunia and frequent UTIs are also consistent with irritation and obstruction caused by the prolapse.
• Option B: Incorrect. A vaginal foreign body can cause vaginal bleeding, discharge, and recurrent UTIs, but it would typically be located within the vagina and not present as a bulging mass specifically at the urethral meatus.
• Option C: Incorrect. A urethral caruncle is a benign fleshy growth at the urethral meatus, typically seen in post-menopausal women. While it can cause dysuria and bleeding, it is rare in pre-pubertal girls and usually appears as a single, small lesion rather than a circumferential prolapse.
• Option D: Incorrect. Rhabdomyosarcoma of the vagina (sarcoma botryoides) is a rare but aggressive childhood cancer that can present with vaginal bleeding and a polypoid mass protruding from the vagina. However, it is typically described as a “grape-like” cluster and would not specifically be a urethral mass. While it’s a differential for vaginal bleeding in this age group, the specific description of a “bulging mass” at the introitus with urinary symptoms makes urethral prolapse more likely.

• Urethral mucosal prolapse is thought to be due to a weakness in the muscular attachments of the urethra, often exacerbated by increased intra-abdominal pressure (e.g., coughing, straining).
• Management:
  • Conservative: Sitz baths, topical oestrogen cream, and analgesia for mild cases.
  • Surgical: Excision and primary repair for symptomatic, necrotic, or recurrent cases.
• It is important to differentiate urethral mucosal prolapse from other conditions such as urethral caruncle, urethral polyp, or even sexual abuse (though the latter would have other signs).

• Key Differentiating Features:

  • Urethral Mucosal Prolapse: Circumferential, reddish-purple mass at the urethral meatus, common in pre-pubertal black girls.
  • Urethral Caruncle: Small, single, red lesion at the posterior aspect of the urethral meatus, common in post-menopausal women.
  • Rhabdomyosarcoma: “Grape-like” mass, typically originating from the vagina, can be aggressive.

The patient’s symptoms are highly suggestive of overactive bladder (OAB), and her reported fluid intake is excessive, making lifestyle modifications the most appropriate first-line intervention.

• Option A: Incorrect. While anticholinergic medications (e.g., oxybutynin, solifenacin) are a common pharmacological treatment for OAB, they are typically considered after lifestyle modifications and conservative measures have been tried and failed.
• Option B: Incorrect. Bladder training exercises (e.g., timed voiding, delaying voiding) are a key component of conservative management for OAB and are highly effective. However, addressing the excessive fluid intake is a more fundamental and immediate first step, as it directly contributes to the high urinary frequency and urgency.
• Option C: Correct. The patient’s reported fluid intake of 4 litres per day is excessive and is a clear contributing factor to her symptoms of polyuria, nocturia, urgency, and urge incontinence. The most appropriate initial advice is to modify her fluid intake to a more normal and appropriate level (e.g., 1.5-2 litres per day, spread throughout the day, with reduced intake before bedtime). This simple lifestyle change can significantly improve symptoms and should always be tried before escalating to other treatments.
• Option D: Incorrect. Urodynamic studies are invasive investigations reserved for cases where the diagnosis is unclear, conservative management has failed, or before surgical intervention. They are not an initial management step for straightforward OAB symptoms, especially when a clear modifiable factor like excessive fluid intake is identified.

• Overactive Bladder (OAB) is characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of urinary tract infection or other obvious pathology.
• First-line management for OAB (as per NICE guidelines) focuses on conservative measures:
  • Lifestyle advice: Fluid modification (reducing excessive intake, avoiding bladder irritants like caffeine/alcohol), weight management.
  • Bladder training: Gradually increasing the time between voids.
  • Pelvic floor muscle training.
• Pharmacological treatments (anticholinergics, beta-3 agonists) are second-line, and more invasive treatments (e.g., Botox injections, sacral neuromodulation) are third-line.

• Fluid Intake Recommendations:

  For most adults, a daily fluid intake of 1.5 to 2 litres is considered adequate. Excessive intake can exacerbate urinary symptoms, while insufficient intake can lead to concentrated urine, which also irritates the bladder.