Day 10 Obstetrics Flashcards
1
Q
A 29-year-old woman has recently given birth to a healthy baby girl but has suffered a perineal tear as the consequence of a difficult birth.
Upon examination, the patient has their internal anal sphincter completely torn
What degree of tear has the patient suffered from? (1)
What is the most appropriate next step in management? (2)
A
Third-degree perineal tears require repair in theatre by a suitably trained clinician
2
Q
A 26-year-old woman at 10 weeks gestation arrives at the emergency department after suffering from severe bouts of vomiting and diarrhoea, which have lasted for the past 10 days.
This has begun to have a significant impact on her day-to-day lifestyle.
She is unable to keep down fluids and despite being prescribed oral cyclizine, there has been no improvement.
When her weight was checked she suddenly realises she has lost a significant amount of weight.
A urine sample is taken and reveals high levels of ketones in her urine.
What is the next most appropriate step in management?
(3)
A
Admit for hydration
Nausea and vomiting in pregnancy: admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics
The correct thing to do in this case is to admit for hydration the patient for possible IV hydration. This is considered a medical emergency due to ketonuria and weight loss.
3
Q
A 23-year-old patient who is 22 weeks pregnant attends your GP clinic concerned about a high reading on a blood pressure machine at home.
She is asymptomatic and has no past medical conditions.
You take her blood pressure at the clinic which is 162/114 mmHg.
There is no evidence of proteinuria on urine dipstick testing.
- *What is the most appropriate management?
(3) **
A
Pregnant women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
The patient might be given labetalol along with aspirin but this would have to be initiated by the obstetric department.
4
Q
A multiparous woman at 29 weeks gestation is admitted to the maternity ward with painless, bright red vaginal bleeding.
The placenta is found to be wholly in the lower uterine segment.
The child is also in breech presentation with a transverse lie.
All of the patient’s previous pregnancies had remained uncomplicated.
What complication of pregnancy is this likely to be?
(2)
A
The correct answer is placenta praevia.
- the painless vaginal bleeding is characteristic of this complication making this the correct option.
Vasa praevia is the incorrect answer as fetal bradycardia is commonly seen in association. It may also present with blood that is darker in colour rather than bright red vaginal bleeding in this case. These factors make this option less likely.
5
Q
Potentially sensitising events in pregnancy:
(10)
A
Potentially sensitising events in pregnancy:
- Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)
6
Q
A 32-year-old woman comes to surgery for her blood results.
She is 25 weeks pregnant and has had her glucose tolerance test.
The results are as follows:
Fasting glucose = 7.1 mmol/L
2-hour glucose = 8.2 mmol/L
What would be the most appropriate next step?
A
If at the time of diagnosis of gestational diabetes, the fasting glucose level is >= 7 mmol/l immediate insulin (plus or minus metformin) should be started
7
Q
A woman at 32 weeks gestation comes into maternity assessment unit for reduced fetal movements (RFM).
She reports that she has not felt her baby move for the last 12 hours.
She has not noticed any vaginal bleeding or experienced any pain.
The midwife cannot detect a heart beat with the handheld Doppler.
What would be done next to investigate the reduced fetal movements?
A
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered
8
Q
Contraindications to the use of epidural anesthesia:
(4)
A
- active maternal hemorrhage
- septicemia
- infection at or near the site of needle insertion
- clinical signs of coagulopathy
9
Q
A 26-year-old woman was admitted at 34 weeks gestation with preterm labour.
On examination she has a blood pressure of 175/105 mmHg.
Urinalysis reveals 3+ proteinuria. She is commenced on magnesium sulphate and labetalol.
She is now complaining of reduced foetal movements.
A cardiotocogram shows late decelerations and a foetal heart rate of 90 beats/minute.
What should be the next step in the management?
(3)
A
Emergency caesarian section
A diagnosis of pre-eclampsia can be made due to the heavy proteinuria and hypertension.
Magnesium sulphate is given to reduce the risk of development of eclampsia, and labetalol is given to control the blood pressure.
Late decelerations and foetal bradycardia on cardiotocography (CTG) is a worrying sign and would justify an emergency caesarian section.
Induction would be inappropriate with an abnormal CTG.
10
Q
A 32-year-old woman presents to the obstetric department in the early stages of labour.
She is 36+4 weeks gestation and the current pregnancy has been complicated by polyhydramnios.
On examination, the foetal head can be palpated at the right side of the maternal pelvis and the buttocks can be palpated at the left side of the maternal pelvis.
The amniotic sac is intact.
What is the most appropriate next step in the management of this patient?
A
You can attempt external cephalic version for a transverse lie if the amniotic sac has not ruptured
11
Q
A 33-year-old woman who is 34 weeks pregnant with twins presents to you with a 3-day history of intense pruritis which has been affecting her sleep. You can see multiple excoriations but no obvious skin rash. Other than this the pregnancy has been going well, and foetal movements are normal.
Bloods are taken:
Bilirubin = 41 µmol/L(3 - 17)
ALP = 213 u/L(30 - 100)
ALT = 189 u/L(3 - 40)
An abdominal ultrasound was normal.
What is the most likely diagnosis? (1)
What is the most likely management plan? (3)
A
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth;
therefore induction of labour is generally offered at 37-38 weeks gestation
Also:
- ursodeoxycholic acid - again widely used but evidence base not clear
- vitamin K supplementation
12
Q
You are urgently bleeped to the labour ward to see a 22-year-old woman who has recently undergone an artificial rupture of membranes.
She is at 40-weeks gestation and has so far, had an uncomplicated pregnancy.
The midwife informs you that the foetal heart rate is abnormal.
On examination, you can palpate the umbilical cord.
What is your management plan?
What drug can you administer whilst waiting to prevent complications?
A
- Emergency C-section
- Terbutaline - Tocolytics may be useful in umbilical cord prolapse to reduce uterine contractions
13
Q
A 32-week gestation woman attends for a repeat ultrasound scan after her 20-week scan showed a low lying placenta.
The repeat ultrasound in the department shows a placenta that is partially covering the top of the cervix.
She is counselled by the obstetric consultant on her mode of delivery.
She has had 4 previous pregnancies which she delivered vaginally and has no other past medical or surgical history.
What is the appropriate offer she should be given regarding recommended mode of delivery?
A
Women with grade III/IV placenta praevia should be offered an
- elective caesarean section
- at 37-38 weeks
14
Q
A 25-year-old woman at 25 weeks gestation presents with constant lower abdominal pain and a small amount of vaginal bleeding.
On examination blood pressure is 90 / 60 mmHg
What is the most likey diagnosis?
A
Placental abruption
15
Q
A 31-year-old woman presents with painless vaginal bleeding at 15 weeks gestation.
She has not yet had any antenatal care despite suffering from severe vomiting.
On examination the uterus is large for dates.
What is the most likey diagnosis?
A
Hydatidiform mole
16
Q
A 19-year-old woman presents with a two day history of central lower abdominal pain and one day history of vaginal bleeding.
Her last period was 8 weeks ago.
On examination her cervix is tender to touch
A
Ectopic pregnancy
17
Q
A 26-year-old woman is found to be hypertensive with a blood pressure of 155/110 mmHg during labour for her first baby at 39 weeks.
Urinalysis shows +++ protein.
Which of these is the most appropriate way to manage her hypertension?
A
Administer intravenous labetalol
with target blood pressure < 135/85 mmHg
18
Q
When is aspirin taken in pregnancy? (2)
Which groups are at risk? (4)
A
Women who are at high risk of developing pre-eclampsia should take aspirin 75mg od from 12 weeks until the birth of the baby.
High risk groups include:
- hypertensive disease during previous pregnancies
- chronic kidney disease
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
19
Q
Nancy is a 25-year-old woman who is 30 weeks pregnant with her first child.
She has not felt the baby kick for 3 hours.
Her pregnancy has been unremarkable, however, her baby is slightly small for gestational age.
She presents to the obstetric emergency walk-in unit at her local hospital.
What is the next best step in the management of this patient?
A
If a pregnant woman reports reduced fetal movements then handheld Doppler should be used to confirm fetal heartbeat as a first step
Then ultrasound
20
Q
After how many weeks is same-day delivery an option?
A
After 34 weeks, same day delivery is an option.
21
Q
What is the cure for eclampsia?
What is the purpose of magnesium sulfate?
A
Delivery is the only cure for pre-eclampsia.
IV magnesium sulphate is used for eclampsia (seizure) prophylaxis.
22
Q
What effect would an epidural anesthetic have on the patient’s blood pressure?
A
epidural anesthesia should reduce blood pressure.
23
Q
A 36-year-old multiparous woman is in advanced labour at 37 weeks gestation.
An ultrasound confirms a breech presentation.
She is fully dilated and has been pushing for an one and a half hours, however the buttocks are still not visible.
How should this situation be managed?
A
Due to the foetal presentation and station, vaginal delivery is likely to be difficult.
Breech extraction is not recommended for singleton pregnancies and requires considerable skill.
Therefore Caesarean section should be advised.
24
Q
Which direction should the fetus be facing during delivery?
A
Occiput anterior to the mother
25
A 32-year-old woman who is 30+2 weeks pregnant, G3 P2+0, presents to the maternity triage unit.
Her past deliveries were both elective Caesarean sections.
Her pregnancy has been uneventful up to this point but she presents to the maternity triage unit this morning with an episode of vaginal bleeding.
She describes the amount as about a tablespoon.
There is no associated pain.
**What should be done next to determine the diagnosis?**
**Ultrasound scan**
26
A 24-year-old woman attends your clinic; she is currently 22 weeks pregnant, with no complications thus far.
2 days ago, her sister and niece visited. Her niece was feeling under the weather at the time, and has since taken ill with chickenpox.
The patient is worried for her pregnancy; she has no symptoms herself, but upon questioning, cannot remember whether or not she had chickenpox as a child herself.
What should the next step be in managing this patient?
Chickenpox exposure in pregnancy \> 20 weeks (if not immune): antivirals or VZIG should be given at days 7-14 post-exposure, not immediately
then oral acyclovir
27
A neonate is born at 38 weeks gestation via spontaneous vaginal delivery. The birth weight was 4.5kg. In the newborn postnatal check the attending doctor notes that there is adduction and internal rotation of the right arm.
**What is the definition of fetal macrosomia? (1)**
**What is the most likely diagnosis? (1)**
**Why does it occur? (1)**
A baby is diagnosed with foetal macrosomia if they have **a birth weight \>4kg** regardless of their gestational age.
**Erb-Duchenne paralysis**
* damage to C5,6 roots, **upper brachial plexus**
* winged scapula
* may be caused by a breech presentation
28
* *What is Klumpke's palsy?
(3) **
**_Klumpke injury_**
* due to damage of the lower trunk of the brachial plexus (C8, T1)
* as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand
* associated with Horner's syndrome
29
**_GESTATIONAL HYPERTENSION_**
**What gestational date does it begin? (1)**
**What is the range of hypertension? (2)**
**What would constitute a diagnosis of pre-eclampsia over GH? (1)**
**What gestational date does it begin? (1)**
* occurs after 20 weeks gestation
**What is the range of hypertension? (1)**
* systolic \> 140 mmHg or diastolic \> 90 mmHg
* or an increase above booking readings of \> 30 mmHg systolic or \> 15 mmHg diastolic
**What would constitute a diagnosis of pre-eclampsia over Gestational Hypertension? (1)**
* proteinuria
30
An obstetrician is preparing themselves to perform an emergency lower segmental caesarian section for a 24-year-old woman who is suffering from complications of pre-eclampsia.
After making an incision through the skin and superficial and deep fascia, what layers will the obstetrician have to cut through/traverse to reach the fetus?
**_Caesarian section, the following lies in between the skin and the fetus:_**
1. Superficial fascia
2. Deep fascia
3. Anterior rectus sheath
4. Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
5. Transversalis fascia
6. Extraperitoneal connective tissue
7. Peritoneum
8. Uterus
31
A 32-year-old multiparous immigrant presents at 36 weeks gestation in established labour.
No history of prenatal care or screening tests is established.
The patient has an uneventful vaginal delivery of a 3.2kg female.
Soon after birth, the baby develops fever, tachycardia and respiratory distress.
What is the most likely cause?
Group B streptococcus infection is the most frequent cause of severe early-onset (\< 7 days) infection in newborn infants.
* benzylpenicillin is the antibiotic of choice for GBS prophylaxis
32
A 29-year-old primiparous woman is in a prolonged labour following an induction at 41 weeks gestation.
She is 6 cm dilated and the fetal head is 1 cm above the ischial spines.
The midwife calls you to look at her CTG.
The fetal heart rate is progressively dropping, it is now below 100 beats per minute, and it has not recovered for more than 3 minutes.
**What is the next best step in management?**
Category 1 Caesarean section
33
A 23-year-old woman attends her antenatal booking appointment.
She thinks that she is 10 weeks pregnant.
This is her first pregnancy.
* *Which one of the following is not routinely performed?
(6) **
**Booking visit**
* general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
* BP, urine dipstick, check BMI
**Booking bloods/urine**
* FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
* hepatitis B, syphilis
* HIV test is offered to all women
* urine culture to detect asymptomatic bacteriuria
34
A primigravid 43 year-old woman, who is at 27 weeks gestation, presents to the maternity unit with regular weak contractions.
Examination reveals her cervix is 3 cm dilated and membranes are intact.
hat would be the most appropriate management?
Admit and administer **tocolytics** and **steroids**
This woman is now in premature labour, although at 3cm dilated it is still in an early stage. Therefore, it may be stopped by administering tocolytic medication. In case the labour continues and delivery is required, steroids are given as a pre-emptively to help the foetal lungs mature. Antibiotics are not required as there is no indication of an infection. Syntocinon injection contains oxytocin which strengthens the contractions of the uterus!
35
A 34-year-old pregnant woman comes to see you in clinic today concerned as her brother's son has just been diagnosed with rubella.
She is 9 weeks pregnant and is unsure of her rubella status.
What is the most appropriate first step to take at this stage?
(3)
## Footnote
**Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit**
If you are suspecting a case of rubella in pregnancy then this should be discussed with the local Health Protection Unit immediately as they can advise on which type of investigations to perform in each individual case.
Guidelines currently recommend that the **MMR vaccine is given in the post-natal period if the mother is non-immune to rubella.** It is unclear whether there is a risk of transmission in this case.
**If transmission has occurred, especially at this stage of pregnancy, advise there is a high risk of damage to the fetus.**
There is no indication for urgent hospital admission at this stage.
36
When is the first screen for **anemia and atypical red cell alloantibodies**?
8 - 12 weeks
37
When is the **early scan to confirm dates?**
## Footnote
`
10 - 13+6 weeks
38
When is the **first dose of anti-D prophylaxis** to rhesus negative women?
28 weeks
39
A 35-year-old nulliparous lady with Factor V Leiden has come for her first antenatal appointment; she has previously had an unprovoked venous thromboembolism (VTE).
The attending doctor discusses thromboprophylaxis with her due to her history.
* *Based on her risk, which treatment pathway should be used?
(2) **
**What is the aetiology of Factor V Leiden?**
* Low molecular weight heparin (LMWH) antenatally
* 6 weeks postpartum
Factor V Leiden (activated protein C resistance) is the most common inherited thrombophilia, being present in around 5% of the UK population.
* The result of the mis-sense mutation is that activated factor V (a clotting factor) is inactivated 10 times more slowly by activated protein C than normal.
40
A 35 year old primiparous woman presents to the maternity unit in a small community hospital with regular painful uterine contractions occurring every 20 minutes and lasting for 60 seconds each.
She is currently 34 weeks pregnant and suffers from gestational hypertension.
A vaginal examination reveals that the cervix is 3cm dilated.
Her membranes rupture during the digital examination.
**What is the next most appropriate step in her management?**
**Give maternal dexamethasone**
**transfer to nearest hospital with a neonatal unit**
41
A 30 year old woman who is 32 weeks pregnant presents to the day assessment unit complaining of a headache and feeling general unwell for the last day or so.
On examination there is mild oedema in her hands and feet and tenderness in the right upper quadrant of her abdomen. symphysis-fundal height is 32cm and fetal heart rate is normal.
Her blood pressure is 160/110 mmHg and pulse rate is 90 bpm.
er booking blood pressure was 115/85 mmHg. **Urinalysis is negative**.
Her bloods show the following abnormalities:
* low haemoglobin
* low platelets
* raised ALT raised bilirubin
**What is the most likely diagnosis?**
**(3)**
**What is the treatment?**
**(1)**
**_HELLP syndrome_**
**She fits the diagnostic criteria as there is suggested**
* haemolysis
* elevated liver enzymes
* low platelet count.
**Furthermore, she also has;**
* headache
* right upper quadrant pain
* peripheral oedema
* hypertension
**Treatment**
* delivery of the baby
42
A 20 year old woman on the postnatal ward is experiencing fresh, painless vaginal bleeding.
She delivered her first baby 2 hours ago at 36 weeks gestation.
The delivery was instrumented with a Ventouse due to failure to progress.
On examination, the uterus is palpable at the level of the umbilicus and there is presence of **striae gravidarum.**
The baby is healthy and has a birthweight of 2.7kg.
**What are the risk factors of postpartum haemorrhage?**
**(4)**
**CAUSES CAN BE REMEBERED FROM THE 4 Ts**
**_Tone_**
* The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.
**_Trauma_**
* This risk is increased in instrumented deliveries.
**_Tissue_**
**_Thrombin_**
43
A 40 year old 17 weeks pregnant woman has come into the antenatal clinic to receive the results for screening for chromosomal abnormalities.
She is told that she has screened positive for Down's syndrome.
**Which of the following results would be expected in this case?**
**(3)**
* Raised HCG
* Lowered AFP
* Thickened nuchal translucency
## Footnote
* Also (AVSD) are the most common defects, followed by ventricular septal defects (VSD).*
* Patients with trisomy 21 are also more likely to have a patent ductus arteriosus (PDA)*
44
A 30 year old woman presents to her GP at 35 weeks gestation with an itchy, papular rash.
She says she first noted it on her abdomen but now her legs are itchy too.
She is otherwise well and is not known to have any dermatological conditions.
Her bloods show no derangement in renal or liver function.
**What is the most likely diagnosis?**
**(3)**
* Polymorphic eruption of pregnancy
* also known as pruritic urtical purpural plaques of prenancy (PUPPP)
Commonly occurs in the third trimester
45
A 36-year-old woman, G5P3+1, presents to the Emergency Department (ED) at 35 weeks gestation.
She complains of a three hour history of cramping **abdominal pain** and **moderately severe back pain.**
She is apyrexial and does not report urinary symptoms.
Her observations show a blood pressure of 100/60 mmHg and heart rate of 100/min.
Abdominal examination shows a gravid uterus consistent with gestation with palpable uterine contractions.
Pelvic examination shows blood and **dark clots** in the vaginal vault.
**What is the most likely cause of her presentation? (3)**
**Placental abruption** is the partial or complete placental detachment prior to delivery of the fetus.
**_It is characterized by:_**
* abrupt third trimester vaginal bleeding
* abdominal and/or back pain
* uterine contractions.
The patient may be hypotensive and tachycardic consistent with bleeding.
Blood or clots maybe visible in the vaginal vault.
46
A 38 year old woman is in labour at 37 weeks gestation for a VBAC.
She has been having contractions every 5 minutes lasting 50 seconds for the last hour.
The midwife calls the obstetrician as following a spontaneous rupture of membranes fifteen minutes ago the cardiotocograph became non-reassuring due to **presence of variable** **decelerations**.
No cord prolapse is found on vaginal examination.
**A fetal blood sample is taken, which shows the following results:**
* pH 7.2
* lactate 4.4mmol/l
**How should these results be interpreted?**
**(2)**
**This is an abnormal result and plans should be made for immediate Caesarean delivery.**
A pH of 7.2 indicates an abnormal result.
**pH**:
* – normal: 7.25 or above
* – borderline: 7.21 to 7.24
* – abnormal: 7.20 or below
**Lactate**:
* Normal: 4.1 mmol/l or below
* Borderline: 4.2 to 4.8 mmol/l
* Abnormal: 4.9 mmol/l or above.
47
A para 1 woman attends her community midwife at her GP surgery for a routine antenatal check at 36+0 weeks gestation and the foetus is in breech position, as it has been at all of her antenatal checks so far.
Her first pregnancy resulted in an uncomplicated cephalic vaginal delivery at term and she is hoping for another uncomplicated vaginal delivery.
**What is the most appropriate management plan?**
**(2)**
**Women with a breech presentation at 36 weeks should be offered a planned ECV.**
## Footnote
The procedure is performed around weeks 37-39 and aims to manually turn the foetus into a cephalic presentation.
48
A 23 year old nulliparous woman attended the labour ward for induction of labour at 39+4 weeks gestation due to two attendances with reduced foetal movements.
She had one 10mg intravaginal Prostaglandin E2 pessary and 24 hours later her midwife examined her and found her Bishop's score to be 10, and performed an artificial rupture of membranes and started IV synthetic Oxytocin (Syntocinon) as per usual protocol.
The woman's contractions are regular, occurring approximately 4 per 10 minute time period, last approximately 40 seconds and are of moderate intensity. Her CTG is reassuring.
**What is the most appropriate action?**
**Continue Syntocinon at the current rate**
Syntocinon is used to augment labour and is routinely used following induction of labour and artificial rupture of membranes in a nulliparous woman.
The aims of Syntocinon is to achieve contractions of a normal rate, duration and intensity to facilitate labour.
In this first stage of labour, contractions should be approximately 3-5 per 10 minute period, lasting 30-60 seconds. Therefore this woman's labour is progressing satisfactorily.
49
A 29-year-old woman comes to the Neurology Clinic for review.
She has been seizure free for more than one year on a combination of **phenytoin and lamotrigine** and would like to start a family as she recently got married.
She wants to know what to do with respect to her anti-epileptic medication.
What would you advise?
Slowly withdraw phenytoin
It is important to continue anti-epileptic medications where possible during pregnancy, as seizures can result in foetal death.
However, dual anti-epileptic treatment is known to be associated with significantly greater risk of teratogenicity versus monotherapy.
Therefore, one of the two medications should be discontinued. Phenytoin is known to interfere with folate metabolism (essential to normal foetal development) and should be discontinued, although this should occur gradually to reduce the risk of rebound seizures.
**Lamotrigine has been shown to be the safest anti-epileptic to use in pregnancy.**
50
A 36 year old woman G3P2 with placenta praevia presents for her foetal growth scan.
**How many weeks along is she?**
Ultrasound scan shows the placenta involving more than half of the myometrium but has not invaded past it.
She denies any symptoms.
Her previous history includes two deliveries done via Caesarean section.
**Which of the following explains the ultrasound findings?**
1. 28 weeks
2. Placental increta
Placenta increta is a condition where there is an abnormal placentation and the placenta infiltrates into the myometrium and invades the muscle rather than being confined to the decidual layer of the endometrium in normal circumstances. It has been associated with raised levels of circulating fetoprotein and b-hCG and is confirmed by ultrasound scanning. It presents a major risk factor for post-partum haemorrhage and the patient is advised to have a caesarean section for delivery. The definitive treatment is hysterectomy.
51
A 24 year old lady presents to her GP with 'niggly' left sided abdominal pain.
Her last menstrual period was four weeks ago and her urinary pregnancy test is positive.
She is systemically well and has no vaginal bleeding.
Her abdomen is soft, but she is mildly tender in the left iliac fossa. On bimanual examination there is no cervical motion tenderness or adnexal masses felt.
Speculum reveals a closed cervix with no evidence of bleeding.
She undergoes a transvaginal ultrasound scan which is reported as normal, however fails to identify a pregnancy.
**What is the most appropriate management?**
**Expectant management with tracking of bHCG levels**
This lady has a 'pregnancy of unknown location', which may be an ectopic pregnancy or may be an intrauterine pregnancy that is too small to see on ultrasound scan at this gestation.
Since she is systemically well with minimal pain, this lady may be suitable for outpatient bHCG tracking depending on initial bCHG level.
In the first trimester of normal pregnancy, bHCG doubles approximately every 48 hours until reaching a peak at around week 8-10. Ectopic pregnancies are associated with a suboptimal rise in bHCG.
52
Misoprostol vs Methotrexate
Methotrexate is used for abortion
Misoprostol is used for passage of miscarriage
53
A 42-year-old woman presents to clinic wishing to discuss screening for trisomy 21.
She is a primagravida at **15+2 weeks gestation.**
Which of the following represents the best screening option for this patient?
**Dating scan plus oestriol, hCG, alpha-fetoprotein (AFP) and inhibin A**
*Given that this patient's pregnancy has progressed beyond the window for a combined test, the quadruple test is recommended.*
**Dating scan includes** blood tests measuring:
* oestriol
* hCG
* AFP
* inhibin A
54
A 46 year old woman who is 7 weeks pregnant presents to her GP with vaginal bleeding.
She also complains of **severe** **nausea** and **vomiting** over the last few days.
On examination, the symphysis-fundal height is 14cm.
She is referred to the Early Pregnancy Assessment Unit where she has a trans-vaginal ultrasound, which is difficult to interpret but does identify some fetal tissue in the uterus.
**What is the most likely diagnosis?**
Partial molar pregnancy
This is the correct answer. The constellation of symptoms of vaginal bleeding, hyperemesis, and a uterus larger than expected for gestational age, are together suggestive of gestational trophoblastic disease. As there is fetal tissue present in the uterus then this is a partial molar pregnancy.
55
How long can a woman go without contraception after birthing?
(2)
Contraception is not required for the first 21 days
Lactational amenorrhoea is recommended until 6 months postpartum and its reliability is dependent on full breast-feeding
56
A 35 year old woman who is 34 weeks pregnant presents to the day assessment unit complaining of abdominal pain, nausea and feeling generally unwell for the past day or so.
She reports no vaginal bleeding and fetal movements have been normal.
On abdominal examination there is some tenderness in the right upper quadrant of her abdomen and she appears to be mildly jaundiced. Her blood pressure is 115/90mmHg, pulse rate is 80bpm and temperature is 38 degrees Celsius. Urinalysis is negative.
Her bloods show the following:
haemoglobin 13g/dL
platelet count 300x10^9/L
WBC 7x10^9/L
ALT 50U/L
AST 65U/L
total bilirubin 5mg/dL
pro-thrombin time 15 seconds.
**What is the likely diagnosis?**
**Acute fatty liver of pregnancy**
This is the most likely diagnosis out of the options provided. Acute fatty liver of pregnancy (AFLP) can be difficult to diagnose as it presents very similarly to other disorders such as HELLP syndrome, acute hepatitis, pre-eclampsia and obstetric cholestasis.
However, the important aspect in this case is to rule out the other options. The combination of abdominal pain, nausea, malaise, deranged liver function tests but negative urinalysis and normal platelets make AFLP the most likely diagnosis.
57
A 38 year old mother presents to the day assessment unit complaining of a headache.
She has also noticed that her vision has been a bit blurry.
She is 35 weeks pregnant and this is her second child.
The first pregnancy was uncomplicated.
Her blood pressure is measured and is found to be 155/105mmHg.
A second blood pressure taken 4 hours later is 158/106 mmHg.
On examination, she is apyrexial and heart rate is 85 bpm.
She has some mild swelling in her legs and also displays hyper-reflexia.
Urinalysis shows proteinuria.
The mother reports normal fetal movements.
Which other investigations are important to carry out in this lady?
FBC and liver function test
It is important to screen for HELLP syndrome (Haemolysis, elevated liver enzymes, low platelets) in a woman with pre-eclampsia and thus FBC and LFTs are appropriate investigations.
58
A 39 year old para 2 woman had a normal vaginal delivery 30 minutes ago of a healthy baby in the midwife-led delivery suite. She delivered the placenta five minutes later. She now has heavy vaginal bleeding, is not feeling well, and her midwife is concerned.
On examination, her pulse is 110pm, blood pressure is 90/65, and she looks pale and sweaty. Her abdomen is tender and fundal palpation reveals a spongy feeling uterus. Vaginal bleeding is ongoing.
**What is the most likely cause of this patient's post partum haemorrhage?**
**Uterine atony**
The examination finding of a 'boggy' or non-contracted uterus suggests the uterus has failed to contract sufficiently to stem blood from from uterine vessels sheared during delivery.
This lady appears hypovolaemic (evidenced by the tachycardia and hypotension) and requires urgent resuscitation, uterine massage and probably uterotonic drugs to encourage uterine contraction.
59
A 38-year-old woman presents to general practice after discovering that she is pregnant.
She has a history of chronic hypertension, which is well controlled with enalapril.
She has no other significant past medical history.
**Which of the option best represents the correct management of this patient's hypertension?**
**Switch enalapril to labetalol**
NICE recommend that ACE-inhibitors should be stopped within two working days of confirmation of pregnancy. Labetalol is a safe alternative in pregnancy
60
A 25 year old woman presents to the day assessment unit with an episode of new vaginal bleeding.
She is 24 weeks pregnant and this is her second pregnancy; her first child was born via an emergency Caesarean section.
She has had two early miscarriages in the past.
She is otherwise well but mentions that she had some thickened vaginal discharge a week ago which cleared up. S
She reports no abdominal pain.
The midwife calls the obstetrician and does not examine her.
**Name the contraindications to vaginal examination (2)**
Contraindications to vaginal examination
**Undiagnosed vaginal bleeding** i.e. if there is possibility of placenta praevia. Performing a digital examination in a woman with placenta praevia can provoke serious haemorrhage.
**Preterm prelabour rupture of membranes without clear contractions**. This is to avoid introducing ascending infection into the uterus.
61
A 38 year old mother presents to the day assessment unit complaining of a headache.
She is 35 weeks pregnant and this is her first child.
She commonly suffered from migraines with aura before her pregnancy.
Her blood pressure is measured and is found to be 155/105 mmHg.
Her booking blood pressure was 130/80.
On examination, she is apyrexial and heart rate is 85 bpm.
She also has some swelling in her legs.
Urine dipstick shows 3+ protein and her creatinine is 75μmol/L.
The mother reports normal fetal movements.
Given these findings, what is the most likely diagnosis?
Pre-eclampsia
Pre-eclampsia is the most likely diagnosis.
Pre-eclampsia is defined as new onset hypertension occurring after 20 weeks gestation with proteinuria.
This woman also is displaying some of the common symptoms of pre-eclampsia which includes headache, visual problems, oedema and hyper-reflexia.
62
A 38 year old mother presents to the day assessment unit complaining of a headache. She is 35 weeks pregnant and this is her first child.
She commonly suffered from migraines with aura before her pregnancy.
Her blood pressure is measured and is found to be 155/105 mmHg. Her booking blood pressure was 130/80.
On examination, she is apyrexial and heart rate is 85 bpm.
She also has some swelling in her legs. Urine dipstick shows 3+ protein and her creatinine is 75μmol/L.
The mother reports normal fetal movements.
**Given these findings, what is the most likely diagnosis? (3)**
**Haemolytic disease of the newborn leading to hydrops fetalis is the most likely cause**
* This woman is rhesus negative, and the history of recent abdominal trauma may have led to Rhesus sensitisation.
* This causes production of maternal anti-D antibodies which cross the placenta and attack the rhesus-positive blood cells in the fetus.
* This leads to fetal haemolysis and subsequent anaemia which causes excessive accumulation of extravascular fluid.
**This has manifested in this case as increased**
* amniotic fluid volume
* placental oedema
* fetal pleural effusion
* pericardial effusion
**This could have been prevented if she was given an extra dose of anti-D prophylaxis immediately after the sensitising event (car accident).**
There is increased risk of intrauterine death with hydrops fetalis so prompt intervention is required.
63
A 30 year old woman presents to the day assessment unit complaining of an intense itch at 37 weeks gestation. It is generalised but most prominent in her hands and feet. She reports no vaginal bleeding and fetal movements have been normal. She has also had some moderate abdominal pain in the right upper quadrant and has felt more tired recently.
On examination there are excoriation marks on her abdomen, hands and feet. She is finding her symptoms very distressing and it is affecting her mood.
Her blood pressure is 120/85mmHg, pulse rate is 80 bpm and temperature is 38ºC.
Urinalysis is negative.
Her bloods show the following:
haemoglobin 13g/dL *(11.6 to 15)*
platelet count 300x10^9/L,
WBC 7x10^9/L,
ALT 50U/L and AST 65U/L,
total bilirubin 5mg/dL and a prothrombin time of 15 seconds.
**What is the most likely diagnosis?**
Obstetric cholestasis
Obstetric cholestasis is a condition of pregnancy presenting with intense pruritus which is worse on the hands and feet. Other symptoms include fatigue, nausea, abdominal pain and occasionally mild jaundice.
64
A 32-year-old (para II, gravida III) presents to your GP clinic with significant anxiety about her current pregnancy.
In a previous pregnancy she delivered a baby who developed Group B Streptococcus (GBS) related sepsis and she is seeking advice on how that can be prevented in her current pregnancy.
Her past medical history includes previous gestational diabetes and mixed anxiety and depression.
**Additionally, she reminds you that she previously had anaphylaxis to a medication given to treat a previous infective mastitis.**
**Which of the following recommendations would you make?**
**Intrapartum vancomycin**
This patient has risk factors that warrant GBS prophylaxis.
She was likely treated for mastitis with flucloxacillin, which likely indicates she in penicillin allergic. Vancomycin is the antibiotic of choice if there is severe allergy to penicillin (which also has a significant risk of cross-reactions with cephalosporins).
65
What is the definition for **major primary post-partum haemorrhage**?
**Blood loss \>1000 ml within 24 hours of delivery**
Post-partum haemorrhage (PPH) is defined as any bleeding from the genital tract following recent delivery. It can be divided into primary and secondary and major and minor. Major PPH is when blood loss is of \>1000 mls within 24 hours of delivery. The most common cause is uterine atony. This is an obstetric emergency and needs prompt resuscitation and treatment often with the use of IV oxytocin and bimanual uterine compression to encourage uterine contraction.
66
A 30 year old woman who is 2 weeks postpartum is admitted to A&E with heavy vaginal bleeding and some cramping abdominal pain. She had just delivered her baby at 38 weeks via an elective Caesarean section. This was her second pregnancy and had so far been uncomplicated with all booking bloods and scans being normal. Her first baby was also delivered via Caesarean section due to a breech presentation.
On examination, her temperature is 38.5°C, heart rate is 135 bpm and blood pressure is 90/45mmHg.
On speculum examination, there is a moderate amount of blood in the vagina and there is some offensive smelling greenish discharge exuding from the external cervical os.
**What is the most likely diagnosis?**
**Endometritis**
This lady is likely to be suffering from endometrial infection, suggested by the fever, secondary postpartum haemorrhage (\>24 hrs after delivery) and offensive discharge.
This may be due to retained placental tissue becoming infected and preventing full contraction of the uterus.
In this case, the retained placental tissue may be embedded in the uterine scar from previous Caesarean section.
67
A 30 year old woman in her 35th week of pregnancy presents to the day assessment unit with vaginal bleeding.
She noticed this morning when she woke up that she had stained her underwear with bright red blood.
She also complains of continuous abdominal pain which came on suddenly this morning.
She had one uncomplicated vagina delivery 3 years ago and her pregnancy so far has been uncomplicated.
An initial ABC examination shows that she is haemodynamically stable. On palpation of the abdomen the uterus feels “woody” and tender.
On speculum examination a small amount of active bleeding is visible but appears to be subsiding.
The cervical os is closed.
**What is the most appropriate management plan? (5)**
* Admit to hospital
* obtain IV access
* crossmatch blood
* monitor fetus with cardiotocography
* consider delivery
68
A 30-year-old trans man has had a long second stage of labour and is becoming exhausted.
In addition, he is finding it increasingly difficult to push as a consequence of his epidural.
He decided to attempt Ventouse delivery, however there is no foetal descent with the initial pull.
**Which of the following is the most appropriate next step in management?**
**Convert to lower segment Caesarean section**
When attempting instrumental delivery, the procedure should be abandoned if there is no foetal descent with each subsequent pull
69
A 29 year old woman delivered her third baby via a spontaneous vaginal delivery.
The following day, she is being assessed for discharge.
Her haemoglobin taken this morning is newly found to be low at 9.8mg/dL with a low mean corpuscular volume (MCV).
She is well, has no syncopal symptoms, shortness of breath or fatigue and is keen to go home.
Her observations are normal.
**What is the most appropriate management of this woman's post partum anaemia?**
**Oral Ferrous fumarate 200mg TDS**
Correct, although this woman's haemoglobin is low, she is asymptomatic and therefore suitable for outpatient treatment with oral Iron. She should have her haemoglobin rechecked in two weeks to ensure it is increasing, and should remain on oral Iron for at least three months.
70
A 35 year old primiparous woman is seen by the obstetrician following an uncomplicated vaginal delivery at 39 weeks gestation.
On examination, she has a **perineal tear which extends through the perineal skin, muscles, fascia and a quarter of the thickness of the external anal sphincter**.
**What degree is this perineal tear classified as?**
**Third degree tear (3a)**
A third degree tear is a perineal tear which has extended into the external anal sphincter. 3a indicates that less than 50% of the thickness is torn.
71
A new-born baby is seen on the postnatal ward with scleral jaundice and yellow pigmentation of the skin.
On further examination there is also hepatosplenomegaly.
He was born 12 hours ago in an uncomplicated vaginal delivery at 38+4 weeks gestation.
His mother did not engage with routine antenatal screening and reports one previous uncomplicated pregnancy delivered via Caesarean section.
Blood tests show a normocytic anaemia with reticulocytosis and bilirubinaemia. Blood film shows nucleated red blood cells. Direct and indirect Coombs test are strongly positive.
**What is the most likely diagnosis?**
**Rhesus haemolytic disease of the new-born**
Rhesus haemolytic disease of the new-born occurs when a mother who is Rhesus negative has a foetus who is Rhesus positive and the mother has previously been exposed to rhesus positive blood, for example through labour and delivery in a previous pregnancy, miscarriage or a blood transfusion.
Once sensitised the mother produces anti-Rh IgG antibodies which can cross the placenta and cause haemolysis of the foetal red blood cells.
The severity can vary. Features in this case pointing to the diagnosis include jaundice within 24 hours of birth (which is always pathological) alongside a normocytic anaemia with raised reticulocytes and bilirubin, confirming haemolysis.
The positive Coomb tests confirm the haemolytic anaemia is immune-mediated, excluding several other choices.
72
A newborn check is carried out on an infant who was delivered vaginally 24 hours ago at 37 weeks gestation. There were no complications during the pregnancy.
On examination there is bilateral loss of the red reflexes, purpuric skin lesions covering the torso and a continuous “machine-like” murmur heard on cardiac auscultation.
An immediate automated otoacoustic emission test is requested which returns an abnormal result.
**What is the likely diagnosis?**
**Congenital Rubella Syndrome**
The classical features of congenital rubella syndrome (CRS) are eye defects, congenital heart disease and sensorineural deafness.
These features are implicated in the history by the loss of red reflex, patent ductus arteriosus (continuous “machine-like” murmur) and abnormal newborn hearing test.
This is the most likely diagnosis. The purpuric skin rash often referred to as “blueberry muffin” rash is also a common finding in CRS.
Often mothers do not realise they have contracted rubella during pregnancy as it can present with little or no symptoms. This woman is likely also to have an absent vaccination history.
73
A 40 year old woman who is 25 weeks pregnant has been referred to the antenatal clinic after her GP noticed that her symphysis-fundal height measured 28cm.
This is her first pregnancy and she has a past medical history of diabetes and asthma.
She had a combined screening test which gave a low risk for chromosomal abnormality.
She tearfully admits that she has been having the odd cigarette when her husband isn’t home and now worries that she has harmed her baby.
A fetal ultrasound is carried out which confirms that she has polyhydramnios.
**Which factor is most likely contributing to the polyhydramnios?**
**Maternal diabetes mellitus**
This is the correct answer. Maternal diabetes mellitus is a recognised cause of polyhydramnios as it causes fetal hyperglycaemia. This results in fetal polyuria and thus polyhydramnios.
74
A 15-year-old presents to a sexual health clinic after discovering they are around 11 weeks pregnant.
They are accompanied by their partner, also 15 years old.
They would like to terminate the pregnancy.
**Which of the following is the best course of action?**
**Assess Fraser competence to inform management**
As this patient is of an age where there is significant variation in the capacity to provide informed consent, following the Fraser guidelines can aid in informing a clinician of how best to manage their care.
75
A 25 year old is 15 weeks pregnant.
She presents to the antenatal clinic for review and it is found that she is rhesus negative.
She is informed about the need to administer anti-D prophylaxis.
**When is the first dose of anti-D prophylaxis administered to rhesus negative women?**
**28 weeks**
Rhesus D isoimmunisation takes place when RhD- women come into contact with the blood of a RhD+ foetus.
The woman's anti-D antibodies cross the placenta and enter foetus circulation, which contains RhD+ blood and bind to the antigens, causing the foetal immune system to attack and destroy its own RBCs leading to the condition known as haemolytic disease of the newborn (HDN).
At 28 weeks first dose of anti-D prophylaxis is given to rhesus negative women.
76
A 35 year old woman presents to the day assessment clinic complaining of a two week history of severe nausea and vomiting as well as some mild abdominal pain.
She is in her 14th week of pregnancy and her early ultrasound scan last week revealed a twin pregnancy.
Her booking bloods were unremarkable.
On examination she is afebrile but tachycardic and appears visibly fatigued.
Her urinary output is reduced and urinalysis shows the presence of ketones.
**What is the most likely diagnosis?**
**Hyperemesis gravidarum**
Hyperemesis gravidarum is the most likely diagnosis. It is classified as severe nausea and vomiting with onset before 20 weeks gestation and should be a diagnosis of exclusion.
Note that multiple pregnancy is a risk factor for hyperemesis gravidarum.
Mild abdominal pain is a common finding in most pregnant women due to growth of the uterus and stretching of the surrounding ligaments and should not be immediately assumed to be pathological.
77
A 23-year-old woman has pregnancy confirmed by her GP.
They provide her with information regarding lifestyle, supplements and the pregnancy care pathway.
She is given advice regarding her booking appointment.
**Which tests are performed at the booking appointment?**
**All expectant mothers are offered blood tests for HIV, hepatitis B and syphilis**
This is the correct answer. Patients are offered these microbiology tests alongside a full blood count and group and save (G&S)
78
A 30 year old woman presents to the labour ward with a sudden episode of bright red vaginal bleeding which occurred 3 hours ago.
Since this episode there has been a leakage of pink-tinged fluid from the vagina.
She is 37 weeks pregnant and her notes reveal that her previous ultrasounds showed Grade III placenta praevia.
She is Rhesus positive.
She feels well and reports no abdominal pain.
On speculum examination there is a small amount of vaginal blood visible and the cervical os is closed.
There are no contractions felt.
**What is the most appropriate management plan?**
**Prepare for Caesarean delivery**
This lady is at term and appears to have rupture her membranes, thus it would be appropriate to prepare for an immediate Caesarean delivery as vaginal delivery would be contraindicated in this woman.
79
A 20 year old patient at 19 weeks gestation comes in for a routine visit.
She undergoes urine dipstick analysis and the results indicate trace glucosuria.
All other tests return as normal.
**Which of the following is the most likely cause of the glucosuria?**
**Normal physiological changes of pregnancy**
Glucosuria, especially in trace amounts, is a common finding during pregnancy as there is an increased glomerular filtration rate and a reduction in tubular reabsorption of filtered glucose.
**Gestational diabetes usually develops around the 24th week of pregnancy**
80
A 27-year-old woman is 13 weeks pregnant. She presents to her GP as over the last 2 days she has been experiencing some vaginal bleeding, accompanied with minor pain. Upon visualisation the cervical os is closed. She is referred to the Early Pregnancy Assessment Unit, where an ultrasound identifies a gestational sac and fetal pole within the uterus. Fetal heart activity is also noted.
## Footnote
**Which of the following is the most likely diagnosis?**
**Threatened miscarriage**
The miscarriage is threatened **when the cervical os is closed and the live fetus is still present in-utero.**
81
What is a missed miscarriage?
| (3)
Missed miscarriage
The **uterus still contains foetal tissue, but the foetus is no longer alive**.
The miscarriage is 'missed' as often the **woman is asymptomatic** so does not realise something is wrong. The cervical os is closed
82
A 34 year old woman attends in her first pregnancy complaining of upper epigastric pain, mild nausea and fatigue. She is 36+2 weeks gestation.
She has no headache, visual disturbance or oedema.
**Her observations are:**
* Pulse 80 bpm.
* Blood pressure: 144/96.
* Respiratory rate: 17.
* Temperature 36.9.
* SpO2 99%.
**Her urinalysis results are:**
* Blood: +
* Leukocytes: negative
* Nitrites: negative
* Protein: ++
* Ketones: negative
* Glucose: negative
* pH: 5.1
**Her blood results are as follows:**
Haemoglobin: 8.9 g/dL
White cell count: 8.2 g/dL
Platelets: 55 × 10^9/L
CRP: \<5
Urea: 2.8 mmol/L
Creatinine: 49 μmol/L
AST: 547 IU/L
ALT: 426 IU/L
LDH: 650 IU/L
Total bilirubin: 2.3mg/dL
Glucose: 5.6 mmol/L
**What is the most accurate diagnosis for this woman?**
HELLP syndrome is considered a variation of severe pre-eclampsia and requires immediate treatment including delivery of the foetus.
The three abnormalities found in HELLP syndrome are haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is managed via urgent delivery of the baby and supportive treatment of organ failure.
83
A 30 year old G1P0 at 38 weeks gestation presents to Accident and Emergency after she collapsed following severe abdominal pain. There is vaginal bleeding present and she is cold to touch. Her blood pressure is 90/54mmHg, heart rate of 120bpm, temperature 37.4 °C, and respiratory rate of 22.
## Footnote
**What is the most appropriate diagnosis?**
**Placental abruption**
Placental abruption is separation of the placenta from the uterine wall and it presents in third trimester with sudden abdominal pain, haemodynamic instability, and vaginal bleeding (though, vaginal bleeding can be absent in 20% of cases).
Risk factors include maternal hypertension as the commonest cause, smoking, and previous history of placental abruption.
It is an emergency resulting in significant maternal haemorrhage causing significant maternal and foetal mortality and morbidity.
84
A 30 year old woman is in the second stage of labour and has delivered the foetal head.
The midwife pulls the emergency buzzer as she is unable to deliver the body of the baby.
The obstetric registrar is already in the room.
**What is the most appropriate next step?**
**McRobert's manoeuvre**
Shoulder dystocia is an obstetric emergency. Important steps in initial management include performing an episiotomy and performing McRobert's manoeuvre, which involves flexing the mother's thighs towards her shoulders while lying supine.
85
**What is Zavanelli manoeuvre?**
**Gaskin's manoeuvre?**
**Mauriceau-Smellie-Veit manoeuvre?**
**Zavanelli manoeuvre**
Zavanelli manoeuvre involves pushing the delivered foetal head back inside the vaginal canal in anticipation of an emergency caesarean section. This may be considered if McRobert's manoeuvre and other manoeuvres fails to facilitate delivery
**Gaskin's manoeuvre**
Gaskin's manoeuvre involves getting the mother onto 'all fours' and can be considered if the first line manoeuvre of McRobert's fails to allow delivery of the foetus.
**Mauriceau-Smellie-Veit manoeuvre**
Mauriceau-Smellie-Veit manoeuvre is utilised in the case of a breech delivery to flex the foetal neck and facilitate delivery.
86
A pregnant woman is referred by the midwife to the antenatal clinic after a recent check-up.
She is currently 32 weeks gestation and this is her first pregnancy.
Her booking blood pressure taken at 12 weeks was 130/85mmHg.
Her blood pressure at her 31 week check was 155/95mmHg.
Urinalysis and blood tests are all normal.
**How should this woman be managed?**
**Oral labetalol for control of her blood pressure**
First line management of gestational hypertension without proteinuria is oral labetalol.
**In women with gestational hypertension (hypertension with onset after 20 weeks gestation and no proteinuria) above 150/100mmHg the first line management is oral labetalol.**
* If there is only mild hypertension (140/90 to 149/99mmHg) during pregnancy then regular blood pressure monitoring should be carried out and no treatment is recommended.
87
A 28 year old woman G2P2 with gestational diabetes presents to for her foetal growth scan at 28 weeks. Ultrasound scan shows the placenta involving more than half of the myometrium.
Which of the following explains the ultrasound findings?
**Placenta increta**
Placenta increta is a condition where there is an abnormal placentation, the placenta infiltrates into the myometrium and invades the muscle rather than being confined to the decidual layer of the endometrium in normal circumstances. It has been associated with raised levels of circulating fetoprotein and b-hCG and is confirmed by ultrasound scanning. It presents a major risk factor for post-partum haemorrhage and the patient is advised to have a caesarean section for delivery. The definitive treatment is hysterectomy.
88
A 30 year old primiparous woman at 35 weeks gestation presents to the maternity unit with rupture of membranes.
She is admitted for observation on the labour ward but 24 hours have now passed with no onset of contractions occurring.
On examination, maternal observations are normal, symphysis-fundal height is 34cm and presentation is cephalic with 3/5 engagement.
Fetal cardiotocogram is reassuring. She is offered an induction of labour but she declines and wishes to go home.
**What complication is she most at risk of?**
**Chorioamnionitis**
Rupture of the amniotic membranes can allow bacteria to enter the uterus which can lead to chorioamnionitis. This is a particular risk in pre-term pre-labour rupture of membranes and these women should be monitored regularly for any signs of infection.
89
A 40-year-old woman is admitted at 38 weeks gestation because she is persistently hypertensive.
You are called by the patient's partner because she is having a 'fit'.
When you arrive she is having a tonic-clonic seizure.
**Once her airway is stabilised, what is the most appropriate next step in management?**
**Intravenous magnesium sulfate**
This patient is likely having an eclamptic seizure. The drug of choice for managing this is magnesium sulfate. It both controls the current episode and prevents further seizures
90
Causes of polyamniohydosis
**_Excess production can be due to increased foetal urination (4)_**
**_Insufficient removal can be due to reduced foetal swallowing (4)_**
**_Excess production can be due to increased foetal urination:_**
* Maternal diabetes mellitus
* Foetal renal disorders
* Foetal anaemia
* Twin-to-twin transfusion syndrome
**_Insufficient removal can be due to reduced foetal swallowing:_**
* Oesophageal or duodenal atresia
* Diaphragmatic hernia
* Anencephaly
* Chromosomal disorders
91
A 17 year old woman attends for a termination of pregnancy. Her last menstrual period was approximately nine weeks ago. She has opted for a medical termination of pregnancy in the hospital setting. A transabdominal scan shows an intrauterine pregnancy of 10 weeks gestation.
## Footnote
**Which initial medication regime is used for medical termination of pregnancy at this gestation?**
**(2)**
**200mg oral Mifepristone** followed **by 800 micrograms Misoprostol vaginally 36-48 hours later**
200mg oral Mifepristone followed by 800 micrograms Misoprostol is recommended for medical termination of pregnancies between 10+1 and 23+6 weeks gestation.
Mifepristone is a progesterone receptor antagonist and functions to inhibit the action of circulating progesterone, causing endometrial degeneration, cervical softening and increases the uterine sensitivity to prostaglandins.
Misoprostol is a prostaglandin analogue which causes smooth muscle contractions of the myometrium, resulting in expulsion of uterine contents.
Following this initial regime, 400 micrograms of Misoprostol is administered every three hours until the products of conception have been expelled.
92
A 26 year old woman presents to the labour ward with moderate vaginal bleeding and some abdominal pain which is 6/10 in severity.
She is currently 34 weeks pregnant and this is her first pregnancy.
She admits to smoking one cigarette a day during the pregnancy.
Her past surgical history includes a cervical cone biopsy.
In this pregnancy she has suffered from pre-eclampsia and is taking anti-hypertensive medication.
On examination, the symphysis-fundal height is 31cm, presentation is cephalic and the head is 3/5 engaged.
**Given the likely diagnosis, which of the following features from her history is a risk factor?**
**Pre-eclampsia**
Pre-eclampsia is a recognised risk factor of placental abruption as well as other hypertensive disorders. Thus, this is the correct answer. Note that her history of smoking is also a risk factor for placental abruption.
93
A 28-year-old woman presents to her GP with abdominal discomfort, nausea and vomiting over the last few days.
She also informs the doctor that she thinks she’s put on about 4kg of weight over the same time frame.
She has a history of pelvic inflammatory disease, and is currently having in-vitro fertilisation.
On examination, her abdomen is distended.
**What is the most likely diagnosis?**
**Ovarian hyper-stimulation syndrome**
The high concentration of oestrogen leads to nausea and vomiting. High levels of vascular endothelial growth factor cause leaking vasculature, causing fluid retention and so weight gain. The ovaries may enlarge which explains the abdominal discomfort. It is a risk in women who are undergoing in-vitro fertilisation (IVF).
As the woman is experiencing all the expected symptoms and is at increased risk, ovarian hyper-stimulation syndrome is the most likely diagnosis.
94
A 19-year-old is brought into hospital by her partner because she experienced a now resolved episode of PV bleeding.
She is 34 weeks pregnant and has had a Caesarean section for a pregnancy two years ago.
The patient is adequately resuscitated and a transvaginal ultrasound is performed.
A diagnosis of major placenta praevia is made.
**Which of the following describes the best management of the patient's pregnancy? (2)**
**Admit the patient**
Symptomatic **major placenta praevia warrants admission from 34 weeks gestation** in order to minimise risk to mother and foetus in the event of further bleeding or initiation of labour
95
A 30 year old woman attends her GP following a positive home pregnancy test. This is her third pregnancy.
Her first was an ectopic pregnancy which was managed surgically with a laparoscopy and left salpingectomy four years ago and she had a medical termination two years ago.
**Having which of the following medical conditions is a recognised risk factor for ectopic pregnancy? (8)**
**Recognised risk factors for ectopic pregnancy include:**
* Previous ectopic pregnancy
* Pelvic inflammatory disease
* intrauterine contraceptive device or system in situ
* Assisted conception e.g. IVF
* Pelvic surgery
* Smoking
* Endometriosis
* Age older than 35
Endometriosis is associated with a greater risk of ectopic pregnancy due to the formation of scar tissue and adhesions which can distort the normal anatomy of the fallopian tubes.
In addition, inflammation present in endometriosis can alter tubal physiology, impairing the normal journey of a fertilised egg.
96
A 35 year old woman is admitted onto the antenatal ward due to poorly controlled pre-eclampsia. She is 30 weeks pregnant with her first child. Whilst the FY1 is examining her alone in the room, she suddenly falls unconscious and begins to seizure on the bed.
**Which of the following is the most appropriate step in the management of this patient?**
**Give IV magnesium sulphate**
After calling for help, the patient’s airway, breathing and circulation should be assessed and they should be moved into the left lateral tilt position in order to reduce aortocaval compression. Then IV magnesium sulphate should be administered as soon as possible to stabilise the cerebral membranes. Only once the mother is stable should plans for delivery of the baby then be made.
97
A 42-year-old woman is 33 weeks pregnant when she presents to her GP with intense pruritus in her palms and soles. A blood test reveals elevated bile acids.
## Footnote
**When should the child plan to be delivered?**
**Aim for delivery at 37-38 weeks**
Obstetric cholestasis is associated with spontaneous foetal death and maternal haemorrhage. Planning delivery for 37-38 weeks allows adequate development of the foetus without unnecessarily prolonging the risk of spontaneous death
98
A 22-year-old presents to clinic 5 days after delivery of her first child.
The labour was difficult and she eventually required an instrumental delivery.
She tells you that she has been crying uncontrollably and struggling to sleep because she is overwhelmed with worry that she will not be a good parent.
She denies any thoughts of harming herself or others.
She denies experiencing hallucinations.
She reports that it is important to her that she continue breastfeeding.
**What is the most appropriate course of action with this patient?**
**(3)**
**Reassurance and regular follow up**
This patient is likely experiencing **'baby blues'**, a common and transient emotional difficulty of the puerperium.
**It is usually self-limiting and resolves after around 10 days.**
Reassuring her that this happens after ~50% of pregnancies and offering her follow up to check on her progress is sufficient
99
A 38 year old mother presents to the day assessment unit complaining of a headache.
She has also noticed that her vision has been a bit blurry.
She is 35 weeks pregnant and this is her second child.
The first pregnancy was uncomplicated.
Her blood pressure is measured and is found to be 160/110 mmHg.
A second blood pressure taken 4 hours later gives the same result.
On examination, she is apyrexial and heart rate is 85 bpm. She has some mild swelling in her legs. Urinalysis shows proteinuria.
The mother reports normal fetal movements.
What is the next appropriate step in management?
**Labetalol**
This is correct. Oral labetalol is the first line pharmacological treatment for pre-eclampsia.
100
A 25 year old female presents to A&E with severe right sided abdominal pain that started 5 hours ago. She has no urinary symptoms or changes in bowel habit.
On examination, she is febrile and has severe pain on palpation of the right upper quadrant of her abdomen. Vaginal examination reveals cervical excitation. Liver function tests are normal. A pregnancy test was negative.
**What is the best treatment for her condition? (3)**
**Ceftriaxone, doxycycline and metronidazole**
This is the best treatment for pelvic inflammatory disease.
She is suffering from Fitz-Hugh-Curtis syndrome, which is perihepatitis arising from inflammation of the liver capsule and surrounding peritoneal surfaces.
Antibiotic regimens need to cover for Chlamydia, gonorrhoea and anaerobic vaginal commensals.
101
You receive a bleep from a midwife who is attending a patient after her delivery.
They estimate that the patient has lost around 800ml of blood and is still bleeding.
The patient's heart rate is 97 and blood pressure is 100/75mmHg.
**Which of the following is the most appropriate first step in management?**
**Insert large bore IV cannulae for group and cross
match, FBC and coagulation studies**
Postpartum haemorrhage is a medical emergency and as such resuscitation measures must be the first priority. The patient is becoming shocked and continuing to become more hypovolaemic.
As such, the above blood tests and fluid resuscitation should be the first step in management
**Postpartum haemorrhage (PPH) is generally the loss of at least 500ml of blood within the first 24 hours of delivery.**
102
A 22 year old woman presents to the obstetric unit in a latent first stage of labour as she is becoming increasingly distressed by pain.
Her midwife examines her and the cervix is found to be 2cm dilated.
She has already taken 1g of Paracetamol at home two hours prior and has spent some time in a warm bath.
She finds moving around helps with the pain, particularly walking and using a birthing ball.
She is using Entonox in the unit however, is still not coping with the pain.
She is otherwise well, this is her first pregnancy, and she has no contraindications to further analgesia.
**What is the most appropriate analgesia to offer this woman?**
**Diamorphine 5mg intramuscular (IM)**
Diamorphine IM is first line for strong opioid analgesia in the latent first stage of labour. It has the advantage of a rapid duration of onset (within 20 minutes) and lasts for 2-4 hours.
**Epidural**
* **Although spinal epidural is a valid form of analgesia, it is usually not sited until the woman is in 'established labour'.**
This woman is in the latent stage so epidural would not be appropriate. In addition, she is keen to remain mobile.
103
A 28 year old woman in her first pregnancy is in the second stage of labour.
Her midwife calls for assistance, as she has been fully dilated for three hours, and actively pushing for the past two hours, however she is becoming increasingly exhausted.
The head is just visible at the height of each contraction.
The woman is fully dilated and has good epidural anaesthesia on board.
**What is the most appropriate next step in facilitating delivery of the baby?** (2)
**Operative delivery using forceps**
This woman is having a prolonged second stage of labour.
* This is defined as **three hours or more from full dilatation** in a nulliparous woman with epidural anaesthesia.
A forceps delivery, via the vagina, is indicated here.
104
A 40 year old primiparous woman is going for her 11 week antenatal appointment.
Her pregnancy was the result of successful IVF treatment.
Two separate gestational sacs are seen on ultrasound, suggesting a twin pregnancy.
The mother is worried about the implications of her having a multiple pregnancy.
**Which types of twins are associated with the greatest risk of complications?**
**Monochorionic-Monoamniotic twins**
Monochorionic monoamniotic twins are identical (monozygotic) twins that share the same amniotic sac. These share a placenta with two separate umbilical cords.
These types of twins are at high risk of developing complications such as cord entanglement (because there is no membrane separating the two umbilical cords), cord compression, twin-to-twin transfusion syndrome and pre-term birth.
