Professional and Linguistic Assessments Board (PLAB) Obstetrics, Gynaecology and Sexual Health Syllabus

What are the seven cardinal movements of labour?

Engagement, descent, flexion, internal rotation, extension, external rotation (restitution), and expulsion.

On a partogram, what do the 'alert' and 'action' lines indicate?

The alert line marks expected minimum progress ($1\ \text{cm/h}$); crossing it signals slow progress. The action line (drawn to the right of alert) triggers intervention/escalation when crossed.

What is the immediate management of shoulder dystocia (first-line manoeuvre)?

McRoberts manoeuvre: hyperflexion and abduction of the maternal hips, plus suprapubic pressure. Call for help and avoid fundal pressure.

List the four 'T' causes of primary postpartum haemorrhage.

Tone (uterine atony, most common), Trauma (lacerations), Tissue (retained placenta), and Thrombin (coagulopathy).

Define primary postpartum haemorrhage.

Blood loss of $\geq 500\ mL$ from the genital tract within 24 hours of delivery. Loss $> 1000\ mL$ or with shock is a major PPH.

What is the stepwise medical management of uterine atony causing PPH?

Uterine massage/bimanual compression, then uterotonics: IV/IM oxytocin, ergometrine (avoid in hypertension), carboprost (avoid in asthma), and misoprostol.

What is the pathophysiology and presentation of amniotic fluid embolism?

Amniotic fluid enters maternal circulation, triggering anaphylactoid reaction and DIC. Sudden cardiovascular collapse, hypoxia, seizures and coagulopathy during labour or shortly after delivery.

What is cord prolapse and its immediate management?

Umbilical cord descends through the cervix below the presenting part after membrane rupture. Manage by elevating the presenting part (manually or knee-chest/Trendelenburg position), avoiding handling the cord, and urgent caesarean delivery.

Define puerperal pyrexia and a key cause.

Temperature $\geq 38^{\circ}\text{C}$ in the first 14 days postpartum. Common causes include endometritis (most common), UTI, mastitis, wound/perineal infection, and VTE.

What features distinguish postpartum 'baby blues', postnatal depression, and puerperal psychosis?

Baby blues: transient low mood days 3-10, self-limiting. Postnatal depression: persistent depression peaking around 1-3 months. Puerperal psychosis: rapid onset within 2 weeks with delusions/hallucinations, a psychiatric emergency.

What is Sheehan's syndrome?

Postpartum hypopituitarism due to pituitary ischaemic necrosis following severe PPH. Presents with failure of lactation, amenorrhoea, and features of hormone deficiency.

What are the three classic features of a typical ectopic pregnancy presentation?

Lower abdominal pain, amenorrhoea (6-8 weeks), and vaginal bleeding. Shoulder-tip pain and cervical excitation suggest peritoneal irritation/rupture.

What is the medical treatment for a suitable unruptured ectopic pregnancy?

Single-dose intramuscular methotrexate (with serum hCG follow-up), suitable when the woman is stable, hCG is low ($< 1500\ \text{IU/L}$, up to 5000), mass $< 35\ mm$, no fetal heartbeat.

Define a miscarriage and distinguish threatened from inevitable miscarriage.

Loss of pregnancy before 24 weeks. Threatened: bleeding with a closed cervix and viable pregnancy. Inevitable: bleeding with an open cervix; miscarriage will proceed.

What hCG pattern and ultrasound finding characterise a complete molar pregnancy?

Markedly elevated $\beta$-hCG with a 'snowstorm'/'bunch of grapes' appearance on ultrasound and no fetal tissue (diploid, entirely paternal genome).

What is the medical management of miscarriage?

Vaginal or oral misoprostol (a prostaglandin analogue) to induce passage of products; mifepristone is added for missed miscarriage in some protocols. Anti-D is given to Rh-negative women after surgical management.

Define menorrhagia and state the first-line medical treatment if the woman wants contraception.

Heavy menstrual bleeding affecting quality of life. First-line is the levonorgestrel intrauterine system (Mirena) when contraception is acceptable.

What are the first-line non-hormonal treatments for menorrhagia in a woman not wanting contraception?

Tranexamic acid (antifibrinolytic, for heavy flow) and mefenamic acid (NSAID, especially with dysmenorrhoea), taken during menstruation.

Distinguish primary from secondary dysmenorrhoea.

Primary: painful periods without underlying pathology, starting soon after menarche, due to prostaglandins. Secondary: develops later, due to pathology such as endometriosis, fibroids, PID, or adenomyosis.

List the Rotterdam criteria for polycystic ovary syndrome.

Two of three: oligo-/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound ($\geq 12$ follicles or ovarian volume $> 10\ \text{mL}$).

What hormonal change defines the menopause and what is the diagnostic clinical criterion?

Loss of ovarian follicular activity with low oestrogen and raised FSH. Diagnosed clinically as 12 months of amenorrhoea (no period), typically around age 51.

Why must a progestogen be added to oestrogen in HRT for women with a uterus?

Unopposed oestrogen causes endometrial hyperplasia and increases the risk of endometrial cancer; the progestogen protects the endometrium.

What is the main benefit and the main risk of combined HRT?

Benefit: relief of vasomotor symptoms and protection against osteoporosis. Risk: small increased risk of breast cancer (combined) and venous thromboembolism (oral route).

What is premature ovarian insufficiency and its hormonal profile?

Menopause before age 40 due to loss of ovarian function. Biochemically: elevated FSH (e.g. $> 25\ \text{IU/L}$ on two occasions) with low oestradiol.

What is endometriosis and its gold-standard diagnostic investigation?

Presence of endometrial-like tissue outside the uterus, causing cyclical pain, dysmenorrhoea, dyspareunia, and subfertility. Laparoscopy is the gold-standard diagnostic (and therapeutic) investigation.

Describe the typical features of uterine fibroids (leiomyomas).

Benign oestrogen-dependent smooth-muscle tumours causing menorrhagia, bulk/pressure symptoms, and subfertility. They enlarge in pregnancy and regress after menopause.

Which gene mutations most increase the risk of ovarian (and breast) cancer?

BRCA1 and BRCA2 mutations. Ovarian cancer is also associated with Lynch syndrome (HNPCC).

What is the most important risk factor for cervical cancer, and what is the screening/prevention strategy?

Persistent high-risk human papillomavirus (HPV types 16 and 18) infection. Prevention is HPV vaccination plus cervical screening with HPV primary testing (cytology if HPV positive).

What is the classic presentation and main risk factors for endometrial cancer?

Postmenopausal bleeding is the cardinal symptom. Risk factors reflect unopposed oestrogen: obesity, nulliparity, late menopause, PCOS, tamoxifen, and unopposed oestrogen HRT.

Compare the typical mechanisms of the combined oral contraceptive pill versus the progestogen-only pill.

COCP mainly inhibits ovulation (suppresses FSH/LH) and also thickens cervical mucus and thins endometrium. Traditional POP mainly thickens cervical mucus; desogestrel POP also reliably inhibits ovulation.

What is the failure rate (Pearl-type 'typical use') ranking that makes LARCs preferred, and give examples of LARCs?

Long-acting reversible contraceptives (copper IUD, levonorgestrel IUS, progestogen implant, injection) are most effective ($> 99\%$) because they are not user-dependent. The implant is the most effective ($< 1$ pregnancy per 1000 over 3 years).

What are key UKMEC category 4 (absolute) contraindications to the combined oral contraceptive pill?

Migraine with aura, history of VTE/thrombophilia, breast cancer, uncontrolled hypertension, smoking $\geq 15$/day at age $\geq 35$, and $< 6$ weeks postpartum if breastfeeding.

Compare the two methods of emergency contraception and their time windows.

Copper IUD: most effective, up to 5 days after unprotected sex or earliest estimated ovulation. Oral: levonorgestrel within 72 h; ulipristal acetate (ellaOne) within 120 h.

What is the mechanism of the copper IUD when used as emergency contraception?

Copper is toxic to sperm and ova (impairs fertilisation) and the IUD induces an endometrial inflammatory reaction preventing implantation.

What advice is given if a woman vomits within 2-3 hours of taking oral emergency contraception?

The dose may not have been absorbed; she should take another dose. Consider an antiemetic or a copper IUD instead.

What organism causes chlamydia, and what is the first-line treatment in the UK?

Chlamydia trachomatis. First-line treatment is doxycycline $100\ mg$ twice daily for 7 days (azithromycin if doxycycline contraindicated, e.g. pregnancy).

What is the classic presentation and treatment of gonorrhoea?

Caused by Neisseria gonorrhoeae; purulent urethral/cervical discharge and dysuria. First-line treatment is a single intramuscular dose of ceftriaxone $1\ g$.

Describe the three stages of syphilis caused by Treponema pallidum.

Primary: painless chancre. Secondary: rash (including palms/soles), condylomata lata, lymphadenopathy. Tertiary: gummata, cardiovascular (aortitis), and neurosyphilis. Treated with benzathine penicillin.

Differentiate bacterial vaginosis from trichomoniasis on examination and discharge.

BV: thin grey-white discharge, fishy odour, clue cells, pH $> 4.5$, no inflammation (Gardnerella, overgrowth). Trichomoniasis: frothy yellow-green discharge, vulvovaginitis, 'strawberry cervix' (Trichomonas vaginalis). Both treated with metronidazole.

What is pelvic inflammatory disease and a key long-term complication?

Ascending infection of the upper genital tract (often Chlamydia/Gonorrhoea) causing lower abdominal pain, discharge, and cervical excitation. Long-term complications include infertility, ectopic pregnancy, and chronic pelvic pain.

Within what timeframe should HIV post-exposure prophylaxis (PEPSE) be started after sexual exposure?

As soon as possible, ideally within 24 hours and no later than 72 hours after exposure; a 28-day course of antiretrovirals is given.

What is the age of consent and the key principle for providing contraception to under-16s in the UK?

Age of consent is 16. Under-16s can receive contraception without parental consent if they meet the Fraser guidelines (sufficient maturity/understanding, cannot be persuaded to inform parents, likely to have sex regardless, health at risk, in their best interests).