Early pregnancy

Question 1

You are performing a laparotomy for a ruptured right ectopic pregnancy in a 17 yo. A 10cm right ovarian cyst is noted. Left ovary appears normal. The most appropriate surgical procedure is:

A - R salpingo-oophorectomy

B - Aspiration of cyst only

C - R ovarian cystectomy

D - Cystectomy and wedge resection of L ovary

E - Oophorectomy with wedge resection of the L ovary

Answer 1

C - R ovarian cystectomy

O

Question 2

A woman has two 23 week pregnancy losses due to a uterine septum. Which of the following is most appropriate advice?

A - metroplasty
B - expectant management
C - she will carry the next pregnancy longer
D - against pregnancy
E - hysteroscopic removal of septum

Answer 2

E - hysteroscopic removal of septum

I think B as similar worded RANZCOG Q says conservative/expectant - 2020 Cochrane review suggests septum resection may not improve pregnancy outcomes

Question 3

Factors that are associated with incompetent cervix include each of the following EXCEPT

A - in utero DES exposure
B - cervical cone biopsy
C - Cervical infection
D- Cervical laceration

Answer 3

C - Cervical infection

O

Question 4

Most common time for subseptate uterus to abort?

A - 8-14 weeks
B - 12-16 weeks
C - 14-18 weeks
D - 18-22 weeks

Answer 4

A - 8-14 weeks

44% risk of first trimester miscarriage
PTB 25% rate

Question 5

Regarding ectopics:

A - continuing US and BHCG delays intervention and leads to greater risk of rupture
B - recurrence risk about 10%
C - better chance of subsequent live birth with salpingostomy vs salpingectomy

Answer 5

B - recurrence risk about 10%

Question 6

1. What is the MINIMUM MSD for the diagnosis of a blighted ovum (anembryonic pregnancy)

a. 15mm
b. 20mm
c. 25mm
d. 30mm

Answer 6

c. 25mm

O

Official answer used to be 20mm but criteria updated since

Question 7

A patient who previously had a pregnancy terminated at 18 weeks for a neural tube defect consults you regarding the likelihood of recurrence of this condition. You advise her that the risk of recurrence is

a. 1/4
b. 1/25
c. 1/100
d. 1/250

Answer 7

b. 1/25

O

The risk of recurrence for isolated NTDs is approximately 5% with one affected sibling
With two affected siblings, the risk is approximately 10%

US: 5.5 per 10,000 live births

Question 8

Chromosome mosaicism is detected at CVS performed for advanced maternal age. As a NEXT STEP you would recommend

a. A repeat of the CVS
b. An amniocentesis
c. Consideration of termination of pregnancy
d. No further action

Answer 8

b. An amniocentesis

O

Unable to exclude confined placental mosaicism

Question 9

The MOST COMMON clinical presentation of women with a Hydatidiform mole is

a. Abnormal bleeding
b. Hyperemesis
c. Preeclampsia
d. Large for dates uterus

Answer 9

a. Abnormal bleeding

O

Question 10

A 35yo G1P0 has a second trimester maternal serum screen (MSST2) arranged by her GP, which is increased risk for Down syndrome. What would you do FIRST?

a. Arrange CVS to karyotype
b. Arrange amniocentesis to karyotype
c. Arrange USS to check gestational age of fetus
d. Arrange a TOP
e. Arrange contact with a Down syndrome support group in case she wishes to continue the pregnancy

Answer 10

c. Arrange USS to check gestational age of fetus

O

MSS2
Quadruple test = oestradiol, inhibin A, AFP, HCG
Can be done 15-20 weeks
Sensitivity 75%, specificity 95%

Question 11

A 20yo woman is seen in the first trimester at 10 weeks. Her last child was born with a closed spina bifida. Which is true?

a. The risk of NTD in this pregnancy is 10 percent
b. Chorionic villus sampling is indicated
c. Amniocentesis is indicated at 15 -16 weeks
d. She should start folic acid now
e. Ultrasound exam is indicated at 11-12 weeks

Answer 11

e. Ultrasound is indicated at 11-12 weeks

O

Question 12

A 40yo primagravida books at 10 weeks. Which is MOST CORRECT

a. The chance of Down syndrome is 3%
b. The chance of any chromosomal abnormality at CVS is 4%
c. The chance of NTD is 1%
d. The chance of miscarriage following amniocentesis at 15 weeks is 2%

Answer 12

b. The chance of any chromosomal abnormality at CVS is 4%

Chance of NTD 2-4%
40y - 1 in 100 risk of Down syndrome

Question 13

At routine AN screening, a woman from Nauru has a negative RPR and positive TPHA. The most likely explanation is

a. The patient has early syphilis
b. The patient has late latent syphilis
c. The result is false positive
d. The patient has been treated for syphilis in the past

Answer 13

d. The patient has been treated for syphilis in the past

Question 14

You are called to the emergency room for a patient with severe abdominal pain, vaginal bleeding, hypotensive and tachycardic. She has bicornuate uterus, positive urine pregnancy test 2 weeks ago. USS shows empty uterus and large adnexal mass. You instruct the ER doctor to

a. Schedule patient for laparoscopy and probable linear salpingostomy
b. Order FBC and LFT in preparation for methotrexate
c. Not make any decisions until you arrive in half an hour
d. Begin scheduling laparoscopy with probable laparotomy

Answer 14

d. Begin scheduling laparoscopy with probable laparotomy

O

Question 15

A woman had a CXR and was found to be 16 weeks pregnant. She asks about the evidence of potential harm from diagnostic radiography on the fetus. You tell her

a. There is no association with proven detrimental effects
b. There is a small increase in childhood malignancy
c. There is a small increase in fetal chromosomal damage
d. There is a small increase in growth restriction

Answer 15

b. There is a small increase in childhood malignancy

Very small potential risk

O

Question 16

All of the following statements about partial molar pregnancy are true except

a. The karyotype is usually triploid
b. Beta HCG follow up is indicated after evacuation
c. Progression to choriocarcinoma doesn’t occur, although there may be persistent trophoblastic disease after evacuation
d. Early pre eclampsia is more common in patients with a partial mole than a normal pregnancy

Answer 16

c. Progression to choriocarcinoma doesn’t occur, although there may be persistent trophoblastic disease after evacuation

O

Question 17

Which is the smallest fetal pole that a sonographer could be confident in diagnosing a missed miscarriage on transvaginal scan because of the absence of cardiac activity?

a. 7mm
b. 9mm
c. 11mm
d. 13mm

Answer 17

a. 7mm

O

Question 18

The most common fetal chromosome abnormality observed in spontaneous miscarriages is

a. Autosomal trisomy
b. Triploidy
c. Sex chromosome abnormality
d. Chromosomal translocation

Answer 18

a. Autosomal trisomy

O

Question 19

Which one of the following statements about spontaneous miscarriage is CORRECT?

A. The incidence of spontaneous abortion is increased in pregnancies if the woman is >40years old
B. Among chromosomally abnormal spontaneous abortuses, the most common chromosomal abnormality is triploidy
C. In utero exposure to diethylstilboestrol (DES) increases a woman’s risk of many pregnancy complications, but not spontaneous abortion
D. The karyotypic abnormalities in spontaneous abortuses are similar to those in liveborn neonates
E. Most spontaneous abortions occur between 12-16 completed weeks of pregnancy
F. Bacterial vaginosis is associated with an increased risk of first trimester miscarriage

Answer 19

A. The incidence of spontaneous abortion is increased in pregnancies if the woman is >40years old

O

Autosomal trisomy is the most common fetal chromosome abnormality observed in spontaneous miscarriages.

Autosomal trisomy 45%
Monosomy X 20-30%
Triploidy 15-20%
Tetraploidy 5%

Question 20

A woman with hyperemesis in the first trimester of pregnancy has thyroid function tests which show reduced TSH, increased T4, and normal T3. This result is most likely to represent:

a. Hydatidiform mole causing thyrotoxicosis and hyperemesis
b. Thyrotoxic phase of autoimmune thyroiditis causing hyperemesis
c. Normal findings in early pregnancy
d. Graves disease (thyrotoxicosis) causing hyperemesis

Answer 20

c. Normal findings in early pregnancy

O

Question 21

Which of the following carries the HIGHEST relative risk of ectopic pregnancy if the woman accidentally becomes pregnant?

A. Condoms
B. Diaphragm
C. Combination oral contraceptive pills
D. Progestogen-only pills

Answer 21

D. Progestogen-only pills

O

Question 22

A 55yo woman seeks your advice regarding exposure to DES. She used DES for the first 4 months during both of her pregnancies. Her daughter is 30 and her son is 28. She is concerned about the risks to herself and her children. All of the following statements are true except:

a - her daughter’s fertility may be impaired due to uterine anomalies
b - the risk of her daughter developing clear cell adenocarcinoma of the vagina is 1%, and increases with time.
c - her daughter’s risk of cervical and vaginal dysplasia is doubled
d - her son has an increased risk of developmental genital tract abnormalities
e - the woman herself is probably at increased risk of breast cancer

Answer 22

b - the risk of her daughter developing clear cell adenocarcinoma of the vagina is 1%, and increases with time

O

The risk is present and historically thought higher in younger years, now thought risk is likely lifelong but not necessarily increasing with age.

Diethylstilboestrol (DES) is a synthetic oestrogen taken in 1940-80s to reduce risk of pregnancy complications (e.g. miscarriage). Interferes with reproductive and endocrine system.

Male offspring - increased risk of epipdidymal cysts, hypogonadism, undescended testes. No cancer risk (aside from separately if testes undescended). No infertility risk.

Female offspring - Significant uterine malformations - T shape. Higher rates of miscarriage but not birth defects. Higher amounts of cervical dysplasia but with appropriate monitoring, not squamous malignancy. Higher rates of vaginal and cervical clear cell adenocarcinoma.

DES users - Breast cancer risk increased by ~30%

https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Diethylstilboestrol-Exposure-in-Utero-(C-Obs-56)-Review-March-2021.pdf?ext=.pdf

Question 23

A 34-year-old woman G7P0M5T1 presents for her first antenatal visit at 10 weeks with a viable singleton pregnancy. All her miscarriages were in the first trimester. She has a normal uterine configuration and is thrombophilia screen negative.
What would be the most appropriate initial preventative management for her recurrent miscarriages?

a. Cervical cerclage.
b. Maternal reassurance with intensive follow-up
c. Low dose aspirin
d. Low molecular weight heparin

Answer 23

b. Maternal reassurance with intensive follow-up

Wouldn’t give LDA or heparin without thrombophilia diagnosis

Evidence that maternal reassurance with intensive f/u improves LBR

Question 24

Which of the following is most suggestive of an ectopic pregnancy?

a. Transabdominal ultrasound reveals no gestational sac; ß-hCG <4,000 mIU/mL
b. Transabdominal ultrasound reveals no gestational sac; ß-hCG >7,000 mIU/mL
c. Transvaginal ultrasound reveals no gestational sac; ß-hCG <600 mIU/mL
d. ß-hCG >7,000 mIU/mL, serum progesterone <40 mg/mL

Answer 24

b. Transabdominal ultrasound reveals no gestational sac; ß-hCG >7,000 mIU/mL

O

Question 25

A 26 year old woman has a history of two midtrimester pregnancy losses. Each was characterised by contractions. A hysterosalpingogram defines a subseptate uterus.
What management is MOST APPROPRIATE for this patient?

a. Strassman procedure
b. McDonald cerclage
c. Hysteroscopic resection of the septum
d. Observation

Answer 25

D. Observation

As per RANZCOG MCQs Feb 2008 AND 2012 answer

Hysteroscopic resection SHOULD theoretically improve outcomes BUT Cochrane review 2017 suggests no good evidence for this, does not support this intervention until further higher quality evidence available.

Strassman procedure is for a bicornuate uterus

Question 26

The doctor is asked to see a new migrant from Sudan. She is 14 years old and presents with her father. She is 10 weeks pregnant. What is the MOST IMPORTANT next step?

a. Discuss female genital mutilation
b. Offer support through migration support services
c. Perform a general examination
d. Use a culturally appropriate translator

Answer 26

d. Use a culturally appropriate translator

O

Question 27

A 27year old woman has had 3 successive spontaneous abortions prior to 12 weeks, and has had no other pregnancies. All other routine investigations for habitual abortion have been negative. Which of the following should you recommend at 7 weeks following last menstrual period in her next pregnancy?

a. Heparin & Aspirin therapy
b. Serial progesterone levels or empirical progesterone therapy
c. Cervical ligature insertion at 13 weeks
d. Pelvic USS
e. Serial BhCG levels

Answer 27

d. Pelvic USS

O

Question 28

A 26 year old Asian woman in her first pregnancy had a missed miscarriage treated by suction evacuation. The histology of the products of conception showed a partial hydatiform mole. Follow up BhCG concentrations:

a. should be continued for 6months
b. can be discontinued if hCG falls to normal by 8 weeks
c. indicate persistent gestational trophoblastic disease if concentrations plateau over 2 weeks
d. indicate persistent gestational trophoblastic disease if there is a rise of 5% over 2 values

Answer 28

b. can be discontinued if hCG falls to normal by 8 weeks

O

Question 29

Your patient has had a child with spina bifida. She has accessed a lot of confusing information and comes to you for advice regarding management of her next pregnancy. Which of the following is NOT appropriate?

a. Vaginal USS at 10weeks
b. USS at 16weeks
c. Amniocentesis and alpha fetoprotein estimation
d. Folate as soon as she stops contraception
e. Folate as soon as a pregnancy is confirmed

Answer 29

e. Folate as soon as a pregnancy is confirmed

O

Too late
5% recurrence after 1 child
Results from failure of neural tube to close day 26-28

Question 30

Suction curettage for missed abortion at 10/40. What size suction catheter should you use?

a. 6
b. 8
c. 10
d. 12
e. 14

Answer 30

c. 10

Should be 1mm less than the weeks of gestation from last menses, although some use smaller (TeLindes). UTD states suction size should equal gestation.

M

Question 31

A woman had a termination of pregnancy at 8/40 gestation at a local clinic under LA. The cervix was difficult to dilate and the uterus appeared to be perforated during this dilation. There was no bleeding or pain. A TVS was performed and showed a viable 8/40 fetus with an intact sac. What is the most appropriate management?

a. Continue with the termination
b. Transfer to hospital and continue termination under GA
c. Insert a cervagem vaginally and wait 4 hrs then attempt the suction termination
d. Perform a laparotomy and repair the defect, continue with suction termination with hysterotomy and removal of POC if necessary
e. Stop the procedure and wait 1-2 weeks then reconsider

Answer 31

TeLindes and UTD state that if perforation occurred with blunt instrument (sound or dilator) then the procedure can be continued under ultrasound guidance. If concerns exist around bleeding laparoscopy is done and the procedure can be finished under laparoscopic guidance

e. Stop the procedure and wait 1-2 weeks then reconsider

M

Question 32

What are the characteristics of beta hCG in early pregnancy?

a. enhances placental-fetal adrenal steroidogenesis
b. supports the corpus luteum
c. enhances the effects of maternal blocking antibodies
d. maternal serum level rises to a peak at 14w
e. is chemically and functionally similar to ACTH

Answer 32

b. supports the corpus luteum

HCG is produced by the syncytiotrophoblast to promote progesterone production by the corpus luteum until placental progesterone supply is established (after 6 weeks). HCG also plays a role in spiral artery angiogenesis (UTD). The alpha subunit is identical to that of TSH, LH and FSH. HCG levels peak at 8-11 weeks gestation.

M

Question 33

In a woman who is 8 weeks pregnant with an IUD in situ the correct management is?

a. Immediate removal of the IUD
b. Advise termination of pregnancy
c. Remove the IUD only if there is evidence of infection
d. If the strings are visible cut them as high up in the cervical canal as possible
e. Immediate laparoscopy to exclude ectopic pregnancy

Answer 33

a. Immediate removal of the IUD

Should confirm pregnancy location first to rule out an ectopic.

Question 34

In a woman who conceives with an IUD inset, all of the following are associated EXCEPT:

a. Miscarriage
b. Prematurity
c. Low birth weight
d. Fetal abnormalities
e. Chorioamnionitis

Answer 34

d. Fetal abnormalities

Question 35

After which procedure is the decay rate of BHCG the fastest?

a. Vacuum curette for termination of pregnancy
b. Vacuum curette for spontaneous abortion
c. Resection of ectopic pregnancy
d. Linear salpingotomy for ectopic pregnancy
e. BHCG decays at the same rate for all procedures

Answer 35

e. BHCG decays at the same rate for all procedures

M

Question 36

Patient presents 6 weeks pregnant. PVB and pain. US live IU pregnancy. Normal FH. Chance of ongoing pregnancy?

a. 90%
b. 70%
c. 50%
d. 30%
e. 10%

Answer 36

a. 90%

(Kerridge notes)

M

Question 37

A woman is 6 weeks late for her period and her BHCG was noted to be 140,000 mIU/ml. The most likely diagnosis is:

a. Single IU pregnancy
b. Tubal ectopic pregnancy
c. IU pregnancy and dysgerminoma
d. Multiple pregnancy
e. Ovarian pregnancy

Answer 37

a. Single IU pregnancy

M

Question 38

Percentage of chromosomal abnormalities in 1st trimester spontaneous miscarriage?

a. 20%
b. 30%
c. 40%
d. 50%
e. 60%

Answer 38

d. 50%

50% of all 1st trimester losses, 30% of 2nd trimester lossess and 3% of stillbirths are karyotypically abnormal. (Speroff)

M

I think it is likely to be higher ?closer to 70%

Question 39

A woman had 3 consecutive first trimester miscarriages. What is the likelihood of miscarriage in the next pregnancy?

a. 5%
b. 10%
c. 30%
d. 50%
e. 70%

Answer 39

c. 30%

If one previous liveborn infant - 32%; if no previous liveborn infants - 40-45%

M

*CHECK these stats

UTD:
RPLs - at 5years 67% livebirth rate
Unexplained RPLs - subsequent conception 75% successful pregnancy beyond 24weeks

Question 40

37 yo with recurrent miscarriage. Most likely diagnosis is:

a. Obstetric Lupus
b. Luteal phase deficiency
c. Uterine anomaly
d. Idiopathic

Answer 40

d. Idiopathic

Acquired and congenital uterine abnormalities are responsible for 10-50% of RPL. Congenital uterine abnormalities are present in 10-15% of women with RPL. Luteal phase defects are present in up to 25%, APLS in 5-15%. No cause is found in 50%.

M

Question 41

A primigravida completed in a running marathon. On the day, the weather was very hot and she suffered from heat stroke. She was admitted to the hospital, diagnosed with hyperthermia. She was treated successfully with rehydration. Her last normal menstrual period was 4 weeks ago and her pregnancy test was positive. She came to you to obtain advice about the effect of this episode on her fetus. Which of the following is the fetus at risk of?

a. VSD
b. Gastroschisis
c. Phocomelia
d. Spina bifida
e. Anencephaly

Answer 41

d. Spina bifida

Increased maternal core temperature during embryogenesis is associated with major abnormalities in animals. These include neural tube defects, micropthalmia, arthrogryposis, abdominal wall defects and limb deficiencies. Phocomelia is the absence of long bones with flipper like hands and feet. Four weeks gestation is a period where the CNS is highly sensitive. (UTD)

M

Question 42

Which investigation delivers the greatest dose of radiation to an 8 weeks fetus?

a. IVP
b. CXR
c. Cholecystogram
d. Barium enema
e. Lumbar spine series

Answer 42

d. Barium enema

M

https://www.aafp.org/pubs/afp/issues/1999/0401/p1813.html

For comparison

Question 43

Advice re alcohol in pregnancy?

a. Only safe thing is not to have any
b. Better to have none but no increase in FAS with one standard drink per day
c. 3 standard drinks per day safe as long as there is no binge drinking
d. A constant low intake best so the fetus is exposed to constant low levels

Answer 43

a. Only safe thing is not to have any

M

Question 44

Which ONE of the following statements about spontaneous miscarriage is CORRECT?

A. Bacterial vaginosis is associated with an increased risk of first trimester miscarriage
B. Among chromosomally abnormal spontaneous abortuses, the most common abnormality is triploidy
C. In utero exposure to DES increases a woman’s risk of spontaneous miscarriage
D. The karyotypic abnormalities in spontaneous abortuses are similar to those in liveborn neonates

Answer 44

C. In utero exposure to DES increases a woman’s risk of spontaneous miscarriage

O

Question 45

A 19-yo nulliparous patient with LMP 6weeks ago presents to ED with sudden pelvic pain and light spotting. Pelvic exam reveals bilateral adnexal tenderness, Pelvic USS shows no gestational sac in the uterus. Quantitative serum hCG is 6000.
The NEXT APPROPRIATE step is

A.   laparotomy
B.   repeat USS in 1 week
C.   laparoscopy
D.   serial hCG determination
E.   endocervical culture for chlamydia

Answer 45

C. laparoscopy

O