Antenatal Care Flashcards
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%
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.
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
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.
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
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.
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
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.
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
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.
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
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.
What is the maximum gauge of the outer needle used in amniocentesis?
a. 22G
b. 20G
c. 16G
d. 14G
e. 12G
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.
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
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.
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
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.
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%
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.
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
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.
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
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).
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
C - 3
Varicella zoster belongs the human herpes-virus family of DNA viruses. It is also known as human herpes-virus 3.
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
D - 7-21 days
Chickenpox has an incubation period ranging from 1-3 weeks; or 7-21 days
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
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.
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
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.
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%
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
What is the reported risk of anaphylaxis following administration of VZIG?
a. <0.1%
b. 0.5%
c. 1%
d. 2%
e. 4%
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.
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%
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.
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
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.
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
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.
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
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.
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
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).
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
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.
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
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.
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
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.
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%
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.
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
B - 1 in 1200-5000
The incidence of vasa praevia is estimated at 1 in 1200-5000 deliveries
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
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.
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
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%.
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
D - Posterior placenta
Posterior placenta praevia is associated with an increased likelihood of persistence
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
C - 32/40
Major placenta praevia , when diagnosed at 20/40, should be re-checked at 32/40
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
D - Colour doppler
A combination of TA and TV colour doppler ultrasound is the preferred imaging modality for the detection of vasa praevia
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
B - 20mm
The minimum distance between the leading edge of the placenta and the internal os to permit vaginal delivery is 20mm
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
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.
- 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
D - Vasa Praevia
Benckiser’s haemorrhage is associated with vasa praevia
What is the incidence of velamentous cord insertion?
a. 1%
b. 2%
c. 5%
d. 10%
e. 15%
A - 1%
The incidence of velamentous cord insertion is 1%, of which up to 6% will be complicated by concurrent vasa praevia
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%
A - 6%
The incidence of velamentous cord insertion is 1%, of which up to 6% will be complicated by concurrent vasa praevia
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
B - 1 in 200
The estimated incidence of placenta praevia at term is as high as 0.5% - 1 in 200.
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
E - Up to 2/3
It is estimated that as many as 2/3 of placenta accreta are only definitively diagnosed at delivery
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
D - Placenta Percreta
The scenario describes placenta percreta which is the most severe form of the placenta accreta spectrum disorder.
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%
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%
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%
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%
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%
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%
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%
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%
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
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
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
B - 36-37/40
Patients with an uncomplicated placenta praevia are recommended to undergo late preterm delivery at 36-37 weeks of gestation
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
C - Weekly
Women with placenta praevia should have a group and save sample collected at least weekly
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
A - 35-36/40
Patients with an uncomplicated placenta accreta are recommended to undergo delivery at 35-36/40
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%
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.
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%
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%.
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%
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.
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%
B - 3%
Reversion to breech presentation following successful ECV is uncommon – occurring in only 3% of cases.
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
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.
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
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.
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%
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%.
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%
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
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%
B - 10%
The recurrence rate of breech presentation is quoted in the RCOG Green Top Guideline as 9.9%
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%
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.
- 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
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.
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
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.
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
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.
What is the risk of caesarean section delivery in women planning vaginal breech birth?
a. 25%
b. 33%
c. 40%
d. 50%
e. 66%
C - 40%
Women planning vaginal breech birth have a higher risk of caesarean section (40%) than equivalent women planning cephalic.
What is the maximum number of attempts at ECV advised during a single session?
a. 1
b. 2
c. 3
d. 4
e. 5
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.
What proportion of babies will be breech at 28/40 gestation?
a. 3%
b. 10%
c. 20%
d. 33%
e. 40%
C - 20%
20% of fetuses will be breech at 28/40 compared with 3% at term.
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
B - 3-7 days
The incubation period of genital HSV is between 3 and 7 days
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
C - 2 weeks
Symptoms typically persist for around 2 weeks in primary outbreaks of genital herpes
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
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.
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.
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.
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%
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.
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%
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.
- 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
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.
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
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.
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%
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.
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
A - <2500g
Independent of centiles or SFGA definitions, any infant weighing <2500g at delivery is considered to be of ‘low birthweight’.
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
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.
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
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.
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
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.
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
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.
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
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
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
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.
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
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.
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
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.
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.
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.
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%
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).
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%
D - 81%
Umbilical artery doppler is normal is around 4/5 of SFGA fetuses and should be repeated every 14 days.
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
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.
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
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.
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
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.
- 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
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.
- 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
B - 37/40
SFGA fetuses in whom umbilical artery doppler is normal, should be delivered at 37/40.
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
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.
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
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.
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
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.
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
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.
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
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%
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%
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%
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
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.
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
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
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
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.
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
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.
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
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.
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
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.
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%
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.
- 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
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).
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%
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.
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
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.
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
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.
What FBC finding may be unexpectedly found in VTE in pregnancy?
a. Neutropenia
b. Increased haematocrit
c. Eosinophilia
d. Leucocytosis
e. Thrombocytopenia
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.
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%
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%.
What is the mortality rate associated with pulmonary embolism in pregnancy?
a. 45%
b. 33%
c. 20%
d. 15%
e. <5%
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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).
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
B - APTT
Patients on IV unfractioned heparin require regular monitoring of APTT to guide dosing and keep in therapeutic range (1.5-2.5).
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
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.
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
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.
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
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).
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
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.
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
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.
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
C - <105g/L
When checked in the third trimester, Hb levels of <105g/L should prompt consideration of cause and treatment.
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
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.
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
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.
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
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.
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
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.
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
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
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
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.
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
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.
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
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.
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
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.
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%
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
What proportion of monochorionic twins are mono-amniotic?
a. 1%
b. 5%
c. 15%
d. 20%
e. 30%
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
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
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
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%
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
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
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
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
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.
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
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.
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
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).
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
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
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%
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).
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%
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).
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%
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).
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
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).
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
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).
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
C - 1 in 100,000
Conjoined twins are incredibly rare – around 1 in 90-100,000 pregnancies.
What proportion of monochorionic twins are affected by TRAP Sequence?
a. 0.1%
b. 0.5%
c. 1%
d. 2.5%
e. 5%
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.
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
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.
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
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.
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
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
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
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
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
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
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
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
What country has the highest prevalence of FGM?
a. Burkina-Faso
b. Egypt
c. Yemen
d. Liberia
e. Somalia
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%).
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
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%).
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
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
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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.
What is the incidence of chromosomal abnormality in stillborn infants?
a. 6%
b. 10%
c. 23%
d. 34%
e. 42%
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.
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
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.
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%
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).
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
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.
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%
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.
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%
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.
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
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.
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%
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.
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
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).
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
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.
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
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.
