(a) (i) Name the clinical tests for checking sapheno-femoral junction competence and deep venous system patency. (ii) Enumerate…

(a)(i) Clinical tests

• Sapheno-femoral junction (SFJ) competence: Brodie-Trendelenburg test. With the leg elevated and veins emptied, a tourniquet (or thumb) occludes the SFJ, the patient stands and the tourniquet is released. Rapid filling from above indicates SFJ incompetence.
• Deep venous patency: Perthes test. A tourniquet is applied below the SFJ and the patient walks or does tiptoe exercises. Emptying of the superficial varices means the deep veins are patent and perforators competent, while increased bursting pain and engorgement mean deep vein obstruction.

(a)(ii) Complications of varicose veins

1. Venous (stasis) eczema, pruritus and haemosiderin pigmentation.
2. Lipodermatosclerosis (inverted champagne-bottle leg) and atrophie blanche.
3. Venous ulceration in the gaiter area, usually above the medial malleolus.
4. Superficial thrombophlebitis, with risk of extension into deep veins (DVT).
5. Haemorrhage from rupture of a thin-walled varix, which can be profuse.
6. Periostitis of the tibia, equinus deformity and, rarely, Marjolin’s ulcer (squamous cell carcinoma) in a long-standing ulcer.

(a)(iii) Management of venous ulcer

• Assessment: duplex ultrasound for reflux and deep patency, ankle-brachial index (ABI above 0.8 before high compression), swab only if clinically infected, biopsy of atypical ulcers.
• Compression is the cornerstone: four-layer or short-stretch bandage (about 40 mmHg at the ankle) or Unna’s boot, then class II-III stockings for life after healing.
• Elevation of the limb above heart level and calf-muscle pump exercises.
• Local care: debridement of slough, treatment of infection, simple non-adherent moist dressings.
• Drugs: pentoxifylline or micronised purified flavonoid fraction to speed healing.
• Correction of superficial reflux (endovenous laser or radiofrequency ablation, foam sclerotherapy, SFJ ligation with stripping) to reduce recurrence. Split-skin grafting for large clean ulcers.

(b)(i) Management of acute retention

1. Confirm a palpable tender bladder, look for constipation and drugs (anticholinergics).
2. Urethral catheterisation under asepsis with a 14-16 Fr Foley and lignocaine gel. Record the residual volume (over 1 litre suggests acute-on-chronic retention).
3. If catheterisation fails, no force: suprapubic catheter (cystostomy) under local anaesthesia, ideally ultrasound-guided.
4. Monitor urine output, renal function and electrolytes for post-obstructive diuresis, send urine culture.
5. Start an alpha-blocker (tamsulosin or alfuzosin) and attempt trial without catheter after 2-3 days.

(b)(ii) Definitive management

• Evaluation: digital rectal examination, PSA, serum creatinine, urine analysis, ultrasound KUB (prostate volume, upper tracts, post-void residue), IPSS score, uroflowmetry once voiding, cystoscopy if needed.
• Acute retention after years of LUTS, or failed trial without catheter, is an indication for surgery. Other indications: recurrent UTI, bladder stones, haematuria, upper tract dilatation or renal impairment.
• Surgery: TURP for glands of about 30-80 g, HoLEP or open prostatectomy (Millin retropubic, Freyer transvesical) for larger glands, TUIP for small glands.
• Medical therapy if unfit or if the trial without catheter succeeds: alpha-blocker plus 5-alpha-reductase inhibitor (finasteride, dutasteride) for large glands. Follow up with IPSS and residual urine.

(c) Shock with retained placenta and previous LSCS

The likely causes are postpartum haemorrhage from retained placenta, morbidly adherent placenta (placenta accreta spectrum, common after caesarean) and scar rupture.

1. Call for help, high-flow oxygen, two wide-bore cannulae, blood for grouping, cross-match (4-6 units), CBC and coagulation profile, start warm crystalloids and transfuse early (massive transfusion protocol if needed).
2. Foley catheter for hourly urine output, keep the patient warm, monitor vitals.
3. Oxytocin infusion, tranexamic acid 1 g IV, broad-spectrum antibiotics.
4. Once stabilised, manual removal of placenta under anaesthesia in theatre, followed by uterotonics (oxytocin, carboprost 250 µg IM, misoprostol) and exploration of the cavity and scar.
5. If the placenta does not separate (accreta) or there is scar rupture or uncontrolled bleeding: laparotomy for repair of rupture, uterine and internal iliac artery ligation, or obstetric hysterectomy.
6. ICU care, correction of coagulopathy, watch for renal failure and Sheehan’s syndrome.

(d)(i) Contraindications to combined oral pills

1. Current or past DVT or pulmonary embolism, known thrombogenic mutations.
2. Ischaemic heart disease, stroke, complicated valvular heart disease.
3. Migraine with aura.
4. Smoker aged 35 years or more (15 or more cigarettes a day).
5. Severe hypertension (160/100 mmHg or more) or vascular disease, diabetes with vascular complications.
6. Current breast cancer.
7. Active liver disease, liver tumours.
8. Breastfeeding under 6 weeks postpartum, major surgery with prolonged immobilisation.
9. Pregnancy and undiagnosed genital bleeding.

(d)(ii) Causes of sterilisation failure

• Females: recanalisation of tubal stumps or tuboperitoneal fistula, ligation of the wrong structure (round ligament), incomplete occlusion, slipped or misplaced clips or rings, luteal phase pregnancy (conception before the operation). Failure carries a high risk of ectopic pregnancy.
• Males: unprotected intercourse before azoospermia is confirmed (3 months or semen analysis), spontaneous recanalisation of the vas, ligation of the wrong structure, failure to excise a segment, rare duplication of the vas.

(e) National guidelines on infant and young child feeding

Issued by the Ministry of Women and Child Development (Food and Nutrition Board), 2004, second edition 2006:

1. Breastfeeding within one hour of birth, feeding colostrum, no prelacteal feeds.
2. Exclusive breastfeeding for the first six months.
3. Complementary foods from six months, adequate in amount, frequency, consistency and variety, prepared hygienically.
4. Continued breastfeeding up to two years or beyond.
5. Active, responsive feeding, extra feeding during and after illness, special care for low birth weight infants and HIV-positive mothers, and enforcement of the IMS Act.

Goals:

1. Advocate infant and young child nutrition through optimal feeding nationwide.
2. Spread correct norms of breastfeeding and complementary feeding from policy level to the public in regional languages.
3. Raise awareness and commitment of government sectors, national organisations and professional groups.
4. Achieve national IYCF targets so as to reduce malnutrition and, through it, infant and child mortality.