Antenatal Care

Question 1

What percentage of the UK pregnant population are offered invasive screening per year?

a. 0.5%
b. 1%
c. 2.5%
d. 5%
e. 7.5%

Answer 1

D - 5%

Approximately 30,000 women are offered invasive prenatal diagnostic testing each year in the UK – equivalent to around 5% of the total obstetric population.

Question 2

What is the maximum outer-gauge needle size used in diagnostic amniocentesis?

a. 0.3mm
b. 0.5mm
c. 0.9mm
d. 1.0mm
e. 1.2mm

Answer 2

C - 0.9mm

The maximum (outer) needle gauge for use in amniocentesis procedures is 0.9mm, equivalent to 20G. There is no firm evidence on the maximum diameter recommended for CVS.

Question 3

A subspecialty trainee is learning to perform amniocentesis and CVS. What is the minimum number of procedures performed per annum required to maintain competency in invasive testing?

a. 30
b. 50
c. 75
d. 100
e. 120

Answer 3

A - 30

The RCOG advise that those performing invasive procedures should be performing a minimum of 30 per annum to maintain competency. Rates of miscarriage are estimated in some studies to be up to 6-8x higher amongst less experienced when compared with ‘very experienced’ operators performing >100 procedures per annum. The guideline does not set 30 as an absolute minimum threshold though suggests that those performing less than 30 procedures each year should meticulously audit their own data to evidence safety.

Question 4

A patient attends for a CVS following a high risk combined test result. On first pass, the operator is unsuccessful in obtaining a satisfactory specimen. What is determined to be an acceptable ‘second insertion’ rate for a given practitioner in invasive testing?

a. 1 in 100
b. 3 in 100
c. 4 in 100
d. 6 in 100
e. 7 in 100

Answer 4

E - 7 in 100

7 cases of ‘second-insertion’ per 100 consecutive procedures is quoted as the upper limit of acceptability. Guidelines suggest that in all cases, no more than 2 attempts should be made by a single practitioner – if unsuccessful twice, a more experienced or senior operator should take over.

Question 5

What is the quoted risk of severe maternal sepsis following amniocentesis or CVS?

a. <1 in 1000
b. 2 in 1000
c. 5 in 1000
d. 7 in 1000
e. 1 in 100

Answer 5

A - <1 in 1000

Severe sepsis (including maternal death) is reported following invasive testing though is rare (<1 in 1000). Potential routes of infection include skin contaminants, inadvertent bowel perforation or organisms present on the probe or gel. Use of a sterile field, sterile gel, probe covers and aseptic precautions help to decrease the risk.

Question 6

With continuous ultrasound visualisation of the needle, what is the incidence of blood-stained specimen collection (‘bloody tap’) in amniocentesis?

a. 1/100
b. 4/100
c. 1/1000
d. 8/1000
e. 15/1000

Answer 6

D - 8/1000

The incidence of blood-stained amniocentesis varies, though with continued visualisation of the needle throughout the procedure, is reduced from ~2.4% to 0.8% - equivalent to 8 bloody taps per 1000 procedures.

Question 7

What is the maximum gauge of the outer needle used in amniocentesis?

a. 22G
b. 20G
c. 16G
d. 14G
e. 12G

Answer 7

B - 20G

The maximum (outer) needle gauge for use in amniocentesis procedures is 0.9mm, equivalent to 20G. There is no firm evidence on the maximum diameter recommended for CVS.

Question 8

In additional to the increased rate of fetal loss, which of the following is increased in those undergoing ‘early’ amniocentesis (i.e. <15/40) compared with when the procedure is performed beyond 15/40?

a. Fetal growth restriction
b. Bloody tap
c. Talipes
d. Long bone deformities
e. Neural tube defects

Answer 8

C - Talipes

While technically possible, amniocentesis generally should not be performed prior to 15+0/40 owing to an increased risk of fetal loss, talipes and respiratory morbidity compared with procedures performed after 15/40.

Question 9

A Para 3 attends for review in fetal medicine at 14+2/40 after receiving a ‘high-risk’ result on her combined screening. She opts for invasive testing. Within which gestational age timeframe can chorionic villus sampling be performed?

a. 9+0 > 14+6
b. 10+0 > 13+6
c. 11+0 > 13+6
d. 12+0 > 14+6
e. 12+0 > 15+6

Answer 9

C - 11+0 > 13+6

CVS may be performed either transabdominally or transcervically (dependent on operator experience) between 11+0 and 13+6 weeks gestation. Amniocentesis should not be performed earlier than 15+0/40. The patient in the scenario will require an amniocentesis.

Question 10

A patient attends the fetal medicine clinic at 15+2/40. She was originally seen with a ‘high-risk’ result on combined screening at 13/40 though it was not possible to perform a CVS owing to placental position. She now wishes to proceed with an amniocentesis. What is the increased risk of miscarriage associated with amniocentesis in addition to background risk?

a. 0.5%
b. 1%
c. 1.5%
d. 2%
e. 2.5%

Answer 10

B - 1%

Women should be informed that the ‘additional’ risk of miscarriage following amniocentesis (that is to say, in addition to existing background risk) is 1% with a ‘slightly higher’ risk for CVS (the guideline does not commit to a number). Several large cohort studies have suggested that the true rate is probably lower, though 1% should be used in counselling patients.

Question 11

A late-booker is offered invasive testing after undergoing her first scan in pregnancy at 31/40. Unfortunately this scan highlights a number of abnormalities which may indicate a chromosomal abnormality. Compared with second trimester amniocentesis, which of the following is increased when the procedure is performed in the third trimester?

a. Emergency delivery
b. Oligohydramnios
c. Fetal growth restriction
d. Bloody tap
e. Infection

Answer 11

D - Bloody Tap

Third trimester amniocentesis is associated with a higher risk of bloody tap (est. 5-10% in one study) and (perhaps surprisingly) multiple attempts (est. 5%) when compared with second trimester procedures. This may be in part attributable to the fact that in addition to late karyotyping as required in this scenario, a number of third trimester procedures are carried out with the intention of detecting suspected fetal infection in the setting of PPROM.

Question 12

A patient who is HIV positive attends for invasive screening after a high risk quadruple test. She is taking highly active anti-retroviral therapy (HAART) and has an undetectable viral load and normal CD4 count. What threshold is advised before undertaking invasive testing in HIV positive mothers?

a. Viral load <1000 copies/ml
b. Viral load <400 copies/ml
c. Viral load <100 copies/ml
d. Undetectable viral load
e. Invasive testing is contraindicated in HIV positive patients

Answer 12

D - Undetectable viral load

All patients undergoing invasive testing should have their blood-borne virus status reviewed prior to the procedure. In HIV positive patients, consideration should be given to delaying the procedure until there is no detectable viral load in patients on treatment. In patients not currently on anti-retroviral therapy, this should be considered before invasive testing is performed. Testing can be performed on women who carry Hep B or C though evidence to support this is lacking. The limited data available appears to suggest the risk of transmission is very low (Hep B) or not increased at all (Hep C). It is worth noting that the exact terminology used differs slightly between the RCOG Green Top Guideline (which states that an ‘undetectable’ viral load must be achieved prior to invasive testing) and the BHIVA Guideline on HIV in Pregnancy (which states <50 copies/ml, though surrounding text suggests that this threshold and ‘undetectable’ may be considered interchangeable).

Question 13

The varicella zoster virus which causes chickenpox belongs to the family of Human Herpes viruses – which number is it allocated?

a. 1
b. 2
c. 3
d. 4
e. 5

Answer 13

C - 3

Varicella zoster belongs the human herpes-virus family of DNA viruses. It is also known as human herpes-virus 3.

Question 14

What is the incubation period of chickenpox infection?

a. 1-2 days
b. 4-5 days
c. 7-10 days
d. 7-21 days
e. 3-4 weeks

Answer 14

D - 7-21 days

Chickenpox has an incubation period ranging from 1-3 weeks; or 7-21 days

Question 15

How long prior to appearances of the chickenpox rash does an infected individual become capable of passing on the virus?

a. At the time of the rash appearing
b. 24 hours
c. 48 hours
d. 72 hours
e. 5 days

Answer 15

C - 48 hours

Individuals with chickenpox are potentially infectious from approximately 48 hours prior to the appearance of the rash until all vesicles have crusted over. This has implications for susceptible pregnant women who may have exposure to an infected individual without knowing it as the rash is yet to appear.

Question 16

What is the approximate incidence of primary VZV infection (chickenpox) in pregnancy in the UK?

a. 3 in 10,000
b. 3 in 1000
c. 7 in 10,000
d. 7 in 1000
e. 1 in 300

Answer 16

B - 3 in 1000

90% of women in the UK are seropositive for VZV although the number may be considerably lower in women from overseas, particularly those from the tropics. It is not routine practice in the UK to test booking bloods for VZV IgG though this can be done on request if required – usually a simple enquiry about a past history of chickenpox will suffice. Around 3 in 1000 pregnancies are complicated by chickenpox on average.

Question 17

What percentage of individuals in the UK are seropositive for varicella zoster virus (chickenpox) IgG?

a. 50%
b. 60%
c. 75%
d. 90%
e. 95%

Answer 17

D - 90%

90% of women in the UK are seropositive for VZV although the number may be considerably lower in women from overseas, particularly those from the tropics. It is not routine practice in the UK to test booking bloods for VZV IgG though this can be done on request if required – usually a simple enquiry about a past history of chickenpox will suffice. Around 3 in 1000 pregnancies are complicated by chickenpox on average.

Question 18

You are asked to review a patient on the post-natal ward who is known to be VZV (chickenpox) seronegative and has been advised to have post-partum vaccination. She asks for more information on the vaccine – specifically how the vaccine is administered. How do you counsel her?

a. Single dose live-attenuated vaccine.
b. Single dose inactivated vaccine
c. Two dose live-attenuated vaccine, 4-8 weeks apart
d. Two dose inactivated vaccine 3-4 months apart
e. Two dose subunit/conjugated vaccine, 4-8 weeks apart

Answer 18

C - Two dose live-attenuated vaccine, 4-8 weeks apart

Vaccination for VZV is via a live-attenuated vaccine given in 2 doses 4-8 weeks apart. As it is a live vaccine it cannot be given in pregnancy though may be given postnatally or pre-conceptually. Deferring pregnancy for 4 weeks after the second dose is advised however. It is safe for women who have been vaccinated to be around pregnant women though not if a post-vaccine rash appears - while this is unlikely, cases of transmission of vaccine virus have been reported. Small studies have failed to detect evidence of the vaccine in breast-milk when given postpartum thus it is safe to breastfeed.

Question 19

A patient on the postnatal ward requires vaccination against chickenpox. She is keen to breastfeed though has some concerns regarding the safety of the vaccine in breastfeeding. She is also hopes to rely on breastfeeding for contraception initially though asks about whether or not falling pregnant after the vaccine would be an issue. What do you tell he?

a. Breastfeeding safe though avoid pregnancy for 4 weeks
b. Breastfeeding safe, no restrictions on pregnancy
c. Avoid vaccine while breastfeeding and avoid conception for 4 months
d. Avoid vaccine while breastfeeding, no restrictions on pregnancy
e. Avoid vaccine while breastfeeding and avoid conception for 4 weeks

Answer 19

A - Breastfeeding safe though avoid pregnancy for 4 weeks

Vaccination for VZV is via a live-attenuated vaccine given in 2 doses 4-8 weeks apart. As it is a live vaccine it cannot be given in pregnancy though may be given postnatally or pre-conceptually. Deferring pregnancy for 4 weeks after the second dose is advised however. It is safe for women who have been vaccinated to be around pregnant women though not if a post-vaccine rash appears - while this is unlikely, cases of transmission of vaccine virus have been reported. Small studies have failed to detect evidence of the vaccine in breast-milk when given postpartum thus it is safe to breastfeed.

Question 20

What time frame spent in the same room or large open ward, is considered the minimum to qualify as ‘significant contact’ with VZV in a non-immune patient?

a. 5 minutes
b. 10 minutes
c. 15 minutes
d. 20 minutes
e. 30 minutes

Answer 20

C - 15 minutes

‘Significant exposure’ is defined as contact in the same room, face to face or in a large open ward for 15 minutes or more with an infectious individual.

Question 21

You receive a phone call from a GP looking for advice regarding a primigravidae at 18/40 gestation, originally from Tanzania, who spent 30 minutes playing with her nephew yesterday. Today however she has been informed that the child has developed a chickenpox rash. The patient does not recall ever having had chickenpox herself. What immediate action do you recommend?

a. No action required as child was not infectious at time of contact
b. No action required as the contact was not significant
c. Immediate VZIG
d. VZV vaccination urgently
e. Blood test for VZV IgG

Answer 21

E - Blood test for VZV IgG

As the patient does not recall having had chickenpox herself, she is at risk of primary infection in pregnancy which is associated with significant maternal and potential fetal morbidity. While 90% of British women are infact seropositive, women from the tropics are less likely to be. While the child in the scenario did not have a rash at the time of contact, the rash has appeared in the subsequent 48 hours thus he was infact infectious at the time. The first step is to ascertain the patient’s IgG status which can be done by either testing her stored booking sample or from a blood test now.

Question 22

You receive a phone call from a GP looking for advice regarding a primigravidae at 18/40 gestation, originally from Tanzania, who spent 30 minutes playing with her nephew yesterday. Today however she has been informed that the child has developed a chickenpox rash. You check the woman’s stored booking sample which tests negative for VZV IgG and thus recommend a course of VZIG urgently. The woman informs the GP that she is unable to wait for this today but may return tomorrow. How long after exposure is VZIG thought to be effective in such a setting?

a. 24 hours
b. 48 hours
c. 5 days
d. 10 days
e. 15 days

Answer 22

D - 10 days

VZIG may be given up to 10 days after significant exposure in susceptible individuals thus there is usually always time to check IgG status rather than rushing to administer needlessly.

Question 23

A primigravida who received VZIG the previous day, following a significant exposure to chickenpox, informs you that her sister is coming to stay with her for a few days the following week. She is also pregnant and the patient asks whether or not there is any risk of her passing VZV on to her sister. How long after exposure to chickenpox should women be regarded as infectious when given VZIG?

a. 7-10 days
b. 7-14 days
c. 8-21 days
d. 8-28 days
e. Women given VZIG are not at risk of passing the virus on

Answer 23

D - 8-28 days

Patients with a history of significant exposure must be treated as potentially infectious regardless of whether they receive VZIG or not as there remains a possibility of them developing infection. While the incubation period of chickenpox is known to be 7-21 days, those who receive VZIG should be treated as potentially infectious for an additional 7 days – i.e. from 8-28 days. Patients who do not receive VZIG after significant exposure should be managed as potentially infectious throughout the incubation period – i.e. from 8-21 days.

Question 24

How long should non-immune exposed women who are not given VZIG be regarded as potentially infectious?

a. 7-10 days
b. 7-14 days
c. 8-21 days
d. 8-28 days
e. 10-14 days

Answer 24

C - 8-21 days

Patients with a history of significant exposure must be treated as potentially infectious regardless of whether they receive VZIG or not as there remains a possibility of them developing infection. While the incubation period of chickenpox is known to be 7-21 days, those who receive VZIG should be treated as potentially infectious for an additional 7 days – i.e. from 8-28 days. Patients who do not receive VZIG after significant exposure should be managed as potentially infectious throughout the incubation period – i.e. from 8-21 days.

Question 25

A woman returns to your clinic 4 weeks after she received a dose of VZIG following a significant exposure to chickenpox and was found to be seronegative upon testing her VZV IgG status. She herself did not develop a rash or any symptoms after administration of VZIG following the initial exposure. Another child in the family has now developed a chickenpox rash and she is anxious about the on-going risk of herself developing primary infection. Where further exposure to chickenpox occurs in pregnancy, how long after initial VZIG administration would a second course be appropriate? a. 1 week b. 3 weeks c. 5 weeks d. 10 weeks e. 12 weeks

Answer 25

B - 3 weeks VZIG courses may be repeated in pregnancy should clinical need arise and assuming the first course was successful in preventing infection. 3-weeks is the minimum recommended time between courses.

Question 26

What is the reported risk of anaphylaxis following administration of VZIG? a. <0.1% b. 0.5% c. 1% d. 2% e. 4%

Answer 26

A - <0.1% VZIG is created using plasma of non-UK donors with high IgG titres. While anaphylactic reactions are possible they are uncommon – less that 0.1%. Erythema and pain around the injection site are far more frequently seen side effects. There are no reported cases of blood borne infection from VZIG.

Question 27

What is the risk of pneumonia amongst pregnant women who develop chickenpox in pregnancy? a. 2-3% b. 5-8% c. 10-14% d. 15-20% e. 20-25%

Answer 27

C - 10-14% While there is a tendency to focus on risks of fetal varicella syndrome arising due to VZV infection in pregnancy, when compared with the risks of maternal infection, this is relatively uncommon (<1%). Infact maternal infection carries a far higher incidence of severe morbidity – pneumonia, hepatitis, encephalitis and even death all being reported.

Question 28

You receive a call from a GP who has been on a house-call to a woman who is 22/40 and has developed a chickenpox rash this morning after her son picked up the virus from a child at nursery 10 days ago. She is systemically well and aside from the rash has no symptoms at present. What is first line treatment for systemically well women who develop a chickenpox rash in pregnancy? a. Oral acyclovir 400mg BD b. Oral acyclovir 800mg 5x/day c. IV acyclovir 400mg TDS d. IV acyclovir 800mg 5x/day e. VZIG

Answer 28

B - Oral aciclovir 800mg 5x/day Oral acyclovir (800mg 5x/day for 7 days) may be administered within 24 hours of a rash appearing as this appears to reduce the duration of fever and symptoms. While it is not licensed for this indication in pregnancy, there is no evidence to suggest a risk of fetal malformation or adverse outcome. The Green Top Guideline states that acyclovir should be given as standard in all >20+0/40 presenting with a rash and considered in those prior to this gestation. Patients with apparent severe infection should receive IV acyclovir.

Question 29

Which of the following features in a clinical history taken from a patient with a chickenpox rash in pregnancy would NOT indicate a need for inpatient review providing the woman is otherwise systemically well: a. Smoker b. Steroid use 3 months prior for refractory hyperemesis c. Gestational age 36/40 d. Photophobia e. Vomiting

Answer 29

E - Vomitting Severe, life-threatening varicella infection is characterised by photophobia, seizures, drowsiness, a haemorrhagic or dense rash and bleeding. Anyone with any of these symptoms, or any patient in the second half of pregnancy, who smokes, has a chronic lung condition, is immunosuppressed or has taken systemic steroids in the preceding 3 months should be reviewed in hospital.

Question 30

A women develops chickenpox for the first time at 38/40 gestation in her first pregnancy. She is struggling to cope with the rash while heavily pregnant and requests induction of labour. What time should ideally elapse between development of the rash and delivery in order to minimise the risk of haemorrhage (secondary to thrombocytopenia), and hepatitis and permit passage of antibodies to reduce the risk of neonatal varicella syndrome? a. 24 hours b. 48 hours c. 7 days d. 14 days e. 28 days

Answer 30

C - 7 days The timing and mode of delivery of pregnant women with chickenpox must be individualised. Consensus dictates however that ideally 7 days should elapse between the onset of the rash and delivery as delivery during the viraemic period may be extremely hazardous, precipitating haemorrhage and/or coagulopathy due to thrombocytopenia or hepatitis. This 7 day period also permits passive transfer of antibodies from the mother to fetus, reducing the risk of neonatal varicella syndrome. In cases of severe pneumonia, delivery may be indicated sooner to assist in ventilation.

Question 31

You see a women in the antenatal clinic at 32/40 who has just recovered from chickenpox. She is anxious about the risk of fetal infection. Until what gestation is fetal varicella syndrome known to occur? a. 12/40 b. 16/40 c. 24/40 d. 28/40 e. Delivery

Answer 31

D - 28/40 FVS is a potential, though uncommon (<1%) complication of primary maternal varicella infection within the first 28/40 of pregnancy. It is characterised by skin scarring in a dermatomal distribution; eye defects (microphthalmia, chorioretinitis or cataracts); hypoplasia of the limbs; and neurological abnormalities (microcephaly, cortical atrophy, mental retardation or dysfunction of bowel and bladder sphincters).

Question 32

You see a woman in the antenatal clinic at 12/40 in her first pregnancy. At 6/40, she developed chickenpox for the first time. She is anxious about the risk of fetal infection. What should your initial management be? a. Reassure there is no risk of fetal varicella syndrome at 6/40 and do nothing b. Administer VZIG c. Refer for immediate fetal medicine review d. Refer for fetal medicine review at 16-20 weeks e. Advise termination of pregnancy

Answer 32

D - Refer for fetal medicine review at 16-20 weeks Women with a history or chickenpox in pregnancy should be referred to fetal medicine for counselling and a detailed scan at 16-20 weeks gestation or 5 weeks after infection – whichever is later. Suspicion of FVS on USS may be complemented by fetal MRI. VZV DNA can be detected in amniotic fluid by PCR however this has a low sensitivity (though high specificity) for the development of FVS in the absence of USS markers.

Question 33

You are called to review a woman in the day assessment unit at 26/40 who has recently recovered from chickenpox. She has had a growth scan today which is normal and reports normal fetal movements. You explain that a scan in fetal medicine to exclude fetal varicella syndrome is indicated. How long after the infection would you arrange this? a. 5 weeks b. 6 weeks c. 4 weeks d. 2 weeks e. Immediately

Answer 33

A - 5 weeks Women with a history or chickenpox in pregnancy should be referred to fetal medicine for counselling and a detailed scan at 16-20 weeks gestation or 5 weeks after infection – whichever is later. Suspicion of FVS on USS may be complemented by fetal MRI. VZV DNA can be detected in amniotic fluid by PCR however this has a low sensitivity (though high specificity) for the development of FVS in the absence of USS markers.

Question 34

Which of the following is not a recognised consequence of fetal varicella syndrome: a. Limb hypoplasia b. Hydrocephalus c. Congenital cataracts d. Microcephaly e. Skin scarring

Answer 34

B - Hydrocephalus Fetal varicella syndrome is characterised by skin scarring in a dermatomal distribution; eye defects (microphthalmia, chorioretinitis or cataracts); hypoplasia of the limbs; and neurological abnormalities (microcephaly, cortical atrophy, mental retardation or dysfunction of bowel and bladder sphincters). Limb deformity, microcephaly, hydrocephalus, soft tissue calcification and fetal growth restriction all can be detected on AN USS thus raising the possibility in at-risk patients.

Question 35

What is the overall risk of the fetus developing fetal varicella syndrome where primary maternal chickenpox infection occurs in the first half of pregnancy? a. 1% b. 2.5% c. 5% d. 12% e. 15%

Answer 35

A - 1% Fetal varicella syndrome is possible where infection occurs prior to 28/40 gestation. The overall incidence is ~1% - probably smaller where infection occurs in the first trimester.

Question 36

What is the estimated incidence of vasa praevia? a. 1 in 500-800 b. 1 in 1200-5000 c. 1 in 5000-8000 d. 1 in 8000-11,000 e. 1 in 12,000-20,000

Answer 36

B - 1 in 1200-5000 The incidence of vasa praevia is estimated at 1 in 1200-5000 deliveries

Question 37

Which of the following is a recognised risk factor for vasa praevia? a. Congenital uterine abnormality b. IVF c. Previous caesarean section d. Maternal BMI >35 e. Polyhydramnios

Answer 37

B - IVF Of the options listed, IVF is a recognised risk factor for vasa praevia. Others include low lying placenta, velamentous cord insertion and accessory lobes.

Question 38

A patient attends for her fetal anomaly scan at 20/40 in her first pregnancy. Following completion of the scan, the sonographer comments that the placenta appears to be ‘low lying’. What is the next step in the management of this patient? a. TVUSS to confirm b. Repeat scan for placental localisation at 32/40 c. Repeat scan for placental localisation at 36/40 d. MRI to exclude morbidly adherent placenta e. Advise the patient to refrain from sexual intercourse

Answer 38

A - TVUSS to confirm The first step when a low lying or apparent placenta praevia is detected on Transabdominal scanning is to perform a TV scan – this will immediately re-classify up to 60%.

Question 39

A patient is found to have a low-lying placenta on her 20/40 anomaly scan. Which of the following factors is associated with a increased-likelihood of the placenta remaining low-lying when the scan is repeated in the third trimester? a. Anterior placenta b. Fetal macrosomia c. Polyhydramnios d. Posterior placenta e. Retroverted uterus

Answer 39

D - Posterior placenta Posterior placenta praevia is associated with an increased likelihood of persistence

Question 40

A patient is diagnosed with major placenta praevia on her anomaly scan at 20/40. When should a repeat scan to further assess placental location be arranged? a. Scan should not be repeated in major praevia b. 30/40 c. 32/40 d. 34/40 e. 36/40

Answer 40

C - 32/40 Major placenta praevia , when diagnosed at 20/40, should be re-checked at 32/40

Question 41

What is the optimum imaging modality for the antenatal detection of vasa praevia? a. Grey-scale ultrasound b. MRI c. 3D power doppler d. Colour doppler e. No suitably sensitive imaging test - clinical diagnosis only

Answer 41

D - Colour doppler A combination of TA and TV colour doppler ultrasound is the preferred imaging modality for the detection of vasa praevia

Question 42

A patient with a history of low-lying placenta attends antenatal clinic at 34/40 to discuss her options for delivery. On her most recent scan, the leading edge of the placenta was 24mm from the internal cervical os. What is the minimum distance between the leading edge of the placenta and internal cervical os required to permit vaginal delivery? a. 15mm b. 20mm c. 25mm d. 30mm e. 35mm

Answer 42

B - 20mm The minimum distance between the leading edge of the placenta and the internal os to permit vaginal delivery is 20mm

Question 43

A primigravida is found to have persistent vasa praevia following an ultrasound scan at 32/40. At what gestation is elective delivery advised? a. From 34/40 b. From 35/40 c. From 36/40 d. From 37/40 e. From 38/40

Answer 43

A - From 34/40 Patients with vasa praevia should be delivered electively from 34/40 under steroid cover. Decision on whether or not to electively admit patients to hospital from 30-32/40 should be based on an individualised assessment of the risk of preterm labour.

Question 44

11. What obstetric complication is associated with Benckiser’s haemorrhage? a. Placenta praevia b. Uterine rupture c. Cervical tear d. Vasa praevia e. Rectal bleeding from placenta percreta

Answer 44

D - Vasa Praevia Benckiser’s haemorrhage is associated with vasa praevia

Question 45

What is the incidence of velamentous cord insertion? a. 1% b. 2% c. 5% d. 10% e. 15%

Answer 45

A - 1% The incidence of velamentous cord insertion is 1%, of which up to 6% will be complicated by concurrent vasa praevia

Question 46

What proportion of velamentous cord insertion will have concurrent vasa praevia? a. Up to 6% b. Up to 12% c. Up to 24% d. Up to 48% e. Up to 60%

Answer 46

A - 6% The incidence of velamentous cord insertion is 1%, of which up to 6% will be complicated by concurrent vasa praevia

Question 47

What is the estimated incidence of placenta praevia at term? a. 1 in 100 b. 1 in 200 c. 1 in 500 d. 1 in 1000 e. 1 in 1500

Answer 47

B - 1 in 200 The estimated incidence of placenta praevia at term is as high as 0.5% - 1 in 200.

Question 48

A patient undergoes an elective caesarean section for placenta praevia. Following delivery of the fetus, the placenta is noticed to be morbidly adherent in parts to the underlying myometrium. This had not been reported antenatally. What proportion of placenta accreta remains undiagnosed prior to delivery? a. Up to 1/5 b. Up to 1/4 c. Up to 1/3 d. Up to 1/2 e. Up to 2/3

Answer 48

E - Up to 2/3 It is estimated that as many as 2/3 of placenta accreta are only definitively diagnosed at delivery

Question 49

A patient attends for an MRI after her mid-trimester ultrasound scan was suggestive of abnormally invasive placentation. This is reported as showing villous perforation through the entire thickness of the myometrium and invading the adjacent bladder serosa. What is the most accurate diagnosis here? a. Placenta Praevia b. Placenta Increta c. Placenta Accreta d. Placenta Percreta e. Vasa Praevia

Answer 49

D - Placenta Percreta The scenario describes placenta percreta which is the most severe form of the placenta accreta spectrum disorder.

Question 50

A 24 year old, Para 1, is seen in the antenatal clinic at 22/40 following her mid-trimester scan. This is reported as showing a major, anterior placenta praevia. Her first pregnancy resulted in an emergency caesarean delivery at 39/40 for failure to progress in labour. What is her risk of placenta accreta? a. <1% b. 3% c. 5% d. 11% e. 17%

Answer 50

B - 3% ``` The risk of a low-lying or placenta praevia representing a placenta accreta or morbidly adherent placenta increases depending on the number of previous caesarean births as follows: • 1 previous – 3% • 2 previous – 11% • 3 previous – 40% • 4 previous – 61% • 5 previous – 67% ```

Question 51

A 27 year old, Para 2, is seen in the antenatal clinic at 22/40 following her mid-trimester scan. This is reported as showing a major, anterior placenta praevia. Both her previous babies were delivered by caesarean section for breech presentation. What is her risk of placenta accreta? a. 3% b. 7% c. 11% d. 17% e. 22%

Answer 51

C - 11% ``` The risk of a low-lying or placenta praevia representing a placenta accreta or morbidly adherent placenta increases depending on the number of previous caesarean births as follows: • 1 previous – 3% • 2 previous – 11% • 3 previous – 40% • 4 previous – 61% • 5 previous – 67% ```

Question 52

A 35 year old, Para 3 – all caesarean births - is seen in the antenatal clinic at 22/40 following her mid-trimester scan. This is reported as showing a major, anterior placenta praevia. What do you advise, is her risk of placenta accreta? a. 3% b. 5% c. 11% d. 22% e. 40%

Answer 52

E - 40% ``` The risk of a low-lying or placenta praevia representing a placenta accreta or morbidly adherent placenta increases depending on the number of previous caesarean births as follows: • 1 previous – 3% • 2 previous – 11% • 3 previous – 40% • 4 previous – 61% • 5 previous – 67% ```

Question 53

A 39 year old, Para 4 – all caesarean births - is seen in the antenatal clinic at 22/40 following her mid-trimester scan. This is reported as showing a major, anterior placenta praevia. What do you advise, is her risk of placenta accreta? a. 5% b. 7% c. 19% d. 40% e. 61%

Answer 53

E - 61% ``` The risk of a low-lying or placenta praevia representing a placenta accreta or morbidly adherent placenta increases depending on the number of previous caesarean births as follows: • 1 previous – 3% • 2 previous – 11% • 3 previous – 40% • 4 previous – 61% • 5 previous – 67% ```

Question 54

A primigravida undergoes a scan for placental localisation at 32/40 after the placenta was noted to be ‘low-lying’ on her mid-trimester scan. On this repeat scan, the leading edge of the placenta is noted to be 9mm from the internal cervical os. What management do you recommend? a. Book elective caesarean birth from 36/40 b. Book elective caesarean birth from 37/40 c. Book elective caesarean birth from 38/40 d. Repeat scan at 36/40 e. Reassure and discharge

Answer 54

D - Repeat scan at 36/40 Patient’s with persistent ‘low-lying’ placenta where the placenta is not covering nor encroaching on the internal os (i.e. ‘minor praevia’) should have one further scan at 36/40

Question 55

When should women with asymptomatic, uncomplicated placenta praevia be delivered? a. 35-36/40 b. 36-37/40 c. 37-38/40 d. 38-39/40 e. 39-40/40

Answer 55

B - 36-37/40 Patients with an uncomplicated placenta praevia are recommended to undergo late preterm delivery at 36-37 weeks of gestation

Question 56

How often should ‘group and save’ samples be sent in women with known placenta praevia? a. Every 72 hours b. Twice weekly c. Weekly d. Fortnightly e. Monthly

Answer 56

C - Weekly Women with placenta praevia should have a group and save sample collected at least weekly

Question 57

When should women with asymptomatic, uncomplicated placenta accreta be delivered? a. 35-36/40 b. 36-37/40 c. 37-38/40 d. 38-39/40 e. 39-40/40

Answer 57

A - 35-36/40 Patients with an uncomplicated placenta accreta are recommended to undergo delivery at 35-36/40

Question 58

What proportion of foetuses will be in a breech presentation at term? a. 1-2% b. 3-4% c. 5-6% d. 7-8% e. 9-10%

Answer 58

B - 3-4% Breech presentation occurs in 3-4% of pregnancies at term. The incidence is higher still in preterm infants. Primigravidae are typically affected more than multigravidae.

Question 59

You see a woman in the antenatal clinic with a breech presentation at 36+2/40 in her first pregnancy. She is unsure how to proceed and asks about the likelihood of the baby turning spontaneously to cephalic. How many babies, when breech at 36/40, might be expected to spontaneously turn cephalic prior to delivery? a. 2% b. 4% c. 6% d. 8% e. 12%

Answer 59

D - 8% Spontaneous version to cephalic after 36/40 is unusual, occurring in only 8% of primigravidae. Rates of spontaneous version are lower still following unsuccessful ECV – estimated around 3-7%.

Question 60

You counsel a woman in the antenatal clinic who has been diagnosed with breech presentation at 36/40 in her first pregnancy. She opts to undergo ECV. What is the quoted success rate of ECV in primigravidae? a. 35% b. 40% c. 45% d. 50% e. 60%

Answer 60

B - 40% The overall success rate of ECV is quoted as 50% with higher rates seen in multigravida (approx. 60%) than primigravidae (40%). Various factors are known to influence the likelihood of success in addition to parity, including: non-engagement of the breech; use of tocolysis; palpation of the fetal head; maternal weight <65kg; complete breech; AFI >10cm and posterior placental localisation.

Question 61

A woman undergoes a successful ECV though is anxious about the possibility of baby turning again to breech. What do you inform her is the likelihood of such an occurrence? a. <1% b. 3% c. 5% d. 8% e. 12%

Answer 61

B - 3% Reversion to breech presentation following successful ECV is uncommon – occurring in only 3% of cases.

Question 62

What is the earliest gestation advisable to perform ECV for breech presentation in primips and multips respectively? a. Both from 36/40 b. Primips from 36/40; Multips from 37/40 c. Primips from 37/40; Multips from 36/40 d. Both from 37/40 e. Primips from 35/40; Multips from 36/40

Answer 62

B - Primips from 36/40; multips from 37/40 ECV is contraindicated prior to 36/60 irrespective of parity as the risk of preterm delivery is considered unacceptably high. ECV should be arranged from 36/40 onwards in primigravidae and slightly later – from 37/40– in multigravidae. There is no ‘upper limit’ on when ECV may be performed and indeed, providing there is no evidence of fetal compromise and membranes are intact, it is possible to perform ECV intrapartum or as part of a ‘stabilising’ induction of labour.

Question 63

A woman who is rhesus D negative is being seen in clinic with a breech presentation and is planning an ECV. She has researched online and is anxious about the prospect of requiring urgent delivery by emergency caesarean section. Which of the following steps must be taken in this woman? a. Fasted before procedure, venous access, routine anti-D, CTG before and after b. Anaesthetic pre-med given, fasting not required, routine anti-D, CTG after only c. Fasted before procedure, anaesthetic pre-med given, venous access, anti-D only if bleeding, CTG before and after d. Routine anti-D, Kleihaur testing, venous access, CTG after procedure e. Routine anti-D, Kleihaur testing, CTG before and after procedure

Answer 63

E - Routine anti-D; Kleihaur testing; CTG before and after procedure Fetal distress necessitating urgent delivery by caesarean section is perhaps the principal concern of both mother and operator when undertaking ECV, though such a complication is rare (0.5% in 24 hours – usually due to vaginal bleeding or abnormal CTG). The usual pre-operative preparations for caesarean section are therefore NOT required routinely in mothers undergoing ECV, though CTG before and after the procedure is advised. Transient bradycardia of ~3 minutes duration is itself not uncommon though if this continues for 6 minutes, preparation for Cat. 1 CS delivery should be initiated.

Question 64

A woman sees her community midwife at 40+7 in her first pregnancy. The midwife palpates her abdomen and suspects the fetus may be breech presentation. She is duly referred for a presentation scan which confirms her suspicion. What is the sensitivity of abdominal palpation alone in detection of breech presentation? a. 60% b. 70% c. 75% d. 80% e. 90%

Answer 64

B - 70% Clinical examination of the maternal abdomen for assessment of fetal position is routine when assessing any women in the third trimester. The sensitivity of abdominal palpation alone in detection of breech presentation however is only 70%.

Question 65

A primigravida attends delivery suite in early labour. The midwife who examines the patient on admission suspects a breech presentation and asks the registrar on-call to confirm this by means of ultrasound. A footling breech presentation is confirmed. The woman is 5cm on VE and plans are made for delivery by caesarean section. What proportion of term breech presentations are undetected? a. 20-30% b. 15-20% c. 10-15% d. 5-10% e. <5%

Answer 65

A - 20-30% 20-32.5% of term breech presentations are undetected. These infants generally have worse outcomes than those where the diagnosis is made in advance of labour and a plan for delivery made. Particular care should be taken in the case of patients with a history of breech presentation, as recurrence rates are as high as 10%. Patients with breech babies who present in labour require individualised assessment and counselling on their mode of delivery – those at or near the second stage should not typically be offered routine LSCS

Question 66

You see a patient on the post-natal ward the morning after an uncomplicated caesarean section for breech presentation. She asks about the likelihood of her next pregnancy being affected by breech presentation. What is the recurrence risk of breech presentation? a. 5% b. 10% c. 15% d. 20% e. 25%

Answer 66

B - 10% The recurrence rate of breech presentation is quoted in the RCOG Green Top Guideline as 9.9%

Question 67

You meet a woman in the ANC at 36/40 in her first pregnancy who is found to have a breech presentation. She is counselled regarding her options for delivery and opts for an elective CS at 39/40. You discuss the risks associated with caesarean section both intra-operatively and implications for future pregnancy. What is the risk of a future pregnancy being affected by morbidly adherent placenta after 1 caesarean section? a. 2.5% b. 1% c. 0.5% d. 0.3% e. 0.1%

Answer 67

D - 0.3% When counselling women about delivery options for breech presentation, it is important to include information on the potential implications a caesarean birth may have on future pregnancies. While rare, the principal concern for most obstetricians is that of morbidly adherent placenta – seen in 0.3% of women after one caesarean section though 2.3% after four.

Question 68

11. A woman is seen in the day-assessment unit at 37/40 after a growth scan. The baby is normally grown though found to be in a breech presentation. The woman has had 3 previous vaginal deliveries and enquiries about the possibility of attempting vaginal breech delivery. Above what estimated fetal weight is there an increased likelihood of adverse outcome in vaginal breech? a. 3.5kg b. 3.8kg c. 4.0kg d. 4.2kg e. 4.5kg

Answer 68

B - 3.8kg A number of factors may influence the likelihood of success and relative safety of vaginal breech birth compared with elective caesarean section. These include: * Where there is an otherwise independent indication for LSCS * Hyperextended fetal neck on scan * EFW >3.8kg * EFW <10th centile * Footling breech * Evidence of AN fetal compromise. The evidence for pelvimetry is unclear.

Question 69

Which of the following is NOT positive predictor of success of ECV in breech presentation? a. Posterior placenta b. Maternal BMI c. Estimated fetal weight d. Palpation of the fetal head e. Multiparity

Answer 69

C - Estimated fetal weight There is no evidence to support an association between estimated fetal weight and the likelihood of success of ECV – posterior placenta, maternal weight <65kg, a palpable fetal head and multiparity (amongst other factors) are all believed to be independent contributory factors to success.

Question 70

What is the recommended dose of salbutamol for use as a tocolytic prior to ECV? a. 50mg s/c b. 100micrograms IM c. 200mg s/c d. 250micrograms IV e. 500mcg IM

Answer 70

D - 250micrograms IV The dose of salbutamol is 250micrograms diluted in 25ml of saline administered by slow IV injection. This is the same dose as terbutaline which is administered subcutaneously.

Question 71

What is the risk of caesarean section delivery in women planning vaginal breech birth? a. 25% b. 33% c. 40% d. 50% e. 66%

Answer 71

C - 40% Women planning vaginal breech birth have a higher risk of caesarean section (40%) than equivalent women planning cephalic.

Question 72

What is the maximum number of attempts at ECV advised during a single session? a. 1 b. 2 c. 3 d. 4 e. 5

Answer 72

D - 4 While firm evidence to guide practice is limited, a maximum of 4 attempts at ECV for a total of 10 minutes overall is recommended.

Question 73

What proportion of babies will be breech at 28/40 gestation? a. 3% b. 10% c. 20% d. 33% e. 40%

Answer 73

C - 20% 20% of fetuses will be breech at 28/40 compared with 3% at term.

Question 74

What is the incubation period of genital herpes simplex virus? a. 1-2 days b. 3-7 days c. 7-12 days d. 18-21 days e. 28-42 days

Answer 74

B - 3-7 days The incubation period of genital HSV is between 3 and 7 days

Question 75

A patient presents to the GUM clinic with a 48 hour history of painful genital ulcers. A diagnosis of genital herpes is made. She wants to know how long the lesions are likely to persist. What is the usual duration of symptoms in a primary outbreak of genital HSV? a. 5 days b. 7 days c. 14 days d. 21 days e. 28 days

Answer 75

C - 2 weeks Symptoms typically persist for around 2 weeks in primary outbreaks of genital herpes

Question 76

You see an otherwise low risk primigravida in the antenatal clinic at 18/40 with what appears to be a primary episode of genital herpes. She is anxious about the impact this will have on her pregnancy and birth. What management do you advise? a. Oral acyclovir and referral to fetal medicine 6 weeks after the outbreak b. Oral acyclovir now and from 36/40, aim for vaginal delivery at term c. Oral acyclovir now and book El. LSCS from 39/40 d. Oral acyclovir now, serial growth scanning of the fetus and El. LSCS from 39/40 e. Urgent referral to fetal medicine for consideration of invasive testing

Answer 76

B - Oral aciclovir now and from 36/40, aim for vaginal delivery at term Providing that delivery does not occur within 6 weeks of this initial infection, patients who develop primary HSV in the 1st or 2nd trimester can aim for vaginal delivery with reassurance that the risk of transmission to the neonate is low (<3%). There is no evidence to suggest that primary genital herpes infection in pregnancy is associated with an increased incidence of congenital abnormality, therefore fetal medicine referral is of little benefit here – the main concern in all cases is of vertical transmission at delivery. Acyclovir treatment (off license) may be given at the time of treatment for symptomatic control and to reduce the likelihood of active lesions at delivery from 36/40. The patient should nevertheless be referred to GUM who will confirm the diagnosis and arrange a full STI screen.

Question 77

You are seeing a 17 year old primigravidae in the antenatal clinic after a growth scan at 32/40. There are no concerns regarding fetal growth and movements are normal, though she has developed painful blisters on the external genitalia after an episode of UPSI with a new partner around 1 week ago. She does not recall a history of such a complaint in the past. You diagnose suspected primary genital herpes, arrange referral to GUM and explain the implications of this to the patient. What management for delivery would you initiate pending confirmation? a. Oral acyclovir now and from 36/40 – aim for vaginal delivery providing lesions healed completely and labour occurs >6 weeks from onset of lesions, otherwise deliver by LSCS b. Book El. LSCS at 39/40. Oral acyclovir for symptom control. c. Book LSCS under steroid cover at 37/40 to reduce risk of ascending infection associated with SROM d. Oral acyclovir now only. Aim for vaginal delivery providing >4 weeks elapsed since onset of lesions and no lesions present at onset of labour e. Swab lesions for viral culture prior to administering treatment. Arrange to see the patient with results in 6 weeks to plan delivery.

Answer 77

B - Book El. LSCS at 39/40. Oral aciclovir for symptoms control This patient has likely developed primary genital herpes in the third trimester and delivery by LSCS is recommended owing to the significantly increased risk of neonatal transmission with vaginal birth (41%). Diagnosis should be confirmed by viral PCR and IgG antibodies to HSV should be checked (as a small number of cases - approx. 15% are infact recurrent). Acyclovir may be prescribed at the usual dose for symptomatic relief.

Question 78

What is the risk of neonatal transmission of HSV with vaginal delivery following a primary outbreak in the third trimester? a. 10% b. 24% c. 31% d. 41% e. 62%

Answer 78

D - 41% Vaginal delivery following primary genital HSV infection in the third trimester (or within 6 weeks of delivery) is associated with a 41% transmission rate to the neonate.

Question 79

You see a primigravida in the ANC at 12/40, referred on account of her past history of genital HSV. She had a primary outbreak some 5 years previously though has had no reported recurrence since. Nevertheless she wishes to discuss the risks of neonatal infection. Where recurrent herpes lesions are present at the time of birth, what is the risk of neonatal infection with vaginal delivery? a. <0.5% b. 0-3% c. 3-5% d. 5-6% e. 8-10%

Answer 79

B - 0-3% The risk of genital HSV infection in the neonate with recurrent infection around delivery – even where lesions are present – is low (<3%). Patients may be offered daily suppressive acyclovir from 36/40 to reduce the likelihood of active lesions at delivery.

Question 80

10. You meet a primigravida in the ANC who has a past history both of HIV and HSV infection. Her HIV is well controlled on HAART and viral load is undetectable. She had a primary episode of genital HSV around 10 years ago and has experienced occasional recurrence since. She wishes to discuss her options for delivery and expresses a preference for vaginal birth. What do you suggest? a. Vaginal birth with daily suppressive acyclovir from 32/40 b. Vaginal birth with daily suppressive acyclovir from 36/40 c. Vaginal birth with daily suppressive acyclovir from 36/40 with IV acyclovir in labour and to the neonate after birth d. Anticipate vaginal birth with daily suppressive acyclovir from 36/40 though with recourse to LSCS if lesion present at onset of labour e. Elective LSCS at 39/40

Answer 80

A - Vaginal birth with daily suppressive aciclovir from 32/40 Women who are HIV positive and who have a history of previous genital HSV infection should be offered daily suppressive acyclovir from 32/40 (i.e. not 36/40 as in the HIV negative population) owing to the increased possibility of preterm labour in HIV-positive women. The mode of delivery should be based upon HIV viral load and additional obstetric factors – in this women, vaginal delivery would be recommended due to her undetectable viral load.

Question 81

What centiles are used for the definitions of SFGA and severe SFGA respectively? a. <10th and <5th b. <10th and <3rd c. <5th and <3rd d. <10th and <1st e. <5th and <1st

Answer 81

B - 10th and 3rd Using customised centile charts, small for gestational age (SFGA) is defined as an estimated fetal weight (EFW) on USS <10th centile while severe SFGA is defined as EFW <3rd.

Question 82

What proportion of SFGA foetuses are ‘constitutionally small’ – or appropriately so for maternal height/weight/ethnicity et al? a. 30-40% b. 40-60% c. 50-70% d. 75-80% e. 80-90%

Answer 82

C - 50-70% The important distinction to be made in SFGA infants is identifying those who are growth restricted as a result of an underlying pathological process from those who are constitutionally small or an appropriate weight for gestation. The terms ‘small for gestational age’ and ‘fetal growth restriction’ are NOT synonymous and should not be used as such. 50-70% of SFGA babies are constitutionally small.

Question 83

What is the cut off for an infant classified as ‘low birth-weight’ regardless of centiles used? a. <2500g b. <2250g c. <2000g d. <1750g e. <1500g

Answer 83

A - <2500g Independent of centiles or SFGA definitions, any infant weighing <2500g at delivery is considered to be of ‘low birthweight’.

Question 84

You see a 36 year old Para 1 in the ANC at booking at 12/40 gestation. Her first delivery was by LSCS aged 28 with a different partner though that pregnancy was otherwise uncomplicated. Maternal BMI at booking is 26. What initial management plan do you initiate with respect to fetal surveillance in this pregnancy? a. Serial growth scans from 26-28/40 b. Uterine artery doppler at 20-24/40 c. Single assessment of growth in the third trimester d. Umbilical artery doppler at 20-24/40 e. SFH measurements with midwife

Answer 84

B - Uterine artery doppler ay 20-24/40 While some of the major/minor risk factors for SFGA given in the RCOG guideline are fairly self-explanatory and easily identified, others are less so. 1 major risk factor should prompt serial scanning of fetal biometry and umbilical artery doppler from 26-28/40, while those with 3 or more minor risk factors should first undergo a uterine artery doppler at 20-24/40 with serial scanning if this is abnormal (PI >95th centile and/or notching). The patient in this scenario satisfies the latter criteria though her three minor risk factors could easily be overlooked, namely: • Maternal age >35 • Inter-pregnancy interval >60 months • Maternal BMI >25 If her uterine artery doppler – which is the next step and thus the answer - is normal, a single estimate of fetal weight and umbilical artery doppler in the third trimester would be indicated.

Question 85

You meet a primigravida at 13/40 in the ANC who wishes to discuss her options for delivery in this pregnancy. The patient is 31 years old and works at a fitness instructor at the local gym and plans to continue working until the third trimester. Her BMI is 21. What initial management plan do you initiate with respect to fetal surveillance in this pregnancy: a. Serial growth scans from 26-28/40 b. Uterine artery doppler at 20-24/40 c. Single assessment of growth in the third trimester d. Umbilical artery doppler at 20-24/40 e. SFH measurements with midwife

Answer 85

A - Serial growth scans from 26-28/40 It can be assumed that a full time fitness instructor who plans on continuing to work throughout pregnancy is likely to satisfy the ‘daily vigorous exercise’ major risk factor for SFGA and thus proceeding directly to serial scans from 26-28/40 would be appropriate here.

Question 86

A 32 year old Para 1 is seen in the ANC at booking to discuss smoking cessation. She currently smokes 10 cigarettes per day. She is otherwise quite fit and well. BMI 19 at booking. She has one child, delivered by SVD at term in her last pregnancy following an induction for mild PET. What initial management plan do you initiate with respect to fetal surveillance in this pregnancy? a. Serial growth scans from 26-28/40 b. Uterine artery doppler at 20-24/40 c. Single assessment of growth in the third trimester d. Umbilical artery doppler at 20-24/40 e. SFH measurements with midwife

Answer 86

B - Uterine artery doppler at 20-24/40 This question draws attention to a few of the subtleties of the major/minor risk factor classification in the RCOG guideline. Smoking status earns 1 minor point if 10 or less cigarettes a day, while 11 or more is considered major. The patient in the scenario has a booking BMI which is in-fact normal (19), though <20 thus scores a further minor point. The third risk factor here is a history of previous pre-eclampsia, again minor, bringing the total to 3 – thus uterine artery doppler at 20-24/40 is indicated.

Question 87

A 21 year old primigravida is seen in the ANC at booking. The referral was made on account of her past history of VTE which developed after surgery to her knee while on the combined-pill 3 years earlier. You note from the patient’s record that she has had 4 admissions during the first trimester with bleeding which has been attributed to a sub-chorionic haematoma. Other than this, no additional obstetric concerns are noted. Her BMI is elevated at 33. What initial management plan do you initiate with respect to fetal surveillance in this pregnancy? a. Serial growth scans from 26-28/40 b. Uterine artery doppler at 20-24/40 c. Single assessment of growth in the third trimester d. Umbilical artery doppler at 20-24/40 e. SFH measurements with midwife

Answer 87

A - Serial growth scans from 26-28/40 Heavy bleeding in the first trimester is a major risk factor for SFGA – serial scans from 26-28/40 are indicated.

Question 88

Which of the following is regarded as a ‘major’ risk factor for SFGA by the RCOG guidance, necessitating serial growth scans in the absence of any other factor? a. Smoking 10/day b. BMI 34 c. IVF pregnancy d. Short inter-pregnancy interval <6 months e. Diabetes with vascular disease

Answer 88

E - Diabetes with vascular disease The full list of major risk factors for SFGA are as follows, and all in isolation require serial scanning: - Maternal age >40 - Maternal SFGA - Smoker >/= 11/day - Chronic Hypertension - Paternal SFGA - DM with Vascular Disease - Cocaine use - Renal Impairment - Daily vigorous exercise - APLS - Previous SFGA baby - Heavy Bleeding (1st T) - Previous Stillbirth - PAPP-A <0.4 MoM

Question 89

You see a couple, both aged 38, in the ANC at booking with their first pregnancy. The referral has been made principally on account of the fact that mum is a smoker (5/day) and has an elevated BMI at 32. You discuss the implications of these factors on the pregnancy in terms of outcomes for mum and baby. During the conversation, dad remarks that he was ‘a small baby’ weighing only 2.1kg when delivered on his due date. What initial management plan do you initiate with respect to fetal surveillance in this pregnancy? a. Serial growth scans from 26-28/40 b. Uterine artery doppler at 20-24/40 c. Single assessment of growth in the third trimester d. Umbilical artery doppler at 20-24/40 e. SFH measurements with midwife

Answer 89

A - Serial growth scans from 26-28/40 Enquiry regarding paternal or even maternal birthweight seldom features in routine antenatal booking consultations and indeed many will be unaware of this even when asked. If disclosed, either qualify as major risk factors and should prompt serial scanning.

Question 90

A women is referred for uterine artery doppler at 24/40 on account of 3 minor risk factors for SFGA being noted by her midwife at booking. The uterine artery doppler is reported as normal. What further management is most appropriate in this case providing no additional obstetric risk factors are present? a. Return to MW led care b. Serial growth scans of the fetus from 28/40 c. One further growth scan at 36/40 d. Repeat uterine artery doppler at 28/40 e. Check fetal growth on scan now and return to MW led care if normal

Answer 90

C - One further growth scan at 36/40 Patients who meet the criteria for uterine artery doppler should have this performed at 20-24 weeks. If abnormal (PI >95th centile and/or notching), serial scanning should then be initiated. If normal, one further scan in the third trimester is advised.

Question 91

What is the optimum frequency between 2 growth scans to determine true growth velocity? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks e. 6 weeks

Answer 91

C - 3 weeks When using two measurements of EFW or AC to estimate growth velocity, these should ideally be 3 weeks apart to minimise risk of over-diagnosing FGR. More frequent monitoring may be appropriate in some instances.

Question 92

A 21 year old primigravida attends for her fetal anomaly scan at 19+3/40. While the fetal anatomy is reported as being within normal limits and the umbilical artery doppler normal, the EFW plots well below the 3rd centile for gestation. What management is required? a. Initiate serial growth scans from 24/40 b. Initiate serial growth scans from 28/40 c. Refer to fetal medicine to re-check d. Refer to fetal medicine for consideration of invasive testing e. Check uterine artery doppler now and initiate serial growth scanning if abnormal.

Answer 92

D - Refer to fetal medicine for consideration of invasive testing Where severe SFGA is identified at the 18-20/40 scan, referral to fetal medicine should be made for detailed scanning and consideration of karyotyping. Karyotyping should be offered to all those with severe SFGA which either presents <23/40 or is accompanied by structural abnormalities as an underlying chromosomal anomaly will be present in up to 19% - triploidy is most common in those referred <26/40 and trisomy 18 thereafter.

Question 93

What percentage of SFGA foetuses are thought to be secondary to maternal infection (CMV, toxoplasmosis et al.)? a. <1% b. 2% c. 5% d. 12% e. 19%

Answer 93

C - 5% Up to 5% of SFGA is thought to be as a result of fetal infection – women with severe SFGA fetuses should undergo testing for CMV and toxoplasmosis (+ syphilis and malaria in high risk populations).

Question 94

A patient attends the ANC at 32/40 in her first pregnancy following a growth scan after SFH plotted <10th centile on a customised centiles chart. The scan is also suggestive of SFGA though the liquor volume and umbilical artery doppler both are normal. What percentage of SFGA foetuses typically have normal UA dopplers? a. 50% b. 67% c. 75% d. 81% e. 90%

Answer 94

D - 81% Umbilical artery doppler is normal is around 4/5 of SFGA fetuses and should be repeated every 14 days.

Question 95

What is the most useful predictor of fetal wellbeing in SFGA foetuses? a. Umbilical artery doppler b. Ductus venosus doppler c. MCA PSV d. MCA doppler e. Fetal heart short term variability

Answer 95

E - Fetal heart short term variability Fetal heart rate variation is the most useful predictor of fetal wellbeing in SFGA babies and is best assessed using computerised CTG which is objective and consistent. Short-term variability of <3ms is associated with high rates of metabolic acidaemia at birth and early neonatal death. CTG should not however, be used in isolation for the surveillance of SFGA fetuses.

Question 96

Which of the following is NOT a component of the fetal biophysical profile? a. Fetal tone b. Liquor volume c. Umbilical artery doppler d. CTG e. Fetal movement

Answer 96

C - Umbilical artery doppler The biophysical profile is not recommended as a surveillance tool in SFGA infants. It is comprised of CTG and ultrasound assessment of liquor volume, fetal movement, tone and breathing, each assigned a score of 2 if normal and 0 if abnormal with lower scores associated with lower umbilical venous pH and increasing perinatal mortality. BPP is time consuming and the incidence of equivocal results (6/10) is high in SFGA though can be improved by use of cCTG over conventional.

Question 97

What feature of the ductus venosus doppler indicates the onset of fetal cardiac compromise? a. Hyperacute a-wave b. Absent a-wave c. Retrograde a-wave d. Increase S:A ratio e. Reversed s-wave

Answer 97

C - Retrograde a-wave Ductus venosus doppler should be used to help in timing delivery in the preterm SFGA fetus as a surveillance tool in SFGA infants with absent or reversed EDF in the umbilical artery under 32/40. DV doppler flow pattern reflects atrial pressure–volume changes during the cardiac cycle - as FGR worsens, velocity reduces in the DV a–wave owing to increased afterload and preload, as well as increased end–diastolic pressure, resulting from the directs effects of hypoxia/acidaemia and increased adrenergic drive. A retrograde a–wave and pulsatile flow in the umbilical vein (UV) signifies the onset of overt fetal cardiac compromise and should prompt immediate delivery planning.

Question 98

18. Which of the following should not be used in timing delivery in the preterm SFGA fetus? a. AREDF in the umbilical artery b. Umbilical vein pulsatile flow c. Abnormal MCA doppler d. Abnormal DV doppler e. Abnormal STV on cCTG

Answer 98

C - Abnormal MCA doppler Middle cerebral artery doppler has limited predictive value for acidaemia and adverse outcome in the preterm SFGA infant and should not be used to time delivery. An abnormal result (defined as MCA PI <5th centile) in a term fetus however is of value in predicting acidosis and should be used to time delivery. The other options given may have a role in planning delivery of the preterm SFGA fetus – absent or reduced EDF in the umbilical artery should prompt delivery beyond 32/40 in isolation (and prompt consideration of delivery between 30 and 32 weeks) while umbilical vein pulsations or abnormal DV doppler signify fetal cardiac compromise and should be used to time delivery at gestations <32/40.

Question 99

19. When should delivery be offered to SFGA foetuses with a normal umbilical artery doppler? a. 36/40 b. 37/40 c. 38/40 d. 39/40 e. No later than 40/40

Answer 99

B - 37/40 SFGA fetuses in whom umbilical artery doppler is normal, should be delivered at 37/40.

Question 100

A patient is seen in the fetal medicine unit at 29/40 in her second pregnancy. Her last child was SFGA at birth and thus serial growth scans have been arranged in this pregnancy. The first of these, performed this morning has demonstrated severe SFGA with the EFW on scan plotting on the 1st centile. There is reversed end-diastolic flow in the umbilical cord and umbilical veins pulsations present. The DV doppler appears normal today. The patient has already had a course of steroids after an episode of threatened pre-term labour at 26/40. When should delivery be planned? a. Immediate induction of labour b. No later than 30/40 with daily dopplers including DV c. No later than 32/40 with daily dopplers including DV d. Immediate induction of labour following a repeat steroid course e. Immediate LSCS

Answer 100

E - Immediate LSCS This patient has abnormal umbilical artery and umbilical venous doppler indicating a fetus at considerable risk – delivery should therefore be arranged as soon as practically possible. The question of whether or not to delay delivery in order to give steroids should be on a case by case basis though doesn’t feature as an issue here as they have already been given. As the patient is <30/40, there would be an argument for administering at least a bolus dose of magnesium sulphate for fetal neuroprotection.

Question 101

Which of the following ultrasound markers is known to be associated with SFGA and should prompt serial scanning after detection? a. Ventriculomegaly b. Hydronephrosis c. Liver cysts d. Echogenic bowel e. 2-vessel cord

Answer 101

D - Echogenic bowel Fetal echogenic bowel has been shown to independently be associated with fetal growth restriction and demise. When seen, it should prompt serial scanning even if no other factors are present.

Question 102

What is the most common chromosomal abnormality identified on karyotyping of early-onset severe-SFGA diagnosed prior to 26/40? a. Trisomy 13 b. Trisomy 18 c. Trisomy 21 d. Monosomy X e. Triploidy

Answer 102

E - Triploidy Karyotyping should be offered to all those presenting with severe SFGA prior to 23/40 as a chromosomal abnormality will be identified in almost one-fifth. Triploidy is the most common chromosomal abnormality diagnosed in fetuses diagnosed as severe SFGA prior to 26/40. Beyond 26/40, trisomy 18 is more common.

Question 103

What is the most common chromosomal abnormality identified on karyotyping of early-onset severe-SFGA diagnosed after 26/40? a. Trisomy 13 b. Trisomy 18 c. Trisomy 21 d. Monosomy X e. Triploidy

Answer 103

B - Trisomy 18 Karyotyping should be offered to all those presenting with severe SFGA prior to 23/40 as a chromosomal abnormality will be identified in almost one-fifth. Triploidy is the most common chromosomal abnormality diagnosed in fetuses diagnosed as severe SFGA prior to 26/40. Beyond 26/40, trisomy 18 is more common.

Question 104

A Para 1 is seen in the ANC at 32/40 in her second pregnancy. In her first pregnancy she tested positive on opportunistic testing for GBS and was treated with IV antibiotic prophylaxis in labour. The baby was not affected. She is anxious about the possibility of recurrence. What management is most appropriate in this instance? a. IV antibiotic prophylaxis in labour b. Testing for GBS now and intrapartum antibiotic prophylaxis if positive c. Either prophylaxis in labour or testing at 35-37/40 and IAP if positive depending on patient choice d. Testing for GBS at 35-37/40 via HVS and IAP if positive e. Testing for GBS at 35-37/40 via urine culture and IAP if positive

Answer 104

C - Either prophylaxis in labour or testing at 35-37/40 and IAP depending on patient choice Women who have tested positive for GBS in a previous pregnancy – assuming the baby was not affected – should be offered a choice between testing at 35-37/40 (or 32-34/40 in multiples) and intrapartum antibiotic prophylaxis. The likelihood of testing positive in this pregnancy is 50%

Question 105

A patient with a history of GBS carriage in a previous pregnancy undergoes testing in a subsequent pregnancy. What is the likelihood of GBS carriage in this pregnancy? a. 25% b. 33% c. 50% d. 66% e. 75%

Answer 105

C - 50% Women who have tested positive for GBS in a previous pregnancy – assuming the baby was not affected – should be offered a choice between testing at 35-37/40 (or 32-34/40 in multiples) and intrapartum antibiotic prophylaxis. The likelihood of testing positive in this pregnancy is 50%

Question 106

A patient is seen in the ANC at 34 weeks gestation in her second pregnancy. Her last child was born prematurely at 32/40. This child was affected by EOGBS disease though made a good recovery. She wishes to discuss management in this pregnancy. You review results of testing on the system and notice that an opportunistic HVS taken at 28/40 did not demonstrate GBS carriage. What is your optimum management in this case? a. Reassure patient of negative carrier status and do nothing b. Repeat testing at 36/40 and offer IAP if positive c. Advise routine IAP for mother and antibiotic prophylaxis for baby at birth d. Repeat testing today and offer IAP if positive e. Offer routine IAP for mother

Answer 106

E - Offer routine IAP for mother Women with a previously affected baby (by either early or late onset GBS) should be offered IAP – there is no need to offer testing unless this were the patient’s preference. The prior negative swab result is a red herring here – even when tested at 35-37/40; as many as 7% of those who test negative will be positive by delivery and as many as 20-30% of positives will be negative. There is no indication for routine antibiotic prophylaxis for the infant at birth, though 2 hourly observation for signs of infection until 12 hours old is advised.

Question 107

At what gestation are the risks of infection thought to overtake those of prematurity in known GBS carriers presenting with preterm labour/PPROM? a. 32/40 b. 33/40 c. 34/40 d. 35/40 e. 36/40

Answer 107

C - 34/40 Management of PPROM in the context of GBS is a contentious issue. The risk of prematurity at 33+6 are thought to outweigh those of infection though the balance is less clear at 34+0. A large RCT examining elective delivery vs. conservative management of PPROM at 34-36/40 (overall – not just GBS) demonstrated no significant difference in neonatal disease or outcomes thus there is little to suggest one form of management should be preferred over any other. There may be disadvantages however with conservative management beyond 34/40 in the presence of known GBS colonisation and thus in this group, early intervention may be preferable

Question 108

A Para 1 attends the ANC at 27/40 in a DCDA twin pregnancy. In her last pregnancy she tested positive for GBS in a urine sample at 36/40 and had IAP in labour. The baby was unaffected. She wishes to discuss her options in this pregnancy as she is aiming for a vaginal birth. What management is advised in this scenario? a. Intrapartum antibiotic prophylaxis in labour b. Either screening at 32/40 or routine antibiotics in labour c. Either screening at 35/40 or routine antibiotics in labour d. Screening at 35/40 and antibiotics only if positive e. No screening necessary

Answer 108

B - Either screening at 32/40 or routine antibiotics in labour Where antenatal screening is performed, this should be done 3-5 weeks in advance of the anticipated delivery date – 35-37/40 for singletons or 32-34/40 for twins.

Question 109

A patient attends ANC at 32/40 and is found to have nitrites and leucocytes in her urine specimen – she is not symptomatic though an MSU is sent which demonstrates GBS carriage. What do you advise based on this result? a. No action necessary b. Antibiotic prophylaxis in labour c. Antibiotic treatment now d. Antibiotic prophylaxis in labour and treatment now e. For testing via HVS at 35/40

Answer 109

D - Antibiotic prophylaxis in labour and treatment now It is not routine nor recommended practise to treat GBS found on an HVS or rectal swab antenatally as this usually represents normal carriage. When GBS infection is found in urine however, treatment of the infection at the time AND in labour is recommended.

Question 110

A patient is referred to the ANC for discussion after disclosing to her midwife that she works as a long distance lorry driver and is worried about the risk of developing ‘clots’ in pregnancy. What journey time – irrespective of modality - is considered ‘long-distance’ by the RCOG VTE score? a. >2 hours b. >4 hours c. >6 hours d. >8 hours e. >10 hours

Answer 110

B - 4 hours Journeys of greater than 4 hours are considered ‘long distance’ and patients undertaking such trips whether or a one-off or regular basis should be encouraged to wear anti-embolism stockings at a pressure of 14-15mmHg to reduce DVT risk. While conventionally we think of long-distance travel in terms of flights, trips by other means should not be overlooked.

Question 111

A 32 year old patient attends the ANC at booking in her first pregnancy. The referral was made by her midwife after she disclosed a history of DVT aged 18. On further questioning, this occurred after the patient underwent a laparotomy and hemi-colectomy following a road-traffic accident. The patient is of normal weight and has no other medical/surgical history to speak of. After initial treatment for VTE at the time, she has had no recurrence. There are no additional obstetric nor VTE risk factors present. What LMWH prophylaxis is advised in this pregnancy? a. Prophylactic dose LMWH from booking b. Treatment dose LMWH from booking c. Prophylactic dose LMWH from 28/40 d. Treatment dose LMWH from 28/40 e. No AN LMWH, prophylaxis for 6/52 PN

Answer 111

C - Prophylactic dose LMWH from 28/40 Pregnant women with a history of VTE generally require prophylaxis with LMWH from booking. The exception is women such as that described in this scenario – where the original VTE was clearly provoked by major surgery from which they have made a full recovery. In the absence of any other clear risk factor, thromboprophylaxis with LMWH may be withheld antenatally until 28 weeks – if any other risk factors are present, offer from booking.

Question 112

In what percentage of pregnancy-associated VTE is a heritable thrombophilia found? a. Up to 20% b. Up to 30% c. Up to 40% d. Up to 50% e. Up to 60%

Answer 112

D - Up to 50% Thrombophilia testing is only recommended following VTE in patients in whom the result may influence the woman’s future management – this might be case for a woman in a family with a history of anti-thrombin deficiency for instance, where higher doses of prophylactic LMWH are indicated (50-75% of treatment dose). An inheritable thrombophilia will be identified on testing in at least 50% of pregnancy-associated VTE.

Question 113

9. What is the relative risk VTE in elective CS compared with vaginal birth and emergency CS relative to elective CS? El. CS vs. VD Em. CS vs. El. CS a. 2x 2x b. 2x 1x c. 5x 2x d. 3x 4x e. 2x 5x

Answer 113

A - 2x and 2x All women who have caesarean section should be considered for thromboprophylaxis with LMWH for a minimum of 10 days postnatally (except those undergoing an elective CS with no other risk factors for VTE). Women delivered by elective caesarean have at least double the post-partum risk of VTE and those undergoing emergency caesarean doubled again (or 4x the risk of vaginal birth).

Question 114

A 36 year old primigravida attends A&E complaining of chest pain and shortness of breath for around 7 days. She is reviewed by the registrar on-call who suspects a pulmonary embolism and arranges objective testing. In what proportion of clinically suspected PE in pregnancy is PE subsequently confirmed? a. 2-6% b. 10-14% c. 23-27% d. 33-39% e. 52-56%

Answer 114

A - 2-6% Subjective clinical assessment of DVT and PE in pregnancy is particularly unreliable in pregnancy and only a minority with clinically suspected VTE have the diagnosis confirmed on objective testing. In women with suspected PE, only ~2-6% will ultimately be diagnosed on objective testing.

Question 115

What is the absolute risk of VTE in pregnancy? a. 1 in 100 b. 1 in 250 c. 1 in 1000 d. 1 in 5000 e. 1 in 10,000

Answer 115

C - 1 in 1000 Despite the considerable increased risk of VTE in pregnancy, the overall, absolute risk remains low – 1-2 in 1000 pregnancies. The risk of PE is lower still at ~1.3 per 10,000 pregnancies.

Question 116

What is the relative risk of VTE in the AN and PN periods respectively compared to non-pregnant controls? AN PN a. 2x 5x b. 3x 10x c. 5x 20x d. 10x 15x e. 15x 25x

Answer 116

C - 5x and 20x Compared with on-pregnant controls, the risk of develops a VTE is around 4-5x greater during the antenatal period and 20x greater postnatally. The highest risk is in the hours immediately following birth.

Question 117

What FBC finding may be unexpectedly found in VTE in pregnancy? a. Neutropenia b. Increased haematocrit c. Eosinophilia d. Leucocytosis e. Thrombocytopenia

Answer 117

D - Leucocytosis The classic symptoms of DVT and PE are well described though be alert to the less obvious ways in these may present in pregnancy. Abdominal pain may be found in patients with iliofemoral DVT for instance (the most common site of DVT in pregnant patients) reflecting extension into the pelvic vessels or development of a collateral circulation. Both a low grade pyrexia and leucocytosis may occur in pregnancy.

Question 118

A pregnant woman diagnosed with a popliteal vein DVT at 26/40 declines LMWH as she is needle-phobic. What proportion of untreated DVT will progress to PE in pregnancy? a. Up to 10% b. Up to 24% c. Up to 36% d. Up to 52% e. Up to 75%

Answer 118

B - Up to 24% objective testing performed as a matter of urgency. Untreated, 15-24% of patients with DVT will progress to PE. PE in pregnancy carries a morality of ~15%.

Question 119

What is the mortality rate associated with pulmonary embolism in pregnancy? a. 45% b. 33% c. 20% d. 15% e. <5%

Answer 119

D - 15% The mortality associated with PE in pregnancy is considerable at ~15%. Around 2/3 of deaths are thought to occur within 30 minutes of the acute event.

Question 120

A patient attends A&E at 32/40 in her first pregnancy with painful swelling of the right calf which first occurred acutely earlier today. On examination, the calf is firm and tender to touch and considerable difference is noted on circumferential measurement compared with the left side. She is commenced on treatment dose LMWH and a compression duplex doppler of the leg is arranged for the following day. This scan is reported as negative though the symptoms persist and fail to resolve with conservative methods. Considering differential diagnoses, you retain some anxiety over DVT as a cause despite the negative scan. What management is appropriate in this case? a. Discontinue LMWH though repeat USS in 3 and 7 days b. Continue LMWH though repeat USS in 3 and 7 days c. Switch to prophylactic LMWH with repeat USS in 7 and 14 days d. Switch to prophylactic LMWH with repeat USS in 3 and 7 days e. Discontinue treatment as scan negative and discharge

Answer 120

A - Discontinue LMWH though repeat USS in 3 and 7 days The management of suspected DVT following a negative doppler ultrasound of the lower limbs depends on the degree of suspicion. If there is a low level of clinical suspicion, then it is reasonable to discontinue LMWH and discharge the patient/consider alternative diagnoses. Where the ultrasound is negative yet a high index of clinical suspicion remains, the ultrasound should be repeat on days 3 and 7 though LMWH discontinued in the meantime.

Question 121

What two initial investigations should be performed in patients presenting with symptoms of acute PE in pregnancy? a. ABG and ECG b. ABG and CTPA c. USS doppler lower limbs and ABG d. CXR and d-dimer e. ECG and CXR

Answer 121

E - ECG and CXR In the non-pregnant patient, both ECGs and ABGs are of limited value in the diagnosis of PE though in pregnancy, the ECG is found to be abnormal in up to 41% - most commonly T-wave inversion (21%); S1Q3T3 (15%) and RBBB (18%). An ECG is additionally useful in an age of increased levels of ischaemic heart disease in pregnancy, where it may enable simultaneous exclusion of other cardiac pathology. CXR may similarly help in ruling out alternative pathology and while it is normal in over half of patients with ultimately proven PE, there are well described abnormalities which may be seen – atelectasis, effusion, focal opacity, regional oligaemia or pulmonary oedema. ABG is of limited diagnostic value in PE in pregnancy – abnormal in ~10% only. First line investigation should thus constitute an ECG and chest x-ray.

Question 122

A patient attends labour ward with symptoms of shortness of breath and pleuritic chest pain which developed suddenly at 27/40. She undergoes testing for a range of differential diagnoses including an erect CXR which is reported as showing ‘left-basal oligaemia and atelectasis’. You suspect a PE clinically and arrange further testing. She has no other symptoms of note aside from a mild tachycardia of 112bpm. What test do you arrange in order to confirm or exclude PE? a. D-dimer b. Doppler USS of lower limbs c. CTPA d. V/Q scan e. MRV lower limbs

Answer 122

C - CTPA The results of the initial chest x-ray may help determine the most appropriate definitive imaging modality. A normal CXR improves the likelihood of a definitive VQ result however where the CXR is abnormal with a clinical suspicion of PE, a CTPA should be performed.

Question 123

A patient attends delivery suit complaining of shortness of breath and chest pain for around 3 days. She says this developed after she initially noticed a tight, tender swelling in her left calf. A CXR performed on admission was reported as normal. What is the preferred initial objective testing modality in this patient? a. V/Q scan b. ECG c. Doppler USS lower limbs d. CTPA e. ABG

Answer 123

C - Doppler USS lower limbs Patients with simultaneous DVT and PE symptoms should have bilateral compression duplex ultrasound studies performed. A diagnosis of DVT may indirectly diagnose a PE, and given anticoagulant therapy is equivalent for both conditions, further investigation may not be necessary, limiting the radiation doses given to mother and fetus. A negative USS lower limb result in this scenario however could not be relied upon to exclude PE, and further testing would be indicated.

Question 124

Levels of which factors may fall in acute VTE? a. FVL and anti-thrombin b. Prothrombin and Factor Xa c. Protein C and Protein S d. Protein S and FVL e. Protein C and antithrombin

Answer 124

E - Protein C and antithrombin Immediate thrombophilia testing is not routinely indicated in patients who develop a VTE in pregnancy – not only because it will not influence the initial management but as the physiology of pregnancy and pathophysiology of acute thrombus render results often un-interpretable. In acute VTE, levels of antithrombin and protein C may falls, especially where the thrombus is extensive.

Question 125

A primigravida who develops a large femoral vein DVT at 36/40 is commenced on unfractioned heparin. How often should platelet count be measured in patients post-operatively on unfractioned heparin? a. Twice daily b. Daily c. Every 2-3 days d. Weekly e. Fortnightly

Answer 125

C - Every 2-3 days Routine platelet monitoring is not necessary in women on heparin as the overall risk of HIT is low, especially with LMWH (only one case report in pregnancy on LMWH). Platelet count should be checked within 24 hours of treatment in patients who have had any heparin therapy in the last 100 days. The frequency of HIT is greater in surgical than medical patients and is more likely with unfractioned heparin – for this reason it is recommended that obstetric post-operative patients on UF have platelet count monitoring every 2-3 days from day 4-14 or until heparin is stopped.

Question 126

A Para 6 is admitted with a large saddle embolus at 32 weeks of gestation and commenced on unfractionated heparin. What dose of IV unfractionated heparin is advised in massive PE with cardiovascular compromise? Loading Init. Maintenance a. 40 units/kg 9 units/kg/hour b. 80 units/kg 18 units/kg/hour c. 120 units/kg 12 units/kg/hour d. 150 units/kg 10 units/kg/hour e. 160 units/kg 15 units/kg/hour

Answer 126

B - 80 units/kg loading; 18 units/kg/hour maintenance The loading dose of unfractioned heparin in massive PE (it is preferred in this scenario due to its more instantaneous effect) is 80 units/kg following by maintenance of 18units/kg/hour (omit the loading dose if thrombolysed). APTT should be measured 4-6 hours after the loading dose, 6 hours after any dose change and then daily when in therapeutic range (1.5-2.5x normal).

Question 127

A Para 5 is admitted with a large pulmonary embolus at 32 weeks of gestation and commenced on unfractionated heparinWhat aspect of the routine coagulation screen should be monitored closely in patients on unfractionated heparin to guide maintenance dosing? a. PT b. APTT c. INR d. Fibrinogen e. Platelet count

Answer 127

B - APTT Patients on IV unfractioned heparin require regular monitoring of APTT to guide dosing and keep in therapeutic range (1.5-2.5).

Question 128

A Para 3 develops a DVT in her left leg at 22 weeks of gestation and is given thromboembolic stockings to wear in order to reduce the risk of post-thrombotic syndrome. What is the target minimal ankle pressure in mmHg in patients with DVT wearing graduated compression stockings? a. 69mmHg b. 47mmHg c. 23mmHg d. 14mmHg e. 7mmHg

Answer 128

C - 23mmHg affected leg to reduce the likelihood of developing post-thrombotic syndrome. Whereas stockings for VTE prophylaxis/prevention should be worn at a pressure of 14-15mmHg, stockings to prevent PTS should be >23mmHg.

Question 129

A primigravida with a left lower limb DVT enquires about treatment duration. How long should patients diagnosed with VTE in pregnancy remain on therapeutic anticoagulation? a. Until 6 weeks postpartum regardless of time of onset b. Until 3 months treatment given in total c. Until 6 months treatment given in total d. Until 12 months postpartum e. Until 2 years treatment given in total

Answer 129

B - Until 3 months treatment given in total Treatment with s/c LMWH should be given following VTE in pregnancy until at least 6 weeks post-partum or until 3 months treatment have completed in total – whichever is longer.

Question 130

A patient is admitted to the antenatal ward with dehydration and vomiting in the third trimester. It is felt she would benefit from LMWH and compression stockings to reduce the risk of her developing VTE while an inpatient. What is the target minimal ankle pressure in mmHg in patients wearing graduated compression stockings for the purposes of preventing DVT? a. 69mmHg b. 47mmHg c. 23mmHg d. 14mmHg e. 7mmHg

Answer 130

D - 14mmHg Anti-embolic compression stockings for prophylaxis of DVT should be worn at an ankle pressure of 14-15mmHg. This is less that for prevention of PTS in women with confirmed DVT (>23mmHg).

Question 131

A patient presents to her midwife at booking in her first pregnancy. During a routine history, she discloses a past history of ‘low blood count’ secondary to heavy menstrual bleeding. What haemoglobin level would be considered the cut off for anaemia in the first trimester? a. <120g/L b. <115g/L c. <110g/L d. <105g/L e. <100g/L

Answer 131

C - <110g/L The BCSH has defined what it considers adequate Hb levels at different stage of pregnancy – if the Hb is <110g/L in the first trimester or <105g/L in the second or third trimester, haematinic deficiency should be considered once haemoglobinopathy excluded.

Question 132

You are seeing a patient in her first pregnancy after a dating scan which has revealed this to be a DCDA twin pregnancy. You explain about the increased risk of anaemia in multiple pregnancy and advise screening – when would you organise this? a. Booking and 28/40 b. Booking, 20/40 and 28/40 c. Booking, 28/40 and 36/40 d. Booking, 20/40, 28/40 and 36/40 e. Booking, 20/40 and 34/40

Answer 132

B - Booking, 20/40 and 28/40 In line with NICE guidelines, screening for anaemia should be offered at booking and again at 28/40 with an additional check at 20-24/40 in multiples.

Question 133

A patient is seen in the ANC at 36/40 in her second pregnancy to plan delivery. A recent full blood count result is reviewed and haemoglobin noted to be outwith the normal laboratory range. What level of haemoglobin is considered the cut off for anaemia in the third trimester? a. <115g/L b. <110g/L c. <105g/L d. <100g/L e. <95g/L

Answer 133

C - <105g/L When checked in the third trimester, Hb levels of <105g/L should prompt consideration of cause and treatment.

Question 134

Iron supplementation has been shown to decrease the incidence of post-partum anaemia in pregnant patients. Which of the following additional outcomes is seen less commonly in patients on iron supplementation? a. PPH b. Operative vaginal delivery c. Delivery by LSCS d. Polyhydramnios e. Low birthweight

Answer 134

E - Low birthweight Women with anaemia where iron deficiency is thought to be the most likely underlying cause should receive oral iron therapy or be considered for parenteral iron if unable to tolerate oral preparations or levels need improving quickly close to term. A Cochrane review found that iron supplementation decreased the incidence of low birthweight babies and helped prevent maternal anaemia.

Question 135

What is the recommended maximum time to have elapsed between Group and Save samples and issue of blood in pregnant patients? a. 24 hours b. 48 hours c. 72 hours d. 7 days e. 14 days

Answer 135

C - 72 hours As transfusion and pregnancy both may stimulate the production of unexpected antibodies in maternal blood through either a primary or secondary immune response, it is important to ensure that specimens used in compatibility testing of blood are representative of the patient’s current immune status. As such, unit matching should be performed on samples collected no more than 3 days/72 hours in advance of the actual transfusion in any patient who has been either transfused or pregnant within the preceding 3 months. A formal deviation to this rule may be used in pregnant women with no significant allo-antibodies who require blood on standby for potential obstetric emergencies – e.g. praevia, with samples sent once a week in such patients. Feto-maternal haemorrhage is a smaller stimulus than transfusion both because the number of foreign antigens is limited and secondly because the actual volume of red cells transfused is too small to elicit a primary response.

Question 136

A patient with major placenta praevia has recurrent admissions during pregnancy with small episodes of vaginal bleeding. How often should Group and Save samples be sent during pregnancy for such patients at high risk of requiring emergency transfusion? a. Weekly b. Fortnightly c. Monthly d. 2-monthly e. No consensus

Answer 136

A - Weekly As transfusion and pregnancy both may stimulate the production of unexpected antibodies in maternal blood through either a primary or secondary immune response, it is important to ensure that specimens used in compatibility testing of blood are representative of the patient’s current immune status. As such, unit matching should be performed on samples collected no more than 3 days/72 hours in advance of the actual transfusion in any patient who has been either transfused or pregnant within the preceding 3 months. A formal deviation to this rule may be used in pregnant women with no significant allo-antibodies who require blood on standby for potential obstetric emergencies – e.g. praevia, with samples sent once a week in such patients. Feto-maternal haemorrhage is a smaller stimulus than transfusion both because the number of foreign antigens is limited and secondly because the actual volume of red cells transfused is too small to elicit a primary response.

Question 137

How much anti-D is required in a patient who receives a mismatched platelet transfusion of 4 units during pregnancy? a. None required b. 250iU c. 500iU d. 1000iU e. 1500iU f. Guide by Kleihaur testing

Answer 137

B - 250iU In order to minimise the risk of development of anti-D antibodies, platelet transfusions should be cross matched to rhesus status – if RhD +ve platelets are issued to a RhD –ve mother, anti-D should be given. A dose of 250iU is sufficient to cover FIVE adult therapeutic doses given within 6 weeks. Subcutaneous administration might be considered to minimise risks of bruising and haematoma.

Question 138

What is the mechanism of tranexamic acid? a. Prevents activation of Factor X b. Stimulates production of fibrin c. Prevents activation of plasminogen d. Prevents breakdown of plasmin e. Stimulates platelet adhesion

Answer 138

C - Prevents activation of plasminogen Tranexamic acid is a synthetic derivative of the amino acid lysine which reversibly binds lysine binding sites on plasminogen. In doing to, it prevents its activation to plasmin and in turn leads to inhibition of fibrinolysis

Question 139

What antibody titres must be considered in transfusing patients with FFP or cryoprecipiate? a. Anti-A and B b. Anti-D c. Anti-Kell d. Anti-e and C e. Anti-E and C

Answer 139

A - Anti-A and B The risk of ABO haemolysis is low following FFP or cryoprecipitate administration though to minimise it further, cross-matching is considered ideal. If not possible, an alternative group may be given providing anti-A or B titres are low. RhD sensitisation with cryoprecipitate or FFP is extremely unlikely thus no anti-D prophylaxis is necessary if mismatch given.

Question 140

A patient is reviewed in the ANC at 28 weeks in her first pregnancy. During this appointment, the results of her 20/40 FBC are reviewed and Hb is noted to be low at 95g/L. What management is advised? a. Commence oral iron and repeat Hb in 2 weeks b. Commence oral iron and repeat Hb in 4 weeks c. Arrange parenteral iron infusion with repeat Hb after 2 weeks d. Commence oral iron and arrange haematinic testing e. Arrange haematinic testing and commence iron once results known, if indicated

Answer 140

A - Commence oral iron and repeat Hb in 2 weeks For women with normo- or microcytic anaemia in pregnancy, a trial of oral iron should be considered first line with a repeat Hb in 2 weeks and further testing (haematinics) if there is no demonstrable improvement. True iron deficiency can be difficult to diagnose as the signs and symptoms are fairly non-specific. Serum ferritin is the most useful test though is an acute phase reactant.

Question 141

Which of the following is the considered the most useful test of iron deficiency in pregnant patients? a. Transferrin b. Ferritin c. Total iron binding capacity d. Serum iron e. Hemosiderin

Answer 141

B - Ferritin For women with normo- or microcytic anaemia in pregnancy, a trial of oral iron should be considered first line with a repeat Hb in 2 weeks and further testing (haematinics) if there is no demonstrable improvement. True iron deficiency can be difficult to diagnose as the signs and symptoms are fairly non-specific. Serum ferritin is the most useful test though is an acute phase reactant.

Question 142

In what population may routine assessment of risk for cord prolapse (on USS) be considered? a. Preterm labour b. Polyhydramnios c. Low lying placenta d. Breech planning vaginal delivery e. Pre-ECV

Answer 142

D - Breech planning vaginal delivery Routine ultrasound examination is neither sufficiently sensitive nor specific to identify cord presentation antenatally and should not be used routinely outwith a research setting. The exception is in women with a term breech baby who are planning or considering vaginal birth.

Question 143

A patient attends for her dating scan at 12+2 weeks of gestation and is found to be carrying an MCDA twin pregnancy. What proportion of twin pregnancies are monochorionic? a. 5% b. 10% c. 20% d. 25% e. 30%

Answer 143

E - 30% Approximately 30% of twin pregnancies in the UK are monochorionic. Of these, 1% are monochorionic, monoamniotic, sharing both a placenta and amniotic sac. MCMA twins carry a very high risk of fetal loss – most commonly prior to 24/40

Question 144

What proportion of monochorionic twins are mono-amniotic? a. 1% b. 5% c. 15% d. 20% e. 30%

Answer 144

A - 1% Approximately 30% of twin pregnancies in the UK are monochorionic. Of these, 1% are monochorionic, monoamniotic, sharing both a placenta and amniotic sac. MCMA twins carry a very high risk of fetal loss – most commonly prior to 24/40

Question 145

A patient pregnant with an MCDA twin pregnancy is reviewed in the ANC at 18/40 gestation in her first pregnancy. On USS there is noted to be a DVP of 13cm around the presenting twin and 1.5cm around the non-presenting twin. The fetal bladder is identified in the presenting twin, though not in the non-presenting twin. Dopplers are normal in both twins and there is no evidence of fetal hydrops. A diagnosis of twin to twin transfusion syndrome is made. What Quintero Stage does this represent? a. I b. II c. III d. IV e. V

Answer 145

B - II Twin to twin transfusion syndrome (TTTS) affects up to 15% of monochorionic twin pregnancies and is characterised by a predominance of unidirectional artery-to-vein anastomoses. TTTS is graded by the ‘Quintero’ staging system as follows: I Discordance in liquor volume Oligohydramnios in the donor (DVP <2) and poly- in the recipient (>8 before 20/40 and >10 after 20/40). Donor bladder and dopplers still visible. II Bladder of donor twin not visible Severe oligo- due to anuria. Doppler not critically abnormal III Doppler critically abnormal in either twin Usually arterial in the donor and/or venous in the recipient IV Ascites/Pericardial/Pleural effusion or overt Hydrops Usually in the recipient V Fetal demise One or both twins

Question 146

A patient attends the ANC after a dating scan which reveals a twin pregnancy. There is some uncertainty regarding the chorionicity of the pregnancy however and a referral is made to fetal medicine for a second opinion. In the meantime, you discuss the important points of twin pregnancy with the patient in broad terms. She is particularly concerned about the risk of twin to twin transfusion syndrome. What is the risk of TTTS in monochorionic twin pregnancy? a. 5% b. 15% c. 25% d. 40% e. 60%

Answer 146

B - 15% Twin to twin transfusion syndrome (TTTS) affects up to 15% of monochorionic twin pregnancies and is characterised by a predominance of unidirectional artery-to-vein anastomoses

Question 147

15% of monochorionic twin pregnancies are complicated by significant growth discordance in the absence of TTTS. What qualifies as ‘significant’ growth discordance? a. Birthweight difference of greater than 250g b. Birthweight difference of greater than 500g c. EFW difference of greater than 15% at any stage d. EFW difference of greater than 20% at any stage e. EFW difference of greater than 25% at any stage

Answer 147

D - Birthweight difference of greater than 20% at any gestation A growth discrepancy in excess of 20% on EFW is considered significant in all twins. This is calculated via the formula: ([EFW larger twin – EFW smaller twin])/EFW larger twin) x 100

Question 148

A patient attends her dating scan in her second pregnancy. By LMP she has calculated her dates to be 11+5/40. Scan demonstrates an MCDA twin pregnancy though the sonographer finds a small discrepancy between the CRL of both twins. What is the advised management in such a case? a. Date the pregnancy by LMP providing this falls +/- 7 days of the date of both twins by CRL b. Use an average of the 2 CRL measurements c. Repeat the scan in 7 days d. Use the CRL of the smaller twin e. Use the CRL of the larger twin

Answer 148

E - Use the CRL of the larger twin In spontaneous conceptions, the gestational age of twins can be determined by using the CRL of the larger fetus to avoid the risk of estimating from a baby with very early onset growth pathology.

Question 149

What discrepancy in newborn haemoglobin level is required for confirmation of suspected TAP sequence in monochorionic twin pregnancy? a. >10g/dL b. >20g/dL c. >40g/dL d. >70g/dL e. >80g>dL

Answer 149

E - >80g/L TAPS – twin anaemia-polycythaemia sequence – is defined by signs of fetal anaemia in the donor (raised MCA PSV >1.5 MoM) with concurrent signs of polycythaemia in the recipient (decreased MCS PSV <1 MoM) without significant oligohydramnios/polyhydramnios. It occurs in around 2% of otherwise uncomplicated MCDA twins and 13% of monochorionic twins post-laser ablation and thus should be screened for in this population with serial MCA PSV. The placental vasculature in TAPS is characterised by only a few small artery-to-vein anastomoses which permit slow transfusion of blood from donor to recipient and a progressive discordance in haemoglobin levels. The diagnosis is confirmed postnatally by detection of haemoglobin discrepancy of greater than 80g/L and a reticulocyte count in the donor of >1.7.

Question 150

What is the first line management for Quintero Stage 2 twin-to-twin transfusion syndrome detected prior to 26/40? a. Repeat USS in 1/52 b. Repeat USS in 2/52 c. Amnioreduction of recipient twin d. Fetoscopic laser ablation of the placenta e. Septostomy

Answer 150

D - Fetoscopic laser ablation of the placenta Where TTTS is detected prior to 26/40 gestation, first line management is by feto-scopic laser ablation rather than alternatives such as septostomy or amnioreduction. The decision of when to treat is individualised though most centres will routinely offer for Stage II Quintero and many will treat if there is Stage I with significant polyhydramnios (>8cm) or cervical shortening (<25mm). Amnioreduction can be considered for cases where the expertise for laser is not available or when the condition is diagnosed after 26/40 (however there is emerging evidence that laser is the best treatment in both early and late-onset disease).

Question 151

A primigravidae attends the fetal medicine clinic for review at 32/40 after a departmental scan reveals a growth discrepancy of 27% in her MCDA twins. Doppler in the smaller twin shows intermittently reversed EDF. The presenting twin is cephalic. What management do you advise? a. Commence twice weekly doppler b. Daily computerised CTG and delivery if STV <4 c. Steroids now, daily doppler and deliver when REDF is a consistent finding d. Steroids now and delivery by LSCS e. Immediate induction of labour

Answer 151

D - Steroids now and delivery by LSCS This question is effectively asking for two answers – firstly, to determine from the information given the stage of sGR described and secondly knowledge of appropriate management based upon this. The scenario describes stage III sGR – the most severe, characterised by significant growth discrepancy (>20%) and intermittently absent or reversed EDF. The RCOG guideline advocates that stage II and III sGR should prompt delivery by 32/40 (or sooner if fetal growth velocity is significantly abnormal or there is worsening of the doppler assessment). Attempting vaginal delivery in this setting would be inappropriate and LSCS is indicated. Delivery in stage I sGR may be deferred until 34-36/40 providing there is satisfactory fetal growth velocity and normal umbilical artery doppler waveforms. I Discordance but +ve diastolic flow in both umbilical arteries II Discordance with AEDF/REDF in one or both foetuses III Discordance with cyclical UA waveforms – intermittent AREDF

Question 152

What is the risk of death to the surviving twin in a case of single twin demise in a monochorionic twin pregnancy? a. 5% b. 15% c. 25% d. 40% e. 55%

Answer 152

B - 15% Where single twin demise occurs in a monochorionic twin pregnancy, the placental vascular anastomoses (which may have contributed) may well remain intact, leaving open the possibility of acute inter-twin tranfusional events leading to death and neurological morbidity. These are believed to occur around the time of death meaning that rushing to deliver the surviving twin upon diagnosis is often unwise as it will add prematurity to the neurological insult which potential has already taken place. The quoted risk of death and neurological abnormality to the surviving twin are of the order of 15% and 26% respectively. For dichorionic twins, the same numbers are 3% and 2%. Conservative management is often appropriate – with serial fetal brain ultrasound and a cranial MRI after 4 weeks of the event (the appearances of cranial neurology can take up to 4 weeks to develop).

Question 153

What is the risk of death to the surviving twin in a case of single twin demise in a dichorionic twin pregnancy? a. <1% b. 3% c. 10% d. 17% e. 25%

Answer 153

B - 3% Where single twin demise occurs in a monochorionic twin pregnancy, the placental vascular anastomoses (which may have contributed) may well remain intact, leaving open the possibility of acute inter-twin tranfusional events leading to death and neurological morbidity. These are believed to occur around the time of death meaning that rushing to deliver the surviving twin upon diagnosis is often unwise as it will add prematurity to the neurological insult which potential has already taken place. The quoted risk of death and neurological abnormality to the surviving twin are of the order of 15% and 26% respectively. For dichorionic twins, the same numbers are 3% and 2%. Conservative management is often appropriate – with serial fetal brain ultrasound and a cranial MRI after 4 weeks of the event (the appearances of cranial neurology can take up to 4 weeks to develop).

Question 154

A primigravida with MCDA twins attends the delivery suite at 29/40 in her first pregnancy reporting reduced fetal movement of one twin. An ultrasound is performed and sadly one of the twins is found to have demised. A CTG is performed on the other twin which is normal. What is the approximate incidence of long term neurodevelopmental impairment in the surviving twin in such instances? a. 5% b. 15% c. 25% d. 33% e. 50%

Answer 154

C - 25% Where single twin demise occurs in a monochorionic twin pregnancy, the placental vascular anastomoses (which may have contributed) may well remain intact, leaving open the possibility of acute inter-twin tranfusional events leading to death and neurological morbidity. These are believed to occur around the time of death meaning that rushing to deliver the surviving twin upon diagnosis is often unwise as it will add prematurity to the neurological insult which potential has already taken place. The quoted risk of death and neurological abnormality to the surviving twin are of the order of 15% and 26% respectively. For dichorionic twins, the same numbers are 3% and 2%. Conservative management is often appropriate – with serial fetal brain ultrasound and a cranial MRI after 4 weeks of the event (the appearances of cranial neurology can take up to 4 weeks to develop).

Question 155

A patient attends her dating scan at 12/40 and is found to have an apparent MCMA twin pregnancy. She has a history of 3 vaginal births. Assuming both twins are cephalic in the third trimester, what is the most appropriate plan for delivery? a. LSCS by 34/40 under steroid cover b. IOL no later than 36/40 c. LSCS by 36/40 under steroid cover d. IOL at 34/40 with steroid cover e. LSCS by 32/40 with steroid cover

Answer 155

A - LSCS at 34/40 under steroid cover The ‘rules’ on timing of delivery in uncomplicated multiple pregnancy is as follows (RCOG and NICE): Chorion. Timing Mode Steroids DCDA From 37/40 Vaginal if cephalic No MCDA From 36/40 Vaginal if cephalic Yes MCMA 32-34/40 LSCS Yes Triplets From 35/40 Individualise Yes 60% of twins will deliver spontaneously prior to 37/40 (75% of triplets prior to 35/40). Continuation of a MC pregnancy beyond 36/40 is not actually associated with increased risk of adverse outcomes (this occurs after 38/40).

Question 156

A primigravida attends the ANC at 32/40 in a MCDA twin pregnancy. The pregnancy has been uncomplicated thus far and no concerns have been noted regarding fetal growth. Both twins are cephalic. Assuming this remains the case, what plan for delivery would you initiate? a. Elective delivery by 34/40; advise caesarean delivery b. Elective delivery by 35/40; can have vaginal birth if desired c. Elective delivery by 35/40; advise caesarean delivery d. Elective delivery by 36/40; can have vaginal birth if desired e. Elective delivery by 36/40; advise caesarean delivery

Answer 156

D - Elective delivery by 36/40; can have vaginal birth if desired The ‘rules’ on timing of delivery in uncomplicated multiple pregnancy is as follows (RCOG and NICE): Chorion. Timing Mode Steroids DCDA From 37/40 Vaginal if cephalic No MCDA From 36/40 Vaginal if cephalic Yes MCMA 32-34/40 LSCS Yes Triplets From 35/40 Individualise Yes 60% of twins will deliver spontaneously prior to 37/40 (75% of triplets prior to 35/40). Continuation of a MC pregnancy beyond 36/40 is not actually associated with increased risk of adverse outcomes (this occurs after 38/40).

Question 157

What is the prevalence of conjoined twins? a. 1 in 25,000 b. 1 in 50,000 c. 1 in 100,000 d. 1 in 500,000 e. 1 in 1,000,000

Answer 157

C - 1 in 100,000 Conjoined twins are incredibly rare – around 1 in 90-100,000 pregnancies.

Question 158

What proportion of monochorionic twins are affected by TRAP Sequence? a. 0.1% b. 0.5% c. 1% d. 2.5% e. 5%

Answer 158

C - 1% TRAP sequence – where an acardiac twin lacking any cardiac tissue is perfused by an anatomically normal ‘pump’ twin via a large artery-artery anastomosis on the placental surface – occurs in approximately 1% of monochorionic twins.

Question 159

A primigravida with MCDA twins attends for a routine growth scan at 22/40. This demonstrates 24% growth discordance between the twins, as well as oligohydramnios and absent end diastolic flow in both. What grade of sGR does this history represent? a. I b. II c. III d. IV e. V

Answer 159

B - II This is grade II sGR – there is absent EDF and a growth discrepancy of >20%. Intermittently absent or intermittently reversed flow would upgrade to III. There is no Grade IV or V in the sGR classification. Grade I is discordance in growth of >20% though positive EDF in both twins’ arteries.

Question 160

What is the risk of chromosomal abnormality with monochorionic twins relative to dichorionic twins? a. 1.5-fold b. Double c. Triple d. Quadruple e. Equivalent

Answer 160

E - Equivalent There is no increased risk of chromosomal abnormality in monochorionic twins when compared with dichorionics, though both carry a slightly higher risk compared with singletons owing to the indirect association with maternal age. Screening for aneuploidy in monochorionics should be via nuchal translucency and first trimester markers (beta-hCG and PAPP-A) at the usual gestation – beyond this quadruple testing. Both will return a ‘pregnancy-specific’ rather than ‘fetus-specific’ risk. Where amniocentesis is required, both sacs should be sampled unless monochorionicity was confirmed prior to 14/40 and the fetuses are concordant for growth and anatomy.

Question 161

You see a 19 year old primigravida at 22/40 in the antenatal clinic. She is a refugee having recently arrived in the UK from Somalia and is not yet booked for antenatal care. During this first consultation she discloses that as a child in Somalia she had ‘cutting’. You explain the need to perform an examination to assess further which reveals an extremely narrow vaginal introitus, the labia having seemingly been fused together in the midline. What ‘type’ of FGM is this? a. Type 1 b. Type 2 c. Type 3 d. Type 4 e. Not FGM

Answer 161

C - Type 3 FGM is defined as any procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons and is graded internationally by the WHO classification as follows: Type 1 Partial or total removal of the clitoris and/or prepuce (cliteroidectomy) Type 2 Partial or total removal of the clitoris and the labia minora with or without excision of the labia majora (excision) Type 3 Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or majora with or without excision of the clitoris (infibulation) Type 4 All other harmful procedures to the female genitalia for non-medical reasons including pricking, piercing, incising, scraping and cauterisation

Question 162

A 32 year old arrives on delivery suite complaining of severe pain around the lower abdomen and pelvis. She speaks little English and has no antenatal notes. Labour is suspected and a vaginal examination performed to assess further. During this examination, it is noted that the clitoris and prepuce appear to have been completely removed. The remainder of the vaginal anatomy appears normal. What ‘type’ of FGM is this? a. Type 1 b. Type 2 c. Type 3 d. Type 4 e. Not FGM

Answer 162

A - Type 1 FGM is defined as any procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons and is graded internationally by the WHO classification as follows: Type 1 Partial or total removal of the clitoris and/or prepuce (cliteroidectomy) Type 2 Partial or total removal of the clitoris and the labia minora with or without excision of the labia majora (excision) Type 3 Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or majora with or without excision of the clitoris (infibulation) Type 4 All other harmful procedures to the female genitalia for non-medical reasons including pricking, piercing, incising, scraping and cauterisation

Question 163

You see a 21 year old primigravida in the day-assessment unit with suspected preterm pre-labour membrane rupture at 32 weeks and perform a speculum examination to confirm. During the examination you observe a piercing of the clitoral prepuce. What type of FGM is this? a. Type 1 b. Type 2 c. Type 3 d. Type 4 e. Not FGM

Answer 163

D - Type 4 FGM is defined as any procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons and is graded internationally by the WHO classification as follows: Type 1 Partial or total removal of the clitoris and/or prepuce (cliteroidectomy) Type 2 Partial or total removal of the clitoris and the labia minora with or without excision of the labia majora (excision) Type 3 Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or majora with or without excision of the clitoris (infibulation) Type 4 All other harmful procedures to the female genitalia for non-medical reasons including pricking, piercing, incising, scraping and cauterisation

Question 164

A 19 year old primigravida from Guinea is referred to the antenatal clinic for review after disclosing a history of FGM to her midwife at booking. On examination, both the clitoris and labia minora have been completely excised. What type of FGM is this? a. Type 1 b. Type 2 c. Type 3 d. Type 4 e. Not FGM

Answer 164

B - Type 2 FGM is defined as any procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons and is graded internationally by the WHO classification as follows: Type 1 Partial or total removal of the clitoris and/or prepuce (cliteroidectomy) Type 2 Partial or total removal of the clitoris and the labia minora with or without excision of the labia majora (excision) Type 3 Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or majora with or without excision of the clitoris (infibulation) Type 4 All other harmful procedures to the female genitalia for non-medical reasons including pricking, piercing, incising, scraping and cauterisation

Question 165

What country has the highest prevalence of FGM? a. Burkina-Faso b. Egypt c. Yemen d. Liberia e. Somalia

Answer 165

E - Somalia FGM is though to affect over 125 million women and girls worldwide and around 137,000 in the UK (of whom 10,000 are girls under 15). The type of FGM performed varies from one country and culture to another – infibulation (type 3) is performed almost exclusively in Africa, usually in the erroneous belief that it is in some way beneficial. The highest rates of FGM worldwide are seen in Somalia (98%) followed by Guinea, Djibouti and Egypt (all >90%).

Question 166

How many women and girls living in the UK are thought to have undergone FGM? a. <1000 b. 1000-10,000 c. 10,000-100,000 d. 100,000-150,000 e. >150,000

Answer 166

D - 100,000-150,000 FGM is though to affect over 125 million women and girls worldwide and around 137,000 in the UK (of whom 10,000 are girls under 15). The type of FGM performed varies from one country and culture to another – infibulation (type 3) is performed almost exclusively in Africa, usually in the erroneous belief that it is in some way beneficial. The highest rates of FGM worldwide are seen in Somalia (98%) followed by Guinea, Djibouti and Egypt (all >90%).

Question 167

Which of the following is NOT a provision of the FGM Act 2003 or Prohibition of FGM (Scotland) Act 2005? a. It is illegal to arrange for a UK national to be taken overseas for the purposes of performing FGM b. It is an offence for anyone with parental responsibility to fail to protect a girl at risk of FGM c. Surgical procedures to the genitalia which are necessary for the woman’s mental or physical health are considered to be legal d. Confirmation of FGM in any girl <18 years should be reported to the police within 1 month e. Confirmation of FGM in any woman of any age should be reported to the police within 6 months of confirmation

Answer 167

E - Confirmation of FGM in any woman of any age should be reported to the police within 6 months of confirmation Both the FGM Act (2003) in England, Wales and NI plus the Prohibition of FGM (Scotland) Act (2005) provide that: • FGM is illegal unless a surgical operation on a woman/girl regardless of age: o Which is necessary for her physical or mental health o She is in any stage of labour or has just given birth, for purposes connected with the labour or birth • It is illegal to arrange or assist in arranging for a UK national or resident to be taken overseas for the purpose of performing FGM • It is an offence for those with parental responsibility to fail to protect a girl from the risk of FGM • If FGM is confirmed in a girl under 18 years of age (either on examination or the verbal say-so of a parent/patient), reporting to the police is mandatory and must be done within 1 month of confirmation

Question 168

What is the obligation of all trusts in respect of reporting of FGM? a. Anonymised reporting to the HSCIC b. Non-anonymised reporting to the HSCIC c. Anonymised reporting to Public Health England d. Non-anonymised reporting to Public Health England e. To Police

Answer 168

B - Non-anonymised reporting to the HSCIC It is important to draw distinction between recording – i.e. documentation in the medical record – from reporting – a referral to police or social service – where FGM is concerned. Health professionals are required to submit personal data without anonymisation (although the data IS anonymised at the point of statistical analysis/publication) to the HSCIC (now known as ‘NHS Digital’). The reporting of all pregnant women to the police or social services is not mandatory – instead an individualised risk assessment should be made by a member of the clinical team (midwife or obstetrician) using an FGM safeguarding risk-assessment tool. In the event the unborn child or any related child is deemed to be at risk, then a report should be made. After the baby is born, relevant information about the mother’s FGM should be recorded in the maternity discharge documentation so that GPs and health visitors are aware. The family history should be recorded in the baby’s personal health record (the ‘Red Book’). It is important to make the above clear to any woman prior to reporting.

Question 169

Screening for which specific infection should be offered in pregnancy in women with a history of previous FGM in addition to those performed routinely? a. N. Gonorrhoea b. C. Trachomitis c. Group B Streptococcus d. Hepatitis C e. HIV Type A

Answer 169

D - Hepatitis C All pregnant women are offered screening for hepatitis B, HIV and syphilis though testing for hepatitis C is not routine. It should however be performed in women with a history of FGM. Women presenting acutely with history of recent FGM should prompt consideration of tetanus infection/inoculation status.

Question 170

A patient is reviewed in the ANC at 12 weeks and noted to have a history of infibulation (Type 3 FGM). On inspection the vaginal introitus is extremely narrow and it is felt that this will preclude safe assessment and delivery in labour. When is the recommended time for de-infibulation to be performed? a. Immediately b. Second trimester c. Third trimester before onset of labour d. First stage of labour e. Second stage of labour

Answer 170

B - Second trimester For women with type 3 FGM where adequate vaginal assessment in labour is unlikely to be possible, antenatal de-infibulation is recommended – usually in the second trimester ~20/40. This ensures the procedure is performed by an adequately trained midwife or obstetrician. Some women however may wish for the procedure to be performed during labour as this is the norm in some countries where FGM is prevalent (where this is done, scissors rather than a scalpel should be used and under local anaesthetic with lidocaine without adrenaline). The woman should be informed that under no circumstances will re-infibulation be performed.

Question 171

What is the overall incidence of stillbirth in the UK? a. 1 in 200 b. 1 in 500 c. 1 in 1000 d. 1 in 2000 e. 1 in 5000

Answer 171

A - 1 in 200 Stillbirth is common – 1 in 200 babies are delivered with no signs of life beyond 24 completed weeks gestation. Overall half of stillbirths are unexplained and one third are found to be small for gestational age. Suboptimal care is found in approximately half of all cases. The rates of stillbirth have been fairly constant since 2000 – it is speculated that rising obesity and maternal age may be offsetting work done to improve outcomes and reduce incidence.

Question 172

What proportion of stillbirths are unexplained? a. 1 in 10 b. 1 in 5 c. 1 in 4 d. 1 in 3 e. 1 in 2

Answer 172

E - 1 in 2 Stillbirth is common – 1 in 200 babies are delivered with no signs of life beyond 24 completed weeks gestation. Overall half of stillbirths are unexplained and one third are found to be small for gestational age. Suboptimal care is found in approximately half of all cases. The rates of stillbirth have been fairly constant since 2000 – it is speculated that rising obesity and maternal age may be offsetting work done to improve outcomes and reduce incidence.

Question 173

What proportion of stillborn infants are found to be small for gestational age (by customised centiles)? a. 1 in 10 b. 1 in 5 c. 1 in 4 d. 1 in 3 e. 2 in 3

Answer 173

D - 1 in 3 Stillbirth is common – 1 in 200 babies are delivered with no signs of life beyond 24 completed weeks gestation. Overall half of stillbirths are unexplained and one third are found to be small for gestational age. Suboptimal care is found in approximately half of all cases. The rates of stillbirth have been fairly constant since 2000 – it is speculated that rising obesity and maternal age may be offsetting work done to improve outcomes and reduce incidence.

Question 174

In patients opting for conservative management of IUFD, how often should platelet count be checked in order to exclude DIC? a. Daily b. Twice weekly c. Weekly d. Fortnightly e. Three-weekly

Answer 174

B - Twice weekly There is a risk of DIC in mothers affected by stillbirth – 10% within the first 4 weeks and 30% thereafter. Platelet count in women choosing expectant management for IUFD should have their platelet count checked twice weekly to monitor for occult DIC.

Question 175

What is the incidence of chromosomal abnormality in stillborn infants? a. 6% b. 10% c. 23% d. 34% e. 42%

Answer 175

A - 6% Karyotyping following IUFD or stillbirth is important as around 6% of infants will be found to have a chromosomal abnormality on testing, some of which may be potentially recurrent and significant for future pregnancies. Culture provides the greatest range of genetic information. Micro-deletions must be requested specifically – usually based on the findings at post-mortem. Where all cultures fail, QF-PCR can be performed on extracted DNA.

Question 176

Which of the following cannot legally certify a stillbirth (assuming the answer describes their only involvement in the care)? a. Doctor present during and after the birth b. Midwife called to inspect baby after the birth c. Doctor called to inspect baby after the birth d. Doctor who diagnosed IUFD on scan upon presentation to the ward e. Midwife providing care in labour and postnatally

Answer 176

D - Doctor who diagnosed IUFD on scan upon presentation to the ward A stillbirth must be medically certified by a fully registered doctor or midwife who must either have been present at, or examined the baby after the birth. In this scenario it is inferred that the doctor who made the diagnosis did not fulfil this criteria and as such cannot legally certify the stillbirth.

Question 177

In what proportion of stillbirths is sub-optimal care identified in the confidential enquiry review? a. <5% b. 10% c. 25% d. 50% e. 75%

Answer 177

D - 50% Suboptimal care is identified as evidence in half of all pregnancies affected by stillbirth by the Confidential Enquiry into Stillbirth and Deaths in Infancy (CESDI).

Question 178

In which of the following instances should Kleihaur testing be performed following diagnosis of IUFD? a. In Rhesus negative women b. Where abruption is felt to be the likely cause c. Where there is PV bleeding d. Where there is discordant Rhesus status between the women and her partner e. All of the above

Answer 178

E - All of the above Kleihaur testing is indicated in all women following stillbirth irrespective of bleeding or rhesus status, as it may help in identifying feto-maternal haemorrhage which may have contributed.

Question 179

A 32 year old woman opts to undergo conservative management following diagnosis of an IUFD, instead of induction of labour with prostaglandins. Assuming she does not labour within that time, what is the likelihood of her developing DIC in the first 4 weeks? a. 2% b. 5% c. 10% d. 30% e. 40%

Answer 179

C - 10% There is a risk of DIC in mothers affected by stillbirth – 10% within the first 4 weeks and 30% thereafter. Platelet count in women choosing expectant management for IUFD should have their platelet count checked twice weekly to monitor for occult DIC.

Question 180

A 23 year old woman opts to undergo conservative management following diagnosis of an IUFD, instead of induction of labour with prostaglandins. Assuming she does not labour within that time, what is the likelihood of her developing DIC after 4 weeks? a. 5% b. 10% c. 30% d. 40% e. 50%

Answer 180

C - 30% There is a risk of DIC in mothers affected by stillbirth – 10% within the first 4 weeks and 30% thereafter. Platelet count in women choosing expectant management for IUFD should have their platelet count checked twice weekly to monitor for occult DIC.

Question 181

A Para 2 presents to the ANC concerned that she is unable to yet feel her baby moving. A scan confirms fetal viability and you seek to reassure her. By how many weeks gestation, can multiparae expect to feel some fetal movement? a. 16/40 b. 18/40 c. 20/40 d. 22/40 e. 24/40

Answer 181

A - 18/40 From 18-20 weeks most pregnant women become aware of fetal activity though some multiparous women may perceive movement as early as 16 weeks gestation.

Question 182

What percentage of women who suffer stillbirth experience some degree of reduced fetal movements preceding fetal demise? a. 25% b. 55% c. 75% d. 80% e. 95%

Answer 182

B - 55% A majority of women (55%) experiencing a stillbirth reported a perceived reduction in fetal movement prior to diagnosis and a number of studies have identified an inappropriate response by clinicians to maternal perception of RFM was a common contributory factor in stillbirth.

Question 183

Which of the following is not known to be associated with a true or perceived reduction in fetal movement? a. Anterior placenta b. Alcohol c. Methadone d. Fetal presentation e. Steroid administration

Answer 183

D - Fetal presentation Certain factors are known to contribute to a woman’s perception of fetal movements including an anterior placenta (though only prior to 28 weeks), certain sedating drugs (alcohol, benzodiazepines, methadone/opioids – some suggest smoking) and – according to some authors – maternal corticosteroids for fetal lung maturation. Fetuses with major malformations too are generally more likely to demonstrate reduced activity. Fetal presentation has no effect on perception of movement though position might (suggestion of a reduction when the spine lies anterior).

Question 184

A woman rings her local maternity unit for advice reporting that she has not noticed fetal movement in the preceding few hours while out shopping. You advise her to lie down on her left side and focus on movements felt. For how long do you suggest she do this before ringing back if no movements are felt? a. 30 minutes b. 45 minutes c. 1 hour d. 1 hour 30 minutes e. 2 hours

Answer 184

E - 2 hours There is insufficient evidence to recommend formal fetal movement counting using specific time limits – women who are concerned about their baby’s individual pattern after 28 weeks should contact their local maternity unit and not wait until the next day. Women who are unsure should be advised to lie on their left and focus on movements for 2 hours – if they do not feel 10 or more in that time, they should contact their midwife or local unit immediately. By term, the average number of movements per hour is ~30 with the longest period between movements (i.e. fetal sleep cycles) of 50-75 minutes. Such sleep cycles rarely last beyond 90 minutes in a healthy normal fetus.

Question 185

Ultrasound assessment of the fetus is a tool commonly employed in assessment of reduced fetal movement after 28 weeks gestation. This is particularly the case where concern around movement persists despite a normal CTG. What specifically should be the main focus of the ultrasound assessment in this context? a. EFW and liquor volume b. Umbilical artery doppler c. EFW and umbilical artery doppler d. Liquor and umbilical artery doppler e. Fetal movement on scan

Answer 185

A - EFW and Liquor Volume Ultrasound scan assessment should be undertaken as part of the preliminary investigations of a woman presenting with RFM after 28 weeks if this persists despite a normal CTG or there are other risk factors for FGR or stillbirth. It should include assessment of the AC/EFW to detect SFGA and assessment of amniotic fluid volume.

Question 186

Which of the following does NOT form part of the ‘biophysical profile’ assessment of the fetus? a. Fetal breathing b. Fetal tone c. CTG d. Fetal movement e. Liquor volume

Answer 186

E - Liquor volume The green-top guideline suggests there ‘may’ be a role for biophysical profile in the management or investigation of reduced fetal movement though a systematic review of the best available evidence did not support this. The components of the BPP are as follows – CTG, fetal tone, fetal movement and fetal movement.

Question 187

A patient attends the ANC at 24 weeks gestation. She has seen her community midwife and is anxious as she has felt no fetal movement thus far in pregnancy. A doppler in clinic confirms fetal heart activity. She already has 2 children, both delivered spontaneously after uncomplicated pregnancies. What management do you recommend? a. USS for EFW and umbilical artery doppler b. Twice weekly CTG monitoring c. Referral to fetal medicine d. Initiate serial growth scanning e. Reassurance

Answer 187

C - Referral to fetal medicine In women who have felt no fetal movements whatsoever by 24 weeks, referral should be made to a specialist fetal medicine centre to look for evidence of a fetal neurological condition.

Question 188

A 24 year old primigravida presents to the delivery suite reporting an unprovoked PV bleed at 27/40. On review of her maternity record, you note that her placenta was found to be ‘low-lying’ on her 20/40 scan. What proportion of pregnancies, as a percentage, are affected by antepartum haemorrhage at some point? a. Up to 5% b. Up to 10% c. Up to 20% d. Up to 30% e. Up to 45%

Answer 188

A - Up to 5% Antepartum haemorrhage complicated 3-5% of pregnancies and is a leading cause of perinatal morbidity and mortality. Worldwide, obstetric haemorrhage is responsible for 50% of all maternal deaths though is rare in the UK – the sixth highest direct cause.

Question 189

A 42 year old primigravida presents to the delivery suite with abdominal pain and heavy blood loss PV. On examination , the uterus is found to be firm with a ‘woody’ consistency. A CTG is commenced and shows a pathological pattern. Which of the following is NOT a recognised risk factor for placental abruption? a. Breech presentation b. Low-maternal BMI c. Cannabis use d. Polyhydramnios e. Previous placental abruption

Answer 189

C - Cannabis use There are numerous risk factors described for placental abruption though in spite of this, 70% of cases occur in ‘low-risk’ pregnancies. The main risk is – as with many things – previous history of abruption (4.4% after 1 and up to 25% after 2). The remainder are as follows: ``` Pre-eclampsia FGR Non-vertex presentation Polyhydramnios Maternal age >40 Low BMI ART pregnancy Infection Trauma to abdomen (Think DV?) Drugs – cocaine/amphetamines Smoking Maternal thrombophilia ```

Question 190

What is the recurrence risk of placental abruption after 1 and 2 abruptions respectively? One Two a. 2% 10% b. 4% 25% c. 15% 50% d. 23% 50% e. 33% 75% f. 50% 75%

Answer 190

B - 4% after 1; 25% after 2 There are numerous risk factors described for placental abruption though in spite of this, 70% of cases occur in ‘low-risk’ pregnancies. The main risk is – as with many things – previous history of abruption (4.4% after 1 and up to 25% after 2).

Question 191

A Para 4 is found to have a low-lying placenta on her 20/40 scan. She wishes to know what her risk factors are for this complication. Which of the following is NOT known to be a risk factor for placenta praevia? a. Previous caesarean delivery b. Advanced maternal age c. Smoking d. Assisted reproductive techniques e. History of cervical treatment

Answer 191

E - History of cervical treatment Numerous risk factors for placenta praevia are described: ``` Previous CS (increasing with no.) Previous TOP Multiparous Age >40 Multiple pregnancy Smoking Deficient endometrium (fibroids, curettage, MROP, endometritis) ART pregnancy ```

Question 192

There are numerous risk factors for placental abruption described and recognised. In spite of this, what proportion of abruptions occur in pregnancies otherwise classified as ‘low-risk’? a. 10% b. 25% c. 30% d. 50% e. 70%

Answer 192

E - 70% Despite the numerous risk factors described, the majority of placental abruption – 70% - occur in otherwise low risk pregnancies

Question 193

A primigravida presents for induction of labour for SFGA at 37/40 and completes a full course of prostaglandins. Shortly afterwards she is found to be suitable for an amniotomy which is undertaken by the delivery suite registrar. A few minutes later, the midwife pulls the emergency bell as there is profuse vaginal bleeding and the fetal heart has fallen to 70bpm on the CTG. The abdomen is soft and non-tender on examination. What is the most likely diagnosis here? a. Placental abruption b. Undiagnosed placenta praevia c. Vasa praevia d. Cord prolapse e. Uterine rupture

Answer 193

C - Vasa praevia The scenario described is classic for vasa praevia – sudden, painless bleeding at the onset of amniotomy or spontaneous membrane rupture. The principle concern here is neonatal/fetal anaemia and delivery should be expedited urgently. There is no reliable point-of-care test to differentiate between maternal or fetal blood.

Question 194

A primigravida, booked as ‘low-risk’ attends the delivery suite at 28/40 reporting unprovoked PV bleeding. On examination there is a normal appearance of the lower genital tract and cervix though a large clot of approx. 100ml in the posterior fornix is seen and removed. Ultrasound scan demonstrates a fundal placenta and fails to detect any signs suggestive of a placental abruption. Assuming the bleeding settles, what is an appropriate plan for on-going management? a. Discharge back to midwife-led care b. Assuming fetal growth, liquor and doppler normal, repeat USS in 3 weeks and if normal and no further bleeding, return to midwife led care c. Initiate serial growth scanning of the fetus and advise delivery by LSCS no later than 38/40 d. Initiate serial growth scanning of the fetus under obstetric led care e. Discharge home though follow up in obstetric led antenatal clinic within 4 weeks

Answer 194

D - Initiate serial growth scanning of the fetus under obstetric led care Following on from a placenta abruption or unexplained APH, the pregnancy should be reclassified as ‘high risk’ and serial growth scanning of the fetus initiated for the remainder of pregnancy

Question 195

A Para 1 attends the delivery suite in preterm labour at 38/40. She has one child born by SVD at home 2 years earlier. She was booked ‘low-risk’ for this pregnancy and, aside from one admission at 33/40 with a minor APH, it has been otherwise straightforward. No cause for this bleed was ever identified though there has been no further bleeding. A growth scan performed last week, showed normal fetal growth and liquor volumes. What birth setting and means of fetal monitoring in labour is advised here? a. I.A on midwife led birth unit b. Continuous CTG on delivery suite c. I.A. on delivery suite d. I.A with 2-hourly CTG on birthing unit e. No monitoring indicated

Answer 195

A - I.A. on midwife led birth unit In women – such as that described in the scenario – who have experienced one episode of minor APH (<50ml) and there have been no subsequent concerns regarding maternal or fetal wellbeing, intermittent auscultation for fetal monitoring in labour is appropriate. For all other women, CFM is recommended.

Question 196

A primigravida, known to be Rhesus D negative, attends labour ward with her third episode of PV bleeding in pregnancy. A full work up has been undertaken each time, though the cause remains elusive. There have been no fetal concerns on ultrasound nor CTG. In such cases of recurrent PV bleeding in rhesus negative mothers, how often should anti-D be administered as a minimum? a. Every 72 hours b. Weekly c. Fortnightly d. Monthly e. 6-weekly

Answer 196

E - 6 weekly Anti-D should be given to all non-sensitised Rh-D negative women presenting with APH irrespective of whether or not routine anti-D has already been given. In women who present with recurrent bleeding after 20/40 – anti-D should be given at a minimum of 6-weekly intervals.

Question 197

What is the mortality associated with septic shock in pregnancy? a. 5% b. 20% c. 30% d. 40% e. 60%

Answer 197

E - 60% Severe sepsis with acute organ dysfunction in pregnancy carries a mortality of 20-40%, rising to 60% should septic shock develops.

Question 198

What is the mortality associated with severe sepsis in pregnancy? a. Up to 10% b. Up to 20% c. Up to 40% d. Up to 60% e. Up to 80%

Answer 198

C - Up to 40% Severe sepsis with acute organ dysfunction in pregnancy carries a mortality of 20-40%, rising to 60% should septic shock develops.

Question 199

Serum lactate can be of value in the septic pregnant patient as a marker of severity. What level indicates tissue hypo-perfusion? a. >2 b. >3 c. >4 d. >5 e. >8

Answer 199

C - >4 Serum lactate should be measured as an initial investigation in all women presenting with suspected sepsis in or following pregnancy to help in guiding management – levels of 4 or more indicated tissue hypoperfusion.

Question 200

What are the most common organisms in women dying from sepsis in pregnancy? a. Group B Streptococcus and Psedumonas b. N. Menigitidis and Staph. Aureus c. Staph Aureus and E. Coli d. Group A Streptococcus and Staph Aureus e. Group A Streptococcus and E. Coli

Answer 200

E - Group A Streptococcus and E. Coli The most common organisms identified in women dying from sepsis in pregnancy are Group A Beta-Haemolytic Streptococcus and E. Coli.

Question 201

A patient with suspected sepsis of unknown origin in pregnancy is referred to delivery suite from A&E. She has been given a stat dose of tazocin prior to transfer. What important organism is NOT covered by tazocin therapy? a. C. Difficile b. MRSA c. Group B Streptococcus d. E. Coli e. Group A Streptococcus

Answer 201

B - MRSA Where genital tract sepsis is suspected in pregnancy, prompt early treatment with a combination of high-dose broad spectrum antibiotics may be life-saving.

Question 202

Metronidazole is a useful adjunctive antibiotic in the treatment of sepsis in pregnancy though has a narrower range of cover than many others. Which bacterial subgroup is metronidazole known to be exclusively effective against? a. Aerobes b. Anaerobes c. Gram +ve d. Gram –ve e. Coliforms

Answer 202

B - Anaerobes Where genital tract sepsis is suspected in pregnancy, prompt early treatment with a combination of high-dose broad spectrum antibiotics may be life-saving.

Question 203

IVIG may be considered as next line therapy in severe, invasive streptococcal or staphylococcal disease when other therapies have failed as it may neutralise the effect of exotoxins and inhibit TNF/inter-leukin production. In which of the following circumstances, is IVIG therapy contraindicated? a. Severe penicillin allergy b. Immunosuppression c. Congenital IgA deficiency d. Neutropenic sepsis e. Group A Strep infection

Answer 203

C - Congenital IgA deficiency IVIG is recommended for use in severe invasive strep or staph infection where other therapies have failed. It acts via an immunomodulatory effect, neutralising the super-antigen effect of exotoxins and inhibiting productions of TNF and interleukins. IVIG is effective in extotoxic (i.e. Gram +ve) shock though there is little evidence of benefit in Gram –ve infection. The main contraindication to its use is a congenital deficiency of IgA.

Question 204

Haemoptysis is a recognised feature of pneumonia triggered by which pathogen? a. H. Influenzae b. Pneumococcus c. Streptococcus d. C. Psitacci e. P. Jiroveci

Answer 204

B - Pneumococcus Severe pneumonia in pregnancy should managed in consultation with respiratory physicians and microbiologists. Treatment of choice is a beta-lactam together with a macrolide to cover both typical and atypical organisms. Haemoptysis is a cardinal feature of pneumococcal pneumonia. Severe haemoptysis and low-white count suggest PVL associated staph. necrotising pneumonia which carries a mortality of >70% in young, fit people.

Question 205

While the majority of cases of pharyngitis are viral in origin, particular care must be taken in an obstetric population as Group A Streptococcus is a potential pathogen. In what proportion of cases of pharyngitis will GAS be identified as the culprit? a. <1% b. 5% c. 10% d. 15% e. 20%

Answer 205

C - 10% Most cases of pharyngitis are viral in origin though 10% of cases in adults are attributable to GAS. If three of the four Centor Criteria (fever, tonsillar exudate, cervical lymphadenopathy, no cough) are present, a bacterial cause is more likely and antibiotic treatment is indicated.

Question 206

The Centor criteria were developed to guide antibiotic use in patients with upper respiratory tract infection/pharyngitis. They suggest that antibiotics be used first line if 3 of the criteria are present as bacterial infection is more likely. Which of the following is NOT a component of the Centor Criteria? a. Tachycardia >100bpm b. Absence of a cough c. Fever d. Tonsillar exudate e. Cervical lymphadenopathy

Answer 206

A - Tachycardia >100bpm Most cases of pharyngitis are viral in origin though 10% of cases in adults are attributable to GAS. If three of the four Centor Criteria (fever, tonsillar exudate, cervical lymphadenopathy, no cough) are present, a bacterial cause is more likely and antibiotic treatment is indicated.

Question 207

What is the antibiotic of choice in treating suspected C. Diff infection in pregnancy? a. Metronidazole b. Cefuroxime c. Gentamicin d. Cefalexin e. Tazocin

Answer 207

A - Metronidazole Offensive diarrhoea or that which develops following any anti-microbial therapy should prompt consideration of C.Diff as a potential cause. While C.Diff does not infect neonates, it can cause up to 30% mortality in mothers if untreated. Pending testing results, empirical metronidazole or vancomycin (orally) may be justified.

Question 208

A primigravida has an HVS at 32/40 during an attendance to delivery suite with threatened preterm labour. She is otherwise well and in 24 hours is discharged home as her symptoms have settled. Some time later you are asked to review the swab result which has grown Group A Streptococcus. What management is appropriate here? a. No action required b. Commence antenatal antibiotic treatment for Group A Strep with test of cure c. IV intrapartum antibiotic prophylaxis d. Repeat swab at 36/40 e. No treatment required for mother antenatally nor in labour though infant should receive routine antibiotic treatment postnatally

Answer 208

B - Commence antenatal antibiotic treatment for GAS with a test of cure Unlike Group B Streptococcus, the antenatal detection of Group A Strep should prompt treatment even if asymptomatic with a follow up ‘test of cure’

Question 209

16. How is Group A Beta-Haemolytic Strep (GAS) also known? a. Strep. Agalactiae b. Strep. Bovis c. Strep.. Dysgalactiae d. Strep. Pyogenes e. Strep. Durans

Answer 209

D - Strep. Pyogenes Group A Streptococcus is also known as Strep. Pyogenes.

Question 210

A 32 year old is admitted at 38/40 with irregular uterine contractions, offensive vaginal discharge and a history of 24 hours of reduced fetal movement. Her temperature on examination is elevated at 39.5C and her pulse is 134bpm. On vaginal examination the cervix is fully effaced and 4cm dilated – membranes are felt to be absent. A CTG is commenced which demonstrates a baseline fetal heart rate of 175bpm. Broad spectrum antibiotics have been commenced following a septic screen including blood cultures. What is the most appropriate management in this case? a. Commence immediate augmentation with oxytocin b. Transfer to theatre for caesarean section under spinal c. Transfer to theatre for caesarean section under general anaesthetic d. Undertake fetal blood sampling e. Re-examine to assess progress in 4 hours

Answer 210

C - Transfer to theatre for caesarean section under GA Epidural or spinal analgesia should be avoided in women with sepsis. This baby requires urgent delivery as chorioamnionitis is likely given this history – a caesarean section under general anaesthetic is indicated here.

Question 211

What antibody subclass are responsible for haemolytic disease of the fetus/newborn? a. IgG b. IgM c. IgA d. IgD e. IgE

Answer 211

A - IgG Haemolytic disease of the fetus and newborn is a condition in which transplacental passage of maternal IgG antibodies results in immune haemolysis of fetal or neonatal red cells.

Question 212

Several red cell antibodies are known to cause clinically significant disease though one in particular does so by a different means to the others. Which red cell antibody causes fetal anaemia secondary to erythroid suppression and destruction of progenitor cells rather that destruction of mature fetal red cells, meaning that significant anaemia may occur even at relatively low titres? a. Anti-D b. Anti-c c. Anti-K d. Anti-e e. Anti-E

Answer 212

C - Anti-K Unlike most other antibodies which cause fetal anaemia, hyperbilirubinaemia and jaundice as a result of haemolysis or impaired erythropoiesis, anti-K acts by erythroid suppression and the immune destruction of erythroid progenitor cells. As such, hyperbilirubinaemia is not a prominent feature. Severe fetal anaemia can occur with even very low anti-K titres, and as such referral to fetal medicine should be made at detection alone.

Question 213

Non-invasive fetal genotyping is possible for the most significant antibodies known to cause fetal anaemia though certain other antibodies may require invasive testing. Which of the following antibodies, known to cause haemolytic anaemia in the newborn cannot be tested for in this way? a. Anti-e b. Anti-C c. Anti-c d. Anti-K e. Anti-M

Answer 213

E - Anti-M Non-invasive fetal genotyping using maternal blood is now possible for D, C, c, E, e and K antigens and should be performed in the first instance where maternal red cell antibodies are detected. For other antigens, invasive testing (amniocentesis/CVS) may be considered.

Question 214

At which level should patients with anti-D antibodies be referred for further review in fetal medicine? a. Any positive titre b. >2iu/ml c. >4iu/ml d. >8iu/ml e. >15iu/ml

Answer 214

C - >4iU/ml Thresholds for referral to fetal medicine of various antibody titres is as follows: Moderate HDFN (REFER) Severe HDFN Anti-D >4iu/ml >15iu/ml Anti-c >7.5iu/ml* >30iu/ml Anti-K ANY (severe anaemia as low as 8) Others >32iu/ml Patients with a history of HFDN may be referred irrespective of titres. Anti-c (little-c) is potentiated by the concurrent presence of anti-E, thus detection of both should prompt early referral irrespective of titres.

Question 215

At what level should patients with anti-c (little-c) antibodies be referred for review in fetal medicine? a. Any positive titre b. >4iu/ml c. >7.5iu/ml d. >15iu/ml e. >32iu/ml

Answer 215

C - >7.5iU/L Thresholds for referral to fetal medicine of various antibody titres is as follows: Moderate HDFN (REFER) Severe HDFN Anti-D >4iu/ml >15iu/ml Anti-c >7.5iu/ml* >30iu/ml Anti-K ANY (severe anaemia as low as 8) Others >32iu/ml Patients with a history of HFDN may be referred irrespective of titres. Anti-c (little-c) is potentiated by the concurrent presence of anti-E, thus detection of both should prompt early referral irrespective of titres.

Question 216

At what level should patients with anti-K antibodies be referred for review in fetal medicine? a. Any positive titre b. >4iu/ml c. >7.5iu/ml d. >15iu/ml e. >32iu/ml

Answer 216

A - Any positive titre Thresholds for referral to fetal medicine of various antibody titres is as follows: Moderate HDFN (REFER) Severe HDFN Anti-D >4iu/ml >15iu/ml Anti-c >7.5iu/ml* >30iu/ml Anti-K ANY (severe anaemia as low as 8) Others >32iu/ml Patients with a history of HFDN may be referred irrespective of titres. Anti-c (little-c) is potentiated by the concurrent presence of anti-E, thus detection of both should prompt early referral irrespective of titres.

Question 217

At what threshold of abnormality in the MCA-PSV should consideration be given to invasive treatment? a. <1 MoM b. <2 MoM c. >1.5 MoM d. >2 MoM e. >2.5 MoM

Answer 217

C - >1.5 MoM

Question 218

At what level should patients with anti-C (big C) antibodies be referred for review in fetal medicine? a. Any positive titre b. >4iu/ml c. >7.5iu/ml d. >15iu/ml e. >32iu/ml

Answer 218

E - >32iU/ml Thresholds for referral to fetal medicine of various antibody titres is as follows: Moderate HDFN (REFER) Severe HDFN Anti-D >4iu/ml >15iu/ml Anti-c >7.5iu/ml* >30iu/ml Anti-K ANY (severe anaemia as low as 8) Others >32iu/ml Patients with a history of HFDN may be referred irrespective of titres. Anti-c (little-c) is potentiated by the concurrent presence of anti-E, thus detection of both should prompt early referral irrespective of titres.

Question 219

The concurrent detection of which antibody is known to potentiate anti-c (little-c) meaning HDFN can occur at lower levels? a. Anti-D b. Anti-e c. Anti-E d. Anti-C e. Anti-K

Answer 219

C - Anti-E Anti-c (little-c) is potentiated by the concurrent presence of anti-E, thus detection of both should prompt early referral irrespective of titres (>7.5iU/ml).

Question 220

A Para 2 is found to have anti-D levels of 2.4 on her booking sample. How often should titres be repeated during pregnancy? a. 4 weekly until delivery b. 2 weekly until delivery c. 4 weekly until 28/40 then 2 weekly until delivery d. 2 weekly until 28/40 then 4 weekly until delivery e. Immediate referral to fetal medicine indicated; further titres of doubtful significance

Answer 220

C - 4 weekly until 28/40 then 2 weekly until delivery Blood samples with women with immune anti-D, c or K should be tested at least monthly until 28/40 and then 2-weekly thereafter until delivery. For all other antibodies, retesting at 28/40 is advised with the exception of women with a history of a previously affected fetus/infant – in these women, early fetal med referral is advised.

Question 221

A Para 2 is reviewed in the antenatal clinic at 18/40. Review of her booking blood identifies that she has tested positive for anti-M antibodies (titre 8iu/ml). Her previous child require blood transfusions following delivery which she believes may have been linked to the same antibody. What management do you recommend? a. Commence serial titres and refer to fetal medicine when above referral threshold b. Repeat titre at 28 weeks c. Refer to fetal medicine now d. Offer non-invasive fetal genotyping e. Initiate serial growth scans of the fetus and refer to fetal medicine if any evidence of hydrops develops

Answer 221

C - Offer referral to fetal medicine now Blood samples with women with immune anti-D, c or K should be tested at least monthly until 28/40 and then 2-weekly thereafter until delivery. For all other antibodies, retesting at 28/40 is advised with the exception of women with a history of a previously affected fetus/infant – in these women, early fetal med referral is advised.

Question 222

What ultrasound marker is used to screen for anaemia in the fetus? a. MCA PI b. MCA PSV c. Ductus venosus doppler d. MCA PI – Umbilical Artery PI ratio e. Umbilical artery RI

Answer 222

B - MCA PSV Where a fetus is found to carry the corresponding antigen for a maternal antibody and titres rise above the thresholds defined above, then the pregnancy should be monitored weekly by ultrasound – specifically to assess the peak systolic velocity of the middle cerebral artery (MCA-PSV). Other signs which may indicate fetal anaemia include skin oedema, cardio megaly and polyhydramnios. Referral to a fetal medicine centre capable of performing intra-uterine transfusion should be considered if the MSA-PSV rises to greater than 1.5x Multiples of the Median.

Question 223

How frequently should ultrasound monitoring be undertaken in fetuses found to be at risk of fetal anaemia, following referral to fetal medicine? a. Daily b. Twice weekly c. Weekly d. Two weekly e. Four weekly

Answer 223

C - Weekly Where a fetus is found to carry the corresponding antigen for a maternal antibody and titres rise above the thresholds defined above, then the pregnancy should be monitored weekly by ultrasound – specifically to assess the peak systolic velocity of the middle cerebral artery (MCA-PSV). Other signs which may indicate fetal anaemia include skin oedema, cardio megaly and polyhydramnios. Referral to a fetal medicine centre capable of performing intra-uterine transfusion should be considered if the MSA-PSV rises to greater than 1.5x Multiples of the Median.

Question 224

In the surveillance of the fetus with suspected anaemia secondary to red-cell isoimmunisation, at what threshold of abnormality in the MCA-PSV should consideration be given to invasive treatment? a. <1 MoM b. <2 MoM c. >1.5 MoM d. >2 MoM e. >2.5 MoM

Answer 224

C - >1.5 MoM Where a fetus is found to carry the corresponding antigen for a maternal antibody and titres rise above the thresholds defined above, then the pregnancy should be monitored weekly by ultrasound – specifically to assess the peak systolic velocity of the middle cerebral artery (MCA-PSV). Other signs which may indicate fetal anaemia include skin oedema, cardio megaly and polyhydramnios. Referral to a fetal medicine centre capable of performing intra-uterine transfusion should be considered if the MSA-PSV rises to greater than 1.5x Multiples of the Median.

Question 225

What specific precaution should be exercised in women with known red-cell antibodies who are themselves at high risk of requiring transfusion in pregnancy? a. Minimum weekly G&S b. Always use O-negative blood c. Keep 4 units of cross-matched blood on labour ward at all times d. Routine parenteral iron infusion at 34/40 to maintain Hb >120 e. Deliver by elective LSCS with ‘cell salvage’ technology to minimise further transfusion requirement

Answer 225

A - Minimum weekly G&S Pregnant women with red cell antibodies deemed to be at a high risk of requiring a blood transfusion in pregnancy should have a cross match sample taken at least every week.

Question 226

What haematocrit of blood is required for fetal blood transfusion? a. 0.4-0.55 b. 0.5-0.6 c. 0.7-0.85 d. 0.9-1.05 e. 1.1-1.25

Answer 226

C - 0.7-0.85 The requirements of blood for fetal blood transfusion are as follows: Group O or ABO identical with fetus (if known) Negative for maternal antibody antigens K-negative <5 days old Citrate-phosphate dextrose anticoagulant CMV negative Hct 0.7-0.85 Irradiated and transfused within 24 hours of irradiation

Question 227

Which of the following is NOT a necessary requirement for fetal blood transfusion? a. Less than 10 days old b. K-negative c. Irradiated d. CMV negative e. Indirect anti-globulin test compatible with maternal blood

Answer 227

A - Less than 10 days old The requirements of blood for fetal blood transfusion are as follows: Group O or ABO identical with fetus (if known) Negative for maternal antibody antigens K-negative <5 days old Citrate-phosphate dextrose anticoagulant CMV negative Hct 0.7-0.85 Irradiated and transfused within 24 hours of irradiation

Question 228

A primigravida with a history of leukaemia in childhood has anti-D antibodies in her booking sample. Her blood group is A-. What anti-D prophylaxis is advised in pregnancy? a. No routine anti-D prophylaxis indicated b. Routine AN and PN prophylaxis c. Routine AN and PN prophylaxis plus additional dose at 12/40 and 16/40 d. Routine PN prophylaxis only e. Prophylaxis only if sensitizing event

Answer 228

A - No routine anti-D prophylaxis indicated No prophylaxis is necessary in women already sensitised with Anti-D antibodies.

Question 229

Where the mother has tested positive for a clinically significant antibody in pregnancy, what tests should be performed on cord blood at delivery? a. Hb only b. Hb and Bilirubin c. Hb, Bilirubin and Direct Anti-globulin Test d. Kleihaur and Hb e. Kleihaur, Hb and Bilirubin

Answer 229

C - Hb, Bilirubin and Direct anti-globulin test In the case of any woman with clinically significant antibodies, cord samples should be taken for a direct-antiglobulin test (DAT - Coomb's)), haemoglobin and bilirubin levels. A positive DAT indicated that the fetal cells are coated in antibody though is unable to predict the severity of haemolysis.

Question 230

What percentage of the British obstetric population are now considered to be obese? a. <10% b. 10% c. 20% d. 30% e. 40%

Answer 230

C - 20%

Question 231

A patient presents for antenatal care. Her BMI at booking is noted to be 38. How would you classify her weight? a. Overweight b. Pre-obese c. Class I obesity d. Class II obesity e. Class III obesity

Answer 231

D - Class II Obesity

Question 232

How much more likely are the infants of obese mothers to require neonatal unit care, when compared with the infants of normal weight mothers? a. Equivalent b. 1.5x c. 2x d. 3x e. 5x

Answer 232

B - 1.5x

Question 233

Obesity is known to increase the risk of a number of complications of pregnancy including maternal mortality. In the latest MBBRACE report, what proportion of women who died were obese? a. 1/5 b. 1/4 c. 1/3 d. 1/2 e. 2/3

Answer 233

C - 1/3

Question 234

What is the recommended daily oral intake of vitamin D amongst women in the UK? a. 10 micrograms b. 100 micrograms c. 10mg d. 100mg e. 1 gram

Answer 234

A - 10 micrograms

Question 235

Which of the following is LESS likely in obese, compared with normal weight women? a. Uterine rupture during VBAC b. Prematurity c. Pre-eclampsia d. Congenital abnormality e. Breastfeeding

Answer 235

E - Breastfeeding

Question 236

A pregnant woman with a booking BMI of 42 asks about the safety of drugs to help her lose weight in pregnancy. She is particularly interested in the appetite suppressant Topiramate. What risk is associated with topiramate use in pregnancy? a. GDM b. Cleft palate c. Long bone abnormalities d. Low birthweight e. Subarachnoid haemorrhage

Answer 236

B - Cleft palate

Question 237

Which of the following should be formally documented in women with a booking BMI >40 presenting for antenatal care? a. Anaesthetic review b. Moving and handling risk assessment c. Pressure sore risk assessment d. Waterloo score e. All of the above

Answer 237

E - All of the above

Question 238

By how much is the risk of developing gestational diabetes increased in women with a BMI >30 compared with normal weight women? a. 2x b. 3x c. 5x d. 10x e. 20x

Answer 238

B - 3x

Question 239

By how much is the risk of congenital abnormalities increased in diabetic, compared with non-diabetic mothers? a. Equivalent b. 2x c. 3x d. 5x e. 10x

Answer 239

C - 3x

Question 240

A primigravida with a booking BMI of 38 presents to the antenatal clinic at 11/40. What do you advise to reduce the risk of pre-eclampsia in this pregnancy? a. 75mg aspirin until delivery b. 75mg aspirin until 36/40 c. 150mg aspirin until delivery d. 150mg aspirin until 36/40 e. Aspirin only indicated if other risk factors for PET

Answer 240

C - 150mg aspirin until delivery

Question 241

A Para 4 with a booking weight of 95kg is commenced on LMWH for antenatal VTE prophylaxis at 28/40. What additional, monitoring, if any, does she require? a. APTT twice weekly b. PT weekly c. Factor Xa levels d. Anti-Xa levels e. No additional monitoring indicated

Answer 241

D - Anti-Xa levels

Question 242

A patient with a booking BMI of 45 attends for her dating scan at 12/40. She wishes to have screening for the common trisomies though the sonographer is unable to obtain an adequate measurement of nuchal translucency. What is the next step in such a scenario? a. Repeat the scan in one week b. Refer to fetal medicine c. Perform quadruple test with serum markers only d. Refer for NIPT e. Attempt NT measurement on TV USS

Answer 242

E - Attempt to measure NT on TVUSS

Question 243

A multipara with a booking BMI of 36 presents in labour at 4cm. She is otherwise low risk and has written a birth plan focused around hypnobirthing in water at home with ‘minimal intervention’ and intermittent auscultation only. What means of delivery do you advise by? a. Deliver on obstetric led unit with continuous CTG on land b. Deliver on obstetric led unit with intermittent auscultation in water c. Deliver on co-located MLU with intermittent auscultation on land d. Delivery on co-located MLU with intermittent auscultation in water e. Delivery at home with intermittent auscultation and in water

Answer 243

D - Delivery on co-located MLU with intermittent auscultation in water

Question 244

By how much is the risk of caesarean section increased in overweight and obese women respectively? Overweight Obese a. 1.5x 2x b. 2x 3x c. 2x 4x d. 4x 6x e. 4x 8x

Answer 244

A - 1.5x in overweight women; 2x in obese women

Question 245

Which of the following risks is increased in women with a supra-pannicular incision at caesarean section in morbidly obese women when compared to infra-pannicular incisions? a. Bleeding b. Classical/vertical hysterotomy c. Hypoxemia post-op d. Respiratory compromise e. All of the above

Answer 245

E - All of the above

Question 246

A patient who has undergone a gastric band procedure for morbid obesity refractory to conventional weight loss presents to the gynaecology clinic to discuss pregnancy. How long after bariatric surgery should patients wait before trying to conceive? a. 6 months b. 6-12 months c. 12-18 months d. 18-24 months e. Patients with previous bariatric surgery should be counselled against pregnancy

Answer 246

C - 12-18 months

Question 247

Which of the following pregnancy-specific complications are women with a history of bariatric surgery at increased risk of, when compared with obese women who have no history of such surgery? a. Pre-eclampsia b. PPH c. GDM d. IUGR e. Caesarean delivery

Answer 247

D - IUGR

Question 248

A primigravida attends for a dating scan in her first pregnancy. She is uncertain of her dates though believes she it be around 14-15 weeks since her last menstrual period. Until what gestation can CRL be used to accurately date a pregnancy? a. 12+6 b. 13+1 c. 13+6 d. 14+1 e. 14+6

Answer 248

C - 13+6

Question 249

What is the maximum CRL (in mm) which can be used to date a pregnancy? a. 72mm b. 78mm c. 81mm d. 84mm e. 92mm

Answer 249

D - 84mm

Question 250

A patient attends for a dating scan around 16/40. She explains that her menstrual cycle was previously irregular and as such she was unaware of the pregnancy. At 16/40, how should this pregnancy be dated? a. Head circumference b. Abdominal circumference c. Biparietal Diameter d. Estimated fetal weight using Hadlock formula e. CRL

Answer 250

A - Head circumference

Question 251

A primigravida sees her midwife at booking to ask about dietary supplements in pregnancy. What do you advise with respect to who should have Vitamin D supplementation in pregnancy? a. Women with identified deficiency b. Women on vegetarian or vegan diets c. Women who cover their skin for cultural reasons d. Women of darker skin complexions e. All women

Answer 251

E - All women

Question 252

A woman speaks with her midwife at a routine appointment about food to avoid in pregnancy. She is confused as information she has been reading online is at times conflicting. Which of the following foodstuffs can safely be consumed in pregnancy? a. Cooked Liver b. Vegetable pâté c. Mayonnaise d. Cottage cheese e. Stilton cheese

Answer 252

D - Cottage cheese

Question 253

When should women with low risk singleton pregnancies be routinely screened for anaemia in pregnancy? a. Only if symptomatic b. Booking only c. 28/40 only d. Booking and 28/40 e. Booking, 20/40 and 28/40

Answer 253

D - Booking and 28/40

Question 254

What Hb level should be considered diagnostic of anaemia in a booking blood sample? a. <120 b. <115 c. <110 d. <105 e. <100

Answer 254

C - <110

Question 255

A patient attends delivery suite in threatened preterm labour at 34/40. A full count is taken and her midwife notes the Hb to be lower than the quoted reference range. At this gestation, what Hb level should be considered diagnostic of anaemia? a. <115 b. <110 c. <105 d. <100 e. <95

Answer 255

C - <105

Question 256

What are the three components of the ‘combined’ test for the common trisomies? a. Beta-hCG; Papp-A and Nuchal translucency b. Beta-hCG; AFP and Papp-A c. AFP; Papp-A and Nuchal Translucency d. Inhibin, AFP and Nuchal Translucency e. Papp-A; Oestriol and AFP

Answer 256

A - Beta-hCG, Papp-A and nuchal translucency

Question 257

What are the four components of the ‘quadruple’ test used to detect common trisomies in women undergoing screening >14/40? a. Beta-hCG, PAPP-A, Inhibin and AFP b. Beta-hCG, Oestriol, Inhibin, AFP c. PAPP-A, AFP, Inhibin, Maternal age d. Nuchal translucency, Beta-hCG, PAPP-A, Inhibin, AFP e. Nuchal translucency, Oestriol, beta-hCG, Inhibin

Answer 257

B - Beta-hCG, Oestriol, Inhibin, AFP

Question 258

Above what level should referral be made to fetal medicine on nuchal translucency alone? a. >3.5mm b. >4mm c. >5mm d. >6mm e. >7mm

Answer 258

D - >6mm

Question 259

Which combination of results in quadruple testing would be expected in pregnancies affected by trisomy 21? a. High inhibin, high hCG, low oestradiol, low AFP b. High inhibin, low hCG, low oestradiol, low AFP c. Low inhibin, high hCG, high oestradiol, low AFP d. Low inhibin, low hCG, high oestradiol, high AFP e. High inhibin, low hCG, low oestradiol, high AFP

Answer 259

A - High inhibin, high hCG, low oestradiol, low AFP

Question 260

What component of the Quadruple test does not form part of the ‘Triple Test’? a. hCG b. Inhibin c. Nuchal translucency d. Oestriol e. AFP

Answer 260

B - Inhibin

Question 261

Screening for which of the following infections should not be offered as part of routine antenatal screening for a woman aged 20? a. HIV b. Hep B c. Hep C d. Syphilis e. Chlamydia

Answer 261

C - Hep C

Question 262

What Korotkoff sound on blood pressure monitoring should be used for identification of diastolic blood pressure in pregnancy? a. Phase I b. Phase II c. Phase III d. Phase IV e. Phase V

Answer 262

E - Phase V

Question 263

From what gestation should SFH be measured as part of routine antenatal care? a. 18/40 b. 20/40 c. 24/40 d. 28/40 e. 30/40

Answer 263

C - 24/40

Question 264

A low-risk primigravida with an uncomplicated pregnancy attends her midwife following her due date for a discussion around induction of labour after 41/40. The patient is not keen on induction and states that she would instead prefer to await spontaneous labour. What monitoring would you advise beyond 42/40 in this case? a. Weekly liquor volume and doppler b. CTG on alternate days c. Twice weekly LV and doppler d. Twice weekly CTG and UA doppler e. Twice weekly CTG and liquor volume

Answer 264

E - Twice weekly CTG and liquor volume

Question 265

What daily dose of vitamin D is recommended to pregnant and breastfeeding women? a. 10mg b. 10iU c. 10 micrograms d. 100mg e. 0.1 micrograms

Answer 265

C - 10 micrograms

Question 266

A patient is advised to abstain completely from alcohol in pregnancy though declines. What do you advise is the upper limit of alcohol consumption in pregnancy which is not known to be harmful to the fetus? a. 0 units/week b. 1 unit/week c. 2 units/week d. 4 units/week e. 6 units/week

Answer 266

B - 1 unit/week

Question 267

A patient has a high vaginal swab taken after presenting with a small PV bleed at 32/40, which is reported as showing evidence of candida infection. What is the first line treatment of vaginal thrush in pregnancy? a. 5 days of oral metronidazole b. Stat dose of vaginal clotrimazole c. Stat dose of oral clotrimazole d. 7 days of oral ketoconazole e. 7 days of vaginal imidazole

Answer 267

E - 7 days of vaginal imidazole

Question 268

A woman in the first trimester scores more than 3 in the 2-item Generalised Anxiety Disorder scale (GAD-2) used to identify anxiety disorders in pregnancy. What is the best plan of care? a. Further assess using the GAD-10 scale b. Further assess using the GAD-7 scale c. Reassured d. Repeat the GAD-2 in 4 weeks e. Repeat the GAD-2 in the second trimester

Answer 268

B - Further assess using the GAD-7 scale

Question 269

A 23 year old primigravida is seen in the antenatal clinic at booking. She discloses that she is taking Risperidone for bipolar disorder. What specific test should be requested? a. Thyroid function b. Parathyroid hormone levels c. Serum calcium d. Serum phosphate e. Serum prolactin

Answer 269

E - Serum prolactin

Question 270

A 25 year old who has recently moved to the UK from overseas attends the antenatal clinic in the first trimester. She has informed her midwife at her initial booking visit that she is taking sodium valproate for bipolar disorder. What advice do you give with respect to her sodium valproate therapy? a. Gradually reduce dose aiming to stop over 4 weeks b. Gradually reduce dose aiming to stop over 8 weeks c. Stop immediately d. Continue e. Stop now, restart from 24/40 if symptoms recur

Answer 270

C - Stop immediately

Question 271

A 32 year old attends the antenatal clinic in the first trimester. She has informed her midwife at her initial booking visit that she is taking lithium for her mania. What advice do you give with respect to her lithium therapy in pregnancy? a. Gradually reduce dose aiming to stop over 4 weeks b. Gradually reduce dose aiming to stop over 8 weeks c. Stop immediately d. Continue e. Stop now, restart from 24/40 if symptoms recur

Answer 271

A - Gradually reduce the dose aiming to stop over 4 weeks

Question 272

Fetuses exposed to lithium in utero are at particular risk of congenital abnormality in which of the following? a. Urogenital tract b. Cardiac c. Facial cleft d. Long bones e. Digits

Answer 272

B - Cardiac

Question 273

A patient taking lithium at booking attempts to wean herself off though finds herself unable to and elects to continue after counselling about the risks associated with lithium in pregnancy. How often should lithium levels be checked during pregnancy in women who chose to continue therapy? a. Fortnightly until delivery b. Weekly until delivery c. 4 weekly until 36 weeks then weekly until delivery d. 2 weekly until 36 weeks then weekly until delivery e. Once in each trimester

Answer 273

C - 4 weekly until 36 weeks then weekly until delivery

Question 274

A primigravida who has been on lithium for bipolar disorder attends in spontaneous preterm labour at 34/40 at 4am. She has forgotten to bring her lithium with her and is due a dose in around 2 hours time. She normally takes 300mg twice daily. There is no supply of lithium on labour ward nor, on searching, on any other ward in the hospital. What do you suggest? a. Contact on-call pharmacist to dispense lithium at usual dose and continue during labour b. Reassure patient that safe to omit one dose though ask a friend or family member to fetch own supply from home to ensure no more than 2 consecutive doses missed c. Prescribe benzodiazepines in lieu of lithium d. Withhold lithium during labour; check levels 12 hours from last dose e. Withhold lithium during labour, no need to check levels

Answer 274

D - Withhold lithium during labour, check levels 12 hours from last dose

Question 275

A patient with a history of mild depressive illness conceives on citalopram 20mg once daily. On review in the antenatal clinic at booking she denies any thoughts of self harm, reports a stable mood and good social support. On further discussion, it would appear her depressive symptoms were triggered by the death of a close friend around 18 months earlier though she still occasionally feels inexplicably ‘blue’ from time to time. What do you suggest? a. Continue citalopram at same dose throughout pregnancy b. Continue citalopram at same dose throughout pregnancy and consider self-referral to facilitated self help c. Reduce citalopram to 10mg OD d. Stop citalopram gradually e. Stop citalopram gradually, consider self-referral to facilitated self-help

Answer 275

E - Stop citalopram gradually, consider self-referral to facilitated self-help

Question 276

A patient with a history of post-traumatic stress disorder stemming from a sexual assault 5 years earlier, books for antenatal care. What intervention is most appropriate here? a. Referral to facilitated self help b. Referral to perinatal psychiatry c. High intensity CBT d. Group therapy e. REM therapy

Answer 276

C - High intensity CBT

Question 277

A patient with bipolar disorder, usually on lithium and risperidone, is admitted with an acute episode of mania. Despite continuing with her medication during her admission her symptoms appear to be increasing in severity. What next step in management is appropriate here? a. CBT b. Add a further anti-psychotic agent c. Add long acting benzo-diazepines d. REM therapy e. ECT

Answer 277

E - ECT

Question 278

A patient presents with iron deficiency anaemia in the first trimester. What proportion of total body iron is stored within haemoglobin? a. 1/10 b. 1/5 c. 1/3 d. 1/2 e. 2/3

Answer 278

E - 2/3

Question 279

What is the normal total body iron weight for a woman of reproductive age? a. 0.5-1g b. 3-4g c. 50-75g d. 100-150g e. 750-1000g

Answer 279

B - 3-4g

Question 280

What is the main hormone involved in the regulation of gut iron absorption and erythrocyte recycling? a. Transferrin b. Ferritin c. Erythropoetin d. Hepcidin e. Ferroportin

Answer 280

B - Ferritin

Question 281

What is the recommended daily intake of iron for women of reproductive age? a. 5mg b. 10mg c. 18mg d. 50mg e. 500mg

Answer 281

C - 18mg

Question 282

What is the most reliable indicator of iron deficiency? a. Mean cell haemoglobin b. Transferrin saturation c. Serum iron level d. Ferritin e. Total iron binding capacity

Answer 282

D - Ferritin

Question 283

A patient with iron deficiency anaemia in the third trimester of her second pregnancy is admitted at 37/40 for a course of parenteral iron therapy in advance of a planned caesarean section at 39/40. Assuming her haemoglobin is recorded as 8.5g/dL pre-treatment, by how much would you anticipate it to rise in the next 7 days following the parenteral iron therapy? a. 0.5g/dL b. 1.0g/dL c. 1.5g/dL d. 2.0g/dL e. 2.5g/dL

Answer 283

D - 2.0g/L

Question 284

What percentage of women on low-molecular weight heparin injections in pregnancy experience side effects of varying severity? a. <10% b. 20% c. 40% d. 60% e. 80%

Answer 284

C - 40%

Question 285

A 33 year old woman with a strong family history of mental illness has been referred by the community midwife at 32 weeks of gestation because of suspicion of a severe mental illness. What would be the advantage of raising awareness and normalising the need to access support in her management? a. Allow the woman to have a better insight into her illness b. Converts a mental problem into an acceptable medical problem that would be managed appropriately c. Demystifies the danger and allows for management of the patient in the community d. Enables caregivers to come closer to reducing a potentially life-threatening risk e. Helps with acceptance of the need for urgent admission and treatment

Answer 285

D - Enables caregivers to come closer to reducing a potentially life threatening problem

Question 286

You have seen a 26 year old primigravida at 36 weeks of gestation, and following consultation, your assessment of her mental health has led you to have concerns regarding the safety of the woman and her baby. What would be the best approach to take in her management? a. Admit her to a mother and baby unit b. Commence anti-psychotic medication c. Escalate to the duty psychiatric or liaison psychiatry nurse d. Refer her to a social worker immediately e. Section the patient under the mental health act

Answer 286

C - Escalate to the duty psychiatric liaison nurse or duty psychiatrist

Question 287

A 24 year old primigravida is booking for antenatal care at 10 weeks of gestation. She is otherwise healthy and has no past medical or family history of relevance, What is the current NICE recommendation with regard to the timing of screening for anaemia in pregnancy in this woman? a. At booking and at 28 weeks of gestation b. At booking and at 36 weeks of gestation c. At booking and then at 28 and 36 weeks of gestation d. At booking then every antenatal visit up to 36 weeks of gestation e. At booking then every 4 weeks until 36 weeks of gestation

Answer 287

A - At booking and at 28/40

Question 288

A 20 year old primigravida was placed on iron tablets after her booking bloods came back showing that she has iron deficiency anaemia. Two weeks later a repeat blood test is performed and confirms she is responding to the iron tablets. She continue with the iron tablets but has now had a full blood count and a serum ferritin that are all normal. How long should be recommended that she continue with the iron tablets? a. For another 1 months b. For another 3 months at least c. She can stop the iron tablets now d. Until the end of pregnancy e. Until the end of the puerperium

Answer 288

B - For another 3 months at least

Question 289

A 21 year old is seen at her first antenatal visit at 8 weeks of gestation. She complains of breathlessness, palpitations and poor concentration. You examine and find that she is anaemic. A full blood count is performed and her haemoglobin comes back at 65g/L. What would be the treatment for this patient? a. Blood transfusion b. Combined parenteral and oral iron treatment c. Iron tablets – double dose d. Iron tablets – standard dose e. Parenteral iron

Answer 289

A - Blood transfusion

Question 290

What is considered an indication for performing a thrombophilia test in a woman who presents at 8 weeks of gestation for booking? a. Previous PET b. Previous SFGA c. Previous stillbirth d. Previous recurrent miscarriage e. When the result will be used to improve or modify management

Answer 290

E - When the result will be used to improve or modify treatment

Question 291

What is the estimated mortality associated with catastrophic antiphospholipid syndrome? a. 10% b. 20% c. 30% d. 40% e. 50%

Answer 291

E - 50%

Question 292

A 25 year old woman attends for her booking visit at 10 weeks of gestation. On questioning you find that she has never had a cervical smear. Why is it not recommended that she undergo a smear at this time? a. The management of an abnormal result would have to be delayed until after pregnancy anyway b. There is an increased risk of a false negative report c. There is an increased risk of a false positive report d. There is an increased risk of having an inadequate report e. There is an increased risk of miscarriage

Answer 292

C - There is an increased risk of a false positive result

Question 293

A 37 year old woman who presented with vaginal bleeding at 19 weeks of gestation was investigated and found to have an invasive squamous cell carcinoma. What would be the best test to assess local and regional spread of her cancer at this stage in pregnancy? a. CT b. EUA + cystoscopy + proctosigmoidoscopy c. MRI d. PET e. USS pelvis

Answer 293

C - MRI

Question 294

What is the fetal mortality rate in pregnancy affected by domestic violence? a. 1 in 1000 b. 2 in 1000 c. 5 in 1000 d. 10 in 1000 e. 16 in 1000

Answer 294

E - 16 in 1000

Question 295

What proportion of women are estimated to be affected by domestic violence during pregnancy? a. 0-3% b. 4-12% c. 15-20% d. 22-26% e. 31-40%

Answer 295

B - 4-12%

Question 296

A 17 year old girl is receiving antenatal care in your unit having booked at 12 weeks of gestation. What in her history will make you suspect child sexual exploitation? a. Failure to disclose the father of the child b. Failure to stop smoking despite counselling c. Lack of proper means of supporting herself and the child d. Repeated presentations in the pregnancy e. The fact that she is pregnant

Answer 296

D - Repeated presentations in the pregnancy

Question 297

What action should be taken if there are concerns about child sexual exploitation who is attending the antenatal clinic? a. Arrange a multi-agency consultation to assess risk and then manage accordingly b. Contact the GP and seek further information as she may already be known to be at risk c. Inform the police and remove her from the home to avoid the risk of this continuing d. Inform social services immediately e. Raise these concerns with the child and share the information following local safeguarding protocols

Answer 297

E - Raise these concerns with the child and share the information following local safeguarding protocols

Question 298

It has been documented that healthcare workers are reluctant to ask, or feel uncomfortable asking, patients about domestic violence. Several reasons have been cited for this. What is the most unlikely? a. Anxiety about the potential impact of mismanagement on their GMC license b. Feeling inadequately informed to manage cases c. Feeling a lack of confidence in managing cases d. Feeling uncomfortable bringing up the subject e. Lacking confidence in enquiring about it

Answer 298

A - Anxiety about the potential impact of mismanagement on their GMC license

Question 299

How does the incidence of domestic violence in pregnancy compare to that of GDM in the UK? a. That of DV is half that of GDM b. That of DV is 10 times that of GDM c. That of DV is 3-4 times that of GDM d. That of DV is more than 10 times that of GDM e. They are similar

Answer 299

D - That of DV is more than 10 times that of GDM

Question 300

A 30 year old G2P1 is seen at 41+0 weeks to plan and book induction of labour on account of her dates. She is known to a GBS carrier. What would be the next logical step to take in her management? a. Book for induction of labour and perform ARM on admission b. Book for induction of labour with prostaglandin E vaginal pessary c. Book for induction of labour with prostaglandin tablets (oral) d. Book for induction of labour with syntocinon e. Offer membrane sweep and give a date for induction of labour

Answer 300

E - Offer membrane sweep and give a date for induction of labour

Question 301

Regarding non-invasive prenatal testing, how soon after delivery is cell free fetal DNA cleared from the maternal circulation? a. Hours after delivery b. 48 hours c. 7 days d. One month e. 90-120 days (life space of red cells)

Answer 301

A - Hours after delivery

Question 302

Regarding non-invasive pre-natal testing, what is the threshold percentage of cffDNA that is required in the maternal circulation before and NIPT can be undertaken? a. 3% b. 4% c. 5% d. 10% e. 20%

Answer 302

B - 4%

Question 303

A couple with a diagnosis of 'vanishing twin' in the first trimester are keen to undergo NIPT following a high risk combined test result for trisomy 21. What is the potential impact of early twin demise on the result of NIPT? a. It increases the reliability of the test compared to if both twins are alive b. The effect of the demised twin’s ffDNA on NIPT is not known c. The demised fetus’ DNA is cleared from the maternal circulation within hours therefore should not impact on the result d. It is advisable to delay testing for at least 24 hours to allow the demised fetus’ DNA to be cleared from the maternal circulation e. There is a tendency for the result to generate a false negative test based on the levels of the demised fetus’ DNA

Answer 303

B - The effect of the demised twin’s ffDNA on NIPT is not known

Question 304

What is the increased perinatal mortality risk in twins compared with singletons? a. 2x b. 3x c. 5x d. 10x e. 15x

Answer 304

B - 3x

Question 305

What proportion of preterm birth in multiple pregnancy is iatrogenic? a. 1/5 b. 1/4 c. 1/3 d. 1/2 e. 2/3

Answer 305

C - 1/3

Question 306

A 30 year old with a twin pregnancy has a cervical length of 22mm at 20/40. Approximately what proportion of women like her will delivery prior to 28/40? a. 20% b. 25% c. 30% d. 35% e. 40%

Answer 306

B - 25%

Question 307

A 29 year old primigravida with a twin pregnancy presents at 22 weeks gestation for routine antenatal assessment. A cervical length measurement is performed and is reduced at 22mm. What intervention has been shown to have the best benefit with respect to reducing the risk of preterm birth in this woman? a. Cervical cerclage b. IM progesterone c. None d. Arabin pessary e. Vaginal progesterone

Answer 307

C - None

Question 308

What is the incidence of fibroids in the first trimester? a. 5% b. 10% c. 15% d. 20% e. 25%

Answer 308

D - 20%

Question 309

Diagnosed on USS at dating, what size of fibroid should prompt obstetric review in pregnancy? a. Any fibroids b. >1cm c. >3cm d. >5cm e. >7cm

Answer 309

D - >5cm

Question 310

A nulliparous women with a dichorionic, diamniotic twin pregnancy presents at 32 weeks of gestation with severe pruritus and an erythematous popular rash on her abdomen with periumbilical sparing. You diagnose polymorphic eruption of pregnancy and commence appropriate management. What is the incidence of polymorphic eruption of pregnancy? a. 1 in 30-60 pregnancies b. 1 in 150-300 pregnancies c. 1 in 500-1000 pregnancies d. 1 in 1500-2000 pregnancies e. 1 in 3000-5000 pregnancies

Answer 310

B - 1 in 150-300 pregnancies

Question 311

A woman attends for a growth scan, referred by her midwife with suspected SFGA and reduced fetal movements. Ultrasound demonstrates a small for gestational age fetus with reduced liquor volume and reversed end diastolic flow pm umbilical artery doppler. CTG is normal. What is thought to be the time frame between the onset of an abnormal umbilical artery doppler waveform (reversed or absent EDF) and acute fetal deterioration? a. 24 hours b. 48 hours c. 7 days d. 12 days e. 14 days

Answer 311

D - 12 days

Question 312

What proportion of pre-eclampsia can be predicted by risk assessment from maternal history alone in the first trimester of pregnancy? a. 10-20% b. 20-30% c. 30-40% d. 40-50% e. 50-60%

Answer 312

D - 40-50%

Question 313

Where calcium supplementation is used to reduce the risk of pre-eclampsia in women at high risk, at what gestation should it be commenced? a. 12 weeks b. 16 weeks c. 20 weeks d. 24 weeks e. 28 weeks

Answer 313

C - 20 weeks

Question 314

A woman attends the antenatal clinic following a scan at 36 weeks of gestation in her fourth pregnancy which identifies an anterior placenta praevia. She has had three previous caesarean births. What is her risk of placenta accreta? a. 3% b. 11% c. 40% d. 61% e. 67%

Answer 314

D - 61% The risk of accreta with praevia is 3%, 11%, 40%, 61% and 67% for first, second, third, fourth and fifth or more caesareans respectively.

Question 315

What is the incidence of acute appendicitis in pregnancy? a. 1 in 400-800 b. 1 in 800-1500 c. 1 in 1500-2000 d. 1 in 2000-2500 e. 1 in 3000

Answer 315

B - 1 in 800-1500

Question 316

A woman presents with vaginal candidiasis at 23 weeks of pregnancy. What treatment should you offer her? a. One stat treatment of live yoghurt b. One stat treatment of topical imidazole c. One week course of oral Ketoconazole d. One week course of oral nystatin e. One week course of topical imidazole

Answer 316

E - One week course of topical imidazole

Question 317

A pregnant woman undergoes a routine anomaly scan at 18 weeks of gestation. No ultrasound soft markers are pregnant. At what nuchal translucency measurement would you refer the woman to fetal medicine services on this basis alone? a. 2mm+ b. 3mm+ c. 4mm+ d. 5mm+ e. 6mm+

Answer 317

E - 6mm+

Question 318

Domestic violence during pregnancy increases the risk of maternal mortality. What is the increase in homicide risk where there is domestic violence in pregnancy? a. 2x b. 3x c. 4x d. 5x e. 6x

Answer 318

B - 3x

Question 319

The perinatal morality rate overall in the UK is approximately 7 per 1000 births. What is the perinatal mortality rate in monoamniotic twin pregnancies? a. 10-30 per 1000 b. 30-70 per 1000 c. 100-300 per 1000 d. 300-700 per 1000 e. 700-9000 per 1000

Answer 319

D - 300-700 per 1000

Question 320

During pregnancy how much calcium is accumulated by the fetus? a. 1-2g b. 10-15g c. 25-30g d. 70-100g e. 150-200g

Answer 320

C - 25-30g

Question 321

A primigravida with BMI of 34 presents at 21 weeks of gestation with severe throbbing headache and vomiting. She gives a history of similar headaches in the past. On examination her blood pressure is normal with no proteinuria and the deep tendon reflexes are normal. A neurological review is arranged as there are no localising neurological signs except mild bilateral sixth nerve paresis. What is the most likely diagnosis? a. Benign idiopathic intracranial hypertension b. Depression c. Migraine d. Pre-eclampsia e. Space occupying lesion

Answer 321

A - Benign idiopathic intracranial hypertension

Question 322

A woman attends clinic for pre-conceptual counselling after previously being treated for breast carcinoma. She is planning a pregnancy. How long after completion of treatment is she advised to wait before conceiving? a. 1 month b. 6 months c. 1 year d. 2 years e. 3 years

Answer 322

D - 2 years

Question 323

A woman attends the antenatal clinic in a wheelchair with known long-term traumatic spinal cord injury. At what level of spinal injury and above would you be concerned about the occurrence of autonomic dysreflexia? a. T6 b. T8 c. T10 d. L3 e. L5

Answer 323

A - T6

Question 324

What percentage of women with pre-labour rupture of membranes at term will labour within the next 24 hours? a. 40% b. 50% c. 60% d. 70% e. 75%

Answer 324

C - 60%

Question 325

A primigravida aged 30 attends the antenatal clinic for booking. She is known to have bipolar disorder and was taking lithium which was stopped pre-conceptually due to concerns around fetal toxicity. Her mother is known to have bipolar disorder. What is her risk of postpartum psychosis? a. 25% b. 35% c. 40% d. 50% e. 70%

Answer 325

E - 70% 25% risk in women with bipolar; 50% risk if family history. Higher still if stopped medication.

Question 326

A para 1 is found have a platelet count of 85 on routine screening at 28 weeks of gestation. This is second pregnancy. Her first child was delivered at term by caesarean section for breech presentation. She reports normal fetal movements and has no history of bruising or bleeding. Which of the following conditions could NOT explain her platelet count? a. Alloimmune thrombocytopenia b. Gestational thrombocytopenia c. Pre-eclampsia d. Anti-phospholipid syndrome e. Immune thrombocytopenic purpura

Answer 326

A - Alloimmune thrombocytopenia

Question 327

You review a 34 year old primigravida at 32 weeks of gestation in your day assessment unit. She presents with a 2-day history of nonspecific headache, nausea, retrobulbar pain and blurred vision. Neurological examination is normal though fundoscopy reveals bilateral papilloedema. A MR-venogram is reported as normal. Lumbar puncture however does show a raised opening pressire but no other abnormality. Her BMI is elevated at 36. What is the drug of choice in this case? a. Triptan b. Nifedipine c. Labetalol d. Acetazolamide e. Hydrochlorathiazide

Answer 327

D - Acetazolamide

Question 328

A 19 year old primigravida is found to have anti-K titres of 8iU/ml after her 28 week routine antibody screen. She thinks the baby was conceived while on holiday and has no contact with the father. What is the next step in her management? a. Amniocentesis b. Cordocentesis c. Free-fetal DNA d. Repeat antibody titres in 2 weeks e. Repeat antibody titres in 4 weeks

Answer 328

C - Free-fetal DNA

Question 329

Following a single fetal death in a monochorionic, diamniotic twin pregnancy, what is the overall rate of survival for the co-twin? a. 68% b. 72% c. 88% d. 93% e. 97%

Answer 329

C - 88%

Question 330

You review a 29 year old primigravida in the antenatal clinic at booking. She has been referred for serial growth scans of her fetus on account of the fact she is known to smoke 20 cigarettes per day. Which of the following is NOT a known risk of smoking in pregnancy? a. Ectopic pregnancy b. Placenta praevia c. Placental abruption d. Pre-eclampsia e. Preterm delivery

Answer 330

D - Pre-eclampsia

Question 331

A 40 year old woman is seen in the antenatal clinic at 20 weeks of gestation. Both her booking and anomaly scan are normal. She has a BMI of 24. She had a previous vaginal delivery at 39 weeks of a baby weighing 1.8kg. She smokes 20 cigarettes per day. What is the next most appropriate investigation? a. Early growth scan at 26-28 weeks of gestation b. Liquor volume at 26-28 weeks of gestation c. Middle cerebral artery doppler at 32 weeks of gestation d. Umbilical artery doppler at 26-28 weeks of gestation e. Uterine artery doppler at 20-24 weeks of gestation

Answer 331

D – Umbilical artery doppler at 26-28 weeks of gestation If women have a major risk factor for fetal growth restriction, they should have serial umbilical artery doppler scans from 26-28 weeks of gestation. This woman has several risk factors including two major risk factors – smoking >11/day and a previous SFGA baby. Note that women with 3 or more minor risk factors should be referred for uterine artery doppler at 20-24 weeks of gestation

Question 332

A 25 year old primigravida is admitted to the labour ward with regular contractions and draining clear liquor. She is a known carrier for Group B Streptococcus in this pregnancy Shortly after being given a loading dose of penicillin, she becomes wheezy, develops a rash and has difficulty breathing. What is the most appropriate initial dose of intramuscular adrenaline? a. 0.01mg (0.1ml of 1:10000) b. 0.05mg (0.5ml of 1:10000) c. 0.1mg (0.1ml of 1:1000) d. 0.5mg (0.5ml of 1:1000) e. 10mg (10ml of 1:1000)

Answer 332

D – 0.5mg (0.5ml of 1:1000) In anaphylactic shock 0.5ml of 1:1000 adrenaline (0.5mg) should be given IM. The other doses given are too small for therapeutic effect given IM and would be more appropriate given IV. 10mg is too large for an initial dose though if there is a suboptimal response to the initial dose, 0.5mg may be repeated every 10 minutes.

Question 333

A 42-year old primigravida presents in spontaneous labour at 37 weeks gestation. She develops central crushing chest pain which radiates to her left jaw. Which of the following cardiac biomarkers is most reliable for diagnosing acute myocardial infarction during labour and delivery? a. Creatinine Kinase b. Isoenzyme MB c. Lactate Dehydrogenase (LDH) d. Myoglobin e. Troponin I

Answer 333

E – Troponin I Troponin I is unaffected by is unaffected by labour, anaesthesia or delivery

Question 334

A woman attends the antenatal clinic at 30 weeks gestation and discloses that she had suspected whooping cough 2 months earlier. What is the single best recommendation regarding pertussis immunisation? a. Maternal pertussis antibodies should be measured b. Maternal vaccination should be given now c. Maternal vaccination should be deferred until 38 weeks d. Maternal vaccination should be given postnatally e. Neonatal immunisation should be given

Answer 334

B – Maternal vaccination should be given now Despite high vaccination coverage in Britain since the 1990s, pertussis continues to display 3-4 yearly peaks in activity. In 2012 there was a major leap with levels above those seen in the preceding 20 years. Infants under 3 months are at the greatest risk of complications and death.

Question 335

A woman who is 24 weeks pregnant contacts the maternity day unit reporting possible exposure to facial shingles 4 days earlier. She believes she has had chickenpox when she was a child. What advice should she be given? a. Offer testing for varicella zoster virus (VZV) immunity, and if non-immune, offer varicella zoster immunoglobulin (VZIG) b. Offer testing for VZV immunity and if non-immune, offer varicella vaccination c. Reassure her that no further action is necessary as she is likely to be immune d. Tell her to report the development of a rash and if it develops, offer treatment with oral acyclovir e. Tell her to report the development of a rash and if it appears, offer her treatment with VZIG

Answer 335

A – Offer testing for VZV immunity and if non-immune, offer VZIG VZV is highly contagious and can be transmitted by respiratory droplets, direct personal contact or fomites. It is possible to catch it from both chickenpox and herpes though highly unlikely if the herpes is in a non-exposed site. VZIG is effective given up to 10 days after contact and the pregnant woman should then be considered infectious for 8-28 days after receiving VZIG.

Question 336

A pregnant woman with a BMI of 25 sees her midwife at 24 weeks of gestation. A single SFH measurement is undertaken which is less than expected for this gestation. What is the most appropriate management? a. Refer if SFH measurement on a customised chart plots below the 10th centile b. Refer if SFH measurement on a population based chart plots on the 10th centile c. Refer if there is a discrepancy of 1cm with gestational age d. Refer if there is a discrepancy of 2cm with gestational age e. Reassess in 2 weeks time by the same clinician and refer if SFH still less than expected

Answer 336

A - Refer if SFH measurement on a customised chart plots below the 10th cent. SFH using a customised growth chart which takes in account maternal height, weight, parity and ethnicity improves prediction of SFGA babies but there is wide variation in the predictive accuracy ranging from a sensitivity of 27-86% and a specificity of 80-93%

Question 337

A 30 year old woman books in the antenatal clinic at 12 weeks gestation with a BMI of 40. This is her first baby and she is normally fit and well with no family history of note. With regards to her BMI, which complication of pregnancy is the highest risk compared to woman with a normal BMI? a. Emergency caesarean b. Gestational diabetes c. Postpartum haemorrhage d. Stillbirth e. Venous thromboembolism

Answer 337

E - Venous thromboembolism The risk of diabetes is around 3 times higher and hypertensive disorders 2-3 times higher. Caesarean section, stillbirth and postpartum haemorrhage are all about twice as likely in women with a high BMI. Venous thromboembolism however is NINE times higher in this group

Question 338

A pregnant women is identified as being susceptible to rubella from her first trimester booking blood results. When discussing this result at the next antenatal clinic appointment what is the most appropriate advice that she should be given? a. A single dose of MMR should be offered at the 6 week check b. A single dose of MMR should be offered immediately postnatally c. A single dose of MMR should be offered both immediately postnatally with a second dose at the six-week check d. A single dose of rubella immunoglobulin should be offered as soon as possible e. A single dose of rubella vaccination should be offered as soon as possible

Answer 338

C - A single dose of MMR should be offered both immediately postnatal and at the 6-week check Clinical diagnosis of rubella is unreliable and since the risk to the fetus is in the first 16 weeks of pregnancy, it is empirical that the woman is immunised before she might become pregnant again. There were only 6 cases of congenital rubella from 2005 to 2009; 5 in mothers born outwith the UK.

Question 339

A 35 year old woman has recently undergone gastric bypass surgery. She is planning a pregnancy. How long should she be advised to delay conception for? a. 1 year b. 2 years c. 3 years d. 4 years e. 5 years

Answer 339

A - 1 year The majority of bariatric surgery is performed on women of childbearing age. Current advice is to defer conception for a year though data to support this advice is lacking with many studies showing no difference in outcomes amongst women conceiving earlier than 12 months and those conceiving later.

Question 340

A 28 year old primigravida presents at 36+3 weeks of gestation in the antenatal clinic with a breech presentation. There are no obstetric nor fetal contraindications to external cephalic version (ECV). A initial ECV without tocolysis failed two days earlier. What is the most appropriate management option? a. Another ECV with tocolysis b. Another ECV without tocolysis c. Caesarean section at 38 weeks of gestation d. Postural management e. Vaginal breech delivery

Answer 340

A - Another ECV with tocolysis ECV should be offered after 37 weeks in multiparous women and after 36 weeks in primiparous women, Another ECV with tocolysis increases the success rate after a failed attempt. If a caesarean section is to be offered it needs to be after 38+6. Breech delivery may not be the most appropriate management as she is primiparous. There is insufficient evidence to support use of postural management or moxibustion as a method of promoting spontaneous version over ECV.

Question 341

A 34 year old primigravida presents to the maternity assessment unit with a second episode of decreased fetal movements at 34+4 weeks of gestation. She is known to be low risk and has had an otherwise uneventful pregnancy. What is the most appropriate management option? a. Advise formal kick counting and review in 2 days b. Arrange a biophysical profile and, if normal, reassure c. Offer two doses of betamethasone 12 hours apart and deliver within 48 hours d. Perform a CTG and arrange a scan e. Perform a CTG and, if normal, reassure

Answer 341

D - Perform a CTG and arrange a scan Counselling of women in the antenatal period about the significance of fetal movement and relationship of this to stillbirth is still being offered in the UK. Delivery would not be warranted unless further testing reveals an abnormality (e.g. abnormal doppler or a pathological CTG). There is no evidence that any formal definition of reduced fetal movement is of greater value than subjective maternal perception in detection of fetal compromise. Biophysical profiling has not shown to be of benefit.

Question 342

A woman presents for booking in the first trimester. She is taking lithium for her mental health. How often should her serum lithium levels be checked? a. Every 1 week until 36 weeks b. Every 2 weeks until 36 weeks c. Every 4 weeks until 36 weeks d. Every 8 weeks until 36 weeks e. Once in every trimester

Answer 342

C - Every 4 weeks until 36 weeks Lithium is an important drug in maintaining mental health though taking it in pregnancy is not without risks as the incidence of fetal heart defects are increased. . If women do not stop lithium prior to conception, lithium levels should be monitored every 4 weeks until 36 weeks gestation and then weekly until delivery. Lithium levels should be checked again within 24 hours of delivery and the dose should be adjusted to maintain a level in the lower part of the therapeutic range.

Question 343

A 25 year old is found to have a platelet count of 110 x 10*9/L when tested routinely at 28 weeks of gestation. Her platelet count at 12 weeks of gestation was 352 x 10*9/L. She has no history of illness. What is the most likely diagnosis from the list given below? a. Gestational thrombocytopenia b. HIV c. Immune thrombocytopenia d. Thrombocytosis e. Vitamin B12 deficiency

Answer 343

A - Gestational thrombocytopenia Gestational thrombocytopenia occurs in up to 1 in 20 pregnancies. If the count is greater than 100 x 10*9/L, no further investigation is necessary but other diagnoses should be considered. If the count falls below this, further investigations are indicated including blood film, coagulation screen, renal and LFTSs, antiphospholipid antibodies and anti-DNA antibodies.

Question 344

A 32 year old primigravida attends the antenatal clinic complaining of persistent mild pruritus due to atopic eruption of pregnancy. What is the first line treatment in reducing pruritus and providing relief of her symptoms? a. Ultraviolet phototherapy b. Emollients c. Oral antihistamines d. Oral prednisolone e. Topical hydrocortisone

Answer 344

B - Emollients The two most common skin problems in pregnancy are atopic eruption of pregnancy and polymorphic eruption of pregnancy. In about half of all women who complain of skin problems in pregnancy, it is an exacerbation of a pre-existing skin condition. Atopic eruption of pregnancy may require topical steroids and antihistamines though can often be managed with emollients alone.

Question 345

A 35 year old woman presents to the antenatal clinic in her first pregnancy at 28 weeks with daily headaches, Her BMI was noted to be 36. The pain is mainly at the back of her eyes and gets worse on eye movement. She describes her headache as throbbing in nature. She also notices transient visual disturbances. Ophthalmological examination revealed papilloedema. Neurological examination was normal. Which of the following is the most appropriate intervention? a. Acetazolamide b. Low-molecular weight heparin c. Nifedipine d. Propranolol e. Sumitriptan

Answer 345

A - Acetazolamide Idiopathic intra-cranial hypertension (IIH) is a rare, but important cause of headache in pregnancy. A detailed history and examination is essential. IIH tends to present in the first half of pregnancy and affected women are often overwight. Diagnosis is made using the ‘modified Dandy criteria’.

Question 346

A primigravida presents at the antenatal clinic with an MCDA twin pregnancy at 24 weeks of gestation. Ultrasound shows that twin 1 has oligohydramnios with absent EDF in the umbilical artery doppler. Twin 2 has polyhydramnios with positive EDF in the doppler. What would be the best management for this finding? a. Preparation for immediate delivery b. Repeat UA doppler in one week c. Urgent referral for amniotic septostomy d. Urgent referral for laser ablation of the placental bed e. Urgent referral for selective amnio-reduction

Answer 346

D – Urgent referral for laser ablation of the placental bed These twins have developed twin to twin transfusion syndrome due to placental vascular anastomosis which are almost universal in monochorionic twins. Despite the anastomosis being almost universal, TTTS occurs in 10-15% of monochorionic twins. It is more common infact amongst MCDA than MCMA twins though the latter carries a high risk of cord entanglement.

Question 347

A 28 year old woman attends for pre-pregnancy counselling. Her maternal grandfather and her mother’s brother both have Haemophilia A. Her husband is healthy and there is no history of haemophilia in the family. What is the risk that any daughter of hers will have haemophilia A? a. 0% b. 25% c. 50% d. 75% e. 100%

Answer 347

A - 0% The patient herself has a 50% chance of being a carrier but with a healthy husband, it is unlikely any daughter of hers will have the disease since she will only inherit an affected gene from her mother unless her husband’s sperm has a new mutation

Question 348

A 35 year old woman presents at 16 weeks in her first pregnancy with a severe throbbing headache lasting for the last 5 days which is aggravated by eye movements and associated with occasional blurred vision, nausea and photophobia. The only abnormalities on examination are bilateral papilledema and a squint of the left eye, which turns inwards. A CT scan shows no abnormality. What is the most likely diagnosis? a. Cerebral venous thrombosis b. Idiopathic intra-cranial hypertension c. Migraine d. Severe pre-eclampsia e. Trigeminal neuralgia

Answer 348

B – Idiopathic intracranial hypertension IIH is a diagnosis of exclusion in pregnant women with headache. It is more common in women than men with a F:M ratio of 8:1 and much more common in obese women (19/100,000 vs. <1/100,000).

Question 349

A recently delivered woman on the postnatal ward tells you her baby has a patent ductus arteriosus. She asks what the ductus arteriosus is connected to when her baby was in utero. Where does the ductus arteriosus connect in a fetus? a. Middle cerebral artery to posterior communication artery b. Pulmonary artery to aorta c. Right and left atria d. Umbilical artery to iliac artery e. Umbilical vein to inferior vena cava

Answer 349

B - Pulmonary artery to aorta An understanding of fetal circulation and congenital heart defects is important to an obstetrician.

Question 350

A couple attend for pre-pregnancy genetic counselling because the partner is known to have haemophilia A. They are seeking information about their future baby’s risk of inheriting the condition. Which of the following statements regarding the heritability of haemophilia A is correct? a. Approximately 50% of newly diagnosed patients have no family history b. Daughters of males with haemophilia A have a 50% chance of being carriers c. Haemophilia cannot arise following a spontaneous mutation d. Sons of males with haemophilia will inherit the disease e. The background risk of carriership is approximately 1 in 50,000 women

Answer 350

A - Approximately 50% of newly diagnosed patients have no family history Daughters of affected males will always be carriers but sons will never inherit the disease from affected fathers. Haemophilia may arise as a spontaneous mutation and carrier risk is 1 in 20,000

Question 351

A 19 year old woman is 28 weeks in her first pregnancy. On routine blood tests her haemoglobin is 95g/L. What is the best test to diagnose iron deficiency anaemia? a. Blood film b. Serum ferritin c. Serum iron levels d. Serum soluble transferrin receptor e. Total iron binding capacity

Answer 351

B - Serum ferritin Though an approximation of iron deficiency can be assessed by MCV, serum ferritin will give an accurate test of iron stores

Question 352

You see a woman who is 35 weeks pregnant in your day assessment unit. She presents with nausea, anorexia and general malaise. Her liver function test demonstrates an ALT of 634. Which of the following features is most useful in distinguishing acute fatty liver of pregnancy from HELLP syndrome? a. Deranged renal function b. Epigastric pain c. Hypertension d. Hypoglycaemia e. Proteinuria

Answer 352

D - Hypoglycaemia Liver disorders are common in pregnancy but seldom cause long term problems. AFLP is rare but serious and shares many common features with HELLP, however hypoglycaemia is common in AFLP but extremely unlikely in HELLP.

Question 353

You see a woman who is 35 weeks pregnant in your day assessment unit. She presents with itching. Your differential diagnosis is obstetric cholestasis. Your ST1 asks you if she should prescribe vitamin K though is unsure how it works. Vitamin K is responsible for the manufacturing of which of the following coagulation factors? a. Factor V b. Factor VIII c. Factor X d. Factor XI e. Factor XII

Answer 353

C - Factor X Vitamin K is required for the manufacture of coagulation factors II, VII, IX and X

Question 354

You see a woman who is 35 weeks pregnant in your day assessment unit. She presents with itching. Your differential diagnosis is polymorphic eruption of pregnancy. What clinical feature is most helpful in diagnosing this condition? a. Facial pigmentation b. Inflamed abdominal striae c. Itching of palms of hands d. Itching of soles of feet e. Umbilical rash

Answer 354

B - Inflamed abdominal striae Polymorphic eruption of pregnancy classically affects the abdominal striae sparing the umbilicus.

Question 355

You see a woman who is 35 weeks pregnant in your day assessment unit She presents with itching, causing insomnia of the palms of hands and soles of feet. There are scratch marks but no rash. Her ALT is 78IU/L (normal 10-35) and bile acids 42 micromol/L (normal 1-10). Which of the following contraceptives should be avoided postnatally? a. Condoms b. Combined pill c. Depo-provera d. LNG-IUS e. Progesterone only pill

Answer 355

B - Combined pill Estrogen containing contraceptives should be avoided in women with obstetric cholestasis

Question 356

A 27 year old primigravida books at the antenatal clinic. She has a heritable thrombophilia and wishes to discuss the implications for her pregnancy. Which heritable thrombophilia produces the greatest risk for VTE in pregnancy? a. Anti-thrombin III deficiency b. Factor V Leiden homozygosity c. Protein C deficiency d. Protein S deficiency e. Prothrombin mutation heterozygosity

Answer 356

B – Factor V Leiden homozygosity

Question 357

A pregnant woman with severe von Willebrand’s disease attends the antenatal clinic. She is non-sensitised RhD negative. What is the recommended management regarding routine antenatal anti-D prophylaxis? a. Administer half the dose of anti-D IM b. Administer IM anti-D in four divided doses c. Administer IV anti-D d. Administer oral anti-D e. Do not administer anti-D

Answer 357

C - Administer IV anti-D

Question 358

A multiparous woman is seen in the antenatal clinic at 34 weeks of gestation following a scan for placental localisation. The scan shows that the placenta is anterior with the leading edge encroaching on the internal os. Which of the following is the strongest predisposing risk factor for developing placenta praevia? a. Maternal age >40 b. Maternal smoking c. Previous caesarean delivery d. Previous myomectomy e. Previous surgical management of miscarriage

Answer 358

A - Maternal age >40 Maternal age >40 is associated with a nine-fold risk of placenta praevia

Question 359

A 21 year old primigravida is admitted for induction at 35 weeks of gestation. She presents with reduced fetal movements and the fetus is thought to be small for gestational age. An ultrasound scan shows that the estimated weight is below the 10th centile and there is reduced EDF. Which condition is this baby most at risk of? a. Acute renal failure b. Hepatosplenomegaly c. Meconium ileus d. Pneumonia e. Polycythaemia

Answer 359

E - Polycythaemia

Question 360

A 22 year old primigravida presents at 32 weeks of gestation with signs and symptoms of acute appendicitis. The CTG is reassuring. What the best laparotomy incision for appendicectomy? a. Lanz b. Low transverse c. Lower midline d. Over the area of maximal tenderness e. Upper midline

Answer 360

C - Lower midline

Question 361

A 30 year old Primigravida is referred for a growth scan. The pregnancy has been uncomplicated thus far, The ultrasonographer reports that the EFW is on the 5th centile for gestation, there is normal liquor and the UA waveform is normal, but the fetal head circumference is on the 1st centile for gestation. What is the most likely infective cause? a. Cytomegalovirus b. Epstein-Barr virus c. Rubella d. Syphilis e. Toxoplasmosis

Answer 361

A - CMV

Question 362

A 35 year old woman presents 4 days following a normal delivery. She complains of a severe headache which has been getting worse and weakness on her left side. What is the most appropriate investigation? a. Cranial ultrasound b. CT scan c. MR venogram d. PET scan e. Skull x-ray

Answer 362

C - MR venogram

Question 363

A school teacher is 26 weeks of gestation into her first pregnancy. One of her pupils has chickenpox. The lesions have crusted over. She cannot recall having had chickenpox herself as a child and wants to know if she is now infected with chickenpox. How long does it usually take for the lesions to crust over from onset of the rash? a. 3 days b. 4 days c. 5 days d. 6 days e. 7 days

Answer 363

C - 5 days

Question 364

A 44 year old woman with BMI of 48 and gestational diabetes presents at 30 weeks of gestation complaining of lethargy associated with a sore throat and is found to have a temperature of 39.6C. A venous blood gas reveals a Hb of 89g/L. What aspect of her history is NOT a risk factor for severe sepsis? a. Anaemia b. Gestational diabetes c. Age d. BMI e. Sore throat

Answer 364

C - Age

Question 365

A woman with a spinal cord transection presents in labour at term. She is having regular, strong uterine contractions but does not experience any pain. What is the level of her spinal cord injury? a. T8 b. T10 c. L2 d. L4 e. S1

Answer 365

B - T10

Question 366

A patient is referred to fetal medicine after her routine fetal anomaly scan. The sonographer is concerned that the aorta and pulmonary trunk appear to leave the heart as one common vessel (truncus arteriosus). What chromosomal defect is most commonly associated with this abnormality? a. Monosomy X b. 5p deletion c. 22q11 deletion d. Trisomy 13 e. Triple X syndrome

Answer 366

C - 22q11 deletion

Question 367

Levels of which of the following clotting factors are decreased in normal pregnancy? a. Factor VIII b. vWF c. Protein C d. Protein S e. Factor V

Answer 367

D - Protein S

Question 368

A patient with bipolar disorder is seen in the antenatal clinic. She is anxious about developing puerperal psychosis as her mother, who also suffers from bipolar, developed this after childbirth. What do you advise is her risk of puerperal psychosis? a. 1 in 2 b. 1 in 3 c. 1 in 4 d. 1 in 5 e. 1 in 8

Answer 368

A - 1 in 2

Question 369

A primigravida with bipolar disorder is seen in the antenatal clinic. You discuss the implications of this on pregnancy and the postnatal period. What do you advise is the risk of her developing puerperal psychosis in this pregnancy? a. 1 in 2 b. 1 in 3 c. 1 in 4 d. 1 in 10 e. 1 in 20

Answer 369

C - 1 in 4

Question 370

A 36 year old with known heterozygous Factor V Leiden is referred to the antenatal clinic at booking. Her booking BMI is 32 though she has no other significant medical history. What, if any prophylactic LMWH does she require in pregnancy? a. From booking and 6/52 postnatally b. From 28/40 and 6/52 postnatally c. 6/52 postnatally d. 10/7 postnatally e. None required unless additional risk develops

Answer 370

B - From 28/40 and for 6/52 postnatally

Question 371

A woman returns to the antenatal clinic following her mid-trimester anomaly scan. On the scan it states that there is an abdominal wall defect present. There is herniation of the small bowel to the right of the cord insertion. The bowel does not appear to be membrane covered and is free floating in the liquor. Fetal biometry appears normal but liquor is subjectively reduced. The rest of the fetal anatomy appears normal. What statement is correct? a. The findings are consistent with a limb-body wall defect; offer termination of pregnancy b. The findings are consistent with exomphalos and likely to be associated with chromosomal abnormalities; offer a termination of pregnancy c. The findings are consistent with gastroschisis; offer to arrange serial growth scans and review at the tertiary fetal medicine unit to discuss the prognosis with the neonatal surgeons d. The findings are consistent with physiological herniation of the bowel that resolves in the vast majority of cases; arrange a follow-up ultrasound scan at 28 weeks e. The findings are likely associated with a chromosomal abnormality; arrange an amniocentesis for the woman

Answer 371

C - The findings are consistent with gastroschisis; offer to arrange serial growth scans and review at the tertiary fetal medicine unit to discuss the prognosis with the neonatal surgeons

Question 372

A woman who has just had her mid-trimester anomaly scan returns to the antenatal clinic to discuss the results. On the scan it is stated that there is complete anhydramnios. The fetus is in a flexed breech presentation. Neither kidney could be identified on the scan with no evidence of renal arteries on colour flow Doppler bilaterally. Within the limitations of the scan, the rest of the fetal anatomy appears normal and biometry supports a gestation of 20 weeks. The woman states that there is no history of leaking per vagina. a. Counsel the woman that the scan findings are incompatible with life and offer termination of pregnancy b. Discharge to midwife led-care c. Offer a further scan at 28/40 to confirm the diagnosis and reassure that the oligohydramnios may well be transient d. Offer amniocentesis to exclude an underlying chromosomal abnormality e. Refer to antenatal triage for a sterile speculum examination to exclude PPROM

Answer 372

A - Counsel the woman that the scan findings are incompatible with life and offer termination of pregnancy This is bilateral renal agenesis and is incompatible with life

Question 373

A 17 year old primigravida gives birth vaginally to a baby boy at term weighing 3750g. Postnatally you review the results of a swab taken at 35/40 during an admission with threatened preterm labour on which C. Trachomitis was grown. This seems to have been missed during the antenatal period and on discussing the result with the mother, she was not informed and thus not treated. What is the risk of her baby developing ophthalmia neonatorum secondary to chlamydial infection? a. 10% b. 25% c. 50% d. 66% e. 80%

Answer 373

C - 50%

Question 374

A 19 year old Para 1 gives birth vaginally to a baby boy at term weighing 3250g. Postnatally you review the results of a swab taken at 36/40 during an admission with ?SROM on which C. Trachomitis was grown. This seems to have been missed during the antenatal period and on discussing the result with the mother, she was not informed and not treated. What is the risk of her baby developing chlamydia pneumonitis? a. <5% b. 15% c. 20% d. 30% e. 45%

Answer 374

B - 15%

Question 375

How soon after treated for chlamydial infection in pregnancy should a test of cure be performed? a. Immediately b. 1-2 weeks c. 3-4 weeks d. 5-6 weeks e. 9-10 weeks

Answer 375

D - 5-6 weeks

Question 376

What is the incidence of early-onset GBS disease in the UK without screening? a. 0.1% b. 0.5% c. 1% d. 1.5% e. 2%

Answer 376

B - 0.5%

Question 377

Which of the following rare complications of pregnancy is more common in mothers carrying a male fetus? a. Acute fatty liver of pregnancy b. Amniotic fluid embolism c. Vasa praevia d. Hypertrophic cardiomyopathy e. Obstetric cholestasis

Answer 377

A - Acute fatty liver of pregnancy

Question 378

A mother undergoes a TORCH screen after polyhydramnios and fetal echogenic bowel is detected on her fetal anomaly scan. Which of the following would indicate recent, primary CMV infection in pregnancy? a. Raised IgG and IgM b. Urine CMV PCR c. Low avidity IgG d. High avidity IgG e. Fourfold rise in IgG compared with booking bloods

Answer 378

C - Low avidity IgG IgM may remain positive for up to 9-12 months after acute infection. IgG avidity testing is therefore of great use in differentiating between acute or chronic infection. In acute infection, avidity of IgG is low while in recurrent infection it is high.

Question 379

A patient with a history of spinal cord injury develops a sudden headache in labour. On review she is tremulous and noted to be flushed with clammy skin and experiencing involuntary muscular spasm. Blood pressure is 145/95mmHg and her pulse is 55bpm. Spinal cord lesions above what level are known to cause autonomic dysreflexia in labour? a. Any level b. L2 c. T6 d. T4 e. C5

Answer 379

C - T

Question 380

A patient attends for antenatal care in her first pregnancy. She is known to be Hepatitis B positive. On review of her serology you find that she is HBsAg positive but HBeAg negative. What is the likelihood of vertical transmission to the neonate? a. Up to 15% b. Up to 25% c. Up to 50% d. Up to 65% e. Up to 95%

Answer 380

A - Up to 15% e-Ag positive; transmission up to 95%; e-Ag negative; transmission up to 15%

Question 381

A patient attends for antenatal care in her first pregnancy. She is known to be Hepatitis B positive. On review of her serology you find that she is HBsAg and HBeAg positive. What is the likelihood of vertical transmission to the neonate? a. Up to 15% b. Up to 25% c. Up to 50% d. Up to 65% e. Up to 95%

Answer 381

E - Up to 95% e-Ag positive; transmission up to 95%; e-Ag negative; transmission up to 15%

Question 382

At what stage of pregnancy and the puerperium is vertical transmission of Hepatitis B most likely to occur? a. First trimester b. Second trimester c. Third trimester d. Delivery e. Postnatally – breastfeeding

Answer 382

D - Delivery The majority of fetal Hepatitis B transmission occurs at delivery - only 5% occurs transplacentally

Question 383

A patient who is prone to migraines is referred to antenatal clinic at 12/40. She wishes to know what the likely effect of pregnancy on her migraines will be. What pattern is typically seen in migraine in pregnancy? a. Increase in frequency and severity b. Increase in frequency though not severity c. No change d. Decrease in frequency and severity e. Decrease in frequency though not severity

Answer 383

D - Decrease in frequency and severity

Question 384

A primigravida is seen in the antenatal clinic at 16/40. She reports a longstanding history of migraines for which she take sumitriptan on a PRN basis. What is the mechanism of action of sumitriptan? a. Selectively inhibits reuptake of noradrenaline b. Inhibits monoamine oxidase c. Serotonin agonist d. Competitively binds and blocks cortisol receptors e. Selective estrogen receptor modulator

Answer 384

C - Serotonin agonist

Question 385

What is known about the safety of triptans in pregnancy? a. Associated with an increased risk of facial cleft when used in the first trimester b. Increased risk of preterm birth when used after 28/40 c. Use at any gestation is associated with an increased risk of fetal growth restriction d. Association of uncertain significance between third trimester use and mild polyhydramnios e. No reported adverse effects

Answer 385

E - No reported adverse effects

Question 386

A patient with a BMI of 45 presents at 26/40 reporting a new generalised, non-throbbing headache which is exacerbated by coughing. She also reports double vision and pain associated with lateral eye movements. On fundoscopy, bilateral papilledema is noted. Which of the following investigations could be used to confirm the most likely diagnosis here, based on the given history? a. Lumbar puncture b. CT head c. MR-venogram d. MRI head e. Skull x-ray

Answer 386

A - Lumbar puncture This history describes idiopathic intracranial hypertension. High opening pressures on lumbar puncture (not routinely indicated per se) would help confirm the diagnosis.

Question 387

Which of the following forms first line drug treatment of idiopathic, intracranial hypertension? a. Labetalol b. Propranolol c. Nifedipine d. Acetazolamide e. Sumitriptan

Answer 387

D - Acetazolamide

Question 388

A patient attends A&E complaining of a severe headache which she has not experienced previously. She describes the onset as occurring gradually over a few hours, unilateral and pulsating in nature. There is no abnormal neurology on examination and she is otherwise largely well, though she has vomited twice and describes mild photophobia. Based on this history, what is the most likely aetiology of her headache? a. Tension b. Migraine c. Cerebral venous thrombosis d. Idiopathic intracranial hypertension e. Subarachnoid haemorrhage

Answer 388

B - Migraine

Question 389

A patient presents is diagnosed with a cerebral venous thrombosis on MRV at 36/40. She is clinically stable and no focal neurological signs are present on examination. What is first line treatment for this condition? a. Unfractioned heparin b. Thrombolysis c. Endovascular therapy d. LMWH for 3 months e. LMWH for 6 months

Answer 389

E - LMWH for 6 months

Question 390

The most significant risk factor for placental abruption in pregnancy is history of previous abruption in a previous pregnancy. What is the recurrence risk of placental abruption are one previously affected pregnancy? a. 2% b. 4% c. 8% d. 16% e. 25%

Answer 390

B - 4% The risk of recurrence of abruption is 4.4% after 1 affected pregnancy and 1-25% after 2

Question 391

The most significant risk factor for placental abruption in pregnancy is history of previous abruption in a previous pregnancy. What is the recurrence risk of placental abruption are one previously affected pregnancy? a. Up to 4% b. Up to 8% c. Up to 16% d. Up to 25% e. Up to 31%

Answer 391

D - Up to 25% The risk of recurrence of abruption is 4.4% after 1 affected pregnancy and up to 25% after 2

Question 392

Women with one or more previous caesarean section scars are at an increased risk of placenta accreta. What has been shown to be the most sensitive and specific test for antenatal diagnosis of placenta accreta? a. Colour doppler b. 3D power doppler c. MRI with gadolinium contrast d. Contrast CT e. Grey scale ultrasound

Answer 392

B - 3D power doppler

Question 393

A triple test is performed for screening at 16 weeks in a 40-year old woman. The results suggest a high risk of trisomy 21. What would you expect them to show? a. Reduced AFP, reduced estradiol, increased hCG b. Increased AFP, reduced estradiol, increased hCG c. Reduced AFP, increased estradiol, increased hCG d. Reduced AFP, increased estradiol, reduced hCG e. Increased AFP, increased estradiol, increased hCG

Answer 393

A - Reduced AFP, reduced estradiol, increased hCG

Question 394

A 32 year old Asian woman with a BMI of 36 attends the antenatal clinic. You recommend vitamin D in pregnancy as per protocol. What is the daily recommended dose of vitamin D for this lady? a. 10iU b. 10 micrograms c. 1000iU d. 1000 micrograms e. 20,000iU

Answer 394

C - 1000iU The recommended doses of vitamin D in pregnancy are as follows: - General population - 10 micrograms (400iU) per day - At risk - 1000iU per day Individuals identified as 'at risk' include: women with increased skin pigmentation, reduced exposure to sunlight, or those who are socially excluded or obese. Vitamin D may be inappropriate in sarcoidosis (where there may be vitamin D sensitivity) or ineffective in renal disease.

Question 395

High dose vitamin D supplementation is recommended for pregnancy women with certain risk factors. What is the most important risk factor for vitamin D deficiency in a Caucasian woman with a low BMI? a. Light skin pigmentation b. Increased exposure to sunlight c. Hypothyroidism d. BMI <19 e. Immobility

Answer 395

E - Immobility

Question 396

A 35 year old Para 3 is currently 16 weeks of gestation and has uncomplicated chronic hypertension. What should the ideal target BP be with treatment? a. <200/110 b. <160/100 c. <150/100 d. <140/100 e. <130/90

Answer 396

C - <150/100

Question 397

97. A 36 year old para 1 presents to the antenatal clinic. She had an emergency caesarean section at 30 weeks in her last pregnancy following a placental abruption. She is currently 20 weeks of gestation and enquires about a further plan of fetal monitoring in this pregnancy? What is the most appropriate advice? a. No extra monitoring is required b. Uterine artery doppler at 22/40 c. Serial scans from 24/40 d. Serial CTG from 28/40 e. Serial scans from 28/40

Answer 397

E - Serial scans from 28/40 The advice is to commence serial scans from 2 weeks prior to the gestation of the last abruption

Question 398

A patient wishes to consider pregnancy following treatment for her breast cancer. What is the most important predictor of a good outcome? a. Young age b. Herceptin positivity c. Estrogen receptor positivity d. BRCA gene positivity e. Family history of treatable breast cancer

Answer 398

C - Estrogen receptor positivity Estrogen receptor positive tumours have a better prognosis compared with estrogen negative tumours. Younger women tend to have more estrogen receptor negative tumours.

Question 399

A 25 year old para 2 is 36 weeks pregnant. Clinically there is strong suspicion of a left calf DVT. CTG is normal. What is the next step in immediate management? a. Plan delivery b. Therapeutic dose of LMWH c. Prophylactic dose of LMWH d. FBC, coagulation screen, LFTs and U&Es e. Thrombophilia screen

Answer 399

D - FBC, coagulation screen, LFTs and U&Es Bloods should be checked prior to commencing treatment dose heparin

Question 400

A 28 year old primigravida is seen in the antenatal clinic . She is 20 weeks of gestation and has had an uneventful antenatal period thus far. Her combined test returned a low risk result. On her anomaly scan, two echogenic foci were seen in the left cardiac ventricle. Based on this information, what would be your advice? a. Refer her for a fetal echocardiogram b. Counsel her towards an amniocentesis c. Reassure her d. Rescan in 2-3 weeks e. Request a TORCH test

Answer 400

C - Reassure her Women who have undergone first trimester screening and determined to be low risk, or women who have declined first trimester screening should NOT be referred for further assessment of chromosomal abnormality even where normal variants such as the following are seen at the mid-trimester scan (even if multiple present): - Choroid plexus cysts - Dilated cisterna magna - Echogenic foci in the heart - Two vessel cord

Question 401

101. When should HIV positive women with no predisposing risk factors for gestational diabetes be screened for diabetes? a. If they report recurrent infections b. If they are on ziduovudine c. If they are on HAART d. If vaginal birth is planned e. If they have hepatitis co-infection

Answer 401

C - If they are on HAART

Question 402

An HIV positive woman is having a planned vaginal birth. At full dilatation, vertex is direct OA at +2 station and the midwife is concerned about a pathological CTG. What is the most appropriate management in this situation? a. Fetal blood sampling b. Fetal scalp electrode monitoring c. Ventouse delivery d. Outlet forceps delivery e. Caesarean section

Answer 402

D - Outlet forceps delivery

Question 403

A 33 year old primigravida presents at 33+4 weeks of gestation with persistent raised blood pressure (between 140/90-145/99) for one week. There is no proteinuria and the SFH measures normal. What is the most appropriate management? a. Weekly blood pressure b. Twice weekly blood pressure c. Admit and do a BP profile d. Weekly blood pressure with fortnightly blood tests e. Offer delivery at 34/40

Answer 403

A - Weekly blood pressure For mild hypertension developing beyond 32 weeks of gestation, weekly blood pressure monitoring only is required; when it develops prior to 32 weeks, twice weekly blood pressure and testing for proteinuria is indicated

Question 404

A 33 year old primigravida presents at 26+4 weeks of gestation with persistent raised blood pressure (between 140/90-145/99) for one week. There is no proteinuria and the SFH measures normal. What is the most appropriate management? a. Weekly blood pressure b. Twice weekly blood pressure c. Admit and do a BP profile d. Weekly blood pressure with fortnightly blood tests e. Offer delivery at 34/40

Answer 404

B - Twice weekly blood pressure For mild hypertension developing beyond 32 weeks of gestation, weekly blood pressure monitoring only is required; when it develops prior to 32 weeks, twice weekly blood pressure and testing for proteinuria is indicated

Question 405

In a second trimester ultrasound scan, which soft marker has the greatest likelihood of predicting a trisomy 21 fetus? a. Echogenic cardiac focus b. Short femur c. Increased nuchal translucency d. Absent of hypoplastic nasal bone e. Echogenic bowel

Answer 405

C - Absence of the nasal bone The nasal bone is absent in ~75% of Down's fetuses at 12/40

Question 406

A 20-year old primigravida who is 24 weeks of gestation attends the antenatal clinic concerned that she has felt no fetal movements thus far. Her 20 week anomaly scan showed an anterior placenta, with a normal looking fetus and a slight reduction in liquor volume. She is known to be a heavy drinker and smoker including throughout pregnancy. With this history, what condition could the fetus potentially suffer from? a. Renal agenesis b. Holoprosencephaly c. Dandy-Walker malformation d. Congenital myasthenia e. Polycystic kidneys

Answer 406

D - Congenital myasthenia Concern in women with fetal movements issues centres around neuromuscular problems. The rest of the anomalies listed have no relation to reduced fetal movements and should have been detected on the mid-trimester scan.

Question 407

What is the most abundant form of vitamin D in the human body? a. Cholecalciferol b. Ergocalciferol c. 25-hydroxyvitamin D d. 7-dehydrocholesterol e. 1, 25-dihydroxylvitamin D

Answer 407

C - 25-hydroxyvitamin D While 1, 25-dihydrox- is the more metabolically active form, levels of 25-hydrox- are higher

Question 408

107. Vitamin K is usually administered to pregnant women on hepatic enzyme inducing drugs from 35 weeks of pregnancy owing the associated reduction in vitamin K dependent clotting factors. Which clotting factor remains unchanged as it is NOT vitamin K dependent? a. Factor XII b. Factor X c. Factor II d. Factor VII e. Factor IX

Answer 408

A - Factor XII The vitamin K dependent clotting factors are II, VII, IX and X (2, 7, 9 and 10)

Question 409

Dopamine for lactation suppression is indicated in a woman diagnosed with a stillbirth. Which of the following conditions is a contraindication to dopamine agonists? a. Thyroid disease b. Systemic lupus erythematosus c. Pre-eclampsia d. Diabetes e. Myasthenia gravis

Answer 409

C - Pre-eclampsia

Question 410

In a pregnant lady, group B bacteruria is identified. What condition does this predispose her to? a. Chorioamnionitis b. Postpartum sepsis c. Pyelonephritis d. Neonatal oropharyngitis e. Neonatal urethritis

Answer 410

A - Chorioamnionitis

Question 411

A woman with a history of depression is seen in the antenatal clinic. Her friend who has bipolar disorder was admitted to a mother and baby unit after developing puerperal psychosis and she is anxious that her own mental health history puts her at risk. What is the risk of her developing postpartum psychosis in this pregnancy? a. 2 per 1000 b. 3 per 1000 c. 4 per 1000 d. 5 per 1000 e. 6 per 1000

Answer 411

A - 2 per 1000 Postpartum depression is common - occurring in 8-15% of women. Only 0.1-2% of women develop postpartum psychosis. Postpartum psychosis carries a 5% of risk of both suicide and infanticide. Women with bipolar disorder are at a considerably increased risk - around 1 in 4.

Question 412

A 27 year old primigravida is diagnosed with hydrops fetalis at 20 weeks of gestation. No immune cause is demonstrated on testing. What is the fetal mortality associated without intervention in non-immune fetal hydrops? a. 20% b. 40% c. 60% d. 80% e. 90%

Answer 412

D - 80% Non-immune hydrops carries a very poor prognosis. Many causes exist including infection, fetal aneuploidy, cardiac and neurological conditions. In up to half of all cases however a cause will not be found.

Question 413

What is the mode of transmission of Rubella? a. Direct contact with an infected individual b. Fomites c. Respiratory droplets d. Faecal-oral e. Blood borne

Answer 413

C - Respiratory droplets

Question 414

A primigravida attends the antenatal clinic anxious about her risk of developing rubella. She is a teacher and has learned that a child in her class has come out in a typical scarletiform rash. She was last in contact with the child 48 hours prior to the rash appearing. How soon prior to the appearance of a rash are individuals with rubella infection infectious? a. 7 days prior to onset of the rash b. 72 hours prior to onset of the rash c. 48 hours prior to onset of the rash d. 24 hours prior to onset of the rash e. Only infectious when rash present

Answer 414

A - 7 days prior to onset of the rash Individuals with rubella are infectious for 14 days - from 7 days prior until 7 days after the onset of the rash

Question 415

Until what gestation is congenital rubella syndrome thought to occur with fetal infection? a. 12/40 b. 16/40 c. 20/40 d. 28/40 e. Delivery

Answer 415

B - 16/40 There is a distinction to be made between fetal infection which is possible at any gestation and congenital rubella syndrome which is only know to occur until 16 weeks of gestation. The risk is undoubtedly highest (90%) in the first 11 weeks, dropping to not more than 33% risk from 11-16/40. From week 16-20 there is a minimal risk of deafness only. Infection beyond 20 weeks carries no known risk other than fetal growth restriction.

Question 416

What is the principle manifestation of congenital rubella syndrome? a. Mental retardation b. Cataracts c. Microcephaly d. Sensorineural deafness e. Pulmonary stenosis

Answer 416

D - Sensorineural deafness While all of the complications described are known risks of CRS, sensorineural deafness (occurring in 75%) is undoubtedly the highest. Cardiac, ophthalmic and CNS defects are seen in 25% of cases.

Question 417

What is the most common intrauterine infection? a. Toxoplasmosis b. Varicella zoster c. Rubella d. Parvovirus B19 e. Cytomegalovirus

Answer 417

E - Cytomegalovirus CMV is though to affect as many as 2.2% of all live births.

Question 418

What is the mode of transmission of cytomegalovirus? a. Faecal oral b. Fomites c. Direct contact d. Blood borne e. Respiratory droplets

Answer 418

E - Respiratory droplets

Question 419

In what percentage of pregnancies in the UK does CMV seroconversion occur? a. 0.01-0.05% b. 0.1-0.5% c. 0.8-1.2% d. 1-4% e. 5-8%

Answer 419

D - 1-4% Seroconversion occurs in 1-4% of all pregnancies in the UK and rates are highest amongst those of low socio-economic status or poor hygiene. Prevalence of congenital CMV is 3 in 1000 live births.

Question 420

What is the prevalence of congenital CMV infection in the UK? a. 0.5 in 1000 b. 1 in 1000 c. 3 in 1000 d. 5 in 1000 e. 10 in 1000

Answer 420

C - 3 in 1000

Question 421

Which of the following statements concerning cytomegalovirus infection in pregnancy is true? a. Seroconversion occurs in 10-15% of pregnancies in the UK b. 90% of infected infants show clinical signs of infection at birth c. High IgG avidity suggests recent infection d. Cerebral calicification, ventriculomegaly, microcephaly and hyperechogenic bowel are seen in only 25% on ultrasound e. Diagnosis is based on a characteristic maternal rash

Answer 421

D - Cerebral calicification, ventriculomegaly, microcephaly and hyperechogenic bowel are seen in only 25% on ultrasound seroconversion occurs in 1-4% of pregnancies in the UK, only 10% of infected infants show clinic signs at birth, low IgG avidity is suggestive of recent infection and may be a useful adjunctive test in diagnosis, ultrasound signs are seen in only 25% of patients and include cerebral calcification, microcephaly and ventriculomegaly – these are similar to findings in congenital toxoplasmosis though CMV is more common. Clinical diagnosis of CMV is challenging at most infections are entirely asymptomatic

Question 422

Following identification of polyhydramnios and hydrocephalus on ultrasound scan at 28 weeks of gestation. A woman undergoes a TORCH screen which suggests recent toxoplasmosis infection. What drug may be of benefit in treating fetal infection? a. Pyrimethamine b. Spiramycin c. Metronidazole d. Penicillin V e. Clotrimazole

Answer 422

A – Pyrimethamine Pyrimethamine may be used beyond 18 weeks of gestation in a bit to treat a fetus with suspected toxoplasmosis infection. It cannot be used prior to this as it is teratogenic. Where known or suspected maternal infection has taken place with no fetal signs on ultrasound, spiramycin may be used to reduce the likelihood of infection (including <18 weeks if required)

Question 423

A primigravida who works in a nursery comes to the antenatal clinic anxious as a number of the children in her class have developed ‘slapped cheek’ syndrome. What is the main fetal consequence of congenital Parvovirus infection? a. Chorioretinitis b. Skin scarring c. Non-immune hydrops d. Microcepahly e. Sensorineural deafness

Answer 423

C - Non-immune hydrops PVB19 (‘slapped cheek’, ‘erythema infectosum’ or ‘fifths disease) occurs in outbreaks of around 6 months duration every 4-5 years. Around 50-60% of the UK population have already been infected though where primary maternal infection occurs in pregnancy, transmission to the fetus occurs in ~1/3. While the fetus is most vulnerable when this occurs in the second trimester, the vast majority of fetuses will have spontaneous resolution with no adverse outcome. The main fetal risk is non-immune fetal hydrops (10% of which is due to PVB19) – in the absence of hydrops, there is no evidence of fetal risk. Where primary maternal infection is confirmed in pregnancy (detection of de novo IgM), USS 4 weeks from seroconversion and then every 1-2 weeks until 30 weeks should be offered. MCA-PSV may also be of use.

Question 424

A 17 year old girl is receiving antenatal care in your unit having booked at 12 weeks of gestation. What in her history will make you suspect child sexual exploitation? a. Failure to disclose the father of the child b. Failure to stop smoking despite counselling c. Lack of proper means of supporting herself and the child d. Repeated presentations in the pregnancy e. The fact that she is pregnant

Answer 424

D - Repeated presentations in the pregnancy

Question 425

What action should be taken if there are concerns about child sexual exploitation who is attending the antenatal clinic? a. Arrange a multi-agency consultation to assess risk and then manage accordingly b. Contact the GP and seek further information as she may already be known to be at risk c. Inform the police and remove her from the home to avoid the risk of this continuing d. Inform social services immediately e. Raise these concerns with the child and share the information following local safeguarding protocols

Answer 425

E - Raise these concerns with the child and share the information following local safeguarding protocols

Question 426

How does the incidence of domestic violence (DV) in pregnancy compare to that of gestational diabetes (GDM) in the UK? a. That of DV is half that of GDM b. That of DV is 2 times that of GDM c. That of DV is 4-5 times that of GDM d. That of DV is more than 10 times that of GDM e. They are similar

Answer 426

D - That of DV is more than 10 times that of GDM

Question 427

A 30 year old G2P1 is seen at 41+0 weeks to plan and book induction of labour on account of her dates. She is known to a GBS carrier. What would be the next logical step to take in her management? a. Book for induction of labour and perform ARM on admission b. Book for induction of labour with prostaglandin E vaginal pessary c. Book for induction of labour with prostaglandin tablets (oral) d. Book for induction of labour with syntocinon e. Offer membrane sweep and give a date for induction of labour

Answer 427

E - Offer membrane sweep and give a date for induction of labour

Question 428

What is the threshold percentage of cffDNA that is required in the maternal circulation before and NIPT can be undertaken? a. 3% b. 4% c. 5% d. 10% e. 20%

Answer 428

B - 4%

Question 429

What is the potential impact of early twin demise on the result of NIPT? a. It increases the reliability of the test compared to if both twins are alive b. The effect of the demised twin’s ffDNA on NIPT is not known c. The demised fetus’ DNA is cleared from the maternal circulation within hours therefore should not impact on the result d. It is advisable to delay testing for at least 24 hours to allow the demised fetus’ DNA to be cleared from the maternal circulation e. There is a tendency for the result to generate a false negative test based on the levels of the demised fetus’ DNA

Answer 429

B - The effect of the demised twin’s ffDNA on NIPT is not known

Question 430

You see a 17 year old girl in the antenatal clinic at booking, who on direct questioning discloses that she has a clitoral piercing. You deem her to be Fraser competent and she states that she voluntarily sought out and underwent the piercing herself. What, if any, reporting obligations do you have in this case? a. No obligation necessary as the girl has capacity and underwent the procedure voluntarily b. Refer to the lead midwife for safeguarding c. Anonymised reporting to HSCIC d. Refer to local social services child protection team e. To police within 1 month

Answer 430

E - To police within 1 month

Question 431

How many women worldwide are thought to have undergone FGM? a. 10 million b. 25 million c. 125 million d. 250 million e. 500 million

Answer 431

C - 125 million

Question 432

When was FGM criminalised in the UK? a. 1970 b. 1985 c. 1997 d. 2003 e. 2015

Answer 432

B - 1985

Question 433

What proportion of women giving birth in England and Wales each year are estimated to have undergone FGM? a. 0.5% b. 1.5% c. 3% d. 5% e. 7%

Answer 433

B - 1.5%

Question 434

What proportion of pregnant women in the UK are seronegative – and therefore susceptible – to cytomegalovirus? a. 10% b. 30% c. 50% d. 70% e. 90%

Answer 434

C - 50% CMV is the most common congenital viral infection amongst infants born in the UK with an incidence of ~0.5%. 40-60% of expectant mothers in the UK are seropositive for CMV at booking, indicating an equivalent number are susceptible to primary infection during pregnancy. TOG 2016

Question 435

What is the most common congenital viral infection amongst infants born in the UK? a. Herpes simplex b. Varicella zoster c. Cytomegalovirus d. Parvovirus B19 e. Toxoplasmosis

Answer 435

C - Cytomegalovirus CMV is the most common congenital viral infection amongst infants born in the UK with an incidence of ~0.5%. 40-60% of expectant mothers in the UK are seropositive for CMV at booking, indicating an equivalent number are susceptible to primary infection during pregnancy. TOG 2016

Question 436

Which of the following statements concerning cytomegalovirus infection in pregnancy is correct? a. Rates of congenital CMV infection increase with advancing gestation b. 80-90% of infected infants will display clinical signs/symptoms at birth c. Congenital infection only occurs in the context of primary maternal infection d. It is the leading non-genetic cause of sensorineural deafness in children e. The majority of maternal infection in pregnancy is detected via the appearance of a characteristic rash

Answer 436

D - It is the leading non-genetic cause of sensorineural deafness a) While the likelihood of vertical transmission increases with advancing gestation, the risk of congenital infection declines in a near-linear relationship, with no cases of severe infection on record where maternal infection occurs beyond 14 weeks of gestation b) 75-90% of congenital CMV infections are asymptomatic at birth (i.e. 10-25% are symptomatic) though a further 10-25% will develop sequelae in time c) While much more common in the setting of primary maternal infection, cases of congenital CMV with secondary maternal infection have been reported e) CMV typically is either asymptomatic or causes a non-specific viral illness in immunocompetent women and children - there is no known associated rash TOG 2016

Question 437

A small for gestational age infant is admitted to the neonatal unit shortly following birth with jaundice and hepatomegaly. Further testing reveals thrombocytopenia and anaemia. Testing confirms congenital CMV infection. What is the mortality rate amongst infants with symptomatic congenital CMV at birth? a. <5% b. 10% c. 30% d. 50% e. 70%

Answer 437

C - 30% Mortality rates of up to 30% are reported amongst infants who are symptomatic at - or develop symptoms shortly after - birth TOG 2016

Question 438

A woman at 14 weeks of gestation is diagnosed with primary CMV infection following a viral illness and wishes to undergo invasive testing to determine whether or not fetal infection has occurred. How soon after maternal primary CMV infection should amniocentesis be offered? a. As soon as possible b. 2 weeks c. 3 weeks d. 5 weeks e. 7 weeks

Answer 438

E - 7 weeks Amniocentesis should be offered no sooner than 7 weeks after suspected infection, and no earlier than 21 weeks of gestation. Ultrasound scanning of the fetus on a 3-4 weekly basis to look for characteristic - though non-specific markers - is also advised where fetal infection is a risk. Ultrasound appearances include periventricular calcifications, microcephaly, echogenic bowel and IUGR - though are seen in as few as 25% of cases even in first trimester infection. TOG 2016

Question 439

You are seeing a 24-year-old woman who received chemotherapy for cancer as a child with doxorubicin, an anthracycline antibiotic, for prepregnancy counselling. What screening should she have prior to becoming pregnant? a. Echocardiography or cardiac MRI b. Follicular phase follicle-stimulating hormone and luteinising hormone c. Liver function test d. Pulmonary function test (lung function test) e. Renal function test

Answer 439

E - Echocardiography or cardiac MRI In women previously treated with anthracycline antibiotics (such as doxorubicin and daunorubicin) for childhood cancer, pregnancy has been shown to precipitate cardiac decompensation. These agents are known to cause ventricular dysfunction, cardiomyopathy and congestive heart failure. These effects can be asymptomatic in up to 60% of patients and therefore, are present for the first time during pregnancy. It is advisable that baseline echocardiography or cardiac MRI is performed prior to pregnancy in women with previous exposure to anthracycline antibiotics. TOG StratOG Resource 2016

Question 440

A 30-year-old primigravida at 14 weeks of gestation was seen 2 days ago with myalgia, rhinitis and a mild temperature. She was investigated and found to have an infection with cytomegalovirus (CMV). Assuming that this is a primary infection, what would be the estimated risk of vertical transmission in this pregnancy? a. Up to 10% b. Up to 25% c. Up to 40% d. Up to 50% e. Up to 75%

Answer 440

D - Up to 50% Following infection in a woman who was previously seronegative, the child transmission rate is estimated to vary from 14.2−52.4%. TOG StratOG Resource

Question 441

A diagnosis of cytomegalovirus (CMV) infection has been made on a 20-year-old primigravida at 16 weeks of gestation. She would like to know whether her baby is infected or not. What investigation will you offer her? a. Amniocentesis 7 weeks after the infection b. Amniocentesis for viral particles as soon as possible c. Fetal blood sample for immunoglobulin M (IgM) d. MRI for typical features on imaging e. Ultrasound on typical features

Answer 441

A - Amniocentesis 7 weeks after the infection Amniocentesis should be performed at least 7 weeks after the presumed time of maternal infection and after 21 weeks of gestation. This interval allows for the maturation of the fetal genitourinary system and excretion of the replicating virus in the urine. If performed too early a false-negative result will be obtained. A blood sample is unreliable as the baby does not produce IgM until much later in pregnancy. TOG StratOG Resource

Question 442

A 35-year-old primigravida with no significant past medical history presents at 30 weeks of gestation with a sudden onset of epigastric pain that is radiating to the back. Prior to this she had been seen repeatedly with right hypochondrial pain. Her BP at the last antenatal clinic visit was normal. She is apyrexial, but tachycardic (pulse 110 bpm) and hypotensive (BP = 80/50 mmHg). What it the most likely diagnosis? a. Abruptio placenta b. Hepatic rupture c. Perforated duodenal ulcer d. Rupture of aortic aneurysm e. Splenic rupture

Answer 442

B - Hepatic rupture Hepatic masses can cause local compressive symptoms or complications on adjacent viscera, capsular stretch from progressive growth or may bleed into the hepatic tissue causing local haematoma. This may be mistaken for dyspepsia, biliary disease, appendicitis, constipation, muscular pain or referred pain from pneumonia. Very rarely, a hepatic lesion can rupture into the peritoneal cavity leading to a risk of exsanguination with fetal hypoxia, potentially leading to fetal and/or maternal death. The possibility of hepatic bleeding should be considered in any patient with severe epigastric pain radiating to the back with signs of hypovolaemic shock as in this patient. TOG StratOG Resource

Question 443

What proportion of successful IVF cycles in the UK result in multiple pregnancy? a. 5% b. 10% c. 15% d. 25% e. 30%

Answer 443

D - 25%

Question 444

What proportion of births in the UK are a result of multiple pregnancies? a. 0.1% b. 0.5% c. 1% d. 2% e. 3%

Answer 444

E - 3%

Question 445

What is the rate of maternal mortality in multiple pregnancy relative to singletons? a. Equivalent b. 1.5x c. 2x d. 2.5x e. 3x

Answer 445

D - 2.5x Maternal mortality is 2.5x higher in multiples than singletons while fetal mortality is as follows: - 5 in 1000 singles - 12 in 1000 twins (20% TTTS) - 35 in 1000 triplets

Question 446

4. What frequency of antenatal scanning is recommended in dichorionic, diamniotic twin pregnancy? a. Fortnightly from 16 weeks, 4 weekly from 24 weeks b. Fortnightly from 16 weeks, 4 weeks from 28 weeks c. Fortnightly from 16 weeks d. 4 weekly from 24 weeks e. 4 weekly from 28 weeks

Answer 446

D - 4 weekly from 24 weeks

Question 447

What frequency of antenatal scanning is recommended in monochorionic, diamniotic twin pregnancy? a. Fortnightly from 16 weeks, 4 weekly from 24 weeks b. Fortnightly from 16 weeks, 4 weeks from 28 weeks c. Fortnightly from 16 weeks d. 4 weekly from 24 weeks e. 4 weekly from 28 weeks

Answer 447

A - Fortnightly from 16 weeks, 4 weekly from 24 weeks With an additional scan at 34 weeks

Question 448

What frequency of antenatal scanning is recommended in monochorionic, monoamniotic twin pregnancy? a. Fortnightly from 16 weeks, 4 weekly from 24 weeks b. Fortnightly from 16 weeks, 4 weeks from 28 weeks c. Fortnightly from 16 weeks d. 4 weekly from 24 weeks e. 4 weekly from 28 weeks

Answer 448

C - Fortnightly from 16 weeks

Question 449

A woman with a DCDA twin pregnancy is observed to have a short cervix (21mm) on her mid-trimester scan. What treatment is indicated here? a. Vaginal progesterone b. Cervical cerclage c. Vaginal progesterone and cervical cerclage d. Vaginal progesterone or cervical cerclage depending on patient’s preference e. No treatment indicated

Answer 449

E - No treatment indicated Preterm labour preventative strategies should not be adopted in multiple pregnancy

Question 450

What proportion of twin pregnancies will delivery spontaneously preterm prior to 37 weeks of gestation? a. 20% b. 30% c. 40% d. 60% e. 80%

Answer 450

D - 60%

Question 451

What proportion of triplet pregnancies will deliver spontaneously preterm prior to 35 weeks of gestation? a. 30% b. 40% c. 60% d. 75% e. >90%

Answer 451

D - 75%

Question 452

Beyond what gestation is the risk of adverse outcomes shown to be increased in monochorionic twin pregnancy? a. 34/40 b. 35/40 c. 36/40 d. 37/40 e. 38/40

Answer 452

E - 38/40

Question 453

A patient with a history of recurrent miscarriage attends for a cervical length scan in her first on-going pregnancy. What is the normal length of the cervix in the second trimester of pregnancy? a. 50mm b. 40mm c. 35mm d. 25mm e. 20mm

Answer 453

B - 40mm TOG 2016

Question 454

What is the normal physiological change in serum creatinine in pregnancy? a. Increases by 35 micromol/L b. Increases by 15 micromol/L c. No change d. Decreases by 15 micromol/L e. Decreases by 35 micromol/L

Answer 454

E - Decreases by 35 micromol/L TOG 2016

Question 455

What is the most common cause of acute kidney injury in pregnancy? a. Pre-eclampsia b. Use of non-steroidal anti-inflammatory drugs c. Exacerbation of existing chronic renal disease d. Urinary tract outlet obstruction e. Urinary tract injury at caesarean section

Answer 455

A - Pre-eclampsia TOG 2016

Question 456

A primigravida develops acute kidney injury at 33 weeks of gestation secondary to severe pre-eclampsia. Her urea and creatinine are both noted to be elevated. Above what value should renal replacement therapy be considered in pregnancy for elevated urea levels? a. 12 b. 17 c. 20 d. 27 e. 30

Answer 456

B - 17 Urea is teratogenic - levels >17 despite medical treatment is a pregnancy specific indication for renal replacement therapy TOG 2016

Question 457

What is the incidence of acute fatty liver of pregnancy in the UK? a. 1 in 50,000 b. 1 in 20,000 c. 1 in 5000 d. 1 in 2500 e. 1 in 1000

Answer 457

B - 1 in 20,000 AFLP is rare, occurring in 1 in 20,000 pregnancies on average TOG 2016

Question 458

A patient presents at 31 weeks of gestation with elevated blood pressure, significant proteinuria and vomiting. Acute fatty liver of pregnancy (AFLP) and HELLP syndrome are considered the leading differential diagnoses. Which of the following results would suggest AFLP is more probable here? a. Low ammonia b. Hyperkalaemia c. Low glucose d. Elevated LDH e. Elevated uric acid

Answer 458

C - Low glucose Low glucose and increased ammonia are suggestive of AFLP over HELLP syndrome. TOG 2016

Question 459

Which of the following NSAIDs carries the highest risk of acute renal failure? a. Ibuprofen b. Diclofenac c. Indomethacin d. Naproxen e. Fenoprofen

Answer 459

D - Naproxen TOG 2016

Question 460

What is the estimated successful pregnancy rate following transabdominal cerclage performed by laparotomy at approximately 11 weeks of gestation? a. 40–50% b. 50–60% c. 60–70% d. 70–80% e. >80%

Answer 460

D - >80% The successful pregnancy rate for transabdominal cerclage varies depending on the experience of the surgeon and the timing of the procedure (whether it is an interval procedure or it is performed during pregnancy). In the reported series performed during pregnancy, the success rates have been at least 80%; some series report rates as high as 97.6%. The success rates from the laparoscopic approach have varied from 71.4% to 83.3%. TOG StratOG Resource

Question 461

You are leading a teaching session on stillbirth for GP trainees and foundation doctors. You discuss the risk factors associated with stillbirth. Mothers with which blood group are noted to be at an increased risk of stillbirth? a. A b. B c. O d. AB e. Equivalent risk across all blood groups

Answer 461

D - AB Mothers with AB blood group are known to be at an increased risk of stillbirth (Adj. OR - 1.96) TOG 2015

Question 462

A primigravida comes to see you in the antenatal clinic at 37 weeks of gestation. She is extremely anxious and requests induction of labour as her friend suffered a stillbirth at 41 weeks of gestation while awaiting induction of labour for postmaturity. What reduction in stillbirth risk is expected if all mothers were offered routine induction of labour at term? a. 10% b. 25% c. 50% d. 75% e. >80%

Answer 462

C - 50% Meta-analyses of RCTs demonstrate that routine induction of labour at term reduces the risk of perinatal death by 50%. These observations make a case for offering induction of labour to all women. Any benefits arising from this would have to be balanced against the increased demands on maternity systems. However, the observations do suggest that a more liberal approach to induction of labour at term may be one approach to reduce stillbirths. TOG 2015

Question 463

A woman with ulcerative colitis is seen in the pre-conceptual counselling clinic. Which of the following medications is it most important she stops prior to conceiving? a. Mycophenolate b. Infliximab c. Adalimubab d. Azathiopine e. Certolizumab

Answer 463

A - Mycophenolate Mycophenolate is associated with both an increased rate of congenital malformations and first trimester loss. Switching to azathioprine which is safe is recommended. The biologics (inflixmiab, adalimubab and certolizumab) should ideally be discontinued around 30-32 weeks of gestation. TOG 2016